HospitalInspections.org

Based on document review and staff interview it was determined in 9 of 9 (MD#2, #3, #4, #5, #6, #7, #8, #9, #10) medical staff files reviewed, the Critical Access Hospital (CAH) failed to ensure practitioner's were licensed, registered and had insurance per policy.

Findings include:

1. The Medical Staff By-laws (revised 3/28/05) were reviewed on 12/4/14 at approximately 1:30 PM. The By-laws stated, on page 7 "The practitioner shall be a physician...and...other health care practitioners...currently licensed in the State of Illinois, who:... (c) Maintain continuous professional liability insurance...(d) Maintain current medical license...(e) Maintain current DEA (Drug Enforcement Agency) certificate..."

2. A medical staff file review was conducted on 12/2/14 at approximately 11:30 AM. Nine (9) of the practitioner files reviewed lacked documentation/proof of the following:
MD#2- insurance
MD#3- license, controlled substance, DEA, insurance
MD#4- license, controlled substance, DEA, insurance
MD#5- license, controlled substance, DEA, insurance
MD#6- insurance
MD#7- license, controlled substance, DEA, insurance
MD#8- license, insurance
MD#9- license, controlled substance, DEA, insurance
MD#10- license, insurance

3. During an interview on 12/3/14 at approximately 2:35 PM, E#2 (Interim Chief Nursing Officer) stated "We don't update the practitioners files until next reappointment time. We use a database for tracking but it's updated at reappointment time too. We know we need a better process and have been trying to educate ourselves on the requirements more." On 12/3/14 throughout the day, multiple licenses, controlled substances, DEA's and proof of insurances were provided by E#2 upon receipt from the physician's or regulatory agencies.

Based on observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure the cardiac rehabilitation room had adequate space to provide services or access patients safely.

Findings include:

1. An observational tour of the cardiac rehabilitation room was conducted on 12/2/14 at approximately 12:10 PM. The cardiac rehabilitation room was approximately 10.5 foot by 12.5 foot square. The room contained a full size electric treadmill, a recumbant excercise bike, an arm ergonometer and was utilized as office space therefore had a desk, computer, printer, patient charts and miscellaneous supplies. The treadmill was backed into a corner which restricted dismount from the left and back of the treadmill and the right side was against a desk and had a handle which allowed an approximately 2 1/2 foot area to dismount the treadmill. The recumbent bike was positioned between the desk and the wall, therefore the desk or the bike would have to be moved to access or dismount the piece of equipment. An ante room was observed outside the cardiac rehabilitation room where the telemetry monitors could be visualized through a window from inside the cardiac rehabilitation room. The cardiac rehabilitation room was not large enough to provide emergency services to a patient if necessitated.

2. During an interview on 12/2/14 at approximately 12:10 PM, the Manager of Cardiac Rehabilitation (E#9) stated "there can be up the three patients and me in here at a time. We have to move the bike over by the door if we use it...It gets tight in here."

3. During an interview on 12/2/14 at approximately 4:00 PM, the Interim Chief Nursing Officer/Risk Manager (E#2) stated "I've seen the bike in the ante room before and that does not block the doorway but it does block access to the ante room which is where emergency responders would access the cardiac rehab. room."

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

Findings include:

1. An observational tour of the Emergency Department was conducted on 12/2/14 at approximately 12:10 PM with the Director of Support Services (E#7). The following outdated biologicals were observed available for use in patient care:
a. In outpatient room #1: three tiger top laboratory tubes (two expired 6/14, one expired 5/14); Hemoccult slides (four expired 11/12, five expired 8/12); two Transystem Swabs (one expired 3/14, one expired 10/14)
b. In outpatient room #2: one tiger top laboratory tube expired 1/14 and two blue top laboratory tubes (one expired 5/14, one expired 7/14)
c. In the trauma room: one open Gastrocult developer with date of opening as 12/27/10 and expiration date of 4/13; three unopened vials of Gastrocult developer expired 4/13; eleven Gastrocult slides expired 4/12.
d. In the Omnicel room: one open liter bottle of sterile water with no date as to when opened.

2. An interview was conducted with E#7 on 12/2/14 at approximately 12:30 PM. E#7 was present throughout the tour of the Emergency Department and verbally agreed the supplies were available for use in patient care and were outdated and the open sterile water should have been dated with the date it was opened.

3. An observational tour of the Intensive Care Unit was conducted on 12/2/14 at approximately 12:40 PM with the Interim Chief Nursing Officer (E#2). The following expired biologicals were observed available for use in patient care:
a. In the medication room: two latex free IV (intravenous) start sets (one expired 7/11, one expired 12/11); ten 20 gauge Safety IV catheters (three expired 8/12, five expired 7/13, two expired 1/14); nine 22 gauge Safety IV catheters (one expired 8/08, four expired 4/10, one expired 7/10, one expired 4/11, two expired 8/12); five 18 gauge IV Plus (three expired 12/09, two expired 6/10); four Endcap ClearLink expired 11/13/09; and three Winged Infusion Sets expired 8/19/11.

4. An observational tour of the Medical Surgical unit was conducted on 12/2/14 at approximately 1:15 PM with the Interim Chief Nursing Officer (E#2). The following expired biologicals were observed available for patient care: one 22 gauge Protect IV (intravenous) Safety IV catheter expired 3/14 and one purple top laboratory tube expired 2/14.

5. An interview was conducted with E#2 on 12/2/14 at approximately 1:30 PM. E#2 was present throughout the tours of the Intensive Care Unit and the Medical Surgical unit and verbally agreed the patient care items were available for use and were expired.

A. Based on document review and interview, it was determined the Critical Access Hospital (CAH) failed to ensure contracted laundry services were evaluated for compliance with infection control measures, such as time, temperature, and disinfection. This has the potential to affect all patients serviced by the CAH.

Findings include:

1. The contract for the laundry services was reviewed on 12/2/14 at approximately 3:00 PM. There was no provision as to the process for ensuring compliance with infection control measures.

2. An interview was conducted with the Director of Support Services (E#7) on 9/3/14 at approximately 9:30 AM. When asked what the process was to ensure the contracted laundry services were compliant with infection control measures, E#7 stated the contracted services representative meets quarterly and annually to determine customer satisfaction related to the laundry process and services, such as if the CAH receives stained or damaged articles back. When asked if the CAH reviews the logs for compliance with time, temperature, and disinfection, E#7 stated "No, but I can."

B. Based on document review and interview, it was determined for 1 of 5 (Pt #8) records reviewed, in which the patient was admitted from a nursing home and/or into Intensive Care, the CAH failed to ensure infection control surveillance was performed in accordance with its' policy and procedure.

Findings include:

1. The policy titled "Multidrug-Resistant Organisms (MDRO) (effective 1/10/14) was reviewed on 12/3/14 at approximate 3:00 PM. The policy stated on page 2 "Procedure: 4. Active surveillance testing (nasal swab) for MRSA will be conducted on all ICU patient admissions, nursing home or jail and those who were discharged from the hospital within the past thirty (30) days." The "MRSA Screening Protocol" (revised 2/17/14) was reviewed on 12/3/14 at approximately 3:00 PM and stated "Nasal swab upon admission for: ... ICU patents; Nursing Home Residents..."

2. Pt #8's record was reviewed on 12/3/14 at approximately 1:30 PM. Pt #8 was admitted from the nursing home to the CAH on 11/24/14 with the diagnoses Pneumonia and Congestive Heart Failure. There was no MRSA screen conducted until 11/27/14 after the physician ordered one.

3. An interview was conducted with the Interim Chief Nursing Officer (E#2) on 12/3/14 at approximately 3:00 PM. E#2 stated the CAH policy/procedure is to do a MRSA nasal swab screening on all patients who are admitted from the nursing home, the jail, readmitted within 30 days, and/or into the Intensive Care Unit. E#2 verbally agreed the MRSA screen was not done upon admission for Pt #8.

C. Based on observational tour and interview, it was determined the CAH failed to ensure a sanitary environment. This has the potential to affect all patient's receiving services at the CAH.

Findings include:

1. During an observational tour of the surgical suites conducted on 12/2/2014, three (3) Yellow Fins Stirrup boots were observed in surgical suite #1 to be torn with the inner foam being exposed.

2. During an interview on 12/2/2014 at approximately 2:15 PM, the Manager of Surgical Services (E#12) stated the stirrup boot could not be disinfected and needed to be replaced.

3. During an observational tour of the outpatient physical therapy department on 12/2/14 at approximately 2:00 PM, six (6) plastic containers with therapy puddy were observed. The containers were not labeled with patient names, were opened and the puddy looked used. Twelve (12) used therabands were observed to be available for multiple patient use and two patients were receiving therapy. A spray bottle of disinfectant was observed to be hanging on a linen cart of wash rags.

4. During a phone interview on 12/2/14 at 3:15 PM, E#14 (Manager Physical Therapy) stated the therapy puddy was used for multiple patients and could not be disinfected . E#14 stated the therabands are used for multiple patients and can be sprayed with the disinfectant although "not always between each patient." E#14 stated housekeeping cleaned the department three (3) times a week and staff cleaned daily but "not always between each patient." E#14 stated the only means of determining if a patient had a communicable disease would be if the patient revealed it during the initial evaluation.

5. During an observational tour of the cardiac rehabilitation room and interview on 12/2/14 at approximately 12:20 PM, the Manager of Cardiac Rehabilitation (E#9) stated "I usually clean the equipment each morning or at least one (1) to two (2) times per week but not between each patient." E#9 stated five (5) patients were currently receiving cardiac rehabilitation three (3) times per week.

6. During an observational tour of the radiology department on 12/2/14 at approximately 12:50 PM with the Manager of Radiology (E#4), the following was observed: two radiology technicians (E#10, E#11) provided patient care in the x-ray room with gloved hands. E#10 and E#11 exited the room without removing the gloves. E#10 went to the desk area and accessed a file with the same gloves on. E#10 and E#11 returned to the X-ray room and transported the patient to the CT (computerized tomography) room. E#10 and E#11 were observed throughout the CT to have the same gloves on.

7. During an interview on 12/2/14 at approximately 1:15 PM, E#4 stated compliance audits were done the previous infection control officer. E#4 said "I don't think its being done at all now. I know I don't do it."

8. The policy titled "Hand Hygiene" (revised 12/18/13 was reviewed on 12/3/14 at 12:00 PM. The policy stated "Patient care personnel should...d. Remove gloves after caring for a patient.

9. During an observational tour of the high level disinfection area on 12/2/14 at approximately 2:30 PM with the Manager of Surgical Services (E#12), the steris processing log was observed to document date and type of scope processed. The log lacked documentation of which scope was processed and what patient the scope was use for.

10. During an interview on 12/2/2014 at approximately 2:30 PM, E#12 stated there are three (3) colonoscopy scopes and four (4) endoscopy scopes currently used. E#12 stated the scopes do not have individual identifiers and there was no way to track which scope was used on a patient.

11. During an interview on 12/4/14 at approximately 9:00 AM, E#2 stated the scope should be labeled and logged with patient name and scope identifier to assist with infection surveillance.

Based on document review, observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure adequate radiation shielding of personnel. This has the potential to affect 6 of 6 radiology technician's employed at the CAH.

Findings include:

1. The policy titled "Radiation Safety" (revised 3/6/2000) was reviewed 12/3/14 at 9:00 AM. The policy stated badges (radiation monitoring devices) will be worn at waist or chest level unless a protective garment (lead shield) is worn, then the badge will be positioned outside of the garment at the collar level. The policy stated the badges are stored in a non-radiation area when not in use.

2. An observational tour of the radiology department was conducted 12/2/14 at approximately 12:50 PM with the Radiology Manager (E#4). Two radiology technicians (E#10, E#11) were observed during an x-ray procedure and a CT (computerized tomography) scan to not be wearing a badge. When asked where the badges are kept when an employee is not on duty, E#4 showed a basket on a desk in the back office. There was one badge in the basket.

3. During an interview on 12/2/14 at approximately 1:05 PM, E#10 produced a badge from the front pocket of a scrub shirt. E#10 verbally agreed the badge was not worn at the collar level during the x-ray or CT scan.

4. During an interview on 12/2/14 at approximately 1:05 PM, E#11 stated "I don't know where my badge is but it's probably in the back on the desk." E#11 then retrieved a badge which was identified as E#11's.

5. During an interview on 12/2/14 at approximately 1:10 PM, E#4 stated "I don't know where they they keep their badges but they are suppose to be kept in that basket. That's not something I monitor." E#4 verbally agreed E#10 badge was not properly worn and E#11 did not wear a badge and should have been.

A. Based on document/record review and staff interview, it was determined in 1 of 5 (Pt #17) patients discharged greater than 30 days, the Critical Access Hospital (CAH) failed to ensure a discharge summary was completed per policy.

Findings include:

1. The Medical Staff Bylaws (revised 3/28/2005) was reviewed on 12/4/14 at approximately 1:45 PM. The Bylaws stated on page 12 "20. The attending practitioner shall complete the medical record at the time of patient's discharge, to include...discharge summary...21. If the medical record is incomplete fourteen days after discharge, a written note shall be sent to the physician..."

2. The clinical record of Pt #17 was reviewed 12/4/14 at approximately 4:00 PM. Pt #17 was discharged on 8/21/14 post mastectomy (surgical removal of breast). The discharge summary was dictated on 9/29/14 (39 days after discharge) and signed 10/6/14 (46 days after discharge).

3. During an interview on 12/4/14 at approximately 1:45 PM, the Medical Records Manager (E#3) stated that a medical record delinquency report is run on the first of each month and a chart may not be delinquent at that time but become delinquent before the next report is generated. E#3 verbally agreed Pt #17's discharge summary was not completed with in the fourteen day requirement and not identified on the delinquency report.

B. Based on document/record review and staff interview, it was determined in 1 of 1 (Pt #3) pulmonary rehabilitation records reviewed, the CAH failed to ensure the record contained documentation of an ongoing assessment, a summary of treatment, disposition or instructions provided to the patient.

Findings include:

1. The policy titled "Discharge Assessment and Follow-up" (effective 8/1/11) was reviewed 12/3/14 at 3:00 PM. The policy stated "It is the policy...to re-assess the patient at the end of pulmonary rehabilitation in order to see if the patient has met their personal and program goals... On the last day of pulmonary rehabilitation... A 6 minute walk test re-evaluation should be completed and charted...A final individualized treatment plan will be filled out and sent to the Pulmonary Rehabilitation Medical Director to review and sign...The primary/pulmonary physician will also receive a copy of all paperwork and a final patient assessment letter." The policy noted the required documentation forms as the following: The 6 minute walk re-evaluation will be documented on the 6 Minute Walk Test Re-evaluation Form #304; The discharge/follow up will be documented on the final Individualized Treatment Plan Form #466 with a new Hospital Anxiety and Depression Scale Questionnaire and St. Gorge's Respiratory Questionnaire result; The final assessment will be documented in the Final Assessment Physician Letter.

2. During an observational tour Pt #3 was observed in the pulmonary rehabilitation room on 12/2/14 at approximately 1:20 PM doing the arm ergometer and was being monitored by a Respiratory Therapist (E#13).

3. The clinical record for Pt #3 was reviewed on 12/3/14 at approximately 2:05 PM with a Respiratory Therapist (E#13). Pt #3 was admitted on 7/26/13 with a diagnosis of Interstitial Pneumonitis. E#13 stated Pt #3 was discharged in January 2014 although continued to do pulmonary rehabilitation through the wellness program. The clinical record lacked documentation of Pt #3's discharge, a 6 minute walk test re-evaluation, an individualized treatment plan, a new Hospital Anxiety and Depression Scale Questionnaire, a new St. Gorge's Respiratory Questionnaire and a final assessment physician letter. The clinical record lacked documentation the pulmonary rehabilitation medical director or primary physician was notified of Pt #3's progress toward program goals, follow up instructions or discharge from program. A consent for treatment was dated 3/4/14, 8 months after treatment was initiated and 2 months after discharge. Pt #3's clinical record had documentation of daily exercise records from the wellness sessions dated January 2014 through 12/2/14.

4. During an interview on 12/3/14 at approximately 2:05 PM, E#13 stated "I've looked every where. I cannot find the documentation. I have no idea why a consent would have been signed in March but I can't find one earlier than that. Maybe it's in the old system." E#13 stated Pt #3 completed phase 2 of the program in January of 2014. Pt #3 continued to do phase 3 which does not require an order because it is elective and provided as a wellness program in which the patient pays for. E#13 stated Pt #3's clinical record was also used as the wellness record (daily exercise records) although Pt #3 was not an actual admitted patient at this time.

5. During an interview on 12/4/14 at approximately 1:00 PM, E#2 (Interim Chief Nursing Officer) stated "I checked into Pt #3's record and the documentation could not be found. I'm starting to see we aren't able to retrieve records very well." E#2 verbally agreed Pt#3's clinical record should be segregated from the wellness record.

Based on document/record review and interview, it was determined for 2 of 5 (Pt #8, #15) records, in which telephone/verbal/standing orders were written, the Critical Access Hospital (CAH) failed to ensure telephone/verbal/standing orders were signed by the physician within the allotted time frame.

Findings include:

1. The Medical Staff Rules and Regulations (revised 3/28/05) were reviewed on 12/2/14 at approximately 3:30 PM. The Rules and Regulations stated, on page 4, "General Conduct of Care: 4. ... Telephone orders must be signed by the authorized person to whom dictated and countersigned by the dictating physician as soon as practicable. 6.... Verbal orders... must be signed by physician before leaving the area. 10... All standing orders and/or instruction sheets must be signed and dated by the responsible practitioner when utilized..."

2. The policy titled "Orders, Inpatient Telephone" (reviewed 9/6/14) was reviewed on 9/4/14 at approximately 1:00 PM. The policy stated "Procedure: 5. Telephone orders will be countersigned by the ordering physician within 48 hours."

3. Pt #8's record was reviewed on 12/3/14 at approximately 1:30 PM. Pt #8 was admitted to the CAH on 11/24/14 with the diagnoses Pneumonia and Congestive Heart Failure. Pt #8's record contained two telephone orders, one written 11/24/14 and one written on 11/25/14. The telephone orders were not signed by the physician until 12/3/14 at 7:45 AM.

4. The clinical record of Pt #15 was reviewed on 12/3/14 at 3:30 PM. Pt #15 was admitted for an esophaogastroduodenoscopy and colonoscopy on 8/11/14. The standing orders titled EGD-esophaogastroduodenoscopy, colonoscopy, adult anesthesia pre-op orders and monitored anesthesia care stated "To be signed by ordering physician within 24 hours after the orders have been initiated." The standing orders were initiated by the Registered Nurse on 8/11/4. The standing orders were electronically signed by the physician on 8/18/14, 7 days after the procedure.

5. During an interview on 12/4/14 at approximately 1:45 PM, the Medical Records Manager (E#3) verbally agreed Pt #8's and Pt #15's orders were not signed by the physician within the appropriate time frame and should have been.


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Based on document review and interview, it was determined for 2 of 3 (fiscal years 2012 and 2013) Annual Evaluations, the Critical Access Hospital (CAH) failed to ensure the evaluation included a review of both active and closed clinical records.

Findings include:

1. The Annual Evaluation evaluations for fiscal years 2011 thru 2013 (2014 will be completed in January 2015) were reviewed on 12/3/14 and 12/4/14. The Annual Evaluations for fiscal year 2012 and 2013 lacked a review of both active and closed clinical records.

2. An interview was conducted with the Interim Chief Nursing Officer (E#2) on 12/3/14 at approximately 12:30 PM. When asked about the review of both active and closed clinical records, E#2 stated "The previous Administrator instructed me to remove it from the review" and verbally agreed the 2012 and 2013 Annual Evaluations lacked a review of both active and closed clinical records. E#2 further stated the 2012 and 2013 Annual Evaluations included items such as Core Measures, Prohibited Abbreviations Monitoring, and Operative Reports are done as closed. Items such as History and Physical are done as active and Medication Therapy Monitoring is done as both active and closed. E#2 verbally agreed there was no clear delineation of what areas were reviewed as active and/or closed.