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Based on review of facility agreements, QAPI meeting minutes, and staff interview, the facility failed to ensure an outside entity reviewed the facility credentialing and QAPI. The findings were:

Review of facility agreements, contracts, and QAPI minutes showed no agreement with an outside source related to monitoring credentialing or QAPI. During an interview with the administrator on 5/2/13 at 8:50 AM, she confirmed the facility failed to ensure an outside entity reviewed credentialing, QAPI, or medical records.

Based on medical record review, facility policy and procedure review, and staff interview, the facility failed to follow their policy and procedure to provide adequate care to 1 of 1 newborn patient (#1). The findings were:

1. Review of the emergency room record for patient #1 showed she was admitted to the emergency room on 12/12/12 at 4:05 AM in active labor with delivery imminent. The patient delivered a baby boy after "pushing" twice. The review showed the mother and newborn were transferred to another hospital via ambulance, and the facility failed to document an assessment for the newborn. Review of the emergency report, signed by physician assistant #1, stated, "No APGAR [an assessment of appearance, pulse, grimace, activity, and respirations] score was done on this baby, but baby was cleaned up and wrapped in warm blankets."

2. Review of the facility policy and procedure titled, "Emergency Management of OB Patient" issued 5/16/00, showed, "H. Mother and infant can be safely transferred after: ... 3. Infant: a. Patent airway, b. Patent airway without respiratory distress, c. Assessment of Apgar score at 1 and 5 minutes. I. Document initial assessment of emergency delivery course and condition of mother and newborn after delivery."

3. Interview with the administrator and DON on 5/1/13 at 9 AM confirmed facility staff failed to follow their policy and procedure for patient #1's newborn after delivery and subsequent transfer.

Based on policy and procedure review and staff interview, the facility failed to ensure policies and procedures were developed with the advice of physicians, physician assistants, nurse practitioners, clinical nurse specialists, and a policy reviewer not on the staff of the CAH. The findings were:

Review of the facility policies and procedures showed one policy was developed by the DON in 2013 to guide nursing staff on giving end of shift report. All other policies were dated before the last survey on 9/3/09, most being dated on various months in the year 2000, and all without revisions or indications of review since. Two examples found during the review were as follows: 1. "Emergency Management of OB Patient" issued 5/16/00, which contained no revisions or indications of review since issued, and 2. "Medical Records" issued 5/16/00 which also contained no revisions or indications of review since issued. During an interview with the administrator and DON on 5/1/13 at 9 AM, they both acknowledged that no nursing or administrative staff members, members of the medical board including mid-level practitioners, and no outside professional reviewed or revised policies and procedures. The administrator stated that an outside physician assistant used to review policies and procedures annually, but that had been "several years" ago.

Based on observation, staff interview, and review of facility policy, the facility failed to assure the pharmaceutical services contract was current. In addition, the facility failed to assure all medication orders were reviewed for appropriateness by a registered pharmacist. The findings were:

Observation of the facility electronic medical record system on 5/1/13 at 10:48 AM revealed patient medications were analyzed for possible negative interactions by the computer system. Interview with the facility DON at that time revealed the facility electronic medical record system had the capability to compare patient medications for possible interactions and would raise questions in the event of possible negative drug interactions. The DON also stated the facility consultant pharmacist would only review prescribed medications in the event the nursing staff had a question about or if the computer system raised an issue with possible negative medication interactions.
Review of the current facility consulting pharmacist services agreement on 5/1/13 at 11:23 AM revealed the consultant pharmacist shall be responsible for reviewing "each hospital patient's drug regimen and submit a report of findings to medical director and administration". Further review of the agreement and interview with the facility administrative assistant on 5/1/13 at 1:23 PM revealed the consultant pharmacist listed on the agreement had retired "several years ago" and another pharmacist was currently serving in that capacity. She confirmed the existing contract was out of date and needed to be revised.

Based on policy and procedure review and staff interview, the facility failed to ensure policies and procedures were reviewed by a group of professionals. The findings were:

Review of the facility policies and procedures showed one policy was developed by the DON in 2013 to guide nursing staff on giving end of shift report. All other policies were dated before the last survey on 9/3/09, most being dated on various months in the year 2000, and all without revisions or indications of review since that time . One example in the review was the facility policy and procedure titled, "Emergency Management of OB Patient" issued 5/16/00, which contained no revisions or indications of a review since it was issued. During an interview with the administrator and DON on 5/1/13 at 9 AM, they both acknowledged that no nursing or administrative staff members, members of the medical board including mid-level practitioners, and no outside professional reviewed or revised policies and procedures. The administrator stated that an outside physician assistant used to review policies and procedures annually, but that had been "several years" ago.

Based on review of medical records and staff interview, the facility failed to ensure care plans were developed for 2 of 20 sample patients (#2, #21): The findings were:

1. Review of the medical record showed patient #2 was admitted to the facility on 3/17/13 with diagnoses of chest pain, diabetes mellitus type II, benign prostatic hypertrophy, peripheral neuropathy, and congestive heart failure. Further review showed the facility failed to initiate a care plan for the patient.

2. Review of the medical record showed patient #21 was admitted to the facility on 3/23/13 with diagnoses of malignant neoplasm of the bronchus, asthma, and chronic obstructive pulmonary disease. Further review showed the facility failed to initiate a care plan for the patient.

3. During an interview with the DON on 4/29/13 at 4 PM, he stated that if information in the electronic medical records was not there, then it was not completed. During an interview with the administrator and DON on 5/1/13 at 9 AM, they acknowledged the electronic medical record system was not utilized correctly by all facility staff, and some required documentation was absent.

Based on medical record review, review of Medical Staff Bylaws, review of facility policy and procedure, and staff interview, the facility failed to ensure the medical records were complete. History and physical (H&P) examinations were not in the medical records of 2 of 20 sample patients (#9, #14). Also, physician progress notes were not in the medical record for 1 of 20 sample patients (#2). The findings were:

1. According to the Medical Staff Bylaws last approved in 2009, a complete medical record for each patient shall include the following items when applicable: "1. Medical Record Components: B. History and Physical: A history and physical examination (H&P) may be either handwritten or dictated; however, a dictated report is preferred. H&P should be completed within 24 hours after admission of any patient." Failure to complete H&Ps as required was identified in the following circumstances:
a. Review of the medical record showed patient #9 was admitted on 3/5/13. Review of the entire medical record showed there was no H&P.
b. Review of the medical record showed patient #14 was admitted on 2/20/13. Review of the entire medical record showed there was no H&P.
c. Interview with the medical records manager on 5/1/13 at 3:30 PM showed the 2 facility physicians did not document in the electronic medical record system, and chose to dictate H&Ps. She further stated that the H&Ps do not always get transcribed in a timely manner.

2. According to the Medical Staff Bylaws last approved in 2009, a complete medical record for each patient shall include the following items when applicable, "1. Medical Record Components: D. Progress Notes: ...1. There shall be pertinent progress notes recorded by a physician (or by the approved physician designee) at regular intervals during the patient's stay. All such notes shall be timed, dated, and signed by the patient's physician. Progress notes shall be written daily for all inpatients to permit continuity of care and transferability." Failure to complete physician progress notes as required was identified in the following circumstance:
a. Review of the medical record showed patient #2 was admitted on 3/7/13. Review of the entire medical record showed there were no physician progress notes.
b. Interview with the medical records manager on 5/1/13 at 3:30 PM showed the 2 facility physicians did not document in the electronic medical record system, and chose to dictate progress notes. She further stated that the progress notes do not always get transcribed in a timely manner.

3. According to the facility policy and procedure titled, "Medical Records" issued 5/16/00, "...4. Records of a discharged patient shall be completed within 15 days of the discharge date."

Based on medical record review, staff interview, and review of medical staff policies and procedures, the facility failed to ensure patient documentation (discharge summary and/or advanced directives) was completed for 7 (#4, #8, #12, #16, #18, #19 and #20) of 20 patients. The findings were:

1. Electronic medical record review showed patient #8 was admitted on 3/2/13 for back pain. The patient was transferred to a swing bed on 3/5/13. Review of the patient record revealed there was no discharge summary from acute care into swing bed status. Review of the discharge summary section of the acute care record actually stated "Patient not yet discharged."

2. Medical record review showed patients #4, #12, #16, #18, #19, and #20 were all admitted as acute care patients. Review of the medical records for all six patients revealed none of them had advanced directives. Interview with the DON on 5/1/13 at 2:48 PM revealed if the electronic medical record did not contain advanced directives, they did not exist.

Based on medical record review, review of facility policy and procedure, and staff interview, the facility failed to ensure the signatures of physicians were obtained concerning a variety of documents/orders for 20 of 20 sample patients (#2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22). The findings were:

Review of the medical records for patients #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, and #22 revealed physician signatures were lacking when physicians dictated various transcribed reports and telephone and verbal orders, including orders written by the two mid-level practitioners at the facility. Interview with the medical records manager on 5/1/13 at 3:30 PM showed the 2 facility physicians did not document in the electronic medical record system, and do not apply electronic signatures. She further stated that the documents and orders that require physician signatures do not routinely get printed for manual signatures. During an interview with the DON on 4/29/13 at 4 PM, he stated that if information in the electronic medical records was not there, then it was not completed. During an interview with the administrator and DON on 5/1/13 at 9 AM, they acknowledged the electronic medical record system was not utilized by physicians, and physician documentation was not electronically signed by the physicians.

According to the facility policy and procedure titled, "Medical Records" issued 5/16/00, "...3. Each record shall include the dated signatures of the physician and the health care professional's documentation." According to the facility policy and procedure titled, "Telephone Orders from Practitioners" issued 5/16/00, " Upon receiving a verbal order, a licensed nurse, shall write the order in the physician orders........Practitioner shall physically sign order within 24 hours of giving licensed nurse the verbal order."

Based on review of quality assurance (QA) meeting minutes, review of CMS-2567 with plan of correction dated 9/3/09, and staff interview, the facility failed to ensure their QA program monitored all departments of the facility to identify and correct concerns. The findings were:

Review of the CMS-2567 dated 9/3/09 showed the facility was cited at C-336 for failure to implement an effective facility-wide program. The corresponding plan of correction with a date of correction of 10/3/09 included the following, "This facility will ensure that there is an effective quality assurance program to evaluate appropriateness of the diagnosis and treatment outcomes....2) Admininstration will identify all departments and contract services and work with each to establish quality indicators, benchmarks, action plans, and goals." The following concerns were identified:
a. Review of the facility QA meeting minutes for 10/4/12, 11/8/12, 12/3/12, and 1/10/13 showed the facility failed to establish effective quality indicators, benchmarks, goals, or action plans for some departments in the facility, including medical records, nursing, and the emergency department.
b. During an interview with the administrator on 5/2/13 at 8:50 AM, she acknowledged the facility QA program did not monitor, review, or set goals for all departments of the facility. She further acknowledged the facility failed to monitor the electronic medical record system utilized by the facility since November 2012, and the policies and procedures which were not updated since the year 2000 (13 years ago).

Based on medical record review, review of quality assurance (QA) meeting minutes, review of the prior CMS-2567 dated 9/3/09, and staff interview, the facility failed to implement a facility-wide program which included monitoring and data collection for all departments, establishment of indicators and benchmarks (goals), develop and implement action plans, and revise those plans when departments failed to reach specified goals. The findings were:

Review of the facility CMS-2567 dated 9/3/09 showed the facility was cited at C-337 for failure to include in their QA program all services that affect patient health and safety. The corresponding plan of correction with a date of correction of 10/3/09 included the following, "This facility will ensure the quality assurance program requires that all patient care services and other services affecting patient health and safety are evaluated....b.) Administrator will work with Director of Nursing to determine hospital quality indicators and benchmarks to include deficiencies noted during this survey." The following concerns were noted:
a. The following citations were written on the 9/3/09 survey, and current concerns in those areas have been identified during medical record review, policy and procedure review, and QA meeting minutes review: C-272, C-280, C-298, C-302, C-304, C-307, C-336, C-337, and C-361.
b. During an interview with the administrator on 5/2/13 at 8:50 AM, she acknowledged that the facility failed to correct some of the deficiencies cited on the 9/3/09 survey, failed to monitor the electronic medical record system utilized by the facility since November 2012, and failed to ensure those medical records were complete and accurate. She also stated that, while emergency room (ER) data was collected, the QA program failed to monitor, identify concerns, and set goals for the emergency room. She acknowledged the facility had not identified concerns regarding a full term delivery of a newborn in the ER on 12/1/12, that were identified by the surveyors (facility failure to perform APGAR [assessment of appearance, pulse, grimace, activity, and respirations] scores on the newborn). She further acknowledged the facility failed to review and/or update the policies and procedures annually, and failed to obtain an outside professional to review policies and procedures, and the QA program.

Based on medical record review and staff interview, the facility failed to ensure the residents were informed both orally and in writing of their rights for 2 of 2 sample swing bed residents (#8, #9). The findings were:

Review of the medical records for swing bed residents #8 and #9 showed no documentation to show either resident was informed of his/her rights. During an interview with the administrator and DON on 5/1/13 at 9 AM, they acknowledged the electronic medical record system, utilized by the facility since November 2012, had no place to document patient/resident rights, and they could not be certain either swing bed resident received them.