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Based on record review and interview the facility failed to ensure the Critical Access Hospital (CAH) had a system in place to conduct a yearly evaluation of the hospital's total program to determine whether the utilization of services was appropriate, the established policies were followed and if any changes were needed. Findings:

Review of the Quality Committee Meeting Minutes for fiscal year 2009 on 3/18/10 revealed evidence the facility was reviewing the volume of patients served, selecting and reviewing both active and closed clinical records, and evaluating, reviewing and revising the CAH's health care policies. However, there was no documented evidence the facility had performed a yearly evaluation of their total program to determine whether the utilization of services was appropriate, the established policies were followed, and if any changes were needed.
Interview with the Hospital Administrator on 3/19/10 at 9:55 am disclosed, "We do not have a summary of the total findings of the Quality Committee annually since I 've been here."

Interview with the Administrator's Assistant on 3/19/10 at 10:15 am revealed, "Each department does a year end summary and that is presented at the August meeting each year. We have not ever had a summary of the department's reports."

Based on observation, policy and procedure review and interview, the facility failed to ensure all medications available to administer to patients had not expired. This placed patients at risk to receive medications with potentially negative outcomes. Findings:

Observation during the tour of the OR (Operating Room) department revealed a locked anesthesia cart in OR room #1 which contained medications for use by anesthesia during a surgical procedure. The anesthesia cart contained the following expired medications:

1. Clindamycin (antibiotic) 600 milligram vials with manufacturer expiration date 2/1/10.
2. Nitro-BID (cardiac medication) 2% 1 gram ointment packets with manufacturer expiration date 1/10 .
3. Metoclopramide (stomach medication)10 milligram 2 milliliter vial with manufacturer expiration date 2/2010.
4. Sterile Water for injection 10 milliliter vial with manufacturer expiration date 2/1/10.

Review of the Policy and Procedure titled "Recalled and Outdated Medications and Parenterals" included: "Outdates, 1. All outdated medications are returned to the Pharmacy to be disposed of or returned for credit or exchange. 3. Drugs will outdate on the last day of the month in which the expiration date is noted by the manufacturer, unless a specific day of the month is specified."

During an interview with the OR Nurse Manager on 3/16/10 at 2:10 pm she stated, "The CRNA (Certified Registered Nurse Anesthetist) is responsible for inventorying the anesthesia medication cart at the beginning of the month and returning any expired medication to the pharmacy and replacing these expired medications."

Based on clinical record review, review of the Medical Staff Bylaws, and interview, the facility failed to ensure all verbal orders were signed by the practitioner giving the order within the acceptable timeframes for 2 out of 21 sampled patients' medical records (#'s 8, 15). Findings:

Review of Patient #15's clinical record revealed the Patient was admitted on 2/11/10 with a diagnosis of severe progressive multiple sclerosis. Further review of the Physician's Order section revealed a verbal order dated 2/11/10 at 10:25 am for, "baclofen (muscle relaxant) 20 mg po (by mounth) x 1". The physician had not signed the order.

Review of Patient #8's clinical record revealed the Patient was admitted on 2/28/10 with a diagnosis of GI bleed. Review of the Physician's Order section revealed a verbal order written 3/1/10 at 2245 pm to give "10 mg vitamin K IM now" and one written on 3/6/10 at 8:35 am for, "Change diet, Advance to full liquid including boost diet suplement, portable chest x-ray this am". The physician had not signed the orders.

Review on 3/18/10 of the Medical Staff Bylaws, updated 4/08, Appendix A, Rules and Regulations revealed, "(3) PHYSICIAN ORDERS All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to a staff member of the facility acting within the scope of their designated field and signed by the attending physician or mid-level practitioner with [in] 72 hours."

Interview on 3/16/10 at 9 am with the Health Information Manager confirmed the forms had not been signed.