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Observations and interviews with the Dietary Manager (DM), Director of Nursing (DON), and Maintenance Personnel (MP) revealed the Critical Access Hospital (CAH) failed to ensure the premises were in good repair in the kitchen. The CAH is licensed for 10 beds and had a census of 0 upon survey entrance. Findings include:

A. Observation of the kitchen and interview with the DM and MP on 4/25/11 at 10:00 AM revealed the kitchen tile floor measuring 418 square feet was originally installed in 1969. Observation revealed numerous areas of deep gouges within the tile and several discolored areas all measuring different shapes and sizes. The elongated seams in tile floor are separating and raising, exposing the underlying cement. This makes it difficult to clean and sanitize properly.

B. Observation of the dishwasher revealed a buildup of lime deposits along the top and edges.

C. Observation of 3 ceiling vents, 1 located in the dishwashing area, all measuring approximately 2 feet by 3 feet had a greasy/dirt buildup along the grids. The ceiling vents also have a rusted appearance. This makes it difficult to clean and sanitize properly.

D. Observation of a 3-shelf hard plastic food cart used to transport food to patients/residents in the CAH and Long Term Care (LTC) was discolored and lacked the manufacturer's finish. Cart also has a deep, round melted/burnt area on the second shelf measuring approximately 12 inches. This makes it difficult to clean and sanitize properly. Interview with the DM revealed someone had put a very hot pan on it (the cart) and burnt it and was not sure how old the cart was.

E. Observation of the kitchen with the DM on 4/25/11 at 10:00 AM identified 25 different food items located in the refrigerator, freezer and dry food storage area that were not sealed or dated after opening, had a buildup of ice crystals on the food and inside the plastic packaging, or were stored openly. DM identified these items being a risk for food-borne illness or attracting rodents. The DM identified the kitchen serves food to the patients of the CAH and residents of the LTC 3 meals a day. Examples of food items include:
1. 1 - 10 pound ham, located on a tray on the top shelf of the refrigerator, thawed and not dated. DM could not be sure when the ham was put in the refrigerator to thaw.
2. 1 - 2 1/2 pound package of frozen chicken strips - package was unsealed and not dated when opened, the chicken strips also had a buildup of ice crystals on the inside of the plastic package and on the food.
3. 6 frozen sausage patties-package opened and not dated with a buildup of ice crystals on the inside of the plastic package and food.

I. Record review and staff interviews revealed the Critical Access Hospital (CAH) failed to follow policies regarding Medical staff privileging. Review of practitioner files revealed the following:
1. Lacked documentation for Medical staff approval of services for Physician D;
2. Failed to ensure Governing Body approval for services for Physician E;
3. Failed to approve a list of specific privileges for Physicians D, E, G, H, I and J;
4. Failed to ensure professional medical licenses were current for Physicians A, B, C, D, E and J;
5. Failed to ensure DEA licenses were current for Physicians C, D and E and;
6. Failed to ensure proper education and training for Physicians D and E.
The CAH is licensed for 10 beds and had a census of 0 upon survey entrance. The CAH has 2 active medical physicians and 2 physician assistants on the medical staff. Findings include:

A. Interview with the Health Information Manager (HIM) on 4/26/11 acknowledged the CAH worked together with their network hospital to ensure proper credentials for the physicians, but held responsibility for the maintenance of physician credential files. There were 2 active medical physicians and 2 physician assistants on staff. The HIM revealed the CAH had approximately 108 courtesy physicians' files located in 5 different drawers in a filing cabinet. HIM interview revealed she was unable to assure the files were up to date or if the physicians provided services at the hospital any more, as there are too many of them to keep track of and did not have the time.

II. Record reviews and staff interviews, and review of the Medical Staff Rules and Regulations revealed the Critical Access Hospital (CAH) governing body failed to ensure policies and procedures were implemented pertaining to the completion of medical records. The CAH is licensed for 10 beds and had a census of 0 upon survey entrance. Findings include:

A. Review of the Medical Staff Rules and Regulations, section 4.10, page 7-8, approval of the Board of Trustees on 4/18/07, and approved by the Medical Staff on 4/11/07 reads: "Completion of Records. Within thirty (30) days of discharge of a patient, the attending practitioner shall see that the record is complete, shall state his or her final diagnosis, and shall sign the record. If the record remains incomplete twenty days (20) after the date of discharge, the Administrator or Medical Records Director may notify the practitioner in writing that his or her admitting privileges will be suspended five (5) days from the date of such notice. Copies of the notice will be sent to the Administrator and the Chairman of the Board of Trustees."

B. Interview with the Medical Records Director (MRD) on 4/26/11 at 10:05 AM revealed the CAH had a total of 38 delinquent medical records. MRD was unsure as to the reason records were delinquent, because they have not had the time to get the delinquent medical records audited. MRD identified that no notification letters had been sent to the physicians regarding their delinquent medical records, no physicians had their admitting privileges suspended and she did not know if any letters or disciplinary action had ever been done per the Medical Staff Rules and Regulations.

Record review, observations and staff interviews revealed the Critical Access Hospital (CAH) failed to develop policies and procedures for pharmaceutical services pertaining to the receiving and distribution of medications to patients in accordance with accepted professional principles. The CAH was ordering a multitude of medications and storing in the Emergency Department (ED) without accountability for the storage and distribution of those medications and according to the CAH medication formulary. The CAH also made available for patient use a drug that was expired. The CAH is licensed for 10 beds and had a census of 0 upon survey entrance. Findings include:

A. Interview and observations of the ED on 5/3/11 at 10:00 AM with Registered Nurse (RN)-A and Director of Nursing (DON) revealed the CAH had assigned RN-A to oversee the ordering of all medications for the CAH under the guidance of a contracted Registered Pharmacist (RP). Interview with RN-A revealed approximately 88 different medications that were administered to patients stored in the CAH pharmacy. RN-A could not be sure of the amount of the various medications, stating "I just eyeball the medications and order if it looks low". The CAH had no records available for review to show when specific medications entered the facility and when they were addministered to assure medications were not being misappropriated or diverted from the pharmacy.

B. Observation and inventory of medications located in the ED crash cart with the DON and RN-A revealed approximately 27 different medications. DON completed an inventory and found 11 of the medications did not match the CAH's medication inventory quantity or dosage list.

C. Observation and inventory of medications located in the ED medication cabinet with the DON and RN-A revealed approximately 81 medications, including 5 narcotics. 39 of the non-narcotic medications did not match the CAH's formulary quantity for storage. Of the 5 scheduled narcotics, 3 of the 5 did not match the documented count. Examples of the narcotics include:
1. Demerol 50 MG should have 2 syringes - actual count 0;
2. Midazolam (Versed) 5 MG injectable 1 vial - actual count 0;
3. Morphine 4 MG injectable 3 syringes - actual count 1.

D. Observation of refrigerator located in the ED found Integrilin 1-2 MG/ML vial stored that had expired February 2011.

E. Interview with RN-A revealed when any medications are used in the ED the nurse is to go to the pharmacy and restock medications, but there is no way to be sure the medications can be accounted for and the pharmacy is inventoried once a year.

Based on staff interviews, a review of personnel files and a lack of documented evidence, the Critical Access Hospital's (CAH) infection prevention program failed to include orientation of all health care workers. The hospital reported 43 acute inpatients within the past year. Findings include:

A. The CAH employs 4 Emergency Medical Technicians (EMTs); however, review of the personnel files of all 4 lacked any evidence of orientation to hand hygiene practices.

B. An interview conducted with the Infection Control Officer on 5/4/11 at 3:30 PM confirmed these individuals did not receive any orientation to infection control or hand hygiene practices to prevent spread of infection to patients.

Staff interview, medical record reviews, review of the Medical Staff Rules and Regulations, and policies and procedures for medical records revealed the Critical Access Hospital (CAH) failed to maintain a medical records system in accordance with the written policies and procedures for the completion of the medical records for 38 patients (Patients 1A-38A) within the allotted time frame of 30 days. CAH also failed to ensure a patient consent to treat form was signed and Advance Directives were addressed for 2 of 2 closed acute care inpatients (Patients 1 and 2). The CAH is licensed for 10 beds and had a census of 0 upon survey entrance. The hospital reported 43 acute inpatiends with the past year. Findings include:

A. Medical record reviews and interviews with the Health Information Manager (HIM) on 4/26/11 at 10:05 AM identified a total of 38 delinquent medical records pertaining to closed Inpatient, Observation and Swingbed medical records. The following is a list of employees and reasons for delinquent records as identified by the HIM:
1.19 of the medical records are located in a bin in the medical records department and identified as over 30 days old. HIM was not sure as to the reason stating the staff has just not had the time to audit them yet;
2. 8 nurses contributed to 18 delinquent medical records for signatures, dates and times, completion of care plans;
3. 2 physicians contributed to 7 delinquent medical records due to the lack of signatures, dates and times on orders, and physician signatures on progress notes;
4. 1 physician assistant contributed to 1 delinquent medical record (reason unknown).

B. Review of the Medical Staff Rules and Regulations on 4/26/1, section 4.10, page 7-8, last reviewed on 4/11/07, reads: "Completion of Records. Within thirty (30) days of discharge of the patient, the attending practitioner shall see that the record is complete, shall state his or her final diagnosis, and shall sign the record." Section 4.5, page 6, reads: "Order For Treatment. All orders must be clear, legible and complete or may not be carried out. The use of "renew", "repeat", and "continue" orders is not acceptable. All orders for drugs and biologicals, including verbal or telephone orders, must be legible, timed, dated and authenticated with the ordering practitioner's signature." Section 2.8, Page 2 reads: "Consents. At the time of admission, an admission form containing general consent to admission and to the conditions of admissions shall be signed by the patient or the patient's legally authorized representative. The admitting clerk shall notify the admitting or co-admitting practitioner whenever such consent has not been obtained."

C. Review of the Policies and Procedures identified as Guidelines for Documentation in the Medical Record for the HIM department, last reviewed on 1/2007, Procedure reads:
"1. All entries or forms shall contain the date AND time.
2. All entries shall be made by the person providing the care and shall be dated, timed and signed with full signature AND professional title."
Interview with the HIM revealed that dates and times for signatures are impossible to get an accurate count due to the multitude of records.

D. Record review on 4/26/11 for Patient 1 revealed an admission date of 7/12/10 and discharged on 7/14/10. Pertinent diagnoses were pathologic left femoral neck fracture, osteopenia, dementia, and a Do Not Resuscitate (DNR) order. Review of the medical record revealed no formal signature for consent to treat and lacked documentation for the Advance Directives order placing the patient on a DNR status.

E. Record review on 4/16/11 for Patient 2 revealed an admission date of 7/13/10 and discharged to a Swingbed status on 7/16/10. Pertinent diagnoses were acute myocardial infarction (MI), coronary artery disease, renal insufficiency and diabetes mellitus. Patient 2 was placed on a DNR status with admission orders. The medical record for Patient 2 lacks documentation concerning Advance Directives or if Patient 2 had a Power of Attorney for health care decisions.

Review of the Advance Directives policies and procedures, revised 2/06, reads: "Procedure. An inquiry will be made by the admitting staff during the admission process of the patient or if the patient is incapacitated, to the patient's significant other, as to whether or not the patient has completed an advance directive. The CAH shall not condition the provision of care or otherwise discriminate against any individual based on whether or not the individual has executed an advance directive. A request of the patient/significant other to provide a copy of the advance directive for the medical record entry will be made by the admitting staff during the admission process." Interview with the HIM revealed the staff does not always check for Advance Directives or put copies in the medical record.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review (C-331); failed to evaluate the utilization of services, including at least the number of patients served and the volume of service (C-332); failed to review a sample of open and closed clinical records (C-333); failed to review the health care policies (C-334); failed to determine whether the utilization of services was appropriate, the established policies were followed and any changes were needed (C-335); failed to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the hospital and of the treatment outcomes (C-336); failed to evaluate patient care services and other services affecting patient health and safety (C-337); failed to determine if antibiotic therapy was appropriate (C-338); failed to determine if the quality and appropriateness of the diagnosis and treatment furnished by mid-level practitioners and physicians (C-339) and (C-340); failed to consider the findings of the evaluations, including any recommendations and take corrective action (C-341); and document outcomes (C-343); therefore, the Condition of Participation Periodic Evaluation and Quality Assurance Review is not met. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality assurance data collected from the past year lacked evidence of an evaluation.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to perform an annual Periodic Evaluation and Quality Assurance Review.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to perform an annual Periodic Evaluation and Quality Assurance Review.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation of the utilization of services, including at least the number of patients served and the volume of services.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to perform an annual Periodic Evaluation and Quality Assurance Review.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation of a representative sample of both active and closed clinical records.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to conduct a review of active and closed clinical records.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an annual evaluation.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to perform an annual review of the CAH's health care policies.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation to determine whether the utilization of services was appropriate, established policies were followed, and if any changes were needed.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to evaluate the utilization of services was appropriate, the established policies were followed and if any changes were needed.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation of the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to evaluate the quality and appropriateness of the diagnosis and treament furnished and of the treatment outcomes.

Based on staff interview, a review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review.
The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation of patient care services and other services affecting patient health and safety.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to evaluate patient care services and other services affecting patient health and safety.

Based on staff interview and a lack of data, the Critical Access Hospital (CAH) failed to evaluate medication therapy. The hospital reported 43 acute care patient admissions within the past year. Findings include:

A. An interview with the Infection Control Officer on 5/4/11 at 3:30 PM revealed that medication therapy, specifically antibiotic therapy, was not evaluated for appropriateness.

B. A review of patients who received antibiotic therapy within the past year lacked evidence of which antibiotic the patient received and whether or not the infectious organism was sensitive or resistant to the antibiotic.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation of the quality and appropriateness of the diagnosis and treatment furnished by the 3 Physician Assistants

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to evaluate the quality and appropriateness of the diagnosis and treatment furnished by the 3 Physician Assistants.

Based on staff interview, review of physician reappointment documentation to the medical staff, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation of the appropriateness of the diagnosis and treatment furnished by doctors.

B. A review of 1 active medical staff member and 2 mid-level practitioners lacked evidence of the results of Peer Review or internal monitoring of quality of care furnished to patients.

C. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to perform an annual Periodic Evaluation and Quality Assurance Review.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to perform an annual Periodic Evaluation and Quality Assurance Review.

C. Since the CAH failed to perform an annual evaluation, they did not consider any findings, or take corrective action.

Based on staff interview, review of meeting minutes and a lack of documented evidence, the Critical Access Hospital (CAH) failed to perform an annual Periodic Evaluation and Quality Assurance Review and therefore failed to document outcomes of any remedial actions. The CAH reported 43 acute care patients admitted within the past year.

A. A review of Quality Assurance data collected from the past year lacked evidence of an evaluation.

B. An interview conducted with the Quality Assurance Coordinator on 5/4/11 at 4:00 PM confirmed the CAH failed to perform an annual Periodic Evaluation and Quality Assurance Review.

C. The CAH failed to perform an annual evaluation of its services and therefore failed to document outcome of remedial action.