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I. Based on observation, review of records and staff interview, the hospital failed to follow their policy for daily defibrillator checks. The critical access hospital (CAH) administrative staff identified the hospital had 6 working defibrillators and 2 of 6 lacked evidence of the completion of daily defibrillator checks (the defibrillators on crash carts in the acute care nursing unit and the surgery unit).

Failure to record and conduct daily defibrillator checks could potentially allow staff to use a malfunctioning defibrillator when needed for a life threatening crisis.

Findings include:

1. During the initial tour of the acute care nursing unit with Staff R, Director of the Acute Care Nursing Unit, on 1/26/15 at 12:00 PM, observation revealed 1 crash cart with a defibrillator. Review of the past records for three months revealed the documentation for daily defibrillator checks lacked evidence of daily checks on the following dates:

November 1, 9, 18, 22, 23, 24, 26, 2014;
December 3, 4, 9, 13, 17, 31, 2014; and
January 1, 3, 4, 10, 23, 2015.

During the initial tour of Surgical Unit with Staff Q, Surgery Manager, on 1/27/15 at 1:00 PM, observation revealed 1 crash cart with a defibrillator. Review of the past records for three months revealed the documentation for daily defibrillator checks lacked evidence of daily checks on the following dates:

November 20, 21, 2014
December 1, 3, 4, 5, 8, 10, 11, 12, 15, 16, 17, 19, 30, 31, 2014
January 6, 7, 8, 9, 12, 21, 22, 23, 2014

2. Review of policy/procedure titled, Emergency Crash Cart, dated 1/14, and revealed in part the following: The defibrillator is test loaded and the integrity of the numbered lock on the medication drawer is checked nightly by an RN. A written record is kept and initialed when a check has been completed.

3. During an interview on 1/26/15 at 1:30 PM, the Acute Care Manager acknowledged the defibrillator is to be checked nightly and the monthly records lack verification showing that this was completed nightly.

During an interview on 1/27/15 at 1:30 PM, the Surgery Manager acknowledged the defibrillator is to be checked daily and the monthly records lack verification that this was completed nightly.


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II. Based on observation and staff interviews, the critical access hospital (CAH) failed to maintain a sanitary environment in the kitchen. The administrative staff identified a census of 5 inpatients and the Assistant Director of Nutrition Services identified dietary staff provided approximately 25-30 patient meals daily.

Failure to maintain a sanitary environment in the Nutrition Services Department could potentially lead to contamination of patient food.

Findings include:

During observation on 1/26/15, at 12:15 PM, with Staff I, Assistant Director of Nutrition Services, identified the following concerns

1. A large area of the dish room ceiling, located above the dish machine, extending toward the middle of the room and along the outside edge of the clean end of the dish machine, revealed cracked, blistered and discolored paint with some areas where the paint had flaked off. The condition of the ceiling allowed for the potential of falling particles to contaminate clean items in the dish room and failed to provide a surface that could be appropriately cleaned

During an interview at the time, Staff I reported this area of the ceiling has been a chronic problem, related to the steam generated from the dish machine and maintenance has fixed it before. She could not recall how long ago they had repaired it last, but reported it had been awhile.

During an interview on 1/27/15 at 9:15 AM, Staff K, Facilities Director, confirmed the dish room ceiling has been a chronic problem related to the steam. He reported the ductwork, to vent the dish machine steam, was replaced a few years ago, and the ceiling repaired at that time. Staff K acknowledged it currently needed repair.

During an interview on 1/28/15 at 7:40 AM, Staff J, Director of Nutrition Services, confirmed the dish room ceiling has been an ongoing problem and fixed several times. She reported they continue to alert maintenance to the need for repair but are frustrated with chronic need of repair. Staff J was not sure when the last repair occurred but estimated maybe a couple years ago.

2. A square ceiling vent, adjacent to the dish machine, had a soiled and rusted surface over the majority of the area.

3. A semi-circular ceiling vent, located across the room from the dish machine, had a soiled and rusted surface over the majority of the area.

During an interview at the time, Staff I reported maintenance was responsible to clean the ceiling vents and not sure at what frequency this occurred.

4. A Dayton wall-mounted fan, located in the dish room, had accumulated dust over the front and back of the fan. Staff I reported Environmental Services cleaned the fan monthly but was not sure when it was last cleaned.

During an interview on 1/26/15, at 12:40 PM, Staff F, Environmental Services Director, reported the January cleaning checklist had not been posted yet and could not locate the previous checklist for the previous month, therefore Staff F was unable to verify when the fan was last cleaned.

The Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2013 editions, requires that food establishment floors, walls and ceilings be designed, constructed, and installed so they are smooth and easily cleanable and non food-contact surfaces of equipment be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) failed to ensure the physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner, for 1 of 1 mid-level practitioner (Practitioner K).

The CAH staff reported the volume of services by the mid-level practitioner (Practitioner K) for 4/1/14 - 12/28/14 as follows: 12 inpatients, 2 observation patients, and 41 outpatients.

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioner limits the opportunity to review specific patient records to ensure quality care is provided by the mid-level practitioner and learning opportunities.

Findings include:

1. Review of CAH policies/procedures, Medical Staff By-Laws and Rules and Regulations revealed they lacked the requirement to ensure the physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

2. Review of documentation revealed no documentation of Physician review of the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner

3. During an interview on 1/28/15 at 10:50 AM, Staff H, Quality and Patient Experience Director, acknowledged Mid-level Practitioner K provided care to patients at the CAH and acknowledged there was no documentation showing the physician reviewed the mid-level practitioner's patient medical records with the mid-level practitioner.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) failed to ensure the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records (Practitioner K).

The CAH staff reported the volume of services by the mid-level practitioner, Practitioner K from 4/1/14 - 12/28/14 was follows: 12 inpatients, 2 observation patients, and 41 outpatients.

Failure of the mid-level practitioner to participate with a physician in the periodic review of the mid-level practitioner's patient records could potentially result in changes in the quality of care provided to patients or in missed opportunities for improvement in patient care.

Findings include:

1. Review of CAH policies/procedures, Medical Staff By-Laws and Rules and Regulations revealed they lacked the requirement to ensure the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records.

2. Review of documentation revealed no documentation the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records.

3. During an interview on 1/28/15 at 10:50 AM, Staff H, Quality and Patient Experience Director, acknowledged Mid-level Practitioner K provided care to patients at the CAH and acknowledged there is no documentation to show the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records.

Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to ensure the required group of professionals, including a mid-level provider, reviewed all patient care policies for 21 of 21 patient care departments (Health Information Management, Plant Operations, Respiratory Therapy/Cardiopulmonary, Obstetrics, Emergency Department, Special Care Unit, Cardiac Rehabilitation/Cardiac Management, Laboratory, Skilled Care, Environmental Services, Infection Prevention, Anesthesia, Physical Rehabilitation/Physical Therapy/Occupational Therapy, Safety/Emergency Preparedness, Radiology, Diabetes Education, Nutritional Services, Pharmacy, Surgery/Operating Room/Post Anesthesia Recovery Unit, Outpatient Nursing Services, and Acute Care/Nursing).

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to ensure the CAH policies were consistent with practice and updated as needed.

Findings include:

1. Review of CAH policy titled "Policy Manual Review", dated 8/14, revealed in part, ". . . All new policies will be developed with the advice of a group of professional personnel, including a physician, nurse practitioners, clinical nurse specialist, if they are on staff, and at least one member who is not a member of the CAH staff, called the CAH policy review committee. . . Policies are reviewed, as needed but at least annually, by the CAH policy review committee. . . ."

2. Review of CAH Policy Review Committee Meeting Minutes for February 25, 2014 documented the absence of a mid-level provider at the meeting and the committee approved policies for Surgery/Operating Room/Post Anesthesia Recovery Unit, Outpatient Nursing Services, and Acute Care/Nursing.

Review of CAH Policy Review Committee Meeting Minutes for May 27, 2014 documented the absence of a mid-level provider at the meeting and the committee approved policies for Physical Rehabilitation/Physical Therapy/Occupational Therapy, Safety/Emergency Preparedness, Radiology, Diabetes Education, Nutritional Services, and Pharmacy.

Review of CAH Policy Review Committee Meeting Minutes for August 26, 2014 documented the absence of a mid-level provider at the meeting and the committee approved policies for Cardiac Rehabilitation/Cardiac Management, Laboratory, Skilled Care, Environmental Services, Infection Prevention, and Anesthesia.

Review of CAH Policy Review Committee Meeting Minutes for November 25, 2014 documented the absence of a mid-level provider at the meeting and the committee approved policies for Health Information Management, Plant Operations, Respiratory Therapy/Cardiopulmonary, Obstetrics, Emergency Department, and Special Care Unit.

3. During an interview on 1/27/14 at 1:55 PM, Staff H, Quality and Patient Experience Director, acknowledged the mid-level provider was not present at the CAH Policy Review Committee meetings on February 25, 2012, or May 27, 2014, or August 26, 2014, or November 25, 2014 for annual review of the above stated policies and the CAH lacked documentation showing the mid-level reviewed those policies.

Based on review of policies and procedures and medication error reports, and staff interview, the Critical Access Hospital (CAH) nursing staff failed to follow the CAH policy for reporting medication errors for 7 of 16 medication error reports (Patients #14, #15, #16, #17, #18, #19, and #20). The Chief Nursing Officer identified an average daily census of approximately 5 patients. The CAH had a census of 5 inpatients at the time of the survey.
Failure to report medication errors when they occur to the physician could potentially harm patients if receiving the wrong medication, receiving medication at the wrong time or by the wrong route.
Findings include:
Review of the CAH policy titled "Medication Errors" revised 5/14, revealed the following in part, ..."When a medication error occurs...the variance will be reported to the attending or on-call physician.
Review of the medication error reports revealed the reports for Patients #14, #15, #16, #17, #18, #19, and #20 lacked documentation the hospital staff notified the attending physician when the medication errors were identified.
During an interview on 1/27/15 at 1:45 PM and a follow up interview on 1/28/15 at 10:00 AM the Pharmacist acknowledged hospital staff failed to notify physicians of medication errors according to the hospital policies and procedures.

Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) Nutrition Services staff failed to use sanitary practices during food handling and patient meal service. The administrative staff identified a census of 5 inpatients and the Assistant Director of Nutrition Services identified dietary staff provided approximately 25-30 patient meals daily.

Failure to maintain sanitary practices during meal service and food handling could potentially result in food contamination of the patients' food leading to foodborne illness.

Findings include:

1. Observation during food preparation and meal service on 1/27/15, from 11:05 AM to 11:53 AM, identified the following concerns:

Staff L, cook, wore gloves while sectioning a 5 pound block of cheese, in order to wrap into smaller packages. Staff L touched several surfaces, including, but not limited to, a labeling marker, cart, clothing, garbage can lid, and the walk-in door handle with gloved hands. Then Staff L handled the cheese during the wrapping process with the same gloves.

Staff N, dietary aide, wore gloves while assembling a sandwich. Staff N obtained a loaf of bread and a margarine container with her gloved hands and opened the bread bag. She removed the bread slices with tongs but then handled the bread without changing the gloves. Staff N touched the garbage can lid with the gloved hands to discard items, took soiled items to the dish room, then obtained a damp cloth and wiped the inside of a margarine container lid, while wearing the contaminated gloves, and put the lid back on the margarine container.

Staff M, cook, was assigned to serve the hot food for the noon patient meal. Staff M initiated the meal service with clean, gloved hands. During meal service she touched a variety of surfaces including, but not limited to, pot holders, steamer handle, clothing and a hamburger bun package and then handled a patient's hamburger bun, a Reuben sandwich and the apple rings for 8 of 10 patient plates, wearing the same gloves. Staff M changed her gloves at one point during the meal service, but failed to wash her hands before donning the new gloves.

2. During an interview on 1/28/15 at 7:40 AM, Staff J, Director of Nutrition Services, reported dietary staff are expected to changes gloves when starting a new task, use clean gloves when handling ready-to-eat food and should wash their hands prior to putting on clean gloves.

3. Review of a Nutrition Services policy titled "Hand Hygiene", reviewed in 5/13, revealed in part ". . . Proper hand hygiene is crucial to lowering the risk of transmitting foodborne illness and nosocomial microorganisms to patients . . . Hands should be washed . . . when changing gloves for any reason.

The Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2013 editions, requires gloves to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Food employees must clean their hands after handling soiled equipment and utensils, during food preparation, as often as necessary to remove soil and prevent cross contamination when changing tasks and before donning gloves for working with food.

Based on observation, review of policies and procedures, and staff interviews, the Critical Access Hospital (CAH) staff failed to secure and protect patient information from unauthorized users in the Laboratory department. The Laboratory staff reported approximately 6,500 patient file folders with reports in the laboratory department and approximately 250,000 patient records in a storage room located at the north end of the laboratory department.

Failure to secure the patient information could potentially cause a misuse of patient information and/or stolen identity for the individual patients.


Findings include:

1. An observation on 1/27/15 at 8:55 AM, during the initial tour of the laboratory department revealed the following.

- An error printer binder that contained approximately 200 patient laboratory testing slips. Each slip contained patient information consisting of name, name of doctor, medical record number, patient account information and confidential medical information.

- A serology log binder titled "I" located on a counter in the laboratory that contained approximately 5,000 patient laboratory procedure information. Each entry contained patient information consisting of name, name of doctor, medical record number, and confidential medical information.

- A blood product log out binder located on a counter in the laboratory that contained approximately 1,000 patient laboratory procedure information. Each entry contained patient information consisting of name, name of doctor, medical record number, and confident medical information.

- A transfusion testing record located on a counter in the laboratory that contained approximately 100 patient laboratory procedure information. Each entry contained patient information consisting of name, name of doctor, medical record number, and confidential medical information.

- 1 of 1 storage room located at the north end of the laboratory that contained open shelving units with approximately 250,000 closed patient file folders with reports. Each folder contained patient information consisting of name, name of doctor, date of birth, age, medical record number, laboratory results, and additional confidential medical information.

2. Review of CAH policy titled "Medical Record Security" revised 11/12, revealed, in part, ..."Areas housing health information shall be restricted to authorized personnel...when in use within the hospital, records shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized users."

Review of CAH policy titled "Confidentiality" revised 8/14, revealed, in part, ...."Information about patients is considered confidential. Gaining access to that information is considered a breach of confidentiality unless employees have a clinical or legal need for information."

3. During an interview at the time of the observation, Staff A, Director of Laboratory, verified that housekeeping cleaned the Laboratory department including the storage area during the evening prior to staff arrival in the morning. Staff A acknowledged the housekeeping staff have a master key to gain access to the laboratory unit and storage room.

During an interview on 1/27/15 at 10:05 AM, Staff F, Director of Environmental Services, verified housekeeping staff cleaned the Laboratory department at night when laboratory staff were not present and they have a master key to gain access to the laboratory unit and storage room.

During an interview on 1/27/15 at 10:15 AM, Staff G, Director of Clinics and Outpatient Services acknowledged CAH laboratory staff failed to follow hospital policy/procedure for security of patients medical record information.





3. During an interview, at the time of the observation, Staff A, Director of Radiology, verified that housekeeping cleaned the Radiology department including the radiology file room prior to staff arrival in the morning. Staff A acknowledged the housekeeping staff have a master key to gain access to the radiology office and radiology file room.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure 6 of 8 active physicians, 2 of 3 courtesy physicians, and 2 of 2 consulting physicians, selected for review, received outside entity peer review performed by the Network Hospital to evaluate the appropriateness and diagnosis and treatment furnished to patients at the CAH in accordance with the CAH's agreement with the Network Hospital (Physicians A, B, C, D, E, F, G, H, I, and J). The CAH credentialed 10 active physicians, 34 courtesy physicians, and 32 consulting physicians.

Failure to ensure all medical staff members received outside entity peer review affects the CAH's ability to assure physicians provide quality care to their patients.

Findings include:

1. Review of CAH policy titled "Provider Peer Review", dated 8/14, revealed in part, ". . . Each provider at Greene County Medical Center will have peer review completed during each credentialing period. . . Peer review will be conducted by [Network Hospital], the network hospital for the medical center's Critical Access Designation. . . Peer review records are available to the credentialing personnel in connection with their responsibility to evaluate clinical performance of the provider. . . ."

2. Review of CAH documentation on 1/27/15 revealed the facility failed to ensure the CAH received completed peer review by the Network Hospital for Physicians A, B, C, D, E, F, G, H, I, and J.

3. During an interview on 1/27/15 at 2:50 PM, Staff H, Quality and Patient Experience Director, stated the CAH staff choose 1 patient medical record from each quarter for each physician on staff at the CAH and send to the Network Hospital for review. Staff H further stated not all of the results of the peer review by the Network Hospital were returned and were not available to the credentialing personnel to evaluate the clinical performance of the provider for Physicians A, B, C, D, E, F, G, and H. Staff H also stated the outside entity peer review for Physicians I, and J were not patients from the CAH.

Based on review of policies and staff interviews, the Critical Access Hospital (CAH) staff failed to updated their patient visitation rights policy and postings of patient visitation rights throughout the hospital to reflect the current requirements. The Director of Nursing identified an current census of 3 swing bed patients and 2 inpatients/acute at the time of survey entrance. The Directors of the out patient areas identified a census for the following areas:

Cardiac Rehab - Approximately 50 patients monthly
Physical Therapy - Approximately 75-100 patients weekly
Occupational Therapy - Approximately 25-30 patients monthly
Speech Therapy - Approximately 1 patient monthly
Respiratory Therapy - Approximately 2 patients weekly
Cardiac Rehab - Approximately 30-40 patients monthly
Pulmonary Rehab - Approximately 3 patients per weekly sessions
Laboratory - Approximately 45 patients daily
Radiology - Approximately 35 patients daily
Sleep lab - Approximately 1 patient weekly
Out patient surgery - Approximately 50-60 patients monthly

Failure to provide all patients, including outpatients, with patient rights information 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 the policy "Patient Rights" review dated 8/31/04, directed all hospital staff to present a listing of the Patient Rights and Responsibilities to all patient upon admission to the CAH for inpatient and outpatient services. The policy lacked the new information, effective 12/2/11, 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 1/26/15 at 2:50 PM, the Chief Nursing Officer (CNO) acknowledged the CAH failed to update the policy to include the updated information contained in the regulatory guidelines, effective 12/2/11.

During an interview on 1/26/15 at 3:00 PM, the CNO said two years ago they changed their practice to presenting patients with the "Notice of Privacy Practices" upon admission. The "Notice of Privacy Practices" dated 9/14 lacked the new information, effective 12/2/11, 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.

During an interview on 1/26/15 at 4:30 PM, Staff Q, Registered Nurse (RN), on the inpatient nursing unit confirmed nursing staff presented the Notice of Privacy Practices to all patients, including inpatients and swing bed patients, upon admission. Staff Q said she thought it contained patient visitation rights and responsibilities and then patients would sign they had received them. Staff Q lacked the knowledge the document did not contain the correct information reflecting the current requirements.

During an interview on 1/27/15 at 8:45 AM, Staff C, Patient Access Representative confirmed they presented the Notice of Privacy Practices to all out patients upon admission. Staff C she thought it contained patient visitation rights and responsibilities and then patients would sign they had received them. Staff C lacked the knowledge the document did not contain the correct information reflecting the current requirements.

Based on document review, staff and patient interviews, the Critical Access Hospital (CAH) failed to ensure patients (or support person) where appropriate were informed of their visitation rights including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend for 3 of 3 active swing bed patients (Patients # 1, #2, and #23), and 5 of 5 closed swing bed patients (Patients #9, #10, #11, #12, and #13). The CAH identified 1 of 1 Patient Rights and Responsibilities/Visitation Policy. The CAH staff reported a current census of 3 swing bed patients at the time of survey entrance.

Failure to inform patients of their visitation rights could potentially result in the staff failing to extend visitation rights to all patient populations.

Findings include:

1. Review of the policy "Patient Rights" review dated 8/31/04, directed all hospital staff to present a listing of the Patient Rights and Responsibilities to all patient upon admission to the CAH for inpatient and outpatient services. The policy lacked the new information, effective 12/2/11, 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. Review of active medical records revealed:

- Patient #1, admitted 1/15/15 for swing bed nursing services, revealed the patient signed they received a copy of Notice of Privacy Practices upon admission.

- Patient #2, admitted 1/14/15 for swing bed nursing services, revealed the patient signed they received a copy of Notice of Privacy Practices upon admission.

- Patient #23, admitted 1/9/15 for swing bed nursing services, revealed the patient signed they received a copy of Notice of Privacy Practices upon admission.

Review of closed swing bed medical records revealed:

- Patient #9, admitted 5/7/14 for swing bed nursing services, revealed the patient signed they received a copy of Notice of Privacy Practices upon admission.

- Patient #10, admitted 6/9/14 for swing bed nursing services, revealed the patient signed they received a copy of Notice of Privacy Practices upon admission.

- Patient #11, admitted 6/30/14 for swing bed nursing services, revealed the patient signed they received a copy of Notice of Privacy Practices upon admission.

- Patient #12, admitted 8/8/14 for swing bed nursing services, revealed the patient signed they received a copy of Notice of Privacy Practices upon admission.

- Patient #13, admitted 9/25/14 for swing bed nursing services, revealed the patient signed they received a copy of Notice of Privacy Practices upon admission.

3. During an interview on 1/26/15 at 2:50 PM, the Chief Nursing Officer (CNO) acknowledged the CAH failed to update the policy to include the updated information contained in the regulatory guidelines, effective 12/2/11.

During an interview on 1/26/15 at 3:00 PM, the CNO said they changed their practice to presenting patients with the "Notice of Privacy Practices" upon admission two years ago. The "Notice of Privacy Practices" dated 9/14 lacked the new information, effective 12/2/11, 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.

During an interview on 1/26/15 at 3:45 PM, Patient #1 said they were informed of their patient rights by a Notice of Privacy Practices brochure reviewed by the nurse when they were admitted to the hospital. Patient #1 the nurse did not review the contents of the brochure.