HospitalInspections.org

I. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the maintenance staff checked all electrical examination tables annually for electrical safety in 2 of 2 off site locations (Guthrie County Hospital Adair Clinic and Guthrie County Hospital Panora Clinic). The CAH clinic staff identified 1981 patient visits at the Guthrie County Hospital Adair Clinic and 2275 patient visits Guthrie County Hospital Panora Clinic for FY 2018 (from July 1, 2017 to June 30, 2018). Failure to ensure the maintenance staff checked all patient care equipment annually for electrical safety could potentially result in patient harm including electrocution and death.

Findings include:

1. Observations during tour of the Guthrie County Hospital Adair Clinic on 8/12/2019 at 1:50 PM with Clinic Licensed Practical Nurse (LPN) H revealed 2 of 4 patient examination tables lacked evidence of electrical safety checks.

Observation during tour of the Guthrie County Hospital Panora Clinic on 8/13/2019 at 9:45 AM with the Clinic Director revealed 2 of 4 patient examination tables lacked evidence of electrical safety checks.

2. Review of the policy "ClinMisc Sweep Definition and Process," dated 3/1/2016, revealed in part, "Brief overview of process: Clinical Miscellaneous (CLINMISC) is utilized for managing medical equipment of negligible risk. This is intended to be used for medical equipment that may be inspected as part of group managed department sweeps. These items may require annual performance verification or annual electrical safety checks, but do not require separate tracking and will not be tagged."

3. Review of the document "Guthrie County Hospital Adair Clinic," dated 6/5/2019, revealed the clinics lacked documentation the maintenance staff performed electrical safety checks for the 2 Enochs examination tables.

Review of document "Guthrie County Hospital Panora Clinic," dated 6/5/2019, revealed the clinics lacked documentation the maintenance staff performed electrical safety checks for the 1 Joerns examination table and 1 Enochs examination table.

4. During an interview on 8/12/2019, during tour of the Guthrie County Hospital Adair Clinic, at approximately 2:15 PM, Clinic Licensed Practical Nurse (LPN) H acknowledged the lack of documentation of electrical safety checks for 2 Enochs examination tables.

During an interview on 8/13/2019, at during tour of the Guthrie County Hospital Panora Clinic, at approximately 10:15 AM, the Clinic Director acknowledged the lack of documentation of electrical safety checks for 1 Joerns examination table and 1 Enochs examination table.

During an interview on 8/13/2019 at 12:45 PM, the Maintenance Manager confirmed the maintenance staff lacked documentation they checked all of the examination tables at the 2 off-site locations for electrical safety.




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II. Based on observation and staff interviews, the Critical Access Hospital (CAH) failed to remove outdated supplies from the Emergency Department (ED) and Wound Care Clinic. Failure to remove outdated patient supplies from the CAH's ED and Wound Care Clinic supplies, available for use in patient care, could potentially result in staff using the expired items for patient care after the manufacturers' expiration date, after which the manufacturer will no longer guarantee the safety and quality of the supply. The CAH identified an average of approximately 236 patient visits per month in the ED, and 61 patient visits in the Wound Care Clinic from July 1,2018 to June 30,2019.

Findings include:

1. Review of the policy "Supply Restocking and Outdates," effective 1/2010, revealed in part, "Nursing staff will check supply volume and outdates for their department on a monthly basis according to the established par levels. Expired supplies are removed from service and returned to the Purchasing Department."

2. Room 201 Wound Care Treatment Room Closet

a. 3 of 6 Unna Boot (compression dressing), expired 9/2017
b. 1 of 1 Aquacel AG (wound dressing), expired 9/2018
c. 1 of 1 Chlorhexidine 4%, 32 fluid ounces (antiseptic agent used to clean the skin), expired 3/2019
d. 1 of 1 Aquacel foam (a foam sterile dressing), expired 6/2019
e. 1 of 1 Medi Honey (a wound gel), expired 1/2018
f. 2 of 2 Tegaderm 6x8"(clear dressing), expired 6/2019
g. 10 of 10 Vaseline packets 5 grams, expired 4/2018
h. 2 of 2 Xeroform (wound dressing with petrolatum), expired 8/2018
i. 9 of 9 Vaseline Gauze Strips 3x9", expired 1/2019
j. 2 of 2 Vaseline Gauze Strips 6x36", expired 12/2018

3. During a tour of the Wound Care Clinic on 8/13/2019 at 3:15 PM Chief Nursing Officer (CNO) acknowledged the identified expired supplies in the closet in room 201. The CNO revealed the clinic staff should have checked the supplies monthly for expired supplies.

4. Emergency Department Room 911

a. 1 of 3 Thora-Para 8Fr. (device used to drain fluid from the chest), expired 5/31/2019
b. 1 of 1 Humidity for sterile water for inhalation 340 ML (used to humidify oxygen), expired 9/2018

5. During an interview on 8/12/19 at 12:47 PM, the Manager of Infection Prevention, Employee Health, and Outpatient Services acknowledged the identified expired supplies in room 911.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) anesthesia staff failed to store Succinylcholine (medication used to relax muscles during surgery) according to manufacturer's recommendations. Failure to store Succinylcholine according to manufacturer's recommendations could potentially result in patients receiving a medication that did not work in the body as expected, resulting in unintended consequences or side effects. The CAH's administrative staff identified the surgical services staff performed an average of 360 surgical procedures per year.

Findings include:

1. Observations in OR #1 on 8/13/19 at 11:38 AM revealed 1 of 1 unopened 200 milligram vial of Succinylcholine in the anesthesia cart stored at room temperature.

2. Review of the manufacturer's recommendations for the storage of Succinylcholine revealed in part: "The multi-dose vials are stable for up to 14 days at room temperature without significant loss of potency."

3. During an interview at the time of the observation, Certified Registered Nurse Anesthetist (CRNA) A revealed they removed the Succinylcholine from the Pyxis machine refrigerator (an automated medication dispensing system) prior to the surgical case under the patient's name and would return the Succinylcholine under the patient's name to the Pyxis refrigerator, post surgery if not opened or used. CRNA A acknowledged he was aware of the manufacturer's recommendations to store Succinylcholine for up to 14 days outside the refrigerator. CRNA A reported he did not date the Succinylcholine once he removed the succinylcholine from the Pyxis refrigerator and before returning to Pyxis refrigerator.

4. During an interview on 8/13/19 at 4:30 PM, the Director of Clinical Services/Pharmacist was aware of CRNA A's practice of returning Succinylcholine undated to stock, post surgery. The Director of Clinical Services stated "zero dates noted on the Succinylcholine bottles by pharmacy techs when restocking meds."

5. During an interview on 8/14/19 at 8:55 AM, the Director of Clinical Services verified CRNA A removed the succinylcholine under the individual patient's names for the 2 surgeries which occurred on 8/13/19. CRNA A returned the succinylcholine to the Pyxis refrigerator stock after CRNA A had the succinylcholine out of the refrigerator for several hours during the surgeries. CRNA A then returned the succinylcholine to the Pyxis refrigerator without documenting the date CRNA A first took the succinylcholine out of the refrigerator. The Director of Clinical Services "agreed this practice is not acceptable policy."

Based on review of the Quality Plan, Quality activities, governing board meeting minutes, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to present or document information regarding the Quality Improvement activities at the Board of Trustees meetings so board members could exercise oversight of the quality for all patient care services for 6 of 28 patient care services (Infection Prevention, Activities, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, and Orthopedic Clinic) and 5 of 6 contracted patient care services (Anesthesia, Echocardiogram, Nuclear Medicine, Magnetic Resonance Imaging (MRI), and Tele Health - psychiatry) for quality of care. Failure of the CAH Board of Trustees to review and evaluate Quality Improvement information could potentially result in the Board of Trustees' inability to provide effective oversight to the Quality Improvement committee and result in the CAH staff delaying actions to correct any identified deficiencies in the quality of care provided to patients at the CAH.

The CAH administrative staff identified the CAH staff provided activities for 73 Swing Bed patients admitted from 7/1/2018 to 6/30/2019. The CAH administrative staff identified the CAH staff provided care to 112 patient visits for Wound Clinic, 582 patient visits for Behavioral Health Clinic, 2268 patient visits for Pediatric Clinic, and 1115 patient visits for Orthopedic Clinic. The CAH administrative staff identified the contracted staff performed 1232 Echocardiogram procedures, 21 Nuclear Medicine procedures, 280 MRI procedures, and 20 Tele Health - psychiatry visits from 7/1/2017 to 6/30/2018. The CAH administrative staff identified the contracted staff performed approximately 30 Anesthesia procedures per month.

Findings include:

1. Review of the "Continuous Quality Improvement (CQI)," dated 6/2019, revealed in part, "The CQI program encompasses all departments and services of the hospital, including those provided under contract ... A summary of CQI reports are reported to the GCH Board of Trustees and Medical Staff by either the Quality & Safety Coordinator or Director of Clinical Safety, Quality, & Compliance...."

2. Review of the CQI Reports from July 2018 through June 2019 revealed the reports lacked documentation which showed the CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for Infection Prevention, Activities, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, and Orthopedic Clinic and contracted patient care services for Anesthesia, Echocardiogram, Nuclear Medicine, Magnetic Resonance Imaging (MRI), and Tele Health - psychiatry.

3. Review of the Board of Trustees Meeting minutes from July 12, 2018 through June 13, 2019 revealed the meeting minutes lacked documentation the Board of Trustees members reviewed and evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for Infection Prevention, Activities, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, and Orthopedic Clinic and contracted patient care services for Anesthesia, Echocardiogram, Nuclear Medicine, Magnetic Resonance Imaging (MRI), and Tele Health - psychiatry.

4. During an interview on 8/14/2019 at 11:10 AM, The Director of Clinical Services acknowledged the CQI Reports from July 2018 through June 2019 revealed the reports lacked documentation which showed the CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for Infection Prevention, Activities, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, and Orthopedic Clinic and contracted patient care services for Anesthesia, Echocardiogram, Nuclear Medicine, Magnetic Resonance Imaging (MRI), and Tele Health - psychiatry.

During an interview on 8/15/2019 at 12:30 PM, the Chief Nursing Officer (CNO) confirmed the Board of Trustees Meeting minutes from July 12, 2018 through June 13, 2019 revealed the meeting minutes lacked documentation the Board of Trustees members reviewed and evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for Infection Prevention, Activities, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, and Orthopedic Clinic and contracted patient care services for Anesthesia, Echocardiogram, Nuclear Medicine, Magnetic Resonance Imaging (MRI), and Tele Health - psychiatry.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure the nursing staff performed a full count of all the surgical sponges in the operating room during 1 of 1 observed surgical procedure (Patient #7). Failure of the nursing staff to perform a full count of all the surgical sponges in the operating room could potentially result in the surgical staff leaving a surgical sponge in the patient's body, potentially causing pain, infection, or death. The CAH's administrative staff identified the surgical staff performed 360 surgical procedures for the fiscal year ending

Findings include:

1. Review of the "Counts: Prevention of Retained Surgical Items--Sharps, sponges, instrument accountability Policy," review date 02/2019, revealed in part, "Documentation of all surgical counts performed (and their results) during the surgical procedure will be reflected on the patient's intraoperative chart."

2. Review of the guideline "Retained Surgical Instrument," by the Association of periOperative Nurses (AORN), revealed in part, "The RN circulator should ... initiate the count ... [and] record ... the counts of soft goods, sharps, miscellaneous items, and items placed in the wound ..."

3. Observations on 8/13/2019 beginning at 11:38 AM before Patient #7's total knee replacement surgical procedure in Operating Room (OR) #1, revealed the following:

--11:42 AM Registered Nurse (RN) D opened sterile lap sponges (sponges used to absorb blood and body fluids) to the sterile field during the set-up of the surgical procedure and the lap sponges fell off the sterile field onto the floor. The lap sponges remained on the floor.

--12:48 AM RN B and RN V completed the pre-op sponge, needle and instrument counts. The lap sponges remained on the floor. RN B and RN V did not include the lap sponges on the floor in the count of all surgical instruments.

--13:10 PM RN E collected the lap sponges from the floor. RN E proceeded to throw the lap sponges into the garbage receptacle. RN E failed to count the lap sponges prior to discarding the lap sponges sitting on the floor.

4. During an interview on 8/14/2019 at 9:20 AM, the OR Manager stated "If the laps had been left on the floor, I would have picked them up and then would place the laps in the corner of the nurse's counter. I would announce to the OR team that the uncounted laps from the floor had been placed in the corner. I would not discard the laps until after the surgery case." The OR Manager admitted they saw the lap sponges in the garbage receptacle. The OR Manager confirmed the OR staff should follow the AORN standards, including the standards for retained surgical instruments.

Based on review of policies/procedures, meeting minutes, documents, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals, including a physician and a mid-level provider, reviewed all patient care policies annually for 6 of 25 patient care departments (Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, Internal Medicine Clinic, Orthopedic Clinic, and Weight Loss Management Clinic). The CAH administrative staff identified a census of 4 patients at the beginning of the survey. Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of the CAH policy "Critical Access Hospital Advisory Committee (CAHAC)," dated 8/2018, revealed in part, "...Patient care policies are reviewed annually by the CAHAC...."

2. Review of "Critical Access Hospital Advisory Committee (CAHAC) Meeting Minutes," dated from
9/7/2018 through 6/14/2019, lacked evidence the CAHAC approved the policies for Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, Internal Medicine Clinic, Orthopedic Clinic, and Weight Loss Management Clinic.

3. Review of the GCH Clinic Policy Manual Summary Sheet revealed the lack of specific patient care policies for the Behavioral Health Clinic, Pediatric Clinic, Internal Medicine Clinic, Orthopedic Clinic, and Weight Loss Management Clinic

4. During an interview on 8/13/2019 at 3:00 PM, the Chief Nursing Officer (CNO) acknowledged the lack of policies for the wound clinic.

5. During an interview on 8/15/2019 at 8:40 AM, the Clinic Director verified the lack of specific patient care policies for Behavioral Health Clinic, Pediatric Clinic, Internal Medicine Clinic, Orthopedic Clinic, and Weight Loss Management Clinics. The Clinic Director acknowledged the above stated clinics follow the general GCH policies.

I. Based on document review and staff interview, the Critical Access Hospital (CAH) failed to implement an effective infection prevention surveillance program for outpatients and hospital personnel which included a clearly defined process for surveillance and tracking of all lab cultures, monitoring hand hygiene, and tracking of hospital personnel's illnesses. Failure to track outpatient lab cultures, monitor hand hygiene, and track hospital personnel's illness may result in missed opportunities to identify, investigate, and control infections, potentially allowing the spread of communicable diseases to the hospital's patients, staff, and the community. The CAH administrative staff identified 152 staff members worked at the CAH, approximately 30,100 outpatient visits from July 1, 2017 to June 30, 2018.

Findings include:

1. Review of the Infection Prevention policies revealed the policies lacked a policy which addressed surveillance and tracking of all lab cultures, monitoring hand hygiene, and tracking of hospital personnel's illnesses.

2. Review of an undated document, "Distribution of Culture Results," revealed the Infection Prevention nurse would monitor inpatient lab cultures and the Pharmacist would review inpatient and emergency department patient lab cultures. Upon further review of the document, the document only addressed Guthrie County Hospital (GCH) clinic patient lab cultures would be reported electronically to the physician.

The documented failed to address who would monitor outpatient lab cultures for wound clinic, pediatric clinic orthopedic clinic, GCH clinic, and outpatient surgery patients.

Review of documentation revealed the lack of evidence hand hygiene was monitored in 2 of 2 off site locations (GCH Adair and Panora Clinics).

Review of documentation lacked evidence of tracking employee illnesses.

3. During an interview on 8/12/2019 at 3:40 PM, the Infection Prevention nurse verified the lack of an Infection Prevention Plan including Infection Prevention Surveillance policy. The Infection Prevention nurse confirmed she only looked at inpatient lab cultures but not any outpatient lab cultures and does not have a system to track all lab cultures.

During an interview on 8/15/2019 at 8:25 AM, the Infection Prevention nurse confirmed the CAH lacked a mechanism to track outpatient lab cultures and employee illnesses. The Infection Prevention nurse further verified the staff did not monitor hand hygiene in the 2 off site locations (GCH Adair and Panora Clinics).



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II. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure surgical staff sanitized their hands after glove use during 1 of 1 observed surgical procedures (Patient #7). Failure to ensure surgical staff followed approved infection control standards of practice in accordance with the Centers for Disease Control (CDC) recommendations could potentially result in the surgical staff failing to remove bacteria which contaminated their hands during a procedure and potentially transmit the bacteria to another patient, potentially causing a life-threatening infection. The CAH's administrative staff identified the surgical staff performed 360 surgical procedures for the fiscal year 2018 (July 1, 2017 to June 30, 2018).

Findings include:

1. Review of the "Hand Hygiene Policy," reviewed 2/2019, revealed in part. "It is the expectation that hand hygiene and appropriate glove use will be practiced at the appropriately 100% of the time (sic)."

2. Review of the policy "Hand Hygiene Surgical Scrub," reviewed 2/2019, revealed in part "Purpose: To provide guidance for hand hygiene for surgical and other invasive procedures." "The key moments when health care workers should perform hang hygiene include: ... Before touching a patient ... Before clean/aseptic procedures ... After touching a patient ..."

3. Review of the Centers for Disease Control and Prevention ' s (CDC) " Guideline for Hand Hygiene in Health-Care Settings, " dated 10/25/02, revealed in part, " Indications for handwashing and hand [hygiene] ... [perform hand hygiene] before inserting indwelling urinary catheters ... or other invasive devices [such as a spinal needle] ... [perform hand hygiene] after removing gloves ... "


4. Observations on 8/13/19, beginning at 11:38 AM during Patient #7 total knee replacement surgery, revealed the following:

--12:13 PM Certified Registered Nurse of Anesthesia (CRNA) A removed their non-sterile gloves and failed to perform hand hygiene.

--12:33 PM CRNA A donned sterile gloves prior to performing the invasive procedure of inserting a needle into Patient #7 ' s back for an epidural pain block. CRNA A failed to perform hand hygiene prior to donning their sterile gloves.

--12:40 PM CRNA A removed their sterile gloves and failed to perform hand hygiene.

--12:48 PM CRNA A donned sterile gloves prior to performing the invasive procedure of inserting a needle into Patient #7 ' s back for an epidural pain block. CRNA A failed to perform hand hygiene prior to donning their sterile gloves.

--1:04 PM CRNA A removed their sterile gloves and failed to perform hand hygiene.

--1:07 PM Registered Nurse (RN) B removed their non-sterile gloves and failed to perform hand hygiene. RN B donned sterile gloves to insert an Foley urinary catheter into Patient #7. RN B failed to perform hand hygiene prior to donning their sterile gloves.

--1:14 PM RN B and RN D removed their non-sterile gloves and failed to perform hand hygiene.

--1:16 PM RN B removed their non-sterile gloves and failed to perform hand hygiene. RN B donned sterile gloves to perform the surgical prep scrub (a process of cleaning the patient ' s skin prior to surgery). RN B failed to perform hand hygiene prior to donning the sterile gloves.

--1:23 PM RN E removed their non-sterile gloves and failed to perform hand hygiene.

--1:25 PM RN D removed their non-sterile gloves and failed to perform hand hygiene.

--1:29 PM RN D changed their non-sterile gloves and failed to perform hand hygiene.

--1:30 PM RN D removed their non-sterile gloves and failed to perform hand hygiene.

--1:44 PM RN B removed their non-sterile gloves and failed to perform hand hygiene.

--2:10 PM RN B removed their non-sterile gloves and failed to perform hand hygiene.

--2:23 PM RN B removed their non-sterile gloves and failed to perform hand hygiene.

--2:26 PM RN B removed their non-sterile gloves and failed to perform hand hygiene.

--2:44 PM RN B removed their non-sterile gloves and failed to perform hand hygiene.

--2:47 PM RN B received a surgical specimen from Patient #7 for post-surgical examination. RN B failed to wear gloves when they received the surgical specimen.

--2:50 PM RN D removed their non-sterile gloves and failed to perform hand hygiene.

--2:51 PM RN D crawled on the OR floor. RN D failed to perform hand hygiene after getting off the floor.

--2:58 PM RN D removed their non-sterile gloves and failed to perform hand hygiene.

--3:00 PM RN D removed their non-sterile gloves and failed to perform hand hygiene.

--3:10 PM RN V removed their non-sterile gloves and failed to perform hand hygiene.

--3:17 PM RN V removed their non-sterile gloves and failed to perform hand hygiene.

4. During an interview on 8/14/2019 at 9:20, Operating Room (OR) Manager revealed they expected the surgical staff to perform hand hygiene at the beginning of the day and whenever the surgical staff donned sterile gloves, including before inserting an urinary catheter. The OR Manager did not know the CDC guidelines for glove usage and hand hygiene.

Based on observation, document review, and staff interviews, Critical Access Hospital (CAH) administrative staff failed to ensure CAH staff tested the laboratory staff, nursing staff, and medical providers for color blindness so staff could correctly interpret the test results for occult blood (blood in the stool) for 1 out of 1 Laboratory Manager, 2 out of 2 Laboratory Technicians (Laboratory Technician G and Laboratory Technician L), 5 out of 5 nursing staff (RN F, RN I, RN J, LPN H and LPN K), 6 out of 6 medical doctors (Medical Doctor M, Medical Doctor N, Medical Doctor Q, Medical Doctor R, Medical Doctor S, and Medical Doctor T), and 2 out of 2 Advanced Registered Nurse Practitioners (ARNP, ARNP O and ARNP P) reviewed. Failure to test laboratory staff, nursing staff, and medical providers for color blindness before performing this test could potentially result in staff misreading the results of the Hemoccult slide, which could potentially adversely affect the diagnosis and treatment plan for patients. The CAH identified a census of 4 patients on entrance, and performed approximately 14 occult blood tests from 8/15/2018 to 8/15/19 in the Emergency Department, Inpatient Medical/Surgical floor performed approximately 13 occult blood test from 8/15/2018 to 8/15/2019, the Off-site Guthrie Center Clinic in Panora performed approximately 5 occult blood test in the last year, and Offsite Guthrie Center Clinic in Adair preformed 1 occult blood test in the last year.

Findings include:

1. Observation on 8/12/19/2019 at 2:15 PM during a tour of the Medical Clinic in Panora with the Clinic Nurse LPN H, revealed Medical Clinic staff utilized Beckman Coulter Hemoccult Slides for testing of occult blood (blood in the stool).

2. During an interview on 8/12/2019 at 10:12 AM with the Laboratory Manager, the Laboratory Manager revealed the laboratory staff read occult blood results during laboratory hours. The Laboratory Manager confirmed they did not test the laboratory staff for color blindness.

During an interview on 8/15/2019 at 8:30 AM, the Manager of Infection Prevention, Employee Health and Outpatient Services revealed the CAH staff did not perform color blindness testing on individuals who could interpret the Hemoccult test results.

During an interview on 8/14/2019 at 3:33 PM with Emergency Department (ED) RN U revealed the ED staff utilized Beckman Coulter Hemoccult Slides for testing of occult blood (blood in the stool), confirmed the nursing staff read Hemoccult card results. If the test did not show clear results, the nurse would consult with the medical doctor. ED RN U acknowledged the CAH staff did not test the ED nursing staff for color blindness.

3. Review of personnel files revealed the following:

a. Review of the Laboratory Manager's personnel file revealed the CAH staff did not test the Laboratory Manager for color blindness.
b. Review of Laboratory Technician G's personnel file revealed the CAH staff did not test Laboratory Technician G for color blindness.
c. Review of Laboratory Technician L's personnel file revealed the CAH staff did not test Laboratory Technician L for color blindness.
d. Review of RN F's personnel file revealed the CAH staff did not test RN F for color blindness.
e. Review of LPN H's personnel file revealed the CAH staff did not test LPN H for color blindness.
g. Review of RN I's personnel file revealed the CAH staff did not test RN I for color blindness.
h. Review of RN J's personnel file revealed the CAH staff did not test RN J for color blindness.
i. Review of LPN K's personnel file revealed the CAH staff did not test LPN K for color blindness.
j. Review of Medical Doctor M's credential file revealed the CAH staff did not test Medical Doctor M for color blindness.
k. Review of Medical Doctor N's credential file revealed the CAH staff did not test Medical Doctor N for color blindness.
l. Review of Medical Doctor Q's credential file revealed the CAH staff did not test Medical Doctor Q for color blindness.
m. Review of Medical Doctor R's credential file revealed the CAH staff did not test Medical Doctor R for color blindness.
n. Review of Medical Doctor S's credential file revealed the CAH staff did not test Medical Doctor S for color blindness.
o. Review of Medical Doctor T's credential file revealed the CAH staff did not test Medical Doctor T for color blindness.
p. Review of ARNP O's credential file revealed the CAH staff did not test ARNP O for color blindness.
q. Review of ARNP P's credential file revealed the CAH staff did not test ARNP P for color blindness.

4. During an interview on 8/15/2019 at 8:30 AM, the Manager of Infection Prevention, Employee Health and Outpatient Services revealed the CAH staff did not perform color blindness testing on individuals who could interpret the Hemoccult test results.

5. Review of the manufacture's directions for the Beckman Coulter Hemoccult Slides, copyright 2015, revealed in part, "The Hemoccult test is a rapid and qualitative method for detecting fecal occult blood (blood in the stool). Read results within 60 seconds, a blue color will appear on the slide after two drops of developer applied directly over the fecal (stool) smear if positive for blood ... Because this test is visually read and requires color differentiation, it should not be interpreted by individuals with blue color deficiency (blindness)..."

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the periodic evaluation of its total program included a representative sample of both active and closed clinical records for 25 of 25 patient care services provided (Food Service, Respiratory Therapy, Surgery, Anesthesia, Laboratory, Nursing, GCH [Guthrie County Hospital] Clinics, Medical Imaging, Physical Therapy, Speech Therapy, Social Services, Activities, Pulmonary Rehabilitation, Pharmacy, Cardiac Rehabilitation, Diabetic Education, Outpatient Infusion, Pain Management, Emergency Department, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, Internal Medicine Clinic, Orthopedic Clinic, and Weight Loss Management Clinic). Failure to include a representative sample of both active and closed clinical records for all patient care services provided in the annual Total Program Evaluation could potentially result in failure to identify potential changes needed in services provided at the CAH. The CAH staff identified a current census of 4 inpatients at the start of the survey.

Findings include:

1. Review of the CAH policy "Critical Access Hospital Annual Evaluation," dated 3/2018, revealed in part, "Guthrie County Hospital will conduct an annual evaluation to determine if the utilization of its services is appropriate, established policies are followed, and if any changes to its services are needed ... At a minimum, the evaluation will include a review of: ... A representative sample of both active and closed clinical records."

2. Review of the "CAH Annual Report 2018" revealed the annual program evaluation lacked documentation the CAH staff reviewed a sample of both active and closed clinical records for Food Service, Respiratory Therapy, Surgery, Anesthesia, Laboratory, Nursing, GCH [Guthrie County Hospital] Clinics, Medical Imaging, Physical Therapy, Speech Therapy, Social Services, Activities, Pulmonary Rehabilitation, Pharmacy, Cardiac Rehabilitation, Diabetic Education, Outpatient Infusion, Pain Management, Emergency Department, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, Internal Medicine Clinic, Orthopedic Clinic, and Weight Loss Management Clinic

3. During an interview on 8/14/2019 at 10:45 AM, the Director of Clinical Services verified the annual evaluation of the CAH Annual Program Evaluation lacked documentation the CAH staff performed a review of a sample of both active and closed clinical records for Food Service, Respiratory Therapy, Surgery, Anesthesia, Laboratory, Nursing, GCH [Guthrie County Hospital] Clinics, Medical Imaging, Physical Therapy, Speech Therapy, Social Services, Activities, Pulmonary Rehabilitation, Pharmacy, Cardiac Rehabilitation, Diabetic Education, Outpatient Infusion, Pain Management, Emergency Department, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, Internal Medicine Clinic, Orthopedic Clinic, and Weight Loss Management Clinic.

Based on review of the Quality Plan, Quality activities, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to evaluate 6 of 28 patient care services (Infection Prevention, Activities, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, and Orthopedic Clinic) and 5 of 6 contracted patient care services (Anesthesia, Echocardiogram, Nuclear Medicine, Magnetic Resonance Imaging (MRI), and Tele Health - psychiatry) for quality of care. Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

The CAH administrative staff identified the CAH staff provided activities for 73 Swing Bed patients admitted from 7/1/2018 to 6/30/2019. The CAH administrative staff identified the CAH staff provided care to 112 patient visits for Wound Clinic, 582 patient visits for Behavioral Health Clinic, 2268 patient visits for Pediatric Clinic, and 1115 patient visits for Orthopedic Clinic. The CAH administrative staff identified the contracted staff performed 1232 Echocardiogram procedures, 21 Nuclear Medicine procedures, 280 MRI procedures, and 20 Tele Health - psychiatry visits from 7/1/2017 to 6/30/2018. The CAH administrative staff identified the contracted staff performed approximately 30 Anesthesia procedures per month.

Findings include:

1. Review of the "Continuous Quality Improvement (CQI)," dated 6/2019, revealed in part, "The CQI program encompasses all departments and services of the hospital, including those provided under contract...."

2. Review of the Continuous Quality Improvement Reports from July 2018 through June 2019 revealed the reports lacked documentation which showed the CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for Infection Prevention, Activities, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, and Orthopedic Clinic and contracted patient care services for Anesthesia, Echocardiogram, Nuclear Medicine, Magnetic Resonance Imaging (MRI), and Tele Health - psychiatry.

3. During an interview on 8/14/2019 at 11:10 AM, the Director of Clinical Services acknowledged the reports lacked documentation which showed the CAH staff evaluated services provided to CAH patients through ongoing monitoring, conclusions, recommendations, and actions taken to improve quality/performance for Infection Prevention, Activities, Wound Clinic, Behavioral Health Clinic, Pediatric Clinic, and Orthopedic Clinic and contracted patient care services for Anesthesia, Echocardiogram, Nuclear Medicine, Magnetic Resonance Imaging (MRI), and Tele Health - psychiatry.

Based on review of swing bed patient rights and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights to include the right to:

a. choose his or her attending physician,
b. retain and use personal possessions, including furnishings and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other patients,
c. share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement,
d. choose to or refuse to perform services for the facility and the facility must not require a patient to perform services for the facility,
e. receive information before, or at the time of admission, and periodically during the patient's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate,
f. provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time.

The CAH administrative staff identified a census of 2 swing bed patients at the beginning of the survey and an average of 6 swing bed patients admitted per month. Failure to present all of the required rights to the patients admitted to swing bed and/or their legal representatives could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This lack of awareness compromises the swing bed patients' ability to exercise their rights.

Findings include:

1. Review of a document provided to swing bed patients titled "Patient Rights and Responsibilities Guthrie County Hospital," dated 06/2019, failed to inform the swing bed patient of their right to:

a. choose his or her attending physician,
b. retain and use personal possessions, including furnishings and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other patients,
c. share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement,
d. choose to or refuse to perform services for the facility and the facility must not require a patient to perform services for the facility,
e. receive information before, or at the time of admission, and periodically during the patient's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate.
f. provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time.

2. During an interview on 08/13/2019 at 03:15 PM, the Chief Nursing Office confirmed the CAH staff failed to inform swing bed patients of all their rights while a swing bed patient at the CAH.

Based on review of policies, patient medical records, and staff interview, the Critical Access Hospital (CAH) swing bed staff failed to perform a comprehensive activities assessment and develop an activities care plan for 2 of 2 (Patient #26 and Patient #27) open and 4 of 4 (Patient #28, Patient #29, Patient #30, and Patient #31) closed swing bed patient medical records reviewed. Failure to perform a comprehensive activities assessment and develop an activities care plan that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well-being and independence possible. The CAH administrative staff identified an average of 6 swing bed patient admissions per month and a census of 2 swing bed patients on entrance.

Findings include:

1. Review of the swing bed policy, "Skilled Nursing Services," revised 06/2019, revealed in part, "...Upon admission ... members of the [swing bed] team will conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each patient's functional capacity ... The comprehensive assessment will include, at a minimum, the following ... psychosocial well-being ... activity pursuit ..."

Review of the swing bed policy, "Activities Program," revised 12/2018, revealed, in part, "Program design must reflect the interests or ability levels of the patients...."

2. Review of 2 of 2 open and 4 of 4 closed swing bed patient medical records on 08/12/2019 revealed the following information:

a. The CAH staff admitted Patient #26 to swing bed services on 08/05/2019. Patient #26's medical record lacked evidence the CAH staff performed a comprehensive activities assessment and developed an activities care plan that directed staff to provide individual or group activities chosen by the patient.

b. The CAH staff admitted Patient #27 to swing bed services on 08/06/2019. Patient #27's medical record lacked evidence the CAH staff performed a comprehensive activities assessment and developed an activities care plan that directed staff to provide individual or group activities chosen by the patient.

c. The CAH staff admitted Patient #28 to swing bed services on 07/16/2019 and discharged on 07/24/2019. Patient #28's medical record lacked evidence the CAH staff performed a comprehensive activities assessment and developed an activities care plan that directed staff to provide individual or group activities chosen by the patient.

d. The CAH staff admitted Patient #29 to swing bed services on 07/12/2019 and discharged on 07/15/2019. Patient #29's medical record lacked evidence the CAH staff performed a comprehensive activities assessment and developed an activities care plan that directed staff to provide individual or group activities chosen by the patient.

e. The CAH staff admitted Patient #30 to swing bed services on 07/09/2019 and discharged on 07/15/2019. Patient #30's medical record lacked evidence the CAH staff performed a comprehensive activities assessment and developed an activities care plan that directed staff to provide individual or group activities chosen by the patient.

f. The CAH staff admitted Patient #31 to swing bed services on 07/05/2019 and discharged on 07/09/2019. Patient #31's medical record lacked evidence the CAH staff performed a comprehensive activities assessment and developed an activities care plan that directed staff to provide individual or group activities chosen by the patient.

3. During an interview on 08/13/2019 at 09:50 AM, the Activity Coordinator acknowledged she was responsible for completing a comprehensive activity assessment and providing an activity program for swing bed patients. The Activity Coordinator verified she failed to document a comprehensive activity assessment and develop and implement an ongoing activities program that included an activities care plan for swing bed Patient #26, Patient #27, Patient #28, Patient #29, Patient #30, and Patient #31.