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.

STROUD REGIONAL MEDICAL CENTER 2308 HIGHWAY 66 WEST STROUD, OK 74079 June 21, 2017
VIOLATION: ORGAN, TISSUE, EYE PROCUREMENT Tag No: C0349
Based on record review and interview, the hospital failed to educated staff regarding organ procurement policies and procedure and staff responsibilities.

This failed practice had the potential for staff responsibilites regarding organ procurement to go unfulfilled, and suitable organs not procured for the patients' in need.

Findings:

7 of 7 personnel records for regisitered nurses (Staff B, C, H, O, Q, R, and S) reviewed showed no evidence of organ procurement training as to the process and their responsibilies.

On 06/21/17 at 11;00 am, Staff B stated current staff had no documentation for current organ procurement training.
VIOLATION: RESIDENTS RIGHTS (483.10(B)(3)) Tag No: C0361
Based on record review and interview the hospital failed to provide notice to swing bed patients prior to or upon admission of swing bed patient rights and responsibilities.

This failed practice had the potential for patients in swing bed status to be unaware of their patient rights while admitted to a swing bed status.


Findings:
Document titled "Swing Bed Program" showed upon admission ...will receive copy of Patient's Bill of Rights and Rules and Regulations

Document titled "Patient Rights" failed to provide evidence of patient rights specific to swing bed patients.

10 (Patient #8, 12, 14, 15, 17, 18, 19, 20, 21, and 29) of 10 medical records showed no evidence for notice of patient rights specific to swing bed upon admission.

On 6/23/17 at 12:00 pm, Staff V and Staff B stated the facility does not have a Patient's Rights packet specific to swing bed patients.

On 06/23/17 at 12:02 pm, Staff V stated they provide the general "Patient's Rights" document, Notice of Privacy Practices and Importance Message from Medicare to in-patients: and reported the documents are scanned into the patient's electronic health record after the patient signs a form for receipt and a copy is provided to the patient or patient representative.
VIOLATION: RESTRAINTS (483.13(A)) Tag No: C0381
Based on record review and interview the hospital failed to ensure patients have the right to be free from physical restraints for purposes of convenience.

This failed practice increased the risk to patient safety in 1 out of 1 patient (Patient #19).

Findings:

Document titled "Restraint Use" showed restraint orders should not be written for PRN (as needed)use ...if patient released from restraint and exhibits behavior that requires reapplication, a new order is required ...a "trial release" constitutes a PRN use of restraint...restraint orders should be renewed every 24 hours.

1 (Patient #19) of 1 medical record showed:

A. Restraints were removed and replaced without a new order obtained from nursing staff for each episode when restraints were reapplied, excluding care/treatment.

B. No evidence of monitoring of patient while in restraints for 05/04/17 or 05/19/17.

C. Evidence patient continued to be removed and released from restraints without an order from 05/20/17 until discharge on 05/23/17.

On 06/22/17 at 10:00 am, Staff B stated restraint use requires an order from the physician; and reported orders allow nursing staff to remove restraints for care/treatment of the patient while under supervision; and reported if patient doing better and restraint removed a new order should be obtained.
VIOLATION: PHYSICAL PLANT AND ENVIRONMENT Tag No: C0220
Based on observation and interview, the hospital failed to:

a. maintain the security of the drug room,
b. see Life Safety Tags.

This failed practice had the potential risk of unauthorized persons of gaining access to medications.

Findings:

a. Drug Room

A review of a policy titled, "Drug Diversion Policy Medication Room" (no date of Governing Body approval) failed to document that securing entrance to the Drug Room was an element of drug security.

On 06/14/17 at 10:25 am, the surveyor observed the drug room door open. The Drug Room was in a semi-public corridor, that had a frequent flow of staff, patients and visitors. It was observed the area contained medications, including narcotics.

On subsequently tours of the medical unit, the drug room door was observed open. Although the entrance door had a combination entry lock, the door did not have an automatic closure, and the door frequently remained open.

On 06/14/17 at 10:25 am, Staff H stated the staff often failed to shut the pharmacy door after entry.

b. See Life Safety Tags.
VIOLATION: PROVISION OF SERVICES Tag No: C0270
Based on record review and interview the hospital failed to:

A. Ensure policies and procedures (P&P) were specific to the hospital, approved by leadership and services furnished were in accordance with the appropriate written P&P

B. Ensure a complete infection control risk assessment, define and enforce policies for isolation precautions and perform an adequate number of hand hygiene surveillance observations

C. Ensure contract/arrangement services were defined by scope and nature.

D. Ensure nursing staff followed P&P for assessment/reassessment, evaluated pain using pain scale, evaluated/treated and provided preventative measures for wounds and emergency department (ED) patients were evaluated, treated, monitored and reassessed.

E. Ensure a Registered Nurse (RN) supervised and evaluated the care for each patient.

F. Ensure nursing staff documented the administration of scheduled medications in the electronic health record.

G. Ensure nursing staff maintained a nursing care plan by assessing the patient's needs per hospital policy.

These failed practices had the potential for inconsistencies in care, delayed recognition in changes to patient's medical condition and increased risk to patient safety.

Findings:

A. See Tag C-0274, C-0276, C-0294

B. See Tag C-0278

C. See Tag C-0291

D. See Tag C-0294

E. See Tag C-0296

F. See Tag C-0297

G. See Tag C-0298
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
Based on record review and interview the hospital failed to:

A. Ensure hospital specific policies and procedures (P&P) were developed, approved and implemented

B. Ensure services are furnished in accordance with appropriate written policies and procedures (See Tag C-0274, C-0276, C-0294)

This failed practice had a greater potential for inconsistencies in patient care, staff confusion and increased risk to patient safety.

Findings:

A. Development and Approval of Hospital Specific P&P

Document titled "Critical Results of Tests and Diagnostic Procedures - Reporting of" showed department as "organization-wide". Policy did not address the following (only by blank lines):
~critical results of tests and diagnostic procedures included for hospital
~individuals who may report critical test results
~licensed healthcare providers who may receive critical test results
~state the healthcare provider is licensed
~time limit for reporting critical test results
Policy failed to provide evidence of being specific to the hospital and approval by leadership including nursing, medical staff and governing body for the hospital.

Document titled "Pain Scale" showed departmental approval on 06/07/16. Policy failed to provide evidence of approval by Quality, Medical Staff or the Governing Board.

Document titled "Drug Diversion Policy for Medication Room" failed to provide evidence of approval by Quality, Medical Staff or the Governing Board.

Document titled "Patient's Own Medication Usage During Admission" failed to provide evidence the policy was specific to the hospital and approved by Quality, Medical Staff or the Governing Board. Policy showed Physicians' Hospital at Anadarko was in the policy.

Document titled "Telephone, Verbal and Written Orders for Medication" showed "Physicians Hospital in Anadarko" within the policy. Hospital leadership identified Physicians Hospital in Anadarko was a hospital within their system. Policy failed to provide evidence of approval by the Governing Board.

2 (Patient #23 and 30) of 4 medical records showed no evidence of critical lab results being reported to the licensed independent practitioner responsible for the patient by the individual who performed the tests.

3 (Patient #13, 23, and 30) of 4 medical records showed no evidence the licensed independent practitioner or registered nurse acknowledged the critical test results through a read-back process in the patient's chart per hospital policy.

On 06/15/17 at 10:00 am, Staff B stated the hospital was reviewing and updating policies and procedures to coordinate with the other hospitals within their organization.

On 6/23/17 at 11:20 am, Staff W stated the lab would notify the charge nurse of the critical test results and then the charge nurse would report the results to the physician; and reported the hospital does not have a critical test log where they keep track of all critical test results. Staff W stated nursing staff usually documents physician notification in the patient's chart; and reported he/or she was unaware of a specific policy on critical test results or panic values.

B. Services in Accordance with P&P

Document titled "Psychiatric Evaluation" showed a "blank" line for the title of the organization ...if a patient is a danger to self, staff or others, a security officer should be requested to continually observe patient ...Call Emergency Psychiatric Evaluation Team (PET). Policy failed to provide evidence of being specific to the hospital or approval by Quality, Medical Staff or the Governing Board.

Document titled "Restraint Use" showed hospital does not use seclusion and throughout the policy the phrase "restraint or seclusion". Policy was hospital specific and approved by Quality, Medical Staff and Governing Board.

Document titled "Restraint or Seclusion Use" showed multiple blanks within the policy for organization name, revision of plan of care, order renewal, and providers allowed to order restraints or seclusion. Policy failed to provide evidence of being specific to the hospital and approval by Quality, Medical Staff or the Governing Board.

Document titled "Restraint and Seclusion - Staff Training and Competency" showed evidence that staff would receive training on seclusion.

Document titled "Restraint and Seclusion - Staff Training and Competency" showed multiple blanks within the policy for hospital name, training requirements for physicians and licensed independent practitioners, and assessment of on-going education and competency for staff. Policy failed to provide evidence of being hospital specific and approval by Quality, Medical Staff or the Governing Board.

On 06/23/17 at 11:30 am, Staff T reviewed restraint policy and referred surveyor to statement that hospital does not use seclusion; and reported the use of the phrase "restraint or seclusion" in the policy is incorrect and the word "seclusion" should be removed.

On 06/15/17 at 10:00 am, Staff B stated the hospital was reviewing and updating policies and procedures to coordinate with the other hospitals within their organization.

On 06/23/17 at 11:55 am, Staff X stated for patients who present with suicidal ideation or self-harm nursing would be 1:1 supervision to ensure safety until police arrive; and reported this should be documented in the chart.
VIOLATION: POLICY - EMERGENCY SERVICES Tag No: C0274
Based on record review and interview the hospital failed to ensure the Emergency Department policies and procedures (P&P) were:

A. Developed based on services provided by the hospital (See Tag C-0294)

B. Specific to the hospital

C. Approved by hospital leadership

This failed practice had a greater potential for inconsistencies in patient care and risk to patient safety.

Findings:

On 06/14/17 surveyors requested a list of all emergency department policies and procedures. Document titled "Emergency Department Policy and Procedure Manual Table of Contents" was provided listing all ED P&P.

All Emergency Department policies and procedures failed to provide evidence of a header or content to identify them as hospital specific and approval by the Emergency Department, Quality, Medical Staff and the Governing Board.

On 06/14/17 at 1:15 pm, Staff B and T stated document titled "Emergency Department Policy and Procedure Manual Table of Contents" was the P&P manual for the hospital.

On 06/15/17 at 10:00 am, Staff B stated the hospital was reviewing and updating policies and procedures to coordinate with the other hospitals within their organization; and reported the ED P&Ps were part of the organization efforts.
VIOLATION: POLICIES - DRUG MANAGEMENT Tag No: C0276
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


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

a. clearly define the home medication policy and failed to appropriately store home medication brought into the facility by patients , and

b. manage and store controlled substances in accordance with accepted professional principles

This failed practice had the potential to increase the risk of drug diversion.

Findings:

a. Home Medications
On 06/14/17 at 10:00 am, the surveyors requested the policies and procedures for the management of home medication. Staff H, the drug room supervisor, provided multiple documents regarding home medication.

A review of a document titled " The Physicians' Hospital of Anadarko [a hospital with business association to this facility] Patient's Own Medication 2017". The document outlined the management for "Not Administering Home Meds" and "Administering Home Meds". The steps for each are as follows:

"Not Administering Home Meds
~ Enter med into Home Meds section of Healthland computer or send medications home with family member
~ If unable to send meds home, enter onto home med form, seal meds with tamper evident tape and place in lockup
~Discharge: Sign meds over to patient."

"Administering Home Meds.
~ Enter med into Home Meds section of Healthland computer
~Keep meds to be administered while admitted (must stated in prescriber's orders: may administer patient own med)
~Complete form for each medication to be administered
~Take med and form to Drug Room for ID. after hours & weekends Nurse ID's meds until next Drug Room Shift
~Meds will be placed in OMNICELL or in lockbox (narcotics)
~retrieve med & record when each dose is administered to patient (on form and in Healthland) Meds will be kept at bedside)
~Discharge: Sign meds over to patient"

A review of a document titled, "[Stroud] Medical Administration 08/16" documented "Medication from home that the patient brings to the hospital shall be disposed of in one of two ways: Sent home with an immediate relative, or sent to the hospital Med Room to be stored until the patient is discharged . Medications are counted by 2 licensed staff placed in a labeled bag, and sent to the Med Room with the Home Med Inventory. If the patient expires, all personal medication shall be destroyed."

A review of a policy titled, "Patient's Own Medication Usage during Admission " (with no hospital's name or approval date) documented, "a patient's personal supply shall be logged into receipt by the Hospital."

On 06/14/17 at 10:25 am, during an inspection of the drug room's patient home medication cabinet, the surveyor observed home medication for the following patients:
~Patients #1 a current patient, had no inventory list
~Patient #10 had no inventory list. Staff H stated Patient #10 was admitted on [DATE] and had expired 05/17/17. Patient #10 's medication included Hydrocodone/acetaminophen (an opioid-narcotic)
~Patient #11 had no inventory list. Staff H the patient was a prisoner, was discharged , and staff did not know what to do with the medication.
A sign in the home medication cabinet read "narcotic count forms for patients with 'own RX' . Please count each shift with 2 nurses." Staff H said the narcotic had not been counted each shift.

On 06/15/17 at 9:33 am, Staff H said two staff should have inventoried the medication, and put the medication in a tamper resistant bag. Staff H stated the consulting Pharmacist did not look in the home medication cabinet during the monthly inspections.

On 06/22/17 at 9:15 am, Staff D, the contracted Pharmacist, told surveyor that she had not aware of the hydrocodone in the drug room that was not inventoried.

b. Narcotic Management

A review of a policy titled, "Drug Diversion Policy Medication Room" (no date of Governing Body approval) documented controlled drugs in the medication room would be counted monthly. The policy failed to clearly define the process of narcotic management and security from procurement to use or destruction. The policy did not address the storage of home medications that were narcotics.

A review of a policy titled, "Medication Administrations 08/16" documented wasted control shall be witnessed and cosigned. The policy failed to address the appropriate method of wasting control medication.

A review of incidents showed on 08/16, an employee called the pharmacy to inquire as to what was the proper method of wasting Morphine, and was told by "pharmacy" to put the filled syringe in the sharps container.

A review of incidents showed on 11/16, a box of Lorazepam (used for anti-anxiety) was found in a red drug supplier box in the pharmacy office, which was accessible to all personnel with a master key.

On 06/14/17 and 06/15/17, the surveyor observed Patient # 1, 10, and 11 home medication were still in the home medication cabinet and not inventoried. Patient #10's Hydrocodone had tape on the bottle's cap with "84 and 2 signatures" written on the tape. On 06/15/17 at 9:19 am, in the presence of the surveyor, Staff H counted the medication in the bottle labeled hydrocodone. Staff H counted 84 full tablets and 14 half tablets. Staff H stated there was no record documenting the amount of Hydrocodone that was brought by Patient #10 at admission.

On 06/15/17 at 9:33am, Staff H stated the hospital' s narcotic were ordered from a distributor. Staff H stated in the presence of another staff, she received the narcotic supply, verified the amount received with the order sheet, and placed the medication in the safe and put the inventory receipt in a drawer. Staff H stated controlled medication was counted if pharmacy staff were "going to be off" and/or monthly.

On 06/15/17 at 9:33am, Staff H said she was the 6th drug room nurse in the past 5 years, and was working with the Pharmacist to create and improve policies.

On 06/15/17 at 9:33am, Staff H stated a former nurse was terminatated, because he or she was suspected for stealing morphine.
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
Based of record review, interview, and observation, the hospital failed to:

a. perform a complete infection control risk assessment,

b. perform an adequate number of hand hygiene surveillance observations in the medical surgical unit (med/sug), and

c. define and enforce policies for isolation precautions in the medical surgical unit.

These failed practices had the potential for inconsistencies in care, delayed recognition in changes to patient's medical condition and increased risk to patient safety.

Findings:

a. Infection Control Risk Assessment

A review of the hospital's policy titled, Infection Control Risk Assessment 03/16" documented risk were identified, prioritized, and goals established. The documented the organiztion's surveillance data will be compared to external benchmarks. The policy documented an example of high prioritized risk to include use of medical equipment cleaning, disinfection, and sterilization.

A review of the Infection Control Risk Assessment for 2017 approved by the Governing Body showed the assessment did not include the hospital's surveillance data to assist the hospital determining the degree of risk. The assessment also did not include a probability of risk ranking for decontamination and sterilization of instruments; yet, Staff A, the CEO, stated surgical services's reopening was planned within the next few months. The assessment ranked the risk probability for hand hygiene as "maybe=2" level. On 06/22/17, the only hand hygiene raw data provided for 2016 was 1 med/surg unit observation and 3 med/surg unit observation in 2017. The assessment documented the probaility of risk for "Lack of Contact Isolation" as "rare" which did not seem a reasonable risk ranking due to surveyor observations and number of isolation patient. A review of the MEC meeting minutes for 06/21/17 documented "10 in contact isolation".

On 06/15/17 at 2:30 pm, Staff C stated she/he had not included the hospital's surveillance data of the Infection Control Risk Assessment.

b. Hand Hygiene Surveillance

A review of hospital's policy titled, "Surveillance Plan 03/16" showed the annual surveillance plan must be approved by the Infection Prevention and Control Commiittee; however, it is the Governing Body who is responsible for all aspects of operation that involves patient safety and quality. The policy provided guidance for surveillance activities for mandatory to the state, and did not address other aspects of infection control surveillance including but not limited to hand hygiene.

A review of hospital's policy titled, "Infection Prevention and Control Program 03/16" documented the program included conducting reliable sampling size for surveillance. The policy did not define the number of hand hygiene observations required for the program or details of the elements of the observations.

On 06/22/17, the surveyor asked for the hand hygiene raw data for med/surg, and recived 1 med/surg unit observation for 2016 and 3 med/surg unit observations in 2017.

On 06/22/17, Staff T stated the raw hand hygiene data provided was all the information available.

c. Isolation Precautions

A review of the hospital policy titled, "Transmission-Based Precautions (Isolation Precautions) 03/16" documented for contact isolation, gowns and gloves should be worn whenever touching or having direct contact with the patient. The policy did not specifically address expectation for visitors and patient sitters.

A review of the MEC meeting minutes for 06/21/17 documented Staff C reported 2 nurses were going into isolation rooms without using precautions.

On 06/21/17 at 10:00 am, the surveyor observed Patient #18's visitors was at the bedside. Patient # 18 was in contact isolation. The 2 visitors were holding the patient's hands and leaning against the bed rails. The visitors were not wearing gowns or gloves.

On 06/21/17 at 10:15 am, the surveyor observed Staff P, an agency sitter with Patient #2. Patient #2 was in contact isolation. The sitter was in a chair near the patient's bed. She was wearing a gown around her neck, and her arms were not in the sleeves of the gown, and she was not wearing gloves. The sitter had her personal food and drink on a table near her chair. The sitter stated whenever she had patient contact she put her arms in the sleeves of the gown and donned gloves.

On 06/21/17, at 10:00 am, Staff B stated staff and family members should wear appropriate PPE when in rooms of patients in contact isolation. Staff B then proceeded to instruct the family to gown and glove. One of the visitors said they had come to the hospital multiple times and were never told to gown and glove.
VIOLATION: AGREEMENTS - LIST OF SERVICES Tag No: C0291
Based on interviews and record review, the hospital failed to ensure that contract/ arrangement services were defined by scope and nature.

This failed practice had the potential to meet the hospital and patient needs due to sub-optimal services from contracted entities.

Findings:
A review of the list of contracted services, dated 2017, showed no documentation that contracted services had been evaluated by the governing body, who is responsible for oversight.

On 06/14/17 at 11:53 am, Staff C stated the contracted services list was incomplete and did not contain all required elements, such as service(s) offered, individual(s) or entity providing the service(s), whether the services are offered on- or off-site, whether there is any limit on the volume or frequency of the services provided, and when the service(s) are available.
VIOLATION: NURSING SERVICES Tag No: C0294
Based on record review and interview the hospital failed to:

A. Ensure hospital nursing staff followed established P&P for assessment and reassessment of patients

B. Ensure nursing staff evaluated patient's pain, use of a pain scale to determine effectiveness of pain control measures, and facilitate regular reassessments per hospital policies

C. Ensure hospital nursing staff evaluated, treated and provided preventative measures for pressure ulcers and wounds according to established policies and procedures.

D. Ensure patients presenting to the ED were evaluated, treated, monitored and reassessed according to policies and procedures for the department.

These failed practices had a greater potential for inconsistencies in patient care and risk to patient safety as diligent nursing surveillance can lead to timely recognition of early clinical deterioration.

A. Nursing Assessment

Document titled "Assessment and Reassessment" showed assessment shall be ongoing ...the assessment process should be individualized to meet the needs of the patient population ...RN shall complete the nursing assessment within 24 hours of patient admission ... reassessment determined by patient diagnosis, treatment setting and patient response to treatment ...any change in condition requires an immediate reassessment. Policy failed to identify criteria for assessments/reassessments for patients admitted to in-patient, swing-bed and high observation units.

Document titled "Assessment and Reassessment" showed admission assessment time frames for medical/surgical unit should be initiated within 30 minutes and completed within 8 hours and critical care units initiated within 5 minutes and completed within 4 hours of patient arrival. Policy failed to identify criteria for reassessment timeframes for patients admitted to in-patient, swing-bed and high observation units. Policy failed to show evidence of being specific to the hospital and approval by Quality, Medical Staff and the Governing Board.

Document titled "Nursing Care" showed level of care is based on patient individual needs ...assessment of RN plays important role in standard of care including frequency of observation, recording of data, and physician communication ...preventative measures include prevention of illness by early diagnosis and control of progression of chronic illnesses.

Document titled "Patient Monitoring" showed vital signs are recorded per provider orders. Policy failed to identify monitoring criteria for patients in acute care, swing bed and high observation.

Document titled "Swing Bed Program" showed skilled nursing beds or swing beds are for patients who still need a higher level of nursing, but not to the same degree as acute care patients.

4 (Patient #13, 18, 19 and 20) 4 of medical records showed admission to beds identified as "ICU" beds. Patient #13 medical record showed patient transferred to ICU following an acute change in condition. No evidence of an increased level of monitoring or nursing assessment for the treatment setting or to meet the needs of the patient based on hospital policies and procedures.

On 06/14/17 at 10:50 am, surveyors toured a unit in the hospital identified as the "high observation" unit. These rooms were located directly across from the nurses' station. This layout provides a direct line of sight for nursing staff of the patients in the unit. Rooms were numbered "ICU" 1 through 4. One patient admitted to the unit at the time of survey was intubated with ventilator support and diagnosis of respiratory failure.

On 06/14/17 at 11:00 am, Staff A and B stated the hospital does not have an "ICU" unit or provide critical care services. Staff B reported he/or she was not aware of any policies or procedures directly related to the high observation unit.

On 6/23/17 at 11:20 am, Staff W stated patients are assessed once a shift; and reported there was no increased assessment or monitoring requirements for patients in the high observation unit. Staff W stated nursing staff are providing more care to these patients but not "taking credit for it" by documenting it; and reported he/or she was not aware of any policies or procedures related to the high observation unit.


B. Pain Assessment

Document titled "Pain Assessment, Reassessment and Management" showed assessment process should be on-going ...reassessment should occur after every pain control mechanism employed by patient care providers.

Document titled "Pain Scale" showed an appropriate pain scale shall be used to determine pain and evaluate effectiveness of pain ...

Document titled "Nursing Care" showed level of care is based on patient individual needs ...nurses will ensure patients receive treatments, medications according to policy.

Document titled "Pain Management in Wound Care - Swing Bed" showed clinical staff should assess and reassess all wound patients for presence or absence of pain.

Document titled "Patient Rights" showed patients have the right to appropriate assessment and management of pain.

Document titled "Pain Assessment, Reassessment and Management - Emergency Department" showed periodic reassessments of patient to determine pain and relief of pain ...reassess within one-half (1/2) hour after pain control mechanism to determine pain control or relief.

10 (Patient #12, 13, 14, 17, 18, 19, 20, 21, 28, and 29) of 11 medical records showed nursing staff failed to assess and reassess pain after the administration of pain medication and consult healthcare providers when pain was unrelieved per hospital policies and procedures. Medical Records failed to show consistent use of a pain rating scale to assess pain or evaluate the effectiveness of pain medication per hospital policy.

On 06/23/17 at 11:20 am, Staff W stated assessment of pain includes use of the numeric scale and asking the patient to rate their pain, and reported for those who cannot verbalize a number staff should use the Faces scale and look for signs of grimacing and other non-verbal indicators of pain. Staff W stated reassessment for effectiveness of pain control measures would include using one of the pain scales and asking the patient if their pain is better; and reported if pain was not controlled, staff would collaborate with the charge nurse to determine other measures to try or notify the physician.

On 06/15/17 at 3:32 pm, Staff B stated his/or her expectations would be for nursing staff to the use a pain scale when assessing a patient's pain and effectiveness of pain control measures.

C. Wound Care Treatment

Document titled "Scope of Services - Wound Management Program - Swing Bed" showed wound management services are provided to inpatients on all patient care units ...develops and implements an individualized treatment plan for each patient

Document titled "Photographing Pressure Injuries/Suspected Physical Abuse" showed a photograph should be taken of all pressure injuries on admission or if one develops in the facility ...staff should measure pressure injury and document size.

Document titled "Pressure Injury Prevention Program" showed treatment program should include identifying and evaluating risk factors and changes in patient's condition, maintaining and improving tissue tolerance to pressure, monitoring the effectiveness of interventions ...reposition every two hours and as needed ...preventive interventions for all patients at risk.

4 (Patient #14, 18, 19 and 20) of 4 medical records showed inconsistent documentation of repositioning and not as ordered or per hospital policy every two hours.

2 (Patient #18 and 20) of 4 medical records showed patients were incontinent of bowel function and documentation by nursing staff was inconsistent for the provision of peri-care and application of sensi-care cream (a protective barrier cream that helps to manage skin that has been compromised by exposure to caustic stool residue).

1 (Patient #20) of 4 medical records showed no evidence wound care services was involved in the patient's wound care treatment until the day of discharge. No evidence in the patient's medical record that the photographs of wound were obtained on admission or when nursing staff identified a change in wound status.

On 06/23/17 at 11:20 am, Staff W stated documentation for positioning would be included in the progress notes or nursing notes; and reported there was no specific form or tool for nursing staff to document repositioning, peri-care, pain assessment/reassessment, linen changes, foley care and other rounding activities for patients. Staff W stated nursing staff contacts the wound care nurse when patients have any kind of wound(s) for a consultation; and reported the wound care nurse would make recommendations to nursing staff for treatments.

D. Emergency Department

Document titled "Fundamental Standards of Care" showed Emergency Severity Index (ESI) Level I-III (5 level triage tool used by the ED to determine patient acuity and number or resources anticipated) vital signs every 30 minutes ...nursing interventions should include close observation, pain management, trauma support, basic comfort measures and timely medication administration.

Document titled "Assessment and Reassessment - Emergency Department" showed ongoing assessment of patients in ED ...reassessments on a regular basis to determine patient response and note significant changes in condition.

Document titled "Triage-Patient Assessment" showed emergency (Level 2) treatment and reassessment within 5 to 15 minutes ...urgent (Level 3) treatment and reassessment in 15-45 minutes.

Document titled "Neurological Assessment" showed neurological assessment performed on all ED patients on admission. Policy failed to identify criteria for reassessment of neurological status and when there is no change in assessment (blank line).

Document titled "CVA or Stroke - Emergency Department" showed patients shall receive following care to include documentation of neurological deficits ...patient diagnosed with stroke not eligible for tPA therapy (Tissue Plasminogen Activator - an injectable/intravenous drug used to breakdown a blood clot, known as the "clot-buster") provide continuous hemodynamic monitoring (blood pressure, heart rate, respirations, oxygen) and assessment of neurological status. Policy failed to identify criteria for monitoring vital signs and assessment/reassessment including neurological status for patients who are not eligible for tPA.

Document titled "Psychiatric Evaluation" showed if a patient was a danger to self, staff or others, a security officer would be requested to continually observe patient ...Call Emergency Psychiatric Evaluation Team (PET).

According to the American Stroke Association Guidelines monitoring of vital signs is recommended every 15 minutes during the acute phase of stroke and hourly for intensive care admissions ...neurological assessments using a standardized tool should be performed frequently.

According to the American Stroke Association Comprehensive Nursing Guidelines emergency room nurses should assess airway, breathing, circulation, vital signs and neurological status frequently ...vital signs in the emergency department should be obtained no less then every 30 minutes.

Emergency Department policies and procedures failed to provide evidence of being specific to the hospital and approval by the Emergency Department, Quality, Medical Staff or the Governing Board.

9 (Patient #16, 22, 23, 24, 25, 26, 27, 30 and 31) of 9 medical records showed nursing staff failed to perform reassessment of patients based on triage level and patient condition per hospital policies and procedures.

2 (Patient #26 and 30) of 2 medical records showed nursing staff failed to assess/reassess the neurological status and monitor vital signs according to national practice standards for patients with stroke. No evidence of continuous monitoring of vital signs and neurological status per hospital policy.

4 (Patient #26, 27, 30 and 31) of 4 medical records showed nursing staff failed to perform a neurological assessment on admission to ED and/or reassessments according to hospital policy in patients with neurological conditions.

2 (Patient #24 and 25) of 2 medical records showed nursing staff failed to reassess and closely monitor patients who presented with suicidal ideations and self-harm and who were awaiting transfer to a psychiatric facility.

7 (Patient #16, 22, 24, 25, 26, 27 and 30) of 9 medical records showed vital signs were not monitored according to the patient's identified triage level and hospital policy.

On 06/14/17 at 1:15 pm, Staff B and T stated document titled "Emergency Department Policy and Procedure Manual Table of Contents" was the P&P manual for the hospital.

On 06/15/17 at 10:00 am, Staff B stated the hospital was reviewing and updating policies and procedures to coordinate with the other hospitals within their organization; and reported some of the policies and procedures would still have the hospital name on them and others would be more general in scope for the organization. Staff B stated the Emergency Department policies and procedures were part of the organization efforts.

On 06/23/17 at 11:55 am, Staff X stated vital signs depends on the chief complaint and/or acuity of the patient; and reported vital signs are usually obtained every hour. Staff X stated for patients with cardiac or blood pressure issues vital signs obtained every 15 minutes; and reported patients presenting with stroke symptoms or trauma vital signs would usually be obtained every 5 minutes. Staff X stated for patients who present with suicidal ideation or self-harm nursing would be 1:1 supervision to ensure safety until the police can arrive; and reported this should be documented in the chart.
VIOLATION: NURSING SERVICES - SUPERVISION OF CARE Tag No: C0296
Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the care of each patient.

This failed practice had the potential to result in a delay in the RN to recognize changes in the patient's condition and responses to treatment.

Findings:

Document titled "Assessment and Reassessment" showed the RN responsible for collecting and analyzing patient data to determine patient healthcare or treatment needs ...the licensed practical nurse (LPN) responsible for completing components of reassessment under direct supervision of an RN ...LPN observes and reports data to the RN who evaluates the clinical condition of the patient ...Scope and intensity of assessment is determined by patient's diagnosis, treatment setting and response to treatment. The policy failed to provide criteria for reassessment frequency for patients admitted to in-patient, swing bed and high observation.

Documented titled "Nursing Care" showed nursing practices for swing bed will follow the same guidelines established for acute care patients ...level of care based on individual needs ...frequency of observation based on professional judgement and assessment of the RN. Policy failed to identify timeframe criteria for assessment and reassessment for patients admitted to in-patient, swing bed and high observation.

Document titled "Swing Bed Program" showed patients admitted to swing bed program are still patients who require a higher level of nursing care.

10 (Patient #12, 13, 14, 17, 18, 19, 20, 21, 28, and 29) of 11 medical records showed nursing assessments were inconsistent, morning and evening assessments varied significantly in time and shift assessments were not documented.

8 (Patient #12, 13, 14, 18, 19, 20, 21, and 28) of 11 medical records showed no evidence of the RN evaluation the LPN's nursing shift assessment.

On 06/14/17 at 10:50 am, Staff B stated RN supervises the LPN and would review the patient assessment.

On 06/23/17 at 11:20 am, Staff W stated patient assessment is required every shift at a minimum; and reported there are no different assessment requirements for patients in the high observation unit.
VIOLATION: NURSING SERVICES - DRUG ADMINISTRATION Tag No: C0297
Based on record review and interview the hospital failed to ensure nursing staff documented the administration of scheduled medications in the electronic health record.

This failed practice had the potential to result in a change of patient condition for 2 (Patient #21 and 29) 11 patients who did not receive regularly scheduled medications.

Findings:

Document titled "Medication Administration" showed medications ordered with a required or precise timing of administration should be administered at a scheduled time. Policy failed to provide criteria for documentation in the electronic health record by healthcare providers when a scheduled medication has not been administered.

Document titled "Medical Record Content Policy" showed the medical record should contain documentation to accurately document treatment, services and patient responses to medication ...all entries into the medical record shall be dated, timed and authenticated ...all medications are documented in the medical record.

2 (Patient #21 and 29) of 11 medical records showed no documentation by licensed nursing staff for administration of scheduled medications.

On 06/23/17 at 11:20 am, Staff W stated the expectation is nursing staff documents "not administered" in the patient's medical administration record when a medication is not given.
VIOLATION: NURSING SERVICES - CARE PLANS Tag No: C0298
Based on record review and interview, the hospital failed to ensure nursing staff maintained a nursing care plan by assessing patient's needs per hospital policy.

This failed practice had the potential to result in delayed recognition and/or treatment of active problems that could influence patient recovery, functional status and quality of life.
Findings:

Document titled "Assessment and Reassessment" showed an individualized prioritized plan of care should be developed based on the RN's initial admission assessment ...plan of care should be revised as patient's condition or diagnosis changes.

Document titled "Pain Assessment, Reassessment and Management" showed assessment information obtained should be used to formulate a plan of care with goals related to pain management.

Document titled "Pressure Injury Prevention Program" showed based on assessment and patient clinical needs the plan of care should include interventions to: redistribute pressure, minimize skin to moisture, keep the skin clean, provide pressure-relieving support and non-irritating surfaces, maintain nutritional and hydration status and monitor for any adverse drug reactions that may cause anorexia or lethargy ...evaluate and revise plan of care based on patient condition.

8 (Patient #13, 15, 18, 19, 20, 21, 28, and 29) of 11 medical records showed no evidence of revising or updating the patient's plan of care based on assessment and prioritized patient needs per hospital policies and procedures.

On 06/23/17 at 11:25 am, Staff W stated care plans are initiated by the RN at the time of patient admission and reviewed by nursing staff every 24 hours; and reported care plans are modified when there is a change in condition.
VIOLATION: RECORDS SYSTEM Tag No: C0304
Based on record review and interview the hospital failed to ensure patient discharge summary was completed per hospital policy and CMS requirements.

This failed practice had the potential for subsequent healthcare providers to be unable to access the procedures performed, discharge diagnosis, care/treatment and services provided and the patient's condition at discharge.

Findings:

Document titled "Medical Record Content Policy" showed discharge summary should include reason for admission, final diagnosis/associated diagnoses, history, pertinent physical and clinical lab findings, any procedures performed, hospital course, discharge medications, condition of patient at discharge and discharge instructions. Policy failed to provide evidence of approval by the Governing Board.

Document titled "Medical Record Guidelines for Physicians" showed discharge summary should be dictated within 24 hours following discharge and include reason for hospitalization , admitting diagnosis, any significant lab/history/physical findings, any procedures performed, treatment or services rendered, condition and disposition at discharge, instructions provided to patient/family, and final diagnosis. Policy failed to provide evidence of approval by the Governing Board.

Document titled "Discharge Summary" showed a discharge summary required on all discharged from in-patient, swing-bed, and from in-patient to swing-bed status ...concise summary includes admitting diagnosis, procedures performed, care/treatment and services provided, condition and disposition at discharge, instructions given to patient/family and discharge diagnosis. Policy failed to provide evidence of approval by the Governing Board.

1 (Patient #29) of 11 medical records showed no evidence of a completed discharge summary per hospital policies and procedures and CMS requirements.

On 06/23/17 at 9:30 am, Staff Y stated physicians should be documenting discharge summaries in the patient's medical record according to the hospital's policy.
VIOLATION: RECORDS SYSTEM Tag No: C0307
Based on record review and interview the hospital failed to:

A. Ensure healthcare providers completed a history and physical examination (H&P) in the patient's electronic health record within 48 hours of admission per hospital policy.

B. Ensure written orders were dated, timed, and authenticated, according to hospital policies and procedures.

C. Follow established policies and procedures and ensure restraint orders are dated, timed, authenticated and not written for use on an as needed basis.

These failed practices had the potential for patients to have a delayed recognition of medical conditions that could influence recovery, functional status, quality of life and increase to patient safety.


Findings:

Document titled "History and Physical" showed a comprehensive medical history and physical (H&P) should be completed within 48 hours of admission to inpatient services.

Document titled "Medical Record Guidelines for Physicians" showed all entries must be timed, dated and authenticated ...H&P should be completed within 24 hours of admission to inpatient services, swing bed services or prior to surgery

Document titled "Medical Record Guidelines for Physicians" showed all entries must be timed, dated and authenticated ...verbal orders must be dated, timed and authenticated.

Document titled "Medical Record Content Policy" showed all entries into the medical record should be dated, timed and authenticated in written or electronic form ...time and date of each entry (orders) must be accurately documented.

Document titled "Telephone, Verbal and Written Orders for Medication" showed all verbal and/or telephone orders for medications should have the date and time of the order.

Document titled "Verbal and Written Orders - General" showed practitioner must date, time and authenticate the order.

Document titled "Restraint Use" showed orders for restraint should not be written for PRN (as needed) use or as a standing order ...patient recently released and exhibit behavior again a new order is required ..."trial release" constitutes PRN use of restraint and is not permitted ...restraint orders must be renewed every 24 hours.

9 (Patient #12, 13, 14, 15, 17, 18, 19, 20, and 29) of 11 medical records failed to provide evidence of the actual time telephone and/or verbal orders were written or obtained from the licensed independent practitioner.

1 (Patient #20) of 11 medical records failed to provide evidence of the actual time telephone and/or verbal orders were written or obtained from the licensed independent practitioner.

1 (Patient #19) of 11 medical records failed to provide evidence of an H&P within 48 hours of the patient's admission per hospital policy.

1 (Patient #19) of 11 medical record failed to provide evidence of:

A. Date, time and/or authentication for telephone restraint orders for 4/30/17 at 6:00 am and 5:00 pm, 05/03/17, 05/04/17, 05/06/17, 05/07/17, 05/08/17, 05/17/17 and 05/19/17

B. Restraint order renewal for 05/15/17 (order expired at 12:00 am and was not renewed until 05/16/17 at 12:00 am) and from 05/20/17 at 6:00 am to patient discharge on 05/23/17.

C. New order obtained for each episode when patient was released from restraints excluding for care and treatments.

On 06/23/17 at 9:30 am, Staff A stated physicians are required to have the H&Ps completed within 48 hours of admissions and all entries into the medical record should be dated, timed and authenticated including orders.

On 06/22/17 at 10:00 am, Staff B stated restraint use requires an order from the physician; and reported orders allow nursing staff to remove restraints for care/treatment of the patient while under supervision.

On 06/23/17 at 11:35 am, Staff W stated staff should not be removing restraints to see how the patient is doing.
VIOLATION: QA - QUALITY OF PATIENT CARE Tag No: C0336
Based on record review and interview, the hospital failed to have an effective quality program that included identification, implementation, and evaluation of corrective actions approved by the Governing Body, who is responsibile for total operation of the hospital and for ensuring quality health care in a safe environment is provided.

This failed practice had the potential to affect the approximately 1953 patients admitted annually to the hospital.

Finding:

a. takes appropriate remedial action to address deficiencies found through the quality assurance program
(See Tag C-0342), and

b. documents the outcome of all remedial action. (See Tag C-0343)
VIOLATION: QA - PERFORMANCE IMPROVEMENT Tag No: C0342
Based on record review and interview, the hospital failed to take appropriate remedial action to address deficiencies found through the quality assurance program.

This failed practice had the potential to affect the approximately 1953 patients admitted annually to the hospital.

Findings:

A review of "Quality Assurance/Performance Improvement Program (QA/PI) 2017" failed to define the action plan method by which quality goals would be achieved such, Plan-Do-Check-Act or Continuous Quality Improvement (CQI), etc..

A review of Governing Body (GB) meeting minutes for 2016 to April 2017 showed mutiple topics being measured. Although some data was analyzed and action plans reported to the Governing Body, for topics such a Nursing Services, Infection Control, Risk Events reporting, and policies and procedures, there was little evidence the Governing Body had participated in the Quality Program. A review of the Governing Body for 03/22/17 showed many standing items, which included goals and benchmarks, the status documented "informational" with and no GB input documented.

(Note: The Governing Body's participation can be reflected in meeting minutes and other documents such as internal detailed reports.)

A review of the Medical Executive Committee meeting minutes for 06/21/17 showed a new format listing study/plan /action. On 06/21/17, Staff T stated this was a pilot format for future meetings.

A. Nursing Services

The quality assurance program failed to take appropriate remedial actions to address the nursing turnover and competencies issues.

A review of hospital document titled "Total Program Evaluation 2016" showed the turnover rate for nursing was 52% with goal listed to: Reduce staff turnover, train nursing staff to provide care for higher acuity, and implement a more formalized orientation for new employees".

A review of hospital document titled, "Quality Assurance/Performance Improvement (QA/PI) 2017" listed the goal of employee competencies, but no comprehensive improvement program information was provided.

A review of the MEC meeting minutes for 06/21/17 documented, "Staffing- filling a lot of open positions. Lots of education being completed as well."

A review of Governing Body meeting minutes for 04/26/17 documented the hospital was making "a concentrated effort to ramp up the ability to staff the hospital". The minutes showed Department Compliance: Nursing= 57%. There was no explaination as to what the value represented.

On 06/15/17 at 2:00 pm, Patient #20's medical record was reviewed. In a 19 day period, 20 different nurses documented care for the patient. Patient continuity of care was potentially affected by excessive rotating of nursing assignments. Within Patient #20's medical record, inconsistent assessments were documented. (See Tag C-0294 and C-0296).

On 06/15/17 at 3:00 pm, Patient #18's medical record was reviewed. In a 10 day period, 11 different nurses documented care for the patient. Patient continuity of care was potentially affected by excessive rotating of nursing assignments. Within Patient #20's medical record, inconsistent assessments were documented. (See Tag C-0294 and C-0296).

A review of 10 RN/LPN personnel files showed the following:
~4 of 8 employed staff : Staff Q - no orientation and no competency; Staff U- self evaluation only for competencies; Staff R competencies not dated or signed; and Staff S- competency self evaluation only.
~2 of 2 agency staff (Staff O and Staff P) had no orientation and no competency.

On 06/23/17 at 10:00 am, Staff B, stated she/or he was the 4th CNO in 4 years, and the current CEO was 5th employed in 5 years.

B. Infection Control

The quality assurance program failed to take appropriate remedial action to address infection control issues, such as performing a complete infection control risk assessment, performing an adequate number of hand hygiene surveillance observations in the medical surgical unit (med/sug), and defining and enforcing policies for isolation precautions in the medical surgical unit. (See tag C-0278)

Also, findings as below:
A review of the MEC meeting minutes for 06/21/17 documented antibiotic use listed per drug, but no determination if the drugs were appropiately used.

C. Risk Event Reporting

A review of Governing Body meeting minutes for 04/26/17 and 03/22/17 showed the "Risk Management Report Events". The report listed the an overview of events, and although some staff actions were discussed, most did not include patient outcomes and staff's actions to minimize untoward patient outcomes and decrease risk to hospital. The status was listed as "informational" for the Governing Body. Events were separated to the day of week and time of day, but no analysis or conclusion was conducted or action plan developed.

A review of the Super Committee meeting minutes for 04/12/17 documented mandated Catheter-associated Urinary Tract Infections (CAUTI) results. The report documented a unidentified patient had a foley urinary catheter inserted on 02/28/17, and had a positive culture on 03/19/17, but no discussion was documented regarding the auditing the medical record to verify that catheter care was performed per policy.

A review of incident reports for 2016 and 2017 to current . On 10/07/17, there were 4 events logged: an IV was not removed from a patient before discharge; a staff was stuck with needle and the event report indicated the staff had to continue work due to the heavy emergency department patient workload. (On 06/22/17 at 1:05 pm, at exit conference, Staff B stated the staff was given the opportunity to leave duty and declined, but no documentation found verifying this); Norco was given too early compared to physican order; and LPN took an EMS report regarding a critical patient because the RN was unavailable. Within the details of the reports, there was no debriefing for such a night regarding lessons learned by leadership.

A review of the document titled, "Quality Initiatives for May 2017" showed rate of "Return to the ER within 24 hours". In 02/17 the value was 14 patients compared to 01/17=6, 03/17= 3, 04/17=06, 05/17=4. There was no analysis regarding the increased volume of patients or action plans if required, or lessons learned.

A review of the MEC meeting minutes for 06/21/17 documented mediation variance with some discussion of the patient's response to the events, but no analsysis, corrective action or lessons learned. Med error with 10 doses of antifungal omitted before the found.

On 06/23/17 at 11:30 am, Staff T, the Risk Manager, stated she/or he had been employed for a month and was developing the risk manangement program.

On 06/23/17 at 10:40 am, the CEO stated new project of sending medical records to OFMQ (Oklahoma Foundation for Medical Quality). He stated no criteria had been developed as to which medical records would be sent for review and no formal plan for managing the information received.

D. Policies and Procedures

A review of the MEC meeting minutes for 06/21/17 documented multiple policies were approved, such as assessment / reassessment policy. This one example of policies that were incomplete and policies had other issues, such as the lack of hospital name on header, the name was that of another hospital on header or within the body, and many policies had blanks throughout the document. (See Tag C-0271)
VIOLATION: QA - DOCUMENTATION Tag No: C0343
Based on record review and interview, the hospital failed to documents the outcome of all remedial action.

This failed practice had the potential to affect the approximately 1953 patients admitted annually to the hospital.

Findings:

See Tag- C-0343.
VIOLATION: ORGAN, TISSUE, EYE PROCUREMENT Tag No: C0344
Based on record review and interview, the hospital failed to have policies and procedure addressing organ procurement.

This failed practice had the potential for staff responsibilites regarding organ procurement to go unfulfilled, and suitable organs not procured for the patients' in need.

Findings:

A review of the policy titled, "Organ /Tissue/ Eye Donation" had no Governing Body approval date. The policy was not associated to Stroud Hospital and the opening paragraph of the policy read, "In Department of Defense hospital, Veteran Affairs Medical Center and other federally administered healthcare facility...". The policy contained 11 eleven blanks that were not completed.

On 06/21/17 at 10:30 am, Staff A stated the policy provided was the hospital's policy for organ procurement.