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Based on observation, policies and staff interviews the Critical Access Hospital (CAH) maintenance staff failed to ensure completion of the required BioMed checks on Intravenous (IV) infusion pumps located in a storage room #149, surgery, Cardiac trauma room, post anesthesia care unit (PACU), Emergency Room (ER) Bay #3, and ER Ortho exam room. The were concerns with 9 of 11 IV infusion pumps set up and available for patient use.

Failure to maintain electrical safety checks could potentially expose patients to IV infusion pumps that may malfunction due to electrical issues.

Findings included:

1. Review of the undated "Electrical Safety and Inspection" policy, revealed it stated in part, "...Electrical safety is the responsibility of the Maintenance Department...Maintenance personnel are responsible for annual...safety tests of all patient beds and electrical receptacles related to patient care for polarity, ground and tension..."

2. Observations during initial tour revealed:

a. The initial tour of the medical surgical unit on 6/6/11 at 11:10 AM, revealed 8 Pulse XL IV infusion pumps were in storage room #149 and 5 of the 8 IV pumps had a BioMed Electrical safety check date of 5/10. The Pulse XL IV infusion pumps were identified as #5083, #5073, #5076, #5077, and #5067.

During an interview on 6/6/11 at 11:15 AM, Staff J, the Nursing IT coordinator, confirmed the staff plugged in the IV infusion pumps to charge them so they were ready for patient use. Staff J confirmed the IV infusion pumps contained outdated BioMed electrical safety checks.

b. Initial tour of the PACU on 6/7/11 at 10:50 AM, revealed a Plum XL IV infusion pump with a BioMed Electrical safety check date of 5/10. During an interview on 6/7 at 10:50 AM, Staff M, the Surgery Manager, confirmed the IV infusion pump were available for patient use.

c. Initial tour of the ER on 6/7/11 at 10:50 AM, revealed Plum XL IV infusion pumps with a BioMed Electrical safety check date of 5/10. One Plum XL IV infusion pump (#5039) was in the ER Cardiac/Trauma room, 1 Plum XL IV infusion pump (#5099) was in ER Bay #3 room, and 1 of 2 Plum XL IV infusion pumps #(5032) had the BioMed Electrical safety check dates of 5/10.

During an interview on 6/7/11 at 10:50 AM, Staff M, Surgery Manager, confirmed the IV infusion pumps located in the ER areas were available for patient use.

3. During an interview on 6/8/11 at 8:45 AM, Staff J stated the BioMed technician did not update the 9 IV infusion pumps because these IV infusion pumps were in use in patient rooms at that time. The plan is to have these IV infusion pumps checked when the Bio Med technician returns later this month.

During an interview on 6/9/11 at 7:30 AM, the Director of Nursing (DON) called the BioMed technician. The BioMed technician acknowledged there were unchecked IV infusion pumps and stated the IV infusion pumps would be checked during the next visit. The DON stated maintenance did not have any documentation explaining the reason the BioMed technician failed to check these IV infusion pumps in a timely manner. The DON stated the BioMed staff technician kept records of the due dates for the IV infusion pumps.

4. Review of the undated "Electrical Safety and Inspection", stated in part, "...Electrical safety is the responsibility of the Maintenance Department...Maintenance personnel are responsible for annual...safety tests of all patient beds and electrical receptacles related to patient care for polarity, ground and tension..."

Based on observations, review of documentation, and staff interviews, the Critical Access Hospital (CAH) Surgery administrative staff failed to ensure proper storage of anesthesia drugs as specified by the manufacturer's recommendations. The CAH Surgery administrative staff reported approximately 10 surgical cases a month required use of the identified medications.

Failure to ensure proper temperature controls of pharmaceuticals could potentially cause pharmaceuticals to lose potency, thus not providing desired effect to patients.

Findings included:

1. Tour of the operating room (OR) on 6/7/11 at 10:50 AM revealed the following anesthesia drugs stored in the single anesthesia carts in the OR area:

a. 1 of 1 unopened Succinylcholine Chloride Inj. 10 ml Multidose Vial lacked the date the staff removed the vial from the refrigerator and stored it at room temperature.

The manufacturer's product insert for Succinylcholine Chloride Inj., dated 2004, stated in part ". . . The multidose vials are stable for up to 14 days at room temperature without significant loss of potency. . . ."

b. 2 of 3 unopened Rocuronium Bromide Inj. Multidose Vials lacked the date the staff removed the vials from the refrigerator and stored them at room temperature.

The manufacturer's product insert for Rocuronium Bromide Inj., dated February 2009, stated in part ". . . Rocuronium Bromide Injection should be stored in a refrigerator, 2-8 degrees C (36-46 degrees F). DO NOT FREEZE. Upon removal from refrigeration to room temperature storage conditions (25 degrees C/77 degrees F), use Rocuronium Bromide Injection within 60 days. Use opened vials of Rocuronium Bromide Injection within 30 days. . . ."

2. Review of Pharmacy documentation for "Refrigerated Medications" stated Rocuronium/Zemuron with recommended storage as refrigeration and stability at room temp of 60 days.

Review of Pharmacy documentation of "Refrigerated Medications" stated Succinylcholine/Anectine Auelicin with recommended storage as refrigeration and stability at room temp of 14 days.

3. During an interview on 6/7/11 at 12:35 PM, Staff Q acknowledged the Succinylcholine and Rocuronium vials lacked evidence showing the date staff removed the vials from the refrigerator. Staff Q stated the vials need to have the date written on the vials when removed from the refrigerator.

During an interview on 6/8/11 at 11:20 AM, Staff K, Pharmacist, stated all vials of Succinylcholine and Rocuronium are to be dated by the person who removes the vials from the refrigerator. Staff K acknowledged the Succinylcholine is good for 14 days after removal from the refrigerator.

Based on observation, policy review, document review and staff interview the Critical Access Hospital (CAH) failed to:

A. measure food temperatures of all foods prior to service, ensure stored food was labeled and dated and protected from contamination, ensure frozen foods were maintained at 0 degrees Fahrenheit or below, and ensure good repair of equipment to maintain good food quality and minimize the potential for foodborne illness; and

B. ensure staff are trained in modified diets and patients nutrient needs are met through following the planned menu, as approved by the CAH dietitian for 7 of 7 patients (Patients #1, 2, 3, 4, 5, 6, 7). The dietary manager reported the CAH served an average of 10 to 17 patients at each meal.

Findings included:

A. Observations during the initial kitchen tour on 6/6/11 beginning at 11:05 a.m., identified the following concerns:

1. Staff stored the following items were opened, unlabeled, and undated:
a. Hobart freezers in the dry storage area contained 3 bags of fish fillets, 2 bags of peas and 1 bag of noodles.
b. The Hobart refrigerators contained a 1 2-cup container of margarine, a salad bar crock of bacon bits, a squeeze bottle of salsa and taco sauce, and a squeeze bottle of ranch and western salad dressing.
c. The True refrigerator contained a 5 pound bag of parmesan cheese, 11 2-cup containers of margarine, 2 1-gallon containers of Kraft mayonnaise, 2 1-gallon containers of pickle relish, a 1 gallon jar of olives, a 1 gallon container of ketchup, and 1 gallon container of mustard.
d. The Victory refrigerator contained a package of sliced American cheese and a package of sliced Swiss cheese.
e. The Victory freezer contained three and a half trays of individually dished ice cream cups.
f. The So-Low freezer contained a bag of eggs rolls, a bag of garlic bread, and a bag of raspberries.

2. The Hobart freezer, located in the dry storage room on the right hand side, revealed a cracked door gasket on the top right side and contained a black substance that wiped off to the touch. The freezer revealed moisture along the top of the door and along the right corner outside of the door. A puddle of water, approximately twelve inches in diameter, was on the floor underneath the right corner of the freezer. The thermometer, located inside the unit, revealed a temperature of 6 degrees Fahrenheit. The same conditions were present the next day, on 6/7/11 at approximately 8:30 a.m., with an inside temperature of 6 degrees Fahrenheit.

Review of a document titled "2011 SR freezer", posted on the right-hand Hobart freezer in the dry storage area, revealed the daily temperature log of the unit beginning in January 2011. All the documentation showed temperatures above 0 degrees Fahrenheit.

Review of a policy titled "Food Storage/Temperatures", with a review/revised date of 6/4/09 revealed item #2 stated in part "Frozen storage space is arranged before food arrives, and frozen foods are stored at 0 degrees Fahrenheit or below." Item #4 stated in part "If temperatures fall outside of the range, maintenance is then notified".

3. Observations on the 6/6/11 tour and on 6/7/11 approximately 8:40 a.m. showed a bulk container of dry milk containing a scoop with the handle touching the product. During an interview at the time of the 6/7/11 observation, Staff A, dietary manager, reported staff were directed to store the scoop upright inside the container, without the scoop handle touching the dry milk.

4. During the full kitchen environment tour on 6/7/11 beginning at 8:30 a.m., observations identified the following concerns.

a. One of 1 medium-sized plastic cutting board and 3 of 3 large plastic cutting boards revealed stained surfaces with multiple surface cuts and a worn, unsantizable finish.

b. An unlabeled four-quart plastic container of a white granulated substance revealed a measuring cup laying on top of the product inside the container. In an interview at the time, Staff A reported the container held instant mashed potatoes and expected no measuring device should be stored inside with the product.

c. Two large Hobart mixers contained a covering of a yellowish-green substance that felt greasy to the touch on the portion of the mixer where the beater attached and rotated. The Hobart mixer located on the floor revealed a liquid brownish-gold substance on an area that appeared ready to drip. Both mixers had stickers with a date of 5/28. In an interview at the time, Staff A reported the sticker indicated the date staff last cleaned the equipment.

5. Observation of meal service on 6/7/11 from approximately 11:05 a.m. to 11:56 a.m. revealed the following concern:

At 11:05 a.m., Staff F, a cook, placed a pan of meat loaf and peas in the steamtable while preparing to serve meals-on-wheels. Meals-on wheels are to-go meals delivered to disabled and elderly persons living in community. Staff F measured and recorded the temperature of the items and proceeded to serve meals-on-wheels. At 11:42 a.m., Staff F, obtained a fresh pan of meatloaf and placed it in the steamtable, in preparation for the CAH patients' meal service. The original pan of peas remained in the steamtable. At 11:47 a.m. Staff F initiated meal service for CAH patients but failed to measure a temperature of the meatloaf, peas, mashed potatoes, pureed meatloaf, and pureed peas.


6. Observation of meal service on 6/8/11 from approximately 11:02 a.m. to 11:54 a. m. revealed the following concern:

At 11:02 a.m., Staff F placed a pan of pork chops and green beans in the steamtable while preparing to serve meals-on-wheels. Staff F measured and recorded the temperature of the items and proceeded to serve meals-on-wheels. When finished, Staff F inquired if she should temp pureed products now and advised to follow the usual routine. Staff F did not measure a temperature of the pureed food products at that time.

At 11:40 a.m., Staff F initiated meal service to patients. Staff F inquired again if she should temp pureed products now and advised her to follow the usual routine. Staff F initiated meal service without measuring a temperature of the pork chops, green beans, pureed pork chops, pureed green beans, 2 baked potatoes, and 2 steaks.

7. Review of a policy titled "Food Storage/Temperatures", with a review/revised date of 6/4/09 revealed item #5b directed staff on the minimum internal cooking temperatures and item #5c directed staff on holding temperatures.

8. During an interview on 6/8/11 at approximately 2:35 p.m., Staff A, dietary manager, reported staff were expected to measure the temperature of all food served to patients.

B. The CAH's Week 3 menu identified a 1/2 cup portion of peas planned for the lunch meal on Tuesday, 6/7/11 and a 1/2 cup portion of green beans planned for the lunch meal on Wednesday, 6/8/11.

1. Staff F, a cook, utilized a 3 ounce spoodle (food portioning device equivalent to 1/3 cup) to serve the peas during meal service on 6/7/11 from approximately 11:05 a.m. to 11:56 a.m. Patients #1, #3, #4 and #5 received a smaller portion size than designated on the CAH menu.

Staff F utilized a 3 ounce spoodle (food portioning device equivalent to 1/3 cup) to serve the green beans during meal service on 6/8/11 from approximately 11:02 a.m. to 11:47 a.m. Patients #1, #2, #6 and #7 received a smaller portion size than designated on the CAH menu.

2. During an interview on 6/8/11 at approximately 1:40 p.m., Staff B, dietitian, reported she planned and approved the CAH's menu and expected dietary staff to serve the portion sizes specified on the menu, in order to meet the patient's nutrient needs.

During an interview on 6/8/11 at approximately 2:35 p.m., Staff A reported staff were expected to serve the portion size specified on the menu.

Review of a policy titled "Food Preparation and Handling", with a review/revised date of 6/8/09, revealed item #12 stated "The Dietary Manager/Dietitian are responsible for teaching portion control to employees, utilizing the portion control recipe guides as tools, and for monitoring and evaluating portions served

3. The CAH's Week 3 menu identified in part a 1/2 cup peas, 1/2 banana, angelfood dessert and bread/margarine planned for the regular lunch meal on Tuesday, 6/7/11 and a 1/2 cup green beans, peanut butter fingers and bread/margarine planned for the lunch meal on Wednesday, 6/8/11.

Observation of meal service and delivery on 6/7/11 from approximately 11:05 a.m. to 12:00 p.m. revealed the following concern:

Observed Staff G, assistant cook, prepare pureed food items for Patient #1. Staff G pureed a 1/3 cup portion of peas. Staff G did not prepare a pureed bread serving for the patient.

At 11:57 a.m., observed Patient #1's meal tray served without a bread serving and with a serving of applesauce and a serving of pudding in place of the designated angelfood dessert and 1/2 banana. Patient #1 did not receive the menu as planned.

Observation of meal service and delivery on 6/8/11 from approximately 11:02 a.m. to 11:54 a.m. revealed the following concern:

At 11:52 a.m. observed patient #1's meal tray served without a bread serving. In addition, observed Patient #1's meal tray served with a serving of pudding in place of the designated peanutbutter fingers. Patient #1 did not receive the menu as planned.

During an interview on 6/8/11 at approximately 11:30 a.m., Staff F reported a pork chop and a 1/3 cup serving of green beans pureed for Patient #1. When Staff F asked how to know what to puree for patients, she reported that a serving of each item on the menu is pureed. When asked about the bread item specified on the menu, she reported the bread is not pureed.

During an interview on 6/8/11 at approximately 1:40 p.m., Staff B, dietitian, reported dietary staff are directed to puree the main menu items, if a patient on a pureed diet has not completed a select menu. Staff B confirmed the bread item specified on the planned menu not pureed for patients on a pureed diet. She stated pureed bread does not work well and had not been well accepted by patients in the past. She admitted there was no replacement of the nutritional value of the bread in another manor.

During an interview on 6/8/11 at approximately 2:35 p.m., Staff A relayed the CAH did not have a policy or specific written guidelines to direct staff on the expectation for pureed food. She reported staff are trained on the process and are directed to puree the items selected, if the patient chose from the menu, and if there was not a menu, are directed to puree the items specified on the main menu. She reported the bread item on the menu not pureed.

Review of a policy titled "The menu" with a review/revised date of 6/5/09 revealed " It is the policy of FCMC to provide patients with a 3-week, selective menu that meets their diet order and nutritional needs. The policy purpose stated in part " ... provision of well-planned nutritious menu". Item #14 stated The dietitian must review and approve in writing all menus used by the CAH, as well as any menu changes/substitutions. Item #15 stated "The regular menu provides the basic pattern for planning all modified diets".

Review of a policy titled "Select Menu System" with a review/revised date of 6/4/09 revealed item #1e stated "if a menu is not completed for the following day, the "special" will be sent to patient if the patient's request was not received prior to service". Staff A relayed the "special" referred to the items listed on the main menu.

4. Review of an untitled document titled "Employee Education" revealed all staff members listed completed a sanitation and simplified diet manual course except Staff C. The document indicated Staff C completed sanitation on 8/21/10 and "working on" the simplified diet manual. The document lacked the newest employee, Staff D, assistant cook.

During an interview on 6/8/11 at approximately 1:40 p.m., Staff B, dietitian, reported new employees received an education packet on sanitation and the simplified diet manual shortly after hire. She relayed all new employees are required to complete the education packets with no specific time frame required for completion. Staff B verified Staff D, assistant cook, completed the sanitation course and provided Staff D's packet the dietitian in the process of checking for review.

During an interview on 6/8/11 at approximately 2:35 p.m., Staff A relayed new employees are provided with an education packet on sanitation and the simplified diet manual within the first month after hire. She reported completion of both education packets were requirements for all staff in the dietary department. She stated staff were directed to complete the sanitation packet first followed by the simplified diet manual packet and were informed of an expected completion date. Staff A reported she generally informed staff to have the material completed within one month. When questioned about the two employees whom have not completed the simplified diet manual packet, Staff A reported Staff C, a dietary aide, trained to fill multiple positions, started in 7/10 and encountered difficulty completing the material because she held a second job and worked many hours. Staff A reported Staff D, employed at the CAH for a couple months, had completed the sanitation course. She reported Staff D received the simplified diet manual packet but had not yet completed it and she had recently followed up to remind Staff D to complete the packet.

Review of a policy titled "Orientation for New Employee for Dietary Department" with a review/revised date of 6/17/09 revealed item #2 stated "Dietary Department orientation will be completed by the new employee within the first month of hire". Item #2a. viii. 1. included "completion of Simplified Diet Manual and test questions" under the orientation requirements.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to protect all confidential patient information from unauthorized access in the Radiology department, the Laboratory department, and the Diabetic Education department, and the Medical Records department. The Radiology administrative staff identified an average of 1005 procedures per month including in-patients and out-patients. The Administrator identified an average of 12 inpatients per day.

Failure to secure medical records against unauthorized access could result in identity theft and/or unauthorized disclosure of personal medical information.

Findings included:

1. Observations during the tour of the Radiology department, with Staff N, Radiology Supervisor, on 6/6/11 at 3:10 PM revealed 2 - 5 shelf units containing approximately 250 film jackets in an open area, called the office. Each film jacket contained patient identification information, x-rays, and reports.

Tour of a file room revealed approximately 15 shelves containing approximately 300 files per shelf in an open area of the room. Each file contained patient identification information, x-rays, and reports. Also in the file room, were 4 barrels 2 feet in diameter and 3 feet tall. These barrels were full of x-ray films containing patient identification information. Another same sized barrel of the contained approximately 10 inches of x-ray films. Staff N identified approximately 140 files per inch for approximately 5,040 films per full barrel.

During an interview on 6/6/11 at 3:10 PM, Staff N, Radiology Supervisor stated the housekeeping staff cleaned the Radiology department at approximately 6:30 PM. Staff N further acknowledged Radiology staff was not always present when the housekeeping staff cleaned the department. According to Staff N, the Radiology department remains unlocked until approximately 8:00 PM.

2. During an interview regarding the facility diabetes education program, on 6/7/11 beginning at 2:10 p.m., Staff E, diabetes education program manager, reported the storage of diabetes education records in a four-drawer unlocked file cabinet in her office. Staff E obtained one record from the cabinet to show surveyor the type of information contained in the records. Observed information included physician referral information, assessment information, blood glucose records, and education information. Staff E estimated she stored approximately thirty records in her office. She reported the file cabinet did not lock. Staff E reported she closed the door to her office when unoccupied, but it remained unlocked during her work hours. She reported housekeeping accessed her office for cleaning purposes weekly on Wednesday at 11:30 AM.

Observation showed the location of Staff E's office was in a hallway with enterostomy therapy, physical therapy and the emergency room. The waiting areas for physical therapy and the emergency room were in close proximity to Staff E's office.

In an interview on 6/8/11 at 8:55 AM, Staff E confirmed lack of a specific policy related to the storage of diabetes education records.

3. Observations on during the tour of the Medical Records department, with Staff O, Health Information Director, on 6/8/11 at 7:50 AM revealed several shelves containing patient medical records. Staff O stated housekeeping staff had a key to the Medical Records department. The housekeeping staff cleaned the department on Wednesday nights after the Medical Records Department closed and staff left for the day. The housekeeping staff did not have supervision by the medical records staff while they cleaned the Medical Records department.

Review of CAH policy/procedure on 6/8/11 titled, "Security in Medical Records" dated 3/11, stated in part ". . . Policy: . . . When the department is closed, the doors are locked, and only the Critical Care Coordinator and Business Office have keys to the department. . . . "

4. Observations with Staff R, Laboratory Manager, on 6/8/11 at 9:05 AM revealed unlocked drawers of reference lab patient information. Staff R stated housekeeping cleaned the department at approximately 6:00 PM when Laboratory staff potentially were not present in the department.

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) Surgical administrative staff failed to ensure delineation of current privileges for 9 of 9 practitioners reviewed. (Practitioners A, B, J, L, P, Q, R, S, T) The CAH Surgical administrative staff reported approximately 90 surgical cases performed each month.

Failure to ensure current delineation of privileges for practitioners providing services in the operating room could potentially result in unauthorized individuals performing surgical procedures that could put the patient at risk for surgical complications.

Findings included:

1. Review of surgeon and anesthesia providers privileges available to the surgery staff revealed the following:
a. Practitioner A privileges revealed no privileges were available;
b. Practitioner B privileges revealed the last re-appointment were dated 12/13/2004;
c. Practitioner J privileges revealed the last re-appointment were dated 5/16/2005;
d. Practitioner L privileges revealed the last re-appointment were dated 12/13/2004;
e. Practitioner P privileges revealed the last re-appointment were dated 12/19/2005;
f. Practitioner Q privileges revealed the last re-appointment were dated 12/13/2004;
g. Practitioner R privileges revealed the last re-appointment were dated 3/12/2009;
h. Practitioner S privileges revealed the last re-appointment were dated 1/24/2008; and
i. Practitioner T privileges revealed no privileges were available

2. During an interview on 6/8/11 at 10:30 AM, Staff M, Surgery Nurse Manager acknowledged the lack of current privileges available for the surgery staff for Practitioners A, B, J, L, P, Q, R, S, and T.

Staff M reported the following information.
a. Practitioner A performed an average of 40 surgical cases per month during the past 12 months with the last surgical case performed on 6/7/11.
b. Practitioner B performed an average of 20 surgical cases per month during the past 12 months with the last surgical case performed on 6/7/11.
c. Practitioner J performed an average of 6 surgical cases per month during the past 12 months with the last surgical case performed 6/3/11.
d. Practitioner L performed an average of 16 surgical cases per month during the past 12 months with the last surgical case performed on 5/27/11.
e. Practitioner P performed an average of 3 surgical cases per month during the past 12 months with the last surgical case performed on 6/6/11.
f. Practitioner Q performed an average of 1 surgical case per month during the past 12 months with the last surgical case performed on 4/25/11.
g. Practitioner R provided anesthesia services to an average of 35 surgical cases per month during the past 12 months with the last service performed on 6/7/11.
h. Practitioner S provided anesthesia services to an average of 10 surgical cases per month during the past 12 months with the last service performed on 6/8/11.
i. Practitioner T provided anesthesia services to an average of 4 surgical cases per month during the past 12 months with the last service performed on 6/3/11.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure completion of an external peer review by the required entity practitioners during the credentialing process. This finding applied to review of 17 of 17 practitioners furnishing care and services to the CAH patients. (Practitioners A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, and Q) The sample included 7 of 7 total active staff, 9 of 86 total courtesy staff, and 1 of 4 total podiatrists.

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff members misdiagnosis and/or providing inappropriate or substandard patient care.

Findings included:

1. Review of documentation for the past credentialing period of 1/1/2011 - 12/31/2012, revealed the CAH quality staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients (Practitioners A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, and Q).

Practitioners A B, C, D, E, F, G, H, I, J, K, and L were re-credentialed on 11/27/2010 by the Medical Staff and on 1/24/2011 by the Governing Body. The documentation lacked evidence charts were sent out for external review.

The CAH administrative staff identified the practitioners provided services to the number of patients the previous 12 months as follows:
a. Practitioner A - average of 40 patients per month
b. Practitioner B - average of 20 patients per month
c. Practitioner C - 62 patients per previous 12 months
d. Practitioner D - 192 patients per previous 12 months
e. Practitioner E - 148 patients per previous 12 months
f. Practitioner F - 147 patients per previous 12 months
g. Practitioner G - 56 patients per previous 12 months
h. Practitioner H - 617 patients per previous 12 months
i. Practitioner I - 1267 patients per previous 12 months
j. Practitioner J - average of 6 patients per month
k. Practitioner K - average of 2 patients per month
l. Practitioner L - average of 16 patients per month

Review of documentation for the past credentialing period of 1/1/2011 - 12/31/2012, revealed the CAH quality staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients (Practitioners M, N, O, Q):

Practitioners M, N, O, Q were re-credentialed on 12/7/2010 by the Medical Staff and on 1/24/2011 by the Governing Body revealed no charts were sent out for external review.

The CAH administrative staff identified the practitioners provided services to the number of patients the previous 12 months as follows:
a. Practitioner M - 77 patients per previous 12 months
b. Practitioner N - 850 patients per previous 12 months
c. Practitioner O - 903 patients per previous 12 months
d. Practitioner Q - average of 1 patient per month

Review of documentation for the past credentialing period of 1/1/2010 - 12/31/2011, revealed the CAH quality staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients (Practitioner P):

Practitioner P re-credentialed on 12/1/2009 by the Medical Staff and on 12/21/2010 by the Governing Body revealed no charts sent out for external review.

The CAH administrative staff reported Practitioner P provided services to an average of 3 patients per month during the previous 12 months.

2. Review of the CAH policy/procedure on 6/9/11 showed the lack of a policy to address the completion of external peer review for all practitioners providing care and services to the CAH patients during the credentialing process.

Review of the CAH Network agreement dated November 2002 revealed the following in part, ". . . [Network Hospital] through participating members of its administrative staff and other personnel designated by [Network Hospital], assists Floyd County Memorial Hospital in reviewing the quality and appropriateness of the diagnosis and treatment furnished by Floyd County Memorial Hospital doctors of medicine or osteopathy for purposes of assisting Floyd County Memorial Hospital carry out the requirements of its quality assurance plan. . . "

3. During an interview on 6/9/11 at 8:40 AM, Staff H, Director of Nursing, stated the CAH administrative staff had not sent records for Practitioners A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q for external peer review. Staff H confirmed Practitioners A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q had provided services to patients of the CAH during the last credentialing period.

Based on review of the Critical Access Hospital (CAH) documents, medical records and staff interviews, the CAH administrative staff failed to ensure the skilled care patients admitted to the swing bed unit received the required Patient Rights document. Concerns for 9 of 9 swing bed medical records reviewed. (Patients # 8, 9, 10, 11, 12, 13, 14, 15, and 16) The administrative staff reported a daily average of 6 skilled care patients in swing beds.

Failure to present and explain to the skilled patients and/or legal representative all of their rights in a language that he or she could understand could potentially place a patient at risk for a lack of understanding of his/her rights while in the skilled care level. The patient and/or legal representative's lack of information of patient's rights could potentially put the patient at risk of the inability to exercise his/her rights and to understand they have a right to be free from coercion, discrimination and reprisal from the CAH.

Findings included:

1. Review of the "Swing Bed Program" document, revised 4/11, stated in part, "...Patient rights on swing bed...the patient's rights...are presented and explained to each patient at the time of admission to swing bed..."

2. Review of the "Swing Bed - Patient Rights", revised 4/11, lacked the following patient rights:
a. (1) The resident has the right to exercise his or her rights as a resident of the facility & as a citizen or resident of the United States.
b. (2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.
c. (3) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf.
d. (4) In the case of a resident who has not been adjudged incompetent by the State court, any legal-surrogate designated in accordance with State law may exercise the resident's rights to the extent provided by State law.

3. Review of the following Swing Bed patient's medical records revealed the patient rights document signed by the patient lacked the above patient rights.
a. Patient #8, admitted to swing bed on 6/6/11, signed the incomplete patient rights document on 6/6/11.
b. Patient #9, admitted to swing bed on 6/4/11, signed the incomplete patient rights document on 6/4/11.
c. Patient #10 admitted to swing bed on 6/4/11, signed the incomplete patient rights document on 6/4/11.
d. Patient #11, admitted to swing bed on 6/3/11, signed the incomplete patient rights document on 6/4/11.
e. Patient #12, admitted to swing bed on 5/6/11, signed the incomplete patient rights document on 5/9/11.
f. Patient #13, admitted to swing bed on 5/11/11, signed the incomplete patient rights document on 5/12/11.
g. Patient #14, admitted to swing bed on 5/7/11, signed the incomplete patient rights document on 5/7/11.
h. Patient #15, admitted to swing bed on 4/5/11, signed the incomplete patient rights document on 4/6/11.
i. Patient #16, admitted to swing bed on 4/18/11, signed the incomplete patient rights document on 4/19/11.

4. During an interview on 6/6/11 at 2:20 PM, Staff L, Registered Nurse (RN) and discharge planner, stated the staff informed the patients of their rights at the time of admission by Staff L, the Activity Coordinator or nurse on duty. The swing bed admission package given to the Swing Bed patients contains 2 patient rights documents, one for the patient to sign and one to keep for review.

During an interview on 6/9/11 at 11:30 AM, Staff L and Staff H, Director of Nursing confirmed the Swing Bed Patient Rights document lacked some of the required patient rights. The DON stated, we took the rights from the CAH regulations, "I guess we missed some".

Based on review of the Critical Access Hospital (CAH) documents, medical records and staff interviews the CAH administrative staff failed to ensure the patients admitted to the swing (skilled) unit received the required Patient Rights document. Concerns for 9 of 9 swing bed medical records reviewed. (Patients # 8, 9, 10, 11, 12, 13, 14, 15, and 16) The administrative staff stated a daily average of 6 skilled patients.

Failure to present and explain to the skilled patients and/or legal representative all of their rights could potentially result in the patients understanding of their right to consent or refuse medical treatment and their right to formulate an advance directive that would assign a person who would be familiar with the patients desires for medical treatment.

Findings included:

1. Review of the "Swing Bed Program" document, revised 4/11, showed it stated in part, "...Patient rights on swing bed...the patient's rights...are presented and explained to each patient at the time of admission to swing bed..."

2. Review of the "Swing Bed - Patient Rights", revised 4/11, lacked the following patient right:
"...provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive..."

3. Review of the following Swing Bed patient's medical records revealed the patient rights document lacked the above patient right.
a. Patient #8, admitted to swing bed on 6/6/11, signed the incomplete patient rights document on 6/6/11.
b. Patient #9, admitted to swing bed on 6/4/11, signed the incomplete patient rights document on 6/4/11.
c. Patient #10, admitted to swing bed on 6/4/11, signed the incomplete patient rights document on 6/4/11.
d. Patient #11, admitted to swing bed on 6/3/11, signed the incomplete patient rights document on 6/4/11.
e. Patient #12, admitted to swing bed on 5/6/11, signed the incomplete patient rights document on 5/9/11.
f. Patient #13, admitted to swing bed on 5/11/11, signed the incomplete patient rights document on 5/12/11.
g. Patient #14, admitted to swing bed on 5/7/11, signed the incomplete patient rights document on 5/7/11.
h. Patient #15, admitted to swing bed on 4/5/11, signed the incomplete patient rights document on 4/6/11.
i. Patient #16, admitted to swing bed on 4/18/11, signed the incomplete patient rights document on 4/19/11.

4. During an interview on 6/6/11 at 2:20 PM, Staff L, Registered Nurse (RN) and discharge planner, stated the staff informed the patients of their rights at the time of admission by Staff L, the Activity Coordinator or nurse on duty. The swing bed admission package given to the Swing Bed patients contains 2 patient rights documents, one for the patient to sign and one to keep for review.

During an interview on 6/9/11 at 11:30 AM, Staff L and Staff H, Director of Nursing confirmed the Swing Bed Patient Rights document lacked all of the required patient rights. The DON stated, we took the rights from the CAH regulations, "I guess we missed some".