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Based on interview, the facility failed to establish and maintain policies and procedures for reporting changes in ownership to the State. This deficient practice had the potential to incorrectly identify or cause delay in identification of the owners, when their identification was required to conduct routine business with the State. The facility census was zero.

Findings included:

During an interview on 10/20/15 at 1:54 PM, Staff O, Chief Executive Officer (CEO), stated that the facility did not have policies or procedures directing a process for identification of a change in ownership and for reporting that information to the State. He stated that he was not aware of the requirement.

Based on interview and record review, the facility failed to develop and maintain a Quality Assurance and Performance Improvement (QAPI) program that included evaluation of all services including those provided by two of three contractors reviewed. One contract was for night time Teleradiology (the transmission of radiological patient images, such as x-rays; computerized tomography [CT, which is x-ray testing that produce images of the body using those X-rays and a computer]; and magnetic resonance imaging [MRI, which is a test that uses a magnetic field and radio waves to create images of the organs and tissues within the body] from one location to another for the purposes of sharing studies with other radiologists and physicians). The second contract was for services of the Certified Registered Nurse Anesthetists (CRNAs, registered nurses, who have acquired graduate-level education and board certification in anesthesia). This lack of evaluation had the potential to permit radiology and/or surgical nursing services to be provided that may adversely affect the health and safety of facility patients. The facility census was zero. The facility performed approximately 170 x-rays per month; an average of 57 CTs per month and an average of 5 MRIs per month. The facility had 71 cases with the CRNAs providing anesthesia care between 04/23/15 and 09/24/15.

Findings included:

1. Record review of the facility's policy titled, "Contracted Services," dated 03/10/14, showed the directive for staff to forward a listing of contract arrangements to the QA department for an annual PI evaluation.

2. During an interview on 10/20/15 at 10:05 AM, Staff O, Chief Executive Officer (CEO), stated that the night time radiology service was provided by a contracted service.

3. Record review of the contract folder for the night time radiology service showed the contract was terminated on 11/30/14.

During an interview on 10/20/15 at 1:54 PM, Staff O, confirmed that the facility currently had no formalized contract with the night time teleradiology service provider (so, did not have QAPI data).

4. Record review of the facility's unsigned and undated document titled, "Anesthesia Services, paragraph 3 b ii, CRNAs Duties," provided by Staff J, Human Resources/Administrative Assistant, showed directives for the quality and appropriateness of patient care services provided be monitored and evaluated, documented and reported (by the CRNAs) for the facility's QA program.

During an interview on 10/20/15 at 8:45 AM, Staff A, Chief Nursing Officer (CNO), stated that she was the facility QAPI program coordinator and the CRNAs were not included in the QAPI program's or the QAPI annual evaluation.

Based on interview and record review, the facility failed to develop and maintain a Quality Assurance and Performance Improvement (QAPI) program that included evaluation of the quality and appropriateness of contracted Radiology physicians providing night time distant site radiology services. The night time distant site radiology contractor provided Teleradiology (the transmission of radiological patient images, such as x-rays; computerized tomography (CT, which is x-ray testing that produce images of the body using those X-rays and a computer); and magnetic resonance imaging (MRI, which is a test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) from one location to another for the purposes of sharing studies with other radiologists and physicians). This lack of evaluation had the potential to permit radiology services to be provided that may adversely affect the health and safety of facility patients. The facility census was zero. The facility performed approximately 170 x-rays per month; 57 CTs per month and 5 MRIs per month.

Findings included:

1. Record review of the facility's policy titled, "Contracted Services," dated 03/10/14, showed the directive for staff to forward a listing of contract arrangements to the QA department for an annual PI evaluation by the QAPI department program coordinator.

2. During an interview on 10/20/15 at 8:45 AM, Staff A, Chief Nursing Officer (CNO), stated that she served as the facility QAPI program coordinator; and the facility did not have policies and procedures directing evaluation of the quality, appropriateness of treatment provided by contracted services (contrary to the directive in the facility policy titled, "Contracted Services").

3. Record review of the facility's current listing of PI studies for 2015, provided by Staff A, showed no studies for the evaluation of the quality and appropriateness of any services provided by distant site physicians or practitioners.

During an interview on 10/20/15 at 10:05 AM, Staff O, Chief Executive Officer (CEO), stated that the radiology service that provided care through the night was a contracted service.

4. Record review of the contract folder for the night time radiology service showed the contract was terminated on 11/30/14.

During an interview on 10/20/15 at 1:54 PM, Staff O, confirmed the facility had no formalized contract with the night time Teleradiology service; the contract was terminated then, services were reestablished on a month to month basis.

Based on interviews, the facility failed to develop and maintain a formalized agreement/contract for pediatric patient referral and transfer to a nearby pediatric specialty facility. This deficient practice had the potential to delay necessary care to pediatric patients who presented to the facility and were found to require a higher level of care. The facility census was zero. The facility transferred nine pediatric patients in the last 11 months.

Findings included:

1. During entrance conference on 10/19/15 at 1:05 PM, Staff A, Chief Nursing Officer (CNO), stated that the facility did periodically admit pediatric patients; however, if the patient needed a higher level of care they were transferred to an appropriate pediatric facility.

2. During an interview on 10/20/15 at approximately 12:50 PM, Staff O, Chief Executive Officer (CEO), stated that the facility had transferred pediatric patients to a nearby pediatric specialty facility in the recent past.

During an interview on 10/20/15 at 1:54 PM, Staff O, stated that there was no agreement/contract for referral and transfer with the pediatric facility.

During an interview on 10/21/15 at 9:35 AM, Staff O, stated that the facility had transferred nine patients in the last 11 months to the nearby pediatric facility.

Based on observation, interview, record review and policy review, the facility failed to ensure staff:
- Performed daily checks on the crash cart (movable cart that contains emergency medication, equipment and supplies) and defibrillator (electronic device that applies an electric shock to restore normal rhythm of the heart) for one of three crash carts observed;
- Identified a contradiction in documentation and/or replacement of a plastic, numbered lock (a zip type tag put on the crash cart to ensure the integrity of the crash cart at all times) for one of three crash carts observed, in the Medical/Surgical unit; and
- Maintained a tracheotomy (an emergency surgical procedure that opens up the windpipe) kit in the Surgery Department that was complete and readily available for use.
These failures had the potential to affect all patients increasing their risk for delayed care in the event of a medical emergency. The Surgery Department performed approximately 72 cases in the operating room over the past six months. The average daily census on the Medical Surgical unit was three. The facility census was zero.

Findings included:

1. Record review of the facility's undated policy titled, "Emergency Crash Carts," showed:
- Emergency drugs and supplies, for use in medical emergencies only, shall be immediately available on all patient care units/areas.
- Crash cart integrity was to be checked daily and checklist initialed; and
- Defibrillator was to be checked and tested daily.

2. Record review of the Surgery Department's crash cart and defibrillator checklist showed the following:
- No daily check for 05/01/15 through 05/12/15 and on 05/15/15;
- No daily check for 06/19/15 and 06/27/15;
- No daily check for 07/17/15 and 07/30/15;
- No daily check for 08/01/15 through 08/09/15 and on 08/17/15;
- No daily check for 10/05/15, 10/07/15, 10/10/15 through 10/18/15.

Record review of the Surgery Department's log book for "Register of Operations," showed:
- Seven cases performed in the operating room on 05/05/15;
- Nine cases performed in the operating room on 05/08/15;
- Five cases performed in the operating room on 08/07/15.
(These were all dates when there was no daily check performed on the crash cart. These patients all received either general anesthesia [treatment with certain medicines that puts the patient into a deep sleep so they do not feel any pain during surgery] or monitored anesthesia care [treatment with local anesthesia with sedation and pain medications]. Anesthesia of any kind increases a patient's risk for the need for emergency equipment).

During an interview on 10/20/15 at 2:25 PM, Staff W, Registered Nurse, (RN), Surgery Department Manager, stated that there was no process in place for the checking of the crash cart. She stated it was checked by any staff member when they remembered to do it.

3. Record review of the facility's undated policy titled, "Emergency Crash Cart Security and Accountability," showed:
- Nursing personnel was to visually inspect the locks located on the emergency crash carts at each shift change;
- A discrepancy, broken lock or missing lock was to be reported to the nursing administrator and pharmacy department;
- The number on the lock was to be tracked on the log sheet in the pharmacy.

4. Observation of the crash cart on the Medical Surgical unit on 10/19/15 at 2:00 PM showed two locks, one securing several drawers on the top portion of the crash cart and one securing one door on the bottom of the crash cart.

5. Record review of the Medical Surgical crash cart log book showed the lock numbers documented did not match the lock numbers that were on the crash cart.

During an interview on 10/19/15 at approximately 2:05 PM, Staff A, Chief Nursing Officer, confirmed the locks and documentation did not match. Staff A later determined the facility Pharmacy Technician had opened the crash cart, about a week prior, and failed to document that the locks were changed. Nursing staff doing subsequent crash cart checks failed to visually inspect the locks and verify the numbers as accurate and continued to document the old lock numbers. Staff A stated the nurses should have noticed this discrepancy.

6. During an interview on 10/20/15 at 1:04 PM, Staff W, RN, stated that she was unsure of the location of a tracheotomy kit. Staff W asked Staff I, Licensed Practical Nurse, (LPN) and Staff Y, Sterile Processing, to locate the kit. After approximately 10 minutes Staff Y located the kit. The kit had been opened and was not complete and readily available for use.






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Based on interview, record review and policy review the facility failed to begin observation services (ongoing short-term assessment, treatment and reassessment, that are provided before a decision can be made regarding whether a patient will require further treatment as an inpatient, or may be safely discharged) with a physician's order for three (#13, #39, and #40) of seven observation patients reviewed. The facility reported approximately 15 observation patients for the prior six months. This has the potential to affect all patients observed as an outpatient by increasing the risk of inappropriate admission classification including the appropriate length of stay. The facility census was zero.

Findings included:

1. Record review of the facility's undated policy titled, "Outpatient Observation," showed physicians' orders must designate, "OBSERVE AS AN OUTPATIENT."

2. Record review of Patient #13's orders in the medical record dated 10/01/15, showed no physician order to observe as an outpatient.

During an interview on 10/20/15 at 2:05 PM, Staff A, Chief Nursing Officer, stated that after further review of Patient #13's record, there was no observation order to begin care. Staff A stated that the physicians should write a specific order to observe as an outpatient to begin care.

3. Record review of Patient #39's orders in the medical record dated 05/19/15, showed no physician order to observe as an outpatient.

4. Record review of Patient #40's orders in the medical record dated 08/28/15, showed no physician order to observe as an outpatient.

Based on interview, the facility failed to establish and maintain policies and procedures for reporting changes in the principal operating official (also called chief executive officer) to the State. This deficient practice had the potential to incorrectly identify or cause delay in identification of the principal operating official, when his identification was required to conduct routine business with the State. The facility census was zero.

Findings included:

During an interview on 10/20/15 at 1:54 PM, Staff O, Chief Executive Officer (CEO), stated that the facility did not have policies or procedures directing a process for identification of a change in the CEO and reporting that information to the State. He stated that he was not aware of the requirement.

Based on interview, the facility failed to establish and maintain policies and procedure for reporting changes in the Chief Medical Officer (CMO, a physician who provided medical direction) to the State. This deficient practice had the potential to incorrectly identify or cause delay in identification of the CMO, when his identification was required to conduct routine business with the State. The facility census was zero.

Findings included:

During an interview on 10/20/15 at 1:54 PM, Staff O, Chief Executive Officer (CEO), stated that the facility did not have policies or procedures directing a process for identification of a change in the CMO and reporting that information to the State. He stated that he was not aware of the requirement.

Based on interview, record review, and policy review the facility failed to notify the Organ Procurement Organization (OPO, an organization responsible to evaluate and obtain human organs for transplantation) within one hour of the patient's death, per their policy, for five ( #10, #17, #18, #20, and #9) of eight records reviewed. The facility reported eight deaths in the prior six months. This has the potential to affect all patients who died and previously requested organ donation, by causing their organ(s) to be nonviable (unusable) due to untimely notification. The facility census was zero.

Findings included:

1. Record review of the facility's policy titled, "Organ, Tissue and Eye Donation," dated 11/01/05, showed direction for staff to refer deaths of all patients to their OPO in a timely manner. Timely notification of a cardiac death is within one hour of standstill.

Record review of the OPO form (Form GP-117) utilized showed, "Cardiac Death Referral: Call within 60 minutes of patient's cardiac time of death to determine tissue &
eye donation potential."

2. Record review of cardiac related deaths showed the following:
- Patient #10 died at 3:57 AM, and the OPO was never notified.
- Patient #17 died at 12:50 AM, and the OPO was not notified until 2:00 AM.
- Patient #18 died at 5:45 PM, and the OPO was not notified until 7:00 PM.
- Patient #20 died at 11:26 AM, and the OPO was not notified until 2:00 PM.
- Patient #9 died at 1:16 AM, and the OPO was not notified until 2:20 AM.

During an interview on 10/19/15 at 2:27 PM, Staff A, Chief Nursing Officer stated that all deaths were to be called in to the OPO within one hour.