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Based on review of hospital documents, policies and procedures, personnel/credential files, and meeting minutes and interviews with hospital staff, the hospital failed to ensure the infection control program included review and evaluation of the surgical and central sterile services practices to avoid sources and possible transmission of infections and a review of non-employee immunization status.

Findings:

1. The hospital's infection control plan did not include evaluation of surgical and central sterile practices.

2. The surgery log for 11/15/2010 showed thirteen cataract surgeries were performed between 0800 and 1045 (a 2.75-hour period). The hospital has one operating room and crew. On 12/17/2010 at 0910, the Director of Nursing told the surveyors that the hospital only had three complete sets of eye instruments and three partial sets.

3. Staff G stated at 0930 that the hospital used a gravity sterilizer. She stated eye instruments were only placed in a single wrap (usually instruments were placed in a double-layer wrap) with a 10-minute sterilization, but a shortened 3-minute dry time. Information provided did not confirm whether anyone was checking the instruments to see if they were dry when they were unwrapped during the surgical procedure.

4. Quality Council and Medical Staff meeting minutes for 2010 did not demonstrate an active monitoring/surveillance of the sterilization and disinfection of equipment for the surgical services to ensure practices were in compliance with standards of practice or evaluation of the types of instruments sterilized with a plan to reduce the number of "flash"/shorten sterilization cycles. The meeting minutes did not mention cleaning and disinfecting of the endoscopic instruments.

5. Quality Council and Medical Staff meeting minutes for 2010 did not demonstrate physician, allied health personnel and non-employ staff's immunization status were reviewed and monitored. Five of seven of these staff, whose health files were reviewed, did not contain complete immunization histories. This finding was reviewed with administrative staff on the afternoon of 12/17/2010.

Based on policy and procedure manual review, review of hospital documents, and interviews with the radiology department manager and administration, the hospital failed to provide orientation, training, and oversight of the radiology services personnel. The hospital also failed to have documentation showing all the contract personnel operating the radiology equipment are qualified and trained.

Findings:

1. On 12/16/2010 surveyors were given radiology personnel files including contract magnetic resonance imaging (MRI). Two of two contract MRI personnel files did not contain orientation, training, competency or evaluation. On the afternoon of 12/16/2010 surveyors spoke with Staff I. Staff I told surveyors the hospital did not have any orientation, training, competencies or evaluations for MRI, contracted ultrasound, or mammography. This finding was reviewed with the administration and no further information was provided.

2. On the morning of 12/16/2010 surveyors were provided radiology policy and procedure. One (H) of three (I,H,Z) radiology personnel providing services at the facility did not have documentation indicating the Medical Staff or radiologist had deemed them competent to provide radiology services. This finding was reviewed with Staff I. No further documentation was provided. This finding was reviewed with administration and no further documentation was provided.

Based on review of the organizational chart, contract personnel files, the quality/performance improvement program/plan and quality/performance improvement meeting minutes for 2010 and interviews with hospital staff, the hospital failed to ensure the quality program evaluated all services provided at the hospital.

Findings:

1. On the afternoon of 12/16/2010 surveyors were provided contract personnel files. Three of three (K,L,O) contract personnel files failed to have orientation, training, or evaluation of services provided. Later in the afternoon, Staff I told surveyors there had not been orientation, training, or evaluation of contracted services in magnetic resonance imaging (MRI), ultrasound, or mammography. On 12/17/2010 this finding was reviewed with Staff A who told surveyors some contract information was reviewed in quality council. Documentation in the quality council meeting minutes did not indicate evaluation of care provided by contract services, only numbers of procedures performed. No further information was provided to surveyors. The hospital failed to evaulate care provided by contract service providers.

Based on record reviews and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program, conducted at least once a year, includes a review of the CAH's health care policies. Ten of seventeen policy manuals had not been reviewed within the last year. This finding was reviewed and verified with the Director of Nursing and Staff D on the afternoon of 12/17/2010. Both stated the hosptial did not have a procedure/plan in effect to ensure all policy and procedure manuals were reviewed annually.

Based on a review of policies and procedures and staff interview, the hospital failed to ensure the swing bed policies included a policy and procedure addressing mistreatment, neglect and abuse and misappropriation of property of swing bed patients that addressed how the hospital would protect the patient and staff while the allegation was being investigated; what the hospital would do if the report was substantiated; and how the hospital would educate staff on recognizing abuse and neglect and the hospital's policy on the procedure to follow if a staff member received an allegation or witnessed abuse, neglect or misappropriation of patient property. This finding was reviewed and verified with the Director of Nursing on the afternoon of 12/17/2010.

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 the individual needs and interests of the patients. This occurred for two of two swingbed patients (Records #5, and 6) whose medical records were reviewed.

Findings:

1. Records #5 and 6 did not contain comprehensive activity assessments with the interests, and the physical, mental, and psychosocial needs of each swingbed patient considered.

2. Records #5 and 6 did not contain documentation that activities had been provided to the patients.

3. The staff on the unit told the surveyors on the afternoon of 12/16/2010 that:
a. The hospital did not have a designated qualified individual to direct the hospital's swingbed activity program.
b. No activity assessment had been performed on swingbed patients.
c. The hospital had not provided organized individual, group or bedside activities to patients based on patient interests and needs assessment.

4. On 12/17/2010, the Director of Nursing told the surveyors that several nursing staff tried to provide individual activities to the swingbed patients, but not personalized activities were utilized as no assessment of the patient likes/dislikes and needs were performed.