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Based on review of the Pharmacy Policy and Procedure Manual, review of the "Pharmacy/Night-Locker:Entry Log" and interview, the facility failed to ensure 8 of 26 entries on the log were done so by an authorized Registered Nurse (Charge Nurse) according to hospital policy when personnel entered the Pharmacy after hours during the time period 05/09/14-06/04/14. The potential existed for the security of the Pharmacy to be compromised. Findings follow:

A. The Pharmacy Policy and Procedure Manual was reviewed on 06/03/14. At 1500 policy "PH26" was reviewed. It reflected "Registered Nurse (Charge Nurse) will have access to hospital pharmacy."
B. The "Pharmacy/Night Locker:Entry Log" was reviewed on 06/04/14 at 1430 for the time period 05/09/14-06/04/14. Eight of twenty-six entries reflected personnel entering the Pharmacy while the department was closed were not an authorized Registered Nurse (Charge Nurse).
C. During an interview on 06/04/14 at 1440, the Director of Pharmacy verified the findings.

Based on review of the Pharmacy Policy and Procedure Manual and interview, the facility failed to ensure the Pharmacy Department had responsibility for medications on four of four crash carts maintained as required by policy "PH17." The potential existed for the integrity and accuracy of the medications to be compromised. Findings follow:

A. The Pharmacy Policy and Procedure Manual was reviewed on 06/03/14. Policy "PH17" was reviewed at 1520. The policy stated "The Pharmacy Department shall be responsible for the integrity and accuracy of medications in the crash cart and use an exchange system to exchange medication trays after each use. The charge nurse or their designees are responsible for equipment maintenance, replenishment, and expiration."
B. During an interview on 06/04/14 at 1530, the Director of Pharmacy revealed the Pharmacy Department did not assume any role in the integrity and accuracy of medications of the crash carts and Nursing Service assumed that responsibility.

Based on observation and interview, it was determined the facility failed to assure clean and dirty equipment and supplies were separated to prevent the contamination and the spread of infection; failed to assure equipment was clean and the surfaces were intact to protect the porous surfaces beneath; and failed to store linen to prevent contamination. It could not be assured sources and transmission of infections and communicable disease would be prevented. The failed practice had the potential to affect the patient census of four and all patients admitted to the facility. The findings were:

A. Observation on 06/04/14 at 1200 of an area identified by the Surgical Services/Medical Surgical Manager as the "soiled utility room" revealed both clean and dirty items were stored concurrently in the room. At the time of the observation, the Surgical Services/Medical Surgical Manager identified the unlabeled bedside commode, trash bags, biohazard bags, arm boards as being clean; there was no evidence visually as to the clean status of the above items. The ladder, biohazard and sharps waste and regular trash were considered dirty. There were 31 microfiber mop pads stored on a shelf. At the time of observation, Environmental Services Employee #1 identified the mop pads stored in the room were clean and retrieved for use in the adjacent operating room suite.
B. Observation on 06/04/14 at 1300 of the Pre/Post Operative Area revealed mattresses in three of three bays (#1-#3) with cracked areas in the vinyl covering. Bay #1 and #3 had rusted areas on the surface of the stretchers. The cracked mattress covering and rusted areas prevented surface disinfection of the areas.
C. Observation on 06/03/14 of patient rooms #41, #45, and #46 revealed one chair in each of the rooms had splits and cracks in the surface of the chair material. The splits in the chair covering created an uneven surface and prevented disinfection of the porous areas. The findings were confirmed at the time of observation.
D. Observation on 06/03/14 at 1030 of the linen storage closet on the Medical Surgical Unit revealed 13 blue blankets stacked one on top of the other with the bottom blanket resting directly on the floor of the storage closet.

E. Observation on 06/03/14 at 1030 of Emergency Services Trauma Room revealed two of two fans with an accumulation of dust on the fan blades and blade housing. One fan, stationed on the top of an unused cart, was in use at the time of the survey. The findings were confirmed at the time of observation by Registered Nurse #1.


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Based on observation and interview, it was determined the facility failed to ensure x-ray table and an air purifier was free of dust and failed to ensure the wooden steps used for weight bearing x-rays were easily cleaned. The failed practice created the potential for the spread of infection due to insufficient cleaning and sanitizing and had the potential to affect any patient needing an x-ray. Findings follow.

A. During a tour of the x-ray room on 06/05/14 at 1015, the following was observed:
1) Dust on the ledge directly under the top surface of the x-ray table.
2) The stair rails were extremely rough and could not be cleaned and sanitized on a set of three wooden stairs used for weight bearing x-rays.
B. During a tour of the Ultrasound Room on 06/05/14 at 1020, an air purifier vent (pointed directly at the exam table) was observed to be coated in dust.
C. Findings were confirmed by the Radiology Supervisor at the time of the tour.

Based on review of policies and procedures and interview, it was determined the facility failed to assure the Emergency Department, Respiratory, Surgical Services, and Nursing Department policy and procedures were reviewed on an annual basis. The facility could not be assured the policies and procedures used by staff reflected current practices. The failed practice had the potential to affect all patients admitted to the facility. The findings were:

A. Policies and procedures were provided by the CNO (Chief Nursing Officer), who was also the Administrator on 06/03/14. The cover page for four of four policy and procedure binders presented included the departments: Emergency, Respiratory, Surgical Services and Nursing.
B. The cover page included a statement, "The Executive Medical Staff has approved each policy and procedure outline in this manual. Chief of staff has reviewed, verified, and signed off on the following policies and procedure based on the recommendation from medical Staff and Administration at Mercy Hospital Ozark for the calendar Year 2013." The Chief of Medical Staff and (former) Director of Nursing's signature and date was 01/21/13.
C. The findings were confirmed by the CNO on 06/05/14 at 1540.

Based on review of clinical records, interview and review of policies and procedures for Swingbeds, it was determined the facility failed to assure three of three swing-bed patients (#1-#3) were informed of their rights, both orally and in writing in a language the patient could understand, such as choose a physician, work or not work, retain and use personal items, and share a room with their spouse. The likelihood existed for all Swing-Bed patients and their legal representatives to be unaware of their rights upon admission to Swing-Bed status. The findings were:

A. Review of clinical record for Patient #1-#3 revealed no documentation of notice of patient rights for Swing-Bed patients, such as choose a physician, work or not work, retain and use personal items, and share a room with their spouse.
B. A copy of the "Patient Rights and Responsibilities" pamphlet for the facility was reviewed and did not include the patients right to choose a physician, work or not work, retain and use personal items, and share a room with their spouse.
C. In an interview with the Administrator/Chief Nursing Officer and the Swing-Bed coordinator on 06/05/14 at 1540, they stated there was not a current policy and procedure for Swing-Bed for patient rights and that "The patient rights are the same as those used by the hospital."