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Tag No.: C0227
Based on a review of personnel files of individuals hired within the past year and staff interviews, the Critical Access Hospital failed to ensure newly hired individuals obtain specific training regarding their unique responsibilities in a non-medical emergency. Findings are:
A. 3 of 3 personnel files reviewed lacked evidence of specific training based on each individual's job responsibilities for non-medical emergencies.
B. Interviews with the Director of Nursing and the Administrator on 7/14/10 at 11:00 AM confirmed a lack of specific training for newly hired individuals prior to the first day of direct patient contact. Examples: 2 RNs and 1 dietary aide.
The hospital reported 112 acute inpatient admissions for the past fiscal year. Current census of 5, including 1 swing-bed patient.
Tag No.: C0272
Based on a review of the Patient Care Policy committee review dated 7/16/09 and staff interview, the Critical Access Hospital failed to include all the required personnel in the meeting. Current census wass 5, including 1 swing-bed patient. Findings are:
A. The most recent patient care policy review documentation revealed that there was no representative who was not a member of the hospital staff.
B. An interview with the Administrator on 7/16/10 at 3:15 PM confirmed the outside individual was not in attendance and did not participate, as required.
Tag No.: C0278
Based on staff interview and review of hospital records, the Critical Access Hospital (CAH) failed to maintain an active program of monitoring hand hygiene practices of direct patient care personnel. Findings are:
A. A review of data collection and reporting of health care associated infections for the past 6 months lacked evidence of data collection regarding direct observations of patient care personnel hand hygiene practices.
B. An interview conducted on 7/13/10 at 3:00 PM with the Infection Control Practitioner confirmed the hospital lacked a program of active monitoring of direct care staff to ensure personnel followed hand hygiene practices during direct patient care contact.
The CAH reported 112 acute care patients were admitted within the past fiscal year.
Tag No.: C0283
Based on staff interview and review of hospital records, Radiology Services failed to ensure patients and personnel were not exposed to radiation hazards. Findings are:
A. An interview conducted with the Radiology Supervisor on 7/14/10 at 11:00 AM revealed the lead aprons, gonad shields and thyroid shields used to protect patients and staff from radiation exposure, had not been evaluated for structural integrity for approximately 3 years.
B. On 7/16/10 at 11:00 AM the Radiology Supervisor provided evidence that all lead protective equipment and been evaluated for structural integrity and was, therefore, corrected at the time of survey.
The department performed 802 radiographic procedures in the most recent fiscal year.
Tag No.: C0321
Based on a review of the clinical surgical privileges compared with the surgery log and staff interview, the Critical Access Hospital failed to approve privileges which actually represented existing practice. Findings are:
A. The privilege list approved by the Governing Body for the general surgeon included thyroidectomy (removal of the thyroid gland), splenectomy (removal of the spleen), and nephrectomy (removal of the kidney) and surgery of the diaphragm. All of the above mentioned procedures require extensive patient support, as well as a large quantity of blood for transfusion, as all can incur substantial blood loss.
B. A review of the surgical case log for the past year confirmed that none of the above procedures were performed at this hospital .
C. Interview with the Director of Nursing and the Administrator on 7/14/10 confirmed none of the above procedures had been performed within the past year.
The facility performed 33 procedures from 1/7/10 to 7/8/10.
Tag No.: C0336
Based on staff interviews, a review of the most recent medical staff reappointment, a review of the quality assurance measures for monitoring the quality and appropriateness of the diagnosis and treatment, and treatment outcomes, as compared with the Medical Staff Bylaws, rules and regulations, the Critical Access Hospital failed to include any quality assurance information in the medical staff reappointment process and failed to follow the bylaws in the reappointment process. Current census was 5, including 1 swing-bed patient.
Findings are:
A. The reappointment of 2 midlevel practitioners, 2 family practitioners and 1 general surgeon were reviewed. All 5 of the files lacked any written evidence of quality assurance measures or treatment outcomes.
B. The Bylaws state the following, on page 15 section 3. "Reappointment Process, ...the clinical privileges to be granted upon reappointment shall be based upon such member's professional competence and clinical judgment in the treatment of patients as demonstrated by reviews and evaluations conducted by committees and quality assurance activities; peer recommendations, his maintenance of timely, accurate and complete medical records; ...attendance at medical staff meetings...", and on page 33 C: "Reappointment to Medical Staff: #2, QA information will be requested from Quality Assurance Committee..."
C. Interviews with the Director of Nursing and the Administrator on 7/14/10 at 3:30 PM confirmed that quality performance measures were not considered during the reappointment process and also confirmed the Bylaws were not followed regarding quality assurance, maintenance of timely, accurate and complete medical records and attendance at medical staff meetings.
Tag No.: C0341
Based on a review of the most recent annual program evaluation and staff interviews, the Critical Access Hospital failed to include all the required elements in the review. Census was 5, including 1 swing-bed patient. Findings are:
A. The annual program evaluation dated 7/16/09 lacked evidence that the hospital staff considers the findings of the evaluations, including any findings or recommendations and takes corrective action if necessary.
B. Interviews conducted on 7/16/10 at 11:00 AM with the Director of Nursing and the Administrator confirmed the annual program evaluations failed to include any findings or recommendations for change and any corrective action, if necessary.