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Based on review of Medical Staff Bylaws, review of policies and procedures, review of Medical Staff and Board of Directors meeting minutes, review of credential files, review of an e-mail from the Network Hospital, and staff interview, the Board of Directors failed to ensure the Medical Staff Bylaws were followed in regards to:
A. Allowing 2 of 10 physicians reviewed to perform procedures/services that the Board of Directors had not granted to these physicians (Physicians P and W);
B. Board of Directors review and approval of initial appointment for 1 of 2 physicians reviewed for initial appointment (Physician P);
C. Medical Staff review with recommendation for reappointment and Board of Directors approval for reappointment of physicians every 2 years for 8 of 8 physicians reviewed for reappointment (Physicians N, O, Q, R, S, T, U and V); and,
D. Querying the National Practitioner Data Bank for 9 of 10 Physicians reviewed (Physicians N, O, Q, R, S, T, U, V and W).

This failed practice has the potential to affect all patients treated by active, radiology and courtesy members of the medical staff at the CAH. The roster of Medical Staff provided by the CAH (Critical Access Hospital) listed 7 Active Staff, 28 Courtesy Staff, and 73 Radiologists. The total number of patients admitted for fiscal year ending 9/30/12 was 774.

Findings are:

A. Review of the Medical Staff Bylaws approved by the Board of Directors on 2/26/2007 under Article VI Clinical Privilege, Section 6.1 Nature of privileges revealed the following:
"Privileges to practice at the Hospital are granted by the Board following recommendation of the Medical Staff....A practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws."

The CAH allowed Physician P to perform a myringotomy with placement of ventilation tube, tonsillectomy and adenoidectomy when review of the credential file for this physician revealed no privileges for these procedures (Refer to C241 Example A - 1). The CAH also allowed Physician W to interpret an MRI diagnostic study when review of the credential file for this physician revealed no privileges for MRI interpretation (Refer to C241 Example A - 2).

B. Review of the Medical Staff Bylaws approved by the Board of Directors on 2/26/07 under Article IV Membership revealed the following:
"Membership on the Medical Staff, including assignment of one of the staff categories, is recommended by the Medical Staff and granted by the Board....Each member must, as a condition for membership, hold clinical privileges under these Bylaws."

Further review of the Medical Staff Bylaws under Article VIII Appointment and Privileging revealed the Executive Committee of the Medical Staff has 60 days to review the physician application for appointment. If the Executive Committee makes a recommendation for granting of privileges the Board of Directors must take action at its next regular meeting. "

Review of the Medical Staff meeting minutes dated 11/14/12 revealed Physician P was recommended for granting of privileges for surgeries and clinic. Review of the first meeting minutes of the Board of Directors after the 11/14/12 Medical Staff meeting revealed a date of 12/27/12 and revealed no information concerning the Boards action on the recommendation from the Medical Staff for granting of privileges to Physician P. Interview with the CEO (Chief Executive Officer) on 12/10/13 when asked about the lack of documentation of the Board of Directors taking action on Physician P's application stated "I must have forgotten to take it to the Board".

C. Review of the Medical Staff Bylaws approved by the Board of Directors on 2/26/07 under Article VIII Appointment and Privileging, Section 8.3 Duration of Appointment revealed "Reappointments shall be considered by the Board every two (2) years." Further review of the Medical Staff Bylaws under Article VIII Appointment and Privileging, Section 8.5 Reappointment/Renewal Process revealed:
"On or before September 1st every other year, each practitioner with clinical privileges at the Hospital must submit to the Administrator a signed, completed application for reappointment and renewal of privileges....The Administrator will then transmit copies of the completed application and all supporting materials to the Executive Committee....the Executive Committee will generally complete its review and transmit its recommendation within thirty (30) days....Upon receipt of a complete, timely application for reappointment, the existing membership and privileges will remain effective until final action by the Board ...."

Interview with the CEO on 11/10/13 at 11:00 AM revealed that physician reappointments were taken to the Governing Body in October of 2012. Review of credential files for Physicians N, O, Q, R, S, T, U and V on 12/10/13 with the HIM (Health Information Management) Supervisor from 8:30 AM to 10:30 AM revealed no information in the electronic credential files concerning the last date the Medical Staff reviewed and recommended approval for reappointment or when the Board of Directors reappointed the physicians. Review of the Medical Staff meeting minutes dated 10/12/13 revealed no information about review and recommendation of physicians for reappointment. Interview with the HIM Supervisor on 12/10/13 at 2:40 PM confirmed the lack of documentation that the physicians reviewed and made recommendation for reappointment of physicians to the medical staff. Further interview with the HIM Supervisor on 12/10/13 at 3:00 PM revealed having reviewed other Medical Staff meeting minutes and could find no documentation of approval for recommending reappointment of physicians in 2012.

Review of the Annual Meeting minutes for the Board of Directors with the date of 10/29/12 and the date of 10/27/13 in the first paragraph, revealed approval of "agenda items listed as items a. through j." The agenda for the Annual Meeting in 2012 had a date of 10/24/12 and documentation after item i. of "Motion to approve the Medical Staff, Medical Staff Privileges, and Medical Staff Appointments". However, there was no listing available for which physicians were approved for appointment/reappointment. (Refer to C241 Example C)

D. Review of an undated policy and procedure titled "Credentialing New Physicians" revealed the following under procedure 5 "The National Practitioner Data Bank must be queried."

Review of the Medical Staff Bylaws approved by the Board of Directors on 2/26/07 under Article VIII Appointment and Privileging, Section 8.5 Reappointment/Renewal Process, 8.5.2 Information revealed:
"In reviewing applications for reappointment and renewal of privileges, the Executive Committee and Board will not be limited to review of information supplied within or in support of the application, but may review and consider any other records and information deemed relevant to their review....National Practitioner Data Bank..."

Review of the credential files for Physicians N, O, Q, R, S, T, U, V and W with the HIM Supervisor on 12/10/13 from 8:30 AM to 10:30 AM revealed these credential files contained no copy of a query to the NPDB (National Practitioner Data Bank). During this review the HIM Supervisor indicated that the Network Hospital (hospital contracted to do credentialing verification for the CAH) usually provides a copy of this query when they are completing the credential verification for physicians. The HIM Supervisor provided a copy of the e-mail received from the Network Hospital that stated "Chadron Community Hospital allowed their NPDB to expire on December 9, 2011...."

The Web Site at www.npdb-hipdb.hrsa.gov/topNavigation/aboutUs.jsp gave the following information about the NPDB. The NPDB was created by Congress as a confidential information clearing house with the primary goals of improving health care quality, protecting the public and reducing health care fraud and abuse in the United States. Information currently collected and disclosed by the NPDB includes: state licensure and certification actions against health care practitioners; negative actions or findings by peer review organizations; certain final adverse actions taken by state law enforcement agencies, State Medicaid Fraud Control units, and state agencies administering or supervising the administration; and information on medical malpractice payments.

Based on review of Medical Staff Bylaws, review of policies and procedures, review of Medical staff and Board of Directors meeting minutes, review of medical records, review of an e-mail from Network Hospital, review of credential files and staff interview, the Governing Body failed to ensure Medical Staff Bylaws and credentialing policy and procedures were followed in regards to:
A. Allowing 2 of 10 physicians reviewed to perform procedures/services that the Board of Directors had not granted to these physicians (Physicians P and W);
B. Board of Directors review and approval of initial appointment for 1 of 2 physicians reviewed for initial appointment (Physician P);
C. Medical Staff review with recommendation for reappointment and Board of Directors approval for reappointment of physicians every 2 years for 8 of 8 physicians reviewed for reappointment (Physicians N, O, Q, R, S, T, U and V); and,
D. Failed to query the National Practitioner Data Bank for 9 of 10 Physicians reviewed (Physicians N, O, Q, R, S, T, U, V and W).

This failed practice has the potential to affect all patients treated by active, radiology and courtesy members of the medical staff at the CAH. The roster of Medical Staff provided by the CAH (Critical Access Hospital) listed 7 Active Staff, 28 Courtesy Staff and 73 Radiologists. The total number of patients admitted for fiscal year ending 9/30/12 was 774.

Findings are:

A. Review of the Medical Staff Bylaws approved by the Board of Directors on 2/26/07 under Article VI Clinical Privilege, Section 6.1 Nature of privileges revealed the following:
"Privileges to practice at the Hospital are granted by the Board following recommendation of the Medical Staff....A practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws."

The CAH allowed the following 2 physicians to perform procedures/services that the physicians had not requested and the Board of Directors had not granted.

1. Review of an ENT (Ears, Noses, Throat) Operative Note from Medical Record 29 dated 11/19/13 revealed Physician P performed a bilateral myringotomy with placement of ventilation tubes (surgery where small tubes are placed into the eardrum to help drain the fluid out of the middle ear in order to reduce the risk of ear infections). Review of a Speciality Operative Note from Medical Record 43 dated 11/5/13 revealed Physician P performed a "Tonsillectomy/adenoidectomy with placement of bilateral myringotomy tubes with ventilation tubes (Tonsillectomy - removal of the tonsil - two oval-shaped pads of tissue at the back of the throat, one tonsil on each side; Adenoidectomy - removal of the adenoids - mass of tissue located behind the nose). Review of the credential file for Physician P revealed a Delineation of Surgical Privileges Desired form that was signed by Physician P and dated 9/26/13. Review of this Privilege form revealed Physician P had not requested surgical privileges for Adenoidectomy, Myringotomy and Tonsillectomy.

2. Review of a report for an MRI (Magnetic Resonance Imaging - a test that makes pictures of organs and structures inside the body) from Medical Record 44 dated 11/14/13 revealed Physician W interpreted this MRI. Review of the credential file for Physician W revealed a Delineation of Radiological Procedures that was dated 1/18/13. Review of this privilege form revealed Physician W had not requested the privilege to interpret MRI studies.

B. Review of the Medical Staff Bylaws approved by the Board of Directors on 2/26/07 under Article IV Membership revealed the following:
"Membership on the Medical Staff, including assignment of one of the staff categories, is recommended by the Medical Staff and granted by the Board....Each member must, as a condition for membership, hold clinical privileges under these Bylaws."
Further review of the Medical Staff Bylaws under Article VIII Appointment and Privileging revealed the Executive Committee of the Medical Staff has 60 days to review the physician application for appointment. If the Executive Committee makes a recommendation for granting of privileges the Board of Directors must take action at its next regular meeting.

Review of the Medical Staff meeting minutes dated 11/14/12 revealed Physician P was recommended for granting of privileges for surgeries and clinic. Review of the 3-ring binder with Board of Director Meeting minutes revealed no meeting was held in November of 2012. The next meeting minutes were dated 12/27/12. Review of the entire meeting minutes revealed no information concerning the Board's action on the recommendation from the Medical Staff for granting of privileges to Physician P. Interview with the CEO (Chief Executive Officer) on 12/10/13 at 11:00 AM when asked about the lack of documentation of the Board of Directors taking action on Physician P's application stated "I must have forgotten to take it to the Board".

C. Review of the Medical Staff Bylaws approved by the Board of Directors on 2/26/07 under Article VIII Appointment and Privileging, Section 8.3 Duration of Appointment revealed "Reappointments shall be considered by the Board every two (2) years."
Further review of the Medical Staff Bylaws under Article VIII Appointment and Privileging, Section 8.5 Reappointment/Renewal Process revealed:
"On or before September 1st every other year, each practitioner with clinical privileges at the Hospital must submit to the Administrator a signed, completed application for reappointment and renewal of privileges....The Administrator will then transmit copies of the completed application and all supporting materials to the Executive Committee....the Executive Committee will generally complete its review and transmit its recommendation within thirty (30) days...."

Review of credential files on 12/10/13 with the HIM (Health Information Management) Supervisor from 8:30 AM to 10:30 AM revealed no information in the electronic credential files concerning the last date the Board of Directors reappointed Physicians N, O, Q, R, S, T, U and V. The HIM Supervisor during this review indicated that these physicians were all reappointed in October of 2012. Interview with the CEO on 12/10/13 at 11:00 AM confirmed that physician reappointments were taken to the Governing Body in October of 2012.

Review of the Medical Staff meeting minutes dated 10/12/13 revealed no information about review and recommendation of physicians for reappointment. Interview with the HIM Supervisor on 12/10/13 at 2:40 PM confirmed the lack of documentation that the physicians reviewed and made recommendation for reappointment of physicians to the medical staff. Further interview with the HIM Supervisor on 12/10/13 at 3:00 PM revealed having review other Medical Staff meeting minutes and could find no documentation of approval for recommending reappointment of physicians in 2012.

Review of the Board of Director Meeting minutes revealed 2 meeting minutes both dated 10/29/12. Review of the minutes titled "Minutes Chadron Community Hospital and Health Services October 29, 2012" revealed no information concerning reappointment of physicians to the Medical Staff. The second set of meeting minutes titled "Minutes Chadron Community Hospital Corporation Annual Meeting October 29, 2012" had a discrepancy as the first paragraph in these meeting minutes states "THE REGULAR ANNUAL MEETING OF THE MEMBERS OF THE CHADRON COMMUNITY HOSPITAL CORPORATION WAS HELD...ON OCTOBER 27th, 2013". Review of these meeting minutes revealed no mention of reappointment of physicians to the Medical Staff. Interview with the Administrative Assistant (duties including keeping minutes of the Board of Directors) on 12/10/13 at 11:45 AM revealed:
1. Paragraph in the meeting minutes that was titled Annual Meeting that stated "All items as listed on the Official Agenda of the Annual Meeting of the Corporation were actively discussed with ample time dedicated to questions as presented by the Board and Corporation Members. Motion was presented by [name of a Board Member] to approve all agenda items listed as items a. through j. as presented....motion approved"
2. Provided a copy of the agenda and pointed out item VI - i. which stated "Motion to approve the Medical Staff, Medical Staff Privileges, Medical Staff Appointments..."
Further review of the Agenda revealed it was for the Annual Meeting of the Chadron Community Hospital Corporation but had a date of October 24, 2012.

A request was made for a list of the physicians that would have been reappointed at this meeting; however, no list was available. Interview with the HIM Supervisor on 12/10/13 at 2:40 PM confirmed that no list is made of physicians who are being reappointed for Medical Staff meeting or Board of Directors meetings.

There was no way to verify when Physicians N, O, Q, R, S, T, U and V were last reviewed by the Medical Staff and reappointed by the Board of Directors due to the discrepancies in the Board meeting minutes and lack of documentation of which physicians were being reviewed.

D. Review of an undated policy and procedure titled "Credentialing New Physicians" revealed the following under procedure 5 "The National Practitioner Data Bank must be queried."

Review of the Medical Staff Bylaws approved by the Board of Directors on 2/26/07 under Article VIII Appointment and Privileging, Section 8.5 Reappointment/Renewal Process, 8.5.2 Information revealed:
"In reviewing applications for reappointment and renewal of privileges, the Executive Committee and Board will not be limited to review of information supplied within or in support of the application, but may review and consider any other records and information deemed relevant to their review....National Practitioner Data Bank..."

Review of the credential files for Physicians N, O, Q, R, S, T, U, V and W with the HIM Supervisor on 12/10/13 from 8:30 AM to 10:30 AM revealed these credential files contained no copy of a query to the NPDB (National Practitioner Data Bank). During this review the HIM Supervisor indicated that the Network Hospital usually provides a copy of this query when they are completing the credential verification for physicians. The HIM Supervisor provided a copy of the e-mail dated 12/10/13 received from the Network Hospital (Hospital that is contracted to completed the credential verification process) that stated "Chadron Community Hospital allowed their NPDB to expire on December 9, 2011...."

Based on review of credential files, review of medical records and staff interview, the CAH (Critical Access Hospital) failed to ensure that 1 of 5 physicians reviewed for surgical procedures, performed surgery within their granted privileges (Physician P). The CAH had 12 physicians on staff that performed surgical procedures. Total surgeries performed for the fiscal year 2012-2013 was 527.

Findings are:

A. Review of an ENT (Ears, Noses, Throat) Operative Note from Medical Record 29 dated 11/19/13 revealed Physician P performed a bilateral myringotomy with placement of ventilation tubes (surgery where small tubes are placed into the eardrum to help drain the fluid out of the middle ear in order to reduce the risk of ear infections). Review of a Speciality Operative Note from Medical Record 43 dated 11/5/13 revealed Physician P performed a "Tonsillectomy/adenoidectomy with placement of bilateral myringotomy tubes with ventilation tubes (Tonsillectomy - removal of the tonsil - two oval-shaped pads of tissue at the back of the throat, one tonsil on each side; Adenoidectomy - removal of the adenoids - mass of tissue located behind the nose).

B. Review of the credential file for Physician P revealed a Delineation of Surgical Privileges Desired form that was signed by Physician P and dated 9/26/13. Review of this Privilege form revealed Physician P had not requested surgical privileges for Adenoidectomy, Myringotomy and Tonsillectomy.

C. Interview with the Director of Surgical Services on 12/10/13 at 10:45 AM revealed the following:
- Physician P had performed surgical procedures on only 2 patients; and
- Lacked a copy of Physician P's privilege list in the surgical area; and,
- Was not aware that Physician P had requested no privileges.

Based on medical record review, review of policy and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure:

1. That the physician' document their examinations of the patients immediately before surgery to evaluate the risk of the procedure to be performed for 6 of 11 discharged surgical records (13, 14, 15, 16, 26 and 27) reviewed; and
2. That the qualified practitioner documented the evaluation for proper anesthesia recovery for 11 of 11 discharged surgical records (13, 14, 15, 16, 17, 26, 27, 28, 29, 30 and 31) reviewed.

This failed practice had the potential to affect all surgical patients of the CAH. Total surgeries performed for the fiscal year 2012-2013 was 527.

Findings are:

I. The facility failed to ensure documentation of patient examinations by a physician immediately before surgery to evaluate the risk of the procedures to be performed as evidenced by:

A. Review of Medical Record 13 on 12/3/13 at 8:30 AM revealed the patient had an appendectomy done on 11/25/13. Review of the form titled Pre-Operative Evaluation By Physician revealed that the form lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 14 on 12/3/13 at 9:00 AM revealed the patient had a postpartum tubal ligation done on 5/12/13. Review of the entire medical record revealed that the record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 15 on 12/3/13 at 9:35 AM revealed the patient had an excision (removal by cutting) of proximal (near center of body) and ascending (moving up) colon done on 10/9/13. Review of the form titled Pre-Operative Evaluation By Physician revealed that the form lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 16 on 12/3/13 at 10:10 AM revealed the patient had a splenectomy done on 10/23/12. Review of the entire medical record revealed that the record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 26 on 12/3/13 at 11:00 AM revealed the patient had a hemorrhoidectomy done on 9/30/13. Review of the entire medical record revealed that the record lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 27 on 12/3/13 at 11:20 AM revealed the patient had a mesh repair of indirect left inguinal hernia done on 11/11/13. Review of the form titled Pre-Operative Evaluation By Physician revealed that the form lacked evidence of a documented patient examination by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

B. Review of Policy and Procedure titled History & Physical (dated of 5/2010) revealed "A chart stamp is signed and dated by surgeon and includes the following:
Pre-Operative Evaluation By Physician:
The patient was examined just prior to surgery to evaluate the risk of anesthesia and the procedure to be performed.
Vital signs and laboratory reviewed. Heart and Lungs are within normal limits. Patient condition is satisfactory for anesthesia and surgery.
Documentation must be included in the medical record."

C. Interview with the Director of Surgical Services on 12/4/13 at 2:00 PM revealed that the "stamp is used on each and every procedure where anesthesia is involved" and confirmed the lack of documented patient examinations by physicians immediately before surgery to evaluate the risk of the procedures to be performed in the above medical records.

II. The facility failed to ensure that surgical records contained evidence of a documented post anesthesia evaluation as evidenced by:

A. Review of Medical Record 13 on 12/3/13 at 8:30 AM revealed the patient had an appendectomy done on 11/25/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 14 on 12/3/13 at 9:00 AM revealed the patient had a postpartum tubal ligation done on 5/12/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. The CRNA 2 (Certified Registered Nurse Anesthetist) charted "VS Stable" and "Alert & Oriented". Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 15 on 12/3/13 at 9:35 AM revealed the patient had an excision of proximal and ascending colon done on 10/9/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 16 on 12/3/13 at 10:10 AM revealed the patient had a splenectomy done on 10/23/12. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 17 on 12/3/13 at 10:30 AM revealed the patient had a exploratory laparotomy with lysis of adhesions (process of cutting scar tissue within the body) on 3/4/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 26 on 12/3/13 at 11:00 AM revealed the patient had a hemorrhoidectomy done on 9/30/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. CRNA 2 charted "VS Stable" and "Alert & Oriented". Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 27 on 12/3/13 at 11:20 AM revealed the patient had a mesh repair of indirect left inguinal hernia done on 11/11/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 28 on 12/3/13 at 11:30 AM revealed the patient had a myringotomy and tube placement done on 11/12/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 29 on 12/3/13 at 1:10 PM revealed the patient had a bilateral myringotomy with placement of ventilation tubes on 11/19/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 30 on 12/3/13 at 1:20 PM revealed the patient had a laparoscopic cholecystectomy on 11/27/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

- Review of Medical Record 31 on 12/3/13 at 1:35 PM revealed the patient had a dilation and curettage (D&C) on 7/30/13. Review of the anesthesia record titled Post Anesthesia Note revealed that the form lacked evidence of a documented post anesthesia evaluation. Review of the entire medical record revealed the record lacked evidence of a documented evaluation for proper anesthesia recovery before discharge.

B. Review of Policy and Procedure titled Pre and Post Anesthesia Evaluation Policy (dated of 6/2010) stated the following: "The post anesthesia evaluation shall include, but is not limited to, assessment of:
- Respiratory function, including respiratory rate, airway patency and oxygen saturation
- Cardiovascular function, including pulse rate and blood pressure
- Mental status
- Temperature
- Pain
- Nausea and vomiting
- Postoperative hydration
Pre and Post Anesthesia Evaluation polices and procedures follow state and federal law and regulations, and have been approved by the medical staff."

C. Interview with CRNA 1 on 12/4/13 at 2:15 PM confirmed the lack of post anesthesia evaluations for proper anesthesia recovery in the above medical records and stated "If it's not documented it's not done".

Based on review of the last annual evaluation provided by the CEO (Chief Executive Officer) and staff interview, the CAH (Critical Access Hospital) failed to complete an annual evaluation in the past year. This failed practice of not completing an annual evaluation has the potential to affect all patients of the CAH. The total number of patients admitted for fiscal year 9/30/12 was 774.

Findings are:

Review of the document provided by the CEO of the last annual evaluation revealed the document was titled "Chadron Community Hospital & Health Services Critical Access Hospital Meeting" with date of Monday, February 13, 2012. Interview with the CEO on 12/10/13 from 3:35 PM to 4:10 PM confirmed that this was the last annual evaluation completed by the CAH.

Based on review of the last annual evaluation provided by the CEO (Chief Executive Officer) and staff interview, the CAH (Critical Access Hospital) failed to complete an annual evaluation in the past year that included at least the number of patients served and the volume of services. This failed practice of not completing an annual evaluation has the potential to affect all patients of the CAH. The total number of patients admitted for fiscal year 9/30/12 was 774.

Findings area:

Review of the document provided by the CEO of the last annual evaluation revealed the document was titled Chadron Community Hospital & Health Services Critical access Hospital Meeting with date of Monday, February 13, 2012. Interview with the CEO on 12/10/13 from 3:35 PM to 4:10 PM confirmed that this was the last annual evaluation completed by the CAH.

Based on review of the last annual evaluation provided by the CEO (Chief Executive Officer) and staff interview, the CAH (Critical Access Hospital) failed to complete an annual evaluation in the past year that included a representative sample of both active and closed clinical records. This failed practice of not completing an annual evaluation has the potential to affect all patients of the CAH. The total number of patients admitted for fiscal year 9/30/12 was 774.

Findings area:

Review of the document provided by the CEO of the last annual evaluation revealed the document was titled "Chadron Community Hospital & Health Services Critical Access Hospital Meeting" with date of Monday, February 13, 2012. Interview with the CEO on 12/10/13 from 3:35 PM to 4:10 PM confirmed that this was the last annual evaluation completed by the CAH.

Based on review of the last annual evaluation provided by the CEO (Chief Executive Officer) and staff interview, the CAH (Critical Access Hospital) failed to complete an annual evaluation in the past year that included a review of the CAH's health care policies. This failed practice of not completing an annual evaluation has the potential to affect all patients of the CAH. The total number of patients admitted for fiscal year 9/30/12 was 774.

Findings area:

Review of the document provided by the CEO of the last annual evaluation revealed the document was titled "Chadron Community Hospital & Health Services Critical Access Hospital Meeting" with date of Monday, February 13, 2012. Interview with the CEO on 12/10/13 from 3:35 PM to 4:10 PM confirmed that this was the last annual evaluation completed by the CAH.

Based on review of the last annual evaluation provided by the CEO (Chief Executive Officer) and staff interview, the CAH (Critical Access Hospital) failed to complete an annual evaluation in the past year that determined whether the utilization of services was appropriate, the established policies were followed, and whether any changes were needed. This failed practice of not completing an annual evaluation has the potential to affect all patients of the CAH. The total number of patients admitted for fiscal year 9/30/12 was 774.

Findings area:

Review of the document provided by the CEO of the last annual evaluation revealed the document was titled "Chadron Community Hospital & Health Services Critical Access Hospital Meeting" with date of Monday, February 13, 2012. Interview with the CEO on 12/10/13 from 3:35 PM to 4:10 PM confirmed that this was the last annual evaluation completed by the CAH.