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I. Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the CAH staff maintained patient medical information secure from unauthorized access in CAH Specialty Clinic in 1 of 4 nursing pods, wound care nursing pod contained patient information related to post-surgical logs, wound care, general surgery, and gastral intestinal (GI) clinic documents. An unlocked cabinet in 1 of 1 Audiology room #102 contained files of patient information for occupation health, Cardiopulmonary, sleep lab and influenza clinic patients. Failure to keep patient medical information confidential could potentially result in theft of a patient's personal information and potentially result in identity theft or unauthorized release of a patient's private medical information. The CAH's administrative staff identified an average monthly census of 39 surgical patients, 52 wound care patients, 17 GI patients, 46 occupational health patients, 452 cardiopulmonary patients, 6 sleep lab patients, and 126 influenza clinic patients, from August 2021 to August 2022.

Findings include:

1. Review of the CAH policy "Securing Protected Health Information," last approved 6/2021, revealed in part, "... Community Memorial Hospital departments that contain protected health information will be locked after hours and when departments are unattended...." "Departments that have minimal protected health information will utilize locked filing cabinets with access only available to department personnel. Cabinets will be locked whenever department is unattended."

2. Review of the CAH policy "Secure Filing of Medical Records," last approved 6/9/2021, revealed in part, "... Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals."

3. Observation on 9/26/22 at approximately 2:30 PM, during a tour of the Specialty Clinic with Team Leader C, revealed 1 of 4 nursing pods, within two cadenza drawers and a cabinet by the wound care nurses pod contained several of the following documents:

Documents in an 8" file with a date range of 1/2021 to 5/2022 that held patient information pertaining to post surgery patients that were being tracked for infection found in the wound care nursing cadenza drawers.

A 4" binder in the wound care nursing cabinet that contained patient names, dates and diagnoses with a date range of 2018 to 2022 from the wound care clinic.

A 4" binder with a list of patients that had a variety of general surgeries that were performed throughout 2022. Binder contained patient names, dates and surgeries.

A 3" binder with a list of patients that had been seen in the GI Clinic. This binder contained patient names, diagnoses and dates of appointments ranging from 2021-2022.

4.Observation on 9/26/22 at approximately 2:45 PM, during a tour of 1 of 1 Audiology room #102 within the Specialty Clinic with Team Leader C, revealed an unlocked cabinet with two drawers containing the following documents:

Pre-employment screenings by Occupational Health which included hearing testing and results, physical therapy, lab results and billing information for patients in 2019.

Cardiopulmonary patient information including name, date and diagnosis from 5/2019 to 12/2019.

Documents from Sleep lab including patient name, date of appointment and underlying diagnosis. Documents dates for the year of 2019.

Documents from the Influenza Clinic in 2020 from Occupational Health including patient name, date of vaccine

5. During an interview on 9/26/22 at approximately 2:00 PM, with the Team Leader C acknowledged RN D and the Audiology Room #102 should not have unsecured patient information. Team Leader C also acknowledged housekeeping does have access to these areas after the Specialty Clinic is closed.

II. Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the CAH staff kept patient medical information secure from unauthorized access in the Surgery Suite. Patient information was found in the surgical suite in 1 of 1 unsecured fax machine at the surgical nurse's station. Failure to keep patient medical information confidential could potentially result in theft of a patient's information and potentially result in identity theft or unauthorized release of a patient's private medical information. The CAH's administrative staff identified an average monthly census of 39 surgical patients, from August 2021 to August 2022.

Findings include:

1. Review of the CAH policy "Securing Protected Health Information," last approved 6/2021, revealed in part, "... Community Memorial Hospital departments that contain protected health information will be locked after hours and when departments are unattended...." "Departments that have minimal protected health information will utilize locked filing cabinets with access only available to department personnel. Cabinets will be locked whenever department is unattended."

2. Review of the CAH policy "Secure Filing of Medical Records," last approved 6/9/2021, revealed in part, "... Medical records housed within the hospital shall be kept in secure areas at all times. Medical records shall not be left unattended in areas accessible to unauthorized individuals."

3. Observation on 9/26/22 at approximately 8:30 AM, during a tour of the Surgery Suite with Team Leader F, revealed 1 of 1 fax machines at the surgical nursing station was not secured. Orders that were faxed would print after hours and sit in fax machine tray until staff arrived the next morning. Housekeeping would clean after hours and have access to the patient information in the fax machine tray. Team Leader F further acknowledged this was against the CAH's policies.

I. Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 Certified Registered Nurse Anesthetist (CRNA A), selected for review, held approved privileges for the CAH's pain clinic. Failure to ensure CRNA A had privileges to perform the services and procedures for the CAH's pain clinic could potentially result in the CAH staff allowing CRNA A to perform a procedure the practitioner lacked competence and skill to safely perform and result in a practitioner providing care beyond their capabilities and compromise safety of CAH patients. The CAH administrative staff identified CRNA A, appointed to the CAH Medical Staff on 8/26/21, provided pain management care for 79 patients in 197 visits from 1/1/22 to 9/27/22.

Findings include:

1. Review of the CAH Medical Staff by-laws, approved 9/27/2016, revealed in part "... Privileges to practice at the Hospital are granted by the Board of Directors following recommendation of the Medical Staff ... A practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws ...".

2. Review of CRNA A's credential file revealed Anesthesiology delineation of privileges, approved by the Medical Staff on 8/5/21 and the Board of Directors on 8/26/21. CRNA A's credential file lacked delineation of privileges to perform services provided as part of the CAH's pain clinic.

3. During an interview on 9/27/22, at 2:00 PM, Credentialing/Coder B acknowledged CRNA A's credential file did not include delineation of privileges for the pain clinic. She reported she would look further and see if she could find some, but didn't think there were any.

3. During an interview on 9/27/22, at 4:20 PM, the Quality/Risk Manager confirmed CRNA A lacked delineation of privileges for the pain clinic and acknowledged the practitioner should have them, as the services and procedures provided would not be covered by the delineation of privileges for anesthesiology. The Quality/Risk Manager reported the pain clinic privilege documents have been sent to CRNA A's office for completion and subsequent approval.





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II. Based on observation, document review, and staff interviews, the Critical Access Hospital's administrative staff failed to ensure that surgical staff were educated on how to access the current roster listing of each practitioner's surgical privileges. Failure to educate surgical staff on how to access the current list of practitioner's surgical privileges to verify a provider's privileges prior to scheduling and performance of a procedure may result in a provider performing a procedure for which they are not privileged to perform due to lack of training, skills, quality, and or sufficient knowledge and may result in a poor patient outcome. The CAH administrative staff identified an average monthly census of 39 surgical procedures performed from August 2021 to August 2022.

Findings include:

1. Review of the CAH policy, "Surgical Roster," approved 3/29/2022 revealed in part, " ...to have available in the Surgery Department and the area where surgical procedures are schedules a roster of providers who have surgical privileges and the specific privileges for the individuals." " ...updated privileges for each provider are located on the N-Drive (Common drive) under Delineation of Privileges."

2. During an interview on 9/28/22 at 11:30 PM, at the time of the tour of the Surgical Department, Team Lead F reported that she was unaware of where a list of current surgical practitioner's privileges is maintained. Team Lead F acknowledged the risk of not knowing where or how to access this information before each surgical or procedural case.

3. During an interview on 9/282022 at 12:30 PM, with the Quality/Risk Manager revealed that each employee has access to the list of provider privileges in the N-Drive on the computer. Quality/Risk Manager later verified Team Lead F was unaware the N-Drive on the computer is where the list of provider privileges was located.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that the Infection Preventionist responsible for the Infection Prevention and control program had been appointed by the Governing Body, and that the appointment was based on the recommendations of medical staff leadership and nursing leadership for 1 of 1 Infection Preventionist. Failure to comply with regulations could potentially hinder the Infection Prevention and control program including surveillance, prevention, and control of hospital-acquired infections (HAI)s, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and address any infection control issues, potentially causing harm or death to patients and their safety. The CAH administrative staff identified an inpatient census of 3 patients upon entrance.

Findings include:

1. Review of the CAH's Policies and Procedures revealed that no policy existed regarding an appointment for the Infection Preventionist by the Governing Board.

2. Review of the Governing Board Meeting Minutes, on 6/23/2022, 7/28/2022, and 8/30/2022, revealed that an appointment had not been made by the Governing Board for the position of Infection Preventionist.

3. During an interview on 9/27/22 at 4:00 PM, with the Infection Preventionist, revealed she had been assigned this position and had been acting as the Infection Preventionist but acknowledged she did not know if she had been appointed as the CAH Infection Preventionist by the Governing Board.

4. During an interview on 9/27/22 at approximately 4:45 PM, with the Quality/Risk Manager confirmed the CAH did not provide recommendations to the P&T Committee (Medical Staff) for approval as needed and was unable to find documentation that the Infection Preventionist was approved by the Governing Board.