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Based on interview and document review, the Critical Access Hospital (CAH) failed to complete vulnerable adult (VA) assessment screenings in accordance with state law for 13 of 20 inpatients (P1, P4, P5, P6, P7, P9, P10, P11, P14, P15, P16, P19, P20) and for 1 of 2 swing bed (SB2) reviewed. This had the potential to affect all patients served by the CAH .



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Vulnerable adult assessment screenings were not completed on all inpatients admitted to the CAH.

Review of the following CAH's inpatient medical records which included the Admission Navigators Assessment and flow sheets revealed the following:

P1 was admitted to the CAH on 5/30/14, P1's medical record lacked documentation of the completion of a vulnerable adult assessment and screening.

P4 was admitted to the CAH on 4/16/14. P4's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P5 was admitted to the CAH on 4/5/14. P5's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P6 was admitted to the CAH on 11/28/13. P6's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P7 was admitted to the CAH on 4/15/14. P7's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P9 was admitted to the CAH on 1/5/14. P9's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P10 was admitted to the CAH on 1/6/14. P10's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P11 was admitted to the CAH on 1/23/14. P11's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P14 was admitted to the CAH on 2/8/14. P14's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P15 was admitted to the CAH on 2/1/14. P15's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P16 was admitted to the CAH on 1/30/14. P16's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P19 was admitted to the CAH on 8/2/13. P19's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

P20 was admitted to the CAH on 7/10/13. P20's medical record lacked documentation of the completion of a vulnerable adult assessment screening.

SB2 was admitted to the CAH on 6/3/14, SB2's medical record lacked documentation of the completion of a vulnerable adult assessment and screening.

On 6/4/14, at 3:55 p.m. registered nurse (RN)-C confirmed the VA screening had not been completed for P4, P5 and P6.

On 6/5/14, at 10:53 a.m. the HIM director confirmed the VA screening had not been completed for P1, P7, P9, P10, P11, P14, P15, P16, P19, P20.






30951

Based on medical staff bylaws, interview and credentialing file review, the Critical Access Hospital (CAH) failed to monitor compliance with policies of the governing body to ensure 4 of 4 radiologists (R1, R2, R3 and R4) contracted by the CAH had licensure verification and proof of insurance according to the medical staff bylaws.

Findings include:


R1's hire date was 11/11/09. R1's credentialing file lacked licensure verification and proof of insurance according to the medical staff bylaws.

R2's hire date was 11/11/09. R2's credentialing file lacked licensure verification and proof of insurance according to the medical staff bylaws.

R3's hire date was 11/11/09. R3's credentialing file lacked licensure verification and proof of insurance according to the medical staff bylaws.

R4's hire date was 11/11/09. R4's credentialing file lacked licensure verification and proof of insurance according to the medical staff bylaws.

The medical staff bylaws dated 3/11/13, indicated: "...The contracted/Consulting Staff shall consist of physicians and/or other staff which Kittson Memorial has a contract with to perform certain specific duties, example radiologists to perform reading and x-rays. Privileges granted will be known by virtue of contract with Kittson Memorial. Any contracts involving Medical Staff shall be written with the assurance that physicians used for the contracted business, have current license and insurance. Contracted/Consulting Staff do not have to go through privileging process. All submitted documents will be reviewed with the President of Medical Staff and CEO."

The health information management (HIM) director was interviewed on 6/4/14, at 10:00 a.m. and verified the CAH had not verified current licensure and current insurance for all of the contracted the radiologists.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure the security of 1 of 2 crash carts in the CAH.

Findings include:

During a tour of the emergency department (ED) on 6/3/14, at 9:00 a.m. p.m. a crash cart containing a variety of emergency medications was observed stored in the middle of the ED. The cart was not locked but secured with a numbered pull-away tab. There was no documentation to identify the cart had been monitored for the security of the medications. Interview with the director of nursing (DON) during this time, confirmed staff were not always present in the ED, the crash carts were not locked and hospital staff, visitors and patients could access the medications in the emergency carts by just removing the pull away tabs.

The pharmacist was interviewed on 6/4/14, at 1:30 p.m. and confirmed the emergency room crash cart was not locked and not in an area that was under constant observation in the ED.

The pharmacy director provided an inventory list of the medications stored in the crash carts [not an inclusive list]:
. Amiodarone (a drug used for many serious arrhythmia's of the heart )
. Aspirin 81 milligrams (mg) (a drug used to decrease platelet aggregation)
. Atropine (treats slow heart rate)
? Lidocaine (treats emergency irregular heart rate)
? Epinephrine (treats cardiac arrest)
? Naloxone (reversal agent for narcotics and treats shock)
? Amiodarone (treats life threatening heart rate)
? Adenosine (treats irregular heart rate)
? Nitroglycerine (treats chest pain)
? Metoprolol (treats high blood pressure)
? Diltiazem (treats high blood pressure & chest pain)
. Valium (used to treat anxiety and seizures)

A total of 34 different medications were contained in the crash cart.

Review of the Pharmacy Policy and Procedure Manual Kittson Memorial Hospital Medication Storage Areas dated 9/2012, identified the following: "Crash Carts: Medications stored in crash carts and anesthesia supply carts will be secured by use of a tear-away seal that gives instant visualization of the integrity of the medication supply. Access to the tear-away seals is controlled by the pharmacy department."

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure hypodermic needles, intravenous supplies, suture kits and procedure equipment were stored in a safe manner in the emergency room and the procedure room in the surgical services area. This had the potential to affect all patients who utilized the emergency room and surgical services. In addition, there was a large hole in the wall in the laundry department which needed repair. A ground fault interrupter plug was not installed in the kitchen where an electric cord was draped over the hand washing sink. Lastly, the ice machine had a white substance buildup and a black substance along the inside of the ice storage compartment.

Findings include:

On 6/3/14, during initial tour of the emergency department (ED) from 9:00 a.m. until 9:30 a.m. unlocked emergency supplies were observed in both bays of the ED. The supplies included many different sizes and styles of hypodermic needles, suture kits, scissors, scalpels, casting supplies, chest tubes, pericardiocentesis tray and extraction equipment. Registered nurse (RN)-C confirmed the supplies were accessible to patients, staff and the public.

Review of the undated Kittson Memorial Hospital Emergency Services Plan policy (undated) revealed it had not addressed the security of these items.

The director of nursing was interviewed on 6/3/14, at 9:30 a.m. and confirmed that these items were accessible to patients, staff and the public.


32601


Laundry:

On 6/4/14, at 10:45 a.m. during the physical environment tour of the laundry area, a hole in the wall was observed. The maintenance director (MD) confirmed the hole measured two feet by three feet and it started at the base of the floor. The open area consisted of broken, crumbling, cement with rusted, metal mesh, wire exposed. The hole was located in the folding area of the laundry department and clean linen was located on a table just four feet away. At 10:50 a.m. the MD and the laundry supervisor confirmed the hole should have been covered to prevent dust and dirt particles from getting on the clean linen.


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Kitchen appliance:

On 6/4/14, at 9:30 a.m. during a kitchen tour with the kitchen manager (KM), an Aeushot (portable food warming appliance) was observed plugged into a standard electrical outlet with the electric cord draped over the kitchen's hand washing sink. The electric appliance was observed sitting on a rolling cart with metal wheels and support poles. The electrical outlet was not a ground fault interrupter (GFI, circuit breaker for safety) and so posed a safety risk in which the electric appliance should not have the plug draped over a water source. The dietary manager stated she was not thinking of that as a hazard, but verified it was a fire hazard and would call maintenance. The electrician was on site and changed the outlet to a GFI on 6/4/14.


Scotsman Prodigy Ice Machine:

On 6/4/14, at 8:00 a.m. during an initial kitchen tour the inside of ice storage bin was observed with white, scale type buildup, greater on the right side than on the left. The storage bin was also observed to have a build up of black, removable material across the top bar, inside the bin.

-at 9:30 a.m. the KM verified the findings and stated a refrigeration man came every six months to take apart the upper parts of the ice maker to clean and sanitize it and the kitchen staff was responsible for the deep cleaning of the ice storage bin. The KM verified the last deep cleaning for the ice machine was done 4/2/14, in which the ice storage bin was emptied, the ice was discarded and the facility used Quat 146 (a sanitizer for hard nonporous surfaces). The KM verified the facility did not follow the manufactures directions to use the Scotsman Clear 1 ice machine scale remover and wash all interior surfaces of the ice storage bin prior to sanitizing.

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Based on observation, interview and document review the Critical Access Hospital (CAH) failed to ensure the High Efficiency Particulate Air (HEPA) care unit (type of air filtration unit which protects against airborne disease transmission) had been properly maintained for 1 of 1 (room 118) negative pressure room.

Findings include:

On 6/4/14, during the physical environment tour from 10:20 a.m. until 11:15 a.m. a HEPA care unit was observed on the nursing unit in patient room 118. The maintenance director (MD) confirmed maintenance staff had not been responsible for maintaining and/or checking the HEPA care unit to ensure it could provide room 118 with negative pressure.

On 6/4/14, at 10:40 a.m. the director of nursing (DON) was unaware of when the last time the HEPA care unit had been checked nor the schedule for this testing to routinely be completed. The DON verified the HEPA care unit had been in room 118 for over five years.

On 6/4/14, at 2:10 p.m. the DON stated she had no documentation of when the HEPA care unit was tested last to ensure room 118 could be converted into a negative pressure room, if necessary.

On 6/5/14, at 9:55 a.m. the DON verified the CAH did not have a routine testing schedule for the HEPA care unit.

The CAH's Emergency Operations Manual - Isolation - Airborne Precautions [undated] policy directed staff on how to convert the patient room from a positive to a negative pressure room. The policy emphasized best practice was to review the user manual for proper use and maintenance of the negative pressure unit.

The manufacture guidelines for the HEPA care unit was requested and not provided.

Based on document review and interview, the Critical Access Hospital (CAH) failed to ensure the Governing Body monitored the implementation of policies related to credentialing for 2 of 13 (MD-D and MD-G) medical staff credentialing files reviewed.

Findings include.

MD-D a contracted board certified pathologist did not have a credentialing file which included a completed State background study, current State licence to practice, application for delineation of privileges, or approval to practice at the facility from the Medical Staff and Governing Body on file in accordance with the Medical Staff By-laws on file. This had the potential to affect all current and future patients of the CAH.

MD-G a member of the Active Medical Staff did not have a current credentialing file which included a current application for delineation of privileges, or a current approval to practice at the facility from the Medical Staff and Governing Body on file in accordance with the Medical Staff By-laws on file.

The Medical Staff By-Laws dated 3/11/14, indicated all medical staff required proof of licensure to practice, identity of qualifications and references, term of appointment, and delineation of privileges. The By-Laws also indicated the authority to grant medical staff privileges was vested in the board through the administrator. The By-Laws also indicated the governing body functions included appointing and overseeing medical staff membership, clinical privileges, and credentialing and granting privileges to medical staff members.

The health information management (HIM) director was interviewed on 6/4/14, at 10:00 a.m. and verified the CAH had not completed the full credentialing process on MD-D and MD-G.

Based on interview and document review, the Critical Access Hospital (CAH) failed to develop and/or revise pharmacy policies with the advice of a group of professional personnel that included at least one or more doctors of medicine or osteopathy and one or more mid-level practitioner such as a physician assistant, nurse practitioner or clinical nurse specialist as required. This had the potential to affect all current and future patients of the CAH.

Findings include:

Review of the CAH's pharmacy policies related to: receipt and distribution of drugs, handling and dispensation of drugs, drug storage, system for labeling and management of outdated drugs, and administration of drugs and biological's revealed the policies had not been developed or reviewed by a group of professional personnel that included at least one or more doctors of medicine or osteopathy and one or more mid-level practitioner such as a physician assistant, nurse practitioner or clinical nurse specialist.

The registered pharmacist was interviewed on 6/4/14, at 1:30 p.m. and confirmed that the pharmacy policy and procedures were not developed and signed authenticating that they had been developed with the advice of a group of professional personnel that included at least one or more doctors of medicine or osteopathy and one or more mid-level practitioner such as a physician assistant, nurse practitioner or clinical nurse specialist.

Based on interview and document review the Critical Access Hospital (CAH) failed to record all drug errors and failed to identify and effectively analyze the system failure of nurses defeating (overridden, or not used at all) the bar code scanning safety feature of the EMAR (electronic medical record) for 7 of 8 medication errors.

Findings include:

A review of medication errors identified the forms lacked completion, missing data included medication route, patient identifiers and recommendations to prevent future errors.

Medication Inadvertent Incident Report form (MIIR)-1 was dated 12/29/13, and indicated Morphine (a narcotic pain killer) 6 milligrams (mg) (no route was documented) was ordered and Demerol 60 mg IM (intramuscular) was given. The cause of the incident was incorrect medication, given by nursing. The follow-up by department manager indicated: "If time permits in ER, going to use BCA (bar coding). A unsigned hand written note at the bottom of the page indicated the doctor "had been notified and he said not to worry about it....he ordered a DuoNeb. I still wanted you to know about it, even I learned a lesson." The MIIR lacked identifying patient information and lacked recommendations to prevent future errors and did not document the date and time of the follow-up. The accompanying Medication Error Analysis Tool (MEAT) completed by the pharmacist indicated: "Demerol 50 mg was administered when the order was for Morphine 6 mg." The error occurred without harm to the patient (level 1 error). wrong drug was given by RN (registered nurse). The problem resolution/outcome documented "Patient had no adverse effects or harm with Demerol. Morphine 6 mg was then given as ordered. Discussed with RN use of barcoding in ER whenever possible as this would have alerted RN the medication was not ordered." The MIIR and MEAT lacked a complete description of the error.

MIIR-2 was dated 1/5/14, and indicated: an incorrect medication was given by an RN to an emergency room patient. DuoNeb (medication in an airborne form (nebulized) that is taken in through a face mask or mouthpiece and inhaled into the lungs which contains both Albuterol Sulfate, and Ipratropium Bromide and is used for the treatment of bronchospasm) instead of an Albuterol neb (used for the treatment of bronchospasm). The follow-up by department manager indicated: reviewed with RN. The recommendations to prevent further errors stated "Follow the five rights (right patient, right drug, right dose, right time, right route). If time allows use BCA to catch wrong medication." The form lacked patient identifying number (MRN) and did not document the date and time of the follow-up. The MEAT indicated: Patient was given a DuoNeb (Ipratropium/Albuterol neb instead of Albuterol Neb. The error occurred without harm to the patient (level 1 error), the wrong drug was given by RN (registered nurse), was not barcode scanned, and RN selected wrong medication and medication wasn't visually verified with Cardinal (video recording cameras that provide communication with pharmacy personal off site) due to level of emergency. The problem resolution/outcome documented indicated: "Patient then received Albuterol neb after DuoNeb was complete. Encourage nursing to use barcode med (medication) administration in the emergency room. Also encourage video verification of meds when possible." The form lacked patient identifying MRN. The form lacked acknowledgement that a duplicate Albuterol neb was a second medication error, since Albuterol is an ingredient in a DuoNeb.

MIIR-3 was dated 1/10/14, and indicated: noon doses of Xanax (an antianxiety drug) and Freshkote eye drops were missed (medication error of omission). The follow-up by department manager indicated: Discussed incident, 5 rights discussed. The form lacked patient identifying MRN, and did not document the date and time of the follow-up. The MEAT indicated: "Noon doses of Xanax and Freshkote eye drops were missed. The error occurred without harm to the patient (level 1 error), the wrong drug was given by RN (registered nurse). The problem/resolution/outcome indicated: "Reminder for nursing to check "overdue" tab on (E)MAR." The form lacked patient identifying MRN.

MIIR-4 was dated 1/20/14, and indicated the patient received Tylenol 650 mg at 9:06 a.m. instead of Tylenol Arthritis 650 mg (extended release tablets), the wrong drug given by RN. The follow-up by department manager indicated: reminder to always double verify order when multiple orders for medication come up on barcode administration. Recommendations to prevent future errors: Pay special attention to scheduled and PRN (as needed) orders involving the same medication name but different strengths. The form lacked patient identifying MRN. The MEAT indicated: Patient has Tylenol arthritis 650 mg every a.m. and Tylenol 650 mg PRN (as needed) order. Regular Tylenol 650 mg was given in the morning instead of the extended release Tylenol arthritis. The error occurred without harm to the patient (level 1 error), the RN selected the wrong order after scanning barcode. The problem/resolution/outcome indicated: "Always pay attention when multiple orders come up after scanning to ensure correct dose/directions/time was selected." The form lacked patient identifying MRN.

MIIR-5 was dated 1/21/14, and indicated: Vicodan 5/325 mg (Opioid analgesic, class 3) was given as Percocet (no dosage documented) (Opioid analgesic class 2). The follow-up by department manager indicated: use 5 rights. Also be sure to have computer in room as BCA would assist with warning Recommendations to prevent future errors: lacked documentation. The form lacked patient identifying MRN. The MEAT dated 1/21/14, Hydrocodone/apap 5/325 mg was given instead of ordered oxycodone 5/325 mg. Medication barcode was scanned but nurse didn't verify on computer screen before administering. The error occurred without harm to the patient (level 1 error), the RN gave an unordered drug. Nurse did not have barcoding computer in room to verify screen after scanning. The problem/resolution/outcome indicated: "Nursing will have computer in room or doorway and will visually look at the computer screen after scanning barcode to ensure drug/dose is correct." The form lacked patient identifying MRN.

An Occurrence report form dated 3/30/14, indicated that a nurse put Swing Bed Patient(SB)-2's eye drops in her pocket (current SBP on a prior admission), so the night nurse on 3/29/14, was not able to provide the prescribed eye drops (omitted medication). This omitted medication "medication error" was documented only on an occurrence report form and was not documented or counted as a medication error.

MIIR-6 was dated 4/7/14, and indicated the patient received two doses of synthroid (thyroid -hormone replacement required for normal bodily function) one at 7:30 a.m. and one at 8:15 p.m. when pharmacy dished up the morning medications. The follow-up by department manager indicated: discussed 5 rights and barcode administration warnings. Recommendations to prevent future errors: "as above". The form lacked patient identifying MRN. The MEAT was not provided or was not completed.

MIIR-7 was dated 4/30/14, and indicated an extra bag of intravenous (IV) fluid with Potassium was hung after the medication had been discontinued, incorrect dosage (extra 30 minutes), nursing and pharmacy incident. The follow-up by department manager indicated: investigating incident as did not show clearly on EMAR for nurse. Did give a warning (EMAR-barcoding) so nurse did call doctor for clarification and it was for one liter only. Pharmacist also reviewing incident. Recommendations to prevent future errors: Will discuss at medical staff meetings and nursing staff meeting. Call MD for clarification on discontinued order barcoding warning before giving medication. Physician should have entered order as "one time order" or been clearer in his directions that only 1 liter was to be given. The form lacked patient identifying MRN. The MEAT dated 4/30/14, indicated 0.9% NS with 40 milliequivalents of potassium in 1000 liters (potassium is an essential element for normal heart and muscle function), it was diluted in normal saline and given IV to correct potassium depletion. The error occurred without harm to the patient (level 1 error), the order was ambiguous and the RN did not clarify until after hanging an additional bag of IV with potassium. The problem/resolution/outcome indicated: "When a warning during barcode medication administration comes up that order has been discontinued, check with MD first. Don't assume it's an error and call after warning is overridden and medication hung. MD could have/should have entered order as one time or been clearer in his directions that only one bag was to be given." The form lacked patient identifying MRN.

On 6/4/14, at 1:00 p.m. the pharmacist stated that she had recognized the bar code scanning system was being defeated, but the CAH had not looked at it as a system issue to be addressed for quality improvement.

On 6/5/14, at 8:00 a.m. the director of nursing (DON) verified the omitted medication on 3/30/14, for SB-2 should have been documented and counted as a medication error. The DON stated she had followed up with the nurses at an individual level after the medication errors, but had not looked at the seven incidents where the bar code scanner safety system was defeated as a system issue. The DON stated she had not compared the previous manual medication process error rate to the barcode system medication error rate to identify if errors were increasing or not. Four of the seven errors were committed by two nurses, showing individual follow-up was not adequate to solve the system problem. The DON verified she had not shared the (de-identified) medication errors with all nursing staff to improve learning and improve compliance with barcoding as a safety function of the EMAR.


The Medication Errors policy dated 11/05, indicated: all medication error reports will be reviewed by the medical staff. All adverse medication events requiring notification through external state, federal, USP or FDA channels, will be reported according to the requirements of the specific organization. Types of medication errors include: wrong drug, dose, route or time, omission, unordered dose.

When a medication error occurred the following should occur in this order:

1. Notify the physician and evaluate the patient.
2. Perform any necessary clinical interventions, within the patient are provider's scope of practice to reduce the negative effects of the identified error.
3. Record the medication as given in the medical record.
4. Record the observed and assessed outcome of the patient in the medical record.
5. Record notification of the physician in the medical record with any resultant orders.
6. Record any actions and clinical interventions taken and the patient's response to the same.
7. Report the error in detail on a medication inadvertent incident report.
..... All medication error reports will be reviewed by the DON and consulting Pharmacist and categorized according to severity, type, cause and drug class involved.... All medication error reports will be referred to the medical staff.

The policy was not updated when barcode scanning was instituted in the facility to identify errors caused by defeating the barcode scanning safety functions as a possible cause of medication error.

Based on interview and document review the Critical Access Hospital (CAH) failed to ensure the physical therapy (PT), occupational therapy (OT) and radiology departments were appropriately disinfecting equipment between patients. In addition, the CAH failed to ensure surveillance of surgical site infections were being completed.

Findings include:

The CAH failed to use an EPA approved product to prevent the transmission of hepatitis B and HIV when disinfecting patient care equipment in the PT/OT department.

On 6/3/14, during the initial tour of the PT/OT department from 8:45 a.m. until 9:10 a.m. the physical therapy assistant (PTA)-A confirmed the treatment tables and exercise equipment were wiped down with a disposable disinfecting cloth between patients. The ingredients on the container of the disinfectant cloth wipes consisted of hydrogen peroxide 1-5% and benzyl alcohol 1-5%. In addition the PTA-A confirmed the pediatric therapy toys were cleaned after each use with a mixture of Dawn dish soap and water.

On 6/3/14, at 1:00 p.m. the chief executive officer (CEO) verified using Dawn dish soap was not considered an appropriate disinfecting solution to clean the toys in the PT/OT department.

The CAH's Physical Therapy Department's infection control policy [undated] directed staff to clean any contaminated equipment after patient use.

The CAH failed to complete surgical site infection surveillance.

On 6/5/14, at 10:50 a.m. the CEO and director of nursing (DON) verified they were unable to provide documentation for monitoring, trending and tracking surgical site infection rates. The CEO stated they relied on the clinic to make them aware of surgical site infections, however, stated the CAH did not have a formal process in place for surveillance of surgical site infections.


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Radiology:

During an initial tour of the radiology department on 6/3/14, at 3:00 p.m. the radiology manager (RM) stated the radiology department used Clorox bleach free wipes in between patients on the patient touch equipment, then at the end of the day they wiped everything down with Lysol foaming disinfectant cleaner. The RM stated that blood could be on the equipment since the radiology department took x-rays for patients in the emergency room, and which could include car accidents and other trauma.

The RM verified the cleaning products used were not effective against blood borne pathogens and further stated they used to use the PDI saniwipes, but those had been replaced with the Kim Tech prep wipes, but it was too hard on their hands, and so the radiology department had stopped using them.

A package of baby wipes was observed in the radiology control room, the RM stated staff sometimes chose to use the baby wipes to clean their hands, if they didn't want to use the sink for a full hand wash, or the hand sanitizer.

The CAH's Radiology Department's infection control policy [undated] directed staff to clean any contaminated equipment after patient use.

Based on observation, interview and document review the Critical Access Hospital (CAH) failed to ensure 4 of 4 radiologists (R1, R2, R3, R4) radiologists were credentialed. In addition, the CAH failed to ensure the radiation safety officer received specialized training, and failed to update policies annually.

Findings include:

R1's hire date was 11/11/09. R1's credentialing file lacked an application for employment including privileges requested.

R2's hire date was 11/11/09. R2's credentialing file lacked an application for employment including privileges requested.

R3's hire date was 11/11/09. R3's credentialing file lacked an application for employment including privileges requested.

R4's hire date was 11/11/09. R4's credentialing file lacked an application for employment including privileges requested.

On 9/28/10, at 9:40 a.m. the human resources manager verified the CAH had not completed the full credentialing process for the radiologists. She stated the CAH had verified current licensure and education history because the company they had contracted the radiologists with, had provided them with the information. She stated they had never credentialed radiologists prior to this.

The contract for the radiologists dated 11/16/09, indicated: "further credentialing requirements as stipulated per client facility bylaws are the responsibility of the client."

On 6/5/14, at 10:00 a.m. the Radiation Safety Officer (RSO), stated she was a radiology tech that was designated as the radiation safety officer and verified she had not received any specialized training. The RSO stated all nuclear medicine was handled by DMS (contracted imaging service), they brought any radioactive doses for imaging, handled the material and took it away with them for disposal. In addition, the RSO stated she was not aware the radiology department was not using EPA approved wipes to eliminate blood borne pathogens between patients.

The RSO verified that only some of the CAH radiology policies were reviewed and updated, mainly those updated in tandem with DMS polices were reviewed for 2014. Other radiology policies had dates ranging from 2009-2013.

Based on interview and document review, the Critical Access Hospital (CAH) failed to assure a comprehensive list of all services furnished under agreements or arrangements had been maintained. This had the potential to affect all patients receiving services at the CAH.

Findings include:

The CAH's undated "Hospital Service provided under agreement or arrangement" list provided by the CAH listed ten services the CAH had an agreement with and the services provided by each, however, lacked documentation of the contracted services responsibilities.

On 6/4/14, at 12:05 p.m. the chief executive officer (CEO) confirmed the list of agreements and/or contracted services for the facility did not include a delineation of the responsibilities of the agreement services, nor was this an inclusive list. The CEO agreed some of the agreement or contracted services which were missing from this list included: Cardinal Health (pharmacy services), Stericycle (medical waste disposal services), United Blood Services, Universal Hospital Services (biomedical services).

Based on staff interview and document review the Critical Access Hospital (CAH) failed to ensure that emergency room treatment consent forms were signed by the patient or legal guardian for 5 of 10 emergency room patients (ER3, ER4, ER5, ER8, ER10) and for 20 of 20 inpatients reviewed (P1, P12, P13, P17, P18, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P14, P15, P16, P19, P20).

Findings includes:

ER3 was provided medical assessment and treatment in the emergency room on 4/29/14. ER3's emergency room record did not include documentation regarding notification of his/her privacy rights or whether consent for general care and treatment was obtained from the patient or guardian..

ER4 was provided medical assessment and treatment in the emergency room on 4/13/14. ER4's emergency room record did include documentation regarding notification of his/her privacy rights or whether consent for general care and treatment was obtained from the patient or guardian.

ER5 was provided medical assessment and treatment in the emergency room on 4/14/14. ER5's emergency room record did include documentation regarding notification of his/her privacy rights or whether consent for general care and treatment was obtained from the patient or guardian.

ER8 was provided medical assessment and treatment in the emergency room on 3/10/14. ER8's emergency room record did include documentation regarding notification of his/her privacy rights or whether consent for general care and treatment was obtained from the patient or guardian.

ER10 was provided medical assessment and treatment in the emergency room on 1/20/14. ER10's emergency room record did include documentation regarding notification of his/her privacy rights or whether consent for general care and treatment was obtained from the patient or guardian.

Review of the CAH policy "POLICY FOR EMERGENCY ROOM DEPARTMENT" dated 3/02 identified the following: "When patients are admitted to the ER for treatment, the following shall be documented on the ER forms 100% of the time...12. Consent for treatment".

Review of the CAH policy Informed consents ER dated 10/91, identified the following: "Non-emergency cases involving minors, incompetents, and or individuals with mental incapacities must have signed consent by the next of kin or legal guardian. Informed consent can be obtained over the phone, but must be witnessed by a second person listening on an extension. 2. Medical Emergencies: No consent is needed for initial treatment, but must be completed as soon as patient is stabilized."

The health information management (HIM) director was interviewed on 6/3/14, at 3:00 p.m. and confirmed that consent for general care and treatment and notification of privacy rights had not been completed on ER3, ER4, ER5, ER8, and ER10.



30951


Inpatients:

P1 was provided medical assessment and was admitted to the CAH on 5/30/14, and remained in the facility currently receiving care, treatment and diagnostic testing. However, the CAH failed to obtain a general consent for treatment, a release of information (provide medical records for review and payment for third party and insurance payors), an acknowledgement of the Patient Rights and Grievance forms or the assignment of individual benefits (insurance payment direct to the facility).

P12 was provided medical assessment and was admitted to the CAH on 6/17/13, received care, treatment, diagnostic testing and was discharged home on 6/25/13. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of the Patient Rights and Grievance forms or the assignment of individual benefits.

P13 was provided medical assessment and was admitted to the CAH on 6/26/13, received care, treatment, diagnostic testing and was discharged home on 6/29/13. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of the Patient Rights and Grievance forms or the assignment of individual benefits.

P17 was provided medical assessment and was admitted to the CAH on 2/20/14, received care, treatment, diagnostic testing and was discharged home on 2/23/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of the Patient Rights and Grievance forms, or the assignment of individual benefits.

P18 was provided medical assessment and was admitted to the CAH on 2/21/14, received care, treatment, diagnostic testing and was discharged home on 2/25/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of the Patient Rights and Grievance forms, or the assignment of individual benefits.


32601


P2 was provided medical assessment and was admitted to the CAH on 3/7/14, received care, treatment, diagnostic testing and was discharged on 3/11/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms or the assignment of individual benefits.

P3 was provided medical assessment and was admitted to the CAH on 5/6/14, received care, treatment, diagnostic testing and was discharged on 5/9/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms or the assignment of individual benefits.

P4 was provided medical assessment and was admitted to the CAH on 4/6/14, received care, treatment, diagnostic testing and was discharged on 4/8/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P5 was provided medical assessment and was admitted to the CAH on 4/5/14, received care, treatment, diagnostic testing and was discharged on 4/11/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P6 was provided medical assessment and was admitted to the CAH on 11/28/13, received care, treatment, diagnostic testing and was discharged on 12/1/13. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P7 was provided medical assessment and was admitted to the CAH on 4/15/14, received care, treatment, and diagnostic testing and was discharged on 4/17/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P8 was provided medical assessment and was admitted to the CAH on 4/17/14, received care, treatment, diagnostic testing and was discharged on 4/21/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P9 was provided medical assessment and was admitted to the CAH on 1/5/14, received care, treatment, diagnostic testing and was discharged on 1/8/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P10 was provided medical assessment and was admitted to the CAH on 1/6/14, received care, treatment, diagnostic testing and was discharged on 1/11/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P11 was provided medical assessment and was admitted to the CAH on 1/23/14, received care, treatment, diagnostic testing and was discharged on 1/28/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P14 was provided medical assessment and was admitted to the CAH on 2/8/14, received care, treatment, diagnostic testing and was discharged on 2/10/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P15 was provided medical assessment and was admitted to the CAH on 2/1/14, received care, treatment, diagnostic testing and was discharged on 2/4/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P16 was provided medical assessment and was admitted to the CAH on 1/30/14, received care, treatment, diagnostic testing and was discharged on 2/1/14. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P19 was provided medical assessment and was admitted to the CAH on 8/2/13, received care, treatment, diagnostic testing and was discharged on 8/3/13. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

P20 was provided medical assessment and was admitted to the CAH on 7/10/13, received care, treatment, diagnostic testing and was discharged on 7/11/13. However, the CAH failed to obtain a general consent for treatment, a release of information, an acknowledgement of Patient Rights and Grievance forms, or the assignment of individual benefits.

On 6/4/14 at 2:05 p.m. the HIM verified the identified medical records lacked consent for care forms and stated "I don't want to make excuses, but we seem to have lost consents when we went electronic."

On 6/5/14 at 8:00 a.m. the director of nursing (DON) stated she had heard that consents were lacking and had instituted the old paper form to be used starting today.

On 6/5/14 at 10:00 a.m. the business office coordinator (BOC) stated she was responsible for getting the financial documents when she was at work, and when she was not at work the nursing staff were responsible for getting the signed paperwork. The BOC stated she had been notified that the consents had been lost when they switched to electronic medical records and stated EPIC (electronic record provider) was building a module for them. The BOC provided a paper copy of the Authorization for Medical Treatment form that included: consent for treatment, release of information, acknowledgement of Patient Bill of Rights and Grievance form, personal valuables statement and assignment of benefits. The BOC verified that patients were not currently being asked to give consent for care, and had not been since the electronic medical record began (12/2012).

On 6/5/14, at 2:10 p.m. the chief executive officer (CEO) confirmed the CAH did not have a policy/procedure for obtaining and/or completing consents for care.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure the security of medical records in the physical therapy/occupational therapy department.

Findings include:

During the initial tour of the physical therapy (PT) and occupational therapy (OT) department on 6/3/14, from 8:45 a.m. until 9:10 a.m. the physical therapy assistant (PTA)-A revealed the medical records for the PT patients were kept in an unlocked filing cabinet at the open station within the PT/OT department. PTA-A verified the PT/OT department was open during the CAH's regular hours of operation and that the housekeeping staff came in after-hours unattended to clean the department.

On 6/3/14, at 1:05 p.m. certified occupational therapy assistant (COTA)-A confirmed the OT patient records were kept in an unlocked filing cabinet at the open station within the PT/OT department.

On 6/4/14, at 9:00 a.m. the health information management (HIM) director confirmed her expectations and the CAH's policy for security of PT/OT medical records indicated the records should have been kept in a locked filing cabinet within the PT/OT department.

The CAH's Facility Physical Safeguards policy dated 4/1/2003, emphasized the CAH's procedure to take all possible measures to protect patient health information.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure a representative sample of active and closed inpatient and outpatient records were reviewed. This had the potential to affect all current and future inpatients and swing bed patients of the CAH.

The findings include:

A review of the CAH's annual review dated 12/4/13, lacked indication a representative sample of inpatient and outpatient records had been reviewed. The CAH lacked documentation of the review of the 10% minimum required active and closed records for all services provided by the CAH. The CAH Annual Review meeting minutes on 12/4/10, indicated the CAH struggled to complete the chart audits and lacked evidence that the review had been completed.

On 6/5/14 at 9:50 a.m. the chief executive officer (CEO) stated the health information manager was responsible for completing the sample of active and closed inpatient and outpatient records. The CEO confirmed the minutes from the annual periodic review completed on 12/4/13, did not include the analysis of the sample of active and closed inpatient and outpatient records.

The health information management director (HIM) was interviewed on 6/5/14, at 10:30 a.m. during which she confirmed that the minimum of 10% active and closed records for all services provided by the facility were not reviewed and criteria for the record reviews had not been established.

Based on interview and document review, the Critical Access Hospital (CAH) failed to include the review of their health care policies as part of their annual program evaluation. This had the potential to affect all current and future CAH patients.

Findings include:

During review of the most recent annual program evaluation 12/4/13, it was noted that the CAH's patient care policies had not been reviewed.

Interview with the Health Information Manager(HIM)/Quality Manager (QA) at 10:30 a.m. on 6/5/14, confirmed the CAH had not reviewed all of the CAH's patient care policies during the annual evaluation of its total program.

A policy related to how the CAH would complete the annual program evaluation was requested but not provided.

Based on interview and document review the Critical Access Hospital (CAH) failed to ensure quality assurance/performance improvement projects were developed and integrated into the CAH's quality improvement program for the following services: medical staff, organ procurement, cardiac rehab, health information systems (clinical records department) and sleep lab. This had the potential to affect all current and future patients of the CAH.

Findings include:

On 6/3/14, at 1:30 p.m. registered nurse (RN)-E was interviewed and verified the cardiac rehabilitation (CR) department did not have a current quality improvement project.

On 6/3/14, at 3:00 p.m. the radiology manager (RM) stated their quality tracking consisted of a retake/repeat analysis, the goal was less than 10% and the department had been ranging between 4-7% retakes, over the last year. The RM verified no other quality assurance data was collected because DMS imaging (contracted service) did it's own QA analysis. The CAH radiology department was not provided a copy of the data for their hospital and did not report this data to the hospital wide quality assurance/performance improvement committee. The RM state the last time a radiologist was present to physically review the unit was probably 2009.

On 6/5/14 at 9:15 a.m. the chief executive officer (CEO) was interviewed and stated she was unaware of a current quality improvement project being completed in the area's of medical staff, organ procurement and health information systems (clinical records department). The CEO stated she could not provide action plans that described quality assurance or process improvement activities for medical staff, organ procurement, cardiac rehab, rehabilitation services, health information systems (clinical records department) and surgical services.


On 6/5/14, at 9:25 a.m. the director of nursing (DON) confirmed the CR department was not currently reporting to the hospital wide quality assurance/performance improvement committee. In addition, the DON confirmed the sleep lab did not have a current quality improvement project nor was this department reporting to the hospital wide quality assurance/performance improvement committee.








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32601

Based on interview, and document review the Critical Access Hospital (CAH) failed to ensure the written policy for organ procurement organization (OPO) included a definition of "imminent death." This had the potential to affect all current and future patients of the CAH.

Findings include:

The policy for tissue and eye donation (undated),was reviewed and it was noted that the policy identified cardiac death, but had not defined "imminent death" as it related to organ procurement.

The director of nursing (DON) was interviewed on 6/5/14, at 10:25 a.m. and confirmed the CAH policy for OPO did not include the definition of "imminent death."