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Based on personnel record review and staff interview, the CAH (Critical Access Hospital) failed to maintain current personnel files with current licensure, certifications or registrations on 5 of 5 contract or locum staff (E1, E2, E3, E4, E5) files reviewed. Findings include.

E1's personnel record lacked verification of a current Physical Therapist license.

E2's personnel record lacked verification of a current Physical Therapy Assistant license.

E3's personnel record lacked verification of a current Occupational Therapist license.

E4's personnel record lacked verification of a current Certified Occupational Therapy Assistant license.

E5's personnel record lacked verification of a current Registered Nurse license.


On 8/4/10, at 2:45 p.m. the administrator verified the facility did not have a personnel file for the contract or locum staff which would contain a current license and other pertinent information.

At 2:45 p.m. the human resource manager verified she did not keep current license of the contracted or locum staff in a personnel file.

Based on record review and interview, the CAH failed to ensure all personnel were trained to manage non-medical emergencies for 4 of 5 (E1, E3, E4, E5) contracted or locum staff reviewed. Findings include:

E1's personnel record lacked documentation of training related to non-medical emergency procedures.

E3's personnel record lacked documentation of training related to non-medical emergency procedures.

E4's personnel record lacked documentation of training related to non-medical emergency procedures.

E5's personnel record lacked documentation of training related to non-medical emergency procedures.

On 8/5/10, at 9:00 a.m. the administrator verified no documentation could be provided related to emergency training. She verified all contract and locum staff are required to have this completed.

Based on interview, policy review and record review, the CAH failed to ensure a physician periodically reviewed the records of care provided to 9 of 20 (P6, P7, P19, P20, P21, P22, P23, P24, P25 ) inpatients who were cared for by midlevel practitioners. Findings included:


The CAH utilized a form to document notification by the midlevel practitioner (Family Nurse Practitioner-FNP, Physician Assistant- PA) to the physician that a patient was admitted to the CAH as an inpatient. The form also included a section on the bottom for the physician to document the review of the record where midlevel services were provided to the patient. The section documented: "This is to certify that I have reviewed this chart and agree with the care of plan and management." However, several records either lacked a review by the physician or the date of the review was the same date of the admission to the CAH and would not include a review of the care provided while an inpatient.

P6 was admitted to the CAH with uncontrolled diabetes mellitus on 10/29/09. The notification of admission was dated 10/22/09 (prior to admit). The physician signed and dated the record had been reviewed on 10/22/09.

P7 was admitted to the CAH with shortness of breath on 3/26/10. The physician signed the patient's record had been reviewed on 3/26/10, the same day as P7's admission.


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P19 was admitted to the CAH as inpatient on 6/27/10 by a FNP. The record lacked documentation the physician reviewed the record. The form used for documentation was blank.

P20 was admitted to the CAH as an inpatient on 5/4/10 by a PA. The record lacked documentation the physician reviewed the record. The form used for documentation was blank.

P21 was admitted to the CAH as an inpatient on 6/10/10 by a FNP. The record lacked documentation the physician reviewed the record. The form used for documentation was blank.

P22 was admitted to the CAH as an inpatient on 2/25/10 by a FNP. The record indicated the physician reviewed the record on the same day as admission. The patient was discharged on 3/4/10.

P23 was admitted to the CAH as an inpatient on 12/7/09 by A PA. The record lacked documentation the physician reviewed the record. The form used for documentation was blank.

P24 was admitted to the CAH as an inpatient on 5/2/10 by a FNP. The record indicated the physician reviewed the record on the same day as admission. The patient was discharged on 5/5/10.

P25 was admitted to the CAH as an inpatient on 12/30/09 by a FNP. The record indicated the physician reviewed the record on 12/10/07 (which was prior to admit and error in year). The patient was discharged on 12/21/09.

The administrator was interviewed on 8/5/10, at 10:00 a.m. and stated the Medical Director was coming to the CAH every 2 weeks and reviewing charts at that time. She was not sure why some of the dates were the same day as admission when the physician was probably not in the CAH at the time of the review. She verified the medical records of patients treated by a Nurse Practitioner (NP) and Physician Assistant (PA) are to be reviewed by the Medical Director.

The policy titled, Medical Record Review of Midlevel Practitioners dated revised 7/09 indicated: "All medical record charts of patients seen by Mahnomen Health Center's Credentialed Family Nurse Practitioners (FNP) and Physician Assistants (PA) will undergo a review of that chart by the Supervising MD or Medical Director. All charts will be signed by the Medical Director using the Notification and Certification Form."

Based on record review, policy review and staff interview, the CAH failed to ensure patients admitted to a swing bed received a tuberculin skin test to rule out tuberculosis for 1 of 4 swing bed patients reviewed. Findings include:

P26 was admitted to the CAH in a swing bed for rehab following a hip replacement on 5/25/10. The "Swing Bed Admission Tuberculin Test" form indicated a tuberculin skin test (TST) was contraindicated as the patient had a chest X-ray prior to admission. On 8/5/10 at 9:00, a.m. RN-B stated that if the patients have a negative chest X-ray on file the patient does not need a TST. However, this is not the practice recommended by the Centers for Disease Control for screening for TB.

The CAH policy for Tuberculosis Screening for Residents dated 2001, and revised in April 2007, indicates:
1. Screening New Admissions or Readmissions:
a. The facility will screen referrals for admission and readmission for information regarding exposure to, or symptoms of, TB and will check results of recent (within 12 months) tuberculin skin tests (TST), or blood assay for Mycobacterium tuberculosis (BAMT) or chest X-rays (CXR).
b. Any resident without documented negative TST, BAMT, or CXR within the previous 12 months will receive a baseline (two step) TST or (one step) BAMT upon admission.

At the time of the exit conference the administrator verified that a two step TST should be given to all swing bed patients unless medically contraindicated.

http://www.cdc.gov/tb/publications/factsheets/testing/skintesting.htm

The Mantoux tuberculin skin test (TST) is the standard method of determining whether a person is infected with Mycobacterium tuberculosis. Reliable administration and reading of the TST requires standardization of procedures, training, supervision, and practice.
Who Can Receive a TST?
Most persons can receive a TST. TST is contraindicated only for persons who have had a severe reaction (e.g., necrosis, blistering, anaphylactic shock, or ulcerations) to a previous TST. It is not contraindicated for any other persons, including infants, children, pregnant women, persons who are HIV-infected, or persons who have been vaccinated with BCG.

Based on record review and interview, the CAH failed to ensure all entries made in the medical record were timed, dated, and authenticated for of 11 of 20 patients (P2, P3, P4, P5, P6, P7, P8, P10, P11, P12, P16) reviewed receiving services at the CAH. Findings include:


P2 was admitted to the CAH with congestive heart failure on 2/16/10. The orders dated 2/15/10, were not timed by the FNP.

P3 was admitted to the CAH with pyelonephritis on 7/5/10. The admission orders were not dated or timed by the physician. The 7/6/10, progress notes were not timed by the physician.


P4 was admitted to the CAH with pneumonia on 3/4/10. The admission orders dated 3/4/10, were not timed by the FNP.

P5 was admitted to the CAH with pneumonia on 8/12/09. The admission orders were not dated or timed by the PA.

P6 was admitted to the CAH with uncontrolled diabetes mellitus on 10/29/09. The admission orders were not timed and dated by the PA. The progress notes were not dated and timed by the physician.

P7 was admitted to the CAH with shortness of breath on 3/26/10. The admission orders were not dated and timed by the PA.


P8 was admitted to the CAH with asthma on 7/5/10. The admission orders and progress notes were not timed by the physician.

On 8/5/10, at 10:30 a.m. medical record staff-A verified the records lacked dates and times.





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P10 was admitted to the CAH on 6/18/10, with diagnoses including acute respiratory failure. The physician orders dated 6/18/10, lacked the time of the entry.

P11 was admitted to the CAH on 11/6/09, with diagnoses including congestive heart failure. The 11/9/09, physician orders lacked a time of the entry.

P12 was admitted to the CAH on 1/1/2010, with diagnoses including congestive heart failure. The admission orders lacked a date and time of the entry. The 1/2/10, and 1/4/10, physician orders lacked the time of the entries.

P16 was admitted to the CAH on 12/11/09, with diagnoses including cellulitis. The 12/14/09, physician progress noted lacked the time of the entry.

On 8/4/10, at 3:25 p.m. RN-B verified these findings.

Based on interview and review of the Quality Assurance (QA) Plan, the CAH failed to provide an effective quality assurance program to evaluate the quality and appropriateness of the treatment and services furnished in the CAH related to 6 of 11 departments reviewed. Findings include:


RN-A was interviewed on 8/4/10 at 4:00 p.m. regarding the quality assurance program in the CAH. The QA activities/monitoring for each service provided by the CAH was reviewed. Several departments were only collecting data that was part of their ongoing responsibilities and not part of a plan to ensure quality of services being provided. She stated Sanford Hospital (network hospital) conducted a Quality Review on 7/21/10 of the CAHs QA Program. They had made recommendations to better track QA activities using graphs and to look at new patient indicators.

The following services did not have an effective QA plan:

NUCLEAR MEDICINE
On 8/4/10, at 3:00 p.m. the radiology manager stated the nuclear medicine department did not submit their QA program to the facility. She added they are a contract service and see few patients. On 8/5/10, at 9:30 a.m. the radiology manager provided the information obtained from nuclear medicine. No ongoing QA monitoring had been completed.


LABORATORY
A review of the laboratory QA revealed all QA indicators lacked patient specific outcomes. The following indicators were being monitored:
1. Specimens are labeled appropriately.
2. External Controls are performed.
3. Proficiency testing is performed per policy.
4. Panic values are immediately called to the provider and documented that result is "read back".


EMS
On 8/5/10, at 10:00 a.m. the Ambulance/EMS director reviewed the QA. He verified they had not been completing patient related outcomes for the services provided. He stated some of the QA indicators have been ongoing for years, others for about a year. He added the CAH completes patient satisfaction surveys, but they don't get a good response from the ambulance patients. A review of the ambulance/EMS QA revealed the indicators were daily maintenance of the equipment, cleaning and reporting for billing.




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DIETARY
On 8/4/10, at 11:15 a.m. the registered dietician (RD) provided documentation that indicated the CAH was monitoring areas that were a part of the staff's routine job requirements. Examples included:
1. Staff completing their daily check sheet to indicate the completion of the sanitizing sink pH.
2. Cleanliness of appliances.
3. Checking kitchen for outdated and no open dates of food items.
4. Appropriate use of gloves.

The indicators being monitored lacked patient specific outcomes.

At this same time, the RD stated the CAH had not identified problems with the current monitoring. She added the administrator had recently directed staff to participate in more patient appropriate QA.


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ENVIRONMENTAL
On 8/4/10, at 2:40 p.m. the maintenance supervisor was interviewed regarding QA activities related to environmental services. He stated the department had discontinued monitoring three quality indicators last quarter and currently had three others they were monitoring. However, all of the QIs mentioned were not identified through patient safety concerns but were part of the departments routine job requirements.
1. Monitoring the isolation room to ensure negative pressure.
2. Monitor fire drills to make sure drill done each shift during each quarter.
3. Monitor generator load tests.
4. Monitor hospital patient room water temperatures.
5. Monitor hot water temperatures during wash/bleach cycles.
6. Monitor for proper exhaust in restrooms.

PHARMACY
On 8/8/3/10, at 1:30 p.m. the pharmacist (RPH-A) was interviewed regarding QA activities related to pharmacy services. RPH-A stated pharmacy services currently did not have a QA activity/indicator being monitored. She added that the CAH was working on new drug protocols which were being discussed at the medical staff meetings. The nursing staff were also monitoring temperatures in the refrigerators, but no other QA.

The 2010 Quality Improvement Plan indicated:
Purpose: The Quality Improvement Program promotes and supports quality outcomes within Mahnomen Health Center. This program is designed to objectively and systematically:
>Identify customer expectations and plan care and services around those expectations (quality planning).
>Measure, monitor and evaluate care and services (quality control)
>Pursue opportunities to improve care and services (quality improvement)
Objectives: To ensure appropriateness and quality of services and care provided to patients/residents and customers.