HospitalInspections.org

Based on record review and interviews with hospital staff the governing body does not ensure that all services provided by the hospital are provided in a safe manner.

Findings:

1. The governing body failed ensure that all services provided to patients in the hospital are provided in a safe and effective manner by personnel who are competent to provide those services. Refer to Tags 0083, 0084 and 0085.

2. The governing body failed to ensure an effective quality assessment and performance improvement (QAPI)program is implemented, developed, maintained and is ongoing and hospital-wide. Refer to Tags 0263, 0265, 0267 and 0290.

3. The governing body failed to ensure medical records services are provided in a organized and structured manner with a medical record for every patient evaluated or treated in the hospital that are complete, retained and properly filed for prompt retrieval. Refer to Tags 0431, 438 and 0449.

4. The governing body failed to ensure radiology services meet the needs of the patients and are in accordance with standards of practice and in a safe manner. Refer to Tags 0529, 0536, 0546 and 0547.

5. The governing body failed to ensure dietary services meet the needs of the patients and are provided by an organized dietary service with oversight by a registered dietitian with regularly scheduled visits and oversight of clinical nutritional services. Refer to Tags 618, 619, 621, 622, 628, 630 and 631.

6. The governing body failed to ensure the hospital has an effective, active ongoing infection control program to provide a sanitary hospital environment to avoid transmission of infections and communicable diseases. Refer to Tags 0747, 0748, 0749, 0750.

7. The governing body failed to ensure physical therapy services are provided to the hospital's patients through an organized department by qualified staff following hospital established policies and procedures. Refer to Tags 1124 and 1132.

Based on record review and interviews with hospital staff the hospital does not ensure an effective quality assessment and performance improvement (QAPI)program is implemented, developed, maintained and is ongoing and hospital-wide. All services including those furnished by contract or agreement within the licensed hospital are not evaluated. Five of five outpatient services provided by either contract, agreement or joint venture are not evaluated by the hospital's QAPI program. The hospital's QAPI program does not evaluate the effectiveness of the data monitored and whether the services provided are improving health outcomes.

Findings:

1. Contracted services or services provided by arrangement or joint venture (oncology/chemotherapy, physical therapy, sleep studies, wound care, organ transplant services) are not included in the QAPI program.

2. QAPI meeting minutes for November was a narrative that did not have an evaluation of data collected for QAPI monitors.

3. The QAPI scorecard presented for review just had numbers and percentages and did not have an evaluation of what the numbers and percentages meant.

Based on record review and interviews with hospital staff, the hospital does not ensure medical records services are provided in a organized and structured manner. The facility failed to maintain a medical record for every patient evaluated or treated in the hospital.

Findings:

1. On 12/6/2011 surveyors reviewed Medical Records policy and procedure. The Medical records policies included one policy entitled "Release of Information; Requirements of Medical Records, Uses and Disclosure of Protected Health Information." There were no policies and procedures developed, reviewed, approved and implemented stipulating all required elements for inpatient and outpatient medical records. There were no policies and procedures developed, reviewed, approved and implemented indicating how to access a complete medical record for inpatients and outpatients. There were no policies indicating what documents comprised a complete outpatient record or a complete inpatient record. There were no policies on documentation standards including processes used to document in the electronic record. There were no policies indicating integration of paper medical records into the electronic medical record. The policy and procedures did not reflect the current medical records practice. There were no policies addressing use of the electronic documentation system and how the clinicians accessed particular documents.

2. On 12/6/2011 surveyors were told the facility had a wound management/hyperbaric facility and a sleep disorder facility. Staff B told surveyors these facilities created a medical record within the hospital's system. Surveyors reviewed both programs medical record documentation. Records from both wound management and sleep disorder did not have the same elements as the hospital's other outpatient records.

3. On 12/6/2011 surveyors were told the facility leases space to an oncology clinic. Staff B told surveyors the clinic patient's were not checked into the hospital's system. Staff B told surveyors the clinic patients were not the hospital's patients. According to documents at the department, the facility has not de-licensed any part of the hospital. Consequently any patients treated within the confines of the hospital are hospital patients. There were no medical records for the oncology clinic patients.

4. The facility's medical records are a combination of electronic medical records and scanned documents. On 12/6/2011 surveyors requested multiple complete closed medical records. On 12/6/2011 all records requested did not have intraoperative documentation. Staff P (Information technology) told surveyors the intraoperative record was unavailable because the nursing staff had not unlocked it. Staff Z told surveyors the lock feature was required while the patient was in the hospital so the next department the patient was seen in could document in the correct flowsheet. Staff Z did not know why the records had not been unlocked. The facility did not have policies and procedures developed and approved through medical staff and governing body related to the computer documentation. There was no evidence the Governing Body had been apprised and action had been taken to correct the problem. The facility could not provide complete medical records timely.

5. On 12/7/2011 surveyors reviewed outpatient procedure records. None of the endoscopy patients had history and physicals documented in the medical record.

6. Three of three records reviewed for nutritional screen/assessment did not have documentation completed as per the nutritional assessment policy. Staff II, the dietary manager did not know where the nutritional assessment would be documented in the electronic record. None of the patients reviewed had nutritional assessments completed.

7. Several records reviewed by surveyors did not have complete assessments by nursing personnel and/or did not have initial nursing assessments. Several records did not include intravenous infusion totals during any of the perioperative period. Several radiology records did not have electronic signatures. There was no documentation provided to surveyors indicating content of medical records were reviewed for completeness and accuracy.

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 12/6/2011 Staff B told surveyors the facility had a contracted dietitian and a full time Certified Dietary manager (CDM) The dietary consultation contract provided to surveyors indicates the contracted dietitian will "provide consultation to Facility to enable Food Services staff to provide dietetic service that meets the daily nutritional needs of patients, the dietitians will provide in service education to the staff in medical nutrition therapy and food service operation, provide consultation to physicians and allied health, provide direct dietary counseling to any patient in accordance with orders, dietitians approve all patient menus, write meal patterns, write diets as necessary and coordinate new menus with advance notice.

According to the policy "Assessment/Reassessment, Nutritional, the admitting nurse will complete the nutritional screen as part of the admit assessment specific nutritional risk indicators for adult patient population are as follows: tube feeding or total parenteral nutrition (TPN); 10 pound weight loss in one month; less than fifty percent of usual oral intake,; dysphagia; diagnosed malnutrition; disease/surgery of the gastrointestinal system; depsis (sp); anorexia/bulmia; electrolyte imbalance; malabsorption; new/uncontrolled diagnosis of diabetes mellitus; human immunodeficiency virus (HIV/AIDS); burns; trauma; post-surgery patient greater than seventy years old; decreased mentation; pressure ulcer; nothing by mouth (NPO) or clear liquid diet greater than three days; intubation greater than forty eight hours without plans for extubation.

1. Three of three (29,30, 31) patients had nutritional conditions requiring nutritional intervention which the facility did not act on. The hospital staff did not identify these conditions through the nutritional screen.

2. Several patients did not have a complete nutritional screen or the screen did not match documentation in the history and physical.

3. The facility failed to train staff, implement policies, and oversee processes to ensure patients nutritional needs are met.

4. No dietitian reports were provided during the survey to show the dietitian (Staff HH) was actively supervising dietary services at the hospital. In an interview at on 12/6/11 Staff II told surveyors the consultant had not provided a monthly report only dietary consultation. Staff II did not know what patient's had been consulted on. There was no list or documentation provided by the consulting dietitian regarding consultations. There was no evidence Staff HH provided oversight to dietary/clinical staff ensuring compliance with dietetic policies effecting patient treatment. During the interview Staff II was asked about processes relating to dietary policies. Staff II was not aware of nutritional policies not matching the nursing nutritional policies. Staff II also told surveyors Staff HH was providing consultant dietitian services but was not sure of all of Staff HH's responsibilities. There was no job description in the dietitian or certified dietary manager's personnel file.

5. Review of Staff HH's personnel file did not show Staff HH had orientation, training, competency or evaluation pertinent to services provided at the hospital. Staff HH's dietitian's license was faxed to the facility the day of the survey.

6. Review of Staff II's personnel file did not indicate Staff II had orientation, training, competency, or evaluation pertinent to services provided at the hospital.

7. During a walkthrough on the morning of 12/6/2011, Staff JJ,KK,LL told surveyors they had not been trained on the use of the chemical sanitization strips for the dishwasher. Staff JJ, KK,LL indicated they had job responsibilities for cleaning/sanitizing patient dishes. This finding was verified with Staff II during the afternoon walk through.

8. Meeting minutes reviewed for 2011 did not document that a dietitian was attending or providing reports in any of the hospital's meetings.

9. The Dietary manual provided to surveyors was dated 1992. Staff II told surveyors this was the manual the dietary department utilized. Later on 12/6/2011 during a walk through of the dietary department Staff II found the dietary manual dated 2006. Staff II was not aware if the facility had approved the manual through medical staff. Staff II also indicated special diets were provided to Dr C's patient. There was no documentation the dietitian reviewed and approved diets and special diets at the facility.

10. Staff II provided surveyors copies of dietary/kitchen inspection reports on 12/6/2011. There was no documentation the inspection reports had been reviewed or acted on in any committee meetings or governance.

11. Policies and procedures provided to surveyors did not contain all the required elements. The policies did not include portioning, revision of special diets, substitutions, use of equipment, sanitization of equipment/department. Some of the nutrition policies did not match the policies in nursing. The process for patient's menu ordering did not match policies provided to surveyors.

12. The facility utilizes a electronic medical record. There was no policy governing documentation of the dietitian consult. There were no dietitian consults found in any records. This finding was verified with Staff II, CDM and Staff P information technology. In an interview on 12/6/2011, Staff II told surveyors he was not sure where the dietary consult would be documented in the record.

Based on observation, record review, and observation, the hospital is not constructed and maintained to ensure the safety of the patient. Findings:

(1) The facility failed to provide anesthetizing locations with relative humidity maintained equal to or greater than 35%. Operating Room 2 was found to be at 18% humidity. The HVAC Energy Management System provided information that humidity on multiple days was under the range of 35%. see ID Prefix tag K078, event ID J05K21

(2) The facility failed to provide hoods in the laboratory and chemotherapy area that are in compliance with NFPA 99. There is no documentation that the exhaust was balanced to provide a negative pressure with respect to surrounding hospital occupancies for either the chemotherapy or laboratory hood and that the roof exhaust for the chemotherapy hood had signs describing the nature of the hazards. see ID Prefix tag K130, event ID J05K21

At the time of the revisit and recertification survey on 12/07/2011, this condition had not been corrected.
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Based on interviews with staff and review of hospital documentation, the hospital failed to maintain an active ongoing infection control program to provide a sanitary hospital environment to avoid transmission of infections and communicable diseases.

Findings:

1. The facility did not ensure that an active ongoing infection control program was being utilized to monitor, track, and control infections and communicable diseases in all hospital units in order to provide a safe and sanitary environment to patients and employees. Staff T, the staff designated as the Infection control nurse, was instructed to provide the infection control log, infection control policies and procedures, documentation of surveillance activities, and the Infection Control Plan for the hospital.

a. On the morning of 12/06/2011, Staff T told the surveyors that she maintains an infection control log. After further interview and document review the infection control log was incomplete due to the omission of required data, including inclusion of employee illnesses.

b. The hospital's infection control program did not specify the types and frequencies of surveillance activities to ensure hospital infection control policies and procedures were monitored and followed. The hospital's infection control program did not monitor to ensure policies and practices developed to provide a sanitary and safe environment and prevent transmission of infectious and communicable diseases were followed. Hospital staff could not supply evidence that infection control interventions were implemented based on measures selected for monitoring or based on risk assessments.

2. The hospital did not have documented evidence that someone monitored the use of the hospital disinfectant on different patient units and surgery, to ensure the disinfectant was applied appropriately and according to manufacture's guidelines. Review of meeting minutes containing infection control did not contain evidence the hospital's infection control program chose the disinfectants or were responsible for selection of the disinfectants, or that the disinfectants were approved by the governing board to ensure effective cleaning and to provide a safe and sanitary environment for patients and employees. Hospital staff interviewed stated no monitoring had taken place.

3. The infection control program did not include proper monitoring of all areas of the hospital. Meeting minutes and interviews with Staff T on 12/06 and 07/2011 did not demonstrate information, based on infection control activities and prevention measures, was continuously analyzed, evaluated, or communicated in the different hospital units and facility departments.

4. The hospital's infection control program did not review its sterilization practice in surgery or provide evidence that staff conducted surveillance activities in the operating rooms and surgical areas. The hospital provided no evidence that infection control policies and procedures for surgical services were being implemented in the surgical areas. The Perioperative Manager (OR), Staff S, stated on 12/07/2011 that she has not documented surveillance activities or monitoring of sterilization processes and conveyed data to Staff T.

5. Environment of Care Committee meeting minutes did not reflect infection control issues/concerns, surveillances, and practices were analyzed with corrective actions to prevent, identify and manage infections and communicable diseases with measures that result in improvement on an ongoing basis.

Based on record review and interviews with hospital staff the hospital does not ensure that all services provided to patients in the hospital are provided in a safe and effective manner by personnel who are competent to provide those services. The hospital does not provide oversight on an oncology and chemotherapy service provided to patients on an outpatient basis within the hospital to assure the services are provided in a safe and effective manner.

Findings:

1. Pharmaceutical services provided for the oncology service do not comply with the requirement of 42 CFR 482.25 (b)(1). All compounding, packaging, and dispensing of drugs and biologicals is not under the supervision of a pharmacist and performed consistent with State and Federal laws. Chemotherapy drugs administered to patients in the hospital are not under the supervision of the pharmacist. Hospital staff stated on 12/07/11 in the morning that the medications are brought into the hospital by the oncology service's nurse in the trunk of a car. The pharmacist does not supervise the medications to ensure the safety of the medications being administered.

2. Nursing personnel working for the oncology physician according to hospital staff do all the mixing of the chemotherapy medications. They are not mixed by a pharmacist.

3. Medical Record Services for the outpatient oncology service do not comply with the requirement of 42 CFR 482.24 (b). The hospital does not maintain a medical record for each inpatient and outpatient. The hospital does not maintain medical records on patients presenting for chemotherapy. Hospital staff stated on 12/07/11 in the afternoon that they did not have records for the oncology patients.

4. Oncology services and chemotherapy infusion services are provided in an area of the hospital that was previously used for storage.

5. Hospital staff stated that they just lease out that space to the physician to provide oncology/chemotherapy services.

Based on record review and interviews with hospital staff, the hospital does not ensure that an oncology/chemotherapy service, a sleep lab, a wound care clinic and physical therapy provided in the licensed hospital are evaluated through a hospital-wide quality assessment and performance improvement (QAPI) program.

Findings:

1. Review of the hospital's QAPI plans for 2011 and 2012, QAPI monitors and meeting minutes did not have evidence of any monitoring and evaluation of the services provided in the hospital by contract, agreement, lease or joint venture.

2. Organ procurement services provided by contract are not evaluated by the hospital's QAPI program.

3. Hospital staff stated on 12/7/11 in the afternoon that these services were not evaluated by QAPI.

Based on record review and interviews with hospital staff, the hospital does not ensure a list of all contracted services is maintained with the scope and nature of the services provides. This was verified on 12/07/11 in the afternoon with Staff.

Based on review of policies and procedures and patient handouts and interviews with hospital staff, the hospital failed to develop a policy with mechanisms/methods defined that clearly describe the procedures to follow when a patient alleges abuse by a hospital employee or contract worker.

Findings:

1. The hospital provided five policies for review that addressed abuse. The policy entitled, "Patient/Employee Abuse Policy" was the only one that addressed allegations of patient abuse that might occur once the patient was present at the hospital. This policy did not clearly define the steps that would be taken concerning the employee/contract worker while the investigation was proceeding. The policy also did not contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect by these individuals.

2. This finding was reviewed and verified with Staff O on 12/07/2011 at 0920.

Based on record reviews and interviews with hospital staff, the hospital does not ensure that medical records are complete, retained and properly filed for prompt retrieval.

Findings:

1. On the morning of 10/26/2011 administrative staff told the surveyors that all patient medical records were maintained on computer/electronic medical records. Later in the morning surveyors were provided access to the electronic medical record and instructions on where documents could be found.

2. On the afternoon of 12/5/2011 surveyors reviewed medical records policy and procedures. Only three policies existed. The policy and procedures did not reflect the current medical records practice. There were no policies addressing use of the electronic documentation system and how the clinicians accessed particular documents.

3. Several records reviewed by surveyors did not have complete assessments by nursing personnel and/or did not have initial nursing assessments. Several records did not include intravenous infusion totals during any of the perioperative period. Several radiology records did not have electronic signatures. There was no documentation provided to surveyors indicating content of medical records were reviewed for completeness and accuracy.

4. On 12/6/2011 surveyors were told the facility had a wound management/hyperbaric facility and a sleep disorder facility. Staff B told surveyors these facilities created a medical record within the hospital's system. Surveyors reviewed both programs medical record documentation. Records from both wound management and sleep disorder did not have the same elements as the hospital's other outpatient records.

5. On 12/6/2011 surveyors were told the facility leases space to an oncology clinic. Staff B told surveyors the clinic patient's were not checked into the hospital's system. Staff B told surveyors the clinic patients were not the hospital's patients. According to documents at the department, the facility has not de-licensed any part of the hospital. Consequently any patients treated within the confines of the hospital are hospital patients. There were no medical records for the oncology clinic patients

6. The facility did not have policy and procedures addressing proper documentation in outpatient and inpatient medical records. There were no policies on record completion, retention, and accessibility. There was no documentation the facility reviewed medical records for required elements.

Based on record review and interviews with hospital staff, the hospital does not ensure that the medical record contains information describing the patients condition, progress and responses to treatment.

Findings:

1. There are no medical records for outpatient oncology patients receiving care at the hospital.

2. The documentation for outpatient wound management and sleep disorder clinics does not match the outpatient records of other departments within the hospital. There are no medical records policies regarding wound management and sleep disorder clinics documentation. There are no policies regarding outpatient medical records and documentation of care.

3. Several records reviewed by surveyors did not have complete assessments by nursing personnel and/or did not have initial nursing assessments. Several records did not include intravenous infusion totals during any of the perioperative period. Several radiology records did not have electronic signatures. There was no documentation provided to surveyors indicating content of medical records were reviewed for completeness and accuracy.

4. On 12/7/2011 surveyors reviewed outpatient procedure records. None of the endoscopy patients had history and physicals documented in the medical record.

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 12/6/2011 staff B 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 12/7/2011 Staff B told surveyors the radiologist in charge was Staff GG. A temporary credentialing and privileging file was provided to surveyors. There was no documentation stipulating Staff GG had been credentialed and privileged as the supervising radiologist.

3. Quality Assurance and Performance Improvement (QAPI) documents did not incorporate radiology and radiology procedures into the plan. QAPI meeting minutes for 2011 did not include a review of radiology services.

4. The facility did not have documentation stipulating staff were licensed, trained, and competent in radiation safety.

5. Three of three radiology staff (V,W,X) did not have departmental orientation and training.

6. There was no documentation V,W,X were competent in radiation safety techniques for themselves and patients.

7. There were no clinical performance evaluations of V,W,X in the personnel files provided to surveyors.

8. There was no documentation in the policy and procedure manual indicating all of the types of radiologic procedures offered by the facility. Policies provided to surveyors did not have current departmental contact information. This finding was verified with Staff A on 12/7/2011.

9. The above findings were reviewed with administration in the exit conference. No further documentation was provided.

Based on review of policy and procedure and interviews with staff the facility failed to ensure radiology exams were provided in a safe manner. The facility did not have documentation stipulating staff were licensed, trained, and competent in radiation safety. Three of three radiology staff (V,W,X) did not have departmental orientation and training. There was no documentation V,W,X were competent in radiation safety techniques for themselves and patients. There were no clinical performance evaluations of V,W,X .

Based on review of policies, and interviews with staff, the hospital failed to ensure a qualified radiologist supervises the radiology services, only personnel designated as qualified by the medical staff used the radiologic equipment and administered procedures.

Findings:

1. On the morning of 12/6/2011 staff B told surveyors radiology services were provided by employees. There were no current policies (reviewed and approved by medical staff and the supervising 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 12/7/2011 Staff B told surveyors the radiologist in charge was Staff GG. A temporary credentialing and privileging file was provided to surveyors. There was no documentation stipulating Staff GG had been credentialed and privileged as the supervising radiologist.

Based on review of policies, personnel files, and interviews with staff the facility failed to provide competent, qualified radiology personnel.

Findings:
1. 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. The facility did not have documentation stipulating staff were licensed, trained, and competent in radiation safety.
3. Three of three radiology staff (V,W,X) did not have departmental orientation and training.
4. There was no documentation V,W,X were competent in radiation safety techniques for themselves and patients.
5. There were no clinical performance evaluations of V,W,X in the personnel files.

Based on review of medical records, policies and procedures, dietary consultation reports, and interviews with staff, the facility failed to ensure dietary services were provided in an organized manner and problems identified in dietary were included in quality assurance performance improvement activities (QAPI).

Findings:

1. No dietitian reports were provided during the survey to show the dietitian (Staff HH) was actively supervising dietary services at the hospital. In an interview at on 12/6/11 Staff II told surveyors the consultant had not provided a monthly report only dietary consultation. Staff II did not know what patient's had been consulted on. There was no list or documentation provided by the consulting dietitian regarding consultations. There was no evidence Staff HH provided oversight to dietary/clinical staff ensuring compliance with dietetic policies effecting patient treatment. During the interview Staff II was asked about processes relating to dietary policies. Staff II was not aware of nutritional policies not matching the nursing nutritional policies. Staff II also told surveyors Staff HH was providing consultant dietitian services but was not sure of all of Staff HH's responsibilities. There was no job description in the dietitian or certified dietary manager's personnel file. Staff HH and Staff II did not have any orientation, training, or competencies in their personnel files. There was no evaluation for Staff HH or II provided to surveyors.

2. On 12/6/11 surveyors were provided a dietitian contract (Staff HH). The contract stipulates the dietitian will consult in menu planning, food production and service, and therapeutic diet orders. The contract further stipulates the dietitian will provide a monthly personnel inservice education, perform monthly written reports summarizing consulting dietitian's activities and evaluation of the food service. There were no monthly reports indicating the dietitian oversaw all required elements of the dietary program.

3. On 12/6/11 surveyors asked Staff II if there was a list of patient's Staff HH had consulted with. Staff II told surveyors Staff HH provided a list of patient's dietary consults were provided but Staff II did not keep the list. Staff II was not aware of any dietary consultations recently. Staff II could not provide surveyors any patient dietary consult information or any changes made to diets by Staff HH. Staff II told surveyors the consultant dietitian did not provide a report to the facility and did not oversee activities in the dietary department.

4. Dietary policies and procedures were provided to surveyors 12/6/11. The policies and procedures had a revision date of 2010. The departmental policies did not have policies regarding portioning. The process for nutritional assessment and nutritional screen did not match the nursing policies regarding assessment and screening. Processes for cleaning and sanitizing the department and equipment did not identify cleaners and sanitizer appropriate for use and instructions for use. There was no evidence the Infection Control processes had been integrated into the departmental policies. Departmental policies regarding hand washing, incident reporting, and complaints do not match hospital policies.

5. There was no documentation in the Quality Assurance Performance Improvement (2010-2011) meeting minutes the clinical nutritional services participated in the program. There was no documentation the dietitian, the dietary department, or clinical nutritional services participated in any of the hospital committees.

6. ON 12/6/11 surveyors Staff II provided surveyors the Oklahoma Diet Manual published 1992. Staff II told surveyors the manual was what the facility was using in dietary. On 12/7/11 during a tour of the kitchen, the 2006 Oklahoma Dietary Manual was found. Staff II told surveyors the 1992 manual was the manual the dietary department currently used.

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. The hospital did not have documentation that the persons doing nutritional consults on patients were qualified (licensed/registered dietitians). There was no evidence the consultant was licensed and qualified as a dietitian.

2. There was no documentation the dietitian was supervising the dietary department, the certified dietary manager, or any aspects of clinical nutrition.

3. There was no documentation the dietitian was trained, competent, and evaluated on a yearly basis.

3. This finding was verified by Staff II on 12/6/11. Administration was provided this information on 12/7/11 and no further information 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 12/6/ 11 surveyors reviewed two dietary employees (HH,II) files. The files did not contain orientation, training, and competencies specific to the department.

2. On 12/6/11 three of three employees (JJ,KK,LL) told surveyors they did not have specific training on job responsibilities related to dishwashing and sanitization. On 12/6/11 surveyors observed these staff performing dishwashing and sanitization.

3. This finding was reviewed with administration at the exit conference. No further documentation was provided.

Based on medical record review, interviews with staff, and policy review the facility failed to provide nutritional assessments by a qualified dietitian to meet the nutritional needs of the patient.

Findings:
According to the policy "assessment/reassessment, Nutritional" the admitting nurse will complete the nutritional screen as part of the admit process. Nutritional triggers will be referred to the consulting dietitian for review and follow-up. Nursing will also refer priority and at risk patients, without a physician order, to the dietitian for comprehensive nutritional assessment. Specific nutritional risk indicators for adult patient populations are as follows: tube feeding; total parenteral nutrition; ten pound weight loss in one month; less than fifty percent of usual oral intake; dysphagia; diagnosed malnutrition; diesterase surgery of the gastrointestinal system; depsis; anorexia/bulemia; electrolyte imbalance; malabsorption; new uncontrolled diagnosis of diabetes mellitus; human immunovirus HIV/AIDS; Burns; Trauma; Post surgery patient older than seventy years of age; decreased mentation; pressure ulcer; nothing by mouth or clear liquid diet greater than three days; intubation greater than forty-eight hours without plans for extubation.

1. Patient #29's medical record indicated the patient was older than 70 and undergoing a surgical procedure. The patient did not have a nutritional screen or a nutritional assessment to ensure nutritional needs were met.

2. Patient #30's medical record indicated the patient was older than 70 and had undergone surgical procedure. The patient had undergone a colon resection. There was no initial nursing assessment documented. There was no dietary screen or nutritional assessment recorded.

3. Patient #31's medical record indicated the patient was older than 70 and had undergone a procedure. The patient had become combative and was restrained. There was no documentation of a nutritional screen or assessment.

4. In an interview with Staff II on 12/7/11 surveyors were told he did not receive specific information through the computer but if a patient needed an assessment the nurses would call the department and let him know. Staff II was not aware the nutritional department policy did not match the nursing nutritional policy.

Based on observations and interviews, the hospital failed to ensure that the current/ latest edition of the Oklahoma Diet Manual is available to all medical and nursing personnel. On 12/6/11 Staff II provided surveyors the Oklahoma Diet Manual published 1992. Staff II told surveyors the manual was what the facility was using in dietary. On 12/7/11 during a tour of the kitchen, the 2006 Oklahoma Dietary Manual was found. The Oklahoma Diet Manual was not approved by the licensed/registered dietitian and medical staff. Staff II told surveyors the 1992 manual was the manual the dietary department currently used.

Based on review of meeting minutes and interviews with hospital staff, the hospital's infection control officer failed to develop a comprehensive infection control plan.

Findings:

1. The infection control plan, developed by the infection control officer, Staff T, specified, except for patient infections, what would be monitored; how the monitoring would be accomplished; and include the frequency of the monitoring.

2. The plan did not include monitoring activities for all departments to ensure infection control policies and procedures would be followed or the frequency they would be monitored and reported to the infection control committee. This was discussed and verified with Staff T.

3. Staff N, S and T stated monitoring of infection control practices in the operating room had not been performed. Staff T could not provide information as to how she planned to monitor to ensure a safe and sanitary environment had been developed.

At the time of the revisit and recertification survey on 12/07/2011, this deficiency had not been corrected.
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Based on staff interviews and review of hospital records, the hospital failed to ensure the infection control officer maintained a comprehensive system for controlling infections and communicable diseases. The infection control officer did not monitor every department to determine a successful infection control plan is implemented and followed.

Findings:

1. Staff T, the infection control officer, presented surveyors with documents titled IC (infection control) rounds. The rounds did not include environmental rounds where staff are observed on the use of cleaning equipment, handwashing, proper disinfecting, donning gloves, proper use of personal protective equipment, and isolation precautions for compliance with hospital policies and procedures and current standards of infection control practice.

2. Staff T stated that she did observe staff, but could not provide evidence that ensures staff are following infection control policies and procedures.

3. Staff T stated on 12/06/2011 that she had looked at two different disinfectants. The surveyor reviewed the disinfectants with Staff T. The disinfectant that Staff T stated she has chosen was not appropriate for the type of patients seen at the hospital.

At the time of the revisit and recertification survey on 12/07/2011, this deficiency had not been corrected.
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Based on record review and interviews with hospital staff the hospital does not ensure that a log of all infections and communicable diseases is maintained that identifies incidents of infection and communicable diseases in both patients and staff that would enable the hospital to evaluate the data contained in the log to determine whether the infections were either present on admission or health-care associated and to protect both the patients and staff from infections.

Findings:

1. On 12/06/2011 Staff T, the person identified as responsible for infection control, provided the hospital's infection control log. The infection control log was not complete. The log did not demonstrate employee infections/illnesses were tracked to ensure infections/illnesses were not transmitted between patients and staff.

2. This findings was reviewed and confirmed with Staff T during both days of the survey, 12/06 and 07/2011.

Based on review of policies and procedures and interviews with staff the facility failed to develop and implement policies and procedures appropriate to the perioperative suite.

Findings:

1. In an interview on 12/7/2011 Staff N and Staff S told surveyors Staff S was the new Director of Perioperative Services. Both staff told surveyors many processes in the perioperative suite had been changed recently. Both indicated processes for moving clean and dirty instruments, flash sterilization, implant tracking, and had been reviewed with changes made and staff educated. No policy and procedure was found by surveyors. Both staff N and Staff S told surveyors they had not revised policies only the processes. There was no documentation the processes had been reviewed and approved through medical staff and governance. There was no documentation staff had been trained and the new procedures implemented.

2. In a separate interview on 12/6/2011 Staff N and Staff S told surveyors they had not updated staff on use of minimizing risks of surgical fires. There was no policy or documentation provided to surveyors the staff were educated on the risk of surgical fires.

2. Policies provided to surveyors on 12/6/2011 indicated implementation dates of 2009. There was no indication the policies and procedures had been reviewed and approved through the medical staff and governing body during recent changes to processes.

Based on review of the hospital records and interviews with staff, the hospital failed to maintain a complete operating room log.

Findings:

1. On 12/6/2011 surveyors Staff A provided surveyors with the surgical log. Column headings do not list all of the required elements. Multiple entries on the log were not complete.

2. On 12/7/2011 surveyors interviewed Staff S. Staff S told surveyors she was aware of the requirements of documentation but did not know many of the entries had blanks and the column headings did not include all of the required elements.

3. There was no policy or procedure provided to surveyors stipulating appropriate documentation in the operating room log. There was no documentation provided to surveyors personnel had been educated on all required elements in the operating room log.

4. This finding was reviewed with administration at the exit conference on 12/6/2011. No further documentation was provided.

Based on review of rehabilitation policy and procedure, hospital documents, personnel files and interviews with staff, the hospital failed to develop and organize the scope of rehabilitative services to be provided to the hospital's patient's.

Findings:

1. According to administrative staff, the hospital's physical therapy (PT) services is provided as a contracted service.

2. Upon entrance to the hospital, the surveyors requested policies and procedures for PT. Administrative staff provided the surveyors with a 12-page (six pages front and back) stapled document entitled, "(Name of contracted therapy service) Policy and Procedure." The policy documented, under Scope of Service, that services provided could include: use of heat, cold, water, electricity, exercises, manipulations, tractions, medication delivered subcutaneously by use of electrical current and ultrasound, immobilization, pressure, biofeedback, education, bracing and orthotics, and evaluation techniques. The document did not contain policies and procedures for all these services listed or describe what equipment would be utilized.

3. The policy did not contain documentation that it had been adopted by the hospital. No other PT policies and procedures were provided and the hospital's computerized policies and procedures did not contain PT policies and procedures.

4. Review of hospital meeting minutes, governing body, medical staff and quality, did not show the hospital had reviewed, approved and adopted the contracted therapy policy and procedure and scope of services that could be provided.

5. Hospital Staff O, P and R identified contract Staff U as the physical therapist who provided PT services to patients. The surveyors asked for Staff U's personnel file. The file consisted of a copy of the therapist's license and cardiopulmonary resuscitation certification that was faxed to the hospital on the second day of the survey, 12/07/2011. No other information was provided. When asked, staff told the surveyors that there was no additional paperwork - competency and orientation was not verified and documented.

Based on review of medical records and hospital documents and interviews with hospital staff, the hospital failed to ensure physical therapy (PT) services were provided according to physician orders. For one of one medical record reviewed (Record #22) that had PT orders, the orders for physical therapy did not contain the type, frequency and duration of services and services were not provided as ordered.

Findings:

1. Record #22 only contained an order for PT eval (evaluation) and treat, dated 12/01/2011. The medical record did not contain additional orders for PT, a physician signature on the PT evaluation, or clarification orders with the required information.
a. The PT evaluation, by the physical therapist on 12/02/2011 at 1030, recommended PT services be provided twice a day for gait training, therapeutic exercises and therapeutic activities.
b. PT services of gait training, therapeutic exercises and therapeutic activities were provided on 12/02/2011 and 12/03/2011 at 1045.

2. The twelve-page PT policy and procedure by the contracted PT company stipulates, on page 2, that the registered physical therapist will complete a plan of care/treatment and the attending physician will approve and sign the plan of care. The policy goes on to document that all treatments provided will be entered into the patient's medical record and 'will be signed by the person rendering the treatment and the attending physician." PT treatment records for Patient #22 were not signed by the physician.

Based on record review and interviews with hospital staff, the hospital does not ensure that all respiratory treatments are administered as ordered and the patient's response to treatment is documented. Two of two patient records reviewed (Record #'s 20 and 21) that had respiratory treatments ordered did not have the treatments given as ordered.

Findings:

1. Patient #20 - On 11/08/2011 at 0530, the physician ordered nebulizer treatments of albuterol 1.25 milligrams four (4) times a day (q.i.d.) and every six (6) hours as needed. The order was recorded in the electronic medication record on 11/08/2011 at 0616. Nebulizer treatments was not administered as ordered on 11/08/2011 or 11/09/2011. This finding was verified by Staff P at the time of review on 12/07/2011 at 1725.

2. Patient #21 - On 11/07/2011 at 1900, the physician ordered nebulizer treatments of Duoneb every six (6) hours and as needed. The order was recorded in the electronic medication record on 11/07/2011 at 1943 for the as needed treatments and 11/07/2011 at 2200 for the every 6 hours. Nebulizer treatments were not administered as ordered on 11/09/2011 or 11/10/2011. This finding was verified by Staff P at the time of review on 11/07/2011 at 1735.

Based on record review and interviews with hospital staff, the hospital does not ensure that the QAPI program indicators are analyzed to determine whether there is measurable improvement in the hospital's processes and health outcomes for patients are improved.

Findings:

1. One QAPI meeting for November 2011 presented for review conducted since the previous survey still did not have evidence the monitors the hospital was following were evaluated and analyzed.

2. The QAPI scorecard presented for review just had numbers and percentages and did not have an evaluation of the significance of what the numbers and percentages meant.

3. Hospital staff verified on 12/07/11 in the morning that there was no further documentation that had evidence of evaluation of data collected.

Based on record review and interviews with hospital staff, the hospital does not ensure that data collected as part of the QAPI program is measured and analyzed to assess the hospital processes and services to assure quality of care is provided.

Findings:

1. Review of Governing Body, Medical Staff and QAPI meeting minutes did not have evidence that data collected was analyzed and evaluated.

2. One QAPI meeting for November 2011 presented for review conducted since the previous survey still did not have evidence the monitors the hospital were following were evaluated and analyzed.

3. Hospital staff verified on 12/07/11 that they did not have any other evidence that data collected was analyzed, evaluated to assure quality of care.

Based on record review and interviews with hospital staff, the hospital does not ensure that data collected to implement performance improvement actions are evaluated to measure the effectiveness of action taken. QAPI meeting minutes reviewed since the October 2011 survey did not have any evidence data collected was evaluated and measured for effectiveness. This was verified by hospital staff on 12/07/11. The QAPI scorecard presented for review just had numbers and percentages and did not have an evaluation of what the significance of the numbers and percentages meant.

Based on a review of policies and procedures, medical records, and staff interviews, the hospital failed to ensure the menus were meeting the needs of the patients.

Findings:

1. On 12/6/2011 Staff A told surveyors the facility had a contracted dietitian and a full time Certified Dietary manager (CDM) The dietary consultation contract provided to surveyors indicates the contracted dietitian will "provide consultation to Facility to enable Food Services staff to provide dietetic service that meets the daily nutritional needs of patients, the dietitians will provide in service education to the staff in medical nutrition therapy and food service operation, provide consultation to physicians and allied health, provide direct dietary counseling to any patient in accordance with orders, dietitians approve all patient menus, write meal patterns, write diets as necessary and coordinate new menus with advance notice.

According to the policy "Assessment/Reassessment, Nutritional, the admitting nurse will complete the nutritional screen as part of the admit assessment specific nutritional risk indicators for adult patient population are as follows: tube feeding or total parenteral nutrition (TPN); 10 pound weight loss in one month; less than fifty percent of usual oral intake,; dysphagia; diagnosed malnutrition; disease/surgery of the gastrointestinal system; depsis (sp); anorexia/bulmia; electrolyte imbalance; malabsorption; new/uncontrolled diagnosis of diabetes mellitus; human immunodeficiency virus (HIV/AIDS); burns; trauma; post-surgery patient greater than seventy years old; decreased mentation; pressure ulcer; nothing by mouth (NPO) or clear liquid diet greater than three days; intubation greater than forty eight hours without plans for extubation.

1. Three of three (29,30, 31) patients had nutritional conditions requiring nutritional intervention which the facility did not act on. The hospital staff did not identify these conditions through the nutritional screen.

2. Several patients did not have a complete nutritional screen or the screen did not match documentation in the history and physical.

3. During the tour of the dietary department, Staff II provided surveyors with current menus. There was no evidence the menus had been reviewed and approved by the dietitian. Staff II told surveyors a physician who provides bariatric surgery orders a special liquid diet for patients after surgery. Staff II did not know if the dietitian had reviewed and collaborated with the physician on the special liquid diet. There was no documentation in committee meeting minutes any of the menus had been reviewed and approved by the dietitian.

4. These findings were reviewed with administration at the exit conference. No further information was provided.