HospitalInspections.org

Based on policy and procedure review, hospital document review and staff interview, 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. establish a grievance process and ensure patients were made aware of the grievance process. See Tag A-0118;

c. ensure patients right to personal privacy. See tag A-0143;

d. ensure patients were cared for in a safe setting. See Tag A-0144;

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

f. establish patient visitation rights policies and procedures and inform patient's of their visitation rights. See Tag A-0216.
In addition, the hospital had no documentation staff were trained on patient's rights annually.

Based on record review and interviews with hospital staff, the hospital failed to develop, implement and maintain a quality assessment and performance improvement program (QAPI) that reflected the complexity of the hospital's organization and services, involved all hospital departments and services including those provided by contract or arrangement and had indicators selected that led to improved health outcomes.

Findings:

1. Review of hospital documents provided as part of a QAPI program did not have evidence of review of services provided by contract or agreement ensure quality of care and safety for patients. See Tag A 0083.

2. Review of hospital documents provided for review as part of a QAPI program did not have evidence of a grievance process to identify areas of improvement to patient care and satisfaction. See A Tag 0118.

3. The hospital did not have QAPI indicators to monitor high risk/low volume processes of care and identify opportunities for improvement. Problems identified during the survey in physical environment, radiology, and infection control had not been identified and monitored through a QAPI program.

4. The hospital did not have an effective, ongoing, hospital-wide data-driven QAPI program.
See Tag 0273.

5. The hospital did not have a QAPI program that included the organ, tissue and eye donation program into the hospital's QAPI program. See Tag 0886.

Based on observation, interviews with staff and review of hospital documentation, the hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff.

Findings:

1. The infection control practitioner has not ensured that infection control policies and procedures have been developed for each unit/area of the hospital. (Refer to Tag A-748)

2. The disinfectants used throughout the hospital have not been reviewed and approved by the hospital's Infection Control committee through the quality program. (Refer to Tag A-749)

3. The hospital does not have an ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained. (Refer to Tag A-749).

4. Surgical practices are not reviewed to ensure they reflect current infection control standards and safe practice.

5. The hospital does not ensure the infections control program has a current tracking mechanism for patients and staff to track infections and possible transmissions of infections and communicable diseases. Immunizations histories are not reviewed.

6. Leadership does not ensure infection control concerns and issues, or lack thereof, are reviewed, analyzed and corrective actions are taken through the quality assessment and performance improvement process. (Refer to Tag A-756).

Based on record review and interviews with staff, the governing body did not ensure all services provided by contract or agreement were evaluated, and in compliance with all applicable Medicare Conditions of Participation. Contracted services were not assessed through the hospital's Quality Assessment Performance Improvement (QAPI) program.

There was no evidence in governing body and medical staff meeting minutes for 2013 or 2014 or hospital documents presented as part of the quality program that services provided by contract or agreement were evaluated for quality of care and for actions taken if needed.

Hospital staff verified that contracted services were not evaluated by the QAPI program.

Based on record review and interviews with hospital staff, the governing body failed to ensure that personnel providing services by contract are oriented, evaluated to ensure competence and meet the same health requirements as employees of the hospital.

Findings:

On the afternoon of 3/11/14, Staff A stated dietician and sleep lab services are provided by a contract with Staff S and Staff DD, respectively.

Review of the personnel files for Staff S and DD did not contain documentation of hospital orientation and health requirement.

In the morning of 3/12/14 Staff B was asked for the health, files for Staff S and DD. Staff B stated he did not keep health files for contracted personnel.

On the afternoon of 3/12/14, Staff A stated the hospital did not provide hospital orientation to the contracted staff.

Based on medical record review and staff interview the hospital failed to inform patients and/or their representatives of all patient's rights. This occurred in twenty of twenty-one (#1 through 20) medical records reviewed for patient's rights information.

Findings:

Review of medical records #1 through 20 did not contain documentation patients were given patient's rights information. The information provided did not contain all the patient rights components as required.

On 03/12/14, A hospital policy, titled, "Patient Rights and Responsibilities", was provided to the hospital surveyors. The policy had not been approved by the governing body or medical staff. There was also no effective date or revised date for the policy.

The above information was presented to the hospital staff during the exit conference, no additional information was provided.

Based on review of hospital documents, medical records and staff interview, the hospital failed to:
a. develop and implement a grievance process
b. inform patient how to lodge a grievance with the hospital and the State Agency (Oklahoma State Department of Health-OSDH) and
c. incorporate grievances into the hospitals quality assurance and performance improvement (QAPI).

Findings:

During the tour of the hospital on 3/11/14, staff was asked about the hospital's grievance process. The DON (Staff J) and Staff O was unable to verbalize what is a grievance or what to do if someone wanted to file a complaint/grievance.

The surveyors requested to review the hospitals grievance policy. None was provided. Staff J stated the hospital did not have a grievance policy.

Review of a document, titled, "Statement of Patient Rights and Responsibilities", did not contain information on how to lodge a complaint with OSDH and inform patients or their representatives of the complaint/grievance process.

The document did not contain information regarding who to contact, at the hospital, to lodge a complaint/grievance with the hospital.

The document did not include information that informed the complainant of the right to seek review by the Quality Improvement Organization (QIO).

There was no documentation the hospital had a QAPI plan and that grievances/complaints were being reviewed in QAPI.

The above information was presented to the hospital staff during the exit conference, no additional information was provided.

Based on observation and staff interview, the hospital failed to ensure the privacy and safety of patients.

Findings:

1. On the morning of 3/11/14, surveyors toured the emergency department (ED). Surveyors observed the OB/GYN Room 3. The pelvic examination (OB/GYN) bed was positioned with the head of the bed at the wall and foot of the bed directly in the line of sight when entering the room. The positioning of the OB/GYN bed does not ensure the patient's basic rights to respect, dignity, and comfort.

2. On the morning of 3/11/14, the Director of Nursing told surveyors the bed had always been positioned that way and did not realize this compromised patient personal privacy.

Based on surveyors' observations, review of hospital documents, and interviews with hospital staff, the hospital failed to ensure infant care was provided in a safe setting.

Findings:

1. The surveyors observed obstetric and newborns care was not provided on a locked unit. Staff A and Staff CC told the surveyor on the morning of 03/11/2014, that one the baby had been delivered and the mother recovered, both the baby and mother would be moved to the medical/surgical unit.

2. Staff A told the surveyor that the hospital did not have an alarm warning system to help ensure infant safety - warning against infant abduction.

3. The hospital had a policy/protocol for infant abduction. The policy was not found in the nursing manual, but in the Safety manual. The policy documented that a "Code Adam" or "Code Eve" would be called. Staff were to position themselves at exits and

4. On the morning of 3/11/14, surveyors asked staff N, what would you do if you needed to call a pediatric code? Staff N told surveyors, "I don't know, call for help or pull the code cord." When asked what she would do if there was an infant abduction, she told the surveyor that she didn't know as she was only "prn" (as needed) staff.

Based on policy and procedure review, personnel file review, and staff interview, the hospital did not ensure patients were free from abuse. The hospital did not had a comprehensive abuse prevention program with policies and procedures that encompassed all required abuse prevention elements; including prevention, screening, identifying, training, protection, investigation, and reporting and response.

Findings:
1. On the afternoon of 3/11/14, the DON told surveyors that there were no current abuse policies and procedures.

2. The DON informed surveyors that the hospital did not have a comprehensive abuse prevention program.

3. There was no documented evidence of abuse training encompassing all the required elements in 24 (Staff B through F, H, J through N, Q through W, Y through CC, NN and OO) of 24 personnel files reviewed.

4. On the morning of 3/11/14, surveyors requested the hospital's abuse policies and procedures. None were provided.

5. On the morning of 3/12/14, surveyors requested the hospital's abuse policies and procedures from the Administrator. During the afternoon, abuse policies and procedures were provided to surveyors. There was no documented evidence that the abuse policy and procedures were approved by the medical staff.

6. On the afternoon of 3/12/14, the administrator verified that the abuse policy and procedure had not been approved by the medical staff.

Based on staff interview, review of hospital documents and medical record review, the hospital failed to ensure patients or their support persons were informed of the patient visitation rights. This occurred in twenty of twenty-one (#1 through 20) medical records reviewed.

Findings:

A hospital policy, titled, "Patient Rights and Responsibilities", was provided to the hospital surveyors. The policy had not been approved by the governing body or medical staff. There was also no effective date or revised date for the policy. The policy did not contain information regarding patient visitation rights.

Review of medical records #1 through 20 did not contain documentation the patients or their support person were informed of the visitation rights.

The above information was presented to the hospital staff during the exit conference, no additional information was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure data collected through patient incident reports were utilized to measure, analyze and track processes of care to monitor the effectiveness and quality of care. Incident reports were not analyzed and tracked through a QAPI (Quality Assurance Performance Improvement) process. The hospital did not have a process to track patient grievances to monitor processes of care. The hospital did not have an effective, ongoing, hospital-wide data-driven QAPI program.

Based on record review, observation and interviews with hospital staff, the hospital does not ensure the Quality Assurance Performance Improvement (QAPI ) program had a plan which included an ongoing program for the development, implementation and maintenance of indicators and program activities to ensure quality patient care and safety.

Findings:

1. 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. See Tag 0701.

2. The hospital failed to provide a hazard free environment for the radiology staff and patients. See Tag 0535.

3. The hospital failed to ensure personnel who provided radiology services were appropriately trained and competent to provide services to patients. See Tag 0545.

4. The hospital failed to ensure equipment and medical devices were safe for patient use. See Tag 0724.

Based on record review and interviews with hospital staff, the hospital failed to include as part of their quality assessment and performance improvement program (QAPI) indicators that reflect the scope and complexity of the hospital's services and operations. Indicators for surgical services and infection control did not reflect the scope and complexity of the services provided.

Findings:

1. The hospital provides surgical services that include, general surgery, endoscopy procedures and caesarian sections. Review of documents provided as part of a QAPI program did not have evidence of indicators to identify and monitor processes in surgery to identify potential patient safety problems.

2. Review of documents provided as part of a QAPI program did not demonstrate surgical services were monitored by infection control. The documentation did not demonstrate the leadership of the hospital ensured surgical services were provided in a safe and sanitary environment according to current standards of practice (See Tag A 749 ).

3. The QAPI program has not provided oversite of the infection control program to ensure a safe environment. The hospital does not have an ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained. See Tags 0747, 0748, 0749, 0756.

Based on record review and interviews with hospital staff, the governing body does not ensure the hospital has an ongoing Quality Assurance Performance Improvement (QAPI )program that reflects the complexity of the hospital's organization and services and involves all hospital departments including contracted or shared services. The hospital documents presented as part of the QAPI program did not have indicators for high risk and complex services such as surgical services and infection prevention. There was no evidence that all contract or shared services were evaluated by the QAPI program. Hospital staff verified that contracted services were not evaluated as part of an ongoing hospital wide QAPI program.

Based on record review and interviews with hospital staff, the governing body does not ensure the hospital has an ongoing program for quality improvement and patient safety, including reduction of medical errors and is defined , implemented and maintained. Review of documentation provided as part of the quality improvement program, governing body and medical staff meeting minutes for 2013 and 2014 did not have evidence of a quality assurance performance improvement (QAPI) plan and program.

Based on record review and staff interview, the hospital failed to ensure a registered nurse assigned care to other nursing personnel according to their specialized qualifications and level of competence, this occurred in 15 (Staff B, D, F, H through J, M, N, R, Y through CC, and OO) of 15 personnel records reviewed.

Findings:

None of the nursing personnel files had documented evidence of specialized qualifications, training, and competence, to include the contractors. This included, but not limited to:
a. Orientation and competency verification by the pharmacist for staff working in the hospital's drug room;
b. Orientation and competency verification by the respiratory therapist for staff providing respiratory treatments;
c. Orientation and competency verification for all staff providing care to obstetric patients and newborns;
d. Orientation and competency verification for staff working in the emergency department;
e. Competency verification for all surgical staff.

The CEO verified that the personnel files were complete during the time of review.

Based on medical record review and interviews with hospital staff, the hospital did not ensure that all entries in the medical record contain the date and time when they were signed or authenticated in electronic or written form by the person responsible for the services provided. This occurred in seven of nine (#3, 4, 7, 9, 12, 19 and 20) written medical records reviewed.

Findings:

Medical records #3, 4, 7, 9, 12, 19 and 20 contained electronic histories and physical and discharge summaries that did not contain the date or time the documents were authenticated by the physician or licensed practitioner.

The above information was presented to the hospital staff during the exit conference, no additional information was provided.

Based on review of medical records, document review, and interviews with hospital staff, the hospital failed to ensure all verbal orders were dated and timed by the ordering physician. This occurred in three (#7 through #9) of nine written medical records reviewed.

Findings:

Review of medical records # 7, 8 and 9 did not contain the date and time the physician signed the verbal orders.

The above information was presented to the hospital staff during the exit conference, no additional information was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure the consultant pharmacist supervises and evaluates the performance and competency of pharmacy personnel who provide pharmacy services when the Consultant Pharmacist/Pharmacist in Charge is not on the premises. Two (I and R) 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 R designated as the Drug Room Supervisor/Pharmacy department manager and Staff I designated as a Pharmacy Tech did not have competency evaluations and orientation by the Consultant Pharmacist specific for the duties they performed in the Drug Room by the Pharmacist/Pharmacist in Charge. They only had general hospital and nursing orientation. .

2. Drug room staff said on 03/11/14 that they had been mixing drugs without pharmacist supervision.

Based on record review and interviews with hospital staff, the hospital failed to ensure that a system is in place to track all scheduled drugs from the point of entry into the hospital to the point of disposition either through the administration to patients or wastage. The system does not ensure records are current and accurate, reconciled by pharmacy personnel and the system provides documentation in a readily retrievable manner. There was no evidence of pharmaceutical services periodically reviewing documentation of doses given and wastage documented. Pharmacy Staff R stated on 03/11/14 that drug discrepancies are not analyzed and trended to determine possible diversion.

Findings:

1. The hospital has automated drug dispensing machines in four areas of the hospital. Staff R stated that discrepancy documentation from the machines had not been retained and analyzed.

2. Documentation provided for review was a physical inventory count by Staff R documenting the drug counts were correct in the automated drug dispensing machines. There was no documentation of any reconciliation of dosages administered to patients with medications removed from the automated dispensing machines to determine if a partial dose was administered and wastage was documented.

Based on record review, observation and interviews with hospital staff, the hospital does not ensure that the hospital has a system in place to identify outdated, mislabeled or unusable drugs in the hospital. The hospital did not have evidence of routine inspections of all medication storage areas in the hospital by pharmacy/drug room personnel to identify outdated, mislabeled or unusable drugs.

Findings:

1. Drug room staff did not have any documentation of routine floor stock medication storage area inspections.

2. Hospital Staff R stated on 03/11/14 in the afternoon that they did not document any hospital medication floor stock storage area inspections.

3. Outdated and unusable drugs were observed in the emergency room, radiology and med-surg unit during the survey.

5. Intravenous (IV) fluids and mannitol solutions were found in the warmer in the emergency department and were not dated as to when they were put in and when they were to expire. Temperatures in the warmers were not monitored and documented to ensure they did not exceed safe temperatures.

6. Outdated drugs were observed in the radiology department emergency cart with an expiration date of 2008. The med-surg emergency cart also had expired intravenous fluids.

7. Review of the consultant pharmacist weekly reports did not have any evidence that the pharmacist conducts periodic routine inspections of drug storage areas in the hospital.

Based on record review and interviews with hospital staff, the hospital does not ensure that medication errors identified by the hospital are measured, analyzed and tracked. Review of Medical Staff Meeting minutes for 2013 and 2014 did not have evidence of any review, analysis or tracking of medication errors identified in incident reports.

Findings:

1. There was no evidence in hospital documents presented as part of the Quality Assurance Performance Improvement (QAPI) program or medical staff meeting minutes that medication errors were reviewed, analyzed or tracked.

5. Hospital staff verified on 03/12/14 in the afternoon that medication errors had not been analyzed or trended as part of the QAPI program.

Based on observations and staff interview, the hospital failed to provide a hazard free environment for the radiology staff and patients.

Findings:

The surveyors toured the radiology department on 03/11/14 accompanied by Staff V, the radiology director.

A spiked 500 milliliter (ml) bag of single use Normal Saline (NS) was observed hanging in the computerized axial tomography (CT) suite. Staff V stated the 500 ml NS bag is used to prime the CT injector. Staff V stated the NS bags remains spiked and hanging in the CT suite for twenty-four hours and is used for multiple patients.

Staff V stated CidexPlus, high level disinfectant (HLD), was used to clean the vaginal transducers for the ultrasound machine. Staff V was asked if she had the test strips to monitor the patency of the solution, Staff V stated no.

Review of the crash cart revealed expired medication and supplies. The intravenous fluids in the crash cart had expired in 2008. The supplies were outdated and were discolored. There was no laryngoscope handle present on the crash cart for the laryngoscope blades. This was confirmed by Staff V during review of the crash cart.

Based on record review and staff interview, 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 (human immunodeficiency virus), HCV (hepatitis C virus) or new blood safety issues related to infectious blood and blood products.

Findings:

Upon entrance to the hospital on the morning of 03/11/2014, the surveyors requested selected laboratory policies and procedures, including the procedure/protocol for policy for infectious/contaminated blood products. This was again requested on the morning of 03/12/2014.

None was provided.

Staff A stated on 03/12/2014 that the hospital did not have a policy and procedure/protocol for infectious/contaminated blood products.

Based on record review and interviews with hospital staff, the hospital failed to ensure the current diet manual had been approved by the Consultant Dietitian and the medical staff and available to all staff. The manual is updated every five years. The most current manual is dated 2012. The manual the hospital provided was dated 2006. Staff NN stated that the manual provided was the hospital's current manual.

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. Although the hospital had emergency preparedness plans, no evidence was given to the surveyors for review to show the hospital had:
a. Provided ongoing training to staff concerning their roles relating to the different types of disasters;
b. Conducted drills, both within the hospital and with community/area-wide resources.

2. On the afternoon of 03/12/2014, Staff A stated he thought the last time emergency preparedness drills were conducted was about 2 years prior.

3. All equipment was not tested/preventative maintenance done to ensure safe operation. Refer to Tag A-0724.

Based on observation and staff interview, the hospital failed to ensure equipment and medical devices were safe for patient use.

Findings:

1. On 3/11/14, surveyors toured the facility and the following observations were made:
~Laryngoscope handle located in the crash cart on the medical/surgical floor was covered with a hard whitish substance.
~Medication refrigerators hospital wide were not inspected, tested, and monitored.
~The Blickman fluid/blanket warmer in the emergency department was not inspected, tested, and monitored.
~Single Chamber Dilution Control System in housekeeping was not inspected, tested, and monitored.
~Commercial washer, dryer, and automated chemical dispensers in the laundry facilities were not inspected, tested, and monitored.
~Non-Commercial Washer in laundry facilities were not inspected, tested, and monitored.

2. Staff J was unable to identify and verbalize what the hard whitish substance was on the laryngoscope handle.

3. On 3/12/14, Staff E could not verify that any of the equipment was inspected and tested. Staff E told surveyors to ask Staff G.

4. Staff G told surveyors the equipment was tested by the manufacture. Staff G was unable to provide documented evidence that the equipment was inspected, tested, and monitored.

5. Staff P verified that the medication refrigerators, fluid/blanket warmer equipment was not inspected, tested, and monitored. Staff P also stated that the Dilution Control System, Non-Commercial washer, Commercial washer and dryer are serviced by the manufactures as needed. No documented evidence was provided to surveyors.

Based on surveyors' observations, hospital document review and interviews with staff, the hospital failed to:
a. Designate/identify in writing, the name of the qualified practitioner responsible for the infection control program;
b. Ensure the infection control preventionist (ICP) assured hospital wide infection control policies were implemented and monitored.

Findings:

1. Upon arrival, administrative staff identified Staff B as the ICP. Review of hospital meeting minutes and Staff B's personnel file did not demonstrate, he had been appointed/designated as the ICP. The personnel file did not contain a change of status notice or a job description for ICP.

2. The hospital provides its own laundry services. The laundry services department did not have policies and procedures for laundry services, including handling, sorting, pre-wash procedures, washing, drying, hand hygiene, protective personal equipment (PPE). The infection control manual did not contain policies and procedures for the laundry services.

3. The infection control manual did not contain infection control policies and procedures for each area/department of the hospital. The manual did not show a current review of the policies and procedures, the last review date was 2009. Findings include, but not limited to:
a. The manual did not contain a current infection control plan risk assessment for both the hospital/community wide and for tuberculosis;
b. The manual did not contain a policy and procedure for State reportable diseases, nor a current list of reportable diseases;
c. The manual did not contain current surgical and central sterile infection control policies, nor were they present in the surgery and central sterile manuals. (Refer to Tag A-0951.)
d. The hospital had no policy on disinfection between patients of commonly used medical equipment such as vital sign monitoring equipment.
e. The hospital did not have a policy for cleaning and disinfecting laryngoscope blades and ensuring they remained clean. Surveyor observed uncovered/unwrapped laryngoscope blade in the emergency department and obstetric/medical/surgical unit emergency carts.

4. No surveillance/monitoring activities were provided to the surveyors to show the ICP had tracked to ensure the policies had been implemented or followed. Staff B, the person identified as the ICP told the surveyors that he had not conducted any surveillance/monitored activities in each department.

5. The hospital did not have a current Infection Control Plan (Plan). The last review of the Plan presented to the surveyors was 01/09. Meeting minutes did not demonstrate the ICP and committee had revised or reviewed the Plan since that time.

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

The hospital does not have an ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained.

Findings:

Disinfectants:
1. The hospital's infection control program had not reviewed and approved disinfectants to use in the hospital.

2. Staff told the surveyors that the hospital currently used "No. 19" (No. 19 by Hillyard-Arsenal) for most disinfectant cleaning. According to the manufacturer, the product must remain wet on the surface for 10 minutes in order to be effective and is mixed from the concentrate as two (2) ounces per gallon. This product/disinfectant is not effective against Clostridium-difficile, but the hospital also had Cavi-Wipes, which is effective.
a. Observed in the emergency department was spray bottle with blue liquid without a product label. On the side the written "No. 19". Staff stated they obtained the liquid from housekeeping, but could not identify how the disinfectant was mixed or the disinfectant time (time the product needed to remain wet on the surface in order to be effective).
b. On the afternoon of 03/12/2014, Staff G told they surveyor that the hospital had an automatic dispenser that mixed the No. 19 disinfectant, but could not tell the surveyor the ratio of the dilution.
c. On the afternoon of 03/12/2014, Staff B told the surveyors that he did not observe disinfectant applications anywhere in the hospital to ensure they were mixed or used appropriately.
d. On 03/12/2014,Staff P told the surveyor that "tomorrow or the next day" the hospital was going to start using a Buckeye disinfectant - E-31. Meeting minutes did not demonstrate the ICP had been involved in the selection of this disinfectant or show a review of the disinfectant's effectiveness.

3. The staff in the laundry area were not trained in laundry disinfection practices. There was no record of monitoring for proper laundry hot water temperatures, drying temperatures and adequate levels of disinfectants.
a. On 03/12/2014, Staff E and G stated they did not monitor laundry and drying temperatures and were unaware of how this could be accomplished.
b. Observed on 03/12/2014, in addition to commercial washing machines, the hospital had a residential type washing machine. Staff E and G told the surveyor that this was used to wash the newborn and pediatric laundry because they used a hypo-allergenic soap. The container for this soap had no label.


Surveillance/Monitoring:
No surveillance data was provided to the surveyors for review. Staff B told the surveyors that the hospital did not monitor to ensure infection control policies and procedures were followed, including monitoring of:

1. Hand hygiene - No documentation of surveillance and monitoring of handwashing among all staff and volunteers (including surgical scrubs and surgical skin preps) was provided to surveyors. On 03/12/2014, six of seven hospital staff, observed by the surveyors (Staff E, G, N, V, Y, and PP of Staff E, G, H, N, V, Y, and PP), did not use hand hygiene as appropriate.

2. Isolation procedures;

3. PPE (personal protective equipment) use and education;

4. Surgical services:
a. Review of the autoclave tapes showed the staff were routinely using "flash"/shortened cycles for surgical eye instruments (Refer to Tag A-0951 for details);
b. For other instrument sets, after cleaning and use of the ultrasonic, surgery staff used a shortened cycle sterilization before the instruments were wrapped and sent back for terminal sterilization. Staff did not visually inspect the instruments with a magnifying glass to ensure effective cleaning of the instruments until after the shortened sterilization cycle;
c. There were no records of pass/fail on the high-level disinfecting scope processor. Records were not kept to identify patients with scopes used for future tracking of possible procedure-related infections.
d. The surgery department had no policy and procedure or mechanism to monitor surgical site infections.

5. Diagnostic services:
a. Radiology staff were using Cidex-Plus to disinfect trans-vaginal transducers/probes. Staff V told the surveyors on 03/12/2014 that she did not use test strips to check to ensure the chemical was still effective.
b. A spiked 500 milliliter (ml) bag of single use Normal Saline (NS) was observed hanging in the computerized axial tomography (CT) suite. Staff V stated the 500 ml NS bag is used to prime the CT injector. Staff V stated the NS bags remains spiked and hanging in the CT suite for twenty-four hours and is used for multiple patients.


Employee Health:
1. Meeting minutes did not reflect the hospital tracked employee exposures to patient blood and body fluids. The hospital had no approved and current bloodborne pathogen exposure control plan. The hospital exposure plan was last reviewed in 2009, with a last revision date of 2006.

2. The hospital did not document personal protective equipment (PPE) required for all job functions in each department. For example, there was no requirement to wear a protective gown and face shields when performing certain tasks in the laundry.

3. Personnel file review did not contain evidence staff were trained on the bloodborne pathogen plan upon hire and again annually.

4. The hospital did not perform annual respirator fit-testing for employees.

5. There was no documentation of surveillance of employee infections.

6. Not all employees had documentation of required immunizations and TB skin testing. This was found hospital wide. With the exception of two contract nursing staff (Staff Y and Z), no other staff personnel files (20 of 22 reviewed), including physicians and allied health, contained complete immunization histories as required by State Hospital Standards and as recommended by Centers for Disease Control and Prevention (CDC) and their advisory committee (ACIP - Advisory Committee on Immunization Practices).

Meeting minutes:
1. Meeting minutes reviewed (quality, medical staff, and governing body) did not reflect infection control issues/concerns, surveillances, and practices, or the lack thereof, were monitored, reviewed and analyzed with corrective actions to prevent, identify and manage infections and communicable diseases with measures that result in improvement on an ongoing basis.

2. Meeting minutes did not contain evidence the infection control monitored to ensure hospital-wide infection control policies and practices, developed to provide a sanitary and safe environment and prevent transmission of infectious and communicable diseases, were followed. It did not contain employee health, infections and illnesses. Staff B stated on 03/12/2014 that he did no monitoring and no infection control meeting minutes were done.

3. The hospital's infection control program did not review surgical services practices with corrective actions to ensure a safe sanitary environment was maintained and instruments were cleaned and sterilized appropriately.

Based on review of hospital documents and staff interview, the hospital failed to ensure policies were written to guide the nursing staff to develop and evaluate the hospital's discharge planning process. On the afternoon of 03/12/14, Staff J was asked for the hospital's discharge planning policies. None was provided.

Based on hospital document review and staff interview, the hospital failed to develop and implement policies and procedures to address organ procurement.

Findings:

Upon entrance to the hospital on the morning of 03/11/2014, the surveyors requested the hospital's policies and procedures/protocols regarding organ procurement. None was provided.

On the morning of 03/12/2014, the surveyors again requested any policies and procedures/protocols dealing with organ procurement. None was provided.

Staff A stated on 03/12/2014, that the surveyors had been provided everything the hospital had.

Based on document review and staff interview, the hospital failed to incorporate an agreement with an Organ Procurement Organization (OPO).

Findings:

1. Upon entrance to the hospital on 03/11/2014, the surveyors requested the hospital's OPO agreement.

2. The OPO agreement with Life Share was dated as starting on 01/04/2011. The contract specified a termination date of three (3) years after the start date. (Expiration date of 01/04/2014).

3. On the morning of 03/12/2014, Staff A told the surveyors that he thought another contract had been executed, but a signed copy had not been returned to the hospital.

4. The copy provided to the surveyors midmorning of 03/12/2014 was a copy of the one executed on 01/04/2011.

5. Staff A stated the hospital would have to obtain a current contract.

6. Review of hospital meeting minutes did not demonstrate the hospital had integrated organ procurement through the quality assesssment and performance improvement program.

Based on review of hospital documents and staff interview, the hospital failed to maintain a roster of practitioners with surgical privileges.

Findings:

During the tour of the operating room (OR) on 3/11/14, Staff B was asked to provide the surveyors with the OR department's roster of medical staff with surgical privileges.

The roster was outdated. The privileges for Staff II, KK and LL, were all granted in 2005. Staff B was asked for the current privileges for the OR staff, none was provided.

The surgery roster was incomplete. The roster did not include the names and privileges of all practitioners with surgical privileges in the OR. This was confirmed by Staff B.

Based on document review and staff interviews, the hospital failed to ensure that surgical services maintained standards of safe patient care.

Findings:

On 3/11/14, the surveyors toured the operating room (OR) accompanied by Staff B. Staff B was asked if the OR processed any instruments using Immediate Use Steam Sterilization (IUSS) or "flash" sterilization, Staff B stated no.

On the afternoon of 3/12/14 the OR log and autoclave log was reviewed with Staff OO.

Review of the autoclave log documented seven loads had been processed on 01/08/14. Six of the seven loads were flashed. Staff OO stated 01/08/14 was cataract surgery day. The hospital has three sets of instruments for cataract surgeries. Review of the OR log showed seven cataract surgeries were performed with a surgical time of ten minutes each. Staff OO was asked if the eye instruments were processed with IUSS after each case, she stated yes.

"Flash" (unwrapped) sterilization:
The Centers for Disease Control (CDC -- from Infection Control and Hospital Epidemiology, "Guideline for Prevention of Surgical Site Infection", April 1999, page 261) and Prevention and the Association of Operating Room Nurses (AORN -- Perioperative Standards and Recommended Practices, pages 578 through 581, 2008 edition) do not recommend the use of "flash" sterilization for the routine sterilization of instruments, reasons of convenience or as an alternative to purchasing additional instrument sets or to save time. "Flash" sterilization, according to current CDC guidelines, should be limited to the purpose of sterilizing a surgical instrument in an emergency, such as when a needed instrument has been dropped or otherwise become contaminated.

The hospital was cited for flash sterilization on 03/19/2009 during the re-certification visit. The POC provided by the hospital documented " The Surgery Supervisor will obtain additional sets of instruments so that "flash" will not be necessary " .

On 03/12/14, Staff B stated endoscopic procedures are performed every Tuesday. Staff B stated he was aware the scopes were to be reprocessed after five days of being idle. Staff B stated the hospital did not reprocess the scopes before use after being idle for 5 days.

The surgery polices were reviewed on 3/12/14. The policies were not documented as reviewed and approved by the medical staff.

Based on review of the hospital's operating room (OR) log and staff interview, the hospital failed to ensure the OR log contained all the required information.

Findings:

1. The OR log was reviewed on the afternoon of 03/12/14.

2. The OR log was a computer generated register. The log did not identify:

a. The name of the person administering the anesthetic;
b. The name of the scrub staff;
c. The name of the circulating nurse;
d. If other individuals, students, representatives, etc. were present, and if so, their names;
e. The time surgery began and ended;
f. Age of the patient;
g. Pre and post-op diagnosis.

3. The above information was presented to the hospital staff during the exit conference, no additional information was provided.

Based on document review and staff interview, the hospital failed to develop, approve and implement adequate policies and procedures related to anesthesia services.

Findings:

Surveyors requested and reviewed the hospital's anesthesia policies on 03/12/14.

The policies were not dated, documented as reviewed and approved by the medical staff. This was confirmed by Staff EE on the afternoon of 3/12/14.

There were no policies that addressed:
Patient consents;
Pre-anesthesia evaluation;
Intraoperative anesthesia report;
Post-anesthesia follow-up report;
Approved anesthesia agents;
Drug accountability procedures in accordance with hospital policies;
Infection control measures;
Safety practices for oxygen and gas anesthetics;
Protocol for supportive life functions, e.g., cardiac and respiratory emergencies;
Reporting requirements:
Documentation requirements:
Equipment requirements, as well as the monitoring, inspection, testing, and maintenance of anesthesia equipment in the hospital's biomedical equipment program.

Based on document review and staff interview the hospital failed to ensure emergency services are under the direction of a qualified member of the hospital's medical staff.

Findings:

1. On the morning of 3/11/14, surveyors asked Staff N to identify the medical director of the emergency department (ED).

~The Director of Nursing told surveyors, "It is either [physician name omitted] or [physician name omitted]."
~Staff N told surveyors, "I don't know, I only work PRN (as needed)."

2. On the afternoon of 3/12/14, hospital administrative staff provided organizational chart which did not list an ED medical director.

Based on document review and staff interview, the hospital failed to ensure the emergency department policies and procedures were updated and approved by the medical staff.

Findings:

1. On the morning of 3/11/14, the surveyors requested policies and procedures for the hospital's emergency services.

2. On the afternoon of 3/12/14, hospital administrative staff brought the emergency department (ED) policies and procedures to the surveyors.

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

4. Medical staff meeting minutes for 2013 through present had no documentation that medical staff approved the ED policies and procedures.

5. The Director of Nursing and Chief Executive Officer verified that the ED policies were new and had not gone through medical staff.

Based on hospital document review, record review, and staff interview, the hospital failed to ensure staff working in the emergency department (ED) had demonstrated specialized training and verified skills competencies. This occurred for three (Staff D, J, and N) of three 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 afternoon of 3/11/14, 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.

3. The Director of Nursing was asked if the hospital required ED skills competency verification. She informed surveyors that they have care learning online competencies.

4. A hospital emergency department document titled, "Position Description/Performance Evaluation" which documented, "...Regulatory Requirements: Current Registered Nurse license...Current BCLS Certification...ACLS certified within three (3) months of hire...PALS within six (6) months of hire ...ENPC ...within one (1) year of hire ...TNCC within one (1) year of hire...MICN...within one (1) year of hire..."

None of the personnel files had documentation of all regulatory requirements as indicated.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to appoint/designate a physician, with knowledge, experience and capabilities to supervise and administer the service properly, to be the director of respiratory care services for the hospital.

Findings:

Review of the hospital's department head list and meeting minutes did not have evidence that a physician had been designated as director of respiratory services.

Respiratory policies provided to the surveyors did not identify a physician director.

On the afternoon of 03/12/2014, the above findings were review with the administrator. No additional information was provided.

Based on review of hospital documents, personnel files and interviews with hospital staff, the hospital failed to ensure respiratory services were administered and supervised by qualified staff, consistent with State law.

Findings:

State Licensure Hospital Standards, Subchapter 23-6(a) requires that "respiratory therapy services, including equipment, shall be supervised by a licensed respiratory therapist".

Review of the hospital's organizational chart listed Staff B, as a RN, RRT (Registered Respiratory Therapist) and the director cardiopulmonary.
Review of the personnel file for Staff B did not contain a current respiratory care practitioner license/certification.

In the morning of 3/11/14, Staff J stated the hospital had two respiratory therapists, Staff B and Staff C.

Review of the personnel file for Staff C did not contain a current respiratory care practitioner license/certification.

The above information was presented to the hospital staff during the exit conference, no additional information was provided.

Based on review of hospital documents and medical records the hospital failed to ensure nursing provided respiratory care according to established policies and standards of practice. This occurred in two of two (#7 and 10) medical records reviewed of patients who received nebulizer treatments.

Findings:

The respiratory policies and procedures were reviewed on 3/12/14. The policies were not documented as reviewed and approved by the medical staff.

The respiratory policy for the hand held nebulizers did not contain documentation of a pre and post nebulizer assessment based on accepted standards of practice.

Medical records #7 and 10 had documentation of hand held nebulizer respiratory treatment, the records did not contain assessment and evaluations of the patient's conditions before and after the treatments, including vital signs, oxygen saturation, lung sounds and presence of a cough, with a description of any productive sputum or if the patient felt or had improved breathing after the treatment.

Based on review of hospital documents, personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure. This occurred in fifteen (Staff B, D, F, H through J, M, N, R, Y through CC, and OO) of fifteen nursing personnel records reviewed.



Findings:

In the morning of 3/11/14, Staff J stated the hospital has a respiratory therapist in-house during the hours of 8:00am until 5:00pm. Staff J stated respiratory care is provided by the nursing staff during the remaining hours.

Staff J, a RN, stated she provided respiratory training to the nursing staff.

Review of Staff B, D, F, H through J, M, N, R, Y through CC, and OO training files did not contain documentation of training and competencies evaluated by the respiratory therapist. This was confirmed by Staff J.

Based on policy and procedure review, staff interview, and review of personnel files, the hospital failed to ensure personnel who provided radiology services were appropriately trained and competent to provide services to patients. This occurred in three of three (U, V and W) radiology employee files reviewed.

Findings:
Staff V, who was the radiology director, was interviewed on the morning of 03/11/14.

Staff V was asked who provided orientation and training to the radiology staff, Staff V stated she provided the training.

Staff V was asked if she had any documentation of the training provided to radiology staff. Staff V stated no.

Staff V stated Staff U performed the computerized axial tomography (CT) procedures.

There was no documentation in Staff U's personnel file documenting competencies or training for CT that had been reviewed and approved by the Radiologist and/or medical staff.

Staff V stated she and Staff W performed CT, ultrasound and mammography procedures.

Review of the personnel file for Staff W and V, did not contain documentation of competencies for CT, ultrasound and mammography that had been reviewed and approved by the Radiologist and/or medical staff.

These findings were confirmed with Staff V at the end of the interview on 03/11/14.

Based on review of hospital documents and meeting minutes, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through quality assessment and performance improvement (QAPI) committee and:

1. Were monitored throughout the hospital, reviewed and analyzed;

2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and

3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. Hospital meeting minutes for 2013 were reviewed. The meeting minutes provided to the surveyors during the on-site survey were Corporate Compliance (identified to the surveyors as the hospital's QAPI), medical staff, and governing body, did not contain evidence/demonstrate the hospital leadership:
a. Reviewed and analyzed infection control data or lack thereof;
b. Ensured that 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 developed, implemented and followed to ensure a safe and sanitary environment and that staff were inserviced on those policies;
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; and
e. Provide follow-up/monitoring to ensure corrective actions taken were effective and sustainable.

2. The same hospital minutes did not contain analysis of employee, contract staff, physician and allied health immunizations, illness and infections to ensure infections and diseases were not transmitted between patients and staff.

3. Meeting minutes did not contain evidence the hospital's leadership has ensured policies and procedure were developed for all areas of the hospital concerning current accepted standards of practice in infection control. The hospital provided on-site laundry services. No policies had been developed to assure the service was performed according to regulatory requirements and current standards of practice.

4. The hospital offers surgical services. The meeting minutes did not demonstrate the leadership of the hospital ensured surgical services were provided in a safe and sanitary environment according to current standards of practice. The infection control portion of the meeting minutes did not demonstrate issues observed by the surveyors were identified, analyzed and corrective actions taken with follow-up to ensure compliance.

5. Meeting minutes did not reflect the hospital's leadership has provided oversite of the infection control program to ensure a safe environment. The meeting minutes did not reflect the hospital's leadership ensured surveillance/monitoring of all areas was performed to ensure current standards of practice in infection control were followed. This included, but not limited to:
a. Hand hygiene;
b. Fit testing;
c. Isolation practices;
d. Disinfectant practices;
e. Instrument and equipment cleaning practices;
f. Sterilization practices;
g. Environmental process inspections.

6. Staff B, the professional identified as the infection control preventionist, told the surveyors on the afternoon of 03/12/2014, that there were no infection control meeting minutes.

7. Corporate Compliance meeting minutes that contained a section labeled "Infection Control" documented no report was submitted.

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

Findings:

1. On 3/11/14 and 3/12/14, 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.

2. The Swing Bed Coordinator was asked if swing bed patients were given notification of all rights related to swing bed status.

She provided a swing bed packet that included patient rights document that did not include all the swing bed patient rights requirements.