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Based on review of information provided to patients on admission, record review, and staff interview, the Critical Access Hospital (CAH) failed to provide the patient written notice of its policies regarding advance directives at the time of admission and failed to document issuance of the notice in the patient's medical record for 7 of 7 active inpatient and swingbed patient (Patient #1, #2, #3, #4, #5, #6, and #7) records reviewed and for 9 of 9 closed inpatient (Patient #8, #9, #10, #11, #12, #13, #14, #15, and #16) records reviewed. Failure to provide this information to patients limited the patients' ability to make informed decisions regarding medical treatment.

Findings include:

Review of information provided to patients at the time of admission occurred on 07/16/15. The information lacked the CAH's advance directive policy or written notice concerning the policy.

Review of Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16's medical records occurred on all days of survey. The records failed to include evidence the CAH issued its advance directive policy or written notice concerning the policy.

During an interview on 07/16/15 at 2:10 p.m., two administrative staff members (#2 and #8) confirmed the CAH failed to provide written notice of its advance directive policies to the patient, therefore, failed to document issuance of this notice.

Based on bylaws review, record review, and staff interview, the governing body failed to ensure the reappointment to the Critical Access Hospital's (CAH's) medical staff for 1 of 1 active physician's (Physician #1) record reviewed followed the medical staff bylaws and failed to ensure appointment to the CAH's medical staff for 2 of 2 physicians (Physicians #3 and #4) providing cardiac stress test and echocardiogram interpretation for the CAH's patients. Failure to ensure medical staff reappointments follow the established timeframes and failure to appoint physicians to the medical staff providing services to the CAH's patients places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the "Medical Staff Bylaws" occurred on 07/14/15 at 2:40 p.m. These bylaws, adopted 04/12/13, stated,
". . . Purposes of the Medical Staff
The purposes of the Staff are: . . .
c. To provided a mechanism for the submission to the Governing Board concerning the qualifications of professionals seeking Staff appointment and specific privileges . . .
Article VI Appointment to the Medical Staff
6.1 Qualifications for Appointment
6.1-1 General: . . . All individuals practicing medicine . . . in this Hospital . . . must first have been appointed to the Medical Staff. . . .
Article VII Actions Affecting Medical Staff Appointees
7.1 Procedure for Reappointment
7.1-1 Application: . . . Reappointment, if granted, shall be for a period of not more than two (2) years. . . .

Review of the governing board's "Bylaws of St. Andrew's Hospital and Nursing Home" occurred on 07/14/15 at 3:55 p.m. These bylaws, undated, stated,
". . . Article VIII Medical Staff
Section 1. General: The Board shall appoint a medical staff operating in accordance with these bylaws and those bylaws of the medical staff approved by the Board. . . ."

- Review of Physician #1's credentialing file occurred on July 15-16, 2015. Physician #1's previous appointment began on 08/16/12 and ended on 08/15/14. The current reappointment began on 10/01/14 approximately six weeks after the previous appointment had expired.

Upon request on 07/16/15, the CAH failed to provide evidence of appointment to medical staff for Physicians #3 and #4 providing cardiac stress test and echocardiogram interpretation for the CAH's patients.

During an interview on 07/15/15 at approximately 4:30 p.m., an administrative radiology staff member (#4) stated Physicians #3 and #4 interpreted cardiac stress tests and echocardiograms for the CAH's patients.

During an interview on 07/16/15 at 11:15 a.m., an administrative staff member (#1) confirmed Physician #1's reappointment in October 2014 was late and Physician #1 treated patients at the CAH between the dates of 08/16/14 and 09/30/14.

During an interview on 07/16/15 at 11:25 a.m., an administrative staff member (#1) confirmed the CAH had not appointed Physicians #3 and #4 to the medical staff.

Based on observation, record review, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed acceptable surgical standards of practice regarding the temperature and humidity of 1 of 1 Operating Room (OR) used for procedures requiring general anesthesia. Failure to document, monitor, and ensure the temperature and humidity of the OR are within the recommended ranges may result in the growth of bacteria and an increase in patient infections.

Findings include:

An article from the Association of Perioperative Registered Nurses (AORN), updated in 2009, stated, ". . . The potential risk of microbial growth increases in areas where sterile supplies are stored when the humidity is too high. . . ."

Another article from the Association of Perioperative Registered Nurses (AORN), updated 11/30/12, stated, ". . . The recommended humidity range in an operating room is between 20% [percent] to 60%. . . . The humidy should be monitored and recorded daily using a log or electronic documentation of the heating, ventilation, and air conditioning (HVAC) system . . ."

Observation of the OR occurred on the afternoon of 07/15/15 with an administrative nurse (#5). A thermometer and hygrometer (gauge use to measure the amount of humidity in the air) located in the OR identified a humidity of 66%.

During an interview on the afternoon of 07/15/15 an administrative nurse (#5) stated she expected the OR humidity to be lower than 60%. The nurse (#5) stated the OR staff check the temperature and humidity on procedure days, but do not keep a log of the measurements. When asked what OR staff do when the humidity is not within the normal range, she stated she would expect the facility to cancel any surgeries scheduled that day.

Reviewed on 07/15/15, the "St. Andrews Health Center Quality Improvement Weekly Documentation" reports from July 2014 through June 2015 identified the humidity measured above 60% on three occasions, below 20% on 14 occasions, and on three occasions facility staff failed to document the humidity.

During an interview on 07/16/15 at 8:10 a.m., an administrative maintenance staff member (#7) stated he did not know what the high end of the humidity should be in the OR until today.

Based on bylaws review, policy review, credentialing files review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the treatment furnished for 2 of 4 active/courtesy staff physicians' (Physicians #1 and #2) reappointment records reviewed. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the treatment furnished by the physicians limits the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the medical staff's bylaws titled "Mercy Medical Center Bylaws" occurred on 7/14/15. These bylaws, adopted 4/12/13, stated, ". . .
Article VII Actions Affecting Medical Staff Appointees
7.1 Procedure for Reappointment . . .
7.1-2 Factors to be Considered: Each recommendation concerning reappointment of a person currently appointed to the Medical Staff . . . shall be based upon such appointee's: . . .
h. Capacity to satisfactorily treat patients as indicated by the results of the Hospital's quality improvement/peer review activities . . ."

Review of the policy titled "Physician Peer-to-Peer Review for /Quality of Care" occurred on 07/15/15. This policy, effective 03/01/09, failed to require a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the treatment furnished by physicians.

Review of the policy titled "Medical Staff Quality Improvement Review" occurred on 07/15/15. This policy, revised 10/2012, failed to require a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the treatment furnished by physicians.

Review of the 2014-2015 physicians' credentialing files occurred on July 15-16, 2015 and included the following:
* Physician #1 reappointed 10/01/14
* Physician #2 reappointed 02/18/15

Upon request on 07/15/15, the CAH failed to provide evidence a network hospital or a QIO or equivalent evaluated the quality and appropriateness of the treatment furnished by Physicians #1 and #2.

During interview at approximately 2:20 p.m. on 07/15/15, an administrative staff member (#2) confirmed Physicians #1 and #2 provided services to the CAH's patients, and the CAH did not have a network hospital or QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment furnished by these physicians.