HospitalInspections.org

Based on interview and document review, the CAH (Critical Access Hospital) failed to maintain current credentialing files with state background studies for 5 of 10 medical staff (MD-A, MD-B, MD-C, DO-A, NP-A) records reviewed. In addition, the facility failed to maintain state background studies for 2 of 14 (E-1, E-4) direct care staff reviewed.

Findings include.

A review of credentialing files for MD-A, MD-B, MD-C, DO-A, and NP-A were found to lack State background studies.

A review of personnel files for E-1 and E-4 were found to lack State background studies.
The CAH's "Personal Background Checks" policy and procedure reviewed on 2/09, indicated a personal background study would be performed on all employees at the time of employment.

On 3/15/12, at 9:33 a.m. the business service manager and director of nursing verified the staff did not have state background studies completed or filed, and stated the studies should have been completed and filed.

At 9:50 a.m. the administrator stated background studies should have been completed on all staff at the time of employment as the policy directs.

Based on document review, and interview, the CAH (Critical Access Hospital) failed to maintain current credentialing files with current licensure, certification, or registration, for 1 of 10 medical staff (MD-A) credentialing files reviewed.

Findings include:

Review of personel records indicated MD-A lacked documentation of current State licensure.

On 3/14/12, at 2:10 p.m. medical records staff-A indicated MD-A provided sleep study consultation at their facility.

On 3/14/12, at 2:10 p.m. the medical records director verified MD-A did not have a personnel record which contained the required documents on file and stated she had "missed it."

On 3/15/12, at approximately 11:00 a.m. the administrator verified the findings.

The By-Laws of the Medical Staff dated 1/9/02, indicated all medical staff shall present copies of their current State license.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure the function of the defibrillator in 1 of 1 emergency room was checked on a regular basis to ensure it was ready to be used in an emergency.

Findings include:

During a tour of the emergency department on 3/13/12, at 1:00 p.m. the ER defibrillator was observed. RN-B stated the defibrillator test included only a check if the monitor turned on and not a test if the unit would charge and release charge. RN-A stated the daily ER (emergency room) checklist directed staff to check the defibrillator monitor.

On 3/13/12, at 2:40 p.m. RN-B stated the inpatient nursing care area defibrillator daily check did include a check if the machine would charge/discharge but not the ER defibrillator.

On 3/14/12, at 9:30 a.m. the director of nurses (DON) stated she expected the defibrillator check in ER to include a check if the machine would charge, not only a check of the monitor.

On 3/14/12, at 3:20 p.m. the DON stated she had talked to staff from the ER and some staff did check if the defibrillator would charge/discharge and others checked only if the monitor would turn on. The DON stated staff would be instructed to check if the defibrillator would charge/discharge with daily checks.

Review of the CAH policy titled ER Safety dated 06/02, directed staff to "test the defibrillator performance once a day by discharging it into a testing device." Review of the Daily ER Checklist directed staff to check monitor, defibrillator.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure patient equipment, including the oxygen delivery system and the ventilation system of the negative pressure room, was maintained in manner that included periodic maintenance and testing to ensure an acceptable level of safety and quality. This practice had the potential to affect all patients in the CAH.

Findings include:

The CAH's piped in oxygen delivery system and airborne isolation room lacked a regular periodic maintenance and testing program.

During the facility tour on 3/13/12, at 8:30 a.m. the maintenance engineer (ME)-A stated he was not aware of any system that alerted staff to a potential interruption with the oxygen delivery from the exterior liquid oxygen tank to the interior piped oxygen locations. No system was observed at this time. In addition, ME-A stated he was unaware of any scheduled periodic testing program of the oxygen delivery system. Additionally, during the tour of the airborne infection isolation room (AIIR), ME-A stated he was not aware of any periodic testing of the room's ventilation system to determine if the room could be maintained at a negative pressure in relation to the hallway if activated.

On 3/14/12, at 9:30 a.m. the director of nurses (DON) stated that she would place any patients with possible tuberculosis (TB) or other conditions that required airborne isolation in the AIIR room and that she would expect to be able to use it at the current time. The DON stated she was not certain of any testing done on the AIIR.

On 3/15/12, at 12:00 p.m. ME-A stated he had contacted the liquid oxygen supplier and they were not aware of any alarm system at the CAH that would signal a potential concern with the system. ME-A stated he had also talked with multiple staff at the facility and no one was aware of an alarm system associated with the oxygen system. ME-A stated there was not a policy on the maintenance or testing of the oxygen delivery system.

On 315/12, at 2:45 p.m. the ancillary manager stated that staff had been able to locate an alarm system for the oxygen system that was located by the inpatient nursing station, but there had been no testing of this system that he was aware of for years and they were not sure if it was functional.

Review of the CAH policy titled Airborne Infection Isolation Room dated 2/10/09, indicated that monitoring of the negative pressure room would be done monthly unless there was a patient in the room, then it would be monitored daily with a digital pressure gauge. Review of the AIIR (Airborne Infection Isolation room) Maintenance Log indicated the AIIR was last tested 10/18/10. This test had not included a pressure reading and the log indicated that the pressure reading had been last checked 7/12/10.

Based on interview, and document review, the CAH (Critical Access Hospital) failed to ensure all personnel were trained to manage non-medical emergencies for 3 of 8 (E-1, E-2, E-3) contracted staff reviewed.

Findings include:

The personnel records of E-1, E-2, and E-3 lacked documentation of training related to non-medical emergency procedures.

On 3/15/12, at 9:33 a.m. the business service manager verified the identified personnel did not have training in non-medical emergency procedures and stated they should have.

At 9:50 a.m. the administrator verified the findings and stated the non-emergency procedure training should have been completed.

Based on document review and interview, the Critical Access Hospital (CAH) failed to ensure the Governing Body monitored the implementation of policies related to credentialing for 1 of 10 (MD-A) medical staff credentialing files reviewed.

Findings include.

MD-A did not have a credentialing file which included a completed State background study, current State licence to practice, application for delineation of privileges, or approval to practice at the facility from the Medical Staff and Governing Body on file in accordance with the Medical Staff By-laws on file.

The undated, Appointment To Medical Staff Checklist form completed prior/upon hire which indicated the credentials required for hire was not not completed for MD-A

The Medical Staff By-Laws dated 2/14/94, indicated all medical staff required proof of licensure to practice, identity of qualifications and references, term of appointment, and delineation of privileges. The By-Laws also indicated the authority to grant medical staff privileges was vested in the board through the administrator.

The facility's "Contract Staff & Locum Competency & Orientation Validation" policy and procedure revised on 11/09, indicated the contract staff competency and orientation validation form which included competency documentation, and verification of mandatory education would be maintained by the manager in his/her file.

The undated, "AMENDED AND RESTATED BYLAWS" indicated the governing body functions included appointing and overseeing medical staff membership, clinical privileges, and credentialing and granting privileges to medical staff members.

On 3/14/12, at 2:10 p.m. the medical records director verified MD-A did not have a personnel record which contained the required documents on file. She added she had "missed it."

On 3/15/12, at 9:50 a.m. the administrator verified MD-A was a contracted member and had not gone through the required credentialing process according to the By-Laws, and also verified the missing documents/file.

Based on observation, interview, and document review, the Critical Access Hospital (CAH) failed to ensure that all drugs and biologicals were secure in 2 of 5 departments (Cardiac Rehab, CT) where medications were utilized. In addition, the facility failed to ensure outdated medications were disposed of appropriately in 3 of 5 departments (Cardiac Rehab, Anesthesia, Emergency Room) reviewed where medications were utilized.

Findings included:

During the tour of the Cardiac Rehab on 3/13/12, at 10:05 a.m. expired medications were noted in an office cabinet used by the respiratory therapist. In addition, the medications were stored in an unlocked office in an unlocked cabinet. The Cardiac Rehab unit was noted to be a fitness center open to the public and/or staff.

Expired medications included:
6 doses of Ipratropium (a bronchodialtor) nebulizer solution were expired on 9/10 and 2 doses were expired on 8/10.
1 dose of Albuterol (a bronchodialtor) nebulizer solution was expired on 2/12.
1 dose of Levalbuterol nebulizer solution was expired on 12/11.
2 doses Sodium Chloride were expired on 10/08, and 1/11.

At 10:05 a.m. the ancillary services manager stated respiratory therapist (RT)-A was responsible for monitoring the expired medication in his office.

At 10:10 a.m. the cardiovascular technician-A stated the door to the office was not locked and the whole cardiac rehab/fitness center was unlocked during the day and locked at night.

On 1:10 p.m. RT-A stated he does not routinely use those medications anymore and gets the medications out of the Omnicell (an automated drug dispenser). He stated he was unaware that expired medications were stored in his office.

At 2:00 p.m. licensed pharmacist (LP)-A stated no expired medication or unsecured medications should be stored in the facility.

During the tour of the CT room on 3/13/12, at 10:30 a.m. several bottles of contrast solution were noted in an unlocked warmer with the key to the warmer in the lock. The door to the CT room was open to the outside hallway during the tour. Radiological tech-A stated the contrast solution was unlocked and unsecured.

During the tour of the surgical suite on 3/14/12, at 1:15 p.m. expired medications and/or medications lacking an open date after initial use were found in the anesthesia cart. The medications included:

1 Narcan (used to reverse the effects of opiates) syringe was outdated 1/12, and 3 Narcan syringes were outdated on 9/11.
2 vials of neostigmine (used to reverse the effects of anesthetics) was outdated 1/12 and 1 vial was noted to be partially used but lacked the date of initial use.
1 vial of diphenhyramine (used for allergic responses) was noted to be partially used but lacked the date of initial use.
1 vial of dexamethasone (a steroid used for bronchospasms) was opened on 12/12/11.
2 syringes of calcium chloride (used in a cardiac arrest) were expired on 1/2011.
1 syringe of epinepherine (used in cardiac arrest or anaphylaxis) was outdated on 6/11.
1 vital of succinyocholine (a paralytic used by anesthesia) was expired on 1/12 and was partially used with no open date noted.
1 Zemuron (used as a muscle relaxant during anesthesia) vial was noted to be partially used but lacked the date of initial use.
1 atropine (used in a cardiac arrest) was noted to be partially used but lacked the date of initial use.
1 vial of ketamine (used to induce anesthesia) was noted to be expired on 1/11.

At this time, registered nurse-A stated anesthesia is responsible for monitoring outdates and medications should be labeled when opened and discarded according to recommended dates.

On 3/15/12, at 9:40 a.m. LP-A stated anesthesia is responsible for checking outdated medications and they would be reviewing the system for monitoring outdate on their medications.

The facility policy Drug Storage Area Reviews dated 2/08, indicated outdated and/or otherwise unusable drugs should be removed from the storage area. They should be sequestered into an area unavailable for patient use until they could be returned to the pharmacy. Staff were to verify that all emergency drug supply's carts were free of any outdated emergency medications. In addition, the policy directed staff to ensure all areas accessible to non-authorized personnel remain locked at all times.


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During a tour of the emergency room (ER) on 3/13/12, at 1:00 p.m. one multidose open vial of dexamethasone (anti-inflammatory, steroid) 4mg/ml was found in the locked pharmacy cupboard that was not dated. RN-B stated medication vials were to be dated when they were first accessed.

Review of the undated policy titled IV Admixture directed staff to "please date vials when opened" and that multiple dose vials were to be discarded after 28 days maximum.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure that each medical entry was properly authenticated with a timed and dated signature for 19 of 33 inpatient/outpatient records (P19, P18, P17, P5, P9, P4, P3, P8, P1, P14, P15, P13, P12, P11, P10, P2, P16, P21, P22) reviewed.

Findings include:

P19 was admitted to the CAH on 10/13/11, for a ventral hernia repair. The Record of Operation dated 10/13/11, lacked a time and date of the physician's signature.

P18 was admitted to the CAH on 12/13/11, after a laproscopic cholecystomy. The Record of Operation dated 12/13/11, lacked a time and date of the physician's signature.

P17 was admitted to the CAH on 3/16/11, after a laproscopic cholecystomy. The admission History and Physical dictated 3/18/11, the Progress Note dictated 3/20/11, and the Discharge Summary dictated 3/19/11, lacked a time and date of the physician's signature. The Record of Operation dictated 3/20/11, lacked a time and date of the physician's signature. In addition, the post anesthetic note lacked a time and a signature from the certified registered nurse anesthetist (CRNA).

P5 was admitted to the CAH on 8/19/11, with an abscess. The Discharge summary dictated 8/29/11, lacked a time and date of the physician's signature. The Physician Orders dated 8/20/11 and 8/21/11, lacked a time and date of the physician's signature. In addition, the telephone orders from 8/24/11, lacked a dated and time of signature by the physician.

P9 was admitted to the CAH on 6/27/11, with chest pain. The Physician Orders dated 6/26/11, 6/27/11, 6/28/11, and 6/29/11, as well as the Medication Reconciliation Report dated 6/29/11, lacked a time of the physician's signature. In addition, the telephone orders from 6/27/11, lacked a dated and time of signature by the physician.

P4 was admitted to the CAH on 5/16/11, with shortness of breath. The Emergency Room report dated 5/16/11, and the Physician Orders dated 5/16/11, 5/17/11, 5/18/11, 5/19/11 and 5/20/11 lacked a time and date of the physician's signature. The date and time was lacking in the co-signature of the physician assistant by the physician. In addition, the telephone orders from 5/16/11 and 5/17/11, lacked a dated and time of signature by the physician.

P3 was admitted to the CAH on 7/27/11, with a respiratory infection. The Physician Orders dated 7/28/11, 7/29/11, and 7/30/11, lacked a time and date of the physician's signature. In addition, the telephone orders signed by the physician on 7/27/11 and 7/28/11 lacked a time and date of the physician's signature.

P8 was admitted to the CAH on 7/31/11, with urosepsis. The Emergency Room report dictated on 7/31/11, admission History and Physical dictated 8/2/11, and the Discharge Summary dictated 8/24/11, lacked a time and date of the physician's signature. In addition, the Physician Orders dated 8/2/11 and 8/3/11, lacked a time and date of the physician's signature. In addition, the telephone orders signed by the physician on 8/1/11, 8/2/11, and 8/3/11 lacked a time and date of the physician's signature.

P1 was admitted to the CAH on 12/19/11, with pneumonia. The Emergency Room report dictated 12/19/11 and the Discharge Summary dictated 1/8/12, lacked a time and date of the physician's signature.

On 3/15/12, at 10:30 a.m. the director of nursing (DON) stated the clinical records were lacking dates and times of signatures. She stated they physicians can electronically sign off, but often do not.


29440



P14 was admitted to the CAH on 3/12/12. The physician's orders dated 3/12/12, and 3/13/12 lacked a time for the entry. Telephone orders dated 3/12/12, and 3/13/12, lacked the date and time of the physcian signature. The Physician Assistant (PA) Emergency Room Report dictated 3/12/12, lacked identification of the time of the PA's report and date and time of the physicians signature.

P15 was admitted to the CAH 11/25/11. The physician order's dated 11/26/11, and 11/27/11, lacked a time for the entry. Verbal orders from 11/25/11, standing orders dated 11/26/11, and telephone orders from 11/26/11, 11/27/11, and 11/28/11, lacked a time and date of the physician signature. The physician progress note dated 11/28/11, and dictated 11/29/11, and the chest x-ray report dated 11/25/11, lacked the date and time of the physician's signature.

P13 was admitted to the CAH 1/3/12. The physician orders dated 1/5/12, the order set for Potassium Replacement for IV/PO administration dated 1/5/12, and the Medication Reconciliation Report dated 1/6/12, lacked timing of the entry. Verbal orders from 1/3/12, and 1/5/12, telephone orders from1/4/12, and 1/5/12, and standing orders from 1/3/12, and 1/4/12, lacked the date and time of the physician's signature.

P12 was admitted to the CAH 2/10/12. Verbal orders from 2/10/12, and 2/11/02, telephone orders from 2/10/12, and 2/11/12, the order set for Potassium Replacement for IV/PO administration dated 2/10/12, and an Adult Alcohol Withdrawl Treatment Protocol order set from 2/11/12, lacked the date and time of the physician's signature.

P11 was admitted to the CAH 5/25/11. Telephone orders from 5/25/11, lacked the date and time of the physician's signature. The Discharge Summary dated 5/30/11, the Emergency Room Report dated 5/25/11, and the History and Physical dated 5/30/12, lacked the date and time of the physician's signature.

P10 was admitted to the CAH 6/11/11. Standing orders dated 6/11/11, lacked the date and time of the physcian's signature. Additionally physician orders dated 6/12/11, the Medication Reconciliation Report dated 7/6/11, and the physician's progress note dated 6/12/11, lacked the time of the entry.

P2 was admitted to the CAH 2/9/12. Verbal orders dated 2/9/12, and telephone orders dated 2/9/12, and 2/10/12, lacked the date and time of the phsycian's signature. The Medication Reconciliation Report signed 2/11/12, lacked the time of the entry. The History and Physical dated 2/10/12, lacked the date and time of the physician's signature.

P16 was admitted to the CAH on 12/29/11. The physician order's dated 12/29/11 and 12/30/11, lacked a time for the entry.

P16 was seen in the Emergency Room (ER) 2/6/12. A Polysomnography Interpretation Report dictated 2/8/12, indicated report was electronically signed but did not indicate date and time this was completed.


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P21 was admitted to the CAH on 10/31/11, due to exacerbation of chronic obstructive pulmonary disease. The Discharge Summary dated 11/4/11, lacked a time and date of the physician's signature. The Clinic Note dated 10/31/11, also lacked a time and date of the physician's signature. Additionally, the History and Physical dated 11/1/11, the Progress Notes dated 11/2/11, and 11/3/11, also lacked a time and date of the physician's signature.

P22 was admitted to the CAH on 10/7/11, for gastritis. The History and Physical dated 10/8/11, lacked a time and date of the physician's signature. Additionally, the Clinic Note dated 10/7/11, and Discharge Summary dated 10/12/11, also lacked a time and date of the physician's signature.

Based upon observation, interview, and document review, the Critical Access Hospital (CAH) was found not to be in compliance with the Condition of Participation of Surgical Services. The CAH did not ensure necessary emergency equipment was immediately accessible in the surgical suite and ensure medications in the anesthesiology cart had not expired. In addition, the CAH failed to ensure the responsible practitioner was involved in the informed consent process prior to the surgical procedure for 3 of 4 patient (P17, P19, P18) records reviewed who required an informed consent. These practices could potentially affect all patients receiving surgical procedures at the CAH.

Findings include:

A tour of the surgical department was completed on 3/14/12, at 1:15 p.m. with registered nurse (RN)-A. The observation of the surgical suite revealed no defibrillator or tracheotomy kit was present in the surgical suite. RN-A ,who acted as the circulating nurse during surgical procedures, stated they do not bring or have a crash cart which would include a defibrillator in the surgical suite during surgical procedures. She stated they would have to get the crash cart or a tracheotomy kit from the emergency room which was down the adjoining hall.

The CAH policy Code Blue in the Operating Room dated 3/08, indicated a crash cart would be secured from the emergency room.

RN-A stated all the medication used in a cardiac event were in the anesthesiology cart. Several of those medications, which would be used in a cardiac event, such as calcium chloride and epinephrine were noted to be expired.

1 Narcan (used to reverse the effects of opiates) syringe was outdated 1/12, and 3 Narcan syringes were outdated on 9/11.
2 vials of neostigmine (used to reverse the effects of anesthetics) was outdated 1/12 and 1 vial was noted to be partially used but lacked the date of initial use.
2 syringes of calcium chloride (used in a cardiac arrest) were expired on 1/2011.
1 syringe of epinepherine (used in cardiac arrest or anaphylaxis) was outdated on 6/11.
1 vital of succinyocholine (a paralytic used by anesthesia) was expired on 1/12 and was partially used with no open date noted.
1 vial of ketamine (used to induce anesthesia) was noted to be expired on 1/11.

At 1:15 p.m. registered nurse (RN)-A stated the medications were ready for use for the next time anesthesia used the cart and the medications would have been used the last time they performed surgery. RN-A also stated anesthesia was responsible for monitoring outdates and medications should be labeled when opened and discarded according to recommended dates.


On 3/14/12, at 2:15 p.m. RN-A reviewed the CAH policy and stated it directed the staff to obtain the crash cart from the emergency room. RN-A stated technically, there was no defibrillator in the surgical suite. She added, she wondered if bringing equipment into the surgical suite from the emergency room was a good idea.

On 3/15/12, at 9:40 a.m. licensed pharmacist (LP)-A stated anesthesia was responsible for checking outdated medications and they would be reviewing the system for monitoring outdates on their medications.

The facility policy Drug Storage Area Reviews dated 2/08, indicated staff should verify that all emergency drug supply's carts are free of any outdated emergency medications.

On 3/15/12, at 10:00 a.m. the director of nursing (DON) stated she had thought about the defibrillator or tracheotomy kit being in the emergency room and felt it was not good practice to have the surgical crew leave to go and get the equipment in a critical moment, especially not knowing what might be going on the emergency room. The DON stated that technically she was ultimately responsible for the surgical department. The DON stated she hoped the new management who had recently taken over the CAH would help take on the management of the surgical department as they had hoped to increase the case load to services once a week.


A review of records for surgical services indicated 3 of 4 surgical procedures reviewed lacked the responsible practitioner's signature on the informed consent.

P17 was admitted to the CAH on 3/18/11, after a laproscopic cholecystectomy. The informed consent dated 3/18/12, lacked a signature of the responsible practitioner performing the procedure as directed on the consent. In addition, the CAH's Verification Form dated 3/18/11, directed staff to ensure a patient and surgeon signature was present on the informed consent.

P19 was admitted to the CAH on 10/13/11, for a ventral hernia repair. The informed consent dated 10/13/11, lacked a signature of the responsible practitioner performing the procedure as directed on the consent. In addition, the facility Verification Form dated 10/13/11, directed staff to ensure a patient and surgeon signature was present on the informed consent.

P18 was admitted to the CAH on 12/13/11, after a laproscopic cholecystectomy. The informed consent dated 12/13/11, lacked a signature of the responsible practitioner performing the procedure as directed on the consent. In addition, the facility Verification Form dated 12/13/11, directed staff to ensure a patient and surgeon signature was present on the informed consent.

On 3/15/12, at 1:10 p.m. RN-A stated she was not aware the responsible practitioner should sign the consent, but added if the CAH's forms directed them to complete this, they should have been doing it.

At 1:50 p.m. the DON stated the responsible practitioner would talk with the patient about the procedure prior to the day of surgery. She stated the nurse obtaining the consent would not have the full context of the procedure to further explain to the patient when the actual consent was obtained.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to ensure 2 of 3 patients (P18, P19) reviewed who had received surgical services had been discharged in the company of a responsible adult.

Findings include:

On 12/13/11, the Record of Operation indicated P18 underwent a laprascopic cholecystomy. P18's clinical record indicated the patient had received a general anesthetic. The clinical record lacked documentation related to P18 being discharged with a responsible adult.


On 10/13/11, the Record of Operation indicated P19 underwent a ventral hernia repair. P19's clinical record indicated the patient had received a general anesthetic. The clinical record lacked documentation related to P19 being discharged with a responsible adult.

On 3/15/12, at 1:50 p.m. the director of nursing (DON) stated the nursing staff should be documenting the discharge status and who the patient was discharged with in the nursing notes. The DON stated this had not been completed.

The CAH policy Discharge Instruction To Home dated 4/08, indicated the patient must have a responsible adult to provide transportation home. No patient would be allowed to drive himself/herself home.

Based on interview and document review, the Critical Access Hospital (CAH) was found not to be in compliance with the Condition of Participation of Periodic Evaluation and Quality Assurance Review. The CAH failed to provide an effective quality assurance (QA) program that maintained ongoing data analysis of patient services and implemented and evaluated corrective actions when problems were identified in order to evaluate the overall ongoing quality and improvement of patient treatment and outcomes in the CAH. In addition, the CAH failed to evaluate all patient care services to evaluate the quality and appropriateness of the treatment and services furnished in the CAH. This practice had the potential to affect all patients the CAH serviced.

Findings include:

Although many of the departments of the CAH had identified their own quality improvement, the CAH failed to ensure ongoing monitoring, and data analysis of identified quality measures. In addition, when problems were identified, corrective actions and evaluations of corrective actions were not completed. Further, not all of the CAH's patient services had been included in quality assurance activities over the last year.


The CAH's Continuous Quality Improvement Plan 2011, (CQI) policy and procedure, signed into effect 2/14/11, indicated the continuing quality improvement procedure would include monitoring, and evaluating the quality and appropriateness of patient care, including identification of trends and patterns in performance. It also indicated when problems were identified, actions would be taken and the effectiveness of those actions would be evaluated. The findings, conclusions, recommendations, actions taken, and results of actions taken would be documented and reported. Additionally, the policy and procedure indicated the quality assurance/CQI committee would assure the monitoring activities selected would cover all types of services and all categories of care rendered and that they were effective. The quality assurance/CQI committee would be responsible for the implementation of appropriate actions to eliminate or reduce identified problems and to determine by subsequent monitoring that such corrective action had been adequate. Complete and accurate documentation of CQI would reflect patient care areas where actions had been taken and follow up had shown that care was improved.

On 3/13/12, at 10:35 a.m. the ancillary manager responsible for the oversight and direction of the quality assurance program verified the facility's quality improvement program lacked ongoing monitoring, data collection details, or analysis of corrective actions implementation, and review.

On 3/15/12, at 10:15 a.m. the director of nursing (DON) stated the CAH did not complete a continuous program evaluation.

Refer to C336. The CAH failed to maintain ongoing quality assurance activities and/or implement corrective actions when problems were identified in order to evaluate the results of the corrective actions for the following departments:
Nuclear Medicine, Organ and Tissue Procurement, Cardiac Rehab, Pulmonary/Respiratory Therapy, Pharmacy/Med errors, Anesthesia, and Swing Bed.


Refer to C337. The CAH failed to complete quality assurance activities over the last year for the following departments:
Nursing, Infection Control, and Sleep Studies.

Based on interview and document review, the Critical Access Hospital (CAH) failed to provide an effective quality assurance (QA) program that maintained ongoing data analysis of patient services and implemented and evaluated corrective actions when problems were identified and to evaluate the overall ongoing quality and improvement of patient treatment and outcomes in the CAH for 7 of 20 departments (Swing Bed, Nuclear Medicine, Organ and Tissue Procurement, Cardiac Rehab, Pulmonary/Respiratory Therapy, Pharmacy/Medication errors, Anesthesia). This practice had the potential to affect all patients the CAH serviced.

Findings include:

Although many of the departments of the CAH had identified their own quality improvement, the CAH failed to ensure ongoing monitoring, data analysis, corrective actions and evaluation of corrective actions were completed.

The Facility's "Continuous Quality Improvement Plan 2011" (CQI) policy and procedure, signed into effect 2/14/11, indicated the continuing quality improvement procedure would include monitoring, and evaluating the quality and appropriateness of patient care, including identification of trends and patterns in performance. It also indicated when problems were identified, actions would be taken and the effectiveness of those actions would be evaluated. The findings, conclusions, recommendations, actions taken, and results of actions taken would be documented and reported. Additionally, the policy and procedure indicated the quality assurance/CQI committee would assure the monitoring activities selected would cover all types of services and all categories of care rendered and that they are effective. The quality assurance/CQI committee would be responsible for the implementation of appropriate actions to eliminate or reduce identified problems and to determine by subsequent monitoring that such corrective action had been adequate. Complete and accurate documentation of CQI would reflect patient care areas where actions had been taken and follow up had shown that care was improved.


Swing Bed (SB)

A review of the 12/14/11, SB "CQI Study Review" form indicated the department required work on dietary notification and discharge planning with education of staff recommended. The form also indicated no follow up was required. No further QA was provided which included implementation of corrective actions, evaluation of corrective actions or measures to improve quality on a continuous basis.

The QA for SB lacked ongoing monitoring or data collection



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Nuclear Medicine:

The facility's CQI Study Review dated 9/14/11, indicated nuclear medicine (NM) evaluated patient delays, isotope administration, equipment failure and radioactive contamination as indicators. All indicators were found to be 100% of the goal met. No further follow up was recommended. No QA was provided which included included identification and data analysis, identification of corrective actions, implementation of corrective actions, evaluation of corrective actions or measures to improve quality on a continuous basis.

Organ and Tissue Procurement:

A review of the Tissue Activity Report dated 2011, gathered by the organ procurement organization for 2011, indicated 14% of referrals for organ procurement occurred at 61-90 minutes after death, which was greater than the recommended time frame of less that 60 minutes after death. Of that 14%, 6% occurred at greater than 180 minutes after death. No further follow up related to the late calls were completed.

On 3/15/12, at 10:00 a.m. the director of nursing stated no further QA had been completed on the program even though timeliness of calling was found to be a concern.

Cardiac Rehab:

The facility's CQI Study Review dated 4/27/11, indicated stress tests canceled for a lack of patient information was evaluated as a QA indicator. The outcome of the study from September through December 2010, indicated 9% of studies were unable to be performed due to lack of all information required to completed a stress test. The desired outcome was 0%. No further follow up was recommended but the study suggested continuing to watch for specific providers and nurses who were not complying. The QA program lacked identification of corrective actions, implementation of corrective actions, evaluation of corrective actions or measures to improve quality on a continuous basis.


Pulmonary/Respiratory Therapy:

The facility's CQI Study Review dated 6/22/11, indicated missed orders were evaluated as an indicator. The study found 90% of nebulizer inpatient orders were entered in the computerized system (CPSI) with a goal of 100%, 96% of the oxygen orders were entered into the CPSI with a goal of 100% and 88% of EKG's from inpatient or emergency room patients were entered in the CPSI with a goal of 100%. The study was completed from April 1 though June 20, 2011. No further follow up was recommended. The QA program lacked identification of corrective actions, implementation of corrective actions, evaluation of corrective actions or measures to improve quality on a continuous basis.

Pharmacy/Med errors:

The facility's CQI Monitoring dated 8/11, indicated from 8/1/11 to 8/31/11, patients were evaluated for Venous thromboembolism (VTE) prophylaxis on 26 inpatient records. The study found only 34.6% of patients meeting the criteria for anticoagulation due to VTE risk, actually receive the prophylactic medications. 19.2% of patients had 3 of more low risk factors and 1 or more moderate factors. Actions taken to improve care included discussion with Pharmacy and Therapeutics committee, medical staff approval if appropriate, staff education and questioned a follow up study. No further information or follow up was provided.

On 3/13/12, at 2:30 p.m. the licensed pharmacist stated they had looked at VTE prophylaxis last year and found that the providers were not always treating the high risk individuals. She stated they gather data over a period of time and had identified this concern, however no further follow up or corrective actions were implement. LP-A verified the QA program lacked identification of corrective actions, implementation of corrective actions, evaluation of corrective actions or measures to improve quality on a continuous basis.


On 3/15/12, at 9:40 a.m. licensed pharmacist-A stated that they do look at medication errors and discuss trends at the pharmacy and therapeutics meeting. A flow sheet of the medication error and source of errors were provided at this time. However, no further QA was provided for the medication errors which included identification and data analysis, identification of corrective actions, implementation of corrective actions, evaluation of corrective actions or measures to improve quality on a continuous basis.

Anesthesia:

The facility CQI Study Review dated 5/18/11, indicated the indicator reviewed was signed consents. 14 records were reviewed and 86% of cases were completed. The outcome of the study was to make sure anesthesia providers were aware and doing the forms and ensure they had a policy that included completion of the consent. No further follow up was recommended. NO further QA was provided which included implementation of corrective actions, evaluation of corrective actions or measures to improve quality on a continuous basis.

On 3/13/12, at 10:35 a.m. the ancillary manager, responsible for the oversight and direction of the quality assurance program, verified the facility's quality improvement program lacked the ongoing monitoring, data collection details, or analysis of corrective actions implementation, and review.

On 3/15/12, at 10:15 a.m. the director of nursing (DON) stated the CAH did not complete a continuous program evaluation.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to evaluate all patient care services to evaluate the quality and appropriateness of the treatment and services furnished in the CAH related to 3 of 20 departments (Sleep Studies, Nursing, and Infection Control). This practice had the potential to affect all patients the CAH served.

Findings include:

Sleep Studies:

No QA was provided for the services of sleep studies when requested.
On 3/15/12, at 9:10 a.m. the administrator and the ancillary services manager stated there was no QA program for sleep study services.



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Nursing
On 3/14/12, at 9:30 a.m. the director of nurses (DON) stated that she was not aware of any quality assurance (QA) done for 2011 for nursing. The DON stated that nursing would be doing a QA project for 2012 on the use of two patient identifiers to identify patients during the provision of care but this had not started yet.
Review of the 2011 CQI (continuous quality improvement) Schedule provided by the facility indicated that nursing would report in November on a study of the use of two patient identifiers. A review of the 2011 minutes did not include a report from nursing on this or any other nursing focus.

Infection Control
On 3/15/12, at 10:00 a.m. the ancillary manager, who was assigned the responsibility of oversight of the QA program, stated he thought that infection control had done something with handwashing for a QA project for 2011. He added he thought the prior director of nursing had completed this QA project. However, no report was found within the QA minutes, no CQI Study Review form could be located or any other evidence that infection control had participated in a QA activity for the year.