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Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) surgical management staff failed to ensure surgical services staff tested the Cidex OPA disinfecting solution before each use. The surgical services charge nurse stated the surgical services staff performed an average of 25 endoscopic procedures per month.

Failure to test the Cidex OPA solution before each use could result in the solution not containing sufficient quantity of the active ingredient to kill all microorganisms, potentially causing an infection in another patient.

Findings include:

1. Observations during a tour of surgical department on 10/27/10 at 10:10 AM, in the sterile processing area, revealed a large container of Cidex OPA solution, and a small container of Cidex OPA solution.

2. Review of the manufacturer's instruction for the Cidex OPA test strips, undated, revealed: "It is recommended that CIDEX OPA solution be tested before each usage with the CIDEX OPA Solution test strips..."

3. Review of the "Cidex Log Sheet", revised 3/18/10, revealed Scrub Technician D had tested the small container of CIDEX OPA solution three times since Scrub Technician D prepared the CIDEX OPA solution.

4. During an interview on 10/27/10 at 1:15 PM, Scrub Technician D stated they tested the CIDEX OPA in the large container before each use. However, if Scrub Technician D needed to use the CIDEX OPA in the small container, they documented the test results for the large container of CIDEX OPA solution. Scrub Technician D did not test the CIDEX OPA solution in the small container. Scrub Technician D stated they would test both solutions in the future.

Based on observation, document review and staff interviews, the hospital staff failed to secure patient information from unauthorized access in the Physical Therapy reception office and Cardiac Rehab department.

The Physical Therapy staff identified an average of 25 outpatient and 2 in patient therapy treatments daily
The Cardiac Rehab staff identified an average of 3 outpatient 3 times a week.

Failure to secure medical records placed patients at risk for identify theft and unauthorized parties to view sensitive personal and medical information.

Findings included:

1. On 10/26/10 at 12:30 PM, Surveyor observed an unlocked door to the unattended Physical Therapy (PT) reception office. At 12:35 PM Staff B, Physical Therapy Aide (PTA) confirmed the unlocked PT reception office due to Staff B had gone to lunch. Staff B disclosed when surveyor arrived at the unlocked/unattended therapy reception office earlier; he/she did not hear or see the surveyor.

Staff B opened an unlocked lateral file drawer in the reception office to reveal multiple medical records in alphabetical order. Staff B confirmed the medical records contained personal and medical information for the current patients. The PT staff identified an average of 25 outpatient and 2 in patient therapy treatments daily.

An unalarmed exit door directly across from the PT reception office door (approximately 10 feet between PT reception office and unalarmed exit door), Staff B stated patients entered the hospital through this door for easy access to PT, Occupational Therapy (OT), Speech Therapy (ST) and Cardiac Rehab.

Outside the exit door, cars used a "u" shape driveway to deliver patients to the unalarmed door for quick and easy access to the therapy hallway. The hall leads patients to the PT, OT, ST and Cardiac Rehab departments for patient therapy.

a. On 10/26/10 at 1:45 PM, surveyor observed an open door to an unattended Cardiac Rehab department. At 1:50 PM, the Surveyor requested Staff C, Administrator Director and manager for Therapies, to observe the Cardiac Rehab department. Staff C confirmed the open door to the unattended Cardiac Rehab department.

Observation showed 5-6 sets of paper on the desk. Staff C stated the papers were patient medical records containing "personal and medical information". Staff C stated, the room "should be closed and locked when no one is in the room". Staff C then closed the door and stated he/she would speak with Cardiac Rehab staff to keep the door locked if no one in the room.

b. On 10/27/10 at 8:30 AM, in 10 minutes 8 persons noted to arrive per car from the "u" shape driveway, entered the hospital per the exit door across from the PT reception area and walked down the therapy hall towards the nursing station.

Three persons entered through the door from the "u" shape driveway and walked towards the PT reception to check in.

2. A review of the hospital policy "Safeguards for Protected Health Information", stated in part,
"... [The hospital] maintains appropriate safeguards as reasonably necessary to protect PHI [protected health information] from unauthorized access and unauthorized uses and disclosures..."
"...the department managers are responsible for ensuring that physical access control and other physical safeguards are implemented to limit physical access...to protect the PHI in maintains against unauthorized access...safeguards include...appropriate locks on doors and drawers..."

3. During an interview on 10/26/10 at 12:35 PM, Staff B confirmed he/she left the PT reception office unlocked and unattended during lunch break. Staff B confirmed the unlocked lateral file contained medical records with personal and medical information of current patients.

a. During an interview on 10/26/10 at 1:00 PM, Staff B stated the exit door across from the PT reception office lead to easy access for patient who received PT, OT, ST and/or Cardiac Rehab therapy.

b. During an interview on 10/27/10 at 9:15 AM, Staff C, stated, "I would be ultimately responsible for the security of medical records in the therapy area." Staff C stated, he/she spoke with the PT and Cardiac Rehab staff about ensuring when their office and/or department was unattended they would lock the doors.

c. During an interview on 10/28/10 at 10:05 AM, Staff C stated a request for a push button code lock for the PT Clerical office. Staff C disclosed he/she visited with the Cardiac Rehab nurse to lock and shut the door when he/she is not physically in the office.

Based on review of policies, patient medical records, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure that a qualified anesthesia practitioner evaluated every patient for proper anesthesia recovery prior to discharge in 5 of 5 closed surgery records reviewed. (Patient's #1, 2, 3, 4, and 5) The surgery department staff reported approximately 10 surgical procedures performed per month.

Failure to provide a proper anesthesia recovery assessment by a qualified practitioner has the potential to harm patients if complications, related to the use of anesthesia, occur after surgery and the patient has returned home.

Findings included:

1. Review of CAH policy titled "Anesthesia Care", approved by the CAH Board Quality Committee on 9/2/10, revealed: " ...D. Post Anesthesia's Assessment 1. The oast-anesthesia follow-up will be documented in the patient's medical record. The following information will be included, but limited to: a) Cardiopulmonary status b) Level of consciousness c) Any follow-up care and/or observations: and d) Any complications occurring during post-anesthesia recovery."

2. Review of the medical records for Patient's #1, 2, 3, 4, and 5 revealed a lack of evidence that a qualified anesthesia practitioner documented a post anesthesia assessment prior to the patient being discharged to home.

4. During an interview and review of medical records for Patient's #1, 2, 3, 4, and 5, on 10/28/10 at 9:20 AM, the Chief Nursing Officer stated that CAH policy and procedures require that a Certified Registered Nurse Anesthetist (CRNA) is to complete a post anesthesia assessment after surgery and prior to discharging the patients. The Chief Nursing Officer acknowledged that the medical records reviewed lacked documentation of the assessments being done.

5. During an interview and review of medical records for Patient's #1, 2, 3, 4, and 5, on 10/28/10 at 10:30 AM, Staff A stated that CAH policy and procedures require that a Certified Registered Nurse Anesthetist (CRNA) is to complete a post anesthesia assessment after surgery and prior to discharging the patients. Staff A acknowledged that the medical records reviewed lacked documentation of the assessments being done.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure nursing staff documented the physician's involvement in the interdisciplinary care conference for 7 of 7 closed swing bed medical records (Patient #6, 7, 8, 9, 10, 11, and 12). The CAH administrative staff identified 3 current swing bed patients.

Failure to include the physician in the interdisciplinary care conference could potentially result in the physician not knowing critical information prior to discharging a patient, potentially resulting in patients not receiving needed services after discharge.

Findings include:

1. Review of the policy "Interdisciplinary Care Conference - Skilled", effective 8/10, revealed in part, "Participants in plan of care process may include: ... Physician .... Nursing Staff, physicians, ... discuss a minimum of three times a week ... to evaluate patient needs. ... If the physician is not available to attend the [Interdisciplinary Care Conference], the nursing staff will communicate any revision in the plan of care ... to the physician. Documentation of the conference will be made in the electronic health record"

2. Review of closed swing bed medical records revealed:

a. The Discharge Planner documented in the Interdisciplinary Rounds section of Patient #6s swing bed medical record that Interdisciplinary Care Conferences occurred on 9/24/10 and 9/30/10. The Discharge Planner did not document they included Patient #'1 physician in the care conference, or notified them of the plan of care.

b. The Discharge Planner documented in the Interdisciplinary Rounds section of Patient #7's swing bed medical record that an Interdisciplinary Care Conference occurred on 10/7/10. The Discharge Planner did not document they included Patient #2's physician in the care conference, or notified them of the plan of care.

c. The Discharge Planner documented in the Interdisciplinary Rounds section of Patient #8's swing bed medical record that an Interdisciplinary Care Conference occurred on 3/11/10. The Discharge Planner did not document they included Patient #3's physician in the care conference, or notified them of the plan of care.

d. The Discharge Planner documented in the Interdisciplinary Rounds section of Patient #9's swing bed medical record that an Interdisciplinary Care Conference occurred on 1/21/10. The Discharge Planner did not document they included Patient #4's physician in the care conference, or notified them of the plan of care.

e. The Discharge Planner documented in the Interdisciplinary Rounds section of Patient #10's swing bed medical record that an Interdisciplinary Care Conference occurred on 1/25/10. The Discharge Planner did not document they included Patient #5's physician in the care conference, or notified them of the plan of care.

f. The Discharge Planner documented in the Interdisciplinary Rounds section of Patient #11's swing bed medical record that an Interdisciplinary Care Conference occurred on 4/19/10. The Discharge Planner did not document they included Patient #6's physician in the care conference, or notified them of the plan of care.

g. The Discharge Planner documented in the Interdisciplinary Rounds section of Patient #12's swing bed medical record that Interdisciplinary Care Conferences occurred on 11/16/09 and 11/19/09. The Discharge Planner did not document they included Patient #7's physician in the care conference, or notified them of the plan of care.

3. During an interview on 10/27/10 at 4:00 PM, the Utilization Review Nurse acknowledged Patients #6, #7, #8, #9, #10, #11, and #12's medical records lacked documented evidence the CAH nursing staff included the patients' physicians in the interdisciplinary care conferences, or notified the physician of the plan of care. The Utilization Review Nurse stated nursing staff discussed the patients' plan of care with their physician every day, including items brought up during the care conference. However, the nursing staff failed to document the fact nursing staff informed the physician of the information presented about the patients' plan of care.