HospitalInspections.org

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH's Medical Staff approved the blood bank agreement. The Laboratory administrative staff reported the laboratory had 6 units of blood products available to CAH patients at the beginning of the survey. Failure to ensure a current, approved blood bank agreement was in place could potentially interrupt the availability of blood products needed for emergencies resulting in patient harm and/or death.

Findings include:

1. Review of the "Blood Supply and Servies Agreement" Agreement," dated 7/20/2020, revealed the CAH's Chief Executive Officer signed the agreement on 7/20/2020. The agreement lacked documentation the CAH's Medical Staff approved the agreement.

2. Review of the CAH's Medical Staff Meeting minutes for 8/11/20, 9/8/20, 10/13/20, 11/10/20, 12/8/20, 1/12/21, 2/9/21, 3/9/21, 4/13/21, 6/8/21, 8/10/21, and 9/14/21 revealed the meeting minutes lacked documentation the CAH's Medical Staff approved the Blood Product Supply Agreement.

3. During an interview on 10/13/20 at 2:30 PM, the Administrative Assistant confirmed the Blood Product Supply Agreement, dated 7/20/2020, lacked approval by the CAH's Medical Staff.

Based on document review, policy review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 4 of 8 consulting physicians (General Surgeon A, Orthopedist B, Ophthalmologist C, and Emergency Medicine Physician D) and 1 of 2 active physicians (Family Medicine Physician E) selected for review, received outside entity peer review by the Network Hospital, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital, prior to reappointment to the medical staff. Failure to ensure all medical staff members received outside entity peer review prior to reappointment, affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff identified the identified physicians provided care to patients from 1/1/2021 to 10/13/2021 as follows:

General Surgeon A - 247 surgical procedures
Orthopedic Surgeon B - 6 surgical procedures
Ophthalmologist C - 85 surgical procedures
Emergency Medicine Physician D - 979 emergency room visits
Family Medicine Physician E - 91 admissions (inpatient, swing, hospice)

Findings include:

1. Review of the CAH's network agreement, effective 4/1/13, revealed in part " ... [Network Hospital] agrees to facilitate and assist CAH in the development and administration of "an effective quality assurance program" ... a program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes, ... evaluation of the quality and appropriateness of the diagnosis and treatment furnished by ... doctors of medicine or osteopathy ...".

2. Review of a document titled "Peer Review Services Agreement", effective 8/1/13, revealed in part "... [Network Hospital] shall, upon the request of CAH, evaluate the diagnosis and treatment provided by physicians at CAH ... Services shall be provided by [Network Hospital] exclusively through physicians who (a) specialize in the same specialty as the physician being evaluated ... All services shall be appropriately documented on the appropriate form(s) ...".

3. Review of a CAH policy titled "Peer/Mid-level Review," effective 4/2021 revealed in part "... process in place to obtain information on physician patterns and the quality of care and services being provided to the patients that we serve ... The quality and appropriateness of the diagnosis and treatment furnished by physicians are evaluated. Random charts of all physicians who provide care and services at the facility ... are reviewed. The Peer Review form will be used for the review process and results will be shared as appropriate with the individual provider being reviewed. The review will be conducted by a qualified entity to meet the CAH guidelines. At least one record review from each provider is reviewed per re-credentialing period ... The results of the peer review will be discussed at the Medical Staff Meetings ...".

4. Review of the credential file for General Surgeon A revealed the medical staff approved the reappointment to the Medical Staff on 11/12/2019. The Board of Trustees approved General Surgeon A for reappointment to the Medical Staff on 11/18/2019. General Surgeon A's external peer review results showed completion on 12/9/2019, completed by Network Hospital (approximately 3 weeks after the Medical Staff and Board of Trustees reappointed General Surgeon A to the Medical Staff).

5. Review of the credential file for Orthopedist B revealed the medical staff approved the reappointment to the Medical Staff on 9/8/2020. The Board of Trustees approved Orthopedist B for reappointment to the Medical Staff on 9/28/2020. Orthopedist B's external peer review results showed completion on 10/9/2020, completed by Network Hospital Health (approximately 2 weeks after the Medical Staff and Board of Trustees reappointed Orthopedist B to the Medical Staff).

6. Review of the credential file for Ophthalmologist C revealed the medical staff approved the reappointment to the Medical Staff on 6/9/2020. The Board of Trustees approved Ophthalmologist C for reappointment to the Medical Staff on 6/22/2020. Ophthalmologist C's external peer review results showed completion on 7/1/2020, completed by Network Hospital (approximately 1 weeks after the Medical Staff and Board of Trustees reappointed Ophthalmologist C to the Medical Staff).

7. Review of the credential file for Emergency Medicine Physician D revealed the medical staff approved the reappointment to the Medical Staff on 6/9/2020. The Board of Trustees approved Emergency Medicine Physician D for reappointment to the Medical Staff on 6/22/2020. Emergency Medicine Physician D's external peer review results showed completion on 6/18/2020, completed by Network Hospital (after the Medical Staff approved Emergency Medicine Physician D for reappointment to the Medical Staff).

8. Review of the credential file for Family Medicine Physician E revealed the medical staff approved the reappointment to the Medical Staff on 12/8/2020. The Board of Trustees approved Family Medicine Physician E for reappointment to the Medical Staff on 12/21/2020. Family Medicine Physician E's external peer review results showed completion on 12/7/2020, completed by Network Hospital (but not available yet to the Medical Staff or Board of Trustees prior to approval for reappointment to the Medical Staff).

9. During an interview on 10/12/2021, at 2:45 PM, the Administrative Assistant reported they utilize their Network Hospital to conduct external peer review for the CAH medical staff. She explained a provider encounter report is reviewed approximately 3 months ahead of reappointment and one random encounter is selected to send for review. The Administrative Assistant explained they attempt to obtain a minimum of 1 review per credential cycle and the results are part of the reappointment packet, available for review by the Medical Staff and Board of Trustees. The Administrative Assistant acknowledged the CAH does not always get the external peer review results back in time for reappointment and acknowledged the reappointment proceeds without the results. She acknowledged the external peer review for General Surgeon A, Orthopedist B, Ophthalmologist C, Emergency Medicine Physician D and Family Practice Physician E did not come back in time to be considered at the time of reappointment.

The Administrative Assistant confirmed the CAH failed to ensure all Medical Staff members had external peer review results prior to reappointment, in order to assist in the evaluation of the appropriateness of diagnosis and treatment furnished to patients at the CAH.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physician notification for the occurrence of a medication error for 2 of 2 medication errors reviewed. (Patient #1 and Patient #2). Failure to notify the physician of medication errors could potentially result in the practitioner not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the practitioner making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff identified a census of 6 patients at the beginning of the survey.

Findings include:

1. Review of CAH policy, "Medication Errors," approved 4/2021, revealed in part, "... medication errors shall be reported immediately upon discovery... practitioner who ordered the medication shall be notified..."


2. Review of medication errors from September 1, 2020 to October 11, 2021 revealed the following:

a. The medical practitioner made a medication error (medication ordered once a day instead of twice a day) on 5/13/21 at 2:17 PM which involved Patient #1. The medication error was discovered on 5/19/21 [time not documented] and the practitioner was notified on 5/20/21 at 2:15 PM. Patient # 1's medication error information lacked documentation that the nursing staff immediately notified the practitioner responsible for Patient #1's medical care of the medication error.

b . The nursing staff made a medication error (medication not given) on 8/5/21 at 11:00 PM which involved Patient #2. Patient #2's medication error information lacked documentation that the nursing staff notified the practitioner responsible for Patient #2's medical care of the medication error.


3. During an interview on 10/13/2021 at 4:15 PM, the Nursing Services Manager, OR, ER, and Med/Surg, acknowledged that the medication errors had not been reported to the practitioner immediately upon discovery and/or documented that the practitioner was notified at all.