HospitalInspections.org

Based on document review, observation and staff interviews, the Governing Body failed to:
1. Ensure the policies governing all departments were up to date.
2. Ensure medical staff requirements were met.
3. Ensure the hospital was in compliance with all CMS regulations.
Findings:
1. On the afternoon of July 28, 2014, surveyors requested and reviewed all departmental policies and procedures that were provided by the hospital.

2. All the Department policies were outdated and were signed by the old administrator.

3. On the afternoon of 07/30/14, surveyors reviewed the credentialing file for Staff T (Director of Radiology). Staff T's appointment had expired 06/2013. Staff T's liability insurance had expired 06/29/2012. See Tag A-0528

4. The hospital failed to have procedures to ensure the confidentiality of patient records. See Tag A-0441

5. The hospital failed to have procedures that medical records were properly stored in secure locations where they are protected. See Tag A-0438

6. The hospital failed to ensure that pharmacy services were appropriately monitored to maintain the safety of the patients. See Tag A-490

7. The hospital failed to ensure that infection control surveillance was monitored actively to maintain the safety of the patients. See Tag A-0747

8. See all other Standard and Condition Level deficiencies on the 2567.

9. This was verified at the time of review and at the exit interview.

Based on policy and procedure review, record review, observation, and staff interview, the hospital failed to ensure medical records:

1. procedures for ensuring the confidentiality of patient records. See Tag A-0441;

2. were properly stored in secure locations where they are protected. See Tag A-0438; and

3. contained discharge summaries and all the components as required. See Tag A-0468.

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

1. Develop comprehensive policies and procedures for the radiology department based on nationally recognized standards of practice.

2. Include radiology services in the hospital-wide QAPI process.

3. Implement radiology policies, procedures and practices that ensured safety for patients and personnel.

4. Ensure radiology personnel had documented evidence of specialized training, education, qualifications, and certification necessary for work in the radiology department.

5. Ensure a qualified radiologist supervised all radiology services.

6. Document in writing the scope and complexity of radiology services offered by the hospital.

7. Ensure the medical staff and the governing body approved the scope and complexity of the radiology services offered.

Findings:

1a. The radiology policies and procedures reviewed did not include policies and procedures for fluoroscopy, cleaning and storing the trans-vaginal ultrasound probe, mammography, MRI, and nuclear medicine.

1b. Staff V told surveyors that contracted services have their own policies and procedures they follow.

1c. There was no evidence that the medical staff and governing body approved/adopted contracted radiology services' policies and procedures.

2a. On the afternoon of 07/29/14, staff V told surveyors that there are issues in radiology but they try to fix them as they occur.

2b. On the afternoon of 07/28/14, surveyors reviewed QAPI meeting minutes for 2013 and 2014. There was no documented evidence that radiological services were integrated into the hospital-wide QAPI program.

3a. On the afternoon of 07/29/14, surveyors toured the radiology department. Surveyors observed a trans-vaginal probe laying on the counter in the room designated for ultrasounds in the radiology department.

3b. Staff U told surveyors she did not recall seeing any policy or procedure on how to clean the trans-vaginal ultrasound probe. She demonstrated how the trans-vaginal ultrasound probe was to be cleaned. Staff U was not wearing personal protective equipment (PPE) while placing and removing the trans-vaginal ultrasound probe into Cidex OPA cleaning solution.

3c. There was no evidence of a policy and procedure used to clean the trans-vaginal probe based on the manufacturer guidelines.

3d. The physicist's report (2013) documented concern about sealed sources related to nuclear medicine. There was no documented evidence for 2014.

3e. Staff V and Staff DD told surveyors that the hospital no longer is providing nuclear medicine services and are trying to get the nuclear storage container removed from the hospital.

3f. The radiology department did not have documentation of policies and procedures that described how radiation hazards were prevented in the department.

3g. On the afternoon of 07/29/14, Staff V stated there was no training or practice drills for emergencies in the radiology department.

4a. The medical staff had not designated qualified staff to operate the radiological equipment and to administer procedures in the radiology department.

4b. There was no documented evidence that radiology personnel had necessary training, education, qualifications, and certification.

4c. There was no documented evidence that radiology personnel performing/working with nuclear medicine had necessary training, education, qualifications, and certification.

5a. On the afternoon of 07/30/14, surveyors reviewed the credentialing file for Staff T. Staff T's appointment had expired 06/2013. Staff T's liability insurance had expired 06/29/2012.

5b. These findings were reviewed and verified with the CEO and hospital administrative staff at exit.

5c. On the afternoon of 07/31/2014, the CEO told surveyors that there would be an emergency meeting to ensure all physicians and providers are currently privileged and appointed to the medical staff.

6a. On 07/28/14, administrative staff and the radiology manager were asked to provide a written scope of services for radiology services offered. The radiology manager provided written scope of services on the afternoon of 0/28/14 that did not have all radiology services offered.

6b. On the afternoon of 04/24/14, surveyors reviewed a binder that was labeled "Policy and Procedure Manual" provided by the radiology department. There was no documentation containing policies and procedures for fluoroscopy, trans-vaginal ultrasounds, mammography, MRI, and nuclear medicine.

6c. On the afternoon of 07/29/14, Staff V verified that the hospital provided fluoroscopy, trans-vaginal ultrasounds, mammography, and MRI.

6d. On the afternoon of 07/28/14, the Chief Financial Officer (CFO) told surveyors that the hospital is no longer offering nuclear medicine services.

7a. There were no meeting minutes that documented the medical staff and governing body approved radiological services of fluoroscopy, trans-vaginal ultrasounds, mammography, and MRI.

7b. There was no meeting minutes that documented that the medical staff and governing body were no longer providing nuclear medicine services.

Based on infection control meeting minutes review, infection control surveillance reports, observation, and staff interview, the hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.

Findings:

1. On the morning of July 29, 2014 surveyors reviewed infection control meeting minutes and infection control surveillance reports.

2. There was no documentation that all the chemicals and disinfectants had been reviewed and approved by the infection control practitioner (ICP), the infection control committee, and medical staff. On the morning of July 29, 2014, the ICP told surveyors that she had not reviewed and approved the chemicals and disinfectants used in the hospital.

3. There was no documentation of a tuberculosis risk assessment. On the morning of July 29, 2014, the ICP told surveyors that the employee health nurse did a tuberculosis risk assessment. On the morning of July 29, 2014 the employee health nurse told surveyors that she had not done a tuberculosis risk assessment for the hospital.

4. There was no documentation of any environmental rounds by the infection control practitioner to all departments of the hospital to include: dietary, laundry, laboratory, radiology, and all patient care areas.

5. On the morning of July 29, 2014, surveyors interviewed the ICP, the ICP told surveyors that every morning she runs all the culture reports from patients who had any cultures done, and looks it over to determine if the patient is on the correct antibiotic that was prescribed or not. The ICP told surveyors if the antibiotic is not correct then she goes to the physician and discusses changing the antibiotics. There was not documentation in infection control meeting minutes, or in infection control surveillance reports. The ICP told surveyors that she does not document it anywhere.

6. On the afternoon of July 28, 2014, surveyors toured the hospital. Surveyors observed the nursery on the obstetric unit. The nursery on the obstetric unit was closed and a regular patient room was being utilized as the nursery. Staff I told surveyors that the hospital was reconstructing the current nursery.

7. On the morning of July 29, 2014, surveyors asked the ICP if she had done a construction risk assessment for the hospital because of the construction in the nursery. The ICP stated that she did not know there was construction going on in the nursery.


Observations:

1. On the afternoon of July 28, 2014, surveyors toured the obstetric department.

2. Surveyors observed one of the labor, delivery and recovery rooms (LDR). Surveyors observed a large bottle of baby shampoo and a large bottle of baby lotion by the sink. Staff I told surveyors that they used the large bottles of baby shampoo and baby lotion for all babies.

3. Surveyors observed an unlocked cabinet in the LDR room, the cabinet contained multiple supplies and linens. Staff I told surveyors that they keep the cabinet stocked for multiple patients and they do not dispose of the linens in the cabinet after a patient is moved from the room.
4. Surveyors observed multiple bottles of ultrasound gel opened in the LDR room and not dated for when it was opened. One bottle did not have a lid on it.

5. Surveyors observed the medication room on the obstetric unit. The medication room contained no sink and served multiple purposes. The medication room was also the nurse's break room where they eat. The medication room was also used for the nurse's to chart patient care.

6. Surveyors observed an ice chest filled with ice in the main patient hallway for everyone to access. The ice scoop was laying next to the ice chest uncovered.

7. Surveyors observed monitor straps stored in the sink in the clean linen room.

8. Surveyors observed multiple storage rooms throughout the hospital that contained equipment such as cribs, wheelchairs, bedside tables and other equipment used for patient care. Some of the equipment was labeled as broken. Surveyors could not determine if the equipment was clean or dirty. Staff OO and staff FF told surveyors that nurse's cleaned the equipment prior to equipment being placed in the room.

9. Surveyors observed throughout the hospital non hospital approved hand sanitizers and hand lotion being used by the hospital staff.

10. Surveyors observed the wound care unit on the third floor of the hospital. The wound care rooms were carpeted. Carpet can not be terminally cleaned.

11. Surveyors observed a tub room on the second floor that was used for storage of IV supplies. The tub room also contained Christmas decorations. The vents on the ceiling in the tub room were covered in dust.

12. Surveyors observed in multiple areas of the hospital linens uncovered and stored in patient care areas.

13. On the afternoon of July 30, 2014, surveyors observed Staff SS cleaning a patient room. The room contained two patient beds. One bed for the patient and one bed for patient's family members. Staff SS was cleaning one bed and changing the linen for one bed. Surveyors asked Staff SS if she would only clean the one bed. Staff SS told surveyors that she would only clean the one bed because "nobody slept in the other bed."

14. On the morning of July 29, 2014, surveyors toured the Operating Room Department.

15. Surveyors observed office chairs in the Operating Rooms made of cloth material. Chairs cannot be terminally cleaned.

16. Surveyors observed papers being kept in wall hangers that were not covered. Papers cannot be protected from spills.

17. Surveyors observed table top pads on the operating room beds that had holes and rips. Fluids can penetrate into the padding and cannot be terminally cleaned.

Based on clinical record review, policy and procedure review, personnel record review and staff interview, the hospital failed to ensure:

a. emergency department policies and procedures were reviewed and approved by the medical staff. See Tag A-1104;

b. emergency services personnel requirements were met. See Tag A-1110; and

c. failure to ensure staff working in the emergency department had demonstrated skills competencies. See Tag A-1112.

Based on document review and staff interview, the hospital failed to ensure contracted services were assessed and complied with the Conditions of Participation.

Findings:

1. On the afternoon of 07/28/14, surveyors reviewed the governing body and medical staff meeting minutes for 2013 and 2014. There was no documented evidence that contracted services were being assessed and evaluated.

2. On the afternoon of 07/28/14, administrative staff provided surveyors with a contracted service list. The contracted service list was incomplete and did not contain all contracted services the hospital provided.

3. On the afternoon of 07/30/14, administrative staff verified the contracted service list was incomplete. No further documentation was provided.

Based on observation and staff interview, the hospital failed to ensure patients received care in a safe setting.

Findings:

1. On the afternoon of July 28, 2014, surveyors toured all areas of the hospital. The hospital did not maintain a sanitary environment. See tag A0747.

2. On the afternoon of July 28, 2014, surveyors toured the obstetric unit. The unit is located on one hallway.

The entrance doors to the unit are locked and visitors must buzz the buzzer to be allowed entrance.

The unit is staffed with only 2 nurses who are both involved in direct patient care.

The entrance doors do not require anyone to "buzz out" to exit the unit and the entrance doors do not contain a security alarm.

3. On the afternoon of July 28, 2014, Staff I told surveyors that the hospital does not utilize infant security alarms.

This was verified with administrative staff upon exit the afternoon of July 31, 2014.

Based on medical record review and staff interview, the hospital failed to ensure that a Registered Nurse (RN) supervised and evaluated the care of each patient. This occurred in 3 of 3 newborn medical records reviewed.

Findings:

1. On the afternoon of July 28, 2014, staff I told surveyors that both RN's and Licensed Practical Nurse's (LPN) provide patient care. Staff I told surveyors that the RN's assess the patients.

2. On the morning of July 31, 2014, surveyors reviewed 3 of 3 newborn medical records. All 3 medical records contained documentation of assessments by the LPN not the RN.

Based on review of policies and procedures and medical records and staff interviews, the hospital failed to develop policies and procedures, ensure medical records were complete, and readily accessible/retrievable.

Findings:

1. On the morning of 07/30/14, surveyors toured the medical records storage facility with Staff HH and MMM.

2. Medical records were not properly stored and secured in locations where they were protected from fire, water damage, and other threats.

3. The medical records storage facility was a metal building filled with propane tanks, aerosolized chemical spray, wood pallets, dozens of black binders with documents, multiple plastic sacs full of documents needing to be shredded, broken down cardboard boxes, medical records from physicians' offices that are not affiliated with the hospital, and multiple rows of unevenly stacked with boxes higher than 6 foot.

4. The metal building contained a standard door lock and a rolled garage type door with a pad lock. The building did not contain any temperature control system, alarm system or sprinkler system.

5. Staff HH and MMM told surveyors that two staff members have to come out early in the morning to look for medical records as it gets too hot in the summer.

6. Staff WW (maintenance/security) told surveyors that he will go out and look for medical records when asked.

7. Staff HH told surveyors that it is almost impossible to find records in the metal building due to the way the boxes are stacked.

8. On the morning of 07/29/14, staff HH told surveyors that there are problems with some providers completing their charts in a timely manner.

9. On the morning of 07/28/14, surveyors requested medical records policies and procedures. On the morning of 07/29/14, staff HH provided surveyors with a binder of medical record policies and procedures that were dated 03/20/2003. Staff HH told surveyors, "The medical records policies are out of date and I am slowly working on updating them."

10. Staff HH told surveyors there were outdated policies and procedures including electronic medical records. There were no policies and procedures developed, reviewed, approved and implemented that required elements for inpatient and outpatient medical records.

11. There were no policies on documentation standards including processes used to document in the electronic record. There were no policies indicating integration of paper medical records into the electronic medical record. There were no policies when the electronic record was down.

12. Review of Medical Records, QAPI, and Medical Staff meeting minutes for 2013 and 2014 did not indicate records were reviewed for completion.

13. There was no evidence that medical record information was presented to the Medical Staff and Governing Body for action as required by the facilities bylaws.

14. Findings were verified at the time of review and at the exit conference on the afternoon of 07/31/14 with administration.

Based on document review, observation, and staff interview, the hospital failed to ensure the confidentiality of patient records and that unauthorized individuals cannot gain access to alter patient records.

Findings:

1. On the morning of 07/29/14 surveyors toured the medical records department inside the hospital.

2. Staff HH told surveyors that certain departments/people have keys to gain access to the medical records department when medical records is closed.

3. Staff HH told surveyors that people entering the medical records department should sign in and document what record they are taking. She told surveyors not everyone signs in/out.

4. Staff HH told surveyors she is unsure who is coming in and out of the medical records department when medical records is closed. Staff HH indicated the cleaning crew likes to take breaks in the medical records department.

5. Staff HH told surveyors, "Psych records are kept in here" and the nursing staff from that unit comes in to get what records they need when medical records are closed.

6. Staff HH told surveyors, "There are no safe guards for any patient record, anyone who can access the medical record department can access the paper medical records."

7. Staff HH told surveyors she does not know how to run reports to see who is looking at what chart, who is deleting what part(s) of the medical record, and who is coming into the medical records department looking at or taking charts.

8. The Information Technology Manager told surveyors that he does not run reports to audit user usage.

9. There was no documented policy and procedure provided to surveyors on confidentiality of records, gaining access to the medical record department/medical record.

10. The findings were verified at the time of review.

Based on medical record review and staff interview, the hospital failed to ensure that each medical record contained a discharge summary to include outcome of hospitalization, condition at discharge, and disposition of the patient at time of discharge. This occurred in 5 of 5 ( #1, 2, 3, 4, & #5) postpartum and newborn medical records reviewed.

Findings:

1. On the morning of July 31, 2014, surveyors reviewed 5 postpartum and newborn medical records (#1, 2, 3, 4, &5).

2. The medical records for patient's #1, 2, 3, & #4 did not contain the condition of the patient at time of discharge and the disposition of the patient at time of discharge.

3. The medical record for patient #5 did not contain a discharge summary.

4. This was verified at the time of record review. Staff FF told surveyors the medical record was complete.

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

a. develop and implement comprehensive pharmacy services policies and procedures, including those to minimize drug errors;

b. provide meaningful participation by pharmacy in the QAPI program;

c. ensure drugs and biologicals were stored according to manufacturer's instructions.

d. ensure the pharmacist was responsible for developing, supervising and coordinating all pharmacy services throughout the hospital.

e. ensure pharmaceutical services staff were sufficiently trained.

f. ensure accurate records were kept of all scheduled drugs.

g. ensure drugs and biological were controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.

h. ensure all drugs and biological were kept in a secure area.

g. ensure all scheduled drugs were locked within a secure area.

i. ensure authorized personnel may have access to locked areas.

j. ensure unusable medications were not available for patient use.

k. the hospital failed to ensure appropriate actions and oversight was taken by the pharmacy services department in response to drug administration errors.

Findings:

1. Pharmacy staff told surveyors they do not see the Pharmacist but she comes in on her off hours.

2. The Consultant Pharmacist was not available during the survey. Pharmacy staff told surveyors the consultant pharmacist had her own business and was not available.

3. Staff TT, a drug room technician was unable to answer basic questions of how she was able to track all medications, biological, narcotics, and scheduled medications throughout the facility from time of entrance to dispensation.

4. Surveyors observed drugs were stored in various unsecured areas throughout the hospital.

5. Keys for the lock box securing narcotics and scheduled medications was located in an unsecured drawer that cannot be locked, in the nursing station on the second floor medication room with the door propped open.

6. Multi-dose scheduled medication vials had hash marks or lines drawn on the bottle of how much of each medication "should be left" in each bottle. Pharmacy and nursing staff throughout the hospital were unable to verbalize or produce a policy and procedure for the correct way to account for injectable narcotic/scheduled medications.

7. Versed, Succinylcholine, and Rocuronium in multiple dose vials were unsecured throughout the hospital. These medications are for sedating and paralyzing patients, typically used for surgery and intubating (inserting a tube to maintain an airway with mechanical ventilation).

8. Succinylcholine (1½ boxes) were found unsecured in the operating room (OR) refrigerator.

9. In the emergency department (ED), outdated medications, intravenous (IV) fluids with the overwrap removed, and unsecured medications were found by surveyors. Bags of hypertonic saline were stored with bags of normal saline and normal saline irrigation.

10. Bags of IV fluids were in the ED fluid warmer without dates indicating how long they had been in the fluid warmer.

11. The Neonatal Crash Box was found in the ED up on an EMS cabinet with linens. The box was covered in dust and had multiple expired life-saving medications with expiration dates of 10/2013.

12. Staff O told surveyors she did not know if the Neonatal Crash Box found in the ED was the hospital's, the CRNA's (Certified Registered Nurse Anesthetist) or EMS's (Emergency Medical Service) life-saving medication box.

13. Review of personnel records indicated there had been no orientation or training on hospital and pharmacy procedures. There was no documentation the drug room supervisor and technicians had been trained to oversee, monitor, and control drugs throughout the hospital.

14. The Drug Room Supervisor did not have evidence of training as a Drug Room Supervisor in her personnel file.

15. There was no evidence from nursing personnel file review, meeting minutes reviewed and interviews with the Director of Nursing and administration that nursing personnel had been instructed on who was authorized to access the drug room.

16. The hospital was asked to provide pharmacy services policies and procedures. There was no organization to the manual. There was no accurate table of contents. The policy and procedure manual provided to the surveyors was not useable in its current state.

17. No comprehensive policies could be found that addressed drug administration errors, adverse drug reactions and drug incompatibilities.

18. A review of QAPI meeting minutes for 2013 and 2014 had no documentation of reporting of indicators by the pharmacy department. The pharmacy QAPI reports for 2013 and 2014 meeting minutes were limited to medications omitted.

19. There was no documented evidence of why medications were omitted. There was no documented evidence of medication errors, drug loss, potential drug diversion as the hospital utilized multi-dose vials used for multiple patient use of narcotics and scheduled medications.

Based on observation and staff interviews, the hospital failed to ensure a current therapeutic manual was readily available and approved by the dietitian.
Findings:
1. The therapeutic manual available was the 2006 edition. The most current therapeutic manual is the 2012 edition.
2. The supervisor of dietary services stated on 07/29/2014 that the 2006 manual was the most current edition that she had.

Based on infection control policy and procedure review and staff interview, the hospital failed to ensure the infection control practitioner (ICP) developed and implemented infection control policies and procedures.

Findings:

1. On the afternoon of July 28, 2014, surveyors requested and reviewed all infection control policies and procedures.

2. All the infection control policies were dated March 2007 and were signed by the old administrator.

3. This was verified at the time of review.

Based on Quality Assessment Performance Improvement (QAPI) meeting minutes, and interview, the hospital failed to reassess its discharge planning process on an on-going basis to include review of discharge plans to ensure they are responsive to discharge needs of the patient.

Findings:

1. On the morning of July 29, 2014, surveyors reviewed QAPI meeting minutes, there was no documentation of discharge planning processes being reviewed and reassessed to ensure the discharge needs of the patient was being met.

2. This was verified at the time of review.

Based on policy and procedure review and staff interview, the hospital failed to develop and implement all necessary policies and procedures related to organ, tissue and eye procurement.

Findings:

1. On 07/28/14, hospital leadership was asked to provide organ, tissue and eye procurement policies and procedures.

2. A book titled, "Tissue Manual" was provided. The Tissue Manual documented how the staff with approach families for organ donation.

3. The hospital had provided a current contract with an Organ Procurement Organization (OPO) that documented, "...[OPO name deleted] staff are only personnel trained according to CMS regulation to approach..."

4. Hospital administrative staff verified findings at the time of review.

Based on hospital document review, record review, and staff interview, the hospital failed to ensure all death records were reviewed to improve identification of potential donors.

Findings:
1. On the afternoon of 07/29/14, surveyors reviewed the organ procurement organization (OPO) death report for 2013 that documented, "total timely referrals 93%."

2. On the afternoon of 07/29/14, surveyors requested OPO data for 2014. None was provided.

3. On the morning of 07/30/14, administrative staff told surveyors all OPO information had been provided and there was no more OPO data.

4. On the afternoon of 07/29/14, surveyors reviewed QAPI meeting minutes for 2013 and 2014. There was no documented evidence that death records were being reviewed, OPO documentation was being reviewed for timely referrals.

5. These findings were verified with administrative staff at the time of review. No further documentation was provided.

Based on observation and staff interviews, the hospital failed to ensure the policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care.
Findings:
1. On the afternoon of July 28, 2014, surveyors requested and reviewed all Surgical Services policies and procedures that were provided by the Surgery Manager.

2. All the Surgical Services policies were dated 2006 and were signed by the old administrator.

3. This was verified at the time of review.

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

Findings:

1. The emergency department (ED) policies and procedures had documentation they were last reviewed in 2008. The hospital's ED policy documented they were to be reviewed, revised, and updated every two years.

2. The ED manager stated the policies and procedures were not current.

3. Medical staff meeting minutes for 2013 had no documentation the medical staff reviewed and approved the emergency department policies and procedures.

Based on document review, observation, and staff interview, the hospital failed to ensure emergency services personnel requirements were met.

Findings:
1. On the afternoon of 07/29/14, surveyors toured and observed the emergency department (ED) waiting area and ED.

2. Surveyors observed registration personnel triaging patients. Registration personnel are not clinical.

3. Surveyors asked Staff YY to explain the process of when a patient presents into the ED.

4. Staff YY told surveyors, "We ask the patient what they need to be seen for. If the patient looks real bad, says they are having chest pain, or trouble breathing we call the nurses in the back. If they look okay, we register the patient and then bring the papers to the back where a nurse will come out to triage the patient when they are available."

5. Four (Staff O through Q and ZZ) of four staff files reviewed showed no evidence of current ED qualifications and competencies.

6. None of the records had documentation of verification of skills competencies related to specialized tasks in the ED.

7. Staff O told surveyors that registration personnel triages the ED patients and makes the decision which patient needs to be seen by a nurse first.

8. Findings were verified at the time of review and at the exit conference.

Based on hospital document review, record review, and staff interview, the hospital failed to ensure staff working in the emergency department (ED) had demonstrated skills competencies. This occurred for four (Staff O through Q and ZZ) of four ED staff files reviewed.

Findings:

1. Staff training and education files were reviewed for evidence of demonstrated skills competencies for specialized tasks performed in the emergency room:

-Triage Assessment using the emergency severity index (ESI);

-Intravenous (IV) insertion, accessing/de-accessing implanted central venous devices, venous blood draw sampling, and blood glucose monitoring;

-Respiratory treatments, assessing, performing, and documentation;

-Accessing, assembling, and delivering oxygen cylinders with regulators for patient use;

- Electrocardiogram (ECG) 12 lead cardiac monitoring and rhythm recognition;

-Neurological assessment using Glasgow coma scale (GCS);

-IV conscious sedation, rapid sequence intubations (RSI), and airway management;

-Calculating and managing critical IV drips;

-Restraints: application, monitoring, assessment, and interventions based on CMS guidelines.

None of the records had documentation of verification of skills competencies related to specialized tasks in the ED.

2. Staff O told surveyors that all nursing personnel working in the ED must have basic life support (BLS), advanced cardiac life support (ACLS), and pediatric life support (PALS) certification.

3. Two (P and ZZ) of four ED personnel files reviewed did not contain documented evidence of advanced cardiac life support (ACLS) certification.

4. On the afternoon of 07/31/2014, hospital administrative staff verified that all personnel files were complete. No further documentation was provided.

Based on review of open and closed records and staff interview, the hospital failed to:
a.) Ensure menus were meeting the needs of the patients.
b.) Ensure nutritional assessments were done to assess the needs of the patients.
This occurred in 21 of 21 medical records reviewed.
Findings:
1. Twenty one of Twenty one patient records showed diagnoses including cardiac arrest, vomiting, cellulitis, anemia, dehydration, and diabetes. There was evidence that a nutritional screen was done, but no documentation on the charts that a nutritional assessment was followed.
2. On the morning of July 31, 2014 Staff (XX) told surveyors that she could locate the nutritional screen and assessment on the medical record. Staff (XX) was unable to locate the nutritional screen or assessment.

Based on Quality Assessment Performance Improvement (QAPI) meeting minute review, and infection control meeting minute review, the hospital failed to identify. address and implement corrective actions regarding infection control issues.

Findings:

1. On the morning of July 29, 2014, surveyors reviewed QAPI meeting minutes and infection control meeting minutes. There was no documentation of infection control issues being identified or addressed. There was no documentation of any corrective actions regarding infection control issues.

Based on personnel file review and interview, the hospital failed to have a system in place that prevents mistreatment, neglect and abuse of patients. This occurred in 29 of 31 personnel files reviewed (B, C, D, E, F, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE)

Findings:

1. On the afternoon of July 30, 2014, surveyors reviewed thirty one personnel files. Twenty nine of thirty one personnel files reviewed (B, C, D, E, F, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE) did not contain nurse aide registry checks.

2. This was verified at time of review.