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Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure criminal background checks were completed or completed in a timely manner for 6 of 9 medical doctors (MD-A, MD-B, MD-D, MD-E, MD-F and MD-G), 2 of 2 certified registered nurse anesthetists (CRNA-A and CRNA-B) and 2 of 13 non-credentialed employees (E-11 and E-12) reviewed, who had been hired since the previous survey had been conducted 9/13 /10.

Findings include:

Medical Staff credentialing was completed with the health information manager (HIM) on 7/29/2014 at 11:30 a.m. The HIM verified the CAH was responsible to complete background checks on all physicians and allied health providers who provided direct patient care.

MD-A, a contract physician, had been hired on 10/25/2000 and a background study could not be found.

MD-B, a contract physician, had been hired in 1983 and a background study could not be found.

MD-D, a locum tenens physician, had been hired on 12/9/2013 and a background study could not be found.

MD-E, a contract physician, had been hired on 5/3/2006 and a background study could not be found.

MD-F, a contract physician, had been hired in 8/2013 and a background study could not be found.

MD-G, a contract physician, had been hired on 7/2/2010 and a background study could not be found.

CRNA-A had been hired on 1/1/1990 and a background study could not be found.

CRNA-B had been hired on 10/2012 and a background study could not be found.

The HIM was interviewed on 7/31/2014 at 10:30 a.m. and stated the CAH was unable to locate the file which contained physician and allied health professional background studies. She confirmed a background study had not been completed on MD-F and was unable to provide evidence that background studies had been completed on MD-A, MD-B, MD-D, MD-E, MD-F, MD-G, CRNA-A and CRNA-B.


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On 7/29/14, at 10:00 a.m. and 7/30/14, at 11:00 a.m. personnel records were reviewed with the human resource (HR) manager who was responsible for the non-credentialed personnel records. The HR manager verified background checks were not conducted in a timely manner or were not conducted at all for the following employees:
? E-11, a licensed social worker, had been hired 10/15/12, and had a background check completed on 4/29/10, approximately 2 and 1/2 years prior to the hire date.
? E-12, a registered dietitian, had been contractually hired on 1/3/14, and no background check had been completed.

A request was made on 7/31/14, for a policy related to Background checks of employees. No policy was provided.

During interview on 7/30/14, at 11:00 a.m. with the HR director stated both of the above staff had direct contact with patients.

Based on interview, the governing body of the critical access hospital (CAH) failed to ensure a written agreement for telemedicine services provided for patients at the CAH was obtained. This had the potential to affect all patients who used these services through the emergency department.

Findings include:

On 7/29/14, at 1:35 p.m. the director of nursing (DON) verified the CAH had been providing telemedicine thru the emergency department. The DON stated the Medical Doctors (MD's), the certified nurse practitioner (CNP), and the staff had been educated on how to provide this service and staff and providers had been utilizing this service. A physician at Avera Hospital in Sioux Falls, South Dakota was available to assist the CAH's medical staff in assessing and treating patients with an emergent condition. Further verified was when an emergency room patient required behavioral health services, telemedicine was provided thru the University of Minnesota Centers for Rural Mental Health Studies out of Duluth, Minnesota. Telemedicine equipment was observed in the emergency department on 7/30/14, at 2:00 p.m.

Review of the Medical Staff Bylaws, Rules and Regulations dated 3/20/14 specified that services will be provided via telemedicine only after a determination has been made by the Medical Staff that the clinical service involved would be appropriately delivered through this medium according to commonly accepted quality standards. Practitioners who diagnose or treat patients via telemedicine link are subject to the same credentialing and privileging process noted in Article 5 (Medical Staff Appointment) and Article 6 (Determination of Clinical privileges).

Review of the written agreements and contracts on 7/31/14, at 12:05 p.m. identified no contract or agreement with Avera Hospital or with the University of Minnesota Centers for Rural Mental Health Studies.

Interview on 7/28/14, at 1:57 p.m. with the administrator verified that he was aware that that the CAH was behind on updating their agreements and contracts with outside agencies.

Based on the Life Safety Code Substantial Allegation survey completed on 7/29/14, the facility was found not in compliance with Life Safety from Fire found at CFR 485.623(d).

Refer to Life Safety Code deficiencies at K0050, K0076 and K0078.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based upon interview, policy review, and a review of committee meeting minutes, medication error reports and medical staff bylaws, the Critical Access Hospital (CAH) did not ensure the Pharmacy and Therapeutics Committee (P and T) convened and implemented an evaluation of medication errors and adverse drug events for 9 of 9 patients (P1, P2, P3, P4, P5, P6, P7, P8, and P9) whose medication error records were reviewed. This deficient practice had the potential to affect any patients receiving medications at the hospital.

Findings include:

Nine Medication Error-Analysis-Incident reports from the period 2/11/2014 to 7/20/14 were reviewed (the total number of medication errors for this period). None of the reports indicated the medication errors had been classified as to the severity of the errors nor was there any evidence the medication errors had been reviewed by the PAC committee.

A review of the PAC meeting minutes dated April 17, 2014, May 22, 2014 and July 17, 2014 (no meeting held in June, 2014) lacked discussion of medication errors or adverse drug reports.

A review of the CAH policy Medication Errors, last reviewed 1/2012, indicated the P and T Committee would review medication error logs and significant medication errors. The policy also indicated that summary data and trend analysis would be performed by the pharmaceutical service department and reports of action taken and appropriate follow-up would be made to the medical staff.

A review of the current Medical Staff Bylaws, Rule and Regulations, dated 2011, addressed Pharmacy and Therapeutics/Drug Usage Evaluation. The bylaws indicated the function of the P and T committee included the review of untoward drug reactions, reviewing and evaluating medication variances and maintaining a record of all activities relating to pharmacy and therapeutic functions and submitting reports and recommendations to the PAC not less than quarterly.

The Pharmacist was interviewed on 7/30/2014 at 1:40 p.m. and stated medication errors and adverse drug reactions had not been taken to the PAC committee for review. The director of nursing, who is a member of the PAC, was interviewed on 7/3/02014 at 3:10 p.m. and stated medication errors had not been reported to the PAC. She stated the pharmacy and therapeutics function of the medical staff is the responsibility of the PAC.

Based upon interview, a review of surgical privileges and policy review, the Critical Access Hospital (CAH) did not ensure the current roster listing each practitioner's surgical privileges had been updated and made available in the surgical suite and in the area where the scheduling of surgical procedures occurred for 3 of 4 medical doctors (MD-A, MD-B, MD-C) also with surgical privileges who practiced at the CAH. This had the potential to affect any patient who had a surgical procedure at the CAH.

Findings include:

During a tour of the surgical suite with the director of nursing (DON) on 7/29/2014 at 9:15 a.m., it was noted the rosters delineating the medical doctors with surgical privileges was not current. The delineation of surgical privileges for MD-A was dated 3/7/2011. The delineation of surgical privileges for MD-B was dated 10/10/11. The surgical privileges for MD-C were not available in the surgical suite or in the area where surgical scheduling occurred.

The hospital policy Delineation of Surgical Privileges, last reviewed 4/2014, indicated medical staff privileges were granted and reviewed every two years. The policy indicated a notebook was maintained in the operating room which contained copies of the Delineation of Medical Privileges Desired checklist from all practitioners who had been granted surgical privileges. The checklist defined what procedures the practitioner had been granted privileges to perform.

The DON was interviewed on 7/29/2014 at 10:15 a.m. and verified the current roster of the surgeon's approved clinical privileges was not available in the surgical suite.

A review of medical staff credentials, provided by the CAH Health Information Manger (HIM), revealed MD-A, MD-B and MD-C all had current surgical privileges which had been granted by the governing body. The HIM was interviewed on 7/29/2014 at 10:30 a.m. and stated she had the responsibility to provide a current listing of each practitioner's surgical privileges to the staff in the surgical suite and in the area where surgical scheduling occurred.

Based upon interview, record review and review of medical staff bylaws, the critical access hospital (CAH) did not ensure a comprehensive pre-anesthetic evaluation was completed for 3 of 6 patients (P1, P2 and P21) who were reviewed for surgical and endoscopy procedures. This had the potential to affect any patient who had anesthesia at the CAH.

Findings include:

Documentation of pre-anesthetic evaluations completed by the certified registered nurse anesthetists (CRNA) who provided anesthesia coverage at the CAH was not complete.

P1 had an inpatient surgical procedure on 8/6/2011 under general anesthesia administered by CRNA-B. There was no documentation of an evaluation of the patient's respiratory status, hepatic/gastrointestinal system, or neuro/musculoskeletal system. Although the Pre-Anesthetic Evaluation form had an area to indicate a review of a system was within normal limits (WNL), nothing had been documented to indicate the systems had been evaluated and were normal.

P2 had an inpatient surgical procedure on 12/11/2013 under monitored anesthesia care by CRNA-B. Although the Pre-Anesthetic Evaluation form indicated the patient used tobacco products, there was no documentation of an evaluation of the patient's respiratory status. Although the evaluation form indicated the patient used alcohol and had used street drugs, there was no evaluation of the patient's hepato/gastrointestinal system. There also was no documentation of an evaluation of the patient ' s neuro/musculoskeletal system or of the renal/endocrine system. Although the Pre-Anesthetic Evaluation form had an area to indicate a review of a system was within normal limits (WNL), nothing had been documented to indicate the systems had been evaluated and were normal.

P21 had an endoscopy procedure as an outpatient under monitored anesthesia care administered by CRNA-A on 3/6/2014. Although the patient's weight was 397 pounds, there was no documentation of an evaluation of the patient's respiratory status, hepato/gastrointestinal system, neuro/muscular systems, or renal/endocrine systems. Although the Pre-Anesthetic Evaluation form had an area to indicate a review of a system was within normal limits (WNL), nothing was documented to indicate the systems had been evaluated and was normal.

A review of the Medical Staff bylaws, Rules and Regulations, dated 2011, indicated it was the responsibility of the surgeon or primary care provider to document in the medical record the pre-anesthetic evaluation within 24 hours prior to surgery. The bylaws indicated the evaluation should include pertinent information relative to the choice of anesthesia, the patient's previous drug history, other anesthesia experienced and any potential anesthetic problems. The bylaws also indicated it was the responsibility of the nurse anesthetist to maintain a complete anesthesia record.

CRNA-A was interviewed via telephone on 7/30/2014 at 10:30 a.m. CRNA-A stated he indicated the pre-anesthesia evaluation had been completed when he signed and dated the Pre-Anesthesia Evaluation form. CRNA-A also stated it would probably be better if they also documented if the system reviews were within normal limits.

Based on review of quality assurance (QA) meeting minutes and on staff interview, the Critical Access Hospital (CAH) failed to have an effective QA program that evaluated all patient care services in the emergency department. This had the potential to impact all patients receiving emergency services from the CAH.

Findings include:

It was noted during review of the QA plan and QA information, that although all patient services were to be evaluated, the CAH had not evaluated the services provided by Telemedicine and Telebehavioral services as part of the QA evaluation process. Reports of QA activities for those areas had not been submitted to the QA committee during the past 6 months.

During interview with the QA coordinator on 3/31/14 at 11:15 a.m. it was confirmed the QA process had not evaluated Telemedicine or Telebehavioral services received by patients in the emergency room. It was confirmed that emergency room department QA information was to be reported to the QA committee at least semi- annually.

The Quality Coordinator stated on 3/31/14 at 11:15 a.m. that the CAH had no other information on contracted quality assurance services, other than the sleep study, laboratory agreements and maintenance agreements.