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Based on policy/procedure review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure all CAH departments developed and had available to CAH staff, policies/procedures to define the expected practices and performances in the provision of patient care services. The problem was identified for 1 of 1 applicable departments (Diabetes Education Program). The Diabetes Education Coordinator identified the program served 15 patients in 2016 and 25 patients in 2015.

Failure to ensure policies and procedures are developed, approved by the medical staff and governing body, and availabel to CAH staff could potentially result in miscommunication of expected practices and performances in the provision of patient care and result in patients receiving less than optimal care or failure to provide the patient with the care and services needed resulting in patient harm.

Findings include:

Review of CAH policies and procedures revealed none existed for the Diabetes Education Program.

During an interview on 10/19/16, at 1:10 p.m., Staff P, Diabetes Education Coordinator, reported the program policies and procedures are reviewed and approved by the program advisory committee but confirmed they are not submitted for approval through the CAH's policy approval process, nor available to CAH employees.

Based on review of policies, meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to ensure the required group of professionals, including a physician and a mid-level provider, annually reviewed all patient care policies for 19 of 19 patient care departments. (Nursing Services, Surgical Services, Anesthesia, Emergency Room, Infection Control, Quality, Cardiopulmonary, Sleep Studies, Specialty Clinics, Ambulance, Laboratory, Pharmacy, Radiology, Rehab Therapy - PT, OT, Speech, Nutrition Services, Environmental Services, HIM, Materials/Purchasing, and Maintenance) The CAH staff identified a census of 12 patients at the beginning of the survey and an average daily census of 5 patients.

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to address and develop policies for changing patient care needs not addressed in the CAH policies and/or opportunities to update the policies as needed.

Findings include:

1. Review of CAH policy titled "Critical Access Hospital Policy", dated 5/9/16, revealed in part, "The policies. . . will be reviewed at least annually by the group of professional personnel required under paragraph (a)(2). . . ."

2. Review of Medical Staff Meeting Minutes from December 2015 to March 2, 2016 and Medical Executive Committee Meeting Minutes from October 2015 to February 2015 to September 2016 lacked documentation of annual approval of all patient care policies.

3. During an interview on 10/20/16 at 9:45 AM, Staff T, Compliance, stated the process of annual policy review was that all new and revised patient care policies were approved at Medical Staff Meetings where a physician and a mid-level provider attend. Staff T acknowledged the lack of a list of those new and revised policies were included in the Medical Staff Meeting minutes. Staff T further stated there was no documentation to show the annual review of all patient care policies for Nursing Services, Surgical Services, Anesthesia, Emergency Room, Infection Control, Quality, Cardiopulmonary, Sleep Studies, Specialty Clinics, Ambulance, Laboratory, Pharmacy, Radiology, Rehab Therapy - PT, OT, Speech, Nutrition Services, Environmental Services, HIM, Materials/Purchasing, and Maintenance.

Based on review of policies/procedures, medication error documentation, medical record review, and staff interview, the Critical Access Hospital (CAH) nursing staff failed to notify the physician when medication errors occurred for 5 of 8 patients from May 1, 2016 to present. (Patients # 1, 2, 3, 4, and 5) The nursing administrative staff identified a census of 12 patients at the beginning of the survey and an average daily census of 5 patients.

Failure to report medication errors to the physician could potentially cause harm to patients if the patient received the wrong dose of medication or the wrong time, or did not receive the medication.

Findings include:

1. Review of CAH policy titled "Medication Errors", dated 10/29/2013, revealed in part, ". . . POLICY: Medication errors shall be reported immediately in accordance with the following procedure. . . Notification to the prescribing physician and pharmacy shall be made. . . ."

2. Review of patient medication error reports revealed the physician was not notified of the following medication errors:

The Medication Error report for Patient #1 revealed the patient did not receive a medication that was ordered.

The Medication Error report for Patient #2 revealed the patient received a wrong dose of medication.

The Medication Error report for Patient #3 revealed the patient received a wrong dose of medication.

The Medication Error report for Patient #4 revealed the patient did not receive a medication that was ordered.

The Medication Error report for Patient #5 revealed the patient received a double dose of medication.

Review of electronic medical records for Patients # 1, 2, 3, 4, and 5 lacked documentation of physician notification of medication errors for these patients.

3. During an interview on 10/19/16 at 12:30 PM, Staff A, Director of Nursing, acknowledged the CAH policy included a requirement for reporting the medication errors to the physician. Staff A also acknowledged documentation on the Medication Error reports and in the patient's electronic medical record revealed nursing staff failed to notify the physician about medication errors for Patients # 1, 2, 3, 4, and 5.

I. Based on review of the Critical Access Hospital (CAH) infection control policy, employee health files and staff interviews the CAH failed to ensure Tuberculosis (TB) testing completed on new employees as per Chapter 59.5(1) All HCWs (Health Care Workers) shall receive baseline TB screening upon hire. Baseline TB screening consists of two components: (1) assessing for current symptoms of active TB disease and (2) using a two-step TST (Tuberculosis Skin Test) or a single IGRA (Interferon-Gamma Release Assays, blood test) to test for infection with M. (Mycobacterium) tuberculosis. Problem identified with 10 of 23 employee files reviewed. (Staff B, C, D, E, F, G, H, I, J, and K)

The CAH reported 20 new employees from November 2015 to October 2016. Failure to ensure employees are free from active TB could potentially compromise the health of already health compensated patients being treated in the CAH.

Finding included:

1) Review of the Policy Tuberculosis (TB) Control revision date 7/11/16 noted:
Policy: It is the policy of the medical group to properly screen all employees and volunteers for the presence of inactive or active Tuberculosis at the time of employment and at least a questionnaire completed annually thereafter.

Procedure, Employee Screening of New Applicants:
Intradermal Mantoux (PPD (Purified Protein Derivative)) test using a 0.1 ml dose of tuberculin PPD, diluted.
If skin test develops no induration or an induration area is <10mm no additional skin testing is required

Review of the provided CAH's new employee list, hired from November 2015 to October 2016 revealed 20 new employees hired during this time.

A review of 23 employee files revealed Staff B-K hired after May of 2013 failed to receive the required 2-step TB test.

In an interview on 10/19/16 at 12:40 PM, Staff S, Infection Control Registered Nurse, (RN) confirmed only the one-step TB test is completed at time of employment. Staff S stated in 2012 the State Health department recommended only the TB one step at hire and to complete an annual TB questionnaire.

In an interview on 10/20/16 at 7:40 AM, the Staff R, Cardio/Pulmonary and Occupational RN confirmed the CAH does not complete a two-step TST or single IGRA to test for infection with M. Tuberculosis. The Staff R confirmed the 20 new employees did not receive a second TB test as per the regulation 59.5(1).

In an interview on 10/20/16 at 8:40 AM, the Staff Q, Employee Health RN, confirmed new hires received only the first step of the two step TB test as per the CAH policy. Staff Q stated this has been the practice since taking over this potion in late 2013.


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II. Based on document review, policy review, and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure employee health exams were completed when required, as part of their system to identify and prevent transmission of infections and communicable diseases. The problem was identified for 2 of 15 employees and 1 of 3 volunteers selected for review. (Staff L, M and N)

Failure to identify infections and communicable diseases among employees and volunteers could potentially result in the transmission of a communicable disease to patients.

Findings include:

Review of an Occupational Medicine and Employee Health policy titled "Employee Physical Exam", approved 2/10/16, identified employees are required to have a physical exam prior to the first day of work and every 48 months from their anniversary date, as a condition of continued employment.

Review of an Employee Health policy titled "Volunteer Health", approved 2/10/16, identified volunteers will have a health assessment completed on hire and every four years.

Review of the health information for Staff L, Licensed Practical Nurse, revealed documented evidence of the most recent health exam on 1/3/12.

Review of the personnel information for Staff M, Registered Nurse, revealed documented evidence of the most recent health exam on 8/29/12.

Review of the health information for Staff N, Volunteer revealed documented evidence of the most recent health exam on 6/13/12.

During an interview on 10/20/16, at 8:20 AM, Staff R, Cardio/Pulmonary and Occupational Health Nurse, confirmed the health exams for Staff L, M and N were past the 4 year requirement. She reported Staff Q, Employee Health Nurse, completes the health exams for employees and volunteers, tracks when the repeat health exams became due and notifies the employees/volunteers accordingly. Staff R reported Staff N had been absent from her volunteer position for awhile and scheduled to have a health assessment this afternoon.

During an interview on 10/20/16, at 8:40 AM, Staff Q acknowledged the health exams for Staff L, M and N were past the required 4 years. She reported she notifies the persons due for their repeat health exams before they are due and attempts to get them done before they extend beyond 4 years. Staff Q did not know how long Staff N had been absent from her volunteer position and reported she returned last week, so was scheduled to come in this afternoon to have the health exam completed. Staff Q reported she the CAH did not have any employment consequences in place for employees that failed to have their repeat health exams completed before they extended beyond 4 years.