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Based on observation, document review and interview, it was determined the hospital's governing body failed to:

a. determine which levels of non-physician practitioners were eligible for medical staff privileges. See tag A-0045;

b. appoint a chief executive officer who was responsible for managing the entire hospital. See tag A-0057;

c. ensure contracted services were evaluated for compliance with all applicable Conditions of Participation. See tag A-0083;

d. include contracted services in the quality assessment and performance improvement plan. See tag A-0084; and

e. the governing body failed to ensure compliance with the following Conditions of Participation:

482.13 Patient's Rights. See tag A-0115.
482.21 Quality Assessment and Performance Improvement. See tag A-0263.
482.28 Food and Dietetic Services. See tag A-0618.
482.41 Physical Environment. See tag A-0700.
482.42 Infection Control. See tag A-0747.
482.43 Discharge Planning. See tag A-0799.
482.45 Organ, Tissue and Eye Procurement. See tag A-0884.
482.51 Surgical Services. See tag A-0940.
482.57 Respiratory Services. See tag A-1151.

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

a. ensure all patients received care in a safe setting. See tag A-0144 and see 482.41 Condition of Participation: Physical Environment tags A-0700, A-0701, A-0702, A-0709, A-0710, A-0711, A-0713, A-0714, A-0715, A-0722, A-0723, A-0724 and A-0726;

b. inform patients and/or their representatives of patient rights. See tag A-0117;

c. respond to grievances in writing. See tag A-0123;

d. notify patients of physican ownership of the hospital and failed to notify patients a physician was not onsite at the hospital 24hours/day, 7 days/week. See tag A-0131; and

e. the hospital failed to protect patient personal information to include disclosure the patient was present at the hospital. See tag A-0143.

Based on document review and staff interview, it was determined the hospital failed to develop, implement and maintain a hospital wide quality assessment and performance improvement (QAPI) program.

Findings:

On 03/02/2016, the hospital was asked to provide the current QAPI program. The CNO provided data and QAPI meeting minutes for 2015. She stated the hospital had not developed a QAPI program for 2016 and the committee had not met this year.

The 2015 program did not document why certain indicators were chosen. Not all departments were represented in the program. Contracted services were not included. When the data showed a worsening of a problem area, there was no documentation of actions taken to correct the decline and improve processes or systems.

Based on hospital document review, staff interview, and observations the hospital failed to:
a) provide an organized dietary service to meet the needs of the patients;
b) ensure a full time employee was available for daily management of the dietary services; (see tag A-0620)
c) ensure the dietician approved all dietary menus;
d) ensure meals provided met the needs of all patients. (see tag A-0629)
Findings:
~ On the morning of March 1, 2016, staff A told surveyors the dietary kitchen was not utilized for making patient meals. Staff A told surveyors patient meals were brought in frozen and the nursing staff prepared the meals in the microwave.
~ Staff A told surveyors the meals were made in a room called "the galley." The galley was a small room behind the nursing station. There was not appropriate room in the galley for meal preparation.
~ Staff A told surveyors Staff I was the Certified Dietary Manager (CDM). Staff A told surveyors Staff I was not a full time hospital employee.
~ Staff A told surveyors Staff I came to the hospital approximately 3 days per week in the afternoon.
~ Staff A told surveyors there were no full time kitchen staff.
~ On March 1, 2016 @ 2:15 p.m., Staff H , a Certified Nursing Aid (CNA) told surveyors that she was one of the staff members responsible for heating up the microwaved meals for the patients.
~ Staff H told surveyors she had not received any training from the Dietician.
~ Staff H told surveyors she did not know how to determine portion size and did not know how to make substitutions if patients wanted another food item. Staff H told surveyors she had been told all the microwave meal options were heart healthy.
~ Staff H told surveyors she did not know how to prepare pureed diets or mechanical soft diets.
~ On March 1, 2016 @ 2:45 p.m., Staff I, a CDM told surveyors she was not a full time employee at the hospital. Staff I told surveyors she only comes in 3 or 4 times per week in the afternoons for around an hour.
~ Staff I told surveyors the gas was shut off to the kitchen and in order to utilize the kitchen, the kitchen would need to be brought up to code.
~ Staff I told surveyors the consultant dietician had approved all menus and had approved all the frozen meals.
~ Staff I told surveyors all the frozen meals were heart healthy and low sodium and proportioned all the same.
~ There was no documentation the dietician had reviewed and approved menus.
~ There was no documentation how the CNA's or nursing staff that prepared the meals would be able to use substitutions.

Based on observation, document review and staff interview, it was determined the hospital failed to ensure the hospital was constructed, arranged and maintained to ensure the safety and to meet the needs of the patients it served. The hospital did not comply with Life Safety Code requirements and failed to maintain its facility in compliance with state regulations for hospitals.

Findings:

See Tags A-0701, A-0702, A-0709, A-0710, A-0711, A-0713, A-0714, A-0715, A-0722, A-0723, A-0724, and A-0726.

See also Life Safety Code survey.

Based on review of infection control meeting minutes, personnel file review, staff interview, and observation, the hospital failed to:

a) maintain a sanitary and safe environment; (see tag A-0747)

b) designate in writing an infection control officer trained/educated and experienced in infection control practices; (see tag A-0748)

c) develop and maintain an active ongoing surveillance program to identify, investigate, and control infectious diseases among patients and staff; (see tag A-0749)

d) ensure the hospital wide Quality Assessment Performance Improvement (QAPI) program identified and took corrective actions for infection control problems identified. (see tag A-0756)

Based on interviews, and document review, the hospital failed to develop a discharge planning process.

Findings:
On 03/01/2016 at 9:45 a.m., the Chief Nursing Officer stated the discharge planner position was vacant.
~The surveyors requested the discharge planning policies and procedures and received a one page document that minimally outlined the process of discharge planning.
~The surveyor found no discharge planning policies specifically for outpatient services. Five of five (Patient # 1,2,3,4,5) out clinical record reviews did not contain evidence of discharge planning.
~Surveyors reviewed Continuous Quality Improvement information. There was no 2016 analysis of 30 readmissions.

Based on hospital document review, and staff interview, the hospital failed to:
a) Incorporate an agreement with an organ procurement organization;
b) Ensure policies and procedures were in place for organ procurement.
c) Incorporate an agreement with at least one tissue bank and at least one eye bank.
Findings:
1. On the morning of March 1, 2016, surveyors requested the hospital's organ procurement agency contract, activity reports and protocols. None were provided.
2. On the afternoon of March 1, 2016, Staff A told surveyors the hospital did not have an organ procurement agreement and protocols.
3. Surveyors reviewed hospital policies and procedures. There were no organ procurement policies and procedures.
4. There was no documentation of organ procurement activity reports.
5. On March 4, 2016 at 1:30 p.m., surveyors requested an organ procurement agreement/contract. Staff A told surveyors the hospital did not procure organs and did not have an agreement/contract.

Based on observations, interviews, and document review, the hospital failed to:
1. ensure all surgical procedures were performed under acceptable conditions and locations appropriate for surgery. The facility had repurposed numerous areas and spaces within the surgical department, so that the department no longer complied with the required zones of restricted, semi-restricted, and unrestricted. The repurposed spaces resulted in incorrect traffic control and flow. See also Tags A-0722 Facilities
2. provide surgical services according to acceptable standards of practices. The facility stated surgical services were limited to gastroenterology endoscopy; however, multiple deficiencies were found with endoscope high level disinfection/reprocessing processes and staff competencies. See A-0749 Infection Control Program;
3. have a cardiac defibrillator available within the surgical department. See Tag A-0956 Required Operating Room Equipment;
4. develop and implement current policies and procedures for the provision of surgical services. See Tag A-0951 Operating Room Policies;
5. integrate surgical services into the hospital ' s QAPI program. See Tag A-0263 QAPI.

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

a) meet the respiratory care needs of the patients served;

b) maintain respiratory care equipment based on the needs of the patients; (see tag A-1152)

c) provide respiratory care training to staff who provided respiratory care to patients; (see tag A-1161)

d) keep a current contract with the consultant respiratory therapist;

e) designate a director of respiratory care qualified through experience and training; (see tag A-1153)

f) provide current approved policies and procedures for each respiratory service provided. (see tag A-1161)


Findings:

1. On the morning of March 1, 2016, administrative staff told surveyors the hospital provided respiratory care to patients. Administrative staff told surveyors the hospital accepted ventilator patients on occassion and would be accepting ventilator patients.

2. On the morning of March 1, 2016, administrative staff told surveyors respiratory services was a contracted service.

3. On March 7, 2016 at 11:55 a.m., surveyors reviewed the personnel file of the contracted Respiratory Therapist. The personnel file contained a contract from the year 2012 and 2013. There was no current contract.

The personnel file for the Respiratory Therapist contained evidence of an as needed (PRN) date of hire as March 7, 2016 for the Respiratory Therapist. This date of hire occured during the course of the survey. The date of hire form documented the Respiratory Therapist would be available at the hospital for ventilator patients. The Chief Nursing Officer (CNO) told surveyors that the Respiratory Therapist had been hired to be in the hospital when a ventilator patient was admitted.

4. On March 1, 2016 at 11:00 a.m., surveyors toured the facility. Staff G, a staff Registered Nurse (RN) told surveyors the nursing staff provided all respiratory care procedures. Staff G told surveyors the hospital accepted ventilator patients from a local nursing home at times. Staff G told surveyors the nursing staff had received some training on ventilators. Staff G told surveyors the hospital did not have ventilators for the patients. Staff G told surveyors the patients on ventilators would bring their own ventilator. Staff G told surveyors there was not a Respiratory Therapist in the hospital while a ventilator patient was admitted.

On the afternoon of March 1, 2016, the Chief Nursing Officer (CNO) verified these findings.

5. Multiple times during the survey, surveyors requested the scope of services for Respiratory Services. None was provided.

6. Review of Governing Body meeting mintues contained no documentation of a physician director of Respiratory Services had been appointed.

7. On March 7, 2016 at 11:10 a.m., surveyors reviewed respiratory services policies and procedures. The policies and procedures were not specific to the hospital.

There was no policy and procedure on ventilators.

There was no documentation the policies and procedures were based on nationally recognized guidelines.

The policies and procedures contained no documentation the policies and procedures had been reviewed and approved by the contracted Respiratory Therapist, medical staff, and the Governing Body.

8. On the morning of March 3, 2016, surveyors reviewed 14 nursing staff personnel files. There was no documentation of respiratory care training by the respiratory therapist in all 14 personnel files reviewed.

Based on document review and staff interview, it was determined the governing body failed to determine which levels of non-physician practitioners were eligible for medical staff privileges.

Findings:

On 03/02/2016, hospital medical staff bylaws documented non-physician practitioners could be granted medical staff privileges; however the bylaws did not specify what levels of non-physician practitioners were eligible.

At the time of the survey, the hospital administrator stated the hospital employed or contracted with physician assistants and advanced practice registered nurses.

Based on document review and staff interview, it was determined the governing body failed to appoint a chief executive officer who was responsible for managing the entire hospital.

Findings:

During the course of the survey, the chief operating officer stated he was responsible for managing the entire hospital. Various documents indicated the chief operating officer was responsible for managing the hospital.

There was no documentation the current hospital governing body had ever appointed a chief executive officer.

Based on document review and interview, it was determined the governing body failed to ensure contracted services were evaluated for compliance with all applicable conditions of participation.

Findings:

On 03/01/2016, the hospital was asked to provide a list of contracted services. The hospital provided a partial list. The hospital administrator stated not all contracted services were represented on the list.

The hospital had not evaluated any contracted services for compliance with the applicable conditions of participation.

Based on document review and staff interview, it was determined the hospital failed to include contracted services in the quality assessment and performance improvement (QAPI)plan.

Findings:

The hospital's QAPI plan for 2015 did not include contracted services. The hospital had not developed a QAPI plan for 2016. The chief nursing office verified this finding.

Based on document review and staff interview, it was determined the hospital failed to specify the delineation of contractor responsibility.

Findings:

The hospital provided a list of contracted services but the hospital had not determined management responsibility for those services. The CNO stated this was not a formalized process.

Based on document review and staff interview, the hospital failed to inform each patient or the patient representative of patient rights.

Findings:

On 03/01/2016, the hospital was asked to provide the patient rights information given to patients. The following documents were provided:

Consent to Treat
Patient Brochure
Information to Patients and Families Regarding Your Medical Treatment Rights Under the Law
Medicare Advance Beneficiary Notice of Non-Coverage
Privacy Practices

The hospital was asked to provide policies and procedures that govern notification of patient rights. The CNO stated a policy may be found within the hospital's policy and procedure manual. None was found.

Medical records reviewed had no documentation of the patient rights information that was actually given to the patients. The hospital did not provide patients with printed patient rights information other than the information above. The CNO stated this information was retained electronically but that it may not be included in the medical record.

The Medicare Notice to Beneficiaries (IM notice) given to patients was no longer current.

Based on document review and staff interview, it was determined the hospital failed to resolve grievances and provide the patient with written notice of its decision, name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process and the date of completion.

Findings:

On 03/01/2016, the hospital was asked to provide documentation of grievances for the past 12 months. The hospital provided one grievance dated 11/11/2015. The hospital was asked to provide documentation of the written response to the patient. None was provided. The CNO stated the administrator was responsible for providing the written response.

Based on document review and staff interview, the hospital failed to inform patients of physician ownership of the hospital and failed to notify patients a physician was not always available onsite.

Findings:

1. On 03/03/2016, the CNO was asked to provide any information regarding patient notification of physician ownership of the hospital. None was provided. The information given to patients did not include this information.

The physician-owner was also an admitting and referring physician on staff at the hospital.

2. The physician-owner stated he was the medical director of a local nursing home that cared for ventilator patients. The physician self-referred patients from the nursing home to the hospital.

3. The hospital had no documentation or signage that notified patients a physician was not available onsite 24 hours/day, 7 days/week.

Based on observation and interview, it was determined the hospital failed to protect patient personal information and privacy when it required outpatients and emergency department patients to sign in with their names on a clipboard located in public corridors. The clipboard was accessible to any person traveling through the corridors and patients could be identified as outpatient or emergency department patients.

The staff confirmed this was the hospital's required procedure.

Based on observation, document review and staff interview, it was determined the hospital failed to ensure the patients' right to receive care in a safe environment. See tags related to Physical Environment and Life Safety Code.

Based on interviews, and document review, the hospital failed to provide registered nurse supervision in the surgery department during post-operative care.

Finding:

On 03/03/2016 at 1:45 p.m., the RN OR manager stated the endosocopic services were staffed with one RN (herself) and two Licensed Practical Nurses (LPNs). She identified herself as the "circulating nurse" in the procedure room and stated an LPN was assigned as a endoscopic technician. A second LPN was assigned to the post-operative care area.

On 03/02/2016 at 2:20 p.m., the surveyor reviewed five closed medical records of patients who had received an endoscopy. Five of five patients were monitored by a licensed practical nurse (LPN) for their post-operative care. No documentation was seen that a RN provided oversight for that care including discharge readiness. (Perioperative Standards and Recommended Practices 2013 documents, "an RN assesses the discharge readiness of the patient ..."

Based on observation and staff interview, the hospital failed to ensure dietary services organization requirements were met.
Findings:
1. On the morning of March 1, 2016, Staff A told surveyors the kitchen was closed. Staff A told surveyors the hospital did not have a full time dietary manager and the hospital did not have full time kitchen staff employed. Staff A told surveyors nursing staff were responsible for making the meals. Staff A told surveyors nursing staff prepared frozen meals for the patients.
2. On March 1, 2016 @ 11:45 a.m., surveyors observed the kitchen was closed, locked and lights were out.

Based on hospital document review, and staff interview, the hospital failed to designate a full time employee who was qualified based on training and education to serve as the director of the food and dietetic services.
Findings:
1. On the morning of March 1, 2016, Staff A told surveyors the kitchen was shut down and all meals were prepared in a room called "the galley." Staff A told surveyors staff N was the consultant dietician, and staff I was the Certified Dietary Manager (CDM).
2. Staff A told surveyors that the nursing staff were responsible for meal prep.
3. Staff A told surveyors the CDM was not a full time employee of the hospital. Staff A told surveyors staff I came to the hospital 3 times per week in the afternoon.
4. Review of hospital documents contained no documentation that staff I had been designated as the CDM.

Based on observation, and staff interview, the hospital failed to maintain administrative and/or technical personnel for dietary services.
Findings:
1. On the morning of March 1, 2016, Staff A told surveyors the kitchen was shut down and all meals were prepared in a room called "the galley." Staff A told surveyors nursing staff were responsible for meal prep.
2. Staff A told surveyors there were no full time kitchen employees.
3. On March 1, 2016 @ 11:45 a.m., surveyors observed the kitchen. Surveyors observed the kitchen was shut down, locked and lights were off.

Based on hospital document review, staff interview, personnel file review, and observation the hospital failed to meet the nutritional needs of all patients.
Findings:
1. On the morning of March 1, 2016, Staff A told surveyors the kitchen was shut down and all meals were prepared in a room called "the galley." Staff A told surveyors the meals were brought in frozen and prepared in a microwave by the nursing staff.
2. On March 1, 2016 @11:45 a.m., surveyors observed the galley. Surveyors observed a freezer in the galley stocked with frozen meals. The frozen meals consisted of items such as, frozen breaded chicken patty meal, frozen grilled chicken patty meal, frozen manicotti, and others.
3. Staff I the Certified Dietary Manager told surveyors the dietician had reviewed and approved the meals. Staff I told surveyors the meals were all equal proportions, heart healthy and low sodium. Staff I told surveyors there were no different meals for diabetics, for low carbohydrate diets, high protein diets or any other special diets.
4. On March 1, 2016 at 2:15 p.m., Staff H a Certified Nursing Aide told surveyors she was one of the staff responsible for preparing the meals. Staff H told surveyors she did not know about special diets and she was told all the frozen meals were appropriate for all patients.
5. Staff I told surveyors nursing staff perform the nutritional screenings. Staff I told surveyors the dietician only came to the hospital once per month.
6. Staff I told surveyors if a patient needed a pureed diet, nursing staff could use a blender.
7. Staff I told surveyors there was no training or documentation provided to nursing staff on nutritional values of the meals or how to substitute food items.
8. Staff I told surveyors if nursing staff had questions they could always call her.
On March 3, 2016 @ 2:00 p.m., surveyors reviewed 15 nursing staff personnel files. The personnel files reviewed included Registered Nurses (RN's), Licensed Practical Nurses (LPN's), and Nursing aids. None of the nursing staff personnel files reviewed contained dietary training. There was no documentation of training on meal prep, no documentation of training on substitutions, no documentation of training on special diet orders, and no documentation of portion control training.

Based on observation of the hospital's physical environment and interviews with staff, it was determined the hospital failed to maintain safe and sanitary conditions within of the hospital, failed to coordinate emergency preparedness with local authorities and failed to perform routine and preventive maintenance and testing of equipment and systems throughout the building. The hospital had not included the physical plant and equipment maintenance and testing as a part of the hospital's quality assessment and performance improvement program.

Findings:

Throughout the course of the survey, the health surveyors and the life safety code surveyor made observations of the hospital's physical plant and environment. The following deficient practices were found:

1. The majority of patient care and other equipment located in various departments had not been inspected and maintained since 2012. The hospital administrator provided a list of equipment that was on contract with a vendor for preventive maintenance. Not all hospital equipment was included on the list. Examples of equipment not tested and maintained included a household toaster and microwave used to prepare patient meals, an infant warmer, electrical patient beds, and an electric examination table used for precipitous infant deliveries.

2. The hospital had no documentation it coordinated emergency preparedness with state and local authorities.

3. Physical hazards to patients were identified during the survey and included:
~ household grade electrical outlets
~ uneven flooring in various areas
~ a large plastic biohazard waste container in a patient room that was unsecured and easily opened by patients and visitors
~ mini blinds in patient rooms with long cords that presented a strangulation/hanging hazard
~ no safety or security patient rooms for the emergency department or the nursing units
~ emergency carts accessible to the public and unprotected against tampering
~ temporary electrical wiring
~ hallways cluttered with equipment and supplies
~ cardiac stress test room with no emergency call system, emergency powered electrical outlets, emergency equipment
~ no sharps collection containers in patient care areas

4. Disrepair was identified to include:
~ rusted and leaking air conditioners/heaters in patient rooms. Filters to these units not cleaned or replaced
~ missing or broken baseboards throughout the building
~ peeling wallpaper in patient rooms
~ chipped paint in multiple areas of the hospital
~ mold and mildew in various locations
~ non-intact, sagging or missing ceiling tiles
~ cabinetry that would not remained closed
~ window glass in a staff conference/training room (licensed as a patient room) with a bullet hole that was temporarily patched
~ live and dead insects, cobwebs in patient rooms, storage rooms, equipment rooms, meeting rooms
~ rusted and dirty equipment, including emergency resuscitation carts
~ medication refrigerator/freezer for the nursing unit had bath towels bunched in the freezer compartment to collect water dripping into the refrigerator compartment where medications were stored
~ sinks with mineral deposits and corrosion.
~ non-intact surfaces that could not be adequately cleaned and/or disinfected
~ air intake vents with accumulations of dust and dirt
~ rooms and departments were unlabeled or were identified with paper signs that had been laminated and taped to walls and doors
~ cracks and holes in flooring in various locations throghout the hospital
~ cracked patient furniture
~ rusted stainless steel medical equipment found throughout the building
~ medical equipment identified as "ready for patient use" was stored with medical gas cylinders and dirty, broken equipment
~ overbed tables in storage and in patient rooms that are used for patient meals and other medical tasks had broken and chipped surfaces that could not be disinfected
~ ice machine used for patient consumption that was not self-dispensing was housed in a dirty utility room outside of the surgery suite
~ light fixtures that were not longer secured to the ceiling were hanging freely
~ air vents were dislodged from their holdings in service areas

5. See also Life Safety Code survey.

Based on observation and interview, it was determined the hospital failed to provide emergency lighting and battery lamps and flashlights where required. See Life Safety Code survey tag K-046 and K-0147.

Based on observation and interview, the hospital failed to insure the life safety from fire requirements were met. See Life Safety Code survey tags K-018, K-021, K-029, K-046, K-048, K-052, K-054, K-062, K-067, K-070, K-071, K-077, K-078, and K-0147.

Based on observation and interview, the hospital failed to insure the life safety from fire requirements were met. See Life Safety Code survey tag K-018.

Based on observation and staff interview, it was determined the hospital failed to properly store and dispose of trash and biohazardous waste.

Findings:

During tours of the hospital, locations inside the hospital where biohazardous waste was collected had not been labeled with the proper signage. The maintenance staff stated the hospital was unaware of this requirement.

The hospital staff stated trash, including biohazardous medical waste was incinerated onsite outdoors behind the hospital. The hospital was unaware and did not follow Federal, State and local laws and regulations regarding incineration and the disposal of biohazardous waste. The hospital had no documentation of compliance with environmental, health and safety requirements and did not have policies and procedures to direct staff on the requirements.

See also Life Safety Code survey tag K-071.

Based on document review and staff interview, the hospital failed to have written fire control plans. See Life Safety Code survey tag K-048.

Based on document review and staff interview, the hospital failed to maintain written evidence of regular inspection and approval by State and local fire control agencies. See Life Safety Code survey tag K-052.

Based on observation, document review and staff interview, it was determined the hospital facilities had been modified without notification and approval by the Oklahoma State Department of Health. As a result, the hospital no longer met the State design regulations for hospitals and did not conform to accepted standards of practice. The hospital had not developed a scope of services and had not documented a functional program for each department.

Findings:
During multiple tours of the facility, the following design and function deficiencies were identified by department or area:

1. The hospital's nursing unit patient rooms had been partially re-purposed into emergency department beds, a staff training room, staff sleep rooms, a cardiac stress test/echocardiogram room, precipitous delivery room, equipment storage rooms and others. Some of the required support service rooms/areas for the nursing units were not provided. As a result, the hospital's nursing medical/surgical units did not provide and/or maintain the following required features:
~ ventilation requirements for the different areas affecting patient care to include air movement, air exchanges, air exhaustion, and air recirculation
~ station outlets for vacuum (suction) and medical air as required for different locations. The hospital leadership stated ventilator dependent patients had been admitted to the hospital and they planned to admit more ventilator patients in the future. The hospital planned to use bedside portable suction for these patients because the rooms did not conform to wall suction as required.
~ filtering efficiencies for central ventilation and air conditioning
~ electrical receptacles as required, to include outlets powered by the emergency generator
~ nurse emergency call systems in all the required locations
~ examination and treatment rooms
~ clean workrooms or supply rooms
~ soiled workrooms or supply rooms
~ medication stations properly designed and equipped
~ nourishment stations properly designed and equipped
~ self-dispensing ice machines
~ adequate equipment storage for each unit
~ storage space for stretchers and wheelchairs
~ special bathing facilities for patients on stretchers, carts or wheelchairs
~ emergency equipment storage
~ housekeeping room for the nursing units that is not used for other departments
~ two airborne infection isolation rooms for the 33 licensed beds
~ security and/or seclusion room

2. The hospital's surgical suite had been modified from its original plans. The Chief Operating Officer and the Chief Nursing Officer (CNO) provided no evidence the changes were submitted to Oklahoma State Department Health (OSDH) for review and approval as required by state regulations. As a result of these unauthorized changes, the surgery department no longer conformed to the design standards and requirements needed to maintain proper infection control and safe surgical practices.

~ The surgery department did not conform to the requirements for ventilation, airflow, air exchanges, temperature and humidity.

~ The hospital provided two different floor plans. One floor plan was dated 1974, and the other was without a date, but was identified by the CNO as being more recent. When the OSDH surveyor toured the surgery department, it was evident the "most recent" floor plan no longer reflected some of the actual rooms in use at the time of survey nor reflected the layout from the 1974 floor plans. Many rooms on the recent floor plan were unlabeled.

~ The surgery department was not divided into clearly designated areas as unrestricted, semi-restricted and restricted asdefined by the physical activities performed in each area. The traffic flow and function of the spaces were defined by the operating room (OR) manager as follows:

~ Staff entered from a public hall, through a code locked door into the central corridor. The staff walked halfway into this semi-restricted corridor to the area labeled " holding area " on the floor plan to don their personal protective equipment. Multiple times during this survey, this door unlocked and the department was accessible to unauthorized personnel.
~ The surgery department had no central control point to monitor the entrance of patients and personnel (authorized or unauthorized).
~ Although the surgery department had both men's and women's dressing rooms, these areas were not arranged to allow a one-way traffic pattern into the suite; therefore, personnel were unable to enter from outside the surgical suite to change clothing and move directly into the surgical suite.
~ The surgery department did not have a required supervisor's office. The operating room manager stated she used an open area labeled "holding area" as her office. This space was adjacent to the central sterile corridor in a restricted corridor and contained two surgical scrub sinks. This "office" area contained a desk, books and paperwork.
~ The surgical department did not have a patient holding area to accommodate stretcher patients waiting for surgery.
~ There was no anesthesia workroom as required for a surgical department. The hospital had an anesthesia machine found stored in the basement boiler room.
~ The surgery suite medication room did not have a medication refrigerator. A refrigerator was located in the room identified as the clean utility room.
~ The surgical suite did not provide a self dispensing ice maker as required.
~ There was no space utilized as a substerile room between the two operating rooms. The blanket warmer which is a requirement for this room was housed in the now decommissioned central sterile processing room.
~ The area on the recent floor plan labeled "Central Sterile" contained an autoclave which was broken. The OR manager stated it had not operated for a couple of years. This room contained general supplies and uncovered linen.
~ The surgery department clean work room was unused. A "clean utility" room near the endoscopy room was used to water rinse endoscopes. Endoscopes were not stored in ventilated and protected cabinet, and were instead hung vertically on a wall in this room.
~ On tour, two OR suites were identified. The OR manager stated only one was operational. She stated only endoscopic procedures were being performed in the operating room labeled "GI Suite" on the recent floor plan. The hospital was not designed and constructed to meet the requirements for an endoscopy suite.
~ The area labeled "recovery" on the floor plan was utilized both for pre-procedural preparation and as a post anesthesia care unit. It did not have the required features of medication station, clinical sink (hopper) or staff toilet. The required privacy curtain only provided privacy for one of two stretchers in this room. On 03/01/2016, the surveyor asked the OR manager how isolation patients were managed. She stated she did not know because she has not had an isolation patient.
~ The OR manager stated there was a second recovery room that was not used. This area was an unlabeled room on the recent floor plan and was not on the 1974 floor plan. It contained a toilet room. This room was located on the opposite side of the central corridor from the main recovery room. The room did not meet the requirements for a post anesthesia care unit (PACU).
~ The CNO manager stated temperature and humidity were not monitored in the OR suites and support areas.
~ The surgical instrument decontamination room had an exhaust fan that was activated by turning on the light switch. On 03/01/2016 and 03/02/2016, the surveyor noted the light switch was turned off. Two vats of high level disinfectant were found in this room. The CNO stated there was no monitoring of air quality and negative airflow pressure was not validated for this room.
~ The surgery department did not designate a room as a soiled utility room. Soiled bio-hazardous waste was kept in a red tub in the OR suite used for endoscopic procedures. Soiled linens were stored in a hamper in the corridor outside the endoscopy room.
3. The hospital administration stated the hospital provided definitive emergency care, but it did not maintain a dedicated emergency department with its own required features. The hospital relocated its emergency department from the original location and placed it within the medical-surgical nursing unit. The emergency department treatment rooms were divided among various locations within a nursing unit. The hospital's emergency services did not provide:
~ ventilation requirements for the different areas affecting patient care to include air movement, air exchanges, air exhaustion, and air recirculation
~ station outlets for vacuum (suction) and medical air as required for different locations
~ filtering efficiencies for central ventilation and air conditioning
~ electrical receptacles as required, to include outlets powered by the emergency generator
~ nurse emergency call systems in all the required locations
~ ambulance and emergency patient entrance directly into the emergency department. Both ambulance and patient entrances were outside of the nursing unit location; therefore these emergency patients had to travel through the hospital to enter the area where emergency department patients were seen. Helicopter transporters had to travel through a nursing unit to reach the emergency department patients located near the nursing station.
~ reception, triage and control stations located to permit staff observation and control access to the treatment area, pedestrian and ambulance entrances and public waiting area. The triage room was actually an alcove across from the nurse station that was enclosed with a curtain
~ treatment rooms with examination lights, work counters, hand washing facilities, medical equipment, cabinets, mediation storage, adequate electrical outlets, counter space for writing
~ storage under staff control for general medical/surgical emergency supplies and equipment. These items (including IV fluids) were stored on open shelves and unsecured within a room for two patients identified as a "trauma room."
~ airborne infection isolation room
~ wheelchair and stretcher storage
~ trauma room that included x-ray film illuminators, counter space for writing, enclosed cabinetry, storage for personal protective equipment
~ provisions for orthopedic and cast work, although the hospital had splints and some orthopedic supplies
~ scrub stations adjacent to the "trauma" room
~ adequate hand washing facilities. The staff stated an alcove outside the trauma rooms was used for staff hand washing. The sink in this location was a cup sink and did not meet the design requirements for a hand washing sink.
~ storage room for clean supplies. Supplies were stored in a corridor that led to an emergency exit.
~ soiled workroom of adequate size. The soiled workroom was not large enough to hold the waste containers located in the room. These items blocked staff access to the hand washing sink.
~ convenient access to hand washing facilities for the nurse station. The all staff working in this area used the cup sink located in the alcove outside the trauma room.
~ convenient and private access to staff toilets, lounge, lockers and securable closets or cabinets for staff
~ housekeeping room exclusive to emergency services. The housekeeping closet and housekeeping equipment was shared throughout the hospital.
~ security station located near the emergency entrances and triage/reception area
~ bereavement room
~ secured holding room
~ decontamination area

4. The hospital provided imaging diagnostics for inpatients and outpatients. The imaging suite did not provide the following:
~ patient waiting area
~ control desk and reception area
~ patient toilet rooms
~ patient dressing rooms
~ film storage
~ clean linen storage
~ soiled holding room

5. The hospital provided laboratory services for inpatients and outpatients. The laboratory suite did not provide the following:
~ vacuum, gases and medical air
~ electrical outlets on emergency power to include power to the refrigerated blood storage facilities
~ emergency shower
~ safety cabinet for storage of flammables
~ hand washing facilities within the blood collection area
~ work counter within the blood collection area

6. The hospital stated it provided respiratory therapy services. The hospital did not provided the following for this service:
~ storage for equipment and supplies. These items were stored in a room identified as a satellite nurse station on a nursing unit
~ separate space to receive and hold dirty equipment
~ space and utilities for cleaning and sanitizing equipment
~ ventilators for the emergency department and the inpatient units that treated ventilator patients

7. The hospital did not provide a morgue accessible through an exterior entrance.

8. The hospital pharmacist stated the hospital operated a drug room. The drug room was one small room that was overly crowded, cluttered and had no useable work space. The pharmacist also stated she re-packaged bulk medications into unit/single doses packages. She stated that because the hospital did not provide a sterile work area for IV solution preparation, the nursing staff prepared IV mixtures on a small counter space next to a shallow hand washing sink in an alcove outside the trauma room. The drug room did not provide the following facilities as required:
~ a dispensing and preparation area
~ pick-up and receiving area
~ compounding area with sink, counter space
~ work counters and space for manual dispensing activities
~ security for drugs and personnel in the dispensing counter area. The staff opened a dutch door (the only door to the drug room) to dispense drugs and conduct business with staff. Persons standing at the door could reach medications stored on shelves near the door. Persons could also reach over the door and open it at will.
~ bulk compounding area
~ provisions for packaging and labeling
~ a quality control area
~ adequate space for storage of medications, narcotics and other controlled substances, general supplies and equipment
~ provision for cross-checking medications and drug profiles of patients
~ poison control, reaction data, and drug information centers
~ a separate room or area for office functions including desk, filing, communication and reference
~ handwashing facilities where open medications were handled
~ sterile work area with a laminar-flow system and HEPA filter for IV solution preparation
~ room for consultation and patient education for medications dispensed to outpatients

9. The hospital had no dietary service facilities. The hospital administrator stated the natural gas was turned off to the kitchen and that other features "were not up to code" so the kitchen and its services were discontinued. The nursing staff prepared patient meals, including mechanically altered diet in a small room ("galley") behind the nurses' station. This area did not meet the requirements for a food service preparation area. The hospital did not provide:
~ food preparation area located in an area adjacent to delivery, interior transportation and storage of food supplies
~ work space for food preparation, portioning and tray assembly
~ dining area for ambulatory patients and visitors
~ ware washing facilities
~storage for trays and other food service utensils
~ food waste storage
~ icemaking equipment

10. The hospital did not provide the following facilities for linen services:
~ a separate room for receiving and holding soiled linen until ready for pick-up. These linens were stored in a corridor.
~ a central clean linen storage and issuing room, in addition to the linen storage required at individual patient care units and other departments
~ service entrance protected from the weather for loading and unloading linen
~ control station for pick-up and receiving

11. The hospital did not provide facilities for cleaning and sanitizing carts.

12. The hospital did not provide employee facilities (lockers, lounges and toilets) for employees and volunteers that were separate from those required for the public.

13. The hospital did not provide separate housekeeping rooms in all the required areas. Where provided, the housekeeping rooms did not have sufficient storage for equipment and supplies. These rooms were not maintained and cleaned.

14. The hospital did not provide waste processing services as required:
~ biohazardous waste storage within the hospital was not labeled as such according to State and Federal regulations.
~ The hospital used an incinerator for the disposal of biomedical waste. The hospital did not provide evidence it met applicable air pollution and life safety code guidelines.

Based on observation and staff interview, it was determined the hospital did not provide cardiac stress testing and endoscopy procedures in facilities designed for those purposes.

Findings:

During the course of the survey, tours were conducted of all areas of the hospital.

1. In a patient room located in the most remote location from the nurses' station, the hospital set up a cardiac stress test room. The room contained a treadmill and other diagnostic equipment to support this service. The room did not contain medical gases, emergency call systems or emergency equipment.

2. The hospital provided endoscopy procedures in the surgical suite. The surgical suite had been modified so extensively that it no longer met the requirements for this service. The suite did not meet the requirements for operating rooms, instrument decontamination, sterile processing and high-level disinfection and all the other service areas required for this department.

Based on observation, document review and staff interview, it was determined the hospital failed to ensure all equipment was inspected and tested for performance and safety.

Findings:

1. Hospital administrative staff and plant operations personnel stated equipment maintenance was conducted using hospital staff and contracted services. The hospital did not maintain records of hospital personnel, including contracted personnel, to demonstrate they were qualified to perform these functions.

2. The hospital did not provide maintenance policies, procedures and programs, specific inventories, and documentation of activities and schedules for equipment maintenance.

3. The hospital did not retain manufacturers' guidelines and recommendations for maintenance and schedules and the associated documentation to show these recommendations were followed.

4. During the course of the survey, non-hospital grade equipment was found to include microwaves and other household items in various rooms, including patient rooms used as staff sleeping rooms. These items were not inspected and tested by the hospital maintenance department.

5. The surgery manager stated the surgery department no longer had a working emergency defibrillator as a part of its required emergency equipment.

Based on observation, record review and staff interview, it was determined the hospital failed to ensure proper ventilation, temperature and humidity controls in the pharmaceutical, food preparation, laboratory and surgery suite.

Findings:

During the course of the survey, the following deficiencies were identified:

1. The hospital did not meet ventilation requirements in the surgical suite and support service areas as required.

2. The hospital did not provide isolation rooms as required by State regulations.

3. The drug room did not provide drug preparation areas that met ventilation, temperature and humidity requirements.

4. The hospital could not verify the laboratory met proper ventilation requirements.

5. The hospital had not identified anesthetizing locations and whether or not the hospital used flammable or non-flammable inhalation anesthetics. The hospital stated it currently was not providing anesthesia; however an anesthesia machine was found in storage in the hospital basement.

6. Humidity was not controlled in the surgical suite. The staff used a portable household dehumidifier in this area.

7. The hospital staff did not document monitoring of ventilation, room temperatures and humidity in various areas.

See also Life Safety Code survey tag K-0147.

Based on review of infection control meeting minutes, review of medical staff meeting minutes, and staff interview, the hospital failed to:

a) designate in writing an Infection Control Officer who was qualified through education and training on infection control practices.

b) ensure the infection control officer was involved in development and implementation of infection control policies and procedures.

Findings:


1. On March 1, 2016, at 10:00 a.m., Staff A told surveyors she was the infection control officer. Staff A told surveyors she had not been the infection control officer for very long.

2. Staff A told surveyors she did not have any infection control training/education.

3. On the afternoon of March 1, 2016, surveyors reviewed the personnel file for Staff A. The personnel file of Staff A contained no documentation of infection control training/education.

3. On the afternoon of March 1, 2016, surveyors reviewed infection control policies and procedures. The infection control policies and procedures were based on a generic infection control manual and not specific to the hospital. There was no evidence the infection control practitioner was involved in the development and implementation of any infection control policies and procedures.

4. On March 3, 2016 at 10:00 a.m., surveyors reviewed infection control meeting minutes and medical staff meeting minutes. There was no documentation Staff A had been designated as the infection control officer.

At the time of the revisit, the hospital had not submitted a plan of correction for the deficient practices identified in this regulation. The hospital did not provide any evidence of actions taken to correct these deficiencies. The following deficiencies remain from the previous survey:

Based on infection control meeting minutes review, infection control policies and procedures review, observation and staff interview, the hospital failed to:

a) develop and maintain an effective system to identify, report, investigate and control infections and communicable diseases of patients and personnel.

b) identify and respond to breaches in infection control practices.

Findings:

1. On the morning of March 1, 2016, surveyors requested all infection control policies and procedures and all infection control surveillance reports.

2. On the morning of March 1, 2016, staff A told surveyors she was the infection control practitioner. On the afternoon of March 2, 2016, staff A told surveyors she had no infection control training.

3. On the afternoon of March 1, 2016, surveyors reviewed infection control policies and procedures. The infection control policies and procedures were based on a generic infection control manual and not specific to the hospital. On the afternoon of March 1, 2016, staff A told surveyors the manual was the infection control policies and procedures used.

4. On the morning of March 1, 2016, surveyors requested a hospital wide Tuberculosis (TB) risk assessment and a hospital wide infection control risk assessment. A TB risk assessment was not provided, staff A told surveyors the hospital did not have one. An infection control risk assessment provided was dated 2014. There was no current infection control risk assessment.

5. On the afternoon of March 2, 2016, Staff A told surveyors she did not track and trend any employee illnesses.

6. There was no current documentation of hospital acquired infections and surgical site infections that were tracked and trended.

7. Observations were made of a CNA performing handwashing on two separate days. This staff person washed her hands for less than five seconds and when finished rinsing, knocked her hands against the inside of the handwashing sink in order to remove excess water, thereby re-contaminating her hands.

8. Various direct patient care staff were observed with artificial nails or nail extenders.

9. A staff member was observed removing contaminated linen from a patient bed. The staff gathered the linen and held it against his torso, contaminating his clothing., while he carried it to linen hamper.

10. The hospital did not reprocess endoscopes and endoscopic accessories according to manufacturer's guidelines. At the time of the revisit survey, the hospital had not addressed these deficient practices.

On 03/02/2016, the hospital policy, titled "OR Surgery-Infection Prevention and Control " documented, "The scopes shall be cleaned, per manufacturer's guidelines." On 03/01/2016 at 2:00 p.m., the OR manager stated the surgical department did not have any manufacturers' instructions for use for the endoscopic equipment and accessories.

On 03/01/2016 at 10:16 a.m. through 11:20 a.m., the surveyor toured the surgical department accompanied by Staff V. The surveyor made the following observations of deficient practices. These cited endoscope handling processes and activities that did not follow manufacturers' guidelines or acceptable standard of practices.
Staff V stated contaminated endoscopes were hand carried into the decontamination room for reprocessing. (Perioperative Standards and Recommended Practices 2013 documents, "during transport to the decontamination area, soiled flexible endoscopes must be contained e.g. enclosed by a plastic bag, container with lid" to prevent exposure to blood, body fluids or infectious organisms.)
Staff V stated she performed leak testing weekly after the scope was disinfected. (Perioperative Standards and Recommended Practices 2013 documents, "In the decontamination area, and before cleaning, leak test should be performed ...leak tests determine if there are any openings in the external and internal channels ...of the endoscope." Its purpose is important for infection control prevention and preventing significant endoscope damage.)
Staff V demonstrated the endoscope pre-cleaning procedure. The endoscope was cleaned in enzymatic solution, flushed with air using syringe, and placed in disinfectant solution. (Olympus Endoscope Reprocessing Manual documents the enzyme should be flushed with air, THEN followed by a designated amount of clean water, THEN followed by a designated amount of air, then placed in to the disinfectant and inner channels filled with disinfectant.)
Staff V stated she used single use cleaning brushes for the day (for approximately 4 patients) and then disposed of them. (Accessories that are manufactured and labeled as single use should only be used one time and then discarded).
Staff V stated she did not instill disinfectant into the inner lumen of endoscope water bottle tubing. (2014 Olympus instructions for use for water containers documented specific instructions regarding the cleaning, disinfecting, rinsing, and drying of the tube interior.) Staff V also stated the process for disinfecting the inner lumen of the spray nozzle of the oral topical anesthetic agent, cetacaine, did not include instilling the lumen with disinfectant. ((Perioperative Standards and Recommended Practices 2013 documents, "lumens and ports should be flushed and filled with the disinfectant ...")
On 03/01/2016 at 11:00 a.m., surveyor toured the "clean utility" room. Staff V stated endoscopes were rinsed with water and alcohol in this area. This area was also used for supply storage. Endoscopes were hung directly on the wall. They were not enclosed in a vented closed cabinet. (Perioperative Standards and Recommended Practices 2013 documents, "Flexible endoscopes should be stored in a closed cabinet with venting ... ").
The endoscopes were hung with electrical cap still on which does not allow for endoscope ventilation. (Olympus Endoscope Reprocessing Manual- Storage of the endoscope documents, " Detach all equipment (the air/water valve, suction valve ...water-resistant cap from the endoscope.")
Staff V stated the disinfectant's concentration was tested daily for effectiveness and temperature. This was also confirmed by review of the hospital's document titled, " Metricide Sterilizing/ Disinfecting Glutaraldehyde Testing Log". (2016 Metricide OPA instruction for use documents, "During reuse, it is recommended that the Metricide OPA Solution be tested ...prior to each use to ensure that the minimum effective concentration of [the active ingredient use ...it is recommended that a thermometer ...be utilized to ensure that optimal conditions are met." Both Staff V and the OR manager stated the disinfectant testing strips were not quality checked when each new bottle was opened. (Metricide OPA- Quick Reference information for using solution test strips 2016 documents, "QC Tests for test strips- Testing of positive and negative controls must be performed on each newly opened bottle ... ")
On 03/02/2016 at 1:45 p.m., the surveyor toured the surgical department accompanied by the operating room (OR) manager. She confirmed the endoscopic cleaning processes as described by Staff V.
The OR manager stated there was no process for reprocessing scopes after 7 days of nonuse. (Perioperative Standards and Recommended Practices 2013 documents," endoscopes should be reprocessed before use if unused for more than five days.")
23. The hospital did not validate staff competency for endoscope and endoscope accessory reprocessing. On 03/01/2016 at 10:15 a.m., Staff V stated she was trained by the OR manager for both endoscopic procedures and endoscope/ accessories reprocessing. On 03/03/2016 at 12:15 p.m., surveyor reviewed the personnel files of both Staff V and the OR manager. Both files showed no documentation of endoscopic disinfectant competencies or chemical safety training. (Perioperative Standards and Recommended Practices 2013 documents, "Administrative personnel should ensure competency validation of personnel participating in decontamination and high level disinfection of invasive instruments."

24. The hospital did not maintain proper tracking of quality controls for endoscope reprocessing. On 03/01/2016, the surveyor requested documentation of the tracking of what endoscope was used during the procedure for each patients. An untitled log was provided. The identified the medical record number of the patient and the model number only of the scope. The serial number of the endoscope was not recorded: therefore, the specific scope for each patient could be identified.
On 03/01/2016, the disinfectant used for endoscopes and accessories was contained in two covered vats and was used in the reprocessing of endoscopic and accessories. The surveyor requested the tracking documents disinfectant solution change (which should include the name of disinfectant, the date, time, lot number, expiration, and staff performing the task). Staff V and the OR manager stated the chemical name, date of change, and disinfectant expiration was written on the lid of each vat and a permanent record was not maintained. The surveyor confirmed the labeling of the vat lid. (2016 Metricide OPA instruction for use documents the disinfectant has a designated maximum "reuse period for disinfection" at which time the "product must be discarded ...even if the [solution test strips] indicate a concentration above the minimum recommendation concentration.)
On 03/02/2016, the surveyor observed a filtration system outside the surgery suite. Tap water was routed through two filters in opaque housings. Staff V stated the water was used to rinse the disinfectant from endoscopes. Staff FF did not know the filters pore size. Staff FF stated the he did not keep documentation for water filter changes.
On 03/01/2016 and 03/02/2016, the surveyor observed the decontamination room. Two vats of high level disinfectant were contained in this room. The surveyor noted the light switch was turned off, and when Staff V turned on the light switch that sound of a fan began. The CNO stated there was no monitoring of air quality and negative pressure was not validated in this room. (Perioperative Standards and Recommended Practices 2013 documents, " the decontamination area ...should be controlled ...at minimum ...negative air pressure, at least six air exchanges per hour, temperature of 60°F to 73°F, and 30% to 60% humidity. "

Based on hospital document review, and staff interview, the hospital failed to implement written protocols for organ procurement.

Findings:

1. On the morning of March 1, 2016, surveyors requested the hospital's organ procurement agency contract, activity reports and protocols. None were provided.

2. On the afternoon of March 1, 2016, Staff A told surveyors the hospital did not have an organ procurement agreement and protocols.

3. Surveyors reviewed hospital policies and procedures. There were no organ procurement policies and procedures.

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

Findings:

1. On the morning of March 1, 2016, surveyors requested the hospital's organ procurement agency contract, activity reports and protocols. None were provided.

2. On the afternoon of March 1, 2016, Staff A told surveyors the hospital did not have an organ procurement agreement and protocols.

3. On March 4, 2016, at 1:30 p.m., surveyors requested an organ procurement agreement/contract. Staff A told surveyors the hospital did not procure organs and did not have an agreement/contract with an OPO.

Based on hospital document review, and staff interview, the hospital failed to incorporate an agreement with at least one tissue bank and at least one eye bank.
Findings:
1. On the morning of March 1, 2016, surveyors requested the hospital's organ procurement agency contract, activity reports and protocols. None were provided.
2. On the afternoon of March 1, 2016, Staff A told surveyors the hospital did not have an organ procurement agreement.
3. On March 4, 2016 at 1:30 p.m., surveyors requested an organ procurement agreement/contract. Staff A told surveyors the hospital did not procure organs and did not have an agreement/contract.
4. Surveyors reviewed many different hospital documents during the course of the survey. There was no documentation of an organ procurement agreement/contract.

Based on observations, interviews, and document review, the hospital failed to establish written policies and procedures for the surgical services that the hospital provided.

Findings:

On 03/02/2016, the CNO provided a binder titled,"Surgical Policies and Procedures". The binder did not contain all of the policies and procedures for surgical services the hospital provided, such as, but not limited to: patient care requirements, patient identification, scheduling of patients for surgery procedures, preoperative work-up, updated examination/reassessment, clinical procedures, post-operative care, duties of scrub and circulating nurse, personnel policies unique to the O.R., DNR status, alcohol skin preparations,surgical fires, and care of surgical specimens.

On 03/01/2016 at 9:45 a.m., the Chief Nursing Officer stated gastrointestinal endoscopy was the exclusive service performed in the surgical suite. The binder did not contain policies, procedures, and protocols for the endoscopic services.

Based on observations and interviews, the hospital did not have the required medical equipment within the surgical department.

Findings:

On 03/02/2016 at 10:06 a.m., the surveyor inspected the surgery department ' s emergency equipment. No defibrillator was found in the surgical department. The OR manager stated the department had not had a defibrillator for more than a year.

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

a) define respiratory services scope of service;

b) provide appropriate equipment to serve the needs of the patients.

Findings:

1. On the morning of March 1, 2016, surveyors requested the scope of service for respiratory services. None was provided.

2. At 11:40 a.m., on March 1, 2016, Staff G, a Registered Nurse (RN) told surveyors the hospital accepted ventilator patients. Staff G told surveyors the hospital did not have ventilators. Staff G told surveyors there was no respiratory therapist in the hospital when there was a ventilator patient.

3. On the afternoon of March 1, 2016, Staff A told surveyors the hospital accepted ventilator patients. Surveyors did not observe any ventilators in the facility. Staff A told surveyors the patients brought their own ventilators.

4. Surveyors requested the scope of services for respiratory services multiple times through out the survey. None was provided. There was no documentation that the respiratory services scope of services had been approved through medical staff.

Based on hospital document review, and staff interview, the hospital failed to ensure a qualified physician of medicine or osteopathy was designated as the director of respiratory care services.

Findings:

1. On the morning of March 1, 2016, surveyors requested medical directors for all departments. None was provided.

2. Review of hospital documents contained no documentation of a medical director of Respiratory services.

3. On the morning of March 1, 2016, Staff G told surveyors she did not know who the medical director of Respiratory services was.

Based on observation and interview, the hospital failed to maintain compliance with Chapter 19.2.9, Emergency Lighting. See Life Safety Code survey tag K-046.

Based on infection control meeting minute review, medical staff meeting minute review, Quality Assessment Performance Improvement (QAPI) meeting minute review, and staff interview, the hospital failed to ensure infection control problems were identified and corrective actions were taken.

Findings:

1. During the course of the survey, surveyors reviewed infection control meeting minutes, medical staff meeting minutes, and QAPI meeting minutes. There was no documentation infection control problems were identified and corrective actions were taken.

2. The Chief Nursing Officer (CNO) verified these findings.