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Based on policy review, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to include consideration of their estimated needs for water (potable and non-potable) and fuel, during an interruption in services, as part of the planning for emergency fuel and water agreements. The administrative staff identified a census of 6 inpatients at the time of the survey and reported an average daily census of 6 inpatients. The CAH employed 116 employees at the time of the survey.

Failure to ensure adequate emergency water and fuel is available to meet the CAH's critical functions during an interruption in services could potentially cause a lack of the necessary fuel and water resources to provide adequate patient care.

Findings include:

1. Review of a maintenance policy titled "Utilities Management", approved in January 2014, revealed in part " . . . D. Plumbing 2d. If there is a City Water Supply failure, a tank truck of water will be supplied by Roberts Dairy company . . . "

Review of a Maintenance policy titled "Procurement of Emergency Water Supply", approved in January 2014, revealed in part ". . . Alegent Health Community Memorial Hospital will ensure a supply of potable water during an emergency . . . " The policy lacked assessment details of the amount of potable and non-potable water that the CAH had on hand, the amount needed to continue services, and how quickly a delivery of emergency water would be needed.

2. During an interview on 10/14/14 at 2:30 PM, Staff D, Maintenance Supervisor, reported he thought the emergency generator fuel tank held about 250 gallons, but was not sure how long that amount of fuel would last on full load. Staff D indicated the CAH had agreements for emergency fuel and water and provided a copy of the Memorandum of Understanding (MOU) documents. He was not aware if the CAH had completed an assessment of the amount of fuel and water (potable and non-potable water) the CAH potentially had on hand, the amount needed to continue services, or how quickly a delivery of emergency fuel and water would be needed.

a. Review of a document title "Memorandum of Understanding", (MOU)dated 10/2/09, revealed an agreement between United Western Coop and the CAH for fuel oil to operate the emergency generator. The document lacked the details to address the expectation for the quantity of fuel delivered and/or time frame of delivery.

b. Review of a document title "Memorandum of Understanding", dated 7/20/09, revealed an agreement between Roberts Dairy Company and the CAH for potable water in the event of an emergency. The MOU failed to address the potential quantity of water needed and did not identify a tank truck of water would be delivered, as stated in the Utilities Management policy. In addition, the MOU lacked details to address the time frame of delivery.

3. During an interview on 10/15/14 at 9:15 AM, Staff E, Safety Specialist/Risk Liaison, reported she was involved in the disaster/emergency planning for the CAH, but was not aware if the CAH had completed an assessment of their estimated needs for fuel and water to assist in planning the agreements with outside entities, and determine how much might be needed, and how quickly it would be needed.

Based on Critical Access Hospital (CAH) medication error reports reviewed , policy review and staff interview, the nursing staff failed to notify the physician when medication errors occurred for 5 of 15 Patients, (Patients #1, #2, #3, #4, and #5). The CAH had a current census of 6 inpatients.

Failure to report medication errors to the physician could potentially cause harm to patients if receiving the wrong medication, receiving medication at the wrong time, or by the wrong route.

Findings include:

1. Review of the CAH policy titled Medication Errors reviewed 7/14, revealed in part... "A. 2. Immediate reporting of all medication errors upon discovery is required, including physician notification."

2. Review of patient medication event reports revealed:

a. The Medication Report for Patient #1 dated 9/18/14 at 3:30 PM revealed Patient #1 received Zosyn (antibiotic) IV (intravenous) 1.5 hours later than the prescribed dose was ordered. Nursing staff failed to notify the physician an error occurred.

b. The Medication Report dated 6/21/14 at 6:17 PM revealed Patient #2 received an extra dose of Spiriva inhalation (breathing medication) without a physician order. Nursing staff failed to notify the physician an error occurred.

c. The Medication Report dated 6/10/14 at 2:12 AM revealed Patient #3 received Diltiazem (blood pressure medication) regular release instead of extended release as ordered by the physician. Nursing staff failed to notify the physician an error occurred.

d. The Medication Report dated 5/9/14 at 5:00 PM revealed Patient #4 did not receive Protonix 40 mg (milligrams), (antacid) as ordered by the physician. Nursing staff failed to notify the physician an error occurred.

e. The Medication Report dated 3/18/14 at 9:00 AM revealed Patient #5 received Alcaine (anesthetic) in the left eye instead of the right eye as ordered by the physician. Nursing staff failed to notify the physician an error occurred.

3. During an interview on 10/13/14 at 2:00 PM, Staff A, Director of Pharmacist stated nurses are to notify the physician of all medication errors that reach the patient.

During an interview on 10/13/14 at 4:00 PM, Staff B, Vice president of Patient Care Services, stated the nursing staff were not notifying the physicians when medication errors occurred. Documentation on the Medication Error forms lacked evidence the nursing staff notified physicians of the medication errors. The nursing staff should notify the physicians when medication errors occur for proper patient care.

Based on review of policies and staff interview, the Critical Access Hospital (CAH) staff failed to update the Patient Rights policy that contained the current Patient Visitation Rights information. The CAH had a current census of 6 inpatients at the beginning of the survey.

The CAH staff identified an average number of outpatients served in the following out patient areas:

-Out patient surgery: 15 patients per month
-Emergency room: 325 patients per month
-Lab: 100 patients per day
-Cardiac rehab: 7 patients per month
-Pulmonary rehab: 1 patients per month
-Respiratory therapy: 8 patients per month
-Sleep study: 2 patients per week
-Physical Therapy: 20 patients per day
-Speech Therapy: 2 patient every 6 months
-X-ray: 650 patients per month
-Ambulatory Infusion Center: 113 patients per month

Failure to provide patients with current visitation rights could potentially result in patients' visitors being restricted.

Findings include:

1. Review of CAH policy titled "Patient Visitation Rights", revised 8/13, revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview on 10/14/14 at 10:05 AM, Staff B, Vice President Patient Care Services, acknowledged the Patient Visitation Rights policy lacked the current patient visitation rights information as required by the regulations.

Based on review of policies and documents, observations, and staff interview, the Critical Access Hospital (CAH) staff had failed to update the CAH visitation policy and include the required patient rights for visitation in accordance with current patient visitation rights. The CAH had a current census of 6 inpatients at the time of the survey.

The CAH staff identified an average number of outpatients served in the following out patient areas:

-Out patient surgery: 15 patients per month
-Emergency room: 325 patients per month
-Lab: 100 patients per day
-Cardiac rehab: 7 patients per month
-Pulmonary rehab: 1 patients per month
-Respiratory therapy: 8 patients per month
-Sleep study: 2 patients per week
-Physical Therapy: 20 patients per day
-Speech Therapy: 2 patient every 6 months
-X-ray: 650 patients per month
-Ambulatory Infusion Center: 113 patients per month

Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care services or treatment modalities.

Findings include:

1. Review of CAH policy titled "Patient Visitation Rights", revised 8/13, revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. Observations during tour of the CAH on 10/14/14 revealed the Patient Handbook that contained the Patient Rights information available at the CAH registration desk where inpatients and outpatients registered for treatment.

Review of the Patient Rights in the Patient Handbook, revised May 2013, revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

3. During an interview on 10/14/14 at 8:05 AM, Staff F, Patient Access Representative, stated registration staff provided patients to be admitted and outpatients a copy of the Patient Handbook during the registration process.

During an interview on 10/14/14 at 10:05 AM, Staff B, Vice President Patient Care Services, acknowledged the Patient Visitation Rights policy and the Patient Handbook lacked the current patient visitation rights information as required by the regulations.