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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on February 18 - 19, 2014, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure that routine maintenance testing was conducted on patient care equipment. This has the potential to affect all patients. Findings include:

1. During a tour of the CAH Radiology Department with the Radiology Supervisor (E5) conducted on 01/07/14 at 1:00 PM, the following equipment items were observed to have no current routine and preventive maintenance testing conducted: two portable suction machines and a blanket warmer had affixed labels, which stated the last maintenance testing was performed on 02/04/2011, with the next testing due 02/2012.

2. The CAH policy titled "Medical Equipment Management Plan" (revised 01/15/13) was reviewed on 01/07/14. The policy stated "VII. Responsibility: A. Manager, Biomedical Services: 1. Ensure an evaluation... of this equipment management plan is completed annually."

3. An interview was conducted with E5 on 01/07/14 at 1:30 PM. E5 stated all patient care equipment required annual preventative maintenance. E#5 confirmed both portable suction machines and the blanket warmer in the Radiology Department had not undergone annual testing and should have.

Based on document/ record review, and interview, it was determined the CAH failed to ensure dietary refrigerator and freezer temperatures were monitored and outlying results were followed up on in accordance with its policy. This has the potential to affect all of the patients and visitors serviced by the CAH Dietary department. Findings include:

1. The policy titled "Maintenance/Safety" (effective 2/13/97) was reviewed 1/9/14. The policy stated "Practice: 5. All equipment... will be checked on a yearly basis...6. All appliances, equipment, etc need to be sent to maintenance.... if too large to move, call Maintenance to come to the department to evaluate."

2. The Dietary Department policy book, provided by the Dietary Manger (E9), was reviewed on 1/7/14. E9 stated "this is what we currently use." The book stated Illinois Department of Public Health "Food Service Sanitation Code (October 1998)". The book stated "Machines using hot water for sanitizing may be used... water shall be maintained at not less than the temperature stated... 150 degrees Fahrenheit...180 degrees Fahrenheit...and cleaned at least daily." The "International Association for Food Protection" temperature guidelines (unknown date) stated "Cold potentially hazardous food must be held at a maximum temperature of 41 degrees Fahrenheit... Freezer 0 degrees Fahrenheit to -10 degrees Fahrenheit."

3. The CAH refrigerator and freezer temperature logs were reviewed on 1/7/14. The following are examples of temperatures not being taken 2 times a day and/or outlying temperatures which were not followed up on, in accordance with its policy. Pie Freezer: Jan 2014 2 of 6 days, November 2013 12 of 30 days; Vegetable Freezer: December 2013 2 of 31 days; Chicken Freezer: January 2014 2 of 6 days, December 2013 5 of 31 days, November 12 of 30 days; Strawberry Freezer: January 204 2 of 6 days, December 6 of 31 days, November 2013 13 of 30 days; Big White Freezer: January 2014 2 of 6 days, December 2013 5 of 31 days, November 2013 13 of 30 days; Milk Cooler: January 2014 2 of 6 days, December 2013 5 of 31 days, November 2013 3 of 30 days. Examples of log sheets that failed to demonstrate outlying temperature were followed up on are as follows: Milk Cooler: January 2014 2 of 6 days, December 2013 10 of 31 days, November 2013 4 of 31 days.

4. The Dish Machine Temperatures Chart stated the temperature range should be 160 degrees Fahrenheit or 170 degrees Fahrenheit. All temperature entries on the Dish Machine Temperature Chart from September 2, 2013 thru December 12, 2013 stated the temperature was 100 degrees Fahrenheit and indicated no action was taken.

5. The water filtration and conditioning programs (reverse osmosis filtration system) used for the ice machine located in the dietary department was stickered by the maintenance department. The sticker stated "last filter change 10/8/12."

6. An interview was conducted with Maintenance Manager (E10) on 1/7/14 at 10:15 AM. E10 stated the filtration system for the ice machine had not been monitored by maintenance since 10/8/12 and it should have been.

7. An interview was conducted with the Dietary Manager (E9) on 1/7/14 at 10:00 AM. E9 stated the expectation that refrigerator and freezer temperatures should be taken 2 times a day every day and outlying temperatures should be reported to Maintenance for follow up and correction of any problems. E9 could not verbalize why the staff did not identify the dishwasher temperatures as out of range or why they were not reported to maintenance.

Based on document review and interview, it was determined the CAH failed to ensure all staff were properly trained in handling all non-medical emergencies. This has the potential to affect all staff and patients. Findings include:

1. The policy titled "Education, Orientation and Mandatory Requirements" (revised 6/15/12) was reviewed on 1/8/14. The policy stated "IV. DEFINITIONS: Leader: Any supervisor, manager, director or executive within a department at... V. General Considerations: ....Leaders will ensure that there is an education plan for orientation and ongoing education...."

2. An interview was conducted with the Emergency Room Registered Nurse (E7) on 1/8/14 at 11:45 AM. E7 stated that most of the disaster preparedness education is provided during staff meetings. E7 was unable to answer questions related to any disaster preparedness other than fire. These questions included what to do in the case of blizzard, tornado, flood, earthquake, or bomb threat. During this interview, the Quality Specialist (E2) was also present and stated disaster training is suppose to take place on an annual basis; however, this had not been completed within the last 2 years.

3. An interview was conducted with Laboratory Manager (E6) on 1/8/14 at 1:05 PM. E6 was unable to answer questions related to any disaster preparedness other than fire. These questions included what to do in the case of blizzard, tornado, flood, earthquake, or bomb threat. When asked when E6 last received disaster preparedness training, other than fire, E6 stated "It has been some time". When asked to define "some time", E6 stated the staff in that unit (Laboratory) had not received disaster preparedness training, other than fire, in at least 2 years.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on February 18 - 19, 2014, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated February 19, 2014.

Based on document/ file review and interview, it was determined for 8 of 8 (ER#1, ER#2, ER#3, ER#4, ER#5, ER#6, P#1, P#2) physicians who had undergone reappointment, an evaluation of services was not included in the reappointment process.
Findings include:

1. The Medical Staff Bylaws (last reviewed 12/2012) were reviewed on 1/8/14. The Bylaws stated "3.5 Procedures for Reappointment:...3.5-2 Information... Appropriate summaries of inpatient admission and surgical procedures, peer recommendations, patterns of care as demonstrated ... compliance with bylaws, policies, rules, regulations, and procedures of the Hospital and Staff. In addition, all quality assurance and utilization review reports, audits, patient complaints... will be used to appraise Medical Staff members for reappointment..."

2. The credential file of ER#1 was reviewed with the Credentialing Coordinator (E8) on 1/8/14. ER#1 was reappointed to the Medical Staff on 11/19/12. There was no documentation of an evaluation of services being included in the reappointment process.

3. The credential file of ER#2 was reviewed with E8 on 1/8/14. ER#2 was reappointed to the Medical Staff on 3/7/13. There was no documentation of an evaluation of services being included in the reappointment process.

4. The credential file of ER#3 was reviewed with E8 on 1/8/14. ER#3 was reappointed to the Medical Staff on 1/21/13. There was no documentation of an evaluation of services being included in the reappointment process.

5. The credential file of ER#4 was reviewed with E8 on 1/8/14. ER#4 was reappointed to the Medical Staff on 3/31/13. There was no documentation of an evaluation of services being included in the reappointment process.

6. The credential file of ER#5 was reviewed with E8 on 1/8/14. ER#5 was reappointed to the Medical Staff on 11/19/12. There was no documentation of an evaluation of services being included in the reappointment process.

7. The credential file of ER#6 was reviewed with E8 on 1/8/14. ER#6 was reappointed to the Medical Staff on 1/16/12. There was no documentation of an evaluation of services being included in the reappointment process.

8. The credential file of P#1 was reviewed with E8 on 1/8/14. P#1 was reappointed to the Medical Staff on 3/7/13. There was no documentation of an evaluation of services being included in the reappointment process.

9. The credential file of P#2 was reviewed with E8 on 1/8/14. P#2 was reappointed to the Medical Staff on 7/16/12. There was no documentation of an evaluation of services being included in the reappointment process.

10. An interview was conducted with the Credentialing Coordinator (E8) on 1/8/14 at 12:00 PM. E8 confirmed, through concurrent credential file review, that 8 out of 8 reappointed physician files (ER#1, ER#2, ER#3, ER#4, ER#5, ER#6, P#1, P#2) failed to include an evaluation of services. E8 stated this should have been included in the reappointment process. E8 stated knowledge of this requirement.

Based on observation, document review, and interview, it was determined the CAH failed to ensure outdated biologicals were not available for use in patient care areas. This has the potential to affect all patients. Findings include:

1. During a tour of the CAH Emergency Department with E2 (Quality Specialist), conducted on 01/08/2014 at 11:00 AM, the following outdated items were observed available for use: Two Microorganism Collection and Transport System culture kits (expiration 03/08/2013), three BD Vacutainer blood collection tubes (expiration 10/2013), four MiniCollect blood collection tubes (expiration 11/2013), and one Vacuette blood collection tube (expiration 08/2013). E2 confirmed, thru concurrent observation, these items were expired and should not be in the patient care area.

2. During a tour of the CAH Laboratory Department with E6 (Laboratory Manager), conducted on 01/08/2014 at 1:00 PM, the following outdated items were observed available for use: four Hewitt blood culture tubes (expiration 12/27/2013), two CELL-DYN HemCal whole blood testing tubes (expiration 12/30/2013), and three Architect, 2nd Generation testosterone control test solution vials (expiration 07/24/2013). E6 confirmed, thru concurrent observation, these items were expired and should not be in the patient care area.

3. The CAH policy titled "OUTDATED MEDICATIONS AND BIOLOGICS" (revised 07/01/2013) was reviewed on 01/08/2014. The policy stated "Medications and biologics are reviewed for expiration before use and on a monthly basis... Outdated medications and biologics should be removed from active stock and returned to pharmacy for proper credit and disposal."

Based on document review and staff interview, it was determined the CAH failed to ensure dishwasher systems were monitored for temperature in accordance with its policies to ensure proper sanitation of dietary items to prevent the spread of communicable diseases. This has the potential to affect all patients and visitors serviced by the CAH Dietary department.
Findings include:

1. The Dietary Department policy book, provided by the Dietary Manger (E9), was reviewed on 1/7/14. E9 stated "this is what we currently use." The book stated Illinois Department of Public Health "Food Service Sanitation Code (October 1998)". The book stated "Machines using hot water for sanitizing may be used... water shall be maintained at not less than the temperature stated... 150 degrees Fahrenheit...180 degrees Fahrenheit... at least daily."

2. The Dish Machine Temperature Charts for the large dishwasher for September 2013 thru December 2013 were reviewed 1/7/14. There was no documentation to indicate the temperatures were checked in September 2013 24 of 31 days, October 2013 21 of 31 days, November 2013 28 of 30 days, or December 2013 14 of 31 days.

3. The Dish machine Log for the small dishwasher for April 2013 thru December 2013 were reviewed 1/7/14. There was no documentation to indicate the temperatures were checked in April 2013 2 of 30 days, May 2013 no log sheet completed, June 2013 no log sheet completed, July 2013 2 of 31 days, August, September, October and November 2013 no log sheet completed and December 2013 16 of 31 days.

4. An interview was conducted with the Dietary Manager (E9) on 1/7/14 at 10:30 AM. E9 stated the expectation is that the staff will check the water temperature once a day and document these results on the log sheets. E9 further confirmed that there was no documentation of checking of the temperature for dishwashers for the above listed dates.

Based on observation and interview, it was determined products and dry goods in the dietary storerooms were not always dated when received or opened and that food was not stored in accordance with first in first out (FIFO) to ensure the quality and safety of food storage and prevention of food borne illnesses. This has the potential to affect all the patients and/or visitors serviced by the Dietary Department.
Findings include:

1. The policy titled "Putting Groceries Away" (effective 8/2004) was reviewed 1/7/14. The policy stated "Practice: A. All groceries are to be labeled and dated when they are put away to ensure that they are being rotated... 1. cans are put in from the top and the old will roll forward...3. Anything put in cooler is to be marked with a color coded dot...as to tell how old it is...4. any new groceries in cooler or freezer need to have the date they came in stamped on them..."

2. During a tour of the CAH, conducted on 1/7/14 at 9:00 AM with the Dietary Manager (E9), the following items were observed to be stored without regard to the date of receiving and/or date of opening: dry storeroom: 1-1 gallon sweet chili sauce opened with no date, 4 containers of Teriyaki glaze were not dated, 2- 8 pound containers of salsa were observed mixed up on the storage shelf with 11/14 up front and 4/11/12 in the back instead of vice versa; walk in freezer: 1 bag chicken tenders, 1 bag of breaded catfish, 1 bag of chicken nuggets and 1 bag of potatoes pancakes were opened and not dated; walk in refrigerator: 1 plastic container with opened sliced cheese and 1 plastic container with opened cubed cheese were not dated. All dry goods and refrigerated/freezer items were observed as dated with month and day only (year not identified) to indicate when they were received and/or when they were opened.

3. An interview was conducted with E9 on 1/7/14 at 10:30 AM. E9 stated all food items were to be dated and stored in FIFO order, including dried goods. E9 confirmed that food items were to be dated when opened and this was not done and should have been.

Based on document/ record review and interview, it was determined for 2 of 3 (Pts #16, #17) patients who received a blood transfusion, vital signs were not monitored in accordance with its policy. Findings include:

1. The CAH policy titled "Blood Therapy" (reviewed/revised 04/13) was reviewed on 1/8/14. The policy stated "VII. Practice/ Procedure: N... Vital signs will be recorded on the Blood Transfusion Record as follows: 2. 15 minutes after the blood has entered the body. 3. One hour after the blood entered the body. 4. Hourly thereafter during the transfusion. 5. One hour after transfusion is complete."

2. The record of Pt #16 was reviewed on 1/9/14. Pt #16 was admitted to the CAH on 12/26/13 with the diagnoses nausea/ vomiting/ diarrhea and gastrointestinal bleeding and received a blood transfusion. On 12/27/13, Blood Transfusion Record documentation stated a unit of packed red blood cells (PRBCs) was started at 2:45 AM and infused at 6:00 AM. There was no documentation of vital signs one hour after the transfusion was completed.

3. The record of Pt #17 was reviewed on 1/9/14. Pt #17 was admitted to the CAH on 12/26/13 with the diagnosis severe anemia and received blood transfusions. On 12/26/13, Blood Transfusion Record documentation stated a unit of PRBCs was started at 6:12 PM and infused at 9:00 PM. There was no documentation of vital signs one hour after the blood entered the body, hourly during the transfusion, or one hour after transfusion completion.

4. An interview was conducted with the Quality Specialist (E2) on 1/9/14 at 4:00 PM. E2 reviewed the records of Pts #16 and #17 and confirmed vital signs were not monitored in accordance with CAH policy during the blood transfusions for both Pts #16 and #17.

A. Based on document/record review and interview, it was determined for 4 of 20 (Pts #3, #4, #17, #18) patients, a consent for admission was not obtained. Findings include:

1. The policy titled "Registration of Outpatient, Inpatient and Emergency services" (reviewed 2/21/13) was reviewed 1/9/14. The policy stated "VII. Practice/Procedure:... D. A COA (Consent form regarding Consent of Admission) is signed for hospital encounters with the signature witnessed by hospital staff... Procedure:...D. The COA is reviewed with the patient, signed by the patient..."

2. The record for Pt #3 was reviewed 1/8/14 with the Quality Specialist (E2). Pt #3 was admitted 12/29/13 with a diagnosis of CHF (Congestive Heart Failure). There was no consent for inpatient admission.

3. The record for Pt #4 was reviewed 1/8/14 with E2. Pt #4 was admitted 1/7/14 with a diagnosis of CHF. There was no consent for inpatient admission.
consents

4. The record of Pt #17 was reviewed on 1/9/14. Pt #17 was admitted to the CAH on 12/26/13 with the diagnosis severe anemia. There was no documentation a consent for inpatient admission was obtained.

5. The record of Pt #18 was reviewed on 1/9/14. Pt #18 was admitted to the CAH on 12/21/13 with the diagnoses pneumonia and weakness. There was no documentation a consent for inpatient admission was obtained.

6. An interview was conducted with the Quality Specialist (E2), along with record reviews, on 1/9/14 at 2:00 PM. E2 confirmed consents for the inpatient admission's were not obtained for Pts #3, #4, #17, #18. E2 stated all patient admissions should have a consent for admission executed.

B. Based on document/ record review and interview, it was determined for 1 of 20 (Pt #4) patients admitted to the CAH, a History and Physical (H&P) was not performed and documented within 24 hours of admission.
Findings include:

1. The Rules and Regulations of the Medical Staff were reviewed on 1/9/13. It indicated "Part 9.4-1 Medical Record Completion:...Histories and Physicals shall be dictated or written within 24 hours of admission..."

2. The record for Pt #4 was reviewed 1/8/14 thru 1/9/14 with the Director of Quality. Pt #4 was admitted 1/7/14 with a diagnosis of CHF. As of 1/9/13 at 3:00 PM, there was no H&P on the medical record to indicate it was completed.

3. An interview was conducted with the Quality Specialist (E2) on 1/9/13 at 3:00 PM. E2 reviewed the record of Pt #4 and confirmed there was no H&P completed within 24 hours of admission and there should have been.

Based on document/record review and staff interview, it was determined for 4 of 20 (Pt # 1, #2, #3 and #4) patients, physician orders were completed for protocols implemented.
Findings include:

1. The Medical Staff Rules and Regulations were reviewed 1/9/14. It indicated "4. Standing orders...shall be signed by the attending practitioner in the same manner as verbal orders..."

2. The policy titled "Patient Orders: Physician, Allied Health Professional, Associated Professional" (reviewed 12/12) as reviewed 1/8/14 at 1:45 PM. The policy stated "VII Practice/Procedure: A practitioner order is needed to initiate a medical protocol..."

3. The record of Pt #1 was reviewed with the Quality Specialist (E2) on 1/8/14 at 9:00 AM. Pt #1 was admitted 1/4/14 with a diagnosis of PN (Pneumonia). The admission orders dated 1/4/14 stated to implement the Oxygen Protocol. There was no Oxygen Protocol standing order completed by the physician.

4. The record of Pt #2 was reviewed with E2 on 1/8/14 at 9:15 AM. Pt #2 was admitted 1/2/14 with a diagnosis of PN. The admission orders dated 1/2/14 stated to implement the Oxygen Protocol. There was no Oxygen Protocol standing order completed by the physician.

5. The record of Pt #3 was reviewed with E2 on 1/8/14 at 9:30 AM. Pt #3 was admitted 12/29/13 with a diagnosis of CHF. The admission orders dated 12/28/13 stated to implement the Oxygen Protocol. There was no Oxygen Protocol standing order completed by the physician.

6. The record of Pt #4 was reviewed with the E2 on 1/8/14 at 9:30 AM. Pt #4 was admitted 1/7/14 with a diagnosis of CHF. The admission orders dated 1/7/14 stated to implement the Oxygen Protocol. There was no Oxygen Protocol standing order completed by the physician.

7. An interview was conducted with E2 on 1/8/14 at 9:30 AM. E2 stated the Oxygen Protocols for Pts #1, #2, #3 and #4 were not signed/ordered by the physician and should have been.

A. Based on policy, record review and staff interview, it was determined in 3 of 20 records reviewed (Pts #14, #18, #19) the CAH failed to ensure all physician telephone orders were authenticated by the ordering physician within 24 hours, in accordance with its' Medical Staff Rules and Regulations.
Findings include:

1. The Medical Staff Rules and Regulations were reviewed 1/9/14. The Rules and Regulations stated "26. All orders shall be in writing...The responsible practitioner shall authenticate such orders within 24 hours.,"

2. The record of Pt #14 was reviewed on 1/9/14. Pt #14 was admitted to the CAH on 10/22/13 with the diagnosis hyponatremia. On 10/27/13 at 9:00 PM, there was a physician telephone order "Decrease IV (intravenous) to 50 mls (milliliters) per hour..." On 10/29/13 at 7:15 PM, there was a physician telephone order "Change Roxanol..." On 10/29/13 at 7:15 PM, there was another physician telephone order "Change Ativan to liquid..." All of these orders were signed by the physician on 11/4/13, beyond the required timeframe.

3. The record of Pt #18 was reviewed on 1/9/14. Pt #18 was admitted to the CAH on 12/21/13 with the diagnoses pneumonia and weakness. On 12/21/13 at 10:47 PM, there was a physician telephone order "Discontinue Ciprofloxacin. Novolog Sliding Scale..." On 12/22/13 at 1:30 PM, there was a physician telephone order "Duoneb nebulizer...." On 12/22/13 at 4:00 PM, there was a physician telephone order "Discontinue Lovenox order..." As of 1/9/13 at 3:45 PM, these orders had not been signed by the physician.

4. The medical record of Pt. #19 was reviewed on 1/8/14. Pt #19 was admitted 12/26/13 with a diagnosis of hyperglycemia. On 12/26/13, there was a physician telephone order for implementation of Sliding Scale Insulin Order protocol. As of 1/9/13 at 3:00 PM, this order had not been signed by the physician.

5. An interview was conducted with the Quality Specialist (E2) 1/9/14 at 10:30 AM. E2 was stated telephone orders were to be signed by the physician within 24 hours. E2 reviewed the records of Pts #14, #18, #19 and confirmed the telephone orders had not been signed by the physician within 24 hours and should have been.

B. Based on document/ record review and interview, it was determined for 4 of 20 records reviewed (Pts #2, #3, #14, #19) the CAH failed to ensure all orders are dated and timed by the ordering physician.
Findings include:

1. The policy titled "Patient Orders: Physician, Allied Health Professional, Associated Professional" (reviewed 12/12) as reviewed 1/8/14 at 1:45 PM. The policy stated "VI. General Considerations: B. All patient medical entries must be legible, complete and include date and time."

2. The record of Pt. #2 was reviewed on 1/8/14. Pt. #2 was admitted on 1/2/14 with diagnosis of PN. The Venous Thromboembolism (VTE) Prophylaxis Orders was signed by the APN (Advanced Practice Nurse) although the signature was not dated or timed to indicate when the order was authenticated.

3. The record of Pt #3 was reviewed on 1/8/14. Pt #3 was admitted 12/29/13 with a diagnosis of CHF. A telephone order written on 12/29/13 at 6:00 AM and was authenticated by the physician;however, there was no date or time to indicate when the order was authenticated.

4. The record of Pt #14 was reviewed on 1/9/14. Pt #14 was admitted to the CAH on 10/22/13 with the diagnosis hyponatremia. A physician order titled "Oxygen Protocol" was signed by the physician; however, there was no date or time to state when the protocol was ordered and/or signed by the physician. On 10/25/13 at 2:50 AM, there was a physician verbal order "Normal Saline 3% IV (Intravenous) at 50 Ml (milliliter) per hour..." On 10/25/13 at 4:00 AM, there was a physician telephone order "May change catheter...." Both of these orders failed to state the date and time as to when the physician signed them.

5. The medical record of Pt. #19 was reviewed on 1/8/14. Pt #19 was admitted 12/26/13 with a diagnosis of hyperglycemia. The Admission Orders were signed by the physician although the signature was not dated or timed to indicate with the orders were authenticated.

6. An interview was conducted with the Quality Specialist (E2) on 1/9/14 at 10:30 AM. E2 stated all orders were to be dated and timed when signed by the physician. E2 reviewed the records of Pts #2, #3, #14, #19 and confirmed the physician signatures had not been dated and timed when they were signed and should have been.

A. Based on document review and interview, it was determined for 3 of 3 (CRNAs #1, #2, #3) Certified Registered Nurse Anesthetists, the Critical Access Hospital (CAH) failed to ensure CRNAs held current Controlled Substance and Federal Drug Enforcement Administration (DEA) licenses for the State of Illinois.
Findings include:

1. The anesthesia agreement was reviewed on 1/8/14. The agreement stated "Whereas.... employs CRNAs, duly licensed in the State of Illinois, by the Illinois Department of Professional Regulation and the Councils of Certification and Recertification of Nurse Anesthetists and is qualified to provide anesthesia services..."

2. The "720 ILCS570/ Illinois Controlled Substances Act" and the "United States Department of Justice DEA "Questions and Answers- What is DEA policy concerning Locum Tenens?"" website information were presented on 1/8/14 at 2:40 PM, by the Credentialing Coordinator (E8). E8 stated both of these requirements have not been met by the CRNAs at the CAH. The "720 ILCS570/ Illinois Controlled Substances Act" stated "Sec. 302. (a) Every person who manufactures, distributes, or dispenses any controlled substances... within this State, must obtain a registration issued by the Department of Financial and Professional Regulation in accordance with its rules... (d) A separate registration is required... " The "United States Department of Justice DEA "Questions and Answers- What is DEA policy concerning Locum Tenens?"" website information stated "Please be aware that practitioners who wish to administer, dispense, or prescribe controlled substances in multiple states have the following options regarding DEA application..."

3. The personnel file of CRNA #1 was reviewed with the Credentialing Coordinator (E8) on 1/8/13. CRNA #1 was initially credentialed by the CAH on 4/1/06 to provide anesthesia services. CRNA #1 was recredentialed on 3/19/12. CRNA #1 had a Controlled Substance and DEA license for the State of Iowa; however, there was no documentation of CRNA #1 having a Controlled Substance or DEA license for the State of Illinois.

4. The personnel file of CRNA #2 was reviewed with E8 on 1/8/13. CRNA #2 was initially credentialed by the CAH on 4/1/06 to provide anesthesia services. CRNA #2 was recredentialed on 3/19/12. CRNA #2 had a Controlled Substance and DEA license for the State of Iowa; however, there was no documentation of CRNA #2 having a Controlled Substance or DEA license for the State of Illinois.

5. The personnel file of CRNA #3 was reviewed with E8 on 1/8/13. CRNA #3 was initially credentialed by the CAH on 3/2006 to provide anesthesia services. CRNA #3 was recredentialed on 8/1/13. CRNA #3 had a Controlled Substance and DEA license for the State of Iowa; however; there was no documentation of CRNA #3 having a Controlled Substance or DEA license for the State of Illinois.

6. An interview was conducted with the (E8) on 1/8/14 at 12:30 PM. When asked if the CRNAs had a Controlled Substance and a DEA license for the State of Illinois, E8 stated "We have them (the Controlled Substance and DEA licenses for the State of Illinois, as well as any other State in which the CRNA works) at our other facilities but not at this facility at this time. I'm sure of it. They should have, but they don't." E8 stated "I know they need to have it in each State they work in just like they have to have their individual State license."

B. Based on document/ file review and interview, it was determined for 1 of 6 (ER#3) emergency room physicians with privileges to use neuromuscular blockage agents as adjunct to intubation, Pediatric Advanced Life Support (PALS) certification was not current.
Findings include:

1. The file of ER#3 was reviewed with the Credentialing Coordinator (E8) on 1/8/14. ER#3 was reappointed to the Medical Staff on 1/21/13. On 1/22/13, a letter confirming reappointment to the Medical Staff stated "The following privilege(s) was/were added to your Delineation of Privileges.... Advanced pediatric resuscitation/ neonatal care... Use of neuromuscular blockage agents as adjunct to intubation..." ER#3 did not have PALS certification.

2. An interview was conducted with the Credentialing Coordinator (E8) on 1/8/14 at 3:00 PM. E8 stated phone contact was made with ER#3 and it was confirmed ER#3 did not have current PALS certification. E8 stated Emergency Room physicians should have PALS certification as they are required to provide care to pediatric patients who could have life threatening conditions that require advanced life support care.

Based on document review and interview, it was determined the CAH failed to ensure it's dietary program was integrated into it's quality program. This has the potential to affect all patients and staff.
Findings include:

1. The CAH policy and procedure titled, "Food Service Sanitation Code" (effective 3/14/05) was reviewed on 1/8/14. The policy stated "VI. A. Food Service Sanitation Code: ...The Director will conduct a monthly sanitation and safety review. Any problems will be brought to the attention of the safety committee, infection control committee, or quality improvement committee, as deemed appropriate." The CAH's quality assurance meeting minutes for 2013 were reviewed on 1/9/14. There was no documentation that indicated the Dietary department was integrated into the Quality program.

2. In interviews with the Quality Specialist (E-2) and the Dietary Manager (E9), conducted on 1/9/14 at 1:10 PM, both stated that Dietary does not participate in the Quality program. E2 stated that currently there are no on-going quality programs in the Dietary Department. E9 also stated that there were no reports sent to the Safely committee, Infection Control committee, or the Quality committee related to Dietary services.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on February 18 - 19, 2014, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on observation, document review, and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure that routine maintenance testing was conducted on patient care equipment. This has the potential to affect all patients. Findings include:

1. During a tour of the CAH Radiology Department with the Radiology Supervisor (E5) conducted on 01/07/14 at 1:00 PM, the following equipment items were observed to have no current routine and preventive maintenance testing conducted: two portable suction machines and a blanket warmer had affixed labels, which stated the last maintenance testing was performed on 02/04/2011, with the next testing due 02/2012.

2. The CAH policy titled "Medical Equipment Management Plan" (revised 01/15/13) was reviewed on 01/07/14. The policy stated "VII. Responsibility: A. Manager, Biomedical Services: 1. Ensure an evaluation... of this equipment management plan is completed annually."

3. An interview was conducted with E5 on 01/07/14 at 1:30 PM. E5 stated all patient care equipment required annual preventative maintenance. E#5 confirmed both portable suction machines and the blanket warmer in the Radiology Department had not undergone annual testing and should have.

Based on document/ record review, and interview, it was determined the CAH failed to ensure dietary refrigerator and freezer temperatures were monitored and outlying results were followed up on in accordance with its policy. This has the potential to affect all of the patients and visitors serviced by the CAH Dietary department. Findings include:

1. The policy titled "Maintenance/Safety" (effective 2/13/97) was reviewed 1/9/14. The policy stated "Practice: 5. All equipment... will be checked on a yearly basis...6. All appliances, equipment, etc need to be sent to maintenance.... if too large to move, call Maintenance to come to the department to evaluate."

2. The Dietary Department policy book, provided by the Dietary Manger (E9), was reviewed on 1/7/14. E9 stated "this is what we currently use." The book stated Illinois Department of Public Health "Food Service Sanitation Code (October 1998)". The book stated "Machines using hot water for sanitizing may be used... water shall be maintained at not less than the temperature stated... 150 degrees Fahrenheit...180 degrees Fahrenheit...and cleaned at least daily." The "International Association for Food Protection" temperature guidelines (unknown date) stated "Cold potentially hazardous food must be held at a maximum temperature of 41 degrees Fahrenheit... Freezer 0 degrees Fahrenheit to -10 degrees Fahrenheit."

3. The CAH refrigerator and freezer temperature logs were reviewed on 1/7/14. The following are examples of temperatures not being taken 2 times a day and/or outlying temperatures which were not followed up on, in accordance with its policy. Pie Freezer: Jan 2014 2 of 6 days, November 2013 12 of 30 days; Vegetable Freezer: December 2013 2 of 31 days; Chicken Freezer: January 2014 2 of 6 days, December 2013 5 of 31 days, November 12 of 30 days; Strawberry Freezer: January 204 2 of 6 days, December 6 of 31 days, November 2013 13 of 30 days; Big White Freezer: January 2014 2 of 6 days, December 2013 5 of 31 days, November 2013 13 of 30 days; Milk Cooler: January 2014 2 of 6 days, December 2013 5 of 31 days, November 2013 3 of 30 days. Examples of log sheets that failed to demonstrate outlying temperature were followed up on are as follows: Milk Cooler: January 2014 2 of 6 days, December 2013 10 of 31 days, November 2013 4 of 31 days.

4. The Dish Machine Temperatures Chart stated the temperature range should be 160 degrees Fahrenheit or 170 degrees Fahrenheit. All temperature entries on the Dish Machine Temperature Chart from September 2, 2013 thru December 12, 2013 stated the temperature was 100 degrees Fahrenheit and indicated no action was taken.

5. The water filtration and conditioning programs (reverse osmosis filtration system) used for the ice machine located in the dietary department was stickered by the maintenance department. The sticker stated "last filter change 10/8/12."

6. An interview was conducted with Maintenance Manager (E10) on 1/7/14 at 10:15 AM. E10 stated the filtration system for the ice machine had not been monitored by maintenance since 10/8/12 and it should have been.

7. An interview was conducted with the Dietary Manager (E9) on 1/7/14 at 10:00 AM. E9 stated the expectation that refrigerator and freezer temperatures should be taken 2 times a day every day and outlying temperatures should be reported to Maintenance for follow up and correction of any problems. E9 could not verbalize why the staff did not identify the dishwasher temperatures as out of range or why they were not reported to maintenance.

Based on document review and interview, it was determined the CAH failed to ensure all staff were properly trained in handling all non-medical emergencies. This has the potential to affect all staff and patients. Findings include:

1. The policy titled "Education, Orientation and Mandatory Requirements" (revised 6/15/12) was reviewed on 1/8/14. The policy stated "IV. DEFINITIONS: Leader: Any supervisor, manager, director or executive within a department at... V. General Considerations: ....Leaders will ensure that there is an education plan for orientation and ongoing education...."

2. An interview was conducted with the Emergency Room Registered Nurse (E7) on 1/8/14 at 11:45 AM. E7 stated that most of the disaster preparedness education is provided during staff meetings. E7 was unable to answer questions related to any disaster preparedness other than fire. These questions included what to do in the case of blizzard, tornado, flood, earthquake, or bomb threat. During this interview, the Quality Specialist (E2) was also present and stated disaster training is suppose to take place on an annual basis; however, this had not been completed within the last 2 years.

3. An interview was conducted with Laboratory Manager (E6) on 1/8/14 at 1:05 PM. E6 was unable to answer questions related to any disaster preparedness other than fire. These questions included what to do in the case of blizzard, tornado, flood, earthquake, or bomb threat. When asked when E6 last received disaster preparedness training, other than fire, E6 stated "It has been some time". When asked to define "some time", E6 stated the staff in that unit (Laboratory) had not received disaster preparedness training, other than fire, in at least 2 years.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on February 18 - 19, 2014, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated February 19, 2014.

Based on document/ file review and interview, it was determined for 8 of 8 (ER#1, ER#2, ER#3, ER#4, ER#5, ER#6, P#1, P#2) physicians who had undergone reappointment, an evaluation of services was not included in the reappointment process.
Findings include:

1. The Medical Staff Bylaws (last reviewed 12/2012) were reviewed on 1/8/14. The Bylaws stated "3.5 Procedures for Reappointment:...3.5-2 Information... Appropriate summaries of inpatient admission and surgical procedures, peer recommendations, patterns of care as demonstrated ... compliance with bylaws, policies, rules, regulations, and procedures of the Hospital and Staff. In addition, all quality assurance and utilization review reports, audits, patient complaints... will be used to appraise Medical Staff members for reappointment..."

2. The credential file of ER#1 was reviewed with the Credentialing Coordinator (E8) on 1/8/14. ER#1 was reappointed to the Medical Staff on 11/19/12. There was no documentation of an evaluation of services being included in the reappointment process.

3. The credential file of ER#2 was reviewed with E8 on 1/8/14. ER#2 was reappointed to the Medical Staff on 3/7/13. There was no documentation of an evaluation of services being included in the reappointment process.

4. The credential file of ER#3 was reviewed with E8 on 1/8/14. ER#3 was reappointed to the Medical Staff on 1/21/13. There was no documentation of an evaluation of services being included in the reappointment process.

5. The credential file of ER#4 was reviewed with E8 on 1/8/14. ER#4 was reappointed to the Medical Staff on 3/31/13. There was no documentation of an evaluation of services being included in the reappointment process.

6. The credential file of ER#5 was reviewed with E8 on 1/8/14. ER#5 was reappointed to the Medical Staff on 11/19/12. There was no documentation of an evaluation of services being included in the reappointment process.

7. The credential file of ER#6 was reviewed with E8 on 1/8/14. ER#6 was reappointed to the Medical Staff on 1/16/12. There was no documentation of an evaluation of services being included in the reappointment process.

8. The credential file of P#1 was reviewed with E8 on 1/8/14. P#1 was reappointed to the Medical Staff on 3/7/13. There was no documentation of an evaluation of services being included in the reappointment process.

9. The credential file of P#2 was reviewed with E8 on 1/8/14. P#2 was reappointed to the Medical Staff on 7/16/12. There was no documentation of an evaluation of services being included in the reappointment process.

10. An interview was conducted with the Credentialing Coordinator (E8) on 1/8/14 at 12:00 PM. E8 confirmed, through concurrent credential file review, that 8 out of 8 reappointed physician files (ER#1, ER#2, ER#3, ER#4, ER#5, ER#6, P#1, P#2) failed to include an evaluation of services. E8 stated this should have been included in the reappointment process. E8 stated knowledge of this requirement.

Based on observation, document review, and interview, it was determined the CAH failed to ensure outdated biologicals were not available for use in patient care areas. This has the potential to affect all patients. Findings include:

1. During a tour of the CAH Emergency Department with E2 (Quality Specialist), conducted on 01/08/2014 at 11:00 AM, the following outdated items were observed available for use: Two Microorganism Collection and Transport System culture kits (expiration 03/08/2013), three BD Vacutainer blood collection tubes (expiration 10/2013), four MiniCollect blood collection tubes (expiration 11/2013), and one Vacuette blood collection tube (expiration 08/2013). E2 confirmed, thru concurrent observation, these items were expired and should not be in the patient care area.

2. During a tour of the CAH Laboratory Department with E6 (Laboratory Manager), conducted on 01/08/2014 at 1:00 PM, the following outdated items were observed available for use: four Hewitt blood culture tubes (expiration 12/27/2013), two CELL-DYN HemCal whole blood testing tubes (expiration 12/30/2013), and three Architect, 2nd Generation testosterone control test solution vials (expiration 07/24/2013). E6 confirmed, thru concurrent observation, these items were expired and should not be in the patient care area.

3. The CAH policy titled "OUTDATED MEDICATIONS AND BIOLOGICS" (revised 07/01/2013) was reviewed on 01/08/2014. The policy stated "Medications and biologics are reviewed for expiration before use and on a monthly basis... Outdated medications and biologics should be removed from active stock and returned to pharmacy for proper credit and disposal."

Based on document review and staff interview, it was determined the CAH failed to ensure dishwasher systems were monitored for temperature in accordance with its policies to ensure proper sanitation of dietary items to prevent the spread of communicable diseases. This has the potential to affect all patients and visitors serviced by the CAH Dietary department.
Findings include:

1. The Dietary Department policy book, provided by the Dietary Manger (E9), was reviewed on 1/7/14. E9 stated "this is what we currently use." The book stated Illinois Department of Public Health "Food Service Sanitation Code (October 1998)". The book stated "Machines using hot water for sanitizing may be used... water shall be maintained at not less than the temperature stated... 150 degrees Fahrenheit...180 degrees Fahrenheit... at least daily."

2. The Dish Machine Temperature Charts for the large dishwasher for September 2013 thru December 2013 were reviewed 1/7/14. There was no documentation to indicate the temperatures were checked in September 2013 24 of 31 days, October 2013 21 of 31 days, November 2013 28 of 30 days, or December 2013 14 of 31 days.

3. The Dish machine Log for the small dishwasher for April 2013 thru December 2013 were reviewed 1/7/14. There was no documentation to indicate the temperatures were checked in April 2013 2 of 30 days, May 2013 no log sheet completed, June 2013 no log sheet completed, July 2013 2 of 31 days, August, September, October and November 2013 no log sheet completed and December 2013 16 of 31 days.

4. An interview was conducted with the Dietary Manager (E9) on 1/7/14 at 10:30 AM. E9 stated the expectation is that the staff will check the water temperature once a day and document these results on the log sheets. E9 further confirmed that there was no documentation of checking of the temperature for dishwashers for the above listed dates.

Based on observation and interview, it was determined products and dry goods in the dietary storerooms were not always dated when received or opened and that food was not stored in accordance with first in first out (FIFO) to ensure the quality and safety of food storage and prevention of food borne illnesses. This has the potential to affect all the patients and/or visitors serviced by the Dietary Department.
Findings include:

1. The policy titled "Putting Groceries Away" (effective 8/2004) was reviewed 1/7/14. The policy stated "Practice: A. All groceries are to be labeled and dated when they are put away to ensure that they are being rotated... 1. cans are put in from the top and the old will roll forward...3. Anything put in cooler is to be marked with a color coded dot...as to tell how old it is...4. any new groceries in cooler or freezer need to have the date they came in stamped on them..."

2. During a tour of the CAH, conducted on 1/7/14 at 9:00 AM with the Dietary Manager (E9), the following items were observed to be stored without regard to the date of receiving and/or date of opening: dry storeroom: 1-1 gallon sweet chili sauce opened with no date, 4 containers of Teriyaki glaze were not dated, 2- 8 pound containers of salsa were observed mixed up on the storage shelf with 11/14 up front and 4/11/12 in the back instead of vice versa; walk in freezer: 1 bag chicken tenders, 1 bag of breaded catfish, 1 bag of chicken nuggets and 1 bag of potatoes pancakes were opened and not dated; walk in refrigerator: 1 plastic container with opened sliced cheese and 1 plastic container with opened cubed cheese were not dated. All dry goods and refrigerated/freezer items were observed as dated with month and day only (year not identified) to indicate when they were received and/or when they were opened.

3. An interview was conducted with E9 on 1/7/14 at 10:30 AM. E9 stated all food items were to be dated and stored in FIFO order, including dried goods. E9 confirmed that food items were to be dated when opened and this was not done and should have been.

Based on document/ record review and interview, it was determined for 2 of 3 (Pts #16, #17) patients who received a blood transfusion, vital signs were not monitored in accordance with its policy. Findings include:

1. The CAH policy titled "Blood Therapy" (reviewed/revised 04/13) was reviewed on 1/8/14. The policy stated "VII. Practice/ Procedure: N... Vital signs will be recorded on the Blood Transfusion Record as follows: 2. 15 minutes after the blood has entered the body. 3. One hour after the blood entered the body. 4. Hourly thereafter during the transfusion. 5. One hour after transfusion is complete."

2. The record of Pt #16 was reviewed on 1/9/14. Pt #16 was admitted to the CAH on 12/26/13 with the diagnoses nausea/ vomiting/ diarrhea and gastrointestinal bleeding and received a blood transfusion. On 12/27/13, Blood Transfusion Record documentation stated a unit of packed red blood cells (PRBCs) was started at 2:45 AM and infused at 6:00 AM. There was no documentation of vital signs one hour after the transfusion was completed.

3. The record of Pt #17 was reviewed on 1/9/14. Pt #17 was admitted to the CAH on 12/26/13 with the diagnosis severe anemia and received blood transfusions. On 12/26/13, Blood Transfusion Record documentation stated a unit of PRBCs was started at 6:12 PM and infused at 9:00 PM. There was no documentation of vital signs one hour after the blood entered the body, hourly during the transfusion, or one hour after transfusion completion.

4. An interview was conducted with the Quality Specialist (E2) on 1/9/14 at 4:00 PM. E2 reviewed the records of Pts #16 and #17 and confirmed vital signs were not monitored in accordance with CAH policy during the blood transfusions for both Pts #16 and #17.

A. Based on document/record review and interview, it was determined for 4 of 20 (Pts #3, #4, #17, #18) patients, a consent for admission was not obtained. Findings include:

1. The policy titled "Registration of Outpatient, Inpatient and Emergency services" (reviewed 2/21/13) was reviewed 1/9/14. The policy stated "VII. Practice/Procedure:... D. A COA (Consent form regarding Consent of Admission) is signed for hospital encounters with the signature witnessed by hospital staff... Procedure:...D. The COA is reviewed with the patient, signed by the patient..."

2. The record for Pt #3 was reviewed 1/8/14 with the Quality Specialist (E2). Pt #3 was admitted 12/29/13 with a diagnosis of CHF (Congestive Heart Failure). There was no consent for inpatient admission.

3. The record for Pt #4 was reviewed 1/8/14 with E2. Pt #4 was admitted 1/7/14 with a diagnosis of CHF. There was no consent for inpatient admission.
consents

4. The record of Pt #17 was reviewed on 1/9/14. Pt #17 was admitted to the CAH on 12/26/13 with the diagnosis severe anemia. There was no documentation a consent for inpatient admission was obtained.

5. The record of Pt #18 was reviewed on 1/9/14. Pt #18 was admitted to the CAH on 12/21/13 with the diagnoses pneumonia and weakness. There was no documentation a consent for inpatient admission was obtained.

6. An interview was conducted with the Quality Specialist (E2), along with record reviews, on 1/9/14 at 2:00 PM. E2 confirmed consents for the inpatient admission's were not obtained for Pts #3, #4, #17, #18. E2 stated all patient admissions should have a consent for admission executed.

B. Based on document/ record review and interview, it was determined for 1 of 20 (Pt #4) patients admitted to the CAH, a History and Physical (H&P) was not performed and documented within 24 hours of admission.
Findings include:

1. The Rules and Regulations of the Medical Staff were reviewed on 1/9/13. It indicated "Part 9.4-1 Medical Record Completion:...Histories and Physicals shall be dictated or written within 24 hours of admission..."

2. The record for Pt #4 was reviewed 1/8/14 thru 1/9/14 with the Director of Quality. Pt #4 was admitted 1/7/14 with a diagnosis of CHF. As of 1/9/13 at 3:00 PM, there was no H&P on the medical record to indicate it was completed.

3. An interview was conducted with the Quality Specialist (E2) on 1/9/13 at 3:00 PM. E2 reviewed the record of Pt #4 and confirmed there was no H&P completed within 24 hours of admission and there should have been.

Based on document/record review and staff interview, it was determined for 4 of 20 (Pt # 1, #2, #3 and #4) patients, physician orders were completed for protocols implemented.
Findings include:

1. The Medical Staff Rules and Regulations were reviewed 1/9/14. It indicated "4. Standing orders...shall be signed by the attending practitioner in the same manner as verbal orders..."

2. The policy titled "Patient Orders: Physician, Allied Health Professional, Associated Professional" (reviewed 12/12) as reviewed 1/8/14 at 1:45 PM. The policy stated "VII Practice/Procedure: A practitioner order is needed to initiate a medical protocol..."

3. The record of Pt #1 was reviewed with the Quality Specialist (E2) on 1/8/14 at 9:00 AM. Pt #1 was admitted 1/4/14 with a diagnosis of PN (Pneumonia). The admission orders dated 1/4/14 stated to implement the Oxygen Protocol. There was no Oxygen Protocol standing order completed by the physician.

4. The record of Pt #2 was reviewed with E2 on 1/8/14 at 9:15 AM. Pt #2 was admitted 1/2/14 with a diagnosis of PN. The admission orders dated 1/2/14 stated to implement the Oxygen Protocol. There was no Oxygen Protocol standing order completed by the physician.

5. The record of Pt #3 was reviewed with E2 on 1/8/14 at 9:30 AM. Pt #3 was admitted 12/29/13 with a diagnosis of CHF. The admission orders dated 12/28/13 stated to implement the Oxygen Protocol. There was no Oxygen Protocol standing order completed by the physician.

6. The record of Pt #4 was reviewed with the E2 on 1/8/14 at 9:30 AM. Pt #4 was admitted 1/7/14 with a diagnosis of CHF. The admission orders dated 1/7/14 stated to implement the Oxygen Protocol. There was no Oxygen Protocol standing order completed by the physician.

7. An interview was conducted with E2 on 1/8/14 at 9:30 AM. E2 stated the Oxygen Protocols for Pts #1, #2, #3 and #4 were not signed/ordered by the physician and should have been.

A. Based on policy, record review and staff interview, it was determined in 3 of 20 records reviewed (Pts #14, #18, #19) the CAH failed to ensure all physician telephone orders were authenticated by the ordering physician within 24 hours, in accordance with its' Medical Staff Rules and Regulations.
Findings include:

1. The Medical Staff Rules and Regulations were reviewed 1/9/14. The Rules and Regulations stated "26. All orders shall be in writing...The responsible practitioner shall authenticate such orders within 24 hours.,"

2. The record of Pt #14 was reviewed on 1/9/14. Pt #14 was admitted to the CAH on 10/22/13 with the diagnosis hyponatremia. On 10/27/13 at 9:00 PM, there was a physician telephone order "Decrease IV (intravenous) to 50 mls (milliliters) per hour..." On 10/29/13 at 7:15 PM, there was a physician telephone order "Change Roxanol..." On 10/29/13 at 7:15 PM, there was another physician telephone order "Change Ativan to liquid..." All of these orders were signed by the physician on 11/4/13, beyond the required timeframe.

3. The record of Pt #18 was reviewed on 1/9/14. Pt #18 was admitted to the CAH on 12/21/13 with the diagnoses pneumonia and weakness. On 12/21/13 at 10:47 PM, there was a physician telephone order "Discontinue Ciprofloxacin. Novolog Sliding Scale..." On 12/22/13 at 1:30 PM, there was a physician telephone order "Duoneb nebulizer...." On 12/22/13 at 4:00 PM, there was a physician telephone order "Discontinue Lovenox order..." As of 1/9/13 at 3:45 PM, these orders had not been signed by the physician.

4. The medical record of Pt. #19 was reviewed on 1/8/14. Pt #19 was admitted 12/26/13 with a diagnosis of hyperglycemia. On 12/26/13, there was a physician telephone order for implementation of Sliding Scale Insulin Order protocol. As of 1/9/13 at 3:00 PM, this order had not been signed by the physician.

5. An interview was conducted with the Quality Specialist (E2) 1/9/14 at 10:30 AM. E2 was stated telephone orders were to be signed by the physician within 24 hours. E2 reviewed the records of Pts #14, #18, #19 and confirmed the telephone orders had not been signed by the physician within 24 hours and should have been.

B. Based on document/ record review and interview, it was determined for 4 of 20 records reviewed (Pts #2, #3, #14, #19) the CAH failed to ensure all orders are dated and timed by the ordering physician.
Findings include:

1. The policy titled "Patient Orders: Physician, Allied Health Professional, Associated Professional" (reviewed 12/12) as reviewed 1/8/14 at 1:45 PM. The policy stated "VI. General Considerations: B. All patient medical entries must be legible, complete and include date and time."

2. The record of Pt. #2 was reviewed on 1/8/14. Pt. #2 was admitted on 1/2/14 with diagnosis of PN. The Venous Thromboembolism (VTE) Prophylaxis Orders was signed by the APN (Advanced Practice Nurse) although the signature was not dated or timed to indicate when the order was authenticated.

3. The record of Pt #3 was reviewed on 1/8/14. Pt #3 was admitted 12/29/13 with a diagnosis of CHF. A telephone order written on 12/29/13 at 6:00 AM and was authenticated by the physician;however, there was no date or time to indicate when the order was authenticated.

4. The record of Pt #14 was reviewed on 1/9/14. Pt #14 was admitted to the CAH on 10/22/13 with the diagnosis hyponatremia. A physician order titled "Oxygen Protocol" was signed by the physician; however, there was no date or time to state when the protocol was ordered and/or signed by the physician. On 10/25/13 at 2:50 AM, there was a physician verbal order "Normal Saline 3% IV (Intravenous) at 50 Ml (milliliter) per hour..." On 10/25/13 at 4:00 AM, there was a physician telephone order "May change catheter...." Both of these orders failed to state the date and time as to when the physician signed them.

5. The medical record of Pt. #19 was reviewed on 1/8/14. Pt #19 was admitted 12/26/13 with a diagnosis of hyperglycemia. The Admission Orders were signed by the physician although the signature was not dated or timed to indicate with the orders were authenticated.

6. An interview was conducted with the Quality Specialist (E2) on 1/9/14 at 10:30 AM. E2 stated all orders were to be dated and timed when signed by the physician. E2 reviewed the records of Pts #2, #3, #14, #19 and confirmed the physician signatures had not been dated and timed when they were signed and should have been.

A. Based on document review and interview, it was determined for 3 of 3 (CRNAs #1, #2, #3) Certified Registered Nurse Anesthetists, the Critical Access Hospital (CAH) failed to ensure CRNAs held current Controlled Substance and Federal Drug Enforcement Administration (DEA) licenses for the State of Illinois.
Findings include:

1. The anesthesia agreement was reviewed on 1/8/14. The agreement stated "Whereas.... employs CRNAs, duly licensed in the State of Illinois, by the Illinois Department of Professional Regulation and the Councils of Certification and Recertification of Nurse Anesthetists and is qualified to provide anesthesia services..."

2. The "720 ILCS570/ Illinois Controlled Substances Act" and the "United States Department of Justice DEA "Questions and Answers- What is DEA policy concerning Locum Tenens?"" website information were presented on 1/8/14 at 2:40 PM, by the Credentialing Coordinator (E8). E8 stated both of these requirements have not been met by the CRNAs at the CAH. The "720 ILCS570/ Illinois Controlled Substances Act" stated "Sec. 302. (a) Every person who manufactures, distributes, or dispenses any controlled substances... within this State, must obtain a registration issued by the Department of Financial and Professional Regulation in accordance with its rules... (d) A separate registration is required... " The "United States Department of Justice DEA "Questions and Answers- What is DEA policy concerning Locum Tenens?"" website information stated "Please be aware that practitioners who wish to administer, dispense, or prescribe controlled substances in multiple states have the following options regarding DEA application..."

3. The personnel file of CRNA #1 was reviewed with the Credentialing Coordinator (E8) on 1/8/13. CRNA #1 was initially credentialed by the CAH on 4/1/06 to provide anesthesia services. CRNA #1 was recredentialed on 3/19/12. CRNA #1 had a Controlled Substance and DEA license for the State of Iowa; however, there was no documentation of CRNA #1 having a Controlled Substance or DEA license for the State of Illinois.

4. The personnel file of CRNA #2 was reviewed with E8 on 1/8/13. CRNA #2 was initially credentialed by the CAH on 4/1/06 to provide anesthesia services. CRNA #2 was recredentialed on 3/19/12. CRNA #2 had a Controlled Substance and DEA license for the State of Iowa; however, there was no documentation of CRNA #2 having a Controlled Substance or DEA license for the State of Illinois.

5. The personnel file of CRNA #3 was reviewed with E8 on 1/8/13. CRNA #3 was initially credentialed by the CAH on 3/2006 to provide anesthesia services. CRNA #3 was recredentialed on 8/1/13. CRNA #3 had a Controlled Substance and DEA license for the State of Iowa; however; there was no documentation of CRNA #3 having a Controlled Substance or DEA license for the State of Illinois.

6. An interview was conducted with the (E8) on 1/8/14 at 12:30 PM. When asked if the CRNAs had a Controlled Substance and a DEA license for the State of Illinois, E8 stated "We have them (the Controlled Substance and DEA licenses for the State of Illinois, as well as any other State in which the CRNA works) at our other facilities but not at this facility at this time. I'm sure of it. They should have, but they don't." E8 stated "I know they need to have it in each State they work in just like they have to have their individual State license."

B. Based on document/ file review and interview, it was determined for 1 of 6 (ER#3) emergency room physicians with privileges to use neuromuscular blockage agents as adjunct to intubation, Pediatric Advanced Life Support (PALS) certification was not current.
Findings include:

1. The file of ER#3 was reviewed with the Credentialing Coordinator (E8) on 1/8/14. ER#3 was reappointed to the Medical Staff on 1/21/13. On 1/22/13, a letter confirming reappointment to the Medical Staff stated "The following privilege(s) was/were added to your Delineation of Privileges.... Advanced pediatric resuscitation/ neonatal care... Use of neuromuscular blockage agents as adjunct to intubation..." ER#3 did not have PALS certification.

2. An interview was conducted with the Credentialing Coordinator (E8) on 1/8/14 at 3:00 PM. E8 stated phone contact was made with ER#3 and it was confirmed ER#3 did not have current PALS certification. E8 stated Emergency Room physicians should have PALS certification as they are required to provide care to pediatric patients who could have life threatening conditions that require advanced life support care.

Based on document review and interview, it was determined the CAH failed to ensure it's dietary program was integrated into it's quality program. This has the potential to affect all patients and staff.
Findings include:

1. The CAH policy and procedure titled, "Food Service Sanitation Code" (effective 3/14/05) was reviewed on 1/8/14. The policy stated "VI. A. Food Service Sanitation Code: ...The Director will conduct a monthly sanitation and safety review. Any problems will be brought to the attention of the safety committee, infection control committee, or quality improvement committee, as deemed appropriate." The CAH's quality assurance meeting minutes for 2013 were reviewed on 1/9/14. There was no documentation that indicated the Dietary department was integrated into the Quality program.

2. In interviews with the Quality Specialist (E-2) and the Dietary Manager (E9), conducted on 1/9/14 at 1:10 PM, both stated that Dietary does not participate in the Quality program. E2 stated that currently there are no on-going quality programs in the Dietary Department. E9 also stated that there were no reports sent to the Safely committee, Infection Control committee, or the Quality committee related to Dietary services.