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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 environment to avoid transmission of infections and communicable diseases.

Findings:

1. On 10/05/2011 Staff A, the person identified as responsible for infection control, told the surveyors the hospital does not have an infection control log for patients and staff to track infections and possible transmissions of infections and communicable diseases.

2. Staff A told the surveyors that no one monitored the use of the hospital disinfectant on the inpatient 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 was responsible for selection of the disinfectants to ensure they were effective for organisms that may potentially occur in the hospital.



3. The current infection control program, with an effective date of April 14, 2009 and a revised date of March 6, 2009, stipulated, "The infection control committee meets every other month after quality assurance." Review of meeting minutes reflected infection control was not communicated in Quality Assurance or that the Infection control committee utilized its purpose as stated in the infection control manual. The policy states " The roles of the Infection Control Committee are planning, monitoring, evaluating, updating, and educating to prevent and control nosocomial infections. It sets general policy and provides input into specific infection control issues". Staff A told surveyors that the information about infection control was communicated in medical staff and that the information reported was lab results reported from Labcore. Staff A also stated that she tracked Clostridium difficile (C-Diff) and Methicillin-resistant Staphylococcus aureus (MRSA). Surveyors were presented with a book that contained information on which patients had these two infections. There was no evidence that the information was continuously analyzed, evaluated, or communicated in QAPI (quality assurance and performance improvement). There was no evidence that these were found to be hospital acquired infections or present on admission. This was verified with administration on 10/06/2011.

5. The hospital's infection control program did not specify the types and frequencies of surveillance activities. 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. Staff A stated on the afternoon of 10/05/2011 that no surveillance activities were conducted in the facility.

6. The hospital's infection control program did not review its sterilization practice in surgery or provide evidence that surveillance activities were conducted in the operating rooms and surgical areas.

7. Review of staff, allied health, and physician health files did not reveal the infection control program reviewed and developed corrective actions to ensure all had complete immunization histories. Four out of four physicians, one out of one physician assistant, one out of one certified nurse anesthetist, eight of seventeen staff did not have complete immunization histories. Staff A stated she did not report this information to infection control.

8. Meeting minutes did not reflect infection control issues/concerns, surveillances, and practices were monitored, reviewed and analyzed with corrective actions to prevent, identify and manage infections and communicable diseases with measures that result in improvement on an ongoing basis.

This information reviewed with administration at exit on 10/6/2011.

Based on review of hospital policies and procedures and patient rights forms provided to patients, the hospital failed to ensure the patient/patient's representative was informed of all of the patient's rights as required by Medicare regulations.

Findings:

1. Although the policy manual contained a patient rights policy and forms that complied with medical requirements, the forms provided to patients and found in the medical records did not inform the patient of all of their rights, including, but not limited to:
a. The right to be free of restraints, unless medically necessary, or seclusion;
b. The right of the patient to have a family member or representative notified pr admission and be involved in the patient's care;
c. The right of the patient to have care in a safe setting; and
d. The right of the patient to be free of abuse, neglect or harassment.

2. This finding was reviewed with hospital staff on the afternoon of 10/06/2011.

Based on review of hospital policies and procedures and the patient rights handouts to patients, the hospital failed to establish a process for prompt resolution of patient grievances and to inform patients of whom to contact to file a grievance.

Findings:

1. The patient rights information provided to patients/patients' representative did not inform the patient of whom or how to file a grievance.
a. The patient rights handouts only said they could have information about the hospital's grievance process and did not explain who to contact or the process for complaints/grievances expressed at the hospital.
b. The forms did not inform the patient/patient representative that they could lodge a grievance with the State or provide contact information and the address for the State Health Department.

2. The grievance policy documented the hospital had 30 business days after the grievance was first reported to provide the complainant with a written resolution. Medicare guidelines recommend most grievances should be investigated and a written notice sent to the complainant within seven days.

Based on review of medical records, hospital documents and personnel files, and interviews with hospital staff, the hospital failed to ensure that the nursing care of each patient is assigned to nursing personnel who are trained, qualified, and competent to care for patients with specialized needs. This occurred for six out of six nursing personnel charts for review.

1. Staff H, J, K,O, P, R personnel files did not have evidence of yearly competencies or evaluation of skills to provide considerations for nursing personnel's qualifications and ability to care for the individual needs of each patient and area in which they are assigned.

Based on record review and interviews with hospital staff, the hospital does not ensure that all entries into the medical record are legible. Three ( #'s 1, 2 & 3 ) of three outpatient procedure electronic records had entries handwritten by the Certified Registered Nurse Anesthetist ( CRNA ) that were illegible. Hospital staff verified on 10/05/11 and 10/06/11 in the afternoon that the records were not legible.

Findings:

1. Patient #1's intraoperative anesthesia record had illegible medication amount entries.

2. Patients #2 & 3 had illegible pre and post anesthesia evaluations by the CRNA.

Based on a review of medical records and interviews with hospital staff, the hospital failed the ensure the medical records were complete and contained all pertinent information such as complete nursing assessments, reports of treatments, documentation of care provided, and medication administration.
Findings:

1. Patient#23's medical records did not contain documentation of patient condition prior to transfer out. The patient was admitted 7/14/11. The patient's attending documented "I do not know where she was disposed. I cannot see it. I think she was admitted to swing bed then she broke her hip and transferred to Lawton". There was no documentation of a fall or injury in Patient #23's chart. An x-ray of the right hip and knee was documented as taken on 7/17/11 and on 7/18/11 a report of comminuted intratrochanteric fracture in a radiology report. There was no documentation of how the fracture occurred. During Patient 23's stay an intravenous catheter (IV) was started with IV fluids to be infused. Documentation on 7/14/11 and 7/17/11 did not include the amount of IV fluids infused. There was no documentation of patient condition at the time of transfer. The facesheet indicated the patient discharged on 7/18/11. The discharge summary was dictated on 8/5/11 and transcribed 8/7/11.

2. Patient #25's medical record did not have a discharge summary. The patient was admitted 8/28/11 and discharged 9/1/11. The patient received IV fluids during the stay. There was no documentation of the amount of fluids received at the time the IV was discontinued.

3. Patient #21 discharged 8/10/11 did not have a current history and physical or a discharge summary. The record did not have a registered nurse assessment on admission. There was no nutritional screen or nutritional assessment completed on the patient. The patient was admitted with a diagnosis of dehydration. The patient was a diabetic and required a special diet.

4. Patient #22's record included narrative documentation by physical therapy. There was no physician order for physical therapy. The physical therapy documentation did not include an evaluation and treatment plan.

5. Patient #7's record did not include a nutritional screen or nutritional assessment. The patient required a special diet. There was no assessment of respiratory status pre or post respiratory treatment by nursing staff.

Based on review of hospital documents, review of personnel files and interviews with administration, the hospital failed to have documentation showing all the personnel operating the imaging equipment are qualified and trained. There was no documentation the medical staff or the radiologist had developed, reviewed, and approved criteria designating personnel competent to perform all radiology procedures.

Based on review of policies, personnel files, and interviews, the hospital failed to provide adequate training and oversight to dietary personnel.

Findings:

1. On 10/5/ 11 surveyors reviewed three dietary employees files. Two (S,T) of three employees records (S,T, G) did not have specific dietary department training or competencies.

2. Three of three (S,T,G) dietary employees did not have current departmental specific evaluation and/or performance reviews.

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

Based on review of records, interview with staff, and administration the facility failed to designate a qualified infection control person.

Findings:

1. Staff A, the designated infection control person, has no evidence of ongoing education, training, or experience in infection control. Staff A has not developed and implemented policies and procedures to communicate, monitor, and control infections and communicable diseases that occurred in the patient population and facility employees.

Based on record review, interview with staff, and administration the infection control officer failed to provide evidence that a system has been developed that identifies, investigates, and reports, infections and communicable diseases of patients and personal.

Findings

1. On October 5, 2011 Staff A , named infection control person stated that there was no surveillance performed to monitor staff to ensure they are using proper precautions, cleaning methods, and asepsis techniques to maintain a sanitary hospital environment.

2. The named infection control person, staff A stated she did not monitor housekeeping to ensure that proper cleaning products are utilized and that they are used per manufactures specifications. Staff A stated that there was no observation being conducted of patient care units to assure staff compliance in infection control practices that provide a safe environment for patients and healthcare workers.


3. The hospital's infection control program did not specify the types and frequencies of surveillance activities. 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. Staff A stated on the afternoon of 10/05/2011 that no surveillance activities were conducted and there was no method for obtaining and reviewing data on infections/communicable diseases.

4. The hospital's infection control program did not review its sterilization practice in surgery or provide evidence that surveillance activities were conducted in the operating rooms and surgical areas.

5. Infection control did not evaluate patient admissions for risks of possible infections present on admission.

6. Review of staff, allied health, and physician health files did not reveal the infection control program reviewed and developed corrective actions to ensure all had complete immunization histories. Four out of four physicians, one out of one physician assistant, one out of one certified nurse anesthetist, Eight of thirteen staff did not have complete immunization histories. Staff A stated she did not report this to infection control.

7. On October 5, 2011 staff A stated she did not monitor for staff compliance with policies and procedures of infection control program requirements. Infection control measures are considered yearly education and are completed by staff on a computer in Carelearning system. The infection control person does not show evidence that this educational tool is compliant with all policies, procedures, and protocols, for infection control requirements.

8. Staff Q interviewed and asked what they used to clean equipment in between patients. Staff Q replied "Whatever I can find." Staff Q was interviewed further about cleaning and stated "I use alcohol.". Green top sanicloths were observed in the emergency room triage. Staff Q stated they clean with Sanicloth wipes when available. Sanicloth wipes with the green top does not kill tuberculosis (TB) or clostridium difficile (C-diff). When asked staff Q could not state what organisms the sanicloth did and did not kill.

Based on record review and interviews with hospital staff the hospital does not ensure that a infection log was implemented and maintained by infection control.

Findings:

1. On 10/05/2011 Staff A, the person identified as responsible for infection control, had trouble defining what the infection control log was. Surveyors were presented a clipboard that contained lab results. Staff A then presented surveyors with a book that contained information on patient's that were positive for C-Diff (clostridium difficile) and MRSA (methicillin resistant staphylococcus aureus). The two records did not contain onset of infection, , the cultures taken, the results when known, any antibiotics administered (and whether the organism is sensitive or resistive to the medication), and the practitioners responsible for care of the patient. There was no official log presented used to investigate, prevent, report, or control any infections. There was no evidence presented that analysis, monitoring, evaluation, or planning was implemented utilizing information obtained from identified risks, trends, or surveillance.


2. Staff A stated the hospital did not have an infection control log that tracked employee health.

Based on review of meeting minutes and emergency services (ER) policies and procedures, the medical staff failed to review, develop and revise policies for the ER policies. The hospital is a small acute care hospital that does not have an obstetric unit. The hospital has not developed a precipitous delivery policy and procedure for individual presenting to the ER in active labor as required. The last time the ER manual was reviewed was October 2008. This finding was reviewed with hospital administrative staff on the afternoon of 10/06/2011.

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 ( #'s 6 & 8 ) of two patient records reviewed which had respiratory treatments ordered did not have the treatments given as ordered or the patients' responses to the treatment.

Findings:

1. Patient # 6 had orders on 07/20/11 for DuoNeb inhalation treatments four times daily with chest percussions after each treatment. Patient # 6's record documented that the patient only received the treatment three times on 07/20/11; two times on 07/21/11, three times on 07/22/11 and one time on 07/25/11. There was no documentation of pre and post treatment evaluations of the patient. The patient was admitted on 07/19/11 and was discharged on 07/25/11.

2. Patient # 8 had orders for Albuterol/Ipratropium 3 ml (milliliter) (DuoNeb) four times a day. Patient # 8's record documented the patient received one treatment at 00:55 07/02/1, three treatments on 07/03/11 at 06:01, 08:13, and 12:44 and one treatment at 00:30 on 07/04/11. Breath sounds were documented, but no heart rate was documented and the documentation did not indicate whether the evaluation was pre or post treatment. The patient was transferred to another hospital on 07/04/11.

3. Staff stated on 10/05/11 in the morning that the respiratory therapist administers the treatments Monday through Friday during the day, but nursing administered the treatments when the respiratory therapist is not there.

Based on record review and interviews with hospital staff, the hospital does not ensure that data collected as part of the Quality Assurance 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 Quality Assurance meeting minutes did not have evidence that data collected was analyzed and evaluated.

2. Medication errors were not analyzed and evaluated.

3. Narcotic documentation was not reconciled to assure the amounts documented as used by the CRNA were the same as the amounts documented on the Narcotic Administration Sheets.

Based on policy and procedure, interviews, and review of personnel files the facility does not ensure personnel providing radiology services are appropriately trained and competent to provide services to patients.

Findings:

1. On the morning of 10/6/2011 surveyors reviewed radiology personnel files. None of the files had current competency reviewed and approved by the radiologist in charge. Staff U's file indicated radiology training was on the job. The last evaluation of Staff U's skills was dated 2009. In 2009, the technician reviewing Staff U's skills indicated an improvement in technique was necessary. There were no evaluations of technique included in Staff U's file since 2009. There was no continuing education or training in Staff U's personnel file.

2. Staff B's personnel file indicated Staff B was the Director of the Radiology department. Staff B's personnel file did not have current competency or evaluation of skills developed, reviewed and approved by the radiologist in charge or the medical staff.

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