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Based on review of credential files, review of Bylaws of the Medical Staff, review of the Board of Director meeting minutes, review of medical records and staff interview; the Critical Access Hospital (CAH) failed to follow their Medical Staff Bylaws in the reappointment for 2 of 8 physician credential files (Physicians J and O) reviewed. The Medical Staff Roster listed 33 physician. This failed practice has the potential to affect all patients receiving services at the hospital.

Findings are:

A. Review of the Bylaws of the Medical Staff (approved by the Board of Directors on 1/20/15) revealed the following under Article III Medical Staff Membership, Section 3 Conditions and Duration of Appointments:
"Initial appointment and reappointment to the Medical Staff shall be made by the Board....Initial appointments shall be for a period of at least 6 months. Reappointments shall be for a period of not more than two years."

Review of the the credential file for Physician O revealed all information for appointment was from 2013. Review of the Board of Director meeting minutes dated 3/19/13 revealed Physician O was initially appointed to the Medical Staff at this meeting. Review of all Board of Director meeting minutes from 3/19/13 through 12/9/15 revealed no reappointment for Physician O. Interview with the Director of Health Information Management (HIM) on 2/10/16 at 3:55 PM after reviewing the Board of Director Meeting minutes from 3/19/13 through 12/9/15 confirmed that Physician O had not been reappointed in that time frame (33 months).

B. Review of the Bylaws of the Medical Staff (approved by the Board of Directors on 1/20/15) revealed the following under Article VIII Procedures for Appointment and Reappointment to the Medical Staff, Section 8 Determination of Clinical Privileges, A. Exercise of Privileges:
"Every Practitioner at this Hospital by virtue of Medical Staff membership or authorization to practice shall be entitled to exercise only those clinical privileges or specified services specifically granted by the Board."

Review of Physician J's credential file revealed an application for Clinical Privileges dated 4/17/15 with the signature of Physician J. This Clinical Privileges application had a listing of privileges with the following instructions "Please select the descriptions of clinical privileges desired and provide any additional description that may be helpful in determining the extent of privileges requested. If you anticipate needing privileges for procedures not listed please include them on the lines provided after each specialty." This application had no selections and nothing had been written in. Review of the medical record for Patient 40 revealed the patient was seen by Physician J on 1/26/16. The progress note for this visit documented under Plan "We will inject the left thumb". Review of the document titled Order Session Review Sheet revealed and order for injectable lidocaine (medication that numbs tissue) and Depo-Medrol (anti-inflammatory medication). Physician J failed to have privileges for joint injections.

C. Review of the Bylaws of the Medical Staff (approved by the Board of Directors on 1/20/15) revealed the following under Article VIII Procedures for Appointment and Reappointment to the Medical Staff, Section 8 Determination of Clinical Privileges, C Basis for Privileges Determination (i) Reappointment:
"Each recommendation concerning reappointment of a person currently appointed to the medical staff or a modification of privileges, where applicable, shall be based upon...Applicant's ethical behavior generally, clinical competence and clinical judgement in the treatment of patients...Compliance with the Hospital bylaws and policies and with the medical staff bylaws, policies and rules and regulations...Behavior in the Hospital, cooperation with medical and Hospital personnel as it relates to patient care or the orderly operation of this Hospital, and general attitude toward patients, the Hospital and its personnel...Use of the Hospital's facilities for patients, taking into consideration the individual's comparative utilization patterns....Capacity to treat patients satisfactorily as indicated in part by observation of patient care provided, the results of the Hospital's Medical Staff Performance Improvement and Utilization Review Activity and risk-management activities or other reasonable indicators of continuing qualifications including assessments of the physician's capabilities in his/her office practice and at other hospitals."

Review of the credential file for Physician J for the reappointment by the Board of Directors on 7/21/15 revealed information on current license, current Drug Enforcement Administration (DEA) license, query of the National Practitioner Data Bank (provides information on malpractice payments and certain adverse actions related to the physician being queried), malpractice insurance, the reappointment application, peer references and hospital references. However, this file lacked information related to the physician's practice at Callaway District Hospital i.e. number of patients seen, following of Bylaws of the Medical Staff, and any information from Hospital's Medical Staff Performance Improvement and Utilization Review Activity and risk-management activities.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to maintain an infection control program which included:
Part I: A system for identifying, tracking and analyzing infectious processes and an evaluation of preventative interventions; and
Part II: Staff training in infection control practices pertinent to their facility roles.

The lack of an inclusive infection control program has the potential to effect all patients served at the CAH.

Findings are:
Part I:
A. A review of the undated "Infection Control Program" Policy and Procedure revealed, "...Goal-To establish an effective infection control program within the hospital to improve patient care practices through education, communication, and surveillance. To develop a working knowledge of the institution to create and implement policies and procedures for infection control." "...Objectives-To institute an active hospital-wide infection control program. A system for reporting, evaluating and maintaining records of infections among patients and personnel.... In-service education for all departments and services relating to infection prevention and control, including training during employee orientation..." "Quality Assurance-Aspects of the Service; develop, implement, and monitor systems for identifying, collecting data, analyzing, and reporting incidents and causes of infection....Provide education for all departments and services relating to infection control...Data Collection; Surveillance of Infections-The goal of surveillance is directed toward identification and analysis of nosocomial infections. Responsibility for completing surveillance forms lies with the committee, but may also completed by any nursing staff member. The committee maintains records of surveillance. Definitions of infections are based on the guidelines established by the CDC (Center for Disease Control)..."

B. An interview with the Infection Control Nurse (ICN) on 2/9/16 at 3:15 PM, revealed that the CAH does not maintain a log/tracking system for staff or patient infectious processes. The ICN revealed that there is not a "committee" that meets monthly, that the ICN gathers the patients names and lab result information monthly and turns that information into the laboratory personnel. Then quarterly that information is reviewed by the pathologist on their visit to the hospital. The ICN revealed that the infection control data is reviewed in Medical Staff Meeting monthly, although, a review of the Medical Staff Meeting Minutes for the last year contained only an Infection Control Report dated February 2015.

Part II

A During an interview with the ICN on 2/9/16 at 3:15 PM, the ICN stated, "I don't have anything to do with the workers, I think HR (Human Resources) or the DON (Director of Nurses) does." "They (new employees) do a Healthstream video about communicable disease and blood borne pathogens."

When the ICN was asked what the measures are for in place for prevention of infections, the ICN stated, "I use this "Hand Hygiene Monitoring Tool" to observe if employee's wash their hands or use hand gel when entering or exiting patient rooms." When asked after reviewing the 2015 Hand Hygiene Monitor Tool results what is done with that information and what steps are in put into place to improve the data outcome, the ICN stated, "Not sure, I collect the information."

Interview with the Director of Nurses (DON) on 2/9/15 at 4:10 PM stated, "No the ICN doesn't do employee health. We have them do a Healthstream video. We don't review it in orientation specifically."

Based on record review, staff interview and a review of Medical Staff Rules and Regulations the Critical Access Hospital (CAH) failed to:PART I: Ensure that within 24 hours of admission to the hospital that 5 of 26 Inpatient records [Patient's that are admitted for medical or surgical care.] (Patient's 1, 2, 3, 13 and 16) contained a History and Physical; and 2 of 5 patients Swing Bed [Patient's that are admitted for skilled care following an inpatient hospital stay] records (Patient's 32 and 36) contained a History and Physical; and
PART II: Ensure that within 30 days of discharge from the hospital that 4 of 26 Inpatient records (Patient's 5, 10, 12 and 16) contained a Discharge Summary; and 2 of 5 patients (Patient's 34 and 36) Swing Bed record contained a Discharge summary; 1 of 26 Inpatient records (Patient 15) contained a completed Discharge Summary dated greater than 3 months after discharge and 1 of 5 Swing bed records (Patient 35) contained a completed Discharge Summary dated greater than 3 months after discharge;and
PART III: Ensure that 3 of 3 Outpatient Speciality Clinic patients records Patient 38, 39 and 40 contained a signed consent for treatment form.

These failed practices had the potential to affect all patients admitted to inpatient and swing bed status; and all patients provided services to the hospital. The CAH reported in the calendar year of 1/1/2015-12/31/2015 a total of 27 patients were admitted to swing bed; 162 patients were admitted to inpatient status; and 303 were provided services in Outpatient Speciality Clinics.

Findings are:

PART I
A. The following patient's medical records lacked a completed History and Physical since admission:
-Patient 1 admitted to inpatient status 2/3/16 and dismissed 2/8/16.
-Patient 2 admitted to inpatient status 1/28/16 and dismissed 1/31/16.
-Patient 3 admitted to inpatient status 1/24/16 and dismissed 1/27/16.
-Patient 13 admitted to inpatient status 1/21/16 and dismissed 1/23/16.
-Patient 16 admitted to inpatient status 9/27/15 and dismissed 9/29/15.

-Patient 32 admitted to swing bed status 1/26/16 and dismissed 1/28/16.
-Patient 36 admitted to swing bed status 9/10/15 and dismissed 9/23/15.

B. A review of the Medical Staff Rules and Regulations approved 1/20/15 stated the following: "A complete history and physical examination shall be recorded within 24 hours of admission. If a complete history has been obtained and a complete physical examination has been performed within a week prior to admission with suitable indication of competence, such as in the office of a physician staff member, a durable, legible copy of this report may be used in the medical record, provided there has been no change subsequent to the original examination or the changes have been recorded at the time of admission. This must be updated by the attending physician."

C. An interview with the Director of Health Information Management (HIM) on 2/10/16 at 3:35 PM stated, "There are currently 14 medical records outstanding that lack a History and Physical."

PART II
A. The following patient's medical records lacked a completed Discharge Summary:
-Patient 5 admitted to inpatient status 11/8/15 and dismissed 11/10/15.
-Patient 10 admitted to inpatient status 9/10/15 and dismissed 9/12/15.
-Patient 12 admitted to inpatient status 12/17/15 and dismissed 12/19/15.
-Patient 16 admitted to inpatient status 9/27/15 and dismissed 9/29/15.

-Patient 34 admitted to swing bed status 10/10/15 and dismissed 10/19/15.
-Patient 36 admitted to swing bed status 9/10/15 and dismissed 9/23/15.

B. The following patient's medical records contained a Discharge Summary dated greater than 3 months after dismissal:
-Patient 15 admitted to inpatient status 8/24/15 and dismissed 8/29/15, the record contained a Discharge Summary completed 12/5/15.
-Patient 35 admitted to swing bed status 10/24/15 and dismissed 10/29/15, the record contained a Discharge Summary completed 2/8/16.

C. A review of the Medical Staff Rules and Regulations approved 1/20/15 stated the following: "A Discharge Summary is required on all patients. Records of short stay patients (two hospital days or less) may have a final progress note as a Discharge Summary. The final progress note must contain a final diagnosis, sufficient data to warrant the treatment and justify the diagnosis, and a note as to condition of patient on discharge."

D. An interview with the Director of Health Information Management (HIM) on 2/10/16 at 3:35 PM stated, "There are currently 18 medical records outstanding that lack a Discharge Summary."



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PART III
A. The following patient's medical records lacked a signed consent for treatment:
-Patient 38 seen in the Surgery Consult Outpatient Clinic on 12/1/15.
-Patient 39 seen in the Podiatry Outpatient Clinic on 1/18/16.
-Patient 40 seen in the Orthopaedic Outpatient Clinic on 1/21/16.

B. During the review of electronic medical records (EMR) for Patients 39 and 40, with RN - U (Registered Nurse U) on 2/8/16 from 3:15 PM to 3:40 PM confirmed that these 2 patient records lacked consent for the Outpatient Specialty Clinic. Review of the EMR for Patient 38 with the Director of Nursing (DON) on 2/8/16 at 3:45 PM confirmed this record lacked a signed consent for treatment.

Based on record review, staff interview and a review of Medical Staff Rules and Regulations the Critical Access Hospital (CAH) failed to:
PART I: Ensure that upon discharge from same day surgical procedures a physician order for discharge was obtained from the provider/surgeon prior to dismissal for 5 of 6 surgical records sampled (Patients 26, 27, 28, 30 and 31); and
PART II: Ensure that physician/provider orders were authenticated by the ordering physician/provider in 3 of 5 Emergency Room (ER) records reviewed (Patients 21, 24 and 25);and
PART III: Ensure that the provider documented the name and amount of medication used in 2 of 2 minor outpatient/emergency room procedures; Patient 40 received an injection of a finger joint and Patient 22 received an injection of local anesthesia prior to sutures; and
PART IV: Ensure that 2 of 3 Outpatient Clinic records Patients 39 and 40 included the nursing assessment performed at the time of the visit.

These failed practices had the potential to affect: all same day surgical patients of the CAH; patients seen in the Emergency Room in which a Physician Assistant (PA) or Nurse Practitioner (NP) provided the nurse orders to be inputted into the Electronic Medical Record (EMR); patients seen and assessed by nursing in outpatient clinics and any patients receiving injections administered by the provider. The CAH reported 65 same day surgical procedures, and 303 patients seen provided outpatient services from January 1 2015-December 31, 2015.

Findings are:

PART I:
A. The following patients same day surgery medical record lacked a discharge order:
-Patient 26 admitted 1/26/16 for a colonoscopy (a procedure that allows the physician to look at the inner lining of the large intestine, by using a flexible tube). Review of the record revealed the lack of a discharge order.
-Patient 27 admitted 1/19/16 for a colonoscopy. Review of the record revealed the lack of a discharge order.
-Patient 28 admitted 10/13/15 for a colonoscopy. Review of the record revealed the lack of a discharge order.
-Patient 30 admitted 12/8/15 for an upper endoscopy (EGD) (a procedure that allows the physician to look at the lining of the upper digestive tract, by using a flexible tube). Review of the record revealed the lack of a discharge order.
-Patient 31 admitted 1/19/16 for a colonoscopy. Review of the record revealed the lack of a discharge order.

B. An interview with Registered Nurse (RN) G on 2/9/16 at 10:45 AM verified that Patient 26, 27, 28, 30 and 31's medical record lacked a discharge order.

C. A review of the Medical Staff Rules and Regulations approved 1/20/15 stated the following: "Patients will be discharged only on order of the attending physician..."
PART II:
A. The following patients emergency room electronic orders lacked the proper provider authentication:
-Patient 21 was admitted to ER for a complaint of epigastric pain (pain in upper abdomen). The patient was examined by Physician Assistant (PA)-R and orders were received for laboratory tests, X-ray's and medication. The orders from PA-R were entered into the EMR by the nurse assisting PA-R in the ER. The orders lacked authentication from the ordering Physician Assistant (PA-R) and were electronically authenticated by Doctor (Dr H).
-Patient 24 was admitted to ER for a complaint of a syncopal (near fainting) episode. The patient was examined by Physician Assistant (PA)-T and orders were received for laboratory tests, CT Scan (computerized scan series) of head and EKG (electrical tracing of heart rhythm). The orders from PA-T were entered into the EMR by the nurse assisting PA-T in the ER. The orders lacked authentication from the ordering Physician Assistant (PA-T) and were electronically authenticated by Doctor (Dr H).
-Patient 25 was admitted to ER for a complaint of a fall and striking head. The patient was examined by the Nurse Practitioner (NP) -Q and orders were received for X-ray's of head, medication and transfer to another hospital. The orders from NP-Q were entered into the EMR by the nurse assisting NP-Q in the ER. The orders lacked authentication from the ordering Nurse Practitioner (NP-Q) and were electronically authenticated by Doctor (Dr H).

B. An interview with RN G on 2/9/16 at 10:45 AM explained, that when the nurse enters the orders for the PA or NP into the EMR; the EMR program requires that their physician name go into the "attending provider" slot and the PA or NP (whoever is seeing the patient and providing orders) goes into the "admitting provider" slot. What then happens when the order is entered is that it automatically populates the "attending provider" name and not the "admitting provider"/ordering provider name onto the electronic order. If the nurses don't realize that and manually change it on the electronic order entry it gets sent to the "attending providers" computer que (messages that alerts them of orders to sign) and does not get sent to the ordering provider or "admitting provider" computer que for signing.

C. A review of the Medical Staff Rules and Regulations approved 1/20/15 stated the following: "...All orders including verbal orders must be dated, timed and authenticated as soon as practically possible, but within 48 hours, by the physician or other practitioner ordering, providing or evaluating the service furnished who is responsible and authorized to write orders by Hospital policy..."

PART III:
A. The following patient records lacked the amount of medication and/or the identification and amount of medication utilized in an injection provided by the Practitioner::
-Patient 22 was admitted to ER for a complaint of hitting head and received a 1.5 inch laceration to scalp. Review of PA-T's progress note identified that the laceration was "cleansed, 1% Xylocaine with Epi (epinepharine) [a local anaesthestic used to numb an area before surgery or after an injury], closed with interrupted 4-0 nylon" (stitches). Patient 22's record lacked the amount of 1% Xylocaine with Epi used to numb the laceration area prior to stitching up the laceration.

B. An interview with RN G on 2/9/16 at 10:45 AM verified that the emergency record for Patient 22 lacked the amount of 1%Xylocaine with Epi used for the sutures.



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C. Patient 40 was seen in the Outpatient Specialty Clinic on 1/21/16 by Physician J. Review of Physician J's progress note for this visit revealed the patient was seen for "Numbness, tingling and pain both hands, worse on the left." Under the section titled Assessment and Plan the physician documented "Left trigger thumb" with plan for "We will inject the left thumb." The progress note lacked information on the injection of this thumb that included what medication and amount of medication that was used.

Interview with the DON on 2/8/16 at 3:45 PM confirmed that the record lacked documentation of the injection of the left thumb.

PART IV
A. Review of the electronic medical record (EMR) for Patients 39 and 40 revealed no documentation from the nursing assessment such as vital signs, height, weight and chief complaint.

B. Interview with RN - U (Registered Nurse U) during the review of the Outpatient Specialty Clinic on 2/8/16 from 3:15 - 3:40 PM revealed that the nurses document their nursing assessment of vitals, height, weight, reason for visit on a sheet provided by each specialty physician. The sheet with the nursing assessment is then given to the physician. After the physician is finished with the document it is shredded.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that 5 of 6 sampled outpatient surgical patients (Patients 26, 27, 28, 30 and 31) received the Pre-Anesthetic Risk Evaluation (The physician evaluates/examines the patients current condition including the heart, lungs and review of test results ordered at the time of the history and physical to assure the patient can safely proceed with the procedure scheduled including receiving the anesthesia) by the physician immediately before surgery. This failure has the potential to effect all patients receiving surgical procedures at the CAH. The CAH identified 65 surgical procedures done from January 1, 2015- December 31, 2015.

Findings are:

A. Patient 26 was admitted 1/26/16 for a colonoscopy (a procedure that allows the physician to look at the inner lining of the large intestine, by using a flexible tube). Patient 26 received a MAC ([monitored anesthesia care] using intravenous conscious sedation to promote relaxation and amnesia types of anesthesia) anethesia for the procedure. On 1/13/16 Physician H completed a History and Physical on Patient 26 at the clinic.

The outpatient surgical record for Patient 26 lacked a Pre-Anesthetic Risk Evaluation by Physician I (the physician performing the procedure) on 1/26/16.

B. Patient 27 was admitted 1/19/16 for a colonoscopy. Patient 27 received a MAC anethesia for the procedure. On 1/5/16 Nurse Practitioner (NP)-V completed a History and Physical on Patient 27 at the clinic.

The outpatient surgical record for Patient 27 lacked a Pre-Anesthetic Risk Evaluation by Physician I on 1/19/16.

C. Patient 28 was admitted 10/13/15 for a colonoscopy. Patient 28 received a MAC anethesia for the procedure. On 10/16/15 NP-V completed a History and Physical on Patient 28 at the clinic.

The outpatient surgical record for Patient 28 lacked a Pre-Anesthetic Risk Evaluation by Physician I on 10/13/15.

D. Patient 30 was admitted 12/8/15 for an upper endoscopy (EGD) (a procedure that allows the physician to look at the lining of the upper digestive tract, by using a flexible tube). Patient 30 received a MAC anethesia for the procedure. On 11/30/15 PA-T completed a History and Physical on Patient 30 at the clinic.

The outpatient surgical record for Patient 30 lacked a Pre-Anesthetic Risk Evaluation by Physician I on 12/8/15.

E. Patient 31 was admitted 1/19/16 for a colonoscopy. Patient 31 received a MAC anethesia for the procedure. On 1/14/16 Physician I completed a History and Physical on Patient 31 at the clinic.

The outpatient surgical record for Patient 31 lacked a Pre-Anesthetic Risk Evaluation by Physician I on 1/19/16.

F. An interview with Registered Nurse (RN) G on 2/9/16 at 10:45 AM verified that Patient 26, 27, 28, 30 and 31's medical records lacked the Pre-Anesthetic Risk Evaluation.

Based on review of the Quality Assurance (QA) Plan, Review of QA meeting minutes and Checklist for Monthly QA Reporting and review of Hospital Listing of Services and staff interview; the Critical Access Hospital (CAH) failed to include 2 of 13 services provided directly by the hospital (surgical services and outpatient specialty clinics) and 3 of 4 services provided through contract (physical therapy, occupational therapy and Doppler/echocardiography ultrasound). This failed practice has the potential to affect all patients seen in the hospital for surgical services, outpatient specialty clinic services, physical therapy services, occupational therapy services and/or echo/vascular ultrasound services.

Findings area:

A. Review of the QA Plan with a last reviewed date of 1/10/2011 revealed the following:
"D. HOSPITAL SERVICES
The Medical Staff delegates the functional responsible for hospital services quality assurance to the director of each individual department. The Director is responsible for effective implementation of quality assurance mechanisms which are designed to monitor and evaluate their services to identify and resolve high priority patient care problems or make improvements in patient care when the occasion arises.

Quality assurance activities shall be documented and reports of these activities shall be shared with the medical staff through the approved organizational structure of the quality assurance program."

and

"QUALITY ASSURANCE RESPONSIBILITIES: HOSPITAL SERVICES
The evaluation of hospital services is to be ongoing. Departments should monitor critical indicators of care or other problems identifiers which serve as 'valid bench marks' of the quality of services provided. When areas of concern or opportunities for improvement are identified, in depth, problem-focused studies of priority issues are encouraged. Criteria that reflect best available current clinical knowledge and skills are used in the department's monitoring, evaluation, and problem-solving activities."

The QA Plan lacked specific reference to contracted services provided to patient in the hospital.

B. Review of the Callaway District Hospital Listing of Services dated 8/2015 revealed the following services as contracted Physical Therapy, Occupational Therapy, Doppler (test using ultrasound waves to measure blood flow through the arteries), and Echocardiography (use of sound waves/ultrasound to create pictures of the heart). This listing included surgical as a direct service and outpatient as both direct and contract which would include the outpatient specialty clinic.

Review of the Quality Assurance meeting minutes and monthly compilation of department reports revealed no reporting for surgery, outpatient specialty clinic, physical therapy, occupational therapy and Doppler/echocardiography ultrasound.

C. Interview with the Quality Assurance designee (responsibilities include collecting all the monthly reports from the departments and compiling them into the meeting minutes) on 2/10/16 from 1:10 PM to 1:25 PM confirmed that no contracted services reported to Quality Assurance and thought all departments reported to quality. Review of the Checklist for Monthly Quality Assurance Reporting provided by the Quality Assurance Designee on 2/11/16 at 10:35 AM revealed a listing of departments; however, this list lacked surgery and outpatient specialty clinic.

Interview with the Radiology Manager (oversee the Doppler/echocardiography ultrasound) on 2/11/16 at 9:00 AM confirmed that the Doppler/echocardiography ultrasound was not included in the CAH's quality program.

Based on review of personnel files, review of the Abuse Policy and staff interview; the Critical Access Hospital (CAH) failed to implement their policy on Abuse by not doing a criminal background check on 2 of 6 personnel files (Nurse Aide - D and Registered Nurse [RN] - F) reviewed and not providing orientation on prohibition of abuse for 5 of 6 personnel files (Dietary - B, Housekeeper - C, Nurse Aide - D, Licensed Practical Nurse [LPN] - E and RN - F) reviewed. The Employee Master Report for the Callaway District Hospital listed 48 employees. This failed practice has the potential to affect all patients of the CAH.

Findings are:

A. Review of the Abuse Policy (no date listed) revealed the following:
"Human Resources will screen potential new employees in order to determine any background history of abuse/neglect. Reasonable efforts will be made to uncover information about any past criminal prosecution."

Review of the personnel files for Nurse Aide - D and RN - F revealed the report from the contracted company completing the background checks lacked reporting of a criminal background check.

Interview with the Human Resource Director on 2/9/16 from 4:20 PM to 5:15 PM confirmed that these 2 employees lacked a criminal background check.

B. Review of the Abuse Policy (no date listed) revealed the following:
"Training of employees:
All new employees will receive abuse prohibition training during the orientation
Issues address in this training will include:
-Information on what constitutes abuse, neglect and misappropriation of property
-Intervention to deal with aggressive and/or catastrophic retains (Sic) of patients
-How to recognize signs of burnout, frustration and stress that may lead to abuse
-The mechanism staff may use to report their knowledge of alleged abuse/neglect."

Review of the personnel files and Student and Group Transcript Report (for computerized training) revealed Dietary Employee - B, Housekeeper - C, Nurse Aide - D, LPN - E and RN - F lacked training on abuse and neglect.

Interview with the Human Resource Director on 2/9/16 from 4:20 PM - 5:15 PM revealed the following concerning abuse training:
-Clinical employees receive computerized training on Patient Abuse/Assault/Neglect but did not think anyone received training on the CAH's Abuse Policy.
-Employees are to complete the computerized training in the first 2 months of employment.
-RN - F (hire date 11/30/15) has been assigned the abuse computerized module but has not completed it.
-LPN - E (hire date 6/10/15) has been assigned the abuse computerized module but has not completed it.
-Nurse Aide - D (hire date 9/28/15) was not in the computerized training system so had nothing assigned to complete.
-Housekeeper - C and Dietary Employee - B would not be assigned the computerized abuse module since they are not clinical staff.

Based on staff interview, review of policy and procedure and review of 5 of 5 swing bed patient records (Patients 29, 30, 31, 32 and 33), the CAH (Critical Access Hospital), failed to ensure that a qualified professional directed the patient activities program for the swing bed patients. This had the potential to effect all patients admitted to swing beds.

Findings are:

A. An interview with the Director of Nurses (DON) on 2/10/16 at 2:50 PM, verified that the nursing staff complete the Activity Assessments for the swing bed patients. The DON verified that (Registered Nurse -G) was currently completing the activity assessments and was not a qualified activity professionals.

B. The patient record review for Patients 29, 30, 31, 32 and 33, revealed that Registered Nurse-G (who did not have the training required to be a qualified activity professional) completed the Activity Assessment for those patients.

C. Review of the undated "Activity Program Policy" revealed, "...The activities program will be directed by a qualified professional..."