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Based on clinical record review, document review and staff interview, it was determined the hospital failed to ensure all patients were admitted to the hospital by a licensed practitioner permitted to do so. This deficient practice was found for three (#22, 23 and #24) of three pain management surgery patient records reviewed.

Findings:

On 01/08/14, the operating room register was reviewed. From July 2013 through December 2013, the register documented 41 pain management surgical procedures were performed by a CRNA. The register did not document a qualified MD/DO was present during the procedures.

Three of these surgery records were reviewed. None of the records documented an admitting physician. The records documented the CRNA as the admitting practitioner.

The clinical record for patient #24 contained a surgical consent form that documented the CRNA was the admitting physician. The CRNA also signed the consent form on the space labeled "Signature of Physician."

The records contained a document titled, "Pain Management Record." The form had a space to document the physician's name. This space was left blank on all three records.

The medical staff by-laws did not allow for a CRNA to be the admitting practitioner.

The CEO stated she was not aware the CRNA was documented as the admitting practitioner.

Based on record review and interviews with hospital staff, the hospital does not ensure that a complete list of all services provided by contract or agreement is maintained which includes the scope and nature of the services provided. The list of contracted services provided for review did not contain all the services provided by contract or agreement.

Findings:

1. Blood bank services provided by contract were not included on the list provided.

2. Reference lab services provided by contract were not included on the list provided.

3. Dietition services provided by contract were not included on the list provided.

4. Consultant Pharmacist services provided by contract were not included on the list provided.

5. These findings were verified by Staff A.

Based on staff interview, medical record and document review, the hospital failed to notify patients and/or their representatives of their rights. This occurred in seventeen of seventeen (#1 through 9 and 11 through 19) inpatient and two of two (#10 and 20) swingbed medical records reviewed.

Findings:

Admission paperwork was provided to the surveyors by Staff A on the afternoon of 01/07/14.

The admission paperwork included a Patient Registration form, Conditions of Admission-Bristow Medical Center and Notice of Privacy Practices. The information provided did not contain all the patient rights components as required.

Staff A was asked if any additional forms are given to the patients upon inpatient and swingbed admission, Staff A stated she was not aware of any additional paperwork.

Review of medical records for Patient #10 and #20 did not contain documentation of the standardized notice, "An Important Message from Medicare"(IM), within 2 days of admission.

Based on medical record review, policy and procedure review and staff interview, the hospital failed to establish a process for patients to lodge a grievance with the State Agency (Oklahoma State Department of Health-OSDH). This occurred in twenty of twenty (#1 through #20) of clinical records reviewed.

Findings:

Admission paperwork was provided to the surveyors by Staff A on the afternoon of 01/07/14.

The admission paperwork included a Patient Registration form, Conditions of Admission-Bristow Medical Center and Notice of Privacy Practices. There was no documented evidence in the patient admission packet that patients were given the State Agency contact information, including the OSDH website, for lodging complaints and grievances.

Staff A was asked if any additional forms are given to the patients upon inpatient and swingbed admission, Staff A stated she was not aware of any additional paperwork.

Based on record review and interviews with hospital staff, the hospital does not ensure that data collected for quality indicators are analyzed to monitor services provided for quality and patient safety. Review of Quality Assurance meeting minutes did not have evidence of analysis of the data collected and the interpretation of the data to monitor whether the care to patients is effective and safe.

Findings:

1. One of the quality indicators documented for surgery was the humidity level in the operating suite. The parameters for humidity levels in the operating suite were between 30% and 60%. The humidity levels were out of range three of four quarters for 2013. There was no action taken or analysis of why the humidity was out of range.

2. One of the quality indicators documented for surgery was the temperature in the operating suite. The parameters for temperature in the operating suite were between 68 degrees F ( Farenheit) and 73 degrees F. The temperatures were out of range three of four quarters for 2013. There was no action taken or analysis of why the temperatures were out of range.

3. Medication error data did not have analysis of errors to determine the possible cause of the errors or whether any harm occured due to the errors.

4. The offsite surgery center had data collected on the number of short cycle sterilization performed, but did not analyze why these were utilized and met the criteria for using short cycle sterilization. There were just numbers documented.

5. Staff A verified that there was no analysis documented of the indicators being tracked.

Based on record review and interviews with hospital staff, the hospital did not ensure that the Quality Assurance Performance Improvement (QAPI) program evaluates the services provided by contract or arrangement. Governing Body, Medical Staff and QAPI meeting minutes did not have evidence of review of services provided by contract or arrangement. Staff A stated on 01/09/14 in the afternoon that these services had not been evaluated by the QAPI program.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a medical history and physical examination (H&P) was provided by a physician for four (#22, 23, 24 and #28) of four surgical patients reviewed.

Findings:

1. On 01/09/14, three clinical records for patients who had pain management surgical procedures were reviewed. All three records documented a CRNA performed a preoperative history and physical examination before the surgical procedure.

The medical staff by-laws did not allow for a CRNA to perform an history and physical examination.

When the CEO was made aware of the findings, she stated the hospital could provide an H&P done by a physician. A faxed copy of an examination by a physician was provided. It did not contain documentation the examination was done in preparation for surgery. This document was not a part of the original medical record provided for review.

2. The clinical record for patient #28 had no H&P examination included in the documentation provided to the surveyors.

Based on hospital document review and staff interview, it was determined the hospital failed to:
a. organize nursing services with a plan of administrative authority and clear delineation of responsibilities for patient care. See Tag A 0386;

b. ensure adequate numbers of registered nurses were present on each patient care unit for every shift. See Tag A 0393;

c. ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient and ensure adequate assessments were provided. See Tag A 0395;

d. ensure a registered nurse assigned care to other nursing personnel according to their qualifications and level of competence. See Tag A 0397;

e. ensure a physician ordered medications and failed to ensure medication orders contained all the required elements. See Tag A 0406; and

g. the hospital failed to develop and implement nursing job descriptions for all nursing positions in the hospital and failed to integrate the nursing service into the Quality Assessment Performance Improvement (QAPI) program.

Based on document review and staff interview, it was determined the hospital failed to develop and implement an organized plan of nursing administration with delineation of responsibility.

At the time of survey, the hospital did not have an organizational chart for nursing services. When the CNO was asked who was the director of the emergency department and surgical services, she stated she was.

The hospital provided surgical services in two locations remote from each other. The CNO was asked if there were charge nurses in place in the surgery departments. She stated there was a supervising circulating nurse at each location. She did not indicate these nurses were also in charge of the pre-operative and recovery areas.

None of the staff identified as supervising circulating nurses had documentation of this designation in their personnel files.

Clinic nursing staff at the off-site location were not included in the hospital's nursing services department.

Based on observation, clinical record review and staff interview, it was determined the hospital failed to ensure adequate numbers of registered nurses were present on each patient care unit for every shift.

1. On 01/07/14, during a tour of the inpatient unit, the staff was asked if a registered nurse was assigned to that unit. The staff stated the RN was not on the unit at the moment because she was also assigned to the emergency department.

While the surveyors were present, the RN spent considerable time in the emergency department caring for patients who were admitted there. The staff stated an RN was usually shared between the inpatient unit and the emergency department.

2. On 01/08/14, the CNO stated an LPN was usually assigned to the pre-operative area. There was no documentation in the clinical records that indicated an RN supervised and evaluated the care provided by the LPN in the pre-operative care area.

3. The staff stated an "urgent care" area was a part of the off-site hospital location. The public could walk-in for emergent care during hours of operation. The urgent care area was not staffed with an RN during hours of operation.

Based on medical record review, observation and staff interview, it was determined the hospital failed to ensure a registered nurse (RN) assessed, planned, supervised and evaluated the nursing care for each patient in 21 (#1-6, 9, 11-14, 18, 20, and 22-#29) of 28 patient records reviewed for nursing assessments.

Findings:

On interview with Staff D, on 1/07/14 in the morning, she stated registered nurses (RNs) were expected to perform an initial nursing assessment and daily assessments on each patient. Staff D verbalized there was no written policy to this effect, but staff understood this was expected.

Patients #3 and #12 were admitted through the emergency department (ED). The medical records did not contain documented evidence of an initial ED assessment completed by the RN.

Review of the medical records for Patients # 3, 4, 6, 9, 11, 12 and 20 did not contain documented evidence of an initial admission assessment by the RN.

Review of the medical records for Patients #1 through 6, 9, 11 through 14 and 20, did not contain documentation of a daily nursing assessment by the RN. This was confirmed by Staff D during chart review.

Patient #18 had an outpatient surgical procedure; review of the medical record did not contain documented evidence of a pre-operative nursing assessment by an RN.

Patients #22-#29 had missing or incomplete pre-operative nursing assessments. None of the records documented an RN assessed, supervised and evaluated the care of the patient.

For example, the clinical record for patient #25 had documentation of incomplete pre-operative nursing assessment. The assessment performed by an LPN omitted information about allergies, alcohol use, drug use and smoking. Home medications listed for the patient did not match the list of home medications documented by the CRNA at the time of the pre-surgical anesthesia evaluation. The form required a registered nurse to develop a care plan and a preliminary discharge plan. There was no documentation on this part of the form.

The clinical record for patient #27 did not document pre-operative information to include who performed the assessment, the reason for surgery, the results of the patient's prep, the time the patient came into the pre-operative area and the time out of the pre-operative area. Incomplete pre-operative vital signs were taken in the pre-op area. No temperature was recorded.

Some pre-operative assessments were completed by phone on an abbreviated form one to two weeks prior to the patient's surgery. No further assessment was done at the time of admission. The form was not signed by the person who completed it.

The clinical record for patient #25

The records for these same patients had minimal and incomplete assessments upon admission and discharge from the post-anesthesia care unit. Some surgical patients had no documentation of recovery nursing care at all.

The clinical record for patient #24 only had RN documentation on the discharge instructions. There was no other evidence in the record that an RN was involved in the patient's care.

Patients who had pain management procedures had no documentation by an RN during any part of the patients' pre, intra or post-operative time periods. Staff stated pain management patients were not handled the same as other surgical patients, because the staff did not consider them to be "real surgery patients."

Based on staff interviews, review of hospital documents, personnel files, and medical records the hospital failed to ensure nursing staff are adequately trained to provide care to meet the needs of the patients.

Findings:

On 01/08/14 in the morning, Staff H stated X-ray ' s and ultrasound services were provided at the off-site unit. Staff H stated that on the weekends Staff CC performed the X-ray procedures. Staff CC is a registered nurse that worked as needed in the pre-operative area at the off-site unit.

Staff H stated she provided the training to Staff CC on how to perform x-ray ' s, Staff H was asked if she had any documentation of the training provided to Staff CC, Staff H stated no.

On 01/07/14 in the morning, Staff D stated the hospital had an emergency delivery in the emergency department (ED). Staff D was asked if the hospital provided any obstetrics training to the nursing staff, she stated no.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a physician ordered medications and failed to ensure medication orders contained all the required elements.

Findings:

1. On 01/09/14, the clinical record for patient #25 was reviewed for physician's orders. The record documented a CRNA gave verbal orders for pain medications to be given during the recovery period. The order did not indicate how often or how many times the patient could receive the medications.

The CRNA who gave the verbal order for pain medications did not have prescriptive authority.

2. The clinical records for three pain management patients had no documentation a physician ordered the medications administered by the CRNA during the procedure. The clinical records contained no physician's orders of any kind.

3. The clinical records for patient #25, 26, 27 and #28 contained standing orders that did not indicate what the nurse should do. None of the choices given on the form were selected by the physician.

Based on observation and staff interview, it was determined the hospital failed to ensure access to medications were restricted to licensed personnel.

Findings:

On 01/08/14, during a tour of the outpatient surgery department, medications were found stored in a room with the door propped open. If the door was closed, it could not be locked. The staff confirmed any surgery department staff could access this area where medications were stored.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital has a system in place to identify outdated, mislabeled or unusable drugs in the hospital. The hospital did not have evidence of routine inspections of all medication storage areas in the hospital by pharmacy/drug room personnel to identify outdated, mislabeled or unusable drugs.

Findings:

1. Drug room staff did not have any documentation of routine floor stock medication storage area inspections.

2. Hospital Staff D and G stated on 01/08/13 in the afternoon that they did not document any hospital medication floor stock storage area inspections.

3. There was no documentation of inspections of medication storage areas located in an off campus outpatient surgery and urgent care center.

4. Outdated and unusable drugs were observed in the emergency room, operating suite and inpatient unit during the survey.

5. Intravenous (IV) fluids and irrigation solutions were found in warmers that were not dated as to when they were put in and when they were to expire. Temperatures in the warmers were not monitored and documented to ensure they did not exceed safe temperatures. Some of the bags and bottles were swollen, indicating they had been exposed to excessive temperatures or had been in the warmers too long.

6. Intravenous (IV) fluids and other sterile solutions were stored in cabinets with cleaning chemicals.

7. Review of the consultant pharmacist weekly reports did not have any evidence that the pharmacist conducts periodic routine inspections of drug storage areas in the hospital and the off campus outpatient surgery and urgent care.

Based on hospital document review, record review, and staff interview, the hospital failed to:

a. ensure radiology personnel requirements were met. See Tag A-0545;

b. ensure a radiologist supervised radiology services. See Tag A-0546; and

c. ensure radiology personnel were designated as qualified by the medical staff to use the radiological equipment and administer procedures. See Tag A-0547.

Based on policy and procedure review, staff interview, and review of personnel files, the facility failed to ensure personnel who provided radiology services were appropriately trained and competent to provide services to patients. This occurred in eight of eight (C, H, I, J, K, L, M and R) radiology employee files reviewed.

Findings:
Staff C, who was the radiology manager, was interviewed on the morning of 01/07/14.

Staff C stated she and Staff I performed the computerized axial tomography (CT) and the magnetic resonance imaging (MRI).

Staff C was asked who provided orientation and training to the radiology staff, Staff C stated she provided the training. There was no documentation in Staff C's personnel file documenting Staff C competencies or training for CT and MRI that had been reviewed and approved by the Radiologist and/or medical staff.

Review of the personnel file for Staff I, did not contain documentation of competencies or training for CT and MRI that had been reviewed and approved by the Radiologist and/or medical staff.

Review of the personnel files for Staff J, L and M did not contain documentation of competencies or training for CT that had been reviewed and approved by the Radiologist and/or medical staff.

Staff C stated ultrasound procedures are provided by Staff K. Staff K's personnel file did not contain documentation of competencies or training for ultrasound that had been reviewed and approved by the Radiologist and/or medical staff.

On the afternoon of 01/08/14, Staff D stated Staff R, who was the sterile technician, operated the C-Arm at the off-site outpatient surgery department.

Review of the personnel files for Staff R did not contain competencies or training that had been reviewed and approved by the Radiologist and/or medical staff.

In the morning of 01/08/14, Staff H stated X-ray's and ultrasound services were provided at the off-site outpatient department. Staff H stated she performed the ultrasounds and x-ray at the offsite unit during regular business hours.

Review of Staff H's personnel file did not contain competencies or training that had been reviewed and approved by the Radiologist and/or medical staff.

Staff H stated that on the weekends Staff CC, a registered nurse, performed the X-ray procedures.

Staff H stated she provided the training on how to perform x-ray ' s to Staff CC, Staff H was asked if she had any documentation of the training provided to Staff CC. Staff H stated no.

Based on record review and staff interview, the hospital failed to ensure the radiology department was supervised by a qualified radiologist approved by the medical staff.

Findings:
On the morning of 01/07/14 Staff C stated Staff BB, a family practice and emergency medicine physician, was the physician over the radiology department.

The hospital did not have documentation a qualified radiologist had been appointed to supervise the radiology department.

Staff C stated the hospital contracted with a radiology group who interpreted radiology studies.

Based on review of hospital documents, medical staff rules and regulations and personnel file review, the facility failed to have only qualified personnel designated by the radiologist in charge and/or the medical staff determine who can use radiology equipment and administer procedures. There was no evidence in personnel files the radiologist/medical staff had reviewed equipment, technique, shielding, and radiation safety requirements and determined staff qualified to operate specific equipment.

Based on observation, document review and staff interview, it was determined the hospital failed to ensure:

a. all equipment used in patient care areas was checked for safety before put into use and failed to ensure oxygen tanks were safely secured. The hospital failed to make necessary repairs to damaged walls, trims, floors and work surfaces. See Tag A-0701;

b. biohazardous waste was collected and stored appropriately. See Tag A-0713;

c. the hospital's surgical suite design was maintained to reflect Federal and State regulations and in a manner to provide a level of service according to national standards of practice and failed to provide post-anesthesia care in a location that met the requirements. The hospital also provided laundry services in an area that was not designed for this purpose. See Tag A-0722;

d. medical equipment was inspected, monitored and maintained as required within the biomedical program and failed to ensure equipment and supplies were stored in a safe manner. See Tag A-0724; and

e. the hospital failed to ensure sterile supplies were stored within acceptable ranges for temperature and humidity and that proper ventilation was maintained for clean and dirty areas. See Tag A-0726.

Based on observation and staff interview, it was determined the hospital failed to ensure all equipment used in patient care areas was checked for safety before put into use and failed to ensure oxygen tanks were safely secured. The hospital failed to make necessary repairs to damaged walls, trims, floors and work surfaces.

Findings:

1. On 01/07/14, a tour of the hospital was conducted. The surveyors observed multiple standing household fans in patient rooms and in other areas of the hospital. None of the fans had documentation they were checked for electrical safety before they were put into patient use.

2. Portable oxygen tanks were found unsecured in various areas. Large standing oxygen tanks were found unsecured in the oxygen storage room.

3. On 01/08/14, electrical dental equipment that was not hospital property was observed in use in the outpatient surgery department. The equipment had not been inspected by the hospital for safety prior to use on hospital patients.

4. Various walls in the hospital were chipped, gouged and had peeling of paint and/or sheetrock. Baseboards were found separated from the walls. Door frames, doors and other wood surfaces were chipped and scratched.

Areas around decontamination sinks and handwashing sinks were no longer intact and could not be disinfected.

Multiple areas of the physical facility in the main surgery department were in disrepair. There were holes in the OR walls and exposed sheetrock. Many surfaces were no longer intact and could not be disinfected.

A closet in one of the recovery rooms was made of unfinished plywood. Sterile medical supplies, IV fluids and patient linen was stored in this closet.

5. There were no safety electrical outlets found in the surgery decontamination room or the sterile processing room. A household powerstrip was found in the sterile processing room.

6. One side of the surgical scrub sink in the main OR had too little water pressure to be useful and it could not maintain control of water temperature.

Staff confirmed these findings during interview.

Based on observation, policy and procedure review and staff interview, it was determined the hospital failed to ensure biohazardous waste was collected and stored appropriately.

During tours of the hospital on 01/07/14 and 01/08/14, the surveyors observed there were no soiled utility areas identified as biohazard waste storage areas.

In the main hospital surgery department, a dirty biohazard material collection box was stored in the sterile corridor. A large, plastic sharps collection box was also stored there.

The staff stated the surgery department did not have an identified biohazard waste collection and storage area.

Based on observation, document review and staff interview, it was determined the hospital failed to:

a. maintain the hospital's surgical suite design to reflect Federal and State regulations and in a manner to provide a level of service according to national standards of practice;

b. provide post-anesthesia care in a location that met the requirements;

c. identify and appropriately utilize spaces in the off-site surgery location; and

d. the hospital failed to provide laundry services in an area designed for this purpose.

Findings:

1. On 01/07/14, hospital leadership was asked to provide a current floor plan. The surveyors were provided an undated "Fire Policy Floor Plan" that was not current and did not identify all rooms in the hospital.

Leadership was asked to provide original hospital and surgery department floor plans. None were provided. Staff stated parts of the current emergency department were originally part of the surgery department.

A tour of the main surgery department was conducted. The following observations were made:

~ The surgery department did not have a semi-restricted corridor. The only entrance to the department was directly into the sterile core from a public, unrestricted corridor shared with the emergency department.

~ The entrance and exit to the sterile processing area was a split, Dutch door. The door was located in the emergency department public hallway outside of the surgery department.

Surgery staff had to go in and out of the restricted surgical area to access the sterile processing area.

~ The surgery department did not have a staff dressing room, toilet, showers or lockers. The surgery staff obtained surgical attire from a remote, unrestricted staff office (former patient room) and then took them to another converted patient room that had been made into the "bone density examination room."

This room was used for outpatient exams and also for storage of a portable x-ray machine. The room did not have the features of a surgical staff support area, was not located within the surgery department and was not an area restricted to OR personnel.

~ The main surgery department did not have a semi-restricted area designated to unpack shipping boxes that contained sterile surgical supplies.

~ The main decontamination room shared air circulation with the sterile processing room. The decontamination room did not have the physical features required for this area, including separate instrument washing/rinsing sinks and staff handwashing sink, among others.

~ The main surgery department had no sterile surgical supply storage area that met requirements. Sterile surgical supplies were stored cramped in a small closet that had a window with an air-conditioning unit. This room was also used to store other equipment, linen and non-sterile supplies. The closet did not maintain the proper temperature, humidity and air circulation requirements for storage of sterile supplies.

~ The surgery department did not have an equipment storage/holding area. Some clean surgical equipment was stored in the janitor's closet with housekeeping supplies and the janitor's sink. Because the janitor's closet was full of other items, the mop bucket was stored in the sterile corridor.

~ The surgery staff used the surgical scrub sink as a utility sink, rather than utilize the janitor's closet as designed.

~ The main surgery department did not have clean and soiled utility rooms and did not have a biohazard waste collection and storage room.

~ The main surgery department did not have storage for non-sterile supplies.

~ The surgery administrative office was remotely located outside the surgery department in another area of the hospital.

2. During the tour, it was determined the hospital did not have a post-operative care area that was separate from the rest of the hospital.

The nursing staff stated patients were sometimes recovered in patient rooms. The staff identified two regular patient rooms within the med/surg unit used to recover patients. These rooms did not meet the requirements for a post-anesthesia care unit.

One room did not have suction available for patients. The other room had a portable suction machine that could be used on one patient, but the room was set up to receive two patients.

Portable oxygen was provided on the stretchers used to recover surgery patients but two of the tanks were empty. One bed did not have oxygen available.

The staff also said one of the examination/treatment rooms within the emergency department was the "recovery room." This room was not a separate area of the hospital and did not meet the requirements for post-anesthesia care area.

3. On 01/08/14, a tour of the off-site outpatient surgery department was conducted.

~ The restricted endoscopy suite contained rooms that were no longer used as designed and were used to store items for other departments, including medical records.

~ A patient holding room was used to store furniture and supplies for other areas of the outpatient facility.

~ The endoscopy janitor's closet was no longer used to service the endoscopy suite, but was used as a storage room for decorations, paint and other non-departmental items.

~ The surgery department at this location did not have a separate sterile surgical supply storage area within the the sterile core. Some sterile supplies were stored in a semi-restricted hallway outside the sterile core.

A large amount of the department's sterile supplies were stored in the sterile processing room that contained the steam sterilizer. Temperature and humidity could not be controlled in a manner required for the storage of sterile supplies.

Staff walked through the sterile processing area to obtain supplies.

4. At the off-site surgery location, a room was being used as an "urgent care" treatment site. The room contained sutures, intubation supplies and equipment, an electrocautery unit, dressings and supplies to administer IV fluids. The room did not meet the requirements for a hospital emergency room and was not considered a part of the hospital's emergency services.

5. During the initial tour of the main hospital, the surveyors observed a household (non-commercial) washer and dryer in a housekeeping closet. The washer and dryer had patient linen and gowns in them.

The staff stated the only items processed in the washer and dryer were housekeeping rags and mop heads. The washer and dryer did not have the capability to appropriately sanitize these items. In addition, the housekeeping closet did not meet the physical design requirements for a hospital laundry department.

Based on observation and staff interview, the hospital failed to inspect, monitor and maintain medical equipment as required within the biomedical program and failed to ensure equipment and supplies were stored in a safe manner.

Findings:

1. On the morning of 1/07/14 and the afternoon of 01/08/14, the surveyors toured the facility and observed the following medical equipment with expired inspections:

Defibrillator on the medical-surgical unit crash cart
Portable suction on the medical-surgical crash cart
Monitor in the emergency department (ED) room #1
ED patient scales
Monitor in ED room #2
Otoscope in ED room #2
Blanket warmer in ED room #3
Monitor in ED room #3

The blanket warmer in ED room #3 had a missing temperature dial. A digital thermometer was located inside the blanket warmer, the display screen was blank. On the afternoon of 01/08/14, Staff D stated the battery needed to be replaced.

2. Observations were made of sterile and non-sterile supplies stored together. Medical supplies were stored with cleaning chemicals. Equipment, medical supplies and linens were not protected from contamination.

Based on observation and staff interview, it was determined the hospital failed to ensure sterile supplies were stored within acceptable ranges for temperature and humidity and that proper ventilation was maintained for clean and dirty areas.

Findings:

On 01/07/14 and 01/08/14, tours were conducted of the hospital's surgical areas. The following observations were made:

1. In the main surgery department, sterile surgical supplies were stored in a small closet that contained a window air-conditioning unit. At the time of the survey, the room was excessively warm. Staff stated they had problems with air circulation and temperature control in this room.

2. At the outpatient surgery department, sterile surgical supplies and equipment were stored in the sterile processing room, exposing them to excessive temperatures and humidity from the steam sterilizer.

3. Observations were made of doors propped open to the soiled storage room and to the sterile processing room at the outpatient site, thus affecting the requirements for special ventilation and airflow in these areas.

Based on document review and staff interview, it was determined the hospital failed to ensure infection control policies and procedures were developed, approved and implemented for:

1. sanitizing hospital laundry
2. evaluation of the contracted linen service for appropriate infection control practices
3. clean and dirty storage of linens and patient gowns
4. cleaning/disinfecting clinical monitors, computers and other medical equipment shared between patients
5. clean storage of laryngoscope blades and oral airways
6. terminal cleaning of the sleep lab between patient uses
7. infection control practices specific to the sleep lab
8. endoscopy infection control practices
9. housekeeping requirements for the operating rooms and related areas
10. single use equipment and supplies
11. reprocessing single use equipment and supplies
12. storage of sterile supplies, drugs and biologicals
13. biohazardous waste collection, storage and disposal
14. terminal cleaning and periodic deep cleaning of the surgical departments and related areas
15. use of disinfectants specific to all areas of the hospital
16. comprehensive policies and procedures for instrument decontamination and sterile processing (the hospital had two policies dated 2000)
17. endoscope processing
18. documentation of sterilization and scope processing loads

On 01/09/14, the CNO stated the surveyors had been provided all the available hospital policies and procedures.

Based on observation, review of infection control data, surveillance activities, personal files, meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and maintained an ongoing comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

The hospital does not have an ongoing infection control/prevention (IC) program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained.

Findings:

Program:
1. The hospital IC program had not performed a hospital risk assessment to determine what organisms are most likely to occur in the hospital and what organisms are most likely to be present in the community.

2. The hospital IC program had not performed an annual tuberculosis (TB) risk assessment.

3. The hospital IC program had not developed a system to ensure appropriate infection control procedures were developed and followed in each department of the hospital.

4. The IC program did not develop measures to evaluate staff and volunteers exposed to patients with infections and communicable diseases.

5. The IC program did not include staff immunizations into the program. At the time of review on 01/07/14, eight of fourteen staff, whose personnel health files were reviewed, did not contain complete immunization records.

6. The IC program did not include details of how monitoring/surveillance would be conducted to ensure a safe and sanitary environment would be maintained according to accepted standards of practice, such as those established by CDC (Centers for Disease Control), OSHA (Occupational Safety and Health Administration), AORN (Association of peri-Operative Registered Nurses) and APIC (Association for Professionals in Infection Control and Epidemiology).

Disinfectants:
1. On tour of the hospital on the morning of 01/07/14, the surveyors observed four products available for use: PDI Sani-Cloth purple top wipes, 3-M Quat, Quat TB (TB Cide), and Virex TB.

2. The hospital's surgical services included endoscopy procedures. The most prevalent organism for colonoscopies is Clostridium difficile (C-diff of C-difficile). None of the hospital products identified during the tours on 01/07 and 08/13 are effective against C-diff.

3. Staff D, the staff identified as responsible for infection control, told the surveyors on 01/07/13 that she thought is the Quat TB was left on the surface for twenty (20) minutes it would kill C-diff. The surveyors reviewed the product with Staff D.

4. The operating room staff used a variety of disinfectants within the surgery departments. When staff was asked to explain the cleaning processes for the department, the staff stated one practice was to take non-concentrated TB Cide, dilute it with water, and use it for wetting cleaning rags and mops used to clean the OR. The staff stated spray TB Cide was used on other OR surfaces. The staff was not aware of the product requirements for saturation and contact times.

Surveillance/Monitoring:

1. At the time of entrance to the hospital, the surveyors requested infection control documentation, including "all surveillance/monitoring activities" for the past 12 months.

2. Review of infection control surveillance/monitoring data did not show the infection control monitored all departments and units to ensure compliance with established hospital policies and procedure and standards of practice to maintain a safe and sanitary environment, including, but not limited to:
a. Fit testing;
b. Isolation practices;
c. Disinfectant practices;
d. Instrument and equipment cleaning practices;
e. Sterilization practices;
f. Environmental process inspections.

3. Staff D told the surveyors on 01/07/13 that besides tracking infections, she only monitored hand washing. She stated that the operating room supervisor supplied autoclave tracking, but no monitoring of cleaning of instruments or the environment was performed.


Infection Control Practices

1. On 01/08/13, during a tour of the endoscopy procedure area, the surveyors observed (and staff confirmed through interview) that this area was not considered "surgery" and was not restricted as such. Staff were allowed to enter this area without surgical attire. The room had evidence it was not cleaned and maintained as a surgical area. Janitorial equipment used the clean this area was shared with main operating suite.

This area did not have evidence of terminal cleaning or periodic deep cleaning.

2. In the endoscopy procedure room, the surveyors observed a partially used bottle of normal saline and used suction tubing attached to the endoscopy equipment. The staff said this set-up was used to irrigate during endoscopy procedures. The staff verified this normal saline solution and the suction tubing was used on multiple patients.

Laundry Services:

The hospital did not ensure hospital linens and patient gowns processed on-site were adequately sanitized and did not ensure laundry items processed by the contracted service were adequately sanitized, packaged, delivered and stored.

1. On 01/07/14, during a tour of the hospital, a non-commercial (household) washer and dryer was observed in a small room that contained housekeeping supplies. On top of the washer and dryer was a gallon of household laundry detergent and a gallon of household bleach.

The staff stated only housekeeping rags and mopheads were processed in the washer and dryer. The surveyors observed the washer and dryer could not reach temperatures high enough to achieve sanitation of these items.

Inside the washer, the surveyors observed several wet patient gowns. Inside the dryer were patient bed linens from the sleep lab.

It was observed that the washing machine water temperature was set to "warm." The dryer was set at "regular." The hospital staff stated they were unsure about how hot the water got for the washer or how hot the drying cycle was for the dryer. No records of laundry water temperatures, wash cycles, disinfection or drying times were kept.

The hospital could not demonstrate or show documentation the linens/gowns were washed with an adequate combination of hot water, bleach and disinfecting laundry detergent to ensure they were sanitized.

2. Linens were not stored in a sanitary manner. The following observations were made on tours of the facility on 01/07/14 and 01/08/14:

a. An open package of pediatric gowns was stored on a dirty shelf in the housekeeping closet.
b. Linens and patient gowns were stored uncovered on open shelves in the clean linen closet.
c. Linens were stored uncovered and exposed to dust, dirt and other contaminants in the operating room.
d. Clean linens and patient gowns were stored with dirty linens in a soiled utility room in the outpatient surgery department.
e. Clean linens and patient gowns were received from the contracted linen service unwrapped and uncovered.
f. Linens were not stored in a clean and sanitary manner in the sleep lab, in the pre/post op patient rooms and in other patient care areas of the hospital.

3. The hospital had not performed an onsite evaluation of the contracted laundry service to ensure linens and patient gowns were handled, disinfected, packaged and delivered in a sanitary manner.

Clinical Environment:

The following observations were made during tours of the hospital on 01/07/14, 01/08/14 and 01/09/14:

1. A patient pillow was stored on a dirty shelf in the housekeeping closet.
2. Laryngoscope blades and oral airways found in the med/surg unit crash cart were not stored in a manner to protect from dust/dirt and other contaminants.
3. The med/surg unit kitchenette had dirty countertops and surfaces that were no longer intact and could not be cleaned/sanitized.
4. The sleep lab did not have evidence of periodic deep cleaning.
5. Clean and soiled utility areas were not clearly designated.
6. Monitors, IV pumps, computer terminals and other patient equipment in rooms and ready for use were dirty and had not been adequately cleaned between patient uses.
7. Sharps containers were full in patient rooms.
8. A guest chair in a patient room had a torn seat cover that exposed the foam padding. This prohibited adequate cleaning.
9. The rooms identified as pre/post op patient rooms had dirty bathroom floors and dirty shower stalls.
10. A soiled utility room door was propped open in one of the surgery departments.
11. Sterile supplies and IV contrast solutions were stored in their original shipping boxes.

Surgery and related areas:

1. Surgery scrub attire was not stored in a restricted area within the surgery department. The scrubs were stored outside the department in a converted patient room bathroom that also stored boxes and miscellaneous office supplies.
2. Non-intact surfaces were found throughout the surgery department. These surfaces could not be adequately disinfected.
3. The operating room had an open hole in the wall. There was a window air-conditioning unit in a sterile surgical supply closet.
4. Floor trim was missing in several areas so that the floor was no longer intact and could not be adequately disinfected.
5. Heavy accumulation of dust was found on the air exchange vent behind the anesthesia machine in the OR.
6. Sterile peel-packs and sterile instrument packs were stored in a small closet that was excessively warm and humid.
7. Sterile supplies were mixed with non-sterile supplies.
8. "Clean" OR equipment was stored in the surgery department janitor's closet.
9. Cleaning chemicals were stored on the surgical scrub sink. The scrub sink was also used as the department's utility sink.
10. A dirty, plastic biohazard box and another large contaminated sharps container was stored in the restricted surgery corridor.
11. One department decontamination room was open to the sterile processing room. The decontamination room had wood cabinetry that could not be disinfected. There was only one sink provided for instrument processing. There was no staff handwashing sink.
12. The sterile processing area had wood cabinetry that could not be disinfected.
13. Sinks and faucets had heavy accumulations of mineral deposits that affected adequate disinfection of those surfaces.
14. None of the above areas had evidence of terminal cleaning or periodic deep cleaning.
15. Corrugated shipping boxes containing sterile supplies were found stored within all areas, including the operating rooms.
16. Oxygen extension tubing was not changed between patients.
17. A velcro safety belt used on the OR table could not be cleaned between patients.

Based on review of hospital documents and meeting minutes concerning infection control, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through quality assessment and performance improvement (QAPI) committee and:

1. Were monitored throughout the hospital, reviewed and analyzed;

2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and

3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. Hospital meeting minutes for 2013 were reviewed. The meeting minutes provided to the surveyors during the on-site survey containing infection control data, QAPI, medical staff, and governing body, did not contain evidence/demonstrate the hospital leadership:
a. Reviewed and analyzed infection control data or lack thereof;
b. Ensured that all departments/units of the hospital were included and monitored through the infection control/prevention program;
c. Ensured infection control/prevention policies and procedures were developed, implemented and followed to ensure a safe and sanitary environment and that staff were inserviced on those policies;
d. Developed corrective plans of action to reduce and/or prevent transmission of organisms and improve patient care, ensure a safe and sanitary environment, and prevent or decrease infections and communicable diseases; and
e. Provide follow-up/monitoring to ensure corrective actions taken were effective and sustainable.

2. The same hospital minutes did not contain analysis of employee immunizations, illness and infections to ensure infections and diseases were not transmitted between patients and staff.

3. Meeting minutes did not contain evidence the hospital's leadership has ensured policies and procedure were developed for all areas of the hospital concerning current accepted standards of practice in infection control. The hospital provided on-site laundry services for patients receiving outpatient sleep lab. No policies had been developed to assure the service was performed according to regulatory requirements and current standards of practice.

4. The hospital offers surgical services, including surgical procedures at an off-site facility. The meeting minutes did not demonstrate the leadership of the hospital ensured surgical services were provided in a safe and sanitary environment according to current standards of practice. The infection control portion of the meeting minutes did not demonstrate issues observed by the surveyors were identified, analyzed and corrective actions taken with follow-up to ensure compliance.

5. The hospital's leadership did not ensure that corrective actions were implemented for concerns identified through infection control surveillance.

6. Meeting minutes did not reflect the hospital's leadership has provided oversite of the infection control program to ensure a safe environment. With the exception of hand hygiene, the meeting minutes did not reflect the hospital's leadership ensured surveillance/monitoring of all areas was performed to ensure current standards of practice in infection control were followed. This included, but not limited to:
a. Fit testing;
b. Isolation practices;
c. Disinfectant practices;
d. Instrument and equipment cleaning practices;
e. Sterilization practices;
f. Environmental process inspections.

Based on observation, document review and staff interview, it was determined the hospital failed to:

a. prohibit a certified registered nurse anesthetist (CRNA) from performing surgical procedures;

b. provide surgical outpatients with the same quality as surgical inpatients;

c. provide surgery and recovery care within a semi-restricted and restricted area of the hospital;

d. ensure adequate cleaning between surgical cases and ensure terminal and periodic deep cleaning of the operating rooms, procedure rooms and associated surgical areas;

e. ensure surgical staff had access to clean surgical attire;

f. include all surgical equipment in the hospital's biomedical program;

g. ensure sterilized materials were stored in a manner protected from dust and moisture and in a manner to guard against breach of the sterile packaging;

h. define a scope of surgical services and provide an organizational chart for all locations where surgery is provided. See Tag A-0941;

i. ensure on-site operating room supervision by an experienced RN. See Tag A-0942;

j. maintain a roster of clinicians with surgical privileges for all surgical locations. See Tag A-0945;

k. develop, approve and implement comprehensive surgical policies and procedures. See Tag A-0951;

l. ensure all required emergency equipment was available to the surgical areas. See Tag A-0956;

m. provide post-operative care according to accepted standards of practice. See Tag A-0957;

n. ensure the operating room register was complete. See Tag A-0958; and

o. the hospital failed to integrate inpatient and outpatient surgical services into the hospital's QAPI program.

Findings:

1. On 01/08/14, the OR staff and the administrative staff stated a CRNA performed pain management procedures in the hospital.
The procedures the CRNA performed involved injection of therapeutic substances into the joints and/or the central nervous system.

The clinical records for three (#22, 23, and #24) of three pain management patients reviewed had documentation the CRNA performed these procedures independently without physician involvement. There was no documentation the physician was present or available during the procedure for supervision.

Some clinical records for pain management patients documented the CRNA was identified as the "admitting physician." There was no documentation a physician examined the patient, determined a course of treatment and provided orders for it.

The medical staff rules and regulations did not allow for a CRNA to perform pain management surgical procedures.

2. Outpatient surgical services were not provided in a manner consistent with inpatient surgery. Not all outpatients were provided a complete nursing assessment pre-operatively. Some outpatients had no pre, intra or post-operative nursing care documentation. The outpatients were not provided the same level of recovery phase care as inpatients.

3. The surgery department had been modified from its' original design. The operating room for the main hospital was located directly off of a public hallway. There was no semi-restricted corridor outside of the surgery restricted corridor. The surgery department did not have all the required rooms and spaces.

The two identified "recovery areas" were not in semi-restricted and restricted areas of the hospital. One recovery area was in an emergency department treatment room and the other recovery area was located off of a public hallway in a regular patient room that did not meet the requirements for a post-anesthesia care unit.

4. The main operating room was not being used on the day of the tour. The staff stated the room was terminally cleaned and ready for the next day's cases. It was evident not all surfaces had been adequately cleaned. Air vents had heavy build-up of dust. The entire department was not regularly terminally cleaned. The department did not appear to have periodic deep cleaning.

The outpatient endoscopy suite was not terminally cleaned in an acceptable manner. Not all surfaces were cleaned. There was evidence of splashes and debris that had not been cleaned. This area did not appear to have periodic deep cleaning.

Both decontamination areas and sterile processing areas were not cleaned completely each day. There was evidence of mineral deposits and stains. Not all surfaces were disinfected. Items on countertops were not removed so that the counter under them could be cleaned. These areas did not have deep cleaning.

Neither of the "recovery areas" were cleaned according to surgical standards. These areas appeared to have the minimum housekeeping services. The restrooms did not appear clean.

5. The main surgery department did not have a staff dressing area. There was no surgical staff dressing area in the hospital. Scrub attire was not stored in an aseptic manner. It was stored in an office bathroom elsewhere in the hospital, along with general storage and miscellaneous items.

6. At the time of survey, dental equipment and dental radiology equipment was in use in the outpatient surgery department that had not been cleared through the hospital's biomedical program.

7. Sterile surgical supplies were stored in areas that were overcrowded and not adequately protected from high humidity, high temperatures, dust and other possible contaminants. Sterile surgical supplies were stored with cleaning chemicals. Sterile supplies were stored overly crowded and vulnerable to compromise of the packaging. Sterile supplies were stored with non-sterile supplies. Sterile supplies were stored outside the sterile core in a service hallway room. Sterile supplies were stored in the surgery department and in the operating rooms in their original shipping boxes. The hospital did not have a "first in - first out" policy and procedure for sterile supplies.

8. The hospital had documentation of data related to types of surgeries performed, but there was no meaningful QAPI activities documented related to surgical services.

Based on document review and staff interview, it was determined the hospital failed to document and approve by the medical staff, the scope of surgical services provided in every surgery location.

The hospital also failed to develop an organizational chart that documented an integrated surgery department and indicated lines of authority and delegation of responsibility.

The CNO verified these findings.

Based on observation, document review and staff interview, it was determined the hospital failed to ensure the surgery departments were supervised by an experienced registered nurse.

Findings:

1. The hospital had no organizational chart that documented lines of authority for surgical services. The CNO stated she was the director of surgery. She stated a registered nurse was assigned to supervise each of the two surgery departments in the hospital.

2. The hospital had no documentation of required qualifications for the director of surgery or surgery supervisors.

3. The hospital had no job description for the director of surgery or for surgery supervisors.

Based on document review and staff interview, it was determined the hospital failed to:

a. maintain a roster of practitioners with surgical privileges;

b. ensure the medical staff approved all non-hospital personnel who acted a surgical assistants or scrub techs;

c. ensure the medical staff and the governing body approved of a CRNA who performed pain management procedures in the operating room; and

d. the hospital failed to ensure CRNAs without prescriptive authority were supervised by the MD/DO surgeon.

Findings:

1. On 01/09/14, the hospital leadership stated they did not have a current roster of practitioners with surgical privileges for each location, and did not have a roster of practitioners with restricted, suspended or revoked surgical privileges.

2. Non-hospital dental assistants worked as surgical assistants and/or as scrub techs in the operating room. The hospital had no documentation the medical staff approved of this practice and specified what tasks and procedures these personnel could perform.

3. A CRNA performed pain management surgical procedures in the outpatient surgery department. There was no documentation the medical staff credentialed the CRNA to perform these procedures. There was no documentation the medical staff and governing body required direct supervision by an MD/DO of the CRNA who performed these procedures.

4. The medical staff and governing body did not ensure an MD/DO surgeon supervised and signed off on medications used by a CRNA who did not have prescriptive authority. Clinical records for patients who received anesthesia/analgesia care by this CRNA did not have documentation an MD/DO approved and signed off on the medications given to the patients.

Based on document review and staff interview, it was determined the hospital failed to ensure current policies, based on nationally recognized standards, were available to the surgical services department.

Findings:

On 01/08/14 and 01/09/14, the policies and procedures for surgical services were reviewed. The policies were not current and lacked documentation they were based on nationally recognized standards.

The surgical services department did not develop, approve and implement all the policies required by regulation such as:

infected versus non-infected cases
department-specific housekeeping requirements
pre-operative and post-operative care
procedure-specific policies and procedures and procedure protocols
duties for all personnel in the surgical areas
surgical counts
surgery scheduling
DNR status
handling of specimens
sterilization and disinfection practices
outpatient requirements
alcohol skin preps
patient position and padding

There were no policies specific to the care of pediatric patients.

The CNO stated work needed to be done on the policies.

Based on observation and interview, it was determined the hospital failed to ensure all required emergency equipment was available to the surgical areas.

Findings:

On 01/07/14, the emergency equipment for the main operating room was reviewed. The staff confirmed there was no defibrillator for the main OR. The staff stated they would use the defibrillator from the emergency department. The staff also confirmed the OR did not have an emergency tracheotomy set.

Based on document review, policy and procedure review and staff interview, it was determined the hospital failed to provide post-operative care according to accepted standards of practice.

Findings:

1. Observations were made of the areas the hospital identified as the "recovery" areas. Both areas identified in the main hospital did not meet the State requirements for post-anesthesia care units and were not separate areas of the hospital. One recovery room was actually an emergency department treatment room and the other recovery room was a regular patient room on the med/surg unit.

The outpatient surgery location identified two recovery areas. One area was identified as a "step-down" unit. This area did not meet the requirements for a post-anesthesia care unit, although it was set up with suction, oxygen and cardiac and oxygen saturation monitoring. The hospital did not have documentation the medical staff defined what clinical criteria met the definition of a "step-down" area.

2. The medical staff had not determined transfer requirements to and from the post-anesthesia care areas.

3. The CNO stated the hospital had no policies and procedures related to recovery room care. None of the 10 records reviewed for surgical procedures documented a head to toe nursing assessment performed upon admission to the recovery room.

4. Clinical records for patients who had pain management surgical procedures had no documentation of recovery care.

5. The recovery room documentation for patient #25 had no assessment of the patient's physical condition specific to the surgery performed. There was no assessment of related body systems. The recovery record did not address the presence or absence of pain or bleeding upon admission or discharge from recovery. The record did not document where the patient went when discharged and who accompanied the patient.

This patient was treated with IV pain medication but there was no documentation of the location of the pain and no description of the type of pain. There was no documentation of the patient's pain level after the medication was given.

When the patient was treated with oral pain medication 20 minutes later, there was again no documentation of an assessment of the patient's pain and the effectiveness of the pain medication.

The patient was discharged from recovery 20 minutes after the second pain medication was administered.

6. Patient #26, a pediatric patient less than 4 years of age, had inhalation anesthesia for a surgical procedure. The clinical record documented the patient had one set of vital signs in the recovery room. There was no documentation nursing assessment of pain, bleeding or assessment of the body system related to the surgery. The patient was discharged home 11 minutes after admission to recovery.

7. Patient #27 had a colonoscopy. There was no documentation of assessment of the patient's abdomen, ability to void, pass flatus, or presence or absence of bleeding. There was no documented pain assessment. The patient was discharged from recovery 22 minutes after admission to recovery. There was no documentation of a discharge assessment or documentation of the patient's ability to ambulate. There was no documentation of where the patient went upon discharge and with whom.

8. Patient #28, a geriatric patient, had an EGD with a biopsy. There was no nursing assessment of the patient documented in the recovery record. The patient was discharged 25 minutes after admission to recovery.

9. Patient #29, a geriatric patient, had an EGD and colonoscopy. There was no documented nursing assessment in the recovery record. The patient was discharged 25 minutes after admission to recovery.

Based on document review and staff interview, it was determined the hospital failed to ensure the operating room register was complete.

Findings:

The operating room register was reviewed on 01/08/14. The register did not document the age of the patient, did not identify scrub nurses or scrub techs by title, and did not document where the surgery was done (as the hospital had two locations where surgery was performed and all surgery patients were listed on one register.)

The register did not identify an MD/DO surgeon for the patients who received surgical pain management procedures. The register documented the CRNA who performed the procedure.

The CNO stated there was no policy and procedure to direct staff on the requirements for the operating room register.

Based on observation, document review and staff interview, it was determined the hospital failed to ensure:

a. a qualified physician was appointed as the director of anesthesia services. The hospital had no organizational chart for anesthesia services and the CEO stated no physician had been appointed as the director of anesthesia;

b. anesthesia services provided throughout the hospital were organized into one anesthesia service. There was no formal description of where and what type, of anesthesia services were provided in various areas of the hospital;

c. anesthesia services policies and procedures were developed and implemented to address the minimum qualifications and supervision requirements for each category of practitioner who was permitted to provide anesthesia, analgesia and moderate sedation;

d. a system and process was in place to evaluate adverse events, medication errors, and other quality indicators related to anesthesia;

e. CRNAs who provided general anesthesia, regional anesthesia, monitored anesthesia and deep sedation/analgesia were supervised by the operating practitioner or an anesthesiologist. See Tag A-1001;

f. comprehensive anesthesia policies and procedures were developed, approved and implemented. See Tag A-1102; and

g. the hospital failed to integrate anesthesia services into the QAPI program.

Based on document review and staff interview, it was determined the hospital failed to ensure CRNAs who provided general anesthesia, regional anesthesia, monitored anesthesia and deep sedation/analgesia were supervised by the operating practitioner or an anesthesiologist.

Findings:

On 01/09/14, the CEO stated the hospital had not established the requirement for supervision of CRNAs by the operating practitioners. She stated the hospital had no anesthesiologist on staff.

There were no hospital policies and procedures that required supervision of CRNAs.

In addition, clinical records documented that CRNAs without prescriptive authority were not signed off by the physician(anesthesia record signed by the supervising physician.)

Based on document review and staff interview, it was determined the hospital failed to develop, approve and implement anesthesia policies and procedures that:

1. delineated pre and post anesthesia responsibilities;
2. described how anesthesia needs within the hospital would be met;
3. instructed staff on requirements for informed consent for anesthesia. The hospital did not require and consistently execute informed consent for different types of anesthesia and analgesia;
4. outlined anesthesia infection control requirements;
5. identified what safety practices were required in all areas identified as anesthetizing locations;
6. documented emergency life support protocols;
7. detailed anesthesia reporting requirements;
8. detailed anesthesia documentation requirements; and
9. established equipment requirements and monitoring, inspection, testing and maintenance of anesthesia equipment.
10. emergency on-call roster and procedures

The anesthesia policies provided were related solely to the CRNAs and focused on code of ethics and general principles. The policies were not specific to the hospital's needs. There were no policies and procedures related to the physicians' role in the supervision of anesthesia services. There were no policies and procedures describing the circulator's role in assisting anesthesia providers and the recovery room nurse's role in collaboration with the anesthesia provider.

The CNO stated the anesthesia policies provided were the only ones available in the hospital.

Based on observation, clinical record review and staff interview, it was determined outpatient services were not provided in a manner consistent with in-patient services.

Findings:

1. Surgical outpatients were treated differently depending on the type of procedure performed. They were not consistently processed as surgical patients and did not receive nursing care consistent with other surgical patients. For example, patients who had pain management surgical procedures did not receive a pre-operative nursing assessment or documentation of pre-op care. There was no documentation of intra-operative nursing care, no documentation of recovery nursing care, and no documentation of an assessment by an RN at the time of discharge from outpatient surgery.

2. Endoscopy patients were not considered "surgery" patients. The pre and post operative care was provided in an abbreviated manner and documented differently compared to other surgical procedures. In addition, the endoscopy suite was not treated and maintained as an area where surgery was performed.

3. Emergency care and treatment ("urgent care") was provided in the off-site surgery location in a space that did not meet the requirements for an emergency room. This area was not included in the hospital's emergency services department and was not identified as an outpatient service.

4. All outpatient services were not included in the hospital's organizational chart and were not coordinated with the hospital's inpatient services. The hospital had not determined who would be responsible for outpatient services at all locations. See Tag A-1077.

5. The hospital did not verify that all staff providing outpatient services were trained and qualified to do so. See Tag A-1079.

6. Outpatient services were not integrated into the hospital's QAPI program.

Based on observation, record review and staff interview, it was determined the hospital did not integrate all outpatient services at all locations with hospital inpatient services.

On 01/08/14, a tour of the off-site outpatient location was conducted. Based on interview with staff, it was evident all services at this location were not integrated with the main hospital location.

For example, the surgical services provided here were not consistent with practices at the main hospital. The staff at the off-site location were not familiar with the hospital's policies and procedures.

The off-site location also had a space the staff called both a "procedure room" and an "urgent care room." The staff stated this room was used by the physician for a variety of reasons, including outpatient IV fluid administration, wound care, minor surgical procedures and emergency care.

The room was supplied with emergency equipment such as a crash cart, intubation supplies and a defibrillator. The room also had an electrocautery device for surgical procedures.

The room did not meet the requirements for an emergency room and did not meet the requirements for an operating room. The hospital staff stated this space was considered "part of the clinic."

Patients treated in this area were not admitted to the hospital as outpatients. Care provided in this space was only documented in the physician's office records. There were no hospital outpatient records found for patients treated in this room.

It was unclear what staff (other than the physician) provided care in this area. The staff roster documented "clinic" staff worked in the physician's office. It was undetermined whether the clinic staff were medical assistants, aides, LPNs or RNs.

This area and the activities conducted there were not intergrated into the hospital's surgical services, emergency services or outpatient services. The CEO stated the hospital had not determined the types and levels of services provided in this location and had not identified what department and manager it should be associated with.

The outpatient services provided in the off-site location were not identified on the hospital's organizational chart.

Based on review of hospital documents, review of personnel files and staff interviews, the hospital failed to have documentation showing all the personnel assigned to the Sleep Study Lab outpatient services were qualified and trained. The hospital did not ensure non-hospital personnel who worked in surgery were qualified and trained to do so.

Findings:

1. On the morning of 01/07/14, Staff B stated the facility sleep study lab services are provided by a hospital employee, Staff Q, in addition to a contract employee.

There was no evidence, in the personnel file, that Staff Q was oriented, trained and competent as a sleep lab technologist.

2. On 01/08/14, the surveyors were told non-hospital employees came to the hospital to work with the dentist in the operating room. The hospital had not verified the personnel were appropriately trained and qualified to work in surgery.

This was reviewed with administrative staff during the exit interview, no additional information was provided.

Based on observation, record review and staff interview, it was determined the hospital failed to meet the emergency needs of patients according to acceptable standards of practice.

Findings:

On 01/08/14, during a tour of the off-site surgery center (located approximately 35 minutes away from the hospital's main campus), the surveyors observed a space being utilized as an emergency room. The room contained an electrocautery unit, sutures, dressings, intubation equipment, a defibrillator and IV fluid administration supplies.

A staff physician stated the area was used as "urgent care" and that he had recently treated a patient in this area on an emergent basis. The patient stayed in this room for four hours while examination was done, lab tests were performed and IV fluids and medications were administered. He stated he was expected to care for emergent patients without all the necessary supplies, support and equipment.
He stated the main hospital was too far away (35 minutes) and he did not want to send patients to the local hospital that was five minutes away, so he often treated them there in the urgent care area.

This area was not considered a part of the hospital's emergency services. It was not overseen by the hospital's emergency department medical director.

It was not integrated with other hospital departments. It was not staffed with a registered nurse and was not included in the hospital's nursing services.

Staff stated the public often mistook it for an emergency room and "just showed up for emergency care." There was no clear designation to the public of the limitations of services provided there. The physician stated one patient was transferred from urgent care by a helicopter.

The hospital did not have records of these patients. The physician stated the only medical records for them was an "office chart."

There were no policies and procedures provided for this area. There was no documentation the medical staff were responsible for medical care provided in the urgent care area.

Based on staff interviews review of hospital documents and medical records, the hospital did not have adequately trained nursing personnel in the emergency department to meet the needs of the facility. This occurred in four of four (D, P, U and V) nursing staff personnel files reviewed.

Findings:

While the hospital did not have an obstetrical, labor and delivery unit, the hospital did provide emergency obstetrical deliveries in the emergency department.

On 01/07/14 in the morning, Staff D stated the hospital had an emergency delivery in the emergency department (ED). This was confirmed by record review. A patient presented on 08/20/13 in labor. The patient delivered a male infant while in the emergency department and then was transferred to another hospital that offered obstetrical services.

Review of the personnel files for Staff D, P, U, and V did not contain any obstetric competencies and training.

Staff D was asked if the hospital provided any obstetrics training to the nursing staff, she stated no.

Based on staff interview, medical record and document review, the hospital failed to notify patients of all rights related to swing bed status. This occurred in two of two (#10 and 20) swingbed medical records reviewed.

Findings:

Swingbed medical records were reviewed on 01/07/14 and 01/08/14.

Admission paperwork was provided to the surveyors by Staff A on the afternoon of 01/07/14.

The admission paperwork included a Patient Registration form, Conditions of Admission-Bristow Medical Center and Notice of Privacy Practices. The information provided did not contain all the swingbed patient rights components as required.

Staff A was asked if any additional forms are given to the patients upon inpatient and swingbed admission, Staff A stated she was not aware of any additional paperwork.

Review of the medical records for Patient #10 and 20 did not contain documentation patients were informed of their rights related to swing bed services.

Based on personnel record review and staff interview, the hospital failed to ensure individuals who had been convicted of abusing, neglecting, or mistreating individuals in a health care setting were not employed. This occurred in six of ten (C, I, J, L, N, and O) employee personnel files reviewed

Findings:

Review of the personnel files for Staff C, I, J, L, N and O did not contain evidence of a criminal background checks and state nurse aide registry checks.

On 1/07/14 in the afternoon, during review of Staff C's personnel file, Staff DD was asked if the hospital had completed a criminal background check, Staff DD stated no.