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Based on interviews and review of the telemedicine contract with a radiology entity in Grand Junction the facility failed to separately contract with a telemedicine entity in Minnesota to provide night time on call coverage needs.


The findings are :
An interview was conducted on August 28, 2012 at approximately 3:00 p.m. with the Radiology department manager. S/he stated the facility had a contract with a Radiology group in Grand Junction to interpret their xrays. Review of the contract identified the radiology group but the contract also stated in part the radiology group "agrees to interpret any/all radiology imaging performed at Rangely District Hospital on a timely basis and will be available for on-call stat readings and consultations 365 days/year. The radiology group may contract night time on-call coverage for preliminary reads with an accredited on-call radiology provider mutually agreed upon".
Rangely District Hospital failed to contract directly with this radiology telemedicine group in Minnesota ( doing night time on-call coverage) separately from the telemedicine group in Grand Junction. The night time readings would not be considered a preliminary read as direct patient care would result in the findings of that read at Rangely District Hospital. The facility must contract directly with the telemedicine group in Minnesota and not sub contract thru the radiology telemedicine group in Grand Junction. The results of the readings from the on call night time telemedicine radiologist in Minnesota are part of the patient medical record and must be maintained in the patient medical record. Any additional reads of those xrays would be considered a quality assurance function.
There was no documentation that the contract between the facility and the telemedicine group in Grand Junction had been reviewed/monitored over the past year for quality and performance standards.

Based on observation and interview the facility failed to ensure that the premises were clean and orderly.

1) The facility did not keep the grounds around the facility free of debris and the structures properly maintained.

a.) During a tour of the facility on 08/28/12 at 1:35 p.m., the facility premises had broken tree branches, leaves, cigarette butts and other trash on the ground. Windows in two patient rooms had unrepaired cracks. Stairs on the ramp across from an adjacent building were cracked and broken. Electrical breaker boxes were left unsecured and open.

b.) In an interview on 08/28/12 the Maintenance Director acknowledged the condition of the stairs and stated that the building was old and the facility would be moving to a new building across the street in a few months.

Based on observation and interview the facility failed to ensure adequate lighting in medication preparation area.

1) The facility did not have light adequate to dispense and gather medications safely.

a.) During a tour on 08/27/12 at 8:30 a.m. the medication/pharmacy room was found to be very dimly lit. There were several light bulbs that were missing or burned out and lamps were being used to augment the poor lighting. Despite the addition of light bulbs the lighting in the room was not adequate for safe preparation of medications.

Based on interview and review of facility documents, the facility failed to have medical staff assist in the development or review of policies and procedures.

The findings are :

Interview with the Chief Nursing Officer (CNO) on August 29, 2012 at approximately 11:30 a.m. and review of the facility policies and procedures there was no evidence that the facility medical staff participated in the writing, reviewing or revising many of the facility policies and procedures including but not limited to nursing, pharmacy, medical records, swing beds and infection control. Many of the policies reviewed by surveyors had not been reviewed since 2007. The CNO was advised that per the Center for Medicare and Medicaid Services (CMS) regulations, the policies and procedures are to be reviewed on an annual basis in Critical Access Hospitals.

Based on interview and review of the facility policies and procedures, the facility failed to ensure that a physician, other professional staff and an individual not a member of the CAH staff were involved in the development of the facility policies.

The finding are:

An interview with the Chief Nursing Officer on August 29, 2012 at approximately 11:30 a.m. and review of facility policies and procedures evidenced that a physician, and a person other than CAH staff were not involved in the development of the facility policies. There also was no evidence that the policies were reviewed on an annual basis as required by the CMS regulations for Critical Access Hospitals or revised as needed.

Based on review of the facility policies and procedures the facility failed to annually review their policies.

The findings are:
The facility policies and procedures for all the departments were reviewed during the survey. Many of the policies for medical records, infection control, nursing, swing beds and pharmacy had not been reviewed or revised in many years, some since 2007. There was no documentation that any professional staff were involved in the review or revision of the facility policies and procedures. Interview with the CNO on 8/29/12 at approximately 11:30 a.m. confirmed that department policies and procedures had not been reviewed annually as required in the CAH regulations.

Based on interview and review of facility documents, the facility failed to have in place a list of contracted services with services provided for each contract identified.

The findings are:
Upon entrance to the facility on August 27, 2012 at approximately 8:00 a.m. a list of contracted services/agreements was requested. Per interview with the CNO and the CEO on 8/28/12 at approximately 10 :00 a.m., no list had yet been provided to the survey team. It was noted that a list comprising all services provided to the hospital was being prepared. The list was provided to the surveyors late on 8/28/12 but was not complete. There was no contract or agreement with the organ procurement organization, an eye bank or the travel nurses company that supplied travel nurses to the facility or a telemedicine radiology group that provided night time on call coverage to the facility. During an interview with the CNO on 8/29/12 at approximately 11:30 a.m., it was noted there was no complete centralized list of services/agreements and that there was no process in place to identify or monitor the quality of the services provided to ensure performance and compliance.

Based on document review and interview the facility failed to maintain a record that included reports of consultative findings.

1) The facility did not keep radiology consultations as a part of the patient's record.

a.) A review of the medical records revealed that final radiology reports were present and initial radiology readings were not present.

b.) In an interview on 08/28/12 at 3:00 p.m., the Radiology Director stated that the initial radiology reading was consultative and was discarded and the final reading was the formal reading and was kept in the record.

Based on document review and interviews the facility failed carry out an evaluation of their quality assurance (QA) program.

Findings:

1) The Facility did not have a method or system for policies and procedures to undergo evaluation that included analysis of adverse events, errors and other quality indicators to determine the effectiveness of the QA program.

a.) The facility ' s Quality Improvement Policy, revised 04/2010, did not define how the data compiled would be included in the evaluation of the program's effectiveness. The policy did not address the method for conducting a yearly review or who would be responsible for the review of the quality program.

b.) There was no evidence in the report that evaluation of the QA program occurred or was expected.

c.) In an interview on 08/29/12 at 11:30 a.m., the Director of Nurses admitted that the program was not evaluated.

Based on document review and interview, the facility failed to audit a representative sample of clinical records as required.

1) The facility did not review clinical records to evaluate the quality of patient care.

a.) There were no chart audit documents provided for review. There was no discussion in the meeting minutes that would confirm that chart audits were conducted or that there was an expectation that chart audits would be conducted.

b.) In an interview on 08/29/12 at 11:30 a.m., the DON stated that " utilization review " occurs, however, she was unsure of the number of charts reviewed. The DON admitted that the data compiled was not analyzed in a way that would lead to the discovery or resolution of problems.

Based on document review and interviews the facility failed to evaluate the health care policies annually as is required.

1) The facility did not have revised, signed and approved policies.

a.) A review of the policies revealed polices with review dates greater than the one year time frame. Of the policies reviewed, most medical record, swing bed, nursing, infection control and pharmacy policies had no signatures demonstrating that the policies had been reviewed and approved by the DON, medical staff or governing body.

b.) In an interview on 08/29/12 at 11:30 a.m., the DON acknowledged that the policies were not signed, stating that the policy revision, review and approval was currently in progress.

Based on document review and interviews the facility failed to have a complete, consistent and effective quality assurance program.

1) The facility did not implement, and maintain an effective, ongoing, hospital-wide, data-driven Quality Assurance (QA) program.

a.) Quality Assurance Reports (reports) from the first and second quarter of 2012 meeting minutes were reviewed. The data compiled did not include identification of corrective actions and measures to continually improve the quality of care.

b.) The facility's Quality Assurance Improvement Plan stated the facility would collect data that measured the performance of potentially high-risk processes. The processes delineated were conscious sedation and other invasive and non-invasive procedures and medication administration processes. There was no documentation provided to demonstrate that these processes were evaluated or measured for quality and safety.

c.) In an interview on 08/29/12 at 11:30 a.m., the DON acknowledged that data was not maintained in a manner that would lead to adequate analysis and evaluation to prevent harm to patients.

Based on interviews and policy and procedure review, the facility failed to have a patient visitation policy in place that identified the right of patients to be aware of any restriction or limitation placed on visiting the patient.

The findings are:
On August 28, 2012 interviews were conducted with the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) after no policy and procedure for Patient visitation rights was found in the facility policies and procedures. The CEO and the CNO confirmed that they were facility had no policy addressing patient visitation rights.

Based on interviews and policy and procedure review, the facility failed to have a patient visitation policy in place that identified the right of patients to be aware of any restriction or limitation placed on visiting the patient. The facility failed to have a policy in place to notify the patient or support person of clinical restrictions or limitations in advance and failed to inform the patient of his /her right to receive visitors designated by the patient.

The findings are:
On August 28, 2012 interviews were conducted with the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) after no policy and procedure for Patient visitation rights was found in the facility policies and procedures. The CEO and the CNO confirmed the facility had no policy addressing patient visitation rights, which also addressed informing the patient of his/her rights to limit or restrict visitors and the patient's right to receive visitors designated by the patient.

Based on interviews and policy and procedure review, the facility failed to have a patient visitation policy in place that identified the right of patients to be aware of any restriction or limitation placed on visiting the patient. The facility failed to have a policy in place to notify the patient or support person of clinical restrictions or to not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. The facility also failed to ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences.

The findings are:
On August 28, 2012 interviews were conducted with the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) after no policy and procedure for Patient visitation rights was found in the facility policies and procedures. The CEO and the CNO confirmed the facility had no policy
to not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. The facility also failed to ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences.