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Based on record review and interviews with hospital staff the hospital does not ensure there is a organized dietary service with oversight by a registered dietitian. The hospital did not have evidence that a dietitian was providing oversight or services with regularly scheduled visits and oversight of clinical nutritional services. The facility failed to meet the nutritional needs of the patient.

Findings:

1. On 3/22/2012 Staff A told surveyors the facility had a contracted dietitian and contracted dietary to an outside company. The dietary consultation contract provided to surveyors was to begin in March of 2012. There was no documentation a dietitian had been overseeing dietary services for the past twelve months. There was no documentation the dietitians had been overseeing all areas of clinical nutrition.

2. On 3/22/2012 Staff A provided files for dietary employees. There was no documentation in the Food Services Director's personnel file he was a Certified Dietary Manager. There was no documentation the Food Services Director had been oriented, trained, and evaluated. There was no documentation a Dietitian oversaw and collaborated with the Food Services Director in menu planning, training, and oversight of the clinical dietetics.

3. On 3/22/2012 other food services personnel files were evaluated. There was no evidence of departmental training specific to food services. There was no documentation the employees were evaluated and competent to provide nutritional services. Dietary policy stipulates dietary employees must have a current food handler's certification. One of two employees did not have current food handler's certification. There was no documentation all food service personnel had been oriented and trained to the policies and procedures. There was no documentation all food service personnel were evaluated for food safety and sanitation competency.

4. Review of medical records indicate patients had nutritional conditions requiring nutritional intervention which the facility did not act on. The hospital staff did not provide nutritional support to meet the needs of the patient.

5. There was no documentation a dietitian reviewed or approved menus, special diets, made recommendations on nutritional issues, oversaw clinical dietetics, reviewed, revised, and implemented policies approved by the medical staff regarding nutritional services.

6. The facility failed to train staff, implement policies, and oversee processes to ensure patients nutritional needs are met.

7. There was no quality assurance performance improvement monitoring for clinical nutritional services.

Based on record review and interviews with hospital staff, the hospital does not ensure that patients receive care in a safe setting. The hospital failed to investigate, take action or have a method to identify incidents or patterns to protect patients.

Findings:

1. Review of Quality Assurance and Performance Improvement Committee Meeting minutes for 2011/ 2012, Governing Body Meeting Minutes, and Medical Staff Meeting Minutes did not include analysis of incidents to identify patterns which might impair patient safety. There was no analysis to develop plans of correction to improve patient safety.

2. Review of Pharmacy and Therapeutics meeting minutes indicated there were no adverse medication events for 2011/2012. Review of risk management information indicated there were multiple medication incidents during this period of time. None of the errors were analyzed for trends or patterns. None of the medication incidents were reviewed by the pharmacist. On 3/22/12 in the afternoon the pharmacist was interviewed regarding medication errors. The pharmacist told surveyors the pharmacy was not aware errors had occurred. This finding was verified with Staff A later in the afternoon.

3. Surveyors reviewed personnel files on 3/22/12. There was no documentation the employees were educated on the current grievance policy. There was no documentation the employees were educated on incident reporting and medication error reporting.

4. Surveyors reviewed personnel files of employees involved in multiple medication errors. There was no documentation in the files the employee had been provided information pertaining to the incidents, any corrective action, or education regarding medication errors. This information was verified with Staff A on 3/22/12.

4. This finding was discussed at the exit conference. No further documentation was provided.

Based on review of policies and procedures and medical records and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. In order to determine the patient's needs/care required, accurate initial and ongoing assessments of the patient's health status/condition, interventions provided and response to interventions must be performed. In eight of nine patient records reviewed for nursing assessments (Records #5, 10, 11, 12, 13, 14, 15 and 16 of Records #5, 6, 10, 11, 12, 13, 14, 15, and 16), the RN did not perform complete nursing daily assessments/evaluations of the patient's status, so that care needs could be identified; changes in the patient's physical condition could be reported; and appropriate nursing interventions could be delivered.

Findings:

1. On 03/22/2012, Staff A and C told the surveyors that nursing assessments were performed every shift and that an RN was required to perform the assessment at least daily.

2. In eight of nine records reviewed for nursing assessments, a RN did not perform an assessment of the patient's condition daily or evaluate the care needs of the patient. Multiple days occurred without evidence a RN assessed the nursing needs, care required, evaluated the interventions provided by other nursing staff and the patient's response to interventions.

Patient #10 - The patient was admitted on 12/16/2011 and discharged by death on 01/11/2012. Eight of the twenty-six days the patient was hospitalized, the patient did not receive an assessment/evaluation by a RN. Five days straight (01/04, 05, 06, 07 and 08/2012), the record did not contain evidence a RN had evaluated the patient's needs and care provided.

3. These findings were reviewed with administrative staff on 03/22/2012.

Based on review of policy and procedure, hospital documents, personnel files, and staff interviews the hospital failed to provide radiology services to meet the needs of the patients that are in accordance with standards of practice.

Findings:

1. On the morning of 3/21/12 staff A told surveyors radiology services were provided by employees and contract staff. There were no current policies reviewed and approved by medical staff and the radiologist indicating what services were provided at the facility. There were no current policies or documents reviewed and approved by the medical staff and radiologist indicating personnel competent to use the radiological equipment and administer procedures.

2. On the afternoon of 3/22/12 Staff A told surveyors the radiologist in charge was Staff R . There was no documentation stipulating Staff R had been credentialed and privileged as the supervising radiologist.

3. Quality Assurance and Performance Improvement (QAPI) documents did not incorporate radiology and radiology procedures into the plan. QAPI meeting minutes for 2011 did not include a review of all radiology services.

4. The facility did not have documentation stipulating staff were trained and competent in radiation safety.

5. Two of two radiology staff (P,Q) did not have departmental orientation and training.

6. There was no documentation P,Q were competent in radiation safety techniques for themselves and patients.

7. There were no clinical performance evaluations of P, Q in the personnel files provided to surveyors.

8. There was no documentation in the policy and procedure manual indicating all of the types of radiologic procedures offered by the facility. Policies provided to surveyors did not have current departmental contact information.

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

Based on review of policies, personnel files, and interviews with staff the facility failed to designate competent, qualified radiology personnel.

Findings:
1. There were no current policies or documents reviewed and approved by the medical staff and radiologist indicating personnel competent to use the radiological equipment and administer procedures.
2. The facility did not have documentation stipulating staff were licensed, trained, and competent in radiation safety.
3. Two of two radiology staff (P,Q) did not have departmental orientation and training.
4. There was no documentation P,Q were competent in radiation safety techniques for themselves and patients.
5. There were no clinical performance evaluations of P,Q in the personnel files.

Based on review of personnel files and interviews with staff the hospital failed to provide oversight of the food and dietetic services.

Findings:

1. On 3/22/2012 Staff A told surveyors food and nutrition services were provided through employees and contract. Staff A told surveyors the facility had a contract for dietitian oversight of the food services.

2. On 3/22/2012 Staff A told surveyors the Food Services Director was not a Certified Dietary Manager (CDM). There was no documentation the Food Services Director had oversight by the dietitian for clinical aspects of nutritional services. Documents provided to surveyors indicate the Food Services Director is overseen by the Chief Clinical Officer. Documentation in the Food Services Director's file indicated the Director signed off on the orientation. There was no other signatures of oversight. There was no evaluation of the Food Services Director for competency by the dietitian. There was no documentation the dietitian oversaw the clinical aspects of the Food Services Director job.

Based on review of hospital documents and interviews, the hospital failed to ensure a qualified dietitian supervises the nutritional aspects of patient care.

Findings:

1. On 3/22/2012 Staff A told surveyors the facility had a contracted dietitian. There was no documentation the dietitians were licensed, trained, competent, and evaluated. There was no evidence the dietitians were oriented to the facility. There was no documentation a dietitian had been overseeing all aspects of clinical nutrition for the past twelve months.

2. Dietary policies stipulate "all patients will be assessed by the dietitian within 96 hours". There was no documentation all patients were assessed by a dietitian within ninety six hours of admission. There was no documentation indicating recommendations by the dietitian were reviewed and implemented. The hospital did not review the recommendations to ensure patients received the appropriate diets or supplements. The hospital did not have documentation nutritional assessments were performed on all patients identified as "at risk" for nutritional issues.


3. This information was provided in the exit conference. No further documentation was provided.

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

Findings:

1. On 3/22/2012 surveyors reviewed dietary personnel records. There was no documentation, policy, procedure, or process in place stipulating how new dietary department employees would be trained on the inservice material presented before they were hired. There was no documentation the employees had been oriented and trained to the facility and specific dietary department.

2, Dietary documents did not include a departmental specific orientation and training for each dietary job description. The facility did not have evidence the dietary department employees were trained to perform the duties each were hired/assigned to do.

3. On 3/22/2012 Staff A told surveyors the Food Services Director was not a Certified Dietary Manager (CDM). There was no documentation the Food Services Director had oversight by the dietitian for clinical aspects of nutritional services. Documents provided to surveyors indicate the Food Services Director is overseen by the Chief Clinical Officer. Documentation in the Food Services Director's file indicated the Director signed off on the orientation. There was no other signatures of oversight. There was no evaluation of the Food Services Director for competency by the dietitian. There was no documentation the dietitian oversaw the clinical aspects of the Food Services Director job.

Based on a review of policies and procedures, medical records, and staff interviews, the hospital failed to ensure the therapeutic diets were meeting the needs of the patients.


Findings:

According to hospital policy all patients will be assessed by the dietitian within ninety six hours of admission.

1. Pt #15 medical record indicated the patient had a complicated wound dehiscence with multiple comorbidities. There was no documentation a dietary consult was performed. There was no documentation as to why the dietary consult was not performed.

2. Patient #11's medical record indicates the patient was admitted for severe venous stasis ulcers, methicillin resistant staph aureas infection, congestive heart failure, Graves disease, and morbid obesity. Orders on admission included a low sodium diet and a dietary consult. The patient was admitted on 12/19-1/19/12 and received a nutrition consult on 12/19/11. There was no further follow up on the patient from dietary.

3. Patient #14's medical record contained a request for dietary consult. The consult was provided and recommendations to add "large portion of meat and eggs every meal to increase protein intake." There was no documentation the increased protein was provided. There was no documentation the therapeutic diet recommendations were followed.

4. Patient #16's medical record indicated a history of severe protein calorie malnutrition. The patient was admitted 12/23-1/25/12. The patient had a dietary consult 12/27/11. The dietitian recommended pre-albumin labs to asses the patient's visceral stores. Pre-albumin was drawn on 1/8/12. There was no documentation as to why the lab was not drawn at the time of the recommendation. There was no documentation in the chart by the physician indicating the recommendation had been reviewed. No further dietary follow up was found.

Based on review of infection control data and meeting minutes and hospital documents, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed and maintained a comprehensive system for reporting, analyzing and controlling infections and communicable diseases among patients and staff and ensuring a sanitary environment.

Findings:

1. The Infection Prevention and Control Plan was for 2011, with an effective/approval date of 01/19/2011. Staff A stated a new Plan had not been completed as they were "looking at revamping" the program.

2. Review of meeting minutes for 2011 and 2012, containing infection control, did not reflect review and analysis with plans of action and follow-up of monitoring or all services/areas of the hospital.

a. Employee health - review of employee illness to ensure transmissions between staff and patients did not occur. For three of three contract staff reviewed (Staff H, I, and J) who provided patient services, the personnel files did not contain complete immunization histories as recommended by CDC (Centers for Disease Control and Prevention) and its Advisory Committee on Immunization Practice (ACIP).

b. Although the infection control professional kept an infection control log, meeting minutes did not reflect analysis of these logs with actions to ensure proper antibiotic usage and control/prevent possible transmission between individuals with measures taken to contain and prevent transmission and whether they were effective.

c. Not all departments/area were reviewed/monitored for compliance with established infection control policies and procedures and standards of practice to prevent and control infections and maintain a sanitary environment.

d. Whatever concerns/problems documented that did have an action plan, the action plan was to continue to monitor without identification of what would be done to improve outcomes/solve the problem. Example: Hand hygiene compliance for January through October 2011 showed only a 60% to 70% compliance - the only action plan was to continue to monitor.

e. Concerns/problems identified in one meeting were not always addressed in the next meeting to analyze if any corrective action taken was effective.

3. These findings were reviewed with hospital administrative staff during the exit conference on the afternoon of 03/22/2012.

Based on review of emergency services/room (ER) policies and procedures and medical records, and interviews with hospital staff, the hospital failed to ensure medical staff enforced the ER policies governing medical care provided in the ER. This occurred in three of three patients (Patients #1, 2, and 3), who presented to the hospital's ER area and whose records were reviewed.

Findings:

1. The hospital's policy, NSG 200 with a review date of 10/10/10, stipulated nursing staff would perform an assessment of the patient, call the physician with a report of the findings, and the physician would be responsible to determine the plan of action to be taken, including whether the patient had an emergency medical condition (EMC). The policy further stipulated, "If the physician does find that an EMC is present, the physician must render treatment as appropriate and if transfer via EMS (emergency medical services - ambulance) to another facility is appropriate, the on-call ER physician must locate and contact an accepting physician to admit the patient."

2. Staff did not follow the hospital's policy. Medical records did not show the physician determined the plan of action for 3 of three individuals presenting and requesting ER services.
a. Patient #1 - The patient presented on 11/15/2011 at 1355 with complaints of pain in the neck and right shoulder. The record did not contain evidence the physician was involved with the patient care or determination of a plan of action. The ER record did not contain documentation that the nurse had called the physician. The patient was discharged at 1435. At the time of review on 03/21/2012, the physician had not documented on or signed the medical record.

b. Patient #2 - The patient presented on 11/07/2011 at 1300 with complaints of unresponsiveness. The individual was visiting with a hospital inpatient when they became unresponsive. Except for a signature on the transfer form by a physician, the ER record did not show the physician was involved with the care and assessment of the patient's condition or plan of treatment. The physician's signature on the transfer form did not contain the date and time the physician signed the form. All other writing on the transfer form was written by the nurse. The patient was transferred to another acute care hospital at family request, but the record did not contain the time that the patient left or the patient's condition.

c. Patient #3 - The patient presented on 02/25/2012 with complaints of assault and trouble breathing. The nursing assessment documented the patient had: a "knot" on the right side of the head; a knot with bruising to the left thigh; and swelling to the right ankle. The nurse documented she assessed the patient; notified police; called the physician; and received a telephone order to transfer the patient to another acute care hospital by ambulance. At the time of record review on 03/21/2012, the physician had not documented or signed the record.

Based on review of medical record and personnel files, and interviews with hospital staff, the hospital failed to ensure nursing staff providing emergency services (ER) were trained and competent to provide complete triage and emergency assessments for patients presenting to the ER. This occurred for three of three individuals who presented to the hospital's ER area and whose records were reviewed. (Patients #1, 2, and 3).

Findings:

1. According to documentation, Staff C provided care to Patients #1 and 2 in ER. The medical record did not contain complete documentation as required by the hospital's policies. Review of Staff C's personnel file did not show Staff C had the specialized training or completed competencies to care to ER patients and provide the required documentation for the patient's condition and services provided.

2. According to documentation, Staff D provided ER care to Patient #3. The medical record did not contain complete documentation as required by the hospital's policies. Review of Staff D's personnel file did not show Staff D had the specialized training or completed competencies to care to ER patients and provide the required documentation for the patient's condition and services provided.

3. On the afternoon of 03/22/2012, Staff A told the surveyors that the hospital had not performed competency testing for the specialized areas some staff worked and no training for the specialty areas of ER and ICU (intensive care unit) had been provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that pharmacy quality indicators tracked as part of the hospital's QAPI program identify opportunities for improvement and changes that will lead to improvement. The indicator scorecard for pharmacy for January through December 2011 had all seven indicators that were tracked at 100% for the entire year. There was no documentation that indicated that the indicators should be changed to identify opportunities for improvement. Hospital Staff A verified this finding.

Based on review of hospital documents for 2011 and 2012 and interviews with hospital staff, the hospital does not ensure that medication errors identified are evaluated, analyzed and action taken to improve the care and safety of patients. Errors were identified but were not analyzed to determine why they were occurring and a plan of action implemented to reduce the errors.

Findings:

1. Staff stated on 03/22/12 in the afternoon medication errors are documented and reported through risk management.

2. Pharmacy is not included in the evaluation of medication errors.

3. There was no evidence in governing body, medical staff or risk management meetings that the errors were analyzed to determine whether it was a personnel or system problem. The only documentation consisted of numbers of errors. It did not include evaluation of possible causes.

4. The errors consisted of : 1. medications incorrectly labeled, a sedative labeled as a cardiovascular drug and the cardiovascular drug labeled as a sedative and a bag of IV Heparin, a blood thinner, mislabeled as Magnesium Sulfate; 2. patients received medications that they were allergic to, a patient allergic to morphine received morphine and another received an antibiotic that the patient was allergic to. There was no documentation that these were analyzed to determine why they occurred, the impact on the patients and a plan of action implemented to prevent future occurrences.

Based on review of policy and procedure and interviews with staff the facility failed to have a policy or process for storage and retrieval of films from the contracted x-ray services. There was no documentation the x-ray service or the local healthcare facility maintained records for a minimum of five years.

Based on review of medical records, policy and procedure, and interviews with staff the facility failed to provide nutritional services that met the needs of the patient. On 3/22/2012 Staff A told surveyors the patient population varied and several types of patients were served by the facility. Review of the patient's medical records indicate patients had varying comorbidities. Several records reviewed indicated patients had disease processes which would increase their nutritional risk. There was no documentation current menus had been reviewed and revised by a clinical dietitian to meet the needs of the types of patients the facility cared for. There was no documentation the supplements and parenteral nutrition were reviewed and approved by the dietitian. There was no documentation modified diets were reviewed and revised by the dietitian.