HospitalInspections.org

A. Based on a review of Illinois Hospital Licensing Requirements, Illinois Nurse Practive Act, Illinois Physician Assistant Practice Act, CAH Medical Staff Bylaws Rules and Regulations, a review of Midlevel practitioner (MLP) credential files, and staff interview, it was determined in 2of 2 (MLP-1, MLP-2) MLP credentials files reviewed, the CAH failed to ensure it's Medical Staff established and implemented guidelines, scope of services, and physician supervision for the utilization of MLPs within the CAH and approved by the Governing Body.

Findings include:

1. The Illinios Hospital Licensing Requirements was reviewed on 12/15/11. The Illinois Administrative Code Section 250.310 Organization indicates "a) The medical staff shall be organized in accordance with written bylaws, rules, and regulations approved by the governing board. The bylaws rules and regulations shall specifically provide but not be limited to: ...14) determining additional privileges that may be granted a staff member for the use of his/her employed allied health personnel in the hospital in accordance with policies and procedures recommended by the medical staff and approved by the governing authority. The policies and procedures shall include, at least, requirements that the staff member requesting this additional privlege shall submit for review and approval by the medical staff and the governing authority of the hospital: A) a curriculum vitae of the identified allied health personnel, and B) a written protocol with a description of the duties, assignments and/or functions, including a description of the manner of performance within the hospital by the allied health personnel in relationship with other hospital staff;..."

2. The Illinois Nurse Practice Act was reviewed on 12/15/11. Section 1300.410 Written Collaborative Agreements indicates "a) A written collaborative agreement shall describe the working relationship of the advanced practice nurse with the collaborating physician or podiatrist and shall authorize the categories of care, treatment or procedures to be performed by the advanced practice nurse. (Section 65-35(b) of the Act)...."
3. The Illinois Physician Assistant Practice Act was reviewed on 12/15/11. Section 1350.90 Scope and Function indicates "b) The physician/physician assistant team shall establish written guidelines that are individual to the physician assistant in the practice setting and keep those guidelines current and available in the supervising physician's office or location where the physician assistant is practicing...."

4. The CAH Medical Staff Bylaws Rules and Regulations were reviewed on 12/15/11. There was no documentation to indicate guidelines, scope of services, or direct physician supervision provisions had been established and implemented to direct the utilization of MLPs to provide services within the CAH.

5. During a staff interview, conducted with the CEO and the Director of Outpatient Services on 12/15/11 at 11:00 AM, it was verbalized, by both, that the ER is staffed by the CAH's own physicians. The MLPs from the Rural Health Clinic can be called in to assist in the ER in the event of a trauma or increased number of critically ill patients in the ER. The MLPs would see the incoming patients and the ER physician would sign off on the patients' records prior to discharge from the ER. When asked how many times the MLPs have assisted in the ER during the past year, it was verbalized, by both, that this was "probably 3 or 4 times this year."

6. The credential files of MLP-1 and MLP-2 were reviewed on 12/15/11. They indicated that MLP-1 had applied for appointment to the Medical Staff on 10/17/11 and MLP-2 had applied on 10/6/11. There was no documentation as to what privileges were being applied for. There was no documentation of a collaborative agreement with a physician for supervision of care to be provided in the CAH. As of 12/16/11 at 11:00 AM, there was no documentation to indicate the Medical Staff had established and implemented MLP guidelines, MLP scope of service, respective collaborative agreements which were approved the use of MLPs in the CAH.

7. During a staff interview, conducted with the CEO on 12/16/11 at 10:00 AM, the above findings were confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on January 30, 2012, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on January 30, 2012 the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the HCFA/CMS Form 2567, dated 7/21/09.

A. Based on a review of physician credential files and staff interview, it was determined in 3 of 3 (P-1, P-2, P-3) physician credential files reviewed, in which the physicians provided Emergency Room (ER) coverage and performed Intravenous (IV) conscious sedation, the Critical Access Hospital (CAH) failed to ensure Medical Staff were privileged to do IV conscious sedation.

Findings include:

1. On 12/14/11, 3 of 3 physician credential files reviewed, in which the physician provides ER services and IV conscious sedation, there was no documentation to indicate that the physicians had applied for and/or were approved by the Medical Staff and the Governing Body to provide IV conscious sedation.

2. During a staff interview, conducted with the Chief Executive Officer (CEO) and the Director of Outpatient Services on 12/15/11 at 11:00 AM, the above findings were confirmed.

A. Based on a review of CAH policy, medical record review, and staff interview, it was determined 1 of 4 (Pts #4) medical records reviewed, in which the patient received a blood transfusion, the CAH failed to ensure it's Blood Transfusion policy was followed.

Findings include:

1. The CAH policy titled "Blood Transfusion", last revised December 2008, was reviewed on 12/14/11. It indicated "2. c. Vital signs will be performed to include.... The provider will be notified if the temperature is greater than 99.6 orally (This is noted in the section to be completed prior to the start of the blood transfusion)... l. Documentation is to include the completion of the transfusion flow sheet..."

2. The medical record of Pt #4 was reviewed on 12/14/11. Pt #4 was admitted to the CAH on 7/25/11 with the diagnoses Dehydration, Pulmonary Emboli, and Anemia. On 7/25/11, there was a physician order to transfuse 2 units of Packed Red Blood Cells (PRBC)s. On 7/25/11 at 1:05 PM, nursing documentation indicated a temperature of 100.1 degrees F, at which time the first unit of PRBC was hung. There was no documentation to indicate the physician was notified of the elevated temperature. The following areas of the "Blood Transfusion Flow Sheet" were not answered: The "must be transfused by", "Permit signed: yes or no", and "Transfusion reaction: yes or no."

3. During a staff interview, conducted with the CEO on 12/15/11 at 3:00 PM, the above findings were confirmed.

A. Based on a review of the laundry requirements, observation, and staff interview, it was determined that the CAH failed to ensure all washed laundry achieved the required minimum temperatures to ensure clean linen is available to 4 of 4 CAH patients.

Findings include:

1. The CAH policy and procedure titled, "INFECTION CONTROL IN THE LAUNDRY"(revised 2004) was reviewed on 12/15/11. It indicated under "PROCEDURES: 5. Equipment and Environment: b. Water used in laundering should be kept at 160 degrees Fahrenheit."

2. During a tour of the Laundry Department, conducted on 12/13/11 at 2:20 PM, it was observed that there was no documentation that indicated the minimum wash temperature of 160 degrees F. was achieved. No wash temperatures were recorded except when preventative maintenance was done once a month.

3. During an interview with the Compliance Officer, conducted on 12/15/11 at 2:30 PM, the above findings were confirmed.

B. Based on a review of policy and procedure, observation, and staff interview, it was determined that the CAH failed to ensure clean laundry was separated from dirty laundry to prevent cross contamination which has the potential to effect 4 of 4 CAH patients.

Findings include:

1. The CAH policy and procedure titled, "INFECTION CONTROL IN THE LAUNDRY" (revised 2004) was reviewed on 12/15/11. It indicated under "PROCEDURES: 3. Clean Linen: 1. The laundry-processing chain should be arranged so that there is no contact between soiled and processed linen."

2. During a tour of the Laundry area, conducted on 12/13/11 at 2:20 PM, it was observed there were micro-fiber mopheads hanging from a line in the dirty laundry weigh and sort room. Laundry personnel identified the mopheads as being processed but were hung up for drying as drying micro-fiber materials in the dryers destroys their cleaning properties.

3. During an interview with the Compliance Officer, conducted on 12/15/11 at 2:30 PM, the above findings were confirmed.

A. Based on a review of policy and procedure, observation, and staff interview, it was determined that the CAH failed to ensure 2 of 2 dietary employee's hair was restrained in the dietary department to ensure clean and sanitary conditions were maintained.

Findings include:

1. The CAH policy and procedure titled, "INFECTION CONTROL IN THE DIETARY DEPARTMENT" (revised 2001) was reviewed on 12/15/11. It indicated under "PERSONNEL: C. ...It will also include wearing protective hair covering at al times with the following restrictions applying as needed...."

2. During a tour of the Dietary Department, conducted on 12/13/11 at 11:00 AM, it was observed that the dietician lead a tour through the entire Dietary Department without any hair restraint. It was also observed that one other individual working in the Dietary area was wearing a hair restraint which did not cover the bangs that were approximately 2 inches in length.

3. During an interview with the Compliance Officer, conducted on 12/13/11 at 11:20 AM, the above findings were confirmed.

B. Based on a review of Illinois Hospital Licensing Requirements, Illinois Administrative Code, contracted provider documentation (CAH guidance), observation, and staff interview, it was determined that the CAH failed to ensure use of the 3 compartment sink was monitored to ensure the testing solution was at room temperature and the efficacy range for the Sanitizer was at the suggested parts per million (ppm) to ensure proper sanitization of all dietary items that are manually washed which has the potential to effect 4 of 4 CAH patients.

Findings include:

1. The Illinois Hospital Licensing Requirements were reviewed on 12/15/11. Section 250.1620 Facilities indicates "b) Dietary areas shall be...equipped with the proper kinds, sizes, and amounts of equipment required to carry out the sanitation and safety objectives of the dietetic service program. (See the Department's current rule, "Food Service Sanitation" (77 Ill. Adm. Code 750) for specific details).

2. The Ill Administrative Code Section 750.820 Manual Cleaning and Sanitizing was reviewed on 12/15/11 and indicates "e) The food-contact surfaces of all equipment and utensils shall be sanitized by:...1) Immersion for at least one-half (1/2) minute in clean, hot water at a temperature of at least 170 degrees F.; or 2) Immersion for at least one minute in a clean solution containing at least 50 parts per million of available chlorine as a hypochlorite and having a temperature of at least 75 degrees F.; or 3) Immersion for at least one minute in a clean solution containing at least 12.5 parts per million of available iodine and having a pH not higher than 5.0 and having a temperature of at least 75 degrees F.; or 4) Immersion in a clean solution containing any other chemical sanitizing agent allowed under 21 CFR 178.1010, that will provide the equivalent bactericidal effect of a solution containing at least 50 parts per million of available chlorine as a hypochlorite and having a temperature of at least 75 degrees F. for one minute...g) When chemicals are used for sanitizing, they shall not have concentrations higher than the maximum permitted under 21 CFR 178.1010, and a test kit or other device that accurately measures the parts per million concentration of the solution shall be provided and used..."

3. The contracted provider document (CAH guidance) titled, "Oasis 146 Multi-Quat Sanitizer" was reviewed on 12/15/11. It indicated that the "Efficacy range for convenient sanitization" is 150-400 ppm." It also indicated that the water temperature should be "at room temperature (65 to 75 degrees F.).

4. During a tour of the Dietary Department, conducted on 12/13/11 at 10:45 AM, it was observed that there were testing papers for the 3 compartment sink but no thermometer. There was no documentation that indicated the temperature of the water in the sanitizer sink or the ppm of the sanitizer were monitored. The dietary manager indicated the 3 compartment sink is only utilized in emergency situations when the dishwasher is broke. The dietary manager also indicated that bleach or Quat sanitizer would be used according to guidelines and the temperature would be within acceptable range, however there is no documentation to indicate if cleaning solution/sanitizer and temperature are within required range.

5. During an interview with the Compliance Officer, conducted on 12/13/11 at 10:50 AM the above findings were confirmed.

C. Based on a review of Illinois Hospital Licensing Requirements, Illinois Administrative Code, CAH guidance form, dishwasher instruction manual, observation, and staff interview, it was determined that the CAH failed to ensure the dishwasher temperatures were periodically checked to ensure proper sanitation, which has the potential to effect 4 of 4 CAH patients.

Findings include:

1. The Illinois Hospital Licensing Requirements were reviewed on 12/15/11. Section 250.1620 Facilities indicates "b) Dietary areas shall be...equipped with the proper kinds, sizes, and amounts of equipment required to carry out the sanitation and safety objectives of the dietetic service program. (See the Department's current rule, "Food Service Sanitation" (77 Ill. Adm. Code 750) for specific details).

2. The Ill Administrative Code Section 750:830 Mechanical Cleaning and Sanitizing was reviewed on 12/15/11 and indicates "g) Machines (Single-tank, stationary-rack, door-type machines and spray-type glass washers) using chemicals for sanitization may be used provided that:...h) Machines using hot water for sanitizing may be used provided that wash water and pumped rinse water be kept clean and water shall be maintained at not less than the temperature stated in Section 750.830(h)(1) through (5)...."

3. The CAH Guidance form titled "Don't Compromise: Clean and Sanitize" was reviewed on 12/15/11. Under "Dishwashing Machine Operation" the guidance form indicates "4. Check temperatures and pressure frequently following the manufacturer's recommendations."

4. The instruction manual for the Hobart Dishwasher in the Dietary Department was reviewed on 12/15/11. It indicated on page 4 the specific "Minimum water temperatures." Depending on the water, chemical (normal duty), chemical (light duty), wash cycle and rinse cycle, the minimum temperatures range from 120 to 180 degrees F.

5. During a tour of the Dietary Department, conducted on 12/13/11 at 10:45 AM, it was observed that there were no temperatures taken or recorded for the dishwasher. The dietary manager indicated that the dishwasher temperatures are checked 3 times a day, however the temperatures are not recorded to indicate if not within parameters.

6. During an interview with the Compliance Officer, conducted on 12/13/11 at 10:50 AM, the above findings were confirmed.

A. Based on a review of the CAH's policy and procedure books, committee meeting minutes, and staff interview, it was determined that the CAH failed to ensure it's policy and procedures were reviewed annually by the group of professionals (GOP).

Findings include:

1. The CAH's policy and procedure books were reviewed on 12/15/11. There was no documentation that indicated the policies and procedure were reviewed by the GOP that included a physician and at least one member that is not a member of the CAH staff.

2. The Medical Executive Committed (MEC), Governing Body, and other committee meeting minutes for 2011 were reviewed on 12/15/11. There was no documentation that indicated the CAH's policies and procedure were reviewed on an annual basis by the GOP.

3. During an interview, conducted with the CEO on 12/15/11 at 2:30 PM, the above findings were confirmed.

A. Based on observation, employee renewal application and letter, and staff interview, it was determined that in 1 of 6 (E-1) employees in the radiology department, the CAH failed to ensure all employees requiring licensure were in possession of a current State of Illinois license.

Findings include:

1. During a tour of the Radiology Department, conducted on 12/13/11, it was observed that the posted license of E-1 was expired as of 11/30/11. There was no documentation presented that indicated E-1 was in possession of a current, valid State of Illinois License from 12/1/11 to 12/12/11.

2. During a staff interview conducted the the Compliance Officer on 12/13/11 at 3:00 PM, it was verbalized that E-1's license did expire 11/30/11. E-1 had not received renewal letter. E-1 reapplied for E-1's license on 12/13/11.

3. A renewal application, dated 12/13/11, was reviewed and indicated E-1 had reapplied for State of Illinois license. A letter from Illinois Emergency Management Agency dated 12/13/11 was reviewed. The letter indicated E-1 was authorized "to perform medical radiation procedures appropriate to the type accreditation being issued or renewed for 10 days from the date of this letter."

4. During an interview with the Compliance Officer, conducted on 12/13/11 at 3:00 PM, the above finding was confirmed.

A. Based on a review of the list of contracted services and staff interview, it was determined that the CAH failed to maintain an appropriate list of contracted services including the nature and scope of services provided to ensure compliance, which has the potential to effect 4 of 4 CAH patients.

Findings include:

1. The list of contracted services was reviewed on 12/14/11. The list failed to include the nature and scope of the contracted services. The list did not include the contract for the blood bank.

2. During an interview with the CEO, conducted on 12/14/11 at 3:00 PM, the above finding was confirmed.

A. Based on medical record review and staff interview, it was determined in 2 of 20 (Pts #5, #10) medical records reviewed, the CAH failed to ensure care was provided as ordered by the physician.

Findings include:

1. The medical record of Pt #5 was reviewed on 12/14/11. Pt #5 was admitted to CAH on 12/9/11 with the diagnoses of Acute Lower Back Pain and Congestive Heart Failure Exacerbation. On 12/9/11, there was a physician order "Lisinopril 40 mg by mouth twice a day." On 12/9/11 and 12/10/11 at 8:00 PM, nursing documentation indicated the dose of Lisinopril was "held due to low blood pressure." There was no documentation to indicate the physician was notified and no order to hold the Lisinopril.

2. The medical record of Pt #10 was reviewed on 12/15/11. Pt #10 was admitted to the CAH on 11/25/11 with the diagnoses Abdominal Pain, Uncontrolled Diabetes, and Renal Insufficiency. On 11/25/11, there was a physician order "Intake and output every 6 hours." There was no nursing documentation to indicate the intake and output was performed every 6 hours.

3. During a staff interview, conducted with the CEO on 12/15/11 at 3:00 PM, the above findings were confirmed.

A . Based on medical record review and staff interview, it was determined in 2 of 20 (Pts #4, #10) medical records reviewed, the CAH failed to ensure discontinuation of IV catheters was documented prior to discharge from the CAH.

Findings include:

1. The medical record of Pt #4 was reviewed on 12/14/11. Pt #4 was admitted to the CAH on 7/25/11 with the diagnosis Dehydration. On 8/1/11, there was a physician order to "Discontinue IV line and IV fluids." There was no documentation to indicate Pt #4's IV line and/or IV fluids were discontinued.

2. The medical record of Pt #10 was reviewed on 12/15/11. Pt #10 was admitted to the CAH on 11/25/11 with the diagnosis Abdominal Pain. On 11/26/11, there was a physician order "Discontinue IV line and IV fluids." There was no documentation to indicate Pt #10's IV line and/or IV fluids were discontinued.

3. During a staff interview, conducted with the CEO on 12/15/11 at 3:00 PM, the above findings were confirmed.

A. Based on a review of the CAH's program evaluation and staff interview, it was determined that the CAH failed to ensure a representative sample of both active and closed records had been reviewed.

Findings include:

1. The CAH's annual program evaluation for the fiscal years of 2008, 2009, and 2010 were reviewed on 12/15/11. There was no documentation to indicate both open and closed charts were reviewed for inclusion in the annual evaluation.

2. During an interview with the CEO, conducted on 12/15/11 at 10:25 AM, it was verbalized that no closed charts were reviewed for the annual program evaluations for fiscal 2008, 2009 or 2010 and confirmed the above findings.

A. Based on a review of the CAH's annual program evaluations and staff interview, it was determined that the CAH failed to ensure it's annual program evaluations included determinations as to whether established policies were followed and if any changes were made.

Findings include:

1. The CAH's annual program evaluations for fiscal years 2008, 2009, and 2010 were reviewed on 12/15/11. There was no documentation that indicated the annual program evaluations included determinations as to whether established policies and procedures were followed or if any changes were made.

2. During an interview with the CEO, conducted on 12/14/11 at 10:45 AM, the above findings were confirmed.