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Based on record review and interviews with hospital staff, the hospital failed to develop, implement and maintain a quality assessment and performance improvement program (QAPI) that reflected the complexity of the hospital's organization and services, involved all hospital departments and services including those provided by contract or arrangement and had indicators selected that led to improved health outcomes.

Findings:

1. The hospital did not ensure the Quality Assessment Performance Improvement Program's (QAPI) scope included indicators from all hospital departments including contracted services to measure, analyze and track processes of care to monitor the effectiveness and quality of care. See Tag A 0273.

2. Review of hospital documents provided as part of a QAPI program did not have evidence of review of services provided by contract or agreement ensure quality of care and safety for patients. See Tag A 0083.

3. The hospital did not include in the quality assessment and performance improvement (QAPI) program measurable indicators to identify and reduce medical errors and adverse patient events, analyze the errors and events and implement changes to improve outcomes. Medication errors and adverse patient were not included as part of the QAPI program. See Tag A 0286.

3. The hospital did not have an ongoing Quality Assurance Performance Improvement (QAPI )program that reflected the complexity of the hospital's organization and services and involves all hospital departments including contracted or shared services. See Tag A 0308.

Hospital Staff A verified on 05/01/14 in the morning that the hospital did not have an ongoing hospital wide QAPI program.

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

a. document in writing the scope and complexity of radiology services offered by the hospital;

b. ensure the medical staff and the governing body approved the scope and complexity of the radiology services offered;

c. ensure the radiology department was supervised by a qualified radiologist approved by the medical staff. See Tag A-0546; and

d. failed to ensure radiology personnel were designated as qualified by the medical staff to use the radiological equipment and administer procedures. See Tag A-0547.

Findings:

On 04/30/14, the radiology department policies and procedures were reviewed. There was no description of the scope and complexity of radiology services provided by the hospital.

The policies and procedures had no documentation they were developed based on nationally recognized standards of practice. There was no documentation the policies were approved by a supervising radiologist.

There was no documentation in the QAPI meeting minutes that indicated radiology services were included in the quality assessment process.

On 05/01/14, the CEO was informed of the findings. No further documentation was provided.

Based on observation, interviews with staff and review of hospital documentation, the hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff.

Findings:

1. The hospital failed to have a qualified Infection Control Preventionist to oversee the infection control program.(Refer to Tag A-748)

2. The hospital does not have an ongoing infection control program that reviews hospital wide practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained. (Refer to Tag A-749).

3. Surgical practices are not reviewed to ensure they reflect current infection control standards and safe practice.

4. The hospital does not ensure the infections control program has a current tracking mechanism for patients and staff to track infections and possible transmissions of infections and communicable diseases. Immunizations histories are not reviewed.

5. Leadership does not ensure infection control concerns and issues, or lack thereof, are reviewed, analyzed and corrective actions are taken through the quality assessment and performance improvement process. (Refer to Tag A-756).

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

Findings:

a. ensure the emergency department policies and procedures were in accordance with nationally recognized standards of practice . See A Tag 1104.

b. ensure staff working in the emergency department had demonstrated skills competencies. See A Tag 1112.

Based on record review and interviews with staff, the governing body did not ensure all services provided by contract or agreement were evaluated, and in compliance with all applicable Medicare Conditions of Participation. Contracted services were not assessed through the hospital's Quality Assessment Performance Improvement (QAPI) program.

There was no evidence in governing body and medical staff meeting minutes for 2013 or 2014 or hospital documents presented as part of the quality program that services provided by contract or agreement were evaluated for quality of care and for actions taken if needed.

Hospital staff verified that contracted services were not evaluated by the QAPI program.

Based on medical record review and staff interview the hospital failed to inform each patient and/or patient's representative of the patient's rights in advance of furnishing care. This occurred in 36 of 36 medical records reviewed.
Findings:
1. On the morning of 04/30/2014, surveyors requested a copy of the patient's rights.
2. Two different versions of patient's rights were provided to the surveyors.
3. On the morning of 04/30/2014, Staff B was asked if all patients receive their patient rights. Staff B stated that patients used to receive a carbon copy of patient rights but since the hospital now used the Electronic Health Record patients have not received their rights.
4. On the afternoon of 05/01/2014, medical records were reviewed. Thirty six of thirty six Medical records reviewed did not contain the patient's rights.

Based on hospital document review, hospital policy review and staff interview, the hospital failed to ensure each patient and/or patient's representative was given complete information on whom to contact to file a grievance.
Findings:
1. On the morning of 04/30/2014, hospital administrative staff was asked to provide the patient's bill of rights and patient's admission packet.
2. Two different versions of the patient's bill of rights were provided. Staff B told surveyors that one version was for swing bed residents and one version was for patients who are admitted to the hospital.
3. Both versions of the patient's bill of rights did not contain the hospital's address, the Oklahoma State Department of Health's address and did not contain the Quality Improvement Organizations (QIO) contact information.
4. A hospital policy titled, "Opportunities to improve", documented, "...the hospital provides information to each patient in the "Patient Rights". The information includes: the address of the hospital, the provision of information regarding the patient's right to file a grievance or complaint with the State Health Department including the address and phone number for the State Health Department; and the right to seek review by a QIO..."

Based on record review and interviews with hospital staff, the hospital did not ensure the Quality Assessment Performance Improvement Program's (QAPI) scope included indicators from all hospital departments including contracted services to measure, analyze and track processes of care to monitor the effectiveness and quality of care.

Findings:

1. Review of governing body, medical staff and QAPI committee meeting minutes for 2013 and 2014 did not have evidence of regular reports from all hospital departments with indicators to assess and monitor processes of care. The quality assurance plan provided by the hospital specified all hospital departments were required to submit a quality assurance report for their department on a quarterly or monthly basis with problems requiring follow-up being reported by the Quality Assurance Coordinator. There was no evidence of quarterly or monthly reports from all the hospital departments.

2. Incident reports were not analyzed and tracked through a QAPI (Quality Assurance Performance Improvement) process. The hospital did not have a process to track patient grievances to monitor processes of care.

3. The QAPI program did not include indicators monitoring medication errors or adverse events.

4. Hospital services provided by contract were not evaluated through the hospital wide QAPI program.

The hospital did not have an effective, ongoing, hospital-wide data-driven QAPI program. This was verified by hospital staff on 05/01/14 in the morning.

Based on record review and interviews with hospital staff, the hospital failed to ensure the quality assessment and performance improvement (QAPI) program included measurable indicators to identify and reduce medical errors and adverse patient events, analyze the errors and events and implement changes to improve outcomes. Medication errors and adverse patient were not included as part of the QAPI program. There was no evidence in QAPI meeting minutes medication errors and adverse patient events were analyzed and preventive measures implemented.

Based on record review and interviews with hospital staff, the governing body does not ensure the hospital had an ongoing Quality Assurance Performance Improvement (QAPI )program that reflects the complexity of the hospital's organization and services and involves all hospital departments including contracted or shared services. The hospital documents presented as part of the QAPI program did not have indicators for high risk and complex services such as surgical services and infection prevention. There was no evidence that all contract or shared services were evaluated by the QAPI program. Hospital staff verified that contracted services were not evaluated as part of an ongoing hospital wide QAPI program.

Based on review of medical records and hospital documents and interviews with hospital staff, the hospital failed to ensure nursing staff prepared and administered drugs and biologicals according to recognized standards of practice. This occurred in seven of nine (Records #21, 22, 23, 26, 27, 28, and 29) surgical records reviewed.

Findings:

1. Records #21, 22, 23, 26, 27, 28, and 29 documented Staff AA, a certified registered nurse anesthetist (CRNA) administered the anesthesia services. The medical record did not contain any physician orders for the medications administered by the CRNA.

2. The credential files for Staff AA did not contain evidence the CRNA had applied to the Oklahoma Board of Nursing for prescriptive authority to select, order, obtain and administer drugs without a physician's order. The files also did not contain the required two narcotic permits required if the CRNA has been granted prescriptive authority.

3. These findings were reviewed and verified with Staff A on the afternoon of 05/01/2014.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure all entries were complete, accurately documented with dates and times of signatures/authentication. This occurred in ten (Records #5, 16, 20, 21, 24, 25, 26, 27, 28, and 29) of thirty medical records reviewed.

Findings:

1. Medical records # 5 and 16 both contained electronic history and physical (H&P) and discharge summaries. Both medical records #5 and 16 did not contain the date and time they were authenticated by the physician.

2. According to the operative procedure reports for Medical records #26, 27, 28, and 29, the patients had administration of the administration of 160 milligrams (mg) of Depo-Medrol and 5 milliliters of 0.25% Marcaine and normal saline to a volume of 15 milliliters. The record did not contain orders for these medications.

3. According to the form, "What To Expect On Your Epidural Injection", for Medical records #26, 27, 28, and 29, the patients also received a local injection of Xylocaine. The records did not contain any other documentation, including an order for this medication with the amount and route. Staff A stated on 05/01/2014 that she knew it was always given.

4. Medical records #26, 27, 28, and 29 did not contain a drug administration record or an interoperative anesthesia record documenting the medication administered.

5. For Medical records #26, 27, and 28, the only nursing notes for the visits were the recording of one set of the patient's vital signs, but the records do not document the name or title of the staff that took the vital signs. No nursing assessment before, during or after the procedure was documented on any of these records.

6. For Medical record #29, some of the nursing entries only contained the staff initials and not the full name and title.

7. Medical records #26, 27, 28, and 29, the records did not contain documentation that a "time out" was called to ensure the correct patient and procedure was being performed.

8. For Medical records #20, 21, 24, 25, the "time out" documentation only contain a check mark. The record did not contain documentation that all staff were present, including the surgeon, or the time that the "time out" procedure was performed.

Based on medical record review and staff interview, the hospital failed to ensure all medical records contained a complete discharge summary with the outcome of hospitalization, disposition of case, and provisions for follow up care. This occurred in 6 of 23 inpatient medical records reviewed (#8, 9, 10, 12, 31 & #32).
Findings:
1. On the afternoon of 05/01/2014, surveyors reviewed medical records.
2. Three of twenty three (#8 , 9, & #31) inpatient medical records contained a discharge summary but did not contain the disposition of the case.
3. Three of twenty three (# 10, 12, & # 32) inpatient medical records did not contain a discharge summary.
4. This was verified at the time of medical record review with administrative staff.

Based on document review, personnel file review, and staff interview, the hospital failed to ensure a radiologist supervised radiology services.

Findings:

1. On the morning of 04/30/14, surveyors asked administrative staff for an organizational chart to include the Director of Radiology.

Administrative staff provided surveyors with a hospital document titled, "Medical Staff Committee." The Director of Radiology was not a radiologist; he was an internal medical doctor of osteopathy.

2. The chief executive officer (CEO) told surveyors that there was not a supervising radiologist. There was an internal medicine physician that was not a radiologist over the radiology department.

3. The director of radiology (Staff K) told surveyors that there was not a supervising radiologist. The radiology director is an internal medicine doctor. She stated, "The hospital contracts with two Radiology groups. One is out of Edmond, Oklahoma and the other is out of California."

4. A hospital document contained in the radiology policy and procedure binder documented, "All radiology procedures...are sent to and read by..." Neither reading radiologists (Staff LL and MM) were the director of radiology. Both reading radiologists were consultant radiologists for the hospital.

5. Surveyors verified findings with the CEO at the time of review.

Based on policy and procedure review, document review and staff interview, the hospital failed to ensure radiology personnel were designated as qualified by the medical staff to use the radiological equipment and administer procedures.

Findings:

1. On 04/30/14, Administrative staff was asked to provide radiology departmental policies and procedures. The policies did not specify what qualifications were necessary for the staff using the radiology equipment.

2. On 04/30/14, the radiology manager told surveyors that there was no written documentation for radiology personnel that specified what radiology equipment they were qualified to use/operate.

3. There was no documented evidence in the medical staff meeting minutes that radiology personnel were designated as qualified by the medical staff to use the radiological equipment and administer procedures.
4. These findings were verified with the chief executive officer. No other documentation was provided.

Based on surveyors' observations and interviews with hospital staff, the hospital failed to ensure the hospital environment was maintained to assure a sanitary environment and the safety and well-being of patients.

Findings:

1. On 05/01/2014, the surveyors observed a physician enter the restricted/sterile corridor still dressed in "street clothes." When asked, he told the surveyors that after the old access had been renovated, their access hall had been taken away. He stated that physical therapy services not occupied the space and they could no longer access the men's changing room without entering the restricted.

2. On 05/01/2014, the surveyors' observed that the door to the endoscope cleaning area had been removed. Staff told the surveyors that the chemicals bothered staff in the enclosed area and so the door was removed.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure the staff identified as the infection control preventionist/practitioner (ICP) has training in establishing and maintaining an effective ongoing infection control program based on current principals and methods of infection control.

Findings:

On 04/30/14, administrative staff identified Staff Q as the person responsible for infection control.

Review of Staff Q's personnel file did not demonstrate Staff Q had any training or experience in establishing and maintaining an effective and ongoing infection control program. This was confirmed with Staff A on the afternoon of 05/01/14.

Based on review of hospital documents, meeting minutes, health files and infection control activity/surveillance reports, surveyor observations, and staff interviews, the hospital failed to ensure the infection control preventionist (ICP) developed and maintained a comprehensive ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained ensuring a safe and sanitary environment.

Findings:

In the morning of 04/30/14, Staff Q was asked for the hospital's infection control plan and hospital wide risk assessment. None was provided.

On 05/1/14, Staff A stated the hospital does not have a infection control plan or a hospital wide risk assessment.

On the afternoon of 05/01/14, Staff P, who is designated as the employee health nurse, was asked if she had performed a Tuberculosis (TB) Risk Assessment for the hospital. Staff P stated no.

The yearly "fit testing" was not complete. The fit testing did not contain documentation the health assessment portion had been completed. These findings were reviewed and verified with Staff P on 04/30/2014 at 1600.

Infection Control Committee (ICC) meeting minutes did not reflect staff immunization status and employee health were reviewed as part of the infection control program. Meeting minutes did not demonstrate analysis of employee, contract staff, physician and allied health immunizations, illness and infections to ensure infections and diseases were not transmitted between patients and staff.

On 04/30/14, Staff Q was asked for the infection control surveillance activities. The surveillance data provided was not hospital-wide.

Staff Q surveillance activity was limited to the surgery department. The hand hygiene surveillance activity was observed on the nursing staff only.

The hospital had recently changed disinfectants, there was no documentation the disinfectants had been approved by the ICC, medical staff or governing board.

There was no documentation the hospital staff had been educated on the new disinfectants.

Dietary services were provided at an off-site location. Staff Q told the surveyor on 04/30/14 that no one had visited the facility to ensure safe and sanitary infection control procedures were followed.

At the time of the survey, the hospital used Virex 256 in the OR to clean between all cases. 1. Hospital does colonoscopies. Virex 256 is not effective against C-Diff.
2. The surgery log for 04/07/2014 and 02/10/2014 showed surgical case turn-around times of 7 to 9 minutes. Virex 256 requires a "wet time" of 10 minutes to be effective.

Surgery observations:
1. The surgeon entered into the restricted/sterile corridor in "street clothes".
2. The CRNA (certified registered nurse anesthetist) wore a non-dedicated jacket in the operating room (OR) during a surgical procedure.
3. The CRNA wore non-dedicated shoes in the OR without shoe covers.
4. The door to the endoscope cleaning room had been removed.
5. There was no hand sanitizer available in the OR.
6. The oxygen extension tube in the procedure room remained after the room had been cleared. Staff Q and R told the surveyor that they had been told it needed to be left.


Emergency Department
On the afternoon of 04/30/14, surveyors asked Staff HH what does the ED do with laryngoscope blades and handles after the physician or nurse practitioner intubates a patient.

Staff HH told surveyors, "I take the blade over to the sink (across from ED room 1) and wash it with soap and water, rinse it and put it here on this towel (a hospital white hand towel on the counter next to the sink). I then spray the blade with this blue cleaner (in a clear rubber maid spray bottle marked with black faded ink that was labeled endozym). Once the blade is dry, it is put back into the crash cart where it came from."

On the morning of 04/30/14, surveyors requested ED policy and procedure for cleaning laryngoscope blades and handles.

Hospital administrative staff brought the emergency department (ED) policy and procedure table of contents to the surveyors. The hospital's ED did not have a policy or procedure for cleaning laryngoscope blades and handles.

On the morning of 05/01/14, the ED Nursing Manager verified that there was not an ED policy and procedure for cleaning laryngoscope blades and handles.

The Joint Commission (www.jointcommission.org ) and The Centers for Disease Control and Prevention (CDC) guidelines titled, "Laryngoscopes Blades and Handles" specifically documented, "...Whenever possible, use steam sterilization (by autoclaving) or high-level disinfection by wet heat...After disinfection, proceed with appropriate ringing, drying, and packaging, taking care not to contaminate..."

On the afternoon of 04/30/14, these findings were discussed with the CEO and discussed with the ED Nurse Manager and hospital administrative staff at exit conference on 05/01/14.

Based on hospital document review and staff interview, the hospital failed to ensure hospital staff was provided with ongoing training regarding organ donation issues.
Findings:
1. On the morning of 04/30/2014, staff B was asked if staff were provided with ongoing inservices and training regarding organ donation issues. Staff B told surveyors that she provided ongoing inservices and training in the nursing meetings. Staff B told surveyors that she did not document the inservices and training provided.
2. On the afternoon of 05/01/2014, personnel files reviewed. All personnel files did not contain documentation of any organ donation inservices or training.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure surgical consents were complete and properly executed. This occurred in four of four (Records #26, 27, 28 and 29) where epidural pain management injections were administered.

Findings:

1. The surgical consents for Records #26, 27, 28, and 29 did not specify the location of the pain management procedure. The four surgical consents only listed the surgical procedure as "Single Steroid Epidural Injection."

2. This findings was reviewed and verified with Staff A on the afternoon of 05/01/2014.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure the operative report for pain management procedures accurately documented the procedure performed. This occurred in four of four (Records #26, 27, 28, and 29) pain management surgical procedures reviewed.

Findings:

1. For Records #26, 27, 28, and 29, the procedure report only listed the procedure as a "lumbar Epidural Steroid Injection" and the report did not document the location(s) of the steroid injection. In all four medical records, the reports documented, "The patient...received a standard lumbar epidural steroid injection..."

2. For Patient #28, procedure date 01/16/2014, the record contained a magnetic resonance imaging (MRI) report indicating the patient had problems with changes at L1-2, L3-4, L5-S1. Again, the procedure report did not document at what space in the lumbar region, the medication was injected.

3. These findings were reviewed and verified with Staff A on the afternoon of 05/01/2014.

Based on review of medical records and personnel files, and staff interviews, the hospital failed to ensure intraoperative anesthesia records followed established policies were complete and accurately documented. This occurred in three of five (Records #21, 22, and 23 of #21, 22, 23, 24, and 24) intraoperative anesthesia records reviewed.

Findings:

1. The intraoperative anesthesia records for Patients #21, 22 and 23 did not document clearly the dosage and time of administration of medication. Examples include, but are not limited to:
a. Patient #21 - the record documented the initial doses and times for Diprivan and Ketamine of 10 milligrams (mg) each, but did not clearly document any additional administrations of the drugs. Staff AA documented the total for Diprivan as 600 mg administered and the total for Ketamine was 150 mg.

b. Patient #22 - the record documented the initial dose of Diprivan of 10, but did not document any further doses. Staff AA documented the total Diprivan administered was 290 mg.

c. Patient #23 - the record documented the initial dose of Diprivan of 10, but did not document any further doses. Staff AA documented the total Diprivan administered was 110 mg.

2. The above medical records did not contain an order for the medications. Staff AA does not have prescriptive authority and no physician co-signed his intraoperative records.

These findings were reviewed and verified with Staff A at the time of review on 05/01/2014

Based on record review and interviews with hospital staff, the hospital failed to ensure postanesthesia evaluations followed established policies and procedures/standards of practice and a postanesthesia evaluation was completed and documented by the one of two certified registered nurse anesthetists. This occurred in two of two surgical records (Records #24 and 25) reviewed in which Staff DD administered the anesthesia.

Findings:

1. The post-operative anesthesia section of the record for Patients #24 and 25 did not contain an evaluation according to current standards of anesthesia care. It did not contain the patients':
a. Respiratory function, including respiratory rate, airway patency, and oxygen saturation;
b. Cardiovascular function, including pulse rate and blood pressure;
c. Mental status;
d. Temperature;
e. Pain; and
f. Nausea and vomiting.

2. These findings were reviewed and verified with Staff A on the afternoon of 05/01/2014.

Based on policy and procedure review, document review and staff interview, the hospital failed to ensure the emergency department (ED) policies and procedures were current, revised as necessary, and approved by the medical staff.

Findings:

1. Surveyors reviewed multiple ED policies and procedures. All ED policies and procedures reviewed were incomplete and did not have documented procedures. Policies were not based off of current and nationally acceptable standards of practice. All ED policies and procedures did not have documented evidence of references.

On the morning of 05/01/14, the ED Nurse Manager told surveyors that she was a new to being an ED Nurse Manager, didn't know what to do and "Created policies and procedures for the emergency department."

On the afternoon of 04/30/14, the chief executive officer (CEO) verified that the ED policies and procedures are unclear and are not based off of nationally accepted standards.

2. On the afternoon of 04/30/14, surveyors asked Staff HH what does the ED do with laryngoscope blades and handles after the physician or nurse practitioner intubates a patient.

Staff HH told surveyors, "I take the blade over to the sink (across from ED room 1) and wash it with soap and water, rinse it and put it here on this towel (a hospital white hand towel on the counter next to the sink). I then spray the blade with this blue cleaner (in a clear rubber maid spray bottle marked with black faded ink that was labeled endozym). Once the blade is dry, it is put back into the crash cart where it came from."

On the morning of 04/30/14, surveyors requested ED policy and procedure for cleaning laryngoscope blades and handles.

Hospital administrative staff brought the emergency department (ED) policy and procedure table of contents to the surveyors. The hospital's ED did not have a policy or procedure for cleaning laryngoscope blades and handles.

On the morning of 05/01/14, the ED Nursing Manager verified that there was not an ED policy and procedure for cleaning laryngoscope blades and handles.

The Joint Commission (www.jointcommission.org ) and The Centers for Disease Control and Prevention (CDC) guidelines titled, "Laryngoscopes Blades and Handles" specifically documented, "...Whenever possible, use steam sterilization (by autoclaving) or high-level disinfection by wet heat...After disinfection, proceed with appropriate ringing, drying, and packaging, taking care not to contaminate..."

On the afternoon of 04/30/14, these findings were discussed with the CEO and discussed with the ED Nurse Manager and hospital administrative staff at exit conference on 05/01/14.

3. The hospital's ED Conscious Sedation policy and procedure does not follow the Oklahoma Board of Nursing policy (OBN Policy/Guideline #P-06), "Moderate (Conscious) Sedation Guidelines for Registered Nurse Managing and Monitoring Patients."

According to the OBN, Moderate (Conscious) Sedation Guidelines for Registered Nurse Managing and Monitoring Patients (OBN Policy/Guideline #P-06), "...The Registered Nurse administering, managing and/or monitoring moderate (conscious) sedation shall have no other responsibilities during the procedure..."

On the Morning of 05/01/14, the ED Nurse Manager told surveyors that the RN is managing the patient and doing multiple tasks during the conscious sedation procedure.

On the afternoon of 04/30/14, staff HH informed surveyors that conscious sedation procedures performed in the ED are carried out with one registered nurse (RN) and one physician or one nurse practitioner.

4. The ED "Conscious Sedation" policy and procedure documented, "...monitored by an RN...has taken the test for Moderate Sedation in addition to a nurse assisting the physician..."

Two (Staff HH and JJ) of two ED nursing personnel files reviewed, did not have documented evidence of moderated sedation testing.

5. The ED "Conscious Sedation" policy and procedure documented, "...If the nurse disagrees with classification...agreement among the RN, Anesthesia personnel and physician on appropriate monitoring...will be determined and agreed upon by those involved..."

The American Society of Anesthesiology (ASA) status classification is not within the registered nurse scope of practice, and is not in accordance with acceptable standards of practice.

6. The ED "Conscious Sedation" policy and procedure documented that ED patients would be monitored differently than inpatients. This is not in accordance with acceptable standards of practice for Moderate (Conscious) Sedation (OBN, Emergency Nurses Association, and American Association of Nurse Anesthetist).

7. There was a hospital document titled, "Emergency Department Policy and Procedure Conscious Sedation" that documented, "...guidelines apply to all locations in the hospital where conscious sedation is administered...Specified Departments: Surgery; Anesthesia; Outpatient Surgery/GI Laboratory; Radiology; Emergency Department; Intensive Care; Cardiopulmonary..."

On the morning of 05/01/14, the ED Nurse Manager told surveyors that conscious sedation is administered only in surgery and the ED and not in radiology. The ED Nurse Manager said there is not an anesthesia department and the hospital does not have an intensive care unit (ICU); outpatient surgery/GI (gastrointestinal) laboratory; and cardiopulmonary unit.

8. On the morning of 04/30/14, the surveyors requested the emergency department (ED) policies and procedures table of contents for the hospital's emergency services.

Hospital administrative staff brought the emergency department (ED) policy and procedure table of contents to the surveyors. Surveyors requested several policies and procedures, including conscious sedation. All ED policies and procedures were not based on nationally accepted/current standards of practice.

9. On the morning of 05/01/14, surveyors asked the ED Nurse Manager if emergency department policies and procedures were being monitored through quality assessment performance improvement (QAPI) program.

The ED Nurse manager told surveyors that she did not know what QAPI was.

10. All findings were discussed with the ED Nurse manager and CEO. The ED Nurse Manager and CEO verified that the ED policies and procedures were not current; contained no documented references, and were not based on nationally accepted/current standards of practice.

Based on hospital document review, record review, and staff interview, the hospital failed to ensure nursing staff working in the emergency department (ED) demonstrated skills competencies. This occurred for two (Staff HH and JJ) of two 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) based on Emergency Nurses Association (ENA) and Agency for Healthcare Research and Quality (AHRQ) guidelines;

-Intravenous (IV) insertion, accessing/de-accessing implanted central venous devices, venous blood draw sampling, and blood glucose monitoring using the Association for Vascular Access (AVA) guidelines;

- Electrocardiogram (ECG) 12 lead cardiac monitoring and rhythm recognition based on the American Heart Association (AHA) guidelines;

-Neurological assessment using Glasgow coma scale (GCS) based on the ENA;

-IV moderate (conscious) sedation, rapid sequence intubations (RSI), and airway management based on American Society of Anesthesiologists guidelines and Oklahoma Board of Nursing;

-Calculating and managing critical IV drips based on the ENA and AHA guidelines.

None of the ED personnel files reviewed had documented evidence of competencies.

2. On the afternoon of 04/30/14, Staff HH was asked to demonstrate how to use/test the defibrillator. Staff HH was unable to articulate and demonstrate how to use/test the defibrillator in the ED.

3. On the morning of 05/01/14, the ED Nurse Manager was asked to tell surveyors how to check/test the defibrillator in the ED to ensure it works.

The ED Nurse Manager told surveyors, "The defibrillator does a self-test every morning at 3 a.m. so there is no need to test it." The ED Nurse Manager was unable to provide the manufacturer's equipment manual and/or documented evidence of the self-test rhythm strips.

The ED Nurse Manager was unable to provide surveyors with manufacture's equipment manual with documented evidence.

The chief executive officer (CEO) was unable to verify that the ED defibrillator was self-testing.

4. On the afternoon of 04/30/14, Staff HH told surveyors that she would use soap and water on a gurney to clean if the patient had C. difficlile (infectious diarrhea caused by bacteria).

Soap and water is not the appropriate national standard of practice to clean surfaces with. The Centers for Disease Control and Prevention (CDC) website (www.cdc.gov) has a link to a published document titled, "Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)", documented, "...EPA-registered disinfectants with a sporicidal..."

Surveyors asked ED personnel (Staff J and HH) who was responsible for cleaning equipment/gurneys in the ED. Staff J and Staff HH informed surveyors that the personnel in the ED "did the cleaning" after patients.

Surveyors asked Staff J and Staff HH if they received any specialized infection control training. Both Staff J and Staff HH told surveyors they did not receive special training for cleaning.

5. On the afternoon of 04/30/14, surveyors toured the ED with Staff HH. Surveyors observed a Wet Task 3.5 gallon plastic bucket on the ED nursing counter. There was no documented evidence of an EPA number on the Wet Task plastic bucket. There was no documented evidence of what chemicals were mixed in the bucket and absorbed on the disposable wipes.

Three (Staff J, HH, and JJ) of three ED personnel were unable to identify what the cleaning product were on the disposable wipes in the Wet Task plastic bucket. The three ED staff members were unable to verbalize what organisms it killed and they were not able to verbalize the wet time (how long the product needs to remain on surfaces wet to kill the specific bacteria/spores).

Three (Staff J, HH, and JJ) of three ED personnel told surveyors that housekeeping refills their bucket with disposable wipes and solution for cleaning.

6. On the afternoon of 04/30/14, surveyors asked Staff HH what does the ED do with laryngoscope blades and handles after the physician or nurse practitioner intubates a patient.

Staff HH told surveyors, "I take the blade over to the sink (across from ED room 1) and wash it with soap and water, rinse it and put it here on this towel (a hospital white hand towel on the counter next to the sink). I then spray the blade with this blue cleaner (in a clear rubber maid spray bottle marked with black faded ink that was labeled endozym). Once the blade is dry, it is put back into the crash cart where it came from."

On the morning of 04/30/14, surveyors requested ED policy and procedure for cleaning laryngoscope blades and handles.

Hospital administrative staff brought the emergency department (ED) policy and procedure table of contents to the surveyors. The hospital's ED did not have a policy or procedure for cleaning laryngoscope blades and handles.

On the morning of 05/01/14, the ED Nursing Manager verified that there was not an ED policy and procedure for cleaning laryngoscope blades and handles.

The Joint Commission (www.jointcommission.org ) and The Centers for Disease Control and Prevention (CDC) guidelines titled, "Laryngoscopes Blades and Handles" specifically documented, "...Whenever possible, use steam sterilization (by autoclaving) or high-level disinfection by wet heat...After disinfection, proceed with appropriate ringing, drying, and packaging, taking care not to contaminate..."

7. On the afternoon of 05/01/14, Staff P verified that hospital personnel files were complete. Two of (Staff HH and JJ) two ED personnel files reviewed, did not have documented evidence of ED competencies.

Based on medical record review, and staff interview, the hospital failed to ensure all respiratory care treatments were documented in the medical record with a pre evaluation and post evaluation of respiratory care received. This occurred in one of two medical records reviewed where respiratory care was provided. (patient #7)
Findings:
1. On the morning of 04/30/2014, Staff A was asked who in the hospital provided the patients with respiratory care. Staff A stated that the nurses provided respiratory services.
2. On the afternoon of 05/01/2014, surveyors reviewed two medical records where patients received nebulizer breathing treatments. One of the two records reviewed (patient #7) contained no documentation of a pre-evaluation and a post-evaluation of the nebulizer breathing treatment.

Based on review of hospital documents and meeting minutes, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were followed through quality assessment and performance improvement (QAPI) committee to assure:

1. Concerns/problems were monitored throughout the hospital, reviewed and analyzed;

2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and

3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

In the morning of 05/01/14 Staff II was asked for the hospital's QAPI meeting minutes. None was provided.

The above information was presented to the administrative staff during the exit conference. No additional information was provided.

Based on staff interview and review of personnel files, the hospital failed to have a system in place that prevents mistreatment, neglect and abuse of residents. This occurred in 4 of 4 personnel files reviewed.

Findings:

1. On the afternoon of 05/01/2014, two housekeeping personnel files were reviewed and two nurse aide personnel files reviewed. All four files reviewed contained no evidence of nurse aide registry checks.

2. On the afternoon of 05/01/2014, staff P told surveyors that nurse aide registry checks have not been done on the housekeepers and the nurse aides.

3. On the afternoon of 05/01/2014, surveyors requested a policy on nurse aid registry checks of new employees. Staff P told surveyors there was not a policy.