A.

BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/12/2014
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0391
260207
06/19/2014
C
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
2828 NORTH NATIONAL
OZARKS COMMUNITY HOSPITAL
SPRINGFIELD, MO 65803
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
A 000
INITIAL COMMENTS
A 000
As directed by the Centers for Medicare & Medicaid Services, an unannounced, on-site allegation survey was conducted at the facility
from 06/17/14 through 06/19/14 to investigate complaint MO00093961 with focus on the Condition of Participation: Nursing Services.
The complaint was substantiated with related deficiencies.
Please refer to the 2567 for additional information.

A 396
482.23(b)(4) NURSING CARE PLAN
The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. The nursing care plan
may be part of an interdisciplinary care plan
This STANDARD is not met as evidenced by:
A 396
Based on record and policy review and interviews, the facility failed to follow their Plan of Care Standards policy when staff failed to
incorporate a nursing care plan that addressed all patient care needs that included measurable goals, interventions and time tables for
two (#9 and #12) out of nine current medical charts reviewed and for two (#3 and #4) out of eight discharged medical charts reviewed.
This failure to develop comprehensive multidisciplinary care plans for patients' individual nursing needs had the potential to affect all
inpatient outcomes. The facility census was 21.
Findings included:
1. Record review of the facility's policy titled, "Documentation-Plan of Care Standards," dated

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of
survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these
documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete
NTKG11
Event ID:
Facility ID:
260207
If continuation sheet Page 1 of 7
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/12/2014
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0391
260207
06/19/2014
C
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
2828 NORTH NATIONAL
OZARKS COMMUNITY HOSPITAL
SPRINGFIELD, MO 65803
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
A 396
Continued From page 1
A 396
01/08, showed the following direction for facility staff:
- An individualized multidisciplinary plan of care is provided for all patients through the assessment process performed by all members of
the health care team as appropriate to the patient's condition.
- All staff is responsible for multidisciplinary collaboration to establish goals and appropriate interventions, as well as, ongoing evaluation
and revisions.
- Care plans are reviewed every shift and updated as necessary depending on changes of patient condition.
- The patient care plan is divided into sections that include:
-Diagnostic Test (for example, laboratory test);
-Integumentary (skin);
-Psychosocial and;
-Discharge Planning & Teaching.
- The information listed on the Patient Care Plan is intended to assist the caregiver in developing individual goals and interventions for
the patient.
- Goals are reviewed and adapted to be:
-Individual for the patient;
-Measurable and;
-Time Oriented.
2. Record review of current Patient #9's Face Sheet showed he was admitted to the facility on 06/12/14 with complaints of orthopedic
(branch of medicine that deals with bones and muscles) leg amputation (surgical removal of a body part).

Record review of the patient's Initial Physical Assessment (Nursing Admission Assessment) dated 06/12/14 showed that staff
documented the following information:
FORM CMS-2567(02-99) Previous Versions Obsolete
NTKG11
Event ID:
Facility ID:
260207
If continuation sheet Page 2 of 7
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/12/2014
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0391
260207
06/19/2014
C
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
2828 NORTH NATIONAL
OZARKS COMMUNITY HOSPITAL
SPRINGFIELD, MO 65803
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
A 396
Continued From page 2
A 396
- Skeletal Assessment: Partial right foot amputation.
- Amputation: New mid right foot.
- Skin Condition: Intact other than surgical site of the right foot.
Record review of the patient's laboratory reports dated 06/13/14 and History and Physical (H&P) dated 06/12/14 showed he was
admitted with multiple medical diagnoses including low albumin (a test that measures the amount of protein made by the liver) levels,
amputation of the right mid foot, osteomyelitis (infection and swelling of the bone or bone marrow-flexible tissue in the interior bones) and
amputation (surgical removal of a body part) of the right mid foot with debridement (removal of nonliving tissue).
Review of the patient's laboratory report dated 06/13/14 showed his albumin level was 1.8 (normal range is 3.4 to 5.0) which was very
low.
Review of the patient's Nutritional Care Plan Follow Up Notes dated 06/14/14 showed that dietary staff documented they completed the
patient's nutritional assessment and recommended the patient be provided a prenatal vitamin and add ProStat or Beneprotein (protein
supplement) TID (three times a day) to address his elevated protein needs.
Review of the patient's Problem List /Problem Activity (Care Plan) dated 06/11/14 (the patient was admitted to the facility on 06/12/14),
revised 06/12/14, 06/15/14 and 06/16/16 showed staff did not include the following patient care needs:
- The patient's need for added protein to his diet and a prenatal vitamin per recommendations from the dietary assessment.
FORM CMS-2567(02-99) Previous Versions Obsolete
NTKG11
Event ID:
Facility ID:
260207
If continuation sheet Page 3 of 7
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/12/2014
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0391
260207
06/19/2014
C
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
2828 NORTH NATIONAL
OZARKS COMMUNITY HOSPITAL
SPRINGFIELD, MO 65803
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
A 396
Continued From page 3
A 396
-Staff did not assess or address the patient's psychosocial needs related to depression and grieving over the loss of his mid right foot per
amputation.
- Wound care related to impaired skin integrity related to his mid right foot incision site, and diagnoses of osteomyelitis.
3. During an interview on 06/19/14 at 9:00 AM, Staff UU, Staff Registered Nurse (RN) stated that when he initiated a patient's Care Plan
he looked at what the patient was diagnosed with and at the patient's mobility, skin and dietary needs.
4. During an interview on 06/19/14 at 9:20 AM, Staff II, RN, Supervisor, stated that she expected patient care plans to reflect current
problems the patient experienced at admission. Staff II stated that she expected care plans to be updated with any change the patient
experienced and she expected staff to look at patient care plans each shift.
5. Record review of current Patient #12's admission history and physical showed the patient was admitted on 06/12/14 with mental status
changes and agitation. Further review showed the physician assessed the patient weighed 118 pounds; had poor dentition and lining of
the mouth was dry.
Record review of the patient's care plan dated 06/12/14 showed staff identified problems, interventions and goals related to multiple
medical conditions but failed to identify problems, interventions and goals related to eating foods or drinking fluids, weight gain, dentition
(teeth) or dry mouth.
FORM CMS-2567(02-99) Previous Versions Obsolete
NTKG11
Event ID:
Facility ID:
260207
If continuation sheet Page 4 of 7
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/12/2014
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0391
260207
06/19/2014
C
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
2828 NORTH NATIONAL
OZARKS COMMUNITY HOSPITAL
SPRINGFIELD, MO 65803
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
A 396
Continued From page 4
A 396
During an interview on 06/19/14 at 9:21 AM, Staff F, Director of Quality, reviewed the patient's care plan and confirmed staff failed to
identify problems, develop interventions and goals related to eating, drinking, weight gain, teeth or dry mouth.
6. Record review of discharged Patient #3's admission history and physical dated 04/01/14 showed the patient was admitted with
multiple medical diagnoses and dysphagia (swallowing difficulties).
Record review of the patient's care plan dated 04/01/14 showed staff identified problems, interventions and goals related to other medical
diagnoses but none related to the patient's swallowing difficulties.
During an interview on 06/18/14 at 3:20 PM, Staff DD, Quality Nurse, reviewed the patient's care plan and confirmed staff failed to
identify the patient's problem with swallowing, plan interventions and set goals.
7. Record review of discharged Patient #4's admission H&P showed she was admitted to the facility on 05/02/14 for exacerbation
(increase in severity of symptoms) of dementia and agitation. The Initial Nursing Assessment performed in the Emergency Department
(ED) showed the patient had moderate intellectual disabilities, hyperlipidemia (abnormally elevated levels of any or all fat soluble proteins
in the blood), nutritional deficiency (malnourished), dental caries (tooth decay or cavities), allergic rhinitis (allergic symptoms affecting the
nose), hypertension (elevated blood pressure) and osteoarthritis (common form of arthritis, occurs when the
FORM CMS-2567(02-99) Previous Versions Obsolete
NTKG11
Event ID:
Facility ID:
260207
If continuation sheet Page 5 of 7
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/12/2014
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0391
260207
06/19/2014
C
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
2828 NORTH NATIONAL
OZARKS COMMUNITY HOSPITAL
SPRINGFIELD, MO 65803
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
A 396
Continued From page 5
A 396
protective cartilage on the ends of bones wears down).
Record review of the patient's admitting physician's H&P dated 05/02/14, showed diagnostic impressions of:
- Mental retardation and psychosis (a loss of contact with reality that usually includes false beliefs about what is taking place or who one
is; seeing or hearing things that aren't there);
- Hypertension;
- Generalized anxiety disorder by history; and
- Myocardial infarction (MI, heart attack) by history.
Plan: to increase her blood pressure medication and monitor serial (appearing in successive numbers for a period of time) blood
pressures.
Record review of the patient's Psychiatric Consultation dated 05/02/14 showed:
- Psychosis not otherwise specified; rule out undifferentiated (uncertain) type schizophrenia (mental disorder that makes it hard to tell the
difference between what is real and not real, think clearly, and/or have normal emotional responses);
- Moderate mental retardation;
- Hyperlipidemia, Hypertension, Allergic rhinitis, Osteoarthritis;
- Ability to function influenced by serious impairment in communication and judgment.
Plan: To be placed on close observation for elopement or assault and medication adjustment.
Record review of the Initial Nursing Interview dated 05/02/14 showed Patient #4 had memory deficit (unable to remember), dementia (a
loss of brain function that occurs with certain diseases and affects memory, thinking, language,
FORM CMS-2567(02-99) Previous Versions Obsolete
NTKG11
Event ID:
Facility ID:
260207
If continuation sheet Page 6 of 7
A. BUILDING ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/12/2014
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0391
260207
06/19/2014
C
STREET ADDRESS, CITY, STATE, ZIP CODE
NAME OF PROVIDER OR SUPPLIER
2828 NORTH NATIONAL
OZARKS COMMUNITY HOSPITAL
SPRINGFIELD, MO 65803
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5)
COMPLETION
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
A 396
Continued From page 6
A 396
judgment, and behavior), history of a MI, Hypertension, and dental/oral problems. The patient was at moderate risk for skin breakdown.
Record review of Care Plans dated 05/02/14, 05/03/14 and 05/04/14 showed the patient had care planning for multiple nursing
diagnoses. Staff did not include in the patient's Care Plan the following patient care needs:
- Increased observation due to elopement risk;
- Barriers to communication and learning;
- Altered skin integrity;
- Nutritional support for hyperlipidemia and nutritional deficiency; and
- Choking hazard due to poor dentition and inability to chew her food.
FORM CMS-2567(02-99) Previous Versions Obsolete
NTKG11
Event ID:
Facility ID:
260207
If continuation sheet Page 7 of 7