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Based on document review and interview, the critical access hospital (CAH) did not ensure background studies had been completed for 3 of 3 employees (certified registered nurse anesthetist (CRNA)-A, registered dietitian (RD)-A and a speech pathologist (SP)-A) who were contract employees providing services in/for the CAH.

Findings include: Criminal background studies had not been completed for the CRNA-A, RD-A and a SP-A who had written contracts with the CAH to provide patient care services. The facility had failed to complete criminal background checks as directed by MN Statute 144.057 Subdivision 1 that reads, "Background studies required. The commissioner of health shall contract with the commissioner of human services to conduct background studies of (1) individuals providing services which have direct contact...with patients and residents in hospitals..."

On 9/5/2013 at 2:00 p.m. credential files were reviewed with the executive assistant (EA) responsible for credentialing. The facility had not completed a criminal background check for CRNA-A, who had a contract with the CAH to provide anesthesia services.

The executive assistant responsible for physician credentialing was interviewed on 9/4/2013 at 2:15 p.m.. She confirmed CRNA was credentialed at the CAH. She stated a criminal background study was not found in the credentialing file and could not be found by the outside agency who completed criminal background studies for the CAH. She stated criminal background study had not been completed.

On 9/5/2013 at 3:05 p.m. personnel files were reviewed with the director of human resources. The facility had not completed criminal background studies on RD-A and SP-A, who had contracts with the CAH to provide patient care services.

The CAH policy from the employee handbook, dated 9/1/2013, was provided by the human resource director. The policy indicated all job offers were contingent upon the successful completion of a background check. The human resource director was interviewed on 9/5/2013 at 3:10 p.m. and stated criminal background checks were completed for employees and volunteers, but not contract employees.

An e-mail received from the executive assistant on 9/9/2013 at 11:38 a.m. confirmed personnel files and review of the employee contracts with CRNA-A, RD-A and SP-A did not indicate a background study had been done prior to employment.

Based on observation and interview, the critical access hospital (CAH) failed to ensure that 4 of 13 patient rooms (116, 115, 114 & 113) had adequate functioning ventilation systems.

Findings include: During the environmental tour on 9/4/13 at 3:30 a.m., it was discovered the air handling systems in patient rooms 116, 115, 114 and 113 were not working to the appropriate capacity. The manager of plant operations, present during the tour, stated he had not been aware of this and agreed this was a problem.

In an interview with the maintenance manager on 9/4/13 at 3:45 p.m., he stated he was unaware if these air handling systems had been checked during routine maintenance of the physical plant. He further stated there was not a policy about the preventive maintenance for the air handling system.

During an interview with the plant operations manager on 9/05/13 at 10:15 a.m., he verified rooms 113, 114, 115, and 116 had been occupied by patients in the past year. After the identification of this problem on the physical plant tour, the maintenance manager planned to change the pulleys for the air handling fans to a smaller size which would result in an increase of the Revolutions per minute (RPM) by approximately 20%. He indicated this approach would provide a stronger draw of air into these rooms.

Based upon interview and document review, the critical access hospital (CAH) did not ensure services were provided in accordance with written policies for documentation of dry time for the use of alcohol based skin preparations for 3 of 3 patients (P1, P2 and P3) who had outpatient surgeries and for 3 of 3 in-patient (IP1, IP2 and IP3) surgical records where an alcohol based skin preparation had been utilized.

Findings include: The CAH did not implement their policy and procedure to ensure compliance with applicable federal regulations and guidelines related to the use of alcohol based skin preparations in the surgical department. CMS (Centers for Medicare and Medicaid Services) had issued a Survey and Certification Memo dated 1/12/2007, addressing risk reduction techniques to permit safe use of alcohol based skin preparations in anesthetizing locations in CAHs. The use of an alcohol based skin preparation in inpatient or outpatient anesthetizing locations is not considered safe, unless appropriate fire risk reduction measures are taken, preferable as part of a systemic approach by the CAH to prevent surgery related fires.

A review of the CAH policy 32145, Skin Preparation in the Operating Room, last revised January 2006, indicated staff were to follow the attached AORN (Association of Operating Room Nursing) standards as well as the manufacture recommendations for all skin preps used. The attached recommendations for the manufacturers of ChloroPrep (currently used by the CAH) indicated the solution was to dry for a minimum of three minutes and to document the time the solution had dried. The CAH did not document the time the alcohol based skin prep was determined to have dried.

An interview was conducted with the perioperative/outreach clinic coordinator on 9/4/2013 at 10:45 a.m. regarding the policy/procedure for use of alcohol based skin preps in the operating room. It was verified some physicians ordered ChloroPrep, an alcohol based skin preparation, as a surgical skin prep. Although the perioperative manager verified the circulating nurse routinely checked to verify the skin preparation solution had completely dried, the CAH staff did not document the dry time in the medical record.

Medical record review revealed ChloroPrep was used as a surgical skin preparation for P1, P2, P3, IP1, IP2 and IP3 who all had a surgical procedure. A review of the perioperative record indicated ChloroPrep had been used as a skin prep on the following: laparoscopic hernia repair on 1/28/2013 (IP1), laparoscopic cholecystectomy on 2/15/2013 (IP2), Caesarean section on 1/3/2013 (IP3), circumcision on 2/6/2013 (P1), bilateral unus procedure on 3/4/2013 (P2) and knee arthroscopy on 3/11/2013 (P3). Review of the perioperative records for all six records confirmed that an alcohol based skin preparation had been utilized. There was no documentation to indicate when it had been determined the alcohol based skin preparation had dried.

The perioperative coordinator was interviewed on 9/6/2013 at 11:15 a.m. and confirmed there was no documentation evident in the patient medical records regarding drying of the prep solution prior to draping. It was explained that since the CAH had initiated electronic medical record documentation, this required component had been missing in the documentation.

Based upon observation, interview and document review, the critical access hospital (CAH) did not ensure medication had been disposed of in a secure manner in 1 of 1 operating room and in 1 of 1 soiled utility room located within the surgical suite.

Findings include: Medications were observed to be accessible in unsecured areas of the hospital, where patients, visitors and other persons without legal access to drugs and biologicals, were present.

During a tour of the operating room suite on 9/4/2013 at 10:30 a.m., a red container labeled "Sharps" was observed unsecured on the anesthesia cart in the operating room. The container had an opening in the top and there were visible vials, bottles and syringes which contained medication. Some of the medications observed in the container included syringes of Propofol (an anesthetic agent), Rocuronium (a muscle relaxant used in anesthesia) and Midazolam (an anesthetic medication.)

A black hazardous waste container, which measured approximately 24 inches in height and 10 inches in width with an opening in the top of the container which measured approximately 8 inches in diameter (which would allow free access to the contence in the container,) was observed in the soiled utility room in the surgical suite. Numerous 500 milliliter bottles with epinephrine (also known as adrenaline or adrenalin is a hormone and a neurotransmitter) and other vials and bottles which contained discarded medications were observed in the container.

The perioperative/outreach clinic manager was interviewed on 9/4/013 at 11:00 a.m. and stated all unused medications in vials, syringes or other containers were disposed of in these hazardous waste containers. She stated the operating room suite was not locked when not in use and the soiled utility room would be accessible to unlicensed staff, patients and visitors. Although the operating room was locked when not in use, unlicensed staff could have access to the operating room when licensed staff were not immediately available.

A review of the CAH policy 32700, Disposal of Anesthetic Agents, reviewed annually, indicated anesthetic agents would be considered hazardous waste.

The pharmacist was interviewed on 9/4/2013 at 11:50 a.m. and stated unlicensed staff should not have access to medications which had been discarded in containers as hazardous waste. The pharmacist was again interviewed on 9/5/2013 at 10:50 a.m. and stated all anesthetic agents should be released to the pharmacy when disposed of as hazardous waste.

Based on observation and staff interview the facility failed to ensure 1 of 1 patient (P1) with a bland diet was served food according to their choice.

Findings include: Record review identified P1 was prescribed a bland diet per physician's orders of 9/4/13.

During observation of the food service on 9/6/2013 at 11:15 a.m., cook (C)-A was serving the dinner meal. C-A looked at P1's food selections on the menu card and arbitrarily changed the patient's choice from ham to salmon patty. C-A stated she did not think ham was an approved selection for a bland diet. C-A did not consult the therapeutic diet spread sheet during the meal service to confirmed if ham was an appropriate choice.

Review of the therapeutic diet spread sheet, dated 9/6/13, identified that either ham or salmon patty was an appropriate choice for a bland diet.

In an interview with the certified dietary manager (CDM) on 9/6/2013 at 11:20 a.m. she reviewed the therapeutic spread sheet and determined that P1's request for ham had been appropriate and therefore P1's request should not have been changed. Upon notice that the incorrect meat selection (main entree) had been dished up for P1, CDM recalled the tray back and instructed C-A to provide the correct choice of meat.

Based upon document review and staff interview, the critical access hospital (CAH) did not ensure that a Registered Nurse (RN) had evaluated and documented ongoing clinical assessments for 1 of 3 patients (P11), who was an in-patient receiving care.

Findings include: Initial and/or follow-up nursing assessments had not always been evident in the record of P11 so an appropriate care plan could be developed and patient progress could be adequately measured.

P11 was admitted to the CAH on 8/29/2013 with diagnoses which included pneumonia, diarrhea and dehydration. The initial nursing assessment documented on the Assessment Notes Report completed by an RN, dated 8/29/2013 at 4:29 p.m., indicated the patient had a decubitus ulcer on the right hip with an intact dressing in place. A Braden Scale completed at this time identified the patient at high risk for the development of a pressure ulcer.

A second Assessment Notes Report, dated 8/29/2013 at 11:00 p.m. indicated the patient had a dressing on the right hip. Another Braden Scale, completed at this time, identified the patient at high risk for the development of a pressure ulcer.

A review of other nursing Assessment Notes Reports confirmed there had been no assessment of the decubitus ulcer on the patient's right hip until the surveyor requested to observe the decubitus on 9/4/2013 at 2:30 p.m., seven (7) days after admission.

The Director of Nursing provided the CAH policy, Standards of Clinical Nursing Practice, reviewed annually, which confirmed the responsibility of the RN to collect patient health information, to formulate a nursing diagnosis based on the assessment data and to document the diagnosis in a manner which facilitated the determination of expected outcomes and plan of care.

The Director of Patient Care Services was interviewed on 9/4/2013 at 2:03 p.m. and confirmed there had not been an assessment of the patient's decubitus ulcer since the patient was admitted on 8/29/13. She stated the usual procedure to initiate treatment of a decubitus ulcer, was for the RN to notify the wound nurse (at the adjacent nursing home care center) for follow up wound care. There was no evidence the wound nurse had been notified of the decubitus ulcer noted on the right hip of P11 on admission nor had any subsequent, follow-up assessments conducted by the RN so that a plan of care could be developed and progress tracked.

Based on document review and interview, the critical access hospital (CAH) failed to ensure telephone orders (TO) were timed and dated by the prescribing physician in a timely manner for 9 of 19 patients (P2, P3, P4, P5, P6, P7, P8, P9 & P10) who were in-patients receiving medical care in the CAH.

Findings include:

P2 was admitted to the CAH on 5/23/13. The verbal orders from 5/24/13 had been signed by physician but were not dated and timed.

P3 was admitted to the CAH on 8/11/13. The verbal orders from 8/13/13 had been signed by physician but were not dated and timed.

P4 was admitted to the CAH on 7/12/13. Two verbal orders from 7/15/13 had not been timed and dated when physician signed orders.

P5 was admitted to the CAH on 5/27/13. The verbal orders from 5/29/13 had not been date and time when the physician signed the orders.

P6 was admitted to the CAH on 4/21/13. The telephone order from 4/21/13 and a verbal order from 4/22/13 had not been dated or timed when the physician signed the orders.

P7 was admitted to the CAH on 4/25/13. The verbal orders from 4/27/13 were not dated and time when physician signed the orders.

P8 was admitted to the CAH on 5/11/13. Neither the telephone order from 5/11/13 nor the verbal order from 5/12/13 had been dated or time by the physician.
P9 was admitted to the CAH on 2/1/13. The verbal orders form 2/1/13, 2/2/13 and a telephone order from 2/3/13 were not timed or dated when the physician signed orders.

P10 was admitted to the CAH on 7/16/13. The verbal order from 7/15/13 was not dated or timed by physician.

In review of the CAH's policy Physician Orders Receiving & Transcribing Policy # 20520 with the last revision 6/2008, this policy does not address the need for the physician to date and time signatures on either verbal or telephone orders. On asking for a different policy that addressed the telephone orders none was provided.

Interview with the medical records staff on 9/5/13 at 3:15 p.m. verified the noted orders lacked dated and/or timed physician signatures ( P2, P3, P4, P5, P6, P7, P8, P9 & P10).

Based upon interview and document review, the critical access hospital (CAH) did not ensure a nursing care plan was developed which was based on the assessed patient nursing care needs for 2 of 2 patients (P11 and P12) who were in-patients receiving medical services from the CAH.

Findings include: .

P11 was admitted to the CAH on 8/29/2013 with diagnoses which included pneumonia, diarrhea, dehydration, and diabetes mellitus. The admission nursing assessment on the Assessment Notes Report, dated 8/29/2013 at 4:29 p.m. identified abnormal findings which included urinary incontinence, nutritional status below requirements, high risk for the development of pressure ulcers, and the presence of a decubitus ulcer on the right hip. The current care plan, last reviewed 9/4/2013, only identified an alteration in bowel elimination and fluid volume deficit. The care plan did not address interventions to manage the patient's urinary incontinence, nutritional status, promotion of skin integrity, care and treatment of the decubitus ulcer and management the patient's diabetes.

P12 was admitted to the CAH on 9/2/2013 with diagnoses which included pneumonia. The admission nursing assessment completed on the Assessment Notes Report, dated 9/2/2013 at 11:00 p.m. identified abnormal findings which included urinary incontinence, inability to communicate (will speak appropriately at times), at high risk for the development of pressure ulcers and abdominal pain. The current care plan, last reviewed 9/3/2013 at 9:00 p.m., did not address interventions to manage the patient's urinary incontinence, communication difficulties, promotion of skin integrity and abdominal pain.

A review of the CAH policy, Standards of Clinical Nursing Practice, reviewed annually, directed nursing staff to individualize the patient's plan of care according to the patient's condition and needs.

The director of patient care services was interviewed on 9/4/2013 at 1:40 p.m. She reviewed the care plans of P11 and P12 and stated they were not comprehensive and did not address problems identified by the nursing assessment.