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Based on record review and interviews with hospital staff, the governing body does not ensure that all functions pertaining to the duties required of the governing body are carried out.

1. The governing body does not ensure accountability of the medical staff for the quality of care provided to patients. See Tag 0049

2. The governing body does not ensure that services provided under a contract are provided in a safe and effective manner. See Tag 0084

3. The governing body does not ensure that the hospital can provide equipment/supplies and facilities to assure prompt emergency treatment if needed. See Tag 0093

3. The governing body does not ensure that the QAPI program has quality indicators to measure, analyze, and track such things as patient events, and other aspects of performance that assess process of care, hospital services and operations.See Tag 0273

4. The governing body does not ensure that all medical record entries are legible, complete, dated, timed and authenticated by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. See Tag 0454.

Based on record review and interviews with hospital staff, the governing body does not ensure the medical staff is accountable to the governing body for the quality of care provided to patients. Three of three physicians and one physician assistant did not have evidence in their files that they had current appointments by the governing body as required by the hospital's bylaws.

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 5/18/11 surveyors requested records for personnel providing services through contract Magnetic Resonance Imaging (MRI), Clinic Radiology Services, and Contract Therapy Services. Personnel files were provided for contract therapy only. Four of four contract therapy files did not have job descriptions, hospital orientation and training, competencies or evaluation. No personnel files were provided for the other contracted services.

2. The hospital policy "Patient Care Service Contracts" stipulates "all contractural agreements will have the nature and scope of care provided by the outside source defined within. Each agreement will be approved and bi-annually reviewed via the contract policy. The Medical staff will approve sources of patient care provided outside the hospital. Review of the Medical Staff Meeting Minutes for 2010-2011 did not indicate contract services were reviewed. There was no review of the outside services by the Governing Body or the Quality Assurance Performance Improvement Plan.

3. The hospital policy "Patient Care Service Contracts" stipulates "when patients are required to leave the hospital for services, the "Authorization for Outside Medical Services" form and the "Transport Arrangement" form will be completed prior to scheduling appointments. The transportation request includes pertinent clinical data about the patient. A "transport progress note" may also accompany the patient as a means for the external service to document patient treatment and response to treatment provided as well as any recommendations for additional medications or treatment to be continued upon return to the hospital." Four of four patient records reviewed for contract services obtained outside of the hospital did not follow the policy. Two of four records indicated patients had central line placement and peg tube placement. Documentation in the medical records did not indicate any report from the sending facility or receiving facility had occurred. There was no documentation from the facility providing the service of the procedure performed or the findings. Two of four records indicated patients had chest x-rays provided by a nearby clinic. Two of two records did not have reports or findings for the x-rays. This information was provided in the exit conference. No further documentation was provided.

Based on document review, surveyors' observations and interviews with hospital staff, the hospital failed to provide equipment/supplies and facilities to assure prompt emergency treatment.

Findings:

1. The "Hospital Emergency Medical Services Classification Report" form, signed 05/06/2010 and received at the Department on 05/24/2010, listed the Hospital provided Emergency general medical services at a Level IV classification.

2.. During the tour of the hospital on 08/17/06 beginning at 0940, the surveyors noted the emergency treatment area (ER):
a. Was not staffed,
b. Was not visible from any nursing units,
c. Did not display any directions/signs telling presenting individuals on how to notify staff of their presence,
d. Did not have any system to alert staff if an individual arrived needing emergency treatment or evaluation,
e. Was cluttered with other furniture, including a large desk, bookcase, chairs and a 4-drawer filing cabinet.

3. The crash cart was in another hallway away from the ER. The defibrillator on top of the crash cart was only checked when plugged into the wall socket. Staff could not assure the unit would discharge if the unit was needed where a wall socket was not available. The crash cart contained expired medication and intravenous fluids. One of the laryngoscope blades did not work. Staff E stated the bulb was loose and demonstrated, but could not tighten the bulb. These finding was reviewed with Staff A and C at the time, on 05/19/2011 at 1410.

4. The hospital did not have sterile surgical trays for chest decompression or airway control/cricothyrotomy. Staff C could not tell the surveyor what the delivery tray contained; there was not list of supplies for the tray; and was unable to produce an umbilical cord clamp.

5. Policies and procedures provided to the surveyors on the afternoon of 05/18/2011 directed staff to call "911" for transport of individuals complaining of chest pain. The hospital is licensed as a hospital, and is required to have a base-station radio for communication with the emergency transport system.

Based on review of the hospitals grievance policy, log and individual grievances, the hospital failed to provide a written response to the complainant with the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This occurred for three of three patients/patients' representatives who filed grievances (Grievance #1, 2, and 5) and the complaint was not resolved at the time of the complaint by staff present or immediately available.

Findings:

1. The hospital's grievance policy, #911.0, provided to the surveyors on the afternoon of 05/18/2011 and identified by the administrator as the current policy, stipulated that grievances would be investigated and the complainant would be provided a written response with the required information within 7 days. The policy stated that if the investigation was not completed within the 7 days, a written response would be sent to the complainant stating the hospital was still investigating and then another written response, with the required information, would be sent when the investigation was complete.

2. From the grievance/concern log, five grievance (Grievances #1 through 5) were selected and the surveyor requested all documentation the hospital had concerning the grievance, including investigation and any written correspondence. Three of the grievances were not resolved at the time of the grievance/concern. The material supplied did not contain documentation a written response had been provided to the complainant as required. The surveyor again asked Staff A if the hospital had any additional documentation. None was provided.

Based on review of Governing Body Meeting Minutes, Medical Staff Meeting Minutes, and Quality Meeting Minutes the hospital failed to analyze, track, trend, data required to improve care.

Findings:

1. On 5/29/2011 surveyors reviewed meeting minutes provided by the facility. Review of blood and blood utilization only included numbers of transfusions. There was no analysis of the need for transfusion, the potential problems associated with transfusion. There was no documentation the facility reviewed transfusion as part of a quality improvement program.

2. On 5/29/2011 surveyors reveiwed meeting minutes provided by the facility. Review of rehabilitative services and outcomes were not included in the program data.

3. On 5/29/2011 surveyors reviewed meeting minutes provided by the facility. There was no analysis of deaths, emergency transfers, or trending for underlying causes or opportunitites for improvment.

4. On 5/29/2011 surveyors reviewed meeting minutes provided by the facility. There was no analysis, tracking, and trending of medication errors. The facility failed to ensure medications were administered in a safe and effective manner.

5. On 5/29/2011 surveyors reviewed meeting minutes provided by the facility. There was no review of medical records. The facility failed to ensure medical records were complete and timely.

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

Based on a review of open records and staff interviews, the facility failed to ensure all nursing notes were informative and described the patient the patient's response to medications and treatments, when nursing staff administered respiratory treatments. In four of four medical records (Patients #1, 6, 12 and 13) reviewed, where respiratory treatments were administered by nursing staff, the nursing notes did not include assessments, interventions and evaluations of the patient's response to the treatments/the notes did not assess the patient's respiratory status before or after the breathing treatments.

Findings:

1. On the morning of 05/19/2011, the Staff A provided the surveyors with policy manuals and told the surveyors that these were the current policy manuals. The hospital respiratory policy, #11:234:00/12:104:00, stipulated that in the absence of the respiratory therapist nursing staff would document treatments on the MAR (medication administration record) and in the Nursing Notes in accordance with policy #12:108:00 "Respiratory Therapy Orders and Documentation". Policy #12:108:00 stipulated documentation included pulse oximetry, if performed; mental status; position of patient during therapy; sputum - color, consistency, and amount; pulse - before and after treatment; breath sounds - before and after treatment, and/or other observations and if any adverse reactions.

2. Nursing notes did not contain any of the above specified documentation, as per the hospital's policy and standard of respiratory practice. The respiratory treatments, administered by nursing staff, were only documented on the MAR for Patients #1, 6, 12, and 13).

Based on record review and interviews with hospital staff, the hospital does not ensure that orders are dated, timed, and authenticated promptly.

Findings:

1. Two of two (Pt's 8,10) medical records reviewed for physician #V did not include authentication by the physician. None of the verbal orders written by nursing, therapy, dietary, and wound management included a physician signature authenticating the order.

2. Pt's #1,4,5,6,7,8,10 medical records included verbal orders received by nursing, physical therapy, or occupational therapy. Pt's #1,4,5,6,7,8,10 records did not have authentication by the ordering physician. Pt's #4,5,6,7,8 medical records did not have orders that were authenticated, dated, and timed.

3. Pt's #1,5,7 medical records included physician authentication by a physician who was not the originator of the order. There was no policy or medical staff bylaw rules and regulations indicating this was acceptable. There was no documentation physician W had the authority to authenticate physician X orders.

4. On 5/29/2011 surveyors reviewed Governing Body, Medical Staff, and Quality Meeting minutes. There was no review of medical records tracked, analyzed, or trended. The hospital governance failed to ensure medical records were complete.


5. The above findings were reviewed with administration and no further documentation was provided.

Based on review of medical records the facility failed to include a discharge summary by the responsible MD in the medical record.

Findings:

1. On 5/19/2011, Pt #6 and Pt #11's medical record did not include a discharge summary. Both patients had been discharged from the facility for greater than thirty days.

2. On 5/19/2011, Pt #1 and Pt#2's medical record included a discharge summary that was dictated by the physician assistant. There was no authentication by the physician assistant. Pt #1 and #2 had been discharged from the facility for greater than thirty days.

2. Pt #5's medical record indicated the patient was transferred emergently. The medical record did not include documentation of the care received, outcomes of the care, and reason for transfer. There was no signed transfer documents. There was no documentation by the physician, physician assistant, or nursing as to the events prior to transfer.

3. On 5/29/2011 surveyors reviewed Governing Body, Medical Staff, and Quality Meeting minutes. There was no review of medical records tracked, analyzed, or trended. The hospital governance failed to ensure medical records were complete and included a discharge summary.

4. The above findings were reviewed with administration at the exit conference and no further information was provided.

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 and are in accordance with standards of practice.

Findings:

1. On the morning of 5/18/2011 staff A told surveyors radiology services were provided by contractual arrangement with a local clinic. There were no policies for radiology or for the contracted radiology provider approved by the medical staff. There was no radiology scope of service or the types of diagnostic examinations available to providers.

2. Two of two records reviewed for compliance indicated patients had chest x-rays provided by the contracted service. Two of two records did not have x-ray reports.

3. The hospital policy "Patient Care Service Contracts" stipulates "when patients are required to leave the hospital for services, the "Authorization for Outside Medical Services" form and the "Transport Arrangement" form will be completed prior to scheduling appointments. The transportation request includes pertinent clinical data about the patient. A "transport progress note" may also accompany the patient as a means for the external service to document patient treatment and response to treatment provided as well as any recommendations for additional medications or treatment to be continued upon return to the hospital." Two of two patient records reviewed for compliance did not follow the policy.

4. Quality Assurance and Performance Improvement (QAPI)documents did not incorporate radiology and radiology procedures into the plan. QAPI meeting minutes for 2010-2011 did not include a review of radiology services.

5. On the morning of 5/18/2011, surveyors requested contract radiology personnel files. None were provided.

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

Based on review of hospital documents and meeting minutes, infection control data and policies, surveyors' observations, and interviews with hospital staff, the hospital failed to ensure the infection control practitioner developed, implemented, and maintained an ongoing infection control program based on nationally recognized infection control guidelines and designed to identify, prevent, control and investigate infections and communicable diseases of patients and personnel. The infection control practitioner failed to ensure the program maintained a comprehensive system for reporting, analyzing, preventing and controlling infections and communicable diseases.

Findings:

1. Staff told the surveyors that Infection Control activities were contained in the hospital's Environment of Care (EOC) committee meeting minutes. The surveyors requested and reviewed 2010 and 2011 meeting minutes. The meeting minutes did not contain documentation to support the hospital had an effective ongoing infection control program that reviewed, evaluated/analyzed and developed corrective action to ensure a safe and sanitary environment and aseptic practices.

2. Infection control data and meeting minutes did not demonstrate review and analysis of patient infections or employee illnesses. Logs were kept for both, but meeting minutes did not reflect the information was presented in the meeting minutes for review or analysis with any action taken. Staff D told the surveyors that the hospital "planned" to implement a new tracking tool for recording infection control information, but this had not been approved and implemented.

3. The infection control logs presented to the surveyors does not contain all the information by the State's Hospital Standards OAC 310:667-13-4(1) - identification and location of the patient, the date of admission, onset of infection, the type of infection, the cultures taken, the results when known, any antibiotics administered and the practitioners responsible for care of the patient.

4. The hospital's infection control program did not specify the types and frequencies of surveillance/monitoring activities. The program did not specify how the surveillance activities would be evaluated. It did not specify that corrective actions would be developed if needed, to ensure infection control policies and recognized aseptic practices were followed.

5. Monitoring activities, provided for review, did not include active surveillance of the practices to ensure staff adhered to aseptic techniques and hospital infection control policies to avoid possible transmission of infections, including hand hygiene surveillance.
a. Staff C stated she had just obtained a template for handwashing surveillance, but had not used it.
b. She stated she had not documented any surveillance of isolation precautions and techniques or if appropriate types of isolation were set-up.
c. She had not monitored disinfection, antiseptics and germicides use to ensure manufacture guidelines for application were followed.

6. On the afternoon of 05/19/2011, the surveyors observed dietary staff:
a. Did not wear gloves or aprons while preparing food.
b. One unidentified staff placed an ungloved finger in the food; licked her finger; and did not sanitize her hands before moving on to the next task.
c. Dietary staff used a cloth to remove a tray from the steam table. The edges of the cloth draped over into the pan.

7. Review of Staff C's personnel file, the person designated as the infection control officer, did not contain evidence of current on-going training in the principles and methods of infection control. The personnel file only contained documentation of one training in 10/2007, "Principles of Infection Prevention and Control." On the afternoon of 05/19/201, Staff C confirmed she had not received any on-going training in infection control.

Based on record review and interviews with hospital staff the hospital does not ensure that a log of all infections and communicable diseases is maintained that identifies incidents of infection and communicable diseases in both patients and staff that would enable the hospital to evaluate the data contained in the log to determine whether the infections were either present on admission or health-care associated and to protect both the patients and staff from infections.

Findings:

1. The infection control logs presented to the surveyors does not contain all the information by the State's Hospital Standards OAC 310:667-13-4(1) - identification and location of the patient, the date of admission, onset of infection, the type of infection, the cultures taken, the results when known, any antibiotics administered (and whether the organism is sensitive or resistive to the medication), and the practitioners responsible for care of the patient.

2. The infection control log did not track employee health. This information was kept on a separate log. Meeting minutes did not reflect the information was presented in the meeting minutes for review or analysis with any action taken. On the afternoon of 05/19/2011, Staff C stated she had not included employee health in infection control for possible tracking of infections and communicable diseases between patients and staff and the information had not been presented to hospital committees for review, evaluation and possible action.

Based on review of rehabilitation policy and procedure, hospital documents, personnel files and interviews with staff, the facility failed to ensure the scope of rehabilitative services meet the needs of the patients.

Findings:
1. On the morning of May 19, 2011, Staff A provided surveyors Rehabilitation Services Policies. The policies did not include a scope of services or the types of rehabilitative treatment provided by the facility. The policies are not approved by the Medical Staff.

2. In an interview with Staff A on the morning of May 19, 2010 surveyors were told rehabilitation services were provided by contract therapists and therapy assistants. Four of four contract therapy personnel selected for review did not have job descriptions, hospital orientation and training, competencies, or evaluations.

3. Inpatient physical therapy evaluation and treatment notes were documented on a form entitled "plan of treatment for outpatient rehabilitation". On the morning of May 19, 2011 surveyors were told the facility did not provide outpatient rehabilitation. Physical Therapy Assistant notes were documented on a separate form. Occupational therapy notes were documented on different forms. Review of all patients receiving physical therapy, occupational therapy, speech pathology, and wound care did not have documentation a comprehensive plan of care was developed by a multidisciplinary team.

3. Medical Staff Meeting minutes for 2010 and 2011 did not include a of review of the rehabilitation services. Quality Assurance Meeting Minutes did not include a review of the rehabiliation services. There was no evaluation the rehabilitative services provided met the needs of the patient.

4. On the morning of May 19, 2011 surveyors toured the rehabilitation area. Staff U provided care to a patient and failed to complete hand hygiene prior to taking care of another patient. There was no hand sanitizer in the gym available for use by the staff. The cold pack unit had extensive ice build up on the inside and a dark greasy film on the handle for opening the unit. The moist heat pack covers were hanging above the hydrocollator. The covers appeared soiled. There was no policy for cleaning of the heat pack covers. There was no record of the hydrocollator being cleaned. Germicidal wipes were provided by the treatment tables only.

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

Based on review of hospital documents, policy and procedure, meeting minutes, medical records, and interviews the hospital failed to ensure the director of rehabilitation services was qualified, trained, and available to supervise therapy services.

Findings:

1. On the afternoon of May 18, 2011 Staff A told surveyors rehabilitation (physical therapy, occupational therapy) services were provided under contract. Hospital documents did not stipulate an individual in charge of the operation of the service.

2. On the afternoon of May 18, 2011 Staff A told surveyors staff Q was in charge of physical therapy. Review of Staff Q's personnel file did not have evidence of a job description. There was no information in the file indicating education, experience, or training to properly oversee services.

3. In an interview with Staff U on the morning of May 19, 2011surveyors were told Staff Q provided evaluation and treatment to patients for eleven hours total during April 2011. Staff Q did not have any administrative time documented for April 2011.

4. This information was reviewed with administration during the exit conference. No further documentation was provided.

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. This occurred for five of seven nursing staff (Staff E, F, H, I and J of Staff E, F, G, H, U, J, and K), whose personnel files were reviewed and who were identified through medical record review as providing respiratory services.

Findings:

1. On the afternoon of 05/18/2011, Staff A told the surveyors that nursing staff provided the respiratory treatments when the respiratory therapist was not at the hospital.

2. Review of personnel files did not demonstrate staff had been trained in providing each respiratory service with a designation by the respiratory therapist of the amount of supervision required for each individual providing the service.

3. This finding was reviewed with administrative staff on the afternoon of 05/19/2011.

Based on policy and procedure, interviews, and review of personnel files the facility does not ensure personnel providing radiology services are appropriately trained and competent to provide services to patients.

Findings:

1. On the morning of 5/18/2011 surveyors were told diagnostic radiology and magnetic resonance imaging (MRI) were provided to the hospital through a contract with a local clinic and MRI company.

2. Surveyors requested personnel records for contracted services. None were provided. The hospital did not have a list of personnel qualified to run the equipment or provide services to patients. The hospital failed to ensure the contract personnel providing services to patients were appropriately trained, competent, and qualified to provide radiology services to patients.

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

Based on interviews with hospital staff and review of documents, the hospital failed to ensure that menus meet the needs of the patients.

Findings:

1. On the morning of 5/18/2011, surveyors were provided with dietary policies, inservices, and menus. The menus listed as "low calorie/fat, low sodium, regular," all stipulated the same items for each menu category. The menus did not have modifications for the items in each category.

2. During the tour of the patient care area patients were provided a menu for a patient with orders for a "healthy heart" diet. The menu did not indicate healthy heart. During the tour of the kitchen, on the morning of 5/19/2011, Staff O told surveyors the meals utilized to feed patients were low calorie and low salt so they did not have to modify them for the patients. Staff O told surveyors the staff had been trained to know low salt and low fat/calorie were healthy heart and a inservice had been provided to staff. Review of inservices for 2010 and 2011 did not indicate staff had been trained on the modification of low salt/low fat/low calorie to healthy heart diet.

3. Dietary policies and procedures provided to surveyors on 5/18/2011 did not indicate how modifications were to be made to the food served in the facility to accomodate special diets.

4. This finding was reviewed with administration in the exit interview and no further documentation was provided.