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Based on review of governing body bylaws, meeting minutes the hospital failed to appoint a Chief Executive Officer who is responsible for the management of the entire hospital.

Findings:
1. On 1/12/11 surveyors received a copy of the hospital's governing body bylaws. The governing body bylaws stipulate "the governing board of directors may delegate the day to day management and conduct of the company's activities and affairs to any person or persons, management company or committee however composed, provided that no such delegation of authority by the governing board of directors precludes the governing board from exercising the authority required to fulfill its responsibility to manage, supervise, and control the corporations activities and affairs." At the time the hospital opened, documents indicate the hospital had a chief executive officer and a chief operating officer. Surveyors requested a copy of the governing board minutes in which the current chief operations officer was named as the chief executive officer. Staff A told surveyors there were no written minutes indicating he had been named chief executive officer but there was a tape recording of the board meeting in which the appointment was made. On 1/12/11 a surveyor listened to a recording dated 8/19/09. The recording did not indicate a vote had occurred and the governing board appointed Staff A to chief executive officer. This finding was reviewed with administration at the exit conference.
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Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure contract personnel are oriented, trained and evaluated specific to the facility.

Findings:

1. On 1/11/11 surveyors requested contract personnel files (EE,FF, GG, HH, II, JJ, KK, LL, MM, NN,) . Ten (10) of ten (10) (EE,FF,GG, HH,II JJ,KK,LL MM,NN) contract personnel files did not contain facility specific orientation, training, and evaluation. On the afternoon of 1/12/11 Staff B confirmed the above findings .

2. These findings were reviewed with administration during the exit interview on 1/12/11. No further documentation was provided.

Based on record review and interviews with hospital staff, the governing body does not ensure that all services performed under contract are provided in a safe and effective manner. Services provided to the hospital by contract are not monitored and evaluated by the hospital's quality assessment and performance improvement (QAPI) program to ensure that they are provided in a safe and effective manner. The governing body does not ensure contract services are provided in a safe and effective manner.

1. On the morning of 1/12/11 surveyors reviewed orientation and training documents for contracted services. This occurred for 10 of 10 (EE,FF,GG,HH,II,JJ,KK,LL,MM,NN,OO) contract personnel whose files were requested for review. This finding was reviewed at the exit conference and no further documentation was provided.

2. According to the policy "Performance Improvement Plan -2010" there were no contracted services indicators included in the plan. This was reviewed with Staff H on the afternoon of 1/12/2010. This finding was also reviewed with administration at the exit interview. No further documentation was provided.

3. On 1/12/2011 surveyors reviewed governing body meeting minutes for 2010. There were no meeting minutes where contracted services were discussed. This finding was reviewed with administration at the exit interview. No further documentation was provided.

Based on record review and interviews with hospital staff, the hospital does not ensure that each patient or their representative is informed of their rights in advance of providing or stopping care.

Findings:

1. On the morning of 1/11/11 surveyors received the patient rights policy and the patient rights handout. The policy "patient rights and responsibilities" stipulated all patients will be informed in writing of their rights upon admission. The written patient rights hand outs provided to surveyors on the morning of 1/11/11 did not contain information about filing complaints with the Oklahoma State Department of Health.

2. Later in the morning, Staff B brought surveyors a notebook entitled "Patient Handbook" and stated "these are all over the hospital and this is how we inform patients of their rights". The notebook did contain information on how to file a complaint with the Department. Staff B also told surveyors patients could view their patient rights via the television in their rooms. On the afternoon of 1/11/11 during a tour of the nursing unit, surveyors asked Patient #16 about accessing patient rights information. Patient #16 did not know where to find patient rights.

3. The policy "patient rights and responsibilities" stipulates "all staff are educated upon hire and on an ongoing basis concerning patient rights, and are informed of the processes in place to support ethical decision making". Sixteen of sixteen personnel files (B, K,L, O,Q,R,S,T,U,V,W,Z,Y,X, AA,BB) did not contain current education regarding patient rights processes. Ten of ten (EE,FF,GG,HH,II, JJ,KK,LL, MM, NN) contract files did not contain education regarding patient rights processes. This finding was confirmed with Staff D and Staff F the afternoon of 1/12/11 and with administration in the exit interview. No further documentation was provided.

Based on review of hospital policies and grievance and complaint log, selected grievances and complaints, and interviews with hospital staff, the hospital failed to ensure the hospital's established grievance process was implemented.

Findings:

1. The hospital's grievance policy, entitled "Patient Complaint/Grievances Procedure," with an issue date of March 2009, appropriately defined the difference between complaints and grievances; provided time frames for investigation and resolution of grievances; stipulated that a written response with the required information would be provided to the complainant; and stipulated the Grievance Coordinator will present the finding of the review to the Performance Improvement Committee which acts as the Grievance Committee and reports finding to the Medical Staff Committee. The policy also states patient satisfaction as well as patient grievances will be submitted to the Board of Governors through the Performance Improvement Committee, which also acts as the grievance committee quarterly or more frequently as indicated. The hospital failed to follow policy.

2. The hospital failed to identify grievances: The surveyors reviewed the grievance log for 2010. There were no grievances listed on the log after July 2010. A review of Governing Board Minutes indicated a review of two written grievances which were not listed on the log. In an interview on the afternoon of 1/12/2011, Staff F told surveyors that all of the grievances and complaints were not provided to the Grievance Coordinator and were not logged. Staff F stated if the grievance went to governing board first they were not always forwarded to the Grievance Coordinator.

3. The data provided to the surveyors did not demonstrate the hospital investigated all the grievances. The grievance log provided to surveyors did not contain all grievances received by the hospital in 2010. There was no documentation of investigation and required elements on the grievances that were not forwarded to the Coordinator. This finding was confirmed with Staff F on the afternoon of 1/12/11.

4. The hospital does not ensure the written response to the complainant contains all of the required elements. All of the grievances listed on the log were reviewed by surveyors. Letters to the complainants did not stipulate what was done to investigate or what actions were taken to resolve the grievance.

5. The hospital does not ensure grievance data is incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care:
In an interview on the afternoon of 1/12/11 Staff F told surveyors there had not been a performance improvement committee meeting for over six months. Surveyors requested performance improvement committee meeting minutes on the morning of 1/11/11. Staff B told surveyors performance improvement was done through performance improvement committee, safety committee, and clinical practice committee. Review of the minutes provided from these committees did not demonstrate that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care. This finding was reviewed with administrative staff on the afternoon of 1/12/2011.

Based on review of the hospital documents and interviews with hospital staff, the hospital failed, after investigation and resolution of the grievance, to provide a written notice to the complainant with the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. All of the grievances listed on the grievance log were reviewed. None of the written responses contained all of the required information to the complainant once the hospital had finished its investigation. On the afternoon of 1/12/2010, surveyors reviewed this finding with Staff F. This finding was reviewed with hospital administration at the exit interview on 01/12/2011.

Based on review of files at the Department, hospital documents and interviews with hospital staff, the hospital failed to provide care in a safe setting to four of four patients (Pt's 11,12,13,14) whose medical records were reviewed.

Findings:

1. According to documents filed with the Department, the hospital is licensed for 45 medical/surgical beds and does not have any specialty units. Three beds on the fourth floor have been converted for post partum cesarean-section patients and certain staff were trained to take care of post partum patients and infants.

2. On 1/12/11 surveyors reviewed four medical records (Pt's 11,12,13, 14) of patients requiring specialty services of critical cardiac intravenous IV drips, telemetry monitoring and or ventilators. From the medical record surveyors selected nursing personnel assigned to care for these patients (Staff). Review of the nursing personnel files, for staff assigned to these patients, and interviews with hospital staff, did not demonstrate the nurses had been trained to provide care for patients requiring the specialized treatments.

3. On 1/11/11 surveyors were given job descriptions for registered nurses (RN) and licensed practical nurses (LPN). The job descriptions stipulated that all nurses will have current certifications in BLS (basic life support), ACLS (advanced cardiac life support), PALS (pediatric advanced life support), and TNCC (trauma nurse core competency within 180 days of employment. Review of the nursing files did not demonstrate staff had completed the requirements either before the 180-day requirement or before being assigned to care for patients requiring competency in this area.

4. On 1/12/11 staff B told surveyors that the hospital did not have any dedicated monitor tech's. Staff B told surveyors that when patients were on telemetry, all nursing staff watched the monitors when they were at the desk. Patient rooms are single occupancy. Review of the staffing sheets for 8/17/2010 indicated Staff B was assigned to care for two patients (room 213 and 211) both patients were on telemetry. The rooms were not next to each other. The nurse could not monitor both patients at the same time. The staffing sheets did not have staff assigned to monitor the telemetry tracings.

5. On 1/12/11 Staff D told surveyors the emergency department had an orientation/competency training document that was to be completed on every nurse working the emergency room. Review of staffing sheets for 8/4,5,6/2010 indicated Staff U was scheduled to work the emergency room. Staff U did not have documentation showing previous experience in the care of emergency patients. Staff U did not have orientation or competency in the emergency room documented in the personnel file. Staff D and Staff G told surveyors there was no documentation

6. Review of three emergency room medical records (Pt# 6,7, and 8) from 8/4/2010 did not show the patients were assessed by a registered nurse. Assessments performed on Pt's 6, 7, and 8 were completed by a paramedic.

7. On 1/12/2010 surveyors were provided staffing sheets for 8/15/2010. According to the documentation Staff V was pulled to work the emergency room on 8/15/2010. Review of Staff V's personnel file did not indicate Staff V had been oriented to the emergency room and had the training required by the facility to care for patient's in the emergency room. Staff V was the only registered nurse assigned to work in the emergency room on 8/15/2010. This finding was verified with Staff D and Staff G on 1/12/2010.

8. On 1/12/2010 surveyors reviewed Pt #12's chart. According to the staffing documentation Staff Z was the only nurse assigned to care for Pt #12 who was on a cardizem drip. Staff Z was in orientation. Review of Staff Z's personnel file did not indicate Staff Z had been oriented to the unit and had critical care training required by the facility to care for patients on intravenous cardiac drips.

9. On 1/12/11 incident reports were reviewed by surveyors. The incident reports provided indicated repeated problems were found with orders being entered into the hospital computer charting program. There was no evidence the incident reports were reviewed, trended, analyzed, and acted on through the performance improvement program.

10. The hospital does not ensure incident reports, grievance data, and infection control data are incorporated in the hospital's Quality Assessment and Performance Improvement (QAPI) Program with analysis of the data and implementation of processes to improve patient care: Surveyors requested performance improvement committee meeting minutes on the morning of 1/11/11. In an interview on the afternoon of 1/12/11 Staff F told surveyors there had not been a performance improvement committee meeting for over six months. On 1/11/11, Staff H told surveyors she was new to the performance improvement and infection control role. Staff H told surveyors the facility was in the process of changing performance improvement indicators and infection control processes. Staff B told surveyors performance improvement and infection control was done through performance improvement committee, safety committee, and clinical practice committee. Review of the minutes provided from these committees did not demonstrate that grievance and complaint data was reviewed, trended and analyzed with implementation of corrective and/or process changes to improve patient care. Review of the minutes provided from these committees did not demonstrate an active infection control surveillance program was in place for the facility. This finding was reviewed with administrative staff on the afternoon of 1/12/2011.

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

Findings:

1. The hospital's job description for registered nurse (RN) and licensed practical nurse (LPN) stipulated that all nurses would have current certifications in BLS (basic life support), ACLS (advanced cardiac life support), PALS (pediatric advanced life support) and TNCC (trauma nurse core competency) within 180 days of employment. At the time of review on 01/12/2011, none of the fifteen licensed staff, whose personnel files were reviewed, had TNCC training.

2. Staff #U did not have orientation, training and competency for the emergency room before working there on 08/04/, 5, and 6/2010.

3. Review of three emergency room medical records (Pt# 6,7, and 8) from 8/4/2010 did not show the patients were assessed by a registered nurse. Assessments performed on Pt's 6, 7, and 8 were completed by a paramedic.

4. On 1/12/2010 surveyors were provided staffing sheets for 8/15/2010. According to the documentation Staff V was pulled to work the emergency room on 8/15/2010. Staff V did not have orientation and training to work in the emergency room. Staff V was the only registered nurse assigned to work in the emergency room on 8/15/2010. This finding was verified with Staff D and Staff G on 1/12/2010.

8. On 1/12/2010 surveyors reviewed Pt #12's chart. According to the staffing documentation Staff Z was the only nurse assigned to care for Pt #12 and was in orientation. Review of Staff Z's personnel file did not indicate Staff Z had been oriented to the unit and critical care training required by the facility to care for patients on intravenous cardiac drips.

Based on review of personnel files and interviews with hospital staff, the hospital failed to ensure the Director of Nursing, or designee, provided orientation and evaluation of agency nursing personnel. This occurred for one of one nursing agency personnel requested for review.

Findings:

1. The surveyors requested one agency personnel record (Staff II). The records provided to surveyors the afternoon of 1/12/2011 contained information from the agency. There was no documentation provided in the agency personnel record the hospital had oriented, trained, or evaluated care provided by the agency staff. None of the documentation indicated the hospital verified current licensure. Later in the afternoon of 1/12/11, Staff B brought other information from contract agency. None of the information reviewed indicated the facility oriented, trained, or evaluated the care provided by the agency nursing staff. On the afternoon of 1/12/2011, Staff (D) told surveyors there had not been a orientation program for the agency nursing personnel. In an interview on the afternoon of 1/12/2011 this finding was verified with Staff B.

2. This finding was reviewed with administration on the afternoon of 1/12/2011. No further information was provided.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to include, analyze and track grievances as part of the quality process to improve patient care and hospital services.

Findings:

1. Review of grievances taken from the grievance log, did not show all the grievances had been investigated and resolved with written response provided to the complainant within the hospital's specified time period. On 1/12/11 Staff F stated not all grievances were reported to the Grievance Coordinator. Staff F stated if the grievance is received into administration first, the grievance doesn't always get forwarded on. This finding was reviewed with administration at the exit interview.

2. Review of the performance improvement meeting minutes for 2010 did not demonstrate grievances were part of the quality improvement program with analysis to improve hospital practices. Staff F stated that there had only been a request to review grievances once. Staff F told surveyors there had been no requests for information to be sent to Governing Body or Performance Improvement for quite some time.

Based on review of governing body meeting minutes, performance improvement meeting minutes, medical staff meeting minutes, performance improvement plan 2010, and staff interviews. The hospital 's governing body failed to ensure a performance improvement activities were reported, documented, analyzed, implemented, and evaluated.

Findings:

1. The performance improvement (PI) plan 2010 provided to surveyors indicates indicators will be provided from the following areas of the hospital: "all clinical departments, human resources, nursing pain management, business office/medical records, preop/POEM, SPD, case management, social work, environment of care, laboratory, post anesthesia recovery, pharmacy, radiology, surgery, endoscopy, respiratory services, facilities, environmental services, emergency department services, information technology, security/communications, food services, along with SCIP (surgical care improvement project) and heart failure". The (PI) plan also stipulates "patient safety goals to be monitored on an ongoing basis in all clinical areas". The PI plan stipulates all data is collected monthly and reported via department scorecards to the Performance Improvement Committee. Opportunities for improvement are assessed and acted upon in accordance with the PI program.

2. On 1/11/11 surveyors were also provided a document entitled "Muskogee Community Hospital - 2010 Scorecard". Later in the morning on 1/11/11 Staff B told surveyors performance improvement monitors were reported on the score card. The indicators listed in the PI plan and the indicators listed on the score card did not match. The score card did not contain analysis incidents, grievances, and infection control.

3. On 1/12/11 surveyors reviewed sixteen governing body meeting minutes from 2010. Ten of sixteen meeting minutes indicated "quality and safety reported in medical staff". No medical staff meeting minutes were provided for the corresponding months. Surveyors were provided medical staff meeting minutes via e-mail from Staff B on 1/13/11. The meeting minutes were labeled "Medical Staff October 19, 2010". The indicators listed in the PI plan and the indicators listed on the score card were not reviewed in the meeting minutes.

4. On 1/11/11 Staff H told surveyors she was new to the Performance Improvement Coordinator position and had not used the performance improvement plan when reporting performance improvement activities. Staff H told surveyors reporting took place in several committees but there was no committee all of the indicators were reviewed, analyzed, trended, and acted upon.

5. On 1/11/11 Staff B told surveyors the performance improvement activities were conducted in multiple meetings: performance improvement, clinical practice, infection control, medical staff, and governing body. Review of each of these committee's meeting minutes indicated none of the data was analyzed, trended, and acted upon with submission to the governance for oversight.

6. On 1/12/11 Staff F told surveyors there had not been a performance improvement committee meeting for over six months.