HospitalInspections.org

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Based on interview and record review, the Critical Access Hospital failed to show that information about the status of patients' advanced directives was obtained for 5 of 6 patient admitted to the acute care unit of the hospital (Patients #1,# 2,# 3, #4, #5).

Failure to address advanced directives creates risk that patients' rights to participate in health care decision making about medical treatments may not be included in determining the plan of care, especially when unanticipated events occur.

Reference:

§ 489.102 Requirements for providers.

(a) Hospitals, critical access hospitals, skilled nursing facilities, nursing facilities, home health agencies, providers of home health care (and for Medicaid purposes, providers of personal care services), hospices, and religious nonmedical health care institutions must maintain written policies and procedures concerning advance directives with respect to all adult individuals receiving medical care, or patient care in the case of a patient in a religious nonmedical health care institution, by or through the provider and are required to:

(1) Provide written information to such individuals ...

(2) Document in a prominent part of the individual's current medical record ... whether or not the individual has executed an advance directive ...

Findings included:

1. Medical record review of five of six patients admitted to inpatient acute care department (Patients #1, #2, #3, #4, #5) showed no documentation related to advance directive status located in the patient medical record.

2. On 07/27/17 at 3:36 PM, the Chief Nursing Officer (CNO) (Staff J) stated that the hospital had no Advance Directive Policy and verified the findings above.

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Based on observation and interview, the Critical Access Hospital failed to ensure that available patient care supplies did not exceed the manufacturer's expiration date.

Failure to properly maintain supplies places patients at risk for infection and delays in treatment.

Findings included:

During the survey, Surveyor #2 made the following observations:

a. On 07/25/17 at 10:50 AM, the observation showed 18 1-Liter IV solution bags that had exceeded their expiration date; November 2015 - 1 bag, December 2015 - 5 bags, April 2016 - 1 bag, August 2016 - 6 bags, September 2016 - 5 bags. The expired IV solution bags were located in the ER/PACU refrigerator. The Director of Facilities (Staff RM - A) directed a Certified Nursing Assistant (Staff RM - B) to discard the expired IV solution bags.

b. On 07/25/17 at 11:10 AM, the observation showed 2 bottles of CIDEX OPA test strips (used to assess the proper concentration of CIDEX OPA, a disinfectant), with expiration dates of December 2014 and June 2015. The expired bottles were located in the Sterilization Department. Staff RM - B discarded both bottles at the time of observation.

c. On 07/27/17 at 11:50 AM, the observation showed a 500-mL bottle of sterile water with an expiration date of May 2014 in the Physical Therapy Clinic. A Physical Therapy Aide (Staff RM - C) stated that she did not know that sterile water was ever used in the clinic.

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Item #1 Crash Carts

Based on observation, interview, and policy and procedure review, the Critical Access Hospital staff failed to regularly check crash carts per hospital policy.

Failure to check crash carts regularly places patients at risk from inadequate care should the need for emergency services arise.

Findings included:

1. The hospitals policy titled, "Code Blue-Cardiac/Respiratory Arrest," Effective Date: 7/10, showed that daily documentation is to be noted on the check list documenting that all supplies are present and functional.

2. On 07/25/17 from 9:33 AM through 10:20 AM, during a tour of the Emergency department, Surveyor #1 inspected the contents of the portable emergency bag. The observation showed the following:

a. There was no check list documenting that all supplies were present and functional per hospital policy

b. The Automated External Defibrillator (AED) (an electronic device that automatically diagnoses the life-threatening cardiac arrhythmias and is able to treat them through defibrillation) was found to be non-functional. When Surveyor #1 attempted to turn on the AED, the machine indicated that the 9-Volt battery needed to be changed.

3. At the time of the observation, the Chief Nursing Officer (Staff J) confirmed the findings.

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Item #2-Semi-Critical Equipment

Based on observation and interview, the Critical Access Hospital failed to reprocess and store semi-critical equipment according to acceptable standards of practice.

Failure to properly reprocess and store semi-critical devices risks contamination with microorganisms and places patients at risk for infection.

Reference: Centers for Disease Control and Prevention. "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008".

Findings included:

1. On 07/25/17 from 9:33 AM through 10:20 AM, during tour of the Emergency department, Surveyor #1 inspected the contents of the portable emergency bag. The observation showed 3 laryngoscope blades that did not have the required protective packaging to ensure protection from sources of contamination.

2. At the time of the observation, the Chief Nursing Officer (Staff J) confirmed the findings and removed the laryngoscope blades.

3. The Chief Nursing Officer (Staff J), was unable to locate a policy or procedure related to reprocessing and storage of semi-critical equipment.

Item #3- Expired Supplies

Based on observation, interview, and review of policy and procedure, the Critical Access Hospital failed to ensure that patient care supplies were not stored or available for patient use beyond the manufacturer's expiration date.

Failure to maintain supplies properly places the patients at risk for delays in treatment and infections.

Findings included:

1. The hospital's policy titled, "Stock Rotation," Effective date: 01/05, showed that all stock will be reviewed monthly by the purchasing staff and any item within 30-days of expiration will be pulled from the shelf and returned to purchasing.

2. On 07/25/17 from 9:33 AM through 10:20 AM, Surveyor #1 toured the Emergency department. The observation showed the following:

a. Located in room #1, one 16 ounce bottle of 3% Hydrogen Peroxide with manufacture expiration date of 06/17.

b. Located in room #2, one 16 ounce bottle of 3% Hydrogen Peroxide with manufacture expiration date of 04/17 and two blood culture bottles with manufacture expiration 04/17.

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Based on observation, interview, and document review, the Critical Access Hospital failed to maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.

Failure to adhere to preventive maintenance schedules for patient care equipment puts patients at risk of injury or illness from faulty equipment.

Findings included:

ITEM #1 - LABORATORY BIOSAFETY CABINET

1. Document review of the LABCONCO Purifier Biosafety Cabinet User's Manual's Routine Maintenance Schedule showed that the cabinet should be re-certified by a qualified certification technician semiannually or annually.

2. On 07/25/17 at 2:45 PM, Surveyor #2 inspected the LABCONCO Purifier Biosafety Cabinet in the laboratory. The observation showed the cabinet had a certification sticker with an expiration date of 02/2017 (Certification #J-10407 Aespsis Services Co.). The Laboratory Manager (Staff RM - D) witnessed the observation.

ITEM #2 - OXYGEN CONCENTRATOR

1. On 07/26/17 at 4:10 PM, Surveyor #2 inspected an EverFlo oxygen concentrator (model 1039362) in Sleep Room #303-2. The observation showed that the EverFlo machine did not have an inventory or asset number. At the time of the observation, the CEO (Staff RM - E) stated that the equipment belonged to the contracted staff who operated the Sleep Lab.

2. On 07/27/17 at 8:30 AM, Surveyor #2 interviewed the Facilities Maintenance Manager (Staff RM - F) about the biomed program. Staff RM - F stated that hospital staff did not inventory or maintain the Sleep Lab equipment.

ITEM #3 - GLUCOMETER

On 07/27/17 at 3:00 PM, Surveyor #2 inspected an Abbott Precision Xceed Pro Glucometer at the Emergency Department nurses' station. The observation showed that the glucometer was not included on the equipment inventory list that the Director of Facilities (Staff RM - A) provided to the surveyor.

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Based on observation, the Critical Access Hospital failed to maintain air pressure relationships as required in clinical care areas.

Failure to maintain proper air pressure relationships puts patients at risk of infection.

REFERENCE: ASHRAE/ASHE Standard 170-2008; Ventilation of Health Care Facilities, Table 7-1 Design Standards.

Findings included:

On 07/27/17 at 10:45 AM, Surveyor #2 used a flutter strip (a lightweight string) to determine the direction of air flow between the Clean Utility Room on the Acute Floor, and the corridor. The flutter strip was drawn into the Clean Utility Room indicating the room was under negative pressure with respect to the corridor, contrary to federal requirements. The Facilities Maintenance Manager (Staff RM - F) witnessed the finding.

Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.

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Based on observation, interview, and review of hospital policies, procedures, and medical records, the Critical Access Hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure.

Failure to ensure that the hospital meets established organizational structure requirements impairs the hospital's ability to provide quality care in a safe environment.

Reference: 42 CFR 485.627(a) Standard: Governing Body or Responsible Individual

The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment

Findings:

The governing body failed to ensure that policies and procedures for patient care were developed and reviewed annually (Refer to C0272), comprehensive assessments were completed and plans of care were developed and implemented for inpatients and "Swing Bed" patients failed to ensure medical record systems were stored, maintained and readily accessible for patient care staff , failed to ensure hospital staff followed patient care policies, failed to evaluate the Quality Assurance program including patient care policies, patient care services, utilization, and infection control, failed to ensure the hospital had policies and procedures developed and implemented for patients admitted to the Critical Access Hospital's "Swing Bed" program and qualified staff available to provide these services.

Due to the severity of deficiencies detailed under the Conditions of Participation for Organizational Structure the Condition of Participation for Organizational Structure was NOT MET.

Cross Reference to C0272, C0276, C0298, C0300, C0301, C0302, C0304, C0305, C0306, C0311, C0330, C0331, C0333, C0334, C0335, C0337, C0338 C0368, C0369, C0371, C0372, C0377, C0385, C0386, C0388, C0395, C0402, C0404, C0407.

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Based on review of hospital policies and interview, the Critical Access Hospital staff failed to review policies on an annual basis.

Failure to review hospital policies and procedures on an annual basis may lead to poor patient care outcomes.

Findings included:

1. The hospital policy titled, "Annual Review of Programs and Policies," Effective date: 09/01/17, stated that policies will be reviewed on a continuous basis during the year.

2. From 07/25/17 through 07/28/17, Surveyor #1 reviewed numerous hospital policies that were not in compliance with the hospital policy including but not limited to:

a. Patient's Rights and responsibilities (Effective date: 04/30/02).
b. Stock Rotation (Effective date: 01/05)
c. Policy Review Group (Effective date: 06/05)
d. Transfer of Patients 9I House): Acute Care, North Wing, Swing bed and Nursing Home (Effective date 04/04).
e. Disclosure of Unanticipated Outcomes to Patients, Families, or surrogate Decision Makers (Effective date 03/29/06).
f. Pain Management (Effective date: 07/10).
g. Code Blue-Cardiac/Respiratory Arrest (Effective date: 07/10).
h. Incident Investigation and Reporting (Effective date 07/10).
i. Admissions from Emergency Department (Effective Date 12/10).
j. Scope of Service Staffing for the Acutely Ill (Effective date: 12/12).
k .Patient flow from the Emergency Department (ED) to Clinic/Inpatient/Outpatient (Effective date: 12/12/12).
l. Medication Administration and Operation of the Automated Dispensing Devise (Pyxis) (Effective date: 10/08/13).
m. Sterile Pharmaceuticals (Effective date: 09/17/13).
n. Patient Transfer to Another Facility (Effective date: 09/01/14).
o. Swing Bed Comprehensive Assessment Policy (Effective date 11/01/14).
p. Swing Bed Care Planning Policy (Effective date 11/01/14).
q. Sterile Admixture (Effective date: 11/01/09).
r. Partners in Care (Effective date: 06/23/14).
s. Blood Administration (Effective date 05/16).
t. Restraint Policy (effective date: 05/01/16).
u. Physical Inventory/Outdated Product Procedure (Effective date 07/04/16).

3. From 07/25/17 through 07/28/17, in addition to expired policies, Surveyor #1 observed numerous nursing, pharmacy and respiratory policies which contained no original dates or effective dates.

4. On 07/27/17 at 3:36 PM, during an interview with the hospital's Director of Quality Improvement (Staff I), Staff I told Surveyor #1 that the "effective date" listed on the policy is the date the policy was last reviewed. .Staff I confirmed the patient care policies were overdue for review. She stated that there were significant issues with policies being reviewed and updated, and there were policies completely missing related to turnover in staff.

5. On 07/27/17 at 10:15 AM, during an interview with the hospital's Chief Nursing Officer (Staff J), Staff J confirmed the missing and outdated patient care policies.

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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure hospital staff members followed the pharmacy's policy for labeling and discarding multi-dose medication vials after opening.

Failure to discard multi-dose vials after 28 days of opening risks contamination of the contents of the vials and transmission of infectious diseases to patients during mediation administration.

Reference:

United States Pharmacopeia (USP) - General Chapter 797 - "Sterile Compounding - Sterile Preparation" (Revised April 2016): reads in part, "If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date."

Findings included:

1. The hospitals policy titled, "Multiple Dose Vials," Effective date: 03/01/17, stated that all multiple dose vials must be dated and initialed by the licensed nurse when first opened for use.

2. On 01/26/17 at 10:04 AM, Surveyor #1 inspected the Emergency Department medication room The observation showed 2 opened vials of insulin located in the refrigerator that were not dated as per hospital policy.

3. At the time of the observation, the Emergency room nurse (Staff N) confirmed the findings and removed the medication.

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ITEM #1 - SEMI-CRITICAL DEVICE

Based on observation and document review, the Critical Access Hospital staff failed to follow manufacturer instructions for use of High Level Disinfection (HLD) chemicals and patient care equipment.

Failure to follow manufacturer instructions puts patients and staff at increased risk of infection due to improper storage of equipment and reduced efficacy of chemicals used for HLD.

REFERENCE: CDC Guideline for Disinfection and Sterilization in healthcare Facilites, 2008. "Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA)...requires users of products to follow explicitly the labeling directions on each product."

Findings included:

1. Document review of GE Healthcare Transducer Cleaning and Disinfection Guidelines showed that hospital staff should refer to the disinfectant manufacturer's guidelines when cleaning and disinfecting transducers.

2. Document review of CIVCO Endocavity Transducer Soaking Cup reference manual showed that hospital staff should refer to the chemical manufacturer's recommendations for proper disinfecting procedures, and that transducers should be removed from the soaking cup when disinfection is complete.

3. Document review of CIDEX OPA Solution (a HLD product) directions for use showed that devices should be soaked for 12 minutes at 20 degrees Celsius [68 degrees Fahrenheit], then thoroughly rinsed and dried.

4. Record review of the hospital's policy titled, "Disinfection of Transvaginal Probes," Reference #7140.45 dated 12/1/2013, showed that hospital staff are to soak the probe in CIDEX OPA solution for 12 minutes, wipe with a paper towel, rinse, and dry thoroughly.

5. On 07/25/17 at 2:15 PM, Surveyor #2 inspected the Ultrasound Room on the Acute Floor. The observation showed a bottle of CIDEX OPA and a bottle of CIDEX OPA test strips on a cabinet shelf, and a transducer-soaking cup in a bracket attached to the wall. The transducer soaking cup held a transvaginal probe soaking in solution.

The surveyor asked the Radiology Department Manager (Staff RM - G) if department staff monitored the temperature of the solution to assure the efficacy of the disinfectant. Staff RM - G stated that the Ultrasound Technician was not available to ask but observed there was no evidence of a log sheet to document daily temperature or an available thermometer. The surveyor asked Staff RM - G about the probe soaking in the solution. Staff RM - G stated that she did not know when the probe was used or how long it had been soaking.

ITEM #2 - ULTRASOUND TRANSMISSION GEL CROSS-CONTAMINATION

Based on observation and interview, the Critical Access Hospital failed to protect ultrasound gel from exposure to harmful bacteria through cross-contamination.

Failure to implement infection control measures on use of ultrasound gel puts patients at risk for infection.

REFERENCE: FDA Safety Communication, "Update on Bacteria Found in Other - Sonic Generic Ultrasound Transmission Gel Poses Risk of Infection" issued 06/08/2012 - "Be aware that once a container of sterile or non-sterile gel is opened, it is no longer sterile and contamination during ongoing use is possible...Never refill or "top off" containers of ultrasound gel during use. The original container should be used and then discarded."

Findings included:

On 07/27/17 at 11:30 AM, Surveyor #2 observed a 5-L container of Aquasonic 100 Ultrasound transmission gel currently in use; 2 unopened 5 L containers, and more than a dozen 0.25-L refill bottles in a cabinet at the Physical Therapy Clinic. The surveyor asked the Physical Therapy Manager (Staff RM - K) about the bulk containers. Staff RM - K stated that the clinic staff was not aware that containers should not be refilled or topped off.

ITEM #3 - ENVIRONMENTAL CLEANING PROCEDURES

Based on observation and interview, the Critical Access Hospital failed to ensure staff used effective infection control techniques following patient discharge from the Emergency Department (ED).

Failure to effectively clean patient care areas puts patients, visitors, and staff at increased risk of infection from cross-contamination.

Findings included:

1. Record review of the hospital's policy titled, "Cleaning Isolation Patient Room-Discharge/Transfer," Reference #8460.35 dated 04/14/2016, showed that hospital staff are to wipe out the waste containers with a germicidal solution, damp wipe the bed frame, both sides of the mattress, and the bed control with germicidal solution. [This policy was provided to the surveyor by the Director of Quality (Staff RM - I) and described as the policy that directs the discharge cleaning of the ED.]

2. On 07/27/17 at 3:25 PM, Surveyor #2 observed a CNA (Staff RM - H) perform a cleaning procedure of ER #1 following patient discharge. Surveyor #2 made the following observations:

a. no part of the waste container was wiped with germicidal solution

b. only the plastic grab sheath of one bed rail was wiped with disinfectant, no other part of the bed was disinfected

c. only the top surface of the matterss was wiped with disinfectant; the surveyor noticed debris remaining on the matterss and stopped Staff RM - H from making the bed with clean linens

d. only the top surface of the instrument tray was wiped with disinfectant, no other part of the tray or tray stand was disinfected

e. only the top surfaces of a rolling stool and two visitor chairs were wiped with disinfectant, no other parts were disinfected

f. no part of the ceiling-mounted exam light was disinfected

At 3:34 PM, following the observation, in an interview with Surveyor #2, the Chief Nursing Officer (Staff RM - J) stated that there is no discharge cleaning policy for the ED and that the CNAs train each other in discharge cleaning procedures.

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Based on interview, record review, and review of hospital policies, the Critical Access Hospital failed to develop a policy and procedure for planning nursing care for patients that included review and revision as necessary, as demonstrated in five of six acute care patient records reviewed (Patients #1, #3, #4, #5, #9), and three of three swing bed patient records reviewed (Patients #6, #7, #8)

Failure to develop an individualized nursing care plan and to evaluate and revise the plan as necessary can result in the inappropriate, inconsistent, or delayed treatment of patient's needs.

Findings included:

1. On 07/26/17 at 2:00 PM, during medical record review the Chief Nursing Officer (Staff J) told Surveyor #1 the hospital did not have a policy on Care Plans.

2. Review of nine patient records for nursing care plans showed the following:

a. The care plan for Patient #1 contained only a problem list and lacked identified interventions or outcomes. The surveyor found no evidence that the care plan received a review to evaluate the effectiveness of the plans and determine if revision of these plans was necessary.

b. The medical records for Patients #3, #7, #8 and #9 contained no care plans.

c. The care plan for Patient #4 contained only a problem list and lacked identified interventions or outcomes. The surveyor found no evidence that the care plan received a review to evaluate the effectiveness of the plans and determine if revision of these plans was necessary.

d. The care plan for Patient #5 contained only a problem list and lacked identified interventions or outcomes. The surveyor found no evidence that the care plan received a review to evaluate the effectiveness of the plans and determine if revision of these plans was necessary.

e. The medical record for Patient #6 could not be located for dates from 01/19/17 through 01/22/17. The care plan for dates 01/23/17 through 02/15/16 contained only a problem list and lacked identified interventions or outcomes. The surveyor found no evidence that the care plan received a review to evaluate the effectiveness of the plans and determine if revision of these plans was necessary.

2. On 07/27/17, at the time of the record review the Quality Director (Staff I) confirmed the findings above for Patients #6, #7, and #8.

3. On 07/27/17 at 3:36 PM, the Chief Nursing Officer (Staff J) confirmed the findings for Patients #1, #3, #4, #5 and #9.

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Based on interview and record review, the Critical Access Hospital failed to document Rehabilitation Services staff training and competency assessment.

Failure to ensure staff have the necessary education, experience, training, and documented competencies places patients at risk of injury and inadequate care.

Findings included:

1. Record review of education and training for the Physical Therapy Aides (Staff RM - C, L, and M), showed that the most recent training and skills competency evaluation was completed in 2014.

2. On 07/27/17 at 12:00 PM, Surveyor #2 interviewed the Physical Therapy Manager (Staff RM - K) about requirements for staff training and competency. Staff RM - K stated that Physical Therapy Aides receive annual training and competency checks but the hospital could provide no documentation of more recent training at the time of survey.

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Based on interview, medical record review for current and discharged patients, and review of deficiencies cited during the survey, the Critical Access Hospital failed to maintain a medical record for each patient admitted or treated at the hospital, failed to ensure each patient medical record was complete and contained the necessary elements per CMS requirements, and failed to ensure the medical record was readily accessible by healthcare providers involved in the patient's care. The cumulative effect of these systemic problems resulted in the Critical Access Hospital's failure to meet the requirements for the Condition of Participation for Clinical Records.

Failure to maintain complete patient medical records that are readily accessible to healthcare providers involved in patient care impairs the facility's ability to provide quality care in a safe environment.

Findings:

Cross-reference to C0301, C0302, C0304, C0305, C0306, C0311

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Based on interview, review of medical records and review of policy and procedures, the Critical Access Hospital failed to verify a medical record was maintained for each person receiving care, failed to verify that medical records were maintained for at least six years per CMS requirements, failed to ensure medical records were stored in a manner that ensured patient care providers prompt retrieval of patient information and failed to develop and implement policies and procedures that guided effective medical record handling, storage and retrieval processes between the new electronic health record implemented in May 2017, the previous electronic health record utilized by the hospital and the paper medical record.

Failure to ensure patient medical records are stored, maintained and readily available for care providers puts all patients at risk for unrecognized and unmet care needs, and inconsistent and unsafe care due to the lack of information readily available to hospital personnel.

Findings included:

1. On 07/27/17, Surveyor #1 and the hospital's Director of Quality Improvement (Staff I) reviewed the medical records of three patients who had been admitted and discharged from the Critical Access Hospital Swing Bed program (Patients #6, #7, #8). The review showed the following:

a. Patient #6 was admitted to the hospital's swing bed program on 01/19/17 and discharged on 02/15/17. The hospital could not locate or retrieve the patient's medical record from 01/19/2017 through 01/22/17.

b. Patient #7, was admitted to the hospital's swing bed program 01/11/17 and discharged on 02/08/17. The hospital could not locate or retrieve the patient's medical record from 01/11/2017 through 01/23/17.

c. Patient #8, was admitted to the hospital's swing bed program 11/07/16 and discharged on 11/15/16. The hospital could not locate or retrieve the patient's medical record for the entire admission except for the physician's Admission History and Physical, the Physician Certification Statement and the Discharge Summary.

2. On 07/27/17, at the time of the medical record review, the hospital's Director of Quality Improvement (Staff I) stated that the hospital had changed documentation systems in May 2017. The missing medical records were the records located in the prior system and specifically the records when the patient was in "certified swing bed status" for part of their admission or in "certified swing bed status" for all of their admission. Staff I was unable to locate or retrieve the missing records and confirmed all the findings above.

3. At this same time, Staff I was unable to locate or retrieve a policy and procedure guiding the systematic storage and retrieval processes for the different electronic medical record systems. She stated that many policies were missing and they (the hospital) realized this was a problem.

Based on interview, medical record review, and review of hospital policies and procedure, the Critical Access Hospital failed to implement a system to ensure a complete medical record was entered and maintained for every individual evaluated or treated in the hospital, the medical records accurately documented all orders, test results, evaluations, treatments, interventions, care provided and the patients response to those treatments, interventions and care and the medical record was readily accessible and systematically organized for 6 of 6 acute care patients reviewed (PatientS #1, #2, #3, #4, #5, #9), and three of three swing bed patients reviewed (Patients #6, #7, #8).

Failure to ensure patient medical records are stored, maintained and readily available for care providers puts all patients at risk for unrecognized and unmet care needs, and inconsistent and unsafe care due to the lack information readily available to hospital personnel.


Findings included:

1. The hospital's policy and procedure titled "Fall Prevention", effective date: 10/25/16, showed that the initial admission assessment includes an assessment of fall risk and a comprehensive Fall Risk Assessment will be done on admission, once a shift, with change in condition, and after a fall.

2. The hospital's policy and procedure titled "Pain Management," effective date 07/10, showed that a pain assessment will be performed at the time of admission during the initial nursing assessment and include an assessment of the patient's cultural, spiritual, ethical, family and personal beliefs and values, learning needs, abilities, preferences and readiness to learn.

3. The electronic medical record review showed the following:

a. The medical record for Patient #1, admitted on 06/04/17 for treatment of left lobar pneumonia did not contain a comprehensive nursing admission assessment or evidence that a fall risk assessment, functional assessment, skin and wound assessment, nutrition assessment, or learning needs assessment had been completed. The medical record did not contain evidence of the status of advance directives, a complete care plan, or documentation of response to care interventions.

b. The medical record for Patient #2, admitted on 06/05/17 for treatment of pneumonia and weakness did not contain a comprehensive nursing admission assessment or evidence that a fall risk assessment, functional assessment, skin and wound assessment, nutrition assessment, or learning needs assessment had been completed.

c. The medical record for Patient #3, admitted on 05/11/17 for treatment of pancreatitis (inflammation of the pancreas) did not contain a comprehensive nursing admission assessment or evidence of a fall risk assessment, functional assessment, and skin and wound assessment, nutrition assessment, or learning needs assessment had been completed. The medical record did not contain evidence of the status of advance directives, a complete care plan, documentation of response to interventions or an admission History and Physical by the admitting Physician.

d. The medical record for Patient #4, admitted on 05/13/17 for treatment of pancreatitis (inflammation of the pancreas) did not contain a comprehensive nursing admission assessment or evidence that a fall risk assessment, functional assessment, skin and wound assessment, nutrition assessment, or learning needs assessment had been completed. The medical record did not contain, evidence of the status of advance directives, or a complete care plan.

e. The medical record for Patient #5, admitted on 02/16/17 for treatment of abdominal pain and Pyelonephritis (inflammation of the kidney) did not contain evidence of the status of advance directives, or a complete care plan.

f. The medical record for Patient #9, admitted on 12/03/16 for the treatment of left lobular pneumonia and died on 12/04/16 did not contain evidence that a Physician History and Physical had been completed, or that a nursing care plan had been initiated or completed.

g. Patient #6 was admitted to the hospital's swing bed program on 01/19/17 and discharged on 02/15/17. The hospital could not locate or retrieve the patient's medical record from 01/19/2017 through 01/22/17.

h. Patient #7, was admitted to the hospital's swing bed program 01/11/17 and discharged on 02/08/17. The hospital could not locate or retrieve the patient's medical record from 01/11/2017 through 01/23/17.

i. Patient #8, was admitted to the hospital's swing bed program 11/07/16 and discharged on 11/15/16. The hospital could not locate or retrieve the patient's medical record for the entire admission except for the physician's Admission History and Physical, the Physician Certification Statement and the Discharge Summary.

4. On 07/27/17 at 11:20 AM, during interview with the hospital's Director of Quality Improvement (Staff I), Staff I stated that the hospital had changed documentation systems in May 2017. The missing medical records for the swing bed patients were the records from the prior electronic health record system (CPSI). Additionally, Staff I stated that the missing records were from the periods when the patient was in "certified swing bed status" for part of their admission or in "certified swing bed status" for all of their admission. Staff I was unable to locate or retrieve the missing medical records for Patients #6, #7, and #8.

5. On 07/27/17 at 3:36 PM, during interview with the Chief Nursing Officer (Staff J), Staff J stated that there was no hospital policy that defined the elements of the admission assessment for patients admitted to the Acute Care Department.

a. At the time of the interview, the surveyor observed that the medical record for Patient 5 who had been admitted to the Acute Care Department did contain a comprehensive admission assessment which included assessment of pertinent history, communication status, current living conditions, activities of daily living, activity, safety, pain, fall risk, psycho-social evaluation, functional status, nutritional assessment and skin and wound risk. Hospital staff completed this patient's admission assessment in the previous electronic health record system (CPSI). The medical records for Patients #1, #2, #3, #4 had been completed in the new electronic health record (Athena) that was implemented in 05/17.

b. During the same interview above, Staff J confirmed that an initial nursing admission assessment had not been built in the new electronic health record system (Athena) and no patients admitted since the implementation in 05/17 would have a comprehensive initial admission assessment completed or documented in the electronic medical record.

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Based on record review and review of hospital policy and procedures, the Critical Access Hospital failed to obtain proper informed consents for 2 of 3 blood transfusion charts reviewed (Patient #9 and #10).

Failure to properly obtain an informed consent risks patients not being fully informed of potential risks.

Findings included:

1. The hospital's policy and procedure titled "Blood Administration," Effective Date: 05/2016, showed that the physician will explain the procedure and associated risks to the patient and obtain consent. The patient consent will documented on an electronic Blood Transfusion Consent form (Exhibit C located in the policy). For emergency blood transfusion, the physician will document consent on the EMERGENCY Blood Transfusion/Release form (Exhibit D in the policy)

2. On 07/26/17 at 2:00 PM, Surveyor #1 and the Chief Nursing Officer (Staff J) reviewed the medical records for three patients who had received blood transfusions. The medical record showed two of the three records did not contain informed consent per hospital policy.

a. Patient #10 was admitted on 09/03/16 for the treatment of a brachial artery laceration. The surveyor found no evidence of the EMERGENCY Blood Transfusion/Release form confirming physician consent in the medical record at the time of the review.

b. Patient #11 was admitted on 11/09/16 for the treatment of weakness and anemia. The surveyor found no evidence of informed consent in the medical record at the time of the review.

3. At the time of the review, the Chief Nursing Officer (Staff J) confirmed the findings above.

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Based on medical record review and review of policies and procedures, the hospital failed to ensure completion or timely completion of a history and physical for three of nine medical records reviewed.

Failure to ensure history and physicals are present in the patient record risks inadequate and/or inappropriate care and treatment during emergencies and on subsequent hospital admissions.

Findings included:

1. The hospital's "Rules and Regulations of the Medical Staff," no date, showed that a complete admission history and physical examination shall be recorded within 24 hours of admission on medical patients.

2. Review of the Electronic Medical Record showed the following:

a. The medical record for Patient #3, admitted on 05/11/17 for treatment of pancreatitis (inflammation of the pancreas), did not contain evidence that a Physician History and Physical had been completed.

b. The medical record for Patient #7, admitted to the hospital's swing bed program 01/11/17 and discharged on 02/08/17, contained a Physicians History and Physical that was dated 02/08/17 (28 days after admission).

c. The medical record for Patient #9, admitted on 12/03/16 for the treatment of left lobular pneumonia, did not contain evidence that a Physician History and Physical had been completed.

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Based on medical record review and interview, the Critical Access Hospital failed to ensure that patient records included documentation of all nursing assessments, nursing notes, lab and radiology reports, vital signs, all care provided and response to interventions and other information necessary to monitor the patient's condition.

Failure to ensure a complete and timely documented medical record puts patients at risk for unrecognized and unmet care needs, and inconsistent and unsafe care due to the lack of complete and accurate information that is readily accessible to hospital personnel.

Findings included:

1. The electronic medical record review showed the following:

a. The medical record for Patient #1, admitted on 06/04/17 for treatment of left lobar pneumonia, did not contain a comprehensive nursing admission assessment or evidence that a fall risk assessment, functional assessment, skin and wound assessment, nutrition assessment, or learning needs assessment had been completed. The medical record did not contain evidence of the status of advance directives, a complete care plan, or documentation of response to care interventions.

b. The medical record for Patient #2, admitted on 06/05/17 for treatment of pneumonia and weakness did not contain a comprehensive nursing admission assessment or evidence that a fall risk assessment, functional assessment, skin and wound assessment, nutrition assessment, or learning needs assessment had been completed. The medical record did not contain evidence of the status of advance directives.

c. The medical record for Patient #3, admitted on 05/11/17 for treatment of pancreatitis (inflammation of the pancreas), did not contain a comprehensive nursing admission assessment or evidence of a fall risk assessment, functional assessment, and skin and wound assessment, nutrition assessment, or learning needs assessment had been completed. The medical record did not contain evidence of the status of advance directives, a complete care plan, documentation of response to interventions or an admission History and Physical by the admitting Physician.

d. The medical record for Patient #4, admitted on 05/13/17 for treatment of pancreatitis (inflammation of the pancreas) did not contain a comprehensive nursing admission assessment or evidence that a fall risk assessment, functional assessment, skin and wound assessment, nutrition assessment, or learning needs assessment had been completed. The medical record did not contain, evidence of the status of advance directives, or a complete care plan.

e. The medical record for Patient #5, admitted on 02/16/17 for treatment of abdominal pain and Pyelonephritis (inflammation of the kidney), did not contain evidence of the status of advance directives, or a complete care plan.

d. The medical record for Patient #9, admitted on 12/03/16 for the treatment of left lobular pneumonia, did not contain evidence that a Physician History and Physical had been completed, or that a nursing care plan had been initiated or completed.

e. Patient 6 was admitted to the hospital's swing bed program on 01/19/17 and discharged on 02/15/17. The hospital could not locate or retrieve the patient's medical record from 01/19/17 through 01/22/17.

f. Patient #7, was admitted to the hospital's swing bed program 01/11/17 and discharged on 02/08/17. The hospital could not locate or retrieve the patient's medical record from 01/11/2017 through 01/23/17.

g. Patient #8, was admitted to the hospital's swing bed program 11/07/16 and discharged on 11/15/16. The hospital could not locate or retrieve the patient's medical record for the entire admission except for the physician's Admission History and Physical, the Physician Certification Statement and the Discharge Summary.

2. On 07/27/17 at 11:20 AM, during interview with the hospital's Director of Quality Improvement (Staff I), Staff I stated that the hospital had changed documentation systems in May 17. The missing medical records for the swing bed patients were the records from the prior electronic health record system (CPSI). Additionally, Staff I stated that the missing records were from the periods when the patient was in "certified swing bed status" for part of their admission or in "certified swing bed status" for all of their admission. Staff I was unable to locate or retrieve the missing medical records for Patients #6, #7, and #8.

3. On 07/27/17 at 3:36 PM, during interview with the Chief Nursing Officer (Staff J), the surveyor observed that the medical record for Patient #5 who had been admitted to the Acute Care Department did contain a comprehensive admission assessment which included assessment of pertinent history, communication status, current living conditions, activities of daily living, activity, safety, pain, fall risk, psycho-social evaluation, functional status, nutritional assessment and skin and wound risk. This patient's admission assessment had been completed in the previous electronic health record system (CPSI). The medical records for Patients #1, #2, #3, #4 had been completed in the new electronic health record (Athena) that was implemented in 05/17.

4. During the same interview above, Staff J confirmed that an initial nursing admission assessment had not been built in the new electronic health record system (Athena) and no patients admitted since the implementation in 05/17 would have a comprehensive initial admission assessment completed or documented in the electronic medical record.

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Based on administrative staff interview and review of medical record the Critical Access Hospital failed to ensure that staff could promptly retrieve medical records for every patient treated in any part of the hospital and that each patient's medical record was retained for at least six years per CMS requirements.

Failure to ensure a complete medical record is retained and can be easily retrieved by hospital personnel providing patient care puts patients at risk for unrecognized and unmet care needs, and inconsistent and unsafe care due to the lack of a complete and accurate information that is readily accessible to hospital personnel.

Findings included:

1. On 07/27/17 Surveyor #1 and the hospital's Director of Quality Improvement (Staff I)
reviewed the medical records of three patients who had been admitted and discharged from the Critical Access Hospital Swing Bed program (Patient #6, #7, #8). The review showed the following:

a. Patient #6 was admitted to the hospital's swing bed program on 01/19/17 and discharged on 02/15/17. The hospital could not locate or retrieve the patient's medical record from 01/19/2017 through 01/22/17.

b. Patient #7, was admitted to the hospital's swing bed program 01/11/17 and discharged on 02/08/17. The hospital could not locate or retrieve the patient's medical record from 01/11/2017 through 01/23/17.

c. Patient #8, was admitted to the hospital's swing bed program 11/07/16 and discharged on 11/15/16. The hospital could not locate or retrieve the patient's medical record for the entire admission except for the physician's Admission History and Physical, the Physician Certification Statement and the Discharge Summary.

2. On 07/27/17, at the time of the medical record review, the hospital's Director of Quality Improvement (Staff I) stated that the hospital had changed documentation systems in May 2017. The missing medical records were the records located in the prior system and specifically the records when the patient was in "certified swing bed status" for part of their admission or in "certified swing bed status" for all of their admission. Staff I was unable to locate or retrieve the missing records and confirmed all the findings above.

3. At this same time, Staff I was unable to locate or retrieve a policy and procedure guiding the systematic storage and retrieval processes for different electronic medical record systems. She stated that many policies were missing.

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Based on administrative staff interview, review of the hospital's quality assurance program, review of quality assurance documentation, and review of deficiencies cited during the current survey, the critical access hospital failed to complete an annual review and update of patient care policies, failed to develop a systematic process for tracking and evaluating action plans to improve hospital performance and failed to implement actions to address deficiencies identified through the quality assurance program. The cumulative effect of these systemic problems resulted in the critical access hospital's failure to meet the requirements for the Condition of Participation for Hospital Wide Periodic Evaluation and Quality Assurance Review.

Failure to develop and implement an effective quality assurance program impairs the facility's ability to provide quality care in a safe environment.

Reference: 485.641(b) "The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes."

Findings:

Cross-reference to C0331, C0333, C0334, C0335, C0336, C0337

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Based on interview, review of the hospital's quality assurance program, and review of quality assurance documentation, the Critical Access Hospital failed to perform an annual program evaluation.

Failure to perform an annual program evaluation impairs the hospital's ability to improve the quality of healthcare it provides to patients.

Findings included:

1. On 07/25/17 between 1:45 PM and 4:00 PM, Surveyor #1 reviewed the CAH's quality assurance program and quality assurance documentation. The review showed:

a. The hospital did not complete a CAH annual program evaluation for 2016.

b. The hospital did not complete a CAH annual program evaluation for 2015 until April of 2017.

2. At the time of the review, Surveyor #1 interviewed the hospital's Chief Executive Officer (Staff E) and the hospital's Director of Quality Improvement (Staff I). The interview revealed the following:

a. The hospital's Chief Executive Officer (Staff E) stated that no review for the year ending 2016 had been completed related to significant changes in administration, but that they are "working on pulling the data together."

b. The hospital's Director of Quality Improvement (Staff I) confirmed the findings above.

3. On 07/26/17 at 1:15 PM, Surveyor #1 interviewed the Chief Executive Officer (Staff E) about their quality program. The staff member stated that the governing body had not reviewed or approved the 2016-2017 Quality Plan.

3. On 07/26/17 at 1:15 PM, interview with the Chief Executive Officer (Staff E) revealed that the "Quincy Valley Medical Center 2016-2017 Quality Plan" had not been reviewed or approved by the governing body per the hospitals Quality Plan.

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Based on interview, review of the hospital's quality assurance program, and review of quality assurance documentation, the Critical Access Hospital failed to provide documentation of a comprehensive program evaluation that contained information from a representative sample of "open" and "closed" patient records.

Failure to document the inclusion of "open" and "closed" records places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings included:

1. The hospital provided a copy of an Annual Quality Program Evaluation for 2015. The annual review for 2015 contained no evidence that any open and closed records received a review, the outcomes of any record reviews, or service changes implemented because of the review.

2. The hospital failed to complete an Annual Quality Program evaluation for 2016. The 2016 Quality Program binder contained monthly line-itemed dashboard spreadsheets showing monthly chart review however, there is no evidence to show what was done with this information or actions taken when the data fell below goals set by the hospital.

3. On 07/25/17 at 2:00 PM, Staff I verified the above findings.

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Based on interview, document review, and review of policy and procedure, the Critical Access Hospital failed to review policies annually.

Failure to review and update patient care policies can result in unsafe and inappropriate care to patients.

Findings included:

1. The hospital policy titled, "Annual Review of Programs and Policies," Policy Reference # 8710-1000, Original Date: 04/04, Effective Date 09/01/17 showed that the hospital will annually evaluate its programs and policies.

2. From 07/25/17 through 07/28/17, Surveyor #1 reviewed 42 hospital policies. Of the 42 policies reviewed, 33 had exceeded at least one year since their last review.

3. On 07/27/17 at 10:15 AM, during an interview with the hospital's Director of Quality Improvement (Staff I), Staff #I confirmed the patient care policies were overdue for review. She stated that there were significant issues with policy review and updates, and due to staff turnover, several policies were completely missing.

4. On 07/27/17 at 3:36 PM, during an interview with the hospital's Chief Nursing Officer (Staff J), Staff J confirmed the patient care policies were overdue for review and many were missing.

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Based on interview, review of the hospital's quality assurance program, and review of quality assurance documentation the Critical Access Hospital (CAH) failed to aggregate and analyze data to determine if utilization of services was appropriate, that established policies were followed, and if any changes to the CAH program are needed as part of the annual program evaluation.

Failure to collect and analyze data on hospital services impairs the facility's ability to improve the quality of healthcare it provides to patients.

Findings:

1. Review of the Critical Access Hospital 2016 Quality Committee Binder showed monthly graphs of the number of patients and volume of services, and a list of items reviewed during clinical record audits. There was no evidence that the hospital had analyzed these items to determine whether utilization and delivery of CAH services was appropriate, that established policies and procedures had been followed, and whether changes to the CAH program were needed.

2. The 2016 Quality Committee Binder contained two abbreviated hand written minutes for the months of January and August. The Chief Executive Officer (Staff E) was able to retrieve three pages of typed minutes for the months of April, June, November and December each containing only three to five sentences of text and which did not reflect required elements above. The surveyor found no other evidence of the 2016 Quality Committee meeting minutes. The hospital held no Quality Improvement Committee meetings in January, February, May, June or July 2017. There were no documented meeting minutes for the March or April 2017 meetings.

3. On 07/25/17 between 1:45 PM and 4:00PM, at the time of the Quality Assurance review, Surveyor #1 interviewed the hospital's Chief Executive Officer (Staff E) and the hospital's Director of Quality Improvement (Staff I). The interview revealed the following:

-The hospital did not complete a CAH annual program evaluation for 2016.
-The hospital did not complete a CAH annual program evaluation for 2015 until April of 2017.
-The hospital's Chief Executive Officer (Staff E) stated that no review for the year ending 2016 had been completed related to significant changes in administration, but that they are "working on pulling the data together".

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Item #1 Tracking and Evaluating Services

Based on interview and review of the hospital's quality program, the Critical Access Hospital failed to develop a systematic process for tracking and evaluating patient care services affecting patient health and safety.

Failure to collect and analyze performance data on quality indicators puts patients at risk from unsafe or inappropriate care.

Findings included:

1. Review of the Critical Access Hospital's document, "Quincy Valley Medical Center 2016-2017 Quality Plan," Approved January 2017, showed that the document provides guidance for performance improvement projects at both an organizational and departmental level. The document included indicators drawn from both Federal and State quality initiatives. However, the hospital was unable to provide evidence of data analysis consistent with goals outlined in the hospitals, "Quincy Valley Medical Center 2016-2017 Quality Plan".

a. There was no evidence of data collected in aggregate for all goals in order to assess program compliance with quality measures identified in the 2016/2017 plan.

b. The hospital was unable to provide evidence of data analysis consistent with goals outlined in the hospital's, "Quincy Valley Medical Center 2016-2017 Quality Plan". There is evidence that there has been data collection but the data had been collected individually as line lists in each department, but there was no evidence of data collected in aggregate for all goals in order to assess program compliance with quality measures identified in the 2016/2017 plan.

2. There is no evidence the hospital is collecting, aggregating, analyzing, or implementing process improvement for Adverse Drug Reactions (ADR's). No pharmacy ADR reports could be located.

A Quality report document titled, "Acute Care Performance Indicators 2016 and 2017 shows zero charts audited in the section titled, "Adverse Health Outcomes." for all months reported from 05/16 through 01/17.

3. The hospital did not complete an annual Quality Program evaluation for 2016.

4. No Quality Improvement Committee meetings were held in January, February, May, June or July 2017. No meeting minutes were completed for the March or April 2017 meetings. There was no evidence of analysis of aggregate data, process improvement plan development or evaluation of action plans to improve hospital performance.

5. At the time of the review, the hospital's Director of Quality Improvement (Staff I) confirmed the findings above.

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Item #2

Based on interviews, and medical record review, the Critical Access Hospital failed to conduct ongoing assessment of its Emergency Department needs and capabilities in order to address policies, procedures, staffing, and training that might be needed.

Failure to conduct ongoing assessment of need and capability impairs the hospitals ability to meet the needs of patients in the emergency department and places patients at risk of harm related to lack of treatment or delays in treatment.

Findings include:

1. On 07/27/17, Surveyor #1 and the Quality Director (Staff #I) reviewed the medical record for Patient #12. The medical record review showed that Patient #12 was admitted to the Critical Access Hospital's Emergency Department on 05/28/17 at 7:45 PM for the treatment of Chest Pain.

a. On 05/28/17 at 8:25 PM, the patient was found unresponsive and emergency resuscitation (cardiopulmonary resuscitation (CPR)) was started.

b. The patient's medical record shows that at 8:31 PM, approximately 8 emergency personnel from Fire District 3 and 6 to 8 emergency personnel from Protection One arrived to the hospital. The emergency personnel were not employees of the Critical Access Hospital.

c. A nursing note entered at 9:35 PM shows that CPR and bagging continued throughout the code and was managed by hospital, Fire District 3, and Protection 1 staff. An intravenous catheter was placed and medication administration was managed by a paramedic throughout the event.

2. On 07/27/17 at 3:36 PM, Surveyor #1 interviewed the Chief Nursing Officer (Staff J) regarding the event described above. Staff J told Surveyor #1 the nurse was overwhelmed and called 911. Staff J told Surveyor #1 that the Paramedics and Ambulance staff are not supposed to give medications or do procedures until the hospital transfers care, but this had been an issue they (the Critical Access Hospital) were working on.

3. On 07/27/17 at 5:00 PM, Surveyor #1 and the Chief Executive Officer (Staff E) discussed the event described above. Staff E stated that the hospital considered the event an, "Internal Disaster" because they "don't have staff to surge." Staff J stated that the event had been discussed with Administrative Staff and the Governing Body. Surveyor #1 questioned Staff J if an Internal Disaster had been activated or if a Root Cause Analysis (A formal method of problem solving used for identifying the root causes problems/issues so that organizations can put processes in place or make changes that prevents the undesired event from recurring) had been completed. Staff J told Surveyor #1 that neither had occurred and there was no documentation.

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ITEM #1 Infection Control Program

Based on interview and document review , the Critical Access Hospital failed develop action plans for performance improvement measures identified as "not meeting goal" on the hospital's infection control reports.

Failure to develop and implement an effective infection control and prevention program risks transmission of communicable diseases to patients, staff, and visitors.

Findings included:

1. On 07/25/17 between 1:45 PM and 4:00 PM, Surveyor #1 reviewed the CAH's infection control data as part of their quality assurance program and quality assurance documentation. The review showed:

a.The hospital's infection control log for 2016 and January through March of 2017 showed performance improvement data in line items on the Infection Control report. The hospital could not locate any action plans to address the measures not meeting goal. Specific measures not meeting compliance for at least one reporting period included: hand hygiene, immunizations (TB, HPV, Influenza, MMR, Varicella, and T Dap), Antimicrobial Stewardship, and Personal Protective Equipment.

2. No Infection Control Committee meeting minutes were available for review.

3. At the same time of the review, Staff I confirmed the above findings.

Cross-refer to C0278

ITEM #2 Medication Errors

Based on interview and review of performance improvement documentation, the critical access hospital failed to systematically collect and assess medication errors for patterns and trends.

Failure to systematically assess medication errors limits the hospital's ability to prevent future errors and reduce risk of patient harm.

Findings included:

1. On 07/25/17 between 1:45 PM and 4:00 PM, Surveyor #1 reviewed the CAH's data on medication errors as part of their quality assurance program and quality assurance documentation. The review showed:

a. The quality improvement data for 2016 and January through April of 2017 contained no medication error data collection or analysis.

2. At the time of the review, Staff I confirmed the above findings.

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Based on observation, interview, record review, and review of hospital policies and procedures, the Critical Access Hospital failed to meet the requirements for the Condition of Participation for "Special Requirements for CAH Providers of Long-Term Care Services ("Swing Beds").

The hospital failed to complete comprehensive assessments and develop and implement plans of care for long-term care ("Swing Bed") patients; and failed to provide for social worker, activities and dental services.

The cumulative effect of these deficiencies resulted in the provision of substandard care to the hospital's long-term care residents. The Condition of Participation for: Long-Term Care Services was NOT MET.

Cross reference to C0361, C0377, C0385, C0386, C0388, C0395, C0402, C0404

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Based on interview and review of patient rights information, the Critical Access Hospital failed to develop a process for informing all patients of their rights as Long-Term Care ("Swing Bed") patients according to Federal regulations.

Failure to inform all patients of their rights limits the patient's ability to exercise those rights.

Reference: 42 CFR §483.10(b) Notice of Rights and Services
(1) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under section 1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing;

Findings included:

1. The Critical Access Hospital's policy titled, "Patient Rights and Responsibilities," Effective date: 04/30/02, did not address the patient's right to work for the facility or refuse to do so, the patient's right to mail privacy and access to supplies for written communication, right to retain and use personal possessions, or the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement The critical Access Hospital did not have a process in place to provide a separate set of Resident Rights once patients transferred to a Swing Bed status.

2. On 07/27/17 from 10:15 AM through 12:00 PM Surveyor #1 and the Director of Quality (Staff #KMB) reviewed the medical records for three patients admitted to the Critical Access Hospital's "Swing Bed" program. The medical record review showed no evidence the patients were advised of their patient rights on admission to the hospital's "Swing Bed" program for 3 of 3 patient records reviewed (Patients #6, #7, and #8).

3. At the time of the review, the Director of Quality (Staff I) confirmed the findings above and told Surveyor #1 the hospital did not have a Patient Rights Policy specific to the "Swing Bed" program. She stated that the hospital had a policy at one time, but most of the policies and procedures for the "Swing Bed" program are missing.

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Based on record review and interview the facility failed to demonstrate that it notified swing bed residents in writing about discharge plans prior to discharge for 3 of 3 medical records reviewed (Patients #6, #7, and #8).

Failure to do so creates risk that residents may not have the opportunity to participate in their discharge plans including, but not limited to, appealing the plan developed by the facility.

Findings:

1. Review of the hospitals policy and procedure titled, "Patient Discharge," Effective date: 07/10 states that social services will prepare and communicate discharge notifications as appropriate.

2. On 07/27/17 from 10:15 AM through 12:00 PM , Surveyor #1 and the Director of Quality (Staff #I) reviewed the medical records for three patients admitted to the Critical Access Hospital's "Swing Bed" program. The medical record review showed the following:

a. Patient #6 was admitted to the hospital's swing bed program on 01/19/17 and discharged on 02/15/17. The hospital could not locate or retrieve the patient's medical record from 01/19/2017 through 01/22/17. The surveyor found no evidence the patient had received written notification about their discharge plan prior to discharge.

b. Patient #7, was admitted to the hospital's swing bed program 01/11/17 and discharged on 02/08/17. The hospital could not locate or retrieve the patient's medical record from 01/11/2017 through 01/23/17. The surveyor found no evidence the patient had received written notification about their discharge plan prior to discharge.

c. Patient #8, was admitted to the hospital's swing bed program 11/07/16 and discharged on 11/15/16. The hospital could not locate or retrieve the patient's medical record for the entire admission except for the physician's Admission History and Physical, the Physician Certification Statement and the Discharge Summary. The surveyor found no evidence the patient had received written notification about their discharge plan prior to discharge.

3. On 07/27/17, at the time of the record review, the Quality Director (Staff I) confirmed the findings above.

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Based on record review and interview, the Critical Access Hospital failed to ensure that staff members developed and implemented an activity program for 3 of 3 "Swing Bed" patients reviewed (Patients #6, #7, #8).

Failure to develop and implement an activities plan for swing bed patients risks impairment of physical, mental, and psychosocial well-being.

1. On 07/27/17 from 10:15 AM through 12:00 PM , Surveyor #1 and the Director of Quality (Staff I) reviewed the medical records for three patients admitted to the Critical Access Hospital's "Swing Bed" program (Patients #6, #7, #8). The record review showed there was no evidence in the patient's medical record that a comprehensive activities assessment was performed.

2. On 07/27/17, at the time of the record review, the Quality Director (Staff I) confirmed the findings above. Staff I told Surveyor #1 the hospital could not provide the services required for "Swing Bed" patient's and the hospital made the decision in February 2017 to not admit patient's to this program. Staff I was unable to locate the Patient Activities policy. Staff I confirmed the missing "Swing Bed" patient care policies.

3. On 07/26/17 at 1:15 PM Surveyor #1 interviewed the Chief Executive Officer (Staff E) and the Quality Director (Staff I) about the hospitals "Swing Bed" program. Staff E and Staff I told Surveyor #1 the "Swing Bed" program had no qualified Activities/Recreation Director.

a. At the time of this interview, the Chief Executive Officer confirmed the Critical Access Hospital had not been admitting patient's to the "Swing Bed" program because the hospital could not provide the required services.

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Based on interview, the Critical Access Hospital failed to provide social services by a qualified social worker holding a Bachelor's degree in social work or other human services field for 3 of 3 swing bed patients reviewed (Patients 6, 7, and 8).

Failure to provide social services by a qualified social worker risks a patient's ability to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Findings included:

1. On 07/26/17 at 1:15 PM Surveyor #1 interviewed the Chief Executive Officer (Staff E) and the Quality Director (Staff I) about the hospitals "Swing Bed" program. Staff E and Staff I told Surveyor #1 the "Swing Bed" program social services were being provided by the Quality Director (Staff I). At the time of this interview, Staff I stated that she holds an Associate Degree in Nursing and did not hold any type of Bachelor Degree.

2. At the time of this interview, the Chief Executive Officer (Staff E) confirmed the Critical Access Hospital had not been admitting patient's to the "Swing Bed" program because the hospital could not provide the required services.

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Based on interview, record review, and review of hospital policies and procedures, the critical access hospital failed to conduct an interdisciplinary comprehensive assessment of the healthcare needs of 3 of 3 "Swing Bed" patients medical records reviewed (Patients #6, #7, and #8).

Failure to perform a comprehensive assessment of a resident's healthcare needs and develop an individualized plan of care according to assessment findings can result in the inappropriate, inconsistent, or delayed treatment

Findings included:

1. The Critical Access Hospital's policy titled, "Swing Bed Comprehensive Policy," Effective date: 11/01/14, showed a comprehensive assessment must be completed within 14 calendar days from admission and include at minimum identification and demographic information, customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, physical functioning and structural problems, continence, disease diagnoses and health conditions, dental and nutritional status, skin condition, activity pursuit, medications, special treatments and procedures, discharge potential, documentation of summary information regarding the additional assessment performed through the resident assessment protocols, documentation of participation in assessment.

2. On 07/27/17 from 10:15 AM through 12:00 PM , Surveyor #1 and the Director of Quality (Staff I) reviewed the medical records for three patients admitted to the Critical Access Hospital's "Swing Bed" program. The medical record review showed the following:

a. Patient #6 was admitted to the hospital's swing bed program on 01/19/17 and discharged on 02/15/17. The hospital could not locate or retrieve the patient's medical record from 01/19/2017 through 01/22/17. The surveyor found no evidence the Critical Access Hospital performed an initial comprehensive assessment.

b. Patient #7, was admitted to the hospital's swing bed program 01/11/17 and discharged on 02/08/17. The hospital could not locate or retrieve the patient's medical record from 01/11/2017 through 01/23/17. The surveyor found no evidence the Critical Access Hospital performed an initial comprehensive assessment.

c. Patient #8, was admitted to the hospital's swing bed program 11/07/16 and discharged on 11/15/16. The hospital could not locate or retrieve the patient's medical record for the entire admission except for the physician's Admission History and Physical, the Physician Certification Statement and the Discharge Summary. The surveyor found no evidence the Hospital performed an initial comprehensive assessment.

3. On 07/27/17, at the time of the record review, the Quality Director (Staff I) confirmed the findings above.

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Based on interview, record review and review of hospital policies and procedures, the critical access hospital failed to develop an individualized nursing care plan for patient care for 3 of 3 "Swing Bed" patients reviewed (Patients #6, #7, and #8).

Failure to develop an individualized plan of care that includes care interventions can result in the inappropriate, inconsistent or delayed treatment of patient's needs.

Findings included:

1. The hospital's policy and procedure titled, "Swing Bed Comprehensive Care Planning," (Effective date: 11/01/14), states that a comprehensive care plan will be initiated upon admission and completed within 7 days following the comprehensive assessment.

2. On 07/27/17 from 10:15 AM through 12:00 PM, Surveyor #1 and the Director of Quality (Staff #KMB) reviewed the medical records for three patients admitted to the Critical Access Hospital's "Swing Bed" program. The medical record review showed the following:

a. Patient #6 was admitted to the hospital's swing bed program on 01/19/17 and discharged on 02/15/17. The hospital could not locate or retrieve the patient's medical record from 01/19/17 through 01/22/17. The surveyor found no evidence the Hospital initiated a comprehensive care plan on admission.

b. Patient #7, was admitted to the hospital's swing bed program 01/11/17 and discharged on 02/08/17. The hospital could not locate or retrieve the patient's medical record from 01/11/2017 through 01/23/17. The surveyor found no evidence the Hospital initiated a comprehensive care plan on admission.

c. Patient #8, was admitted to the hospital's swing bed program 11/07/16 and discharged on 11/15/16. The hospital could not locate or retrieve the patient's medical record for the entire admission except for the physician's Admission History and Physical, the Physician Certification Statement and the Discharge Summary. The surveyor found no evidence the Hospital initiated a comprehensive care plan on admission.

3. On 07/27/17, at the time of the record review, the Quality Director (Staff I) confirmed the findings above.

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Based on interview, the Critical Access Hospital did not provide speech-language and occupational therapy services.

Failure to provide specialized rehabilitative services including speech-language and occupational therapy risks a patient's ability to attain or maintain the highest practicable physical, mental and psychosocial well-being.

Findings included:

1. On 07/27/17 from 10:15 AM through 12:00 PM, Surveyor #1 and the Director of Quality (Staff I) reviewed the medical records for three patients admitted to the Critical Access Hospital's "Swing Bed" program. At the time of the record review, the Quality Director (Staff I) told Surveyor #1 that the hospital did not provide specialized rehabilitative services including speech-language and occupational therapy and there was no contracted services available to perform these services.

2. On 07/26/17 at 1:15 PM Surveyor #1 interviewed the Chief Executive Officer (Staff E) and the Quality Director (Staff #I) about the hospitals "Swing Bed" program. The Chief Executive Officer confirmed the Critical Access Hospital had not been admitting patient's to the "Swing Bed" program because the hospital could not provide the required services.

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Based on interview, the Critical Access Hospital did not have a policy and procedure for assisting Swing Bed patients to obtain dental care as needed.

Failure to assist residents to obtain dental care risks oral injury and malnutrition related to impaired ability to eat.

Findings:

1. On 07/27/17 from 10:15 AM through 12:00 PM, Surveyor #1 and the Director of Quality (Staff I) reviewed the medical records for three patients admitted to the Critical Access Hospital's "Swing Bed" program. At the time of the record review, the Quality Director (Staff I) told Surveyor #1 that the hospital did not have a policy and procedure for assisting "swing bed" patients obtain dental care and the hospital did not have a service or a contracted service that could provide dental services for patients in the "Swing Bed" program.

2. On 07/26/17 at 1:15 PM Surveyor #1 interviewed the Chief Executive Officer (Staff E) and the Quality Director (Staff I) about the hospitals "Swing Bed" program. The Chief Executive Officer confirmed the Critical Access Hospital had not been admitting patient's to the "Swing Bed" program because the hospital could not provide the required services.