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Based on observation, interview and policy review, the facility failed to maintain electrical equipment to ensure an acceptable level of safety and quality for patients. The facility census was four.

Findings included:

1. Record review of the facility's undated policy "PM's & Repair of Bio-Medical Equipment," showed the following direction:
-The facility has a contract with Company X and it will perform Preventive Maintenance (PM) and Repairs on all applicable equipment. Company X will create a separate account for the purpose of maintaining an equipment inventory, documenting service events and PM's performed, and providing reports on equipment activity.

2. During a telephone interview on 04/13/12, Staff G, Director of Environmental Services, stated that he did not have a policy that addressed which pieces of equipment needed to be checked and the frequency of the checks. He stated that he only had the above policy in reference to preventive maintenance of equipment.

3. Observation on 04/03/12 at 3:25 PM showed a storage area with respiratory equipment not in use. A closer review of the equipment in the room showed the following equipment had outdated stickers:
-Equipment #003667-CHA000998 - Ventilator
According to the stickers on the piece of equipment, the equipment needed to be checked every six months. One sticker showed the equipment received a check on 06/11 and another sticker showed it required another check on 12/11. As of 04/03/12, the equipment had not been rechecked.
-Equipment: Lifepak 12 - Biphasic Defibrillator
According to the stickers on the piece of equipment, the equipment needed to be checked every six months. One sticker showed the equipment received a check on 06/11 and another sticker showed it required another check on 12/11. As of 04/03/12, the equipment had not been rechecked.

Observation of the patient care area on 04/03/12 at 3:35 PM showed the following pieces of equipment with outdated check stickers:
-Equipment: #CHA000300 - Dash 3000 - Vital Sign Machine
Contained a sticker that showed the next check should have been 09/09/11. As of 04/03/12, the equipment had not been rechecked.
-Equipment: #CHA000484 - Nihon Kohden - Vital Sign Machine
Contained a sticker that showed the next check should have been 12/09/11. As of 04/03/12, the equipment had not been rechecked.

4. During a telephone interview on 04/13/12, Staff G stated that he relied on the contracted company to keep the checks on the equipment updated and to keep records of equipment they checked and when. He concurred that the contracted company did not do an adequate job in maintaining equipment and keeping the check-ups current on them. He stated that he did not have his own records, but would start tracking each piece of equipment himself to ensure they maintain current.

Based on interview and record review, the facility failed to assure the safety of patients in non-medical emergencies, including evacuation of patients, personnel and guests, coordination with fire fighting and disaster authorities. This failure affects all staff, visitors, outpatient and inpatients. The facility census was four.

Findings included:

1. During an interview on 04/05/12 at 3:00 PM, Staff O, Emergency Response and Disaster Plan Coordinator stated that she spends most of her time functioning in her regular capacity as manager of the Radiology Department. She stated that the last person in charge of planning for the hospital's disaster response took the manual with her when she left and all she has is information she's pieced together from classes, meetings and first responder training she has received during the last four years she has worked at the facility. She stated that she has worked and attended limited training with local, state and regional coalitions including the local County Health Department, local Volunteer Fire Department and MHA, (Missouri Hospital Association).

She stated that she has not been able to spend time to develop the hospital's disaster plans, has not conducted in-house drills, such as rehearsals of mass casualty events. She stated that she has no plan written at this time for such an event, no scenario plan and no evacuation plan or location identified for relocating patients to safety in the event the facility's capability to care for patients is compromised to the point the hospital has shut down or goes on diversion.

2. Record review on 04/05/12 at 3:00 PM showed no written documentation or record of completed in-house disaster drills, no after action review/critiques, no written coordination or MOU (Memorandum of Understanding) with local and regional authorities for dedicated support or relief in a disaster situation and no plan for evacuation of the hospital if it were determined to be untenable and be forced to shut down.

Based on observation, interview and record review the facility failed to ensure ten laboratory blood tubes were removed from services even though they were expired, failed to label opened and partially used, multi-use solutions per the facility policy, and failed to ensure medications stored outside the pharmacy were secure and inaccessible to unauthorized individuals. The facility census was four.

Findings included:

1. Review of facility policy titled, "Proper Labeling, Ordering and Storage of Medication," revised 09/07, showed the following:
-Storage, dispensing and labeling of medications are in accordance with state and federal regulations, hospital policies and procedures;
-All multi-dose vials shall be dated on the date they are opened, and destroyed 30-days from the date opened;
-A crash cart containing emergency medications is kept locked with a plastic lock;
-The pharmacy will examine all nursing areas monthly to check for expiration dates.

2. Observation and concurrent interview on 04/03/12, at 9:16 AM, showed the following in the medication room:
-Five 16-oz, opened bottles of Hydrogen Peroxide, at various levels of fill, that were not dated as to when opened;
-Two blue top blood tubes that expired in 02/12;
-The Director of Nurses stated all opened, multi-use solutions should be dated when opened.

Observation in the obstetric (OB) supply room on 04/05/12, at 8:40 AM, showed two opened bottles of alcohol, at various levels of fill, that were not dated as to when opened.

Observation in OB patient room #116 on 04/05/12, at 8:58 AM, showed a 500 milliliter opened bottle of sterile water, about one-half full, that was not dated as to when opened.

Observation in OB patient room #115 (in a drawer in an infant warmer) on 04/05/12, at 9:04 AM, showed an emergency box full of medications that was unlocked, and accessible to any person, patient or visitor, in the OB unit. The box had a place for a plastic lock; however, staff failed to put one on the box. The inventory list of the medications contained in this box included such things as:
-Vitamin K injectables x 2 (clots the blood);
-Narcan injectables x 3 (used to reverse adverse medication reactions);
-Atropine Sulfate injectables x 2 (reduces secretions);
-Epinephrine injectables x 3 (used to treat cardiac arrest);
-Sodium Bicarbonate injectables x 3 (used to reduce acidity, and for overdose of certain drugs).

During an interview on 04/05/12, at 9:55 AM, the OB Supervisor, Staff Q, stated she examined the OB medication box weekly and it was supposed to be locked with a plastic lock; however, she did not know how/why/when the box became unlocked. Staff Q stated the alcohol was used to clean the newborn umbilicus, and it was to be dated when opened.

Observation in the Emergency Department Trauma Room Crash Cart on 04/03/12 at 9:00 AM showed:
-Two red top blood tubes, one that expired in 06/11 and one that expired in 10/11;
-Two blue top blood tubes that expired in 06/11;
-Two green top blood tubes that expired in 08/11; and
-Two purple top blood tubes that expired in 11/11

During an interview on 04/03/12 at 9:30 AM Staff M, ER (Emergency Room) Supervisor, stated that the ER nurses are responsible to check expiration dates and that they must have missed those.

Observation in the "Endoscopy Room (a procedure to examine the esophagus (swallowing tube), stomach, and duodenum (first portion of the small bowel) on 04/04/12 at 9:45 AM showed the room was unlocked and not in use. An unlocked "Anesthesia cart" located in the Endoscopy Room showed:
-Two vials of Glycopyrrolate (medication used to control muscle spasms);
-One vial of Anectine (a medication used to paralyze patient during surgery) 200 milligrams (unit of measure) per 10 milliliters (unit of volume) in an unlocked drawer. The medication had a manufacturer's expiration date of 02/12.

During an interview on 04/04/12 at 10:00 AM Staff K, Operating Room Supervisor, stated that the Surgical area has limited access but just last week she found a delivery man wandering through the area. Staff K stated that medications should always be secured.


29511

Based on observation, interview and policy review, the facility failed to prescribe five (Patients #21, 26, 27, 28 and 29) of eight discharged patients' diet orders in accordance with the current diet manual's terminology and according to its policy. The facility census was four.

Findings included:

1. Record review of the facility's Policy titled "Diet Reports, Diet Orders, Diet Changes," dated 04/05/11 showed the following direction:
-Any dietary regimen served a patient is ordered by the attending physician or Family Nurse Practitioner (FNP) on duty. Any changes or modifications of that diet are ordered by the physician or FNP. The prescribed diet is then interpreted and transcribed into food by the Nutritional Services Staff.
-The diet order or any change, discontinuance, or modification of the diet order is made by the physician, and the signed order is recorded on the physician's order sheet in the patient's medical record.
-Diets should be ordered using the terminology of the approved diet manual.
-Combination diets should be clearly specified, such as Heart Healthy consistent carbohydrate diet or 2 gram (gm) Sodium, Soft Diet.
-The diet order for various levels of nutrients (such as grams of protein, milligrams (mg) of sodium, etc.) should include the specific level desired, ie: (that is) 20 gm protein, 2 gm Sodium according to the online American Dietetic Association (ADA) Nutrition Care Manual.
-A "Diet as Tolerated" (DAT) diet ordered by the physician shall be determined by the nurse in charge. He or she will decide the type of diet depending on the diagnosis and condition of the patient. The diet needs to be specified on the order following the DAT order.

2. Record review of Patient #21's diet order dated 01/23/12 at 1:12 PM showed the physician ordered a diabetic diet, which was not a diet terminology in the approved Diet Manual. Staff S, Registered Dietitian (RD) interpreted the diet order as and served the patient a Consistent Carbohydrate Diet.

Record review of Patient #26's diet order dated 01/11/12 (no time indicated) showed the physician ordered a diabetic diet, which was not a diet terminology in the approved Diet Manual. Staff S, RD, interpreted the diet order as and served the patient a Consistent Carbohydrate Diet.

Record review of Patient #27's diet order dated 01/23/12 at 3:00 PM showed the physician ordered a Diet as Tolerated, which was not a diet terminology in the approved Diet Manual. Nursing Staff and Staff R, Certified Dietary Manager, (CDM), interpreted the diet order as and served the patient a Regular Diet, but did not specify the diet's interpretation on the order following the DAT order as directed by the facility's policy.

Record review of Patient #28's medical orders dated 03/06/12 at 10:35 AM through 03/13/12 at 1:15 PM showed the physician did not order a diet for the patient during his entire admission to the facility. Staff R indicated on her nutritional assessment that the patient received a Regular Diet.

Record review of Patient #29's diet order dated 01/18/12 at 7:00 PM showed the physician ordered a General Diet, which was not a diet terminology in the approved Diet Manual. Nursing Staff and Staff R interpreted the diet order as and served the patient a Regular Diet.

3. During an interview on 04/05/12 at 10:39 AM, Staff R stated that she and Staff S missed some of the charts' diet orders that needed clarification by the physician in the instance in which the physician did not order a diet for the patient. She stated that she knew she should have gotten a diet order for the patient prior to serving food to the patient.

Staff R stated that she and Staff S interpreted Diet as Tolerated as a Regular Diet and Diabetic Diet as Consistent Carbohydrate Diet. She stated that she and Staff S interpreted and served them to the patients without getting clarification from the attending physician.

Based on observation, interview and record review the facility failed to develop individualized, comprehensive care plans based upon the history and assessment for five of five patients (#1, #2, #3, #4, and #5) reviewed. The facility census was four.

Findings included:

1. Review of a facility policy titled, "Patient Care Plans," revised 10/09, showed the following:
-The care plan provides the basis for all patient care and provides continuity;
-The admission nursing assessment is the basis of the care plan. Numerous problems may be found relating to several systems, requiring more than one care plan;
-Care plans are revised and kept current based on patient response and re-evaluation.

2. Review of Patient #1's History and Physical (H & P), dated 03/31/12, showed the patient was admitted on 03/30/12 with a diagnosis of pneumonia (a lung infection).

Review of Patient #1's Emergency Department records, dated 03/30/12, showed the patient had back pain at all times.

Review of Physician's orders, dated 03/30/12 showed the patient had community acquired pneumonia.

Review of Physician's orders, dated 03/31/12, showed the following: Ultram 100 milligrams (mg) every four hours as needed for pain. The patient also had orders for two intravenous (IV) antibiotics, Levaquin 750 mg, and Doxycycline 100 mg every 12-hours.

Review of medication administration records from admission through 04/02/12, showed the patient received the Levaquin daily, the Doxycycline twice daily (each 24-hour period), and the Ultram five times.

Review of the patient's 03/30/12 care plan, on 04/02/12, showed staff failed to address the patient's pain and pneumonia infection. Therefore, there were no goals or interventions related to these problems.

During an interview on 04/02/12 at 4:05 PM, Registered Nurse (RN) Staff member A, stated the RN admitting the patient initiated the care plan, and then each subsequent nurse reviewed it, updating it as appropriate. Staff A stated the computerized care plan system was capable of addressing the problems pain and infection, and the nurse could individualize/add or delete information as necessary.

3. Review of Patient #2's H & P, dated 04/01/12, showed the patient was admitted on 03/31/12 with a diagnosis of bronchial pneumonia.

Review of medication administration records from admission through 04/02/12, showed the patient received antibiotics called Azithromycin 500 mg IV and Ceftriaxone 1 gram every 24-hours.

Review of the patient's care plan, dated 03/31/12, showed staff failed to address the patient's pneumonia infection. Therefore, there were no goals or interventions related to this problem.

4. Review of Patient #3's H & P, dated 04/02/12, showed the patient was admitted that day, at 10:33 AM, with a diagnosis of pneumonia.

Review of the nursing admission assessment, dated 04/02/12, showed the patient was hard of hearing and had hearing aides, but did not wear them.

Review of medication administration records from admission through approximately 4:30 PM on 04/02/12, showed the patient received antibiotics called Zosyn 3.375 grams IV at 12:13 PM, and Azactam 1 GM IV at 2:14 PM.

Observation and interview on 04/03/12 at 11:15 AM, showed patient #3 sitting in a recliner chair in his room. Patient #3 said he had hearing aides but did not like them. Patient #3 had to ask the surveyor to repeat questions over and over so he could hear. Patient #3 would cup his left ear and lean into the surveyor so as to hear better.

Observation on 04/05/12 at 10:00 AM, showed the patient received an IV dose of Zyvox 600 mg IV. The nurse administering this medication, Staff Y, stated the patient was very hard of hearing and this medication was for his pneumonia infection.

Review of the patient's care plan, on 04/02/12 at approximately 4:40 PM, showed staff failed to address the patient's pneumonia infection, and hard of hearing status. Therefore, there were no goals or interventions related to these problems.

5. Review of Patient #4's H & P, dated 04/01/12, showed the patient was admitted on 03/31/12 with a diagnosis of pneumonia, and a history of lung cancer with resulting chemotherapy, requiring an implanted IV port in his upper left chest.

Review of nursing progress notes, dated 03/31/12, showed the patient required partial assistance for mobility. A progress note dated 04/02/12, at 1:06 PM, showed the patient received an IV antibiotic called Vancomycin. On 04/03/12, at 1:10 AM, the patient was found on the floor, on his back. The patient sustained an abrasion to the left eye, along with some swelling.

Observation on 04/05/12, at approximately 10:15 AM, showed Staff Y de-access (take the needle out of the skin/port-this is a sterile procedure to prevent infection in the bloodstream) the patient's IV port.

Review of the patient's 03/31/12 care plan, on 04/02/12, showed staff failed to address the patient's pneumonia infection, implanted port care, and falls/safety. Therefore, there were no goals or interventions related to these problems.

6. Review of discharged Patient #5's H & P, dated 02/06/12, showed the patient was admitted to Swing Bed status (an admission requiring skilled care for specialized reimbursement) on 02/10/12, with a diagnosis of back discomfort from previous fractures, and a history of moderate to severe constipation. The patient was discharged on 02/16/12.

Review of the admission physician's orders, dated 02/10/12, showed the patient received a pain patch called Duragesic, 25 micrograms every three days, Tylenol as needed, and Milk of Magnesia as needed for constipation.

Review of the nursing admission assessment, dated 02/10/12, showed the patient said she had not had a bowel movement for six days, and had chronic back pain.

Review of Physical Therapy (PT) notes, throughout the patient's stay, showed the patient complained of pain when ambulating, sitting or transferring. Staff documented some pain ratings as high as "8" on a scale of "1-10", with "10" being the worst pain.

Review of the patient's 02/10/12 care plan, on 04/03/12, showed staff failed to address the patient's constipation, and chronic pain. Therefore, there were no goals or interventions related to these problems.

Based on interview and record review, the facility failed to provide a complete discharge summary for six (Patient #19, 21, 27, 30, 31, and 32) of eleven discharged patients' reviewed for medical record completion. The facility census was four.

Findings included:

1. Record review of the facility's policy "Documentation of History and Physical and Discharge Summary," revised 10/09 showed the following direction:
-A Discharge Summary on all inpatient medical records shall be completed within 14 days of discharge by the attending physician.
-Discharge Summary information to include primary diagnosis and secondary diagnosis description of course in the hospital, discharge instruction and follow up.

Record review of the facility's "Medical Staff By Laws, Rules and Regulations," dated 06/24/08 showed the following direction:
-A discharge summary shall be written or dictated on all medical records of patients hospitalized.
-In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result.

2. Record review of Patient #19's medical record showed that he was admitted to the facility on 01/18/12 for sigmoid colon colectomy (removal of the s-shaped colon). Record review of the facility's discharge summary for the patient showed a 3-line summary of the patient's stay in the facility. The summary did not give a complete diagnosis description of the course of the patient's stay in the facility nor did it include discharge instructions to the patient other than to follow up with a physician the following week.

3. Record review of Patient #21's medical record showed that she was admitted to the facility on 01/23/12 for pneumonia. Record review of the facility's discharge summary for the patient showed a 3-line summary of the patient's stay in the facility. The summary did not give a complete diagnosis description of the course of the patient's stay in the facility, the patient's disposition nor did it include discharge instructions and follow up instructions to the patient.

4. Record review of Patient #27's medical record showed that she was admitted to the facility on 01/23/12 for respiratory failure secondary to pneumonia. Record review of the facility's discharge summary for the patient showed a 4-line summary of the patient's stay in the facility. The summary did not give a complete diagnosis description of the course of the patient's stay in the facility.

5. Record review of Staff Z's, Physician Peer Reviewer, peer review of Patients #30, 31 and 32's medical records showed the following:

-Patient #30 was discharged on 02/15/12 with a discharge diagnosis of bronchitis. The report showed that the facility failed to provide a complete discharge summary of the patient's admission. The peer reviewer noted #7 (Discharge Summary) as "2 Lines - No detail."

-Patient #31 was discharged on 02/28/12 with a discharge diagnosis of pneumonia. The report showed that the facility failed to provide a complete discharge summary of the patient's admission. The peer reviewer noted #7 (Discharge Summary) as "usual format."

-Patient #32 was discharged on 03/31/12 with a discharge diagnosis of dementia, Chronic liver failure and history of falls. The report showed that the facility failed to provide a complete discharge summary of the patient's admission. The peer reviewer noted #7 (Discharge Summary) as "No comments about labs and x-ray findings."

6. During an interview on 04/05/12 at 9:48 AM, Staff O, Health Information Manager (HIM), stated that the facility had problems with incomplete discharges for the past 10 years. She stated that the she discussed the issue with the physician in violation and he told her he covered everything he needed to cover in his reports. Staff O stated that sometimes she must ask the physician in violation to write more on his reports to end up with the information on the discharge summaries she received.

Based on observation, interview and record review, the facility failed to ensure the confidentiality of patients' medical records were safeguarded and protected from the possibility of loss, destruction or unauthorized persons reviewing them by:
- Allowing 70 staff other than Medical Records Staff badge access to the Medical Records Department in the absence of Medical Records Staff.
-Allowing Maintenance staff to transport outdated medical records to shredder in the absence of Medical Records' Staff. The facility census was four.

Findings included:

1. Record review of the facility's policy "Confidentiality of the Medical Record and Patient Information," dated 04/03 showed the following direction:
- The patient's clinical record is the property of the hospital and it is the responsibility of the hospital and its staff to safeguard both the record and information contained in the record from loss, defacement, tampering and observation or use by any unauthorized individual.
- Only individuals directly involved in the patient's care are allowed access to the medical record or any information contained in the medical record.
-Written consent of the patient or his legal representative is required for release of medical information to persons not otherwise authorized to receive information.

Record review of the facility's policy "Confidentiality of the Medical Record," dated 11/05/08 showed the following direction:
-For confidential purposes as well as legal, no one shall have access to the information documented in the patient's medical records.
-This does not include Health Information Management (HIM) personnel, physicians, or other medical or administrative personnel who have a professional "need to know" for treatment, payment or healthcare operations.
-Written consent shall be obtained from the patient or the patient's legal representative for access to/or release of copies of the patient record.

2. Observation on 04/04/12 between 10:35 AM and 11:30 AM, 1:30 PM and 3:30 PM and on 04/05/12 between 9:15 AM and 10:30 AM showed various hospital staff, such as Administrative Staff, Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) in various patient care areas, Patient Accounts Staff, etc. used their badges to enter the HIM department.

During an interview on 04/04/12 at 10:45 AM, Staff O, Health Information Manager, stated that Administrative Staff, the physicians, Nurse Practitioners (NP), RNs and some other medical professionals had access to the department with their employee identification badges. Staff stated that Maintenance and Housekeeping Staff did not have access to the department with their badges.

During an interview on 04/05/12 at 9:48 AM Staff O stated that she needed to correct a previous statement she made. She stated that the two housekeeping staff had access to the department with their badges, but maintenance did not have access to the department. She stated that the housekeeping staff usually cleaned the department during the hours of operation in the presence of HIM Staff.

3. Record review of the list of hospital personnel who had badge access to the HIM department showed that a total of 69 non-HIM Staff and one non-staff (Johnson Controls Staff - Staff from an outside company who serviced the facility's computer system) had access to the department. In addition to the group of staff in the above paragraph who had badge access to the department, the following staff also had badge access to the department: Radiologist and Radiology Technicians (Techs), Laboratory Medical Techs, Human Resource (HR) Coordinator, Outpatient Scheduler, Clinical Assistants, Social Services Staff, Rehabilitation Clerk/Tech, Respiratory Staff, Admitting Manager, Sterile Supply Tech, Operating Room (OR) Tech and Material Management Staff.

During an interview on 04/04/12 at 10:55 AM, Staff O stated that the 69 Staff from the various departments had access to the department to access records if they needed to in the absence of the HIM staff. Staff stated that the facility had a security system that tracked who entered the department with badges and at what time. However, the system did not have a way to track what medical records staff accessed once they entered the department. Staff O concurred that the facility's Staff who entered the department had the capability of accessing whatever patients' record they wanted to once they entered the room.

4. Observation on 04/05/12 at 11:15 AM showed the HIM department stored several years of patients' medical records on shelves in the department. The opened, general area of the medical records department contained four or five rows of storage racks that contained complete patients' medical records stored on the front and back of each row. Observations showed the medical records included the name, address, phone number, social security number, date of birth, age and marital status, diagnoses, treatment orders, insurance information, and billing charges of the patient.

Observations also showed approximately 6-8 boxes stacked in a corner of the room labeled to be shredded. A closer look at the content in the boxes showed complete old patients' medical records that past the destroy dates and needed to be shredded. The boxes holding the content of the old records did not have secured lids.

During the interview on 04/05/12 at 11:20 AM, Staff O stated those boxes of records needed to be destroyed and the Maintenance Staff accompanied those records to the destroy site off facility's grounds. When asked if any HIM Staff also accompanied the Maintenance staff and she stated they did not.

Observations showed the boxes contained complete patients' medical records, which included the name, address, phone number, social security number, date of birth, age, marital status, diagnoses, treatment orders, insurance information, and billing charges of the patient.

Based on interview, record review, and policy review, the facility failed to:
- Ensure that there was an effective, ongoing, comprehensive, hospital-wide quality assurance/performance improvement program, responsible to the Governing Body, which would lead to reduced medical errors, adverse events, and improved patient health outcomes;
- Ensure collaborative participation from both clinical and nonclinical areas of service;
- Provide for assessment and coordination of quality improvement activities through an established oversight team that meets on an established periodic basis; and
- Ensure ongoing communication, reporting and documentation of patient-care issues and quality improvement activities and their effectiveness to the governing body at least quarterly. The facility census was four.

Findings included:

1. Record review of the facility's policy titled, "Performance Improvement Program," dated 11/09, showed the following direction:
-Policy Statement: [The facility] is committed to Quality Assessment and Continuous Performance Improvement to ensure quality care, efficiency, and continuous improvement of our work processes. This program is approved by the Board of Directors and the CEO [Chief Executive Officer.]
Employees, Medical Staff, Nurse Practitioners, and Contract Services are participants in our Performance Improvement Program.
-Purpose: To evaluate patient care services and other services affecting patients' and stakeholders' health and safety.
-Responsibility: Medical Staff, Department Directors, Managers, and Supervisors
-Procedure: Medical Staff, Department Directors, Managers, and Supervisors will be responsible to evaluate the services their department provides through ongoing monitors and data collection, development of goals and measures for improvements; implement action or correction plans, when appropriate, evaluate effectiveness of correction actions, and perform ongoing analysis for problem prevention, identification and improvement.
Project reports will be given at the scheduled monthly meetings (Medical Staff, Department Directors and Supervisors and the PIOC (Performance Improvement and Oversight Committee).

Record review of the facility's document titled, "Periodic Evaluation for the Fiscal Year Ending June 30, 2011, "showed a summary of review for multiple departments but did not include a summary for some ancillary services such as Maintenance, Laundry, Housekeeping or contracted services. Data pertaining to Incident Reports, Complaint/Grievance data, Orientation and Continuing Education, etc. was not included in the annual report.

There was no evidence of recommendations made as a result of the data in the report. There was no evidence that the information was analyzed related to patient care improvements. There was no evidence that the report was shared with the Governing Body, the Center for Medicare and Medicaid Services (CMS) approved Quality Improvement Organization (QIO), or with a collaborative facility.

Record review of the Board of Directors Meeting Minutes for March 27, 2012 and December 20, 2011 showed no reporting or discussion of specific Quality monitoring activity.

Record review of the Performance Improvement Oversight Committee meeting minutes of 3/ 27/12, 2/28/12, and 1/24/12 showed no reporting, analysis or discussion of individual department data collection or monitoring.

2. During an interview on 04/3/12 at 9:30 AM, Staff M, ER (Emergency Room) Supervisor, stated that she did not know of any quality or performance improvement projects for the ER. Staff M stated that the ER charts were audited for completeness of documentation and follow up calls were made to discharged patients but wasn't sure what information was tracked or trended.

During an interview on 04/3/12 at 11:00 AM, Staff X, Director of Radiology, stated that the department does some internal audits of radiation badges, fluoroscopy, and has a Physicist visit once a year but she does not submit data for review or analysis to the Performance Improvement Oversight Committee.

During an interview on 04/3/12 at 2:00 PM, Staff L, Director of Pharmacy, stated that all orders are reviewed and data regarding core measures was collected but "not much else" was reported to the Performance Improvement Oversight Committee.

During an interview on 04/4/12 at 11:15 AM, Staff J, Lab Supervisor, stated that a lot of data was collected on lab results, lab equipment, and lab operations but "we don't send much" to the Performance Improvement Oversight Committee.

During an interview on 04/5/12 at 12:55 PM, Staff P, Chief Operating Officer, stated that "It's a weak spot" (referring to the aggregation, analysis, and reporting up of Quality Information).

During an interview on 04/05/12 at 09:20 AM, Staff G, Environmental Services Director, stated that maintenance was not currently participating in an integrated facility-wide quality assurance (QA) program. He stated that the work order system they use is computerized and he periodically checks outstanding work orders against those completed, but he does not tabulate or use the data as a monitor of the contribution maintenance makes toward improved patient care. He stated he constantly monitors the status of maintenance needs in the facility but has not been tasked to assimilate data and present it to a quality assurance committee, Medical Staff or Board of Directors.

3. Record review on 04/05/12 at 9:20 AM showed the maintenance department had documented several potential performance improvement projects (mostly on computer files) but had not compiled evidence that could aid in development of a QA program to improve the Maintenance Department's contribution to improved patient care.

During an interview on 04/05/12 at 10:40 AM, Staff G, Environmental Services Director, stated that he makes regular rounds on rooms that have been cleaned. He stated that he does not document and does not do comparative surveys to measure the effect housekeeping and laundry services may have on patient care. He stated that he does not have a formal written policy on quality improvement, but daily completes rounds on an average of 69 rooms a month to check on the progress of housekeepers. He stated that he often uses a black light to scrutinize hard-to-reach spaces for fingerprints and signs of neglect. He stated he is not currently submitting any paperwork or written data scorecard information for the purpose of quality improvement. He stated that he uses the information from patient survey cards, black light rounds, and random interviews with department managers ("formal rounds") to gauge the effectiveness of housekeeping and laundry services. He stated that both clinical and non-clinical department directors have an opportunity at least one time annually to report progress and new challenges, such as shortage of staff or having to train additional staff. He stated that there were no formal policies or procedures to address quality assurance and performance improvement projects in the Laundry Department. He said most of the interaction there was ongoing inspection of linen for "rag-out" (torn, frayed or non-serviceable), and regular preventive maintenance to washers and dryers.

4. Review of a facility-provided nursing quality Periodic Evaluation of Services, for fiscal year 7/10-7/11, showed a summary of multiple issues, but staff failed to include a review and summary for specific nursing unit, health-related, indicators, with the exception of identifying the most common diagnoses over the prior year.

During an interview on 04/03/12, at 2:37 PM, the Director of Nurses, Staff D, stated the nursing quality monitoring included patient satisfaction, congestive heart failure and chronic obstructive pulmonary disease (both lung diseases).

Staff failed to present, even though requested, analysis and trending of data and documentation of evaluation and/or corrective action implementation after issue identification. Staff also failed to identify, via documentation, any other unit-specific nursing issues tracked and/or included in the quality plan.

5. During an interview on 04/03/12, at 3:07 PM, the Social Service Designee, Staff F, stated the quality monitoring she had completed was to address failure of the front office staff to complete patients' demographic information, during the admission process. However, this process had not been documented. Staff F stated she also monitored appropriate completion of the form, "Important Message," by staff. However, this was not documented, trended, or formally analyzed for future inquiry. Staff F stated she had not attended, or been involved in, an overall, multidisciplinary quality meeting for a few years.

During an interview on 04/04/12, at 8:38 AM, the Utilization Review Registered Nurse, Staff N, stated that she reviewed emergency, outpatient, observation, and random acute charts for many things. However, she did this without department direction, and did not have a formalized/structured plan. Staff failed to document that the chart audits lead to corrective action implementation, or that the issues identified were analyzed for trends, or continued correction.

During an interview on 04/05/12, at 11:00 AM, Staff Q, Obstetric Supervisor, stated that she follows up on issues in the department as they occur. There was no formalized, documented quality plan for her department. She identified no trends or systemic problems with intervention and review documentation. Staff Q stated she had not attended a quality meeting to discuss her findings since 12/11, or approximately four months prior.

6. Record review of a facility-provided Nutritional Services quality Periodic Evaluation of Services report for fiscal year 2011 showed the following:
-Utilization of services;
Number of patient meals served
Total meals served for fiscal year 2011
Volume of services
Changes of services
-Review of clinical records;
Active and closed records not less than 10% of all services provided
-Evaluation of health care policies.
Policies and procedures revised or deleted: Reviewed all policies
Revised: Guest meal trays which included pediatric/parent meals; Diet orders (changed wording for on-line diet manual; and Tube feeding policy.

Record review of the report showed the patient assessments decreased 15% from previous fiscal year. Inpatient diet instructions increased by one patient and outpatient decreased. Total meals decreased by 2.5% from the previous year.

Review of the report showed the facility did not analyze and trend data. Staff also did not document the evaluation and/or corrective action implemented after issues identified. Review of the documentation showed that Staff failed to identify other unit-specific nutrition care issues tracked and/or included in their quality plan.

7. During an interview on 04/03/12 at 10:43 AM, Staff R, Certified Dietary Manager (CDM), stated that she monitored department specific issues, but did not report those to anyone. She stated that the department no longer reported on a quarterly basis, but prepared an annual evaluation of services report of the department for the Administrator. She stated that the facility also currently used the Balanced Score Card for reporting issues.

8. Record review of the Balanced Score Card showed that most of the items the department focused on did not pertain to nutrition care services. The Balanced Score Card consisted of the following topics:
-Financial
-Customer and Community Satisfaction
-Learning, Leadership and Facilities
-Internal and Clinical Processes
-Prevent Healthcare Associated Infections
-Prevent Harm from Drugs
-Pneumonia Measures
-Congestive Heart Measures

Staff R stated that she noticed some of the items on the Balanced Score Card did not pertain specifically to her department, but she tried to adapt them the best that she could.

9. During an interview on 04/03/12 at 1:05 PM, Staff T, Director of Rehabilitation (rehab) Services, stated that she was new to the position, but currently monitored outpatient rehab appointment logs for no-shows and cancellations of appointments. She stated that she noted a larger percentage of patients missed appointments that she anticipated. Staff T stated that she coordinated care with nursing services for occupational therapy services by starting a communication board. She stated that she also tracked hand hygiene. Staff T stated that she was in the data-gathering process and only monitored those items for the past two months. She stated that she attended the monthly department head meetings and she discussed items for the Balanced Score Card.

10. Review of the Periodic Evaluation of Services report for Rehabilitation Services showed the previous Director failed to submit a report for fiscal year 2011.

11. During an interview on 04/03/12 at 2:41 PM, Staff U, Director of Respiratory Services, stated that she had been in the position for two months and had only assessed the need for and provided
respiratory training to the nursing staff. She stated that she planned to start smoking sensation at the facility, but had not implemented it. She stated that she attended the monthly department head meetings and she discussed items for the Balanced Score Card.

Review of the Periodic Evaluation of Services report for Respiratory Services showed the previous Director failed to submit a report for fiscal year 2011.

12. During an interview on 04/04/12 at 9:30 AM, Staff V, Director of Cardiac Rehabilitation Services, stated that she had only been in the position for 3-4 months, but currently monitored pre/post outcomes to see if outcomes changed. Staff V stated that she conducted chart audits to ensure patients signed all consent forms, physician signed all orders, staff signed all care plans, treatment plans and staff and patients used equipments safely. She stated she collected her data and reported it in the monthly meeting, but did not turn it in to anyone because no one asked for it. She stated that she also discussed items for the Balanced Score Card.

Review of the Periodic Evaluation of Services report for Cardiac Rehabilitation Services showed the previous Director failed to submit a report for fiscal year 2011.

13. Record review of current quality monitoring throughout the facility showed surveillance in various areas of the facility (emergency department, radiology, pharmacy, laboratory, nursing, outpatient, obstetrics, observation, nutrition, dietary. rehabilitation, respiratory, cardiac rehabilitation) but there was no evidence of analysis and systematic performance improvement applications. Some Department Directors collected data, but the data was not elevated to an appropriate level for review and analysis. A few departments within the facility had no quality improvement surveillance in place (maintenance, laundry, housekeeping), or had ineffective quality improvement activities.


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