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Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure the Network Hospital staff evaluated the CAH's credentialing process, in accordance with the Network Agreement for Credentialing. The CAH staff reported 8 active, 47 courtesy/consulting, 9 emergency services, 1 reference, and 13 allied health professional medical staff members.

Failure to ensure the Network Hospital staff evaluated the CAH's credentialing process, in accordance with the Network Agreement for Credentialing, could potentially result in the facility's Medical Staff and Board of Directors failure to credential all medical staff members according to the facility's policy.

Findings include:

1. Review of the Network Agreement, dated June 1, 2005, revealed in part, ". . . [Network Hospital] shall bi-annually review the forms, process and credentialing process and credentialing criteria for physicians requesting both initial and reappointment privileges at VMH [Veterans Memorial Hospital]. Bi-annual reappointment shall be accomplished by a representative of [Network Hospital] reviewing information gathered by VMH based upon forms, process and criteria mutually agreed upon by the Parties. This may be accomplished by phone conferences. Initial appointments shall be performed based upon criteria developed by both Parties.

Representatives of the Parties administration and or Quality Assurance, medical staff and other appropriate individuals shall meet at least quarterly to discuss issues that directly impact VMH and [Network Hospital]. A communication log shall be kept regarding credentialing and quality assurance issues. . . ."

Further document review revealed the lack of documentation the Network Hospital bi-annually reviewed the above stated documents in accordance with the Network Agreement.

2. During an interview on 4/22/15 at 9:55 AM, Staff B, Health Information Director responsible for credentialing, acknowledged the lack of Network Hospital staff evaluated the CAH's credentialing process, in accordance with the Network Agreement for Credentialing. Staff B further stated the CAH credentialing staff communicate via telephone with the Network Hospital staff regarding credentialing concerns but have not maintained a communication log documentation of those telephone calls.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner, for 4 of 4 mid-level practitioners. (Practitioners A, B, C, D)

The CAH staff reported the volume of services by the mid-level practitioners for 1/1/14 through 12/31/14 as follows:
Practitioner A - 27 inpatients and 138 ER patients,
Practitioner B - 18 inpatients and 144 ER patients,
Practitioner C - 20 inpatients and 155 ER patients, and
Practitioner D - 16 inpatients and 130 ER patients.

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioners could potentially limit opportunities for improving the quality of patient care for the CAH patients.

Findings include:

1. Review of CAH policies/procedures, Medical Staff By-Laws and Rules and Regulations revealed they lacked the requirement to ensure the physician periodically reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner.

2. Review of documentation revealed no documentation of Physician review of the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner.

3. During an interview on 4/22/15 at 9:10 AM, Staff B, Health Information Director, and Staff C, Emergency Room Supervisor, acknowledged Practitioners A, B, C, and D provided care to patients at the CAH and also acknowledged the lack of documentation to show the physician reviewed the mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the mid-level practitioner participated with a physician in the periodic review of 4 of 4 mid-level practitioner's patient medical records. (Practitioners A, B, C, D)

The CAH staff reported the volume of services by the mid-level practitioners for 1/1/14 - 12/31/14 as follows:
Practitioner A - 27 inpatients and 138 ER patients,
Practitioner B - 18 inpatients and 144 ER patients,
Practitioner C - 20 inpatients and 155 ER patients, and
Practitioner D - 16 inpatients and 130 ER patients.

Failure of the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioners' patient medical records could potentially potentially limit opportunities for improving the quality of patient care for the CAH patients.

Findings include:

1. Review of CAH policies/procedures, Medical Staff By-Laws and Rules and Regulations revealed they lacked the requirement to ensure the mid-level practitioners participated with a physician in the periodic review of the mid-level practitioners' patient medical records.

2. Review of documentation revealed no documentation the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioners' patient medical records.

3. During an interview on 4/22/15 at 9:10 AM, Staff B, Health Information Director, and Staff C, Emergency Room Supervisor, acknowledged Practitioners A, B, C, and D provided care to patients at the CAH and also acknowledged the lack of documentation to show the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioners' patient medical records.

Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the required group of professionals, including a mid-level provider, reviewed all patient care policies for 21 of 21 patient care departments. (Nutrition Services, Safety, Risk Management, Human Resources, ER, Laboratory, Med Surgical, Radiology, Diabetes Education, Infection Control, Cardiac Rehab, Maintenance, Anesthesia, OR, Respiratory Therapy, EMS, OB, Rehab, Housekeeping, HIM [Medical Records], and Pharmacy)

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify any policies needing revisions or updating.

Findings include:

1. Review of CAH policy titled "Critical Access", dated 2/2010, revealed in part, ". . . The CAH Steering Committee will include at least the following members . . . one midlevel provider. . . Will conduct a periodic evaluation of the total CAH program at least annually. This review will include at least the following: CAH healthcare policies review and approval. . . ."

2. Review of Critical Access Steering Committee Meeting Minutes for June 17, 2014 documented the absence of a mid-level provider and the committee approved policies for Nutrition Services, Safety, Risk Management, Human Resources, ER, Laboratory, Med Surgical, Radiology, Diabetes Education, Infection Control, Cardiac Rehab, Maintenance, Anesthesia, OR, Respiratory Therapy, EMS, OB, Rehab, Housekeeping, HIM [Medical Records], and Pharmacy.

3. During an interview on 4/21/15 at 4:25 PM, Staff A, Quality Assurance/Risk Management Registered Nurse, acknowledged a mid-level provider was not present at the Critical Access Steering Committee meeting on June 17, 2014 for the annual review of the above stated CAH patient care policies and lacked documentation showing any review by a mid-level provider of those policies.

Based on observation, review of policies/procedures and documents, and staff interview, the Critical Access Hospital (CAH) radiology staff failed to follow manufacturers recommendations for testing the concentration of ortho-phthalaldehyde (high-level disinfectant solution) with Cidex OPA test strips. The CAH radiology manager reported approximately 10 ultrasound probe procedures monthly that required use of test strips to determine if the concentration of the solution adequately decontaminated and disinfected the ultra sound probe.

Failure to date the containers of the testing strips when initially opened allows the test strips to be used past the date by staff when the manufacturer no longer considers the test strips reliable.

Findings included:

Review of manufacturer's instructions for the Chemical Indicator Test Strips for Cidex OPA (high-level disinfectant solution) stated the following in part, ..."when opening the bottle...record the date opened in the space provided on the label...do not use remaining strips 90 days after opening bottle."

Observations during tour of the Radiology department on 4/21/15 at 1:35 PM revealed 1 of 1 opened bottle of Cidex OPA chemical indicator test strips lacked evidence of the date staff opened the bottle.

During an interview at the time of the observation, Staff G, ultrasound technician, stated he performed all ultrasound probe procedures and used the Cidex OPA solution to disinfect ultrasound probes after each patient use. Staff G acknowledged he failed to document the date he opened the test strips but recalled documenting the date on the "Cidex OPA Documentation" log sheets. Staff G said he received education for the use of Cidex OPA solution and test strips but did not recall being told the test strips needed to be dated when opened although that is clearly identified on the bottle and the manufacturer's insert information on the side of the bottle.

Review of "Cidex OPA Documentation" log sheets revealed Staff G documented the date he opened the bottle of test strips 12/8/14. Per manufacturer's directions the test strips expired on 3/12/15. At the time of the review, Staff H, Radiology Supervisor, acknowledged Staff G failed to follow manufacturer's directions for dating test strips when opened and stated 14 ultrasound procedures were completed after the test strips had expired. Staff H disposed of the remaining 7 test strips.

Review of policy/procedure "Methods of disinfection and/or sterilization of equipment after use" revised 8/12, revealed the following in part, ...Steps in cleaning. As follows...follow device manufacturer's recommendations for cleaning and maintaining medical equipment."

During an interview on 4/22/15 at 7:10 AM, Staff E, Director of Nursing (DON) said the only staff in the hospital that uses the Cidex OPA solution is the radiology and surgical departments. Staff E said she would expect all staff to follow the hospital policies on infection control practices for sterilization/disinfecting of all medical equipment used for patients. She emphasized the main reason for this was to protect patients from nosocomial infections (infections acquired in the hospital) and cross contamination from another patient.

Based on review of policies and staff interviews, the Critical Access Hospital (CAH) staff failed to updated their patient visitation rights policy and postings of patient visitation rights throughout the hospital to reflect the current requirements. The Patient Care Coordinator identified a current census of 1 of 1 swing bed patients and 8 inpatients/acute at the time of survey entrance.

The Director of Nursing identified a census in the following areas (fiscal year July 2013 to June 2014):

Emergency Room: 3,525 patients
Observation: 536 patients
Same Day Stay: 57 patients
Laboratory Out Patient (OP): 5,6198
Laboratory inpatient (IP): 231 patients
Cardiac Stress: 819 patients
Cardiac Rehab: 819 patients
Respiratory Therapy OP: 618 patients
Respiratory Therapy IP: 3,345 patients
X-Ray OP: 2,253 patients
X-Ray IP: 301 patients
Sleep Study: 55
Physical Therapy OP: 2,0941
Physical Therapy IP: 4,700
Occupational Therapy OP: 4,189
Occupational Therapy IP: 3,697
Speech Therapy OP: 274
Speech Therapy IP: 163
Surgery: 2,941

Failure to provide all patients, including outpatients, with patient rights information could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care services or treatment modalities.

Findings include:

Review of the policy "Patient Rights-Visitation" review dated 5/14, directed all hospital staff to present a listing of the Patient Rights and Responsibilities to all patient upon admission to the CAH for inpatient and outpatient services. The policy lacked the new information, effective 12/2/11, regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

Review of documents "Your Rights and Responsibilities as a Patient - Skilled" undated included in a binder located in all of the patient rooms on the medical surgical nursing unit revealed the documents lacked the news information, effective 12/2/11, regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

During an interview on 4/20/15 at 3:00 PM, Staff D, RN/Patient Care Manager acknowledged the CAH failed to update the policy to include the updated information contained in the regulatory guidelines, effective 12/2/11. Staff D said they were aware of the regulatory changes a long time ago and failed to implement them in both their policies and procedures, what is provided to patients on admission to their medical/surgical nursing unit.

During an interview on 4/20/14 at 3:15 PM, Staff C, RN/ED Nursing Supervisor confirmed the hospital's Patient Rights and Responsibilities are posted in the ED waiting room for patients to reference. Staff C said she thought the document contained patient visitation rights and responsibilities. Staff C was not aware that the document did not contain the correct information reflecting the current regulatory requirements.

During an interview on 4/21/15 at 10:50 AM, Staff K, Receptionist, confirmed they referenced the Patient Rights and Responsibilities postings with patients upon admission to their hospital for OP services. Staff K said although they did not present patient rights and responsibilities to the patient physically, they had access to the posted information and could reference this information at any time during the admission process. Staff K was unaware the patient rights and responsibilities posting lacked the required patient visitation rights. Staff K lacked the knowledge the document did not contain the correct information reflecting regulatory requirements.

During an interview on 4/21/15 at 4:30 PM, Staff E, Director of Nurses (DON) acknowledged CAH staff failed to update the patient rights and responsibilities policies to include visitation rights and include new information, effective 12/2/11, regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. Staff E admitted they were aware of the changes but had failed to implement them at the time they occurred.


Refer to C-1001

Based on document review, staff and patient interviews, the Critical Access Hospital (CAH) failed to ensure patients (or support person) were informed of their visitation rights including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner), another family member, or friend, for 1 of 1 swing bed patients (Patients # 1) and 5 of 5 closed swing bed patients (Patients #3, #4, #5, #6, and #7) and outpatients. The Patient Care Coordinator identified a current census of 1 swing bed patients, 7 acute patients and 1 observation patient at the time of survey entrance.
The Patient Care Coordinator identified an average daily census of approximately 5 acute patients, 2 observation patients and 2 skilled patients.

Failure to provide all patients, including outpatients, with patient rights information could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care services or treatment modalities.

Findings include:

Review of the policy "Patient Rights-Visitation" review dated 5/14, directed all hospital staff to present a listing of the Patient Rights and Responsibilities to all patient upon admission to the CAH for inpatient and outpatient services. The policy lacked the new information, effective 12/2/11, regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

Review of documents "Your Rights and Responsibilities as a Patient - Skilled" undated included in a binder located in all of the patient rooms on the medical surgical nursing unit revealed the documents lacked the news information, effective 12/2/11, regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

Review of documentation in patient #1's medical record, revealed the patient's signed the patient received a copy of the Patient Rights and Responsibilities information.

Review of documentation in the medical records of Patients #3, 4, 5, 6, and 7 revealed the patients signed a document indicating they received a copy of the Patient Rights and Responsibilities information.

During an interview on 4/20/15 at 11:47 AM, Staff F, RN said nursing staff are responsible for reviewing the Rights and Responsibilities information contained in binders with the patient upon admission for skilled nursing services and they acknowledge they received the information on a consent titled "Swing-Bed Program Consent and Receipt of Information." Staff F said the consents of the patients would be a permanent part of their medical records.

During an interview on 4/20/15 at 12:00 PM, Patient #2 reported remembering a nurse reviewing the Rights and Responsibilities information contained in a binder on the bedside table at the time of admission to the CAH for acute nursing services.

During an interview on 4/20/15 at 12:15 PM, Patient #1 reported being informed of the patient rights provided by nursing staff at admission to the CAH for skilled services. Patient #1 stated the nursing staff provided information that indicated patients could have visitors but said nothing about who could or could not visit them. Patient #1 reported signing a consent form after nursing staff reviewed the information in the document.

During an interview on 4/21/14 at 4:30 PM, the Director of Nursing acknowledged the current information provided to outpatients and swing bed patients and the Swing Bed policy lacked the regulatory changes to the patient bill of rights and responsibilities and said they would take steps to make the necessary changes immediately.