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Based on document review and staff interview, the facility administrative staff failed to ensure a written emergency water arrangement with an outside entity was in place to ensure adequate water was available in the event of an interruption in the water supply during an emergency. The facility staff reported a census of 13 inpatients at the time of the survey with an average census of 12 inpatients.

Failure to have a system in place to ensure they could meet their water needs during an emergency loss of water could potentially result in the compromise of patient safety during the loss of normal water service.

Findings include:

1. Review of a facility policy titled "Potable Water Failure", dated 8/21/13, revealed in part, "In situations where drinking water is determined to be limited in supply, unsafe or potentially unsafe, bottled water will be utilized. . . 4. Engineering Department will notify Materials Management and bottled water will be purchased. . . ."

The policy failed to identify an estimate of the potential quantity of water the facility would need or identify any potential supplier(s) with the ability to meet facility needs.

2. During an interview on 10/3/13 at 10:50 a.m., Staff K, Safety Officer and Ambulance Manager, and Staff BB, Engineering Services Director, reviewed the facility's plans for emergency fuel and water. Staff K and Staff BB confirmed the facility did not have a written agreement for the provision of water by an outside source in the event of an emergency resulting in the loss of water for the facility. Staff BB explained there is a working system in place to connect a tanker of water to the facilities water lines and but confirmed the facility lacked a written agreement with the entity identified to provide the tanker of water or the entity identified to provide bottled water for the patients.

Based on medical record review, document review, and staff interviews, the Cardiac Rehab unit failed to have a system in place to ensure the Cardiac Rehab Medical Director ordered, reviewed, and signed Phase II exercise prescriptions based upon the graded exercise test completed by the Cardiac Rehab Registered Nurse Supervisor at the start of cardiac rehab for 10 of 10 sampled open cardiac rehab patients (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). The Clinic Administrator for Cardiac Rehab identified a census of approximately 8 Phase II cardiac patients daily. The Cardiac Registered Nurse Rehab Supervisor identified 12 cardiac rehab patients currently enrolled in the exercise program.

Failure to review and sign the Phase II exercise prescriptions could potentially have a direct effect on the quality, effectiveness, and safety to patients ultimately impacting the outcome for patients participating in the Phase II cardiac rehab.

Findings include:

1. Review of the facility's Medical Staff Rules and Regulations, revised by the active Medical Staff on 8/1/2012 and approved by the Board of Trustees on 9/5/12, revealed the following, in part, ". . . Responsibilities of Medical Staff Members...all orders for treatments shall be in writing. . . ."

Review of facility's policy for Rehab Services "Plan of Care and Provider Involvement", last revised 11/12, revealed the following, in part, ". . . a written plan of care is established and is reviewed by a physician or licensed practitioner. . . the plan of care, findings, and results of treatment are reviewed. . . following initiation of treatment. . . ."

Review of facility's policy "Cardiac Rehabilitation Phase II Roles and Responsibilities", last revised 11/12, revealed the following, in part, "Cardiac Rehab Medical Director. . . prepare Phase II. . . exercise prescriptions based upon the graded exercise test. . . Rehab Personnel. . . implement participant's. . . exercise program in conjunction with medical staff. . . ."

2. Review of Patient's medical record revealed the following information.

a. Patient #1's medical record revealed diagnoses including Coronary Artery Disease (a narrowing of the small blood vessels that supply blood and oxygen to the heart muscle that acts as a pump) and stent placement (placement of an open-ended tubular device surgically placed to keep an artery open to blood flow) on 3/4/13.

A 4-paged dismissal summary from another hospital for Patient #1, dated 3/5/13, included evidence of discussion of the Cardiovascular Health Clinic staff with the patient involving follow-up Cardiac Rehabilitation recommendations. The dismissal summary lacked any further information specifying the recommendations for Cardiac Rehabilitation and lacked the signature by a physician. Due to additional medical problems the patient experienced after 3/5/13, the patient did not begin Phase II Cardiac Rehab treatment until July of 2013. The patient required hospitalization at this critical access hospital on 3/21/13.

The monitored Cardiac Phase II session report and Individualized Treatment Plan lacked evidence of the Cardiac Rehab Medical Director's signature for Patient #1's Phase II Cardiac Rehab Therapy until 7/16/13. Patient #1 received Cardiac Rehab therapy on 7/10, 7/12, and 7/15/13 without a physician's order or signed prescription for exercises.

b. Patient #2's medical record revealed diagnoses including myocardial infarction (commonly referred to as a heart attack) on 9/14/13.

The patient's medical record contained a dismissal summary from another hospital dated 9/16/13. This document included a list of Follow-Up Recommendations including a recommendation for patient to start Phase II Cardiac Rehabilitation. The 3-paged dismissal summary included the electronic signature of a cardiovascular physician from the other hospital.

The monitored Cardiac Phase II session report and Individualized Treatment Plan lacked evidence of the Cardiac Rehab Medical Director's signature for Patient #2's Phase II Cardiac Rehab Therapy until 10/2/13. Patient #2 received Cardiac Rehab therapy on 9/30/13 without a physician's order and prescription for exercises.

c. Patient #3's medical record revealed diagnoses including paroxysmal atrial fibrillation with rapid ventricular response (a heart rhythm disorder) and the patient received a permanent pacemaker on 4/4/13.

The patient's medical record included a dismissal summary dated 4/6/13 from another hospital. The document included a list of Follow-Up Recommendation that included Phase II Cardiac Rehabilitation with information indicating the patient agreed to attend Phase II at the Critical Access Hospital in Decorah. The dismissal summary was electronically signed by a Certified Nurse Practitioner.

A monitored cardiac phase II session report and Individualized Treatment Plan lacked evidence of the Cardiac Rehab Medical Director's signature for Patient 3's Phase II Cardiac Rehab Therapy until 5/22/13. Patient #3 received Cardiac Rehab therapy beginning on 5/20/13.

d. Patient #4's medical record revealed the patient had Coronary Artery Bypass Graft surgery on 6/21/13 due to Coronary Artery Disease followed by a stent placement in a coronary artery on 7/1/13 at another hospital. The patient's clinical record included information about a hospitalization at the other hospital for angina pectoris (chest pain from 7/5/13 to 7/7/13. The 4-paged dismissal summary from the other hospital dated 7/7/13 included the instruction "Please continue with your cardiac rehab in Decorah, Iowa" and was electronically signed by a physician. Notes in the patient's medical record indicated that the critical access hospital received the records for the patient from the other hospital on 7/9/13.

The patient phoned Cardiac Rehabilitation on 7/15/13 requesting an appointment for his first session of cardiac rehab. The patient went to the initial appointment on 7/19/13 and on 7/22/13 but the monitored Cardiac Phase II session report and Individualized Treatment Plan lacked evidence of the Cardiac Rehab Medical Director's signature for Patient 4's Phase II Cardiac Rehab Therapy until until 7/23/13.

e. Patient #5's medical record revealed diagnoses including but not limited to Coronary Artery Disease with coronary artery bypass (a type of surgery that improves blood flow to the heart).

The patient's medical record included an order on the patient's 7-paged discharge summary, dated 8/14/13, for Cardiac Rehab for 12 sessions electronically signed by a nurse practitioner from another hospital.

A monitored Cardiac Phase II session report and Individualized Treatment Plan (ITP) lacked evidence of the Cardiac Rehab Medical Director's signature for Patient #5's Phase II Cardiac Rehab Therapy until 9/19/13. Patient #5 received Cardiac Rehab therapy on 9/9/13, 9/11/13, 9/13/13, and 9/16/13.

f. Patient #6's medical record revealed diagnoses including but not limited to acute coronary syndrome and a myocardial infarction (heart attack) on 8/16/13.

The patient's medical record contained a 4-paged dismissal summary from another hospital, dated 8/18/13, and electronically signed by a physician assistant. The dismissal summary included discussion with the patient regarding Phase II Cardiac Rehabilitation, which was strongly recommended. The patient agreed to attend cardiac rehab at the critical access hospital in Decorah. A referral was called to the critical access hospital's rehab department on 8/18/13.

A monitored Cardiac Phase II session report and Individualized Treatment Plan (ITP) was signed by the Cardiac Rehab Medical Director however the signature lacked the date it was signed. Patient #6 had received Cardiac Rehab therapy on 9/4/13, 9/6/13, 9/9/13, 9/11/13, 9/25/13, 9/27/13, and 9/30/13 without a physician's dated order and prescription for exercises or evidence of further involvement by the Cardiac Rehab Medical Director.

g. Patient #7's medical record revealed diagnoses including a history of Coronary Artery Disease with coronary artery bypass grafting surgery on 7/10/13.

The patient's medical record included a 4-paged dismissal summary from another hospital dated 7/14/13. This document included a section titled Information for Continuing Care with a recommendation for Phase II Cardiac Rehabilitation. The dismissal summary was electronically signed by a physician assistant from the other hospital.

A monitored Cardiac Phase II session report and Individualized Treatment Plan (ITP) included the undated signature of the Cardiac Rehab Medical Director but lacked evidence of the Cardiac Rehab Medical Director's dated signature for Patient #7's Phase II Cardiac Rehab Therapy until 9/19/13. Patient #7 had received Cardiac Rehab therapy on 8/9/13, 8/12/13, 8/16/13, 8/19/13, 8/21/13, 8/23/13, 8/26/13, 8/28/13, 8/30/13,9/4/13, 9/6/13, 9/11/13, 9/13/13, and 9/11/13 without evidence of a physician's order and prescription for exercises.

h. Patient #8's medical record revealed diagnoses including myocardial infarction and a procedure for stent placement. The patient's medical record included a 4-paged dismissal summary from another hospital which included evidence of a follow-up recommendation for cardiac rehab to which Patient #8 agreed. The dismissal summary was electronically signed by a physician on 9/11/13.

A monitored Cardiac Phase II session report and Individualized Treatment Plan (ITP) lacked evidence of the Cardiac Rehab Medical Director's signature for Patient #8's Phase II Cardiac Rehab Therapy until 9/25/13. Patient #8 had received Cardiac Rehab therapy on 9/23/13 without a physician's order and prescription for exercises.

i. Patient #9's medical record revealed a history of Cardiomyopathy (a disease of the heart muscle) and previous coronary artery bypass surgery. On 8/1/13 two stents were placed in the patient's right coronary artery. The medical record contained documentation form another hospital cardiovascular clinic dated 7/29/13. The nurse's notes documented a cal was received from a clinic on 8/2/13 with a referral for cardiac rehab for Patient #9.

The patient's medical record showed the patient began cardiac rehab on 8/2/13. A monitored Cardiac Phase II session report and Individualized Treatment Plan (ITP) lacked evidence of the Cardiac Rehab Medical Director's dated signature for Patient #9's Phase II Cardiac Rehab Therapy until 9/19/13. There was an earlier signature of the Cardiac Rehab Medical Director's signature included at the end of documentation on 8/12/13 but it lacked a date. Patient #9 had received Cardiac Rehab therapy on 8/12/13, 8/14/13, 8/16/13, 8/19/13, 8/21/13, 8/26/13, 8/28/13, 8/30/13, 9/4/13, 9/6/13, 9/9/13, 9/11/13, 9/13/13, 9/16/13 times without a physician's order and prescription for exercises.

j. Patient #10's medical record revealed diagnoses including recent mitral valve replacement on 7/26/13. The patient's medical record included a copy of a clinical document, dated 7/30/13 showing a recommendations for cardiac rehabilitation program. Patient #10 agreed and was provided with the contact information for cardiac rehab at the critical access hospital. The document was electronically signed by the physician. The patient's medical record included a copy of a 13-paged dismissal summary, dated 8/1/13. This document referred to the patient's agreement with the referral to cardiac rehab at the critical access hospital and was electronically signed by a nurse practitioner.

A monitored Cardiac Phase II session report and Individualized Treatment Plan (ITP) lacked evidence of the Cardiac Rehab Medical Director's signature for Patient #10's Phase II Cardiac Rehab Therapy until 9/19/13. Patient #10 received cardiac rehab therapy on 9/11/13, 9/13/13, and on 9/16/13 without a physician's order and prescription for exercises.

3. During an interview on 10/2/13 at 4:15 PM, Staff A, Cardiac Rehab Nurse, stated after the initial patient interview she would be responsible for completing the ITP and then would forward that to the Cardiac Medical Director (Physician A). Staff A reported the ITP required a physician to review and sign the order because that would be outside her scope of practice as a nurse. Additionally, Staff A acknowledged the exercise and ITP for the 10 patients reviewed during the Cardiac Rehab survey lacked a physician's signature and that this had been a problem for a long time.

During an interview on 10/3/13 at 8:20 AM, Staff V, Clinic Administrator of the Cardiac Rehab, stated the facility policy for ITP exercises required a physician's order and that they were unaware that there were problems. Staff V said the ITP is geared to "that individual patient's cardiac rehab exercise" and it would be based on the information the nurse obtained with the initial patient interview and assessment to ascertain what the patient's capabilities were. Staff V stated the physician responsible currently for signing ITP was Physician A, MD and Medical Director of the Cardiac Rehab unit. When asked why it would be important to have a physician's order for the ITP, Staff V stated it would be critical to have that collaboration of care services for the patients "best" outcome and "ultimately" the physician would be responsible for the patient.

During an interview on 10/3/13 at 8:45 AM, Staff V and the Chief Nursing Officer acknowledged the facilities Medical Director for the Cardiac Rehab failed to review Phase II exercise prescriptions based upon the graded exercise test for the ten of ten patients reviewed and failed to follow facility policies regarding signing and dating orders.

Based on observation, document review, and staff interviews, the facility dietary staff failed to handle food in a safe and sanitary manner. The facility administrative staff reported a census of 13 inpatients at the time of the survey, with an average daily census of 12 patients. The Director of Nutrition Services reported the dietary staff provided an average of 45 to 50 patient meals daily.

Failure to handle food in a sanitary manner could potentially result in the contamination of the patients' food and potentially cause food borne illness.

Findings include:

1. Observations included:

a. Observation during noon patient meal preparation and service, on 10/1/13 from 11:25 AM to 12:17 PM, revealed the following concerns.

Observed Staff P, cook, don gloves at 11:40 AM. Staff P continued to wear the same pair of gloves until 12:07 PM, touching multiple items including, but not limited to, freezer handles, microwave, steamer handle, convection oven handle, food pans, pot holders and handled patient plates and food with the contaminated gloves (sliced buns and brussel sprouts).

Observed Staff F, cook, don gloves multiple times without performing handwashing before and after changing gloves, while touching multiple items in between changing gloves, including, but not limited to, refrigerator handles and plastic bread wrappers. Staff F handled patient food items with contaminated gloves, including lettuce, shredded cheese, carrots, sliced ham, sliced turkey, cherry tomatoes, and a boiled sliced egg.

Observed Staff G, cook, don gloves multiple times without performing handwashing before and after changing gloves, while touching multiple items in between changing gloves, including, but not limited to, plastic bread wrappers, refrigerator handles and a water faucet at produce sink. Staff G handled patient food items with contaminated gloves, including bread and a fresh apple.

b. Observation during breakfast meal preparation and service on 10/2/13, from 7:30 AM to 8:35 AM, revealed the following concerns:

Observed Staff H, cook, don gloves multiple times without performing handwashing before and after changing gloves, while touching multiple items in between changes, including, but not limited to, a yellow highlighter, pen, paper, cafe door, plastic bread wrappers, refrigerator handles, freezer handles, microwave, condiment caddy, telephone and toaster handles. Staff H handled patient food items with contaminated gloves, including toast, muffins, and an English muffin.

Observed Staff I, cook, don gloves multiple times without performing handwashing before and after changing gloves, while touching multiple items in between changes, including, but not limited to, toaster handles, telephone, pen, papers, refrigerator handles, freezer handles, microwave, plastic bread wrappers. Staff I handled patient food items with contaminated gloves, including an English muffin, bread, and a muffin.

2. During an interview on 10/2/13 at 10:10 AM, Staff C, Director of Nutrition Services, reported staff are trained and expected: to wear clean gloves when handling any ready to eat food; to perform handwashing before donning clean gloves; and should avoid performing multiple tasks with the same gloves.

During an interview on 10/2/13 at 1:50 PM, Staff M, Infection Control Officer, reported the infection control organizational polices do not address specific procedures for glove use in relation to food handling but she would expect employees to perform handwashing prior to donning gloves and after removal.

3. Review of a Nutrition Services policy titled "Employee Sanitation", dated 5/1/13, revealed in part "To minimize the spread of any illness/disease or bacteriological contamination employee cleanliness is vital within the organization. . . 3d. When necessary to use hands for any foods that will not be cooked, clean gloves must be worn. . . ."

The Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2009 editions requires single-use gloves be used for only one task such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. In addition, food employees shall clean their hands immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, after handling soiled equipment or utensils, and before donning gloves for working with food.

Based on policy/procedure review, and staff interview, the facility staff failed to provide dosimetry badges (small devices used to measure a staff member's exposure to radiation) for 12 of 12 operating room practitioners, (Practitioner B, C, D, E, F, G, H, I, J, K, L, and M) while performing procedures involving a C-Arm fluoroscope (a portable device creating real-time radiological images). The facility completed approximately 23 procedures a month using the C-Arm with fluoroscopy.

Failure to provide staff with dosimeter badges could potentially allow a staff member to receive unrecognized large quantities of radiation, and result in health hazards for the staff person.

Findings include:

1. Review of the facility policy, Personnel Monitoring & Film Badges, revised 12/2008 revealed in part... "Standard, Personnel dosimeters will be provided to all radiation workers (e.g., radiologists, radiology technologists) and various personnel involved with holding patients for x-rays, frequent fluoroscopy procedures and/or therapeutic doses of radioactive materials, (e.g., surgery, respiratory, laboratory)." 3. "The dosimeters shall be worn at all times while personnel are involved in procedures using radiation."

2. During an interview on 10/1/13 at 1:35 PM, Staff R, RN (Registered Nurse) and Operating Room Manager stated the physicians/ surgeons stay in the operating room during procedures requiring C-Arm fluoroscopy and do not wear dosimeter badges. All other staff in the operating room utilize the dosimeter badges.

3. During an interview on 10/2/13 at 3:00 PM, Staff K, Radiology Supervisor stated the operating room surgeons performing procedures using C-Arm fluoroscopy do not wear dosimeter badges while performing the procedures. The hospital allowed the surgeons to decide if they wanted to use dosimeter badges and the surgeons declined the use of dosimeter badges. The facility did not have dosimeter badge reports for the surgeons because they do not use the badges. Staff K stated the surgeons should be wearing a dosimetry badge during procedures using fluoroscopy.

4. Review of the list of surgeons performing C-Arm Fluoroscope procedures provided by the facility staff revealed the following:

a. Practitioner B completed an average of 16 procedures a month requiring use of the C-Arm fluoroscopy.
b. Practitioner C completed 2 procedures in the last year requiring use of the C-Arm fluoroscope.
c. Practitioner D completed 5 procedures in the last year requiring use of the C-Arm fluoroscope.
d. Practitioner E completed 1 procedure in the last year requiring use of the C-Arm fluoroscope.
e. Practitioner F completed 2 procedures in the last year requiring use of the C-Arm fluoroscope.
f. Practitioner G completed 14 procedures in the last year requiring use of the C-Arm fluoroscope.
g. Practitioner H completed 24 procedures in the last year requiring use of the C-Arm fluoroscope.
h. Practitioner I completed 4 procedures in the last year requiring use of the C-Arm fluoroscope.
i. Practitioner J completed 1 procedure in the last year requiring use of the C-Arm fluoroscope.
j. Practitioner K completed 10 procedures in the last year requiring use of the C-Arm fluoroscope.
k. Practitioner L completed 17 procedures in the last year requiring use of the C-Arm fluoroscope.
l. Practitioner M completed 1 procedure in the last year requiring use of the C-Arm fluoroscope.

Based on observations, review of policies and procedures, and staff interviews, the facility staff failed to ensure the security of all patient medical records against unauthorized access in two of nine areas where records are stored. (Same Day Surgery/Infusion Center, Clinic) The facility reported approximately 195 same day surgery patients per month, approximately 60 infusion patients per month, approximately 181 patient visits per month for Provider P, approximately 153 patient visits per month for Provider S, and approximately 160 patient visits per month for Provider R.

Failure to protect medical records from unauthorized access could potentially result in identity theft, theft of financial/insurance information, and/or unauthorized disclosure of personal medical information.

Findings include:

1. Observations during a tour of the Same Day Surgery/Infusion Center area on 10/1/13 at 3:15 PM, with Staff R, Director of Surgery Services, revealed the following:

a. Same Day Surgery area:

- 1 of 1 unlocked 2-drawer file cabinet that contained approximately 7 patient surgery orders. The unsecured patient orders contained confidential patient information.

b. Infusion Center area:
- 1 of 1 unlocked 2-drawer file cabinet that contained approximately 100 patient infusion orders. The unsecured patient orders contained confidential patient information.

Observations during a tour of the Clinic area on 10/2/13 at 10:10 PM, with the Clinic Manager, revealed the following:

a. Provider P's work space:
- Approximately 30 patient medical records used for future patient visits stored on an open shelf. The unsecured patient orders contained confidential patient information.

b. Provider S's work space:
- Approximately 26 patient medical records used for future patient visits stored on an open shelf. The unsecured patient orders contained confidential patient information.

c. Provider R's work space:
- Approximately 34 patient medical records used for future patient visits stored on an open shelf. The unsecured patient orders contained confidential patient information.

2. Review of policy titled "HIPAA - Work Space Security", dated May 2005, stated, in part, ". . . File cabinets containing PHI [protected health information] must be locked when not in use and any time they are left unattended. . . All WMC [Winneshiek Medical Center] staff are responsible to assure the security of patient information or any PHI. This includes not leaving information, charts, or any documents containing PHI on desks, in offices, in conference rooms, or any other location where unauthorized individuals may access the information."

3. During an interview on 10/1/13 at 3:30 PM, Staff W, RN (Registered Nurse), Same Day Surgery/Infusion Center, reported the medical records observed in the Same Day Surgery/Infusion Center area were not locked after staff leave each evening. Staff W stated the staff did not lock the file cabinets before they left for the evening. Staff W reported that unsupervised housekeeping staff cleaned the Same Day Surgery/Infusion Center area each day after the staff leave each evening and would have access to the unsecured medical records stored in this area. Staff W also acknowledged that housekeeping staff did not have a need to know the personal or medical information contained in the medical records.

During an interview on 10/2/13 at 10:50 AM, Staff Y, Clinic RN, reported the medical records observed in Providers P and S work space were not locked after staff leave each evening. Staff Y reported that unsupervised housekeeping staff cleaned the Clinic area each day after the staff leave each evening and would have access to the unsecured medical records stored in this area. Staff Y also acknowledged that housekeeping staff did not have a need to know the personal or medical information contained in the medical records.

During an interview on 10/2/13 at 11:25 AM, Staff Z, Clinic RN, reported the medical records observed in Provider R work space were not locked after staff leave each evening. Staff Z reported that unsupervised housekeeping staff cleaned the Clinic area each day after the staff leave each evening and would have access to the unsecured medical records stored in this area. Staff Z also acknowledged that housekeeping staff did not have a need to know the personal or medical information contained in the medical records.

Based on document review and staff interviews, the facility failed to ensure 7 of 10 active and 1 of 1 courtesy physicians, selected for review, received outside entity peer review performed by the Network Hospital to evaluate the appropriateness and diagnosis and treatment furnished to patients at the Critical Access Hospital in accordance with the facility's agreement with the Network Hospital. (Physicians C, G, H, J, L, N, O, and Q). The facility had 34 active and 49 courtesy physicians.

Failure to ensure all medical staff members received outside entity peer review affects the facility's ability to assure physicians provide quality care to their patients.

Findings include:

1. Review of the "Critical Access Hospital [CAH] Transfer Agreement", dated October 8, 2004, revealed in part, ". . . [Network Hospital] assists Winneshiek County Memorial Hospital in reviewing the quality and appropriateness of the diagnosis and treatment furnished by Winneshiek County Memorial Hospital doctors of medicine or osteopathy for purposes of assisting Winneshiek County Memorial Hospital carry out the requirements of its quality assurance plan. . . ."

2. Review of facility documentation on 10/2/13 revealed the facility failed to ensure the Network Hospital completed peer review for Physicians C, G, H, J, L, N, O, and Q.

3. During an interview on 10/2/13 at 5:15 PM, Staff AA, Director of Quality Management, stated the facility staff choose 1 patient medical record from each physician on staff at the CAH to the Network Hospital for review. Staff AA further stated the records are chosen from patients that have been transferred to the Network Hospital.

During an interview on 10/3/13 at 9:10 AM, Staff B, Chief Nursing Officer, acknowledged the facility lacked documentation of Network Hospital peer review for Physicians C, G, H, J, L, N, O, and Q.