HospitalInspections.org

Based on review of the Safety policy and procedure manual and staff interview the Critical Access Hospital (CAH) failed to develop a disaster plan that included sewer system failure and cooling system failure. Census on the first day of survey was 1 swing bed patient. The total patients served for fiscal year 2014 (7/1/13 to 6/30/14) included 1044 Specialty Clinic patients, 85 acute inpatients and 48 swing bed patients. The lack of a plan for sewer system failure and cooling system failure has the potential to affect all patients of the CAH.

Findings are:

A. Review of the Safety policy and procedure manual (which included the Disaster Plan and plan for utility failures) revealed no plan for sewer or cooling systems failures.

B. Interview with the Director of Maintenance and the Safety Coordinator on 8/20/14 from 8:05 AM to 8:30 AM revealed the following:
- Confirmed the lack of a plan for sewer system failure;
- Identified the chillers (cooling system) required electricity and were not hooked to the emergency generator; and,
- Confirmed no plan to provide for comfort and safety of patients in the event that electricity outage and chillers not operating.

Based on review of Medical Staff Bylaws, review of credential files, review of 6 surgical medical records and staff interview, the Critical Access Hospital (CAH) failed to follow the Medical Staff Bylaws regarding the appointment of 1 of 2 Certified Registered Nurse Anesthetists (CRNA) listed on the Medical Staff roster (CRNA-V). (A CRNA is a registered nurse who has specialized training to administer medications during surgery that minimizes pain during the procedure). This failed practice has the potential to affect all surgical procedures where CRNA-V was involved. The CAH completed 80 outpatient surgeries for Fiscal Year 2014 (7/1/13 - 6/30/14).

Findings are:

A. Review of the Medical Staff Bylaws approved by the Board on 1/30/13 revealed the following:
- Article IV - Membership: "Membership on the Medical Staff, including assignment to one of the staff categories, is recommended by the Executive Committee and granted by the Board."
- Article V - Categories of Membership and Duties Section 2 - Affiliate Staff: "The Affiliate Staff consists of all non-physician practitioners who hold clinical privileges at the Hospital....The Affiliate Staff includes...certified registered nurse anesthetists (CRNAs)...."
- Article VI Clinical Privileges, Section 1 - Nature of Privileges: "Privileges to practice at the Hospital are granted by the Board following recommendation of the Executive Committee....A practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws."

B. On 8/19/14 at 4:00 PM the surveyor requested the credential file for CRNA- from the Director of Quality/Risk. (A credential file contains the verification that the individual is who he/she claims to be, has been properly licensed, has appropriate malpractice insurance and meets the requirements establish by the CAH for the person to be on the medical staff.) The Director of Quality/Risk Management stated "It's bad news. I've kept [CRNA-V] as contract and not taken it through the credential process." (Meaning the process where the Executive Committee recommends appointment and the Board grants specific privileges.) The Director of Quality/Risk looked through the folder containing information on CRNA-V and commented that "an application was completed in 2002".

C. Review of the credential file for CRNA-V revealed the following items in the file:
- Declination of Privileges sign 8/15/02 by CRNA-V;
- Certification of Nebraska Licensure for CRNA-V created on 8/19/14;
- Copies of CRNA license;
- Copy of Registered Nurse (RN) license;
- Copy of card that certified completion of Advanced Cardiovascular Life Support Program;
- Copy of card that certified completion of Basic Life Support for Healthcare Providers Program;
- Copy of membership card for American Association of Nurse Anesthetists;
- Copy of verification card for National Board of Certification & Recertification for Nurse Anesthetists;
- Certificate of Liability Insurance; and,
- Universal Provider Application (application requesting privileges at the CAH) signed by CRNA-V on 8/15/02.
The CAH failed to take any action on the request for privileges.

D. Review of Medical Records 26, 27, 28, 29, 30 and 31 revealed that CRNA-V administered the anesthesia medication for all 6 patients.

Based on staff interview and documented evidence, the infection prevention program failed to maintain an ongoing mechanism to monitor hand hygiene practices of direct patient care staff.

Findings include:

A. A review of the infection control and quality assurance reports submitted to the medical staff for the time period January through July, 2014 lacked any mention of hand hygiene practices by direct patient care staff.

B. An interview with the Infection Preventionist (IP) on 8/21/14 and subsequent review of a document titled, "Kearney County Health Services, Quality Improvement Activity, Infection Control, Acute Care, Handwashing" indicated hand hygiene practices of the patient care staff were observed from 10/14/13 through 10/ 21/13 during the day shift only. The IP confirmed the 7 day period in October, 2013 was the only occasion during which hand hygiene practices were monitored and documented. At the bottom of the page, the same document stated, "Review study with acute care staff and review handwashing and infection control, Restudy 2014".

C. During the same interview, the IP confirmed that other shifts (night or evening , weekend or holidays) had not been observed, nor had there been any follow up hand hygiene observations performed to date in 2014 (10 months) to determine baseline staff performance, thresholds of acceptability or performance improvement.

Based on review of the dietary policy and procedure manual, review of the last annual evaluation and staff interview, the Critical Access Hospital (CAH) failed to ensure the group of professionals reviewed 1 of 8 types of policies and procedures (policies and procedures to ensure the nutritional needs of inpatients are met - dietary) in the past year. Census on the first day of survey was 1 swing bed patient. For Fiscal Year 2014 (7/1/13 - 6/30/14) acute inpatient admissions was 85 and swing bed admissions was 48. This failed practice has the potential to affect any acute inpatient and/or swing bed patient with a nutritional problem.

Findings are:

A. Interview with the Director of Quality/Risk on 8/18/14 from 11:20 AM to 11:25 AM revealed that documentation of the annual review of policies and procedures by the group of professionals could be found in the Annual Evaluation.

B. Review of the last Annual Evaluation dated 12/17/13 revealed a 3-page section titled Health Care Policies - New and Reviewed; however, these 3 pages listed no policies and/or procedures for dietary/nutritional services. A review of the Dietary policy and procedure manual revealed a policy and procedure titled "Fluid Restrictions" with an implementation date of 1/22/13. This new dietary policy and procedure lacked review by the group of professionals.

C. Interview with the Dietary Supervisor (DS) on 9/20/14 from 9:05 AM to 10:15 AM revealed the following:
- DS looked through the policy and procedure manual with the Registered Dietitian;
- DS aware that changes need to be made; and,
- Confirmed that the dietary policies and procedures have not been reviewed by any committee at the CAH.

D. Interview with the Director of Quality/Risk on 8/21/14 at 11:15 AM revealed the following:
- Could provide no written policy on how the group of professionals annually reviews policies and procedures;
- Verbally described that new and revised policies and procedures go to medical staff for review and approval;
- At time of the Annual Evaluation a list is made with all of the new and revised policies for the last year.
- Confirmed that dietary policies and procedures do not go to the medical staff of the CAH for review and would not be listed in the Annual Evaluation.

Based on record review, review of policy and procedures and staff interview, the facility failed to have complete, accurate and readily accessible medical records for 6 of 40 sampled records. Of the 6 records; 3 records (Patients 3, 4 and 11) lacked a signed consent to treat form; 2 outpatient records (Patients 39 and 40) lacked a nursing assessment; and 1 medical record (Patient 30) that was not readily accessible. The total patients (Pts) served for fiscal year 2014 included 1044 for Specialty Clinics, 85 Acute Inpatient Stays and 48 Swing Bed stays. The facility census at time of entering the facility was 1 swing bed patient. This failed practice has the potential to affect all patients served by the Critical Access Hospital.

Findings are:

A. Review of Pt 3's medical record for a stay from 4/2/14 at 8:00 AM to 4/2/14 at 1335 (1:35 PM) revealed:
- An order on 4/2/14 at 8:00 AM from the Medical Provider to Admit to Acute Care; and
- Review of the Hospital Inpatient and Outpatient Admission Agreement (Consent to Treatment) lacked a signature from the Patient, an Authorized Representative or a Staff Person.

B. Review of Pt 4's medical record for a stay from 4/10/14 at 1305 (1:05 PM) to 4/12/14 at 1014 (10:14 AM) revealed:
- An order on 4/10/14 at 1305 from the Medical Provider to Admit to Acute Care Status; and
- Review of the Hospital Inpatient and Outpatient Admission Agreement lacked a signature from the Patient, an Authorized Representative or a Staff Person.

C. Review of Pt 11's medical record for a stay from 4/29/14 at 2310 (11:10 PM) to 5/3/14 at 1805 (6:05 PM) revealed:
- An order on 4/29/14 at 2310 from the Medical Provider to Admit to Acute Care; and
- Review of the Hospital Inpatient and Outpatient Admission Agreement lacked a signature from the Patient, an Authorized Representative or a Staff Person.

D. Review of Pt 30's Electronic Medical Record and paper Medical Record for the EGD (Esophagogastroduodenoscopy- a procedure to examine, diagnose and take tissue samples of issues of the esophagus, stomach and beginning of the small intestine.) on 2/13/14 was completed. The record contained only a demographic sheet, a dictated operative report, pictures taken during the procedure and the pathology from the biopsies obtained during the procedure.

Interview with the Director of Medical Records on 8/21/14 at 8:05 AM revealed, "We were unable to locate the rest of the record for (Pt 30). I guess I would call it an incomplete chart. We have looked for it and can't find it. We don't know if it got lost before getting to medical records or if it got there and was misfiled or not scanned into the correct chart."

E. Review of Pt 39's Outpatient record revealed, on 2/3/14 Pt 39 saw the Orthopedic Physician (a bone specialist.) in the outpatient clinic. The medical record lacked a nursing assessment or vital signs. The physician made a notation on the facesheet identifying the left wrist and diagnosis. The facesheet lacked any nursing assessment documentation.

F. Review of Pt 40's Outpatient record revealed, on 8/11/14 Pt 40 saw the Urologist (a physician that specializes in the diseases of the urinary organs.) in the outpatient clinic. The medical record lacked a nursing assessment or vital signs. The physician dictated a progress note. The facesheet lacked any nursing assessment documentation.

G. Review of the Policy and Procedure for Outpatient Services with an effective date 10/1/13 revealed:
#13) Nursing documentation of the treatment room visit is done in the patient's electronic medical record using the appropriate documentation modules. a) Record time in and time out of patient as well as any pertinent patient information, assessments, tolerance to treatment and medications given, supplies used. b) Record start and stop times of infusions.
#14) Vital signs should be taken on admission to treatment room. If the patient is here for a brief injection, vital signs may not need to be taken prior to discharge. If the treatment provided is longer than 30 minutes, obtain discharge vital signs.

H. Interview on 8/18/14 at 1:50 PM with the Outpatient Specialty Clinic Manager stated (when asked where the nurses document their findings for the visit) "On the Face Sheet or use a form from the physician."

Based on a review of the current Quality Improvement Plan, annual program evaluation, staff interview and a lack of data, the Critical Access Hospital's quality assurance program failed to follow the Quality Improvement plan, failed to evaluate the quality and appropriateness of the diagnosis and treatment furnished and treatment outcomes for the outpatient services performed at the hospital. The hospital reported 956 outpatients served in 2013 and 1044 outpatients as of 7/31/14.

Findings Include:

A. The current Quality Improvement (QI) plan stated under Scope "The Quality Improvement Program includes the following activities: All direct patient care services and indirect services affecting patient health and safety..."

B. A review of the Annual Program evaluation for 2013 lacked any mention of quality monitoring of any of the outpatient services. A review of the quality assurance department reports submitted for 2014 lacked reporting from any of the Outpatient services area.

C. An interview conducted with the Quality Assurance Coordinator at 12:45 PM on 8/21/14 revealed "The hospital offered the following services on an outpatient basis: Ophthalmology, Orthopedics, Podiatry, Urology, Cardiology, Nuclear Medicine, Wound Care.

D. During the same interview, the Quality Improvement coordinator stated none of the above mentioned services were included in the quality assurance program, nor were there any quality indicators established to ensure the appropriateness of the diagnosis and treatment of patients treated in the outpatient services department.