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Based on observation, and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of patients.

Findings include:

Refer to A709 for the hospital's failure to comply with the Life Safety Code, and A710 for the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association.

Based on review of the medical staff by laws, staff interview and review of physician credentialing, the Governing Body failed to ensure that medical staff operated under current bylaws.

Findings include:

On April 27, 2011, at approximately 11:30 a.m., review of the bylaws provided by the facility revealed an approval date of December 9, 1980. The by laws stated that all appointments and reappointments to the medical staff shall be done for one (1) year only, that this review will be conducted in September.

Interview with the Chief Operations Officer (COO) revealed that appointments and reappointments of medical staff should be every two (2) years. The COO also stated that there was another set of by laws with a more current date but was unable to provide them.

On April 28, 2011, at approximately 10:30 a.m., an interview with the Director of Human Resources/Comptroller revealed that there was a current set of by laws but that they were unable to find them.

Review of the Chief of Staff Credentialing file revealed recommendations for appointment/reappointment dates of 10/18/06 and 09/28/10.

Documentation revealed that this facility had only one (1) physician that admits and treats patients.

Based on review of the medical staff by laws, staff interviews and review of physician credentialing, the medical staff failed to ensure that the Chief of Staff had been granted medical staff privileges yearly as their by laws state.

Findings include:

Cross Refer to A0047 for the facility's failure to ensure the medical staff operates under current bylaws.

Based on lack of hospital documentation and staff interview, the facility failed to ensure the provision of approved medical staff policies and procedures regarding hospital routine in the administration of drugs and biologicals given in the hospital.

Findings include:

On 04/26/11 at 11:45 a.m. Registered Nurse (RN) #1 revealed that she was the only RN in the hospital today. She stated that the Policies & Procedures Manual was not kept at the nurse's station. She denied ever seeing a Policies & Procedures Manual (she has worked at the hospital as a RN for last 10 months).

On 04/26/11 at 12:00 noon an interview with the Chief Operations Officer (COO) revealed that the Director of Nursing (DON) was out on medical leave. The COO stated that he could not provide any Nursing Polices or Procedures for review. After looking in the DON's office the COO, "I can not find them."

Based on lack of hospital documentation and staff interview, the facility failed to ensure the provision of a policy related to hospital routine in administration of influenza and pneumococcal drugs.

Findings include:

On 04/26/11 at 11:45 a.m. Registered Nurse (RN) #1 revealed she was the only RN in the hospital today. Shestated that the Policies & Procedures Manual was not kept at the nurse's station and that she had never seen a Policies & Procedures Manual even though she had worked at the hospital as a RN for the last 10 months.

On 4/26/11 at 12:00 noon an interview with the Chief Operations Officer (COO) revealed that the Director of Nursing (DON) was out on medical leave. After looking in the DON's office the COO stated that he could not provide any Nursing Polices or Procedures for review, "I can not find them"

Based on lack of hospital documentation and staff interview, the facility failed to ensure the provision of a policy regarding how verbal orders are used in the hospital.

Findings include:

On 04/26/11 at 11:45 a.m. Registered Nurse (RN) #1 stated that she was the only RN in the hospital today. She stated that the Policies & Procedures Manual was not kept at the nurse's station. She also denied ever seeing a Policies & Procedures Manual even though she had worked at the hospital as a RN for last 10 months.

On 04/26/11 at 12:00 noon an interview with the Chief Operations Officer (COO) revealed that the Director of Nursing (DON) was out on medical leave. After looking in the DON's office the COO stated that he could not provide any Nursing Polices or Procedures, "I can not find them".

Based on lack of hospital documentation and staff interview, the facility failed to ensure the provision of a policy regarding reporting blood transfusion reactions, adverse drug reactions, and errors in administration of drugs.

Findings include:

On 04/26/11 at 11:45 a.m. Registered Nurse (RN) #1 stated that she was the only RN in the hospital today. She stated that the Policies & Procedures Manual was not kept at the nurse's station. She also denied ever seeing a Policies & Procedures Manual even though she had worked at the hospital as a RN for last 10 months.

On 04/26/11 at 12:00 noon an interview with the Chief Operations Officer (COO) revealed that the Director of Nursing (DON) was out on medical leave. After looking in the DON's office the COO stated that he could not provide any Nursing Polices or Procedures, "I can not find them".

Based on review of Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all entries in 20 of 20 medical records reviewed were timed.

Findings include:

Twelve (12) discharged medical records were selected at random from a list of recent discharges from February and March 2011. These records were reviewed along with the last seven (7) discharges from the hospital and one (1) inpatient medical record for a total of 20 medical records reviewed.

20 of 20 medical records reviewed revealed that progress notes had not been timed when entered in the medical record.

All dictated reports found in the 20 medical records reviewed did not include the time the reports were dictated, or the time that they were transcribed.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintain to ensure the safety of the patients.

Findings include:

The standard of Life Safety Code is considered not met due to the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to A710

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

1. Refer to K-018- The hospital failed to provide doors protecting corridor openings in accordance with 19.3.6.3.3.

2. Refer to K-029- The hospital failed to provide the smoke resisting partitions and doors in accordance with 8.4.1 and/or 19.3.5.4.

3. Refer to K-050- The hospital failed to provide the required Fire drill documentation as per NFPA 101 chapter 18.7.1.2, 19.7.1.2.

4. Refer to K-056- The hospital failed to provide a supervised automatic sprinkler system with complete coverage for all portions of the building in accordance with section 9.7.

5. Refer to K-062- The hospital failed to a) properly test and maintain the automatic sprinkler system contrary to NFPA 13, NFPA 25. and b) to properly insure the operability of the sprinkler system as required by NFPA 13 5-5.5.1.

6. Refer to K-144- The hospital failed to provide monthly generator testing in accordance with NFPA99.

Based on lack of hospital documentation and staff interview, the facility failed to ensure the designation of an infection control officer to develop and implement polices governing control of infections and communicable diseases.

Findings include:

On 04/28/11 at 1:00 p.m. an interview with Licensed Practical Nurse (LPN) #1 revealed that had been working at this facility for last seven (7) years. She denied knowing anything about how the facility monitors infection control. She stated, "We have not had a patient in a long time that required isolation."

On 04/28/11 at 12:00 p.m. the COO provided an Infection Control Committee Policy dated November 1988. The COO denied knowing of any other documentation on Infection Control. He stated that the Director of Nursing (DON) was over the Infection Control Program but that she was out on Medical Leave.