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Based on record review and interviews with staff, the hospital failed to have an agreement with an outside source for credentialing and quality assurance to assure the quality and medical necessity of medical care at the hospital as required.

Findings:

1. Currently, in addition to emergency services and inpatient internal medicine, the hospital offers surgical services, including cataract, podiatry, endoscopic, pain management and occasional arthroscopic. This was confirmed with surgery staff on the afternoon of 10/22/14.

2. Medical record review, for the purpose of determination of the physician's delivery of quality care and medical necessity (peer review), was not being conducted.

3. Records provided did not contain evidence the hospital had an outside source to perform peer review functions and assist with the credentialing process for medical staff appointment. Staff A, I and C told the surveyors that they had these services at one time, but no longer.

4. The above findings were reviewed and verified with Staff A and I on 10/21/14 and 10/22/14.

Based on surveyors' observations, review of hospital documents and interviews with hospital staff, the hospital failed to ensure the physical plant and environment is constructed, arranged, and maintained to ensure the safety of patients. The hospital failed to:

a. Ensure the hospital was constructed, arranged and maintained in a condition to ensure the adequate care and safety of the patients and staff. See Tag C-0221;

b. Ensure proper storage of trash and biohazard waste was provided. Refer to Tag C-0223;

c. Maintain clean and sanitary facilities for safety of patients and personnel. See Tag C-0225;

d. Ensure temperature, humidity and ventilation was maintained within acceptable standards. See Tag C-0226.

See also LSC Tags

Based on surveyors' observations and interviews with staff, the hospital failed to ensure the hospital was constructed, arranged and maintained in a condition to ensure the adequate care and safety of the patients and staff.

Findings:

A tour of the hospital was conducted on the 10/21 and 10/22/14.

The hospital converted the morgue into Emergency Room (ED) #3. The room did not contain medical gases. This was confirmed by Staff J during the tour.

Surgery Department (OR):
Two leather chairs; a tiled coffee table; a covered glass painting with a wooden frame; two wood chair rails; and a large trash receptacle were observed in the semi-restricted area.

There were no:
1. Handwashing sink in the the clean workroom or the decontamination room.
2. Physical barrier between the anesthesia workroom and the central processing room.
3. Physical barrier between central storage and the central processing room.
4. Janitor's closet or soiled holding room.

Acoustic ceiling tile in the equipment room in the semi-restricted corridor.

The hospital performs various types of surgical procedures to include, but limited to orthopedic, ophthalmology and pain management.

The OR did not have a equipment storage room for the storage of equipment used in the OR. Surgical equipment,such as the C-arm and two Phacoemulsification machines, were stored outside the OR in a patient room on the medical-surgical unit.

The above observations were confirmed by the administrative staff during the tour.

Based on surveyor observations and interviews with staff, the hospital failed to ensure proper storage of trash and biohazard waste was provided.

Findings:

A tour was conducted of the hospital on 10/21 and 10/22/14.

NFPA (National Fire Protection Association) 2000 guidelines 19.7.5.5 requires: "...Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (gallons - 121 Liters) shall be located in a room protected as a hazardous area when not attended."

There were no designated areas/rooms for collection and holding of biohazard waste and trash for pick-up in the surgery (OR) department.

A gray trash (greater than 32 gallons) receptacle was observed in the semi-restricted area of the OR.

A green trash (greater than 32 gallons) receptacle was observed in the ambulance entrance.

The above information was confirmed by Staff J.

Based on surveyors' observations and interviews with hospital staff, the hospital failed to maintain clean and sanitary facilities for safety of patients and personnel.

Findings:

A tour of the hospital was conducted on the 10/21 and 10/22/14.

Patient room #111 is was in the process of being converted into a patient activity room and beauty salon.

Patient rooms #116 and 117( negative airflow rooms), 115, 211 and 215 were being used as sleep rooms for hospital staff.

Patient rooms #212, 214, 216 and 217 were being used to store hospital equipment and equipment currently being used in the surgery department.

The above observations were confirmed by Staff J during the tour.

The ambulance entrance in the ED was used to store patient care equipment. An uncovered baby warmer (Staff B stated it was clean), two wheelchairs and two clean bedside commodes were observed in the ambulance entrance.

Based on observation, hospital document review and staff interview, it was determined the hospital failed to ensure humidity and ventilation was maintained within acceptable standards.

Findings:

A tour was conducted of the hospital on 10/21 and 10/22/14 with the administrative staff.

There was no monitor for the negative air flow rooms (#116 and 117).

Review of hospital documents, documented negative air flow in the sterilizer equipment and sterile storage rooms in the surgery (OR) department.

Temperature and humidity monitoring logs for the (OR) documented humidity in the OR ranged between 20-77%. Normal humidity ranges for the OR is 30-60%.

Based on review of governing body meeting minutes and hospital documents, surveyors' observations, and interviews with hospital staff, the hospital does not ensure the organizational structure of the hospital is effective in providing quality health care in a safe environment. The governing body failed to monitor, evaluate and ensure the services of the hospital. See Tag C- 241 for details and findings.

Based on review of hospital documents, credential files, surveyors' observations, and interviews with hospital staff, the governing body does not:

a. ensure that policies governing the hospital's total operation are implemented:
b. ensure quality health care is provided in a safe environment.
c. ensure that all practitioners providing patient care are qualified and have current privileges granted and health histories.

Findings:

Policies and procedures were not reviewed at least yearly as required. Refer to Tag C-0334.

The physical environment was not constructed and maintained to ensure a safe and sanitary environment. Refer to Tags 0221, 0223, 0225, 0226, and 0278.

There was no evidence of current privileges granted or complete health history for Staff GG the dentist for the Swing Bed program.

Four of six (T, AA, CC and DD) credential files reviewed did not contain evidence of current yearly Tuberculosis (TB) screening/questionnaire.

The above information was confirmed by Staff B on the afternoon of 10/23/14.

Based on record review and interviews with hospital staff the hospital does not ensure patients admitted to the hospital by a nurse practitioner are being monitored by a physician who is responsible for any medical problem outside the scope of practice of the admitting practitioner. One (Patient # 20) of one patient admitted by the nurse practitioner did not have evidence of physician monitoring. This was confirmed by Staff EE during medical record review on the afternoon of 10/23/14.

Based on review of hospital documents, meeting minutes, surveyors' observations, and interviews with hospital staff, the hospital failed to develop and ensure services were provided according to standards and written policies, as evidenced by failure to:

1. Ensure that outdated, mislabeled or otherwise unusable drugs are not available for patient use and ensure drug room staff are adequately trained. Refer to Tag C-0276.

2. Ensure the infection control program developed and monitored hospital-wide practices to ensure a safe and sanitary environment was maintained. Refer to Tag C-0278.

3. Ensure the quality program evaluated all services provided at the hospital. Refer to Tag C-0285.

4. Ensure nursing staff were trained and competent to perform the essential functions of their jobs. Refer to Tag C-0294.

5. Ensure a registered nurse evaluated the care of each patient. Refer to Tag C-0296.

6. Ensure orders and drug administration were provided to patients according to written and signed orders. Refer to Tag C-0297.

Based on surveyor observations and interviews with hospital staff, the hospital does not ensure:
a. the pharmacist follows the flow of medications from entry into the hospital to disposition;
b. outdated and unusable drugs are not available for patient use; and
c. maintains control over the medications in all the hospital locations.

Findings:

A tour of the hospital was conducted on 10/21 and 10/22/14.

Staff K identified by hospital staff as the drug room supervisor, was asked if she compared the Narcotic Administration Record to the patients' medical records to verify the amount of narcotics the patients' received in the surgical department (OR). She stated no.

Two bottles of Normal Saline irrigation solution were observed in the fluid warmer in the OR. Both bottles were swollen, indicating they had been exposed to excessive temperatures or had been in the warmers too long.

Staff K was asked if she performed a narcotic inventory for the medications in the OR. She stated no.

During the tour of the OR, Staff FF was asked how often the OR staff performed a narcotic inventory for the OR department. Staff FF stated the nurses did not count the narcotic in the OR. This was confirmed by Staff D on the afternoon of 10/23/14.

Based on review of hospital documents, policies and procedures and meeting minutes, surveyors' observations and interviews with staff, the hospital failed to ensure the infection control program developed and monitored hospital-wide practices to ensure a safe and sanitary environment was maintained.

Findings:

1. The current risk assessment did not contain a review of the organisms prevalent in the community and hospital to ensure the hospital's disinfectants were effective.

Vesphene II SE, used in the surgical department is not effective against Clostridium difficile (C-diff) or Hepatitis C virus. The hospital offers colonoscopy services. The most prevalent organism is C-diff.

2. Surveillance activity documents provided to the surveyors did not include disinfectant application.

This was confirmed with Staff C on the afternoon of 10/21/14 and again on 10/22/14.

Vesphene II SE, used in surgical services requires a ten (10) minute wet time on surfaces in order to be effective. Staff E told the surveyor that she was not aware of anyone monitoring to ensure surfaces remained wet the required time. Staff D confirmed that she had not timed the application to ensure it was applies according to manufacturer's guidelines.

3. On the afternoon of 10/21/14, Staff C told the surveyor that she did not go back to surgery and did not monitor/conduct surveillance of surgical services practices, including central processing practices. Staff D told the surveyors that she had not documentation of conducting surveillance of surgical services practices/processes.

4. The governing body did not ensure the physical environment was not constructed and maintained to ensure a safe and sanitary environment. Refer to Tags C- 0221, 0223, 0225, and 0226.

Based on review of contract staff personnel files, the quality performance improvement program (QAPI) plan and meeting minutes and interviews with hospital staff, the hospital failed to ensure the quality program evaluated all services provided at the hospital.

Findings:

On 10/21 and 10/22/14 surveyors were provided contract staff personnel files. Five of five (D, E, V, W and FF) contract staff personnel files did not contain orientation, training, or evaluation of services provided. The personnel files did not have evidence of review and evaluation through the QAPI program of the services provided by contract.

Review of QAPI, medical staff and governing body meeting minutes did not contain evidence review of services utilized at the hospital was reviewed and analyzed to determine if services were provided appropriate or any addition or deletion of services was needed.

The above information was presented to the administrative staff during the exit interview on the evening of 10/23/14.

Based on review of medical records, personnel files and staff interview, the hospital failed to ensure nursing staff were trained on competency to perform the essential functions of their jobs. This occurred in five of six (Staff C, D, K, N and O) education/training files reviewed.

Findings:

Staff K identified by hospital staff as the drug room supervisor, stated she and Staff B work in the drug room. Review of the personnel files for Staff K and B did not contain evidence of training and competency verification for their duties in the drug room by the hospital's pharmacist. This was confirmed by Staff K.

Surgical (OR) services are provided at the hospital by contracted staff. Staff B was asked for competency verification for the OR staff. Staff B stated she did not maintain competencies for the OR staff.

Staff B told the surveyors that licensed nursing staff administered respiratory treatments that included nebulizer treatments. The personnel files for Staff C, D, K, N and O did not contain documentation of training by the respiratory therapist.

Staff B was asked for competency verification for the medical-surgical and emergency room staff. None was provided. Staff B stated she had not developed any competencies for the nursing staff. The hospital is a critical access hospital that provides care to all age patients (birth through geriatric).

Based on medical record review and staff interview the hospital failed to ensure a registered nurse evaluated the care of each patient. This occurred in nine of twenty-two (#3, 4, 7, 8, 14, 16, 17, 21 and 22 ) medical records reviewed.

Findings:

Medical records #7, 8, 14, 16 and 17 had documentation of hand held nebulizer respiratory treatment administered by the nursing staff, the records did not contain assessment and evaluations of the patient's conditions before and after the treatments, including vital signs, lung sounds and presence of a cough, with a description of any productive sputum or if the patient felt or had improved breathing after the treatment.

Medical records # 3, 4, 21 and 22 did not contain evidence of a pediatric assessment by the nursing staff. The initial nursing assessment for Medical record #8, a 5 year old, was not orientated to/specific for a pediatric patient.

The above information was confirmed by Staff EE during chart review.

Medical record #22 documented the patient was an inpatient from 08/06-09/14. Three of three nursing shift assessments did not contain evidence the patient was evaluated a registered nurse.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure orders and drug administration were provided to patients according to written and signed orders. This occurred in two (#9 and 10) of three surgery records reviewed.

Findings:

Medical records were reviewed on the afternoon of 10/23/14 with Staff EE.

Medical record # 9 contained a physician orders to administer Valium and Versed orally. The nursing documentation in the medical record did not contain the route of administration for the Valium or Versed.

Medical record # 10 contained a physician order to administer Lactated Ringers (LR) solution. The pre-op nurse documented the patient received one liter of Normal Saline (NS).

Staff T documented on the anesthesia flowsheet that Patient #10 received Fentanyl 2 milliliters (ml) and Versed 3 milligrams (mg). Staff T later documented Fentanyl - 1 ml given with 1 ml wasted and Versed - 2 mg given with 3 mg wasted.

The above information was confirmed by Staff EE and D.

Based on medical record review and interviews with hospital staff, the hospital failed to ensure patients discharged from the emergency room were given written instructions for follow-up care. This occurred in three of four (#1, 3, and 5) emergency records reviewed for discharge instructions and follow-up care. These findings were reviewed and verified with Staff B and MM at the time of review on the afternoon of 10/22/14.

Based on review of medical records and interviews with hospital staff, the hospital failed to ensure all entries in the medical record were signed and contained the date and time of the signatures/authentication. This occurred in three of three surgical records (#9, 10 and 11) and one of one (#22) written record reviewed for completed entries.

Findings:

Medical records were reviewed on the October 23, 2014 with Staff EE.

Records #9 and 10 - the History and Physical (h and p) did not contain the time the physician signed the document, the Operative (OP) Report and Surgical Consent did not contain the date and time the physician signed the documents. The pre-printed Post-Anesthesia Care Unit (PACU) and Pre/Post Operative Surgery orders did not contain the date and time the physician signed the documents.

Record # 10- the pre-printed Post-Operative EGD/Colonoscopy orders did not contain the date and time the physician signed the document. The pre-printed Pre-Op orders did not contain the time the physician signed the document.

Record #11- the consent and OP report did not contain the time the physician signed the documents, the anesthesia pre and post surgical evaluations did not contain the date and time the practitioner signed the document.

Record #22- the Hospital Progress Notes did not contain the time the physician signed the written documents, five of the six written physician orders did not contain the time the physician signed the orders, the electronic h and p and Discharge Summary did not contain the time the physician signed the documents.

The above information was presented to the administrative staff during the exit interview on the evening of October 23, 2014.

Based on record review and interviews with hospital staff, the hospital does not ensure that the critical access hospital (CAH) performs a periodic evaluation and quality assurance review as required. The hospital has not conducted an annual periodic evaluation with all the required elements and does not have an effective and ongoing quality assurance program.

1. The hospital does not ensure a yearly program evaluation reviewing the utilization of CAH services, including the volume of services that are furnished. Refer to Tag C-0331.

2. The hospital does not ensure the complete periodic evaluation of the hospital's total program includes a review of a representative sample of both active and closed medical records. Refer to Tag C-0333.

3. The hospital does not ensure that the periodic evaluation of its total program is conducted at least once a year and includes a review of all (each department/service) of the CAH's health care policies to ensure they reflected current standards of practice. Refer to Tag C-0334.

5. The hospital does not ensure that a periodic evaluation of its total program is conducted at least once a year and includes an evaluation of the utilization of services, if policies were followed and what changes if any were needed. Refer to Tag C-0331.

6. The hospital does not have an effective quality assessment and performance improvement (QAPI) program that is implemented to evaluate the quality and appropriateness of the diagnosis and treatment of patients in the hospital through a functioning effective QAPI program. Refer to Tag C-0336.

7. The hospital does not have an effective QAPI program to ensure an appropriate outside source provided peer review to evaluate the quality and appropriateness of the diagnosis and treatment furnished by the physicians. Refer to Tag C-0340.

8. The hospital does not have a functioning effective QAPI system implemented so that remedial/corrective action can address deficiencies found through the QAPI program. Refer to Tag C-0342.

Based on review of quality assessment/performance improvement (QAPI - the hospital's Quality Meeting) and governing body meeting minutes and interviews with hospital staff, the hospital failed to perform at least an annual evaluation of its total program that included:
a. The number/volume and type of services provided and the utilization of the services offered at the hospital;
b. Review of services, including contracted services, to determination if the services were appropriate and followed standards of care and hospital policies;
c. Medical record review of both active and closed records;
d. Review of the utilization of services to determine if any changes in services were needed; and
e. Annual review of all hospital policies and procedures.

Findings:

1. Upon arrival on 10/21/14, the surveyors requested the hospital's evaluation of its total program, with all the required elements. None was provided.

2. Review of QAPI and governing body meeting minutes did not contain evidence the hospital had conducted a review of its total program.

3. Review of quality assessment and performance improvement, medical staff and governing body meeting minutes did not contain evidence medical record review was conducted.

4. Review of quality assessment and performance improvement, medical staff and governing body meeting minutes did not contain evidence review of services utilized at the hospital was was reviewed and analyzed to determine if services were provided appropriate or any addition or deletion of services was needed.

5. Staff told the surveyors on 10/22/14 and again on 10/23/14 that one could not be located.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to ensure a complete periodic evaluation of the hospital's total program included a review of a representative sample of both active and closed medical records. Review of quality assessment and performance improvement, medical staff and governing body meeting minutes did not contain evidence medical record review was conducted. This findings was reviewed and confirmed with administrative staff on 10/23/14.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital had an annual program evaluation which included a review of the hospital's health care policies. The hospital did not have an annual program evaluation that had evidence of review of the hospital's policies for each department/service furnished in the hospital.

Findings:

The policies and procedures for all departments/services of the hospital were not reviewed, including, but not limited to:
Nursing - last review 12/14/12
Emergency Services - last review 12/12
Physical Therapy - last review 12/11/12
Swing Bed - 06/16/11.

The findings were reviewed with Staff B on 12/22/14.

Based on hospital documents and record review and interviews with hospital staff, the hospital failed to ensure the hospital has an effective quality assessment and performance improvement (QAPI) program that collects relevant data, includes all analyzes the data and implements corrective action to ensure the quality and appropriateness of all patient care was furnished.

Findings:

Upon arrival, the surveyors requested the quality assessment and performance improvement (QAPI) plan and meeting minutes for the last year.

1. The only QAPI meeting minutes that were provided for review on site/during the survey (October 21, 22 and 23, 2014) were for May 14, 2014. Additional minutes for August 22, 2014 were emailed to the surveyors on October 27, 2014. The meeting minutes did not have relevant indicators to identify potential problems and opportunities to improve quality of care for all areas of the hospital. There was no analysis of any data that was collected and no evidence of the implementation of any corrective action taken.

2. The QAPI plan did not contain indicators for the surgery anesthesia and central sterile departments. The only thing the meeting minutes contained was the item for surgical site infections.

3. These findings were reviewed with administrative staff on 10/23/14.

Based on record review and interviews with staff, the hospital failed to have an agreement with an outside source for credentialing and quality assurance to assure the quality and medical necessity of medical care at the hospital as required.

Findings:

1. Currently, in addition to emergency services and inpatient internal medicine, the hospital offers surgical services, including cataract, podiatry, endoscopic, pain management and occasional arthroscopic. This was confirmed with surgery staff on the afternoon of 10/22/14.

2. Medical record review, for the purpose of determination of the physician's delivery of quality care and medical necessity (peer review), was not being conducted.

3. Records provided did not contain evidence the hospital had an outside source to perform peer review functions and assist with the credentialing process for medical staff appointment. Staff A, I and C told the surveyors that they had these services at one time, but no longer.

4. The above findings were reviewed and verified with Staff A and I on 10/21/14 and 10/22/14.

Based on hospital documents and record review and interviews with hospital staff, the hospital does not ensure that appropriate remedial action is taken to address deficiencies identified through the quality assessment and performance improvement (QAPI) program. The only QAPI meeting minutes that were provided for review on site/during the survey (October 21, 22 and 23, 2014) were for May 14, 2014. Additional minutes for August 22, 2014 were emailed to the surveyors on October 27, 2014. The meeting minutes did not have relevant indicators to identify potential problems and opportunities to improve quality of care for all areas of the hospital. There was no analysis of any data that was collected and no evidence of the implementation of any corrective action taken. Findings were reviewed with administrative staff on the afternoon of 10/23/14.

Based on review of contracts and interviews with hospital staff, the hospital failed to have a current written agreement with an Organ Procurement Organization (OPO). The hospital's written agreement with LifeShare (the hospital's OPO) provided to the surveyors on 10/23/14 was expired. This was confirmed with administrative staff on the afternoon of 10/23/14.