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Based on document review, policy review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 1of 1 General Surgeon, 1of 1 General Medicine Physician, 1 of 1 Radiologists, 1 of 1 Orthopedic Surgeons, 1 of 1 Emergency Medicine Physicians, 1 of 1 Otolaryngologist, 1 of 1 Podiatrist and 1 of 1 Urologist selected for review received outside entity peer review by the Network Hospital, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital, prior to reappointment to the medical staff. Failure to ensure all medical staff members received outside entity peer review, by the appropriate entity, prior to reappointment, affects the CAH's ability to assure physicians provide quality care to the CAH patients. (General Surgeon H, General Medicine Physician I, Radiologist J, Orthopedic Surgeon K, Emergency Medicine Physician L, Otolaryngologist M, Podiatrist N and Urologist O).

The CAH administrative staff identified the identified physicians provided care to patients from 1/1/2021 to 6/16/2021 as follows:

General Surgeon H - 406 clinic visits and 202 procedures
General Medicine Physician I - 105 inpatients and 36 outpatients
Radiologist J - 116 radiology reports
Orthopedic Surgeon K - 49 procedures
Emergency Medicine Physician L - 62 emergency room patients
Otolaryngologist M - 24 procedures
Podiatrist N - 4 procedures
Urologist O - 5 procedures

Findings include:

1. Review of the CAH's network agreement, effective 11/26/202, revealed in part " ... [Hospital] through participating members of its administrative staff and other personnel designated by [Hospital], assists [CAH] in reviewing the quality and appropriateness of the diagnosis and treatment furnished by [CAH] doctor of medicine or osteopathy for purposes of assisting [CAH] carry out the requirements of its quality assurance plan ..."

2. Review of a CAH policy titled "Peer Review/Mortality Review," reviewed 3/2021 revealed in part "... Providers with privileges at [CAH] will have an external peer review of a chart, once per credentialing period ... Currently [CAH A] reviews these charts ...".

3. Review of external peer review for the selected physicians revealed the medical staff approved General Surgeon H for reappointment to the Medical Staff on 2/2/2021. The Board of Commissioners approved General Surgeon H for reappointment to the Medical Staff on 3/3/2021. General Surgeon H's external peer review results showed completion by CAH A.

4. Review of external peer review for the selected physicians revealed the medical staff approved General Medicine Physician I for reappointment to the Medical Staff on 2/2/2021. The Board of Commissioners approved General Medicine Physician I for reappointment to the Medical Staff on 3/3/2021. General Medicine Physician I's external peer review results showed completion by CAH A.

5. Review of external peer review for the selected physicians revealed the medical staff approved Radiologist J for reappointment to the Medical Staff on 3/24/2021. The Board of Commissioners approved Radiologist J for reappointment to the Medical Staff on 4/1/2021. Radiologist J's external peer review results showed completion by CAH A.

6. Review of external peer review for the selected physicians revealed the medical staff approved Orthopedic Surgery K for reappointment to the Medical Staff on 2/2/2021. The Board of Commissioners approved Orthopedic Surgeon K for reappointment to the Medical Staff on 3/3/2021. Orthopedic Surgeon K's external peer review results showed completion by CAH A.

7. Review of external peer review for the selected physicians revealed the medical staff approved Emergency Medicine Physician L for reappointment to the Medical Staff on 2/2/2021. The Board of Commissioners approved Emergency Medicine Physician L for reappointment to the Medical Staff on 3/3/2021. Emergency Room Medicine Physician L's external peer review results showed completion by CAH A.

8. Review of external peer review for the selected physicians revealed the medical staff approved Otolaryngologist M for reappointment to the Medical Staff on 2/2/2021. The Board of Commissioners approved Otolaryngologist M for reappointment to the Medical Staff on 3/3/2021. Otolaryngologist M's external peer review results showed completion by CAH A.

9. Review of external peer review for the selected physicians revealed the medical staff approved Podiatrist N for reappointment to the Medical Staff on 1/7/2020. The Board of Commissioners approved Podiatrist N for reappointment to the Medical Staff on 1/20/2020. Podiatrist N's external peer review results showed completion by CAH A.

10. Review of external peer review for the selected physicians revealed the medical staff approved Urologist O for reappointment to the Medical Staff on 3/24/2021. The Board of Commissioners approved General Urologist O for reappointment to the Medical Staff on 4/1/2021. Podiatrist O's external peer review results showed completion by CAH A.

11. During an interview on 6/16/2021, at 1:30 PM the Medical Records Director reported the CAH utilizes CAH A to conduct the external peer review on their physicians. She acknowledged the service is conducted with CAH A and they do not involve their Network Hospital in the external peer review process.

The Medical Records Director confirmed their Network Hospital does not participate in the evaluation of the appropriateness of diagnosis and treatment furnished to patients at the CAH through peer review, prior to reappointment to the medical staff..

Based on observation, document review, and interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the surgery staff changed 2 of 2 observed sterile water flush bottles after endoscope procedures for each patient, in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient. The OR Outpatient Services Manager and Infection Control Lead identified that the surgery staff performed an average of 28 endoscope procedures from 1/1/20 to 12/31/20.

Findings include:

1. Observations during a tour of the surgery department on 6/15/21 at approximately 8:10 AM in Operating Room (OR) #2 revealed 1 of 1 bottle B Braun 1000 mL bottle of sterile water and 1 of 1 bottle of Baxter 250 mL for irrigation connected to the endoscope equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract).

2. Review of the manufacturer's instructions revealed in part, "Single unit container. Discard unused portion." (The hospital staff must discard any unused portions of the sterile water for irrigation after use on a single patient. The sterile water for irrigation did not contain any chemicals to prevent bacteria from growing in the sterile water once the hospital staff opened the bottles of sterile water for irrigation.)

3. During an interview at the time of the tour, the Surgical Service Director revealed the surgery staff opened
the bottles of sterile water for irrigation each day for endoscope procedures that are scheduled and connected it to the equipment. The equipment contained a one-way valve to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscope procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscope procedures. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscope procedures for the day or if the bottle ran empty.

4. During an interview on 06/15/2021 at approximately 10:05 AM, the Surgical Service Director verified
they reviewed and confirmed the manufacturer's directions for the B Braun 1000 mL bottles of sterile water and the 250 mL Baxter bottles of sterile water for irrigation. The Surgical Service Director acknowledged the manufacturer did not support using the bottles of sterile water for irrigation for more than 1 patient.

Based on observation, document review, and staff interviews, the hospital's administrative staff failed to ensure 6 out of 7 observed surgical staff (Housekeeper B, CRNA D, LPN C, RN E, RN A, and RN G) wore head coverings which fully covered all of their hair. Failure to wear head coverings that fully cover all hair could potentially result in bacteria, fungi, or viruses on the surgical staff members' hair entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The hospital's administrative staff identified the surgical services staff performed an average of 97 surgical procedures per month during the calendar year of 2020.

Findings include:

1. During an interview on 06/15/2021 at approximately 10:15 AM, the Surgical Service Director revealed the most of the hospitals surgical staff and contracted CRNAs wore skull caps. The Surgical Service Director reported the hospital followed the AORN (Association of Peri-Operative Registered Nurses, a nationally recognized guideline agency) guidelines and American College of Surgeons (a professional organization for surgeons) statement for surgical attire.

2. Review of the AORN Guideline for Surgical Attire, copyright 2020, revealed in part, "The revision stated that the scalp and hair should be covered when entering the semi-restricted and restricted areas ..."

3. Review of the hospital's Dress Code/Personnel Attire (Surgery Department), reviewed on 1/2021, revealed the policy in part ... "All head and facial hair, including sideburns, beards, and neckline, must be covered completely with clean, lint-free cap or surgical hood while in restricted area."

4. Observations on 06/15/2021 at approximately 8:05 AM, during a tour of the Surgical Services Department Housekeeper B was wearing a skull cap. The skull cap consisted of a cap covering forehead and central part of the surgical staff's hair. The skull cap did not cover the lower approximately two inches of hair from the sides of the head to the back of the head.

5. Observations on 06/15/2021 at approximately 8:24 AM, during an ORIF (Open reduction internal fixation) of the right wrist surgical procedure (ORIF of the wrist is a surgical technique employed for the treatment of severe wrist fractures to restore normal anatomy and improve range of motion and function.), revealed Patient # 1 underwent a surgical procedure in operating room #1. Observations from inside the operating room revealed CRNA D (Certified Registered Nurse Anesthetist, a registered nurse with specialized training in administering medication to render a patient unconscious for surgery), LPN C (License Practicing Nurse), RN E (Registered Nurse), RN F, RN A and RN G all wore a skull caps. The skull cap consisted of a cap covering forehead and central part of the surgical staff's hair. The skull cap did not cover the lower approximately one inch to two inches of surgical staff's hair on the sides of their heads and the hair on the back of their heads.

6. During an interview on 06/15/2021 at approximately 12:10 PM, the CNO (Chief Nursing Officer) acknowledged the surgical staff currently wore skull caps.