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.

MEMORIAL HOSPITAL 1401 WEST LOCUST STILWELL, OK 74960 June 21, 2012
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on record review and interviews with hospital staff, the hospital does not ensure that performance improvement projects that are monitored to improve patient care and safety are documented and the results of the monitoring and action taken are communicated through the Quality Assurance/Performance Improvement Committee.

Findings:

1. Staff (A) stated on 06/21/12 in the afternoon that several projects involving patient falls and medication errors had been conducted.

2. Review of QA/PI meeting minutes did not document anything except numbers of falls or medication errors. There was no documentation of evaluation of the action taken to reduce the incidences of falls or medication errors.

3. Governing body and Medical Staff meeting minutes did not have documentation of the results of the QA/PI projects and if any improvement was accomplished.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on the review of abuse and neglect policies and procedures and various policies interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describes the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

1. The hospital provided policies for review. The policies concerned child abuse, elder abuse, sexual abuse and spousal/domestic abuse concerning patients who present to the hospital. The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker or contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect .

2. Interviews with hospital staff on 06/21/12 in the afternoon verified that the hospital does not have a written policy that includes the required elements for effective abuse protection.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on record review and staff interview, it was determined the hospital failed to ensure there was one unified nursing service hospital-wide under the direction of one RN.

On 06/21/12, the DON was asked to provide schedules for all nursing staff working in the hospital currently and for the previous two months. The schedules provided by the DON had no documentation of nursing staff working on the geriatric psychiatric unit.

The DON was asked if she directed all nursing services provided by the hospital. She stated she did not.

She stated there were two separate nursing staff - one for the medical side of the hospital and one for the geriatric psychiatry program. She stated the nursing staff were not shared between the two services and operated independently.

She was asked if the geri-psych nurses reported to her. She stated they did not. She stated she oversaw the nursing staff on the medical side and another RN oversaw the nursing staff on the geri-psych side of the hospital.

She stated the RN director of the geriatric psychiatry program did not report to her.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on clinical record review and staff interview, it was determined the hospital failed to ensure an RN assessed and evaluated each patient after a change in condition or status. Findings:

1. Patient #1 had two falls on 01/29/12. The first fall occurred at 7:35 a.m. There was no documentation in the nurse's notes of interventions put in place in response to the fall.

Documentation was found on another hospital form that indicated the patient fell again at 9:00 p.m. The nurse's notes did not document the fall and did not indicate the patient was evaluated for a change in condition and what nursing interventions were put in place to prevent another fall.

2. Patient #2 had a fall on 03/17/12 at 2:50 a.m. There was no documentation in the clinical record regarding nursing interventions put in place in response to the fall. The patient fell again at 7:50 a.m. Both falls occurred when the patient attempted to ambulate by herself to the bathroom.

At 3:40 p.m., the nurses' notes documented the patient was observed returning from an unassisted trip to the restroom. There was no documentation in the nurses' notes regarding nursing assessment and interventions put in place in response to the patient's continued attempts to toilet herself without assistance from staff.

On 03/18/12 at 4:00 a.m., the nurses' notes documented the patient had another fall while ambulating during toileting. The patient suffered a fractured hip.

3. Patient #3 had a fall on 06/10/12. There was no documentation of the fall in the clinical record. At the time of the fall there was documentation of a nursing assessment of the patient's condition.

There was no documentation as to why a full assessment was being done at that time and no documentation of nursing interventions put in place as indicated by the results of the assessment.

On 06/21/12, the DON was asked if nurses should assess and put interventions in place in response to a patient occurrence or change in status. She stated they should. She was asked if nurses should evaluate the patient's response to nursing interventions. She stated they should.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on clinical record review and staff interview, it was detrmined the hospital failed to ensure information was documented in the clinical record to accurately reflect the patient's status. Findings:

1. Patient #1 had two falls on 01/29/12. The fall at 9:00 p.m. was not documented in the clinical record.

2. Patient #2 had a fall on 03/18/12. The information documented in the clinical record did not include all the details about the fall, and what actions were taken as a result.

3. Patient #3 had a fall on 06/10/12. There was no documentation of the fall in the clinical record.

On 06/21/12, the DON was asked if unusual occurrences and changes in patient condition or status should be documented in the clinical record. She stated they should.