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Based on record review, interview, review of the hospital's policies and procedures, and the "Nebraska Administrative Code"; the facility failed to ensure that 2 out of 12 unlicensed staff members had a criminal background screen completed prior to employment. This deficient practice had the potential to affect all of the patients who were admitted to this hospital for services and treatment. Census at the time of survey was 3. Sample size was 27.

Findings include:

A. Review of 12 personnel files on 9/28/17 at 2:00 p.m., indicated 2 unlicensed Nursing Assistants (NA) did not receive a criminal background screen prior to employment.

- Review of the personnel file for NA9 indicated he/she was hired on 6/8/99; however, his/her personnel file did not contain a criminal background screen.

- Review of the personnel file for NA10 indicated he/she was hired on 8/7/08; however, his/her personnel file did not contain a criminal background screen.

B. Review of the "Nebraska Administrative Code, Title 175 Health Care Facilities and Services Licensure, Chapter 9 Hospitals," effective 10/30/06, provided the following information: "9-006.03A3 Criminal Background and Registry Checks: Each hospital must complete and maintain documentation of pre-employment criminal background and registry checks on each unlicensed direct care staff member."

C. Review of the facility's policies and procedures revealed a document titled, "New Hires" dated December 2016, which provided the following information: "After (the) interviewing process and (the) candidate is chosen, a letter to new employees ...is sent to the new hires that is (sic) welcoming them to the facility and (is) to include the following forms: ...Criminal History Background Check ..."

E. During an interview on 9/28/17 at 2:00 p.m., the Department Head for Human Resources/Credentialing stated "it was a Nebraska State requirement and the policy of the facility to ensure each employee received a criminal background screen before beginning their employment at the facility". He/she confirmed that NA9 and NA10 did not have a criminal background screen in their personnel file and stated he/she would begin the criminal background screen process immediately.

Based on staff interview, record review, and review of policies and procedures; the Critical Access Hospital (CAH) failed to ensure the swing bed patient care policies and procedures were reviewed and approved annually by the CAH's administration. This deficient practice had the potential to affect all patients admitted to the CAH's swing bed patient care department. Facility census at the time of survey was 3.

Findings include:

A. Review of the "Patient Care Policies" manual review sheet on 9/28/17 at 3:00 p.m. revealed the swing bed policy and procedure manual was approved for the year 2014 to 2015. The policy manual lacked the annual review for 2015-2016.

B. An interview with the Social Worker/Quality Assurance (SW/QA) staff person on 9/28/17 at 3:15 p.m. verified the swing bed policy and procedure manual had not been reviewed since the 2013-2014 calendar year.

C. Review of the policy titled, "Policy Development and Review," written 12/28/15 and revised 2/5/16, provided the following information:

" ...9. Monitor, review, revise; Policy and procedure will be reviewed annually at the department level. Department review will flow to the Policy Review Committee which will finalize new policy, review and approve policy changes or discontinue current policy ...11. Each Policy shall have a signature line/page for approvers ...Signatures shall carry a date of approval ..."

Based on observation, staff interview, record review, and review of policies and procedures; the Critical Access Hospital (CAH) failed to ensure the pharmacist developed a policy and procedure specific for mixing/compounding intravenous (IV) medications. This deficient practice affected 1 of 1 patients (Patient (P) 4) with orders for a compounded antibiotic medication, and had the potential to affect all future patients admitted to the CAH with orders for a compounded IV medication. Facility census at the time of survey was 3.

Findings include:

A. Review of P4's medical record on 9/26/17 indicated the hospital admitted the patient on 9/23/17 with a diagnosis of urosepsis (septic poisoning from retained and absorbed urinary substances).

B. Review of P4's physician orders indicated her medication orders included pip/tazobactam (piperacillin/tazobactam- a penicillin antibiotic used to treat certain kinds of bacterial infections) 3.375 grams (gm) IV every 6 hours.

C.Tour and observation of the CAH's pharmacy on 9/26/17 at 11:00 a.m. with the pharmacist, revealed the department had an ante room that led into the compounding room. During an interview with the pharmacist at that same time, the pharmacist stated she routinely used the compounding room to mix the physician-ordered IV antibiotics.

D. Review of the pharmacy's policy and procedures on 9/26/17 at 12:03 p.m. indicated the pharmacy had no policies and procedures in place to ensure best practices were followed that were consistent with accepted professional principles regarding the minimum standards of safe practice applicable to both sterile and non-sterile compounding.

E. During an interview on 9/26/17 at 12:03 p.m., the pharmacist stated she had not developed policy's specific for compounding medications that included routine sampling, cleaning and disinfection, and the use of aseptic technique during the compounding process.

Based on medical record review and interview, the facility failed to ensure that each patients' medical record was signed and completed in a timely fashion. This deficient practice affected 1 of 27 patients reviewed, (Patient (P) 15). Facility census at the time of survey was 3.

Findings include:

A. Review of the medical record for P15 indicated the hospital admitted the patient on 5/12/17 with a diagnosis of cellulitis (an infection of the skin). P15 was discharged on 5/15/17 with a risk for skin breakdown and a prescription for antibiotics.

B. Review of P15's closed medical record on 9/27/17 at 10:00 a.m. revealed the physician failed to sign and complete P15's medical record timely. The physician signed and dated the record on 7/16/17 at 1:14 p.m., approximately 2 months after the patient was discharged.

C. During an interview on 9/27/17 at 10:15 a.m., the Department Head of Health Information Management (HIM) stated it is the facility's policy to ensure that each medical record is signed and dated within 30 days after the patient is discharged. He/she stated the facility's policy read, "The entire medical record shall be completed within thirty (30) days following the patient's discharge ..." The Department Head of HIM confirmed that P15's medical record was delinquent when the physician failed to complete and sign within 30 days of discharge.

Based on record review, interview, and review of the hospital's policies and procedures; the facility failed to ensure that the internal "Periodic Evaluation" of the "Quality Assurance Program" included an annual appraisal of the effectiveness of the total program. This deficient practice had the potential to affect each patient that received treatment and services from this Critical Access Hospital (CAH). Facility census at the time of survey was 3.

Findings include:

A. During an interview on 9/28/17 at 1:45 p.m., the Quality Assurance (QA) Coordinator stated the facility developed a policy and procedure for how to effectively conduct their QA program. Per the QA Coordinator, the hospital also developed a "Quality Assurance Plan" which describes in detail how the QA Program is to be conducted throughout each of the separate hospital departments.

B. Review of the policies and procedures revealed a policy titled, "Quality Assurance Plan," revised on 9/23/15, which provided the following information:

"Policy: The objective of the Quality Assurance Plan is to preserve and enhance the high quality of patient care at (name of facility) in Part (sic) by ensuring that: ...6. All elements entering into the care of patients are subjected to periodic review, either retrospective or concurrent, with the use of pre-established objective criteria and documentation of findings; and 7. The findings of patient care review are utilized by the hospital in concrete ways to fulfill the objectives of the hospital's quality assurance program ..."

"Procedures: ...7. Annual appraisal of the effectiveness of the Quality Assurance Program ... Organization, Duties, and Meetings of the quality assurance committee..."

"Membership of the Q.A. Committee: ...1. The Quality Assurance Committee will consist of the hospital CEO (Chief Executive Officer), President of the Medical Staff, the CNO (Chief Nursing Officer), the Director of Health Information and the Quality Assurance Coordinator ..."

"Duties: ... Among the duties of the Q.A. Committee will be the following:

1. Establishing a schedule of quality review studies for the hospital on a quarterly basis;
2. Reviewing and approving the choice study topics and criteria submitted to it by the various services responsible for performing quality review studies;
3. Reviewing and accepting the reports of all quality review studies performed in the hospital;
4. Reporting on the findings of quality review studies to the Medical Staff and the Executive Board;
5. Referring all matters requiring educational or corrective action to the appropriate department heads with recommendations and target dates for follow-up;
6. Conducting an annual evaluation of the effectiveness of the Quality Assurance program; and
7. Providing general direction and coordination to all quality assurance activities of the hospital ..."

C. An interview with the CEO and the QA Coordinator on 9/26/17 at 10:30 a.m. revealed the hospital's QA Committee did not include the President of the Medical Staff. The CEO and the QA Coordinator stated they were unaware that the QA policy and procedure required the President of the Medical Staff to be a member of the QA Committee. Consequently, he/she did not attend the monthly meetings, was not involved in the quarterly meetings, and was not involved in the annual periodic report studies.

D. Review of the "Periodic Evaluation of the Critical Access Hospital, July 1, 2005 through June 30, 2016" report revealed the evaluation was not an appraisal of the effectiveness of the Quality Assurance Program. The 4-page report included a summary of services provided during the past year; it did not include an evaluation of the total program. The following information was obtained from the periodic evaluation:

- Patients served (acute care) - 122
- Inpatient average length of stay - 3.18 days
- Occupancy - 17 licensed beds with a 6.23% occupancy
- Skilled care - 40 patients were discharged from the "Swing Bed Program"
- Surgery - 138 outpatients and 98 endoscopies
- Emergency room visits - 616 and 103 of those patients were admitted from the Emergency room to observation or inpatient status
- Outpatient Procedures - 535
- Specialty Clinic Visits - 1476 with a breakdown of how many patients visited the different areas of the hospital
- Radiology procedures - 2787
- Laboratory procedures - 21,168; outpatients: 17, 735 and inpatients: 3,433
- Telemedicine - included a breakdown of services
- Appropriateness of utilization of services: "Utilization management monitors the completeness of the patient charts, H&Ps (history and physical) are expected to be on the inpatient charts within 24 hours of admissions. This is monitored daily through the week and providers are notified if not on the chart."
- Service Additions- included a list of new services
- Basic Trauma Certification - included a summary of what the multi-disciplinary trauma committee is expected to complete
- Participation in national quality initiatives - "The facility continues to participate in the national quality initiatives for Community Acquired Pneumonia and Heart Failure. We also report EDTC (Emergency Department Transfer Communication) data, long bone fracture and Immunizations."
- Policies and Procedures - "Policies and procedures were reviewed and amended by an established committee as required by CAH regulations. Policies and procedures are reviewed on a quarterly basis."
- Record Review - "As part of the Quality Improvement process, records are regularly reviewed. Areas targeted for improvement are communicated to staff ...As part of the Compliance Program, records are also reviewed for appropriate charges and
documentation ..."
- Method of transfer - included ground, air, private and law enforcement
- Facilities transferred to - included different hospitals throughout the area.

The last page of the periodic evaluation included a "Project Summary" for each department, which included a summary of what each department was to continue to monitor.

E. An interview with the QA Program Coordinator on 9/28/17 at 1:45 p.m. revealed that he/she was new to this position; however, he/she understood that the "Periodic Evaluation of the Critical Access Hospital" report was supposed to be an appraisal and an evaluation of the hospital's QA program and not just a summary of services and treatments the hospital provided during the past year. He/she added that currently, the periodic review was not an appraisal or an evaluation of the total program that included recommendations for change and improvement. The QA Coordinator added that it was the facility's policy and plan to ensure that the annual periodic evaluation of the QA process included recommendations, suggestions, plans for improvement, cost improvements, outcome of the medical record review, the outcome of the peer reviews, and a detailed investigation into the utilization process, and that all results and details of the periodic appraisals were provided to the hospital's Board of Directors to ensure the QA program was effective.

F. Review of the "Quality Assurance Plan," revised in 9/2015, revealed the following information:

"The objective of the Quality Assurance Plan is to preserve and enhance the high quality of patient care at (name of hospital) in Part (sic) by ensure that:

1. Patient care personnel are qualified and effectively supervised;
2. Patient care services are appropriately organized with clear channels of supervision, responsibility and accountability;
3. Patient care appropriate to the needs of patients is delivered in a timely manner, is optimal within the range of available resources, is consistent with achievable goals and is properly documented;
4. Patient care is delivered in as cost-effective a manner as possible;
5. Documentation facilitates the continuity of care and the evaluation of services;
6. All elements entering into the care of patients are subjected to periodic review, either retrospective or concurrent, with the use of per-established objective criteria and documentation of findings; and
7. The findings of patient care review are utilized by the hospital in concrete ways to fulfill the objectives of the hospital's Quality Assurance Program.

"Authority...It is the responsibility of the Board of Directors to establish, maintain and support, through the CEO (Chief Executive Officer) and the President of the Medical Staff, an ongoing Quality Assurance Program that includes effective mechanisms for the review and evaluation of patient care and that provides for effective responses to the findings of such evaluation. Toward this end the hospital will establish a Quality Assurance Committee"...

"Organization, Duties and Meetings of the Quality Assurance Committee: A. Membership of the Q.A. Committee:...1. The Quality Assurance Committee will consist of the hospital CEO (Chief Executive Officer), Medical Staff Representative, CNO (Chief Nursing Officer), the Director of Health Information and the Quality Assurance Coordinator ..."

"Duties...Among the duties of the Q.A. Committee will be the following...6. Conducting an annual evaluation of the effectiveness of the Quality Assurance Program; and 7. Providing general direction and coordination to all quality assurance activities of the hospital ..."

"Minutes of all meetings will be kept...A log book will be maintained by the Q.A. Coordinator, listing all evaluation studies, actions taken, monitoring activities and dates of Committee reports to the Medical Staff, Administrator and Executive Board ...."

G. During an interview on 9/28/17 at 1:45 p.m., the QA Coordinator stated the hospital did not currently have a log book. The QA Coordinator also stated, at this time, the hospital did not complete peer reviews, reviews of patient records, or an evaluation of the utilization review process. He/she added that the annual "Periodic Evaluation of the Critical Access Hospital" was not completed, reviewed, or following the hospital's QA Policy and Procedure or the QA Plan.