HospitalInspections.org

Based on review of hospital documents, surveyor observations and interviews with staff, the hospital failed to ensure patients/patients' representatives are informed how to file a grievance with the State agency. The hospital's grievance policy and patient rights information did not include the telephone number and address of the Oklahoma State Health Department as required. This finding was reviewed and verified by administrative staff on 05/03/2012.

Based on review of the hospital's grievance/complaint policy, grievance log and seven grievances and interviews with hospital staff, the hospital failed to follow its policy and provide a written notice to the complainant with the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This occurred for two of three patients/patients' representatives who filed grievances. These findings were reviewed and verified with Staff D on the afternoon of 05/03/2012.

Based on policy and procedure review and staff interview, it was determined the hospital failed to fully develop the abuse/neglect program to include a policy and procedure to protect the patient during an abuse/neglect investigation and to include written steps to take during and after an abuse/ neglect investigation. Findings:

A hospital policy, titled, "Identifying and Reporting Suspected Abuse/Neglect", did not include how the hospital would protect a patient when an allegation of abuse and/or neglect against an employee was being investigated.

The policy did not include procedures to guide staff in an abuse/neglect investigation.

The policy did not include what actions would be taken when an investigation indicated an allegation of abuse/neglect was substantiated.

On 05/03/12, the QI Manager and the Risk/Compliance Manager stated they were aware the hospital abuse/neglect program was not fully developed.

Based on record review and interviews with hospital staff, the hospital does not ensure the Quality Assessment/Performance Improvement (QAPI) program evaluates all services provided by the hospital. Review of the QAPI meeting minutes for 2011 and 2012 did include evaluation of radiology services, dietary services, patient grievances, incident reports and organ procurement participation.

Based on review of Governing Body, Medical Staff and Quality Assessment/Performance Improvement meeting minutes and incident reports for 2011 and 2012 , the hospital does not ensure that medication errors identified are analyzed and opportunities for the reduction of the errors are evaluated and a plan of action initiated. Incident reports are initiated documenting medication errors, but there is no evidence in meeting minutes that they are analyzed to determine causes and implement actions to reduce their occurrence.

Based on review of infection control data and meeting minutes containing infection control for the past twelve months, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. On 05/03/2012, administrative staff told the surveyors that infection control activities were part of the Quality/Performance Improvement Committee (PIC) and infection control data would be in those meeting minutes.

2. Review of meeting minutes for the past twelve months did not demonstrate the hospital had an ongoing infection control program that reviewed and analyzed infection control practices and concerns with corrective action taken when indicated and follow-up to ensure the action taken was effective.
a. The only meeting that contained a section for infection control was 10/06/2011. The roster of attendance did not include an infection control professional. The documentation identified problems, but did not contain analysis with corrective actions to be taken and follow-up.
b. The meeting minutes for 08/04/2011 contained an entry that documented no nosocomial infections reported on Med/Surg/ ICU. No other information was provided that showed how this was determined - no review and analysis.
c. The meeting minutes for 12/01/2011 documented plan to change the pneumonia order set. Nothing in the meeting minutes demonstrated what precipitated this change or a follow-up in later meeting minutes to determine if this change provided improved outcomes in patient care.

3. The surveillance/monitoring notebook showed exceptions to expected practices from the environmental rounds performed, but these were not documented in the meeting minutes with corrective actions and follow-up to ensure improvement.

4. Monitor/surveillance activities and meeting minutes did not reflect the application of the disinfectant was monitored to ensure it followed the manufacturer guidelines for application and "wet time".

5. Review of meeting minutes and policies and procedures showed the most current review date of the infection policies and procedures was in 2007. The last review of the infection control plan was 2009. This was confirmed with Staff C on the afternoon of 05/03/2012.

6. These findings were reviewed with administrative staff during the exit conference on the afternoon of 05/03/2012. No additional data was provided.