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Based on review of personnel files, medical records, hospital documents, and interviews, the hospital failed to verify personnel were licensed, trained, and competent.

Findings:


1. On 5/31/12 surveyors reviewed personnel files. Four of six (Staff L, N, O and Q) registered/licensed nurse personnel files reviewed for licensure verification did not contain licensure verification.

2. On 5/30/2012 surveyors reviewed contracted radiology services. The contracted provider did not have documentation of licensure, training, or competency.

3. On 5/30/2012 surveyors reviewed the contract dietitian's personnel file. There was no documentation the contract dietitian had been oriented, trained, or was competent.

4. On 05/31/2012, the surveyors reviewed the contract respiratory therapist file. The file contained no evidence the respiratory therapist had been oriented to the hospital. The orientation and performance evaluation contained in the personnel file was for another hospital.

5. On 05/31/2012, the surveyors requested the personnel files for the contract physical therapy staff. The files did not contain evidence of orientation to the hospital and competency verification.

Based on record review and interviews with staff, the hospital does not ensure that medication errors and adverse drug events are evaluated to determine possible causative factors and create systems to prevent their reoccurrence.

Findings:

1. Review of Governing Body, Medical Staff and Pharmacy and Therapeutic ( P & T) committee meeting minutes for 2011 and 2012 did not have any review or evaluation of medication errors or adverse drug events. The only documentation of medication errors and an adverse medication reaction was in the P&T meeting minutes for the third quarter of 2011. The documentation just gave numbers, no evaluation of the adverse event or medication errors.

2. Hospital staff stated in an interview on 05/31/12 in the afternoon that medication errors were identified on an incident report form and were sent to the DON and the Consultant Pharmacist for review. There was no evidence these medication errors were analyzed and a plan of action developed to prevent their reoccurrence.

3. The Consultant Pharmacist's weekly reports did not have any review of medication errors and adverse drug events.

Based on review of the infection control documents, hospital meeting minutes, policies, procedures and personnel files, and interviews with staff, the hospital failed to:
1. Designate a person qualified through training and/or experience as the infection control professional/officer/preventionist (ICP) and provide ongoing education in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program and,
2. Develop and maintain an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff.

Findings:

1. Administration identified Staff B as the ICP. Review of Staff B's personnel file did not contain evidence Staff B had any experience or training in infection control principles. On the afternoon of 05/31/2012, Staff B verified she had no previous experience or training in infection control. She stated she had not received any training in developing and directing an infection control program since hire.

2. Review of meeting minutes for Medical Staff and Governing Body did not contain evidence Staff B had been appointed as the infection control professional. Staff B's personnel file contained no documentation she had been appointed as the infection control professional or job description for infection control. This was reviewed with administration and Staff B on the afternoon of 05/31/2012.

3. The hospital did not have a current infection control plan and the infection control policies did not show review since 2006. The most current Plan was dated 2008. The plan did not specify how the hospital infection control program would ensure infection control policies and procedures were followed or specify the frequency of monitoring. The Plan did not designate how often the infection control would meet. (Oklahoma State Hospital Standards, Subchapter 39, require meetings for infection control to be performed at least quarterly.) Review of meeting minutes did not reflect infection control was presented, reviewed and analyzed quarterly.

4. Review of minutes of meetings containing infection control did not reflect the hospital had an ongoing hospital-wide infection control program with data collection, analysis, corrective action taken when needed and follow-up to ensure corrective actions were effective.
a. Five of seven staff health files did not contain complete immunization records as recommended by CDC (Centers for Disease Control) and its Advisory Committee on Immunization Practices and those required by Oklahoma State Hospital Standards. Meeting minutes did not reflect immunization practices were monitored through infection control.
b. Meeting minutes did not reflect employee health was monitored through infection control or that the infection control program/ICP reviewed employee illnesses for possible transmission of infections and illness between patients and staff.
c. Active monitoring of handwashing practices were not performed.
d. Problems identified in the monthly walk-though environmental rounds were not reviewed in infection control with corrective actions taken and follow-up to ensure the actions were effective.
e. The infection control program has not reviewed the disinfectants used in the hospital to ensure they are effective against the organisms prevalent at the hospital. No monitoring of disinfectant applications has been performed to ensure application follows the manufacture guidelines for mixture and "wet" times.
f. Monitoring of isolation precautions, including adequate supplies and equipment, and personnel following CDC established guidelines is not performed.

5. These findings were reviewed with administrative staff on the afternoon of 05/31/2012. No additional information was provided.

Based on document reviews and interviews, the hospital failed to assure that the nutritional needs of inpatients are met in accordance with recognized dietary practices.

Findings:

1. On the afternoon of 5/30/12 Staff D told the surveyors that Staff D and/or the consultant dietitian completed all of the nutritional assessments on patients. The policy entitled "Basic Nutritional Assessment" stipulates the Certified Dietary Manager (CDM) visits the patient on the second day of confinement and a basic nutritional assessment is completed using the "basic nutritional assessment form. The policy further stipulates the assessment is filed in the patients chart in the progress notes section on top of the dietary intake data form and the assessment is signed and dated by the certified dietary manager. The consultant dietitian reviews the assessments of patients during her monthly visit. The policy does not indicate what each section of the form is for. There is no direction in the policy or on the form if a patient is categorized as "high nutritional risk". There is no direction in the policy for recommendations for diet changes and the process the hospital utilizes to notify the physician if a patient needs additional nutritional support.

2. 11 of 11 medical records #1,2,3,4,5,6,7,8,9,10,11 reviewed for nutritional assessment completion do not have documentation the consultant dietitian collaborated on the assessment. Three of the eleven (3,4,5) medical records did not include a nutritional assessment by the CDM or nursing staff. Three of the eleven 6, 7,10 medical records included a nutritional screen completed by Staff J. Staff J was not identified as the CDM or the Dietitian. Staff J's personnel file did not have documentation Staff J had been trained and was qualified to perform the nutritional assessments. Two (6,10) of the three medical records (6,7,10) did not have any authentication by the CDM or the Dietitian.

3. Several of the nutritional assessments completed by Staff J and Staff D 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 or comorbidities including dehydration, extreme emaciation, diabetes, nausea, vomiting, and morbid obesity. None of the nutritional assessments included documentation these conditions were addressed.

4. Dietary and nursing policies did not include a policy and procedure for nutritional screens/nutritional consults. There are no current dietary policies and procedures. Policies regarding handwashing do not have current CDC recommendations and do not include use of hand sanitizers. There is no documentation the facilities infection control processes have been implemented in the department.

5. According to Staff B the consultant dietitian provides the hospital a monthly report. Surveyors did not received reports for June, July, September, October, December 2011 and January, February 2012. There was no documentation regarding what patient's were consulted by the dietitian. There was no documentation the dietitian had been oriented, trained, and was competent to provide services at the facility. The dietitian's license was not current.

5. Review of Quality Assurance Performance Improvement 2011 data did not include clinical nutritional services.

6. The above findings were reviewed with the administrative team at the exit conference on 5/31/12. 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:

On the morning of 5/30/2012 surveyors were given copies of the Radiology, Nursing, Dietary Department and Infection Control policy and procedure manual. There was no documentation the policies and procedures had been reviewed, revised, and approved annually.

1. On the morning of 5/30/2012 Radiology policy and procedure was reviewed. Many of the policies were dated 2004 and/or 2006. There was no evidence the hospital had reviewed, approved, and implemented radiology policy and procedure annually.

2. On the morning of 5/30/12 Dietary department policies were provided to surveyors. 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 5/30/12 surveyors requested physical therapy policies and procedures. Staff B told surveyors there were no therapy policies written, reviewed and approved through governance. .

4. On the morning of 5/30/12 Respiratory policies were provided to surveyors. The policies were established 08/10/2007. There was no evidence the policies and procedures had been reviewed, revised and approved through governance since that time.

5. On the afternoon of 5/30/2012 Infection Control policies were provided to surveyors. Although the manual contained an Infection Control Plan for 2008, the latest review and revision for the policies and procedures was dated 2006. There was no evidence current infection control practices recommended through national resources had been developed, reviewed, approved, and implemented throughout the hospital.

6. The above findings were reviewed with administrative team members on the afternoon of 5/31/12. 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 5/30/2012 Staff A told surveyors some of the radiology services (ultrasound) were contract. There was no documentation the personnel providing the services were oriented, trained, and competent. There were no policies and procedures written, reviewed, approved, and implemented for these services.

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

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

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. Review of seven medical records (Records 2, 6, 7, 9, 13, 16, and 20) of patients who received nebulizer treatments, showed nursing staff as administering the respiratory treatments. On 05/30/2012, administrative staff confirmed that respiratory therapy treatments were provided by nursing staff.

2. The respiratory policies stipulated that pre-treatment and post-treatment evaluation of the patient's respiratory status would be performed and documented. This was not done in the seven of seven medical records mentioned in Finding #1.

3. Review of six staff personnel files (Staff, K, I, N, O, P and Q), of staff identified through chart review as administering respiratory treatments, did not contain evidence the respiratory therapist had provided training and competency verification, with the level of supervision required, for each staff member.

4. These findings were reviewed and verified with Staff B.


Orientation and Nursing Competency:

1. Nursing personnel files for Staff B, I, K and Q did not contain evidence the staff had been orientated to the hospital.

2. Personnel files (Staff B, I, K, L, N, O, P, Q) did not contain current nursing competency, including medication and blood administration, isolation precautions.

3. According to medical record review, Staff N, O, and Q assessed patients and performed patient care in the specialty area of emergency services. Review of personnel files did not contain evidence the three staff had competency training and verification to provide care in the specialty area.

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

Findings:

1. Review of the documentation in the material provided as the hospital's annual periodic evaluation did not include documentation of a review and an evaluation of both active and closed clinical records.

2. Interviews with hospital personnel on the afternoon of 05/31/12 verified that the annual periodic evaluation did not contain a review of medical records.

Based on record review and interviews with hospital staff, the hospital does not ensure that a review of the CAH's health care polices are reviewed once a year as part of the hospital total program evaluation.

Findings:

1. Policies for swing bed, physical therapy, radiology, physical therapy, infection control, respiratory and dietary had not been reviewed at least once a year.

2. Review of the hospital's policies was not included in the hospital's quarterly review and included as part of an evaluation of the hospital's total program.

3. Hospital Staff (A) verified on 05/31/12 in the afternoon that all policies had not been reviewed.

Based on record review and interviews with hospital staff, the hospital had not conducted an annual total program evaluation that determined whether the utilization of hospital services were appropriate, policies were followed and if any changes were needed. Hospital Staff (A) verified on 05/31/12 that this evaluation of the utilization of the hospitals services had not been conducted.

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 QA/PI documentation presented for review for housekeeping and dietary consisted of check lists with check marks for each month. There was no evaluation or analyzation of the items checked.

3. There was no evidence of reviews of nosocomial infections and medication therapy in the hospital meeting minutes provided for review.

4. All hospital departments are not participating in the QA/PI program.

5. These findings were verified by staff (A) on 05/31/12 in the afternoon.

Based on record review and interviews with hospital staff, the hospital does not ensure that nosocomial infections and medication therapy are evaluated as a part of the Quality Assurance/Performance Improvement program. Medical Staff , QA/PI and infection control meeting minutes for 2011 and 2012 did not have evidence of evaluation of nosocomial infections and medication therapy.

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 that addressed 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 finding was reviewed with administrative staff on the afternoon of 05/31/2012.

Based on a review of personnel files, swingbed policies and procedures, and interviews with hospital staff, the facility failed to ensure that the State nurse aide registry was checked for findings when individuals are offered employment. In sixteen of sixteen personnel files (Staff B, D, F, G, H, I, J, K, L, M, N, O, P, Q, R, and S) that were reviewed, no evidence of inquiry was documented. The hospital's swingbed policy also required criminal background checks through the Oklahoma State Bureau of Investigation to be performed. This was also not completed on the sixteen personnel. These findings were reviewed and verified with administrative staff on the afternoon of 05/31/2012,