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Based on review of the infection control documents, hospital meeting minutes, and policies and procedures, and interviews with staff, the hospital failed to develop an active ongoing infection control program that reviewed and evaluated practices in the hospital, with corrective actions and follow-up taken when needed, to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

Findings:

1. Although the meeting minutes contained a section for central sterile/surgical services. No problems were reviewed, analyzed with corrective actions taken to ensure a sanitary and safe environment with follow-up to ensure the corrective actions were effective.
a. On 04/05/2012, Staff H autoclaved full tonsil and adenoid and myringotomy trays on a shortened cycle with no dry time as the first load of the day. This was confirmed by review of the "flash" log and sterilizer tape. On the morning of 10/03/2012, Staff H confirmed she "flashed" both the instrument trays and the dart test as the first load of the day. Infection control meeting minutes did not reflect this had been reviewed and analyzed.
b. On 10/03/2012 Staff B told the surveyor bleach products were only used in the scope procedure room if they were aware the patient had clostridium difficile (C-diff). No review had been performed to determine if dormant cases of C-diff would be effected by the colonoscopy prep to make them a potential hazard.
c. Surgery staff has been having problems with the autoclave - aborted cycles, unexpected shutdown of the autoclave and power outages - these problems have not been reported and followed in infection control.
d. Review of the sterilizer tape and "flash" log did not contain identification
e. No monitoring of the disinfectants to ensure they were applied according to manufacture directions has occurred.

2. The infection control program has not reviewed the hospital's disinfectants to ensure they are effective against the organisms prevalent at the hospital. This was confirmed with Staff B on 10/03/2012.

3. Meeting minutes did not consistently show issues/items identified in infection control were analyzed with corrective actions and follow-up to ensure corrective actions taken were effective.
a. Handwashing - although monthly/quarterly data was provided, if a corrective action was documented, it was to continue to monitor and inservice. Minutes did not reflect analysis of the actions, whether they were effective and/or if any other corrective actions were needed.
b. Attachments showed hospital infections, some were identified as community acquired; others contained no identification as to whether they were community or hospital acquired. Meeting minutes did not demonstrate review and analysis to determine if any hospital practices needed changed.
c. Meeting minutes contained documentation of staff injuries and exposures, but did not demonstrate review to ensure policies and procedures for follow-up care or review and analysis to identify whether corrective actions or policy and procedures changed needed to occur.
d. Meeting minutes identified the hospital had patients requiring isolation. Meeting minutes and documents supplied did not contain evidence of monitoring to ensure isolation policies were followed and all individuals who entered the room wore appropriate isolation equipment. The meeting minutes did not demonstrate review or analysis to determine if any corrective actions or changes in procedures needed to occur.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the nutritional needs of patients were met in accordance with recognized dietary practices. Findings:

1.5 or 5 clinical records (reviewed for nutritional assessment completion) did not have documentation the nursing staff, nutritional services personnel , and/or the consultant dietitian reviewed the patients' record to determine the patient required further nutritional care.

2. The patients' nutritional screen did not match the diagnosis, complaints, and co-morbidities listed in the history and physical examination by the physician. There was no documentation the dietitian assessed the patients' conditions and reviewed the medical record to insure accuracy of the forms completed by dietary staff.

3. Several of the nutritional assessments completed by dietary staff did not match the patient's condition documented by the physician. Many of the medical records indicated on the history and physical the patients were admitted with , diabetes, anorexia nervosa or comorbidities that included dehydration, nausea, vomiting, fluid volume deficit and anemia. None of these nutritional conditions were addressed by the dietitian or dietary staff.
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4. Review of personnel files for Staff W the licensed/registered dietitian did not include Staff W had been oriented, trained and evaluated by the facility. There was no documentation Staff N the dietary supervisor had been oriented and trained to be the dietary supervisor. The only documentation in Staff N files was a job description/evaluation for Dietary Aide. Staff N told surveyors in an interview on 10/03/12 she was made the dietary supervisor in July 2012. Staff N also told surveyors she had recently enrolled in a certified dietary manager position (CDM)

5. Surveyors reviewed quality and infection control meeting minutes 2012. There was no documentation the facility included clinical nutrition services in quality meetings. There was no documentation food services was included in quality or infection control activities.

6. The above findings were reviewed with administration at the exit conference. No further documentation was provided.

Based on policy and procedure manual review and interview with the hospital staff, the hospital failed to ensure policies are reviewed at least annually.

Findings:


1. On the morning of 10/3/2012 Radiology policy and procedure was reviewed. None of the policies were current. The last updated policies were 2007. There was no evidence the hospital had reviewed, approved, and implemented radiology policy and procedure annually. The hospital also provides magnetic resonance imaging (MRI) services. There were no policies reviewed, approved and implemented through medical staff for MRI.

2. On the morning of 10;/2/2012 Dietary department policies were provided to surveyors. The policies provided to not reflect current practice. The last update of policies was 2003. There was no policy provided stipulating nutritional assessment and nutritional screen. Review of the policies did not follow current Center for Disease Control (CDC) hand hygiene guidelines. The hand hygiene policy also did not include all required elements for Food Service Establishments. There was no documentation sanitizers and disinfectants had been reviewed and approved through the hospital infection control committee. There was no documentation the policy and procedure manual had been reviewed and approved through Medical Staff and Governing Body.

3. On the morning of 10/2/12 surveyors requested physical therapy policies and procedures. The manual had a review date of 2011. The policies did not match the current practices documented by therapy. There was no documentation the policies had been reviewed and approved by a physical therapist and approved through medical staff and governance.

4. These findings were presented at the exit conference. No further documentation was provided.

Based on review of hospital documents, review of personnel files and interviews with the radiology department manager, the hospital failed to have documentation showing all the personnel operating the diagnostic radiology equipment are qualified and trained, and the radiology department has oversight by the Radiologist, Medical Staff, and Governing Body.

Findings:

1. In an interview on the afternoon of 10/2/2012 Staff B told surveyors radiology services were provided by hospital employees and contract magnetic resonance imaging (MRI) personnel.

There was no documentation the personnel providing the services were oriented, trained, and deemed competent by the supervising radiologist and/or medical staff.

2. Policies and procedures written and reviewed had a date of approval 2007. There was no documentation the policies had been reviewed and approved through the radiologist and medical staff.

3. Radiology personnel records did not include competencies reviewed and approved through the radiologist and medical staff. There was no documentation of radiation safety inservices.

4. The above findings were reviewed with administration at the exit conference. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital failed to ensure that a list of all services provided through arrangements, contracts or agreements is maintained describing the nature and scope of the services provided.

Findings:

1. Magnetic Resonance Imaging services provided by arrangement or contract was not listed on the contracted service list with the nature and scope of service provided.

2. Consultant dietitian services provided from another hospital by arrangement was not included on the contracted service list with the nature and scope of service provided.

3. Hospital staff verified on 03/03/12 in the afternoon that all contracted or services provided by arrangement were not included on the list provided.

Based on review of policies and procedures and medical records, and interviews with hospital staff, the hospital failed to ensure medical records contain pertinent orders, information and reports. Documentation pertinent to the continued care of the patient was missing or not completed.

Findings:

1. Four of four emergency room patients (Patients #2, 4, 5, and 6) who had intravenous feeding (IVs), the nurse did not document the amount IV fluid infused.
a. Patient #4 - Nursing notes documented the patient already had an IV established at the time of arrival. The notes did not state what fluid was infusing or amount remaining at the time of arrival. The physician ordered normal saline 1000 milliliters to run at 100 milliliters an hour. Notes did not document if the nurse changed the solution or at the time of discharge how much IV fluid had infused.
b. Patients #2 and #6 - The patients were transferred to another acute care hospitals with IVs infusing. Nursing notes did not record the amount of IV fluid had infused at the time of transfer.
c. Patient #5 - Nursing noted did not record the amount of IV fluid infused at the time the IV was discontinued.

2. Patient #9 - The patient had a colonoscopy and esophagastroduodenoscopy (EGD). The record did not include:
a. Orders for the EGD
b. Discharge instructions for be followed for the EGD
c. IV infusion documentation for:
i. Amount of fluid hung
ii. Amount of fluid infused in each area - pre-operative, intra-operative and post-operative
iii. Documentation if post-operative amount of 800 milliliters infused at the time of discharge was just for post-operative or for the entire visit.

3. Patients # 13, 14, 17 and 23 had admission diagnosis or operative procedures that would required dietary monitoring (evaluation and/or consult). The medical records did not contain nutritions assessments/evaluations by dietary staff or dietary consults by the dietitian.

4. Five of five medical records reviewed for nutritional screen and/or assessment did not include all the required documentation. Three of five nutritional screens were not completed. Two of five nutritional screens were completed but did not include documentation the nutritional screen score was acted upon.

5. Five of five medical records (27, 28, 29, 30, 31) reviewed for completion of graphics for intake and output did not include documentation for every day of the patient's stay.

6. Two of two patients (20,30) reviewed for diabetic/insulin flowsheet did not have flowsheets completed with actions required when finger stick blood sugars are out of range. There was no documented actions as indicated on the sheet for blood sugars higher than 300 mg/dl.

7. Skin assessments were not accurately reported on a daily basis. Patient # 30's initial nursing assessment indicated the patient had sores on buttocks on admission. Review of documentation did not indicate any breakdown on the next two days of stay.

8. Patient #27 was transferred to swingbed. The physical therapy evaluation did not indicate the patient's progression since admission. The evaluation was documented on a copied progress note with documentation stating "pt (patient) moved to sb (swingbed), PT eval (evaluation) essentially the same with the exception of gait". The documentation did not reflect the facility policy. There were no goals for treatment during the swingbed stay.

9. The above information was reviewed with administration at the time of the exit conference. No further documentation was provided.

Based on observation, staff interviews, and a review of policies and procedures, the hospital failed to ensure that surgical procedures are performed in a safe manner.

Findings:

1. There was no physician designated as the chief of surgery or designated as the chief of anesthesia. The peri-operative staff stated they had no physician resource for the department.

2. There were no pediatric policies and procedures for the peri-operative areas.

3. There were no policies and procedures specific to emergencies within the peri-operative areas such as power failure, equipment failure, evacuation, and resuscitation. Sterilizer tape review for April through September 2012 showed this has occurred.

4. There were no policies and procedures to guide care and services provided to patients during the pre-operative period. There was no consistent documentation of a pre-operative checklist to ensure all safety, surgical preparation and legal consent procedures were performed prior to surgical procedures. There were no policies and procedures to guide nursing documentation for the pre-operative period.

There were no policies that defined informed consent and guidance for staff for obtaining informed consent prior to surgery. There were no policies for standing orders.

A review of clinical records for those patients who had a procedure indicated there was no clear, designated pre-operative period.

5. The intra-operative policies and procedures did not document what surgical procedures were performed by the surgical department. The intra-operative policies and procedures did not include procedure-specific guidance to staff including, equipment, instruments and supplies needed, patient positioning, special safety requirements, skin preparation, etc.

There were no policies and procedures to guide nursing documentation during the intra-operative period.

6. The central sterile processing policies and procedures did not include guidance on how to use the sterilizers, explanations of what each cycle did and how and when they should be used, how the sterilizers should be routinely cleaned and maintained, and what to do for sterilizer failure or malfunction.

A review of the sterilizer tape for the past six months indicated there were unplanned shut-downs and cycle failures. There was no documentation of what actions were taken in response to these events.

The staff were unable to determine what loads matched the times on the sterilizer tapes. On 10/03/2012, Staff H stated the sterilizer did not document the correct time of each load. She stated that problem had not been resolved.

There was no documentation of routine testing of the sterilizers prior to the first use each day and there were no policies and procedures to guide staff on biological testing.

There were no policies and procedures to guide documentation requirements for each load processed. There was no flash sterilization policy and procedure that met current standards of practice. The flash sterilizer log did not identify patients attached to the flash load.

7. There were no policies to guide surgical staff on how to use the hospital approved disinfectants within the OR.

8. There were no nursing post anesthesia care policies. There were no policies to guide nursing documentation for the post operative period. There were no policies to define the criteria for discharge from the recovery period. Documentation found in the clinical records indicated the staff use the Aldrete scoring system for discharge from the post-anesthesia period. There was no policy and procedure for the Aldrete scoring system.

There were no policies and procedures for standing orders and no policies that guided staff in emergency situations specific to the post-operative period.

9. The surgery log did not document the OR or procedure room used for each case. The log did not contain and pre and post-operative diagnosis.

Interviews with various peri-operative staff on 10/02/12 and 10/03/12 confirmed there were many missing policies and procedures.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital performs a periodic evaluation and quality assurance review as required. The hospital has not conducted an annual periodic evaluation and does not have an effective and ongoing quality assurance program.

1. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag # 0331.

2. The hospital does not ensure a yearly program evaluation reviewing the utilization of CAH services, including the number of patients served and the volume of services is conducted. Refer to Tag # 0332.

3. The hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records. Refer to Tag # 0333.

4. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies. Refer to Tag # 0334.

5. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag # 0335.

6. The hospital does not have an effective Quality Assurance/Performance Improvement (QA/PI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. Refer to Tag # 0336.

7. The hospital does have an effective quality assurance program that is implemented to evaluate the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI program. Refer to Tag # 0337.

8. The hospital does not have an effective quality assurance program implemented to evaluate nosocomial infections and medication therapy. Refer to Tag # 0338.

9. The hospital does not have a functioning QA/PI system is implemented so that remedial action can address deficiencies found through the QA/PI program. Refer to Tag # 0342.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Interviews with hospital personnel on the afternoon of 10/03/12 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of active and closed records, hospital policies and procedures and evaluation of the services provided and if changes were needed.

2. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interview with hospital staff, the hospital does not ensure a yearly program evaluation reviewing the utilization of CAH services, including the number of patients served and the volume of services is conducted.

Findings:

1. Interviews with hospital personnel on the afternoon of 10/03/12 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of the utilization of CAH services, including the number of patients served and the volume of services is conducted.


2. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interviews with hospital staff, the hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Hospital personnel stated on the afternoon of 10/03/2012 that they did not have an annual periodic evaluation that included a representative sample of active and closed medical records.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program which included a review of all of the CAH's health care policies.

2. Interviews with hospital personnel on the afternoon of 10/03/12 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review the CAH's health care policies.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program to determine if services were effectively utilized, policies were followed and if changes were needed.

2. Hospital staff stated on the afternoon of 10/03/2012 that they had not conducted a periodic evaluation that included all the requirements.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital has an effective Quality Assurance/Performance Improvement (QA/PI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital conducting a collection and analysis of data concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2011 and 2012 did not contain evidence of any analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. The hospital provided a QA/PI plan for 2012 for the hospital for review but the quality data provided to surveyors did not include any analysis, surveillance, and performance improvement based on findings.

3. There was no evidence of reviews of nosocomial infections and medication therapy in the medical staff meeting minutes. Hospital staff said Infection Control information was reviewed in the Quality Meeting. There was no review, analysis of data, and implementation measures documented with evidence of infection control in the quality documentation presented for review.

4. Organ procurement is not reviewed as part of the QA/PI program to ensure compliance with the requirement of assuring all deaths are reported to Life Share.

5. The hospital failed to ensure that surgical procedures are performed in a safe manner. See Tag 0320.

6. Hospital staff verified on 10/03/12 in the afternoon that the hospital's QA/PI program had not been an active functioning program.

Based on record review and interviews with hospital staff, the hospital does not ensure that an effective quality assurance program is implemented and evaluates the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI program. All patient care services and other services affecting patient health and safety are not evaluated and the hospital does not collect and analyze data concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. There is no documentation quality assurance information is provided to the Governing Body.
2. There is no documentation incidents, complaints, grievances, medication errors, surveillance activities are reviewed and analyzed with performance improvement plans developed and implemented to improve patient health and safety.
3. These findings were reviewed at the exit conference. No further documentation was provided.

Based on record review and staff interview, it was determined the hospital failed to ensure medication errors were identified, analyzed and that action was taken to improve the care and safety of patients.

Findings:

1. Hospital staff stated that medication errors were reviewed by the pharmacist and a physician in the pharmacy and therapeutics committee meeting. The minutes did not have documentation medication errors were analyzed to determine root causes, trends, actions taken to prevent recurrence and evaluation of those actions.

2. There was no documentation in governing body, medical staff or any quality meeting minutes documenting review and action on medication errors.

Based on record review and interviews with hospital staff, the hospital does not insure that a functioning QA/PI system is implemented so that remedial action can address deficiencies found through the QA/PI program. Review of Governing Body and Medical Staff meeting minutes for 2011 and 2012 and interviews with hospital staff during the survey did not have evidence the hospital has a functioning QA/PI program.

Based on document review, policy and procedure review and staff interview, it was determined the hospital failed to notify the patient of all the patient's rights contained in the SNF regulation. Findings:

The hospital was asked to provide all the documents, including patient's rights notification given to swing bed patients upon admission.

The patient's rights document did not information about items and services that are included in the charges and those items and services that are not included.

The hospital policies for swing bed patients did not include this information.

The findings were addressed during the exit conference. No additional information was provided.

Based on document review and staff interview, it was determined the hospital did not inform swing bed patients of their right to choose their own personal physician. Findings:

The hospital was asked to provide all the documents, including patient's rights notification given to swing bed patients upon admission.

The documentation did not include notification to patients that they had the right to choose their own physician.

The hospital policies for swing bed patients did not include this information.

The findings were addressed during the exit conference. No additional information was provided.

Based on document review and staff interview, it was determined the hospital failed to fully inform swing bed patient's of their rights regarding transfer and discharge. Findings:

The hospital was asked to provide all the documents, including patient's rights notification given to swing bed patients upon admission.

The documentation provided did not inform swing bed patients of all of their rights concerning discharge and transfer.

The hospital policies for swing bed patients did not include this information.

The findings were addressed during the exit conference. No additional information was provided.