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Based on review of credential files, review of Medical Staff Bylaws and staff interview, the CAH (Critical Access Hospital) failed to follow the Medical Staff Bylaws in the reappointment of 5 of 9 sampled physician and non-physician credential files reviewed (Physicians G, H, J and K and Non-Physician I) by not ensuring that granting of privileges was based on continued qualifications as spelled out in the Medical Staff Bylaws. This failed practice has the potential to affect all patients of the hospital. The list of physicians on the medical staff (no date) provided by the Administrator listed 2 active staff (physicians who admit patients to the hospital), 19 consulting physician and non-physician practitioners (practitioners who are recognized specialists willing to serve in a consulting capacity) and 3 affiliate staff (certified registered nurse anesthetists and advanced practice registered nurses).

Findings are:

A. Review of the Medical Staff Bylaws approved by the Governing Board on 10/29/13 revealed the following under Article V Clinical Privileges Section 2 Qualifications (b, c, m):
"The following constitute continuing qualifications for the exercise of privileges at the hospital...
b. Competence. Possess and maintain demonstrated clinical competence including current knowledge, judgment and technique, in his or her speciality area and for all privileges held or applied for;
c. Sufficient Contact/Review of Competence. Demonstrate that he or she will have sufficient patient care contact at the Hospital to permit the Medical Staff to continually assess competency for all requested privileges....
m. Responsibilities of Membership. Demonstrate a willingness and ability to comply with responsibilities of Medical Staff membership as set out in Article IV, Section 7."

Further review of the Medical Staff Bylaws revealed the following under Article IV Categories of Membership, Section 7 Meetings and Responsibilities (d and f):
"Application for and acceptance of membership on the Medical Staff constitutes acceptance of the following responsibilities and other responsibilities established under these Bylaws....
d. Abide by these Bylaws and the Medical Staff Rules and Regulations, the Hospital Bylaws and applicable policies of the Hospital and Medical Staff....
f. Prepare and timely complete medical records for all Hospital patients to whom the member provides care...

Section 8 Attendance. Members of the Active and Affiliate Staff shall attend not fewer than 50% of the meetings of their categories and of all committees to which they are assigned each Medical Staff year, including the annual meeting of the Medical Staff."

B. Review of Physician G's credential file (last reappointment by Governing Board 4/29/14); Physician H's credential file (last reappointment by Governing Board 11/25/14); Physician I's credential file (last reappointment by Governing Board 8/27/13); Physician J's credential file (last reappointment by Governing Board 8/25/14), and Physician K's credential file (last reappointment by Governing Board 4/29/14); revealed no information in regard to:
- Current demonstrated clinical competence including current knowledge, judgment, and technique from quality reviews;
- Number of admissions to CAH and patients attended in the emergency room;
- Information on compliance with medical staff bylaws or CAH policies and procedures.

(A physician credential file contains the information gathered at the time of appointment/reappointment to the hospitals medical staff and includes information such as: an application; list of privileges requested; verifications of education, training, work experience licenses, registrations and references; background checks; and, quality and activity at the CAH.)

C. Interview with the Administrator on 2/9/15 from 2:15 PM to 2:30 PM confirmed the credential files lacked information in regard to activity and quality at the CAH.

Based on record review, staff interview and review of the CAH (Critical Access Hospital) 2013 Medical Staff Bylaws Rules and Regulations, the facility failed to ensure that 5 of 7 sampled swingbed patients (Patients 32, 33, 34, 35 and 36) had an updated/current History and Physical (H&P) completed by the attending physician within 24 hours of admission. The total sample was 40 and the CAH census was 2 swingbed patients and 2 private pay patients. The total patients admitted to swingbed for fiscal year 2014 (9/1/13-8/31/14) was 21. This failed practice has the potential to affect all patients admitted to swingbed at the CAH.

Findings are:

A. Review of the 2013 Medical Staff Bylaws revealed, "A medical history and physical examination must be completed and documented for each patient no more than 30 days before or 24 hours after admission but prior to surgery or a procedure requiring anesthesia services...When the H&P is conducted within 30 days before admission or registration, an updated examination of the patient, including any changes in the patient's condition, must be completed and documented within 24 hours after admission...Swingbed patient admissions may be based on the inpatient admitting history and physical provided that it was completed within thirty (30) days prior to admission to swingbed care, subject to updating in the progress notes any change in physical condition. Swingbed patient will have an annual history and physical examination."

B. Review of Patient 32's swingbed record revealed the patient had been admitted on 8/4/14 for physical therapy and strengthening following an inpatient admission at the referring hospital.

The History and Physical on Patient 32's swingbed record was completed at the referring hospital on 7/25/14.

Patient 32's swingbed record lacked a progress note updating the patient's condition upon admission or within 24 hours of admission to the CAH.


C. Review of Patient 33's swingbed record revealed the patient had been admitted on 10/20/14 for physical therapy and strengthening following an inpatient admission at the referring hospital.

The History and Physical on Patient 33's swingbed record was completed at the referring hospital on 10/16/14.

Patient 33's swingbed record lacked a progress note updating the patient's condition upon admission or within 24 hours of admission to the CAH.

D. Review of Patient 34's swingbed record revealed the patient had been admitted on 3/18/14 for physical therapy, strengthening and intravenous antibiotic therapy following an inpatient admission at the referring hospital.

The History and Physical on Patient 34's swingbed record was completed at the referring hospital on 3/9/14.

Patient 34's swingbed record lacked a progress note updating the patient's condition upon admission or within 24 hours of admission to the CAH.

E. Review of Patient 35's swingbed record revealed the patient had been admitted on 3/14/14 for physical therapy and strengthening following an inpatient admission at the referring hospital.

The Discharge Summary (for the H&P) on Patient 35's swingbed record was completed at the referring hospital on 3/13/14.

Patient 35's swingbed record lacked a progress note updating the patient's condition upon admission or within 24 hours of admission to the CAH.

F. Review of Patient 36's swingbed record revealed the patient had been admitted on 8/9/14 for physical therapy and strengthening following an inpatient admission at the referring hospital.

The History and Physical on Patient 36's swingbed record was completed at the referring hospital on 8/6/14.

Patient 36's swingbed record lacked a progress note updating the patient's condition upon admission or within 24 hours of admission to the CAH.

G. An interview with the Director of Nurses on 2/10/15 at 10:25 AM revealed, "The H&P's from the referring hospitals are what we use when they are admitted to swingbed. The doctor is supposed to make a progress note within 24 hours of admission regarding their condition. I looked in those records (Patients 32, 33, 34, 35 and 36) and I didn't find a progress note or addendum when they were admitted."

Based on record review, staff interview and review of the CAH (Critical Access Hospital) Policy and Procedure, the facility failed to ensure that 5 of 6 sampled outpatient surgical patients (Patients 26, 28, 29, 30 and 31) received the Pre-Anesthetic Risk Evaluation (The physician evaluates/examines the patients current condition including the heart, lungs and review of test results ordered at the time of the history and physical to assure the patient can safely proceed with the procedure scheduled including receiving the anesthesia) by the physician immediately before surgery. The total sample was 40 and the CAH census was 2 swingbed patients and 2 private pay patients. The total patients having surgical procedures for fiscal year 2014 (9/1/13-8/31/14) was 28. This failed practice has the potential to affect all patients receiving surgical procedures at the CAH.

Findings are:

A. Review of the 11/2000 policy titled "Pre-Anesthetic Risk Evaluation" revealed;
"All surgical candidates who undergo anesthesia must have a anesthetic risk evaluation done by a M.D.(doctor) prior to the procedure. This includes... MAC ([monitored anesthesia care] using intravenous conscious sedation to promote relaxation and amnesia types of anesthesia). A history and physical which has been completed within 24 hours prior to the procedure will be an acceptable pre-anesthesia risk evaluation."

B. Review of Patient 26's outpatient surgical record revealed the patient had been admitted on 12/17/14 for a EGD with dilation (Esophagogastroduodenoscopy- a procedure which a small tube with a camera is passed from the mouth down the esophagus to the stomach. A dilation is when during the procedure (EGD) the physician widens narrowed strictures of the esophagus) under MAC anesthesia.

On 12/10/14 Physician H (the surgeon performing the procedures) competed a History and Physical on Patient 26 at the clinic.

Patient 26's scheduled EGD with Dilation was completed. The outpatient surgical record for Patient 26 lacked a Pre-Anesthetic Risk Evaluation by Physician H immediately prior to the procedure.

C. Review of Patient 28's outpatient surgical record revealed the patient had been admitted on 5/21/14 for removal of a subcutaneous lesion from the occipital fascia (removing a lesion from under the skin on the back of the head) under MAC anesthesia.

On 5/10/14 Physician H competed a History and Physical on Patient 28 at the clinic.

Patient 28's scheduled removal of a subcutaneous lesion from the occipital fascia was completed. The outpatient surgical medical record for Patient 28 lacked a Pre-Anesthetic Risk Evaluation by Physician H immediately prior to the procedure.

D. Review of Patient 29's outpatient surgical record revealed the patient had been admitted on 1/21/15 for a colonoscopy (a procedure which a flexible tube is inserted from the rectum into the colon [bowel]) under MAC anesthesia.

On 1/7/15 Physician H competed a History and Physical on Patient 29 at the clinic.

Patient 29's scheduled colonoscopy was completed. The outpatient surgical record for Patient 29 lacked a Pre-Anesthetic Risk Evaluation by Physician H immediately prior to the procedure.

E. Review of Patient 30's outpatient surgical record revealed the patient had been admitted on 8/27/14 for an endoscopy and a colonoscopy under MAC anesthesia.

On 8/13/14 Physician H competed a History and Physical on Patient 30 at the clinic.

Patient 30's scheduled endoscopy and colonoscopy was completed. The outpatient surgical record for Patient 30 lacked a Pre-Anesthetic Risk Evaluation by Physician H immediately prior to the procedure.

F. Review of Patient 31's outpatient surgical record revealed the patient had been admitted on 7/23/14 for a colonoscopy under MAC anesthesia.

On 7/16/14 Physician H competed a History and Physical on Patient 31 at the clinic.

Patient 31's scheduled colonoscopy was completed. The outpatient surgical record for Patient 31 lacked a Pre-Anesthetic Risk Evaluation by Physician H immediately prior to the procedure.

G. An interview with Physician H on 2/4/15 at 1:55 PM revealed when asked where [gender] documented of the Pre-Anesthetic Risk Evaluation was found in the surgical chart, "I usually make an addendum on the History and Physical from the clinic. I write "no issues and proceed" after I go in and do my evaluation before the procedure. I guess I didn't get that on these (Patients 26, 28, 29, 30 and 31) records, I will do better."

Based on review of employee personnel files, review of policies and procedures and staff interview, the CAH (Critical Access Hospital) failed to implement their policy for Abuse and Neglect by not completing pre-employment screening as spelled out in the policy for 4 of 4 employee files reviewed (Employees A, B, C and D). This failed practice has the potential to affect all patients served by the hospital. The list of employee provided by the Administrator contained 29 employees with 5 employees hired since 1/1/14.

Findings are:

A. Review of the policy and procedure titled Personal Conduct/Abuse and Neglect (Effective 10/01/14) revealed the following under Pre-Employment Screening:
"All new NVH [Niobrara Valley Hospital] employees are subject to screening through: (1) the Nebraska Department of Health and Human Services ('NDHHS') Child/Adult Abuse and Neglect Central Registry, (2) the National Sex Offender Registry, (3) criminal background check through [name of a company that does different background checks], and (4) permitted verifications with the Nebraska Department of Motor Vehicles. These screenings are completed through the Human Resources office prior to completion of the hiring process."

B. Review of the personnel files for Employee A with a hire date of 6/2/14, Employee B with a hire date of 5/2/14, Employee C with a hire date of 6/4/14 and Employee D with a hire date of 6/26/14 revealed no information concerning pre-employment screening with Nebraska Department of Health and Human Services Child/Adult Abuse and Neglect Central Registry, National Sex offender Registry, a criminal background check or verifications with the Nebraska Department of Motor Vehicles.

C. Interview with the Administrator on 2/4/15 at 1:45 PM confirmed the lack of any of these pre-employment screenings.

Based on staff interview, review of the policy and procedure, and record review of 7 patient records (Patients 1, 2, 32, 33, 34, 35 and 36), the CAH (Critical Access Hospital) failed to ensure a qualified professional (A licensed or registered therapeutic recreation specialist, an occupational therapist, or has completed a training course approved by the State) directed the patient activities program. The total swingbed sample was 7. The swingbed census during survey was 2. The total patients admitted to swingbed for fiscal year 2014 (9/1/13-8/31/14) was 21. This failed practice has the potential to affect all patients admitted to swingbed at the CAH.

Findings are:

A. An interview with the Director of Nurses on 2/10/15 at 10:25 AM stated, "There isn't a qualified person doing Activity Assessments right now. We had someone that had been grandfathered in, but [gender] retired in May 2014. The nurses on the floor or myself do the assessments for activities on the swingbed patients and chart their participation."

B. The patient record review for Patients 1,2, 32, 33, 34, 35 and 36 showed an Activity Assessment completed by various registered nurses at the time of admission, who did not have the training to be a qualified professional to direct the activity program for the swingbed patients.

C. Review of an undated policy and procedure titled "Activities" from the NVH (Niobrara Valley Hospital) CAH Policy Manual revealed, "NVH will provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment the interests and the physical, mental, and psychosocial well-being of each resident. The activities program must be directed by a qualified professional...."