HospitalInspections.org

Based on record review and staff interview, it was determined the hospital failed to ensure staff were licensed and/or certified to perform the essential functions of their jobs.

Findings:

1. Staff Z was employed by the hospital as a radiology technician. There was no documentation of registration/licensure or certification to perform general radiology procedures.

2. Staff BB was employed by the hospital as a CNA. There was no documentation of current CNA certification with the State Nurse Aide Registry.

3. Staff DD was employed by the hospital as a physical therapy assistant. There was no documentation of current registration/ certification to perform the essential functions of the position.

4. Staff W was employed by the hospital as a licensed practical nurse. There was no documentation of a current LPN license found in the record.

On 06/14/12, the CEO was asked if all staff were verified to be licensed/certified or otherwise credentialed to perform their jobs. She stated they were not.

Based on review of governing body meeting minutes and hospital documents and interviews with hospital staff, the hospital does not ensure the organizational structure of the hospital is effective in providing quality health care in a safe environment. The governing body failed to monitor, evaluate and ensure the services of the hospital. Refer to Tag C-241 for details and findings.

Based on record review and interviews with hospital staff, the governing body does not ensure that policies governing the CAH"s total operation are implemented and ensure quality health care is provided in a safe environment.

Findings:

1. According to multiple personnel at the facility Physician P refuses to follow hospital policy and procedure and medical staff bylaws. There is no evidence the Governing Body has acted to remediate any of the issues with Physician P.

2. The governing body does not ensure a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed and has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. Refer to Tag 0330

3. The governing body does not ensure Medical Staff and Allied Health are credentialed and privileged. There is no documentation the governing body ensures care provided by medical staff and allied health are reviewed and evaluated for appropriateness.

4. The governing body did not ensure the hospital had developed an active ongoing infection control program led by a trained professional that reviewed and evaluated practices in the hospital, with corrective actions taken when needed, to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel. Refer to Tag 278.

5. The governing body does not ensure that the hospital has an effective Quality Assurance/Performance Improvement (QA/PI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital collecting and analyzing data concerning the quality and appropriateness of all patient care furnished in the CAH. Refer to Tag 0336

6. The governing body does not ensure competency and licensure of contract staff. On the morning of 06/14/2012, the surveyors asked for personnel files for three contract physical therapists and the pharmacist. Staff A told the surveyors that the hospital did not keep files on contract staff. Staff A confirmed that the hospital has not checked to ensure contract staff are licensed.

7. The governing body does not ensure nursing staff are trained and competent to provide care to patients. Refer to Tag 094

8. The governing body does not ensure respiratory services were provided according to State Hospital Licensure Standards, Subchapter 23. The governing body does not ensure respiratory services are supervised by a license respiratory therapist. The respiratory policies, developed in 2008, did not contain evidence a respiratory therapist developed or participated in the development of the policies and procedures. The governing body did not ensure that a respiratory therapist trained nursing staff to perform respiratory procedures and designate in writing each procedure performed by each staff with the amount of supervision required when performing the procedure.

Based on record review and interviews with hospital staff, the hospital did not ensure that a physician provided adequate oversite and medical supervision of the personnel providing patient care.

Two (#15 and #5) of two patient records that required physician supervision and oversite did not have evidence that a physician provided appropriate supervision.

Findings:

1. The emergency room record for patient #15 documented a physician's assistant provided care to a child. The record documented a variance occurred with an order for a medication.

There was no documentation the supervising physician provided oversite to the physician's assistant.

2. Patient #5's ER record documented that a medical student was providing part of the patient's care and was only supervised by a physician assistant. There was no documentation that a physician supervised the care given by the medical student.

On 06/14/12, the risk manager was asked if there was any documentation of physician supervision and oversite for the care provided to the patients. She stated there was not.

Based on review of policy and procedure, committee meeting minutes, and personnel interviews the facility failed to provide current policies and procedures reviewed and approved through Medical Staff and Governance. None of the policy and procedure manuals provided to surveyors had documentation the current Medical Staff reviewed and approved the policies. There was no documentation in any of the meeting minutes any of the hospital's policies and procedures had been reviewed in any hospital committees.

Based on review of medical records, policy and procedure, meeting minutes, and medical staff files, the hospital failed to review care provided by mid-level practitioners.

Findings:

1. On 6/14/2012, seven emergency room records were reviewed for care provided by mid-level practitioners.

The medical record for patient #15 documented a medication variance that occurred in the emergency room. The record did not indicate the mid-level practitioner consulted the supervising physician.

None of the seven emergency room records reviewed (including records of treatment for infants and children) indicated the mid-level practitioners consulted the medical staff assigned to the them for supervision.

2. Review of medical staff meeting and governing body meeting minutes did not indicate death charts were reviewed by medical staff.

There was no documentation provided to surveyors indicating the quality of care and treatment provided by mid-level practitioners was reviewed.

This finding was verified with administration during the exit conference.

Based on review of personnel files and medical staff by-laws and Rules and Regulations and interviews with hospital staff, the hospital failed to ensure the scope of medical acts that may be performed by mid-level practitioners were appropriate. One of three mid-level practitioners reviewed (Staff J) had privileges greater than his supervising physician. This finding was reviewed with administrative staff on the afternoon of 06/14/2012. No additional data was provided.

Based on record review and staff interview, it was determined the hospital failed to ensure

a. the pharmacy services department operated with current policies and procedures in accordance with professional principles and practices;

b. the pharmacist was involved in the review, investigation, analysis, action-planning, monitoring and trending of medication errors within the facility; and

c. failed to ensure an MD and the DON were involved in the Pharmacy and Therapeutics Committee.

Findings:

1. On 06/13/12, the pharmacy policy and procedure manual was reviewed. The manual had not been reviewed or updated since January 2005.

The drug room supervisor (an LPN) was asked about the pharmacy policy and procedure manual. She stated she was in the process of reviewing the policies and procedures.

She was asked if the pharmacist was involved in the review and the updating of policies/procedures. She stated, "Some."

2. Medication error reports for January through June 2012 were reviewed. None of the error reports documented involvement/oversight by the pharmacist and had no documentation the pharmacist was involved in the review, investigation, analysis, action-planning, monitoring and trending of medication errors.

On 06/14/12, the risk manager and the DON were asked if the pharmacist was involved in the analysis of medication errors. She stated she was not.

3. A review of the most current minutes for the Pharmacy and Therapeutics Committee meeting documented there was no attendance by an MD or the DON.

4. The findings were discussed with the CEO and the corporate vice president during the exit conference on 06/14/12. No additional information was provided.

Based on record review and staff interview, it was determined the hospital failed to ensure there was a system in place to identify, review, analyze, respond, trend and monitor medication errors within the facility.

Findings:

On 06/13/12, the pharmacy policy and procedure manual was reviewed. The manual had not been reviewed or updated since 2005.

There were no policies that addressed systems in place to minimize adverse drug events with high risk medications.

There were no policies to address the methods used (in addition to incident/variance reporting) to identify medication errors and actions to be taken once an error was identified.

Medication error reports for January 2012 through June 2012 were reviewed.

None of the error reports documented involvement/oversight by the pharmacist and had no documentation the pharmacist was involved in the review, investigation, analysis, action-planning, monitoring and trending of medication errors.

None of the error reports documented actions taken by the reviewer or any other staff person in response to the error.

None of the medications errors were documented in the patients' medical record.

On 06/14/12, the risk manager and the DON were asked to provide additional information and documentation the hospital took in response to medication errors. They stated no other information was available.

Based on review of infection control policies and procedures and documents; hospital documents and meeting minutes; and personnel files, and interviews with hospital staff, it was determined the hospital failed to:
1. Develop and maintain an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff, and
2. Ensure the person designated as the infection control officer/preventionist (ICO) has ongoing education in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program.

Findings:

1. Upon arrival at the hospital on the morning of 06/13/2012, the surveyors asked for infection control policies, infection control plan, surveillance/monitoring activities and meeting minutes for infection control.

2. On the afternoon of 06/13/2012 Infection Control policies were provided to surveyors. Although the manual contained an Infection Control Plan/Program, it was dated for 2009 and did not demonstrate review by the current infection control professional. The latest review and revision for the policies and procedures was dated 2009. There was no evidence current infection control practices recommended through national resources had been developed, reviewed, approved, and implemented throughout the hospital. The hospital had not conducted a risk assessment to identify potential organisms likely to be present in the community.

3. The Infection Control Program/Plan provided to the surveyors on 06/13/2012, documented:
a. "The Infection Control Nurse (ICO) in conjunction with the Infection Control Committee is responsible for the review and addition Infection Control administrative Policies and Procedures." Staff A, B and H told the surveyors on 06/13/2012 that the hospital did not have an infection control committee and that infection control was conducted as part of the QA (Quality Assessment and Performance Improvement) meeting.
b. The ICO was responsible for "review and approval of policies and procedures relating to infection control annually." Meeting minutes and the policy manual did not contain evidence this occurred.

4. The Infection Control Program/Plan did not specify how the hospital infection control program would ensure infection control policies and procedures were followed or specify the frequency of monitoring. The Plan did not designate how often the infection control would meet. (Oklahoma State Hospital Standards, Subchapter 39, require meetings for infection control to be performed at least quarterly.) Although review of meeting minutes contained headings of infection control, the meeting minutes did not reflect the hospital had an ongoing hospital-wide infection control program with data collection, analysis, corrective action taken when needed and follow-up to ensure corrective actions were effective.

5. Surveillance/Monitoring:
a. Other than a notebook containing lab culture information on patients, no surveillance/monitoring activities were provided to the surveyors for review.
b. Active monitoring of handwashing practices were not performed. Staff H stated on the afternoon of 06/14/2012 that she did not document hand hygiene observations.
c. The infection control program has not reviewed the disinfectants used in the hospital to ensure they are effective against the organisms prevalent at the hospital. No monitoring of disinfectant applications has been performed to ensure application follows the manufacture guidelines for mixture and "wet" times. This was confirmed with Staff H on the afternoon of 06/14/2012.
d. Monitoring of isolation precautions, including adequate supplies and equipment, and personnel following CDC established guidelines is not performed. This finding was confirmed with Staff H on the afternoon of 06/14/2012.
e. Health files did not contain complete immunization records as recommended by CDC (Centers for Disease Control) and its Advisory Committee on Immunization Practices and those required by Oklahoma State Hospital Standards. (This included fifteen of sixteen staff personnel records reviewed and six of six physician and allied health personnel/credential files reviewed on 06/14/2012.) the hospital did not have health files for contract physical therapists and the pharmacist. Meeting minutes did not reflect immunization practices were monitored through infection control.
f. Meeting minutes did not reflect employee health was monitored through infection control or that the infection control program/ICP reviewed employee illnesses for possible transmission of infections and illness between patients and staff. This was confirmed by Staff H, the person identified as the ICO, on the afternoon of 06/14/2012. She stated that another person kept the employee health information and the information was not analyzed.
g. Sterilization practices are not monitored. Staff H and Staff FF told the surveyors on 06/14/2012 that central sterile processing data was not reviewed and analyzed as part of QAPI (quality assurance) or infection control. This was confirmed with review of meeting minutes.
h. The infection control program does not monitor the environment to ensure a safe and sanitary environment is maintained. No environmental surveillance was submitted for review. On the morning of 06/14/2012, the surveyors observed clean equipment/supplies in the same storage room that contained a hopper, dirty linen, trash and biohazardous waste.
i. There was documentation found that indicated under-cooked chicken had been served to patients. There was no documentation this was reported to the infection control committee. There was no documentationof further actions were taken to include monitoring of safe food preparation practices and kitchen sanitation. There was no documentation dietary services reported infection control monitoring to the infection control committee.

6. Meeting minutes containing infection control headings did not show analysis of data with corrective actions and follow-up to ensure corrective actions were effective.

7. The hospital did not ensure the ICO was trained/educated or provided training/education in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program. Staff H stated on 06/14/2012 at 1600 that she did not have any infection control training or experience. She stated she only knew what Staff B told her what needed to be filled out/done.

8. These findings were reviewed with administrative staff on the afternoon of 06/14/2012. No additional information was provided.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the nutritional needs of inpatients were met in accordance with recognized dietary practices. Findings:

1. On the afternoon of 6/13/12 Staff F told the surveyors that Staff F or another member of the dietary department completed all of the nutritional assessments on patients. The dietary policies were dated 1997. The policy and procedures provided indicated a nutritional assessment would be completed within 24 hours of admission. There was no process for updating the patient dietary needs after the assessment. There was no process for nursing to notify dietary of patient's at nutritional risk. The policy did not detail the responsibilities of the dietary assistant and the dietitian. The policy does not indicate what each section of the nutritional assessment form is for. There is no direction in the policy or on the form if a patient is categorized as "high nutritional risk". There is no direction in the policy for recommendations for diet changes and the process the hospital utilizes to notify the physician if a patient needs additional nutritional support.

2. Four of four closed clinical records (#4, 22, 23 and #24) that were reviewed for nutritional assessment completion did not have documentation the consultant dietitian reviewed the patients' histories and presentation on admission and compared the documentation to the form completed by dietary staff.

The patients' nutritional assessments did not match the diagnosis, complaints, and co-morbidities listed in the history and physical examination by the physician. There was no documentation the dietitian assessed the patients' who were "at risk" and made recommendations based on the assessment.

3. Several of the nutritional assessments completed by Staff J and Staff D did not match the patient's condition documented by the physician. Many of the medical records indicated on the history and physical the patients were admitted with diabetes or comorbidities that included dehydration, protein calorie malnutrition, diabetes, nausea, vomiting, and morbid obesity.

None of the nutritional assessments included documentation these conditions were addressed.

4. Open clinical records for three patients currently hospitalized were reviewed for evidence the dietitian performed professional nutritional assessments and made appropriate recommendations.

One record (patient #22) documented the dietitian signed the dietary manager's nutritional assessment form seven days after the patient was admitted. The patient required a therapeutic diet. There was no documentation of the dietitian's professional assessment and further recommendations or agreement with the dietary manager's plan.

One record (patient #23) had no documentation of assessment and recommendations from the dietitian. The dietitian had not reviewed the dietary manager's plan. The patient had been in the hospital for 10 days and required a therapeutic diet with additional supplements.

Patient #24 was admitted to the hospital with diagnoses which included renal insufficiency and atrial fibrillation. The clinical record documented the patient required a mechanical soft diet.

Physician's orders included monitoring the patient's weight weekly.

The patient's admission weight had been recorded by the nursing staff. On 06/14/12, one week after the patient was admitted, the patient had not had a second weight recorded.

The surveyor asked the nurse if the patient had been weighed. She stated she had not.

The surveyor asked that the patient be weighed. The resulting weight indicated the patient lost 5 pounds in one week.

The clinical record did not have documentation of meal percentages recorded for each meal. On the days the meal percentages were recorded, the patient often ate less than 50%.

There was no documentation the clinical dietitian had provided a professional nutritional assessment, had reviewed the dietary manager's plan and had made recommendations based on all clinical data available.

There was no documentation the nursing staff consulted with the clinical dietitian or the dietary manager regarding the patient's low intake during meals.

The nurses were asked how they would contact the dietitian for a nutritional consult. They stated they relied on the dietary manager to do that.

5. Dietary and nursing policies did not include a policy and procedure for nutritional screens/nutritional consults. There were no current dietary policies and procedures.

6. Policies regarding handwashing did not include current CDC recommendations and did not include use of hand sanitizers. There was no documentation the hospital's infection control processes had been implemented in the dietary department.

7. According to Staff B the consultant dietitian provides the hospital a monthly report. Surveyors did not received reports for June, July, September, October, December 2011 and January, February 2012. There was no documentation regarding what patient's were consulted by the dietitian. There was no documentation the dietitian had been oriented, trained, and was competent to provide services at the facility. The dietitian's license was not current.

8. Review of Quality Assurance Performance Improvement 2011 data did not include clinical nutritional services.

9. The above findings were reviewed with the administrative team at the exit conference on 06/14/12. No further documentation was provided.

Based on policy and procedure manual review and interview with the hospital staff, the hospital failed to ensure policies are reviewed at least annually.

Findings:

On the morning of 6/13/2012 surveyors were given copies of the Radiology, Nursing, Dietary, Pharmacy and Infection Control policy and procedure manuals. There was no documentation the policies and procedures had been reviewed, revised, and approved annually.

1. On the morning of 6/13/2012 Radiology policy and procedure was reviewed. None of the policies were dated. There was no evidence the hospital had reviewed, approved, and implemented radiology policy and procedure annually.

2. On the morning of 6/13/12 Dietary department policies were provided to surveyors. Review of the policies did not follow current Center for Disease Control (CDC) hand hygiene guidelines. The hand hygiene policy also did not include all required elements for Food Service Establishments. There was no documentation sanitizers and disinfectants had been reviewed and approved through the hospital infection control committee. There was no documentation the policy and procedure manual had been reviewed and approved through Medical Staff and Governing Body.

3. On the morning of 6/13/12 surveyors requested physical therapy policies and procedures. The manual had a review date of 2012 signed by the physical therapy assistant (PTA). There was no documentation the policies had been reviewed and approved by a physical therapist and approved through medical staff and governance.

4. On the morning of 6/13/12 Respiratory policies were provided to surveyors. The policies were established 2008. The policies did not contain evidence that a respiratory therapist had been involved in the development of the policies. There was no evidence the policies and procedures had been reviewed, revised and approved through governance since that time.

5. On the afternoon of 06/13/2012 Infection Control policies were provided to surveyors. Although the manual contained an Infection Control Plan/Program, it was dated for 2009 and was signed by another individual, not the current infection control practitioner. The latest review and revision for the policies and procedures was dated 2009. There was no evidence current infection control practices recommended through national resources had been developed, reviewed, approved, and implemented throughout the hospital. The hospital had not conducted a risk assessment to identify potential organisms likely to be present in the community.

6. On the morning of 06/13/12, the Pharmacy policy and procedure manual was reviewed. It had not been reviewed or updated since 2005.

7. On the afternoon of 06/13/2012, the Emergency Room policy manual was reviewed. The last review documented as 2010, but only by the Director of Nursing. The manual showed not review by the medical staff.

8. The above findings were reviewed with administrative team members on the afternoon of 6/14/12. No further documentation was provided.

Based on review of hospital documents, review of personnel files and interviews with the radiology department manager, the hospital failed to have documentation showing all the personnel operating the diagnostic radiology equipment are qualified and trained, and the radiology department has oversight by the Radiologist, Medical Staff, and Governing Body.

Findings:

1. In an interview on the afternoon of 6/13/2012 Staff A told surveyors radiology services were provided by hospital employees.

There was no documentation the personnel providing the services were oriented, trained, and deemed competent by the supervising radiologist.

2. Policies and procedures written and reviewed did not have a date of approval. There was no documentation the policies had been reviewed and approved throught the radiologist and medical staff.

3. Radiology personnel records for Staff Z and EE did not include competencies reviewed and approved through the radiologist and medical staff. There was no documentation of radiation safety inservices.

4. The above findings were reviewed with administration at the exit conference. No further documentation was provided.

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.

Findings:

1. Eight of eight nursing employee records had no documentation of formal orientation to their departments.

2. Eight of eight nursing employee records had no documentation of specialized training in their areas.

3. Seven of eight nursing employee records had no documentation of demonstrated competencies to perform the essential functions of their jobs, including competencies to administer medications.

4. Eight of eight nursing employee records had no documentation of age specific competencies relevant to their areas.

5. Three of eight nursing care staff had no documentation of current CPR, PALS or ACLS certification.

6. None of the nursing staff employee records had documentation of training and skill competencies in respiratory care including breathing treatments and oxygen set up and administration performed by a respiratory therapist as required by Licensure Standards.

7. There was no documentation found that indicated nursing staff who made medication or other patient care errors had competency review in order to evaluate their abilities to safely provide patient care.

On 06/14/12 the DON was asked if all nursing staff were oriented to their work areas and had demonstrated competencies to perform the essential functions of their jobs. She stated there was no documentation to support this.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure all entries in the medical record were signed and contained the date and time of the signatures/authenticated. This occurred in three (#1, 2 and #3) of three records reviewed for completed entries.

Findings:

1. Records #1,2 and #3 did not have the date and time of authentication by the physician on orders, history and physicals, and discharge summaries.

2. According to staff A, D, and E, physician P did not authenticate records timely. There was no documentation this information was provided to Medical Staff or Governing Body. There was no documentation of any action taken by the medical staff on Physician P's privileges as required by the hospital Medical Staff bylaws.

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 evauation and does not have an effective and ongoing quality assurance program.

1. 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 following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag # 0331.

2. 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 # 0332.

3. The hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records. Refer to Tag # 0333.

4. 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 # 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 # 0335.

6. The hospital does not have an effective Quality Assurance/Performance Improvement (QA/PI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. Refer to Tag # 0336.

7. The hospital does 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 # 0337.

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

9. The hospital does not have a functioning QA/PI system is implemented so that remedial action can address deficiencies found through the QA/PI program. Refer to Tag # 0342.

Based on record review and interviews with hospital staff, 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 following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Interviews with hospital personnel on the afternoon of 6/14/2012 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of active and closed records, hospital policies and procedures and evaluation of the services provided and if changes were needed.

2. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interview with hospital staff, 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.

Findings:

1. Interviews with hospital personnel on the afternoon of 6/14/2012 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of the utilization of CAH services, including the number of patients served and the volume of services is conducted.


2. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interviews with hospital staff, the hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Interviews with hospital personnel on the afternoon of 06/14/2012 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of a representative sample of active and closed medical records.

Based on record review and interviews with hospital staff, 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.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Review of selected hospital services had no documentation of yearly review as required. The hospital department policy and procedure manuals had the following review dates:

~Dietary Department 1996
~Infection Control Program 2009
~Emergency Room Services 2010 (reviewed only by the DON)
~Pharmacy Services 2005
~Respiratory Therapy Services 2007 (with no evidence of a respiratory therapist involvement)
~Radiology Services (no date of review)

There was no documentation in the Governing Body or Medical Staff meeting minutes of hospital department policy and procedure review.

3. Hospital personnel stated on the afternoon of 06/14/2012 that they did not have any other documentation of departmental policy and procedure review.

Based on record review and interviews with hospital staff, 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.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2011 and 2012 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program to determine if services were effectively utilized, policies were followed and if changes were needed.

2. Hospital staff stated on the afternoon of 6/14/2012 that they had not conducted a periodic evaluation that included all the requirements.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital has an effective Quality Assurance/Performance Improvement (QA/PI) 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 concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2011 and 2012 did not contain evidence of any analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. The hospital provided a QA/PI plan for the hospital for review but the quality data provided to surveyors did not include any analysis, surveillance, and performance improvement based on findings.

3. There was no evidence of reviews of nosocomial infections and medication therapy in the medical staff meeting minutes. Infection Control information was reviewed in the Quality Meeting. There was no review, analysis of data, and implementation measures documented with evidence of follow up to indicate if the measures worked.

4. Hospital staff verified on 6/14/2012 in the afternoon that the hospital's QA/PI program is not reviewed by governance.

Based on record review and interviews with hospital staff, the hospital does not ensure that an effective quality assurance program is implemented and evaluates the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI program. All patient care services and other services affecting patient health and safety are not evaluated and the hospital does not collect and analyze data concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. There is no documentation quality assurance information is provided to the Governing Body.
2. There is no documentation incidents, complaints, grievances, medication errors, surveillance activities are reviewed and analyzed with performance improvement plans developed and implemented to improve patient health and safety.
3. These findings were reviewed at the exit conference. No further documentation was provided.

Based on record review and staff interview, it was determined the hospital failed to ensure medication errors were identified, analyzed and that action was taken to improve the care and safety of patients.

Findings:

1. The Risk Manager verified on 06/14/12 that medication errors were documented by staff and reviewed by herself or the DON.

She stated only monthly numbers of medication errors were reported through the Pharmacy and Therapeutics committee and the QA/PI committee.

2. There was no documentation medication errors were analyzed to determine root causes, trends, actions taken to prevent recurrence and evaluation of those actions.

Based on review of credentialing files, meeting minutes, hospital documents, and personnel interviews the hospital does not ensure that an effective quality assurance program is implemented and evaluates the appropriateness of the diagnosis and treatment of patients int he hospital throughQA/PI program. The hospital does not collect or review data on patient care services provided by mid-level practitioners.

Findings:

1. On 6/14/2012 Medical Staff meeting minutes were reviewed. There was no documentation of mid-level care evaluations.

2. Credentialing and privileging documents provded on three midlevel practitioners did not indicate review and evaluation of performance by the physician overseeing care.

3. There was no information in Governing Body Meeting Minutes indicating any medical record review, morbidity and mortality, or evaluation of care occurred.

4. These findings were confirmed with administration on 6/14/2012.

Based on record review and interviews with hospital staff, the hospital does not insure that a functioning QA/PI system is implemented so that remedial action can address deficiencies found through the QA/PI program. Review of Governing Body and Medical Staff meeting minutes for 2011 and 2012 and interviews with hospital staff during the survey did not have evidence the hospital has a functioning QA/PI program.

Based on record review and staff interview, it was determined the hospital failed to ensure persons with a history of abuse were not employed. Findings:

Fourteen employee records were reviewed. There was no documentation of criminal background investigation before the staff were hired.

There was no documentation the State Nurse Aide Registry had been checked for history of alleged patient abuse or misappropriation among potential staff.

On 06/14/12, the CEO was asked if there were any background investigation checks done on the employees of the hospital. She stated there were no other records available.

Based on clinical record review and interview, it was determined the hospital failed to provide activities to meet the needs of the individual for three of three patients cared for in swing beds.

Findings:

On 06/13/12, an activities calendar posted on a wall across from the nurses' station documented the activities for that day were, "... Patio... Snacks... Mail..."

Clinical records were reviewed for patients # 22, 23 and #24.

None of the records had documentation of a comprehensive activities assessment. There was no documentation of an activities plan that was individualized for each patient.

There was no documentation of any activities provided to the patients on any day during the hospitalization.

On 06/14/12 at 11:00 a.m., patient #22 was asked if he was provided any activities related to his interests. He stated, "Not really."

At 5:30 p.m., the CEO was asked if the patio, snacks and mail should be considered activities for the patients. She stated they should not.

She was asked if the patients were offered activities related to their interests and needs. She stated she thought they were.