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Based on medical record review, review of policy and procedures, Rules and Regulations review and staff interview the CAH (Critical Access Hospital) failed to (A) ensure a physician examined 2 of 6 surgical patients (Patients 26 & 31) reviewed immediately before surgery to evaluate the risk of the procedure to be performed and (B) failed to ensure an anesthesia qualified practitioner evaluated each patient after surgery for proper anesthesia recovery before discharge for 3 of 6 surgical patients (Patients 26, 27 & 28) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. Total number of surgical procedures for Fiscal Year 2021 (May 2021-May 2022) was 283.

Findings are:

(A)

A. Review of Patient 26's medical record (8/17/22 at 11:20 AM) revealed the patient had a colonoscopy ( a procedure to look at the inside of the colon and rectum) under MAC (Monitored Anesthesia Care) with sedation on 4/27/22. The physician signed on 4/27/22 that "This chart had been reviewed and this patient remains a good surgical candidate. There have been no changes to his/her physical status since the physical was performed..." with no evidence of time to ensure the examination took place immediately before surgery (procedure start time 11:40 AM).

-Review of Patient 31's medical record (8/17/22 at 1:25 PM) revealed the patient had a hysterscopy with polypectomy (an exam of the inside of the cervix and uterus with a thin, lighted telescope-like device and small instruments are inserted through the hysterscope to remove the polyp) under general anesthesia on 8/11/22. The physician signed on 8/11/22 that "This chart had been reviewed and this patient remains a good surgical candidate. There have been no changes to his/her physical status since the physical was performed..." with no evidence of time to ensure the examination took place immediately before surgery (procedure start time 10:05 AM).

B. Interview with the Director of Surgery (8/18/22 at 9 AM) confirmed no policy and procedure was in place for the process of physician evaluation for the risk of the procedure immediately before surgery and confirmed the above medical records lacked a time of the assessment by the surgeon ensuring completion immediately before surgery.

(B)

A. Review of Patient 26's medical record (8/17/22 at 11:20 AM) revealed the patient had a colonoscopy under MAC with sedation on 4/27/22. Review of the Post-Anesthesia Note revealed a lack of evidence of VS (vital signs) and the time the assessment was completed.

-Review of Patient 27's medical record (8/17/22 at 12:00 PM) revealed the patient had a esophagogastroduodenoscopy (EGD-a test to examine the lining of the esophagus, stomach, and first part of the small intestine-the duodenum) and colonoscopy under MAC with sedation. Review of the Post-Anesthesia Note revealed a lack of evidence of a documented assessment being completed.

-Review of Patient 28's medical record ( 8/17/22 at 12:20 PM) revealed the patient had a laparoscopic cholecystectomy (procedure performed through 4 small incisions with use of a camera to visualize the inside of the abdomen and long tools to remove the gallbladder) under general anesthesia. Review of the Post-Anesthesia Note revealed a lack of evidence of a documented assessment being completed.

B. Review of the Rules and Regulations (Review Date 2/21) stated the following under Postanesthetic Care:
"The post anesthesia record shall be completed by the CRNA [Certified Registered Nurse Anesthetist] immediately in the postoperative care area with the following information properly documented, dated and times:
Type of anesthesia and surgery performed.
Patient's physical condition including stability of vital signs, principal ailment of patient, quantity of blood loss, status of fluid replacement and level of consciousness on entering and leaving the PACU [Post-anesthesia care unit].
Written and verbal orders for any additional medication related to anesthesia.
Oxygen therapy for recovering patient as necessary. Special positioning of the patient.
Special monitoring if required."

C. Interview with the Director of Surgery (8/18/22 at 8:45 AM) confirmed the post-anesthesia assessments were not completed per Rules and Regulations on the above medical records including the lack of documented time of assessment, lack of documented vital signs and lacked evidence of post-anesthesia assessments being completed before discharge from the CAH.

Based on review of hospital staff vaccination records, review of policy and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure all hospital staff were fully vaccinated or had an approved exemption for 2 of 9 facility staff members (Staff Members A & B) reviewed resulting in a 98% vaccination rate. This failed practice had the potential to affect all patients and staff of the CAH. Total number of current staff was 106. The CAH census on 8/15/22 was 5.

Findings are:

A. Review of Staff Member A's COVID-19 requirement revealed a hire date of 2/12/22 and lacked evidence of proof of vaccination or evidence of a medical or religious exemption.

-Review of Staff Member B's COVID-19 requirement revealed a hire date of 2/22/22 and lacked evidence of proof of vaccination or evidence of a medical or religious exemption.

B. Review of policy and procedure titled Mandatory Vaccination Policy (Effective Date 11/17/21) stated the following:

-"It is the policy of Cozad Community Health System that this Mandatory COVID-19 Vaccination policy applies to all facility staff, regardless of clinical responsibility or patient contact, who provide care, treatment, or other services for the facility and/or its patients including: facility employees; licensed practitioners; students, trainees, and volunteers; and individuals who provide care, treatment, or other services for the facility and/or its patients, under contract or by other agreement."
-"All covered staff covered by this policy are required to be fully vaccinated. Staff are considered fully vaccinated two weeks after completing primary vaccination with a COVID-19 vaccine, with, as applicable, at least the minimum recommended interval between doses."
-"Staff may request an exemption from this mandatory vaccine policy if the vaccine is medically contraindicated for them or medical necessity requires a delay in vaccination. Staff also may be entitled to a reasonable accommodation if they cannot be vaccinated and/or wear a face covering (as otherwise required by this policy) because of a of a disability, or if the provisions in this policy for vaccination and/or wearing a face covering conflict with sincerely held religious belief, practice, or observance. Requests for exemptions and reasonable accommodations must be initiated by making a request with Human Resources."

C. Review of Mandatory Vaccination Policy Process - Human Resources (No Date) Tracking and Maintaining Records stated
"Human Resources is responsible for tracking and maintaining vaccination records and/or approved exemption requests, including signed agreements, for all CCHS [Cozad Community Health System] employees, contracted employees, students and job shadows."

D. Interview with The Director of Human Resources (8/17/22 at 10:10 AM) stated that the two above staff members were unvaccinated and were given the exemption paperwork but did not return it and stated "I did not follow-up with it and did not follow the process for tracking and documenting vaccination or exemption status."