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Based on record review, observation, and interview, it was determined that the the Critical Access Hospital (CAH) failed to monitor appropriate pressure differentials in 2 out of 2 sub-sterile rooms in the surgical department.

Findings include:

Observation on 9/28/2022 revealed that 2 sub-sterile rooms were present in the CAH's surgical department.

Record review on 9/29/2022 of the CAH's report titled "Test, Adjust, and Balance Report," provided by AIRADIGM Solutions, with report issue date 9/28/2022, revealed that 2 out of 2 sub-sterile rooms in the surgical department were not present and measured on the report.

Interview on 9/29/2022 with Staff D (Operations Specialist) confirmed the above findings.

Based on record review and interview, it was determined that the Critical Access Hospital (CAH) failed to assure that physcian assistants and/or nurse practictions periodically review the CAH's patient records inconjuction with a doctor of medicine or osteopathy.

Findings include:

Record review on 9/27/2022 of the CAH's "Medical Staff Leadership Organizational Chart," dated November 2021, revealed that an advanced practice registered nurse (APRN) was identified as the director of the hospitalist department overseeing inpatient care.

Interview on 9/28/2022 at approximately 1:00 p.m. with Staff E (Chief Medical Officer) confirmed the above finding. Interview further revealed that the APRN functioning as the director of the hospitalist department was responsible for periodically reviewing a sample of inpatient medical records cared for by nurse practitioners and physician assistants in the hospitalist department. A doctor of medicine or osteopathy would only review inpatient medical records if the reviewing APRN identified a quality concern during the periodic review.

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to distinctly discharge patients from acute status and then admit to swing bed status in 2 out of 2 patients reviewed for swing bed status for 21 in-patient charts reviewed. (Patient identifiers are #10 and #18).

Findings include:

Based on interview and record review, it was determined that the Critical Access Hospital failed to distinctly discharge patients from acute status and then admit to swing bed status in 2 out of 2 patients admitted to swing bed status in a standard survey sample of 21 in-patient charts reviewed. (Patient identifiers are #10 and #18).

Findings include:

Patient #10

Review on 9/28/22 of Patient #10's clinical records revealed that he/she was discharged from acute care to swing bed status on 7/8/22.

Review on 9/28/22 of Patient #10's clinical record revealed that on 9/4/22 a physicians progress note to admit to acute in-patient care (from swing bed status) due to diagnosis of cellulitis on the right thigh. This note was timed at 10:25 a.m. A clear physician's order to admit the patient to acute care was not found.

Review on 9/28/22 of Patient #10's clinical record revealed that on 9/13/22 there was a swing bed program certification. There was not a distinct physician's order discharging the patient from acute care and admitting to swing bed status.

Interview on 9/28/22 at approximately 2:30 p.m. with Staff B (Clinical Information Specialist) confirmed the absence of a distinct order to discharge patient from acute care and admit the patient to swing bed status.

Patient #18

Review on 9/29/22 of Patient #18's clinical record revealed a physician's order dated 6/3/22 to discharge from acute care. Further review revealed that Patient #18 remained in the hospital, but there was not a distinct physician's order to admit to swing bed status until 6/4/22.

Interview on 9/29/22 at approximately 9:30 a.m. with Staff B confirmed that the physician's order to admit to swing bed status was dated 6/4/22.

Review on 9/29/22 of the facility's policy titled "Swing Bed Policy and Procedure" revised October 2021 revealed, "...Procedure... B. The patient's physician will enter/transcribe an order SNF [Skilled Nursing Facility] Swing... G. Patients accepted into a SNF Swing status are treated as separate admission and not treated as an internal transfer... 3. The Attending Physician will... ii. Transcribe/enter new Physician "SNF Swing Orders"..."

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to ensure that the patient medical records included properly executed informed consents for 1 out of 21 inpatient records reviewed and for 3 out of 10 surgical patient records reviewed. (Patient identifiers are #21, #22, #23, and #24.)

Findings include:

Patient #22

Review on 9/28/22 of Patient #22's operative note dated 7/6/22 revealed that Patient #22 had sutures removed under sedation.

Review on 9/28/22 of Patient #22's medical records revealed no surgical consent for the above mentioned procedure.

Interview on 9/29/22 at approximately 9:50 a.m. with Staff A (Clinical Manager) confirmed the above findings for Patient #22.

Patient #23

Review on 9/28/22 of Patient #23's operative note dated 6/3/22 revealed that Patient #23 had a amputation of the right great toe and amputation of the left great toe.

Review on 9/28/22 of Patient #23's medical records revealed no surgical consent for the above procedure for Patient #23.

Interview on 9/29/22 at approximately 9:50 a.m. with Staff A confirmed the above findings for Patient #23.

Patient #24

Review on 9/28/22 of Patient #24's operative note dated 8/24/22 revealed that Patient #24 had a myringotomy.

Review on 9/28/22 of Patient #'24's surgical consent form revealed that that Patient #24 and surgeon signed a consent for the myringotomy procedure. Further review of Patient #24's surgical consent revealed that there was no date and time when surgical consent was executed.

Interview on 9/29/22 at approximately 9:50 a.m. with Staff A confirmed the above findings for Patient #24. Staff A stated that there should be a date when surgical consent was executed.

Review on 9/29/22 of the CAH's surgical consent policy with review date of May 2022 revealed "...PURPOSE: To obtain written consent for surgery/procedure and inform patient of risk. POLICY: Written surgical consents are obtained on all elective cases prior to surgery and whenever possible prior to admission...PROCEDURE: 1. It is the responsibility of the surgeon to obtain a written permission to perform an operative procedure prior to surgery...2. Documentation of this information on the patient's chart is required prior to surgery...7. Consent documentation must include:...First and last name and date of birth of Patient. Pre-procedure diagnosis. Recommended procedure to treat the patient's condition. The potential risks and complications associated with the procedure. Consent for Blood Transfusion. Signature of patient, date and time. Name and signature of legally authorized representative with date and time...Printed and written signature of witness along with date and time...Printed name and written signature of Physician obtaining consent along with date and time...".


43002


Resident #21

Review on 9/29/22 of Patient #21's Admission History and Physical dated 3/26/22 revealed that Patient #21 was "interactive and responding appropriately to queries" and "[Pronoun omitted] is alert and oriented to person, place, and time."

Review on 9/29/22 of Patient #21's Discharge progress note, signed by the physician on 4/2/22 revealed that on 3/31/22 at 6:26 a.m. chest compressions were started by nursing and Patient #21 was intubated at 6:43 a.m. Further review revealed that Patient #21's family on 3/31/22 agreed to withdraw life support and Patient #21 passed away on 3/31/22.

Review on 9/29/22 of Patient #21's clinical record revealed that there was not a signed Consent for Treatment until 3/31/22 (by a family member), which was 5 days after admission.

Review on 9/29/22 of the facility's policy titled "Consent" revised April 3, 2019, revealed "... Informed consent is obtained from all patients prior to procedures being performed on them. The conscious and responsible person cannot be forced to accept treatment he or she may need, but to which he/she does not consent. Record the fact that he/she refused and have him/her sign a Release from Responsibility, or his/her refusal to sign..."

Based on record review, observation, and interview, it was determined that the Critical Access Hospital (CAH) failed to employ methods for cleaning and disinfecting equipment to prevent and control the potential transmission of infections within the CAH for 1 out of 4 departments serving patients that disinfected ultrasound equipment.

Findings include:

Observation on 9/28/2022 at approximately 9:15 a.m. of the outpatient urology department revealed 1 Trophon EPR machine used to high-level disinfect ultrasound probes.

Review on 9/28/2022 of the outpatient urology department's Trophon logbook with entries dated from 2/11/2022 through 9/26/2022 revealed that the CAH failed to consistently document the results of chemical indicators to validate high-level disinfection of ultrasound probes when using the trophon EPR for 10 out of 72 logged disinfection cycles.

Review on 9/28/2022 of the CAH's policy titled "Trophon EPR," with revision date 11/8/2018, revealed the following: "...Trophon EPR Disinfection Procedure...12. Document the chemical indicator results on the log after each use on the printer label with the operator initials...The following information needs to be documented for the quality control testing of the Trophon EPR...3. Chemical Indicator Status (pass or fail)...".

Interview on 9/28/2022 at approximately 1:30 p.m. with Staff C (Certified Medical Assistant) revealed that Staff C, as well as other medical assistant and nursing staff in the outpatient urology department, are responsible for performing high-level disinfection of ultrasound probes using the Trophon EPR and for documenting results in the Trophon logbook. Interview further revealed that Staff C is primarily responsible for periodically reviewing the Trophon logbook, and that Staff C was not aware of inconsistent documentation of chemical indicator results.