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The Critical Access Hospital (CAH) reported a census of two swing bed patients. The Critical Access Hospital (CAH) reported an average daily census of seven patients with a current census of five patients, four acute patient and one swing bed patients. Based on observation, staff interview, and policy review the CAH failed to ensure expired supplies were unavailable for patient use in one of one nursing station storage cabinet, one of one emergency department Broselow bags (a pediatric emergency kit), and one of clean utility rooms.

Findings include:

- Supply cabinet located at the nurses station observed on 1/4/2016 at 11:30 AM revealed the following expired supplies:
1. One cotton tipped applicator with an expiration date of 11/2015.
2. One Specimen collection kit with an expiration date of 11/30/2015.
3. Three Para-Pak Culture and Sensitivity containers with an expiration date of 11/2015.
4. One ChloraPrep (antibacterial used on the skin) with an expiration date of 7/2013.


Licensed Practical Nurse Staff C interviewed on 1/4/2016 at 11:30 AM acknowledged the expired supplies.

- Emergency Department room 1 observed on 1/4/2016 at 12:00pm revealed the following outdated emergency supplies:
1. Broselow Bag (a pediatric emergency kit):
Seven intraosseous modules (to inject directly into the marrow of a bone to provide a non- collapsible entry point) with expired dates of 6/13, 8/13, 9/13, 3/14, and 6/14.
Seven intubation modules (used to maintain an airway) with expired dates of 8/12, 9/12, 12/12, 3/13, and 4/14.

Registered Nurse Staff E interviewed on 1/4/2016 at 12:00pm acknowledged the outdated unusable Broselow Bag. Staff E stated they do have the required intubation equipment for Pediatric emergency.

- Clean Utility room observed on 1/4/16 at 12:10pm revealed the following outdated supplies:
1. Two sterile gauze sponges 4x4 packages with expired dates of 8/15.
2. Opsite flexigrip (transparent adhesive film for wounds) 19 packages with expired dates of 8/14.

Licensed Practical Nurse Staff C interviewed on 1/4/16 at 12:14pm acknowledged the outdated supplies.

Policy review on 1/6/2016 at 1:15 PM revealed the CAH lacked evidence of a policy directing staff to dispose of expired supplies.

Administrative Staff A interviewed at on 1/6/2016 at 9:00 AM acknowledged they were unaware of any policies that directed staff to remove expired supplies.

The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on observation, policy review, and staff interview the CAH failed to perform disaster drills and evaluations in cooperation with firefighting and disaster authorities, and post fire plan signs with evacuation procedures throughout the facility. This failure has the potential to endanger patients and staff in the CAH.

Findings include:

- Tour of the CAH on 1/6/16 at 3:43pm revealed they lacked evidence of fire plan signs with evacuation procedures posted throughout the facility.

Staff A interviewed on 1/6/16 at 4:00pm acknowledged no fire plan signs had been posted in the facility.

Administrative Staff A interviewed on 1/7/2015 indicated they do not currently participate in disaster drills with the inclusion of hospital staff. Staff A revealed that they attend meetings with the local emergency manager and they have a current disaster plan.

- Policy review on 1/7/2015 revealed the facility lacked evidence of a policy directing the CAH to conduct disaster drills at least two times per year.

- Policy titled F.W. Huston Emergency Operations Plan reviewed on 1/11/16 at 3:50 PM directed " ...Floor plans identifying the locations of the following are located in facility hallways, Exits, Primary evacuation routes, Secondary evacuation routes, Accessible egress routes, Areas of refuge, Manual fire alarm boxes, Portable fire extinguishers, Occupant-use hose stations, Fire alarm and controls, Sprinkler control valves ... "

The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on policy review, medical record review, and staff interview, the CAH lacked evidence the Governing Body ensured the Critical Access Hospital (CAH) followed the Medical Staff Bylaws requiring suspension of privileges for delinquent medical records for one of four physicians' (Medical Staff F); lacked evidence they reviewed all hospital policies annually; and failed to update Staff M's credentialing re-appointment with privileges since 2008. This failure has the potential to cause poor patient outcomes.

Findings include:

Delinquent Medical Records

- Patient #6's medical record reviewed on 1/5/2016 revealed an admission date of 5/25/2105 with a diagnosis of congestive heart failure and acute renal failure with a discharge date of 6/1/2015. Patient #6's medical record revealed a discharge summary was currently not completed (seven months after discharge). The CAH failed to ensure Patient #6's medical record contained a discharge summary completed within 30 days after discharge.

- Patient #8's medical record reviewed on 1/5/2016 revealed an admission date of 5/6/2105 with a diagnosis of hip fracture (broken hip) and prostate cancer with a discharge date of 7/23/2015. Patient #8's medical record revealed a discharge summary was currently not completed (six months after discharge). The CAH failed to ensure Patient #8's medical record contained a discharge summary completed within 30 days after discharge.

- Patient #28's medical record reviewed on 1/6/2016 revealed an admission date of 3/9/2105 with a diagnosis of a kidney infection and a discharge date of 3/11/2015. Patient #28's medical record revealed a discharge summary was completed (seven months after discharge). The CAH failed to ensure Patient #6's medical record contained a discharge summary completed within 30 days after discharge.

Medical Record Staff B interviewed on 1/5/2016 at 3:15 PM acknowledged the discharge summaries for patient #'s 6 and 8 were not completed within 30 days. Staff B indicated they notify the physicians when charts are incomplete. Staff B reported they also notify the Chief Executive Officer (CEO) at least two days a week so they are aware of delinquent charts. Staff B stated, " We have met with one of our physicians (Physician Staff F) repeatedly to try and get documentation completed as required". Staff B acknowledged the CAH failed to follow Medical Staff Bylaws requiring the suspension of privileges of a negligent provider.


Governing Body Meeting Minutes reviewed on 1/6/2016 at 11:00 AM revealed during the January 2014 board meeting, the minutes indicated the provider (Medical Staff F) continues to be late with completion of charts. Review of all 2014 and 2015 meeting minutes revealed continuous review of chart completeness was conducted but lacked evidence of any corrective action taken.


Medical Director Staff D interviewed on 1/5/2016 at 1:35 PM indicated there is one physician (Medical Staff F) that is continually late with completing charts. Staff D stated, " I have no power to make them comply because of our situation, we only have two physicians employed by the hospital".


Medical Staff F interviewed on 1/6/2016 at 10:15 AM indicated they were late with the discharge summaries because the CAH had recently undergone changes to the EHR (electronic health record) system and are using both paper and the EHR for charting making it more difficult to complete charts in a timely manner. Staff F stated, "Some of it's me".


- Medical Staff Bylaws reviewed on 1/6/2016 at 7:30 PM directed "...The Discharge Summary must be completed within 30 days after the patient's discharge..."

Policy Review

- Administrative Staff A interviewed on 1/6/2016 at 9:50 AM indicated the CAH's policies were approved during monthly board meetings. Staff A acknowledged they did not document they had conducted a periodic policy review by the physician, physician's assistant and/or the nurse practitioner.

Medical Staff F interviewed on 1/6/2016 at 10:40 AM indicated that all providers are required to attend the Medical Staff meetings. Staff F revealed policies are developed and reviewed during the meetings, but is unaware if all policies are reviewed at least annually.

Administrative Staff F interviewed 1/5/2016 at 3:30 PM indicated the CAH did not have a current policy requiring physicians in conjunction with the physician's assistant and/or the nurse practitioner to conduct policy reviews.

Medical Staff Meeting Minutes reviewed on 1/6/2016 at 11:28 AM revealed meetings occurred on 1/21/2015, 3/25/2015. 5/20/2015, 7/22/2015, 9/30/2015, 11/8/2015. The minutes lacked evidence policy reviews were conducted during the Medical Staff Meetings.

Policy review on 1/6/2016 at 10:00 AM revealed the CAH lacked a policy directing them to conduct a periodic policy review by the physician, physician's assistant and/or the nurse practitioner.

- Review of the hospital's Governing Body meeting minutes and Quality Committee Council meeting minutes lacked documentation their utilization of services review was used to determine if services were appropriate, if policies were followed, and if any changes were needed.

- Administrative Staff A interviewed on 1/6/2016 at 10:00 AM acknowledged the CAH lacked evidence the utilization of services review was used to determine if services were appropriate, if policies were followed, and if any changes were needed.


Medical Staff Re-Appointment

- Staff M's medical staff credentials reviewed on 1/7/2016 revealed re-appointment with priveledges were not renewed since 2008. The CAH failed to ensure Staff M's credentials were updated.

Staff B interviewed on 1/7/2016 at 11:30pm acknowledged the CAH failed to renew Staff M credentials. Staff B indicated Staff M rarely comes to the CAH, only when covering for another physician. Staff M provided services at the CAH on one day in 2015.

The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on policy review and staff interview, the CAH failed to ensure a physician in conjunction with the physician's assistant and/or the nurse practitioner participated in the development and periodic review of the CAH's written policies. This failure has the potential to cause poor patient outcomes.

Findings include:

Medical Staff Meeting Minutes reviewed on 1/6/2016 at 11:28 AM revealed meetings occurred on 1/21/2015, 3/25/2015. 5/20/2015, 7/22/2015, 9/30/2015, 11/8/2015. The minutes lacked evidence policy reviews were conducted during the Medical Staff Meetings.

Administrative Staff A interviewed on 1/6/2016 at 9:50 AM indicated the CAH's policies were approved during monthly board meetings. Staff A acknowledged they did not document they had conducted a periodic policy review by the physician, physician's assistant and/or the nurse practitioner.

Medical Staff F interviewed on 1/6/2016 at 10:40 AM indicated that all providers are required to attend the Medical Staff meetings. Staff F revealed policies are developed and reviewed during the meetings, but is unaware if all policies are reviewed at least annually.

Policy review on 1/6/2016 at 10:00 AM revealed the CAH lacked a policy directing them to conduct a periodic policy review by the physician, physician's assistant and/or the nurse practitioner.

The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on policy review and staff interview, the CAH lacked evidence they ensured the physician's assistant and the nurse practitioner members of the CAH's staff participated in the development, execution, and periodic review of the written policies governing the services the CAH furnishes. This failure has the potential to cause poor patient outcomes.

Findings include:

Medical Staff Meeting Minutes reviewed on 1/6/2016 at 11:28 AM revealed meetings occurred on 1/21/2015, 3/25/2015. 5/20/2015, 7/22/2015, 9/30/2015, 11/8/2015. The minutes lacked evidence policy reviews were conducted during the Medical Staff Meetings.

Administrative Staff A interviewed on 1/6/2015 at 9:50 AM indicated the CAH's policies were approved during monthly board meetings. Staff A acknowledged they did not document they had conducted a periodic policy review by the physician, physician's assistant and/or the nurse practitioner.

Medical Staff F interviewed on 1/6/2016 at 10:40 AM indicated that all providers are required to attend the Medical Staff meetings. Staff F revealed policies are developed and reviewed during the meetings, but is unaware if all policies are reviewed at least annually.

Policy review on 1/6/2015 at 10:00 AM revealed the CAH lacked a policy directing them to conduct a periodic policy review by the physician, physician's assistant and/or the nurse practitioner.

The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on policy review and staff interview, the CAH failed to ensure a physician in conjunction with the physician' assistant and/or the nurse practitioner reviewed their written policies at least annually. This failure has the potential to cause poor patient outcomes.

Findings include:

Administrative Staff A interviewed on 1/6/2015 at 9:50 AM indicated the CAH's policies are approved during monthly board meetings. Staff A acknowledged they did not document they had conducted a periodic policy review by the physician, physician's assistant and/or the nurse practitioner at least annually.

Medical Staff F interviewed on 1/6/2015 at 10:40 AM indicated that all providers are required to attend the Medical Staff meetings. Staff F revealed policies are developed and reviewed during the meetings, but is unaware if all policies are reviewed at least annually.

Policy review on 1/6/2015 at 10:00 AM revealed the CAH lacked a policy directing them to conduct a periodic policy review by the physician, physician's assistant and/or the nurse practitioner. The CAH's policies provided for review lacked evidence of review dates and reviewer's signatures.

The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on observation, policy review and staff interview, the CAH failed to develop an active and comprehensive infection control system. The CAH failed to: ensure one of one chairs in the outpatient treatment areas was cleanable and ensure open supplies were unavailable for use in one of two emergency department rooms (room #1). The failure of the CAH to ensure infection control practices are followed has the potential to affect all patients in the CAH.

Findings include:

- The Emergency Department room # 1 observed on 1/4/2016 at 11:30am revealed the following sterile supplies opened and unavailable for use:
1. One package of sterile gauze sponge open in top drawer of cabinet.
2. One sterile Yankauer (oral suctioning tube) in open package connected to suction machine on emergency crash cart.

Licensed Practical Nurse Staff C interviewed on 1/4/2016 at 11:30am acknowledged the sterile gauze was opened and should have been disposed.

Registered Nurse Staff E interviewed on 1/4/2016 at 11:40am acknowledged the sterile Yankauer was opened and should have been disposed.

Administrative Staff A interviewed on 1/5/2016 at 3:00pm indicated the CAH does not currently have an infection control program with active surveillance.

The CAH (Critical Access Hospital) reported a census of two patients. Based on policy review, medical review and staff interview the hospital failed to ensure nursing staff adequately assessed one of twenty patients (Patient#1) when they failed to perform and document skin and wound assessments and notify physician promptly when the wound worsened. This deficient practice has the potential of causing patients at risk for severe infection or death.

Finding including:

- Patient #1 ' s medical record reviewed on 11/4/16 revealed the patient was admitted with a diagnosis of status post CABG (Coronary artery bypass grafting) for admission to swing bed status for skilled nursing care. Upon admission to the CAH, patient #1 had a sternal incision that appeared clean but was very ecchymotic (skin discoloration reddish or bluish) in the area surrounding the incision, extending to both breasts with a small subcutaneous (beneath the skin) and painful hematoma (localized collection of blood outside the blood vessels) left lower breast area. The medical record revealed on 11/9/15 the area around patient #1's sternal incision showed more black bloody crusting and eventual evidence of possible dry necrosis (death of living tissue) of the skin and the large ecchymosis still over left breast. On 11/11/15 Medical Staff D stated in their progress notes that patient #1's chest wall still dark bloody crusting around incision site with large ecchymosis and subcutaneous firmness over left medial breast measuring 1.5 x 3.5cm (centimeters) of skin under left medical breast that is dark brown, dry and well demarcated (setting apart) appearing to be necrotic. The medical record lacked evidence of nursing documentation indicating a concern with the wound on 11/11/15 and 11/12/15. The medical record revealed on 11/13/15 the day shift nurse (RN Staff H), who had not seen patient #1 since 11/10/15, performed an assessment on patient #1 and noted the wound had worsened, looking dark brown and had black skin necrosis under breast area where hematoma was. The size had enlarged to 3 x 4cm. RN Staff H notified Medical Staff D of wound. Later that day, Patient #1 transferred to Hospital B (acute care hospital where patient had CABG) by EMS (Emergency Medical Services) in stable condition for a higher level of wound care.

Review of records from hospital B documented that patient #1's sternal wound necrosis worsened and she ended up having to having multiple surgeries to debride (remove dead skin and tissue), had complications of respiratory failure, delirium (confused thinking and decreased awareness of your environment) and sepsis (a life-threatening complication of an infection). Patient #1 passed away about 6 weeks later (12/27/15).

RN Staff H, interviewed on 1/4/16 at 1:55pm indicated when patient #1 arrived to this hospital, she had a large amount of bruising to left side upper chest and staples had been removed at mid sternal area that had small area not approximated (the edges of a wound are brought together) with a small amount of serosanguinous (yellowish with small amounts of blood) drainage on patient #1's gown. RN Staff H cared for patient #1 the day the patient was transferred back to Hospital B. RN Staff H stated during patient #1's assessment, the tissue around the incision looked "dangerous". RN Staff H contacted Medical Staff D and was given orders to call hospital B's Cardiothoracic surgeon (surgeon performs operations on the heart, lungs, esophagus and other organs in the chest). Cardiothoracic surgeon, Medical Staff L's partner requested pictures of patient #1's wound. RN Staff H got the patient #1's consent and sent pictures to Medical Staff L's office and RN Staff H received call back from Medical Staff L's office to transfer patient back to hospital B. Transfer arrangements were made and patient #1 was sent by EMS (Emergency Medical Service).

Medical Staff D, interviewed on 1/5/16 at 1:00pm indicated they saw patient #1 the day after patient got to this hospital. Patient #1's wound wasn't necrotic (the death of cells or tissues) looking, the wound was ecchymotic (non-raised skin discoloration caused by the escape of blood into the tissue) and soft. Medical Staff D stated by the 9th or 11th of November patient #1's wound looked black, was superficial (beneath the skin), and there was nothing one can do, just to observe area. Medical Staff D stated the hematoma (localized collection of blood outside the blood vessels) was superficial looking, so the nurses tried putting dressing or cushioning under the breast. On November 12th, Medical Staff D stated they were in a care plan meeting and saw patient #1 that day, but did not inspect patient's wound. On November 13th, Medical Staff D indicated they received a call from the day shift RN (RN Staff H) that the patient's (Patient #1) wound was worse. Medical Staff D ordered the RN (RN Staff H) to call hospital B's Cardiothoracic Surgeon (Medical Staff L). After Medical Staff L reviewed the pictures of patient #1's wound, they requested patient #1 be transferred back to hospital B.

RN Staff G, interviewed on 1/6/16 at 10:00am indicated patient #1 came to our facility with a chest incision scabbed, did not really look all that great and had a hematoma from chest wall incision toward left breast. The hematoma was very large, egg size, when patient arrived to facility. RN Staff G described patient #1's chest incision and to the left breast was hard to touch, skin around it looked normal and the mid sternal area not as clean as normal. RN Staff G stated the 3rd day of patient #1's stay, patient #1's mid-sternal toward left breast skin starting to slough off, looking like sunburn. The 4th and 5th day of patient #1's stay, the wound area starting to peel but patient seemed like she was not hurting any worse. RN Staff G had notified Medical Staff D of patient #1's mid-sternal area to under left breast getting dark purple. RN Staff G was concerned about patient #1's wound. RN Staff G was told by Medical Staff D there was nothing they can do about patient #1's wound. RN Staff G indicated on 11/13/15, she gave the day shift RN (RN Staff H) report and both discussed together their concern of patient #1's wound.

- Policy reviewed on 1/7/16 at 1:00pm revealed the CAH lacked a policy directing the nursing staff how and when to perform and document skin and wound assessments.

The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on policy review, medical record review, and staff interview, the CAH failed to ensure medical records completion no later than 30 days after discharging a patient for 2 of 30 medical records reviewed (Patient #'s 6 and 8). The CAH's failure to ensure patients' discharge summaries are competed in a timely manner has the potential for poor patient outcomes.

Findings include:


- Patient #6's medical record reviewed on 1/5/2016 revealed an admission date of 5/25/2105 with a diagnosis of congestive heart failure and acute renal failure. Patient #6's medical record revealed a discharge summary was currently not competed (seven months after discharge). The CAH failed to ensure Patient #6's medical record contained a discharge summary completed within 30 days after discharge.

- Patient #8's medical record reviewed on 1/5/2016 revealed an admission date of 5/6/2105 with a diagnosis of hip fracture (broken hip) and prostate cancer. Patient #8's medical record revealed a discharge summary was currently not competed (six months after discharge). The CAH failed to ensure Patient #8's medical record contained a discharge summary completed within 30 days after discharge.

Medical Record Staff B interviewed on 1/5/2016 at 3:15 PM acknowledged the discharge summaries for patient #'s 6 and 8 were not completed within 30 days. Staff B indicated they notify the physicians when charts are incomplete. Staff B reported they also notify the CEO at least two days a week so they are aware of delinquent charts. Staff B stated, " We have met with one of our physicians (Physician Staff F) repeatedly to try and get documentation completed as required". Staff B acknowledged the CAH failed to follow Medical Staff Bylaws requiring the suspension of privileges of a negligent provider.


Medical Director Staff D interviewed on 1/5/2016 at 1:35 PM indicated there is one physician (Medical Staff F) that is continually late with completing charts. Staff D stated," I have no power to make them comply because of our situation, we only have two physicians employed by the hospital".


Medical Staff F interviewed on 1/6/2016 at 10:15 AM indicated they were late with the discharge summaries because the CAH had recently undergone changes to the EHR (electronic health record) system and are using both paper and the EHR for charting making it more difficult to complete charts in a timely manner. Staff F stated," Some of it's me".


- Medical Staff Bylaws reviewed on 1/6/2015 at 7:30 PM directed "...The Discharge Summary must be completed within 30 days after the patient's discharge ..." and "... The Chief of Staff shall suspend, by written notice, the privileges of this negligent physician

- Governing Body meeting minutes reviewed on 1/7/2016 revealed the minutes lacked evidence of disciplinary action taken as required by the Medical Staff Bylaws when a provider's medical records are incomplete.

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The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on policy review and staff interview, the CAH failed to arrange for a periodic evaluation of their health care policies at least once a year. This failure has the potential to cause poor patient outcomes.

Findings include:


- Review of the hospital's Governing Body meeting minutes lacked documentation of a periodic evaluation of their health care policies.

Administrative Staff A interviewed on 1/6/2016 at 10:00 AM acknowledged the Governing Body failed to perform a periodic evaluation of their health care policies. Staff A indicated they were unsure when the last periodic review of policies were conducted.

The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on policy review and staff interview, the CAH failed to evaluate if the utilization of services was appropriate, if policies were followed, and identify if changes were needed. This failure has the potential to cause poor patient outcomes.

Findings include:


- Review of the hospital's Governing Body meeting minutes and Quality Committee Council meeting minutes lacked documentation their utilization of services review was used to determine if services were appropriate, if policies were followed, and if any changes were needed.

- Administrative Staff A interviewed on 1/6/2016 at 10:00 AM acknowledged the CAH lacked evidence the utilization of services review was used to determine if services were appropriate, if policies were followed, and if any changes were needed.

The Critical Access Hospital (CAH) reported a census of two swing bed patients. Based on policy review, medical record review, and staff interview, the CAH failed to ensure the medical records contained a discharge summary for one of ten swing bed patients (Patient # 8). The CAH's failure to ensure patients' discharge summaries are competed has the potential for poor patient outcomes.

Findings include:

- Patient #8's medical record reviewed on 1/5/2016 revealed an admission date of 5/6/2016 with a diagnosis of hip fracture (broken hip) and prostate cancer. Patient #8's medical record revealed a discharge summary was currently not competed (six months after discharge). The CAH failed to ensure Patient #8's medical record contained a discharge summary completed within 30 days after discharge.

Medical Record Staff B interviewed on 1/5/2016 at 3:15 PM acknowledged the discharge summary for patient # 8 is not complete. Staff B indicated they notify the physicians when charts are incomplete. Staff B reported they also notify the CEO at least two days a week so they are aware of delinquent charts and can speak with the provider. Staff B stated, " We have met with one of our physicians (Medical Staff F) repeatedly to try and get documentation completed as required ". Staff B acknowledged the CAH failed to follow Medical Staff Bylaws requiring the suspension of privileges of a negligent provider.



Medical Director Staff D interviewed on 1/5/2016 at 1:35 PM indicated there is one physician (Medical Staff F) that is continually late with completing charts. Staff D stated, " I have no power to make them comply because of our situation, we only have two physicians employed by the hospital " .

Medical Staff F interviewed on 1/6/2016 at 10:15am indicated they were late with the discharge summaries because the CAH had recently undergone changes to the EHR (electronic health record) system and are using both paper and the HER for charting making it more difficult to complete charts in a timely manner. Staff F stated, "Some of it's me ".


- Medical Staff Bylaws reviewed on 1/6/2015 at 7:30 PM directed " ...The Discharge Summary must be completed within 30 days after the patient's discharge ... "