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Based on observation, policy and procedure review, record review and interview, it was determined the facility failed to ensure medical equipment in need of repair was removed from service.
Findings:

1. According to the policy titled, Work Orders, documented, "... Upon receipt of notification of a situation, the Plant Operations Coordinator will issue a work order..."

On 04/23/12 at 3:00 p.m., the patient in room 116 was observed sitting in a recliner beside his bed. There was a pressure-relieving air mattress on the bed.The patient was asked if there were any mechanical problems with his room. He stated the air mattress on his bed did not work. He stated he reported the problem to the nursing staff a day or two ago and a maintenance person checked the mattress, but could not identify the problem. He was asked if the deflated mattress was uncomfortable. He stated he tried to stay out of his bed as much as possible because lying on the mattress felt like lying on a bare bed frame.

The patient also stated a blood pressure cuff on the wall did not work and staff had to bring in a portable machine to take his blood pressure. No work orders for the faulty air mattress and the blood pressure cuff were found.

2. On 4/23/2012 surveyors reviewed several months of work orders and preventive maintenance schedules. Included in this information was documentation regarding the hospital ' s operating room humidifiers. The humidifiers were listed as " out of service " . In an interview with Staff D and E, this problem initially started about the time the transition to new ownership. Staff E indicated to surveyors the previous Director had been waiting on parts. There was no documentation the problems had been identified and made known to administration. There was no documentation the operating rooms were in compliance with humidity.

3. When asked, Staff E told surveyors there had been issues with the call light remaining on and this had been corrected. There was no departmental documentation of the problem or the work order correcting the problem. Staff E also indicated problems (sparking) with an outlet when a piece of equipment was plugged in. Staff E stated this issue had been fixed. There were no documents, work order, meeting notes, or incident reports identifying this problem and the corrective steps taken.

4. The above information was provided at the exit conference on 4/23/2012. No further documentation was provided.




28997

Based on review of hospital documents, policies, and interviews with staff the hospital failed to provide a preventive maintenance program and oversight of environmental services that ensures a safe patient care environment.

Findings:

1. Review of work orders and continued maintenance over the last six months included information regarding the hospital ' s operating room humidifiers. The humidifiers were listed as " out of service " for several months. In an interview with plant operations staff, this problem initially started about the time the transition to new ownership. Staff E indicated to surveyors the previous Director had been waiting on parts. There was no documentation the problems had been identified and made known to administration. There was no documentation the operating rooms were in compliance with humidity.

2. On 4/23/2012 surveyors reviewed committee meeting minutes. There were no Safety Committee meetings and minutes after July 27, 2011. On the morning of 4/23/2012, Staff D told surveyors the committee had not been functioning since the transition of ownership but that Staff D would send out work orders, review scheduling, and coordinate activities for the plant operations as well as oversee housekeeping services. Staff D told surveyors Staff D reported to Staff B.

In a separate interview that afternoon, Staff C told surveyors prior to the transition the committee functions were the responsibility of the Plant Operations Director and the facility no longer had that position. Staff D's job description indicated Staff D coordinated Safety Committee Meetings, prepared agendas, and takes minutes. Staff C confirmed Staff D did not perform many of the duties of Plant Operations Director but coordinated activities and performed administrative duties for the Plant Operations Department. Staff C also confirmed Staff D did not have departmental training documented for either role.

3. There is no documentation preventive programs are in place and functioning. There is no documentation the hospital reviews facility preventive maintenance programs and/or issues with plant operations to ensure a safe environment for the patients and visitors.

Based on record review and interviews with hospital staff, the governing body of the Critical Access Hospital (CAH) does not ensure that policies for the CAH are implemented and monitored to ensure quality health care is provided in a safe environment.

Findings:

1. There is no documentation variances occurring in the plant operations department and clinical equipment are being tracked, trended and analyzed to ensure a safe environment of care. When asked plant operations staff told surveyors of problems with the nurse call light, electrical system, and gaps around doors. There is no documentation these variances were reported through the incident reporting system or through the preventive maintenance schedule and log. There is no documentation of Safety Committee Meeting Minutes since July 2011.

2. Review of Governing Board Meeting minutes indicate many of the committees had not reported for the past eight months. There was no Safety Committee reporting in any of the Board Meeting Minutes for 2011-2012. There is no quality reporting from all departments/services in any of the governance meeting minutes for 2011-2012.

3. The hospital does not have quality assurance indicators and/or monitoring for all departments in the hospital. The hospital does not have a functioning quality assurance program to assure quality health care in a safe environment. Refer to Tag # 0222 and 0226

4. The hospital does not assure all personnel are trained, competent, and evaluated for their specific departmental duties. Job duties and reporting structures do not match current practice. See tag #0226.

5. The hospital does not have current policy and procedure reviewed, approved, and implemented for all departments. The plant operations policies do not match current practice. See tag #0222

6. The hospital does not have a contract or policy indicating what services/personnel will be provided by the partner hospital.

7. These findings were reviewed during the exit conference with administration. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital has a contract defining the services to be provided by the partner hospital The hospital failed to have documentation stipulating what services are provided and no documentation of processes to how staff at the to assure the services rendered are monitored and care for hospital patients is adequately supervised by licensed personnel.

Findings:

1. The hospital does not have written agreements or contracts with the owners for the specific services that are provided. On 4/23/12 Staff B and C stated that some staff were provided by Mercy Oklahoma City. There were no shared services contracts provided for review that defined the services provided by each of the entities. There was no documentation of processes for sharing staff.

2. On 4/23/2012 surveyors were provided policies for facilities management. On 4/23/12 Staff D and E told surveyors they received plant operations support from Mercy Oklahoma City. Staff D and E said there was no formalized process but they would call the facilities personnel and Mercy Oklahoma City provided support if they could. The policies provided did not reflect these processes. Job descriptions for Staff D and E include reporting structure to employees/positions that were deleted during the transition.

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