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Based on observation and staff interview, the Critical Access Hospital (CAH) Administrative staff failed to post a notice in a place likely to be noticed by all individuals entering the dedicated Emergency Department that the CAH does not have a physician present in the hospital 24 hours a day, 7 days a week, and indicate how the CAH staff will meet the medical needs of any patient with an emergency medical condition. Failure to post a notice in a noticeable place in the Emergency Department that the CAH lacks 24/7 physician coverage interferes with a patient's ability to make an informed decision if the patient wants to receive care at the CAH. The Administrative Staff identified 1686 patients presented to the emergency department for FY 2020 who sought emergency medical treatment.

Findings Include:

1. Observations on 10/4/21 at 3:10 PM, during a tour of the Emergency Department, revealed the CAH lacked a posted notice that the CAH did not have a physician present in the hospital 24 hours a day, 7 days a week.

2. During an interview on 10/4/21 at the time of the tour, the Nursing Supervisor verified the CAH did not have a physician present in the hospital 24 hours a day, 7 days a week and that the CAH staff failed to display a notice in a clearly visible area to ED patients that the CAH did not have a physician present in the hospital 24 hours a day, 7 days a week.

Based on document review and staff interviews the Critical Access Hospital (CAH) administrative staff failed to ensure state employment requirements were met for the individual responsible for the operation of the Nutrition Services Department. The administrative staff identified a census of 5 inpatients at the time of the survey and an average census of 3 patients. The Nutrition Services department served an average of 8 patient meals daily. Failure to ensure a qualified person manages the food service department could potentially result in poor dietary practices impacting the health and nutritional needs of the patients.

State rule:
51.20(3) b. If a licensed dietitian is not employed full-time, then one must be employed on a part-time or consultation basis with an additional full-time person who has completed a 250-hour dietary manager course and who shall be employed to be responsible for the operation of the food service.

Findings include:

1. The Human Resources/Executive Assistant confirmed the Nutrition Services Coordinator transferred to the position on 2/21/21.

2. Review of the job description for the Nutrition Services Coordinator, dated 1/2018, revealed the position included oversight of the day to day operations of the Food and Nutrition Services. The minimum qualifications identify a requirement to become a Certified Dietary Manager (CDM) within 36 months, which fails to meet the state requirement.

3. Review of the Nutrition Services Coordinator enrollment confirmation for a CDM program identified an enrollment date of 7/14/21 and a course end date of 7/14/22.

4. During an interview on 10/4/21 at 1:30 PM, the Nutrition Services Coordinator reported she has been in her current position since March 2021 and is responsible for the Nutrition Services Department operations. She acknowledged she is not a Certified Dietary Manager (CDM) but enrolled in an online CDM program on 7/14/21, and has 1 year to complete the program. She reported she has not completed any formal training related to foodservice management but had previous foodservice experience at a supermarket deli.

5. During a follow-up interview on 10/5/21 at 8:30 AM, the Nutrition Services Coordinator acknowledged she has not progressed past Lesson 1 of 15 for the CDM course and found it difficult to find time to work on the course as she has to cover shifts in the kitchen due to low staffing.

6. During an interview on 10/5/21 at 1:15 PM, the President acknowledged the current Nutrition Services Coordinator did not meet the regulatory requirements for the operation of the foodservice department. He reported she has a year to complete the program but reported he did realize she has made minimal progress on the CDM program.

Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the staff removed outdated medication and supplies from Surgery and Outpatient Service area. Failure to remove outdated medications and supplies from the CAH's supplies, available for patient use, could potentially result in the staff using expired medications and/or supplies for patient use after the manufacturer's expiration date, potentially resulting in the staff using medication on a patient after the date which the manufacturer guaranteed the sterility and efficacy of the medication and supplies. The CAH administrative staff identified a total average of 438 outpatient's surgeries/procedures per month from June 2020 until July 2021.

Findings included:

1. During a tour of the Surgery Department on 10/05/21 at 10:45 AM revealed the following outdated supplies:

a. In Recovery room #5, two of two 22 gauge (G) 1 inch 0.9 x 25 millimeter (mm) BD Insyte autoguard syringe, expired on 7/31/2021.

b. In clean storage next to central supply, 10 of 10 Sterile Covertors U-Drape, expired on 5/2021; 14 of 14 BD SafetyGlide Needles 22 G x 1 ½ inch, expired on 9/2018.

c. In drawer under the sink next to Recovery room #5, 1 of 1 Mallickrodt 2.5mm tracheal tube, expired on 12/1/20; 1 of 1 Nasal cannula with C02 sampling, expired on 12/2019; 1 of 1 BD Safetyglide 22G x 1 ½ inch needle, expired on 2/2021.

d. In Recovery room #3, 1 of 2 Adult Ambubag, expired on 5/2019; 3 of 3 Bard Urethral Catheterization Tray, expired on 8/31/21;1 of 1 Humid-Vent, expired on 4/2019; 2 of 2 MasimoSet Pediatric Pulse Oximeter Adhesive Sensor, expired on 4/1/20.

2. During an interview on 10/06/21 at 8:31 AM with the Supervisor of Outpatient Nursing Services, acknowledged several outdates throughout the surgical and recovery rooms suites. The Supervisor of Outpatient Nursing Services also acknowledged the CAH did not have a policy to manage outdated supplies, but did have a policy for the management of outdated medication.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) Radiology staff failed to ensure 2 full and 1 partially full boxes of computed tomography (CT) Syringe Kits were properly stored off the floor in the CT Store Room. The Radiology staff identified 523 patient exams performed from July 1, 2020 to June 30, 2021. Failure to store boxes of CT syringe kits off the floor could result in the CAH staff not being able to ensure an acceptable level of safety and quality for the stored CT syringe kits after delivery.

Findings include:

1. Observation on 10/4/21 at approximately 11:30 AM, during tour of the Radiology department with the Supervisor of Secondary Services, revealed 2 boxes of CT Syringe Kits that contained 20 kits per box and 1 box that contained 10 CT Syringe Kits stored on the floor in the CT Store Room.

2. Review of the CAH policy, "Storage of Medical Supplies," dated 4/2020, revealed in part, "All supply items must be stored at least 6 inches from the floor to allow for cleaning ... At no time will any supply be placed directly on the floor ..."

3. During an interview on 10/4/21 at approximately 11:30 AM, the Supervisor of Secondary Services acknowledged the boxes of CT Syringe Kits were stored on the floor.

I. Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure all patient care policies were reviewed annually by the required group of professionals, including a physician and a mid-level provider, in accordance with facility policy, for 19 of 19 patient care departments (Surgery, Emergency Room, Pharmacy, Laboratory, Respiratory Therapy, Nutritional Services, Nursing Services, Skilled Care, Sleep Study, Maintenance, Health Information Management, Environmental Services, Chemotherapy, Discharge Planning, Infection Control, and Radiology including Computed Tomography (CT), Dexa Scan, Ultrasound), as well as 10 of 10 contracted services (Anesthesia, Speech Therapy, Occupational Therapy, Physical Therapy, Magnetic Resonance Imaging (MRI), Nuclear Medicine, Positron Emission Tomography/Computed Tomography (PET/CT), Wound Clinic, Senior Life Solutions, and Specialty Clinics which includes 8 services - Gastrointestinal, Obstetrics/Gynecology, Orthopedics, Podiatry, Urology, Dermatology, Cardiology, and General Surgery). The CAH administrative staff identified a census of 5 patients at the beginning of the survey. Failure to ensure all patient care policies were reviewed annually by the required group of professionals could potentially result in the CAH staff failing to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of the CAH policy, "Policy and Procedure Development," dated 5/2/21, revealed in part, "Required group of Critical Access Hospital (CAH) staff (including a physician and mid-level provider) review all of the CAH policies annually ..."

2. Review of the "CAH Advisory Committee Meeting Minutes," dated 6/14/21; 3/15/21; and 12/14/20, revealed the Advisory Committee reviewed and approved only revised policies.

3. Review of the "Annual Critical Access Hospital (CAH) Program Evaluation" meeting minutes, dated 9/23/21, lacked a physician and mid-level provider attended, and revealed in part, "... CAH Policy and Procedure Review - The CAH Advisory Committee reviewed each of the following Critical Access Program policies and procedures for quality and appropriateness. Appropriate action on each has been noted and follow-up will be completed. Annual Critical Access Review Program - deemed appropriate. Services provided - deemed appropriate. Advanced Practice Clinicians - deemed appropriate. The CAH Advisory Committee reviewed policies/other documents for quality and appropriateness. The committee verified that all policies/other documents are followed as written and revisions are made as needed. See attached listing of specific policies/other documents and action required. All policies/other documents go to the Department Supervisors, Department Staff, Department Medical Director and to the CAH Advisory Committee ... By vote of conscious, all policies/other documents and privileges were approved as presented ...."


4. Review of the "Annual Critical Access Hospital (CAH) Program Evaluation" meeting minutes, dated 9/23/21, included attachments titled:

a. "Document Review Summary to the Critical Access Hospital Advisory Committee September 23, 2021" which listed revised policies and Annual Policy Review by Department (Blood Banking, Cardiopulmonary Rehabilitation, Chemistry, Coagulation, Dietary, Emergency, Environmental Services, General Medicine, Hematology, Maintenance, Medical Records, Microbiology, Pharmacy, Radiology, Rehabilitation Services, Respiratory Therapy, Risk Management, Skilled Care, Sleep Studies, Specialty Care, Specimen Collection, Surgery, Urinalysis).

b. "CAH Advisory Committee: Please review the attached packet and bring you feedback to the meeting scheduled on September 23, 2021. If you are unable to attend, please check the appropriate box and sign below verifying your review of the information ... No changes suggested." - 1 copy signed by a physician and 1 copy signed by a mid-level provider and dated 10/1/21.


5. During an interview on 10/6/2021 at 11:35 AM, the Network Coordinator stated they were not an employee of the CAH but did attend the quarterly CAH Advisory Committee Meetings. The Network Coordinator confirmed the Advisory Committee reviewed and approved only revised policies and not all policies.

During an interview on 10/6/2021 at 12:20 PM, the CAH's President stated the annual policy/procedure review process occurred during the "Annual Critical Access Hospital (CAH) Program Evaluation" meeting held September 23, 2021 at which a Physician and a Mid-Level Provider did not attend.

During an interview on 10/6/2021 at 1:30 PM, the Department Support Assistant stated the physician and mid-level provider were provided the Total Program Evaluation packet dated September 23, 2021 and confirmed the packet did not include actual policies to be reviewed.




II. Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the policies and procedures maintained by the CAH were specific to the CAH for 2 of 9 departments (Imaging and Respiratory Therapy) reviewed. The CAH administrative staff identified a census of 5 patients at the beginning of the survey. Failure to ensure all patient care policies were specific to the CAH could potentially result in the CAH staff unable to provide adequately provide patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of the CAH policy, "Policy and Procedure Development," dated May 2/2021, failed to ensure the policies and procedures maintained by the CAH were specific to the CAH.

2. Review of list of policies and procedures revealed policies not specific to the CAH to include:
a. Imaging policies included policies for example Cath Lab and Angio Sterile.
b. Respiratory Therapy policies included policies for example Flexible Bronchoscopy, Heliox (Helium/Oxygen) Administration, Infant Ventilator Management, Neonatal Continuous Positive Airway Pressure, and Pediatric Ventilator Management.

3. During an interview 10/6/2021 at 2:00 PM, the Nursing Supervisor confirmed the CAH does not perform all procedures that were listed including those stated above. The President stated the policies listed for the CAH includes policies for the [system] and were not specific to the CAH.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program individual (or individuals), had been appointed by the Governing Body, and that the appointment was based on the recommendations of medical staff leadership and nursing leadership. Failure to comply with regulations could potentially hinder the infection prevention and control program including surveillance, prevention, and control of hospital-acquired infections (HAI)s, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and address any infection control issues, potentially causing harm or death to patients and their safety. The CAH administrative staff identified an inpatient census of 5 patients upon entrance.

Findings include:

1. Review of Policies and Procedures revealed that no policy existed regarding an appointment for the Infection Preventionist by the Governing Board.

2. Review of the Governing Board Meeting Minutes, from 9/24/20 to 9/23/21, revealed that an appointment had not been made by the Governing Board for the position of Infection Preventionist.

3. During an interview on 10/6/21 at 1:00 PM, the Infection Preventionist reported she believed she had been appointed as the CAH Infection Preventionist by the Governing Board.

4. Review of facility document, "SUBJECT: Appointment of Infection Preventionist" dated 9/29/20, revealed in part, "... To: CHI Health Board of Directors .... From: President, Medical Staff ... VP Patient Services ... document serves as an appointment letter for [name] as the Infection Preventionist for [name of hospital] ... qualifications ... NICN Basic Training Course ... Infection Prevention Specific Training ... 2 years experience in current Infection Prevention role ... based on recommendations of ... medical staff leadership and nursing leadership ... respectfully request that the Board of Directors approve this appointment..."

6. During an interview on 10/7/21 at 8:45 AM, Administrative Assistant reported the CAH was unable to find documentation that the Infection Preventionist was approved by the Governing Board

7. During an interview with the Chief Executive Officer (CEO) on 10/7/21 at 10:20 AM, the CEO confirmed the CAH staff could not locate documentation that the Governing Board appointed the Infection Preventionist to their position.

I. Based on observation, document review, and staff interviews, the hospital's administrative staff failed to ensure 1 out of 1 observed surgical staff wore head coverings which fully covered all of their hair. Failure to wear head coverings that fully cover all hair could potentially result in bacteria, fungi, or viruses on the surgical staff members' hair entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The hospital's administrative staff identified the surgical services staff performed an average of 438 surgical procedures per month during the fiscal year from June 2020 to July 2021.

Findings include:

1. Observations on 10/5/2021 at approximately 10:45 AM, during a colonoscopy (an exam used to detect changes or abnormalities in the large intestine (colon) and rectum) revealed Patient #1 was undergoing a procedure in the Minor procedure room (which is located within the surgical suite). Observations from inside the Minor procedure room revealed Physician A did not wear any hair covering during the procedure.

2. Review of the CAH's policy, "Surgical Attire," approved on 1/2020, revealed in part ... "Head covering (including bouffant, surgical head cover .... Cover the scalp and hair when entering the semi-restricted and restricted areas."

3. During an interview on 10/6/21 at approximately 8:31 AM, the Supervisor of Outpatient Nursing Services acknowledged Physician A did not wear any hair covering during the procedure. The Supervisor of Outpatient Nursing Services reported the hospital followed the AORN (Association of Peri-Operative Registered Nurses, a nationally recognized guideline agency) guidelines statement for surgical attire.

4. Review of the AORN Guideline for Surgical Attire, copyright 2021, revealed in part, "Cover the scalp and hair when entering the semi-restricted and restricted area. [Recommendation]." " ... hair and skin can harbor bacteria that may dispersed into the perioperative environment."



II. Based on observation, document review, and staff interviews, the hospital's administrative staff failed to ensure surgical staff wear shoe coverings. Failure to ensure surgical staff wore shoe coverings and changing them between procedures could potentially result in bacteria, fungi, or viruses being transmitted into other procedure rooms potentially resulting in the patient developing a life-threatening surgical site infection. The hospital's administrative staff identified the surgical services staff performed an average of 438 surgical procedures per month during the fiscal year from June 2020 to July 2021.

Findings include:

1. Observations on 10/5/2021 at approximately 10:45 AM, during a colonoscopy (an exam used to detect changes or abnormalities in the large intestine (colon) and rectum) revealed Patient #1 was undergoing a procedure in the Minor procedure room (which is located within the surgical suite). Observations from inside the Minor procedure room revealed Physician A did not wear any shoe covering during the procedure.

2. Review of the CAH's policy, "Surgical Attire," approved on 1/2020, revealed the policy in part ... "Shoe covers will be worn when ... street shoes not limited to use within the building are worn."

3. During an interview on 10/6/21 at approximately 8:31 AM, the Supervisor of Outpatient Nursing Services acknowledged Physician A did not wear any shoe covering during the procedure. The Supervisor of Outpatient Nursing Services reported the hospital followed the AORN (Association of Peri-Operative Registered Nurses, a nationally recognized guideline agency) guidelines statement for surgical attire.

4. Review of the AORN Guideline for Surgical Attire, copyright 2021, revealed in part, "Wear protective footwear that meets the health care organization's safety requirements."

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure all contracted services reported on quality measures related to improved health outcomes that are shown to be predictive of desired patient outcomes for 3 of 10 contracted services (Magnetic Resonance Imaging (MRI), Nuclear Medicine, and Specialty Clinics which includes 8 services - Gastrointestinal, Obstetrics/Gynecology, Orthopedics, Podiatry, Urology, Dermatology, Cardiology, and General Surgery). The CAH administrative staff identified a census of 5 patients at the beginning of the survey. Failure to focus on measures related to improved health outcomes that are shown to be predictive of desired patient outcomes to include involvement of all of the CAH's departments on a continuous basis could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH "Quality, Safety, and Performance Improvement Plan FY 2021," revised 9/2020, revealed in part, "... Collection and analysis of data on performance outcomes and other key prioritized activities improves the hospitals ability to provide quality care, treatment, and services. a. Data is collected from many sources, including employees, patients, volunteers, licensed independent practitioners, allied health professionals, contract staff, and others who provide care, treatment, and services ... The administration and leaders of each hospital are directly responsible for the safety and quality of care, treatment, and services which include many factors, such as: ... Ensuring that the frequency of data collection activities through the organization focus on meaningful measures that address the needs of the patients (high volume, high risk, or problem prone) ...."

2. Review of the CAH's quality documentation from 9/16/2020 to 9/15/2021 revealed the following:

a. No quality indicators were identified for Specialty Clinics which includes 8 services - Gastrointestinal, Obstetrics/Gynecology, Orthopedics, Podiatry, Urology, Dermatology, Cardiology, and General Surgery.

b. Review of the MRI and Nuclear Medicine quality indicators revealed the documentation lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

3. During an interview on 10/6/21 at 3:20 PM, the Quality Coordinator verified the CAH staff failed to ensure all contracted services reported on quality measures related to improved health outcomes that are shown to be predictive of desired patient outcomes.

Based on review of policy/procedure and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 abuse policy contained the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for swing bed patients. The CAH administrative staff identified a monthly average of 51 skilled patients from June 2020 until July 2021. Failure to include the required language in the abuse policy could potentially prevent CAH staff from reporting alleged violations involving abuse to the CAH administrator and to other officials (including to the State Survey Agency) in a timely manner.

Findings include:

1. Review of the CAH's policy "Suspected Abuse/Neglect of a Child or Vulnerable Adult," approved date, 1/2020, failed to include the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).

2. During an interview on 10/06/21 at 8:31 AM, the Supervisor of Outpatient Nursing Services acknowledged the abuse policy failed to include the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).