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Based on observation, review of documents, and interview with staff, the critical access hospital (CAH) failed to secure 8 of 16 large medical gas cylinders in the Surgery Department. The CAH administrative staff identified performing approximately 20 surgical procedures a month.

Failure to store medical gas cylinders upright and secured to prevent the cylinders from tipping is very important. When a medical gas cylinder tips over, it may result in the cylinder's valve to break. This could result in tremendous force when the high pressure gas escapes rapidly and present a serious hazards.

Findings include:

Observation on 3/10/15 at 8:35 AM, with Staff C and D, Operating Room Technicians and Emergency Department Manager, revealed 8 of 16 large medical gas cylinders located in the surgery storage closet lacked a securing device.

Review of policy titled, Safety in the Operating Room dated 3/14, stated in part .... 11. Free-standing cylinders shall be chained in place or placed in cylinder cart.

Interview at time of the observation with Staff C and D confirmed the 8 large medical gas cylinders lacked a securing device.

Based on review of policies/procedures, document review, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure 2 of 2 active practitioners (Practitioners B and C) and 1 of 1 general surgeon (Practitioner A), selected for review, received outside entity peer review performed by the Network Hospital prior to re-appointment. The purpose of the outside entity review is to evaluate the appropriateness of diagnosis and treatment furnished at the CAH. The CAH identified 2 family practice practitioners and 1 general surgeon.

Administrative staff reported Practitioner A preformed approximately 88 surgical procedures yearly, Practitioner B provided care and services to approximately 34 patients yearly and Practitioner C provided care and services to approximately 148 patients yearly.

Failure to ensure the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially lead to medical staff providing substandard patient care.

Findings included:

1. Review of CAH policy/procedure titled "External Peer Review" reviewed 5/14, revealed the following in part, " ...to assure quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at Central Community Hospital (CCH), one chart of each provider creating a chart will be reviewed annually...with network hospital."

2. Review of peer review documentation for the past 24 months revealed the CAH failed to ensure a qualified entity completed peer review for Practitioners A, B, and C prior to reappointment.

3. During an interview on 3/1/15 at 9:55 AM, Staff E, Chief Executive Officer (CEO) confirmed the three practitioners identified received external peer review during the credentialing cycle however the reviews were conducted by another CAH. Staff E acknowledged the Network Agreement failed to address external peer review for family practice physicians and general surgeons.

Staff E acknowledged the information from the external peer review process was included in the physician's credential files and was available for review by the medical staff and the governing body at the time of reappointment.
and reviewed by the medical staff and the governing body at the time of reappointment.

Staff E acknowledged that 3 of 12 practitioners, with privileges at the CAH, lacked evidence that showed an evaluation of the quality and appropriateness of the diagnosis and treatment they furnished to CAH patients had occurred.

The medical staff and governing body lacked information from the external peer review process, including the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH, in the physician's credential files at the time of reappointment for the 3 physicians.

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 same-sex domestic partner), another family member, or friend for 4 of 4 swing bed patients (Patients # 6, #7, #8, and #9) and 5 of 5 closed swing bed patients (Patients #1, #2, #3, #4, and #5) and outpatients. The Chief Nursing Officer identified a current census of 4 swing bed patients at the time of survey entrance.

The Chief Executive Officer identified a yearly census in the following outpatient areas:
Physical Therapy: 333
Speech Therapy: 25
Occupational Therapy: 176
Emergency Room: 946
Out Patient IV Infusions: 40
Radiology: 1, 736
Sleep Study: 25
Lab: 3, 101

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

Findings include:

1. Review of the brochure titled, "Your Rights and Responsibilities, undated, provided to all patients upon admission to swing bed services, inpatients and outpatients, did not include the patient's rights 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.

Review of policy/procedure titled, "Swing Bed Bill of Rights", review date 8/14, failed to include the patient's rights 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.

Review of documentation in patient #6, #7, #8 and #9 medical records, revealed the patient's signed they received a copy of the Patient Rights and Responsibilities information.

Review of documentation in patient #1, #2, #3, #4, and #5 medical records, revealed the patient's signed they received a copy of the Patient Rights and Responsibilities information.

2. During an interview on 3/9/15 at 10:50 AM, Staff F, Registrations clerk stated they provided all outpatients on admission for outpatient services, a patient rights brochure. Staff F said she did not know the brochure lacked the patients' right 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.

During an interview on 3/10/15 at 10:20 AM, Patient #7 reported being informed of the patient rights by a brochure provided by nursing staff at admission to the CAH for skilled nursing services. Patient #7 further stated the nursing staff provided information that indicated patients could have visitors but said nothing about who could or could not visit them.

During an interview on 3/10/15 at 10:35 AM, the Chief Nursing Officer acknowledged the current brochure provided to outpatients and swing bed patients and the Swing Bed policy lacked the regulatory changes to the patient bill of rights and responsibilities and said they would take steps to make the necessary changes immediately.