HospitalInspections.org

Based on observation, staff interview, review of an operation manual and review of a lease agreement, the CAH (Critical Access Hospital) failed to ensure that 2 randomly observed pieces of patient care equipment:
- Received routine preventive maintenance (CT-Injector - computerized tomography); and
- A hospital-constructed knee positioning device was safe for patient use.
The last Annual Evaluation dated 8/30/11 indicated there was a total of 3,203 radiology visits with 736 CT scans completed from 7/1/10 to 6/30/11. Patient census on first day of survey was 1 acute patient, 3 swing-bed patients and 1 observation patient. Findings include:

A. Review of the Radiology Department on 4/17/12 from 1:30 PM to 2:30 PM with the Radiology Department Head revealed the CT room had a power injector device (for injecting contrast media for enhanced visualization in CT diagnostic imagining procedures). This power injector had no tags indicating that a preventive maintenance inspection had been completed. Interview with the Department Head during this observation revealed that no one looks at it for preventive maintenance and that the injector was leased from an outside company.

Review of the lease agreement for this piece of equipment, that had an expiration date of 9/18/14, revealed that Exhibit A listed the power injector and that it was the responsibility of the leasing company to provide preventive maintenance.

Review of the Operation Manual for the Injection System revealed the following under Appendix C: Service, Maintenance under the Annually section:
- "Perform an Electrical Leakage and Ground Continuity test";and
- "Perform a complete system calibration and operation check. (This should be done by [Brand Name] Service or [Brand Name] certified technician)".

The CAH had failed to follow the operation manual for the annual maintenance and had failed to contact the leasing company to arrange for this service.

B. Review of the Radiology Department on 4/17/12 from 1:30 PM to 2:30 PM with the Radiology Department Head revealed the general x-ray room had a device made with unfinished wood. Interview with the Department Head during this tour revealed the device was made by the CAH maintenance department and was used to position a patient's knees to get a view of the distance between the knee cap and the leg bone. The CAH could not ensure that a patient would not get a wood splinter or that the wood could be adequately sanitized and cleaned.

Based on review of credential files, review of Medical Staff Bylaws, review of Governing Body meeting minutes and staff interview, the CAH (Critical Access Hospital) failed to ensure that the Medical Staff followed their Bylaws in regards to:
- Reappointment for 7 of 9 physicians (Physicians K, L, M, N, P, Q and S) reviewed; and
- Granting of new surgical privileges for 1 of 9 physicians (Physician K) reviewed.
The listing of Medical Staff provided by the CAH had 26 physicians. Census on the first day of survey was 1 acute inpatient, 3 swing-bed patients and 1 observation patient. Findings include:

A. Review of the Medical Staff Bylaws with an adopted date of 5/25/04 revealed the following:

Article VI Clinical Privileges, Section 2. Qualifications.
"The following constitute continuing qualifications for the exercise of privileges at the Hospital. Each member and each applicant for membership and/or privileges, shall...
2. Competence: Possess and maintain demonstrated clinical competence, including current knowledge, judgment and technique, in his/her specialty area and for all privileges held or applied for;
3. Review of Competence: Demonstrate that he/she
a) Will have sufficient patient care contact at the Hospital to permit the Medical Staff to continually assess competency for all requested privileges....
19. Compliance with Rules: Abide by the terms, conditions and procedures of these Bylaws, the Medical Staff rules and regulations, and the governing documents and policies of the Hospital..."

Article VIII Appointment and Privileging, Section 5. Reappointment/Renewal Process.
"In reviewing applications for reappointment and renewal of privileges, the Credentials Committee and Board will not be limited to review of information supplied within or in support of the application, but may review and consider any other records and information deemed relevant to their review. Without limitation, this may include review of such items as Board, Medical Staff, or committee meeting minutes or records; utilization review, quality assurance, and other peer review record and reports; patient charts; incident reports....complaints or comments from other members of the Hospital staff, the Administrator, patients, or members of the public; and any other relevant documents or correspondence....The Credentials Committee and Board may also consider whether the, practitioner has actually exercised all the requested privileges with sufficient frequency since the time of last appointment or reappointment, to indicate current proficiency."

B. Review of physician credential files on 4/17 and 18/12 revealed the following information was available for review: verification of current Nebraska physician's license; application; current DEA (Drug Enforcement Administration) License; Query of the National Practitioner Data Bank; Certificate of Insurance; Privilege listing; 2-3 Peer References and in some cases other hospital references. This information was reviewed for Physicians K, L, M, N, P, Q and S; however, no information was available concerning competence including current knowledge, judgment and technique. The credential files contained no information concerning utilization review, quality assurance, and other peer review record and reports, complaints or comments for other members of Hospital staff, the Administrator, patients or members of the public. The Medical Staff and Board would not have enough information available to know they should be reviewing other documents if there was a problem.

Interview with the Administrator on 4/18/12 from 9:45 AM to 10:10 AM revealed the following:
- Confirmed the lack of information on physician competence, following of Medical Staff Bylaw, and complaints against the physician;
- Indicated that they have a Physician Performance Profile for their Active Staff but the form is not available to Medical Staff or Board during the appointment/reappointment process; and
- Indicated that they had been talking about this problem but not done anything yet.

C. Review of the Board meeting minutes dated 12/22/11 revealed the Board approved the addition of surgical privileges for "ear tubes procedure" for Physician K. Review of Physician K's credential file revealed a privilege sheet with the privilege of "Myringotomy" (Surgical procedure where an incision is made in the ear drum, the fluid in ear canal is suctioned out and small tubes are put in place to allow future drainage in the event of an infection) checked and with the Board of Directors signature dated of 12/22/11. However, the credential file included no information that the physician was trained and was competent for this additional procedure. Interview with the Administrator on 4/18/12 at 9:45 AM to 10:10 AM confirmed there was no documentation in the file concerning Physician K's competency and training for Myringotomy.

Based on review of the Annual Evaluation dated 8/30/11, review of policy and procedure manuals, review of Policy Committee Meeting minutes and staff interview, the CAH (Critical Access Hospital failed to include the required professional members (physician, physician assistant/nurse practitioner and someone not on staff at the hospital) in the annual review of patient care policies. Census on the first day of survey was 1 acute inpatient, 3 swing-bed patients and 1 observation patient. Findings include:

A. Interview with the Administrator on 4/17/12 from 10:45 AM to 11:15 AM revealed the following:
- Indicated that the "Past" procedure for review of the policies included review by the department manager and administration and then these changes and suggestions for changes were reviewed at the annual meeting which included a physician, a physician assistant and a board member for the person not on staff;
- About 3 - 4 years ago had a change in nursing secretarial staff and this process has gone by the wayside.
- Just last month put together a group of individuals to form a Policy Committee; and
- Do not have a physician or physician assistant assigned to the committee yet.
Review of the minutes titled Policy Committee Meeting with a date of 3/12/12 revealed the members present were all hospital staff and no physician or physician assistant were in attendance.

B. Review of the policy and procedure manuals for Pharmacy, Exposure Control/Infection Control, Dietary and Emergency Room revealed a verification sheet with the department name and the statement "The policies and procedures in this manual have been reviewed." Underneath this statement was a signature block. The above department's policy manual all had signatures of the respective manager with a date June, July August or November 2011. There was no signature sheet to indicate these patient care policies had been reviewed by the group of professionals.

C. Review of the Annual Evaluation dated 8/30/11 revealed the following summary for the section titled Review of Health Care and Patient Care policies:
"The annual review of the organizational Health Care & Patient Care policies has been completed at Butler County Health Care Center as per the organization's policy and procedures." Interview with the Administrator on 4/19/12 from 9:05 AM to 9:15 AM revealed the following:
- There was no policy and procedure for the review of policies by the group of professionals; and
- Indicated that new policies or policies that had been revised were not evaluated during the Annual Review meeting.

Based on medical record review and staff interview the CAH (Critical Access Hospital) failed to ensure the medical records of 10 of 38 sampled patients (Patients 1, 5, 6, 7, 8, 9, 10, 11, 14 and 16) included physician signatures that were dated. Facility census on the 1st day of survey was 1 acute care patient, 1 observation patient and 3 swing-bed patients. Findings include:

The following are from each of the patient medical records cited but do not include all of the non dated signatures found in each record:

A. Review of the Patient Data Sheet found that Patient 1 had a hospital stay beginning 4/14/12 with discharge on 4/18/12. Review of physician orders found on 4/14/12 telephone orders to clarify medication orders, an order for an IV bolus, an order for Zofran, and an order for another IV bolus, along with an order for Solu Medrol to be given by IV that had all been signed by the patient's physician but failed to have a date as to when the physician had signed the orders.

B. Review of the Patient Data Sheet found that Patient 5 had a hospital stay from 1/3/12 to 1/13/12. Review of the physician orders revealed the patient's physician had given the following orders by telephone: lab tests - T 4, TSH, a diet change to 1200-calorie ADA low sodium diet, a clarification order for Lovenox 40 subcutaneous every day. The orders had all been signed by the physician but the physician had not dated his signature.

C. Review of the Patient Data Sheet found that Patient 6 was a patient at the CAH from 1/13/12 to 1/15/12. Review of the physician orders found that on 1/13/2012 the patient's physician had provided admission orders by telephone order, followed by another telephone order to give Normal Saline 500 cc bolus, and ordered a CT scan of the chest to look for a pulmonary embolism. The orders had been signed by the ordering physician, but the physician did not date the signature.

D. Review of the Patient Data Sheet found that Patient 7 was admitted to the CAH on 1/30/12 and discharged 2/3/12. Review of the physician orders found a telephone order written on 1/31/12 that stated "Clarification: Compazine 25 mg supp PR [Suppository per rectum] every 4 hours prn (as needed). The order had been authenticated/signed by the physician but the physician had not dated his signature.

E. Review of the Patient Data Sheet found that Patient 8 had a hospital stay from 2/2/12 to 2/5/12. Review of the physician orders for Patient 8 found a telephone order dated 2/2/12 for Clarification of a dressing the patient had on at admission. The order was signed by the physician but the signature did not include a date. A verbal order to wrap the wound with Kling and change twice a day taken on 2/3/12 was again signed by the physician, but failed to have the date of the signature. Another telephone order on 2/3/12 was given on 2/3/12 for clarification of a medication order for Tylenol prn, that was signed by the physician but did not have the date the physician signed it.

F. Review of the Patient Data Sheet found that Patient 9 was admitted on 3/5/12 and discharged on 3/6/12. Review of the physician orders found that telephone orders given on 3/3/12 for a CBC and UA lab tests, and another order for a medication (Toradol 60 mg IV now) was signed by the ordering physician but without dating the signature.

G Review of the Patient Data Sheet for Patient 10 revealed the patient was admitted on 3/25/12 and was discharged on 3/27/12. Review of the physician orders found 2 telephone orders given on 3/26/12 that included discontinue NG, and an order for Bentyl 20 mg orally every 6 hours prn. Both orders were signed by the ordering physician but neither was dated by the physician.

H. Review of the Patient Data Sheet for Patient 11 revealed the patient had an admission date of 12/26/11 and a discharge date of 12/30/11. Review of the physician orders found an undated telephone order for clarification of an order for a CT scan. The order was signed by the physician but it was not dated. This order failed to have any date documented. Another telephone order written on 12/26/11 for Novolog 14 units sub cutaneous now times 1 was signed by the ordering physician but the signature was not dated.

I. Review of the Patient Dataheet for Patient 14 showed an admission date of 3/18/12 and a discharge date of 3/19/12. Review of the physician orders found on 3/18/12 a verbal order for Oxygen to be given at 15 liters, start an intravenous lock and admit to observation that was signed by the physician without a date for the signature. Another order, given by telephone on 3/18/12 for clarification of an Ativan order along with a NO CODE status and may start on all home meds on 3/19/2012 was signed by the ordering physician without having dated his signature.

J. Review of the Patient Data Sheet for Patient 16 found the patient was admitted for surgery on 1/11/12 and discharged on 1/14/12. Review of the physician orders revealed the Pre and Post Operative orders for a Total Knee were signed by the physician but the signature was not dated by the physician. A telephone order written on 1/12/12 for a change of Benadryl to every 6 hours prn was signed by the physician but did not have a date when the signature was written.