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Based on review of the infection control documents, hospital meeting minutes, policies, procedures and personnel files, and interviews with staff, the hospital failed to develop an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer (ICO).

Findings:

1. The personnel file for the person identified as the ICO did not contain evidence the individual had training or experience in infection control. On the morning of 09/15/2010 Staff C stated she did not have any previous experience in infection control and had not received any infection control training on setting up an infection control program with active surveillance and analysis of data.

2. The hospital's infection control plan has not been reviewed and revised since 2008.

3. The infection control plan for 2008 appropriately required surveillance, monitoring and evaluation of all aseptic, isolation and sanitation procedures, including "activities that address patient and personnel in each area of the facility to ensure compliance with Infections Prevention and Control Standards".

Review of medical staff meeting minutes for 2009 and 2010, where infection control was listed as reporting, did not contain data from active surveillance of staff or analysis of any infection control data. On the morning of 09/15/2010, Staff C stated surveillance/observation activities of staff to ensure policies and procedures were followed had not been part of the infection control reporting. Staff C stated she had not inserviced employees on proper handwashing/hand cleansing techniques or performed any hand sanitation surveillance. She stated that information on employee health and staff immunizations were not part of data she collected.

4. The 2008 plan did not address where reporting and analysis of infection control data/activities occur or specify that they would occur at least quarterly as required by Hospital Licensure Standards.

Review of medical staff meeting minutes for 2009 and 2010, where infection control was listed as a topic, did not show the infection control program had been reviewed, evaluated and revised to ensure the program included monitoring of the environment to provide a safe and sanitary environment; and provisions to identify, investigate, report, and prevent the spread of infections and communicable diseases among patients and the staff, including contract staff, physicians and allied health workers and volunteers. Minutes of the medical staff meeting for the months where infection control reported did not demonstrate the data collected for positive culture results had been reviewed, evaluated and analyzed to ensure antibiotic therapy was appropriate. The only meeting minutes that contained infection control data were from January 26, 2010 and the attachment only contained listing for 4th Quarter positive culture infections with no other data or analysis of the log provided. This was reviewed with Staff C on 09/15/2010.

Based on review of hospital documents and interviews with hospital staff, the hospital does not assure nursing staff are adequately trained to meet the needs of the patients. Two of two agency nursing personnel (Staff ) did not have departmental orientation, competency, and evaluation for the specialized areas where they worked.

Findings:

1. On the afternoon of 9/14/2010 surveyors were provided registered nurse personnel files. Two of the files were nursing agency staff. There was no documentation provided indicating agency personnel had orientation to the hospital and specific departments. This finding was confirmed in an interview on 9/15/2010 with Staff B who indicated the facility had not required the agency staff to complete facility and department specific orientation.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to assure nursing staff are adequately trained, oriented and competent to provide care to meet the needs of the patients.

Findings:

Nursing respiratory competency:

1. On the afternoon of 09/14/2010, administrative staff told the surveyors that respiratory therapy treatments were provided by nursing staff.

2. Review of Patient #6's chart showed Staff U administered respiratory treatments to the patient. When interviewed during the tour of the inpatient unit on 09/15/2010 at 1430, Staff U confirmed that she administered hand held nebulizer respiratory therapy treatments. She told the surveyors that she had not received any respiratory training or evaluations/competency testing by a respiratory therapist to administer respiratory treatments.

3. Eleven of eleven licensed nursing personnel files reviewed did not contain evidence the staff had received training and competency verification for respiratory therapy treatments.

4. In interview with the Chief Nursing Officer and Staff V on 09/15/2010, they stated that respiratory therapy training had not been part of the competency training/verification process. They stated the hospital did not have a current agreement with a respiratory therapist to provide consultation and training to nursing staff on respiratory therapy treatments.

The hospital does not meet the Condition of Participation for Periodic Evaluation and Quality
Assurance Review CFR 485.641.

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 and has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital conducting ongoing monitoring and data collection and analysis of patient care.
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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 09/14/10 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, Medical Staff and Quality Assessment/Performance Improvement meeting minutes for 2009 and 2010 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 09/14/10 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 volumn of services is conducted.


2. Governing Body, Medical Staff and Quality Assessment/Performance Improvement meeting minutes for 2009 and 2010 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, Medical Staff and Quality Assessment/Performance Improvement meeting minutes for 2009 and 2010 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Interviews with hospital personnel on the afternoon of 09/14/10 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of 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, Medical Staff and Quality Assessment/Performance Improvement meeting minutes for 2009 and 2010 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Review of selected hospital policies did not document a yearly review of hospital policies. Nursing, Radiology, and Dietary policies were last reviewed and approved in 2005. Pharmacy policies were last reviewed in 2007. Respiratory policies were last reviewed in 1988 and Infection Control was last reviewed in 2008.

3. Hospital personnel stated on the morning of 09/14/10 that they were in the process of trying to review all hospital 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, Medical Staff and Quality Assessment/Performance Improvement meeting minutes for 2009 and 2010 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 09/14/10 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 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 program and all patient care services and other services affecting patient health and safety are evaluated and the hospital collects and analyzes data concerning the quality and appropriateness of all patient care furnished in the CAH.


Findings:

1. QA meeting minutes for 2009 and 2010 did not contain evidence of the analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. Governing Body and Medical Staff meeting minutes for 2009 and 2010 did not contain evidence of any QA analysis of data presented to identify problems, evaluate situations, and take corrective actions.

3. There was no evidence of reviews of nosocomial infections and medication therapy in medical staff meeting minutes presented for review.

4. All departments providing patient care do not participate in the hospital's QA program. This was verified with hospital staff on the afternoon of 09/15/10.

5. The QA meeting minutes binder presented for surveyor review had the minutes for one meeting in 2008 and one meeting in 2009 and no meetings in 2010.

Based on record review and interviews with hospital staff the hospital does not ensure that an effective quality assurance program is implemented and nosocomial infections and medication therapy are evaluated. Review of infection control documents, hospital meeting minutes, policies and procedures and personnel files, and interviews with staff, the hospital failed to develop an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer (ICO).

Based on record review and interviews with hospital staff the hospital does not ensure that a functioning QA program is implemented in the hospital. The hospital has not documented any remedial action because the QA program has not been active. The QA meeting minutes binder presented for surveyor review had the minutes for one meeting in 2008 and one meeting in 2009 and no meetings in 2010.

Based on a review of policies and procedures and staff interview, the hospital failed to ensure the swing bed policies included a policy and procedure addressing mistreatment, neglect and abuse and misappropriation of property of swing bed patients.

Findings:

1. At the time of review on the morning of 09/15/2010, the hospital did not have a policy addressing mistreatment, neglect and abuse and misappropriation of property of swing bed patients, including how the hospital would protect the patient and staff while the allegation was being investigated and how the hospital would educate staff on recognizing abuse and neglect and the hospital's policy on the procedure to follow if a staff member received an allegation or witnessed abuse, neglect or misappropriation of patient property.

This was confirmed with Staff B on 09/15/2010.

2. The hospital does not check with the State Nurse Aide Registry to ensure no staff has been convicted of abusing, neglecting or mistreating patients. This was confirmed by interview with Staff B and V on 09/15/2010.