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.

NYE REGIONAL MEDICAL CENTER 825 ERIE MAIN ST (AKA SOUTH MAIN) TONOPAH, NV Dec. 12, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and document review, the facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital. The governing body failed to insure medical staff were properly credentialed and granted privileges prior to providing care in the hospital (A-0046). The governing body failed to ensure medical staff operated under current bylaws, rules and policies approved by the governing body (A-0049).

The governing body failed to ensure the hospital developed and maintained an effective, on-going, hospital wide, data driven quality assessment and performance improvement program (A-0263). The governing body failed to ensure nursing services were furnished in accordance with facility policies and procedures (A-0385). The governing body failed to ensure the facility had an active program for the prevention, control and investigation of infections and communicable diseases (A-0747).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients.
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Based on interview, document review and medical staff credentialing file review, the facility's governing body failed to enforce medical staff bylaws and medical staff rules approved by the governing body that required medical staff to be properly credentialed and granted specific privileges prior to performing patient care at the facility. (Physician Assistants #1, #2) (Physician #1, #2, #3)

Findings include:

On 12/12/12 at 2:00 PM, the Assistant Administrator acknowledged two physician assistants who were working in the emergency department and medical physicians who were providing supervision to physician assistants working in the emergency department at the facility had not been granted membership to the facility's medical staff or granted clinical privileges to work in the emergency department or the hospital by the Chief of Staff and Medical Executive Committee. The Assistant Administrator acknowledged the facility's Medical Staff By-laws required all medical staff practitioners to be be properly credentialed and granted specific clinical privileges prior to being allowed to provide care to patients in the emergency department and hospital. The Assistant Administrator acknowledged medical staff working at the facility were required to have documented emergency department orientation and clinical competencies that included current ACLS (Advanced Cardiac Life Support) certification in their credentialing files.

Medical Staff Membership Bylaws dated 03/02 included the following:

Medical Staff Membership: Membership on the Medical Staff and/or Clinical privileges shall be extended to, and may be maintained only by those professionally competent Practitioners who continuously meet the qualifications, standards and requirements set forth in these Bylaws. Except as otherwise provided in the Medical Staff Rules, a Practitioner, including those in a medical administrative position by virtue of a contact with the Hospital, shall admit or provide medical or health-related services to patients in the Hospital only if he/she is a member of the Medical Staff or has been granted Clinical Privileges in accordance with the procedure set forth in these Bylaws. Appointment to the Medical Staff shall confer only such Clinical privileges and prerogative as have been granted by the Governing Body in accordance with these Bylaws.

All new Staff members shall be appointed to the Provisional Staff and subjected to a period of formal observation and review.

Exercise of Privileges: Except as otherwise provided in the Bylaws or the Medical Staff Rules, every Practitioner or other professional providing direct clinical services at this Hospital shall be entitled to exercise only those clinical privileges or services specifically granted to him/her.

Requests for clinical privileges shall be evaluated on the basis of the Practitioner's education, training, experience, and demonstrated ability and judgement. The bases for privileges determinations, in connection with periodic reappointment or otherwise, shall include any observed clinical performance and judgement, performance of a sufficient number of procedures each year to develop and maintain the Practitioners skill and knowledge, and the documented results of patient care audit and other quality improvement activities required by the Medical Staff Bylaws and Rules.

All medical staff shall have demonstrated clinical competency in his/her field of practice.

Clinical Services: Each service is responsible for the quality of care within the service, and for the effective performance of the following as relates to members of the service and Allied Health Professionals practicing within the service.

1. Patient care evaluation, observation, and monitoring including periodic demonstrations of ability consistent with guidelines developed by the Care Review Committee, Utilization Review Committee, Medical Records, Medical Executive Committee and Infection Control Committee.

2. Credentialing review, consistent with guidelines developed by the Medical Executive Committee.

Chief of Medical Staff duties included the following:

1. The development and implementation of policies and procedures that guide and support the provisions of service.

2. The recommendation for a sufficient number of qualified and competent persons to provide care/service.

3. Continuing surveillance of the professional performance of all individuals who have delineated clinical privileges in the service.

4. Recommending clinical privileges for each member of the service and each staff member desiring to exercise privileges in the service.

5. The determination of the qualifications and competence of Allied Health Professionals who provide patient care services within the purview of the service.

6. The continuous assessment and improvement of the quality of care and services provided in the service.

7. The orientation and continuing education of all persons in the service, in coordination with the Medical Staff Education.

8. Assure that all records of performance are maintained and updated from all members of the service.

A review of physician credentialing files included the following:

1. Physician Assistant #1 was hired 09/01/12 to work in the facility's emergency department. There was no documented evidence Physician Assistant #1 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file.

On 12/12/12 at 2:00 PM, Physician Assistant #1 acknowledged working numerous shifts in the emergency department since 10/12 providing assessment, evaluation, treatment, writing medical orders and prescribing medication to emergency department patients. Physician Assistant #1 reported being unaware the granting of clinical privileges by the facility was required prior to providing patient care in the emergency department of the facility. Physician Assistant #1 acknowledged not being informed verbally or in writing from the facility that clinical privileges had been granted. Physician Assistant #1 reported the Medical Director had provided an orientation to the emergency department but no clinical competencies or performance evaluations were completed prior to being allowed to conduct patient care. Physician Assistant #1 had not been provided with a copy of the facility's medical staff bylaws or medical staff rules upon hire.

2. Physician Assistant #2 was hired on 11/13/12 as a new graduate physician assistant to work in the facility's emergency department. There was no documented evidence Physician Assistant #2 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file. There was no documented evidence of ACLS (Advanced Cardiac Life Support) certification or BLS (Basic Life Support) certification located in the credentialing file.

On 12/12/12 at 2:30 PM, Physician Assistant #2 reported being a new graduate physician assistant graduating on 06/12. Physician Assistant #2 acknowledged working approximately 12 shifts in the emergency department since 11/12 providing assessment, evaluation, treatment, writing medical orders and prescribing medication to emergency department patients. Physician Assistant #2 reported being unaware the granting of clinical privileges by the facility was required prior to providing patient care in the emergency department of the facility. Physician Assistant #2 acknowledged not being informed verbally or in writing from the facility that clinical privileges had been granted. Physician Assistant #2 reported having no emergency department experience or training outside of clinical rotations while in a physician assistant training program. The Medical Director had provided an orientation to the emergency department but no clinical competencies or performance evaluations were completed prior to being allowed to conduct patient care. Physician Assistant #2 acknowledged being contacted by the facility's administrator after it was learned he had been writing medication prescriptions for emergency department patients without a Nevada Pharmacy License. Physician Assistant #2 reported he was not aware a pharmacy license was required to write medication prescriptions. Physician Assistant #2 had not been provided with a copy of the facility's medical staff bylaws or medical staff rules upon hire.

3. Physician #1 was hired on 02/06/12 to work at the facility's clinic. A Notification to Nevada State Board of Medical Examiners of Supervision of Physician Assistant #1 dated 09/04/12 documented Physician #1 had assumed the duties and responsibilities for supervising Physician Assistant #1 in the emergency department. There was no documented evidence Physician #1 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee to work in the emergency department or supervise Physician Assistants working in the emergency department or hospital. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file. Physician #1 ACLS certification expired 02/12.

On 12/12/12 at 5:00 PM, Physician #1 acknowledged having the duties and responsibilities for supervising Physician Assistant #1 in the clinic and emergency department. Physician #1 acknowledged not being informed verbally or in writing from the facility's Medical Director or Medical Executive Committee that clinical privileges had been granted to work in the emergency department or hospital. Physician #1 acknowledged in order to properly supervise Physician Assistant #1's treatment and care of patients in the emergency department clinical privileges must be granted by the facility to both the physician assistant and medical physician supervising the physician assistant. Physician #1 acknowledged not receiving any emergency department orientation, clinical competency or performance evaluations by facility staff.

4. Physician #2 (Medical Director) had a hire date of 1999. Clinical privileges were first granted in the year 2004. A reappointment request with no change in privileges was partially completed by Physician #2 on 12/13/11 for reappointment to 12/13/13. There was no documented evidence the reappointment request was granted or signed by the Medical Staff Chairman or Medical Executive Committee.

5. Physician #3 had a hire date of 07/01/12 as an emergency department physician. There was no documented evidence Physician #3 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee to provide care to patients in the emergency department or hospital.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on interview, document review and medical staff credentialing file review, the facility's governing body failed to ensure medical staff was accountable to the governing body for the quality of care provided to patients and failed to ensure medical staff to be properly credentialed and granted specific privileges prior to performing patient care at the facility. (Physician Assistants #1, #2) (Physician #1, #2, #3)

Findings include:

On 12/12/12 at 2:00 PM, the Assistant Administrator acknowledged two physician assistants who were working in the emergency department and two medical physicians who were providing care and treatment to patients in the emergency department had not been granted membership to the facility's medical staff or granted clinical privileges to work in the emergency department or the hospital by the Chief of Staff and Medical Executive Committee. The Assistant Administrator acknowledged one physician who was supervising physician assistants in the emergency department was not properly credentialed or granted privileges to work in the emergency department. The Assistant Administrator acknowledged the facility's Medical Staff By-laws required all medical staff practitioners to be be properly credentialed and granted specific clinical privileges prior to being allowed to provide care to patients in the emergency department and hospital. The Assistant Administrator acknowledged several medical staff members working at the facility failed to have the required documented emergency department orientation and clinical competencies that included current ACLS (Advanced Cardiac Life Support) certification in their credentialing files.

Medical Staff Membership Bylaws dated 03/02 included the following:

Medical Staff Membership: Membership on the Medical Staff and/or Clinical privileges shall be extended to, and may be maintained only by those professionally competent Practitioners who continuously meet the qualifications, standards and requirements set forth in these Bylaws. Except as otherwise provided in the Medical Staff Rules, a Practitioner, including those in a medical administrative position by virtue of a contact with the Hospital, shall admit or provide medical or health-related services to patients in the Hospital only if he/she is a member of the Medical Staff or has been granted Clinical Privileges in accordance with the procedure set forth in these Bylaws. Appointment to the Medical Staff shall confer only such Clinical privileges and prerogative as have been granted by the Governing Body in accordance with these Bylaws.

All new Staff members shall be appointed to the Provisional Staff and subjected to a period of formal observation and review.

Exercise of Privileges: Except as otherwise provided in the Bylaws or the Medical Staff Rules, every Practitioner or other professional providing direct clinical services at this Hospital shall be entitled to exercise only those clinical privileges or services specifically granted to him/her.

Requests for clinical privileges shall be evaluated on the basis of the Practitioner's education, training, experience, and demonstrated ability and judgement. The bases for privileges determinations, in connection with periodic reappointment or otherwise, shall include any observed clinical performance and judgement, performance of a sufficient number of procedures each year to develop and maintain the Practitioners skill and knowledge, and the documented results of patient care audit and other quality improvement activities required by the Medical Staff Bylaws and Rules.

All medical staff shall have demonstrated clinical competency in his/her field of practice.

Clinical Services: Each service is responsible for the quality of care within the service, and for the effective performance of the following as relates to members of the service and Allied Health Professionals practicing within the service.

1. Patient care evaluation, observation, and monitoring (including periodic demonstrations of ability consistent with guidelines developed by the Care Review Committee, Utilization Review Committee, Medical Records, Medical Executive Committee and Infection Control Committee.

2. Credentialing review, consistent with guidelines developed by the Medical Executive Committee.

Chief of Medical Staff duties included the following:

1. The development and implementation of policies and procedures that guide and support the provisions of service.

2. The recommendation for a sufficient number of qualified and competent persons to provide care/service.

3. Continuing surveillance of the professional performance of all individuals who have delineated clinical privileges in the service.

4. Recommending clinical privileges for each member of the service and each staff member desiring to exercise privileges in the service.

5. The determination of the qualifications and competence of Allied Health Professionals who provide patient care services within the purview of the service.

6. The continuous assessment and improvement of the quality of care and services provided in the service.

7. The orientation and continuing education of all persons in the service, in coordination with the Medical Staff Education.

8. Assure that all records of performance are maintained and updated from all members of the service.

A review of physician credentialing files included the following:

1. Physician Assistant #1 was hired 09/01/12 to work in the facility's emergency department. There was no documented evidence Physician Assistant #1 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file.

On 12/12/12 at 2:00 PM, Physician Assistant #1 acknowledged working numerous shifts in the emergency department since 10/12 providing assessment, evaluation, treatment, writing medical orders and prescribing medication to emergency department patients. Physician Assistant #1 reported being unaware the granting of clinical privileges by the facility was required prior to providing patient care in the emergency department of the facility. Physician Assistant #1 acknowledged not being informed verbally or in writing from the facility that clinical privileges had been granted. Physician Assistant #1 reported the Medical Director had provided an orientation to the emergency department but no clinical competencies or performance evaluations were completed prior to being allowed to conduct patient care. Physician Assistant #1 had not been provided with a copy of the facility's medical staff bylaws or medical staff rules upon hire.

2. Physician Assistant #2 was hired on 11/13/12 as a new graduate physician assistant to work in the facility's emergency department. There was no documented evidence Physician Assistant #2 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file. There was no documented evidence of ACLS (Advanced Cardiac Life Support) certification or BLS (Basic Life Support) certification located in the credentialing file.

On 12/12/12 at 2:30 PM, Physician Assistant #2 reported being a new graduate physician assistant graduating on 06/12. Physician Assistant #2 acknowledged working approximately 12 shifts in the emergency department since 11/12 providing assessment, evaluation, treatment, writing medical orders and prescribing medication to emergency department patients. Physician Assistant #2 reported being unaware the granting of clinical privileges by the facility was required prior to providing patient care in the emergency department of the facility. Physician Assistant #2 acknowledged not being informed verbally or in writing from the facility that clinical privileges had been granted. Physician Assistant #2 reported having no emergency department experience or training outside of clinical rotations while in a physician assistant training program. The Medical Director had provided an orientation to the emergency department but no clinical competencies or performance evaluations were completed prior to being allowed to conduct patient care. Physician Assistant #2 acknowledged being contacted by the facility's administrator after it was learned he had been writing medication prescriptions for emergency department patients without a Nevada Pharmacy License. Physician Assistant #2 reported he was not aware a pharmacy license was required to write medication prescriptions. Physician Assistant #2 had not been provided with a copy of the facility's medical staff bylaws or medical staff rules upon hire.

3. Physician #1 was hired on 02/06/12 to work at the facility's clinic. A Notification to Nevada State Board of Medical Examiners of Supervision of Physician Assistant #1 dated 09/04/12 documented Physician #1 had assumed the duties and responsibilities for supervising Physician Assistant #1 in the emergency department. There was no documented evidence Physician #1 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee to work in the emergency department or supervise Physician Assistants working in the emergency department or hospital. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file. Physician #1 ACLS certification expired 02/12.

On 12/12/12 at 5:00 PM, Physician #1 acknowledged having the duties and responsibilities for supervising Physician Assistant #1 in the clinic and emergency department. Physician #1 acknowledged not being informed verbally or in writing from the facility's Medical Director or Medical Executive Committee that clinical privileges had been granted to work in the emergency department or hospital. Physician #1 acknowledged in order to properly supervise Physician Assistant #1's treatment and care of patients in the emergency department clinical privileges must be granted by the facility to both the physician assistant and medical physician supervising the physician assistant. Physician #1 acknowledged not receiving any emergency department orientation, clinical competency or performance evaluations by facility staff.

4. Physician #2 (Medical Director) had a hire date of 1999. Clinical privileges were first granted in the year 2004. A reappointment request with no change in privileges was partially completed by Physician #2 on 12/13/11 for reappointment to 12/13/13. There was no documented evidence the reappointment request was granted or signed by the Medical Staff Chairman or Medical Executive Committee.

5. Physician #3 had a hire date of 07/01/12 as an emergency department physician. There was no documented evidence Physician #3 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee to provide care to patients in the emergency department or hospital. There was no documented evidence Physician #3 had completed an emergency department orientation or competency evaluation prior to working in the emergency department. There was no documented evidence Physician #3 had completed an ACLS certification course.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on interview, personal record review and document review, the facility failed to consistently provide an orientation process, proficiency testing, job training and ensure certification in cardiopulmonary resuscitation for eight out of eight nurses hired at the facility to work in the emergency department and acute care unit. (Nurse #1, #2, #3, #4, #5, #6, #7, #8)

Findings include:

On 12/12/12 at 10:00 AM a review of licensed nursing staff personnel records included the following:

1. Licensed Emergency Department and Acute Care Nurse hired 05/11/09: There was no documented evidence of any orientation checklist or competency checklist located in the employees personnel record.

2. Licensed Emergency Department and Acute Care Nurse hired 11/15/12: There was no documented evidence of any orientation checklist, infection control training or competency checklist located in the employees personnel record. The employee had no documented evidence of completed ACLS course (Advanced Cardiac Life Support) or PALS (Pediatric Advanced Life Support) certification required by the facility.

3. Licensed Emergency Department and Acute Care Nurse hired 05/18/09: The employee had no documented evidence of completed ACLS course (Advanced Cardiac Life Support) required by the facility. The employees PALS (Pediatric Advanced Life Support) certification required by the facility expired 04/12. The employees BLS (Basic Life Support) certificate expired 04/12.

4. Licensed Emergency Department and Acute Care Nurse hired 10/03/11: There was no documented evidence of any orientation checklist located in the employees personnel record.

5. A Licensed Emergency Department and Acute Care Nurse hired 04/01/10: There was no documented evidence of a current ACLS course (Advanced Cardiac Life Support) required by the facility located in the employees personnel record. The employees ACLS certification expired 05/12.

6. Licensed Emergency Department and Acute Care Nurse hired 05/31/10: There was no documented evidence of any orientation checklist located in the employees personnel record. The employees ACLS certification expired 10/12. The employees PALS certification expired 10/12.

7. Licensed Emergency Department and Acute Care Nurse hired 10/22/11: There was no documented evidence of any orientation checklist located in the employees personnel record.

8. Licensed Emergency Department and Acute Care Nurse hired 08/27/12: There was no documented evidence of any orientation checklist or competency checklist located in the employees personnel record. The Employees ACLS certification expired 11/12.

On 12/12/12 at 10:00 AM, Administrative staff reported the facility's acute care policy and procedure required all licensed nursing staff who worked in the emergency department and on the acute care unit to have current BLS (Basic Life Support) ACLS (Advanced Cardiac Life Support) and PALS (Pediatric Advanced Life Support) certificates. All nursing staff employees were required to have an orientation to the emergency department and acute care unit and complete a competency evaluation under the supervision of a trained nurse manager or team leader. Successful completion of orientation and competency were to be documented and kept in the employees personnel file. Administrative staff acknowledged due to the facility's nursing staffing shortage there was no active orientation program or competency evaluation program for new nurses being conducted at the facility.

The facility's Staff Orientation Emergency Department Policy and Procedure last revised 01/08/09 included the following:

Purpose: Establish standard criteria for orientation of new nursing staff to the Emergency Department and re-orientation of current nursing staff.

Policy: All nursing personnel will attend an initial orientation as per hospital policy. Nursing personnel will then attend an orientation to the Emergency Department under the supervision of the Emergency Department Nurse manager or team leader. Emergency Department orientation shall be based on the ability of the new staff member to function effectively prior to hands on patient care.

Hospital orientation shall include:

1. Orientation to hospital policy and procedure.
2. Safety
3. Security
4. Workplace violence
5. Case management
6. Infection control
7. Emergency management
8. Hazardous materials
9. Electrical safety
10. Fire safety
11. Orientation to hospital departments
12. Computer orientation
13. Orientation to emergency department
14. Introduction to emergency department forms and equipment
15. Admission of patients to emergency department
16. Triage area
17. Crash carts
18. Skills checklist
19. Evaluation by Emergency Department Nurse Manager
20. Competency Evaluation by Emergency Department Nurse Manager

The facility's Staff Orientation Acute Care Policy and Procedure last revised 05/26/09 included the following:

Policy: Orientation to the facility will be determined and conducted by the department managers/supervisors involved, and will include as related to job function, but may not be limited to :

1. Safety and infection control issues

2. Cultural diversity and sensitivity.

3. Patient rights and ethical aspects of care, treatment and services.

4. Procedures for responding to unusual clinical events and incidents.

5. Clinical issues, security issues, administrative issues, seclusion and restraint.

The employee will be assessed for his/her ability to carry out assigned responsibilities safely, competently and in a timely manner upon completion of orientation by his/her department manager/director/supervisor. Successful completion of orientation will be documented on the New Hire Processing Checklist by the employees department manager/director/supervisor and kept in the employees personnel file.

A facility BCLS/ACLS Resuscitation Certificate Policy and Procedure last revised 05/26/12 included the following:

Policy: It is the responsibility of the employee to maintain a current BCLS/ACLS certification and provide evidence of recertification according to policy and procedure.

A copy of the card will be kept in each employees file current and updated according to policy and procedure.
VIOLATION: QAPI Tag No: A0263
Based on interview and document review, the facility failed to implement and maintain an effective ongoing, hospital wide, data driven quality assessment program (QAPI), that reflected the complexity of the hospitals organization and services involving all hospital departments and contracted services. The following processes were not in place: QAPI Indicators (A-0267) and Executive Responsibilities (A-0310).

The cumulative effect of systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on interview and document review the facility failed to have a designated infection control officer to develop and carry out policies governing the prevention, control and investigations of infections and communicable diseases at the facility.

Findings include:


On 12/11/12 at 2:00 PM and 12/12/12 at 8:00 AM, interviews were conducted with Assistant Administrator and Director of Nursing who acknowledged the facility had no active infection control program since June of 2012 when the infection control nurse was laid off due to budget issues. The facility had no infection control nurse on staff since June of 2012. There had been no active tracking and trending or investigations of infections in the facility since June of 2012. The Assistant Administrator and Director of Nursing acknowledged there had been no active infection control committee meetings taking place at the facility since June of 2012. The Administrative staff acknowledged the hospitals infection control program was not integrated into the hospital wide Quality Assurance Program which had not been active since April of 2012.

A review of the facility's Infection Control meetings indicated meetings were conducted on 02/06/12 and 02/27/12. There was no documented evidence of any further infection control meetings held for the year 2012. There was no documented evidence any staff member at the facility was functioning as an infection control nurse or actively tracking, trending or investigating infections at the facility.

The facility's Medical Staff Rules dated 03/1999 included the following:

The Quality Improvement Committee shall meet at least quarterly and report to the Medical Executive Committee.

Infection Control Committee:

a. Representatives from nursing, housekeeping, laundry, dietetic services, environmental services and pharmacy shall be available to the Performance Improvement Committee on a consultant and ad hoc basis.

Purpose: The purpose of the infection control review is to develop and monitor the Hospital's infection control program, and the staffs treatment of infectious disease., including the review of the use of antimicrobials.

Infection control shall be reviewed at least every other month.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and document review the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) program that collected data related to patients and failed to measure, analyze, and tract quality indicators that included adverse patient events, infection control issues and processes of care provided at the facility.

Findings include:

On 12/11/12 at 2:00 PM, the Assistant Administrator and Director of Nursing confirmed the facility had no active Quality Assurance Performance Improvement Committee and had no active Comprehensive Quality Improvement Program to evaluate the provisions of care to patients since April of 2012.

The facility had not been measuring, analyzing, tracking or trending quality indicators which included adverse patient events since April of 2012.

The Assistant Administrator and Director of Nursing acknowledged that infection control issues at the facility were not being incorporated into the QAPI program at the facility.

The Assistant Administrator acknowledged there was no QAPI data which included medical errors, adverse patient events or performance improvement activities discussed at any of the Medical Staff meetings held in 2012.

A review of Quality Assurance and Risk Management meetings held for the year 2012 revealed there was one documented meeting held on 01/31/12. There were no further documented Quality Assurance Performance Improvement Committee meetings held for the year 2012.

The facility could not provide a roster of Quality Assurance Committee members for the year 2012. The facility could not provide a list or any data of quality indicators that were being tracked at the facility. The facility could not provide a list of adverse patient events that had occurred at the facility for the year 2012.

A review of the facility's Medical Staff Meeting Minutes for the year 2012 revealed no documented evidence Quality Assurance Performance Improvement data, quality indicators, infection control activities, medical errors or adverse patient events were discussed at any meetings held in 2012.
The facility's Quality Improvement Plan Policy and Procedure last revised 06/11/08 included the following:

Purpose: The purpose of the Quality Improvement Plan is to ensure that the Governing Body, medical staff and professional services staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care services in an environment of minimal risk.

Goals of Quality Improvement: The primary goal of the Quality Improvement Plan is to continually systemically plan, design, measure, assess and improve performance of hospital wide key functions and processes relative to patient care.

Organization: The organizational Quality Assurance Committee meets on at least a quarterly basis to review and prioritize issues throughout the organization. The Quality Assurance Committee will consist of one representative from each department in the facility, a representative from administration, Director of Nursing or nursing representative, and a physician representative. Each department will be represented at each meeting. Meeting minutes will be distributed to all attending parties, as well as the Medical Director.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on interview and document review the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) program that collected data related to patients and failed to measure, analyze, and tract quality indicators that included adverse patient events, infection control issues and processes of care provided at the facility.

Findings include:

On 12/11/12 at 2:00 PM, the Assistant Administrator and Director of Nursing confirmed the facility had no active Quality Assurance Performance Improvement Committee and had no active Comprehensive Quality Improvement Program to evaluate the provisions of care to patients since April of 2012.

The facility had not been measuring, analyzing, tracking or trending quality indicators which included adverse patient events since April of 2012.

The Assistant Administrator and Director of Nursing acknowledged that infection control issues at the facility were not being incorporated into the QAPI program at the facility.

The Assistant Administrator acknowledged there was no QAPI data which included medical errors, adverse patient events or performance improvement activities discussed at any of the Medical Staff meetings held in 2012.

A review of Quality Assurance and Risk Management meetings held for the year 2012 revealed there was one documented meeting held on 01/31/12. There were no further documented Quality Assurance Performance Improvement Committee meetings held for the year 2012.

The facility could not provide a roster of Quality Assurance Committee members for the year 2012. The facility could not provide a list or any data of quality indicators that were being tracked at the facility. The facility could not provide a list of adverse patient events that had occurred at the facility for the year 2012.

A review of the facility's Medical Staff Meeting Minutes for the year 2012 revealed no documented evidence Quality Assurance Performance Improvement data, quality indicators, infection control activities, medical errors or adverse patient events were discussed at any meetings held in 2012.
The facility's Quality Improvement Plan Policy and Procedure last revised 06/11/08 included the following:

Purpose: The purpose of the Quality Improvement Plan is to ensure that the Governing Body, medical staff and professional services staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care services in an environment of minimal risk.

Goals of Quality Improvement: The primary goal of the Quality Improvement Plan is to continually systemically plan, design, measure, assess and improve performance of hospital wide key functions and processes relative to patient care.

Organization: The organizational Quality Assurance Committee meets on at least a quarterly basis to review and prioritize issues throughout the organization. The Quality Assurance Committee will consist of one representative from each department in the facility, a representative from administration, Director of Nursing or nursing representative, and a physician representative. Each department will be represented at each meeting. Meeting minutes will be distributed to all attending parties, as well as the Medical Director.
VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on interview and document review, the facility failed to ensure there was a sufficient number of dietary staff properly trained and competent to prepare meals for patients at the facility.

Findings include:

On 12/12/12 at 8:00 AM, the Director of Nursing reported due to dietary staff shortages nursing and respiratory therapy staff were utilized six times in the month of December 2012 to cook food for patients and put trays together and deliver trays to patients. The Director of Nursing acknowledged nursing and respiratory therapy staff members assigned to cook and prepare food had no formal experience or training in food preparation.

On 12/11/12 at 4:00 PM, a Licensed Emergency Department Nurse acknowledged the facility had a severe staffing shortage. The nurse reported due to staffing shortages in nursing, dietary, housekeeping and laundry services, registered nurses assigned to the emergency department were assigned six times in the month of December to cook meals and assemble meal trays for patients.

A Transferring From Environmental to Nutritional Services Policy and procedure last revised 02/27/12 included the following:

Policy: Due to staffing shortages at the (facility) Environmental Services will double as Nutritional Staff as needed.

Environmental Services personnel will change to clean scrubs in the changing room, don head and shoe covers, and wash their hands to the elbows thoroughly before entering the kitchen.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on interview and document review, the facility failed to maintain an active program for the prevention, control and investigation of infections and communicable diseases at the facility (A-0747). The facility failed to have a person designated as the infection control officer to develop and implement policies governing control of infections and communicable diseases (A-0748). The facility failed to have an infection control officer who maintained a log of incidents related to infections and communicable diseases (A-0750). The facility failed to integrate the hospitals infection control program into its hospital wide Quality Assurance and Performance Improvement Program (A-0756).

The cumulative effect of systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on interview and document review the facility failed to implement and maintain a Quality Assurance Performance Improvement (QAPI) program that collected data related to patients and failed to measure, analyze, and tract quality indicators and processes of care provided at the facility.

Findings include:

On 12/11/12 at 2:00 PM, the Assistant Administrator and Director of Nursing confirmed the facility had no active Quality Assurance Performance Improvement Committee and had no active Comprehensive Quality Improvement Program to evaluate the provisions of care to patients since April of 2012. The facility had not been measuring, analyzing, tracking or trending quality indicators which included adverse patient events since April of 2012.

The Assistant Administrator and Director of Nursing acknowledged that infection control issues at the facility were not being incorporated into the QAPI program at the facility.

The Assistant Administrator acknowledged there was no QAPI data which included medical errors, adverse patient events or performance improvement activities discussed at any of the Medical Staff meetings held in 2012.

A review of Quality Assurance and Risk Management meetings held for the year 2012 revealed there was one documented meeting held on 01/31/12. There were no further documented Quality Assurance Performance Improvement Committee meetings held for the year 2012.

The facility could not provide a roster of Quality Assurance Committee members for the year 2012. The facility could not provide a list or any data of quality indicators that were being tracked at the facility. The facility could not provide a list of adverse patient events that had occurred at the facility for the year 2012.

A review of the facility's Medical Staff Meeting Minutes for the year 2012 revealed no documented evidence Quality Assurance Performance Improvement data, quality indicators, infection control activities, medical errors or adverse patient events were discussed at any meetings held in 2012.

The facility's Quality Improvement Plan Policy and Procedure last revised 06/11/08 included the following:

Purpose: The purpose of the Quality Improvement Plan is to ensure that the Governing Body, medical staff and professional services staff demonstrate a consistent endeavor to deliver safe, effective, optimal patient care services in an environment of minimal risk.

Goals of Quality Improvement: The primary goal of the Quality Improvement Plan is to continually systemically plan, design, measure, assess and improve performance of hospital wide key functions and processes relative to patient care.

Organization: The organizational Quality Assurance Committee meets on at least a quarterly basis to review and prioritize issues throughout the organization. The Quality Assurance Committee will consist of one representative from each department in the facility, a representative from administration, Director of Nursing or nursing representative, and a physician representative. Each department will be represented at each meeting. Meeting minutes will be distributed to all attending parties, as well as the Medical Director.

The facility's Medical Staff Rules dated 03/1999 included the following:

Performance Improvement Committee: The purpose of the Performance Improvement Committee is to direct and integrate all performance improvement activities conducted throughout the hospital to assure ongoing and comprehensive Performance Improvement Program designated to improve patient care services; to assure integration of data to enhance effectiveness and eliminate duplicate efforts; to assure appropriate actions are taken to eliminate identified problems; to monitor corrective actions through to resolution; and to maintain records that substantiate program effectiveness in improving patient care.

The Quality Improvement Committee shall oversee the following activities:

1. Blood usage.
2. Emergency care.
3. Infection Control.
4. Medical records.
5. Medication administration and usage.
6. Surgical and invasive procedures.
7. Utilization review.

The Quality Improvement Committee shall meet at least quarterly and report to the Medical Executive Committee.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
Based on interview, document review and physician credentialing file review, the medical staff failed to follow established bylaws and medical staff rules approved by the governing body when credentialing and granting medical privileges to medical staff and ensuring medical staff received the proper competency performance evaluations.

Findings include:

On 12/12/12 at 2:00 PM the Assistant Administrator acknowledged two physician assistants who were working in the emergency department and two physicians who were working and providing supervision to physician assistants working in the emergency department at the facility had not been granted membership to the facility's medical staff or granted clinical privileges to work in the emergency department or the hospital by the Chief of Staff and Medical Executive Committee. The Assistant Administrator acknowledged the facility's Medical Staff By-laws required all medical staff practitioners to be be properly credentialed and granted specific clinical privileges prior to being allowed to provide care to patients in the emergency department and hospital.

Medical Staff Membership Bylaws dated 03/02 included the following:

Medical Staff Membership: Membership on the Medical Staff and/or Clinical privileges shall be extended to, and may be maintained only by those professionally competent Practitioners who continuously meet the qualifications, standards and requirements set forth in these Bylaws. Except as otherwise provided in the Medical Staff Rules, a Practitioner, including those in a medical administrative position by virtue of a contact with the Hospital, shall admit or provide medical or health-related services to patients in the Hospital only if he/she is a member of the Medical Staff or has been granted Clinical Privileges in accordance with the procedure set forth in these Bylaws. Appointment to the Medical Staff shall confer only such Clinical privileges and prerogative as have been granted by the Governing Body in accordance with these Bylaws.

All new Staff members shall be appointed to the Provisional Staff and subjected to a period of formal observation and review.

Exercise of Privileges: Except as otherwise provided in the Bylaws or the Medical Staff Rules, every Practitioner or other professional providing direct clinical services at this Hospital shall be entitled to exercise only those clinical privileges or services specifically granted to him/her.

Requests for clinical privileges shall be evaluated on the basis of the Practitioner's education, training, experience, and demonstrated ability and judgement. The bases for privileges determinations, in connection with periodic reappointment or otherwise, shall include any observed clinical performance and judgement, performance of a sufficient number of procedures each year to develop and maintain the Practitioners skill and knowledge, and the documented results of patient care audit and other quality improvement activities required by the Medical Staff Bylaws and Rules.

All medical staff shall have demonstrated clinical competency in his/her field of practice.

Clinical Services: Each service is responsible for the quality of care within the service, and for the effective performance of the following as relates to members of the service and Allied Health Professionals practicing within the service.

1. Patient care evaluation, observation, and monitoring (including periodic demonstrations of ability consistent with guidelines developed by the Care Review Committee, Utilization Review Committee, Medical Records, Medical Executive Committee and Infection Control Committee.

2. Credentialing review, consistent with guidelines developed by the Medical Executive Committee.

Chief of Medical Staff duties included the following:

1. The development and implementation of policies and procedures that guide and support the provisions of service.

2. The recommendation for a sufficient number of qualified and competent persons to provide care/service.

3. Continuing surveillance of the professional performance of all individuals who have delineated clinical privileges in the service.

4. Recommending clinical privileges for each member of the service and each staff member desiring to exercise privileges in the service.

5. The determination of the qualifications and competence of Allied Health Professionals who provide patient care services within the purview of the service.

6. The continuous assessment and improvement of the quality of care and services provided in the service.

7. The orientation and continuing education of all persons in the service, in coordination with the Medical Staff Education.

8. Assure that all records of performance are maintained and updated from all members of the service.

A review of physician credentialing files included the following:

1. Physician Assistant #1 was hired 09/01/12 to work in the facility's emergency department. There was no documented evidence Physician Assistant #1 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file.

On 12/12/12 at 2:00 PM, Physician Assistant #1 acknowledged working numerous shifts in the emergency department since 10/12 providing assessment, evaluation, treatment, writing medical orders and prescribing medication to emergency department patients. Physician Assistant #1 reported being unaware the granting of clinical privileges by the facility was required prior to providing patient care in the emergency department of the facility. Physician Assistant #1 acknowledged not being informed verbally or in writing from the facility that clinical privileges had been granted. Physician Assistant #1 reported the Medical Director had provided an orientation to the emergency department but no clinical competencies or performance evaluations were completed prior to being allowed to conduct patient care. Physician Assistant #1 had not been provided with a copy of the facility's medical staff bylaws or medical staff rules upon hire.

2. Physician Assistant #2 was hired on 11/13/12 as a new graduate physician assistant to work in the facility's emergency department. There was no documented evidence Physician Assistant #2 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file. There was no documented evidence of ACLS (Advanced Cardiac Life Support) certification or BLS (Basic Life Support) certification located in the credentialing file.

On 12/12/12 at 2:30 PM, Physician Assistant #2 reported being a new graduate physician assistant graduating on 06/12. Physician #2 acknowledged working approximately 12 shifts in the emergency department since 11/12 providing assessment, evaluation, treatment, writing medical orders and prescribing medication to emergency department patients. Physician Assistant #2 reported being unaware the granting of clinical privileges by the facility was required prior to providing patient care in the emergency department of the facility. Physician Assistant #2 acknowledged not being informed verbally or in writing from the facility that clinical privileges had been granted. Physician Assistant #2 reported having no emergency department experience or training outside of clinical rotations while in a physician assistant training program. The Medical Director had provided an orientation to the emergency department but no clinical competencies or performance evaluations were completed prior to being allowed to conduct patient care. Physician Assistant #2 acknowledged being contacted by the facility's administrator after it was learned he had been writing medication prescriptions for emergency department patients without a Nevada Pharmacy License. Physician Assistant #2 reported he was not aware a pharmacy license was required to write medication prescriptions. Physician Assistant #2 had not been provided with a copy of the facility's medical staff bylaws or medical staff rules upon hire.

3. Physician #1 was hired on 02/06/12 to work at the facility's clinic. A Notification to Nevada State Board of Medical Examiners of Supervision of Physician Assistant #1 dated 09/04/12 documented Physician #1 had assumed the duties and responsibilities for supervising Physician Assistant #1 in the emergency department. There was no documented evidence Physician #1 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee to work in the emergency department or supervise Physician Assistants working in the emergency department or hospital. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file. Physician #1 ACLS certification expired 02/12.

On 12/12/12 at 5:00 PM, Physician #1 acknowledged having the duties and responsibilities for supervising Physician Assistant #1 in the clinic and emergency department. Physician #1 acknowledged not being informed verbally or in writing from the facility's Medical Director or Medical Executive Committee that clinical privileges had been granted to work in the emergency department or hospital. Physician #1 acknowledged in order to properly supervise Physician Assistant #1's treatment and care of patients in the emergency department clinical privileges must be granted by the facility to both the physician assistant and medical physician supervising the physician assistant. Physician #1 acknowledged not receiving any emergency department orientation, clinical competency or performance evaluations by facility staff.

4. Physician #2 (Medical Director) had a hire date of 1999. Clinical privileges were first granted in the year 2004. A reappointment request with no change in privileges was partially completed by Physician #2 on 12/13/11 for reappointment to 12/13/13. There was no documented evidence the reappointment request was granted or signed by the Medical Staff Chairman or Medical Executive Committee.

5. Physician #3 had a hire date of 07/01/12 as an emergency department physician. There was no documented evidence Physician #3 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee to provide care to patients in the emergency department or hospital.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview and document review, the facility failed to have an organized nursing service with an adequate number of registered nurses to provide nursing care and supervision to all patients as needed (A-0392). The facility failed to have a well organized service that determined and provided the types and numbers of nursing care personnel necessary to provide nursing care to all areas of the hospital (A-0386).

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the provision of quality health care in a safe setting.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on observation, interview and document review the facility failed to have a well organized nursing service which included a process to determine the types and numbers of nursing personnel and staff necessary to provide nursing care to all areas of the hospital.

Findings include:

On 12/11/12 at 2:00 PM and 12/12/12 at 8:00 AM, interviews were conducted with the Assistant Administrator and Director of Nursing who reported out of the eight full time registered nursing positions budgeted, the facility currently had five vacant full time registered nurse positions and there was not a sufficient amount of nursing staff available to safely staff the emergency department and medical unit of the hospital.

The Administrative Staff reported staffing consisted of one registered nurse assigned to the emergency department and one registered nurse assigned to the acute medical unit on each shift. If the nurse in the emergency department required assistance the nurse assigned to the medical unit would have to leave the medical unit and assist the emergency department nurse leaving patients on the medical unit unsupervised.

If the medical unit nurse required assistance the emergency department nurse would leave the emergency department to respond to assist the medical unit nurse leaving patients in the emergency department unsupervised.

The Assistant Administrator reported due to the nursing staff shortage, the Director of Nursing had to function as an emergency department nurse working full time in the emergency department which left no time to recruit new nurses, perform administrative duties and direct and supervise nursing services.

The Director of Nursing reported due to dietary staff shortages nursing and respiratory therapy staff were utilized six times in the month of December 2012 to cook food for patients and put trays together and deliver trays to patients.

The Assistant Administrator and Director of Nursing reported per diem nursing staff were being utilized to fill in nursing staff shortages, but it was difficult to fill day and night shifts with per diem staff since most of the per diem nurses worked full time at other facilities and were not always available to cover vacant shifts.

The Assistant Administrator and Director of Nursing acknowledged due to the staffing shortage the facility had no active comprehensive Quality Assurance Performance Improvement Program to evaluate the provisions of care to patients since April of 2012. Administrative Staff acknowledged the facility had no active infection control program since June of 2012 when the infection control nurse was laid off due to budget issues. There had been no active tracking and trending or investigations of infections in the facility since June of 2012 and no infection control meetings since February of 2012. Administrative Staff acknowledged the facility had no active patient safety committee and there had been no safety committee meetings since January of 2012.

The Director of Nursing acknowledged the staffing patterns in the hospital were to be based on acuity and numbers of patients. The Director of Nursing acknowledged the facility did not have or utilize any type of patient acuity tool when analyzing staffing patterns or making patient assignments in the emergency department or on the acute medical unit.

A review of Committee meeting minutes revealed the following:

1. Quality Assurance Performance Improvement Committee meeting was held 01/31/12. No other meetings were held for 2012

2. Infection Control Committee meetings was held 02/06/12 and 02/27/12: No other meetings were held for 2012

3. Safety Committee Meeting was held 01/31/12. No other meetings were held for 2012

On 12/11/12 at 4:00 PM, observations made in the emergency department and acute medical unit confirmed there was one registered nurse assigned to each unit. There were no other licensed nurses available in the facility to assist in providing emergency bedside nursing or responding to emergency situations. There were no other licensed nurses available to relieve the emergency department nurse or acute care unit nurse for meals or breaks.

While interviewing the emergency department nurse, the acute care unit nurse arrived at the emergency department seeking help from the emergency department nurse in administering intravenous medications to patients on the acute unit and gaining access to the computer system. The acute care nurse was observed away from the acute care unit for five minutes. During that time period three patients on the acute care unit were left unsupervised. Patient call lights could not be visualized from inside the emergency department.

On 12/11/12 at 4:00 PM, a Licensed Emergency Department Nurse acknowledged the facility had a severe staffing shortage. The nurse reported facility staffing consisted of one nurse assigned to the emergency department and one nurse assigned to the acute care unit each shift. There were no other nurses available to assist with immediate bedside nursing, emergencies or meal breaks. The nurse reported being the only nurse assigned to the emergency department for the day shift. The nurse reported an assignment that consisted of covering the emergency department, having a one patient assignment on the acute medical unit and the responsibility for training a new nurse assigned to the acute medical unit.

The nurse acknowledged having to leave the emergency department approximately twenty times during the shift at times when patients were present in the emergency department to assist the new nurse on the acute medical unit with patient care tasks and training and check on the patient assigned to her. The nurse acknowledged emergency department patients were left unattended for up to ten minutes at a time which presented a patient safety issue. The nurse advised the Director of Nursing was notified of the unsafe staffing situation earlier in the shift.

The nurse reported due to staffing shortages in dietary, housekeeping and laundry services registered nurses assigned to the emergency department were assigned six times in the month of December to cook meals and assemble meal trays for patients.

On 12/11/12 at 4:30 PM, a Licensed Medical Acute Care Unit nurse reported being a newly hired nurse in the third day of training. The nurse reported being the only nurse assigned to work on the acute care unit for the day shift. The nurse acknowledged having to physically leave the unit numerous times during the shift to seek help and assistance in patient care issues from the emergency department nurse. The nurse acknowledged patients were sometimes left unattended for up to five minutes at a time while being away from the unit. The nurse reported there was no patient acuity tool being utilized at the facility to evaluate staffing levels. The nurse acknowledged she had not received any formal orientation program and had not competed any competency or performance evaluations prior to being the only nurse physically assigned to work on the acute care unit. The nurse reported the staffing on the unit was not safe and there was no additional nurse other than the emergency department nurse available to immediately assist in patient care or emergency situations on the unit.

A review of facility Staffing schedules for November 2012 and December 2012 confirmed staffing at the facility consisted of one registered nurse assigned to the emergency department and one registered nurse assigned to the acute medical unit. The Director of Nursing was consistently assigned as the full time emergency department nurse on the schedule working ten full time shifts in the emergency department from November 26, 2012 to December 12 th 2012.

A review of the Licensed Acute Care Unit nurses personnel record revealed the nurse was hired on 11/15/12 to work in the emergency department and acute care unit. There was no documented evidence of a completed emergency department and medical unit orientation checklist in the personnel file. There was no documented evidence of completed clinical competency or performance evaluations for the medical unit and emergency department. There was no documented evidence the nurse had completed the required ACLS (Advanced Cardiac Life Support), BLS (Basic Life Support) or PALS (Pediatric Advanced Life Support) certifications.

A facility Job description for the Director of Nursing included the following:

1. Collects and analyzes staffing patterns by acuity and overall patient care staffing plans.
2. Maintains and directs staff education, continuing education and skill training programs for nursing personnel.
3. Represents Nursing service on various committees, ie, Infection Control, Pain Management, Performance Improvement, Medical Staff and Hospital Board committees.

The facility's Staffing Plan last revised 05/21/12 included the following:

Policy: It is the policy of the Acute Care Unit to provide adequate staffing to meet the physical and psychological needs of patients housed on this unit.

Procedure: It must be understood that patient acuity levels dictate the amount of staff and the professional qualifications of staff assigned to the Acute Care Unit. The Director of Nursing and his/her designee will assess patient acuity on a shift by shift basis, and upgrade or downgrade staffing assignments in accordance with patient acuity.

A review of the facility's General Staffing Policy revised 01/08/09 included the following:

Policy: Each unit or area where patient care is provided will have a staffing plan to provide for a sufficient number of professional nursing staff (RN, LPN/LVN, CNAs) and professional ancillary staff (Registered Physical Therapists, Registered Respiratory Therapists, etc) to carry out at least the following activities:

Prescription of care, treatment and services care for patients based on:

1. Assessment data and other relevant information.
2. Identified patient needs/problems.
3. Appropriate healthcare interventions as specified in standards, policies and procedures, protocols or as determined by professional judgement.
4. The patients response to healthcare interventions.

Clinical and service indicators will be utilized in combination with human resource screening indicators to assess staffing effectiveness. revisions in staffing plans and processes will be made according to evaluation of staff effectiveness.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, interview and document review the facility failed to have an adequate number of licensed registered nurses and other personnel to provide proper safe nursing care to all patients as needed.

Findings include:

On 12/11/12 at 2:00 PM and 12/12/12 at 8:00 AM, interviews were conducted with the Assistant Administrator and Director of Nursing who reported out of the eight full time registered nursing positions budgeted, the facility currently had five vacant full time registered nurse positions and there was not a sufficient amount of nursing staff available to safely staff the emergency department and medical unit of the hospital.

The Administrative Staff reported staffing consisted of one registered nurse assigned to the emergency department and one registered nurse assigned to the acute medical unit on each shift. If the nurse in the emergency department required assistance the nurse assigned to the medical unit would have to leave the medical unit and assist the emergency department nurse leaving patients on the medical unit unsupervised.

If the medical unit nurse required assistance the emergency department nurse would leave the emergency department to respond to assist the medical unit nurse leaving patients in the emergency department unsupervised. Administrative Staff reported due to the nursing staffing shortage the Director of Nursing had to function as an emergency department nurse working full time in the emergency department which left no time to recruit new nurses, perform administrative duties and direct and supervise nursing services.

Administrative Staff reported due to dietary staff shortages nursing and respiratory therapy staff were utilized six times in the month of December 2012 to cook food for patients and put trays together and deliver trays to patients.

Administrative Staff reported per diem nursing staff were being utilized to fill in nursing staff shortages but it was difficult to fill day and night shifts with per diem staff since most of the per diem nurses worked full time at other facilities and were not always available to cover vacant shifts.

The Director of Nursing acknowledged the staffing patterns in the hospital were to be based on acuity and numbers of patients. The Director of Nursing acknowledged the facility did not have or utilize any type of patient acuity tool when analyzing staffing patterns or making patient assignments in the emergency department or on the acute medical unit.

On 12/11/12 at 4:00 PM, observations made on the emergency department and acute medical unit confirmed there was one registered nurse assigned to each unit. There were no other licensed nurses available in the facility to assist in providing emergency bedside nursing or responding to emergency situations. There were no other licensed nurses available to relieve the emergency department nurse or acute care unit nurse for meals or breaks. While interviewing the emergency department nurse, the acute care unit nurse arrived at the emergency department seeking help from the emergency department nurse in administering intravenous medications to patients on the acute unit and gaining access to the computer system. The acute care nurse was observed away from the acute care unit for five minutes. During that time period three patients on the acute care unit were left unsupervised. Patient call lights could not be visualized from inside the emergency department.

On 12/11/12 at 4:00 PM, a Licensed Emergency Department Nurse acknowledged the facility had a severe staffing shortage. The nurse reported facility staffing consisted of one nurse assigned to the emergency department and one nurse assigned to the acute care unit each shift. There were no other nurses available to assist with immediate bedside nursing, emergencies or meal breaks. The nurse reported being the only nurse assigned to the emergency department for the day shift. The nurse reported an assignment that consisted of covering the emergency department, having a one patient assignment on the acute medical unit and the responsibility for training a new nurse assigned to the acute medical unit.

The nurse acknowledged having to leave the emergency department approximately twenty times during the shift at times when patients were present in the emergency department to assist the new nurse on the acute medical unit with patient care tasks and training and check on the patient assigned to her. The nurse acknowledged emergency department patients were left unattended for up to ten minutes at a time which presented a patient safety issue. The nurse advised the Director of Nursing was notified of the unsafe staffing situation earlier in the shift.

The nurse reported due to staffing shortages in dietary, housekeeping and laundry services registered nurses assigned to the emergency department were assigned six times in the month of December to cook meals and assemble meal trays for patients.

On 12/11/12 at 4:30 PM, a Licensed Medical Acute Care Unit nurse reported being a newly hired nurse in the third day of training. The nurse reported being the only nurse assigned to work on the acute care unit for the day shift. The nurse acknowledged having to physically leave the unit numerous times during the shift to seek help and assistance in patient care issues from the emergency department nurse. The nurse acknowledged patients were sometimes left unattended for up to five minutes at a time while being away from the unit. The nurse reported there was no patient acuity tool being utilized at the facility to evaluate staffing levels. The nurse acknowledged she had not received any formal orientation program and had not competed any competency or performance evaluations prior to being the only nurse physically assigned to work on the acute care unit. The nurse reported the staffing on the unit was not safe and there was no additional nurse other than the emergency department nurse available to immediately assist in patient care or emergency situations on the unit.

A review of facility Staffing schedules for November 2012 and December 2012 confirmed staffing at the facility consisted of one registered nurse assigned to the emergency department and one registered nurse assigned to the acute medical unit. The Director of Nursing was consistently assigned as the full time emergency department nurse on the schedule working ten full time shifts in the emergency department from November 26, 2012 to December 12 th 2012.

A review of the Licensed Acute Care Unit nurses personnel record revealed the nurse was hired 11/15/12 to work in the emergency department and acute care unit. There was no documented evidence of a completed emergency department and medical unit orientation checklist in the personnel file. There was no documented evidence of completed clinical competency or performance evaluations for the medical unit and emergency department. There was no documented evidence the nurse had completed the required ACLS (Advanced Cardiac Life Support), BLS (Basic Life Support) or PALS (Pediatric Advanced Life Support) certifications.

The facility's Staffing Plan last revised 05/21/12 included the following:

Policy: It is the policy of the Acute Care Unit to provide adequate staffing to meet the physical and psychological needs of patients housed on this unit.

Procedure: It must be understood that patient acuity levels dictate the amount of staff and the professional qualifications of staff assigned to the Acute Care Unit. The Director of Nursing and his/her designee will assess patient acuity on a shift by shift basis, and upgrade or downgrade staffing assignments in accordance with patient acuity.

A review of the facility's General Staffing Policy revised 01/08/09 included the following:

Policy: Each unit or area where patient care is provided will have a staffing plan to provide for a sufficient number of professional nursing staff (RN, LPN/LVN, CNAs) and professional ancillary staff (Registered Physical Therapists, Registered Respiratory Therapists, etc) to carry out at least the following activities:

Prescription of care, treatment and services care for patients based on:

1. Assessment data and other relevant information.
2. Identified patient needs/problems.
3. Appropriate healthcare interventions as specified in standards, policies and procedures,protocols or as determined by professional judgement.
4. The patients response to healthcare interventions.

Clinical and service indicators will be utilized in combination with human resource screening indicators to assess staffing effectiveness. revisions in staffing plans and processes will be made according to evaluation of staff effectiveness.
VIOLATION: LEADERSHIP RESPONSIBILITIES Tag No: A0756
Based on interview and document review the facility failed to carry out an active program for the prevention, control and investigations of infections and failed to integrate the Infection Control Program into its hospital-wide Quality Assurance Performance Improvement Program.

Findings include:

On 12/11/12 at 2:00 PM, the Assistant Administrator and Director of Nursing acknowledged the facility had no active infection control program since June of 2012 when the infection control nurse was laid off due to budget issues. The facility had no infection control nurse on staff since June of 2012. There had been no active tracking and trending or investigations of infections in the facility since June of 2012. The Administrative staff acknowledged there had been no active infection control committee meetings taking place at the facility since June of 2012. The Director of Nursing acknowledged the hospitals infection control program was not integrated into the hospital wide Quality Assurance Performance Improvement Program which had not been active since April of 2012. Quality Assurance and Infection Control issues were not discussed at any of the Medical Staff meetings held for the year 2012.

A review of the facility's Infection Control and Quality Improvement Plan last revised 06/11/08 indicated infection control issues, relevant findings and tracking and trending of infections were to be incorporated into the facility's quarterly Quality Assurance meetings.

A review of the facility's Infection Control Committee meetings indicated meetings were conducted on 02/06/12 and 02/27/12. There was no documented evidence of any further Infection Control Committee meetings held for the year 2012. Administrative staff could not provide any documentation the facility was actively tracking and trending infections at the facility.

A review of Quality Assurance Performance Improvement Committee meetings held for the year 2012 revealed there was one documented meeting held on 01/31/12. There were no further documented Quality Assurance Performance Improvement Committee meetings held for the year 2012. The facility could not provide a roster of Quality Assurance Committee members for the year 2012.

The facility's Medical Staff Rules dated 03/1999 included the following:

Performance Improvement Committee: The purpose of the Performance Improvement Committee is to direct and integrate all performance improvement activities conducted throughout the hospital to assure ongoing and comprehensive Performance Improvement Program designated to improve patient care services; to assure integration of data to enhance effectiveness and eliminate duplicate efforts; to assure appropriate actions are taken to eliminate identified problems; to monitor corrective actions through to resolution; and to maintain records that substantiate program effectiveness in improving patient care.

The Quality Improvement Committee shall oversee the following activities:

1. Blood usage.
2. Emergency care.
3. Infection Control.
4. Medical records.
5. Medication administration and usage.
6. Surgical and invasive procedures.
7. Utilization review.

The Quality Improvement Committee shall meet at least quarterly and report to the Medical Executive Committee.

Infection Control Committee:

a. Representatives from nursing, housekeeping, laundry, dietetic services, environmental services and pharmacy shall be available to the Performance Improvement Committee on a consultant and ad hoc basis.

Purpose: The purpose of the infection control review is to develop and monitor the Hospital's infection control program, and the staffs treatment of infectious disease., including the review of the use of antimicrobials.

Infection control shall be reviewed at least every other month.
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
Based on interview, physician credentialing file review and personnel record review, the facility failed to ensure emergency department medical staff and nursing staff were properly qualified, credentialed, granted privileges and had documented clinical competency, certifications, training and experience to meet the emergency needs of patients who presented to the emergency department. (Physician Assistants #1, #2) (Physician #1, #2, #3)
(Nurses #1, #2, #3, #4, #5, #6)

Findings include:

On 12/12/12 at 2:00 PM, the Assistant Administrator and Director of Nursing acknowledged two physician assistants who were working in the emergency department and physicians who were providing care to patients and supervision of physician assistants working in the emergency department at the facility had not been granted membership to the facility's medical staff or granted clinical privileges to work in the emergency department or the hospital by the Chief of Staff and Medical Executive Committee.

Administrative Staff acknowledged some nursing personnel working in the emergency department did not have required current ACLS (Advanced Cardiac Life Support) certification and documentation that required clinical competencies were completed prior to being allowed to work in the emergency department.

Administrative Staff acknowledged the facility's Medical Staff By-laws required all medical staff practitioners to be be properly credentialed and granted specific clinical privileges prior to being allowed to provide care to patients in the emergency department and hospital.

Administrative Staff acknowledged medical staff and nursing staff working at the facility were required to have documented emergency department orientation and clinical competencies that included current ACLS (Advanced Cardiac Life Support) certification in their credentialing and personnel files.

Medical Staff Membership Bylaws dated 03/02 included the following:

Medical Staff Membership: Membership on the Medical Staff and/or Clinical privileges shall be extended to, and may be maintained only by those professionally competent Practitioners who continuously meet the qualifications, standards and requirements set forth in these Bylaws. Except as otherwise provided in the Medical Staff Rules, a Practitioner, including those in a medical administrative position by virtue of a contact with the Hospital, shall admit or provide medical or health-related services to patients in the Hospital only if he/she is a member of the Medical Staff or has been granted Clinical Privileges in accordance with the procedure set forth in these Bylaws. Appointment to the Medical Staff shall confer only such Clinical privileges and prerogative as have been granted by the Governing Body in accordance with these Bylaws.

All new Staff members shall be appointed to the Provisional Staff and subjected to a period of formal observation and review.

Exercise of Privileges: Except as otherwise provided in the Bylaws or the Medical Staff Rules, every Practitioner or other professional providing direct clinical services at this Hospital shall be entitled to exercise only those clinical privileges or services specifically granted to him/her.

Requests for clinical privileges shall be evaluated on the basis of the Practitioner's education, training, experience, and demonstrated ability and judgement. The bases for privileges determinations, in connection with periodic reappointment or otherwise, shall include any observed clinical performance and judgement, performance of a sufficient number of procedures each year to develop and maintain the Practitioners skill and knowledge, and the documented results of patient care audit and other quality improvement activities required by the Medical Staff Bylaws and Rules.

All medical staff shall have demonstrated clinical competency in his/her field of practice.

Clinical Services: Each service is responsible for the quality of care within the service, and for the effective performance of the following as relates to members of the service and Allied Health Professionals practicing within the service.

1. Patient care evaluation, observation, and monitoring (including periodic demonstrations of ability consistent with guidelines developed by the Care Review Committee, Utilization Review Committee, Medical Records, Medical Executive Committee and Infection Control Committee.

2. Credentialing review, consistent with guidelines developed by the Medical Executive Committee.

Chief of Medical Staff duties included the following:

1. The development and implementation of policies and procedures that guide and support the provisions of service.

2. The recommendation for a sufficient number of qualified and competent persons to provide care/service.

3. Continuing surveillance of the professional performance of all individuals who have delineated clinical privileges in the service.

4. Recommending clinical privileges for each member of the service and each staff member desiring to exercise privileges in the service.

5. The determination of the qualifications and competence of Allied Health Professionals who provide patient care services within the purview of the service.

6. The continuous assessment and improvement of the quality of care and services provided in the service.

7. The orientation and continuing education of all persons in the service, in coordination with the Medical Staff Education.

8. Assure that all records of performance are maintained and updated from all members of the service.

A review of physician credentialing files included the following:

1. Physician Assistant #1 was hired 09/01/12 to work in the facility's emergency department. There was no documented evidence Physician Assistant #1 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file. There was no documented evidence the physician assistant was being supervised by a credentialed medical physician who had clinical privileges granted by the facility.

On 12/12/12 at 2:00 PM, Physician Assistant #1 acknowledged working numerous shifts in the emergency department since 10/12 providing assessment, evaluation, treatment, writing medical orders and prescribing medication to emergency department patients. Physician Assistant #1 reported being unaware the granting of clinical privileges by the facility was required prior to providing patient care in the emergency department of the facility. Physician Assistant #1 acknowledged not being informed verbally or in writing from the facility that clinical privileges had been granted. Physician Assistant #1 reported the Medical Director had provided an orientation to the emergency department but no clinical competencies or performance evaluations were completed prior to being allowed to conduct patient care. Physician Assistant #1 had not been provided with a copy of the facility's medical staff bylaws or medical staff rules upon hire.

2. Physician Assistant #2 was hired on 11/13/12 as a new graduate physician assistant to work in the facility's emergency department. There was no documented evidence Physician Assistant #2 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file. There was no documented evidence of ACLS (Advanced Cardiac Life Support) certification or BLS (Basic Life Support) certification located in the credentialing file.

On 12/12/12 at 2:30 PM, Physician Assistant #2 reported being a new graduate physician assistant graduating on 06/12. Physician #2 acknowledged working approximately 12 shifts in the emergency department since 11/12 providing assessment, evaluation, treatment, writing medical orders and prescribing medication to emergency department patients. Physician Assistant #2 reported being unaware the granting of clinical privileges by the facility was required prior to providing patient care in the emergency department of the facility. Physician Assistant #2 acknowledged not being informed verbally or in writing from the facility that clinical privileges had been granted. Physician Assistant #2 reported having no emergency department experience or training outside of clinical rotations while in a physician assistant training program. The Medical Director had provided an orientation to the emergency department but no clinical competencies or performance evaluations were completed prior to being allowed to conduct patient care. Physician Assistant #2 acknowledged being contacted by the facility's administrator after it was learned he had been writing medication prescriptions for emergency department patients without a Nevada Pharmacy License. Physician Assistant #2 reported he was not aware a pharmacy license was required to write medication prescriptions. Physician Assistant #2 had not been provided with a copy of the facility's medical staff bylaws or medical staff rules upon hire.

3. Physician #1 was hired on 02/06/12 to work at the facility's clinic. A Notification to Nevada State Board of Medical Examiners of Supervision of Physician Assistant #1 dated 09/04/12 documented Physician #1 had assumed the duties and responsibilities for supervising Physician Assistant #1 in the emergency department. There was no documented evidence Physician #1 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee to work in the emergency department or supervise Physician Assistants working in the emergency department or hospital. There was no documented evidence of any clinical competency or completed performance evaluation located in the credentialing file. There was no documented evidence of a completed orientation checklist for the emergency department located in the credentialing file. Physician #1 ACLS certification expired 02/12.

On 12/12/12 at 5:00 PM, Physician #1 acknowledged having the duties and responsibilities for supervising Physician Assistant #1 in the clinic and emergency department. Physician #1 acknowledged not being informed verbally or in writing from the facility's Medical Director or Medical Executive Committee that clinical privileges had been granted to work in the emergency department or hospital. Physician #1 acknowledged in order to properly supervise Physician Assistant #1's treatment and care of patients in the emergency department clinical privileges must be granted by the facility to both the physician assistant and medical physician supervising the physician assistant. Physician #1 acknowledged not receiving any emergency department orientation, clinical competency or performance evaluations by facility staff.

4. Physician #2 (Medical Director) had a hire date of 1999. Clinical privileges were first granted in the year 2004. A reappointment request with no change in privileges was partially completed by Physician #2 on 12/13/11 for reappointment to 12/13/13. There was no documented evidence the reappointment request was granted or signed by the Medical Staff Chairman or Medical Executive Committee.

5. Physician #3 had a hire date of 07/01/12 as an emergency department physician. There was no documented evidence Physician #3 had been granted clinical privileges by the Chief of Staff and Medical Executive Committee to provide care to patients in the emergency department or hospital.

6. Licensed Nurse #1 was hired 05/11/09 to work in the emergency department and acute care unit. There was no documented evidence of a completed orientation checklist in the personnel file. There was no documented evidence of completed clinical competency or performance evaluations for the emergency department.

7. Licensed Nurse #2 was hired 11/15/12 to work in the emergency department and acute care unit. There was no documented evidence of a completed emergency department orientation checklist in the personnel file. There was no documented evidence of completed clinical competency or performance evaluations for the emergency department. There was no documented evidence the nurse had completed the required ACLS, BLS or PALS (Pediatric Advanced Life Support) certifications.

8. Licensed Nurse #3 was hired 05/18/09 to work in the emergency department and acute care unit. There was no documented evidence the nurse had completed the required ACLS certification. The BLS certification expired 04/12. The PALS certification expired 04/12.

9. Licensed Nurse #4 was hired 04/01/10 to work in the emergency department and acute care unit. The nurses ACLS certification expired 05/12.

10. Licensed Nurse #5 was hired 05/31/10 to work in the emergency department and acute care unit. There was no documented evidence of a completed emergency department orientation checklist in the personnel file. The nurses ACLS and PALS certification expired 10/12.

11. Licensed Nurse #6 was hired 08/27/12 to work in the emergency department and acute care unit. There was no documented evidence of a completed emergency department orientation checklist in the personnel file. There was no documented evidence of completed clinical competency or performance evaluations for the emergency department.

On 12/12/12 at 10:00 AM, the Director of Nursing reported the facility's acute care policy and procedure required all licensed nursing staff who worked in the emergency department and on the acute care unit to have current BLS (Basic Life Support), ACLS (Advanced Cardiac Life Support) and PALS (Pediatric Advanced Life Support) certificates. All nursing staff employees were required to have an orientation to the emergency department and acute care unit and complete a competency evaluation under the supervision of a trained nurse manager or team leader. Successful completion of orientation and competency were to be documented and kept in the employees personnel file. Administrative staff acknowledged due to the facility's nursing staffing shortage there was no active orientation program or competency evaluation program for new nurses being conducted at the facility.

The facility's Staff Orientation Emergency Department Policy and Procedure last revised 01/08/09 included the following:

Purpose: Establish standard criteria for orientation of new nursing staff to the Emergency Department and re-orientation of current nursing staff.

Policy: All nursing personnel will attend an initial orientation as per hospital policy. Nursing personnel will then attend an orientation to the Emergency Department under the supervision of the Emergency Department Nurse manager or team leader. Emergency Department orientation shall be based on the ability of the new staff member to function effectively prior to hands on patient care.

Hospital orientation shall include:

1. Orientation to hospital policy and procedure.
2. Safety
3. Security
4. Workplace violence
5. Case management
6. Infection control
7. Emergency management
8. Hazardous materials
9. Electrical safety
10. Fire safety
11. Orientation to hospital departments
12. Computer orientation
13. Orientation to emergency department
14. Introduction to emergency department forms and equipment
15. Admission of patients to emergency department
16. Triage area
17. Crash carts
18. Skills checklist
19. Evaluation by Emergency Department Nurse Manager
20. Competency Evaluation by Emergency Department Nurse Manager


The facility's Staff Orientation Acute Care Policy and Procedure last revised 05/26/09 included the following:

Policy: Orientation to the facility will be determined and conducted by the department managers/supervisors involved, and will include as related to job function, but may not be limited to :

1. Safety and infection control issues

2. Cultural diversity and sensitivity

3. Patient rights and ethical aspects of care, treatment and services

4. Procedures for responding to unusual clinical events and incidents

5. Clinical issues, security issues, administrative issues, seclusion and restraint

The employee will be assessed for his/her ability to carry out assigned responsibilities safely, competently and in a timely manner upon completion of orientation by his/her department manager/director/supervisor. Successful completion of orientation will be documented on the New Hire Processing Checklist by the employees department manager/director/supervisor and kept in the employees personnel file.

A facility BCLS/ACLS Resuscitation Certificate Policy and Procedure last revised 05/26/12 included the following:

Policy: It is the responsibility of the employee to maintain a current BCLS/ACLS certification and provide evidence of recertification according to policy and procedure.

A copy of the card will be kept in each employees file current and updated according to policy and procedure.