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Based on review of medical staff by-laws, credential file review, and staff interview, the facility failed to ensure 4 of 7 active medical staff (PA-C #1, PA-C #2, MD #1, DO #1) had been approved by the governing body for current medical staff privileges. The findings were:

1. Review of the credential file for PA-C #1 showed the last approval letter granting privileges to practice medicine at the hospital was dated 5/15/07.

2. Review of the credential file for PA-C #2 showed the last approval letter granting privileges to practice medicine at the hospital was dated September 2006.

3. Review of the credential file for MD #1 showed the last approval letter granting privileges to practice medicine at the hospital was dated in 2005.

4. Review of the credential file for DO #1 showed his December 2016 request for temporary privileges had been approved by the CEO and chief of staff but had not been approved by the governing board.

5. Interview with the Human Resources Director on 3/14/17 at 2:10 PM verified these medical staff practitioners were active staff who provided care at the hospital. Interview with the CEO on 3/15/17 at 4:50 PM revealed the responsibility for maintaining the credentialing files had been recently reassigned. In the interview he verified the process for obtaining approval from the governing body to have privileges renewed for the above practitioners had not been completed.

6. Review of the Medical Staff By-laws, dated 2009, Section 2., titled "Terms of Appointment and Reappointment", showed "Appointments and reappointments to the Active, Associate, Courtesy, Consulting, and Dental Staff and allied health professional shall be made by the Governing Board after recommendations of the Executive Committee and the Medical Staff. No appointment or reappointment shall be for a period exceeding two years."

Based on policy review and staff interview, the facility failed to ensure policies were reviewed annually by professional members of the staff. The findings were:

Review of facility policies revealed the facility failed to review the following policies annually:
1. The policy titled, "Pnuemococcal and Influenza Vaccination Program was last reviewed on 4/13/15.
2. The policy titled, "Infection Control-to ensure a sanitary environment for the patients" was last reviewed on 4/13/15.
3. The policy titled, "Infection Control-Operation of committee" was last reviewed on 4/13/15.
4. The policy titled, "Infection Control-Quality Assurance/Improvement" was last reviewed on 4/13/15.
5. The policy titled, "Infection Control-Facility Infection Control" was last reviewed on 4/13/15.
6. The policy titled, "Employee Health-for ill employees" was last reviewed on 4/13/15.
7. The policy titled, "Hepatitis B Vaccine" was last reviewed on 4/13/15.
8. The policy titled, "Employee Absence Due to Illness" was last reviewed on 1/25/11.
9. The policy titled, "Employee Training and Education in Infection Control" was last reviewed on 4/13/15.
10. The policy titled, "Infection Control-Hand Hygiene" was last reviewed on 4/13/15.
11. The policy titled, "Infection Control-Tuberculosis Testing" was last reviewed on 4/13/15.
12. The policy titled, "Exposure Incident Follow-up" was last reviewed on 4/13/15.
13. The policy titled, "Infection Control-Reportable disease reporting" was last reviewed on 6/13/14.
14. The policy titled, "Infection Control-Emergency Infections" was last reviewed on 4/13/15.
15. The policy titled, "Infection Control-Surveillance and tracking infections" was last reviewed on 6/17/14.
16. The policy titled, "Infection Control-Surveillance triggers" was last reviewed on 4/13/15.
17. The policy titled, "Infection Control-Risk Assessments for Construction" was last reviewed on 4/13/15.
18. The policy titled, "Infection Control-Antibiotic Stewardship Program" was last reviewed on 4/13/15.
19. The policy titled, "Determination of an Epidemic" was last reviewed on 4/13/15.
20. The policy titled, "Action Plan for Epidemics" was last reviewed on 4/13/15.
21. The policy titled, "Disease Outbreak Screening Collection" was last reviewed on 4/13/15.
22. The policy titled, "Surveillance During Suspected Epidemics" was last reviewed on 4/13/15.
23. The policy titled, "Reduction of Disease Transmission During Epidemics" was last reviewed on 4/13/15.
24. The policy titled, "Environmental Cultures" was last reviewed on 3/9/01.
25. The policy titled, "Bagging Linen and Waste Materials" was last reviewed on 4/13/15.

Interview with the administrator and CNO on 3/15/17 at 4 PM confirmed the facility failed to review policies annually.

Based on observation, staff interview, and acceptable standards of infection control practices, the facility failed to ensure high-level disinfected laryngoscope blades in 1 of 2 observed laryngoscope blade storage areas (emergency cart) were stored in a manner to prevent recontamination. The findings were:

1. Observation with the CNO and infection control practitioner on 3/15/17 at 4:30 PM revealed multiple unpackaged laryngoscope blades were stored in an enclosed case in the emergency cart. At that time the CNO stated the blades had been placed in the case after they were disinfected. She further stated she did not know how long the blades had been unpackaged in the case, nor did she know how many times there had been exposure to contaminants when the case had been opened.

2. Review of the 2015 Edition of Guidelines for Preoperative Practice, published by AORN (Association of periOperative Registered Nurses) revealed the following recommendation: "XII.c. Cleaned and disinfected laryngoscope blades and handles should be packaged and stored in a manner that prevents contamination. Packaging assists in preventing recontamination of items that have been high-level disinfected. Packaging of laryngoscope blades to prevent recontamination is a CDC (Centers for Disease Control Prevention) recommendation."

3. According to the CDC's HICPAC (Healthcare Infection Control Practices Advisory Committee) document titled Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008, laryngoscopes should be kept free from contamination until the time of use. Once opened, there is potential for microorganisms to settle on the equipment the longer it remains open and unused. In addition, increased handling of the opened unused blade increases the probability of contamination. Ensure that the storage area provides protection against dust, moisture, temperature and humidity extremes.

Based on observation, staff interview, medical record review, and review of manufacturer recommendations and of policies and procedures, the facility failed to ensure adequate pain management for 2 of 4 sample patients (#10, #11) who had pain, and physician's orders were followed for neurological assessments for 1 of 1 sample patients (#12) with orders for this type of assessment. In addition the facility failed to ensure nursing staff performed quality control testing for 1 of 1 glucometer in the emergency department. The findings were:

Regarding ineffective pain management:

1. Review of the medical record showed patient #11 was admitted on 12/20/16 due to stroke symptoms and pain. Review of the 12/20/16 admission orders showed Oxycodone 15 milligrams (mg) was ordered for pain every 4 to 6 hours as needed. Review of the care plan showed identified problems included chronic pain control, chronic back pain, and new onset of knee pain. Further review revealed interventions for pain included "place in position of comfort" and administer pain medications as ordered. The following concerns were identified:
a. According to the nursing notes dated 12/21/16 the patient was very restless, complained of leg pain, and received Morphine 15 mg at 2 AM. At 3:05 AM the patient was still having pain, and at that time was repositioned after receiving an anti-anxiety medication. An assessment for effectiveness was not completed after the medications were administration at 2 AM and 3:05 AM.
b. Review of the 12/21/16 nursing notes showed the patient complained of pain and received Oxycodone 15 mg at 5:41 AM (3 hours and 41 minutes after receiving the previous dose). This review revealed an assessment for effectiveness was not done and nonpharmacological approaches were not assessed.

2. Review of the physician's history and physical for patient #10 showed the patient had abdominal pain and was admitted on 2/9/17 with orders for intravenous Morphine 4 milligrams (mg) every 2 hours as needed. Review of the care plan showed the patient arrived at the emergency department with a pain scale of 8 to 9 out of 10 (according to the scale, 10 is the most severe) and one of the interventions was administer pain medication. Review of the medication administration record and nursing notes, dated 2/9/17, showed Morphine was administered 3 times on 2/9/17. This review revealed a pain assessment was not done to determine the effectiveness of the medication and nonpharmacological approaches were not attempted at any time.

3. On 3/15/17 at 2:45 PM, the medical records for patient #10 and #11 were reviewed with the RN hospital supervisor. At that time she verified the lack of pain assessments, and stated pain assessments, medication effectiveness, and nonpharmacological interventions should have been documented for the two patients as directed by the pain management policy and procedure.

4. Review of the policy and procedure for pain management, issued 5/9/16, showed the following: "...The LN [licensed nurse] and CNA [Certified Nurse Aide] are responsible to help patient to find nonpharmacological methods of pain control, and to use them in conjunction with pharmacological methods of pain control to reach the highest level of comfort for each patient. Nonpharmacological methods of pain control may also be used alone for the patient if effective... Upon onset of any new pain, patient will be reassessed, and provider will be notified. Any PRN [as needed] medications given for pain will be documented on the eMAR [electronic Medication Administration Record], and will also have a follow up for effectiveness documented".

Regarding failure to follow physician's orders for neurological assessments:

Review of the medical record revealed patient #12 was admitted on 1/12/17 due to altered mental status. Further review revealed physician's admission orders included neurological assessments every 4 hours with vital signs. Review of the nursing notes, vital signs, and neurological assessments revealed the vital signs were done as ordered; however, the neurological assessments were completed only 6 times from 1/12/17 to 1/15/17. In addition, review of the nursing notes showed the patient had periods of disorientation during that time. Interview with the RN hospital supervisor on 3/15/17 at 3:40 PM revealed staff had not completed the neurological assessment as ordered. The supervisor also stated it was her expectation that all licensed staff perform neurological assessments according to acceptable standards of practice and according to physician's orders.

Regarding lack of quality control testing for the glucometer:

Observation of the multi-patient use glucometer in the emergency department with LPN #1 on 3/15/17 at 4:50 PM revealed the glucometer was stored in a case with a partially used container of finger testing strips. Continued observation revealed no quality control strips in or near the area. Interview with the LPN at that time revealed she did not know the location of the quality control strips because staff did not use them. Review of the glucose results log showed the glucometer had been used 37 times from 1/24/17 to 3/11/17. Further review revealed no evidence of when the last time a quality control test was performed. Review of the manufacturer's recommendations showed the quality control testing was required prior to inserting the first finger testing strip from a newly opened container. Interview with the CNO on 1/13/17 at 5 PM verified staff had not been doing the required quality testing.

Based on medical record review and staff interview, the facility failed to ensure the medical record was complete in a variety of areas for 13 of 22 sample patients (#1, #4, #6, #7, #8, #10, #11, #13, #14, #19, #20, #21, #22). The findings were:

1. Medical record review on 3/14/17 for patient #1 showed the patient was admitted to the hospital on 3/1/17 and changed to swing bed status on 3/6/17. The review revealed the facility failed to ensure a history and physical was completed.

2. Medical record review showed patient #4 was admitted to the facility on 10/30/16 and discharged on 10/31/16. The review showed the facility failed to ensure the patient's history and physical was signed by a physician or mid-level practitioner.

3. Review of the medical record revealed patient #6 was admitted on 1/8/17 and discharged on the same day. Further review revealed the physician progress note for that day had not been signed.

4. Medical record review showed patient #7 was admitted to the facility on 11/14/16 and discharged on 11/17/16. The review showed the facility failed to ensure the patient's 11/14/17 history and physical was signed by a physician or mid-level practitioner.

5. Review of the medical record revealed patient #8 was admitted on 12/12/16 and discharged to swing bed status on 12/15/16. This review also showed the 12/12/16 physician progress note was not signed and the history and physical and discharge summary were not in the medical record.

6. Review of the medical record revealed patient #10 was admitted on 2/9/17 and discharged on 2/11/17. Further review revealed the history and physical and dictated physician's progress note were not signed.

7. Review of the medical record revealed patient #11 was admitted on 12/20/16 and discharged on 12/23/16. This review revealed the electronic admission orders had not been signed by the physician.

8. Medical record review showed patient #13 was admitted to the facility on 2/4/17 and discharged on 2/6/17. The review showed the facility failed to ensure the patient's 2/4/17 history and physical and 2/3/17 progress note were signed by a physician or mid-level practitioner.

9. Medical record review showed patient #14 was admitted to the facility on 12/2/16 and discharged on 12/3/16. The review showed the facility failed to ensure the patient's 12/3/17 discharge summary was signed by a physician or mid-level practitioner.

10. Medical record review showed patient #19 was admitted to the facility on 12/30/16 and discharged on 1/2/17. The review showed the facility failed to ensure the patient's 1/2//17 discharge summary, and progress notes dated 1/1/17 (two notes) and 12/31/16 were signed by a physician or mid-level practitioner.

11. Medical record review showed patient #20 was admitted to the facility on 11/23/16 and discharged on 11/24/16. The review showed the facility failed to ensure the patient's 11/24/16 discharge summary was signed by a physician or mid-level practitioner.

12. Medical record review showed patient #21 was admitted to the facility on 10/27/16 and discharged on 11/2/16. The review showed the facility failed to ensure the patient's 11/2/16 discharge summary, and progress notes dated 10/28/16, 10/29/16, 10/30/16, and 10/31/16 were signed by a physician or mid-level practitioner.

13. Medical record review showed patient #22 was admitted to the emergency room and discharged on 11/25/16. The review showed the facility failed to ensure the patient's emergency report was signed by a physician or mid-level practitioner.

Interview with the administrator and CNO on 3/15/17 at 4 PM confirmed the facility continued to have difficulty obtaining physician and mid-level practitioner signatures on a variety of forms including history and physicals, progress notes, and discharge summaries. The facility had started issuing fines in an attempt to elicit compliance.

According to the facility Medical Staff Bylaws, last dated 2009, ..."Section 2. Medical Record Documentation. A complete and legible medical record for each patient shall include the following items when applicable: ...a history and physical exam, discharge summary or final progress report...No medical record shall be filed until it is complete except on the order of the Chair of the Utilization Review Committee...D. Progress Notes: ...Progress notes shall be written daily for all inpatients to permit continuity of care and transferability. 3. Definition of Delinquent Records: All records which are past seven days of patient discharge and are still lacking dictation or signature of the following: H&P [history and physical], Discharge Summary or consultation."

Based on staff interview and review of QA activities, the facility failed to ensure all services were involved in the QA program. The findings were:

Review of QA activities from 4/1/16 to 3/14/17 showed quarterly reports, committee evaluations, data reviews, project reviews, data analysis, evaluations of care and services, and identified measures to improve quality from each department except the medical records and social services departments. Further review revealed 5/14/16 was the most current date of participation from the pharmacy department. In an interview on 3/15/17 at 2:45 PM, the quality assurance manager stated there had been recent discussions with the pharmacy staff about projects and data that has been collected, but this information had not been presented to the QA committee. She also verified the lack of QA involvement from the medical records and social services departments.

Based on medical record review, patient interview, and staff interview, the facility failed to ensure 3 of 3 sample swing bed patients (#1, #2, #18) were given a copy of resident rights. The findings were:

1. Medical record review showed patient #2 was admitted to swing bed status on 3/8/17. The review showed no evidence the resident was told about resident rights or provided a copy of resident rights. Interview with the patient on 3/13/17 at 4:50 PM revealed the facility failed to provide him/her a copy of resident rights, and s/he was not informed of those rights.

2. Medical record review showed patient #1 was admitted to swing bed status on 3/6/17. The review showed no evidence the resident was told about resident rights or provided a copy of resident rights. Interview with the patient's spouse on 3/13/17 at 4 PM revealed the facility failed to provide the patient or family a copy of resident rights, and neither the patient nor family was informed of those rights.

3. Review of the medical record showed patient #18 was admitted to swing bed status on 3/13/17. Further review revealed no evidence the resident or family received oral or written information regarding resident rights.

4. Interview with the CNO on 3/15/17 at 4 PM confirmed the facility failed to provide swing bed patients #1, #2, and #18 a copy of resident rights or discuss resident rights with the patients.