HospitalInspections.org

Based on bylaws review, agreement review, and staff interview, the Critical Access Hospital (CAH) failed to approve the appointment/privileges for practitioners providing services for 1 of 1 current cardiology telemedicine/contracted entity (Entity #1). Failure to appoint/credential the practitioners providing telemedicine services placed the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the "BY-LAWS RULES AND REGULATIONS Of the MEDICAL STAFF" occurred on 03/26/19. These bylaws, revised September 2014, identified, "Section 4: PROCEDURE FOR APPOINTMENT . . . B) SPECIFIC QUALIFICATIONS: Only physicians, allied health professionals, podiatrists, dentists, optometrists and telemedicine practitioners who [are]: . . . b. Credentialed to provide services . . . D) Telemedicine: Telemedicine is the use of medical information exchanged from one site to another via electronic communication for the purpose of patient care, treatment and services. Individuals providing telemedicine services from a 'distant site' must be appointed to the Telemedicine Staff, unless the telemedicine service is provided in conjunction with a licensed practitioner at the hospital who is responsible for the patient's care. Telemedicine Services which require telemedicine privileges at the hospital may be processed by the hospital's credentialing committee or by . . . utilizing credentialing and privileging information from the telemedicine provider or practitioner's primary hospital/group or from a credentialing verification organization. . . ."

Review of the CAH's agreement with a cardiology services contractor occurred on 03/27/19. The agreement, dated April 1, 2016, stated, ". . . The interpretative services to be provided by the Cardiologists shall be completed in accordance with Contractor policies and procedures, as well as any and all applicable federal, state and local laws, rules and regulations, and the requirements of applicable accreditation agencies. . . . The Cardiologists who shall provide interpretive services shall be required to obtain and maintain clinical privileges and medical staff status in the appropriate category with Hospital prior to providing any services under the provisions of this Agreement. . . ."

On 03/26/19 at 4:00 p.m., a staff member (#3) stated the CAH had not appointed the physicians providing services through the cardiology agreement/contract with [Entity #1], and failed to know the names of the physicians who interpreted the electrocardiograms (ECGs).

On the morning of 03/27/19, a staff member (#2) verified the facility sent ECGs to the telemedicine cardiology department of Entity #1 for interpretation.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to store medications in a manner that prevented unauthorized access for 1 of 5 (Radiology Department) medication storage areas. Failure to store all medications securely may result in unauthorized access to medications.

Findings include:

Observation of the Radiology Department on 03/26/19 at 9:45 a.m. with the department's director (#2) showed an emergency kit (E-kit) located in the computed tomography (CT) scan room. The CT room and the E-kit lacked a locking system.

Review of the E-kit medication list showed medications included Benadryl, Adrenalin (stimulant), and Solu Medrol (steroid) administered for various contrast reactions during a CT scan.

During interview on 03/26/19 at 10:15 a.m., the radiology director (#12) confirmed staff should lock the E-kit in the cabinet to prevent possible unauthorized access.

Based on observation, facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed appropriate infection control practices related to Personal Protective Equipment (PPE) when cleaning/disinfecting soiled equipment, preparing equipment for sterilization and removing equipment from the steam sterilizer for 1 of 1 processing rooms. Failure to follow appropriate PPE and infection control practices may result in transmission of organisms and pathogens from equipment to patients.

Findings include:

Review of the CAH's policy titled, "Colonoscope policy and procedure for cleaning after use" occurred on 03/27/19. This policy, revised December 2018, stated,". . . Manual Cleaning-Apply PPE. . . ."

Observation of the surgical processing room occurred on 03/25/19 at 2:30 p.m. with a surgical registered nurse (#1). When asked about PPE worn during the sterilization process the nurse stated, "No I do not wear any PPE." The nurse stated staff wear the same attire during the entire cleaning and sterilization process.