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Based on document review, staff interview and due to the hospital not providing emergency services it was determined the governing body failed to develop and implement a policy and process for ensuring that all licensed nursing personnel have at a minimum a current cardiac pulmonary resuscitation (CPR) card/training. This deficient practice was found in six (6) of sixteen (16) personnel records reviewed (Registered Nurse (RN) #1, 2, 3, 4, 7 and Licensed Practical Nurse (LPN) #5). When there is not a requirement or process for ensuring that all licensed staff have current CPR training it can result in staff providing ineffective or incorrect emergency care/CPR with a possible continued deterioration in the patients condition.

Findings include:

1. Review of the personnel records for RN #1, #2, #3, #4, #7 and LPN #5 revealed the files lacked documentation of a current CPR card/training. Additionally the roster of attendance for the hospital provided CPR classes was reviewed for 2/5/10 to present and none of the six (6) employees had documentation of attending any of these classes. Additionally, there were no policies for CPR training requirements or processes to track and ensure that all licensed personnel have documentation of current training.

2. The above six (6) employee records and CPR class attendance roster were reviewed with the Chief Executive Office (CEO) on 2/29/12 at 1445 hours and she agreed they were unable to find evidence of the CPR training for the above six (6) staff members. The CEO did concur the hospital does not currently have an approved policy for CPR training.

At the time of exit on 2/29/12 at 1500 hours the CEO presented a code blue policy dated with an effective date of 1/2012 which states in part that licensed members of the nursing staff shall maintain current basic life support (BLS) cards as a condition of employment. When questioned if this policy had been approved she stated it is going for approval tomorrow.

Based on review of medical records and interview with staff, it was determined the hospital failed to ensure patient rights information was provided at the time of admission and/or prior to the provision of care for at least one (1) of eight (8) closed inpatient medical records reviewed (patient #3). This has the potential for patients to not be well informed of their rights in a timely manner.

Findings include:

1. Review of the medical record for patient #3 revealed the patient was admitted to the inpatient hospital unit in the afternoon on 11/2/2011. The information sheet on patients' rights, the "important message from Medicare" form and the advance directives form were all signed by the patient on 11/3/2011 and was co-signed by the hospital's Social Worker.

2. The Social Worker was interviewed on 2/28/2012 at 3:30 p.m. She stated she works part time at the hospital, three (3) days per week. She stated that currently she is the person responsible to ensure patients are provided information relative to rights. She concurred that patients may not receive that information on the day of admission and prior to receiving care.

Based on medical record review, review of policy and staff interview it was determined the hospital failed to ensure the nursing staff developed and kept current nursing care plans for nine (9) of nineteen (19) inpatient records reviewed (patients #1, 2, 3, 9, 10, 11, 12, 19 and 20). This failure creates the potential for the nursing care of all patients to be adversely affected.

Findings include:

1. The Nursing Care Plan Policy was requested and provided by the Director of Nursing (DON) at 0845 on 2/28/12. Review of the policy "Interdisciplinary Rehabilitation Plan of Care," effective date 6/11, revealed it did not reference how or when a nursing care plan is initiated, who initiates the nursing care plan or how the nursing care plan is updated and kept current. The "Interdisciplinary Team Plan of Care" form which is currently being used was provided and reviewed. It has five (5) sections: medical, activities of daily living, bowel and bladder, mobility and executive function/cognition.

2. The policy and form were reviewed and discussed with the DON at this time. He acknowledged the policy and form were developed for the Interdisciplinary Team process/plan. He agreed the policy and form did not make any reference to the nursing care plan process. He stated that currently the medical and bowel and bladder sections of the Interdisciplinary Team Plan of Care were serving as the nursing care plan. He stated the Registered Nurse (RN) is responsible to initiate the plan at the time of admission and the plan should be implemented no more that twenty-four (24) hours after admission.

3. Review of the medical record for patient #1 revealed the patient was admitted on 2/25/12 after falling in a facility with a resulting hip fracture that required surgical repair. On admission the patient was diagnosed with a Clostridium Difficile urinary tract infection and had orders to be placed in contact isolation. The current plan of care did not address the patient's isolation and special measures to be taken when performing care and treatments.

4. This record was reviewed and discussed with RN #4 at 1315 on 2/28/12. She agreed with this finding.

5. Review of the Interdisciplinary Team Care Plan for patient #2 revealed the plan was initiated by a Licensed Practical Nurse (LPN) on 2/28/11.

6. Review of the Interdisciplinary Team Care Plan for patient #3 revealed the plan was initiated by a LPN on 11/4/11, which was two (2) days after the patient's 11/2/11 admission.

7. These two (2) Care Plans were discussed with the DON at 0950 on 2/29/12. He acknowledged the plans were initiated by the LPN, not the RN as required and he agreed with these findings.

8. Review of the medical record for patient #9 revealed the patient was admitted on 2/18/12 with a diagnosis of morbid obesity, severe lymphedema, cellulitis and hypertension. At 0950 on 2/23/12 the nurse documented the patient fell. This was the second documented fall since admission. The current plan of care did not address the second fall. Additionally this plan lacked nursing interventions and safety measures to prevent future falls.

9. This record was reviewed with the DON at 1600 on 2/28/11 and he agreed with these findings.

10. Review of the Interdisciplinary Team Care Plan for patient #10 revealed the patient was admitted on 2/22/12 and the plan was initiated on that date. Review of the medical record revealed the patient eloped from the hospital on 2/26/12. The record reflected the patient crossed the alley behind the hospital and was found to have fallen off a small concrete ledge/wall. Review of the care plan revealed it was not updated to reflect the patient's elopement and fall risks.

11. Review of the Interdisciplinary Team Care Plan for patient #11 revealed the patient was admitted on 2/24/12 and the plan was initiated on that date. Review of the bowel and bladder section of the plan revealed it was initiated by the LPN. Review of the record reflected the patient fell on 2/26/12. Review of the care plan revealed it was not updated to reflect the patient's fall risk.

12. These two (2) Care Plans were discussed with RN #7 at 1130 on 2/28/12. She agreed with these findings.

13. Review of the medical record for patient #12 revealed the patient was admitted on 2/4/12. The nurse assessed the patient to be a high risk for falls at the time of admission. Review of the Interdisciplinary Team Care Plan initiated on 2/4/12 revealed the nurse failed to include the patient's high risk for falls in the plan of care.

14. Review of the Interdisciplinary Team Care Plan for patient #19 revealed it was initiated on 12/12/11 by the LPN.

15. These records were discussed with the DON at 0845 on 2/29/12 and he agreed with these findings.

16. Review of the medical record for patient #20 revealed the patient was admitted on 2/22/12 with a history of a fall that resulted in spinal compression fractures which required surgical interventions and stabilization. The patient's admission fall assessment identified the patient as a high risk for falls. The current plan of care did not address the patient's high risk for falls and failed to identify any nursing interventions to prevent falls and improve safety.

17. This record was reviewed with RN #11 at 0945 on 2/29/12. She agreed with these findings.

Based on review of medical records and interview with staff, it was determined the hospital failed to ensure there is documented evidence that physicians reviewed their dictated entries after each entry was transcribed. This deficient practice was noted on eight (8) of eight (8) closed inpatient medical records reviewed (patients #2, 3, 14, 15, 16, 17, 18, and 19). This has the potential for medical records to have inaccurate entries when they have not been reviewed by the person who dictated the transcribed forms.

Findings include:

1. Review of the closed medical record for patients #2, 3, 14, 15, 16, 17, 18 and 19 revealed that all records had dictated History and Physical (H & P) examinations and dictated Discharge Summaries. On all the documents, it was noted there were printed electronic signatures.

2. The Executive Officer was interviewed on 2/28/2012 at 11:10 a.m. relative to the findings. She stated the physicians dictate those documents by phone to a transcription service. She stated the transcription occurs automatically through voice recognition software. She stated the completed document is emailed to the Medical Records department and is then printed and placed on the medical record. The Executive Officer stated that the electronic signature is automatically attached at the time of transcription, and prior to the time the physician actually reviews the document after it is transcribed and printed. There were no other initials, signatures or notations on any of the documents to indicate that each physician had seen and reviewed the documents for accuracy after being printed.

Based on observation and staff interview, the facility failed to maintain a stock of drugs, sterile supplies and biologicals for patient use that were in date and not expired. Having expired sterile supplies, testing supplies and medications readily available for patient use can result in patients receiving materials that may have deteriorated and/or are not sterile which can possibly result in inaccurate test results, patient infections or injuries.

Findings include:

1. During a tour of 1st floor "clean" room on 2/28/12 at approximately 0930 the following items were found to be expired/outdated and available for use on patients:

a. Two (2) 50 ml. vials of 8.4% Sodium Bicarbonate. One (1) with an expiration date of February 2011. One (1) with expiration date of June 2011.

b. Nine (9) Insyte N Autogard IV catheters, ranging in size between 18 gauge, 20 gauge, 22 gauge and 24 gauge were found to be expired. Dates of expiration ranged from May 2010 to December 2011.

c. Four (4) Luer Adapters were found to be expired. Dates of expiration ranged from January 2001 to April 2003.

d. Ten (10) Vacutainer blood collection tubes were found to be expired. Dates of expiration ranged from February 2007 to February 2010.

e. One (1) secondary IV set, 37". Date of expiration was December 2001.

f. One (1) secondary IV set, 32". Date of expiration was November 2000.

g. One (1) KCI vacuum dressing, 10 x 15 cm. Date of expiration was November 2011.

h. One (1) Flexicol dressing, 4x4". Date of expiration was May 2009.

i. One (1) 4 lb. bag of Epsom Salts. Date of expiration was November 2011.

j. Five (5) packets Bacitracin ointment. Date of expiration December 2008.

k. One (1) culture swab. Date of expiration March 2009.

l. One (1) 14 French self urinary catheter. Date of expiration July 2011.

m. Seven (7) filter straws. Five (5) with date of expiration May 2009. Two (2) had expiration dates of December 2007.

2. The Director of Nursing (DON) and Chief Executive Officer (CEO) were interviewed at 1015 on 2/28/12 and verified the above findings. Items were placed in a paper bag by this surveyor on 2/28/12 at 1015 to be disposed of and to prevent usage on a patient.

Based on observation and staff interview it was determined the hospital failed to provide a preventative maintenance program that ensured all patient care equipment is maintained in safe operating condition.

Findings include:

1. On 02/28/12 at approximately 10:00 a.m., a tour of the rehabilitation hospital unit and physical therapy unit was conducted. At this time, the following equipment was observed to have expired safety inspection stickers:

a. Medtronic teletracic (serial # GQ0172543P) located in clean utility room (last inspection date 08/03/05).

b. Hydro-collator (Biomed #164228) located in clean utility room (last inspection date 06/10).

c. Blood pressure machine (Biomed #164214) located at nurse station (last inspection 06/10).

d. Suction machine located in occupational therapy area (last inspection date 06/10).

e. Whirlpool tub and lift chair (last inspection date 05/10).

f. Hydro-collator located in outpatient gym area (last inspection date 06/10).

g. Dynatron 709 (Biomed #164263) located in outpatient gym area (last inspection date 05/10).

2. On 02/28/12 at approximately 4:00 p.m., an interview with the hospital administrator revealed there was no documented evidence available to verify that the aforementioned patient equipment had safety inspections in the previous twelve (12) month period.

A. Based on observations and staff interviews, it was determined that the facility failed to maintain a clean sanitary environment in all areas of the hospital, including floors, ice machines, countertops, sinks and failed to ensure that all surfaces are smooth and intact which can be effectively cleaned,. Failure to maintain a clean environment with smooth intact surfaces that can be effectively cleaned may cause the proliferation of bacteria in these areas that may result in patient exposure to contaminates from these areas with the possible development of patient infections or deterioration in condition.

Findings include:

1. The following observations were made of environmental infection control issues on the acute hospital unit on 2/28/12 at approximately 0915:

a. Located on a counter in the unit kitchen was an ice machine that had a crusty white material scattered over a majority of the dispensing area surface and drip pan. Similar areas of this crusty white material were present at the base of the ice machine and extended onto the counter top surface around the machine. The top of the ice machine was covered with a layer of dust. The ice machine drip pan was not covered by a rack and there was a collection of water in the pan that did not drain during the observations. This represents non-intact surfaces which can not be effectively cleaned. Additionally having standing water in a drip pan can result in growth of bacteria and failure to have a rack over this area can lead to this water contaminating items used for ice dispensing.

b. The drain area of a water fountain, located in the hallway across from the nurses station, was covered with a white pasty material.

c. The "soiled" utility room sink was noted to be coated with a white film and there was a crusty residue in the basin with areas of whitish splashes across the counter top.

d. The "clean" room counter tops were cluttered with supplies and patient care items. The bottom tier of the EKG machine cart exhibited a layer of dust, lint and what appeared to be tape residue. The counter tops had multiple areas where there appeared to have had been tape leaving an area that had a sticky rough residue. The cool Pac Hydrocollator had a layer of dust on the top with areas that were rough and discolored areas. The Hydrocollator had white splatters across the surface. There was an open floor drain located to the right of the door that had a thick layer of what appeared to be dirt and lint. The floor of this room appeared dirty in areas and there was a build up of dust and loose debris around the perimeter of the room at the floor baseboard junction.

2. The Chief Executive Officer (CEO) and Director of Nursing (DON) were interviewed on 2/28/12 at approximately 1000 hours and reviewed the issues in the clean room and concurred with the findings.

3. During a tour of the physical therapy area of the hospital on 2/29/12 at approximately 0940 the following observations were made of environmental infection control issues:

a. The "whirlpool room" sink was found to have areas that had white splatters with a crusty white residue at the drain and faucet bases. Horizontal surfaces had a sticky residue. The top of the refrigerator had a layer of dust. The floor appeared dirty and had a "gritty feeling" when walking across it. There was lint and dust on the floor, especially at baseboards/perimeter.

b. The carpeted areas of the outpatient rehabilitation room had scattered pieces of paper/debris on the floor surface with an accumulation of dust and debris at baseboards, particularly in the corners.

B. Based on observations and staff interviews, it was determined the facility failed to maintain the integrity of all sterile kits that were readily available for use on a patient during their care or treatment. When sterile supplies are readily available for patient use whose packing has been breached leading to contamination of the product can result in patients being exposed to bacteria which could result in patient infections and/or negative patient outcomes.

Findings include:

1. Observations made of the hospital unit clean room on 2/28/12 at approximately 0930 revealed the following sterile items which were found to have been compromised:

a. In the clean room was a tracheostomy care kit that had a torn exterior cover/lid, exposing the contents.

b. A suture removal tray was found to be opened with contents partially removed.

2. The condition of these items were verified with the CEO and DON upon interview at approximately 0950 on 2/28/12.

C. Based upon document review and staff interview it was determined that infection control failed to maintain the most current (9/2011) listing of West Virginia Reportable Diseases and timeframe's which is used to determine what diseases need to be reported and when to make these reports. When all required infectious/communicable diseases are not recognized and reported within the specific timeframe's it can result in patient/staff and community members having exposure incidents and lead to a hospital or community outbreak.

Findings include:

1. Review of the hospital's infection control manual revealed a list of West Virginia Reportable Infectious Diseases dated April 2004.

2. The most recent listing of reportable diseases available from the WVDHRR Bureau of Public Health, Office of Epidemiology and Prevention Services was revised and made available 09/2011.

3. The list the hospital was using did not contain all of the current reportable diseases such as, Severe Acute Respiratory Syndrome (SARS), Q-Fever (coxiella burnetti), and arboviral infection. Additionally the 2004 list did not reflect the current reporting timeframe's such as, Giardia which is now required to be reported to the local health department within seventy-two (72) hours, and in 2004 it was to be reported to the patient's county of residence within one (1) week of diagnosis.

4. When the outdated reportable disease list (2004) was discussed at interview with the CEO on 2/28/12 at 1400 hours, she stated she was sure they were doing the right thing since their medical director was associated with the county health department.

Based on document review, medical record review and staff interviews it was determined the facility individual record review failed to enforce and follow policies and standards that require when flushing a peripherally inserted central catheter (PICC) that specific flush orders are obtained that include, the flushing agent, strength/concentration, volume and frequency. This deficient practice was found in one (1) of (1) record reviewed which had intravenous therapy and a PICC line (patient #22). When specific orders are not obtained for PICC line flushes this can result in staff administering incorrect intravenous flushes with resulting patient injury or deterioration in condition.

Findings include:

1. Review of patient record #22 revealed the patient was admitted on 2/17/12 with a post surgical abscess and was ordered Vancomycin 1.5 grams every twelve (12) hours. Admission orders directed nursing to provide "routine care per protocol for PICC."

2. Review of the intravenous medication administration record from 2/17/12 to the time of review on 2/29/12 revealed directions to "flush port per protocol" and there were nurses initials (on each shift) in the administration time area. The specific times of administration, types of solutions and amounts were not documented. Additionally, there was no documentation of any PICC line flushes only port flushes. The record lacked protocols for port or PICC line flushes.

3. The unit nursing staff and the Director of Nursing (DON) were interviewed on 2/29/12 at approximately 1030 hours about procedures for flushing PICC lines and all staff indicated they follow protocols. There were no protocols available for review on the nursing unit and a request was made to review this protocol.

4. At 1430 hours on 2/29/12 the DON presented a policy entitled Peripherally Inserted Central Line Catheter with an effective date of 1/2012. The policy stated in part that a physician order is required to flush a catheter and must include the flushing agent, strength/concentration, volume and frequency.

5. The Director agreed at 1440 hours on 2/29/12 that record #22 did not have specific orders for the flushes and there were no documented specific times of administration, type of solution and amount and this does not follow policy or clinical standards.