HospitalInspections.org

Based on document reviews and interviews, the hospital failed to assure that the nutritional needs of inpatients are met in accordance with recognized dietary practices.

Findings:

1. Staff E told the surveyors a nutritional screen was completed on every person by the dietary department. Staff E also stated if patients needed further nutritional assessment the contracted dietitian was contacted and the assessment was completed by the consultant. In six of six (5,7,8,10,11,13) medical records reviewed for nutritional documentation, the nutritional section was incomplete or not documented. In three of three (5,10,11) patients on specialized diets there was no documentation why the patient was on a special diet, nutritional consultation had been provided and if the patient received the appropriate diet.

2. Two of two (Staff E,W) dietary employee files did not contain orientation, training, evaluation, and competency for specific job duties. There was no documentation dietary employees had oversight by the dietitian.

3. Dietary and nursing policies did not include a policy and procedure for nutritional screens/nutritional consults. Dietary policies had a review date of 2006.

4. The above findings were reviewed with administration at the exit conference. 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. On the morning of 12/14/2011 surveyors were given copies of the Dietary Department policy and procedure manual. Policies and procedures were revised 2006. There was no documentation the Dietary policy and procedures had been reviewed and approved since 2006.

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 x-ray 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 12/14/11 Staff S stated all of the employees received competency training for specific radiology modalities at the facility. The competencies were not developed in coordination with the radiologist. There was no indication the competencies had been reviewed and approved by the radiologist or the medical staff. Staff S verified this finding with surveyors.

2. Personnel files (T,U,V) provided to surveyors did not include competencies for specific radiology modalities. There was no departmental orientation, evaluation of radiology procedures performed by staff. This finding was reviewed with Staff S on 12/14/2011.

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

Based on record review and interviews with hospital staff, the hospital does not ensure the contracted consultant pharmacist provides visits as required by the rules and regulations for Drug Rooms by the Oklahoma State Department of Health Hospital Licensure Standards and the Oklahoma State Board of Pharmacy.

Findings:

1. The requirements for the consultant pharmacist in a hospital drug room are for at least 52 visits per calendar year with not more than five in one month.

2. The consultant pharmacist has only documented 22 visits for the year 2011. At the time of the survey on 12/15/11, the pharmacist would be unable to fulfill the requirement for 52 visits.

3. This was verified by hospital staff on 12/06/11 in the afternoon.

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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 12/15/11 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 2010 and 2011 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 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 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Review of selected hospital policies did not document a yearly review as required. The following policies did not have evidence of an annual review; Physical Therapy, Dietary and Emergency Services. Medical Staff bylaws and rules and regulations did not have any evidence of review since 2006.

3. Hospital personnel stated in the afternoon of 12/15/11 that they did not have any other documentation of policy 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, policies were followed and what changes if any were needed.

Findings:

1. Review of Governing Body and Medical Staff meeting minutes for 2010 and 2011 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 12/15/11 in the afternoon that they had not conducted a periodic evaluation that included all the requirements.

Based on review of the hospital's death register, the written contract with the OPO (organ procurement organization - LifeShare of Oklahoma), the referral Activity Report from the OPO for the time period of January through December 2, 2011, medical records and hospital documents, and interviews with hospital staff, the hospital failed to:
1. Enforce its patient death protocol, concerning reporting to the OPO (This occurred in eight of ten death records reviewed [Records #18, 19, 20, 22, 23, 25, 26, and 27] .); and
2. Include in the protocol how referrals would be tracked through the Quality program to ensure all deaths were reported to the OPO.

Findings:

1. Upon arrival at the hospital on the morning of 12/13/2011, the surveyors requested the OPO contract, the OPO Activity Reports for 2011, and the hospital's death list for 2011.

2. The original OPO Activity Reports from the OPO only contain only four names, starting with May and June 2011. Staff B stated she had contacted the OPO representative and requested a full report for 2011. The fax copies received contained two additional names. The third copy, faxed to the facility on the afternoon of 12/14/2011, was from 05/05/2011 to 12/02/2011 and contained seven names. The reports did not contain any patients for the time period of 01/01/2011 through 04/30/2011. No additional data could be obtained from the OPO representative.

3. According to the the hospital's death register/log book supplied to the to surveyors on the afternoon of 12/13/2011, twenty deaths had occurred at the hospital between the dates of 01/01/2011 and 12/12/2011. This was confirmed with the Chief Nursing Officer at the time.

4. According to the hospital's patient death reporting protocol, found in the hospital's death register book, the procedure staff were to follow included, "4. Call Oklahoma Lifeshare (big pink sign at nurses desk by phone). Have them fax you a copy of this referral to (number given) and place copy in chart."

a. Eight of ten death medical records reviewed (Records #18, 19, 20, 22, 23, 25, 26, and 27 of Records #18, 19, 20, 21, 22, 23, 24, 25, 26, and 27) did not contain a copy of the faxed form from the OPO.

b. Staff B said staff should document in the medical record, not only that they had called OPO, but the Oklahoma OPO referral number. Four of the remaining eight records reviewed (Records # 18, 19, 20,and 25) did not contain documentation of the OPO Oklahoma referral number to show staff had called the OPO and obtained a referral number.

c. Two of ten death medical records reviewed (Records 19 and 20) did not contain the OPO referral form or documentation that the staff had called the OPO. These patient names were also not contained on the OPO Activity Reports.

d. The above findings (a through c) were verified with Staff B at the time of reviews on 12/14/2011.

5. Review of meeting minutes for Quality and Medical Staff did not contain evidence the OPO activity and tracking of deaths for compliance with the requirements were integrated into the quality process. This finding was confirmed with Staff B on 12/14/2011 at 1520.