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Based on review of Medical Staff Bylaws, review of physician credential files and staff interview, the CAH (Critical Access Hospital) failed to ensure that the reappointment for 3 of 9 physicians (Physicians B, C and D) reviewed, were reappointed in accordance with the Medical Staff Bylaws which requires that reappointments be based on the provider's competence, compliance with bylaws, rules and regulations and record completion. Consulting Staff Physicians B, C and D have privileges for and have performed surgical procedures for the CAH. A total of 12 physician credential files were reviewed. The Medical Staff Roster dated May 2014 listed 1 Active Staff, 18 Consulting Staff, 3 Courtesy Staff and 37 teleradiology staff. This failed practice has the potential to affect all surgical patients at the hospital. The Total Program Review for Fiscal Year 2012/2013 statistical summary identified completion of 303 surgeries and procedures.

Findings are:

A. Review of the Medical Staff Bylaws approved in 2002, under Article IX - Clinical Privileges Section 2 - Physician Qualifications listed the following continuing qualifications for the exercise of privileges at the hospital:
1. "Competence: Possess and maintain demonstrated clinical competence, including current knowledge, judgement and techniques, in his or her specialty area and for all privileges held or applied for".
2 "Education, Training and Competence...Possess demonstrated current competence, including current knowledge, judgement and technique in his or her field or specialty area".
3. "Compliance with Bylaws, Rules, and Regulations".
4. "Observation: Perform a sufficient number of procedures, manage a sufficient number of cases, and have sufficient patient care contract with the hospital to permit the proctor or medical staff to assess the current competency for all requested privileges...".
5. "Record. Complete all required patient care records in a thorough, professional and timely fashion".

B. Review of the credential files for Consulting Staff Physician B (last reappointment by governing body dated 6/27/13), Consulting Staff Physician C (last reappointment by governing body dated 11/20//13) and Consulting Staff Physician D (last reappointment by governing body dated 3/27/14) revealed no information concerning these 3 physicians function at the CAH including: demonstration of clinical competence, number of surgeries/procedures completed, compliance with bylaws, rules and regulations or completion of medical records.

C. Interview with the HIM Director (Health Information Management - responsibilities include maintaining and presenting physician credential files to medical staff at medical staff meetings) on 6/18/14 from 1:50 AM - 2:00 PM and on 6/24/14 from 2:15 PM - 3:15 PM revealed the following:
-For Active Medical Staff they have a Quality Profile that includes information on number of patients admitted, any records taken to medical staff for review, medical record completions;
-Do not have a Quality Profile for Consulting or Courtesy staff;
-Just discuss issues with physicians as they come up and not necessarily at the time of reappointment.

The CAH could provide no evidence that reappointment of physician by the governing body was based on competence, compliance with bylaws, rules and regulations and/or numbers of patient contact in the CAH.

Based on observation, record review and staff interview, the facility failed to keep an accurate record system to account for and ensure the control of the distribution, use and disposition of the scheduled/controlled medications (classifications of medications based on their "potential for abuse"). The facility census was 1 swing bed and 1 observation patient.

Findings are:

A. An observation in the pharmacy with the Pharmacy Assistant-Registered Nurse-T [RN-T] on 6/19/14 from 10:15 AM to 11:30 AM revealed 4 locked cupboards where the Scheduled Medications were stored. Of the 4 locked cupboards, 2 of the cupboards had a lock that only the Consulting Pharmacist had a key; 1 cupboard identified as "Cupboard 11-Surgery Cupboard" was locked with the key kept in the pharmacy and accessible to staff; 1 cupboard identified as "Cupboard 10" was locked and the Consulting Pharmacist, RN-T and the Director of Nurses (DON) had the key. The Pharmacist had the Count Book (The Count Books possessed a separate page for each medication with the name of the medication, strength of the medication and the balance of the current medication on hand in the pharmacy) that was used to count the controlled medications locked up in the cupboard that only the Consulting Pharmacist possessed the key.

B. Cupboard 11 had a red box that was identified as "External Return Bin-Narcs [narcotics] only." The External Return Bin contained:
- Morphine Sulfate (a narcotic pain medication) 10 mg/ml (10 milligram per milliliter) 1 vial for injection, there was no associated count sheet accompanying the medication.
- Morphine Sulfate 5 mg/ml (5 milligram per milliliter) 1 vial for injection, there was no associated count sheet accompanying the medication.
- Lorazepam (Ativan-an antianxiety medication) 2 mg/ml (2 milligram per milliliter) 1 vial for injection, there was no associated count sheet accompanying the medication.
- Diazepam (Valium-an antianxiety medication) 5 mg tablets, 5 sheets of tablets with 10 tablets per sheet equaling (50) 5 mg tablets, there was no associated count sheet accompanying the medication.
- Diazepam 10mg/2ml (10 milligrams per 2 milliliter) for injection, there was no associated count sheet accompanying the medication.
- OxyContin (a narcotic pain medication) 10mg tablet, there was no associated count sheet accompanying the medication.
- Fentanyl Patches (A narcotic pain medication that is absorbed through the skin. The patch is changed every 72 hours); (3) 50 mcg/hr [50 micrograms per hour] patches; (1) 12 mcg/hr patch, there was no associated count sheet accompanying the medication.

C. Cupboard 10 had the following medications:
- Morphine Sulfate (a narcotic pain medication) 50 mg/ml (50 milligram per milliliter) 20 ml vial for injection, there was no associated count sheet accompanying the medication.
- Diazepam (Valium-an antianxiety medication) 5 mg tablets, 5 sheets of tablets with 10 tablets per sheet equaling (50) 5 mg tablets, there was no associated count sheet accompanying the medication.
- Fentanyl Patches (A narcotic pain medication that is absorbed through the skin. The patch is changed every 72 hours); (5) 50 mcg/hr [50 micrograms per hour] patches, there was no associated count sheet accompanying the medication.

D. Interview with RN-T on 6/19/14 at 11:30 AM revealed that "We put the meds/narcotics we pull out of the MDG (a medication dispensing machine) and then don't use or the outdated medications in the Red Box in Cupboard 11. We don't have any kind of a count sheet with those medications. They just stay there until the Consulting Pharmacist comes and takes care of them, which can be up to a month. We keep the key in here [the pharmacy] in the drawer so the nurses can put the items in there if they need to." "We count all the scheduled meds (Schedule I, II, III and IV medications via the perpetual count in the MDG ( a medication dispensing machine). When we put them in the box we don't have a count sheet or anything."

E. An interview with the Pharmacist on 6/24/14 at 8:00 AM revealed, "The MDG (a medication dispensing machine) keeps a perpetual count with the Scheduled/Control Medications that are in the machine. I keep the count in the pharmacy, I have the only key for these 2 cupboards and keep the book in there. I, the Director of Nurses and the Pharmacy Assistant Nurse have the key to this cupboard (cupboard 10). This cupboard (Cupboard 11-surgical cupboard) anyone that has access to the pharmacy has access to the key for it." "No there hasn't been any count sheets that are put in with these Scheduled Medication outdates or returned medications (in cupboard 10 and 11). I can see that there would be the potential for someone to get into them, I guess I don't really have an answer for that."

F. Review of the Controlled (Scheduled) Medications policy dated 8/13 revealed:
- All narcotics shall be maintained behind 2 locked doors. The extra stock of narcotics shall be stored in a designated cabinet within the pharmacy and shall be maintained by our consulting pharmacist. Only he will have access to this stock.
- At the end of each shift the nurses shall do a "last accessed" controlled count in the automated dispensing machine and if they have any discrepancies they will research and resolve them prior to their leaving.

G. Review of the Consultant Pharmacist, consulting duties policy dated 12/13 revealed:
- Supervising procurement, handling, storage and dispensing, administering and disposal of medications.
- Maintain a log of all narcotic inventory receipt of meds and restocking to the MDG.

H. Review of the Consultant Pharmacist Retainer Agreement dated 6/2010 revealed:
-Consultant Responsibilities 4) Supervise the records of receipt and distribution of all controlled substances and the maintenance of such records in sufficient detail to allow for an accurate reconciliation.

Based on observation, review of policies and procedures, review of Education & Information provided to dietary employees and staff interview, the CAH (Critical Access Hospital) failed to follow recognized dietary standards identified in the Food Code published by the United States Public Health Service Food and Drug Administration. During 1 of 2 meal observations dietary employee failed to handle food in a way to prevent cross-contamination and failed to maintain foods at the acceptable temperatures. These identified problems have the potential to affect all patients receiving meals. Census on the first day of survey was 1 skilled care patient. The Total Program Review for fiscal year 2012-2013 identified 151 acute patient admissions and 32 skilled care patient admissions.

Findings are:

A. During the evening meal on 6/24/14 from 4:30 PM to 5:00 PM, Dietary Employee-S took a bowl of roast beef from the microwave to drain the water/broth off in the vegetable preparation sink. During this process a piece of the hot roast beef fell onto the counter by the sink. Dietary Employee-S picked up the piece of hot roast beef with bare hand and put it back into the bowl of roast beef served to the patients.

During the same meal observation Dietary Employee-S used a bare hand to take 2 slices of bread from the package of bread. The bread was placed onto the counter top, cut in half and bare hand used to place the bread onto the plates for patients.

The Food Code is a model that assists food control jurisdictions at all levels of government by providing them with a scientifically sound technical and legal basis for regulating the retail and food service segment of the industry (restaurants and grocery stores and institutions such as hospitals and nursing homes).

Regulations listed in the Food Code regarding contamination:
"3-301.11 Preventing Contamination from Hands....FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT."

Interview with the Dietary Manager on 6/24/14 from 8:30 AM to 9:20 AM revealed that all dietary employees were provided a 3-ring binder that was titled Dietary Education & Information. Review of this binder revealed the following education for dietary staff:
-"Ready-to-eat foods are those that do not require any further cooking. Avoid cross contamination at mealtimes. When assisting at meals, do no use bare hands to hold foods such as....bread".

B. Observation of the evening meal service on 6/24/13 revealed containers of food were taken from the stove and placed on the counter (with no means of keeping the food hot) and temperatures were taken at 4:49 PM with the following results:
-Roast Beef - 169 degrees Fahrenheit
-Green Beans - 151 degrees Fahrenheit
-Mashed potatoes (that contained milk and butter) - 130 degrees Fahrenheit
-Beef Gravy - 178 degrees Fahrenheit

After the temperatures were taken, the food was portioned onto plates and placed in the heated side of a large food cart at 4:54 PM. At 5:00 PM Dietary Employee-S assembled the patient trays using the following process:
-Trays with cold food were removed from the cold portion of the cart and placed onto another cart that had no means of maintaining the food temperatures;
-The plates of food were then taken from the heated side of the food cart and placed onto the cold trays.
-The cart with no means to keep hot food hot and cold foods cold was used to transport the trays to the patients.

The temperatures of the foods taken on a test tray after the last patient was served at 5:08 PM revealed the following temperatures:
-Mashed potatoes with gravy - 111 degrees Fahrenheit
-Roast Beef with gravy - 112 degrees Fahrenheit
-Green beans - 103 degrees Fahrenheit

The Dietary Manager tasted the food after these temperatures were taken on 6/24/14 at 5:10 PM and indicated that the "foods not hot enough".

Regulation in the Food Code concerning temperatures of foods:
"3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding....FOOD shall be maintained at a 135 degrees Fahrenheit or above."

Review of the policy and procedure titled Food/Beverage Temperatures reviewed December 2011 revealed the following "Hot food/Beverage served is heated to, at least, 165 degrees F [Fahrenheit] and held above 140 degrees F."

Based on medical record review, staff interview and review of policies and procedures, the CAH (Critical Access Hospital) failed to ensure that 2 of 2 (Medical Records 41 and 42) sampled outpatient Cardiac Rehabilitation outpatients had physician orders for Cardiac Rehabilitation. The CAH had 26 Cardiac Rehabilitation outpatients on 6/17/14. From 1/1/14 to 6/17/14 the CAH had 47 Cardiac Rehabilitation outpatients.

Cardiac and Pulmonary Rehabilitation helps patients improve their health and live a more active life after major or ongoing heart or lung problems.

Findings are:

A. During review of the medical record for Patient 41 on 6/17/14 , Cardiac Rehabilitation Nurse-T provided a document titled Phase I Inpatient Cardiac Rehabilitation Education Flowsheet as the physician order. This document lacked identification of what facility it came from but did list that it was Faxed to this CAH. Towards the bottom left side of the form was a section titled "Indications for Phase II CR [Cardiac Rehabilitation]". Within this section the following items were checked "Valve Replacement/Repair", CABG [coronary artery bypass grafting - heart surgery]" and "Diabetes" with date of event listed as "5/5". This form also had the names of 2 referring cardiologists but no signatures from the cardiologist. This form was an Education Flowsheet and not a physician order. Interview with Cardiac Rehabilitation Nurse-T on 6/17/14 at 4:00 PM revealed they usually did not get referral from this facility and was not familiar with this form.

B. Review of the medical record for Patient 42 on 6/17/14, Cardiac Rehabilitation Nurse-T provided a document for the physician order and indicated this was the form they usually received. This form was titled CARDIOPULMONARY REHAB [Rehabilitation] ORDER. This document was computer-generated and contained no handwriting and lacked indications of an electronic signature. Towards the bottom left hand side listed ORDER with D/C [Discharge] Cardiac Rehab. Interview with Cardiac Rehabilitation Nurse-T on 6/17/14 at 4:10 PM confirmed that this was the only thing available for a physician order.

C. Review of the policy and procedure titled Medical Record Content last revised February 2010 revealed the following concerning doctor's orders:
"The provider's orders must be written in ink, and must include date and time. Orders must be complete and legible and those which are illegible or improperly written will not be carried out until rewritten or clarified by the nurse."

Based on medical record review, staff interview and review of policies and procedures, the CAH (Critical Access Hospital) failed to ensure that 3 of 3 sampled (Medical Records 41, 42 and 43) electronic medical records for Cardiac and Pulmonary Rehabilitation included electronic signatures to identify the author of the information entered into the computer. The CAH had 26 Cardiac Rehabilitation outpatients and 4 Pulmonary Rehabilitation outpatients. From 1/1/14 to 6/17/14 the CAH had a total of 54 Cardiac and Pulmonary Rehabilitation outpatients.

Cardiac and Pulmonary Rehabilitation helps patients improve their health and live a more active life after major or ongoing heart or lung problems.

Findings are:

A. Review of the electronic medical record for Cardiac Rehabilitation Patients 41 and 42 with Cardiac Rehabilitation Nurse-T on 6/17/14 revealed the entries into this system contained no electronic signature of the person making the entries. Interview with Cardiac Rehabilitation Nurse-T on 6/17/14 at 4:15 PM confirmed the lack of electronic signatures for the person making the entries.

B. Review of the printed medical record for Pulmonary Rehabilitation Patient 43 revealed, 13 Daily Report documents with dates between 8/29/13 and 10/15/13. These forms had a signature line where a name could be handwritten but these forms were blank.

Interview with Respiratory Therapist-U on 6/18/14 at 9:45 AM revealed the Daily Report documents stay in the Cardiac/Pulmonary Rehabilitation program and confirmed the lack of author identification\signature.

C. Review of the policy and procedure titled Medical Record Content with last revised date of 2/10 revealed the following "Pertinent progress notes will be recorded at the time of observation....and must be signed promptly."

Based on review of the electronic record system used for Cardiac and Pulmonary Rehabilitation, review of policies and procedures, review of the Operator's Manual for Cardiopulmonary Rehabilitation System and staff interview, the CAH (Critical Access Hospital) failed to ensure the confidentiality and potential unauthorized use of medical record information for 3 of 3 Cardiac and/or Pulmonary Rehabilitation records reviewed (Medical Records 41, 42 and 43). The CAH currently had 30 Cardiac and Pulmonary Rehabilitation outpatients. From 1/1/14 to 6/17/14 the CAH had a total of 54 Cardiac and Pulmonary Rehabilitation outpatients.

Cardiac and Pulmonary Rehabilitation helps patients improve their health and live a more active life after major or ongoing heart or lung problems.

Findings are:

A. During the review of the electronic medical record for Patients 41 and 42 and interview with Cardiac Rehabilitation Nurse-T on 6/17/14 from 4:00 PM to 4:30 PM revealed the following:
-The Cardiopulmonary Rehabilitation System was on the computer located in the Cardiopulmonary Rehabilitation which was shared with physical therapy patients.
-When Cardiac Rehabilitation Nurse-T accessed the program no username or password was required to access patient information.
-Cardiac Rehabilitation Nurse-T was able to access a Pulmonary Rehabilitation patient record and could have made changes to the record that would have been entered by Respiratory Therapist-U.
-Cardiac Rehabilitation Nurse-T confirmed there was no security of the patient record information contained in the Cardiopulmonary Rehabilitation System.

B. Interview with Respiratory Therapist-U on 6/18/14 from 9:45 AM to 10:00 AM revealed the following:
-Uses the same Cardiopulmonary Rehabilitation System as Cardiac Rehabilitation;
-The Cardiopulmonary Rehabilitation System has been used for approximately 3 years; and,
-Confirmed the program could be accessed without entering a username and password.

C. Review of the policies and procedures titled System Access Policy identified as Version 1.0 revealed the following:
"It is the policy of CCCH [Chase County Community Hospital] to safeguard the confidentiality, integrity, and availability of protected health information (PHI)....by controlling access to these systems/applications....The same levels of confidentiality that exist for hard copy PHI....apply to digital and/or electronic protected health information (ePHI)....Person or Entity Authentication...Each user has and uses a unique User Login ID and password that identifies him/her as the user of the information system."

D. Review of the Cardiopulmonary Rehabilitation System Operator's Manual dated October 2010 revealed the following:
"If the System Administrator has activated the security features of the program, you must login....Type your User Name in the first field and....then enter your password." (The System Administrator would be the person at the CAH that has responsibility for computer security.) The CAH failed to activate the security system for the Cardiopulmonary Rehabilitation computer system.