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Based on review of records, and interviews, the director of nursing services did not ensure that non-employee (NE) nurses' clinical activities were evaluated or that they adhered to hospital policies and procedures, for 2 of 2 NE nurses (NE #1 & #2) who worked in August 2009.

FINDINGS:
The listing of non-employee nurses included:
1) NE nurse #1 worked as the registered nurse (RN) on the night shift in the hospital emergency department (ED) on 08/18/09, 08/19/09, and 08/20/09.
In an interview with NE #1 the morning of 01/08/10, she was asked what duties she performed while working those dates. She stated that she assessed patients coming into the ED, started intravenous (IV) sites, and administered medications. She also said that she felt she needed to "strengthen her emergency department skills."

2) NE nurse #2 worked as a licensed vocational nurse (LVN) on the inpatient nursing unit on 08/03/09, 08/06/09, 08/15/09, and 08/22/09. The medical record for Patient #24 who had chest pain and a recent myocardial infarction, noted that NE nurse #2 was the inpatient admitting nurse, and performed patient assessments, pain assessments, telemetry and IV site monitoring.

In an interview the morning of 01/08/10 with NE nurse #1, she was asked if her clinical activities had been evaluated by hospital staff. She said "no." NE nurse #1 stated that she was working as the inpatient unit charge nurse on this day, and she had checked blood for a transfusion that was given to Patient #39. She confirmed she had not reviewed this hospital's blood transfusion policy.

In an interview the afternoon of 01/08/10 with the director of nursing (DON), she was asked how the hospital ensured NE nurses were informed of, and followed hospital policies and procedures, and how their clinical activities were evaluated. She said that the hospital did not have a process to ensure that NE nurses were informed of their policies, or for evaluation of their clinical activities.

Based on review of records, and interviews, the hospital failed to time medical record entries of 6 of 6 patients (Patients #1, 12, 13, 15, 37 & 38) who were admitted from 10/12/09 to 11/28/09.

FINDINGS:
History & Physical records and/or Nursing Assessment records were not timed on the following dates:
1) Patient # 1 - 10/13/09 through 10/16/09
2) Patient #12 - 10/12/09 through 10/16/09
3) Patient #13 - 10/20/09 through 10/22/09
4) Patient #15 - 11/24/09 through 11/26/09
5) Patient #37 - 11/20/09 through 11/22/09
6) Patient #38 - 11/26/09 through 11/28/09

Physician Orders were not timed:
1) Patient #13 - 10/20/09
2) Patient #37 - 11/20/09 & 11/21/09
3) Patient #38 - 11/26/09

In an interview with Personnel #8 the afternoon of 01/08/10, she confirmed the above records were not timed.

The hospital "Medical Record Contents" policy notes that "all clinical entries in the patient's medical record shall be accurately dated, authenticated and legible."

In an interview the morning of 01/07/09, Personnel #5 stated that the medical record department does not look for or track "times" in the medical records. She also stated that the hospital does not have a policy with regard to documentation of time in all medical record entries.

Based on observation and interview, the hospital failed to maintain the hospital environment related to the unprotected "CT" walkway, rusty over-the-bed tables, damaged ceiling in the medical records department, odor in the patient hallway, and damaged ceiling, floor and countertops in the kitchen.

During a tour of the hospital the afternoons of 01/06/2010, 01/07/2010, and 01/08/2010, the following observations were made:
1) The outside open area between the hospital and the separate "CT" building included an area approximately 36 feet long that was uncovered and exposed to the elements of the weather. The section of the pavement in front of the hospital door that led to the separate "CT" building was cracked and unlevel making walking and the transfer of patients in wheelchairs or on stretchers difficult. The Director of the Radiology department (Personnel #6) was asked how patients were taken to have a "CT" scan. Personnel #6 said that patients were taken out of the hospital building to the separate "CT" building along this pathway in wheelchairs or on stretchers.

2) Three over-the bed tables had exposed rusted metal frames that came in contact with employees and patients. These tables were pushed over the patient's beds and chairs at meal times and were a source of possible infections for open wounds.

3) The Medical Record Department had one 2' x 2' bulging tile and one 2' x 2' missing tile with ceiling pipes exposed. The Maintenance Manager (Personnel #7) was asked why the tiles were not replaced. Personnel #7 said that the roof leaked and this had to be corrected before the tiles were replaced.

4) There was a strong pungent odor in the hall outside patient room #19. The Director of Nurses (Personnel #1) said that the hallway smelled like mold. Personnel #1 was asked if patient room #19 was used and said that it was used as needed.

5) A large ceiling vent in the kitchen was covered with a a grease-like gray substance. There was a hole in the ceiling approximately 4" x 4" next to this vent that was uncovered. Kitchen floors had visible crack lines running approximately the length and width of the floors. One large food prepatory laminated countertop and one small prepatory laminated countertop had multiple worn sections with exposed unprotected counter layers available for contact with food during daily meal preparations. The Maintenance Manager (Personnel #7) was shown these dietary areas of concern and said that they could be fixed.

Based on review of records, and interviews, the hospital's medical staff did not ensure that the physician on-call responded within 30 minutes, as required, for 1 of 7 patients (Patients #7), seen in the emergency department (ED) during November 2009.

FINDINGS:
Patient # 7 was admitted to the ED on 11/16/09. Nurses notes document the
nurse attempted to notify the doctor's office (Personnel #18), with no answer by telephone at 10:45, 11:06,and 11:16. After notifying the supervising nurse (RN), the ED nurse received a call at 11:44 from the doctor (Personnel #18). Response time from when the nurse called the doctor, and his return telephone call was 59 minutes.

The hospital Medical Staff Rules and Regulations note that "if a patient presents to the Emergency Room and the family physician cannot be reached after 30 minutes, the Emergency Room physician will see the patient, if the patient is agreeable."

In an interview the morning of 01/07/10 with the ED nurse (Personnel #9) who had assessed Patient #7, she was asked if the physician on-call for the ED always called or came to evaluate the patient within 30 minutes. She said "no."

In a telephone interview the morning of 01/12/2010 with Personnel #18, he was asked if he was the physician on-call for the date and time noted above when Patient #7 presented to the ED. He said "yes."