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Staff interviews, review of the Medical Staff Rules and Regulations and review of patient medical record information revealed the Critical Access Hospital (CAH) failed to follow the Medical Staff Rules and Regulations pertaining to the notification and disciplinary action for Physician-1, for failing to complete outpatients medical records (Patients A-L) in the time allowed by the Medical Staff Rules and Regulations. The CAH is licensed for 16 beds and had census of 4 Swingbed patients and 1 acute care patient upon survey entrance.

A. Review on 9/20/11 at 2:00 PM of the Medical Staff Rules and Regulations, revision date of 2009, pages 8-9, section M, reads: "COMPLETION OF RECORDS: Within twenty days of discharge of the patient, the attending practitioner shall see that the record is complete, shall state his or her final diagnosis, and shall sign the record. If the record review remains incomplete twenty (20) days after discharge, the Administrator or Medical Records Director may notify the practitioner in writing that his or her admitting or coadmitting privileges will be suspended five (5) days from the date of notice. If the record is not completed five (5) days from the date of such notice, the practitioner's admitting or coadmitting privileges will be suspended until such records have been completed."

B. Interview with the Health Information Management (HIM) and CAH Administrator on 9/20/11 at 2:00 PM identified Physician-1 to be an Orthopedic outpatient consultant that sees patients on an outpatient basis one time per month. Physician-1 had a total of 12 delinquent medical records due to the lack of summary notes. Interview with Administrator revealed that all physicians providing services to patients must follow the Medical Staff Rules and Regulations and complete their records within 20 days. Administrator acknowledged that Physician-1 had not received a letter indicating his delinquent medical records.

On 9/21/11 surveyor was notified by the Administrator that a letter had been sent to Physician-1 on 9/20/11 and the CAH had received a prompt response from Physician-1 on 9/21/11 with all information necessary to complete the 12 delinquent outpatient medical records.

I. Based on direct observation, staff interview and a lack of written policies, the Critical Access Hospital (CAH) failed to ensure accurate records of the distribution of all medications were maintained and failed to ensure outdated medications and biologicals were not available for patient use. According to the most recent annual program evaluation, the hospital served 123 acute care patients. Findings are:

A. A tour of the Outpatient area on 9/22/11 at 11:30 AM revealed a locked storage cabinet, which contained the following outdated medications and biologicals available for patient use:
- 5 bottles bacteriastatic NaCl 0.9% expired 8/1/10;
- 1 bottle Lidocaine HCl 1% expired 12/1/10; and
- 1 bottle Lidocaine HCl 2% expired 8/1/11.

B. An interview, during this same tour, with the Outpatient Charge Nurse revealed an inventory of the medications stored in this area was not maintained.


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II. Record review, observations , and staff interviews revealed the Critical Access Hospital (CAH) failed to have policies and procedures for pharmaceutical services pertaining to the receiving and distribution of medications in accordance with accepted professional principles for medications located in the emergency department (ED), 2 crash carts and an anesthesia cart. The CAH failed to follow the policies and procedures for the accountability of narcotics stored in the ED. The CAH is licensed for 16 beds and had a census of 4 Swingbed patients and 1 acute care patient upon survey entrance. Findings are:

A..Review of the Narcotics count sheet located in the ED revealed the staff failed to initial the counting of narcotics on the ED narcotic log sheet by 2 qualified personnel approximately 373 times from January 2011 through Sept 21, 2011. Interview with the DON acknowledged the nurses are not signing off or able to prove the narcotics in the ED are counted as the policies and procedures say.

B. Review of the Daily Ancillary Medication Control Record utilized for the medications located in the ED are to count 67 different drugs with discrepancies noted for 40 medications. Examples are:
1. Phenergan 25 MG/ML count 10--survey count 1-50 MG/ML vial;
2. Ultram Tablets (no dosage noted on formulary) 10--survey count 8 (no dosage noted);
3. Toradol 30 mg syringes/ vial count 2 and 60 mg syringes/vials count 4--survey count 30 mg syringes/vials 4, 60 mg count 2.

C. Observation of the patient crash cart located in Hallway A with the Director of Nursing (DON) on 9/21/11 at 2:00 PM revealed in comparison to the CAH formulary a total of 32 various medications with inventory descripencies of 13 medications. Examples include:
1. Epinephrine 1:10,000 injection count 1--survey count 0; and
2. Epinephrine 1:10,000 injection 1 MG/10ML count 4--survey count 0.

D. Observation of the ED/Operating Room crash cart located in the ED with the DON on 9/21/11 at 3:00 PM revealed in comparison to the formulary a total of 31 various medications with inventory discrepancies of 19 medications. Examples include:
1. Dextrose injection 50% 25 G/50ML count 2--survey count 1;
2. Adenosine injection 6 MG/2 ML count 2--survey count 3; and
3. In the crash cart, but not listed on the formulary, is Adenosine injection 12 MG/4 ML count 0--survey count 2.

E. Interview and observations conducted with the Director of Surgical Services on 9/21/11 at 4:30 PM revealed a list of medications used and stored in the anesthesia cart to be a count of 33. Further interview revealed the Director of Surgical Services to have no knowledge of the exact mediations or the count and stated that the CRNA stocks what he wants, not sure of what he wants stocked on the cart. The CRNA pulls the anesthesia cart to the nurses station to stock and tells the charge nurse what he needs and they get it for him, does not reconcile the anesthesia cart with the CRNA at the end of the day's procedures and would not know if something was missing.

F. Interview with the DON acknowledged that there are no policies or procedures giving guidance for the staff pertaining to the 2 crash carts, medications located in the ED, or anesthesia cart.

G. Interview and observations of the ED, crash carts, and anesthesia cart on 9/21/11 at 10:00 AM conducted with the DON revealed the CAH had assigned 2 Registered Nurses (RN-A and RN-B) to oversee the ordering of all medications for the CAH under the direction and guidance of the DON and a contracted Registered Pharmacist (RP). The DON could not be sure of the exact medications stored in the crash carts, ED, or anesthesia cart and was unsure if medications were being misappropriated or diverted from the pharmacy by staff. Further noting the RP came to the facility once a month and was not sure exactly what the RP did when in the CAH.

H. Review of the policies and procedures, revised 7/21/11, for the Pharmacy accountability reads: Pharmacy Department Hours: The pharmacy is a decentralized department, open 24 hours a day, under the direction of a licensed pharmacist, or in the absence of the pharmacist, the nurse in charge. Pharmacy Department Personnel: The Director of Pharmacy is the R.P, who is responsible to the CAH Administrator. The pharmacy supervisor is the DON. The Director of Pharmacy is assisted designated Pharmacy Supervisor who is responsible for directing pharmacy services in the absence of the Pharmacy Director. The Pharmacy Supervisor and the Director of Pharmacy are responsible for establishing pharmacy policies and procedures. The Director of Pharmacy and Pharmacy Supervisor are responsible for orienting, assisting, instructing, and supervising the nursing personnel in all pharmacy activities. The Director of Pharmacy and Pharmacy Supervisor are jointly responsible for maintaining pharmacy records. Only Registered Pharmacists, Registered Nurses and Licensed Practical Nurses may be involved in pharmacy procedures.

Duties, Responsibilities, Scheduled Hours of the Consultant Pharmacist reads: Duties:
1. Monitor drug use and storage in the facility.
2. Monitor the use of controlled drugs and regularly check inventories.
3. Advise on drug purchasing to ensure economy.
4. QA studies concerning drug usage.
5. Meet with the medical staff concerning drug use.
6. Develop and maintain a house drug formulary.
7. Be available for drug related questions.
8. Check stock for outdated drug items.

I. Review of the policies and procedures on 9/21/11 at 11:00 AM reads: Narcotics: All narcotics administered will be signed for by the licensed nurse who administers them. All narcotics will be counted for at the end of each shift. Counting will be done by two persons: (one from the day shift and one from the night shift). When the count is completed, both parties will initial the Narcotics Count Record, verifying said count. Count sheets will be retained in the designated notebooks.

Based on staff interview and a lack of data, the infection prevention program could not be considered adequate. According to the most recent annual program evaluation, the Critical Access Hospital (CAH) had 123 acute care patient admissions. Findings are:

A. A review of infection surveillance records for the current year lacked any information regarding staff hand hygiene practices during direct patient care.

B. An interview conducted with the Infection Control Nurse at 3:30 PM on 9/20/11 confirmed the program did not include monitoring of staff hand hygiene practices.