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Based on Quality Assessment Performance Improvement (QAPI) review, Governing Body meeting minutes review, and medical staff meeting minutes review, the hospital failed to ensure contracted services were provided to comply with all Medicare Conditions of Participation.

Findings:

1. On the morning of 09/22/2014, surveyors requested a list of all contracted services. Staff A told surveyors that some services were provided under contract. No list of contracted services was provided.

2. On the morning of 09/22/2014, surveyors requested and reviewed QAPI meeting minutes, Governing Body meeting minutes, and Medical Staff meeting minutes. There was no documentation that contracted services had been evaluated.

3. Surveyors requested a list of all contracted services multiple times throughout the survey. No list of contracted services was provided.

Based on Quality Assessment Performance Improvement (QAPI) review, Governing Body meeting minutes review, and medical staff meeting minutes review, the hospital failed to ensure all contracted services were provided in a safe and effective manner.

Findings:

1. On the morning of 09/22/2014, surveyors requested a list of all contracted services. Staff A told surveyors that some services were provided under contract. No list of contracted services was provided.

2. On the morning of 09/22/2014, surveyors requested and reviewed QAPI meeting minutes, Governing Body meeting minutes, and Medical Staff meeting minutes. There was no documentation that contracted services had been evaluated.

3. Surveyors requested a list of all contracted services multiple times throughout the survey. No list of contracted services was provided.

Based on hospital document review and staff interview, the hospital failed to maintain a list of contracted services provided to include nature and scope of services provided.

Findings:

1. On the morning of 09/22/2014, Staff A told surveyors that some services are provided under contract. Surveyors requested a list of all contracted services. No list of contracted services was provided.

2. Surveyors requested a list of all contracted services mulitple times throughout the survey. No list of contracted services was provided.

Based on policy and procedure review, hospital handouts, and staff interview, the hospital failed to inform each patient or patient's representative with a phone number and address to file a grievance with the State Agency.

Findings:

1. On the morning of 09/22/2014, surveyors requested and reviewed a patient admission packet to include notice of patient's rights, and the hospital grievance policy and procedure.

2. Surveyors reviewed a hospital handout that is given to patient's and/or patient's representatives upon admission, titled, "Notice of Privacy Practices." The "Notice of Privacy Practices," documented, "...you also have the right to file a complaint if you think your privacy rights have been violated. To file a complaint you may contact the ODMHSAS Inspector General/Consumer Advocate; the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights; or the State Attorney General..."

3. The "Notice of Privacy Practices" did not contain information to file a grievance with the State Agency or contact information for the State Agency.

4. A hospital policy, titled, "Clients' Grievance," documented, "...Clients have the right to appeal to the Consumer Advocacy Division of the Department of Mental Health and Substance Abuse Services..."
The hospital policy did not contain information to file a grievance with the State Agency or the contact information for the State Agency.

Based on policy and procedure review and interview, the hospital failed to have mechanisms in place to ensure all patients were free from abuse or harassment.
Findings:
1. On the morning of 09/22/2014, surveyors requested the abuse policy. No abuse policy was provided.
2. On the afternoon of 09/23/2014, surveyors requested the abuse policy. A policy, titled, "Employee Code of Ethics"was provided. The policy did not address all of the CMS (Center for Medicare and Medicaid Services) requirements for abuse. A policy, titled, "DMHSAS Investigations - Employees' Responsibilities and Rights" was provided. The policy did not address all of the CMS requirements for abuse.
3. Staff A told surveyors that the policies provided were the policies used by the hospital.

Based on personnel file review and interview, the hospital failed to ensure the patient has the right to safe implementation of restraints and/or seclusion by trained staff. This occurred in 11 of 11 personnel files reviewed.
Findings:
1. On the morning of 09/22/2014, Staff D told surveyors that the hospital had soft wrist restraints available for use. Staff D told surveyors that chemical restraints were used at the hospital. Staff D told surveyors that there is no documented staff training on chemical restraints, soft wrist restraints or seclusion.
2. On the morning of 09/22/2014, Staff D told surveyors that seclusion is used on occasion.
3. On the afternoon of 09/23/2014, surveyors reviewed 11 personnel files. There was no documentation of any restraint and or seclusion training.
4. On the afternoon of 09/23/2014, Staff B told surveyors that the direct patient care staff had been trained on restraints. Staff B told surveyors the training was not documented.

Based on personnel file review and staff interview, the hospital failed:
a. to ensure direct patient care staff were deemed competent in the application of restraints, and the implementation of seclusion to include patient assessment and monitoring.
b. to ensure staff were deemed competent upon initial orientation and periodically.

This occurred in 11 of 11 personnel files reviewed.

Findings:

1. On the morning of 09/22/2014, Staff D told surveyors the hospital had soft wrist restraints available for patient use. Staff D told surveyors that chemical restraints and seclusion were occasionally used on the patients.

2. On the afternoon of 09/23/2014, surveyors reviewed 11 personnel files. None of the personnel files reviewed contained restraint and seclusion competencies. Staff D told surveyors there is no documented competencies for the direct patient care staff.

Based on policy and procedure review, observation, and staff interview, the hospital failed to ensure outdated, mislabled, or otherwise unusable drugs and biologicals were not available for patient use.

Findings:

1. On the morning of 09/23/2014, surveyors toured the medication room.

2. Staff D told surveyors that the pharmacist checks medications once per week

3. Surveyors observed a refrigerator in the medication room. There was 5 vials of insulin that were open. None of the vials of insulin contained a date, time or initials of the person who opened them.

4. Staff D told surveyors that the nurses were to date vials of medication on the date they are opened with a 28 day expiration date.

A hospital policy, titled, "Liquids and Injectables - Date & Initial Upon Opening," documented, "...upon opening of liquid and injectables, the bottle or vial will contain a label with the date when opened and initials of person opening container." The policy also documented "the liquid and injectable medication, after being opened for 28 days, will then be discarded."

Based on hospital document review and staff interview, the hospital failed to ensure a current therapeutic dietary manual was readily available and approved by the dietician.
Findings:
1. On the morning of 09/22/14, surveyors requested a current dietary manual. A 2006 dietary manual was provided. The most current therapeutic dietary manual is the 2012 edition.
2. Administrative staff verified at the time of review that the 2006 dietary manual was the only dietary manual that was used.

Based on hospital document review, observation, and staff interview, the hospital failed to have a preventative maintenance program in place to ensure medical supplies and equipment were maintained and safe for use.
Findings:
1. On the morning of 09/22/2014, surveyors requested preventative maintenance logs and preventative maintenance policies and procedures. No preventative maintenance logs were provided.
2. On the morning of 09/23/2014, surveyors toured the hospital. Surveyors observed medical equipment such as a portable oxygen concentrator, an automated external defibrillator (AED), and a portable data scope (device used to obtain vital signs). All equipment was available for patient use. There was no evidence that any of the medical equipment had been inspected, tested, and maintained to ensure safe patient care.
3. Staff D told surveyors that the equipment had not been checked on a routine basis by maintenance or a biomedical company. Staff A told surveyors that some of the equipment is new.
4. A hospital policy, titled, "Preventative Maintenance," documented, "...specific equipment is checked on a scheduled basis in accordance with the maintenance department and nursing service with appropriate records kept on each piece of equipment..." The policy also documented, "...preventative maintenance monitoring is conducted monthly on designated equipment and reports are submitted to the safety office, nursing coordinator, and or maintenance..."
5. A hospital document, titled, "NCBH Infection Control Housekeeping Department," documented, "...There will be an effective preventive maintenance program on all equipment with proper documentation..."

Based on infection control meeting minutes review, infection control surveillance, infection control policy and procedures, observation, and staff interview, the hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings:

1. On the morning of 09/22/2014, surveyors asked for and reviewed, infection control policies and procedures, and infection control meeting minutes.

2. There was no documentation that all chemicals and disinfectants used at the hospital had been reviewed and approved by the infection control officer, infection control committee, and medical staff. Staff B told surveyors that she had not reviewed and approved all chemicals and disinfectants used at the hospital.

3. There was no documentation of any environmental rounds and surveillance to include, dietary, laundry, laboratory, and all departments in the hospital.

4. There was no documentation of a hospital Tuberculosis Risk Assessment. Staff B told surveyors that she had not conducted a Tuberculosis Risk Assessment for the hospital.

5. There was no documentation that employee illnesses were reviewed and tracked. Staff B told surveyors that she had not reviewed or tracked employee illnesses.

Observations:

1. On the morning of 09/23/2014, surveyors toured the hospital.

2. Surveyors observed a room that contained a desk and a datascope for taking vital signs. Staff D told surveyors the room was used for taking patient's vital signs. There was no sink for handwashing. There was an empty hand sanitizer container on the wall. Staff D told surveyors that the hand sanitizer remains empty for patient safety and the nurses carry their own hand sanitizer in their pockets.

Staff D told surveyors that the nurses clean the datascope between each patient use with sani-wipes. There were no sani-wipes in the room.

3. Surveyors observed the medication room. The room was cluttered and unkept. The counter tops were cluttered with books, binders, storage bins and various other items.

Surveyors observed the narcotic cabinet. Narcotics were stored in regular prescription bottles. Staff D told surveyors that the nurses count the narcotics with every shift change (three times per day). Staff D told surveyors that the nurses empty all the pills on a tray and hand count the pills.

Surveyors observed a refrigerator in the medication room. The refrigerator contained vials of insulin stored with gatorade, ensure, and pitchers of water.

Surveyors observed 5 vials of insulin that were not dated, timed and initialed that were being used for patient use.

4. Surveyors observed a room that staff called "clean laundry room." The room contained uncovered linens, corrugated boxes, and Christmas decorations. Staff D told surveyors that sometimes the linens stored there were used for patient use.

The "clean laundry room" contained multiple wheelchairs, and a cot. Surveyors asked Staff D how would staff know if the equipment was clean. Staff D told surveyors that the equipment was to be cleaned before placed in room.

5. Surveyors observed a storage room that contained clean and sterile items. The clean and sterile items were stored next to corrugated boxes.

6. Surveyors observed a laundry room. Staff D told surveyors that the laundry room was for the patient's personal laundry. The laundry room contained 2 household washers and 2 houshold dryers (non-commercial grade).

Staff D told surveyors that all the patient's personal laundry is laundered with other patient's personal laundry. Staff D told surveyors that each patient had their own laundry bag but all laundry was washed together.

There was no clear separation of dirty and clean linen.

There were clean clothes folded and placed uncovered on the counter in the laundry room. There were cabinets in the laundry room that contained patient's snacks.
There was a microwave and a coffee pot on the counter in the laundry room.

There was no policy and procedure for staff guidance on water temperature and laundry detergent and disinfectant use.

Based on infection control meeting minutes review, governing body meeting minutes review, staff interview, and personnel file review, the hospital failed to designate in writing an infection control officer who was qualified through education, training, experience, or certification in infection control practices.

Findings:

1. On the morning of 09/22/2014, Staff D told surveyors that Staff B was the designated infection control officer.

2. On the morning of 09/22/2014, surveyors reviewed infection control meeting minutes, and governing body meeting minutes. There was no documentation that Staff B had been designated in writing as the infection control officer.

3. On the afternoon of 09/23/2014, surveyors reviewed the personnel file of Staff B. There was no documentation of any infection control training or experience. Staff B told surveyors that she had not had infection control training.

Based on infection control meeting minutes review, infection control policy and procedures review, and staff interview, the hospital failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings:

1. On the morning of 09/22/2014, surveyors asked for and reviewed, infection control policies and procedures, and infection control meeting minutes.

2. There was no documentation that all chemicals and disinfectants used at the hospital had been reviewed and approved by the infection control officer, infection control committee, and medical staff. Staff B told surveyors that she had not reviewed and approved all chemicals and disinfectants used at the hospital.

3. There was no documentation of any environmental rounds and surveillance to include, dietary, laundry, laboratory, and all departments in the hospital.

4. There was no documentation of a hospital Tuberculosis Risk Assessment. Staff B told surveyors that she had not conducted a Tuberculosis Risk Assessment for the hospital.

5. There was no documentation that employee illnesses were reviewed and tracked. Staff B told surveyors that she had not reviewed or tracked employee illnesses.

Based on facility document review, policy and procedure review, staff interview, and personnel file review, the hospital failed to:

a. ensure organ, tissue, and eye procurement requirements were met.
b. ensure policies and procedures were in place for organ, tissue, and eye procurement.
c. notify the OPO (Organ Procurement Organization) of patient's death.
d. ensure staff were educated and trained regarding organ procurement requirements.

This occurred in 1 of 1 patient death record reviewed, and 11 of 11 personnel files reviewed.

Findings:

1. On the morning of 09/22/2014, surveyors requested an organ procurement agreement and organ procurement policies and procedures. No policies and procedures were provided.

2. An agreement with Life Share documented, "...All patient deaths will be referred to LifeShare within one hour of cardiac death..."

3. On the morning of 09/23/2014, surveyors reviewed one of one death record (patient #1) there was no documentation that Life Share was notified of patient death.

4. On the morning of 09/22/2014, Staff D told surveyors that the facility had not notified Life Share within one hour of any patient death.

5. On the afternoon of 09/23/2014, surveyors reviewed 11 personnel files. There was no documentation of any Life Share education and/or training.

Based on policy and procedure review, facility document review, and staff interview, the hospital failed to:

a. provide respiratory care services in accordance with CMS guidelines.
b. ensure the scope of respiratory services were defined in writing and approved by the medical staff.
c. ensure a qualified doctor of medicine or osteopathy had been appointed as the respiratory care director.

Findings:

1. On the morning of 09/22/2014, Staff A told surveyors the hospital does not have a respiratory department.

2. On the afternoon of 09/22/2014, Staff D told surveyors that nebulizer breathing treatments were administered to some patients. Staff D told surveyors that the patients administered their own nebulizer breathing treatments but the nurse opened the medication.

3. On the afternoon of 09/22/2014, Staff D told surveyors that the nursing staff are not trained in administering nebulizer breathing treatments. A policy, titled, "Respiratory Care and Equipment," documented, "...yearly in-service training will be provided to stay current with Respiratory Care and Equipment."

4. The facility had a policy in place titled, "Respiratory Care and Equipment" that provided guidance for the use of Oxygen, an E-Cylinder, CPAP/BIPAP (Continous Positive Airway Pressure/Bilevel Positive Airway Pressure), and nebulizer (breathing treatments).

5. There was no documentation in medical staff meeting minutes that a physician had been appointed as the respiratory care director.