HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure Respiratory Therapy medications were stored in a locked area. Findings are:

A. Observation during tour of the Respiratory Therapy department on 2/14/12 between 10:00 AM and 10:15 AM revealed a clean supply room which was unlocked without staff present. Respiratory therapy medications were kept in an unlocked drawer in the supply room.

B. Upon request the Director of Nursing inventoried the unsecured drawer and stated on 12/14/11 at 2:40 PM that the drawer contained 12 DuoNeb unit doses and 10 Albuterol unit doses. Both medications are used for prescribed respiratory treatments.

Based on observation, staff interview and review of documents provided by the Maintenance Supervisor, the CAH (Critical Access Hospital) failed to ensure that the kitchen was maintained in an orderly clean manner as there was a leaking fire sprinkler head and at least 13 stained and/or broken ceiling tiles in the kitchen area. On the first day of survey, 2/6/12, there were 4 acute care patients, 3 skilled patients and 1 observation patient. Findings are:

A. During tour of the kitchen on 2/9/12 from 9:35 AM - 10:15 AM revealed a red plastic bucket setting on the floor. Interview with the Dietary Supervisor at the time of this observation revealed the following:
- The bucket was to catch water from the sprinkler head that was dripping;
- The sprinkler head had been dripping for 2-3 months;
- The maintenance department had been told about the problem; and
- The maintenance department had told them that they (maintenance) had to get the fire sprinkler company to come out to fix the problem.

Interview with the Maintenance Supervisor on 2/9/12 from 10:55 AM to 11:00 AM revealed the following:
- Knew that the sprinkler head was dripping;
- The fire sprinkler company had been out to look at it but did not have the right sprinkler head or tools to change it;
- The fire sprinkler company was involved with a remodeling that was taking place in the hospital;
- Were waiting for them to fix the dripping sprinkler head when they were back on site for the remodeling project;
- Did not know how long ago it had been when dietary reported the dripping sprinkler head; and,
- Agreed to look for any documentation that was in the maintenance office concerning this issue.

On 2/9/12 at 11:30 AM the Maintenance Supervisor provided a copy of a November calendar that had documented on the 16th "Sprinkler leaking - dietary". Also provided at this same time was a plain sheet of paper with the following typed "Dec 16 [name of the sprinkler company] here to finish tie in. He did not have part to repair leak in dietary. We set off alarms, and tested sprinklers."

It had been 3 months since dietary had reported the leaking sprinkler head to the Maintenance Department with no resolution of the problem.

B. Tour of the kitchen on 2/9/12 from 9:35 AM - 10:15 AM with the Dietary Supervisor revealed ceiling tiles that were stained and/or broken in the following areas:
- 3 ceiling tiles in the food storage area;
- 5 ceiling tiles in the aides' work area by the ice machine; and
- 5 ceiling tiles by the pop storage shelf.

Interview with the Dietary Supervisor during these observations revealed the Consultant Dietitian had identified the issue of stained kitchen ceiling tiles and was told by Administration that it was in the plans to have the ceiling tiles replaced.

Interview with the Administrator on 2/9/12 from 1:00 PM to 1:08 PM revealed the following:
- Awareness of the stained ceiling tile;
- Plans were to replace the tiles; however, there was nothing in writing and no definite time frame for the replacement.

Based on review of credential files, review of policies and procedures, review of Medical Staff Bylaws, review of radiology reports, review of facility administrative documents and staff interview, the CAH (Critical Access Hospital) failed to ensure that:
- The Medical Staff Bylaws were followed for physicians providing services to CAH patients for 1 of 9 practitioners reviewed (Physician R); and
- The Peer and Midlevel Review policy was followed.
On the first day of survey, 2/6/12, there were 4 acute care patients, 3 skilled patients and 1 observation patient. Findings are:

I. Review of Medical Staff By-laws, review of radiology reports, review of requested credential files and staff interview revealed the CAH failed to follow the Medical Staff Bylaws for a teleradiologist (Physician R) who was not on the Medical Staff Roster provided by the CAH and was not part of the Radiology group that the CAH had a contract with. Findings are:

A. Interview with the Radiology Supervisor on 2/8/12 from 9:45 AM to 10:45 AM revealed the following:
- The CAH has a contract with a radiology group in Norfolk;
- This group has 3 radiologists;
- Sometimes the radiologist that is on call for nights requests that the CAH uses another radiology group that the hospital in Norfolk has a contract with;
- The CAH gets a preliminary radiology report from the other radiology group;
- The CAH's contracted radiology group over reads the diagnostic imaging results and provides a final report, usually the next day; and
- The CAH rarely uses this other group of radiologists.

B. The Radiology Supervisor provided a copy of a Preliminary Radiology Report on 2/8/12 at 2:40 PM. Review of this report revealed Physician R dictated and authenticated a CT (Computed Tomography) of the brain/head on 1/22/12 at 1:42 AM. Review of the Medical Staff 2011 roster provided by the hospital revealed Physician R was not on the list. Interview with the Medical Staff Coordinator (duties include credentialing) on 2/13/12 at 1:40 PM revealed the CAH had no information on Physician R and could provide no credential file.

C. Review of the Medical Staff Bylaws with a last amended and approved date of 4/20/09 revealed the following amendment that was approved 9/27/05:

"ALTERNATIVE CREDENTIALING FOR PRACTITIONERS WITH LIMITED CONTACT. In certain circumstances, practitioners requesting services from the Hospital, or rendering services to the Hospital, will have limited contact with the Hospital, the nature of which does not necessarily require Medical Staff membership. In those cases, in the discretion of the Administrator, in consultation with the Active Staff, the following procedures may be applied:
a. Providers of Remote Service. Physicians or other practitioners who provide service to the Hospital from off-site, such as providers of remote diagnostic/telemedicine services, may be authorized by the Administrator to provide services without applying for and maintaining Medical Staff membership. In such cases, the practitioner will be required to document evidence of licensure, training and expertise in the field of services being provided, and satisfactory professional liability insurance, together with other documentation and assurances deemed appropriate by the Administrator."

Interview with the Administrator on 2/14/12 from 9:20 AM to 9:40 AM confirmed the CAH had no credentialing information on Physician R.

II. Based on staff interview, review of policies and procedures and review of administrative documents the CAH failed to follow the policy and procedure titled Peer and Mid-Level Review. Findings are:

A. Review of the policy and procedure titled Peer and Mid-Level Review with a last Revision Date of 9/18/06 and 9/27/06 [sic] revealed that for Outside Peer Review "At Least two charts per physician, per quarter shall be sent for review." The section titled Mid-level practitioners revealed that mid-level practitioner charts are reviewed by a staff physician. The process also states that "An outside Peer Review by [contracted peer review group's name] may be requested by the reviewing Physician or the UR [Utilization Review] Committee."

B. Interview with the Compliance Manager (duties include coordination of peer review function) on 2/13/12 from 2:30 PM to 3:30 PM revealed the following:
- Thought it had been 6 months since any records had been for outside peer review;
- Since the CAH went to computer physician order entry has had a hard time figuring out how to print the record off without numerous pages;
- Is getting ready to send out 8 records this month that are obstetrics and newborns because those record are still paper and not computerized.

C. Review of administrative documents provided by the Compliance Manager revealed the last time any records were sent for outside review was in April 2011. Review of a document titled Physician Review of Nurse Practitioners Chart revealed the physician reviewer requested further review by the contracted peer review group. Interview with the Compliance Manager on 2/14/12 at 8:00 AM confirmed that this record had not been sent out for outside peer review.

Based on record review of 1 of 1 surgical patients (Patient 15) reviewed and staff interview, the facility failed to ensure scheduled inpatient surgical patients had documentation that a qualified practitioner (physician) examined the patient immediately before the operation to evaluate surgical risk and anesthesia risk. Findings are.

A. Record review on 2/9/12 of inpatient record for Patient 15 revealed the patient was scheduled for a c-section on 11/19/11. The record failed to contain a physician evaluation of the risk of the procedure prior to surgery on 11/19/11.

B. Interview on 2/9/12 at 10:00 AM with Licensed Practical Nurse (LPN)-N who is the facility Nurse Infomatacist confirmed this finding. LPN-N stated that the facility went to completely on-line order entry by physicians for inpatients only on 2/1/11. The physician certification form was missed. The LPN stated "we won't find this done for any inpatient surgicals since 2/1/11."

Based on staff interview, review of the Performance Improvement Plan (PI Plan), review of Quality Council Meeting minutes, review of services/department balanced scorecards and review of Board of Trustee meeting minutes, the CAH failed to ensure there was an effective performance improvement program by not:
- Holding meeting as spelled out in the PI Plan;
- Reporting the results of the PI program to the Board of Trustees;
- Including all contracted services in the Performance Improve program; and
- Ensuring that department/services documented the remedial actions taken when quality indicators fell below the target goal identified by the department.
On the first day of survey 2/6/12, there were 4 acute care patients, 3 skilled patients and 1 observation patient. Findings are:

A. Review of the PI Plan approved by the Board of Trustees 1/24/12 revealed the Performance Improvement Council (Quality Council) was to meet monthly. The Quality Improvement Coordinator provided 4 meeting minutes for the Quality Council from January 2011 to 2/8/12. (Refer to C336 paragraph B)

B. Review of the Board of Trustee Meeting minutes for January 2011 through December 2011 revealed no information concerning reports from the Quality Improvement Coordinator. (Refer to C336 paragraph A)

C. Interview with the Quality Improvement Coordinator on 2/14/12 from 12:30 PM to 1:45 PM revealed the contracted services of Occupational Therapy, Nuclear Medicine and Mammography have not been included in the quality improvement program. (Refer to C337)

D. Review of Department/Service 2011 balanced scorecards and review of the Quality Council meeting minutes dated 2/9/11, 3/17/11, 5/18/11 and 11/16/11 revealed that remedial actions were not always documented when a quality indicator on the balanced scorecard fell below target goals. (Refer to C342)

Based on staff interview, review of the Performance Improvement Plan (PI Plan), and review of the Governing Body Meeting minutes, the CAH (Critical Access Hospital) failed to ensure they had an effective quality assurance program by not:
- Holding Quality Council meetings in accordance with the PI Plan;
- Not reporting to the Board of Directors as identified in the PI Plan; and
- Not ensuring that departments were up to date on reporting the results on their balanced scorecards.
On the first day of survey 2/6/12 there were 4 acute care patients, 3 skilled patients and 1 observation patient. Findings are:

A. Review of the PI Plan approved by the Board of Trustees on 1/24/12 revealed the following in regard to Reports of Performance Improvement Activity:
"The report to the Board of Directors will be prepared quarterly by the Performance Improvement Coordinator and will include:
An overview of results of relevant monitoring activity
An overview of PI Team results and status
A benefit/cost analysis of PI team activity (every 6 months)
An overview of improvement activity as a result or [sic] PI monitoring"

Interview with the Quality Improvement Coordinator on 2/14/12 from 12:30 PM to 1:45 PM revealed the following:
- Does not prepare a quarterly report as spelled out in the PI Plan; but,
- Does gives the Quality Council meeting minutes and any Patient Satisfaction surveys to the Medical Staff Coordinator, then thought from Medical Staff it got reported to the board;

Review of the Board of Trustee Meeting Minutes for January - November 2011 revealed no information about Quality Assurance. Interview with the Administrator on 2/14/12 at 1:20 PM confirmed the lack of evidence that the patient satisfaction survey results and the Quality Council meeting minutes were reported to the Board of Trustees.

B. Review of the PI Plan approved by the Board of Trustees on 1/24/12 revealed the following concerning the Performance Improvement Committee:
"The Performance Improvement Committee is the hospital's vehicle for providing a formal, systematic mechanism for communication and coordination among departments and individuals with respect to the provision of competent and high quality patient care and services...The committee will meet monthly until that time the Balance Scorecard implementation is completed and all departments are in compliance with this policy...."

The Quality Improvement Coordinator could only provide meeting minutes for February, March, May and November, 2011 and no meeting minutes for 2012. Interview with the Quality Improvement Coordinator on 2/14/12 from 12:30 PM to 1:45 PM revealed the following:
- Coordinator was out on medical leave for June, July and August, 2011;
- September, October, December 2011 and January 2012 just "got dropped"; and
- Had a meeting scheduled for February 8, 2012, but that was when the survey started so it was canceled.

C. Review of the PI Plan approved by the Board of Trustees on 1/24/12 revealed the following "All services shall participate in performance improvement efforts using the balanced scorecard approach." Interview with the Quality Improvement Coordinator on 2/14/12 from 12:30 PM to 1:45 PM revealed that this year departments are about 2 quarters behind with reporting their results. Review of the departmental/services balanced score cards revealed 6 of 15 departments had not reported results for the second or third quarter of 2011. Human Resources, Business Office and Nursing had reported results only for the first and second quarters (January - June). Medical Records and Lab had reported results for only the first quarter. Pharmacy had reported the results for only the first and second quarters for 4 indicators and only the first quarter for 2 indicators.

Review of the Quality Council Meeting minutes dated 2/9/11 revealed the following documentation:
"...In addition to the departmental scorecards, there was another scorecard, it will be call the Quality Council Scorecard, this will report on all the departments' status in regards to how up to date they are with their reports. That also will be reviewed on a quarterly basis."
Review of the meeting minutes for March, May and November revealed no discussion of this Quality Council Scorecard. No Quality Council Scorecard was provided for surveyor review.

Based on review of the Performance Improvement Plan (PI Plan), review of quality reports, review of Quality Council meeting minutes and staff interview, the CAH failed to include in their Quality Improvement program 3 of 6 contracted services (Nuclear Medicine, Mammography and Occupational Therapy). On the first day of survey, 2/6/12, there were 4 acute care patients, 3 skilled patients and 1 observation patient. Findings are:

A. Review of the PI Plan approved by the Board of Trustees on 1/24/12 revealed no mention of including contracted services in this program. The only documentation found was "All services shall participate in performance improvement efforts using the balanced scorecard approach."

B. Interview with the Radiology Supervisor on 2/8/12 from 9:45 AM to 10:45 AM revealed the following:
- Nuclear medicine and mammography were provided through contracts for mobile services;
- Nuclear medicine sends a quality report; and
- Mammography has never provided a quality report.
Further interview with the Radiology Supervisor on 2/8/12 at 2:30 PM revealed the following:
- Had talked with the mammography technologist;
- Quality report was kept on the mammography truck; and
- Provided a copy of what had been kept on the truck.

C. Interview with the Occupational Therapist on 2/8/12 from 10:55 AM to 11:10 AM revealed she had a contract with the CAH and was not an employee. When asked about quality assurance/quality improvement studies that had been done, indicated that she had done no quality studies for the CAH and was not aware whether the CAH was doing any studies concerning occupational therapy.

D. Interview with the Quality Improvement Coordinator on 2/14/12 from 12:30 PM to 1:45 PM revealed the following:
- Thought occupational therapy quality was completed by physical therapy;and
- Has never seen a report for nuclear medicine or mammography.

Interview with the Physical Therapist on 2/8/12 revealed that the Occupational Therapist had a separate contract and they had no authority over that service.

Review of the Department quality reports and review of the 2011 Quality Council meeting minutes provided revealed no quality information reported for the services of mammography, nuclear medicine and occupational therapy.

Based on review of the Performance Improvement Plan (PI Plan), review of Quality Council Meeting minutes, review of Medical Staff and Utilization Review (UR) meeting minutes and staff interview, revealed nosocomial infections and medication therapy related to infections were not collaborated between Quality Improvement Committee and the Infection Control Committee. On the first day of survey, 2/6/12, there were 4 acute care patients, 3 skilled patients and 1 observation patient. Findings are:

Review of the CAH's PI Plan approved by the Board of Trustees on 1/24/12 revealed the following concerning infection control "To coordinate medical staff performance improvement activities with those of the organization's and integrate efforts whenever appropriate. Specifically, medical staff PI activities relative to Utilization Review, Infection Control and Corporate Compliance will be carried out collaboratively. Collaborative efforts are not limited to these areas, however, and are encouraged for all clinical and other PI processes." Interview with the Quality Improvement Coordinator on 2/14/12 from 12:30 PM to 1:15 PM revealed that review of nosocomial infections is done by the infection control committee and does not get reported to Performance Improvement - Quality Council. Interview with the Infection Control Coordinator on 2/14/12 at 10:20 AM revealed the Infection Control report gets turned into the Medical Staff. Without the collaboration of PI Committee and reports from the infection control committee the CAH could not ensure that all efforts were being made to evaluate hospital infections related to departments other than Medical Staff.

Based on review of Departmental Balanced Score Cards (reporting tool for quality indicators), review of Quality Council Meeting minutes, review of the Performance Improvement Plan (PI Plan) and staff interview, the CAH (Critical Access Hospital) failed to identify and document remedial actions to address quality indicators that fell below the target set by the CAH for 3 of 9 departments with results on 1 or more indicators that fell below target. On the first day of survey, 2/6/12, there were 4 acute care patients, 3 skilled patients and 1 observation patient. Findings are:

A. Review of the 2011 Departmental quality reports provided by the Quality Improvement Coordinator revealed quality indicators were listed under the 4 main objectives spelled out in the PI Plan. To the right of the quality indicator were the target goals set by the departments. To the right of the target goals was an area to document the results for the first, second, third and fourth quarters. The results were documented by a color code where red represented below target.

B. Interview with the Quality Improvement Coordinator on 2/14/12 from 12:30 PM to 1:45 PM revealed the following:
- The plan was to have the departments document on the bottom of the department balanced scorecard the plan of action when an indicator had results that were red (below goal);
- To have the department director come to the Quality Council meetings to report and talk about their departments report; and
- Indicated that neither of these things had happened.

C. Review of the Radiology 2011 balanced scorecard revealed a report for the first quarter for CT (Computed Tomography) advanced registry. There was no action plan on the bottom of the report for these below target results. Review of the Quality Council meeting minutes dated 3/17/11 revealed the following documentation: "The department's goal is to have all technicians obtain their CT advanced registry, they have 3 techs that have completed their CT registry." The meeting minutes contained no information on how many technicians still needed to obtain CT advance registry or what the plans were for the remaining technicians to obtain their CT advance registry.

D. Review of the Pharmacy 2011 balanced scorecard revealed below target results for the first and second quarters for "Chart audits without errors" and ER [emergency room] charges vs [versus] Pyxis [medication dispensing equipment] % charts without errors". At the bottom of the report was the following "Progress is being made in ER vs Pyxis of charts without errors this quarter at 86%". However, there was no documentation of what action was being taken to improve the results for this indicator. Review of the Quality Council Meeting minutes dated 11/16/11 revealed the following documentation "Pharmacy was below target in two areas, 1) chart audits without errors and 2) ER charges vs. Pyxis %. These are both two areas that are somewhat out of the realm of control for pharmacy, but pharmacy still feels it's important to monitor." There was no discussion concerning what departments/staff had control of these issues and whether these departments/staff should be involved to help develop an action plan to improve the results.

E. Review of the Nursing 2011 balanced scorecard revealed below target results for the first quarter for Name Band Audits and below target results for Recapitulations of patient discharges for the first and second quarters. Review of the bottom of the balanced scorecard revealed no information on action plan to improve the results for these indicators. Review of the Quality Council Meeting minutes dated 5/18/11 revealed the following: "Nursing is red in two areas, Name Band audits and the recapulation [sic] of patient discharges. Not all patients are arriving to the floors with their name bands on, which in many ways is a safety issue. And with the new medication scanning could be a billing issue as well. They are looking at ways that they can improve this. The recapulation [sic] is an issue that was done in the past and seemed to slip to the wayside when the computerization was completed. It is an issue that has been popping up in some surveys and Nursing needs to get back on track and get this started up again. Action Nursing will restart the recapulation [sic] of patient stays and report back in September on their progress. The name band issue will be reported back again next month as it does present a major patient safety issue." This action plan does not address how they will get nursing to start doing the recapitulation or whether it will take changes in the computer system used for electronic records. The minutes state that "they" are looking at ways to improve; however, no documentation was provided for what ways were identified to improve the results.

Based on staff interview, review of department quality reports, and staff interview, the CAH (Critical Access Hospital failed to consistently identify remedial actions for quality indicators falling below target which results in an inability to identify specific actions that were effective or ineffective. On the first day of survey, 2/6/12, there were 4 acute care patients, 3 skilled patients and 1 observation patient. Findings are:

A. Interview with the Quality Improvement Coordinator on 2/14/11 from 12:30 PM to 1:45 PM revealed the following:
- The plan was to have the departments document on the bottom of the department quality reports the plan of action when an indicator had results that were red (below goal);
- To have the department director come to the Quality Counsel meetings to report and talk about their departments report; and
- Indicated that neither of these things had happened.

B. Review of the quality reports for Nursing, Pharmacy and Radiology for 2011 revealed all had quality indicators that were below target without remedial actions identified on the report or in the Quality Council meeting minutes for February, March, May and November 2011 (the only meeting held).

The Radiology report indicator for CT (Computed Tomography) advanced registry showed below target for the 1st quarter and then was not monitored for the second and third quarters.

Review of the Quality Council Meeting minutes dated 11/16/11 revealed the following documentation "Pharmacy was below target in two areas, 1) chart audits without errors and 2) ER charges vs. Pyxis %. These are both two areas that are somewhat out of the realm of control for pharmacy, but pharmacy still feels it's important to monitor." Review of the Pharmacy quality report for 2011 revealed these 2 indicators were below target for both first and second quarters. No results were available for the third and fourth quarters. Without identified action plans improvements in results, if they happen, cannot be tied to any specific action.

Review of the Nursing 2011 quality report revealed below target results for the first quarter for Name Band Audits. Review of the bottom of the quality report revealed no information on an action plan to improve the results for this indicator. Review of the Quality Council Meeting minutes dated May 18, 2011 revealed the following: "Nursing is red in two areas, Name Band audits....Not all patients are arriving to the floors with their name bands on, which in many ways is a safety issue. And with the new medication scanning could be a billing issue as well. They are looking at ways that they can improve this." The Nursing quality report showed that the Name Band audit was at target for the second quarter but there is no information relating what action was taken to make this improvement.