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Based on review of hospital policies and procedures and grievances and interviews with hospital staff, the hospital failed to develop and enforce a grievance policy and process with time frames for review, investigation and a provision for a written response to the complainant with the required information.

Findings:

1. The hospital's policy, RM 1.3, did not identify the difference between a complaint/concern and a grievance. The only time frame identified in the policy was that the "Patient Complaint Form" would be sent to the Risk Management Department within 5-7 days so that an investigation can be initiated. The policy does not contain any time frame for investigation, resolution, written response, or notification to the complainant if the grievance cannot be resolved within the specified time frame.

2. Two of two grievances reviewed did not contain evidence the grievance had been investigated. The grievance documentation for both stated the hospital would investigate, but no evidence of investigation was documented or provided to the surveyors for review.

Based on review of hospital policies and procedures and grievances, the hospital failed to provide a written response to the complainant with the required information. This occurred in two of two grievances (Records #14 and 15) reviewed.

1. Record #14 - The grievance was filed on 01/17/2012. Although the documentation recorded Staff C met with the complainant on that day, the documentation recorded the complainant was told hospital would conduct an investigation. The documentation provided did not contain evidence the hospital had conducted an investigation or provided a written response, with the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion, to the complainant. On 03/14/2012, Staff C stated that no written response had been sent to the complainant with the required information.

2. Record #15 - The grievance was filed on 10/04/2011. Documentation provided did not contain evidence the complaint had been investigated. The letter sent to the complainant on 10/11/2011 did not address all of the patient's verbalized issues, the steps taken to investigate, and results of the grievance process with the date of completion. This was reviewed with Staff C on the afternoon of 03/14/2012.

Based on record review and interviews with hospital staff, the hospital does not ensure that an ongoing, hospital-wide, data-driven quality assessment and performance improvement ( QAPI) program is implemented and maintained. Review of governing body and medical staff meeting minutes for 2011 and 2012 did not have evidence of reports from the hospital's QAPI program. A manual titled Performance Improvement/Infection Control/Safety presented for review did not have reports documenting QAPI.

Findings:

1. Medical Staff, Governing Body meeting minutes reviewed did not have any attachments with QAPI indicators/monitors from the hospital's services.

2. QAPI meeting minutes presented for review by the surveyor consisted mainly of infection control information.

3. Hospital staff stated on 03/14/12 in the afternoon that the last QAPI coordinator took all the QAPI documentation with her when she left employment in the hospital.

4. The QAPI plan that was presented for review did not have any documentation in the governing body meeting minutes that it had been approved by the governing body.

5. Individual departments according to hospital staff had their indicators/monitors that they were following, there were no meeting minutes documenting that these were reported, analyzed and action taken if needed.

8. Hospital staff verified on 03/14/12 during the exit conference that they did not have a functioning QAPI program.

Based on record review the hospital does not ensure an ongoing QAPI program is implemented with measurable indicators that show improvement. The hospital does not have an ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program implemented and maintained.

Findings:

1. Medical Staff, Governing Body meeting minutes reviewed did not have any attachments with QAPI indicators/monitors from the hospital's services.

2. Hospital staff stated on 03/14/12 in the afternoon that the last QAPI coordinator took all the QAPI documentation with her when she left employment in the hospital.

3. Individual departments according to hospital staff had their indicators/monitors that they were following, there were no meeting minutes documenting that these were reported, analyzed and action taken if needed.

4. Hospital staff verified on 03/14/12 during the exit conference that they did not have a functioning QAPI program.

Based on record review and interviews with hospital staff the governing body, medical staff and administrative officials do not ensure an ongoing QAPI program is defined, implemented and maintained. The hospital does not have a functioning ongoing QAPI program. Finding:
There were no governing body, medical staff or QAPI meeting minutes with evidence of QAPI activities.

Based on record reviews and interviews with hospital staff, the hospital does not ensure that medical records are complete, retained and properly filed for prompt retrieval.

Findings:

1. On the morning of 3/13/2012 administrative staff told the surveyors that all patient medical records were maintained on computer/electronic medical records or initially completed on paper and scanned into the record. Later in the morning surveyors were provided access to the electronic medical record and instructions on where documents could be found.

2. On the afternoon of 3/13 and 3/14/2012 surveyors reviewed policy and procedures. The policy and procedures did not reflect electronic medical record practice. There were no policies addressing use of the electronic documentation system and how the clinicians accessed particular documents.

3. No surgical records had documentation of surgical prep, location of cautery ground pad, cautery settings, use of safety strap, intravenous fluids infused during the procedure. Several records did not have updated history and physicals prior to surgery or procedures. Several records reviewed by surveyors did not have complete assessments by nursing personnel and/or did not have initial nursing assessments. Several records did not include intravenous infusion totals during any of the perioperative period. None of the surgical records included a complete nursing assessment after the procedure and prior to discharge. Several records did not include information regarding patient transfer or discharge. There was no documentation provided to surveyors indicating the content of medical records was reviewed for completeness and accuracy.

4. These 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 does not ensure that the medical record contains information describing the patients condition, progress and responses to treatment.

Findings:

1. Several records reviewed by surveyors did not have complete assessments by nursing personnel and/or did not have initial nursing assessments or post procedure assessments. Several records did not include intravenous infusion totals during any of the perioperative period. There was no documentation of surgical prep, drape, safety equipment, cautery settings with ground pad placement, and time out.

2. On 3/13/2012 surveyors reviewed outpatient procedure records. Some of the endoscopy patients had history and physicals documented in the medical record which were not updated prior to surgery. Physician orders were not present for medication given throughout the perioperative stay.

3. There was no documentation provided to surveyors indicating the content of medical records was reviewed for completeness and accuracy. There was no documentation medical records were reviewed through the quality process.

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

Based on a review of medical records and interviews with hospital staff, the hospital failed the ensure the medical records were complete and contained all pertinent information such as complete nursing assessments, reports of treatments, documentation of care provided, medication administration, and vital signs monitoring.

Findings:

1. On 3/13/12 surveyors reviewed nine surgical/procedure charts. Nine of nine records did not include a time out procedure. Nine of nine did not have documentation of surgical scrub or prep. Nine of nine did not have documentation of use of safety strap or grounding pad placement. Nine of nine records included documentation medications were given to the patient without physician orders. Nine of nine records did not include documentation a surgical count was performed. Nine of nine records did not have a complete registered nurse assessment of the patient's post-operative status.

2. Nine of nine surgical/procedure medical records reviewed did not have documentation of the patient's status immediately post operative, during the recovery phase, and at discharge.

3. Nine of nine surgical/procedure medical records reviewed did not have post anesthesia care orders. There were no orders specific to the immediate postoperative care episode. Documentation indicated patients received oxygen, medications, and frequent monitoring of vital signs. The orders did not reflect the type of care provided to the post surgical patients.

4. Nine of nine surgical procedure medical records did not include the patient status at the time of discharge. There was no documentation the anesthesia provider or the physician assessed and cleared the patient for discharge. There was no discharge criteria developed, reviewed, approved, and implemented to provide for a safe discharge.

5. Several of the surgical/procedure patients did not have documentation a registered nurse assessed or cared for the patient during the immediate postoperative phase.

6. Patient #24's medical record indicated the intravenous fluids (IVF) Lactated Ringers 1000 ml were to be changed to Normal Saline with 10 milliequivalents (meq) of potassium chloride (KCL) after the patient completed a bowel prep. There was no documentation throughout the perioperative phase the IVF's were changed after the prep. There was no documentation of the amount of fluids infused in the recovery room. There was no documentation of the patient's condition at the time of transfer. There was no documentation where the patient transferred.

Patient #16's medical record indicated the patient had a upper gastrointestinal endoscopy. The patient did not have physician orders for intravenous access, type of fluid to infuse, rate of infusion, physiologic monitoring parameters, preoperative and post procedure medications. There was no documentation of the amount of fluids the patient received during the procedure, or the patient's status on discharge.

Patient #17's medical record indicated the patient had endoscopy procedures. The history and physical was not complete. There was no date and time indicated when the history and physical was completed. There were no physician signed orders. The patient received intravenous fluids, medication, oxygen, oral medications, and physiological monitoring.

Patient #18's medical record indicated the patient underwent a surgical procedure for abscess removal. There were no signed orders for the medications and intravenous fluids ordered during the perioperative period.

Patient #19's medical record indicated the patient underwent a laparoscopic cholecystectomy. The physician ordered dextrose 5% in half normal saline (D51/2NS) to be infused postoperatively. Documentation on the chart indicated Lactated Ringers infused throughout the postoperative phase. The physician ordered Demerol to be given intramuscularly (IM). Documentation by nursing staff indicate the patient was given intravenous doses of Demerol and IM doses of Demerol. There was no documentation of where the patient was transferred. There was no nursing notes indicating how the patient was discharged or where the patient went post recovery room.

Patient #22's medical record indicated the patient underwent a wide excision of lymph nodes. The physician ordered antibiotics to be given prior to surgery start. There was no documentation indicating the amount of antibiotics given, the time it was given, or the route the medication was provided. None of the scrub and circulating nurses were identified on the operative record. Medication was ordered to be administered intramuscularly. Documentation indicated the medications were given IM and IV. There was no documentation the IV was discontinued after the procedure at discharge.

Based on review of medical records, policies and procedures, dietary consultation reports, and interviews with staff, the facility failed to ensure dietary services were provided in an organized manner and policies, procedures, and processes were reviewed, approved and implemented.

Findings:


1. The dietary manual was provided to surveyors. No other dietary policies and procedures were provided to surveyors. There was no documentation indicating the policies had been reviewed and approved through the hospital's medical staff or governing body. There were no menus with appropriate portioning provided to surveyors. No formalized policy for nutritional screening and nutritional assessment were provided. There were no nursing policies regarding nutritional screening. There was no evidence the nutritional policies and procedures had been written, reviewed and revised.

2. Dietary personnel files were reviewed. There was no dietary departmental specific training included. The dietitian indicated in the monthly consultation report training topics for the month. There was no documentation indicating how staff hired after a particular training was provided would obtain the information they needed. There was no formalized orientation and training plan provided. There was no evidence a formalized orientation, training and competency program had been developed based on dietary policies, procedures, and processes.

3. On 3/14/2012, surveyors reviewed dietary consultation reports. The reports included recommendations for process improvement. There was no documentation any of the recommendations were taken through the quality assurance process. There was no documentation any of the recommendations were acted on.

Based on review of personnel files and meeting minutes and interviews with hospital staff, the hospital failed to designate/appoint an appropriate infection control professional.

Findings:

1. Staff B, C and D told the surveyors on 03/13/2012 that, as of February, Staff D was the infection control officer.

2. Review of Staff D's personnel file did not contain evidence that Staff D had been designated an the infection control professional - no job description for the infection control professional, performance evaluation, or documentation of appointment. On the afternoon of 03/14/2012, this finding was reviewed with Staff F, the person identified as responsible for the personnel files, who stated he was unaware Staff D's job title change.

3. Review of quality, medical staff and governing body meeting minutes did not reflect Staff D have been designated/appointed as the infection control profession.

4. These findings were reviewed and verified with Staff B and C on the afternoon of 03/14/2012.

Based on review of infection control data and meeting minutes and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. The surveyors reviewed meeting minutes for 2011 and 2012 containing Infection Control. The hospital did not have meeting minutes addressing infection control for 2012. This finding was confirmed with Staff D, the person identified as the infection control professional, on 03/14/2012.

2. Meeting minutes containing infection control, did not reflect the program contained review and analysis with plans of action and follow-up of monitoring:
a. Employee health and tracking of employee illness to ensure transmissions between staff and patients did not occur;
b. Infections and communicable diseases - The modes of possible transmission between individuals (patients and staff) with analysis of measures taken to contain and prevent transmission and whether they were effective.
c. Except for handwashing, monitoring in all areas of the hospital to ensure that staff followed established policies and procedures and standards of practice to prevent and control infections and maintain a sanitary environment.
d. Concerns/problems identified in one meeting were not reported in the next meeting with an analysis of corrective actions to determine needed further follow-up or change.

3. Monitoring activities, provided for review, did not include active surveillance of the practices, to ensure staff adhered to the policies to avoid possible transmission of infections throughout the hospital, including the proper application of disinfectants.

4. These findings were reviewed with hospital administrative staff during the exit conference on the afternoon of 03/14/2012.

Based on surveyors observations, review of facility documents and interviews with facility staff, the facility failed to provide surgical services in accordance with acceptable standards of practice.

Findings:

1. There is no documentation staff designated as perioperative personnel have education, training, and competency in perioperative services. See tag 0942

2. Infection Control Meeting Minutes 2011 do not include any surveillance for the Operating Room. There is no documentation the Infection Control Program reviews and analyzes sterilization practices, hand hygiene, or any infection control practices in the perioperative suite. Staff D, P, and T did not know the name of the products used to clean with between cases and were not aware of the kill time for the product. See tag 749

3. Review of Quality Assurance Performance Improvement does not include specific indicators designated for Surgical Services. In an interview 3/14/2012 Staff A stated data was collected by the departments. There was no documentation the facility collected, reviewed and analyzed data in relation to quality assurance and performance improvement.

4. Perioperative medical records are not complete and do not indicate the type of surgical preparation, safety measures, medications, fluids, physiological assessment, and care provided to the patient. See tag 0941

5. Staff identified as central sterilization employees were not aware of current sterilization and disinfection practices. Sterilization logs indicated shortened cycle sterilization processes were being utilized. Staff were unable to identify critical components of the sterilization tapes to insure instruments had been sterilized. Sterilization and high level disinfection processes specific to the hospital were not documented in policy and procedure. See tag 0951

6. There are no perioperative policies and procedures written, reviewed, and approved through the medical staff and governing body specific to the facility. See tag 0951

7. There are no policies and procedures written, reviewed, and approved through medical staff and governing body specific to the post anesthesia phase through transfer and discharge. See tag 0957

Based on surveyors observations, review of facility documents and interviews with facility staff, the facility failed to provide surgical services in an organized manner with qualified personnel in accordance with acceptable standards of practice.

Findings:

1. Three of three operating room personnel did not have current job descriptions, departmental competencies, and evaluation of skills for the jobs each stated they were performing. There is no evidence personnel have the training and competency to perform the specialized skills.

In a interview on 3/14/2012 Staff P told surveyors she was in charge of surgery and oversaw preoperative and postoperative care areas as well as central sterile. Staff P also told surveyors she worked in other areas of the hospital where needed. There was no documentation in Staff P's personnel file indicating Staff P was the operating room supervisor in charge of the preoperative and postoperative areas as well as central sterile. There was no documentation Staff P had current training in perioperative standards, central sterilization protocols, and pre/postoperative management of patients.

Staff T identified as surgical technician did not have any documentation of training as a surgical technician or central sterile processing, Staff T did not have documented training through a surgical technologist program. Staff T told surveyors his responsibilities were to scrub cases and run the sterilizer. There was no documentation Staff T had training as a central sterilization technician. Staff T's initial application to the facility indicated he was hired as a certified nursing assistant. There was no documentation further education and training was provided regarding surgical services.

Staff S a surgical technician did have documentation of training as a scrub technician through a technology program. There was no documentation in Staff S's personnel file Staff S had current education, competency in standards of perioperative practice, infection control, sterilization practices and had been reviewed and evaluated and competent to perform the duties.

2. The facility failed to integrate surgical services into the Infection Control Program and Quality Assurance Performance Improvement. See tags 0263 and 0747.

3. On 3/13/12 surveyors requested operating room policies. Surveyors were provided a policy indicating the Association of Perioperative Registered Nurses (AORN) "Perioperative Standards and Recommended Practices" was adopted as the facility protocol. There were no policies specific to the facility, types of patients provided surgical care, procedures performed, equipment in the department, layout of the department and the coordination of care throughout the hospital.

4. On 3/13/12 surveyors reviewed nine surgical/procedure charts. Nine of nine records did not include a time out procedure. Nine of nine did not have documentation of surgical scrub or prep. Nine of nine did not have documentation of use of safety strap or grounding pad placement. Nine of nine records included documentation medications were given to the patient without physician orders. Nine of nine records did not include documentation a surgical count was performed. Nine of nine records did not have a complete registered nurse assessment of the patient's post-operative status.

Patient #24's medical record indicated the intravenous fluids (IVF) Lactated Ringers 1000 ml were to be changed to Normal Saline with 10 milliequivalents (meq) of potassium chloride (KCL) after the patient completed a bowel prep. There was no documentation throughout the perioperative phase the IVF's were changed after the prep. There was no documentation of the amount of fluids infused in the recovery room. There was no documentation of the patient condition at the time of transfer. There was no documentation where the patient transferred.

Patient #16's medical record indicated the patient had a upper gastrointestinal endoscopy. The patient did not have physician orders for intravenous access, type of fluid to infuse, rate of infusion, physiologic monitoring parameters, preoperative and post procedure medications. There was no documentation of the amount of fluids the patient received during the procedure, or the patient's status on discharge.

Patient #17's medical record indicated the patient had endoscopy procedures. The history and physical was not complete. There was no date and time indicated when the history and physical was completed. There were no physician signed orders. The patient received intravenous fluids, medication, oxygen, oral medications, and physiological monitoring.

Patient #18's medical record indicated the patient underwent a surgical procedure for abscess removal. There were no signed orders for the medications and intravenous fluids ordered during the perioperative period.

Patient #19's medical record indicated the patient underwent a laparoscopic cholecystectomy. The physician ordered dextrose 5% in half normal saline (D51/2NS) to be infused postoperatively. Documentation on the chart indicated Lactated Ringers infused throughout the postoperative phase. The physician ordered Demerol to be given intramuscularly (IM). Documentation by nursing staff indicate the patient was given intravenous doses of Demerol and IM doses of Demerol. There was no documentation of where the patient was transferred. There was no nursing notes indicating how the patient was discharged or where the patient went post recovery room.

Patient #22's medical record indicated the patient underwent a wide excision of lymph nodes. The physician ordered antibiotics to be given prior to surgery start. There was no documentation indicating the amount of antibiotics given, the time it was given, or the route the medication was provided. None of the scrub and circulating nurses were identified on the operative record. Medication was ordered to be administered intramuscularly. Documentation indicated the medications were given IM and IV. There was no documentation the IV was discontinued after the procedure at discharge.

These findings were reviewed with Staff P on the afternoon of 3/13/12.

5. On 3/14/2012 surveyors reviewed sterilization logs and tapes with Staff P and Staff T. Staff T was not aware of elements to review on the sterilizer tapes to insure the sterilizer had successfully completed a full cycle. There was no documentation indicating the sterilizer logs were reviewed by infection control. There was no indication all sterilization and high level disinfection processes were evaluated by infection control or the surgical services personnel. There were no policies and procedures specific to the hospital sterilization equipment reviewed, approved, and implemented through the medical staff and governing body.

Based on interviews with staff, review of personnel files and policy and procedures the facility failed to insure the surgical services were supervised by a qualified registered nurse with ongoing education, competency and training in surgical services. On 3/14/2012 surveyors reviewed Staff P, Operating Room Supervisor's personnel records. Documentation in the file did not indicate any training in the operating room other than on the job. There was no documentation indicating Staff P had current education and training as the Operating Room Supervisor. On 3/14/2012 Staff B told surveyors she had access to outside resources such as Association of Perioperative Nursing (AORN) and thought she had training back about a year ago. There was no documentation Staff P had current specific training to oversee the perioperative areas.

Based on review of policy and procedures the facility failed to provide policy and procedures specific to the perioperative care provided at the facility.

Findings:

1. On 3/13/12 surveyors requested operating room policies. Surveyors were provided a policy indicating the Association of Perioperative Registered Nurses (AORN) "Perioperative Standards and Recommended Practices" was adopted as the facility protocol. There were no polices specific to the facility, types of patients provided surgical care, procedures performed, equipment in the department, layout of the department and the coordination of care throughout the hospital.

2. There are no policies and procedures written, reviewed, approved and implemented governing the care provided during the recovery room phase.

3. There are no policies and procedures written, reviewed, approved, and implemented governing the central sterile processing equipment and processes.

4. The above findings were provided to the administration at the exit conference on 3/14/2012. No further documentation was provided.

Based on review of medical records, hospital documents, and personnel interviews the facility failed to provide immediate postoperative care according to acceptable standards of practice.

Findings:

1. There are no policies and procedures written, reviewed, approved and implemented governing the care provided during the recovery room phase.

2. Nine of nine surgical/procedure medical records reviewed did not have documentation of the patient's status immediately post operative, during the recovery phase, and at discharge.

3. Nine of nine surgical/procedure medical records reviewed did not have post anesthesia care orders. There were no orders specific to the immediate postoperative care episode. Documentation indicated patients received oxygen, medications, and frequent monitoring of vital signs. The orders did not reflect the type of care provided to the post surgical patients.

4. Nine of nine surgical procedure medical records did not include the patient status at the time of discharge. There was no documentation the anesthesia provider or the physician assessed and cleared the patient for discharge. There was no discharge criteria developed, reviewed, approved, and implemented to provide for a safe discharge.

5. Several of the surgical/procedure patients did not have documentation a registered nurse assessed or cared for the patient during the immediate postoperative phase.

6. These findings were reviewed with the administration on 3/14/2012. No further documentation was provided.