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Based on observation, review of documents, and staff interview, the Critical Assess Hospital (CAH), failed to conduct preventative maintenance for 2 of 2 EKG (Electrocardiogram) machines and 2 of 2 sleep study machines on a yearly basis. The CAH identified 2,605 EKG's and 131 sleep studies for 2014.

Failure to inspect patient care equipment could potentially result in patient injury and unreliable readings from the equipment.

Findings include:

1. Observation on 3/17/15 at 3:30 PM, Staff F, Director of Respiratory Therapy, during the initial tour of the Respiratory Department revealed the 2 EKG machines lacked verification of a maintenance inspection.

2. Observation on 3/17/15 at 3:45 PM, Staff F, Director of Respiratory Therapy, during the initial tour of the Sleep Study Department revealed the 2 sleep study machines lacked verification of a maintenance inspection.

3. Review of policy titled Biomedical Equipment Management dated 3/7/15, states in part ...All mechanical and electrical patient care equipment will be evaluated prior to use based on function, physical risks associated with clinical use, maintenance requirements and equipment incidents. An inventory of equipment included in the program and equipment maintenance records documenting all maintenance on equipment is kept in the Maintenance office

During an interview on 3/18/15 at 5:00 PM, with Staff G, Maintenance Supervisor acknowledged the maintenance log lacked documentation of inspections of the EKG and sleep study machines.

Based on review of medication error reports, patient medical records, policies and procedures, and staff interviews, the Critical Access Hospital (CAH) staff failed to notify the physician when medication errors occurred for 5 of 20 patients (Patients # 7, 8, 9, 10, and 11). The CAH staff reported a census of 8 inpatients at the start of the survey.

Failure to report medication errors when they occur to the physician could potentially cause harm to patients if receiving the wrong medication, receiving medication at the wrong time, or by the wrong route.

Findings include:

1. Review of the CAH policies/procedures revealed the lack of a policy that addressed notification of the physician when a medication error occurred.

2. Review of the Medication Error Reports for Patients # 7, 8, 9, 10, and 11 and review of the patient's medical records lacked documentation the physician was notified the medication errors occurred.

3. During an interview on 3/24/15 at 10:10 AM, Staff B, Chief Nursing Officer, stated nurses were to notify the physician of all medication errors that occurred but lacked a policy that addressed notification of the physician when a medication error occurred. Staff B verified the lack of documentation the physicians were notified when medication errors occurred for Patients # 7, 8, 9, 10, and 11.

During an interview on 3/16/15 at 3:40 PM, Staff D, Registered Nurse (RN), stated the nursing staff were to notify the physician when medication errors occurred.

During an interview on 3/16/15 at 3:50 PM, Staff E, RN, stated the nursing staff were to notify the physician when medication errors occurred.

Based on review of policies/procedures, closed surgical patient medical records, and staff interviews, the Critical Access Hospital (CAH) anesthesia staff failed to ensure the completion of a post anesthesia evaluation for 3 of 9 patients that required anesthesia for a surgical procedure (Patients # 12, 13, and 14). The CAH staff reported an average of 150 patients that received anesthesia per month.

Failure to perform a post-anesthesia evaluation could potentially result in patients having unrecognized complications.

Findings include:

1. Review of policy/procedure titled "Pre and Post Anesthesia Evaluation Policy", dated October 14, 2013, revealed in part, ". . . All patients receiving general, regional or monitored anesthesia shall have a post anesthesia evaluation completed and documented by a practitioner qualified to administer anesthesia, as stated above, no later than 48-hours after surgery or a procedure requiring anesthesia services. . . ."

2. Review of closed surgical patient medical records for Patients # 12, 13, and 14 revealed the lack of documentation of completion of a post anesthesia evaluation.

3. During an interview on 3/24/15 at 5:50 PM, Staff H, Certified Registered Nurse Anesthetist (CRNA), acknowledged the CAH's policy/procedure required all patients who received anesthesia will have a post anesthesia evaluation completed. Staff H verified the lack of documentation of the completion of a post anesthesia evaluation for Patients # 12, 13, and 14.

I. Based on document review and staff interviews, the Critical Access Hospital (CAH) failed to ensure 8 of 11 active physicians, selected for review, received outside entity review, to evaluate the quality and appropriateness of the diagnosis and treatment furnished to the CAH patients, prior to their re-appointment to the medical staff. (Practitioners A, B, C, D, E, F, G and H). The CAH identified 99 current active practitioners provided care to their patients.

The CAH administrative staff identified the practitioners provided services to patients as follows:

-- Practitioner A - interpreted 27 radiology reports in 2014
-- Practitioner B - interpreted 19 radiology reports in 2014
-- Practitioner C - interpreted 32 radiology reports in 2014
-- Practitioner D - 9 surgical procedures in fiscal year 2014
-- Practitioner E - 22 surgical procedures thus far in fiscal year 2015
-- Practitioner F - 3 surgical procedures in fiscal year 2014
-- Practitioner G - 82 surgical procedures in fiscal year 2014
-- Practitioner H - 522 surgical procedures in fiscal year 2014

Failure to ensure all medical staff members received outside entity review affects the CAH's ability to assure physicians provide quality care to the CAH patients.

Findings include:

During an interview on 3/18/15 at 4:30 PM, Staff A, Quality Director, acknowledged she failed to send records of patients, cared for by Practitioners A through H, for outside entity review prior to their last credentialing period. Staff A reported she did not know peer review was required for physicians not employed by the CAH.

Review of a document titled "Peer Review Plan", dated 4/8/14, revealed in part ". . . Peer reviews shall be performed for all patient care services and other services affecting patient health and safety . . . "


II. Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 3 of 11 active physicians, selected for review, received outside entity review performed by an appropriate external entity, to evaluate the quality and appropriateness of the diagnosis and treatment furnished to the CAH patients, prior to their re-appointment to the medical staff. (Practitioners I, J and K). The administrative staff identified 99 current active practitioners provided care to their patients.

The CAH administrative staff identified the practitioners provided services to patients as follows:

-- Practitioner I - treated 482 emergency room patients in 2014
-- Practitioner J - treated 439 emergency room patients in 2014
-- Practitioner K - performed 344 surgical procedures in fiscal year 2014

Failure to ensure all applicable practitioners received external entity review affects the CAH's ability to assure physicians provide quality care to their patients.

Findings include:

During an interview on 3/18/15 at 4:15 PM, Staff A, Quality Director, reported the CAH has a contract with another CAH to complete outside entity review for all practitioners. She relayed they are in the process of working on a contract with their network hospital to take over this function, after discovering they were using an inappropriate entity for the outside entity review. Staff A confirmed all the peer review completed on Practitioners I, J and K were completed by another CAH.

During an interview on 3/19/15 at 7:45 AM, Staff B, Vice President of Patient Care, confirmed the CAH is in the process of developing a contract with their network hospital to provide outside entity review and revising their CAH's peer review plan, which lacked identification of the process for outside entity review of physicians previous to re-appointment to the medical staff.

Based on record review and staff interview the facility failed to offer an ongoing activity program to the skilled patients of the Critical Access Hospital (CAH). The CAH identified a census of 8 patients, with 1 patient (Patient #1) receiving skilled services, and 4 of 5 closed charts of skilled patients (Patients #2, 3, 4,and 5) reviewed.

Failure to offer daily activities to skilled patients could potentially result in patients becoming disengaged and unmotivated in completing daily activities of living.

Findings include:

1. Review of the medical records revealed the following information.

a. Patient #1's medical record revealed an Activity Assessment with a completion date of 3/5/15. The Activity Assessment lacked daily documentation of activities and activities Patient #1 would be likely to complete in his/her normal daily routine. Patient #1 medical record lacked an activities care plan and associated documentation related to activities.

b. Patient #2's closed skilled record revealed an Activity Assessment with a completion date of 1/27/15. The Activity Assessment lacked daily documentation of activities and activities Patient #2 would be likely to complete in his/her normal daily routine. Patient #2 medical record lacked an activities care plan and associated documentation related to activities.

c. Patient #3's closed skilled record revealed an Activity Assessment with a completion date of 1/8/15. The Activity Assessment lacked daily documentation of activities and activities Patient #3 would be likely to complete in his/her normal daily routine. Patient #3 medical record lacked an activities care plan and associated documentation related to activities.

d. Patient #4's closed skilled record revealed an Activity Assessment with a completion date of 1/8/15. The Activity Assessment lacked daily documentation of activities and activities Patient #4 would be likely to complete in his/her normal daily routine. Patient #4 medical record lacked an activities care plan and associated documentation related to activities. Patient #4 medical record lacked an activities care plan and associated documentation related to activities.

e. Patient #5's closed skilled record revealed an Activity Assessment with a completion date of 1/8/15. The Activity Assessment lacked daily documentation of activities and activities Patient #5 would be likely to complete in his/her normal daily routine. Patient #5 medical record lacked an activities care plan and associated documentation related to activities.

2. The policy titled Swing Bed Activities Plan dated 9/14, stated in part ... Each swing bed patient will have an assessment and written activities plan that is not in conflict with medical plan of care.

3. During an interview on 3/17/15 at 11:00 AM, Staff I, Activity Assistant, verified he/she visits the skilled care patients explains the activities offered at the nursing home and encourages the patients to attend.

During an interview on 3/17/15 at 12:00 AM, Staff J, Activities Director, acknowledged the skilled care patients lacked activity care plans, daily activity charting and specialization of activities if patients do not attend the activities offered at the nursing home.

Based on review of documents and staff interview the Critical Access Hospital (CAH) failed to provide inpatients and out patients with the correct visitation rights. The CAH identified 649 inpatients and 79,873 outpatients per year.

Failure to provide the correct patient rights to patients of the CAH could potentially result in lack of patients receiving important visitors to hasten their recovery.

Findings include:

Review of the document titled Patient Rights and Responsibilities dated 1/2011, stated in part ...9. Receive or refuse to receive visitors of your choice unless there are clinical or legal reasons for visitor restrictions. All visitors may enjoy full and equal visitation privileges consistent with patient preferences. In the event of clinical or legal restrictions and explanation will be provided to you or your representative.

The patient visitation rights lacked the following: the right to receive visitors whom he or she designates, including, but not limited to, a spouse, domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

During an interview on 3/17/15 at 10:30 AM, Staff C, Director of Medical/Surgical verified all patients of the CAH receive the same patient rights.