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Based on medical record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the physician examined the patient immediately before surgery for 5 of 6 discharged surgical patients (22, 23, 24, 25 and 26) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. Total procedures/surgeries from 1/1/18 to 7/31/18 was 410.

Findings are:

A. Review of Patient 22's medical record (8/22/18 at 10:45 AM) revealed the patient had a right inguinal hernia (part of the membrane lining the abdominal cavity or intestine protrudes through a weak spot in the abdomen) repair. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (8:36 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 23's medical record (8/22/18 at 11:30 AM) revealed the patient had a colonoscopy. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (9:05 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 24's medical record (8/22/18 at 11:50 AM) revealed the patient had a laparoscopic (a lighted tube with a camera that is placed through a small cut near your belly button) assisted vaginal hysterectomy (removal of the uterus, it may also involve removal of the cervix, ovaries, fallopian tubes and other surrounding structures). Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (7:46 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 25's medical record (8/22/18 at 12:35 PM) revealed the patient had right leg hardware removal. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (11:38 AM) to evaluate the risk of the procedure to be performed.

-Review of Patient 26's medical record (8/22/18 at 1:15 PM) revealed the patient had right knee arthroscopy (interior of a joint inspected and/or operated on). Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery (2:01 PM) to evaluate the risk of the procedure to be performed.

B. Interview with the Surgical Services Director (8/23/18 at 1:20 PM) confirmed the above medical records lack the evidence of the patient examinations completed by the physicians immediately before surgery to evaluate the risk of the procedure to be performed.

E 041 Hospital CAH and LTC Emergency Power
CFR(s): 485.625(e)

(e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section.

482.15(e)(2), §483.73(e)(2), §485.625(e)(2)
Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code.
482.15(e)(3), §483.73(e)(3), §485.625(e)(3)

*[For hospitals at §482.15(h), LTC at §483.73(g), and CAHs §485.625(g):]
The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part
51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_fe deral_regulations/ibr_locations.html.
If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes.
(1) National Fire Protection Association, 1 Batterymarch Park,
Quincy, MA 02169, www.nfpa.org, 1.617.770.3000.
(i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011.
(ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011.
(iii) TIA 12-3 to NFPA 99, issued August 9, 2012.
(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(i) NFPA 101, Life Safety Code, 2012 edition,
issued August 11, 2011.
(ii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(iii) TIA 12-2 to NFPA 101, issued October 30, 2012.
(iv) TIA 12-3 to NFPA 101, issued October 22, 2013.
(v) TIA 12-4 to NFPA 101, issued October 22, 2013.
(xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.

This STANDARD is not met as evidenced below:

Based on record review and staff interview, the facility failed to have the diesel fuel serving the emergency generator tested annually for quality. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:

Record review on 8/22/18, at 11:26 am revealed documentation was not provided to verify the diesel fuel for the generator tank was tested annually for quality.

In an interview on 8/22/18, at 11:26 am, Maintenance A confirmed the testing was not conducted.

NFPA 99, 2012, 8.3.8 A fuel quality test shall be performed at least annually
using tests approved by ASTM standards.