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Based on record review and interview, the hospital's Governing Body failed to:

a. ensure the hospital identified and evaluated all contracted services for quality and safety (See tag A-0084),

b. adopt policies and procedures that specifically applied to the hospital's scope of practice. (see findings below),

c. ensure the hospital developed and implemented an effective and active Quality Assessment and Performance Improvement program. (See tag A-0263, A-0273, A-0283, A-0286, and A-0297);

d. ensure nursing staff are competent/qualified to perform nursing interventions, perform timely assessments based on patient needs and safety, assessment/reassess patient's pain within identified timeframes, revise care plan based on patient's response to care and contract nursing staff adhere to policy and procedures. (See tags A-0392, A0395, A-0396, and A-0398);

e. adopt a drug formulary specifically applied to the hospital's scope of practice. (see Tag A-0500)

f. ensure the hospital developed and implemented an effective infection control program to prevent, control and investigate infections and communicable diseases in patients and staff. (See below findings and also tag A-0749),

These failed practices had the potential to affect the quality of care for all patients receiving services at the hospital; to increase the risk that a policies and procedures would be followed that were not within the capability and capacity of the hospital.


Findings:

a. Contracted Services (See tag A-0084)

b. Policies and Procedures

Although it had its own CMS provider and state licensure number, the Long Term Acute Care Hospital (LTACH) was associated with an acute hospital with a separate provider and licensure number. The same tribal governance was responsible for both facilities. The tribal governance had created "organizational" policies for the LTACH and acute hospital.

The surveyors requested various hospital policies and received policies titled, "Muscogee Nation". Many policies documented that it applied to "MCNDH" (Muscogee (Creek) Nation Health Department. Some policies documented that it applied to "MCNPRC" (Muscogee (Creek) Nation Physical Rehabilitation Center, which had been closed.

On 06/07/17 at 08:22 am, Staff A, the COO, stated policies were developed for the entire tribal system. Staff A stated the Governing Body has not approved policies that were exclusively designated for use at the LTACH. Staff A stated the LTACH used the most stringent policies.


c. QAPI (see Tag A-0263, A-0273, A-0283, and A-0297)

d. Nursing (see Tag A-0392, A0395, A-0396, and A-0398)

e. Pharmacy

Although it had its own CMS provider and state licensure number, the Long Term Acute Care Hospital (LTACH) was associated with an acute hospital with a separate provider and licensure number. The same tribal governance was responsible for both facilities. The tribal governance had created "organizational" formulary for the LTACH and acute hospital.

The surveyors requested various hospital policies and received policies titled, ""Muscogee Nation". Many policies documented that it applied to "MCNDH" (Muscogee (Creek) Nation Health Department. A review of a policy titled, "MCNDH Formulary Selection dated 03/16" documented all pharmacies would maintain and enforce formulary selection and restriction was directed through the MCNDH Pharmacy and Therapeutics Committee. No evidence was provided for the LTACH had designated a specific drug formulary.

On 06/07/17 at 11:07 am, Staff E, the pharmacist, stated the LTACH did not have a pharmaceutical formulary designated for the service provided. Staff E stated the LTACH utilized the tribal formulary.


f. Infection Control (also see Tag -A-0749)

1. Although it had its own CMS provider and state licensure number, the Long Term Acute Care Hospital (LTACH) was associated with an acute hospital with a separate provider and licensure number. The same tribal governance was responsible for both facilities. The tribal governance had created "organizational" policies for the LTACH and acute hospital.

The tribal policy titled, "MCNPRC Tuberculosis Control Plan". "MCNPRC" (Muscogee (Creek) Nation Physical Rehabilitation Center had been closed. This policy documented the facility was on total divert for receiving any direct admits suspected of known Active Latent TB patients.

Per incident log and investigation, on 08/17/16, a patient with severe respiratory symptoms, was admitted and placed on droplet isolation. On 08/22/16 at 4:15 pm, Staff Z, received a phone call from the transfering facility stating the patient had 3 positive AFB cultures. (AFB testing may be used to detect several different types of acid-fast bacilli, but it is most commonly used to identify an active tuberculosis (TB) infection).

CDC TB guidelines documents the use of environmental controls to prevent the spread and reduce the concentration of infectious droplets for TB. The guidelines require the TB patient to be placed in a room with local exhaust ventilation and airflow that is controlled to prevent contamination of air in areas adjacent to the source airborne infection isolation rooms. The guidelines recommended the use of high efficiency particulate air (HEPA) filtration to clean the air.

On 06/06/17 at 11:14 am, Staff B stated the LTACH did not have a room with negative air flow or an air filter system.

A 06/07/17 memorandum from the LTACH to the Oklahoma State Department of Health documented 14 staff were potentially exposed as a result of this patient admission and had to follow the exposure protocol.

On 06/07/17 at 3:20 pm, Staff A, the COO and Staff F, the Infection Control Preventionist (ICP), said there was no documentation the Medical Staff and Governing Body had reviewed this case through QAPI.

2. On 06/07/17, Staff F stated the Governing Body had not reviewed and approved the hospital's disinfectants and cleaning products for 5 years. Staff A provided a list of disinfectants and cleaning products utilized by the LTACH.

Based on record review and interview, the hospital failed to:
A. Analyze data
B. Identify changes that will lead to improvement
C. Document reason for conducting the project and the measurable progress achieved.

Findings:

A. Analyze data (See Tag 273)
B. Identify changes that will lead to improvement (See Tag A-283)
C. Document reason for conducting the project and the measurable progress achieved (See Tag A-297)

Based on record review and interview the hospital failed to:

a. Ensure nursing personnel are competent and qualified to perform nursing functions and treatments, (See Tag A-0392)

b. Ensure nursing staff perform consistent and timely assessment to meet patient needs and safety, and control patient's pain within identified timeframes (See Tag A-0395)

c. Ensure nursing staff revised the plan of care based on evaluation of patient's response to care relative to the planned patient outcomes (See Tag A-0396)

d. Ensure contracted nursing staff are oriented and adhere to the hospital's policies and procedures. (See Tag A-0398)

Based on record review and interview the hospital failed to have written policies and procedures implementing a formal discharge planning process.

This failed practice had the potential for increased risk of a patient's readmission due to the patient not having adequate resources or follow up at the time of discharge.

Findings:

A review of 20 medical records showed no formal discharge planning process.

5 of 20 medical records (Patient #2, 5, 6, 15 and 18) had no evidence of a discharge evaluation documented in the medical record.

On 06/07/17, administrative staff were asked to provide discharge planning policies and procedures. Administrative staff provided a document titled "Patient Progress Meetings" from the Physical Rehabilitation Center. No policies or procedures related to a formal process for discharge planning were provided.

On 06/08/17 at 10:50 am, Staff A stated the LTAH has no written policies or procedures identifying a discharge planning process. Staff A stated the hospital does have a discharge planner who will perform a discharge evaluation and interdisciplinary meetings are conducted.

Based on record review and interview, the hospital failed to ensure that contracted services were evaluated for safety and effectiveness.

This failed practice had the potential to compromise patients' safety due to suboptimal services from contracted entities.

Findings:

A review of a list of contracted services showed no documentation the contracted services had been evaluated by the governing body, who is responsible for oversight.

Although it had its own CMS provider and state licensure number, the Long Term Acute Care Hospital (LTACH) was associated with an acute hospital with a separate licensure and provider number. The same tribal governance was responsible for both facilities. The tribal governance had created joint policies for the LTACH and acute hospital. (see Tag A-0043 for policy deficiency)

On 06/07/17, the tribal governance policy titled, "Contract Management dated 10/9/13" documented all contractors must meet defined qualifications. The policy documented contractors were subject to monitoring and evaluation of their performance as evidence by the reviewing official's completion of a progress report.

On 06/07/17 at 8:22 am, Staff A, the Chief Operating Officer, stated contracted services were not evaluated by established quality criteria, and performance progress reports had not been completed for LTACH contracts.

Based on record review and interview, the hospital failed to list the Oklahoma State Department of Health as an entity for patients to contact to register a complaint.

Findings:

A document titled "Patient Rights and Responsibilities" listed a section "Complaints, Concerns and Questions". The section did not list the Oklahoma State Department of Health.

On 06/07/17 at 10:00 am, Staff A stated the Oklahoma State Department of Health was not listed on the notice given to patients and the posted notices.

Based on record review and interview the hospital failed to have a policy that described the steps to follow when a patient alleges abuse by a hospital employee or contract worker that included all components necessary for effective abuse protection. The necessary components include screening, identification, training, protection from the alleged abuser, investigation and reporting/responding.

This failed practice increased the risk of abuse from failure to identify, investigate and protect patients.

Findings:

Document titled "Abuse, Neglect and Misappropriate of Residents" showed...staff should facilitate discovery of events and occurrences that may constitute or contribute to abuse ...protect residents, families and staff from harm during an investigation. No evidence this policy applies to the Long Term Acute Care Hospital.

Document titled "Abuse of Children, Elderly, and Incapacitated Adults and Mandatory Reporting" show guidelines for mandatory reporting for the abuse of a child, older person or vulnerable adult ...staff must report the suspected crime...notify department supervisor, facility administrator, security and Patient Safety/Clinical Risk Management Coordinator ...if suspected abuser present, ensure safety of patient. No evidence of all necessary component of an effective abuse protection program.

Document titled "Workplace Violence' show prohibition of threats and acts of violence against personnel, patients and visitors...prevention program includes staff training, initial pre-employment screening ...personnel shall report immediately any acts or threats of violence occurring. No evidence of all necessary components of an effective abuse protection program

On 06/08/17 at 10:50 am, Staff A and Staff B stated the LTACH did not have a policy specific to the long term acute care hospital (LTACH) on abuse and/or neglect of patients that had the required elements for screening, identifying, protection from the alleged abuser, investigation and reporting/responding. Staff A and Staff B stated their current policies did not address removal of employees during investigation for alleged incidents of abuse/violence against another employee or patient. Staff A stated they do have a policy specific to the Skilled Nursing Facility that addresses each of these required elements.

Based on record review and interview, the hospital failed to analyze and document the data collected.

Findings:
Documents titled "Quality/Safety/Infection Prevention Committee" dated 2016 and 2017 were provided to surveyors. The minutes did not reflect an analysis of data showing a measurable improvement with evidence of how this will improve health outcomes.

On 06/07/17 at 11:45 am, Staff C stated the data was not analyzed. Staff C stated the minutes did not reflect all that transpired through the meeting and there were no attachments. Staff C stated she understood the minutes were incomplete and did not reflect an analysis of data.

Based on record review and interview, the hospital failed to identify the changes that will lead to improvement.

Findings:
A review of documents titled 'Quality/Safety/Infection Prevention Committee' dated 2016 and 2017 indicate the only PI project attributed to the LTACH was to increase the number of patient satisfaction surveys received per year. In the minutes, there was no analysis of data shown, no implementation of processes to improve data, no indication of maintenance of data and no indication of how the changes lead to improvement. There was no indication of how this project affects health outcomes, patient safety and quality of care.

On 06/07/17 at 11:45 am, Staff C stated the data is not analyzed. Staff C stated the minutes did not reflect all that transpired through the meeting . Staff C stated she understood the minutes were incomplete and there were no attachments showing an analysis of the data collected.

Based on record review and interview, the hospital failed to document reason for conducting the project and the measurable progress achieved.

Finding:
A review of documents titled "Quality/Safety/Infection Prevention Committee" dated 2016 and 2017 indicate the only PI project attributed to the LTACH was to increase the number of patient satisfaction surveys received per year (from 1 to 10). There was no documentation of the reason for conducting this project, and there was no documented measurable progress achieved in this project indicated in the minutes.

See Tag A-283.

Based on record review and staff interview the hospital failed to ensure healthcare providers completed a history and physical examination (H&P) in the patient's electronic health record within twenty-four (24) hours of admission.

This failed practice had the potential for 6 of 20 patients (Patients # 1, 5, 6, 7, 9, and 18) to have delayed recognition of medical conditions, affect medical treatment decisions, discharge planning and care plans.

Findings:

Document titled "History and Physical Examination" showed a comprehensive medical H&P examination shall be completed within 24 hours of admission to inpatient services or prior to surgery or procedure requiring anesthesia ...prior to surgery or procedure regardless of whether care is being provided on an inpatient or outpatient basis.

Document titled "Governing Body - Long Term Acute Care Hospital" dated June through August 2016 showed discussion regarding areas of delinquency for H&Ps not being completed within 24 hours per hospital policy and CMS requirements.

6 of 20 medical records (Patient #1, 5, 6, 7, 9, and 18) showed the H&P was not completed and documented in the patient's electronic health record within 24 hours of hospital admission.

On 06/08/17 at 10:50 am, Staff A stated physicians are required to complete the patient's H&P within 24 hours of the patient's admission. Staff A stated there are multiple ways to complete an H&P. The physician can dictate and have it transcribed and they can complete it in the computer. Staff A stated verification is when the physician signs the H&P.

Based on record review and interview the hospital failed to ensure nursing personnel were competent and qualified to perform nursing functions and treatments.

This failed practice had the potential to increase the risk to patient safety and infection for those with central lines.

Findings:

Document titled "Staff Qualifications and Competency" showed staff shall have a documented competency assessment completed every three (3) years or more frequently as defined by hospital policy or law and regulation.

Document titled "Central Line/PICC (Peripherally Inserted Central Catheter) Line; Insertion, Maintenance, and Discontinuance" showed...placement of central venous catheter (CVC) and PICC line is limited to persons certified in line placement ...maintenance limited to RNs that have received training and demonstrated competence ...shall receive education at time of hire, and annually ...only staff who have been trained and demonstrate competence shall provide care and treatment for patient with central lines.

1 of 9 personnel files (Staff X) reviewed showed staff member did not have documentation of annual competencies per hospital policy.

1of 1 agency personnel file (Staff W) reviewed showed no evidence of PICC line insertion and maintenance education and competency per hospital policy.

On 06/07/17 at 10:33 am, Staff G stated during orientation nurses learn how to assess patients, prepare and administer medications. Staff G stated peripherally inserted central line insertion, care education and competency is provided annually. Nurses have a medication test that is provided by the pharmacist annually. Staff G stated nurses also have online learning and cultural competency training through the Creek Nation.

On 06/08/17 at 10:50 am, Staff A and Staff B stated that last year the hospital did not provide the annual skills fair to nursing staff but are planning one for 2017.

Based on record review and interview the hospital failed to:

a. Ensure assessment of patients were consistent and timely to meet patient needs and safety.

This failed practice had the potential to affect patient safety as diligent nursing surveillance secondary to consistent patient assessment can lead to timely recognition of early clinical deterioration.

b. Ensure patient's pain is adequately controlled per hospital policy.

This failed practice had the potential for patients to have poorly controlled pain which could cause significant physical and psychological consequences.

Findings:

A. Nursing Assessment

Document titled "Hospital Admission Assessment" show ...purpose for timely patient admission assessments ...time frames are established for completing admission process for each unit. Reassessment by RN should occur at a minimum each shift. No evidence of a time frame for the Long Term Acute Care Hospital (LTACH) nursing staff to initiate or complete admission assessments.

10 of 20 medical records (Patient #1, 3, 4, 5, 6, 7, 8, 16, 17, and 18) showed missed nursing assessments and nursing assessment greater than 4 hours from the start of the shift.

On 06/08/17 at 11:10 am, Staff B stated initial admission nursing assessment should be completed within a couple of hours of patient admission. Staff B stated her expectation for shift nursing assessments would be for the nurse to get report and perform a patient assessment within the first couple of hours of beginning shift and document in the patient's chart.

On 06/07/17 at 10:33 am, Staff G stated nursing assessment is on-going during the shift. Nursing staff should be charting the nursing assessment in the patient's chart before 10:00 am. Staff G stated shifts are 12 hour shifts. Day shift starts at 7:00 am with breakfast at 7:30 am. Nurses start by reviewing patient's medical administration records and pulling medications then take patients to dining room for breakfast and administer medications. Staff G stated nurses usually start charting around 9:30 am.

B. Pain Assessment

Document titled "Pain Assessment; Reassessment and Management" show...patients have the right to assessment and management ...reassessment after every pain control measure ...reassessment will occur within 30 minutes for intravenous medication and within one hour after oral medication.

Document titled "Governing Board - Long Term Acute Care Hospital" dated 08/26/16 show deficient in area of nursing documentation for patient's pain within designated time frames. On 09/20/16 show deficient area in nursing documentation of patient's pain within time frame now in 90 percentile.

7 of 20 medical records (Patient #1, 2, 3, 4, 5, 8, 18) show inconsistency in documentation by nursing staff for assessment and/or reassessment when administering pain medications per hospital policy and procedures.

On 06/07/17 at 10:33 am, Staff G stated nurses assess patient's pain throughout the shift. Staff G stated when pain medication is given patient should be re-assessed within 60 minutes to determine effectiveness. Staff G stated when pain is unrelieved options would include repositioning, heat/ice, distraction, or call the physician.

On 06/07/17 surveyors made a request for medical records including nursing assessments for identified patients. At time of exit, nursing assessments had not been provided for identified patients.

Based on record review and interview the hospital failed to ensure nursing staff revised the plan of care based on evaluation of the patient's response to care relative to the planned patient outcomes per hospital policy.

This failed practice had the potential to result in delayed recognition and/or treatment of active problems that could influence recovery, functional status and quality of life

Findings:

Document titled "Patient Care Plans" show...each shift the RN will document assessment of patient's care needs and response to interventions ...update or revise nursing care plan in response to interventions.

Document titled "Governing Board - Long Term Acute Care Hospital" dated 02/21/17 showed charting of care plans needed to be more specific on patient goals, interventions, functional assessment and documentation on fall risks.

7 of 7 medical records (Patient #1, 2, 3, 4, 5, 6, and 7) showed no evidence of revising or updating the patient's plan of care based on assessment and prioritized patient need.

On 06/07/17 at 10:30 am, Staff G stated care plans are initiated on admission and reviewed or updated every shift. Staff G stated the care plan can be revised if needed based on patient assessment. The "x" on the care plan means that goal is not being met.

Based on record review and interview the hospital failed to:

a. Ensure agency (non-employee) nurses were oriented to hospital policies and procedures before they provided patient care.

b. DON oriented and evaluated the competency of agency nursing staff before they provided patient care.

This failed practice increased risk the to patient safety provided by agency staff who are not orientated to practices and procedures for the hospital and could lead to adverse patient outcomes.

Findings:

Document titled "Staff Qualifications and Competency" showed staff shall have a documented competency assessment completed every three (3) years or more frequently as defined by hospital policy or law and regulation. No evidence of agency (non-employee) nurses are required to be oriented to hospital or nursing policies and procedures prior to providing patient care or DON must provide oversight of agency nursing staff.

1of 1 agency personnel file (Staff W) reviewed showed no evidence of demonstrated education the hospital's policies and procedures.

On 06/08/17 at 10:50 am, Staff B stated review of policy and procedures are not part of the education provided to contract employees. Currently, the hospital only has one contract employee. Staff B stated there is no formal process for orientation and evaluation for competency of agency staff.

Based on record review and interview the hospital failed to ensure healthcare providers completed a history and physical examination (H&P) in the patient's electronic health record within twenty-four (24) hours of admission per hospital policy.

This failed practice had the potential for 6 of 20 patients (Patient #1, 5, 6, 7, 9, and 18) to have delayed recognition of medical conditions, affect medical treatment decisions, discharge planning and care plans.

Findings:

See tag A-0358.

Based on record review and interview the hospital failed to ensure patient discharge summary was completed per CMS requirements.

Findings:

Document titled "Governing Board - Long Term Acute Care Hospital" from 06/21/16 through 3/21/17 showed no evidence of discussion for delinquency of patient medical records not being completed within 30 days of discharge, including the completion of a discharge summary.

Document titled "Medical Executive Committee" from 01/04/17 through 05/10/17 showed no evidence of discussion for delinquency of patient medical records not being completed within 30 days of discharge, including the completion of a discharge summary.

Document titled "Utilization Review Committee - MCN Department of Health Physical Rehabilitation Center" from 02/08/16 through 04/00/17 showed no evidence of discussion or reporting of delinquent medical records greater than 30 days post patient discharge.

No evidence of policy or procedures for completion of a patient's medical record including discharge summary within the required 30 days. This was requested by surveyors and not provided by the time of exit.

5 of 20 medical records (Patient#10, 13, 14, 16, and 18) showed the discharge summary had not been completed within 30 days of the patient's discharge from the hospital.

On 06/08/17 at 10:50 am, Staff A and Staff B stated physicians are required to complete a discharge summary in the patient's electronic health record within 30 days of the patient's discharge from the hospital. Staff A stated the discharge summary is not completed within 30 days of discharge it is reported in Quality Assurance and in Utilization Review. Staff A stated physicians also get deficiency reports. Staff A stated the Chief Medical Officer has a discussion with physician and deficiency is also reported to Governing Body, which is usually in tandem.

Based on record review and interview, the hospital's Governing Body failed to adopt a drug formulary specifically applied to the hospital's scope of practice. (See Tag A-0043)

This failed practice had the potential to increase the risk that medications would be administered that were not within the capability and capacity of the hospital.

Based on record review, observation, and interview, the hospital failed to ensure food was labeled and stored according to dietary requirements.

The failed practice had the potential to make patients ill by providing them expired food.

Findings:

A review of the hospital's, "Food Storage Policy date 10/13/15 " documented all food (including dry foods as well as perishable foods) would be labeled with date when opened, removed from original container and with product named and date. The policy also documented designated personnel would check for expired foods before serving food or beverages to patients. Designee would check for expired food on a weekly basis. Expired foods would be discarded immediately.

On 06/07/2017 at 10:17 am, during a tour of the kitchen, the following expired/out of date or unlabeled items were observed:

Reach-in refrigerator:
~Whipped topping labeled, "use by" 06/04/17
~Yellow Mustard 9oz bottle with an expiration date of 07/22/16
~Molly's Kitchen Beef Base Paste with a deliver date 12/16/16 and an open date of 02/03/16
~Molly's Kitchen Chicken Base Paste dated 08/13/17
~1 large unlabeled bag of Coconut Flakes

Walk-in Cooler
~ 1-one gallon bottle of skim milk one-fourth full dated 06/05/17
~ 1-Container of Magic Blend Coleslaw dressing with a "use by" date of 07/30/15
~ 1-gallon bottle of Free Italian Dressing half full with an open date of 05/21/17 and a receive date of 03/31/17

Dry Storage
~ 5-Yellow Mustard 9oz bottles with an expiration date of 07/22/16
~ 1-4lb bag of Lasco Cheesecake Mix dated 12/23/15 and an open date of 02/14/17

On 06/07/2017 at 10:17 am, Staff J, the Food Service Supervisor stated that all food items that were identified were either unlabeled and/or contained expired dates.

Based on observation and interview, the hospital did not maintain supplies, equipment to ensure an acceptable level of safety and quality in regard to reusable laryngoscope blades, the crash cart and glucometer testing fluid and strips.

This failed practice had the potential to increase the safety risk of all patients admitted to the hospital.

Findings:

Although it had its own CMS provider and state licensure number, the Long Term Acute Care Hospital (LTACH) was associated with an acute hospital with a separate provider and licensure number. The same tribal governance was responsible for both facilities. The surveyors requested various hospital policies and received policies titled, ""Muscogee Nation" and "MCNDH" (Muscogee (Creek) Nation Health Department".

1. Laryngoscope Blades

A review of the policy "MCNDH" (Muscogee (Creek) Nation Health Department-High Level Disinfection of Semicritical Items dated 07/16" documented semi-critical instruments such as laryngeal blades required high level disinfection.

On 06/06/07 at 11:15 am, during a tour of the medical unit, laryngoscope blades were observed in the crash cart bottom drawer. The reusable laryngoscope blades were in a zip lock bag. Staff B was unable to identify if the blades were clean or when they had been cleaned. Staff B stated the hospital's process was to use disposable blades.

2. Crash Cart Defibrillator and Oxygen

A review of the policy "MCNDH" (Muscogee (Creek) Nation Health Department-Emergency Cart Checks dated 04/17" documented crash carts would be checked each shift (12 hours). The policy indicated the checks included testing the defibrillator. The policy did not define the crash cart checks included verifying the volume of the oxygen in the cart's associate E-cylinder.

On 06/06/17 at 11:15 am, during a tour of the medical unit, the surveyor observed the screen on the defibrillator appeared "readiness test failed". Staff B and Staff O, both RNs, stated they did not know how to test the defibrillator and did not know the meaning of the defibrillator fault message. Staff B and Staff O stated the night shift staff checked the cart and logged the results in the computer.

During the same crash cart inspection, the oxygen E-cylinder gauge indicator was in the red zone, indicating that it was not full.

A review of paper log for 06/05/17, showed the crash cart had been checked.

3. Glucometer Testing Fluid and Strips

On 06/06/17 at 11:10 am, during a tour of the medical unit, the surveyor observed the glucometer supplies in the medication room had expired: fluid expired 06/15 and strips expired 04/16.

On 06/06/17 at 11:10 am, Staff O stated the observed glucometer supplies were in use and verified the expiration dates.

Based on observation and interview, the hospital did not develop a system for identifying, reporting, investigating and controlling infections of patients and personnel.

Findings:

A. During a tour of the facility on 06/06/17 11:25 am, laryngoscope blades were observed in the crash cart bottom drawer. Staff were unable to identify if the blades had been cleaned. Staff B stated the hospital's process was to use disposable blades.

B. Linens were observed in an enclosed cabinet in the hallway. A vent in the top of the cabinet was blowing onto the linens. The linens were not covered. On 06/06/17 at 11:25 am, during the tour, Staff F stated she would have the linens covered.

C. Staff were unable to produce a listing of FDA-approved housekeeping products. Staff F stated there was no record in the minutes for the last 5 years of Infection Control Committee or Governing Body approval of the cleaning products used in the facility.

D. In the supply room, there were several pieces of equipment. Surveyors observed some of the equipment was wrapped. Staff B stated after the equipment is cleaned, it was then wrapped and that was how staff knew if it was appropriate for use. A bedside commode was labeled stating "Cleaned" and a date, but was not wrapped. Staff B stated it was unclear if this piece of equipment was clean.

E. A review of the Medical Staff policy titled, "Credentialing Policy dated 09/15" documented the required vaccination history included purified protein derivative (PPD) and influenza.

A review of 4 medical staff credential files revealed that 2 of 4 staff (Staff #L and M) did not have current influenza vaccination . 2 of 4 staff (Staff #M and N) did not have current TB skin testing.











36432

Based on record review and interview the hospital failed to have policies and procedures in place to identify patients who may require discharge planning.

This failed practice had the potential for increased risk of a patient's readmission due to the patient not having adequate resources or follow up at the time of discharge.

Findings:

See Tag A-0799

Based on record review and interview, the hospital failed to have organ procurement policies and procedures.

This failed practice potentially increased likelihood of outcomes that would result in the failure to obtain a viable organ for a patient in need.

Findings:

Although it had its own CMS provider and state licensure number, the Long Term Acute Care Hospital (LTACH) was associated with an acute hospital with a separate provider and licensure number. The same tribal governance was responsible for both facilities. The tribal governance had created "organizational" policies for the LTACH and acute hospital.

The surveyor requested the organ procurement policies for the LTACH and received a policy titled, ""Muscogee Nation". The policy documented it applied to "MCNDH" (Muscogee (Creek) Nation Health Department.

On 06/07/17 at 08:22 am, Staff A stated policies were developed for the entire tribal system. Staff A stated the Governing Body has not approved policies that were exclusively designated for use at the LTACH. Staff A stated the LTACH used the most stringent policies.

Based on record review and interview, the hospital failed have an organ procurement agreement.

This failed practice potentially increased likelihood of outcomes that would result in the failure to obtain a viable organ for a patient in need.

Findings:

Although it had its own CMS provider and state licensure number, the Long Term Acute Care Hospital (LTACH) was associated with an acute hospital with a separate provider and licensure number. The same tribal governance was responsible for both facilities. The tribal governance had created "organizational" agreements for the LTACH and acute hospital.

The surveyor requested the organ procurement agreement for the LTACH and received an agreement between Lifeshare and MCNDH" (Muscogee (Creek) Nation Health Department. The agreement failed to include the definition of "imminent death" and the interventions that the hospital interventions would utilize to maintain potential organ donor patients so that the patient organs remain viable.

On 06/07/17 at 08:15 am, Staff A stated contracts were developed for the entire tribal system. Staff A stated the Governing Body has not approved agreements that were exclusively designated for use at the LTACH.