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Based on personnel record reviews, policy/procedure review, and staff interview, the Critical Access Hospital (CAH) staff failed to complete criminal and adult/child abuse background checks, for 2 of 2 Radiology Technicians (Staff H and Staff I). The CAH identified hiring approximately 40 employees per year.

Failure to complete criminal background and adult/child abuse checks for newly hired personnel has the potential to put patients at risk for abuse and/or criminal activities due to lack of proper screening of employees.

Findings include:

1. Review of Staff H's, Radiology Technicon (RT), personnel record, revealed a hire date of 5/01/10. The personnel record lacked evidence the CAH staff conducted a criminal background and adult/child abuse check prior to hire.

2. Review of Staff I's, Radiology Technicon (RT), personnel record revealed a hire date of 7/5/10. The personnel record lacked evidence the CAH staff conducted a criminal background and adult/child abuse check prior to hire.

3. During an interview, on 7/27/10 at 4:00 PM, Staff F, the Director of Organizational Excellence and Staff G, Human Resources Director stated:
a. Criminal background and adult/child abuse checks were not completed for Staff H and Staff I prior to hire.
b. The CAH administrative staff did not considered Staff H and Staff I as new hires as both worked at the CAH prior to hire as contract employees. Staff F and Staff G considered this a change of status as apposed to truly new hires.
c. Staff F and Staff G had no knowledge that criminal background and adult/child abuse checks are required when an employee changes from
contract employee to CAH employee.

4. Review of the CAH policy/procedure titled " New Hires", revised on 1/09, showed the policy/procedure lacked a requirement for criminal background and adult/child abuse checks prior to employment for contract employees who become CAH employees.

Based on patient outpatient medical record review, policy/ procedure review, and staff interview the Critical Access Hospital (CAH) staff failed to provide patient rights information for 10 of 10 closed, outpatient surgical patient records reviewed (Patient #17, #18, #19, #20, #21, #22, #23, #24, #25, and #26). CAH surgical staff reported approximately 60 outpatient surgical procedures per month.

Failure to provide patient rights to outpatient surgical patients has the potential to leave the patient without knowledge of their rights and remedies for violation of these rights as patient of the CAH.

Findings include:

1. Review of closed, outpatient surgical records for Patient #17, #18, #19, #20, #21, #22, #23, #24, #25, and #26 revealed the medical records lacked documentation that CAH staff provided patient rights information to outpatient surgical patients.

2. Review of CAH policy and procedure titled "Notification of Patient Rights", reviewed 1/2010, revealed the CAH makes every effort to ensure that all inpatients and outpatients, are informed of their rights in advance of care provided.

3. During interview, on 7/28/10 at 10:05 AM, Staff L, Financial Services Manager, stated only inpatients of the CAH receive patient rights information. Outpatient surgical patient are not provided with patient rights information.







25917

I. Based on observation, staff interview, and Dietary policy/procedure review, the Critical Access Hospital (CAH) dietary staff failed to change contaminated gloves prior to serving unwrapped food intended for patient consumption. The CAH staff identified an inpatient census of 7 patients.

Failure to change contaminated gloves, prior to serving unwrapped food to patients, has the potential to expose the patient to food borne illness, further compromise the patient's health, and increase the patient's hospital stay.

Findings Include:

1. Observation of the noon meal preparation, on 7/27/10 at 11:35 AM, Staff J, cook, used her gloved hands to touch potholders, food packages, and various contaminated cooking surfaces. Then, without changing to clean gloves, Staff J proceeded to pick up and place servings of unwrapped baked potatoes on patient food trays.

2. During an interview, on 7/28/10 at 11:40 AM, Staff K, dietitian/health coach, acknowledged that Staff J failed to change her contaminated gloves prior to touching unwrapped patient food and that Staff J failed to follow CAH Dietary policy/procedures.

3. Review of the Dietary policy/procedure, titled "Basic Sanitation Procedure/Orientation", dated 6/09, states in part ...Plastic gloves are worn in direct handling of foods served and changed after touching dirty item ...

II. Based on observation, staff interview, and review of policy/procedure manual, titled "Patient Menu 'A' Weekend week 2" (menus), the Critical Access Hospital (CAH) dietary staff failed to follow the correct serving size for vegetables for 2 of 2 meal preparations observed. The CAH staff identified an inpatient census of 7 patients.

Failure to follow a prescribed menu, including serving size, has the potential to result in patients not meeting their prescribed daily nutritional requirements, further compromise the patient's health, and increase the patient's hospital stay.

Findings include:

1. Observation of the noon meal preparations, on 7/27/10 at 11:35 AM, Staff J, cook, used a slotted spoon to serve vegetables on patient trays. Observation revealed that Staff J's use of a slotted spoon resulted in inconsistent serving sizes of vegetables for each patient's tray. Observation in the kitchen area also revealed 1/2 cup measuring scoops available for use to ensure the correct serving size for each patient.

2. During an interview, on 7/28/10 at 11:40 AM, Staff K, dietitian/health coach, acknowledged Staff J used a slotted spoon while serving vegetables for patient trays. Staff K also acknowledged that a slotted spoon does not yield a 1/2 cup serving size and is not the correct utensil to ensure correct service size for each patient.

3. Review of the Dietary policy/procedure manual, titled "Patient Menu 'A' Weekend week 2" (menus), the prescribed vegetable serving size, for the noon patient meal, is 1/2 cup.

4. Review of the general, Dietary policy/procedure manual revealed no requirement that staff follow all prescribed patient menus and use correct serving utensils when serving patient trays.

Based on patient medical record review and staff interview the Critical Access Hospital (CAH) failed to have complete care plans including Activities for 3 of 3 current patients (Patient #11, #12 and #13) and 3 of 3 closed patient medical records (Patient #14, #15 and #16) reviewed. The CAH reported a current census of 7 patients.

Failure to retain updated care plans could potentially interfere with patients overall recovery from the present illness.

Findings include:

Review of 3 of 3 current patient medical records revealed:

1. Patient #11's medical record lacked documentation of a current care plan reflecting activities provided to the patient.

2. Patient #12's medical record lacked documentation of a current care plan reflecting activities provided to the patient.

3. Patient #13's medical record lacked documentation of a current care plan reflecting activities provided to the patient.

Review of 3 of 3 discharged patient medical records revealed:

1. Patient #14's medical record lacked documentation of a current care plan reflecting activities provided to the patient.

2. Patient #15's medical record lacked documentation of a current care plan reflecting activities provided to the patient.

3. Patient #16's medical record lacked documentation of a current care plan reflecting activities provided to the patient.

During an interview on 7/26/10 at 10:50 AM Staff K Case Manager confirmed the patient care plans lacked documentation for activities.

II. Based on Swing Bed medical record review, policy/procedure review, and staff interview the Critical Access Hospital (CAH) staff failed to document that activities were offered to the patient, the patients participation in the activity, and the patients response to the activity. Lack of documentation was found for 3 of 3 open swing bed patients (Patient #11, #12 and #13) and 3 of 3 closed swing bed patient medical records reviewed (Patient #14, #15 and #16). The CAH staff reported a current census of 3 swing bed patients.

Failure to document which activities are appropriate for each patient, that the activities are offered to the patient, the patient's participation in the activity, and the patient's response to the activity has the potential to deny the swing bed patient of interactions with other patients/staff, a lack of physical and mental stimulation, and a decrease in his/her psychosocial well being.

Findings include:

1. Review of open and closed swing bed patient medical records failed to reveal documentation that activities were offered to the patient, the patients participation in the activity, and the patient's response to the activity in 3 of 3 open swing bed medical records (Patient #11, #12 and #13) and 3 of 3 closed swing bed patient medical records (Patient #14, #15 and #16).

2. Review of the CAH Activities Program policy/procedure manual, reviewed 11/09, revealed ... Attendance records and outcome/ response to activities may be documented on the Therapeutic Record Daily Note Form in the medical record.

3. During an interview, on 7/27/10 at 1:50 PM, the Activates Coordinator stated that documentation is not included in the patient's medical record that shows which activities are offered to patients, the patient's participation in the activity, and the patient's response to the activity.


25917


Based on patient interviews, observations, open and closed medical record review, policy/procedure review, and staff interviews the Critical Access Hospital (CAH) staff failed to provide an ongoing activity program to meet the individual needs of the swing bed patients (Patient #11, #12, #13, #14, #15 and #16). The CAH reported a current census of 3 swing bed patients.

Failure to provide activities that are appropriate for each patient needs and to ensure that those activities are consistently offered to the patient has the potential to deny the swing bed patient of interactions with other patients/staff, a lack of physical and mental stimulation, and a decrease in his/her psychosocial well being.


Finding included:

1. During interviews with Patients #12 and #13, on 7/26/10 at 10:20 AM and 10:30 AM respectively, the patients denied knowledge of any type of activities program or activities calender. Patient #13 reported that a lady comes in a couple times a week and brings me books but we don't do anything else.

2. Observations, on 7/26/2010, during the patient care tour revealed the CAH staff failed to post or make available a monthly activity calender identifying activities provided or available for swing bed patients.

3. Review of open and closed swing bed medical records failed to reveal documentation that patients were provided activities or that an activities calender is provided to patients in 3 of 3 open, swing bed medical records (Patient #11, #12 and #13) and 3 of 3 closed swing bed patient medical records (Patient #14, #15 and #16).

4. Review of the CAH Activities Program policy/procedure manual, reviewed 11/09, revealed patients will be provided an activities list to inform the patient of available activities. Attendance records and outcomes/ responses to activities may be documented on the Therapeutic Record Daily Note Form in the medical record.

5. During an interview, on 7/27/10 at 1:50 PM, the Activates Coordinator stated that the CAH staff does not provide a formal activities program for the swing bed patients, she does not provide an activities calender to each patient, and only the activities assessment is documented in the patient's medical record. The Activities Coordinator also stated that she had no knowledge that a formal activities program was required and that her job was to complete an activities assessment, visit the swing bed patients a couple times a week, and offer the patient something to do.

6. During an interview, on 7/28/10 at 9:40 AM, the Chief Nursing Officer reported the CAH does not have a formal activities program and we (the CAH staff) have not met the requirements for an activities program.