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Based on observation, record review, policy review and interview, it was determined that the Critical Access Hospital (CAH) failed to ensure that the physical environment for 2 of 6 surgical areas in relation to air exchange and pressurization were monitored and that equipment used for occupational therapy was maintained in a manner to ensure the health and safety of all patients.

Findings include:

Review on 7/13/17 of balancing reports for the operating room/surgical areas for 2016 and 2017 revealed the CAH did not have record of the room pressurization and the air distribution for the decontamination room adjacent to the main hospital corridor or for the sterile storage room adjacent to the semi-restricted hallway.

Interview on 7/13/17 at approximately 9:00 a.m. with Staff H (Facilities Manager) confirmed there were no measurements taken of room pressurization and air distribution for the decontamination room or the sterile storage room in 2016 and 2017.


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Review of the Table of Contents for the Rehabilitation Services (Inpatient) Policy & Procedure Manual reveals that the document for "Cleaning Paraffin Bath" was last reviewed on 7/12/16 and the date for its next review is 7/12/18. During interview with Staff C, Rehabilitation Manager on 7/12/17, a copy/printout of this policy was requested.

Review of the CAH policy, entitled "CLEANING PARAFFIN BATH" and provided by Staff C on 7/12/17 revealed that "Cleaning of the unit is to be done once a month, or as needed when used excessively for that month."

Observation on 7/12/17 revealed that the facility has a paraffin bath unit that was positioned on a shelf in the Occupational Therapy room, and that this unit had an equipment inspection sticker that was up to date.

Interview on 7/12/17 with Staff B (Occupational Therapist) revealed that the paraffin bath is infrequently used, only on average about once a month. Staff B related they change the paraffin when it gets low (or if there is debris in it), but not monthly, and Staff B does not keep a log of dates when the paraffin bath is cleaned.

Based on record review and interview, the Criticial Access Hospital (CAH) failed to periodically check all staff regularly exposed to radiation for the amount of radiation exposure of personnel in the operating room and an outpatient location.

Findings include:

Review on 7/13/17 of the dosimetry reports from to 7/29/16 to 5/18/17 revealed that the CAH was scheduled to exchange their badges quarterly with the dosimetry company. Badges for the period 7/15/16 to 10/14/16 from the operating room for the personnel that were exposed to radiation from the C-arm used for fluoroscopic imaging during surgery, did not have their badges sent to the dosimetry company for testing until 2/24/17

Interview on 7/13/17 at approxmatley 2 p.m. with the Staff F (Director of Imaging Services) confirmed the above finding and revealed that when badges are not returned to radiology to be sent out for testing timely, they are sent with the next quarter's badges.

Review of the CAH's procedure titled "Radiation Protection Program", dated January 9, 2012, revealed the following: "Monitoring of diagnostic imaging personnel who have direct contact with the possibility of contact with ionizing radiation shall be conducted at monthly intervals."

Review of the CAH's procedure titled "Worker Instruction", dated January 9, 2012 revealed the following: "Employees will be supplied with personnel monitoring equipment, such as a film badge or ring and shall be required to use these monitors at all times during their shifts. Records will be maintained for radiation exposure for all employees."

Interview with Staff G (Provider) on 7/12/17 at approximately 10:30 a.m. revealed that the orthopedic practice used a mini C-arm used for fluoroscopic imaging during procedures performed in the practice. Staff G also revealed that staff do have dosimetry badges for the procedures the orthopedic staff perform at hospital in the operating room but they do not use those badges for procedures performed in the orthopedic office and do not have separate badges for the procedures performed in the orthopedic office.

Based on record review and interview, it was determined that the facility failed to ensure its clinical records were complete and accurately documented for 3 of 3 swing bed transfer patients reviewed, and 1 of 10 Emergency Department patients reviewed. (Patient identifiers are #22, #23, #25, and #50.)

Findings include:

Patient #22
Review of this patient's clinical record revealed that the patient was transferred from an acute stay at Memorial Hospital to swing bed status on 5/19/17. An admission order to swing bed status was evident in the record, and was signed by the physician; however, there was no discharge hospital order to discharge the patient from the acute hospital stay. While there was a discharge summary for the acute hospital stay (5/15/17 - 5/19/17), there was no discharge summary for the 5/23/17 discharge from swing to home with visiting nurses services. This was established by Staff D (unit manager) who navigating the computer during record review, was unable to find the discharge order from acute or the discharge summary from swing.

Patient #23
Review of this patient's clinical record revealed that the patient was transferred from an acute stay at Memorial Hospital to skilled, swing bed status on 5/26/17. An admission order to swing bed status was evident in the record, and was electronically signed by the physician; however, there was no discharge hospital order to discharge the patient from the acute hospital stay. This was established by Staff D, who navigating the computer during record review, found no discharge order from the acute stay.

Patient #25
Review of this patient's clinical record revealed that the patient was transferred from an acute stay at Memorial Hospital to swing bed status on 2/17/17. An admission order to swing bed status was evident in the record and was dated 2/17/17; however, there was no discharge hospital order to discharge the patient from the acute hospital stay. This was established by Staff E (nursing services/staffing) and Staff D, who navigating the computer during record review, found no discharge order from the acute stay.


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Patient #50
Review of the medical record on 7/12/17 indicated that this Patient was admitted on 6/25/17 for an alleged sexual assault, was examined and treated. The physician decided that a SANE ( Sexual Assault Nurse Examiner) needed to be involved in this treatment, the facility did not have a SANE nurse available and one was located at another facility. Arrangements were made and the patient was discharged from the hospital and would proceed to the other facility (All consents were signed).
Review of the complete emergency room record for this patient showed no documented evidence that the nursing staff or the physician educated the patient on what they should or should not do in preparation for the SANE exam to preserve any evidence that might be collected, (i.e. not to shower, bathe, eat or change clothes). The patient proceeded to go to their home shower, change clothes and eat lunch prior to proceeding to the awaiting facility for the continued examination.

Based on record review and interview the facility failed to ensure that all patients were given the opportunity to execute informed consent for treatment for 3 acute admissions, 2 Emergency patients and 1 procedural consent in an out-patient setting. Patient identifiers are #22, #23, #24, #37, #46, and #51.

Finding include:

Patients #37 and #46
During recertification survey on 7/11/2017 a review of Emergency Department records was completed. This review identified that Patient #37 was seen and treated on 3/26/17 and Patient #46 was seen and treated on 2/11/17. In neither record was any documented evidence that a consent to treat had been given, or signed by the patients or their representative. Interview with Staff K (Emergency Department Director) on 7/12/17 confirmed the above findings.

Patient #51,
Review on 7/12/17 of the out-patient urology site identified that Patient #51 on 7/11/17 had been seen, treated and a procedure performed to remove a lesion. Review of the medical record for this visit revealed no documented evidence of a consent by this patient for this procedure.

Interview on 7/12/17 with Staff J (Practice Manager) confirmed the above missing consent.


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Patient #23
Review of this patient's record with Staff D (unit manager) navigating the computer revealed this patient was admitted to an acute stay at Memorial Hospital followed by transfer to swing bed status on 5/26/17; however, review of the clinical record, as navigated by Staff D, revealed no consent to treat was obtained from the patient or legal representative, for the patient's care and treatment.

Patient #24
Review of this patient's record with Staff E (nursing services/staffing) and Staff D navigating the computer revealed this patient was admitted to an acute stay at Memorial Hospital on 6/9/17, with a history and physical dictated on that date; however, the only consent to treat identified in the record, as navigated by Staff D and/or Staff E, was a consent for treatment signed by the SIL, and interview during record review with Staff E determined that SIL probably stood for son-in-law, with no evidence in the record of a consent signed by the patient, next of kin, or durable power of attorney.

Based on record review, it was determined that the hospital failed to provide anesthesia follow up for 2 of 3 obstetric patients and 1 out of 11 surgical patients who received anesthesia in a survey sample of 51. (Patient identifiers are: #9, #11 and #32 .)

Findings include:

Patient #9
Review of 7/12/17 of Patient #9 closed medical record revealed that Resident #9 was admitted to the hospital on 6/29/17 for labor and delivery. Resident #9 required an epidural then a emergency cesarean section. Review of the anesthesia record of 7/12/17 revealed that there was no anesthesia follow up evaluation for this patient prior to being discharge home on 7/2/17.

Resident #11
Review of 7/12/17 of Patient #11 medical record revealed that Resident #11 was admitted to the hospital on 7/10/17 for labor and delivery. Resident #11 required an epidural for pain management. Review of the anesthesia record of 7/12/17 revealed that there was no anesthesia follow up evaluation for this patient. This patient was being discharged home on later on 7/12/17 or early 7/13/17. The anesthesiologist did a post operative note dated 7/12/17 with the following comments: "Epidural catheter discontinued by L & D RN, blue tip reported intact. VS stable. See hospital EHR." Section for Physical exam all areas are marked.

Interview 7/10/17 at approximately 11:30 a.m. with Staff A (Registered Nurse/Obstetric) RN/OB revealed that the anesthesiologist is always on the floor looking at the patients. The anesthesiologist stated that they do not write a follow up note for the epidurals on the OB floor.


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Patient #32
Review of the surgical medical record identified that on 8/30/16 this patient underwent a procedure requiring anesthesia. There was no documented evidence in the record that a post anesthesia evaluation of this patient was completed. Staff I (Director of surgical services) was also unable to locate the evaluation.