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I. Based on observation and staff interviews, the Critical Access Hospital (CAH) failed to remove outdated supplies from the Medical/Surgical Unit (Med/Surg), Same Day Surgery/Outpatient Unit (SDS/OP), and Operating Room (OR). Failure to remove outdated patient supplies from the CAH's Med/Surg, SDS/OP, and OR resulted in expired supplies remaining available for use in patient care, potentially resulting in staff using the expired items for patient care after the manufacturers' expiration date (the date after which the manufacturer will no longer guarantee the safety and quality of the supply). The CAH identified census of 9 patients at the beginning of the survey and a combined total of 472 patients visits in the SDS/OP and OR for the 2020 fiscal year.

Findings include:

1. Observations during a tour on the MED/Surg Unit on 06/28/2021 at 12:20 PM, revealed the following expired supplies:

Trauma Room 3 Crash Cart
a. 4 of 4 Primary Plum Sets (IV Tubing), 4 expired 06/01/2021
b. 2 of 2 BD Insyte Autoguard IV Catheter 14 Ga. x 1.75 in., 2 expired 02/28/2021
c. 2 of 2 Blunt Fill Needle-Filter 18 Ga. x 1 1/2 in., 2 expired 02/2021
d. 2 of 2 bottles Sterile Water 20 ml, 2 expired 03/2021
e. 1 of 1 0.9% Sodium Chloride 500 ml bag, expired 10/2020
f. 1 of 1 Covidien Monject Syringe 12 ml, expired 05/2020
g. 2 of 4 Covidien Mallinckrodt Nasal Trach Tube 9 mm, 2 expired 08/2020

2. Observations during a tour of the SDS/OP Unit on 06/29/2021 at 11:30 AM, revealed the following expired supplies:

Nurse's Station Cupboards
a. 1 of 2 Pediatric Catheter Kits 8 Fr., 1 expired 01/31/2021
b. 1 of 2 Small, regular, knee length, Covidien T.E.D. Anti-embolism stockings, 1 expired 12/2020

3. Observations during the tour of the OR area on 06/30/2021 at 10:20 AM, revealed the following expired supplies:

Dantrium Cart
a. 2 of 2 60 ml Syringes, 2 expired 10/2018

Sterile Supply Room
a. 1 of 2 Sterile Disposable Tourniquet Cuff 42 inch single bladder, 1 expired 01/2021
b. 1 of 1 Sterile Disposable Tourniquet Cuff 34 inch single bladder, 1 expired 03/2021

OR Room #1
a. 1 of 1 Cividien Salem Sump tube 12 Fr., 1 expired 03/2021

Post Anesthesia Care Unit (PACU)
a. 1 of 1 Airlife Sterile Water for inhalation 1000 ml bottle, expired 01/10/2021

4. During an interview at the time of the tour of the Med/Surg Unit, the Nurse Manager revealed they expected the Med/Surg staff to check the supplies every month and remove any outdated supplies. The Nurse Manager acknowledged the Med/Surg staff failed to remove the expired supplies from the Med/Surg Unit. The Nurse Manager then acknowledged, that since the Med/Surg staff failed to remove the expired supplies from the unit, the Med/Surg staff could potentially use the expired supplies for patient care.

5. During an interview at the time of the tour of the SDS/OP Unit, the OR Supervisor revealed they expected the SDS/OP staff to check the supplies every month and remove any outdated supplies. The OR Supervisor acknowledged the SD/OP staff failed to remove the expired supplies from the SDS/OP Unit. The OR Supervisor then acknowledged, that since the SDS/OP staff failed to remove the expired supplies from the unit, the SDS/OP staff could potentially use the expired supplies for patient care.

6. During an interview at the time of the OR area, the OR Supervisor revealed they expected the OR staff to check the supplies every month and remove any outdated supplies. The OR Supervisor acknowledged the OR staff failed to remove the expired supplies from the OR area. The OR Supervisor then acknowledged, that since the OR staff failed to remove the expired supplies from the unit, the OR staff could potentially use the expired supplies for patient care.



II. Based on observation, document review, and staff interviews, the Critical Access Hospital's(CAH) administrative staff failed to ensure staff inventoried and performed preventative maintenance on all Stryker electric hospital beds located within the hospital. Failure to inventory equipment and perform preventative maintenance on all patient equipment could potentially result in the equipment failing to function when needed for the care and treatment of a patient, and may result in delayed care, treatment, and patient harm. The CAH's administrative staff identified a census of 9 patients at the start of the survey.

1. Review of the Preventive Maintenance binder containing "Preventive Maintenance Checklist" revealed the CAH staff lacked Preventive Maintenance Inventory (PMI) safety checklists for 5 of 27 inventoried hospital beds. The binder lacked documentation the Maintenance staff checked the equipment for electrical safety.


2. Review of policy, "Safety Check Intervals", reviewed 03/05/2021, revealed in part, "Electrical equipment will be inspected and tested at the following intervals ... Patient Care Equipment - Annually ..."

3. During an interview on 06/30/2021 at approximately 4:40 PM, the Plant Operations Manager verified 22 PMI safety checklists for the 22 hospital beds were available in the maintenance binder and 5 PMI safety checklists were not accounted for of 5 additional inventoried hospital beds.

Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals, including a physician and a mid-level provider, reviewed all patient care policies annually, in accordance with facility policy, for 8 of 32 patient care departments (Speech Therapy, Nuclear Medicine, Teleradiology, Dexa/Bone Scan, Sleep Study, Wound Care, Infusion, and Urology Clinic). The CAH administrative staff identified a census of 8 patients at the beginning of the survey. Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in the CAH staff failing to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of CAH policy "CAH Program Evaluation Quality Assurance - Sheldon," dated 6/15/21, revealed in part "...The CAH Committee is responsible to complete an annual review of the CAH program and services provided. An annual evaluation will be completed each year. The CAH Committee includes: a. A member of the active Medical Staff, b. A physician assistant or nurse practitioner member of the medical staff...The annual program evaluation will include at a minimum: A summary of the annual review, revision and evaluation of policy and procedure manuals...."

2. Review of document titled "Critical Access Hospital (CAH) - Program Evaluation Committee Meeting Minutes," dated April 22, 2021 lacked documentation that the required group of professionals, including a physician and mid-level provider, reviewed all policies for Speech Therapy, Nuclear Medicine, Teleradiology, Dexa/Bone Scan, Sleep Study, Wound Care, Infusion, and Urology Clinic.

3. During an interview on 6/30/2021 at 3:36 PM, the Senior Director confirmed the annual review of all health care policies by a group of professionals which included a physician and the policy lacked review of policies for Speech Therapy, Nuclear Medicine, Teleradiology, Dexa/Bone Scan, Sleep Study, Wound Care, Infusion, and Urology Clinic.

Based on observation, document review, and interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the surgery staff changed the 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 hospital's administrative staff identified surgical services staff performed 299 endoscope procedures during the 2020 fiscal year.

Findings include:

1. Observations during a tour of the surgery department on 06/30/2021 at approximately 7:45 AM in Endo Suite #1 revealed 1 of 1 bottle ICUmedical 1000 mL bottle of sterile water for irrigation single-dose 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 indicated in part... "intended for use only as a single-dose or short procedure irrigation." ... "Unused portions should be discarded..." and a fresh container of appropriate size used for the start up of each cycle or repeat procedure." 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 contains no bacteriostat, antimicrobial agent or buffer 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, Operating Room Manager stated 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 luer-lock check valve and a 24 hour use irrigation tubing which included a one-way valve for added protection to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the one-way luer-lock check valve after each endoscope procedure, but did not change 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 06/30/2021 at approximately 11:00 AM, the OR Supervisor verified they reviewed and confirmed the manufacturer's directions for the ICUmedical 1000 mL bottles of sterile water for irrigation. The OR Supervisor acknowledged the manufacturer did not support using the bottles of sterile water for irrigation for more than one patient.

Based on policy/procedure, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physician notification for the occurrence of a medication error for 5 of 14 medication errors reviewed. (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5). The CAH administrative staff reported a census of 8 patients at the beginning of the survey. Failure to notify the physician of medication errors could potentially result in the provider not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the provider making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction.

Findings include:

1. Review of CAH policy, "Medication Monitoring, Variances - Sheldon," dated 4/13/2021, revealed in part, "...Medication errors shall be reported in a timely manner to the practitioner who ordered the medication. If the practitioner who ordered the medication is unavailable, the error shall be reported to the attending practitioner or another responsible practitioner...."

2. Review of medication errors from November 30, 2020 to June 20, 2021 revealed the following:

a. The nursing staff made a medication error (medication ordered not given) on 6/15/2021 at 10:00 AM which involved Patient #1. Patient #1's medication error information lacked documentation the nursing staff notified the practitioner responsible for Patient #1's medical care of the medication error.

b. The nursing staff made a medication error (medication ordered not given) on 6/3/2021 at 9:00 AM which involved Patient #2. Patient #2's medication error information lacked documentation the nursing staff notified the practitioner responsible for Patient #2's medical care of the medication error.

c. The nursing staff made a medication error (medication ordered not given) on 5/10/2021 at 6:18 AM which involved Patient #3. Patient #3's medication error information lacked documentation the nursing staff notified the practitioner responsible for Patient #3's medical care of the medication error.

d. The nursing staff made a medication error (wrong medication given) on 2/27/2021 at 11:00 AM which involved Patient #4. Patient #4's medication error information lacked documentation the nursing staff notified the practitioner responsible for Patient #4's medical care of the medication error.

e. The nursing staff made a medication error (wrong dose) on 1/9/2021 at 8:50 AM which involved Patient #5. Patient #5's medication error information lacked documentation the nursing staff notified the practitioner responsible for Patient #5's medical care of the medication error.

3. During an interview on 6/29/2021 at 9:45 AM, the Quality/Risk Management staff member acknowledged the medication error information for Patients #1, 2, 3, 4, and 5 lacked documentation that the nursing staff notified the patient's provider of the medication error.

Based on observation, document and policy/procedure review, and staff interview, the Critical Access Hospital (CAH) Radiology staff failed to ensure inspection of all radiology equipment on an annual basis in accordance with Iowa Code 41 for 2 of 5 radiology equipment (CT scanner and Radiographic room). The CAH administrative staff identified a census of 8 patients at the beginning of the survey. Failure to ensure annual inspection of all radiology equipment could potentially result in the x-ray equipment not functioning properly and causing harm to patients and staff.

Findings include:

1. During tour of the radiology department on 6/28/2021 from 3:15 PM to 4:00 PM with the Radiology Supervisor revealed 5 pieces of X-ray equipment (Radiology Room, Radiology/Fluoroscopy Room, Portable X-ray Unit, Dexa Unit, and the C-Arm Unit kept in surgery).

2. Review of CAH policy "Calibration and Equipment Quality Survey." dated 03/08/2021, revealed in part "...Radiology Department equipment will be inspected on at least an annual basis by a qualified radiation Physicist, Biomedical Technician or Medical Service Engineer to determine the accuracy of calibration and the relative safety of the equipment. The services of a qualified GE Technician or a Medical Service Engineer will inspect all Radiology Department equipment including the Radiographic and Fluoroscopic Rooms, portable Radiographic equipment, CT scanner and injector, MRI scanner and injector, Dexa scanner, US equipment, and CR readers...."

3. Review of Iowa Code Chapter 41 stated "...The registrant shall be responsible for maintaining and directing the operation of the X-ray system(s) under the registrant's administrative control, for ensuring that the requirements of
these rules are met in the operation of the X-ray system(s), and for having the following minimum tests
performed by a registered service facility according to the following schedule: 1. Medical/chiropractic: timer accuracy, exposure reproducibility, kVp accuracy as set forth in 41.1(6), and light field/X-ray field alignment as set forth in 41.1(6) every two years...3. Fluoroscopic: entrance exposure rate (41.1(5)"c"), and minimum SSD (41.1(5)"f") annually...."

4. Review of documentation revealed the following:
a. CT scanner unit inspected by a radiation Physicist on 6/23/2020 and lacked evidence of annual inspection.
b. Radiographic room inspection dated 04Feb2021 lacked evidence of inspection of timer accuracy, exposure reproducibility, kVp accuracy, and light field alignment as required by Iowa Code Chapter 41.

5. During an interview on 6/29/2021 at 8:30 AM, the Radiology Supervisor acknowledge the lack of annual inspection of the CT scanner and Radiographic room equipment.

Based on document review and staff interviews, the Critical Access Hospital (CAH) Administrative staff failed to ensure obstetrical nursing staff administered newborn erythromycin ophthalmic (eye) ointment and aquamephyton (vitamin K) intramuscularly (IM) injection within 1 hour of birth as ordered by the physician for 1 of 4 closed newborn medical records reviewed (Patient # 6). Failure to administer erythromycin antimicrobial eye ointment within one hour of birth, as ordered by the physician, may increase the risk of the newborn for the development of sight-threatening gonococccal eye infection and/or potential blindness. Failure to administer Vitamin K intramuscularly within one hour of birth, as ordered by the physician, could potentially lead to the development of Vitamin K deficiency bleeding (VKDB), a condition in which newborn babies bleed uncontrollably because they do not have enough vitamin K in their blood, which could result in excessive blood loss and potential death of the newborn baby. The CAH administrative staff identified 128 babies delivered January 1- December 31, 2020.

Findings include:

1. Review of "2013 Appendices to the Guidelines for Perinatal Services", Iowa Department of Public Health, revealed in part, "Appendix 8...Statute and Rules for Ophthalmia Prophylactics...Code of Iowa 139 A.38: Medical treatment of newly born...Each physician attending the birth of a child, shall cause to be instilled into the eyes of the newly born infant a prophylactic solution approved by the Iowa department of public health...Iowa Administrative Code 641-1.7(139 A): Treatment of infant eyes...Prophylaxis should be given after birth, but in no instance delayed for more than one hour after delivery..."

2. Review of CAH policy, "Skin to Skin Golden ", Dated Reviewed/Revised 1/02/2020, revealed in part, "...Erythromycin eye ointment should be given shortly after birth, but may be delayed up to 1 hour...Vitamin K administration ...traditionally ...given within 1 hour of birth but may be delayed...".

3. Review of 4 newborn medical records revealed each record contained the standing physician orders for "erythromycin ophthalmic ointment to both eyes, within 1 hour of birth" and "Vitamin K , (Aquamephyton) 1 mg/0.5 ml injection, give within 1 hour of birth"

Review of Patient #6's closed medical record revealed Patient #6 was born 2/16/2021 at 7:23 AM. Patient #6's Medication Administration Record (MAR) documented erythromycin ophthalmic ointment was administered at 10:20 AM by RN S, 1 hour and 57 minutes beyond the "within 1 hour of birth" physician ordered time and Vitamin K, (Aquamephyton) 1 mg was administered at 10:20 AM by RN S, 1 hour and 57 minutes beyond the "within 1 hour of birth" physician ordered time.

4. During an interview on 6/29/2021 at 11:30 AM, at the time of the newborn record review, OB Coordinator revealed the Obstetrical (OB) nurses often delay the administration of erythromycin ointment and the Vitamin K injection beyond 1 hour of birth, often delayed for two hours or more and verbalized surprise that only 1 record was noted to have the administration of these meds beyond the within 1 hour of birth ordered time frame. The OB Coordinator acknowledged she did not realize the physicians order was specifically written to be administered within 1 hour of birth and that she was not aware of the Code of Iowa Statute and the Iowa Administrative Code guidance specific to the treatment of infant eyes.

6. During an interview on 7/1/21 at 9:20 AM, CNO acknowledged the nursing staff often delayed the administration of newborn vitamin K and erythromycin eye ointment beyond the physician ordered administration time and as outlined in the Iowa Administrative Code.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to follow policy for each swing bed patient to sign their patient rights and responsibilities for 3 of 5 swing bed patients (Patient #1, Paitent #2, and Patient #3) reviewed. Failure to follow policy could potentially result in the swing bed patient lacking review of their patient rights with documentation. The CAH's administrative staff identified 179 Swing Bed Patients for the 2020 Fiscal year. ( July 1, 2019 - June 30, 2020).

Findings include:

1. Review of CAH policy "Patient Rights & Responsibilities, Swing bed", reviewed 04/21/2021, revealed in part, "...Always try to have the patient sign the Bill of Rights...".

2. Documentation review of Patient #7, Patient #8, and Patient #9 charts lacked documentation of the Bill of Rights having been signed by Patient #7, Patient #8, and Patient #9.

3. During an interview on 07/01/2021 at approximately 9:15 AM, the Senior Director and Risk & Quality Manager confirmed the Patient Rights and Responsibilies,Swing Bed policy was not being followed for signage by patients following review of those rights.

Based on observation, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the staff kept patient medical information secure from unauthorized access to faxes sent to an unsecured fax machines with patient information in the Therapy room (Cardiac Rehab, Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and Same Day Surgery (SDS)/Outpatient Services. Unsecured logbook with patient information was found in the Ultrasound room sitting on the counter, an unsecured printer located in Respiratory Therapy (RT) office with patient orders, and radiological films were found in unsecured location in the basement. Failure to keep patient medical information confidential could potentially result in unauthorized access of a patient's personal/medical information and potentially result in unauthorized release of personal information. The CAH administrative staff identified the following patient encounters by department for the calendar year of 2020:

Surgery Inpatient: 58
Surgery Outpatient: 499
Ultrasound: 1760
PT: 7265
OT: 2266
ST: 754
Cardiac Rehab: 489
RT: 689

Findings include:

1. Review of policy, "IT Security - Enterprise" revised 08/06/2020 revealed in part, "Confidential information should only be accessed, copied or securely stored solely for the purpose of performing job duties. Perusal of confidential information should be limited to minimum necessary as to accomplish the task."

2. Review of policy, "Confidentiality-Enterprise" revised 06/09/2021, revealed in part, "The "Need to Know" ...Employees should only access and share information they "Need to Know" to perform their work-related responsibilities."

3. Observation on 06/28/2021 at 3:15 PM, during a tour of the radiology's storage room with Radiology Supervisor, revealed approximately 300 radiological films with patient information in the basement which housed two of housekeeping's cleaning carts, allowing housekeeping access, and potentially allowing unauthorized personnel access to confidential patient information.

4. During an interview on 06/28/2021 at approximately 3:15 PM, at the time of the tour, the Radiology Supervisor verified housekeeping has a key to access the storage area.

5. Observation on 06/28/2021 at 4:30 PM, during a tour of the Ultrasound Department with Radiology Supervisor, revealed a ultrasound logbook with approximately 135 record entries with patient information sitting on the counter unsecured.

6. During an interview on 06/28/2021 at approximately 4:30 PM, at the time of the tour, the Radiology Supervisor and the Ultrasound Tech A verified housekeeping has access to this room after hours for cleaning.

7. Observation on 06/29/2021 at 10:43 AM, during a tour of the SDS/Outpatient Services Department with the Operating Room (OR) Supervisor, revealed an unsecured fax machine.

8. During an interview on 06/29/2021 at approximately 10:43 AM, during a tour of the SDS/Outpatient Services Department with OR Supervisor, acknowledged housekeeping has access after 4 PM for cleaning and faxes are received after hours and left in the fax tray, this was verified by staff Registered Nurse (RN) C and RN D. An unknown number of unattended faxes are received after hours and on weekends.

9. During an interview on 06/29/2021 at 12:55 PM, with the Respiratory Therapist (RT) E, revealed a printer which receives patient orders in the RT office is left unattended and unsecured after hours. RT E acknowledged the door is unlocked after hours to allow housekeeping access to confidential patient information. An unknown number of unattended faxes are received after hours and on weekends.

11. Observation on 06/30/2021 at 8:56 AM with Cardiac Rehab Coordinator, revealed an unsecured fax machine.

12. During an interview on 06/30/2021 at 11:05 AM, with Therapy Manager and Therapy Aide B verified housekeeping has access to the therapy room after house for cleaning. An unknown number of unattended faxes are received after hours and on weekend.

13. During an interview on 06/30/2021 at approximately 3:45 PM with Risk and Quality Manager, acknowledged that private and confidential patient information should be secured and accessible to only those that "Need to Know" per the hospital's policy.

Based on review of records, policy, and staff interviews the Critical Access Hospital's (CAH) Administrative staff failed to ensure Patient #10, Patient #11, and Patient #12 that received anesthesia services or surgical services had a properly executed informed consent for 3 of 9 consents reviewed in surgery and obstetrics. Failure to inform all patients who received anesthesia of the options and consequences needed in order to make an informed consent to a procedure or treatment could potentially result in the patient having received an unwanted procedure. The CAH administrative staff identified 472 surgical procedures and 33 C-sections for fiscal year 2020 (July 1, 2019 - June 30, 2020).

Findings include:

1. Review of records revealed:

a. 2 of 9 anesthesia consent forms were not completed with type of anesthesia to be administered and were signed by the patient ( Patient #10, Patient #11)

Patient # 10's anesthesia consent signed by Patient #10 and witness on 02/16/2021 at 6:15 AM, revealed the type of anesthesia to be administered was not documented for Patient #10

Patient #11 anesthesia consent signed by Patient #11 and the witness on 03/03/2021 at 9:00 AM, revealed the type of anesthesia to be administered was not documented for Patient #11.

b. 1 of 9 Consent for Surgery or Procedure form signed by Patient #12 and witness on 03/04/2021 at 12:50 PM lacked documentation of the surgical procedure to be performed on Patient #12.

2. Review of policy "Informed Consent" revised on 08/06/2018, revealed in part..." Informed consent means the patient or patient representative is given ... the information needed in order to consent to a procedure or treatment...All surgeries... All other invasive and non-invasive procedures carrying a risk to the patient. (Particularly anything that would involve penetration of the skin)."

3. During an interview on 06/30/2021 at 11:10 AM, the OR Supervisior verified the surgical staff and anesthesia providers must assure the anesthesia and surgical consents are completed prior to the patient signing and staff witnessing the signature. The OR Supervisor confirmed Patient #4, Patient #5, and Patient #6's s consent forms lacked required elements of documentation for an informed consent.

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) administrative staff failed to evaluate all patient care services, including contracted services, offered at the CAH for 8 of 32 services (Speech Therapy, Occupational Therapy, Physical Therapy, Cardiovascular/Echo, Teleradiology, Dexa Bone Scan, Wound Care, Urology Clinic). The administrative staff identified a current census of 9 inpatients at the beginning of the survey. Failure to evaluate all patient care services could potentially result in the CAH staff's failure to identify, monitor, address, and improve patient care problems in each patient care area through the efforts of all involved patient care services.

Findings include:

1. Review of the CAH "Quality Assurance & Performance Improvement (QAPI) Plan 2021," approved by QAPI Committee 12/9/2020, revealed in part, "...The QAPI plan provides a description of the strategic approach to prevention, identification, reporting, investigation, analysis, and development of performance improvement activities to reflect the complexity of care and services provided...."

2. Review of the CAH's documents revealed the lack of documentation the CAH evaluated all patient care services, including contracted services, offered at the CAH (Speech Therapy, Occupational Therapy, Physical Therapy, Cardiovascular/Echo, Teleradiology, Dexa Bone Scan, Wound Care, Urology Clinic).

3. During an interview on 6/30/2021 at 2:20 PM, the Quality/Risk Lead and Director of Nursing verified the lack of documented evidence of evaluation of services for Speech Therapy, Occupational Therapy, Physical Therapy, Cardiovascular/Echo, Teleradiology, Dexa Bone Scan, Wound Care, Urology Clinic.