The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ATOKA COUNTY MEDICAL CENTER 1590 WEST LIBERTY ROAD ATOKA, OK 74525 Feb. 20, 2013
VIOLATION: RECORDS SYSTEM Tag No: C0301
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure:

a. there were written policies and procedures to insure the integrity and security of patient records;

b. each entry in the medical record identified the author; and

c. patient records were accurate, completed and readily accessible.
Findings:

1. On 01/15/13, staff LL stated there were no electronic medical record policies and procedures.

2. The clinical record for patient #8 documented electronic entries made by "Nurse A". Staff were unable to determine exactly who "Nurse A" was, but they guessed it was probably an agency nurse. After researching the issue, the staff were unable to identify Nurse A.

The clinical record, over 60 days old, had an incomplete history and physical examination report. The discharge summary had no final diagnosis. A physician's progress note, dated 10/14/12, referred to the patient as "he" and "his" although the patient was a female.

3. The clinical record for patient #9, (a swing bed patient), had no order to admit to swing bed status. There were no physician's orders written for swing bed care. The last written nurse's note was documented on 10/21/12 at midnight. The patient was discharged during the day on 10/21/12. There were no nurse's notes that documented the condition of the patient after midnight or the patient's condition at the time of discharge. There was no nursing discharge summary and no documentation of discharge instructions given.

4. The clinical record for patient #6 had no history and physical examination report on the chart.

5. The clinical record for patient #7 had no orders for swing bed status and no physician's orders for swing bed care.

6. A pre-operative assessment for patient #20 had no signature of the person who documented on the record.

7. On 01/15/13, Staff LL verified there was no process in place to audit charts for the deficiencies identified above.
VIOLATION: NURSING SERVICES - DRUG ADMINISTRATION Tag No: C0297
Based on observation, clinical record review and staff interview, it was determined the hospital failed to ensure verbal orders were limited to urgent situations and not used routinely and for convenience. Findings:

1. The clinical records for patients #1 through #19, documented multiple verbal orders for each patient. There were very few written physician orders found in these records.

2. On 01/15 and 01/16/13, observations were made of nursing staff writing verbal orders when the physician was present and could have written the orders.

3. There was no documentation by the nursing staff to indicate the verbal orders were repeated back to the physician.

4. The verbal orders did not include all the required elements. For example, medication orders did not always include the purpose or indication for use. The time of the verbal order was not always documented.

5. Not all verbal orders had been authenticated by the physician within a reasonable time. A review of closed clinical records indicated some records had unsigned verbal orders older than 90 days.

6. When asked, unit staff nurses stated verbal orders were "the norm" and were a usual practice at the hospital.
VIOLATION: CLINICAL RECORDS Tag No: C0300
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to meet Medicare CFR 485.638 Condition of Participation for Clinical Records, as evidenced by failure to provide:

a. written policies and procedures to insure the integrity and security of electronic patient records. See Tag C-0301;

b. clinical records that were complete and documented all care provided. See Tag C-0302;

c. patient identifying information and social data, properly executed informed consents, complete and timely history and physical examinations, complete discharge summaries and complete discharge instructions to patients. See Tag C-0304;

d. sufficient information in the clinical record in order to monitor the patient's condition and to provide adequate care. See Tag C-0306;

e. staff signatures on all clinical records and authentication of all entries made in the medical record. See Tag C-0307; and

f. failure to provide policies and procedures to guide the staff on the use and retrieval of electronic medical record information and to guide staff on actions to take when the electronic medical record system is down. See Tag C-0309.
VIOLATION: PERIODIC EVALUATION OF PATIENT RECORDS Tag No: C0333
Based on record review and interviews with hospital staff, the hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records.

Findings:

1. Governing Body, Medical Staff and Compliance Committee meeting minutes for 2012 and 2013 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Hospital personnel stated on the afternoon of 01/15/13 in the afternoon that they did not have an annual periodic evaluation that included a representative sample of active and closed medical records.
VIOLATION: PERIODIC EVALUATION OF POLICIES Tag No: C0334
Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's (critical access hospital's) health care policies.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2012 and 2013 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program which included a review of all of the CAH's health care policies. Some policies reviewed had a cover sheet with the signatures of the CEO, Chairman of the Board of Trustees, Chief of Staff and the Chief Nursing Officer (CNO). The policies did not reflect the current procedures utilized by hospital staff.

2. Interviews with hospital personnel on the afternoon of 01/15/13 in the afternoon stated that the hospital had not conducted an evaluation of its total program at least annually which included a review the CAH's health care policies.
VIOLATION: PERIODIC EVALUATION Tag No: C0335
Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2012 and 2013 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program to determine if services were effectively utilized, policies were followed and if changes were needed.

2. Hospital staff stated on the afternoon of 01/15/13 that they had not conducted a periodic evaluation that included all the requirements.
VIOLATION: ANNUAL PROGRAM EVALUATION Tag No: C0331
Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's (critical access hospital's) health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Interviews with hospital personnel on the afternoon of 01/15/13 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of active and closed records, hospital policies and procedures and evaluation of the services provided and if changes were needed.

2. Governing Body and Medical Staff meeting minutes for 2012 and 2013 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.
VIOLATION: EVALUATIONS - PRE-OP & POST-OP Tag No: C0322
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure all patients are evaluated for proper anesthesia recovery. Findings:

The clinical record for one (patient #20) of four records reviewed had no documentation of a post-anesthesia evaluation by the CRNA who provided anesthesia.

There were no surgery or anesthesia department policy and procedure that directed staff on post-anesthesia evaluation requirements.

On 01/16/13, staff K verified this finding.
VIOLATION: AGREEMENTS - LIST OF SERVICES Tag No: C0291
Based on record review and interviews with hospital staff, the hospital failed to ensure that a list of all services provided through arrangements, contracts or agreements is maintained describing the nature and scope of the services provided. The list of contracted services provided by the hospital did not define the nature and scope of the services. This was verified by hospital staff.
VIOLATION: PROVISION OF SERVICES Tag No: C0270
Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to meet Medicare CFR 485.635 Condition of Participation for Provision of Services, as evidenced by failure to provide:

a. comprehensive policies and procedures to guide staff on the provision of patient care. See Tag C-0270;

b. policies developed with the collaboration of healthcare specialists, such as physicians, registered nurses, dietitians, and CRNAs (certified registered nurse anesthetists). See Tag C-0272;

c. policies to describe specific services provided by the hospital and those services provided through contractual agreement. See Tag C-273;

d. guidelines for the scope of practice for physician assistants. See Tag C-0275;

e. pharmaceutical services provided and implemented according to current policies and procedures that have been approved by the pharmacy director with appropriate input from staff and committees and in a safe manner. See Tag C-0276;

f. policies and procedures for the identification and investigation of medication errors. See Tag C-0277;

g. a comprehensive infection control program. See Tag C-0278;

h. nutritional services to meet the needs of the patients. See Tag C-0279; and

i. failure to provide an annual review of all patient care policies and procedures. See Tag C-280.
VIOLATION: PATIENT CARE POLICIES Tag No: C0273
Based on review of hospital documents and observations, and interviews with hospital staff, the hospital failed to develop and revise policies and procedures and delineation of services the hospital furnishes directly or those furnished through an agreement or contract.

Findings:

1. A list of hospital services provided by contract reviewed during the survey did not specify what each contracted service provides for the hospital.

2. The hospital's "Organizational Plan for Provision of Patient Care Services", provided by the administrator to the surveyors on 01/15/13, documents, "...Scope of services provided by each department is defined in writing..."

3. Respiratory Services - The hospital's "Organizational Plan for Provision of Patient Care Services", section XX, records, "...The services of the respiratory care department are available to all patients (adult, pediatric, and neonatal) 7 days a week, 12 hours a day..." The plan records "...the following services are available: 1. Therapeutic Treatments: Passive aerosol nebulizer, chest physiotherapy, incentive spirometry, Metered does inhaler, naso-tracheal suction, Pentamidine treatment, Intermittent positive pressure breathing. 2. Oxygen: Nasal cannula, face tent, croupette, non-rebreathing mask, Simple mask, trach collar, ventimask, partial rebreathing mask, Aerosol mask oxy-hood, T-Bar, CPAP/Bi-PAP, portable. 3. Critical Care: Mechanical ventilatory support tracheal suctioning, Airway management, patient transport assist. 4. Diagnostic Services: Arterial blood gas analysis, bronchoscopy assist, Sputum induction, pulmonary function testing, Pulse oximetry, end tidal CO2 monitors, PFT testing, Halter monitor testing.
Any respiratory order provided by medical staff can be performed by the nursing team. The respiratory care department provides the services of a respiratory care practitioners from 6:30 a.m. until 3:00 p.m. 5 days a week....The respiratory care department has a policy to establish priorities for service delivery..."

a. Staff B told the surveyors the respiratory therapist was a contract service. (This was confirmed by review of contract on 01/15/13 and by interview with the respiratory therapist on 01/23/13.) According to Staff B, he works 8 hours a day, Monday through Friday. This was confirmed by the respiratory therapist, staff L on 01/23/13 at 1115. He stated his extended contract was due to expire sometime in February.

b. The last time the respiratory policies and procedures were reviewed by a respiratory therapist was 01/19/2005. The respiratory therapist who reviewed and revised the policies is not the current respiratory therapist. On 01/23/13 at 1120, the current respiratory therapist confirmed he had not reviewed and updated the respiratory policies.

c. Although the hospital's "Organizational Plan for Provision of Patient Care Services", section XX record "...respiratory services will be provided 12 hours a day...", respiratory services- oxygen and nebulizer treatments- are ordered and documented as provided around the clock/twenty-four hours a day.

d. The hospital's respiratory policies and procedures manual does not contain policies and procedures for Pentamidine treatment, CPAP/Bi-PAP, oxy-hood, oxygen administration by face tent, listed in the hospital's "Organizational Plan for Provision of Patient Care Services", section XX.

e. The hospital does not have policies and procedures describing the scope of services that can be performed/provided at the hospital or delineating who can perform what respiratory services.

f. The hospital's "Organizational Plan for Provision of Patient Care Services", section XX documented nursing staff could perform respiratory services when the respiratory therapist was not available, but personnel files reviewed showed nursing staff had only been trained and competency verified by respiratory therapist on nebulizer treatments and pulse ox. On the morning of 01/23/13, Staff L confirmed he had not performed any training or competency testing since he had been at the hospital.

g. The respiratory policy on N-95 respirator masks stipulated that the respiratory therapist would perform fit testing yearly. Personnel file review did not demonstrate this have ever been done for nursing personnel. When interviewed on 01/01/16/13, Staff E, F, K and I stated they had not been fit tested for the N-95 mask and did not know if the hospital had any of the masks. On the morning of 01/23/13, Staff L stated he had not done any fit testing on the staff and although he had been told the hospital had the N-95 masks, he had not been able to find any and no one had been able to show him where they were located. On 01/23/13 at 1540, Staff B contacted another staff and a partial box of N-95 masks were located in the supply room. There were no enough types and sizes of N-95 particulate respirator masks available for all staff who may need them in an airborne isolation room.

h. The hospital's "Organizational Plan for Provision of Patient Care Services", section XX, referred to ventilator services being provided at the hospital, but Staff B stated it would only be for emergency and patients requiring the service would be transferred. The respiratory policy referred to a Bear 1000 ventilator. This ventilator was found in a storage shed on 01/18/13 by one of the surveyors and Staff V. Staff was unsure if the ventilator was in working order. On the afternoon of 01/23/13, Staff L told the surveyors that he had pulled the portable ventilator, Auto Vent 3000, located in the ER Trauma Room 1, before because of a "cracked head". He stated he had tried to order a replacement, but was on back order. Staff L stated the ambulance service had been able to provide him with "one that fit" so it could be placed back in use. Asked what staff did/would do while the portable ventilator was down, Staff L stated they had to use ambu bags until the ambulance arrived and they could be switched over to the ambulance's ventilator. On 01/23/13, at 1550, the surveyor observed the Auto Vent 3000. The pressure hose had a tear/cut in the outer casing exposing the inside sheath. This was observed by Staff B at the time. At 1555 on 01/23/13, Staff L stated he was unaware of the tear. Staff L stated that besides himself, he thought the emergency room (ER) physicians and one ER registered nurse, Staff I, knew how to operate the portable ventilator, but that he was unaware of any documentation of competency.

Staff I's personnel file was not reviewed, but she told the surveyor, on the afternoon of 01/16/2013, that she had been hired by the past Director of Nurses (CNO) and did not remember any documentation of orientation and training being completed. She stated no training/competency verification had been provided since her initial training.

Staff L told the surveyors that since he was only "certified, not registered", he could not do any training. Staff L's personnel file did not contain competency verification by the hospital.

i. On 01/15/13, the clinical record for patient #6 contained a nursing progress note at 11:00 a.m. that documented the patient was receiving oxygen at two liters per minute delivered by a nasal cannula. During an observation of the patient, no oxygen was being administered. Staff F was asked if the patient should be wearing the oxygen cannula. She stated, "She should. She needs it, but she won't wear it." There was no order for oxygen administration in the patient's chart.

Staff F, the RN on the inpatient unit, was asked if she had been trained on the administration of oxygen. She stated she had not.
VIOLATION: POLICIES - DRUG MANAGEMENT Tag No: C0276
Based on record review, observation and interviews with hospital staff, the hospital does not ensure that the provision of pharmaceutical services is provided and implemented according to current policies and procedures that have been approved by the pharmacy director with appropriate input from staff and committees and in a safe manner. Pharmacy policies and procedures presented for review were not reflective of current hospital processes. Pharmacy staff, consisting of a Consultant Pharmacist who had been on the job about two weeks and the the Drug Room Supervisor a LPN (licensed practical nurse), who had been on the job a little over a month, and currently providing pharmaceutical services in the hospital have not been trained and competency assessed for providing pharmaceutical services in the drug room within the scope of their license and in accordance with all Federal and State laws, regulations and guidelines.

Findings:

1. The Consultant Pharmacist stated on 01/14/13 in the afternoon that her experience as a pharmacist was in retail pharmacy and infusion pharmacy. She said she had not had hospital pharmacy experience. The current Consultant Pharmacist had only been acting as the Pharmacist In Charge (PIC) for less than two weeks. There had been no orientation or training on hospital and pharmacy procedures or how to use the hospital's computer system to monitor and control drugs throughout the hospital.

2. The Drug Room Supervisor, who had been working in this position for a little over one month, did not have evidence of experience being a Drug Room Supervisor in her personnel file.

3. Drugs are stored in the hospital mainly in three Pyxis machines, automated medication dispensing machines. Pharmacy/Drug Room policies and procedures were not developed and implemented by the hospital describing how medications stored in the Pyxis are to be accessed and by whom and how this process works.

4. Pharmacy policies and procedures had a cover sheet signed by the CEO (Chief Executive Officer), Chairman of the Governing Board, CNO (Chief Nursing Officer), who no longer works at the hospital and the Chief of Staff on 05/22/12 signifying the policies were reviewed and approved . The pharmacy/drug room policies did not have evidence of review and approval by the Consultant Pharmacist .

3. The process for ordering Scheduled drugs on the DEA (Drug Enforcement Agency) 222 narcotic requisition forms did not reflect the same process that was stated in the pharmacy policy and procedure manual. Of the authorized persons documented in the policies and procedures only one was still working at the hospital. According to staff II, the Drug Room Supervisor, in an interview on 01/15/13 in the afternoon, the authorized person was the Drug Room Supervisor, a Licensed Practical Nurse (LPN) who had only been employed since December 2012, a little over a month. There was no evidence that this had been approved by the pharmacist or the CEO. There was no evidence that the Drug Room Supervisor had been oriented and trained and deemed competent to work as a Drug Room Supervisor in the drug room. This person did not have any experience as a Drug Room Supervisor in her personnel file.

4. The hospital has been without a Drug Room Supervisor, which is required by Oklahoma Hospital Licensure Standards and Oklahoma State Board of Pharmacy regulations for licensed drug rooms, for one entire week due to the illness of the Drug Room Supervisor. The person (Staff R) identified to the surveyor as the person assigned to the drug room, had not been designated by the CEO and the Consultant Pharmacist to be the Drug Room Supervisor, but was working in that capacity. There was no documentation the facility had trained this person to be the Drug Room Supervisor. There was no documentation the Pharmacist had overseen training.

2. On 01/23/13 in the afternoon, Staff R, was asked who was acting in the Drug Room Supervisor's absence. She stated that she was, but she was also working as a nurse on the floor taking care of patients. She said she was called in when the hospital needed to order drugs. The CEO and the Consultant Pharmacist had not designated Staff R to be an alternate Drug Room Supervisor.

3. Staff F, the charge nurse, stated when asked who accessed the drug room, that the key was just given to whoever needed to get into the drug room. State hospital and pharmacy regulations require that access to the drug room is restricted to authorized personnel.

4. There was no evidence from nursing personnel files, meeting minutes reviewed and interviews with Staff C, the human resource manager, that nursing personnel had been instructed on who could access the drug room.
VIOLATION: EMERGENCY PROCEDURES Tag No: C0230
Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to develop and implement a comprehensive emergency preparedness plan. Findings:

1. The hospital disaster plan did not include a risk assessment to identify the types of disasters that may occur within the hospital and in the community. For example, the hospital provides hyperbaric services and relies on internet and intranet connectivity to support patient care. The hospital is also located across the street from a small general aviation airport. There are oil and natural gas industries in the community, as well as farming and ranching.

2. The hospital did not have evidence the plan was developed and periodically reviewed in coordination with local emergency management officials.

3. There was no evidence of annual internal and external disaster drills.

4. The disaster plan was not updated to include current staff names, phone numbers and disaster response job assignments.

5. An incident report dated 06/01/12, documented, "... At 9:03 AM all incoming and outgoing electronic transmission were interrupted due to a severed fiber optics line, which was confirmed by AT&T. The services interrupted include phone, fax, and data transmission (i.e. internet service). The areas affected are Radiology (orders and results), Lab (orders and results), Nursing (orders and results), Pharmacy (orders), and all other areas depending on these services for continuity of care. As of 11:55 AM there was still no resolution to the issue..."

6. There was no documentation this event was handled as an internal disaster. There was no comprehensive analysis to include how each hospital department was affected and what actions each department took to maintain, modify, or suspend patient care services during the event.

7. There was no documentation of the total duration of the event, any lasting effects on hospital departments and/or systems, and the identification of new or on-going problems.

8. There was no evidence each department had documented an identified problem list with corrective action plans and suggestions for modification of the hospital-wide disaster plan.

9. There was no evidence policies and procedures were developed or modified in response to the event. At the time of the survey, the information technology staff stated there were no policies and procedures in place for internet/intranet "downtime" events.

10. According to reports received at the Oklahoma State Health Department (OSDH) on 01/02/13, the hospital central heating system was not working. Documents provided to OSDH indicated attempts were made to contact the CEO for permission to have the system repaired. In the meantime, employees were to provide "extra blankets" for the patients. There was no documentation the facility implemented an internal disaster plan. There was no documentation the facility analyzed patient care areas and services. There was no comprehensive analysis to include how each hospital department was affected and what actions each department took to maintain, modify, or suspend, patient care services during the event.

11. On 01/16/13, the CEO and the COO acknowledged the disaster plan was not current.

12. Review of documents, policies, and processes does not stipulate the facility has considered the unique risks associated with a hyperbaric chamber. There were no policy and procedures developed and implemented to ensure safe operation, mitigation of risks, and potential disaster situations posed by hyperbarics and hyper-oxygenated areas.
VIOLATION: EMERGENCY PROCEDURES, TRAINING Tag No: C0227
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to train staff on disaster preparedness. Findings:

1. The hospital disaster plan was reviewed. The plan did not include identification of the types of disasters more likely to occur in the community. The hospital is located across the street from a small general aviation airport. There are oil and natural gas industries in the community, as well as farming and ranching.

The plan did not include what type of training staff would receive, or when and how often they would be trained. The plan did not include regular disaster drill exercises.

2. On 01/15 and 01/16/13, 18 staff education files were reviewed. The files had no documentation that disaster preparedness was included in new employee orientation or in annual re-training.

3. The hospital had no disaster training program to include departmental and individual job assignments in the event of various internal and external disasters.

4. On 01/14/13, the quality and risk manager was asked if disaster training was included in routine employee training. She stated the staff were trained on fire safety.

5. On 01/16/13, two registered nurses were asked what to do in case of a fire. Neither could explain what actions they should take. When asked if they were familiar with the RACE protocol (rescue, alarm, contain, extinguish/evacuate), they said they were familiar with it, but did not think of it and did not remember any training on it.

6. When asked about other emergency preparedness training, one CNA stated she knew what to do in the event of a tornado. None of the staff interviewed stated they had been trained on various internal and external disasters. They stated they were not aware of their roles and responsibilities during a disaster. They stated they had not been involved in disaster drills.

7. Again on 01/23/13, nursing staff were asked if they had received any additional emergency preparedness training during the interval since the surveyors were last on-site. They stated they had not.

8. On 1/15/13, surveyors requested a complete set of construction drawings for fixed equipment, mechanical and electrical systems, and life safety drawings as required by NFPA (National Fire Protection Association)101. Surveyors also requested manufacturer's equipment manuals for the building's fixed equipment. The Director of Plant Operations could not locate several of the construction drawings and equipment manuals. He was not able to locate a fire system life safety drawing. He did not have knowledge of critical points for the fire alarm system so that accurate checks of all of the system could be performed.

9. The Director of Plant Operations did not have a key to access the main gas shut off valves to the hospital and the hyperbaric chamber. He told surveyors he had not been oriented and trained on these items.

10. On 01/15/13, the surveyors requested a complete set of construction drawings for fixed equipment, mechanical and electrical systems, and life safety drawings as required by NFPA . Surveyors also requested manufacturer's equipment manuals for the building's fixed and biomedical equipment. The Director of Plant Operations could not locate several of the construction drawings and equipment manuals.

He was not able to locate a fire system life safety drawing. He did not have knowledge of critical points for the fire alarm system so that accurate checks of all of the system could be performed.

He did not have a key to access the main gas shut off valves to the hospital and hyperbaric chamber. He stated he had not been oriented and trained on these items.

11. On 01/15/13, surveyors observed two yellow tags on the main fire panel. One tag, dated 11/19/11, documented, "... unit 1 + 5 are in trouble and do not shutdown on alarm!..." Another tag, dated 11/15/12, documented, "... 3 troubles on the panel..."

On 01/15/13, surveyors asked for documents stipulating the contractor had repaired the fire alarm system. There was no documentation the system had been repaired.

On 01/18/13, yellow tags were observed still on the system. According to documents provided later in the survey, on 12/18/12 the system was repaired. However, the hospital did not have documentation to show a re-acceptance test in accordance with NFPA 72, 7-1.6.2.. The Director of Plant Operations stated he was unaware of the need for the documentation and the need for a re-acceptance test.

12. According to NFPA 99 19-3.1.3.3 "The ultimate responsibility for the care and safety of patients and personnel is that of the governing board. Hence it is incumbent upon that body to insist that adequate rules and regulations with respect to practices and conduct in hyperbaric facilities, including qualifications and training of hyperbaric personnel, be adopted by the medical or administrative staff of the institution, and that adequate regulations for inspection and maintenance are in use by the administrative, maintenance, and ancillary (and in the case of a hospital, nursing and other professional) personnel. "

During a tour of the hospital on [DATE], the surveyors observed a hyperbaric program within the hospital's licensed space. There was no evidence the hyperbaric chamber and the risks associated therein had been assessed and addressed through plant operations and the governing body. There was no documentation the governing body had appointed a hyperbarics safety officer.

The Director of Plant Operations stated he didn't know anything about the hyperbaric chamber. He stated he had no orientation and training regarding hyperbarics.

There was no documentation the general staff had been trained on hyperbaric chamber safety risks. There was no documentation the hyperbaric chamber had been considered an internal disaster risk in the hospital disaster preparedness plan.

The Director of Plant Operations stated he could not locate the key to access the main oxygen shut off valve to the hyperbaric equipment.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on surveyors' observations, review of medical records, personnel and credential files, infection control and hospital documents and meeting minutes, and interviews with hospital staff, the hospital failed to:

1. Ensure the person designated as the infection control officer/preventionist (ICP) has ongoing education in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program;

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

3. Analyze infection control surveillance data and concerns, develop corrective actions when needed and conduct follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

Findings:

Upon arrival on the morning of 01/14/13, the surveyors requested the infection control policies and procedures, all surveillance for the past year, and meeting minutes where infection control activities were performed. The surveyors were told infection control was part of the Quality program and infection control activities would be conducted there. The policy manual had a review date of 2005.

The organizational charts provided to the surveyors 01/14 and 01/23/13 did not contain Infection Control.


Infection Control Preventionist:
1. At the same time on 01/14/13, the surveyor requested and name and personnel file, with documentation of training, of the Infection Control Officer/Professional/Preventionist (ICP). Administrative staff told the surveyors that the Chief Nursing Officer, Staff E, was the ICP.

2. Review of Staff E's personnel file did not contain documentation of any training or prior experience in infection control. The personnel file did not contain a job description for ICP. Staff C stated on 01/15/13 that she did not have any additional data or training to add for review.

3. Meeting minutes did not reflect Staff E had been appointed the ICP.

4. On 01/16/13 at 1310 Staff E confirmed that she did not have any training or experience in developing and directing an infection control program and analysis of infection control data and plans.

5. On the morning of 01/23/13, Staff O, the laboratory manager, told the surveyors that he was told by administration that he had been put in charge of infection control as of the evening of 01/16/13. He stated he had not been designated in writing and did not have any infection control training in developing and directing an infection control program and analysis of infection control data and plans. This was confirmed by personnel file review.


Infection Control Plan:
1. The plan contained in the Infection Control Policy and Procedure Manual was last revised in February 2005. The surveyors were told that this was the current plan. Although the plan documented the program would include preventive surveillance of all departments, including surgical practices, to ensure policies and procedure were followed, and review of infections, patients and staff, with analyzed and required follow-up action, it did not describe the methods or frequency of surveillance/monitoring.

2. On 01/15/13 at 0945, Staff B brought the surveyors two more infection control plans and stated these were the correct current infection control plans.
a. Although the heading on one documented it was for the hospital, the plan was for a much larger hospital and was not appropriate for this size hospital (a 25-bed Critical Access Hospital). It documented "targeted" surveillance and "residents of treatment units" being "responsible for maintaining a safe and clean living area." It recorded keeping of the infection control committee meeting minutes and forwarding it to Director of Compliance. The hospital does not have a separate infection control committee. It is part of Quality/Compliance.
b. The second "Plan" was also for a much larger facility, with the initials of CHH, and was not appropriate for this small rural hospital with a single 25-bed nursing unit. This plan identifies its facility has two infection preventionists - "Both are registered nurses; one is master's prepared with documented training in infection control practices and is certified in infection control. The second registered nurse is newly hired and working towards a master's in nursing informatics and certification in infection control." It also documents an infection control committee, "sanctioned by the Medical Executive Committee and is a multidisciplinary team. The Chairperson of the Infection Control Committee is a physician with special education and experience in infection control practices." The document describes "units" and disciplines, such as dental and residents, that the hospital does not have.

3. The hospital has not conducted a hospital-wide infection control risk assessment to identify the types of patients, risks/concerns, organisms, and diseases prevalent in the community and hospital. This was confirmed with administrative staff on 01/15/13.

4. According to the documents provided, the last tuberculosis risk assessment was performed in 2002. No further documents were provided.


Surveillance:
1. The only surveillance provided to the surveyors for review was the positive laboratory culture log.

2. The Centers for Disease Control (CDC) and the Association for Professionals in Infection Control and Epidemiology (APIC) have identified hand hygiene as the first avenue/most important tool in the prevention of spread of organisms and diseases. The infection control program does not monitor hand hygiene practices throughout the hospital and does not have a tool for monitoring.

3. The infection control policies and procedures contain sections with infection control policies and procedures for each department of the hospital. The infection control program has not monitored to ensure the policies were followed.

4. Surgical services and central sterile is not monitored, including, but not limited to, use of disinfectants and sterilizing practices.

5. There is no monitoring of endoscopes to ensure cleaning and disinfecting are completed appropriately.

6. Isolation is not monitored to ensure:

a. Patient are placed in appropriate isolation according to current CDC guidelines,

b. Isolation carts are stocked appropriately,

c. Staff, physicians, volunteers, and visitor follow appropriate isolation requirements.

7. The hospital has a negative pressure room. The room has not been monitored to ensure it is kept in working order.

8. Employee illness and infections are not monitored to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.

9. No monitoring of disinfectant applications throughout the hospital departments and locations.


Policies and Procedures:

1. The infection control manual had the appropriate requirement for N-95 respirators with the requirement that the respiratory therapist was to do fit testing of staff yearly.

a. The policy did not give detail of how this was to be accomplished. (The respiratory manual did not contain a policy on N-95 respiratory of fit testing.)

b. Personnel files contained no documentation of N-95 fit testing.

c. When asked, nursing staff stated no fit testing had been performed.

2. The infection control program does not have policies and procedures on how patients with potential or confirmed influenza will be medically managed, including:

a. Screening,

b. Any required tests to confirm infection,

c. Any particular requirements according to current CDC guidelines

d. Procedure for reporting reportable infections and diseases to the proper authorities, with delineation of responsibilities.

3. Policies concerning the use of the negative airflow room, including:

a. What patients will be placed in the room

b. What would need to be done if the room was occupied and another patient was admitted requiring respiratory isolation or if another patient was admitted that CDC recommended placing the patient in negative airflow rooms.

4. Policies on disinfectant approval and list of approved disinfectants with what area used and application requirements, including:

a. mixture

b. wet time contact with surface to be effective

c. what organisms the disinfectant kills

5. Policies concerning what immunizations and documentation the hospital will require of staff (employees, contract, physicians, allied health and volunteers), based on CDC and its Advisory Committee on Immunization Practices (ACIP) and as required by State Licensure Hospital Standards.

6. Policies and procedures outlining and describing the procedure for working with local, State, and Federal health authorities in emergency preparedness situations and to address communicable disease threats and outbreaks,


Observations:

1. The hospital's infection control policy, AMH Volunteers with effective date of February 2005, records, "..Upon implementation of Bloodborne Pathogen guidelines Atoka Memorial Hospital volunteers no longer perform longer perform duties that require direct in-patient contact..." On 01/15/13 one surveyor observed a volunteer pushing a cart with ice delivering it to patient rooms. On the afternoon of 01/16/13, another surveyor observed a volunteer having patient contact to deliver water to the patient.

2. On the afternoon of 01/15/13, surveyors accompanied plant management, Staff V, to the negative airflow room. Staff V was unable to activate the negative flow. Staff V told the surveyors that it had been turned off because the alarm kept going off. He stated he thought the alarm went off because the nurses kept leaving the door open.

3. On the afternoon of 01/15/13, nursing staff told the surveyors that Patient #1 was in droplet observation for flu (influenza). The only documentation on Patient #1's medical record that gave any indication the patient had influenza was the physician's order for Tamiflu (oseltamivir phosphate), medication used to treat influenza. The dosage prescribed was for active influenza and not the prophylactic dose. No laboratory tests had been performed or ordered to confirm influenza. The patient was admitted on [DATE]. Other that orders, the only documentation from the physician was the History and Physical from the patient's 12/30/2012 hospital stay. This record documented the patient had pneumonia. Nursing staff could not tell the surveyors why they felt this patient had influenza .

One surveyor observed two of seven patients reviewed had been on Tamiflu, but no laboratory testing had been performed. The dosage prescribed was for active influenza. This was not monitored through infection control and no evidence was found that the hospital had reported any cases of influenza.

4. On the morning of 01/23/13, the surveyors observed a patient in Room #107 with documentation the patient was in contact isolation. When the surveyors asked Staff F about this, she stated the patient was really in reverse isolation for a very low white cell count. When asked how they determined what type of isolation, she stated it's whatever the doctor tells them.

On the afternoon of 01/23/13, Staff F told the surveyors that she thought they also had a policy concerning the required type of isolation. She handed the surveyors a policy and procedure manual. The table of contents did not contain any policies on isolation. The surveyors went through the manual, but no policies for isolation were found.


5. On 01/16/13, the operating rooms and the sterile processing areas were observed. Staff were asked for infection control policies for the OR and for sterile processing. The staff said they had no policies available to them.


Steam Sterilization and Flash Sterilization:

The staff were asked for flash sterilization records. They stated they did not have any flash sterilization records or a log that documented when flashing was done. They stated they had no flash sterilizing policy and procedures. They were asked for policies and procedures or manuals for the use of the sterilizers. The staff said they did not have any.

Sterilization records were reviewed. The Sterrad records did not document what items were contained in each load. The steam sterilizer envelopes documented instruments contained in each load, but there were no sterilizer tapes that documented the parameters of the sterilizing cycles.

Endoscope Processing:

The staff stated they used a manufacturer's guide for the endoscope processor but they had no hospital policy on it's use. The endoscope processing records had no documentation of who processed the scopes. There was no documentation of "pass/fail" for the scope processing.

The staff person who worked in sterile processing stated she was oriented to the hospital OR. She stated her formal training for sterile processing included a two week experience in her surgical technology training program. She stated she had some on the job experience at her last place of employment, but sterile processing was not her primary job. She stated she had no formal sterile processing course or certification.

4. On the afternoon of 01/15/13, staff were interviewed about the use and availability of N-95 respirators. Staff could not identify when the masks would be needed or the location of any N-95 masks. They stated they have not been fitted for N-95 respirator masks. This was confirmed by personnel record review.


Meeting Minutes:

1. Meeting minutes that contained infection control information did not contain an analysis of infections reported in the hospital, noting those infections that were hospital acquired (HAI/nosocomial) with corrective actions (including, but not limited to, change of policies and procedures and/or disinfectants, and education to staff) when needed and conduct follow-up to ensure corrective actions are appropriate and sustained. The log of positive lab cultures reflect nosocomial infections. These were not mentioned in meeting minutes. No analysis of employee illnesses and infections had occurred to ensure transmissions of organisms and communicable diseases were not being transmitted between staff and patients.

2. The minutes did not contain a review of disinfectant utilized throughout the hospital with a review by infection control to ensure they were effective against the prevalent organisms of the hospital. The Policy, with an approval and review date of June 21, 2012, provided to the surveyors by Staff B on 01/15/13, documented "materials Management will select the cleaning and disinfection solutions to be used." The policy did not contain evidence the ICP would be involved in the selection to ensure the disinfectants chosen were appropriate and effective for their intended purpose.

3. Meeting minutes did not contain review of employee health and immunization status. Nine (Staff F, G, K, L P, Q, R, S, and T) of twelve staff and seven of seven physicians and allied health did not have complete immunizations histories as required by State Licensure Hospital Standards or as recommended by ACIP and CDC. Three of three temporary agency nurse files reviewed had no documentation of current TB skin testing. The contracted dietitian and the contracted activities/social services staff had no immunization or TB skin testing records.

4. Meeting minutes did not reflect isolation procedures and requirements had been reviewed, investigated and corrective action taken when needed.
a. Staff did not know the location of N-95 respirator masks and had not been fit tested .
b. The negative airflow patient room was non-functioning.

5. Meeting minutes did not reflect aseptic and sterile practices for surgery services, were identified, reviewed and analyzed with corrective actions and follow-up.

6. Meeting minutes did not demonstrate infection control problems observed by the surveyors had been addressed.

7. Meeting minutes did not reflect staff infection control education needs had been identified and an ongoing infection control training program had been instituted. Personnel files only contained initial orientation tests/questionnaires on infection control. No further training opportunities had been provided.

8. Meeting minutes did not demonstrate the hospital had conducted a hospital-wide risk assessment of the prevalent organisms and diseases in the community and that might present to the hospital and from this information develop a current infection control plan with details of monitoring for providing a sanitary environment and avoid sources and transmission of infections.

9. Meeting minutes did not demonstrate the Governing Body had evaluated the infection control program and the ICP position to:

a. Ensure the hospital had an effective and ongoing infection control program to provide a safe and sanitary environment and avoid sources and transmission of infections; and

b. Ensure a qualified professional with education and ongoing training in the principles and methods of infection control in order to develop, establish and direct an ongoing/sustainable infection control program was appointed the ICP.
VIOLATION: POLICIES - MED ERRORS & ADRS Tag No: C0277
Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to develop a system for identifying and investigating medication errors and failed to ensure the physician was notified when an error occurred.

Findings:

1. The pharmacy policy and procedure manual stated that medication errors would be entered on an incident report, reviewed by the Risk Manager and categorized according to severity, type, cause and drug class involved.

Review of the 2012 QA/PI and Compliance meeting minutes did not have evidence of in depth medication error review and analysis. The medication error information reported to the committee consisted of raw data (numbers) only. There was no documentation the details of medication errors were reported in any committee meeting.

2. On 01/15/13 and 01/16/13, open and closed medical records were reviewed. Daily twenty-four hour chart checks to verify accurate transcription and processing of physician's medication orders was not always completed by the nursing staff.

3. On 01/15/13, the clinical record for patient #6 documented,
"... 01/09/13... Stalevo 25/200/100 [one by mouth three times a day]..." The medication administration record documented Stalevo 25/200/100 was given every day from 01/09/13 through 01/14/13.

An unsigned note to the physician, dated 01/12/13, documented, "... don't have the above dose [Stalevo 25/200/100] - have Stalevo 37.5/150/200..." On 01/14/13, the physician documented on the form, "...OK..."

On 01/15/13, the RN charge nurse, staff K, was asked to review the patient's medication administration record, the physician's orders, and the note to the physician. She was asked if she could determine what dosage of Stalevo the patient received on each day. After reviewing the documents, she stated she couldn't be sure.

She was asked if it was likely the patient received Stalevo 37.5/150/200 every day since the original order, and not the dose ordered by the physician, since the higher dose was the only dose of Stalevo the hospital supplied in the pharmacy. She stated it was possible.

She was asked if this was a medication error. She stated it probably was. She stated if the staff did not have the medication in the dose ordered by the physician, they should have immediately called to have the order changed.

The medication found on the patient care unit was Stalevo 37.5/150/200. Staff K stated she believed this was the only dose of the medication ever provided to the patient.

Nursing and medical record staff stated regular chart audits were not performed. Nursing staff stated medication errors were found "by accident". She stated she wasn't sure incident reports were completed for medication errors.

4. Patient #6 was ordered to have a Duragesic Patch applied every 72 hours. The medication administration record documented the patient received a Duragesic Patch at the following intervals:

01/11/12 at 5:00 p.m., then
01/12/12 at 9:00 a.m. (16 hours later) then again on
01/14/13 at 8:52 a.m.. (approximately 48 hours later).

The medication was not given at 72 hour intervals as ordered by the physician. The medication was discontinued by the physician after reports in the medical record indicated the patient was too sedated.

Staff K stated she did not believe this had been identified by anyone as a medication error.

5. Review of the former Consultant Pharmacist's reports for August 29 and 31, 2012, September 3 and 14, 2012 documented multiple notifications to nursing about medication errors. Consultant Pharmacist report for 09/28/12 stated "Spoke with nursing about nursing not clarifying med errors. Nurse said she was given reports but didn't know what to do with it." Some error discrepancies from 3 days prior not rectified."

There were no medication errors documented in the incident reports for September 2012.

Errors documented on incident reports from February 2012 through December 2012 did not have the name of the medication just "med error or med omission."

6. The Consultant Pharmacist report dated August 31, 2012 documented a phone conversation between the Consultant Pharmacist and the charge nurse on duty. Patient was ordered Dobutamine 2.5 mcg (micrograms)/kg (kilogram)/min.(minute). Charge nurse called the pharmacist to clarify the mcg/kg/min as well as figure the dose based on patients current weight of 255 lbs. The nurse first stated the medication was Dopamine. I figured dose at 255 mcg/min and notified nurse that any number greater than 240 required a central line for Dopamine and to call Doctor to see what his next orders were. She stated Dr. [name deleted] is on a plane and can't be reached. I stated to call who is covering for him or ER (emergency room ) PA (physician assistant) to assist. The nurse stated would probably just give 240 mcg dose to be safe. The pharmacist told the nurse that a new order would be needed for an order outside 2.5 mcg/kg/min or would be a med error. The pharmacist called the PA on duty to see if he was aware of the situation and he was not and was extremely busy with 5 current patients in ER. The PA said sorry, but I can't assist at this time. The pharmacist then logged into the computer system checking orders and noticed the patient's order was for Dobutamine. The pharmacist then called the nurse to inform her of this. She said yes the order was for Dobutamine and may have misspoke saying Dopamine. The pharmacist told the nurse that no central line was necessary, but patient needed to be carefully monitored via BP (blood pressure) and ECG (electrocardiogram). The pharmacist told the nurse to ask the CNO (Chief Nursing Officer) for assistance since she was unfamiliar with information from GlobalRPH.com (a drug information website) concerning Dobutamine. The pharmacist told the nurse to call back before administering if the site didn't cover what she needed to know. The pharmacist also called the hospital human resources director to let her know my concerns with the CNO and charge nurse not being familiar with Dopamine or Dobutamine guidelines or how to dose if the hospital was going to administer. The pharmacist called his pharmacist employer and told him of the situation. He agreed I needed to come to the Drug Room to assist ASAP [as soon as possible] and provide any knowledge or help. There was no incident report made about this.

7. On 01/15/13, the second day of the survey, the new Consultant Pharmacist (employed for less than two weeks), when asked about medication errors, stated that the first two patient charts she reviewed for correctness contained medication errors. One of the examples the consultant pharmacist gave was that the nurse gave a regular aspirin instead of an enteric coated aspirin. The doctor's order was for an 81 mg (milligram) enteric coated aspirin. She stated that she instructed the nurse on the difference and why that was a medication error. There was no evidence an incident report was initiated.
VIOLATION: POLICIES - NUTRITION Tag No: C0279
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure:

a. development and implementation of comprehensive dietary and nutritional services policies and procedures approved by the dietitian, the medical staff and the governing board;

b. a qualified person was appointed by the medical staff and the governing board to be responsible for the daily management of dietary services;

c. the contracted dietitian adequately supervised and/or provided the nutritional aspects of patient care;

d. therapeutic diets were ordered by qualified practitioners; and

e. failed to ensure documentation of the patient's daily meal intake, fluid intake and the provision of nutritional supplements.
Findings:

1. Dietary policies and procedures were reviewed. The documents provided by staff had no evidence of review and approval by the dietitian, the medical staff and the governing board.

There was no dietary department description that included the scope of nutritional services provided by the hospital. There was no organizational chart that detailed the management and reporting structure of the department.

The policies did not include descriptions and requirements for therapeutic diets. The policies did not indicate what types of alternative means of nutrition could be provided, such as tube feedings, parenteral nutrition, etc. The policies did not include how nutritional supplements would be provided to patients, such as furnished by the dietary department or by nursing staff from a unit supply.

There were no policies to address how diets were ordered or how diet orders were to be changed. There was no policy stating only a licensed independent practitioner could order a therapeutic diet, or change a patient's diet.

There were no policies and procedures that described regular nutritional assessments and who was responsible for them.

2. According to hospital documents and staff interview on 01/14/13, a registered/licensed dietitian was contracted as a consultant to the hospital. Staff B stated the dietitian was present at the hospital once a month and performed a kitchen survey, some staff training and assessment of acute bed patients in the hospital on that day.

The dietary manager provided records of monthly dietitian visits. The only documentation from the dietitian was on a form kept in the dietary department. The form included a table with patients' names and recommendations to "continue the plan of care" or an occasional recommendation of a therapeutic diet. There was no corresponding documentation of this information in the patients' clinical records that could be found by the surveyors.

There was no documentation provided of any comprehensive nutritional assessments that were performed by the dietitian.

3. Staff B stated the dietary manager was in charge of the daily management of dietary services.

The dietary manager was not certified in dietary management and did not have documented education, experience or other training to qualify as the director of food and nutrition services.

A policy titled, "Dietary Manager's Responsibilities", did not include accountability for collaboration with the dietitian and did not include quality assurance or performance improvement responsibilities. The policy did not include nutritional assessment responsibilities.

Staff B stated the dietary manager was not qualified or trained to contribute to nutritional assessments and was not performing them. However, she stated the dietitian was in the process of teaching the dietary manager to do them. No documentation of this was found in the records provided.

There was no dietary policy and procedure that designated the scope of practice for all members of the dietary department. There was no policy that described the scope of services to be provided by the dietitian.

4. There was no documentation the dietitian provided comprehensive nutritional assessments for the patients reviewed, although nutritional assessments were indicated. There was no documentation of collaboration with medical staff, nursing staff or pharmacy staff. There was no documentation the dietitian provided patient, family or caretaker dietary counseling or education.

There was no documentation the dietitian audited clinical records for appropriate nutritional assessments. There was no documentation the nursing staff performed basic nutritional assessments or consulted with the dietitian when indicated.

The staff were asked for policies and procedures that described when and how the staff (dietary, nursing or others) could consult with the dietitian. None were provided. The staff were asked for policies and procedures that described what services the dietitian provided to the various healthcare staff. None was provided.

When clinical records indicated the patient's physical status required a comprehensive nutritional assessment, the nursing staff were often documenting no consultation was required or no dietitian assessment was necessary.

When nursing staff were interviewed, they did not know how to contact or consult with the dietitian. The nursing staff were not familiar with the electronic nutritional assessment portion of the comprehensive patient assessment. They could not locate nutritional information on the electronic medical record.

5. Patient #9 was admitted with diagnoses which included first and second degree burns to both legs and feet, a urinary tract infection, diabetes mellitus type II, Alzheimer's disease and dementia. The patient was ordered to have a high protein, pureed diet. The clinical record documented the following daily meal intake for breakfast, lunch and dinner:

10/13/12: 10% for all three meals

10/14/12: 45%, 15%, and 10%

10/15/12: 0%, 50%, no documentation for dinner

10/16/12: no documentation for the day

10/17/12: 40%, 15% and 10%

10/18/12: 10%, 15% and 10%

10/19/12: 0%, 0% and no documentation for dinner

10/20/12: 0% for all three meals

10/21/12: no documentation for the day

A nurse's note, dated 10/13/12, documented the patient had "dark amber urine." There was no documentation the physician was notified of this finding. There was no documentation extra fluids were offered to the patient.

The patient had abnormally high blood sugar levels for the entire stay in the hospital. There was no documentation the nursing staff notified the physician or consulted with the dietitian.

There was no documentation of a comprehensive nutritional assessment by the nursing or dietary staff.

6. Patient #11 was admitted with an IV, a foley catheter and a diagnosis of debility and generalized weakness. The physician ordered a heart healthy diet. The clinical record had no documentation of the type of diet provided to the patient, or of amounts consumed. There was no nutritional assessment and no documentation of consultation with the dietitian.

7. On 01/15/13, a review of in-patient records (patients #6 through #12) indicated staff nurses were ordering therapeutic diets without a physician's order, or were changing diet orders without a physician's order.

Patient #7 was admitted to the hospital with orders for a regular diet and nutritional supplement shakes to be given three times a day. There was no documentation of a nutritional assessment or consultation with the dietitian.

On day three of admission, the clinical flowsheet documented the patient was receiving a regular soft diet, and then an 1800 calorie ADA soft diet. There was no corresponding physician's order for this. On day five, the physician ordered a mechanical soft diet.

Staff F was asked to find where the supplement shakes were documented in the electronic medical record. She stated she wasn't sure where those were documented. No documentation of the supplement shakes could be found.
VIOLATION: QUALITY ASSURANCE Tag No: C0337
Based on record review and interviews with hospital staff, the hospital does not ensure that an effective quality assurance program is implemented and evaluates the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI (quality assessment and performance improvement) program. All patient care services and other services affecting patient health and safety are not evaluated and the hospital does not collect and analyze data concerning the quality and appropriateness of all patient care services affecting health and safety furnished in the CAH (critical access hospital).

Findings:

1. There is no documentation incidents, complaints, grievances, medication errors, surveillance activities are reviewed and analyzed with performance improvement plans developed and implemented to improve patient health and safety.

2.. Nursing and medical record staff stated regular chart audits were not performed. Nursing staff stated medication errors were found "by accident". Twenty-four hour chart checks of physician's medication orders were not always done.

3. Mechanical problems identified by hospital staff were not reviewed through the QAPI program and action taken to correct the problems.

4. Computer problems identified through staff interviews during the survey were not identified and analyzed and action taken through the QAPI program.

5. Services provided by contract or arrangement are not evaluated by the QAPI program.

6. These findings were reviewed at the exit conference. No further documentation was provided.
VIOLATION: QA - MEDS & INFECTIONS Tag No: C0338
Based on record review and staff interview, it was determined the hospital failed to ensure medication errors and nosocomial infections were identified, analyzed and that action was taken to improve the care and safety of patients.

Findings:

1. QAPI (quality assessment and performance improvement) minutes did not have documentation medication errors or nosocomial infections were analyzed to determine root causes, trends, actions taken to prevent recurrence and evaluation of those actions.

2. There was no documentation in governing body, medical staff or any quality meeting minutes documenting review and action on medication errors or nosocomial infections.

3. Nursing and medical record staff stated on 01/15/13 regular chart audits were not performed. Nursing staff stated medication errors were found "by accident". Twenty-four hour chart checks of physician's medication orders were not always done.


4. The pharmacy policy and procedure manual stated that medication errors would be entered on an incident report, reviewed by the Risk Manager and categorized according to severity, type, cause and drug class involved. Review of the QA/PI/Compliance meeting minutes did not have evidence of medication error review and analysis of medication errors. The data reported was only numbers.
VIOLATION: RECORDS SYSTEM Tag No: C0302
Based on clinical record review and staff interview, it was determined the hospital failed to ensure the clinical record was complete and documented all care provided. Findings:

The hospital was asked to provide printed copies of electronic records (including all scanned documents) for patients #12, 20 and #21.

1. The records provided included computer screen shots that did not contain all the information actually documented by the authors.
The screen shots did not allow the reader to see complete documentation in the fields where free text was written.

2. Some of the forms in the electronic record had no documentation at all.

3. Some scanned documents (EKG strips) were not readable.

4. Some electronic records did not have scanned documents attached.

5. Some staff assigned to retrieve and print electronic records were no adequately trained to do so. Not all medical record staff were able to produce a complete, readable, printed copy of the electronic medical record.

6. On 01/15/13, staff LL stated not all medical record staff were proficient in retrieving a complete medical record from the electronic system.
VIOLATION: RECORDS SYSTEM Tag No: C0304
Based on clinical record review and staff interview, it was determined the hospital failed to ensure all patient medical records contained patient identifying and social data, properly executed informed consents, complete and timely history and physical examinations, completed discharge summaries and complete discharge instructions for patients. Findings:

1. Patient #1 had been in the hospital for five days. The clinical record had no face sheet that included identifying information and social data.

2. The clinical record for patient #8 was over 60 days old. It had an incomplete history and physical examination report that had not been dictated until the day of the patient's discharge. There was no discharge summary.

3. The clinical record for patient #9 had no documentation of discharge instructions given.

4. The clinical record for patient #6 had no history and physical examination report.

5. The clinical record for patient #20 had a consent form for a diagnostic procedure. The procedure was grossly misspelled. The person who signed the document was not identified as self, guardian, spouse, etc. The history and physical exam had no final diagnosis documented. Incomplete discharge instructions were found in the record. The record had no discharge summary.

6. The clinical record for patient #21 had a consent for a diagnostic procedure. The person who signed the document was not identified as self, guardian, spouse, etc. There was no witness designated on the consent. The history and physical exam had no final diagnosis documented. The record had no discharge summary.

7. The clinical record for patient #12 had a consent for a surgical procedure. The consent had no date and time the document was signed. The history and physical exam had no final diagnosis documented.

8. Clinical records for swing bed patients had no discharge summaries completed at the time of discharge from the acute care admission.

9. On 01/15/13, medical record staff confirmed on-going problems with the completion of medical records.
VIOLATION: RECORDS SYSTEM Tag No: C0306
Based on clinical record review and staff interview, it was determined the hospital failed to ensure the patient's medical record contained sufficient information in order to monitor the patient's condition and to ensure adequate care for four (#9,12, 20 and #21) of four records reviewed. Findings:

1. Patient #9 was admitted to a swing bed. There was no comprehensive nursing assessment completed at the time the patient was admitted to the swing bed. There were no physician's orders for admission to the swing bed. There were no nurse's notes after midnight on 10/21/12. The patient remained in the hospital for several hours after that time, and was discharged that day. There was no documentation of the patient's condition after midnight.

There was a physician's order for discharge planning, but no documentation of discharge planning activities.

2. The electronic clinical record for patient #12 contained the following findings:

Surgery Pre-Op Assessment:

~There was no documentation the patient was properly identified (picture ID, etc.) at the time of admission for surgery.

~ Lactated Ringers was administered to the patient, but there was no documentation of how much fluid was started and no documentation of an administration flow rate.

~ There was no documentation whether or not the patient was on an anti-coagulant or aspirin therapy prior to surgery.

~ There was no documentation when the patient's routine home medications were last taken prior to surgery.

~ There was no documentation of prior history of difficulty with sedation or anesthesia.

~ There was no documentation of family history of anesthetic reactions.

~ The cardiovascular assessment documented "other" conditions, but these conditions were not described or detailed.

~ There was a code number ("2") under the headings of respirations, circulatory, level of consciousness, color, and activity, but there was no legend to explain what "2" meant.

~ There was no documentation a pre-operative checklist was completed by the pre-op nurse.

~ The anesthesia care orders were not dated and timed, and and had no order to start intravenous fluids, although the patient did receive IV fluids.

Nursing Intra-Procedure Record:

~ The "time out" was performed by the circulating RN and the CRNA (certified registered nurse anesthetist) only. There was no documentation the physician and the scrub tech were included in the "time out" procedure.

~ There was no documentation as to what operating room suite was used for the procedure. There was no nursing documentation of the time the patient left the operating room to go to recovery.

~ There was no documentation of the type of anesthesia or sedation used. There was no nursing documentation of anesthesia start and stop times.

~ Nursing documented the procedure performed was "replace battery in pacemaker". The physician documented the procedure performed was a replacement of the entire pacemaker.

~ Fluoroscopy was used during the procedure. No total fluoroscopy time was documented by the RN.

~ There was no documentation of patient positioning and padding devices used.
~ There was no documentation of the type of skin prep solution used.
~ There was no documentation of how much injectable lidocaine was administered by the physician during surgery.
~ There was no documentation of medical equipment used during surgery, including a cautery device (and placement of the grounding pad) and patient warming devices.

~ The surgeon documented Ancef was used to irrigate the surgical site. The circulating RN did not document this in the intra-operative record.

~ There was no documentation of the type of wound closure used on the patient and no documentation of the type of dressing applied.

~ There was no nursing documentation of the newly implanted pacemaker to include the type, manufacturer and other required information associated with an implantable device.

PACU Record:

~ There was no documentation discharge instructions were given to the patient or representative.

3. The electronic medical record for patient #21 contained the following findings:

History and Physical Examination:

~ There was no documentation of a final diagnosis and no clearance by the physician to proceed with anesthesia or sedation as planned.

Informed Consent:

~ The form had no designation of the relationship or capacity of the person signing the consent. There was no witness designated.

Surgery Pre-Op Assessment:

~ The record documented the patient was admitted for an EGD. There was no documentation of a reason for the procedure, except "to look at the stomach."

~ Documentation in the nursing physical assessment and history section documented the patient had no gastrointestinal problems.

~ The physician documented the patient had epigastric pain.

~ There was no documentation the patient was identified with a picture ID or other approved method prior to surgery.

~ There was documentation an IV was started with Lactated Ringers, but there was no documentation of the amount of fluid started and the administration flow rate.

~ There was no documentation of a complete set of vital signs taken in the pre-op area prior to surgery.

~ There was no documentation the patient's dentures were removed and secured prior to the procedure.

~ There were no current medications or prior surgeries documented on the record. However, another form listed 23 medications the patient routinely took at home. Many of the medications could potentially affect anesthesia administration.

Intra-Procedure Report:

~ There was no documentation on this report. There was no nursing documentation of the intra-operative care provided or of the surgical procedure found in the clinical record.

Operative Report:

~ The physician's operative report had no documentation of the presence or absence of complications.

4. The electronic medical record for patient #20 contained the following findings:

History and Physical Examination:

~ There was no documentation of a final diagnosis and no clearance by the physician to proceed with anesthesia or sedation as planned.

Informed Consent:

~ The procedure on the consent form was grossly misspelled.

~ The form had no designation of the relationship or capacity of the person signing the consent.

Pre-Op Admission Form:

~ The pre-op checklist was not completed prior to surgery.

Surgery Pre-Op Assessment:

~ There was no documentation of the patient's weight prior to surgery.

~ There was no documentation the patient was identified with a photo ID or other approved method prior to surgery.

~ There was no documentation of current medications or previous surgeries.

~ There was documentation an IV was started with Lactated Ringers, but there was no documentation of the administration flow rate.

~ There was no documentation of the author of the pre-op assessment.

Anesthesia Care Orders:

~ There were no pre-operative anesthesia care orders documented, although an IV was started on the patient prior to surgery.

Intra-Procedure Report:

~ There was no documentation on this report. There was no nursing documentation of intra-operative information found in the clinical record.

Anesthesia Record:
~ The anesthesia record had no documentation of a post-operative evaluation.

Operative Report:

~ The operative report had no documentation of the presence or absence of complications.

Discharge Instructions:

~ There were no complete discharge instructions found in the record.

5. On 01/15/13, Staff LL verified there was no process in place to audit charts for the deficiencies identified above.
VIOLATION: QA - DOCUMENTATION Tag No: C0343
Based on record review and interviews with hospital staff, the hospital does not insure that a functioning QA/PI (quality assessment and performance improvement) system is implemented so that remedial action can address deficiencies found through the QA/PI program. Review of Governing Body and Medical Staff meeting minutes for 2012 and 2013 and interviews with hospital staff during the survey did not have evidence the hospital has a functioning QA/PI program that identifies deficiencies and implements remedial action.

Findings:

1. There was no evidence medication errors identified by the Consultant Pharmacist were analyzed and a plan of action instituted through a functioning QA/PI program. See Tag C 277.

2. The CAH (critical access hospital) did not implement a plan of action to correct deficiencies identified in the physical plant and environment through a functioning QA/PI program. See Tag C 0220.
VIOLATION: QA - PERFORMANCE IMPROVEMENT Tag No: C0342
Based on record review and interviews with hospital staff, the hospital does not insure that a functioning QA/PI (quality assessment and performance improvement) system is implemented so that remedial action can address deficiencies found through the QA/PI program. Review of Governing Body and Medical Staff meeting minutes for 2012 and 2013 and interviews with hospital staff during the survey did not have evidence the hospital has a functioning QA/PI program that identifies deficiencies and implements remedial action.

Findings:

1. There was no evidence medication errors identified by the Consultant Pharmacist were analyzed and a plan of action instituted through a functioning QA/PI program. See Tag C 277.

2. The CAH (critical access hospital) did not implement a plan of action to correct deficiencies identified in the physical plant and environment through a functioning QA/PI program. See Tags C 0220, 0221, 0222, 0223, 0224, 0225, 0226, 0227, 0228, 0229, 0230 and 0234.
VIOLATION: GOVERNING BODY Tag No: C0241
Based on record review, observations and interviews with hospital staff, the governing body does not ensure that oversight of the hospital is provided to assure safety and quality of care for patients.
Findings:

1. According to an employment agreement between the Atoka County Healthcare Authority, d/b/a Atoka County Medical Center (Owner) and Staff A the CEO (Manager) the following duties were agreed upon,

"... Article II. Manager's responsibilities, 2.7 Maintenance and Repair. At the sole expense of the Owner and in the name of the Owner, Manager shall, with the prior approval or other direction of Owner and in accordance with the Approved Budget, make, install or cause to be installed all reasonably necessary and proper repairs, replacements, additions and improvements in and to Hospital, its furnishings and equipment, in order to keep and maintain the same in good repair, working order and condition in the same general manner as other hospitals of a similar nature in the geographic area in which the Hospital is located..."

a. Serious mechanical deficiencies were not corrected in a timely manner. See Tag C 0220.

2. According to an employment agreement between the Atoka County Healthcare Authority, d/b/a Atoka County Medical Center (Owner) and Staff A the CEO (Manager) the following duties were agreed upon,

".... Article II. Manager's responsibilities 2.17 Quality Assurance, Performance Improvement, Risk Management and Utilization Review Manager shall assist Owner in the support of its quality assurance, performance improvement, risk management and utilization review plans... Specifically, Manager will assist Owner in fulfilling its obligation to its patients to maintain high quality hospital services, including patient satisfaction programs, employee education, outcomes analysis, utilization programs, clinical protocol development and risk management programs.... The costs of such programs as may be authorized by the Board shall be a Hospital Expense...."

a. Staff were not oriented and trained to assure competency when providing patient care. See Tag C 0294.

b. An annual periodic evaluation of the hospital's total program and a quality assurance plan that identifies problems, implements corrective actions and evaluates whether remedial action is needed was not implemented by the Governing Body. See Tags C 0330, 0331, 0333, 0334, 0335, 0337, 0338, 0342 and 0343.


3. According to an employment agreement between the Atoka County Healthcare Authority, d/b/a Atoka County Medical Center (Owner) and Staff A the CEO (Manager) the following duties were agreed upon,

".... Article III. Personnel Matters 3.1 Personnel Matters Manager shall use reasonable efforts to advise and assist Owner with respect to recruiting, hiring, training, promoting, assigning, supervising and discharging the medical, nursing, administrative, and any other staff providing service at Hospital... Such efforts shall include advice and consulting concerning the number and qualifications of employees needed in the various departments of Hospital.... Manager shall also use reasonable efforts to advise and assist Owner with respect to the formulation, implementation, modification and administration of wage scales, rates of compensation, employee benefits, rates and conditions of employment, in-service training, attendance at seminars or conferences, staffing schedules, job descriptions and personnel policies with respect to all staff of Owner and/or Hospital.... Manager, in the name of Owner, as appropriate, may hire, discharge and supervise the work of all employees of Owner performing services in or about Hospital...."

a. Adequate staff was not provided for safe and competent patient care. See Tags C 0200 0252, 0253, 0276, 0294 and 0295.

4. The CEO's Curriculum Vitae lists him as Chief Executive Officer over Atoka County Medical Center a non-profit, public trust, 25 bed critical access medical center in Atoka, Oklahoma and [hospital name deleted] Hospital, a non-profit, public trust, 25 bed critical access hospital approximately 32 miles away.

5. The CEO stated on 01/14/13 in the afternoon that staff were shared between the two hospitals. He stated nursing, administrative, medical records, human resources and plant operations and others would be shared. During the survey the surveyors observed several hospital staff were working at both hospitals. The CEO was at the other hospital the first day of the survey. The nurse identified as the CNO was not available at the hospital the second day of the survey because she was working as a staff nurse in surgery at the other hospital. On 1/15/13, surveyors observed unrestricted access to the hospital's main electrical panel. Staff V, the plant operations director, was notified of the finding. Again on 1/18/13, surveyors observed the same unsecured access to the electrical panel. On 1/23/13, surveyors noted the same findings. Staff V told surveyors he had been too busy with the other co-managed hospital to get anything done.
VIOLATION: ORGANIZATIONAL STRUCTURE Tag No: C0240
Based on observation, interview and review of hospital documents, the governing body failed to provide the following:

1. A preventive maintenance program for the buildings physical plant, fixed building equipment, and clinical equipment to assure a safe environment of care;

2. Education, training, assessment of competency for all staff (clinical and non-clinical);

3. Review, revision, approval, and implementation (orientation and training) of hospital policies and procedures;

4. Assurance of trained and competent staff for the care and safety of patients; assurance of adequate staff to meet the needs and complexities of the patient population;

5. Review, analysis, and oversight of quality monitors, incident reports, risk management reporting, infection control monitoring, and safety monitoring to improve patient safety and minimize risk to patients.

The governing body failed to take actions to implement measures to assure quality of care and safety resulting in Condition Level Deficiencies.

Findings:

1. The Governing Body failed to ensure the maintenance of special buildings systems, fire systems, clinical and non-clinical equipment to ensure patient and employee safety. See Tags C 0220, 0221, 0222, 0223, 0224, 0225, 0226, 0227, 0228, 0229, 0230 and 0234.

2. The Governing Body failed to ensure the hospital conducts an annual periodic evaluation and has an effective and on-going quality assurance program. See Tags C 0330, 0331, 0333, 0334, 0335, 0336, 0337, 0338, 0342 and 0343.

3. The Governing Body failed to ensure the hospital's clinical and non-clinical personnel were adequately trained and oriented to hospital policies and procedures, were adequately supervised, and their clinical activities evaluated. See Tags C 0252, 0253, 0276, 0294, and 0295.
VIOLATION: RECORDS SYSTEM Tag No: C0307
Based on clinical record review and staff interview, it was determined the hospital failed to ensure clinician signatures were obtained and authenticated for entries made in the medical record for nine (#6, 7, 8, 9, 10,11,12, 20 and #21) of nine paper and electronic records reviewed. Findings:

1. The clinical records documented multiple verbal orders written by nurses but unsigned by the physicians.

2. There were dictated documents that had not been signed by the physicians.

3. The electronic medical records had documented entries with no identified authors.

4. The hospital medical records and information technology staff stated there were no policies and procedures governing the use and the security of the electronic medical record.

5. There was no evidence the entries in the record had been authenticated. One record had entries written by "Nurse A." When asked, the hospital staff could not identify this person.

6. The electronic medical records had entries that did not match the actual dates and times of service or care. There was no designation these were late entries.

7. On 01/15/13, staff LL verified that many medical records were incomplete.
VIOLATION: SUPERVISION - ANCILLARY STAFF Tag No: C0252
Based on review of hospital documents, surveyor observations and interviews with hospital staff, the hospital failed to develop and ensure staff were supervised by appropriate professional staff and all departments/services were included on the organizational chart.

Findings:

1. Although the most current organizational chart, given to the surveyors on the morning of 01/23/13, documented nursing staff was under the direction of the Chief Nursing Officer, Staff E stated on the afternoon of 01/16/13 and on 01/23/13 that Staff B, the Chief Operating Officer (COO), did the nursing scheduling and made out the schedule. Staff B told the surveyors on the morning of 01/14/13 that she was not a nurse and did not know anything about nursing when asked questions.
a. Staff F, K and I told the surveyors on the afternoon of 01/15/13 and 01/16/13 that Staff B made the schedule and she was the person they had to check with in order to approve any changes or add additional staff.
b. On the afternoon of 01/16/13, the current posted nursing schedule was reviewed. At the top of the schedule was handwritten, "This was approved thru admin (administration) can't be changed without adminis (administration's) approval. [initials of staff B]." The schedule was signed by the CEO and the COO. There was no signature by the Chief Nursing Officer. On 01/16/13 and again on 01/23/13, the Chief Nursing Officer stated she was not consulted on the nursing schedule and had no input in it's development. She stated the COO had control over the nursing schedules.
c. Posted in the emergency room staff area was a memorandum dated 12/28/12. It documented, "All schedules must be approved through Administration before being posted. After they have been approved and signed no changes are to be made unless it has been signed by [CEO and COO name deleted]. The only changes that can be made are even trades that cause no Overtime." This was signed by the CEO and the COO.

On the afternoon of 01/14/13, the Chief Executive Officer (CEO) told the surveyors that since his hire the hospital has had an "almost 100% turn-over" in personnel. This was reiterated by the Chairman of the Board (COB) and the CEO during the surveyors' exits on 01/16/13 and 01/23/13. The COB stated that there had been no control over nursing staff and since that time, if staff did not do what they expected/wanted them to do," they were gone." He stated before the CEO arrived, he felt nursing was overstaffed and over-time was abused. Although the COB made these statements, there was no evidence the entire Governing Body reviewed and analyzed these.

The COB stated, because of the changes made, the hospital has gone from being in debt to having over "three million dollars in the bank".

The Chief Operating Officer, who is not a nurse and has no clinical background, with the authorization of the COB and CEO has taken over nursing staffing control. (Refer to Tag C-295 for further details/examples.) The COB is not a health care professional. Although the CEO stated he was a RN, he does not provide patient care and does not have a license to practice in Oklahoma.

2. After review of the nursing policies and procedures on 01/14/13, the surveyors requested the nursing organizational chart. None was provided. The surveyors requested a nursing organizational chart again on 01/15/13 and 01/23/13.

a. On the afternoon of 01/15/13, Staff B, C and D told the surveyors there was no organizational chart for nursing. Again on 01/23/13, Staff B stated they still did not have a nursing organization with delineation of supervisory positions.
b. The Chief Nursing Officer was not available at the hospital on 01/14 and 01/15/13. When asked who was the supervisor in charge of nursing when the Chief Nursing Officer was unavailable, Staff B stated the hospital did not have an assistant director of nurses or nursing house supervisors. Staff B told the surveyors the floor charge nurse was in charge of nursing when the Chief Nursing Officer was absent.
c. Personnel file review for Staff F, had no documentation of a signed job description for a Charge/Supervisor position. There was no documentation of orientation or training for nursing house supervisor. Staff C stated there were no other documents available.
d. Staff F stated on 01/15/13 that she was in charge of the nursing floor only. She denied being the House Supervisor and was not in charge of nursing service. She stated she did not have any orientation, training or competency evaluation for her job except respiratory skills since she was hired in 2012.
e. On the morning of 01/16/13, Staff B brought the surveyors a policy entitled, "Chain of Command", with the last review date of 05/01/12. The policy documented, "In the absence of the CNO/DON (Chief Nursing Officer) the charge (Floor) nurse is considered the House Supervisor. Will make all decisions for the Nursing division." Staff B stated the policy was on the hospital's intranet. On 01/16/13 at 0930, the surveyors reviewed the policy on the hospital's intranet site. The computer program documented the policy was last "modified" on 01/15/13 at 1721. The policy documented it originated from an out of state health facility.
f. On 1/23/13 Staff B told surveyors the CNO was at the co-managed hospital and Staff B would notify her that she needed to come to this facility. Surveyors waited approximately 4 hours and decided to contact the CNO at the co-managed facility. When surveyors arrived at the comanaged facility, the CNO told surveyors there had been no contact from Staff B except Staff B told her she was needed at the co-managed facility to work on the floor. The CNO said there had been no attempts to contact her so she would be available for requested discussions with surveyors back at the hospital being surveyed. .

3. None of the hospital's organizational charts provided to the surveyors, (including the last version on the morning of 01/23/13) documented all the "essential services" listed in the hospital's "Organizational Plan for Provision of Patient Care Services". The organization chart did not include:
a. Medical Services/staff
b. Emergency Care Services
c. Hyperbaric Services
d. IOP (intensive outpatient psychiatric services)
e. Wound Care
f. Health and Wellness Center
g. Chaplaincy
h. Outpatient clinics

4. The hospital's "Organizational Plan for Provision of Patient Care Services" and the organizational charts also did not include Infection Control.
VIOLATION: SUFFICIENT STAFF Tag No: C0253
Based on review of hospital documents, policies and procedures and staffing sheets, surveyor observations, and staff interviews, the hospital failed to provide sufficient nursing staff.

Findings:

1. On the afternoon of 01/15/13, a surveyor observed one RN working in the ER. She was observed trying to discharge one patient, admit one patient and take care of another who had just arrive back from radiology. The nurse had no aide/CNA or other support staff to assist with patient care. Staff K stated she was the only staff there besides the physician and could not get help from the floor as they were busy also. Staff K stated she had never worked in the ER prior to this employment and had not been given any orientation or training to work in the ER. She stated when the hospital first called her to "help out" in the ER, she thought she would be following someone and doing tasks assigned with supervision. She stated she accepted the ER assignment only to find when she arrived for duty, she was the only nurse working in the ER. She stated she usually worked as the only ER nurse when she was assigned to that area. Staff K stated she was hired to work in the OR (surgery area) and that was her primary area of expertise.

Review of the staffing sheet and the calendar kept by the Risk Manager (Staff D), showed only one nurse for each 12-hour shift in the ER from January 1 through 15, 2013. Review of the ER log for the same time period showed the majority of the patients presented to the ER between 0700 and 2100. The ER log documented between 4 and 16 patients presented to the department during these times.

2. On 01/16/13 at 1330, Staff T and N stated usually there was only one RN and one physician on duty in the ER. Staff N stated, "It doesn't take much to get swamped; could always use another person to help." Staff N stated most times the floor/inpatient unit was busy and floor staff could not help in the ER. Staff N told the surveyor that if they had two patients in a code blue situation, the nurse on the floor would help, but then that left the floor without an RN usually.

3. The staffing matrix, Master Staffing Plan, given to the surveyors on 01/16/13 at 0930 by Staff D applied only to the inpatient unit. The staffing matrix only included staffing guidelines up to twelve patients. Staff E stated on the afternoon of 01/16/13 that this Master Staffing Plan was the only one she had also been given, but that staffing was now done by Staff B, who is not a nurse. (Refer to Tag C-252 for details) For 12 patients, the staffing matrix showed 3 RNs, 2 aides (CNAs) for a total of 5 staff on the 0700 to 1900 (day) shift and 3 RNs and 1 aide for a total of 4 staff on the 1900 to 0700 (night) shift. Staffing sheets did not demonstrate this matrix was followed.

4. Review of midnight census reports for January 1 through 22, 2013 showed four nights of inpatient census greater than 12 with usual staffing of a total between three and four staff on day shift and a total between three and four staff on night shift. This did not take into account the acuity of patients, the number of patients in isolation, or the number of patients admitted or discharged . The hospital did not have a nursing supervisory/24-hour report that showed this information.

5. On 01/16/13 at 8:30 a.m., staff K was observed assigned to the OR. There were two pediatric ear/nose/throat (ENT) surgery cases scheduled with a new physician. The OR was staffed with staff K and a scrub tech. The scrub tech was also responsible for sterile processing. The staff said they had not done pediatric ENT cases at this hospital, and they had not worked with the new surgeon before this date.

On this date, staff K was also responsible for orienting a new nurse to the peri-operative areas. This was the first day the new nurse had been to the hospital. Staff K was asked who was scheduled as the RN for the pre-operative and recovery areas. She said she was covering all three positions that day (OR, pre-op and recovery). She was asked how she could manage two back to back pediatric patients, alone. She stated she didn't know, but she would make it work. She stated she would rely heavily on the new orientee. She stated there were no other trained staff to help in the peri-operative areas.

Staff B was asked if the CNO was available to assist the staff that day. She stated the CNO was not available. She stated the CNO had been assigned by administration to go to a sister hospital to help in their surgery department.

6. On 01/23/13, the 0700 to 1900 shift had two RNs (one RN in new employee orientation), one LPN (licensed practical nurse) and one nurse's aide. The new RN had a patient care assignment and the LPN was also working in the drug room , besides having a patient care assignment. Staff E, the Chief Nursing Officer, was unavailable because she had been pulled by administration and told to work as a staff nurse in surgery at another hospital. Between 0930 and 1730, the following occurred:
a. The inpatient unit had a starting census of 14 with one patient on reverse isolation.
b. Four patients were discharged .
c. Four patients were admitted .
d. One patient was moved to another room.
e. Four patients were being monitored on telemetry.

Staff F stated the nursing staff were always short-handed and worked many overtime shifts. She stated she was scheduled to work seven 12 hours shifts in a row and staff K was on her eleventh 12 hour shift in a row. Staff F stated the nursing unit worked last week without a CNA, except for one day when the CNA worked a partial shift. She stated the nurses usually worked longer than 12 hours a shift because they have to stay over to catchup on their documentation in the computer.

Time card punch detail reports for January 2013 documented the registered nurses regularly worked longer than 12 hours a shift.
VIOLATION: NURSING SERVICES Tag No: C0294
Based on record review and staff interview, it was determined the hospital failed to ensure:

1. Nursing services were well-organized and under the direction of a registered nurse, and

2. Nursing staff were trained and evaluated on competency to perform the essential functions of their jobs.

Findings:

1. The hospital does not have an organizational chart for nursing services.

a. On the afternoon of 01/15/13, Staff B, C and D told the surveyors that there was no organizational chart for nursing. Again on 01/23/13, Staff B stated they still did not have a nursing organization with delineation of supervisory positions. This was confirmed with Staff E, the Chief Nursing Officer (CNO) on 01/16/13.

b. On the afternoon of 01/23/13, Staff E stated that although she had the title of CNO, she was not included in administrative meetings and did not have any say in the nursing staffing schedule. The nursing staffing was developed and approved by Staff B, who is not a nurse. (Refer to Tags C-200, C-252 and C-253 for details on staffing.)

c. Although the hospital has a staffing matrix, it only gives guidance for inpatients up to 12 patients. The did not take into account the acuity of patients, number of patients in isolations, or the number of patients admitted or discharged . The hospital did not have a nursing supervisory/24-hour report that showed this information. (Refer to Tag C-253)

d. Staff B told the surveyor on 01/15/13 that the floor charge nurse was in charge of all nursing services/acted as the house supervisor for nursing, when the CNO was absent. This position was refuted by nursing staff. (Refer to Tag C-252 for details.)

2. Eleven of eleven (Staff E, F, G, J, K, M, P, R, T, U, and II) nursing employee records reviewed did not have documentation of formal orientation to their departments.

3. Five of five (Staff,J, K, P, R and II) licensed nursing employee records reviewed did not have documentation of specialized training in their areas of emergency room , pharmacy, and surgery.

4. Eleven of eleven (Staff E, F, G, J, K, M, P, R, T, U, and II) nursing employee records reviewed did not have documentation of demonstrated competencies to perform the essential functions of their jobs, including competencies to administer medications and age specific competencies relevant to their areas.

5. None of the licensed nursing staff employee records reviewed had documentation of training and skill competencies in respiratory care, other than nebulizer and pulse ox, including oxygen set up and administration performed by a respiratory therapist as required by Licensure Standards.

6. When nursing staff were interviewed, they did not know how to contact or consult with the dietitian. The nursing staff were not familiar with the electronic nutritional assessment portion of the comprehensive patient assessment. They could not locate nutritional information on the electronic medical record.

On the afternoon of 01/16/13, Staff M, RN on orientation, stated it was good thing she use the same system at (hospital name deleted) or she would know where/how to chart.

7. There was no documentation found that indicated nursing staff who made medication or other patient care errors had competency review in order to evaluate their abilities to safely provide patient care.

8. Three of three agency nursing personnel records review did not have orientation or competency verification.

9. The surveyors asked if another file existed with area specific orientation, education/training and competency verification. Staff B and C stated on 01/15/13 at 1700 that there was no more files/competencies. On 01/16/13, Staff E confirmed that since her hire date she had been unable to complete and verify nursing competencies. On the afternoon of 01/16/2013, Staff E told the surveyors that she had not completed any competency training or verification on staff because she was either busy having to help with patient care at this hospital or was pulled to another hospital by administration to work as a surgery nurse.

10. On the afternoon of 01/14/13, the Chief Executive Officer (CEO) told the surveyors that since his hire the hospital has had an "almost 100%" turn-over in personnel. This was reiterated by the Chairman of the Board (COB) and the CEO during the surveyors' exits on 01/16/13 and 01/23/13. The COB stated that there had been no control over nursing staff and since that time, if staff did not do what they expected/wanted them to do," they were gone". He stated before the CEO arrived, he felt nursing was overstaffed and over-time was abused.

The COB stated, because of the changes made, the hospital has gone from being in debt to having over "three million dollars in the bank".

The Chief Operating Officer, who is not a nurse and has no clinical background, with the authorization of the COB and CEO, has taken over nursing staffing control. (Refer to Tag C-295 for further details/examples.)
The COB is not a health care professional. Although the CEO stated he was a RN, he does not provide patient care and does not have a license to practice as a registered nurse in Oklahoma.
VIOLATION: PROTECTION OF RECORD INFORMATION Tag No: C0309
Based on observation, clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to provide policies and procedures to guide the staff on the use of the electronic medical record information system and to guide staff on actions to take when the electronic medical record system was down.

On 01/14/13, the nursing staff were observed using the electronic medical record (EMR). The staff were asked if they had written policies and procedures or a user's manual to instruct them on the use of the electronic record. They stated they did not. They were asked if they had sufficient training to adequately use the EMR. They stated they did not.

The staff were unable to articulate or demonstrate how to navigate around all parts of the EMR. They could not retrieve all information vital to patient care. Staff were asked to obtain a record of all medications administered to patient #6 from the time of admission to the present. They were unable to do so.

They were asked how they could determine if it was safe and appropriate to administer an "as needed" medication if they could not retrieve information on how many times and when the medication had been given previously. No answer was given.

They were asked if they knew how to run reports or documents from the EMR. They stated the could run some things but were not sure what reports were available. They were asked who provided support for the use of the EMR. They stated the IT (information technology) department, but there was no medical person who was available as resource.

The staff were asked what they were to do if the electronic medical record system was down. They stated they had packets of paper documents to use. They were asked if they had written policies and procedures to guide them during a downtime event. They stated they did not.

The information technology staff was interviewed. He was asked if he could locate nutritional assessment information in the EMR. He stated he could not. He stated he could not explain all the aspects of the electronic medical record because he was not a clinical person.

He was asked if there was an identified EMR "super user" among the nursing staff who could be a guide and resource for the other staff. He stated someone was going to be trained but no one was available at that time.

He was asked if there were written downtime policies and procedures. He stated there were not.
VIOLATION: PATIENT CARE POLICIES Tag No: C0272
Based on policy and procedure review and staff interview, it was determined the hospital failed to develop patient care policies and procedures with the input and approval of qualified practitioners. Findings:

On 01/14/13 through 01/16/13, hospital policies and procedures were reviewed. None of the individual departmental policies and procedures had been signed as reviewed and approved annually by qualified practitioners, the medical staff or by the governing body.

For example, none of the dietary and nutritional services policies had been developed or reviewed by the registered and licensed dietitian. The dietary supervisor confirmed this finding.

The respiratory therapy policies had not been developed and reviewed by the certified and registered respiratory therapist. The respiratory therapist confirmed this finding.

Surgery policies and procedures had no documentation they were developed and approved by certified surgical nursing staff and/or physicians with surgery privileges.

There was no documentation a CRNA (certified registered nurse anesthetist) or an anesthesiologist had participated in the development and approval of the hospital's anesthesia policies.

While the hospital's policy and procedure manuals had cover sheets approved and signed by executive staff, medical staff and the governing body in 2012, the actual content of the policies was outdated and was not relevant to the services provided by the hospital at the present time.

The majority of the individual departmental policies were dated 2005 or earlier, and did not always reflect current standards of practice. None of the policies reviewed made reference to nationally recognized sources of information.
VIOLATION: PERIODIC EVALUATION & QA REVIEW Tag No: C0330
Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital performs a periodic evaluation and quality assurance review as required. The hospital has not conducted an annual periodic evaluation and does not have an effective and ongoing quality assurance program.

1. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's (critical access hospital's) health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag # 0331.

2. The hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records. Refer to Tag # 0333.

4. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies. Refer to Tag # 0334.

5. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag # 0335.

6. The hospital does not have an effective Quality Assurance/Performance Improvement (QA/PI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. Refer to Tag # 0336.

7. The hospital does have an effective quality assurance program that is implemented to evaluate the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI program. Refer to Tag # 0337.

8. The hospital does not have an effective quality assurance program implemented to evaluate nosocomial infections and medication therapy. Refer to Tag # 0338.

9. The hospital does not have a functioning QA/PI system implemented so that remedial action can address deficiencies found through the QA/PI program. Refer to Tag # 0342.
VIOLATION: VENTILATION, LIGHTING, TEMP CONTROLS Tag No: C0226
Based on interviews with staff, hospital documents, and policies the facility failed to maintain a safe environment with proper ventilation, temperature, and humidity.

1. On 01/15/13, 01/18/13 and 01/23/13, surveyors reviewed generator load testing documents. In an interview with the plant operations director, on 01/23/13, he stipulated the information on the load testing documents did not reflect actual readings from the generator. He stated he wrote the same numbers based on what others had documented at the top of the page. He stated he did not really know what those numbers meant. The director told surveyors he had not been trained to operate the generator when he took the job. When asked if the generator transfer switches had been inspected during exercise of the generator, the director could not provide evidence these inspections were occurring. No transfer switch testing program was provided. There was no documentation the emergency back up power generator was maintained and serviced properly.

2. On 01/15/13, surveyors requested preventative maintenance logs for the hospital boiler. None were provided. There was no documentation the facility was maintaining the boilers to prevent essential equipment and services failure.

3. On 01/23/13, surveyors reviewed humidity levels documented for the operating rooms. Several dates in December 2012 and January 2013 documented the humidity levels were 24% or less. The logs documented, "notified safety." The humidity range in operating rooms must be in the range of 30% to 60% to decrease the potential for electrostatic shock which can increase combustion possibilities in a hyper-oxygenated areas like the operating room.

On 01/23/13, the plant operations director told surveyors "safety" meant "he" was notified. He told surveyors he did not do anything with this information. He stated the humidity levels have been an issue in the hospital for a long time. He stated administration was working on a contract with the HVAC system, but no one could do anything about the humidity until the vendor came out to correct it.

There was no documentation the facility attempted to correct the humidity problems. There was no documentation the HVAC (heating, ventilation and air conditioning) system was maintained to ensure correct humidity controls and temperature balance. There was no documentation surgery cases were postponed, or rescheduled until humidity returned to an acceptable range.

4. On the afternoon of 01/15/2013, surveyors accompanied the director of plant operations to the negative airflow respiratory isolation room. He was unable to activate the negative airflow system. He stated the monitor continued to alarm and was irritating to the nurses, so he disabled the system. He stated he did not know what was wrong with it and no repair had been ordered. The facility failed to maintain essential components of an effective infection control program because the negative pressure airflow isolation room was unavailable to house patients who may require this type of isolation.

5. According to work orders and vendor documents received by the hospital, the HVAC system was down on 12/14/12 and 12/19/12. During these incidents, the hospital received complaints of patient room temperatures being too cold. The hospital maintenance department documented patient room temperatures as low as 58 degrees. The vendor performed some assessment and work on the HVAC system on those dates.

Again on 12/31/12, complaints were made to the hospital regarding cold patient rooms. According to a documented phone conversation between OSDH (Oklahoma State Department of Health) staff and the director of plant operations on 01/02/2013, it was verified that on 12/31/12, "the patient wing lost heat." According to the hospital's Plan of Action report provided to OSDH and signed by the Director of Plant Operations and the COO, the hospital staff identified a loss of heat at 5:30 a.m. on 01/01/13. According to the document, the hospital plant operations manager was two hours away from the hospital. The hospital "on-call" person (the information technology manager) was called to come to the hospital. He was 45 minutes away. When he arrived, he determined the unit providing heat to the patient rooms had shut down. A service technician was called and heat was restored to the patient rooms at 2:15 p.m. According to the information written in the hospital's Plan of Action report, the COO and the Director of Plant Operations acknowledged a loss of heat to patient rooms for at least eight hours and 15 minutes on 01/01/13.

Hospital records documented that on 01/08/13 and again on 01/10/13, a vendor was at the hospital to repair the HVAC outside air dampers. However, the director of plant operations stated stated the HVAC system is still an on-going problem. He stated the leaving air temperature varies from 59 degrees to 120 degrees intermittently. He stated the HVAC control system is computerized and requires a specialist technician to service it. He stated the hospital did not have a vendor contract to provide this type of service. On 01/14 and 01/15/13, the surveyors noticed cold spots in the hospital. An occupied patient room was noticeable colder than the hallway. The patient in the room was non-verbal and was unable to answer questions about being too cold.

On 01/23/13, the CEO stated the hospital had no current service agreement with the manufacturer to provide on-going maintenance and service to the HVAC system. He stated he was in the process of securing a service agreement. At the time of the exit conference, no service agreement was in place.

At the exit conference held on 01/23/13, the Governing Body Chairman stated there have been problems with the HVAC system since the hospital was constructed and had never been fully resolved.

6. At the time of the survey, the plant operations director was the only person identified by the hospital who was responsible for all the maintenance of the hospital facilities, structures and special systems, including fire systems, medical gas systems, HVAC, electrical, mechanical and biomedical equipment. There was no other employee in the facility maintenance department. When asked about his previous experience and qualifications for Director of Hospital Plant Operations, he stated he worked in "R and D for a limousine manufacturer."
VIOLATION: SURGICAL SERVICES Tag No: C0320
Based on observation, clinical record review, document review and staff interview, it was determined the hospital failed to meet the Medicare CFR 485.639 Condition of Participation for Surgical Services, as evidenced by failure to ensure:

a. the surgery department was supervised by a qualified and experienced registered nurse;

b. surgery department policies and procedures were current and reflected accepted standards of surgical care;

c. informed consents were properly executed;

d. the operating room register contained required information;

e. operative reports included information about surgical complications;

f. sterilizers, anesthesia machines and defibrillators are monitored, inspected and tested according to the biomedical equipment program;

g. the surgery department maintained a current list of surgeons and other practitioners with specific surgical privileges and those with suspended or restricted privileges. See Tag C-0321; and

h. failed to ensure all patients are evaluated for proper anesthesia recovery. See Tag C-0322.

Findings:

1. On 01/14/13, surgery department policies and procedures were reviewed. There was no policy that described an OR director or supervisor. There was no organizational chart for the surgery department. Staff B stated the surgery department was supervised by staff K.

On 01/15/13, the training file for staff K was reviewed for education and training for surgery. There was no documentation of hospital orientation to the OR. There was no documentation of surgery skills competency assessment. There was no documentation of surgery specific education and training.

On 01/15/13, the personnel file for staff K was reviewed. It contained a signed job description for surgery staff nurse (preoperative, intraoperative and postoperative), not OR supervisor.

On 01/16/13, staff K stated she was not the OR supervisor and had never been told she was. She stated she had no OR management experience.

2. The surgery department policies and procedures had no documents related to:

~ aseptic surveillance and practice

~ surgical scrub requirements

~ identification of infected and non-infected cases

~ housekeeping requirements

~ clinical procedures

~ patient identification and time out procedures

~ duties of all staff categories working in the OR

~ surgical count requirements

~ scheduling of patients for the OR

~ specific surgical personnel policies, such as hygiene, attire, employee health, etc.

~ resuscitative techniques unique to the OR

~ care of surgical specimens

~ protocols for all types of procedures performed

~ decontamination and sterile processing

~ orientation, training and competency assessment for all staff categories

~ infection control activities and participation in the hospital quality assurance program

None of the surgery policies reflected review and approval by qualified OR personnel. The policies did not reflect references to nationally recognized authorities in peri-operative care. The policies were dated 2005.

3. On 01/15/13, four surgery patient records were reviewed. Three of the four records (patients # 12, 20 and #21) had consents that were not properly executed. The consents lacked date and time of execution, no witness, misspelled surgical procedure names and lack of designation of the relationship of the person signing the consent. Two of the consents had information documented in the wrong section and on the wrong line.

4. On 01/14/13, the surgery register was reviewed for 2012 and 2013. There were incomplete entries from 08/21/12 to the present.
There were large gaps in documentation where it appeared no surgical procedures were done at all.

The register lacked full names of staff, inappropriate or absent pre and post operative diagnosis, no registered nurse identified, no anesthesia provider name or the type of anesthesia provided, no procedure documented, no documentation of complications, the post-operative condition or time in surgery.

5. Surgical patient records for two (patients #20 and #21) of four reviewed, contained operative reports that had no documentation of the presence or absence of surgical complications.

6. On 01/16/13, anesthesia machines were observed in service that were out of date for routine inspection and preventive maintenance since December 2012. A Sterrad sterilizer was observed in use. It had a printed alert for the staff that preventive maintenance was required since October 2012. Staff P stated she notified hospital management of this in October 2012 but no action was taken.

The surgery/recovery department defibrillator had no current biomedical equipment check.
VIOLATION: SURGICAL PRIVILEGING Tag No: C0321
Based on record review and staff interview, it was determined the surgery department failed to maintain a current list of surgeons and other practitioners with specific surgical privileges and those with suspended or restricted privileges. The department also failed to maintain a list of credentialed CRNAs (certified registered nurse anesthetist) and their privileges.

On 01/16/13, surgery staff confirmed this finding.
VIOLATION: SERVICES PROVIDED THRU AGREEMENT/ARRANGEMENT Tag No: C0285
Based on review of hospital documents and interviews with staff, the governing body does not ensure all services provided by contract or agreement are evaluated by the hospital's quality program. Review of the hospital's quality/compliance, governing body and medical staff committee meetings for 2012 and 2013 and three contract nursing personnel files did not have evidence of review and evaluation through the QA/PI (quality assessment and performance improvement) program of the services provided by contract.

Findings:

1. There was no evidence hyperbaric services provided by contract are evaluated by the hospital's QA/PI program.

2. There was no evidence outpatient psychiatric services (intensive outpatient psychiatric services) provided by the hospital were evaluated by the hospital's QA/PI program.

3. No additional information was provided by hospital staff during the survey concerning contract services evaluation by the QA/PI program.
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0220
Based on interviews with staff, review of policies and procedures, and hospital documents the facility failed to maintain special buildings systems, fire systems, clinical and non-clinical equipment to ensure patient and employee safety. The facility does not meet Medicare CFR 485.623 Condition of Participation: Physical Plant and Environment Findings:

The facility failed to implement a facilities maintenance and preventive maintenance program with trained competent personnel implementing and overseeing the program. See Tag C-0222 and LSC (Life Safety Code) survey.

The facility failed to implement a clinical equipment preventive maintenance program with trained and competent personnel performing and overseeing testing. See Tag C-0222 and LSC survey.

The facility failed to provide ongoing facilities maintenance and upkeep to prevent or mitigate the risk of equipment and facility systems failure. See Tag C-0222 and LSC survey.

The facility failed to ensure biohazardous waste was stored appropriately. See Tag C-0223.

The facility failed to ensure drugs and biologicals were appropriately stored and locked. See Tag C-0224.

The facility failed to provide emergency lighting. See Tag C-0228 and LSC survey.

The facility failed to ensure adequate security for the emergency gas supplies and failed to ensure staff knew how to access gas supplies in the event of an emergency. See Tag C-0229 and LSC survey.

The facility failed to develop and implement a comprehensive Life Safety Program which included ongoing surveillance and upkeep of fire systems, fire and evacuation training, and risk assessment and abatement with special systems. The facility failed to provide competent trained staff to oversee and implement the program. The facility failed to train personnel on essential components of Life Safety. See LSC survey and Tags C-0230 and C-0234.

The facility failed to develop, implement, a Disaster Preparedness Program which incorporated clinical and non-clinical disasters, risk assessment associated with special systems, facilities, and equipment at the facility. The facility failed to provide trained, competent staff to oversee programs. The facility failed to train all staff in Disaster Preparedness. See Tag C-0227 and C-0230.

The facility failed to develop and implement a comprehensive Quality Assurance and Performance Improvement program which included Plant Operations, Clinical Equipment, Life Safety, and Disaster Preparedness. See Tags C-0330, C-0331 and C-0342.
VIOLATION: MAINTENANCE Tag No: C0222
Based on interviews of staff, review of hospital documents, and inspection of facility and clinical equipment, the hospital failed to maintain mechanical, electrical, and patient care equipment in a safe operating manner.

Findings:

According to NFPA (National Fire Protection Association) 99 7-6.5.1 "Personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education. 7-6.3.1.2 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. At a minimum, this record shall contain the date, unique identification of the equipment tested , and an indication of which items have met or have failed to meet the performance requirements of this section. 7-6.3.1.3 A log of test results and repairs shall be maintained and kept for an appropriate time."

1. On 01/15/13, surveyors observed defibrillators in several areas of the hospital, including the emergency room , that did not have current clinical equipment inspection tags. The equipment was tagged last in 2008. In an interview on 01/15/13, the plant operations director, told surveyors there was no clinical equipment preventative maintenance program.

2. On 01/16/13, anesthesia machines were observed in service that were out of date for routine inspection and preventive maintenance since December 2012. On 1/23/13 the anesthesia machines had not had preventive maintenance. On 1/23/13 Surveyors contacted the vendor utilized by the facility during the last preventive maintenance recorded (June 2012) The vendor told surveyors the PM work had been done in June in "good faith" in hopes a contract for continued maintenance would be secured. When the pricing schedule was received by administration, the hospital rejected the pricing and no contract was obtained. The vendor told surveyors the work on the anesthesia machines had not been paid for, but the vendor returned the machines as an act of "good faith".

3. On 01/16/13, a Sterrad sterilizer was observed in use. It had a printed alert for the staff that preventive maintenance was required since October 2012. Staff P, the person working in the sterile processing department, stated she notified hospital management of the alert for preventive maintenance in October 2012, but no action was taken. There was no documentation any of the sterilizing equipment had preventive maintenance performed.

4. The surgery/recovery department defibrillator had no current biomedical equipment check to determine effective and safe use on patients. The last clinical equipment check was dated 2008. There was no documentation that indicated the defibrillator batteries had been replaced every two years as recommended by the manufacturer.

5. On the afternoon of 01/23/2013, the respiratory therapist told the surveyors he had previously taken the portable ventilator out of service because of a "cracked head". He stated he tried to order a replacement part, but it was "on back order." Staff L stated the local ambulance service had been able to provide him with "one that fit," so the portable ventilator could be placed back in use. There was no evidence the replacement part was an appropriate and acceptable replacement. There was no documentation a suitable replacement part was ordered by the hospital.

At 3:50 p.m., the surveyor observed the portable ventilator in the emergency room . The pressure hose had a tear or cut in the outer casing of the pressure hose that exposed the inside sheath. The respiratory therapist stated he was unaware of the tear. There was no documentation the ventilator had ever been inspected and checked for safe and effective operation.

6. On 01/23/2013, the inpatient unit had six patients with physician's orders for telemetry. The charge nurse, Staff F, stated the hospital only had four working telemetry monitors. Staff F stated they were going to triage (with the advice of the attending physicians) to see if two patients could be taken off telemetry. She stated in the past, she notified hospital administration that more telemetry units were needed. She stated no action had been taken to obtain more telemetry units.

7. On 01/15/13, the Director of Plant Operations told the surveyors he did not know how to inspect and check biomedical equipment and the hospital did not have a preventive maintenance program.

8. On 01/15/13, 01/18/13 and 01/23/13, surveyors reviewed generator load testing documents. On 01/23/13, the Director of Plant Operations stated the information on the load testing documents did not reflect actual readings from the generator. He stated he wrote the same numbers based on what others had documented at the top of the page. He stated he did not really know what those numbers meant. He told surveyors he had not been trained to operate the generator when he took the job as Director of Plant Operations. When asked if the generator transfer switches had been inspected during exercise of the generator, he could not provide evidence these inspections were occurring.

9. On 01/15/13, surveyors requested preventative maintenance logs for the hospital boiler. The facility did not have any preventative maintenance documentation for the hospital boiler.

10. On the afternoon of 01/23/2013, the charge nurse, Staff F, told the surveyors the nurses could not admit patients to rooms 105 and 106 because the roof leaked when it rained. Staff F stated the leak problem had been going on for several months.

The Director of Plant Operations was asked about the leaking roof and the lack of repair. He stated he did not have authorization to have it repaired. At 7:00 p.m., the Chairman of the Board and the CEO told surveyors the facility had trouble getting the roof fixed because there was only one company that repaired flat roofs.

11. On 01/15/13, the surveyors requested a complete set of construction drawings for fixed equipment, mechanical and electrical systems, and life safety drawings as required by NFPA . Surveyors also requested manufacturer's equipment manuals for the building's fixed and biomedical equipment. The Director of Plant Operations could not locate several of the construction drawings and equipment manuals.

He was not able to locate a fire system life safety drawing. He did not have knowledge of critical points for the fire alarm system so that accurate checks of all of the system could be performed.

He did not have a key to access the main gas shut off valves to the hospital and hyperbaric chamber. He stated he had not been oriented and trained on these items. On 01/15/13, surveyors observed two yellow tags on the main fire panel. One tag, dated 11/19/11, documented, "... unit 1 + 5 are in trouble and do not shutdown on alarm!..." Another tag, dated 11/15/12, documented, "... 3 troubles on the panel..."

On 01/15/13, surveyors asked for documents stipulating the contractor had repaired the fire alarm system. There was no documentation the system had been repaired.

On 01/18/13, yellow tags were observed still on the system. According to documents provided later in the survey, on 12/18/12 the system was repaired. However, the hospital did not have documentation to show a re-acceptance test in accordance with NFPA 72, 7-1.6.2.. The Director of Plant Operations stated he was unaware of the need for the documentation and the need for a re-acceptance test.

12. According to daily monitoring logs kept by the Director of Plant Operations, the exhaust system for Isolation Room 7 (a negative airflow pressure room) was not functioning as of September 20, 2012.

At the time of survey on January 15, 2013 and again on January 18, 2013, the isolation room remained out of service. When questioned, the Director of Plant Operations told the surveyors he did not know where the circuit breaker for the exhaust system was. He was asked to retrieve the blueprints and locate the circuit breaker. He stated he had not been taught to read blueprints.

On January 21, 2013, the Director of Plant Operations reported to surveyors via telephone the isolation exhaust fan was now functioning. He stated an electrician went to the roof and found a reset button that was tripped on the motor. The Director of Plant Operations explained he had never been in-serviced on the fan operation or knew where the manual was for that piece of equipment.

13. According to NFPA 99 19-3.1.3.3, "... The ultimate responsibility for the care and safety of patients and personnel is that of the governing board. Hence it is incumbent upon that body to insist that adequate rules and regulations with respect to practices and conduct in hyperbaric facilities, including qualifications and training of hyperbaric personnel, be adopted by the medical or administrative staff of the institution, and that adequate regulations for inspection and maintenance are in use by the administrative, maintenance, and ancillary (and in the case of a hospital, nursing and other professional) personnel..."

On 01/15/13 during a tour of the hospital, surveyors observed a hyperbaric program located within the licensed hospital space. The Director of Plant Operations stated he had no knowledge or information about the hyperbaric chamber.

There was no documentation found in any hospital records that indicated the hyperbaric chamber and the safety risks associated with it had been assessed and addressed through the hospital safety committee and governing body. There was no documentation the governing body had appointed a hyperbarics safety officer.

There was no documentation of proper training for the maintenance of the hyperbaric chamber for plant operations personnel. There was no documentation any staff had been trained to be aware of hyperbaric chamber risks. There was no documentation the hyperbaric chamber had been considered as a possible internal disaster risk in the hospital disaster preparedness plan.

On 01/23/13, the Director of Plant Operations stated he did not know who was the hyperbaric safety officer.

14. On 01/15/13, surveyors observed bulk oxygen storage that was secured in accordance with requirements. However, the Director of Plant Operations could not locate a key to access the area. The bulk oxygen storage area contained the source shut off valve for the main hospital oxygen supply. Without a key, there was no emergency access in case of a fire, explosion, or other disaster situation.

On 01/23/13, the Director of Plant Operations stated he had no time to look for the key because he had been too busy attending to the needs of the co-managed hospital where he was also acting as Director of Plant Operations.

15. According to work orders and vendor documents received by the hospital, the HVAC (heating, ventilation, and air conditioning) system was down on 12/14/12 and 12/19/12. During these incidents, the hospital received complaints the patient room temperatures were too cold. The hospital maintenance department documented patient room temperatures as low as 58 degrees. A vendor performed some assessment and work on the HVAC system on those dates.

According to work orders and vendor documents received by the hospital, the HVAC system was down on 12/14/12 and 12/19/12. During these incidents, the hospital received complaints of patient room temperatures being too cold. The hospital maintenance department documented patient room temperatures as low as 58 degrees. The vendor performed some assessment and work on the HVAC system on those dates.

Again on 12/31/12, complaints were made to the hospital regarding cold patient rooms. According to a documented phone conversation between OSDH (Oklahoma State Department of Health) staff and the director of plant operations on 01/02/2013, it was verified that on 12/31/12, "the patient wing lost heat." According to the hospital's Plan of Action report provided to OSDH and signed by the Director of Plant Operations and the COO, the hospital staff identified a loss of heat at 5:30 a.m. on 01/01/13. According to the document, the hospital plant operations manager was two hours away from the hospital. The hospital "on-call" person (the information technology manager) was called to come to the hospital. He was 45 minutes away. When he arrived, he determined the unit providing heat to the patient rooms had shut down. A service technician was called and heat was restored to the patient rooms at 2:15 p.m. According to the information written in the hospital's Plan of Action report, the COO and the Director of Plant Operations acknowledged a loss of heat to patient rooms for at least eight hours and 15 minutes on 01/01/13.

Hospital records documented that on 01/08/13 and again on 01/10/13, a vendor was at the hospital to repair the HVAC outside air dampers. However, the director of plant operations stated stated the HVAC system is still an on-going problem. He stated the leaving air temperature varies from 59 degrees to 120 degrees intermittently. He stated the HVAC control system is computerized and requires a specialist technician to service it. He stated the hospital did not have a vendor contract to provide this type of service. On 01/14 and 01/15/13, the surveyors noticed cold spots in the hospital. An occupied patient room was noticeable colder than the hallway. The patient in the room was non-verbal and was unable to answer questions about being too cold.

On 01/23/13, the CEO stated the hospital had no current service agreement with the manufacturer to provide on-going maintenance and service to the HVAC system. He stated he was in the process of securing a service agreement. At the time of the exit conference, no service agreement was in place.

At the exit conference held on 01/23/13, the Governing Body Chairman stated there have been problems with the HVAC system since the hospital was constructed and had never been fully resolved.

16. At the time of the survey, the plant operations director was the only person identified by the hospital who was responsible for all the maintenance of the hospital facilities, structures and special systems, including fire systems, medical gas systems, HVAC, electrical, mechanical and biomedical equipment. There was no other employee in the facility maintenance department. When asked about his previous experience and qualifications for Director of Hospital Plant Operations, he stated he worked in "R and D for a limousine manufacturer."

17. The hospital COO also identified the Director of Plant Operations as the safety officer. When interviewed, the Director stated he was not sure what he was supposed to do as the hospital safety officer.

18. On 01/23/13, the surveyors asked if the hospital had a supply of N95 Particulate Respirators for use in the airborne isolation rooms. One partial box of respirators was found. The hospital did not supply an adequate amount of respirators in a variety of sizes and shapes to fit all employees who may be required to wear them.

19. There were no policies and procedures reviewed, approved, and implemented to ensure a comprehensive clinical equipment program/ facilities maintenance program was in place to meet the care and safety needs of the patients. There was no documentation the hospital facilities program was reviewed through appropriate committees or presented to QA/PI meetings.
VIOLATION: EMERGENCY SERVICES Tag No: C0200
Based on review of hospital documents, staffing sheets, emergency room log (ER), and personnel files, surveyor observations and staff interviews, the hospital failed to meet Medicare CFR 485.618 Condition of Participation for Emergency Services, as evidenced by failure to provide:

1. Designation of a qualified member of the medical staff as the Medical Director for Emergency Services (ER);

2. Review of ER services as part of the Performance Improvement and Quality Assessment program (Compliance);

3. Adequate, experienced, and trained nursing staff in the ER;

4. Defined, developed policies and trained staff to perform respiratory services; and

5. Assurance that emergency equipment is maintained. Refer to Tag C-204.

Findings:

1. Medical Staff was not included in the hospital organization chart provided to the surveyors on 01/14/2013 or 01/23/2013.

2. Meeting minutes of Medical Staff and Governing Body did not reflect appointment of a qualified physician to be the Medical Director for Emergency Services.

3. Meeting minutes for Compliance, Medical Staff and Governing Body did not reflect services provided in the emergency room were reviewed, evaluated/analyzed with corrective action taken when indicated through the quality program.

4. The last review of ER policies and procedures by ER medical staff and nursing was 2005.

5. On the afternoon of 01/15/2013, one surveyor observed one RN working in the ER. She was observed trying to discharge one patient, admit one patient and take care of another who had just arrived back from radiology. Staff K stated she was the only staff there besides the physician and could not get help from the floor as they were busy also. Staff K stated she had never worked in the ER prior to this employment and had not been given any orientation or training to work in the ER. She stated when the hospital first called her to "help out" in the ER, she thought she would be following someone and doing tasks assigned with supervision. She stated she accepted the duty only to arrive and find out she was the only nurse. When assigned to the ER, she usually worked as the only ER nurse.

Review of the staffing sheet and the calendar kept by the Risk Manager (Staff D), showed only one nurse for each 12-hour shift in the ER from January 1 through 15, 2013.

6. During a tour of the emergency room , surveyors observed ChloraPrep (a potentially combustible, alcohol-based skin preparation solution) and single use, battery operated cautery devices stored in a drawer. The surveyor asked the registered nurse working in the ER how these items were used. She stated the ChloraPrep and the cautery were used for minor surgical procedures.

She was asked if staff in the emergency room were trained on the risk of surgical fires and the precautions needed to safely use alcohol-based skin prep solutions and an ignition source, such as the cautery device. She stated no one had been trained on this.

She was asked if there was an emergency room policy that addressed this. She stated she was not a trained emergency room nurse, had not been oriented to the emergency room , and was not knowledgeable about the scope and contents of the emergency room policies.

7. On 01/16/2013 at 1330, Staff T and N stated usually there was only one RN and one physician on duty in the ER. Staff N stated, "It doesn't take much to get swamped, could always use another person to help." Staff N stated most times the floor/inpatient unit was busy and floor staff could not help. Staff N told the surveyor that if they had two patients in a code blue situation, the nurse on the floor would help, but then that left the floor without an RN usually.

8. Two of two (Staff K and J) RNs that had worked in the ER and their files were reviewed, did not show they had been orientated, trained and competency verified for their duties in the ER, including competency training and verification of the portable ventilator.. This was confirmed with Staff C on the afternoon of 01/15/2013.

9. The hospital failed to define, develop policies and train staff to perform respiratory services. Refer to Tag C-273.

At 1555 on 01/23/2013, Staff L, the contracted respiratory care practitioner, stated that besides himself, he thought the emergency room (ER) physicians and one ER registered nurse, Staff I, knew how to operate the portable ventilator, Auto Vent 3000, but that he was unaware of any documentation of competency.

Staff I's personnel file was not reviewed, but she told the surveyor, on the afternoon of 01/16/2013, that she had been hired by the past Director of Nurses (CNO) and did not remember any documentation of orientation and training being completed. She stated no training/competency verification had been provided since her initial training.

On 01/23/13 Staff L told the surveyors that since he was "only certified, not registered," he could not do any training. Staff L's personnel file did not contain competency verification by the hospital. Staff L told the surveyors on the morning of 01/23/13 that he had a temporary contract to provide respiratory services. He stated his original contract, starting 08/27/12, was for thirteen weeks. He told the surveyors that his contract had been extended for another thirteen weeks, but that it was ending "sometime in February" and he did not know what would happen.
VIOLATION: DRUG STORAGE Tag No: C0224
Based on record review, observation and interviews with hospital staff, the hospital does not ensure that drugs and biologicals are stored within areas that are only accessed by authorized personnel and are accessible to these authorized personnel as required by State and Federal law.

Findings:

1. Drugs are stored in the hospital mainly in three Pyxis machines which are automated medication dispensing machines. Pharmacy/Drug Room policies and procedures were not developed and implemented describing how this process works and how medications are to be accessed through this system. The pharmacy policies and procedures provided for surveyor review described the process before the hospital had the Pyxis machines and the CPSI computer system. Staff II, the Drug Room Supervisor, stated on 01/15/13 in the afternoon, that a problem had occurred during the previous night with the Pyxis machine and nursing staff were unable to access medications for patients.

2. Staff II, the Drug Room Supervisor, stated on 01/15/13 in the afternoon that she had come in during the previous night to help remove medications from the Pyxis in the nurses medication room since the nurses were unable to access the medications themselves from the Pyxis machine. Staff II, the Drug Room Supervisor, was able to access the machine because she was the Drug Room Supervisor and had access to refill the machine. She said she just stood in the medication room and opened the machine when the nurses needed medications. Staffing sheets documented the inpatient census was at 5 patients on 01/14/13 and on 01/15/13 the inpatient census was documented at 8. Three patients were admitted sometime during the night of the 14th or the morning of the 15th. Nurse staffing was documented as one RN, one LPN and one aide.

3. The hospital's computer software is the CPSI system. Staff II, the Drug Room Supervisor, stated on 01/15/13 in the afternoon that the computer system doesn't always "talk" to the Pyxis an automated medication dispensing machine to allow nurses to access the medications in the Pyxis for administration to patients. There was no documentation in incident reports, quality assurance/performance improvement documentation or meeting minutes that this problem had been acted on.

4. Staff F, a registered nurse on the floor stated on 01/23/13 in the afternoon, when asked who accessed the drug room when the Drug Room Supervisor was not there " the key was just given to whoever needed to get into the drug room." State hospital and pharmacy regulations require that access to the drug room is restricted to authorized personnel.
VIOLATION: CLEAN FACILITY Tag No: C0225
Based on observation and review of documents the facility failed to maintain the facilities for safety of patients and personnel.

1. On 1/23/13 surveyors observed outer exit doors propped open with doorstops. One door led to an open field. The facility failed to prevent the potential for rodents, insects and animals from entering the facility and potentially contaminating areas. With the doors open, the facility could not control the air balance and stabilize air flow.

2. On the afternoon of 01/23/2013, the charge nurse, Staff F, told the surveyors the nurses could not admit patients to rooms 105 and 106 because the roof leaked when it rained. Staff F stated the leak problem had been going on for several months.

The Director of Plant Operations was asked about the leaking roof and the lack of repair. He stated he did not have authorization to have it repaired. At 7:00 p.m., the Chairman of the Board and the CEO told surveyors the facility had trouble getting the roof fixed because there was only one company that repaired flat roofs.

3. There were no policies and procedures reviewed, approved, and implemented by plant operations or the governing body, regarding environment of care.
VIOLATION: REQS FOR CAH PROVIDERS OF LTC SERVICES Tag No: C0350
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to meet the Medicare CFR 485.645 Condition of Participation for Special Requirements for CAH Providers of Long Term Care Services, as evidenced by failure to ensure:

a. patients were informed of their rights as swing bed residents. See Tag C-0361;

b. residents were informed of items and services that would not be charged to them and were informed of items and services that may be charged, and the amount of charges for those items or services. See Tag C-0363;

c. individuals were not employed who had been found guilty of abuse, neglect, mistreatment or misappropriation. See Tag C-0384;

d. an ongoing program of activities for swing bed residents, based on their individual needs assessment. See Tag C-0385;

e. medically-related social services. See Tag C-0386;

f. discharge planning and complete discharge summaries were provided. See Tag C-0399; and

g. failed to ensure swing bed residents maintained acceptable nutritional status and received therapeutic diets when indicated. See Tags C-0400 and C-0401.
VIOLATION: SNF SERVICES Tag No: C0360
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital:

a. failed to ensure that swing bed residents were informed of their rights. See Tags C-0361 and C-0363;

b. failed to ensurethat individuals were not employed who had been found guilty of abuse, neglect, mistreatment or misappropriation. See Tag C- 0384;

c. failed to ensure an ongoing program of activities was provided for swing bed residents. See Tag C-0385;

d. failed to ensure that medically-related social services were provided. See Tag C-0386;

e. failed to ensure discharge planning and discharge summaries were provided. See Tag C-0399; and

f. failed to provide nutritional assessments and therapeutic diets as indicated. See Tags C-0400 and C-0401.
VIOLATION: RESIDENTS RIGHTS (483.10(B)(3)) Tag No: C0361
Based on clinical record review, document review and staff interview, it was determined the hospital failed to ensure swing bed residents were informed of their rights. Findings:

On 01/15/13, clinical records (two open and two closed) were reviewed for four (#7, 9, 10, and #11) swing bed patients. None of the clinical records included documentation the residents were given notification of their rights.

The medical records staff were asked if there were any scanned documents for the records reviewed. They stated there were not.

Swing bed policies and procedures had no documentation of Patients Rights information or an example of the rights information to be given to the patients.

At 10:00 a.m., nursing staff was asked what they knew about swing bed patient's rights. They stated they did not know about any special rights for swing bed patients. They stated they had no swing bed policies for reference.
VIOLATION: EMERGENCY POWER & LIGHTING Tag No: C0228
Based on review of hospital documents, interviews with staff, and observation of clinical and non clinical areas the facility failed ensure back up power and lighting are maintained.

Findings:
According to NFPA (National Fire Protection Association) 99-Chapter 11 Health Care Emergency Preparedness health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: a. electricity; b. water; c. ventilation, d. fire protection, e. fuel sources, f. medical gas and vacuum systems; g. communications.

1. On 01/15/13, 01/18/13 and 01/23/13, surveyors reviewed generator load testing documents. On 01/23/13, the Director of Plant Operations stated the information on the load testing documents did not reflect actual readings from the generator. He stated he wrote the same numbers based on what others had documented at the top of the page. He stated he did not really know what those numbers meant. He told surveyors he had not been trained to operate the generator when he took the job as Director of Plant Operations. When asked if the generator transfer switches had been inspected during exercise of the generator, he could not provide evidence these inspections were occurring.

2. The boiler and water heaters are installed with natural gas supply and backed up with an emergency propane supply that is stored in large tanks outside the hospital in a fenced enclosure. The emergency propane supply was not secured. The propane remained unsecured on for the duration of the survey on 01/15, 01/16, 01/18, and 01/23/13.

The gauge to the pressure reducing valve on the supply line inside was fogged over and could not be read. The Director of Plant Operations could not demonstrate how to switch the natural gas supply to emergency propane. He stated he monitored the propane levels occasionally to verify the tanks were full, but this had never been part of an established emergency preparedness routine. The surveyor observed one of the four propane tanks was empty. The Director of Plant Operations stated he was unaware the tank was empty and was not aware of it's role in an emergency.
VIOLATION: EMERGENCY FUEL & WATER Tag No: C0229
Based on inspection of hospital equipment and facilities, interviews with staff, and review of documents the facility failed to assure the safety of patients during emergencies.


1. On 01/15/13, surveyors observed unrestricted access to the hospital's main electrical panel. The plant operations director was notified of the finding. Again on 01/18/13, surveyors observed the same unsecured access to the electrical panel. On 01/23/13, surveyors noted the same findings. The Director of Plant Operations told surveyors he had been too busy with the other co-managed hospital (where he was also in charge of Plant Operations) to get anything done.

2. On 01/15/13, the surveyors observed the back up propane tanks for the boilers was unsecured. During inspection, surveyors found one propane tank was empty. The Director of Plant Operations stated the tanks had never been inspected. He told surveyors he was not sure how to check the tanks and how to verify the amount of propane. He stated he did not know how to switch the natural gas supply to the back up propane supply in the event of an emergency. He stated he had not been trained on this.

3. On 01/15/13, and again on 01/23/13, surveyors requested physical plant policies and disaster preparedness checklists. None were provided.

4. The employee file for the Director of Plant Operations had no documentation of orientation and training for the position. There was no documentation of prior experience in hospital facility maintenance. He stated no one was available to orient him when he came on staff, as the prior plant operations manager had already left the position.

5. Interviews with hospital staff indicated the staff had not been trained on fire response. On 01/16/13, two registered nurses were asked what to do in case of a fire. Neither could explain what actions they should take. When asked if they were familiar with the RACE protocol (rescue, alarm, contain, extinguish/evacuate), they said they were familiar with it, but did not think of it when asked, and did not remember training on it.

When asked about other emergency preparedness training, one staff person stated she knew what to do in the event of a tornado. Other staff stated they had not been trained on various internal and external disasters. They stated they were not aware of their roles and responsibilities during a disaster. They stated they had not been involved in disaster drills.

On 01/23/13, staff were asked if they had received any additional emergency preparedness training during the interval since the surveyors were last on-site. They stated they had not.
VIOLATION: EQUIPMENT AND SUPPLIES Tag No: C0204
Based on review of hospital documents, surveyor observations, and interviews with staff, the hospital failed to ensure equipment and supplies are maintained and available.

Findings:

1. The hospital's medical equipment has not been checked for accuracy and safety since 2008, this included defibrillators, cardiac monitors, and telemetry equipment. Without the defibrillators being checked and maintained, there was no way to assure the defibrillators delivered the proper/intended joules (electrical charge).There is no documentation staff have been trained and competency verified on the use of this equipment. There is no documentation the equipment has been part of a clinical equipment program with scheduled preventive maintenance. The person in charge of plant operations told surveyors he was not trained on clinical equipment and did not have the expertise to provide the necessary preventive maintenance regimen.

2. The portable ventilator, Auto Vent 3000, located in the ER, did not contain identification as to when it was last checked. This was confirmed with Staff B, at the time of the observation, on 01/23/2013 at 1550. There is no documentation staff have been trained on the use of this equipment. There is no documentation the equipment has been part of a clinical equipment program with scheduled preventive maintenance. The person in charge of plant operations told surveyors he was not trained on clinical equipment and did not have the expertise to provide the necessary preventive maintenance regimen.

3. On the afternoon of 01/23/2013, Staff L told the surveyors that he had pulled the portable ventilator, located in the ER Trauma Room 1, before because of a "Cracked head". He stated he had tried to order a replacement, but it was on back order. Staff L stated the ambulance service had been able to provide him with "one that fit" so the portable ventilator could be placed back in use. Asked what staff did/would do while the portable ventilator was down, Staff L stated they had to use ambu bags until the ambulance arrived and they could be switched over to the ambulance's ventilator. There is no documentation staff have been trained to "bag" patient's with an ambu bag utilizing the equipment and supplies at the facility. There is no documentation any employee or clinician received training on the portable ventilator. There is no clinical equipment log indicating preventive maintenance has been completed on this piece of equipment. There is no documentation regarding the "cracked head" and if this has occurred several times. Meeting minutes did not reflect a problem with the ventilator had been processed through the Quality program or brought to the Governing Body's attention.

On 01/23/2013, at 1550, the surveyor observed the Auto Vent 3000. The pressure hose had a tear/cut in the outer casing exposing the inside sheath. This was observed by Staff B at the time. At 1555 on 01/23/2013, Staff L stated he was unaware of the tear.
There was no documentation any staff had been trained on this equipment. There was no clinical equipment inventory to review to indicate if the ventilator had been regularly maintained. There was no user guide, maintenance log, or equipment competency for this equipment.

4. On 01/23/2013, the inpatient unit had six patients with physician's orders for telemetry. Staff F stated the hospital only had four working telemetry monitors. Staff F stated they had to triage who needed telemetry most critically. The staff said they called the physicians to see if two patients could be taken off telemetry. She stated in the past, she notified hospital administration more telemetry units were needed. She stated no action had been taken to obtain more units. There was no policy and procedure to direct staff with decision making when critical equipment is needed but not available. There was no process or documentation at the hospital indicating what patients could be triaged off of the monitors. There was no documentation to determine if patients actually requiring telemetry were removed and less critical patients were put on telemetry.

None of the nursing staff had competencies indicating they had been trained in basic heart monitoring or electrocardiograph (EKG) interpretations. There was no documentation the staff were trained on the specific telemetry units. Five of five RN's (Staff E, F, K, J and M) and two or two licensed practical nurse's (Staff G and R) personnel files reviewed did not contain any competency training or verification of skills of any kind. On 01/15/13 Staff C told the surveyors that there were no other training/competency verifications. On the afternoon of 01/16/13, Staff E told the surveyors that she had not completed any competency training or verification on staff because she was busy having to help with patient care either at this hospital or was pulled to another hospital by administration to work as a surgery nurse.

There was no documentation the telemetry units had been checked for safety and were in working order. The person in charge of plant operations told surveyors, on 01/15/13 and again on 01/23/13, he was not trained on clinical equipment and did not have the expertise to provide the necessary preventive maintenance regimen.

5. On 01/15/13, Staff V, identified by administration as the staff responsible for plant operations, told the surveyors that he did not know how to inspect the equipment and the hospital did not have a maintenance program. This was confirmed by document and equipment review.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: C0234
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on inspection of the facility, review of maintenance documents, interviews with staff, and review of committee meeting minutes the hospital failed to maintain the facility to ensure safety of the patients.

Findings:

1. On 01/15/13 surveyors requested a complete set of construction drawings for fixed equipment, mechanical and electrical systems, and life safety drawings as required by NFPA (National Fire Protection Association). Surveyors also requested manufacturer's equipment manuals for the building's fixed equipment. The Director of Plant Operations could not locate several of the construction drawings and equipment manuals. He was not able to locate a fire system life safety drawing. He did not have knowledge of critical points for the fire alarm system so that accurate checks of all of the system could be performed. He did not have a key to access the main gas shut off valves to the hospital and hyperbaric chambers. The Director of Plant Operations told surveyors he had not been oriented and trained on these items.

2. On 01/15/13, surveyors observed two yellow tags on the main fire panel. One tag, dated 11/19/11, documented, "... unit 1 + 5 are in trouble and do not shutdown on alarm!" Another tag, dated 11/15/12, documented, "... 3 troubles on the panel."

On 01/15/13, surveyors asked for documents to indicate the contractor had repaired the system. There was no documentation the system had been repaired. On 01/18/13, yellow tags were observed still on the system. On 01/23/12, surveyors received documentation the system had been approved.

Annual inspections of the fire system documentation failed to document testing of the combination fire and smoke dampers and Smoke Evacuation System for the operating rooms.

3. On 01/23/13 surveyors requested Life Safety Policies and Procedures and/or Fire Safety Policies. None were provided. On 01/15/13 surveyors asked operating room (OR) personnel if they had been trained on OR fire safety and emergency procedures. The staff member could not remember any training and was unable articulate any type of acronym for fire safety, for example, "R.A.C.E." There was no documentation in the OR personnel education files that indicated the staff had been oriented and trained in fire safety, and other special circumstances in the operating room regarding fire.

4. Hyperbarics 14. According to NFPA 99 19-3.1.2, "The hazards involved in the use of hyperbaric facilities can be mitigated successfully only when all of the areas of hazard are fully recognized by all personnel and when the physical protection provided is complete and is augmented by attention to detail by all personnel of administration and maintenance having any responsibility for the functioning of the hyperbaric facility. The ultimate responsibility for the care and safety of patients and personnel is that of the governing board. Hence it is incumbent upon that body to insist that adequate rules and regulations with respect to practices and conduct in hyperbaric facilities, including qualifications and training of hyperbaric personnel, be adopted by the medical or administrative staff of the institution, and that adequate regulations for inspection and maintenance are in use by the administrative, maintenance, and ancillary (and in the case of a hospital, nursing and other professional) personnel."

During a tour of the hospital on [DATE], the surveyors observed a hyperbaric program within the hospital's licensed space. There was no evidence the hyperbaric chamber and the risks associated therein had been assessed and addressed through plant operations and the governing body.

The Director of Plant Operations stated he didn't know anything about the hyperbaric chamber. He stated he had no orientation and training regarding hyperbarics.

There was no documentation the general staff had been trained on hyperbaric chamber safety risks. There was no documentation the hyperbaric chamber had been considered an internal disaster risk in the hospital disaster preparedness plan.

The Director of Plant Operations stated he could not locate the key to access the main oxygen shut off valve to the hyperbaric equipment.

5. On 01/15/13, surveyors observed bulk oxygen storage that was secured in accordance with requirements. However, the Director of Plant Operations could not locate a key to access the area. The bulk oxygen storage area contained the source shut off valve for the main hospital oxygen supply. Without a key, there was no emergency access in case of a fire, explosion, or other disaster situation.

On 01/23/13, the Director of Plant Operations stated he had no time to look for the key because he had been too busy attending to the needs of the co-managed hospital where he was also acting as Director of Plant Operations.
VIOLATION: CONSTRUCTION Tag No: C0221
Based on inspection of the facility, review of maintenance documents, interviews with staff, and review of committee meeting minutes, the hospital failed to maintain the facility in a condition to ensure the adequate care and safety of the patients and staff.

Findings:
1. On 01/15/13, surveyors requested a complete set of construction drawings for fixed equipment, mechanical and electrical systems, and life safety drawings as required by NFPA (National Fire Protection Association) 101 from the Director of Plant Operations. Surveyors also requested manufacturer's equipment manuals for the building's fixed equipment. The Director of Plant Operations could not locate several of the construction drawings and equipment manuals. He was not able to locate a fire system life safety drawing. He did not have knowledge of critical points for the fire alarm system so that accurate checks of all of the system could be performed. He did not have a key to access the main gas shut off valves to the hospital and hyperbaric chamber. The Director of Plant Operations told surveyors he had not been oriented and trained in these areas.

2. On 01/15/13, 01/18/13 and 01/23/13, surveyors reviewed generator load testing documents. In an interview with the plant operations director, on 01/23/13, he stipulated the information on the load testing documents did not reflect actual readings from the generator. He stated he wrote the same numbers based on what others had documented at the top of the page. He stated he did not really know what those numbers meant. The director told surveyors he had not been trained to operate the generator when he took the job. When asked if the generator transfer switches had been inspected during exercise of the generator, the director could not provide evidence these inspections were occurring. No transfer switch testing program was provided. There was no documentation the emergency back up power generator was maintained and serviced properly.

3. On 01/15/13, surveyors requested preventative maintenance logs for the hospital boiler. None were provided. There was no documentation the facility was maintaining the boilers to prevent essential equipment and services failure.

4. On 01/15/13, surveyors observed two yellow tags on the main fire panel. One tag dated 11/19/11, documented, "...unit 1 + 5 are in trouble and do not shutdown on alarm!" Another tag dated 11/15/12, documented, "...3 troubles on the panel." On 01/15/13, surveyors asked for documents to show the contractor had repaired the system. There was no documentation the system had been repaired. On 01/18/13, the yellow tags were observed still on the system. On 01/23/13, surveyors received documentation the system had been approved. The facility failed to maintain the fire system for over a year.

5. On 01/23/13, surveyors reviewed humidity levels documented for the operating rooms. Several dates in December 2012 and January 2013 documented the humidity levels were 24% or less. The logs documented, "notified safety." The humidity range in operating rooms are required to be in the range of 30% to 60% to decrease the potential for electrostatic shock which can increase combustion possibilities in a hyper-oxygenated area like the operating room.

On 01/23/13, the plant operations director told surveyors "safety" meant "he" was notified. He told surveyors he did not do anything with this information. He stated the humidity levels have been an issue in the hospital for a long time. He stated administration was working on a contract with the HVAC system, but no one could do anything about the humidity until the vendor came out to correct it.

There was no documentation the facility attempted to correct the humidity problems. There was no documentation the HVAC (heating, ventilation and air conditioning) system was maintained to ensure correct humidity controls and temperature balance. There was no documentation surgery cases were postponed, or rescheduled until humidity returned to an acceptable range.

6. On 01/15/13, surveyors notified the plant operations director, the main power electrical panel needed to be secured and access to the back propane supply needed to be secured. He was also notified there needed to be a key available to unlock the bulk oxygen storage enclosure. Eight days later on 01/23/13, the surveyors determined these items had not been corrected. At the time of exit from the facility, the hospital continued to fail to maintain and secure critical components of the hospital's emergency power and oxygen supplies.

7. On the afternoon of 01/15/2013, surveyors accompanied the director of plant operations to the negative airflow respiratory isolation room. He was unable to activate the negative airflow system. He stated the monitor continued to alarm and was irritating to the nurses, so he disabled the system. He stated he did not know what was wrong with it and no repair had been ordered. The facility failed to maintain essential components of an effective infection control program because the negative pressure airflow isolation room was unavailable to house patients who may require this type of isolation.

8. According to work orders and vendor documents received by the hospital, the HVAC system was down on 12/14/12 and 12/19/12. During these incidents, the hospital received complaints of patient room temperatures being too cold. The hospital maintenance department documented patient room temperatures as low as 58 degrees. The vendor performed some assessment and work on the HVAC system on those dates.

Again on 12/31/12, complaints were made to the hospital regarding cold patient rooms. According to a documented phone conversation between OSDH (Oklahoma State Department of Health) staff and the director of plant operations on 01/02/2013, it was verified that on 12/31/12, "the patient wing lost heat." According to the hospital's Plan of Action report provided to OSDH and signed by the Director of Plant Operations and the COO, the hospital staff identified a loss of heat at 5:30 a.m. on 01/01/13. According to the document, the hospital plant operations manager was two hours away from the hospital. The hospital "on-call" person (the information technology manager) was called to come to the hospital. He was 45 minutes away. When he arrived, he determined the unit providing heat to the patient rooms had shut down. A service technician was called and heat was restored to the patient rooms at 2:15 p.m. According to the information written in the hospital's Plan of Action report, the COO and the Director of Plant Operations acknowledged a loss of heat to patient rooms for at least eight hours and 15 minutes on 01/01/13.

Hospital records documented that on 01/08/13 and again on 01/10/13, a vendor was at the hospital to repair the HVAC outside air dampers. However, the director of plant operations stated stated the HVAC system is still an on-going problem. He stated the leaving air temperature varies from 59 degrees to 120 degrees intermittently. He stated the HVAC control system is computerized and requires a specialist technician to service it. He stated the hospital did not have a vendor contract to provide this type of service. On 01/14 and 01/15/13, the surveyors noticed cold spots in the hospital. An occupied patient room was noticeable colder than the hallway. The patient in the room was non-verbal and was unable to answer questions about being too cold.

On 01/23/13, the CEO stated the hospital had no current service agreement with the manufacturer to provide on-going maintenance and service to the HVAC system. He stated he was in the process of securing a service agreement. At the time of the exit conference, no service agreement was in place.

At the exit conference held on 01/23/13, the Governing Body Chairman stated there have been problems with the HVAC system since the hospital was constructed and had never been fully resolved.

8. At the time of the survey, the plant operations director was the only person identified by the hospital who was responsible for all the maintenance of the hospital facilities, structures and special systems, including fire systems, medical gas systems, HVAC, electrical, mechanical and biomedical equipment. There was no other employee in the facility maintenance department. When asked about his previous experience and qualifications for Director of Hospital Plant Operations, he stated he worked in "R and D for a limousine manufacturer."

9. The hospital COO also identified the Director of Plant Operations as the safety officer. When interviewed, the Director stated he was not sure what he was supposed to do as the hospital safety officer.
VIOLATION: ORGAN, TISSUE, EYE PROCUREMENT Tag No: C0345
Based on review of the hospital's death register, the written contract with the OPO (organ procurement organization - LifeShare of Oklahoma), the referral Activity Report from the OPO for the time period of January 1 through December 31, 2012, medical records and hospital documents, and interviews with hospital staff, the hospital failed to:
1. Enforce its patient death protocol, concerning reporting to the OPO (This occurred in three [Records #3, 4, and 5] of fifteen death records reviewed for the time period of September 7 through December 26, 2012.); and
2. Include OPO referral tracking through the Quality program to ensure all deaths were reported to the OPO.

Findings:

1. Upon arrival at the hospital on the morning of 01/14/13, the surveyors requested the OPO contract, the OPO Activity Reports for 2012, and the hospital's death list for 2012.

2. The death list provided for the surveyor contained 15 names for the time period of September 7 through December 26, 2012. Seven names were not contained on the OPO referral report. Three (Records #3, 4, and 5) death medical records reviewed did not contain the OPO referral form or documentation that the staff had called the OPO. This was confirmed with medical records staff at the time of review on 01/15/13.

3. Review of meeting minutes for Quality and Medical Staff did not contain evidence the OPO activity and tracking of deaths for compliance with the requirements were integrated into the quality process. This finding was confirmed with Staff D on the afternoon of 01/15/13.
VIOLATION: RESIDENTS RIGHTS (483.10(B)(5)) Tag No: C0363
Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure residents were informed of items and services that would not be charged to them and notified of items and services that may be charged, and the amount of charges for those items or services. Findings:

On 01/15/13, clinical records (two open and two closed) were reviewed for four (#7, 9, 10, and #11) swing bed patients. None of the clinical records included documentation the residents were given notification of items and services that may or may not be charged to them. There was no documentation of a list of costs for non-covered services/items that may be charged to the resident.

The medical records staff were asked if there were any scanned documents for the records reviewed. They stated there were not.

Swing bed policies and procedures had no documentation of patient charges information. There was no example of a document explaining items and services covered or not covered by Medicare. There was no list of charges for items not covered by Medicare. There was no policy that documented who informed swing bed patients of this right.

At 10:00 a.m., nursing staff was asked what they knew about swing bed patient charges for services. They stated they did not know about any special notification of charges. They stated they had no swing bed policies for reference.
VIOLATION: SOCIAL SERVICES (483.15(G)) Tag No: C0386
Based on clinical record review, document review and staff interview, it was determined the hospital failed to provide medically-related social services. Findings:

1. On 01/14/13, staff B stated the hospital contracted with someone to provide activities and social services to swing bed patients. (It was noted at the time of survey 50% of the hospital census was classified as swing bed patients.)

Clinical records for four (#7, 9, 10 and 11) swing bed patients had no documentation of social service assessment and interventions.

On 01/15/13, nursing staff stated they were not aware of a contracted person to help with social service needs. They stated they were responsible for arranging for adaptive equipment, clothing and personal items.

They stated they worked with patients and families on discharge planning arrangements.

The staff were asked if they had training in these tasks. They said they did not. They were asked if they had experience in discharge planning. They stated they did not.

There were no policies and procedures to guide staff on social services and discharge planning. The staff had no resource materials on aftercare providers.

The staff said social services and discharge planning were not a part of the patient's care plan.
VIOLATION: STAFF TREATMENT OF RESIDENTS (483.13(C)) Tag No: C0384
Based on record review and staff interview, it was determined the hospital failed to ensure individuals were not employed who had been found guilty of abuse, neglect, mistreatment or misappropriation. Findings:

The employee records for the contracted dietitians and the contracted activities/social services staff member had no evidence of a criminal background check.

There was no documentation that indicated the State Nurse Aide registry was checked for findings on employees hired by the hospital.

Staff C stated there were no other employee documents available.
VIOLATION: POLICY - EMERGENCY SERVICES Tag No: C0274
Based on review of hospital documents, staffing sheets, and interview with staff, the hospital failed to develop, review and revise policies and procedures for emergency medical services.

Findings:

1. The last review of ER (emergency services) policies and procedures by ER medical staff and nursing was 2005. The policies and procedures still reflected physician assistants worked in the emergency room . On the morning of 01/14/13, Staff B told the surveyors that the ER was staffed with a physician 24-hours a day and no physician assistants worked in the ER.

2. The emergency department policies and procedures had no documentation of the role and capabilities of the ER in the event of internal or external disasters.

3. The hospital emergency preparedness plan had no documentation of the emergency department's role and capabilities in the event of various internal and external disasters.

4. There was no emergency department policy and procedure for the participation in internal and external disaster drills.
VIOLATION: PATIENT ACTIVITIES (483.15(F)) Tag No: C0385
Based on observation, clinical record review, document review and staff interview, it was determined the hospital failed to provide an ongoing program of activities for swing bed residents. Findings:

1. On 01/14/13, staff B stated the hospital contracted with someone to provide activities and social services to swing bed patients. (It was noted at the time of survey 50% of the hospital census was classified as swing bed patients.)

2. There was no activities calendar posted in the patient care area. There was no activities calendar provided to the swing bed patients. There were no patient activities conducted during the entire survey.

3. The clinical records for four (#7, 9, 10 and #11) were reviewed for evidence of activity planning for each patient. There was no documentation of an activities assessment and plan for the patients.

There was no documentation the patients were offered or engaged in any hospital facilitated activities.

4. The nursing staff were asked if they knew who provided activities for the swing bed patients. They stated they walked the patients in the halls periodically, but they were not aware of any other activities provided by anyone.

They were asked if they were aware of an activities coordinator contracted by the hospital. They were not aware. The activities coordinator was not present at any time during the survey.

5. There were no policies and procedures that described the job responsibilities for the activities coordinator.

6. The activities coordinator had not provided an individualized activities care plan for the swing bed patients.
VIOLATION: DISCHARGE PLANNING (483.20(L)) Tag No: C0399
Based on clinical record review and staff interview, it was determined the hospital failed to ensure discharge planning and complete discharge summaries were provided for four (#7, 9, 10 and #11) of four swing bed resident records reviewed. Findings:

On 01/15/13, staff F was asked how discharge planning was done for swing bed residents. She stated the nurses helped residents with home health or nursing home placement.

She was asked if there were discharge planning policies and procedures to assist the nurses. She stated there were none. She was asked if the hospital provided resources for the nurses related to discharge planning. She stated she was not aware of any.

She was asked if the activities/social services coordinator provided any discharge planning for the residents. She stated, "No." She was asked if the nurses documented discharge planning activities. She stated they did not.

The clinical records for swing bed residents #7, 9, 10 and #11 had no documentation of a discharge plan or of discharge planning activities.

None of the records had complete discharge summaries when the residents left acute care and were then admitted to swing bed status.
VIOLATION: NUTRITION (483.25(I)(1)) Tag No: C0400
Based on clinical record review and staff interview, it was determined the hospital failed to ensure the swing bed residents maintained acceptable nutritional status. Findings:

The clinical records for swing bed residents #7, 9, 10 and #11 were reviewed. There was no documentation of any type of nutritional assessment by the nursing staff or the consultant dietitian.

When clinical records indicated the patient's physical status required a comprehensive nutritional assessment, the nursing staff were often documenting no consultation was required or no dietitian assessment was necessary.

When nursing staff were interviewed, they did not know how to contact or consult with the dietitian. The nursing staff were not familiar with the electronic nutritional assessment portion of the comprehensive patient assessment. They could not locate nutritional information on the electronic medical record.

There was no documentation of on-going nutritional status assessment even when there was evidence of a risk for weight loss and malnutrition.
VIOLATION: NUTRITION (483.25(I)(2)) Tag No: C0401
Based on clinical record review and staff interview, it was determined the hospital failed to ensure swing bed residents received a therapeutic diet when there was clinical indication for it. Findings:

Patient #9 was admitted with diagnoses which included first and second degree burns to both legs and feet, a urinary tract infection, diabetes mellitus type II, Alzheimer's disease and dementia. The patient was ordered to have a high protein, pureed diet. The clinical record documented the following daily meal intake for breakfast, lunch and dinner:

10/13/12: 10% for all three meals

10/14/12: 45%, 15%, and 10%

10/15/12: 0%, 50%, no documentation for dinner

10/16/12: no documentation for the day

10/17/12: 40%, 15% and 10%

10/18/12: 10%, 15% and 10%

10/19/12: 0%, 0% and no documentation for dinner

10/20/12: 0% for all three meals

10/21/12: no documentation for the day

A nurse's note, dated 10/13/12, documented the patient had "dark amber urine." There was no documentation the physician was notified of this finding. There was no documentation extra fluids were offered to the patient.

The patient had abnormally high blood sugar levels for the entire stay in the hospital. There was no documentation the nursing staff notified the physician or consulted with the dietitian.

There was no documentation of a comprehensive nutritional assessment by the nursing or dietary staff.

Although the patient had poor intake, there was only one weight taken during the patient's hospitalization . The patient was weighed on his admission to acute care, not the swing bed admission.

Patient #11 was admitted with an IV, a foley catheter and a diagnosis of debility and generalized weakness. The physician ordered a heart healthy diet. The clinical record had no documentation of the type of diet provided to the patient, or of amounts consumed. There was no nutritional assessment and no documentation of consultation with the dietitian.

On 01/15/13, a review of in-patient records (patients #6 through #12) indicated staff nurses were ordering therapeutic diets without a physician's order, or were changing diet orders without a physician's order.

Patient #7 was admitted to the hospital with orders for a regular diet and nutritional supplement shakes to be given three times a day. There was no documentation of a nutritional assessment or consultation with the dietitian.

On day three of admission, the clinical flowsheet documented the patient was receiving a regular soft diet, and then an 1800 calorie ADA soft diet. There was no corresponding physician's order for this. On day five, the physician ordered a mechanical soft diet.

Staff F, nurse on the unit, was asked to find where the supplement shakes were documented in the electronic medical record. She stated she wasn't sure where those were documented. No documentation of the supplement shakes could be found.
VIOLATION: PATIENT CARE POLICIES Tag No: C0275
Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to designate the scope of practice for physician assistants (PAs).

Findings:

On 01/15/13, staff B stated physician assistants did not practice in the hospital.

On 01/15 and 01/16/13, open and closed clinical records were reviewed. The records documented physician's orders and progress notes written by PAs. There were no hospital policies that documented the approved scope of practice for these allied health professionals.
VIOLATION: PATIENT CARE POLICIES Tag No: C0280
Based on review of policy and procedure manuals, Governing Board and Medical Staff meeting minutes for 2012 and 2013 and interview with hospital staff, the hospital failed to ensure policies are reviewed and revised to meet current practices at least annually.

Findings:


1. Drug Room policies and procedures were reviewed. Policies did not reflect the current practices in the Drug Room. The policies had a cover sheet with the signatures of the CEO, Medical Director, Chief Nursing Officer ( who no longer was employed by the hospital) and the Chairman of the Board of Trustees and was dated 05/22/12. The Consultant Pharmacist's signature was not on the cover sheet signifying review of the policies. None of the policies were current. The policies were describing practices from a previous administration.

2. None of the individual departmental policies and procedures had been signed as reviewed and approved annually by qualified practitioners.

For example, none of the dietary and nutritional services policies had been developed or reviewed by the registered and licensed dietitian. The dietary supervisor confirmed this finding.

The respiratory therapy policies had not been developed and reviewed by the certified and registered respiratory therapist. The respiratory therapist confirmed this finding.

emergency room policies and procedures had not been reviewed since 2005 by emergency room physicians or nursing staff.

The nursing policies and procedures did not contain evidence they had been reviewed by Chief Nursing Officer since 2008. Most policies had the date of 2005, including the front cover-sheet.

Surgery policies and procedures had no documentation they were developed and approved by certified surgical nursing staff and/or physicians with surgery privileges.

There was no documentation a CRNA (certified registered nurse anesthetist) or an anesthesiologist had participated in the development and approval of the hospital's anesthesia policies.

While the policy and procedure manuals had cover sheets signed by staff as approved in 2012, the actual content of the policies was outdated and not relevant to the services provided by the hospital at the present time.

The majority of the individual departmental policies were dated 2005 or earlier, and did not always reflect current standards of practice. None of the policies reviewed made reference to nationally recognized sources of information.
VIOLATION: LICENSURE OF CAH Tag No: C0153
Based on interviews with staff, review of hospital documents, and review of Department documents, the facility failed to renew their Hospital License for 54 days.

Findings:

1. On October 10, 2012 Oklahoma State Department of Health (OSDH) Medical Facilities Division sent a reminder licensure notification to the facility. The letter documented the facility license was due to expire on November 30, 2012. On December 26, 2012 Staff B contacted OSDH via e-mail indicating a check and application would be mailed overnight and Staff B would send a follow up e-mail the next day with the documents scanned. No check or application was received via overnight delivery. No e-mail was received at OSDH the following day.

2. On December 31, 2012 OSDH staff sent a copy of the renewal notification to Staff B and asked if the facility had found the forms for renewal. No communication was received from the facility.

3. OSDH staff left voice messages on the administrative contact phone in January requesting the licensure application and fees. No telephone calls were returned by any facility staff.

4. On January 22, 2013 OSDH staff sent e-mail communication to the facility. The e-mail stated the license had expired 11/30/2012 and OSDH had not received any paperwork. Later that day Staff B e-mailed the department indicating the facility would be sending another check overnight as the other check had not cleared.

5. On 1/23/13 Staff B told surveyors the application and check was sent overnight on 12/27/12. There was no documentation the license renewal was sent overnight. There was no documentation the application and fees had been sent. Surveyors asked for documents indicating the information had been overnighted or sent. None were provided. There was no documentation at the Department the application had been overnighted.
VIOLATION: MANAGEMENT OF TRASH Tag No: C0223
Based on interviews with staff, observations, and review of documents the facility failed to ensure appropriate storage of biohazardous waste.

Findings:

1. On 01/15/13 during a facility tour, surveyors observed large plastic bio-hazardous material containers stored in the boiler room and fire pump area. The containers were full of biohazardous waste. The boiler room was not labeled and designated as a biohazardous waste collection area.

The Director of Plant Operations stated he was not aware biohazardous waste could not be stored in that area.

2. Surveyors requested policies and procedures pertaining to environmental services, storage of biohazardous waste and the environment of care. No policies and procedures were provided.
VIOLATION: QA - QUALITY OF PATIENT CARE Tag No: C0336
Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital has an effective Quality Assurance/Performance Improvement (QA/PI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital conducting a collection and analysis of data concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2012 and 2013 did not contain evidence of any analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. There were no Medical Staff meeting minutes from June through December 2012.

3. The QA/PI program does not include the following: an active on-going infection control program for ensuring a sanitary environment; identification and prevention of infections and communicable diseases among patients and staff; analysis of infection control surveillance data and concerns with development of corrective actions when needed; follow-up to ensure corrective actions are appropriate and sustained to ensure a sanitary environment and avoid sources and transmission of infections for patients and personnel.

4. Organ procurement is not reviewed as part of the QA/PI program to ensure compliance with the requirement of assuring all deaths are reported to Life Share.

5. The hospital failed to ensure that surgical procedures are performed in a safe manner. See Tag 0320.