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Based on record review and interviews with hospital staff, the hospital's governing body failed to ensure that processes necessary for safe and appropriate hospital operations are carried out.


Findings:

1. The Governing Body failed to ensure the Medical Staff Bylaws were current and appropriate for the types of clinicians working in the hospital. There was no documentation the Governing Body ensured clinicians practiced according to the Medical Staff Bylaws. There was no documentation the Governing Body reviewed the practice of the Medical Staff to determine safe and effective care is provided. See A tags A43, A44, A45, A49, A50, A65, A67, A338, A340, A341, A353, A355

2. The Governing Body failed to ensure the maintenance of an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff. See A Tags 0747, 0749, 0756.

3. The governing body failed to ensure the QAPI program defines, implements and maintains a program to monitor the quality of care provided by employees and services provided by contract and agreement and adequate resources are allocated to provide quality of care for patients. See Tags A 263, A273, A283, A286, A297, A308, A309, A315.

4. The hospital failed to promote each patient's rights. See Tag A 0115,
a. inform patients and/or their representatives of all patient's rights. See Tag A-0117;
b. ensure patients were made aware of the grievance process. See Tag A-0118;
c. ensure the grievance process was approved by the governing body. See Tag A-0119;
d. provide patients and/or their representatives information about how to submit a grievance. See Tag A-0121;
e. identify and adhere to a reasonable time frame for the hospital's written response to a patient grievance. See
Tag A-0122;
f. respond to all grievances in writing. See Tag A-0123; and
g. failed to develop and implement a comprehensive policy and effective processes to prohibit all forms of abuse.
See Tag A-0144.

5. The hospital did not ensure a registered nurse (RN)assesses patient's care needs, health status and conditioning, as well as response to interventions and to ensure staff are adequately trained, oriented and have demonstrated skills competency for their assigned care areas. See Tags A 0385, A392, A405, A406, A407, A409.

6. The governing body failed to ensure emergency services were provided under the direction of a qualified physician; policies were current; and policies addressed emergency care and on call responsibilities of all clinicians. A Tags 1100, 1104, 1111, 1112

7. The governing body failed to ensure the hospital has an effective discharge planning process that applies to all patients and is specified in writing. Refer to A Tags 799, 885.

8. The governing body failed to ensure all contracted services are appropriately overseen by the hospital. Refer to tag A0083, 0084, 0085

9 The governing body failed to ensure pharmacy services are delivered in accordance with acceptable standards of practice and measures are taken to reduce medication errors and incidents of diversion.. See A tags 490, 491, 492, 493, 494, 500, 501, 502, 504, 511.

10. The governing body failed to ensure laboratory services are delivered in accordance with acceptable standards of practice. See A tags 056,0592, 0593

11. The governing body failed to ensure radiology services are delivered in accordance with acceptable standards of practice. See A tags 0528, 0546, 0547

12. The governing body failed to ensure the swing bed program services are delivered in accordance with acceptable standards of practice. See A tags 1500, 1505, 1508, 1510, 1515, 1517, 1518, 1519, 1522, 1523, 1525, 1526, 1527, 1528, 1534, 1537, 1538, 1541, 1548, 1549, 1550, 1551, 1552

13. The governing body failed to ensure the Food and Dietetic Services are delivered in accordance with acceptable standards of practice. See A tags 618, 620, 621, 628

Based on policy and procedure review, hospital document review and staff interview, it was determined the hospital failed to promote each patient's rights as evidenced by failure to:

a. inform patients and/or their representatives of all patient's rights. See Tag A-0117;

b. ensure patients were made aware of the grievance process. See Tag A-0118;

c. ensure the grievance process was approved by the governing body. See Tag A-0119;

d. provide patients and/or their representatives information about how to submit a grievance. See Tag A-0121;

e. identify and adhere to a reasonable time frame for the hospital's written response to a patient grievance. See Tag A-0122;

f. respond to all grievances in writing. See Tag A-0123;

g. develop processes to review hospital incidents, medication errors, grievances and complaints for the use in improving patient care and failed to ensure patients were cared for in a safe setting. See Tag A-0144;

h. develop and implement a comprehensive policy and effective processes to prohibit all forms of abuse. See Tag A-0145; and

i. failure to ensure patient visitation rights. See Tag A-0215.
In addition, the hospital had no documentation staff were trained on patient's rights annually.

Based on review of committee meeting minutes, interviews with staff, review of policies and procedures the facility failed to ensure a Quality Assurance Performance Improvement Program with all of the required elements was implemented.
Findings:
1. Quality Assurance Performance Improvement Plans and Meeting Minutes for 2013 did not include review of all incidents, medication errors, and grievances/complaints. Governing Body Meeting Minutes 2013 did not include review and analysis of all incidents, medication errors, grievances and complaints. A264, A310
2. Review of Quality Meeting Minutes for 2013 indicated pharmacy, physical therapy, and clinical nutrition performance information was not provided. There was no participation by the clinicians overseeing those areas. According to Safety Meeting Minutes the Director of Nurses or the Drug Room Supervisor provided information on medication errors, recalls, and shortages. The information did not include an analysis of the errors, plans for shortages or recalls.
3. Review of Quality Meeting Minutes 2013 indicate data is reported from some of the clinical areas. The hospital and governance does not ensure a hospital wide quality improvement program is implemented, analyzed, and evaluated. There is no documentation in the meeting minutes the Quality Assurance Performance Improvement (QAPI) committee analyzes the data reported and makes recommendations to Medical Staff and Governing Body to improve care. A267
4. The Quality Meeting Minutes 2013 did not include patient care data such as morbidity, mortality review, patient care review, peer review, emergency room care review. There was no documentation the facility reviewed, analyzed, and implemented processes based on Quality Improvement data.
5. The Quality Meeting Minutes 2013 did not indicate priorities to improve patient safety had been developed and implemented. Meeting minutes documented collection of data. The reporting methods and what each indicator meant was not included. There was no documentation in the meeting minutes the data was analyzed and reviewed to formulate improvement in the patient care environment.
6. Governing Body Meeting Minutes 2013 did not include documentation QAPI data was reviewed and analyzed with performance improvement directives formulated. A309, A289
7. The Quality Meeting Minutes 2013 did not include documentation any distinct quality improvement projects had been developed and implemented. A302, A301, A300, A298

Based on review of Medical Staff bylaws, Medical Staff meeting minutes, Quality Meeting Minutes, credential files, and medical records the hospital failed to ensure the Medical Staff functioned under the established Medical Staff bylaws and oversee the quality of medical care provided by the Medical Staff.
Findings:
1. Review of Medical Staff bylaws did not stipulate categories which included advanced practice nurses. Two advanced practice nurses currently provide care in the emergency room and on the acute care unit. The bylaws do not include a category of the organized staff in which this type of clinical care is provided. There is no criteria established specific to role of the advanced practice nurse. There are no staff stipulations as to the Medical Staff responsibility in oversight of the care provided by these clinicians.
2. The Medical Staff bylaws stipulate there are to be several committees functioning and reporting specific details and reviews of care. There is no documentation these committees are functioning and the reporting stipulated in the Medical Staff bylaws occurs.
3. The Medical Staff bylaws do not include current terminology for specific health care providers. The bylaws indicate there are " physician assistant category A " that can provide care at the facility. There is not a physician category A recognized by the Oklahoma Medical Board.
4. The Medical Staff bylaws stipulate a physician must live in close proximity to the hospital to be a member of the active staff. Several radiologist are credentialed. These radiologist live in other states and cannot meet active staff requirements in the current Medical Staff bylaws.

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

a. ensure a registered nurse was assigned solely to the emergency department 24 hours a day, seven days a week. See Tag A-0392;

b. ensure medication and treatment orders were accurately transcribed, appropriately documented and administered as ordered by the physician. See Tag A-0405;

c. ensure verbal orders are used infrequently. See Tag A-0407; and

d. failed to ensure policies and procedures for intravenous medications and blood transfusions were developed and approved by the medical staff and that nursing staff were trained and had demonstrated skills competencies for these procedures. See Tag A-0409.

Based on document review and staff interview, it was determined the hospital failed to:

a. document in writing the scope and complexity of radiology services offered by the hospital;

b. ensure the medical staff and the governing body approved the scope and complexity of the radiology services offered;

c. develop policies and procedures for the radiology department that were based on nationally recognized standards of practice;

d. include radiology services in the hospital-wide QAPI process;

e. ensure the radiology department was supervised by a qualified radiologist approved by the medical staff. See Tag A-0546; and

f. failed to ensure radiology personnel were designated as qualified by the medical staff to use the radiological equipment and administer procedures. See Tag A-0547.

Findings:

On 09/03/13, the radiology department policies and procedures were reviewed. There was no description of the scope and complexity of radiology services provided by the hospital.

The policies and procedures had no documentation they were developed based on nationally recognized standards of practice. There was no documentation the policies were approved by a supervising radiologist.

There was no documentation in the medical staff meeting minutes or in the governing body meeting minutes that stated the hospital's radiology services were approved by these groups.

There was no documentation in the QAPI meeting minutes that indicated radiology services were included in the quality assessment process.

On 09/05/13, the CEO was informed of the findings. No comment was made.

Based on record review and staff interview, it was determined the hospital failed to:

a. develop and implement a system to take appropriate action when notified that blood or blood components it received may be at increased risk of transmitting HIV or HCV. See Tag A-0592;

b. develop and implement a policy and procedure specific to appropriate testing and quarantining of infectious blood and blood components. See Tag A-0593; and

c. failed to ensure the nursing staff administered blood products safely.

Findings:

In March 2013, the OSDH CLIA surveyors identified deficient practices in the administration of blood products. They documented that nursing staff allowed up to seven hours for blood administration from the time the blood left the lab refrigerator.

In response to this deficient practice, the hospital developed and implemented a policy that required nursing staff to follow all the steps necessary for safe blood administration, including a requirement that blood products were never infused over a period greater than four hours. The policy also required complete documentation of blood administration start and stop times.

The laboratory staff implemented a process to monitor blood administration start and stop times.

On 09/04/13, the laboratory staff were asked to provide documentation related to monitoring blood administration. The staff provided records (lab slips) of blood administration for April through August 2013. The lab slips required the nursing staff to document blood administration start and stop times.

The laboratory staff identified on-going problems related to incomplete blood product administration documentation. The issues were identified every month from April through August 2013.

A review of the records indicated the nursing staff failed to document start and stop times, amount of blood administered and failed to sign the blood product lab slip. According to the documentation, it could not be verified that blood products were infused within the appropriate time frame.

The DON was asked if the nursing staff had been trained on the blood administration policy. She stated they had. She was asked to provide documentation of the training. None was provided.

The DON stated she was not aware the nurses failed to document all the required elements of blood product administration.

Based on observation, document review and staff interview, it was determined the hospital failed to:

a. develop and implement policies and procedures based on national guidelines that reflected current practices within the hospital;

b. provide a therapeutic diet menu;

c. include the food and nutrition program in the QAPI and infection control programs;

d. have a qualified and certified dietary manager. See Tag A-0620;

e. ensure the registered/licensed dietitian adequately supervised the nutritional aspects of patient care. See Tag A-0621; and

f. failed to provide menus to meet the special needs of the patients. See Tag A-0628.

Findings:

On 09/03/13, the dietary department policies and procedures were reviewed. The policies had documentation of review and approval by the dietitian. The policies did not have documentation they were based on national guidelines.

The policies were outdated and did not reflect current practices at the hospital. For example, the nutritional screening form used by the dietary manager and the nutritional assessment form used by the dietitian were not the forms found in the dietary policies and procedures.

On 09/04/13, a survey was conducted of the kitchen. The staff were asked if the hospital had an approved menu that was followed each week. They stated they did not. They stated the kitchen provided meals according to what food they had on hand. The cook stated the patients did not always get the same food that was served to the staff.

When she was asked to explain, she stated, "For example, diabetic patients might not get fried foods because diabetics shouldn't eat fried foods."

On 09/05/13, the dietary staff provided a printed weekly menu. The menu did not reflect what was served in the kitchen during the survey. The printed menu was for a regular diet only. The kitchen staff did not provide an altered or modified diet menu.

At the time of the survey, there were patients present in the hospital who had orders for liquid diets and pureed diets.

During the course of the survey, the QAPI meeting minutes and the infection control committee meeting minutes were reviewed. There was no documentation food and nutrition services was included for review in these areas.

Based on observation, interviews with staff and review of hospital documentation, the hospital failed to maintain a current, active and on-going infection control program and failed to provide a sanitary environment to minimize infections and communicable diseases in patients and staff.

Findings:

1. The hospital's infection control program was no longer current and did not have updated policies and procedures that conformed to current national standards of practice.

2. The disinfectants used throughout the hospital had not been reviewed and approved by the hospital's infection control and quality programs. See Tag A-749.

3. The hospital infection control program did not review departmental infection control practices, did not monitor employee infections/communicable diseases, did not analyze infection control data, did not develop action plans in response to findings and did not follow-up to ensure corrective actions were appropriate, adequate and sustained. (Refer to Tag A-749).

4. The hospital did not ensure the infection control program had a mechanism to track patient and staff infections and possible transmissions of communicable diseases between patients and staff.

5. Leadership did not ensure infection control concerns and issues were reviewed, analyzed and corrective actions were taken through the quality assessment and performance improvement process. (Refer to Tag A-756).

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to develop and implement a discharge planning process.

The hospital failed to meet any of the standards under the Condition of Participation for Discharge Planning.

1. The hospital had a single policy and procedure for discharge planning. It documented a description and/or a definition of discharge planning. The policy did not provide guidance to staff on how discharge planning should be implemented.

2. Open and closed clinical records had no documentation of discharge planning activities or of a discharge plan.

3. Patient #19, a non- English speaking male, was provided with discharge instructions written in English. There was no documentation the instructions were translated for the patient. There was no documentation the nursing staff verified the patient understood the discharge instructions.

4. Patient #16 was discharged to a nursing home. There was no discharge note written by the RN. There was no documentation of any information for continuation of care provided to the nursing home.

5. Interviews with nursing staff indicated they were required to contact and make arrangements with other healthcare entities for discharge planning. They stated there was no education and training for the staff on discharge planning. They stated there was no identified process for discharge planning and they were not aware of documentation requirement for discharge planning plans and actions taken by staff.

6. The DON and the administrator stated hospital re-admissions were not reviewed through the quality assessment process.

Based on clinical record review, policy and procedure review, personnel record review and staff interview, it was determined the hospital failed to ensure emergency care was provided to patients in accordance with acceptable standards of practice.

Findings:

a. The hospital failed to ensure the emergency department policies and procedures were approved by medical staff. See A Tag 1104.

b. The hospital failed to ensure the emergency department had been supervised by a qualified member of the medical staff. See A Tag 1111.

c. The hospital failed to ensure staff working in the emergency department had demonstrated skills competencies. See A Tag 1112.

Based on observation, record review and staff interview, it was determined the hospital failed to:

comply with skilled nursing facility requirements. See Tag A-1505;

notify patients of all rights related to swing bed status. See Tag A- 1508;

inform swing bed patients of items and services that may or may not be charged to the patient. See Tag A-1510;

notify swing bed patients of rights related to performing work for the facility. See Tag A-1515;

ensure swing bed patients had access to visitors. See Tag A-1517;

inform swing bed patients of their rights related to personal possessions. See Tag A-1518;

notify swing bed patients of rights related to married couples. SeeTag A-1519;

develop and implement a comprehensive policy that correctly reflected swing bed patient rights related to transfer and discharge. See Tag A-1522;

implement a policy to assess a patient's needs prior to transfer or discharge to determine if a new care plan would allow the hospital to meet the patient's needs. See Tag A-1523;

inform swing bed patients, families and/or legal representative in writing of the reason for transfer or discharge. See Tag A-1525;

develop policy and procedures to meet the requirements for the discharge and transfer of swing bed patients. See Tags A-1526, A-1527 and A-1528;

prevent the employment of individuals convicted of abusing, neglecting or mistreating individuals in a health care related setting. See Tag A-1534;

provide an activities program for swing bed patients. See Tag A-1537;

provide medically-related social services to swing bed patients. See Tag 1538;

ensure swing bed patients had adequate discharge summaries that included sufficient information pertinent to continuing care and failed to ensure a discharge plan of care was developed with the participation of the patient and the family. See Tag A-1541;

meet the dental needs of swing bed patients. See Tags A-1548, A-1549, A-1550, A-1551 and A-1552.

Based on review of Medical Staff Bylaws, Medical Staff Committee Meeting Minutes, Governing Body Meeting Minutes, and interviews with staff the governing body failed to ensure the Medical Staff functioned in accordance with Medical Staff Bylaws, Medical Staff rules and regulations and Governing Body Bylaws.

FIndings:

1. Medical Staff Bylaws do not include a way for advance practice registered nurses (APRN) to be credentialed as Medical Staff members. The Allied Health Category included provisions for a physician assistant (PA) only. According to administration and emergency room schedules two APRN's (Staff A and CC )are employed and provide care to patients at the facility. The Hospital Medical Staff Bylaws do not include a provision for APRN.
2. Medical Staff Bylaws stipulate care provided must be solely under the direction or supervision of a MD appointee. The bylaws also stipulate a PA is the only clinician other than a physician delegated to perform a history and physical. The majority of medical records reviewed include documentation Staff A and Staff CC performed history and physicals. Physician authentication occurred after the patient discharged, weeks after discharge or not at all.
3. Multiple committees are listed as part of the Medical Staff Bylaws. Joint Conference Committee, Quality Assurance Meeting, Utilization Review Subcommitteee, Infection Control Committee, Pharmacy and Therapeutics Committee, Safety Subcommittee. The bylaws stipulate the responsibilities of each committee and physician involvement of the committee. According to the bylaws these committees could report as a "committee of the whole". According to minutes reviewed of 2013, many of the committees established in the bylaws along with reporting requirements did not report. For instance, there was no Mortality and Morbidity, Physician practice Pattern Monitor Outcome, Pharmacy and Therapeutics, Discharge Planning, Utilization Review, Emergency Room, and Joint Conference Committee as stipulated in the bylaws. There was no review of physician care or allied health care documented in any meeting minutes.
3. The Governing Body failed to oversee and ensure Medical Staff functions occurred according to the approved bylaws and regulation.

Based on review of Medical Staff Bylaws, Credentialing materials, Medical Staff Meeting Minutes and Governing Body meeting Minutes the Governing Body failed to ensure members of the medical staff are credentialed according to current Medical Staff bylaws.

1. Medical Staff Bylaws included a category for Allied Health. The only practitioner stipulated in the category was a Physician Assistant (PA). The Allied Health Category did not stipulate Advance Practice Nurses could be admitted to this category. There were no categories of Medical Staff whereby an APRN could be admitted to the Medical Staff. The Medical Staff roster includes two nurse practitioners (Staff A and Staff CC). According to staffing schedules and interviews Staff A and Staff CC work in the Emergency Room and on the patient care unit routinely providing care.
2. Review of Staff A and Staff CC ' s files stipulate they are members of the Medical Staff.
3. Medical Staff Bylaws include a category for Allied Health. The only practitioner stipulated in the category was a Physician Assistant (PA). The bylaw category included stipulations regarding PA with an A . This category of PA does not exist in Oklahoma Medical Board licensing. According to the administration, the facility does not utilize PA ' s currently.
4. There is no documentation the Governing Body reviews an approves practitioners credentialing in accordance with Medical Staff Bylaws.

Based on Governing Body Meeting Minutes, Medical Staff Meeting Minutes, Quality Meeting Minutes and interviews the Governing Body failed to ensure the Medical Staff provided care in a safe and effective manner.

Findings:

1. 2012-2013 Governing Body Meeting minutes did not include documentation that medical staff quality of care was reviewed to ensure quality and effectiveness of care.
2. 2012-2013 Governing Body Meeting Minutes did not include any peer review, quality of care review. Medical Staff re-credentialing did not include any type of peer review, morbidity mortality review, utilization of services, medical record delinquency. There was no documentation the Governing Body was aware of quality of care delivered by the Medical Staff.
3. There was no documentation incidents, grievances, medication errors, and complaints were reviewed by Governing Body. There was no documentation the Governing Body acted on incidents, grievances, medication errors, and complaints to improve patient safety.

4. Review of Medical Records Committee statistics stipulated multiple practitioners consistently delinquent on completion of medical records throughout 2012 and 2013. There was no documentation this information was reviewed and discussed by Governing Body. There was no documentation the Governing Body reviewed credentialing information that included peer review, medical staff incidents, medical staff utilization of services when determining credentialing of Medical Staff.

Based on review of Medical Staff Meeting Minutes, Governing Body Meeting Minutes, credentialing files, and Medical Staff Bylaws the Governing Body failed to ensure Medical Staff bylaws included appropriate criteria for each category of the medical staff and the credentialing process was followed according to Medical Staff Bylaws.

Findings:

1. Medical Staff Bylaws do not include a category of staff which includes advanced practice nurses (APRN). There is no written criteria to grant APRN's credentials and privileges. Two APRN's have credentialing files with privileges approved to work in the facility. Privileging documents for the APRN's do not include all of the duties and responsibilities included in their contracts.

2. Physician Y was appointed to the Medical Staff several years ago. Upon review of Physician Y's credentialing file no documentation was found which included review of the quality of care, utilization of resources, medical records review, or peer review. Medical Records statistics stipulated multiple records incomplete and delinquent over several years. Staff Y's orders were not complete in current charts and were not legible. There was no documentation the Governing Body reviewed committee findings or criteria established in the bylaws (such as medical records delinquencies, legibility) in determining continued credentialing and privileging.

3. Six of six physician files (Staff W, X, Y, Z, AA, BB) reviewed did not contain documentation quality of care, competence, continued training were utilized as part of the credentialing process.

.

Based on review of credentialing files and medical staff bylaws the Governing Body failed to ensure Medical Staff Bylaws and Credentialing included a categories, criteria, and process for advanced practice nurses to be admitted to the Medical Staff.

Findings:

1. Medical Staff bylaws did not include advanced practice nurse in any category of the medical staff including Allied Health.
2. The bylaws do not stipulate how APRNs are to function and be supervised in the facility.
3. There are no specific privileges reviewed and approved through Medical Staff and Governing Body. The privileges in the APRN's files is the same as the physician and is not established in the Medical Staff Bylaws as appropriate for the category of practitioner.
4. The Governing Body failed to ensure all practitioners are appropriately credentialed and privileged.

Based on review of medical records, medical staff bylaws, and interviews with staff, the Governing Body failed to ensure a medical doctor was on call and available at all times to come to the hospital to provide needed care.

Findings:

1. The clinical record for patient #2 documented the patient arrived to the ED " ...blue from physician ' s office. " The patient went into cardiac arrest shortly after arrival to the ED. The clinical record documented the physician arrived to the ED 45 minutes after notification that the patient had arrived in the ED.

2. On the morning of 09/03/13, Staff N told surveyors that there were no physicians or licensed independent practitioners physically present at all times in the ED or nearby within the hospital. Staff N stated there were no policies or procedures that indicated a physician or licensed independent practitioner had to be present in the ED or how soon they had to arrive after notification by the nursing staff.

3. On the afternoon of 09/04/13, Staff O and Staff P stated, " There are no physicians or mid-level practitioners staffed in the ED but one could be available within an hour. "

4. There is no documentation the Governing Body developed, implemented and enforced Medical Staff policies which stipulate how the Emergency room coverage for physicians would occur.

Based on record review and staff interview, it was determined the hospital failed to ensure the QA/PI program included all programs and services, including contract services. Findings:


1. On the morning of September 3, 2013 surveyors requested a list of contracted services with the information on the services each contractor provided. Later in the day the facility provided a list of contractors. The list did not include the services each contractor provided. The list did not include all services provided under contract or agreement. Several patient care services were missing from the contract list including physical therapy, pharmacy, and dietary.

2. There was no dcoumentation all contracted services were addressed through QA/PI.

3. There was no documentation the contractors licenses, education, orientation and training were reviewed by the facility. Physical therapy, Clinical Dietetics, and Pharmacy provided by contractors did not have current licenses, orientation to the facility, review of competency or any quality review.

Based on staff interview and record review, it was determined the hospital failed to ensure all contracted services were evaluated for quality assurance and performance improvement to ensure services were provided in a safe and effective manner. Findings:

1. Quality assurance and performance improvement (QAPI) records for 2012 and 2013 did not include documentation that all contracted service providers were included in the QAPI program.

2. None of the clinical contractors had current licensing, evaluation of competency, or training.

3. On 9/5/13, administration confirmed contracted services were not evaluated by the QAPI process.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital maintains a list of all contracted services. The list of contracted services provided for review did not have all the services which are provided by contract listed. The list did not contain the scope and nature of the services provided.

Based on document review and staff interview, it was determined the hospital failed to inform patients and/or their representatives of all required patient's rights. Findings:

On 09/03/13, the hospital administrative staff were asked to provide patient rights information given to patients and/or their representative at the time of admission.

The staff provided a patient's bill of rights given to inpatients that did not include all patients rights as determined by federal regulation.

The staff stated outpatients did not receive the patient bill of rights information.

Hospital records and clinical documentation indicated the hospital treated non-English speaking people on a regular basis. The hospital did not provide patient rights written in any other language.

Based on document review and staff interview, it was determined the hospital failed to develop and implement a grievance process according to CMS requirements. Findings:

On 09/03/13, the hospital administrative staff were asked to provide all patient's rights information given to patients at the time of admission. The staff provided a patient's bill of rights document that did not inform patients or others of the complaint/grievance process.

On 09/04/13, the hospital's grievance policy was reviewed. The policy was not dated and did not show evidence it had been approved by any entity. The policy did not distinguish between a complaint and a grievance. The policy did not indicate who could lodge a complaint or grievance.

The policy directed staff on how to respond to grievances but the hospital did not follow it's policy to respond to the complainant in writing.

The policy did not include information that informed the complainant of the right to seek review by the QIO.

The hospital administrative staff were asked to provide a list of complaints and grievances for 2012 and 2013. The administrator stated the hospital only had documentation of grievances and did not record complaints.

Based on document review and staff interview, it was determined the hospital failed to establish a grievance process approved by the governing body. Findings:

On 09/03/13, the CEO was asked to provide governing body meeting minutes for the past year. Over the course of the survey, the governing body meeting minutes were reviewed.

There was no documentation in the meeting minutes that indicated the governing body reviewed and approved the hospital's grievance process.

The hospital's grievance policy was not signed or dated as approved by any entity.

At the conclusion of the survey, the CEO stated there may have been governing body meeting minutes that were in her office and not reviewed by the surveyors.

Based on document review and staff interview, it was determined the hospital failed to provide patients and/or their representatives with information about how to submit a grievance. Findings:

On 09/03/13, the hospital administrative staff were asked to provide patient rights information given to patients and/or their representative at the time of admission.

Inpatients received a patient's bill of rights document that had no information about how to submit a complaint or grievance.

Outpatients did not receive any complaint or grievance information.

The CEO stated no other information was provided to patients.

Based on document review and staff interview, it was determined the hospital failed to notify patients of the established time frames for response to grievances. Findings:

On 09/03/13, the CEO was asked if patients were informed of the hospital's time frame for responding to grievances. She said they were not.

Based on document review and staff interview, it was determined the hospital failed to respond to all grievances in writing. Findings:

On 09/03/13, the hospital CEO was asked to provide documentation of all complaints and grievances for the previous six months. Documentation of two grievances was provided.

One grievance involved an allegation that a patient's privacy regarding protected health information had been violated. The other grievance involved an allegation of mistreatment by a nurse.

There was no documentation the complainants were provided a written response by the hospital.

On 09/05/13, the CEO confirmed that grievances were not always responded to in writing.

Based on review of Quality Meeting Minutes 2012-2013, Governing Body Meeting Minutes 2012-2013, Medical Staff meeting minutes 2012-2013 the hospital failed to develop processes to review hospital incidents, medication errors, grievances and complaints for the use in improving patient care.

The hospital also failed to ensure patients were cared for in a safe environment.

Findings:

1. Medical Staff Meeting minutes did not contain evidence practitioners care was reviewed through quality or peer review.

2. Quality Meeting Minutes did not contain documentation all incidents, grievances, complaints and medication errors were reviewed and analyzed by appropriate personnel to improve patient care and safety.

3. Governing Body Meeting Minutes did not include documentation that patient care issues, incidents, and errors were reviewed, analyzed and acted on by Governance to improve patient safety.

4. Throughout the survey, department of corrections inmates were observed working in the housekeeping office. The housekeeping office was located immediately adjacent to the patient rooms identified for pediatric patients. The inmates were observed in the hallways in the patient care areas. The inmates were observed outside the hospital performing jobs they were assigned.

None of the inmates had direct supervision by a corrections officer or other qualified person.

During the exit conference, the leadership staff were asked if they had knowledge of the inmates' convictions. They stated they did not know the specifics but said they were told the inmates were "non-violent offenders."

The staff acknowledged the presence of inmates within the hospital posed a security risk to patients, especially pediatric patients.

5. The administrative staff were asked if the State Nurse Aide Registry was checked for every potential employee who may have patient contact. They stated only certified nurse's aides were checked through the Nurse Aide Registry.

Based on document review and staff interview, it was determined the hospital failed to develop and implement an effective system to protect patients from abuse, neglect and harassment. Findings:

1. The hospital's policies did not address how the hospital would prevent abuse, neglect and harassment. The policies did not address how potential employees would be screened for a record of abuse and/or neglect.

2. The hospital had no documentation employees had on-going training related to the patient abuse, neglect and harassment prevention program.

3. A hospital policy, titled "Patient Abuse By Employee," documented, "...Within 24 hours of CEO receiving the allegation of patient abuse, the CEO will determine whether the allegation, if true, would constitute patient abuse. If so, then the CEO will request an investigation into the abuse. The findings of the investigation are then submitted to the CEO for final determination of abuse..."

The policy did not document a written procedure for investigating allegations of abuse. The policy did not clarify how the hospital substantiated allegations of abuse.

4. Two patient grievances were reviewed. One grievance alleged a child was bullied at school because a hospital employee disclosed to the child's classmate embarrassing details about the child's medical symptoms while in the hospital.

The other grievance alleged a nurse treated a patient in a demeaning and ridiculing manner.

Neither of these events had documentation to show sufficient investigation into the allegations. There was no documentation to show how patients were protected during the investigation.

There was no documentation of the hospital's analysis of the information discovered during the investigation, the conclusions made, and any further actions taken to respond to the allegations.

The CEO stated the hospital had not done adequate documentation of the investigation into the allegations of abuse.

Based on review of policies and procedures, interviews with staff, signage displayed in the hospital the facility failed to ensure patient visitation rights.
Findings:
1. On 9/3/13 surveyors observed signs displayed on the entrance to the hospital and the emergency room indicating visitors would not be allowed in the facility during severe weather outbreaks and that staff would "do the best they could to ensure the patients were cared for". There was no policy reviewed and approved through Governing Body stipulating patient ' s visitation hours. There was no policy and procedure reviewed and approved through Governing Body that included the signage located on both entrance doors.
2. On 9/3/13 surveyors reviewed patient rights signage and patient rights information provided at admission. There was no notification regarding patient visitation limits.

Based on review of Quality Meeting Minutes 2012-2013, Governing Body Meeting Minutes 2012-13 the facility failed to develop a quality program that reviewed and analyzed all patient care processes with evidence of performance improvement.

Findings:
1. The Quality Meeting Minutes 2013 did not indicate priorities to improve patient care and safety had been developed and implemented. Meeting minutes documented collection of data. The reporting methods and what each indicator meant was not included.

2. There was no documentation a comprehensive quality improvement plan had been developed and implemented based on patient care issues. Meeting Minutes and policies did not include documentation that data was analyzed and reviewed to formulate improvement in the patient care environment

Based on review of meeting minutes, interviews with staff and review of policy the facility failed to implement a quality improvement program which had set priorities focused on patient care activities that are high risk, problem prone and affect patient safety.

1. Quality Assurance Performance Improvement Plans and Meeting Minutes for 2013 did not include review of all incidents, medication errors, and grievances/complaints. Governing Body Meeting Minutes 2013 did not include review and analysis of all incidents, medication errors, grievances and complaints.
2. The hospital did not include comprehensive plan to improve the quality of care and reduce risks associated with healthcare. The hospital did not have a current Quality Improvement Plan.

3. Quality Meeting minutes did not include reporting by multiple clinical areas/services.

Based on review of meeting minutes, interviews with staff, and review of policy the facility faile to implement a quality improvement program which had set priorites focused on patient care activity thereby improving patient safety.. There was no documentation incidents, errors and patient care problems were reviewed by any committees with analysis and recommendation for improvement.

Based on review of meeting minutes, policies and procedures, personnel files, and interviews with staff the facility failed to have a comprehensive QAPI program which implemented processes to improve care. There was no documentation the program data is utilized to change processes, staffing, training, or equipment/facility. There was no documentation QI projects had been conducted

Based on review of hospital documents, Governing Body Meeting Minutes, QAPI meeting minutes and interviews with staff the Governing Body failed to implement and oversee quality improvement projects. There was no documentation QI projects had been conducted.

Based on review of Governing Body Meeting Minutes, QAPI meeting minutes the governing body failed to develop, implement and maintain a Quality Assurance Performance Improvement plan which encompassed all required elements. There was no quality plan developed reviewed and approved through governing body. Data reviewed in Quality meeting minutes did not have analysis or documentation the data was used to develop a comprehensive plan to improve patient safety. Governing Body meeting minutes did not reflect priorities for improvement had been identified through analysis of data. There was no documentation the Governing Body evaluated data gathered from clinical areas and developed strategic plans which are measurable to improve care. There was no documentation the Governing Body allocated funds for Quality and Performance Improvement activities.

Based on review of Medical Staff meeting minutes, Governing Body Meeting Minutes, and credentialing files the Governing Body failed to evaluate the performance of practitioners during the credentialing and recredentialing process to determine if credentialing status and privileges are appropriate.

Findings:

1. Medical Staff Bylaws and credentialing do not include licensed independent practitioners currently working in the facility. Two advanced practice nurses are providing care in the emergency room and patient care units. Medical record documentation stipulates the practitioners obtain history and physicals, write admitting orders, provide emergency room care among many clinical activities. There is no category established with criteria specific to the role of the advanced practice nurses.

2. Six of six physician files reviewed did not have documentation of continuing education, review of care, and peer review.

3. Medical Staff bylaws were not current with specific clinician titles. Medical Staff bylaws indicated "physician assistants in the A category" could provide care. Oklahoma Board of Medical Licensure does not have an A category for PA practitioners.

4. Many of the committees and their functions listed in the Medical Staff bylaws are not documented in any meeting minutes on any hospital committees.

5. There is no specific criteria developed, reviewed, and approved through Medical Staff or Governing Body which sets criteria for re-credentialing.

Based on review of Medical Staff bylaws, credentialing and privileging files, and Meeting Minutes the facility failed to develop and implement a process for Medical Staff credentialing which considered physician performance and hospital stipulated criteria when credentialing.
1. Medical Staff Meeting Minutes 2012 -2013 did not include any information regarding peer review, utilization of resources, and any Medical Staff performance measures.
2. Review of Medical Staff Bylaws does not include requirements for assessment of practitioners ' performance as part of credentialing and re-credentialing
3. Several Medical Staff Members credentialing and privileging files did not include any performance based reviews.

Based on review of Medical Staff bylaws, Medical Staff meeting minutes, Governing Body meeting minutes, and credentialing files the hospital failed to adopt and enforce Medical Staff bylaws that reflect current requirements of state and federal regulation.

1. The Medical Staff bylaws included many elements which were no longer relevant to medical staff practice. Several committees listed in the bylaws did not function and could not be found in documentation. For example, "Medical Staff Bylaw 7.8 Joint Conference Function....is made up of two representatives of the Medical Staff and two representatives of the Governing Board. These representatives are to be appointed by the Chairman of the Governing Body. 7.8.2 Duties ....responsible for Disaster Planning"; 7.10.-4 Pharmacy and Therapeutics Committee; 7.9 Quality Assurance function, 7.9.1 The QA functions of the MEC will be performed on initial review by the following standing subcommittees which will retain minutes and meet regularly: A. Blood Utilization Review; B. Utilization Review; C. Infection Control; D. Emergency Room; E. Pharmacy and Therapeutics; F. Safety. There was no documentation the Medical Staff participated or convened meetings as required by the Medical Staff Bylaws.
2. The Categories of medical staff did not include advanced nurse practitioners. The facility had credentialed and privileged two nurse practitioners. The practitioners did not have a category listed in the bylaws which allowed them to function in the facility.
3. The Medical staff bylaws did not address current electronic health record and completion of medical records.
4. Quality Meeting minutes indicated several practitioners had been delinquent in completion of records. Although the bylaws called for practitioners to be penalized for delinquencies, no enforcement actions were taken.
5. The Medical Staff bylaws did not address physician or mid-level practitioner responsibilities in coordination of patient care, supervision, and oversight.

Based on review of the Medical Staff bylaws the hospital failed to include the duties and privileges of all clinicians practicing in the facility. Two advanced practice nurses are currently providing care in the emergency room and on the acute care unit. There is no statement of duties and privileges stipulated in the bylaws.

Based on review of the Medical Staff bylaws the facility failed to stipulate criteria to be used to assess practitioners ' qualification when requesting privileges. There was no criteria developed and documented to utilize when advanced practice nurses requested credentialing to the medical staff.

Based on observation and staff interview, it was determined the hospital failed to ensure a registered nurse was assigned solely to the emergency department 24 hours a day, seven days a week.

Hospital staff indicated a registered nurse was shared between the inpatient unit and the emergency department. This nurse had patient care assignments on the inpatient unit.

The hospital did not ensure a registered nurse was physically present and available at all times in the emergency department.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure medication and treatment orders were accurately transcribed, appropriately documented and administered as ordered by the physician.

Findings:

1. On 09/03/13 and 09/04/13, open and closed medical records were reviewed for medication orders.

2. The medical record for patient #17 documented a physician's order that stated, "... cont. [continue] home meds..." Staff O stated this order would be faxed to the nursing home when the patient was discharged.

He was asked if a medication reconciliation form was used. He stated," Not every time."

A review of the patient's medical record indicated the patient's admission medications had been changed and/or discontinued during the patient's hospitalization. The hospital staff did not provide the nursing home with a current, accurate list of medications to be continued at the nursing home.

3. The clinical record for patient #19 documented a physician's order for three liters of normal saline to be given as a bolus. The nursing staff documented they administered two liters. There was no documentation as to why two liters was given rather than three as ordered by the physician.

A verbal order was written for the patient to receive oxygen, but the order did not include a rate or a method of delivery.

4. A medication reconciliation form documented four errors in transcription for patient #16. Two medications the patient received in the nursing home (Lumigan and Timoptic) were not transcribed with the medication strength to be given. Systane eye drops to be used as needed were completely omitted from the medication list. The patient had been getting Colace 100 mg by mouth twice a day in the nursing home. The hospital staff transcribed the Colace to be given one time daily.

Two other telephone orders for Claritin and Demerol were documented on the physician's orders but were not transcribed to medication administration record. There was no documentation these medications were given.

There were physician's orders for an IV with fluids to be administered and the placement of a foley catheter. There was no documentation in the clinical record that these things were done.

5. Documentation in patient #12's chart indicated the patient was on an insulin drip. There was no documentation the pharmacist compounded the drip. There was documentation what type of fluid and amount was used to mix the insulin drip.

Based on policy and procedure review, medical record review and staff interview, it was determined the hospital failed to ensure verbal orders are used infrequently for 22 of ????22 medical records reviewed for verbal orders.

Findings:

On 09/04/13, ten emergency department (ED) medical records and twelve closed inpatient medical records were reviewed. All the records had documentation of frequent use of verbal orders. There was no documentation the nurses conducted a read-back verification for the verbal orders.

The hospital did not have a policy that addressed verbal orders.

On the morning of 09/05/13, surveyors asked nursing staff how often verbal orders were used. Staff N stated, "We use verbal orders all the time because there are no physicians or mid-level practitioners in the facility."

The DON stated verbal orders were the primary method physician's orders were obtained.

Based on review of nursing policies and procedures, hospital documents, nursing personnel files and staff interviews, the hospital failed to ensure policies and procedures for intravenous (IV) medications and blood transfusions were developed and approved by the medical staff and that nursing staff were trained and had demonstrated skills competencies for these procedures.

Findings:

On 09/03/13, hospital leadership were asked to provide departmental policies and procedures. The nursing department and the emergency department (ED) policy and procedure manuals did not contain policies for IV medication administration and blood administration.

The director of nursing (DON) was asked to provide these policies. None was provided.

On 09/03/13 and 09/04/13 surveyors asked nursing staff where to find hospital policy and procedure manuals. Staff N stated, "I don't know." Staff O stated, "I have never seen a manual for policy and procedures." Staff P stated, "I didn't even know there were manuals."

On the afternoon of 09/04/13, surveyors asked the DON for documentation of all nursing training and evaluation of skills competencies.

The DON stated, "We don't do that here. They (the nursing staff) should have been trained when they were in their nursing programs and when they took their boards."

Surveyors asked nursing staff what training they received to administer IV medications and blood transfusions. Staff N stated there was no training or proficiencies for any skills.

Review of nursing personnel files had no documentation nursing staff had been trained and had demonstrated skills competencies to administer blood and IV medications.

Nursing staff were observed using a 250 cc bag of normal saline to reconstitute several different patient medications. The same bag was observed all three days of the survey. The staff stated they were not aware an IV bag could not be repeatedly punctured.

Nursing staff was observed preparing a 1000 cc bag of IV fluid. The nurse added Rocephin to the bag. She was asked why she added the Rocephin to the 1000 cc bag and did not use a smaller piggy back administration system. She stated, "This is how we do it here."

Based on clinical record review and staff interview, it was determined the hospital failed to ensure patient records included sufficient documentation to support admission and hospitalization.

Findings:

1. The clinical record for patient #19 admitted to the emergency room and then to an inpatient bed had the following documentation deficiencies:

~No documentation by the physician for the time the patient was in the ER.
~No documentation by nursing that the physician saw the patient before admission to inpatient status.
~The patient was admitted for dehydration but there was no documentation of a nursing assessment of the patient's skin, neuro status, respiratory system (although the patient was given oxygen), cardiovascular status, urine output, intake of fluids and mental status for the entire stay.
~Nurses' notes were written but were not timed.
~There was no documentation of discharge plans.

2. The clinical record for patient #16 had the following documentation deficiencies:

~No RN signature, time or date on an ER assessment.
~Oxygen was ordered to be given in the ER but there was no documentation as to when this was done.
~A breathing treatment was administered but there was no documentation as to who provided it.
~Daily weights were ordered but were not documented in the record.

3. The clinical record for patient #11 had the following documentation deficiencies:
~The patient was transferred to another hospital for a higher level of care. There was no discharge assessment of the patient. The documentation only stipulated the date and time.
~Medication reconciliation documentation did not stipulate what happened to the patient's medication brought from the nursing home.
~The history and physical did not include a physician signature.
~Emergency room documentation did not include a clinical impression or treatment, no physician orders although the ER nurse documented "IV D51/2 NS in RFA at 1455"

4. The clinical record for patient #12 had the following documentation deficiencies:
~physician orders were not complete and not noted. For example:
"access mediport, 1L NS, R MT 1L NS" There was no policy that included these abbreviations.
~physician orders were not noted.

5. The clinical record for patient #26 had the following documentation deficiencies:

~physician orders did not include amounts to be infused, amounts for antibiotics to be mixed in for example: "Vanc 1500 mg Q 12 IVPB, Protonix IVPB, Azythromycin IVPB"

~Respiratory treatments were incomplete for example: "Albuterol Neb 0.5/3ml"

6. The clinical record for patient #13 had the following documentation deficiencies:

~Emergency room sheet did not include all Physician documentation.
~Medication orders were not complete. For example: "start SL"
~Physician orders were not signed.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the nursing staff signed, dated and timed physician's orders when they were received for 25 of 25 records reviewed for physician's orders.

All 25 records had documentation of physician's orders (both verbal and written by the physician) that were not signed, dated and timed when received by the nursing staff.

The DON stated charts were not reviewed for this.

Based on review of medical records the facility failed to ensure patient's records were complete and contained information to monitor the patient's condition.

Findings:

1. Physician orders for medication were not complete. They did not contain information such as amount of fluid to be used, rate of infusion, route of medication. This occurred in 5 of 5 patient records (11, 12, 13, 14, 26)

2. Physician orders did not contain physician signatures. This occurred in 5 of 5 patients records (11,12, 13, 14, 26)

3. Four of four emergency room records did not have the entire emergency room record completed. (11, 12, 13, 14)

4. One patient (Pt #11) transferred did not have documentation of assessment and physiologic status documented at discharge.

5. Five of five (11,12, 13,14, 26) patient history and physicals dictated by advanced practice nurses did not have physician authentication.

Based on record review, observation and interviews with hospital staff, the hospital does not ensure that the provision of pharmaceutical services is provided and implemented according to current policies and procedures that have been approved by the pharmacy director with appropriate input from staff and committees and in a safe manner. Pharmacy policies and procedures presented for review were not reflective of current hospital processes. Pharmacy staff, consisting of a Consultant Pharmacist who had been on the job only a few weeks and the the Drug Room Supervisor a LPN (licensed practical nurse) and currently providing pharmaceutical services in the hospital have not been trained and competency assessed for providing pharmaceutical services in the drug room within the scope of their license and in accordance with all Federal and State laws, regulations and guidelines.

Findings:

1. The Consultant Pharmacist was not available during the survey. Administration told surveyors the consultant pharmacist was newly hired. Review of personnel records indicated there had been no orientation or training on hospital and pharmacy procedures except on how to use the hospital's computer system to verify orders. There was no documentation the pharmacist or the drug room supervisor had been trained to oversee, monitor, and control drugs throughout the hospital.

2. The Drug Room Supervisor did not have evidence of training as a Drug Room Supervisor in her personnel file.

3. Drugs are stored in various areas of the hospital. In the emergency room, outdated medications, intravenous fluids with the overwrap removed, and unsecured medications were found by surveyors. Bags of hypertonic saline were stored with bags of normal saline.

4. It was standard practice for patients, families and friends to be left in the emergency room unsupervised by staff for periods of time. Medications and supplies were accessible to unauthorized personnel and vulnerable to tampering or misappropriation. Pharmacy/Drug Room policies and procedures were not implemented by the hospital describing how medications stored in satellite areas are to be accessed and by whom and how this process works.

5. Pharmacy policies and procedures did not reflect current practice at the facility. The pharmacy/drug room policies did not have evidence of review and approval by the current Consultant Pharmacist .

6. Several staff members stated that access to the drug room was given to whoever needed to get in. State hospital and pharmacy regulations require that access to the drug room is restricted to authorized personnel only.

8. There was no evidence from nursing personnel file review, meeting minutes reviewed and interviews with the Director of Nursing and administration that nursing personnel had been instructed on who was authorized to access the drug room.

Based on record review, observation and interviews with hospital staff, the hospital does not ensure the drug room and other medication storage areas are administered in accordance with accepted professional principles. All drugs are not mixed and dispensed by a licensed pharmacist or pharmacy-supervised personnel. There is no documentation repackaging of drugs is overseen by a pharmacist or reviewed to ensure accuracy during repackaging

Findings:

1. Intravenous medications are mixed by nursing personnel. There is no documentation personnel are trained and competent in intravenous admixtures.
2. Pharmacy policies and procedures have been developed but do not match the operational practices observed by the surveyors during the tour of the facility.
3. There is no oversight of medications in various areas of the hospital. The facility does not have specific formularies for the satellite locations. There is no inventory of the amount of medications in each area, and types of medications and fluids in each area.
4. Staff told surveyors on occasion there will be intravenous pain pumps (PCA) used by patients. There was no documentation the nursing staff are trained in the set up, use, and discontinuation of the pumps. There was no documentation the controlled medications used in the PCA pumps were controlled by the pharmacist and usage reviewed to determine appropriate dosing, wastage, and monitoring was in place.

5. The hospital is not a licensed hospital pharmacy with a full time pharmacist. The hospital is a licensed drug room with a consultant pharmacist.

ased on record review and staff interview, the hospital does not ensure the consultant pharmacist coordinates all the activities, supervises and evaluates the performance and competency of pharmacy personnel who provide pharmacy services when the Consultant Pharmacist is not on the premises. Two of two pharmacy/drug room personnel files reviewed did not have evidence of competency evaluations and orientation specifically for the pharmacy/drug room by the Consultant Pharmacist/Pharmacist in Charge.

Findings:

1. Staff I was designated as the Drug Room Supervisor. Review of Staff I's personnel files did not contain evidence competency evaluations and orientation by the Consultant Pharmacist, specific for the duties they performed in the drug room.

2. Staff DD was designated as the pharmacist in charge. Staff DD did not have evidence of a current pharmacist's license in the personnel files. There was no documentation of orientation and training for Staff DD.

3. Documentation in medical records stipulated orders for "insulin drip, PCA pain medication, lasix drip". There was no documentation of the pharmacist compounding the medications. There was no documentation the nursing staff had been trained to mix medications. There was no documentation the pharmacist reviewed medications administered to determine if they had been compounded correctly.

4. Review of the contracted pharmacist documentation did not include participation in committees, review of orders, review of logs, review of drug room personnel performance.


4.

Based on review of personnel records, interviews with staff, review of policies, and meeting minutes the facility failed to provide pharmaceutical services that met the needs of the patients.

Findings:

1. Review of Quality Meeting Minutes 2013, Governing Body Meeting Minutes 2013, and Medical Staff Meeting Minutes 2013 did not include any documentation the pharmacist participated. The pharmacist is a consultant.
2. In an interview on September 5, 2013 the Director of Nurses told surveyors the pharmacist did not do any type of medication error review.
3. There was no documentation the Pharmacist or the drug room supervisor had been oriented and trained to the hospital, to the specific requirements of a drug room.
4. There was no documentation the Consultant Pharmacist oversaw the procurement and dissemination of medications.

Based on review of medical records, policies and procedure, pharmacy documents, and interviews with staff, the facility failed to have a system to maintain current and accurate records of all scheduled drugs.

Findings:

1. The facility did not monitor medication administration records and narcotics check out logs to ensure all scheduled drugs are accounted for. See tag

2. The facility did not have formularies for medications kept in areas outside of the drug room. There was no documentation scheduled medications are tracked from point of entry to point of use or destruction.

3. The facility did not have an active medication error review process. The facility provided surveyors 5 medication errors for the year. Surveyors reviewed medical records and found at least one transcription or omission error per medical record. There is no active surveillance of medication administration records to determine possible diversion. There is no documentation narcotic wastage is reviewed.

Based on review of medical records, interviews with staff, training records, and policies the facility failed to provide medications safely.

Findings:

1. Review of patient records indicate several intravenous medications requiring compounding, such as: insulin drips, lasix drips, patient controlled analgesia (PCA). There was no documentation the pharmacist had mixed or overseen the compounding/mixing of these medications.

2. There was no documentation the pharmacist had developed and approved policies/processes for mixing intravenous medications with intravenous fluids.

3. There was no documentation the pharmacist had developed and approved policies and processes for administering and overseeing PCA medications.

4. The Director of Nursing told surveyors nursing staff had not had any training in the process of intravenous admixtures.
5. There was no documentation in any nursing files the staff had been assessed for competency in the process of intravenous admixture or PCA administration.

Based on review of facility documents, interviews with staff, and policies, the faciity failed to have pharmacy services supervised by a pharmacist.

Findings:

1. During a tour of the facility surveyors observed intravenous bags of fluid in varying amounts used to mix intravenous medications. There was no policy and procedure which stipulated what types and amounts of intravenous fluids should be used in admixtures. The DON was asked if there had been any specialized training for mixing intravenous medications. The DON told surveyors the nurses learned that in school and that they did not need to be taught. None of the personnel files included any competencies addressing admixtures. There was no policy and procedure developed and approved by pharmacy for non-pharmacist staff to mix intravenous medications.

? Nursing staff were observed using a 250 cc bag of normal saline to reconstitute several different patient medications. The same bag was observed all three days of the survey. The staff stated they were not aware an IV bag could not be repeatedly punctured.
? Nursing staff was observed preparing a 1000 cc bag of IV fluid. The nurse added Rocephin to the bag. She was asked why she added the Rocephin to the 1000 cc bag and did not use a smaller piggy back administration system. She stated, "This is how we do it here."


2. Review of the consultant pharmacists report did not stipulate any type of oversight of intravenous admixture.

3. These findings were confirmed at the exit conference with administration.

Based on review of policies and procedures, interveiws with staff, and tour of the facility the hospital failed to secure medications throughout the facility.

Findings:

1. On 9/3/13 surveyors observed the drug room storage door open. Two staff members were in the drug room. At that time the surveyors asked the staff members if access to the drug room was controlled. Both staff members indicated the drug room was open all the time for staff members to access medications as needed.

2. On the afternoon of 9/3/13 surveyors toured the facility. In the emergency room area medications were out on counters, in unsecured bins. Intravenous fluid was found without the outer wrap laying in bins. The rooms did not have continual surveillance. The emergency room medications were not controlled to prevent access and tampering.

3. On the morning of 9/3/13 surveyors received a formulary for the hospital. The formulary did not include any information as to where each medication was kept and in what quantity. The hospital could not track movement of medications from the drug room to the satellite areas to administration.

Based on review of policies and procedures, tour of the facility, and interviews with staff the facility failed to designate appropriate access to locked areas of drug storage.

Findings:

1. On 9/3/13 surveyors found the door to the drug room propped open.

2. There was no education and training of the nursing staff about drug room rules and usage. Staff members told surveyors they could go in and out of the drug room whenever they wanted.

3. There was no staff member designated, trained, and supervised by the pharmacist as the drug room supervisor.

4. There was no documentation the pharmacist reviewed entries into the drug room to determine compliance with drug room laws and regulations promulgated by the Oklahoma Pharmacy Board.

5. Several unlocked, unmonitored, and easily accessed areas of the hospital were found with medications and intravenous fluids out and available for tampering or diversion.

Based on review of pharmacy records and interviews with staff the facility failed to develop a formulary specific to the clinical areas served. There was no formulary provided that documented what pharmaceuticals are kept in satellite areas of the facility. There was no documentation indicating the amount of drugs and pharmaceuticals kept in satellite locations. The facility could not track and account for medications utilized throughout the facility.

Based on record review and staff interview, it was determined the hospital failed to ensure the radiology department was supervised by a qualified radiologist approved by the medical staff.

On 09/04/13, the CEO stated the hospital did not have a contract with a radiologist to oversee the radiology department. She stated the hospital contracted with an out of state group of radiologists who interpreted radiology studies only.

The hospital did not have documentation a qualified physician had been appointed to supervise the radiology department.

Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to ensure radiology personnel were designated as qualified by the medical staff to use the radiological equipment and administer procedures. Findings:

On 09/03/13, the hospital leadership staff were asked to provide radiology departmental policies and procedures. The policies did not specify what qualifications were necessary for the staff using the radiology equipment.

One policy documented the radiology staff could start IVs and administer IV contrast material. There was no documentation in the employee files that indicated the staff were evaluated for competency to perform these tasks.

Hospital leadership stated the policy was not correct because the radiology staff did not start IVs. However, the DON verified the radiology staff administered IV contrast material.

In addition, the radiology staff were assigned to perform EKGs. There were no policies and procedures to guide staff on this task. There was no documentation the radiology staff were evaluated for skills competency to perform EKGs.

Based on record review and staff interview, it was determined the hospital failed to develop and implement a system to take appropriate action when notified that blood or blood components it received may be at increased risk of transmitting HIV or HCV. Findings:

On 09/03/13, the lab policies and procedures were reviewed. There was no policy that addressed the actions needed if the hospital was notified of HIV or HCV contaminated blood or blood products.

On 09/04/13, the lab manager was asked if the hospital had a system in place to address the situation of a potentially infectious blood or blood component and the notification of patients. She stated it did not.

Based on document review and staff interview, it was determined the hospital failed to develop and implement a policy and procedure specific to appropriate testing and quarantining of infectious blood and blood components.

There was no policy and procedure for notification and counseling of recipients of the infectious blood and blood products.

On 09/04/13, the lab manager stated the hospital did not have a look-back policy for the lab.

Based on record review and staff interview, it was determined the hospital failed to employ a qualified and certified dietary manager. Findings:

According to State licensure requirements, Chapter 667 Hospital Standards, subchapter 17 (a) (3) "If the licensed/registered dietitian is employed on a part-time basis or consultant basis, a designee for clinical aspects of patient care shall be a certified dietary manager or a registered dietary technician."

The employee file for the dietary manager had no documentation of certification. There was no documentation the dietary manager was a registered dietary technician.

A review of clinical records showed the dietary manager performed nutritional screening of patients.

On 09/03/13, the CEO stated she was aware the dietary manager did not have the State required qualifications for the job.

Based on document review and staff interview, it was determined the hospital failed to ensure the registered/licensed dietitian adequately supervised the nutritional aspects of patient care.

Findings:

Throughout the course of the survey, documents were reviewed for work products produced by the consultant dietitian.

On 09/04/13, the dietary staff provided the dietitian's monthly consultation reports. The reports usually documented the same things, including kitchen sanitation and signing off on the dietary manager's "completed nutritional assessments."

In fact, the dietary manager was not qualified to do "nutritional assessments" or "nutritional screening."

The clinical records for the majority of those patients reviewed had no documentation from the dietitian, even when patients were on mechanically altered or restricted diets. When there was a nutritional assessment performed by the dietitian, there was no documentation of patient, family or caregiver counseling.

The clinical records had no documentation of ongoing nutritional assessment for those patients who required it, such as patients with weight loss, NPO status, liquid diets or other medically significant issues that affected nutritional status.

The dietary staff stated the dietitian only saw patients on the one day a month she was actually in the hospital. The staff were asked how the dietitian was consulted for patient nutritional needs at other times. The dietary staff stated they could call her.

When the nursing staff were interviewed about consulting the dietitian for patient nutritional needs, they stated there was "not really a process for that."

A swing bed policy documented, "... Each swing bed patient will have a dietary assessment upon admission..." None of the swing bed patient records reviewed had documentation of a dietary assessment.

The kitchen staff had no documentation the dietitian reviewed and approved weekly menus. There was no documentation of dietitian approved food substitutions.

There was no documentation the dietitian participated in the QAPI process. There was no documentation the dietitian consulted with the infection control nurse or that she provided documentation and surveillance associated with infection control activities in the dietary department.

There was no documentation the dietitian provided education to the dietary and nursing staff.

The dietary policies and procedures were reviewed for documentation of the dietitian's responsibilities. There was no policy to address this.

The dietitian's employee file had no documentation of a job description.

Based on observation, document review and staff interview, it was determined the hospital failed to develop, maintain and test it's emergency preparedness plans and failed to ensure the condition of the hospital was maintained in a safe manner for the well-being of patients.

Findings:

1. The hospital's Disaster Preparedness Plan was last reviewed and approved on 03/26/99. There was no documentation the disaster plan was developed in coordination with local and state authorities.

2. A form within the plan, titled, "Disaster Plan Assignments List," had documentation of staff who were no longer employed. Many phone numbers listed for current staff were no longer valid.

3. The hospital had no documentation of disaster drills.

4. The hospital had documentation of only one fire drill in 2012 and one drill in 2013.

At the time of the exit conference, the administrative staff stated the Disaster Plan was no longer current.

5. The ceiling in many areas of the hospital, including patient care rooms, is covered with asbestos insulation. The asbestos had previously been encapsulated, but in many locations throughout the facility, asbestos was observed to have been disturbed and exposed to the atmosphere. In some areas, larger sections of asbestos have begun separating from the concrete and are at risk of falling.

6. On 09/04/13, an unsecured oxygen tank was observed lying on it's side on a shelf in the large emergency room anteroom.

7. In the small emergency room, several pieces of medical equipment were plugged into a household power strip.

8. See also the Life Safety survey conducted on 09/04/13.

Based on plan review and staff interview, it was determined the hospital failed to ensure adequate supplies of water were available in the event of an emergency. Findings:

On 09/03/13, the hospital's emergency preparedness plans were reviewed. One part of the plan documented the hospital kept "5 gallons of water on hand for emergencies."

There was no documentation the hospital actually calculated it's minimum water needs in the event of an emergency. The hospital's plan did not determine how emergency stores of water would be used.

There was no documentation of coordination and agreement with an outside source for replenishment of emergency water supplies.

At the time of the exit conference, the administrative staff acknowledged the hospital's emergency preparedness plans were not current.

Based on observation, review of infection control data, surveillance activities, personnel files, meeting minutes, hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and maintained an ongoing comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff.

The hospital failed to have an ongoing infection control/prevention (IC) program that reviewed hospital practices and infections/communicable diseases, analyzed data and developed qualitative plans of action. The infection control program failed to provide follow-up to ensure corrective actions were appropriate, effective and sustained.

Findings:

Program
1. The hospital IC practitioner (ICP) had not performed a hospital risk assessment to determine what organisms were most likely to occur within the hospital and what organisms were most likely to be present in the community.

2. The hospital IC program had not developed a system to ensure appropriate infection control procedures were implemented and evaluated for each department of the hospital. Departmental policies and procedures were reviewed for specialized infection control practices for those areas. The manuals did not have infection control policies specific to any area, except the kitchen. The infection control practices for the kitchen and dietary services had not been reviewed and approved by the infection control practitioner.

3. There was no documentation all department managers reported regular, ongoing infection control activities and surveillance to the infection control committee.

4. The hospital IC program did not have an annual surveillance calendar.

5. The hospital IC program did not include contracted services (such as linen service, among others) in the IC program.

Disinfectants
1. A list of chemicals used by the housekeeping department for hospital cleaning and disinfecting was provided to the surveyors. The list documented 10 different chemical agents. Some chemicals on the the list were not disinfecting agents.

There was no documentation the chemicals used for disinfection were approved by the infection control committee and the medical staff. There were no policies and procedures developed that instructed staff (housekeeping and nursing) on how the chemicals should be used.

There was no documentation the infection control practitioner was aware of all the disinfectant agents used in the hospital. There was no documentation staff were trained on the appropriate use of the disinfectants.

There were no policies that instructed various staff (kitchen, housekeeping, nursing and others) on specific infection control and disinfection responsibilities in their areas. For example, there were no policies and procedures that instructed nursing staff on disinfection activities between patients in the emergency department. Likewise, there were no policies and procedures to guide the housekeeping staff in their disinfection responsibilities in the emergency department. Interviews with staff indicated they were not certain of their own responsibilities and were not aware of other staff responsibilities.

Staff were not knowledgeable about the disinfecting products used in their areas. They did not know how the agents should be used or how long the chemicals had to remain in contact to adequately disinfect. There was no documentation staff were trained to use the disinfecting agents in their areas.

2. The surface disinfectant used in the hospital was not effective against C-difficile, although this was an organism that had been identified in the hospital and in the community.

3. There was no documentation of regular deep cleaning and deep disinfection in any department.

Surveillance/Monitoring
Review of infection control surveillance/monitoring data did not show evidence the infection control program monitored all departments and units to ensure compliance with established hospital policies and procedure and standards of practice to maintain a safe and sanitary environment.

1. There was no documentation of regular environmental rounds.
2. There was no documentation isolation procedures were followed by all staff, including physicians and visitors, according to current CDC guidelines.
3. There was no documentation the IC practitioner evaluated disinfection in isolation rooms. There was no documentation of special terminal cleaning with the correct disinfecting agent when the isolation ended.
4. The ICP did not monitor and track staff illness to ensure infections and communicable diseases were not transmitted between staff and between patients and staff.
5. The ICP did not ensure all staff had documentation of all required immunizations and TB skin testing. The ICP did not ensure all physicians, allied health and contracted workers had current immunizations and TB skin testing.
6. The ICP had not completed an annual hospital TB risk assessment.

Observations
1. Sterile and non-sterile supplies were stored together on the same shelves and in cabinets in the emergency department.
2. Dirty and clean items were stored together in the emergency department.
3. IV solution and tube feeding solution was stored in a dirty utility room.
4. The drug room was cluttered and dirty. Counters and other surfaces were not regularly cleaned and disinfected. The room did not have a hand-washing sink.
5. Patient rooms had wall air conditioning units with filters. There was no policy and procedure for cleaning/replacing the filters.
6. Nursing staff were observed providing direct patient care while wearing long, artificial nails.

Meeting minutes
1. The IC meeting minutes did not demonstrate review and analysis of staff exposures to bloodborne pathogens with review to ensure OSHA (Occupational Safety and Health Administration) guidelines were followed.
2. The meeting minutes did not demonstrate that any of the observations or problems identified by the surveyors had been identified or reviewed for compliance.

Based on policy and procedure review and staff interview, it was determined the hospital failed to develop and implement all necessary policies and procedures related to organ, tissue and eye procurement.

Findings:

On 09/03/13, hospital leadership was asked to provide organ, tissue and eye procurement policies and procedures. One policy was provided. No other policies were provided that addressed all the necessary requirements for organ procurement responsibilities.

On 09/05/13, the director of nursing said there were no other policies and procedures.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the OPO was notified of all deaths or imminent deaths within the hospital.

On 09/05/13, clinical records were reviewed for patients who had died in the hospital. Four out of five records had no documentation the OPO was notified of the deaths.

Nursing staff interviewed about the organ donation process stated they were not aware of the requirement to notify the OPO of all deaths.

Staff N verified that all records of patients' deaths may not have documentation the OPO was notified.

Based on document and staff interview, it was determined the hospital failed to ensure the emergency department policies and procedures were approved by the medical staff.
Findings:

1. On the morning of 09/03/13, the surveyors requested policies and procedures for the hospital's emergency services.

On the afternoon of 09/03/13, the director of nursing (DON) brought the emergency department (ED) policy and procedure manual to the surveyors. She stated that the facility was using the policies and procedures currently in the procedure manual and was approved by hospital administrative and medical staff.

The DON verified two untitled loose leaf papers in the ED policy and procedure manual as Eye Injury and Dental Emergency policies and procedures not approved by the hospital administrative and medical staff.

The chief executive officer (CEO) told the surveyors that their policies and procedures are not current.

The ED policies did not contain evidence of review, revision and or approval by appropriate staff.

2. Medical staff meeting minutes for 2012 and 2013 had no documentation that medical staff approved the emergency department policies and procedures.

Based on hospital document review, record review, and staff interview, it was determined the hospital failed to ensure the emergency department (ED) had been supervised by a qualified member of the medical staff.

Findings:

A hospital document posted in multiple areas of the facility titled, " NOTICE " , documented, " ...the hospital will have qualified physicians or licensed independent practitioners regularly available at all times for the emergency service, either on duty or on call ... "

On the morning of 09/03/13, Staff N told surveyors that there were no physicians or licensed independent practitioners physically present at all times in the ED or nearby within the hospital.

The clinical record for patient #2 documented the patient arrived to the ED " ...blue from physician ' s office. " The patient went into cardiac arrest shortly after arrival to the ED. The clinical record documented the physician arrived to the ED 45 minutes after notification that the patient had arrived in the ED.

Staff N stated there were no policies or procedures that indicated a physician or licensed independent practitioner had to be present in the ED or how soon they had to arrive after notification by the nursing staff.

On the afternoon of 09/04/13, Staff O and Staff P stated, " There are no physicians or mid-level practitioners staffed in the ED but one could be available within an hour. "

Based on hospital document review, record review, and staff interview, it was determined the hospital failed to ensure staff working in the emergency department (ED) had demonstrated specialized training and verified skills competencies. This occurred for twelve (Staff A, E, G, H, J through P, and Staff S) of twelve staff files reviewed.

Findings:

1. Staff training and education files were reviewed for evidence of demonstrated skills competencies for specialized tasks performed in the emergency department.

None of the records had documentation of verification of skills competencies related to specialized tasks in the ED.

2. On the morning of 09/04/13, Staff N told surveyors the hospital had not provided skills competency training and had not performed competency testing for nursing staff that worked in the ED.

On the afternoon of 09/04/13, Staff O and Staff P stated the hospital had not provided skills competency training and had not performed competency testing for nursing staff that worked in the ED.

3. The Director of Nursing (DON) was asked if the hospital required ED skills competency verification. She stated, "I don't do any. The nursing staff get the skills when in a nursing school program and when they take their tests to be certified or licensed."

4. A hospital emergency department policy titled, "Cardiac Arrest-Code Blue" documented, "... All Emergency Department staff will be CPR certified... All physicians and nursing staff within the Emergency Department will be ACLS certified ..."

Eight of nine personnel files reviewed had documentation of expired CPR, ACLS, and PALS certifications.

The DON verified that ED staff did not have current CPR, ACLS and PALS certification.

Based on observation, document review and staff interview, it was determined the hospital failed to provide menus approved by the dietitian, post menus in the kitchen, follow the menus and provide for initial nutritional assessments and on-going nutritional assessments as warranted by the patient's condition.

Findings:

During a tour of the kitchen on 09/04/13, no menu was posted in the kitchen. The dietary staff stated they did not really follow the menu.

On 09/05/13, the dietary staff provided a menu for the week of the survey. The menu did not reflect what was actually prepared in the kitchen for those days.

There was no documentation the menus were approved by the dietitian.

A review of clinical records indicated there was no consistent initial nutritional assessment and reassessment of the patients' nutritional status. For example, the clinical record for patient #19 documented the patient was admitted for severe dehydration. A nutritional screening form did not include the physician's order to push fluids and an order for strict monitoring of intake and output. There was no documentation of the patient's preferences for fluids.

Except for the one day a month when the dietitian was present in the hospital, there was no evidence the dietitian participated in the oversight of patients' nutritional status.

Based on review of hospital documents and meeting minutes concerning infection control, infection control policies and procedures and interviews with staff, the hospital leadership failed to ensure infection problems were addressed through the quality assessment and performance improvement (QAPI) committee. Hospital leadership also failed to ensure corrective action plans were implemented.

Findings:

1. Infection control, QAPI, medical staff and governing body meeting minutes did not document evidence the hospital leadership:

a. reviewed and analyzed infection control data or lack thereof;
b. ensured all departments/units of the hospital were included and monitored through the infection control/prevention program;
c. ensured infection control/prevention policies and procedures were based on current national standards and were developed, implemented and followed;
d. developed corrective plans of action to reduce and/or prevent transmission of organisms and improve patient care, ensure a safe and sanitary environment, and prevent or decrease infections and communicable diseases;
e. provided follow-up/monitoring to ensure corrective actions taken were effective and sustainable; and
f. the meeting minutes did not document the hospital leadership required ongoing infection control training and competency for all hospital staff.

2. The same hospital minutes failed to document review and analysis of employee immunizations, illnesses and infections to ensure infection and disease were not transmitted between patients and staff. The hospital leadership failed to ensure employee bloodborne pathogen exposures events were followed as part of the infection control program. Meeting minutes did not demonstrate exposure incidents were analyzed and corrective actions were considered and implemented to reduce future exposures.

3. Meeting minutes did not contain evidence the hospital leadership ensured policies and procedure were developed and implemented for all areas of the hospital according to current accepted standards of practice for infection control.

4. Meeting minute documentation did not show evidence the hospital leadership provided oversight of the total infection control program (including on-site and off-site services) to ensure a safe patient/staff environment. This included but was not limited to:

a. Hand hygiene;
b. Isolation practices;
c. Disinfectant practices;
d. Instrument and equipment cleaning practices;
e. Sterilization practices;
f. Environmental inspection;
g. Respirator fit-testing;
h. Kitchen sanitation and food safety;
i. Laboratory;
j. Physical therapy;
k. Linen services;
l. Respiratory therapy;
m. Employee, student, volunteer health.

Based on observation, document review and staff interview, it was determined the hospital failed to comply with skilled nursing facility requirements.

Findings:

See Tags A-1508, A-1510, A-1515, A-1517, A-1518, A-1519, A-1522, A-1523, A-1525, A-1526, A-1527, A-1528, A-1534, A-1537, A-1538, A-1541, A-1548, A-1549, A-1550, A-1551, A-1552.

Based on document review and staff interview, it was determined the hospital failed to notify patients of all rights related to swing bed status.

Findings:

On 09/03/13 and 09/04/13, open and closed records were reviewed for evidence patients were informed of their rights upon admission to a swing bed.

None of the records had documentation of swing bed patient rights. The DON and the administrator were asked if swing bed patients were given notification of all rights related to swing bed status.

They provided a generic patient rights document that was given to all patients. The document did not include all the swing bed patient rights requirements.

Based on document review, policy and procedure review and staff interview, it was determined the facility failed to inform swing bed patients of items and services that may or may not be charged to the patient.

Findings:

Open and closed swing bed patient records were reviewed. None of the records had documentation the patients were notified of items and services that may or may not be charged to the patient.

The DON and the administrator confirmed this finding.

Based on document review and staff interview, it was determined the hospital failed to notify swing bed patients of rights related to performing work for the facility.

Findings:

Open and closed patient records were reviewed for documentation swing bed patients were notified of their rights related to performing work for the facility.

There was no documentation the patients were notified of these rights.

The DON and the administrator confirmed these findings.

Based on document review and staff interview, it was determined the hospital failed to ensure swing bed patients had access to visitors.

Findings:

During the survey, signs and notices were posted on doors to the hospital that notified patients and visitors that the hospital would be "locked down" in the event of a weather related emergency. The notice documented that patient access to visitors (including family members) would be restricted during this time.

The administrator stated she was not aware this policy violated patient rights related to visitors.

Based on document review and staff interview, it was determined the hospital failed to inform swing bed patients of their rights related to personal possessions.

Findings:

Open and closed swing bed patient records were reviewed. There was no documentation patients were notified of their rights to personal possessions.

The DON and the administrator stated they were not aware of these requirements for swing bed patients.

Based on document review and staff interview, it was determined the hospital failed to notify swing bed patients of rights related to married couples.

Findings:

Open and closed swing bed patient records had no documentation swing bed patients were notified of their rights as married couples.

The DON and the administrator stated they were not aware of all the swing bed patient rights.

Based on policy and procedure review and staff interview, it was determined the hospital failed to develop and implement a comprehensive policy that correctly reflected swing bed patient rights related to transfer and discharge.

Findings:

A hospital document was found on open and closed swing bed patient records that notified the patients the hospital could discharge them against their will if an acute care bed was needed.

It documented, "... All swing bed patients must be fully aware that the principal purpose of Harmon Memorial Hospital is to provide acute care services to acutely ill patients. It may, therefore, become necessary to discharge Swing Bed patients if beds are needed for acutely ill patients and no such beds are available elsewhere in the hospital... The hospital staff will, to the extent possible, make arrangements for alternative care for the swing bed patient and will work to ensure a smooth and orderly transfer..."

The administrator stated she was not aware of all the rights related to swing bed patients.

Based on document review and staff interview, it was determined the hospital failed to implement a policy to assess a patient's needs prior to transfer or discharge to determine if a new care plan would allow the hospital to meet the patient's needs.

Findings:

Closed swing bed patient records were reviewed. The records had no physician documentation that indicated why the patient was discharged or transferred.

The administrator stated she was not aware of all the patient's rights related to swing bed status.

Based on record review and staff interview, it was determined the hospital failed to inform swing bed patients, families and/or legal representative in writing of the reason for transfer or discharge.

Findings:

Closed records were reviewed for swing bed patients. The records had no documentation patients, families and/or legal representatives were notified in writing of the reason for transfer or discharge.

The administrator stated she was not aware of all the requirements for swing bed patients.

Based on document review and staff interview, it was determined the hospital failed to develop policy and procedures to meet the requirements for the discharge and transfer of swing bed patients.

Findings:

A review of swing bed policies and procedures indicated the hospital had not developed all swing bed patient transfer and discharge policies according to the requirements.

The administrator stated she not aware of the requirements.

Based on document review and staff interview, it was determined the hospital failed to develop policy and procedures to meet the requirements for the discharge and transfer of swing bed patients.

Findings:

A review of swing bed policies and procedures indicated the hospital had not developed all swing bed patient transfer and discharge policies according to the requirements.

The administrator stated she not aware of the requirements.

Based on document review and staff interview, it was determined the hospital failed to develop policy and procedures to meet the requirements for the discharge and transfer of swing bed patients.

Findings:

A review of swing bed policies and procedures indicated the hospital had not developed all swing bed patient transfer and discharge policies according to the requirements.

The administrator stated she not aware of the requirements.

Based on record review and staff interview, it was determined the hospital failed to prevent the employment of individuals convicted of abusing, neglecting or mistreating individuals in a health care related setting.

Findings:

During the survey, the surveyors observed department of correction inmates in and around the hospital, including within patient care areas.

The administrator was asked if the hospital had information on the inmates convictions. She stated they did not have the specifics, but they were assured the inmates were "non-violent offenders."

The administrator was asked if all potential employees (not only CNAs) were checked through the State Nurse Aide Registry. She stated they were not.

Based on record review and staff interview, it was determined the hospital failed to provide an activities program for swing bed patients.

Findings:

1. The hospital had no policies and procedures for the activities program.

2. The hospital had not developed an activities calendar.

3. Open and closed swing bed patient records were reviewed. There was no documentation of an activity assessment based patient interests and needs. There was no activities care plan developed for the patients. There was no indication nursing staff were instructed how to provide activities after hours and on weekends.

4. During the survey, no patient activities were observed.

5. There was no documentation in the records that indicated appropriate activities were provided to swing bed patients.

6. The activities coordinator stated one patient was offered a manicure, but the patient declined, stating she did not feel up to it that day. The activities coordinator was asked if activities were provided at times convenient and acceptable to the patient. She stated she thought so. She stated however, activities were not provided when she was not there such as evenings, nights, weekends and holidays.

7. The hospital could not demonstrate activities supplies were available in the hospital.

Based on record review and staff interview, it was determined the hospital failed to provide medically-related social services to swing bed patients.

Findings:

Open and closed swing bed patients were reviewed for evidence that medically-related social service needs were identified and assessed.

None of the records had documentation of social services assessment. None of the records documented staff efforts to assist patients with arrangements with equipment, clothing and personal items. There was no documentation of assistance with referrals to outside sources.

There was no documentation the social services coordinator contributed to discharge planning activities.

The social services coordinator was asked how she provided medically-related social services to the swing bed patients. She stated she rarely did those things. She stated, "The nurses usually take care of that."

The hospital had no policies and procedures related to the provision of medical social services.

Based on record review and staff interview, it was determined the hospital failed to ensure swing bed patients had adequate discharge summaries that included sufficient information pertinent to continuing care and failed to ensure a discharge plan of care was developed with the participation of the patient and the family.

Findings:

Closed swing bed patient records were reviewed. The discharge summaries did not have information regarding continuing care needs for the patients.

The discharge summaries did not include a discharge plan of care.

There were no policies and procedures related to discharge summaries and discharge planning needs for swing bed patients.

The administrator stated she was not aware of those requirements for swing bed patients.

Based on record review, policy and procedure review and staff interview, it was determined the hospital had no provision to meet the dental needs of swing bed patients.

Findings:

The hospital's swing bed policies and procedures had documentation of a cooperative agreement with a dentist to provide services to swing bed patients. The agreement was several years old and had not been renewed.

The administrator stated the dentist no longer practiced in the area and no other dentist had been contracted to provide services to swing bed patients.

The hospital had no policies related to patient dental needs assessment, provision of dental services, payment requirements or the provision of alternative funding sources or alternative service delivery systems for the provision of dental services.

The social services coordinator was asked how patients' dental needs were assessed. She stated she did not know. She was asked what would happen if a patient needed dental services. She stated she did not know.

Based on record review, policy and procedure review and staff interview, it was determined the hospital had no provision to meet the dental needs of swing bed patients.

Findings:

The hospital's swing bed policies and procedures had documentation of a cooperative agreement with a dentist to provide services to swing bed patients. The agreement was several years old and had not been renewed.

The administrator stated the dentist no longer practiced in the area and no other dentist had been contracted to provide services to swing bed patients.

The hospital had no policies related to patient dental needs assessment, provision of dental services, payment requirements or the provision of alternative funding sources or alternative service delivery systems for the provision of dental services.

The social services coordinator was asked how patients' dental needs were assessed. She stated she did not know. She was asked what would happen if a patient needed dental services. She stated she did not know.

Based on record review, policy and procedure review and staff interview, it was determined the hospital had no provision to meet the dental needs of swing bed patients.

Findings:

The hospital's swing bed policies and procedures had documentation of a cooperative agreement with a dentist to provide services to swing bed patients. The agreement was several years old and had not been renewed.

The administrator stated the dentist no longer practiced in the area and no other dentist had been contracted to provide services to swing bed patients.

The hospital had no policies related to patient dental needs assessment, provision of dental services, payment requirements or the provision of alternative funding sources or alternative service delivery systems for the provision of dental services.

The social services coordinator was asked how patients' dental needs were assessed. She stated she did not know. She was asked what would happen if a patient needed dental services. She stated she did not know.

Based on record review, policy and procedure review and staff interview, it was determined the hospital had no provision to meet the dental needs of swing bed patients.

Findings:

The hospital's swing bed policies and procedures had documentation of a cooperative agreement with a dentist to provide services to swing bed patients. The agreement was several years old and had not been renewed.

The administrator stated the dentist no longer practiced in the area and no other dentist had been contracted to provide services to swing bed patients.

The hospital had no policies related to patient dental needs assessment, provision of dental services, payment requirements or the provision of alternative funding sources or alternative service delivery systems for the provision of dental services.

The social services coordinator was asked how patients' dental needs were assessed. She stated she did not know. She was asked what would happen if a patient needed dental services. She stated she did not know.

Based on record review, policy and procedure review and staff interview, it was determined the hospital had no provision to meet the dental needs of swing bed patients.

Findings:

The hospital's swing bed policies and procedures had documentation of a cooperative agreement with a dentist to provide services to swing bed patients. The agreement was several years old and had not been renewed.

The administrator stated the dentist no longer practiced in the area and no other dentist had been contracted to provide services to swing bed patients.

The hospital had no policies related to patient dental needs assessment, provision of dental services, payment requirements or the provision of alternative funding sources or alternative service delivery systems for the provision of dental services.

The social services coordinator was asked how patients' dental needs were assessed. She stated she did not know. She was asked what would happen if a patient needed dental services. She stated she did not know.