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Based on document review, and staff interviews, the Board of Trustees failed to ensure the medical staff received the required outside entity peer review performed by the Network Hospital prior to recommending 5 of 8 active and 5 of 5 associate physicians, selected for review, for reappointment. (Physicians A, C, D, E, G, H, I, J, K, L) The facility had 10 active, 25 associate, and 38 consulting physicians.

Physician A, active staff, provided care to 249 in-patients and 1264 outpatients during the previous 2 year credentialing period of 6/30/08 to 7/1/10.

Physician C, active staff, provided care to 273 in-patients and 1219 outpatients during the previous 2 year credentialing period of 4/1/09 to 3/31/11.

Physician D, active staff, provided care to 352 in-patients and 1061 outpatients during the previous 2 year credentialing period of 10/1/08 to 9/30/10.

Physician E, active staff, provided care to 306 in-patients and 1993 outpatients during the previous 2 year credentialing period of 10/1/09 to 9/31/11.

Physician G, active staff, provided care to 814 in-patients and 213 outpatients during the previous 2 year credentialing period of 7/1/09 to 6/30/11.

Physician H, associate staff, provided care to 192 outpatients during the previous 2 year credentialing period of 1/1/08 to 12/31/10.

Physician I, associate staff, provided care to 53 outpatients during the previous 2 year credentialing period of 7/1/08 to 6/30/10.

Physician J, associate staff, provided care to 8 outpatients during the previous 2 year credentialing period of 10/1/09 to 9/30/11.

Physician K, associate staff, provided care to 146 outpatients during the previous 2 year credentialing period of 7/1/09 to 6/30/11.

Physician L, associate staff, provided care to 21 outpatients during the previous 2 year credentialing period of 4/1/09 to 3/31/11.

Failure to provide the Medical Staff and Board of Trustees with the Network Hospital peer review results affects the facility's ability to assure physicians provide quality care to their patients.

Findings include:

1. Review of the "Network Agreement for Critical Access Hospital," dated April 2010, revealed, in part, ". . . Services Provided by [Network Hospital]. [Network Hospital] agrees to facilitate and assist CAH [Critical Access Hospital] in the development and administration of 'an effective quality assurance program' . . . which shall include, without limitation, . . . evaluation of the quality and appropriateness of the diagnosis and treatment furnished by . . . doctors of medicine or osteopathy. . . ."

2. The Medical Staff Bylaws and General Rules and Regulations, adopted by the Medical Staff on 6/28/2011 and adopted by the Board of Trustees on 6/30 2011, revealed, in part, ". . . The duties of the Executive Committee [Medical Staff] shall be to: . . . review the credentials of applicants and to make recommendations for Staff membership . . . review periodically all information available regarding the performance and clinical competence of Staff members . . . and, as a result of such reviews, make recommendations for reappointments and renewal or changes in clinical or practice privileges. . . ."

3. Review of medical staff credentialing documentation on 4/3/12, revealed the following medical staff members lacked evidence of a Network Hospital peer review.

a. The Medical Staff recommended Physician A, Family Practice, for reappointment to the Medical Staff on 5/25/10. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician A on 5/26/10.

b. The Medical Staff recommended Physician C, Family Practice, for reappointment to the Medical Staff on 3/22/11. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician C on 3/24/11.

c. The Medical Staff recommended Physician D, Family Practice, for reappointment to the Medical Staff on 8/24/10. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician D on 8/25/10.

d. The Medical Staff recommended Physician E, Family Practice, for reappointment to the Medical Staff on 9/19/11. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician E on 9/20/11.

e. The Medical Staff recommended Physician G, Family Practice, for reappointment to the Medical Staff on 6/28/11. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician G on 6/30/11.

f. The Medical Staff recommended Physician H, Ophthalmology, for reappointment to the Medical Staff on 11/23/10. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician H on 11/30/10.

g. The Medical Staff recommended Physician I, Orthopedic Surgery, for reappointment to the Medical Staff on 5/25/10. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician I on 5/26/10.

h. The Medical Staff recommended Physician J, Podiatry, for reappointment to the Medical Staff on 9/19/11. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician J on 9/20/11.

i. The Medical Staff recommended Physician K, Ear Nose and Throat, for reappointment to the Medical Staff on 6/28/11. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician K on 6/30/11.

j. The Medical Staff recommended Physician L, Urology, for reappointment to the Medical Staff on 3/22/11. The Board of Trustees approved the Medical Staff's recommendation and reappointed Physician L on 3/24/11.

4. The facility lacked a policy/procedure that addressed how the facility's Medical Staff and Board of Trustees received and utilized the Network Hospital peer review results.

5. During an interview on 4/3/12 at 10:30 AM, Staff B, Assistant Administrator, stated when it is time for a physician to be recredentialed, the Medical Staff uses the Network Hospital peer review results to evaluate the care and treatment of the patients by the physician.

Staff B acknowledged the facility lacked a system or policy that directed how the Medical Staff and Board of Trustees received, reviewed and used the Network Hospital peer review results.

6. During an interview on 4/3/12 at 1:25 PM, Staff D, Health Information Manager, stated Staff B and Staff D received the Network Hospital peer review results. Staff D further stated the Network Hospital peer review results are not shared with the Medical Staff during the physician recredentialing process.

7. During an interview on 4/3/12 at 3:00 PM, Staff B, Assistant Administrator, stated, during the recredentialing process, the Network Hospital peer review results were not included in the Medical Staff credentialing information sent to the Medical Staff and the Board of Trustees, for review, at the time of recredentialing for Physicians A, C, D, E, G, H, I, J, K, L.

8. During an interview on 4/4/12 at 10:35 AM, Staff F, Network Representative, stated as part of the Network Hospital responsibilities during medical staff reappointments, Staff F reviewed the medical staff credentialing information and the outside entity peer review results performed by the Network Hospital are not included with the medical staff credentialing information sent for review by the Medical Staff or the Board of Trustees.

I. Based on document review and staff interview, the facility failed to create an active program to identify surgical site infections in 1 (of 1) infection control program. The Surgical Services Manager identified an average of approximately 100 surgical patients per month.

Failure to have a system in place that identifies surgical site infections could potentially result in the infection control staff failing to identify all surgical site infections. This failure would affect the infection control staffs ability to take remedial action to prevent surgical site infections.

Findings include:

1. Review of the "Infection Control Plan", last approved 6/30/11, revealed in part, "Establishes a system of surveillance to monitor ... infection rates through collection and analysis of data, identification of patterns or trends, and implementation of actions to prevent infections."

2. During an interview on 4/4/12 at 8:20 AM, Infection Preventionist K stated they relied on the staff at the surgeons' offices to send them data if the patient developed a surgical site infection. The Infection Control staff did not request information from the surgeons' offices to determine if patients developed a surgical site infection. Infection Preventionist K stated their data collection practice would not detect if a patient underwent surgery from a surgeon such as the eye surgeon, or the foot surgeon. Infection Preventionist K acknowledged the CAH lacked an active process to detect all surgical site infections that occurred at the CAH.


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II. Based on observation, staff interview, and document review, the facility failed to ensure surgical staff tested 1 (of 1) disinfecting solutions for efficacy before each use, and failed to date the Comply-Cold Sterilog test strips, as required by the manufacturer. The surgical staff identified an average of 25 to 30 endoscopic procedures per month, and each would require the use of the disinfecting solutions for cleaning after the procedure.

Failure to test the disinfecting solutions prior to each use and date test strips when opened could result in staff using disinfecting solution that did not contain a sufficient strength of the active ingredient to kill all microorganisms, potentially resulting in the spread of infectious microorganisms between patients.

Findings include:

1. Observation, during a tour of the Operating Room Endoscopy Room, on 4/3/12 at 10:00 AM, revealed an automated endoscope reprocessor. Review of the endoscope reprocessor log revealed Operating Room staff tested the disinfectant, Rapicide, once a day, when the staff used the automated endoscope reprocessor. Observations also revealed an undated bottle of Comply-Cold Sterilog 1.5% test strips.

2. During an interview on 4/3 at 11:05 AM, at the time of the tour, Staff A, (Operating Room Manager) stated the Operating Room Staff test the Rapicide once a day, before reprocessing any endoscopes. Staff A said operating room staff should date the Comply-Cold test strips when they are opened. Staff A stated operating room staff did not know the Rapicide needed testing prior to each reprocessing cycle.

3. Review of the policy "Disinfecting items unable to sterilize," effective 2/09, revealed in part, "An indicator dip check test must be done prior to the immersion of any item as per manufacturer's instruction..."

4. Review of the manufacturer's directions for Rapicide, revealed in part, "Monitor the glutaraldehyde concentration prior to each reprocessing cycle using Medivators Rapicide Glutaraldehyde Indicator Test Strips."

Based on observation, policy/procedure review, and staff interviews, the facility failed to secure all medical records against unauthorized access in 3 of 7 clinical areas (Surgery department, Therapy Department, and Imaging Department). The CAH nurse manager reported an average daily census of 13 inpatients.

Failure to secure medical records against unauthorized access could result in identity theft, theft of financial/insurance information, or unauthorized disclosure of personal medical information.

Findings include:

1. Observation, during initial tour of the Physical Therapy department, on 4/2/12 at 3:45 PM, revealed 3 of 3 active Cardiac Rehab medical records located in an unlocked drawer at the Cardiac Rehab station. Each medical record contained the patient's name, date of birth, social security number, and past medical history.

During an interview on 4/2/12 at 3:45 PM, Staff G, Physical Therapy Manager, stated housekeeping staff clean the therapy area after hours unsupervised and would have access to the medical records. Staff G also acknowledged, housekeeping staff did not need to know personal/medical information contained in the medical records to perform their job duties.

2. Observation, during initial tour of the Imaging Department, on 4/3/12 at 8:00 AM, revealed approximately 7500 x-ray films, compact discs (CD's) containing patient radiology exams, 7 copy paper boxes filled with physician orders for radiology exams, and 7 scheduling log books located on 4 floor to ceiling, rolling file shelves. The medical records contained radiology exams, personal patient information, and medical information.

During an interview on 4/3/12 at 8:45 AM, Staff C, Imaging Manager, stated housekeeping staff clean the area after hours unsupervised and would have access to the medical records. Staff C stated, there is "no other option we [imaging staff] have come up with to secure the patient information." Staff C also agreed that housekeeping staff did not need to know personal/medical information contained in the medical records to perform their job duties.

3. Observation, during initial tour of the Pre/Post Operative area, on 4/3/12 at 10:00 AM, revealed the following:

A cardboard box labeled "Shred Box", located on the floor near the nurses' station, contained 3 patient forms that listed patient's name, date of birth, date of service, and surgical procedure performed.

An Operative Room (OR) log book, dated from 3/09 to present, located at the nurses' station, listed approximately 3,000 patient names, dates of birth, dates of service, and what surgical procedure was performed.

An Implant log book, dated 1/4/12 to 3/26/12, located at the nurses' station, listed 50 patient names, dates of birth, dates of service, surgical procedure performed, and medical device implanted.

During an interview on 4/3/12 at 11:15 AM, Staff A, Surgery Manager, stated housekeeping staff clean after hours unsupervised and would have access to the surgical patient information. Staff A also agreed that housekeeping staff did not need to know protected medical/surgical information to perform their job duties.

4. Review of policy, "Confidentiality of Information", approved 6/11, revealed in part: "Policy:...[The CAH] will maintain the confidentiality of record information and provide safeguards against loss, destruction or unauthorized use". ..."Storage and Security: [The CAH] will ensure the physical protection of records by persons or organizations receiving, processing, storing or handling such records to prevent theft, destruction, loss or other forms of unapproved access".

5. During an interview on 4/4/12 at 11:30 AM, Staff B, Director of Nursing, acknowledged that in some areas of the CAH, housekeeping does have access to confidential medical records and that confidential patient information may be accessed. Staff B also stated that housekeeping staff do not need to know personnel patient information to perform their job duties.

Based on document review and staff interviews, the facility failed to ensure 2 of 8 active and 4 of 4 consulting physicians, selected for review, received outside entity peer review performed by the Network Hospital in accordance with the facility's Network Agreement. (Physicians B, F, M, N, O, P) The facility had 10 active, 25 associate, and 38 consulting physicians.

Failure to ensure all medical staff members received outside entity peer review affects the facility's ability to assure physicians provide quality care to their patients.

Findings include:

1. Review of the "Network Agreement for Critical Access Hospital", dated April 2010, revealed, in part, ". . . Services Provided by [Network Hospital]. [Network Hospital] agrees to facilitate and assist CAH [Critical Access Hospital] in the development and administration of 'an effective quality assurance program'. . . which shall include, without limitation, . . . evaluation of the quality and appropriateness of the diagnosis and treatment furnished by . . . doctors of medicine or osteopathy. . . ."

2. Review of facility documentation on 4/3/12 revealed the facility failed to ensure the Network Hospital completed peer review for Physicians B, F, M, N, O, P.

3. During an interview on 4/3/12 at 10:30 AM, Staff B, Assistant Administrator, acknowledged the facility lacked documentation of Network Hospital peer review for Physicians B, F, M, N, O, P.