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Based on record review and interviews with hospital staff, the governing body failed to ensure quality of care and hospital operations are conducted in a safe manner and environment.

Findings:

1. Based on document review and staff interviews, the governing body failed to ensure all hospital services furnished were assessed, analyzed, and improved through QAPI (Quality Assessment Performance Improvement). See Tag A 0083.

2. Based on document review and staff interviews, the governing body failed to ensure that every contract service was provided effectively and evaluated. The governing body failed to ensure that personnel providing services by contract were oriented to the hospital. This occurred in four (Staff F,G, V and W) of four contract staff and two of two (Staff CC and DD) credentialed dental staff personnel files reviewed. See Tag A 0084.

3. Based on document review and staff interviews, the hospital failed to ensure that there was a complete list of all contracted services. See Tag A 0085.

4. Based on document review and staff interviews, the hospital failed to ensure emergency services were under the direction of a qualified member of the medical staff. See Tag A 0091.

5. Based on observation and staff interview, it was determined the hospital failed to:

a. ensure the condition of the hospital was maintained for the safety and well-being of patients. See Tag A-0701;

b. ensure proper storage and disposal of biohazardous waste. See Tag A-0713;

c. to maintain a biohazard waste collection and storage room in the hospital's surgical department (OR) to reflect Federal and State regulations. See Tag A 0722;

d. the hospital failed to provide services in operating rooms with adequate humidity control. See Tag A 0726.

Based on document review and staff interviews, the governing body failed to ensure all hospital services furnished were assessed, analyzed, and improved through QAPI (Quality Assessment Performance Improvement).

Findings:
1. There was no documented evidence that the Governing Body, Medical and Administrative Staff were aware of the surgery department's humidity levels, which were outside of federal and state guidelines.

2. On the afternoon of 10/13/14, surveyors requested the surgery department temperature and humidity log. The director of surgical services provided surveyors with a document titled, "Temperature and Humidity Log."

3. The Temperature and Humidity Log documented, "...Report to DSS (director of surgical services) or DPS (director of plant services) if outside perimeters."

4. There was no documentation provided to surveyors that the temperature/humidity levels were reported to the DSS/DPS.

5. The surgery department Temperature and Humidity Log had several documented entries ranging from 18-69 percent humidity on the Temperature and Humidity log.

6. On the afternoon of 10/13/14, surveyors asked administrative staff to provide documentation for maintenance records. None were provided.

7. On the afternoon of 10/13/14, surveyors asked the director of surgical services why the surgery department was so humid and warm.

~The director of surgical services said that the hospital follows the humidity range of 20-60 percent.
~ On the afternoon of 10/14/14, the director of surgical services told surveyors that she was unaware of following more stringent guidelines set by the State (humidity guideline ranges between 30-60 percent).

8. On the morning of 10/14/14, surveyors requested documentation for pest control services. None was provided.

9. On the morning of 10/14/14, surveyors requested documentation for medical record audits/reviews. None was provided.

10. On the morning of 10/13/14, Staff A informed surveyors that UR has not been done since staff A was employed (August 2014) at the hospital.

11. On the morning of 10/13/14, surveyors requested documentation for Utilization Review (UR). An organizational chart was provided. There was no documentation that UR existed.

12. On the afternoon of 10/13/14, administrative staff verified that there was not UR listed on the organization chart.

13. On the afternoon of 10/13/14, surveyors reviewed QAPI, Medical Staff and Governing Body meeting minutes. All hospital services were not assessed, reviewed, analyzed.

Based on document review and staff interviews, the governing body failed to ensure that every contract service was provided effectively and evaluated. The governing body failed to ensure that personnel providing services by contract were oriented to the hospital. This occurred in four (Staff F,G, V and W) of four contract staff and two of two (Staff CC and DD) credentialed dental staff personnel files reviewed.

Findings:

1. Both Governing Body and Medical Staff meeting minutes did not contain documented evidence that all services provided were being evaluated through QAPI (Quality Assessment Performance Improvement).
2. On the morning of 10/14/14, administrative staff told surveyors, "There were multiple issues with the facility and having difficulties getting the problems fixed by the building owners."
3. On the morning of 10/14/14, surveyors reviewed the incident reports where there was a report of a non-operable elevator. There was no other documented evidence about the elevator, if and when it was repaired and safe for patient and employee use.
4. On the morning of 10/14/14, administrative staff confirmed that the elevator was non-operable and did not receive any documentation stating it was fixed and safe for patient and employee usage.
5. On the morning of 10/13/14, surveyors requested Governing Body and Medical Staff meeting minutes from 2013 through current. Administrative staff provided Governing Body and Medical Staff meeting minutes. There was no documented evidence about a non-operable elevator.
6. On the morning of 10/13/14, surveyors requested a list of all contracted services. Administrative staff provided surveyors with a contract list that did not contain all services.
7. On the afternoon of 10/13/14, surveyors asked for documented evidence of contract service evaluations. None was provided.
8. Review of the personnel files for Staff F, G, V, W, CC and DD did not contain documented evidence of hospital orientation.

9. The above information was presented to the administrative staff during the exit conference on the afternoon of 10/14/14. No additional information was provided.

Based on document review and staff interviews, the hospital failed to ensure that there was a complete list of all contracted services.

Findings:

1. On the morning of 10/13/14, surveyors requested a list of all contracted services including the scope and services provided. Administrative staff provided the surveyors with a list that was incomplete and did not contain all contracted services.

2. On the afternoon of 10/14/14, administrative staff told surveyors that the list of contracted services was incomplete and missing some services such as contracted physicians and pest control.

Based on document review and staff interviews, the hospital failed to ensure emergency services were under the direction of a qualified member of the medical staff.

Findings:

1. On the morning of 10/13/14, surveyors reviewed Governing Body meeting minutes, Medical Staff meeting minutes, and the hospital organizational chart. There was no documented evidence that the hospital appointed a qualified member of the medical staff to be responsible as medical director of the emergency department.

2. On the morning of 10/14/14, surveyors reviewed 9 (Q, R, T, Y, AA, BB, EE, FF, and GG) of 9 physician credentialing files. None of the physician files reviewed contained documented evidence that a physician was appointed as medical director over the emergency department.

3. On the afternoon of 10/14/14, staff U verified that none of the credentialing files contained documentation of an appointed medical director over the emergency department.

4. On the afternoon of 10/14/14, administrative staff verified that there was not documented evidence of a physician appointed over the emergency department.

Based on review of patient rights' handouts, policies and signage, and interviews with hospital staff, the hospital failed to ensure patients and patient representatives were informed of:

a. The correct person at the hospital with whom to file a grievance;

b. The correct address for lodging a grievance with the State.

Findings:

1. The hospital's posted patient rights' notice and the patient rights' policy did not have the current hospital staff listed for patients and patient representatives to file a grievance.

2. Upon arrival, the surveyors requested a copy of the handouts given to patients. The patient rights' portion containing information about grievances did not have the correct State agency, address and telephone number listed for patients and patient representatives to lodge a grievance with the State.

3. The original patient rights' policy, provided to the surveyors, did not contain the correct State agency, address and telephone number or the current hospital staff listed for patients and patient representatives to lodge a grievance.

4. These findings were reviewed with hospital staff during the exit conference on 10/14/14.

Based on document review and staff interviews, the governing body does not ensure the hospital had an ongoing Quality Assurance Performance Improvement (QAPI ) program that reflects the complexity of the hospital's organization and services and involves all hospital departments including contracted or shared services.

Findings:

1. The hospital documents presented as part of the QAPI program did not have indicators for high risk and complex services such as surgical services and was missing second quarter infection prevention.

2. There was no evidence that all contract or shared services were evaluated by the QAPI program.

3. On the morning of 10/14/14, administrative staff verified that contracted services were not evaluated as part of an ongoing hospital wide QAPI program.

Based on document review and staff interviews, the medical staff failed to conduct periodic appraisals for each practitioner.

Findings:
1. On the afternoon of 10/14/14, the credentialing specialist verified that there were no appraisals and no peer reviews in all 14 credentialing files.

2. On the morning of 10/14/14, surveyors reviewed 14 (Staff Q through T and X through GG) of 14 credentialed files. None of the credential files reviewed contained documented evidence of appraisals and peer reviews.

Based on document review and staff interviews the hospital failed to ensure that there was a single individual to lead the medical staff and be responsible for the organization and conduct of the medical staff.

Findings:

1. On the morning of 10/13/14, surveyors requested Governing Body and Medical Staff meeting minutes. Administrative staff provided Governing Body and Medical Staff meeting minutes.
~The meeting minutes for both Governing Body and Medical Staff did not contain documentation of an appointed chief of staff.
~The meeting minutes for both Governing Body and Medical Staff did not contain documented evidence delineating lines of authority over each department.

2. On the afternoon of 10/13/14, administrative staff told surveyors that staff Q was the chief of staff.

3. On the morning of 10/14/14, surveyors reviewed staff Q's credentialing file. Staff Q's credentialing file did not contain documented evidence of being appointed as chief of staff.

4. On the afternoon of 10/14/14, the credentialing specialist verified that staff Q's credentialing file did not contain evidence of being appointed chief of staff.

5. On the afternoon of 10/14/14, the credentialing specialist verified that none of the credentialing files contained documented evidence of any physician appointed to any department in the hospital.

6. On the morning of 10/14/14, surveyors reviewed 14 (Staff Q through T and X through GG) of 14 credentialed files, none contained documented evidence of peer reviews.

7. On the afternoon of 10/14/14, the credentialing specialist verified that there were no peer reviews in all 14 credentialing files.

Based on document review and staff interviews, the hospital failed to ensure that all duties and privileges of staff were well defined.

Findings:

1. On the morning of 10/13/14, surveyors requested Governing Body and Medical Staff Bylaws. Adminstrative staff provided both Governing Body and Medical Staff Bylaws. Neither set of Bylaws contained the duties and scope of privileges for a registered nurse first assistant (RNFA).

2. On the afternoon of 10/14/14, surveyors reviewed personnel files. One (Staff K and X) of two personnel files did not contain the scope of privileges for a RNFA.

3. On the afternoon of 10/14/14, the credentialing specialist verified there was no documented evidence containing the scope of privileges for Staff K.

Based on interviews with hospital staff and review of personnel, education and training files, the hospital failed to ensure nursing staff are adequately trained and have demonstrated skills competency for their assigned care areas. Review of three of six nursing staff (K, O and C) who provided care in specialty areas and whose personnel files were reviewed did not have current job specific competencies, training and education.

Findings:

Staff K worked as a Registered Nurse First Assist (RNFA). Review of the personnel and training files for Staff K did not contain documentation competencies were verified by the medical staff.

The surveyors were told Staff O was the nurse responsible for the drug room. Review of the personnel and training files for Staff O did not contain evidence of orientation and competencies for the position/responsibility were verified by the pharmacist.

Staff C is designated as the Infection Control Nurse (ICN). Review of the personnel and training files for Staff C did not contain evidence of infection control training or education.

The above information was confirmed by Staff B on the afternoon of 10/14/14.

Based on review of hospital policies and interviews with hospital staff, the hospital failed to develop, maintain and enforce a system to take appropriate action when notified that blood or blood components it received may be at increased risk of transmitting HIV (human immunodeficiency virus), HCV (hepatitis C virus) or new blood safety issues related to infectious blood and blood products.

Findings:

Upon arrival, the surveyors requested table of contents for hospital policies and procedures. The information provided did not contain documentation that the hospital had a policy and procedure for infectious/contaminated blood products, including procedure to follow if the hospital was notified contaminated products had been administered.

On 10/13/14, hospital staff told the surveyors that the hospital did administer blood products to patients. The surveyors requested if the hospital had a policy and procedure/protocol for staff to follow if infectious blood products were administered to patients, and if so, to review this policy and procedure. None was provided.

On the afternoon of 10/14/14, Staff B stated that the hospital did not have a policy and procedure/protocol for infectious/contaminated blood products.

This was reviewed during the exit conference on the afternoon of 10/14/14. No additional information was provided.

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

a. ensure the condition of the hospital was maintained for the safety and well-being of patients. See Tag A-0701;

b. ensure proper storage and disposal of biohazardous waste. See Tag A-0713;

c. to maintain a biohazard waste collection and storage room in the hospital's surgical department (OR) to reflect Federal and State regulations. See Tag A 0722;

d. the hospital failed to provide services in operating rooms with adequate humidity control. See Tag A 0726.

Based on surveyors' observations and interviews with hospital staff, the hospital failed to ensure the surgical environment was maintained to assure a sanitary environment and the safety and well-being of patients.

Findings:

A tour of the surgical department (OR) was conducted on the morning of 10/13/14.

The janitor's closet was not utilized for it's intended purposes. The janitor's closet is used to drain the Neptune Waste Management System.

A corrugated box was observed on a cabinet in the anesthesia workroom..

A 10cc syringe labeled Lidocaine 1% and another 10cc syringe labeled Marcaine 0.5% each contained clear fluid were left on a cabinet in OR #1.

The above information was confirmed by Staff D during the tour.

Based on observation and staff interview, it was determined the hospital failed to store trash and biohazardous waste generated in the surgical department (OR) as required.

Findings:

A tour of the OR, with Staff D, was conducted on the morning of 10/13/14.

Biohazard waste was stored in the decontamination room.

A housekeeping cart and a large gray trash (greater than 32 gallons) receptacle was stored in an alcove in the semi-restricted area of the OR.

The above information was verified by Staff D during the tour.

Based on observation and staff interview, it was determined the hospital failed to maintain a biohazard waste collection and storage room in the hospital's surgical department (OR) to reflect Federal and State regulations. This was confirmed by Staff D on the morning of 10/13/14, during the tour of the OR.

Based on observation, record review and staff interview, it was determined the hospital failed to ensure proper humidity control in the surgery department (OR).

Findings:

1. The humidity logs from January through September 2014, for OR #1 and #2, were requested and reviewed on the afternoon of 10/13/14. Normal humidity ranges for the OR is 30-60%.

a. Review of the logs documented for the months of January through March 2014 the humidity in both OR's were consistently below the minimum requirement.

Examples include, but not limited to:
January 2014 both OR's were below the minimum required range nineteen of twenty-one documented days.

February 2014 both OR's were below the minimum required range sixteen of twenty documented days.

b. Review of the logs documented for the months of May through September 2014 the humidity in both OR's were consistently above the maximum requirement.

Examples include, but not limited to:
May 2014 OR #1 was above the maximum required range thirteen of twenty-one documented days. OR #2 was above the maximum required range ten of the twenty-one documented days.

July 2014 OR #1 was above the maximum required range eleven of seventeen documented days. OR # 2 was above the maximum required range thirteen of seventeen documented days.

2. The only action documented by the hospital to correct the humidity issues was "dehumidification". There was no evidence the hospital notified the building supervisor the humidity was outside of the required parameter.

3. The above information was presented to the administrative staff during the exit conference on the afternoon of 10/13/14.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure the staff identified as the infection control preventionist/nurse (ICP or ICN) had training in establishing and maintaining an effective ongoing infection control program based on current principals and methods of infection control.

Findings:

1. Administrative staff identified Staff C as the infection control nurse.

2. Review of Staff C's personnel file did not contain evidence she had received training in establishing and maintaining an effective ongoing infection control program based on current principals and methods of infection control.

3. This was reviewed with Staff B on 10/13/14. She stated that the former ICP had provided some training for Staff C and they were going to send Staff C to training. The surveyor asked if there was any information to verify this. No additional information was provided.

Based on surveyors' observations, review of hospital documents and meeting minutes and interviews with hospital staff, the hospital failed to ensure the infection control practitioner/nurse (ICP or ICN) 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.

Findings:

1. Administrative staff told the surveyors that infection control activities and reviews were contained in the Committee of the Whole (COW) meetings.

2. COW meeting minutes for December 2013 through September 2014 were reviewed.

3. The meeting minutes did not contain evidence staff (employee, contract, volunteer and credentialed) immunizations records were reviewed as part of the infection control program.

The hospital had appropriate policies for employee immunizations. Eight (Staff H, I, J, K, V, W, CC and DD) of twenty-four personnel files reviewed did not contain all the hospital required immunizations.
a. Staff CC and DD only had documentation that titers were done, but no results were documented or provided.
b. Staff J, V, and W did not have evidence of current influenza immunizations or documentation of refusals.
c. Staff I, a new hire, did not have evidence of two-step tuberculin skin testing as required.
d. Staff J and K did not have evidence of immunity to measles, mumps and rubella.
e. Staff H and J did not have evidence of immunity to varicella.

4. Meeting minutes did not reflect, other than recording the number of surgical site infections, patient and staff infections and illnesses (employee health) were reviewed to ensure organisms were not transmitted between patients and staff.

5. Meeting minutes contain documentation of hand hygiene and disinfectant application, but did not contain analysis and plans of action to improve compliance or follow-up for the plans of action.

6. Surveillance did not include monitoring of other departments for compliance with infection control practices, including observations of surgical and central sterile area and monitoring of the areas for sanitary conditions.
a. No evidence was presented and meeting minutes did not reflect monitoring of surgical and central sterile processes were observed.
b. No evidence the ICP monitored the surgical environment. See Tags A-700, A-701, A-713, A-722 and A-726 for surveyor observations.