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Based on review of the infection control documents, hospital meeting minutes, policies and procedures and personnel files, and interviews with staff, the hospital failed to develop an active infection control program for identifying, reporting, and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer (ICO).

Findings:

1. The personnel file, for the person identified as the ICO, did not contain evidence the individual had training or experience in infection control. On 08/10/2010 at 1315 Staff C stated she did not have any previous experience in infection control and had not received any infection control training on setting up an infection control program with active surveillance and analysis of data.

2. Review of infection control data and meeting minutes for medical staff and quality did not show ongoing analysis of patient infections. The last patient data was for May 2010. On the afternoon of 08/10/2010, Staff C stated the last time she did infection control was April or May 2010.

3. Review of infection control data and meeting minutes for medical staff and quality did not contain employee health data. On the afternoon of 08/10/2010, Staff C stated staff/employee health and immunization was not part of the infection control program. Four of four physician files did not contain complete immunization histories.

4. Review of infection control data and meeting minutes for medical staff and quality did not contain data from active surveillance of staff. On the afternoon of 08/10/2010, Staff C stated she did not conduct surveillance/observation activities of staff to ensure policies and procedures were followed. She stated she had not inserviced employees on proper handwashing/hand cleansing techniques or performed any hand sanitation surveillance.

Based on review of hospital documents, review of personnel and interviews with the radiology department manager, the hospital failed to have documentation showing all the personnel operating the diagnostic x-ray equipment are qualified and trained.

Findings:

1. In an interview on the afternoon of 8/9/2010 Staff R stated all of the employees in lab (R,S,T) were on-the-job trained to take x-rays. Radiology information provided to surveyors did not indicate what types of procedures or equipment the employees were competent to utilize. Personnel files for employees identified as radiology technicians (R,S,T) did not have radiology training. Three of three radiology personnel (R,S,T) did not have competency or evaluation on use of radiology equipment. On 8/20/2010 this finding was reviewed with administration and no further documents were provided.


2. On 8/9/2010 surveyors were given Quality Assurance Meeting Minutes. Review of minutes did not indicate there was any type of radiology department review. On 8/20/2010 this finding was reviewed with administration and no further documents were provided.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to assure nursing staff are adequately trained, oriented and competent to provide care to meet the needs of the patients.

Findings:

1. Nursing competencies/skills check:

a. Seven nursing personnel files were chosen for review. Seven of seven (C,M,N,O,P,Q,W) did not contain competency- performance evaluation. Seven of seven did not have unit specific/department specific training. On the afternoon of 8/1/2010 Staff C told surveyors they had not done any competencies or unit specific training.

2. Nursing Blood Administration competency:

a. Six of six nursing personnel files (C,M,N,O,P, Q) reviewed did not contain documentation they had been trained and observed for competency to administer blood. On the afternoon of 8/10/2010 Staff C told surveyors they had not done any blood competencies.

3. Nursing respiratory competency:

a In interview with the respiratory therapist, she supplied documentation of training to nursing staff on respiratory services. Three of the registered nurses (D,Y,X) scheduled on the current schedule did not have current training. This finding was confirmed with the respiratory therapist.

b. Review of two medical records (Records #5 and 6), of patients who had respiratory services, compared to the respiratory therapist competency documentation, demonstrated that two of six nursing staff (D,Y) who administered hand held nebulizer treatments had not been trained to administer the treatments.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital has an effective quality assurance (QA) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital conducting a collection and analysis of data collected concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. QA meeting minutes for 2009 and 2010 did not contain evidence of the analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. Governing Body and Medical Staff meeting minutes did not contain evidence of any analysis of data presented to identify problems, evaluate situations, and take corrective actions.

3. There was no evidence of reviews of nosocomial infections and medication therapy in the infection control meeting minutes or medical staff meeting minutes.

4. All departments providing patient care do not participate in the hospital's QA program. This was verified with hospital staff during the exit conference on 08/10/10.

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. This was confirmed with the Interim Director of Nursing on 08/10/2010 at 1500.

Based on review of the medical records and an interview with staff, the hospital failed to provide a comprehensive assessment that would allow individual activity needs for patients. This occurred in one of two (Record #11 of Records #10 and 11) swing-bed patients who's medical records were reviewed. This was reviewed with administrative staff on the afternoon of 08/10/2010.