HospitalInspections.org

Based on document review, observation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to notify patients the CAH did not have either a medical doctor (MD) or doctor of osteopathy (DO) present at the hospital 7 days a week, 24 hours a day. Failure to provide notice the CAH did not have a physician on-site 24 hours a day, 7 days a week resulted in the patients lacking sufficient information to determine if they wanted to receive care at the CAH, without a physician present at all times. The CAH identified a census of 8 patients on entrance and average daily census of 7. The CAH performs approximately 109 surgical procedures/month, approximately 270 ER visits/month, and delivered approximately 16 babies/month.

Findings include:

1. Review of the Emergency Department (ED) provider schedule for July 2019 revealed the CAH staff chose to use a mixture of physicians and Advanced Registered Nurse Practitioners (ARNPs, nurses with advanced training which allows them to diagnose, treat, and prescribe medications to patients). The ARNP was scheduled as the sole medical provider in the Emergency Department for 132 hours in July 2019 (out of 744 hours in the month).

2. Observations during a tour of the Emergency Department on 7/29/2019 at approximately 12:38 PM revealed the Emergency Department staff failed to provide notice to patients the CAH did not have a physician present at the CAH 24 hours per day, 7 days per week.

3. During an interview on 7/29/19 at approximately 12:38 PM, the Quality Improvement Director confirmed that a MD or DO does not staff the ED on site 24 hours per day, 7 days per week. During an interview on 8//1/19 at approximately 8:00 AM, the Emergency Services Director confirmed that ARNPs provide services in the ED without a physician present in the hospital.

4. Review of Patients' Rights brochure revealed the CAH staff failed to include a notice notifying patients that a physician is not present in the hospital 24 hours per day, 7 days a week.

Based on document review and staff interview, the Critical Access Hospital (CAH) laboratory administrative staff failed to ensure the CAH's Medical Staff approved the updated blood bank agreement. Failure to ensure a current, approved blood bank agreement was in place could potentially interrupt the availability of blood products needed for emergencies resulting in patient harm and/or death. The laboratory administrative staff reported the laboratory had 30 units of blood products available to CAH patients at the beginning of the survey.

Findings include:

1. Document review of the "Blood Supply and Services Agreement, dated 10/1/11, revealed the Chief Executive Officer signed the agreement on 11/1/11.

2. Review of the CAH's Medical Staff Meeting minutes from November 2011 revealed the CAH's Medical Staff did not approve the Blood Bank Agreement.

3. During an interview on 8/1/19, the Quality Director acknowledged the CAH's Medical Staff failed to approve the Blood Bank Agreement.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from supplies available for patient use in the Emergency Department (ED), inpatient care area, and laboratory. Failure to remove outdated supplies could potentially result in staff using the expired items for patient care beyond the manufacturers' expiration dates, after which the manufacturer will no longer guarantee the safety and quality of the supplies. The CAH administrative staff identified a census of 8 patients at the beginning of the survey, 272 ED visits per month, and 5,144 lab tests per month for fiscal year ending 6/30/2019.

Findings include:

1. Observations during a tour of the ED on 7/29/19 at approximately 12:38 PM, with the Quality Improvement Director, revealed the following expired supplies:

ED Room #3
a. 1 of 4 marble top laboratory tubes for blood collection, expired 1/31/2019.
b. 6 of 6 yellow top laboratory culture tubes for blood collection, 4 expired 8/2018, 1 expired 2/2019, 1 expired 4/2019.

ED Room #4
a. 15 of 17 povidone-iodine swab sticks for cleansing, 1 expired 9/2017 , 4 expired 1/2018, 6 expired 7/2018, 2 expired 1/2019, 1 expired 3/2019, and 1 expired 6/2019.
b. 1 of 2 4-oz Hibiclens antibacterial cleanser, expired 4/2019.
c. 1 of 1 BDE Swab for body fluid collection, expired 3/31/2019.
d. 3 of 6 red top laboratory tubes for blood collection, 3 expired 3/31/2019.
e. 5 of 5 marble top laboratory tubes for blood collection, 1 expired 1/2017, 2 expired 1/31/2018, 1 expired 3/31/2018, and 1 expired 2/28/2019.
f. 3 of 3 yellow top laboratory tubes for blood collection, 2 expired 4/30/2018 and 1 expired 12/31/2018 .

2. Review of the policy, "ED Outdate Checking Protocol," dated 07/2019, revealed in part, "...Each patient room in the ED will be checked monthly according to schedule for outdated supplies ... A log of staff responsible for completing outdates will be maintained and signed by staff responsible for completion ..."

3. During an interview on 7/31/2019 at 10:32 AM, the Emergency Services Director revealed the emergency department nursing staff failed to follow the expectations for restocking practices and failed to maintain a log of staff responsible for removing outdated supplies.

4. Observations during a tour of the inpatient nursing unit on 7/29/19 at approximately 09:15 AM, with the Chief Nursing Officer (CNO), revealed the following expired items in the Patient Supply Room:

a. 2 of 2 Gastrocult tests for occult blood, 2 expired 5/2019
b. 59 of 59 Povidine iodine pads, 9 expired in 2015, 29 expired in 2016, and 21 expired in 2018.

5. During an interview on 7/29/2019 at 10:15 AM, the Medical Surgical Unit Manager verified the expired supplies and acknowledged the nursing staff failed to remove the expired supplies from the supply room.

6. Observations during a tour of the laboratory on 7/29/19 at 11:30 PM revealed one 540 milliliter bottle of Ecolab gel hand sanitizer, expiration date 9/18/19.

7. During an interview at the time of the tour, Medical Technician A confirmed the hand sanitizer was outdated.

Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure the Certified Nurse Midwife (CNM) notified a physician when the CNM admitted 2 of 3 patients (Patient #2 and Patient #3). Failure to notify the physician of a patient admitted by an CNM resulted in the lack of the physician's ability to provide medical direction, consultative services, and could potentially result in missed diagnosis, treatment, and care of the patient. Administrative staff identified the Certified Nurse Midwife admitted 37 patients from January 2019 through July 2019.


Findings include:


1. Review of Medical Staff Bylaws, revised December 2018, revealed in part "Certified Nurse Midwife will be allowed to admit to the obstetrical unit independently."

2. Review of CAH policies revealed the CAH lacked a policy requiring the Certified Nurse Midwife to notify a physician when the CNM, a mid-level practitioner, admitted a patient, in accordance with the regulations.

3. Review of Patient #2's medical record revealed the CNM admitted Patient #2 to the hospital on 6/3/19. Patient #2's medical record lacked evidence the CNM notified a physician that the CNM admitted Patient #2 to the CAH.

4. Review of Patient #3's medical record revealed the CNM admitted Patient #3 to the hospital on 6/24/19. Patient #3's medical record lacked evidence the CNM notified a physician that the CNM admitted Patient #3 to the CAH.

5. During an interview on 7/30/19 at 3:30 PM, the Obstetrical Director was not aware of the requirement that the CNM notify a physician when the CNM admitted a patient to the CAH and that the CNM needed to document notifying a physician of the admission.

6. During an interview on 7/31/19 at 3:20 PM, the CNM revealed she notified her back-up physician when the CNM admitted a patient to the CAH. However, the CNM acknowledged she failed to document that she notified the physician in the patient's medical record.

7. During an interview on 7/31/19 at 10:20 AM, the Process/Quality Improvement Director indicated she was not aware of the requirement for a mid-level provider to notify a physician that the mid-level provider admitted a patient to the CAH. The Process/Quality Improvement Director verified the CAH lacked a policy that required a mid-level provider to notify a physician when a mid-level practitioner admitted a patient to the CAH. The Process/Quality Improvement Director verified the medical record for Patient #2 and Patient #3 lacked documentation that the CNM, a mid-level provider, notified a physician when the CNM admitted Patient #2 and Patient #3 to the CAH.

Based on review of policies, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals, including a physician and a mid-level provider, reviewed all patient care policies annually for 21 of 21 patient care departments (Infection Prevention, Health Information Management, Rehabilitation Services, Safety, Swing Bed, Food Service, Environmental Services, Nursing/Obstetrics, Intensive Care Unit, Surgery, Radiology, Laboratory, Ambulance, Respiratory Therapy, Emergency Department, Plant Operations, Pharmacy, Cardiac Rehabilitation, Anesthesia, Chemotherapy, and Wound Clinic). The CAH administrative staff identified a census of 8 patients at the beginning of the survey. Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of the CAH policy "CAH Professional/Advisory Committee," revised 10/2018, revealed in part, "...The committee shall meet a minimum of one time a year, and will meet more often as needed, for policy approval and review...The committee shall consist of the CEO [Chief Executive Officer] or his/her designee, one physician medical staff member, one nurse practitioner or physician assistant, QI [Quality Improvement] Council member, Chief Nursing Officer or designee...."

2. Review of the Critical Access Hospital Committee Meeting minutes dated July 25, 2018, revealed the committee members performed the Annual Policy Review for Surgery, Laboratory, Pharmacy, and Safety. The meeting minutes lacked documentation a physician attended the meeting.

Review of Critical Access Hospital Committee Meeting minutes dated August 22, 2018, revealed the committee members performed the Annual Policy Review for Ambulance, Respiratory Therapy, Emergency Department, and Plant Operations. The meeting minutes lacked documentation a physician attended the meeting.

Review of Critical Access Hospital Committee Meeting minutes dated December 26, 2018, revealed the committee members performed the Annual Policy Review for Food Service, Environmental Services, Radiology, Nursing/Obstetrics, and Intensive Care Unit. The meeting minutes lacked documentation a physician attended the meeting.

Review of Critical Access Hospital Committee Meeting minutes dated February 2019, revealed the committee members performed the Annual Policy Review for Swing Bed. The meeting minutes lacked documentation a physician attended the meeting.

Review of Critical Access Hospital Committee Meeting minutes dated March 2019, revealed the committee members performed the Annual Policy Review for Rehabilitation Services. The meeting minutes lacked documentation a physician was present at the meeting.

Review of Critical Access Hospital Committee Meeting minutes dated June 2019, revealed the committee members performed the Annual Policy Review for Infection Prevention and Health Information Management. The meeting minutes lacked documentation a physician and a mid-level provider attended the meeting.

Review of Critical Access Hospital Committee Meeting minutes from July 25, 2018 through June 2019 revealed the CAH staff failed to ensure a physician and mid-level provider performed the annual policy review for the Cardiac Rehabilitation, Anesthesia, Chemotherapy, and Wound Clinic policies.

3. During an interview on 8/1/19 at 11:20 AM, the Quality Improvement Director confirmed the CAH's policies lacked the requirements for a physician and mid-level provider to participate in the annual policy review for Infection Prevention, Health Information Management, Rehabilitation Services, Safety, Swing Bed, Food Service, Environmental Services, Nursing/Obstetrics, Intensive Care Unit, Surgery, Radiology, Laboratory, Ambulance, Respiratory Therapy, Emergency Department, Plant Operations, Pharmacy, Cardiac Rehabilitation, Anesthesia, Chemotherapy, and Wound Clinic.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) emergency services staff failed follow the manufacturer's instructions when the Emergency Department (ED) staff warmed 2 of 2 bags of intravenous (IV) fluids utilizing a warming unit which the warming unit manufacturer did not warrant for warming IV fluids. Failure to utilize a warming unit approved to warm IV fluids could potentially result in the warming unit warming the IV fluid warmer than the IV fluid manufacturer warrants or the fluid becoming too warm for the patient. Warming the IV fluid warmer than the IV fluid manufacturer's specifications could potentially result in chemicals from the plastic IV fluid bag seeping into the IV fluid or the IV fluid allowing bacteria to grow, either way potentially causing the patient to develop a life threatening reaction or life threatening bacterial infection. Warming the IV fluid too warm for the patient could potentially result in the fluid becoming too warm and potentially burning the patient. The CAH administrative staff identified an average of 270 patients who presented to the ED each month.


Findings include:

1. Observations on 7/30/19 at approximately 9:15 AM, during a tour of the ED, revealed 2 one-liter bags of normal saline in plastic overwraps as packaged from the manufacturer in a "Sage Products Inc" warming unit located above the medication station in the ED.

2. Review of the Sage Products, Inc. manufacturer's Operating Instructions for the warming unit revealed in part, "...This warmer is to be used SOLELY for premoistened cloth and hair care products...DO NOT use to heat or store any other material or products...."

3. During an interview on 7/30/19 at approximately 8:05 AM, the Emergency Services Director acknowledged the ED staff had placed IV fluid bags in a warmer specifically designed for warming disposable cleansing cloths.



II. Based on observation, document review and staff interview, the Critical Access Hospital (CAH) Pharmacy staff failed to ensure the pharmacy staff monitored the temperature for 2 of 2 refrigerators located in the pharmacy department. Failure to ensure staff monitored the temperature of the pharmacy refrigerators could potentially result in the pharmacy staff failing to detect if the refrigerators went out of an acceptable temperature range, and potentially could result in the medications lacking the expected potency, potentially resulting in the medication not providing the expected effect for the patient. The Pharmacy had 2 refrigerators.

Findings include:

1. Observations on 7/30/19, at approximately 10:23 AM, during a tour of the Pharmacy revealed 2 of 2 temperature monitored refrigerators. Further observations revealed 1 refrigerator in the main pharmacy area, and 1 refrigerator in the mixing room. Observations revealed the staff had installed temperature monitors, which would provide audible alarms only audible in the pharmacy area.

2. Review of the refrigerator temperature log for June 2019 revealed the CAH pharmacy staff failed to document refrigerator temperatures 20 out of 30 days in June for both refrigerators.

3. Review of the pharmacy policy "Refrigerated/Freezer Drug Storage," last reviewed 7/2019, revealed in part, "... ensure medications are stored within manufacturer's recommended temperature ranges ... Refrigerator temperature range: 2 degrees C (Celsius) and 8 degrees C ... If the temperature varies outside the normal range, pharmacy personnel will attempt an adjustment of the temperature dial and re-evaluate in two (2) hours ... If storage temperatures exceed the set limits, an alarm will alert the pharmacy staff...."

4. Review of the manufacturer's instructions for the traceable memory detachable probe thermometers used in the pharmacy refrigerators revealed in part, "...the alarm will sound for 1 minute and issue a 3 second repeater beep every minute thereafter, for up to 12 hours...."

5. During an interview at the time of the tour, Pharmacist I acknowledged the medication refrigerators contained multiple medications which required refrigerated temperatures between 2 and 8 degrees Celsius. Pharmacist I acknowledged, while the refrigerators contained temperature alarms, if the temperature went outside the desired range during a time when the pharmacy staff were not present for over 12 hours, and the refrigerator went outside the desired range for over 12 hours, the pharmacy staff would not know the refrigerator had gone outside the desired temperature range or if the temperature returned to the desired range prior to the pharmacy staff returning to the pharmacy, the pharmacy staff would not know the refrigerators had gone outside the desired temperature range.




III. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) emergency services staff failed to failed to monitor temperatures of the warmed intravenous (IV) fluids in 1 of 1 ambulance. Failure to ensure CAH emergency services staff monitored the temperatures of the fluids could potentially result in patients receiving fluids that do not work in the body as expected, resulting in unintended consequences or side effects including infection. The CAH Emergency Services Director reported the ambulance has made 127 ambulance runs since 1/1/2019.

Findings include:

1. Observations on 7/29/19 at approximately 12:38 PM, during a tour of the ambulance, revealed 2 one-liter bags of normal saline and 1 one-liter bag of lactated ringers in plastic overwraps as packaged from the manufacturer, sitting on a FloorMount IV fluid warmer.

2. Review of the manufacturer's instructions for the FloorMount IV Fluid Warmer, not dated, revealed in part, "Maintenance ... Daily confirm the temperature of the fluids."

3. During an interview at the time of the tour, the Quality Improvement Director and Advanced Emergency Medical Technician (AEMT) A acknowledged the CAH's emergency medical services staff failed to monitor the temperature of the IV fluids on a daily basis.



IV. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) emergency medical services (EMS) staff failed to label warmed intravenous (IV) fluid bags with date placed in warmer, date to be removed from warmer, and new expiration date on 3 of 3 IV fluid bags located on an open warmer in 1 of 1 ambulance. Failure to ensure the CAH EMS staff documented the date they placed the IV fluids on the warmer and the shortened expiration date could potentially result in the EMS staff failing to remove the IV fluids after the IV fluid manufacturer's recommended warming time, potentially resulting in bacteria growing in the IV fluids, and potentially resulting in a patient developing a life-threatening infection. The CAH EMS staff made 127 ambulance trips since 1/1/19.

Findings include:

1. Observations on 7/29/19 at approximately 12:38 PM, during a tour of the ambulance, revealed 2 Hospira 1 liter bags of normal saline and 1 Hospira 1 liter bag of lactated ringers in plastic overwraps, as packaged from the manufacturer, sitting on an open style fluid warmer on shelving behind driver's seat.

2. Review of hospital process "Warmed IV Fluids-New Process," dated 3/2017, revealed the policy required that when the CAH staff placed an IV fluid bag on a warmer, the CAH staff needed to place a sticker on the IV fluid bag indicating the "... date put in warmer ... date to be removed ... and revised expiration date."

3. Review of Hospira's directions for IV fluid in plastic overwraps, dated 1/4/11, revealed in part, "Solutions ... may be warmed ... for a period no longer than two weeks (14 days). Once the product is removed from the warming cabinet, it should be clearly labeled with a revised expiration date. The revised expiration date ... is obtained by deducting eight weeks (56 days) from the original expiration date of the solution ..."

4. During an interview at the time of the tour, the Quality Improvement Director and Advanced Emergency Medical Technician (AEMT) A acknowledged the 3 IV fluid bags in the ambulance lacked the required information on when the EMS staff placed the IV fluid bags on the warmer, the date the EMS staff needed to remove the IV fluids from the warmer, and the revised expiration date.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure the surgical staff sanitized their hands before and after glove use during 1 of 1 observed surgeries (Patient #1) and 1 of 1 observed endoscopies (examination of inside of the body using a flexible scope) procedures (Patient #4). Failure to ensure the surgical staff followed approved infection control techniques could potentially cause bacterial and other infectious contaminants to remain on the skin. The CAH staff could unknowingly touch equipment, surfaces, patients, and other staff causing the cross contamination of bacterial and/or other infectious contaminants which could cause severe illness and/or death. The CAH's administrative staff identified the surgical staff performed 1,309 surgical procedures and 225 endoscopies for the fiscal year ending 6/30/19.

Findings include:

1. Review of the "Hand Hygiene Policy," revised 6/2019, revealed in part, "...personnel should always perform hand hygiene ... After removing gloves ... Before performing invasive procedures whether or not sterile gloves are worn."

2. Review of the CDC (Centers for Disease Control and Prevention, a government agency providing nationally recognized guidelines) "Guidelines for Hand Hygiene in Healthcare Settings," dated 10/25/02, revealed in part, "Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment. Perform hand hygiene immediately after removing gloves."


3. Observations on 7/30/19, beginning at 12:09 PM during Patient #1's total knee replacement surgery in OR #2, revealed the following:

-- 12:12 PM CRNA B removed non-sterile gloves and did not perform hand hygiene prior to donning sterile gloves to perform an invasive procedure involving insertion of needle for spinal anesthesia.

-- 12:34 PM, CRNA B changed gloves without performing hand hygiene. CRNA B adjust CRNA B's glasses and the drape between CRNA B and the patient.

-- 12:35 PM, CRNA B changed gloves without performing hand hygiene. CRNA B draw up a medication from a vial and injected the medication into an IV bag and administered the medication to Patient #1.

-- 12:44 PM, the Director of Surgery donned gloves without performing hand hygiene. The Director of Surgery opened cupboard doors, handled a surgical specimen, and handled boxes containing sterile implants for Patient #1's surgery.

-- 12:50 PM, RN C donned gloves without performing hand hygiene. RN C handled boxes containing sterile implants for Patient #1's surgery, put items into the garbage, punctured an IV bag containing Betadine (provides infection protection) for sterile irrigation of Patient #1's knee, and typed on the computer.

-- 1:25 PM, RN C changed gloves without performing hand hygiene.

-- 1:27 PM, RN C changed gloves without performing hand hygiene.

-- 1:32 PM, RN C changed gloves without performing hand hygiene.

-- 1:32 PM, Surgeon D removed their sterile gloves and did not perform hand hygiene. Then Surgeon D typed on the computer.

-- 1:39 PM, RN C changed gloves without performing hand hygiene..

-- 1:42 PM RN C changed gloves without performing hand hygiene.

-- 1:49 PM, RN C changed gloves without performing hand hygiene.

-- 1:51 PM, RN C changed gloves without performing hand hygiene.

-- 1:59 PM, the Director of Surgery donned gloves without performing hand hygiene



4. Observations 7/31/19, beginning at 12:38 PM, during Patient #4's endoscopy in OR #2, revealed the following:

-- 12:39 PM, DO K and MD L entered OR #1 and donned gloves without washing hands or performing hand hygiene.

-- 12:41 PM, MD L performed a rectal exam and then changed their right hand glove without performing hand hygiene.

-- 12:41 PM, DO K changed gloves without performing hand hygiene.

-- 1:19 PM, DO K and MD L both removed gloves and did not perform hand hygiene. DO K and MD L then typed at the computer.

-- 1:19 PM, the Director of Surgery donned gloves without performing hand hygiene.

-- 1:24 PM, CRNA M removed their gloves and did not perform hand hygiene.


5. During an interview on 7/31/19 at approximately 2:00 PM, the Director of Surgery revealed they expected the staff to perform hand hygiene after removing their gloves. The Director of Surgery based the CAH's hand hygiene policy on the CDC's hand hygiene guidelines. The Director of Surgery did not know that the guidelines and CAH policy required the CAH staff to perform hand hygiene prior to putting gloves on and perform hand hygiene after removing their gloves.

Based on observation, document review and staff interviews, Critical Access Hospital (CAH) administration failed to ensure 2 of 2 reviewed laboratory staff members (Medical Technologist A and Medical Technologist N) and 3 of 3 reviewed registered nurses (RN O, RN P, and RN Q) had color vision proficiency prior to interpreting the results of fecal occult blood (blood in stool) tests for all laboratory, nursing and medical staff who read the results of the test. Failure to test all laboratory, nursing and medical staff for color blindness before performing this test may result in staff misreading the results of the fecal occult blood test which could potentially adversely affect the diagnosis and treatment plan for patients. The CAH performed 37 fecal occult blood tests in the last fiscal year.

Findings include:

1. Observation on 7/29/19 at 11:30 PM, during a tour of the Laboratory revealed the laboratory staff utilized Beckman Coulter Hemoccult slides to check stool for occult blood.

2. Observation on 7/29/19 at approximately 10:00, during a tour of the Inpatient Unit, revealed nursing staff utilized Beckman Coulter Hemoccult slides to check stool for occult blood.

3. Observation on 7/29/19 at 12:30 PM, during a tour of the Emergency Department, revealed staff utilized Beckman Coulter Hemoccult slides to check stool for occult blood.

4. During an interview at the time of the tour of the laboratory, Medical Technologist A reported the staff identified a positive test result by identifying the slide turned the color blue. Medical Technologist A acknowledged staff interpreting the test would require the ability to identify the color blue.

5. During an interview on 7/30/19 at 2:15 PM, the Director of Emergency Services confirmed all physicians and Advanced Practice Practitioners (Advanced Registered Nurse Practitioners and Physician Assistants) working in the ER used Beckman Coulter Hemoccult slides to check stool for occult blood in the ED.

5. Review of manufacturer's recommendations for Beckman Coulter Hemoccult slides revealed, in part: "Because the test is visually read and requires color differentiation, it should not be interpreted by individuals with blue color deficiency (blindness)."

6. Review of personnel files revealed the following:

a. Medical Technologist A started working at the CAH on 2/4/09. Medical Technologist A's personnel file lacked documentation the CAH staff tested Medical Technologist A for blue color vision proficiency upon hire or at any time after hire.

b. Medical Technologist N started working at the CAH on 8/1/89. Medical Technologist N's personnel file lacked documentation the CAH staff tested Medical Technologist N for blue color vision proficiency upon hire or at any time after hire.

c. Registered Nurse (RN) O started working at the CAH on 2/22/08. RN O's personnel file lacked documentation the CAH staff tested RN O for blue color vision proficiency upon hire or at any time after hire.

d. RN P started working at the CAH on 10/30/00. RN P's personnel file lacked documentation the CAH staff tested RN P for blue color vision proficiency upon hire or at any time after hire.

e. RN Q started working at the CAH on 3/8/04. RN Q's personnel file lacked documentation the CAH staff tested RN Q for blue color vision proficiency upon hire or at any time after hire.

7. During an interview on 7/30/19, at 9:30 AM, the Human Resources Director confirmed CAH staff did not perform testing for color blindness on any of the CAH employees, including the physicians and Advanced Practice Practitioners.

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) administrative staff failed to maintain 1 of 1 complete list of contracted services that described the nature and scope of services provided. The CAH administrative staff identified a census of 8 patients at the beginning of the survey. Lack of a complete list of contracted services including the delineation of the nature and scope of the contracted services could potentially result in failure of compliance of the contracted services' responsibilities.

Findings include:

1. Review of documents revealed the CAH staff lacked a list of contracted services to include a description of the nature and scope of the services each contracted entity provided.

2. During an interview on 7/30/19 at 11:35 AM, the Chief Executive Officer (CEO) confirmed the CAH staff lacked a list of contracted services to include a description of the nature and scope of the services each contracted entity would provide.

Based on review of the Quality Plan, Quality activities, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to evaluate 7 of 7 contracted patient care services for quality of care including Ultrasound, Nuclear Medicine, E-ICU, Tele-psychiatry, Speech Therapy, Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) scan. The CAH administrative staff identified 1337 Ultrasound procedures; 131 Nuclear medicine procedures; 12 E-ICU patients; 31 Tele-psychiatry patients; 71 Speech Therapy patient visits; 410 MRI procedures; and 13 PET procedures from June 2018 to July 2019. Failure to monitor and evaluate all patient car services for quality of care could potentially expose patients to inappropriate and/or substantial care.

Findings include:

1. Review of the "Quality Assurance/Quality Improvement Program," dated 4/2019, revealed in part, "...An ongoing quality monitoring approach for the identification, evaluation, recommendation, action and follow-up of QA/QI activities will be done... The scope of the QA/QI Program is organizational-wide and involves all departments."

2. Review of the Quality Improvement Meeting Minutes from December 18, 2018 through June 19, 2019 lacked documentation that showed CAH staff evaluated services provided to CAH patients through identification, evaluation, recommendation, action and follow-up of QA/QI activities to improve quality for contracted services to include Ultrasound, Nuclear Medicine, E-ICU, Tele-psychiatry, Speech Therapy, Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) scan.

3. During an interview on 7/31/19 at 2:35 PM, the Quality Improvement Director acknowledged the lack of participation in the quality assurance process to include identification, evaluation, recommendation, action and follow-up of QA/QI activities to improve quality for contracted services to include Ultrasound, Nuclear Medicine, E-ICU, Tele-psychiatry, Speech Therapy, Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) scan.

Based on document review, policy review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 8 active physicians selected for review (Physician G and Physician H), received outside entity peer review by the appropriate entity, 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 by the appropriate entity, affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff identified the physician provided care to patients from 2/1/19 to 7/31/19 as follows:

- Physician G: 79 patient visits
- Physician H: 10 patients

Findings include:

1. Review of the CAH's network agreement, effective 7/1/16, revealed the CAH had an agreement with Network Hospital A to function as the Network Hospital for the CAH. Review of the agreement revealed in part, " ... Upon request by CAH external peer review and credentialing services will be provided by Hospital A ..."

2. Review of the CAH Peer Review Services Agreement, effective 2/20/15, revealed in part, "... The Network Hospital employs or contracts with physicians who are qualified and capable of evaluating the diagnosis and treatment of the CAH and/or associated clinics physicians. The CAH desires for [Network Hospital A's name] to provide such evaluation and the Network Hospital agrees to provide evaluation services pursuant to the terms and conditions outlined herein."

3. Review of a CAH agreement titled "Agreement for Review Services," effective 5/2/2008, revealed in part "... [CAH] desires to utilize the services of [independent peer review entity] for independent peer review, internal quality control and quality oversight for improving care ... for the purposes of rendering an opinion regarding the medical necessity and/or quality of care for the treatment rendered ... "

4. Review of external peer review completed for the applicable physicians selected for review revealed the following:

- Physician G's file contained the results of 1 external peer review completed by an independent peer review entity on 1/23/19 and the file lacked external peer review completed by the CAH's Network Hospital. The CAH's medical staff and governing body approved Physician G's reappointment to medical staff on 6/12/19 and 6/17/19, respectively.

- Physician H's file contained the results of 1 external peer review completed by an independent peer review entity on 1/23/19 and the file lacked external peer review completed by the CAH's Network Hospital. The CAH's medical staff and governing body approved Physician H's reappointment to medical staff on 6/12/19 and 6/17/19, respectively.

5. Review of the CAH policy "Credentialing and Quality Assurance," revised 10/2018, revealed in part " ... To establish and provide a collaborative approach for CAH and Network Hospital to objectively and systematically monitor and evaluate the appropriateness of diagnosis and treatment, quality of patient care, and clinical outcomes ... CAH has authorized the Network Hospital access to medical records for the purpose of conducting medical staff review as an aspect of credentialing ... Results of peer review will be considered prior to reappointment to the medical staff ... One hospital chart or record from each physician on staff the CAH will be copied and forwarded to the QM department at the Network Hospital during the two-year appointment cycle and prior to reappointment..."

6. During an interview on 7/30/19, at 1:10 PM and 4:00 PM, the Director of Quality reported the CAH utilized their network provider to complete the majority of external peer review but verified they utilized an independent peer review entity for some of the external peer review. She reported the CAH encountered problems with their Network Provider completing some groups of physician external peer review so the CAH staff elected to use another entity for some groups of physician external peer review.

The Quality Improvement Director confirmed the independent peer review entity conducted the external peer review for Physician G and Physician H and the CAH lacked any external peer review conducted by their network hospital for Physician G and Physician H.