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Based on observation, interview, and record review, the Critical Access Hospital failed to maintain a safe physical plant and environment by failing to maintain the building in compliance with the Life Safety Code (Refer C231). Failure to maintain a safe physical plant and environment places all patients at risk.

Based on observation, interview and record review, the Critical Access Hospital failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to CMS-2567 for K tags cited as a result of the on-site survey completed 10/22/2019.

Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing body failed to ensure the appointment/reappointment for 4 of 8 physician (#1, #2, #3, and #4) credentialing files reviewed followed the medical staff bylaws. Failure to reappoint physicians every two years and approve delineated privileges limited the governing body's ability to ensure the CAH's patients received treatment/services from qualified practitioners.

Findings include:

Review of the "West River Regional Medical Center Bylaws of the Medical Staff" occurred on 10/21/19 at 3:20 p.m. These bylaws, approved 01/17/18, stated,
". . . Article III: Medical Staff Membership
3.1 . . . Membership on the medical staff of the hospital is a privilege that shall be extended only to professionally competent physicians . . . who continuously meet the qualifications, standards and requirements set forth in these bylaws. . . .
3.3.2 . . . Reappointments shall be for a period of not more than two medical staff years. . . .
3.3.6 Appointment to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the governing body, in accordance with these bylaws. . . ."

Review of the governing body's bylaws, titled "Bylaws West River Health Services Hettinger, North Dakota," occurred on 10/22/19 at 8:30 a.m. These bylaws, approved 09/28/16, stated,
" . . . Article V - Board of Directors . . .
Section 6 Responsibilities. Responsibilities of the Board include: . . . maintain a qualified medical staff . . .
Article XI - Medical Staff
Section 1 . . .
a. the Board of Directors shall organize the physicians and appropriate other persons granted practice privileges in the hospital into a medical staff under medical staff bylaws approved by the Chairman and the Board of Directors. The Board of Directors shall consider recommendations of the medical staff and appoint to the medical staff . . . physicians and others who meet the qualifications for membership as set forth in the bylaws of the medical staff. . . .
c. . . . Re-appointments shall be for a period of not more than two medical staff years. . . .
Section 2 . . .
c. The medical staff shall make recommendations to the Chairman and the Board of Directors concerning: (1) appointments, re-appointments . . . (2) granting of clinical privileges . . ."

Reviewed on 10/23/19, the CAH's current credentialing records indicated the following:
- Physician #1: the governing body approved the most current reappointment on 05/22/19, two years and two months after the previous appointment of 03/22/17.
- Physician #2: the governing body approved the most current reappointment on 06/27/18, two years and one month after the previous appointment of 05/25/16.
- Physician #3: lacked evidence the medical staff recommended and the governing body approved privileges for initial appointment on 06/27/18.
- Physician #4: lacked evidence the medical staff recommended and the governing body approved privileges for initial appointment on 03/27/19.

Reviewed on 10/23/19, the CAH's admission listing from 03/23/19 through 05/21/19 indicated Physician #1 provided care to the CAH's patients during this timeframe.

Reviewed on 10/23/19, the CAH's outpatient surgical listing from 05/26/18 through 06/26/18 indicated Physician #2 provided treatment to the CAH's patients on 06/12/18.

During interview on 10/23/19 at 11:10 a.m., an administrative staff member (#16) confirmed the most current reappointments for Physicians #1 and #2 exceeded two years from the past appointments; and Physicians #3 and #4 provided telemedicine services to the CAH's patients and did not have privileges delineated and approved.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed appropriate infection control practices for 1 of 1 reprocessing room (decontamination room). Failure to follow appropriate infection control practices may result in transmission of organisms and pathogens from equipment to patients.

Findings include

Observation of the decontamination room on 10/22/19 at 10:00 a.m. with a surgical nurse (#1) and a surgical technician (#2) showed a utility sink centrally located with two Steris chemical sterilant processors (one located on each side of the sink) approximately ten inches away.

During interview on 10/22/19 at 10:00 a.m., a surgical technician (#2) stated staff use the utility sink to clean scopes after use. The surgical technician (#2) stated staff clean the scopes with enzymatic cleaner in the utility sink and then transfer the scopes to either Steris processor for chemical sterilization.

The facility failed to ensure a "one way" work flow to separate contaminated work spaces from clean work spaces and failed to maintain a sterile environment for the Steris processors and scopes after sterilization.

Upon request, the CAH failed to provide a policy for Infection Control practices regarding moving from a dirty to a clean environment.