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At the time of the revisit on 02/27/2014, this deficiency was not corrected.
Based on policy and procedure review, hospital document review and staff interview it was determined the hospital failed to have a grievance process that meets all CMS requirements.
Findings:
1. On the morning of 02/27/2014 surveyors requested the hospital's patient admission packet to include the patient's bill of rights and the patient rights policy and procedure.
2. Surveyors reviewed a policy, titled, "patient rights." The policy did not contain contact information for the Oklahoma State Department of Health (OSDH).
3. A hospital document, titled, "Notice of Privacy Practices" that is given to the patient upon admission contained contact information for a State Agency for filing grievances, but the contact information was not for OSDH. This document also documented, "...If you believe your privacy rights have been violated, you may file a written complaint with the hospital or with the Secretary of the Department of Health and Human Services."
4. The Chief Compliance Officer was asked if patients were required to submit a grievance in writing. She stated that "yes, I do have them submit it in writing."
5. A hospital document, titled, "Pushmataha Hospital and Home Health Patient's Rights and Notice of Privacy Practices" that is given to the patient upon admission to sign contained contact information for a State Agency for filing grievances, but the contact information was not for OSDH.
6. A patient rights handout, titled, "Pushmataha Hospital and Home Health Patient Rights", documented,"...If you have a Grievance/Complaint you have 7 days to submit to Pushmataha Hospital and Home Health." The Chief Compliance Officer was asked if patients only have 7 days to submit a grievance. She stated no.
7. On the afternoon of 02/27/2014 surveyors toured the medical surgical unit. The patient rooms did contain a copy of "Pushmataha Hospital and Home Health Patient Rights", but the patient rights did not contain contact information for OSDH for filing grievances.
8. On the afternoon of 02/27/2014, the Chief Compliance Officer provided surveyors with a revised copy of the patient rights handout that did not contain a time limit for the patient to submit a grievance.
9. On the afternoon of 02/27/2014 the Chief Compliance Officer provided surveyors with a revised copy of the "Pushmataha Hospital and Home Health Patient Rights and Notice of Privacy Practices." This copy contained contact information for OSDH.

At the time of the revisit on 02/27/2014 this deficiency was not corrected.
Based on review of governing body meeting minutes, review of Quality Assessment Performance Improvement (QAPI) meeting minutes and staff interview, it was determined the hospital failed to ensure grievance were reviewed by the governing body or a committee appointed by the governing body. This occurred in 2 of 2 grievances reviewed for 2014 (#8 & 9).
Findings:
1. There was no documentation grievances were reviewed through the governing body or a committee appointed by the governing body. There was no evidence the facility used grievances to improve patient care.
2. A hospital binder, titled, "Complaint Book 2014" was reviewed by the surveyors. There were two grievances listed. It was documented that one grievance went to QAPI on 01/27/2014 (#8) and it was documented that the second grievance went to QAPI on 01/23/2014 (#9). Review of QAPI meeting minutes for 01/2014 contained no evidence of the grievances being reviewed.
3. On the afternoon of 02/27/2014, the compliance officer was asked if the grievances documented in 01/2014 went to QAPI. She stated that no grievances had gone to QAPI, but they will go to QAPI next month. She stated that grievances will start being reviewed in QAPI on a quarterly basis.

Based on review of credentialing files and staff interview the medical staff failed to evaluate the performance of credentialed staff during the credentialing process. This occurred in three of three (EE, FF and GG) dental assistant, whose credential files, were reviewed.

Findings:

The credentialing process for the allied health practitioners, dental assistant, included a skills checklist, written competency exam and a review of privileges requested by the medical staff.

Review of the credential files for Staff EE, FF and GG did not contain the above information.

This was confirmed by Staff D and CC on 02/27/14 at 1:20.

Based on review of the hospital ' s surgery log, physician credential files and staff interview the hospital failed to provide specific privileges for each practitioner credentialed by the hospital. This occurred in two of two (Staff HH and II) physician credential files reviewed.

Findings:

A letter submitted by the hospital on September 27, 2013, to remove the Immediate Jeopardy, documented, " ...In response to the recent findings as of 8:00 am Friday September 27th, 2013 all Surgical Services has been stopped and all surgeries/procedures have been cancelled ... " , signed by the CEO, COO and Board of trustee, President ... "

Review of the hospital ' s surgery log, documented that Endoscopy/Colonoscopy procedures were performed from October 6, 2013 through December 5, 2013 by both Staff HH and II.

Documentation in the physician credential files stipulated if a physician wanted to be privileged to perform Gastrointestinal Endoscopic procedures, an additional form had to be requested.

Review of Staff HH credential files documented " General Surgery Core Privileges " and " Family Medicine Privileges " were requested and granted. The credential file did not contain documentation Staff HH had requested and been privileged to perform Gastrointestinal Endoscopic procedures.

Review of Staff II credential files documented " General Surgery Core Privileges " were requested and granted. The credential file did not contain documentation Staff II had requested and had been privileged to perform Gastrointestinal Endoscopic procedures.

This was confirmed by Staff D in the afternoon of 02/28/14.

At the time of revisit February 27, 2014, this deficiency was not corrected.
Based on document review, staff interview, and observation, the hospital failed to ensure patient examination, treatment, and consultation rooms were performed in rooms designed for that purpose.
Findings:
1. A plan of correction (POC) was submitted to the Department on February 25, 2014, that documented, "...The consult room (room 188) in the original plan was being utilized as the triage room...The DON [director of nursing]/safety director monitors the procedures in the ER to maintain correct utilization of room designation. Any proposed room changes must follow chain of command up to including the board..." The corrective action/completion date documented on the POC was 11/08/13.
2. On February 27, 2014 at 1415, surveyors toured the emergency department (ED) with the director of nursing (DON). Surveyors observed the consultation room which was also being used as a storage room for patient wheel chairs and gurney.
3. The DON told surveyors the consultation room is used for consultations, re-assessing patients as needed when the ED is full, and overflow storage for wheel chairs and gurneys.

At the time of the revisit on 02/27/2014, this deficiency was not corrected.

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 (ICP) 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. The hospital's health status for credential and agency staff was not complete, including immunization status. This was evident for six of six credentialed staff reviewed (Staff B, EE, FF, GG, HH and II). Staff JJ, staff identified as the infection control practitioner, and Staff AA told the surveyors that credential and agency staff were not followed by infection control.

2. On 02/27/2014, the surveyors observed the hospital's emergency department (ED) had re-purposed the ED consultation room (Room 188) and now also used it as a storage room for patient wheel chairs and other equipment. The Staff C told surveyors the consultation room is used for consultations, re-assessing patients as needed when the ED is full, and overflow storage for wheel chairs and gurneys.
When asked on 02/27/2014, if there was any designation as to what equipment was dirty and what was dirty, staff told the surveyors there was not.

Meeting minutes and policies did not demonstrate, this finding had been reviewed and analyzed to ensure a sanitary environment was maintained.

At the time of the revisit on February 27, 2014, the deficiency was not corrected.

Based on review of hospital documents, personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure.

Findings:
The POC submitted by the hospital documented, " ...education will be provided at scheduled nursing meeting on 11/21/13 by respiratory therapist to nursing staff competencies will be completed and documentation to show that each staff performing respiratory treatments are qualified to perform them, documentation will be placed in employee files..."

Seven of seven (F, G, H, I, P, Q and R) nursing personnel files reviewed did not contain respiratory competency verification completed by the respiratory therapist as required.

This was confirmed by Staff A, D and CC on 02/28/14.