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Based on record review and interviews with hospital staff, the governing body of the Critical Access Hospital (CAH) does not ensure that bylaws, rules and regulations and policies for the CAH are implemented and monitored to ensure quality health care is provided in a safe environment.

Findings:

1. Three of three ( T, U & V) physicians and two of two ( W & X) nurse practitioners providing patient care either did not have any or current privileges designated and approved by the governing body.

2. Medical Staff Rules and Regulations concerning the admitting of patients by the mid-level practitioner are not being followed. Refer to Tag # 0268.

3. The hospital does not have a functioning quality assurance program to assure quality health care in a safe environment. Refer to Tag # 0330.

4. These findings were reviewed during the exit conference on 12/01/11 with hospital staff.

Based on record review and interviews with hospital staff the hospital does not ensure patients are admitted to the hospital by a nurse practitioner who has current hospital privileges and is being monitored by a physician who is responsible for any medical problem outside the scope of practice of the admitting practitioner. Three of three (#'s 19, 21 & 29) patients admitted during October and November 2011 were admitted by the nurse practitioner without current admitting privileges. These admissions did not have evidence of physician monitoring.

Findings:

1. The hospital's rules and regulations specify the all patients have to be admitted by a physician.

2. In Section II Subsection 1 of the Rules and Regulations it states that a Nurse Practitioner may admit patients to their service in the hospital. It also states the there must be a MD/DO designated to monitor every patient admitted to these mid-level practitioners. Patients #'s 19, 21 & 29 did not have evidence in their records showing physician monitoring.

3. The Nurse Practitioner's privileges granted by the Governing Body did not include admitting privileges.

Based on review of the policy and procedure manual, infection control logs, meeting minutes, and staff interview the facility failed to provide an active infection control program that contained specific measures for the prevention of infections and communicable diseases in the facility.

Findings:

(1) The facility did not provide evidence that there was an active and ongoing surveillance program for infection control that includes defined and specific measures that will prevent the spread of infections and communicable diseases in patients and personnel including contract and agency staff in the facility.

a. Three personnel files reviewed were identified as contracted or agency staff. Three out of three files, Staff H, G, D did not contain information or evidence that immunization histories were verified.

b. Three physicians and two nurse practitioners health files were reviewed. Five out of five (T,U,V,W,X), staff health files contained no evidence that immunization histories were verified.

(2) On the morning of 11/30/2011 surveyors were given the infection control policies and procedures that were reviewed and revised on 7/31/2011 by administration. When interviewed about the implementation of policies and procedures, the infection control officer, Staff B stated that she did not perform surveillance activities at the facility to ensure that policies and procedures were implemented and followed.

(3) The policy titled "Purpose" of the infection control plan states "Infection control nurse: assures a high quality of patient care by: eliminating /reducing risks of infection to patients and employees through careful surveillance. Surveillance methods: routine rounds of all departments" On the afternoon of 12/01/2011, the infection control nurse, Staff B, stated she did not conduct surveillance activities or routine rounds.

(4) Policy 2.104 titled "Tracking and Reporting" states "Infection Control Data Sheet:
1. This tool is used on every patient. It is initiated on admission and consists of a number of questions pertaining to signs and symptoms of infection. If a possible Health Care Acquired infection is identified the reports are taken to Infection Control Committee for review. Suggestions for reducing the risk, action to prevent infection, and action for instruction are given at the infection control meeting and carried to the appropriate personnel to reduce further risks."
Review of the infection control log and meeting minutes for the infection control committee did not provided evidence that any action was taken to control, educate, investigate, evaluate, and revise interventions performed to prevent the spread of infection.

(5) The infection control officer, staff B, stated on the afternoon of 12/1/2011 that she did not conduct inservices as part of her infection control responsibilities to provide ongoing education to staff regarding infection control issues identified through the program, handwashing, aseptic technique, and isolation precautions.

(6) The infection control officer, staff B, presented the infection control log to surveyors. The log did not contain all instances of infections and communicable diseases including those identified through employee health.

(7) On the morning of 11/30/2011 surveyors requested minutes from the facilities Quality Assurance (QA) program. There was no evidence provided that infection control was reported through quality assurance or that problems or trends were identified and addressed.

Based on document reviews and interviews, the hospital failed to assure that the nutritional needs of inpatients are met in accordance with recognized dietary practices.

Findings:

1. Staff R, S and B told the surveyors that nursing did the initial nutritional screening as part of their initial nursing assessment and those that had conditions that needed further nutritional assessments would be completed by dietary. Three of five current patients (Patients #1, 21 and 22), whose medical records were reviewed for nutritional assessments, did not have nutritional screens documented by nursing. Patients #15 and 21 had diagnoses that included diabetes and decubitus ulcers. The patients did not receive additional nutritional screening/assessments by dietary. Patient #18 had diagnoses that included diabetes and hypoglycemia. Patient #18 did not receive additional nutritional screening by dietary.

2. Dietary and nursing policies did not include a policy and procedure for nutritional screens/nutritional consults. In an interview 11/30/11 Staff J told surveyors she was not sure how a nutritional screen or nutritional assessment got completed.

3. The hospital uses the services of a consultant dietitian. Staff A told surveyors on 11/30/2011 Staff E was the consultant dietitian. Staff E's personnel file did not have documentation of orientation and training in the facility. Staff A told surveyors Staff C was the dietary manager. There was no documentation in Staff C's personnel file indicating Staff C was trained, competent, and had education appropriate to Staff C's duties.

4. Staff F was listed as a dietary aide. There was no documentation Staff E or Staff C reviewed or evaluated Staff F's performance. There were no records of competencies or training in Staff F's personnel file.

Based on policy and procedure manual review and interview with the hospital staff, the hospital failed to ensure policies are reviewed at least annually.

Findings:

On the morning of 11/30/2011 surveyors were given copies of the Dietary Department policy and procedure manual. Policies and procedures were revised 2005. No review and approval of the policies since 2005 was documented.

Based on review of medical records and hospital documents and interviews with hospital staff, the hospital failed to ensure physical therapy (PT) services were provided according to physician orders and according to medical staff Rules and Regulations. For three of four medical records reviewed (Records #19, 24, and 29 of Records #15, 19, 24, and 29), the orders for physical therapy did not contain the type, frequency and duration of services.

Findings:

1. The hospital's medical staff Rules and Regulations gave two ways for complete PT orders to be initiated:
a. Orders written with required information, or
b. Signing of the PT evaluation.

2. Records #19 and 24 had PT orders for evaluation for strengthening, but the PT evaluations were not signed by the physician, and no clarification orders were written with the required information. Treatments provided included transfer, exercises and gait training.

3. Record #29 only contained an order for PT eval (evaluation) and treat. The medical record did not contain a physician signature on the PT evaluation or clarification orders with the required information.

Based on policy and procedure manual review, review of hospital documents, and interviews with staff, the hospital failed to maintain current dosimetry badges and monitoring . The hospital also failed to have documentation showing all the personnel operating the diagnostic equipment are qualified and trained.

Findings:

1. On the morning of 11/30/2011 Staff A told surveyors the dosimetry badges had not been monitored for the past year.
2. On the afternoon of 11/30/2011, Staff A told surveyors the ultrasound procedures were provided by Staff H who was a contractor. There was no information in Staff H's personnel file indicating he had been oriented, trained, and evaluated.

Based on record review, review of personnel files, and interview with the staff, the facility failed to supervise and determine that nursing staff is qualified and competent to meet the needs of patients.

Findings:

1. There is no documentation that nursing personnel assigned to provide care to patients with respiratory therapy orders are trained, qualified, and competent to care for the patients.

2. On the afternoon of 12/01/2011 administrative staff stated agency nursing staff is utilized in the facility to provide patient care. Staff B was asked by surveyors to provide staff G's personnel file. Staff G is an agency nurse who worked last on 11/25/2011 and documented on patient # 17's chart. The records presented to the surveyors did not have evidence of review of competencies or evaluation of skills to ensure qualifications and ability to care for the individual needs of each patient and area in which they are assigned, orientation to the facility, or that a review of the facilities policies and procedures was conducted.

3. This information was reviewed with administration on the afternoon of 12/01/2011.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital performs a periodic evaluation and quality assurance review as required. The hospital has not conducted an annual periodic evauation and does not have an effective and ongoing quality assurance program.

1. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag # 0331.

2. The hospital does not ensure a yearly program evaluation reviewing the utilization of CAH services, including the number of patients served and the volume of services is conducted. Refer to Tag # 0332.

3. The hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records. Refer to Tag # 0333.

4. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies. Refer to Tag # 0334.

5. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag # 0335.

6. The hospital does not have an effective Quality Assurance/Performance Improvement (QA/PI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. Refer to Tag # 0336.

7. The hospital does have an effective quality assurance program that is implemented to evaluate the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI program. Refer to Tag # 0337.

8. The hospital does not have an effective quality assurance program implemented to evaluate nosocomial infections and medication therapy. Refer to Tag # 0338.

9. The hospital does not have a functioning QA/PI system is implemented so that remedial action can address deficiencies found through the QA/PI program. Refer to Tag # 0342.

10. The hospital does not ensure that a functioning QA/PI program is implemented in the hospital. Refer to Tag # 0343.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Interviews with hospital personnel on the afternoon of 12/01/11 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of active and closed records, hospital policies and procedures and evaluation of the services provided and if changes were needed.

2. Governing Body and Medical Staff meeting minutes for 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interview with hospital staff, the hospital does not ensure a yearly program evaluation reviewing the utilization of CAH services, including the number of patients served and the volume of services is conducted.

Findings:

1. Interviews with hospital personnel on the afternoon of 12/01/11 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of the utilization of CAH services, including the number of patients served and the volume of services is conducted.


2. Governing Body and Medical Staff meeting minutes for 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

Based on record review and interviews with hospital staff, the hospital does not ensure that a yearly periodic evaluation was conducted which included a representative sample of active and closed medical records.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Interviews with hospital personnel on the afternoon of 12/01/11 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of a representative sample of active and closed medical records.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes a review of the CAH's health care policies.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

2. Review of selected hospital policies did not document a yearly review as required. The following policies had the following review dates Radiology 2005, Dietary 2005, and Respiratory 2000 and 2001.

3. Hospital personnel stated in the afternoon of 12/01/11 that they did not have any other documentation of policy review.

Based on record review and interviews with hospital staff, the hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2010 and 2011 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program to determine if services were effectively utilized, policies were followed and if changes were needed.

2. Hospital staff stated on the afternoon of 12/01/11 that they had not conducted a periodic evaluation that included all the requirements.

Based on record review and interviews with hospital staff, the hospital does not ensure that the hospital has an effective Quality Assurance/Performance Improvement (QA/PI) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished. There was no evidence of the hospital conducting a collection and analysis of data concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. Governing Body and Medical Staff meeting minutes for 2010 and 2011 did not contain evidence of any analysis of data presented to identify problems, evaluate situations, and take corrective actions.

2. The hospital could not provide a QA/PI plan for the hospital for review .

3. There was no evidence of reviews of nosocomial infections and medication therapy in the medical staff meeting minutes. There were no infection control meeting minutes for review.

4. Hospital staff verified on 12/01/11 in the afternoon that the hospital does not have a functioning QA/PI program.

Based on record review and interviews with hospital staff, the hospital does not ensure that an effective quality assurance program is implemented and evaluates the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning QA/PI program. All patient care services and other services affecting patient health and safety are not evaluated and the hospital does not collect and analyze data concerning the quality and appropriateness of all patient care furnished in the CAH.

Findings:

1. The hospital stated on 12/01/11 in the afternoon that they do not have a functioning QA/PI program.

2. The last QA meeting minutes presented for review were dated 2008.

Based on review of infection control documents, hospital meeting minutes, policies and procedures and personnel files, and interviews with staff, the hospital does not ensure that an effective quality assurance program is implemented and nosocomial infections and medication therapy are evaluated. The hospital failed to develop an active on-going infection control program for ensuring a sanitary environment, and identifying and preventing infections and communicable diseases by designating a person qualified through training and/or experience as the infection control officer (ICO).

Based on record review and interviews with hospital staff, the hospital does not insure that a functioning QA/PI system is implemented so that remedial action can address deficiencies found through the QA/PI program. Review of Governing Body and Medical Staff meeting minutes for 2010 and 2011 and interviews with hospital staff during the survey did not have evidence the hospital has a functioning QA/PI program.

Based on record review and interviews with hospital staff the hospital does not ensure that a functioning QA/PI program is implemented in the hospital. The hospital has not documented any remedial action because the QA/PI program has not been active. This was verified by hospital staff on 12/01/11 and by review of Governing Body and Medical Staff meeting minutes for 2010 and 2011.

Based on the review of abuse and neglect policies and procedures and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describe the procedures to follow when a patient alleges abuse by a hospital employee.

Findings:

1. The hospital policies provided for review addressed abuse that occurred prior to when the patient presented to the hospital. The policies did not clearly define the steps to be followed when a patient alleges abuse or neglect by a hospital employee or contract worker and did not contain the components to prevent, screen, identify, train, and report/respond to allegations of abuse/neglect by these individuals.

2. Interviews with Staff A and B in the afternoon of 12/01/2011 verified that the hospital does not have a written policy that includes the required elements for effective abuse and neglect protection that could occur in the hospital.

Based on a review of personnel files and interviews with hospital staff, the facility failed to ensure that the State nurse aide registry was checked for findings when individuals are offered employment. In eleven of eleven personnel files (Staff B, D, G, H, I, K, L, M, N, O, and P)that were reviewed, no evidence of inquiry was documented. The Administrator stated on the morning of 12/01/2011 that background checks with the State nurse aide registry was not performed.

Based on review of the hospital's swing bed policies and procedures, personnel files, and medical records, and interviews with hospital staff, the hospital failed to provide an ongoing activity program directed by a qualified staff member with activities based on the individual needs and interests assessments of the patients. This occurred for four of four swingbed patients (Records #15, 19, 25, and 28) whose medical records were reviewed.

Findings:

1. On the afternoon of 11/30/2011, Staff B told the surveyors that Staff K was the Swingbed activity coordinator. She stated that the prior activity's staff, who quite in January 2011, had gone to training, but that Staff K had not received any training for the position. This was confirmed by personnel file review and by Staff K on the afternoon of 12/01/2011.

2. Records #15, 19, and 28 did not contain comprehensive activity assessments with the interests, and the physical, mental, and psychosocial needs of each swingbed patient considered.

3. Medical record review of four Swingbed patients did not demonstrate the hospital had not provided organized individual, group or bedside activities to patients based on patient interests and needs assessment. Records #15, 19, and 28 did not contain documentation that activities had been provided or offered to the patients. Record #25 did not contain documentation that activities were provided or offered every day of the patient's stay.

4. Findings of medical record review were discussed with Staff B and K on the afternoon of 12/01/2011.