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.

MERCY HOSPITAL TISHOMINGO 1000 SOUTH BYRD TISHOMINGO, OK 73460 March 7, 2014
VIOLATION: QA - MEDS & INFECTIONS Tag No: C0338
Based on record review and interviews with hospital staff, the hospital does not ensure nosocomial infections and medication therapy are evaluated as part of a Quality Assurance Performance Improvement (QAPI) program. Review of medical staff , governing body and quality meeting minutes for 2013 and 2014 did not have evidence of evaluation of nosocomial infections or medication therapy. Although meeting minutes documented positive cultures and identified the organisms, the minutes did not reflect if any of the positive cultures were nosocomial/hospital acquired infections. This was verified with hospital staff on 03/07/14.
VIOLATION: POLICIES - DRUG MANAGEMENT Tag No: C0276
Based on record review and interviews with hospital staff, the hospital does not ensure that licensed pharmacy personnel are trained, evaluated and have a job description. Staff FF did not have a job description defining her job duties in the hospital's drug room. Staff FF did not have any competencies or evaluations by the Consultant Pharmacist for the duties performed in the drug room. This was verified by staff on 03/07/14.
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 03/07/14 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 2013 and 2014 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.
VIOLATION: PERIODIC EVALUATION OF SERVICES Tag No: C0332
Based on record review and interviews with hospital staff, the hospital does not ensure the hospital had a yearly program evaluation which includes a review of the number of patients served and the volume of services. Hospital staff verified on 03/07/14 in the afternoon the hospital did not have an annual program evaluation which included these statistics.
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 Performan Improvement meeting minutes for 2013 and 2014 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 03/07/14 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 the hospital had an annual program evaluation which included a review of the hospital's health care policies. The hospital did not have an annual program evaluation that had evidence of review of the hospital's policies. This was verified with hospital staff on 03/07/14 in the afternoon.
VIOLATION: PERIODIC EVALUATION Tag No: C0335
Based on record review and interviews with hospital staff, the hospital does not ensure the hospital had an annual program evaluation that determined whether the utilization of services was appropriate, established policies were followed and any changes were needed. The hospital did not have an annual program evaluation that documented whether any changes to hospital services or policies were added or revised because of information from an annual program evaluation. This was verified by hospital staff during the survey.
VIOLATION: QUALITY ASSURANCE Tag No: C0337
Based on record review and interviews with hospital staff, the hospital does not ensure that the quality assurance (QAPI) program evaluates the hospital's patient care services to ensure patient health and safety.

Findings:

1. Services provided by contract were not evaluated by the QAPI program

2. Medication errors reported to QAPI were not analyzed and trended to evaluate and formulate an action plan to decrease medication errors.

3. Dietary data reported to QAPI was the number of meals served and the cost of the meals. There were no indicators in dietary to evaluate if the nutritional needs of patients were met.

4. Infection control data reported to QAPI did not analyze and trend infections and medication therapy to protect patients and ensure their safety.
VIOLATION: GOVERNING BODY Tag No: C0241
Based on record review and interviews with hospital staff, the governing body does not ensure that all practitioners providing patient care are qualified and have current appointments and federal and state narcotic permits. Four of seven physicians' and one of two allied health practitioners credential files reviewed were incomplete and did not have either evidence of current appointment to the medical staff or current federl and state narcotic permits.

Findings:

1. Three ( HH, II, JJ) of seven physicians' credential files reviewed did not have evidence of current federal narcotic permits.

2. Two ( GG & HH) of seven physicians' credential files reviewed did not have evidence of current state narcotic permits.

3. One ( KK) of two allied health personnel did not have evidence of current appointment to the medical by the governing body.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
Based on review of hospital documents and personnel records and interviews with hospital staff, the hospital failed to ensure the hospital had an ongoing infection control program with active hospital wide surveillance, review and analysis of concerns identified an corrective actions when needed and follow-up to ensure continued compliance.

Findings:

1. The hospital does not have a current infection control plan that:
a. specified all departments would be reviewed
b. identified what would be reviewed
c. how often the review would occur.

2. The infection preventionist did not conductive active surveillance and observe processes/procedures to ensure infection control policies and procedures were followed throughout the hospital. The only documents provided for review contained sections/headings for handwashing and isolation and two environmental rounds/walk-throughs. Each had a notation that, at the time of the observations, no patients were currently on isolation precautions. Staff D told the surveyors on 03/07/2014 that he had not monitored each department to ensure infection control policies and procedures were followed.

3. Meeting minutes did not demonstrate concerns and problems identified in the surveillances conducted were reviewed, analyzed and corrective actions taken.

4. Employee health was not reviewed to ensure transmission of illnesses and diseases were not transmitted between patients and staff. Seven physician and two allied health credential files reviewed did not contain complete immunization histories. Meeting minutes did not reflect this had been reviewed.

5. Although meeting minutes documented positive cultures and identified the organisms, the minutes did not reflect if any of the positive cultures were nosocomial/hospital acquired infections.

6. Meeting minutes did not reflect the infection control committee had reviewed and selected the disinfectants used throughout the hospital. The surveyors observed PDI products available for use on the units and in the departments. On 03/07/2014, Staff D stated he thought the hospital was going to start using Diversity products, but did could not tell the surveyors which products; amount of time the product needed to remain wet on surfaces to be effective; or against what organisms the products were effective.
VIOLATION: POLICIES - NUTRITION Tag No: C0279
Based on review of medical records and hospital documents, and interviews with hospital staff, the hospital failed to ensure the nutritional needs of inpatients were met in accordance with recognized practices. This occurred for thirteen of thirteen medical records (Records #1, 2, 4, and 7 through 16) reviewed.

Findings:

1. Medical records # 1, 2, 4, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16 did not contain a nutritional assessment to determine if their nutritional needs were being met or if they needed additional interventions.

2. The contract with the dietitian documented the dietitian would review medical records during her consultation visits.

3. Review of the consultant dietitian's visit reports only showed one episode of chart review, 02/13/2013. Although the report documents the dietitian reviewed records, it did not contain documentation of findings. This finding was confirmed with Staff J on 03/07/2013.

4. These findings were reviewed with administrative staff during the exit conference on 03/07/2014. No further information was provided.
VIOLATION: MAINTENANCE Tag No: C0222
Based on document review and staff interview, the hospital did not ensure all patient care equipment was maintained in safe operating condition.

Findings:
1. On the afternoon of March 6, 2014, surveyors toured the emergency department (ED) and the mobile Computed Tomography (CT) department.
~Surveyors observed a monitor that was used to take vital signs in Room 2 that was not inspected or tested .
~Surveyors observed a power injector in the CT room that was not inspected or tested .
2. Staff U told surveyors that all equipment is inspected by maintenance, stickered, and dated which indicates equipment is safe for patient use.
~Staff U verified that the vital signs monitor in ED Room 2 did not have a sticker indicating it was inspected.
~Staff E verified that the power injector (injects contrast media into the bloodstream of patients) in CT did not have a sticker indicating it was inspected or tested .
3. On the afternoon of March 7, 2014, Staff W told surveyors that the vital signs monitor in ED Room 2 was new equipment, not on the hospital inventory list, and was not inspected. Staff W also indicated that the power injector in CT was not inspected and tested but was on the inventory list to be serviced.
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 was 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 and did not include all services provided.
Findings:

1. A shared services contract with a network hospital did not include physical therapy services provided by the network hospital.

2. A mental health service provided by contract within licensed hospital space was not included in the list of contracted services.

3. This was verified by hospital staff on 03/07/14 in the afternoon.