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Based on record review and interviews with hospital staff, the CAH does not have a governing body that oversees and is responsible for the conduct of the CAH. The Governing Board did not meet for the first four months of 2010. The governing body meeting minutes provided for review were from May 2010 through November 2010.

Findings:

1. The bylaws for the Governing Board state that the Board will meet monthly.

2. The Governing Board did not ensure that the hospital had a functioning Quality Assurance/Performance Improvement program or Infection Control program.

3. Staff member A stated on 12/08/10 in the morning there were no Board meetings prior to May 2010.

4. The Governing Board did not ensure the hospital's medical staff meets as required. Meeting minutes provided for review did not have any minutes for 2009. The minutes were from March 18, 2008, March 22, May 13, June 10, August 3, September 7, October 5, and December 7, 2010.

Based on record review and interviews with staff, the hospital does not ensure that current and accurate records are maintained that follow the flow of drugs from entry into the CAH through dispensation and administration. Drugs retrieved from the drug room after hours are not always documented as to what was taken, by whom and to what patient they were administered. Pharmacy staff stated on 12/08/10 in the afternoon that they did not reconcile what drugs were taken from the pharmacy with the orders for the patients.

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 to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

Findings:

1. On the morning of 12/08/2010, the administrator told the surveyors that Staff C was in charge of the infection control program. Review of personnel files, and hospital meeting minutes, including medical staff meeting minutes and governing body meeting minutes, did not reflect Staff C had been designated as infection control practitioner/nurse. Staff C's personnel files did not contained evidence she had been trained or experience in infection control. On the afternoon of 12/09/2010, Staff C stated she did not have any previous experience in infection control and had not received any infection control training on setting up an infection control program with active surveillance and analysis of data. She stated she had been designated by the governing body or medical staff as the individual responsible for infection control.

2. The surveyors asked for infection control meeting minutes for the last year. Administrative staff provided only one infection control committee meeting minutes - 11/01/2010. Administrative staff stated they had just started and had not met quarterly as required. Review of infection control data and meeting minutes for medical staff and quality assurance did not show ongoing analysis of patient and hospital staff infections. The infection control log only listed patients who had positive cultures and did not designate if they were nosocomial. Staff C stated that was all she collected.

3. Review of infection control data and meeting minutes for medical staff and quality did not contain analysis of employee health data. Except for the the mention that 50 influenza vaccines had been given, it did not contain staff and physicians immunization data. On the afternoon of 12/09/2010, Staff C stated staff/employee health and immunization analysis was not part of the infection control program. Four of four physicians and allied health files did not contain complete immunization histories.

4. Review of infection control data and meeting minutes for medical staff and quality did not contain data from active surveillance of staff or monitoring of staff to ensure recognized aseptic practices were followed. On the afternoon of 12/09/2010, Staff C stated she did not conduct surveillance/observation activities of staff to ensure policies and procedures and standards were followed. She had not inserviced employees on proper handwashing/hand cleansing techniques or performed any hand sanitation surveillance.

5. Operation room staff stated that eye instruments were "flash" sterilized. The use of "flash" sterilization and the analysis of this practice was not monitored by infection control with actions to limit the use.

6. Review of hospital meeting minutes did not demonstrate an infection control plan and infection control policies had been reviewed annually with revisions as needed. The hospital did not have a policy defining nosocomial infections and did not have a policy detailing the different types of isolation, equipment needed and and the indications for use. Staff C and the administrator stated on the afternoon of 12/09/2010, that they were just starting to develop new policies and procedures for infection control.

Based on policy and procedure manual review and interviews with the staff, the hospital failed to have documentation showing all the personnel operating the diagnostic x-ray equipment are qualified.

Findings:

On the morning of December 8, 2010 surveyors received radiology policy and procedure. The policy and procedure manual did not contain current policies and procedure. There were no verification of competencies, evaluation and departmental training. There was no evidence the Medical Staff or radiologist in charge had established competencies and reviewed policies. These findings were reviewed with administration at the exit conference on December 9, 2010. No further documentation was provided.

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. Five of five nursing personnel (Staff B,F,L,M,S) did not have departmental orientation, competency, and evaluation for the specialized areas where they worked.

Findings:

1. On the afternoon of 12/08 /2010 surveyors were provided ten nurse personnel files (Staff F,N,O,R,S,T,U,V,W,X) ten of ten files did not have specialty orientation, current competencies, or evaluations. This finding was confirmed with Staff A who indicated there were no documents supporting staff had been oriented to specialty areas such as emergency room, surgical services, general nursing, and post anesthesia recovery.

2. On the morning of 12/08/2010, Staff F told surveyors registered nursing staff performed conscious sedation. Ten of ten nurse personnel files (F,N,O,R,S,T,U,V,W,X) did not contain training for conscious sedation.

3. Staff A told surveyors on the afternoon of 12/09/2010 that nursing staff administered respiratory treatments. Ten of ten nurse personnel files (F,N,O,R,S,T,U,V,W,X) did not contain competency and training for administration of respiratory therapy treatments.

6. On the afternoon of 12/09/2010, the above findings were reviewed with the administration and no further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed and has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital conducting ongoing monitoring and data collection and analysis of patient care.
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Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Interviews with hospital personnel on the afternoon of 12/08/10 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of active and closed records, hospital policies and procedures and evaluation of the services provided and if changes were needed.

2. Governing Body, Medical Staff and Quality Assessment/Performance Improvement meeting minutes for 2010 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interview with hospital staff, the hospital does not ensure a yearly program evaluation reviewing the utilization of CAH services, including the number of patients served and the volume of services is conducted.

Findings:

1. Interviews with hospital personnel on the afternoon of 12/08/10 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of the utilization of CAH services, including the number of patients served and the volumn of services is conducted.


2. Governing Body, Medical Staff and Quality Assessment/Performance Improvement meeting minutes for 2010 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interviews with hospital staff, the hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records.

Findings:

1. Governing Body, Medical Staff and Quality Assessment/Performance Improvement meeting minutes for 2010 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Interviews with hospital personnel on the afternoon of 12/08/10 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of a representative sample of active and closed medical records.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies.

Findings:

1. Governing Body, Medical Staff and Quality Assessment/Performance Improvement meeting minutes 2010 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Review of selected hospital policies did not document a yearly review of hospital policies. Radiology Infection Control, Swing Bed and Respiratory did not have evidence of review.

3. Hospital personnel stated on the morning of 12/08/10 that they were in the process of trying to review all hospital policies.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Governing Body, Medical Staff and Quality Assessment/Performance Improvement meeting minutes for 2010 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program to determine if services were effectively utilized, policies were followed and if changes were needed.

2. Hospital staff stated on the afternoon of 12/08/10 that they had not conducted a periodic evaluation that included all the requirements.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital has an effective quality assurance (QA) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital conducting a collection and analysis of data collected concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. QA meeting minutes presented for review were dated 2008 and only had two departments, dietary and radiology, reporting. No documentation of an active ongoing QA program which demonstrated evidence of the analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. Governing Body and Medical Staff meeting minutes did not contain evidence of any analysis of data presented to identify problems, evaluate situations, and take corrective actions.

3. There was no evidence of reviews of nosocomial infections and medication therapy in the infection control meeting minutes or medical staff meeting minutes.

4. All departments providing patient care do not participate in the hospital's QA program. This was verified with hospital staff during the exit conference on 12/09/10 in the afternoon.

Based on record review and interviews with hospital staff the hospital does not ensure that an effective quality assurance program is implemented and evaluates the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA program and all patient care services and other services affecting patient health and safety are evaluated and the hospital collects and analyzes data concerning the quality and appropriateness of all patient care furnished in the CAH.


Findings:

1. Medical Staff meeting minutes for did not contain evidence of the analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. Governing Body and Medical Staff meeting minutes for 2010 did not contain evidence of any QA analysis of data presented to identify problems, evaluate situations, and take corrective actions.

3. There was no evidence of reviews of nosocomial infections and medication therapy in Governing Body, Medical Staff or QA meeting minutes presented for review.

4. All departments providing patient care do not participate in the hospital's QA program. This was verified with hospital staff on the afternoon of 12/09/10.

5. The QA meeting minutes folder presented for surveyor review only had the meeting minutes for dietary and radiology for 2008.

Based on a review of personnel files and interviews with hospital staff, the facility failed to ensure that the State nurse aide registry was checked for findings when individuals are offered employment. In 13 of 13 personnel files that were reviewed, no evidence of inquiry was documented. The Administrator stated that background checks with the State nurse aide registry was not performed.

Based on review of the hospital's swing bed policies and procedures and medical records, and interviews with hospital staff, the hospital failed to provide an ongoing activity program directed by a qualified staff member with activities based on the individual needs and interests of the patients. This occurred for three of three swingbed patients (Records #1, 2, and 3) whose medical records were reviewed.

Findings:

1. Records #1, 2, and 3 did not contain comprehensive activity assessments with the interests, and the physical, mental, and psychosocial needs of each swingbed patient considered.

2. Records #1, 2, and 3 did not contain documentation that activities had been provided to the patients.

3. The Administrator and Swingbed Coordinator told the surveyors on 12/09/2010 that:
a. The hospital did not have a designated qualified individual to direct the hospital's swingbed activity program.
b. No activity assessment had been performed on swingbed patients.
c. The hospital had not provided organized individual, group or bedside activities to patients based on patient interests and needs assessment.