HospitalInspections.org

Based on record review and interviews with hospital staff, the hospital does not ensure that all hospital personnel providing patient care have current and valid licenses, certifications and registrations. Review of physicians' credentials and contract personnel documents did not contain evidence of current licensure or narcotic registration permits.

Findings:

1. Medical staff T and V did not have evidence of current Federal narcotic permits as required.

2. The hospital did not maintain verification of current licensure for staff E, D,C and S who provide patient care services by contract.

3. Hospital staff verified on 12/04/13 in the afternoon they did not have evidence of the requested documents.

Based on staff interview, review of hospital documents, and observation of hospital clinical equipment, the hospital failed to have a preventative maintenance program to ensure the hospital's medical devices and equipment were maintained in safe operating condition.

Findings:

The surveyors were given a tour of the hospital on 12/02/13 by Staff G.

Observations revealed:

The defibrillator on the crash cart for the medical-surgical unit contained a biomed inspection sticker dated 03/29/11.

The defibrillator on the crash cart in the emergency department did not contain any evidence of a biomedical inspection.

These observations were confirmed by Staff G during the hospital tour.

Review of the radiology department documents revealed the hospital's X-Ray machine was last inspected in 2008 by the Oklahoma State Department of Health. This was confirmed by Staff L on the afternoon of 12/02/13.

On 12/02/13, Staff L stated the hospital purchased a refurbished Computed Tomography (CT) machine on 11/15/13. The hospital did not provide any documentation the CT machine had any preventative maintenance prior to usage. Staff L was asked if the hospital had any preventative maintenance for the CT machine, Staff L stated no.

Radiology inspection documents provided for review, documented a physicist report dated August 14, 2006. Staff L was asked for a current physicist report. None was provided.

In an interview with the State X-Ray Inspector he stated he did not perform inspections on CT scanners. He stated he does not have the equipment to inspect the CT scanners. He stated the CT scanners need to be inspected annually by a medical physicist.

On the morning of 12/04/13, Staff Z was asked for the preventative maintenance inspections for the hospital. None was provided. When asked if anyone provided preventative maintenance on the hospital's clinical equipment, Staff Z stated no.

On the morning of 12/04/13, Staff L was asked if the hospital had a contract with a biomed company to perform preventative maintenance for the hospital's medical devices and equipment. Staff L stated no, she said the last biomed contract the hospital had was in 2005 or 2008.

The hospital does not perform any surgical procedures, but maintains a autoclave for cleaning instruments that are used in the emergency room and the medical-surgical unit. On the morning of 12/03/13, Staff J was asked if preventative maintenance had been completed on the autoclave, she stated she did not know.

Staff J stated the temperature cycle wheel on the autoclave did not work properly. Staff J stated she was unable to determine the length of the time the autoclave maintained the temperature during each cleaning cycle. Staff J stated no work order had been requested for the autoclave.

Based on observation and interviews with hospital staff, the hospital does not ensure that drugs and biologicals are stored appropriately in a secure environment. Emergency drugs in two emergency carts were observed unsecured and stored within areas accessible by unauthorized personnel.

Findings:

1. Two of two emergency carts, one in the emergency room and one in the medical surgical hallway, containing emergency drugs were observed at random times during the three days of the survey. These carts were without a plastic breakaway lock and were not within a locked area to ensure the security of the drugs. Plastic breakaway locks are used to assure emergency drugs are available as needed and have not been tampered with.

2. The plastic breakaway locks were available on the cart and accessible to anyone and would not prevent awareness of access by unauthorized personnel.

3. Staff G verified on 12/02/13 in the morning that the emergency carts were not secure.

Based on review of hospital documents and staff interview, the hospital failed to develop and implement an emergency preparedness plan.

Findings:

Staff B was interviewed on the afternoon of 12/03/13, regarding the hospital's emergency preparedness plan.

Staff B was asked for documentation regarding disaster drills for the hospital. None was provided. Staff B stated the hospital had not performed any disaster drills for 2013 year.

Staff B stated she along with other hospital staff participated in a disaster drill with a neighboring hospital. Staff B was asked for documentation regarding the disaster drill such as, the date of the drill, list of participating personnel, the type of disaster drill conducted and the evaluation of the disaster drill. Staff B stated she did not have any of the requested documentation.

Staff B was asked if the hospital had any arrangements with utility companies, grocery stores and pharmacy for the provision of water, gas, food and medications in case of an emergency/disaster situations. Staff B stated the hospital did not have any arrangements.

Based on record review and interviews with hospital staff, the hospital's governing body failed to ensure the responsibility for the conduct of the hospital is determined, implemented and monitored to ensure quality of care and patient safety.

a. The governing body did not have evidence of adherence to governing body bylaws.

b.. The governing body did not have evidence of appointment to the medical staff of the practitioners providing patient care in accordance with medical staff bylaws.

c. The governing body did not have evidence of oversight of the maintenance of the physical envirornment.

Findings:

1. Board of Trustee's bylaws documented the Board of Trustees/governing body would be composed of 5 trustees. Board of Trustees meeting minutes for 2013 only had evidence of 4 trustees on the Board. Staff A stated on 12/02/13 in the afternoon the hospital had been unable to find someone to fill the vacancy on the Board.

2. Board of Trustees bylaws state under the duties and powers of the Board, that the Board is to appoint the medical staff. There was no evidence in Board meeting minutes or medical staff credential files of the Board appointing any of the medical staff who were providing patient care.

3. Board of Trustee's bylaws state under the duties and powers of the Board, that the Board will inspect the hospital monthly. There was no evidence the Board inspected the hospital monthly to ensure a safe physical environment.

Based on record review and interviews with hospital staff, the hospital does not ensure the physician reviews and signs the records of all inpatients cared for by the physician assistant. Twenty-three (1 through 23) of 23 patient records reviewed did not have evidence of review and authentication of care provided by the physician assistant by the physician.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to develop and provide services according to standards and written policies, as evidenced by failure to:

1. Ensure that drug storage areas are administered according to accepted professional principles and hospital policy and procedures and all outdated, mislabeled or otherwise unusable drugs are unavailable for patient use. (Refer to Tag C-0276)

2. Develop and maintain an effective ongoing infection control program, directed by a qualified staff with training, that reviewed, analyzed and provided corrective actions to prevent and reduce spread of hospital acquired infections and communicable diseases. (Refer to Tag C-0278)

3. Ensure that the current diet manual utilized in the hospital has been approved by both the dietitian and the medical staff. (Refer to Tag C-0279)

4. Ensure patient care policies are reviewed annually by the group of professional personnel as required. (Refer to Tag C-0280)

5. Develop policy and procedures to protect patients and staff from radiation hazards and ensure the radiology department has oversight by a Radiologist or qualified Medical Staff. (Refer to Tag C-0283)

6. Ensure all services provided by contract or agreement are evaluated by the hospital's quality program. (Refer to Tag C-285)

7. Ensure nursing staff were trained and evaluated on competency to perform the essential functions of their jobs. (Refer to Tag C-294)

Based on record review, observation and interviews with hospital staff, the hospital does not ensure that drug storage areas are administered according to accepted professional principles and hospital policy and procedures and all outdated, mislabeled or otherwise unusable drugs are unavailable for patient use. The hospital does not ensure the Consultant Pharmacist develops, implements and monitors policies and procedures in the Drug Room to assure proper storage, pharmaceutical services are provided by employees within their scope of license and only pharmacists or pharmacy-supervised personnel compound, label and dispense drugs and biologicals.

Findings:

1. Multiple outdated drugs were observed in the emergency room, emergency cart, and medication cart and medication room that were either outdated or mislabeled. The drug room supervisor stated on 12/03/13 in the afternoon that it was nursing's responsibility to check for outdates. Pharmacy policies state that the pharmacist or pharmacy technician will be responsible for recorded periodic inspections of medication storage areas at least monthly.

2. The repackaging log did not have a date authenticating when the pharmacist checked the drugs repackaged by the Drug Room Supervisor who is a Licensed Practical Nurse (LPN) to ensure they were not given to patients before the pharmacist checks them for accuracy. Majority of all the drugs used in the hospital are not in unit dose packaging and have to be repackaged.

3. Two plastic 8 oz.(ounce) bottles containing liquids were observed in the nurses' station medication room. One was labeled "Pink Elephant" and documented the following on a paper label ; " Xylocaine visc. 1 1/2 oz., Benadryl liquid - 1 1/2 oz., Maalox liquid - 5 oz. Filled 11/16/13 (init.)" drug room supervisor's initials. The drug room supervisor verified she had mixed this medication. The second bottle was labeled GI Cocktail and documented on the label was "Gaviscon, Donnatol, Reglan and Zylocaine viscous." The amounts of each drug used in the mixture were not documented on the label. Documented on the label were the drug room supervisors initials and "Filled 7/14/13 (init)" drug room supervisor's initials. The drug room supervisor verified she had mixed this medication. There was no evidence the pharmacist had mixed the medications or had supervised the mixing of the medications. Pharmacy policies on prepackaging drugs are specific that all drugs are to be verified by the pharmacist before being available to patients. The policy also specifies the label requirements and what records need to be maintained.

4. The consultant pharmacist did not have a job description or a contract specifying what his duties or responsibilities were. The only documentation provided for review was the pharmacist's license.

5. The hospital had two drug room personnel listed as assigned to the drug room. The drug room supervisor who is an LPN and a pharmacy tech who is listed as the pharmacy tech/business office manager. Their personnel files did not have any orientation to their drug room duties or competencies performed by the consultant pharmacist.

6. There was no evidence that the pharmacist reviewed and monitored the medication therapy of patients. Review of reports from the consultant pharmacist for the past 12 months did not have any documentation of specific duties performed during the visit. The reports consisted of only check marks on a check list. There were no details or narrative on duties performed.

7. Nursing prepares all IV (intravenous) admixtures, not in a premixed form, in a laminar flow hood in the nurses' station medication room. There was no evidence of training of nursing staff in IV admixtures and proper use of the laminar flow hood.

8. During a tour of the nursing station medication room, a tray was observed in the laminar flow hood obstructing the flow of air in the hood.. Requirements when using the hood are that there cannot be anything in the hood to obstruct the flow of the air.

Based on review of hospital documents, policies and procedures and meeting minutes, surveyors' observations and interviews with staff, the hospital failed to:

a. Develop and maintain an active on-going infection control/infection prevention (IC) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff;

b. Analyze IP surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel; and

c. Provide initial and on-going education/training for the infection preventionist (IP) in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program.

Findings:

Plan/Program:

1. The hospital has not conducted a hospital-wide IC risk assessment to identify the types of patients, risks/concerns, organisms, and diseases prevalent in the community and hospital.

2. The hospital has not conducted a tuberculosis risk assessment.

3. The Infection Control Plan (Plan), provided to the surveyors on 12/02/13 in the IC policy and procedure notebook, is not current.
a. At the bottom of the Plan is the date 03/27/11 and initialed by the IP.
b. The Plan says a physician with knowledge of infection control practices will govern the infection control committee. Medical Staff by-laws also require a physician to attend infection control. Meeting minutes did not show a physician attended the infection control meetings.
c. The Plan, with the exception of hand hygiene did not specify the infection control program would monitor to ensure all infection control policies and procedures would be monitored to ensure they were followed in all departments/areas of the hospital. No frequency of monitoring or how monitor would occur was not documented.
d. Although the Plan documented one of the goals was prevention of infections and communicable diseases, the Plan did not specify how this would occur and the written Plan only dealt with identification and containment of infections and communicable diseases.


IP Training/Education:

1. On the morning of 12/02/13, administrative staff told the surveyors that Staff W was the infection control preventionist (IP).

2. Review of Staff W's personnel files did not contain documentation of training in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program.

3. On the morning of 12/03/13, Staff W confirmed she had not received any training in establishing and maintaining a comprehensive effective infection control program.


Surveillance:

On the afternoon of 12/02/13, Staff W told the surveyors that, except for monitoring infections that occurred in the hospital, she did no surveillance.

1. The IC program has not monitored to ensure all departments followed infection control policies and current recognized infection control practices .

2. The Centers for Disease Control (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) have identified hand hygiene as the first avenue/most important tool in the prevention of spread of organisms and diseases. The Plan documented hand hygiene would be monitored, but no monitoring documentation was provided and the IC manual did not contain a monitoring tool for hand hygiene. The IP stated on 12/03/13 that hand hygiene surveillance was not performed.

3. Documents provided and meeting minutes did not demonstrate that, other than positive cultures of patients, the IC program monitored and evaluated infections of patients and staff to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

4. Central sterile processing is not monitored, including, but not limited to:
a. Maintenance and monitoring to ensure safe and effective autoclave sterilization;
b. Use of required testing for the autoclave is performed, including Bowie Dick/Dart testing and biological testing;
c. Appropriate cleaning and packaging of instruments occurs;
d. Sterilization practices - correct temperature, correct sterilizing time and correct dry time;
e. High level disinfection practices - correct product at correct temperature for correct amount of time; and
f. Appropriate disinfection occurs - products used according to manufacture's guidelines.

5. Isolation is not monitored to ensure:
a. Patient are placed in appropriate isolation according to current CDC guidelines;
b. Isolation carts are stocked appropriately;
c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements; and
d. Appropriate disinfection of the room occurs.

6. No monitoring of disinfectant applications throughout the hospital departments and locations to ensure:
a. Appropriate disinfectants are selected and used; and
b. The disinfectants are applied and remain "wet" contact time according to the manufacturers guidelines.


Policies and Procedures:

1. The 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. Central sterile services, including policies and procedures on how to process instruments and the requirements testing of the equipment;
b. Housekeeping services, with guidelines on appropriate cleaning and guidelines for disinfectant use;
c. Laundry services - specifying detergent(s) required for different types of loads; and how monitoring would occur to ensure adequate temperature were utilized;
d. Dietary services;
e. Pharmaceutical services;
f. Radiology services;
g. Physical Therapy services;
h. Respiratory therapy services.

2. The IC manual and the Nursing policy and procedure manual did not have isolation policies that reflected current CDC guidelines and recommendations.

3. The IC manual policy and procedure did not contain specific policies for respiratory isolation protection and requirement of specialized masks, N-95 respirator, other than the hospital should "use Delta N-95 masks for TB exposure" and have available sizes of small, medium and large. The IC policies and procedures did not specify:
a. Detail on how this was to be accomplished and by whom; and
b. Based on the current standards of practice and requirements by OSHA (Occupational Safety and Health Administration), how often fit testing would be performed.
c. Some staff interviewed did not know the hospital had N-95 masks or where they were kept.
d. No staff had been Fit tested to ensure the proper mask was identified and available.
e. The hospital only had one brand,Moldex-N-95, and one size, medium.

4. The IC manual did not contain a policy and procedures on how patients and staff with potential or confirmed influenza will be medically managed, including:
a. Screening;
b. Any required tests to confirm infection;
c. Any particular requirements according to current CDC guidelines.

5. Although the IC manual's Table of Contents listed reportable diseases, it was not the current list (05/13). The manual did not contain a policy and procedure for reporting reportable infections and diseases to the proper authorities, with delineation of responsibilities.

6. The IC manual did not contain policies on disinfectant approval and list of approved disinfectants with what area used and application requirements, including:
a. mixture;
b. wet time contact with surface to be effective; and
c. what organisms each approved disinfectant kill.

7. The IC manual did not contain policies and procedures concerning nail hygiene and artificial nails.


Observations:

1. Staff G accompanied the surveyors on a tour of the hospital areas on 12/02/13. The surveyors observed Staff G had polished artificial nails with a length that extended beyond the fingertips. This is not the usual recommended practice for staff that provide patient care.

2. During the tour of the emergency department (ER) on 12/02/13, the only one disinfectant was observed, Virex TB. Staff G stated that the ER occasionally had patients presenting with loose stools or diarrhea, possible Clostridium difficile (C-diff). When asked what she would use, she replied the Virex TB. Review of this disinfectant showed it was not effective for C-diff.

3. During the tour of the central sterile area with Staff J, the person identified as responsible for sterilization processes, she explained the procedures she followed to process, sterilize and store instruments. She stated (confirmed by policy review):
a. The department did not have written policies and procedures for processing instruments, including soaking, cleaning, inspection, ultrasonic process, rinsing, lubricating, sterilizing and storing sterile instruments.
b. Staff J stated that although another staff had trained her on what needed to be done, no documentation of this training had been done.
c. The autoclave wheel did not turn and the lead did not always mark, so there was no way to ensure the autoclave reached and maintained the required temperature for the time necessary to ensure the items were sterilized.
d. Staff J did not know a Bowie Dick or Dart test was required on the first load.
e. Staff J stated she had been told that biological testing was no longer necessary since the hospital no longer did surgery. The biological testing vials found expired in 2008.

4. During a tour of the Laundry area on 12/03/2013, the surveyors observed no laundry instructions/policies and procedures were posted. The washers did not have a temperature gauge. On 12/03/13 at 0905, Staff R stated the only laundry policy she had, had just been "handed down". The surveyors found two policies, one in the IC manual and one supplied by housekeeping.
a. The policy found in the IC manual documented laundry should be washed in water temperature above 160 degrees Fahrenheit for 25 minutes with bleach or other chemical treatments to further reduce microbial contamination. No specifics or ratios of detergent and bleach are documented.
b. The housekeeping policy did not identify at what temperature(s) laundry was to be washed. Although the policy gave the amount of laundry soap, Pinesol and bleach to be used, without knowledge of the capacity of water the washer held, one could not determine if the bleach was effective to kill the organisms. It did not specify dryer temps.
c. The housekeeping policy specifies that nursing is responsible for "all human waste being removed from linens before put in laundry bags." Nursing did not have a policy concerning this. Staff R stated they would "sometimes" get items that had not been thoroughly cleaned or bagged correctly.


5. During a tour of the Drug Room, the surveyor observed a plastic medication repackaging tray. On 12/03/13 at 1130, Staff Y confirmed they were reused and that they were not cleaned/disinfected between use.


Meeting Minutes:

On the morning of 12/02/13, administrative staff told the surveyors that IC meeting minutes were part of the Infections Control Committee and Medical Staff Meeting. This was later confirmed with Staff W, the person identified as the IP. The surveyors reviewed the Infection Control Committee and Medical Staff Meeting minutes from September 1012 to present.

1. The meeting minutes did not contain review, evaluation and analysis of infections to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

2. The meeting minutes did not demonstrate central sterile services were monitored, reviewed and analyzed with corrective actions taken and follow-up to ensure compliance with accepted standards of practice.

3. Concerns/items reported in "Infection Control Rounds" were not mentioned in meeting minutes. Examples include, but not limited to: walls with chipping paint that could not be cleaned; chairs and mattresses with splits that cannot be disinfected; and a dirty commode in an unoccupied room.

4. Concerns/items mentioned in meeting minutes were not followed to ensure corrective actions were taken and sustained. Example: nosocomial/hospital acquired infections; and positive C-diff. The 3/27/13 Infection Control Committee meeting minutes documented that the monitoring of the temperatures in laundry had not been started. This was not discussed again. On 12/03/13, Staff W and R stated that laundry water temperature were not monitored.

5. The meeting minutes did not contain documentation and review of surveillance/monitoring to ensure IC policies and procedures and current standards of practice are followed. Staff W stated on the afternoon of 12/02/13 that this did no occur.

6. The meeting minutes did not contain evidence disinfectants used in the hospital had been reviewed for appropriateness and approved for use. Staff W confirmed disinfectants had not been reviewed as part of IC. The surveyors observed Virex TB available for use in the emergency department, radiology and housekeeping cart. Virex TB is not effective for C-diff.

7. The meeting minutes did not reflect employee illnesses and immunizations were part of the program. Review of personnel files, including contract and physician and allied health files did not show complete immunizations as recommended by CDC and its advisory committee (ACIP). The hospital did not maintain health files on contract staff that provided care to patients. This was confirmed with staff at the time of review on 12/03/13 and again during the exit conference on 12/04/13. No additional information was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that the current diet manual utilized in the hospital has been approved by both the dietitian and the medical staff. The diet manual presented for review only had the signature of consultant dietitian.

Findings:

1. Medical staff meeting minutes reviewed did not have evidence that the medical staff had approved the diet manual presented for review.

2. Hospital staff verified that the diet manual had not been approved by the medical staff.

Based on record review and interviews with hospital staff, the hospital does not ensure patient care policies are reviewed annually by the group of professional personnel as required. Six of eleven department policies reviewed had not been reviewed by the group of professional personnel as required at least annually. There was no evidence in medical staff or Board of Trustees meeting minutes for 2013 of policy review.

Findings:

1. Pharmacy policies and procedures were last reviewed in May 2012.

2. Nursing policies and procedures were last reviewed in June 2012.

3. Emergency room policies and procedures were last reviewed in June 2012.

4. Swing bed policies and procedures did not have evidence of a date of review.

5. Central sterile policies and procedures were last reviewed in 2008.

6. Physical therapy policies and procedures did not have evidence of a date of review.

7. This was verified with hospital staff.

Based on review of hospital policy and procedures, review of personnel files and interviews with the radiology department manager, the hospital failed to develop policy and procedures to protect patients and staff from radiation hazards and ensure the radiology department has oversight by a Radiologist or qualified Medical Staff.

Findings:

On 12/02/13 at 1525, Staff L was asked for the hospital's radiation exposure policy. None was provided. Staff L stated the hospital did not have a radiation exposure policy.

Review of the radiology department documents revealed the hospital X-Ray machine was last inspected in 2008 by the Oklahoma State Department of Health. This was confirmed by Staff L on the afternoon of 12/02/13.

On 12/02/13, Staff L the hospital purchased a refurbished Computed Tomography (CT) machine on 11/15/13. The hospital did not provide any documentation the CT machine had any preventative maintenance prior to usage. Staff L was asked if the hospital had any preventative maintenance for the CT machine, Staff L stated no.

Radiology inspection documents provided for review, documented a physicist report dated August 14, 2006. Staff L was asked for a current physicist report. None was provided.

In an interview with the State X-Ray Inspector he stated he did not perform inspections on CT scanners. He stated he does not have the equipment to inspect the CT scanners. He stated the CT scanners need to be inspected annually by a medical physicist.

On 12/02/13 in the morning, Staff Q was asked, who is the radiologist for the radiology department, Staff Q stated there is no radiologist for the radiology department. Staff Q stated the hospital has a contract with two different radiology companies to interpret the radiological exams neither company provided a radiologist to have oversight of the department.

A radiology department competency checklist for the radiology staff, titled, Radiology Department, documented, " ...has been designated by the Cimarron Memorial Hospital medical staff as being qualified to operate radiographic equipment for routine diagnostic x-ray and CT imaging ... " The documented contained a signature line, for the Chief of Staff, Administrator and the Chief X-Ray Technician.

On 11/23/13, Staff T, a physician on staff, signed a radiology competency checklist for Staff L as Chief of Staff.

There was no evidence Staff T had been credentialed by the Governing Body. There was no evidence Staff T had radiology qualifications.

Based on review of hospital documents and interviews with staff, the governing body does not ensure all services provided by contract or agreement are evaluated by the hospital's quality program. Review of the hospital's quality/compliance, governing body and medical staff committee meetings for 2013 and contract personnel files did not have evidence of review and evaluation through the QA/PI (quality assessment and performance improvement) program of the services provided by contract.

Findings:

There was no evidence rehabilitative, dietetic and radiology services provided by contract are evaluated by the hospital's QA/PI program.

No additional information was provided by hospital staff during the survey concerning contract services evaluation by the QA/PI program.

Based on record review 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 six of six licensed nursing personnel (Staff B, G, H,Y, AA and BB) and one central sterile nursing staff (Staff J), whose personnel files were reviewed. Two of two nurse's aides(Staff I and J) did not have current cardiopulmonary resuscitation training.

Findings:

1. The hospital takes care of all age patients in the emergency room and/or as inpatients. The personnel files for Staff B, G, H, Y, AA and BB did not contain evidence of training, testing and/or age-specific competency verification.

2. Although the hospital does not offer obstetrics as a routine service, the hospital's ER has received obstetrical patients in labor and has had to perform emergency deliveries. The latest occurred on 10/14/13. The personnel files for Staff B, G, H, Y and BB did not contain evidence of training and competency verification for perinatal patients and emergency deliveries, including fetal monitoring and newborn assessments.

3. Staff Y also worked in the drug room. Staff Y's personnel file did not contain evidence Staff Y had been orientated and trained for her duties or that the pharmacist had performed competency verification of those skills.

4. Staff J was identified as the nursing staff responsible for central sterile supply. Staff J's personnel file did not contain evidence of training or competency verification for cleaning, processing and sterilizing instruments. Staff J told the surveyors on the afternoon of 12/03/13 that although she had been taught by the previous staff, no documentation of her training had been performed.

5. Staff I and J did not have current training to perform cardiopulmonary resuscitation.

6. These findings were reviewed and verified with administrative staff on the morning of 12/04/13. No additional data was provided.

Based on record record review and interviews with hospital staff, the hospital does not ensure all patient records have entries that are timed, dated and authenticated. Nineteen of 23 records were incomplete and did not have orders with the required elements. The records did not always medication orders that were authenticated, dated and timed.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital performs a periodic evaluation and quality assurance review as required. The hospital has not conducted an annual periodic evaluation with all the required elements and does not have an effective and ongoing quality assurance program.

1. The hospital does not ensure a yearly program evaluation reviewing the utilization of CAH services, including the number of patients served and the volume of services is conducted. Refer to Tag C 0332.

3. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies. Refer to Tag C 0334.

5. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag C 0335.

6. The hospital does not have an effective quality assurance program that is implemented to evaluate the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI program. Refer to Tag C 0337.

7. The hospital does not have an effective quality assurance program implemented to evaluate nosocomial infections and medication therapy. Refer to Tag C 0338.

8. The hospital does not ensure that the physician assistant providing patient care is evaluated by a physician member of the medical staff of the hospital. Refer to Tag C 339.

9. The hospital does not have a functioning QAPI system implemented so that remedial action can address deficiencies found through the QAPI program. Refer to Tag C 0342.

10. The hospital does not document the outcome of any remedial action taken by the QAPI program. Refer to Tag C 0343.

Based on record review and interviews with hospital staff, the hospital does not ensure the yearly program evaluation includes a review of the number of patients served and the volume of services. Hospital staff verified the annual program evaluation did not include these statistics.

Based on record review and interviews with hospital staff, the hospital does not ensure the annual program evaluation includes a review of the hospital's health care policies. The annual program evaluation for 2012 did not have evidence of review of the following policies:

1. Swing bed policies and procedures did not have evidence of a date of review.

2. Central sterile policies and procedures were last reviewed in 2008.

3. Physical therapy policies and procedures did not have evidence of a date of review.

This was verified with hospital staff.

Based on record review and interviews with hospital staff, the hospital does not ensure the annual program evaluation had determined whether the utilization of services were appropriate, established policies were followed and any changes were needed. The program evaluation did not have evidence that any changes to hospital services or policies were added or revised because of information from the annual program evaluation. This was verified by hospital staff during the survey.

Based on record review and interviews with hospital staff, the hospital does not ensure that the quality assurance (QAPI) program evaluates the hospital's patient care services to ensure patient health and safety.

Findings:

1. Services provided by contract were not evaluated by the QAPI program

2. Medication errors reported to QAPI were not analyzed and trended to evaluate and formulate an action plan to decrease medication errors.

3. Dietary data reported to QAPI was the number of meals served and the cost of the various grocery store prices. There were no indicators in dietary to evaluate if the nutritional needs of patients were met.

4. Infection control data reported to QAPI did not analyze and trend infections and medication therapy to protect patients and ensure their safety.

Based on record review and interviews with hosptial staff, the hospital does not ensure that nosocomial infections and medication therapy are analyzed to determine why the infections were hospital acquired or if the medication therapy used for infections was appropriate.

Findings:

1. Infection control reports in medical staff meeting minutes for 2013 did not have evidence of analysis of nosocomial/hospital acquired infections to evaluate the hospital's infection control processes.

2. Infection control reports in medical staff meeting minutes for 2013 did not evaluate whether the appropriate medication therapy was utilized and appropriate.

3. Pharmacy and therapeutics (P&T) meeting minutes for 2013 had the identical minutes for all four quarters. The minutes documented the following : stop order audits; no reactions, no adverse events. There was no discussion or evaluation of any data reported during the meetings. There were no reports, analysis or plans of action documented for medication errors reported to quality assessment performance improvement. The consultant pharmacist did not attend any of the P&T committee meeting minutes.

Based on record review and interviews with hospital staff, the hospital does not ensure that the physician assistant providing patient care is evaluated by a physician member of the medical staff of the hospital. There was no evidence in 23( #'s 1 through 23 ) of 23 patient records reviewed, 3 ( #'s T, U & V ) physician credential files or medical staff meeting minutes of evaluation of the care provided by the physician assistant.

Based on record review and interviews with hospital staff, the hospital does not ensure that appropriate remedial action is taken to address deficiencies identified through the quality assurance program. Medication errors and nosicomial infections identified were not analyzed and an remedial action plan implemented to correct the identified deficiencies. This was verified by hospital staff.

Based on record review and interviews with hospital staff, the hospital does not document the outcome of any remedial action taken. Quality Assurance Performance Improvement (QAPI), medical staff and Board of Trustees meeting minutes for 2012 an 2013 did not have evidence any remedial action taken to address any deficiencies identified by the QAPI program.

Based on review of medical records, policies and procedures, personnel files and staff interviews, the hospital failed to ensure staff were adequately trained:
a. to monitor and assess patients in seclusion.
b. to provide monitoring, assessing and safe application to patients in restraints.

This occurred in eight of eight (B, G, H, I, J, Y, AA and BB) personnel files reviewed.

Findings:
Review of the swingbed policies and procedures revealed the hospital had a restraint and seclusion policy.

Medical records for Patients #1, 2, 3 and 4 were reviewed on the afternoon of 12/03/13.

Review of the medical records revealed, each swingbed patient signed a hospital document, titled, " Consent For The Use of Restraints " , upon admission. The document is included in the admission paperwork for patients admitted to the swingbed unit. This was confirmed by Staff B during medical record review.

Review of the personnel files for Staff B, G, H, I, J, Y, AA and BB did not contain evidence of restraint and seclusion training.

On 12/03/13 at 1600, Staff B was asked if the hospital provided restraint training to the staff. Staff B stated no.

Based on a review of personnel files, swingbed policies and procedures, and interviews with hospital staff, the hospital failed to ensure the State nurse aide registry was checked for findings for contract staff. This occurred in four of four (C, D, E, and S) contract staff personnel files reviewed.

Findings:

The hospital rehabilitation (Staff D and E), dietary (Staff C) and pharmacy (Staff S) services are provided through a contract.

Staff M was asked for the personnel files for the contract staff. None was provided.

There was no documentation of a State nurse aide registry inquiry and evidence that a criminal background check by the Oklahoma State Bureau of Investigation had been performed for Staff C, D, E and S.

The above findings were reviewed with hospital staff during the exit conference on 12/04/13.

Based on medical record review, personnel file review and staff interview, the hospital failed to provide an activities program that provides individual, group and/or bedside activities based on the patient's assessment. This occurred in four of four (#1 through 4) medical records reviewed.

Findings:

On the morning of 12/02/13, Staff X was identified as the Swingbed Activities Program Coordinator.

Review of medical records revealed:

Patient #1 was a current swingbed patient admitted on 11/14/13. The initial activities assessment was completed on 11/14/13. There was no evidence of any activities documented in the medical record by Staff X.

Patient # 2 was a current swingbed patient admitted on 11/27/13. There was no documentation of a completed activities assessment by Staff X. This was confirmed by Staff B on 12/03/13 at 1540 during medical record review.

Patient # 3 was a swingbed patient 10/28/13 through 11/13/13. The initial activities assessment was completed by Staff X. There was no evidence of any activities documented in the medical record by Staff X.

Patient #4 was a swingbed patient 11/13/13 through 11/23/13. The initial activities assessment was completed on 11/14/13 by Staff X. There is no evidence of additional activities documented for the following dates: 11/15/13 through 11/17/13 and 11/19/13 through 11/23/13.

On the afternoon of 12/03/13, Staff X was asked how often she visited with the swingbed patients. Staff X stated the she completes an activity assessment within twenty-four hours of admission to swing bed status. Staff X also stated she did not visit patients on a daily basis.

Staff X told the surveyors she did not have an Activities Calendar.

Based on medical record review and staff interview the hospital failed to ensure a comprehensive on-going nutritional assessment was developed and implemented for patients admitted to the swingbed unit. This occurred in four or four (#1 through 4) medical records reviewed.

Findings:

On the morning of 12/02/13, Staff N identified herself as the dietary manager. Staff N was asked if she is a certified dietary manager (CDM). She stated no.

Staff M is the human resource manager, according to the hospital organizational chart. Staff M has a CDM certificate. Staff M stated she completes the nutritional assessments for the swing bed patients.

Staff M was asked how often nutritional assessments are completed on the swingbed patients. Staff M stated upon admission. Staff M was asked if swingbed patients received any on-going nutritional assessments. Staff N stated no.

Staff M stated she completed the nutritional assessments based on the data from the patients' medical record. When asked if she completed a bedside (face-to-face) nutritional assessment, Staff M stated she did not.

Based on staff interview, medical record review and personnel file review, the hospital failed to ensure rehabilitative services were provided by qualified personnel. This occurred in two of four (#1 and 4) swingbed records reviewed.

Findings:

Rehabilitative services are a contracted service provided by Staff D and E.

Staff M was asked for the personnel files for Staff D and E. None was provided.

The hospital was asked for hospital orientation, competencies, evaluations and immunization history for Staff D and E. None was provided.

During the exit conference on 12/04/13, hospital administration was asked who was responsible to maintain the personnel files for contracted staff (D and E), no one acknowledged responsibility.

Review of medical record #1 documented a Physical Therapy Evaluation by Staff D on 11/12/13. There was documentation for physical therapy treatments by Staff E on the following dates: 11/12/13, 11/14/13, 11/20/13, 11/21/13, 11/25/13, 11/26/13, 12/02/13 and 12/03/13.

Medical record #3 contained a Physical Therapy Evaluation by Staff E on 10/31/13. There was documentation for physical therapy treatments by Staff E on the following dates: 11/04/13, 11/05/13, 11/06/13, and 11/10/13 by Staff E.