HospitalInspections.org

Based on review of Board of Trustees Bylaws, Quality Council Meeting minutes, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the board members followed the Quality Council Committee requirements as stated in the Board of Trustees Bylaws. The CAH staff identified 1 of 1 governing body.

Failure of the CAH's governing body Quality Council committee to follow the Board of Trustees bylaws could potentially result in a decline or failure in the CAH Quality Improvement program and delay in needed actions.

Findings include:

1. Review of the Bylaws of the Board of Trustees, dated March 17, 1999, revealed in part ". . . Article V. Committees - Committees of the Hospital Board of Trustees shall be standing or special. Standing committees of the Board shall be the Executive Committee and the Quality Council. . . The Quality Council. . . The Council shall meet at least quarterly and shall hear reports from various bodies, including but not limited to quality improvement teams, the Compliance Committee, the Risk Management Committee, the Quality Review Committee, the Infection Control Committee, and the Allstar Team in regard to employee benefits. . . ."

2. Review of Quality Council Meeting minutes dated 6/16/14 and 7/22/15 lacked reports from quality improvement teams, the Compliance Committee, the Risk Management Committee, the Quality Review Committee, the Infection Control Committee, and the Allstar Team in regard to employee benefits.

The Quality Council Committee failed to meet quarterly as stated in the Bylaws of the Board of Trustees.

3. During an interview on 4/27/16 at 3:15 PM, Staff C, Chief Operating Officer (COO), and Staff D, Director of Quality, acknowledged the Quality Council - a committee of the Board of Trustees - only met one time in 2014 and 2015 and failed to hear reports from the quality improvement teams, the Compliance Committee, the Risk Management Committee, the Quality Review Committee, the Infection Control Committee, and the Allstar Team in regard to employee benefits. Staff C, COO, stated he attended the monthly Board of Trustees meetings and he gives a key quality report if there is an issue. Staff C agreed that only the Director of Quality sees the departmental quality reports and the departmental quality reports are not shared with the Quality Council.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the physician periodically reviewed 1 of 1 applicable mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner. (Staff G)

The CAH staff reported the volume of services by mid-level Staff G of 1782 wound clinic patient visits for the year of 2015.

Failure to ensure a physician periodically reviewed 1 of 1 applicable mid-level practitioner's patient medical records in conjunction with the mid-level practitioner could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policies/procedures revealed the lack of a requirement to ensure the physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

2. Review of documentation revealed the lack of documentation of physician review of the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

3. During an interview on 4/27/16 at 10:30 AM, Staff G, Advanced Registered Nurse Practitioner (ARNP), in the Wound Clinic, when asked if she periodically completes patient medical record chart review with a physician, Staff G stated "I did not complete a face to face medical record review of my patients because I am an ARNP and the State does not require I do this because of my licensing".

During an interview on 4/28/16 at 10:15 AM, Staff C, Chief Operating Officer, acknowledged the lack of a policy to ensure a physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

During an interview on 4/28/16 at 10:15 AM, Staff H, Physician, stated he was Staff G, Wound Clinic ARNP's supervising physician. Staff H acknowledged he had not sat down with Staff G to review wound clinic patient medical records.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the mid-level practitioner participated with a physician in the periodic review of 1 of 1 applicable mid-level practitioner's patient medical records. (Staff G)

The CAH staff reported the volume of services by mid-level Staff G of 1782 wound clinic patient visits for the year of 2015.

Failure to ensure the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records could potentially result in the mid-level practitioner misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policies/procedures revealed the lack of a requirement to ensure the physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

2. Review of documentation revealed the lack of documentation of physician review of the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

3. During an interview on 4/27/16 at 10:30 AM, Staff G, Advanced Registered Nurse Practitioner (ARNP), in the Wound Clinic, when asked if she periodically completes patient medical record chart review with a physician, Staff G stated "I did not complete a face to face medical record review of my patients because I am an ARNP and the State does not require I do this because of my licensing".

During an interview on 4/28/16 at 10:15 AM, Staff C, Chief Operating Officer, acknowledged the lack of a policy to ensure a physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

During an interview on 4/28/16 at 10:15 AM, Staff H, Physician, stated he was Staff G, Wound Clinic ARNP's supervising physician. Staff H acknowledged he had not sat down with Staff G to review wound clinic patient medical records.

0279

Based on observation, review of CAH (Critical Access Hospital) policy, and staff interview the CAH failed to ensure the CRNA (Certified Registered Nurse Anesthetist) cleanse the medication hubs and intravenous (IV) ports, with alcohol, prior to giving medications for an endoscopic procedure. Three medications were given during the procedure, 3 of 3 medications failed to have the hub or the IV port cleansed prior to giving the medication.

Failure to cleanse the medication vials and IV hubs prior to giving medications could potentially result in passing of infectious organisms to the patient during medication administration, and in this case the patient's blood would be contaminated resulting in a systemic infectious process that could lead to sepsis and death.

Findings include:

Observation on 4/26/16 at 8:05 AM, during Patient #36 colonoscopy revealed, Staff B, CRNA providing anesthesia. Staff B administered 3 anesthetic medications (propofol, versed, and fentanyl). Staff B failed to cleanse the medication hubs and the IV ports, with alcohol, prior to instilling the medications into the IV line. Additional observation revealed the CRNA lacked alcohol wipes on the work surface of the anesthesia cart.

Review of the policy titled, IC (Infection Control) for Patient with Peripheral Intravenous Therapy, revision date of 2/9/16, states in part ...the purpose is to establish standards of practice for intravenous therapy to minimize the risk of peripheral IV associated infections.
All entries into the tubing, as for administration of medications, will be made with sterile equipment through injection ports that are disinfected with a 70% alcohol swab.

During an interview on 4/26/16 at 8:15 AM, Staff B verified failure to cleanse the IV ports, and medication hubs prior to instilling the medications. Staff B was unable to locate the alcohol wipes on the anesthesia cart.

During an interview on 4/26/16 at 10:40 AM, Staff A, Director of Nursing, acknowledged having the alcohol wipe discussion with Staff B at an earlier time, but was unable to provide documentation of the discussion.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the periodic evaluation of its total program included a representative sample of both active and closed clinical records for 12 of 16 patient care services provided. (Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehabilitation, Diabetic Education, Wound Clinic, Outpatient Infusion/Chemotherapy, Clinic, Pulmonary Rehabilitation, Respiratory Therapy, Laboratory, and Radiology) The CAH staff identified a current census of 14 inpatients at the start of the survey.

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 changed needed in services provided.

Findings include:

1. Review of CAH policy/procedure titled "Annual Program Evaluation" dated 5/19/05, revealed in part, ". . . The annual evaluation at a minimum will include: . . . An audit of a representative sample of both active and closed clinical records. . . ."

2. Review of the "2014/2015 Critical Access Hospital Annual Review" lacked documentation of review of a sample of both active and closed clinical records for Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehabilitation, Diabetic Education, Wound Clinic, Outpatient Infusion/Chemotherapy, Clinic, Pulmonary Rehabilitation, Respiratory Therapy, Laboratory, and Radiology.

3. During an interview on 4/27/16 at 11:00 AM, Staff D, Director Quality, verified the annual evaluation of the CAH Annual Program Evaluation lacked documentation of review of a sample of both active and closed clinical records for Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Rehabilitation, Diabetic Education, Wound Clinic, Outpatient Infusion/Chemotherapy, Clinic, Pulmonary Rehabilitation, Respiratory Therapy, Laboratory, and Radiology.

Based on review of documentation and staff interviews, the Critical Access Hospital (CAH) failed to have an effective quality program to ensure the evaluation of all patient care services (Refer to C-0337) and the CAH's Quality Committee failed to evaluate departmental quality indicators and report all information to the Governing Board in accordance with the CAH's Quality Assessment and Performance Improvement Plan.

Failure to have an effective quality improvement program that included involvement of the Quality Committee and all of the CAH's departments to improve quality on a continuous basis could potentially result in failure to ensure patient care problems were identified, monitored, addressed and improved in each patient care area through the efforts of all involved departments.

Findings include:

1. Review of CAH's "Quality Assessment and Performance Improvement Plan", approved by the Governing Board 2/18/15, revealed in part, ". . . QAPI Committee. . . Responsibilities - Ensure the quality efforts of OCAHS are focused and effective. . . Evaluate QAPI indicators, indicator goals, data, and quality reports with each department and service. Communicate QAPI information to employees, medical staff, governing board, and community as appropriate. . . ."

2. Review of the CAH's QAPI Committee Meeting minutes dated 6/15/15, 12/1/15/ and 3/2/16 revealed the lack of review of department quality reports.

Review of Quality Council Meeting minutes, a committee of the Governing Board, dated 6/16/14 and 7/22/15, revealed the lack of review of department quality reports.

Review of Board of Trustees Meeting minutes from February 18, 2015 to April 20, 2016 revealed the lack of review of department quality reports.

3. During an interview on 4/27/16 at 2:15 PM, Staff D, Director Quality, acknowledged she is the only staff that looks at the department quality reports and are not discussed at the QAPI committee or the Board of Trustees.

During an interview on 4/27/16 at 3:15 PM, Staff C, Chief Operating Officer (COO), and Staff D verified department quality reports are not discussed at the Quality Council, a committee of the Governing Board, or the Board of Trustees.

I. Based on documentation and staff interviews, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate 11 of 21 patient care services in accordance with the CAH's Quality Assessment and Performance Improvement Plan (Pulmonary Rehabilitation, Outpatient Infusion/Chemotherapy, Clinic, Housekeeping, Cardiac Rehabilitation, Respiratory Therapy/Cardiopulmonary, Sleep Study, Physical Therapy, Occupational Therapy, Nuclear Medicine, and V-Radiology).

Pulmonary Rehabilitation - 74 patients in 2015
Outpatient Infusion/Chemotherapy - staff failed to supply volume
Clinic - 28,401 patient visits in 2015
Housekeeping - average daily patient census - 10 in 2015
Cardiac Rehabilitation - 1001 patient visits in 2015
Respiratory Therapy/Cardiopulmonary - 4,705 patient procedures in 2015
Sleep Study - staff failed to supply volume
Physical Therapy - 28,830 procedures in 2015
Occupational Therapy - 2,338 procedures in 2015
Nuclear Medicine - 73 studies in 2015
V-Radiology - staff failed to supply volume

Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

Findings include:

1. Review of CAH's "Quality Assessment and Performance Improvement Plan", approved by the Governing Board 2/18/15, revealed in part, ". . . The QAPI [Quality Assessment Performance Improvement] plan applies to all departments, services, practitioners, and staff. . . The process of improving organizational performance requires a systematic approach to change. OCAHS utilizes the Plan Do Study Act (PDSA) method. . . ."

2. Review of quality reports for patient care services lacked reports from Pulmonary Rehabilitation, Outpatient Infusion/Chemotherapy, Clinic, Housekeeping, Cardiac Rehabilitation, and Respiratory Therapy/Cardiopulmonary.

Review of quality report for Sleep Study failed to reveal the quality improvement activities are specific to the CAH.

Review of quality reports for patient care services for Physical Therapy, Occupational Therapy, Nuclear Medicine and V-Radiology revealed data collection only and failed to include analysis of the data and any corrective actions taken.

3. During an interview on 4/26/16 at 10:15 AM, Staff F, Registered Nurse (RN), stated pulmonary rehabilitation service failed to complete quality improvement activities since 2014.

During an interview on 4/26/16 at 12:45 PM, Staff E, Chemotherapy Manager, stated Out Patient (OP) Infusion/Chemotherapy service failed to complete quality improvement activities in 5 years.

During an interview on 4/27/16 between 1:15 PM and 4:00 PM, Staff D, Director of Quality, confirmed the lack of quality reports for Pulmonary Rehabilitation, OP Infusion/Chemotherapy Clinic, Housekeeping, Cardiac Rehabilitation, and Respiratory Therapy/Cardiopulmonary. Staff D also verified quality reports for Sleep Study failed to contain information specific for the CAH and included information from other facilities. Staff D also confirmed the quality reports for patient care services for Physical Therapy, Occupational Therapy, Nuclear Medicine and V-Radiology revealed data collection only and failed to include analysis of the data and any corrective actions taken.

II. Based on documentation and staff interview, the CAH quality improvement staff failed to ensure the quarterly evaluation of 8 of 21 patient care services in accordance with the CAH's Quality Assessment and Performance Improvement Plan (Medical/Surgical, Surgery, Obstetrics, Radiology, Laboratory, Diabetic Education, Dietary, and Wound Ostomy Clinic).

Medical/Surgical - average daily patient census - 10 in 2015
Surgery - 1,236 procedures in 2015
Obstetrics - 191 births in 2015
Radiology - 11,298 procedures in 2015
Laboratory - 190,169 tests in 2015
Diabetic Education - staff failed to supply volume
Dietary - average daily patient census - 10 in 2015
Wound Ostomy Clinic - 1,330 patient visits in 2015

Failure to monitor all patient care services for quality of care could potentially expose patients to inappropriate and/or substandard care.

Findings include:

1. Review of CAH's "Quality Assessment and Performance Improvement Plan", approved by the Governing Board 2/18/15, revealed in part, ". . . The QAPI [Quality Assessment Performance Improvement] plan applies to all departments, services, practitioners, and staff. . . All direct care departments will report quarterly to the OCAHS Quality Department. . . . "

2. Review of facility quality reports revealed the following departments lacked quarterly reports in accordance with the CAH's QAPI:
a. Medical/Surgical - reported 7/20/15 and 11/18/15
b. Surgery - 7/20/15 and 11/18/15
c. Obstetrics - 8/13/15 and 11/18/15
d. Radiology - 11/18/15 and 4/21/16
e. Laboratory - 7/15/15 and 10/15/15
f. Diabetic Education - 7/16/15
g. Dietary - 4/5/15 and 7/26/15
h. Wound Ostomy Clinic - 4/22/15, 8/17/15, and 10/15/15.

3. During an interview on 4/27/16 between 1:15 PM and 4:00 PM, Staff D, Director of Quality, confirmed the lack of quarterly quality reports for Medical/Surgical, Surgery, Obstetrics, Radiology, Laboratory, Diabetic Education, Dietary, and Wound Ostomy Clinic in accordance with the CAH's Quality Assessment and Performance Improvement Plan.

Based on Patient Rights policy/procedure review and staff interviews, the Critical Access Hospital (CAH) failed to update the facility patient visitation policy to include the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and another family member or friend. The CAH had a current census of 6 swing bed patient, 4 observation patients and 4 acute care patients. The CAH administrative staff reported a census of approximately 251,454 outpatient visits last year.

Failure to update correct language in the visitation policy in accordance with regulations potentially results in restricted patient's visitation.

Findings include:

Review of the CAH policy titled Bill of Rights/ Patients' Rights last approved 6/3/2011 revealed the policy lacked language in accordance with the regulations to include the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and other family members or friends.

During an interview with Staff A, Director of Patient Care acknowledged the Patient Rights policy lacked the language to include the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and another family
member or friend. The CAH lacked a specific visitation policy and accurate verbiage was lacking in the Patient Rights Policy.

Based on Patient Rights document review, medical record review and staff interview, the CAH failed to ensure patients, inpatients and outpatients are informed of visitation rights including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and other family members or friends for 6 of 6 current swing bed patients (Patients #9, 10, 11, 12, 13 and 14), 5 of 5 closed swing bed patients (Patients #18, 19, 20, 40 and 41), 4 of 4 current acute care inpatients (Patients #2, 3, 4 and 5), 4 of 4 current observation patients (Patient #1, 6, 7 and 8) and all outpatients. The CAH administrative staff reported a census of approximately 251,454 outpatient visits a year received services.

Failure to provide all inpatients, skilled patients and outpatients with patient rights information potentially resulted in limited or restricted access of visitors to patients and infringed on patients rights to have a support person present during provided care services or treatment modalities.

Findings include:

Review of the undated document titled " Your rights and responsibilities as a patient" provided to swing bed patients, acute care patients, observation patients and outpatients on admit to the CAH, revealed a lack of documentation regarding patient consent to receive visitors designated by the patient, including but not limited to, a spouse, a domestic partner (including a same sex domestic partner), other family members or friends.

Review of documentation in Patient (#9, 10, 11, 12, 13 and 14's) current swing bed patient's medical records, and closed records for Patient #18, 19, 20, 40 and 41's discharged medical records, revealed documentation staff provided patients a copy of the Swing Nursing Patient's Bill of Rights lacking the above information.

During an interview on 4/25/16 at 2:25 PM, Staff A, Director of Patient Care, acknowledged the Patient Rights provided to swing bed patients, acute care patients and outpatients lacked information for same sex and domestic partner. The Patient Rights provided to patients failed to contain required language.