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Based on random observations and staff interview, the CAH (Critical Access Hospital) failed to ensure safety of patients by not securing cleaning products and disinfectants to prevent accidental ingestion, inhalation or consumption by patients. Census on the first day of survey was 1 acute inpatient and 1 swing bed patient. Findings are:

A. Tour of the ED (Emergency Department) on 11/17/10 at 11:00 AM with the Acting CNO (Chief Nursing Officer) revealed a one-step disinfectant cleaner and deodorant stored in an unlocked cabinet under the sink in the ED minor room. The MSDS (Material Safety Data Sheet) for this product listed the Emergency Overview as "DANGER, CORROSIVE, CAUSES EYE AND SKIN BURNS, HARMFUL OR FATAL IF SWALLOWED."

B. Tour of the Dietary Services on 11/16/10 from 10:15 AM to 10:55 AM with the Dietary Director revealed a dietary janitor's closet in the public hallway leading to the cafeteria. The door to this janitor's closet was not locked. Setting on the floor of this closet was a plastic jug of kitchen degreaser and kitchen cleaner. Both of the labels on these products cautioned "KEEP OUT OF REACH OF CHILDREN".

C. Tour of the Physical Therapy area on 11/15/10 from 12:45 PM to 1:00 PM with the Director of Rehabilitation Services revealed 3 different disinfectants stored in an unlocked cabinet under the sink in the patient care area. One of the disinfectants was the same as found in the ED.

D. Interview with the Chief Operating Officer on 11/18/10 at 9:30 AM revealed the CAH had no policy and procedure on storing cleaning products and/or disinfectants to ensure safety of patients. There is the potential for children and confused adults to access the above products.

Based on review of Medical Staff Bylaws, review of the Critical Access Hospital Annual Evaluation, review of physician and affiliate credential files, review of medical records and staff interview, the CAH (Critical Access Hospital) failed to:
- Follow the medical staff bylaws for reappointment of physicians to the CAH medical staff for 7 of 8 physician credential files reviewed (Physicians A, B, C, E, F, G and H);
- Ensure that 1 of 8 physician credential files reviewed for physicians providing services to patients in the CAH had been granted membership and privileges by the Governing Body; and
- Ensure that 1 of 3 Affiliate Staff were granted only those privileges within their scope of practice.
The listing of Medical Staff provided by the CAH had 57 physicians and 16 Affiliate Staff. Census on the first day of survey was 1 acute inpatient and 1 swing bed patient. Findings are:

A. Review of the Medical Staff Bylaws with an approval date of 12/27/07 revealed the following:

Article III Membership:
"Responsibilities of Membership. Application for or acceptance of membership on the Medical Staff constitutes acceptance of the following responsibilities...Abide by these Bylaws and Medical Staff Rules and Regulations...Timely complete and sign medical records for all Hospital patients to whom the member provides care."

Article IV Clinical Privileges:
"Qualifications. The following constitute continuing qualifications for the exercise of privileges at the Hospital. Each member and applicant for membership shall...Demonstrate current competence, including current knowledge, judgement, training, and technique, in his or her specialty area and for all privileges held or applied for."

Review of physician credential files on 11/16/10 revealed the following information was available for review: verification of current Nebraska physician's license; application; current DEA (Drug Enforcement Administration) License; Query of the National Practitioner Data Bank; Certificate of Insurance; Privilege listing; 2-3 Peer References; Office of Inspector General Sanctions (query to find out if practitioner has been excluded or sanctioned from participating in Medicare, Medicaid or other Federally funded health care programs); and, some files included evaluations from other hospitals where the physician held privileges. This information was reviewed for Physicians A, B, C, E, F, G and H; however, no information was available concerning current knowledge, judgement, technique and compliance with the Medical Staff Bylaws and Rules and Regulations or timely completion of medical records.

Interview with the Director of HIM (Health Information Management - responsibilities include physician credentialing) on 11/16/10 from 4:25 PM to 4:50 PM revealed the following:
- Working on developing a provider scorecard but had not presented this to the medical staff at this time;
- The scorecard would include information on quality concerns, medical record completion, and other pertinent information; and
- Had been working with their Network Hospital Representative to formulate this document.

Review of the CAH Annual Evaluation dated 7/21/10 under the section titled Credentialing - Summary of Meeting revealed the following "Continuing to develop policy and procedures for provider scorecards".

B. Review of the Medical Staff Bylaws with an approval date of 12/27/07 revealed the following:

Article IV Clinical Privileges:
"Nature of Privileges. Privileges to practice at the Hospital are granted by the Board following recommendation of the Medical Staff....A practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws."

Review of Medical Record 6 revealed a radiology report dated 7/9/10 for 2 chest x-rays with the findings completed by Physician D. Review of the listing of the Medical Staff provided by the CAH revealed Physician D was not on this list. Review of the credential file for Physician D revealed a Re-Appointment Review Request with a check mark in front of the statement "I do not want to continue my Medical Staff status at Community Memorial Hospital". This document was signed by Physician D and dated 3/21/02.

Interview with the Director of HIM on 11/16/10 from 4:25 PM to 4:50 PM confirmed that Physician D was not on the Medical Staff and was not aware that this physician was providing services in the CAH.

C. Review of the credential files for CRNA (Certified Registered Nurse Anesthetist)-J revealed a Delineation of Privileges form that was the same form as used for the physicians including surgeons. Review of this Delineation of Privileges form under the sections titled General Surgery, Eye Surgery, Ear/Nose/Throat Surgery, Neurological Surgery, Urological Surgery and Special Surgical Procedures Providing Supporting Documentation, CRNA-J had requested privileges for all procedures listed. Examples of the requested privileges were: Gastric Surgery; Gallbladder and common duct surgery; Colonoscopy; Laparoscopic Cholecystectomy and Rectal Surgery. The very top header on this page was "Delineation of Anesthetic Privileges Desired". This form was confusing as to whether these were just anesthetic privileges for the listed surgeries or for the actual procedure. The CAH was using it as both. Review of the credential file for Physician B, who was a Surgeon, revealed this same Delineation of Privileges form was used to request surgical privileges.

Interview with the Director of HIM on 11/17/10 from 4:25 PM to 4:50 PM was unable to clarify whether this page which included surgical procedures was for the procedure or for anesthesia for that particular procedure.

Based on staff interview and facility policy, the facility failed to have a qualified individual to direct the activities program for swing bed patients. Census on the first day of survey was 1 acute inpatient and 1 swing bed patient. Findings are:

A. Staff interview with the facility Chief Operating Officer on 11/18/10 at 10:50 AM confirmed the facility has not employed an individual qualified to direct the swing bed activities program since the previous employee left on 10/21/10.

B. Review of the undated facility policy/procedure titled "Swing Bed Activities Program" states "The Swing Bed Activities Program is administered by a person who has completed a State-approved resident activities course."

Based on record review, staff interview and facility policy review, the facility failed to ensure 1 of 2 swing bed residents (Resident 32) had a comprehensive assessment within 14 days of admission. The total sample was 5. The facility census was 1 acute inpatient and 1 swing bed patient. Findings are:

A. Closed medical record review revealed Resident 32 was admitted to the facility as a swing bed resident on 6/28/10. The patient was discharged on 7/15/10. A comprehensive assessment was not found during the record review.

B. Staff interview on 11/15/10 with the acting Chief Nursing Officer (CNO) at 2:00 PM confirmed the comprehensive assessment was not completed as required. The CNO related the assessment is to be completed by the CNO with the floor nurse's input. The CNO stated the facility "rarely has a swing bed patient for more than 14 days."

C. The undated facility policy/procedure titled "Swing Bed-admission procedure" states "A "Swing Bed Comprehensive Assessment for Nebraska Critical Access Hospitals is to be completed and placed in the chart by day 14."