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Based on interview and document review, the critical access hospital (CAH) failed to ensure performance reviews were completed in a timely manner for 9 of 14 employees (ancillary services director - ASD, registered nurse- RN-E, RN-F, lab supervisor - LS, radiology supervisor - RS, director of nursing - DON, respiratory therapist - RT, RN-H, food service director- FSD) whose personnel records were reviewed. This had the potential to affect all current and future patients of the CAH.

Findings include:

On 4/16/15, at 10:40 a.m. the personnel records were reviewed with the human resource director (HRD). The HRD confirmed performance reviews should be completed annually on each employee. The HRD verified the performance review information on the following employees:
· ASD's last performance review had been completed on 1/2009
· RN-E's last performance review had been completed on 2/25/2009
· RN-F's last performance review had been completed on 2/4/2009
· LS's last performance review had been completed on 5/29/2013
· RS's last performance review had been completed on 6/6/2013
· DON's last performance review had been completed on 7/2009
· RT's last performance review had been completed on 3/13/2013
· RN-H's last performance review had been completed on 6/2009
· FSD's last performance review had been completed in 2006

The CAH's Personnel Policy Handbook dated 4/4/2013, indicated that all employees were entitled to know how their job performances were being evaluated: therefore, supervisors were required to complete the evaluation process in a timely fashion. In addition, performance reviews would be conducted annually.

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.


Findings include:


Please refer to Life Safety Code inspection tags: K-0029, K-0144, K-0147, K-0011, K-0029, K-0154, K-0155

Based on interview and document review, the critical access hospital (CAH) failed to ensure the change in administration was reported to the State Agency (SA).

Findings include:

On 4/16/15, at 2:10 p.m. the chief executive officer (CEO) confirmed his first day at the CAH as the interim CEO was 1/12/15.

On 4/16/15, at 2:20 p.m. the executive assistant (EA) and interim CEO confirmed as far as they were aware the SA had not been notified of the change in administration at the CAH, prior to or after the interim CEO's appointment.

On 4/17/15, at 9:10 a.m. the EA provided an e-mail correspondence from the CEO at Lake Region Healthcare. The CEO at Lake Region Healthcare verified in this correspondence that the change in administration needed to be reported to the SA.

The governing board meeting minutes dated 1/13/15, extended a welcome to the interim CEO.

Based on interview and document review, the critical access hospital (CAH) failed to develop and implement an infection control program related to ongoing surveillance and trending of patient infections according to established policies. This had the potential to affect all patients who were treated at the CAH. In addition, the facility failed to ensure personal protective equipment was appropriately utilized during cleaning and disinfecting of 1 of 1 endoscopes in order to minimize infection and cross contamination.

Findings include:

On 4/15/15, at 10:00 a.m. registered nurse (RN)-A stated the CAH did not have a process for tracking and trending of infections/communicable diseases or nosocomial infections of patients who had been treated at the facility. RN-A stated she had been working part time in the role of infection control nurse since 10/14, and verified the facility didn't have any method of logging infections prior to or since that time. RN-A stated there was so much that needed to be done related to infection control throughout the facility that she could work full time for a while to get the process to where it needed to be. The CAH was unable to provide documentation of infections that included: hospital acquired infections, signs and symptoms of infections that were related to the admission diagnosis, signs and symptoms of infection during their hospital stay, type of infection, culture sensitivities, and antibiotics used.



Review of the Infection Control Plan last reviewed on 12/29/14, identified the following purpose of, "To provide a safe, clean environment. To perform ongoing surveillance studies." The policy went on to describe general principles to be followed which included recognition of infections in patients, personnel, visitors and the community and also appropriate medical treatment of infections, including antibiotic stewardship.


The Infection Control Bylaws last reviewed on 12/3/14, indicated there would be an active hospital/facility wide infection control program which would include the following:
· A system of evaluating and reporting infections in patients and personnel
· Preventative, surveillance and control procedures relating to the inanimate hospital environment



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Personal Protective Equipment:


During observation on 4/16/15, at 10:52 a.m., licensed practical nurse (LPN)-B was observed cleaning and disinfecting an endoscope, (a flexible instrument used to examine the interior of a hollow organ or cavity of the body, most commonly for the stomach or bowel). The endoscope was visibly contaminated with body fluids after a patient procedure was completed. While wearing gloves, LPN-B placed the soiled endoscope in a sink and submerged it in water with enzymatic cleaner. The sink was approximately 3/4 full. LPN-B wore a thin fabric hospital patient gown over fabric scrub attire. LPN-B continued the cleaning process, washed the entire scope down with gauze, brushed all of the smaller parts and valves on the outside of the scope and utilized a special wire-type cleaning utensil with a brush on the end to clean all the interior channels of the scope, taking the parts of the scope in and out of the water as it was submerged in the sink. LPN-B leaned on the edge of the wet sink throughout this process. LPN-B then attached the scope to a suction receptacle, which was set on the edge of the wet sink, and suctioned water and alcohol through the scope. During this time, the scope and cleaning equipment were wet. When all required cleaning processes were complete, LPN-B then detached the scope from suction and placed it in a bath of high-level disinfectant. Throughout this process, LPN-B wore the same thin fabric hospital gown over the fabric scrub attire.


When interviewed on 4/16/15, at 11:29 a.m. LPN-B confirmed it was usual practice to wear the thin fabric hospital gown over scrub attire while cleaning the soiled endoscopes. LPN-B verified the gown was not impermeable to fluid and would not prevent fluids on the scope, soiled from a patient's colon or stomach procedure, from leaking through to the scrub attire which was then worn throughout the day. LPN-B indicated it was not an effective infection control practice and a fluid impermeable cover should be worn over the fabric scrub attire during cleaning of a contaminated endoscope.


When interviewed on 4/16/15, at 12:59 p.m., the facility surgical supervisor registered nurse (RN)-E confirmed a fluid impermeable gown should be worn during the cleaning and disinfecting of contaminated endoscopes.


Review of facility policy titled, Flexible Endoscope Reprocessing, dated 1/2015, directed staff to utilize proper personal protective equipment for the reprocessing of contaminated endoscopes.

Based on document review and interview, the critical access hospital (CAH) failed to ensure each medical record entry by the physician and/or nurse practitioners were properly dated, timed and signed in a timely manor for 13 of 20 patient (P1, P2, P3, P4, P6, P7, P8, P12, P15, P16, P17, P18, P19) records reviewed.


Findings include:


During record review of the aforementioned patients on 4/15/15, from 10 a.m. to 4:40 p.m. with health information management director (HIM)-D, documents in the patient records lacked timely and/or complete authentication. The documents included progress notes, physician orders, discharge summaries, verbal orders, and history and physical exams. HIM-D verified all patient medical record findings.


An interview with HIM-D at 10:45 a.m. on 4/16/15, whom verified entries in the medical records reviewed, lacked consistent authentication of date/time by the author. She further indicated the CAH had a policy of medical record completion timeline which needed to be followed.


The medical staff by-laws dated 2010 state "All progress notes will be timed, dated and signed by the practitioner making the note."


A policy entitled, Medical Record Dictation Timeline Completion Medical Records/HIM dated 3/1/15, indicated complete signatures would be provided within 24-48 hours.

Based on interview and document review the critical access hospital (CAH) failed to ensure quality assurance/performance improvement (QAPI) projects were developed and integrated in the CAH's quality improvement program for the following services: infection control and anesthesia. This had the potential to affect all current and future patients of the CAH.

Findings include:

During interview on 4/15/15, at 10:00 a.m. registered nurse (RN)-A stated there was no formal QAPI project with goals, analysis or communication to evaluate the ongoing infection control program that was incorporated into the facility wide quality program. There were no documents available for review.



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During telephone interview on 4/17/15, at 9:05 a.m., a facility contracted certified registered nurse anesthetist (CRNA)-A was unaware of any performance improvement project for the anesthesia company.


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On 4/17/15, at 9:10 a.m. the ancillary services director (ASD,) who oversees the CAH's quality improvement program, confirmed the anesthesia department had identified one QAPI project which they had been working on since 10/14/13. Anesthesia's quality assurance reports revealed anesthesia services had been 100% compliant with this QAPI project since 10/14/13. The ASD stated since the anesthesia department had demonstrated compliance with this QAPI project for this length of time; anesthesia services should have identified a new QAPI project.


The CAH's Quality Assurance Plan dated 5/27/14, indicated all patient care services would be evaluated through the quality assurance process. Infection control and anesthesia were scheduled to report quarterly. In addition, as directed through the CAH's QAPI process projects would be evaluated and monitored until the established outcome was met.