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Based on review of personnel files, interviews with staff, and hospital documents the facility failed to ensure personnel are licensed, competent, and qualified to perform the duties they are assigned. According to Staff A several clinical services are contracted out to the facility the hospital leases space from. There was no documentation the personnel provided by the contractor had current licensure, competency, background, and orientation to the facility. This finding was confirmed with Staff C.

Based on record review and interviews with hospital staff, the governing body does not ensure that services performed under a contract are provided in a safe and effective manner. Multiple contracted services/personnel are not evaluated by the QAPI program to assure the services are performed in a safe and effective manner by qualified personnel.

Findings:

1. Contract personnel are not oriented, trained, and evaluated by the hospital to ensure the contractor follows hospital policies, and are competent. There was no documentation all contracted personnel had been oriented, trained, and evaluated by the hospital.

2. In an interview on 9/13/2012, Staff C told surveyors not all of the contract staff had orientation and training to the facility.

3. These findings were reviewed at the exit conference. No further documentation was provided.

Based on review of the hospital's grievance, complaint and variance manual and interviews with hospital staff, the hospital did not follow its grievance process. Three of four complaints voiced, that were not resolved at the time of the complaint were not identified as grievances and processed through the hospital's grievance process.

Findings:

1. The hospital's grievance policy, PCS 1.16, correctly identifies that complaints that are not resolved at the time are identified as grievances and processed through the hospital's grievance program.

2. Three of four complaints (Complaints #2, 3, and 4) reviewed did not show investigation and evidence a written response, with the required information, had been sent to the complainants.

3. Staff C told the surveyors on 08/13/2012 at 1200 that she could not find notes of investigation for three of the complaints. She verified that no written response had been sent/provided to the complainants.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure restraints were used in accordance with physician's orders. Three of three patients (Patients #1, 4, 14) restrained and whose medical records were reviewed, were not restrained according to physician's orders.

Findings:

1. Patient #1 - On 06/12/2012 at 0700 a posted restraint order was placed on the chart and signed by the physician. The order was not complete. It did not contain the type or restraint to be used or the reason for the restraint.

2. Patient #4 - Nursing narratives documented the patient was restrained on admission, 09/07/2012. The nursing flow chart/sheet was not completed (every two hour documentation of patient status and an assessment by the registered nurse every eight hours) as required per hospital policy. There was no physician order for the restraint. Subsequent orders for restraints were not complete. Nursing staff did not document on the flow chart; the only mention of restraints were in the nursing narrative notes.

3. Patient #14 - The patient was admitted on 09/07/2012. According to the nursing narrative notes, the patient was restrained on 09/09, 11 and 12/2012. The nursing flow charting was not completed as specified by policy and requirements. The patient was restrained on admission according to the nurses notes. There were not physician orders for the restraint. The physician orders for the rest of the restraint days were not complete, only signed.

Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to follow its policy and ensure orders for restraint use were not written on an as needed basis. This occurred in one of three patient records reviewed who had documentation of restraints.

Findings:

1. The hospital's policy, 3.191.3, stipulates that restraints are not to be written as an as needed order.

2. Patient #1-
a. The physician wrote an order a Posey restraint on 06/07/2012 at 1650. Nursing documentation did not record restraint usage on this date. Nursing notes documented that a Posey was not available. The record did not contain evidence the patient needed restrained.
b. On 06/08/2012 at 0700 a restraint order was posted and signed by the physician for a jacket restraint for 24 hours. Nursing documentation did not record the use of restraint until 2000.
c. On 06/09/2012 at 0700 a restraint order was posted and signed by the physician for a jacket restraint for 24 hours. Nursing documentation recorded restraint usage from 0800 to 1800 and 0400-0600 (for 06/10/2012). The record did not contain an entry as to why the restraint was discontinued or an order for when the restraint was reinstituted.

3. The above findings were reviewed with Staff C on 08/13/2012 at 1400. She stated that staff tried to use restraints as little as possible and remove them as soon as possible. She stated that the physician would sometimes write the order "just in case we might need it".

Based on review of medical records and interviews with staff, the facility failed to enforce the required bylaws and ensure a history and physical examination was performed within 30 days of admission, or 24 hours after admission or prior to a procedure which required anesthesia. There was no evidence the facility enforced any bylaws regarding medical record completion.

Findings:

According to the Medical Staff Bylaws and Rules/regulations "Admission and Discharge, History and Physical 5. A medical hisotory and physical must be completed and documented for each patient no more than 30 days before or twenty four hours after admisssion or registration provided, however if it occurs after admission or registration the patient will have a provisional diagnosis or valid reason for admission.

1. Pt #8 was admitted for respiratory distress, cellulitis, and chronic pain. The history and physical was dictated one month after the patient was admitted. There was no handwritten history and physical. There was no discharge summary. The medical record was over 45 days old.

2. At the time of the survey, patient #6's open medical record indicated the patient was admitted on 8/29/12. There was no history and physical in the medical record.

3. Patient #14 was admitted for acute respiratory failure. The history and physical was dictated after the patient discharged. There was no written history and physical in the medical record. The record was greater than 45 days old.

4. Patient #12 and #11 included partial history and physical with a notation "full note to follow". There was no note either handwritten or dictated dated and timed during the patient stay. The completed note was dictated 45 days after discharge.

5. Review of meeting minutes included medical record delinquencies. There was no evidence Medical Staff and Governing Body acted on the delinquencies as required by the facilities bylaws.

Based on record review and interviews with hospital staff, the hospital does not ensure that all drugs are administered to patients according to hospital policy. 3 of 3 patient's record's indicating the patient's received intravenous drips of narcotics did not follow the hospital's policy for narcotic administration.
Findings:

1. Three records reviewed for narcotic administration traceability did not have the amount of narcotic initiated, amounts administered from shift to shift, and amounts infused at discontinuation. There was no documentation included which indicated the volume of medication left once the medications were discontinued.

2. Pharmacy records did not reconcile the amount of narcotic received and the amount wasted.

3. Three of three medical records did not include documentation of the infusion in the designated area of the chart form as required by policy. This was verified with Staff C.

4. Pain assessment in the medical records were not consistently completed. Staff did not consistently document pain levels or response to pain medication.

5. These findings were reviewed with administration at the time of the exit conference. No further documentation was provided.

Based on review of medical records and hospital documents and interviews with hospital staff, the hospital failed to ensure medical records were complete and accurate. Two (Patient #1 and 4) of four patient records reviewed for skin assessment did not contain complete assessments of the patients' skin integrity.

Findings:

1. Patient #1 - The patient was admitted with a "Port-a-cath" and an unhealing abdominal incision. The nurse did not complete describe the patient's skin integrity and wound on 06/04-14/2012. The only descriptions of the wound were documented by the wound care nurse on 06/06 and 11/2012. This finding was reviewed and verified with Staff C on the afternoon of 09/13/2012.

2. Patient #4 - The nursing assessments did not contain complete skin assessments on 09/07, 08, 10, and 11/2012.

Based on review of medical records, interviews with staff, review of meeting minutes, and hospital documents the facility failed to provide a medical record containing all the required elements.

Findings:

1. Patients #15's medical records included documentation the patient had a fentanyl drip on arrival to the facility. Admitting orders included an order for Fentanyl intravenously every hour. There was no order for the Fentanyl drip until a verbal order was given 4 hours after arrival. There was no documentation of the rate, pain, or sedation level. According to the nursing narrative the nursing staff were to wean the Fentanyl drip. The order did not specify paramaters for weaning. Later documentation indicated the Fentanyl drip was turned off. There was no documentation indicating the amount of medication remaining at the time the medication was discontinued. There was no documentation of wastage of remaining narcotic. Documentation in the medication administration record stipulated "off" by the medication but no signatures were present.

The initial nursing documentation also stipulates the patient was on Ativan drip on arrival. There was no documentation of the amount of medication received. The order for the medication was given 4 hours after the patient arrival. There was no consistent documentation of the medication infusion rate, volume remaining, and volume infused throughout the time of the infusion. There was no documentation of the medication infused at the time the nurse documented "off".

The initial nursing documentation also documented the patient was on Levophed and Neosynephrine drips. There was no documentation of the volume remaining, rate, or amount infused throughout the patient stay.
On 9/13/12 these findings were verified with Staff C.

2. Patient #4's medical record indicated the patient arrived with a Fentanyl drip infusing. There was no documentation of the volume of the infusion received on arrival, there was no documentation regarding amount infused, or amount wasted when the medication was discontinued. There was no verification of wastage by a second licensed signature.

3. Several medical records reviewed included orders for intake and output. None of the records reviewed consistently included intravenous fluid administration totals.
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4. Patient #8's medical record indicated the patient arrested and a code blue was initiated. There was no code blue sheet as required by hospital policy. There was no documentation of what occurred during the code blue and there was no discharge summary.

5. The above findings were reviewed at the exit conference 9/13/2012. No further documentation was provided.

Based on review of interviews with staff, policies and procedures, the facility failed to develop, review, approve and implement radiology policies and procedures to protect patients and personnel. There is no documentation the facility had policies and procedures for radiation safety had been developed and implemented. This finding was verified with Staff C on 9/13/2012.

Based on review of medical records, contracts, and interviews with staff the facility failed to have a radiologist supervising the radiology services.

Findings:

1. On 9/13/2012 Staff A told surveyors the facility contracts for radiology services. There was no documentation indicating the facility had a radiologist in charge of the radiology services.

2. On 9/12 and 9/13/2012 surveyors reviewed hospital policies and procedures. There were no radiology policies and procedures reviewed, approved, and implemented regarding procedures performed at the facility and/or outside of the facility. There was no documentation the personnel were licensed and appropriately trained. There were no radiology polices and procedures regarding storage and retrieval of films, data files, or radiology reports.

3. There was no documentation a radiologist oversaw radiology procedures performed at the facility ensuring competency of the radiology personnel.

4. The above findings were reviewed with administration at the time of the exit conference. No further documentation was provided.

Based on review of medical records, hospital contracts, and interviews with staff the facility failed to have only qualified personnel designated by the radiologist in charge and/or the medical staff use radiology equipment and administer procedures.

Findings:

1. On 9/12/2012 Staff A told surveyors the facility had contracted radiology through the separately licensed medical facility the hospital leases space from. There was no documentation indicating the contracted radiology personnel were licensed, trained, and evaluated competent.

2. On 9/13/2012 Staff C told surveyors the facility had adopted the radiology policies from the separately licensed facility. There was no documentation the policies/procedures were revised to meet the needs of the hospital. There was no documentation the hospital reviewed the practices of the contracted personnel to determine the quality and competency of the services provided.

3. The above findings were presented in the exit conference with administration. No further documentation was provided.

Based on review of policies and procedures, interveiws with staff, and hospital documents the facility failed to assess, evaluate and make improvements to the facilities emergency preparedness needs.

Findings:
According to the facilities policy "Emergency Preparedness-Disaster Plan; General Considerations "all disasster drill will be followed by critques which may include written after action reports to identify shorfalls and make corrective actions / recommendations".
Further the policy stipulates 1. Initiation of a disaster plan the host facility will announce overhead "code yellow". The senior most member of the staff present in the facility will notify the CEO and senior administration...."

1. On 9/12/2012 Staff I told surveyors the facility received power and emergency power from the licensed medical facility it leases space from. According to documents received at the Department, the health facility leasing space to the hospital incurred catastrophic emergency generator failure around the end of June 2012 on a Saturday. As a result of this failure the hospital incurred total electrical loss for a minimum of 45 minutes.

Interviews with administrative staff indicate the administrative staff were not notified by staff present during the incident. Staff I told surveyors he was told the facility leasing space to the hospital announced a "code yellow" overhead but Staff I did not receive notification of the outage until return to work on Monday

There was no documentation by the staff at the time of the failure through incident reporting the power failure occurred.

On 9/13/2012 Staff I provided surveyors a drill critque which Staff I stated was "draft" form. Staff I stated he had been in contact with the Safety Officer for the other facility and was waiting on the results from the other facility. The draft did not have any information as to the lack of notification of senior leadership. There was no documentation included indicating interviews with leadership at the other facility had been conducted, interviews with staff present had been conducted, and evaluation of the plan with suggestions for improvement had occurred.

The facility failed to follow policy. The facility failed to develop and revise the emergency preparedness plan utilizing lessons learned from interruption of facility power.

2. These findings were confirmed with Staff I on 9/13/2012.