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I. Based on observations, document review and staff interviews, the Critical Access Hospital (CAH) maintenance staff failed to ensure patient safety from burns related to hot water temperatures. Problems identified with hot water temperatures in 2 of 2 sinks in the nursery area. The CAH identified an average weekly census of 6 obstetrical deliveries.

Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury relates directly to the temperature and duration of exposure to the water. The length of exposure required for a third degree burn to occur is 1 second at 155 degrees, 2 seconds at 148 degrees, 5 seconds at 140 degrees, 15 seconds at 133 degrees, 1 minute at 127 degrees, and 3 minutes at 124 degrees for adults. The length of exposure required for a third degree burn to occur for babies is 30 seconds at 125 degrees, the higher the temperature the less time for the fragile thin layer of skin on a new born.

Findings include:

1. Review of CAH documents revealed:
a. Policy, "Water Temperature" effective 9/98, "Purpose: To insure the safety of the patient while under hospital care...maintenance Department will record the temperature of the water in the system and it shall be maintained at less than 130 degrees F [Fahrenheit]..."

During a conversation on 11/2/11 at 9:45 AM, Staff K, Maintenance Leader, stated a staff made a typing error on the temperature in the policy, it should read 120 degrees. Staff K provided an updated policy dated 11/2/11 with corrected temperature of 120 degrees.

b. "The New Mom's Handbook" revised 2/11, "Bathe every day using warm-not hot- water..."

c. Water logs revealed in part:
11/1/11, room #10 located in Obstetrics (OB), temperature of 120 degrees
10/24/11, room #25 located in medical/surgical areas, temperature of 131 degrees,
9/26/11, room # 26 located in medical/surgical areas, temperature of 122 degrees
8/29/11, room #24 located in medical/surgical areas, temperature of 127 degrees

During an interview on 11/2/11 at 9:45 AM, Staff J, Maintenance, confirmed the high water temperatures documented in the log and stated staff did not document any follow up on the hot temperatures. Staff J stated the water heater for Medical/surgical patient room areas would be the same water heaters for the nursery.

d. Variance report dated 10/31/11 at 10:30 AM, " ...Detail summary of event: Temperature at sink was found to be 129 which is 10 degrees higher than normal.
...Report of Investigation Findings: Temperature setting was corrected at water heater, and re-tested at 6:30 on 11/1/11. The temperature was found to be 119.3 at that time..."

2. Observations during a tour of the nursery accompanied by Staff B, Registered Nurse (RN) on 10/31/11 at 10:30, revealed the following hot water temperatures and confirmed by Staff B.
a. Nursery sink #1 located in back area of the nursery: 129.6 degrees at 10:30 AM.
b. Nursery sink #2 located in front area of the nursery: 129.7 degrees at 10:30 AM.

3. During an interview on 10/31/11 at 10:30 AM, Staff B explained the Physician used the back area of the nursery for circumcision, so staff used the sink to wash the baby as needed. Staff B stated staff used both sinks to provide water for the baby's sponge bath. Staff B stated the nurses did not temp the water with a thermometer, but with their hand. Staff B acknowledged the high water temperature and notified maintenance of the water temperatures.

During an interview on 10/31/11 at 11:30 AM, Staff J confirmed the water temperature in the nursery tested at 129.4 with the facility thermometer. Staff J stated the staff turned down the water heater and staff would be checking the water temperature frequently until water temperature under 120 degrees.

During an interview on 11/1/11 at 4:20 PM, Staff J, Maintenance, stated the maintenance staff tested water temperatures in various areas weekly on Monday. Staff J stated the staff did not routinely test the nursery and the log did not note if/when the nursery water temperature last checked.
Staff J provided the 10/31/11 variance report and stated staff monitored the nursery water temperature frequently until water temperatures fell below 120 degrees. Staff J stated staff did not document their monitoring of water temperatures during this time.

During an interview on 11/2/11 at 9:30 AM, Staff J, RN, stated the hospital did not have a policy specific to bathing a baby, but would follow the same bathing process the nursing staff instructed the parent on from the handbook, "The New Mom's Handbook." Staff J acknowledged the handbook lacked identifying the correct temperature of the bath water.


Surveyor: Davis, Thomas D.



22064

Based on observations, review of records and staff interviews, the CAH (Critical Access Hospital) ED (Emergency Department) staff failed to secure the medications in 1 of 1 crash cart found in the trauma bay of the ED. The CAH administrative staff reported an average daily census of 11 patients.
Failure to properly secure the crash cart medications could potentially result in medication theft/loss.
Findings include:
1. Observation, during the initial tour of Emergency Department, on 10/31/11 at 3:00 PM, revealed the crash cart top drawer contained the emergency drugs. The crash cart appeared secured with a red breakaway type lock located on the bottom drawer. The top drawer of the crash cart opened, easily, to expose all of the emergency drugs. Staff A, ED RN (Registered Nurse), made several attempts to secure the top medication drawer. Finally, Staff A did successfully secure the drawer.
2. Review of a policy titled, "Crash Cart/Code Cart" undated, stated in part ..." Crash Cart Security, locked at all times. Unlocked during use and immediately following use, RN (Registered Nurse) restocks and relock's. Unlocked for checking supplies and outdates.
3. During an interview on 10/31/11 at 3:30 PM, Staff C, ED RN, verified that she replaced the medication drawer in the crash cart at approximately 8:45 AM. Staff A revealed she was unaware that the crash cart was not locking correctly and the crash cart was approximately 18 years old.

I. Based on observations, review of records, and staff interviews the CAH (Critical Access Hospital) revealed 1 of 1 soiled utility room located in the Emergency Department (ED) contained clean and soiled supplies. The ED staff reported approximately 600 monthly visits to the ED.
Failure to separate soiled and clean supplies could potentially result in contamination of the clean items and spread of infections.
Findings include:
1. Observation, during the initial tour of the ED, on 10/31/11 at 3:00 PM, revealed a soiled utility room that contained crutches wrapped in clear plastic wrap, clean commodes, casting supplies, gauze, a hopper (a large sink that flushes), trash, biohazard trash, and empty pop cans.
2. Review of the policy/procedures revealed the CAH administrative staff failed to develop and implement a policy for the separation of clean and soiled supplies.
3. During an interview on 10/31/11 at 3:30 PM, Staff A, ED RN (Registered Nurse), verified that clean supplies were stored with soiled supplies in the soiled utility room. During an additional interview on 11/1/11 at 8:30 AM, Staff B, Infection Control RN, verified staff should not store clean supplies with soiled supplies and the CAH failed to have a policy for the separation of clean supplies form soiled supplies.
II. Based on observation, review of records and staff interview, the Emergency Department (ED) failed to store the linen, used for patient care, in a clean environment in 5 of 5 bays. The ED staff reported approximately 600 monthly visits to the ED.
Failure to maintain a clean environment for the storage of linen could potentially result in contaminated and infectious linen for patient use.
Findings include:
1. An observation on 10/31/11 at 3:30 PM revealed 5 of 5 ED bays stored patient care linens under the sink. Under the sink, storage is a dirty area. Items stored under the sink would include chemicals, used for cleaning and other tasks.
2. Review of the policy/procedures revealed the CAH administrative staff failed to develop and implement a policy that identified appropriate supplies to be stored under the sinks.

3. During an interview on 10/31/11 at 3:30 PM, Staff A, ED RN, verified the storage of patient linen under 5 of 5 sinks in the ED. During an additional interview on 11/1/11 at 8:30 AM, Staff B, Infection Control RN, verified linen should not be stored under the sinks in ER and the CAH failed to have a policy for storage of supplies under sinks.

III. Based on observation, review of records, and staff interviews, the Critical Access Hospital (CAH) failed to maintain a clean and sanitary environment in the Dietary Department. The CAH administrative staff reported a daily average meal production of 384 meals.
Failure to maintain a clean and sanitary environment in the Dietary Department could potentially result in foodborne illness.
Findings include:
1. An observation, during the initial tour of the Dietary Department, on 10/31/11 at 1:02 PM, revealed the following areas in need of additional cleaning: Vulcan Range, 2 floor fans, 3 wall mounted fans, and microwave oven.
a. the Vulcan Range had 3 areas, approximately 6 x 6, on the back splash that were dark brown-black in color. The front of the range had numerous dried on food spills that ran down the oven door surface.
b. Two floor fans had a moderate accumulation of a dark brown substance on the fan blades.
c. Three wall mounted fans had moderate accumulation of a dark brown substance on the fan blades. One of the fans was blowing directly on the clean dishes as they exited the dish machine. Spreading the dark brown substance onto the clean dishes.
d. The inside of the microwave oven contained numerous areas of dried on food on the roof, back and front glass.
2. Review of the policy/procedures revealed the CAH administrative staff failed to develop and implement a policy for cleaning the Vulcan Range, fans, and microwave oven. The daily cleaning log failed to include the Vulcan Range, fans, and microwave oven.
3. During an interview on 10/31/11 at 1:30 PM Staff C, Dietary Manger, verified the above areas were in need of additional cleaning, and the Dietary Department administrative staff failed to develop and implement a policy that addressed cleaning these items. Staff C stated they would add the items to the daily cleaning list.

IV. Based on observation, staff interview, and document review, the Critical Access Hospital (CAH) radiology management staff failed to ensure radiology staff tested 1 of 1 disinfecting solutions for efficacy before each use, and dated 1 of 1 test strip containers when opened as required by the manufacturer. The CAH radiology staff identified an average of 22 ultrasound procedures per month, and each would require the use of the disinfecting solutions for cleaning after the procedure.

Failure to test the disinfecting solutions prior to each use and date test strip containers when opened could result in the disinfecting solution not containing a sufficient strength of the active ingredient to kill all microorganisms, potentially resulting in the spread of infectious microorganisms between patients.

Findings include:

1. Observations during a tour of the Radiology Department ultrasound room on 10/31/11 at 2:45 PM, revealed 1 of 1 Cidex test strip container not dated when opened. A log sitting next to the machine revealed Radiology staff tested the disinfectant, Cidex, once a day, when the staff used the ultrasound for pelvic exams.

2. During an interview on 10/31 at 2:45 PM, the Radiology manager stated the Radiology staff test the Cidex once a day, before completing ultrasound exams. The Radiology manager stated the Radiology staff completed approximately 22 pelvic exams a month and did not check the disinfectant between uses if performing more than one pelvic exam a day.

3. During an interview on 10/31 at 2:45 PM, Staff N, Ultrasound Technologist said staff do not date Cidex test strips when opening them and do not test the Cidex solution between patients if completing more than one pelvic ultrasound a day.

4. Review of the policy "Use of Cidex for Cleaning Ultrasound Probes," effective 2/22/2011, revealed in part... "The Cidex solution should be tested daily and Pass/Fail marked on log sheet along with tester's initials."

5. Review of the manufacturer's directions for Cidex, revealed in part... "Reuse Period... Test the solution prior to each use."

6. Review of the manufacturer's directions for Cidex Solution Test Strips, revealed in part..." When opening the bottle for the first time, record date opened in the space provided on the label. Do not use any remaining strips 90 days after opening the bottle."


22898

Based on review of Critical Access Hospital policy, medical records, and staff interview, the administrative staff failed to ensure the CAH patients signed an informed consent prior to treatments and services at the CAH. The CAH administrative staff reported an average daily census of 11 patients.

Failure to provide the patient with information needed to make an informed decision could potentially result in the patient receiving a treatment or procedure which the patient did not want or agree to which could cause the patient adverse physical and/or mental outcomes.

Findings include:

1. Review of "Medical Record Documentation" dated 5/1/10 revealed in part, "...evidence of patient's informed consent for any...medical, or diagnostic treatment or procedure is documented in the medical record. the consent form may be completed...within 30 days prior to a procedure."

2. On 11/2/11 review of 17 of 17 closed records revealed "permit for treatment and surgical care" document lacked a date when the patient and/guardian signed the consent.

a. Patient #11 received care during a hospital stay from 4/11/11 to 4/15/11 for Pneumonia. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

b. Patient #12 received care during a hospital stay from 5/5/11 to 5/6/11. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

c. Patient #13 received care during a hospital stay from 4/14/11 to 4/20/11 for a compression fracture of the spine. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

d. Patient #14 received care during a hospital stay from 8/6/11 to 8/7/11 for chest pain. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

e. Patient #15 received care during a hospital stay from 9/10/11 to 9/11/11 for labor and delivery of a baby. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

f. Patient #16 received care during a hospital stay from 7/5/11 to 7/7/11 for labor and delivery of a baby. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

g. Patient #17 reviewed care during a hospital stay from 9/5/11 to 9/8/11 for labor and delivery of a baby. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

Surveyor: Balough, Jean
h. Patient #1 received care during a hospital stay from 5/26/11 to 5/29/11 for a failed hip surgery. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

i. Patient #2 received care during a hospital stay from 9/6/11 to 9/8/11 for knee surgery. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

j. Patient #3 received care during a hospital stay from 8/23/11 to 9/1/11 for orthopedic surgery. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

k. Patient #4 received care during a one day surgery hospital stay on 9/8/11 for bladder repair surgery. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

l. Patient #5 received care during a one day surgery hospital stay on 9/21/11 for bladder repair surgery. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

m. Patient #6 received care during a one day surgery hospital stay on 10/12/11. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

n. Patient #7 received care during a one day surgery hospital stay on 10/20/11. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

o. Patient #8 received care during a one day surgery hospital stay on 10/21/11. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

p. Patient #9 received care during a one day surgery hospital stay on 10/20/11. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

q. Patient #10 received care during a one day surgery hospital stay on 10/20/11. Review of the medical record revealed a "permit for treatment and surgical care" document that lacked a date when the patient and/or guardian signed the consent.

3. During an interview on 11/2/11 at 1:30 PM, Staff I, Chief Nursing Officer, confirmed the findings. Staff I stated the patient should sign the consent form during registration or at admit by the nursing staff. Staff I stated staff would not be able to tell when the patients signed the consent due to the lack of date.



25917

I. Based on review of documents, medical records and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure all physician included a date when they authenticated their verbal orders in the medical records. The CAH administrative staff reported an average daily census of 11 patients.

Physicians authenticate verbal orders to accept responsibility for the order and validate the order is complete, accurate, and based on the patient's condition. The date on the authentication signature establishes when the Physician validated the accuracy of the verbal order.

Findings include:

1. Review of CAH documents revealed in part:

a. Medical Staff Bylaws, "All verbal orders for medications and standing orders must be authenticated by the responsible physician within 30 days..."

b. Policy, "Health Information management" dated 1/1/05, "All entries in record are to be dated..."

2 On 11/2/11 a review of 8 closed medical records, dated at least 30 days after discharged, revealed 7 of 8 closed medical records lacked a date the Physician authenticated the verbal orders:

a. Patient #1 received care during a hospital stay from 5/26/11 to 5/29/11 for failed hip surgery. Review of the Physician verbal orders revealed 4 of 4 verbal orders lacked a date the Physician authenticated the verbal order.

b. Patient #2 received care during a hospital stay from 9/6/11 to 9/8/11 for knee surgery. Review of the Physician verbal orders revealed 12 of 12 verbal orders lacked a date the Physician authenticated the verbal order.

c. Patient #11 received care during a hospital stay from 4/11/11 to 4/15/11 for Pneumonia. Review of the Physician verbal orders revealed 5 of 5 verbal orders lacked a date the Physician authenticated the verbal order.

d. Patient #13 received care during a hospital stay from 4/14/11 to 4/20/11 for a partial small bowel obstruction. Review of the Physician verbal orders revealed 5 of 5 verbal orders lacked a date the Physician authenticated the verbal order.

e. Patient #14 received care during a hospital stay from 8/6/11 to 8/7/11 for chest pain. Review of the Physician verbal orders revealed 1 of 1 verbal orders lacked a date the Physician authenticated the verbal order.

f. Patient #15 received care during a hospital stay from 9/10/11 to 9/11/11 for labor and delivery of a baby. Review of the Physician verbal orders revealed 3 of 3 verbal orders lacked a date the Physician authenticated the verbal order.

g. Patient #16 received care during a hospital stay from 7/5/11 to 7/7/11 for labor and delivery of a baby. Review of the Physician verbal orders revealed 1 of 1 verbal order lacked a date the Physician authenticated the verbal order.

h. Patient #17 reviewed care during a hospital stay from 9/5/11 to 9/8/11 for labor and delivery of a baby. Review of the Physician verbal orders revealed 2 of 2 verbal orders lacked a date the Physician authenticated the verbal order.

3. During an interview on 11/2/11 at 1:30 PM, Staff I, Chief Nursing Officer, confirmed the findings. Staff I stated "all Physician's signatures need to be dated and should be timed."


25917


II. Based on review of policy/procedure, medical records, and staff interviews, the CAH administrative staff failed to ensure all physicians and midlevel providers authenticated and dated History and Physical (H &P) updates prior to surgery in 2 of 2 inpatient surgical records (Patient # 1 and #2) and 2 of 8 outpatient surgical records (Patient # 3 and #6). The CAH administrative staff reported completing approximately 100 surgical cases per month.

Failure to authenticate and date medical record entries could potentially cause harm to patients by delay in treatments, actions, or assessments provided.

Findings included:

1. Review of CAH policy "Health Information Management, Purpose and Objectives", effective 1/05, revealed in part, "...All entries in the record are to be dated and authenticated."

2. Review of CAH policy "History and Physical Prior to Surgery," revised 8/2009, revealed in part, "Policy: An H & P will be done within 30 days of surgery. If H & P is done greater than 7 days prior to surgery the surgeon needs to update the H & P within 24 hours of surgery."

3. Findings for 2 of 2 closed inpatient surgical records reviewed (Patients #1 and 2) and 2 of 8 outpatient surgical records (Patients # 3 and 6) include:

a. Review of Patient #1's inpatient surgical record revealed an admission date of 5/26/11 for orthopedic surgery and a discharge date of 5/29/11.

Patient #1's surgical record revealed documentation of a preoperative History and Physical (H & P) on 5/23/11. Surgeon D authenticated but did not date an update note of the H & P prior to surgery.

b. Review of Patient #2's closed inpatient surgical record revealed an admission date of 9/6/11 for orthopedic surgery and a discharge date of 9/8/11.

Patient #2's surgical record revealed documentation of a preoperative H & P on 8/23/11. Surgeon D authenticated but did not date an update note of the H & P prior to surgery.

c. Review of Patient #3's closed outpatient surgical record revealed an admission date of 9/1/11 for orthopedic surgery and a discharge date of 9/1/11.

Patient #3's surgical record revealed documentation of a preoperative H & P on 8/24/11. Surgeon D authenticated but did not date an update note of the H & P prior to surgery.

d. Review of Patient #6's closed outpatient surgical record revealed an admission date of 10/12/11 for surgery and a discharge date of 10/12/11.

Patient #6's surgical record revealed documentation of a preoperative H & P on 10/10/11. Surgeon E did not sign or date an update note of the H & P prior to surgery.

4. During an interview on 11/2/11 at 10:30 AM, Staff E, Surgical Leader, verified the physician entries in the medical records lacked signatures and dated entries. Staff E reported surgeons are required to update H & P's prior to surgery to assure no changes in the patient's condition had occurred. Staff E also stated "the surgeons are responsible for authenticating and dating all entries".

5. During an interview on 11/2/11 at 11:35 AM, Staff G, Chief Nursing Officer, verified the physician entries in the surgical records lacked signatures and dated entries. Staff G reported that "we [CAH Administrative Staff] have been working with the Medical Staff to increase compliance with signing and dating all entries in the medical record but still have problems with consistency".


III. Based on review of policy/procedures, medical records, and staff interview, the CAH administrative staff failed to ensure all physicians and midlevel providers dated all entries in the medical record in 1 of 2 inpatient surgical records (Patient # 1) and 8 of 8 outpatient surgical records (Patients # 3, 4, 5, 6, 7, 8, 9, and 10). The CAH administrative staff reported approximately 100 surgical cases per month.

Failure to date medical record entries could potentially cause harm to patients by a delay in treatments, actions, or assessments provided.

Findings included:

1. Review of CAH policy "Health Information Management, Purpose and Objectives," effective 1/05, revealed in part, "...All entries in the record are to be dated and authenticated."

2. Review of CAH policy "Medical Record Documentation," revised 5-1-10, revealed in part, "...IX. Orders A. All orders for treatment are in electronic format or in writing and are dated and signed by the responsible physician."

3. Findings for 1 of 2 closed inpatient surgical records reviewed (Patients #1 and 2) and 8 of 8 outpatient surgical records (Patients # 3 and 6) include:

a. Review of Patient #1's closed inpatient surgical record revealed an admission date of 5/26/11 for orthopedic surgery and a discharge date of 5/29/11.

Patient #1's surgical record lacked a dated signature for 1 of 1 Pre-operative Physician Order set and 1 of 1 Anesthesia Pre-operative Order set.

b. Review of Patient #3's closed outpatient surgical record revealed an admission date of 9/1/11 for orthopedic surgery and a discharge date of 9/1/11.

Patient #3's surgical record lacked a dated signature for 1 of 1 Anesthesia Pre-operative Order set.

c. Review of Patient #4's closed outpatient surgical record revealed an admission date of 9/8/11 for bladder surgery and a discharge date of 9/8/11.

Patient #4's surgical record lacked a dated signature for 1 of 1 Anesthesia Pre-operative Order set.

d. Review of Patient #5's closed outpatient surgical record revealed an admission date of 9/21/11 for bladder surgery and a discharge date of 9/21/11.

Patient #5's surgical record lacked a dated signature for 1 of 1 Anesthesia Pre-operative Order set.

e. Review of Patient #6's closed outpatient surgical record revealed an admission date of 10/12/11 for surgery and a discharge date of 10/12/11.

Patient #6's surgical record lacked a dated signature for 1 of 1 Anesthesia Pre-operative Order set.

f. Review of Patient #7's closed outpatient surgical record revealed an admission date of 10202/11 for surgery and a discharge date of 10/20/11.

Patient #7's surgical record lacked a dated signature for 1 of 1 Anesthesia Pre-operative Order set and 1 of 1 Post Surgery Order set.

g. Review of Patient #8's closed outpatient surgical record revealed an admission date of 10/21/11 for surgery and a discharge date of 10/21/11.

Patient #8's surgical record lacked a dated signature for 1 of 1 Anesthesia Pre-operative Order set.

h. Review of Patient #9's closed outpatient surgical record revealed an admission date of 10/31/11 for surgery and a discharge date of 10/31/11.

Patient #9's surgical record lacked a dated signature for 1 of 1 Anesthesia Pre-operative Order set.

i. Review of Patient #10's closed outpatient surgical record revealed an admission date of 10/31/11 for surgery and a discharge date of 10/31/11.

Patient #10's surgical record lacked a dated signature for 1 of 1 Peri-operative (during surgery) Order set and 1 of 1 Anesthesia Pre-operative Order set.

4. During an interview on 11/2/11 at 10:30 AM, Staff E, Surgical Leader, verified the physician and anesthesia orders in the medical records lacked dated entries. Staff E stated "the surgeons and Certified Registered Nurse Anesthetists (CRNA) are responsible for dating all orders and they know this."

5. During an interview on 11/2/11 at 11:35 AM, Staff G, Chief Nursing Officer, verified the physician and anesthesia entries in the surgical records lacked dates. Staff G reported that "we (CAH Administrative Staff) have been working with the Medical Staff to increase compliance with signing and dating all entries in the medical record but still have problems with consistency."

Based on review of policy/procedure, medical records, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a qualified practitioner evaluated each patient for proper anesthesia recovery prior to discharge for 4 of 8 outpatient surgical patients, (Patients #6, 7, 8, and 9) closed records reviewed. The CAH administrative staff reported completing approximately 60 outpatient surgeries per month.

Failure to provide a proper anesthesia recovery assessment by a qualified practitioner could potentially harm patients if complications, related to the use of anesthesia, occur after surgery and the patient has returned home.

Findings include:

1. Review of the CAH documents revealed the following:

a. Policy, "Postoperative Anesthesia Care," revision date 5/04, revealed in part, "...Responsibilities: The attending anesthetist is responsible for postanesthesia care of all patients who have received anesthesia (general, spinal, local anesthesia with standby). This includes documentation of all postanesthesia visits...".

b. "Amended and Restated Bylaws, Rules, Regulations of Medical Staff," approved 2011, revealed the Medical Staff bylaws lacked a requirement for the anesthesia provider to complete a postanesthesia assessment prior to discharge from the CAH.

2. Review of surgical records for Patients #6, 7, #8, and 9 revealed the following:

a. Review of Patient #6's closed outpatient surgical record revealed an admission date of 10/12/11 for surgery and a discharge date of 10/12/11.

Review of Patient #6's Postanesthesia Note revealed the CRNA failed to document a postanesthesia assessment following surgery and prior to the patients' discharge from the CAH.

b. Review of Patient #7's closed outpatient surgical record revealed an admission date of 10/20/2011 for surgery and a discharge date of 10/20/11. The Anesthesia Record, dated 10/20/11, revealed an anesthesia start time at 7:25 AM and stop time 8:40 AM.

Review of Patient #7's Postanesthesia Note revealed the CRNA completed the postanesthesia assessment at 8:40 AM. The CRNA failed to document any further assessment prior to the patients' discharge from the CAH.

c. Review of Patient #8's closed outpatient surgical record revealed an admission date of 10/21/2011 for surgery and a discharge date of 10/21/11. The Anesthesia Record, dated 10/21/11, revealed an anesthesia start time at 1:23 PM and stop time 3:16 PM.

Review of Patient #8's Postanesthesia Note revealed the CRNA completed the postanesthesia assessment at 3:30 PM. The CRNA failed to document any further assessment prior to the patients' discharge from the CAH.

d. Review of Patient #9's closed outpatient surgical record revealed an admission date of 10/31/2011 for surgery and a discharge date of 10/31/11. The Anesthesia Record, dated 10/31/11, revealed an anesthesia start time at 9:58 AM and stop time 10:35 AM.

Review of Patient #9's Postanesthesia Note revealed the CRNA failed to document the time the postanesthesia assessment was completed prior to the patients' discharge from the CAH.

3. During an interview on 11/2/11 at 10:30 AM, Staff E, Surgical Leader, verified the CRNA's failed to consistently document a postanesthesia assessment on all outpatient surgical patients. The CRNA's "are responsible for completing a postanesthesia assessment prior to a patients' discharge from the CAH and they are not following CAH policy."

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to include all practitioners that provided care and services to the CAH patients, in their external peer review process for 10 of 10 applicable practitioners. (Practitioners A, B and C). The CAH administrative staff reported an average of 42 radiology films a month and the teleradiologists read about 5 x-rays a month.

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff members misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of policy/procedure titled, "Peer Review Plan", dated 1/07, revealed in part. ". . .Circumstances that require external peer review include a routine random sample, consisting of not less than 4 closed records per year."

2. Review of peer review documentation for the past credentialing period of 2 years revealed the CAH staff failed to include all Practitioners (Practitioners A, B and C) in the CAH's external peer review process.

3. During an interview on 11/2/11 at 7:35 AM, the Director of Quality acknowledged the CAH quality staff failed to send out records of patients cared by Practitioners A, B and C for external peer review for the last credentialing period. The Director of Quality verified Practitioners A, B and C had provided services to patients of the CAH during the last credentialing period. The Director of Quality also stated the hospital needs to complete external peer review on all practitioners.