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Based on observation, policy review, and staff interviews, the Critical Access Hospital (CAH) staff failed to properly secure 3 of 3 small compressed gas storage cylinders in the Medical Gas Storage Room in the Operating Rooms area. The CAH identified a census of 10 inpatients at the time of the survey.

Failure to properly secure compressed gas storage cylinders could potentially result in damage to the compressed gas cylinder, resulting in damage to the cylinder and the potential to harm patients and staff and cause property damage.

Findings include:

1. A tour of the Operating Rooms Medical Gas Storage Room on 6/21/10 at 3:15 PM, revealed 3 small compressed gas cylinders (Carbon Dioxide, Oxygen, and Nitrous Oxide) placed against a wall, without a device to secure the cylinders to the wall.

2. Review of the policy, "Compressed Gas and Oxygen Use", reviewed 12/09, revealed in part, "Storage: ...Store upright and firmly secured to prevent falling or being knocked over." "Special Precautionary Note: ... cylinders can present a severe hazard. Cylinders store gases/oxygen at extremely high pressure that can turn a damaged cylinder into a torpedo capable of going through multiple concrete block walls. They are often termed 'sleeping giants'".

3. During an interview at the time of the tour, the Operating Rooms Director acknowledged staff did not secure the compressed gas cylinders, and acknowledged the risks an unsecured compressed gas cylinder presented to staff and patients.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) radiology staff failed to ensure warmed radiology contrast media did not stay in the warming cabinet over 1 month, as per manufacturer direction, in 1 of 1 contrast media warming cabinet in the CT room. The CAH radiology staff identified an average of 33 CT procedures per month utilizing warmed contrast media.

Failure to follow manufacturer's directions about the length of time contrast media can stay in warming cabinets could potentially expose patients to ineffective contrast media, or increase the risk of infection from bacteria growing in the contrast media.

Findings include:

1. A tour of the CT room in the Radiology Department, on 6/22/10 at 10:20 AM, revealed a contrast media warming cabinet set to 37.5 Degrees Celsius (99.5 Degrees Fahrenheit). The warming cabinet contained:

a. Eight bottles of 100 mL Visipaque 320 mgI/mL contrast media lacked evidence of the date staff placed the bottles in the warmer.

b. Two bottles of 75 mL Isovue 370 contrast media lacked evidence of the date staff placed the bottles in the warmer.

c. Ten bottles of 150 mL Isovue 300 contrast media bottles lacked evidence of the date staff placed the bottles in the warmer.

2. Review of the manufacturer's directions for the Visipaque 320 contrast media revealed, "Visipaque vials... may be stored at 37 [Degrees Celsius](98.6 [Degrees Fahrenheit]) for up to one month in a contrast agent warmer..."

3. Review of the manufacturer's directions for the Isovue 300 and Isovue 370 contrast media revealed, "...we do have data to support allowing Isovue to remain in the contrast warmer... provided it has been in a contrast warmer not exceeding 98.6 [Degrees Fahrenheit] (37 [Degrees Celsius]) for less than one month..."

4. During an interview at the time of the tour, the Radiology Director agreed, and stated the contrast media lacked evidence of the date staff placed the bottles in the contrast media warmer.

Based on review of water and gas contracts and interview with staff, the Critical Access Hospital (CAH) failed to ensure the safety of patients in non-medical emergencies by having emergency fuel and water contracts that included nationally accepted referenced or calculations for determining the need for water and gas. The CAH identified a census of 10 patients.

Failure to obtain emergency contracts that include estimated calculations for water and gas could potentially result in a lack of the essential resources in an emergency.

Findings include:

1. A review of the Emergency Water Contract, dated 08/25/08, showed it stated in part ...West Union agrees to supply potable water to Palmer Lutheran Health Center upon request, subject to supplies available and area disaster situations.... The contract lacked any calculation for determining the amount of water needed.

2. A review of the Emergency Gas contract, dated 08/25/08, showed it stated in part ...Energy Resources agrees to supply fuel oil to Palmer Lutheran Health Center for the boilers and generator upon request.... The contract lacked any calculation for determining the amount of gas needed.

3. During an interview on 06/23/10 at 9:00 am, Staff A, Director of Support Services, verified the signed emergency contracts lacked information for calculating the CAH's need for water and gas.

Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to assure staff followed the policy for hair covering while in the kitchen and failed to assure all refrigerators/freezers had thermometers to measure and record internal temperatures. The CAH identified a census of 10 inpatients at the time of the survey.

Failure to follow acceptable guidelines for hygiene practices of food service personnel and kitchen sanitation could potentially result in an outbreak of food borne illness.

Findings include:

1. An observation on 06/21/10 at 3:00 pm revealed Staff B, the dietary supervisor, lacked a hair covering. Staff B accompanied the surveyor on initial tour of the kitchen environment. The dietary tour included all areas of the kitchen including production, dry storage, refrigerator, and freezer storage areas.

All individuals must wear a hair covering to prevent contamination of the food while in the production area of the kitchen. A review of the policy/procedure titled Dress Code, dated 2/2010, showed it lacked information regarding appropriate hair coverings for dietary personnel.

During an interview on 06/23/10 at 12:15 pm, Staff B verified the lack of a hair covering during the initial dietary tour and failure to wear an appropriate hair covering at any time during the survey process.

2. An observation on 06/21/10 at 3:00 pm, during the initial tour of the dietary department revealed four of six refrigerator/freezers lacked an internal thermometer for measuring and recording of temperatures.

The facility lacked a policy/procedure for placement of an internal thermometer in the refrigerator/freezers.

During an interview on 06/21/10 at 3:00 pm, Staff B verified the lack of an internal thermometer in 4 of 6 refrigerator/freezers.

I. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 sampled teleradiologist (Teleradiologist P) received medical staff approval, and governing body appointment to the medical staff. The CAH staff identified 16 teleradiologists who provided medical services to CAH patients in the last year.

Failure to appoint teleradiologists to the medical staff potentially places patients at risk of misdiagnosis and inappropriate treatment.

Findings include:

1. Review of Teleradiologist P's credential file revealed the credential file lacked evidence the medical staff approved Teleradiologist P's appointment to the medical staff of the CAH. Teleradiologist P's credential file also lacked evidence the governing body appointed Teleradiologist P to the medical staff of the CAH.

2. Review of the policy, "Radiologists", effective 4/10, revealed in part, "Teleradiologists are not credentialed or given privileges at Palmer Lutheran Health Center."

3. During an interview on 6/23/10 at 4:10 PM, the Utilization Review/Resource Management Director stated the CAH does not credential teleradiologists. Instead, the teleradiologist were credentialed at the network hospital, and the CAH relies on the network hospital's credentialing process to monitor the quality of the teleradiologists care at the CAH.


II. Based on credential file review and staff interview, the CAH administrative staff failed to evaluate the quality and appropriateness of the diagnosis and treatment furnished by 7 of 16 medical practitioners (Practitioners I, J, K, L, M, N, O). The CAH had a census of 5 inpatients at the time of the survey.

Failure to ensure the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by medical practitioners at the CAH could potentially lead to substandard patient care.

Findings include:

1. Review of credential files revealed the following information.

a. Practitioner I's credential file contained a "Low Volume Provider" evaluation and lacked evidence of external peer review on care provided at the CAH by Practitioner I.

b. Practitioner J's credential file contained a "Low Volume Provider" evaluation and lacked evidence of external peer review on care provided at the CAH by Practitioner J.

c. Practitioner K's credential file contained a "Low Volume Provider" evaluation and lacked evidence of external peer review on care provided at the CAH by Practitioner K.

d. Practitioner L's credential file contained a "Low Volume Provider" evaluation and lacked evidence of external peer review on care provided at the CAH by Practitioner L.

e. Practitioner M's credential file contained a "Low Volume Provider" evaluation and lacked evidence of external peer review on care provided at the CAH by Practitioner M.

f. Practitioner N's credential file contained a "Low Volume Provider" evaluation and lacked evidence of external peer review on care provided at the CAH by Practitioner N.

g. Practitioner O's credential file contained a "Low Volume Provider" evaluation and lacked evidence of external peer review on care provided at the CAH by Practitioner O.

2. During an interview on 6/23/10 at 11:20 AM, the Utilization Review/Resource Management Director stated the CAH performs peer review on "low volume providers". The CAH does not send charts where the provider furnished medical care to patients at the CAH for external peer review. Instead, the CAH relies on data provided by the provider's primary practice location for quality data on the provider. The chief of the medical staff at the CAH reviews the data for completeness, but can't evaluate the specialty care provided by specialty low volume providers, since the chief of the medical staff specialized in family practice medicine.

The Utilization Review/Resource Management Director also stated the CAH lacked a policy addressing the criteria to define a low volume provider. If a medical record meets pre-determined criteria for external peer review, the CAH sends the medical record for external review. However, if a provider is otherwise a low volume provider, and they don't have charts meet the pre-determined criteria for external peer review, the CAH staff make a judgment call. "We don't have any hard and fast rules to determine who is a low volume provider."

Based on review of the Critical Access Hospital (CAH) policy, job description, medical records, activity calendar and staff interviews the Activity Coordinator failed to provide ongoing activity programs developed according to the comprehensive assessment and activity interest of 2 of 3 skilled patients (Patient #1 and #3) and 4 of 4 discharged skilled patients (Patient #4, #5, #6, and #7).

The CAH reported a census of three skilled inpatients at the time of the survey.

Failure to develop ongoing activities according to the interest and needs of the CAH patients could interfere with the continuity of care of the patient while hospitalized.

Findings included:

1. A review of the CAH policy "Activity Services", revised 3/2010, showed it stated the CAH will provide an activities program to provide ongoing activities designed to meet, with the comprehensive assessment, needs and interest of each patient. The activity program will occur within the context of each skilled patient with needs identified in the comprehensive assessment and care plan.

2. A review of the CAH job description for Activity program coordinator, dated 7/2001, showed it stated the Director should be flexible, organize activities and supervise the activity of each patient as necessary. The Director develops an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, documents the activity program for each patient and will provide activities in group settings.

3. A review the open medical records of skilled inpatient revealed the following information.

a. Patient # 1's medical record showed an admit date to skilled care on 6/15/10 with a diagnosis of profound weakness and hypertension. Patient #1's medical record lacked a comprehensive activity assessment and care plan addressing the activity interest of the patient.

b. Patient # 3's medical record showed an admit date to skilled care on 6/20/10 with a diagnosis of right total hip arthroscopic replacement. Patient #3's medical record lacked a comprehensive activity assessment and care plan addressing the activity interest of the patient.

4. A review of the closed medical records of discharged skilled patients revealed the following information.

a. Patient # 4's medical record showed an admit date to skilled care on 2/1/10 with a diagnosis of bowel resection and a discharge date of 2/22/10. Patient #4's medical record lacked a comprehensive activity assessment and care plan addressing the activity interest of the patient.

b. Patient # 5's medical record showed an admit date to skilled care on 8/12/10 with a diagnosis of CVA with hypertension and a discharge date of 8/21/10. Patient #5's medical record lacked a comprehensive activity assessment and care plan addressing the activity interest of the patient.

c. Patient # 6's medical record showed an admit date to skilled care on 12/2/09 with diagnosis of COPD with exacerbation, bronchitis and a discharge date of 12/10/09. Patient #6's medical record lacked a comprehensive activity assessment and care plan addressing the activity interest of the patient.

d. Patient # 7's medical record showed an admit date to skilled care on 3/27/10 with a diagnosis of right total hip arthroscopic replacement and a discharge date of 3/31/10. Patient #7's medical record lacked a comprehensive activity assessment and care plan addressing the activity interest of the patient.

The medical records of Patients #1, #3, #4, #5, #6, and #7 lacked individualized activity care plans with measurable goals and interventions reflecting each patient's unique needs and interests.

5. A review of the monthly activity calendar showed it stated it stated 1-1 Monday thru Friday at assigned hours and when Activity Coordinator on duty. The word "off" was on days when Activity Coordinator was off work for the day.

6. During an interview on 6/23/10 at 9:15 AM, the Activity Coordinator acknowledged the Activity calendar reflected the times when activities could be provided for the patients and confirmed the lack of weekend activities. The Activity Coordinator acknowledged 1-1's were the only scheduled activity noted on the calendar.

Based on review of the Critical Access Hospital (CAH) policy, job description, medical records, activity calendar and staff interviews the Activity Coordinator failed to complete a comprehensive assessment with inquiries regarding activity interest for 2 of 3 skilled inpatients (Patient #1, and #3) and 4 of 4 discharged skilled patients (Patient #4, #5, #6, and #7).

The CAH reported a census of three skilled inpatients at the time of the survey.

Failure to complete an activity comprehensive assessment could result in failure to provide activities directed towards the patient's individual interest and needs to promote a sense of well-being and self-esteem.

Findings included:

1. A review of the CAH policy "Activity Services", revised 3/2010, showed it stated, the CAH will provide an activities program to provide ongoing activities designed to meet, with the comprehensive assessment, needs and interest of each patient. The activity program will occur within the context of each skilled patient with needs identified in the comprehensive assessment.

2. A review of the CAH job description for Activity program coordinator, dated 7/2001, showed it stated, the Director should be flexible, organize activities and supervise the activity of each patient as necessary. The Director develops an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, documents the activity program for each patient and will provide activities in group settings.

3. A review of skilled open medical records revealed the following.

a. Patient # 1's medical record revealed an admit date to skilled care on 6/15/10 with diagnosis of profound weakness and hypertension. Patient #1's medical record included an undated Activities Assessment. This assessment lacked documentation regarding the patient's activity interests prior to hospitalization.

b. Patient # 3's medical record revealed an admit date to skilled care on 6/20/10 with diagnosis of right total hip arthroscopic replacement. Patient #3's medical record included an undated Activities Assessment. This assessment lacked documentation regarding the patient's activity interests prior to hospitalization.

4. A review of skilled closed medical records revealed the following:

a. Patient # 4's medical record revealed an admit date to skilled care on 2/1/10 with diagnosis of bowel resection and a discharge date of 2/22/10. Patient #4's medical record included an undated Activities Assessment. This assessment lacked documentation regarding the patient's activity interests prior to hospitalization.

b. Patient # 5's medical record revealed an admit date to skilled care on 8/12/10 with diagnosis of CVA with hypertension and a discharge date of 8/21/10. Patient #5's medical record included an undated Activities Assessment. This assessment lacked documentation regarding the patient's activity interests prior to hospitalization.

c. Patient # 6's medical record revealed an admit date to skilled care on 12/2/09 with diagnosis of COPD with exacerbation, bronchitis and a discharge date of 12/10/09. Patient #6's medical record included an undated Activities Assessment. This assessment lacked documentation regarding the patient's activity interests prior to hospitalization.

d. Patient # 7's medical record revealed an admit date to skilled care on 3/27/10 with diagnosis of right total hip arthroscopic replacement and discharged on 3/31/10. Patient #7's medical record included an undated Activities Assessment. This assessment lacked documentation regarding the patient's activity interests prior to hospitalization.

5. During an interview on 6/23/10 at 9:15 AM, the Activity Coordinator acknowledged the Activity Assessment form lacked questions about patient interests or past activities. The Activity Coordinator stated the Activity Assessment needed updating to include questions regarding the patients' interest prior to hospitalization.

Based on review of Critical Access Hospital (CAH) policy, job description, medical records, activity calendar and staff interviews, the Activity Coordinator failed to develop an individualized care plan with measurable goals and interventions for activities of interest for 2 of the 3 skilled inpatients (Patient #1, and #3) and 4 of 4 discharged skilled patients (Patient #4, #5, #6, and #7).

The CAH reported a census of 3 skilled inpatients at the time of the survey.

Failure to develop an individualized care plan with measurable goals could interfere with the continuity of care provided to skilled patients.

Findings include:

1. A review of the CAH policy "Activity Services", revised 3/2010, showed it stated, the CAH will provide an activities program to provide ongoing activities designed to meet, with the comprehensive assessment, needs and interest of each patient. The activity program will occur within the context of each skilled patient with needs identified in the comprehensive assessment and care plan.

2. A review of the CAH job description for Activity Program Coordinator, dated 7/2001, showed it stated the Director should be flexible, organize activities and supervise the activity of each patient as necessary. The Director develops an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, documents the activity program for each patient and will provide activities in group settings.

3. A review of open medical records of skilled patients revealed the following information.

a. Patient # 1's medical record showed an admit date to skilled care on 6/15/10 with diagnosis of profound weakness and hypertension and included an undated Activities Assessment as follows.

Activity Goals and Plan (restorative, strengthening, diversion): Will participate in 1-1 activities 2-3 times a week as condition allows

Plan: Schedule 1-1 activities 2-3 times a week and bring material of interest to patient

Goal: Will socialize with visitors/callers 2-3 times a week as able

Goal: Will maintain improve mobility/strength as condition allows

Plan: Follow Dr. orders/PT-OT (Physical Therapy/Occupational Therapy) guidelines for ambulation/exercises as condition allows

Patient #1's Activity progress notes lacked documentation of outcomes and responses to activities interventions of the activity care plan.

b. Patient # 3's medical record revealed an admit date to skilled care on 6/20/10 with diagnosis of right total hip arthroscopic replacement. Patient #3's medicall record included an undated Activities Assessment as follows.

Activity Goals and Plan (restorative, strengthening, diversion): Will participate in 1-1 activities 2-3 times a week as condition allows

Plan: Schedule 1-1 activities 2-3 times a week and bring material of interest to patient

Goal: Will socialize with visitors/callers 2-3 times a week as able

Plan: Encourage family/friends to visit/phone and notify of visiting hours/phone # if needed

Goal: Will maintain improve mobility/strength as condition allows

Plan: Follow Dr. orders/PT-OT guidelines for ambulation/exercises as condition allows

4. A review of closed medical records of skilled patients revealed the following information.

a. Patient # 4's medical record revealed an admit date to skilled care on 2/1/10 with diagnosis of bowel resection and a discharge date of 2/22/10. Patient #4's medical record noted an undated Activities Assessment as follows.

Activity Goals and Plan (restorative, strengthening, diversion): Will participate in 1-1 activities 2-3 times a week as condition allows

Plan: Schedule 1-1 activities 2-3 times a week and bring material of interest to patient

Goal: Will socialize with visitors/callers 2-3 times a week as able

Plan: Encourage family/friends to visit/phone and notify of visiting hours/phone # if needed

Goal: Will maintain improve mobility/strength as condition allows

Plan: Follow Dr. orders/PT-OT guidelines for ambulation/exercises as condition allows

Patient #4's Activity progress notes lacked documentation of outcomes and responses to activities interventions of the activity care plan.

b. Patient # 5's medical record revealed an admit date to skilled care on 8/12/10 with diagnosis of CVA with hypertension and a discharge date of 8/21/10. Patient #5's medical record noted an undated Activities Assessment as follows.

Activity Goals and Plan (restorative, strengthening, diversion): Will participate in 1-1 activities 2-3 times a week as condition allows

Plan: Schedule 1-1 activities 2-3 times a week and bring material of interest to patient

Goal: Will socialize with visitors/callers 2-3 times a week as able

Plan: Encourage family/friends to visit/phone and notify of visiting hours/phone # if needed

Goal: Will maintain improve mobility/strength as condition allows

Plan: Follow Dr. orders/PT-OT guidelines for ambulation/exercises as condition allows

Patient #5's Activity progress notes lacked documentation of outcomes and responses to the interventions of the activity care plan.

c. Patient # 6's medical record revealed an admit date to skilled care on 12/2/09 with diagnosis of COPD with exacerbation, bronchitis and discharged on 12/10/09. Patient #6's medical record included an undated Activities Assessment as follows.

Activity Goals and Plan (restorative, strengthening, diversion): Will participate in 1-1 activities 2-3 times a week as condition allows

Plan: Schedule 1-1 activities 2-3 times a week and bring material of interest to patient

Goal: Will socialize with visitors/callers 2-3 times a week as able

Plan: Encourage family/friends to visit/phone and notify of visiting hours/phone # if needed

Goal: Will maintain improve mobility/strength as condition allows

Plan: Follow Dr. orders/PT-OT guidelines for ambulation/exercises as condition allows

Patient #6's Activity progress notes lacked documentation of outcomes and responses to activity interventions of the activity care plan.

d. Patient # 7's medical record revealed an admit date to skilled care on 3/27/10 with diagnosis of right total hip arthroscopic replacement and a discharge date of 3/31/10. Patient #7's medical record included an undated Activities Assessment as follows.

Activity Goals and Plan (restorative, strengthening, diversion): Will participate in 1-1 activities 2-3 times a week as condition allows

Plan: Schedule 1-1 activities 2-3 times a week and bring material of interest to patient

Goal: Will socialize with visitors/callers 2-3 times a week as able

Plan: Encourage family/friends to visit/phone and notify of visiting hours/phone # if needed

Goal: Will maintain improve mobility/strength as condition allows

Plan: Follow Dr. orders/PT-OT guidelines for ambulation/exercises as condition allows

Patient #7's Activity progress notes lacked documentation of outcomes and responses to activity interventions of the activity care plan.

The Medical Records for Patients #1, #3, #4, #5, #6, and #7 noted the patients were admitted with various medical conditions but lacked individualized activity care plans with measurable goals and interventions reflecting each patient's unique needs and interests.

5. A review of the monthly activity calendar stated 1-1 Monday thru Friday at assigned hours and when Activity Coordinator on duty. The word "off" noted on days when Activity Coordinator not working on the day.

6. During an interview on 6/23/10 at 9:15 AM, the Activity Coordinator acknowledged the Activity calendar reflected the times when activities could be provided for the patients and confirmed the lack of weekend activities. The Activity Coordinator acknowledged 1-1's were the only scheduled activity noted on the calendar.
The Activity Coordinator stated group activities were discussed but at this time group activities were not scheduled. The Activity Coordinated acknowledged the patients' comprehensive assessments lacked information regarding the patient's activity interest, therefore, the skilled patients care plans lacked measurable individualized activity goals and interventions.