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I. Based on observations, document review, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to create and implement an effective system to ensure staff detected when hot water temperatures exceeded the CAH's acceptable range for hot water (between 110 - 120 degrees Fahrenheit) in the Radiology Department bathroom, the Laboratory (Lab) bathroom, Medical/Surgical (Med/Surg) Unit patient rooms, and 1 of 2 public restrooms. Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury related directly to the temperature and duration of exposure to the hot water. Exposure to hot water at 133 degrees Fahrenheit can cause a third degree burn (destruction of the outer layer of skin and the entire layer beneath) to occur is 15 seconds, one minute at 127 degrees Fahrenheit, and 3 minutes at 124 degrees Fahrenheit. The CAH's administrative staff reported approximately 48 radiology patient visits per month, approximately 550 laboratory patient visits per month, 113 Med/Surg Unit inpatients from January 2021 to July 2021, and census of 3 patients upon entrance of survey.

Findings include:

1. Observations on 7/12/2021 at approximately 1:40 PM, during a tour of the Radiology Department with the Radiology Manager, revealed the following hot water temperature at the hand washing sink in 1 of 1 patient bathroom:

a. Radiology patient bathroom sink 126.7 degrees Fahrenheit

2. Observations on 7/12/2021 at approximately 12:50 PM, during a tour of the Lab with the Lab Manager, revealed the following hot water temperature at the hand washing sink in 1 of 1 patient bathroom:

a. Laboratory patient bathroom sink 126.5 degrees Fahrenheit and 126 degrees Fahrenheit during observation with Maintenance Supervisor on 7/12/2021 at 1:46 PM

3. Observations on 07/12/2021 at approximately 9:35 AM, during a tour of the Med/Surg Unit with the Assistant Director of Nursing (DON), revealed the following hot water temperatures in 3 of 4 patient rooms:

a. Patient room #112 hand washing sink 122 degrees Fahrenheit and bathroom sink 123.8 degrees Fahrenheit
b. Patient room #113 hand washing sink 126.9 degrees Fahrenheit and bathroom sink 125.6 degrees Fahrenheit
c. Patient room #114 hand washing sink 122.5 degrees Fahrenheit, Hospice room kitchen sink 127.4 degrees Fahrenheit

4. Observations on 07/12/2021 at approximately 11:45 AM in Administration women's bathroom, revealed the following hot water temperature at the hand washing sink:

a. Administration women's bathroom sink 128.8 degrees Fahrenheit and 126.9 degrees Fahrenheit during observation with Maintenance Supervisor on 07/12/2021 at 1:42 PM

5. Observations on 07/12/2021 at approximately 11:55 AM in CAH front lobby women's bathroom, revealed the following hot water temperature at the hand washing sink:

a. Front lobby women's bathroom sink 120.4 degrees Fahrenheit


6. Review of the documents "Water Temperature Logs" revealed:

a. for the month of March 2021, the maintenance staff checked the water temperatures at the CAH and documented the hot water temperatures at the CAH between 116 - 118 degrees Fahrenheit.

b. for the month of April 2021, the maintenance staff checked the hot water temperatures at the CAH and documented the hot water temperatures at the CAH between 114 - 118 degrees Fahrenheit.

c. for the month of May 2021, the maintenance staff checked the hot water temperatures at the CAH and documented the hot water temperatures at the CAH between 113 - 118 degrees Fahrenheit.

d. for the month of June 2021, the maintenance staff checked the hot water temperatures at the CAH and documented the hot water temperatures at the CAH between 117 - 120 degrees Fahrenheit.

The documentation revealed that the maintenance staff failed to detect the hot water temperatures in the CAH exceeded the CAH's acceptable range for hot water temperatures.


7. Review of "Water Temperature" policy, reviewed 3/23/21, revealed in part, "Maintenance will record the temperature of the water in the system and it shall be maintained between 110 degrees and 120 degrees."

8. During an interview on 07/13/2021 at 7:55 AM, the Maintenance Supervisor acknowledged the water temperatures exceeded the CAH's acceptable limit for hot water temperatures (120 degrees Fahrenheit) and the maintenance staff failed to previously identify the elevated hot water temperatures.





II. Based on observation, document review and staff interviews the Critical Access Hospital (CAH) staff failed to provide a multi patient use glucometer (a medical device used for determining the approximate concentration of glucose in the blood. A small drop of blood, obtained by pricking the skin with a lancet, is place on a disposable test strip that the meter reads and uses to calculate the blood glucose level) and glucometer specific strips for measuring accurate blood glucose (the main type of sugar in the blood and is the main source of energy for the body's cells) for patient care using 1 of 1 glucometer. Failure to provide multi patient use glucometers with the appropriate usage of controls (solutions used to test the functionality of the meter and test strips) may result in inaccurate blood glucose readings which may lead to inappropriate patient care and harm. The CAH administrative staff reported approximately 12 acute/swing bed patients with orders requiring accucheck monitoring from April - July 2021. The patient census was 3 on the day of entrance.

Findings include:

1. Observation on 07/12/2021 at 10:30 AM, during a tour of the Med/Surg Unit, revealed an "ACCU-CHEK Aviva Plus" blood glucose monitor intended for single patient usage was available for blood sugar monitoring.

2. Review of the Roche Diagnostics manufacturer's information for ACCU-CHEK Aviva Plus Blood Glucose Monitoring System, dated 2014, revealed in part, "This system is intended to be used by a single person and should not be shared."

3. During an interview at the time of the Med/Surg Unit tour, Assistant Director of Nursing and Staff A RN verified using the ACCU-CHEK Aviva Plus blood glucose monitor on multiple patients and were not aware the ACCU-CHECK Aviva Plus blood glucose monitor was a single patient use device.

4. During an interview on 07/13/2021 at 11:40 AM, the Director of Nursing (DON) acknowledged the blood glucose monitoring system should be a multiple patient usage device for monitoring blood sugars.





III. Based on observation and staff interviews, the Critical Access Hospital (CAH) failed to remove outdated supplies from the Medical/Surgical Unit (Med/Surg) and Emergency Department (ED). Failure to remove outdated patient supplies from the CAH's Med/Surg and ED resulted in expired supplies remaining available for use in patient care, potentially resulting in staff using the expired items for patient care after the manufacturers' expiration date (the date after which the manufacturer will no longer guarantee the safety and quality of the supply). The CAH identified approximately 198 ED patient visits per month for 2020 fiscal year (July 1-June 30) and census of 3 patients at the beginning of the survey.

Findings include:

1. Observations during a tour on the MED/Surg Unit on 07/12/2021 at approximately 9:35 AM, revealed the following expired supplies:

Whirlpool room
a. 1 of 2 boxes Halyard Purple Nitrile Powder-Free Exam gloves, size small, expired 01/2020

In patient lab room off the nurses station
a. 1 of 1 box Kimberly Clark Purple Nitrile Powder-Free Gloves, size small, expired 06/2018

2. Observations during a tour of the ED on 07/12/2021 at 9:30 AM with the Director of Nursing (DON), revealed the following expired supplies:

Emergency Medical Service (EMS) Storage B closet
a. 43 of 43 3M Tegaderm film #1624W (used as a protective dressing/cover over at-risk skin), expired 02/2021
b. 6 of 6 BD SafetyGlide Needles 25Ga x 1 in (0.5 mm x 25mm), expired 05/31/2021

EMS Storage A closet
a. 2 of 2 Introducer/Bougie Endotracheal Tube (an effective and inexpensive adjunct to difficult airway management) Adult size 15FR x 70cm, 1 expired 06/05/2021 and 1 expired 05/02/2021.

Trauma room #1 PEDs Crash Cart
a. 1 of 1 Mallinckrodt Intubating Stylet (Covidien) 10Fr/CH (3.3cm), expired 04/11/2021


3. Review of "Outdated Medication and Supplies-Checking of" policy, revised 10/2014, revealed in part, "To ensure that all patient care medication and supplies are current and safe to use."

4. During an interview at the time of the tour of the Med/Surg Unit, the Assistant Director of Nursing (ADON) revealed they expected the Med/Surg staff to check the supplies every month and remove any outdated supplies. The ADON acknowledged the Med/Surg staff failed to remove the expired supplies from the Med/Surg Unit. The ADON then acknowledged, that since the Med/Surg staff failed to remove the expired supplies from the unit, the Med/Surg staff could potentially use the expired supplies for patient care.

5. During interviews at the time of the ED tour, the DON and Ambulance Manager revealed they expected the ED/EMS staff to check the supplies every month and remove any outdated supplies. The DON and Ambulance Manager acknowledged the ED/EMS staff failed to remove the expired supplies from the ED/EMS Storage closets. The DON and Ambulance Manager then acknowledged, that since the ED/EMS staff failed to remove the expired supplies from the ED, the ED/EMS staff could potentially use the expired supplies for patient care.

I. Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 4 of 5 Emergency Room practitioners (Emergency Room Physician Assistant B, Emergency Room Physician C, Emergency Room Physician D and Emergency Room Physician Assistant E), selected for review, held approved delineated privileges for inpatient care. Failure to ensure practitioners hold privileges specific to the care they are expected to provide could potentially result in practitioners providing care beyond the practitioner or CAH's capabilities and compromise safety of CAH patients. The CAH administrative staff reported the identified practitioners provided care to patients, from 7/1/2020 to 7/13/2021, as follows:

Emergency Room Physician Assistant B - 8 inpatients
Emergency Room Physician C - 18 inpatients
Emergency Room Physician D - 5 inpatients
Emergency Room Physician Assistant E - 12 inpatients

Findings include:

1. Review of the CAH Board of Trustees by-laws, dated 2021, revealed in part "... The Board may approve, upon recommendation of the Medical Staff, Medical Staff Bylaws which shall outline the nature and purposes for the Medical Staff ... the procedures and criteria for appointment, reappointment, limitation and termination of membership or privileges, ... The Board of Trustees shall appoint a Medical Staff comprised of physicians and other practitioners who are authorized by law and by the Board to independently exercise clinical privileges and render patient care services at the Hospital ...".

2. Review of the CAH Medical Staff by-laws, approved by the Board of Trustees on 1/20/2021, revealed in part "... Clinical Privileges or Privileges means the permission granted by the Governing Body to a Practitioner, subject to the availability of appropriate facilities, equipment, staff, and other resources at the health Center to provide specified diagnostic or therapeutic health services, subject to any limitations imposed by the Board ... The Active Staff consists of physicians who meet all the criteria for clinical and admitting privileges, who regularly admit and attend patients at the Health Center ... A Practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws ... ".

3. Review of a CAH policy titled "Medical Staff Initial Appointment and Reappointment", effective 5/18/2021, revealed in part "... [CAH] has a contract with the [Network Hospital] Clinical/Staff Office to complete primary source verification of all applicants applying for privileges at the [CAH] ... Upon receipt of the returned application the credentialing coordinator will verify that the following is current and assemble into a credentialing file designated for the practitioner ... privilege request ...".

4. Review of Emergency Room Physician Assistant B's credential file revealed a privilege request for the delineation of emergency room privileges, dated 9/4/2019, which included privileges for initial assessment and treatment of patients of all ages presenting to the Emergency Room (ER) and initial admission orders for patients admitted through the ER, along with other privileges for care that may be required in an emergency situation. The credential file lacked a delineation of privileges for ongoing assessment and treatment and additional care after an inpatient admission. The credential file showed the Medical Staff approved reappointment for Emergency Room Physician Assistant B on 11/6/2019 and approved by the Board of Trustees on 12/5/2019.

5. Review of Emergency Room Physician C's credential file revealed a privilege request for the delineation of emergency room privileges, dated 12/22/2020, which included privileges for the initial assessment and treatment of patients of all ages presenting to the Emergency Room (ER) and the initial admission orders for patients admitted through the ER, along with other privileges for care that may be required in an emergency situation. The credential file lacked a delineation of privileges for an admission from a setting other than ER and privileges for ongoing assessment, treatment and additional care after an inpatient admission from the ER. The credential file lacked a delineation of privileges for inpatient care. The credential file showed the Medical Staff approved reappointment for Emergency Room Physician C on 2/23/2021 and approved by the Board of Trustees on 3/31/2021.

6. Review of Emergency Room Physician D's credential file revealed a privilege request for the delineation of emergency room privileges, dated 8/5/2019, which included privileges for the initial assessment and treatment of patients of all ages presenting to the Emergency Room (ER) and the initial admission orders for patients admitted through the ER, along with other privileges for care that may be required in an emergency situation. The credential file lacked a delineation of privileges for an admission from a setting other than ER and privileges for ongoing assessment, treatment and additional care after an inpatient admission. The credential file lacked a delineation of privileges for inpatient care. The credential file showed the Medical Staff approved reappointment for Emergency Room Physician D on 9/10/2019 and approved by the Board of Trustees on 9/26/2019.

7. Review of Emergency Room Physician Assistant E's credential file revealed a privilege request for the delineation of emergency room privileges, dated 6/2/2020, which included privileges for the initial assessment and treatment of patients of all ages presenting to the Emergency Room (ER) and the initial admission orders for patients admitted through the ER, along with other privileges for care that may be required in an emergency situation. The credential file lacked a delineation of privileges for an admission from a setting other than ER and privileges ongoing assessment, treatment and additional care after an inpatient admission. The credential file lacked a delineation of privileges for inpatient care. The credential file showed the Medical Staff approved reappointment for Emergency Room Physician Assistant E on 7/13/2020 and approved by the Board of Trustees on 7/29/2019.

8. During an interview on 7/13/2021, at 2:30 PM, the Credentialing Coordinator reported the Emergency Room Practitioners provide services for patients in the Emergency Room and patients admitted for inpatient care and pointed out the privilege list included the admission, assessment and and treatment of patients but acknowledged the privilege identified these activities as initial, specific to the ER setting, and the delineation of privileges did not identify ongoing assessment and treatment or additional care after an inpatient admission for an inpatient stay. She confirmed the identified practitioners had one set of privileges for the Emergency Room, which did not include a delineation of privileges for inpatient care.

9. During an interview on 7/13/2021, at 2:45 PM, the Chief Executive Officer, reported approximately a year and a half ago the CAH changed their process for Emergency Room and inpatient coverage from utilizing the medical clinic practitioners to a group of 5 practitioners to cover both areas of service. He confirmed the identified practitioners provide services to Emergency Room patients and inpatients and have a single set of Emergency Room privileges and thought it would be sufficient to cover both areas.




II. Based on document review and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 2 of 2 Teleradiologists (Teleradiologist G and Teleradiologist H), selected for review, held delineated privileges specific to Teleradiology services at the CAH. Failure to ensure practitioners held delineated privileges specific to the CAH could potentially result in the CAH staff allowing a practitioner to perform a procedure beyond the capabilities of the practitioner or CAH and compromise safety of CAH patients. The CAH administrative staff reported the identified practitioners provided care to patients, from 1/1/2020 to 6/30/2021, as follows:

Teleradiologist G - 79 patients
Teleradiologist H - 32 patients

1. Review of the CAH Board of Trustees by-laws, dated 2021, revealed in part "... The Board may approve, upon recommendation of the Medical Staff, Medical Staff Bylaws which shall outline the nature and purposes of the Medical Staff ... the procedures and criteria for appointment, reappointment, limitation and termination of membership or privileges, ... The Board of Trustees shall appoint a Medical Staff comprised of physicians and other practitioners who are authorized by law and by the Board to independently exercise clinical privileges and render patient care services at the Hospital ... ...".

2. Review of the CAH Medical Staff by-laws, approved by the Board of Trustees on 1/20/2021, revealed in part "... Clinical Privileges or Privileges means the permission granted by the Governing Body to a Practitioner, subject to the availability of appropriate facilities, equipment, staff, and other resources at the health Center to provide specified diagnostic or therapeutic health services, subject to any limitations imposed by the Board ... Practitioners who, via telemedicine or from a remote site, render a diagnosis or otherwise provide clinical treatment to a patient at the Health Center shall be credentialed and privileged in accordance with these Bylaws and related Health Center and Medical Staff policies governing credentialing ... A Practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws ... If the Health Center uses the distant site credentialing and privileging process for the distant site practitioner, the following conditions must be met ... The distant site provides the Health Center with a current list of the licensed independent practitioners' privileges ... ".

3. Review of a document titled "Physician Services Agreement", effective on 7/1/2011, revealed an agreement with the Network Hospital for teleradiology coverage to the CAH on a 24 hour/7 days week basis.

4. Review of a document titled "Definition of Full Clinical Privileges and Professional Practitioner Evaluation Plan, Department of Radiology", dated 1/6/2021, revealed in part "... Full clinical privileges in Radiology include performing and interpreting imaging examinations (including radiography and fluoroscopy), ultrasound, computerized tomography (CT), magnetic resonance imaging (MR) examinations of all parts of the body including the head and neck, and extremities, and performing basic interventional or invasive procedures under imaging guidance for patients of all ages ...".

5. Review of Teleradiologist G's credential file revealed the Medical Staff approved the reappointment of Teleradiologist G, for full clinical privileges in General Radiology, on 11/4/2020 and the Board of Trustees approved the reappointment on 11/25/2020.

6. Review of Teleradiologist H's credential file revealed the Medical Staff approved the reappointment of Teleradiologist H, for full clinical privileges in General Radiology, on 9/3/2020 and the Board of Trustees approved the reappointment on 9/30/2020.

7. During an interview on 7/13/2021, at 3:30 PM, the Credentialing Coordinator explained the CAH used the distant site credentialing and privileging process of the Network Hospital for the appointment of Teleradiologists and provided a document to show the privileges identified for the Teleradiologists. She acknowledged the Teleradiologists only conduct interpretation of imaging and the privilege list identified procedures the Teleradiologists could not do since they not come on site.

8. During an interview on 7/14/2021, at 9:05 AM, the Radiology Manager reported all of the interpretation of imaging studies are performed remotely by a group of Teleradiologists. She confirmed the privileges identified procedures that are not conducted at the CAH including fluoroscopy and interventional or invasive procedures under imaging guidance.

9. During an interview on 7/14/2021, at 9:25 AM, the Chief Executive Officer confirmed the CAH has an agreement with a group of Teleradiologists for the interpretation of imaging studies and do not perform on-site services.

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician periodically reviewed the care provided for CAH patients, in conjunction with the mid-level provider, for 2 of 2 mid-level providers selected for review. (Physician Assistant B and Physician Assistant E). Failure to ensure a physician periodically reviewed mid-level provider's patient medical records, in conjunction with the mid-level provider, could potentially result in the misdiagnosis of a patient and/or providing inappropriate or substandard patient care.

The Credentialing Coordinator identified the mid-level providers provided care to patients from 7/1/2020 to 7/13/2021 as follows:

Physician Assistant B - 806 Emergency Room patients and 8 inpatients
Physician Assistant E - 12 Emergency Room patients

Findings include:

1. Review of a CAH policy, revised 10/2011, titled "Periodic Review of PA (Physician Assistant) and/or ARNP (Advanced Registered Nurse Practitioner) Records" revealed in part "... [CAH] and its medical staff are responsible for the quality of care provided to the patient population seen throughout the institution ... In conjunction with is defined as: MD/DO and Mid-Level practitioner are present together with chart in hand ... This purpose will be met by having the doctor of medicine or osteopathy (MD/DO), in conjunction with the physician assistant and/or nurse practitioner members, periodically review the CAH's inpatient records ... the record review will look for ... the appropriateness of diagnosis and treatment provided by the PA or ARNP ..."

2. Review of documentation to show physician review of appropriateness of diagnosis and treatment provided by Physician Assistant B and Physician Assistant E revealed a physician reviewed multiple charts for each Physician Assistant, over the past year, but the documented dates by the Physician occurred at a time different from the documented date by the Physician Assistants.

3. During an interview on 7/13/2021, at 4:00 PM, the Credentialing Coordinator reported their policy is to have chart review conducted by the Physician together with the Physician Assistant and thought she may be showing the wrong forms. She reported the person who coordinates the process is on vacation so will visit with one of the Physicians and verify the process.

4. During an interview on 7/14/2021, at 8:10 AM, the Credentialing Coordinator reported she visited with Emergency Room Physician C, Chief of Staff, and he reported they have not been conducting the chart review together due to scheduling difficulties. The Credentialing Coordinator acknowledged the CAH policy is for a Physician to complete record review together with the PA/ARNP's and confirmed the CAH failed to ensure Physicians fulfilled the requirement.

5. During an interview on 7/15/2021, at 9:50 AM, the Utilization Review/Social Services Registered Nurse acknowledged their CAH policy identifies a physician will conduct chart review, in conjunction with the mid-level practitioners quarterly but is only done on inpatient admission, so if they have not had any inpatient admissions the chart review is not done. She explained she thought she only needed to select inpatient admissions so does not select any patients treated by either Physician Assistant, if they did not admit them, and does not select any Emergency Room patients cared for by Physician Assistant B and Physician Assistant E. The Utilization Review/Social Services Registered Nurse confirmed she does not have any results of patient chart review, conducted between a physician and Physician Assistant E, as he had not had any inpatient admissions. She had results of patient chart review, conducted between a physician and Physician Assistant B for the second and third quarter of 2020 and the second quarter of 2021 but confirmed she did not have any results for the first and fourth quarters of 2020 or the first quarter of 2021.

Based on observation, policy review and staff interview, the Critical Access Hospital (CAH) nursing administrative staff failed to ensure the staff kept patient medical information secure from unauthorized access to pregnancy and rapid strep test results of patients posted on clipboards found in 1 of 1 Emergency Soiled Holding room. Failure to keep patient medical information confidential could potentially result in unauthorized access of a patient's personal/medical information and potentially result in unauthorized release of personal information. The CAH's nursing administrative staff identified 184 lab results from June 2015 to June 2021.

Findings include:

1. Review of the policy, "Secure Filing of Medical Records," effective 07/2000 and revised 10/2001, revealed in part, "Medical records housed within the hospital shall be kept in secured areas ...not be left unattended in areas accessible to unauthorized individuals."

2. Observation on 07/12/2021 at 12:00 PM, during a tour of the Emergency/Medical Surgical unsecured storage room called 'Emergency Soiled Holding' with DON, revealed approximately 99 rapid strep test results with patient information and 85 pregnancy test results on sheets attached to two separate clipboards hanging on the wall, allowing housekeeping access, and potentially allowing unauthorized personnel access to confidential patient information.

3. During an interview on 7/12/2021 at approximately 12:10 PM with RN I, verified housekeeping cleans this room daily. RN I also revealed this room has keys to vehicles used to transport patients stored in this room which are accessed by two contracted individuals. The room can be accessed at any time as it has no lock on it.

4. During an interview on 07/12/2021 at approximately 1:00 PM with DON revealed she was unaware any patient information was posted in this room and removed the clipboards immediately.

Based on document review and staff interviews the Critical Access Hospital (CAH) failed to ensure each patient that received CAH services had a complete and accurately documented medical record when 4 of 16 Emergency Department (ED) patient records (Patients #1, Patient #2, Patient #3) reviewed lacked complete and accurately documented medical records. The CAH failed to ensure the medical records accurately reflects the medication that was administered resulting in. The CAH administrative staff identified 16 medication errors from January 2020 to May 2021.

Findings include:

1. Review of the CAH policy, "Medication Errors," effective 09/1995 and revised 09/2011, revealed in part, "that in the event of a medication error appropriate documentation and provider notification will be completed."

Review of the CAH policy, "Documentation Guidelines," effective 01/2010 and revised 02/2012, revealed in part, "At a minimum, the medical record ...will...keep notes factual, accurate, complete, and timely."

Review of the CAH policy, "Documentation," effective 10/1996 and revised 10/2011, revealed in part, "Documentation should be clear, concise, consecutive, correct ...:

Review of the CAH policy, "Medical Record Content," revised on 7/2018, revealed in part, "Process used to validate accuracy of information."

Review of the CAH policy, "Making Corrections in the Electronic Health Record," effective 12/01/2016, revealed in part, "Ensure documentation is complete and accurate."

2. Review of charts on 07/14/2021 at 8:45 AM with HIM Assistant revealed the following:

a. Patient #1 arrived in the Emergency Room (ER) on 5/17/2021 at 4:14 PM was ordered Orbactiv (antibiotic for skin infection) intravenously (IV) 1200mg one time infusion. Patient #1 did not receive the full dose of 1200mg Orbactiv, Patient #1 was given 400mg which was infused over 159 minutes. Review of the medical record lacked no documentation was found that only 400mg of Orbactiv was given. The chart reflected the patient received 1200mg of Orbactiv was infused over 159 minutes.

During an interview on 7/14/2021 at 9:35 AM with Pharmacy Director, pharmacy discovered the mistake, notified the physician which resulted in Patient #1 returning to have the remaining 800mg of Orbactiv to be administered on 5/25/2021. The medical record documentation on 5/25/2021 did not reveal the remainder of this medication was administered to Patient #1.

b. Patient #2 arrived on 3/29/2021 at 3:52 PM in ER procedure area for an ordered scheduled infusion of IV Vancomycin (antibiotic) 300mg at a rate of 100 mL/hour. Patient #2 was infused 300mg of Vancomycin at a rate of 999 mL/hour. Medical record revealed no documentation of Vancomycin being infused at 999 mL/hour.

Patient #2 arrived on 12/22/2020 at 11:00 AM in ER procedure area for an ordered scheduled infusion of IV Vancomycin 400mg. Patient #2 received 500mg of IV Vancomycin. Medical record revealed no documentation that 500mg of IV Vancomycin was administered to Patient #2.

c. Patient #3 arrived on 3/4/2021 at 11:37 PM in ER an order for 10mg diazepam was placed. Patient #3 was given 10mg diltiazem. Medical record revealed no documentation that 10mg of diltiazem was administered to Patient #3.

3. During an interview on 7/14/2021, at 1:20 PM with Director of Nursing (DON) and Assistant Director of Nursing (ADON), revealed nursing staff will need education in regards to understanding the difference between not noting an incident in the chart verses documenting the accuracy of what was administered to the patient.

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) administrative staff failed to evaluate all patient care services, including contracted services, offered at the CAH for 3 of 7 contracted services (Speech Therapy, Occupational Therapy, and Teleradiology). The administrative staff identified a current census of 3 inpatients at the beginning of the survey. Failure to evaluate all patient care services could potentially result in the CAH staff's failure to identify, monitor, address, and improve patient care problems in each patient care area through the efforts of all involved patient care services.

Findings include:

1. Review of the CAH "Organizational Quality Assurance and Performance Improvement [QAPI] Plan," revised 1/2021, revealed in part, "... KCHC's [Keokuk County Health Center] QAPI Program encompasses all services provided by the facility and this includes any contracted services ... Contracted services shall report to the department director and the director will be responsible for assuring: the collection, analysis, evaluation and ongoing monitoring of quality related data, relevant to the services provided ...."

2. Review of the CAH's documents for January 2020 to present revealed the lack of documentation the CAH evaluated all patient care services, including contracted services, offered at the CAH (Speech Therapy, Occupational Therapy, and Teleradiology).

3. During an interview on 7/14/2021 at 9:00 AM, the QAPI Coordinator verified the lack of documented evidence of evaluation of services for Speech Therapy, Occupational Therapy, and Teleradiology.

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) administrative staff failed to utilize objective measures to evaluate organizational processes and services for all services, including contracted services, offered at the CAH for 3 of 7 contracted services (Bone Density, Ultrasound and Magnetic Resonance Imaging [MRI]). The administrative staff identified a current census of 3 inpatients at the beginning of the survey. Failure to create and implement an effective quality improvement program that included involvement of all of the CAH's departments to improve quality on a continuous basis could potentially result in the CAH staff's failure to identify, monitor, address, and improve patient care problems in each patient care area through the efforts of all involved departments.

Findings include:

1. Review of the CAH "Organizational Quality Assurance and Performance Improvement Plan," revised 1/2021, revealed in part, "...Contracted services shall report to the department director and the director will be responsible for assuring: the collection, analysis, evaluation and ongoing monitoring of quality related data, relevant to the services provided...."

2. Review of the CAH's documents from January 2020 to present revealed the CAH staff lacked evidence the quality program utilized objective measures to evaluate organizational processes and services for all services including Bone Density, Ultrasound and MRI.

3. During an interview on 7/14/2021 at 9:00 AM, the Quality Assurance Performance Improvement Coordinator verified the lack of documented evidence of utilize objective measures to evaluate organizational processes and services for all services including Bone Density, Ultrasound and MRI.