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Based on observation, hospital policy review and staff interview, the facility failed to ensure that the Critical Access Hospital (CAH) had rules for storage, handling, dispensation, and administration of drugs and biological.


Findings include:


On 11/09/11 at 11:00 a.m. a tour of the Pharmacy was conducted with the Director of Nursing (DON), who could not provide any information about pharmacy procedures. She was unable to provide any documented evidence regarding storage, handling, and dispensation.


On 11/09/11 at 2:00 p.m. an interview with the Pharmacy Technician revealed that she was the person in charge of the Pharmacy. She stated that the hospital had hired a part-time pharmacist on 11/04/11, and that same evening the pharmacist was killed in a car accident. As a result of that event, the hospital hired an interim pharmacist. No documentation was provided on the interim pharmacist.


On 11/09/11 at 3:00 p.m. an interview with the DON and the Pharmacist Technician revealed that they could not provide any policies or procedures that govern how the pharmacy operates.

Based on observation, staff interview, policy review and in-service review, the Critical Access Hospital (CAH) failed to have a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

Findings include:

Cross Refer to C336 for the facility's failure to have a functioning quality assurance program to include Infection Control.

On 11/09/11 at 2:00 p.m. a housekeeping cart was observed in the hallway outside of patient Room #2, which had a 'Contact Precaution (isolation)' sign on the door. The housekeeper came out of the room wearing a disposable gown and gloves. She removed an entire roll of plastic bags from the cart, took them into Room #2, then left the room and returned the roll to the cart. She then removed the broom from the cart, took it into Room #2, and then returned it to the housekeeping cart.

On 11/09/11 at 2:10 p.m. the Director of Nursing (DON) was notified of the Housekeeper's breach in Infection Control. The DON observed the housekeeper remove a mop from the cart to take into Room #2. The DON notified the Housekeeping Director stating that she was responsible for housekeeping staff. Before the housekeeper could take the mop she had taken from the cart into Room #2, she was asked to wait for the Housekeeping Director.

On 11/09/11 at 2:10 p.m. the Housekeeping Director arrived and was informed of the Housekeeper's actions. The Housekeeping Director stated, "The housekeeper who normally cleans this hall is out sick, and this housekeeper is filling in today." When the housekeeper was asked had she been in-serviced in infection control practices, she stated that she had not. The Housekeeping Director confirmed that the housekeeper had not attended infection control in-services.

On 11/09/11 at 2:30 p.m. the Infection Control Nurse was interviewed. She stated that she had taken the position in August 2011 and there had been no in-services since she had taken the position. When asked for the Infection Control Policy and Procedure manual she stated that she was unable to find the manual. On 11/10/11 at 10:30 a.m. the Infection Control Nurse was able to provide the manual. Review of the hospital's "Contact Precautions" policy revealed, "These precautions are to be used to reduce the risk of transmission of resistant microorganisms by direct or indirect contact with a patient and/or patient's environment."

On 11/10/11 at 11:30 a.m. the Infection Control Nurse was asked what training, experience, certifications or competencies she possessed to be qualified for the position she held. The Infection Control Nurse stated that she had just assumed the position in August 2011 and was scheduled to attend training in the near future.

On 11/10/11 at 11:52 a.m. an interview with the DON revealed that the housekeeper's hire date was 06/02/2011 and that there was no documentation of an infection control in-service attended by her. The DON stated that she is responsible for providing in-services for the Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants and the Ward Clerks.

Based on observation, staff interview, policy review and in-service review, the Critical Access Hospital (CAH) failed to have nursing services to meet the needs of patients.

Findings include:

Cross Refer to C278 for the facility's failure to have a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.

Based on observation and staff interview, the facility failed to ensure that medical records in storage are secure, protected from unauthorized use, and readily accessible.


Findings include:


On 11/10/11 at 9:30 a.m., accompanied by the Director of the Medical Record Department and an employee from Maintenance, the storage building on the hospital's property was accessed to observe the facility's death records. This storage building was found to be unlocked. Observation revealed that several types of records were stored in this building such as death records, therapy records, clinic records, and business office records, along with equipment such air conditioners and ceiling tiles. Boxes of records were observed in no specific order. It appeared that the boxes had been in order at one time, and as boxes had been pulled out to retrieve medical records, they had not been placed back in the order they belonged. Pages of medical records were observed no longer bound in a record, but spilled out on top of boxes and the floor. The maintenance employee stated that someone had been in the building getting ceiling tiles earlier that morning and had left the building unlocked.

Based on review of medical records, the facility failed to ensure that all pages in 16 of 16 medical records contained the patient's name and/or medical record number.


Findings include:


Ten discharged medical records were selected from a list of discharges from July 1, 2011 through October 31, 2011 for review, along with two (2) inpatient medical records and the last four (4) discharges from the hospital for a total of 16 medical records. Pages were found in all 16 medical records reviewed that did not contain the patient's name and/or medical record number.

Based on Policy and Procedure review and review of medical records, the facility failed to ensure that all entries in 16 of 16 medical records reviewed were dated and timed and were signed by the person making the entry.


Findings include:


Ten (10) discharged medical records were selected from a list of discharges from July 1, 2011 through October 31, 2011 for review, along with two (2) inpatient medical records and the last four (4) discharges from the hospital for a total of 16 medical records. All 16 medical records reviewed had physician orders that had not been timed when entered into the medical record. This included those orders written by the physician as well as those telephone orders taken by a nurse. All 16 medical records reviewed contained progress notes that had not been timed when entered into the medical record. Transcribed reports, such as the History and Physical (H&P) exam and Discharge Summary did not include the time of dictation and time of transcription.


Three (3) of the 16 medical records reviewed contained a H&P examination hand-written by the physician. On one (1) record the H&P examination had not been dated or timed when it was recorded. On the second record the H&P had not been timed when it was written. On the third record the H&P had not been timed when written, nor signed by the physician.

Based on Policy and Procedure review, Governing Body meeting minutes review and staff interview, the facility failed to carry out an evaluation of its total program at least once a year.


Findings include:


Review of the facility's Policy and Procedure manual revealed no documented evidence of policies and procedures for an annual evaluation specifying how the Critical Access Hospital (CAH) was to conduct the evaluation, who was responsible for conducting the evaluation, and what information was to be included in the evaluation. Interview with the Administrator revealed that the CAH had not conducted an annual evaluation of its total program during the past year.

Based on Policy and Procedure review, document review, Governing Body meeting minutes review and staff interview, the facility failed to review the utilization of their services, including the number of patients served and the volume of services as part of an annual evaluation.


Findings include:

Documentation review revealed no documented evidence that a yearly program evaluation was performed by the facility which included all of the Critical Access Hospital's services, the number of patients served, and the volume of services provided. Review of the Governing Body Minutes and interview with the Administrator revealed that the number of patients served was reported each month, but there was no documentation available to show an annual total.

Based on record review, Policy and Procedure review and review of the minutes of the Governing Body meetings, the facility failed to ensure that a representative sample of both active and closed clinical records were reviewed as part of the annual evaluation.


Findings include:


Review of the facility's Policy and Procedure manual, review of the minutes of the Governing Body meetings and record review revealed that review of both active and closed records was not performed as part of an annual evaluation.

Based on Policy and Procedure review and review of the minutes of the Governing Body meetings, the facility failed to ensure that the review of their policies and procedures was done in conjunction with an annual evaluation.


Findings include:


Review of the minutes of the Governing Body meetings and review of the facility's policies and procedures revealed that their Policies and Procedures were approved by the Governing Board on October 06, 2011, but this was not done in conjunction with an annual evaluation.

Based on Policy and Procedure review and review of the minutes of the Governing Body meetings, the facility failed to ensure an evaluation was done to determine whether the utilization of services was appropriate, the established policies were followed, and any changes are needed.

Findings include:


Review of the facility's Policy and Procedure manual and review of minutes of the Quality Assurance Committee meetings revealed no documented evidence there was a functioning Quality Assurance Committee from October, 2010 through September, 2011 to ensure that an evaluation was done to determine whether the utilization of services was appropriate, the established policies were followed, and any changes are needed.

Based on Policy and Procedure review, review of minutes of the Quality Assurance Committee meetings, and staff interview, the facility failed to ensure a functioning Quality Assurance program during the past year.


Findings include:


Review of minutes of the Quality Assurance Committee meetings revealed no documented evidence of any minutes available from October, 2010 through September, 2011 and no documented evidence of a Quality Assurance Plan.


There were no monitors available for review for the different departments of the Critical Access Hospital (CAH). According to several department managers interviewed, they did not have current monitors in place for their departments to show that they had been performing Quality Assurance during the past year.

Based on Policy and Procedure review and review of minutes of the Quality Assurance Committee meetings, the facility failed to ensure that all patient care services affecting patient health and safety are evaluated.


Findings include:


Review of the facility's Policy and Procedure manual and review of minutes of the Quality Assurance Committee meetings revealed no documented evidence there was a functioning Quality Assurance Committee from October, 2010 through September, 2011.

Based on Policy and Procedure review and review of minutes of the Quality Assurance Committee meetings, the facility failed to ensure that nosocomial infections and medication therapy were evaluated.


Findings include:


Review of the facility's Policy and Procedure manual and review of minutes of the Quality Assurance Committee meetings revealed no documented evidence there was a functioning Quality Assurance Committee from October, 2010 through September, 2011 to evaluate nosocomial infections and medication therapy.

Based on Policy and Procedure review and review of minutes of the Quality Assurance Committee, the facility failed to ensure that the quality and appropriateness of the diagnosis furnished by the physicians are evaluated.


Findings include:


Review of the facility's Policy and Procedure manual and review of minutes of the Quality Assurance Committee revealed no documented evidence that the facility had been participating with IQH and performing studies of CORE measures.

Based on Policy and Procedure review and review of minutes of the Quality Assurance Committee, the facility failed to ensure the staff reviewed the findings of the evaluations, including any findings or recommendations of IQH, and take corrective action if necessary.


Findings include:


Review of the facility's Policy and Procedure manual and review of minutes of the Quality Assurance Committee meetings revealed no documented evidence that the facility had been participating with IQH and their studies.

Based on Policy and Procedure review and review of minutes of the Quality Assurance Committee meetings, the facility failed to ensure that appropriate remedial actions were taken to address deficiencies found through their Quality Assurance Program.

Findings include:


Review of the facility's Policy and Procedure manual and review of minutes of the Quality Assurance Committee meetings revealed no documented evidence there was a functioning Quality Assurance Committee from October, 2010 through September, 2011 to ensure that appropriate remedial actions were taken to address deficiencies found through their Quality Assurance Program.

Based on Policy and Procedure review and review of minutes of the Quality Assurance Committee meetings, the facility failed to ensure documentation of any outcomes of remedial actions taken.



Findings include:


Review of the facility's Policy and Procedure manual and review of minutes of the Quality Assurance Committee meetings revealed no documented evidence there was a functioning Quality Assurance Committee from October, 2010 through September, 2011 to ensure that appropriate remedial actions were taken with documentated outcomes to address deficiencies found through their Quality Assurance Program.

Based on swing bed policy review, review of existing contracts/agreements and staff interview, the Critical Access Hospital (CAH) failed to ensure that residents in need of dental care would be assisted.

Findings include:

Review of the facility's Swing Bed policy and procedure manual revealed no documented evidence of a policy that addressed the availability of a dentist for residents. Review of the facility's contracts/agreements revealed no documented evidence of one for dental services.

On 11/10/11 at 11:30 a.m. an interview with the Director of Nursing (DON) confirmed that the swing bed does not have any arrangement with a dentist or a dental policy.