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Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the staff removed outdated medication and supplies from the Emergency and Medical/Surgical areas. Failure to remove outdated medications and supplies from the CAH's supplies, available for patient use, could potentially result in the staff using expired medications and/or supplies for patient use after the manufacturer's expiration date, potentially resulting in the staff using medication on a patient after the date which the manufacturer guaranteed the sterility and efficacy of the medication and supplies. The CAH administrative staff identified the census on 12/6/2021 was 6 patients.

Findings included:
1. Observation during a tour of the Emergency Department on 12/6/21 at 12:45 PM revealed the following outdated supplies:
a. In Emergency Room Pediatric Cart:
- 1 of 1 Covidien Argyle 20 milliliter (ml) mucous trap, expired on 11/30/2021
- 2 of 2 Cobas PCR urine sample pad, expired 11/30/2021
- 1 of 2 Nellcor infant SpO2 Sensor, expired 10/31/2021
- 1 of 1 Hudson PCI ET tube, size 4.0, expired 11/9/2021
- 1 of 1 Rusch ET tube, size 6.0, expired 11/28/2021.

b. In Emergency Room Crash Cart:
- 1 of 2 Rusch ET tube, size 6.0, expired 11/28/2021
- 1 of 2 Rusch ET tube, size 7.0, expired 11/28/2021
- 1 of 2 Rusch ET tube, size 8.0, expired 11/28/2021


2. Observation during a tour of the Medical Surgical Nursing Floor on 12/6/21 at 1:00 PM revealed the following outdated supplies:

a. In Medical Surgical Floor Crash Cart:
- 1 of 1 Broselow/Hinkle Pediatric Emergency System, expired 11/2020

b. In Medical Surgical Floor Storage:
- 1 of 1 WelchAllyn Disposable resting ECG electrodes, expired 9/9/2021
- 6 of 6 3M PICC/CVC Securement dressing, expired 5/21/2021
- 1 of 1 Honeywell Eyesaline, expired 7/2021.

3. Review of CAH policy "Expiration Dates, Materials", reviewed 10/2020, revealed in part, "Departments are responsible for keeping track of their own expiration dates, ... to check their stock monthly ... any supply items that have reached or are near expiration will be pulled ..."

4. During an interview on 12/6/2021 at approximately 1:30 PM, the Emergency Room Director acknowledged several outdates in the emergency room crash carts.

5. During an interview on 12/7/2021 at approximately 8:30 AM, the Chief Nursing Officer acknowledged several outdates on the medical surgical floor.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to monitor and track the temperature of the blanket warmer located on the medical surgical floor. Failure to monitor and track the temperature of this device could potentially result in the blanket warmer excessively heating a blanket, potentially resulting in the patient getting burned. The CAH's administrative staff identified a current census of 6 patients on entrance.

Findings include:

1. Observations during a tour of the medical surgical floor on 12/06/21 at 3:30 PM revealed a blanket warmer. Further observations of the blanket warmer revealed that the blanket warmer lacked a system for the hospital staff to document they verified the blanket warmer stayed within a safe range of temperatures.

2. Review of the CAH's policies revealed that the CAH lacked a policy instructing the CAH staff to monitor the blanket warmer's temperature.

3. During an interview on 12/07/2021 at 8:45 AM, the Inpatient Director verified the CAH staff failed to monitor the temperature of the blanket warmer on the medical/surgical floor. The Inpatient Director also verified the CAH lacked a policy instructing the CAH staff to monitor the temperature of the blanket warmer.

I. Based on document review, policy review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 General Surgeon, 1 of 1 Ears Nose and Throat Specialist (ENT), and 1 of 1 Ophthalmologist selected for review, received peer review by a qualified peer, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital. Failure to ensure all medical staff members received peer review by a qualified peer affects the CAH's ability to assure physicians provide quality care to the CAH patients. The CAH administrative staff identified the identified physicians provided care to patients in fiscal year 2020 as follows:

General Surgeon - 93 surgical procedures
ENT - 18 surgical procedures
Ophthalmologist- 31 surgical procedures

Findings include:

1. Review of the CAH's network agreement, executed 4/29/19, revealed in part " ... Hospital provider peer review will be performed by [Network Hospital] ... in addition ... [the Network Hospitla] will serve as peer review resource for selected case based on quality concerns, clinical competency, or care issues ..."

2. Review of the CAH Medical Staff Bylaws, approved on 12/10/2018, revealed in part " ... Peer review ... includes ... representatives of the Network Hospital when called for under the CAH Network Agreement ... Peer Review structure consists of an external physician appointed by the Medical Staff to conduct peer review for [the CAH]. The appointed physician will review a minimum of one chart per year for each provider who furnished services to [the CAH's] patients during the year ...".

The medical staff bylaws lacked a requirement for the peer review to be performed by a qualified peer, i.e. a general surgeon reviewed the general surgeon's records, an ENT surgeon reviewed the ENT surgeon's medical records, and an ophthalmologist surgeon reviewed the ophthalmologist surgeon's records to ensure the appropriateness of diagnosis and treatment provided to the CAH's patients.


3. Review of the CAH policy "Healthcare Provider Credentialing", reviewed 4/2020, revealed in part "... Peer review will be performed biannually as set up in the Critical Access Hospital Network Agreement ...".

The Policy lacked a requirement for the peer review to be performed by a qualified peer, i.e. a general surgeon reviewed the general surgeon's records, an ENT surgeon reviewed the ENT surgeon's medical records, and an ophthalmologist surgeon reviewed the ophthalmologist surgeon's records to ensure the appropriateness of diagnosis and treatment provided to the CAH's patients.


4. Review of the credential file and external peer review for the General Surgeon revealed the medical staff approved his reappointment to the Medical Staff on 5/20/2020. The Governing Board approved the General Surgeon for reappointment to the Medical staff on 6/22/2020. The General Surgeon's credential file included the results from 4 external peer reviews during the prior credentialing period, each performed by a Network Hospital Emergency Medicine Physician, rather than a General Surgeon.

5. Review of the credential file and external peer review for the ENT surgeon revealed the medical staff approved his reappointment to the Medical Staff on 5/20/2020. The Governing Board approved the ENT surgeon for reappointment to the Medical staff on 6/22/2020. The ENT surgeon's credential file included the results from 2 external peer reviews during the prior credentialing period, each performed by a Network Hospital Emergency Medicine Physician, rather than an ENT surgeon.

6. Review of the credential file and external peer review for the Ophthalmology surgeon revealed the medical staff approved her reappointment to the Medical Staff on 6/12/2021. The Governing Board approved the Ophthalmology surgeon for reappointment to the Medical staff on 6/28/2021. The Opthamologiy surgeon's credential file included the results from 2 external peer reviews during the prior credentialing period, each performed by a Network Hospital Emergency Medicine Physician, rather than an opthalmology surgeon.

7. During an interview on 12/9/2021, at 10:40 AM, the Revenue Cycle Director reported she was responsible for overseeing the peer review process. The Revenue Cycle Director verified that a Network Hospital Emergency Medicine Physician performed all of the CAH's external peer reviews. The Revenue Cycle Director acknowledged that the Network Hospital Emergency Medicine Physician was not in the same specialty of medicine (a qualified peer) as the ENT surgeon, the Opthamology surgeon, and the General Surgeon.


8. During an interview on 12/9/2021, at approximately 11:45 AM, the CEO acknowledged the CAH's Network Hospital provided the peer review as addressed in the Network Agreement and that 1 Network physician performed all the peer review for the CAH physician providers.





II. Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 2 Teleradiologists selected for review, received outside entity peer review by a qualified peer, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital. Failure to ensure all medical staff members received outside entity peer review affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff identified the identified physicians provided care to patients in fiscal year 2020 as follows:

Teleradiologist F- 5,703 radiology procedure reads
Teleradiologist G- 87 radiology procedure reads

Findings include:

1. Review of the CAH's network agreement, executed 4/29/19, revealed in part " ... Hospital provider peer review will be performed by [Network Hospital]...in addition...will serve as peer review resource for selected case based on quality concerns, clinical competency, or care issues ..."

2. Review of the document, "Professional Teleradiology Services Agreement", effective on 7/23/2015, revealed in part, "... Quality Assurance Program. Group shall provide an ongoing quality assurance program and ongoing internal radiologist evaluation and performance reviews... " The radiology group did not identify itself as being part of a Hospital and termed itself a "Group". The services agreement lacked mention of a peer review process.

3. Review of the CAH Medical Staff Bylaws, approved by the Governing Board on 12/10/2018, revealed in part " ... Peer review...includes...representatives of the Network Hospital when called for under the CAH Network Agreement...Peer Review structure consists of an external physician appointed by the Medical Staff to conduct peer review for [CAH] The appointed physician will review a minimum of one chart per year for each provider who furnished services to [CAH] patients during the year ...". The medical staff bylaws lacked a requirement for the peer review to be performed by a qualified peer, i.e. a general surgeon reviewed the general surgeon's records, an ENT surgeon reviewed the ENT surgeon's medical records, and an ophthalmologist surgeon reviewed the ophthalmologist surgeon's records to ensure the appropriateness of diagnosis and treatment provided to the CAH's patients.

4. Review of CAH policy, "Healthcare Provider Credentialing", reviewed 4/2020, revealed in part "... Peer review will be performed biannually as set up in the Critical Access Hospital Network Agreement ...". The policy lacked a requirement for the peer review to be performed by a qualified peer, i.e. a general surgeon reviewed the general surgeon's records, an ENT surgeon reviewed the ENT surgeon's medical records, and an ophthalmologist surgeon reviewed the ophthalmologist surgeon's records to ensure the appropriateness of diagnosis and treatment provided to the CAH's patients.

5. Review of the credential file and external peer review for Teleradiologist F revealed the medical staff approved his reappointment to the Medical Staff on 2/20/2021. The Governing Board approved Teleradiologist F for reappointment to the Medical staff on 2/22/2021. Teleradiologist F lacked documentation of peer review in his file.

6. Review of the credential file and external peer review for Teleradiologist G revealed the medical staff approved his reappointment to the Medical Staff on 1/15/2020. The Governing Board approved Teleradiologist F for reappointment to the Medical staff on 1/27/2020. Teleradiologist F lacked documentation of peer review in his file.

7. During an interview on 12/9/2021, at 10:40 AM, the Revenue Cycle Director reported she was responsible for overseeing the peer review process and confirmed Teleradiologist F and Teleradiologist G lacked peer review by the Network Hospital, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital.

8. During an interview on 12/9/2021 at approximately 11:45 AM, the CEO acknowledged the CAH's Network Hospital provided the peer review as addressed in the Network Agreement and that teleradiologists did not receive peer review of the care they provided to the CAH's patients.

I. Based on document review and staff interviews the Critical Access Hospital (CAH) failed to ensure compliance with applicable Iowa state law that governs the qualifications and licensure of staff who dispense drugs when the CAH allowed registered nurses to dispense drugs to patients, for take home use, from the CAH emergency department after regular hospital pharmacy hours for 2 of 2 emergency room patient records reviewed (Patient #11 and Patient #12) . Failure to ensure registered nurses practiced within their scope of practice and license placed the CAH's patients at risk for harm. The CAH administrative staff identified 2,265 patients presented to it's emergency department for emergency care in fiscal year 2020.

Findings include:


1. Review of "Chapter 7 Advance Registered Nurse Practitioners" dated IAC [Iowa Administrative Code] 2/13/19 revealed in part, "...Dispense means to provide a prescription drug to a patient for self-use outside of the ARNP's practice location..." An Advanced Registered Nurse Practitioner (ARNP) may prescribe a drug and it is in their scope of practice and training to dispense medication . Dispensing medication is not in the scope of practice for a registered nurse.

2. Review of "IAC 657--7.12(124,126,155A) Drugs in the emergency department", dated 3/18/20, revealed in part "... Drugs maintained in the emergency department are kept for use by or at the direction of prescribers in the emergency department... 7.12(3) Drug dispensing. Only a pharmacist or prescriber may dispense any drugs to an emergency department patient..." A registered nurse (RN) is not a prescriber.

3. Review of Iowa Code 2021, Section 147.107, "Drug dispensing, supplying, and prescribing -- Limitations" revealed in part, "... A registered nurse may supply...a quantity of properly packaged and labeled prescription drugs, controlled substances..." The registered nurse may "supply" or provide the medication , Macmillan dictionary definition- "dispense - to prepare medicines and give them to people".

4. Review of the "Medication Policy, Emergency Department," revised 2/2020, revealed in part, "... Medications may be dispensed to patients through the ED if the local pharmacy is closed... nurse may dispense only enough of the medication until a retail pharmacy is open ... nurse must completely fill out the label on the medication then sign out the medication ..."

5. During an interview on 12/7/21 at 1:00 PM, the Pharmacy Director verbalized only a pharmacist or a physician could dispense drugs in the CAH, however a nurse could dispense a maximum of a 3 day supply of medication from the emergency department after hours at night and on weekends when the hospital pharmacy and local retail pharmacy is closed.

6. Review of the emergency room medical record for Patient #11 revealed Patient #11 presented to the emergency department on 12/5/21 at 7:02 PM with complaints of right flank pain and discharged on 12/5/21 at 9:48 PM. ER Dr. I ordered HYDROCODONE/APAP 5/325 mg, 3 tablets dispensed to Patient #11 at 9:27 PM for take home use. ER RN D dispensed the 3 tablets of HYDROCODONE/APAP 5 mg/325 mg at 9:40 PM. A picture with 3 HYDROCODONE/APAP 5 mg/325 mg unit dose medication tablets, a completed medication label sticker, and Patient #11 medical record identification sticker is documented in Patient #11's medical record.

Review of document "Emergency Room - Dispensable Medication Log" revealed in part, on "12/5/21...9:30 PM...[Patient #11]...[ER Dr I]..HYDROCODONE/ACETAMINOPHEN 5 mg/325 mg #3...[ER RN D].


7. During an interview on 12/13/21 at 3:38 PM, ER RN D reported that when an emergency patient required medication for take home use, i.e. when a retail pharmacy was not open to fill a prescription, the ER doctor would write or give a verbal order for the medication that the patient was to take home. ER RN D and/or the doctor would determine the number of pills the patient would need until a prescription could be filled, but the number of pills could not exceed 3 days worth of medication. Narcotic medications were limited to a maximum of 6 tablets. ER RN D was required to choose "dispense" in order to retrieve the medication from the automated medication dispensing machine. ER RN D pulled the ordered number of medications tablets out of the machine and placed them in a little Ziploc bag, completed a sticker that required the doctors name, date, account number, patient name, instructions, name of medication, and attached the sticker to the Ziploc bag of medication. ER RN D then took a picture of the sticker and the individual tablets of medication provided to the patient and included the picture in the patients medical record. The medication dispensed is then recorded in a book in the medication room to sign out and sign off the medications for the pharmacy. ER RN D reported the doctor's role was to provide the medication order and give instructions to the patient about what medications are being sent home with the patient. The ER Doctors are not required to verify the contents of the Ziploc bag of medication provided to the patient. ER RN D reviewed Patient #11's medical record and acknowledged ED RN D took the picture present in the record of the HYDROCODONE/APAP 5 mg/325 mg unit dose tablets, filled out the medication label that was present in the picture, and attached the patients medical record identification sticker.


8. Review of the emergency room medical record for Patient #12 revealed Patient #12 presented to the emergency department on 11/13/21 at 4:17 PM with a complaint of abdominal pain and discharged on 11/13/21 at 6:18 PM. ER Doctor J ordered HYDROCODONE/APAP 5 mg/325 mg, 6 tablets at 5:10 PM to be dispensed for Patient #12's take home use. ER RN E dispensed 6 unit dose tablets of HYDROCODONE /APAP 5 mg/325 mg at 5:10 PM with instructions to take 1 tablet by mouth every 8 hours as needed for pain.

Review of the "Emergency Room - Dispensable Medication Log" revealed in part, on "11/13/21...5:15 PM...[Patient # 12]...[ER Doctor J]...Hydrocodone5/325 mg #6...[ER RN E]".


9. During an interview on 12/13/21 at 4:00 PM , ER RN E reported they dispensed prescription medications from the automated medication dispensing unit for ER patients to take home upon a written or verbal order form the doctor. ER RN E verbalized there were limited amounts of medications that could be provided, no more than 3 days worth of medication or 6 tablets of a narcotic medication, just enough to get the patient by until they can get their prescription filled. ER RN E provided a blank medication label and indicated the RN completed the label with the name of the doctor, date, patient's account number, patient's name, instructions for use and the name of the medication. The completed label is then attached to the medication baggies and the ER RN gives the medication to the ER patient. The ER Doctor is not generally involved in dispensing the medication outside of providing the order and telling the patient about the medication that has been ordered.

10. During an interview on 12/8/21 at 12:05 PM, the CNO confirmed ER nurses pulled medications, as ordered by a physician, from the automated dispensing unit, packaged the quantity of medication ordered in small plastic Ziploc bag, then labeled the bag with the name of the medication, dose, instructions for use and provided the package of medication to the ER patient.



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II. Based on observation, document review, and interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the surgery staff changed the sterile water flush bottles after endoscope procedures for each patient, in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacterial growing in the sterile water and potentially causing an infection in the next patient. The hospital's administrative staff identified surgical services staff performed 66 endoscopic procedures per calendar year in 2020.

Findings include:

1. Observations during a tour of the surgery department on 12/07/2021 at approximately 12:40 PM during a demonstration of an endoscopic cleaning revealed 1 of 1 bottle Baxter 1000 milliliter (mL) bottle of sterile water for irrigation connected to the endoscope equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract) was not changed prior to the next endoscopic procedure.

2. Review of the manufacturer's instructions for the Baxter 1000 mL bottle of sterile water indicated in part... "For single-dose only." " ... Use the contents of the opened container immediately to minimize the potential for bacterial growth." The hospital staff must discard any unused portions of the sterile water for irrigation after use on a single patient. The sterile water for irrigation did not contain any chemicals to prevent bacteria from growing in the sterile water once the hospital staff opened the bottles of sterile water for irrigation.

3. During an interview on 12/07/21 at 1:20 PM with Surgery Director, acknowledged the surgery staff opened the bottles of sterile water for irrigation each day for endoscope procedures that are scheduled and connected it to the equipment. The equipment contained a one-way valve to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscope procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscope procedures. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscope procedures for the day or if the bottle ran empty.




III. Based on observation, document review, and interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the Rehabilitation Service staff utilized the Aquasonic gel as single use only during each therapeutic ultrasound for each patient, in accordance with the manufacturer's directions. Failure to discard the unused portion of gel after each patient could potentially result in bacterial growing in the ultrasound gel and potentially causing an infection in the next patient. The hospital's administrative staff identified Rehabilitation Service staff performed 82 therapeutic ultrasounds per calendar year 2021.

Findings include:

1. Observations during a tour of the Rehabilitation Service department on 12/07/2021 at approximately 9:30 AM revealed 3 of 6 Aquasonic 100 Ultrasound Transmission Gel single use packettes used for therapeutic ultrasound noninvasive procedures. The Rehabilitation Services staff had placed the unused portion of a single use packette in a plastic container with the unopened single use packettes, allowing the staff to reuse the single use packette for another patient.

2. Review of the manufacturer's instructions for the Aquasonic 100 Ultrasound Transmission Gel indicated in part... "For single-dose only." " ...can be used on intact, unbroken skin and natural body orifices and on all patients in facilities where cross contamination is of concern." "Discard packette after use." The hospital staff must discard any unused portions of the gel after use on a single patient. The Aquasonic 100 Ultrasound Transmission Gel did not contain any chemicals to prevent bacteria from growing in the gel once the Rehabilitation Service staff opened the packette of gel for therapeutic ultrasound.

3. During an interview on 12/07/21 at 3:00 PM with Rehabilitation Manager, verified the physical therapists and physical therapy assistants would opened a packette of Aquasonic 100 Ultrasound Transmission gel for a therapeutic ultrasound noninvasive procedure and not discard the unused portion but would place the unused portion in plastic contain with unopened packettes for reuse. The Rehabilitation Manager acknowledged these packettes are for single use only and should be discarded after each therapeutic ultrasound.

Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the hospital staff kept patient medical information secure from unauthorized access in the rehabilitation area. Failure to keep patient medical information confidential could potentially result in theft of a patient's information and potentially result in identity theft. The CAH's administrative staff identified a current census of 6 patients on entrance.

Findings include:

1. Observations during a tour of the Rehabilitation Service Department on 12/07/2021 at 9:07 AM, with the Rehabilitation Manager revealed, the therapy office, which is located in the center of the Rehabilitation Service Department is locked at night but housekeeping has access to the Rehabilitation Service Departments key and to the reception desk when rehabilitation staff is not present.

2. Review of the CAHs policy titled "Security Awareness Confidentiality Policy," effective 12/2008, revealed in part "...Never leave PHI or ePHI unattended unless encrypted, or secured with locks or other means of preventing unauthorized disclosure of the information."

3. During an interview on 12/07/2021 at 9:45 AM with the Rehab Service Coordinator, revealed once a month ,the Rehab Service Coordinator gathers information pertaining to how many visits the Rehabilitation department receives from patients to track charges. This requires a report of what patients have visited. The report reflects each patient's name, date of visit and what rehabilitation area was scheduled (physical therapy, speech therapy, cardiac rehab, etc.). This information is gathered and placed in an unlocked drawer at the reception desk located by the fax machine. The drawer contained reports from June 2021-November 2021. The Rehab Service Coordinator further revealed, once the drawer becomes full the reports are placed in a banker's box an unlocked room adjacent to the therapy office, then once that box is full it is transferred to the basement by a physical therapy tech.

4. During an interview on 12/07/2021 at 10:35 AM with Physical Therapy Tech A revealed rehabilitation service department month end documents are taken to the basement once banker boxes are full. Physical therapy tech A then escorted this surveyor to the basement to reveal a locked room in which the key was on a nail next to the door. The storage room had, old equipment, supplies, Christmas decorations, and approximately 406 banker boxes containing unsecured patient information, such as lab results with patient identifiers present, nursing worksheets, therapy month end with patient names and visit dates, telephone triage information, and physician orders with patient information.

5. During an interview on 12/07/21 at 3:00 PM, the Rehab Manager revealed they were unaware of the storage of unsecured patient information in the basement. Once they toured the storage area and discovered the easy access to the key, the Rehab Manager acknowledged these records with patient information were unsecured.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 Registered Nurses (Contracted RN H), who assisted the Ears Nose and Throat (ENT) Surgeon during surgical procedures, was qualified to assist. Failure to ensure the qualifications of all individuals providing assistance to surgical procedures of CAH patients could potentially result in the performance of care beyond their capabilities and placing the patient at risk for surgical complications and potential harm. The administrative staff identified RN H assisted the ENT surgeon on 18 surgical procedures in fiscal year 2020.

Findings include:

1. During an interview on 12/7/2021 at 1:25 PM, the Surgical Director reported the ENT Surgeon provided surgical services with a nurse not employed by the CAH, who performs duties as a first assistant nurse.

2. Review of the Surgical privileges binder, at the time of the interview with the Surgical Director, revealed the Surgical department staff lacked privileges for Contracted RN H that identified the duties Contracted RN H was allowed to perform in the surgical suite.

3. During an interview on 12/8/21, at 8:40 AM the Revenue Cycle Director reported she was responsible for the process of credentialing and privileging of providers and staff. The Revenue Cycle Director reported she was unaware that the ENT Surgeon brought Contracted RN H to assist the ENT Surgeon in surgery and that Contracted RN H had not been credentialed or privileged. The Revenue Cycle Director verbalized the hospital lacked a policy for credentialing and privileging of staff a surgeon may bring with them to assist with procedures. The Revenue Cycle Director verbalized the Human Resources department may have information on Contracted RN H.

4. During an interview on 12/8/21 at approximately 2:00 PM, the Human Resources Director revealed she had not been aware Contracted RN H came with the ENT Surgeon and assisted with ENT surgical procedures. The Human Resources Director reported she did not have a file or information on Contracted RN H.

5. During an interview on 12/9/2021, at 12.00 PM, the CNO acknowledged the CAH did not identify the expectations for qualifications of an individual accompanying the ENT surgeon to assist during a surgical procedure and the CAH failed to confirm Contracted RN H's qualifications and define her privileges at the CAH.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to focus on measures related to improved health outcomes that are shown to be predictive of desired patient outcomes for all services, including contracted services for 11 of 27 departments (Anesthesia, Speech Therapy, Occupational Therapy, Physical Therapy, Nuclear Medicine, CAT scan, MRI, Materials Management, Wound Clinic, Health Information Management, and Infusion Clinic) by failing to involve all deparments to report objective measures for ongoing evaluation for the prevention, reduction of errors, and to improve health outcomes in accordance with facility policy. The CAH administrative staff identified a census of 6 patients at the beginning of the survey. Failure to focus on measures related to improved health outcomes that are shown to be predictive of desired patient outcomes to include involvement of all of the CAH's departments on a continuous basis could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH "Horn Memorial Hospital Quality Assurance Performance Improvement (QAPI) Program 2021," revised 12/2020, revealed in part, "All employees of HMH will participate in quality improvement efforts ..." " ...involves all department and services, including those services furnished under contract or arrangement."

2. Review of the CAH's quality documentation revealed the following:

a. No quality indicators were identified for Anesthesia, Nuclear Medicine, CAT Scan, MRI, Wound Care, and Infusion for the year 2021.

b. Review of the Speech Therapy, Occupational Therapy, Physical Therapy, Materials Management, Health Information Management, and Infusion documentation for year 2021 revealed the documentation lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

3. During an interview on 12/13/2021 at 11:14 AM, the Quality Coordinator and Infection Prevention Nurse verified the CAH staff failed to ensure each department report and address problems that provide focused measures related to improved health outcomes.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 2 contracted Registered Nurses (RN) reviewed received a child and dependent adult abuse registry background check (Agency RN B and Agency RN C) prior to initially starting to work at the CAH. Failure to conduct child and dependent adult abuse registry background checks could potentially result in the CAH staff placing patients at risk for becoming victims of abuse from new contracted staff, as the hospital staff could not guarantee the new contracted staff member did not have a record of child or dependent adult abuse. Administrative staff identified 12 agency nurses contracted as of 12/6/21.


Findings include:

1. Review of a CAH document "Employee Handbook", dated on 2/17/19, revealed in part "... if the applicant accepts, [an offer of employment] ... dependent adult/child abuse records will be obtained... ". The CAH lacked a policy that addressed the performance of child and adult background registry checks for staff that cared for the CAH's patients.

2. Review of Agency RN B's personnel file revealed a start date of 2/8/21. A 12 page document provided by Staffing Agency A, dated 9/3/21, revealed the results of criminal and sex offender registry check, but failed to show verification of a child or dependent adult abuse registry check.

3. Review of Agency RN C's personnel file revealed a start date of 10/18/21 . A 12 page document provided by Staffing Agency A, dated 10/7/21, revealed the results of criminal and sex offender registry check, but failed to show verification of a child or dependent adult abuse registry check.

4. During an interview on 12/9/21, at 1:30 PM, the Human Resources Director acknowledged a child and dependent adult abuse registry check should have been conducted and the personnel files lacked documentation to show the results of a child and dependent adult abuse registry check. The CAH had accepted the background check performed by the staffing agency and had not identified that the staffing agency report lacked a child or dependent adult abuse registry check.

The Human Resources Director confirmed the Hospital did not obtain a child and dependent adult abuse background check for Agency RN B and Agency RN C, prior to them beginning work.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to document a comprehensive care plan (including interventions, goals or outcomes) for 10 of 10 patient records (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10) that is tailored to the patient's diagnosis. Failure to develop a comprehensive care plan could potentially impede the patient's progression toward attaining goals and achieving the highest level of well-being and independence possible. The CAH administrative staff identified a census of 6 acute patients at the beginning of the survey.


Findings include:

1. Review of the CAH policy "Comprehensive Assessment, Care plan, and Discharge Planning Swing Bed Skilled Care," dated revised 12/2021, revealed in part, "...Care plan includes measurable objectives and timeframes to meet the patient's medical, nursing, and mental and psychosocial needs ... In consultation with the patient and patient's representative the patient's goals for admission and desired outcomes."


2. Review of 5 of 5 skilled patient records revealed the following:

a. Review of open medical records on 11/30/2021 at 8:40 AM, revealed Patient #1's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes.

b. Review of open medical records on 11/29/2021 at 8:40AM, revealed Patient #2's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes.

c. Review of open medical records on 11/29/2021 at 8:40 AM, revealed Patient #3's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes.

d. Review of closed medical records on 11/29/2021 at 8:40 AM, revealed Patient #4's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes.

e. Review of closed medical records on 11/29/2021 at 8:40 AM, revealed Patient #5's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes.


3. Review of CAH policy "Plan of Care policy," dated last reviewed August 2019, revealed in part, "...A comprehensive Nursing Plan of Care will be developed and kept current for each Observation, Inpatient, and Skilled patient ... the Nursing Plan of Care, interventions/educational needs, family concerns and discharge plans will be addressed and kept current ..."


4. Review of acute inpatient medical records revealed the following:

a. Review of open medical records on 12/8/2021 at 12:30 PM, revealed Patient #6's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes.

b. Review of open medical records on 12/8/2021 at 12:30 PM, revealed Patient #7's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes..

c. Review of open medical records on 12/8/2021 at 12:30 PM, revealed Patient #8's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes.

d. Review of closed medical records on 12/8/2021 at 12:30 PM, revealed Patient #9's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes.

e. Review of closed medical records on 12/8/2021 at 12:30 PM, revealed Patient #10's medical record lacked evidence that the care plan addressed the patient's goals for admission and desired outcomes.


5. During an interview on 12/8/2021 at 2:45 PM, the Inpatient Nursing Director acknowledged patient medical records (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10) lacked a care plan that addressed the patient's goals for admission and desired outcomes.

6. During an interview on 12/13/2021 at 9:00 AM, the Quality Coordinator and IP RN acknowledged patient medical records (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10) lacked a care plan that addressed the patient's goals for admission and desired outcomes.