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Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the physician periodically reviewed 3 of 3 applicable mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner. (Staff D, E and F)

The CAH administrative staff reported the volume of services provided by the selected mid-level providers for the fiscal year 7/1/2015 to 6/30/2016 included 233 patients for Staff D, 15 patients for Staff E and 18 patients for Staff F.

Failure to ensure a physician periodically reviewed mid-level practitioners' patient medical records in conjunction with the mid-level practitioner could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of a CAH policy titled "Physician Oversight of Mid-Level Practitioners", updated 4/2016, revealed the policy required the physician to document periodic review of patient medical records in conjunction with the mid-level practitioner but lacked a procedure to ensure documented periodic review occurred.

2. Review of documentation revealed the lack of documented physician review of Staff D, Physician Assistant, Staff E, Nurse Practitioner and Staff F, Physician Assistant patient medical records, in conjunction with the mid-level practitioner.

3. During an interview on 9/20/16 at 12:45 p.m.., Staff G, Medical Records Manager reported periodic mid-level/physician medical record review occurred but the CAH failed to use a form to document the discussion. During a follow-up interview on 9/21/16, at 8:45 a.m., Staff G, reported mid-level practitioner's are included in the facility external peer review process and the peer review results are discussed at the medical staff meetings. She acknowledged the medical staff minutes documented the case discussions but failed to ensure the mid-level and physician involved in each medical record discussion were present at the meeting and part of the discussion. Staff G confirmed the CAH lacked documentation of physician chart review of patient medical records in conjunction with Staff D, Staff E and Staff F.

Based on review of policies/procedures, documentation, and staff interviews, the CAH failed to ensure the mid-level practitioner participated with a physician in the periodic review for 3 of 3 applicable mid-level practitioner's patient medical records. (Staff D, E and F)

The CAH administrative staff reported the volume of services provided by the selected mid-level providers for the fiscal year 7/1/2015 to 6/30/2016 included 233 patients for Staff D, 15 patients for Staff E and 18 patients for Staff F.

Failure to ensure the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records could potentially result in the mid-level practitioner misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of a CAH policy titled "Physician Oversight of Mid-Level Practitioners", updated 4/2016, revealed the policy required the physician to document periodic review of patient medical records in conjunction with the mid-level practitioner but lacked a procedure to ensure documented periodic review occurred.

2. Review of documentation revealed the lack of documented physician review of Staff D, Physician Assistant, Staff E, Nurse Practitioner and Staff F, Physician Assistant patient medical records, in conjunction with the mid-level practitioner.

3. During an interview on 9/20/16 at 12:45 p.m., Staff G, Medical Records Manager reported the mid-level/physician medical record review occurred but the CAH failed to use a form to document the discussion. During a follow-up interview on 9/21/16, at 8:45 a.m., Staff G, reported mid-level practitioner's are included in the facility external peer review process and the peer review results are discussed at the medical staff meetings. She acknowledged the medical staff minutes documented the case discussions but failed to ensure the mid-level and physician involved in each medical record discussion were present at the meeting and part of the discussion. Staff G confirmed the CAH lacked documentation of physician chart review of patient medical records in conjunction with Staff D, Staff E and Staff F.

Based on record review and staff interview the CAH administrative staff failed to ensure nursing staff notified the medical provider when a medication error occurred. Involved 3 of 9 medication errors reviewed and failed to include appropriate provider notification. The CAH census was 0 at entrance.

Failure to ensure nursing staff notified the provider of medication errors could potentially result in medications being given/or not given to the patient.

Findings include:

1. Review of medication errors on 9/21/16 revealed 3 of 9 (Patient #1, Patient #2, & Patient #3) errors selected for review lacked provider notification of the medication error.

Review of policy titled Medication Errors, revised on 5/15, reads in part ...1. The primary care provider or provider on call will be notified of an error in a timely manner. The nurse will use discretion depending on the hour and severity of the error, but the provider must be notified on his/her next visit to the patient if not previously called.

2. An interview on 9/21/16 at 11:15 a.m., with Staff H, Registered Nurse (RN) and Staff I, RN, revealed medication errors are to be reported to the provider in a timely manner and charted in the patient's medical record and on the medication error report.

An interview on 9/21/16 at 11:20 a.m., with Staff A, RN DON (Director of Nursing), revealed nursing staff are to notify the medical provider of a medication error. Review of Patient #1, Patient #2, & Patient #3's medical records lacked provider notification along with the medication errors reports failed to include provider notification.

Based on review of CAH periodic evaluation of the total program the CAH administrative staff failed to provide information regarding policy/procedure review in the total program report. The CAH identified 0 patients at the time of entrance.

Failure to provide information regarding policy/procedure review in the total program report could potentially result in policy and procedure information lack of communication to the board and other interested parties that read the total program evaluation.

Findings include:

1. Review of the Critical Access Hospital Program Evaluation, dated 2014-2015, lacked specific information related to the policy/procedure review, including policy changes, updates, and deleted items.

Review of the policy titled Administrative Policy and Procedure Description of Services, revised on 5/14, reads in part ... Annual Review: An annual program review will be conducted by CAH Committee as outlined in the policy governing the Program evaluation. The results of the Annual Program Evaluation will be used to add, delete or revise facility policies, procedures, and practices if necessary. The report of the CAH Committee will be submitted to the Baum-Harmon Mercy Board of Directors and the Mercy Medical Center, Sioux City, Director of Quality to be presented to the Quality Committee of Mercy Medical Center, Sioux City.

2. An interview on 9/21/16 at 2:20 p.m., with Staff B, RN Quality Manager and Staff C, RN Project Manager acknowledged the 2014-2015 CAH Program Evaluation lacked information regarding the annual policy/procedure review.

Based on review of the CAH periodic evaluation of the total program the CAH administrative staff failed to utilize the information, provided in the report, to make changes in services provided to the patients. The CAH identified a census of 0 at the time of entrance.

Failure to utilize the information provided in the total program review, including additions/deletions of services, and policy/procedure changes could potentially result in the CAH missing opportunities for changes.

Findings include:

1. Review of the CAH Program Evaluation, dated 2014-2015, lacked specific information related to the outcome of the review, and how the CAH utilized the information provided in the review.

Review of the policy titled Administrative Policy and Procedure Description of Services, revised on 5/14, reads in part ... Annual Review: An annual program review will be conducted by CAH Committee as outlined in the policy governing the Program evaluation. The results of the Annual Program Evaluation will be used to add, delete or revise facility policies, procedures, and practices if necessary. The report of the CAH Committee will be submitted to the Baum-Harmon Mercy Board of Directors and the Mercy Medical Center, Sioux City, Director of Quality to be presented to the Quality Committee of Mercy Medical Center, Sioux City.

2. An interview on 9/21/16 at 2:20 p.m., with Staff B, RN Quality Manager and Staff C, RN Project Manager acknowledged the 2014-2015 CAH Program Evaluation lacked information related to the outcome of the review, and how the CAH utilized the information provided in the review.