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Observation with the Surgical Supervisor on 3/16/11 at 2:00 PM revealed the Critical Access Hospital (CAH) failed to ensure the environments in the operating scrub area, operating procedure room, operating room, recovery room, and dirty utility room were in good repair. The CAH is licensed for 21 beds and had a census of 5 patients upon survey entrance. Findings include:

A. The walls located in the surgical scrub area are marred and have numerous holes exposing the underlying surfaces and lacks paint to ensure proper cleaning.

B. Two (2) wooden doors measuring approximately 7 foot X 36 inches that accommodate staff and patient entrances from the scrub area into the procedure and operating room have numerous deep marring and chipping on the inside and outside of the doors exposing the underlying wood which lacks the manufacturer's finish and does not allow for proper cleaning.

C. The procedure room south wall has compound filling hole in wall, but lacks a painted finish for proper cleaning.

D. The procedure room has a total of 11 white double plastic covered overhead fluorescent lights. 2 of the double fluorescent lights have what appears to be dead bugs on the inside of the plastic coverings.

E. The Operating Room has a total of 14 double plastic covered fluorescent lights. 3 of the plastic covers are discolored and appear yellow with a blackened substance on the lining. Interview with the surgical supervisor stated "wasn't sure what the black substance was and the discoloration on the plastic light coverings could have been from when the roof leaked." The trim areas around the overhead lights have several areas where the paint and wall finish is peeling and chipping, exposing the underlying wall surface. The east wall has an approximate 2 foot scrape exposing the underlying plaster and lacks paint for proper cleaning.

F. The cleaning/storage closet in the North/South hallway in the operating room area has numerous wall cracks and paint chipping, which impedes the ability to properly clean the room. The tile surrounding the dump sink is stained and discolored, making it unable to determine the actual color of the tile. The tile lacks a manufacturer's finish which does not allow for proper cleaning

G. 2 white overhead plastic-covered fluorescent lights located in the recovery room have an unidentified black substance. Interview with the Operating Supervisor acknowledged the areas identified as "in need of attention in the procedure room, recovery room and operating room."

Based on a review of the Medical Staff Rules and Regulations, Medical Staff reappointment and performance history, staff interviews, and patient medical record reviews, the Governing Body failed to enforce the Medical Staff Rules and Regulations, as written. The Critical Access Hospital reported a current census of 5 patients on the first survey day (3/14/2011) and an average daily census for the past fiscal year of 3.0. Findings include:

A. The Medical Staff Rules and Regulations, pages 7 & 8 Section 4. Medical Records part M states, "Delinquent Charts. The entire medical record shall be completed within thirty (30) days following the patient's discharge. If the record remains incomplete thirty (30) days after discharge, or if any part of the record is otherwise delinquent, the Administrator or the President of the Medical Staff, or their designee, shall notify the practitioner in writing that his or her clinic privileges, including admitting privileges, will be automatically suspended five (5) days from the date of the notice, unless the practitioner completes the records within such period of provides evidence and the Executive Committee concurs that there is good cause for such delinquency. The Administrator shall notify the Executive Committee of the delinquency and suspension of privileges and shall notify the Hospital admissions office of the suspension."

B. On 3/16/11 at 1:00 PM the Health Information Department Manager reported 3 of 6 active medical staff members currently had delinquent medical records. Furthermore, the practitioners had not been notified of the delinquencies, nor had they received notice of suspension of privileges. Examples:
- Practitioner B should have been suspended 2/18/11; however, treated 49 patients from 2/18/11 to 3/16/11.
- Practitioner E should have had his privileges suspended 2/7/11; however, treated 36 patients from 2/7/11 to 3/16/11.
- Practitioner F should have been suspended 3/9/11; however, treated 34 patients from 3/9/11 to 3/16/11.

C. Interviews with the Administrator and the Health Information Department Manager on 3/16/11 at 3 :00 PM confirmed the letters notifying practitioners of suspension had not been initiated.

Based on record review and staff interview, the Critical Access Hospital failed to include all the required members for the Patient Care Policy Review Committee.

The hospital reported 5 patients on the first survey day of 3/14/11 and an annual average daily census of 3.0 for the most recent fiscal year. Findings include:

A. A review of the past 2 annual program evaluations lacked evidence of an outside community member in attendance for the Patient Care Committee Policy Review.

B. Interview with the Quality Assurance Coordinator on 3/17/11 at 2:50 PM confirmed the lack of an outside member of the committee.

Based on staff interviews and a lack of written evidence, the Critical Access Hospital failed to include all the required elements in the infection prevention program. The census was 5 patients on 3/14/11, the first survey day and the hospital reported an average daily census of 3.0 for the most recent fiscal year. Findings include:

A. A review of surveillance records for 2010 lacked data regarding monitoring direct patient care personnel for good hand hygiene practices.

B. Interview with the Director of Infection Prevention for the hospital confirmed the program lacked monitoring of direct care staff for hand hygiene practices.

Based on staff interviews and review of Medical Records completion information and the Medical Staff Rules and Regulations, the Critical Access Hospital (CAH) failed to ensure 48 medical records were completed within 30 days of patients' discharge dates as required in the Medical Staff Rules and Regulations. The CAH is licensed for 21 beds and had a census of 5 patients upon survey entrance. Findings include:

A. Review of the Medical Staff Rules and Regulations, Revised 2000, (Page 7) Section 4 entitled Medical Records part M reads: "Delinquent Charts. The entire medical record shall be completed within thirty (30) days following the patient's discharge..."

B. Interview with the Health Information Manager (HIM) and review of medical records completion information on 3/15/11 at 11:00 AM identified the CAH had a total of 48 delinquent medical records that were not considered to be complete due to a lack of physician signatures, physician reports, and nurses' signatures. Review of medical record completion information showed that of the 48 delinquent medical records, 26 records were incomplete due to a lack of nurses' signatures.