HospitalInspections.org

Based on a review of personnel files of individuals hired within the past year, staff interviews and a lack of evidence, the Critical Access Hospital failed to ensure newly hired individuals obtain specific training regarding their responsibilities in a non medical emergency. The facility is licensed for 20 beds with a reported annual average daily census of 2.25 patients. Findings are:

A. 4 of 4 personnel files reviewed lacked evidence of specific training based on each individual's job responsibilities for non-medical emergencies.

B. Interviews with the Director of Nursing and the Administrator on 9/9/10 at 5:30 PM confirmed a lack of specific training for newly hired individuals prior to the first day of direct patient contact.

Examples: 1 RN,1 Radiology Technologist, 1 Housekeeper and 1 Health Information Specialist.

Based on a review of the Medical Staff ByLaws, Rules and Regulations, Physician reappointment to the Medical Staff, and staff interviews, the Governing Body failed to enforce the ByLaws in the reappointment process. The Medical Staff consists of 5 Practitioners. Findings are:

A. 1. A review of the current Medical Staff ByLaws, Rules and Regulations states on page 10, 7.2.5 "Review of Competence Demonstrate that he or she will have sufficient patient care contact at the hospital to permit the Medical Staff to continually assess competency for all requested privileges..."
2. Page 39, 14.2.3 "Utilization Review ...Monitor the accuracy of diagnoses..."
3. Page 42, Section 15.1-2 "Minimum attendance. Members of the Active Staff must attend at least two-thirds (2/3) of all meetings."

B. A review of the files of the 5 practitioners (Practitioners A, B, C, D and E) lacked evidence of review of competencies, accuracy of diagnoses or minimum attendance at staff meetings.

C. Interviews with the Administrator and the Quality Assurance Coordinator on 9/9/10 at 5:30 PM confirmed the reappointment process failed to follow the current ByLaws, as specified.

Based on staff interview, a review of the current infection control procedure manual and a lack of evidence, the Critical Access Hospital (CAH) failed to include in the infection control program measures to monitor hand hygiene practices of personnel and failed to include current acceptable practices. The CAH is licensed for 20 beds and had an average daily acute care census of 2.25 patients per day. Findings are:

A. A review of the surveillance documentation for 2010 lacked any evidence of direct monitoring of hand hygiene practices in the hospital.

B. A review of the hand hygiene policy for surgery described a 10-minute scrub, which is no longer the standard of practice. The World Health Organization recommends a 3-minute scrub technique.

C. On 9/9/10 at 4:30 PM, an interview conducted with the Infection Prevention Practitioner confirmed that the infection prevention program did not include any monitoring of direct patient care staff for hand hygiene practices, nor did it include any monitoring of surgical scrub technique.

Based on a review of surgical privileges, as compared with the surgery log and staff interview, the Critical Access Hospital (CAH) failed to ensure physicians' privileges reflected actual practice and failed to include signed recommendations of the active medical staff and governing body approval. The Medical Staff consisted of 5 Practitioners. Findings are:

A. The credentialing file of Practitioner B lacked a privilege list authorized by the current medical staff, but rather included a privilege list from a different hospital which itemized such procedures as Bariatric surgery for morbid obesity. (This is considered a high risk procedure)

B. A review of the surgical roster for the time period 2009 and 2010 lacked evidence of Bariatric surgery.

C. Interviews with the Director of Quality Assurance and the Administrator on 9/9/10 at 5:30 PM confirmed that the privilege listing for Practitioner B failed to accurately reflect the CAH's actual surgical practices.

D. The file of Practitioner A included a note at the top of the privilege list, which stated, "Remove OB, 2002". A review of the most recent reappointment dated 2009 included obstetric privileges.

E. Interview with the Administrator on 9/9/10 at 5:30 PM confirmed the hospital did not offer obstetric services.