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Based on interview and document review the critical access hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency. This had the potential to affect all patients and staff of the CAH.

Findings include:

During review of the CAH's emergency operations plan policy, it was noted that backup resources were evident for both potable and non-potable water in case of an interruption in normal water supply. The backup resources listed in the policy indicated there were 50 gallon barrels of non-potable water stored in the facility basement and a tank located near the loading dock which would supply 3 days of water shortage. Although the policy included the backup resource for non-potable water, it did not include a water distribution plan to be implemented during an emergency which involved loss of water supply.

During interview with the facility maintenance consultant on 8/12/14, at 9:30 a.m. it was indicated he was unaware of any plan which specified the amounts of water required by the various departments within the CAH nor of the need to plan for specified amounts of non-potable water in the event of water loss.

During interview with the manager of the Emergency Preparedness Program on 8/13/14, at 10:00 a.m. he indicated a plan which included the amount of water required during an interruption of normal water supply had not been developed nor had a water distribution plan been developed. The manager confirmed the CAH lacked a written plan /policy which specified the amounts of potable and non-potable water required during an emergency situation.

Based on interview and document review the critical access hospital (CAH) failed to ensure policies were developed with the advice of a group of professional personnel which included both a physician member and a member not a member of the CAH staff. This had the potential to affect all inpatients and outpatients who received care by CAH staff.

Findings include:

The CAH did not have a group of professional personnel established which provided advice with policy development and documentation was lacking to substantiate the group of professional personnel had been involved with policy review.

The Vice President of Patient Care Services was interviewed on 8/13/14, at 11:10 a.m. and stated the CAH had not yet established a group of professional personnel which included one or more physicians and at least one member who was not a member of the CAH staff. No further information was presented for review.

Based upon interview and document review the critical access hospital (CAH) failed to ensure a post-anesthetic evaluation had been completed for 4 of 8 outpatient surgical records reviewed (P1, P2, P3 & P4). This had the potential to affect any surgical outpatient who had anesthesia administered at the CAH.

Findings include:

The CAH did not ensure a post-anesthesia evaluation which included the patient's cardiopulmonary status, level of consciousness and any complications had occurred during the post-anesthesia recovery period.

P1 had an outpatient surgical procedure on 8/11/14 performed under general anesthesia administered by certified registered nurse anesthetist (CRNA)-A. There was no post-anesthesia evaluation documented in the medical record.

P2 had an outpatient surgical procedure performed on 8/12/14 under monitored anesthesia care (MAC) which included intravenous Versed (a sedative) and Fentanyl (an anesthetic medication) administered by CRNA-B. There was no post-anesthesia evaluation documented in the medical record.

P3 had an outpatient surgical procedure performed on 8/11/14 under general anesthesia administered by CRNA-A. There was no post-anesthesia evaluation documented in the medical record.

P4 had an outpatient surgical procedure on 8/12/14 under general anesthesia administered by CRNA-B. There was no post-anesthesia evaluation documented in the medical record.

CRNA-A was interviewed on 8/12/14, at 3:30 p.m. and verified a post-anesthesia evaluation had not been completed for P1 and P3. CRNA-A stated a post-anesthesia evaluation often was not completed for outpatients who had received anesthesia for same day surgical procedures. CRNA-A stated the CRNA staff often were busy in the surgical suite and were unable to complete a post-anesthesia evaluation prior to patient discharge.

The director of anesthesia services was interviewed on 8/13/14, at 12:35 p.m. and stated three CRNA staff were available in the surgical suite Monday through Friday from 7:00 a.m. until 3:30 p.m. and after hours were covered by the on-call CRNA. He stated a post-anesthesia evaluation was to be completed on every outpatient who received anesthesia including MAC and stated he was unaware the evaluations were not being completed.

A review of the Scope and Standards of Practice for Anesthesia Services, last revised July 2014, indicated a post-operative patient evaluation and treatment would be provided and would include determination of patient status on admission and of the post-operative surveillance period. The policy also indicated discharge documentation would include, but not be limited to, status of patient at discharge and compliance with discharge criteria.