HospitalInspections.org

Based on review of Medical Staff Bylaws, review of Administration Policies and Procedures, review of physician credential files, review of physician roster and staff interview, the CAH (Critical Access Hospital) failed to follow the Medical Staff Bylaws by not:
- Ensuring that the listing of requested privileges was legible for 2 of 8 physician credential files reviewed (Physicians K and L);
- Ensuring that the privilege forms used were for Niobrara Valley Hospital and not another hospital for 2 of 8 credential files reviewed (Physicians J and P);
- Ensuring that the privileges granted were for procedures that were performed at Niobrara Valley Hospital for 3 of 8 credential files reviewed (Physicians M and N and Osteopathic Physician O);
- Ensuring that all necessary documents were included in the credential file for 1 of 3 physician credential files for initial appointment (Physician P);
- Ensuring that granting of privileges was based on continued qualifications as spelled out in the medical staff bylaws for 2 of 8 physician credentials files reviewed (Physicians K and L); and
- Ensuring that a staff category as spelled out in the bylaws was specified for 3 of 8 credential files reviewed (Physicians M, P and Q).

The Facility Provider Listing with a print date of 4/1/11 listed 12 physicians, osteopathic physicians and/or podiatrists. Census on the first day of survey was 2 respite patients. Findings include:

A. Review of the Medical Staff Bylaws approved by the Governing Board on 11/30/09 revealed the following under Article V Clinical Privileges Section 2 Qualifications:
"The following constitute continuing qualifications for the exercise of privileges at the hospital. Each member and applicant for membership and clinical privileges, shall...
b. Competence. Possess and maintain demonstrated clinical competence including current knowledge, judgment, and technique, in his or her specialty area and for all privileges held or applied for;
c. Sufficient Contact/Review of Competence. Demonstrate that he or she will have sufficient patient care contact at the Hospital to permit the Medical Staff to continually assess competency for all requested privileges...
m. Compliance With Rules: Abide by the terms, conditions, and procedures of these Bylaws and the governing documents and policies of the Hospital;"

Review of the Administration Policy and Procedure with the objective "To establish guidelines for the collection and verification of credentials in accordance with the Medical Staff Bylaws" with a last reviewed date of 10/10 revealed a listing of items to be gathered after receipt of an application. This list included verifying the applicant's license on the Internet, querying the National Practitioner Data Bank and obtaining 3 professional peer evaluations.

This policy failed to include what information would be gathered to show continued competency, sufficient contact and compliance with rules.

B. Review of Physician K's credential file revealed a last approval date of 8/26/10 by the governing board and review of Physician L's credential file revealed a last approval date of 12/8/10 by the governing board. The delineation of privilege lists were copies with portions of the copy not legible. There were check marks in the requested columns for privileges that were not legible. Interview with the Administrator on 5/11/11 from 10:20 AM to 11:15 AM agreed that the privilege forms were not legible.

C. Review of Physician P's credential file and Podiatrist J's credential files revealed delineation of privilege lists with another CAH's name on the forms. Interview with the Administrator on 5/11/11 from 10:20 AM to 11:15 AM revealed the following:
- Was working on developing a different privilege list for Niobrara Valley Hospital but had not completed that task; and
- Was aware that they had used the privilege list from another hospital.

D. During the entrance conference on 5/9/11 from 12:45 PM to 1:00 PM with the Administrator and DON (Director of Nursing) revealed that the only surgical procedures that were performed in the hospital were endoscopes i.e., endoscopies and colonoscopies. Review of credential files revealed the following 3 physicians had requested and been granted privileges for procedures not performed at this CAH:
- Osteopathic Physician O - Carpal tunnel surgery, bone graft, joint reconstruction and amputations;
- Physician M - simple inguinal hernia surgery and venous ligation and stripping surgery; and
- Physician N - gall bladder surgery, small and large bowel surgery, carpal tunnel release, pancreatic surgery, simple inguinal hernia surgery and appendectomy.
Interview with the Administrator on 5/11/11 from 10:20 AM to 11:15 AM agreed that these 3 physicians and/or osteopathic physicians had been granted privileges for procedures that were not performed at this CAH.

E. Review of Physician P's credential file revealed the credential file lacked the following items that were required by the CAH's policies and procedures:
- a verification of the physician license on the Nebraska Department of Health and Human Services Website;
- Query of the National Practitioner Data Bank;
- 3 peer professional evaluations.
The credential file contained no information on this physician's competency.

F. Review of Physician K's and Physician L's credential files revealed no information in regards to:
- Current demonstrated clinical competence including current knowledge, judgment, and technique from quality reviews;
- Number of admissions to hospital and patients attended in the emergency room;
- Information on compliance with medical staff bylaws or hospital policies and procedures.
Interview with the Administrator on 5/11/11 from 10:20 AM to 11:15 AM confirmed the credential files lacked information on activity at the hospital.

G. Review of credential files for Physicians M, P and Q revealed these physicians had not been assigned to a medical staff category as required by the medical staff bylaws. The medical staff bylaws under Article IV listed the following medical staff categories: Active Staff; Affiliate Staff; Courtesy Staff; Consulting Staff; and Honorary Staff. Article III Section 2 stated "Membership on the Medical Staff, including assignment to on of the staff categories...granted by the Board."

Based on staff interview and review of the Annual Evaluation dated 9/1/09 through 8/31/10, the CAH (Critical Access Hospital) failed to ensure that the CAH's only NP (nurse practitioner) periodically reviewed the policies governing the services the CAH furnished. Census on the first day of survey was 2 respite patients. Findings include:

A. Telephone interview with the CAH's only NP on 5/12/11 at 9:45 AM to 10:30 AM revealed the following concerning review of policies and procedures:
- Does not participate in any committee that reviews policies and procedures; and
- Reviewed some specific policies and procedures that have gone through the Medical Staff for approval.

B. Review of the Annual Evaluation dated 9/01/09 - 8/31/10 revealed a page titled Health Care Policies with the following statement "A comprehensive review of all policy and procedure manuals was performed with the following individuals taking part..." Following the statement was a list of 12 individuals that participated in this review. The list did not include the CAH's only NP.

C. Interview with the Administrator on 5/11/11 from 12:10 PM to 12:40 PM revealed the NP started working at the hospital on 3/1/10. The Administrator confirmed that the NP had not participated in review of the CAH's policies and procedures since employment on 3/1/10.

Based on staff interview and review of policies and procedures, the CAH (Critical Access Hospital) failed to develop 1 of 8 types of policies and procedures (guidelines for the medical management of health problems that included the conditions requiring medical consultation and/or patient referral). The CAH had 1 nurse practitioner and no physician assistants working at the hospital. The census on the first day of survey was 2 respite patients. Findings include:

A. Review of the Niobrara Valley Hospital Emergency Room Policy Manual and the Niobrara Valley Hospital CAH Policy Manual, and review of the Medical Staff Bylaws and Rules and Regulations revealed no policy that indicated what regimens the CAH's only Nurse Practitioner should follow and also stipulated the condition in the illness or health care management when the Nurse Practitioner was to seek consultation from the collaborating physician and/or needed to refer the patient to a physician.

B. Interview with the CAH's only Nurse Practitioner on 5/12/11 revealed no awareness of a policy for medical management. Interview with the DON (Director of Nursing) on 5/12/11 at 11:05 AM indicated no awareness of a policy and procedure for medical management by the nurse practitioner. Interview with the Administrator on 5/12/11 at 9:40 AM also indicated no awareness of a policy for medical management by the nurse practitioner.

Based on review of the Annual Evaluation dated 9/1/09 through 8/31/10 and staff interview, the CAH (Critical Access Hospital) failed to include 2 of the 3 required professional members in the annual review of policies (nurse practitioner and a member not on staff at the CAH). Census on the first day of survey was 2 respite patients. Findings include:

A. Review of the Annual Evaluation dated 9/01/09 - 8/31/10 revealed a page titled Health Care Policies with the following statement "A comprehensive review of all policy and procedure manuals was performed with the following individuals taking part..." Following the statement was a list of 12 individuals that participated in this review. The list did not include the CAH's only nurse practitioner and did not include an individual not on staff at the hospital.

B. Telephone interview with the CAH's only nurse practitioner on 5/12/11 at 9:45 AM to 10:30 AM revealed the following concerning review of policies and procedures:
- Does not participate in any committee that reviews policies and procedures; and
-Reviewed a few specific policies and procedures that have gone through the Medical Staff for approval.

C. Interview with the Administrator on 5/11/11 from 12:10 PM to 12:40 PM confirmed that the CAH's only nurse practitioner and a member not on staff at the hospital were not included in the annual review of policies and procedures.

Based on observation, medical record review, policy review and interview, the facility failed to ensure medications were administered in accordance with facility policy and accepted standards of practice for 1 sampled plus 1 additional non-sampled patient (Patients 19 and 31). The census on the first day of survey was 2 respite patients. Findings include:

A. Review of the medical record for Patient 19 found the patient had been admitted for respite care on 3/17/09. Further review of the record found a physician order for the patient to receive Lasix 80 mg (millligrams) every AM and 40 mg every PM. (Lasix is a diuretic used to reduce excess fluid in the body). According to the history and physical dated 7/2/09 that was updated with physician visits, the patient had diagnoses that included congestive heart failure and atrial fibrillation.

Observation of medication pass on 5/11/11 at 5:00 PM for Patient 19 revealed the Licensed Practical Nurse (LPN) setting up the medication for 5:00 PM, brought into the medication room a metal cardex holder, picked up several medication cards, and explained they still used this system for medication administration. She pointed out the medication shelf for the 2 respite patients and she reached for a bottle of Lasix 80 mg that she took off the shelf for this patient. She opened the bottle of Lasix 80 mg and tapped out the pills into the lid. She said there weren't any half tablets so she would have to split 1 in half to get the correct dosage of 40 mg. She then got a pill cutter and set it on the counter. Using her bare fingers she took a pill from the lid of the bottle and placed in the cutter, she split the pill, removed the 2 halves with her bare fingers and placed them in the bottle lid. She put half in a medication souffle cup and the other half back in the pill bottle. She said "There will be a half tablet in the bottle for the next time." She recapped the bottle and placed it back on the shelf. She had touched many surfaces prior to touching the pill with her bare fingers. The medication was taken to the patient's room and administered as ordered. The LPN contaminated the pill by handling it bare handed and contaminated the whole bottle of Lasix 80 mg by putting half of a pill back in the bottle.

At www.royalfree.org web site, there is information on Oral Drug Administration Guidelines that states "Without touching the drug, empty the required dose into a clean medicine container." The reason for doing this is stated as "To prevent cross infection and protect the nurses from exposure (and possible absorption) of the active ingredient."

An interview with the Director of Nursing (DON) on 5/12/11 at 10:20 AM revealed she would expect handwashing and wearing gloves to cut the pill. She also said she would not have put the half pill back in the bottle, but would have wasted it.

B. On 5/11/11 the facility admitted another patient to a swingbed in the afternoon. Observation of the administration of an intravenous (IV) antibiotic was completed on 5/11/11 at 5:15 PM. Patient 31 was an un-sampled patient admitted on 5/11/11 with an order for Levaquin 750 mg IV. The Registered Nurse (RN) was going to administer the medication around 5:00 PM. She obtained the supplies needed, including the bags of Levaquin and Normal Saline, IV tubing, alcohol pads, medication card, 10 cc bottle of sterile saline for flush, a 10 cc syringe to do the flush. She drew up the 10 cc in the syringe for the flush in the medication room, then took everything to the patient's room. There was already a Plum IV Pump in the room to regulate the infusion of the medication. The RN explained to the patient what she was doing. She washed her hands at the sink in the room. The RN removed the protective cap from the infusion outlet port and removed the cap from the IV tubing spike and spiked the infusion bag. She hung the 1st bag (Normal Saline) on the IV pole, then did the same process with the bag of Levaquin and tubing. Handling bag and tubing uncovered on both bags while spiking and hanging on the IV pole. The tubing was filled and run through the Plum pump. Then she accessed the peripheral indwelling central catheter line (PICC), wiped it with an alcohol wipe and completed the flush with 10 cc of normal saline. The RN then wiped the PICC line access again with alcohol and put in the IV tubing line. The Plum pump was set for the amount of time to infuse and activated without difficulty. The RN cleaned up her supplies and disposed of them, then washed her hands.

Review of the facility policy on changing IV tubing provided by the DON on 5/12/11 revealed it had been reviewed and revised 12/08. The DON said this was the only policy that addressed the situation with Patient 31. The policy directed the RN was to wear disposable gloves. An interview with the DON on 5/12/11 at 10:20 AM confirmed she would expect the RN to wear gloves for IV medication administration.