HospitalInspections.org

Based on review of personnel files, policy and procedures, meeting minutes the hospital failed to appoint a Chief Executive Officer who is responsible for the management of the entire hospital.

Findings:

1. On 10/26/2010 surveyors Staff O told surveyors the Chief Executive Officer was employed through a contract between the hospital and Cornerstone Management.

2. On 10/27/2010 surveyors were provided the Chief Executive Officer's (CEO) personnel file. The CEO's file did not have a job description for the Chief Executive Officer position. The CEO's personnel file did not include any documentation stipulating job responsibilities for the CEO position. The personnel record did not include any general orientation and training to the facility. A document in the personnel file labeled "application" indicated the position applied for was "contract management". There was no documentation in the personnel file or the Cornerstone management contract indicating the CEO was responsible for the management of the hospital.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure contract personnel are oriented, trained and evaluated specific to the facility.

Findings:

1. On 10/26/2010 surveyors requested contract personnel files (C,L,M,N,O,Q,R,S,T,Y,Z,AA) . Eleven(C,L,M,N,O,R,S,T,Y,AA) of thirteen contract personnel files did not contain facility specific orientation, training, and evaluation. On the morning of 10/27/2010 Staff O confirmed the above findings .

2. These findings were reviewed with administration during the exit interview on 10/27/2010. No further documentation was provided.

Based on review of patient information handouts, patient rights forms and grievance policies, surveyor observation and interviews with hospital staff, the hospital failed to develop a process to notify patients/patients' representatives that they have the right for referral to the Quality Improvement Organization (QIO - Oklahoma Foundation for Medical Quality) for concerns of care or early discharge. Two of two patient medical records (Records #7 and 9) reviewed of patients with Medicare coverage, did not contain evidence the hospital had informed the Medicare patients that they had a right to ask for a referral to the QIO if they felt they were being discharged early or had concerns about their care.

Findings:

1. Patient information handouts and forms found on the medical records did not provide notification to the patient/patient's representative that they could ask for a QIO review if they had concerns regarding quality of care provided or premature discharge. This was confirmed with Staff B and J at the time of review of medical records for Patients #7 and 9 on the afternoon of 10/26/2010.

2. Hospital policies did not address that patients/patients' representatives were provided information that they could ask for a QIO review if they had concerns regarding quality of care provided or premature discharge.

3. On the afternoon of 10/27/2010, Staff B and O confirmed this information was not provided to patients.

Based on review of medical records, policy and interviews with staff the hospital did not ensure that only authorized personnel accepted verbal orders per hospital policy.

Findings:

1. On the morning of 10/26/2010 surveyors reviewed the policy "Verbal Orders". The policy stipulates: "2. Clinical staff authorized to receive telephone and verbal orders are: registered nurse, registered pharmacist".

2. On 10/26/2010 surveyors reviewed medical record for pt #19. Patient #19's chart stipulated on 9/13/2010 at 1755 "DC IV per Dr. Soo's phone order". The order was written and signed by Staff AA. Documentation in Staff AA's personnel file indicated they were a Master's of Business Administration (MBA). There was no documentation Staff AA was a registered nurse or a registered pharmacist.

3. This finding was reviewed with administration during the exit conference. No further documentation was provided.

Based review of medical records, hospital policy, and emergency room log the facility failed to maintain emergency room records in their original and legal form.

Findings:

1. On 10/26/2010 surveyors requested the emergency room records for eight patients. Three of eight (#14,15,16) patient records could not be located. On 10/27/2010 Staff O told surveyors the patient records could not be located in the facility.

2. On 10/27/2010 these findings were confirmed with administration. No further documentation was provided.

Based on review of medical records and hospital documents, the hospital failed to ensure medical records entries are, signed, dated and timed promptly by the prescribing physician or practitioner. This occurred in six of fourteen (#1, 2, 3, 4,20, and 26) medical records reviewed.

Findings:

For Records #1,2,3,4,20, and 26 the verbal orders were not dated, timed, and/or authenticated promptly by the ordering physician or practitioner.

a. Record #1 - Verbal orders on 08/04/10 at 1340 were not dated, or timed by the physician, and on 08/05/10 at 2020 were not signed dated, or timed by the practitioner.
b. Record #2 - Verbal orders on 08/23/10 at 1525 and 08/24/10 at 0720 were not signed, dated, or timed by the physician and practitioner.
c. Record #3 - Verbal orders on 08/26/10 at 1400 were not signed, dated, or timed by the physician.
d. Record #4 - Verbal orders on 09/08/10 at 1140 were not signed, dated, or timed by the physician.
e. Record #20 - Two verbal orders on 10/11/10 were not dated, or timed by the physician, and on 10/13/10 at 1438, one verbal order was not signed dated, or timed by the physician.
f. Record #26 - Five verbal orders on 09/21 & 9/22/10 were not dated, or timed by the physician.

Based on record review and interviews with hospital staff, the hospital does not ensure that medications are documented accurately and in accordance with physicians' orders. Seven ( #'s 6, 19, 20, 21, 22, 26 and 27 ) of sixteen patients with orders for prophylactic intravenous ( IV ) antibiotics had the antibiotics documented in the record as given two times when the order was for the antibiotic to be given one time.

Findings:

1. Physician's orders for prophylactic antibiotics to be given preoperatively were documented as "hung" by nursing on the preop nursing note. These were initialed by the nurse and a time written down.

2. There was documentation in the intraoperative operating room ( OR ) note by the anesthetist that the prophylactic antibiotic ordered to be given preoperatively by the physician and already documented by nursing as "hung" was administered in the perioperative surgical period. These also documented a time given.

3. Hospital staff stated on 10/26/10 in the afternoon that they were told to document when they prepared the antibiotic, but that antibiotic wasn't given until the patient was in the OR. The documentation was unclear as to what time the antibiotic was actually administered to the patient.

Based on record review and interviews with hospital staff the hospital does not ensure that all drugs and biologicals are controlled and distributed in accordance with applicable standards to provide patient safety. One ( # 19 ) of one patient was administered an investigational drug and the hospital does not have a written process for the use of investigational drugs that reviews, approves, supervises and monitors investigational drugs.

Findings:

1. Review of Patient # 19's record stated that they were performing a lumbar intradiscal injection of an investigational medication.

2. The hospital policies and procedures stated that the hospital would not be involved with research or experimental treatments. The policy also stated if the hospital wishes to conduct research or experimental treatments then it would have to be approved by the Governing Board and if approved, the Board would have to define the parameters for the research or experimental treatments.

3. The hospital does not have written policies defining the procedures and protocols to be followed when using an investigational medicatiion.

4. Hospital staff verified during the exit conference that there were no written policies or protocols for the investigational drug used on Patient #19.

Based on review of hospital documents, review of personnel and interviews with the administration, the hospital failed to have documentation showing all the personnel operating the diagnostic x-ray equipment are qualified and trained.

Findings:

1. On the morning of 10/26/2010 surveyors requested radiology policy and procedure manuals and radiology personnel files. Contract personnel (Staff L,R, Y) files did not indicate personnel providing radiology services for the hospital had been oriented or trained in the facility. There was no documentation the medical staff or the radiologist had developed, reviewed, and approved criteria designating personnel competent to perform radiologic procedures. On the afternoon of 10/27/2010, Staff O confirmed this finding.

2. On 10/27/2010 these findings were presented to administration in the exit conference. No further documentation was provided.

Based on review of policy and procedure, medical records, and interviews with staff, the hospital failed to maintain records for all radiology procedures performed.

Findings:

1. On 10/26/2010 surveyors requested radiology policies. According to Staff O, radiology services are provided under contract. None (zero of two) of the radiology policies stipulated how radiology films would be stored and retrieved. None of the policies (zero of two) stipulated storage and retrieval of fluoroscopy films. This was verified with Staff O 10/27/2010.

2. On 10/27/2010 this finding was reviewed with administrations. No further documentation was provided.

Based on interviews with hospital staff and review of documents, the hospital failed to ensure that menus meet the needs of the patients.

Findings:

1. On the morning of 10/26/2010, surveyors were provided with dietary policies, inservices, and menus. The menus listed as "low calorie, low sodium, regular, pureed" all stipulated the same items for each menu category. The menus did not have modifications for the items in each category. The menus did not contain portioning of serving sizes to establish if they meet nutritional needs of patients or to provide serving sizes for the dispensing of foods on the menus to patients.
2. During the tour of the nourishment/kitchen, on the afternoon of 10/26/2010, Staff G told surveyors all of the frozen meals utilized to feed patients were low calorie and low salt so they did not have to modify them for the patients. Staff G also told the surveyor she did not portion out any of the frozen entrees. Surveyors asked to see the frozen entrees listed on the menu. Documentation on the frozen entree labeled "Marie Callender's Meat Loaf and Gravy and Healthy Choice Beef Pot Roast" did not indicate the serving sizes or nutrient facts were the same. There was no documentation either entree was low sodium. Serving portions for each meal did not provide the same amount of calories, protein, fat, or carbohydrates. Staff B told the surveyor they had not been trained in the modification of the frozen entree to meet special menus
3. Dietary policies and procedures provided to surveyors on 10/26/2010 did not indicate how modifications were to be made to the food served in the facility to accomodate special diets.
4. Dietary inservices provided to the surveyors on 10/26/2010 did not indicate staff had any training on portioning of the food served in the facility.
5. This finding was reviewed with administration in the exit interview and no further documentation was provided.