HospitalInspections.org

Based on observation, document review, and interviews, the Critical Access Hospital (CAH)
administrative staff failed to ensure the surgery staff changed the sterile water flush bottles after
endoscope procedures for each patient, in accordance with the manufacturer's directions, for 1 of 1 endoscopy room. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria
growing in the sterile water and potentially causing an infection in the next patient. The CAH administrative staff reported that the surgery staff performed approximately 586 endoscope procedures from 7/1/20 to 6/30/21.

Findings include:

1. Observations during a tour of the surgery department on 07/28/2021 at approximately 11:30 AM in the endosocopy room revealed 1 of 1 bottle ICU Medical 1000 ml bottle of sterile water for irrigation connected to the endoscope equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract).

2. Review of the manufacturer's instructions for the ICU Medical 1000 mL bottle of sterile water indicated in part... "Single-dose container. Discard unused portion." The hospital staff must discard any unused portions of the sterile water for irrigation after use on a single patient. The sterile water for irrigation did not contain any chemicals to prevent bacteria from growing in the sterile water once the hospital staff opened the bottles of sterile water for irrigation.

3. During an interview on 7/28/2021, at the time of the observation, the Surgery Nurse Manager revealed that the surgery staff opened the bottles of sterile water for irrigation each day for endoscope procedures that are scheduled
and connected it to the equipment. The equipment contained a one-way valve to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscope procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscope procedures. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscope procedures for the day or if the bottle ran empty.

4. During an interview on 07/28/2021 at approximately 12:30 PM, the Surgery Nurse Manager verified
they reviewed and confirmed the manufacturer's directions for ICU Medical 1000 ml bottles of sterile water for irrigation. The Surgery Nurse Manager acknowledged the manufacturer did not support using the bottles of sterile water for irrigation for more than one patient.

Based on review of Board of Trustees meeting minutes and staff interviews, the Board of Trustees (governing body) failed to ensure the Board of Trustees administered policies to determine and maintain quality health care at the Critical Access Hospital.

1. The Board of Trustees failed to ensure the CAH had an effective quality program with governing body oversight that evaluated all patient care services including contracted services and failed to ensure quality improvement information was reviewed. Please refer to C-0962.

2. The Board of Trustees failed to ensure the Professional Advisory Committee developed policies and procedures for all services offered by the CAH. Please refer to C-1008.


The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to ensure the quality health care provided to patients.

Based on document review and staff interviews, the Board of Trustees failed to ensure the medical staff received the required outside entity peer review performed by the Network Hospital prior to recommending 2 of 3 active physicians (General Surgeon A and Family Practice Physician C) and 4 of 8 consulting physicians (Orthopedic Surgeon B, Ophthalmologist D, Otolaryngologist E and Teleradiologist F) selected for review, for reappointment to the Medical Staff. Failure to provide the Medical Staff and Board of Trustees with the Network Hospital peer review results could potentially result in the Medical Staff and Board of Trustees reappointing a physician to the Medical Staff that provided substandard or inadequate care to the CAH's patients.

The CAH administrative staff revealed the identified physicians provided care to patients from 7/1/20 to 6/30/21 as follows:

General Surgeon A - 731 surgical procedures and 19 inpatient admissions
Orthopedic Surgeon B - 21 surgical procedures
Family Medicine Physician C - 80 inpatient admissions, 58 observation admissions, 21 emergency room encounters, and 28 surgical procedures
Ophthalmologist D - 78 surgical procedures
Otolaryngologist E -51 surgical procedures
Teleradiologist F - 15 imaging interpretations

Findings include:

1. Review of the CAH's network agreement, effective 4/1/13, revealed in part " ... [Network Hospital] agrees to facilitate and assist CAH in the development and administration of "an effective quality assurance program" ... a program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes, ... evaluation of the quality and appropriateness of the diagnosis and treatment furnished by ... doctors of medicine or osteopathy ...".

2. Review of the CAH Board of Trustee bylaws, approved on 6/29/21, identified the Board of Trustees are responsible for assuring there an effective, health center-wide quality assurance program to evaluate provision of patient care. The bylaws revealed in part "... The Board of Trustees shall have final responsibility for appointing and reappointing the members of the Medical Staff and delineating their staff privileges ... and reviewing and monitoring the quality management/improvement programs developed by the Medical Staff ...".

3. Review of a CAH policy titled "Peer Review," effective 4/2021 revealed in part "... process ... to obtain information on physician patterns and the quality of care and services being provided to the patients that we serve ... The quality and appropriateness of the diagnosis and treatment furnished by physicians are evaluated. Random charts of all physicians who provide care and services at the facility ... are reviewed. The Peer Review form will be used for the review process and results will be shared as appropriate with the individual provider being reviewed. The review will be conducted by [Network Hospital System Affiliate A]. At least one record review from each provider is reviewed per re-credentialing period ... [CAH] only sends out [Radiology Entity B] external peer reviews to [Network Hospital System Affiliate A] utilizing the same process as the family practice physicians ... Each Tele Rad's (sic) interpretation is reviewed by [Radiology Entity B] and discrepancies discussed ...".


4. Review of medical staff credentialing documentation on 7/28/2021, revealed the following medical staff members lacked evidence of a Network Hospital peer review:

a. Review of the credential file for General Surgeon A revealed the medical staff approved the reappointment to the Medical Staff on 6/9/2020. The Board of Trustees approved General Surgeon A for reappointment to the Medical Staff on 6/23/2020.

b. Review of the credential file for Orthopedic Surgeon B revealed the medical staff approved the reappointment to the Medical Staff on 6/25/2021. The Board of Trustees approved Orthopedic Surgeon B for reappointment to the Medical Staff on 6/29/2021.

c. Review of the credential file for Family Practice Physician C revealed the medical staff approved the reappointment to the Medical Staff on 9/18/2020. The Board of Trustees approved Family Practice Physician C for reappointment to the Medical Staff on 9/29/2020.

d. Review of the credential file for Ophthalmologist D revealed the medical staff approved the reappointment to the Medical Staff on 6/9/2020. The Board of Trustees approved Ophthalmologist D for reappointment to the Medical Staff on 6/23/2020.

e. Review of the credential file for Otolaryngologist E revealed the medical staff approved the reappointment to the Medical Staff on 6/25/2021. The Board of Trustees approved Otolaryngologist E for reappointment to the Medical Staff on 6/29/2021.

f. Review of the credential file for Teleradiologist F revealed the medical staff approved the reappointment to the Medical Staff on 11/21/2019. The Board of Trustees approved Teleradiologist F for reappointment to the Medical Staff on 11/27/2019.


5. During an interview on 7/28/2021, at 9:40 AM, the Health Information (HIM) Manger reported they utilize Network Hospital Health System Affiliate A to conduct external peer review for the CAH medical staff. She explained they attempt to obtain a minimum of 1 review per credential cycle and the results are part of the reappointment packet, available for review by the Medical Staff and Board of Trustees. If the review contains any adverse comments, they are flagged for attention and further review. The HIM manager reported the CAH staff does not always get the external peer review results back in time for reappointment and acknowledged the reappointment proceeds without the results of the external peer review.

The Health Information Manger confirmed the CAH staff failed to ensure all Medical Staff members had external peer review results prior to reappointment, in order to assist in the evaluation of the appropriateness of diagnosis and treatment furnished to patients at the CAH.









42028


Based on review of documentation, governing board meeting minutes, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to present or document appropriate and adequate information regarding the Quality Improvement activities at the Board of Trustees meetings so board members could exercise oversight of the quality for all patient care services, including contracted services, offered at the CAH for 31 of 33 departments (Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit). The CAH administrative staff identified an average daily census of 6 inpatients for fiscal year 2020. Failure of the CAH Board of Trustees to review and evaluate Quality Improvement information could potentially result in the Board of Trustees inability to provide effective oversight to the Quality Improvement committee and result in the CAH staff delaying actions to correct any identified deficiencies in the quality of care provided to patients at the CAH.

Findings include:

1. Review of the Kossuth Regional Health Center Board of Trustees By-laws, approved 6/29/21, revealed in part, "The duties of the Board are strategic in nature including ... assuring quality ..."

2. Review of the CAH's "Quality Plan," revised 6/2021, revealed in part, "The Kossuth Regional Health Center Board maintains the ultimate accountability/responsibility ... The Kossuth Regional Health Center Board [KRHC] ensures an effective, organization wide program for quality improvement and patient safety, is defined, implemented, and maintained. The board ensures this program functions to evaluate clinical care and services, reflecting the complexity of the organization and services provided ... The Quality Program encompasses all services and operations and includes an ongoing program that shows measurable improvement in outcomes, goals identification and reduction of adverse events ... Each service/department services report monitoring and evaluation activities at least annually, to the Quality Improvement Committee ... The Plan is reviewed and approved by the [KRHC] Board...on an annual basis."

2. Review of the Board of Trustees Meeting minutes, from 7/28/20 to 6/29/21, revealed the CAH's quality staff provided the Board of Trustees with quality presentations that addressed topics including the CAH's initiative to collect copays from patients; the CAH's financial savings initiatives; redesigned huddle boards; employee injuries; and the CAH's patient satisfaction scores. The meeting minutes lacked information on the CAH's Quality Improvement activities for Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit.

3. During an interview on 07/29/2021 at 10:44 AM, the Process, Excellence & Quality Director acknowledged they failed to present the Board of Trustees at least annually with information on the CAH staff's quality improvement efforts to prevent problems, create measurable goals, corrective actions taken for identified problems, and outcomes of the corrective actions for the Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit.

Based on document review, policy review, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 3 active physicians (General Surgeon A and Family Practice Physician C) and 4 of 8 consulting physicians (Orthopedic Surgeon B, Ophthalmologist D, Otolaryngologist E and Teleradiologist F) selected for review, received outside entity peer review by the Network Hospital, to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital, prior to reappointment to the medical staff. Failure to ensure all medical staff members received outside entity peer review prior to reappointment, affects the CAH's ability to assure physicians provide quality care to the CAH patients.

The CAH administrative staff identified the identified physicians provided care to patients from 7/1/2020 to 6/30/2021 as follows:

General Surgeon A - 731 surgical procedures and 19 inpatient admissions
Orthopedic Surgeon B - 21 surgical procedures
Family Medicine Physician C - 80 inpatient admissions, 58 observations admissions, 21 emergency room encounters and 28 surgical procedures
Ophthalmologist D - 78 surgical procedures
Otolaryngologist E -51 surgical procedures
Teleradiologist F - 15 imaging interpretations

Findings include:

1. Review of the CAH's network agreement, effective 4/1/13, revealed in part " ... [Network Hospital] agrees to facilitate and assist CAH in the development and administration of "an effective quality assurance program" ... a program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes, ... evaluation of the quality and appropriateness of the diagnosis and treatment furnished by ... doctors of medicine or osteopathy ...".

2. Review of the CAH Board of Trustee bylaws, approved on 6/29/21, identified the Board of Trustees is responsible for assuring there is an effective, health center-wide quality assurance program to evaluate provision of patient care. The bylaws revealed in part "... The Board of Trustees shall have final responsibility for ... reviewing and monitoring the quality management/improvement programs developed by the Medical Staff ...".

3. Review of a document titled "Peer Review Services Agreement", effective 8/1/13, revealed in part "... [Network Hospital Health System Affiliate A] shall, upon the request of CAH, evaluate the diagnosis and treatment provided by physicians at CAH and/or clinics ... Services shall be provided by [Network Hospital Health System Affiliate A] exclusively through physicians who (a) specialize in the same specialty as the physician being evaluated ... All services shall be appropriately documented on the appropriate form(s)... Peer review will be completed within 60 days of receipt ...".

4. Review of a CAH policy titled "Peer Review," effective 4/2021 revealed in part "... process in place to obtain information on physician patterns and the quality of care and services being provided to the patients that we serve ... The quality and appropriateness of the diagnosis and treatment furnished by physicians are evaluated. Random charts of all physicians who provide care and services at the facility ... are reviewed. The Peer Review form will be used for the review process and results will be shared as appropriate with the individual provider being reviewed. The review will be conducted by [Network Hospital System Affiliate A]. At least one record review from each provider is reviewed per re-credentialing period ... [CAH] only sends out [Radiology Entity B] external peer reviews to [Network Hospital System Affiliate A] utilizing the same process as the family practice physicians ... Each Tele Rad's interpretation is reviewed by [Teleradiology Entity B] and discrepancies discussed ... The results of the peer review are reviewed by the re-credentialing committee ...".

5. Review of the credential file for General Surgeon A revealed the medical staff approved the reappointment to the Medical Staff on 6/9/2020. The Board of Trustees approved General Surgeon A for reappointment to the Medical Staff on 6/23/2020. General Surgeon A's external peer review results showed completion on 8/7/2020, completed by Network Hospital Health System Affiliate A (approximately 1.5 months after the Medical Staff and Board of Trustees reappointed General Surgeon A to the Medical Staff).

6. Review of the credential file for Orthopedic Surgeon B revealed the medical staff approved the reappointment to the Medical Staff on 6/25/2021. The Board of Trustees approved Orthopedic Surgeon B for reappointment to the Medical Staff on 6/29/2021. Orthopedic Surgeon B did not have any external peer review completed by Network Hospital Health System Affiliate A prior to reappointment to the medical staff.

7. Review of the credential file for Family Practice Physician C revealed the medical staff approved the reappointment to the Medical Staff on 9/18/2020. The Board of Trustees approved Family Practice Physician C for reappointment to the Medical Staff on 9/29/2020. Family Practice Physician C's external peer review results showed completion on 9/30/2020, completed by Network Hospital Health System Affiliate A (after the Medical Staff and Board of Trustees reappointed Family Practice Physician C to the Medical Staff).

8. Review of the credential file for Ophthalmologist D revealed the medical staff approved the reappointment to the Medical Staff on 6/9/2020. The Board of Trustees approved Ophthalmologist D for reappointment to the Medical Staff on 6/23/2020. Ophthalmologist D's external peer review results showed completion on 7/1/2020, completed by Network Hospital Health System Affiliate A (after the Medical Staff and Board of Trustees reappointed Ophthalmologist D to the Medical Staff).

9. Review of the credential file for Otolaryngologist E revealed the medical staff approved the reappointment to the Medical Staff on 6/25/2021. The Board of Trustees approved Otolaryngologist E for reappointment to the Medical Staff on 6/29/2021. Otolaryngologist E did not have any external peer review completed by Network Hospital Health System Affiliate A prior to reappointment to the medical staff.

10. Review of the credential file for Teleradiologist F revealed the medical staff approved the reappointment to the Medical Staff on 11/21/2019. The Board of Trustees approved Teleradiologist F for reappointment to the Medical Staff on 11/27/2019. The external peer review on file for Teleradiologist F consisted only of a preliminary findings image interpretation report for a Computerized Tomography (CT) scan, completed by Teleradiologist F on 2/19/19 and a final image interpretation report for the same test, completed by a Radiology Entity B Radiologist, on 2/20/2019. Teleradiologist F did not have any external peer review completed by the Network Hospital Health System Affiliate A, prior to reappointment to the medical staff, which evaluated the quality and appropriateness of the diagnosis.

11. During an interview on 7/28/2021, at 9:40 AM, the Health Information (HIM) Manger reported they utilize Network Hospital Health System Affiliate A to conduct external peer review for the CAH medical staff. She explained a provider encounter report is reviewed approximately 3 months ahead of reappointment and a random encounter is selected to send for review. The HIM Manager reported they attempt to obtain a minimum of 1 review per credential cycle and the results are part of the reappointment packet, available for review by the Medical Staff and Board of Trustees. If the review contains any adverse comments, the adverse comments are flagged for attention and further review. The HIM Manager reported the CAH does not always get the external peer review results back in time for reappointment and acknowledged the reappointment proceeds without the results. The HIM Manager acknowledged the external peer review for General Surgeon A, Orthopedic Surgeon B, Family Practice Physician C, Ophthalmologist D and Otolaryngologist E's did not come back in time to be considered at the time of reappointment.

The HIM manager reported all of the Teleradiologist image interpretations are preliminary reports and undergo a secondary radiology interpretation the next day, by Radiology Entity B, which is the final report. She explained the peer review process for the Teleradiologists is different because of this and only consists of including a preliminary report, prepared by the Teleradiologist, and the final report, prepared by the Radiology Entity B Radiologist. She acknowledged this process does not include the evaluation for the quality and appropriateness of the diagnosis identified by the Teleradiologist.

The Health Information Manger confirmed the CAH failed to ensure all Medical Staff members had external peer review results prior to reappointment, in order to assist in the evaluation of the appropriateness of diagnosis and treatment furnished to patients at the CAH.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure all patient care policies were reviewed annually, in accordance with facility policy, for 3 of 33 patient care departments (Infusion Therapy), including contracted services (Speech Therapy and Nuclear Medicine (Nuclear Med)). The CAH administrative staff identified an average daily census of 6 patients for fiscal year 2020. Failure to ensure all patient care policies were reviewed annually by the required group of professionals could potentially result in the CAH staff failing to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of the CAH policy, "Provision of Services", dated 6/2021, revealed in part, "The policies are developed with the advice of the Professional Advisory Committee (PAC)." "These policies are reviewed and revised ... at least annually by the PAC."

2. Review of the CAH policy, "Professional Advisory Committee, effective 6/2021, revealed in part, "The Professional Advisory Committee (PAC) serves to develop, execute, and periodically review the CAH ... written policies governing the patient care services provided [at the CAH]. Patient [care] related policies and procedures are developed with the recommendation and approval of this group, and all patient care policies are reviewed and approved annually."

3. Review of the "Professional Advisory Committee Agenda/ Minutes," dated 9/16/20 through 6/23/21, revealed the meeting minutes lacked documentation that the Professional Advisory Committee reviewed and approved the policies for Infusion Therapy, Speech Therapy, and Nuclear Medicine.

4. Review of an undated list of all policies at the CAH revealed the CAH lacked documentation the PAC members developed, let alone reviewed and approved, policies specific to Infusion Therapy, Speech Therapy, and Nuclear Medicine.

5. During an interview on 7/29/21 at 10:44 AM, the Process Excellence and Quality Director confirmed the PAC members failed to develop, review, or approve policies specific to Infusion Therapy, Speech Therapy, and Nuclear Medicine.

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 1 of 1 x-ray film storage room and 1 of 1 ultrasound room. The Radiology Manager identified approximately 1,000 x-ray films stored unsecured in the x-ray film storage room. The Ultrasound Technician identified 566 patient entries in 3 log books stored unsecured in the ultrasound room. 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.

Findings include:

1. Review of the CAH policy "Confidentiality of Information," last approved 5/2021, revealed in part, "... Kossuth Regional Health Center will ensure that all locations where medical records are stored or maintained will ensure the integrity, security and protection of the records...."

2. Review of the CAH policy "Access to Records," last approved 4/2021, revealed in part, "... All patient care information, both central records and clinical record information that may be kept at dispersed locations, shall be regarded as confidential and available only to authorized users ... Access should be restricted to the patient, the patient's authorized representative, the attending physician and personnel with a legitimate need to know...."

3. Observation on 7/27/21 at approximately 1:40 PM, during a tour of the x-ray film storage room with the Radiology Manager, revealed 1 of 1 x-ray film storage area in the CAH basement storage area. The Radiology Manager identified approximately 1,000 x-ray films stored on 10 open shelving units and 1 55-gallon drum 1/3 full of x-ray films in the basement storage area. The Radiology Manager identified Housekeeping staff, Health Information staff, Clinic staff, Pharmacy staff, and a Psychiatrist all have a key to the basement film storage room.

4. Observation on 7/28/21 at approximately 9:05 AM, during a tour of the ultrasound room with the Ultrasound Technician, revealed 3 log books stored unsecured in the ultrasound room. The Ultrasound Technician identified 566 patient entries in 3 log books stored unsecured in the ultrasound room.

5. During an interview on 7/27/21 at 1:40 PM, the Radiology Manager acknowledged the x-ray films contained patient information and Housekeeping staff, Health Information staff, Clinic staff, Pharmacy staff, and a Psychiatrist all have a key to the basement film storage room. The Radiology Manager verified the Housekeeping staff, Health Information staff, Clinic staff, Pharmacy staff, and the Psychiatrist do not have the need to know the patient information contained in the x-ray film jackets.

6. During an interview on 7/28/21 at 9:05 AM, the Ultrasound Technician acknowledged the 3 unsecured log books contained patient information. The Ultrasound Technician stated the housekeeping staff clean the ultrasound room when staff are not present.

I. Based on document review and staff interview, the Critical Access Hospital (CAH) surgical staff failed to ensure examination of the patient by a physician immediately before surgery to evaluate the surgical risks prior to the performance of the procedure in 2 of 4 closed medical records (Patient #2 and Patient #4). Failure of a physician to examine a patient immediately before surgery could result in surgery performed on an unstable patient. The CAH administrative staff identified 1,066 surgery and endoscopy procedures in the past fiscal year, 7/1/2020 - 6/30/2021.

Findings include:

1. Review of closed surgical records revealed the following:

a. On 5/26/21 at approximately 1:30 PM, Surgeon B performed a right knee arthroscopy (surgical procedure that can diagnose and treat problems of the knee joint using a tiny surgical instrument with a light and camera at the end inserted into the knee) on Patient #2. Patient #2's medical record lacked documentation that Surgeon B examined Patient #2 immediately before surgery to evaluate the risk of the procedure to be performed.

b. On 6/16/21 at approximately 10:00 AM, Surgeon A performed a laparoscopic cholecystectomy (surgical procedure to remove the gallbladder) on Patient #4. Patient #4's medical record lacked documentation that Surgeon A examined Patient #4 immediately before surgery to evaluate the risk of the procedure to be performed.


2. Review of the "Medical Staff Rules and Regulations", undated, revealed the document lacked a requirement for a physician to examine a patient immediately before surgery to evaluate the risks of the procedure to be performed.

3. During an interview on 7/29/21 at 10:50 AM, the Surgery Nurse Manager acknowledged the closed medical records for Patient #2 and Patient #4 lacked documentation of an examination by a physician immediately before urgery to evaluate the risks prior to the performance of the procedure. The Surgery Nurse Manager reported the CAH lacked a policy and procedure that required an examination by the surgeon immediately before surgery to evaluate the risks of the procedure to be performed.






II. Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure 1 of 1 active anesthesia staff (CRNA G) documented the date and time of the post anesthesia evaluation for 3 of 4 patients (Patient #2, Patient #3, and Patient #4) who received general anesthesia for their surgeries. Failure to appropriately date and time the completion of a post anesthesia evaluation may result in an inadequate medical record that could adversely affect a patient's medical care. The CAH performed 1,066 surgeries the past fiscal year, 7/1/2020 - 6/30/2021.

Findings include:

1. Review of the policy " Post Op Anesthesia Care/Discharge," approved 6/2021, revealed in part, "... CRNA [will] make [a] ... post-anesthetic visit, describing the presence or absence of anesthesia related complications ... prior to discharging from surgery and anesthesia services ..."

2. Review of medical records on 7/28/21 at 12:00 PM revealed the following:

a. On 5/26/21 at approximately 1:30 PM, Patient #2 received general anesthesia (a combination of medications that put you in a sleep-like state before surgery, completely unconscious) for a right knee arthroscopy (surgical procedure that can diagnose and treat problems of the knee joint using a tiny surgical instrument with a light and camera at the end inserted into the knee). Review of post anesthesia documentation revealed CRNA G documented the post anesthesia examination was performed 5/26/21 at 7:41 PM. Patient #2's medical record revealed Patient #2 was discharged 5/26/21 at 3:00 PM, 4 hours 41 minutes prior to the evaluation. CRNA G failed to document the actual time the Post anesthesia evaluation was performed.

b. On 6/7/21 at approximately 10:00 AM, Patient #3 received general anesthesia for a tubal ligation (surgical procedure to prevent pregnancy). Review of post anesthesia documentation revealed CRNA G documented the post anesthesia examination was performed 6/7/21 at 4:44 PM. Patient #3's medical record revealed Patient #3 was discharged 6/7/21 at 12:40 PM, 4 hours prior to the evaluation. CRNA G failed to document the actual time the post anesthesia evaluation was actually performed.

c. On 06/16/21 at approximately 10:00 AM, Patient #4 received general anesthesia for a laparoscopic cholecystectomy (surgical procedure to remove the gallbladder). Review of post anesthesia documentation revealed CRNA G documented the post anesthesia examination was performed 6/17/21 at 8:53 AM. Patient #4's medical record revealed Patient #4 was discharged 6/16/21 at 1:15 PM, the prior day. CRNA G failed to document the actual time the Post anesthesia evaluation was actually performed.


3. During an interview on 7/28/21, at the time of the record review, Surgery Nurse Manager acknowledged Patient #2's, Patient #3's, and Patient #4's medical record did not contain the time that CRNA G actually conducted the post anesthesia evaluation was performed as the patients had already been discharged from the hospital.

4. During an interview on 7/29/21 at 10:14 AM, CRNA G explained they usually performed the post anesthesia evaluation about 30 minutes after the patient entered the recovery room, but CRNA G does not always get the documentation done at that time. CRNA E acknowledged the medical record did not include the required date and time of the post anesthesia evaluation was actually performed.

Based on policy/procedure, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure surgical services staff discharged a patient who received anesthesia to the company of a responsible adult for 3 of 3 surgical patients reviewed (Patients #2, Patient #3, and Patient #4). Failure to ensure surgical services staff discharged patients who received anesthesia in the company of a responsible adult could potentially result in the patient discharging and lacking someone to monitor them following surgery, and potentially allowing a life-threatening complication to occur unnoticed. The CAH administrative staff reported approximately 1066 surgical procedures from 7/1/20 - 6/30/21.

Findings include:

1. Review the policy "Post Anesthesia Care / Discharge", approved 6/2021, revealed in part, "... All patients are discharged in the company of a responsible adult ..."

2. Review of policy "Discharge Protocol", last approved 6/2021, revealed in part, "... All patients are discharged in the company of a responsible adult ..."

3. Review of patient medical records revealed the following:

a. Patient #2 received anesthesia for a surgical procedure on 5/26/21. The surgical services staff discharged Patient #2 on 5/26/21 at 3:00 PM. Patient #2's medical record lacked documentation the surgical services staff discharged Patient #2 in the company of a responsible adult.

b. Patient #3 received anesthesia for a surgical procedure on 6/7/21. The surgical services staff discharged Patient #3 on 6/7/21 at 12:40 PM. Patient #3's medical record lacked documentation the surgical services staff discharged Patient #3 in the company of a responsible adult.

c. Patient #4 received anesthesia for a surgical procedure on 6/16/21. The surgical services staff discharged Patient #4 on 6/16/21 at 1:15 PM. Patient #4's medical record lacked documentation the surgical services staff discharged Patient #4 in the company of a responsible adult.


3. During an interview on 7/28/21 at 1:00 PM, the Surgery Nurse Manager confirmed Patient #2's, Patient #3's, and Patient #4's medical record lacked documentation the surgical services staff discharged the patients in the company of a responsible adult after the patients received anesthesia.

Based on document review and staff interviews, the CAH's Quality Improvement and Performance Improvement staff failed to develop, implement, and maintain an effective, ongoing, CAH-wide data-driven quality assessment and performance improvement program.

1. The CAH's Quality Assurance/Improvement program (QAPI) failed to involve all department of the CAH and services provided to the CAH's patients. Please refer to C-1306.

2. The CAH's Quality Assurance/Improvement program (QAPI) failed to utilize objective measures to evaluate organizational processes and services for all services, including contracted services. Please refer to C-1309.

3. The CAH's Quality Assurance/Improvement program (QAPI) failed to address outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, CAH acquired conditions, and transitions of care, including readmissions. Please refer to C-1311.

4. The CAH failed to have an effective quality program with governing body oversight that evaluated all patient care services including contracted services and failed to ensure quality improvement information was reviewed. Please refer to C-1313.

5. The CAH's Quality Assurance/Improvement program (QAPI) failed to focus on measures related to improved health outcomes that are shown to be predictive of desired patient outcomes. Please refer to C-1315.

6. The CAH's Quality Assurance/Improvement program (QAPI) failed to use the measures to analyze and track its performance for predictive patient outcomes. Please refer to C-1319.

7. The CAH's Quality Assurance/Improvement program (QAPI) failed to set priorities for performance improvement with consideration of high volume, high -risk services or problem prone areas. Please refer to C-1321

8. The CAH's Quality Assurance/Improvement program (QAPI) failed to incorporate quality indicator data including patient care data, and other relevant data, in order to achieve the goals of the QAPI program. Please refer to C-1325

The cumulative effect of these systemic failures and deficient practices resulted in the CAH staff's inability to ensure the CAH staff provided quality health care provided to patients.

Based on review of documentation and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the QAPI program included all departments of the CAH and contracted services at the CAH for 8 of 33 departments and services offered at the CAH (anesthesia, speech therapy, CT scan, echocardiogram, tele-radiology, DEXA scan, ultrasound, Magnetic Resonance Imaging (MRI)). The CAH administrative staff identified an average daily census of 6 inpatients for fiscal year 2020. Failure to include all departments and services offered at the CAH could potentially result in the CAH staff failing to identify areas where the CAH staff could improve the delivery of patient care.

Findings include:

1. Review of the CAH's "Quality Plan, revised 6/2021, revealed in part, "The Quality Program encompasses all services and operations and includes an ongoing program that shows measurable improvement in outcomes, goal identification and reduction of adverse events." "Each service/department services (sic) report monitoring and evaluation activities at least annually, to the Quality Improvement Committee."

2. Review of the CAH's quality improvement committee "KRHC Quality" meeting minutes, from 7/15/20 to 7/19/21, revealed the CAH staff failed to include the following departments/services in the CAH's Quality Improvement program: anesthesia; speech therapy; CT scan; echocardiogram; tele-radiology; DEXA scan; ultrasound; and Magnetic Resonance Imaging (MRI).

3. Review of the document "Condition of Participation: Periodic Evaluation and Quality Assurance Review," dated 9/9/20, revealed the the CAH staff was informed that the CAH's Quality Improvement Program lacked information on every service provided at the CAH and the CAH staff needed to identify quality improvement measures for every service provided at the CAH.

4. During an interview on 7/28/21 at 1:20 PM, the Process Excellence and Quality Director verified they failed to include the anesthesia, speech therapy, CT scan, echocardiogram, tele-radiology, DEXA scan, ultrasound, and MRI departments/services in the CAH's quality improvement program, despite being informed of the requirement on 9/9/20.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) Quality Assurance/Improvement program failed to utilize objective measures to evaluate organizational processes and services for all services, including contracted services for 31 of 33 departments (Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit). The CAH administrative staff identified an average daily census of 6 inpatients for fiscal year 2020. Failure to utilize objective measures in the CAH's quality improvement program resulted in the CAH staff failing to identify patient care concerns and potentially failed to identify trends impacting patient care, potentially resulting in the CAH staff failing to prevent negative patient outcomes such as greater lengths of hospitalization, medically acquired infections, or potentially even a patient's death.

Findings include:

1. Review of the CAH's "Quality Plan," revised 6/2021, revealed in part, "Purpose: To define the ongoing performance improvement expectations to ... improve quality outcomes by using a data-driven quality assessment and performance improvement program, maintained and demonstrated with documentation evidence of the quality improvement projects being conducted, ... and the measurable progress achieved on these projects." "Maintain an on-going organization wide, ... objective, ... effective data driven approach to improvement including monitoring, data collection and analysis, designing, implementing, evaluating and maintaining process changes to improve the safety, quality, and appropriateness of care, treatment, and services."

2. Review of the "KRHC Quality" documentation revealed the following:

a. Review of the 7/15/20 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Nuclear Medicine, Obstetric unit, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department created a trauma audit worksheet as the department's quality project. The Cardiac Rehabilitation department identified COVID-19 Patient Care Responsibilities as the department's quality project. The Nuclear Medicine department changed to a different method of performing a cardiac stress test on patients as the department's quality project. The Obstetric unit investigated the use of an education app for prenatal care and signing eligible patients up for government benefits as the department's quality project. The Infection Control department created a COVID-19 testing cheat sheet and employee/manager questions as the department's quality project. The Dietary department removed unpopular food items and patient satisfaction as the department's quality project. The Occupational Therapy department identified what supplies they needed and how to order the supplies as the department's quality project. The document lacked evidence that the CAH's quality staff utilized objective data to evaluate the CAH's processes, functions, and services.

b. Review of the 8/19/20 KRHC Quality presentation revealed the staff discussed the Housekeeping, Maintenance, Hospital Admissions, and Health Information Management (HIM, Medical Records) departments' quality projects. The Housekeeping department reminded staff to turn off lights as the department's quality project. The HIM department listed payment codes for ED visits which would not get paid by an insurance company as the department's quality project. The Hospital Admissions department reminded admissions staff to collect the patient's copay upon registration of outpatient services. The document lacked evidence that the CAH's quality staff utilized objective data to evaluate the CAH's processes, functions, and services.

c. Review of the 9/16/20 KRHC Quality presentation revealed the staff discussed the Pharmacy remodeling project, then the Laboratory, Surgery, Anesthesia, and Central Sterile Processing departments' quality projects. The documentation regarding the Pharmacy remodeling project lacked evidence that the CAH quality staff utilized objective data to evaluate the CAH's processes, functions, and services.

d. Review of the 10/21/20 KRHC Quality presentation revealed the staff discussed the Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatric unit, the Emergency Room, the Obstetrical unit, Nuclear Medicine, Dietary, Diabetic Education. The Emergency Room department verified if they had PPE available for staff and the location of medications in the medication dispensing cabinet as the department's quality project. The Nuclear Medicine department instructed patients with a history of reflux to drink soda as the department's quality project. The Obstetrical department updated the quality program on using an education app as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH quality staff utilized objective data to evaluate the CAH's processes, functions, and services.

e. Review of the 11/18/20 KRHC Quality presentation revealed the staff discussed the Housekeeping and Maintenance departments' quality projects. The Housekeeping department reminded staff to turn off lights as the department's quality project. The document lacked evidence that the CAH quality staff utilized objective data to evaluate the CAH's processes, functions, and services.

f. Review of the 1/20/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatrics unit, Obstetrical unit, Diabetic Education, Nuclear Medicine, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department changed the EMS radios and trained a nurse in the examination of sexual assault victims as the department's quality project. The Infection Control department identified if staff used medical or non-medical protective equipment as the department's quality project. The Obstetrical unit put new infant warmers into service, created a lipid rescue protocol, and newborn hearing screening policy as the department's quality project. The Dietary department encouraged dietary staff to read their work email at least twice a week as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence the CAH quality staff utilized objective data to evaluate the CAH's processes, functions, and services.

g. Review of the 4/21/21 KRHC Quality presentation revealed the staff discussed the ED/Trauma/Outpatient Infusions, Nuclear Medicine, Inpatient/Swing Bed/Pediatrics unit, Infection Prevention, Occupational Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Obstetric unit, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department purchased a new EKG machine and added access to remote neurologists as the department's quality project. The Pulmonary Rehabilitation department purchased portable oxygen condensers as the department's quality project. The Nuclear Medicine department changed the way they performed patient testing as the department's quality project. The Obstetric unit implemented a new policy on patient education as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence the CAH staff utilized objective data to evaluate the CAH's processes, functions, and services.

h. Review of the 7/19/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, Nuclear Medicine, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department updated a nursing documentation flowsheet, purchased supplies to reduce the pain of procedures for pediatric patients, and created a checklist to check the crash cart as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit educated the nursing staff about how to document a patient's fluid intake when the patient's physician restricted the amount of fluid a patient can have in a day as the department's quality project. The Obstetric unit provided education to the nursing staff about decreasing the number of Cesarean sections performed at the facility as the department's quality project. The Infection Control department created new guidelines for staff use of protective equipment and treatment of infectious diarrhea as the department's quality project. The Dietary department verified the patient rooms had menus as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence the CAH staff utilized objective data to evaluate the CAH's processes, functions, and services.


3. Review of the document "Condition of Participation: Periodic Evaluation and Quality Assurance Review," dated 9/9/20, revealed the the CAH staff was informed that the CAH's Quality Improvement Program staff needed to identify quality improvement measures utilizing objective data for every service provided at the CAH.

4. During an interview on 7/28/21 at 1:20 PM, the Process Excellence and Quality Director acknowledged the CAH staff failed to utilize objective data to evaluate the CAH's process, functions, and services in the identified departments, despite the CAH staff being informed of the requirement on 9/9/20.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) Quality Assurance/Improvement program failed to address outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, CAH acquired conditions, and transitions of care, including readmission for all services, including contracted services for 31 of 33 departments (Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit). The CAH administrative staff identified an average daily census of 6 inpatients for fiscal year 2020. Failure to address outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, CAH acquired conditions, and transitions of care, including readmissions could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH "Quality Plan," revised 6/2021, revealed in part, "Objectives: Maintain an on-going organization wide, comprehensive, objective, systematic and effective data driven approach to improvement including monitoring, data collection and analysis, designing, implementing, evaluating and maintaining process changes to improve the safety, quality, and appropriateness of care, treatment, and services ..."


2. Review of the "KRHC Quality" documentation revealed the following:

a. Review of the 7/15/20 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Nuclear Medicine, Obstetric unit, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department created a trauma audit worksheet as the department's quality project. The Cardiac Rehabilitation department identified COVID-19 Patient Care Responsibilities as the department's quality project. The Nuclear Medicine department changed to a different method of performing a cardiac stress test on patients as the department's quality project. The Obstetric unit investigated the use of an education app for prenatal care and signing eligible patients up for government benefits as the department's quality project. The Infection Control department created a COVID-19 testing cheat sheet and employee/manager questions as the department's quality project. The Dietary department removed unpopular food items and patient satisfaction as the department's quality project. The Occupational Therapy department identified what supplies they needed and how to order the supplies as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

b. Review of the 8/19/20 KRHC Quality presentation revealed the staff discussed the Housekeeping, Maintenance, Hospital Admissions, and Health Information Management (HIM, Medical Records) departments' quality projects. The Housekeeping department reminded staff to turn off lights as the department's quality project. The HIM department listed payment codes for ED visits which would not get paid by an insurance company as the department's quality project. The Hospital Admissions department reminded admissions staff to collect the patient's copay upon registration of outpatient services. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

c. Review of the 9/16/20 KRHC Quality presentation revealed the staff discussed the Pharmacy remodeling project, then the Laboratory, Surgery, Anesthesia, and Central Sterile Processing departments' quality projects. The Laboratory department checked outdated supplies as the department's quality project. The Central Sterile Processing department monitored if the autoclave functioned properly as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

d. Review of the 10/21/20 KRHC Quality presentation revealed the staff discussed the Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatric unit, the Emergency Room, the Obstetrical unit, Nuclear Medicine, Dietary, Diabetic Education. The Emergency Room department verified if they had PPE available for staff and the location of medications in the medication dispensing cabinet as the department's quality project. Cardiac Rehabilitation and Pulmonary Rehabilitation tracked the number of referrals as their departments' quality project. The Nuclear Medicine department instructed patients with a history of reflux to drink soda as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked staff missed meal breaks and process breaks that caused patient care delays as the department's quality project. The Obstetrical department updated the quality program on using an education app as the department's quality project. The Dietary department used patient satisfaction scores as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

e. Review of the 11/18/20 KRHC Quality presentation revealed the staff discussed the Housekeeping and Maintenance departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department reminded staff to turn off lights as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

f. Review of the 12/26/20 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Central Sterile Processing department monitored the functioning of the autoclave and the number of canceled surgeries as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

g. Review of the 1/20/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatrics unit, Obstetrical unit, Diabetic Education, Nuclear Medicine, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department changed the EMS radios and trained a nurse in the examination of sexual assault victims as the department's quality project. The Cardiac Rehabilitation and Pulmonary Rehabilitation department tracked the number of post-COVID-19 referrals as the department's quality project. The Nuclear Medicine tracked patient delays during the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked the number of unscheduled outpatient visits as the department's quality project. The Infection Control department identified if staff used medical or non-medical protective equipment as the department's quality project. The Obstetrical unit put new infant warmers into service, created a lipid rescue protocol, and newborn hearing screening policy as the department's quality project. The Dietary department encouraged dietary staff to read their work email at least twice a week as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

h. Review of the 2/17/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the number of patients who rated the CAH's cleanliness with the top score on a patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

i. Review of the 3/17/21 KRHC Quality presentation revealed the staff discussed the Inpatient Pharmacy, Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

j. Review of the 4/21/21 KRHC Quality presentation revealed the staff discussed the ED/Trauma/Outpatient Infusions, Nuclear Medicine, Inpatient/Swing Bed/Pediatrics unit, Infection Prevention, Occupational Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Obstetric unit, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department purchased a new EKG machine and added access to remote neurologists as the department's quality project. The Pulmonary Rehabilitation department purchased portable oxygen condensers as the department's quality project. The Nuclear Medicine department changed the way they performed patient testing as the department's quality project. The Obstetric unit implemented a new policy on patient education as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

k. Review of the 5/19/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the percentage of patients who gave the CAH positive results about the CAH's cleanliness on the patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

l. Review of the 6/21/21 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures and the number of empty supply bins found as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.

m. Review of the 7/19/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, Nuclear Medicine, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department updated a nursing documentation flowsheet, purchased supplies to reduce the pain of procedures for pediatric patients, and created a checklist to check the crash cart as the department's quality project. The Nuclear Medicine department tracked the number of patients educated about the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit educated the nursing staff about how to document a patient's fluid intake when the patient's physician restricted the amount of fluid a patient can have in a day as the department's quality project. The Obstetric unit provided education to the nursing staff about decreasing the number of Cesarean sections performed at the facility as the department's quality project. The Infection Control department created new guidelines for staff use of protective equipment and treatment of infectious diarrhea as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Dietary department verified the patient rooms had menus as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff ensured the departments' quality projects addressed outcome indicators related to improved patient health outcomes.


3. Review of the document "Condition of Participation: Periodic Evaluation and Quality Assurance Review," dated 9/9/20, revealed the the CAH staff was informed that the CAH's Quality Improvement Program staff needed to ensure each service provided at the CAH quality projects addressed outcome indicators related to improved patient health.

4. During an interview on 7/28/21 at 1:20 PM, the Process Excellence and Quality Director acknowledged the CAH staff failed to ensure each service offered at the CAH identified quality projects that addressed outcome indicators related to improved patient health outcomes, despite the CAH staff being informed of the requirement on 9/9/20.

Based on review of documentation, governing board meeting minutes, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed ensure the Board of Trustees has sufficient information regarding the CAH's quality improvement activities to ensure the CAH's Board of Trustees could exercise oversight of the quality for all patient care services, including contracted services, offered at the CAH for 31 of 33 departments (Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit). The CAH administrative staff identified an average daily census of 6 inpatients for fiscal year 2020. Failure of the CAH Board of Trustees to review and evaluate Quality Improvement information could potentially result in the Board of Trustees inability to provide effective oversight to the Quality Improvement committee and result in the CAH staff delaying actions to correct any identified deficiencies in the quality of care provided to patients at the CAH.

Findings include:

1. Review of the Kossuth Regional Health Center Board of Trustees By-laws, approved 6/29/21, revealed in part, "The duties of the Board are strategic in nature including ... assuring quality ..."

2. Review of the CAH's "Quality Plan," revised 6/2021, revealed in part, "The Kossuth Regional Health Center Board maintains the ultimate accountability/responsibility ... The Kossuth Regional Health Center Board [KRHC] ensures an effective, organization wide program for quality improvement and patient safety, is defined, implemented, and maintained. The board ensures this program functions to evaluate clinical care and services, reflecting the complexity of the organization and services provided ... The Quality Program encompasses all services and operations and includes an ongoing program that shows measurable improvement in outcomes, goals identification and reduction of adverse events ... Each service/department services report monitoring and evaluation activities at least annually, to the Quality Improvement Committee ... The Plan is reviewed and approved by the [KRHC] Board...on an annual basis."

2. Review of the Board of Trustees Meeting minutes, from 7/28/20 to 6/29/21, revealed the CAH's quality staff provided the Board of Trustees with quality presentations that addressed topics including the CAH's initiative to collect copays from patients; the CAH's financial savings initiatives; redesigned huddle boards; employee injuries; and the CAH's patient satisfaction scores. The meeting minutes lacked information on the CAH's Quality Improvement activities for Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit.

3. During an interview on 07/29/2021 at 10:44 AM, the Process, Excellence & Quality Director acknowledged they failed to present the Board of Trustees at least annually with information on the CAH staff's quality improvement efforts to prevent problems, create measurable goals, corrective actions taken for identified problems, and outcomes of the corrective actions for the Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) failed to focus on measures related to improved health outcomes that are shown to be predictive of desired patient outcomes for all services, including contracted services for 31 of 33 departments (Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit). The CAH administrative staff identified an average daily census of 6 inpatients for fiscal year 2020. Failure to focus on measures related to improved health outcomes that are shown to be predictive of desired patient outcomes to include involvement of all of the CAH's departments on a continuous basis could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH "Quality Plan," revised 6/2021, revealed in part, "Objectives: Maintain an on-going organization wide, comprehensive, objective, systematic and effective data driven approach to improvement including monitoring, data collection and analysis, designing, implementing, evaluating and maintaining process changes to improve the safety, quality, and appropriateness of care, treatment, and services ..."


2. Review of the "KRHC Quality" documentation revealed the following:

a. Review of the 7/15/20 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Nuclear Medicine, Obstetric unit, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department created a trauma audit worksheet as the department's quality project. The Cardiac Rehabilitation department identified COVID-19 Patient Care Responsibilities as the department's quality project. The Nuclear Medicine department changed to a different method of performing a cardiac stress test on patients as the department's quality project. The Obstetric unit investigated the use of an education app for prenatal care and signing eligible patients up for government benefits as the department's quality project. The Infection Control department created a COVID-19 testing cheat sheet and employee/manager questions as the department's quality project. The Dietary department removed unpopular food items and patient satisfaction as the department's quality project. The Occupational Therapy department identified what supplies they needed and how to order the supplies as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

b. Review of the 8/19/20 KRHC Quality presentation revealed the staff discussed the Housekeeping, Maintenance, Hospital Admissions, and Health Information Management (HIM, Medical Records) departments' quality projects. The Housekeeping department reminded staff to turn off lights as the department's quality project. The HIM department listed payment codes for ED visits which would not get paid by an insurance company as the department's quality project. The Hospital Admissions department reminded admissions staff to collect the patient's copay upon registration of outpatient services. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

c. Review of the 9/16/20 KRHC Quality presentation revealed the staff discussed the Pharmacy remodeling project, then the Laboratory, Surgery, Anesthesia, and Central Sterile Processing departments' quality projects. The Laboratory department checked outdated supplies as the department's quality project. The Central Sterile Processing department monitored if the autoclave functioned properly as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

d. Review of the 10/21/20 KRHC Quality presentation revealed the staff discussed the Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatric unit, the Emergency Room, the Obstetrical unit, Nuclear Medicine, Dietary, Diabetic Education. The Emergency Room department verified if they had PPE available for staff and the location of medications in the medication dispensing cabinet as the department's quality project. Cardiac Rehabilitation and Pulmonary Rehabilitation tracked the number of referrals as their departments' quality project. The Nuclear Medicine department instructed patients with a history of reflux to drink soda as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked staff missed meal breaks and process breaks that caused patient care delays as the department's quality project. The Obstetrical department updated the quality program on using an education app as the department's quality project. The Dietary department used patient satisfaction scores as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

e. Review of the 11/18/20 KRHC Quality presentation revealed the staff discussed the Housekeeping and Maintenance departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department reminded staff to turn off lights as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

f. Review of the 12/26/20 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Central Sterile Processing department monitored the functioning of the autoclave and the number of canceled surgeries as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

g. Review of the 1/20/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatrics unit, Obstetrical unit, Diabetic Education, Nuclear Medicine, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department changed the EMS radios and trained a nurse in the examination of sexual assault victims as the department's quality project. The Cardiac Rehabilitation and Pulmonary Rehabilitation department tracked the number of post-COVID-19 referrals as the department's quality project. The Nuclear Medicine tracked patient delays during the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked the number of unscheduled outpatient visits as the department's quality project. The Infection Control department identified if staff used medical or non-medical protective equipment as the department's quality project. The Obstetrical unit put new infant warmers into service, created a lipid rescue protocol, and newborn hearing screening policy as the department's quality project. The Dietary department encouraged dietary staff to read their work email at least twice a week as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

h. Review of the 2/17/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the number of patients who rated the CAH's cleanliness with the top score on a patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

i. Review of the 3/17/21 KRHC Quality presentation revealed the staff discussed the Inpatient Pharmacy, Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

j. Review of the 4/21/21 KRHC Quality presentation revealed the staff discussed the ED/Trauma/Outpatient Infusions, Nuclear Medicine, Inpatient/Swing Bed/Pediatrics unit, Infection Prevention, Occupational Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Obstetric unit, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department purchased a new EKG machine and added access to remote neurologists as the department's quality project. The Pulmonary Rehabilitation department purchased portable oxygen condensers as the department's quality project. The Nuclear Medicine department changed the way they performed patient testing as the department's quality project. The Obstetric unit implemented a new policy on patient education as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

k. Review of the 5/19/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the percentage of patients who gave the CAH positive results about the CAH's cleanliness on the patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

l. Review of the 6/21/21 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures and the number of empty supply bins found as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.

m. Review of the 7/19/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, Nuclear Medicine, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department updated a nursing documentation flowsheet, purchased supplies to reduce the pain of procedures for pediatric patients, and created a checklist to check the crash cart as the department's quality project. The Nuclear Medicine department tracked the number of patients educated about the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit educated the nursing staff about how to document a patient's fluid intake when the patient's physician restricted the amount of fluid a patient can have in a day as the department's quality project. The Obstetric unit provided education to the nursing staff about decreasing the number of Cesarean sections performed at the facility as the department's quality project. The Infection Control department created new guidelines for staff use of protective equipment and treatment of infectious diarrhea as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Dietary department verified the patient rooms had menus as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures related to improved health outcomes for patients.


3. Review of the document "Condition of Participation: Periodic Evaluation and Quality Assurance Review," dated 9/9/20, revealed the the CAH staff was informed that the CAH's Quality Improvement Program staff needed to ensure each service provided at the CAH's quality projects focused on measures related to improved health outcomes for patients.

4. During an interview on 7/28/21 at 1:20 PM, the Process Excellence and Quality Director acknowledged the CAH staff failed to ensure each service offered at the CAH identified quality projects that focused on measures related to improved health outcomes for patients, despite the CAH staff being informed of the requirement on 9/9/20.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) failed to use the quality measures to analyze and track performance for predictive patient outcomes for all services, including contracted services for 31 of 33 departments (Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit). The CAH administrative staff identified an average daily census of 6 inpatients for fiscal year 2020. Failure to use the quality measures to analyze and track performance for predictive patient outcomes for all services to include involvement of all of the CAH's departments on a continuous basis could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH "Quality Plan," revised 6/2021, revealed in part, "Objectives: Maintain an on-going organization wide, comprehensive, objective, systematic and effective data driven approach to improvement including monitoring, data collection and analysis, designing, implementing, evaluating and maintaining process changes to improve the safety, quality, and appropriateness of care, treatment, and services ..."


2. Review of the "KRHC Quality" documentation revealed the following:

a. Review of the 7/15/20 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Nuclear Medicine, Obstetric unit, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department created a trauma audit worksheet as the department's quality project. The Cardiac Rehabilitation department identified COVID-19 Patient Care Responsibilities as the department's quality project. The Nuclear Medicine department changed to a different method of performing a cardiac stress test on patients as the department's quality project. The Obstetric unit investigated the use of an education app for prenatal care and signing eligible patients up for government benefits as the department's quality project. The Infection Control department created a COVID-19 testing cheat sheet and employee/manager questions as the department's quality project. The Dietary department removed unpopular food items and patient satisfaction as the department's quality project. The Occupational Therapy department identified what supplies they needed and how to order the supplies as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

b. Review of the 8/19/20 KRHC Quality presentation revealed the staff discussed the Housekeeping, Maintenance, Hospital Admissions, and Health Information Management (HIM, Medical Records) departments' quality projects. The Housekeeping department reminded staff to turn off lights as the department's quality project. The HIM department listed payment codes for ED visits which would not get paid by an insurance company as the department's quality project. The Hospital Admissions department reminded admissions staff to collect the patient's copay upon registration of outpatient services. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

c. Review of the 9/16/20 KRHC Quality presentation revealed the staff discussed the Pharmacy remodeling project, then the Laboratory, Surgery, Anesthesia, and Central Sterile Processing departments' quality projects. The Laboratory department checked outdated supplies as the department's quality project. The Central Sterile Processing department monitored if the autoclave functioned properly as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

d. Review of the 10/21/20 KRHC Quality presentation revealed the staff discussed the Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatric unit, the Emergency Room, the Obstetrical unit, Nuclear Medicine, Dietary, Diabetic Education. The Emergency Room department verified if they had PPE available for staff and the location of medications in the medication dispensing cabinet as the department's quality project. Cardiac Rehabilitation and Pulmonary Rehabilitation tracked the number of referrals as their departments' quality project. The Nuclear Medicine department instructed patients with a history of reflux to drink soda as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked staff missed meal breaks and process breaks that caused patient care delays as the department's quality project. The Obstetrical department updated the quality program on using an education app as the department's quality project. The Dietary department used patient satisfaction scores as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

e. Review of the 11/18/20 KRHC Quality presentation revealed the staff discussed the Housekeeping and Maintenance departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department reminded staff to turn off lights as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

f. Review of the 12/26/20 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Central Sterile Processing department monitored the functioning of the autoclave and the number of canceled surgeries as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

g. Review of the 1/20/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatrics unit, Obstetrical unit, Diabetic Education, Nuclear Medicine, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department changed the EMS radios and trained a nurse in the examination of sexual assault victims as the department's quality project. The Cardiac Rehabilitation and Pulmonary Rehabilitation department tracked the number of post-COVID-19 referrals as the department's quality project. The Nuclear Medicine tracked patient delays during the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked the number of unscheduled outpatient visits as the department's quality project. The Infection Control department identified if staff used medical or non-medical protective equipment as the department's quality project. The Obstetrical unit put new infant warmers into service, created a lipid rescue protocol, and newborn hearing screening policy as the department's quality project. The Dietary department encouraged dietary staff to read their work email at least twice a week as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

h. Review of the 2/17/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the number of patients who rated the CAH's cleanliness with the top score on a patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

i. Review of the 3/17/21 KRHC Quality presentation revealed the staff discussed the Inpatient Pharmacy, Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

j. Review of the 4/21/21 KRHC Quality presentation revealed the staff discussed the ED/Trauma/Outpatient Infusions, Nuclear Medicine, Inpatient/Swing Bed/Pediatrics unit, Infection Prevention, Occupational Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Obstetric unit, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department purchased a new EKG machine and added access to remote neurologists as the department's quality project. The Pulmonary Rehabilitation department purchased portable oxygen condensers as the department's quality project. The Nuclear Medicine department changed the way they performed patient testing as the department's quality project. The Obstetric unit implemented a new policy on patient education as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

k. Review of the 5/19/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the percentage of patients who gave the CAH positive results about the CAH's cleanliness on the patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

l. Review of the 6/21/21 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures and the number of empty supply bins found as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.

m. Review of the 7/19/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, Nuclear Medicine, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department updated a nursing documentation flowsheet, purchased supplies to reduce the pain of procedures for pediatric patients, and created a checklist to check the crash cart as the department's quality project. The Nuclear Medicine department tracked the number of patients educated about the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit educated the nursing staff about how to document a patient's fluid intake when the patient's physician restricted the amount of fluid a patient can have in a day as the department's quality project. The Obstetric unit provided education to the nursing staff about decreasing the number of Cesarean sections performed at the facility as the department's quality project. The Infection Control department created new guidelines for staff use of protective equipment and treatment of infectious diarrhea as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Dietary department verified the patient rooms had menus as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff focused on measures to analyze and track the quality program's performance.


3. Review of the document "Condition of Participation: Periodic Evaluation and Quality Assurance Review," dated 9/9/20, revealed the the CAH staff was informed that the CAH's Quality Improvement Program staff needed to ensure each service provided at the CAH's quality projects focused on measures to analyze and track the quality program's performance.

4. During an interview on 7/28/21 at 1:20 PM, the Process Excellence and Quality Director acknowledged the CAH staff failed to ensure each service offered at the CAH identified quality projects that focused on measures to analyze and track the quality program's performance, despite the CAH staff being informed of the requirement on 9/9/20.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) failed to set priorities for performance improvement with consideration of high volume, high -risk services or problem prone areas for predictive patient outcomes for all services, including contracted services for 31 of 33 departments (Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit). The CAH administrative staff identified an average daily census of 6 inpatients for fiscal year 2020. Failure to set priorities for performance improvement with consideration of high volume, high -risk services or problem prone areas for predictive patient outcomes for all services to include involvement of all of the CAH's departments on a continuous basis could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH "Quality Plan," revised 6/2021, revealed in part, "Objectives: Maintain an on-going organization wide, comprehensive, objective, systematic and effective data driven approach to improvement including monitoring, data collection and analysis, designing, implementing, evaluating and maintaining process changes to improve the safety, quality, and appropriateness of care, treatment, and services ..."


2. Review of the "KRHC Quality" documentation revealed the following:

a. Review of the 7/15/20 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Nuclear Medicine, Obstetric unit, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department created a trauma audit worksheet as the department's quality project. The Cardiac Rehabilitation department identified COVID-19 Patient Care Responsibilities as the department's quality project. The Nuclear Medicine department changed to a different method of performing a cardiac stress test on patients as the department's quality project. The Obstetric unit investigated the use of an education app for prenatal care and signing eligible patients up for government benefits as the department's quality project. The Infection Control department created a COVID-19 testing cheat sheet and employee/manager questions as the department's quality project. The Dietary department removed unpopular food items and patient satisfaction as the department's quality project. The Occupational Therapy department identified what supplies they needed and how to order the supplies as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

b. Review of the 8/19/20 KRHC Quality presentation revealed the staff discussed the Housekeeping, Maintenance, Hospital Admissions, and Health Information Management (HIM, Medical Records) departments' quality projects. The Housekeeping department reminded staff to turn off lights as the department's quality project. The HIM department listed payment codes for ED visits which would not get paid by an insurance company as the department's quality project. The Hospital Admissions department reminded admissions staff to collect the patient's copay upon registration of outpatient services. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

c. Review of the 9/16/20 KRHC Quality presentation revealed the staff discussed the Pharmacy remodeling project, then the Laboratory, Surgery, Anesthesia, and Central Sterile Processing departments' quality projects. The Laboratory department checked outdated supplies as the department's quality project. The Central Sterile Processing department monitored if the autoclave functioned properly as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

d. Review of the 10/21/20 KRHC Quality presentation revealed the staff discussed the Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatric unit, the Emergency Room, the Obstetrical unit, Nuclear Medicine, Dietary, Diabetic Education. The Emergency Room department verified if they had PPE available for staff and the location of medications in the medication dispensing cabinet as the department's quality project. Cardiac Rehabilitation and Pulmonary Rehabilitation tracked the number of referrals as their departments' quality project. The Nuclear Medicine department instructed patients with a history of reflux to drink soda as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked staff missed meal breaks and process breaks that caused patient care delays as the department's quality project. The Obstetrical department updated the quality program on using an education app as the department's quality project. The Dietary department used patient satisfaction scores as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

e. Review of the 11/18/20 KRHC Quality presentation revealed the staff discussed the Housekeeping and Maintenance departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department reminded staff to turn off lights as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

f. Review of the 12/26/20 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Central Sterile Processing department monitored the functioning of the autoclave and the number of canceled surgeries as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

g. Review of the 1/20/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatrics unit, Obstetrical unit, Diabetic Education, Nuclear Medicine, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department changed the EMS radios and trained a nurse in the examination of sexual assault victims as the department's quality project. The Cardiac Rehabilitation and Pulmonary Rehabilitation department tracked the number of post-COVID-19 referrals as the department's quality project. The Nuclear Medicine tracked patient delays during the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked the number of unscheduled outpatient visits as the department's quality project. The Infection Control department identified if staff used medical or non-medical protective equipment as the department's quality project. The Obstetrical unit put new infant warmers into service, created a lipid rescue protocol, and newborn hearing screening policy as the department's quality project. The Dietary department encouraged dietary staff to read their work email at least twice a week as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

h. Review of the 2/17/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the number of patients who rated the CAH's cleanliness with the top score on a patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

i. Review of the 3/17/21 KRHC Quality presentation revealed the staff discussed the Inpatient Pharmacy, Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

j. Review of the 4/21/21 KRHC Quality presentation revealed the staff discussed the ED/Trauma/Outpatient Infusions, Nuclear Medicine, Inpatient/Swing Bed/Pediatrics unit, Infection Prevention, Occupational Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Obstetric unit, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department purchased a new EKG machine and added access to remote neurologists as the department's quality project. The Pulmonary Rehabilitation department purchased portable oxygen condensers as the department's quality project. The Nuclear Medicine department changed the way they performed patient testing as the department's quality project. The Obstetric unit implemented a new policy on patient education as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

k. Review of the 5/19/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the percentage of patients who gave the CAH positive results about the CAH's cleanliness on the patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

l. Review of the 6/21/21 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures and the number of empty supply bins found as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.

m. Review of the 7/19/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, Nuclear Medicine, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department updated a nursing documentation flowsheet, purchased supplies to reduce the pain of procedures for pediatric patients, and created a checklist to check the crash cart as the department's quality project. The Nuclear Medicine department tracked the number of patients educated about the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit educated the nursing staff about how to document a patient's fluid intake when the patient's physician restricted the amount of fluid a patient can have in a day as the department's quality project. The Obstetric unit provided education to the nursing staff about decreasing the number of Cesarean sections performed at the facility as the department's quality project. The Infection Control department created new guidelines for staff use of protective equipment and treatment of infectious diarrhea as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Dietary department verified the patient rooms had menus as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff focused on priorities that considered high volume, high-risk services, or problem prone areas.


3. Review of the document "Condition of Participation: Periodic Evaluation and Quality Assurance Review," dated 9/9/20, revealed the the CAH staff was informed that the CAH's Quality Improvement Program staff needed to ensure each service provided at the CAH's quality projects considered high volume, high-risk services, or problem prone areas.

4. During an interview on 7/28/21 at 1:20 PM, the Process Excellence and Quality Director acknowledged the CAH staff failed to ensure each service offered at the CAH identified quality projects that focused on measures that considered high volume, high-risk services, or problem prone areas, despite the CAH staff being informed of the requirement on 9/9/20.

Based on review of documentation and staff interview, the Critical Access Hospital's (CAH) Quality Assurance/Improvement program (QAPI) failed to incorporate quality indicator data including patient care data, and other relevant data, in order to achieve the goals of the QAPI program predictive patient outcomes for all services, including contracted services for 31 of 33 departments (Anesthesia, Surgical services, Emergency Room [ER], Pharmacy, Laboratory, Central Sterile [CS], Respiratory Therapy [RT], Speech Therapy, Occupational Therapy, Radiology, Nuclear Medicine, CAT Scan, Echocardiogram Scans, Teleradiology, Dexa Scan, Ultrasound, Magnetic Resonance Imaging [MRI], Dietary, Dietician, Medical/Surgical [Med/Surg] Unit, Diabetic Education, Swing Bed, Pulmonary Rehab, Cardiac Rehab, Health Information Management, IV Infusion, Discharge Planning, Housekeeping, Infection Control, and OB Unit). The CAH administrative staff identified an average daily census of 6 inpatients for fiscal year 2020. Failure to incorporate quality indicator data including patient care data, and other relevant data, in order to achieve the goals of the QAPI program for predictive patient outcomes for all services to include involvement of all of the CAH's departments on a continuous basis could potentially result in the CAH quality staff failing to identify potentially significant patient care concerns while monitoring items not related to patient care, thus missing potentially life-threatening patient care concerns.

Findings include:

1. Review of the CAH "Quality Plan," revised 6/2021, revealed in part, "Objectives: Maintain an on-going organization wide, comprehensive, objective, systematic and effective data driven approach to improvement including monitoring, data collection and analysis, designing, implementing, evaluating and maintaining process changes to improve the safety, quality, and appropriateness of care, treatment, and services ..."


2. Review of the "KRHC Quality" documentation revealed the following:

a. Review of the 7/15/20 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Nuclear Medicine, Obstetric unit, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department created a trauma audit worksheet as the department's quality project. The Cardiac Rehabilitation department identified COVID-19 Patient Care Responsibilities as the department's quality project. The Nuclear Medicine department changed to a different method of performing a cardiac stress test on patients as the department's quality project. The Obstetric unit investigated the use of an education app for prenatal care and signing eligible patients up for government benefits as the department's quality project. The Infection Control department created a COVID-19 testing cheat sheet and employee/manager questions as the department's quality project. The Dietary department removed unpopular food items and patient satisfaction as the department's quality project. The Occupational Therapy department identified what supplies they needed and how to order the supplies as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

b. Review of the 8/19/20 KRHC Quality presentation revealed the staff discussed the Housekeeping, Maintenance, Hospital Admissions, and Health Information Management (HIM, Medical Records) departments' quality projects. The Housekeeping department reminded staff to turn off lights as the department's quality project. The HIM department listed payment codes for ED visits which would not get paid by an insurance company as the department's quality project. The Hospital Admissions department reminded admissions staff to collect the patient's copay upon registration of outpatient services. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

c. Review of the 9/16/20 KRHC Quality presentation revealed the staff discussed the Pharmacy remodeling project, then the Laboratory, Surgery, Anesthesia, and Central Sterile Processing departments' quality projects. The Laboratory department checked outdated supplies as the department's quality project. The Central Sterile Processing department monitored if the autoclave functioned properly as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

d. Review of the 10/21/20 KRHC Quality presentation revealed the staff discussed the Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatric unit, the Emergency Room, the Obstetrical unit, Nuclear Medicine, Dietary, Diabetic Education. The Emergency Room department verified if they had PPE available for staff and the location of medications in the medication dispensing cabinet as the department's quality project. Cardiac Rehabilitation and Pulmonary Rehabilitation tracked the number of referrals as their departments' quality project. The Nuclear Medicine department instructed patients with a history of reflux to drink soda as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked staff missed meal breaks and process breaks that caused patient care delays as the department's quality project. The Obstetrical department updated the quality program on using an education app as the department's quality project. The Dietary department used patient satisfaction scores as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

e. Review of the 11/18/20 KRHC Quality presentation revealed the staff discussed the Housekeeping and Maintenance departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department reminded staff to turn off lights as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

f. Review of the 12/26/20 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Central Sterile Processing department monitored the functioning of the autoclave and the number of canceled surgeries as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

g. Review of the 1/20/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Cardiac Rehabilitation, Pulmonary Rehabilitation, Inpatient/Swing Bed/Pediatrics unit, Obstetrical unit, Diabetic Education, Nuclear Medicine, and Dietary departments' quality projects. The ER/Trauma/Outpatient Infusions department changed the EMS radios and trained a nurse in the examination of sexual assault victims as the department's quality project. The Cardiac Rehabilitation and Pulmonary Rehabilitation department tracked the number of post-COVID-19 referrals as the department's quality project. The Nuclear Medicine tracked patient delays during the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit tracked the number of unscheduled outpatient visits as the department's quality project. The Infection Control department identified if staff used medical or non-medical protective equipment as the department's quality project. The Obstetrical unit put new infant warmers into service, created a lipid rescue protocol, and newborn hearing screening policy as the department's quality project. The Dietary department encouraged dietary staff to read their work email at least twice a week as the department's quality project. The Diabetic Education department used implementing COVID-19 precautions as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

h. Review of the 2/17/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the number of patients who rated the CAH's cleanliness with the top score on a patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

i. Review of the 3/17/21 KRHC Quality presentation revealed the staff discussed the Inpatient Pharmacy, Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

j. Review of the 4/21/21 KRHC Quality presentation revealed the staff discussed the ED/Trauma/Outpatient Infusions, Nuclear Medicine, Inpatient/Swing Bed/Pediatrics unit, Infection Prevention, Occupational Therapy, Cardiac Rehabilitation, Pulmonary Rehabilitation, Obstetric unit, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department purchased a new EKG machine and added access to remote neurologists as the department's quality project. The Pulmonary Rehabilitation department purchased portable oxygen condensers as the department's quality project. The Nuclear Medicine department changed the way they performed patient testing as the department's quality project. The Obstetric unit implemented a new policy on patient education as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

k. Review of the 5/19/21 KRHC Quality presentation revealed the staff discussed the Housekeeping and HIM departments' quality projects. The Maintenance department tracked the number of hours staff came in after hours as the department's quality project. The Housekeeping department tracked the percentage of patients who gave the CAH positive results about the CAH's cleanliness on the patient satisfaction survey as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

l. Review of the 6/21/21 KRHC Quality presentation revealed the staff discussed the Lab/Blood Bank/EKG, Surgery, Anesthesia, Central Sterile Processing, and Radiology departments' quality projects. The Laboratory department checked for outdated supplies as the department's quality project. The Surgery department tracked the number of patients who rescheduled their procedures and the number of empty supply bins found as the department's quality project. The Central Sterile Processing department tracked the functioning of the autoclave as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

m. Review of the 7/19/21 KRHC Quality presentation revealed the staff discussed the ER/Trauma/Outpatient Infusions, Inpatient/Swing Bed/Pediatrics unit, Infection Control, Occupational Therapy, Nuclear Medicine, Sleep Study, and Diabetic Education departments' quality projects. The ER/Trauma/Outpatient Infusions department updated a nursing documentation flowsheet, purchased supplies to reduce the pain of procedures for pediatric patients, and created a checklist to check the crash cart as the department's quality project. The Nuclear Medicine department tracked the number of patients educated about the procedure as the department's quality project. The Inpatient/Swing Bed/Pediatrics unit educated the nursing staff about how to document a patient's fluid intake when the patient's physician restricted the amount of fluid a patient can have in a day as the department's quality project. The Obstetric unit provided education to the nursing staff about decreasing the number of Cesarean sections performed at the facility as the department's quality project. The Infection Control department created new guidelines for staff use of protective equipment and treatment of infectious diarrhea as the department's quality project. The Sleep Study department tracked the time a physician took to interpret the sleep study as the department's quality project. The Dietary department verified the patient rooms had menus as the department's quality project. The Occupational Therapy department trained a therapist in a new technique as the department's quality project. The document lacked evidence that the CAH's quality staff incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.


3. Review of the document "Condition of Participation: Periodic Evaluation and Quality Assurance Review," dated 9/9/20, revealed the the CAH staff was informed that the CAH's Quality Improvement Program staff needed to ensure each service provided at the CAH's quality projects incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program.

4. During an interview on 7/28/21 at 1:20 PM, the Process Excellence and Quality Director acknowledged the CAH staff failed to ensure each service offered at the CAH incorporated quality indicator data, including patient care data, to achieve the goals of the QAPI program, despite the CAH staff being informed of the requirement on 9/9/20.

Based on review of policy/procedure and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 abuse policy contained the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for swing bd patients. The CAH administrative staff identified 5 skilled patients at the beginning of the survey. Failure to include the required language in the abuse policy could potentially prevent CAH staff from reporting alleged violations involving abuse to the CAH administrator and to other officials (including to the State Survey Agency) in a timely manner.

Findings include:

1. Review of the CAH's policy "Mandatory Reporting - Child Abuse/Neglect, Dependent Adult Abuse, Suspicious Burns, Wounds or Injuries from Criminal Activity, and Dog Bites," last approved 6/2021, failed to include the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).

2. During an interview on 7/28/21 at 8:45 AM, the Director of Process Excellence and Quality acknowledged the abuse policy failed to include the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).

During an interview on 7/29/21 at 11:20 AM, the Chief Executive Officer/Chief Nursing Officer acknowledged the abuse policy failed to include the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).

Based on review of policy/procedure and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the skilled nursing policy addressed the CAH staff must assist skilled nursing patients in obtaining 24-hour emergency dental care. The CAH administrative staff identified 5 skilled patients at the beginning of the survey. Failure to include the skilled nursing policy addressed the CAH staff must assist skilled nursing patients in obtaining 24-hour emergency dental care could potentially prevent CAH staff from assisting skilled nursing patients in obtaining emergency dental care when needed.

Findings include:

1. Review of the CAH policy "Skilled Nursing," last approved 6/2021, failed to address the regulatory requirement that the CAH staff must assist skilled nursing patients in obtaining 24-hour emergency dental care.

2. During an interview on 7/29/21 at 11:20 AM, the Chief Executive Officer/Chief Nursing Officer acknowledged the skilled nursing policy failed to address the CAH staff must assist skilled nursing patients in obtaining 24-hour emergency dental care.