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Based upon review of contracted services and staff interviews, the hospital failed to ensure the scope and nature of the services provided were delineated as evidenced by failing to ensure the contracts for Radiological Services, Laboratory Services, and Respiratory Care Services were specific for the scope and nature of the service to be provided. Findings:

On 11/16/10, interview with the Director of Nursing S1 and the Nurse Consultant S2 revealed Respiratory, Radiology, and Laboratory services were provided by Contract A Hospital.

Review of the Hospital Contract A revealed the body of the contract failed to identify the provision of the contract services which were to be provided. Further review of Contract A revealed at the end of the contract was a single sheet of paper titled "Exhibit A" that identified:
"A. Respiratory: For Respiratory Services JSCH (Jennings Senior Care Hospital) shall pay to (Contract A Hospital) fees and charges equal to 80% of (Contract A Hospital) customary billed charges for such services."
"B. Laboratory and Blood Products: For Laboratory Services JSCH fees and charges equal to 80% of (Contract A Hospital) customary billed charges for such services. For blood products, JSCH will reimburse (Contract A Hospital) at one hundred percent (100%) of cost."
"E. Radiology and Diagnostic Imagery: For all Radiology Services provided JSCH shall pay (Contract A Hospital) an amount equal to 80% of (Contract A Hospital) charges for radiology services rendered, as reflected on (Contract A Hospital) Chargemaster at the time the radiology service was provided."

The hospital failed to ensure the contracted services for Radiology, Laboratory and Respiratory were specific and described the contractor responsibilities, and time frames for obtaining and reporting of the test results for Radiology, Laboratory, and Respiratory Care Services.

Based upon review of policies and procedures and staff interview, the hospital failed to ensure the policy for appraisal of emergencies was treatment specific related to any individual who presented to the hospital requesting emergency care. Findings:

Interview with the Director of Nursing (DON) S1, and the Nurse Consultant, S2, on 11/18/10, 10:30 AM, revealed the hospital did not have an Emergency Department. When asked about the provision of emergency care to patients presenting to the hospital with an emergent condition, S1 and S2 stated the hospital staff would provide care, such as cardio-pulmonary resuscitation, and 911 (Emergency Medical Services) would be called and the patient transferred to an acute care hospital.

Review of policy and procedure "Non-Patient Medical Emergency" revealed "The hospital has no emergency services and will follow the procedure below for handling medical emergencies arriving at the facility". "A medical emergency is defined as a situation existing when anyone presents to the hospital with physical symptoms of a medical problem such as fainting, seizure, heart attack, injury, etc. The following actions will be taken in the event that an emergency situation presents to the facility: 1) Assess the situation, 2) Call 911, 3) Provide supportive care (i.e. CPR) until Emergency Services arrive."

The policy failed to identify the patient's emergent condition would be evaluated by a Registered Nurse, the procedure for evaluating the emergent condition, and the supplies required to provide emergency care to the patient.

Based upon review of the Performance Improvement Program Activities and staff interview, the hospital failed to ensure performance improvement projects were conducted. Findings:

Review of the Performance Improvement Program Activities revealed there failed to be evidence the hospital had implemented performance improvement projects. Interview with the Director of Nursing on 11/18/10 confirmed the hospital had not conducted any performance improvement projects.

Based upon reviews of 2 of 2 medical records (#1,6, who received respiratory therapy services), Administrative and staff interviews, the Registered Nurse failed to ensure each patients' care was evaluated by an RN as evidenced by patient #s1 and 2, who received respiratory interventions and did not have a documented RN evaluation relative to the effectiveness of the respiratory intervention. Findings:

Review of patient #1's medical record revealed a medical diagnosis of COPD (chronic obstructive pulmonary disease) and a physician's order, dated 11/05/10, for treatment (every 6 hours), with Albuterol and Atrovent (medications used in respiratory diseases, administered by inhalation) via hand held nebulizer (HHN).

Review of a form titled "Respiratory Care Department", that was in patient #1's medical record revealed the following documentation:
11/05/10 8pm, Licensed Practical Nurse (LPN) S26 documented: "Breath Sounds before Tx (treatment): wheezing" "Breath Sounds after tx: decreased wheezing"
11/06/10 8am, LPN S8 documented: "Breath Sounds before tx: wheezing" "Breath Sounds after tx: Same"; 2pm "Breath Sounds before tx: wheezing" "Breath Sounds after tx: decreased wheezing"
11/06/10 8pm, LPN S24 documented: "Breath Sounds before tx: wheezing" "Breath sounds after tx: decreased wheezing".

Continued review of the respiratory care documentation revealed LPNs S7, 8, 23, 24, 25, and 26 continued with documentation from 11/07/10 8am through 11/17/10 8am (8am, 2pm, 8pm, 2am). The 2am treatments were documented as "asleep".

Review of the "Breath sounds" documentation revealed the LPNs (S7, 8, 23, 24, 25, and 26) failed to describe the location (i.e. both lungs; throughout lung fields; upper, middle, or lower lobes) in patient #1's lung where the "wheezing", "diminished", and "coarse" sounds were heard.

Review of the respiratory care documentation revealed there failed to be evidence patient #1's respiratory status had been evaluated by an RN before or after the respiratory treatment.

Review of patient #6's medical record revealed a physician's order, dated 11/09/10, for HHN treatments with Albuterol and Atrovent.

Review of the "Respiratory Care Department" form, contained in patient #6's medical record, revealed LPNs S7, 8, 23, 24, 25 and 26 had documented, 11/09/10 through 11/17/10, "Breath sounds" before and after treatments as "wheezing", "crackles", "congestion & wheezing", "wheezing, Rhonchi"; however, they failed to document the location of these sounds. (i.e. both lungs; throughout lung fields; upper, middle, or lower lobes)

Continued review of the respiratory care form revealed there failed to be documented evidence an RN had evaluated patient #6's respiratory status before or after respiratory treatments.

Interview, 11/17/10 at 10:40am, with LPN S7 revealed she had not received training from a respiratory therapist or RN relative to respiratory assessments prior to her performing respiratory treatments/interventions. LPN S7 stated a "nurse" had shown her how to do the respiratory treatments; further questioning revealed LPN S7 could not remember the name of the "nurse".

Interview, 11/18/10, with Director of Nursing (DON) S1 confirmed the nurses (LPNs and RNs) had not received training prior to them performing respiratory care services. DON S1 further confirmed patient #'s 1 and 6 had not had their respiratory status evaluated by an RN, nor was their responses to the respiratory interventions administered by LPNs evaluated by an RN.

Based upon reviews of medical records (6 of 12), Administrative and staff interviews the hospital failed to ensure all entries in the patients' medical records were legible as evidenced by the documentation authenticated by the Psychiatric Nurse Practitioner (S16) and the attending Psychiatrist (S18) in medical records of patients #s 1,3,7,9,11, and 12. Findings:

Review of patient #1's medical record revealed a "Physician's Admit Note/Psychiatric Evaluation", dated 11/05/10, and authenticated by Psychiatrist S18. Continued review of the Physician's Admit Note/Psychiatric Evaluation (dated 11/12/10), revealed a section titled "Reason for Admission/Signs/Symptoms/Precipitating Factors". Interviews, 11/17/10, with hospital staff members (Registered Nurse S3 and Health Information Management Person S4) confirmed they were unable to read the documentation under this section that had been documented by Psychiatrist S18.

Review of patient #3's medical record revealed Psychiatrist S18 had authenticated the documentation on the form titled "Physician's Admit Note/Psychiatric Evaluation, dated 11/12/10. Interview, 11/17/10, with hospital staff members, Registered Nurse (RN) S3 and Health Information Management (HIM) S4 revealed they were unable to read the documentation on this form authenticated by Psychiatrist S18.

Review of patient #7's medical record revealed a Psychiatric Evaluation, dated 06/24/10, and authenticated by Psychiatric Nurse Practitioner (NP) S16. Interviews, 11/17/10, with RN S3 and HIM S4 confirmed they were unable to read the documentation on this form made by NP S16.

Review of patient #9's medical record revealed a Psychiatric Evaluation, dated 09/07/10, and authenticated by NP S16. Interviews, 11/17/10, with RN S3 and HIM S4 confirmed they were unable to read all of the documentation on this form made by NP S16.

Review of patient #11's medical record revealed a form titled "Physician's Admit Note/Psychiatric Evaluation", dated 11/09/10, and authenticated by NP S16. Interviews, 11/17/10, with RN S3 and HIM S4 revealed when they were asked if they could read the documentation contained on this form, both replied, "only some of it".

Review of patient #12's medical record revealed a "Physician's Admit Note/Psychiatric Evaluation", dated 11/12/10, with documentation and authentication by NP S16. Interviews, 11/17/10, with RN S3 and HIM S4 revealed when they were asked if they could read the documentation on this form, both replied "only some of it".

Interviews, 11/17/10, 8:55am, with RN S3 and HIM S4 confirmed the medical records for patient #s 1,3,7,9, 11 and 12 contained documentation that was not legible.

Interview, 11/17/10, 2:10pm, with psychiatric Nurse Practitioner S16 agreed his documentation in patients' medical records was not legible. S16 was questioned if he had received telephone calls from nurses concerning his documentation on orders; he replied he attempted to print plainly on the orders; however, he did confirm his documentation on the Progress notes and psychiatric evaluations was not always legible.

Interviews, 11/18/10, with Director of Nursing S1 and HIM S4 confirmed Psychiatrist S18 and NP S16's documentation in patients' medical records were not legible.

Based upon review of contract service agreements, physician roster, and staff interview, the hospital failed to ensure there was a qualified full-time, part-time, or consulting radiologist to interpret radiological tests provided by Contract A Hospital. Findings:

Review of the hospital's physician roster and interview with the credentialing person, S4, revealed the hospital did not have a Radiologist on the Medical Staff. Interview with the Nurse Consultant (S2) and the Director of Nursing (S1) on 11/17/10, revealed the Radiological Services were provided by Hospital Contract A, and the Radiologists from this hospital interpreted the radiological tests performed. When asked if there were any Radiologists appointed to the Medical Staff, S1 and S2 replied "no".

Based upon reviews of credentialing files (5of 5, #s S17, 18, 19, 20, 21), Governing Body/Medical Staff meeting minutes, and Administrative interviews the hospital failed to ensure a Medical Director for Respiratory Therapy Services had been appointed. Findings:

Review of physician credentialing files for #s S17, 18, 19, 20, and 21 revealed the Medical Staff had not appointed a physician (and approved by the Governing Body) to act as the Director of Respiratory Services.

Review of Governing Body/Medical Staff meeting minutes, dated Jan-Oct 2010, revealed a lack of documented evidence a physician had been appointed by the Medical Staff and approved by the Governing Body to act as the Director for Respiratory Services.

Interview, 11/18/2010, 10:35am, with Director of Nursing (DON) S1, confirmed the hospital had not appointed a physician to serve/act as the Director of Respiratory Services.

Based upon review of hospital policies and procedures and Administrative interviews, the hospital failed to ensure the Medical Staff had formulated and implemented policies and procedures relative to respiratory treatments and/or interventions. Findings:

Review of the hospital's policies and procedures revealed there lacked documented evidence policies and procedures relative to Respiratory Services treatments/interventions had been formulated and implemented.

Interviews, 11/18/2010, 10:35am, with Director of Nursing (DON) S1 and Corporate Compliance Registered Nurse S2, confirmed the Medical Staff had not formulated and implemented Respiratory Therapy Services policies and procedures.

Based upon review of hospital policies and procedures and Administrative interview the hospital failed to ensure written policies that defined the type of respiratory therapy services provided by the hospital and the qualifications of the personnel who were to perform the respiratory procedures had been formulated and implemented. Findings:

Review of hospital policies and procedures revealed there lacked policies and procedures specific to Respiratory Therapy Services.

Interview, 11/18/10, 10:35am, with Director of Nursing (DON) S1 confirmed the hospital did not have policies and procedures specific to Respiratory Therapy Services that the hospital provided. DON S1 further confirmed there lacked written procedures and the amount of supervision required to perform respiratory care services provided by the hospital.

Based upon reviews of 9 of 12 psychiatric evaluations (patients 1,3,4,5,7,8,10,11,12) and Administrative interview the hospital failed to ensure the psychiatric evaluation included an evaluation of the patients' assets. Findings:

Review of patient #1's psychiatric evaluation, dated 11/05/10, and documented by psychiatrist S18, revealed under the section titled "Patient Assets" a circle had been placed around the typewritten "Family". Continued review of the psychiatric evaluation revealed there lacked other documentation relative to patient #1's assets.

Review of patient #3's psychiatric evaluation, dated 11/12/10, documented by psychiatrist S18, revealed a section titled "Patient Assets" with a circle placed around the typewritten "Family/Peer support" and "Motivated". Continued review of the psychiatric evaluation revealed there lacked other documentation relative to patient #3's assets.

Review of patient #4's psychiatric evaluation, dated 11/08/10, documented by psychiatrist S18, revealed under the section titled "Patient Assets" there lacked documentation. Continued review of the psychiatric evaluation revealed there lacked documented evidence relative to patient #4's assets.

Review of patient #5's psychiatric evaluation, dated 11/05/10, documented by psychiatric Nurse Practitioner S16, revealed a section titled "Patient Assets". Under "Patient Assets", psychiatric Nurse Practitioner S16 had placed a hand written "R.F." next to the typewritten "other". Further review of the psychiatric evaluation revealed there lacked documented evidence of patient #5's assets.

Review of patient #7's psychiatric evaluation, dated 06/24/10, documented by Nurse Practitioner S16, revealed under "Patient Assets", S16 had placed an "x" by "Family" and "Other". Next to the typewritten "Other", S16 had handwritten "RF". Further review of the psychiatric evaluation revealed there failed to be other documentation relative to patient #7's assets.

Review of patient #8's psychiatric evaluation, dated 08/16/10, documented by psychiatrist S18, revealed under the section "Patient Assets", S18 had place a check mark next to "Motivated". Further review of the psychiatric evaluation revealed there failed to be other documentation relative to patient #8's assets.

Review of patient #10's psychiatric evaluation, dated 09/17/10, documented by psychiatrist S18, revealed a section "Patient Assets". Psychiatrist S18 had placed a circle around a typewritten "Motivated"; and "Family/Peer support" had a line placed through it and "NH" had been handwritten above "Family/Peer support". Further review revealed a lack of other documentation relative to patient #10's assets.

Review of patient #11's psychiatric evaluation, dated 11/09/10, documented by Nurse Practitioner S16, revealed a section titled "Patient Assets". Nurse Practitioner S16 had placed a mark next to "Other" and had handwritten "R.F./med/tx compliant". Continued review of the psychiatric evaluation revealed there failed to be other documentation relative to patient #11's assets.

Review of patient #12's psychiatric evaluation, dated 11/11/10, documented by Nurse Practitioner S16, revealed a section titled "Patient Assets". S16 had placed a mark next to "Other" and had handwritten "R.F..." Continued review of the psychiatric evaluation revealed there failed to be other documentation relative to patient #12's assets.

Interviews, 11/18/10, with Director of Nursing and Corporate Compliance Registered Nurse S2, confirmed the "Patient Assets" portion on the psychiatric evaluations for patient #s 1,3,4,5,7,8,10,11, and 12 were not completed.