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Based on record review and interviews with hospital staff, the hospital does not ensure that the consultant pharmacist orients and evaluates the drug room supervisor and other hospital personnel that work in the drug room. Review of one of one drug room supervisor's personnel file did not have evidence of orientation and evaluation of drug room duties by the Consultant Pharmacist. Hospital staff verified that the Consultant Pharmacist had not oriented and evaluated the Drug Room Supervisor.

Based on record review and interviews with staff, the hospital does not ensure that medication errors and adverse drug events are evaluated to determine possible causative factors and create systems to prevent their reoccurrence.

Findings:

1. Review of Governing Body, Medical Staff and Quality Assurance committee meeting minutes for 2013 and 2014 did not have any review or evaluation of medication errors or adverse drug events.

2. Hospital staff stated in an interview on 03/19/14 in the afternoon that medication errors were identified on an incident report form and were sent to the DON (Director of Nursing) for review. There was no evidence these medication errors were analyzed and a plan of action developed to prevent their reoccurrence.

3. The Consultant Pharmacist's weekly reports did not have any review of medication errors and adverse drug events.

Based on review of hospital documents and personnel records and interviews with hospital staff, the hospital failed to have a hospital wide infection control program to:

a. identify and control infections and communicable diseases of patients and hospital staff and
b. analyze concerns identified through the infection control surveillance program with corrective actions when needed and follow-up to ensure continued compliance.

Findings:

Review of the hospitals current infection control plan documented the infection control practitioner (ICP) performed surveillance on the following: Tuberculosis(TB) Risk Assessment, needle stick/sharps injuries rates, annual influenza vaccinations rates, employee illness tracking and staff in-services. Employee health was not reviewed to ensure transmission of illnesses and diseases were not transmitted between patients and staff. Seven employee files reviewed did not contain complete immunization histories.

On 3/18/14, Staff A stated she performed sterile processing in the hospital. There was no documentation the ICP had performed surveillance of the central sterile process.

On 3/19/14, Staff G stated laundry services are performed in-house. There was no documentation the ICP had performed surveillance of the laundry services provided by the hospital.

The infection control (IC) policy and procedure manual did not contain specific IC policies and procedures for each department/service (or notification of where to find specific IC policies for each department) for:
a. Laundry services - specifying detergent(s) required for different types of loads; and how monitoring would occur to ensure adequate temperature were utilized;
b. Dietary services and
c. Pharmaceutical services.


There was no documentation of N-95 respirator fit test per Occupational Safety and health Administration (OSHA) guidelines.

Quality assessment , governing body and medical staff meeting minutes were reviewed. There was no documentation that the surveillance program was analyzed and corrective action implemented as necessary.

The above findings were presented in the exit interview with the administrative staff, no further information was provided.

Based on review of medical records and personnel files and staff interview, it was determined the hospital failed to ensure nursing staff were trained and evaluated on competency to perform the essential functions of their jobs. This occurred for four of four licensed nursing personnel (Staff A, Q, U, and T) whose personnel files were reviewed.

Findings:

1. The hospital takes care of all age patients in the emergency room and/or as inpatients. The personnel files for Staff A, Q, U, and T did not contain evidence of training, testing and/or age-specific competency verification.

2. Patient #13 received Dopamine, a cardiac medication, by calculated continuous drip (micrograms of medication per kilogram of patient weight per minute) on 12/05 and 06/2013. One nurse documented as administering and calculating the drip was Staff Q, whose personnel file was reviewed. Staff Q's personnel file did not show training and competency verification to administer cardiac medication. Staff Q also did not have Advanced Cardiac Life Support training.

3. Staff A, who was identified as the Drug Room Supervisor, did not have evidence of training and competency verification for her duties in the drug room by the hospital's contract pharmacist.

4. Staff S told the surveyors that licensed nursing staff administered respiratory treatments that included nebulizer treatments. (This also was confirmed by medical record review of Records #2, 4, and 17). Although the personnel records showed documentation of training by the respiratory therapist, the training record and the policies did not demonstrate staff were taught to document respiratory evaluations according to accepted standards of practice. Respiratory nebulizer treatments recorded for Patients #2, 4, and 17 did not show assessment of the patients respiratory status, before and after treatments, that always included at least lung sounds, respirations, pulse and oxygen saturation.

Based on record review and interviews with hospital staff, the hospital does not ensure all doctor's orders for drugs for the care of the patient are contained in the patients' medical record. One of one patient's medical record did not contain a complete and properly authenticated physician's order. An order was written stating "May use standing orders." A copy of the standing order was not in the patient's record and properly authenticated by the physician. There also was no written orders for those drugs.

Findings:

1. Staff stated on 03/19/14 in the afternoon that they did not put a copy of the standing orders in the patient record.

2. The standing orders provided for review had two drugs for fever, one drug for cough, one drug for nausea, one drug for flatulence, two drugs for constipation and one drug for indigestion.

3. The drugs were not documented in the patient's record to use as prn (as needed) drugs.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure all entries in the medical record were signed and contained the date and time of the signatures/authenticated. This occurred in nine of sixteen records (#1, 2, 4, 8 through 11, 13 and 14) reviewed for completed entries.

Findings:

Record #1, 2, 13 and 14-the electronic Discharge Summary and History and Physical did not contain the date and time the physician signed/authenticated the dictated document.

Record #4 - the electronic Discharge Summary and History and Physical did not contain the date, time and physician signature on the dictated document.

Records #8 , 10, and 11- the electronic History and Physical did not contain the date, time and physician signature on the dictated document.

Record #9 - the electronic History and Physical did not contain the date and time the physician signed/authenticated the dictated document.

The above findings were reviewed with administrative staff during the exit interview.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital has an effective quality assurance program that collects relevant data, analyzes the data and implements corrective action. The quality assurance meeting minutes for 2013 and 2014 provided for review did not have relevant indicators to identify potential problems and opportunities to improve quality of care. There was no analysis of any data that was collected and no evidence of the implementation of any corrective action taken.

Findings:

1. Indicators provided for the drug room were lists of how many of medications for each route of administration were used monthly. Examples of the amounts of IV (intraveneous) drugs used ( ivpb, ivp, flushes iv fluids), oral medications were listed and at the bottom of the page the total for the medications given. There was no explanation of what was the reason for this data collection or analysis of this data.

2. Indicators documented for the autoclave and data collected were the following: date autoclaving done, load number, test done, inspection of the indicator strip, package outdate checks and package integrity checks. There was no analysis of what this data meant.

Based on a review of policies and procedures, and personnel training files, and staff interview, the hospital failed to ensure the swing bed policies addressed how the hospital would educate staff on recognizing abuse and neglect and to train staff on recognition and the procedure to follow if a staff member received an allegation or witnessed abuse, neglect or misappropriation of patient property.

Findings:

1. Ten of ten personnel files reviewed did not show education/training on abuse, neglect.

2. This finding was reviewed with administrative staff on the afternoon of 03/19/2014.

Based on a review of personnel files and interviews with hospital staff, the facility failed to ensure that the State nurse aide registry was checked for findings for staff that might have patient contact. In two of two unlicensed personnel files that were reviewed, no evidence of inquiry was documented. On 03/16/2014, administrative staff told the surveyors that the hospital only did background checks with the State nurse aide registry for nursing staff.

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 with activities based on the individual needs and interests of the patients. This occurred for three of three swingbed patients (Records #4, 5, and 11) whose medical records were reviewed.

Findings:

1. The hospital's swing bed policy documented each swingbed patient would have an activity assessment with the required elements and ongoing activities would be provided to the patients based on their assessment.

2. Records #4, 5 and 11 did contain comprehensive activity assessments with the interests, and the physical, mental, and psychosocial needs of each swingbed patient considered, but there was no evidence activities were provided for these patients.

3. On the afternoon of 03/19/2014, the above finding was reviewed and verified with Staff A.

Based on staff interview, review of hospital documents and medical record review, the hospital failed to ensure patients or their support persons were informed of the patient visitation rights. This occurred in twenty of twenty (#1 through 20) medical records reviewed.

Findings:

1. A hospital's patient handout, titled, "Patient Rights and Responsibilities", was provided to the hospital surveyors. The handout did not contain information regarding patient visitation rights.

2. The hospital's patient's rights policy did not contain information regarding patient visitation rights.

3. Review of medical records #1 through 20 did not contain documentation the patients or their support person were informed of the visitation rights.

4. The hospital did not have posted visitation times or restrictions.

5. The above information was presented to the hospital staff during the exit conference, no additional information was provided.