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Based on inpatient census review, staff interview, hospital bed count and hospital license review, it was determined that the hospital routinely exceeds the number of behavioral health patients it is licensed for.


Findings include:


Patient bed count, made with Registered Nurse (RN) #1 during the initial environmental tour of the behavioral health unit on January 24, 2012 beginning at 11:20 a.m., revealed that 19 beds were set up. The behavioral health unit is licensed for a total of 18 beds.


Interview with the Director of Nursing (DON) during an environmental tour on January 24, 2012 beginning at 3:00 p.m. revealed that the behavioral health unit had removed one (1) bed from Room #126, thus making the bed count 18.


On January 25, 2012 at 10:00 a.m. review of the inpatient census from July 1, 2011 through December 31, 2011 revealed that the behavioral health unit routinely had a patient census above 18. Maximum patient census was noted to be 20.


On January 25, 2012 at 10:00 a.m., interview with the Medical Record Supervisor confirmed the aforementioned findings.

Based on observation and staff interview, the facility failed to ensure that each patient has the right to personal privacy.


Findings include:


Observation with Registered Nurse (RN) #1 during the initial environmental tour, on January 24, 2012 beginning at 11:20 a.m., revealed no privacy curtain between beds in Patient Rooms #125 and #126. Patient Room #125 had two (2) beds set up and Room #126 had three (3) beds set up. Interview with RN #1 during this environmental tour on January 24, 2012 confirmed these findings.


Observation with RN #2 during an environmental tour on January 25, 2012 beginning at 12:00 p.m. revealed a privacy curtain between the two (2) beds in Patient Rooms #125 and #126. The third (3rd) bed in Room #126 had been removed.

Based on observation, policy review and staff interview, the facility failed to maintain the hospital environment in a manner that protected the safety and well-being of patients, as evidenced by call lights (communication system for patients) not functioning properly and not providing one call system for every bed.


Findings include:


Observation with Registered Nurse (RN) #1 during the initial environmental tour on January 24, 2012 beginning at 11:20 a.m. revealed that the call lights in Patient Rooms #102, #103, #107, #115 and #126 were not functioning properly. Patient Room #125 had two (2) beds but only one (1) call system and Room #126 had three (3) beds set up with only one (1) call system.
Interview with RN #1 during this environmental tour confirmed these findings. RN #1 stated that the rooms with call lights which did not function properly would be repaired.


Observation, made with the Director of Nursing (DON) during an environmental tour on January 24, 2012 beginning at 3:00 p.m., revealed that the call lights in Patient Rooms #102, #103, and #115 were now functioning properly. The DON stated that Rooms #107 and #126 would not be used for patients until the call system was fixed or a bell placed at the bedside.


Review of the hospital policy "Call Light" revealed:
"Equipment: Functioning call bell.
Implementation: 7. If call bell is defective, report immediately to maintenance."

Based on review of the hospital's Quality Assessment (QA) and Performance Improvement (PI) Plan, review of the minutes of the Quality Assurance Committee, review of minutes of the Medical Staff, and review of minutes of the Governing Body, the hospital failed to ensure that an effective, on-going, hospital wide, data driven QA and PI Program is maintained.


Findings include:


Cross Refer to A0265 for the hospital's failure to ensure that all departments of the hospital had developed measurable improvement indicators to improve health outcomes.


Cross Refer to A0266 for the hospital's failure to ensure that it had identified and reduced medical errors, and had measured the success of corrective actions.


Cross Refer to A0267 for the hospital's failure to ensure that it had measured, analyzed and tracked quality indicators, including adverse patient events, and other aspects performance and assess processes of care, hospital service and operations.


Cross Refer to A0275 for the hospital's failure to ensure that it had monitored the effectiveness and safety of services and quality of care.


Cross Refer to A0276 for the hospital's failure to ensure that it had identified opportunities for improvement and changes that will lead to improvement.


Cross Refer to A0285 for the hospital's failure to ensure that it had set priorities for performance improvement activities that focus on high-risk, high volume, or problem-prone areas.


Cross Refer to A0288 for the hospital's failure to ensure that it had implemented preventive actions and mechanisms that included feedback and learning throughout the hospital.


Cross Refer to A0289 for the hospital's failure to ensure that it had taken actions aimed at performance improvement.


Cross Refer to A0291 for the hospital's failure to ensure that it had taken actions aimed at performance improvement, measured its success, and tracked performance to determine that the improvements are sustained.


Cross Refer to A0297 for the hospital's failure to ensure that performance improvement projects are conducted.


Cross Refer to A0310 for the hospital's Governing Body, Medical Staff and Administrative officials failure to ensure an ongoing hospital-wide program of QA/PI Program.

Based on review of the hospital's Quality Assessment and Performance Improvement (QA/PI) Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the hospital failed to ensure that an ongoing program for QA/PI showed measurable improvement in indicators for which there was evidence that it improved health outcomes.


Findings include:


The hospital had no documented evidence available for review to show that departments of the hospital had developed indicators and applied those indicators in performing QA/PI.


Review of the Minutes of the Quality Assurance Committee revealed that they did not reflect that there was reporting of QA/PI activities by all departments of the hospital.

Based on review of the hospital's Quality Assessment and Performance Improvement (QA/PI) Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the hospital failed to ensure that the program for QA/PI had identified and reduced medical errors.


Findings include:


There was no documented information available for review to show that the hospital had identified and reduced medical errors.

Based on review of the hospital's Quality Assessment and Performance Improvement (QA/PI) Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the hospital failed to ensure that it had measured, analyzed and tracked quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.


Findings include:


There was no documented evidence available for review to show that the hospital had an ongoing program of QA/PI to measure, analyze and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.

Based on review of the hospital's Quality Assessment and Performance Improvement (QA/PI) Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the hospital failed to ensure that it had monitored the effectiveness and safety of services and quality of care.


Findings include:


There was no documented evidence available for review to show that the hospital had an ongoing program of QA/PI to monitor the effectiveness and safety of services and quality of care.

Based on review of the hospital's Quality Assessment and Performance Improvement (QA/PI) Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the hospital failed to ensure that it had identified opportunities for improvement and changes that will lead to improvement.


Findings include:


There was no documented evidence available for review to show that the hospital had an ongoing program of QA/PI to identify opportunities for improvement and changes that will lead to improvement.

Based on review of the hospital's Quality Assessment and Performance Improvement Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the hospital failed to ensure that it had set priorities for performance improvement activities that focus on high-risk, high volume, or problem-prone areas.


Findings include:


There was no documented evidence available for review to show that the hospital had an ongoing program of QA/PI to set priorities for performance improvement activities that focus on high-risk, high volume, or problem-prone areas.

Based on review of the hospital's Quality Assessment and Performance Improvement (QA/PI) Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the hospital failed to ensure that it had implemented preventive actions and mechanisms that included feedback and learning throughout the hospital.


Findings include:


There was no documented evidence available for review to show that the hospital had an ongoing program of QA/PI to implement preventive actions and mechanisms that included feedback and learning throughout the hospital.

Based on review of the hospital's Quality Assessment and Performance Improvement (QA/PI) Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the hospital failed to ensure that it had taken actions aimed at performance improvement.


Findings include:


The hospital staff could not provide documented evidence showing that the hospital had taken any actions aimed at performance improvement as a result of an ongoing QA/PI program.

Based on review of the hospital's Quality Assessment and Performance Improvement Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the hospital failed to ensure that it had taken actions aimed at performance improvement, measured its success, and tracked performance to determine that the improvements are sustained.


Findings include:


The hospital staff could not provide documented evidence showing that the hospital had taken any actions aimed at performance improvement as a result of an ongoing QA/PI program.

Based on review of the hospital's Quality Assessment and Performance Improvement (QA/PI) Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and reviewof the minutes of the Governing Body, the hospital failed to ensure that it had conducted performance improvement projects.


Findings include:


The hospital staff failed to provide documented evidence showing that they had performed any performance improvement projects as part of an ongoing QA/PI program.

Based on review of the hospital's Quality Assessment and Performance Improvement (QA/PI) Plan, review of the minutes of the Quality Assurance Committee, review of the minutes of the Medical Staff, and review of the minutes of the Governing Body, the Hospital's Governing Body, Medical Staff and Administrative Officials failed to ensure that an ongoing program for quality improvement is maintained.


Findings include:


Review of the minutes of the Governing Body and minutes of the Medical Staff revealed no documented evidence that QA/PI activities were being reported.

There was no documented evidence available for review to show that the hospital had an ongoing program of QA/PI.

Based on review of the policy and procedure manual for the medical record department, the hospital failed to ensure that the medical record department was operating with current policies and procedures addressing all aspects of the service.


Findings include:


Review of the Hospital's policy and procedure manual for their medical record department revealed that the last documented review of the medical record department's policy and procedure manual was prior to the last survey of the hospital on 09-12-07.

Based on review of the Medical Staff's Rules and Regulations and review of medical records, the hospital failed to ensure that all lab reports are filed on the correct patient's medical records, and that all medical records were complete prior to being filed in permanent files. This involved 18 medical records selected at random from a list of discharges from July 2011 through December 2011, along with two (2) inpatient medical records, and the last four (4) patients discharged from the hospital between January 20 and January 24, 2012, for a total of 24 medical records.


Findings include:

Cross Refer to A0454 for the hospital's failure to ensure that eight (8) of the 18 discharged medical records reviewed had complete and signed physician orders prior to being filed.


Review of 24 medical records revealed that lab reports were misfiled on the wrong patient's medical record on four (4) of the medical records reviewed. One (1) of these records had four (4) misfiled reports belonging to three (3) other patients. Two (2) misfiled reports were found filed on each of the other three (3) records.

Based on review of 24 medical records, the hospital failed to ensure that all entries in the medical record had been timed and dated.


Findings include:


18 medical records were selected at random from a list of discharges from July, 2011, through December, 2011, along with two (2) inpatient medical records, and the last four (4) patients discharged from the hospital between January 20 and January 24, 2012, for a total of 24 medical records. Review of these 24 medical records revealed:

1. 23 of 24 medical records reviewed had progress notes that had not been timed when written.

2. 20 of 24 medical records reviewed had physician's orders that had not been timed when entered into the medical record. This included orders written by the physician and verbal orders taken by a nurse.

3. 13 of 24 medical records reviewed had history and physical exams that had not been timed when the physician dictated the report.

4. Nine (9) of 24 medical records reviewed had a history and physical exam that had been handwritten by the physician. The date of admission was recorded on the form by the physician, but the physician had not timed and dated the history and physical as to when he had documented the report.

5. 11 of 18 discharged medical records reviewed had discharge summaries that had not been timed when the physician dictated the report.

6. Seven (7) of 18 discharged medical records reviewed had the date of admission and discharge recorded on the discharge summary form, but the physician had not timed and dated the discharge summary as to when he had documented the report.

Based on medical record review, the hospital failed to ensure that all physician's orders are signed within 48 hours by the ordering practitioner.


Findings include:


Record review revealed that verbal orders had not been signed by the responsible physician on eight (8) of 18 discharged medical records reviewed. These medical records had been filed as complete with these unsigned orders.

Based on observation and staff interview, the facility failed to maintain facilities, supplies and equipment to ensure an acceptable level of safety and quality.


Findings include:


Observations made with the Dietary Manager during the initial dietary and cafeteria environmental tour on January 24, 2012 beginning at 11:00 a.m. revealed:
1. Two (2) corridor doors on the inside and outside of the dietary department were marred, scarred and soiled.
2. There was dried debris and spills noted on the dietary floor behind and between the stoves, food preparation area, refrigerators and freezers.
3. The carpet in the Cafeteria was dirty.


Observations made with Registered Nurse (RN) #1 during the initial environmental tour on January 24, 2012 beginning at 11:20 a.m., revealed:
1. Window blind slates were bent and broken in Patient Rooms #103, #104, #105, #106, #107, #109, #112, #117, #122, and #123.
2. The acute care patient common bathroom's bath tub faucet was broken, which made the tub non functional.
3. The pharmacy door had heavy dust build up covering the vent.

Based on observation, staff interview, record review and document review, the hospital failed to meet the needs of patients in accordance with acceptable standards of practice, as evidenced by lack of policy and procedures, lack of documentation in records and lack of referrals in 10 of 10 records reviewed, Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10.


Findings include:


Observation of the hospital on 01/24/2012 at 10:15 a.m. revealed that neither crash cart had a daily check list for checking the defibrillator. A daily check list was placed on the Emergency Room (ER) Cart during the first day of survey.


Review of hospital Policies and Procedures revealed no documented evidence of ER Policy and Procedures. An interview with the Director of Nursing (DON) revealed that they had some, but that they were old. The policy and procedure book produced by the DON contained no ER policies.


Review of 10 ER charts revealed that none of the charts were complete and no two (2) charts were filled out the same way. There was no documented evidence of a policy and procedure stating how ER charts were to be completed.


Review of two (2) of two (2) charts for patients that the complaint was rape (Patient #6 and #7) revealed no documentation by the Registered Nurse (RN) of a vaginal exam. The RN check list was marked N/A (not applicable) for OB/GYN (Obstetrics/Gynocology). There was no documented evidence of the rape kit number, how it was processed or who it was turned over to (what authorities were contacted). One patient's chart did have that the incident was reported to MS. (Mississippi) Child Abuse Exploitation. There was no documented evidence of a policy and procedure for the ER stating the procedure for processing an alleged rape.


Review of two (2) of two (2) charts for patients that had an x-ray ordered (Patient #8 and #9) revealed that for both patients the orbital rim appeared to be broken. A cat scan was recommended for both patients. There was no documented evidence that either of the patients were notified. Patient #8's chart had no documented evidence that an attempt for a phone call was made regarding a referral. Patient #9's record stated that the phone was disconnected. There was no documented evidence that an attempt by mail, etc. was made to contact either of these patients. There was no documented evidence of a policy and procedure describing how this procedure was to be handled.


There were no documented evidence of a policy and procedure regarding triage and/or medical screening and there was no designated place in the ER to triage. There was only one (1) room and it was considered the Emergency Room.