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

Findings:

1. Upon arrival at the hospital on the morning of 02/21/2012, the surveyors asked for infection control policies, infection control plan surveillance/monitoring activities and meeting minutes for infection control.

2. Staff provided the infection control policy manual on the afternoon of 02/22/2012. The manual, with policies and procedures and the infection control plan had not been reviewed and updated to demonstrate it was based on current nationally recognized infection control guidelines. According to documentation, the infection control policies were last reviewed in 2007. This finding was confirmed with Staff G, the individual identified as the infection control preventionist, on the afternoon of 02/22/2012.

3. The plan did not contain a date to identify whether it had been reviewed or if it was the current plan. Meeting minutes for the past year did not contain evidence the plan had been review and revised. The plan did not specify what, how, or how often monitoring would occur to ensure policies and procedures were followed and the hospital maintained a sanitary environment preventing infections and communicable diseases among patients and staff.

4. Other than the monthly list of positive cultures with antibiotic sensitivity report attached to the medical staff meeting minutes, no monitor activities were provided. Staff G stated on the afternoon of 02/22/2012 that he and other staff monitored and educated staff, but no documentation was provided. Meeting minutes did not reflect monitoring/surveillance review or analysis.

5. Other than the monthly list of positive cultures with antibiotic sensitivity report attached to the medical staff meeting minutes, an infection control log was not provided. Staff G stated on 02/22/2012 that he did not have an infection control log with the required information for staff and patients.

6. Review of hospital documents and meeting minutes did not show the infection control program had been reviewed, evaluated and revised to ensure the program included monitoring of the environment to provide a safe and sanitary environment; and provisions to identify, investigate, report, and prevent the spread of infections and communicable diseases among patients and the staff, including contract staff, physicians and allied health workers and volunteers.

7. The meeting minutes provided did not demonstrate the hospital reviewed and analyzed infection control problems, concerns, and infections to ensure a safe and sanitary environment. There was no evidence the data collected by Staff G had been reviewed and analyzed to ensure antibiotic therapy was appropriate.

8. Review of the hospital documents and meeting minutes did not contain staff health and immunization histories. Staff G stated on the afternoon of 02/22/2012 that he did not track this. He stated Staff D did this, but he did not report it.

9. Review of documents and the personnel file provided did not demonstrate Staff G was provided ongoing education in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program. Other than continuing education in laboratory leadership and hospital required education, Staff G had one class, "Introduction to Basic Epidemiology", that dealt with infection control. Staff G confirmed he had not taken any other classes/training on establishing and implementing an effective and ongoing infection control program based on current infection control guidelines.

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

Findings:

1. On the afternoon of 2/22/12 Staff D told the surveyors that Staff H did all of the nutritional screens on patients. Staff D did not know a specific time frame for completion. In an interview on 2/22/12 with Staff H, Staff H told surveyors she did all of the nutritional screens and when a patient required a nutritional assessments she completed those as well. Staff H told surveyors the contract dietitian would review some of assessments.

2. Dietary and nursing policies did not include a policy and procedure for nutritional screens/nutritional consults. In an interview on 2/22/12 Staff H told surveyors she would attempt to complete the nutritional screen on a patient within the first 24 hours of admission but there were no screens completed on the weekends or if she was off. Review of nursing and dietary policy manuals did not include a policy regarding nutritional screen and nutritional assessment. This finding was reviewed with Staff H.

3. The hospital uses the services of a consultant dietitian. Staff B told surveyors on 2/21/12 Staff I was the consultant dietitian. Staff I did not have documentation of orientation and training in the facility. Staff I did not have a current license/certification.

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

5. The above findings were reviewed with the administrative team at the exit conference on 2/22/12. No further documentation was provided.

Based on policy and procedure manual review and interview with the hospital staff, the hospital failed to ensure policies are reviewed at least annually.

Findings:

On the morning of 2/21/12 surveyors were given copies of the Radiology, Nursing, Dietary Department policy and procedure manual. No review and approval of the policies since 2005 was documented.

1. On the morning of 2/21/12 Staff O told surveyors the Radiology Department did not have current policies because the computer had crashed. There was no evidence the hospital had reviewed, approved, and implemented radiology policy and procedure.

2. On the morning of 2/21/12 Dietary department policies were provided to surveyors. The latest review and revision was dated 2005. In an interview 2/22/12 Staff H told surveyors the department did not have current policies.

3. On the morning of 2/21/12 Physical Therapy policies were provided to surveyors. The latest review and revision was dated 3/2001. The policies were from a contracted outpatient physical therapy company. Many of the policies included treatments that were not provided at the facility. There was no current infection control policies for cleaning and decontaminating equipment, hand hygiene, and isolation protocols.

4. On the morning of 2/21/12 Nursing policies were provided to surveyors. The latest review and revision was dated 9/15/10.

5. On the afternoon of 2/22/12 Infection Control policies were provided to surveyors. The latest review and revision was dated 2007 There was no evidence current infection control practices recommended through national resources had been developed, reviewed, approved, and implemented throughout the hospital.

6. The above findings were reviewed with administrative team members on the afternoon of 2/22/12. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that all nursing staff have competencies and job descriptions specific for their job assignment and have been deemed competent by a peer qualified to assess their competency. Two (U and V) of two (U and V) nursing personnel files reviewed did not have performance evaluations by a peer qualified to evaluate their job performance. One (U) of two (U and V) personnel files reviewed did not have a job description of their primary responsibility as the Drug Room Supervisor.

Findings:

1. Staff U did not have a performance evaluation by the Consultant Pharmacist evaluating her primary job duties as the Drug Room Supervisor. The only evaluation was for her duties as a Charge Nurse.

2. Staff V, a Licensed Practical Nurse, did not have a performance evaluation by a peer (nurse). The performance evaluation was performed by the business office director.

3. Staff U did not have a job description for her primary responsibility as the hospital's Drug Room Supervisor.

4. These findings were verified by hospital staff on 02/22/12 in the afternoon.

Based on review of rehabilitation policy and procedure, hospital documents, personnel files and interviews with staff, the facility failed to ensure the scope of rehabilitative services meet the needs of the patients.

Findings:
1. On the morning of 2/21/12, Staff A provided surveyors contracted physical and occupational therapy services policies. The policies did not include a scope of services or the types of rehabilitative treatment provided by the facility. The policies are not approved by the Medical Staff.

2. In an interview with Staff A on the morning of 2/21/12 surveyors were told rehabilitation services were provided by contract therapists and therapy assistants. Four of four (Q,R,S,T) contract therapy personnel selected for review did not have current licenses, job descriptions, hospital orientation and training, competencies, or evaluations.

3. Inpatient physical therapy evaluation and treatment notes are documented in the electronic medical record.
a. Four of seven patients (Patients #1,2,13 and 14 of Patients #1, 2, 10, 11, 12, 13 and 14) receiving physical therapy or occupational therapy did not have documentation of evaluations with all the required elements. Many of the patients with orders for therapy did not have documentation of evaluations by a qualified practitioner. Many of the patients with orders for therapy did not have all treatments documented.
b. Patient #13 received physical therapy on 01/25/2012 and 01/26/2012 without physician's orders. The only order was for evaluation and treat. The initial physical therapy evaluation, performed on 01/24/2012, although it contained the required elements (modalities, frequency of visits and duration), was not signed by the physician.
c. Patient #14 received physical therapy and occupational therapy without orders. The only order by the physician was for evaluation and treat. The occupational evaluation, which contained the required elements, was not signed by the physician. The physical therapist did not perform an evaluation, but treatments were provided based on the initial evaluation performed by the therapist on 01/24/2012, during the patient's acute care stay.

4. Medical Staff Meeting minutes for 2011 did not include a of review of the rehabilitation services. Quality Assurance Meeting Minutes did not include a review of the rehabilitation services. There was no evaluation the rehabilitative services provided met the needs of the patient.

5. The above findings were reviewed with administration in the exit conference. No further information was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure the periodic evaluation includes a review of the CAH's health care policies. Radiology, Nursing and Dietary Department policy and procedure manuals had not been reviewed/revised since 2005. The hospital's annual review did not have any documentation of review of these policies. Hospital staff verified on 02/22/12 in the afternoon that review of policies had not been done.

Based on review of the hospital's death register, the written contract with the OPO (organ procurement organization - LifeShare of Oklahoma), the referral Activity Report from the OPO for the time period of January through December 2011, medical records and hospital documents, and interviews with hospital staff, the hospital failed to:
1. Enforce its patient death protocol/contract with OPO, concerning reporting to the OPO, for nine of forty-two deaths that occurred in the hospital; and
2. Include in its policies and Quality program how referrals would be tracked through the Quality program to ensure all deaths were reported to the OPO.

Findings:

1. Upon arrival at the hospital on the morning of 02/21/2012, the surveyors requested the OPO contract, the OPO Activity Reports for 2011, and the hospital's death list for 2011.

2. The list of deaths that occurred in the hospital in 2011 contained forty-two names.

3. Staff D stated on the afternoon of 02/21/2012 that staff recorded each death, along with the requestor number provided by OPO, in a log book. She presented the log for review. Nine of the names listed on the death list were not recorded in the hospital's organ requestor log book.

4. During the morning of 02/22/2012, Staff D reviewed findings. Record # 19 was reviewed with Staff D for documentation of notification to OPO. None was found in the record or on the OPO Activity Report. Staff D stated that all nine names that were not referred to OPO were ER patients.

5. Review of meeting minutes for Quality and Medical Staff did not contain evidence the OPO activity and tracking of deaths for compliance with the requirements were integrated into the quality process.

Based on review of the hospital's swing bed policies and procedures and medical records, and interviews with hospital staff, the hospital failed to provide an ongoing activity program directed by a qualified staff member with activities based on a comprehensive assessment of the individual needs and interests of the patients. Although the hospital provides activities for swingbed patients, five of five swingbed medical records reviewed (Records #2, 14, 15, 18 and 19) did not contain activity assessments that would allow individual activities to be provided based on the patient's needs and interests.