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Based on Life Safety Code (LSC) Validation survey, Jay County Hospital was found not in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 482.41(b), Life Safety from Fire and the 2000 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). The original building and the 1992 first floor Emergency Room and Specialty Referral addition were surveyed with Chapter 19, Existing Health Care Occupancies. The Surgery Outpatient building and the Medical Office building were surveyed with Chapter 39, Existing Business Occupancies.

The main hospital is a two story, fully sprinklered building of Type II (222) construction with a basement. The main hospital has a fire alarm system with smoke detection in the corridors, spaces open to the corridors, and all patient sleeping rooms. The facility has a capacity of 35 and had a census of 27 at the time of this visit.

The Surgery Outpatient building is a one story, fully sprinklered building of Type II (222) construction currently housing only physician offices. The facility has a fire alarm system with smoke detection in the corridors and spaces open to the corridors.

The Medical Office building is a two story, nonsprinklered building of Type V (000) construction. The facility does not have a fire alarm system.

Based on LSC survey and deficiency found (see CMS 2567L), it was determined that the facility failed to ensure 1 of 2 buildings classified as business occupancies was provided with a fire alarm system (see K 130).

The effect of this systemic problem resulted in the hospital's inability to ensure that all locations from which it provides services are constructed, arranged and maintained to ensure the provision of quality health care in a safe environment.

Based on observation and interview, the facility failed to ensure 1 of 2 buildings classified as business occupancies was provided with a fire alarm system. LSC 39.3.4.1 requires a fire alarm system in accordance with Section 9.6 shall be provided in any business occupancy where any of the following conditions exists: (1) The building is two or more stories in height above the level of exit discharge. (2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge. (3) The occupancy is subject to 1000 or more total occupants. This deficient practice could affect all patients using the Medical Office building.

Findings include:

Based on observation on 06/06 11 at 12:30 p.m. with the maintenance supervisor, the Medical Office building which was a two story building was not provided with a fire alarm system. This was verified by the maintenance supervisor at the time of observation.

Based on policy and procedure review, patient medical record review and staff interview, the facility failed to implement its policies related to: Fall assessment/reassessment; fall precaution implementation documentation; Braden scale assessment/reassessment; and follow up after pain medication was given for 1 of 4 acute care patients (N1) and 2 of 4 swing bed patients (N10 and N12).

Findings:
1. At 1:00 PM on 6/8/11, review of the policy "Falls Prevention Protocol" (Policy Number: NURS 438.001), indicated:
a. under "Procedure", it read: "...5. The Falls Prevention Reassessment Form...the RN reassesses the patient every 24 hours,...6... If the patient is a level 3, a red dot will be hung on the bulletin board. A bed check alarm is also to be used. If the patient is allowed to sit up in a chair, a chair check sensor mat will be placed in the chair and hooked into the bed check alarm while the patient is up..."

2. At 1:05 PM on 6/8/11, review of the policy "Skin Integrity Policy (Policy Number: 630.000), indicated:
a. under "Assessment", it read: "Complete Braden Scale on all patients upon admission...Repeat daily throughout patient stay..."

3. At 2:20 PM on 6/8/11, review of the policy "Pain Management Policy" (Policy Number 339.002), indicated:
a. under "Policy", it read: "7. Each pain relief measure will have a follow-up pain rating chart within an appropriate timeframe to determine effectiveness and the need for further interventions..."

4. Review of patient records at 3:15 PM on 6/6/11 and 11:15 AM on 6/8/11 indicated:
a. pt. N1 was assessed on 3/28/11 as a Level III (High risk for falls) and was lacking documentation on the Nursing Bedside Flow Sheet of placement of a Bed Check Alarm (or chair alarm) during the 7 PM to 7 AM time

b. pt. N10:
A. was assessed on 2/27/11 as a Level III (High risk for falls) and was lacking documentation on the Nursing Bedside Flow Sheet of placement of a Bed Check Alarm (or chair alarm) for both the 7 AM to 7 PM shift and the 7 PM to 7 AM time frame
B. was lacking a fall reassessment on 3/7/11
C. was lacking a Braden Scale reassessment on 3/2/11
D. had pain medication given:
I. at 2150 hours on 2/28/11 with the follow up at 0005
II. at 0805 hours on 3/1/11 with the follow up at 1000 hours
III. at 1615 hours (pain at level "6") with the next documentation of pain (level "6") at 2015 hours on 3/1/11
IV. on 3/2/11 pain at 0005 hours of "5" and the next documentation at 0650 hours at a level of "5"
V. on 3/4/11 pain at a level of "4" at 1640 hours with the next documentation at 2100 hours (level "8")
VI. on 3/4/11 pain at level "6" at 2200 hours with the next documentation of pain at 0515 on 3/5/11 at a level of "5"

c. pt. N12 was admitted on 4/2/11 and was lacking:
A. a Braden skin reassessment on 4/5/11
B. a fall reassessment on 4/4/11
C. documentation on the Nursing Bedside Flow Sheet of placement of a Bed Check Alarm (or chair alarm) during the 7 AM to 7 PM shifts on 4/2/11 and 4/7/11 and 1600 hours to 1900 hours on the 4/5/11 flow sheet (the patient scored at a level III (High risk for falls on those days)

5. Interview with staff member NI at 12:00 PM on 6/8/11 indicated the medical records for pts. N1, N10 and N12 were lacking:
a. Braden skin and Fall risk reassessments as noted in 4. above
b. documentation of implementation of bed/chair alarms for patients who scored at high risk for falls,
as stated in 4. above
c. appropriate follow up after pain medication was given for patient N10

Based on policy/procedure review, personnel file review and interview, the facility failed to evaluate healthcare workers for communicable diseases for 10 (E#1, E#2, E#4, E#5, E#6, E#8, E#9, E#10, E#11, E#12) of 12 nursing staff.

Findings included:
1. Jay County Hospital Infection Control policy "Employee Health Requirements", written 1975, last revised: 9/06, last reviewed: 2/23/11, includes "pre-employment procedures shall consist of the following: proof of immunity to mumps, rubella, varicella and tetanus...any employee determined non-immune to mumps, rubella, varicella or tetanus must be vaccinated."
2. During personnel file review on 6/7/11 and 6/8/11, the following was found:
a. E#1 (LPN) had no proof of immunity to Rubeola or Varicella
b. E#2 (LPN) had no proof of immunity to Rubeola or Varicella
c. E#4 (RN) had no proof of immunity to Rubeola or Varicella
d. E#5 (PCT-Patient Care Technician) had no proof of immunity to Varicella other than self-attestation of having had chicken pox
e. E#6 (RN) had no proof of immunity to Varicella other than self-attestation of having had chicken pox
f. E#8 (LPN) had no proof of immunity to Rubeola or Varicella other than self-attestation of having had chicken pox
g. E#9 (RN) had no proof of immunity to Rubeola or Varicella other than self-attestation of having had chicken pox
h. E#10 (RN) had no proof of immunity to Rubeola or Varicella other than self-attestation of having had chicken pox
i. E#11 (RN) had no proof of immunity to Rubeola or Varicella other than self-attestation of having had chicken pox
j. E#12 (RN) had no proof of immunity to Rubeola or Varicella other than self-attestation of having had chicken pox.
3. E#4 (CNO) reviewed and confirmed this information.

Based on document review and interview, the facility failed to review its policies/procedures at least annually by a group of professional personnel that included at least one doctor of medicine (MD) or osteopathy (DO).

Findings:

1. Review of the committee minutes considered by the facility to be the professional group for 2010 and 2011 failed to indicate a review of all facility policies/procedures was performed on an annual basis and failed to indicate an MD or DO was present for the meetings as a committee member.

2. Review of the patient care policy/procedures failed to indicate an annual review by the professional group.

3. During an interview on 06-08-11 at 0950 hours with employee #AD 19, the employee indicated they could not recall the last time an annual review had been performed by the professional group, and no MD/DO was a member of the committee or participated in an annual review of all policies/procedures with the group.

4. During an interview on 06-08-11 at 1028 hours, employee #AD 3 confirmed the committee does not perform a full annual review of its policies/procedures.

Based on document review and interview, the facility failed to maintain a current list of all contracted services including the nature and scope of services provided to the facility.

Findings:

1. Review of the document Contract Spreadsheet listed 24 providers for clinical engineering services for the facility.

2. Review of the facility document Contract Spreadsheet failed to include current service provider agreements for 6 services (biohazardous waste management, fire systems maintenance, fire extinguisher maintenance, generator preventive maintenance, pest control services and after-hours radiology interpretation) and listed agreements with 5 providers no longer providing services (biohazardous waste management, biomed equipment preventive maintenance, generator preventive maintenance, magnetic resonance service and speech pathology service).

3. During an interview on 06-06-11 at 1500, employee #AD1 confirmed the list of contracts had not been maintained.

Based on policy and procedure review, patient ED (emergency department) medical record review and interview, the facility failed to ensure that records were complete for 4 of 5 ED records (N5, N7, N8 and N9).

Findings:
1. At 1:00 PM on 6/8/11, review of Medical Staff Rules and Regulations, with approval dates of November 18, 2010 (by Medical Staff) and December 15, 2010 (by the Hospital Board), indicated:
a. in Article XVI "Emergency Department Records", it read: "...The medical records of patients who received emergency care will contain the information specific to the emergency visit and the relevant information required for medical records. *Time and means of arrival...*The medical record notes the conclusions at termination of treatment, including final disposition, condition at discharge,..."

2. At 1:00 PM on 6/8/11, review of the policy "Medical Record Content Requirements/Designated Record Set" (Policy Number HIM 102.000), indicated:
a. under "Procedure", it read: "...3. All entries must be legible and complete..."

3. Review of ED patient medical records at 9 AM on 6/8/11 indicated:
a. the record for pt. N5 was lacking: "Past HX (history), Social HX and Family HX" and "Disposition Decision/Time" information on the "Emergency Physician Record" form
b. the record for pt. N7 was lacking documentation of the "Disposition Time" on the "Emergency Physician Record" form
c. the record for pt. N8 was lacking:
A. documentation of the "Depart Time" on the "Emergency Nursing Record" form
B. documentation of the "Disposition Time" on the "Emergency Physician Record" form
d. the record for pt. N9 was lacking:
A. documentation of the "Condition" on discharge on the "Emergency Nursing Record" form
B. documentation of the "Disposition Time" on the "Emergency Physician Record" form

4. Interview with staff member NI at 12:00 PM on 6/8/11 indicated the areas listed in 2. above, for patients N5, N7, N8 and N9, were not completed, and should have been completed on the ED forms

Based on document review and interview, the facility failed to follow its policy/procedure ensuring sufficient safeguards against unauthorized access to medical record (MR) information.

Findings:

1. The policy/procedure Patient's Right for Confidentiality of Records (approved 9-27-05) indicated the following: Jay County Hospital must ensure that unauthorized individuals cannot gain access to or alter patient records.

2. The policy/procedure Security of Medical Records (approved 02-23-11) failed to indicate housekeeping personnel are authorized to provide area cleaning in the Health Information Management (HIM) Department after hours or when HIM personnel are not present.

3. During an interview on 06-07-11 at 1050 hours, employee #AD 5 indicated the department is cleaned by housekeeping staff after HIM personnel leave for the day and confidential records being processed are covered with a sheet by department staff before leaving and are not placed into locked storage. The employee confirmed that housekeeping staff are not authorized by policy/procedure to be permitted access to record information.

Based on document review and interview, the facility failed to review its health care policies/procedures at least annually.
Findings:
1. Review of the committee minutes considered by the facility to be the professional group for 2010 and 2011 failed to indicate a review of all facility policies/procedures was performed on an annual basis.

2. Review of the patient care policy/procedures failed to indicate an annual review was performed by the professional group.
3. During an interview on 06-08-11 at 0950 hours with employee #AD 19, the employee indicated he/she could not recall the last time a complete review of policies/procedures had been performed.
4. During an interview on 06-08-11 at 1028 hours, employee #AD 3 confirmed the committee does not perform a full annual review of its policies/procedures.

Based on document review and interview, the facility failed to include all services affecting patient health and safety in its Quality Assessment/Performance Improvement plan for one service (clinical engineering).

Findings:

1. Review of the document Contract Spreadsheet listed 24 providers for clinical engineering service and none of the providers were indicated on the Performance Improvement (PI) reports for 2010 and 2011.

2. Review of the document Performance Improvement Plan for 2010 failed to indicate monitoring and reporting for any of the services described above.

3. During an interview on 06-07-11 at 1140, employee #AD16 was asked if any clinical engineering providers were included in the PI plan reports for 2010 and 2011 and the employee indicated they were not.

Based on policy and procedure review and patient medical record review, the facility failed to ensure that all members of the multidisciplinary committee participated in the weekly team/committee conferences for three meetings held for two patients (pts. N10 and N12).

Findings:
1. At 1:20 PM on 6/8/11, review of the policy and procedure "Swing Bed Program", "Multidisciplinary Committee Policy", indicated:
a. under section IV. "PROCEDURE", it read: "A. Committee membership includes, but is not limited to, representation from the following health care disciplines. 1. Nursing Services 2. Rehabilitation Services 3. Social Services and/or Discharge Planner 4. Nutritional Services 5. Activity Director 6. Patient and/ or representative 7. Respiratory Care 8. Physicians are invited/encouraged to attend care conferences. However, when physicians are unable to attend they are notified of critical information pertinent to the patient's progress via phone call or communication in the medical record. A written summary of the case conference is included in the medical record..."

2. Review of swing bed patient medical records at 11:15 AM on 6/8/11 indicated:
a. pt. N10 had documentation of a multidisciplinary conference on 3/1/11 and 3/8/11 that were lacking any attendance by a physician or other documentation of input/contact with a physician
b. pt. N12 had documentation of a multidisciplinary conference on 4/5/11 that was lacking attendance or input by: nursing, dietary/nutritional services, and a physician