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Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician periodically reviewed the care provided for emergency room (ER) and clinic patient medical records, in conjunction with the mid-level provider, for 2 of 2 applicable mid-level providers selected for review. (Provider K and Provider G).

The hospital staff identified the mid-level providers provided care to patients from June 1, 2018 to May 31, 2019 as follows:

- Provider K, Physician Assistant (PA): 154 ER patients and 1951 clinic patients
- Provider G, Advanced Registered Nurse Practitioner (ARNP): 60 ER patients

Failure to ensure a physician periodically reviewed mid-level provider's patient medical records, in conjunction with the mid-level provider, could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of the CAH's Medical Staff Bylaws and Rules and Regulations revealed they lacked the description of a process for the periodic review of the patient care provided by mid-level provider by a physician, in conjunction with the mid-level provider.

2. During an interview on 6/5/19, at 3:15 PM and 4:20 PM, the Chief Nursing Officer reported the CAH staff included the mid-level providers in the peer review process. However, the Chief Nursing Officer confirmed the mid-level provider and physician do not review any of the ER records or records for patients seen in the clinic by the mid-level provider, in conjunction with each other.

The Chief Nursing Officer confirmed the CAH lacks a policy/procedure which addressed the requirement for a physician to review patient care by a mid-level provider, in conjunction with each other.

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a mid-level provider participated in a periodic review of the care provided for emergency room (ER) and clinic patient medical records, in conjunction with a physician, for 2 of 2 applicable mid-level providers selected for review. (Provider K and Provider G).

The CAH administrative staff reported the volume of service provided by the selected mid-level providers from June 1, 2018 to May 31, 2019 as follows:

- Provider K, Physician Assistant (PA): 154 ER patients and 1951 clinic patients
- Provider G, Advanced Registered Nurse Practitioner (ARNP): 60 ER patients

Failure to ensure a mid-level provider participated with a physician in the periodic review of the mid-level provider's patient medical records could potentially result in the mid-level misdiagnosing patient and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of the CAH's Medical Staff Bylaws and Rules and Regulations revealed they lacked the description of a process for the periodic review of the patient care provided by mid-level provider by a physician, in conjunction with the mid-level provider.

2. During an interview on 6/5/19, at 3:15 PM and 4:20 PM, the Chief Nursing Officer reported the CAH staff included the mid-level providers in the peer review process. However, the Chief Nursing Officer confirmed the mid-level provider and physician do not review any of the ER records or records for patients seen in the clinic by the mid-level provider, in conjunction with each other.

The Chief Nursing Officer confirmed the CAH lacks a policy/procedure which addressed the requirement for a physician to review patient care by a mid-level provider, in conjunction with each other.

Based on observation, document review, and staff interviews, Critical Access Hospital (CAH) administration failed to ensure CAH staff tested the laboratory staff, nursing staff, and medical providers for color blindness for color so staff could correctly read results for occult blood (blood in the stool) for 1 out of 1 Medical Technologists (professional lab staff who perform laboratory tests) (Staff E), 5 out of 5 nursing staff (Staff A, D, F, G, and H), and 3 out of 3 medical providers (Staff I, J, K) reviewed. Failure to test laboratory staff, nursing staff, and medical providers for color blindness before performing this test may result in staff misreading the results of the Hemoccult slide which could potentially adversely affect the diagnosis and treatment plan for patients. The CAH identified a census of 3 patients on entrance, and performed approximately 45 occult blood tests per year.

Findings include:

1. Observation on 6/3/2019 at 10:51 AM during a tour of the Medical Surgical Unit with the Director of Nursing (DON), revealed Medical Surgical Unit nursing staff utilized Beckman Coulter Hemoccult Slides for testing of occult blood (blood in the stool).


2. During an interview at the time of the tour, the Director of Nursing confirmed the CAH staff did not test the the nursing staff members for color blindness.

Interview on 6/3/2019 at 1:30 PM with Laboratory Manager revealed laboratory staff read occult blood results during laboratory hours. Laboratory Manager also reveled nursing staff have been trained how read occult blood results if specimen obtained after laboratory hours. Laboratory Manager confirmed the laboratory staff was not tested for color blindness.


3. Review of personnel files revealed the following:

a. Review of Staff E's personnel file revealed the CAH staff did not test Staff E for color blindness.

b. Review of Staff A's personnel file revealed the CAH staff did not test Staff A for color blindness.

c. Review of Staff D's personal file revealed the CAH staff did not test Staff D for color blindness.

d. Review of Staff F's personal file revealed the CAH staff did not test Staff F for color blindness.

e. Review of Staff G's personal file revealed the CAH staff did not test Staff G for color blindness.

f. Review of Staff H's personal file revealed the CAH staff did not test Staff H for color blindness.

g. Review of Staff I 's personal file revealed the CAH staff did not test Staff I for color blindness.

h. Review of Staff J's personal file revealed the CAH staff did not test Staff J for color blindness.

i. Review of Staff K's personal file revealed the CAH staff did not test Staff K for color blindness. .


4. Review of manufacturer's directions for the Beckman Coulter Hemoccult Slides, copyright 2015 revealed in part, "...The Hemoccult test is a rapid and qualitative method for detecting fecal occult blood (blood in the stool). Read results within 60 seconds, a blue color will appear on the slide after two drops of developer applied directly over the fecal (stool) smear if positive for blood...Because this test is visually read and requires color differentiation, it should not be interpreted by individuals with blue color deficiency (blindness)..."

Based on review of policy/procedure, skilled patient medical records, and staff interviews, the Critical Access Hospital (CAH) nursing staff failed to ensure the interdisciplinary team documented who attended the multidisciplinary care conference to evaluate/re-evaluate the patient's health needs and plan of care in accordance with the CAH's policy for 1 of 2 open (Patient #1) and 2 of 3 closed skilled patient medical records reviewed (Patients #2, and #3). The CAH administrative staff identified 2 skilled patients at the beginning of the survey. Failure to document who attended the multidisciplinary care conference could potentially fail to ensure all disciplines provided input into the patient's care.

Findings include:

1. Review of the CAH policy "Multidisciplinary Care Conference," dated 12-30-2016, revealed in part, "...Objectives of the care conference are: To evaluate and re-evaluate the patient/resident's health needs and plan of care...Each person attending the care conference shall be informed that their name will be included in the Care Conference documentation in the patient's E.H.R. [Electronic Health Record]...."


2. Review of skilled patient medical records revealed the following:

a. Patient #1, admitted 5/30/19 and discharged 6/4/19, revealed the medical record lacked documentation of who attended the multidisciplinary care conferences on 5/31/19 and 6/4/19.

b. Patient #2, admitted 11/11/18 and discharged 11/20/18, revealed the medical record lacked documentation of who attended the multidisciplinary care conferences on 11/12/18, 11/13/18, 11/14/18, 11/15/18, 11/16/18, and 11/19/18.

c. Patient #3, admitted 4/6/19 and discharged 4/12/19, revealed the medical record lacked documentation of who attended the multidisciplinary care conferences on 4/15/19, 4/16/19, and 4/19/19.


3. During an interview on 6/6/19 at 8:10 AM, the Registered Nurse - Information Technology and the Registered Nurse - Care Coordinator/Activities confirmed the documentation in the skilled patient medical records lacked who attended the multidisciplinary care conferences for Patients #1, #2, and #3.