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Based on document review, observation, and staff interviews, the hospital failed to ensure that emergency services:

1. established policies and procedures consistent with State law and acceptable standards of practice.

2. provided qualified personnel necessary to furnish all services offered in a safe manner in accordance with acceptable standards of practice.

3. were reviewed and included as part of the Quality Assessment Performance Improvement program.

Findings:
1. According to the Oklahoma Nursing Practice Act (effective as of November 1, 2013), it is not within the Registered Nurses scope of practice to establish an airway.

2. A document titled "Emergency Treatment in the Absence of a Physician" documented, "Occasionally, there are times when a physician is not readily available...When this occurs and patient needs emergent treatment, the Registered Nurse should administer such treatment he/she feels is both indicated by patient condition and justified by his/her training and experience. This would include measures as: A. Establishing an airway..."

3. On the afternoon of 08/12/14, Staff S told surveyors that a registered nurse would intubate a patient if needed. Staff S was aware that intubating a patient was not within the registered nurse's scope of practice.

4. On the afternoon of 08/12/14, surveyors reviewed the ED log. There was no documentation on each patient and their level of triage.

5. 6 (#15, 17, 20, 22, 23, and #24) of 6 medical records reviewed had documented incorrect triage levels for patients presenting to the ED. The facility used a five level triage system. Level 1-resuscitation, 2-emergent, 3-urgent, 4-less urgent, 5-nonurgent.

6. Staff S verified that all six (#15, 17, 20, 22, 23, and #24) patient's were triaged incorrectly.

7. On the afternoon of 08/13/14, surveyors reviewed personnel files. The ED nursing personnel files did not include skills specialized for working in the ED.

Staff training and education files were reviewed for evidence of demonstrated skills competencies for specialized tasks performed in the emergency room:

-Triage Assessment using the emergency severity index (ESI);

-Intravenous (IV) insertion, accessing/de-accessing implanted central venous devices, venous blood draw sampling, and blood glucose monitoring;

-Respiratory treatments, assessing, performing, and documenting;

-Accessing, assembling, and delivering oxygen cylinders with regulators for patient use;

-Neurological assessment using Glasgow coma scale;

-IV conscious sedation, rapid sequence intubations (RSI), and airway management based on American Society of Anesthesiologists guidelines;

-Restraint training (crisis intervention protection);

-Restraint application, use, monitoring, and documenting;

-Abuse training.

None of the records had documentation of verification of skills competencies related to specialized tasks in the ED.

8. On the morning of 08/12/14, surveyors requested emergency department (ED) policies and procedures. Surveyors reviewed ED policies and procedures.

9. All ED policies and procedures did not have documented evidence that the ED Medical Director, Medical Staff and Governing Body had approved/signed all ED policies and procedures.

10. There was no documented evidence of ED services being included into quality meeting minutes.

11. Findings were verified during review and at exit conference the afternoon of 08/14/14.

Based on document review and staff interview, the hospital did not ensure all patient care equipment was maintained in safe operating condition.

Findings:
1. On the morning of 08/13/14, surveyors toured the facility with hospital administration.

2. Surveyors observed two portable x-ray machines in the hallway across from the CT (computed tomography) room.

3. Staff T told surveyors that one of the two portable x-ray machines were not working appropriately as identified by the physicist.

4. Surveyors reviewed a report from Staff DD on 7/15/13, "...portable xray SN....requires the adjustment of the light field to radiation field alignment..." There was no documented evidence this was repaired and safe for patient use.

5. Staff T and Staff Q both verified that the one portable x-ray machine was not repaired.

6. Surveyors observed a power injector in the CT room. There was no documented evidence the power injector was tested and safe for patient use.

7. Surveyors observed multiple pieces of lead in the radiology department. There was no documented evidence the lead was examined and safe for patient use.

8. Staff T told surveyors that the lead had not been checked when Staff DD had recently been at the facility.

9. Surveyors reviewed Staff DD's report from 07/15/13 that documented, "...All aspects of image quality were good except the CT number for air...this issue can be addressed by service at the next scheduled maintenance..."

There was no documented evidence this identified problem was corrected as indicated.

10. These findings were verified at the time of review and at exit conference on 08/14/14.

Based on hospital document review, and staff interview, the Critical Access Hospital failed to:

a. develop and maintain an active on-going infection control program. See Tag C-0278;

b. designate an infection control practitioner who is qualified through education, training, certification or licensure. See Tag C-0278;

c. meet the nutritional needs of inpatients with accordance to recognized dietary practices. See Tag C-0279;

d. ensure a qualified dietitian supervised the nutritional aspects of patient care. See Tag C-0279;

e. ensure all Critical Access Hospital policies and procedures were reviewed at least annually by Medical Staff. See Tag C-0280.

f. maintain a list of all services furnished under arrangements or agreements. See Tag C-0291;

g. ensure a nursing care plan was developed and kept current for each inpatient. See Tag C-0298.

Based on review of infection control surveillance activities, infection control meeting minutes, infection control policies and procedures, observation, and interview, the hospital failed to:
a. designate an infection control practitioner who is qualified through education, training or certification.
b. Maintain a safe environment for preventing infections consistent with nationally recognized infection control precautions.
Findings:
1. On the morning of August 12, 2014, surveyors reviewed infection control meeting minutes, infection control surveillance reports, and infection control policies and procedures.
2. On the morning of August 12, 2014, administrative staff told surveyors that staff CC was the infection control practitioner. The personnel file of staff CC contained no documentation of infection control experience, training or certification.
3. On the afternoon of August 12, 2014, staff CC told surveyors that she had not had any infection control training but had some infection control experience through a previous job.
4. Review of infection control policies contained no documentation that the infection control practitioner developed the infection control policies and procedures.
5. The infection control policies were dated 2012 and had no documentation of approval with signatures from the infection control practitioner, infection control committee, and medical staff.
6. There was no documentation that all the chemicals and disinfectants used at the Critical Access Hospital (CAH) had been reviewed and approved by the infection control practitioner, the infection control committee, and medical staff.
7. On the afternoon of August 12, 2014, Staff CC told surveyors that she had not reviewed and approved all chemicals and disinfectants used.
8. There was no documentation that the infection control practitioner made departmental rounds to include all departments in the hospital.
9. On the morning of staff Q told surveyors that the linen service for the CAH was a contracted service. There was no documentation that the infection control practitioner had visited the contracted linen service to ensure infection control processes were met. On the afternoon of August 12, 2014, staff CC told surveyors that she had not visited the contracted linen service. An infection control policy, documented, "...outsourced laundry facilities shall be toured on an annual basi ..."
Observation:
1. On the morning of August 12, 2014, surveyors toured the Critical Access Hospital (CAH).
2. Surveyors observed 2 patient rooms with signs on the door that read "keep door closed" Staff Q told surveyors that the 2 rooms were being renovated. Surveyors asked the infection control practitioner (ICP) if she had done a construction risk assessment. The ICP told surveyors that she had given a construction risk assessment form to staff V and he had not returned the form to her.
3. On the morning of August 12, 2014, surveyors observed the emergency department. Surveyors observed a used fly swatter sitting on a counter in one of the emergency department treatment rooms.
4. Surveyors observed a gurney outside of the emergency department in the hallway. Surveyors could not determine if the gurney was clean or dirty.
5. Surveyors observed multiple rooms used for storage of equipment such as walkers, wheelchairs, beds and mattresses. Surveyors were unable to determine if the equipment was clean or dirty.
6. On the afternoon of August 12, 2014, Staff CC told surveyors that the staff were to clean equipment prior to storing it.

Based on review of open and closed records and staff interviews, the hospital failed to:
a.) Ensure menus were meeting the needs of the patients.
b.) Ensure nutritional assessments were done to assess the needs of the patients.
Findings:
1. On the afternoon of 08/13/14, Staff C told surveyors she did not always interview patients and used her judgment when doing patient nutritional assessments. She told surveyors she uses her knowledge from being a ward clerk.
2. Staff C stated when doing assessments she did not review the patient's chart or labs. She based her information off of what the nurse told her and what they ate off their meal tray.
3. Staff C documented on medical record (#16 and #17) calcium intake was good and had visual disturbances. When questioned about the answers she stated, "They drank their milk and they wore glasses."
4. On the afternoon of 08/13/14, Staff C told surveyors that she was performing the dietary nutritional assessments on all hospital patients. Staff C told surveyors, "The only time the dietician evaluates a patient is when a provider puts in for a consult or when the dietician is in the facility once a month."
5. On the afternoon of 08/13/14, Staff C told surveyors, "I am attending classes to become a CDM but had not finished classes and could not take the test yet." Staff C told surveyors that she used to be a ward clerk and was not a Certified Dietary Manager (CDM).
6. On the afternoon of 08/13/14, surveyors reviewed the personnel file for Staff C. There was no documented evidence that Staff C was a certified dietary manager (CDM). There was no documented evidence that Staff C had training or education to perform the duties of a certified/clinical dietary manager.
7. The licensed/registered dietician was only doing nutritional assessments when she was in the facility.
8. One of 24 medical records reviewed documented a nutritional assessment completed by the licensed/registered dietician.
9. Findings were verified at the time of review hospital administration and at the exit conference 08/14/14.

Based on policy and procedure review and staff interview, the Critical Access Hospital (CAH) failed to ensure all policy and procedures were reviewed at least annually by Medical Staff.

Findings:

1. Surveyors reviewed all CAH policy and procedures throughout the three day survey.

2. None of the CAH policy and procedures contained documentation of Medical Staff review at least annually.

3. Staff Q told surveyors that she was aware all CAH policies and procedures were not current, and not reviewed annually by Medical Staff.

Based on document review, personnel file review, and staff interviews, the hospital failed to ensure that radiology service personnel were qualified and designated to use the radiological equipment and administer procedures.

Findings:

1. All contracted/staff personnel files reviewed did not contain documented evidence that they were designated and qualified to use radiological equipment and administer procedures.

2. On the morning of 08/13/14, surveyors spoke with Staff T. She told surveyors the hospital did not have any orientation, training, competencies or evaluations for any contracted employee.

3. On the afternoon of 08/13/14, surveyors were given all radiology personnel files including contract personnel. All radiology personnel files did not contain orientation, training, competency or evaluation.

4. On the afternoon of 08/13/14, surveyors asked the radiology manager if radiology staff had received training with the cleaning products that the radiology department used.
The radiology manager told surveyors no infection control training had been provided to the radiology staff.

5. On 08/13/14, surveyors were given Governing Body and Medical Staff Meeting Minutes. Review of minutes did not indicate there was any type of radiology department review.

6. There was no evidence of a written policy that was developed and approved which designates which personnel are qualified to use the radiological equipment, and administer procedures.

Based on record review and staff interview, the hospital failed to ensure that a list of all services provided through arrangements, contracts or agreements was maintained describing the nature and scope of the services provided. The hospital failed to provide a list of contracted services.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2013/2014 were reviewed and did not contain evidence of the contracted services evaluation.

2. On the afternoon of 08/12/2014 Surveyors asked Staff Q for a list of contracted services, Staff Q stated they did not have a list.

3. Surveyors asked Staff Q if the Hospital evaluated contracts, Staff Q stated not formally.

4. This was verified with hospital staff during survey and at exit.

Based on medical record review and staff interview, the Critical Access Hospital did not ensure that each CAH patient received a care plan based on the patient's nursing care needs with appropriate nursing interventions in response to those needs. This occurred in thirteen of fifteen swing bed and inpatient medical records reviewed ( # 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, & #21)

Findings:

1. On the morning of 08/14/2014, surveyors reviewed medical records.

2. Three of three ( #11, 16, & #21) swing bed medical records reviewed did not contain an individualized care plan.

3. Ten of twelve ( #8, 9, 10, 12, 14, 15, 17, 18, 19, & #20) inpatient medical records reviewed did not contain an individualized care plan.

Based on policy and procedure review, medical record review, and staff interview the hospital failed to:

a. ensure the medical record system correctly identified the author of every medical record entry.

b. maintain a clinical record system in accordance with written policies and procedures.

c. ensure all medical records were accurately written and contained all information as required by CMS.

d. ensure all medical records were promptly completed.

Findings:
1. On the afternoon of 08/13/14, surveyors reviewed 24 (#1 through #24) of 24 medical records. None of the medical records identified the author of every entry.
2. On the afternoon of 08/13/14 and the morning of 08/14/14, surveyors reviewed 24 (#1 through #24) of 24 medical records. All 24 medical records had documented patient disposition, "discharge to home or self-care."
-Two medical records reviewed documented the patient had expired.
-Two medical records reviewed documented the patient was transferred to a different facility.
-20 medical records reviewed documented the patient was admitted to the hospital.
3. Sixteen (#7 through #22) of twenty-two medical records reviewed did not contain documentation of admission orders.
4. Sixteen (#7 through #22) of twenty-two medical records reviewed did not contain documentation of discharge orders.
5. On the afternoon of 08/13/14, Staff S verified findings at the time of review.
6. On the morning of 08/12/14, surveyors requested medical records policies and procedures. None were provided.
7. On the morning of 08/13/14, Staff V told surveyors that there were no written policies and procedures.
8. On the afternoon of 08/13/14 and the morning of 08/14/14, surveyors reviewed 18 (#7 through #24) of 24 medical records. 18 medical records failed to document response to interventions, care, and treatments.
9. Three of three ( #7, 8, & #13) medical records reviewed where respiratory interventions were given contained no documentation of a before and after assessment.
10. On the morning of 08/14/14, surveyors reviewed patient #20's medical record. Patient #20's medical record did not have a consent form for a procedure that required conscious sedation.
The medical record did not contain descriptive nursing notes, vital signs, and pain documented.
The medical record documented an incorrect triage level and abnormal vital signs. There were no documented nursing interventions and repeat vital signs.
The medical record documented patient was discharged home when the patient had been admitted to the hospital.
11. Six (#1 through #6) of six surgery records did not contain physician dating and timing orders.
12. See Tag C-0350.
13. All findings were verified at the time of review and at the exit conference on 08/14/14 with hospital administration.

Based on record review and interviews with hospital staff, the hospital failed to ensure that a periodic evaluation of its total program was conducted at least once a year and included 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. Surveyors interviewed Staff Q on the afternoon of 08/14/2014, Staff Q 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 2013/2014 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on policies and procedure review and interview the hospital failed to revise all hospital policies and procedures.

Findings:

1. All departmental policies were not updated, approved by the governing board and signed.

2. All policies reviewed were not specific to the Critical Access Hospital.


This was verified with hospital staff during survey and at exit.

Based on policy and procedure review and staff interview the hospital failed to ensure policies and procedures were developed and current.

Findings:
1. On the morning of 08/12/14, surveyors requested all organ procurement organization (OPO) policies and procedures. A binder was provided that did not include policies and procedures, only a death register.

2. On the afternoon of 08/12/14, surveyors asked Staff S if there were any OPO policies and procedures. Staff S told surveyors that it should be in the OPO binder.

3. On the afternoon of 08/13/14, surveyors reviewed two (#23 and #24) of two death records. One (#24) of two death records did not have documented evidence that the OPO was called.

4. Staff S verified that there was no documentation for patient # 24, indicating if the OPO was called.

5. Staff S told surveyors that chart audits on death records had not been done.

6. Findings were verified at the time of review with hospital administration.

Based on swing bed resident's medical record review and staff interview, the Critical Access Hospital (CAH) did not meet all the requirements for post CAH skilled nursing facility care (SNF). This occurred in three of three ( #11, 16, & #21) swing bed resident's medical records reviewed.

Findings:

1. Three of Three ( #11, 16, & #21) swing bed resident's medical records did not contain discharge orders from acute care services.

2. Three of Three ( #11, 16, & #21) swing bed resident's medical records did not contain admission orders to swing bed status.

3. Three of Three ( #11, 16, & 21) swing bed resident's medical records did not contain swing bed progress notes.

4. Three of Three ( #11, 16, & 21) swing bed resident's medical records did not contain an acute care discharge summary.

5. This was verified at the time of medical record review.

Based on hospital document review, medical record review, and staff interview, the hospital failed to provide each swing bed resident of their resident rights both in writing and verbally. This occurred in three of three swing bed medical records reviewed (#11, 16, & #21)

Findings:

1. On the morning of August 13, 2014, surveyors requested an admission packet for swing bed residents to include a copy of the resident's rights.

2. Two different admission packets were provided. Staff S told surveyors that one packet was used when or if the electronic health record was not working and one packet was used on the electronic health record.

3. Both admission packets reviewed did not contain information regarding resident rights.

4. Staff S told surveyors the admission packets contained all the information that was provided to swing bed residents.

5. On the morning of August 14, 2014, surveyors reviewed three (#11, 16, & #21) swing bed resident's medical records. None of the records contained signed resident rights.

Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for each swing bed resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. This occurred in three of three (#11, 16, & #21) swing bed medical records reviewed.

Findings:

1. On the morning of August 14, 2014, surveyors reviewed three (#11, 16, & #21) swing bed resident's medical records.

2. None of the swing bed medical records reviewed contained a comprehensive care plan that included measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs.

3. This was verified at time of record review.

Based on medical record review and staff interview, the facility failed to:

a. develop a comprehensive care plan for swing bed patients within 7 days after completion of a comprehensive exam.

b. ensure that a comprehensive careplan was prepared by an interdisciplinary team.

This occurred in three of three swing bed resident's medical record review (#11, 16, & #21)

Findings:

1. On the morning of August 14, 2014, surveyors reviewed three (#11, 16, & #21) swing bed resident's medical records.

2. None of the swing bed resident's medical records reviewed contained a care plan.

3. This was verified at time of record review.