HospitalInspections.org

I. Based on document review, observation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure pharmacy staff provided oversight of the sample medications in the physician clinic. The Clinic Manager stated clinic staff saw an average of 120 patients per day.

Failure to provide oversight of the sample medications could result in clinic staff providing patients with expired drugs that may lack efficacy, or failure to notify patients if they received drugs the manufacturer had later recalled.

Findings include:

1. Review of the policy, "DRUG SAMPLES", reviewed 5/11, revealed in part, "It is the responsibility of the pharmaceutical representative to complete a Drug Sample Dispensing Record (DSDR) for each lot number of drug provided.... The pages are placed in a binder arranged alphabetically by the drug's brand name."

2. Observations during a tour of the clinic on 10/11/10 at 10:40 AM, revealed approximately 20 sample medications locked in a cabinet at a nurse's station desk. Observations also revealed a large, locked room that contained approximately 100 sample medications. Neither location contained a log of medications dispensed to patients.

3. During an interview at the time of the tour, the Clinic Manager stated the clinic lacked a log to document when patients received sample medications from clinic staff.

4. During an interview on 10/12/11 at 1:55 PM, Pharmacist F stated the pharmacy staff did not provide oversight of the sample medications dispensed by the clinic. Pharmacist F also stated the pharmacy did not maintain a log of the samples dispensed to clinic patients.


II. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure radiology staff followed the manufacturer's recommendations for storage of 10 of 10 bottles of normal saline stored in the fluid warmer in the CT scanner room. The Laboratory/Radiology Director stated radiology staff performed an average of 19 radiology procedures per month.

Failure to follow the manufacturer's storage recommendations could potentially result in patients receiving medications with reduced potency, due to storage outside the recommended temperatures.

Findings include:

1. Observations during a tour of the Radiology department on 10/11/10 at 8:20 AM revealed 10 vials of Normal Saline (50 mL) stored in a fluid warmer in the CT scanner room at 37 C (98.5 F).

2. Review of the manufacturer's instructions for the 50 mL vial of Normal Saline revealed "Store at ... 68 to 77 [degrees] F[ahrenheit]."

3. During an interview on 10/12/11 at 1:55 PM, Pharmacist F stated they contacted the manufacturer of the Normal Saline vials. The manufacturer's representative stated the CAH pharmacy staff should not store the vials at 37 C (98.5 F), and stated staff should not use the warmed vials for patients.

Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) Dietary management staff failed to ensure all staff maintained the concentration of the sanitizer solutions in the pot and pan sink and the sanitizer cloth containers at a minimum of 200 parts per million (ppm) in accordance with the Manager of Nutrition ' s requirements. The Manager of Nutrition Services reported an average of 24-30 patient meals served daily.

Failure to ensure all staff maintain the sanitizing solution concentration at a minimum of 200 ppm could potentially result in ineffective sanitizing performance when cleaning food preparation surfaces and equipment, possibly leading to contaminated patient food and/or foodborne illness.

Findings include:

1. On 10/11/11 at 8:15 AM, upon request, Patient Meal Service Worker (PMSW) E checked the sanitizer solution concentration in the third compartment of the pot and pan sink. PMSW E obtained a test strip from a vial located on the ledge above the sinks, and dipped the test strip into the water. The test strip failed to show any color change.

During an interview, at the time of the observation, Staff E reported staff checked the sanitizer level each time they filled the sink, and the strips had not been working recently but they had ordered new strips.

2. Observation of the sanitizer solution container revealed the product labeled Oasis 146 Multi-Quat Sanitizer (a quaternary-based chemical sanitizer designed to kill germs on food contact surfaces in institutional and industrial settings). Observation of the sanitizer test strips bottle revealed the strips were intended for a chlorine-based chemical sanitizing solution.

3. During an interview on 10/11/11 at 8:20 AM, Staff C, cook, confirmed the test strips had not been working for about a week and questioned if they were the wrong strips. Staff C thought they had recently changed the chemical sanitizer and that was why the strips were the wrong ones. Staff C was also aware they had ordered new strips.

4. During an interview on 10/11/11 at 9:15 AM, the Manager of Nutrition Services reported the Ecolab chemical supplier representative completed the most recent preventative maintenance check last week. She further reported the chemical for the pot and pan sink had not been changed, but believed the chemical representative left the wrong test strips on his visit. The Manager of Nutrition Services confirmed staff used the Oasis 146 Multi-Quat Sanitizer used for the third compartment of the pot and pan sink, as well as, the sanitizing cloth solution. Staff used the sanitizing cloths to sanitize the food preparation equipment, counters, and patient meal-tray delivery carts. The Manager further reported that checking the sanitizer concentration each time staff filled the sink was part of the required training however, staff were not required to record the information so she could not verify appropriate sanitizer concentrations had been maintained.

5. The Nutrition Services Supervisor confirmed the correct test strips for the quaternary chemical were not available for staff use and staff had reported the available test strips were not working last week. She further reported she emailed the chemical representative last week and requested the correct test strips.

6. Review of a document titled "Routine Preventative Maintenance Service Detail Report - Warewashing" from Ecolab, confirmed an Ecolab representative completed a preventive maintenance check on 9/29/11. Page 5 of the report listed products supplied to the facility at the time of the visit; the list did not include sanitizer test strips.

7. During an interview on 10/11/11 at 11:25 AM, the Manager of Nutrition Services reported the test strips did not appear on the service detail report because Ecolab supplied test strips to the CAH as needed at no charge.

8. During an interview on 10/11/11 at 10:50 AM, the Manager of Nutrition Services reported she obtained the appropriate test strips for the quaternary chemical from another facility.

Upon request, she tested the sanitizing solution in the pot and pan sink which revealed a concentration of 200 parts per million (ppm) and tested a container of sanitizing cloths, which revealed a concentration of 300 ppm. According to the Nutrition Services Manager, 200 ppm was the minimum concentration required to ensure effective sanitization.

9. During an interview on 10/11/11 at 3:00 PM, the Manager of Nutrition Services acknowledged their failure to obtain the correct strips to assure proper concentrations of the sanitizing solution for nearly 2 weeks after staff identified the problem was a concern. According to the Manager, they had not required staff to document the level of concentration, to show the water contained the required concentration of sanitizing solution, in the past however, was considering initiating staff documentation as a routine monitor.

10. Review of a policy titled "Cleaning Department Equipment", approved on 1/11/11, revealed in part "Table Top Surfaces 1. Surfaces are cleaned with a disposable towel soaked in sanitizer solution ... Washing Pots and Pans ... 5. Items are then placed in third sink which is filled with hot water and sanitizing solution to the appropriate sanitizer concentration ... Hobart Mixer ... 3. Wipe down with sanitizing solution ... Steamer ... 3. Apply sanitizing solution and wipe dry ... Food carts 2. Apply sanitizing solution and wipe dry ... Steam Table ... 3. Apply sanitizing solution and dry thoroughly ... Cutting Boards ... 2. Boards are washed and sanitized in the pot and pan area after each use ... Deep Fryer ... 2. Remove oil well and clean and sanitize the well in three compartment sink ... Manual Can Opener (Table mounted) 1. Remove can opener shaft from support bracket daily. Clean shaft using the three compartment sink wash method. Clean and sanitize surface of table support bracket daily. 2. Remove table support bracket once a week. Clean and sanitize using the three compartment sink wash method. 3. Scrub and sanitize surface underneath table support bracket."

Based on clinical record review, observation, facility menu review, staff interviews and policy review, the facility failed to follow the physician ordered diets documented for 2 of 7 Critical Access Hospital (CAH) patients (Patient #1 and #2). The CAH administrative staff reported a census of 7 patients. The Manager of Nutrition Services reported an average of 24-30 patient meals served daily.

Failure to follow the physician's order for a diet could potentially result in patient complications including in part, fluid imbalance contributing to swelling in the arms, legs, lungs and/or abdomen, shortness of breath, dizziness, and reduced urine output.
Findings include:
1. Review of Patient #1 ' s medical record revealed physician orders for a 2000-milliliter (ml)/24 hours fluid restriction dated 10/4/11and no oral fluid restriction through the night tonight dated 10/6/11 at 6:30 PM.

a. Review of a document titled "Current Diets" for 10/10/11 and 10/11/11, showed staff failed to include the physician ordered fluid restriction for Patient #1.

b. Observation of Patient #1's meal tray card, during meal service, on 10/11/11, from 7:25 AM to 7:55 AM, showed staff failed to document Patient #1 ' s fluid restriction on the meal tray card as required.

c. Review of an undated document titled "Fluid Restrictions," posted in the patient tray-line area, revealed the following fluid limit guidelines for patients on a fluid restriction. The guidelines for a 2000 ml/day fluid restriction included 300 ml/tray and the guidelines for a 1500 ml/day fluid restriction included 225 ml/tray.

d. During an interview and review of Patient #1's medical record on 10/11/11 at 1:30 PM, Staff B, ward clerk, confirmed the physician ' s order dated 10/6/11 said no oral fluid restriction through the night. Staff B also acknowledged, Patient #1 should have continued on a 2000 ml fluid restriction beginning the next morning. Staff B entered the 2000 ml fluid restriction into the electronic medical record as part of Patient #1's diet order.

2. Review of Patient #2 ' s medical record revealed a physician order for a regular, No Added Salt (NAS) diet, and 1500 cubic centimeters (cc) fluid restriction dated 10/6/11.

a. Observation of Patient #2's meal tray card, during meal service, on 10/11/11, from 7:25 AM to 7:55 AM, revealed a NAS, 225 cc fluid per tray diet. Staff A placed 3 sausage links on Patient # 2's plate. Staff C, cook, placed 120 cc of grape juice and 105 cc ' s of coffee on Patient #2's meal tray. During an interview, at the time of the observation, Staff C reported they had the guidelines for fluid restrictions posted in the patient tray-line area.

b. Review of an undated document titled "Fluid Restrictions," posted in the patient tray-line area, revealed the following fluid limit guidelines for patients on a fluid restriction. The guidelines for a 2000 ml/day fluid restriction included 300 ml/tray and the guidelines for a 1500 ml/day fluid restriction included 225 ml/tray.

c. Review of the facility ' s menu for Day 5 (yellow) showed to fulfill the requirements for the NAS breakfast diet, staff should have served 1 sausage link.

d. During an interview on 10/11/11 at 3:00 PM, the Manager of Nutrition Services confirmed that according to the NAS diet, Staff A should have placed only 1 sausage link on Patient #2 ' s tray. Staff A further reported that tray line staff received training that included referring to the menus, located in the serving area, at each meal to assure they served the appropriate menu items in the appropriate portions for each diet type.

e. During an interview on 10/12/11 at 2:25 PM, the Clinical Dietitian reported dietary staff training included, serving the menu items and portions as planned on the menu. The Clinical Dietitian confirmed that for a patient on a NAS diet staff should have served 1 sausage link, not 3 as Staff A served.

f. During an interview and review of Patient #2 ' s medical record on 10/11/11 at 1:30 PM, Staff B, ward clerk, confirmed the medical record contained a physician order for Regular NAS diet however, the orders lacked evidence of a fluid restriction. According to Staff B, the physician generally ordered a fluid restriction for patients with congestive heart failure (CHF). Staff B explained; if a fluid restriction order existed during the acute care stay, the fluid restriction order was usually continued in the electronic record with the swing bed patient orders, even if the physician did not include the order on the swing bed order sheet.

g. During an interview on 10/12/11 at 10:50 AM, Staff L, Nurse Manager, reported staff completed the swing-bed physician order sheet when a patient transferred from acute to swing bed-status. According to the Nurse Manager, if staff were supposed to continue the acute diet order through their swing-bed level of care, they should ensure that all orders were included on this sheet. The Nurse Manager confirmed staff had not documented Patient #2 ' s 1500 ml fluid restriction on the swing-bed physician order sheet and that the order should not have continued to swing-bed status as part of the Patient ' s diet.

3. During an interview on 10/13/11 at 9:10 AM, the Vice President of Patient Care reported the facility did not have a policy that addressed fluid restrictions for patients.

4. Review of a nursing services policy titled "Physician Orders," approved on 11/9/10 revealed, in part "Policy Statement - To assure that physician orders are correctly written and transferred to the necessary forms in order for them to safely communicate to the health care team all medical, nursing, and ancillary treatments, procedures, and modalities. General Information 1. All physician orders must be documented ... Procedure 3. Place a check and your initials at the end of each individual order after it has been transcribed ... c. By initialing next to the check, the person transcribing the orders is accepting responsibility for his/her work. 4. After the orders have been transcribed, a licensed nurse must note the orders. a. When noting the orders make sure that orders have been transcribed onto the Kardex and MAR correctly ...."

a. Review of a Nutrition Services policy titled "Diet Orders", approved on 1/11/11 revealed, in part "Policy - Patients receive specific diet according to physician's order. Each order is to be entered into the patients ' electronic medical record ... 1. The physician orders diet for patient ... "

b. Review of a Nutrition Services policy titled "Patient Tray Identification", approved on 1/11/11, revealed, in part "... 2. Patient meal service is responsible to insure the appropriate foods and condiments are served to the patient according to the instructions on the tray card and therapeutic diet information sheet."

Based on document review, observations and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure staff in all departments' secured confidential patient information from unauthorized access in the following departments.

Medical Record Department: The Medical Record Manager identified approximately 75-80,000 hospital medical records and 15-20,000 clinic medical records stored in the medical record department.

Medical Surgical/Special Care Unit: The CAH administrative staff identified a daily average of 7 patients.

Physical Therapy (PT): The Physical Therapist identified a daily average of 2 inpatients and 21 out patients.

Occupational Therapy (OT): The Occupational Therapist identified a daily average of 1 inpatient and 5-6 out patients.

Respiratory Therapy (RT): The Respiratory Therapist identified a daily average of 1 inpatient and 5-6 out patients.

Laboratory: The Laboratory/Radiology Director identified a yearly average of approximately 100,000 laboratory test procedures.

Radiology/Laboratory storage area: The Laboratory/Radiology Director identified approximately 2080 radiology films stored in a storage room.

Surgical/Recovery area: The Surgical Manager identified an unsecured surgery log and patient information in an unlocked file drawer

Failure to secure medical record information against unauthorized access could result in identify theft or unauthorized disclosure of personal medical information.

Findings include:

1. Review of the "Confidentiality" policy, effective 5/1/04, revealed in part, "Storage and Security. Patient information located in patient care areas shall be housed in physically secured areas; and all other medical records are housed in physically secured areas within the Medical Record Department. ...It is the responsibility of the hospital and its co-works to safeguard information of patients and to see that pertinent information is available to properly authorized individuals or parties..."

2. Tour of the hospital departments revealed:

a. Observations during a tour of the medical records department on 10/11/11 at 9:15 AM, revealed moveable shelving units which contained information including, but not limited to, the patient's name, date of birth, medical record number, and confidential medical diagnosis, progress notes, medical procedures, etc. During an interview, at the time of the tour, the Medical Record Manager stated the shelving units contained approximately 75,000-80,000 CAH patient medical records and 15,000-20,000 clinic patient medical records. The Medical Record Manager acknowledged that housekeeping services staff cleaned the medical record department unsupervised, and the housekeeping staff could access information contained in the shelving units. The Medical Record Manager acknowledged the housekeeping staff did not need to know the patient's medical and/or personal information to conduct their job duties.

b. Observations during a tour of the medical/surgical department on 10/10/11 at 9:30 AM revealed 2 open boxes under the nursing station labeled "shredding box." Each box contained patient information papers that included, but not limited to, the patient's name, date of birth, medical record number, and confidential medical diagnosis, progress notes, procedures performed, etc. During an interview, at the time of the tour, the Nurse Manager confirmed the open boxes contained patient information. The Nurse Manager acknowledged that housekeeping services staff cleaned the nursing station and nursing staff did not supervise the housekeeping staff at all times while cleaning, therefore, housekeeping staff could access information contained in the open boxes. The Nurse Manager acknowledged the housekeeping staff did not need to know the patient's medical and/or personal information to conduct their job duties.

c. Observations, during a tour of the Physical Therapy department, on 10/12/11 at 8:45 AM, revealed an open box labeled "shredding box" under the receptionist desk and the Physical Therapists dictation desk. Each box contained patient information papers that included, but not limited to, the patient's name, date of birth, medical record number, and confidential medical diagnosis, progress notes, procedures performed, etc. During an interview, at the time of the tour, the Physical Therapist Manager confirmed the open boxes contained patient information. The Physical Therapist Manager acknowledged the housekeeping services staff cleaned the Physical Therapy department unsupervised, therefore, the housekeeping staff could access patient information contained in the open boxes. The Physical Therapist Manager acknowledged the housekeeping staff did not need to know the patient's medical and/or personal information to conduct their job duties.

d. Observations during a tour of the Respiratory Therapy (RT) department 10/11/11 at 3:45 PM revealed an open box labeled "shredding box" under the Respiratory Therapist's desk. The open box contained patient information papers that included, but not limited to, the patient's name, date of birth, medical record number, and confidential medical diagnosis, progress notes, procedures performed, etc. During an interview, at the time of the tour, the Respiratory Therapist Manager, confirmed the open box contained patient information. The Respiratory Therapist Manager acknowledged staff did not lock the door to the office, or the door at the end of the hallway that lead to the Respiratory Therapy Department. The Respiratory Therapist Manager acknowledged the housekeeping services staff cleaned the RT department after hours unsupervised, therefore, the housekeeping staff could access patient information contained in the open boxes. The Respiratory Therapy Manager acknowledged the housekeeping staff did not need to know the patient's medical and/or personal information to conduct their job duties.

e. Observations, during a tour of the Occupational Therapy (OT) department, on 10/12/11 at 9:00 AM revealed an open box labeled "shredding box" under the Occupational Therapist's desk. The open box contained patient information papers that included, but not limited to, the patient's name, date of birth, medical record number, and confidential medical diagnosis, procedures performed, progress notes, etc. During an interview, at the time of the tour, the Physical Occupational Therapist Manager confirmed the open box contained patient information. The Physical Occupational Therapist Manager acknowledged the housekeeping services staff cleaned the OT department after hours unsupervised, therefore, the housekeeping staff could access the patient information contained in the open boxes. The Physical Occupational Therapist Manager acknowledged the housekeeping staff did not need to know the patient's medical and/or personal information to conduct their job duties.


27303


f. Observations, during a tour of the laboratory department, on 10/12/11 at 8:45 AM, revealed a small open black bin on the counter in the room. The bin contained 10 patient arm bands that had the patient's name, date of birth and reason for the visit on the arm band. The bin also included 3 stickers that had the patient's name and lab test performed. The Laboratory/Radiology Director removed the items in the black bin and placed the the papers in an open box labeled "Shred Box" under the desk in the reception area.

Further observation in the laboratory reception area revealed 2 unlocked filing drawers. Each drawer contained a month's worth of lab results from the clinic. The Laboratory/Radiology Director acknowledged the papers contained confidential patient information, and stated the housekeeping staff cleaned the reception area without supervision from the laboratory staff. The Laboratory/Radiology Director acknowledged the housekeeping staff did not need to know about the patient's medical and/or personal information to conduct their job duties.

g. Observations, during a tour of the laboratory/radiology storage room, on 10/11/11 at 8:20 AM revealed one side of the room contained approximately 2,080 mammography records. The records contained the patient's name, date of birth, past medial history, and radiologist's interpretation of the mammogram. The other side of the room contained records of every lab test from the prior 2 years (approximately 200,000 total test) and all the blood transfusion records since 1990. During an interview, at the time of the tour, the Laboratory/Radiology Director stated the CAH performed approximately 450 blood cross-matches per year (approximately 9,000 total records). The Director also stated that laboratory and radiology staff had access to the room, and the room lacked a mechanism to prevent staff from accessing information they didn't need to know.

h. Observations, during a tour of the operating and recovery areas, on 10/11/11 at 1:30 PM, revealed 3 unlocked drawers with patient information papers. The top unlocked drawer contained 1 of 1 recovery room register that had 1,175 records. Each record contained the patient's name, date of service, surgical procedure, anesthesia type and recovery notes. The Operating Room (OR) Supervisor acknowledged the staff did not secure the register, and stated the housekeeping staff cleaned the area after the recovery room staff left for the day. The OR Supervisor acknowledged the housekeeping staff did not need to know the information in the register to conduct their job duties.

Additional observations, during the tour of the recovery isolation room, revealed a cart with several unlocked drawers. The top drawer contained a small notebook with patient stickers and implant stickers. The log contained 280 records that contained the patient's name, date of birth, and type of implant. The OR Supervisor acknowledged the housekeeping staff cleaned the recovery isolation room after recovery room staff left, and the housekeeping staff did not need to know the information to conduct their job duties.

Observations at the OR nurses' station revealed the OR Staff stored the OR log in an unlocked drawer at the nursing station. Review of the OR log revealed patient's name, date of service, procedure, and any complications noted at the time of surgery or recovery. The log contained the last 2 months of procedures. The CAH surgical staff performed 76 surgical procedures the prior month and 703 procedures year to date. The OR Supervisor stated the housekeeping staff performed deep cleaning of the OR areas after OR staff left for the day, and acknowledged the housekeeping staff did not need to know the patient's medical and/or personal information to conduct their job duties.

i. During an interview on 10/13/11 at 4:00 PM, the Vice President of Patient Care confirmed the housekeeping staff do not need to know about the patient's medical and/or personal information.

Based on observation and staff interview, the Critical Access Hospital (CAH) surgical administrative staff failed to ensure surgical staff had access to the current credentials of 2 of 2 selected surgeons (Surgeons F and G). The Operating Room Supervisor stated the surgical services staff performed an average of 70 surgeries per month.

Failure to ensure surgical staff had access to the current privileges could potentially result in surgical staff allowing a surgeon to perform a surgical procedure they lacked approved credentials, capability, equipment and/or staff to perform.

Findings include:

1. Observations, during a tour of the Operating Rooms, on 10/11/11 at 1:30 PM revealed 1 of 1 Credentials Book. Review of the Credential book showed the Governing Body and Medical Staff had approved the credentials for Surgeons F and G in 2006. However, the documents lacked evidence the credentials in the book, available to the surgery staff, were the most current credentials available for these surgeons.

2. During an interview, at the time of the tour, the Operating Room Director stated they had not received any updated surgical privileges, paper or otherwise, for the surgeons, including Surgeons F and G, in the prior 4 years. The Operating Room Director contacted the Credentialing Manager, and the Credentialing Manager stated the Operating Room Director could access the surgical privileges for Surgeon F and G on the computer. The Operating Room director attempted to access the surgical privileges on the computer, but could not access them because the Director did not have the level of security required to access the privileges.

3. During an interview on 10/13/11 at 9:30 AM, the Credentialing Manager stated the CAH lacked a policy requiring the surgical staff to have access to the current list of surgical privileges for the surgeons.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician evaluated the care 1 of 1 selected Certified Registered Nurse Anesthetist (CRNA) (CRNA J) provided to patients of the CAH. The CAH administrative staff identified 11 CRNAs on the Medical Staff. The Operating Room director identified an average of 40 surgical procedures that required anesthesia per month.

Failure to ensure a physician evaluates the care provided by all CRNAs to patients of the CAH could potentially result in the CRNA providing inappropriate care and treatment, and/or CAH staff failing to recognize the inappropriate care.

Findings include:

1. Review of the credential file for CRNA J on 10/12/11 at 4:30 PM, revealed the credential file lacked documented evidence of a physician providing review of the care CRNA J provided to the patients at the CAH.

2. During an interview on 10/13/11 at 9:30 AM, the Credentialing Manager acknowledged the credential file lacked evidence of physician review of the care CRNA J provided to patients at the CAH. The Credentialing Manager stated the CAH lacked a policy requiring a physician to provide a review of the care the CRNAs provided to patients at the CAH.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure an outside entity conducted a peer review for all physicians that provided care to patients of the CAH. Problems identified with 2 of 3 selected Radiologists (Radiologist D and K), 2 of 2 selected Surgeons (Surgeon F and G), and 2 of 2 selected Pathologists (Pathologist A and H). The administrative staff identified 51 Radiologist members of the Medical Staff, 7 Surgeon members of the Medical Staff, and 3 Pathologist members of the Medical Staff. The administrative staff identified an average of 19 radiology procedures interpreted by the radiologists per month, an average of 48 pathology specimens interpreted by the pathologists per month, and an average of 70 surgical procedures performed at the CAH per month.

Failure to provide outside peer review inhibits the Medial Staff and Board of Directors ability to have all the required information prior to appointing physicians and/or practitioners to the Medical Staff.

Findings include:

1. Review of physician credential files on 10/12/11 at 4:30 PM revealed the following:

a. Pathologist A, D, F, G, H, and K's credential files lacked documentation that showed an outside peer review of the physician's quality and appropriateness of the diagnosis and treatment furnished to patients' of the CAH occurred during the most current credentialing period.

b. Review of the facility's "Iowa Critical Access Hospital Program network Agreement dated May 1, 2003 revealed, in part. "...The parties agree that McKennan, through participating members of its medical staff or other personal designated by McKennan, shall meet with CAH's QA representatives no less than on a semi-annual basis to provide objective oversight and assistance to CAH in reviewing the quality and appropriateness of the diagnosis and treatment furnished by CAH's doctors of medicine or osteopathy..."

2. During an interview on 10/13/11 at 9:30 AM, the Credentialing Manager stated the credential files lacked external peer review, since the Credentialing Manager only subjected the Family Practice Physicians at the CAH to external peer review. The Credentialing Manager also stated the CAH lacked a policy requiring physicians to receive external peer review on the care they provided to patients at the CAH.