HospitalInspections.org

Based on the review of medical staff bylaws, hospital documents, medical provider credentialing files and staff interviews, it was determined the Critical Access Hospital (CAH) failed to ensure that one (1) medical provider had current Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) certifications. The deficient practice poses a potential risk to the health and safety of patients not receiving proper care in an emergency or critical situation.

Findings include:

Review of the hospital document titled "Medical Staff Bylaws Rules and Regulations", current 10/2019, revealed:"...3.6 Procedure for Appointment:3.6.1 Appointment and reappointment to the Medical Staff begins with completion of the application form...4.2 Active Staff...4.2.3 Responsibilities: Each appointee of the Active Medical Staff shall:...F. Practitioners providing primary care in the emergency room shall be ACLS and Advanced Trauma Life Support (ATLS) certified and maintain the certification, at their expense...."

A review of the hospital document titled "Little Colorado Medical Center Medical Staff Credentials File Checklist" current 11/2008, revealed:'...3. CPR (cardiopulmonary resuscitation), ATLS, ACLS, PALS (pediatric advanced life support), NALS (neonatal advanced life support) cards: Expiration dates...."

Review of the hospital document titled "Application for Appointment to the Medical Staff and Delineation of Privileges", revised 12/2021, revealed:'...Please attach copies of the following to your application: ... Any current CPR/ACLS/PALS/NALS/ATLS Certifications...."

A review of five (5) medical providers credentialing files was conducted on 02/01/2022 which revealed one (1) medical provider did not have current BLS or ACLS certifications. Provider #2 BLS certification had an expiration date of 09/30/2021. Provider #2 ACLS certification had an expiration date of 09/30/2021.

Employee #4 confirmed during an interview on 02/01/2022 that one (1) medical provider's BLS and ACLS certifications had expired and were not current.

Employee #2 confirmed during an interview on 02/02/2022 that BLS and ACLS certifications were required for medical providers to be reappointed and it was expected that BLS and ACLS certifications were current for medical providers.

Based on observation and staff interviews, it was determined the Critical Access Hospital (CAH) failed to ensure a radiation warning sign was posted at or on the door of the Computerized Tomography (CT) scanner room. The deficient practice could pose a potential risk to the health and safety of patients and staff by them being inadvertently exposed to radiation.

Findings include:

A request for a policy regarding Radiation signage was requested. The CAH had no policy.

Observation during the hospital tour on 02/01/2022 revealed no radiation warning sign posted at or on the door of the CT scanner room in the Emergency Department.

Employee #2 confirmed during an interview on 02/01/2022 that there was no radiation warning sign at or on the door to the CT scanner room in the Emergency Department.

Based on the review of policies and procedures, medical records, and staff interviews, it was determined the Critical Access Hospital (CAH) failed to ensure that automatic stop dates were implemented for two (2) patients prescribed antibiotics. This deficient practice could pose a risk to the health and safety of patients by exposing patients to prolonged and unnecessary antibiotic usage.

Findings include:

Hospital policy titled "Automatic Stop Orders", revised 12/2013, revealed:"...The hospital shall limit the duration of drug therapy in the absence of the prescriber's specific indication of the duration of drug therapy...Controlled substances and antibiotics are subject to a 3-day soft stop time or a different parameter if adopted by the Pharmacy and Therapeutics Committee, the medical staff by-laws, or medical executive committee...."

A review of twenty-two (22) patient medical records was conducted on 02/01/2022, which revealed two (2) patients had antibiotics ordered with no automatic stop dates. Medical record review for Patient #2 revealed an order for Ceftriaxone 2 grams daily every 24 hours with no stop date or duration indicated on the order. Medical record review for Patient #9 revealed an order for Ceftriaxone 1 gram daily every 24 hours and order for Azithromycin 250 milligrams once daily with no stop date or duration written for either antibiotic in the orders.

Employee #6 confirmed during an interview on 01/31/2022 that as part of the Antibiotic Stewardship Program all antibiotics ordered have an automatic stop date.

Employee #13 confirmed during an interview on 02/01/2022 that all antibiotics ordered have an automatic stop date. Pharmacy is alerted at forty-eight (48) hours of a soft stop date and the pharmacist will discuss with the prescribing provider the indications and duration for the antibiotic at that time.

Employee #8 confirmed during an interview on 02/01/2022 that there were no automatic stop dates on the antibiotics ordered for Patient #2 and Patient #9.

Based on the review of the documents and interviews, it was determined that the facility failed to ensure that medical staff members were completing patient medical records in a timely manner. Three (3) of three (3) providers were delinquent in completing patient medical records within 30 days according to the facility's Bylaws/Rules and Regulations. This deficient practice poses a potential risk to incorrect treatment decisions that could compromise the patient's safety.

Findings include:

Hospital document titled "(name of facility) Medical Staff Bylaws, Rules & Regulations," revealed: "...Incomplete Medical Records...a. A patient's medical record is considered incomplete/delinquent if deficiencies have not been completed within thirty (30) consecutive days after the patient's discharge...."

Hospital document titled "Deficiency Reporting by Physician Summary Report" dated 01/31/2022, revealed reporting on all hospital physicians, there were "222" total deficiencies in "114" charts ranging in oldest deficiency days from "2" days to "412" days for the hospital. There were three (3) providers that had deficiencies greater than 30 days, not including medication refills. Reporting for the physician's office there were "1,061" total deficiencies in "1,039" charts ranging in oldest deficiency days from "4" days to "1,370" days. There were three (3) providers and one (1) scribe that had deficiencies greater than 30 days, not including medication refills.

Employee #8 confirmed during interviews conducted on 02/01/2022 and 02/02/2022, that the system pulls several items that are not part of the medical record including medication refills. The scribes work for the same providers that are delinquent in completing the patient medical records.

Employee #34 confirmed during an interview conducted on 02/02/2022, that the facility has been working with the providers to complete the medical records. The providers were making genuine progress, however, the deficiencies have grown due to the COVID pandemic and the loss of one (1) clinic doctor and one (1) nurse practitioner.

Based on the review of Governing Body Meeting Minutes, employee files, and staff interviews, it was determined the Critical Access Hospital (CAH) failed to have the Infection Preventionist appointed by the Governing Body. The deficient practice could pose a potential health risk to patients and staff by not having a qualified individual responsible for the CAH's Infection Control Program.

Findings include:

A review of the Governing Body Meeting Minutes from January 2020 through March 2020 revealed the Infection Preventionist had not been appointed to the position by the Governing Board.

A review of an addendum notes to the Medical Executive Meeting Minutes dated January 14, 2020, revealed the Infection Preventionist was introduced to the Medical Executive Board members by the Chief Nursing Officer.

A review of the employee file for the Infection Preventionist revealed the Infection Preventionist had transferred from a staff nurse position into the Infection Preventionist position 02/2020.

Employee #3 confirmed during an interview on 01/31/2022 that the Infection Preventionist had not been appointed by the Governing Board. Employee #3 stated the Infection Preventionist had been introduced to the Medical Executive Board in January 2020, however, there was not a specific appointment of the Infection Preventionist.