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Based on interview and record review, the facility failed to ensure patients the right to formulate advance directives and have staff uphold their directive for 15 of 15 inpatients
( Patient ID #s : 1,2,3,4,5,6,19,20,21,22,23,24,25,26,27).

Findings include:

Review of 15 inpatient medical records (Patient ID #s:: 1, 2,3,4,5,6,19,20,21,22,23 24,25,26,27) failed to reveal documentation that patients were asked about Advance Directives on admission. Further review of the medical records failed to reveal documentation of written notice of the facility ' s Advance Directive policies for the 15 patient records reviewed ( ID # s 1, 2,3,4,5,6,19,20,21,22,23,24,25,26,27)

Interview on 07-13-12 at 2:00 p.m. with the Corporate Director of Nursing ( Staff ID # 81) she stated the facility had recently become aware of the facility ' s noncompliance with respect to Advance Directive requirements through an accrediting agency survey. She further reported the facility had developed a draft Advance Directive policy and the facility was in the process of staff education.

Based on interview and record review, the facility failed to conduct a performance improvement project for 2011 or 2012 YTD.

Findings include:

Review on 07-11-12 of the facility Quality Committee meeting minutes for 2011 (dated 01-26-11; 05-03-11; 07-07-11; 08-24-11; 10-28-11) failed to reveal documentation of any facility performance improvement projects.

Review on 07-11-12 of the 2012 facility Quality Committee meeting minutes (dated 05-9-12 and 06-13-12) failed to reveal documentation of any facility performance improvement projects.

Interview on 07-12-12 at 10:10 a.m with the Chief Nursing Officer ( CNO/ ID # 51) he stated the facility was working on improving " follow-up vital signs " and had collected data for April, May, and June 2012. The staff had been educated and " vital signs " had been added as a chart review component. The CNO acknowledged the effort was part of a Plan of Correction action based ion a previously cited federal deficiency.

Interim Quality Director (Staff ID # 67, he acknowledged the facility had not established specific PI projects but this issue was to be included in the effort to improve the facility Quality Program.

Based on interview and record review, the facility ' s governing body failed to ensure that an on-going program for quality improvement was implemented and maintained.

Findings include:

Review on 07-11-12 of the facility Quality Committee meeting minutes for 2011 (dated 01-26-11; 05-03-11; 07-07-11; 08-24-11; 10-28-11) failed to reveal documentation of any quality indicator data and on-going analysis of quality indicator data. The 10-28-11 meeting minutes documented that ' Hand Hygiene " statistics were reviewed; however there was no comparison to any previous data or other analysis documented.

Review on 07-11-12 of the 2012 facility Quality Committee meeting minutes (dated 05-9-12 and 06-13-12) failed to reveal documentation any quality indicator data and on-going analysis of quality indicator data.

Interview on 07-12-12 at 2:15 p.m. with Interim Quality Director (Staff ID # 67, he acknowledged the facility had not established quality indicators or conducted on-going analysis for the year 2011 and the beginning of 2012. He went on to say that although much data had been previously collected by various departments; it had not been consistently reported and analyzed for need for improvement by the Quality Committee.

Staff ID # 67 went on to say he was hired in March 2012 as Interim Quality Director and had been working with all departments to identify and coordinate specific quality indicators that included numerators, denominators, and target objectives.

Review of the facility Quality Committee meeting minutes dated 07-12-12 supported the facility had established quality indicators and reported data.

Review of the facility Medical Staff Rules Regulations, approved by the Governing Body (undated) read: " ...Performance improvement activities of the Medial Staff and all appropriate services and disciplines that impact patient care and safety are reviewed with the Quality Committee Structure .... "

Based on record review and interview the Hospital:
1) Failed to ensure Physician orders were dated and times in 5 of 27 records reviewed
2) Failed to ensure Nursing staff indicated if physician orders were either telephone or verbal orders in 11 of 27 records reviewed.

(ID#'s 1, 3, 5, 6, 7, 21, 22, 23, 25, 26, and 27)

Findings include:

Record review of patient records revealed physician orders were not dated and timed by the physician as follows:

Patient ID# 3 Physician admission order dated 7/9/12 (this order was dated by a nurse)
Patient ID# 5 Physician admission order dated 7/8/12 (this order was dated by a nurse)
Patient ID# 6 Physician admission order dated 7/11/12 (this order was dated by a nurse)
Patient ID# 7 Physician admission order dated 7/10/12 (this order was dated by a nurse)
Patient ID# 25 Physician order dated 6/12/12 (this order was dated by a nurse)

The Director of Nursing (ID# 51) acknowledged 7/11/12 at 2 p.m. the Hospital had recently identified that physician orders were not always dated and timed.

Record review of patient medical records revealed nursing staff failed to indicate if physician orders were either telephone or verbal as follows:

Patient ID# 1 The nurse had written physician orders 6/23/12 at 3:55 a.m.
Patient ID# 3 The nurse had written physician orders 7/9/12 at 21:27 p.m.
Patient ID# 5 The nurse had written physician orders 7/8/12 at 21:00 p.m.
Patient ID# 6 The nurse had written physician orders 7/11/12 at 5:52 a.m.
Patient ID# 7 The nurse had written physician orders 7/10/12 at 22:06 p.m.
Patient ID# 21 The nurse had written physician orders 4/6/12 at 00:30 a.m.
Patient ID# 22 The nurse had written physician orders 2/19/12 at 16:35 p.m.
Patient ID# 23 The nurse had written physician orders 5/24/12 at 19:00 p.m.
Patient ID# 25 The nurse had written physician orders 6/12/12 at 23:30 p.m.
Patient ID# 26 The nurse had written physician orders 2/6/12 at 22:50 p.m.
Patient ID# 27 The nurse had written physician orders 3/27/12 at 00:00 a.m.

Record review of Medical Staff Rules and Regulations (no date) stated "Medical Records: b. Written orders for all medications and other treatments the physician must have signed and noted the date and time of each order..."

Record review of a policy titled "Pharmacy - Medication Management: General: Verbal and written orders" (no date) stated "f. Indicate either the telephone or the verbal order in the written record..."

Based on interview and record review the hospital failed to ensure the Food Service Supervisor (ID# 60) had experience or training for the operation of the dietary services.

Findings include:

The Food Service Supervisor (ID# 60) acknowledged 7/12/12 at 1:30 p.m. he has not had any training related to Dietary Services.

Record review of the personnel file for the Food Service Supervisor (ID# 60) revealed a job description titled "Front Office Manager / Dietary Assistant." The job description did not list any required education / experience to supervise the Dietary department. Further review revealed the file lacked Annual Competency training related to the Dietary Assistant position.

Based on interview and record review the hospital failed to ensure the therapeutic diet manual was approved by a dietitian.

Findings include:

Record review of the "Dietary Manual" revealed it was approved June 2012 by the Medical Director
(ID# 52). The Dietary Manual was not signed by a Dietitian.

The Food Service Supervisor (ID#60) acknowledged 7/12/12 at 2 p.m. that the new Dietary Manual was not signed / approved by the Dietician.

Record review of a contract with the Dietician (ID# 78) dated 3/5/12 stated "General: The facility and the Registered Dietician shall mutually review and approve the dietary service policies and future considerations on a monthly basis..."

Based on interview and record review, the facility failed to measure, analyze, and track quality indicators related to processes of care for the year 2011 and the first 2 quarters of 2012.

Findings include:

Review on 07-11-12 of the facility Quality Committee meeting minutes for 2011 (dated 01-26-11; 05-03-11; 07-07-11; 08-24-11; 10-28-11) failed to reveal documentation of any quality indicator data and on-going analysis of quality indicator data. The 10-28-11 meeting minutes documented that ' Hand Hygiene " statistics were reviewed; however there was no comparison to any previous data or other analysis documented.

Review on 07-11-12 of the 2012 facility Quality Committee meeting minutes (dated 05-9-12 and 06-13-12) failed to reveal documentation any quality indicator data and on-going analysis of quality indicator data.

Interview on 07-12-12 at 2:15 p.m. with Interim Quality Director (Staff ID # 67, he acknowledged the facility had not established quality indicators or conducted on-going analysis for the year 2011 and the beginning of 2012. He went on to say that although much data had been previously collected by various departments; it had not been consistently reported and analyzed for need for improvement by the Quality Committee.

Staff ID # 67 went on to say he was hired in March 2012 as Interim Quality Director and had been working with all departments to identify and coordinate specific quality indicators that included numerators, denominators, and target objectives. .

Review of the facility Quality Committee meeting minutes dated 07-12-12 supported the facility had established quality indicators and reported data.