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Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 3 of 4 applicable consulting physicians (Physician A, Physician B, and Physician C) selected for review, received outside entity peer review by a physician with similar qualifications 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, by a physician with similar qualifications, affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff identified the physicians provided care to an approximate number of patients, from 10/2/19 to 10/30/20, as follows:

- Physician A: 1 patient
- Physician B: 39 patients
- Physician C: 5 patients

Findings include:

1. Review of the CAH's network agreement, dated 2/5/07, revealed in part " ... As necessary, and upon request ... peer review assistance will be provided by [Network Hospital], the peer review organization currently under contract with [CAH] for this service ..."

2. Review of a CAH's peer review agreement, dated 12/28/11, revealed in part "... [Peer Reviewer Family Medicine Physician D] will integrate medical staff peer review/quality assurance activities into the established quality assurance Program at [the CAH] for the purpose of assessing the quality of medical care provided at [the CAH] ..."

3. Review of a CAH's peer review agreement, dated 12/28/11, revealed in part "... [Peer Reviewer Family Medicine Physician E] will integrate medical staff peer review/quality assurance activities into the established quality assurance Program at [the CAH] for the purpose of assessing the quality of medical care provided at [the CAH] ..."

4 Review of the CAH policy "Medical Staff Peer Review," approved 5/2020, revealed in part "... Peer review means evaluation of professional services rendered by a person licensed to practice as a health care professional by another practitioner with [similar] experience or training ... Prior to reappointment, all active,courtesy, and consulting medical staff will have external peer review completed on at least 1 patient that they administered care to ..."

5. Review of external peer review for Urologist A (a physician with specialized training in treatment of the urinary tract) revealed the medical staff approved Urologist A for reappointment to the Medical Staff on 6/16/20. The Board of Trustees approved Urologist A for reappointment to the Medical Staff on 6/25/20. Urologist A's external peer review results showed they were conducted by peer reviewer Family Medicine Physician D.

6. Review of external peer review for Opthalmologist B (a physician with specialized training in treatment of the eye) revealed the medical staff approved Opthalmologist B for reappointment to the Medical Staff on 9/17/19. The Board of Trustees approved Opthalmologist B for reappointment to the Medical Staff on 9/24/19. Opthalmologist B's external peer review results showed they were conducted by peer reviewer, Family Medicine Physician E.

7. Review of external peer review for Orthopedic Surgeon revealed the medical staff approved Orthopedic Surveon C for reappointment to the Medical Staff on 2/18/20. The Board of Trustees approved Orthopedic Surgeon C for reappointment to the Medical Staff on 2/27/20. Orthopedic Surgeon C's external peer review results showed they were conducted by peer reviewer, Family Medicine Physician E.

8. During an interview on 11/4/20, at 8:30 AM, the Quality Improvement Director reported the majority of the CAH's medical staff external peer review is conducted through contracted arrangements with 2 Network Hospital Physicians, Family Medicine Physician D and Family Medicine Physician E.

9. During an interview on 11/4/20, at 11:45 AM, the Quality Improvement Director confirmed Family Medicine Physician D and Family Medicine Physician E would not be considered a comparable specialty, with the necessary qualifications, to ensure a comprehensive quality review of care provided to the CAH patients of Urologist A, Opthalmologist B and Orthopedic Surgeon C.

Based on staff interview, the Critical Access Hospital (CAH) administrative staff failed to secure an emergency fuel agreement to ensure the availability of fuel in the event of an interruption in electrical service. The administrative staff identified a census of 7 patients at the time of the survey. The CAH identified 215 employees at the time of the survey. Failure to ensure fuel is available to meet the facility's critical functions during an emergency situation inhibits the facility's ability to ensure patient safety and quality of care while responding to and recovering from disruption of power.

Findings include:

1. During an interview on 11/2/20, at 1:55 PM, the Plant Operations Manager and Chief Executive Officer reported they have been unable to locate an emergency fuel agreement. The Plant operations Manager reported he spoke with the previous manager, who informed him the CAH has previously had an agreement with a local fuel supplier, but has been unable to locate it.

2. During an interview on 11/4/20. 1:10 PM, the Plant Operations Manager confirmed the CAH did not have an emergency fuel agreement.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from 1 of 1 inpatient units (OB Department) and 1 of 1 Surgery Department. Failure to remove outdated patient supplies from the CAH's supplies, available for use in patient care, could potentially result in staff using the expired items for patient care after which the manufacturer will no longer guarantee the quality and effectiveness of the supply. The CAH administrative staff identified approximately 72 deliveries and 269 endoscopies in fiscal year 2019.

Findings include:

1. Observations on 11/02/20 at 3:30 PM, during a tour of the OB Department, revealed the following expired supplies in 3 of 3 Labor, Delivery and Postpartum Rooms (LDRP):

a. LDRP 108: 1 of 1 PDI Sani Cloths HB germicidal disposable wipes located on a Fetal Monitor Cart, Exp. 8/2020

B. LDRP 109: 1 of 1 PDI Sani Cloths HB germicidal disposable wipes located on a Fetal Monitor Cart, Exp. 8/2020 and 1 of 1 Cavi Wipes for general disinfecting located on room counter by sink, Exp. 2020-8-01

c. LDRP 110: 1 of 1 PDI Sani Cloths HB germicidal disposable wipes located on a Fetal Monitor Cart, Exp. 8/2020

During an interview, at the time of the tour on 11/02/20, Director of Nursing (DON) reported the PDI Sani Cloths HB germicidal wipes were used to disinfect the fetal monitor equipment following each patient use. The Cavi Wipes were used to disinfect other patient care equipment between patient uses. The DON acknowledged the 2 types of wipes, in all 3 LDRP rooms, were expired, may not have been effective disinfecting patient equipment as the manufacture intended, and should not have been used to disinfect the fetal monitors and other patient care equipment. The DON reported she was not aware of a policy that included checking for outdated disinfecting wipes.

During an interview on 11/05/20 at 8:22 AM, Director of Patient Care reported 12 OB patients had delivered babies since 8/2020.


2. Observations on 11/04/2020 at 11:20 AM, during an observation of colonoscope ( flexible tube inserted through the rectum to view the lining of the large intestine, colon, and rectum) cleaning, revealed RAPICIDE PA Test Strips, used to effectively measure the minimum recommended concentration (MRC) of RAPICIDE PA High-Level Disinfectant, expired 2020-07-25. The RAPICIDE PA Test Strips ensure that each cycle run in an Automated Endoscope Reprocessor (AER) meets the MRC and can effectively disinfect the device (the colonoscope).

During an interview on 11/4/2020, at the time of the observation, OR Tech F verified the RAPICIDE PA Test Strips, sitting on the counter by the AER, had been used to test the MRC of High-Level Disinfectant in the AER had expired 2020-07-25.

During an interview on 11/4/2020 at 11:52 AM, the Surgery Nurse Coordinator acknowledged the RAPICIDE PA Test Strips had expired and should not be used. The Surgery Nurse Coordinator was not aware of a hospital or department policy that specifically addressed checking for outdated supplies, but stated staff checked for outdated supplies monthly.

Review of document titled "OR Cleaning Schedule", dated "October", revealed in part, "Monthly:...Check Outdates....30...[OR Tech F's initials]". The document lacked identification of supplies to be checked.




II. Based on observation, document review and staff interviews the Critical Access Hospital's (CAH) Staff failed to follow the manufacturer's instructions for the use of Revital Ox enzymatic detergent, used to clean endoscopes prior to high-level disinfection. Failure to follow the Revital Ox manufacturer's instructions for use (IFU) may result in ineffective cleaning of the endoscope. The CAH reported the Surgery Department performed approximately 269 endoscopies in the past fiscal year.

Findings include:

1. Observation on 11/04/2020 at 11:20 AM, during an observation of colonoscope cleaning in the surgery department, revealed the endoscope cleaning sink marked with tape and a clearly labeled fill line a few inches below the top of edge of the sink. No other water levels marked. OR Tech staff G filled the sink with water approximately one fourth the way up to the fill line. OR Tech staff G then pressed a button on the Acu-sInQ Chemical Dosing System and added the Revital Ox presoak enzymatic detergent.

2. During an interview on 11/04/2020 at the time of the observation, OR Tech staff G reported the Acu-sInQ machine had been set to deliver the amount of Revital Ox cleaning solution required for a sink filled half way to the fill mark. OR Tech staff G acknowledged the sink had not been marked with tape to indicate the half filled level and OR Tech staff G had filled the sink with water to approximately one fourth the distance to the fill mark. OR Tech staff G confirmed the Revital Ox would be more concentrated with the sink filled with only one quarter of the water verses half filled as the Acu-sInQ was pre-set to administer Revital Ox. OR Tech staff G verbalized she was not aware if not using the prescribed amount of water and Revital Ox effected the cleaning process.

3. Review of "Steris Acu-sInQ Chemical Dosing System" dated 12/09/14, revealed in part, "... is a dispensing system used to transfer precise amounts of presoak chemicals into a prewash sink ... multiple dosing levels can be programmed to meet specific soil conditions ... providing optimal cleaning results ..."

Review of Revital Ox label, revealed in part, "Dilute 1/8 to 1/2 fl oz per gallon ... depending on soil load.."

Review of document "Olympus Endoscope 190 Cleaning Instructions", revealed in part, "Fill sink to fill line ... Add purple enzymatic water in sink ..."

Review of policy "Flexible Endoscope Handling, Cleaning, and Storage", dated last approved 09/2020, revealed in part, "Add purple enzymatic to water in sink..." The policy lacked the volume of water and enzymatic detergent to be used.

Review of "Guidelines for Perioperative Practice", 2019 EDITION, Association of periOperative Nurses, revealed in part, "Flexible Endoscopes...cleaning solution manufacturer's IFU [Instructions for Use] should be followed for...concentration and dilution...Deviations from the manufacturer's IFU may render the cleaning product ineffective...a strong solution may produce an increased number of bubbles, creating air pockets that prohibit surface contact of the cleaning chemical...under-diluted enzymatic cleaning solutions are difficult to remove...may lead to residual cleaning solutions...proteinaceous material in the endoscope that provide a foundation for biofilm formation...lead to processing failures..."

3. During an interview on 11/04/2020 at 11:52 AM, the Surgery Nurse Coordinator verified the Acu-sInQ Chemical Dosing System was preset to deliver the appropriate amount of Revital OX for the endoscope cleaning sink half filled with water. The Surgery Nurse Coordinator acknowledged the endoscope cleaning sink was only marked with a fill line of a full sink and lacked a fill line for half fill for which the Acu-sInQ had been preset to deliver. Lack of a clear mark for half filled required staff to guess for the appropriate fill level. Surgery Nurse Coordinator reported the hospital utilized the AORN's practice guidelines for the delivery of patient care in the surgery department.

Based on review of policies/procedures, meeting minutes, 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 27 of 27 patient care departments (Pharmacy, Radiology, Emergency Department, Infection Prevention, Quality/Risk Management, Credentialing, Laboratory, Health Information, Cardiac Rehabilitation, Hegg Medical Clinic, Respiratory Care, Medical/Surgical, Organ Donation, Nutrition Services, Activities, Maintenance, Rehab, Pediatrics, Obstetrics, Laundry, Materials Management, Diabetic Education, Social Services, Housekeeping, Emergency Preparedness, Outpatient, and Surgery/Anesthesia). The CAH administrative staff identified a census of 7 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 policies revealed the lack of a policy to address the required group of professionals, including a physician, and a mid-level provider reviewed all patient care policies annually for all patient care departments.

2. Review of the "CAH Annual Policy Review Committee," meeting minutes for May 2020 and October 16, 2020 lacked approval for all policies for Pharmacy, Radiology, Emergency Department, Infection Prevention, Quality/Risk Management, Credentialing, Laboratory, Health Information, Cardiac Rehabilitation, Hegg Medical Clinic, Respiratory Care, Medical/Surgical, Organ Donation, Nutrition Services, Activities, Maintenance, Rehab, Pediatrics, Obstetrics, Laundry, Materials Management, Diabetic Education, Social Services, Housekeeping, Emergency Preparedness, Outpatient, and Surgery/Anesthesia.

3. During an interview on 11/04/2020 at 4:45 PM, the Quality/Infection Preventionist acknowledged the Policy Review Committee met in May 2020 and 10/16/2020 and reviewed only new and revised policies for Pharmacy, Radiology, Emergency Department, Infection Prevention, Quality/Risk Management, Credentialing, Laboratory, Health Information, Cardiac Rehabilitation, Hegg Medical Clinic, Respiratory Care, Medical/Surgical, Organ Donation, Nutrition Services, Activities, Maintenance, Rehab, Pediatrics, Obstetrics, Laundry, Materials Management, Diabetic Education, Social Services, Housekeeping, Emergency Preparedness, Outpatient, and Surgery/Anesthesia.

During an interview on 11/05/2020 at 8:40 AM, The Director of Patient Care confirmed only the list of new and revised policies go to the Policy Review Committee and not the policy manuals to include all and the rest of the department's existing policies

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) administrative staff failed to maintain a complete list of contracted services that described the nature and scope of services provided. Failure to maintain a complete list of contracted services including the delineation of the nature and scope of the contracted services could potentially result in failure of compliance of the contracted services' responsibilities. The CAH administrative staff identified a census of 7 patients at the beginning of the survey.


Findings include:

1. Review of administration document, "Provision of Services" lacked a complete list of contracted services to include a description of the nature and scope of the services each contracted entity would provide. The document failed to identify and include the contracted services provided by Certified Registered Nurse Anesthetists (CRNA's) contracted through another hospital (Hospital A) and Rural Emergency Medical Providers (REMP) group for emergency room coverage.

2. During an interview on 11/03/20 at 9:51 AM, the Director of Patient Services confirmed the "Provision of Services" document lacked a complete listing of contracted services the CAH provided to its patients and failed to include a description of the nature and scope of the services provided by each of the contracted entities. The Director of Patient Services reported the CAH currently lacked a well defined process to maintain a complete and current list of contracted services.

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 1 of 5 Obstetrical (OB) patient records (Patients #11 and Patient #12), 4 of 5 Emergency Department (ED) patient records (Patient #8, Patient #10, Patient #13, and Patient #14), and 5 of 7 Operating Room (OR) patient records(Patient #2, Patient #3, Patient #5, Patient #6, and Patient #7) reviewed lacked various elements of an accurately dated, timed, and witnessed consent forms. Failure to ensure all consent forms are accurately dated, timed and witnessed resulted in an inaccurately documented record and may result in ambiguity as to when the consent was signed and if it was signed prior to the care or services provided. The CAH administrative staff identified the hospital provided the following: OB - 72 deliveries, ED - 1,437 patients, and OR - 425 surgical procedures in the past fiscal year.

Findings include:

1. Review of 1 of 5 OB medical records (Patient # 11) revealed "Consent - Hospital Registration (CAH)" and "Consent for Surgical or Invasive Procedures" forms lacked the date and time Patient #12 signed the consent forms.

2. Review of 4 of 5 ED medical records (Patient #8, Patient #10, Patient #13, and Patient #14) revealed the following:

a. Patient # 8's "EMTALA Transfer Form - Ambulance/Helicopter" lacked the time the transferring physician signed the form and lacked a check in the box that indicated patient #12 consented to transfer.
b. Patient # 10's "Consent - Hospital Registration (CAH)" lacked the date and time 2 staff witnessed a verbal consent and the source of the verbal consent.
c. Patient # 13's "Consent - Hospital Registration (CAH)" lacked identification of the source of the verbal consent and the "EMTALA Transfer Form" lacked a check in the box that indicated patient #13 consented to transfer.
d. Patient # 14's "Consent - Hospital Registration (CAH)" lacked the time the witness signed the form.

During an interview on 11/2/2020, at the time of the OB and ED records review with the Director of Nursing, the Director of Nursing acknowledged the consent forms lacked all the required elements expected, which included the date and time the patient and witness signed each consent form.

3. Review of 5 of 7 OR medical records (Patient #2, Patient #3, Patient #5, Patient #6, and Patient #7) revealed the following:

a. Patient # 2's "Consent for Surgical or Invasive Procedures" form lacked the time Patient #2 signed the consent form and lacked the time the witness signed the consent form.
b. Patient #3's "Consent - Hospital Registration (CAH)" lacked the date and time Patient #3 signed the consent form.
c. Patient #5's "Consent - Hospital Registration CAH)" lacked the time Patient #5 signed the consent form.
d. Patient #6's "Consent- Hospital Registration (CAH)" lacked the time Patient #5 signed the consent form and lacked the time the witness signed the consent form. Patient #6's "Consent for Surgical or Invasive Procedures" from lacked the date and time Patient #6 signed the consent form.
e. Patient #7's "Consent - Hospital Registration (CAH)" lacked the time Patient #7 signed the consent form.

During an interview on 11/4/2020, at the time of the OR record review with the Surgery Nurse Coordinator, the Surgery Nurse Coordinator acknowledged the consent forms reviewed lacked all of the required elements she would expect in an accurately completed consent form, which would include the date and time the patient signed the form and the date and time the witness signed the consent form.

4. During an interview on 11/10/2020 at 10:50 AM, Patient Care Director communicated the CAH lacked a policy that identified the required elements of an accurately completed consent form which included date and time the patient and the witness signed the consent form.

Based on review of documents and staff interviews the Critical Access Hospital failed to ensure each surgical patient had a properly executed informed consent for anesthesia when the surgical consent failed to identify the name of the practitioner performing the anesthesia and the name of the anesthesia to be performed in 2 of 2 open records (Patient #1 and Patient #2) and 7 of 7 (Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #11, and Patient #12) applicable closed medical records reviewed. Failure to ensure each patient that required anesthesia had a properly executed informed consent could result in a patient not receiving the type of anesthesia desired, such as not being awake for the birth of a baby or being awake and aware during a procedure when the patient preferred to be asleep due to anxiety or other factors. The CAH administrative staff identified approximately 425 surgical procedures in the past fiscal year.

Findings include:

1. Review of 2 of 2 open surgical medical records (Patient #1 and Patient #2) revealed a surgical consent form that lacked the name of the Certified Registered Nurse Anesthetist (CRNA) that administered the anesthesia and lacked the name or type of anesthesia provided.

2. Review of 7 of 7 closed surgical medical records (Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #11, and Patient #12) revealed surgical consent forms that lacked the name of the CRNA that administered the anesthesia and lacked the name or type of anesthesia provided.

3. Review of Patient #12's medical record revealed Patient #12 also had an "Acute Anesthesia Procedure", an epidural blood patch procedure (a surgical procedure that used the patients own blood in order to close, or patch, a hole in the dura matter of the spinal cord, a potential result of a previous lumbar puncture. The procedure is used to relieve post dural puncture headaches) performed by CRNA H 2 days after the initial surgical procedure. Patient #12's record lacked an informed consent for the "Acute Anesthesia Procedure", blood patch, performed by CRNA H.

4. Review of "Medical Staff Bylaws and Rules & Regulations" dated last approved 10-29-20 revealed in part, "Informed Consent:..patient is given information... needed in order to consent to a procedure or treatment...requires patient have a full understanding of that to which...has consented..who will actually perform....written informed consent...obtained for all invasive and non invasive treatments...procedures carrying a significant risk... required for...not limited to...anesthesia administration (general, spinal, IV/conscious sedation, selected local)."

5. Review of policy "Informed Consent", dated Last Approved 4/2019, revealed in part, "to provide...information to make an informed decision regarding all aspects of care...authorization ...who does not understand what he/she is consenting to is not informed consent...obtained by the practitioner performing the procedure...required for, but not limited to...administration of anesthesia (general, spinal, IV/conscious sedation, selected local)."

6. During an interview on 11/4/2020 at 10:00 AM, the Surgery Nurse Manager acknowledged the surgical consent forms for Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #11, and Patient #12 lacked the name of the CRNA that provided the anesthesia and the name/type of anesthesia that was provided.

7. During an interview on 11/4/2020 at 3:00 PM, the Director of Patient Care acknowledged the current surgical consent form lacked a space to enter the name of the CRNA that provided the anesthesia and a space to enter the name/type of anesthesia that was provided as a properly executed consent for anesthesia required.

Based on observation, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the Health Information Management (HIM) staff kept patient medical information secure from unauthorized access in 1 of 2 HIM medical record storage room and 1 of 1 medical clinic. Failure to keep patient medical information confidential could potentially result in unauthorized use of a patients personal/medical information and potentially result in unauthorized release of personal information and identity theft.

Findings include:

Review of a CAH policy titled "Standards for Accessing PHI (protected health information)", approved 7/2020, revealed in part "... All patients and employees of [CAH] must have their medical and [personal] information maintained in a confidential manner free from unauthorized access. Only persons who have a 'need to know' are permitted access to such information. 'Need to know' is defined as providing access to protected health information only to those employees who need access to carry out their duties ... All information is regarded as confidential and made available only to authorized users who are determined based on job responsibilities and then only for official purposes ..."

1. Observation of the medical record storage room, adjacent to the Materials Management Department, on 11/2/20, at 2:45 PM, revealed the room had a small break room area, with portable room dividers to partition off an area with multiple open shelves containing medical clinic patient records and radiology films. A second partitioned area stored patient care supplies. During an interview at the time, the HIM Coordinator reported the breakroom area is utilized by the materials management staff. She acknowledged in addition to herself and another HIM employee, the Materials Management manager and 2 materials management staff had the code for the keypad, that would allow the staff to access the HIM storage room. During an interview at the time of the tour, the HIM Coordinator acknowledged Materials Management staff had access to patient information and those employees would not need access to patient information to carry out their duties.

During a follow-up interview on 11/4/20, at 8:15 AM the HIM Coordinator estimated the identified HIM medical records storage stored approximately 5,000 medical clinic patient records.

2. Observation of the medical record storage room on 11/04/2020, at approximately 8:45 AM, with the Director of Radiology and the HIM Coordinator revealed 1 of 1 x-ray film storage area in 1 of 1 medical record storage room. The Director of Radiology identified approximately 400 x-ray films stored on 1 open shelving unit and 1-55 gallon barrel that contained an undetermined number of loose x-rays in the HIM storage room. Further observation revealed a second unsecured door into the HIM storage room from an adjacent open and unoccupied Materials Manager's office.

During an interview at the time of the tour, the Director of Radiology acknowledged the x-ray films contained patient information.

During an interview at the time of the tour, the HIM Coordinator acknowledged the 3 materials management staff and 2 HIM staff have the code for the keypad that would allow the staff to access the HIM storage room.

3. Observation on 11/03/2020 at 03:15 PM, during a tour of the Hegg Clinic, revealed 2 of 2 FAX machines located in an unlocked area of each nursing office space, potentially allowing unauthorized personnel access to confidential patient information.

During an interview on 11/03/2020 at 03:25 PM, at the time of the tour, the Nurse Manager of Hegg Clinic revealed the clinic areas are locked when the departments are closed, however, housekeeping staff have access to the locked departments and clean in the early morning hours when the departments have no staff present. Fax machines are not secured and private patient information is received after hours and sit on the Fax machines until staff retrieves the information. The Nurse Manager of Hegg Clinic acknowledged that the private patient information on the FAX machine is available for unauthorized personnel access. The Nurse Manager and Clinic Director of Hegg Clinic acknowledged the private and confidential patient information is not secured as hospital policy requires.

During an interview on 11/04/2020, at approximately 8:15 AM, Nurse Manager of Hegg Clinic, reported the clinic provides services to approximately 1,619 patients monthly and received approximately 80 faxes per month (approximately 4 per day) after the clinic has closed.

Based on review of policies/procedures, medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure examination of the patient by a physician immediately before surgery to evaluate the risks prior to the performance of the procedure in 2 of 2 open medical records (Patient #1 and Patient #2) and 6 of of 7 closed patient medical records reviewed. (Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, and Patient #12) Failure of a physician to examine a patient immediately before surgery could result in surgery performed on an unstable patient. The CAH administrativie staff identified 425 surgery and endoscopy procedures in the past fiscal year.

Findings include:

1. Review of open surgical records revealed 2 of 2 records (Patient #1 and Patient #2) lacked evidence of an examination by a physician immediately before surgery to evaluate the risks of the procedure to be performed.


2. Review of closed surgical records revealed 6 of 7 (Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #12) applicable closed records lacked evidence of an examination by a physician immediately before surgery to evaluate the risks of the procedure to be performed.


3. During an interview on 11/04/2020 at 10:00 AM, the Surgery Nurse Coordinator acknowledged the open (Patients #1, 2) and closed medical records (Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, and Patient #12) lacked documentation of an examination by a physician immediately before surgery to evaluate the risks prior to the performance of the procedure. The Surgery Nurse Coordinator reported the CAH was not aware of the requirement and lacked a policy and procedure that required an examination by the physician immediately before surgery to evaluate the risks of the procdeure to be performed.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program individual (or individuals), had been appointed by the Governing Body, and that the appointment was based on the recommendations of medical staff leadership and nursing leadership. Failure to comply with regulations could potentially hinder the infection prevention and control program including surveillance, prevention, and control of hospital-acquired infections (HAI)s, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and address any infection control issues, potentially causing harm or death to patients and their safety. The CAH administrative staff identified an inpatient census of 7 patients upon entrance.

Findings include:

1. Review of Policies and Procedures revealed that no policy existed regarding an appointment for the Infection Preventionist by the Governing Board.

2. Review of the Medical Staff Meeting Minutes from October 15, 2019 to October 20, 2020 revealed that an appointment had not been made by the Governing Board for the position of Infection Preventionist.

3. Review of the Governing Board Meeting Minutes from October 24, 2019 to October 29, 2020 revealed that an appointment had not been made by the Governing Board for the position of Infection Preventionist.

4. Interview with Infection Preventionist on 11/04/2020 at 01:30 PM confirmed that the Infection Preventionist had not been appointed by the Governing Board.

5. Interview with Chief Executive Officer (CNO) on 11/04/2020 at approximately 03:10 PM confirmed that the Infection Preventionist had not been appointed by the Governing Board.

Based on review of policies/procedures, documentation, and patient medical records, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure Swing Bed patients signed their Bill of Rights in accordance with the facility policy for 1 of 1 closed swing bed patients reviewed (Patient #17). The CAH administrative staff identified a census of 4 swing bed patients at the beginning of the survey. Failure to inform each swing bed patients of their rights could potentially result in the patients being not aware of their rights for the provisions of their care, services, or treatment.

Findings include:

1. Review of CAH policy "Swing Bed (SNF, ECF)," dated 3/2020, revealed in part, "...Consent Forms for Swing Bed Status...Bill of Rights (signed original to chart, copy to patient)...."

2. Review of Patient #17's medical record revealed the lack of a signed copy of Swing Bed Bill of Rights.

3. During an interview on 11/04/2020 at 4:40 PM, the Med/Surg Coordinator confirmed the lack of a signed copy of Swing Bed Bill of Rights for Patient #17.