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Based on staff interview, review of hospital documents, and observation of hospital clinical equipment, the hospital failed to have a preventative maintenance program to ensure the hospital's medical devices and equipment were maintained in safe operating condition.

Findings:

The surveyors were given a tour of the hospital on the morning of 05/06/14 by Staff A and J.

The intravenous (IV) pumps in the patient rooms were last inspected March 2013. Only two IV pumps had evidence of a current inspection. The above findings were confirmed by Staff J during the hospital tour.

On the morning of 05/06/14, Staff I was asked for the preventative maintenance inspections for the hospital. None was provided.

Staff E was asked if the hospital had a preventative maintenance program for the hospital's radiology equipment. Staff U stated no.

The surveyors were told they hospital did not have a tracking program to ensure equipment was inspected according to manufacturer's guidelines.

On 05/06/14, Staff U was asked for documentation of the preventative maintenance for the magnetic imaging resonance (MRI) and the ultrasound equipment. Staff E stated she did not have the documentation.

The radiology equipment manuals were reviewed on the afternoon of 05/07/14. The equipment manuals documented preventative maintenance should be performed every six months.

On 05/09/14, a current preventative maintenance inspection list, to include the IV pumps in the patient rooms, were provided to the surveyors via e-mail after the survey exit date.

Based on review of hospital documents, policies and procedures and meeting minutes, surveyors' observations and interviews with staff, the hospital failed to:

a. Develop and maintain an active on-going infection control/infection prevention (IC) program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases among patients and staff;

b. Analyze IC surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel; and

c. Designate in witting the qualified infection control preventionist.

d. Provide initial and on-going education/training for the infection preventionist in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program.

Findings:

Plan/Program:

1. The hospital has not conducted a hospital-wide IC risk assessment to identify the types of patients, risks/concerns, organisms, and diseases prevalent in the community and hospital.

2. The hospital does not have a current infection control plan (Plan). The Plan contained in the IC policy and procedure manual had not been completed.

3. These findings were reviewed and confirmed with Staff A, the person identified as the infection control preventionist on the afternoon of 05/06/2014.


IP Training/Education:

1. On the morning of 05/06/2014, administrative staff told the surveyors that Staff A was the infection control preventionist (IP).

2. Review of Staff A's personnel files and meeting minutes that contained infection control data did not contain a designation in writing that Staff A was the IP.

3. Review of Staff A's personnel files did not contain documentation of training in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program.

4. On the morning of 05/07/2014, Staff A confirmed she had not received any training in establishing and maintaining a comprehensive effective infection control program.


Policies and Procedures:

1. The IC manual, adopted/approved on 11/25/2014, provided to the surveyor was not complete. Portions of the manual were just copies of a manual provided by the Department as a guide for the hospital to develop its own policies and procedures. Example: The policy for the IC committee only stated it would been on a "regular basis", but no time frame was given and did not list the members/disciplines that would comprise the IC committee (that area was left blank).

2. The IC policy and procedure manual did not contain specific IC policies and procedures for each department/service (or notification of where to find specific IC policies for each department) for:
a. Physical therapy;
b. Pharmaceutical services;
c. Radiology services;
d. Respiratory therapy services.

2. The IC manual policy and procedure did not contain specific policies for respiratory isolation protection with requirement of specialized masks, N-95 respirator. The IC policies and procedures did not specify:
a. Detail on how this was to be accomplished and by whom; and
b. Based on the current standards of practice and requirements by OSHA (Occupational Safety and Health Administration), how often fit testing would be performed.
c. Not all staff had been Fit tested to ensure the proper mask was identified and available.
d. Those staff that had been tested, no evidence that the medical questionnaire/assessment had been completed.

3. The IC manual did not contain a policy and procedures on how patients and staff with potential or confirmed influenza will be medically managed, including:
a. Screening;
b. Any required tests to confirm infection;
c. Any particular requirements according to current CDC guidelines.

4. Although the IC manual's Table of Contents listed reportable diseases, At the time of review on 05/06/2014, it did not contain a procedure for submission to the Department or the current list (05/13).

5. The IC manual did not contain policies on disinfectant approval and list of approved disinfectants with what area used and application requirements, including:
a. mixture;
b. wet time contact with surface to be effective; and
c. what organisms each approved disinfectant kill.

6. Policies and procedures manuals available within the different departments, including Nursing, did not contain handwashing and isolation policies.


Surveillance:

On the afternoon of 05/06/2014, Staff A told the surveyors that, except for monitoring patient infections that occurred and hand hygiene, she did no surveillance.

1. The IC program has not monitored to ensure all departments followed infection control policies and current recognized infection control practices.

2. The Centers for Disease Control (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) have identified hand hygiene as the first avenue/most important tool in the prevention of spread of organisms and diseases. Monitoring provided documented 100% compliance, but only a limited number of observations were recorded and only one observation for each staff identified. Staff A told the surveyor that whenever some saw her coming, the would perform hand hygiene.

3. Documents provided and meeting minutes did not demonstrate that, other than patient infections, the IC program monitored and evaluated infections of patients and staff to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

4. Isolation is not monitored to ensure:
a. Patient are placed in appropriate isolation according to current CDC guidelines;
b. Isolation materials/supplies are readily available (Although staff knew the locations,staff had to go from area to area to show the surveyor where they would obtain the needed supplies, including the isolation signs.);
c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements; and
d. Appropriate disinfection of the room occurs.

6. No monitoring of disinfectant applications throughout the hospital departments and locations to ensure:
a. Appropriate disinfectants are selected and used; and
b. The disinfectants are applied and remain "wet" contact time according to the manufacturers guidelines.
c. Nursing staff interviewed did not know if the hospital's disinfectant was effective against C-difficile and did not know the "wet" contact time in order for the disinfectant to be effective.


Meeting Minutes:

On 05/06/2014, Staff A told the surveyors that IC meeting minutes were kept, but they were also processed through other meeting minutes of quality, medical staff and governing body. The surveyors reviews meeting minutes for IC committee, quality, medical staff and governing body where infection control was listed as a topic.

1. The meeting minutes did not contain review, evaluation and analysis of infections to ensure infections and communicable diseases were not transmitted between staff and between patients and staff. Although nosocomial/HAI (hospital acquired infections) were identified in the attached reports, there was not review and analysis to determine if process should be changed to improve patient care and outcomes.

2. The infection control meeting for 01/28/2014 documented that monitoring of the isolation carts would be added to Quality starting in January. This has not been done. The IC committee has not follow-up to ensure this tracking is being performed.

3. The meeting minutes did not contain documentation and review of surveillance/monitoring to ensure IC policies and procedures and current standards of practice are followed.

4. Concerns identified in meeting minutes showed no analysis to determine if corrective actions need to be developed or if current policies and procedures were followed.

5. The meeting minutes did not contain evidence disinfectants used in the hospital had been reviewed for appropriateness and approved for use. Staff A confirmed disinfectants had not been reviewed as part of IC.

6. The meeting minutes did not reflect employee illnesses and immunizations were part of the program. Review of personnel files, including contract and physician did not show complete immunizations as recommended by CDC and its advisory committee (ACIP). Contract staff did not have health files for review during the survey process. Staff told the surveyors that they did not have contract staff files and their health histories had not been reviewed.

7. The meeting minutes for 10/22/2013 documented that the hospital had influenza vaccines and were available at the clinic and hospital. No further follow-up was recorded. No information was provided as to the status of employee vaccinations. Review of personnel files did not contain documentation that the influenza vaccine had been administered to all staff, including physicians.

The findings were reviewed with hospital administrative staff during the exit conference on 05/07/2014. No additional information was provided at the time.

Based on interviews with staff, review of hospital documents, review of policies and procedures the hospital failed to have a process in place to take appropriate action when notified of blood or blood components potential infected with human immunovirus (HIV) or hepatitis C virus (HCV).

Findings:

1. The hospital's laboratory services offers blood administration and has blood storage for blood administration. This was confirmed on 05/06/2014 with laboratory personnel.

2. At the time of review, the hospital did not have a policy and procedure in place if they were notified of infected blood products. This was confirmed with Staff U on 05/01/2014.

3. Although before the end of the survey on 05/01/2014, Staff U submitted a policy and procedure for notification of infected blood products, Staff U told the surveyor at 1215, that the policy had not been submitted and approved by medical staff and governing body.

Based on review of the radiology department documents, review of personnel files and interviews with hospital staff, the hospital failed to develop policy and procedures to protect patients and staff from radiation hazards.

Findings:

The radiology equipment manuals were reviewed on the afternoon of 05/07/14. The equipment manuals documented preventative maintenance should be performed every six months.

Staff U was asked if the hospital had a preventative maintenance program for the hospital's radiology equipment. Staff E stated no.

On the afternoon of 05/07/14, Staff U stated maintenance is performed when problems occur with the equipment.

On 05/07/14, Staff U was asked for documentation of the preventative maintenance for the magnetic imaging resonance (MRI) and the ultrasound equipment. Staff U stated she did not have the documentation.

The hospital's MRI and ultrasound services are provided through a contract. There was no evidence the hospital had written and approved policies and procedures for MRI and ultrasound.

In an interview on the on the morning of 05/06/14, Staff J told surveyors radiology services were provided by hospital employees, contract magnetic resonance imaging (MRI) and contract ultrasound personnel.

There was no documentation the contract personnel providing the services were oriented to the hospital, trained, and deemed competent by the supervising radiologist and/or medical staff.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to assure nursing staff are adequately trained, oriented and competent to provide care to meet the needs of the patients.

Findings:

Orientation and Nursing Competency:

1. Nursing personnel file for Staff Z, an agency nurse did not contain evidence the staff had been orientated to the hospital.

2. Staff B, was assigned to the drug room, review of the education and training file for Staff B did not contain current pharmacy competencies that had been verified by the pharmacist.

3. The above information was presented in the exit interview with the administrative staff. No further information was provided.

Based on medical record review and staff interview the hospital failed to ensure a registered nurse evaluated the care of each patient. This occurred in one of four (#1) medical records reviewed for respiratory therapy treatments administered by the nursing staff.

Findings:

Medical record #1 had documentation of hand held nebulizer respiratory treatment administered by the nursing staff, the records did not contain assessment and evaluations of the patient's conditions before and after the treatments, including vital signs, oxygen saturation, lung sounds and presence of a cough, with a description of any productive sputum or if the patient felt or had improved breathing after the treatment.

This was confirmed by Staff A and J during chart review.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure all entries in the medical record were signed and contained the date and time of the signatures/authenticated. This occurred in ten of fifteen records (#3, 4, 7 and 12 through 18) reviewed for completed entries.

Findings:

Records #3, 4, 7 and 12 through 18 - the electronic Discharge Summary and History and Physical did not contain the date and time the physician signed the electronic document.

Records #7, 15 and 18 - the electronic Consult note did not contain the date and time the physician signed the electronic document.

Record #15- the electronic Progress Note by the physician did not contain the date and time the physician signed the electronic document.

The above findings were reviewed with administrative staff during the exit interview. No additional information was provided.

Based on review of hospital documents, medical records, and meeting minutes, and interviews with hospital staff, the hospital failed to ensure the quality assessment and performance improvement (QAPI) program evaluated all patient care services provided at the hospital to ensure patient health and safety.

Findings:

1. The hospital's meeting minutes, QAPI, medical staff, and governing body did not ensure all patient care services were evaluated. Hospital contract services of magnetic resonance imaging (MRI), ultrasound, and agency nursing staff were not evaluated through the QAPI program.

2. Problems and monitors that did not meet set goals, identified in QAPI reports, did not always show analysis and corrective action with follow-up to ensure the corrective action was effective. For example:
a. Respiratory pre-procedure and post-procedure evaluations - The documents recorded continued deficient practices.
i. The corrective action for 2013 for May/June and July/August recorded, "DON will review with staff."
ii. The reports did not show the corrective actions were evaluated to ensure the actions were effective.
iii. The reports continually documented non-compliance with the expected benchmark. (February 2014 compliance was 75%). No further analysis with corrective actions were identified.
iv. One of four (Record #1, of 1, 2, 9, and 10) medical records reviewed for respiratory treatments did not contain the assessments of the patient's respiratory statue before and after respiratory hand held nebulizer treatments.

b. Continued problems identified for Nursing documented the plan of action remained the same, that the DON would review procedures with staff. There was not follow-up review and analysis as to why this was not effective with implementation of revised plans of actions.

c. Radiology, and Medical Records did not have any analysis with plan of actions and follow-up