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Based upon record review and interview, the governing body failed to

A. ensure the necessary documentation was maintained for the credentialing of the medical staff. The Governing Board also failed to ensure the appointment to the medical staff of 5 (#16, 18, 19, 22, 23) out of 9 (#15, 16, 17, 18, 19, 20, 21, 22, 23) physician files reviewed. Refer to A-046

B. ensure the Quality Assessment Performance Improvement program included all departments within the scope of services as evidenced by 8 of 10 departments not represented and the Performance Improvement projects for the facility were evaluated and reviewed. Refer to A-308, A309

C. provide an Infection Control (IC) professional to establish an IC plan for reporting, surveillance, tracking and investigation of potential and actual infections, resolve known risk factors for potential infectious outbreak by failing to establish and follow an IC plan, and maintain an Infection Control log the year 2012. Refer to A-749, A750

D. ensure policies and procedures were established for organ procurement requirements in the event of a patient death, have an agreeement with an OPO (Organ Procurement Organization), and ensure an agreement with a tissue bank and eye bank that specifies criteria for referral of all potential donors. Refer to A-885, A-886, A-887

E. provide policy and procedures for Respiratory Services, ensure respiratory service was integrated into its hospital-wide QAPI program, and ensure personnel competencies for respiratory services acceptable to thescope of services and standards of practice. Refer to A-1152

Based on interview and document review the Governing Body (GB) failed to ensure the facility implemented and maintained an ongoing, data driven Quality Assessment and Performance Improvement (QAPI) program.

Review of the bylaws revealed "Article 701 Governing Board Responsibilities - The Governing Board shall establish, maintain and support an ongoing Performance Improvement Program. After considering the recommendations of the Medical Staff, the Governing Board shall require the conducting of specific review and evaluation activities to assess, preserve and improve the overall quality and efficiency of patient care and staff performance in the hospital. The Governing Board through the Administrator, shall provide whatever administrative assistance is reasonably necessary to support and facilitate the implementation and the ongoing operation such specific review and evaluation activities."

Review of Governing Board Meeting Minutes provided revealed meetings were conducted on 6/23/2011, 1/24/2012, and 11/29/12. The minutes reviewed did not document any performance improvement reports, reviews, or recommendations by the Governing Board pertaining to Quality Assurance/Performance Improvement.

An interview was conducted with Staff #3 on 1/10/13 at 1:30 pm. in the conference room. Staff #3 reported that the department quarterly reports were presented to the Medical Staff for review and recommendation and it is then sent to the corporate office but is unsure what happens to it from there.

The Governing Body failed to ensure two (2) PI projects listed in the annual PI plan were evaluated and reviewed. Refer to A308

The Governing Body failed to ensure all departments participated in Quality Assessment Process Improvements within the scope of services provided over a 12 month period evidenced by 8/10 departments not represented. The failed practice had the potential to affect all patient services within the hospital. Refer to A 0309

Based on observation, contract reviews, and staff interviews, the facility failed to provide a written contract for a diagnostic radiology service. The facility failed to review the quality of this service in the QAPI program.

Findings:

Review of the facility's policy and procedures for 'Radiological Services NUR- 7:045' reveals, "It is the policy of Behavioral Hospital of Longview does not have its own radiological services. Our patients do not generally require radiology services. Patients with serious medical illnesses require complex treatment will be referred for treatment in facilities that have the requisite associated services. On those occasions where radiological services are needed for patients, they will be referred out to the nearest Diagnostic Imaging Center."

The facility was unable to produce a contract with a diagnostic radiology service. Interview with staff #1 on 01/08/2013 at 9:40am confirmed there is no written contracts for radiological services. Staff #1 stated, "If a patient needs an x-ray they are sent to a hospital of the patients choice."

On 01/10/2012 Further review of the PI minutes for 2012/2013 reveals no evidence of QAPI intergrated into the hospital wide system.

On 01/10/2013 at 1400 staff #3 confirmed that radiological services have not been intergrated into the hospital wide QAPI program.

Based on observation, contract reviews, and staff interviews, the facility failed to provide a written contract for 'stat/emergent' laboratory services rendered through the local hospitals. The facility failed to review the quality of this service in the QAPI program.

On review of the facilities policy and procedures manuals only one policy was located for laboratory." Policy No. NUR-7:029 Laboratory Results, PURPOSE: The purpose of this policy is to ensure that laboratory results are noted and posted in patient records in a timely fashion."

Review of the facilities contracts pertaining to laboratory services revealed a contract with a clinical laboratory, located in Florida that was licensed in the State of Texas.
According to the service agreement, "Lab will provide any and all 'non-stat' laboratory services requested by the client during the term of agreement."

Interview with staff #1 and #2 on 01/08/2013 at 9:50am reported, stat or emergent lab is sent to a local hospital and the facility has sent lab over recently. No contracts for laboratory services are located for the local hospitals.

Further review of the PI minutes for years 2012/2013 revealed no QAPI for laboratory had been intergrated to hospital wide program.

Interview with Staff #2 and staff #3 on 01/08/2013 at 9:50 confirmed there was no QAPI data for laboratory services.

Staff #2 stated, "I don't have any. I wasn't told I needed to report it." Staff #2 reported, she was unaware of any other policies for laboratory.

Staff #2 produced a log of patient labs but was unable to produce a list of emergent versus non emergent labs.

Based on document review and interview the facility failed to provide an Infection Control professional to establish reporting, surveillance, tracking and investigation of potential and actual infections for 10 months and failed to resolve known risk factors for potential infectious outbreak over a 4 month time frame by failing to establish and follow an IC plan and maintain an Infection Control log the year 2012. The failed practice had the potential to affect all patients admitted to the hospital. Refer to A0749, A0750

Based upon record review and interview, the facility failed to ensure policies and procedures were established for organ procurement requirements in the event of a patient death, have an agreeement with an OPO (Organ Procurement Organization), and ensure an agreement with a tissue bank and eye bank that specifies criteria for referral of all potential donors. Refer to A-885, A-886, A-887

Based on record review and interview, the facility failed to provide policy and procedures, respiratory service integrated into its hospital-wide QAPI program, or personnel competencies for respiratory services acceptable to the standards of practice.

Refer to A-1152

Based on observation, record review and staff interviews, the Governing Board failed to ensure the necessary documentation was maintained for the credentialing of the medical staff. The Governing Board also failed to ensure the appointment to the medical staff of 5 (#16, 18, 19, 22, 23) out of 9 (#15, 16, 17, 18, 19, 20, 21, 22, 23) physician files reviewed.

Review of a document titled "Governing Board Bylaws" revealed the following: "Article II - Board of Directors, Section 201, Board of Directors. The Board is the ultimate authority for the overall operations of the Facility, and from time to time it may, as it sees fit, delegate authority to individuals, such as the Medical Director, Administrator and Controller. Section 203, Regular Meetings. Meetings of the Board shall be held at least annually to review and evaluate the performance of all programs and to consider and act upon reports. Section 204, Special Board Meeting. Special Board meetings may be called at any time upon 24 hour notice given either oral or in writing."

"Section 213 Minutes of the Directors Meetings. Minutes shall be kept of the meetings of the Board and shall set forth the date of the meeting, the names of the directors attending, the topics discussed, any decisions reached or actions taken, together with dates established for implementation, and summary of any report delivered by the Chief Executive Office or any other officer or staff member."

"Section 604 A. Delegation to the Medical Staff. The Governing Board shall delegate to the Medical Staff the responsibility and authority to investigate and evaluate matters relating to Medical Staff membership, clinical privileges, and corrective action on behalf of the facility. The Governing Board shall require that the Meduical Staff adopt and forward to it specific written recommendations with appropriate supporting documentation that will allow the Governing Board to take informed action regarding such matters."

Review of the facilities medical staff by-laws revealed "ARTICLE 5. - PROCEDURES FOR APPOINTMENT AND REAPPOINTMENT AND GRANTING AND RENEWAL OF CLINICAL PRIVILEGES
5.1 General Procedure: The Medical Staff through its services, committees, and officer shall investigate and consider each application for appointment and reappointment and for granting and renewing or revising hospital-specific clinical privileges and shall adopt and transmit recommendations thereon to the board, for final decision."

On review of the Governing Board minutes provided for 06/23/2011, 01/24/2012, and 11/29/2012 there was no documentation that physicians (#16, 18, 19, 22, 23) were approved for appointment.

Review of staff chart #16 revealed no letter of appointment. Appointment decision had signatures from CEO and Medical director with no dates but no Governing Board appointment. There was no documentation in the Governing Board meeting minutes that the Governing Board had approved the appointment.

Review of staff chart #18 revealed no letter of appointment, privilege delineation form, or hospital orientation. There was no documentation in the Governing Board meeting minutes that the Governing Board had approved the appointment.

Review of staff chart #19 revealed no letter of appointment. Appointment decision has signatures from CEO and Medical director with no dates, or hospital orientation. There was no approval of appointment from the Governing Board. There was no documentation in the Governing Board meeting minutes that the Governing Board had approved the appointment.

Review of staff chart #22 revealed no letter of appointment. Appointment delineation form had signatures from CEO with a date of 9/18/2012, Credentialing chair signature with a date of 08/31/2012. There was no approval of appointment from the Governing Board. There was no documentation in the Governing Board meeting minutes that the Governing Board had approved the appointment.

Review of staff chart #23 has no letter of appointment. Appointment decision has signatures from CEO and Medical director with no dates. The Appointment decision form was signed by a member of the Governing Board but there was no documentation in the Governing Board meeting minutes that the Governing Board had approved the appointment.

During an interview with Staff #13 on 1/10/2013 at 2:30pm, staff #13 confirmed that he is not aware of missing letters of appointments, orientations, or delineation forms. Staff #13 confirmed he is not aware of what materials needed to be in the physician credentialing files. Staff #13 reported he has not been in this position long and has never been trained on physician credentialing or the care of medical staff records.

Based upon record review, the facility to ensure there was a policy that specified the training requirements for the use of restraint or seclusion for physicians. The facility failed to ensure 3 of 3 (#15, #16, #17) physicians reviewed received training regarding the use of restraint and seclusion.

Review of the Medical Staff Bylaws, Rules, and Regulations adopted 4/30/10 revealed there was no policy, provisions, and/or requirements for the use of restraint and seclusion or training requirements for physicians related to the use of restraint and seclusion.

Review of the facility policy # NUR-7:113 titled "Seclusion and Restraint" revealed the requirements for training and competencies for all direct care staff who would be involved in the initiation and application of restraint/seclusion and monitoring of a patient while in restraint and seclusion. The policy did not address training requirements for physicians for the use of restraint or seclusion.

Review of the credentialing files for physicians (#15, #16, #17) revealed no documentation of training related to the use of restraint or seclusion.

Based upon record review, the facility failed to ensure the physician documented the face to face one-hour evaluation for 3 of 4 (#7, #8, #22) patients reviewed that had restraint and seclusion used as an intervention for managing behaviors. The facility also failed to ensure the face to face one-hour evaluation for 1 of 4 (#3) patients reviewed was complete with the patient's medical and behavioral condition.

Review of patient record #7 revealed telephone order dated 12/14/12 at 10:00 am: "May initiate restraints per protocol." The order did not contain specific interventions for how to restrain, why to restrain, or for how long to restrain. Further review revealed a physician's order written by (#16) at 11:15 am that stated the following: "Please call me in 1 hour to determine if patient able to be out of restraints. I discussed this plan with the patient, who was understanding." This information would lead one to believe the physician saw the patient but there was no documentation of a comprehensive review of the patient's condition.

Review of patient record #8 revealed a physician's ( #17) written order dated 11/22/12 at 9:45am: "Restraints for safety 1-4 hours until safe-patient assaultive to 2 people". Further review of physician order form revealed physician (#15) wrote the following on 11/22/12 at 11:06 am: "Pt. seen face to face. Discontinue leg restraints". Further review of the patient record revealed no other documentation of physician's (#15) evaluation that included a complete review of systems, behavioral assessment as well as the patient's history.

Review of patient record #22 revealed physician's order dated 11/26/12 at 1:05 pm: "Retraints/secluded for patient protection." The order did not contain specific interventions for how to restrain, how to seclude, how long to restrain or seclude, or why patient needed to be restrained and secluded. Further review of the patient record revealed there was no documentation that physicians (#16, #17) had conducted a face to face evaluation of the patient to assess medical and behavioral conditions or the continued need for restraint.

Record review of patient record #3 revealed physician's(#16) order dated 11/30/12 at 11:45 am: "Seclude/restraints for patient protection-not to exceed 4 hours". The physician order was not specific about how to restrain and there was no documentation why the order was for seclude and restraint.
Further review of the patient record revealed a physician progress note dated 11/30/12 at 12:45 pm. that stated the following: "Patient seen in restraints-still agitated and uncooperative to make contract for safety. Not as agitated as one hour ago. Oriented, alert, in one leg restraint-delusional and poor insight."
There was no documentation of patient's medical condition or the need to continue the restraint.

Review of the facility's policy #NUR-7:113 titled "Seclusion and Restraint" - Section C. Documentation of Seclusion and Restraint Episodes - Evaluation of the Individual in Restraint or Seclusion revealed : "The licensed independent practitioner who is responsible for the individual's ongoing care. The purpose of the in-person evaluation by the licensed independent practitioner/specially trained RN, is to work with the individual and staff to identify ways to assist the individual regain control, make revisions to the treatment plan and if necessary provide a new written order. This order and any subsequent orders follow the time limits allowed. An evaluation will be conducted within 1 hour of initiation of the seclusion/restraint.

Review of the Medical Staff Bylaws, Rules and Regulations dated 4/30/10 revealed no provisions, requirements, or policies related to identifying approved behavioral interventions and use of restraint and seclusion in the facility.

Based on interview and document review the Governing Body failed to ensure the Quality Assessment Perfromance Improvement program included all departments within the scope of services provided over a 12 month period evidenced by 8 of 10 departments not represented.

Review of the bylaws revealed "Article 701 Governing Board Responsibilities - The Governing Board shall establish, maintain and support an ongoing Performance Improvement Program. After considering the recommendations of the Medical Staff, the Governing Board shall require the conducting of specific review and evaluation activities to assess, preserve and improve the overall quality and efficiency of patient care and staff performance in the hospital. The Governing Board through the Administrator, shall provide whatever administrative assistance is reasonably necessary to support and facilitate the implementation and the ongoing operation such specific review and evaluation activities."


On 1/8/2013 in the conference room the Quality Assurance Performance Improvement (QAPI) for the facility was reviewed and revealed the following departments submitted no information for QAPI during the year 2012:

No information submitted:
Laboratory services
Housekeeping services
Radiology services
Laundry services

Further review of Performance Improvement Plan for the facility for the year 2012 revealed the Performance Improvement (PI) listed by department for the first quarter did not show data for the following departments:
Infection control
Medical staff
Utilization Review
Pharmacy services

On 1/11/2012 at 9:00 AM the officer for Risk Management and Quality Assurance confirmed all departments had not contributed to the QAPI program of the facility.

Based on interview and document review the facility's Governing Board (GB) failed to ensure the Process Improvement (PI) projects for the facility were evaluated and reviewed based on two (2) PI projects listed in the annual PI plan.

On 1/9/2013 at 2:00 PM in the conference room the facility Performance Improvement Plan was reviewed and two (2) targets were identified for improvement.

1. Telephone orders signed, justification, and dated within 48 hours was below the benchmark of 90%. As of November the response/evaluation from the nursing staff revealed 54% compliance of the target goal. No data from the GB was found reviewing this goal.

2. The walk in cooler/Refrigerator temperature was reading above the maximum allowed temperature of 40 degrees. Identified in March of 2012.

At 1:15 PM, on 1/8/2013, in the conference room, the temperature logs for the walk in cooler were reviewed and revealed the following:

17 of 30 days in September of 2012 the walk in refrigerator temperature was recorded as greater than 40 degrees Fahrenheit but not greater than 45 degrees Fahrenheit.

24 of 31 days in October of 2012 the recorded temperature of the walk in refrigerator was greater than 40 degrees Fahrenheit but less than 45 degrees Fahrenheit.

18 of 30 days in November of 2012 the recorded temperature for the walk in refrigerator was greater than 40 degrees Fahrenheit but less than 44 degrees Fahrenheit.

14 of 31 days in December of 2012 the recorded temperature of the walk refrigerator was greater than 40 degrees Fahrenheit but less than 43 degrees Fahrenheit.

As of January of 2013 the walk in Cooler (refrigerator) remains out of compliance with temperatures above the 40 degree temperature. There was no data from the GB explaining why the recommendations submitted in March of 2012 to replace the walk in refrigerator was not accepted or followed upon. Data reflects that in April and again in May quotes to replace the walk in refrigerator were received, yet the refrigerator was not replaced. Nor were sufficient repairs done to insure the safety of the food products stored within the refrigerator. In July the motor was replaced but the temperatures remained out of compliance and in September another quote to replace the walk in refrigerator was obtained. No action was taken by the GB to resolve this problem.

On 1/9/2013 at 1:00 PM the the officer for Risk Management and Quality Assurance confirmed the Governing Board had not followed through with support for repairs.

Based upon record review and interview, the facility failed to ensure 19 of 19 (#1 - #19) patients received a complete nursing assessment. Physical Assessments were not being completed on 19 of 19 ( #1 - #19) patients reviewed.

Review of medical record of patients #1 - #19 revealed a nursing assessment pre-printed form titled "Daily Nursing Assessment". The top part of the form addresses mental status and psychiatric issues. The next section was titled "Physical Assessment" and contained the headings: Neurological, Cardiovascular, Respiratory, Gastrointestinal, GU/Renal (Genitourinary), Musculoskeletal, and Integumentary (Skin). The instructions for this section was to "Check if within normal limits". The form also contained a section for "Fall Assessment" and "Pain Assessment".

Further review of the medical records revealed the "Physical Assessment" was not being done consistently and nurses were writing "See H & P" (History and Physical examination done by the physician on admission) in that section and not completing the checklist. The following list indicates the number of physical assessments not done for the number of times during the patient's hospitalization that they should have received a complete nursing assessment.

Patient #1 - 6 of 16 nursing assessments did not include a physical assessment
Patient #2 - 9 of 16 nursing assessments did not include a physical assessment
Patient #3 - 68 of 88 nursing assessments did not include a physical assessment
Patient #4 - 28 of 56 nursing assessments did not include a physical assessment
Patient #5 - 31 of 58 nursing assessments did not include a physical assessment
Patient #6 - 14 of 26 nursing assessments did not include a physical assessment
Patient #7 - 35 of 63 nursing assessments did not include a physical assessment
Patient #8 - 45 of 64 nursing assessments did not include a physical assessment
Patient #9 - 10 of 26 nursing assessments did not include a physical assessment
Patient #10 - 30 of 32 nursing assessments did not include a physical assessment
Patient #11 - 45 of 58 nursing assessments did not include a physical assessment
Patient #12 - 12 of 40 nursing assessments did not include a physical assessment
Patient #13 - 21 of 42 nursing assessments did not include a physical assessment
Patient #14 - 3 of 18 nursing assessments did not include a physical assessment
Patient #15 - 22 of 46 nursing assessments did not include a physical assessment
Patient #16 - 29 of 56 nursing assessments did not include a physical assessment
Patient #17 - 11 of 18 nursing assessments did not include a physical assessment
Patient #18 - 8 of 14 nursing assessments did not include a physical assessment
Patient #19 - 25 of 30 nursing assessments did not include a physical assessment

An interview was conducted with Staff #2 in the conference room on 1/11/13 at 10:00 am. Staff #2 reviewed a number of nursing assessments and confirmed the physical assessment was not consistently being done by the RN.

Based on observation and interview the facility failed to demonstrate safe storage of items intended for trash disposal on or very near the back loading dock.

On 1/8/2013 at 10:30 AM during a tour of the facility grounds, two (2) commercial dumpsters were observed in very close proximity, approximately 10 feet, from the facility's back loading dock. Housekeeping employees could stand on the loading dock and toss light weight bags into the dumpsters. The loading dock was also observed to have broken items that were no longer in use stored on the dock. A laundry cart, that was full of both bagged and non-bagged linen was positioned between the dock and the nearest dumpster.

On 1/8/2013 at 10:30 the Maintenance Director agreed the dock was cluttered with "stuff that doesn't need to be here" and also confirmed the dumpsters had been moved closer for the housekeeping staff. stating "We may have to move them back out there" indicating a greater distance from the back loading dock.

Based on observation and interview the facility failed to maintain safe facility structure for the mobility of patients through the building based on unfinished floor surfaces.

On 1/8/2013 during the tour of the building a portion of the building was observed to have new flooring.

During the tour of the building on 1/8/2013 at 10:00 AM an interview with the Maintenance Director/Safety Director (MD/SD) revealed the census was down and two (2) patient units were closed. The flooring was replaced on these two units. It was also observed that the common hallway had new flooring and the thresh holds of the doorways were not covered by the new flooring and concrete and a yellow substance was visible. The MD/SD revealed the plan was to replace the flooring throughout the building, however there was not a completion date as yet.

On 1/9/2013 at 10:00 AM in the conference room the Administrator was questioned regarding the completion of the thresholds. The Administrator reported the company that began the floor replacement was small and wanted to be paid in order to purchase the material to complete the job and the facility ownership wanted the job finished before they paid for the work. However, reportedly the company had been paid and work would resume.

Based on observation, interview and documentation review the facility failed to provide an Infection Control professional to establish an IC plan for reporting, surveillance, tracking and investigation of potential and actual infections for 10/12 months and failed to resolve known risk factors for potential infectious outbreak over a 4/12 month time frame.

On 1/8/2013 10:30 AM during a tour of the building, a large box was observed on the floor in a mechanical room. The Maintenance Director confirmed the box contained the new compressor for the walk in refrigerator in the dietary department and he was waiting for the refrigeration company to send someone to install the compressor.

On 1/8/2013 at 11:00 AM while touring the building in the dietary department the one (1) walk in refrigerator was observed to be holding a temperature of 44 degrees. The Food Services Supervisor confirmed the cooler had not maintained a safe food storage temperature since September of 2012. She voiced her frustration with the slow response for repair time.

On 1/8/2013 at 1:00 PM, in the conference room, the facilities Dietary policy for safe food storage temperatures was reviewed and revealed the following:
Policy FOS-3:004 effective date 1/4/12
Policy: if is the policy of the facility that All perishable items are to be properly stored upon receipt and to prevent deterioration and spoilage and to maintain quality.
Procedure:
3. Every freezer and refrigerator unit has a thermometer in it, accessible to be checked and charted each day.
4. Required temperature:
A. Freezer -10 to 10 degrees Fahrenheit
B. Refrigerator 40 degrees of below

On 1/8/2013 at 1:15 PM in the conference room the temperature logs for the walk in cooler were reviewed and revealed the following:

17 of 30 days in September of 2012 the walk in refrigerator temperature was recorded as greater than 40 degrees Fahrenheit but not greater than 45 degrees Fahrenheit.

24 of 31 days in October of 2012 the recorded temperature of the walk in refrigerator was greater than 40 degrees Fahrenheit but less than 45 degrees Fahrenheit.

18 of 30 days in November of 2012 the recorded temperature for the walk in refrigerator was greater than 40 degrees Fahrenheit but less than 44 degrees Fahrenheit.

14 of 31 days the recorded temperature of the walk refrigerator was greater than 40 degrees Fahrenheit but less than 43 degrees Fahrenheit.

On 1/8/2013 at 2:00 PM in the conference room the Quality Assurance (QA) officer was interview and revealed the dietary supervisor collects her information and submits it for the QA report but her request dies at corporate.

On 1/10/2013 at 12:30 PM in the conference room the Infection Control (IC) officer was interviewed and confirmed he had been hired 1 month ago. He worked 20 hours a week and usually came by the facility after 4:00 PM. He had not yet developed an IC plan. He had made environmental rounds throughout the building. When asked if he was aware the walk in refrigerator in the dietary department was not holding a safe food storage temperature he stated "No, he was not aware of the problem". In the presence of the IC officer a review of the existing IC data, that had been submitted to the QA committee for review, revealed no data was submitted for March, April, May, June, July, August, September November or December of 2012.(10 months) Further review revealed, of the data submitted there was no written IC plan of action observed.

Based on documentation review and interview the facility failed to maintain an Infection Control (IC) log for the year 2012.

On 1/9/2013 at 1:00 PM a review of the IC data that was submitted to the QA committee for review revealed no data was submitted for March, April, May, June, July, August, September November or December of 2012.(10 months) Further review revealed, of the data submitted, there was no written IC plan of action observed. There was no IC log to review. There was no investigation into any infection identified within the building for the year 2012. There was no ongoing Quality Assessment Process Improvement submitted by the facility.

On 1/10/2013 in the conference room the Infection Control (IC) officer was interviewed and revealed he had been hired 1 month ago. He worked 20 hours a week and usually came by the facility after 4:00 PM. He had not yet developed an IC plan for the facility.

Based upon record review and interview, the facility failed to ensure policies and procedures were established for organ procurement requirements in the event of a patient death.

Review of the Administration, Clinical, and Nursing policies and procedure manual revealed no policies pertaining to the facility's requirements for organ, tissue, or eye procurement in the event of a patient death.

An interview was conducted on 1/9/2013 at 1:30pm with the Administrator in the conference room. The Administrator confirmed there were no policies related to organ procurement.

Based upon record review and interview, the facility failed to have an agreeement with an OPO (Organ Procurement Organization).

Review of all contracts, agreements and Memorandum of Understanding revealed no agreement with an OPO.

An interview was conducted with the Administrator on 1/9/2013 at 1:30 pm. The Administrator reported there was no agreement with an OPO.

Based upon record review and interview, the facility failed to ensure an agreement with a tissue bank and eye bank that specifies criteria for referral of all potential donors.

Review of contracts, agreements, and memorandum of understanding revealed no agreement with an eye or tissue bank for referral of all potential donors.

An interview with the Administrator on 1/9/2013 at 1:30 pm confirmed that an agreement did not exist.

Based on record review and interviews, the facility failed to provide a director of respiratory services, or policy and procedures for supervision of respiratory services.

Findings include:

Review of the facility's policy and procedures manual revealed there is no policy and procedures for respiratory care.

Interview with staff #2 on 01/10/2013 at 1400 confirmed there were no policy or procedures for respiratory care.

Staff #2 reported that breathing treatments, hand held nebulizers, and Oxygen were used on patients in the facility. Staff #2 confirmed no specific training to respiratory care had been initiated for the personnel.

Interview with Staff #28 confirmed that she has received no formal instruction for respiratory treatments from the facility and has administered hand held nebs. Staff #28 stated, "The doctor writes the orders and I give it."