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Based on record review and interviews with hospital staff, the hospital's governing body failed to ensure that processes necessary for safe and appropriate hospital operations are carried out.

Findings:

1. The governing body failed to ensure members of the medical staff have current appointments and re-appointments to the medical staff with specified privileges delineated before providing patient care. See Tag A 0046;

2. The hospital failed to promote each patient's rights. See Tag A 0115,
a. inform patients and/or their representatives of all patient's rights. See Tag A-0117;

b. ensure patients were made aware of the grievance process. See Tag A-0118;

c. ensure the grievance process was approved by the governing body. See Tag A-0119;

d. provide patients and/or their representatives information about how to submit a grievance. See Tag A-0121;

e. identify and adhere to a reasonable time frame for the hospital's written response to a patient grievance. See Tag A-0122;

f. respond to all grievances in writing. See Tag A-0123; and

g. failed to develop and implement a comprehensive policy and effective processes to prohibit all forms of abuse. See Tag A-0145.

3. The governing body failed to ensure the QAPI program defines, implements and maintains a program to monitor the quality of care provided by employees and services provided by contract and agreement and adequate resources are allocated to provide quality of care for patients. See Tags A 0309 and A 0315.

4. The governing body failed to ensure the hospital provides organized nursing services with delineated duties and adequate numbers and types of nursing staff to provide care and supervision for all patients. See Tags A 0386 and A 0392.

5. The hospital did not ensure a registered nurse (RN)assesses patient's care needs, health status and conditioning, as well as response to interventions and to ensure staff are adequately trained, oriented and have demonstrated skills competency for their assigned care areas. See Tags A 0395 A 0397.

6. The hospital did not ensure all drugs and blood were administered to patients according to hospital policy and standards of practice and nursing staff were trained and competent in the administration of blood and intravenous medications. See Tags A 0405 and A 0409.

7. The hospital failed to ensure:

a. the paper medical record included complete and accurate patient care information. See Tag A-0449;

b. informed consents were obtained. See Tag A-0466;

c. a discharge summary was documented in the clinical record. See Tag A-0468.

d. to provide a medical record containing all the required elements. See Tag A- 0467 and A-0468.

8. The hospital failed to ensure that the hospital is constructed and arranged to provide safe facilities for the special services provided.

a. The hospital failed to ensure regular inspection and preventive maintenance of all hospital equipment; and to develop and implement emergency preparedness plans. See Tag A - 0701

b. The hospital failed to ensure the endoscopy suite and the procedure room were equipped with emergency lighting. See Tag A- 0702

c. The hospital failed to ensure the facility is designed and maintained to reflect the scope and complexity of the services it offers in accordance with accepted standards of practice. See Tag A 0722

d. The hospital failed to ensure that procedures performed in the hospital are in areas/rooms specifically designed for the purpose intended. Invasive medical procedures were performed in settings that are not intended or licensed for these types of procedures. See Tag A 0723

e. The hospital did not maintain the facility's supplies and equipment to ensure an acceptable level of safety and quality. See Tag A 0724

f. The hospital failed to provide services in procedure rooms with adequate ventilation, temperature, and humidity control. See Tag A 0726

9. The hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff. See Tags A - 0748, A- 0749, A- 0756.

10. The hospital failed to:

a. define the scope of surgical services provided and failed to delineate lines of authority and delegate responsibilities for surgical services. See Tag A 0941;

b. identify an experienced supervisor of surgical services. See Tag A 0942;

c. validate through staffing schedules that an RN supervised staff in the operating rooms. See Tag A 0943;

d. establish qualifications for personnel who may perform circulating duties. See Tag A 0944;

e. grant surgical privileges to those practitioners who were performing surgery at the hospital and failed to maintain a current roster listing of practitioners and their specific privileges. See Tag A 0945;

f. develop and implement current policies and procedures relevant to the surgical services provided. See Tag A 0951;

g. ensure a complete history and physical examination was performed prior to surgery. See Tag A 0952;

h. obtain a properly executed informed consent. See Tag A 0955;

i. provide emergency equipment for the operating room. See Tag A 0956;

j. provide adequate post-operative care. See Tag A 0957;

k. maintain a complete operating room register. See Tag A 0958; and

l. failed to ensure the operative report contained all the required elements. See Tag A 0959.

11. The hospital failed to define and organize it's anesthesia services. See Tag A 1000.

12. The hospital failed to provide respiratory services in accordance with acceptable standards of practice and Oklahoma State Hospital Standards Licensure requirements. See Tags A- 1153, A- 1154, A- 1160 and A - 1161.

Based on policy and procedure review, hospital document review and staff interview, it was determined the hospital failed to promote each patient's rights as evidenced by failure to:

a. inform patients and/or their representatives of all patient's rights. See Tag A-0117;

b. ensure patients were made aware of the grievance process. See Tag A-0118;

c. ensure the grievance process was approved by the governing body. See Tag A-0119;

d. provide patients and/or their representatives information about how to submit a grievance. See Tag A-0121;

e. identify and adhere to a reasonable time frame for the hospital's written response to a patient grievance. See Tag A-0122;

f. respond to all grievances in writing. See Tag A-0123; and

g. failed to develop and implement a comprehensive policy and effective processes to prohibit all forms of abuse. See Tag A-0145.

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

a. an organized nursing service with delineation of responsibilities. See Tag A 0386;

b. there were adequate numbers and types of nursing staff to provide care and supervision for all patients as needed. See Tag A 0392;

c. a registered nurse assessed patient care needs, health status, conditioning and response to interventions. See Tag A 0395;

d. nursing staff are adequately trained, oriented and have demonstrated skills competencies for their assigned care areas. See Tag A 0397;

e. all drugs were administered to patients according to hospital policy and standards of practice. See Tag A 0405; and

f. failed to ensure nursing staff were trained on blood and intravenous medication administration policies approved by the medical staff and were trained and evaluated for skills competencies related to these procedures. See Tag A 0409.

In addition, nursing services was not integrated into the hospital's QAPI program.

A review of the 2012 QAPI meeting minutes had no documentation nursing services were included in the evaluation of services provided by the hospital. There were no 2013 QAPI meeting minutes.

Based on clinical record review and staff interview, it was determined the hospital failed to:

a. ensure the paper medical record included complete and accurate patient care information. See Tag A-0449;

b. obtain informed consents. See Tag A-0466;

c. ensure a discharge summary was documented in the clinical record. See Tag A-0468.

d. to provide a medical record containing all the required elements. See Tag A- 0467 and A-0468.

Based on record review, observation and interviews with hospital staff, the hospital failed to ensure that the hospital is constructed and arranged to provide safe facilities for the special services provided.

Findings:

1. The hospital failed to:

a. ensure regular inspection and preventive maintenance of all hospital equipment; and

b. failed to develop and implement emergency preparedness plans. See Tag A - 0701

2. The hospital failed to ensure the endoscopy suite and the procedure room were equipped with emergency lighting. See Tag A- 0702

3. The hospital failed to ensure the facility is designed and maintained to reflect the scope and complexity of the services it offers in accordance with accepted standards of practice. See Tag A 0722

4. The hospital failed to ensure that procedures performed in the hospital are in areas/rooms specifically designed for the purpose intended. Invasive medical procedures were performed in settings that are not intended or licensed for these types of procedures. See Tag A 0723

5. The hospital did not maintain the facility's supplies and equipment to ensure an acceptable level of safety and quality. See Tag A 0724

6. The hospital failed to provide services in procedure rooms with adequate ventilation, temperature, and humidity control. See Tag A 0726

Based on observation, interviews with staff and review of hospital documentation and infection control (IC) policies and procedures, the hospital failed to maintain an active ongoing program to prevent, control, and investigate infections and communicable diseases to minimize infections and communicable diseases in patients and staff.

Findings:

1. The staff identified as the infection control preventionist has not been designated by the hospital as the infection control preventionist and does not have experience or training in establishing and maintaining an effective ongoing infection control program. (Refer to Tag A - 748)

2. The disinfectant used throughout the hospital has not been reviewed and approved by the hospital's Infection Control committee and is not effective against Clostridium difficile (C-diff).

3. The hospital does not have an ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained. (Refer to Tag A-749).

4. The hospital does not ensure the infections control program has a current tracking mechanism for patients and staff to track infections and possible transmissions of infections and communicable diseases and maintain a safe and sanitary environment. (Refer to Tag A-749).

5. Leadership does not ensure infection control concerns and issues are reviewed, analyzed and corrective actions are taken through the quality assessment and performance improvement process. (Refer to Tag A-756).

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to provide discharge planning services.

On 03/21/13, the hospital administration stated they had no formal discharge planning services. No policies and procedures related to discharge planning were provided.

There were no staff identified as discharge planners or who were designated with discharge planning responsibilities.

None of the clinical records reviewed had documentation of discharge planning activities.

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

a. define the scope of surgical services provided and failed to delineate lines of authority and delegate responsibilities for surgical services. See Tag A 0941;

b. identify an experienced supervisor of surgical services. See Tag A 0942;

c. validate through staffing schedules that an RN supervised staff in the operating rooms. See Tag A 0943;

d. establish qualifications for personnel who may perform circulating duties. See Tag A 0944;

e. grant surgical privileges to those practitioners who were performing surgery at the hospital and failed to maintain a current roster listing of practitioners and their specific privileges. See Tag A 0945;

f. develop and implement current policies and procedures relevant to the surgical services provided. See Tag A 0951;

g. ensure a complete history and physical examination was performed prior to surgery. See Tag A 0952;

h. obtain a properly executed informed consent. See Tag A 0955;

i. provide emergency equipment for the operating room. See Tag A 0956;

j. provide adequate post-operative care. See Tag A 0957;

k. maintain a complete operating room register. See Tag A 0958; and

l. failed to ensure the operative report contained all the required elements. See Tag A 0959.

Additional findings were:

The hospital was not originally constructed with a surgery suite. Modifications were made to a sterile processing room and it was converted into an endoscopy suite. The endoscopy suite had an open window directly into the decontamination room where scopes and other instruments were cleaned and processed. The endoscopy suite did not maintain negative airflow pressure and shared air circulation with the decontamination area.

Proper humidity and temperature was not maintained in the endoscopy suite. There was no documentation temperature and humidity was monitored daily in this area.

The endoscopy suite had no surgical scrub sink outside the room.

A patient room had been converted into an invasive pain management procedure room where fluoroscopy was used. There was not enough square footage in this room to safely perform procedures. The room did not maintain positive airflow pressure. Humidity and temperature could not be maintained within acceptable parameters and was not monitored.

There was no surgical scrub sink outside this room.

The surgery suite and the invasive procedure room were open and accessible to anyone. Neither of these rooms were located in a restricted area. No emergency lighting was available in these areas.

Sterile supplies and clean equipment were stored on open shelves in the endoscopy suite and in the procedure room.

Staff and visitors were allowed in the endoscopy suite while not wearing appropriate surgical attire. This was also true of the procedure room. It could not be determined whether these areas had been terminally cleaned. There were no policies for terminal cleaning.

There was no record of sterilization, although instruments were being sterilized on a regular basis. Sterilization indicators were not placed in sterile packages. Indicator tape was not used.

Sterilization was performed in the same room as decontamination. An autoclave was housed directly across (less than three feet) from a hopper. Housekeeping supplies, non-sterile supplies, and miscellaneous items were stored with clean and sterile supplies.

Instrument sterilization was also performed in the emergency department sterile/clean supply room. Contaminated instruments were placed in a staff handwashing sink and cleaned with Hibiclens. They were placed on a towel to dry on a counter next to an infant scale. (Staff stated they brought infants into this area to be weighed.) The autoclave sat on the other side of the infant scale on the counter. No records were kept of sterilization in this area. Sterile indicators and tape was not used in this area.

Adequate records were not kept of endoscope disinfection. The hospital staff did not record what specific scope was used on each patient. Pass/fail was not recorded for each scope that was disinfected.

A piece of dirty carpet was on the floor in front of an instrument washing sink.

Biomedical equipment in the surgical areas had not been monitored, tested and inspected.

Surgical services was not integrated into the hospital's QAPI program.

Staff assigned to work in the endoscopy suite and the procedure room were not oriented, trained and evaluated for skills competency. None of the staff had documented prior job experience in surgery or in sterile processing.

Based on clinical record review, policy and procedure review, and staff interview, it was determined the hospital failed to define and organize it's anesthesia services. Findings:

The hospital did not provide an organizational chart that included anesthesia services. No qualified practitioner had been identified as a director of anesthesia services. None of the medical or allied health staff had been credentialed to provide anesthesia or deep/moderate sedation.

On 03/21/13, the interim CEO stated the hospital did not provide anesthesia services. However, an endoscopy policy and procedure manual documented an approved procedure list that included sclerotherapy of internal hemorrhoids, liver biopsy and endoscopic retrograde cholangiopancreatography.

On this date, the surveyors observed multiple vials of Propofol (an agent used to induce anesthesia and deep sedation) stored in the endoscopy suite.

Rescue drugs such as atropine, ephedrine, epinephrine, naloxone, and diphenhydramine were also located in the endoscopy suite.

The hospital had no policies and procedures to govern anesthesia services.

Based on review of hospital documents, personnel files, contracts, and medical records, 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.

Findings:

1. On the afternoon of 03/20/13 Staff A told the surveyors the hospital provides respiratory services. Staff A stated that all respiratory services were provided by nursing staff.

2. The surveyors requested to review the hospital's respiratory policies. None were provided. When the surveyors asked about the policies, Staff A stated that all respiratory policies and procedures were contained in the Nursing manual. According to policies, the hospital provides respiratory services of oxygen, hand held nebulizers/aerosol therapy, intermittent positive pressure ventilations (IPPB), incentive spirometry, pulse oximetry, chest physiotherapy, and automatic resuscitator/minute volume ventilator. This was finding confirmed with Staff A on the afternoon of 03/21/13. The respiratory policies were not developed by or in consultation with a respiratory therapist and did not show they had been approved by the medical staff. (Refer to Tag #1160).

3. The hospital failed to appoint/designate a physician, with knowledge, experience and capabilities to supervise and administer the service properly, to be the director of respiratory care services for the hospital. (Refer to Tag #1153.)

5. The hospital failed to ensure respiratory services were supervised by a respiratory therapist and provided by trained and competent staff. (Refer to Tag #1154 and Tag #1161).

6. Review of meeting minutes did not demonstrate respiratory services provided at the hospital were integrated and reviewed in the quality assessment and performance improvement and infection control programs.

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

a. inform patients of their rights when they were admitted to swing bed services. See Tag A 1508;

b. inform swing bed patients of items and services that may be charged to the patient. See Tag A 1510;

c. notify swing bed patients of their right to choose a personal physician. See Tag A 1511;

d. notify swing bed patients of rights related to work performed for the hospital. See Tag A 1515;

e. notify swing bed patients of rights related to sending and receiving mail. See Tag A 1516;

f. notify swing bed patients of rights related to personal property. See Tag A 1518;

g. notify swing bed patients of rights related to married couples. See Tag A 1519;

h. notify swing bed patients of transfer and discharge requirements. See Tag A 1523;

i. provide an activities program for swing bed patients. See Tag A 1537; and

j. failed to provide medically-related social services. See Tag A 1538.

On 03/21/13, the CEO confirmed these findings.

Based on record review and interviews with hospital staff, the governing body failed to ensure members of the medical staff have current appointments and re-appointments to the medical staff with specified privileges delineated before providing patient care.

Six (V,W,X,Y,BB,CC) of seven physicians on the current physician list for 2013 did not have current appointments to the medical staff. Four (Z, AA, DD, EE) of five allied health personnel on the current medical staff list for 2013 did not have current appointments to the medical staff.

Findings:

1. Staff B stated on 03/21/13 in the afternoon that only one of the physicians and one allied health person had been re-credentialed and appointed by the governing body.

2. Review of patient procedure records for the past six months documented that physician BB had performed endoscopic procedures. Physician BB did not have a current appointment to the medical staff with privileges delineated.

Based on record review and interviews with hospital staff, the governing body failed to ensure that services provided under contract are evaluated as part of the hospital's quality assessment and performance improvement (QAPI) program and provided in a safe and effective manner.

Findings:

1. Consultant Pharmacy services are provided by contract. There was no evaluation through the QAPI of pharmacy services provided.

2. Medical procedures provided on an outpatient basis are not evaluated as part of the QAPI program to assure quality of care and patient safety. See Tag A 0309.

Based on clinical record review, policy and procedure review, hospital document review and staff interview, it was determined the hospital failed to inform patients and/or their representatives of all patient's rights. Findings:

Twenty nine open and closed patient records were reviewed. There was no documentation patients were given patient's rights information. A hospital document, titled, "Patient Agreements on Admission," signed by patients upon admission, had no reference to the provision of patient's rights information.

There was no evidence in the medical record that indicated patients received patient's rights information.

The hospital had no policy and procedure for notification of patient's rights.

On 03/20/13, hospital administrative staff were asked to provide evidence that patient's rights information was given to patients. They stated patient's rights information was given to patients at the time of admission, but there was no documentation of this in the clinical record.

Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to ensure patients were made aware of the grievance process. Findings:

Twenty-nine patient records were reviewed. There was no documentation patients had been given information concerning the hospital's grievance process.

A hospital policy, titled, "Patient and Family Grievance," documented, "... At the time of admission to the hospital, the patient or their representative will be provided information related to reporting complaints and the formal grievance process... During the admission process or shortly thereafter, the admission staff will provide the patient or their representative with written information how he/she reports or files a grievance..."

The hospital administrative staff were asked to provide a copy of grievance information given to patients. A Patient Grievance Form was provided. This form was a blank document where patients and/or others could write a grievance. The only instructions for submitting the grievance included how to mail the form to the hospital grievance coordinator.

The form did not include information that patients could make a complaint or grievance verbally or to other entities, including the Oklahoma State Department of Health.

Administrative staff stated patient care staff could notify administration if someone had a complaint or grievance, but this information was not written for patients as a part of the grievance process.

Based on hospital document review, hospital policy and procedure review and staff interview, it was determined the hospital failed to ensure the grievance process was approved by the governing body. Findings:

On 03/20/13, Governing Body meeting minutes were reviewed for 2012. There were no meeting minutes available for 2013. There was no documentation the Governing Body had reviewed the grievance process and had approved it. There was no documentation the Governing Body reviewed annual reports on complaints and grievances.

The CEO was asked if the grievance process was approved by the Governing Body. He stated he was not certain.

A hospital policy and procedure, titled, "Patient and Family Grievance Policy," had no documentation the grievance process had been approved by the Governing Body. The policy referenced the Grievance Coordinator as the person accountable for oversight of the grievance process. This person was also identified as the Quality Improvement Coordinator.

The policy documented the QI Coordinator "will submit an annual summary of patient/family complaints to the Quality Improvement Committee, which will be reported to the Board of Directors..."

The QAPI meeting minutes for 2012. There was no documentation complaints and grievances were reviewed by this committee. There were no QAPI meeting minutes for 2013.

Based on record review, policy and procedure review and patient interview, it was determined the hospital failed to provide patients and/or their representatives with information on how to submit a grievance to the hospital. Findings:

Twenty-nine patient records were reviewed. There was no documentation patients had been given information concerning the grievance process.

A hospital policy, titled, "Patient and Family Grievance," documented, "... At the time of admission to the hospital, the patient or their representative will be provided information related to reporting complaints and the formal grievance process... During the admission process or shortly thereafter, the admission staff will provide the patient or their representative with written information how he/she reports or files a grievance..."

The hospital administrative staff were asked to provide a copy of grievance information given to patients. A Patient Grievance Form was provided. This form was a blank document where patients and/or others could write a grievance. The only instructions for submitting the grievance included how to mail the form to the hospital grievance coordinator.

The form did not include information that patients could make a complaint or grievance verbally to staff or that they could make a complaint to other regulatory entities, including the Oklahoma State Department of Health.

On 03/20/13, a representative for patient #28 stated she was not aware of any information provided by the hospital regarding grievances or complaints.

The hospital was asked to provide a list of complaints and grievances from October 2012 to the present. The hospital had documentation of three grievances for 2012 and one for 2013.

Based on policy and procedure review, document review and staff interview, it was determined the hospital failed to identify and adhere to a reasonable time frame for the hospital's written response to a patient grievance. Findings:

The hospital grievance policy did not specify when a written response would be provided to a complainant regarding a grievance.

An untitled form provided by hospital administration, documented, "... You will receive a response within 30 days of our receipt of your formal complaint..." The form also specified patient grievances were to be made in writing. The information did not allow for parties to submit a grievance verbally.

The hospital provided a list of three grievances in 2012 and one in 2013. Two grievances had not been responded to in writing. One grievance was responded to more than 30 days after the grievance was received.

Two grievances responded to in writing documented, "... We are currently in the process of completing our investigation regarding your concerns... Once the investigation is complete, we will follow up with you in writing regarding our findings and recommendations. Please allow a 30 day time frame to complete the investigation..."

The hospital did not provide any further documentation of investigation and follow-up to these grievances. There was no further evidence of a written response to the complainants of the results of any investigation and actions taken. The grievance coordinator stated no other documentation could be located.

Based on record review and staff interview, it was determined the hospital failed to respond to all grievances in writing. Findings:

The hospital provided a list of three grievances in 2012 and one in 2013. Two grievances had not been responded to in writing.

Two grievances, dated November and December 2012 were responded to in writing and documented, "... We are currently in the process of completing our investigation regarding your concerns... Once the investigation is complete, we will follow up with you in writing regarding our findings and recommendations. Please allow a 30 day time frame to complete the investigation..."

On 03/21/13, the hospital grievance coordinator stated no other documentation of investigation and follow-up for these grievances could be located. The hospital had not provided any other written response to the complainants.

Based on policy and procedure review and staff interview, it was determined the hospital failed to develop and implement a comprehensive policy and adequate processes to prohibit all forms of abuse. Findings:

The hospital administrative staff were asked to provide the hospital's abuse policy. No policy was provided. The staff were asked if they had reports or had identified any patients who may have been abused. They stated they did not.

Three patient care staff were asked about their knowledge of hospital policies on patient abuse. They stated they were not aware of the hospital's policy but they could identify types of abuse.

Staff training records were reviewed. The transcripts documented staff received nine minutes of patient abuse training annually. There was no documentation of the content of this training.

Based on record review and interviews with hospital staff, the governing body failed to ensure that adverse events such as incidences and medication errors are identified, tracked, analyzed and preventative actions taken. Adverse events were not tracked and analyzed as part of an ongoing Quality Assurance/Performance Improvement (QA/PI) program.

Findings:

1. There was no documentation of the analysis and trending of medication errors and incident reports by hospital staff as part of an ongoing QA/PI program.

2. Staff (C, F and FF) stated on 03/21/13 that there was no trending and analysis of medication errors.

Based on record review, observations, and interview with hospital staff, the governing body failed to ensure the QAPI program defined, implemented and maintained a program to monitor the quality of care provided by employees and the quality of services provided by contract and agreement.

Findings:

1. Medical procedures provided on an outpatient basis were not evaluated as part of the QAPI program to assure quality of care and patient safety.

2. Invasive medical procedures were performed in settings that were not intended, designed or licensed for these types of procedures.

3. Colonoscopy procedures and EGD (esophagogastroduodenoscopy) procedures were performed in a room designated as a sterile processing room. The original approved hospital building plans did not include a space designed for these types of procedures.

4. Pain procedures, such as RF (Radio Frequency Targeted) Percutaneous Vertebral Augmentation, were performed in a regular, single occupancy patient room. Pain procedures were not performed in an area that met the requirements of a regular operating room area, including surgical scrub facilities and positive air flow pressure for invasive procedures.

5. The RF Percutaneous Vertebral Augmentation procedure required the mixing of a sterile bone cement mixture which is deposited within the patient's vertebral space. Because this invasive procedure was performed in a regular patient room (and not an appropriately designed surgical suite), the bone cement was not mixed in an environment that would ensure the sterility of the mixture.

Based on record review, observation, and interviews with hospital staff, the governing body failed to ensure that adequate resources were allocated to provide quality of care for patients. The hospital did not provide adequate nursing staff and facilities for services provided by the hospital such as inpatient, emergency room, outpatient, swing bed and pharmacy/drug room services.

Findings:

1. Private pay respite care patients were not considered to need as much nursing care as other inpatients. Hospital leadership made nursing staffing decisions based on an assumption that these patients were always self-care. Review of patient records and staff interviews indicated these patients required at least the same nursing care as all other acute care inpatients and/or swing bed patients. It was observed that some of these private pay patients required total assistance with all activities of daily living, and at times, complex nursing care.

2. The December 18, 2012 Medical Executive Committee meeting minutes noted the lack of nursing staff and the effect it was having on providing for patients' basic care needs. There was no documentation of actions taken in response to this identified problem.

3. Nursing staff assigned to non-direct patient care areas were taken away from those assignments to work in bedside patient care on a regular basis. Staff C, who was assigned to work as the Drug Room Supervisor, was called to work in many other areas on a regular basis. Staff C stated it was difficult to meet all the responsibilities as a Drug Room Supervisor when she was pulled to work in direct patient care areas. She stated she was also pulled from the pharmacy/drug room to work in surgical procedures at times. She stated she was also assigned to work in the sterile processing area and was responsible for all surgical instruments and equipment. On March 21, 2013, the surveyors observed staff C was pulled to work as a second nurse in the emergency room because of the number of patients presenting to the ER.

4. Outpatient services provided by the hospital were not performed in settings that were intended or licensed for these types of procedures.

a. Colonoscopy procedures and EGD (esophagogastroduodenoscopy) procedures were performed in a room designated as a sterile processing room. The original approved hospital building plans did not include a procedure room/operating room for these types of procedures.

b. Pain procedures, that included RF (Radio Frequency Targeted) Percutaneous Vertebral Augmentation, were performed in a regular single occupancy patient room. This room was not an area that met the requirements of a regular operating room area with surgical scrub areas and positive air flow pressure for invasive procedures.

c. The RF Percutaneous Vertebral Augmentation procedure required the mixing of a sterile bone cement mixture which is deposited within the patient's vertebral space. Because this invasive procedure was performed in a regular patient room (and not an appropriately designed surgical suite), the bone cement was not mixed in an environment that would ensure the sterility of the mixture.

Based on record review and staff interview, it was determined the hospital failed to ensure the hospital provided an organized nursing service with clear delineation of authority. Findings:

The hospital had no organizational chart for the nursing department. The hospital organizational chart documented the Chief Nursing Officer (CNO) was responsible for inpatient and outpatient nursing services (including psychiatric services), case management, utilization review, quality assurance, swing bed services, social services, home health services and pharmacy services.

Other than the CNO position, there was no clear delineation of lines of nursing authority for all patient care areas, such unit managers, shift supervisors, charge nurses or lead nurses.

There no evidence the hospital had identified front line managers/supervisors/lead nurses for the emergency or surgery departments. There was no manager or lead nurse for the in-patient care area. Nursing staff assigned to these areas stated they came in to work a shift assignment only, and had no leadership responsibilities. There were no nursing staff directly accountable to ensure the day to day functioning of any patient care areas.

There was no documentation of lines of authority for non-licensed nursing personnel or nursing support personnel.

The hospital had not developed job descriptions for all nursing department positions within the hospital.

One registered nurse was classified as "anesthesia." There was no documentation to describe the job title and this nurse's responsibilities. Another nurse was identified as "informatics." There was no job description for this position.

On 03/21/13, the CNO stated she was an interim director and was still assessing the nursing department organizational structure.

Based on observation, staff interview and document review, it was determined the hospital failed to ensure there were adequate numbers and types of nursing staff to provide care and supervision for all patients as needed. Findings:

The December 18, 2012 Medical Executive Committee meeting minutes noted the lack of nursing staff and the effect it was having on providing for patients' basic care needs. There was no documentation of actions taken in response to this identified problem.

Review of documents provided by hospital leadership did not include a nursing staff to patient ratio acuity measuring tool. This was confirmed with the nursing staff working on the afternoon of March 21, 2013. The staff stated staffing decisions were based on numbers of patients only, and not the complexity of care.

The staffing policy provided to the surveyors documented private pay (respite) patients were not considered "acute" care patients. Hospital leadership made nursing staffing decisions based on an assumption that these patients were always self-care. Clinical records and staff interviews indicated these patients required at least the same nursing care as acute care and swing bed patients. It was observed that some of these "respite" patients required total assistance with all activities of daily living, and at times, complex nursing care.

Nursing staff assigned to non-direct patient care areas were taken away from those assignments to work in bedside patient care on a regular basis.

On March 21, 2013, the surveyors observed staff C, (who was assigned to work as the Drug Room Supervisor), was pulled to work as a second nurse in the emergency room. The emergency room was routinely staffed with one registered nurse, when patient census and acuity in the emergency room regularly required the services of two nurses.

Hospital leadership had not analyzed the emergency department work load and the numbers of patients served, in order to make appropriate nursing staff assignments for that area.

Staffing schedules and patient census documents indicated there were not enough direct patient care staff assigned to care for all patients served in all areas of the hospital. Minimal staffing guidelines that were put in place by hospital management, did not allow for increases in census and fluctuation within the emergency department.

There were no consistent nursing personnel assigned to the surgery department. At times, home health nurses floated to this area.

Staff C stated it was difficult to meet all the responsibilities as a Drug Room Supervisor when she was pulled to work in direct patient care areas. She stated she was also pulled from the pharmacy to work in surgical procedures at times. She stated she had administered conscious sedation for procedures. She stated she was also assigned to work in the sterile processing area and was responsible for all surgical instruments and equipment.

She stated she had no formal training or experience in sterile processing.

Several other nursing staff were required to function in several direct and non-direct patient care areas, often at the same time, being pulled from one job assignment to another throughout a shift.

Employment records for nursing staff who were pulled to various patient care areas had no documentation of experience, training, or competencies in all areas assigned.

Nursing staff who administered conscious sedation had documentation of training utilizing an American Nurses Association position statement for conscious sedation dated 1993. There was no training using current standards of practice for conscious sedation and no training on the Oklahoma Board of Nursing requirements for the administration of conscious sedation by registered nurses.

Based on review of hospital documents and interviews with the staff, the hospital did not ensure a registered nurse (RN) assessed patient's care needs, health status and conditioning, as well as response to interventions.

Findings:

1. On the afternoon of March 21, 2013, Staff C and G, both stated that licensed practical nurses (LPNs) usually provided the care and assessments for the "private pay patients". The staff stated they were referring to the respite patients. These patients were not routinely assessed by an RN. Review of patient medical records for patients #1, 2, and #3 confirmed this finding. Two "private pay patients" (#2 and #3) both had documented skin breakdown that was not regularly assessed by an RN.

2. According to the hospital's staffing matrix, one RN per shift is assigned to work on the medical-surgical unit and one RN is scheduled to work in the emergency room (ER) per shift.

3. On the afternoon of March 23, 2013, Staff C, F, and G told the surveyors that often the RN assigned to work on the medical-surgical unit had to help in the ER, leaving the medical-surgical unit without a RN.

Based on observation, clinical record review, staff interview, it was determined the hospital failed to ensure specialized care was provided by nursing personnel with appropriate education, experience, licensure and skills competence. Findings:

1. Open and closed clinical records were reviewed for patients classified as "private-pay (respite)" patients. There was no documentation a registered nurse assessed, planned, evaluated and supervised care on a daily basis for these patients.

Licensed practical nurses were assigned to the assessment and care of these patients without the daily oversight by a registered nurse.

2. Clinical records documented various registered nurses were assigned to the care for patients during the perioperative period. None of the nurses had documentation of previous experience, training, orientation or skills competency evaluation for pre-operative care, intraoperative care and post-operative care.

3. Clinical records documented various registered nurses were assigned to provide conscious sedation to patients during surgical procedures. None of the nurses had documentation of adequate training and skills competencies for the provision of conscious sedation.

4. Clinical records indicated various registered nurses were assigned to administer critical care intravenous medications, such as propofol, levophed and diltiazem drips. None of the nurses had documentation of training and skills competencies for the administration of critical care intravenous medications.

5. Staff assigned to decontaminate, clean, process and sterilize surgical equipment had no documentation of prior experience, training and skills competencies to perform these procedures.

6. On 03/21/13, the CNO confirmed these findings.

Based on observation, clinical record review, medical staff meeting minutes and staff interview, the hospital did not ensure all drugs were administered to patients according to hospital policy and standards of practice.

Findings:

1. Medical staff meeting minutes in 2012 documented a need to develop an approved protocol for rapid sequence intubation.

On 03/20/13, closed clinical record reviews for patients #18 and #19 documented both patients received medications for rapid sequence intubation in November and December 2012. These medications were documented as administered by a registered nurse (staff FF).

At the time of survey, a rapid sequence intubation protocol had not been approved by the medical staff and no hospital policy and procedure had been developed.

The medical staff had not designated what staff were qualified to administer drugs for rapid sequence intubation.

There was no documentation staff FF was qualified and trained in the administration of rapid sequence intubation medications.

2. Clinical records for patient #29 documented the patient was administered conscious sedation medications by a registered nurse (staff P). There was no documentation staff P was trained and had demonstrated skills competency in conscious sedation.

This patient's clinical record had documentation another registered nurse (staff GG) provided conscious sedation during another procedure. This nurse's training file had no evidence of education and skills competency in conscious sedation.

3. The CNO identified two other registered nurses who she stated were trained in conscious sedation. The training files documented the nurses were trained using an American Nurses Association Position Statement, dated 1993, on Conscious Sedation. A five question test was attached.

The hospital was not using current recognized standards of practice guidelines for training on conscious sedation and did not include the Oklahoma State Board of Nursing requirements for conscious sedation. There was no evidence skills competencies were evaluated.

Based on review of nursing policies and procedures, hospital documents, nursing personnel files and interviews with staff, the hospital failed to ensure:

a. nursing staff were trained on blood and intravenous medication administration policies and procedures approved by the medical staff; and

b. nursing staff had demonstrated skills competencies for these procedures.

Findings:

1. The nursing manual table of contents did not list a policy for blood administration. Staff could not produce a blood administration policy. Staff brought the surveyors a blood administration policy and told the surveyors that it came from the emergency room (ER) policy manual.

2. Review of the blood administration policy from the ER policy manual and medical staff meeting minutes did not contain evidence the medical staff had reviewed, revised and approved the policy.

3. The hospital also nursing policies for administration of IV conscious sedation and critical drip medication. Review of the policies and meeting minutes did not contain evidence the medical staff had reviewed, revised and approved the policies.

4. Review of nursing personnel files did not demonstrate nursing staff had been trained and demonstrated annual competency to administer blood and IV medications, including:

a. fluid and electrolyte balance;
b. venipuncture techniques - with demonstrated and supervised practice;
c. requirements for monitoring, including frequency and documentation of monitoring;
d. review of hospital policies, State law, and nationally recognized standards of practice;
e. for blood transfusions, blood components, verification of right blood product for right patient and identification and treatment of transfusion reactions.

5. Review of patient #18 and #19 clinical records indicated that both patients were administered propofol drips by staff registered nurses.

6. Review of patient #2 clinical records indicated that he was administered a Diltiazem drip on 02/15/13 by staff registered nurses.

7. Review of patient #19 clinical records indicated intravenous Levophed was administered by a staff registered nurse.

8. Review of Patients #1 and #20 clinical records indicated conscious sedation medications were administered to both patients by staff registered nurses.

9. Training files for registered nurses who administered the medications listed above, had no documentation of training and skills competencies for the administration of critical care intravenous medications.

Based on clinical record review and staff interview, the hospital failed to ensure the medical record included complete and accurate patient care information.

Findings:

1. Patient #21 was admitted for an out-patient magnetic resonance imaging (MRI) procedure. The hospital was asked to provide a printed copy of the entire medical record. The following documentation was missing from the medical record: patient identifiers (demographic sheet), physician order or radiology requisition, "Patient Agreements on Admission", MRI patient screening, and "Request for Surgical, Medical, or Diagnostic Procedures and Acknowledgement of Receipt of Information (MRI Consent)".

2. Six outpatient MRI medical records were reviewed, the following documentation was missing from four medical records ( # 25, 26, 22, and 27): demographic sheet, MRI consent, and MRI patient screening. Patient #24 outpatient chart was missing the demographic sheet and MRI consent.

3. Patient #6 was a 91 year old female admitted through to the hospital after being evaluated in the emergency department (ED). The hospital was asked to provide a printed copy of the complete medical record. The following documentation was missing from the medical record:
admission orders for the medical-surgical unit,"Patient Agreements on Admission, An Important Message from Medicare...", history and physical, discharge summary, initial nursing and nutrition assessment, 24- hour summary, progress notes, medication record, signature report and problem activity.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a complete history and physical examination was performed within 24 hours of admission. Findings:

Patient #10 was admitted on 10/18/12. No history and physical examination was found in the clinical record.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the medical record included an informed consent for diagnostic radiology. Findings:

Six outpatient MRI medical records were reviewed. Six (#21, 22, 24, 25, 26, and #27) of the six medical records were missing the "Request for Surgical, Medical, or Diagnostic Procedures and Acknowledgement of Receipt of Information (MRI Consent)."

Based on review of medical records and interviews with staff, the facility failed to provide a medical record containing all the required elements.

The following elements were missing from Patient #6's chart: doctors orders, nursing notes, patient progress notes, history and physical, medication summary, initial assessment, lab and radiology reports.

The following elements were missing from Patient #15 chart: history and physical, doctors orders, nursing and patient progress notes.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure a discharge summary was documented in the closed records reviewed. Two ( # 1 and 20 ) of two closed patient records reviewed did not contain a discharge summary within thirty days. Patient #1 was admitted on 10/12/12 and #20 was admitted on 01/14/13. There was no documentation of a discharge summary found in either of the clinical records.

Based on record review and interviews with hospital staff, the consultant pharmacist failed to ensure that all drug storage areas in the hospital are secure and that no outdated unusable drugs are available for patient use.

Findings:

1. During a tour of the hospital a red unlocked cart was observed in the hospital's unlocked "procedure" room containing multiple drugs. Also there were five vials of drugs sitting on top of a monitor stand in the unlocked room. This area was not locked or staffed at the time and no procedures were being performed.

2. Drugs were observed in the hospital's procedure room that were out of date and available for patient use. Twenty vials of Naloxone with an expiration date of January 2013; 50 vials of epinephrine with an expiration date of March 1, 2013 and two vials of xylocaine 1% with an expiration date of September 2012 were observed in a red unlocked cart in the procedure room.

3. Review of the Consultant Pharmacist reports did not document the pharmacist checks for outdated drugs or to see if hospital staff are checking for outdated drugs in various areas of the hospital.

Based on record review and interviews with hospital staff, the hospital failed to ensure that an adequate number of personnel are alloted to provide quality pharmaceutical services. The nurse identified as the Drug Room Supervisor has other duties assigned which include central processing, helping in the emergency room, working the floor and works as the circulator in the procedure room. The Drug Room Supervisor also monitors scheduled drugs and medication errors. During the resurvey outdated drugs were found in the procedure room and schedule drug records were incorrect.

Based on record review and interviews with hospital staff, the hospital failed to ensure that scheduled drug records are accurate. The amount of Versed, a schedule IV (four) drug documented in the patient's chart did not match the amount documented in the Narcotic Administration record required by the Drug Enforcement Administration ( DEA ) and the
(OBNDD) Oklahoma Bureau of Narcotics and Dangerous Drugs.

Findings:

1. The amount of Versed, a schedule IV drug, was documented in Patient #1 chart as 4 mg (milligrams) administered. The narcotic administration record documented by the the person administering the drug during the procedure and the legal record required by the Drug Enforcement Administration ( DEA ) and the (OBNDD) Oklahoma Bureau of Narcotics and Dangerous Drugs documented that Patient #1 only received 1mg and 1 mg was wasted.

2. Staff C stated on 03/21/13 that they didn't reconcile the narcotic administration records with the amounts documented in the Med Dispense ( automatic drug dispensing machine) to assure that the documentation of the amount of drug administered was accurate.

Based on record review, observation and interviews with hospital staff, the hospital failed to ensure that drugs are stored in a secure area. A red unlocked cart in the hospital's unlocked "procedure" room contained multiple drugs. Also there were five vials of drugs sitting on top of a monitor stand in the unlocked room. This area was not locked or staffed at the time and no procedures were being performed.

Based on record review, observation and interviews with hospital staff, the hospital failed to ensure outdated and unusable drugs are not available for patient use.

Findings:

1. Drugs were observed in the hospital's "procedure" room that were out of date and available for patient use. Twenty vials of Naloxone with an expiration date of January 2013; 50 vials of epinephrine with an expiration date of March 1, 2013 and two vials of xylocaine 1% with an expiration date of September 2012 were observed in a red unlocked cart in the procedure room.

2. Staff C stated that she had forgotten that drugs were there in the cart. Staff C who is the drug room supervisor also works in many other areas of the hospital. The hospital had reduced staff and each staff person has had to assume duties in several different areas.

3. Review of the Consultant Pharmacist reports did not document the pharmacist checks for outdated drugs or to see if hospital staff are checking for outdated drugs in various areas of the hospital. Staff C on 03/21/13 verified that the Consultant Pharmacist did not check for outdated drugs.

4. The Consultant Pharmacist weekly reports did not document any review of hospital storage areas

Based on review of medical records, contracts, and interviews with staff, the facility failed to have a radiologist supervising the radiology services.

Findings:

1. Staff N stated that if she had any concerns with radiology, Staff W was her resource person. There was no documentation indicating the facility had appointed Staff W as Director of Radiology.

2. Article IV of the Legal Compliance Program Policy states Medical Staff appoints a medical director for the Department of Radiology. There was no documentation of such appointment in Medical Staff minutes or Governing Body minutes. Staff N stated on 3/21/13 in the afternoon that they did not have a Director of Radiology.

3. The contract with Shared Medical Services documented that a mock Code Blue would be conducted annually. The last mock Code Blue was completed in 2011.

Based on record review and interviews with hospital staff, the hospital failed to ensure the laboratory has written protocols and they are implemented for the tracking of all tissue specimens. Staff K stated on 03/20/13 the laboratory does not track all specimens. They do not track any specimens that are private insurance, only Medicare and Medicade patient specimens.

Based on policy and procedure review and hospital meeting minutes review, it was determined the hospital failed to ensure the dietary manual was approved by the dietician and the medical staff.

Findings:

1. On March 20, 2013, the hospital's diet manual was provided to the surveyors. The manual did not contain approval signatures.

2. Medical Staff meeting minutes provided for review did not reflect the medical staff had approved the Therapeutic diet manual.

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

a. ensure regular inspection and preventive maintenance of all hospital equipment; and

b. failed to develop and implement emergency preparedness plans.

Findings:

1. On 03/20/13, the surveyors toured the endoscopy suite and the procedure room. None of the electrical medical equipment in these areas was tagged with a date of regular safety inspection. The plant operations manager was asked if the equipment should be inspected and tagged on a regular basis. He stated it should.

He was asked if there was documentation of preventive maintenance of medical equipment according to manufacturer's guidelines. No documentation was provided.

On the afternoon of 03/20/13, the surveyors observed the electrical medical equipment in the endoscopy suite and the procedure room had been tagged with a green sticker indicating a safety inspection had been done on this date 03/20/13.

2. The hospital's Emergency Operation Plan was reviewed. It was last approved in March 2011. The plan did not address contingency plans for the loss of phone/internet/computer systems.

The plan did not address qualifications and training requirements for all types of hospital personnel to carry out emergency procedures in the event of an internal or external disaster.

A community disaster drill was held on 11/07/12. There was no documentation the hospital had critiqued the drill and had evaluated each department and staff performance. There was no evidence a problem analysis had been done.

Review of staff training files documented staff received 16 minutes of computer-based disaster training annually.

Based on observation and staff interview, it was determined the hospital failed to ensure the endoscopy suite and the invasive procedure room were equipped with emergency lighting as required in a surgical area. Findings:

On 03/20/13, the surveyors toured the endoscopy suite and the procedure room. These areas were not equipped with emergency lighting.

The plant operations manager confirmed this finding.

Based on record review and interviews with hospital staff, the hospital failed to ensure that procedures performed in the hospital are in areas/rooms specifically designed for the purpose intended. Invasive medical procedures were performed in settings that are not intended or licensed for these types of procedures.

Findings:

1. Colonoscopy procedures and EGD (esophagogastroduodenoscopy) procedures were performed in a room originally designed and equipped as a sterile processing room. The original approved hospital building construction plans did not include an invasive procedure room or a surgical suite. This endoscopy suite did not meet the requirements for a surgical suite with scrub sinks located outside the suite. The suite was not equipped with negative airflow pressure as required for endoscopy procedures.

2. Pain procedures, which include RF Percutaneous Vertebral Augmentation, were performed in a regular, single patient room. This room did not meet the requirements of a regular operating room area with scrub areas and positive air flow pressure for invasive procedures.

3. The RF Percutaneous Vertebral Augmentation procedure requires the mixing of a bone cement mixture which is deposited within the patient's vertebral space. This mixture was not mixed in an environment which would assure the sterility of the mixture.

4. Surgical instrument processing and sterilization was being performed in a scope decontamination room and also in the emergency department medical supply room. These areas were not designed and built for surgical instrument processing.

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

a. monitor and maintain medical equipment;

b. monitor airborne isolation rooms;

c. store medical equipment in a manner that will not block access to an emergency care area;

d. store clean and sterile supplies in a manner to prevent contamination

Findings:

1. A hospital policy documented the blanket warmer temperature setting should not be higher than 130 degrees Fahrenheit. On the afternoon of March 21, 2013, one surveyor noted the temperature setting on the blanket warmer was 150 degrees Fahrenheit. The surveyor also observed the temperature/thermometer reading inside the blanket warmer registered 210 degrees Fahrenheit. Staff C stated the hospital did not monitor and document temperature readings for the blanket warmer.

2. Hospital policy documented blanket warmers were to be inspected annually by clinical engineering to verify proper temperature setting and performance. On March 20, 2013, the surveyor and Staff C noted the blanket warmer was last inspected in 2011.

3. There was no pressure log for the negative air flow isolation room. On March 20, 2013, the hospital surveyor asked Staff C if there was a pressure log for the negative air-flow isolation room. Staff C stated negative airflow pressure was not monitored.

4. On 03/20/13 during a tour of the hospital, the surveyors observed an alcove outside the decontamination room that was near the emergency department. The plant operations manager stated this decontamination room would be used to care for a patient or staff who required emergency decontamination after exposure to a hazardous substance, such as chemical exposure, biological weapon exposure or radiation exposure. The entrance to this emergency decontamination room was blocked with various pieces of large medical equipment. It would take several minutes to move this equipment in the event the room was needed in an emergency. The hospital staff stated they did not have adequate equipment storage space.

5. The decontamination room was being used to process scopes, such as colonoscopes. The same area was used to decontaminate, clean and then sterilize surgical instruments.

The decontamination room had been divided into two parts by a strip of red tape on the floor that designated one side of the room was "dirty" and one side was "clean." There was no physical separation between the two areas.

The "clean" side of the room housed an open hopper and a steam sterilizer. Clean and sterile supplies stored on open shelves on the "clean" side of the room were exposed to the excessive heat and humidity from the sterilizer. These supplies were also exposed to aerosolized biohazardous materials or chemicals flushed in the hopper.

In addition, the clean and sterile supplies (injectable saline, safety needles, and oral suction tips) were stored with chemicals and trash bags.

The decontamination side of the room had a window cut into the wall that opened to the endoscopy suite. Air circulation was shared between these two areas.

6. The endoscopy suite (formerly the sterile processing room) was used to perform endoscopic procedures. Sterile and non-sterile supplies for endoscopic procedures were stored on open metal shelves in this room. The supplies were not covered or contained in a way to protect them from splashed or aerosolized contaminants.

Surgical gowns and other staff personal protective equipment was stored uncovered in the endoscopy suite and were exposed to contaminants that were likely to be present during endoscopy procedures.

7. The patient room designated as the invasive procedure room, stored sterile and clean supplies on uncovered open shelves inside the room. The supplies were not stored in a manner to protect them from splashed or aerosolized contaminants.


8. An emergency department supply room was used to store clean and sterile medical supplies. These supplies were exposed to the heat and humidity from a small steam sterilizer that had been placed on a counter top in this area. A handwashing sink in this room was being used to wash contaminated surgical instruments.

Based on observation and staff interview, it was determined the hospital failed to ensure:

a. proper temperature and humidity control and proper ventilation for the areas used to perform surgical procedures; and

b. failed to ensure the airborne isolation room was monitored for effective negative airflow pressure.

Findings:

1. The room used as an endoscopy suite did not maintain adequate temperature and humidity control. The room was open to the endoscope decontamination room via a "window" cut into the common wall between the two rooms. This "window" did not have glass and there was no way to prevent air circulation between the two areas.

Through this window, airborne contaminants from the decontamination room could circulate to the "clean" endoscopy suite. In addition, heat and steam from an autoclave in the decontamination room could pass through the window to the endoscopy suite.

The endoscopy suite was not designed to maintain negative airflow pressure as required.

2. The patient room used to perform invasive pain procedures was not monitored for proper temperature and humidity control and did not provide adequate positive airflow pressure required for a surgical area.

3. None of the hospital staff interviewed were aware of temperature, humidity and ventilation requirements in areas where surgery is performed.

4. The airborne isolation room was not monitored for adequate negative airflow pressure. On 03/20/13, the surveyors observed the negative airflow pressure valve was turned off. When nursing staff were interviewed, they did not know how to turn the negative airflow on. They stated no one monitored this isolation room to ensure negative airflow could be maintained.

Based on review of personnel files and meeting minutes, and interviews with hospital staff, the hospital failed to provide and designate a qualified, trained individual to develop, implement and maintain an ongoing infection control program based on current principals and methods of infection control.

Findings:

1. On 03/20/13, Staff A told the surveyors that Staff K was the case manager and infection control preventionist (ICP).

2. Review of personnel files for Staff K, including Staff K's job resume did not contain evidence Staff K had training or experience in developing and maintaining an effective and ongoing infection control program.
a. Staff K's personnel file did not contain a job description for ICP
b. Staff K was unavailable for interview.
c. The surveyors asked if there was any data to support Staff K's training. None was provided.

3. Meeting minutes of quality and performance improvement, medical staff and governing body did not show Staff K had been designated as the ICP for the hospital.

Based on observation, review of infection control data, surveillance activities, personal files, meeting minutes, and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner (ICP) developed and maintained an ongoing comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

The hospital does not have an ongoing infection control (IC) program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained.

Findings:

Program:
1. The last meeting minutes containing IC was April 14, 2012 and the last data found by hospital staff was marked October 2012. Oklahoma State Licensure Hospital Standards Chapter 667, Subchapter 13-2 requires that infection control meetings must be done on at least a quarterly basis.

2. Oklahoma State Licensure Hospital Standards Chapter 667, Subchapter 13-3 requires the "infection control committee (or its equivalent) shall evaluate, revise as necessary, and approve the type and scope of surveillance activities utilized (the IC Plan) at least annually." According to documentation, the last review of IC policy and procedure manual was 01/15/07. The IC Plan, contained in the IC manual did not contain a date of approval. The hospital's Infection Control Plan, Policy #I.C.1.a, was developed for a hospital with specialty units that the hospital does not provide, such as obstetrics and newborn nursery. Meeting minutes containing infection control did not document review, revision or approval of the IC Plan.

3. The policy and attachment of state reportable diseases and infections was not current.

4. The hospital had not developed a policy and procedure/protocol to coordinate with federal, state and local emergency preparedness and health authorities to address communicable disease threats, bioterrorism and outbreaks.

5. The hospital IC program had not performed a hospital risk assessment to determine what organisms are most likely to occur in the hospital and what organisms are most likely to be present in the community.

6. The hospital IC program had not performed a tuberculosis (TB) risk assessment.

7. The hospital IC program had not developed a system to ensure appropriate infection control procedures were developed and followed in each department of the hospital.

8. The hospital had no policies and procedures for sterilization processes or for cleaning/terminally cleaning the surgical areas.

Disinfectant:
1. The hospital services included endoscopy procedures. The most prevalent organism for colonoscopies is Clostridium difficile (C-diff) Staff A, C, F and FF told the surveyor that the hospital also has admitted patient who either had C-diff on admission or developed C-diff.

2. The hospital uses PDI Sani Cloth Plus Wipes (red top container). This produce is not effective against C-diff.

3. The IC program has not reviewed disinfectant products to ensure they are appropriate.

4. The IC program did not contain a review of staff immunization history. Meeting minutes did not demonstrate immunization histories were reviewed and discussed. Review of ten of twelve staff files and two of two credentialed physician and allied health files did not contain complete immunization histories as as required by Oklahoma State Hospital Licensure Standards and recommended by Centers for Disease Control (CDC) and its Advisory Committee on Immunization Practices (ACIP).

Monitoring/Active Surveillance:
1. The program did not include monitoring/surveillance to ensure hospital infection control policies and procedures were followed. Other than the infection report (last data provided was October 2012), no other surveillance/monitoring was provided to the surveyors.

2. The program did not include active monitoring/surveillance to ensure disinfectants used were appropriate for their intended purpose and applied according to manufacturer's guidelines in all departments/areas of the hospital.

3. The ICP had not monitored to ensure isolation precautions were appropriate and followed.

4. Hand hygiene monitoring/surveillance was not being performed to ensure the hospital's hand hygiene policy and CDC recommendation were being followed.

5. The hospital sterilizes instruments. The surveyors asked for the sterilizer/autoclave log on arrival on 0320/2013. The log did not include all the required information for each lead. The hospital did not follow its policy #I.C.4.a.o. that policy required the facility to keep a log of each autoclave operation with load number, contents of each load (specify what was sterilized), exposure/cycle time and temperature, and the name of the operator. The policy further stipulated that a "chemical indicator will be used outside and inside each package to be sterilized." Package sterilized surgical instruments were observed on 03/20/13 and 03/21/13. None of the sterile packages had sterile indicators inside the packages. The packages were not sealed with indicator tape. The ICP has not monitored to ensure current sterilization practice guidelines were followed.

Meeting minutes concerning IC for surgery/sterile processing only gave the dates the autoclave was used and that "All spore tests run on autoclave were negative."

Endoscope processing was not documented appropriately and there was no documentation of a specific scope number identified for each patient who had an endoscopic procedure.

6. Monitoring of staff illnesses to ensure infections and communicable disease were not transmitted/spread between staff and patients was not included.

7. Monitoring of aseptic techniques/practices were not conducted to ensure infection control standards and hospital policies were followed.

Observation:

1. The endoscopy suite was open to the decontamination room and allowed airborne contaminates to circulate between the rooms. The endoscopy suite did not maintain negative airflow pressure. The surgical scrub sink was manually operated and was located inside the endoscopy suite. The endoscopy suite had an open drain in the floor.

2. Clean and sterile supplies were stored open and uncovered in the endoscopy suite, in the invasive procedure room and in the scope decontamination room.

3. Clean and sterile medical supplies were exposed to excessive heat and humidity because they were stored in rooms with steam sterilizers. Clean and sterile supplies were stored with chemicals, "dirty" equipment and housekeeping supplies.

4. Dirty and clean instruments were processed in the same room. This room was used to process dirty scopes and was used to sterilize instruments.

5. Dirty instruments were processed in a handwashing sink in the emergency department clean/sterile medical supply room.

6. A steam sterilizer was installed three feet across from a hopper.

7. Sterility indicator strips and sterile indicator tape was not used in processing sterile instruments.

8. An emergency obstetrical pack was soiled and had evidence of liquid contamination.

9. Unpacked shipping boxes were stored in the decontamination room.

10. A regular patient room was used for invasive pain procedures. The room did not maintain proper humidity, temperature and positive airflow pressure to aid in infection control for a surgical area. Bone cement for injection was prepared in this room.

11. Hibiclens was used to wash contaminated surgical instruments.

12. Sick/injured infants were brought into the emergency room clean/sterile supply room to be weighed on a countertop infant scale where dirty and clean surgical instruments were also processed.

13. The negative air-flow ventilation system for the airborne isolation room was turned off. Nursing staff stated they did not know how to restart the ventilation system if it was needed. No monitoring of the system had been done to ensure it was in operational order in the event it would be needed..



`

Based on document review, observation and staff interview, it was determined the hospital failed to define the scope of surgical services provided and failed to delineate lines of authority and delegate responsibilities for surgical services. Findings:

On 03/20/13, hospital administrative staff stated surgical procedures were performed, to include endoscopy procedures and pain management procedures.

The hospital's organizational chart had no reference to surgical services. There was no documentation the medical staff defined and approved the scope of surgical services provided in the hospital.

There was no documentation of lines of authority for surgical services and no delegation of authority.

Floor plans of the hospital showed there was no surgery suite or surgical department, and no recovery area.

Observations were made of two areas within the hospital where the hospital administrative staff indicated surgical procedures were performed. One area being used for endoscopy procedures, was in a space that was originally designed and constructed to be a sterile processing area. The area did not meet the requirements for an operating room.

Another area used for invasive pain management procedures was originally designed to be a patient room. This area did not meet the requirements for an operating room.

On 03/21/13, the interim CEO stated the hospital did not have surgical services as a part of it's original design and mission.

Based on document review and staff interview, it was determined the hospital had not identified an experienced RN, MD or DO supervisor of surgical services. Findings:

On 03/21/13, the interim CEO and interim CNO confirmed this finding.

Personnel files were reviewed for those staff working in surgery. None of the registered nurses working in the surgical cases had documented orientation, experience or training for surgery.

Based on record review and staff interview, the hospital could not validate through staffing schedules that an RN supervised staff in the operating rooms.

Findings:

The hospital did not provide staffing schedules to the surveyors. It could not be determined what staff were assigned to surgery on any given day.

On 03/20/13, the CNO confirmed this finding.

Because circulating nurses were also required to recover surgery patients, it could not determined that an RN was available to supervise activities within the OR in preparation for subsequent surgical cases.

Based on document review and staff interview, it was determined the hospital failed to establish qualifications for personnel who may perform circulating duties. Findings:

On 03/20/13, the CNO stated the hospital had no job description for circulating nurses and did not designate qualifications for other staff who may perform circulating duties under the direction and supervision of an RN.

Based on document review and staff interview, it was determined the hospital failed to grant surgical privileges to those practitioners who were performing surgery at the hospital and failed to maintain a current roster listing of practitioners and their specific privileges.

On 03/21/13, the CEO and the CNO confirmed this finding.

Based on policy and procedure review and staff interview, it was determined the hospital failed to develop and implement current policies and procedures relevant to the surgical services provided.

Findings:

On 03/20/13, the CNO stated there were no current surgery department policies and procedures. She stated there were some policies related to endoscopy procedures but the policies had not been reviewed and approved.

There were no policies related to invasive procedures performed in the procedure room.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to ensure a complete history and physical examination was performed prior to surgery.
Findings:

Patient #1 had a surgical procedure performed on 12/31/12. A form found in the clinical record, titled, "Pre-Operative Questionnaire and Short Form H&P for Moderate Sedation and Podiatry," documented only a chief complaint and the name of the planned procedure. The "exam" portion of the form documented, "...Airway: II... Heart: RR... Lungs: CTA... Very tender to palpation @T10..." No other information related to the history and physical was documented by the physician.

Patient #29 had a surgical procedure performed on 11/26/12. There was no history and physical examination in the clinical record.

The patient had another procedure performed on 12/10/12. There was no complete history and physical examination found in the clinical record.

Again, the patient had another procedure performed on 01/14/13.
There was no complete history and physical examination found in the clinical record.

On 02/11/13, there was no complete history and physical examination performed before a surgical procedure on this date.

On 03/20/13, staff A stated there was no policy related to pre-operative history and physical examination. She stated she was not sure if the medical records department audited charts for completed history and physicals.

Based on clinical record review and staff interview, it was determined the hospital failed to obtain a properly executed informed consent. Findings:

Patient #29 had a surgical procedure performed on 11/26/12. The informed consent form found in the clinical record did not notify the patient of any risks specific to the procedure performed. The clinical records documented the same findings for informed consent documents executed on 12/10/12, 01/28/13, 02/11/13, and 03/04/13.

Patient #1 had a surgical procedure performed on 12/31/12. The informed consent form found in the clinical record did not notify the patient of any risks specific to the procedure performed.

The patient's signature did not match the name printed on the informed consent.

On 03/21/13, staff A was asked to provide an informed consent policy. None was provided.

Based on observation, policy and procedure review and staff interview, it was determined the hospital failed to provide emergency equipment for the operating room. Findings:

On 03/20/13, the endoscopy suite was observed. There was no emergency equipment such as a defibrillator and tracheotomy set available.

Staff C stated if there was an emergency during a procedure, the staff would leave the endoscopy suite and obtain the emergency cart used for the medical-surgical inpatients. She stated there was no emergency cart dedicated to the surgical department.

The medical-surgical emergency cart was not located near the surgical area. The cart did not have a tracheotomy set.

There were no surgery policies related to emergency equipment for that area.

Based on observation, policy and procedure review and staff interview, it was determined the hospital failed to provide adequate post-operative care. Findings:

On 03/20/13, staff A was asked where the recovery area was located. She stated the hospital did not have an identified recovery area. She stated patients were recovered in the endoscopy room or inpatient rooms.

There were no hospital policies related to post-operative care.

There was no hospital requirement that stated recovering patients would be provided with direct observation by a qualified RN in the patient's room until the patient regained consciousness.

Six of six clinical record for patients who had surgical procedures performed did not have documentation of post-operative assessment or care.

None of the records had specific physician's post-operative (recovery) orders. None of the records had discharge criteria documented.

Personnel files for registered nurses who provided post-operative care. None of the files had documentation of orientation, training and competencies for post-operative care.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to maintain a complete operating room register. Findings:

On 03/20/13, staff A was asked to provide the hospital's operating room register. The register did not always identify all personnel present and their professional titles.

The register did not always document the type of anesthesia used. There was no documentation of pre and post operative diagnosis.

None of the pain management procedures were documented in the operating room register.

Staff A stated there was no policy for an operating room register.

Based on clinical record review and staff interview, it was determined the hospital failed to ensure the operative report contained all the required elements. Findings:

Patient #29 had pain management procedures performed at the hospital. The clinical records were reviewed and had the following deficiencies:

11/26/12: No date/time on the operative report. The typed report had words or numbers marked out and handwritten changes were made. Another operative report was found in the clinical record for the same date. This report was worded exactly the same, but had changed the word "cervical" to "lumbar."

Both reports documented conscious sedation was provided to the patient, but there was no documentation of this for either procedure performed on 11/26/12.

A third procedure (left shoulder joint injection) was documented on another operative report. There was no date/time on this operative report. Parts of the operative report were marked through and additional words and numbers were handwritten in.

12/10/12: No date/time on the operative report. The report stated conscious sedation was performed, but there was no documentation of this.

01/14/13: The operative report was written exactly as the others with words and numbers marked through and changes made by hand. The report referenced conscious sedation but there was no documentation of this in the clinical record.

Two operative reports, dated 01/28/13, had parts marked through and handwritten changes made. The reports referenced conscious sedation but there was no documentation of this in the clinical record.

Similar findings were found for operative reports dated 02/11/13 and 03/04/13.

On 03/21/13, staff A stated she was not aware of chart auditing for the accuracy and completion of operative reports.

Based on review of hospital policy and procedures, medical executive committee meeting minutes, employee personnel files and clinical records, it was determined that the hospital does not have nursing personnel qualified in emergency care to meet the written emergency procedures and need anticipated by the hospital.

Findings:

1. Patient #18 a 27 year old female and patient #19 a 74 year old male, both were evaluated in the Emergency Department(ED) and intubated using the Rapid Intubation Sequence(RIS) protocol performed by Staff FF. The hospital does not have a policy regarding RIS. Review of personnel file for Staff FF, there was no documentation that Staff FF has been trained or is qualified in the RIS protocol.

2. The hospital did not have a policy for Rapid Intubation Sequence drug administration. Medical Executive Committee meeting minutes documented the hospital needed to develop a Rapid Intubation Sequence policy.

3. Patient #19 was administered a Levophed drip an inotropic/vasopressor drug which needs to be closely monitored in the ED by Staff FF. The personnel file for Staff F did not document that Staff FF had been trained or was qualified to administer Levophed.

Based on review of policies and procedures and hospital documents and interviews with hospital staff, the hospital failed to appoint/designate a physician, with knowledge, experience and capabilities to supervise and administer the service properly, to be the director of respiratory care services for the hospital.

Findings:

1. Hospital policies documents the hospital can provide respiratory services of oxygen, hand held nebulizers/aerosol therapy, intermittent positive pressure ventilations (IPPB), incentive spirometry, pulse oximetry, chest physiotherapy, and automatic resuscitator/minute volume ventilator. This was finding confirmed with Staff A on the afternoon of 03/21/13. The respiratory policies did not contain evidence they were developed by or with consultation by a respiratory therapist and a physician director with knowledge and experience.
This was confirmed by interview with hospital staff on 03/21/13.

2. Review of the hospital's respiratory policies and procedures, department head list and meeting minutes did not show that a physician had been designated as director for respiratory services

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. The hospital has policies documenting the hospital provides respiratory services of oxygen, hand held nebulizers/aerosol therapy, intermittent positive pressure ventilations (IPPB), incentive spirometry, pulse oximetry, chest physiotherapy, and automatic resuscitator/minute volume ventilator. Documentation did not contain evidence the policies were developed by or in consultation with a respiratory therapist. On 03/21/13, staff confirmed the hospital provided respiratory services.

2. Review of the hospital's department head list, contracts and employee list did not show respiratory services. This was confirmed with Staff A and administration on 03/21/13.

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. Staff A, C, F and FF confirmed on 03/21/13, that the hospital did not employee a respiratory therapist and did not have a contract with a respiratory therapist to provide supervision and training to staff providing respiratory services.

4. Staff A, C, F and FF told the surveyors that nursing personnel provided the hospital's respiratory services, but confirmed a respiratory therapist had not provided training.

5. Review of meeting minutes did not demonstrate respiratory services provided at the hospital were integrated and reviewed in the quality assessment and performance improvement and infection control programs.

Based on review of hospital documents and interviews with staff, the hospital's medical staff failed to develop policies and a scope of services for respiratory services.

Findings:

1. On the morning of 03/20/13, administrative staff told the surveyors that the hospital provided respiratory services. Staff A told the surveyors that all the respiratory services and treatments were provided by nursing staff.

2. The surveyors requested to review the hospital's respiratory policies. None were provided. When the surveyors asked about the policies, Staff A stated that all respiratory policies and procedures were contained in the Nursing manual. According to policies, the hospital provides respiratory services of oxygen, hand held nebulizers/aerosol therapy, intermittent positive pressure ventilations (IPPB), incentive spirometry, pulse oximetry, chest physiotherapy, and automatic resuscitator/minute volume ventilator.

3. The policies did not contain:
a. Equipment assembly, operation, and preventative maintenance;
b. Safety practices, including infection control measures for equipment, biohazardous waste or length of use before cleaning or disposal;
c. Cleaning, disinfecting and storage of the equipment; and
d. Procedures to follow in the advent of adverse reactions to treatments or interventions.

4. The respiratory policies did not contain evidence they were developed by or in consultation with a respiratory therapist and did not show they had been approved by the medical staff. This was finding confirmed with Staff A on the afternoon of 03/21/13.

5. Meeting minutes for the medical staff did not demonstrate the medical staff review and/or revision of the respiratory policies.

Based on review of hospital documents, personnel files and interview with staff, the hospital failed to ensure that respiratory services/procedures were administered by trained staff with each respiratory therapy procedure performed by each employee designated in writing, including the amount of supervision required when performing each procedure.

Findings:

1. Review of Patient #2 medical records indicated that Albuterol and Xopenex nebulizer respiratory treatments were ordered and administered.

2. Hospital policies, found the the Nursing manual, document the hospital can provide respiratory services of oxygen, hand held nebulizers/aerosol therapy, intermittent positive pressure ventilations (IPPB), incentive spirometry, pulse oximetry, chest physiotherapy, and automatic resuscitator/minute volume ventilator.

3. Nursing staff administer respiratory treatments. Review of licensed nursing staff personnel files did not contain documentation of respiratory training and competency testing. Staff C stated on March 20, 2013 that the hospital did not have a skills checklist for Respiratory Therapy or a respiratory therapist. This finding was confirmed by administration.

Based on interview with staff and review of medical records, the hospital did not meet the dietary requirements of patients at risk for altered nutritional status.

Findings:

On March 20, 2013, Staff E stated that all new admissions receive a nutritional assessment, as well as on-going nutritional monitoring. Three electronic medical records(EMR) that were reviewed (Records #1, 2, and 3), did not contain nutritional assessments or any on-going nutrition monitoring. This finding was confirmed with Staff A at the time of review.

Based on review of hospital documents and meeting minutes concerning infection control, and infection control policies and procedures, and interviews with hospital staff, the hospital's leadership failed to ensure infection control activities, issues, and problems, were processed through Quality Assessment and Performance Improvement (QAPI) and:

1. Were monitored, reviewed and analyzed;

2. Corrective actions were taken to prevent, identify and manage infections and communicable diseases with measures that resulted in improvement on an ongoing basis; and

3. Corrective actions were followed to ensure improvement resulted and alternative solutions/actions were not needed.

Findings:

1. Hospital meeting minutes, QAPI, medical staff and governing body, containing infection control data did not contain evidence/demonstrate the hospital leadership:
a. Reviewed and analyzed infection control data or lack thereof;
b. Developed corrective plans of action to reduce and/or prevent transmission of organisms and improve patient care, ensure a safe and sanitary environment, and decrease or prevent infections and communicable diseases; and
c. Provide follow-up/monitoring to ensure corrective actions taken were effective and sustainable.

2. The same hospital minutes did not contain review and analysis of employee immunizations, illness and infections to ensure infections and diseases were not transmitted between patients and staff. The hospital's leadership failed to ensure employee exposures were processed according to standards of practice. Meeting minutes did not demonstrate the incidents were analyzed or provision of corrective actions to reduce exposures.

3. The hospital offers surgical services of pain management and endoscopy procedures. The only infection control information concerning surgical services was the biological testing of the autoclave. The minutes did not demonstrate the leadership of the hospital ensured surgical services were provided in a safe and sanitary environment according to current standards of practice (Refer to Tags A 749 for details).

4. The QAPI program has not provided oversite of the infection control program to ensure a safe environment. Staff A stated on 03/21/13 that she could not find any data on monitoring; the past ICP left in December 2012 and that neither she nor Staff K had not conducted any surveillance/monitoring to ensure infection control policies were followed. This included, but not limited to:
a. Hand hygiene practices;
b. Isolation practices;
c. Disinfectant practices;
d. Environmental inspections.

Based on clinical record review, document review, policy and procedure review and interview, it was determined the hospital failed to inform patients of their rights when they were admitted to swing bed services. Findings:

On 03/20/13, open and closed swing bed clinical records were reviewed. There was no documentation patients were informed of their rights related to swing bed services.

The hospital patient's rights document did not include rights protected in the swing bed regulation.

A relative of patient #28, (a patient who could not speak for herself), stated they were not notified of special swing bed patient rights.

The hospital had no policy and procedure related to swing bed patient's rights.

Based on document review, clinical record review and interview, it was determined the hospital failed to inform swing bed patients of items and services that may be charged to the patient.

On 03/20/13, open and closed swing bed clinical records were reviewed. There was no documentation patients were notified of items and services that may be charged to the patient.

The hospital patient's rights document did not include those rights protected in the swing bed regulation.

A relative of patient #28, (a patient who could not speak for herself), stated they were not notified of special swing bed patient rights.

The hospital had no policy and procedure related to swing bed patient's rights.

Based on document review, policy and procedure review and interview, it was determined the hospital failed to notify swing bed patients of their right to choose a personal physician. Findings:

On 03/20/13, open and closed swing bed clinical records were reviewed. There was no documentation patients were notified of the right to choose a personal physician.

The hospital patient's rights document did not include those rights protected in the swing bed regulation.

A relative of patient #28, (a patient who could not speak for herself), stated they were not notified of the right to choose a physician.

The hospital had no policy and procedure related to swing bed patient's rights.

Based on document review and interview, it was determined the hospital failed to notify swing bed patients of rights related to work performed for the hospital. Findings:

On 03/20/13, open and closed swing bed clinical records were reviewed. There was no documentation patients were notified of rights related to work performed for the hospital.

The hospital patient's rights document did not include those rights protected in the swing bed regulation.

A relative of patient #28, (a patient who could not speak for herself), stated they were not notified of rights related to work done for the hospital.

The hospital had no policy and procedure related to swing bed patient's rights.

Based on document review and interview, it was determined the hospital failed to notify swing bed patients of rights related to sending and receiving mail.

On 03/20/13, open and closed swing bed clinical records were reviewed. There was no documentation patients were notified of rights related to mail.

The hospital patient's rights document did not include those rights protected in the swing bed regulation.

A relative of patient #28, (a patient who could not speak for herself), stated they were not notified of swing bed patient's rights.

The hospital had no policy and procedure related to swing bed patient's rights.

Based on document review and interview, it was determined the hospital failed to notify swing bed patients of rights related to personal property. Findings:

On 03/20/13, open and closed swing bed clinical records were reviewed. There was no documentation patients were notified of rights related to personal property.

The hospital patient's rights document did not include those rights protected in the swing bed regulation.

A relative of patient #28, (a patient who could not speak for herself), stated they were not notified of swing bed patient's rights.

The hospital had no policy and procedure related to swing bed patient's rights.

Based on document review and interview, it was determined the hospital failed to notify swing bed patients of rights related to married couples. Findings:

On 03/20/13, open and closed swing bed clinical records were reviewed. There was no documentation patients were notified of rights related to married couples.

The hospital patient's rights document did not include those rights protected in the swing bed regulation.

A relative of patient #28, (a patient who could not speak for herself), stated they were not notified of swing bed patient's rights.

The hospital had no policy and procedure related to swing bed patient's rights.

Based on document review and interview, it was determined the hospital failed to notify swing bed patients of rights related to transfer and discharge requirements. Findings:

On 03/20/13, open and closed swing bed clinical records were reviewed. There was no documentation patients were notified of transfer and discharge requirements.

The hospital patient's rights document did not include those rights protected in the swing bed regulation.

A relative of patient #28, (a patient who could not speak for herself), stated they were not notified of swing bed patient's rights.

The hospital had no policy and procedure related to swing bed patient's rights.

Based on observation, document review, clinical record review and staff interview, it was determined the hospital failed to provide an activities program for swing bed patients. Findings:

On 03/20/13, the hospital's swing bed policies were reviewed. There were no policies related to activities for swing bed patients.

There was no activities calendar prepared for swing bed patients.

The nursing staff stated they were unaware of an activities program for swing bed patients.

The CNO stated the hospital did not have an activities program but they planned to hire an activities coordinator.

Based on clinical record review, policy and procedure review and staff interview, it was determined the hospital failed to provide medically-related social services.

On 03/20/13, open and closed swing bed records had no documentation of social services provided to patients.

The hospital had no policies and procedures related to social services.

The CNO confirmed these findings.