HospitalInspections.org

Based on policy/procedure review, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to include all practitioners that provided care and services to the CAH patients, in their external peer review process. Problems identified with 30 of 46 physicians (contracted teleradiologists A - EE).

Failure to ensure an external entity the evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policy/procedure titled "PEER Review Policy" revised 8/08 revealed the following in part "Peer Review organization or committee: To the extent that external persons or entities shall be considered agents of the peer review committee....Cherokee Regional Medical Center is a member of a rural health (critical access) network that has arranged for credentialing and quality assurance oversight to be provided by another designated hospital that is a member of the Network Hospital....Health care providers subject to peer review shall be: Physicians. Locum tenens practitioners, and affiliate staff professionals and midlevel practitioners (dentists, ARNPs, and PAs).

2. Review of peer review documentation for the past 12 months revealed the CAH staff failed to include all physicians in contracted radiologist group A (contracted teleradiologists A - EE) in the CAH external peer review process.

3. During an interview on 8/11/10 at 9:10 AM, the Vice President of Nursing and Regulatory Services stated the contracted teleradiologists did not have a Peer review completed by an external source since the last privileging period for the teleradiologists. Contracted teleradiologists group A provide services for the CAH and the current on staff radiologist over reads all x-rays completed by contracted teleradiologist group A. The hospital does not complete an external peer review for the contracted group A teleradiologists.

I. Based on review of hospital policies/procedures, medical records and staff interview the Critical Access Hospital (CAH) failed to complete a comprehensive activity assessment for 1 of 5 closed swing bed patients (Patient #1). The CAH had an average daily census of 6.2 swing bed nursing patients.

Failure to complete a comprehensive activity assessment could potentially impede the provision of activities directed towards the patient's individual interests and needs to promote a sense of well-being and self-esteem.

Findings included:

1. Review of the Activity Program Policy, revision dated 8/08 revealed in part:
" ...3. An activities plan will be developed for each patient consistent with his/her interests and wishes. This plan will be based on the activity assessment completed by the Social Worker ..."

2. Review of Patient #1's medical record lacked documentation of an activity assessment.

3. During an interview on 8/10/10 at 2:45 PM, Staff A, RN/Utilization Review Manager acknowledged Patient #1's medical record lacked an activity assessment. Staff A stated,"I looked and found no activity assessment or progress notes, this should have been completed."

II. Based on review of medical records, observation, patient and staff interview, the CAH failed to provide an activity calendar for 2 of 2 active swing bed patients (Patient's #6 and #7) and 5 of 5 closed swing bed patients (Patient's #1,#2,#3,#4 and #5).

Failure to provide activity calendars reflecting types and hours of scheduled activities could potentially affect a patient's involvement in activities designed to enhance their emotional and psychosocial well being.

Findings include:

1. Observation of the medical/surgical nursing unit on 8/9/10 at 11:00 AM revealed skilled nursing patient rooms lacked monthly activity calendars.

2. During an interview on 8/9/10 at 11:05 AM, Patient #1 stated, "I've been here one week today. My friends brought me a book. I don't have an activity calendar."

3. During an interview on 8/9/10 at 11:25 AM, Staff A stated, "We've never had activity calendars. I was unaware that we needed to provide patient's with activity calendars."

4. During an interview on 8/10/10 at 11:30 AM, Staff E, Occupational Therapist (OT)/Activities Supervisor stated, "I've been here since 1983 and we've never had activity calendars."

III. Based on review of hospital policies/procedures, job descriptions, medical records, patient and staff interviews, the CAH staff failed to document that individual or group activities occurred with skilled patients or their outcomes/responses to activities interventions. Additionally, CAH staff failed to ensure the patient plan of care included activity goals for 2 of 2 active swing bed patients (Patient's #6 and #7) and 5 of 5 closed swing bed patients (Patient's #1,#2, #3,#4 and #5).

Failure to provide an activity program that meets the physical and psychosocial needs of the individual patient could potentially impede the physical and psychological healing and well being of patients.

Findings include:

1. Review of the Activity Program Policy, revision dated 8/08 revealed in part:
"...1. The Activities program will be supervised by the Occupational Therapist, and most of the activities and patient interaction will be the responsibility of a Patient Activities Provider.."
"...3. An activities plan will be developed for each patient consistent with his/her interests and wishes..."
"...4. Following each activities visit, the Activities Provider will document interactions and patient participation..."

2. Review of certified nursing assistant (CNA) job descriptions dated 2/10 revealed nursing assistants are required to complete social activities with swing bed patients.

3. During an interview on 8/9/10 at 11:25 AM, Staff A stated, "The nurse aides do the activities and should document this in the patient's electronic record."

4. During an interview on 8/9/10 at 11:05 AM, Patient #1 stated, "I've been here one week today. My friends brought me a book. As far as I know I've not gotten any activities other than physical therapy. I didn't know they had one."

5. Review of Patient #5 ' s open medical record showed that CAH staff admitted the patient to skilled services on 8/2/10. The medical record revealed no documented evidence that showed the CNA offered and\or completed any social activities with the patient. Additional review showed CAH staff failed to include a comprehensive activity care plan that included measurable goals/outcomes.

6. During an interview on 8/9/10 at 11:55 AM, Staff A stated the following in regards to Patient #5. "The medical record does not include an activities program or care plan documentation of activities. There's only one activity documented by the aides and this was on 8/9/10 at 3:00 AM, they documented TV. This is not an activity."

7. Review of Patient #6 ' s open medical record showed that CAH staff admitted the patient to skilled services on 8/5/10. The medical record revealed no documented evidence that showed the CNA offered and\or completed any social activities with the patient. Additional review showed CAH staff failed to include a comprehensive activity care plan that included measurable goals/outcomes.

8. During an interview on 8/9/10 at 1:45 PM, Staff A stated the following inregards to Patient #6. "The aides have documented TV on a couple of entries. This would not be an activity per our policy and their training. There is no activity care plan, you are correct."

9. Review of the closed medical records for Patients #1-5 revealed no documented evidence that showed the CNAs offered and\or completed any social activities with the patients. Additional review showed CAH staff failed to include comprehensive activity care plans that included measurable goals/outcomes for each patient.

10. During an interview on 8/10/10 at 2:45 PM, Staff A verified the medical records for Patient's #1,# 2, #3, #4 and #5 lacked documented evidence of activities provided for the Swing Bed patients by the CNA's. Staff A stated, "I looked and found no activity care plans for the patient's and there is no documentation from the nurse aides that activities were provided other than TV."

11. During an interview on 8/10/10 at 11:30 AM with Staff E stated, "Sleeping, resting and TV are not diversion activities. The activity program would not be reevaluated and there is no activities plan. When we went to electronics a couple of years ago, I have to admit it's been hard for me to follow it. I am not involved with the patient's care plan and I do not attend care plan meetings. I oversee the program."

IV. Based on review of job descriptions and staff interview, the CAH staff failed to appropriately train and orient each CNA that provided social activities to Swing Bed patients prior to providing the service.

Failure to provide training for activities programs that meets the physical and psychosocial needs of the individual patient could potentially impede the physical and psychological healing and well being of patients.

Findings include:

1. Review of certified nursing assistant (CNA) job descriptions dated 2/10 revealed nursing assistants are required to complete social activities with swing bed patients. During an interview on 8/9/10 at 11:25 AM, Staff A stated, "The nurse aides do the activities and should document this in the patient's electronic record."

2. During an interview on 8/10/10 at 11:30 AM with Staff E stated, "The nurse aides do actual hands on care, I oversee the activity program. I probably haven't met with CNA's for over a year. Some may not be oriented to the activities program."

3. During an interview on 8/11/10 at 7:35 AM the Vice President of Nursing stated, "The CNA's would do the hands on activities. [Staff E] had done general training but in the last couple of years the new aides that have just been hired have not had specific training for the activities program responsibilities. We will make sure they receive training in the next 3 months."

4. During an interview on 8/11/10 at 7:55 AM, Staff A stated, "The nurse manager on the skilled nursing unit identified that we lacked orientation with occupational therapy for CNA's to us in the last week or so. We will include this with their orientation check list."