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Based on record review and interviews with hospital staff, the governing body does not ensure that all practitioners providing patient care are qualified and have current privileges granted and health histories. One (# DD) of three ( #'s BB, CC & DD) emergency room contract physicians' and one (# Q) of one hospital employed physician's credential files reviewed were incomplete and did not have evidence of current privileges granted and complete health histories.

Based on personnel file review, and interview, the hospital failed to ensure nursing services were provided to meet the needs of all patients. This occurred in 5 of 8 personnel files reviewed for skills competencies and 4 of 8 personnel files reviewed for facility orientation.

Findings:

1. On the morning of 05/29/2014, surveyors reviewed 8 (A, B, I, K, N, P, R, & Z) nursing staff personnel files.

Five of eight (A, B, K N, & Z) personnel files reviewed did not contain current skills competencies.

Four of eight ( B, I, K, & R) personnel files reviewed did not contain facility orientation.

2. On the morning of 05/29/2014, Staff A told surveyors that the nursing staff received yearly competencies.

3. On the morning of 05/29/2014, Staff C told surveyors that the hospital provided patient care to patients of all ages.

4. Eight of eight (A, B, I, K, N, P, R, & Z) personnel files reviewed did not contain age specific competencies or training.

Based on observation and staff interview, the hospital failed to ensure the pharmacist in charge (PIC) is responsible for developing, supervising, and coordinating all the activities of the CAH's (Critical Access Hospital) pharmaceutical service. There was no evidence licensed hospital personnel were trained in drug room duties, had a job description describing duties in the drug room and had been oriented to drug room principles by the pharmacist. The drug room policies and procedures were not approved by the PIC

Findings:

1. Staff B's, the Drug Room Supervisor, personnel file did not have evidence of a job description, orientation or competency evaluation for the drug room.

2. These findings were verified on 05/30/14 with hospital staff.

Based on infection control meeting minutes review, infection control surveillance, infection control policies and procedures, staff interview, and observation, the hospital failed to maintain an active infection control program that includes specific measures for prevention, early detection, control, education, and investigation of communicable diseases.

Findings:

1. On the morning of 05/28/2014, surveyors requested infection control meeting minutes, infection control policies and procedures and infection control surveillance activities.

2. On the morning of 05/29/2014, surveyors reviewed infection control meeting minutes, infection control policies and procedures and infection control surveillance activities.

3. On the morning of 05/28/2014, staff A and staff B, the designated infection control officers, told surveyors that the hospital had not had an infection control program until recently. Staff A and Staff B told surveyors they had just attended infection control training and were just getting the program started.

4. The infection control meeting minutes and surveillance activities contained no documentation of regular environmental rounding in all departments of the hospital.

5. On the morning of 05/28/2014, Staff A and Staff B told surveyors that the dietary department is located in the nursing home. Staff A and Staff B told surveyors that they had not monitored dietary infection control processes. Staff A and Staff B told surveyors that they planned to.

6. On the morning of 05/28/2014, Staff A told surveyors that hospital laundry was done through an outside company and that the hospital instrument sterile processing was done through another company. Staff A told surveyors that she had not monitored infection control processes at the laundry facility or the sterile processing facility but she planned to.

7. The infection control meeting minutes and infection control surveillance activities contained no documentation that hospital acquired infections were monitored and investigated.

8. The infection control meeting minutes and infection control surveillance activities contained no documentation that employee illnesses were monitored and investigated.

Observations:

1. On the morning of 05/28/2014, surveyors toured the hospital.

2. On the morning of 05/28/2014, surveyors toured the physical therapy department. Surveyors observed clean towels in the physical therapy department accessible to the public not covered or protected from contamination.

3. On the morning of 05/28/2014, surveyors observed equipment, such as; patient lifts, and patient walkers in a room that was the "new supply room." It could not be determined if the equipment was clean or dirty. Surveyors asked staff A how she would know if the equipment was clean. Staff A told surveyors that she would know and that the staff would know by general inspection of the equipment.

4. On the morning of 05/28/2014, surveyors observed wheelchairs stored in the main hallway of the hospital accessible to the public. Surveyors asked staff A and staff B how they would know if the wheel chairs were clean. Staff A and Staff B told surveyors that the wheelchairs were wiped down after patient use and placed there.

Surveyors observed one wheelchair with a used Kleenex in the seat. The wheelchairs had a disposable plastic patient wrist band attached to them. One wheelchair contained a paper wrist band. Paper can not be disinfected. Staff B told surveyors the wrist bands are to identify the wheelchairs as the hospital's wheelchairs and not the nursing home's wheelchairs.

5. On the morning of 05/28/2014, Staff A told surveyors that ultrasound services were provided by a contracted service. Staff A told surveyors that the ultrasound technician brought in a vaginal probe for transvaginal ultrasound. Staff A told surveyors that the ultrasound technician disinfects the vaginal probe after the procedure and then takes the equipment with her.

Surveyors asked Staff A how would the facility know if the vaginal probe is clean prior to patient use. Staff A stated that they would not really know.

6. On the afternoon of 05/29/2014, surveyors observed the clean linen storage room. The room was labeled "storage 139." The room contained clean linen not covered and protected from contamination. There was a hole cut out in the ceiling with electrical wires hanging out and connected to the wall. Staff B told surveyors that the wires were the phone system.

Based on record review and interviews with hospital staff, the hospital did not ensure that the hospital had a current therapeutic diet manual in the hospital that had been approved by both the dietitian and the medical staff. The diet manual presented for review was not the current diet manual and was not approved by the dietitian and the medical staff.

Findings:

1. Medical staff meeting minutes reviewed did not have evidence that the medical staff had approved the diet manual.

2. The diet manual presented for review did not have a signature page with any signatures documented.

3. The diet manual presented for review was the 12 th edition published in 2006 . The current manual is the 13 th edition published in 2012.

Hospital staff verified that the diet manual had not been approved by the medical staff.

Based on record review, policy and procedure review, and staff interview, the hospital failed to ensure radiology services were provided by personnel qualified under State law and ensure that critical access hospital (CAH) patients or personnel were not exposed to radiation hazards.

Findings:
1. The radiology personnel were not supervised and did not perform radiological procedures according to accepted national standards.

2. On the afternoon of 05/28/14, the radiology department manager told surveyors that many patients have to have repeated radiological procedures.

3. On the morning of 05/28/14, the radiology manager and the hospital administrator informed surveyors that two nurses and radiology personnel had one in service by the computerized tomography (CT) scanner company and was now performing CT examinations.

4. On the morning of 05/28/14, the radiology department manager told surveyors that she was not qualified to be the radiology manager. The radiology department manager told surveyors, "I got OJT (on the job training)" and was not comfortable performing radiology procedures.

5. On the morning of 05/28/14, surveyors asked the radiology department manager and the hospital administrator who the qualified person over radiology services was. The radiology manager stated, "No one." The hospital administrator verified the radiology manager's statement.

6. On the afternoon of 05/28/14, the hospital administrator told surveyors that inexperienced radiology personnel have been a problem.

7. Radiology staff personnel files (E, M, X, and AA) reviewed did not contain documented evidence that they were designated and qualified to use radiological equipment and administer procedures.

8. Four (E, M, X, and AA) of four radiology personnel files reviewed did not contain documented evidence that radiology staff were oriented , trained, evaluated, and competent to perform radiology procedures offered at the CAH.

9. On the morning of 05/30/14, the facility could not provide documentation indicating the Medical Staff or governing body had deemed radiology personnel were competent to provide radiology services.

10. All radiology department policies and procedures were not current with nationally accepted standards of practice.

11. Radiology department policies and procedures had multiple dates listed on multiple policies ranging from 1984 through 1999.

12. Radiology department document titled, "Department of Radiology" documented, "...The contents of the Radiology Department Manual are in accordance of ..."

13. Radiology department policies that were developed and approved by the medical staff was dated "4/9/99."

14. The radiology manager, director of nursing (DON), and hospital administrator verified that the radiology manual was the current manual at the time of review.

15. There was no documented evidence which studies required interpretation by a radiologist.

16. On the afternoon of 05/28/14, the Hospital Administrator verified that there was no Radiologist appointed over radiology services and had no knowledge that there was a document indicating which radiologic studies required interpretation by a radiologist.

17. There were no policies and procedures in place to ensure that periodic inspections of radiology equipment were conducted and problems identified were corrected in a timely manner.

Based on clinical record review, policy and procedure review, personnel file review, and staff interview the hospital failed to meet Medicare CFR 485.638 Condition of Participation for Clinical Records, as evidenced by failure to provide:

1. written policies and procedures to insure the integrity and security of electronic patient records and clinical records are kept secure and only viewed when necessary.

2. clinical records that were complete and documented all care provided and sufficient information in the clinical record in order to monitor the patient's condition and to provide adequate care.

3. staff signatures on all clinical records and authentication of all entries made in the medical record.

4. failure to provide policies and procedures to guide the staff on the use and retrieval of electronic medical record information and to guide staff on actions to take when the electronic medical record system is down.

Findings:
1a. On the morning of 05/29/14, the director of nursing (DON) told surveyors that there are not any medical record policies and procedures because the facility recently went to using an electronic health record.

1b. On the afternoon of 05/29/14, the health information manager (HIM) told surveyors that there are no policies and procedures for medical records.

1c. On the morning of 05/29/14, DON accessed three (#22 through #23) of three in-patient medical records and one (#20) of one closed records. The DON was unable to identify the authors of entries in all four patient medical records.

1d. On the afternoon of 05/29/14, the HIM manager told surveyors that staff was not limited to what they can access with the electronic medical record. He also told surveyors that there is no way for him to ensure employees were accessing medical records as needed to provide care to patients.

1e. On the morning of 05/29/14, surveyors asked the DON and HIM for the hospital's written medical records policies and procedures. None was provided.

2a. Twenty-four (#1 through #24) of twenty-four records reviewed contained documentation by emergency department nurses of medical diagnoses as the patients chief complaint.

2b. On the morning of 05/29/14, the DON told surveyors, "There is no option to free text the patient's chief complaint there is only the option to pick a medical diagnosis. We nurses have to figure out what is the closest diagnosis to the chief complaint."

2c. On the morning of 05/29/14, staff nurse N told surveyors, "The medical record won't allow free texting, so I have to choose a medical diagnosis closest to the patient's chief complaint. This is the only option we have."

2d. Surveyors observed the DON attempting to free text a chief complaint into the electronic medical record under a test patient. The medical record did not accept free texting and only allowed the staff to choose a preloaded medical diagnosis.

2e. On the day of 05/29/14, the DON, HIM, and staff N pulled up patient medical records.

2f. Surveyors reviewed 24 (#1 through #24) of 24 medical records, surveyors were unable to determine what care was provided to patients.

2g. There were no documented evidence of comprehensive nursing assessments in 24 (#1 through #24) of 24 records reviewed.

2h. There was no documented evidence of dietary assessments in 24 (#1 through #24) of 24 records reviewed.

2i. There was no documented evidence of activity assessments in two (#6 and #22) of two swing bed patients.

2j. There was no documented evidence of patient responses to treatments and interventions in 24 (#1 through #24) of 24 records reviewed.

2k. There was no documented evidence of nursing assessments completed in the emergency department in 24 (#1 through #24) of 24 records reviewed.

2l. There was no documented evidence of a acuity level.

2m. There was no documented evidence of interventions done if there were abnormal values documented.

2n. There was conflicting documentation in patient #20's medical record.

2o. On the morning of 05/29/14, the DON told surveyors, "If entries that are within normal limits are entered into the medical record that information disappears and no one can see it again."

2p. These findings were verified by the DON, HIM, and hospital administrator.

3a. On the morning of 05/29/14, surveyors reviewed patient # 20's medical record.

3b. The medical record documented, "...This is a corrected result..." without evidence of the author.

3c. The medical record documented, "...ED Initial Screening (all recorded) Screening Questions None..." without evidence of the author.

3d. The medical record documented, "...Breath Sounds Clear..." without evidence of the author.

3e. The medical record documented, "...Urine Color Yellow; Bloody Clear..." without evidence of the author.

3f. The medical record documented, "...Respiratory Exceptions..." without evidence of what the exceptions were and without evidence of the author.

3g. The medical record documented, "...Radiology Reports...site of exam...site of dictation..." without evidence of the author.

3h. The medical record documented multiple duplicate order entries and cancellations without the evidence of the author.

4a. On the afternoon of 05/29/14, the HIM and the DON said that there is no policies or procedures in place to guide the staff on the use of the electronic health record if the electronic health record goes down. They told surveyors that they are still trying to figure out the electronic health record because it is so new.

4b. On the morning of 05/29/14, the DON told surveyors that the facility does have the paper forms previously used before going to the electronic health record and can use those papers as downtime forms.

4c. On the afternoon of 05/29/14, surveyors requested medical records policies and procedures that help guide staff when the electronic medical record is down. None was provided.

The above findings were verified with the administrative staff at the time of review. The findings were discussed with the administrator at the time of exit.

Based on record review and interviews with hospital staff, the hospital does not ensure that an annual periodic evaluation of its total program is conducted at least once a year and includes a review of the following: a representative sample of both active and closed medical records; a review of the CAH's (critical access hospital's) health care policies; and an evaluation of the utilization of services, if policies were followed and what changes if any were needed.

Findings:

1. Interviews with hospital personnel on the afternoon of 05/30/14 stated that the hospital had not conducted an evaluation of its total program at least annually which included a review of active and closed records, hospital policies and procedures and evaluation of the services provided and if changes were needed.

2. Governing Body and Medical Staff meeting minutes for 2013 and 2014 were reviewed and did not have evidence of a periodic evaluation of the hospital's total program.

3. Staff provided documentation of a periodic evaluation for the year of 2011, but an annual periodic evaluation had not been done for 2012 or 2013.

Based on record review and interviews with hospital staff, the hospital does not ensure the hospital has an effective facility wide quality assurance (QA) program that : 1. includes all departments; 2. services provided under contract; collects relevant data; analyzes the data and implements corrective action. The quality assurance meeting minutes for 2013 and 2014 provided for review did not have relevant indicators to identify potential problems and opportunities to improve quality of care. There was no analysis of data that was collected and no evidence of the implementation of any corrective action taken. There was no review of services provided to the CAH under contract.

Findings:

1. Quality indicators documented in the quality minutes for the radiology department consisted of the percentage of repeat radiology procedures performed each month. The percentages of retakes were consistently in the 40 percentage range. There was no analysis of these indicators or any corrective action taken.

2. Review of the quality meeting minutes for 2013 and 2014 did not have evidence any QA indicators or monitoring for dietary services provided by contract.

3. There were no quality indicators or data on the hospital's recent change to an electronic medical record to evaluate compliance with the Condition of Participation 485.638 Clinical Records.

These findings were verified with hospital staff.