HospitalInspections.org

Based on observation and interview, the critical access hospital (CAH) failed to ensure signage was posted in all visible areas of the Emergency Department (ED) and at the front clinic entrance identifying a medical doctor was not on duty 24 hours a day/7 day a week. This had the potential to affect all admitted patients and/or those seen in the ED.

Findings include:

During a tour/interview on 2/25/25 at 2:45 p.m., a tour of the emergency department (ED) was completed with the director of nursing (DON). The ED had three treatment rooms used for ED patients. Treatment room one (closest to the nurse's station) and treatment room three (closest to the ED entrance) had doors accessing the rooms. Treatment room two was located between treatment room one and treatment room three. Patients could access the ED through the ED entrance (entering through the ambulance garage door and walking approximately 25 feet up a ramp to the facility entrance door) or through the main clinic door (during normal business hours). The only posted notification identifying a medical doctor was not on duty on a 24/7 basis was located outside treatment room one's door. The notification was typed on an 8 ½ inch by 11-inch sheet of paper and placed into a frame approximately five feet off the floor. The notification would not be seen by patients entering the ED through the ambulance garage and entering treatment room three for services in treatment rooms two or three. In addition, no notification was posted in any ED treatment room.

During an observation on 2/26/25 at 10:30 a.m., notification identifying a provider was not on duty on a 24/7 basis was not posted in the main clinic entrance which was an additional entrance for patients seeking services in the ED. In addition, no notification was posted in the only waiting area within the hospital where patients could wait to be seen for medical treatment in the ED. The notification would not be seen by individuals entering the facility through the main clinic door and entering treatment room three for services in treatment room two or three.

During an interview on 2/26/25 at 11:30 a.m., DON confirmed the above findings and stated the facility had been working on getting updated notifications, but it had been missed. DON stated it was important to have notifications at all entrances where patients could access ED services as well as posting notifications within each ED treatment room. DON indicated the facility would be working to update notifications promptly.

A hospital policy was not obtained.

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: K0363, K0372, and K0901.

Based on interview and document review, the facility failed to ensure informed consent forms included the signature of the patient or legal guardian for 1 of 8 patients (P21) reviewed for surgical procedures.

Findings include:

P21's pre-operative history and physical (H&P) dated 12/6/24 indicated P21 had an intellectual disability, generalized anxiety disorder and epilepsy. Review of guardianship, healthcare agents and power of attorney/conservatorship indicated none was on file in the medical record. Review of Health Care Directive, scanned to medical record 5/4/18 indicated FM-D was the healthcare agent.

P21's document titled Patient Consent for neck mass excision was signed, dated, and timed by caregiver (C)-B. Registered nurse (RN)-A stated P21 was from a group home and was accompanied by one of the group home workers for his surgery. Review of medical record indicated emergency contact as FM-C who RN-A indicated was not present on site the day of the surgical procedure. RN-A confirmed the emergency contact, guardian or power of attorney should have signed the Patient Consent form versus the group home employee. RN-A added they should have called FM-C or FM-D and got a verbal consent with two witnesses.

P21's Admission assessment and documentation identified family present as other, Caregiver-B.

The Consent for Surgical or Invasive Procedure policy dated 2/2025, directed all consents are to be informed consents meaning the practitioner has provided sufficient information in words the patient or their representative can understand to make an informed decision. The "informed consent" must be signed by the patient or their representative the day of the surgery/procedure or in the attending or performing practitioner's office. The following patients are responsible for their own consents: Adults, 18 years and older, who are not under guardianship or mentally incompetent.

On 2/26/25 at 12:50 p.m., the director of nursing confirmed the Patient Consent should have been signed by the patient or a family member for the surgical procedure.

Based on interview and document review, the facility failed to ensure a current roster listing specific to each practitioner's surgical privileges was available in the surgical suite or where scheduling of surgical procedures is done, and that staff were aware of where these documents were located.

Findings include:

On interview and tour of the surgical unit 2/24/25 at 2:47 p.m., registered nurse (RN)-B stated she wasn't aware of a privilege list located in the surgery department or where to find one and would verify with the provider if they are privileged to do the procedure if she had any questions.

On interview 2/25/25 at 8:20 a.m., RN-A, also identified as surgery director, was not aware of a privileging list being in the surgery department and stated they take some surgeons for granted that they have the designated surgical procedure privileges. RN-A added they have worked with some of these doctors for 30 years, they have a degree in surgery, and they know what the surgeons can do. RN-A added they do not do any major surgical procedures at the facility.

On interview 2/25/25 at 10:46 a.m., RN-C indicated she is not aware of a credentialing list and if she questioned anything she would ask the surgery manager.

On interview 2/26/25 at 10:57 a.m., RN-A stated she was able to locate the credentialing lists on the computer and stated there are only three surgeons listed that are still here practicing and some of the newer surgeon's credentialing lists were not present. RN-A stated she will get this updated and complete education for the surgical staff.

On interview 2/26/25 at 10:25 a.m., the director of nursing (DON) and executive assistant (AA)-A also identified as person responsible for credentialing, were not aware of any list of privileges for the surgeons or of any electronic files of privileges. AA-A indicated they have had turnover in the credentialing role over the past year and she recently took over the duties. The DON confirmed a list should be available for surgical staff.

A policy and procedure for credentialing was requested. The Rules and Regulations of the Medical Staff was received and included patients may be treated only by providers who have submitted proper applications and have been duly appointment to membership on the medical staff or granted temporary privileges.

Based on interview and record review the Critical Access Hospital (CAH) failed to ensure medical records were evaluated through the quality assessment and performance improvement (QAPI) program.

Findings include:

During and interview on 2/25/25 at 2:36 p.m., health information management director (HIMD) indicated record keeping was not involved QAPI and she did not report anything formally to QAPI. HIMD further indicated she was unaware of any goals or measurements medical records/record keeping had for QAPI.

During an interview on 2/25/25 at 4:01 p.m., director of nursing (DON) indicated she did not put QAPI information together for medical records/record keeping as it was the responsibility of the HIMD. DON further indicated the quality director (QA) was responsible for putting together all departments QAPI information.

During a follow-up interview on 2/26/25 at 11:30 p.m., DON stated that medical records/record keeping did not directly report to QAPI. DON stated that the HIMD was responsible for reviewing and auditing medical charts and this information was shared during reviews but was unable to locate the information within the QAPI report. DON agreed HIMD should share medical information more formally as it was scattered throughout QAPI. DON stated this would ensure the goals and measurements are being met.

Review of Johnson Memorial Health Services Quality Plan dated 2024, identified the objectives were to promote and maintain high quality and continuity of care. This included the coordination and integration of all quality activities at Johnson Memorial Health Services.

Based on interview and document review, the critical access hospital (CAH) failed to have a system to collaborate and communicate with the Organ Procurement Organization (OPO) for 2 of 2 patients (P1 and P5) reviewed to ensure every patient's death was being reviewed.

Findings include:

Review of P1 and P5's electronic medical records (EMR) dated 4/1/24 through 12/31/24, the facility followed the policy and contacted LifeSource within the required one hour for both patients identified on the facilities Hospital Program overview.

Review of the facility's Hospital Program overview dated 4/1/24 through 9/30/24, the facility had two referrals to LifeSource for the facility.

Review of the facility's Lion's Gift of Sight report dated quarter one 2022 through quarter four 2024, the facility had four potential eye donor, two actual eye donors, four transplant tissue donors, and two late referrals.

During an interview on 2/25/25 at 3:55 p.m., director of nursing (DON) stated she receives a quarterly report from LifeSource, reviews the report, which does not contain patient names or medical record numbers and compares it to the death of the patient to verify compliance with staff contacting LifeSource within the one hour time frame; however, if the hospital had a death and LifeSource was not contacted, the patient identification is not on the LifeSource Report. The DON stated she receives Lion's Gift of Sight report yearly, reviews the report, which does not contain patient names or medical record numbers, for donations or rejections but does not compare the report to any medical records or facility tracking system. In addition, either OPO tracking is not brought forward to QAPI. She stated the hospital did have two eye donations that were not reviewed or brought to the attention of QAPI.

During a follow-up interview on 2/26/25 at 11:55 a.m., DON stated she was the only one in charge of the OPO information and again confirmed the reports were not part of QAPI.

Facility policy titled Organ and Tissue Donation revised 10/22, did not provide any information related to OPO and QAPI.