HospitalInspections.org

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the medical staff reviewed and approved the CAH's 1 of 1 Blood Supply and Services Agreement.

An approved Blood Supply and Services Agreement assures an immediate supply of blood products for patient. A CAH has the responsibility to ensure an approved Blood Supply and Services Agreement is in place to ensure all patients who require the administration of blood products have access to potentially lifesaving blood supplies.

Failure to ensure the medical staff reviewed and approved the Blood Supply and Services Agreement could result in lack of available blood supplies and the patient could potentially experience adverse outcomes or even death.

Findings include:

1. Review of document titled, "Blood Supply and Services Agreement" dated 9/20/2011 lacked evidence the medical staff reviewed and approved the Blood Supply and Services Agreement annually.

Review of documents titled, "Medical Staff Minutes" dated January 1, 2015 through December 21, 2015 lacked evidence of approval of the Blood Supply and Services Agreement.

2. An interview on 1/6/15 at 4:25 PM, with Staff C, Chief Operating Officer, acknowledged the Blood Supply and Services Agreement dated 9/20/2011 lacked evidence the medical staff reviewed and approved the Blood Supply and Services Agreement annually.

Based on policy, procedure, documents review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians and mid-level providers annually reviewed all patient care polices and procedures for 17 of 17 patient care areas. (Nursing, Surgery, Emergency Department, Pharmacy, Diabetic Education, Laboratory, Radiology, Infusion, Respiratory Therapy, Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehabilitation, Wound Center, Nutritional Services, Maintenance, and Environmental Services)

Failure to ensure a group of professionals including a physician and mid level provider reviewed all patient care policies annually could potentially result in the failure to identify an opportunity to improve patient care.

Findings include:

1. Review of policy and procedure titled "Policy Development and Management", revised 11/24/2015, included in part, "...all policies will be prepared, submitted for approval, distributed, reviewed, and retained in accordance with the procedures outlined within this policy...If the policy involves medical care of the patient or the practice of the physician, review and approval by the owner's Medical Director is needed...Policies must be reviewed annually by the department/service..."

2. Review of documents titled, "Medical Staff Meeting Minutes" from January 19, 2015 through December 21, 2015 lacked evidence of an annual review of all the CAH patient care policies and procedures.

3. During an interview on 1/7/16 at 8:10 AM, Staff G, Compliance/Credentialing Officer, stated the process of annual policy review started at the department level. Staff G reported the physician and mid level practitioner received a list of the policies and procedures at Medical Staff Meeting.

Based on document review and staff interviews, the Critical Access Hospital (CAH) failed to delineate privileges to perform specific surgical procedures or tasks for 1 of 1 Certified Surgical Technician and 1 of 1 Orthopedic Physician Assistant (PA). (Staff V, Certified Surgical Technician and Staff W, PA)

Failure to ensure the CAH delineate privileges to perform specific surgical procedures for all Certified Surgical Technicians and PA's that assisted providers during surgical procedures during 2015 could potentially result in patients receiving surgical intervention from unqualified professionals.

Findings include:

1. Review of Medical Staff Bylaws, dated 10/2015, revealed in part, "..Practitioners can only provide professional services consistent with the privileges granted; patients shall be treated only by practitioners holding privileges appropriate for the treatment..."

2. Review of document titled, "Operating Room Log" revealed Staff V assisted with 127 ophthalmology surgical procedures and Staff W assisted with 2 orthopedic surgical procedures during 2015.

3. During an interview on 1/5/2016 at 9:25 AM, Staff B, Surgical Services Manager, verified that Staff V and Staff W lacked surgical privileges to provide assistance during surgical procedures in the operating room and verified non-employees V and W assisted during surgical procedures in the operating room.

During an interview on 1/6/2016 at 1:40 PM, Staff G, Compliance Credentialing Officer reported Staff V and Staff W did not work at the CAH. The Compliance Credentialing Officer reported the CAH lacked a process to delineate privileges for non-employees of the CAH.

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for 4 of 6 contracted patient care services that included Nuclear Medicine, Sleep Study, Anesthesia, and Stereotactic Breast Biopsy.

Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

Findings include:

1. Review of document titled,"QAPI Plan - Quality Assurance and Performance Improvement Plan", dated 2015, included in part "...The QAPI program encompasses all departments and services within Buchanan County Health Center. The purpose of the QAPI Program is to improve performance and foster transparency for the purpose of organizational learning..."

2. Review of documents titled, "Quality and Patient Safety Meeting Minutes" dated May 28, 2015 through December 30, 2015 and Performance Dashboard for July tthrough December 2015 revealed the CAH lacked evidence of reports on the quality of patient care and/or any issues involving patient care from Nuclear Medicine, Sleep Study, Anesthesia, and Stereotactic Breast Biopsy.

3. During an interview on 1/6/2016 at 3:15 PM, Staff F, Patient Safety Officer, confirmed the contracted patient services, Nuclear Medicine, Sleep Study, Anesthesia, and Stereotactic Breast Biopsy did not provide reports to the Quality and Patient Safety Meeting regarding the quality of patient care and/or any issues involving patient care.