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Based on record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure its policies and procedures regarding advance directives included required and appropriate information for filing complaints and a statement of limitation; failed to educate staff regarding its advance directives policies and procedures; and failed to document whether or not the patient executed an advance directive for 10 of 10 closed patient records reviewed (Patients #4, #5, #6, #7, #8, #9, #10, #11, #12, and #24). Failure to include this information in the policies and procedures limited the patients' and their responsible parties' abilities to make informed decisions regarding their medical care. Failure to educate CAH staff regarding the CAH's policies and procedures limited the staff's ability to educate patients and responsible parties. Failure to document the existence of an advance directive may have resulted in the provision of undesired medical treatment.

Findings include:

Review of the policy and procedure "Advance Directives," the "Resident Information Regarding Advance Directive Policy" provided to swing bed patients, and an untitled document provided to acute inpatients occurred on 11/28/12. These undated documents lacked a statement of limitation clarifying conscience objections that practitioners may raise and lacked information regarding filing of complaints with the State survey and certification agency.

Review of information included in the annual education provided to all staff members identified a lack of information regarding conscience objections and filing complaints with the State survey and certification agency. The staff education information stated, "The hospital . . . must ask if the patient has an advance directive, and must include that information in the patient records."

Review of patient medical records identified areas on the Nursing Assessment and on the care plan for CAH staff to document if the patient had an advance directive. Review of the following records showed the CAH staff failed to complete these areas of the medical record:

Patient #4 - admitted 06/18/12, discharged 06/22/12
Patient #5 - admitted 09/19/12, discharged 09/20/12
Patient #6 - admitted 09/05/12, discharged 09/06/12
Patient #7 - admitted 09/22/12, to acute inpatient 09/24/12
Patient #8 - admitted 06/20/12, discharged 07/05/12
Patient #9 - admitted 08/09/12, discharged 09/13/12
Patient #10 - admitted 07/19/12, discharged 08/14/12
Patient #11 - admitted 10/05/12, discharged 10/12/12
Patient #12 - admitted 05/06/12, discharged 05/09/12
Patient #24 - admitted 07/27/12, discharged 07/28/12

During interview, on 11/27/12 at 3:30 p.m., an administrative nursing staff member (#1) confirmed CAH staff should complete the Nursing Assessment and care plan areas regarding patients' advance directives.

During interview, on 11/28/12 at 9:30 a.m., a social work management staff member (#10) confirmed the documents provided to acute inpatients and swing bed patients lacked the information previously noted.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the availability of drugs and biologicals commonly used in life-saving procedures for prompt use when the CAH removed 1 of 1 Emergency Room (ER) crash cart containing life-saving drugs and biologicals, from the ER for use on the nursing unit. Removing the crash cart from the ER limited the availability of drugs and biologicals used for treatment of life-threatening situations to patients presenting to the ER.

Findings include:

Observation of the ER on 11/27/12 at 11:00 a.m. with an administrative nurse (#1) showed a crash cart containing various medications, including cardiac glycosides, antiarrhythmics, antihypertensives, analgesics, anesthetics, and electrolytes and replacement solutions, used in life-saving procedures.

During an interview on 11/27/12 at 12:20 p.m., an administrative nurse (#1) stated when patients on the nursing unit coded (exhibited signs and symptoms of a respiratory or cardiac arrest), the CAH staff removed the crash cart from the ER for use on the patients. The nurse (#1) confirmed the crash cart contained the ER's life-saving medications needed in emergency situations such as cardiac and trauma events.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the safety of patients, staff, and the public by not securely storing oxygen tanks in 1 of 2 oxygen storage areas (at the nurse's station). Failure to secure oxygen tanks places any person in the vicinity at risk for injury should the tank fall or become damaged.

Findings include:

The CAH did not provide a facility policy regarding the secure storage of oxygen.

Observation of the respiratory therapy storage areas, on 11/26/12 at 3:30 p.m., identified 17 oxygen M-tanks unsecured in a plastic basket on a shelf approximately three feet off the floor in a storeroom behind the nurse's station. A respiratory therapy management staff member (#9) present during the observation confirmed the CAH should secure the tanks.

Observation, at approximately 10:00 a.m. on 11/28/12, identified 17 oxygen M-tanks stored unsecured in a plastic basket on a shelf in a storeroom behind the nurse's station. A maintenance staff member (#4) present during the observation confirmed the CAH staff failed to store the oxygen M-tanks at the nurse's station in a secure manner.




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2. Based on observation, review of hospital construction standards, and staff interview, the Critical Access Hospital (CAH) failed to ensure an accessible emergency call system for 1 of 1 central patient tub/shower room on the nursing unit. Failure to provide patients access to a call light while in the central shower posed a safety hazard to patients should the need to summon assistance occur.

Findings include:

The 1992-93 Guidelines for Construction and Equipment of Hospital and Medical Facilities has outlined the standards regarding a nurses calling system stated, ". . . A nurses emergency call system shall be provided at each inpatient . . . shower room. This system shall be accessible to a collapsed patient lying on the floor. . . ."

Observation of the central tub/shower room occurred on 11/27/12 at 10:00 a.m. and showed two separate areas in the room for the tub and the shower. The immediate area surrounding the shower, located across the room from the tub, lacked a call light.

During an interview on 11/27/12 at 10:05 a.m., a nursing staff member (#7) stated the CAH occasionally utilized the central shower for patients and stated staff left some patients alone in the shower depending on their level of assistance. The staff member (#7) confirmed if a patient required immediate assistance while showering in the room, the patient would have to walk across the room to access the call light by the tub as the shower lacked a call light.

During an interview on 11/27/12 at 10:10 a.m., two nursing staff members (#1 and #7) confirmed a patient recently used the central shower.

Based on bylaws review, record review, and staff interview, the Critical Access Hospital (CAH) failed to appoint 2 of 2 consulting physicians (Providers #4 and #5) and 1 of 1 Allied Health Professional (AHP) (Provider #6) to the CAH's medical staff before the physicians and AHP provided treatment or services to the CAH's patients. Failure to ensure credentialing of physicians and AHP's places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the governing board's "Corporate Bylaws of the Nelson County Health System" occurred on 11/26/12. These bylaws, adopted 05/06/03, stated,
". . . Article 6. . . .
Section 9(a). Medical Staff. Appointments to the medical staff shall be made by the Board of Directors of the Corporation. . . ."

Review of the "Medical Staff By-Laws of the Nelson County Health System" occurred on 11/26/12. These bylaws, adopted 03/30/04, stated,
". . . ARTICLE IV Procedures for Appointment and Reappointment
Section 2. Appointment Process
Subsection 1. . . . the Medical Staff shall review the completed application and make a recommendation to the governing body that the applicant be either appointed to the Medical Staff or rejected for medical staff membership or that the application be deferred for further consideration.
Subsection 2. The governing body at its next regular meeting, shall, with the recommendations of the Medical Staff and administrator, render a decision concerning the appointment of the applicant. . . .
ARTICLE V Clinical Privileges
Section 1. Specific Clinical Privileges.
Subsection 1. Every initial application for staff membership must contain a request for specific clinical privileges desired by the applicant, according to the provisions of Section 2 of Article IV of these bylaws. The governing body shall make final determination to whether or not these privileges will be granted and to what extent. . . .
ARTICLE VIII Medical Staff Categories
Section 1. The Medical Staff
The Medical Staff shall be divided into active, courtesy, consulting, and AHP. . . .
Section 4. Allied Health Professionals (AHP) . . .
Subsection 2. An application for specified services for an allied health professional shall be submitted and processed in the same manner as provided in Article V for clinical privileges. . . .
The Consulting Staff . . .
They shall be appointed in the same manner as other members of the Medical Staff. . . . Consulting medical staff members must have staff privileges at another health service organization and be in good standing. They shall be North Dakota licensed practitioners. . . ."

Review of the "Nelson County Health System Medical Rules and Regulations" section of the bylaws occurred on 11/26/12. These rules and regulations, adopted 03/30/04, stated,
". . . E. Nurse Practitioner
1. Nurse Practitioners are required to be credentialed per NCHS [Nelson County Health System] Medical Staff Bylaws as Allied Health Professionals . . ."

Upon request on 11/27/12, the CAH failed to provide evidence of credentialing for two consulting physicians, Providers #4 and #5, and for one AHP, Provider #6.

Reviewed at 4:40 p.m. on 11/26/12, the CAH's emergency room log indicated Provider #5 provided telemedicine treatment to CAH patients on 06/13/12, 07/06/12, 08/16/12, and 10/23/12.

During interview at approximately 10:30 a.m. on 11/27/12, an administrative radiology staff member (#6) confirmed Provider #4 had provided diagnostic readings of radiographic images for the CAH since 2009.

During interview at approximately 3:35 p.m. on 11/27/12, an administrative staff member (#3) confirmed Provider #4 provided teleradiology services, Provider #5 provided telemedicine services, and Provider #6 provided treatment and services to the CAH's patients for many years. This staff member (#3) confirmed the CAH had not credentialed Providers #4, #5, and #6.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/25/09.

Based on review of policies and procedures and staff interview, the Critical Access Hospital (CAH) failed to furnish acute care and swing bed physical and occupational therapy services in accordance with appropriate written policies and procedures for 3 of 3 days of survey (November 26-28, 2012). The lack of current, up to date policies and procedures placed patients at risk of inconsistent treatment and services and failed to provide direction for the duties and responsibilities of each department.

Findings include:

During interview on 11/27/12 at 9:45 a.m., a CAH administrative staff member (#11) reported a contracted provider provides physical and occupational therapy services to the CAH's acute and swing bed patients.

During interview, on 11/27/12 at 9:00 a.m., a physical therapy staff member (#12) reported the contracted provider provided policies and procedures available to physical therapy and occupational therapy. This staff member (#12) reported he was not aware of any CAH policies and procedures for either service. This staff member (#12) further stated therapists passed information regarding operation of the department from therapist to therapist or obtained information from CAH staff.

The contracted provider's policies and procedures failed to address processes specific to the CAH, such as handling of linen, use of the CAH's pieces of equipment, documentation requirements, or processes.

1. Based on observation, review of professional standards of practice, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff distributed drugs and biologicals in accordance with professional principles on 3 of 3 days of survey (November 26-28, 2012). Failure to properly distribute drugs and biologicals limited the CAH's ability to ensure accurate and safe medication administration, prevent unauthorized use of medications, and maintain control of medications.

Findings include:

The American Society of Health System Pharmacists (ASHP) publication titled "ASHP: Minimum Standard for Pharmacies in Hospitals", dated 2012, page 459, stated, ". . . Review of Medication Orders. All medication orders shall be prospectively reviewed by a pharmacist and assessed in relation to pertinent patient and clinical information before the first dose is administered or made available in an automated dispensing device, except in emergent situations in which the treatment of the patient would be significantly compromised by the delay that would result from pharmacist review of the order. There shall be a procedure for retrospective review of these orders. . . ."

- Observation of medication administration showed the following:
*On 11/27/12 at 8:10 a.m. an administrative nurse (#1) entered the pharmacy and attempted to obtain Cardizem (diltiazem) ER (Extended Release) (an antianginal medication) as ordered for Patient #1 from a stock bottle. The nurse observed the stock bottle of diltiazem before dispensing the medication. The bottle contained immediate release diltiazem and not extended release as ordered. The nurse (#1) retrieved a medication bottle (labeled with Patient #1's name) of diltiazem ER 180 mg from a drawer in the medication cart labeled with Patient #1's room number.

When asked why some medications are in stock bottles and some are contained in bottles labeled with the patient's name, the nurse (#1) stated if the medication is not in stock in the pharmacy, nursing staff must order the medication from an outside pharmacy located 30 miles away. The outside pharmacy dispenses the medication for the patient, designating the medication as the patient's own individual medication, and sends the medication to the CAH. The nursing staff place the patient's own medications in a drawer labeled with the patient's room number in the pharmacy. The nurse (#1) stated nursing staff identify whether a medication is administered from stock or from the patient's own medications on the medication administration record (MAR), noting an "S" for stock medication or an "O" for the patient's own medication.

Review of Patient #1's medical record occurred on all days of survey. The record identified an admission date of 11/26/12 and diagnoses included acute exacerbation of congestive heart failure. Record review identified a Physician's order for Cardizem ER. Patient #1's MAR identified Cardizem ER administered from a stock bottle on 11/26/12. Based on the above observation of medication administration, the stock bottle contained diltiazem in immediate release form instead of extended release form.

During an interview on 11/27/12 at 3:30 p.m., an administrative nurse (#1) confirmed the nurse (#8) gave the wrong form of diltiazem to Patient #1 on 11/26/12.

- Observation of the pharmacy occurred on 11/27/12 at 4:30 p.m. with an administrative nurse (#1). Observation of the pharmacy showed several different types of oral and injectable medications located in drawers and on the shelves of the pharmacy. The pharmacy stocked the medications in different strengths and in bottles with multiple doses. When asked about the process to obtain ordered medications for patients, the administrative nurse (#1) stated nursing staff retrieved the medication from the pharmacy by removing each individual medication from the shelf or drawer to administer to the patients. She stated the pharmacist does not review the patients' medication orders prior to administration and does not fill the patients' ordered medications for nursing staff to administer. The nurse (#1) confirmed nursing staff filled or dispensed medications for patients from the pharmacy upon admission or medication change (discontinued or new medication, change in dose, extra dose, etc.) by picking and choosing which medications to administer according to the order.

Failure to obtain a pharmacist's review of all medication orders prior to administration and ensure a pharmacist dispensed all medications limited the pharmacist's ability to ensure safe medication practices.

2. Based on observation, review of the North Dakota Administrative Code, and staff interview, the Critical Access Hospital (CAH) failed to limit access to the pharmacy in the absence of the pharmacist, ensure staff removed drugs and biologicals only in amounts sufficient for immediate therapeutic needs, and kept and maintained records to follow the flow of pharmaceuticals from the pharmacy for 1 of 1 hospital pharmacy. This failure has the potential to create insufficient distribution, control, and accountability of medications.

Findings include:

The North Dakota Administrative Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. 1. General. During such times as a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance . . . for the provision of drugs . . . by use of night cabinets or floor stock, or both, and in emergency circumstances, by access to the pharmacy . . . 3. Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section. . . . Removal of any drug from the pharmacy by an authorized nurse must be recorded on a suitable form showing patient name, room number, name of drug, strength, amount, date, time, and signature of nurse. b. Such form must be left with the container from which the drug was removed, both placed conspicuously so that it will be found by a pharmacist and checked properly and promptly; or, in the case of a unit dose, place an additional dose of the drug, or the box, on the form. . . ."

- Observation of medication administration occurred on 11/26/12 at 2:05 p.m. and 5:05 p.m. with a licensed nurse (#8) and on 11/27/12 at 8:10 a.m. with an administrative nurse (#1). The nurses entered the pharmacy and retrieved several medications for Patient #1 from a stock supply of medications in the pharmacy.

- Observation of the pharmacy, on 11/27/12 at 4:30 p.m. with an administrative nurse (#1), showed one large room with several different types of oral and injectable medications stored on shelves, in cupboards, and drawers. The pharmacy contained stocked medications in different strengths and in bottles with multiple doses. The room contained all drugs, biologicals, and pharmaceuticals included in a pharmacy and also contained a nurse medication cart, an outdated medication bin, pre-filled prescription medications for outpatients, bags of non-medicated intravenous (IV) solution, IV tubing/supplies, and items nursing staff used on a regular basis.

During an interview on 11/27/12 at 4:30 p.m., when asked about the process to obtain ordered medications for patients, the administrative nurse (#1) stated nursing staff retrieved the medication from the pharmacy whenever needed by removing each individual medication from the shelf or drawer to administer to the patients. She stated the pharmacist does not fill the patients' ordered medications for nursing staff to administer. The nurse (#1) confirmed nursing staff filled or dispensed medications for patients from the pharmacy upon admission or medication change (discontinued or new medication, change in dose, extra dose, etc.) by picking and choosing which medications to administer according to the order. The administrative nurse (#1) identified the pharmacy as the nursing medication room. She confirmed nursing staff accessed the pharmacy in the absence of the pharmacist to remove medications whenever needed for administration to patients, and stated nursing staff did not log the medications removed from the pharmacy. She stated pharmacy staff visited the CAH approximately once a month to remove outdated medications, but did nothing further in the pharmacy. The administrative nurse (#1) stated the CAH failed to realize the CAH must limit access to the pharmacy in the absence of the pharmacist.


22495

22495

Based on review of infection control reports and meeting minutes, review of facility policy, record review, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, track, report, investigate, and control infections and communicable diseases for inpatients and outpatients of the CAH for 6 of 6 months (May-October, 2012). Failure to identify and address incidents of infections among all patients has the potential for infections to spread, or reoccur; affecting the health of all patients, personnel, and visitors of the CAH.

Findings include:

Review of the facility policy titled "Infection Control Committee" occurred on 11/28/12. This policy, dated 2004, stated, "The Committee of the Whole shall serve as the authority for overseeing the surveillance, prevention, and control of infections within this facility. Under the guidance and recommendations . . . this committee will also function as an advisory group to the Quality Assurance/Quality Improvement program. . . . Proactively, any identified Infection Control concerns will be immediately directed to the Medical Staff and appropriate department manager to be acted upon to resolve/correct issues and implement preventative actions. Issues related to Infection Control will be discussed at any appropriate meeting as necessary, with a minimum of at least quarterly to be achieved."

Review of the policy "Infection Control Nurse" occurred on 11/28/12. This undated policy stated, "The primary purpose of your job position is to plan, organize, develop, and direct the Infection Control activities in accordance with current Federal and State Regulations governing our facility, and as may be directed by the Administrator, to assure that our facility investigates, controls and prevents infections. . . . Major duties and responsibilities: Formulate policies and procedures for infection control based on data generated by surveillance, other sources, and current CDC [Centers for Disease Control and Prevention] and OSHA [Occupational Safety and Health Administration] guidelines. . . . Track all infections in the facility, patient/resident and employee. Develop and participate in the planning, conducting, scheduling, etc., of inservice training classes, on-the-job training and orientation programs for facility personnel. Assume the responsibility for maintaining your professional competence through participation in programs of continuing education. . . ."

- Review of Patient #5's closed record occurred on 11/27/12 and identified the CAH admitted the patient to observation on 09/19/12 with acute gastroenteritis and dehydration. The admission history and physical (H&P) listed Patient #5's symptoms as abdominal cramping, diarrhea, and weakness, and identified a temperature of 100 degrees Fahrenheit. The record showed an order for a stool culture and identified staff collected a stool sample on 09/19/12. Patient #5's condition improved and the CAH discharged the patient on 09/20/12. The final lab report of the stool culture, dated 09/23/12, identified Salmonella.

Patient #5's record lacked evidence CAH staff reported, tracked, and followed up with the infection when identified on 09/23/12. Review of the infection control reports and log for September 2012 failed to include Patient #5.

During an interview on 11/28/12 at 11:00 a.m., the infection control nurse (#2) could not provide information or evidence of surveillance for Patient #5's known infection of Salmonella. The nurse (#2) confirmed she did not receive the lab report for Patient #5 and was not aware of the Salmonella. When asked to clarify the process or system the CAH implemented to identify, report, and investigate infections, the nurse (#2) stated it is the nurse on duty's responsibility to inform her via email of all patients with signs and/or symptoms of infections and/or active infections. She stated staff do not provider lab reports to her unless she specifically asked for a report.

- Review of the infection control program occurred on November 26-28, 2012. The infection control reports, logs, and meetings from May through October 2012 failed to include information and documentation of outpatients (emergency room, procedure/treatment, therapies, etc.) with known or suspected cases of infections and/or communicable diseases and failed to include information from August through October 2012. The infection control program failed to include established thresholds of acceptability to ensure the effectiveness of the program and provide corrective action when necessary.

During an interview on 11/26/12 at 4:00 p.m., the infection control nurse (#2) stated the CAH lacked an infection control committee and confirmed she lacked involvement in staff's initial, annual, and ongoing infection control education. The nurse (#2) stated she did not receive or request infection control information from outpatients and confirmed the CAH did not document and include outpatients in infection control surveillance. The infection control nurse (#2) stated she did not receive lab reports from patients with known or suspected infections unless she specifically identified the patient and requested the report herself. The nurse (#2) confirmed the current process the CAH utilized for reporting and tracking infections failed to capture all of the information the program needed to perform thorough surveillance.

Based on record review, review of Medical Staff By-Laws, review of Medical Staff Rules And Regulations, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to maintain medical records for each patient that included dated signatures of the physician or health care professionals for 12 of 27 patient records (Patients #4, #5, #6, #7, #8, #9, #10, #11, #12, #19, #20, and #22) reviewed. Failure to ensure the signing or co-signing of histories and physicals, the signing of physician verbal or telephone orders, the signing of medication reconciliation forms on admission or discharge, the co-signing of allied health professional (AHP) orders by the physician, the co-signing of AHP progress notes by the physician, the signing of ED records by the physician, and the signing of physical therapy and occupational therapy plans of treatment by the physician limited the CAH's ability to ensure the quality and appropriateness of patient care.

Findings include:

Review of the CAH's Medical Staff By-Laws occurred on November 26-28, 2012. This document, approved 11/18/03, stated, ". . . Definitions . . . 5. 'Allied Health Professional' or AHP means an individual, who is either a licensed nurse practitioner, physician assistant, or advanced practice nurse . . . who is qualified to render direct or indirect patient care under the supervision of a licensed practitioner who is an active or courtesy member of NCHS [Nelson County Health System] medical staff. . . .

ARTICLE VIII MEDICAL STAFF CATEGORIES . . . Section 4. Allied Health Professionals (AHP) . . . Subsection 3. The perogatives of an allied health professional shall be to: . . . b. Write orders to be countersigned by the attending practitioner within 48 hours . . ."

Review of the CAH's Medical Staff Rules and Regulations occurred on November 26-28, 2012. This document, approved 03/30/04, stated, ". . .
C. MEDICAL RECORDS 1. The attending health care practitioner shall be responsible for the preparation of a complete and legible medical record for each patient/resident. . . . 4. All clinical entries in the patient/resident's medical record shall be signed, including date and time. . . . 12. Medical staff will review and sign all records written by mid-level practitioners.
D. GENERAL CONDUCT OF CARE . . . 3. All orders must be . . . signed by the medical practitioner within the time frames established. . . .
E. NURSE PRACTITIONER . . . 5. The Nurse Practitioner's supervising physician . . . shall collaborate with the Nurse Practitioner, provide direction, and review/sign off on all NCHS patients. . . ."

Review of the policy, "Medical Record Documentation," occurred on 11/28/12. This undated policy stated,
". . . DIAGNOSTIC AND THERAPEUTIC ORDERS . . . Orders must be authenticated by the attending physician. Verbal orders must be authenticated within 48 hours. Orders must be dated and timed, the signature must be dated and timed. . . .
EMERGENCY ROOM RECORDS . . . Each patient's medical record will be signed by the practitioner in attendance who is responsible for its clinical accuracy. . . ."

Review of closed medical records on November 26-28, 2012 identified the CAH staff failed to ensure the records included physician or AHP signatures as follows:
*Histories and physicals
- Patient #7, Observation, admitted 09/22/12, transferred to acute inpatient on 09/24/12.
- Patient #8, Swing Bed, admitted 06/20/12, discharged 07/05/12.
- Patient #11, Swing Bed, admitted 10/05/12, discharged 10/12/12.

*Verbal and telephone orders
- Patient #8, Swing Bed, admitted 06/20/12, discharged 07/05/12, two orders.
- Patient #9, Swing Bed, admitted 08/09/12, discharged 09/13/12, eleven orders.
- Patient #10, Swing Bed, admitted 07/19/12, discharged 08/14/12, ten orders.
- Patient #11, Swing Bed, admitted 10/05/12, discharged 10/12/12, three orders.

*Medication reconciliation forms on admission or discharge (medication orders)
- Patient #8, Swing Bed, admitted 06/20/12, discharged 07/05/12, admission.
- Patient #9, Swing Bed, admitted 08/09/12, discharged 09/13/12, discharge.
- Patient #10, Swing Bed, admitted 07/19/12, discharged 08/14/12, admission.

*AHP orders not co-signed by physician
- Patient #4, Acute Inpatient, admitted 06/18/12, discharged 06/22/12, three orders.
- Patient #5, Observation, admitted 09/19/12, discharged 09/20/12, six orders.
- Patient #6, Acute Inpatient, admitted 09/05/12, discharged 09/06/12, six orders.
- Patient #7, Observation and Acute Inpatient, admitted 09/22/12, discharged 09/26/12, six orders.
- Patient #8, Swing Bed, admitted 06/20/12, discharged 07/05/12, two orders.
- Patient #12, Acute Inpatient, admitted 05/06/12, discharged 05/09/12, one order.

*AHP progress notes not co-signed by physician
- Patient #7, Observation and Acute Inpatient, admitted 09/22/12, discharged 09/26/12, three notes.
- Patient #11, Swing Bed, admitted 10/05/12, discharged 10/12/12, two notes.
- Patient #12, Acute Inpatient, admitted 05/06/12, discharged 05/09/12, one note.

*ED record not signed by the physician
- Patient #19, admitted 10/22/12.
- Patient #20, admitted 10/30/12.
- Patient #22, admitted 09/10/12 (AHP signature not co-signed).

*Physical therapy and occupational therapy plans of treatment not signed by the physician
- Patient #7, Observation and Acute Inpatient, admitted 09/22/12, discharged 09/26/12.
- Patient #9, Swing Bed, admitted 08/09/12, discharged 09/13/12.
- Patient #10, Swing Bed, admitted 07/19/12, discharged 08/14/12.

During interview, on 11/28/12 at 8:30 a.m., a medical records management staff member (#5) confirmed the CAH medical staff should sign the documents, orders, and progress notes identified. This staff member reported her expectation is CAH nursing staff will review the medical record to obtain signatures before the CAH discharges the patient from the facility, and the medical records staff review the records for signatures and completeness after discharge.

Failure to monitor the medical records for completeness limited the ability of the CAH staff to track and trend this issue; provide a mechanism for corrective action; provide a means to measure improvement; and, ensure the quality of patient care.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/25/09.

Based on observation, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure the confidentiality of record information and failed to provide safeguards against potential loss, destruction, or unauthorized use of patient medical records in 1 of 1 rehabilitation service office on 1 of 3 days of survey (11/27/12). Failure to secure the medical records limited the CAH's ability to maintain the confidentiality and security of the medical records and prevent the risk of unauthorized use.

Findings include:

Review of the CAH policy, "Confidentiality and Safekeeping of Medical Records," occurred on 11/28/12. This undated policy stated "It is the policy of NCHS [Nelson County Health System] to ensure the confidentiality of all medical records. . . ."

During the tour of the Rehabilitation Services Department, on 11/26/12 at 9:00 a.m., a physical therapy staff member (#11) reported the CAH offers physical therapy, occupational therapy, and speech-language pathology services. This staff member reported the services share an office in the department. Observation of the Rehabilitation Services Department, on 11/26/12 at 9:00 a.m., identified an unlocked file cabinet in the office area.

Observation of the Rehabilitation Services Department, on 11/26/12 at 12:15 p.m. and at 5:20 p.m., identified the department unstaffed and the doors closed and unlocked. The file cabinet in the department office remained unlocked. The file cabinet contained patient medical records.

During interview, on 11/28/12 at 10:10 a.m., a physical therapy staff member (#11) confirmed the records in the file cabinet contain patient protected health information and the staff should lock the file cabinet.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 02/25/09.

Based on bylaws review, policy review, record review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Assurance (QA) program evaluated all patient care services and other services affecting patient health and safety for 12 of 12 months reviewed (October 2011-September 2012) and failed to ensure the reporting of the QA program results to the governing body for 11 of 11 months reviewed (November 2011-September 2012). Failure to ensure departments report to the QA Committee as scheduled and establish thresholds of acceptability for QA monitoring and failure to inform the governing body of QA monitoring results limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the governing board's "Corporate Bylaws of the Nelson County Health System" occurred on 11/26/12. These bylaws, adopted 05/06/03, stated,
". . . Article 6. . . .
Section 9(c). Patient Care. The Board of Directors shall see that quality care is provided and that it is periodically reviewed by them. . . . An over-all, NCHS wide healthcare program, consistent with the services offered and available resources, shall be established and maintained to evaluate, and where deemed necessary, to alter the quality of healthcare received by patients/residents. All patient/resident healthcare related services shall be included in the program. . . ."

Review of the "Medical Staff By-Laws of the Nelson County Health System [NCHS]" occurred on 11/26/12. These bylaws, adopted 03/30/04, stated,
". . . Article II Objectives and Responsibilities
Section 2. Responsibilities . . .
c. To account to the governing body for the quality and efficiency of healthcare rendered to patients/residents at NCHS through regular reports and recommendations concerning the implementation, operation and results of the patient/resident care audit and other quality maintenance activities. . . ."

Review of the policy titled "Quality Assurance Program" occurred on 11/26/12. This policy, revised 11/01, stated,
"Purpose: To implement a quality assurance program designed to monitor, evaluate, maintain, and/or improve the quality and appropriateness of patient care . . .
Scope: The Quality Assurance Program shall be facility wide, apply to all departments, services, and practitioners whose activities within the hospital have direct influence on the quality of patient care. The main coordinating responsibility shall be with the Quality Assurance Coordinator.
Methodology: . . . The components of quality assurance activities are:
Surveillance: 1. Development of a planned and systematic method for monitoring and evaluating the quality and appropriateness of services provided. 2. Routine collection of information about the important aspects of the services and periodic assessment of the information to assure conformance with acceptable levels of performance.
Conclusion: 1. Establishment of criteria or acceptable levels of performance by which to measure acceptable quality. . . .
Documentation: 1. The findings and analysis of monitoring activities and the action taken to correct problems and improve patient/resident care are documented, reported as appropriate, and integrated with the overall hospital's Quality Assurance Program. . . .
Responsibilities of the QA Committee . . . The following is an outline of the proposed Quality Assurance activities: . . . Quarterly . . . 7. Quarterly board reports will be completed by the Quality Assurance Coordinator; these reports will be a summary for the quarterly QA activities. . . . Monthly: 1. Each month different departments will present QA to the QA meeting. This will result in each department submitting a report quarterly. . . .
Implementation: The findings of the Quality Assurance activities throughout the hospital shall be reported to the Quality Assurance Coordinator, in a written report . . . The Quality Assurance Coordinator will in turn submit a written quarterly analysis/report to the Administrator. The Administrator will submit the quarterly report to the Governing Board. This report shall include the problems identified, actions taken, and overall progress of the Quality Assurance Program. . . .
Authority and Responsibility: The governing body and administrator will support quality assurance activities within the institution by assuming responsibility for the ongoing Quality Assurance Program. . . . The Quality Assurance Committee obtains its authority from the governing body and this committee is responsible to the governing body. . . . As specified in the plan, each clinical discipline and service will participate in the review of the patient care it provides. . . ."

Reviewed on November 26, 2012, the November 2011-September 2012 Board of Directors Meeting Minutes lacked evidence of receipt and review of quarterly QA Committee reports.

Reviewed on November 27, 2012, the 2012 Medical Staff Minutes (including the QA Committee reports from monitoring conducted October 2011-September 2012) indicated the following departments did not submit reports at the quarterly meetings:
Medical Staff (Peer Review) - July
Housekeeping - April, July, October
Maintenance - April, October
Activities - January, April, July, October
Lab - January, July, October
X-ray - January, July, October
Quarterly Report to Board - January, April, July, October
Nursing - October
Medical Records - January, April, July, October
Infection Control - April
Pharmacy - October
Dietary - October
Respiratory Therapy - January, April, July, October
Emergency Room - January, July, October

The following 2012 QA monitors lacked evidence the departments set thresholds of acceptability: nursing, infection control, safety/risk, respiratory therapy, housekeeping, maintenance, pharmacy, and dietary.

During interview the afternoon of 11/26/12, a nursing staff member (#2) responsible for QA for nursing services and Infection Control stated she does not conduct monitoring for nursing service quality of care.

During interview at approximately 10:25 a.m. on 11/27/12, an administrative nursing staff member (#1) stated the department did not document monitoring activities, set thresholds of acceptability for the monitors, or submit reports to the QA Committee.

During interview at approximately 10:35 a.m. on 11/27/12, an administrative medical records staff member (#5) stated the department did not document monitoring activities, set thresholds of acceptability for the monitors, or submit reports to the QA Committee.

During interview at approximately 10:50 a.m. on 11/27/12, a respiratory therapy staff member (#9) stated the department had not conducted QA monitoring prior to November 2012 and the department had not set thresholds of acceptability for the monitors.

During interview at approximately 10:25 a.m. on 11/28/12, an administrative maintenance staff member (#4) stated the department did not document monitoring activities, set thresholds of acceptability for the monitors, or submit reports to the QA Committee.

During interviews the morning of 11/28/12, an administrative staff member (#3) confirmed all departments had not submitted QA reports as required and the QA Committee had not monitored to ensure departments submitted their QA reports; all departments had not set thresholds of acceptability for their QA monitoring; and the CAH did not have evidence of submitting quarterly reports to the governing board.

Based on bylaws review, policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the quality and appropriateness of the treatment furnished in 2011 by 1 of 1 Allied Health Professional (AHP) (Provider #6) providing care to the CAH's patients. Failure to evaluate the quality and appropriateness of the treatment furnished has the potential to affect patient outcomes involving care provided by AHP's.

Findings include:

Review of the governing board's "Corporate Bylaws of the Nelson County Health System" occurred on 11/26/12. These bylaws, adopted 05/06/03, stated, ". . . Article 6. . . . Section 9(c). Patient Care. . . . The Medical Staff shall be responsible to the Board of Directors for the quality of healthcare received by the patients/residents. . . ."

Review of the "Medical Staff By-Laws of the Nelson County Health System" occurred on 11/26/12. These bylaws, adopted 03/30/04, stated,
". . . Article II . . . Section 1. Objectives . . .
d. To insure [sic] a high level of professional performance through an ongoing review and evaluation of each practitioner's and AHP's performance at NCHS [Nelson County Health System]."

Review of the policy titled "Quality Assurance Program" occurred on 11/26/12. This policy, revised 11/01, stated, ". . . Responsibilities of the QA [Quality Assurance] Committee . . . Quarterly 1. A doctor of medicine, who is a member of the medical staff, will at least quarterly conduct reviews of all practitioners to determine the quality and appropriateness of the diagnosis and treatment provided to patients. . . ."

Reviewed on 11/26/12, the CAH's 2011-2012 peer review records did not include evaluations for Provider #6. Upon request on 11/27/12, the CAH failed to provide evidence a physician evaluated the quality and appropriateness of the treatment furnished by Provider #6.

During interview at approximately 3:35 p.m. on 11/27/12, an administrative staff member (#3) confirmed Provider #6 delivered care to the CAH's patients in 2011-2012 and the CAH did not have a physician evaluate the appropriateness of the diagnosis and treatment furnished by Provider #6.

Based on bylaws review, policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the treatment furnished in 2011 by 3 of 3 physicians (Providers # 1, #2, and #3) reviewed. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the treatment furnished by the physicians limits the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the governing board's "Corporate Bylaws of the Nelson County Health System" occurred on 11/26/12. These bylaws, adopted 05/06/03, stated, ". . . Article 6. . . . Section 9(c). Patient Care. . . . The Medical Staff shall be responsible to the Board of Directors for the quality of healthcare received by the patients/residents. . . ."

Review of the "Medical Staff By-Laws of the Nelson County Health System" occurred on 11/26/12. These bylaws, adopted 03/30/04, stated,
". . . Article II . . . Section 1. Objectives . . .
d. To insure [sic] a high level of professional performance through an ongoing review and evaluation of each practitioner's . . . performance at NCHS [Nelson County Health System]."

Review of the policy titled "Nelson County Health System Peer Review Guidelines" occurred on 11/26/12. This policy, undated, stated, ". . . 4. Peer Review Process: . . . For the purposes of the external peer review program, a peer reviewer shall be designated by the circumstance requiring peer review from one of the referral hospitals of NCHS. . . ." The policy did not require a network hospital or a quality improvement organization (QIO) or equivalent to evaluate the quality and appropriateness of the treatment furnished by physicians at the CAH.

Reviewed on 11/26/12, the CAH's 2011-2012 peer review records did not include evaluations for Providers #1, #2, and #3 by a network hospital or a quality improvement organization (QIO) or equivalent. Upon request on 11/27/12, the CAH failed to provide evidence a network hospital or a quality improvement organization (QIO) or equivalent evaluated the quality and appropriateness of the treatment provided by Providers #1, #2, and #3.

During interview at approximately 3:35 p.m. on 11/27/12, an administrative staff member (#3) confirmed the CAH did not have a network hospital or QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment furnished by Providers #1, #2, and #3.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure notification of the organ procurement organization (OPO) for 1 of 1 patient record (Patient #3) reviewed of a patient who died in the CAH. Failure to notify the OPO prevented the opportunity to determine the medical suitability for organ donation.

Findings include:

Review of Patient #3's closed emergency department (ED) medical record occurred on 11/26/12. The CAH admitted the patient to the ED on 05/07/12, and the patient expired the same day. The form "Record Of Death," dated 05/07/12, stated, "Required Referral and Required Request for Organ/Tissue/Eye Donation (Must be completed on all deaths)." This part of the form was blank. The medical record lacked evidence the CAH staff contacted the OPO.

During interview, on 11/27/12 at 2:55 p.m., an administrative nursing staff member (#1) reported the CAH staff should contact the OPO for all deaths.