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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 3/10/11 surveyors reviewed personnel files. Three of four (D,E,N)registered nurse personnel files reviewed for licensure verification did not contain licensure verification.

2. Two personnel listed (Staff J and P)on the surgery log as providing care did not have personnel or credentialing files. Two medical students (Staff L and M) were listed as "assistants" on the surgery log. Staff L and M did not have any personnel or credentialing files. On the morning of 3/10/11 Staff A told there was no documentation available on Staff L and M.

3. Four of four nursing personnel files did not contain training required by the hospital to provide care in a specialty area as stipulated by hospital policy. Staff D, E, G, N were documented in the emergency record as the registered nurse caring for patients. Staff D, E, G, N did not have current advanced cardiac life support or pediatric life support required in hospital policy to work in the specialty area. Staff G and E did not have documented departmental orientation as stipulated by hospital policy and job descriptions.

Based on record review and interviews with hospital staff, the governing body does not ensure that policies governing the CAH"s total operation are implemented, medical staff providing patient care are evaluated and appointed by the governing body and ensure quality health care is provided in a safe envirornment.

Findings:

1. Seven ( w, z, Aa, Bb. Cc. Dd, Ee, Ff) of eight physicians, one ( x ) of one physician assistant and two ( w & x ) of two certified registered nurse anesthetists providing patient care did not have evidence in their credential files or in meeting minutes of appointment to the medical staff by the governing body.

2. A third year medical student, a physician's private nurse and scrub tech provided patient care and assistance during several surgical procedures. The hospital did not have any files containing license verifications, health status or competencies on these persons.

3. The governing body did not ensure the hospital had developed an active ongoing infection control program that reviewed and evaluated practices in the hospital, with corrective actions taken when needed, to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel. Refer to Tag 278.

4. The governing body does not assure nursing staff are adequately trained to meet the needs of the patients. Nine of fourteen nursing (B,C,D,E,F,G,J,K,L,M,N,O,P,Q) personnel did not have departmental orientation, competency, and evaluation for the specialized areas where they worked. Refer to Tag 294.

5. The governing body does not ensure that surgical procedures are performed in a safe manner. Refer to Tag 320

Based on review of medical records, policy and procedure, meeting minutes, and medical staff files, the hospital failed to review care provided by mid-level practitioners.

Findings:

1. On the afternoon of 3/10/2011 three death records (Pt #16,17,18) from the emergency room were reviewed. Three of three records did not indicate the mid-level practitioners caring for patient's during advanced cardiac life support consulted medical staff assigned to the mid-level practitioner prior to pronouncing patients dead and removal of life support.

2. Review of medical staff meeting and governing body meeting minutes did not indicate death charts were reviewed by medical staff. There was no documentation provided to surveyors indicating the quality of care and treatment provided by mid-level practitioners was reviewed. This finding was verified with administration during the exit conference.

Based on record review and interviews with staff, the hospital does not ensure that medication errors are evaluated to determine possible causitive factors and create systems to prevent their reoccurance.

Findings:

1. Incident reports for 2010 did not document medication errors.

2. The clinical review log for 2010 documented only the number of medication errors each month, but did not evaluate the possible cause or any trends.

3. Hospital staff did not provide any additional information on 03/10/11 in the afternoon.

Based on review of the infection control documents, hospital meeting minutes, policies and procedures and personnel 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 taken when needed, to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

Findings:

The surveyors asked for infection control meeting minutes for the last year. Administrative staff told the surveyors that infection control was now included in the "Super Committee" meeting minutes. The surveyors reviewed the 2010 to present Super Committee, Medical Staff and Governing Body meeting minutes for infection control information/data. Meeting minutes referred in the deficiency reflect all of the above meeting minutes.

1. On the afternoon of 03/09/2011, the administrator and Director of Nursing told the surveyors that Staff D was in charge of the infection control program. The Infection Control Plan, item #16, stipulated that the infection control nurse was to "stay abreast of issues via CDC (Centers for Disease Control) website, state and county health department, and continuing education." Staff D's personnel files did not contained evidence she had been trained or had experience in infection control. On 03/10/2011 at 1440, Staff D stated she had not received any infection control training on setting up an infection control program with active surveillance and analysis of data.

2. Review of hospital policies and meeting minutes did not demonstrate an infection control plan and infection control policies had been reviewed annually with revisions as needed.

3. The infection control log only listed patients who had positive cultures. The log only listed the date the patient's culture was obtained and did not record the date of admission and the date of noted symptoms of infection. The log did not designate if they were nosocomial. Although the log recorded whether the organism was sensitive or resistive to the antibiotic, when it was noted to be resistant, it did not show if the physician was notified and whether the antibiotic was changed. On 03/10/2011 at 1445, Staff D stated that was all she collected.

4. Review of the surgery log showed 14 cataract eye surgeries were performed on 02/25/2011. On the afternoon of 03/10/2011, operating room Staff C stated that the surgeon brought 4 instrument sets with him and staff "flashed" (autoclaved uncovered at a shorted time with only one minute dry time) the eye instruments for all cases.

Review of meeting minutes did not demonstrate the use of "flash" sterilization and the analysis of this practice was monitored by infection control with actions to limit the use. On the afternoon of 03/10/2011, Staff C and Staff D stated that this practice was reported and reviewed.

5. The surgery log showed the turn-around time (time between when one patient left the OR and another patient was brought into the room) did not allow sufficient time for disinfection according to the hospital's selected disinfectants' manufacture guidelines. The surgical area uses Virex 256 and Nutra Quat. Both products require a ten (10) minute wet contact time on all surfaces to be effective. Turn-around time for most of the eye cases were less that three (3) minutes. This was verified with Staff C on 03/10/2011 at 1550. He stated no one from infection control monitored cleaning practices and he did not report any data to infection control. He did not have any data to show he had monitored or tried to correct the practice.

Review of meeting minutes and surveillance material did not reflect cleaning times for any area of the hospital had been observed or reviewed.

6. The Infection Control Plan stipulated, item #10, the infection control program would "monitor employee health needs and immunization status and maintain records." Review of meeting minutes did not contain analysis of employee health data. Sixteen of eighteen personnel files, seven of eight physician files and three of three allied health files did not contain complete immunization histories as required by Hospital Licensure Standards and recommended by CDC.

7. The Infection Control Plan stipulated, item #4 and 5, the infection control program would provide inservice education on infection control to reduce nosocomial infections. Personnel files reviewed did not contain evidence staff were provided ongoing education on infection control. Review of meeting minutes did not reflect infection control education was reviewed or analyzed with corrective action and follow-up.

8. Review of meeting minutes did not contain data from active surveillance of staff or monitoring of staff to ensure recognized aseptic practices were followed. The surveillance data, provided to the surveyors on 03/10/2011, documented surveillance/monitoring, but the data did not record the types of discipline observed or the number of opportunities observed and did not include all infection control practices/policies and procedures. This finding was reviewed with Staff D and Staff S, the individuals who conducted the surveillance activities.

9. The Infection Control Plan, item #16, stipulated that the infection control nurse was to "stay abreast of issues via CDC (Centers for Disease Control) website." The hospital's Handwashing policy and procedure does not reflect current CDC recommendations.

10. The meeting minutes did not reflect infection control issues were evaluated with corrective action and follow-up of the corrective action. The meeting minutes documented four needle sticks for 2010. The minutes did not address the reason for the needlesticks, analysis to ensure practices needed to be changed. Infections, employee and patient, were not reported, reviewed or analyzed to discern whether corrective actions or changes in practices needed to occur.

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. Nine of fourteen nursing (B,C,D,E,F,G,J,K,L,M,N,O,P,Q) personnel did not have departmental orientation, competency, and evaluation for the specialized areas where they worked.

Findings:

1. On the afternoon of 3/10/11 surveyors were provided personnel files. There was no documentation provided indicating (B,C,DE,F,G,J,K,N,O,P,Q) nursing personnel had orientation to the hospital and specific departments.

2. On the morning of 3/9/11 surveyors reviewed the surgical log. Staff C,J,K,L,M,N,O,P,Q were listed in the surgery log as providing care during procedures. Staff J,K,L,M,N,P,Q did not have personnel files available for review. The hospital did not provide documentation staff were properly trained to work in surgery.

3. On the morning of 3/9/11 surveyors reviewed the emergency room log. Staff G, F and N were listed as providing care in the emergency room during January of 2011. There was no documentation Staff G,F, and N had been oriented to the hospital or the emergency room.

4. On the morning of 3/9/11 Staff A told surveyor's Staff D was the infection control practitioner. Staff D'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 3/10/11.

5. On the morning of 3/10/11 surveyors observed nursing personnel (Staff N and S) providing respiratory treatment. Review of documentation did not indicate an assessment was performed pre and post treatment. Staff S told surveyors the nursing staff had not been trained in respiratory. On the afternoon of 3/10/11 surveyors were provided personnel files. None of the nursing personnel files (Staff B,C,D,E,G,N,S) selected for review included competencies for respiratory treatment.

5. The above findings were reviewed with administration on the afternoon of 3/10/11. No further documentation was provided.

Based on review of medical records and respiratory policies and procedures, and interviews with staff, the hospital failed to ensure notes for respiratory therapy treatments were descriptive of the patient's pre-assessment and post-assessment of the patient's respiratory condition with evaluation of the patient's response to the respiratory treatment. This occurred in two of two medical records reviewed, of patients currently receiving respiratory therapy treatments (Records #20 and 24) and one of one closed medical record (Record #13) of a patient receiving a respiratory treatment in the emergency room.

Findings:

1. Administrative staff told the surveyors on the morning of 03/09/2010 that hand held nebulizer treatments were performed by nursing staff.

2. The hospital's policy required staff to do a pre-assessment and post-assessment of the patient's respiratory system, including a pulse oxygen notation. The form attached to the policy showed pre and post-assessment that included documentation of the patient's pulse, breath sounds and also whether cough was present with sputum.

3. Record #13, showed the patient received hand held nebulizer treatments. The record did not contain pre-assessment and post-assessment of the patient's respiratory condition.

4. Staff S stated on 03/10/2011 at 1400 that she gave hand held nebulizer treatments and only charted in the medication administration record. She stated that if she did a pre-assessment and post-assessment of the patient's respiratory condition, she would chart it in the nursing notes, but did not always remember to do this. She stated she did not use the form identified in the policy. The surveyors reviewed medical records with staff and pre-assessment and post-assessment of the patient's respiratory condition was not charted.

5. These findings were reviewed and verified with Staff B.

Based on observation, staff interviews, and a review of policies and procedures, the hospital failed to ensure that surgical procedures are performed in a safe manner.

Findings:

1. Two medical students, two scrub tech students, and two clinical staff working in the operating room were not authorized by the Governing Body and Medical Staff to perform procedures or work in the operating room. Refer to tag #321.

2. On 3/10/2011 surveyors reviewed the flash sterilization log for 2/25/11. Fifteen eye cases were performed on 2/25/11. All eye surgical instruments were sterilized by a "short cycle"/flash sterilization. During an interview on 3/10/11 at 1550 Staff C told surveyors there were four sets of eye instruments and all eye instruments were "flashed". Staff C also told surveyors the flash cycle for these instruments were in flashed in an open container for three minutes and a dry time of one minute.

3. Review of the operating room log indicated all eye cases were performed in OR #1 on 2/25/2011. The times indicated on the operating room log from the end of one case to the beginning of another was one to five minutes. Disinfectant cleaners used by the facility required a ten minute kill time for adequate disinfecting of surfaces. On 3/10/11 at 1550 Staff C told surveyors he was aware the time necessary for appropriate disinfecting of equipment and surfaces was not being followed.

4. On 3/10/11 surveyors reviewed Governing Body Meeting Minutes, Medical Staff Meeting Minutes, and Super Committee Meeting minutes. There was no review of surgical services where quality of care, incidents related to surgery, or surgical infection control practices were reviewed.

Pt. #3 was listed as having a surgical procedure 2/17/11. Pt. #3 returned to the hospital's emergency room on 2/20/11 with abdominal pain. According to the documentation, Pt #3 had a pneumoperitonitis diagnosed by computed tomography. In an interview on 3/10/11, Staff C told surveyors he was aware of the complication. Staff C told surveyors he spoke with the doctor but did not document the conversation. There was no documentation care of patient #3 was reviewed.

5. On 3/10/11 surveyors reviewed 2010 competency training for personnel working in the operating room and the PACU. Several of the competencies were not signed by the personnel being evaluated. Six of eight competency sheets did not indicate if the personnel were competent. Review of the medical record #3 indicated Staff U provided care in the post anesthesia care unit (PACU). Staff U did not have documentation of training in the PACU.


6. The policies and procedures for the operating room have not been reviewed or approved since 2006.

Based on review of medical records and interviews with surgical staff, the hospital failed to ensure all clinicians assisting in or performing procedures are credentialed and privileged.

Findings:

1. On the morning of 3/9/11, surveyors reviewed the operating room log. Staff L, M were listed as "assistants" on multiple procedures and the log indicated they were medical students. On 3/10/2011 Staff A told surveyors there was no credentialing, privileging, or information available on the medical students.

2. Staff J and P were listed on the surgery log and patient medical records as providing patient care as "circulator" and "scrub tech". The hospital could not provide surveyors evidence of credentialing or privileging. Staff J and P did not have any evidence of orientation to the hospital or surgical services department. This finding was reviewed with the administrative staff at the exit conference on the afternoon of 03/11/10.

3. Staff K and R were listed on the surgery log and patient medical records as providing "others in operating suite". On the morning of 3/10/11 surveyors were told Staff K and R were scrub tech students. Staff K and R did not have any evidence of orientation to the hospital or surgical services. There were no documents available on K and R for review.

Based on record review and interviews with hospital staff, the hospital does not ensure the quality assurance program evaluates the quality and appropriateness of diagnosis and treatment furnished in the CAH. Review of quality assurance, medical staff and governing body meeting minutes for 2010 and 2011 did not have evidence that the CAH reviews and evaluates the quality and appropriateness of treatment in the event of blood utilization and patient deaths.

Based on review of facility policies the facility failed to develop and implement written policies and procedures to prevent verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility was unable to provide copies of policies and procedures addressing verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

Based on review of facility policies the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility could not provide written policies and procedures that address mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Based on a review of personnel files and an interviews with hospital staff, the facility failed to ensure that the State nurse aide registry was checked for findings when individuals are offered employment. On the afternoon of 03/10/2011, Hospital staff stated the State nurse aide registry had only been checked for nursing personnel and was not checked other disciplines and contract staff that had patient contact. This finding was reviewed with administrative staff at the exit conference on the afternoon of 03/10/2011.

Based on review of the hospital's swing bed policies, patient records, personnel files and interview with staff, the hospital failed to ensure patient activities are directed either by a qualified professional meeting the requirements of ?485.15(f)(2), or by an individual on the facility staff who is designated as the activities director and who serves in consultation with a therapeutic recreation specialist, occupational therapist, or other professional with experience or education in recreational therapy.
Findings:

1. Review of personnel file for Employee (S) who was responsible for swing bed activities did not contain documentation they qualified as a professional meeting the requirements of ?485.15(f)(2), or that they consulted with a therapeutic recreation specialist, occupational therapist, or other professional with experience or education in recreational therapy.

2. Swing bed patient records (#11,12,21,22,23) did not contain documentation that there was monitoring of activities to ensure they were meeting the patient care needs and goals. Interview of Employee (S) confirmed no records of therapeutic activities were available.

Based on review of swing bed patient records and interview with staff, the hospital failed to conduct initial comprehensive assessments of each resident's needs within 14 days of admission.
Findings:

Swing bed patient records (#'s 11,12,21,22,23) did not contain an initial assessment completed within 14 days of admission.