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Based on review of policies and procedures and staff interview, the Critical Access Hospital (CAH) failed to develop a disaster plan that included sewer system failure and heating system failure. Census on the first day of survey was 4 acute patients and 3 swingbed patients. The total patients served for fiscal year 2014 (7/1/13 to 6/30/14) included 187 medical/surgical inpatients, 75 mothers with newborn infants, 245 observation patients, 70 swingbed patients and 8 inpatients receiving hospice services (care, comfort and support for persons with a terminal illness). The lack of a plan for sewer system failure and heating system failure has the potential to affect all patients of the CAH.

Findings are:

A. Review of the Disaster Plan (reviewed and revised 5/08), the Internal Disaster Plan (effective 5/27/08) and the Evacuation Plan (last reviewed 4/14) revealed no plan for sewer or heating system failures.

B. Interview with the Director of Maintenance on 9/23/14 from 1:30 PM to 1:50 PM revealed the following:
- Confirmed the lack of a plan for sewer system failure;
- Identified the boilers provide heating for the hospital and run off natural gas; and,
- Confirmed there was no plan if natural gas supply was interrupted.

C. During the exit conference on 9/29/14 from 5:45 PM to 6:00 PM the Chief Executive Officer identified that the patient wing heating system runs on electricity and confirmed the rest of the hospital would be with out heat during and interruption of natural gas.

Based on review of physician credential files, review of Bylaws of the Medical Staff and staff interview, the Critical Access Hospital (CAH) failed to follow the Bylaws of the Medical Staff during reappointment for 7 of 13 practitioner (Practitioners A, D, E, F, G, I and M) reviewed. (The term "practitioner" includes physicians, dentists, optometrist and/or podiatrists.) The Bylaws of the Medical Staff required that reappointments be based on "professional competence and clinical judgment in the treatment of patients as demonstrated by reviews and peer recommendations; maintenance of timely, accurate, and complete medical records....attendance at Medical Staff meetings....cooperation with hospital personnel: use of Hospital's facilities for his/her patients". However, the CAH could provide no evidence that the Medical Staff and Governing Body reviewed this information during the reappointment of practitioners. A total of 13 practitioner credential files were reviewed. The Medical Staff Roster (no date) listed 49 practitioners. Census on the first day of survey was 4 acute patients and 3 swingbed patients. The total patients served for fiscal year 2014 (7/1/13 to 6/30/14) included 187 medical/surgical inpatients, 75 mothers with newborn infants, 245 observation patients, 70 swingbed patients and 8 inpatients receiving hospice services (care, comfort and support for persons with a terminal illness). This failed practice has the potential to affect all patients treated by practitioners at the hospital.

Findings are:

A. Review of the Bylaws of the Medical Staff (approved by the Governing Body on 3/20/14) under Article 7 Appointment and Privileging, Section 5 Renewal Procedure listed the following criteria for reappointment:
- "professional competence and clinical judgment in the treatment of patients as demonstrated by reviews and evaluations conducted by committees in quality management activities";
- "maintenance of timely, accurate, and complete medical records";
- "attendance at Medical Staff meetings and participation in staff affairs";
- "compliance with Medical Staff Bylaws and the Medical Staff Rules and Regulations";
- "cooperation with hospital personnel"; and,
- "use of Hospital's facilities for his/her patients".
Review of the Bylaws of the Medical Staff approved by the Governing Body on 5/17/12 revealed the previous Bylaws contained this same criteria for reappointment.

B. Review of the credential files for Practitioner A (last reappointment dated 11/15/12), Practitioner D (last reappointment dated 6/26/14), Practitioner E (last reappointment dated 8/21/14), Practitioner F (last reappointment dated 4/17/14, Practitioner G (last reappointment dated 6/16/14), Practitioner I (last reappointment dated 12/20/12), and Practitioner M (last reappointment dated 2/21/14) revealed no information concerning these 7 practitioners' performance at the CAH including: reviews by quality management; timely, accurately completed medical records; attendance at Medical Staff meetings; compliance with Medical Staff Bylaws and Medical Staff Rules and Regulations; cooperation with hospital personnel; and/or use of Hospital's facilities for his/her patients.

C. Interview with the Credentialing Manager on 9/24/14 from 1:40 PM to 2:30 PM revealed the following:
- Only the information in the credential file would be given to the Medical Staff and the Governing Body for review at time of reappointment;
- A provider profile document had been developed to use with the Active Staff Physicians (physicians that attend, admit and use this hospital as their primary hospital);
- The provider profile document had not yet been approved by the medical staff; and,
- Nothing had been developed for consulting and/or affiliate staff (non-physician practitioners including dentists, podiatrists, physician assistants, advanced practice registered nurse and certified registered nurse anesthetists).

D. Review of the Provider Profile revealed the following information would be collected for the year: admission statistics; quality management activities; and attendance at medical staff meeting.

E. Interview with the Chief Executive Officer (CEO) on 9/29/14 from 5:40 PM to 5:45 PM confirmed that the only information the Medical Staff and Governing Body would have available during the reappointment process would be the information contained in the credential files.

Based on staff interview and medical record review, the Critical Access Hospital (CAH) failed to have a Care Plan (an outline of nursing care to be provided for the patient) on 3 of 40 Patients (Pt) (Patients 6, 12 and 17). The CAH census on the first day of survey was 4 acute patients and 3 swingbed patients. This had the potential to affect nursing care for any inpatients of the Critical Access Hospital.

Findings are:

A. A review of Patient 6's medical record revealed the patient was admitted on 6/24/14 and dismissed on 6/26/14. The medical record lacked a Care Plan for Patient 6.

B. A review of Patient 12's medical record revealed the patient was admitted on 2/17/14 and dismissed on 2/21/14. The medical record lacked a Care Plan for Patient 12.

C. A review of Patient 17's medical record revealed the patient was admitted on 2/27/14 and dismissed on 2/28/14. The medical record lacked a Care Plan for Patient 17.

D. An interview with the Chief Nursing Officer on 9/24/14 at 5:15 PM regarding the follow up questions related to medical records for Patients 6, 12 and 17 revealed, "No I don't see a Care Plan on their records either. The nurses are suppose to start the Care Plan on admission and review it every shift"

E. A review of the Policy and Procedure titled "Nursing Care Plan" dated 12/00 and revised 12/09 revealed:
- "It is the policy of (the CAH) to provide care for patients admitted to Acute Care, OB (obstetrics-specialty that deals with pregnancy and childbirth), Skilled Care and Outpatients admitted for greater than 12 hours, utilizing a documented, integrated plan of care.
- Upon receiving admission orders, the Charge RN (registered nurse) or delegate will initiate the Care Plan Process."

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to:
Part I - Have accurate documentation for the times that the Anesthesia (a method to induce loss of sensation and consciousness as a result of administration of medication to perform a surgical procedure) Services provided a pre and/or post surgery visit for 5 of 6 surgical patients (Patients 26, 27, 28, 29 and 30).
Part II - Ensure the medical record was complete for 2 of 40 (Patients 10 and 24) records reviewed. Patient 10's medical record lacked a provider discharge summary (a document summarizing the patient's hospital stay); and Patient 24's medical record lacked an order for an ultrasound (a test that uses sound waves to visualize parts of the body beneath the skin) of the abdomen. The total patients served for fiscal year 2014 (7/1/13 to 6/30/14) included 187 medical/surgical inpatients, 75 mothers with newborn infants, 245 observation patients, 70 swingbed patients and 8 inpatients receiving hospice services (care, comfort and support for persons with a terminal illness). This failed practice has the potential to affect all patients treated by practitioners at the hospital.


Findings are:

Part I
A. Patient 26 had a Hysteroscopy (a procedure to see inside the uterus (womb) using a viewing scope) and Dilation and Curettage (D&C-a procedure in which the uterus is expanded so that the uterine lining can be removed) on 9/19/14 from 0745 (7:45 AM) - 0855 (8:55 AM). The medical record showed that the pre and post anesthesia visits were completed, although the documentation of the date lacked the year and time in which the visits were completed. The postanesthesia note lacked the minimal information of Cardiopulmonary status (heart and lung status); Level of consciousness (alertness of patient); any follow-up care and/or observations; and any complications occurring during the post-anesthesia recovery. Patient 26's postanesthesia note revealed, "did well".

B. Patient 27 had a Laparoscopic Cholecystectomy (removing the gallbladder-an organ that stores bile/fluid through small holes in the abdomen using an instrument that allows the surgeon to see the organs inside the abdomen) on 8/29/14 from 1401 (2:01 PM) - 1547 (3:47 PM). The medical record showed that the post anesthesia visit was completed, although the documentation of the date lacked the year and time in which the visit was completed and the minimal information of Cardiopulmonary status (heart and lung status); Level of consciousness (alertness of patient); any follow-up care and/or observations; and any complications occurring during the post-anesthesia recovery. Patient 27's postanesthesia note revealed, "did well".

C. Patient 28 had a TURB (Transurethral Resection of Bladder Tumor - removal of a tumor in the bladder - an organ that collects urine) through the urethra (tube throughwhich urine is excreted) on 7/17/14 from 0901 (9:01 AM) - 0932 (9:32 AM). The medical record showed that the post anesthesia visit was completed, although the documentation of the date lacked the year and time in which the visit was completed and the minimal information of Cardiopulmonary status (heart and lung status); Level of consciousness (alertness of patient); any follow-up care and/or observations; and any complications occurring during the post-anesthesia recovery. Patient 28's postanesthesia note revealed, "did well".

D. Patient 29 had a Left Rotator Cuff Repair Surgery (surgery on the shoulder to repair a torn tendon in the shoulder) on 6/4/14 from 0915 (9:15 AM) - 1135 (11:35 AM). The medical record showed that the post anesthesia visit was completed, although the form lacked documentation of the date and time in which the visit was completed and the minimal information of Cardiopulmonary status (heart and lung status); Level of consciousness (alertness of patient); any follow-up care and/or observations; and any complications occurring during the post-anesthesia recovery.

E. Patient 30 had a LAVH (Laparoscopically Assisted Vaginal Hysterectomy - use of a scope through small holes in the abdomen to allow the surgeon to detach the uterus from their ligaments (supporting structure) and blood supply. The uterus is then removed through an incision inside the vagina) on 5/16/14 from 0900 (9:00 AM) -1110 (11:10 AM). The medical record showed that the post anesthesia visit was completed, although the form lacked documentation of the date and time in which the visit was completed and the minimal information of Cardiopulmonary status (heart and lung status); Level of consciousness (alertness of patient); any follow-up care and/or observations; and any complications occurring during the post-anesthesia recovery.

F. An interview with CRNA (Certified Registered Nurse Anesthetist - a nurse that specializes in anesthesia administration)-B on 9/24/14 at 1:40 PM regarding the follow-up questions related to medical records for Patients 26, 27, 28, 29 and 30 revealed, "Yes, I can see that this is just incomplete charting. I guess I just got lax on that, I will work on it."

G. A review of the undated Policy and Procedure for the Preanesthesia Assessment and the Postoperative Anesthesia Care revealed, "Each postanesthesia visit will be documented on the postanesthesia evaluation form or the progress notes. The date and time of each visit will be specified."

Part II
AA. A review of Patient 10's medical record showed the patient was admitted on 3/12/14 and discharged on 3/14/14. The medical record lacked a Discharge Summary from the health care provider at time of discharge.

BB. A review of Patient 24's medical record showed that Patient 24 received Emergency Room Care on 6/16/14 from 8:05 AM until discharge at 10:40 AM. The record showed a report of an Ultrasound of the Abdomen completed 6/16/14 at 8:45 AM. Review of the physician orders revealed a lack of an order for the ultrasound.

CC. An interview with the Chief Nursing Officer on 9/24/14 at 5:15 PM regarding the follow-up questions related to medical records for Patients 10 and 24 revealed, "No I don't see the Discharge Summary (on Patient 10's record) or the physician order (on Patient 24's record) on their records either."

Based on review of the last Periodic Evaluation, review of policies and procedures and staff interview, the Critical Access Hospital (CAH) failed to ensure annual review of health care policies and the inclusion of this review in the Periodic Evaluation. The Director of Regulatory Services identified 17 CAH departments with health care policies on 9/29/14 at 3:30 PM. Five (5) of these departments (Nutritional Services, Physical Therapy/Occupational Therapy/Speech Therapy, Health Information Management, Materials Management and Environmental Services) lacked evidence of review of the policies and procedures during the 2014 fiscal year (7/1/13 through 6/30/14). Census on the first day of survey was 4 acute patients and 3 swingbed patients. The total patients served for fiscal year 2014 included 187 medical/surgical inpatients, 75 mothers with newborn infants, 245 observation patients, 70 swingbed patients and 8 inpatients receiving hospice services (care, comfort and support for persons with a terminal illness). The lack of review of these policies and procedures has the potential to affect all patients of the CAH.

Findings are:

A. Review of the Periodic Evaluation dated 7/1/13 - 6/30/14 revealed the following under Policies and Procedures: "26 policies and procedures were reviewed and amended by an established committee as required by CAH regulations. Departments review policies on a regular basis."

B. Interview with the Nutritional Services Director and the Consultant Dietitian on 9/24/14 from 9:55 AM to 11:15 AM, when asked when the nutritional services policies and procedures were last reviewed the Consultant Dietitian commented "Something we have not gotten done."

Interview with the Director of Health Information Management (HIM) on 9/29/14 at 4:00 PM revealed only half of the HIM policies and procedures were reviewed last year.

Interview with Director of Regulatory Services on 9/29/14 at 4:05 PM confirmed the lack of review of polices and procedures by Materials Management and Environmental Services.

Interview with the Director of PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy) on 9/23/14 from 11:30 AM to 12:00 noon when asked the question of when the PT/OT/ST polices and procedure were last reviewed indicated 2010 when many the policies and procedures were rewritten.

C. Review of the following 2 policies and procedures Disaster Plan (last reviewed date of 7/08) and Internal Disaster Plan (effective date 5/27/08 with no reviewed or revised date) both listed information for Long Term Care which closed 9/30/2010.

D. Interview with the Director of Regulatory Services and the Chief Nursing Officer (CNO) on 9/29/14 from 11:05 AM to 11:40 AM revealed the following concerning review of departmental policies and procedures:
- "Have assumed they [meaning department directors] have done this";
- Have formed a policy and procedure task force that started in May 2014;
- Working on getting all of the policies and procedures into the same format not really reviewing the content;
- When asked if all departments had review policies and procedures in the last year the comment by Director of Regulatory Services was "I don't think they have".

Based on staff interview and medical record review, the Critical Access Hospital (CAH) failed to have a Comprehensive Care Plan (a care plan to be developed within 7 days following the comprehensive assessment) on 2 of 5 swingbed patients (Patients 32 and 33). The CAH census on the first day of survey was 4 acute patients and 3 swingbed patients. This had the potential to affect nursing care for all swingbed patients of the Critical Access Hospital.

Findings are:

A. The review of Patient 32's medical record on 9/23/14 revealed the patient was admitted to swingbed on 8/19/14 and continued to be a current swingbed patient at the time of the survey exit on 9/29/14. The 14 day comprehensive assessment was completed on 9/5/14. The medical record lacked the Comprehensive Care Plan which needed to be developed within 7 days of the comprehensive assessment (9/12/14).

The Comprehensive Care Plan should be developed in collaboration with the team of professionals (therapies, nursing, physician, dietary) working with the patient during their swingbed stay. The team should seek input from the patient and/or their representative to set goals related to their treatment plan.

B. The review of Patient 33's medical record on 9/23/14 revealed the patient was admitted to swingbed on 8/29/14 and continued to be a current swingbed patient at the time of the survey exit on 9/29/14. The 14-day comprehensive assessment was completed on 9/12/14. The medical record lacked the Comprehensive Care Plan which needed to be developed within 7 days of the comprehensive assessment (9/19/14).

C. An interview with the Quality Assurance Director on 9/24/14 at 11:00 AM regarding the follow-up questions related to medical records for Patient 32 and 33 revealed, "No, there isn't a Comprehensive Care Plan on their records."

D. A review of the Policy and Procedure titled "Swing Bed Plan of Care" dated 03/94 and revised 4/10 revealed:
- "An individualized and comprehensive plan of care will be developed on each patient."
- "The care plan will be updated as the patient's condition and needs change."
- "As the plan is developed, a multi-disciplinary approach should be used in order to meet the patient's physical, psychosocial and spiritual needs."
- "The patient and their family should be included in the care planning process."