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Based on observation, review of policies/procedures and staff interviews, the critical access hospital (CAH) pharmacy staff failed to develop and maintain a system to track and account for the general and sample medications used in 2 of 2 offsite provider-based clinics. Problems were identified at the Van Diest Medical Center - Stratford Clinic and the Van Diest Medical Center - Jewell Clinic.

The Manager of Clinics reported an average of 120 patients received services monthly at the Stratford Clinic and an average of 200 patients received services monthly at the Jewell Clinic that could receive the medications.

Failure of pharmacy staff to provide tracking and oversight of medications in the clinics potentially results in outdated or recalled medications being available for physicians and mid-level providers to give to patients or the potential theft of medications by unauthorized persons.

Findings include:

1. Observation during tour at the Stratford Clinic on 4/1/14 at 8:20 AM with Staff D, CNO (Chief Nursing Officer) revealed approximately 215 general medications and 765 sample medications locked in a cabinet or closet. The medications were available for patient use as prescribed by physicians and mid-level staff.

Observation during the environmental tour at the Jewell Clinic on 4/1/14 at 9:30 AM with Staff D revealed 112 general and 24 sample medications locked in a cupboard. The medications were available for patient use as prescribed by physicians and mid-level staff.

2. Review of Pharmacy policy titled "Ongoing Oversite and Quarterly Inspection of Hospital Patient Care Areas and Bi-annual Inspections of Main and Satellite Clinics Stock Medications"", reviewed 3/13 stated in part... " A. Van Diest Clinic and both Jewell and Stratford Satellite Clinics will be inspected semi-annually."

3. During an interview on 4/1/14 at 8:20 AM, Practitioner A, PA (Physician's Assistant) at the Stratford Clinic stated the pharmacist does not come to the clinic to evaluate the medications on hand at the clinic.

During an interview on 4/1/14 at 9:30 AM, Staff C, CMA (Certified Medical Assistant) at the Jewell Clinic stated the pharmacist does not have any oversight of the medications at the clinic.

During an interview on 4/1/14 at 10:30 AM, Staff B, Pharmacist stated pharmacy should have oversight of the sample and general medications at the 2 offsite clinics. The clinics send outdated medications back to the facility pharmacy, but the pharmacists do not go to the clinics to oversee the general and sample medications.

Based on observation and staff interviews, the critical access hospital (CAH) failed to distribute patient food and maintain the kitchen environment in a sanitary manner. The administrative staff reported a census of 16 patients, with an average daily census of 12 patients. The Foodservice Director reported the dietary staff provided approximately 36-45 patient meals daily.

Failure to properly distribute food and maintain the kitchen environment in a sanitary manner could potentially result in the contamination of the patient's food.

Findings include:

1. Observation of the Manitowoc ice machine, located in the CAH kitchen, on 3/31/14 at 10:00 AM, revealed the machine drain pipe ended at the flood rim level of the kitchen floor and failed to provide a required air gap to provide backflow prevention, in the event of a drain back-up.

During an interview on 4/3/14 at 8:00 AM, Staff S, Director of Maintenance, confirmed the Manitowoc ice machine did not have a built in back-flow device on the drain and had already cut the end of the drain pipe to provide an air gap.

2. Observation of the kitchen environment on 3/31/14, at 11:35 AM, revealed 7 of 13 ceiling vents had dust around the perimeter of the vent and the ceiling tiles surrounding the vents.

During an interview on 3/31/14 at 1:50 PM, Staff K, Foodservice Director, acknowledged the soiled condition of the identified ceiling vents and ceiling tiles and reported they are not on the departments routine cleaning schedule. Staff K relayed she has attempted to request maintenance or environmental services clean them on a regular basis but this has not occurred.

3. Observation of the patient meal trayline on 3/31/14, from 11:45 AM to 11:58 AM, revealed uncovered dishes of peaches, strawberry desserts, tomato cucumber salads and lettuce salads placed on 13 of 14 patient trays. Staff M, cook, transported the 2nd enclosed cart, with 8 patient meal trays, to the east portion of the patient care unit. The meal cart was placed mid way down the hall and patient meal trays were delivered, from that point through the length of the hall, to the patient rooms with uncovered food items.

Observation of patient meal tray pass on 4/1/14, from 12:07 PM to 12:10 PM, revealed uncovered dishes of grapes, mandarin oranges, custard and lettuce salads on 8 of 8 patient meal trays. Staff L, food service worker, placed the meal cart at the mid point of the west portion of the patient care unit. Staff L took one of the patient meal trays off the unit to the Emergency Department and the remaining 7 patient meal trays were delivered through the length of the hall, to patient rooms with uncovered food items.

During an interview on 4/3/14 at 9:15 AM, Staff K acknowledged some uncovered items are placed on patient meal trays, if they are being transported to the unit in the enclosed cart. She reported all items would be covered if a patient meal tray was not transported in an enclosed cart. Staff K relayed she thought as long as the trays were transported to the unit in the enclosed cart, it was sufficient, but acknowledged if the cart remained in one spot, food items would be uncovered as the trays were carried throughout the hallway.

Based on observation, staff interview, and policy review, the critical access hospital (CAH) failed to ensure 2 of 2 radiation exposure cords were secured to prevent staff from entering the x-ray rooms during testing of patients. The CAH staff reported completing an average of 300 x-rays a week.

Failure to secure radiation exposure cords prevent staff access to the x-ray room during the procedure, exposing staff to unnecessary radiation.

Findings include:

1. During tour of the radiology department on 4/1/14 at 2:05 PM with Staff A, Director of Radiology revealed two radiation exposure cords in the 2 general x-ray rooms were not secured and reaching approximately 5 to 6 feet into the x-ray rooms. This allows staff to walk into the x-ray rooms during procedures.

2. During an interview on 4/1/14 at 2:20 PM, Staff A agreed the radiation emitting cords were not secured and would allow staff access to the x-ray rooms during x-ray procedures. Staff A said the cords should be secured at a short length to prevent staff access to the x-ray rooms during procedures. A company just installed new direct radiology equipment 10/2013 and failed to secure the exposure cords.

3. Review of the CAH policy General Radiation Safety Policy, reviewed 2/14 revealed in part... "6. All personnel and/or family members are required to leave the room during all x-ray exposures. No one except the patient should ever be within the direct field of the x-ray beam."

Based on observation, review of policies and procedures, and staff interviews, the surgery department failed to secure and protect patient information from unauthorized users by not securing 3 of 3 log books and 3 of 3 binders containing specimen logs. The surgery department performed 622 surgical cases and 553 endoscope procedures in 2013.

Failure to secure the patient information could potentially cause a misuse of patient information and a loss of identity for the individual patients.

Findings include:

1. An observation on 4/1/14 at 8:00 AM, during the initial tour of the surgical department revealed 2 of 2 endoscope suites each containing l log book and 1 binder of logged specimens collected. Additional books were found at the nurses desk in the surgical department, for a total of 3 log books and 3 specimen binders. Each book contained patient information consisting of name, name of doctor, medical record number, date of birth, age, and admit date. The books were found on the counters alongside of the computer monitors.

2. During an interview, at the time of the observation, Staff G RN verified that housekeeping terminally cleans the surgical unit after hours. The surgical area is not staffed 24 hours a day.

Review of policy titled, Hamilton County Public Hospital Medical Records Policy, dated 4/2013 states in part ...Statement of Purpose: Hamilton County Public Hospital has the responsibility of ensuring that the information contained in a patient medical record is protected against loss, defacement, tampering, unauthorized access, or misuse.

Based on document review and staff interview the critical access hospital failed to privilege 1 of 1 surgical assistant (RN), who was not an employee of the hospital, to assist with surgical procedures. The RN assisted with 18 of 36 surgical procedures completed by associated practitioners.

Failure to privilege all assistants that accompany providers could result in patients receiving surgical intervention from unqualified professionals.

Findings include:

While reviewing the Operating Room Log on 4/1/14 at 9:45 AM, it showed a lack of privileges for 1 of 1 Registered Nurses (RN, Practitioner B). Practitioner B accompanied 2 medical doctors (Practitioners L and M), and provided surgical assistance during surgical interventions for patients. Practitioner B assisted with 11 of 19 surgical cases performed by Practitioner L in 2013 and 7 of 17 surgical cases performed by Practitioner M in 2013.

During an interview on 4/1/14 at 9:30 AM, Staff E RN verified that Practitioner B lacked surgical privileges to perform assistance during surgical interventions with Practitioners L and M.

Based on document review and staff interviews, the critical access hospital (CAH) failed to ensure 1 of 3 active physicians, 2 of 2 teleradiologists and 1 of 1 consulting pulmonologists, selected for review, received outside entity peer review performed by the Network Hospital prior to re-appointment. The purpose of the outside entity review is to evaluate the appropriateness of diagnosis and treatment furnished to patients at the CAH, in accordance with the CAH's agreement with the Network Hospital. (Physicians F, G, H and K). The CAH identified 12 active, 46 consulting, and 30 contract physicians.

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

Findings include:

1. Review of the "Critical Access Hospital (CAH) Network Agreement", dated 6/13/12 and approved in 7/2012, revealed in part, ". . . "Medical records review as part of the quality and medical necessity of medical care at [Van Diest Medical Center] . . . shall be included in the services provided by [Network Hospital] to [Van Diest Medical Center] under this Agreement. . .'

2. Review of CAH documentation on 4/2/14 revealed the CAH failed to ensure the Network Hospital completed peer review for Physicians F, G, H and K prior to reappointment.

3. During an interview on 4/2/14 at 9:50 AM, Staff N, Director of Medical Staff Services, reported she chooses at least 1 patient medical record from each physician on staff to send to another CAH in their network or the Network Hospital for review, previous to the physicians re-appointment. Staff N reported Physicians F, G and H had not provided any services for the CAH patients until the end of 2013 so did not think she needed to send any patient medical records out for peer review, prior to the physician's re-appointment.

During a follow-up interview on 4/3/14 at 8:30 AM, Staff N confirmed Physician F performed services for CAH patients 4 times in the last quarter of 2013, Physician G performed services for CAH patients twice in the last quarter of 2013 and Staff H performed services for CAH patients 9 times in 2012, which allowed for patient medical records to be sent out for peer review prior to the physician's re-appointment. Staff N was not aware that it was not acceptable for a CAH to conduct peer review to ensure the quality and appropriateness of the diagnosis and treatment of a patient by the physicians at another CAH. The peer review must be completed by a hospital not a CAH.

4. Review of a CAH policy titled "Request for External Peer Review", dated 2/2014, revealed in part "A minimum of one chart from each physician on staff will be copied and forwarded..."

Review of the medical staff bylaws, reviewed and amended on 10/14/10, revealed in part "...A minimum of one peer review case per physician will be externally reviewed within a credentialing period. . ."

Based on review of swing bed policies, medical records, and interviews with staff, the swing bed skilled interdisciplinary team and nurse manager failed to ensure the attending physician participated in the interdisciplinary care conferences for the development of the patient's individualized care plan.

Failure to obtain input from the attending physician while formulating and revising the patient's individualized care plan could result in delays in implementing treatment modalities to improve the patient's functional abilities, to enhance healing, and to shorten the stay at the hospital.

The Chief Nursing Officer reported a current census of 2 Swing Bed patients with an average daily census of 2 Swing Bed patients.

Concerns were noted for 2 of 2 swing bed in-patients (Patients #6 and 7) and 2 of 5 closed swing bed patients (Patients #1 and 5).

Findings include:

1. Review of "Swing Bed - General Nursing" policy, review date 4/2013, revealed in part, ..."Care plan will be planned using the interdisciplinary approach...care conferences are held twice per week with recommendations, problems and resolutions documented in the patient's medical record...the comprehensive care plan done for each resident...includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial need. The care plan will be reviewed and signed weekly by attending physician."

2. Review of 2 of 2 swing bed in-patients medical records (Patient #6 and #7) revealed the following:

a. A physician's order, dated 3/23/14, for skilled nursing services for wound care and treatment of decubitus ulcers (wounds) on both of Patient #6's lower extremities and daily intravenous antibiotics (medications administered directly into a vein). A history and physical dated 3/23/14 revealed admitting diagnoses included psyoderma gangrenosum (a rare ulcerating skin disease).

A review of the patient's medical record revealed a care conference occurred on 3/31/14, but the documentation in the record lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conference.

b. A physician's order, dated 3/17/14, for skilled nursing services for wound care and treatment of large decubitus ulcers in the sacral area (the lowest portion of the spine) for Patient #7 and daily intravenous antibiotics. A history and physical, dated 3/7/14, revealed admission diagnoses included cachexia (a profound state of ill health and malnutrition) and peripheral vascular disease (narrowing or blockage of the arteries that cause poor blood flow to nerves and tissues of the body).

A review of the medical record revealed documentation of care conferences on 3/31/14 and 4/2/14 and two care conferences that occurred but were not documented in the patient's medical record. Additionally, the medical record lacked evidence showing the physician participated, signed, and/or Patient 7's physician was updated on the care plan developed and reviewed at the care conferences by the interdisciplinary team. During an interview on 4/1/14 at 4:15 PM, Staff J, Registered Nurse (RN)/Swing bed Manager acknowledged she failed to document the 2 additional care plan conferences in the patient's medical record but said they were completed by the interdisciplinary team.

3. Review of 2 of 5 closed (Patient # 1 and #5) swing bed medical records revealed the following:

a. A physician's order, dated 3/9/14, for skilled nursing services for daily physical and occupational therapy services for Patient #1. The primary diagnosis for skilled nursing services was Congestive Heart Failure (a condition in which the heart cannot pump enough blood to the rest of the body). A review of the medical record revealed care plan conferences on 1/16/14 and 1/18/14, but lacked evidence the physician participated, signed, and/or was updated on the care plan developed and reviewed at the care conferences by the interdisciplinary team.

b. A physician's order, dated 1/28/14, for close observation and assessment related to Patient #5's respiratory status by skilled nursing staff. A history and physical dated 1/25/14 revealed admission diagnoses included end-stage Chronic Obstructive Pulmonary Disease and bronchitis. A review of the medical record revealed care plan conferences occurred on 2/3/14 and 2/6/14, but the record lacked evidence the physician participated, signed, and/or was updated on the care plan developed and reviewed at the care conferences by the interdisciplinary team.

4. During an interview on 4/1/14 at 4:30 PM, Staff J stated she was responsible to coordinate and manage interdisciplinary care conferences and confirmed the physician did not attend the care conferences. Staff J acknowledged she failed to update or review any changes in the patients' plans of care that may or may not occur after the care plan conferences for Patient's #1, #5, #6, and #7. Staff J admitted she was aware that this would be a "problem".

Based on document review and interview the critical access hospital (CAH) failed to maintain a dental services contract for skilled patients in swing beds. The administrative staff identified a census of 2 skilled patients at the time of the survey.

Failure to ensure dental services are available for skilled patients may potentially result in unmet dental care needs for skilled patients.

Findings include:

During an interview on 4/2/14, 10:45 AM, Staff J, RN/Skilled Nurse Manager reported dental services are offered or obtained for skilled patients in swing beds from Provider I.

Review of CAH documentation on 4/2/14 revealed the CAH did not have a current contract with a dentist upon the initiation of the recertification survey. The previous dentist was last credentialed in 2010. Staff N, Director of Medical Staff Services, reported Provider I last provided services in 2011.

During an interview on 4/2/14 at 11:40 AM, Staff O, Administrative Assistant, reported she was not aware of a contracted dentist until the request for Provider I's credential file was submitted. Staff O relayed she found a file on Provider I with the closed files, which revealed the dentist chose not to renew the contract in 2012 and confirmed the CAH had not had an agreement for dental services from that point forward.

Based on review of policies and documents, and staff interview hospital staff provided all patients (inpatients and outpatients) with patient rights and responsibilities information that lacked the updated Patient Visitation Rights information effective 12/2/11.

Failure to provide patient with could potentially result in limiting/restricting access of visitors to patients infringing on their right to have a support person present when they are provided any type of care services or treatment modalities.

Findings include:

1. Review of the policy "Swing Bed Bill of Rights" review date 4/13, directed all hospital staff to review and provide a copy of the the Swing Bed Bill of Rights to the patient, family, or responsible party upon admission to skilled care during the admission process for skilled nursing services.

Review of the "Swing Bed Bill of Rights" brochure, undated, revealed the brochure lacked the new information, effective 12/2/11, regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. Review of the General Hospital "Patient Rights and Responsibilities" policy, review date 4/13, directed all hospital staff to review and provide a copy of the patient rights and responsibilities information sheet to each patient during the admission process to the emergency room, specialty clinics, main clinic, satellite clinics and outpatient therapy units in a patient welcome packet.

Review of the "Patient Rights and Responsibilities" brochure, revealed the brochure lacked the new information, effective 12/2/11, regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

3. During an interview on 4/1/14 at 2:55 PM, the Chief Nursing Officer (CNO) acknowledged the patient rights and responsibilities policies and brochures given to all patients at the time of admission to their hospital for inpatient and outpatient services failed to include the updated information contained in the regulatory guidelines. The CNO stated administrative staff were responsible for updating the patient rights policies and brochures and acknowledged they failed to update the forms reflecting the regulatory guideline changes. On 4/2/14 at 10:30 AM the CNO presented the surveyor with a document stating they had updated their patient rights and responsibilities and the swing bed bill of rights to include the changes reflective of September 7, 2011 S&C notification to all hospitals and Critical Access Hospitals (CAH).

During an interview on 4/2/14 at 8:00 AM, Staff P, ER Registrar stated they were responsible for providing patients with their patient rights and responsibilities information and that it was also posted on the registrar's desk. Staff P stated she was unaware that the information contained in the rights and responsibilities sheets were incorrect until yesterday when the CNO provided instruction to all staff to post and distribute the revised patient rights and responsibilities sheets.

During an interview on 4/2/14 at 8:20 AM, Staff Q, Hospital Registrar stated they were responsible for providing patient their rights and responsibilities information and that it was also posted on their desk. Staff Q said she was unaware that the information contained in the rights and responsibilities sheets were outdated. At the time of the interview the CNO informed Staff Q that there were revisions made to reflect regulatory changes and she had disposed of the old rights and responsibilities sheets and personally posted the "new" ones in the stand up frames at their desk, yesterday.

Refer to C-1001

Based on document review, staff and patient interviews, the critical access hospital (CAH) failed to ensure patients and visitors were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, for 2 of 2 swing bed patient records reviewed. (Patient #6 and #7). The CAH identified a current census of 2 swing bed patients at the time of survey entrance. Additionally the Chief Financial Officer (CFO) identified patient encounters for the following inpatient and outpatient areas:

Cardiac Rehab: 1,706 patients
Emergency room: 6,369 patients
Lab: 5,362 outpatients
Scopes: 553 patients
Sleep lab: 76 patients
X-ray: 2,270 outpatients
Therapy: 3,016 patients (Physical, occupational and speech therapy)
Surgical clinic: 556 patients
Wound clinic: 20 patients
Main clinic: 403 patients
2 Satellite clinics: 4,558 patients

Failure to inform patients of their visitation rights could potentially result in the staff failing to extend visitation rights to all patient populations and their visitors.

Findings include:

1. Review of the brochure titled, "Patient Rights and Responsibilities", revised date 4/14 provided to all patients upon admission to swing bed services, inpatients and outpatients, did not include the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Review of policy/procedure titled, "Swing Bed Bill of Rights", review date 4/13, did not include the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

Review of documentation in patient #6 and #7 medical records, revealed the patient's signed they received a copy of the Patient Rights and Responsibilities information.

2. During an interview on 3/31/14 at 10:15 AM, Staff R, Registered Nurse (RN) on the medical-surgical unit stated they provided all patients who received skilled services at the time of their admission, a patient rights information sheet. Staff R said she did not know the information sheet lacked the patients' rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.

During an interview on 3/31/14 at 11:00 AM, Patient #6 reported being informed of the patient rights by a sheet in a "welcome packet" provided at admission to the CAH for skilled nursing services. Patient #6 further stated the nursing staff provided information that indicated patients could have visitors but said nothing about who could or could not visit them.

During an interview on 4/1/14 at 10:00 AM, Staff J RN/Skilled Nursing Services Manager, reviewed the current Swing Bed Bill of Rights and stated she was not familiar with regulatory changes to the patient bill of rights and responsibilities and said they would take steps to make the necessary changes immediately.

During an interview on 4/1/14 at 2:55 PM, the Chief Nursing Officer (CNO) acknowledged the patient rights information provided to patients did not include the patient's rights to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend.