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Based on review of policy and procedure, hospital documents, personnel files, and staff interviews the hospital failed to provide radiology services to meet the needs of the patients and are in accordance with standards of practice.

Findings:

1. On the morning of 03/28/2012 Staff A told surveyors radiology services were provided by employees. There was no documentation the employees were trained and competent to use the equipment at the hospital.

2. There were no current policies reviewed and approved by medical staff and the radiologist indicating what services were provided at the facility.

3. There were no current policies or documents reviewed and approved by the medical staff and radiologist indicating personnel competent to use the radiological equipment and administer procedures.

4. On the afternoon of 3/29/2012 Staff A told surveyors the facility did not have a radiologist in charge of the radiology department.

5. Policies and procedures for the radiology department were dated 2004. There was no documentation the facility had current radiology policies and procedures reviewed and approved through medical staff and governance.

6. There was no documentation the radiology services provided were incorporated into the facilities quality assurance performance improvement data.

7. There was no documentation radiology employees were competent in radiology safety. There was no documentation the facility had oversight by a medical physicist.

8. There was no documentation the infection control processes were incorporated into the radiology departments operating practices.

Based on record review and interviews with hospital staff the hospital does not ensure there is a organized dietary service with oversight by a registered dietitian. The hospital did not have evidence that a dietitian was providing oversight or services with regularly scheduled visits and oversight of clinical nutritional services. The facility failed to meet the nutritional needs of the patient.

Findings:

1. On 3/28/2012 Staff A told surveyors the facility had a contracted dietitian and nursing personal provided meals. Consultants reports for three months were provided to surveyors. There was no documentation a dietitian had been overseeing dietary services for the past twelve months. Staff A did not have documentation of any orientation and training or competency information on the dietitians. Staff A told surveyors multiple dietitians were provided through the contract company. Not all dietitians listed as providing services to the facility had proof of licensure.

2. On 3/28/2012 Staff A told surveyors there was not one employee responsible for preparing meals. Staff A told surveyors the responsibility for cooking and plating meals was divided among nursing personnel. On 3/29/2012 Staff A told surveyors the facility did not have a certified dietary manager or a registered dietary technician overseeing dietary services. The hospital failed to have a full time employee qualified by education and training in charge of the dietary program.

3. There was no documentation any of the nursing staff had been trained, evaluated, and reviewed for competency in food services, oriented and trained to current dietary policies and procedures, or all nursing personnel were evaluated for food safety and sanitation competency by the dietitian.

4. Review of medical records indicate patients had nutritional conditions requiring nutritional intervention which the facility did not act on. The hospital staff did not provide nutritional support to meet the needs of the patient.

5. There was no documentation a dietitian reviewed or approved menus, special diets, made recommendations on nutritional issues, oversaw clinical dietetics, reviewed, revised, and implemented policies approved by the medical staff regarding nutritional services.

6. Dietary policies reviewed on 3/29/12 did not include current dietary practices at the hospital. The facility failed to implement policies, and oversee processes to ensure patients nutritional needs are met.

7. There was no quality assurance performance improvement monitoring for clinical nutritional services.

Based on review of records, interviews with staff, review of hospital documents, and review of policies, the hospital does not ensure that all patient grievances are reviewed, resolved, and a written response sent through the hospital's grievance process. Findings:
(1) Two medical records ( 11,16 ) had incidents of complaints/grievances documented. The facility did not recognize these occurrences as grievances. There was no documentation the complaints/grievances had been reviewed through the governing body or the committee delegated to oversee grievances.
(2) Six medical records ( 9,10,11,12, 13, 14) had incidents of complaints/grievances documented. The facility documented these grievances as complaints, initial letters were sent but no follow up letters with all of the required elements. There was no documentation the complaints/grievances had been reviewed through the governing body or the committee delegated to oversee grievances.

Based on a review of policies and procedures, complaint/grievance reports, and staff interview, the hospital failed to ensure a written notice of the patients' grievance resolutions containing the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion were provided to the complainants. Six of six (9,10,11, 12, 13, 14)grievances did not include a written response with all required elements to the complainants.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. The hospital failed to investigate, take action or have a method to identify incidents or patterns to protect patients.

Findings:

1. Review of Quality Assurance and Performance Improvement Committee Meeting minutes for 2011/ 2012, Governing Body Meeting Minutes, and Medical Staff Meeting Minutes did not include analysis of incidents to identify patterns which might impair patient safety. There was no analysis of incidents or grievances to develop plans of correction to improve patient safety.

2. Review of Pharmacy and Therapeutics meeting minutes indicated there were no adverse medication events for 2011/2012. Review of risk management information indicated there were multiple medication incidents during this period of time. None of the errors were analyzed for trends or patterns. None of the medication incidents were analyzed to determine if it was a personnel or system issue.

3. Surveyors reviewed personnel files on 3/29/12. There was no documentation the employees were educated on the current grievance policy. There was no documentation the employees were educated on incident reporting and medication error reporting.

4. Surveyors reviewed personnel files of employees involved in multiple medication errors. There was no documentation in the files the employee had been provided information pertaining to the incidents, any corrective action, or education regarding medication errors. This information was verified with Staff A on 3/29/12.

5. This finding was discussed at the exit conference. No further documentation was provided.

Based on a review of medical records and staff interviews, the hospital failed to ensure that all out-patient procedure records contained a history and physical (H&P) in the record before surgery. Two(1,2) of three (patient records 1,2,3 ) out-patient procedure records did not contain a H&P prior to the patient's surgery.

Findings:

1. Patient record #1 The patient was admitted on 3/20/12 for an out-patient procedure. The physician dictated a history and physical 3/20/12 but it was not transcribed until the day after the procedure. No handwritten H&P was on the chart.

2. Patient record #3 The patient was admitted on 3/13/12 for an out-patient procedure. The physician dictated a history and physical 3/13/12 but it was not transcribed until the day after the procedure. No handwritten H&P was on the chart.

3. The above findings were reviewed at the exit conference. No further documentation was provided.

Based on a review of medical records and interviews with hospital staff, the hospital failed the ensure the medical records were complete and contained all pertinent information such as complete nursing assessments, reports of treatments, documentation of care provided, medication administration, and vital signs monitoring.

Findings:

1. On 3/28/12 surveyors reviewed three procedure charts. Three (1,2,3) of three (1,2,3) procedure records did not have orders noted pre and post procedure.

2. Two (1,3) of three (1,2,3) procedure records did not follow the correct oxygen order.

3. One(2) of three procedure records (1,2,3) included orders for pre procedure antibiotics. Antibiotics were documented as "Ancef 1 gm (gram) and Gentamycin 60 mg (milligram). There was no documentation of the type of admixture amount or route. There was no intravenous site documented, type of solution, time started, time infused.

4. Documentation in medical record 1 and 2 indicated patients were given "gas drops and cetacaine spray". There was no date, time, and route of administration. There were no orders written by the physician for these medications.

5. There was no documentation provided to surveyors that medical records were reviewed for accuracy and completion.

6. The above findings were reviewed at the exit conference 3/29/2012. No further documentation was provided.

Based on review of policy and procedure, hospital documents, personnel files, and staff interviews the hospital failed to provide radiology services to meet the needs of the patients and are in accordance with standards of practice.

Findings:

1. On the morning of 03/28/2012 Staff A told surveyors radiology services were provided by employees. There were no current policies reviewed and approved by medical staff and the radiologist indicating what services were provided at the facility. There were no current policies or documents reviewed and approved by the medical staff and radiologist indicating personnel competent to use the radiological equipment and administer procedures.

2. On the afternoon of 3/29/2012 Staff A told surveyors the facility did not have a radiologist in charge of the radiology department.

3. Policies and procedures for the radiology department were dated 2004. There was no documentation the facility had current radiology policies and procedures reviewed and approved through medical staff and governance.

Based on review of policies, interviews with staff, and review of medical records the facility failed to provide radiological services in a safe manner.

1. On 3/28/12 Staff A told surveyors X-ray services were provided by employees. The facility did not have current radiology policies and procedures.

2. On 3/29/12 personnel files provided to surveyors did not indicate personnel operating the radiology equipment were competent, oriented, and trained.

3. There was no evidence the radiology equipment used was safe and routinely inspected by qualified personnel.

4. There was no documentation the facility had oversight by a medical physicist.

Based on review of policies, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services.

Findings:

On the afternoon of 3/28/12 Staff A told surveyors the facility did not have a radiologist that supervised radiology services.

These findings were discussed with administration at the exit conference 3/29/12.

Based on interviews with staff, review of hospital documents, review of policies and procedures the hospital failed to have a process in place to take appropriate action when notified of blood or blood components potential infected with human immunovirus (HIV) or hepatitis C virus (HCV).

Findings:

1. On 3/28/12 surveyors requested hospital policies regarding blood and blood components. In particular surveyors requested the hospital's policy regarding transfusion of potentially infected blood and blood products. Staff B told surveyors on 3/29/12 the facility did not have a policy.

2. This finding was confirmed with Staff A on 3/29/12.

Based on review of personnel files and interviews with staff the hospital failed to provide oversight of the food and dietetic services.

Findings:

1. On 3/28/2012 Staff A told surveyors food and nutrition services were provided through employees and contract. Staff A told surveyors the facility had a contract for dietitian oversight of the food services.

2. On 3/28/2012 Staff A told surveyors the facility did not have a dietitian on staff full time or a full time certified dietary manager or registered dietary technician.

3. These findings were reviewed at the exit conference 3/29/12. No further documentation was provided.

Based on review of hospital documents and interviews, the hospital failed to ensure a qualified dietitian supervises the nutritional aspects of patient care.

Findings:

1. On 3/28/2012 Staff A told surveyors the facility had a contracted dietitian and nursing personal provided. There was no documentation the dietitians were licensed, trained, competent, and evaluated. There was no evidence the dietitians were oriented to the facility. There was no documentation a dietitian had been overseeing all aspects of clinical nutrition for the past twelve months.

2. On 3/28/2012 the facility provided surveyors a "nutritional assessment form" . There was no policy or procedure which matched the form. Medical records reviewed did not utilize this form. There was no evidence patient's at risk for nutritional problems were assessed by a dietitian and were provided nutrition to meet their needs. The hospital did not have documentation nutritional assessments were performed on all patients identified as "at risk" for nutritional issues.

3. On 3/28/2012 consultants reports for three months were provided to surveyors. The consultants report did not contain all of the required elements for oversight. There was no documentation a dietitian had been overseeing dietary services for the past twelve months. Staff A did not have any orientation and training or competency information on the dietitians. Staff A told surveyors multiple dietitians were provided through the contract company. Not all dietitians listed as providing services to the facility had proof of licensure.

4. There was no documentation the consultant participated in the hospital quality assurance performance improvement activities.

4. This information was provided in the exit conference. No further documentation was provided.

Based on review of policies, personnel files, and interviews, the hospital failed to provide adequate training and oversight to dietary personnel.

Findings:

1. On 3/28/2012 Staff A told surveyors nursing personnel provided dietary services. There was no documentation, policy, procedure, or process in place stipulating how nursing department employees would be trained regarding dietary. There was no documentation the employees had been oriented and trained to the facilities dietary department, departmental sanitation, and clinical nutritional services.

2, On 3/28/2012 Staff A told surveyors the facility did not have a full time certified dietary manager (CDM) or registered dietary technician. The facility failed to provide dietary services with oversight by trained, competent, employees.

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

Findings:

1. Staff A, B, and C told the surveyors on 03/29/2012 that, as of March 2012 Staff K was the infection control officer.

2. Review of Staff K's personnel file did not contain evidence that Staff K had been designated as the infection control professional - no job description for the infection control professional, performance evaluation, or documentation of appointment.

3. Review of quality, medical staff and governing body meeting minutes did not reflect Staff K have been designated/appointed as the infection control profession.

4. These findings were reviewed and verified administration on the afternoon of 03/29/2012.

Based on review of infection control data and meeting minutes and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. The Infection Prevention and Control Plan was for 2011, with an effective/approval date of 2010. On the afternoon of 3/29/2012 Staff C told surveyors she had revised the 2010 plan and it had been approved in Medical Staff and Governing Body but not implemented as Staff C resigned as the infection control practitioner to return to school.

2. Review of meeting minutes for 2011 and 2012, containing infection control, did not reflect review and analysis with plans of action and follow-up of monitoring or all services/areas of the hospital.

a. Employee health - review of employee illness to ensure transmissions between staff and patients did not occur. For three of three staff reviewed (Staff H, I, and J) who provided patient services, the personnel files did not contain complete immunization histories as recommended by CDC (Centers for Disease Control and Prevention) and its Advisory Committee on Immunization Practice (ACIP).

b. Although the infection control professional kept an infection control log, the log was a listing of meeting minutes and did not reflect analysis of these logs with actions to ensure proper antibiotic usage and control/prevent possible transmission between individuals with measures taken to contain and prevent transmission and whether they were effective. Staff C told surveyors the log was not representative of all infections but all patients. Staff C told surveyors Staff C requested all patients be written into the log and if cultures came back positive Staff C would complete information in the log. Staff C was not aware if the new infection control practitioner was aware of this practice.

c. Not all departments/area were reviewed/monitored for compliance with established policies and procedures and standards of practice to prevent and control infections and maintain a sanitary environment.

d. Surveillance activities did not match the stated Infection Control Surveillance objectives. There was no documentation why the facility did not follow the current plan.

e. Concerns/problems identified in one meeting were not always addressed in the next meeting to analyze if any corrective action taken was effective.

f. Staff working in the procedure room were unable to identify the type of disinfectant used to clean between procedures and the length of kill time required for the disinfectant.

3. These findings were reviewed with hospital administrative staff during the exit conference on the afternoon of 03/29/2012.

Based on review of policy and procedure and the infection control log the facility failed to maintain an infection control log with all the required elements. Although the infection control professional kept an infection control log, the log was a listing of meeting minutes and did not reflect analysis of these logs with actions to ensure proper antibiotic usage and control/prevent possible transmission between individuals with measures taken to contain and prevent transmission and whether they were effective. Staff C told surveyors the log was not representative of all infections but all patients. Staff C told surveyors Staff C requested all patients be written into the log and if cultures came back positive Staff C would complete information in the log. Staff C was not aware if the new infection control practitioner was aware of this practice.

Based on a review of medical records and staff interviews, the hospital failed to ensure that all out-patient procedure records contained a history and physical (H&P) in the record before surgery. Two(1,2) of three (patient records 1,2,3 ) out-patient procedure records did not contain a H&P prior to the patient's surgery.

Findings:

1. Patient record #1 . The patient was admitted on 3/20/12 for out-patient procedure. The physician dictated a history and physical 3/20/12 but it was not transcribed until the day after the procedure. No handwritten H&P was on the chart.

2. Patient record #3 . The patient was admitted on 3/13/12 for out-patient procedure. The physician dictated a history and physical 3/13/12 but it was not transcribed until the day after the procedure. No handwritten H&P was on the chart.

3. The above findings were reviewed at the exit conference. No further documentation was provided.

Based on review of hospital documents and personnel files and interviews with hospital staff, the hospital failed to ensure respiratory services were supervised and provided by qualified staff.

Findings:

1. The hospital provides respiratory services of oxygen, hand held nebulizer, and occasional intubations through the emergency room. This was finding confirmed with Staff B and C on the afternoon of 3/28/2012.

2. Review of the hospital's organizational chart, contracts and employee list did not show respiratory services. This finding was confirmed with Staff A on the afternoon of 3/28/2012.

3. State Licensure Hospital Standards, Subchapter 23-6(a) requires that "respiratory therapy services, including equipment, shall be supervised by a licensed respiratory therapist. Staff A confirmed on 3/28/2012 that the hospital did not employ respiratory therapist and did not have a contract with a respiratory therapist to provide supervision and training to staff providing respiratory services.

4. Staff A and B told the surveyors that nursing personnel provided the hospital's respiratory services, but stated a respiratory therapist had not provided training.

Based on review of hospital documents for 2011 and 2012 and interviews with hospital staff, the hospital does not ensure that medication errors identified are evaluated, analyzed and action taken to improve the care and safety of patients. Errors were identified but were not analyzed to determine why they were occurring and a plan of action implemented to reduce the errors.

Findings:

1. Staff stated on 03/29/12 in the afternoon medication errors are reported and documented on medication error sheets then are reviewed by the pharmacist and the Director of Nurses. The sheets are then taken to Pharmacy and Therapeutics (P & T )meeting for the physician to review.

2. The pharmacist is a consultant and comes once a week. The P & T meetings are quarterly.

3. The only actions documented as action taken were memos to nursing about documentation. There was no evidence that the errors were analyzed to determine whether it was a personnel or system problem.

4. The errors were repeat errors month after month.