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Based on interview and document review, the Critical Access Hospital failed to ensure the Governing Body monitored the implementation of policies related to credentialing for 5 of 12 medical staff (MD-A, MD-B, MD-C, MD-E, DDS-D). In addition, MD-F was not board certified.

Findings include:

The Bylaws, Rules and Regulations of the Medical Staff, revised 5/12, direct medical staff appointments and reappointments shall be for a period of two years, and the medical staff must have specialty board certification.

Medical Doctor (MD)-A was reappointed by medical staff on 8/17/09, and had Governing Body approval on 9/24/09.

MD-B was reappointed by medical staff on 6/21/10, and had Governing Body approval on 6/22/10.

MD-C was reappointed by medical staff on 6/21/10, and had Governing Body approval on 6/22/10.

MD-E was reappointed by medical staff on 11/22/10, and had Governing Body approval 11/22/10.

Doctor of Dental Services (DDS)-D was reappointed by medical staff on 2/15/10, and had Governing Body approval on 2/23/10.

MD-F did not have a specialty board certification.

On 8/7/13, at 2:00 p.m., health information specialist (HIS)-D was interviewed, and verified reappointments were not completed for MD-A, MD-B, MD-C, MD-E, and DDS-D. HIS-D also verified MD-F was lacking specialty board certification.

On 8/8/13, at 9:05 a.m., the assistant administrator stated medical staff reappointments are for a period of two years, and all medical staff should have specialty board certification. The assistant administrator verified the lack of reappointments and the specialty board certification.

Based on observation and interview, the Critical Access Hospital (CAH) failed to ensure sanitary storage of lab specimens, vaccines and equipment to prevent potential cross contamination in 1 of 2 laboratory areas reviewed.


Findings include;


During a tour of the CAHs offsite lab on 8/7/13 at 2:05 p.m. a Styrofoam container dated 8-1 with 6 puncture holes in the plastic lid was noted in the lab refrigerator. The medical lab technician (Employee G) indicated the container held leeches (fish bait) and that she had placed them in the refrigerator "last Friday" (8/1/13) and should have taken them home.

There were 10 boxes of vaccines, 8 boxes of lab slides and cartridges, 4 unused culture plates and 3 urine samples were noted in the refrigerator at the time.


On 8/7/13 at 4:00 p.m. the director of lab services was interviewed and stated the CAH did not have a policy regarding non-laboratory items being stored in lab refrigerators. However; the director stated it was unacceptable to have fish bait stored in lab refrigerators.

Based on record review, policy review, and interview, the facility failed to ensure verbal orders were authenticated according to the CAH policy for 5 of 5 patients (P21, P22, P23, P24, P25) reviewed for verbal order authentication. Additionally, there were copious amounts of verbal orders by CAH physicians.

Findings include:


The Cook Hospital verbal/Telephone Orders report indicated there were 2,386 verbal orders by CAH physicians during the three month period between 5/5/13 and 8/4/13.





Physician-A gave a verbal order for oral Ativan (anti-anxiety medication) for P21 on 5/12/13. The verbal order was not electronically signed as authenticated by the physician until 5/26/13 (14 days after the order was given).


Physician-A gave a verbal order for oral Lanoxin and Toprol XL (medications to lower your heart rate and blood pressure) for P22 on 5/13/13. The verbal order was not electronically signed as authenticated by the physician until 5/26/13 (13 days after the order was given).


Physician-B gave a verbal order for an injection of hydromorphone (a strong narcotic pain medication) for P23 on 5/19/13. The verbal order was not electronically signed as authenticated by the physician until 5/28/13 (9 days after the order was given).


Physician-C gave a verbal order for oral synthroid (medication used to treat low thyroid hormone) for P24 on 7/31/13. The verbal order was not electronically signed as authenticated by the physician until 8/5/13 (5 days after the order was given).


Physician-D gave a verbal order for oral Zocor (a medication used to lower cholesterol) for P25 on 7/13/13. The verbal order was not electronically signed as authenticated by the physician until 7/21/13 (8 days after the order was given).


Review of the policy for "VERBAL AND/OR TELEPHONE ORDERS" dated as last revised January 2010, the following was noted: "5... M.D. is to countersign verbal and/or telephone orders within 48 hours (Hospital only)."


The Director of Nursing (DON), interviewed on 8/8/13, at 10:20 a.m., stated the average daily CAH census was less than 2 inpatients per day. The DON stated that there was a "huge problem" with physicians giving verbal orders to the nurses rather than entering orders into the electronic medical record (EMR). CAH physicians did not like the EMR The DON stated she brought the concern to the CAH administrator, but did not know if the CAH medical director was consulted. In addition, there was no quality assurance project to address the quality concern. The DON stated that verbal and telephone orders should be used sparingly to avoid errors in medication and treatment. The DON verified the lack of timely authentication of verbal orders by physicians A, B, C, and D.

Based on observation, interview, and staff interview the critical access hospital (CAH) failed to assure that a nursing care plan be developed that described patient goals consistent with the attending practitioner's plan for medical care for 10 of 20 patients (P8, P9, P10, P12, P13, P15, P17, P18, P20, P16) reviewed.


Findings include:


Patient care plans lacked individualized nursing diagnosis, expected outcomes and/or interventions. Each care plan was automatically populated by the computer program used for the electronic medical record and included a psychosocial care plan; multiple possible "nursing diagnoses"; multiple possible "evidenced by" statements; and multiple possible "related to" statements that were not edited or made appropriate to the individual patient's condition.


P8 was admitted to the hospital on 3/8/13, with primary diagnoses that included acute alcohol withdrawal with anxiety and muscular tension and chest pain. The care plan addressed cardiac interventions, chest pain assessment and CHF [congestive heart failure] with discharge instructions provided. P8 did not have CHF and did not require CHF discharge instructions. The care plan did not include goals or interventions related to alcohol withdrawal and anxiety.


P9 was admitted to the hospital on 7/22/13, with primary diagnoses that included exacerbation of multiple myeloma pain in right shoulder. The care plan dated 7/23/13, lacked interventions or goals related to pain.


P10 was admitted to the hospital on 2/17/13, with primary diagnoses that included acute bronchitis and rule out pneumonia. The care plan dated 2/17/13, included a nursing diagnoses of respiratory with a goal of "respiratory stability" by a target date of 2/20/13. There were no nursing interventions related to care of the patient.


P12 was admitted to the hospital on 6/10/13,with primary diagnoses that included gastroenteritis secondary to the use of synthetic marijuana. The care plan dated 6/10/13, included nursing diagnoses of, "Gastrointestinal; Maintain fluid and electrolyte balance; Psychosocial Well Being; Knowledge deficit; and Understand Disease Process". The interventions included "Assess Bowel Stoma..." P12 did not have a bowel stoma. Additional interventions included: Collaborate with dietician; Collaborate with social services; and Teaching record general. Nursing interventions for the care of a patient with gastroenteritis related to smoking synthetic marijuana were not identified.


P13 was admitted to the hospital on 6/26/13, with primary diagnoses that included accidental medicinal poisoning. The care plan dated 6/27/13, included nursing diagnoses for Stable Neurological status; Psychosocial well being; Knowledge Deficit; and Understand disease process. Nursing interventions included "Neurological Assessment; Implement Seizure Precautions; Collaborate Social Services; and Teaching Record General." Nursing interventions related to assessment and teaching safe medication use were not included on the care plan.


P15 was admitted to the hospital on 6/23/13, with primary diagnoses that included pelvic fracture and chronic obstructive pulmonary disease. The care plan dated 6/23/13, included Respiratory; Psychosocial Well Being; Knowledge Deficit; and Understand disease process. Nursing interventions included Collaborate Social Services. Further medical record review determined P15 did not have an identified psychosocial issue or knowledge deficit. No further interventions were identified for the patients respiratory concerns or pelvic fracture including pain.


P17 was admitted to the hospital on 8/6/13, with primary diagnoses that included chronic obstructive pulmonary disease and congestive heart failure. The patient was observed on 8/7/13, at 8:40 a.m. with 3 liters of oxygen per nasal cannula. P17 was extremely hard of hearing; alert and oriented to person place and time; received intravenous (IV) Lasix (a diuretic medication) and Zosyn (an antibiotic medication); received subcutaneous insulin; and had weeping wounds on bilateral lower extremities. The care plan dated 8/7/13, included nursing diagnoses for Metabolic; Maintain fluid and electrolyte balance; Psychosocial Well Being; Knowledge Deficit; and Understand disease process. Nursing interventions included Monitor s/s fluid/electrolyte imbalance; Collaborate Social Services; and Teaching Record General. Further medical record review indicated P17 did not have an identified psychosocial issue or knowledge deficit. The care plan did not address respiratory assessment or interventions or interventions for congestive heart failure, diabetes and wound assessment/treatment.



P18 was admitted to the hospital on 4/28/13, with primary diagnoses that included motor vehicle accident with head trauma; left hip pain and right ankle strain. The care plan dated 4/28/13, identified nursing diagnoses that included Stable Neurological status; Psychosocial Well Being; Knowledge Deficit; and Understand disease process. Nursing interventions included Neurological Assessment; Implement Seizure Precautions; Collaborate Social Services; and Teaching Record General. The care plan did not address assessment and care of multiple deep abrasions of the scalp; hip and ankle pain; or mobility. The nursing diagnoses of Psychosocial Well Being; Knowledge Deficit; and Understand disease process were not applicable to P18's condition.


P20 was admitted to the hospital on 5/19/13, with primary diagnoses that included low back pain. The care plan dated 5/19/13, identified nursing diagnoses that included Musculoskeletal; Maintain optimal mobility; Activity Intolerance; and Psychosocial Well Being. Nursing interventions included Collaborate with PT and OT; and Collaborate with Social Services. The care plan lacked interventions related to assessment and treatment of pain.



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P16 was admitted to the hospital on 3/4/13,with primary diagnoses that included weight loss, nausea and vomiting, hypertension and obstructive uropathy. The care plan dated 3/5/13, included nursing diagnoses of Gastrointestinal: Maintain fluid and electrolyte balance; Psychosocial Well Being and Potential for imbalanced nutrition. The interventions identified included, "Asses Bowel Stoma.." P16 did not have a bowel stoma. The care plan lacked assessment or treatment of nausea and vomiting, hypertension and urinary status.


The director of nursing (DON), interviewed on 8/7/13, at 1:43 p.m., stated the computer program builds the care plans auto populates the care plan. It was the nurse's responsibility to choose the correct nursing diagnoses and appropriate interventions, as well as to delete what is not pertinent to the patient. The DON reviewed the aforementioned care plans and confirmed they were inaccurate and not individualized according to patient needs.



The CAH policy for Care Planning dated May 2011, indicated: "Each patient must have a care plan or plans added to them for the diagnoses they are admitted with and also any existing diagnoses they may have. For example, if you are admitting a patient with pneumonia and they are also diabetic, you will add the "Respiratory" care plan and also the "Metabolic" care plan. There is no limit on the number of care plans you can add to each patient...for each problem listed, there will be goals (long term and short term) and interventions listed under that problem...Review all of the interventions. If something does not pertain to your patient, delete it from this screen, and it will not show up on your list. Whatever is left will flow to your intervention list...remember that the problems "PSYCHOSOC" and "KND" [psychosocial well being and knowledge deficit] are attached to every care plan, so you should delete these problems from each additional care plan that you add at the care plan level."

Based on observation, interview and record review, the CAH failed to maintain the confidentiality of record information and provide safeguards against loss, destruction, or unauthorized use in the office of RN-B.


The findings include:


The CAH's telemedicine sleep records and surgical records were accessible to unauthorized personnel.


During the tour of the telemedicine sleep area on 8/5/13, at 2:43 p.m., medical records for the patients who use the sleep telemedicine services were observed to be unlocked in the office of registered nurse (RN)-B. At least 5 patient surgical records were not secured on RN-B's desk.


Review of the CAH policy SECURITY OF HEALTH INFORMATION dated as last revised January 2013, identified the following: "1. All medical information shall be maintained in a secure environment and not left unattended in areas accessible by unauthorized individuals."


RN-B, interviewed during the tour, stated that surgical and telemedicine sleep records were kept in her office with the door unlocked and open directly into a main hallway where they were accessible to patients, visitors and unauthorized hospital staff

Based on document review and staff interview, the critical access hospital (CAH) failed to have an effective program that evaluated the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes so that corrective actions could be evaluated, and measures implemented to improve quality on a continuous basis.


Findings include:


The quality assurance (QA) and performance improvement (PI) plan did not address contracted services for sleep and telemedicine.


Review of the CAH policy for QUALITY ASSURANCE PLAN dated as last revised on September 2011, the following was identified: " ...all clinical departments, services and practitioners shall be involved with QA activities." and "Department Managers will be responsible for: 1. Developing systems and procedures for identifying and solving problems in the delivery of care/services provided in their departments. 2. Establishing and maintaining a systematic process of monitoring and evaluating the quality and appropriateness of the care/services provided in their departments..."

Registered nurse (RN)-B, interviewed on 8/5/13, at 3:20 p.m., stated she was in charge of the quality improvement projects for sleep and telemedicine services. She confirmed that she currently did not have any quality assurance projects for sleep, and telemedicine services.

Based on quality assurance review minutes and staff interview the critical access hospital (CAH) failed to integrate the organ, tissue, and eye donation program into the quality assurance (QA) program. This had the potential to affect all current and future CAH patients.


The findings include:


The Quality Assurance Plan policy and procedure dated as last revised September 2011, indicated, "To fulfill the objectives of the Cook Hospital and C&NC Unit Quality Assurance Plan, all clinical departments, services and practitioners shall be involved with QA activities."


The director of nurses (DON), interviewed on 8/7/13, at 2:30 p.m., stated the CAH was monitoring statistics from the Organ Donation Activity Report from Life Source (the CAH's organ procurement agency). There was no current QA project developed related to the organ, tissue and eye donation program. The DON, added that, when a death occurred in the CAH, it was usually unexpected. Family members would become upset when donation was discusses following a death. The DON verified the lack of community outreach detailing donation as part of the QA program.

Based on interview and document review the Critical Access Hospital (CAH) failed to conduct a background study on 1 of 5 newly employed staff (employee (E)-J).


Finding include:


Record review indicated E-J was hired as a student lab technician on 3/18/12, and was hired as a permanent medical lab technician on 6/25/13. E-J's personnel file lacked a criminal background study.


Interview with the Human Resource Director on 8/7/13 at 2:50 p.m. revealed the study should have been completed by the CAH prior to E-J starting as a student a year and a half earlier.


The CAHs Vulnerable Adult Maltreatment Prevention Plan policy dated June 2011, indicated the screening of potential employees includes a criminal background study prior to the first patient/resident contact.