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Based on review of the Network Hospital Agreement, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the Network Hospital staff met with the CAH's Quality Assurance representatives and provided oversight and assistance in reviewing their quality program semi-annually in accordance with the Network agreement. The CAH staff reported a current census of 20 patients.

Failure to ensure the implementation of the approved agreement for quality assurance could potentially result in the lack of medical record review as part of the determination of the quality and medical necessity of medical care at the CAH.

Findings included:

1. Review of the Network Agreement, dated 2-1-2008, revealed in part, Quality Assurance. [Network Hospital] Participation. [Network Hospital], through participating members of its medical staff or other personnel designated by [Network Hospital], shall meet with the Hospital's QA representatives no less than on a semi-annual basis to provide objective oversight and assistance to Hospital in reviewing the quality and appropriateness of the diagnosis and treatment furnished by Hospital's physicians, to assist Hospital to implement its QA Plan, to review findings under Hospital's QA Plan, to facilitate development and implementation of quality plans, and to propose corrective steps as needed.

2. Review of Montgomery County Memorial Hospital Networking Meeting minutes showed the CAH's Quality Assurance representatives met with the Network hospital representatives on August 14, 1009. The meeting minutes lacked documentation that showed a second meeting in 2009.

3. During an interview on 9/1/10 at 3:00 PM, the Quality/Infection Control Manager acknowledged the Network Hospital representative and CAH Quality Assurance staff only met one time in 2009.

Based on document review, observation, and staff interview, the Critical Access Hospital (CAH) surgical staff failed to date each container of Steris System1 test strips in accordance with the manufacturer's recommendations. Problem identified with 1 (of 1) opened container of test strips. The CAH staff performed approximately 50 surgical procedures per month.

Failure to date the containers when opened could potentially allow staff to use ineffective sterilizing solutions on reusable patient care devices, resulting in life threatening infections transferring between patients.

Findings include:

1. Review of the manufacturer's instructions for the "Chemical Indicator for System1 Sterile Processing Systems", dated 10/08, revealed in part, "If new container is being opened, record the date it was first opened and the new 6 month expiration date on the container..."

2. Observations during a tour of the surgical procedure room on 8/31/10 at 3:00 PM revealed 1 of 1 opened bottle of Steris System chemical indicator test strips lacked evidence of the date the staff opened the bottle.

3. During an interview on 8/31/10 at 3:00 PM, RN D acknowledged the staff failed to record the date staff opened the test strips on the bottle.

Based on observation, staff interview and review of dietary and nursing policy/procedures, the Critical Access Hospital (CAH) dietary and nursing staff failed to measure and record daily temperatures for 1 (of 1) milk cooler in the dietary department and 1 (of 1) nourishment refrigerator on the acute nursing floor. The CAH identified a census of 20 patients.

Failure to ensure nursing and dietary staff measure and record temperatures of refrigerators could potentially lead to food spoiling, resulting in a food borne illness.

Findings include:

1. Observations during a tour on 8/30/10 at 11:35 AM revealed the nourishment room on the acute nursing floor contained a household Hotpoint refrigerator/freezer. The refrigerator/freezer contained nourishment items for patients, including milk, juices, and microwavable meals. Staff had posted a document on the freezer section titled "Documentation of Refrigerator Temperature Recordings". Review of the document revealed nursing staff failed to document the temperature readings for 22 (of 31) days in 7/10, and 23 (of 31) days in 8/10.

During an interview on 8/31/10 at 1:48 PM, the Quality/Infection Control Manager verified staff failed to document the temperature of the refrigerator or freezer. The Quality/Infection Control Manager also verified the CAH administrative staff failed to develop and implement policy/procedure that delineated measuring and recording of the nourishment refrigerator temperatures.

2. During the initial dietary department tour on 8/30/10 at 1:48 PM, Registered Dietician C provided the "Milk Cooler" temperature log. Review of the "Milk Cooler" temperature log revealed dietary staff failed to document temperature readings for 2 days in 6/2010, 1 day in 7/10, and 2 days in 8/10.

During an interview on 8/30/10 at 2:00 PM, Registered Dietician C acknowledged the dietary staff failed to measure and record the Milk Cooler temperatures on the posted log each day.

3. Review of the policy "Food Service Supervisor Job Description", reviewed 12/14/09, revealed in part, "... Check documentation of refrigeration and freezer temperatures..."

Based on policy/procedure review, document review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to include 26 of 44 physicians (Radiologists A-L, Teleradiologists M-Z) in the external peer review process.

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policy/procedure titled "Medical Staff Peer Review Process" with renewal date of 1-28-10 revealed the following in part "PURPOSE: To define a consistent process in which medical records are reviewed by an outside source with the goal of identifying opportunities for improvement and assuring high quality patient care at [Montgomery County Memorial Hospital]. PROCEDURE: Sending Records for External Peer Review: A sample of one chart per active staff physician per six months is sent for peer review. One chart per year is sent for the remainder of consulting and [Emergency Practice Associates] physicians."

2. Review of credential files for all radiologists (Radiologists A-L) and all contracted teleradiologists (Teleradiologists M-Z) revealed the credential files lacked documented evidence of external peer review during the prior 2 year credentialing period.

3. During an interview on 8/30/10 at 1:05 PM, the Health Information Manager/Medical Staff stated staff had not conducted an external peer review of the radiologists and contracted teleradiologists since the prior credentialing period.

4. During an interview on 8/30/10 at 1:40 PM, the Quality/Infection Control Manager stated the radiologists and contracted teleradiologists did not have a peer review completed by an external source since the last credentialing period. The contracted teleradiologists (M-Z) interperet x-rays for the CAH, and the on-staff radiologist over-reads all x-rays the contracted teleradiologist interpret. The CAH staff do not send medical records for the radiologists or contracted teleradiologists for external peer review.