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Based on review of the hospital's incident reports and interviews with hospital staff, the hospital did not follow its grievance process and did not identify complaints that could not be resolved at bedside and required investigation. Three of three incidents (Incidents #1, 2, and 3) reviewed, that were identified as complaints not resolved at the time of the complaint, were not identified as grievances and processed through the hospital's grievance process.

Findings:

1. The hospital's grievance policy, correctly identifies that complaints that are not resolved at the time are identified as grievances and processed through the hospital's grievance program.

2. Three of three complaints ( #s1, 2, and 3) reviewed identified as from incident reports did not show investigation and evidence a written response, with the required information, had been sent to the complainants.

3. On the afternoon of 04/22/2013, staff confirmed there were no notes of investigation for three of the complaints and verified that no written response had been sent/provided to the complainants.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed,and reassessed/evaluated the nursing needs and care for patients upon admission. In five (Records #1, 3, 8, 9, and 16) of nineteen medical records reviewed, the licensed practical nurses (LPNs) completed the initial nursing notes and assessment. The medical records did not demonstrate the RN assessed/evaluated the patient on admission to determined the nursing needs and care required for the patient. On the morning of 04/22/13, Staff B confirmed that sometimes admission assessments are completed by LPNs, but stated the RN's should verify the accuracy and is responsible for the documentation of this.

Based on a review of open records and staff interviews, the facility failed to ensure all nursing notes were informative and described the patient the patient's response to medications and treatments, when nursing staff administered respiratory treatments. In one of one medical record (Patient #1) reviewed, where respiratory treatments were administered by nursing staff, the nursing notes did not include assessments, interventions and evaluations of the patient's response to the treatments/the notes did not assess the patient's respiratory status before or after the breathing treatments. This finding was confirmed with Staff B at the time of review on the morning of 04/22/13.

Based on medical record review and interviews with hospital staff, the hospital does not ensure that all entries in the medical record contain the date and time when they were signed. This occurred in nineteen of nineteen (Records #1 through 19) medical records reviewed.

Findings:

1. Medical records (#1 through 19) contained a history and physical (H&P) that did not have the date and time authenticated/signed by the physician or licensed practitioner.

2. Thirteen of thirteen (#5 through 17), of discharged patients, medical records reviewed did not contain a discharge summary with the date and time the attending physician and licensed practitioner signed the document.

3. Interview with Staff B, in the morning of April 22, 2013, at the time of review for medical record #1, Staff B verified that the physician and the licensed practitioner did not document the date and time they signed the document.

Based on record review and interviews with pharmacy personnel, the hospital does not ensure that personnel working in the drug room were trained and oriented and evaluated to provide pharmacy services within the scope of their licenses and education. Three (# F, K & L ) of three (# F, K & L ) pharmacy personnel identified as persons assigned to provide services in the drug room did not have evidence of orientation, training and competencies for the drug room by the Consultant Pharmacist.

Findings:

1. Staff #L was identified as a relief pharmacy tech, but did not have any evidence of orientation, training and competency evaluations for the drug room.

2. Staff # K was identified as the full time pharmacy tech, but did not have any evidence of orientation, training and competency evaluations for the drug room.

3. The Consultant Pharmacist stated on 04/22/13 in the afternoon that there were no written documentation of orientation, training or competency evaluations for the two pharmacy techs.

Based on hospital document review, policy and procedure review and staff interview, it was determined the hospital failed to:

a. develop and implement a comprehensive bloodborne pathogen exposure control plan according to current OSHA standards;

b. ensure staff were adequately immunized and screened for communicable diseases;

c. ensure a sanitary environment was maintained;

d. ensure infection control policies and procedures and practices are based on current recognized standards.

Findings:

1. The hospital's bloodborne pathogen policy did not reflect current OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030. Meeting minutes did not reflect the policy had been reviewed to ensure it was current and updated as needed.

2. Review of contract staff personnel files and Infection Control meeting minutes did not contain evidence the hospital's infection control program included review of contract staff's immunization history. Two of two contract staff (Staff F and AA) did not have immunization records. On 04/22/13 at 1350, Staff BB stated she did not have health files on contract staff.

3. The hospital's infection control program does not ensure a sanitary environment.
a. The hospital uses a Quat product for a disinfectant. The hospital has admitted and treated patients with clostridium difficile. Quat products are not effective against clostridium difficile.
b. On the morning of 04/22/13, during the tour of the facility, Staff B stated the hospital did patient clothes. She stated the hospital not have infection control policies concerning the cleaning and disinfectant procedures staff were expected to follow between laundry loads. Staff B told the surveyors that no disinfectant was used between laundry loads.
c. Review of surveillance data and meeting minutes did not demonstrate the infection control program monitored, reviewed and analyzed disinfectant use and application.

4. The hospital's policy and procedure for State reportable diseases documented the State form was attached as part of the policy. No current list of State reportable diseases and organisms was attached.

Based on review of hospital documents, and personnel files, and interviews with hospital staff, the hospital failed to provide respiratory services in accordance with acceptable standards of practice and Oklahoma State Hospital Standards Licensure requirements by trained staff and supervised by a respiratory therapist.


Findings:

1. Hospital administrative staff told the surveyors on the morning of 04/22/13 that the hospital provides the respiratory services of oxygen, hand held nebulizers/aerosol therapy, pulse oximetry, C-PAP (continuous positive airway pressure), and BiPAP (. Documentation provided did not contain evidence policies for these procedures/services were developed by or in consultation with a respiratory therapist.

2. Staff B told the surveyors on the morning of 04/19/13 that nursing staff provided the respiratory services to patients. Medical record review for Patient #1 confirmed that nursing staff provided the hand held nebulizer treatments for this patient.

3. Oklahoma State Licensure Hospital Standards, Subchapter 23-6(a) requires that "respiratory therapy services, including equipment, shall be supervised by a licensed respiratory therapist. Subchapter 23 -6(e)(1) requires each procedure performed by each employee shall be designated in writing by the department head and shall include the amount of supervision required when performing the procedure.

4. Six of six licensed nursing personnel files reviewed (Staff B, C, M, N, O and P) did not demonstrate the respiratory therapist had provided respiratory competency validation on the staff with documentation of the amount of supervision required while performing each task.