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Based on review of personnel files, medical records, hospital documents, and interviews, the hospital failed to verify personnel were licensed, trained, and competent.

Findings:


1. On 3/2/12 surveyors reviewed personnel files. Three of four (D,E,N)registered nurse personnel files reviewed for licensure verification did not contain licensure verification.

2. Three personnel listed (Staff M, N, and O) on the surgery log as providing care did not have personnel or credentialing files. On the morning of 3/10/11 Staff H told there was no documentation available on Staff M,N, and O.

3. On 3/2/2012 surveyors reviewed contracted radiology services with Staff J. None of the contracted providers had documentation of licensure, training, or competency.

4. Staff G was listed as the dietitian and the food services manager. Staff G's personnel file did not include a current license.

5. On 3/2/2012 surveyors reviewed the contract nursing personnel file. There was no documentation the contract nurse had been oriented, trained, or was competent to provide care.

Based on review of the infection control documents, hospital meeting minutes, policies and procedures and personnel and credential files, and interviews with staff, the hospital failed to develop an active ongoing infection control program that reviewed and evaluated practices in the hospital, with corrective actions and follow-up taken when needed, to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

Findings:

1. Upon arrival at the hospital on 02/29/2012, the surveyors requested infection control policies and procedures, infection control plan, meeting minutes for infection control, the infection control log, and surveillance/monitoring activities for the last year.

2. Documents provided did not contain an infection control plan. On 03/01/2012 at 1045 and 1130, Staff C and F stated the hospital was still in the process of developing a plan for infection control.

3. Although the policy and procedure manual contained a review date of 03/29/2011, it did not document who review, revised and approved the manual. Meeting minutes for infection control, quality, medical staff and governing body did not contain evidence of review, revision and/or approval of the infection control policies and procedures.

4. Surveillance activities only contain environment of care (EOC) rounds and hand hygiene monitoring activities. Both sets of types of monitor documented problems observed, but meeting minutes and the forms did not provide evidence of review and analysis with corrective actions and follow-up. No other monitoring activities were provided, including monitoring of disinfectant application for appropriate application according to manufacturer guidelines.

5. When ask on the morning of 03/01/2012, Staff F, the person identified as the infection control practitioner, stated she did not know what disinfectant was utilized in the different areas of the hospital or the manufacturers recommended length of time the disinfectant needed to stay wet on the surface in order to be effective. When asked, she stated the infection control committee had not reviewed and approved the disinfectants utilized in the different areas of the hospital.

6. The hospital has a varied and extensive surgical program, including endoscopy procedures, and cataract and orthopedic surgeries. Documents provided did not demonstrate the infection control program monitored the surgical services to ensure safe surgical practices and a sanitary environment.
a. Disinfectant:
i. Staff F did not know what disinfectant was utilized in the different areas of the hospital or the manufacturers recommended length of time the disinfectant needed to stay wet on the surface in order to be effective.
ii. Staff A told the surveyor on the afternoon of 03/01/2011, that the hospital used Quat products and the product was to remain wet on the surface between 10 and 30 minutes.
iii. Review of the surgical log for 12/13/2011 showed 12 cataract eye surgeries were performed. The time of turn around between cases was two (2) to (3) minutes.

b. Sterilization process:
i. Staff B, C and H told the surveyors that cataract eye instrument sets were supplied by the surgeon and "flash"/ shortened cycle sterilization was performed between patient cases.
ii. Meeting minutes did not refect sterilization practices, including shortened cycle sterilization, was included in the infection control program with actions to limit shortened cycle use.
iii. On the morning of Staff F stated stated sterilization practices were not reviewed in infection control.

7. The infection control program did not monitor employee health and immunization history for possible transmission of infections and communicable diseases between staff and patients. Two of four personnel, including one contract staff, and six of six physician and allied health personnel did not have complete immunization histories as required by State Licensure Hospital Standards.

8. These findings were reviewed with administrative staff at the time of findings and at the exit conference on the afternoon of 03/01/2012.

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 3/2/12 Staff J told surveyors some of the radiology services were contract. There was no documentation the personnel providing the services were oriented, trained, and competent. There were no policies and procedures written, reviewed, approved, and implemented for these services.

2. Personnel files (K, T) provided to surveyors did not include competencies reviewed and approved through the radiologist and medical staff. This finding was confirmed with Staff J on the afternoon of 3/2/2012.

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

Based on review of hospital documents and interviews with hospital staff, the hospital does not assure nursing staff are adequately trained to meet the needs of the patients. Six of six personnel did not have departmental orientation, competency, and evaluation for the specialized areas where they worked.

Findings:

1. On the afternoon of 2/29/12 surveyors were provided personnel files. There was no documentation provided indicating Staff ( M) had orientation to the hospital and specific departments.

2. On the morning of 2/29/12 surveyors reviewed the surgical log. Staff H, I, R, U were listed in the surgery log as providing care during procedures. The hospital did not provide documentation staff were properly trained and evaluated competent to work in surgery, central sterile, and or post anesthesia care.

3. On the morning of 2/29/12 surveyors reviewed the emergency room log. Staff M and R were listed as providing care in the emergency room. There was no documentation M and R had been oriented to the hospital or the emergency room.

4. On the morning of 3/9/12 Staff A told surveyor's Staff F was the infection control practitioner. Staff F's personnel file did not contain a job description for the infection control practitioner position. This finding was verified in a conversation with Staff A and B on the afternoon of 3/1/2012.

5. Medical record review indicated the some respiratory treatments were provided by nursing personnel. Staff Q and M provided hand held nebulizer treatments. Review of documentation did not indicate an assessment was performed pre and post treatment. On the afternoon of 2/29/12 surveyors were provided personnel files. Staff Q and M did not have documentation of respiratory care competencies.

Based on review of medical records and deficiency listings and interviews with hospital staff, the hospital failed to ensure medical records contain pertinent information and reports. Documentation pertinent to the continued care of the patient was missing or not completed timely in eight of eight surgical/procedural charts.

Findings:

1. Three of three patient records (Records #12, 18 and 19), reviewed for respiratory services, did not contain pre-procedure and post-procedure assessments of the patient's respiratory status by qualified nursing staff as required by the hospital's respiratory policy for nebulizer treatments.
a. The hospital's respiratory policy stipulated respiratory treatments would be documented in the medication administration record (MAR) and on the respiratory treatment forms. Nursing staff only documented on the MAR and did not document required assessments on the respiratory forms or in the nursing notes.
b. Review of two of two personnel files reviewed, of nursing staff who provided respiratory treatments, did not contain evidence the respiratory therapist had checked and validated the competency of the nurses (Staff Q and M) to perform these treatments.

2. The hospital provides a varied surgical service with procedures ranging from gastrointestinal endoscopy to a total joint program. 6 of 8 surgical or procedural charts did not have documentation of initial type and amount of intravenous (IV) fluids. 6 of 8 surgical charts did not have documentation of IV fluid infusion during the intraoperative period. 6 of 8 charts did not have documentation of the type of fluid infusing or the amount of fluid infused during the intraoperative or post anesthesia care phase. One chart (pt #11) did not have documentation of vital signs or monitoring occurring during a procedure.

3. 4 of 8 surgical or procedural charts did not have updated history and physicals prior to the start of the procedure. Dictation of operative procedures occurred many days after the procedure and no brief written note was on the chart. This occurred in of 2 charts. Two preprocedure charts included "clinic" notes for history and physicals. The clinic notes did not contain all of the required elements as established in the medical staff bylaws as components of a history and physical.

4. Patients receiving ophthalmic procedures did not have medications documented with amount given, time, date, and route. Physician orders for eye drops and preoperative medications administered did not match. This was verified with staff B on 2/29/12.

5. The above information was reviewed with administration at the time of the exit conference. No further documentation was provided.

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

Findings:

1. Review of the documentation in the material provided as the hospital's annual periodic evaluation did not include documentation of a review and an evaluation of both active and closed clinical records.

2. Interviews with hospital personnel on the afternoon of 03/01/12 verified that the annual periodic evaluation did not contain a review of medical records.

Based on record review and interviews with hospital staff, the hospital does not ensure the periodic evaluation includes a review of the CAH's health care policies. The hospital's annual review did not have any documentation of review of the hospital's patient care policies. Hospital staff verified on 03/01/12 in the afternoon that review of policies had not been done as part of the periodic evaluation.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital's meeting minutes document a plan of action and results of the plan of action for quality monitors that do not meet performance criteria. Review of Quality Committee, Medical Staff and Governing Board meeting minutes for 2011 and 2012 did not have documentation of any remedial action taken by the hospital to address deficiencies found through the quality assurance program. This was verified by hospital staff on 03/01/12 in the afternoon.

Based on review of the hospital's swing bed policies and procedures and medical records, and interviews with hospital staff, the hospital failed to provide an ongoing activity program directed by a qualified staff member with activities based on a comprehensive assessment of the individual needs and interests of the patients. Although the hospital provides activities for swingbed patients, five of five swingbed medical records reviewed (Records #2, 4, 14, 15 and 16) did not contain activity assessments by a qualified activity program individual that would allow individual activities to be provided based on the patient's needs and interests. Staff S provided the initial designation of activities for the patients and has not received training for this position. These findings were reviewed with administrative staff on the morning of 03/01/2012.