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Based on Policy and Procedure review, minutes of the Governing Body meetings review, and review of the facility's Strategic Plan, the facility failed to ensure that an annual evaluation of the CAH's total program was performed during the past year.


Findings include:

There was not available for review a policy for conducting an annual evaluation of the CAH's total program, specifying what information is to be included in the evaluation, how the evaluation is to be conducted, and who is responsible for the annual evaluation.

Review of the minutes of the Governing Body meetings and review of the facility's Strategic Plan revealed no documented evidence showing that the facility had conducted an annual evaluation of its total program.

Based on review of the CAH's policies and procedures, minutes of the Governing Body meetings, and interview with staff, the facility failed to review the utilization of CAH services, including the number of patients served and the volume of services as part of an annual evaluation.


Findings include:


1. There was not available for review a yearly program evaluation performed by the facility that included all the CAH services, the number of patients served, and the volume of services provided.


2. According to the Administrator and Governing Body Minutes, the number of patients served is reported each month, but there is nothing available to show a cumulative total in an annual program evaluation.

Based on review of the CAH's policies and procedures and minutes of the Governing Body meetings, the facility failed to ensure that a representative sample of both active and closed clinical records were reviewed as part of the annual evaluation.


Findings include:


Review of the CAH's policies and procedures and minutes of the Governing Body meetings revealed no documented evidence that a clinical record review of both active and closed records was performed as part of an annual evaluation.

Based on review of the CAH's policies and procedures and minutes of the Governing Body meetings, the facility failed to ensure that the review of the CAH's policies and procedures was done in conjunction with an annual evaluation.


Findings include:


Review of the CAH's policies and procedures and minutes of the Governing Body meetings revealed that the facility had reviewed its policies and procedures, and that they were approved by the Governing Board on June 03, 2011, but this was not done in conjunction with an annual evaluation.

Based on review of the CAH's policies and procedures, minutes of the Governing Body meetings and the Strategic Plan, the facility failed to ensure that an annual evaluation had been done to determine if utilization of services was appropriate, if established policies were followed, and if any changes were needed.


Findings include:


Review of the CAH's policies and procedures, minutes of the Governing Body meetings and the Strategic Plan revealed that thefacility had not determined whether the utilization of services was appropriate, the established policies were followed and any changes were needed as a result of a program evaluation.

Based on review of the CAH's policies and procedures, Quality Assurance committee minutes, minutes of the Medical Staff meetings, Quality Assurance Dashboard reports and departmental monitors, the facility failed to ensure that it had an effective performance improvement program during the past year.


Findings include:


Review of the CAH's policies and procedures, Quality Assurance committee minutes, minutes of the Medical Staff meetings, Quality Assurance Dashboard reports and departmental monitors revealed that Departmental Indicators had been developed and monitored. However, there were no objectives documented for these indicators, and there was no documentation that data analysis of the monitoring was performed.

Based on review of the CAH's policies and procedures, Quality Assurance committee minutes, minutes of the Medical Staff meetings, Quality Assurance Dashboard reports and departmental monitors, the facility failed to ensure that appropriate remedial action had been taken to address deficient practices found through the quality assurance program during the past year.


Findings include:


Review of the CAH's policies and procedures, Quality Assurance committee minutes, minutes of the Medical Staff meetings, Quality Assurance Dashboard reports and departmental monitors revealed that Departmental Indicators had been developed and monitored. However, there were no objectives documented for these indicators, and there was no documentation that data analysis of the monitoring was performed. There was also no documented evidence of actions taken to improve deficient practices throughout the facility during the past year.

Based on review of the CAH's policies and procedures, Quality Assurance committee minutes, minutes of the Medical Staff meetings, Quality Assurance Dashboard reports and departmental monitors, the facility failed to ensure that it had documented the outcome of remedial action.


Findings include:


Review of the CAH's policies and procedures, Quality Assurance committee minutes, minutes of the Medical Staff meetings, Quality Assurance Dashboard reports and departmental monitors revealed no doucmented evidence that remedial action had been taken and evaluated during the past year.

Based on record review, staff interview and policy and procedure review, the facility failed to meet the needs of two (2) of two (2) patients receiving pain medication by failing to reassess for pain. Patient #1 and #3.

Findings include:

Record review revealed no documented evidence that Patients #1 was reassessed within one (1) hour after receiving pain medication. Patient #1 received three (3) doses of Morphine intravenously (IV) in a five (5) hour time frame; no reassessments were documented.

Record review revealed no documented evidence that Patients #3 was reassessed within one (1) hour after receiving pain medication. Patient # 3 received a Torodol injection and a Dilaudid by mouth; no reassessment was documented.

Review of the facility's undated "Acute Pain" policy revealed:
"Procedure - Pain intensity and relief must be assessed and reassessed at regular intervals.
Nursing Interventions - 2. Pain assessments will be conducted...at regular intervals. A. Assess and reassess pain frequently..."


At 2:00 p.m. on December 07, 2011 the Director of Nursing (DON) stated the patients receiving pain medication are to be reassessed in the Emergency Room every 30 minutes and every hour on the floor.
Upon exit, no further documentation was provided by Administration.

Based on Policy and Procedure review and medical record review, the facility failed to ensure that all entries in the medical record were timed on five (5) of 21 records reviewed.


Findings include:

14 medical records were selected at random from a list of discharges from August 1, 2011 through November 30, 2011 and reviewed along with seven (7) inpatient medical records. For a total 21 medical records.


On five (5) of 21 medical records reviewed all physician orders had not been timed when entered into the medical record. This included orders written by the Physician and those written by a Nurse Practitioner.