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Based on observations, interviews and record reviews conducted by State Fire Marshal survey staff; the facility failed to meet life safety code regulations which had the potential to place all patients, staff and visitors at risk (see K-130, K144 and K145). This resulted in the Condition of Participation for Physical Environment not being met. The hospital is licensed for 19 beds. At the time of survey, the facility census was 3.

Findings are:

A. (K-130) The facility failed to:

-Provide a remote manual shutdown for the generator;
-Provide a 2 hour fire rated separation from the rest of the facility;
-Verify adequate ventilation for operation of the generator;
-Verify adequate combustion air for the operation of the generator;
-Verify air intake and discharge for the operation of the generator;
-To assure the audible alarm for the fueling of the generator was operable; and
-To house the generator in a space away from facility supplies.
These failures had the potential for damage to the generator related to a fire originating in the room where the generator was housed, as well as the potential for overfueling of the generator without a way to alert personnel.

B. (K-144) The facility failed to:
- Document the test methods used to determine and confirm the generator was tested to 30% of it's load rating.
This failure had the potential to result in loss of required electrical power during an emergency.

C. (K-145) The facility failed to:
- Identify transfer switches;
- Confirm what electrical panels provided life safety, critical and equipment circuits; and
- Ensure that electrical panel boxed throughout the facility did not have intermixed systems within the branches.
These failures had the potential to affect the egress lighting and emergency systems of the facility.

LICENSURE REFERENCE NUMBER 175 NAC 9-006.03B1a

Based on review of nursing staff schedules, review of training documentation, review of policies and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure that physicians and physicians assistants involved in the supervision of EMT - Paramedics (Emergency Medical Technician-Paramedics) were oriented to the scope of practice of an EMT - Paramedic and the supervision requirements as to be determined by the medical staff of the CAH and failed to ensure that registered nurses (RN) were oriented to the supervision requirements for EMT - Paramedics. The CAH had 2 Active Family Practice physicians, 1 Family Practice PAs (physician assistants) and 7 RNs (registered nurses) working in acute care and/or emergency room. This failed practice has the potential to affect all acute inpatients, skilled inpatients, and patients seen in the emergency department.

Findings are:

A. Review of the nursing staff schedule for June, July and August 2016 revealed EMT - Paramedic - A was listed on the schedule and/or worked 19 days on the day shift. Review of the nursing staff schedule for June, July and August 2016 revealed EMT-Paramedic-B was listed on the schedule and/or worked 43 days on the night shift.

B. Review of the policy and procedure titled Paramedic Staffing with revision date of 10/26/15 revealed:
-"It is the policy of (The CAH) to employ paramedic's as member of the health care team at their level of certification, recognized by the hospital, and based on the Emergency Medical Technician-Paramedic Act and NE. Rev. Stat. #71-5508."
-"A paramedic must function under the direction and/or supervision of a physician, registered nurse, advanced practice registered nurse, or physician assistant."
-"Paramedics hired for (The CAH) will adhere to the job description."

C. A review of the Medical Staff Bylaws and Medical Staff Rules and Regulations dated 1/27/16, lacked mention of Paramedics including their scope of practice and the orientation for those which provided the supervision requirements by physicians, PA's and RN's.

D. Interview with the Administrator on 8/4/16 at 10:30 AM verified understanding that the Paramedics scope of practice and the need for orientation for all physicians and PAs who would have the responsibility for supervision of the Paramedics should be mentioned in the Medical Staff Bylaws and Medical Staff Rules and Regulations.

E. Review of the Governing Board meeting minutes for 2016 revealed no documentation that the Governing Board had approved EMT-Paramedicss to work in the hospital within their scope of practice.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that 3 out of 8 inpatients (Patient 2, 3 and 4) in the last year included the completed Physical (PT) or Occupational Therapy (OT) Evaluations as ordered by the physician/provider. (Physical Therapy Evaluation- An evaluation to determine mobility and function of muscles and joints.) (Occupational Therapy Evaluation- An evaluation to assess gross and fine motor skills and self care abilities.) This failed practice of incomplete medical records/physician orders had the potential to affect all patents that were provided services at the CAH.

Findings are:

A. A review of Patient 2's medical record revealed the patient was admitted on 4/6/16 and dismissed on 4/11/16 with a bilateral sacral ala fractures. (The sacrum is a triangular bone below the lumbar spine. At the top of the sacrum there are wings from each side called the sacral ala.) On 4/8/16 the provider initiated an order for OT to evaluate and treat Patient 2. Review of the medical record lacked any documentation that the Occupational Therapist provided the Evaluation as ordered.

-An interview with Clinic Manager on 8/3/16 at 10:45 AM verified that Patient 2's medical record lacked an OT evaluation during the hospital stay from 4/6/16-4/11/16. The Clinic Manager revealed that the facility practice should be that if the patient discharges before the evaluation can be completed that the nursing staff check with the physician for further instructions regarding the evaluation.

B. A review of Patient 3's medical record revealed the patient was admitted on 5/24/16 and dismissed on 5/25/16 with hypokalemia (low potassium count in the blood) and dehydration. On 5/24/16 the provider initiated an order for OT to evaluate and treat Patient 3. Review of the medical record lacked any documentation that the Occupational Therapist provided the Evaluation as ordered.

-An interview with Clinic Manager on 8/3/16 at 10:45 AM verified that Patient 3's medical record lacked an OT evaluation during the hospital stay from 5/24/16-5/25/16. The Clinic Manager revealed that the facility practice should be that if the patient discharges before the evaluation can be completed that the nursing staff check with the physician for further instructions regarding the evaluation.

C. A review of Patient 4's medical record revealed the patient was admitted on 12/17/15 and dismissed on 12/18/15 with hyponatremia (low salt count in the blood), alcohol dependence and chronic obstructive pulmonary disease. On 12/17/15 the provider initiated an order for PT to evaluate and treat Patient 4. Review of the medical record lacked any documentation that the Physical Therapist provided the Evaluation as ordered.

-An interview with Clinic Manager on 8/3/16 at 10:45 AM verified that Patient 4's medical record lacked a PT evaluation during the hospital stay from 12/17/15-12/18/15. The Clinic Manager revealed that the facility practice should be that if the patient discharges before the evaluation can be completed that the nursing staff check with the physician for further instructions regarding the evaluation.

D. The facility was not able to provide a policy or procedure related to notification and processing of OT and PT orders for evaluation and treatment when asked while on survey.

Based on medical record review and staff interview; the CAH (Critical Access Hospital) failed to ensure that a physician examined the patient immediately before surgery to evaluate the risk of the planned procedure for 2 of 6 surgical medical records (20 and 21) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. The average number of surgical procedures performed at the CAH on a monthly basis is 1.

A. Review of Patient 20's medical record on 8/2/16 at 1:00 PM revealed the patient had teeth extraction on 11/18/15. Review of the entire medical record revealed that the record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.

-Review of Patient 21's medical record on 8/2/16 at 1:30 PM revealed the patient had cysts (sac-like pockets of tissue that contains fluid, air, or other substances) removal on 2/26/16. Review of the entire medical record revealed that the record lacked evidence of an examination of the patient by a physician immediately before surgery to evaluate the risk of the procedure to be performed.
B. Interview with the Director of Nursing on 8/3/16 at 10:45 AM confirmed the above records lacked the physician documented examinations immediately before surgery to evaluate the risks of the procedure to be performed.

Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program, (See C-0331) at least annually, as required. (See C-0332, failed to review a sample of clinical records (See C-0333, failed to determine if the policies were followed (See C-0335)

In addition, there was a lack of a hospital wide Quality Assurance Program (See C-336) including all departments, involved in patient care, including contracted services and other services proved by the CAH.
The CAH could not provide an inpatient census for 2015 or thus far in 2016 , as those records has not been maintained. This failed practice had the potential to affect all patients who received services at the CAH, as well as, current and future patients of the CAH.

The Condition of Periodic Evaluation and Quality Assurance Review is not met.
Facility census at the time of survey was 3.

Based on staff interview and a lack of documented evidence, the the Critical Access Hospital (CAH) failed of to carry out or arrange for a periodic evaluation of its total program, at least annually, as required.

The CAH could not provide an inpatient census for 2015 or thus far in 2016, as those records had not been maintained. This failed practice had the potential to affect all patients who received services at the CAH, as well as, current patients of the CAH.
The census at the time of survey was 3.

Findings include:

1. On 8/3/2016 at 11:00 AM an interview with the Administrator revealed the CAH had not performed an evaluation of its total program. (The current administrator had been employed for approximately one month, at the time of the survey).

Surveyor: Arends, Mary C.

Based on staff interview and a lack of documented evidence, the the Critical Access Hospital (CAH) failed to carry out or arrange for a periodic evaluation of its total program, at least annually, as required.
The CAH could not provide an inpatient census for 2015 or thus far in 2016, as those records had not been maintained. This failed practice had the potential to affect all patients who received services at the CAH, as well as, current patients of the CAH.
The census at the time survey was 3.

Findings include:

1. On 8/3/2016 at 11:00 AM an interview with the Administrator revealed the CAH had not performed an evaluation of its total program. (The current administrator had been employed for approximately one month, at the time of the survey).


2. Since the facility lacked an annual program evaluation, the number of patients served and the volume of services had not been calculated and was unavailable at the time of survey.

Based on staff interview and a lack of evidence, the Critical Access Hospital(CAH) failed to revaluate a sample of open and closed clinical records. This had the potential to affect all patients served in the CAH. Census at the time of survey was 3.

Findings include:

On 8/3/2016 at 11:00 AM an interview conducted with the Administrator revealed the CAH had failed to conduct an evaluation of sampled open and closed clinical records, as required.

Based on staff interview and a lack of evidence, the Critical Access Hospital(CAH) failed to evaluate the services provided and failed to determine if the services were appropriate, if established policies were followed, and if any changes were needed. This failed practice had the potential to affect all patients served in the CAH. Census was 3 at the time of survey.

Findings include:

On 8/3/2016 at 11:00 AM an interview conducted with the Administrator revealed the CAH failed to conduct an evaluation of the services provided, and failed to determine if they were appropriate, therefore, a determination as to whether the policies were followed could not be established.

Based on staff interview and a lack of written evidence, the Critical Access Hospital (CAH) failed to maintain an effective hospital wide quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes for all patient care services, included services provided directly and those provided or arranged for under arrangements or contracts. This failed practice had the potential to affect all patients served in the CAH, The census at survey was 3 patients.

Findings include:

1. An interview with the Administrator on 8/3/2016 at 11:00 AM confirmed the CAH did not have a current hospital wide quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment in the CAH and of the treatment outcomes.

Based on staff interviews and a review of the facility's contracted Rehabilitation Services contract, the facility failed to ensure quality assurance data was collected and reported to Quality Assurance (QA) to ensure the contracted service was providing quality care to their patients. Failure to collect and report quality assurance data has the ability to affect all patients requiring their services both inpatient and outpatient. The facility census was 3.

Findings include:

A. Staff interview with Physical Therapist (PT) "A" on 8/1/16 at 12:30 PM revealed the facility provides both inpatient and outpatient Physical Therapy Services. PT A provides services 5 days per week and is contracted through [Name Acute Care Hospital D]. PT A stated "I do not perform any QA audits or data collection or report any QA data for the hospital."

B. Review of the contract for Physical Therapy services signed 9/15/2010 and automatically renewed annually fails to have any provisions for QA reporting to the hospital.

C. Staff interview with Occupational Therapist (OT) "C" on 8/2/16 at 11:45 AM revealed the services are provided to inpatients and outpatients. The services for OT and Speech Therapy are contracted through [Name of Critical Access Hospital (CAH) B]. OT C confirmed the facility performs QA on their patients at CAH B hospital but not at Warren Memorial Hospital.

D. Phone interview on 8/3/16 at 4:30 PM with Speech Therapist (ST) B confirmed QA is performed for CAH B patients but not on patients at Warren Memorial Hospital.

Based on staff interview and a lack of written evidence, the Critical Access Hospital (CAH) failed to maintain an effective hospital wide quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment. This failed practice had the potential to affect all patients served in the CAH. Census was 3 during the survey.

Findings include:

1. An interview with the Administrator on 8/3/2016 at 11:00 AM confirmed the CAH did not have a current hospital wide quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment in the CAH and of the treatment outcomes.

2. The facility is a member of a network, however, was unable to provide any evidence of a review or oversite by the network provider, for the appropriateness of diagnosis and treatment furnished in the CAH and of the treatment outcomes.

Based on staff interview and a lack of written evidence, the Critical Access Hospital(CAH) failed to consider the findings of the evaluations, including any recommendations of the QIO, therefore, failed to take corrective action. This had the potential to affect all patients served by the CAH. Census at the time of survey was 3.

Findings include:

1. An interview conducted with the Administrator on 8/3/2016 at 11:00 AM confirmed the CAH failed to maintain a hospital wide quality assurance program, failed to participate in a medical staff , external, peer review process with the network provider, and therefore, were unable to consider any findings or evaluate any recommendations, or take corrective action.

Based on staff interview and a lack of documented evidence, the Critical Access Hospital (CAH) failed to take appropriate remedial action to address deficiencies found through the quality assurance program. This failed practice had the potential to affect all patients who received care at the facility. Facility census was 3.

Findings include:

1. An interview conducted with the Administrator on 8/3/2016 At 11:00 AM confirmed the CAH failed to maintain a hospital wide quality assurance program to identify or address deficiencies or to take appropriate remedial action through the quality assurance program.

Based on staff interview and a lack of written documentation, the Critical Access Hospital (CAH) failed to document the outcome of all remedial action. This failed practice had the potential to affect all patients receiving services at the CAH. Census was 3.

Findings include:

1. An interview with the Administrator on 8/3/2016 revealed the CAH failed to maintain a facility wide quality assurance program to identify problems, take remedial action, and document the outcome of all the remedial action taken.

Based on staff interview and record review the facility failed to develop or complete a standardized comprehensive resident assessment as required to assess each resident's functional capacity. 2 of 2 Swing Bed Residents (35 and 36) were in the facility greater than 14 days and did not have a comprehensive assessment performed. This failure has the potential to affect all Swing Bed Residents due to failure to identify a need which, if addressed, would allow the patient to achieve their highest level of functioning. The Swing Bed census was zero.The Swing Bed Sample was 5.

Findings include:

A. Record review of the Swing Bed medical record for Resident 35 revealed the resident was in the facility from 3/15/16 until 4/29/16. The record failed to contain a comprehensive assessment of the resident's functional capacity.

B. Record review of the Swing Bed medical record for Resident 36 revealed the resident was in the facility from 7/5/16 until 7/21/16. The record failed to contain a comprehensive assessment of the resident's functional capacity.

C. Interview with the Director of Nursing (DON) on 8/2/16 at 2:15 PM revealed the DON "was not aware of Comprehensive Assessment requirements for Swing Bed's." The DON further confirmed the facility does not have a Comprehensive Assessment form on paper or electronic for staff to use. The facility also does not have a policy developed to direct staff to complete a Comprehensive Assessment by the 14th day of admission to a Swing Bed.

Based on staff interview and record review, the facility failed to develop or complete a standardized comprehensive resident assessment as required to assess each resident's functional capacity within 14 days of admission. 2 of 2 Swing Bed Residents (35 and 36) were in the facility greater than 14 days and did not have a comprehensive assessment performed. This failure has the potential to affect all Swing Bed Residents due to failure to identify a need which, if addressed, would allow the patient to achieve their highest level of functioning. The Swing Bed census was zero.The Swing Bed sample was 5.

Findings include:

A. Record review of the Swing Bed medical record for Resident 35 revealed the resident was in the facility from 3/15/16 until 4/29/16 (45 days). The record failed to contain a comprehensive assessment of the resident's functional capacity.

B. Record review of the Swing Bed medical record for Resident 36 revealed the resident was in the facility from 7/5/16 until 7/21/16(16 days). The record failed to contain a comprehensive assessment of the resident's functional capacity.

C. Interview with the Director of Nursing (DON) on 8/2/16 at 2:15 PM revealed the DON "was not aware of Comprehensive Assessment requirements for Swing Bed's." The DON further confirmed the facility does not have a Comprehensive Assessment form on paper or electronic for staff to use. The facility also does not have a policy developed to direct staff to complete a Comprehensive Assessment by the 14th day of admission to a Swing Bed.

Based on staff interview and record review the facility failed to develop a Comprehensive Care Plan developed by an interdisciplinary team within 21 days of admission for 1 of 1 Swing Bed Residents (35) who was in the facility greater than 21 days. This failure has the potential to affect all Swing Bed Residents due to failure to identify a need which, if addressed, would allow the patient to achieve their highest level of function. The Swing Bed census was zero.The Swing Bed Sample was 5.

Findings include:

A. Record review of the Swing Bed medical record for Resident 35 revealed the resident was in the facility from 3/15/16 until 4/29/16 (45 days). The record failed to contain a comprehensive assessment of the resident's functional capacity. Record review revealed the resident was admitted after an acute hospital stay in which the resident had an extensive abdominal surgery for pancreatic cancer. The resident was admitted on tube feedings via gastric tube and had orders for Physical Therapy, Speech Therapy and Occupational Therapy. The plan of care included only the problems of Constipation and Risk of Falls. The Plan of Care was developed by nursing on 3/16/16 and updated 4/4/16. The DON on 8/2/16 at 2:15 PM confirmed the plan of care did not meet the requirements for a Comprehensive Care Plan developed by an interdisciplinary team.

B. Interview with the Director of Nursing (DON) on 8/2/16 at 2:15 PM revealed the DON "was not aware of Comprehensive Assessment requirements for Swing Bed's." The DON further confirmed the facility does not have a Comprehensive Assessment form on paper or electronic for staff to use. The facility also does not have a policy developed to direct staff to complete a Comprehensive Assessment by the 14th day of admission to a Swing Bed or to use that assessment to develop a Comprehensive Care Plan based on needs identified in the assessment by the 21st day after admission.

Based on staff interview and record review the facility failed to develop a Comprehensive Care Plan developed by an interdisciplinary team within 21 days of admission for 1 of 1 Swing Bed Residents (35) who was in the facility greater than 21 days. This failure has the potential to affect all Swing Bed Residents due to failure to identify a need which, if addressed, would allow the patient to achieve their highest level of functioning. The Swing Bed census was zero. The Swing Bed sample was 5.

Findings include:

A. Record review of the Swing Bed medical record for Resident 35 revealed the resident was in the facility from 3/15/16 until 4/29/16 (45 days). The record failed to contain a comprehensive assessment of the resident's functional capacity. Record review revealed the resident was admitted after an acute hospital stay in which the resident had an extensive abdominal surgery for pancreatic cancer. The resident was admitted on tube feedings via gastric tube and had orders for Physical Therapy, Speech Therapy and Occupational Therapy. The plan of care included only the problems of Constipation and Risk of Falls. The Plan of Care was developed by nursing on 3/16/16 and updated 4/4/16. The DON on 8/2/16 at 2:15 PM confirmed the plan of care did not meet the requirements for a Comprehensive Care Plan developed by an interdisciplinary team.

B. Interview with the Director of Nursing (DON) on 8/2/16 at 2:15 PM revealed the DON "was not aware of Comprehensive Assessment requirements for Swing Bed's." The DON further confirmed the facility does not have a Comprehensive Assessment form on paper or electronic for staff to use. The facility also does not have a policy developed to direct staff to complete a Comprehensive Assessment by the 14th day of admission to a Swing Bed or to use that assessment to develop a Comprehensive Care Plan based on needs identified in the assessmentby the 21st day after admission.