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Based on observation and staff interview, it was determined the hospital failed to ensure emergency supplies and equipment were:

a. readily available to staff in the procedure room;

b. maintained, monitored, replaced, and tested; and

c. the hospital failed to check for expiration dates on emergency medications and supplies.

Findings:

On 08/05/13 and 08/06/13, observations were made of the surgical areas.

1. The crash cart in the surgery suite had no current documentation the defibrillator and suction machine were checked for proper functioning. There was no documentation the level in the oxygen tank was checked. There was no documentation the medications and supplies were checked for expiration dates.

There was no documentation emergency supply inventory was maintained. There were no hospital or surgery department specific policies and procedures that addressed all the requirements for the availability and maintenance of emergency supplies and equipment.

2. The procedure suite, a separate area from the surgery suite, had no crash cart or emergency supplies.

3. In the surgery suite, emergency medications and supplies for malignant hyperthermia were stored on a shelf and on the floor in a plastic tub. The supplies and equipment were not stored on a movable cart or stored in a manner to allow quick retrieval by one staff person in the event of an emergency.

4. Staff present during the tour of the surgical areas were not aware of the processes related to the emergency cart and emergency supplies in this area.

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

a. appropriately modify rooms within the surgical areas according to nationally recognized requirements for these areas. See Tag C-0221;

b. provide housekeeping and preventive maintenance in the surgical areas to ensure the facilities, supplies and equipment were maintained for safety and quality. See Tag C-0222;

c. collect and handle trash in the surgery areas appropriately. See Tag C-0223 and K-75;

d. store and secure drugs and biologicals appropriately. See Tag C-0224;

e. ensure the surgical areas were clean and orderly. See Tag C-0225;

f. maintain proper ventilation, temperature and humidity controls in the surgical areas. See Tag C-0226 and K-67; and

g. the hospital failed to provide an automatic sprinkler system that is installed in accordance with NFPA 13. See Tag C-0231.

See also LSC Tags K-147, K-130, K-106 and K-78.

Based on observation and staff interview, it was determined the hospital inappropriately modified rooms within the surgical department.

Findings:

On 08/05/13 and 08/06/13, the following observations were made of the surgical areas:

~ Rooms within all areas of the surgical department were not properly labeled to designate what they were. Because the rooms were extremely cluttered and improperly used (clean and dirty items stored together, sterile and non-sterile stored together) it was difficult to distinguish "clean" versus "dirty" areas within the department. A few doors were labeled with paper signs.

The functionality of many rooms within the surgery department had been changed from the original design. For example,

~ The identified "recovery room" was not originally designed for that purpose. The area did not have emergency power from the critical care branch. The room had an open hopper in the corner of the room within six feet of the recovery bed.

Because the recovery room had only a single bed, it could not be determined how multiple patients were recovered at the same time. For instance, there were occasions when the operating room register documented 16 or 17 patients received eye surgery in a six hour period. The register showed 12 -15 minute turnover time between patients, indicating that more than one patient had to be "recovered" at the same time.

In addition, there were days when multiple endoscopic procedures were done with minimal turnover time. These patients required a longer recovery period than eye cases. Based on the times documented on the OR register, the patients would have to be recovered during periods of time that overlapped.

The staff did not identify any other "recovery" room in the facility. On a tour of the department, the surveyors noted there was no other space that met the requirements of a recovery room. The staff who accompanied the surveyors on the tour had no information about how the surgical services patient flow was handled.

There was inadequate storage space in the recovery room. Supplies were stored unsecured on open shelves. The recovery room had no patient toilet and hand-washing sink.

~ A janitor's closet, with the hopper still in place, was converted into an endoscope decontamination room. There was not enough space in this room to process the number of scopes used. There was not enough storage space in this room for all the supplies and equipment necessary for endoscope processing. At the time of survey, two wet endoscopes had been stored inside the automated washer. The room had a sink for gross decontamination of the endoscopes, but there was no hand-washing sink for staff.

~ An endoscope storage room/utility room also held a small medication refrigerator. The endoscope cabinet was left open. Two endoscopes were hanging inside it. An unlocked medication refrigerator sat on a table in front of the endoscope cabinet. The placement of the medication refrigerator impeded movement and blocked counter space and other storage in the room.

~ The surgical instrument decontamination room had a single sink where instruments were washed. There was no separate staff hand-washing sink. There was not adequate counter top space to process surgical instruments before and after washing. Unnecessary supplies and equipment were also stored in this room.

~ The sterile supply room in the surgery area was originally designed to be a utility room. The room had a sink and counter top. There was not enough space to accommodate all the department's sterile supplies. For this reason, sterile supplies were found randomly stored in various areas throughout the department.

There was improper storage of non-surgical supplies in the sterile supply room. Multi-use patient care items were improperly stored in this area. An electric razor was stored on the counter next to a plastic basin. Linen was stored on the counter top as well.

The sterile supply room did not meet requirements for airflow, temperature and humidity.

~ The surgery suite and the procedure suite did not have an identified anesthesia work room that contained anesthesia supplies, equipment and medications dedicated to that department. Instead, anesthesia supplies, equipment and medications were stored randomly throughout the suites.

~ A steam sterilizer had been removed from the surgery restricted corridor but the plumbing and the drain remained open and exposed. The surfaces had not been repaired and sealed.

~ The hospital did not replace the steam sterilizer within the surgical suite for use in an emergency when flash sterilization was required. The only steam sterilizer available was outside of the surgery department and was not easily accessible to staff in an emergency.

~ The identified pre-op room had no patient toilet and hand-washing sink.

~ A closet had been converted into a staff kitchen that opened directly into the semi-restricted hallway within the surgical area. There was no door to separate the "kitchen" from the semi-restricted corridor. Microwave cooking was allowed in this room.

~ Staff stated the interior semi-restricted corridor to the surgery suite was used as a tornado shelter for all staff, visitors and patients who may be in the hospital during a weather emergency.

The staff were asked if this surgical hallway was the only interior safe area. The staff stated there were interior corridors, other than the surgical suite, that could be used as a tornado shelter.

~ The women's dressing room in the surgical area was carpeted and could not be adequately cleaned and sanitized on a daily basis.

~ Papers were taped on the walls throughout the pre-op, surgery, recovery, decontamination and sterile processing areas.

Staff that accompanied the surveyors on a tour of the surgical areas made no comment regarding the findings.

Based on observation, record review and staff interview, it was determined the hospital failed to provide housekeeping and preventive maintenance in the surgical areas to ensure the facilities, supplies and equipment were maintained for safety and quality.

Findings:

On 08/05/13 and 08/06/13, a tour of the surgical and related areas was conducted.

1. The surgical light over the OR table area in the procedure room did not work.

2. A nurse call system in the procedure suite did not work.

3. There was an exposed pipe and an open hole in the floor in the restricted corridor of the surgery suite.

3. Throughout the surgical areas walls, floors, and ceiling tiles were in disrepair. Baseboards were missing or broken. Peeling wallpaper and exposed sheet-rock was found on some walls within the procedure suite. Wall paint was chipped. Wood doors were gouged and scratched. Because of the types and condition of the walls, floors, doors and ceiling tiles, regular dusting, disinfection and deep cleaning could not be adequately carried out.

Water stains were found on ceiling tiles. Ceiling tiles were misshapen in some places and were no longer in proper position.

Cabinets and drawers could not be opened or closed correctly. Old wood surfaces on the cabinets and drawers were marred, chipped, cracked or had peeling varnish. None of the wood surfaces could be adequately sanitized.

4. Some walls within the restricted and semi-restricted surgical areas had textured wallpaper that could not be cleaned or sanitized as necessary.

5. There was no documentation of preventive maintenance for the steam sterilizer and no records of repair. There was no record of preventive maintenance and repair for the sonic instrument washer or the automated endoscope cleaner. The plant manager stated he was not aware that all surgical equipment needed to be on a regular maintenance schedule.

6. The sonic surgical instrument washer was not installed correctly. Staff had to attach a hose from the instrument sink faucet to the washer to fill it. Likewise, a waste water hose was draped back into the instrument sink to drain. The automated washer sat on a steel cart over unfinished flooring that could not be cleaned and disinfected. There was a large hole in the wall under the washer that went completely through the sheet rock.

7. The instrument decontamination sink was rusted and had evidence of mineral build-up. The counter tops, walls and surfaces in the decontamination area were dirty, grimy, and cluttered. Surfaces were chipped, marred and broken and could not be sanitized.

8. In the instrument processing room, cleaning chemicals were stored on a shelf over personal protective equipment and other supplies. Clean supplies items were stored on the counter top and not within closed cabinets in the decontamination room. These items were exposed to splashing from dirty water when instruments were being washed.

9. Drawers and cabinets did not close properly in the decontamination room. Baseboards were missing and there were gouges in the walls. The area had no evidence it had ever been terminally cleaned. The area was cluttered and disorganized.

10. A multi-drawer rolling cabinet in the recovery room was marred, chipped and had plastic trim broken off. The surfaces could not be sanitized.

11. The findings were discussed with the administrator. She stated she did not know why staff had not reported the needed repairs to maintenance.

Based on observation and interview, it was determined the hospital failed to collect and handle trash in the surgery area appropriately. Findings:

On 08/05/13, a large, industrial size gray garbage can was observed stored in the semi-restricted hallway in the surgical area. The can held trash from the surgical area and food waste. The trash can did not have a cover and had not been emptied in four or more days.

The staff stated the trash can had always been there and no one knew there was anything wrong with it.

Based on observation, record review and staff interview, it was determined the hospital failed to store and secure drugs and biologicals appropriately. Findings:

On 08/05/13 and 08/06/13, observations were made of the surgical areas.

1. Intravenous solution bags were stored in the bottom of the surgical scrub sink. Staff stated it was "probably stored there for use at another time."

2. Medications were stored unsecured in all areas of the surgical department. There were no locking cabinets designated for medications in the procedure area or the surgery area. Medications were stored in random cabinets and drawers throughout the department. Staff were asked how the hospital could manage inventory and ensure all medications were routinely checked for expiration dates. No reply was given.

3. Expired medications and IV solutions were found in various surgical areas.

4. Opened medications were not dated when opened.

5. A medication that was manufactured in a light-protected package was open to the light and left on a counter.

6. Multiple pre-packaged bags of take home eye medications were found in an unlocked cabinet. The staff did not know who accounted for these medications and who checked for expiration dates.

7. Syringes of sterile normal saline for injection and syringes with needles were found in drawers with office supplies in the recovery room.

8. Bags of intravenous solution were stored in a warming cabinet without evidence of monitoring of temperature. The bags were not labeled with an expiration date after they were placed in the warmer.

9. Malignant hyperthermia emergency medications and IV fluids were stored on an open shelf under a medication administration machine. They were not protected from possible splashing when the floor was mopped.

Based on observation and interview, it was determined the hospital failed to ensure there was adequate storage for equipment and supplies, failed to ensure there were no obstructions to movement within the surgical areas and failed to maintain the surgery services departments in a clean and orderly fashion. Findings:

On 08/05/13 and 08/06/13, the following observations were made of the surgical areas:

~ Equipment, such as surgical positioning devices and lead radiology vests, were hung on the outside of doors facing within the surgery restricted corridor. This had the potential to impede movement of patients and staff through the area.

~ Equipment stored along the walls in the restricted corridors impeded movement of staff and patient stretchers.

~ None of the surgical related areas had adequate storage for equipment and supplies. All areas were cluttered, disorganized and difficult to move through.

~ Various supplies were stored in a haphazard manner on a metal shelving unit in the recovery room. The supplies were not in an enclosed cabinet to protect from contamination or tampering.

~ Emergency equipment was not easily accessible. Supplies for a malignant hyperthermia emergency were stored on the floor and on an open shelf under a medication administration machine. The supplies were not organized and easily accessible and quickly transportable.

~ The crash cart in surgery suite was cluttered, disorganized and dirty. Unnecessary items were stored on it.

~ An infant warmer to be used for an emergency delivery was blocked by multiple pieces of equipment, supplies and boxes. The warmer was not clean, had "party supplies" stored on top of it, and had not been checked for proper functioning.

~ Equipment and supplies were stored in corridors and in "trash" receptacles.

~ There was no organization to the storage of sterile supplies, as these were found stored everywhere throughout the surgical areas.

~ The sterile processing room was dirty. Counter tops were cluttered, the floors were dirty and there were dead insects on the floor and on the window ledge. The window was coverred with long verticle blinds that were dirty. There was no evidence the room had been terminally cleaned or the floors stripped and waxed.

~ Throughout the surgical areas there were multiple areas of peeling paint, water leaks and general disrepair.

~The sink and counter top in the recovery room was dirty. The sink had stains and mineral deposits.

~ An "office" work area was set up in the restricted corridor of the procedure area. There was a cluttered desk that had stacks of papers, books, binders and other clerical materials. There was a cluttered book shelving unit that held the same items. A rolling cart with binders and files was stored directly next to the surgical scrub sink within the splash zone. The combination of the desk, a shredder box and the rolling cart obstructed the egress out of the procedure area.

~ Paper instrument wrappers were taped over door windows.

Based on observation, record review and staff interview, it was determined the hospital failed to maintain proper ventilation, temperature and humidity controls in the surgical areas.

Findings:

On 08/05/13 and 08/06/13, observations were made of the surgical areas.

The air conditioning had been turned off in the procedure suite, the surgical suite, the pre-op and recovery area for three days. The areas were hot, humid and had no air circulation. There was a musty, moldy smell in the procedure area.

The staff did not monitor temperature, humidity, air exchanges or positive airflow pressure in the surgery suite or the procedure room.

The staff did not monitor temperature, humidity, air exchanges or negative airflow pressure in the decontamination area and in the endoscope processing area.

The sterile processing room air conditioner had been turned off and the room was too warm, had no air circulation or humidity control. The staff stated the air was turned off when the department was closed.

The staff did not monitor temperature, humidity, air exchanges or positive airflow pressure in the sterile processing area.

Based on observation and interview with staff, the hospital failed to provide an automatic sprinkler system that is installed in accordance with NFPA 13. Findings:

Refer to LSC survey tags K-52 and K-56.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital's pharmaceutical service maintains control over all drugs and medications in all drug storage areas of the hospital and orients and evaluates pharmacy staff to the specific duties required according to accepted professional principles. Pharmacy/drug room personnel did not have job descriptions, orientation and evaluations specific for the pharmacy/drug room performed by the Consultant Pharmacist. Pharmacy/drug room personnel do not inspect all areas of the hospital where drugs and medications are used and stored.

Findings:

1. Pharmacy Staff O and P stated on 08/06/13 in the afternoon they do not check the drugs that are stored and used in the surgical area to assure they are stored appropriately and in a secure manner and are not outdated, mislabeled or otherwise unusable.

2. The fulltime drug room supervisor/tech and the alternate pharmacy tech do not have job decriptions, orientation, and evaluations specific for the pharmacy/drug room conducted by the Consultant Pharmacist.

Based on review of hospital documents and meeting minutes and interviews with staff, the hospital failed to:

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

b. Analyze IP 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. Provide 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 IP risk assessment to identify the types of patients, risks/concerns, organisms, and diseases prevalent in the community and hospital.

2. The hospital has not conducted a tuberculosis risk assessment.

3. The Infection Control Plan (Plan), provided to the surveyors on 08/05/13 in the IP policy and procedure notebook, is not current.
a. The last Plan approval date is 03/08/10.
b. The Plan lists hospital services of "special care units", obstetrics and newborn nursery. The hospital is a 25-bed critical access hospital that does not have "special care units". On 08/05/13, the administrator told the surveyors that the hospital only offered obstetrics and newborn services on an emergency basis.


Surveillance:

The IP plan provided to the surveyors on 08/05/13 documented the program surveillance/monitoring would include all department/areas of the organization/hospital.

1. The IP program has not monitored to ensure the policies were followed.

2. Documents provided and meeting minutes did not demonstrate that, other than positive cultures of patients, the IP 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.

3. 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. The infection control program does not monitor hand hygiene practices throughout the hospital and does not have a tool for monitoring. This was confirmed with Staff C on the afternoon of 08/06/13.

4. Surgical services and central sterile processing is not monitored, including, but not limited to, maintenance of a clean and sanitary environment; use of disinfectants; cleaning and packaging of instruments; sterilization practices; and high level disinfection practices. (Refer to Tag C-320 for details and observations.)

5. Isolation is not monitored to ensure:
a. Patient are placed in appropriate isolation according to current CDC guidelines,
b. Isolation carts are stocked appropriately,
c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements,
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.


Policies and Procedures:

1. The IP policy and procedure manual did not contain IP policies and procedures that included departments/services of:
a. Surgical services - surgery, endoscopy and central sterile,
b. Housekeeping services, with guidelines on appropriate cleaning,
c. Sleep lab and outpatient services

2. The IP manual (and employee health manual) policy and procedure for respiratory isolation masks, N-95 respirators, 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.

3. The IP 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 IP manual's Table of Contents listed reportable diseases, it was not the current list (05/13). The manual did not contain a policy and procedure for reporting reportable infections and diseases to the proper authorities, with delineation of responsibilities.

5. The IP 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
c. what organisms each approved disinfectant kill.

6. The IP manual did not contain policies and procedures concerning surgical site infections, with details of:
a. Who would be responsible,
b. How information would be obtained, and
c. When the tracking would be performed.


Observations:

1. The hospital does surgical procedures, including eye, general, pain management, and endoscopy. Clean and sanitary conditions were not maintained in the surgical area, with staff following current standards of practice.
a. The most prevalent organism for colonoscopy procedures is Clostridium difficile (C-diff). The surveyors did not observe any disinfectants that would be effective against C-diff, available for use.
b. Staff told the surveyors the hospital had that "flash"/shortened cycles were not used to process instruments, even on eye cases. Review of autoclave documentation showed:
i. On 04/04/13, sixteen (16) loads, all eye instruments, were run on the "Express" cycle - sterilize time of four (4) minutes at 270 degrees and a dry time of three (3) minutes. The first load contain two sets of eye instruments and all the others contained only one set at a time. No full cycle/prevac loads - 4 minute sterilization at 270 degrees and a dry time of twenty (20) minutes - were processed for that day.
ii. On 07/09/13, eight (8) loads, all eye instruments were run on the "Express" cycle, with the first load containing two sets of eye instruments and only one set at a time for the rest of the loads. No full cycle/prevac loads were processed for that day.

2. During the tour of the emergency department(ER), Staff S told the surveyors individuals have presented to the ER with of loose stools or diarrhea. Staff S stated that until it could be proven otherwise, the individual would be regarded as possibly having C-diff and treated as such.
a. The surveyors observed two different types of PDI Sani-cloth Wipes (purple and red tops) on the counters in Exam Room I and outside the door was a spray bottle of Virex 256. None of these products are effective against C-diff.
b. Staff S could not tell surveyors what hospital product would be effective and used to kill C-diff.
c. When the surveyors observed a spray bottle of Dispatch, which is effective against C-diff on a shelf at the back of the ER charting area, Staff S was unaware the product was present.

3. During a tour of the surgical areas, the following observations were made:
a. Staff members were entering the semi-restricted and restricted areas in street clothes and without any protective equipment such as hair covers, gowns or shoe covers. Staff stated this was normal practice when surgeries were not going on and the areas had not been terminally cleaned.
b. Staff stated the surgery department was last operational three days prior to the survey. None of the areas had been terminally cleaned since they were last used.
c. Surgical hair covers, gloves, a flashlight, uncovered paper towels, and hand lotion were stored directly over the surgical scrub sinks and within splashing distance.
d. Two endoscopes had been stored wet for three days in the automatic washer.
e. "Clean" endoscopes were stored in an open cabinet. The back of the cabinet had exposed particle board and could not be cleaned. The bottom of the cabinet held dirty towels. There was dirt, dust and debris in the bottom of the cabinet. None of the scopes were labeled as to when they were last disinfected. The hospital did not have a policy to address reprocessing scopes before use if unused for more than five days.
f. Fabric curtains covered a window inside the procedure suite.
g. Inside the procedure suite, medical gas lines were taped together with silk bandaging tape that could not be disinfected.
h. The anesthesia provider's chair had cracked upholstery that could not be sanitized.
i. Old oxygen tubing was still connected to the anesthesia machine and old suction tubing and a suction tip was still attached to the suction machine in the procedure room from procedures performed three days before.
j. Staff stated there was no policy and procedure to terminally clean the restricted corridor when it had been used as an emergency tornado shelter.
k. Inside the procedure suite, there was a box of three milliliter syringes still in the original cardboard shipping boxes.
l. The high level disinfectant solution test strips were not dated when they were opened.
m.There was no instruction manual provided for the automated scope cleaner. The tech stated she only knew to push certain cycle buttons but was not sure what the cycle actually was.
n. The surgery department had no flash sterilization log, although flash sterilization was used on a regular basis. There were no departmental policies that described flash sterilization cycles.
o. Sterilization loads were not always documented according to national standards of practice. According to the 2012 Association for the Advancement of Medical Instrumentation / Advancing Safety in Medical Technology ST79 American National Standard, "... For immediate use steam sterilization (IUSS) (formerly known as flash sterilization), labels with lot numbers are not used, however, a lot number should be assigned to each IUSS load and a load record should be generated for each sterilization cycle. The load should document:

a) the assigned lot number, including sterilizer identification and cycle number;
b) the general contents of the load
c) the duration and temperature of the exposure phase of the cycle;
d) the signature or other identification of the operator; and
e) the date and time of the cycle...

For each sterilization cycle, the following information should be recorded and maintained:

a) the lot number;
b) the specific contents of the lot or load, including quantity, department, and a specific description of the items (e.g., towel packs, type/name of instrument sets);
c) the exposure time and temperature,if not provided on the sterilizer recording chart;
d) the name or initials of the operator;
e) the results of biological testing, if applicable;
f) the results of Bowie-Dick testing, if applicable;
g) the response of the chemical indicator (CI) placed in the process challenge device, if applicable; and
h) any reports of inconclusive or non-responsive CI found later in the load..."

p. Large items in peel packages were stored on an open shelf in the decontamination room.
q. Items too large, too bulky and too heavy for peel-packaging were processed and sterilized in this manner.
r. Too many items were sterilized together in peel packs. One peel pack contained over thirty metal tracheostomy pieces in one peel pack.
s. Peel packs were not initialed by the person who processed them.
t. Some peel packs did not have a visible internal chemical indicator strip.
u. Some peel packs were dated as processed over a year ago. The hospital had no "first in, first out" policy for the use of sterile supplies.
v. Sterile supplies, still in the original shipping boxes, were opened and stored on the floor in a restricted hallway.
w. Anesthesia breathing circuits were stored in a plastic trash can in a restricted hallway and in another plastic trash can in an area outside of the operating room.
x. Sterile items in peel packs were stored in non-sterile supply areas, in cabinets, on open shelves, in drawers, on counter tops, stacked on top of each other, and stored under shopping bags and various other items in a manner as to compromise integrity.
y. Metal racks in the sterile processing area were designed to allow air circulation to all sides of sterile packages and sterile instrument sets that were removed hot from the steam sterilizer. This would prevent condensation and the potential recontamination of the sterilized items.
The staff had covered the shelves with bedsheets that prevented adequate air circulation. The sheets had evidence of dead insects on them.
z. Instrument sets were not wrapped tightly enough for sterilization and in a manner to adequately protect the items for storage.
aa. A tray of several peel packs was left sitting in the steam sterilizer. It could not be determined how long the items had been left in the warm autoclave.
bb. In the surgical sterile supply storage room, unboxed sterile supplies were stored on shelves next to sterile supplies still in the original, dirty shipping boxes.
cc. Sutures and sterile supplies were stored in the supply room without attention to heat and humidity levels.
dd. Endoscopes were cleaned and processed in a small room with an open hopper.
ee. A single bed recovery room had not been terminal cleaned from the week before. There was trash on the floor. An open hopper stood in one corner of the room, with a toilet brush on the floor next to it. The hopper was immediately adjacent to a counter top where medications should be prepared. The counter top also held a printer and a coffee maker. The hopper was less than six feet from the recovery bed.
ff. A chair at the bedside in the recovery area was upholstered with a material that could not be sanitized.
gg. Throughout the surgical areas, open containers of disinfectant were found stored with the flip-top open. The wipes were dried out and no longer effective for use.

Meeting Minutes:

On the morning of 08/05/13, Staff A told the surveyors that IP meeting minutes were part of the Infections Control and Safety Committee Meeting. The surveyors reviewed the Infection Control and Safety Committee Meeting minutes from November 20, 12 through 07/16/13.

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.

2. The meeting minutes did not demonstrate surgery - preoperative, intraoperative and post-operative, central supply and endoscopy were monitored, reviewed and analyzed with corrective actions taken and follow-up to ensure compliance with accepted standards of practice.

3. The meeting minutes for 02/19/13 documented a patient, positive for tuberculosis, came through the emergency department and although staff wore masks, they were not the correct masks (N-95, respiratory particulate masks). The minutes did not contain:
a. A plan of action for following the employees exposed, including exposure testing;
b. Corrective action and follow-up to ensure staff were trained as to the use of the appropriate mask;
c. Corrective action to ensure adequate supplies were maintained and available for staff use.

4. Concerns/items reported in one meeting minutes were not followed to ensure corrective actions were taken and sustained. Example: equipment, masks and signs instructing individuals/visitors on respiratory/flu responsibilities.

5. The meeting minutes did not contain documentation and review of surveillance/monitoring to ensure IP policies and procedures are followed. Staff C stated on the afternoon of 08/06/13 that, except for one walk-through/rounding, this surveillance was not performed.

6. The meeting minutes did not contain evidence disinfectants used in the hospital had been reviewed for appropriateness and approved for use. The surveyors observed Virex 256 spray, and PDI Sani-cloth Wipes (purple and red tops), and Dispatch spray available for use in the emergency department. Staff C confirmed on 08/06/13 this had not been performed.


IP Training/Education:

1. On the morning of 08/05/13, administrative staff told the surveyors that Staff C was the infection control preventionist.

2. Review of Staff C'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.

3. On the morning of 08/06/13, Staff C provided documentation of IP training in 2011. She stated that was the last time she had any training in IP.

Based on review of hospital documents, review of personnel files and interviews, the hospital failed to have documentation showing all the personnel assigned to the outpatient department (Sleep Study Lab) are qualified and trained, and the department has oversight by a manager.

Finding:

On 8/6/13 in the afternoon, Staff A stated the facility provided sleep study lab services by a contracted employee and hospital employee, Staff H.

There was no evidence, in the personnel file, that Staff H was oriented, trained and competent as a sleep lab technologist.

On 8/5/13, the hospital failed to develop and implement sleep study policy and procedures to direct staff. The surveyors asked Staff A for the policy and procedures for the sleep study lab. None was provided.

Review of the Governing Body meeting minutes showed no evidence that a manger had been assigned to the sleep study lab.

Based on review of personnel files and staff interview, the hospital failed to ensure nursing staff were trained and evaluated on competency to perform the essential functions of their jobs.

Findings:

None of the nursing staff employee records had skills verification in respiratory care including breathing treatments, oxygen set-up and administration performed by a respiratory therapist as required by State Hospital Licensure Standards. This was confirmed by Staff C on 8/6/13 at 1:50pm.

The hospital did not provide skill verification for seven of nine clinical employee records reviewed.

Personnel records were reviewed for registered nurses who provided conscious sedation. None of the records documented annual training and competency evaluation to perform this level of patient care. There was no documentation the nurses had ACLS certification as required by the hospital ' s policy for those nurses who provide conscious sedation.

Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to ensure that a registered nurse (RN) supervised and evaluated the nursing care for twenty (#22 through #31 and #39 through #48) of twenty emergency department (ED) patient records reviewed.

Findings:
1. On 08/06/13, a hospital policy titled, "Assessment of the Emergency Department Patient ," documented, "... all patients admitted to the Emergency Department will have the following documentation...response to medication..."

Eleven (#23, 24 through 28, 30, 39, 41, 43, 44, and #48) clinical records reviewed had no documented evidence of pain levels assessed before and after pain medication administration for patients with complaints such as chest pain, trauma, abdominal pain, flank pain, snake bite, and end stage cancer.

2. On 08/06/13, a hospital policy titled, "Standard of Care-Chest Pain or Myocardial Infarction," documented, "... arrives at the Emergency Department with chest pain ... Documentation shall include, but is not limited to: time of onset, severity of pain on 1-10 scale, provocation, location, description of pain..."

Of three (# 30, 43, and #48) clinical records reviewed for patients with chest pain, none of the records documented evidence that patient pain assessments were completed before or after treatments provided in the ED.

3. On the afternoon of 08/06/13, Staff S stated, "We are supposed to document the patient responses to pain, treatments, and medications."

4. On the morning of 08/05/13, the surveyors asked the Health Information/Business Office Manager if the surveyors had been given complete medical records. She stated, "Yes, there are no other documents available."

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

a. properly executed informed consents for five (#2, 32, 33, 34 and #38) of ten records reviewed for informed consents;
b. discharge summaries for two (#11 and #12) of nine records reviewed for discharge summaries;
c. nursing assessments for six (9, 10, 14, 15, 16 and #17) of nine records reviewed for nursing assessments; and
d. failed to ensure all clinical records documented a nursing care plan for two (#10 and #17) of nine records reviewed for nursing care plans.

Findings:

On 08/06/13, clinical records were reviewed for required documentation.

1. The clinical for patient #2 documented the patient consented to the use of blood products. The physician had not signed the consent form.
2. The record for patient #32 did not have an informed consent documented in the medical record.
3. The informed consent for patient #33 was not signed by the physician.
4. The informed consent for patient #34 was not signed by the physician. An anesthesia consent form for the patient was not signed by the anesthesia provider.
5. The anesthesia consent form for patient #38 was not signed by the anesthesia provider.
6. Although the informed consent for surgical procedures form required patients to sign for the acceptance or the declination of blood and/or blood products, the staff did not have the patients sign this portion of the form.
7. Clinical records for patients #11 and #12 had no documentation of a discharge summary that contained information about the patient ' s stay, the disposition of the patient and the instructions for aftercare.
8. A hospital policy, titled, " Medical-Surgical Scope of Care, " documented, " ... Re-assessments are done every twelve hours and documented in the medical record ... " The clinical records for patients #9, 10, 14, 15, 16 and #17 were missing nursing assessments every twelve hours. Some records were missing nursing assessments for a 24 period.
9. The clinical records for patient #10 and #17 had no documentation of a nursing care plan.
10. When the health information manager was asked if the surveyors had been given complete medical records, she stated, " Yes, there are no other documents available. "

Based on policy and procedure review, clinical record review and staff interview, it was determined the hospital failed to ensure emergency department (ED) patient medical records contained sufficient information in order to monitor the patient's condition and to ensure adequate care for twenty (#22 through 31 and #39 through 48) of twenty records reviewed.

Findings:
1. On 08/06/13, a hospital policy titled, "Assessment of the Emergency Department Patient," documented, "... all patients admitted to the Emergency Department will have the following documentation... response to medication..."

Eleven (#23, 24 through 28, 30, 39, 41, 43, 44, and #48) clinical records reviewed, had no documented evidence of pain levels assessed before and after pain medication administration for patients with chest pain, trauma, abdominal pain, flank pain, snake bite, and end stage cancer.

2. On 08/06/13, a hospital policy titled, "Standard of Care-Chest Pain or Myocardial Infarction," documented, "... arrives at the Emergency Department with chest pain ... will receive the following care... Documentation shall include, but is not limited to: time of onset, severity of pain on 1-10 scale, provocation, location, description of pain..."

Three (# 30, 43, and #48) clinical records reviewed for chest pain patients, had no documented evidence that patient pain assessments were completed before or after treatments provided in the ED.

3. For twenty (#22 through #31 and #39 through #48) clinical records reviewed, none had documented evidence of nursing assessments of patients' responses to treatments.

4. Sixteen (#22, 24, 25, #27 through #31, #39 through #44, 47, and #48) clinical records reviewed, had no documented evidence intravenous (IV) assessments were completed after insertion, infusion, and completion of IV medication therapy for patients with chest pain, traumas, abdominal pain, flank pain, snake bite, diabetes, weakness, difficulty breathing, facial swelling, and end stage cancer.

5. On 08/06/13, a hospital policy titled, "Emergency Medical Conditions," documented, "... The physician must countersign the certification to transfer... "

Five (# 22, 27, 30, 41, and #46) clinical records reviewed for patients who were transferred had no documentation the physician countersigned the certification of transfer form.

6. On 08/06/13, a hospital policy titled, "Reporting Animal Bites," documented,
"... Utilize" Animal Bites Form"... "

One (#27) clinical record reviewed for a patient with an animal bite had no documentation the Animal Bites form was used or the animal bite was reported to County Health Department.

7. On 08/06/13, a hospital policy titled, "Patient Identification," documented, "... Any patient who has an allergy to a medication will receive a RED identification bracelet... This will be applied to the patient's wrist..."

Twenty (#22 through #31 and #39 through #48) records reviewed had no documentation allergy bands were applied in the ED. Clinical records indicated patients had allergies listed in their medical records. The electronic health record (EHR) and the printed records required the documentation of allergy band application.

8. On the afternoon of 08/06/13, Staff S stated, "We are supposed to apply allergy bands and document it, as well as the responses of pain, treatments, and medications."

9. On the morning of 08/05/13, the surveyors asked the Health Information/Business Office Manager if the surveyors had been given complete medical records. She stated, "Yes, there are no other documents available."

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 three of three records (#10, 11, and 15) reviewed for completed entries.

Findings:

Record # 10- the written Discharge Summary did not contain the date and time the physician signed/authenticated the dictated document. Physician orders written on 6/28/13, 6/2913, 6/30/13 did not contain the time the physician wrote the order.

Record # 11- Two physician orders written on days 6/27/13 and 6/28/13 did not contain the time the physician wrote the order.

Record #15- Physician orders written on 6/5/13 did not contain the time the physician wrote the order.

The findings were reviewed with administrative staff on the afternoon of 8/6/13.

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

a. perioperative services were supervised by an experienced staff member;

b. policies and procedures were developed and implemented according to nationally recognized standards of practice;

c. history and physical examinations were performed within the required time frame before surgery;

d. informed consent was obtained for all patients prior to surgery;

e. conscious sedation was provided by qualified, trained and deemed competent registered nurses;

f. post-operative care was provided according to acceptable standards of practice;

g. surgical care was provided in a clean and safe environment. See also Tags C-0220, C-0221, C-0222, C-0223, C-0224, C-0225, C-0226, C-0231 and LSC Survey K Tags;

h. sterilization and high level disinfection were provided according to accepted standards of practice. See also Tag C-0278;

i. sterilized materials were handled and stored appropriately. See also Tag C-0278;

j. surgical staff had a current roster listing of each practitioner's surgical privileges, privilege suspension or restrictions. See Tag C-0321;

k. pre-and post anesthesia evaluation was performed for all surgery patients. See Tag C-0322; and

l. the hospital failed to ensure all patients were discharged in the care of a responsible adult. See Tag C-0325.

Findings:

On 08/05/13 and 08/06/13, observations were made of the pre-operative area, the surgical area and the recovery room. Hospital policies and procedures were reviewed. Staff employment and training files were reviewed. Surgical patient records were reviewed.

1. The administrator stated the surgery manager supervised the surgery department, sterile processing and the pre-operative and recovery areas. The personnel file for the surgery manager was reviewed. There was no documentation of prior surgery experience, specific surgery training or certification. There was no documentation of experience and training in the areas of recovery and sterile processing.

There was no job description and no documentation of orientation to the areas the surgery manager supervised. While the file had current generic annual hospital training, there was no documentation of department specific training. There was no evidence of evaluation of job-specific competencies.

There was no documentation the surgery manager was affiliated with any perioperative professional organization, was mentored by an experienced surgery manager or received any relevant continuing education in the areas she supervised.

There was no documentation of the manager had current certification in CPR, PALS, or ACLS certification. There was no documentation of conscious sedation training and competency, although the manager was required to performed all these functions.

None of the other staff members in the perioperative areas had documentation of job descriptions, department specific orientation and training, competency evaluation or on-going continuing education in their areas.

2. The hospital did not have the policies to address:
a. reprocessing scopes before use if unused for more than five days.
b. periodic deep cleaning of all surgical areas. There were no policies for general housekeeping in the pre-op, recovery, decontamination and sterile processing areas.
c. use of the steam sterilizer and automatic endoscope processor.
d. nursing assessment in the recovery room
e. use of Rapicide, the high level disinfectant used in the surgery department, as no product information was available as referenced in the policy
f. department-specific infection control surveillance
g. all decontamination processes
h. instrument care, cleaning, wrapping, packaging and processing
i. aseptic techniques
j. specific surgical procedure protocols
k. involvement of the surgery department in the QAPI process

None of the policies currently used by the hospital had evidence the information contained within was based on nationally recognized standards. Some of the policy information was not applicable or did not match what was actually done in the surgical areas.

While some policies were comprehensive in scope and gave appropriate guidance, there was evidence through surveyor observation that policies were not followed.

The surgical department did not have any nationally recognized reference manuals for surgical services, perioperative nursing, decontamination, high level disinfection and sterile processing.

There were no manufacturer's instruction manuals for the steam sterilizer, the automated endoscope processor or the sonic instrument washer.

3. Three (#32, 33 and #34) of seven patient records reviewed for timely history and physical examinations (H&P) did not have and H&P examination within 30 days of surgery.

4. Four (#32, 33, 34 and #38) of seven patient records reviewed for surgery and anesthesia consents documented the following:

a. The record for patient #32 did not have an informed consent documented in the medical record.
b. The informed consent for patient #33 was not signed by the physician.
c. The informed consent for patient #34 was not signed by the physician. An anesthesia consent form for the patient was not signed by the anesthesia provider.
d. The anesthesia consent form for patient #38 was not signed by the anesthesia provider.
e. Although the informed consent for surgical procedures form required the patients to sign for the acceptance or the declination of blood and/or blood products, the staff did not have the patients sign this portion of the form.

5. Clinical records documented conscious sedation was provided by registered nurses. The nurses' files had no documentation of annual training and competency to provide this level of care. Some of the nurses providing conscious sedation did not have evidence of ACLS certification or of basic ECG interpretation.

6. Patients were recovered in a room not originally designed as a recovery room. The room did not have emergency power from the critical care branch. The room had an open hopper in the corner of the room within six feet of the recovery bed.

Because the recovery room had only a single bed, it could not be determined how multiple patients were recovered at the same time. For instance, there were occasions when the operating room register documented 16 or 17 patients received eye surgery in a six hour period. The register showed 12 -15 minute turnover time between patients, indicating that more than one patient had to be "recovered" at the same time.

In addition, there were days when multiple endoscopic procedures were done with minimal turnover time. These patients required a longer recovery period than eye cases. Based on the times documented on the OR register, the patients would have to be recovered during periods of time that overlapped.

The staff did not identify any other "recovery" room in the facility. On a tour of the department, the surveyors noted there was no other space that met the requirements of a recovery room. The staff who accompanied the surveyors on the tour had no information about how the surgical services patient flow was handled.

~ Seven patient records (#32 - #38) were reviewed for post-anesthesia care. The records contained standing recovery orders that included discharge criteria. All records documented the patients were recovered and discharged within 35-45 minutes post-procedure, irregardless of the patient's age, physical condition or surgical procedure performed.

Patient #37 had a diagnostic laparoscopy that then required an "open" laparotomy. The patient was under general anesthesia for two hours and ten minutes. The clinical record documented the patient was discharged home 45 minutes after surgery.

In all cases, documentation indicated the nursing assessment and the decision to discharge the patient home, was based entirely on an Aldrete score. (The Aldrete score is a criteria used to determined a safe discharge from the recovery area to the next level of nursing care and is not intended to solely determine the patient's condition for safe discharge home.)

For example, the recovery nursing documentation did not include the patient's ability to remain awake for 20 minutes without stimulation, ability to sit, stand or walk, the ability to answer questions appropriately, the ability to take oral fluids, the ability to void and other indicators the patient could return home safely.

None of the records documented the patients received comprehensive assessments at the beginning of the recovery period and then again immediately prior to discharge.

None of the records had documentation of recovery nursing assessments that were relevant to the patient's specific surgical procedure. For example, patients who had an EGD (esophagogastroduodenoscopy) were not assessed for swallowing, bloating, coughing, among others. Colonoscopy patients were not assessed for bloating, abdominal tenderness, the ability to expel gas, etc.

Patient #37 (diagnostic laparoscopy/laparotomy) had no nursing assessment related to the patient's surgical procedure except documentation the patient's dressing was "clean, dry and intact." The document did not specify where the dressing was or what type. There was no documentation of assessment of the patient's abdomen or other body systems.

Other findings related to post-operative care included:

Patient #32: The record had no documentation of the amount of IV fluid the patient received in recovery. There were no discharge vital signs recorded. There was no documentation of the patient's destination at discharge and who the patient left with.

Patient #33: The record had no documentation of who drove the patient home and no documentation of discharge instructions.

Patient #34: There was no documentation of the patient's destination at discharge and who the patient left with. There was no documentation of discharge instructions.

Patient #35: There was no documentation of who the patient left with at discharge.

Patient #36: The record had no documentation of the amount of IV fluid the patient received in recovery. There was no documentation of the patient's destination at discharge and who the patient left with.

7. A review of the OR register indicated that when eye cases were scheduled, there were as many as 16-17 cases done in a six hour period. The hospital only had one OR suite available. It was not possible to turnover the OR suite thoroughly (cleaning and preparation) when the records indicated there was only 12-14 minutes in between cases.

At the time of survey, all surgical areas were cluttered and not maintained in a clean or aseptic manner. Housekeeping and general routine maintenance of the areas was not performed. There were no schedules or requirements for cleaning between patients, terminal cleaning at the end of the day and deep cleaning on a routine basis.

Rooms had been modified to change functionality and did not conform to accepted standards for the design and construction of surgical areas.

The location and storage of equipment and supplies did not conform to national standards for the surgical areas.

Temperature, humidity and air exchanges were not monitored and maintained in a manner to prevent the growth and spread of microorganisms.

Department equipment was not routinely maintained or repaired.

Emergency equipment and supplies were not available in all areas where surgery was performed.

Drugs and biologicals were not secured and stored appropriately.

8. Surgical instruments were not cleaned and sterilized appropriately. There were no policies and procedures to guide staff on these processes. There were no equipment manuals and manufacturer's instructions available to staff for the sterilizer and the endoscope processor. There was no documentation that indicated these pieces of equipment were serviced and maintained as required. Adequate records were not kept of sterilization loads and of high-level disinfection cycles.

Staff stated eye sets were routinely processed using the "immediate use cycle." We asked to clarify that they were referring to "flash" sterilization. The tech stated, "No, it's not flash. It is just a shortened cycle."

9. Items for sterilization were not wrapped or packaged appropriately. Not all sterile packages had clear indication they were actually "sterile" because the hospital did not use chemical indicator tape and the inside indicator could not always be seen. Once processed, sterile instruments and supplies were not stored appropriately.

Endoscopes were not stored appropriately. They were not reprocessed when unused for five days.

There was no documentation of staff orientation, training and competency for decontamination processes, high-level disinfection and sterilization.

Based on document review and staff interview, it was determined the hospital failed to maintain a current roster with each practitioner's specific surgical privileges available to the surgery department and in the area where surgeries are scheduled.

Findings:

On 08/06/13, OR staff were asked to provide this information. They stated it could not be located. The staff stated they also did not have any written information on practitioners with suspended or restricted privileges.

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

a. a qualified practitioner performed a pre-anesthesia risk evaluation; and

b. failed to ensure a qualified practitioner performed an anesthesia recovery evaluation for two (#32 and #38) of seven surgical records reviewed.

Findings:

A hospital policy, titled "Anesthesia Pre-Operative Requirements," documented, "... The ASA [American Society of Anesthesiologists] class assigned will be assigned by the Anesthesia provider, or the surgeon if no anesthesia provider is to be present during a local procedure... All patients who are undergoing operative and/or invasive procedures requiring anesthesia require assessment for clinical stability prior to the procedure..."

A hospital policy, titled "Post-Operative Anesthesia Care," documented, "... A licensed independent practitioner will document in the medical record the discharge of the patient from the PACU [post anesthesia care unit], when the patient's condition is stable and the patient meets the PACU discharge criteria (Aldrete Scoring System). At least one post-anesthetic visit will be recorded, describing the presence or absence of anesthesia related complications... The date and time of each visit will be specified... The attending physician who discharges the patient will be responsible for meeting the same requirements..."

1. The clinical record for patient #32 had no documentation of an anesthesia risk assessment or ASA designation prior to surgery.

2. The clinical record for patient #38 had no documentation of a post-anesthesia risk assessment or ASA score prior to surgery. There was no documentation of a post-anesthesia visit.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure all patients were discharged in the company of a responsible adult for five (#32, 33, 34, 35 and #36) of seven surgical records reviewed.

Findings:

The clinical records for patients #32, #33, #34, #35, #36 had no documentation of who the patient left the hospital with.

The administrator stated there were gaps in documentation.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital has an effective quality assurance program that collects data, analyzes the data and implements corrective action. The quality assurance meeting minutes for 2012 and 2013 provided for review did not have analysis of any data that was collected and no evidence of the implementation of any corrective action taken.

Findings:

1. The Quality Indicator Report for the three quarters from October 2012 through June 2013 documented the following:

a. Surgery/Recovery Room indicators only had data (numbers) no analysis of what the numbers signified.

b. The only Infection control indicator documented only had numbers of MRSA (methacyline resistant Staph Aureas) ER (emergency room ) wounds and no analysis of what the numbers signified.

c. An indicator listed a patient complaints just had the number of complaints each month, but no analysis of the types of complaints that were lodged from the patients and whether they could be used to improve quality of care.

d. Maintenance documented an indicator Generator Test and batteries. The indicator reports just had dates of testing. There were no results of the testing and whether there was any problem.

e. There was no evidence of indicators for Central Sterile processing.

f. There was no evidence of any review of the organ procurement program by the quality assurance program.

Based on review of the hospital's death register, other death lists provided by the hospital, medical records, and the referral reports from the OPO (organ procurement organization - LifeShare of Oklahoma) for the time period of January 2012 through August 2, 2013, and interviews with hospital staff, the hospital failed to ensure:

a. All deaths were reported to the OPO. The hospital does not have a system in place to ensure all deaths are reported.

b. Incorporate organ procurement activities into the quality assessment and performance improvement (QAPI) program.

Findings:

1. The death register provided to the surveyors on 08/05/13 did not contain all the deaths that occurred in the hospital during the above mentioned time period. Staff Q stated, on 08/05/13 at 1600, that when she was hired she noted that not all deaths were being recorded in the register and so she ran her own list of deaths and highlighted the 2012 deaths that occurred.

2. OPO referral reports did not show all deaths recorded on the both hospital lists were reported to the OPO. When this was discussed with Staff Q on 08/06/13, she said she thought the death list provided to the surveyor contain names of individuals that did not die at the hospital.

3. The third list provided to the surveyors on 08/06/13, listed three deaths that were not listed on the OPO activity referral reports. Staff Q did not produce documentation to show two of the deaths had been reported to the OPO.

4. Review of hospital QAPI meeting minutes did not demonstrate organ procurement activities and program was part of the QAPI program. This was reviewed with administrative staff on 08/06/13.

Based on observation, clinical record review and staff interview, in three of three swing bed records reviewed, there was no evidence that activities were provided for swing bed patients.

Findings:
Although there was an activities schedule for swing bed patients, there was no evidence of activities being provided to swing bed patients.
The Surveyor attempted to talk with the activities director who was not available at the time of the survey. No staff was able to provide information regarding activities being provided.