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Based on observation and staff interview, it was determined the governing body failed to ensure:

a. the hospital had a safe electrical system that was installed and maintained according to required national standards. This deficient practice constituted an Immediate Jeopardy situation that was likely to impact the safety of patients, staff and visitors in manner to cause serious injury, harm, impairment or death. See Tag A-0700;

b. contracted electrical services were provided in manner to comply with the applicable conditions of participation. See Tag A-0083;

c. all hospital contracted services were subject to quality assessment and performance improvement (QAPI) evaluation. See Tag A-0084; and

d. the governing body failed to maintain a list of all contracted services provided to the hospital. See Tag A-0085.


Findings:

On 09/17/14 at 3:20 p.m., the OSDH Life Safety Code surveyor received a significant electrical shock when he touched a metal ceiling support and a fire sprinkler pipe during an inspection of the area above the ceiling tiles in a common hallway. This indicated that the electrical system was not completely grounded.

Further inspection of the hospital's electrical system showed that the electrical system throughout the hospital had been inappropriately and unsafely modified.

The plant operations manager stated he was not aware of the extent of the problem with the electrical system.

The surveyors requested and reviewed governing body meeting minutes for 2013 and 2014. The meeting minutes documented election of board members and audit/financial reports only. There was no documentation of oversight and review of contracted services.

On 09/18/14 at 1:50 p.m., the surveyors notified the hospital leadership staff that an Immediate Jeopardy situation existed due to a hospital-wide electrical system that was not properly installed and maintained. The leadership staff were notified this failure placed the hospital at serious risk for electrical fire and also exposed patients, staff and the public to a serious risk for electrical shock. The hospital leadership staff stated they were not aware the hospital's electrical system was in this condition.

Based on observation and staff interview, it was determined the hospital failed to ensure the hospital's electrical system was installed and maintained according to required national standards. This deficient practice constituted an Immediate Jeopardy situation that was likely to impact the safety of patients, staff and visitors in manner to cause serious injury, harm, impairment or death.

Findings:

On 09/17/14 at 3:20 p.m., the OSDH Life Safety Code surveyor received a significant electrical shock when he touched a metal ceiling support and a fire sprinkler pipe during an inspection of the area above the ceiling tiles in a common hallway. This indicated that the electrical system was not completely grounded.

Further inspection of the hospital's electrical system showed that the electrical system throughout the hospital had been inappropriately and unsafely modified.

The plant operations manager stated he was not aware of the extent of the problem with the electrical system.

On 09/18/14 at 1:50 p.m., the surveyors notified the hospital leadership staff that an Immediate Jeopardy situation existed due to a hospital-wide electrical system that was not properly installed and maintained. The leadership staff were notified this failure placed the hospital at serious risk for electrical fire and also exposed patients, staff and the public to a serious risk for electrical shock.

The hospital leadership staff were informed that based on observation, record review and interview, it was determined the deficient practices found within the hospital likely posed an immediate threat of serious injury, harm, impairment or death to patients, staff and the public.

The hospital was unable to remove the immediacy of the threat and the hospital remained in an Immediate Jeopardy situation at the conclusion of the survey.

See also the Life Safety Code survey conducted on these dates.

On 10/10/14 at 2:30 p.m., the Life Safety Code surveyor verified, during an onsite inspection, that sufficient progress had been made on the correction of the hospital's electrical system problem to warrant removal of the Immediate Jeopardy finding.

The hospital remained at Condition-level non-compliance for Tag A-0700 Physical Environment.

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

a. analyze and respond to infection control data collected each quarter;

b. develop and implement employee health related infection control policies;

c. review and approve all disinfectant agents used in the hospital;

d. ensure appropriate hand washing agents were provided to staff;

e. store clean linen in a sanitary manner;

f. ensure laboratory functions were carried out in an area that was clean, regularly disinfected and free of clutter; and

g. the hospital failed to ensure food service was provided in a sanitary manner.

Findings:

1. On 09/17/14, the surveyors reviewed the infection control surveillance information. Data was collected but was not analyzed. The same recommended actions were documented every quarter, no matter what the data showed.

The infection control plan documented head lice prevention/reduction was a primary goal for 2013 and that staff was educated on treating the environment and patient care needs related to this problem.

However, the data collected for 2013 showed increasing numbers of lice/scabies cases in the second and third quarter of 2013 and a slight reduction in the fourth quarter. There was no analysis of this at the end of 2013 and there was no documentation of recommended actions to be taken in response to this increase in lice/scabies infections.

The infection control nurse was not available for interview at the time of survey and the staff present could not speak to why investigation, analysis and responsive actions were not taken.

2. The hospital had employee health policies and procedures related to new employees only. The hospital did not have infection control/employee health policies and procedures for all employees after they were hired. There were no policies and procedures for TB skin testing, immunization requirements, or the reporting of infections or exposures to infections, among others.

3. The hospital leadership was asked if the infection control committee annually reviewed and approved all disinfectant agents used in the hospital. They stated they were not. The staff was not familiar with the characteristics and capabilities of the disinfectants used in the hospital. They were unfamiliar with the types of microorganisms killed by the agents used in the hospital.

4. During a tour of the hospital, household (non-clinical) hand soap was found in the laboratory area. The staff stated they did not know this type of hand cleanser was brought into the hospital. The staff stated they were uncertain as to what type of hand washing soap was normally provided for staff. Hand sanitizing agents were not provided for staff use in areas restricted from patients.

5. During the hospital tour, clean linen was found stored uncovered on rusted wire racks in the area where dirty laundry was stored and processed. The staff stated they did not have separate clean and soiled linen storage areas on the patient units.

6. The room used for laboratory tasks and procedures was too small for the necessary functions. The room was cluttered and used for excess storage. There was evidence the room was never regular cleaned. The countertop and sink had visible grime, dirt and was sticky to the touch. The floor was dirty. There was no clean and sanitary space to process lab specimens. The staff were uncertain as to who was responsible to regularly clean/mop this room.

7. Observations were made of the kitchen and food service provided by the hospital. The following infection control breaches were observed:

~The food service staff preparing and serving food in the hospital did not wear hair covering appropriately. Hair was seen hanging from under the cap around the forehead and ears.

~The food service staff person had long, polished fingernails. This staff was observed handling lettuce, cheese, tortillas and other foods with her bare hands. This staff was never observed practicing hand washing during the preparation or meal service. Gloves were never worn.

~The kitchen staff stored mopheads and cleaning rags in covered bins next to the dishwashing sinks, rather than in a separate janitor's closet with the cleaning supplies. Disposable plates and food carry-out containers were stored on top of these bins next to the sinks.

~A dead insect was found in a pocket of a plastic hanging organizer that held the patient diet cards.

~A broom and mop were stored in the kitchen area near the dishwashing sinks, rather than in a janitor's closet.

~On the patient care units, gallon jugs of milk for patients were stored in "mini" refrigerators that also held staff food and non-patient items. The mini refrigerator was located on the floor immediately outside the staff restroom.

~During a tour of the patient units, the dietary staff was observed bring patient snacks into the unit staff break/work room. The snacks consisted of a tray of uncovered apples. The staff placed the uncovered apples on a shelf near the door to the staff restroom. The staff were asked if the apples should have been individually wrapped to protect from contamination. They stated they should.

Hospital leadership was made aware of the findings at the time of the survey.

Based on observation, document review and staff interview, it was determined the hospital governing body failed to ensure contracted electrical services were provide in a manner to protect the safety of patients, staff and visitors.

Findings:

On 09/17/14 at 3:20 p.m., the OSDH Life Safety Code surveyor received a significant electrical shock when he touched a metal ceiling support and a fire sprinkler pipe during an inspection of the area above the ceiling tiles in a common hallway. This indicated that the electrical system was not completely grounded.

Further inspection of the hospital's electrical system showed that the electrical system throughout the hospital had been inappropriately and unsafely modified.

The plant operations manager stated he was not aware of the extent of the problem with the electrical system.

The hospital had no documentation the governing body ensured that all contracted services provided in the hospital met the applicable conditions of participation.

Based on document review and staff interview, it was determined the governing body failed to ensure all hospital contracted services were subject to quality assessment and performance improvement (QAPI) evaluation.

Findings:

On 09/17/14, the hospital's QAPI meeting minutes were reviewed. There was no documentation hospital contracted services were evaluated through the QAPI process.

The leadership staff stated the hospital did not evaluate contracted services through the QAPI process.

Based on document review and staff interviews, the hospital failed to maintain a list of all contracted services including the scope and nature of the services provided.

Findings:
1. On the morning of 09/16/14, surveyors requested a list of all contracted services. None was provided.

2. On the morning of 09/17/14, surveyors were told, "The list of contracted services is being worked on."

3. On the afternoon of 09/18/14, Staff X told surveyors that the hospital did not have a list of contracted services.

4. Findings were verified with administrative staff at the time of review.

Based on document review and staff interview, the hospital failed to respond to all grievances in writing.

Findings:

1. On 09/16/14, hospital administration was asked to provide documentation of all complaints and grievances for the previous six months. Documentation of one grievance was provided.

2. There was no documentation the complainant was provided a written response by the hospital.

3. On 09/17/14, hospital administration confirmed that grievances were not responded to in writing.

Based on personnel file review, medical staff meeting minutes review, governing body meeting minutes review and staff interview, the hospital failed to ensure there was a medical director appointed to the medical staff.

Findings:

1. The Chief Operating Officer, Assistant Administrator, and HR Specialist all verified that there was no documented evidence of a medical director appointed by the governing body.

2. On the afternoon of 09/18/14, surveyors reviewed Staff Q's credentialing file. The file did not contain current documented evidence of appointment as medical director by the governing body.

3. On the morning of 09/16/14, the Assistant Administrator told surveyors that Staff Q was the medical director.

4. On the afternoon of 09/18/14, the HR Specialist provided surveyors a letter that appointed Staff Q as the medical director from 2004-2006. The HR Specialist was not able to provide surveyors a current document that appointed Staff Q as the medical director.

5. There was no documented evidence in the medical staff and governing body meeting minutes that a medical director was appointed to the medical staff.

Based on policy and procedure review, observation, and staff interviews, the hospital failed to ensure basic safe practices for medication administration.

Findings:

1. On the morning of 09/18/14, surveyors toured the adolescent unit medication room with the Director of Patient Care Services, Assistant Director of Patient Care, and Assistant Administrator.

2. Surveyors observed:

Three milliliter Novolog Flex Pens (injectable insulin, fast acting) opened and not dated.

One milliliter Levemir Flex Pen (injectable insulin, long acting) with rubber bands wrapped around the barrel of the pen completely covering the label, opened and not dated.

3. Staff W told surveyors the rubber bands wrapped on the injectable medication pen allows for quick identification of the long acting insulin pen.

4. Surveyors were unable to identify the name on the injectable medication pen due to the obstruction from the rubber bands.

5. Staff W was unable to read the name on the injectable medication pen due to the obstruction from the rubber bands.

6. Staff W told surveyors that the green medication pen with the rubber bands on it was how staff identified and confirmed the injectable medication as the long acting insulin before administering it to the patient.

7. On the afternoon of 09/17/14, surveyors requested medication administration policy and procedure that was specific to insulin. A medication administration policy and procedure was provided that documented all insulin will be dated with the date it was opened and the date when it would be expired. The policy and procedure documented that once insulin was open it would expire 28 days after it was opened.

8. On the morning of 09/18/14, the Director of Patient Care verified findings at the time of review.

Based on document review and staff interviews, the hospital failed to ensure there was a written description of laboratory services.
Findings:
1. The morning of 09/16/14, surveyors requested a laboratory services list. None was provided.
2. On the afternoon of 09/16/14, the Director of Patient Care told surveyors that the facility provides very few laboratory tests such as drug testing and monitoring blood glucose (blood sugar) and they send out most lab work (including pregnancy testing).
3. On the morning of 09/17/14, surveyors requested a laboratory services list. Administrative staff provided a multiple page document that listed name of lab and procedural codes for billing.
4. There was no documented evidence provided to surveyors throughout the survey to which laboratory services were provided.
5. The findings were verified with the Director of Patient Care and Assistant Administrator at the time of review.

Based on observation, document review and staff interview, it was determined the hospital failed to ensure menus were provided that met the needs of the patients.

Findings:

On 09/17/14 at 3:30 p.m., a tour was conducted of the kitchen. There was no evidence of evening meal preparation. A review of the posted menu for the day indicated the patients were to receive a hot meal for dinner.

At the time of the meal observation, the patients actually received food that was not on the menu to include chicken club wraps, sliced cucumbers, ice cream pops and pudding. There was no documentation the dietitian approved substitutions for any meal.

The chicken club wraps were made of a white flour tortilla that held breaded chicken strips (that appeared to be undercooked, not browned), shredded lettuce and cheese only. The patients were given ranch dressing for the wraps and for the sliced cucumbers.

Many patients did not eat the chicken wrap or the cucumbers. Many patients ate the ice cream pops.

There was no evidence in the kitchen refrigerators or freezers that the food planned according to the menu was available in the kitchen. There was no evidence the kitchen had the food for any of the meals on the monthly rotation. The kitchen staff stated they changed the menu depending on what they had on hand.

The hospital leadership was asked if the dietitian was consulted about menu changes/substitutions and the special needs of adolescent and children patients. They stated they thought the dietitian could do a better job.

Based on document review and staff interview, the hospital failed to ensure the diet manual was approved by the dietician and medical staff.

Findings:
1. There was no documented evidence that the dietician and medical staff approved the dietary manual the hospital was currently using.

2. The dietary manual was dated 08/02/2004 and from a different state.

3. The diet manual did not have documented evidence that it followed the Recommended Dietary Allowance (RDA) or the Dietary Reference Intake (DRI).