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Based on record review and interviews with hospital staff, the governing body failed to ensure that personnel providing services by contract are oriented and evaluated to ensure competence and meet the same requirements as employees of the hospital. This occurred in one (Staff II) of two contract staff personnel files reviewed.

Findings:

The hospital contract with orthopedic representatives to deliver orthopedic equipment for surgical procedures. The representatives are present in the operating suite during surgical procedures.

On 03/01/14, Staff D stated Staff II was a contract representative that provided services to the hospital.

Review of the personnel files for Staff II did not contain documentation of hospital orientation.

On the afternoon of 04/01/14, Staff N stated she did not provide hospital orientation to the contracted staff.

Based on review of medical records and policies and procedures and interviews with hospital staff, the hospital failed to ensure patients were restrained in accordance with a physician's order and in accordance with hospital policy. This occurred in two of two patient medical records reviewed (Record #15 and 21) where restraints were utilized.

Findings:

1. The hospital restraint policy and procedure stipulated:
a. Restraint orders must contain: date and time; reason for restraint; type of restraint to be used; duration (time limit) for restraint - not to exceed 24 hours for non-protocol restraint and 72 hours for protocol restraint; if verbal order, signature of RN writing order; and physician signature.
b. Restraints would be implemented in the least restrictive manner.
c. Documentation would include: order for restraint (with requirements listed in [a]); and results of ongoing assessment of patient and rational for continued use of restraint. "The continued need for the use of restraint will be reassessed and documented every 2 hours for restraint...Patients in medical surgical restraint will be continually assessed for the opportunity for removal or restraints. This reassessment should be documented at least every 2 hours."

2. Patient #15- the restraint orders on 06/03/2013, did not contain the reason for the four-point soft restraints and the duration for the restraint. The restraint was initiated at 2200 on 06/03/2013 and discontinued at 0433 on 06/04/2013.

3. Patient #21 - The patient was restrained from 0720 on 01/13/2014 until 2142 on 01/14/2014 and again on 01/15/2014 (specific times not specified).

a. Although the nurse documented in the nurses notes the physician gave orders for restraints because the patient kept pulling out intravenous (IV) lines and Foley catheter, there was no order for the wrist restraints applied on 01/13/2014 at 0720.

b. Documentation every two (2) hours lacked justification for continued restraint use, with the exception of: 0851 and 2316 on 01/13/2014; and 0600, 0629, 0730 1430 and 1609 on 01/14/2014. The rest of the nursing notes only identified the patient as resting, quiet or asleep.

c. The only physician order for restraints was an order on 01/14/2014 at 1312 to "continue restraints". Although the order contained both the physician assistant's and physician's signature, the order was not complete according to the hospital's policy (See Finding #1).

d. Nursing notes and restraint documentation reflected the nurse discontinued the wrist restraints on 01/14/2014 at 2142.

e. The nurse documented the patient pulled out the IV at 0315 on 01/15/2014, but does not state whether restraints were reapplied at that time.

f. On 01/15/2014 at 0700, the nurse documented "Restraints in place."

g. No order was written for restraints on 01/15/2014.

h. The medical record did not contain any more documentation of continued restraints or removal of the restraints. The patient was discharged to a skilled nursing facility on 01/15/2014 at 1600.

i. The above findings were reviewed and verified with Staff B at the time of review on 04/03/2014 at 1100.

4. The above findings were reviewed with administrative staff during the exit conference on the afternoon of 04/03/2014. No additional information was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure evidence is maintained and demonstrated for CMS review to show measurement, analysis and tracking of data used to assess processes of care, hospital service and operations with actions taken and results of the action.

Findings:

1. Review of Governing Body, Medical Staff and Quality Assessment Performance Improvement meeting minutes for 2013 and 2014 did not have any evidence of analysis of data used for measurement of hospital processes, results of that analysis or actions taken, if any.

2. Hospital staff stated during the survey that analysis of QAPI data was not always documented in meeting minutes.

Based on medical record review and interviews with hospital staff, the hospital did not ensure that all entries in the medical record were complete and contained the time they were signed or authenticated in electronic or written form by the person responsible for the services provided. This occurred in six (#3, 4, 8, 15, 17 and 19) of twenty written medical records reviewed.

Findings:

Medical records # 3, 4 and 8 contained preprinted Pre-Anesthesia Orders and Post Anesthesia Care Unit Orders, the orders did not document the time they were authenticated by the physician or licensed practitioner.

This was confirmed by Staff D in the afternoon of 04/03/14 during chart review.

Medical records #17 and 19 contained written physician orders that did not document the time they were authenticated by the physician or licensed practitioner.

Medical records #3 and 15 had radiological procedures performed during surgery. Review of the medical records did not contain the name of the radiology technician that operated the radiology equipment.

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

Based on observations and staff interview, the hospital failed to provide a hazard free environment for the radiology staff and patients.

Findings:

The surveyors toured the radiology department on 04/02/14 accompanied by Staff U, the radiology director.

A spiked 500 milliliter (ml) bag of single use Normal Saline (NS) was observed hanging in the computerized axial tomography (CT) suite. Staff U stated the 500 ml NS bag is used to prime the CT injector. The NS bag remains spiked and hanging in the CT suite and is used for multiple patients.

The above information was presented to the administrative staff during the exit interview.

Based on observation, review of infection control data, surveillance activities, personal files, hospital documents, and meeting minutes, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and maintained a comprehensive ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained ensuring a safe and sanitary environment.

Findings:

1. On 04/02/2014, surveyors toured the radiology department, accompanied by Staff U, the radiology director. A spiked 500 milliliter (ml) bag of single use Normal Saline (NS) was observed hanging in the computerized axial tomography (CT) suite. Staff U stated the 500 ml NS bag is used to prime the CT injector. The NS bag remains spiked and hanging in the CT suite and is used for multiple patients. Meeting minutes, containing infection control, did not reflect this finding had been identified, reviewed or analyzed with corrective actions taken.

2. On the morning of 04/03/2014, one surveyor observed Staff JJ provide care for three different patients without hand hygiene. Although meeting minutes provided hand hygiene percentages, the meeting minutes and accompanying attachments did not show corrective actions and follow-up of those actions. Staff D told the surveyors that inservice had been provided to staff. The meeting minutes did not reflect review and analysis to determine what action needed to be taken.

3. The disinfectant observed as being used at the main campus for all areas was PDI Sani-Cloths (purple and yellow/bleach tops) and Diversity Virex. The surveyor observed TB Quat being used at the hospital's off-site outpatient facility. Meeting minutes did not reflect review and determination that different disinfectants that would be used at different facilities.

4. Although meeting minutes for 2013 showed employee illnesses, there was not review and analysis to determine if there was a correlation between staff to staff and staff to patient illnesses and whether any corrective actions were needed.

5. Although the ICP had a calendar that included all departments of the hospital, including off-site facilities, documentation provided did not demonstrate what was reviewed, other than hand hygiene and environmental rounds. This was not broken down to determine the deficient practices at the off-site facilities. Meeting minutes did not reflect all departments were involved in the infection control program to show infection control policies and procedures were followed.

Based on record review and interviews with hospital staff, the hospital does not ensure that all respiratory treatments are administered as ordered and the patient's response to treatment is documented. Three of four patient records reviewed (Record #'s 3, 16 and 19) that had respiratory treatments ordered did not have the treatments given as ordered.

Findings:

1. In an interview with Staff D on 04/03/14 at 1145, Staff D stated the respiratory therapist (RT) provided the education to the patients regarding the incentive spirometer (IS). Staff D stated RT documented their findings in the medical record.

2. Patient #3 - On 10/23/13, the physician wrote an order for RT to evaluate and treat Patient #3. Review of the medical record did not contain documentation the patient had been evaluated and/or treated by RT. This finding was verified by Staff D at the time of review on 04/03/14.

3. Patient #16 and 19 - Orders were recorded in the electronic medication record for IS. Review of the medical records for both patients did not contain documentation of education for the IS by the RT. This finding was verified by Staff D at the time of review on 04/03/14.