HospitalInspections.org

I. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the Medical Staff recommended and Board of Directors approved medical staff appointment for 13 of 14 pathologists prior to providing care to patients of the CAH. The CAH administrative staff stated pathologists provide services to 25 patients per month.

Failure of the Medical Staff to assure the pathologists had the required education, knowledge, skills, and credentials to perform their duties prior to providing care could potentially expose patients to inappropriate diagnosis, unnecessary and/or inappropriate care.

Findings include:

1. Review of the "LIST OF CREDENTIALED MEDICAL STAFF FOR 2011-2012 OSCEOLA COMMUNITY HOSPITAL", not dated, revealed the list contained 1 pathologist, Pathologist B.

2. Review of the Medical Staff Rules and Regulations, revised 4/11, revealed in part, "Patients may be treated only by physicians who have submitted proper credentials and have been duly appointed to membership of the Medical Staff."

3. During an interview on 4/20/11 at 8:00 AM, the Health Information Management (HIM) Director stated the CAH contracted with a group of 14 pathologists to provide pathology services to the CAH. If a CAH patient required on-site pathology services, the pathology groups would send 1 of the 14 pathologists to the CAH. The pathologist the group sent could potentially include any of the 14 pathologists, not just Pathologist B who was a member of the Medical Staff. The HIM Director acknowledged 13 of the 14 pathologists could provide care to CAH patients, and the 13 pathologists had not applied for membership in the Medical Staff.

II. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 29 (Teleradiologist C) Tele-Radiologists' (Tele-Radiology Group B) credential files contained all required information (NPDB Query) at the time of their reappointment to the Medical Staff. The CAH administrative staff identified an average of 14 radiology procedures interpreted per month by Tele-Radiology Group B.

Failure to include all required information could potentially result in the Medical Staff lacking pertinent information to make an informed decision about appointing Tele-Radiologists to the Medical Staff.

Findings include:

1. Review of Tele-Radiologist C's credential file on 4/19/11 at 4:00 PM revealed the credential file lacked documented evidence of a National Practitioner Data Base (NPDB) query prior to the Medical Staff and governing body re-credentialing Tele-Radiologist C.

2. Review of the policy, "Credentialing Process", revised in 2006, revealed in part, "Reappointment ... the following verification process is initiated: ... National Practitioner Data Bank [query]"

3. During an interview on 4/20/11 at 8:00 AM, the Health Information Management (HIM) Director stated Tele-Radiologist C belonged to Tele-Radiology Group B. Tele-Radiology Group B had 29 Tele-Radiologists. The HIM Director acknowledged Tele-Radiologist C's credential file lacked documented evidence of a NPDB query prior to re-credentialing. The HIM Director stated none of the Tele-Radiologists' credential files from Tele-Radiology Group B contained a NPDB query prior to re-credentialing.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) Safety staff failed to ensure nursing staff notified the patient's physician in 6 of 12 medication errors reviewed. (Patients # 1, 2, 3, 4, 5, 6) The CAH administrative staff reported a current census of 3 in-patients.

Failure to notify the physician of medication errors could potentially result in the patient developing an untreated life-threatening condition, or unexpected complications from the medication error.

Findings include:

1. Review of the policy "Variance Reporting", reviewed 3/10, revealed in part, "The patient's doctor must be made aware of the medication error and sign the variance report. . . ."

2. Review of 12 medication errors from January 2010 to April 2011 revealed:

a. on 2/24/11 at Midnight, nursing staff discovered a medication error that involved Patient #1. The Medication Error form lacked documented evidence nursing staff notified Patient #1's physician of the medication error.

b. on 4/10/11 at 6:45 PM, nursing staff discovered a medication error that involved Patient #2. The Medication Error form lacked documented evidence nursing staff notified Patient #2's physician of the medication error.

c. on 4/6/11 at 8:00 AM, nursing staff discovered a medication error that involved Patient #3. The Medication Error form lacked documented evidence nursing staff notified Patient #3's physician of the medication error.

d. on 11/24/10 at an undocumented time, nursing staff discovered a medication error that involved Patient #4. The Medication Error form lacked documented evidence nursing staff notified Patient #4's physician of the medication error.

e. on 10/10/10 at Midnight, nursing staff discovered a medication error that involved Patient #5. The Medication Error form lacked documented evidence nursing staff notified Patient #5's physician of the medication error.

f. on 2/6/10 at 6:00 PM, nursing staff discovered a medication error that involved Patient #6. The Medication Error form lacked documented evidence nursing staff notified Patient #6's physician of the medication error.


3. During an interview on 4/19/11 at 1:30 PM, Registered Nurse I acknowledged the Medication Error forms for Patients #1, 2, 3, 4, 5, and 6, lacked documented evidence the nursing staff notified the patient's physician of the medication error.

Registered Nurse I stated nursing staff received education in January 2011, instructing the nursing staff to document when they notified the patient's physician after the discovery of a medication error.

I. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) Surgical Services administrative staff failed to ensure surgical staff tested the Cidex OPA disinfecting solution in 1 of 1 disinfecting tub prior to each use, in accordance with the manufacturer's recommendations. (Surgery Decontamination Room) The Operating Room Supervisor stated the Surgical Services staff performed an average of 31 endoscopic procedures per month. The Radiology Co-Supervisor identified an average of 5 ultrasound procedures using the transvaginal probe per month.

Failure to test the disinfecting solutions prior to each use could potentially result in the disinfecting solution lacking sufficient strength of the active ingredient to kill all microorganisms, resulting in the spread of infectious microorganisms between patients.

Findings include:

1. Observations during a tour of the Surgery Decontamination Room, on 4/18/11 at 1:35 PM, revealed 1 of 1 disinfecting tub that contained Cidex OPA Solution.

2. Review of the Cidex OPA Solution Test Log, revealed Surgery and Radiology Staff failed to test the Cidex OPA Solution prior to each use.

3. During an interview at the time of the tour, the Operating Room Supervisor stated Surgery staff only tested the Cidex OPA Solution daily, and not prior to each use, per the manufacturer's recommendations. The Operating Room Supervisor stated the Radiology staff used the same Cidex OPA disinfecting solution to clean the transvaginal ultrasound probe.

4. Review of the manufacturer's directions for Cidex OPA Solution, dated 2006, revealed in part, "The [active ingredient] concentration of Cidex OPA Solution during its use-life must be verified by the Cidex OPA Solution Test Strips prior to each use. . . ."

5. Review of the policy, "Cleaning Endoscopes, Gastroscopes, and Colonoscope", reviewed 1/11, revealed the policy failed to require Surgical Services staff to test the Cidex OPA disinfecting solution prior to each use, as required by the manufacturer.



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II. Based on document review, observation, and staff interview, the Critical Access Hospital (CAH) dietary staff failed to maintain a sanitary kitchen environment. The CAH dietary staff reported the staff prepare 50 meals a day.

Failure to maintain a dietary environment in a sanitary manner could potentially result in the outbreak of a foodborne illness.

Findings included:

1. Review of the Infection Control policy, revised on 2/11, revealed in part, "...strict sanitary conditions is of paramount importance in the ...dietary department in order to eliminate food contamination... [staff must have] clean hair-covered with an effective hair restraint..."

Review of the Food Service Supervisor "Job Description", revised on 2/11, revealed in part, "...responsible for maintaining high standards of sanitation and safety..."

2. Observation, during the initial tour, on 4/18/11 at 9:45 AM, showed the Dietary Manager's hair net did not cover the bangs or the sides of their hair.

Further observation, during the initial tour, also showed Dietary Aide B's hair net did not cover the bangs or the sides of their hair.

Observation on 4/19/11 at 7:23 AM, showed the Dietary Manager's hair net did not cover the bangs or the sides of their hair. Dietary Aide C's hair net only covered the back of their hair.

During an observation on 4/19/11 at 8:20 AM, a non-employee entered the kitchen carrying 2 containers, walked past a food prep counter and a steam table to the ice machine. The Non-employee, opened the ice machine and scooped ice into the containers. Dietary Aide C identified the non-employee as a nurse from the Physician clinic attached to the hospital. Dietary Aide C stated this person was not an employee of the hospital.

During an observation on 4/19/11 at 10:35 AM, Dietary Aide D entered the kitchen without wearing a hair net. The Dietary Manager stated Dietary Aide D was not on duty, but "just stopped to say Hi". The Dietary Manager confirmed Dietary Aide D was not wearing a hair net at the time of the observation.

3. During an interview on 4/19/11 at 8:25 AM, the Dietary Manager stated employees, or non-employees, should not enter the kitchen without a hair net covering all of their hair. The Dietary Manager confirmed the employees working in the kitchen should have all of their hair covered while working in the kitchen.

During an interview on 4/19/11 at 1:50 PM, the Dietary Manager stated the ice machine in the kitchen was the only ice machine in the hospital, so hospital and clinic staff entered the kitchen to get ice when they needed ice. The Dietary Manager further stated the CAH lacked a policy that required all staff entering the kitchen to wear hair nets."We just know that is good practice."

During an interview on 4/19/11 at 1:35 PM, the Infection Control Nurse stated the education provided to kitchen staff included some infection control information, but did not cover hair nets. The education also did not cover what employees, or non-employees, should do when they entered the kitchen for ice.

During an interview on 4/19/11 at 3:50 the Dietitian stated staff needed to wear a hair net when in the kitchen. The hair net needed to cover all of the staff's hair. According to the Dietician, the CAH did not have a policy that Clarified who could enter the kitchen. The Dietician stated, "The ice machine is a problem, not sure what we will do, but I understand this concern over staff entering the kitchen to get ice. I didn't realize non-employees entered the kitchen to get ice. I see this needs to be looked at."

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to include 1 of 1 Occupational Therapy (OT) and 1 of 1 Speech Therapy (ST) program in the annual total program evaluation. The CAH administrator identified an average of 10 patients received OT services per month, and an average of 5 patients received ST services per month.

Failure to include all services in the total program evaluation could potentially result in CAH staff failing to identify under-utilized services, or appropriately allocate resources for over-utilized services.

Findings include:

1. Review of the "Total Program Evaluation" on 4/19/11 at 1:15 PM revealed it lacked documented evidence CAH staff had included the OT and ST programs in the annual review of services provided by the CAH staff.

2. During an interview on 4/19/11 at 3:00 PM, the Director of Nursing acknowledged the total program evaluation did not include the OT and ST services offered to CAH patients.

3. During an interview on 4/20/11 at 8:00 AM, the Director of Nursing stated the CAH lacked a policy that required CAH staff to include all services offered at the CAH in the annual total program evaluation.

Based on document review and staff interview, the administrative staff failed to include all practitioners that provided care and services to the Critical Access Hospital (CAH) patients in their external peer review process for 1 of 2 Radiologists (A), 1 of 1 Pathologist (B), and 2 of 52 Tele-Radiologists (C and D). The CAH administrative staff identified an average of 241 radiology films reviewed by radiologists per month, an average of 39 specimens reviewed by pathologists per month, and 14 radiology procedures reviewed by tele-radiologists per month.

Failure to ensure all physicians receive external peer review could potentially expose patients to inappropriate, or ineffective, treatment.

Findings include:

1. Review of credential files on 4/19/11 at 3:00 PM revealed:

a. Radiologist A's credential file lacked documented evidence of external peer review.
b. Pathologist B's credential file lacked documented evidence of external peer review.
c. Tele-Radiologist C's credential file lacked documented evidence of external peer review.
d. Tele-Radiologist D's credential file lacked documented evidence of external peer review.

2. Review of the policy "Credentialing Process", revised in 2006, revealed in part, "REAPPOINTMENT ... the following verification process is initiated: ... 1- [External] Peer Review [medical record]..."

3. During an interview on 4/20/11 at 8:00 AM, the Health Information Management (HIM) Director stated the CAH's Medical Staff included 2 Radiologists, 1 Pathologist, and 52 Tele-Radiologists. The CAH's radiology department contracted with Tele-Radiology Group A that employed 23 tele-radiologists. In addition, the CAH's radiology department contracted with Tele-Radiology Group B that employed an additional 29 Tele-Radiologists. The CAH administrative staff did not perform external peer review for any of the Radiologists, the Pathologist, or any of the Tele-Radiologists.