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Based on observation made during medication pass, staff interview and facility policy review, the facility failed to ensure intravenous (IV) admixtures were performed after handwashing and in a clean area to prevent the introduction of potential disease-producing pathogens to the patient. Facility census was 9. Total sample size was 42. Findings are:

A. Observation of medication pass on 6/22/11 at 11:05 AM revealed Registered Nurse (RN)-V was requested by Licensed Practical Nurse Certified (LPNC)-W to add Rocephin 2 Grams to 100 cubic centimeters (cc) of 0.9% Normal Saline IV solution. RN-V proceeded to use the computer/keyboard to review the order and then without washing his/her hands began to add the medication to the IV solution. The surveyor stopped the nurse before the medication was added and requested he/she wash his/her hands. The nurse then washed his/her hands and added the medication at the handwashing sink behind the open nurses station (a dirty area). Adjacent to the handwashing sink was the nurses station fax machine and piled papers. The medication was given by LPNC-W to Patient 39.

B. Staff interview with the Director of Nursing on 6/22/11 at 12:30 PM revealed IV admixtures are to be done in the medication room (a clean area).

C. Record review of facility policy titled "Medication Administration-Adding Medication to Intravenous Fluid Containers" effective 3/24/08 identifies that staff are to "Perform hand hygiene" prior to starting the procedure. The procedure also stated that the nurse is to "Add medication to new container (usually done in medication room or at medication cart).

D. Pharmacy was open with a pharmacist on duty at the time the nurse added the medication to the IV solution for Patient 39. The pharmacy is the optimum environment for performing IV admixtures.

Based on staff interview, review of the policy and procedure for the Annual Evaluation and Quality Assurance Review for CAH (Critical Access Hospital) and review of the 2009 Annual Evaluation of Services completed on 8/31/10, the facility failed to a have a group of professionals including at least 1 physician, the physician assistant and at least 1 member not on staff at the CAH review the patient care policies in the last year. Census on the first day of survey was 6 acute inpatients, 1 swingbed patient and 2 observations patients. The CAH had 6 physicians listed as Active Medical Staff and 1 physician assistant. Findings are:

A. Interview with the Quality and Risk Program Manager on 6/21/11 from 1:00 PM to 1:15 PM revealed the following:
- The company that manages/operates the CAH has a group called SPOT (System Practice Oversight Team) that reviews system policies and procedures;
- There are 2 employees of the CAH that serve on this committee and neither one is a physician or physician assistant; and
- The meeting minutes from this group was the only documentation available for review of policies and procedure.

Further interview with the Quality and Risk Program Manager on 6/22/11 from 2:30 PM to 1:45 PM revealed the following:
- Confirmed that no physician or midlevel served on the SPOT committee;
- Has been employed at the CAH for approximately 2 years;
- Found out by talking to other employees that review of policies by the group of professionals usually occurred around the time of the annual evaluation; and
- Confirmed that the patient care policies were not reviewed by the group of professionals in the past year.

B. Review of the policy and procedure titled Annual Evaluation and Quality Assurance Review for CAH with a revised date of 6/2003 revealed the following:
"The Ogallala Community Hospital will perform an annual evaluation of services in June of each year. The committee made up of the Management Team, Quality Manager, MD [medical doctor], PA [physician assistant] and a representative from the Network hospital will perform the evaluation....Healthcare Policy Review....Department managers and/or the Chief of Staff and CEO review healthcare policies throughout the year. A summarized report provided by the Quality Manager of these reviews will be examined during the annual evaluation...The Organizational Plan for Patient Care and Services will be reviewed at this time also."

C. Review of the Annual Evaluation completed in 2010 revealed no information for review of policies and procedures other than the policies reviewed by the SPOT team.

Based on record review, staff interview, and review of facility policy the facility failed to ensure 1 of 2 specialty clinic surgical records contained an informed consent for the surgery (Patient 38) and 2 of 2 clinic records failed to document the patients' current assessment of health status and needs, a brief summary of the procedure and instructions provided to the patients (Patients 37 and 38). Facility census was 9. Total sample was 42. Findings are:

A. Record review of Patient 37's outpatient specialty clinic record dated 5/25/11 revealed the patient signed a consent for Cystoscope to be performed by MD (Medical Doctor)-X on 5/25/11 at 10:10 AM. The record fails to contain any nursing documentation by nursing on 5/25/11 related to the patient's stay. MD-X documented a cystoscopy was performed without anesthesia. The physician documentation also noted the patient was to start taking Trimethoprim 100 mg (milligrams) at bedtime and see the physician again in 6 months. The record fails to contain any discharge teaching regarding the medication or followup visit instructions.

Staff interview with specialty clinic RN (Registered Nurse)-Z on 6/22/11 at 10:30 AM confirmed there was no documentation regarding Patient 37 by nursing. The nurse stated "all we do is vital signs and weights. The Doctor (referring to MD-X) has his/her own electronic medical record (EMR). The Cerner [facility EMR] is not set up for EMR documentation in the Specialty Clinic. We use paper records for all but [MD-X's] patients." The nurse further related that the nurse does the vital signs/weight and gives the information to MD-X to document on his/her EMR. The nurse reported nursing is in attendance during the procedure but do not document any procedure notes. The nurse also revealed they do not document discharge teaching as they do not see the patient after the procedure, only the physician does.

RN-Z related that they have not done any documentation for MD-X's patients, since MD-X began using his/her EMR system on 1/12/11. On 6/22/11 at 11:30 AM, the nurse confirmed 13 cystoscopy patients were done by MD-X since 1/12/11. RN-A confirmed all those records would also lack nursing documentation.

B. Record review of Patient 38's outpatient specialty clinic record dated 5/23/11 noted the patient had an order for a cervical and vaginal biopsy dated 5/23/11 at 10:30 AM. Nursing documentation on the form titled "Specialty Clinic Assessment" noted the patient's vital signs, current medications and history prior to the procedure. Physician notes document the patient had a colposcopy with biopsy done 5/23/11. The record failed to contain an informed consent signed by the patient for the procedure. The record also failed to contain any procedure notes or discharge instructions. Staff interview with RN-Z on 6/22/11 at 11:30 AM confirmed these findings.

C. Record review of facility policy titled "Consent Guidelines for Banner Health" effective date 2/27/09 states "A written informed consent form must be executed whenever required by law and prior to Surgical Services, except in emergencies".

Record review of facility policy titled "Ambulatory Treatment Unit, Outpatient Treatment (& Infusion) Center, and Transitional Care Unit Patient Standards of Care" effective date 9/1/10 states that assessments by nursing staff included the following:
- Current reason for seeking healthcare;
- Admission history, allergies, medication and vital signs;
- Height and actual weight if possible;
- Assess for risk factors for the treatment ordered;
- Results of diagnostic testing;
- Availability of safe transportation home
- Consents required for treatment/procedure are reviewed for completeness, accuracy and congruency with the patient's statements and health record; and,
- Patient and family education begins on arrival and will include material appropriate to the patient condition, expectations during their stay, and include information on medication, signs and symptoms to be reported, discharge information and any followup care.

Based on review of the 2009 Annual Evaluation of Services completed on 8/31/10, review of polices and procedures and staff interview, the facility failed to include a review of the facility specific policies and procedures in the Annual Evaluation. Census on the first day of survey was 6 acute inpatients, 1 swingbed patient and 2 observations patients. Findings are:

A. Review of the policy and procedure titled Annual Evaluation and Quality Assurance Review for CAH with a revised date of 6/2003 revealed the following:
"Healthcare Policy Review....Department managers and/or the Chief of Staff and CEO review healthcare policies throughout the year. A summarized report provided by the Quality Manager of these reviews will be examined during the annual evaluation...The Organizational Plan for Patient Care and Services will be reviewed at this time also."

B. Review of the 2009 Annual Evaluation of Services dated 8/31/10 which was placed in a 3-ring binder revealed a section titled Policies and Procedures that included 8 pages that listed the policy title with with numerous columns. One of the columns listed the review date and another column listed the scheduled review date. Under another column listed Facility was typed system for all but 5 policies. This 2009 Annual Evaluation included no more information on review of policies and procedures.

C. Interview with the Quality and Risk Program Manager on 6/22/11 from 2:30 PM to 2:45 PM confirmed that the only policies included in the 2009 Annual Evaluation of Services were the system policies and procedures and they did not include facility specific policies and procedures.

Based on review of the 2009 Annual Evaluation of Services completed on 8/31/10, review of polices and procedures and staff interview, the facility failed to document the results of the last annual evaluation that included whether the utilization of services was appropriate, whether established policies were followed and identify any changes that were needed. Census on the first day of survey was 6 acute inpatients, 1 swingbed patient and 2 observations patients. Findings are:

A. Review of the policy and procedure titled Annual Evaluation and Quality Assurance Review for CAH with a revised date of 6/2003 revealed the following:
"Purpose:
To provide a means of evaluating the overall services provided
To evaluate the appropriateness of the services provided
To Provide a means of assuring healthcare policies are being followed
To Identify opportunities for quality improvement..."

B. Review of the 2009 Annual Evaluation of Services dated 8/31/10 which was placed in a 3-ring binder revealed nothing concerning whether the utilization of services were appropriate, whether policies were being followed or identifying changes that were needed.

C. Interview with the Quality and Risk Program Manager and the Care Management Assistant on 6/22 from 2:30 PM to 2:45 PM revealed the following:
- There was a meeting on 8/31/10 where they discussed the results including changes they wanted to make; and
- Confirmed that there was no report that showed the results including utilization of services, whether policies were followed and changes that needed to be made.

Based on resident interview and record review, 6 of 6 Swing Bed records failed to have evidence of written resident notification of expected benefits under Medicaid/Medicare and what items the resident may be responsible for either at admission or during their stay (Residents 7, 31, 32, 33, 34, 35). SwingBed census was 1. Total Swing Bed sample was 6. Findings are:

A. Review of Swing Bed records for Resident 7 (admit date 6/16/11 and current resident), Resident 31 (admit/discharge dates 12/11/10-12/15/10), Resident 32 (5/6/11-5/11/11, Resident 33 (4/26/11-5/2/11), Resident 34 (4/29/11-5/3/11), and Resident 35 (1/10/11- 1/25/11) failed to have a signed Swing Bed agreement type form outlining the expected benefit and expected costs for items not covered during their Swing Bed stay.

B. Staff interview with RN (Registered Nurse)-Aa, Social Service Director, on 6/21/11 at 1:40 PM related that for the 3 years he/she had worked in the facility Swing Bed residents were only given the Resident Rights Handbook and signed the hospital Consent to Treat form. RN-Aa confirmed the Swing Bed residents are not notified of any financial benefits or costs expected that are not covered during their stay.

C. Interview with Resident 7 on 6/22/11 at 1:20 PM revealed the resident stated he/she was "not given any information about payment for stay here." The resident had no idea what items are covered or not covered by his/her Medicare or how long his/her stay would be covered by Medicare.

D. Staff Interview with the facility Quality Improvement Manager on 6/22/11 from 7:30 - 7:45 AM related the facility had developed policies and procedures for Swing Bed residents after their last survey (7/14/06), but that no one could find them. The policies and procedures were on the computer of the previous Chief Nursing Officer and they were unable to access them. At the end of the survey on 6/23/11 the facility was still unable to locate the policies for Swing Bed residents.

Based on staff interview and record review, 4 of 6 Swing Bed residents failed to have documentation of any activities being offered to them (Residents 31, 32, 34 and 35). Facility Swing Bed Census was 1. Total Swing Bed Sample was 6. Findings are:

A. Record review revealed Swing Bed Resident 31 was admitted on 12/11/10 and stayed until 12/15/10. Record review of the Electronic Medical Record (EMR) form titled "Diversional Activities Initial Assessment" dated 12/12/10 at 3:23 PM documented the resident enjoyed socializing with others. Review of the activities provided or offered section of the EMR found none were offered to the resident. This information was confirmed by RN (Registered Nurse)-Bb from Clinical Infomatics on 6/21/11 at 11:08 AM. RN-Bb stated that if activities are offered and refused the refusal is to be documented in the Activities log section of the EMR.

B. Record review for Swing Bed Resident 32 revealed the resident was admitted 5/6/11 and discharged 5/11/11. An Activities Assessment was found in the EMR dated 5/7/11 and noted the resident enjoyed the newspaper, reading, crossword puzzles, and watching sports, especially football. Review of the EMR found the resident was not offered any activities during the stay. This information was confirmed by RN-Bb on 6/21/11 at 11:45 AM.

C. Record review for Swing Bed Resident 34 revealed the resident was admitted 4/29/11 and discharged 5/3/11. An Activities Assessment was performed on 4/29/11. The EMR failed to have any documentation of any activities offered to this resident. This information was confirmed by RN-Bb on 6/21/11 at 2:55 PM.

D. Record review for Swing Bed Resident 35 revealed the resident was admitted 1/10/11 and expired 1/25/11. Review of the EMR failed to find documentation of an Activities Assessment being done or any activities offered to the resident. This information was confirmed by RN-Bb on 6/21/11 at 3:50 PM.

E. Staff interview with the Activities Director (AD) on 6/22/11 at 2:30 PM revealed Activity Assessments are to be done within 2 days of admission by either the AD or nursing. The AD related that since he/she is also a Physical Therapy Aide that the residents are seen daily and the activity is walking or exercises done with therapy and not documented. The AD related residents are usually in the facility a short time so an Activities Calendar has not been developed. The AD stated he/she is not always informed when a Swing Bed resident comes in and that there is not a system in place to ensure the Activities Assessment is done. The AD stated that for the last 1 1/2 years they have been trying to develop protocols for activities and were working with the previous Chief Nursing Officer who has since left the facility. The AD did not have any policies and procedures for Swing Bed residents to ensure activities were offered.

Based on staff interview and record review, 1 of 1 Swing Bed residents who had been in the facility for 14 days or more failed to have a comprehensive, accurate, standardized, reproducible assessment of the resident's functional capacity (Patient 35). Swing Bed census was 1. Swing Bed sample was 6. Findings are:

A. Record review revealed Swing Bed Resident 35 was admitted on 1/10/11 status post-fractured wrist and small bowel resection. The resident expired 1/25/11. Review of the entire electronic medical record (EMR) on 6/21/11 failed to find a standardized comprehensive assessment performed. Staff interview on 6/21/11 at 3:50 PM with RN (Registered Nurse)-Bb confirmed this finding.

B. Staff interview with RN-Cc, a Swing Bed Charge Nurse on 6/21/11 at 11:00 AM revealed the facility EMR system uses the same physical assessment form for acute inpatients as the Swing Bed residents. RN-Cc said the EMR system has been live since 2008.

C. Staff interview with RN-Aa, Social Services Director on 6/21/11 at 1:40 PM confirmed the facility does not have a standardized Comprehensive Assessment Form for use with Swing Bed residents.

D. Staff Interview with the facility Quality Improvement Manager on 6/22/11 from 7:30 - 7:45 AM related the facility had developed policies and procedures for Swing Bed residents after their last survey (7/14/06), but that no one could find them. The policies and procedures were on the computer of the previous Chief Nursing Officer and they were unable to access them. At the end of the survey on 6/23/11 the facility was still unable to locate the policies for Swing Bed residents.

Based on ataff interview and record review of 5 of 5 discharged Swing Bed patients, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, a summary of the resident's status included in the Comprehensive Assessment, and a post-discharge plan of care (Residents 31, 32, 33, 34 and 35). Swing bed Census was 1. Swing Bed sample was 6. Findings are:

A. Record review for Resident 31 (discharged 12/10/11), Resident 32 (discharged 5/11/11), Resident 33 (discharged 5/2/11), Resident 34 (discharged 5/3/11) and Resident 35 (expired 1/25/11) all failed to have a discharge summary completed by nursing staff which included a recapitulation of the residents' stay, a summary of their status, and post discharge plan of care. The facility does not perform the Comprehensive Assessment so they do not have the data available to include a summary of the residents' status.

B. Staff interview with RN (Registered Nurse)-Cc, Charge Nurse on Swing Bed unit on 6/21/11 at 11 AM confirmed the staff do not do a discharge summary for Swing Bed residents and stated we "never do that here". The RN confirmed he/she had worked in the facility for 4 years.

C. Staff Interview with the facility Quality Improvement Manager on 6/22/11 from 7:30 - 7:45 AM related the facility had developed policies and procedures for Swing Bed residents after their last survey (7/14/06), but that no one could find them. The policies and procedures were on the computer of the previous Chief Nursing Officer and they were unable to access them. At the end of the survey on 6/23/11 the facility was still unable to locate the policies for Swing Bed residents.