HospitalInspections.org

Based on observation, staff interview, review of hand hygiene monitoring tool and review of policies and procedures, the CAH (Critical Access Hospital) failed to identify a failure of hand hygiene (either hand washing or using a hand sanitizer) when dietary staff went from one patient room to the next to pass meal trays during 2 of 2 observations. This failure of hand hygiene had the potential to affect all patients receiving meals at the CAH. Review of the statistical report for FY2013/2014 dated 4/22/14 revealed the CAH had admitted 58 acute inpatients and 35 skilled patients from 7/1/13 to 3/31/14. Patient census on the first day of survey was 1 skilled patient and 1 acute inpatient.

Findings are:

A. Observation on 5/14/14 from 11:35 AM - 11:45 AM revealed Cook-W went into Room 110 with a meal tray and touched the bedside table then left the room without washing hands or using hand sanitizer. Cook-W proceeded down the hall and took a meal tray into Room 130 and touched the bedside table and removed the covers on the food items and touched the sink while talking to patient in the room. Cook-W left this room without washing hands or using hand sanitizer. Cook-W proceeded to Room 136 and set up 2 tray tables, placed a tablecloth over the tray tables and put meal trays for patient and husband on the bedside table. Cook-W then proceeded to go back to the kitchen and completed handwashing after entering the kitchen.

B. Observation on 5/15/14 from 11:20 AM to 11:28 AM revealed Cook-W went into Room 122 with a meal tray and touched bedside table and left the room without washing hands or using hand sanitizer. Cook-W proceeded to Room 130 and delivered a meal tray and touched bedside table and left room without washing hands or using hand sanitizer.

C. Interview with Cook-W and Dietary Manager on 5/15/14 at 11:28 AM revealed nursing used to pass the meal trays and thought dietary started passing them to patients about 3 months ago and never thought about having to wash hands since the patient was not touched.

D. Interview with the Quality Improvement/Infection Control Nurse on 5/19/14 from 9:00 AM to 9:30 AM revealed in June 2013 they started monitoring hand hygiene. Review of the Hand Hygiene Monitoring Tool used revealed hand hygiene should take place after contact with patient environment. Examples of patient environment included bed, chair, bedside stand, over-bed table.

E. Review of dietary policy and procedure titled Room Trays with an effective date of 9/1/11 revealed the following: "Food service will notify the appropriate nursing as the tray is ready for delivery. Nursing staff will deliver the room tray...." The policy was not changed to reflect the current practice.

Based on record review, staff interview, review of the Medical Staff Rules and Regulations and review of the policy and procedures, the facility failed to ensure verbal and telephone orders were utilized infrequently. A review of 36 inpatient/swing bed records revealed that 13.7% of the physician orders were received by telephone or verbally from the health care provider. This failure had the potential to increase the risk for medication error due to the potential for misunderstanding or incorrect transcription of the providers order. The facility census was 2 inpatients and 1 swing bed on entrance. The total sample size was 41.

Findings are:

A. A review of 36 inpatient and swing bed patient records with their hospital stay ranging between 11/3/13 and 5/19/14 was completed. The patient records contained orders from Physicians and a Physician Assistant. The review of the 36 patient records identified that the nurses input into the computer, 281 verbal or telephone orders out of 2050 total physician orders or 13.7%.

B. A review of the 2013 Medical Staff Rules and Regulations for the facility noted under the section titled "TREATMENT - GENERAL" that "(2) Verbal and telephone orders shall be used only when necessary and as infrequently as possible."

C. A review of the facility policy and procedure titled, "Procedure for Charting Rules" dated 9/2012, identified to encourage doctors to write or enter their orders at the time they are making rounds. The physician orders are placed electronically in the CPOE (Computer Physician Order Entry-where physician orders are entered electronically) by either a provider or nurse.

D. An interview with the Director of Nurses (DON) on 5/19/14 at 8:40 AM revealed, "I reviewed the 36 records we looked at last week and 13.7% of the orders for those patients were either verbal or telephone orders. I know the doctors and PA (Physician Assistant) have been trained in using the computer for inputting the orders. We will have to work with them to be sure they are comfortable putting them in. Our goal is that they put their own orders in unless it is necessary to give the nurses a verbal or telephone order."

Based on review of Agreements, review of the Medical Staff Bylaws, interview with staff and review of the Annual Periodic Evaluation, the CAH (Critical Access Hospital) failed to have the quality and appropriateness of diagnosis and treatment furnished by doctors of medicine or osteopathy evaluated by an external reviewer in accordance with the Network Agreement. The medical staff of the CAH consisted of 2 Active Staff and 63 Consulting Staff. This failed practice had the potential to affect all patients treated at the CAH. Review of the statistical report for FY2013/2014 dated 4/22/14 revealed the facility had admitted 58 acute inpatients and 35 skilled patients from 7/1/13 to 3/31/14. Patient census on the first day of survey was 1 skilled patient and one acute inpatient.

Findings are:

A. Review of the Critical Access Hospital and Rural Health Clinic(s) Annual Assessment for Fiscal Year 2013/21014 revealed the following under the section titled Peer Review:
"Peer Review of our Medical Records was performed by [names of Physicians A and B] ....currently we do not have any external peer review. "

The Medical Staff Bylaws approved by the Board of Director on 7/8/13 gives the following definition for Peer Review:
"...the procedure by which health care providers evaluate the quality and efficiency of services ordered or performed by other health care providers...Peer Review is a cooperative effort and includes the activities of officers, trustees, agents, and employees of Hospital, as well as members of the Medical Staff and AHPs (Allied Health Professionals), including representative of the Network Hospital when called for under the CAH Network Agreement or representatives of accrediting organizations."

B. Interview with the Quality Improvement Coordinator on 5/15/14 from 10:35 AM to 11:00 AM revealed the Active Medical Staff (consisting of 2 physicians) did peer reviews on 14 to 15 charts each month. Further interview revealed no records had been sent for external peer review in the last 3 and 1/2 years.

Interview with the CEO (Chief Executive Officer) on 5/15/14 indicated that the CAH had been working with their Network Hospital to get external peer review started, but confirmed it had not been set up yet. Further interview revealed the Network Agreement had been revised to be more specific for Peer Review.

C. Review of the Network Agreement with an effective date of 8/26/13 revealed the following:
"The parties agree that [Name of Network Hospital], through participating members of its medical staff or other personnel designated by [Name of Network Hospital], shall meet with the CAH's QA (Quality Assurance) representatives no less than on an annual basis to provide objective oversight and assistance to the CAH in reviewing the quality and appropriateness of the diagnosis and treatment furnished by CAH's doctors of medicine or osteopathy....As necessary, and upon request of QA representatives of the CAH, the CAH's Medical Staff, the CAH's Administrator/CEO, or the CAH's governing body, peer review assistance will be provided by the peer review organization currently under contract with the CAH for this service."

Review of the Network Agreement (with the same hospital as above) that was in place from 2/1/2000 to 8/25/13 revealed the following:
"The parties agree that [Network Hospital], through participating members of its medical staff and other personnel designated by [Network Hospital], shall assist the [CAH] in reviewing the quality and appropriateness of diagnosis and treatment furnished by the [CAH's] doctors of medicine or osteopathy from time to time for purpose or plan..."

On 5/15/15 the CEO provided a copy of an Agreement for External Peer Review Services with the Network Hospital. This agreement had just been signed by the CEO of the Network Hospital on 5/14/14 and by the CEO of the CAH on 5/15/14.