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Based on document review and staff interview, the Critical Access Hospital (CAH) Governing Board failed to ensure the CAH Board of Directors reviewed 1 of 1 set of CAH Board of Directors Bylaws every other year, as required by the CAH Board of Directors Bylaws. Failure to review the CAH Board of Directors Bylaws every other year could potentially result in the Board of Directors Bylaws failing to ensure the CAH Board of Directors had the ability to oversee all aspects of the CAH's operations and failing to adapt to new challenges facing the CAH. The CAH identified 1 of 1 Board of Directors and a census of 1 inpatient at the beginning of the survey.

Findings include:

1. Review of the "Restated Bylaws of Community Memorial Hospital Board of Directors," adopted and approved on 3/18/14, revealed in part, "These Bylaws shall be reviewed biennially (every 2 years)."

2. Review of the Board of Directors meeting minutes from 2018 and 2019 revealed the CAH's Board of Directors failed to review and approve the Restated Bylaws of Community Memorial Hospital Board of Directors during 2018 or 2019.

3. During an interview on 4/1/19 at approximately 4:30 PM, the VP of Nursing Services acknowledged the Governing Board failed to review and approve the CAH Restated Bylaws of Community Memorial Hospital Board of Directors biennially as required by the Bylaws.

I. Based on observation and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the endoscopy staff changed the sterile water flush bottles in 1 of 1 endoscopy rooms after each patient, in accordance with the manufacturer's directions. 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 OR Supervisor identified that the endoscopy staff performed an average of 144 endoscopy procedures per year.

Findings include:

1. Observations on 4/17/19 at approximately 8:00 AM in the Endoscopy Room during an endoscopy procedure (a surgical procedure where a physician inserters a flexible camera into a patient's body) for Patient #1, revealed 1 of 1 Hospira 1000 mL bottle of sterile water for irrigation connected to the endoscopy equipment. Review of the manufacturer's instructions on the bottle indicated the CAH 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.

2. During an interview after the endoscopy procedure, the OR Supervisor revealed the endoscopy staff opened a bottle of sterile water for irrigation each day with scheduled endoscopic procedures and connected the bottle of water to the equipment. The endoscopy staff did not change the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscopy procedures. The endoscopy staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscopy procedures for the day or if the bottle ran empty.

3. During an interview on 4/17/19 at approximately 1:45 PM, the OR Supervisor confirmed the manufacturer's directions for the Hospira 1000 mL bottles of sterile water for irrigation did not support using the bottles of sterile water for irrigation for more than one patient.


II. Based on observation and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 observed Certified Registered Nurse Anesthetist (CRNA) A cleansed the stopper on medication vials prior to removing the medication from the vial for 1 of 1 observed surgical patients (Patient #2). Failure to cleanse the stopper could potentially result in the staff introducing bacteria, viruses, or fungi into the medication and then administering the contaminated medication to the patient. Administering contaminated medication could potentially result in the patient developing a life threatening infection. The OR Supervisor identified the hospital staff performed an average of 180 surgical procedures per year.

Findings include:

1. Observations on 4/18/19 in the OR during a surgical procedure for Patient #2 revealed the following:

a. At approximately 9:35 AM, CRNA A (a nurse with specialized training to administer the medications used during surgery to ensure patients do not feel pain during surgery) removed the plastic cover on the top of the medication vial and removed 200 mg (milligrams) of Propofol (drug used for anesthesia and sedation) with a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

b. At approximately 9:35 AM CRNA A removed the plastic cover on the top of the medication vial and removed 200 mg from a second vial of Propofol with a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

c. At approximately 9:35 AM CRNA A) removed the plastic cover on the top of the medication vial and removed 200 mg from a third vial of Propofol with a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

d. At approximately 9:35 AM CRNA A removed the plastic cover on the top of the medication vial and removed Xylocaine 2% (drug used to numb an area of the body) from the vial, using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

e. At approximately 9:35 AM CRNA A removed the plastic cover on the top of the medication vial and removed Xylocaine 2% from a second vial, using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

f. At approximately 9:35 AM CRNA A removed the plastic cover on the top of the medication vial and removed 80 mcg (micrograms) of Precedex from a vial, using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

g. At approximately 9:35 AM CRNA A removed the plastic cover on the top of the medication vial and removed 10 mg of Rocuronium (drug used for muscle relaxation) from a vial, using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

h. At approximately 9:35 AM CRNA A removed the plastic cover on the top of the medication vial and removed 30 mg of Toradol (drug used for pain) from a vial, using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

i. At approximately 9:35 AM CRNA A removed the plastic cover on the top of the medication vial and removed 500 mg of Ketamine (drug used for anesthesia) from a vial, using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

j. At approximately 10:16 AM CRNA A removed the plastic cover on the top of the medication vial and removed 10 mg of Rocuronium from a vial, using a needle attached to a syringe. CRNA A failed to cleanse the vial stopper prior to removing the medication from the vial.

2. During an interview on 4/18/19 at approximately 9:50 AM, CRNA A acknowledged they failed to cleanse the vial stopper prior to removing the medications from the vials.

3. During an interview on 4/18/19 at 1:45 PM, the OR Supervisor revealed they expected the OR staff, including CRNA A, to cleanse the stoppers of medication vials prior to removing the medication from a vial.

Based on review of policies, documentation, and staff interviews, the Critical Access Hospital (CAH) staff failed to utilize 1 of 1 Annual Critical Access Hospital Reports to determine the appropriate utilization of services at the facility, determine if the facility followed established policies, and determine if the facility needed to make changes. The CAH performed 1 Annual Critical Access Hospital Report per year. Failure to utilize the report to determine the appropriateness of utilization of services, determine if the facility followed policies, and determine if the facility needed to make changes in their services could potentially result in the facility failing to identify areas that need improvement, and potentially failing to implement improvements. The CAH's administrative staff identified a census of 1 inpatient at the beginning of the survey.

Findings include:

1. Review of the "January - December 2018 12-month CQI Summaries," undated, revealed the CAH staff failed to determine the appropriate utilization of services at the facility, failed to determine if the facility staff followed established policies, and failed to determine if the facility staff needed to make changes based upon the review.

Review of the "CAH Minutes, dated 1/29/19, revealed the CAH staff failed to determine the appropriate utilization of services at the facility, failed to determine if the facility staff followed established policies, and failed to determine if the facility staff needed to make changes based upon the review.

2. During an interview on 4/18/19 at 10:35 AM, the Analytic Manager, Compliance, Privacy, Quality, and Credentialing acknowledged the CAH failed to include the 12-month CQI Summaries and the January 2019 CAH Meeting minutes during the Annual Program Review to determine the appropriate utilization of services at the facility, determine if the facility staff followed established policies, and determine if the facility staff needed to make changes based upon the review.

Based on review of the Performance Improvement Plan, Quality Improvement meetings/activities, documentation, and staff interviews, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for 6 of 8 contracted patient care services (MRI - Magnetic Resonance Imaging, Nuclear Medicine, Anesthesia, Echo/Ultrasound, Tele-Health-Psychiatry, and Tele-Radiology). Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care. The CAH administrative staff reported a census of 1 patient at the beginning of the survey. The CAH administrative staff reported the following procedures for January 1, 2018 to December 31, 2018 - MRI 214, Nuclear Medicine 17, Anesthesia 314, Echo/Ultrasound 13, and Tele-Health-Psychiatry 18, and April 1, 2018 to March 31, 2019 - Tele-Radiology 1,164.

Findings include:

1. Review of CAH "Performance Improvement Plan 2019," revealed in part, "Departments or services shall participate in performance improvement activities with an ongoing and systematic process for monitoring and evaluating the services provided.... Reporting of Performance Improvement Information i. Each department shall review, summarize, and report the findings of its performance improvement activities to the quality director on a monthly/quarterly basis. ii. Each department shall evaluate the effectiveness of its performance improvement activities on an annual basis. The documentation of this review should include opportunities to improve care/service identified during the past year with a brief synopsis of the actions taken and any evidence that such action was effective..."

2. Review of the "CQI/Risk Management Committee" Meeting minutes from May 2018 through January 2019 evidence the CAH staff monitored, evaluated, and reported quality improvement activities regarding patient care services for: MRI - Magnetic Resonance Imaging, Nuclear Medicine, Anesthesia, Echo/Ultrasound, Tele-Health-Psychiatry, and Tele-Radiology.

Review of "Documentation Request Follow-up," dated 1/1/2019, provided by the Radiology Supervisor on 4/15/19 at 1:45 PM revealed in part, "Echo/Ultrasound is [an as needed] service as of March 24, 2016. Because it is PRN I do not have QA or Patient Survey Reports..."

3. During an interview on 4/15/19 at 1:45 PM, the Radiology Supervisor acknowledged they did not monitor, evaluate, or ensure reporting of quality improvement patient care services for the contracted patient care services of MRI - Magnetic Resonance Imaging, Nuclear Medicine, and Echo/Ultrasound. The Radiology Supervisor further acknowledged the quality reports received from MRI and Nuclear Medicine only included numbers of tests ordered and completed.

During an interview on 4/18/19 at 10:05 AM, the Analytic Manager, Compliance, Privacy, Quality and Credentialing acknowledged the CAH staff failed to ensure the CAH staff monitored, evaluated, and reported quality improvement activities regarding patient care services for MRI - Magnetic Resonance Imaging, Nuclear Medicine, Anesthesia, Echo/Ultrasound, Tele-Health-Psychiatry, and Tele-Radiology.

Based on document review, policy review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 applicable tele-radiologists selected for review (Tele-radiologist B), received outside entity peer review to evaluate the appropriateness of diagnosis and treatment furnished to patients at the Critical Access Hospital. Failure to ensure all medical staff members received outside entity peer review affects the CAH's ability to assure physicians provide quality care to the CAH patients. The CAH administrative staff reported Tele-radiologist B provided services to 37 patients from March 2018 to March 2019.

Findings include:

1. Review of the "Physician Credentialing and Privileging Agreement," with Virtual Radiologic Professionals (vRad, a company which provides telemedicine physicians to interpret radiology test results), effective November 2011, revealed in part " ... if hospital is a critical access hospital, hospital is responsible for periodic evaluation and quality assurance reviews ..."

2. Review of the CAH network agreement, signed 1/16/19, revealed in part, "For all initial and 2 year reappointments of family practice or specialty practice, Allen Credentialing shall provide to [Community Memorial Hospital] : primary source verification, annual and ongoing performance appraisal review, auditing of files ... [Community Memorial Hospital] will annually evaluate credential and privileging process and perform ongoing medical record review as part of the peer review process ..."

3. Review of the "Payer Direct Teleradiology Services Agreement," signed in October 2017, revealed in part "... vRad will routinely make available to authorized individuals representing Client of Facility(ies) confidential quality data relating to radiology interpretations (other than Peer Review Reports) ... "

4. Review of a CAH policy "Peer Review", effective 2/1/2018, revealed in part " ... It is the policy of Community Memorial Hospital to conduct and facilitate the Peer Review process to promote quality assurance and improvement related to medical care provided ... Each provider who provides billable services at Community Memorial Hospital will have at least one external peer review performed per credentialing cycle on a randomly selected chart ... "

5. Review of the electronic external peer review files of selected providers with the Director of Analytics revealed Tele-radiologist B lacked evidence the CAH staff performed external peer review on a randomly selected chart of a patient who Tele-radiologist B interpreted a radiology test result on, prior to Tele-radiologist B's reappointment to the medical staff at the CAH.

6. During an interview on 4/17/19, beginning at 12:25 PM, the Director of Analytics acknowledged she did not request any, nor receive, any external peer review from the contracted tele-radiology service nor any of the tele-radiologists.

Based on review of policies, swing bed patient rights, patient medical records, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure all swing bed patients received the required Swing Bed Patient Rights to include the right to share a room with his or her spouse when married patients live in the same facility and both spouses consent to the arrangement for 1 of 1 open skilled patient and 4 closed skilled patients (Patients #3, #5, #6, and #7). Failure to present all of the required rights to the patients admitted to swing bed patients and/or their legal representative could result in the patients and/or their legal representatives being unaware of all their rights as swing bed patients while they are continuing to receive skilled level of care. This unawareness compromises the swing bed patients' ability to exercise their rights. The CAH administrative staff identified a census of 1 swing bed patient at the beginning of the survey and an average of 6 swing bed patients admitted per month.

Findings include:

1. Review of the CAH policy "Skilled Patient Rights and Responsibilities," dated 2/2019, revealed in part, "...The patient has a right to share a room with his/her spouse and both spouses consent to the arrangement...."

2. Review of the document "Skilled/Swing Bed Patient Rights & Responsibilities," provided to swing bed patients, dated 5/2013, revealed the document lacked information informing swing bed patients of their right to share a room with their spouse when married patients live in the same facility, and both spouses consent to the arrangement.

3. Review of Patient #3's skilled patient medical record revealed the CAH staff admitted Patient #3 to skilled level of care on 3/26/19. Patient #3's skilled patient medical record lacked documentation the CAH staff informed Patient #3 of their right to share a room with their spouse when married patients live in the same facility and both spouses consent to the arrangement.

4. Review of Patient #5's skilled patient medical record revealed the CAH staff admitted Patient #5 to skilled level of care on 2/6/19. Patient #5's skilled patient medical record lacked documentation the CAH staff informed Patient #5 of their right to share a room with their spouse when married patients live in the same facility and both spouses consent to the arrangement.

5. Review of Patient #6's skilled patient medical record revealed the CAH staff admitted Patient #6 to skilled level of care on 2/11/19. Patient #6's skilled patient medical record lacked documentation the CAH staff informed Patient #6 of their right to share a room with their spouse when married patients live in the same facility and both spouses consent to the arrangement.

6. Review of Patient #7's skilled patient medical record revealed the CAH staff admitted Patient #7 to skilled level of care on 2/25/19. Patient #7's skilled patient medical record lacked documentation the CAH staff informed Patient #7 of their right to share a room with their spouse when married patients live in the same facility and both spouses consent to the arrangement.

7. During an interview on 4/15/19 at 4:05 PM, the Vice President Nursing confirmed the document "Skilled/Swing Bed Patient Rights & Responsibilities" and Patient #3, Patient #5, Patient #6, and Patient #7's medical records lacked information that the CAH staff informed the skilled patients of their right to share a room with their spouse when married patients live in the same facility and both spouses consent to the arrangement.