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Based on record review and interviews with hospital staff, the governing body does not ensure that services performed under a contract are provided in a safe and effective manner. Diagnostic sleep studies provided by a contract/agreement are not evaluated by the QAPI program to assure the services are performed in a safe and effective manner by qualified personnel.

Findings:

1. Diagnostic sleep studies are provided in an unlicensed area of the hospital and do not meet the requirements for life safety in a health care facility. This area is on the second floor of the two story building. The ground floor is the licensed hospital.

2. Sleep study patients are admitted by the hospital's admitting service and are listed as patients on the hospital's discharge log.

3. Personnel overseeing the sleep study patients are not evaluated to determine competence and whether they are oriented to hospital emergency procedures. There were no personnel files for employees of the contracted sleep study company.

4. A contract sleep study person requested assistance from nursing personnel one evening with a patient who was having difficulty during a sleep study. The contract person was told to call 911. There was no incident report prepared or evaluation of the incident.

5. On 3/19/2012 Staff A told surveyors the facility had a contracted dietitian and contracted dietary to an outside company. The dietary consultation contract provided to surveyors was to begin in March of 2012. There was no documentation a dietitian had been overseeing dietary services for the past twelve months. Staff A told surveyors the dietitians had not been overseeing services. There was no documentation the dietitian had education and training to provide clinical nutritional services.

6. On 3/20/2012 Staff A provided files for contract dietary employees. There was no documentation in the Food Services Director's personnel file she was a Certified Dietary Manager. There was no documentation the Food Services Director had been oriented, trained, and evaluated. There was no documentation a Dietitian oversaw and collaborated with the Food Services Director in menu planning, training, and oversight of the clinical dietetics. An organizational chart provided to surveyors indicated the plant operations manager oversaw the dietary director. The plant operations manager is also a contracted employee.

7. On 3/20/2012 Staff A told surveyors she was not sure of all the food service employees but the contracted company had information on all of them. There was no documentation all food service personnel had been oriented and trained to the facilities policies and procedures. There was no documentation all food service personnel were evaluated for food safety and sanitation competency. There was no documentation the food service personnel were current with all required immunizations.

Based on review of medical records, policy and procedure, hospital documents, interviews with staff, and observation, the hospital failed to provide care in a safe setting.

Findings:
1. On 3/22/12 surveyors reviewed the incident report log. Hospital documents included a narrative written by a contracted clinician regarding a situation that occurred with a sleep apnea patient. The clinician indicated the contracted service personnel requested assistance of the nursing personnel of the hospital but were told the situation had to be emergent. Documentation provided indicates the patient was transported via ambulance to another facility. The clinician did not complete a facility incident report form. There was no documentation the facility reviewed the occurrence in Quality/Performance Improvement, Medical Staff, or Governing Body. No incidents or occurrences were reviewed in any of the hospital's meeting minutes provided to surveyors. There was no documentation the facility reviewed occurrences to improve patient safety.

2. On 3/22/12 surveyors reviewed the complaint and grievance log. There were no grievances or complaints in the log. Review of the grievance policy entitled "Patient Relations and Complaints" does not define the terms "complaint" and "grievance". The policy does not define when a complaint becomes a grievance. The policy does not include all the required elements.

3. On 3/22/12 surveyors reviewed several employees personnel files. There was no documentation employees or contract personnel were educated on incident reporting or the grievance process.

4. On 3/21/12 surveyors reviewed the operating room log for January-February 2012. There were multiple occurrences of unplanned returns to the operating room. There was no documentation the occurrences were reviewed with Medical Staff or Governing Body to improve patient safety.

5. On 3/22/12 surveyors reviewed the operating room sterilizer logs. There were multiple incidents of "flash" sterilization on sets of instruments. There was no documentation of infection control surveillance in the perioperative area. There was no documentation sterilization, disinfection practices in the operating room were reviewed in Infection Control Meeting, Medical Staff Meeting, Quality Meeting, or Governing Body Meeting.


6. Contract staff were not trained and evaluated as competent to provide care in the facility. None of the contract files contained orientation and training to the facility. The facility did not verify licensure on all contractors.

7. On 3/21/12 surveyors were told the facility had electronic records. Surveyors requested access to review emergency room records. One emergency room record was reviewed during a three hour period. The medical record system locked up multiple times during the review. On the morning 3/22/2012 surveyors requested one medical record in hard copy format. The medical record was not provided for three hours. Staff told surveyors it was difficult to print the record as the system would lock up or the person printing would be bumped off the system.

A second computer was obtained for review. The same types of occurrences continued. Surveyors eventually required review of hard copy medical records due to the inability of the system to remain operational. Staff indicated problems occur with the system frequently and the facility is reviewing new modules. There is no documentation the facility can provide access to a complete medical record in a timely manner. There is no documentation in Governing Body or Quality Meeting Minutes system operational issues including timely access to medical records has been addressed.

Based on interviews with staff, review of medical records and review of policy and procedure the facility failed to implement a medical records system which allows timely access to pertinent patient information.

Findings:

1. On 3/21/12 surveyors requested access to electronic records. On the afternoon of 3/21/12 surveyors reviewed three emergency room records. During the reviews the surveyors encountered multiple delays in accessing the medical records network. Surveyors were repeatedly locked out of the record and locked out of the network. Staff assisting the surveyors stated the electronic system had the above issues frequently. Staff indicated there were difficulties retrieving information on current patients related to the electronic medical record access issues and network problems.

2. On 3/21/12 surveyors were told medical records are electronic and paper. Policies and procedures for medical records services do not stipulate what documents are electronic and what documents are paper to be scanned. There are no processes reviewed, approved, and implemented integrating the hard copy documents into the electronic documentation.

3. There are no policies and procedures stipulating when a chart is considered complete in the electronic medical record. Multiple charts reviewed electronically and hard copy were not complete. There was no documentation medical records were reviewed for timely completion. One medical record reviewed indicated the patient had two surgeries. Both operative notes did not have signatures. Both surgeries were greater than 30 days old.

4. On 3/21/12 Staff A told surveyors Staff D was in charge of medical records. According to Staff D she also served in other roles for the facility. There was no documentation Staff D had education, training, and experience in medical records or the electronic medical record system.

Based on record reviews and interviews with hospital staff, the hospital does not ensure that medical records are complete, retained, and properly filed for prompt retrieval.

Findings:

1. On the morning of 3/19/2012, administrative staff told the surveyors that all patient medical records were maintained on computer/electronic medical records. In the afternoon, surveyors were provided access to the electronic medical record and instructions on where documents could be found. During the afternoon computer session surveyors were not able to review records without multiple problems with the computer and being locked out of the network. Of the three records (1,2,3) reviewed that afternoon, three of three were not complete.

2. On the afternoon of 03/19/2012 and the morning of 03/20/2012, one surveyor reviewed the medical record of a patient, Patient #2, who received respiratory nebulizer treatments on 01/03/2012. The computerized documentation, reviewed on the afternoon of 03/19/2012, recorded a treatment was provided at 2051, the the documentation did not contain an assessment of the patient's pre-treatment and post-treatment respiratory status. Because of difficulty of maintaining access to the hospital's computer system, the surveyor requested a printed copy of the entire record be made available. The printed medical record, reviewed on 03/20/2012, not only did not contain documentation of a pre and post evaluation of respiratory treatment, but did not contain nursing or respiratory documentation at all.

3. On the afternoon of 3/20/2012 surveyors reviewed medical records policy and procedures. The policy and procedures did not reflect the current medical records practice. There were no policies addressing use of the electronic documentation system and how the clinicians accessed particular documents.

4. The facility allows physicians to provide hand written orders or physicians may enter their own orders electronically. There is no policy regarding physician orders. There is no policy stipulating who enters orders. There is no policy on verification and noting of orders electronically. There is no policy stipulating the types of authorizations particular clinicians have. There was no documentation provided to surveyors indicating content of medical records were reviewed for completeness and accuracy.

5. On 3/19/2012 surveyors were told the facility had a a sleep disorder program. Staff A told surveyors the sleep apnea patients were registered through the hospital's computer system. Surveyors reviewed medical record documentation for the sleep apnea patients. Sleep disorder records did not have the same elements as the hospital's other outpatient records. Not all records had orders noted and acted on by personnel authorized by hospital policy.

6. The facility did not have policy and procedures addressing electronic documentation in outpatient and inpatient medical records. There were no policies on electronic record completion, retention, security, and accessibility.

7. The above findings were reviewed with administration at the exit conference. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that the medical record contains information describing the patients condition, progress and responses to treatment.

Findings:

1. The documentation for sleep disorder clinics does not match the outpatient records of other departments within the hospital. There are no medical records policies regarding sleep disorder clinics documentation. Documentation and content provided for other outpatient procedures/records does not match the sleep disorder clinics records.

2. Several records reviewed by surveyors did not have physician signatures authenticating the entry or the document. There was no documentation provided to surveyors indicating content of medical records were reviewed for completeness and accuracy.

3. On 3/20/2012 surveyors reviewed physical therapy notes. None of the patients had all of the elements required in the physical therapy policies. All of the documentation in the medical record was narrative format. The policies provided to surveyors indicated physical therapy documented on a template form.

4. On the afternoon of 03/19/2012 and the morning of 03/20/2012, one surveyor reviewed the medical record of a patient, Patient #2, who received respiratory nebulizer treatments on 01/03/2012. The computerized documentation, reviewed on the afternoon of 03/19/2012, recorded a treatment was provided at 2051, the the documentation did not contain an assessment of the patient's pre-treatment and post-treatment respiratory status. Because of difficulty of maintaining access to the hospital's computer system, the surveyor requested a printed copy of the entire record be made available. The printed medical record, reviewed on 03/20/2012, did not contain nursing or respiratory documentation.

5. The above findings were reviewed with administration at the time of the exit conference.

Based on review of medical records and hospital documents the facility failed to document complications in the medical record. On 3/20/12 surveyors reviewed the incident report log. Hospital documents included a narrative written by a contracted clinician regarding a situation that occurred with a sleep apnea patient. The clinician indicated the contracted service personnel requested assistance of the nursing personnel of the hospital but were told the situation had to be emergent. Documentation provided indicates the patient was transported via ambulance to another facility. The patient's clinical problems and mode of discharge were not documented in the patient's medical record. There was no documentation of any physical status change during the patient's stay.

Based on review of policy and procedure and interviews with staff the facility failed to ensure radiology exams were provided in a safe manner. The facility did not have documentation stipulating staff were licensed, trained, and competent in radiation safety. Radiology staff did not have departmental orientation and training. There was no documentation radiology staff were competent in radiation safety techniques for themselves and patients. There were no current clinical performance evaluations of radiology staff.

Based on review of hospital documents, review of personnel and interviews with the administration, the hospital failed to have documentation showing all the personnel operating the diagnostic x-ray equipment are qualified and trained.

Findings:

1. On the morning of 3/20/2012 surveyors requested radiology personnel files. Employee and contract personnel files did not indicate personnel providing radiology services for the hospital had been oriented or trained in the facility. There was no documentation the medical staff or the radiologist had developed, reviewed, and approved criteria designating personnel competent to perform radiologic procedures.

2. On 3/20/2012 these findings were presented to administration in the exit conference. No further documentation was provided.

Based on record review and interviews with hospital staff the hospital does not ensure there is a organized dietary service with oversight by a registered dietitian. The hospital did not have evidence that a dietitian was providing oversight or services with regularly scheduled visits and oversight of clinical nutritional services. The facility failed to meet the nutritional needs of the patient.

Findings:

1. On 3/19/2012 Staff A told surveyors the facility had a contracted dietitian and contracted dietary to an outside company. The dietary consultation contract provided to surveyors was to begin in March of 2012. There was no documentation a dietitian had been overseeing dietary services for the past twelve months. Staff A did not have documentation of the dietitian(s) qualifications only a contract signed by the owner of the contracted company. Staff A told surveyors the dietitians had not been overseeing services.

2. On 3/20/2012 Staff A provided files for contract dietary employees. There was no documentation in the Food Services Director's personnel file she was a Certified Dietary Manager. There was no documentation the Food Services Director had been oriented, trained, and evaluated. There was no documentation a Dietitian oversaw and collaborated with the Food Services Director in menu planning, training, and oversight of the clinical dietetics. An organizational chart provided to surveyors indicated the plant operations manager oversaw the dietary director.

3. On 3/20/2012 Staff A told surveyors she was not sure of all the food service employees but the contracted company had information on all of them. There was no documentation all food service personnel had been oriented and trained to the facilities policies and procedures. There was no documentation all food service personnel were evaluated for food safety and sanitation competency.

4. Review of medical records indicate patients had nutritional conditions requiring nutritional intervention which the facility did not act on. The hospital staff did not provide nutritional support to meet the needs of the patient.

5. There was no documentation a dietitian reviewed or approved menus, special diets, made recommendations on nutritional issues, oversaw clinical dietetics, reviewed, revised, and implemented policies approved by the medical staff regarding nutritional services.

6. The facility failed to train staff, implement policies, and oversee processes to ensure patients nutritional needs are met.

Based on review of personnel files and interviews with staff the hospital failed to provide oversight of the food and dietetic services.

Findings:

1. On 3/19/2012 Staff A told surveyors food and nutrition services were provided through a contracted company. Staff A told surveyors a contract had recently been signed for dietitian oversight of the food services.

2. On 3/20/2012 Staff A told surveyors the Food Services Director was not a Certified Dietary Manager (CDM). There was no documentation the Food Services Director was a full time employee of the facility. Documents provided to surveyors indicate the Food Services Director is a contract employee. Job responsibilities listed on employee's paper work indicate the Food Services Director also serves as the Environmental Services Manager. There was no documentation the Food Services Director had been oriented and trained to the facilities policies, procedures, and equipment. There was no evaluation of the Food Services Director for competency by the dietitian. There was no documentation the dietitian oversaw the clinical aspects of the Food Services Director job. The organizational chart provided to surveyors indicated the Food Services Director reported to the Plant Operations Manager (who is also a contracted service provider).

Based on review of hospital documents and interviews, the hospital failed to ensure a qualified dietitian supervises the nutritional aspects of patient care.

Findings:

1. The hospital did not have documentation nutritional assessments were performed on patients identified as "at risk" for nutritional issues.

2. On 3/19/2012 Staff A told surveyors the facility had a contracted dietitian and contracted dietary to an outside company. The dietary consultation contract provided to surveyors was to begin in March of 2012. There was no documentation a dietitian had been overseeing dietary services for the past twelve months. Staff A did not have documentation of the dietitian(s) qualifications only a contract signed by the owner of the contracted company. Staff A told surveyors the dietitians had not been overseeing services

3. There is no documentation a licensed/registered dietitian supervised the clinical/nutritional dietetics to hospital patients.

3. This information was provided in the exit conference. No further documentation was provided.

Based on review of policies, personnel files, and interviews, the hospital failed to provide adequate training and oversight to dietary personnel.

Findings:

1. On 3/20/2012 surveyors reviewed dietary personnel records. There was no documentation, policy, procedure, or process in place stipulating how new dietary department employees would be trained on the inservice material presented before they were hired. There was no documentation the employees had been oriented and trained to the facility and specific dietary department.

2, Dietary documents did not include a departmental specific orientation and training for each dietary job description. The facility did not have evidence the dietary department employees were trained to perform the duties each were hired/assigned to do.

3. On 3/20/2012 Staff A told surveyors the Food Services Director was not a Certified Dietary Manager (CDM). There was no documentation the Food Services Director was a full time employee of the facility. Documents provided to surveyors indicate the Food Services Director is a contract employee. Job responsibilities listed on employee's paper work indicate the Food Services Director also serves as the Environmental Services Manager. There was no documentation the Food Services Director had been oriented and trained to the facilities policies, procedures, and equipment. There was no evaluation of the Food Services Director for competency by the dietitian. There was no documentation the dietitian oversaw the clinical aspects of the Food Services Director job. The organizational chart provided to surveyors indicated the Food Services Director reported to the Plant Operations Manager (who is also a contracted service provider).


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Based on review of medical records, policy and procedure, and interviews with staff the facility failed to provide nutritional services that met the needs of the patient. On 3/19/2012 Staff A told surveyors the patient population varied and several types of patients were served by the facility (bariatric, orthopedic, orthopedic spine, ophthalmology, colonoscopes, gynecology). Review of the patient's medical records indicate patients had varying comorbidities. Several records reviewed indicated patients had disease processes which would increase their nutritional risk. There was no documentation current menus had been reviewed and revised by a clinical dietitian to meet the needs of the types of patients the facility cared for. There was no documentation the supplements and parenteral nutrition was reviewed and approved by the dietitian. There was no documentation modified diets were reviewed and revised by the dietitian.

Based on review of hospital meeting minutes, infection control/prevention (IC) policies and procedures and plan for the fiscal year 2012, and interviews with hospital staff, the hospital's leadership failed to ensure problems identified by the infection control practitioner were reviewed and analyzed with corrective actions taken to ensure problems were corrected

Findings:

1. Upon entrance to the hospital on the morning of 03/19/2012, the surveyors requested all IC policies and procedures and plan, activities/surveillance, and meeting minutes for the last twelve minutes.

2. No infection control meeting minutes were provided. The IC Plan for Fiscal Year 2012 (August 2011 to July 2012) recorded the IC program would be monitored by the Medical Executive Committee. On 03/20/2012 at 1030, Staff A and B stated IC was part of the the Quality (Quality Assessment and Performance Improvement) program and met quarterly.

3. Surveillance activities did not include review/monitoring of surgery sterilization practices to ensure practices followed hospital IC policies and standards of practice. Staff O told the surveyors on 03/20/2012 at 1600 that, other than dropped instruments, the only instruments that were put through a "shortened/immediate use" cycle were eye instrument sets. She stated the hospital only had three sets of eye instruments and if more than three cases were scheduled, they would use the shortened cycle for the remainder of the cases if there was inadequate time to do a full cycle. The hospital did not provide information that the eye instrument manufacture approved/recommended this method of sterilization for routine purposes. Review of the two sterilizer logs for the Week of January 3 through 6, 2012 identified other instruments, including two sets of laparoscopic instruments, were also processed by "shortened/immediate use" cycle.

4. Surveillance activities did not include the review/monitor of application of the hospital approved disinfectants for the appropriate use according to manufacture guidelines, including allowing the product to remain wet on the surface for the appropriate amount of time to be effective.

5. Surveillance activities reviewed for the last twelve months documented problems/concerns were identified. Review of meeting minutes for Quality and Medical Staff did not contain IC specifics with review, analysis, corrective actions taken, or review of the corrective actions to ensure the problems were corrected/remained corrected.

6. These findings were reviewed with administrative staff on the afternoon of 03/20/2012. No additional information was provided.

Based on staff interviews and policies and procedures, the hospital failed to ensure surgical services maintained appropriate standards of practice for safe patient care.

Findings:

1. Review of operating room personnel files did not indicate the personnel were oriented and trained to their specific responsibilities in the operating room. One registered nurse file reviewed indicated the nurse had recently been hired. There was no evaluation of operating room competency, review of skills in the operating room, or review of operating room policies. There was no evidence the RN had been oriented to specific duties in the operating room. Two personnel identified as central sterilization employees did not have any documentation they had been oriented, trained, evaluated, and were competent to operate specific equipment in the department. One employee had no previous operating room/central sterile experience prior to being employed as the central sterile technician. There was no documentation either employee was observed and evaluated competent to clean and sterilize instruments.

2. On 3/20/2012 surveyors reviewed sterilization logs. On multiple occasions eye instruments were processed using a shortened cycle. Operating room personnel told surveyors there were three sets of ophthalmic instruments.
During the interview with the OR manager, the manager stated that the only time flash sterilization was used was for emergencies such as a dropped instrument. The hospital is not following their policy.

3. There was no documentation in personnel files staff had been updated on minimizing risks of surgical fires. There was no policy or documentation provided to surveyors the staff were educated on the risk of surgical fires.

Based on review of emergency services/room (ER) policies and procedures and medical records, and interviews with hospital staff, the hospital failed to ensure medical staff enforced the ER policies governing medical care provided in the ER. This occurred in one of two patients (Patient #1), who presented to the hospital's ER area and whose records were reviewed.

Findings:

1. The hospital's policy, ED2041 - Provision of Care, on page 2 documented the medical screening examination would be performed by the physician, physician assistant (PA) or qualified medical person (This was identified in the Medical Staff Rules and Regulations as a nurse practitioner).

2. Patient #1 - The patient presented on 08/30/2011 at 1745. The electronic medical record for Patient #1, reviewed and verified on the afternoon of 03/19/2012 with Staff C, did not contain documentation of a medical screening examination by a qualified medical person was performed. All orders were written as read back verbal/telephone orders. At the time of review, the medical record did not contain a physician's signature for the order or on the physician's certification portion of the transfer form. Although the nurse documented the physician was at the bedside at 1800, the record did not contain evidence of an examination by the physician. Because the hospital has hybrid records (some generated by paper/handwritten forms and some by computer), the surveyor asked for a copy of the complete/entire medical record for the patient. The medical record still did not contain evidence a medical screening examination was performed according to the Medical Staff by-laws and Rules and Regulations and hospital policies.

3. This finding was reviewed with hospital staff on 03/20/2012.

Based on review of rehabilitation policy and procedure, hospital documents, personnel files and interviews with staff, the hospital failed to develop and organize the scope of rehabilitative services to be provided to the hospital's patient's.

Findings:

1. According to administrative staff, the hospital's physical therapy (PT) service is provided as a contracted service.

2. Upon entrance to the hospital, the surveyors requested policies and procedures for PT. The policies contained documentation standards for patient treatment. Review of medical records where patients received physical therapy did not match the documentation standards described in the policies. Physical therapy wrote a narrative note that did not include an assessment, history, goals and expectations of therapy, short and long term objectives. The physical therapy policies did not match the services provided to patients. There was no documentation how PT documented in the electronic system.

4. Review of hospital meeting minutes, governing body, medical staff and quality, did not show the hospital had reviewed and evaluated the contracted therapy services.

5. Surveyors asked for the personnel file of the physical therapist who provided PT services to patients. The facility did not have current personnel information on the therapist documenting in patient's records. There was no orientation and training to the facility documented. There was no competency or evaluation documented for the physical therapist.

Based on review physical therapy policies and procedures, personnel/contract files, medical records, and interviews with staff the facility failed to provide therapy services with qualified staff to meet the needs of the patients. Surveyors asked for the the physical therapist (PT) who provided PT services to patients personnel file The facility did not have current personnel information on the therapist. There was no documentation of orientation and training to the facility, competency or evaluation.