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Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all patient care equipment was maintained in safe operating condition as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the CAH patient beds.

Findings:

Observation on 1/24/18 at 1:00 p.m. revealed a nurse call button was noted to be on the handrail of the beds in rooms #35, #40, 41 and OP #1 and #2. The button was noted to be non- functional as it failed to activate any type of nurse call system.

During an interview on 1/25/18 at 12:30 p.m. S20Case Manager, she stated 30 of the 31 total beds used in the CAH have call bell buttons on the the handrail and 30 out of 30 handrail call bells do not work. S20Case Manager continued to state the CAH had a new call bell system installed and because of problems with the new system and the beds and some of the bed alarms not functioning, the beds were no longer wired to the call bell system.

Based on record review and interview, the CAH failed to ensure the governing body privileged medical staff members as part of the reappointment process, according to the Medical Staff Bylaws, for 3 (S22MD, S23D, S24MD) of 3 physicians' credentialing files reviewed.

Findings:

Review of the hospital's Medical Staff Bylaws revealed in part: Section 5. Reappointment Process. B. Each member of the medical staff shall be subject to reappointment one year from the date of initial appointment and 2 years from the date of the last reappointment. C. No member of the medical staff shall be reappointed without prior specific review and evaluation of the member's performance and qualifications as provided herein. The review shall include, but not limited to, (1) clinical privileges requested, with any basis for change.....

S22MD
Review of S22MD's credentialing file revealed he was reappointed to the medical staff in April 2016 for a period of 2 years. Further review revealed no current documentation of delineation of privileges. The last documented delineation of privileges was dated 2011.

S23MD
Review of S23MD's credentialing file revealed he was reappointed to the medical staff in October 2016 for a period of 2 years. Further review revealed no current documentation of delineation of privileges. The last documented delineation of privileges was dated 2006.

S24MD
Review of S24MD's credentialing file revealed he was reappointed to the medical staff in July 2017 for a period of 2 years. Further review revealed no current documentation of delineation of privileges. The last documented delineation of privileges was dated 2007.

On 01/24/18 at 10:00 a.m., review of the above credentialing files with S2Medical Records Director revealed no documented evidence that a current delineation of privileges was submitted with the applicant's reappointment applications. The was no documented evidence that the medical staff and the board reviewed current delineated privileges for the most recent reappointments.

In an interview on 01/24/18 at 11:00 a.m. with S2Medical Records Director, she stated that she was responsible for the documentation regarding reappointments. She stated that she does not require the applicants to complete a new list of delineated clinical privileges with each reappointment application. She stated that the original delineation of privileges is reviewed at each reappointment. She further verified that the above physicians did not have delineated privileges for their most recent reappointments to the medical staff.

Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure identified medication errors were documented in the patient's electronic medical record for 3 of 3 (Patients #24, 25, 26) hospital identified medication errors reviewed.
Findings:

Patient #24
Review of the CAH's medication variance reports revealed Patient #24 had received a dose of Cleocin 600mg on 9/26/17 instead of ordered dose of Cleocin 100mg. Review of the patient's electronic medical record failed to reveal documentation of the medication error in the patient's medical record.

During an interview on 1/24/18 at 2:30 p.m. S17Pharmacy Director stated the pharmacist and the physician are notified for any drug errors and the notification and the details of the medication error should be documented in the patients medical record.

During an interview on 1/24/18 at 2:45 p.m., S7RN confirmed, after review of patient #24's medical record, that the medication error was not documented in the patient's electronic medical record.

Patient #25
Review of the CAH's medication variance reports revealed Patient #25 had an order for Cleocin 600mg IV every 8 hours and the medication administered was Vancomycin 600mg, labeled as Cleocin 600mg. Review of the patient's electronic medical record failed to reveal documentation of the medication error in the patient's medical record.

During an interview on 1/24/18 at 2:50 p.m., S7RN confirmed, after review of patient #25's medical record, that the medication error was not documented in the patient's electronic medical record.

Patient #26
Review of the CHA's medication variance reports revealed Patient #26 was to be given Solumedrol 125mg intravenous on 10/3/17 at 10:00 p.m. but the dose was given on 10/4/17 at 2:00 a.m. Review of the patient's electronic medical record failed to reveal documentation of the medication error in the patient's medical record.

During an interview on 1/24/18 at 2:55 p.m., S7RN confirmed, after review of patient #26's medical record, that the medication error was not documented in the patient's electronic medical record.

I. Based on observation and interview, the Critical Access Hospital (CAH) failed to maintain a system for controlling infections and communicable diseases of patients as evidenced by having an unsanitary kitchen environment which included expired, unlabeled and undated stored foods and improper sanitization procedures of cooking utensils.
Findings:

On 01/24/18 at 9:40AM, a tour of the dietary department with S5Dietary Manager revealed the following:
In the freezer, one bag of hushpuppies (as identified by S5Dietary Manager) was open. There was no open date or label on the bag.
In the refrigerator, two containers of cottage cheese were open. There was no open date on either container, and the expiration date was 01/02/18.
In the pantry, one large can of tomatoes with a large dent in the top seam of the can was stored with the foods available for use. S5Dietary Manager confirmed it should not be stored in the pantry.
In a corner of the kitchen, a large trash can was located between two food preparation tables and was within inches of each table. The lid of the trash can was just slightly above the level of the table surfaces, and the can was blocking full access to a drawer containing cooking utensils. An uncovered pan of butter was sitting on the top of one of the tables in front of the microwave, just inches from the trash can lid. An interview with S5Dietary Manager confirmed the location of the trash can could be a potential for food contamination.

Observation of the cleaning and sanitizing process at the 3 compartment sink by S6Dietary Staff revealed she dipped a flat pan into the sanitizing sink and placed in on a towel to dry. An interview with S6Dietary Staff at this time revealed she didn't usually wash the dishes in the 3 compartment sink, but she stated that her understanding of the sanitizing process was to dip the items in the sanitizing sink and then let them dry. She was unaware of the amount of time they should be left sitting in the solution. An interview with S5Dietary Manager at this time revealed the dishes should sit 10-20 seconds in the sanitizing solution. Review of the manufacturer's product label on the side of the container revealed the items should be in the solution for a minimum of 60 seconds.

II. Based on observation and interview, the CAH failed to maintain a system for controlling infections and communicable diseases of patients as evidenced by failing to ensure that the ultrasound, x-ray and CT tables and pillows were disinfected after each patient use and failing to ensure clean and dirty items were not stored tother.

Findings:

Observation on 1/24/18 at 12:35 p.m. revealed the exam table in the ultrasound room had a tear in the upper portion of the table and tears on the edges of the table. During an interview at this time S18Radiology Department Manager acknowledged the table's tears and confirmed it was an infection control issue.

Observaion on 1/24/18 at 12:40 p.m. revealed a fabric covered pillow on the x-ray table covered with a towel. During an interview as this time S18Radiology Department Manager acknowledged this type of pillow could not be sanitized and confirmed it was an infection control issue.

Observation on 1/24/18 at 12:45 p.m. revealed an area within the xray room with 3 walkers and a four point cane which were leaning against, and stored with a dirty linen container. During an interview at this time S18Radiology Department Manager stated the equipment was physical therapy's and the equipment was clean. She acknowledged at this time the clean equipment and dirty laundry hamper should not be stored together and confirmed it was an infection control issue.

Observation on 1/24/18 at 1:30 p.m. revealed 2 cloth covered pillows stacked on top of the other on the CT bed. During an interview at this time, S18Radiology Department Manager acknowledged the pillows could not be sanitized and confirmed it was an infection control issue.

III. Based on review, observation and interview, the CAH failed to maintain a system for controlling infections and communicable diseases of patients as evidenced by failing to ensure housekeeping used proper hand hygiene when cleaning a patient's room and patient room furnishing were maintained so they could be sanitized.

Findings:

Review of CHA's policy titled Hand Hygiene revealed in part:
I.Purpose: #3 To guide compliance for hand hygiene with the Center for Disease Control (CDC) Guidelines for Hand Hygiene in Health care Settings recommendations.
II. Policy: CHA...ednorses CDC Guidelines for Hand Hygiene...All employees are responsible for maintaining adequate hand hygiene by adhering to specific infection control proctices.
IV. General Procedures: 1. After contact with inanimate objects... 4. ...Dirty gloves can soil hands

Observation on 1/24/18 at 1:10 p.m. revealed housekeeper was observed placing a dirty rag and dirty gloves on the top of her housekeeping cart after exiting room #22. She reached into her pocket and removed her keys and unlocked her cabinet without saniizing her hands. During an interview at this time S19Housekeeping Staff described her process with the use of separate cleaning rags and the toilet being cleaned with the final rag and acknowledged this was the final rag used. She acknowledged this was an infection control issue and she should have put the soiled rag in the dirty linen hamper and then remove her gloves and sanitize her hands. Continued observation at this time revealed S19Housekeeping Staff touch her keys to the dirty rag while again unlocking the cart and then placing the dirty keys in her pocket. This action was noted to S19Housekeeping Staff and she acknowledged she had contaminated the keys and put them in her pocket. She stated "I did bad and I should know better because I have been here a long time." She acknowledged this was an infection control issue.

Observation of room #22 on 1/24/18 at 1:20 p.m. revealed a sofa with tears to the left upper arm. During an interview at this time, S19Housekeeping Staff acknowledged the tears could not be sanitized and they were an infection control issue.

Based on record review and interview the Critical Access Hospital (CAH) failed to ensure the clinical records system was maintained in accordance with written policies and procedures as evidenced by failure to ensure medical records of patients were promptly completed as set forth in the CAH's policies for completion of medical records.
Findings:

Review of the hospital's policy titled Health Information Management Policy 6:3: Incomplete Health Record revealed in part:
Policy: It is the policy of the hospital that health records shall be completed and authenticated by Hospital Staff no later than thirty days after a patient's discharge.
Procedure: 3. In the event that the health record has not been completed in the thirty day timeframe the health record is then logged onto the Health Information Management Department's deficiency list.
Review of the hospital's Medical Staff By-laws, Rules and Regulations revealed in part:
Section 3 - Automatic Suspension
A. Medical Records: When a member fails to complete medical records within the time prescribed by the Medical Staff Rules and Regulation, he/she shall be given a warning. If the member fails to adhere to the warning, a temporary suspension of admitting privileges, both acute and observation, consultation privileges and /or scheduling of elective surgery shall be automatically imposed by the Chief of Staff and shall remain in effect until such medical records are complete. Failure to complete the records within three (3) months after receiving a suspension shall be deemed a voluntary resignation of the member's Medical Staff membership and privileges.

Review of the hospital's Deficiency Detail Report - By Assignee dated 01/01/00 to 1/25/18 revealed the following medical record deficiencies:

S8Physician: 31-60 days deficient: 6; 61-90 days deficient: 1; 91 days or greater: 0; Total deficient records: 7.

S9Physician: 31-60 days deficient: 3; 61-90 days deficient: 1; 91 days or greater: 1; Total deficient records: 5.

S10Physician: 31-60 days deficient: 2; 61-90 days deficient: 0; 91 days or greater: 0; Total deficient records: 2.

S11Physician: 31-60 days deficient: 8; 61-90 days deficient: 5; 91 days or greater: 1; Total deficient records 14.

S12Physician: 31-60 days deficient: 0; 61-90 days deficient: 2; 91 days or greater: 0; Total deficient records: 2.

S13Physician: 31-60 days deficient: 0; 61-90 days deficient: 5; 91 days or greater: 0; Total deficient records 5.

S14Physician: 31-60 days deficient: 0; 61-90 days deficient: 0; 91 days or greater: 7; Total deficient records: 7.

S15Physician: 31-60 days deficient: 0; 61-90 days deficient: 1; 91 days or greater: 1; Total deficient records: 2.

S16Physician: 31-60 days deficient: 9; 61-90 days deficient: 0; 91 days or greater: 0; Total deficient records: 9.

Further review revealed a grand total of 53 medical records that were 31 days deficient to greater than 91 days deficient from 1/1/00 - 1/25/18.

During an interview on 1/25/18 at 9:55 a.m., S2Medical Records Director stated there were no suspension of physician's privileges and acknowledged the CAH was not following its By-Laws.

Based on observation and interview, the Critical Access Hospital (CAH) failed to ensure patient medical records were protected against loss or destruction as evidenced by failure to protect its 2010-2014 patient medical records that had not been scanned, copied or backed up from potential destruction/damage from fire.
Findings:

Observation on 1/25/18 at 10:15 a.m. revealed a room within a storage building which measured 8'x6' with 11 (10" high shelves on the 3 interior walls) completely filled with patient medical records dating from 2010 to 2014 that had not been scanned, copied or backed up from potential destruction/damage from fire. Continued observation failed to reveal a fire-suppression/sprinkler system in this room.

During an interview on 1/25/18 at 9:45 a.m., S4Maintenance Manager stated the room which stores the medical records in the outbuilding is not equipped with a fire-suppression/sprinkler system.

During an interview on 1/25/18 at 9:50 a.m., S2Medical Records Director stated the room in the outbuilding houses the 2010-2014 patient medical records and these records have not been scanned, copied or backed up. She continued to state the room is not equipped with a fire-suppression/sprinkler system.