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Based on observation, interview and record review the governing body failed to demonstrate that the hospital can separately and independently comply with the all hospital Conditions of Participation.
Findings are:
-Review of hospital policy indicated the collocated hospital would approve the institutional budget for this hospital (Refer to A-0073).
-Evaluation of the hospital's QAPI plan indicated that the hospital did not have a method to independently validate the performance of the contracted services that the hospital receives from the collocated hospital (Refer to A-0084).
-Review of clinical policies indicated that the rapid response team from the collocated hospital would respond to this hospital's emergencies (Refer to A-0093).

Based on record review the governing body failed to ensure the institutional budget was prepared by provider staff. Specifically, records reviewed stated the provider's budget was prepared by staff from the collocated hospital.
Findings:
On 10/12/11 the provider's Generic Structure Standards were reviewed. Section 9, pages 50-51 indicated that the institutional budget would be approved by the Vice President for Finance of the collocated hospital.

Based on interview and record review the governing body failed to ensure that the services performed under a contract are provided in a safe and effective manner. Specifically, the provider did not have a process to independently validate contractor data.
Findings:
On 10/12/11 the provider's quality assessment and performance improvement (QAPI) plan was reviewed. The plan stated the service contractors would provide data for performance evaluation. This was confirmed during interview with the Director of Quality Assurance on 10/12/11 at 15:00 and the Infection Control Practitioner on 10/12/11 at 15:15. The provider did not have a process to independently validate contractor data.

Based on observation, interview and record review the governing body failed to ensure there were written policies and procedures for appraisal of emergencies, initial treatment, and referral when appropriate. Specifically, the provider plan for emergencies stated medical and nursing staff from the collocated hospital would respond to medical emergencies.
Findings:
On 10/12/11 at 10:30 during a tour of the hospital, posters for the collocated hospital's Rapid Response Team were noted on the walls in patient rooms. The provider's Generic Structure Standards were reviewed on 10/12/11. The addendum that addressed emergencies stated the Rapid Response Team from the collocated hospital would respond to, assess, and initiate treatment for medical emergencies. This was confirmed with the Executive Director during interview on 10/13/11 at 10:00.

Based on record review, nursing staff failed to develop a written nursing care plan for 1 of 20 patients in the medical record sample (#9).

Findings are:

Patient medical records were reviewed on 10/12-10/13/2011. The medical record of patient # 9 lacked both an intrapartum and postpartum nursing care plan. This was verified with the hospital Executive Director during the exit conference on 10/14/2011 at 11:00AM.

Based on medical record review, medical record entries were incomplete in 2 of 20 medical records reviewed.
Findings:
Medical records for patients # 3 and 4 did not include a timed or dated Pre-op and Post-op Anesthesia Evaluation.

Based on record review, the hospital has not ensured that all patient consent forms are properly completed in 8out of 20 medical records reviewed.

Findings are:

Patient medical records were reviewed on 10/12-10/13/2011. The following entries were missing from the consent forms in the patient medical records:

Medical records for patients # 1 and 2; general consent forms were not signed.
Medical record for patient # 3; no time was documented on the general consent or surgical consent.
Medical record for patients # 3, 5, and 8; no date or time on the anesthesia consent.
Medical record for patient #4; no date or time on the general consent and no time on the surgical consent.
Medical record for patient #6; no consent form for the induction/augmentation for patient in labor.
Medical record for patient #7; no general consent form.
Medical record for patient # 8; Anesthesia consent form was not signed by the patient and was not witnessed.

Based on record review on 10/13/11, the hospital failed to provide written evidence of an inspection and approval by the local fire control agency.

Finding:

The hospital Director of Security confirmed during interview on 10/13/11 that the local fire department had not conducted an inspection of the hospital.

Based on interview and record review of 2 surgical cases the facility failed to have an operating room register to log their operating room cases.
Findings:
Medical records for patients # 3 and 4 documented they had surgery in the facility operating room. During interview on 4/13/11 at 16:00 the Executive Director confirmed the facility did not have an operating room register.