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Based on interview and record review a physician failed to periodically review the records of care provided to 1 of 7 (P6) inpatients by physician assistants (PA). Findings included:

P6 was admitted to the CAH on 11/14/09, with artrial fibrillation. On 11/15/09, the patient was transferred to another facility to receive further treatment. The record lacked any signature or review from a physician.

On 7/1/10, at 1:45 p.m. the director of nursing (DON) verified a physician is required to review the clinical record.

Based on interview and record, the CAH failed to notify a physician of a patient admission by a physician assistant (PA) for 1 of 7 (P6) patient records who were admitted by a PA. Findings include:

P6 was admitted to the CAH on 11/14/09, with atrial fibrillation. On 11/15/09, the patient was transferred to another facility to receive further treatment. The record lacked any signature or review from a physician.

PA-1 completed documentation on 12/20/09, that physician-1 was notified of P6's admission. The form lacked a signature from physician-1 verifying notification of the admission.


On 7/1/10, at 1:45 p.m. the DON verified the PA is required to notify the physician of an admission.

The undated facility policy "Doctor Notification Policy" indicated a midlevel practitioner is to notify a doctor when a patient is admitted to the CAH.

Based on observation and staff interview, the CAH failed to ensure outdated drugs and biologicals were not available for patient use in the emergency and surgical departments. Findings include:

A tour of the emergency room was conducted on 6/29/10, at 1:00 p.m. with the DON. The following expired medications were observed stored in the medication cupboard in the emergency room.

-Flumazenil expired on 4/10
-Atropine expired on 5/10
-Six Leet syringes expired on 11/2/09
-Six bisacodyl suppositories expired on 12/09
-Two bottles of 5% dextrose solution expired on 3/10
-Eight bottles of sodium chloride expired on 5/10


A tour of the surgical suite was conducted with the DON at 1:45 p.m.. The following expired medications were observed stored in the cupboard/drawer in the surgical suite:

-Three 50 mL bottles of lidocaine expired on 11/09
-One bottle of benzoin tincture expired on 1/10
-Seven vials of sterile water expired on 5/10

On 6/29/10, at 12:00 p.m. the DON verified these findings and stated the nursing staff are to be checking for outdated medications on a monthly basis.

Based on policy review and staff interview, the CAH failed to ensure the system of maintaining logs for patient and employee infections was implemented and kept current in order to appropriately identify, track, and investigate infections. In addition, the CAH failed to maintain an adequate system to identify and implement appropriate interventions to prevent the spread of infection for 1 of 1 patients (P19) who received blood glucose testing by the use of a glucometer. Findings include:

A review of the infection control meeting minutes on 6/30/10 indicated the CAH had no infections dating back to 2008. No log was maintained to monitor patient or staff infections and surveillance. In addition, the CAH lacked current policy and procedures related to infection control within the facility. The policies provided were dated from the years of 1993 to 2000 and lacked current guidelines related to Centers for Disease Control recommendation.

A random review of 20 patient records indicated:

P1 was admitted on 4/30/10 with pneumonia.
P2 was admitted on 3/12/10 with pneumonia.
P3 was admitted on 12/27/09 with pneumonia.
P7 was admitted on 5/6/10 with pneumonia.
P8 was admitted on 3/12/10 after experiencing Methicillin Resistant Staphylococcus Aureus (MRSA) sepsis.
P10 was admitted on 5/6/10 with recent Clostridium Difficile (C-Diff).
P16 was admitted on 1/11/10 with a urinary tract infection.

On 6/30/10, at 10:19 a.m. the DON verified no log was maintained to monitor staff infections. In addition, he was unaware of any documented surveillance of staff to monitor compliance with proper infection control procedures.

On 7/1/10, at 10:00 a.m. the DON verified these findings. The DON was unable to provide current policy and procedures related to infection control. He stated they had current policies but he was unable to locate them.


The CAH failed to ensure adequate disinfection of the multi-use glucometer used for checking blood glucose levels between patient use. The CAH was not utilizing an EPA approved product to prevent the transmission of hepatitis B and HIV.

P19 was currently admitted to the CAH and required glucose monitoring by nursing staff.

On 6/30/10, at 2:30 p.m. RN-A stated the glucometer is disinfected with 70% alcohol wipes in between patient use.

On 7/1/10, at 8:40 a.m. RN-B stated the glucometer is disinfected with 70% alcohol wipes in between patient use.

At 10:00 a.m. the DON stated the glucometer should be disinfected with a CaviWipe XL wipe in between patient use. He stated this should be in the policy.

The current facility policy "Care and Clearing of the Accu-Check meter" dated 4/27/10, directed staff to use a soft cloth with 70% isopropyl alcohol to cleanse the monitor. The policy did not direct staff as to when the machine should be cleansed.

Based on record review, policy review, and interview, the CAH (Critical Access Hospital) failed to ensure all entries made in the medical record were timed, dated, and authenticated for of 29 of 38 patients (P1, P2, P3, P4, P5, P7, P8, P10, P11, P14, P16, P17, P18, P21, P23, P24, P25, P26, P27, P28, P29, P30, P31, P32, P33, P34, P36, P37, P38) reviewed receiving services at the CAH. Findings include:

P1 was admitted on 4/30/10, with pneumonia. The progress notes dated 5/2/10, were not timed by the physician. The physician orders on 5/1/10, 5/2/10 and 5/3/10, were untimed.

P2 was admitted on 3/12/10, with pneumonia. The physician orders on 3/12/10, 3/13/10, 3/14/10, and 3/16/10, were untimed.

P3 was admitted on 12/27/09 with pneumonia. The physician progress noted was undated and not timed by the physician.

P4 was admitted on 12/8/09 with dehydration. The progress notes dated 12/9/09, and 12/10/10, were not timed by the physician.

P5 was admitted on 8/7/09. The physician progress noted on 8/10/09, and 8/11/09, were not timed by the physician. The discharge summary was undated and not timed by the physician. The physician orders on 8/11/09, and 8/12/09, were untimed.

P7 was admitted on 5/6/10, with pneumonia. The physician progress noted on 5/7/10, and 8/11/09, were not timed by the physician. The discharge and history and physical summary were undated and not timed by the physician. The physician orders on 5/6/10, and 5/7/10, were not timed.

P8 was admitted on 3/12/10, with pneumonia. The swing discharge and history and physical summary were undated and not timed by the physician. The swing bed standing physician orders dated 3/12/10, were not timed.

P10 was admitted on 5/6/10, with Crohn's disease. The physician orders on 5/6/10, and 5/7/10, were not timed. The discharge summary was undated and not timed by the physician.

P11 was admitted with a gastrointestinal bleed on 9/4/09. The discharge summary was undated and not timed by the physician assistant.

P14 was admitted on 1/13/09, with kidney disease. The physician progress noted on 1/14/10, and 1/15/10, were not timed by the physician. The discharge and history and physical summary was undated and not timed by the physician assistant.

P16 was admitted on 1/11/10, with a stroke. The physician progress noted on 1/12/10, and 1/13/10, were not timed by the physician. The discharge and history and physical summary was undated and not timed by the physician assistant. The physician orders on 1/12/10, 1/13/10, and 1/14/10, were not timed.

P17 was admitted on 2/6/10, with pain. The history and physical summary was undated and not timed by the physician assistant. The physician orders on 2/9/10, were not timed.

P18 was admitted with chest pain on 5/3/10. The history and physical summary was undated and not timed by the physician assistant.



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P21 was admitted to the CAH on 2/6/10. The history and physical dated 2/6/10, the physician progress note dated 2/12/10, and the discharge summary dated 2/15/10, lacked dates and times of the physician signature.

P23 was admitted to the CAH on 4/15/10, for outpatient surgery. The operative report dated 4/15/10, and four physician progress notes/orders dated 4/15/10, lacked a time and date. The introperative record and the preoperative history and physical lacked a time of the entry.

P24 was admitted to the CAH on 10/29/19, for outpatient surgery. The three physician progress notes dated 10/29/09, lacked a time of the entries. The post anesthetic note dated 10/29/10, lacked a time of the entry.

P25 was admitted to the CAH on 2/18/10, for outpatient surgery. The physician progress note dated 2/18/10, lacked a time of the dictated entry and lacked time and date of the physician signature.

P26 was admitted to the CAH on 10/15/09, for outpatient surgery. The preoperative physical dated 10/8/09, the operative report dated 10/15/09, and the three physician progress note dated 10/15/09, lacked a time of the entries.

P27 was admitted to the CAH on 6/10/10, for outpatient surgery. Two physician progress notes lacked timing of the entry.

P28 was admitted to the ER (emergency room) on 2/16/10. The dictated ER note dated 2/16/10, lacked timing of the entry and the date and time of the physician signature.

P29 was admitted to the ER on 12/30/09. The dictated ER note dated 1/5/10, lacked timing of the entry and the date and time of the physician signature.

P30 was admitted to the ER on 11/13/09. The dictated ER note dated 11/13/19, lacked timing of the entry and the date and time of the physician signature.

P31 was admitted to the ER on 5/1/10. The ER note signed by the physician lacked a time and date.

P32 was admitted to the ER on 6/26/10. The ER note signed by the physician lacked a time of the entry.

P33 was admitted to the ER on 12/9/09. The dictated ER note dated 12/9/09, lacked timing of the entry and the date and time of the physician signature.

P34 was admitted to the ER on 5/23/10. The ER note signed by the physician lacked a time of the entry.

P36 was admitted to the ER on 6/3/10. The dictated ER note dated 6/3/10, lacked timing of the entry and the date and time of the physician signature.

P37 was admitted to the CAH on 6/23/10. The dictated history and physical note dated 6/23/10, lacked timing of the entry and the date and time of the physician signature.

P38 was admitted to the ER on 4/14/10. The dictated ER note dated 4/14/10, lacked timing of the entry and the date and time of the physician signature.

On 7/1/10, at 1:30 p.m. the director of nursing verified these findings.

Based on interview and policy review, the CAH was found not to be in compliance with the Condition of Participation of Surgical Services. The CAH failed to ensure proper sterilization of surgical instruments for patients who underwent cataract extraction with intraocular lens implant. This potentially could effect most patients provided eye surgery at the CAH. Findings include:

During the tour of the surgical department/sterile supply on 7/1/10, at 12:45 p.m. the surgical technician-A (ST-A) and DON were interviewed regarding the use of flash sterilization. The ST-A stated the microsurgical eye instruments are placed in the flash sterilizer in a tray (not wrapped) and the gravity cycle is used for 10 minutes between each surgical procedure. The manufacturer recommendations and current policy for use of flash sterilization on surgical instruments was requested.

On 7/1/10 the CAH provided a copy of the current policy. The current policy indicated unwrapped metal instruments at 270 degrees Farenheit: gravity 4 minutes with 1 minute dry time, and unwrapped items (with lumens, porous items, or pans with numerous items: gravity 10 minutes with 1 minute dry time. However, the revised policy dated 6/30/10 (time of survey and not yet implemented) documented:
1. The flash cycle is a programmed gravity type cycle. Flash cycles should be used for unwrapped items intended for emergent use only - see Flash Sterilization Policy.
2. Gravity cycles can be used for wrapped loads. a. Instrument sets less than 17 pounds i. Wrapped instruments sterilized at 270 degrees Farenheit should be sterilized for 5 minutes with a dry time of 20 minutes. The ST-A verified the instruments are not wrapped prior to placing in the flash sterilizer.

The DON verified at 12:45 p.m. that the surgical department was using flash sterilization between cataract procedures without wrapping the instruments. He added the CAH had just revised the policy regarding the use of flash sterilization and surgical instruments but had not yet implemented. The DON stated the CAH performs 4-6 cataract procedures per month. He also not aware of any problems with surgical infections for cataract patients.

Based on interview and record review, the facility failed to develop a Quality Assurance (QA) program that evaluated the quality and appropriateness of the facility's infection control program. Findings include:

On 6/30/10, at 4:00 p.m. the CAH's QA plan and documentation was reviewed with the DON. It was noted that each department/service provided by the CAH currently had QA activities except for Infection Control.

A review of the infection control meeting minutes on 6/30/10 for the past two years revealed no active QA projects related to infection control. There was no log maintained to monitor patient or staff infections and surveillance. In addition, the CAH lacked current policy and procedures related to infection control within the facility. The policies provided were dated from the years of 1993 to 2000 and lacked current guidelines related to Centers for Disease Control recommendation.

On 7/1/10, at 10:00 a.m. the DON verified these findings.