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Based on record review and interviews with hospital staff, the governing body failed to ensure quality of care and hospital operations are conducted in safe manner.

Findings:

1. The hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff. See Tags A748, A749, A750 and A756.

2. The hospital failed to develop and implement a discharge planning process to ensure all patients were appropriately discharged with needs assessment, interventions, teaching and follow-up care to minimize the likelihood of having any patient rehospitalized for reasons that could have been prevented.

3. The hospital failed to ensure the following:

a. the scope of surgical services provided by the hospital was defined in writing and was approved by the medical staff. See A Tag 0941;

b. a surgery department organizational chart was developed and implemented. See A Tag 0941;

c. the surgery department was supervised by an experienced and qualified Registered Nurse. See A Tag 0942;

d. the surgery department maintained a current list of qualified practitioners with specific surgery privileges. See A Tag 0945;

e. the operating rooms policies and procedures were developed according to national standards of practice and were comprehensive in such a manner as to address the needs of the department. See A Tag 0951;

f. all required emergency equipment was available, inspected and tested. See A Tag 0956;

g. post-operative care was provided in a separate area of the hospital and failed to develop policies and procedures for the care of the patient during the post-operative period. See A Tag 0957; and

h. the hospital failed to provide an operating room register that met all requirements. See A Tag 0958.

4. The hospital failed to ensure the following:

a. define the scope of anesthesia services provided and failed to identify a qualified physician to oversee the anesthesia department. See A Tag 1001;

b. develop anesthesia services policies and procedures that reflected current standards of practice. See A Tag 1002;

c. ensure an adequate pre-anesthesia evaluation was documented on every surgery patient. See A Tag 1003;

d. ensure an adequate intraoperative anesthesia record was documented for every surgery patient. See A Tag 1004; and

e. failure to provide a post-anesthesia record that contained all the required elements. See A Tag 1005.

5. The hospital failed to ensure the following:

a. inform swing bed patients of all their rights as required. See A Tag 1508;

b. notify swing bed patients of charges for items and services not covered by Medicare or Medicaid. See A Tag 1510;

c. provide an activities program to swing bed patients. See A Tag 1537;

d. ensure patients' medically-related social services needs were assessed and provided for as required. See A Tag 1538; and

e. failed to ensure dental services could be provided to swing bed patients. See A Tag 1548.

The hospital's swing bed policies and procedures were developed in 1993 and had not been reviewed or updated since that time. The policies and procedures did not reflect current CMS requirements for swing bed patients. The hospital could not provide evidence current swing bed requirements were being met.

Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to:

a. clearly define the difference between a complaint and a grievance in the hospital's policy and procedure;

b. inform the patient of the internal grievance process, including whom to contact to file a complaint or grievance;

c. notify patients of the right to file a grievance with the Oklahoma State Department of Health regardless of whether he/she first used the hospital's grievance process; and

d. failed to routinely acknowledge, document and respond to patient complaints and grievances. Findings:

1. A hospital policy, titled, "Patient Grievance Process," documented, "... Definitions: Concerns: are issues or problems identified while the patient/customer is still within the care of Memorial Hospital. Complaints: are issues or problems identified when the patient/customer are no longer with the care of Memorial Hospital..."

The policy did not correctly define complaints versus grievances, according to CMS regulations.

2. A patient's rights handbook documented, "... You have the right to file a grievance. To file a grievance call [phone number deleted] to speak to a representative during normal business hours. A grievance can also be filed with Oklahoma State Department of Health..."

The handbook did not identify who in the hospital to contact to file a complaint, (i.e., Compliance Officer), other than a "representative." The handbook had no information on the hospital's internal grievance process to include written responses to grievances and time frames for responses. The handbook did not instruct patients on how to file a complaint or grievance after hours and on weekends.

3. The handbook did not inform patients they could contact the Oklahoma State Department of Health without using the hospital's internal grievance process first.

4. The hospital was asked to provide a list of complaints and grievances for the previous 12 months (March 2012 to present). The hospital provided five grievances received by the hospital from June 2012 to December 2012. The assistant administrator stated there were no records of grievances between January 2012 and June 2012. She stated the hospital had no record of complaints for 2012. She also stated there were no complaints or grievances recorded for 2013.

5. Of the five grievances recorded in 2012, two of the five had no written response, even though both required a written response by the hospital.

Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to ensure:

a. the governing body approved the grievance process;

b. a grievance committee was established to review and resolve grievances; and

c. failed to take what was learned from grievances through the QAPI process. Findings:

1. The hospital had no documentation the governing body reviewed and approved the grievance process.

2. There was no documentation the governing body assumed responsibility for responding to grievances or had delegated the responsibility to a grievance committee. The assistant administrator stated she was the compliance officer and handled all complaints and grievances herself. She stated she requested assistance from various staff as needed for investigation of issues.

3. The hospital grievance policy had no reference to the governing body responsibilities, no reference to a grievance committee, or documentation of a requirement to include complaint and grievance information taken through the QAPI process.

4. A review of the QAPI committee meeting minutes for 2012 and 2013 had no documentation of a review of complaints and grievances. There was no documentation of knowledge taken from grievances that was presented to the committee for process/performance or systems changes.

Based on observation and staff interview, it was determined the hospital failed to ensure patient privacy, dignity and comfort during changing, toileting and nursing care for patients during the recovery period. Findings:

On 03/14/13, two designated recovery areas identified by the hospital were observed. One recovery area had two patient beds in an "alcove" directly adjacent to the hallway into the surgery suite. This area had no space for patients to change clothes. There was no curtain to provide privacy between the two beds.

Another single recovery bed was located inside the sterile core of the surgery suite next to the surgery control desk.

Neither area provided for patient toileting needs. The only toileting facilities in the surgical area were located in the staff male and female dressing rooms.

Surgery staff were asked how patient toileting needs could be met in this area. They made no comment.

Based on record review and interviews with hospital staff, the governing body failed to ensure that adverse events such as incidences and medication errors are identified, tracked, analyzed and preventative actions taken. Adverse events were not tracked and analyzed as part of an ongoing Quality Assurance/Performance Improvement (QA/PI) program.

Findings:

1. There was no documentation of the analysis and trending of medication errors and incident reports by hospital staff as part of an ongoing QA/PI program.

2. Staff N stated on 03/14/13 that there was no trending and analysis of medication errors.

Based on record review and interviews with hospital staff the hospital failed to ensure that pharmaceutical services provide medication oversight in all areas where medications are used and stored. The hospital's pharmaceutical service does not inspect or show oversight within the surgical area. Pharmacy does not have policies and procedures developed and implemented governing the provision of services throughout the hospital. The hospital's pharmaceutical service does not ensure all medications are stored according too manufacturer's guidelines.

Findings:

1. Staff N stated on 03/14/13 that pharmacy does not inspect the drugs in the operating room (OR) area.

2. Surveyors observed medications in the OR area that were: 1. out of date and available for use; 2. stored in a dirty cart; 3. medications for intraveneous and oral use were stored in the same cart drawer with topical medications and 4. medications were stored with unlabled surgical prep solutions.

3. Pharmacy does not inspect the scheduled drugs in the OR area, or do inventory counts and ensure that all scheduled drugs are stored securely.

4. Intravenously solutions and sterile irrigation fluids were stored in a warmer. The items were not dated when they were placed in the warmer. There was no daily monitoring of warming temperatures of these fluids.

5. Expired intravenous solutions were found in the operating room that was available for use.

Based on review of radiology personnel files and the radiology policy and procedures, the facility failed to have only qualified personnel designated by the radiologist in charge and/or the medical staff use radiology equipment and administer procedures. There was no documentation in the radiology personnel files or policies that the radiologist/medical staff had reviewed equipment, technique, shielding, and radiation safety requirements and determined that staff was qualified to operate specific equipment.

Based on medical record review and policy and procedure review, it was determined the hospital failed to identify and provide a dietary assessment to new patients who were admitted to the hospital. Ten of thirteen paper/hand written medical records reviewed (records # 4,7,8,9,10,11, 13, 17, 18 and 19) did not contain a nutritional assessment as specified by policy.

Findings:

1. The hospital policy "Patient Nutrition Assessment", states new patients will be assessed by the Certified dietary manger for food preferences, allergies and eating abilities, as well as nutritional needs for calorie and protein.

2. Three Electronic Medical Records(EMR) and thirteen paper medical records were reviewed. All three EMR's had a completed nutritional assessment. Three of the thirteen paper medical records contained a nutritional assessment.

Based on policy and procedure review and hospital meeting minutes review, it was determined the hospital failed to ensure the dietary manual was current and approved by the dietician and the medical staff.

Findings:

1. On March 13, 2013, the hospital's diet manual was provided to the surveyors. The manual contained a cover sheet without any signatures.

2. Meeting minutes did not reflect the medical staff had approved the Therapeutic diet manual.

Based on observation, record review and staff interview, it was determined the hospital failed to:

a. construct an appropriate recovery area outside the surgical suite that conforms to national standards, CMS requirements, and state regulations;

b. provide preventive maintenance of the surgery suite and surgical equipment;

c. arrange the surgical suite and equipment for the safety of patients and staff; and

d. failed to ensure the proper storage of trash, soiled linen and biohazardous waste within the surgical suite. See A Tag 0713.

Findings:

1. A two bed recovery "alcove" was built between two sets of double doors within the surgical suite. This post-operative care area was not located in a separate area of the hospital.

The recovery beds were located directly across from the OR suite medical gas shut off valves for that area and were not separated as required in the Life Safety Code Standards.

The two bed recovery area had no nurses' station, no medication storage or preparation areas, and no patient toilets.

Another single recovery bed was set up inside the surgery suite next to the surgery department control desk. This area did not have the availability of medication storage and preparation areas. There was no availability of a patient toilet.

All traffic entering and exiting the OR, including all patients and staff, had to pass through the recovery "area" when entering the surgery suite.

2. On 03/14/13, the surgery department supervisor accompanied the surveyors on a tour of a two room surgical suite. The following environmental deficiencies were observed:

~the line isolation monitors for the operating rooms were not functional. The fuses had been removed to prevent the audible and visual alarms from functioning. The monitors were blocked with large pieces of equipment.

~a functioning janitor's closet used to store biohazardous waste boxes, a mop and bucket and other janitorial cleaning supplies, had been modified and was being used to receive and decontaminate surgical instruments. This room was also used to store sterile supplies such as specimen cups, biopsy kits and skin prep solutions.

~unpacked, dirty shipping boxes of supplies and equipment were stored in various areas, including along a wall in the sterile corridor across from an operating room and in various supply rooms, within the surgery suite.

~other utility items (urinals, a wet floor sign, OR table parts) were stored in rooms with sterile supplies.

~operating room #2 (that had been terminally cleaned) had trash and debris under storage cabinets and under the anesthesia machine. Bags of sterile irrigation fluid opened during another surgery case were stored on a bottom shelf of the cautery unit where the foot pedal was stored.

~multiple equipment surfaces (including kick buckets, ring stands, supply cabinets, cautery units, sitting stools, and the OR tables) had remnants of betadine splashes and/or evidence of rust and corroded metal.

~medications, sterile prep solutions and sterile specimen containers were stored on a dusty, bottom shelf of a rusted equipment cart where OR table parts and other miscellaneous items were stored. This equipment cart was found in OR #2.

~ceiling tiles in various areas of the OR suite were stained with previous exposure to moisture. Some ceiling tiles in OR #2 were flaked and peeling.

~OR walls and doors were splitting, scraped, and chipped. There were multiple gouges in the OR walls that exposed sheet rock. The operating room walls had peeling paint.

~shelves, cabinets and storage closets throughout the surgery suite were dusty, dirty and excessively cluttered.

~floors in the surgery department were yellowed and stained.

~the staff stated there was no regular deep cleaning of the entire surgery suite. The OR staff stated they were responsible for stripping and re-waxing the floors, but had no process for deep cleaning. The staff stated they had no training in floor care or of deep cleaning the OR.

~the surgery suite had no dedicated cleaning equipment such as floor buffer pads, and floor scrubbing/stripping pads. There were no dust mops and other dusting equipment available in the suite. The mops used to clean and disinfect the OR floors were household sponge mops that could not be disassembled and effectively sanitized.

~there was a broken thermostat without a protective cover on the wall in OR #2.

~a broken Mayo stand was in use in OR #2.

~the fire sprinkler head was dislodged from the ceiling in OR #2.

~equipment throughout the surgery suite did not have evidence of preventive maintenance.

~there was no documentation of monitoring of surgery department humidity and temperature.

~sterile intravenous and irrigation fluids were stored in a warming cabinet that was not monitored for proper temperature. There was no record of daily temperature monitoring.

~patient blankets were stored in a warming cabinet. There was no record of daily temperature monitoring.

3. All storage rooms, work areas, and corridors were cluttered, unorganized, dirty, dusty and not used appropriately.

The anesthesia workroom was used to store OR equipment that made access to cabinets, counters and closets impossible. Also stored in the anesthesia workroom were inhalant anesthetic agents, injectable medications and anesthesia supplies and equipment.

Some anesthesia supplies were so old, the packaging was yellowed and brittle. Endotracheal tubes were stored on shelves in their original shipping boxes.

A wrinkled, brown paper lunch bag stored in a cabinet shelf contained a laryngoscope, blades, a metal Tubex injection cartridge and trash.

The workroom closets had supplies stacked to the ceiling and interfered with the automatic sprinkler heads.

4. Sterile supplies were stored with unsterile supplies throughout the surgery department. Sterile supplies and clean supplies were stored with dirty equipment. Janitorial equipment was stored with surgery supplies.

5. As second surgery suite had been built for use within the hospital's OB-GYN services. The surveyors were not told about this area at the time of survey. OSDH was not aware of it's existence until after the survey was concluded.

During the survey, the surveyors were told c-sections were done in OR #2, the only surgery suite disclosed to the surveyors. After the survey, the staff stated c-sections were done in the "new" surgical suite associated with the labor and delivery area.

No policies and procedures for this area were found. There were no records of procedures done in this area. There was no documentation of preventative maintenance for the suite and equipment.

Based on observation, staff interview, and policy and procedure review, it was determined the hospital failed to handle and store trash and biohazardous waste generated in the surgical suite as required by regulation. Findings:

On 03/14/13, large, cardboard disposal boxes of trash and biohazardous waste were observed in the sterile corridor immediately outside operating room #1. The staff were observed placing waste from a surgical case in these boxes.

The surgical staff were asked why the trash and bio-waste boxes were not stored in the room labeled for biohazardous waste. They stated there was no room left in that area for storage of waste because the room was being used for other purposes, such as dirty instrument processing and storage of clean and sterile supplies.

The hospital had no surgery policy for handling trash and biohazardous waste.

Based on observation, interviews with staff and review of hospital documentation, the hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff.

Findings:

1. The staff identified as the infection control preventionist has not been designated by the hospital as the infection control preventionist and does not have experience or training in establishing and maintaining an effective ongoing infection control program. (Refer to Tag A - 748)

2. The disinfectant used throughout the hospital has not been reviewed and approved by the hospital's Infection Control committee and is not effective against Clostridium difficile (C-diff).

3. The hospital does not have an ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained. (Refer to Tag A-749).

4. The hospital does not ensure the infections control program has a current tracking mechanism for patients and staff to track infections and possible transmissions of infections and communicable diseases.

5. Leadership does not ensure infection control concerns and issues are reviewed, analyzed and corrective actions are taken through the quality assessment and performance improvement process. (Refer to Tag A-756).

Based on review of personnel files and meeting minutes, and interviews with hospital staff, the hospital failed to provide and designate a qualified, trained individual to develop, implement and maintain an ongoing infection control program based on current principals and methods of infection control.

Findings:

1. On the morning of 03/13/13, administrative staff told the surveyors that Staff Q was in charge of infection control.

2. Review of Staff Q's personnel file did not contain evidence that Staff Q had training or experience in developing, implementing and maintaining an infection control program. The personnel file did not contain a job description for infection control preventionist. On 03/14/13 at 1240, Staff Q stated she did not have training or experience in developing, implementing and maintaining an infection control program.

3. Review of Staff R's personnel file did not contain evidence that Staff R had training or experience in developing, implementing and maintaining an infection control program. The personnel file did not contain a job description for infection control preventionist. Staff R verified on the afternoon of 03/14/13 that she did not have any training on setting up an infection control program.

4. Hospital meeting minutes did not show evidence Staff Q or Staff R had been appointed as the infection control preventionist.

Based on observation, review of infection control data, surveillance activities, personal files, and meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

The hospital does not have an ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained.

Findings:

Policy and Procedures:
1. The infection control (IFC) policy manual provided to the surveyors did not show a current review of the policies and procedures.
2. The manual did not contain a current infection control plan or risk assessment.
3. The isolation policies did not reflect current CDC (Center for Disease Control) standards.
4. The State reportable diseases list is not current.
5. The policy manual stated surgical and central sterile would have infection control policies. Surgical services does not have infection control policies.
6. The hospital does its own laundry onsite, but has no policies on required washing and drying temperatures and general laundry sanitation practices.
7. The hospital had no policy on disinfection between patients of commonly used medical equipment such as vital sign monitoring equipment.
8. There were no surgery department policies and procedures related to sterile processing.
9. There were no surgery department policies related to environmental cleaning practices.
10. The IFC manual did not include policies and procedures specific to obstetrics and neonates.

Disinfectants:
1. The hospital's infection control program had not reviewed and approved disinfectants to use in the hospital.
2. Environmental cultures are performed on a monthly basis, but documents provided did not support that environmental rounds were conducted to ensure policies and procedures were enforced or that manufacturer guidelines on disinfectants were followed.
3. The surgery department disinfectant was not effective against clostridium difficile. The OR personnel stated that procedures were performed on patients with this infection.
4. The surgery department had no policies and procedures on how the OR disinfectant should be used.
5. The surgery department had no policy and procedure for disinfecting the glucometer between patient uses.
6. There were no disinfectants identified in the laundry area. The staff were not trained in laundry disinfection practices. There was no record of monitoring for proper laundry hot water temperatures, drying temperatures and adequate levels of disinfectants.
7. Linens and surgical scrubs that had been laundered by the hospital were stained and dingy.

Surveillance/Monitoring:
1. No surveillance data was provided to the surveyors for review. Staff Q and R told the surveyors that the hospital did not monitor to ensure infection control policies and procedures were followed, including monitoring of:
A. Hand hygiene - No documentation of surveillance and monitoring of handwashing among all staff and volunteers (including surgical scrubs and surgical skin preps) was provided to surveyors
B. Isolation procedures were followed appropriately
C. Surgical services. Staff Q and R stated they did not go into the surgical area. Staff R stated that even the environmental culture were collected by surgical staff, not laboratory or infection control staff.
D. The only surveillance data provided was environmental cultures which is not a current standard of practice for infection control monitoring, unless a problem or outbreak has been identified.
3. The surgery department did not identify and record infected versus non-infected surgical cases.
4. The surgery department did not record sterilizer loads for efficacy and proper sterility.
5. There were no records of pass/fail on the high-level disinfecting scope processor. Records were not kept to identify patients with scopes used for future tracking of possible procedure-related infections.
6. The surgery department had no policy and procedure or mechanism to monitor surgical site infections.
7. The surgery department had no flash sterilization policy and associated monitoring. Because there was no record of each sterilizer load and it's cycle, there was no way to identify a "flash" load.
8. When there was documented bacterial growth in the automatic surgical instrument washer, there was no evidence of actions taken and plans to continue to monitor on a regular basis. There was no policy and procedure for regular disinfection of this piece of equipment.
9. There was no documentation of special load testing after steam sterilizers and high level disinfectant equipment was repaired.
10. The chemical indicator strips used to test the disinfectant solution in the Steris machine had not been dated as to when they were first opened. Efficacy of these test strips could not be guaranteed.

Employee Health:
1. The hospital had documented employee exposures to patient blood and body fluids. The hospital had no approved and current bloodborne pathogen exposure control plan. The hospital had a plan borrowed from a linen company contractor dated 1992 that was not applicable to the hospital.
2. The hospital did not follow infection control guidelines for employee exposure testing and follow-up as required by OSHA. The hospital did not maintain required documentation of actions taken when an employee was exposed to blood and/or body fluids. The hospital had no Sharps Injury Log.
3. The hospital did not document personal protective equipment (PPE) required for all job functions in each department. For example, the laundry policies stated the only PPE required was "gloves" when handling linens. There was no requirement to wear a protective gown and face shields when performing certain tasks in the laundry.
4. There were no PPE requirements documented for the surgical instruments decontamination area.
5. The hospital had not ensured needleless systems were available in all areas of the hospital. The surgery department staff stated they still used IV systems that required access by a needle.
6. Staff stated they were not trained on the bloodborne pathogen plan upon hire and again annually.
7. A hospital policy related to airborne infection precautions documented employees were to wear an N-95 Particulate Respirator when working with a patient in airborne isolation. The hospital did not perform annual respirator fit-testing for employees.
8. There was no documentation of surveillance of employee infections.
9. No all employees had documentation of required immunizations and TB skin testing.

Tuberculosis Control Plan:
1. The hospital had no TB control plan.
2. The hospital had not performed an annual facility TB Risk assessment.
3. There was no documentation the infection control committee reviewed TB testing conversion rates and compliance with annual TB skin testing among staff, volunteers and patients.
4. There was no hospital TB testing policy and no records volunteers were included in annual testing.

Surgery Environment:
1. Supplies (such as boxes of 4x4 guaze sponges and others) that had been opened during a previous surgical case were left open in the OR suites to be used on other surgical cases. Unused, opened normal saline irrigation bags were removed from the ORs after surgical cases and stored elsewhere in the surgical department for use on other surgery cases.
2. Unpacked shipping boxes and other unsterile items (urinals, a wet floor sign, OR table parts) were stored with sterile supplies.
3. Sterile supplies were stored on solid metal shelves that did not allow air circulation. The metal shelves were marked with crayon and showed obvious signs of rust.
4. A janitor's closet that stored biohazardous waste boxes, a mop and bucket and other janitorial cleaning supplies was used to decontaminate and clean surgical instruments. This room also stored sterile specimen cups, biopsy kits and skin prep solutions.
5. Biohazardous waste boxes that held solid and liquid bio-waste, as well as soiled linen hampers were stored in the sterile corridor immediately outside of OR #1.
6. Sterile instruments sets were stored on solid metal shelves that promoted condensation and compromised sterility.
7. Sterile supplies, such as endotracheal tubes and other sterile anesthesia supplies were stored in their original shipping boxes within the surgery suite.
8. Intravenous solutions and sterile irrigation fluids were stored in the sterile corridor in their original shipping containers.
9. Operating rooms that had been terminally cleaned had trash and debris under storage cabinets and under the anesthesia machine. Open bags of sterile irrigation fluid were stored on a shelf with the foot pedal for the cautery unit in a room that had been terminally cleaned.
10. Multiple equipment surfaces in the operating rooms suites had retained splashes of betadine or evidence of rust.
11. Medications, sterile prep solutions and sterile specimen containers were stored on a dusty shelf with OR table parts and other misc. items in the surgery suites.
12. Equipment dedicated to the OR was taken out of the surgery department and used in other areas. The staff stated this was a routine practice at the hospital. Terminal cleaning of this equipment prior to return to the OR could not be guaranteed.
13. Ceiling tiles in the OR suite were stained with previous exposure to moisture.
14. OR walls and doors were scraped, chipped and split and could not be disinfected. There were multiple gouges in the OR walls with exposed sheet rock.
15. Shelves and storage closets throughout the surgery suite were dusty, dirty and excessively cluttered.
16. Surgery department and OR floors were stained.
17. There was no regular deep cleaning of the entire surgery suite. The OR staff stated they were responsible for stripping and re-waxing the floors.
18. The surgery suite had no dedicated cleaning equipment such as floor buffer pads, and floor scrubbing/stripping pads. There were no dust mops and other dusting equipment. The mops used to disinfect OR floors were household sponge mops that could not be disassembled and sanitized.

Meeting minutes:
1. Medical staff meeting minutes containing infection control did not reflect infection control issues/concerns, surveillances, and practices were monitored, reviewed and analyzed with corrective actions to prevent, identify and manage infections and communicable diseases with measures that result in improvement on an ongoing basis.

2. Meeting minutes and surveillance activities did not contain evidence the infection control monitored to ensure hospital-wide infection control policies and practices, developed to provide a sanitary and safe environment and prevent transmission of infectious and communicable diseases, were followed. It did not contain employee health, infections and illnesses.

3. The hospital's infection control program did not review surgical services practices with corrective actions to ensure a safe sanitary environment was maintained and instruments were cleaned and sterilized appropriately.

Based on review of infection control documents and interviews with hospital staff, the hospital failed to maintain a log of infections and communicable diseases for patient and staff. No infection control log was provided to surveyor review as required by State Hospital Standards. This was confirmed with hospital staff on 03/13/13.

Based on review of hospital documents and meeting minutes concerning infection control, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through Quality Assessment and Performance Improvement (QAPI) and:
1. Were monitored, reviewed and analyzed;
2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and
3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

On 03/13/13, administrative staff told the surveyors that infection control activities were part of the Medical Staff meeting minutes.

1. Medical Staff meeting minutes containing infection control data did not demonstrate review, analysis and corrective actions to improve patient care, ensure a safe and sanitary environment, and decrease or prevent infections and communicable diseases.

2. The Medical Staff meeting minutes, with the exception of employee exposures, did not contain review and analysis of employee immunizations, illness and infections to ensure infections and diseases were not transmitted between patients and staff. The employee exposure only documented whether policy for review was provided, but did not analyze or provide corrective actions to reduce exposures.

3. The only infection control information concerning surgical services was the environmental culture (spot cultures on equipment in the operating room and recovery area). The minutes did not demonstrate the leadership of the hospital ensured surgical services were provided in a safe and sanitary environment according to current standards of practice (Refer to Tags A 749 for details).

Based on review of hospital documents and policies and procedures and interviews with hospital staff, the hospital failed to develop and implement a discharge planning process to ensure all patients were appropriately discharged with needs assessment, interventions, teaching and follow-up care to minimize the likelihood of having any patient rehospitalized for reasons that could have been prevented. On 03/14/13, Staff Q stated the hospital did not have a case manager or social worker or a discharge planning process and policies to meet the requirements.

Based on observation, record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure:

a. the scope of surgical services provided by the hospital was defined in writing and was approved by the medical staff. See A Tag 0941;

b. a surgery department organizational chart was developed and implemented. See A Tag 0941;

c. the surgery department was supervised by an experienced and qualified Registered Nurse. See A Tag 0942;

d. the surgery department maintained a current list of qualified practitioners with specific surgery privileges. See A Tag 0945;

e. the operating rooms policies and procedures were developed according to national standards of practice and were comprehensive in such a manner as to address the needs of the department. See A Tag 0951;

f. all required emergency equipment was available, inspected and tested. See A Tag 0956;

g. post-operative care was provided in a separate area of the hospital and failed to develop policies and procedures for the care of the patient during the post-operative period. See A Tag 0957; and

h. the hospital failed to provide an operating room register that met all requirements. See A Tag 0958.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure:

a. the scope of surgical services provided by the hospital was defined in writing and was approved by the medical staff; and

b. failed to ensure a surgery department organizational chart was developed and implemented. Findings:

On 03/13/13, the surgery department policies and procedures were reviewed. There was no documentation of the scope of surgical services provided by the hospital. There was no evidence the medical staff approved the surgical services provided by the hospital.

There was no documentation of a surgery department organizational chart that included all surgery department positions with titles and lines of authority.

Based on record review and staff interview, it was determined the hospital failed to ensure the surgery department was supervised by an experienced and qualified registered nurse. Findings:

On 03/13/13, the DON stated staff T was the surgery manager.

The employment records for staff T had no documentation of education and experience that would qualify this nurse as an operating room nurse or as a surgery manager. Staff T stated she had experience as an ER nurse and only gained operating room skills on the job at this hospital. She stated she had not been trained by an experienced OR nurse. There was no documentation of orientation and training for the operating room. There were no OR skills competencies found.

The file had no documentation of a hospital job description for the position of surgery manager. Staff T stated she was not the surgery manager. She stated her job was to supervise the staff in the OR when she was present. She stated she was not always assigned to surgery when cases were being done.

Staff T stated the DON was the Director of Surgery and had management responsibilities for the OR. There was no job description for a Director of Surgery found in the DON's employment file. There was no documentation of prior operating room experience. There was no documentation of orientation, training and skills competencies for the OR.

Staff T was asked who had been named the hospital's Chief of Surgery. She identified a physician who had been on medical leave for several months. She stated she was not aware of a replacement chief.

On 03/14/13, the assistant administrator stated staff V had been named Chief of Surgery on 03/13/13. Staff V was interviewed by phone. He stated he had agreed to review surgery charts but was not aware of his appointment as the Chief of Surgery.

Based on document review and staff interview, the hospital failed to ensure the surgery department maintained a current list of qualified practitioners with specific surgery privileges. Findings:

On 03/14/13, the operating room staff were asked to provide a current list of qualified practitioners and there specific surgery privileges.

The list provided included information as old as 2008. The most recent privileges were designated in 2010.

The OR staff stated they did not get updated lists on practitioners and privileges.

Based on policy and procedure review and staff interview, it was determined the hospital failed to ensure the operating room policies and procedures were developed according to national standards of practice and were comprehensive in such a manner as to address the needs of the department. Findings:

On 03/13/13 and 03/14/13, the hospitals surgery department policies were reviewed. The policies and procedures had not been reviewed annually by the surgery manager or the Chief of Surgery.

The majority of policies in the surgery department manual were generic in nature and did not address needs specific to the OR. For example, the isolation policies in the surgery department manual applied to the general medical-surgical nursing care units and did not include guidance for the OR.

The surgery department manual had no policies related to:

~aseptic and sterile surveillance and practice
~scrub techniques
~identification of infected and non-infected cases
~all special housekeeping requirements, including the appropriate use of disinfectant agents and routine and terminal cleaning procedures. There were no policies and procedures for routine deep cleaning and floor care.
~handling surgical trash, linens and biohazardous waste
~OR safety practices, such as "time-out", patient positioning, patient warming devices, use of cautery, surgical counts, etc.
~patient identification procedures in all peri-operative areas
~pre-operative work-up requirements, pre-operative checklists and nursing care
~surgical procedures, protocols, equipment and supply lists for each type of procedure performed
~duties of all personnel including circulators, scrub techs and others
~prevention of surgical fires including policies and procedures specific to the use of alcohol preps
~sterilization and disinfection processes
~OR attire and hygiene requirements
~surgery department emergency response and responsibilities during various internal and external disasters
~maintenance and availability of emergency equipment
~out-patient post-operative care planning and coordination and provisions for follow-up care
~safe warming of intravenous and irrigation fluids
~safe warming of patient blankets
~use of a multi-patient glucometer
~medication administration, handling and storage
~requirements for visitors, vendors, non-surgery department staff and others who may need or request entrance to the OR

The policy addressing the treatment of malignant hyperthermia did not reflect current standards of practice.

There was no surgery policy for patient DNR status. There was no provision for continuing or discontinuing the patient's DNR status during the peri-operative period.

Surgical staff interviewed stated they were not familiar with OR policies and procedures.

Based on policy and procedure review, observation and staff interview, it was determined the hospital failed to ensure all required emergency equipment was available, inspected and tested. Findings:

On 03/14/13, an emergency cart for the surgery suite was observed. The cart was broken, rusted and dirty. The cart was not locked.

The cardiac monitor, defibrillator and suction machine did not have current biomedical inspection and testing.

The cart did not have all required emergency medications, including medication to treat malignant hyperthermia.

Three surgery staff personnel were asked if there was a tracheotomy set available in the OR. None could be located.

Based on observation, policy and procedure review and staff interview, it was determined the hospital failed to ensure post-operative care was provided in a separate area of the hospital and failed to develop policies and procedures for the care of the patient during the post-operative period. Findings:

On 03/14/13, a single post-operative bed was observed inside the sterile core of the operating room in a cubicle next to the operating room desk. The staff stated this was where the physicians preferred to have patients recover from surgery.

Another two post-operative beds were located inside the surgery department between two sets of double doors. The staff stated these beds were "not really used for recovery" because they did not have a nurse's station in that space.

There was not an identified post-operative care or recovery room in a separate area of the hospital.

The staff were asked if there were patient care policies and procedures for the post-operative (recovery) period. They stated there were no policies.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to provide an operating room register that met all requirements. Findings:

A hospital policy, dated October 2011 and titled, "Surgical Logbook," documented, "... The following information will be included in the surgical logbook for all procedures:
a. hospital number
b. patient name
c. surgeon and assistant surgeon, as applicable
d. circulating and scrub technician
e. date of procedure
f. pre-operative diagnosis
g. operative or invasive procedure
h. post-operative diagnosis
i. complications
j. anesthesia and surgery start and finish times
k. type of anesthesia used
l. sponge, needle and instrument count status..."

On 03/13/13, the staff were asked to provide the operating room register. Four separate logs were provided. They were labeled "Inpatient", "Outpatient", "Inpatient Endoscopy", and "Outpatient Endoscopy."

None of the logs were complete. The endoscopy log books also included inpatient and outpatient surgical procedures, other than endoscopy.

Not all surgeries performed could be found in the logs. The surveyors requested selected patient surgical records and did not find those cases (such as c-sections and GYN) listed in any logbook.

In addition, the surveyors noted the following missing information in the surgery logs:

~no patient age documented
~incomplete names of anesthesia providers
~no anesthesia type documented
~no pre and post-operative diagnosis documented
~not all nursing personnel present in the room were documented
~some documentation on the log was illegible

Surgery personnel stated they were not aware of the requirements for the surgery register.

Based on document review, policy and procedure review and staff interview, it was determined the hospital failed to:

a. define the scope of anesthesia services provided and failed to identify a qualified physician to oversee the anesthesia department. See A Tag 1001;

b. develop anesthesia services policies and procedures that reflected current standards of practice. See A Tag 1002;

c. ensure an adequate pre-anesthesia evaluation was documented on every surgery patient. See A Tag 1003;

d. ensure an adequate intraoperative anesthesia record was documented for every surgery patient. See A Tag 1004; and

e. failure to provide a post-anesthesia record that contained all the required elements. See A Tag 1005.

Based on policy and procedure review and staff interview, it was determined the hospital failed to define the scope of anesthesia services provided and failed to identify a qualified physician to oversee the anesthesia department. Findings:

On 03/13/13, the hospital's administrative staff were asked to provide policies and procedures for anesthesia services. There was one policy dated September 2011, entitled, "Anesthesia." The policy was signed as "approved" by the Director of Nurses. No other anesthesia policies were provided.

The was no organizational chart for the anesthesia department. There was no document that described the scope of anesthesia services and what qualified practitioners were granted privileges to provide those services.

On 03/14/13, the assistant administrator stated no physician had been appointed the director of anesthesia services and no other anesthesia-related documents were available.

Based on policy and procedure review and staff interview, it was determined the hospital failed to develop anesthesia services policies and procedures that reflected current standards of practice. Findings:

On 03/13/13, the hospital administrative staff were asked to provide anesthesia policies and procedures. A single, one page policy was provided. The policy did not reflect current standards of practice and was limited in content.

On 03/14/13, staff U stated he was aware there were no policies and procedures for the anesthesia department. He stated he had begun to develop some policies on his own.

Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to ensure aa adequate pre-anesthesia evaluation was documented on every surgery patient. Findings:

On 03/13/13, the hospital administrative personnel provided a single, one page policy dated September 2011. The policy, titled "Anesthesia", documented, "... All surgery patients are to be seen by anesthesia personnel prior to their surgery..."

The policy had no other guidance or requirements for the pre-anesthesia evaluation.

Clinical records for five surgical patients were reviewed. None of the five records contained a pre-anesthesia evaluation with all the required elements.

On 03/14/13, staff U stated he was aware of the lack of policies for anesthesia services.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure an adequate intraoperative anesthesia record was documented for every surgery patient. Findings:

A hospital policy and procedure, titled, "Anesthesia", documented, "... Anesthesia personnel are responsible for ensuring complete and accurate documentation of any care they provide, pre-operative medications, intra-operative medications, post-operative medications, patient status, vital signs, time anesthesia is started and stopped..."

The policy did not document all the required elements for intra-operative anesthesia documentation.

Clinical records for five surgery patients were reviewed. None of the records contained intra-operative documentation that included the required elements.

On 03/14/13, staff U stated he was aware anesthesia policies needed to be written.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to provide a post-anesthesia record that contained all the required elements. Findings:

A hospital policy and procedure, titled, "Anesthesia", documented, "... Anesthesia personnel are responsible for ensuring complete and accurate documentation of any care they provide, pre-operative medications, intra-operative medications, post-operative medications, patient status, vital signs, time anesthesia is started and stopped..."

There was no other directive or guidance on what should be documented in the required post-operative anesthesia care record.

Five clinical records were reviewed for post-operative anesthesia documentation of care. None of the records contained all the information required.

On 03/14/13, staff U stated he was working on anesthesia policies.

Based on review of hospital documents, personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure.

Findings:

1. According to the respiratory therapist, nursing staff administered respiratory therapy treatment to patients between midnight and 0700.

2. Two of two nursing personnel files reviewed did not contain respiratory competency training and verification completed by the respiratory therapist as required.

3. The respiratory therapist on duty on the afternoon of 03/14/13 stated he had not provided any competency verification or training and did not think the supervisor had done so.

4. Staff Q stated on the afternoon of 03/14/13 that the respiratory therapist had not provided competency verification or training since she had been there (since 2010).

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to:

a. inform swing bed patients of all their rights as required. See A Tag 1508;

b. notify swing bed patients of charges for items and services not covered by Medicare or Medicaid. See A Tag 1510;

c. provide an activities program to swing bed patients. See A Tag 1537;

d. ensure patients' medically-related social services needs were assessed and provided for as required. See A Tag 1538; and

e. failed to ensure dental services could be provided to swing bed patients. See A Tag 1548.

The hospital's swing bed policies and procedures were developed in 1993 and had not been reviewed or updated since that time. The policies and procedures did not reflect current CMS requirements for swing bed patients. The hospital could not provide evidence current swing bed requirements were being met.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to inform swing bed patients of all their rights as required. Findings:

On 03/13/13, the hospital was asked to provide patients' rights documents. The document given to swing bed patients did not include all the patients' rights information as required.

The administrative staff stated no other information was given to patients about their rights when admitted to a swing bed.

Based on document review, policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to notify swing bed patients of charges for items and services not covered by Medicare or Medicaid. Findings:

The hospital had no policy and procedure related to charges for items and services not covered by Medicare/Medicaid. The clinical records for swing bed patients had no documentation of notice regarding possible charges at the time of admission to a swing bed.

The administrative staff stated no other information for swing beds was available.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to provide an activities program to swing bed patients. Findings:

Clinical records were reviewed for three swing bed patients. The records contained partial activities assessments or no activities assessments. There was no documentation of an activities plan for each patient. There was no documentation of the patients' preferences for activities.

There was no documentation of any activities actually provided to patients to include who provided the activity, when it was provided and the patient's response. One record (patient #9) documented the activities provided to the patient on the activities record were "showered, walked, sleeping, talking..."

The hospital did not provide a monthly activities calendar.

The hospital had no current activities policies and procedures.

On 03/13/13, the administrative staff stated the nursing staff provided the activities program for swing bed patients.

The nursing staff were asked if they were aware of an activities program for swing bed patients. They stated they were not.

Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to ensure patients' medically-related social services needs were assessed and provided for as required. Findings:

Three swing bed patient records were reviewed. Two records (#28 and #9) documented admission social services assessments were completed and needs were identified. There was no documentation of actions taken or social services provided to the patients.

One swing bed record had no documentation of social services in any form.

The hospital's swing bed policies were last reviewed in 1993.

The hospital administrative staff were asked if they could provide any other social services information. None was provided.

Based on policy and procedure review and staff interview, it was determined the hospital failed to ensure dental services could be provided to swing bed patients. Findings:

The hospital's swing bed policies and procedures were last reviewed in 1993. Included in the policies was a contract with a local dentist for services related to swing bed patients. The contract was signed in 1993.

The administrative staff stated there was no current contract or arrangements for dental services for swing bed patients.