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.
|SAYRE COMMUNITY HOSPITAL||911 HOSPITAL DRIVE SAYRE, OK||March 21, 2013|
|VIOLATION: NURSING SERVICES||Tag No: A0385|
|Based on review of staffing records, policy and procedures, hospital documents, and time sheets, surveyor observation and interviews with hospital staff, the hospital does not ensure the organized nursing service provides safe delivery of patient care. The hospital does not comply with Medicare Condition of Participation: 482.23 Nursing Services.
1. The hospital failed to ensure adequate numbers of trained nursing personnel were available to meet the needs of the patient population. Refer to tag A-0392
2. The hospital failed to ensure a Registered Nurse supervises and evaluates nursing care for each patient. Refer to tag A-0395.
3. The hospital failed to include nursing problems, staffing, incidents, medication errors into the hospital-wide quality assessment and performance improvement (QAPI) program.
4. The hospital failed to develop job descriptions for all nursing staff positions. This included the Chief Nursing Officer (CNO), Infection Control Preventionist, and nurses who worked in the emergency room , medical-surgical unit, and procedure areas.
|VIOLATION: PATIENT SAFETY||Tag No: A0286|
|Based on record review and interviews with hospital staff, the governing body failed to ensure that adverse events were identified, tracked, analyzed and preventative actions taken. Adverse events were not tracked and analyzed as part of an ongoing Quality Assurance/Performance Improvement (QA/PI) program.
1. From January 2013 until the present, hospital surveyors were presented with two patient fall incident reports. Interviews with Staff C, F and G stated there were more than two patient falls. The reports had not been analyzed or tracked.
2. Per hospital policy blanket warmers will be inspected annually by Clinical Engineering to verify proper temperature settings and performance. The blanket warmer was last inspected in 2011.
3. Hospital policy the blanket warmer temperature will not be set higher than 130 degrees Fahrenheit. On the afternoon of March 21, 2013, one surveyor noted the temperature setting on the blanket warmer was 150 degrees Fahrenheit. The surveyor also observed the temperature/thermometer reading on the blanket warmer to be 210 degrees Fahrenheit. Per Staff C, the hospital did not document a temperature log for the blanket warmer.
|VIOLATION: EXECUTIVE RESPONSIBILITIES||Tag No: A0309|
|Based on review of hospital documents, job descriptions, policies and procedures, Governing Board Minutes, Medical Staff Meeting Minutes, Quality Assurance Plans and meeting minutes, and interviews with staff, it was determined the hospital facility failed to ensure the CEO and the Governing Body had adequate oversight of the Quality Assurance and Performance Improvement program.
1. Per hospital policy blanket warmers will be inspected annually by Clinical Engineering to verify proper temperature settings and performance. The blanket warmer was last inspected in 2011.
2. Per hospital policy the blanket warmer temperature will not be set higher than 130 degrees Fahrenheit. On March 21, 2013, one surveyor noted the temperature setting on the blanket warmer to be 150 degrees Fahrenheit. The surveyor observed the temperature reading on the blanket warmer to be 210 degrees Fahrenheit. Per Staff C, the hospital did not keep a temperature log for the blanket warmer.
3. The pressure in the negative air-flow room is not routinely monitored according to Staff C.
|VIOLATION: ORGANIZATION OF NURSING SERVICES||Tag No: A0386|
|Based on record review and staff interview, it was determined the hospital failed to ensure an organized nursing service with clear delineation of authority.
1. The hospital had no organizational chart for the nursing department. The hospital organizational chart documented the Chief Nursing Officer (CNO) was responsible for inpatient and outpatient nursing services (including psychiatric services), case management, utilization review, quality assurance, swing bed services, social services, home health services and pharmacy services.
2. Other than the CNO position, there was no clear delineation of lines of nursing authority for all patient care areas, i.e., unit managers, supervisors, charge nurses or lead nurses.
3. There no evidence the hospital had identified front line managers/supervisors/lead nurses for the emergency or surgery departments. There was no manager or lead nurse for the in-patient care area. Nursing staff assigned to these areas stated they came in to work an assignment only, and had no leadership responsibilities. There were no nursing staff directly accountable to ensure the day to day functioning of these areas.
4. There was no documentation of lines of authority for non-licensed nursing personnel or nursing support personnel.
5. The hospital had not developed job descriptions for all nursing department positions within the hospital.
6. One registered nurse was classified as "anesthesia." There was no documentation to describe the job title and this nurse's responsibilities. Another nurse was identified as "informatics." There was no job description for this position.
7. On March 21, 2013, the CNO stated she was an interim director and was still assessing the nursing department organizational structure.
8. The hospital's organizational chart list an Assistant CNO (Chief Nursing Officer), at present the position is vacant.
|VIOLATION: STAFFING AND DELIVERY OF CARE||Tag No: A0392|
|Based on observation, staff interview and document review, it was determined the hospital failed to ensure there were adequate nursing staff and supervision to provide care to all patients as needed.
1. The staffing policy provided to the surveyors on staffing documented private pay (respite)patients were not considered in the acuity level. These patients still require at least the same nursing care as acute care and swing bed patients.
2. Review of documents provided did not demonstrate the hospital had an acuity measuring tool. This was confirmed with the staff on the floor on the afternoon of March 21, 2013.
3. On March 21, 2013, the surveyors observed, Staff C, who was assigned to work in the Pharmacy, was pulled from the Pharmacy to assist Staff G in the emergency room . When interviewed, on the same day, Staff C stated at times if was difficult to get everything accomplished when she was pulled to help out in other areas.
4. The December 18, 2012 Medical Executive Committee meeting minutes noted the lack of nursing staff and the effect it was having on providing for the patients basic needs.
5. Two (#2 and #3) of the three private pay patients have documented skin care issues.
6. The hospital's organizational chart list an Assistant CNO (Chief Nursing Officer), at present the position is vacant.
7. Nursing staff administer respiratory treatments. Review of licensed nursing staff personnel files did not contain documentation of respiratory training and competency testing. Staff C stated on March 20, 2013 that the hospital did not have a skills checklist for Respiratory Therapy or a respiratory therapist. This finding was confirmed by administration.
8. Hospital leadership had not analyzed the emergency department work load and the numbers of patients served, in order to make appropriate nursing staff assignments for that area.
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|Based on review of hospital documents and interviews with the staff, the hospital does not ensure a registered nurse (RN)assesses patient's care needs, health status and conditioning, as well as response to interventions.
1. On the afternoon of March 21, 2013, Staff C and G, both stated that licensed practical nurses (LPNs) usually provided the licensed care and assessments for the "private pay patients". These patients were not routinely assessed by an RN. Review of medical records (Records #1, 2, and 3) confirmed this finding.
2. According to the hospital's staffing matrix, one RN per shift is assigned to work on the medical-surgical unit. The emergency room (ER) is only staffed with one RN and a physician or midlevel practitioner.
3. On the afternoon of March 23, 2013, Staff C, F, and G told the surveyors that often the RN assigned to work on the medical-surgical unit had to help in the ER, leaving the medical-surgical unit without a RN.
|VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL||Tag No: A1112|
|Based on observations and staff interviews, the hospital did not have adequate nursing personnel in the emergency department to meet the needs of the facility.
1. On March 21, 2013, the hospital surveyors observed Staff C, who was assigned to work in pharmacy, assisting Staff G in the Emergency Department.
2. Hospital policy recorded, there will be two RN's present on all shifts. The policy also states the CNO (Chief Nursing Officer) and the assistant CNO will adjust their work time to allow for two RN's to be present on all shifts. Currently there is no assistant CNO. Staff A stated that she often had to work on the medical-surgical unit because of staffing needs and patient acuity.
3. Review of personnel files did not contain evidence that Staff C, F, and G had been trained to work in the emergency department and administer/monitor patients receiving critical drip medications. This was confirmed by interviews with the staff.