HospitalInspections.org

Based on review of a Critical Access Hospital (CAH) letter to patients, CAH policy, and staff interview, the CAH failed to ensure staff informed patients of their right to file a complaint with the State survey and certification agency (SA) and failed to provide community education regarding advance directives for 1 of 1 advance directive policy. These failures limited patients' and the community's ability to make informed decisions regarding advance directives and/or file complaints with the SA.

Findings include:

Review of the CAH policy "Advance Directives" occurred on 05/23/12. This policy, revised 04/08, failed to identify the patients' right to file complaints regarding advance directives with the SA and failed to identify the CAH providing community education regarding issues concerning advance directives.

Review of advance directive information provided to patients in the form of a letter occurred on 05/23/12. This letter, revised 03/08, also failed to include information indicating patients may file a complaint with the SA.

An interview with an administrative nurse (#2) occurred on 05/23/12 at 1:45 p.m. regarding the CAH's advance directive procedures. The nurse confirmed the patient letter and CAH policy lacked information regarding filing complaints with the SA. When asked if the CAH provided education to the community regarding advance directives, the nurse (#2) stated the CAH has provided no education to the community regarding advance directives.

Based on review of the Critical Access Hospital (CAH) Rural Health Network agreements and staff interview, the CAH failed to have an agreement for credentialing and quality assurance (QA) with a hospital that is a member of the network or the quality improvement organization or equivalent entity on 3 of 3 days of survey (5/21/12, 5/22/12, and 5/23/12). Failure to have an agreement for credentialing and quality assurance may limit the CAH's ability to ensure proper credentialing and performance of quality assurance.

Findings include:

Review of the CAH's Agreements with Hospital A, Hospital B, and Hospital C occurred on 05/23/12. These agreements lacked a provision or service for credentialing and QA.

Upon request during interview on the morning of 05/23/12, an administrative member (#10) failed to provide an agreement for the CAH in obtaining assistance from another entity with the credentialing process and QA service.

Based on review of medical staff by-laws, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a qualified medical provider was available on site within 30 minutes for 5 of 9 closed emergency department records (Patient #20, #22, #23, #25, and #26) reviewed. Failure to have a qualified medical provider immediately available by telephone and available on site within 30 minutes placed all patients presenting to the emergency department at risk for complications related to illness or injury and has the potential to cause a delay in assessment and treatment.

Findings include:

Review of "Medical Staff By-Laws Linton Hospital" occurred on 05/21/12. This document, undated and unsigned, stated, " . . . Each physician [medical provider/practitioner is expected to be within a fifteen minute drive of the [Hospital] when on-call. . . ."

- Review of Patient #20's closed emergency room (ER) record occurred on May 22-23, 2012. The record identified the patient presented to the emergency room on 04/13/12 at 8:30 p.m. Emergency Room staff did not complete the section on the Outpatient Record form that identified "Time Physician Called" and "Time Physician in ER." The medical record did not identify the time the medical provider arrived in the ER.

- Review of Patient #22's closed ER record occurred on May 22-23, 2012. The record identified the patient presented to the emergency room on 02/03/11 at 12:27 p.m., and ER staff called the medical provider at 12:50 p.m. The record did not identify the time the medical provider arrived in ER.

- Review of Patient #23's closed ER record occurred on May 22-23, 2012. The record identified the patient presented to the emergency room on 02/03/11 at 12:25 p.m., and ER staff called the medical provider at 12:50 p.m. The record did not identify the time the medical provider arrived in ER.

- Review of Patient #25's closed ER record occurred on May 23, 2012. The record identified the patient presented to the emergency room on 05/06/12 at 7:57 p.m., and ER staff called the medical provider at 8:05 p.m. The record did not identify the time the medical provider arrived in the ER.

- Review of Patient #26's closed ER record occurred on May 23, 2012. The record identified the patient presented to the emergency room on 03/06/12 at 9:30 a.m. The medical record did not identify the time the medical provider arrived in the ER.

The documentation failed to demonstrate the qualified medical provider was available on site within the required 30 minutes.

During interview on 05/23/12 at 10:35 a.m., a medical records management staff member confirmed the medical records did not identify the time the medical provider arrived in the ER.

During interview, the afternoon of 05/23/12, an administrative staff nurse (#2) confirmed staff should document when the medical provider arrived in the ER.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the environment remained as free of accident hazards as possible regarding storage of hazardous chemicals in 2 of 2 housekeeping storage rooms (first floor and basement). Failure to store chemicals utilized by the housekeeping staff places cognitively impaired patients who display confusion and wandering behaviors, as well as children, at risk of having accidents with the accessibility to hazardous chemicals.

Findings include:

A tour of the plant environment occurred on the morning of 05/23/12 with two supervisory staff members (#8 and #9).

Observation showed the housekeeping storage room on the first floor and in the basement of the CAH unlocked. Both rooms contained several cleaning chemicals with labels stating "Keep out of reach of children." The housekeeping storage room in the basement identified a sign dated 01/23/02 and stated: "The housekeeping supply room is to be LOCKED at all times."

During the environmental tour, both supervisory staff member (#8 and #9), present during the observation, stated staff should lock the rooms at all times.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/03/10.

Based on review of Medical Staff By-laws, Governing Board By-laws, review of credentialing files, and staff interview, the Critical Access Hospital (CAH) failed to ensure proper procedure for adopting and approval of medical staff bylaws, following of governing body bylaws, and appointment/reappointment consistent with Medical Staff By-laws for 6 of 8 providers (Provider #1, #2, #3, #4, #5, and #6) reviewed. These failures do not ensure consistency among the medical staff and governing board, and does not ensure a consistent credentialing process prior to granting medical staff appointments/privileges.

Findings include:

- Review of the current Governing Board Bylaws occurred on the afternoon of 05/21/12. The bylaws, dated 12/04/08, stated, ". . . Article V Medical Staff . . . Section 2. That said medical staff shall create and adopt its own bylaws, rules and regulations, and that said bylaws, rules and regulations governing the medical staff of the Linton Hospital shall be subject to the Board of Director's approval. . . ."

Review of the current Medical Staff By-laws occurred on 5/21/12. The Medical Staff By-laws lacked a date and signature by the Chief of Medical staff indicating the active medical staff adopted this version of the bylaws, and a date and signature of the President of the Board of Directors indicating the Board of Directors approved the by-laws. During an interview on 05/22/12 at 10:00 a.m., a staff member (#5) stated the CAH administrative staff were unable to locate a signed copy of the Medical Staff By-laws and Rules and Regulations developed in June 2010.

Review of the current Medical Staff Rules and Regulations, although signed, lacked a legible date of the signatures by the Chief of Medical staff and President of the Board of Directors identifying when the active medical staff adopted this version of the rules and regulations, and when the governing board approved the rules and regulations.

Review of Governing Body By-laws occurred on 05/21/12. The by-laws in Article IX, Amendments, stated, ". . . These bylaws shall be reviewed at least every 2 years." The by-laws indicated the last review occurred on 12/04/08, three and a half years, after stated in the by-laws.

Review of the current Medical Staff By-Laws, undated and unsigned, stated,
". . . Section 4. Procedure of Appointment
1. Application for membership on the Medical Staff shall be presented in writing, and shall include qualifications, National Practitioner Databank Query, two references that state professional competence, professional liability, ethical character, and . . . request of privileges of the applicant and shall also signify his/her agreement to abide by the By-laws . . . as well as a copy of state license number and DEA [Drug Enforcement Administration number . . . 2. At the first regular meeting thereafter the Administrator or designee shall present the completed application to the Medical Staff for review and recommendation to the Governing Board . . . Recommendations for reappointment shall be considered at the Medical Staff meeting prior to the expiration of an individual's membership . . . and shall include privileges, and service for each practitioner. . . . ARTICLE IV CATEGORIES OF THE MEDICAL STAFF . . . The Medical Staff shall be divided into: 1. Active 2. Courtesy 3. Honorary 4. Affiliate 5. Consult/telemedicine . . . The Courtesy Medical Staff shall consist of those practitioners who occasionally admit patients and are primarily consultants to the active medical staff. . . ."

Review of random list of provider credentialing files occurred at 1:30 p.m. on 05/22/12. The credentialing files for each provider lacked the following as required in the Medical Staff By-Laws:
* Provider #1's file lacked two reference letters; the file contained one.
* Provider #2's file showed a letter sent to the provider on 06/03/11 requesting two reference letters for the "Application for Medical Staff Privileges." The re-appointment occurred on 10/29/11. The file lacked two references and lacked a National Practitioners Data Bank (NPDB) check prior to re-appointment.
* Provider #3's file showed the provider submitted an application for appointment on 01/24/12. The file lacked a NPDB check prior to re-appointment in 2012.
* Provider #4's and #5's files contained letters stating appointment occurred for them as courtesy staff. During a staff interview (#7), on 05/22/12 at 4:10 p.m., the staff member confirmed Provider #4 and #5 practice as active staff providers, and not courtesy staff. The staff member confirmed the copy of the letters sent to these two providers as incorrect.
* Provider #6's file contained one un-dated reference prior to the appointment.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/03/10.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to secure medications in accordance with accepted professional principles in 1 of 1 off-site clinic (Hazelton Clinic). Failure to adequately secure and restrict access to medications could result in unauthorized use of the medications.

Findings include:

Review of the Hazelton Clinic policy "Medication Administration" occurred on 05/23/12. This policy, revised 07/11, stated, ". . . The medication cabinet will remained locked at all times when not in use."

- A tour of the Hazelton Clinic occurred on 05/21/12 at 10:25 a.m. When asked where staff store medications, a licensed nurse (#4) pointed out a padlocked cabinet in the treatment area. Observation showed multiple injectable medications stored in the cabinet. In a provider's office, observation revealed a padlocked cupboard filled with sample medications. In the reception area, observation showed medications stored in a refrigerator with an unlocked padlock. When asked which staff members have keys to the padlocks for the medication storage areas, the nurse (#4) indicated she and the receptionist (#3) have access to the keys.

During an interview on 05/21/12 at 10:40 a.m., a provider (#11) confirmed both the licensed nurse (#4) and receptionist (#3) have access to the keys to the medication storage areas. The provider (#11) stated when she arrives in the morning staff have unlocked the cupboards and refrigerator and they remain unlocked throughout the day.

During an interview on 05/21/12 at 10:50 a.m., a receptionist (#3) stated she has the only key for a locked box in her desk, which contains the keys to the medication cupboards and the refrigerator. The staff member (#3) confirmed she is not a licensed nurse.

During an interview on 05/23/12 at 9:20 a.m. two administrative nurses (#1 and #2) stated they expect only licensed nurses to have access to medications.

When interviewed, on 05/23/12 at 11:10 a.m. a clinic manager (#5) confirmed the medication cabinets and refrigerator at the Hazelton clinic remain unlocked throughout the day.

Based on observation, record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to follow appropriate infection control practices regarding equipment storage and during observations of care and performance of a urine test on 2 of 3 days of survey (May 21-22, 2012). Failure to follow infection control practices could result in transmission of organisms from patient to patient, and/or to staff and visitors.

Findings include:

Review of the CAH policy "Handwashing" occurred on 05/23/11. This policy, revised 06/08, stated, ". . . Proper hand washing is the single most important way to prevent and reduce infections . . . wash your hands: *Before and after patient contact *Before putting on gloves and after taking them off *After touching blood or other body substances . . . even if you wear gloves . . . Alcohol based antiseptic hand wash is an acceptable substitute for hand washing if hands are not visibly soiled. . . ."

- A tour of the off-site clinic occurred on 05/21/12 at 10:25 a.m. and identified the following:
* Upon entering, observation showed a licensed nurse (#4) performing a dipstick urine test. Observation identified a plastic specimen cup, partially filled with urine, in the handwashing sink.
* Observation at 10:30 a.m. showed a centrifuge (a device for spinning blood samples) placed directly on the floor in the clinic's furnace room and plugged into an outlet. The licensed nurse (#4) identified the machine as a "back-up" for the centrifuge in the treatment area and stated she used the "back-up" centrifuge about once a week.
* Observation at 10:35 a.m. showed a licensed nurse (#4) performing a venipuncture (blood draw) for an unidentified patient. She asked the receptionist to assist. The receptionist (#3) washed her hands in the same sink which previously held the urine specimen, donned gloves, and assisted the nurse (#4) with the venipuncture. The nurse was unable to obtain enough blood to fill the tubes, so performed a second venipuncture. After obtaining the samples, the nurse (#4) removed her gloves, but failed to perform hand hygiene prior to starting another task. The receptionist (#3) removed her gloves and failed to perform hand hygiene prior to leaving the treatment area.

- Review of Patient #3's medical record occurred on May 22 - 23, 2012 and identified admission diagnoses of vomiting and diarrhea. On 05/22/12 at 10:30 a.m. observation showed a licensed nurse (#12) and student nurse (#13) assisted Patient #3 to ambulate from her bed to the bathroom. The patient voided and performed her own perineal cares. The staff members (#12 and #13) assisted Patient #3 back to bed without offering/encouraging the patient to wash her hands after performing perineal cares.

During an interview on 05/23/12 at 9:20 a.m., two administrative nurses (#1 and #2) stated they expect staff members to wash their hands after performing a venipuncture and to encourage patients to wash their hands after perineal care.

When interviewed, on 05/23/12 at 11:10 a.m., a clinic manager (#5) stated staff should place a paper towel on the counter and place the urine specimen on the paper towel, not in the handwashing sink, when performing dipstick urine tests.

Based on policy and procedure manual review and staff interview, the Critical Access Hospital (CAH) failed to ensure the required group of professionals annually reviewed 8 of 9 policy and procedure manuals (Emergency Room, Pharmacy, Operating Room, Nursing, Radiology, Swing Bed, Dietary, and Medical Records). Failure to ensure the group performed the annual reviews limits the CAH's ability to ensure the policies and procedures model the CAH's current practices and are in compliance with federal and state regulations.

Findings include:

Review of the CAH policy and procedure manuals occurred on all days of survey and identified the following:
Emergency Room - reviewed in November 2004
Pharmacy - no documentation of reviews
Operating Room - no documentation of reviews
Nursing - reviewed in 2009
Radiology - no documentation of reviews
Swing Bed - reviewed in 2009
Dietary - reviewed in 2009
Medical Records - reviewed in 2009

During an interview on 05/23/12 at 2:00 p.m., an administrative nurse (#2) confirmed the required group had not completed the annual policy review.

Based on observation, record review, review of professional literature, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to administer medications in accordance with the physician's orders and accepted standards of practice for 1 of 1 swing bed patient (Patient #1) whose medication administration record (MAR) did not match the physician's orders and for 1 of 1 acute patient (Patient #3) observed receiving intravenous medication; and failed to maintain a sufficient supply of diluent to reconstitute a medication required to treat a life threatening condition (Malignant Hyperthermia) in 1 of 1 operating suite. Failure to ensure the MAR matched the physician's orders resulted in Patient #1 receiving medication not ordered by the physician. Failure to follow professional standards regarding intravenous medication could result in the patient experiencing an infection. Failure to maintain a sufficient supply of diluent for the medication could result in the patient's death.

Findings include:

- Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, page 847 stated, ". . . Medication Reconciliation. Another safety issue that affects the nurse is to ensure that clients receive the appropriate medications and dosages on admission, during transfer, and at discharge . . . The IHI [Institute for Healthcare Improvement] defines medication reconciliation as 'the process of creating the most accurate list possible of all medications a patient is taking . . . and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patients at all transition points within the hospital.' . . ."

Review of Patient #1's medical record occurred on all days of survey. The record showed the CAH transferred Patient #1 from acute care to swing bed on 05/17/12. Review of Patient #1's swing bed MAR identified the patient received colchicine (a medication to treat gout) 0.6 milligrams (mg) at 8:00 a.m. from May 18-21, 2012 (four days). Review of physician's orders failed to identify an order for the colchicine.

An interview with an administrative nurse (#1) occurred on 05/21/12 at 1:20 p.m. The nurse stated Patient #1 received colchicine 0.6 mg daily while in acute care. She stated staff inadvertently transferred the order to the swing bed MAR with his admission to swing bed on 05/17/12 and confirmed Patient #1 should not have received the colchicine while in swing bed care.

- Taylor, Lillis, and LeMone, Fundamentals of Nursing, Fourth Edition, Lippincott, Philadelphia, Pennsylvania, page 592 stated, "Removing Medication From a Vial . . . Remove the metal or plastic cap on the vial that protects the rubber stopper . . . Swab the rubber top with the alcohol swab . . . draw up the prescribed amount of medication . . ."

On 05/22/12 at 12:50 p.m., observation revealed a licensed nurse (#14) prepared intravenous medication for Patient #3. The nurse removed the cap from a vial of Zofran (a medication for nausea) 4 mg/milliliter (mL). Without swabbing the rubber stopper with alcohol, the nurse (#14) inserted a syringe into the vial and withdrew 2 mL Zofran. The nurse proceeded to Patient #3's room and administered the medication intravenously.

During an interview, on 05/23/12 at 9:20 a.m., an administrative nurse (#2) stated she expects nurses to swab the rubber stopper on a medication vial prior to drawing up the medication.

- Review of the CAH policy "Malignant Hyperthermia" occurred on 05/22/12. The policy, dated 01/12/04, stated, ". . . A malignant hyperthermia (MH) crisis will be treated following the guidelines as set forth by the Malignant Hyperthermia Association of the United States (MHAUS) . . . Because malignant hyperthermia is a rare condition which must be treated quickly, guidelines are necessary to treat patients appropriately and rapidly when the crisis occurs. . . ."

The MHAUS, online brochure titled "What is Malignant Hyperthermia?", dated 01/27/10, stated, ". . . The MH crisis is a biochemical chain reaction response 'triggered' by commonly used general anesthetics . . . signs of the MH crisis include tachycardia, a greatly increased body metabolism, muscle rigidity and/or fever that may exceed 110 degrees F [Fahrenheit]. Severe complications include: cardiac arrest, brain damage, internal bleeding or failure of other body systems. Thus, death, primarily due to a secondary cardiovascular collapse, can result. . . . Treatment is predicted upon preparation for a rare event. . . . With the plan in place, treatment can be prompt and lifesaving . . . all locations where general anesthesia is administered should contain a plan to treat MH . . . An MH cart or kit containing the required drugs, equipment, supplies and forms should be immediately accessible to operating rooms. . . ."

The MHAUS, online brochure titled "Drugs, Equipment, and Dantrolene - Managing MH," dated 01/27/10, stated, ". . . Dantrolene is the only currently accepted specific treatment for MH. . . . All facilities . . . where MH triggering anesthetics . . . are administered, should stock a minimum of 36 vials of dantrolene, along with the other drugs and devices necessary to treat an MH reaction . . ."

2012 Intravenous Medication, Twenty-eighth Edition, Gahart and Nazareno, Mosby, St. Louis, Missouri, page 388 stated, "Dantrolene Sodium . . . Dilution: Each 20 mg must be diluted with 60 mL SW [sterile water] for injection without a bacteriostatic agent [preservative]. . . ."

A tour of the operating suite occurred on 05/22/12 at 9:25 a.m. with a surgical nurse (#6). Observation of the MH cart revealed 36 vials of Dantrolene available, but showed only half the amount of sterile water without preservative required to reconstitute the 36 vials. The nurse (#6) immediately placed a call to the pharmacy and verified the CAH had enough sterile water without preservative to reconstitute 18 vials of Dantrolene.

- Review of Patient #8's closed medical record occurred on May 22-23, 2012. The CAH admitted Patient #8 to the hospital due to dehydration and kidney failure. Patient #8 experienced pain, agitation, and respiratory symptoms while hospitalized and received pain medications (Morphine), as well as anti-psychotic (Haldol) and anti-anxiety (Ativan) medications.

The comprehensive care plan did not address Patient #8's pain, agitation, respiratory symptoms, or use of psychotropic medications, nor did it identify non-pharmacological interventions or approaches for staff to use during episodes of pain and/or agitation.

- Review of Patient #11's closed medical record occurred on May 22-23, 2012. The CAH admitted Patient #11 to the hospital due to a change in mental status, agitation, and psychotic symptoms. Patient #11 experienced agitation and confusion while hospitalized and received anti-psychotic (Haldol and Zyprexa) and anti-anxiety (Ativan and Valium) medications.

The comprehensive care plan did not address Patient #11's agitation and use of psychotropic medication, nor did it identify non-pharmacological interventions or approaches for staff to use during episodes of agitation.

During interview on the afternoon of 05/23/12, an administrative nurse (#1) confirmed staff should develop and individualize care plans based on patient assessment.



15707

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/03/10.

Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff developed a care plan for each patient for 1 of 1 active swing bed patient (Patient #1) and failed to ensure staff developed an individualized care plan based on assessment for 2 of 3 closed acute patient (Patients #8 and #11) records reviewed. Failure to develop a care plan limits staff's ability to ensure continuity of care and meet patients' needs.

Findings include:

Review of the CAH policy "Swingbed Patient Care Plan" occurred on 05/23/12. The policy, revised 8/03, stated, ". . . An interdisciplinary patient care plan will be developed for each patient in coordination with the patient and appropriate health care personnel . . . Nursing assessment will begin upon admission, with the patient care plan initiated within 24 hours of admission . . ."

- Review of Patient #1's active swing bed record occurred on all days of survey. The record showed the CAH transferred Patient #1 from acute to swing bed care on 05/17/12 and discharged the patient on 05/21/12. Record review identified staff failed to develop a care plan during Patient #1's swing bed stay.

Based on record review, review of policy and procedures, review of Medical Staff rules and regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure the medical record included autopsy findings for 1 of 1 closed record (Patient #19) who required an autopsy. Failure to maintain medical records according to the CAH's medical staff by-laws and policy/procedure does not ensure patient records are accurate and complete.

Findings include:

Review of "Medical Staff Rules and Regulations Linton Hospital"occurred on 05/21/12. This document, date illegible, stated " . . . Medical Records 1. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current. Shall include: . . . Autopsy report when performed . . ."

Review of the medical record policy, "An Explanation of the Hospital Medical Record" occurred on 05/23/12. This policy, revised 01/20/09, stated, " . . . 16. Autopsy Report: Autopsy findings in a complete protocol shall be filed in the record when an autopsy is performed. . . ."

Review of Patient #19's closed record occurred on 05/22/12. The medical record identified the patient expired on 10/29/11. The "Notification of Death and Authorization to Release and Embalm" form identified Patient #19's family signed a consent for an autopsy, which was authorized by the physician. The medical record did not include the autopsy report.

During an interview the afternoon of 05/22/12, an administrative nursing staff member (#1) confirmed the CAH did not have the autopsy results in Patient #19's medical record.

Based on review of policy and procedures, medical record review, and staff interview, the Critical Access Hospital (CAH) failed to obtain a complete consent for 2 of 2 closed surgical records (Patient #15 and #16) who had two separate procedures performed. Failure to obtain a complete consent limited the patients' awareness of the procedure and placed the CAH at risk of providing unwanted treatment.

Findings include:

Review of the CAH's policy "Patient Consent" occurred on 05/23/12. This policy, revised 02/03/09, stated, ". . . 9. Patients must sign operative or procedural informed consents before the procedure . . ."

- Review of Patient #15's closed surgical record occurred on May 22-23, 2012. The operative report, dated 06/15/11, identified the surgeon performed an "Upper GI (gastrointestinal) endoscope and biopsy . . ." and a "Colonoscope (an endoscopy procedure which examines the lower GI tract) . . ." Patient #15's consent form identified the procedure "Colonoscopy" but did not include the upper GI endoscopy.

- Review of Patient #16's closed surgical record occurred on May 22-23, 2012. The operative report, dated 5/25/11, identified the surgeon performed an "EGD (Esophagogastroduodenoscopy) (an endoscopy procedure which examines the upper GI tract) . . . and colonoscope with biopsies." Patient #16's consent form identified the procedure "Colonoscopy" but did not include the EGD (upper GI endoscopy).

During interview the afternoon of 05/22/12, an administrative surgical nurse (#6) confirmed the incomplete consents should have included the EGD procedure for both of these patients.

Based on medical record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure patient records included authenticated physician orders for 1 of 1 active cardiac rehabilitation record (Patient #4), 1 of 1 closed cardiac rehabilitation record (Patient #6) and 2 of 5 closed surgical records (Patient #15 and #16) reviewed. Failure to ensure physicians' authenticate orders limited the physicians' and staff's ability to ensure the accuracy and continuity of patient care.

Findings include:

Review of the CAH's medical record policy, "An Explanation of the Hospital Medical Record" occurred on 05/23/12. This policy, revised 01/20/09, stated ". . . 8. Physician Orders: Written, authenticated orders for care by the physician to nursing and ancillary staff. . . . Completion Requirements of the Medical Record: . . . e) Physician's Orders - daily, must be authenticated within 48 hrs [hours]. . . ."

- Review of Patient #15's medical record occurred on 05/22/12. The record identified Patient #15 had a surgical procedure on 06/15/11. The physician did not sign, date, or time the orders until 07/01/11, approximately 16 days after the procedure.

- Review of Patient #16's medical record occurred on 05/22/12. The record identified Patient #16 had a surgical procedure on 05/25/11. The physician did not sign, date or time the orders until 06/15/11, approximately 3 week after the procedure.

During interview on the afternoon of 05/22/12, an administrative surgical nurse (#6) confirmed the physician signed, dated, and timed the orders after the surgical procedure.


15707


- Review of Patient #4's active outpatient record occurred on 05/22/12 and identified the CAH admitted the patient for cardiac rehabilitation (rehab) on 03/09/12. The record showed physician's orders for treatment not signed until 03/30/12, three weeks after Patient #4 began therapy.

- Review of Patient #6's closed outpatient record occurred on 05/22/12 and identified the CAH admitted the patient for cardiac rehab on 05/23/11 and discharged him on 06/08/11. Record review failed to identify signed physician's orders for treatment.

Based on record review, medical staff by-laws, quality assurance plan and reports, meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to perform (or arrange) an annual periodic evaluation of its total program for 13 of 13 months (April 2011-April 2012) reviewed (refer to C331); failed to ensure the annual periodic evaluation of the CAH included a review of the utilization of services, including at least the number of patients served, and the volume of services (refer to C332); failed to ensure the completion of an annual periodic evaluation which included a review of a representative sample of both active and closed clinical records (Refer to C333); failed to ensure the completion of an annual periodic evaluation which included a review of the CAH's health care policies (refer to C334); failed to complete an annual program evaluation to determine the appropriateness of the utilization of services, the following of its policies, and the need for any changes (refer to C335); failed to ensure the Quality Assurance (QA) program maintained meeting minutes, the medical staff and governing body ensured QA addressed areas for improved quality of care, and the CAH maintained an effective quality assurance program to evaluate the quality care (Refer to C336); failed to ensure the QA program evaluated all patient care services and other services affecting patient health and safety (Refer to C337); and failed to evaluate the quality and appropriateness of the treatment furnished by a Certified Registered Nurse Anesthetist (CRNA) (Refer to C339).

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to perform (or arrange) an annual periodic evaluation of its total program for 13 of 13 months (April 2011-April 2012 ) reviewed. Failure to complete an annual periodic evaluation has the potential to impact patient care by limiting the CAH's ability to determine the appropriateness of services utilized; following of established policies, and whether changes necessary.

Findings include:

Record review on the morning of 05/23/12, identified an annual program review dated April 2010 - March 2011. The facility failed to provide evidence of an annual program review for April 2011 - March 2012.

During an interview on the morning of 05/23/12, an administrative staff member (#10) confirmed the last annual program review occurred from April 2010 through March 2011. The staff member stated no review had occurred for April 2011 through March 2012, nor had the CAH started one.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the annual periodic evaluation of the CAH included a review of the utilization of services, including at least the number of patients served, and the volume of services for 13 of 13 months (April 2011-April 2012 ) reviewed. Failure to review the utilization of services as part of an annual program evaluation has the potential to impact patient care by limiting the CAH's ability to determine the appropriateness of services utilized.

Findings include:

Record review on the morning of 05/23/12 identified an annual program review dated April 2010 - March 2011. The facility failed to provide evidence of an annual program review for April 2011 - March 2012.

During an interview on the morning of 05/23/12, an administrative staff member (#10) confirmed the last annual program review occurred from April 2010 through March 2011. The staff member stated no review had occurred for April 2011 through March 2012, nor had the CAH started one.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/03/10.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the completion of an annual periodic evaluation which included a review of a representative sample of both active and closed clinical records for 13 of 13 months (April 2011-April 2012) reviewed. Failure to review clinical records as part of an annual program evaluation has the potential to impact patient care by limiting the CAH's ability to determine the need for changes.

Findings include:

Record review on the morning of 05/23/12 identified an annual program review dated April 2010 - March 2011. The facility failed to provide evidence of an annual program review for April 2011 - March 2012.

During an interview on the morning of 05/23/12, an administrative staff member (#10) confirmed the last annual program review occurred from April 2010 through March 2011. The staff member stated no review had occurred for April 2011 through March 2012, nor had the CAH started one.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the completion of an annual periodic evaluation which included a review of the CAH's health care policies for 13 of 13 months reviewed (April 2011 through April 2012). Failure to review the CAH's healthcare policies as part of an annual program evaluation has the potential to impact patient care by limiting the CAH's ability to determine if policies are followed and changes are needed.

Findings include:

Record review on the morning of 05/23/12 identified an annual program review dated April 2010 - March 2011. The facility failed to provide evidence of an annual program review for April 2011 - March 2012.

During an interview on the morning of 05/23/12, an administrative staff member (#10) confirmed the last annual program review occurred from April 2010 through March 2011. The staff member stated no review had occurred for April 2011 through March 2012, nor had the CAH started one.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to complete an annual program evaluation to determine the appropriateness of the utilization of services, the following of its policies, and the need for any changes for 13 of 13 months (April 2011-April 2012) reviewed. Failure to complete an annual program evaluation has the potential to impact patient care by limiting the CAH's ability to determine the need for changes.


Findings include:

Record review on the morning of 05/23/12 identified an annual program review dated April 2010 - March 2011. The facility failed to provide evidence of an annual program review for April 2011 - March 2012.

During an interview on the morning of 05/23/12, an administrative staff member (#10) confirmed the last annual program review occurred from April 2010 through March 2011. The staff member stated no review had occurred for April 2011 through March 2012, nor had the CAH started one.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/03/10.

Based on review of medical staff bylaws, quality assurance (QA) plan and reports, meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to ensure the QA program maintained meeting minutes for 3 of 4 quarters reviewed (April 2011 - December 2011); the medical staff and governing body ensured QA addressed areas for improved quality of care; and the CAH maintained an effective quality assurance program to evaluate the quality care for 13 of 13 months reviewed (April 2011-April 2012). Failure to maintain an effective quality assurance program limits the CAH's ability to identify risk factors affecting patient diagnosis and treatment and to develop and implement corrective action if necessary.

Findings include:

Review of "Medical Staff By-Laws Linton Hospital" occurred on 05/21/12. This document (undated and unsigned) stated, ". . . Article VII Officers and Committees . . . Section 2. Committees and Responsibilities . . .
6. Quality Assurance Committee: . . . Minutes will be recorded and attached to the QA report summary . . ."

Review of the policy titled "Linton Hospital Quality Assurance Plan" occurred on 05/22/12. This policy, dated 02/15/05, stated,
". . . III. Objectives: 1. To provide an ongoing system of monitoring and evaluation of the effectiveness and safety of patient care . . . . 4. To provide documentation that will substantiate action taken on problems and resolution of results incurred from those actions, using data from quality indicator projects, patient care, and other relevant sources. . . .
V. . . . Documentation: 1. The findings and analysis of monitoring activities and the action taken to correct problems and improve patient care are documented, reported as appropriate, and integrated with the overall hospital's quality assurance program. . . .
X. Annual Review:
Annual review will be done during the January quality assurance, medical staff, and governing board meetings. Considerations for annual review . . . 2. To review departmental activities of quality occurrence to determine if they meet established standards of review and evaluation, including priorities addressing improved quality of care. . . ."

- Review of the CAH's departmental Quarterly QA Reports occurred on 05/22/12. The reports identified the physical therapy (P.T.) and swingbed departments failed to evaluate the quality of patient care as part of their monitoring activities.

- Review of the QA committee meetings minutes occurred on 05/22/12. Information provided identified one QA Quarterly Meeting for four quarters reviewed (first quarter). The QA coordinator completed minutes for a meeting held on 04/17/12, and lacked minutes for the three quarters previously scheduled meetings between April 2011 through December 2011. The minutes, dated 04/17/12, identified review of QA completed from January 1, 2012 to March 31, 2012. The minutes stated, ". . . Staff did go over all the QA's. Did discuss proper action and implementation at the meeting." The 04/17/12 meeting minutes failed to identify that P.T. and the swingbed department did not evaluate the quality of patient care. These meeting minutes lacked evidence the QA committee discussed which departments did not evaluate the quality of patient care, and implement corrective action. The lack of the previous three quarterly minutes affects the CAH's ability to ensure monitoring and evaluation provided by each department.

- Review of the March 2011-April 2012 Medical Staff and Governing Board meeting minutes occurred on May 21-22, 2012. These minutes failed to identify the lack of monitoring activities to address improved quality of care for the P.T. and swingbed departments and the lack of quarterly meeting minutes.

During an interview at 10:30 a.m. on 05/23/12, a supervisory staff member (#2) confirmed the lack of meeting minutes.

Based on review of medical staff bylaws, quality assurance (QA) plan and reports, meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to ensure the QA program evaluated all patient care services and other services affecting patient health and safety for 13 of 13 months reviewed (April 2011-April 2012). The CAH failure to ensure the QA program evaluated all patient care services and services affecting patient health and safety limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of "Medical Staff By-Laws Linton Hospital" occurred on 05/21/12. This document (undated and unsigned), stated, ". . . Article VII Officers and Committees . . . Section 2. Committees and Responsibilities . . .
6. Quality Assurance Committee: The Linton Hospital quality improvement plan shall be facility wide; to include all departments whose activities directly influence patient care. . . . The Quality Assurance Coordinator will require departmental reports prior to the monthly meeting in order to have adequate time to read and summarize the reports and distribute them to the core committee members. . . . Minutes will be recorded and attached to the QA report summary . . ."

Review of the policy titled "Linton Hospital Quality Assurance Plan" occurred on 05/22/12. This policy, dated 02/15/05, stated,
". . . III. Objectives: 1. To provide an ongoing system of monitoring and evaluation of the effectiveness and safety of patient care provided at Linton Hospital, including but not limited to measurable improvement in indicators that will identify and reduce medical errors and improve health outcomes. 2. To identify problems or important concerns regarding the quality of care provided to patients. 3. To provide for a system of follow-up and implementation of actions designed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects performance that assess processes of care, hospital services, and operations. 4. To provide documentation that will substantiate action taken on problems and resolution of results incurred from those actions, using data from quality indicator projects, patient care, and other relevant sources. . . .
IV. Scope: The Linton Hospital Quality Assurance Plan shall be facility wide, to include all departments whose activities directly influence patient care. . . .
V. . . . Documentation: 1. The findings and analysis of monitoring activities and the action taken to correct problems and improve patient care are documented, reported as appropriate, and integrated with the overall hospital's quality assurance program. . . .
VIII. Departments: The following departments will perform Quality Assurance activities: . . . Physical Therapy [P.T.] . . . Swingbed."

- Review of the CAH's departmental Quarterly QA Reports between April 2011-April 2012 occurred on 05/22/12. The reports identified two departments failed to evaluate the quality of patient care as part of their monitoring activities:
* Physical Therapy: "Activity Monitored: monitor accuracy of billing procedure . . ."
* Swingbed: "Activity Monitored: Make sure nurses notify swingbed coordinator of admission so proper paper work can be filled out correctly."

- Review of the Quality Assurance committee meetings minutes occurred on 05/22/12. Information provided identified one QA Quarterly Meeting held on 04/17/12, providing review of the QA submitted from January 1, 2012 to March 31, 2012. The minutes stated, ". . . Staff did go over all the QA's. Did discuss proper action and implementation at the meeting." The meeting minutes failed to identify P.T. and the swingbed department did not evaluate the quality of patient care as part of their monitoring activities. The meeting minutes lacked evidence the committee discussed the departments not evaluating the quality of patient care, and corrective action during either the monthly reviews or quarterly QA reviews/meetings.

During an interview at 10:30 a.m. on 05/23/12, a supervisory staff member (#2) agreed the P.T. and swingbed departments failed to evaluate the quality of patient care as part of their monitoring activities. This staff member stated the CAH started keeping meeting minutes in April 2012.

Based on a review of nurse anesthetist provider files, policy review and staff interview, the Critical Access Hospital (CAH) failed to evaluate the quality and appropriateness of the treatment furnished by 1 of 1 Certified Registered Nurse Anesthetist (CRNA) (Provider #1) reviewed providing care to the CAH's patients within the past year. Failure to evaluate the quality and appropriateness of the treatment furnished has the potential to affect patient outcomes involving surgical procedures requiring anesthesia services provided by the CRNA staff.

Findings include:

Review of the CAH's Quality Assurance Plan occurred on 05/22/12. The plan, dated 02/15/05, stated, ". . . Medical Staff Review Functions: . . . 4. External peer reviews will be performed by a doctor of medicine . . . to determine the quality and appropriateness of the diagnosis and treatment provided to patients. . . ."

Review of the CAH's "Peer Review" policy occurred on 05/22/12. The policy, dated 03/11/12, stated, ". . . 3. Peer Review is a part of the overall quality and utilization review process and enhances all other policies, procedures, and bylaws which address quality of care concerns. 4. There will be a Peer Review Committee to accomplish peer review and other quality of care issues. . . . The committee has been granted the ability to contact the appropriate physicians and other providers to engage in Peer Review activities . . . Peer Review should: a. Be performed by a provider from the same discipline with the same type of practice. . . . b. This process should assess the quality of care rendered . . . c. The end-product of this process should be improvement of the patient care through education and health system improvement. . . ."

- Review of the CAH's current list of providers occurred on the afternoon of 05/22/12 and identified three CRNAs on the list. During interview, a risk management staff member (#16) stated one of the CRNAs performed all but one surgical procedure within the last year.

During interview on 05/22/12 at 1:00 p.m., the risk manager (#16) confirmed the facility failed to evaluate the quality and appropriateness of the treatment furnished by the CRNA staff.