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At the time of the revisit this deficiency had not been corrected.

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 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. Governing Body and Medical Staff Meeting minutes did not reflect physician and allied health providers credentialing files had been reviewed and approved.

3. 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. There was no documentation in Governing Body or Medical Staff Quality data had been reviewed and utilized to develop performance improvement plans.

4. These findings were presented at the exit conference. No further documentation wa provided.

At the time of the revisit this deficiency had not been corrected.

Based on review of medical records, policy and procedure, meeting minutes, and medical staff files, the hospital failed to review care provided by practitioners. Review of medical staff meeting minutes and governing body meeting minutes does not include review of practitioner care. This finding was presented at the exit conference and no further documentation was provided.

At the time of the revisit this deficiency had not been corrected.

Based on record review and staff interview, it was determined the hospital failed to ensure pharmacist oversight of medication errors and pharmacy. There was no documentation appropriate committee members attended pharmacy and therapeutics meetings.

Findings:

1. There was no documentation provided to surveyors indicating the pharmacist had reviewed and analyzed medication errors with recommendations to reduce errors.
2. There was no documentation the pharmacy and therapeutics committee reviewed errors and made recommendations to Medical Staff and Governance.
3. The findings were discussed with the CEO and the corporate vice president during the exit conference on 08/09/12. No additional information was provided.

At the time of the revisit on 08/09/2012, this deficiency was not corrected.
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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. Meeting minutes did not contain infection control information. Staff B stated that there had not been any meeting minutes for infection control as yet.

2. At the time of revisit on 08/09/2012, the hospital and/or ICO had not developed and adopted a current Infection Control Program/Plan that specified how the hospital infection control program would ensure infection control policies and procedures were followed or specify the frequency of monitoring.

3. Although administrative staff told the surveyors on 08/09/2012 that the ICO and alternate would be provided training in infection control, no evidence of training or acceptance in any infection control training/education that provided education in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program was provided. Staff A and B stated this had not been accomplished yet.

4. These findings were reviewed with administrative staff during the exit conference on the afternoon of 08/09/2012. No additional information was provided.

At the time of the revist this deficiency was not corrected.

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

1.Two (#3,4) of three closed clinical records (#3, 4, 5) 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' conditions and reviewed the medical record to insure accuracy of the forms completed by dietary staff.

3. Several of the nutritional assessments completed by dietary staff 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, nausea, vomiting, fluid volume deficit and anemia.

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

4. Review of policies and procedures stipulated the nutritional policies had been reviewed and approved through governance. Review of the manual on the day of the survey did not indicate the policies had been completely updated and were appropriate for current practice.

At the time of the revisit on 08/09/2012, this deficiency was not corrected.
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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 respiratory therapy functions of their jobs. One of two nursing staff (Staff H) who administered respiratory treatments to emergency room patients had not been trained and verified competent to perform respiratory treatments by the respiratory therapist. This finding was reviewed and verified with Staff B at the time of review on 08/09/2012.

At the time of the revisit this deficiency was not corrected.

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. The hospital's periodic evaluation did not have a review of a representative sample of active and closed medical records.

At the time of the revisit this deficiency had not been corrected.

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. There was no documentation any of the quality data was used to improve performance or make changes in the organizational performance.

3. Hospital committee meeting minutes do not include any documentation the committees make recommendations to be forwarded up through medical staff and/or governing body to be acted on.

At the time of the revisit this deficiency had not been corrected.

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.

At the time of the revisit on 8/9/2012 this deficiency was not corrected.

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. There was no documentation provided to surveyors indicating medication errors were reviewed with recommendations for improvement and safety. There was no documentation in the Medical Staff meeting minutes or Governing Body regarding medication error rates and plans for improved performance.

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

At the time of the revisit this deficiency had not been corrected.

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 8/9/2012 Medical Staff meeting minutes were reviewed. There was no documentation of mid-level care evaluations.

2. Credentialing and privileging documents did not indicate review and evaluation of performance. The majority of the providers did not have current credentials.

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 8/9/2012.

At the time of the revisit this deficiency had not been corrected.

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.

At the time of the revisit, this deficiency had not been corrected.
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Based on clinical record review and interview, it was determined the hospital failed to provide activities to meet the needs of the individual for one of one patients cared for in swing beds and whose medical record was reviewed.

Findings:

1. Patient #5, swingbed admission 07/06-15/2012.
a. The medical record contained an activity assessment form, but except for the patient's name, date of birth, age, sex and physician's name, the form was blank. An activity assessment of the patient's interests and physical, mental and psychosocial well-being had not been performed.
b. The Activity Flow sheet only document activities were provided to the patient on 07/07 and 08/2012.

2. These findings were reviewed with administrative staff on the afternoon of 08/09/2012. No additional information was provided.