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Based on observation and interview the CAH failed to ensure the condition of the hospital environment were maintained and all patient care equipment had current preventative maintenance and testing.

This failed practice had the potential risk to increase patient and/or staff injury.

Findings:

1. See deficient practices cited under the Life Safety Code K-tags.

2. Multiple water spots were observed throughout the facility and broken light covers were observed in laboratory. Several electrical receptacles were observed too close to water sources.

3. Central Supply located in an area with exposed pipes.

4. During the tour of the radiology department, surveyors observed:
~ a portable X-Ray with expired preventative maintenance (PM) due 11/16.
~ Vital sign machine PM expired on 02/17.

5. Several storage areas were observed with supplies/items stacked up to the ceilings.

On 06/06/17 at 11:21 AM, Staff E stated a contracted service were on site monthly to complete preventative maintenance and testing equipment.

See Life Safety Code K- tags & tag C-0276

See Life Safety Code K- tags, tag C-0222 & C-0278

Based on record review and interview, the hospital failed to determine, implement, and monitor policies for the administration of quality patient care in a safe environment.

This failed practice had the potential to affect all current patients due to the lack of policies for determination of quality of care.

Findings:

A document titled "Executive Board of Director Meeting Minutes- May Regular Board Meeting Minutes" dated 06/05/17 contained no documentation of a review of policies and procedures.

A document titled "Total Annual Program Evaluation" dated December 2016 contained no documentation of policies and procedures for the QA/PI program or the evaluation of policies and procedures for the QA/PI program.

On 06/09/17 at 3:35 pm, Staff E stated there was no system in place for investigating incidents, creating a performance improvement plan, or evaluating the reoccurrence of similar incidents, and any actions taken would be documented in "Closing Remarks" in SQSS; and reported being unaware of any policies or procedures and did not have any policies or procedures to give the surveyors for review.

Based on record review and interview the hospital failed to:

A. Ensure Emergency Department policies were reviewed and approved by governing body.
B. Ensure Nursing Department policies were reviewed and approved by governing body.
C. Ensure Swing Bed policies were reviewed and approved by governing body.

This deficient practice had the potential to affect all patients admitted to the hospital.

Findings:

A. Emergency Department

On 06/06/17 at 10:40 am, surveyors requested all current policy and procedures for the hospital's emergency department. Staff R presented surveyors with a three ring binder contained a title page that read "Emergency Room Policy and Procedure Manual". The printed effective dates of these policies was 08/26/2014 - 08/26/2015.

On 06/08/17 at 1:30 pm, Staff R stated the provided policies were being revised but were the current policies followed by the Emergency Department. No current documents were provided.

On 06/09/17 at 3:50 PM, Staff R stated a second time that the policies provided were the current policies being used by the ER staff.


B. Nursing Department

On 06/07/17 at 10:45 am, surveyors made a second request for the current policy and procedure manual for the Nursing Department. The policies provided were signed by the Medical Director, Chief Executive Officer and Director of Nursing on 02/28/17. A member of the Governing Body signature was added on 04/19/17.

The signature page in the Nursing policy and procedure manual did not specify which policy numbers had been reviewed and approved. None of the policies within the manual had review or acceptance dates that matched the dates listed on the signature page.

On 06/09/17 at 2:45 pm, Staff B stated she could not confirm which policies specifically had been reviewed and accepted by the governing body.

C. Swing Bed

On 06/06/17 at 10:40 am, surveyors requested policy and procedures for the hospital's Swing Bed program.

A three ring binder titled "Swing Bed Program" which had policies that had not been reviewed since 05/19/97.

On 06/09/17 at 2:50 pm, Staff B stated that there were no up-to-date policies for the Swing Bed Program and that she was aware that they were in need of review, revision and approval by the governing body.

Based on record review, observation, and interview, the CAH failed to:

a. ensure outdated medications were not available for patient use.
b. ensure medications are secure at all times.

These failed practices had the risk of un-authorized persons gaining access to and improper accounting of medications and the effectiveness of medications.

Findings:

A.

A hospital policy titled " Drug Inventory Control" documented expired medications would be removed from drug storage areas within the hospital during the pharmacy inspection performed monthly.

On 06/06/17 at 11:21 AM, surveyor observed the following items outdated:

~ a crash cart located in emergency room 2 which contained nitroglycerin intravenous piggyback (IVPB) with an expiration date of 04/17.

~ 9 bags of Lactated Ringer's in 5% Dextrose 1000 milliliter Intravenous (IV) fluid had an expiration date of 03/01/17.

~12 Lactated Ringer's 1000 milliliter IV fluid bags had an expiration date of 05/01/17.

On 06/06/17 at 11:21 AM, Staff E stated the medications observed by the surveyor were outdated .

B.

A hospital policy titled " Drug Inventory Control" documented medication rooms on patient care units use for storage of floor stock medications shall remain locked and access limited to licensed nursing staff.

During the entire survey (4 days), the medication storage room located on the 2nd floor was unlocked and at times the door was opened which allowed access to all individuals.

On 06/06/17 at 11:21 AM, Staff E stated the lock on the door of the medication storage room was broken.

Based on record review, observation, and interview the hospital failed to:

a. designate an individual who is qualified through education, training, experience and certification or licensure, as an infection control preventionist (ICP).

b. maintain an ongoing infection control program that includes active surveillance, specific measure for prevention, early detection, control, and education consistent with nationally recognized infection control practices or guidelines.

These failed practices had the potential to create an ineffective infection control program and increased the infection control risk to the hospital's inpatients and outpatients.

Finding:

A. Qualified Personnel

A hospital policy titled "Infection Prevention and Control Committee-Organization and Function" documented the Infection Preventionist shall attend training in infection prevention and control courses, or participate in a local and national meetings organized by recognized professional societies.

The personnel file for Staff E identified as the infection control preventionist (ICP) did not contain documentation the individual had training or experience in infection control.

On 06/09/17 at 3:02 PM, Staff E stated the individual did not have any previous experience in infection control and had not received any infection control training.

B. System Maintenance

A hospital policy titled "Infection Prevention and Control Committee-Organization and Function" documented the ICP was responsible for surveillance, data collection and analysis.

A hospital policy titled "Infection Prevention and Control Incident Tracking" documented the ICP was responsible for maintaining a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and staff.

~Identifying:

Surveyor requested infection control surveillances and monitoring activities. Surveyor received the following 3 documents:

A document titled "Infection Control QI/PI for June 2016 to May 2017", documented performance goal/quality improvement (QI) Initiative for <2.6% of UTIs reported in patients with indwelling urinary catheters, less than 1% rate of bloodstream infections secondary to CAUTI, no sign and symptoms of central line associated blood stream infection, and 100% of employees compliant to hand hygiene.

The document did not consistently show specific plans, actions, or outcomes for the performance goal/QI initiative.

Document titled "Investigation of Potential Hospital Acquired Infection" did not document specific hospital acquired infections (HAIs) infections identified within the CAH for improvement opportunities.

Document titled "Environmental Monitoring" failed to show any specific tasks, department locations, or staff being monitored on a consistent basis.

The surveyor requested current tuberculosis (TB) risk assessment, none were provided.

~Investigating:

A document titled "Investigation of Potential Hospital Acquired Infection" reported 90.9% compliance and 9.1% "uncomplete" last updated on 01/23/17. The document did not contain any specific data/infections in which the compliance percentage referred to or which data was incomplete. The document did not contain any evidence that incidents, problems, or trends that were analyzed and/or corrective actions taken.

Document titled "Environmental Monitoring" reported 95.8% compliance and 4.2% "uncomplete" last updated on 01/23/17. The document did not contain any description of what data was being monitored; no incidents or trends analyzed with corrective action taken.

~Controlling:

A policy titled "Infection Risk Assessment" documented an infection risk assessment would be conducted annually.

Surveyor requested documentation reporting any control measures including infection risk assessment, national recognized infections compared to the CAH's infections, staff education for hand hygiene, isolation precautions, personal protective equipment (PPE) and corrective actions for surveillance. None were provided.

~Reporting:

Infection Control Meeting Minutes for March 17, 2017 documented two problems; hand hygiene and room 203 needed to be cultured.

A review of "Quality Care Committee Meeting Minutes" for October 12, 2016 and January 11, 2017 documented only one problem, hand hygiene. An action plan was proposed to utilize a black UV light to highlight germs after handwashing.

A document review of "QCC Meeting Minutes" for February 8, 2017 documented hand hygiene issues remained, and the action plan was to continue to monitor staff. No documentation updated the status of the previous action plan from October and January to purchase a black UV light to highlight germs.

A "Draft" of Board of Director Meeting Minutes for June 5, 2017 continued to show the problem with hand hygiene compliance as 92% (goal is 100%) with no action plan taken.

On 06/09/17 at 3:02 PM, Staff E stated she had no training or experience developing an infection control program with active surveillance, analysis, and reporting of data; and she was unaware of the responsibilities/duties as an ICP.


Observation:

On 06/06/17 from 10:57 AM to 12:40 PM, during a tour of the facility with Staff E, the following were observed by the surveyors:

Patient Care Area

~5 staff members; 2 nurses, the case manager, a physician, and a certified nursing assistance (CNA) were observed entering a contact isolation room without downing personal protective equipment (PPE).

~Patient's belongings in soiled/dirty utility room. Staff E reported it is not normal practice to store patient belongings in this area and the belongings may be there related to a patient/family member not being notified to pick up the belongings. (The soiled utility room is considered a contaminated area.)

~Linen cart observed in the hallway with clean linen uncovered.

~Housekeeping closet was unlocked and contained harmful chemicals inside; Staff E reported closet should be locked.

~Room labeled "Bath" had clean equipment including pillows that were uncovered and bedside commodes without a label marking the equipment clean/ready for use.

~Approximately 10 wheelchairs were stored in the hallway. Surveyors could not verify if the wheelchairs were clean or dirty. (Wheelchairs should be disinfected after each use.)

Patient Care Nursing Station

~ 9 bags of Lactated Ringer's in 5% Dextrose 1000 milliliter Intravenous (IV) fluid had an expiration date of 03/01/17.

~12 Lactated Ringer's 1000 milliliter IV fluid bags had an expiration date of 05/01/17.

Emergency Department

~Clean linen stored in a closet on shelves were uncovered.

~ Staff E reported the shower was not in use. Surveyors observed water spots and a pair of flip flops as if the shower was used. Staff E stated the water should be turned off to avoid use; surveyors observed running water.

~Emergency Room 1 designated as "ready to use" contained opened patient care wipes observed on the container. (New unopened patient care wipes should be utilized on each patient to avoid the spread of infection.)

~A crash cart located in emergency room 2 contained a medication, nitroglycerin intravenous piggyback (IVPB) with an expiration date of 04/17.

~Emergency Room 2 crash cart contained 2 opened needles taped to syringes. (Needles should be in sterile packaging to prevent infection.)

~Emergency Room 2 contained opened suction catheters. (Suction catheters should be in sterile packaging to prevent infection.)

~ There were oscillating fans in the clean linen room. (Oscillating fans pose a risk for infection control issues.) There was no policy in place to guide the use of fans in the hospital and to guide cleaning of the fans.

Radiology Department

~In the Computed Tomography (CT) area a basin with a dirty towel observed under a stretcher.

~Clean linen was uncovered and stored on a bedside table in the X-ray room.

~Supplies were observed in the splash zone, located in the nursing supply room. (Supplies that are not in a cleanable package may become soiled and contaminated.)

Laboratory

~Cavicide disinfectant was observed on the sink in the outpatient drawing station with an expiration date of November 2016.

~3 sinks were observed in the laboratory that contained supplies/equipment in the splash zone; including blood collection tubes, Strep and RSV test swabs in paper packaging. (Supplies that are not in a cleanable package may become soiled and contaminated.)

Physical Therapy Department

~ Dead insects and roaches were found in the Physical Therapy area near the whirlpool.

~A bundle of clean towels and patient gowns were stored in a chair uncovered in the physical therapy gym.

~ Clean linen was stored uncovered in a closet with orthopedic equipment.

~Clean cloth hot pads were hanging uncovered in area with the hydrocollator.

First floor

~ Dead insects and roaches were found on the floor of the hospital's entrance for 2 days during the survey.

Employee Health

~23 of 23 employee and medical staff files did not contain documentation of current TB skin testing or TB symptoms assessment.

~23 of 23 employee and medical staff files had no documentation of immunization records, blood titers or attestation documents.

Based on observation, record review and interview the hospital failed to ensure the nutritional needs of the patients were met.

This deficient practice had the potential to affect the nutritional needs for every patient admitted to the hospital.

Findings:

A review of hospital policy #7009 titled, "Nutritional Assessment by Registered Dietician", stated the Registered Dietician shall complete a nutritional assessment within 72 hours of admission for all patients having moderate to high nutritional risk. Hospital policy stated the Dietary Manager could complete these assessments if designated by the Registered Dietician.

"Swing Bed Dietary Assessment and Care policy" stated the Dietician or designee must complete a dietary assessment and it must be charted within 24 hours of admission.

Record review showed the Dietary Manager had entered assessments on patients who fit into the moderate category. Surveyors requested proof of this designation by the Registered Dietician and competencies for the Dietary Manager to perform these duties, none was provided. Additionally this document showed no formal designee or approval by governing body for any person to act in place of the registered dietician.

4 of 4 Swing Bed patient charts reviewed showed no assessment charted by the registered dietician or designee within 24 hours.

On 06/07/2017 at 1:30 pm, Staff I and T stated that the Dietary Manager completes nutritional assessments and nutritional care plans.

Based on record review and interview the CAH failed to ensure imaging staff met qualifications to utilize radiological equipment.

This failed practice had the potential to impact the safety of each patient receiving imaging services.

A hospital policy titled "Departmental Orientation" documented imaging technologist would be oriented to radiation safety policies and procedures, an overview of various scanners, safe procedures for operating each type of equipment, basic scanner and unit maintenance and troubleshooting, documentation and record keeping, transporting patient to and from the unit, and CT safety.

Surveyor requested competencies for the imaging staff, none were provided.

On 06/07/17 at 11:52 PM, Staff O stated staff does not have documented competencies for the Imaging Service Department.

Based on record review and interview the hospital failed to:

A. Ensure Emergency Department nursing staff were competent and qualified.
B. Ensure nursing staff are competent and qualified.
C. Ensure agency nursing staff were competent and qualified.

This deficient practice had the potential for sub-optimal nursing care for all patients.

Findings:

A. Emergency Department

2 of 2 Emergency Department nursing personnel records showed no annual competencies or training specific to the Emergency Department or in providing emergency care.

On 06/08/17 at 11:00 am, Staff B stated the personnel records provided were complete and no competencies were documented or filed in another location to prove nursing staff qualifications to provide emergency care.

B. Nursing Department

6 of 7 nursing personnel files reviewed showed no annual competencies, education or training. There was no documentation to determine how proficient nursing staff were in assessment, interventions or utilizing proper techniques required in any areas of patient care.

On 06/08/17 at 11:05 am, Staff B stated that there were no annual competencies, training or continuing education documented to verify nurses were competent and qualified to provide care to the hospital's patient population.

C. Agency Staff

3 of 3 agency nursing staff personnel records showed no hospital specific orientation and competencies.

On 06/08/17 at 11:08 am, Staff B stated agency nurses competencies are completed with the agency they are employed with and no specific hospital competencies had been completed.

Based on record review and interview, the hospital failed to ensure IV medications were administered per a physician's order for 1 (Patient #19) of 20 patients reviewed.

This failed practice had the potential to affect all current patients receiving IV medications.

Findings:

A review of QA/PI records from SQSS of incidents from June 2016 to present. The documentation included the following incidents:

1. An incident dated 09/06/16 under the heading "Administered wrong medication" reported a patient received D5 NS IV solution instead of the ordered 1/2 NS solution. The section labeled "Closing Remarks" was left blank. There was no information available to identify the specific patient.

2. An incident dated 01/20/17 under the heading "Administered wrong medication" reported a patient received 0.9% NS IV solution instead of the ordered D5 1/2 NS solution. The section labeled "Closing Remarks" was left blank. There was no information available to identify the specific patient.

3. An incident dated 05/29/17 under the heading "Administered wrong medication" (discovered to be related to Patient #19) reported Patient #19 received D5W IV solution instead of the ordered 0.9% NS solution. The section labeled "Closing Remarks" was left blank. The clinical record contained documentation of a physician's order for 0.9% NS dated 05/28/17 at 1:37 pm. There was no documentation the order was discontinued or a subsequent order to change the solution to D5W was received.

On 06/09/17 at 10:30 am, Staff B stated the process of administering a medication starts with verifying the physician's order in the EMR, or printing a medication list; and reported no IV solutions should be obtained or administered prior to verifying the physician's order.

Based on record review and interview, the hospital failed to ensure medical records included evidence of properly executed medical consent forms for 6 (Patients #15-20) of 20 patient records reviewed.

This failed practice had the potential to affect all current patients due to failure to ensure patients were given consent forms and consent was obtained prior to treatment.

Findings:

A group of papers labeled "In Patient Forms" was provided and described as an admission packet. The packet included a document titled "Conditions of Admission". The document included information regarding medical and surgical consent and a space for the patient or patient's representative to sign.

A review of records on 06/08/17 showed no "Conditions of Admission" forms were included and there was no documentation of medical and/or surgical consent for Patients #15-20. Patients #15-20 were all discharged in March 2017.

On 06/09/17 at 2:00 pm, Staff A stated the hospital did not have documentation of consent for treatment for Patients #15-20.

On 06/06/17 at 12:40 pm, Staff D stated all records are entered or scanned into the EMR; and stated the chart should be completed with all records in the EMR within 15 days after discharge, with any discrepancies reported to HIM committee every month.

Based on observation and interview, the hospital failed to keep examination records safe from unauthorized use.

This failed practice had the potential to affect any patients receiving radiological examinations due to the inappropriate storage of records.

Findings:

During a tour of the CAH on 06/06/17 at 11:45 am, the surveyor observed the "CT room". A beige file cabinet with three drawers was unlocked and contained records with patient-identifiable information for radiological examinations dating back to 01/01/15.

On 06/06/17 at 11:55 am, Staff O stated the cabinet contained "old exams", it was unlocked but it should have been locked.

Based on record review and interview, the hospital failed to:

1. Develop a quality assurance program to assess quality of care to ensure patient safety. (see C0336)

2. Take appropriate action to address documented deficiencies in (a) medication administration errors, (b) mishandling of laboratory specimens, and (c) unavailability of personnel. (see C0342)

3. Document outcomes of remedial actions taken to correct unsafe practices. (see C0343)

Based on record review and interview, the hospital failed to develop a quality assurance program to assess quality of care to ensure patient safety.

This failed practice had the potential to affect all current patients due to the lack of analysis of errors, lack of corrective actions, and lack of subsequent evaluation of corrective actions to improve quality of care.

Findings:

A review of QA/PI records from SQSS of incidents from June 2016 to present. 3 of 3 medication errors reviewed showed no documentation of analysis of the events that led to the error, no documentation of corrective actions taken, and no documentation of subsequent evaluation of quality of care following implementation of corrective actions. 3 of 3 laboratory errors reviewed showed no documentation of corrective actions taken or subsequent evaluation of quality of care following implementation of the corrective actions.

A document titled "Quality Management Plan". There was no documentation of policies or procedures to follow to improve care after the identification of errors.

On 06/09/17 at 3:35 pm, Staff E stated there was no system in place for investigating incidents, creating a performance improvement plan, or evaluating the reoccurrence of similar incidents (see tag C0241), also any actions taken would be documented in "Closing Remarks" in SQSS; and reported being unaware of any policies or procedures and did not have any policies or procedures to give the surveyors for review.

Based on record review and interview, the hospital failed to take appropriate action to address documented deficiencies in (a) medication administration errors, (b) mishandling of laboratory specimens, and (c) unavailability of personnel.

This failed practice had the potential to affect all current patients receiving medications and/or laboratory studies, and the potential to affect any community members seeking services in the ER due to the lack of correction of noted problems.

Findings:

A. A review of QA/PI records from SQSS of incidents from June 2016 to present. The documentation included the following incidents:

1. An incident dated 09/06/16 under the heading "Administered wrong medication" reported a patient received D5NS IV solution instead of the ordered 1/2 NS solution (there was no additional information to identify the specific patient). The section labeled "Closing Remarks" was left blank. A document titled "Quality Care Committee Meeting Minutes" dated 10/12/16 contained no documentation of an investigation of the medication error or a plan to prevent the reoccurrence of the error.

2. An incident dated 01/20/17 under the heading "Administered wrong medication" reported a patient received 0.9% NS IV solution instead of the ordered D5 1/2 NS solution (there was no additional information to identify the specific patient). The section labeled "Closing Remarks" was left blank. A document titled "Quality Care Committee Meeting Minutes" dated 02/08/17 contained no documentation of an investigation of the medication error or a plan to prevent the reoccurrence of the error.

3. An incident dated 05/29/17 under the heading "Administered wrong medication" (discovered to be related to Patient #19) reported Patient #19 received D5W IV solution instead of the ordered 0.9% NS solution. The section labeled "Closing Remarks" was left blank. The clinical record contained documentation of a physician's order for 0.9% NS dated 05/28/17 at 1:37 pm. There was no documentation the order was discontinued or a subsequent order for D5W solution was received.

B. A document titled "Laboratory Test Menu" showed urine cultures and blood pathogen testing (such as HIV and HBV testing) were not performed by the hospital laboratory. A document titled "Description of Laboratory Services" stated some tests must be referred to a reference laboratory. There was no documentation of the procedures to submit a specimen for outside testing.

A policy titled "Laboratory Hours of Operation" stated a laboratory technician/technologist would be available at all times, including nights and weekends.

A review of QA/PI records from SQSS of incidents from June 2016 to present. The documentation included the following incidents:

1. An incident dated 11/30/16 at 12:48 am under the heading "Missed test/procedure (non-surgical related)" reported a urine specimen that required a reference laboratory to perform a bacterial culture was not sent out. There was no documentation of corrective actions taken to ensure accurate processing of laboratory specimens.

2. An incident dated 04/05/17 at 12:00 am under the heading "Needle Stick" reported an employee blood specimen was collected on 04/05/17 (a Wednesday) that required a reference lab to perform blood pathogen testing. The specimen remained in the hospital laboratory until 04/11/17 (the following Tuesday). The report stated "The lab director was notified by a lab employee- but things stood still over the weekend." There was no documentation of corrective actions taken to ensure timely processing of laboratory specimens.

3. An incident dated 04/07/17 at 3:00 pm under the heading "Improper processing of tissues/samples obtained as part of procedure/test" reported 2 blood specimens were collected in the ER on 04/07/17 (a Friday) that required a reference lab to perform blood pathogen testing. The specimens remained in the hospital laboratory until 04/11/17 (the following Tuesday). The report stated "Blood specimens sat all weekend- presumably because it was the weekend." There was no documentation of corrective actions taken to ensure timely processing of laboratory specimens.

C. A policy titled "Availability of Personnel" stated the laboratory technician/technologist on shift must remain on-site until the oncoming technician/technologist arrives or can arrive within 15 minutes.

A policy titled "Laboratory Hours of Operation" stated a laboratory technician/technologist would be available at all times. Personnel working evening, night, and weekend shifts may be able to leave the campus for a maximum of 15 minutes but must provide ER personnel "a means of constant contact".

An incident dated 05/29/17 (a holiday) at 10:30 pm under the heading "Other" reported a patient with a possible stroke was being brought to the hospital by EMS. Documentation showed 5 unsuccessful attempts to call laboratory personnel, at which point the hospital advised EMS to transport the patient to a different hospital as laboratory services were not available at that time. There was no documentation of corrective actions taken to ensure constant availability of lab personnel.

A review of a document titled "Quality Management Plan" showed no documentation of policies or procedures to follow to improve care after the identification of errors.

On 06/09/17 at 3:35 pm, Staff E stated QA/PI information is documented in a system called "SQSS" and incidents are reviewed the following month in a committee meeting.

On 06/09/17 at 3:35 pm, Staff E stated there was no system in place for investigating incidents, creating a performance improvement plan, or evaluating the reoccurrence of similar incidents, and any actions taken would be documented in "Closing Remarks" in SQSS; and reported being unaware of any policies or procedures and did not have any policies or procedures to give the surveyors for review.

Based on record review and interview, the hospital failed to document outcomes of remedial actions taken to correct unsafe practices.

This failed practice had the potential to affect all current patients due to the potential of remedial actions to be ineffective.

Findings:

A document titled "Total Program Evaluation" dated December 2016 showed no documentation of outcomes resulting from any corrective actions taken to demonstrate improvement in the identified issues.

A document titled "Quality Care Committee Meeting Minutes" dated 10/12/16 showed problems with medication errors. There was no documentation of follow up assessment of patient outcomes.

A document titled "Quality Management Plan" showed there was no documentation of policies or procedures to follow to improve care after the identification of errors.

On 06/09/17 at 3:35 pm, Staff E stated there was no system in place for investigating incidents, creating a performance improvement plan, or evaluating the reoccurrence of similar incidents; and reported being unaware of any policies or procedures.

Based on document review and interview, the Critical Access Hospital (CAH) failed to ensure the following specific organ, tissue, and eye procurement requirements were met:

a. maintain a current policy and procedure to address its organ procurement responsibilities;

b. provide a valid agreement with an organ procurement organization (OPO); (see tag C-0345).

c. provide an agreement with an eye bank; (see tag C-0346).

d. provide documentation for all patient care staff education on organ, tissue and eye donations; (see tag C-0347).

This failed practice had the potential to prevent the identification of individuals suitable for eye, tissue and organ donation.

Based on document review and interview the CAH failed to ensure:

a. a policy and procedure pertaining to organ procurement was current.

b. a valid and/or current organ procurement organization (OPO) agreement was maintained.

Findings:

A.
A policy titled "Organ Donation" did not contain a date the policy was approved, an effective date, or a revision date. The policy referred to an OPO by the name of "Organ Sharing Network"; surveyor reviewed the hospital's agreement with OPO, LifeShare.

On 06/09/17 at 10:30 AM, Staff B stated there are no dates on the OPO policy and procedure.

B.
A document titled " Organ and Tissue Recovery Agreement" stated the obligations within the agreement expires in a period of one year. Also, the CAH's CEO authenticated the agreement with a date of 12/12/10 which conflicted with the OPO Lifeshare's CEO authentication dated 11/25/13.

On 06/09/17 at 12:32 PM, Staff G stated the agreement was invalid.

Based on document review and interview the hospital failed to provide a current policy and procedure pertaining to an eye bank and an agreement with an eye bank.

Findings:

A policy titled "Organ Donation" did not contain a date the policy was approved, an effective date, or a revision date. The policy stated eye only donors will be referred to the Oklahoma Lion's Eye Bank directly.

On 06/09/17 at 09:50 AM, surveyor requested an eye bank agreement; none were provided.

On 06/09/17 at 10:30 AM, Staff B who stated there are no dates on the "Organ Donation" policy and procedure.

On 06/09/17 at 12:32 PM, Staff G stated the hospital does not have an eye bank agreement.

Based on document review and interview the hospital failed to provide documentation for all patient care staff education on organ, tissue and eye donations.

Findings:

A policy titled "Organ Donation" did not contain a date the policy was approved, an effective date, or a revision date. The policy stated each procurement agency will provide in-service education to hospital staff.

Employee files showed no documentation of education/training pertaining to organ donation.

On 06/09//17 at 10:00 AM, Staff B stated there was no documentation of competencies for hospital staff pertaining to death or organ donation.