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A. Based on a review of CAH (Critical Access Hospital) policy and procedure, medical record review, and staff interview, it was determined that in 1 of 6 (Pt #7) medical records in which the patient received surgical services, the CAH failed to ensure it's policy for the removal of tissue was followed.

Findings include:

1. The CAH policy and procedure titled, "Surgical Specimens" was reviewed on 4/1/10. It indicated under "PROCEDURE: C. The surgeon makes the ultimate decision whether or not individual case specimen should be sent for pathology. If the surgeon decides not to send a specimen to pathology then: 1. The surgeon records a detailed description of the specimen including disposition in the post-operative note. 2. The circulating nurse records specimen name, disposition, and ordering physician..."

2. The medical record of Pt #7 was reviewed on 4/1/10. It indicated Pt #1 was admitted on 1/12/10 with a diagnoses of Diabetes and Hypoglycemia. A physician's post-operative note, dated 1/15/10, indicated under, "SPECIMEN: Necrotic tissue and callus, cultures sent." Also, on a handwritten post-op report, dated 1/15/10, indicated under "5. SPECIMENS REMOVED: Necrotic tissue and callus." There was no documentation if the specimen was sent to pathology or if the specimen was disposed of. There no documentation of the required information related to the disposition of the tissue.

3. During an interview with the Director of Surgery, conducted on 4/1/10 at 2:00 PM, the above finding was confirmed.

A. Based on a review of CAH (Critical Access Hospital) policy and procedure, a review of anesthesia controlled medication waste records, and staff interview, it was determined that the CAH failed to ensure there were 2 signatures for each wasted controlled medication.

Findings include:

1. The CAH policy and procedure titled, "CONTROLLED DRUGS" was reviewed on 4/1/10. It indicated under, PROCEDURE: J. Two licensed healthcare professionals shall witness and waste partially used doses of controlled substances...."

2. The anesthesia "CONTROLLED SUBSTANCE ADMINISTRATION RECORD" sheets for the month of March 2010 were reviewed. There was no documentation that indicated two licensed professionals were witnessing/signing for wasted controlled medications.

3. During an interview with the Pharmacy Director, conducted on 3/30/10 at 2:15 PM, the above findings were confirmed.

B. Based on a review of CAH policy and procedure, observation, and staff interview, it was determined that the CAH failed to ensure all expired drugs/biologicals were removed from patient use areas.

Findings include:

1. The CAH policy and procedure titled, "Checking the expiration date of inventory supplies" was reviewed. It indicated under, "PROCEDURE: Any inventory supply that is marked with an expiration date by the Manufacturer will be checked monthly to ensure the date has not passed to prevent using expired supplies on patients...."

2. During a tour of the laboratory facilities, conducted on 3/30/10 at 2:00 PM, the following outdated items were found to be in areas for use: 2 - vials BioStar RSV + controls, both expired 9/08; 3 vials BioStar RSV- controls expired in 7/08, 9/08, and 12/08; 12 large yellow topped Vacutainer, 4 expired 11/08, 2 expired 5/09, 1 expired 8/09, and 5 expired 2/10; 6 purple topped Microtainers all expired 12/09; 9 small yellow topped Vacutainers 3.2ml, all expired 12/09; 1 blue topped Vacutainer 6.0ml expired 1/10; 2 plastic yellow topped Vacutainers 5.0ml both expired 9/09; 1 plastic purple topped Vacutainer 2.0ml expired 7/09; 1 blue plastic topped Vacutainer 1.8ml expired 11/09; 1 bottle Surgipath Cytologic Fixative 4 fl oz, expired 11/09; 14 Exel Int Spinal Needles 20Gx31/2" all expired 12/09. During a tour of radiology, conducted on 3/31/10 at 2:45 PM, in the emergency treatment box 1 vial of dexamethasone 1ml, expired 2/10. In the Surgery department, the following outdated items were observed: In the Urology room, one Bacti- Stat AE, expired 2/07; In pre-op room #2- one Bacti-Stat AE, expired 11/08; and in pre-op room #3- one Bacti-Stat AE, expired 10/08. In the Pediatric Crash Cart, two #6.0 Shiley tracheostomy cuffs were observed, expired 7/09.

3. During a staff interview, conducted on 3/30/10 at 2:30 PM with the Vice President Support Services, the above findings were confirmed.

A. Based on a review of the required wet contact time for the disinfectant used in radiology and staff interview, it was determined that the CAH failed to ensure all disinfectants were used in an appropriate manner.

Findings include:

1. During a tour of radiology, conducted on 3/31/10 at 1:30 PM, the instructions for use of the disinfectant used in the department, CaviCide, were reviewed. They indicated that the minimum wet contact time for disinfection was 3 minutes.

2. During an interview with the lead radiology technician, conducted on 3/31/10 at 1:40 PM, it was verbalized that when disinfecting the tables and equipment in the department, the technicians spray the CaviCide on and wipe it immediately off. This does not meet the minimum wet contact time of three minutes. Also, it was verbalized that the technician did not know there was a wet contact time to reach maximum disinfections.

B. Based on observation, a review of Ecolab documentation, and staff interview, it was determined that the CAH failed to ensure that Linen Services were maintained in a manner to prevent potential and/or actual cross contamination.

Findings include:

1. During a tour of the Linen Services, conducted on 3/30/10 at 2:30 PM with the Administrator, it was verbalized by the Director of Materials Management that when a linen machine was demonstrating a potential problem, such as not rinsing completely or stains remaining on linen, that the Ecolab (company from which the machines and disinfecting items are obtained) is notified. Ecolab then services the equipment. However, it was further verbalized that the machine(s) are not necessarily taken out of service prior to servicing, which could lead to potential and/or actual cross contamination and infection.. There was no documentation to indicate when the Ecolab was notified, how long before the machine(s) were serviced, and whether the machine(s) were removed from service during the period of questionable performance.

2. A document titled "Service Detail Report: Ecolab" for service date of 5/18/09 was reviewed on 3/31/10. It failed to indicate when the service request was made. It indicated the service item as 3 Wascomats and 1 Washex. There was no documentation to indicate whether these items were currently in service or not.

3. During a staff interview, conducted with the Administrator on 3/31/10 at 2:00 PM, the above findings were confirmed.

C. Based on medical record review and staff interview, it was determined that in 1 of 1 (Pt #19) medical records reviewed in which the patient was placed in isolation, the CAH failed to ensure the isolation was appropriately documented.

Findings include:

1. The medical record of Pt #19 was reviewed on 4/1/10. It indicated Pt #19 was admitted on 9/8/09 with a diagnosis of Acute Febrile Illness. A nurses note indicated "...Isolation precautions maintained..." There was no documentation in the medical record as to why the patient was placed in isolation or when the isolation was initiated.

2. During an interview with the Clinical Systems Specialist, conducted on 4/1/10 at 3:30 PM, the above finding was confirmed.

D. Based on a review of the surgery department's flash sterilization process and staff interview, it was determined that the CAH failed to ensure it's flash sterilization process prevented the potential cross contamination of organisms.

Findings include:

1. The CAH's flash sterilization process was reviewed on 4/1/10. It indicated that any instrument that was flash sterilized was placed uncovered in the sterilizer. When the sterilization was complete, the instruments are carried to the operating suite uncovered, potentially exposing them to organisms in the hallways.

2. During an interview with the Surgery Supervisor, conducted on 4/1/10 at 10:45 AM, the above finding was confirmed.

A. Based on medical record review and staff interview, it was determined in 1 of 20 (Pt #11) medical records reviewed, that the CAH failed to ensure that physician orders were followed.

Findings include:

1. The medical record of Pt #11 was reviewed on 4/1/10. Pt #11 was admitted to the CAH on 9/28/09 with the diagnosis of Hyperosmolar, Hyperglycemic State. On 9/28/09 at 6:25 PM, there was a physician's order "Accucheck every 4 hours..." There was no documentation of an Accucheck around the time of 9/29/09 at 12:30 AM. On 9/29/09 at 7:00 AM, there was a physician's order "Accucheck before meals and at bedtime with sliding scale." The sliding scale indicated that the physician was to be notified if the blood sugar was over 300. On 9/29/09 at 10:15 PM, nursing documentation indicated "blood sugar 371." There was no documentation to indicate that the physician was notified. On 9/29/09 at 10:15 PM, there was a physician's order "For blood sugar greater than 300, give 6 units of Humulin R." On 10/1/09 at 5:20 AM, nursing documentation indicated a blood sugar of 323 and there was no documentation to indicate that insulin was given.

2. During a staff interview, conducted with the Vice President of Clinical Services on 4/1/10 at 2:30 PM, the above finding was confirmed.

B. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 5 out 8 (Pts #4, #10, #11, #12, #15) medical records reviewed, in which the discharge process was reviewed, that the CAH failed to ensure that discharge medication orders were written, as per CAH policy.

Findings include:

1. The CAH policy titled "Medication Reconciliation Process" was reviewed on 4/1/10. It indicated "F. Discharge to Home following Hospitalization... 1. Print the Medication Reconciliation Report (MRR). 2. Place the report in front of the physician orders in the record for physician review and/or completion...4. Inconsistencies should be clarified with the physician prior to the patient's discharge from the hospital."

2. The medical record of Pt #4 was reviewed on 3/30/10. Pt #4 was admitted to the CAH on 2/27/10 with the diagnoses of Chest Pain and Pneumonia. On 3/30/10, there was a physician's order "May have Levaquin early and then discharge... Upon discharge please specify changes in meds like Diovan and Simvastatin and to discontinue Altace... Script in chart." There was no MRR for discharge on the medical record. There was no order addressing whether Pt #4 was to continue with antibiotics and/or the other medications that were ordered while in the hospital. There was no documentation to indicate that the physician was contacted to clarify the discharge orders.

3. The medical record of Pt #10 was reviewed on 4/1/10. Pt #10 was admitted to the CAH on 1/11/10 with the diagnoses of Congestive Heart Failure and Pneumonia. On 1/14/10, there was a physician's order "Discharge home... Patient to take 60 mg Lasix at home." There was no discharge MRR on the record. There were no orders for the patient's other medications. The CAH discharge instructions given to the patient, listed all medications that the patient had been on in the hospital, in addition to the Lasix. There was no documentation to indicate that the physician was contacted to clarify the discharge orders.

4. The medical record of Pt #11 was reviewed on 4/1/10. Pt #11 was admitted to the CAH on 9/28/09 with the diagnosis of Hyperosmolar, Hyperglycemic State. On 10/1/09, there was a physician's order "May discharge. Patient to take Humalog Insulin 18 units with meals at home. Follow up in 1 week." There was no discharge MRR on the record. There were no orders for the patient's other medications. The CAH discharge instructions given to the patient, listed all medications that the patient had been on prior to hospitalization. There was no documentation to indicate that the physician was contacted to clarify the discharge orders.

5. The medical record of Pt #12 was reviewed on 4/1/10. Pt #12 was admitted to the CAH on 9/14/09 with the diagnosis of Abscess Thoracic Spine. Pt #12 underwent an Incision and Debridement on 9/15/09 and then was discharged back to the nursing home. Medical record documentation indicated that Pt #12 received Ancef every 8 hours intravenously. There was no discharge MRR on the record. There were no orders for the patient's other medications. There was no documentation to indicate that the physician was contacted to clarify the discharge orders as to what the patient was to take upon discharge and whether the Ancef was to be continued or not.

6. The medical record of Pt #15 was reviewed on 4/1/10. Pt #15 was admitted to the CAH on 9/29/09 with the diagnosis of Osteoarthritis Right Knee. On 10/2/09, there was an orthopedic order "OK to discharge home 10/3/09 if ok with attending physician and attending physician will manage all primary care medications..." It further indicated orders for Norco and Colace. On 10/3/09, there was an attending physician order "OK to discharge." Pt #15 had been put on Coumadin 5 mg daily by mouth for Deep Vein Thrombosis prevention. There was no discharge MRR completed. There were no orders for the patient's other medications. There was no documentation to indicate that the physician was contacted to clarify the discharge orders as to what the patient was to take upon discharge and whether the Coumadin was to be continued or not.

7. During a staff interview, conducted with the Vice President of Clinical Services on 4/1/10 at 2:30 PM, the above findings were confirmed.

C. Based on a review of the CAH's policy and procedure, medical record review, and staff interview, it was determined that in 1 of 20 (Pt #19), medical records reviewed, that the CAH failed to ensure orders related to advanced directives were written.

Findings include:

1. The CAH policy and procedure related to "Do Not Resuscitate (DNR)" was reviewed. It indicated "II. Resuscitative Order: Patient wishes regarding resuscitative measures shall be assessed...A. A DNR order must be written and it must be specific...1. If the patient has verbally expressed their wishes relative to DNR status, the circumstances of the discussion must be documented in the patient's medical record. The DNR order must be signed by the patient's physician, and two witnesses 18 years of age or older."

2. The medical record of Pt #19 was reviewed on 4/1/10. It indicated Pt #19 was admitted on 9/8/09 with a diagnosis of Acute Febrile Illness. A nurse's note in the initial assessment, dated 9/8/09, indicated that the Pt #19 requested to be placed on DNR status, There was no further documentation in the chart that indicated the patient's request was addressed or that the patient was placed in DNR status.

3. During an interview with the Clinical Systems Specialist, conducted on 4/1/10 at 1:45 PM, the above finding was confirmed.

A. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 6 of 20 (Pts #6, #10, #11, #12, #14, #15) medical records reviewed, that the CAH failed to ensure that medical record entries were dated and/or timed.

Findings include:

1. The CAH policy titled "Patient Documentation" was reviewed on 3/31/10. It indicated "Guidelines: 2. b. The date and time should be included with information entered."

2. The medical record of Pt #6 was reviewed on 3/31/10. Pt #6 was admitted to the CAH on 3/30/10 with the diagnosis of Newborn. On 3/31/10, the "Newborn 12 to 24 Hours" and "Newborn 24 hours +" order sheets failed to include the date and time that they were authenticated.

3. The medical record of Pt #10 was reviewed on 4/1/10. Pt #10 was admitted to the CAH on 1/11/10 at 10:16 (military time) with the diagnoses of Congestive Heart Failure and Pneumonia. The History and Physical (H&P) indicated that it was dictated at "02:48," which is prior to the patient being seen in the CAH. On 1/12/10, the Medical Screening Examination (MSE) failed to indicate the time it was completed.
The Patient Progress Record lacked the time of the entries on 2 out of 2 entries dated 1/12/10 and 1/13/10. The Physician orders dated 1/11/10 thru 1/13/10 lacked the time that the order was written.

4. The medical record of Pt #11 was reviewed on 4/1/10. Pt #11 was admitted to the CAH on 9/28/09 with the diagnosis of Hyperosmolar, Hyperglycemic State. The Patient Progress Record lacked the time of the entries on 3 out of 3 entries dated 9/29/09 thru 10/1/09. On 9/29/09, the MSE failed to indicate the time it was completed.

5. The medical record of Pt #12 was reviewed on 4/1/10. Pt #12 was admitted to the CAH on 9/14/09 at 08:33 (military time) with the diagnosis of Abscess Thoracic Spine. On 9/14/09, the H&P indicated that it was dictated at "04:00" and the Surgical Consult indicated that it was dictated at "01:53," both times of which were prior to the patient being seen in the CAH. The "Pre-Anesthesia Evaluation" form, which is signed by both the physician and the Certified Registered Nurse Anesthetist (CRNA) prior to surgery, failed to include the date and time that this was signed.

6. The medical record of Pt #14 was reviewed on 4/1/10. Pt #14 was admitted to the CAH on 12/7/09 with the diagnosis of Ascending Colon/ Cecal Polyps. The Patient Progress Record lacked the time of entries on 6 out of 6 entries dated 12/8/09 thru 12/13/09. The "Pre-Anesthesia Evaluation" form failed to indicate the time that it was signed.

7. The medical record of Pt #15 was reviewed on 4/1/10. Pt #15 was admitted to the CAH on 9/29/09 with the diagnosis of Osteoarthritis Right Knee. The Patient Progress Record lacked the time of entries on 3 out of 3 entries dated 9/30/09 thru 10/2/09. The "Pre-Anesthesia Evaluation" form failed to indicate the time that it was signed. On 9/29/09, the Operative Report indicated that it was dictated at "04:26," which was prior to the surgery being performed.

8. During a staff interview, conducted with the Vice President of Clinical Services on 4/1/10 at 2:30 PM, the above findings were confirmed.

B. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 2 of 20 (Pts #3, #4) medical records reviewed, that the CAH failed to ensure that telephone orders were signed, as per CAH policy.

Findings include:

1. The CAH policy titled "Physician's Orders" was reviewed on 4/1/10. It indicated "Procedure I: Telephone Orders: B. The physician's signature should be obtained for the record upon his/her next visit to the unit."

2. The medical record of Pt #3 was reviewed on 3/30/10. Pt #3 was admitted to the CAH on 3/28/10 with the diagnosis of Pneumonia. On 3/28/10, there were telephone orders "1000 ml Normal Saline bolus..." and "Protime/ INR in AM. Increase Intravenous rate to 200 ml/hour Normal Saline." As of 3/31/10 at 10:00 AM, further physician visits to the unit were documented; however, the above orders had not been signed.

3. The medical record of Pt #4 was reviewed on 3/30/10. Pt #4 was admitted to the CAH on 3/27/10 with the diagnoses of Chest Pain and Pneumonia. On 3/27/10, there was an Emergency Room physician verbal/telephone order sheet that was not signed by the physician, as of 3/31/10 at 10:00 AM.

C. Based on a review of CAH policy and procedure, medical record review, and staff interview, it was determined that in 1 of 20 (Pt #20)medical records reviewed, the CAH failed to ensure all physician orders for medications included the reason for the medication.

Findings include:

1. The CAH policy and procedure titled, "Physician's Orders" was reviewed on 4/2/10. It indicated under "PROCEDURE: A. ...The order includes the name of the medication, the dosage, the route, reason,..."

2. The medical record of Pt #20 was reviewed on 4/2/10. It indicated Pt #20 was admitted on 1/6/10 with a diagnosis of Pneumonia. A physician's order, dated 1/7/10, was for "Lorazepam 0.25mg BID (twice a day) PRN (as needed) PO (by mouth)." There was no reason given for the administration of the medication such as anxiety, restlessness, sleeplessness, etc.

3. During an interview with a Clinical Systems Specialist, conducted on 4/2/10 at 9:30 AM, the above finding was confirmed.

A. Based on medical record review and staff interview, it was determined in 2 of 6 (Pts #14, #16) medical records reviewed, in which the patient required surgical services, that the CAH failed to ensure that an pre-anesthesia evaluation was conducted prior to the procedure.

Findings include:

1. The medical record of Pt #14 was reviewed on 4/1/10. Pt #14 was admitted to the CAH on 12/7/09 with the diagnosis of Ascending Colon/Cecal Polyps and underwent a Right Hemicolectomy on 12/7/09. There was no documentation to indicate what time the pre-anesthesia evaluation was completed, the risk level, or the choice of anesthesia.

2. The medical record of Pt #16 was reviewed on 4/1/10. Pt #16 was admitted to the CAH on 12/8/09 with the diagnosis of Gastrointestinal Bleeding and underwent a Sigmoid Colectomy on 12/9/09. There was no documentation of a date or time on the Anesthesia Questionnaire, no documentation of a pre-anesthesia examination, and no documentation of a post-anesthesia examination.

3. During a staff interview, conducted on 4/1/10 at 2:30 PM with the Clinical Systems Specialist, the above findings were confirmed.

A. Based on a review of the Quality Assurance program and staff interview, it was determined that the CAH failed to ensure that medical records were sent to an outside program to ensure the care provided met quality and appropriateness of the diagnosis and treatment furnished.

Findings include:

1. The Quality Assurance program was reviewed on 4/1/10. There was no indication any medical records were sent to an outside source for review in the last 2 years to ensure the quality and appropriateness of the diagnosis and treatments furnished.

2. During an interview with the CEO, conducted on 4/1/10 at 1:45 PM, the above finding was confirmed.