HospitalInspections.org

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to meet the Conditions of Participation related to Patients' Rights as evidenced by:

1. The hospital did not ensure patients were informed of their rights and of any limitations of those rights. See Tag 0117.

2. The hospital did not follow it's policies and procedures to promptly respond to patient complaints and grievances. See Tag 0118.

3. The hospital did not have a quality assurance/performance improvement process to trend, analyze and respond to patient complaints and grievances. See Tag 0119.

4. The hospital failed to respond to patient grievances in writing. See Tag 0122.

5. The hospital failed to respond to patient grievances to include steps taken to investigate allegations, actions taken in response to the findings of the investigation and resolution of the grievance. See Tag 0123.

6. The hospital failed to ensure patient privacy through the use of 24 hour recording video cameras. See Tag 0143.

7. The hospital failed to ensure the patients were free from abuse and neglect. See Tag 0145.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure the patients were informed of their rights and informed of limitations of those rights to include:

a. failure to provide information on how to make a complaint to the Oklahoma State Department of Health;

b. failure to identify to whom patients can submit complaints to at the hospital regarding privacy practices;

c. failure to provide information on how to make a complaint to the Secretary of the Department of Health And Human Services regarding privacy practices; and

d. failure to notify patients of 24 hour videotaping of all common areas of the hospital (including lobbies, day rooms, cafeteria, visiting areas, hallways, nursing stations, etc.) and certain restricted areas of the hospital. Findings:

1. The hospital patient handbook included a document titled, "Brookhaven Hospital Grievance Filing Notice." The document provided information on how to contact the Oklahoma Department of Mental Health Consumer Advocate or the Joint Commission Office of Quality Monitoring to file a complaint.

The document did not include information on how to contact the Oklahoma State Department of Health to file a complaint.

2. The hospital patient handbook included a document titled, "Notice of Privacy Practices." The form had no information on whom to contact at the hospital for complaints regarding privacy practices.

The document had no information on how to make a complaint regarding privacy practices with the Secretary of Health and Human Services.

3. A hospital form titled, "Informed Consent for Treatment and Release", documented, "... It is the policy of Brookhaven Hospital to photograph each patient for the purpose of staff identification during treatment. This photograph becomes a confidential component of the permanent record of the patient. The undersigned patient hereby authorizes Brookhaven hospital to photograph the patient for this purpose..."

A hospital form titled, "Patient's Bill of Rights", documented, "... You are entitled to the following rights:... 23. To have protection of the patient rights and privacy during visitation..."

The patient handbook documented, "... Generally visitation in patient rooms is not permitted unless authorized... Visiting may occur in the dining room, as deemed appropriate... Visitation guidelines... Due to HIPAA laws and the confidentiality of all, no pictures...

There was no documentation in the Informed Consent form, in the Patient's Rights information or in the Patient Handbook of notification of 24 hour videotaping of many areas within the hospital and that videotaping was also done in the visitation areas.

There was no policy or other documentation that indicated patients were formally notified, had acknowledged and/or consented to videotaping within the hospital.

On 08/21/12, staff A and C were asked if patients were provided information in the patient handbook on how to contact the Oklahoma State Department of Health to make a complaint. They stated the information was in the hospital policy on grievances.

They were asked if the policy was provided to the patients. They stated it was not.

They were asked if the patients were provided information on whom to contact at the hospital regarding a complaint about privacy practices and how to contact the Secretary at the Department of Health and Human Services regarding privacy practices. They stated they were not aware of that requirement.

They were asked if the patients had been notified of the hospital practice to videotape all common areas of the hospital and to videotape certain restricted areas of the hospital. They stated it was "common knowledge" there were video cameras in the hospital.

They were asked if the patients had given written consent or acknowledgment of videotaping within the hospital. They stated they had not. They stated the patients were only asked to sign consent to be photographed for the medical record.

Staff A and C were asked if the patients were aware private visitation in the common areas was being videotaped. They stated they thought patients were aware.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to:

a. provide information to patients on how to contact the Oklahoma State Department of Health for advocacy and assistance for the resolution of complaints and grievances;

b. failed to respond to a written grievance from a discharged patient's representative alleging abuse from a caregiver;

c. failed to respond to a telephone call from a discharged patient regarding an allegation of abuse during hospitalization and;

d. failed to follow hospital policies for handling and resolution of patient grievances.

Findings:

A hospital form found in the Patient Handbook, titled "Grievance Filing Notice" documented, "... Within two business days after your grievance is filed, an attempt will be made, with your participation, to resolve the problem. When a decision is made concerning your grievance, the hospital must provide you with a written notice of its decision. The written notice must include the name of the hospital contact person, steps taken on your behalf to investigate, the results of the grievance process, and the date of completion..."

1. The Grievance Filing Notice form from the Patient Handbook provided information on how to contact the Oklahoma Department of Mental Health Consumer Advocate or the Joint Commission Office of Quality Monitoring to file a complaint.

The document did not include information on how to contact the Oklahoma State Department of Health to file a complaint.

2. A hospital Grievance and Resolution Report, dated 08/01/12, documented an advocate for patient #4 complained that staff S had been verbally abusive and physically intimidating to patient #4 in her presence.

The report form documented, "... CEO will address issue w/ (staff S)..."

On 08/21/12, staff C was asked to provide documentation of evidence the hospital had investigated the incident and had addressed the issue with staff S. No documentation was provided.

Staff C was asked if the hospital had responded to the complainant in writing. He stated they had not.

3. A hospital Grievance and Resolution Report, dated 08/13/12, documented patient #5 called the hospital to report an allegation of abuse that occurred during her hospitalization. There no documentation of investigation or of action taken in response to the allegations. There was no documentation of a written response to the complainant.

On 08/21/12, staff D was asked if the hospital investigated, determined actions to be taken in response to grievances and then provided a written response to the complainants. She stated they did not.

Based on policy and procedure review, record review and staff interview, it was determined the hospital failed to ensure grievances were reviewed, analyzed and trended, and failed to ensure the results of the analysis were reported to QAPI committee for further recommendations and actions.

1. A hospital policy, titled "Resolution Procedure For Recurrent Complaints", documented, "... The hospital requires that all grievances be routed to the Facility Compliance Officer to establish a system of tracking the resolution of the complaint and to develop an overview of complaints and grievances by frequency, occurrence rates, and types. The Facility Compliance Officer assures that all complaints and grievances are responded to in a timely and complete manner...

Procedures: 1. On a quarterly interval the Facility Compliance Officer conducts a trending analysis of all complaints and grievances received in the period. Recurrent grievance types are identified to determine if the grievance relates to unresolved problems in the delivery of services which require either a system or program change. The Facility Compliance Officer will publish the results of the trending analysis for the Chief Executive Officer and Management Team Members. 2. Upon receipt of the trending analysis, the Chief Executive Officer and involved members of the management team will develop and implement a plan of response. 3. Trending reports and response plans will be incorporated into the Performance Improvement Committee process..."

2. On 08/21/12, eleven grievance reports were reviewed for a period from May 2012 through August 2012. None of the grievance reports had documentation of investigation, actions taken to resolve the grievance or a written response to the complainant.

There was no documentation the Facility Compliance Officer had analyzed and trended information taken from the grievance reports. There was no documentation any grievances had been referred to the any committee for review.

3. On 08/21/12, Staff B stated grievances were reviewed through the Ethics Committee. There was no documentation the Ethics Committee had reviewed grievances.

4. QAPI meeting minutes were reviewed for August 2011 to the present. There was no documentation of QAPI oversight of the grievance process or of analysis of grievances reported to the hospital.

5. On 08/22/12, staff D was asked if there was documentation of analysis and trending of grievances and reports of the findings to any other committee. She stated there was not.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to provide a written response to patient grievances in the time frame specified in it's policy.

Findings:

A hospital form found in the Patient Handbook, titled "Grievance Filing Notice" documented, "... Within two business days after your grievance is filed, an attempt will be made, with your participation, to resolve the problem. When a decision is made concerning your grievance, the hospital must provide you with a written notice of its decision. The written notice must include the name of the hospital contact person, steps taken on your behalf to investigate, the results of the grievance process, and the date of completion..."

On 08/21/12, eleven grievance reports were reviewed for a period from May 2012 through August 2012. None of the grievance reports had documentation of investigation, actions taken to resolve the grievance or a written response to the complainant.

On 08/22/12, staff A and D stated they were not aware all grievances had to be responded to in writing. They stated they were not aware of the time frames established in the policy.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to respond to patient grievances in writing to include all the required elements.

Findings:

A hospital form found in the Patient Handbook, titled "Grievance Filing Notice" documented, "... Within two business days after your grievance is filed, an attempt will be made, with your participation, to resolve the problem. When a decision is made concerning your grievance, the hospital must provide you with a written notice of its decision. The written notice must include the name of the hospital contact person, steps taken on your behalf to investigate, the results of the grievance process, and the date of completion..."

On 08/21/12, eleven grievance reports were reviewed for a period from May 2012 through August 2012. None of the grievance reports had documentation of investigation, actions taken to resolve the grievance or a written response to the complainant that included the elements as defined in the hospital policy.

Based on observation and staff interview, it was determined the hospital failed to ensure patient privacy through the use of 24 hour recording video cameras. Findings:

On 08/21/12, video cameras were noted to be present in areas throughout the hospital including near nurse's stations, in day areas, visiting areas, patient hallways and the cafeteria.

Staff C was asked if the video cameras were operational 24 hours a day. He stated they were and provided recordings that could be reviewed. He stated the video cameras were for safety.

He stated the cameras were also in secure locations within the hospital such as in the pharmacy. He was asked if the patients had given informed consent or acknowledgment of the video cameras. He stated they had not.

Staff A was asked if any patient visits were recorded in the common areas. He stated they were. He was asked if patient care or procedures such as vital sign monitoring, medication administration or interactions with staff could be recorded on the video. He stated it could. He stated visitation in the common areas could be videotaped.

The hospital had no policies and procedures concerning the use of the video cameras.

Based on record review, policy and procedure review and staff interview, it was determined the hospital did not ensure patients were free from abuse by failure to:

a. perform criminal background checks on all employees before hiring;

b. train staff to identify and to immediately report abuse;

c. provide additional training when there was evidence staff did not respond to acts of abuse in an appropriate or timely manner;

d. protect patients during investigations of abuse;

e. thoroughly investigate all allegations of abuse and;

f. failure to ensure the hospital had a comprehensive abuse prevention program with policies and procedures that encompassed all required abuse prevention elements; including prevention, screening, identifying, training, protection, investigation, and reporting and response.

The hospital failed to demonstrate corrective actions were taken when the abuse prevention program was inadequate or not followed as directed in the policies and procedures.

Findings:

A hospital policy titled, "Reporting Patient Abuse/Neglect", documented, "... Employees of Brookhaven hospital are required to immediately report suspected abuse or neglect to their immediate supervisor or the Director of Nursing..."

A hospital policy titled, "Protocol For Alleged Abuse Investigations", documented, "... All staff are considered to be mandated reported of abuse... Reporting of the allegation must occur to the immediate supervisor upon the earliest observation of the allegation and no later than the close of the shift... A written report will be submitted within 24 hours...

The investigation will be conducted as follows... Securement of statements via interview of the patient, involved staff, observing staff and others. The Ad Hoc Committee will initiate their investigatory review as follows: Review report by the patient, by observing staff and/or other witnesses. Review of written reports, nursing notes... and other documentation which contains information about the alleged abuse...

Formulation of preliminary findings in a report to the CEO; including recommendations for personnel action; training/re-training , and analysis of the alleged situation to support an effective response... Incorporation of findings into preventative action to enhance/improve patient services..."

On 08/21/12, staff C was asked about abuse allegations and investigations in the past year. He stated, "All allegations of abuse are investigated. There was only one in the past year."

He was asked who handled abuse investigations. He stated, "(Staff A)."

Staff A was asked about the abuse investigation conducted in the past year. He stated he investigated a report from an LPN (staff G) who witnessed an RN (staff T) throw an orange at a patient on 01/22/12. The LPN stated a patient came near the nurse's station and in an angry manner, threw an orange at the RN. He stated the RN immediately retaliated by angrily throwing the orange back at the patient, in an attempt to strike the patient . The LPN stated there was another RN (staff K) who also witnessed the incident.

This witness (staff K) never came forward about witnessing the incident until confronted by staff A during a counseling session.

Staff T was also counseled about the incident. She stated she had an "impulse problem." She was given a warning and returned to work.

There was no documentation of how the hospital protected patients during the investigation. There was no documentation of additional interviews with other staff, the patient involved in alleged abuse or other patients on the unit. There was no documentation of any further investigation of the incident or of any further actions taken by the hospital.

There was no formal report found regarding this incident. Staff A and C said there was no other documentation regarding the incident.

Staff A stated that around the end of February 2012, he became aware of another incident involving staff T that occurred in November of 2011. He stated he was able to determine through interviews that staff T became enraged by a patient during a physical acting out episode. The witnesses stated staff T cursed at the patient and kicked the patient several times in the head while the patient was on the floor.

The staff witnesses did not come forward voluntarily. They admitted to what they had seen when compelled by staff A. They both stated they witnessed the cursing and the physical assault of the patient during a toileting episode on the night shift. They stated they didn't report the incident because they didn't want to get the nurse in trouble.

There was no documentation of further investigation into the allegation of abuse. There was no documentation of interviews with other staff who worked with the perpetrator, interviews with the patient involved or with other patients on the unit.

There was no documentation of actions to protect patients during the investigation of the abuse.

There was no documentation of meetings with leadership regarding the allegations of abuse. There was no documentation of plans for analysis and corrective actions.

Disciplinary actions were taken with the nurse who committed the abuse and with the two witnesses.

Staff A was asked what actions had been taken in response to the abuse. He stated he had re-trained staff on reporting abuse on 08/14/12 (approximately six months after the hospital became aware of the allegations). He stated a copy of the hospital abuse policy had been given to the staff at that meeting.

Staff A was asked the hospital policy on abuse prevention training. He stated abuse training was provided upon hire and again annually. He was asked to provide the abuse prevention training materials to the surveyor. The training consisted of two power point slides that detailed definitions of abuse. The training did not include when and how to report abuse. There was no evidence the staff received the hospital abuse policy upon hire.

Written grievances from patients alleging abuse and/or neglect were reviewed for June 2012 through August 2012. There were seven allegations of abuse that included staff to patient abuse, patient to patient abuse and allegations of staff neglect. There was no documentation to support the allegations had been investigated or acted upon by the hospital.

On the afternoon of 08/21/12, staff C and staff D were asked to provide evidence of criminal background checks for various staff working in the facility. They stated the background checks could be found in the human resources files for each employee. The files were reviewed by the surveyors and no evidence of criminal background checks were found.

On the morning of 08/22/12, staff D was informed the surveyors had not been provided with criminal background checks for the employees reviewed. She stated the background checks where in the files.

On the afternoon of 08/22/12, staff C was informed there were no criminal background checks (to include a check of the nurse aide registry for unlicensed staff) found in the employee files given to the surveyors. No additional information was provided.

During the exit conference held at 5:00 p.m., staff D brought two background check records to the surveyors. Neither were records of employees requested by the surveyors. The background checks did not include the Oklahoma State Bureau of Investigation, the sex offender registry or the state nurse aide registry.

Based on record review and interview with hospital staff, the hospital does not ensure that medication errors are analyzed after they are identified. Review of the professional standards committee meeting minutes and pharmacist documentation, did not have documentation of medication error review that included analyzing the causes and instituting measures to reduce their occurrence. This was verified by hospital staff on 08/22/12 in the afternoon.

A patient grievance form, dated 08/08/12, documented patient # 6 alleged she was almost given thorazine by mistake. There was no documentation the hospital investigated this "near miss" incident.

Based on record review and interviews with hospital staff, the hospital does not ensure that medications ordered for patients are provided and administered. Medication ordered for one ( # 1) of one ( #1) patient was not either provided as ordered and administered or reasons why it was not provided and administered documented in the patient's record.

Findings:

1. A medication needed for Patient #1's multiple sclerosis was ordered by the physician on the first day of the patient's admission to the hospital. The medication was documented on the medication administration record (MAR) from 06/10/12 through 06/22/12. The medication was never documented as administered or why it was not administered.

2. The back of the MAR had places for documentation of why a medication was not administered as ordered. There was no documentation on the back of the MAR as to why or why not the medication was not administered.

3. Physician orders on 06/10/12 directed the staff (either pharmacy or nursing) to have the patient's family bring the medication. On 06/20/12, a patient grievance form written by patient #1documented, "... I have requested my Avonex to the nurse station 5 days in a row.... I have not had a dose in over 90 days. It is prescribed once per week... Please help!! It's free delivery by my pharmacy. I have also shared that information over and over..."

4. On 06/21/12 the physician's progress note stated that he told the patient to have his family bring in his medication. There was no documentation either from pharmacy or nursing concerning any attempts to get the patient's medication. This was verified on 08/22/12 in the afternoon by staff.

Based on record review and staff interview, it was determined the hospital failed to ensure there was a full-time director of food and dietetic services.

On 08/21/12, staff D was asked if the hospital had a full-time certified dietary manager or a full-time registered dietician employed to oversee the hospital food and nutrition services. She stated they had not had one since August 1, 2012. She stated a full time registered dietician would be starting in September 2012.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a qualified dietitian performed and documented nutritional assessments that were ordered by the physician. Findings:

A hospital policy titled, "Nutrition Screening and Assessment", documented, "... Nutritional assessments are performed on all patients on special diets and those determined to be at nutritional risk by initial assessment... A nutrition assessment/consult ordered by a physician will be completed within 3 days of the order..."

On 06/22/12, a physician ordered patient #4 to receive a gluten free diet and to be evaluated by the dietitian. The dietitian documented she notified the kitchen of the restrictions. There was no documentation of an assessment of the patient as ordered by the physician.

Staff AA was asked what kind of nutritional assessment should be done when ordered by the physician. She stated, "A full assessment should be done by the dietitian."

Based on record review and staff interview, it was determined the hospital failed to ensure dietary personnel were qualified through training and experience to perform their assigned duties.

Personnel records for dietary services personnel were reviewed for evidence of food handler certification. None of the records had this documentation.

On 08/22/12, staff D was asked if the dietary personnel had food handler certification. She stated the certificates were kept in the files in the kitchen. She was asked to provide the certificates to the surveyors. Three certificates were provided. Staff D was asked if the other seven employees listed in the dietary department roster had food handler certificates. She stated they may have that documentation in their wallets.

Based on policy and procedure review and staff interview, it was determined the hospital failed to ensure the dietary manual was current and approved by the dietician and the medical staff. Findings:

On 08/22/12, a hospital dietary department policy and procedure manual was provided to the surveyors. Staff D stated this was the manual used by the kitchen and the nursing staff.

A review of the manual indicated the majority of the policies were dated 1998 and 2002. A cover sheet documented the manual was reviewed in 2002.

During an exit conference held on the afternoon of 08/22/12, staff AA stated the surveyors had not been provided with the correct manual. She brought a manual that had been approved the chief executive officer on 08/20/2010. This manual had not been reviewed and approved by the dietician and the medical staff.

Based on review of personnel files and meeting minutes and interviews with hospital staff, the hospital failed to provide a qualified, trained individual to implement the infection control program.

Findings:

1. On 08/21/2012, the administrator and Staff B told the surveyors that Staff A was the infection control officer/preventionist.

2. Review of Staff A's personnel file did not contain evidence that Staff A had training or experience in infection control. The information provided did not contain documentation of training and experience on the principals and methods of infection control. The personnel file did not contain a job description for infection control preventionist.

3. On 08/22/2012, Staff A stated he did not have formal or documented courses or training in infection control principals or setting up an infection control program. He stated he had an infection control magazine subscription and read the articles.

Based on review of infection control data, surveillance activities, meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control preventionist (ICP) 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:

Policies:
1. The hospital has two policies concerning hand hygiene, Policy #1521 and Policy #6233. Policy #1521 says current CDC guidelines will be followed, but does not detail when hand hygiene is expected to occur. Neither policy state when it appropriate to use hand sanitizer or detail use.

2. The last time infection control policies were reviewed was 2010.


Immunizations:
1. On 08/22/12, thirteen employee health records and five physician files were reviewed for documentation of immunization status and evidence of TB skin testing. Findings were as follows:
a. Three employees had no documentation of TB skin testing or of a tuberculosis symptom questionnaire;
b. Four employees had no documentation of hepatitis B immunization;
c. Three employees had requested hepatitis B vaccination but there was no documentation it was given;
d. Three employees had no documentation of MMR immunization status;
e. Six employees had no documentation of varicella immunity status;
f. Five of five physician files did not contain complete immunization histories. Only one had documentation of influenza vaccine.

2. Staff A was asked who oversaw the employee health program. He stated, "(Staff D)". He stated he was not aware there were gaps in documentation in immunization status.

3. Meeting minutes did not reflect immunization practices and histories were reviewed, analyzed and corrective action taken if needed.


Bloodborne Pathogen Exposures:
1. Staff A was asked about the hospital's bloodborne pathogen exposure control plan. He stated the hospital had a policy for that. He was asked if there had been any employee exposures in the last year. He stated there had been no needlesicks. He was asked if there had been any other exposures. He stated, "There have not. But we have had human bites."

2. He was asked if the bites were treated as exposures according to the bloodborne pathogen exposure control plan. He stated they had not. No documentation of monitoring was provided.

3. The infection control plan does not include monitoring and analysis of all bloodborne pathogen exposure and follow-up to determine compliance.

4. Meeting minutes did not include review of exposures with analysis of data and plans of action.


Disinfectant:
1. Staff A and U told the surveyors that the hospital used two different disinfectants in the hospital, Cavi-Wipes and Sani Care Quat.
2. Meeting minutes did not reflect where the disinfectant had been reviewed by the infection control program.
3. Although the hospital's Quat product is EPA (Environmental Protection Agency) registered, it is not effective against tuberculosis. This was reviewed and verified with Staff U at 1551 on 08/22/2012.


Surveillance:
1. The infection control program does not monitor to ensure infection control policies are followed.
a. On 08/22/2012, Staff A showed the surveyors where he presented hand hygiene and isolation education on 10/11 and 31/2011, but confirmed he has not monitored to ensure staff are compliant with training.
b. Staff A and U told the surveyors that no documented monitoring of the disinfectant application had been done to ensure the disinfectants were applied according to the manufacturers' guidelines.

2. Although Staff A monitored infections, meeting minutes and documents provided did not reflect the infections had been analyzed to determine if policies and procedures or practices needed to be changed to reduce infections and ensure transmission of infections did not occur between patients and/or staff.

3. Data collected and reported were inaccurate. A note on the sheets documented that "All patents of NRI (neuro restorative institute unit) are classified as CAI (community acquired infections) due to length of stay." NRI patients are still part of the acute care hospital and any infections would still meet the CDC (Centers for Disease Control and Prevention) definition for nosocomial/healthcare acquired infections.


No meeting minutes reviewed showed analysis of infection control with corrective actions and follow-up to ensure compliance.

Based on review of hospital documents and meeting minutes concerning infection control, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, through Quality Assessment and Performance Improvement (QAPI):
1. Were monitored, reviewed and analyzed;
2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and
3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. Meeting minutes that contain infection control data reported nosocomial infection. The QAPI meeting minutes did not contain analysis or plans of action taken to reduce infections.

2. The QAPI program has not provided oversite of the infection control program to ensure a safe environment. Staff A stated on 08/22/2012 that he has not conducted any surveillance/monitoring to ensure infection control policies were followed. This included, but not limited to:
a. Hand hygiene practices;
b. Isolation practices;
c. Disinfectant practices.

3. Review of infection control data showed patient's admitted with infectious diseases and patients who acquired nosocomial infections while in the hospital. Meeting minutes did not contain evidence the hospital leadership analyzed the data; developed a plan of action to reduce and/or prevent transmission of organisms; and provide follow-up to ensure corrective actions taken were effective.

Based on review of hospital records and interviews with hospital staff, it was determined the hospital does not meet the needs of patients in accordance with acceptable standards of practice. The hospital does not have a base station radio, as required by Oklahoma State Hospital Standards, or some way to communicate with emergency services other than calling "911."

Findings include:

1. On 08/21/2012 at 1130, the administrator and Staff B told the surveyors that the hospital did not have a base station radio to communicated with ambulance/emergency services.

2. Hospital policies and procedures indicated if a visitor or other person presented for emergency care, staff was to call "911" to transfer the individual.

3. These findings were reviewed and verified with hospital staff at the exit conference.

Based on review of hospital documents, personnel files, and medical records, and interviews with hospital staff, the hospital failed to provide respiratory services in accordance with acceptable standards of practice and Oklahoma State Hospital Standards Licensure requirements.

Findings:

1. The hospital administrator and Staff B told the surveyors on 08/21/2012 at 1130, that the hospital provides respiratory services of oxygen, hand held nebulizers and C-PAP (continuous positive airway pressure). This was finding confirmed with Staff A on the afternoon of 08/22/2012.

2. The surveyors requested to review the hospital's respiratory policies. None were provided. When the surveyors asked about the policies, Staff A told the surveyors that the policies were included in the Nursing manual. The respiratory policies were not developed by or in consultation with a respiratory therapist and were not complete to all the types of respiratory services provided at the hospital. (Refer to Tag #1160).

3. The hospital failed to appoint/designate a physician, with knowledge, experience and capabilities to supervise and administer the service properly, to be the director of respiratory care services for the hospital. (Refer to Tag #1153.)

5. The hospital failed to ensure respiratory services were supervised by a respiratory therapist and provided by trained and competent staff. (Refer to Tag #1154 and Tag #1161).

6. Review of meeting minutes did not demonstrate respiratory services provided at the hospital were integrated and reviewed in the quality assessment and performance improvement and infection control programs.

Based on review of hospital documents, personnel files, and medical records, and interviews with hospital staff, the hospital failed to appoint/designate a physician, with knowledge, experience and capabilities to supervise and administer the service properly, to be the director of respiratory care services for the hospital.

Findings:

1. The hospital administrator and Staff B told the surveyors on 08/21/2012 at 1130, that the hospital provides respiratory services of oxygen, hand held nebulizers and C-PAP (continuous positive airway pressure).

2. Review of the hospital's department head list and meeting minutes did not show that a physician had been designated as director for respiratory services

3. Staff A told the surveyors that respiratory policies were contained in the nursing manual. Review of the manual did not contain evidence respiratory policies had not been developed for all the respiratory services provided. The policies did not contain evidence they were developed by or with consultation by a respiratory therapist and a physician director with knowledge and experience.

Based on review of hospital documents and personnel files and interviews with hospital staff, the hospital failed to ensure respiratory services were supervised and provided by qualified staff.

Findings:

1. The hospital administrator and Staff B told the surveyors on 08/21/2012 at 1130, that the hospital provides respiratory services of oxygen, hand held nebulizers and C-PAP (continuous positive airway pressure).

2. Review of the hospital's department head list, contracts and employee list did not show respiratory services. This was confirmed with the administrator on the morning of 08/21/2012.

3. State Licensure Hospital Standards, Subchapter 23-6(a) requires that "respiratory therapy services, including equipment, shall be supervised by a licensed respiratory therapist. Staff B and C confirmed on 08/21/2012 that the hospital did not employee a respiratory therapist and did not have a contract with a respiratory therapist to provide supervision and training to staff providing respiratory services.

4. Staff A told the surveyors that nursing personnel provided the hospital's respiratory services, but confirmed a respiratory therapist had not provided training.

Based on review of hospital documents and interviews with staff, the hospital's medical staff failed to develop and enforce policies for respiratory services.

Findings:

1. The administrator told the surveyors on 08/21/2012 at 1130, that the hospital provides respiratory services of oxygen, hand held nebulizers and C-PAP (continuous positive airway pressure). This was finding confirmed with Staff A on the afternoon of 08/22/2012.

2. The hospital's medical staff has not defined the scope of respiratory services that will be offered to patients.

3. Staff A told the surveyors that respiratory policies were contained in the nursing manual. Review of the manual did not contain evidence respiratory policies had not been developed for all the respiratory services provided. The policies did not contain evidence they were developed with involvement by a respiratory therapist. The hospital did not have complete respiratory policies, including:
a. Scope of services;
b. Equipment assemble, operation, cleaning, and preventive maintenance;
c. Safety practices, including infection control measures for equipment and supplies;
d. Documentation required pre and post treatments, including oxygen saturation, vital signs, lung sounds, and presence with description of any cough or sputum;
e. Procedures to follow in the advent of adverse reactions to treatments or interventions;
f. Aerosol, humidification and therapeutic gas administrations/treatments; and
g. Storage, access, control and administration of medications and medications errors.

Based on review of hospital documents, personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure. Six of six licensed nursing personnel (Staff A, G, H, I, K, and M), whose personnel files were reviewed, did not have documented training and competencies.

Findings:

1. According to the administrator and Staff B on the morning of 08/21/2012, the hospital provides respiratory services of oxygen, hand held nebulizers and C-PAP (continuous positive airway pressure). This was finding confirmed with Staff A on the afternoon of 08/22/2012.

2. Staff A, B and C told the surveyors that the hospital did not have a respiratory therapist to provide the respiratory services; services were provided by nursing staff.