HospitalInspections.org

Based on review of hospital documents and interviews with hospital staff, the hospital failed to have bylaws that define the organization's structure of governance and to define who is responsible for the conduct of the hospital's operations. No documentation was presented that defined who was ultimately responsible for appointing the medical staff and quality of care provided to patients.

Findings:

1. No bylaws were provided for review that defines how the governance of the hospital is organized and who is responsible for the conduct of the hospital operations including the appointment of medical staff members after recommendations by the medical staff.

2. The Governing Body failed to ensure the maintenance of an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff. See A Tags 0748, 0749, 0750, 0756.

3. The Governing Body failed to ensure services are provided in specialized areas appropriate for the service. See A Tag 0723.

4. The Governing body failed to ensure the electronic medical record included complete and accurate patient care information, timely authentication of verbal orders and documentation of complications. See A Tags 449, 457, 458, and 465.

5. The Governing body failed to ensure surgical services were provided in accordance with current standards of practice. See A Tags 0941, 0942, 0944, 0945, 0951, 0952, 0955, 0957, 0958, and 0959.

6. The governing body failed to ensure anesthesia services were provided under the direction of a qualified physician; department policies included current policies and procedures to address the provision of anesthesia in all areas to include the OR, the outpatient specialty clinic, the pain management area and the ER; an accurate, complete and legible intraoperative anesthesia record was provided; and a post-anesthesia evaluation was performed by a qualified practitioner. A Tags 1001, 1002, 1004 and 1005.

7. The governing body failed to ensure the hospital has an effective discharge planning process that applies to all patients and is specified in writing. Refer to A Tags 0800,0806,0810,0811,0812,0817,0820 and 0823.

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

a. ensure the electronic medical record included complete and accurate patient care information;

b. authenticate verbal orders within forty eight hours;

c. ensure complete history and physical examinations were available in the medical record within required State and Federal regulation time frames;

d. document complications in the medical record;

e. obtain informed consents; and

f. failed to ensure a discharge summary was documented in the clinical record.

The hospital failed to meet the Medicare Hospital Condition of Participation for 42 CFR 482.24 - Medical Record Services. See A Tags 0449, 0458, 0465, 0466, and 0468.

Based on 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 staff identified as the infection control preventionist has not been designated by the hospital as the infection control preventionist and does not have experience or training in establishing and maintaining an effective ongoing infection control program. (Refer to Tag A - 748)

2. The disinfectant used throughout the hospital has not been reviewed and approved by the hospital's Infection Control committee and is not effective against tuberculosis and Clostridium difficile (C-diff).

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. 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. The log of patient infections is based on positive culture from the lab and does not identify if the infections are hospital acquired/ nosocomial. (Refer to Tag A-750).

5. Infection control is not part of the quality assessment and performance improvement process. (Refer to Tag A-756).

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

a. ensure clinical staff had knowledge of the triggers that could be used to identify patients with potential discharge planning needs;

b. ensure there was a discharge planning evaluation for those patients who needed post-hospital services;

c. ensure discharge planning evaluations were done in a timely manner;

d. document results of the discharge planning evaluation with the patient or person acting on the patient's behalf;

e. document discharge planning evaluations in the patient's clinical record;

f. ensure a qualified staff person developed or supervised the development of an appropriate discharge plan if needed;

g. document discharge planning arrangements made on the patient's behalf; and

h. failed to provide a list of home health agencies that may be available for the patient's choice.

The hospital failed to meet the Medicare Condition of Participation for 42 CFR 482.43 Discharge Planning. See also A tags 0800, 0806, 0810, 0811, 0812, 0817, 0820 and 0823.

Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to ensure surgical services were provided in accordance with current standards of practice as evidenced by:

a. failure to ensure there was a clearly defined organizational structure within the surgery department to include the scope of surgical services provided, approval by the medical staff and to include all surgery department job descriptions, responsibilities and functions;

b. failure to ensure the surgery department was supervised by an experienced registered nurse;

c. failure to ensure a current roster of each practitioner's surgical privileges was available in all areas where procedures were performed;

d. failure to fully develop, review and update surgical department policies and procedures to reflect current standards of practice. The policies and procedures were not comprehensive in a manner and scope to address the surgical services provided, including failure to have an alcohol-based skin preparation and safety policy;

e. failure to ensure a complete history and physical examination was performed within required time frames and was made available prior to surgery or anesthesia;

f. failure to obtain formal consents for anesthesia and for a surgical procedure;

g. failure to ensure post-operative care was provided according to acceptable standards of practice;

h. failure to ensure there was an operating room register that contained all the required information;

i. failure to ensure the operative report include all the required elements;

j. failure to strictly limit flash sterilization to emergency situations and to prohibit routine flash sterilization for reasons of convenience; and

k. failure to document all items sterilized in each load for each sterilizer in order to quickly and efficiently identify any items that may need to be recalled in the event of suspected sterilizer failure.

The hospital failed to meet the Medicare Hospital Condition of Participation for 42 CFR 482.51- Surgical Services. See A Tags 0941, 0942, 0944, 0945, 0951, 0952, 0955, 0957, 0958, and 0959.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure anesthesia services:

a. were provided under the direction of a qualified physician;

b. department policies included current policies and procedures to address the provision of anesthesia in all areas to include the OR, the outpatient specialty clinic, the pain management area and the ER;

c. provided an accurate, complete and legible intraoperative anesthesia record; and

d. provided a post-anesthesia evaluation that was performed by a qualified practitioner.

The hospital failed to meet the Medicare Hospital Condition of Participation for 42 CFR 482.52- Anesthesia Services. See A Tags 1001, 1002, 1004 and 1005.

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

a. have policies and procedures that governed outpatient services and the integration with inpatient services; and

b. failed to develop an organizational plan to establish leadership and responsibility for outpatient services. There was no documentation of lines of authority for outpatient services.

The hospital failed to meet the Medicare Condition of Participation 42 CFR 482.54 Outpatient Services. See A tags 1077 and 1079.

Based on record review and interviews with hospital staff, the governing body failed to appoint members of the medical staff. Physician credential files, advisory board and medical staff meeting minutes did not have evidence of appointments of the medical staff by the governing body.

Based on record review and interviews with hospital staff, the governing body failed to ensure that services provided by contract or a joint venture are provided in a manner the same as if they were provided by hospital staff. Sevices provided by another hospital are not evaluated by the QA/PI program to assure they are provided safely, in compliance with the Medicare Conditions of participation and acceptaable standards of practice.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the patient or the patient's representative was informed of the patient's rights. Findings:

Patient #4 was a 19 month old female admitted to the hospital for an out-patient procedure. The patient demographics form did not list the patient's mother on the contact information section. The form listed a friend and the grandmother as contacts. There was no documentation to indicate who was the legal guardian for the patient. There was no documentation to indicate who accompanied the patient to the hospital.

There was no documentation of notification of patient's rights found in the clinical record.

On 09/27/12, staff B was asked to provide the documentation of patient's rights notification. She stated they it not be located. She was asked if there were policies and procedures to govern admission consents and other legal documentation. She stated there was not.

Based on clinical record review and staff interview, it was determine the hospital failed to obtain legal consents for admission, for anesthesia and for a surgical procedure. Findings:

Patient #4 was a 19 month old female admitted to the hospital for an out-patient procedure. The patient demographics form did not list the patient's mother on the contact information section. The form listed a friend and the grandmother as contacts. There was no documentation to indicate who was the legal guardian for the patient. There was no documentation to indicate who accompanied the patient to the hospital.

There were no signed consents for admission to the hospital, for anesthesia and for the surgical procedure documented in the medical record.

On 09/27/12, staff B was asked to provide the informed consents for this patient's admission. She stated they could not be located.
She was asked if there were policies and procedures to govern admission consents and other legal documentation. She stated there was not.

Based on record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure there was a comprehensive system in place to protect patients from all forms and sources of abuse and neglect. Findings:

The hospital's abuse policy was reviewed. The policy was written to address staff identification and response to suspected patient abuse by others outside the hospital system. The policy did not address the following:

a. training staff to recognize and report potential abuse or neglect by a staff person, volunteer or other person within the hospital system;

b. how a possible victim of abuse or neglect (and other potential victims) would be protected during an investigation;

c. actions the hospital should take to investigate all allegations of abuse and neglect; and

d. requirements for documentation of allegations or suspicions of abuse and/or neglect, the investigative steps taken, the conclusion of the investigation and documentation of actions taken in response to the findings.

On 09/27/12, staff B verified the hospital's policy was limited to response to patient abuse and neglect by persons outside the hospital system. She stated it did not address the possibility of abuse and neglect by someone within the hospital.

Based on record review and interviews with hospital staff, the governing body failed to ensure that adverse events such as incidences and medication errors are identified, tracked, analyzed and preventative actions taken. Adverse events were not tracked and analyzed as part of an ongoing Quality Assurance/Performance Improvement (QA/PI) program.

Findings:

1. The hospital experienced a hospital wide power failure with concurrent generator failure. There was no documentation of an investigation of the cause and steps taken to ensure no reoccurance.

2. There was no documentation of the analyzing of medication errors by hospital staff as part of an ongoing QA/PI program.

3. Services provided by contract are not evaluated by the QA/PI program.

4. The hospital's PI plan for 2012 states that all medication errors are to be recorded and submitted to the department supervisor for trending and process review. There was no documentation this was occurring.

5. The hospital's PI plan for 2012 states that all departments will evaluate patient care services provided by contracts to ensure services are provided in a safe and effective manner. There was no documentation this was occurring.

Based on review of medical records, medical staff bylaws, rules and regulations, Medical Staff Meeting Minutes 2012 and Governing Body meeting minutes 2012 the hospital failed to develop, review, approve, implement, and enforce Medical Staff Bylaws which comply with State and Federal regulation and current standards of practice.

Findings:

1. On 9/27/2012 surveyors reviewed Medical Staff Bylaws rules and regulations the bylaws dated 2008 include a provision for "rules and regulations". The Medical Staff Rules and Regulations stipulate:

6. "All orders for treatment shall be in writing. An order is considered to be in writing if dictated to a registered nurse or licensed practical nurse. orders may also be dictated to the respiratory therpist and physical therapist for the functions which they legal can perform. Orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician per his or her own name. At his next visit, the attending physician shall sign such orders." The time frame for authentication does not meet Federal and State standards. There is no stipulation limiting the frequency of the use of verbal orders.

7. Each member of the Medical Staff not a resident of the City of El Reno or the immediate vicinity shall name a member of the Medical Staff who is a resident of El Reno or immediate vicinity who may be called to attend patients in case of emergency. In case of failure to name such asociate, the administrator of the hospital shall have the authority to call any member of the Medical Staff should he/she consider it necessary. Review of credentialing files did not stipulate the physicians on the medical staff are compliant with this rule. There was no evidence surgeons residing outside of El Reno had designated a surgeon within the city limits to care for their patients.

9. Except in emergency, no patient shall be admitted to the hospital until after a provisional diagnosis has been stated and the consent of the administrator or his delegate secured. As required in the Federal regulations patients must be admitted under the order of a physician.

15. Patients shall be discharged only on written order of the attending physician. At the time of discharge the attending physician shall see that the recordis complete, state his final diagnosis and sign the record. Any patient who requests or demads to leave the hospital without permission of the physician must sign a release from responsibility for discharge releasing the hospital, hospital staff and the attending physician from all responsibilities for any ill effect which may result from such discharge. There is no evidence the facility reviews medical records for discharge on written order of the attending physician. Several records did not have documentation the patient was discharged on the order of an physician.

17. A complete history and physical examination shall be written within forty eight hours after admission of the patient. The facility failed to meet Federal and State all requirements for history and physical completion.

24. Operative reports must be dictated within twenty-four (24) hours following surgery or medical staff privileges may be withdrawn. There is no evidence the facility reviews medical records for this requirement. Four of five procedure charts reviewed had operative reports dictated after the procedure (at times months after the procedure) without evidence a hand written operative summary was in the medical record.

34. When a patient is admitted in a condition of abortion, she or her representative shall sign a statemnt certifying that neither any employee of the hospital or the attending physician was directly or indirectly responsible for its production. The facility failed to provide patients a notice of this requirement.

31. Consultations (b) Essentials of a consultation: A satisfactory consultation includes examination of the patient and the record. A written opinion signed by the consultant must be included in the medical record. Then operative procedures are involved, the consultation note, except in emergency, shall be recorded prior tot he operation. The facility failed to enforce this rule. Patient #5's medical record included documentation the anesthesia provider had consulted with other physicians for emergent treatment of a blood dyscrasia. There was no documentation in the record of the consult..

21. Free access to all medical records of all patients shall be afforded to staff physicians in good standing for bonafide study and research, consistent with preserving the confidentiality of personal information conerning the individual patients. SUbject to the discretion of the administrator, former members of the medical staff shall be permitted free access to information from the medical records of their patients coverinag all periods during which they attended such patients int he hospital. The facility failed to protect the privacy of the patients as there is no evidence the facility notifies patients of these types of disclosure. There is no evidene all patients medical records are appropriate to be released to all physicians in good standing for bonafide study and research.

Based on review of five procedure charts the hospital failed to develop, review, approve, and enforce bylaws, rules and regulations which require a history and physical documented within 24 hours of admission and immediately prior to surgery. Five of five medical procedure charts did not have history and physicals or did not have updated history and physicals immediately prior to surgery.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the nursing staff provided care according to accepted standards of practice. Findings:

1. Patient #4 was a 19 month old female admitted to the hospital for an out-patient procedure. The hospital was asked to provide a printed copy of the entire medical record. The record was reviewed for evidence of the nursing care provided.

2. The nursing staff did not document who accompanied the child to the hospital and who was the legal guardian and/or primary care giver. There were no signed consents for admission to the hospital, for anesthesia or for the surgical procedure.

3. The record indicated the toddler was placed in a regular bed with side rails. There was no indication the child was placed in a crib. "Safety Factors" documented for the child were designed for an adult. There were no pediatric-specific safety interventions documented.

4. A "Problem List" for the patient documented, "... Patient denies relevant surgical history... Patient denies relevant medical history... Family: Father-Other... Healthy-mother..." There was no narrative documentation as to what "other" meant for information about the father's health history. There was no documentation of who answered the health history questions for this child.

The problem list went on to document assessment of the patient's tobacco use, alcohol use, drug use, sexual activity, social activities of daily living, occupation and socioeconomic status. The problem list and assessment did not document issues relevant to a toddler.

5. A "Patient Education" section documented, "... None..." This indicated the person(s) who accompanied the child to the hospital received no instructions during the out-patient visit.

6. A "Flowsheet" documented an assessment performed pre-operatively. It documented, "... Cognitive/Perceptual/Neuro WDL... Cardiovascular WDL... Peripheral Neurovascular WDL... Respiratory WDL... Gastrointestinal WDL... Genitourinary WDL... Musculoskeletal WDL... Skin WDL except abscess - draining abscess left perineum..."

There was no documentation of what "WDL" meant. Staff B stated it meant "within defined limits." She did not know what those parameters were and did not know if the parameters were pediatric or adult specific.

There was no documentation that indicated how cognitive/perceptual/neuro/cardiovascular/peripheral neurovascular/respiratory/gastrointestinal/genitourinary/ musculoskeletal systems were determined to be within defined limits.

There was no documentation of an assessment post-operatively.

7. A "Modified Aldrete" post-anesthesia assessment was performed before the surgical procedure. There was no documentation of an Aldrete assessment performed after surgery.

8. A "Pre-Op Pre-Procedure Checklist" was completed on 08/30/12 at 7:48 a.m.. This was a day after the patient was discharged. The checklist documented the history and physical exam was completed pre-operatively. However, the clinical record documented the history and physical examination was completed by the physician after surgery was completed.

The checklist documented the patient was on current antibiotic therapy. There was no documentation of what antibiotic the patient was taking, why the patient was taking it and when the last dose was last taken.

The checklist indicated the patient's last food intake was on 08/28/12, the day before admission. There was no documentation as to the time of the last intake.

The checklist documented the patient had pierced ears. There was no documentation the earrings were removed prior to going to surgery.

The checklist documented there was no IV inserted pre-operatively. The patient was to have general anesthesia by mask. There was no documentation of a plan to insert an IV in the OR, after the patient was asleep.

The checklist documented the patient had a "bath/shower, skin prep." There was no documentation as to which of these were completed and where, and no documentation as to what pre-surgical skin cleanser was used. There was no documentation of what the skin prep included.

The checklist documented pre-op teaching was performed. There was no documentation of what was taught. There was documentation of a "learning response" by the mother, but there was no documentation as to what the learning response was.

The checklist documented there was no pre-procedural sedation. It could not be determined in the documentation if the CRNA gave the toddler a sedative prior to going to the operating room.

9. A "Side and Site Verify" form, completed the day after discharge, documented the patient's identification was verified prior to surgery by asking the patient, a toddler, her name and date of birth. The form did not document the mother or guardian verified the patient's identification.

The form documented the surgical procedure was verified with the history and physical examination. The history and physical was not performed until after the surgical procedure.

The form documented consents for the surgery and anesthesia were signed and verified. There was no documentation as to who signed consent for the patient, a minor. The consent forms could not be found by the hospital.

The form documented "Implants/Special Equipment Available." There was no documentation as to what implants or special equipment was used during surgery.

10. The clinical record documented vital signs were taken by the nursing staff one time before surgery on 08/29/12 at 7:43 a.m.. The vital signs did not include documentation of respiration rate, pulse oximetry, or of temperature. There was no documentation of any vital signs taken after surgery.

11. There was no documentation of the patient's discharge and of the condition at the time of discharge.

12. There was no documentation of discharge teaching instructions.

Staff B was asked if the clinical record documented all the nursing care that was provided to the patient. She stated she believed so.

Based on review of hospital documents personnel files, and medical records and interviews with hospital staff, the hospital failed to ensure nursing staff are adequately trained, oriented and have demonstrated skills competency for their assigned care areas and are competent to provide care to meet the needs of the patients.

Findings:

1. The hospital is an acute care hospital that cares for patients of all ages in the emergency, surgical and inpatient settings.

2. Review of eight of eight nursing staff (Staff F, G, H, I, N, Q, R, and S) and two of two paramedics (Staff O and P), who provide nursing care and whose personnel files were reviewed, did not have current age-specific competencies. The most current training/competency verification was 2009.

3. Staff I, who had recently been promoted to medical/surgical manager had not been provided orientation and training for this position.

4. Staff L, who also worked as the pharmacy tech/drug room staff, did not have orientation and training to the drug room by the pharmacist and the last medication competency was 04/2009.

5. Surgical staff F, G and H did not have orientation, training and competencies for their duties in the surgical and endoscopy areas.

6. Staff N, who administered Propofol and Versed to Patient #1 on 09/24/2012 in the emergency room did not have a competency verification for administration of conscious sedation.

Based on review of medical records the hospital failed to ensure verbal orders are used infrequently. 10 of 11 medical records included verbal orders.

1. Review of five surgical records indicated all preoperative orders were initiated as verbal orders. There was no authentication by the physician.

2. Review of meeting minutes did not include any review of medical records for appropriate use and frequency of use of verbal orders.

3. Review of medical records staff rules and regulations "6. ...Orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician per his or her own name. At his next visit, the attending physician shall sign such orders." The facility failed to address frequency of use, and a time frame for authentication which meets Federal and State regulation.

Based on interviews with staff, hospital documents, and policies the facility failed to have an organized medical records service which met the scope and complexity of the service.

Findings:

1. On 9/27/12 surveyors reviewed several records. Multiple problems with completion were noted. Several operative notes, history and physicals, nursing documentation were missing or did not meet time requirements set by hospital bylaws or State and Federal regulations. There was no documentation these issues had been reviewed and remediated by the governing body, medical staff, or medical records committee.

2. The facility recently transitioned from hard copy medical records to a combination of hard copy and electronic medical record. There were not policies and procedures addressing a complete medical record which could be released to the patient. Staff E provided surveyors a copy of a vendor guide which included instruction for determining where many of the documents resided. There was no policy and procedure reviewed and approved through governance which directed staff as to where or how to provide a complete medical record.

3. There was no evidence in committee meeting minutes the facility reviewed records for completion. There was no evidence in the meeting minutes the facility reviewed the medical records for delinquencies and submitted this information for action to the Medical Staff or Governing Body.

4. There were no policies and procedures developed, reviewed, approved, and implemented for the Medical Records Department. Policies and procedures did not address the complexities of the electronic record, completion of records, and down time procedures for the facility. Most of the policies provided during survey addressed the larger related entity. Processes identified at the facility did not have policies and procedures developed.

5. On 9/27/12 Staff E told surveyors she had recently been promoted to the manger of the medical records department. There was no evidence Staff E had been oriented and trained for the position. Staff E told surveyors prior to overseeing the medical records department she had been a transcriptionist.. There was no evidence Staff E possessed adequate training and education to ensure the facility maintained accurate complete medical records.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the electronic medical record included complete and accurate patient care information. Findings:

1. Patient #4 was a 19 month old female admitted to the hospital for an out-patient procedure. The hospital was asked to provide a printed copy of the completed medical record. The following deficiencies were found:

a. The patient demographics form did not list the patient's mother on the contact information section. The form listed a "friend" and the grandmother as contacts. There was no documentation to indicate who was the legal guardian for the patient. There was no documentation of who accompanied the patient to the hospital and who was the primary caregiver.

b. A "General Information" section of the medical record documented, "...Orientation to Hospital: CL; BR; BC; TV..."
The General Information section also documented, "... Armband Location: LA... Safety Factors: Adult: upper side rails raised x 2, lower side rail raised x 1..." This information did not appear to be related to the care of the patient who was a child.

The form did not indicate the toddler was placed in a crib.

Staff B was asked what the abbreviations CL, BR, BC, TV, and LA stood for. She stated she did not know for sure. She was asked if the electronic record designated what abbreviations stood for. She stated it did not. She was asked if she could determine by this general information if the patient was a child. She said she could not.

c. A "Problem List" for the patient documented, "... Patient denies relevant surgical history... Patient denies relevant medical history... Family: Father-Other... Healthy-mother..." There was no narrative documentation as to what "other" meant for information about the father's health history. There was no documentation of who answered the health history questions for this child.

The problem list went on to document assessment of the patient's tobacco use, alcohol use, drug use, sexual activity, social activities of daily living, occupation and socioeconomic status. The problem list did not document issues relevant to a toddler.

d. A "History and Physical" form dictated and signed by the physician on 08/29/12 at 8:33 a.m., (after the surgery was completed) documented, "... [Left] perineal area abscess in need of [incision and debridement] [without] signs of generalized infection, stable cardiopulmonary exam..."

This was the entire history and physical examination. There was no other medical history or physical examination by the physician documented on the form or elsewhere in the clinical record.

e. In an operative note, dated 08/29/12, the physician documented, "... The patient is an 18 month old female with infection, what looks like MRSA, in left sided perineal area..." There was no documentation in the clinical record that indicated the physician communicated the possibility of MRSA infection to staff and there was no documentation the physician ordered contact precautions.

There was no documentation of discharge instructions given to the patient's family regarding possible MRSA and contact precautions. (A culture performed during the procedure later returned results that were positive for MRSA.)

f. A "Patient Education" section documented, "... None..." This indicated the person(s) who accompanied the child to the hospital received no instructions during the out-patient visit.

g. A "Flowsheet" documented, "... Assessment: Cognitive/Perceptual/Neuro WDL... Cardiovascular WDL... Peripheral Neurovascular WDL... Respiratory WDL... Gastrointestinal WDL... Genitourinary WDL... Musculoskeletal WDL... Skin WDL except abscess - draining abscess left perineum..."

There was no documentation of what "WDL" meant. Staff B stated it meant "within defined limits." She did not know what those parameters were. The form documented this assessment occurred on 08/29/12 at 7:45 a.m. and again at 7:47 a.m.. Both assessments contained exactly the same information. Staff could not explain why two assessments would be performed two minutes apart.

There were no other assessments documented in the clinical record.

The Flowsheet also documented, "... Fire Risk Assessment 08/30/12 at 7:58 a.m.... Fire Risk Score 1..." This fire risk was performed the day after the patient was discharged. There was no documentation this was a late entry. It could not be determined by the documentation that this fire risk assessment was performed as a part of the intraoperative care. There was no documentation as to what a fire risk score of "1" meant.

h. A "General Information" form, dated 08/30/12 at 7:47 a.m. documented, "...Orientation to Hospital: CL; BR; BC; TV..."
The General Information section also documented, "... Armband Location: LA... Safety Factors: Adult: upper side rails raised x 2, lower side rail raised x 1..." This information appeared to indicate the patient was either re-admitted to the hospital or was still a patient on 08/30/12, when other documentation indicated the patient was discharged on 08/29/12. The documentation did not indicate this was a late entry.

i. A "Modified Aldrete" form, dated 08/29/12 at 7:44 a.m., documented, "... Modified Aldrete Postanesthesia Score: Activity 2, Respiration 2, Consciousness 2, O2 Saturation 2, Dressing 2, Pain 2, Ambulation 2, Fasting/Feeding 2, Urine Output 2..." This documentation of a post-anesthesia assessment was done prior to the surgical procedure.

The form did not indicate what an Aldrete score of "2" meant. There was no documentation an Aldrete postanesthesia assessment was performed upon admission to the recovery period and at the time of discharge from recovery.

j. A "Pre-Op Pre-Procedure Checklist" was completed on 08/30/12 at 7:48 a.m.. This was a day after the patient was discharged. The checklist documented the history and physical exam was completed pre-operatively. However, the clinical record documented the history and physical examination was completed by the physician after surgery was completed.

The checklist documented the patient was on current antibiotic therapy. There was no documentation of what antibiotic the patient was taking, why the patient was taking it and when the last dose was last taken.

The checklist indicated the patient's last food intake was on 08/28/12, the day before admission. There was no documentation as to the time of the last intake.

The checklist documented the patient had pierced ears. There was no documentation the earrings were removed prior to going to surgery.

The checklist documented there was no IV inserted pre-operatively. The patient was to have general anesthesia by mask. There was no documentation of a plan to insert an IV in the OR, after the patient was asleep.

The checklist documented the patient had a "bath/shower, skin prep." There was no documentation as to which of these were completed and where, and no documentation as to what pre-surgical skin cleanser was used. There was no documentation of what the skin prep included.

The checklist documented pre-op teaching was performed. There was no documentation of what was taught. There was documentation of a "learning response" by the mother, but there was no documentation as to what the learning response was.

The checklist documented there was no pre-procedural sedation. It could not be determined in the documentation if the CRNA gave the toddler a sedative prior to going to the operating room.

k. A "Side and Site Verify" form, completed the day after discharge, documented the patient's identification was verified prior to surgery by asking the patient, a toddler, her name and date of birth. The form did not document the mother or guardian verified the patient's identification.

The form documented the surgical procedure was verified with the history and physical examination. The history and physical was not performed until after the surgical procedure.

The form documented consents for the surgery and anesthesia were signed and verified. There was no documentation as to who signed consent for the patient, a minor. The consent forms could not be found by the hospital.

The form documented "Implants/Special Equipment Available." There was no documentation as to what implants or special equipment was used during surgery.

l. The clinical record documented vital signs were taken by the nursing staff one time before surgery on 08/29/12 at 7:43 a.m.. The vital signs did not include no documentation of respiration rate, pulse oximetry, or of temperature. There was no documentation of any vital signs taken after surgery.

m. A scanned anesthesia record was included in the completed electronic record. The scanned form had been reduced in size to fit the electronic page and could not be read. The original form could not be located by the hospital. It could not be determined what medications were administered to the patient during the procedure.

The form did not document an assessment by the CRNA post-procedure. There was no documentation of vital signs taken when anesthesia was stopped. The CRNA did not document the presence or absence of complications post-procedure.

Based on review of medical records the hospital failed to authenticate verbal orders within forty eight hours.

1. 10 of 11 medical records containing verbal orders did not have verbal orders authenticated by practitioners within 48 hours.

2. Review of medical records staff rules and regulations "6. ...Orders dictated over the telephone shall be signed by the person to whom dictated with the name of the physician per his or her own name. At his next visit, the attending physician shall sign such orders." The facility failed to address frequency of use, and a time frame for authentication which meets Federal and State regulation.

3. Review of meeting minutes for Medical Staff, Quality, Governance did not include information regarding the use of verbal orders and decreasing the frequency of use.

Based on review of medical records, medical staff bylaws, and interviews with staff the hospital failed to ensure history and physical examinations are available in the medical record within required State and Federal regulation time frames.

Findings:

1. According to the Medical Staff Bylaws, Rules and Regulations, 17. A complete history and physical examination shall be written within forty-eight hours after admission of the patient. 18. When such history and physical examination or permission for surgery are not recorded before the time stated for operation, the operation shall be canceled unless the attending physician states in writing that such delay would constitute a hazard to the patient. 5 of 5 medical records did not contain and history and physical or did not contain a history and physical in a timely fashion.

2. Patient #9's medical record indicated the patient had a closed reduction under anesthesia. The medical record contained a face sheet, a admission sheet, and an operative note. There was no history and physical in the medical record.

3. Patient #5's medical record indicated the patient had a history and physical the day before surgery. The medical record indicated the patient had lab work pending. The day of surgery there was no update to the history and physical regarding the pending lab. The lab work was abnormal. The patient had a low platelet count and the surgery was aborted due to bleeding.

4. Patient#11's medical record indicated the patient's history and physical was dictated on the day of admission but was not transcribed until 12 days after the patient was discharged. There was no handwritten documentation of history and physical in the chart.

5. Patient #10's medical record indicated the patient's history and physical was dictated and transcribed greater than 90 days after admission. There was no handwritten history and physical in the medical record.

6. Patient #6's medical record indicated the patient's history and physical was dictated prior to admission. There was no update to the history and physical prior to a procedure being performed.

7. Patient #4's completed medical record documented a history and physical examination was dictated and signed by the physician after the patient's surgery was completed. The entire history and physical documented, "... [Left] perineal area abscess in need of [incision and debridement] [without] signs of generalized infection, stable cardiopulmonary exam..." There was no other medical history or physical examination information documented on the form or elsewhere in the clinical record.

8. There was no documentation the facility reviewed records for timeliness of history and physical. The facility failed to ensure the patient's had a current, updated history and physical in the medical record.

9. The above findings were presented at the exit conference. No further documentation was provided.

Based on review of medical records the hospital failed to document complications in the medical record. Patient # 5's medical record indicated the patient had a procedure that had to be aborted due to bleeding. The operative note was reviewed. In the category complication: the physician documented "none". There is no documentation the facility reviews medical records for complications.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to obtain informed consent. Findings:

Patient #4 was a 19 month old female admitted to the hospital for an out-patient procedure.

The patient demographics form did not list the patient's mother on the contact information section. The form listed a "friend" and the grandmother as contacts. There was no documentation to indicate who was the legal guardian for the patient. There was no documentation of who accompanied the patient to the hospital and who was the primary caregiver.

There were no signed consents for admission to the hospital, for anesthesia or for the surgical procedure. On 09/27/12, staff B stated the consents could not be found.

Staff B stated there were no hospital policies and procedures to guide the staff for obtaining informed consents.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a discharge summary was documented. Findings:

Patient # 4 was admitted for an outpatient surgical procedure. The patient required home health care post-operatively. There was no documentation of a discharge summary found in the clinical record.

Staff B confirmed there should be a discharge summary as required by the hospital.

Patient #5 was admitted for a surgical procedure. A complication occurred and the procedure was aborted. The medical record did not contain a discharge summary.

Based on interviews and review of contracts the facility failed to provide qualified dietary staff.

Findings:

1. On 9/27/2012 surveyors reviewed dietary personnel files. Staff J and Staff X did not have documentation they had been trained and were competent in food services and dietary responsibilities. The last documentation of competencies or inservicing was 2009.

2. On 9/27/2012 these findings were presented to the administrative staff. No further documentation was provided.

Based on record review and staff interview, it was determined the hospital failed to develop a comprehensive emergency preparedness plan to include various types of internal and external disasters. Findings:

On 09/26/12, the hospital administrative staff were asked to provide all policies and procedures for disaster preparedness. On 09/27/12, the following policies were provided to the surveyors in a binder titled, "Disaster Manual." Policies and procedures included in the manual were:

Emergency Codes, dated July 2006
Security, dated June 2006
Infant Abductions, dated July 2006
External Disaster, dated July 2006
Bomb Threat, dated July 2006
Fire Plan, dated June 2006
Fire Alarm Monitoring, Dated March 2001
Workplace Violence, dated July 2006
Evacuation, dated May 2009
Fatality Management Agreement, dated May 2009
Fatality Management Policy, dated June 2009
Severe Weather Policy, dated November 2011
Incident Command Structure, dated September 2009

The Incident Command Structure listed many personnel and positions no longer associated with the hospital. A "Fire and Disaster Call Back Roster" was last revised on 07/17/2001. The majority of staff on the roster were no longer working at the hospital.

There were no emergency policies and procedures that addressed power failure and disruption of other utilities. There was no policy and procedure to address the loss of internet and/or intranet connectivity.

There was no evidence the hospital had consulted with local authorities to identify risks for the hospital's locality. There was no documentation of disaster drills.

There were no policies that addressed mass casualties and the identification of community resources with names and contact information.

Staff A and C stated the disaster policy manual provided to the surveyors was the only information available to the staff in the event of disaster.

Based on a tour of the facility and interviews with staff the facility failed to provide emergency power to critical equipment in accordance with State and Federal regulation. The blood storage refrigerator is not on emergency power.

Findings:

1. On 9/26/2012 surveyors reviewed the emergency power and lighting branches with plant operations. On a tour of the blood bank area lab personnel told surveyors the blood bank refrigerator was not on emergency power and when the power fails personnel place units of blood in an ice chest for cooling.

2. This finding was verified with the plant maintenance employee on 9/26/12.

3. The above information was provided to administration at the time of the exit conference. No further documentation was provided.

Based on review of hospital documents, interviews with staff, and tour of the facility the hospital failed to provide services in specialized areas appropriate for the service. Pain management procedures are being performed in areas of the hospital designated as patient rooms. Pain management includes the use of c-arm (radiology) equipment. There is no documentation or evidence the rooms have shielding or safety measures instituted for use of c-arms in these rooms.

Based on review of policies and procedures, hospital documents, and interviews with staff 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 disaster drill will be followed by critiques which may include written after action reports to identify shortfalls 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 9/27/2012 surveyors reviewed documents stipulating the facility encountered a catastrophic power failure in which the emergency generator did not engage after routine electrical power was lost. There was no documentation the facility considered this a disaster. There was no documentation the facility reviewed the disaster to determine process improvement needs.

Staff B told surveyors in an interview on 9/27/2012 no disaster drill was called. She also stated there had been no notification of the failure through governance and incident reporting the power failure occurred. There was no record of the facility calling the PSO to determine how long the power would be off, what the problem was, and alternatives were available in solving the problem.

2. Review of Governing Body and Quality meeting minutes 2012 did not stipulate a catastrophic loss of power had occurred. There was no information presented to governance regarding this occurrence.

3. Review of generator logs indicated the facility had not correctly exercised generators. There was no indication the problem with the generator had been fixed or if there had been a root cause for the failure discovered.
As a result of this failure the hospital incurred total electrical loss for a minimum of 2 hours.

4. These findings were reviewed with administrative staff at the time of the exit conference. No further information was provided.

Based on interviews with staff and a tour of the hospital the facility failed to provide services in procedure rooms with adequate ventilation, temperature, and humidity control.

1. On 9/26/2012 surveyors toured an area outside of the medical/surgical floor. This unit was labeled as the "obstetrics" area. Three doors had signage posted indicated they were set up for pain management procedures. According to Staff DD these areas had been patient rooms when the facility had an active obstetrical program but were now being used for procedures.

2. On 9/27/2012 Staff B verified procedures had been done in these rooms.

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

Based on review of personnel files and meeting minutes and interviews with hospital staff, the hospital failed to designate/appoint an appropriate infection control professional.

Findings:

1. Staff B, D and E told the surveyors on 09/26/2012 that Staff C was the infection control preventionist.

2. Review of Staff C's personnel file and hospital meeting minutes did not contain evidence that Staff D had been designated an the infection control professional/preventionist (ICP).
a. The personnel file did not contain a signed job description for ICP; payroll action form; performance evaluation; or documentation of appointment as the ICP.
b. Hospital meeting minutes, quality, medical staff and governing body, did not specify Staff C as the hospital's designated ICP.

3. Review of the infection control manual and Staff C's personnel file did not contain evidence Staff C had experience and/or training the principals and methods of infection control. The personnel file contained no evidence of experience or training and the manual only contained a certificate for Epidemiology 101. On the afternoon of 09/26/2012, Staff C confirmed he had not taken any infection control training on principals and methods of infection control and implementing an effective infection prevention program.

4. These findings were reviewed and verified with Staff A and B on the afternoon of 09/27/2012. No additional data was provided.

Based on 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:

1. State Hospital Standards require meeting for infection control to be conducted at least quarterly. The surveyors requested meeting minutes concerning infection control for the past 12 months. The surveyors were given two documents of infection control meeting, August 9, 2011 and March 21, 2012. Staff C confirmed that no other meetings had been conducted/held.

2. Meeting minutes reviewed did not reflect infection control issues/concerns, surveillances, and practices 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. The two meeting minutes provided did not contain any of the above information.

3. The disinfectant, Vindicator +, used throughout the hospital, has not been reviewed and approved by the hospital's Infection Control committee to ensure it is effective against the organisms that might occur in the hospital.
a. Vindicator + is not effective against tuberculosis and Clostridium difficile (C-diff). This was reviewed and confirmed with Staff C and K on the afternoon of 09/26/2012 The hospital routinely does colonoscopy procedures. C-diff is the prevalent organism. No review had been performed to determine if dormant cases of C-diff would be effected by the colonoscopy prep to make them a potential hazard.
b. The disinfectant application is not monitored to ensure the disinfectant is applied and remains wet on the surface the required 10 minutes in order to be effective.
c. These findings were confirmed by Staff C and K on the afternoon of 09/26/2012.

4. Meeting minutes and surveillance activities 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.
a. Monitoring activities provided only contained three monitor sheets of hand hygiene surveillance. The sheet with the most surveillance performed, April 2012, only contained five observations. No other surveillance of practices have been performed/monitored, including observations of isolation practices.
b. The infection control log only contain confirmed patient infections based on positive lab cultures. The log and meeting minutes did not contain designation whether any of the infections were hospital acquired infections. It did not contain staff infections or any method to determine if transmissions had occurred. Staff C told the surveyors on 09/26/2012 at 1645, that he did not receive information about staff infections or immunizations.
i. Preliminary review of employee health files on 09/26/2012 did not contain all the State required health/immunization information. This was reviewed with Staff D and E on the afternoon of 09/26/2012, who said that all the information may not be present.
ii. On the morning of 09/27/2012, Staff DD said she was able to produce all the required information with few exceptions.
iii. Review of Staff C's file on 09/26/2012 showed he was unable to have PPD (Purified Protein Derivative) skin test because of a previous positive reaction and, at that time of this review, did not have a questionnaire concerning any tuberculosis symptoms.
iv. Review of Staff C's personnel file on the morning of 09/27/2012 contained a form documenting he had a negative PPD skin test. On 09/27/2012 at 1010, Staff C said he could not and did not take a PPD test, but also did not fill out a questionnaire as usual. About the signature on the page, he said he thought he was signing a decline of the flu shot.
v. Employee immunization records for staff F and H indicated a lapse of over one year between TB skin tests. This lapse required that a two step TB skin test be performed. Neither staff person had a two-step TB skin test. A hospital policy documented that all new employees would receive a two step TB skin test. Two step tests were not documented upon hire for staff F and H.

c. The hospital requires "yearly fit testing for TB (tuberculosis) mask". This was last done in 2010. This had not been followed in the infection control program.

5. The hospital's infection control program did not review surgical services practices with corrective actions to limit the use of unwrapped/"flashed" instruments. Staff C stated he was told the hospital did not utilize shortened cycles. Review of sterilizer tapes showed full instruments sets were flash sterilized.

6. In an operative note for patient # 4, dated 08/29/12, the physician documented, "... The patient is an 18 month old female with infection, what looks like MRSA, in left sided perineal area..." There was no documentation in the clinical record that indicated the physician communicated the possibility of MRSA infection with staff. The physician did not designated this as a contaminated case. The physician did nor order contact precautions.

There was no documentation the surgical staff handled this as a contaminated case. There was no documentation the surgical staff notified the infection control officer of this case and the possibility of MRSA infection.

The patient's abscess was later determined to be positive for MRSA.

7. The hospital had no policy on disinfection between patients of commonly used medical equipment such as vital sign monitoring equipment.

8. The soiled utility room on the medical/surgical unit contained biohazardous waste and contaminated materials. The room had no outside designation as a biohazard area.

9. Staff in the physical therapy department were not aware the disinfectant used in the department had to stay wet for 10 minutes to be effective.

10. There were no policies and procedures in place for cleaning the pain management rooms. An observation of one room set up for a lumbar procedure had trash in the room, the floors were dirty and counter tops were cluttered and dusty. A supply cart was covered with a white bath towel that had a dark brown crusty substance on it.

11. Clean linens were stored uncovered on a multi-shelf cart in a basement hallway.

12. Staff in the outpatient specialty clinic were processing endoscopes without instructions from the manufacturer and without guidance from hospital policies and procedures. There was no process for cleaning and disinfecting the scopes. There were no policies for the use of the scope processing machine. There was no documentation of testing the Cidex solution for effectiveness everyday it is used. The staff were not aware of policies and procedures for the monitoring and use of the Cidex scope disinfectant solution. There were no complete records of scope disinfection.

Based on review of infection control data and meeting minutes and interviews with hospital staff, the hospital does not ensure the infections control program has a current log/tracking mechanism for patients and staff to track infections and possible transmissions of infections and communicable diseases.

Findings:

1. The log of patient infections is based on positive patient cultures from the lab and does not identify if the infections are hospital acquired/ nosocomial.

2. The log did not contain data concerning patients infections treated empirically with antibiotics or staff infections.

3. On 09/26/2012 at 1645, Staff C, the person identified as responsible for infection control, told the surveyors that he does not get information about employees.

Based on policy and procedure review and staff interview, it was determined the hospital failed to ensure clinical staff had knowledge of the triggers that could be used to identify patients with potential discharge planning needs.

On 09/26/12, the hospital was asked to provide policies and procedures for discharge planning. On 09/27/12, the policies were provided.

A policy titled, "Social Work High Risk Screening Criteria," documented several triggers for consultation with the social worker for discharge planning.

Staff B was asked if this information was available to staff. She stated it was available to the discharge planning nurse.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure there was a discharge planning evaluation for those patients who needed post-hospital services.

Patient # 4 was admitted for outpatient surgery. The patient required wound care at home. There was no documentation of a discharge planning evaluation.

Staff B stated this had not been done.

Three other clinical records were reviewed for evidence of discharge planning evaluations. None were found.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure there was a discharge planning evaluation for those patients who needed post-hospital services.

Patient # 4 was admitted for outpatient surgery. The patient required wound care at home. There was no documentation of a discharge planning evaluation.

Staff B stated this had not been done.

Three other clinical records were reviewed for evidence of discharge planning evaluations. None were found.

Based on clinical record review and staff interview, it was determined the hospital failed to document results of the discharge planning evaluation with the patient or person acting on the patient's behalf. Findings:

Four clinical records were reviewed for evidence of discharge planning. There was no documentation found.

Patient # 4 required home health services. There was no documentation of discussion with the patient's care-giver of discharge planning.

Based on clinical record review and staff interview, it was determined the hospital failed to document discharge planning evaluations in the patient's clinical record. Findings:

Four clinical records were reviewed for evidence of discharge planning activities. No documentation was found.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a qualified staff person developed or supervised the development of a discharge plan for patients who required discharge planning. Findings:

Four clinical records were reviewed for evidence of discharge planning activities. No documentation was found.

Patient # 4 required home health care after discharge. There was no documentation of discharge planning activities.

Based on clinical record review and staff interview, it was determined the hospital failed to document arrangements for implementation of the patient's discharge plan. Findings:

Patient # 4 required home health care for post-hospitalization wound care. There was no documentation of the hospital's efforts to assist the patient with selection of a home health agency. There was no documentation of discharge instructions given to the patient's care giver regarding the patient's dressing, wound care, signs and symptoms to watch for postoperatively, instructions for the antibiotic prescription given to the patient, or pain management.

There was no documentation of discussion with the patient's care giver of steps taken to implement the discharge plan.

Staff F reviewed the clinical record and confirmed this finding.

Based on clinical record review and staff interview, it was determined the hospital failed to provide a list of home health agencies to the patient's caregiver. Findings:

Patient # 4 required wound care to be provided by a home health agency. There was no documentation the hospital provided a list of home health agencies to the caregiver. There was no documentation any home health agency was contacted by the hospital.

Staff F stated he did not know what home health agency the patient decided to use. He stated he did not know if a home health agency was contacted by anyone at the hospital.

Based on clinical record review, hospital policy and procedure review and staff interview, it was determined the hospital failed to clearly define in writing the scope of surgical services provided and failed to provide documentation the hospital's surgical services had been approved by the medical staff. There was no documentation the surgical department staff were trained and competent to perform their job duties. Findings:

1. On 09/26/12, the hospital was asked to provide an organizational chart for surgical services. An out-dated organizational chart last updated on 06/15/10 was provided. A surgery manual provided to the surveyors had no documentation of review and approval by the Chief of Surgery, the medical staff or the governing body.

Staff G stated the hospital provided inpatient and outpatient surgical services. She stated outpatient procedures were done in the operating room, the outpatient specialty clinic and in the former labor and delivery area.

She was asked if there was an organizational chart or policy and procedure that designated what staff worked in each area, their responsibilities, lines of authority and what services were provided in each department. She stated there was no such documentation.

2. A review of the education and training record for staff G (a registered nurse circulator) documented expired CPR and ACLS certification. The last documented conscious sedation training and competency was in 1994. There were no competencies related to age-specific patient groups and no competencies for electronic medical record documentation and medication administration using the electronic system (OmniCell).

There was no signed job description, no OR department orientation, skills competencies or annual evaluations. The last documented OR specific training was in 2008.

Staff G stated that RNs within the surgery departments (inpatient or outpatient) were expected to perform conscious sedation at times and were expected to recover patients after procedures. She was asked if she had specific training in post-anesthesia care. She stated she did not.

3. A review of the education and training record for staff H (a scrub tech) had no documentation of a resume, job history or evidence of training and experience related to assigned job duties.

There was no signed job description in the file. There was no documentation of surgery department orientation. The last annual performance evaluation was completed in 2009. There were no competencies documented for scrub tech duties or for sterile processing duties.

Based on staff record review and interview, it was determined the hospital failed to ensure the surgery department was supervised by an experienced registered nurse. Findings:

On 09/26/12, staff B was asked to provide an organizational chart for the surgery department. She stated there had been many staff changes and there was not a current organizational chart. She identified the OR supervisor as staff F.

Staff B also stated there was no Chief of Surgery identified by the hospital.

The education and training file for staff F had no documentation of orientation to the OR, had no OR clinical competencies, had no performance evaluations and had no signed job description for the position of OR supervisor.

The file documented staff F had no current training and/or certification in: CPR, ACLS, PALS, conscious sedation, pediatric care in the OR, the electronic medication administration system or electronic medical record documentation.

There was no documentation the OR supervisor was a member of any professional organization, such as AORN.

Staff F stated RNs within the surgery department were required to recover patients after anesthesia. He stated he did not have training specific to post-anesthesia care.

Based on clinical record review, hospital document review, policy and procedure review and staff interview, it was determined the hospital failed to ensure an experienced circulating RN was available to respond immediately to an emergency in all areas where surgical and other procedures were being performed. Findings:

On 09/26/12, the hospital was asked to provide documentation of the inpatient and outpatient surgery departments organizational structure. No documentation was provided.

Staff G stated surgical procedures were performed in the hospital operating rooms, the specialty clinic and in the former labor and delivery area.

Staff G stated sometimes surgical technicians provided some assistance with circulating duties when an RN might not be present. She stated this happened when the RN was already working as a circulator in another case.

The surgery department policies and procedures did not have guidance for non-RN staff to perform circulating duties.

Based on hospital document review and staff interview, it was determined the hospital failed to ensure a current roster of each practitioner's surgical privileges was available in all areas where procedures are performed. Findings:

On 09/27/12, staff G stated surgical procedures were performed in the hospital operating room, the outpatient specialty clinic and in the former labor and delivery area where pain management procedures were provided.

Staff B and staff F were asked to provide documentation of current practitioners' surgical privileges for these areas. The staff provided a surgery policy that listed procedures performed in the OR. It was last updated on 10/19/10 and did not include all procedures performed at the hospital.

No list of practitioners and privileges was provided.

A review of surgery policies and procedures did not include an organizational structure and a policy to address the need for current practitioner privilege information in each area where procedures were performed.

Based on policy and procedure review and staff interview, it was determined the hospital failed to ensure there were policies and procedures to govern surgical care provided in all areas where procedures were performed. Findings:

1. The hospital staff stated surgical procedures were performed in the hospital operating room, the outpatient specialty clinic and in the former labor and delivery area. A single policy manual for the hospital operating room was provided. There were no policies and procedures specific to each of the areas where surgical procedures were performed.

The surgery policy and procedure manual had no documentation of approval by a chief of surgery, the medical staff or the governing body.

2. The following surgery department policies and procedures were not found:

a. Traffic control and access to the OR, specialty clinic and the labor and delivery area. The labor and delivery area was identified as being used for pain management spinal procedures. The area was not locked and was accessible to anyone, including visitors. Sterile supplies, injectable solutions and medical equipment was found in this area.

b. aseptic and sterile technique and aseptic/sterile technique surveillance activities

c. room cleaning between cases and terminal cleaning at the end of the day, and general OR cleaning practices

d. surgery attire, hair, face and skin covering requirements

e. temperature and humidity control requirements for each area

f. safety policies

g. all policies to govern all pre-procedure care including but not limited to: requirements for the history and physical, pre-operative testing, consents, advanced directives, patient and site identification, safety checklist and documentation

h. duties, responsibilities and line of authority for all surgical department personnel

i. intraoperative requirements for safety, specimen handling, and procedure-specific protocols for all procedures performed in the various areas

j. the malignant hyperthermia policy was not current and the Malignant Hyperthermia Hotline was not included in the policy

k. disinfection and sterilization policies and procedures

l. surgical fire and other departmental disasters

m. alcohol-based skin preparation and safety requirements for
use in the procedure areas

n. implant policies

o. OR visitor policies

p. intraoperative documentation

q. post anesthesia care policies and procedures

r. outpatient post-operative care planning and coordination and provisions for follow-up care

s. emergency policies specific to each area where surgical procedures were performed, and for the pre and post-op areas; and

t. flash sterilizing and flash load documentation policies.

Staff B was asked if the policy and procedure manual contained all policies for the department. She stated the manual included all the policies for pre-op, OR, sterile processing and post-op.

3. The former labor and delivery area was being used for invasive, fluoroscopy-guided pain management procedures. The area was unsecured and was accessible to anyone.

One room in that area was set up for a lumbar procedure. There was no ability to suction a patient in an emergency. While there was a wall suction unit, there was no suction tubing of a compatible size to fit the suction cannister. The length of the suction tubing would not allow it to reach the patient. The nearest emergency cart was down two hallways, through double doors to the medical/surgical unit. The emergency cart was stored on the medical/surgical unit.

Sterile instrument sets, pre-packaged sterile procedure sets, bottles of injectable solutions were found unsecured in the procedure room. Epidural anesthesia trays with lidocaine were stored in a cabinet unlocked.

In an ante-room outside the room, a biohazardous waste container was stored with suture, sterile instrument sets and other clean or sterile supplies.

The procedure room was cluttered, disorganized and had not been cleaned. The counters were dusty and dirty. Supplies were scattered all over counters and over all available surfaces.

A red metal supply cart was covered by a white bath towel that had a dark brown, dried crusty substance on it. The floor was dirty. The room did not have adequate lighting.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure a complete history and physical examination was performed within required time frames and was made available prior to surgery or anesthesia for six of six surgical records reviewed. Findings:

1. According to the hospital Medical Staff Bylaws, Rules and Regulations, a complete history and physical examination shall be written within forty-eight hours after admission of the patient.

When such history and physical examination or permission for surgery are not recorded before the time stated for operation, the operation shall be canceled unless the attending physician states in writing that such delay would constitute a hazard to the patient.

2. Patient #8's medical record indicated the patient had a closed reduction under anesthesia. The medical record contained a face sheet, an admission sheet, and an operative note. There was no history and physical in the medical record.

3. Patient #5's medical record indicated the patient had a history and physical the day before surgery. The medical record indicated the patient had lab work pending. On the day of surgery, there was no update to the history and physical regarding the pending lab. The lab work was abnormal. The patient had a low platelet count and the surgery was aborted due to excessive bleeding.

4. Patient #11's medical record indicated the patient's history and physical was dictated on the day of admission but was not transcribed until 12 days after the patient was discharged. There was no handwritten documentation of history and physical in the chart.

5. Patient #6 medical record indicated the patient's history and physical was dictated and transcribed greater than 90 days after admission. There was no handwritten history and physical in the medical record.

6. Patient #9's medical record indicated the patient's history and physical was dictated prior to admission. There was no update to the history and physical prior to a procedure being performed.

7. Patient # 4's completed medical record documented a history and physical examination was dictated and signed by the physician after the patient's surgery was completed. The entire history and physical examination documented, "... [Left] perineal area abscess in need of [incision and debridement] [without] signs of generalized infection, stable cardiopulmonary exam..." There was no other medical history or physical examination information documented on the form or elsewhere in the clinical record.

A "Side and Site Verify" form found in the clinical record and completed the day after discharge, documented the surgical procedure was verified with the history and physical examination. The history and physical was not performed until after the surgical procedure.

8. There was no documentation the facility reviewed records for timeliness of history and physical. The facility failed to ensure the patient's had a complete, current and updated history and physical in the medical record.

9. The above findings were presented at the exit conference. No further documentation was provided.

Based on clinical record review and staff interview, it was determine the hospital failed to obtain legal consents for anesthesia and for a surgical procedure. Findings:

Patient #4 was a 19 month old female admitted to the hospital for an out-patient surgical procedure.

There were no signed consents for anesthesia or for the surgical procedure documented in the medical record.

A "Side and Site Verify" form found in the clinical record and completed the day after discharge, documented consents for the surgery and anesthesia were signed and verified. There was no documentation as to who signed consent for the patient and the consent forms could not be found by the hospital.

On 09/27/12, staff B was asked to provide the informed consents for this patient's admission. She stated they could not be located.
She was asked if there were policies and procedures to govern informed consents. She stated there was not.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure post-operative care was provided according to acceptable standards of practice. Findings:

1. Staff F was asked to provide policies related to post-operative care. None were provided.

2. A review of the clinical record for patient #4 documented the following for the post-operative period:

~ A "Modified Aldrete" form, dated 08/29/12 at 7:44 a.m., was completed prior to surgery. It documented, "... Modified Aldrete Postanesthesia Score: Activity 2, Respiration 2, Consciousness 2, O2 Saturation 2, Dressing 2, Pain 2, Ambulation 2, Fasting/Feeding 2, Urine Output 2..."

The form did not indicate what a score of "2" meant. There was no documentation an Aldrete post-anesthesia assessment was performed upon admission to the recovery period and at the time of discharge from recovery.

~ There was no clear documentation that indicated when the patient was admitted to the recovery area. There was no assessment of the patient's condition immediately post-op, during the recovery phase and at the time of discharge from recovery.

Based on hospital record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure there was an operating room register that contained all the required information. Findings:

On 09/26/12, staff B and staff F were asked to provide the surgery log for the previous six months. The staff were not able to provide a log due to "a problem with the computer program."

Later in the day, staff F brought three versions of a surgery and procedure log. The logs were not in chronological order and did not have patients' names, only patient identification numbers. The logs also did not include:

~ total surgery time
~ names of any surgical assistants
~ type of anesthesia
~ anesthetists' names and credential, i.e., MD or CRNA
~ pre-operative and post operative diagnoses
~ patient age
~ location of the procedure

It could not be determined from the log whether the patient's procedure was in the OR, the outpatient specialty clinic or in the labor and delivery (pain management) area.

At times, the surgery log documented, "... sedation monitoring nurse..." The log did not enter a staff name or credentials. It could not be determined what type of sedation was used.

Staff F was asked if there was a OR policy related to the surgery department log requirements. He stated there was not.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the operative report include all the required elements. Findings:

An operative report for patient # 4 was reviewed for the required elements. The following items were not found:

~ the time of the procedure
~ post-operative diagnosis
~ no documentation of the type of packing used in the wound and the type of dressing

Staff F stated he was not aware of the requirements for the operative report. Staff E stated no audits of operative reports had been done.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure anesthesia services were provided under the direction of a qualified physician. Findings:

On 09/26/12, anesthesia policies were reviewed. The anesthesia department policies had not been approved by a chief of anesthesia. There was no organizational structure for anesthesia services. There were no policies that governed the scope of practice for various practitioners including CRNAs, RNs and paramedics that may be providing various levels of sedation.

Staff B was asked to identify the hospital's chief of anesthesia. She stated no one had been identified by the hospital for that position. She stated anesthesia was provided primarily by CRNAs.

She stated there was one anesthesiologist on staff who performed pain management procedures. That person was not involved in the oversight of the hospital's anesthesia services.

There was no documentation anesthesia services were a part of the QAPI program.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure anesthesia department policies included current policies to address the provision of anesthesia in all areas of the hospital to include the OR, the outpatient specialty clinic, the pain management area and the ER. Findings:

Anesthesia policies and procedures were reviewed. The following items were not found:

anesthesia coverage for the hospital
patient consent for anesthesia policies
infection control practices specific to anesthesia delivery and care
safety practices in all anesthetizing areas
cardiac and respiratory emergencies
reporting and documentation requirements
responsibilities for anesthesia equipment, including inspection, monitoring, and testing
pre and post anesthesia responsibilities

Staff B stated there was no one designated to oversee the anesthesia services and the policies were not current.

A review of the clinical record for patient #4 indicated there was a scanned anesthesia record that was included in the completed electronic record. The scanned form had been reduced in size to fit the electronic page and was not legible. The original form could not be located by the hospital. It could not be determined what medications were administered to the patient during the surgical procedure.

A pharmacy report documented succinylcholine chloride was obtained for the patient's use and was not returned to the pharmacy unused. It could not be determined by the anesthesia record if succinylcholine chloride was administered to the patient.

The anesthesia record did not document an assessment by the CRNA post-procedure. There was no documentation of vital signs or the presence or absence of complications post-procedure. There was no documentation the CRNA determined the patient was appropriate for discharge from recovery.

The findings were discussed during an exit conference. No additional information was provided.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure an accurate, complete and legible intraoperative anesthesia record. Findings:

The anesthesia record for patient # 4 was reviewed. The following deficiencies were noted:

~ the record was largely illegible
~ the name, dosage, route and time of administration of drugs and anesthesia agents could not be determined
~ patient positioning was not documented
~ physical assessment at the conclusion of anesthesia was not documented

The hand-written anesthesia record was scanned into the completed electronic record. The scanned form had been reduced in size to fit the electronic page and could not be read. The original form could not be located by the hospital. It could not be determined what medications were administered to the patient during the procedure.

A pharmacy report documented succinylcholine chloride was issued for the patient's use and was not returned to the pharmacy supply as unused. It could not be determined if succinylcholine chloride was administered to the patient. This information was confirmed by the consulting pharmacist.

The form did not document an assessment by the CRNA post-procedure. There was no documentation of vital signs or the presence or absence of complications post-procedure.

On 09/27/12, staff E stated anesthesia records were not reviewed for completion and accuracy.

Based on clinical record review and staff interview it was determined the hospital failed to ensure a post-anesthesia evaluation was performed by a qualified practitioner for six of six records reviewed for surgical procedures that required a post anesthesia evaluation. Findings:

1. Anesthesia policies and procedures were reviewed for current practices related to post-anesthesia evaluation. There was no policy to address this requirement and of required documentation.

2. A review of the anesthesia record for patients #4, #_______ had no documentation of a post-anesthesia evaluation. There was no documentation of post anesthesia vital signs, a physical assessment, mental status, pain, nausea and vomiting and hydration. There was no documentation of the presence or absence of anesthesia complications.

3. Staff E stated anesthesia records were not reviewed for post-anesthesia documentation requirements.

Based on document review, policy and procedure review and staff interview, it was determined the hospital failed to have policies and procedures that governed outpatient services and the integration with inpatient services.

On 09/27/12, staff B stated there were no policies and procedures specific to outpatient services. She stated the hospital provided a variety of outpatient services including surgery, radiology, laboratory and physical/occupational therapy.

Based on document review and staff interview, it was determined the hospital failed to develop an organizational plan to establish leadership and responsibility for outpatient services. There was no documentation of lines of authority for outpatient services.

The hospital had no documentation of staff who provided outpatient services.

Staff B stated the inpatient staff all had outpatient care responsibilities. Staff V stated she also had home health care responsibilities. There was no designation of these responsibilities in any hospital document.

Based on review of hospital documents and meeting minutes concerning infection control, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, through Quality Assessment and Performance Improvement (QAPI):
1. Were monitored, 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. The QAPI meeting minutes did not contain evidence infection control issues were presented to the committee. The meeting minutes did not contain analysis or plans of action taken to reduce infections and ensure a sanitary environment.

2. The QAPI program has not provided oversite of the infection control program to ensure a safe environment and prevent transmission of infections.
Infection control monitoring activity, in addition to the documented patient infections, only recorded sporadic handwashing observation/monitoring. The documents presented for review did not show any surveillance/monitoring to ensure infection control policies were followed. This included, but not limited to:
a. Surgical Services practices;
b. Isolation practices;
c. Disinfectant practices.

3. Meeting minutes did not contain evidence the hospital leadership analyzed infection control data or lack thereof; developed a plan of action to reduce and/or prevent transmission of organisms; and provide follow-up/monitoring to ensure corrective actions taken were effective and sustainable.

4. Documents provided did not contain evidence the infection control/prevention program monitor/reviewed staff illness to ensure transmission between staff and patients did not occur. Meeting minutes did not reflect this had been identified or reviewed as a possible avenue to reduce transmissions of infections.