HospitalInspections.org

The Medicare Modernization ACT has changed the total number of beds a Critical Access Hospital (CAH) may have and maintain. The CAH may not have more than 25 beds that could be used for inpatient care.

Failure to ensure the CAH maintained a 25 bed count could potentially result in the CAH's ability to provide care and services for its patients within the scope of services offered by a CAH. The average daily census for a recent 12 month period was 10 patients.

Based on observation and staff interview, the CAH failed to ensure their total number of beds immediately available for inpatients did not exceed 25.


Findings include:

1. Observation during tour of the inpatient care area with Staff Z, Registered Nurse Supervisor, on 7/28/14 ending at 11:40 AM revealed there 27 beds, available for inpatient use in the nursing unit.

2. During at interview on 7/28/14 at 11:40 AM, Staff Z acknowledged the hospital's total number of beds available for inpatients was 27. The number of beds in patient rooms was 25 and 2 cribs could be immediately used in a storage room adjacent to the inpatient area.

During an interview on 7/28/14 at 12:05 PM, Staff I, Chief Clinical Officer, acknowledged the hospital's total number of beds available for inpatients was 27 that included 2 cribs ready for use stored in a room adjacent to the inpatient area.

I. Based on observation, review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure 1 (of 1) laminar flow hood was maintained in the pharmacy in safe operating condition. (Pharmacy) The CAH staff reported a current census of 9 inpatients .

Failure to complete annual inspections of electric equipment could potentially result in unsafe operation of the equipment without staff awareness as they continue to work in the laminar flow hood.

Findings included:

1. Observation during tour of the Pharmacy on 7/28/14 at 2:20 PM revealed the Pharmagard Positive Pressure Recirculating Compounding Aseptic Isolator with documentation of Performance Certification posted on the front of the hood stated - "Due for Retest June 2014".

2. Review of Pharmacy policy/procedure titled "Recirculating Aseptic Compounding Isolator Operating and Cleaning Procedure", dated 7-26-2011, revealed, in part, ". . . Decontamination of the interior surfaces should be repeated after removal of all materials. A careful check of work zone should be made for spilled or splashed nutrients, which may support fungus growth and resulting spore liberation that contaminates the protected work environment. . . ."

3. During an interview on 7/28/14 at 2:20 PM, Staff K, the Pharmacy Director, acknowledged the Laminar Flow Hood was due for retest in June 2014 and it had not occurred.


II. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) failed to ensure boxes of IV solutions were properly stored off of the floor in 1 of 1 IV storage room. The CAH staff reported a current census of 9 inpatients.

Failure to store boxes of IV solutions off the floor could result the CAH staff not being able to ensure an acceptable level of safety and quality for the stored IV solutions after delivery.

Findings include:

1. Observation during tour of the IV storage room on 7/28/14 at 3:20 PM with Staff K, Pharmacy Director, revealed the following boxes of IV solutions were stored directly on the floor.
- 1 box of 24 bags of 250 ml 0.9% Sodium Chloride with no date delivered;
- 1 box of 48 bags of 100 ml 0.9% Sodium Chloride delivered February 10, 2014;
- 1 box of 24 bags of 250 ml 25,000 units Heparin in 5% D5W March 14, 2014;
- 1 box of 12 bags of 1000 ml D5 Normal Saline delivered June 3, 2014;
- 1 box of 12 bags of 1000 ml Lactated Ringer delivered June 30, 2014;
- 2 boxes of 12 bags of 1000 ml 0.9% Sodium Chloride delivered July 1, 2014;
- 5 boxes of 12 bags of 1000 ml Lactated Ringer delivered July 14, 2014;
- 1 box of 12 bags of 1000 ml 0.9% Sodium Chloride delivered July 20, 2014; and
- 2 boxes of 24 bags of 500 ml 0.9% Sodium Chloride delivered July 25, 2014

2. Review of a document titled "Dept. EOC (Environment of Care) Survey", dated 6/18/14, revealed the following in part, "General appearance of area being inspected: . . . All items stored off the floor. . . ."

3. During an interview on 7/28/14 at 3:20 PM, Staff K, Pharmacy Director, acknowledged the boxes of IV solutions were stored on the floor and those boxes should not be stored on the floor.

Based on review of documents including policies/procedures and interview with staff,
the Critical Access Hospital (CAH) administrative staff failed to ensure a physician reviewed the care provided by 4 of 4 sampled mid-level providers to patients at the CAH's two provider-based clinics by 2 Physician Assistants and 2 Advanced Registered Nurse Practitioners (PA J, PA L, ARNP K, and ARNP M); and to ensure a physician reviewed care provided by 8 of 8 mid-level providers to patients in the emergency department (ARNP B, ARNP D, ARNP E, ARNP G, PA C, PA F, PA H, and PA I).

Failure to ensure a physician periodically reviews, in conjunction with the mid-level providers, the care provided by the mid-level practitioners affects the CAH's ability to assure the mid-level providers are consistently providing quality care to its patients.

Findings include:

The clinic's administrative assistant identified approximate number of patient encounters with patients receiving care and services from PA J, ARNP K, PA L, and ARNP M at the clinic locations was 9,800 during 2013. The emergency department staff identified a yearly total of approximately 5,709 emergency department visits. ARNP B, ARNP D, ARNP E, ARNP G, PA C, PA F, PA H, and PA I worked in the emergency department.

1. Review of the "Governing Board Bylaws", approved 2/27/14, revealed the bylaws lacked a requirement for a physician to review the patient care provided at the CAH by the mid-level providers.

Review of the "Knoxville Hospital MEDICAL STAFF BYLAWS and RULES and REGULATIONS", approved 12/12/12, revealed the rules and regulations lacked a requirement for a physician to review the patient care provided at the CAH by the mid-level providers.

Review policy titled "ED Midlevel Provider Supervision Procedure", revised 2/10/12, revealed the following in part, ..."The Emergency Department Medical Director shall ensure Mid-level provider (MLP) charts are reviewed per regulatory requirements in a timely manner. The Emergency Department Medical Director shall review appropriateness of diagnosis, treatment, and disposition with each MLP on a routine basis."

Review of policy titled "Mid-Level Provider Supervision", revised 7/29/14, revealed the following in part, ..."MLP may be assigned to the Emergency Department and Clinics at Knoxville Hospital and Clinics...guidelines shall be developed by the Medical staff...for the periodic review and evaluation of services furnished by the CAH...the quality and appropriateness of diagnoses and treatment furnished by MLPs are evaluated by a member of the Medical Staff who is a doctor of medicine or osteopathy."

2. There were 8 of 8 mid-level practitioners that provided care to patients in the emergency department (ARNP B, ARNP D, ARNP E, ARNP G, PA C, PA F, PA H, and PA I).

During an interview on 7/29/14 at 3:05 PM, with Staff A, Chief Operating Officer (COO), the COO reported having responsibility to oversee the Quality Assurance (QA) and documentation of the periodic chart reviews for all MLPs at the CAH and clinics. The COO was unable to provide evidence of periodic chart reviews of the MLPs working in the clinics and emergency department at the CAH related to problems they had with the electronic server from the time it went "live" in December 2013. Staff A reported there would be a reflection of the detail of verbal discussions of MLP chart reviews from the last CQI/Risk Management meeting. A review of the CQI/Risk Management documentation showed it did not reflect details of verbal discussions of MLP chart reviews.

During an interview on 7/30/14 at 10:00 AM, with Staff I, Chief Clinical Coordinator (CCO) acknowledged Staff A failed to document periodic chart reviews of MLPs in the Emergency Department and clinics and reported being unaware of this problem until the survey team discovered it on 7/29/14. Staff I said their policies specified Emergency Department and Clinic MLP oversight by the assigned physicians, the periodic review of charts for appropriateness of care and services does occur at their hospital but it was not documented "properly".

During an interview on 7/30/14 at 11:45 AM, ARNP M said she would discuss the care she provides to patients with physicians. It is discussion regarding the care she provided to clinic patients routinely with all CAH physicians but most often with Physician N in periodic chart reviews. ARNP M reported documenting this information on the non-worksheet daily summary/schedule sheets however these sheets are not retained and are disposed of on a weekly basis. Staff M reported she did not document these verbal discussions regarding appropriateness of care and services to clinic patients prior to several months ago but the discussions did occur.

During an interview on 7/31/14 at 8:00 AM, Physician N reported conducting periodic chart reviews for MLPs on a daily basis and advises the MLPs to include these reviews in the patients medical record. Physician A acknowledged the CAH lacked a process to track the reviews as completed and don't have evidence to provide to verify this. Physician N reported being aware of this problem and the CAH was attempting to find a solution to this problem.

Based on review of documents including policies/procedures and interview with staff,
the Critical Access Hospital (CAH) administrative staff failed to ensure the physician assistants (PAs) and Advanced Registered Practitioners (ARNPs) participated with a physician in a periodic review of the patients medical records for the care provided by 4 of 4 mid-level providers to patients at the CAH's two provider-based clinics and the 8 of 8 mid-level providers emergency department. There were 2 Physician Assistants (PA) and 2 Advanced Registered Nurse Practitioners (ARNP) providing care at the CAH's clinics (PA J, PA L, ARNP K, and ARNP M) and eight mid-level providers providing care to patients in the emergency department (ARNP B, ARNP D, ARNP E, ARNP G, PA C, PA F, PA H, and PA I).

Failure to ensure the mid-level providers, the care provided by the mid-level practitioners in conjunction with a physician affects the CAH's ability to assure the mid-level providers are consistently providing quality care to its patients.

Findings include:

The clinic's administrative assistant identified approximate number of patient encounters with patients receiving care and services from PA J, ARNP K, PA L, and ARNP M at the clinic locations was 9,800 during 2013. The emergency department staff identified a yearly total of approximately 5,709 emergency department visits. ARNP B, ARNP D, ARNP E, ARNP G, PA C, PA F, PA H, and PA I worked in the emergency department.

1. Review of the "Governing Board Bylaws", approved 2/27/14, revealed the bylaws lacked a requirement for a physician to review the patient care provided by the mid-level providers at the CAH with the mid-level providers.

Review of the "Knoxville Hospital MEDICAL STAFF BYLAWS and RULES and REGULATIONS", approved 12/12/12, revealed the rules and regulations lacked a requirement for a physician to review the patient care provided at the CAH by the mid-level providers.

Review policy titled "ED Midlevel Provider Supervision Procedure", revised 2/10/12, revealed the following in part, ..."The Emergency Department Medical Director shall ensure Mid-level provider (MLP) charts are reviewed per regulatory requirements in a timely manner. The Emergency Department Medical Director shall review appropriateness of diagnosis, treatment, and disposition with each MLP on a routine basis."

Review of policy titled "Mid-Level Provider Supervision", revised 7/29/14, revealed the following in part, ..."MLP may be assigned to the Emergency Department and Clinics at Knoxville Hospital and Clinics...guidelines shall be developed by the Medical staff...for the periodic review and evaluation of services furnished by the CAH...the quality and appropriateness of diagnoses and treatment furnished by MLPs are evaluated by a member of the Medical Staff who is a doctor of medicine or osteopathy."

2. During an interview on 7/29/14 at 3:05 PM, with Staff A, Chief Operating Officer (COO), the COO reported having responsibility to oversee the Quality Assurance (QA) and documentation of the periodic chart reviews for all MLPs at the CAH and clinics. The COO was unable to provide evidence of periodic chart reviews of the MLPs working in the clinics and emergency department at the CAH related to problems they had with the electronic server from the time it went "live" in December 2013. Staff A reported there would be a reflection of the detail of verbal discussions of MLP chart reviews from the last CQI/Risk Management meeting. A review of the CQI/Risk Management documentation showed it did not reflect details of verbal discussions of MLP chart reviews.

During an interview on 7/30/14 at 10:00 AM, with Staff I, Chief Clinical Coordinator (CCO) acknowledged Staff A failed to document periodic chart reviews of MLPs in the Emergency Department and clinics and reported being unaware of this problem until the survey team discovered it on 7/29/14. Staff I said their policies specified Emergency Department and Clinic MLP oversight by the assigned physicians, the periodic review of charts for appropriateness of care and services does occur at their hospital but it was not documented "properly".

During an interview on 7/30/14 at 11:45 AM, ARNP M said she would discuss the care she provides to patients with physicians. It is discussion regarding the care she provided to clinic patients routinely with all CAH physicians but most often with Physician N in periodic chart reviews. ARNP M reported documenting this information on the non-worksheet daily summary/schedule sheets however these sheets are not retained and are disposed of on a weekly basis. Staff M reported she did not document these verbal discussions regarding appropriateness of care and services to clinic patients prior to several months ago but the discussions did occur.

During an interview on 7/31/14 at 8:00 AM, Physician N reported conducting periodic chart reviews for MLPs on a daily basis and advises the MLPs to include these reviews in the patients medical record. Physician A acknowledged the CAH lacked a process to track the reviews as completed and don't have evidence to provide to verify this. Physician N reported being aware of this problem and the CAH was attempting to find a solution to this problem.

Based on staff interview, review of administrative documents, and review of medical records, and observation, the critical access hospital (CAH):

1. failed to ensure all pharmaceuticals including insulin and other medications used to treat diabetes were under the control of the pharmacist, failed to ensure there physician order for insulin and other medications used to treat diabetes was written by and received from a physician, and allowed a dietitian to dispense insulin or other medication used to treat diabetes to patients in the CAH's Diabetes education program. Refer to C 276.

2. failed to ensure radiology staff in the Computed Tomography room (CT) used a separate intravenous (IV) solution bags labeled "single-dose" for each patient needing IV access for the procedure. Refer to C 278.

The cumulative effect of these systemic problems resulted in the CAH's inability to ensure the delivery of quality health care in the diabetic education program and the CT room.

Based on policy review, document review, clinical record review, and staff interviews the Critical Access Hospital (CAH) administrative staff failed to ensure pharmacy maintained control and oversight of manufacturer's samples of injectable diabetic medications; to ensure physician orders were obtained and documented by staff authorized to write or accept orders; prior to dispensing the samples; and to ensure dispensing of samples to patients was conducted by employees allowed to dispense samples of medications. The Clinical Dietitian reported furnishing serving 45 diabetic education patients in the past 7 months and reported 7 of the diabetic patients needed injection instruction since September of 2013.

Failure of pharmacy staff to provide oversight of sample medications resulted in samples of insulin and other injectable medications used to treat diabetes to be dispensed by the dietitian without written orders. This system could result in inappropriate insulin or other medication samples for diabetic patients and allow inappropriate, outdated, recalled, or otherwise unusable samples dispensed to patients for use.

Findings include:

1. During an interview on 7/28/14, at 3:45 PM, Staff J, Clinical Dietitian/Diabetes Education Coordinator, reported she used prefilled injectable diabetic medication pens (a simple device to set a medication dose and inject) and insulin vial samples to teach outpatient diabetes education patients how to manage their diabetes and dispensed samples for patient use at home.

Staff J reported she received and maintained a log of the injectable diabetic medication samples from the manufacturers. She relayed the pharmacist was aware of the insulin samples, but was not involved in the process. Staff J reported she began the log in September of 2013 and completed an inventory of all samples at the time. She not aware of the person previously keeping track of the samples or dispensing the samples.

Staff J reported she inventoried the supply again in March of 2014 and discovered discrepancies. She did not know who took them or what patient or patients received them. Staff J reported a new system was put into place at that time, whereby the insulin samples were locked in 2 boxes, stored in the clinic medication refrigerator. She had the key to the boxes. She reported she recorded the date samples are received, date the samples were dispensed, the identity of patient receiving the samples and the amount supplied.

When asked about the physician orders for any insulin dispensed, Staff J reported sometimes the provider would include an insulin type, as part of the dietitian consult order, but otherwise, she would see the patient, formulate a recommendation and then call the provider to determine if they were in agreement with her recommendations. Staff J confirmed she does not receive authenticated medication orders nor does she document any verbal instructions as medication orders, but acknowledged she instructs patients on the use of the injectables and gives medication to patients to take home for their use.

2. Observation of Staff J's sample supply, on 7/29/14, at 8:15 AM, revealed the following samples were stored in locked boxes in the medication room refrigerator, located in the Knoxville Clinic.

1 NovoLog FlexPen prefilled with 3 milliliters (ml) of insulin
7 Levemir FlexPens prefilled with 3 ml of insulin
15 Victoza pens prefilled with 3 ml of a non-insulin medication used to treat diabetes
14 Humalog KwikPens prefilled with 3 ml of insulin
3 Humalog 10 ml insulin vials
6 Lantus SoloStar pens prefilled with 3 ml of insulin
4 Bydureon injection systems with 3 ml of a non-insulin medication used to treat diabetes
3 Novolog 70/30 Mix FlexPens prefilled with 3 ml of insulin
6 Apidra SoloStar pens prefilled with 3 ml of insulin
5 Novolog 10 ml insulin vials
1 Humulin N pen prefilled with 3 ml of insulin

3. Review of a document titled "Diabetes Injectable Log" revealed a spreadsheet which contained the injectable samples on hand, lot numbers, expiration dates, number received, date dispensed, number given, patient's name and date of birth. The log identified 7 patients who received samples since the initiation of the log on 9/13/13.

4. During an interview on 7/29/14 at 10:50 AM, Staff K, Pharmacy Director, confirmed he was aware of the injectable samples dispensed by Staff J but had no role in the process from the receipt to the dispensing. He reported he chose not to be involved in the process related to a recommendation from the Iowa pharmacy board. He reported the clinics quit handling medication samples a couple years ago but the providers wanted to keep the injectable diabetic medication samples. Staff K stated he believed Staff J was knowledgeable and capable of managing the samples and thought it should be up to the physicians whether or not she could provide patients with the samples.

5. Review of a CAH policy titled "Distribution of Manufacturer's Drug Samples", approved on 11/21/13, stated "No professional samples will be stocked or dispensed at the Knoxville Hospital, including the Emergency Department. All medications will be dispensed by the Pharmacy department from stock obtained from their drug wholesaler".

Review of a CAH policy titled "General Medication Policy", approved on 11/21/13, revealed in part "Purpose: To ensure that medications are dispensed properly in a consistent manner . . . Manufacturer's representatives will not distribute drug samples in the hospital. The clinic will have samples of insulin only for patient teaching . . ."

Review of a CAH policy titled "Noting Physician order Policy and Procedure", approved on 5/22/14, revealed in part " . . . Telephone or verbal order(s) may be taken by any licensed nursing personnel. . . "

Review of a document titled "Knoxville Hospital and Clinics Medical Staff Rules and Regulations", approved on 12/12/12, failed to identify Registered Dietitians as a person allowed to take physician's verbal medication orders.

6. During an interview on 7/30/14 at 2:15 PM, Staff J confirmed she dispensed injectable diabetic medication samples to 6 of 7 patients listed on the "Diabetes Injectable Log". Review of the log and patient clinical records revealed the following:

Staff J documented Patient #16 was provided with 3 Bydureon injectable samples on 12/20/14. Staff J confirmed she dispensed the samples to the patient at the request of the physician but failed to document the information in the patient's clinical record.

Staff J documented Patient #20 was provided with 1 Novolog insulin pen on 3/6/14. Review of the patient's clinical record revealed a physician order for diabetic education on 3/3/14. Staff J met with the patient on 3/6/14, and documented a conversation with an on-call physician regarding patient insulin needs and was directed to have the patient decrease their Novolog dose to 5 units before meals. Staff J documented instruction to the patient on the use of a Novolog insulin pen. She confirmed she dispensed 1 pen for patient use at home and failed to document the information in the clinical record.

Staff J documented Patient #19 was provided with 3 Victoza insulin pens on 4/22/14. Review of the patient's clinical record revealed a physician order for a dietitian consult on 4/18/14, which identified the patient needed Victoza samples and instruction. Staff J met with the patient on 4/22/14 and documented education on use of the pen and dispensation of 3 pens to the patient for use at home.

Staff J documented Patient #17 was provided with 3 Lantus insulin pens on 5/19/14. Review of the patient's clinical record revealed a physician order for a dietary consult and referral to diabetic educator on 2/27/14. Staff J met with the patient on 5/19/14 and documented the patient's physician had ordered 5 units of Levemir daily. Staff J documented she was out of Levemir samples and substituted Lantus for teaching purposes and documented dispensation of 3 Lantus pens for patient use at home.

Staff J documented Patient #21 was provided with 3 Lantus insulin pens on 7/3/14. Review of the patient's clinical record revealed a mid-level provider order for a dietary consult on 6/24/14, which identified the need to start the patient on insulin. Staff J met with the patient on 7/3/14 and documented discussion on use of a Lantus pen. Staff J further documented she instructed him/her to start on 12 units of Lantus daily and the dispensation of 3 Lantus pens for patient use at home.

Staff J documented Patient #18 was provided with 1 Novolog insulin pen on 7/10/14. Review of the patient's clinical record revealed a mid-level provider order for a dietitian consult on 4/24/14, which identified the need to split or increase the patient's Lantus insulin dose. Staff J met with the patient on 7/10/14. The clinical record showed Staff J discussed with the provider, decreasing the patient's current Lantus dose and starting a new medication of 4 units of Novolog insulin daily. Staff J documented education with the patient on use of the Novolog pen and dispensation of 1 pen for patient use at home.

7. During an interview on 7/30/14 at 2:15 PM, Staff I, Chief Clinical Officer, confirmed verbal orders for medication need to be authenticated by the provider and a dietitian may not take verbal orders for medications, according to hospital policy and the medical staff rules and regulations. Staff I acknowledged the hospital pharmacist should be involved in the oversight of the injectable medication samples used by Staff J.

8. Review of the Iowa Administrative Code, Chapter 7 titled "Hospital Pharmacy Practice", last updated 2/5/14, revealed in part ". . . 7.8(8) Samples. The use of drug samples within the institution shall be eliminated to the extent possible . . . If the use of drug samples is permitted for hospital outpatients, that use of samples shall be controlled and the samples shall be distributed through the pharmacy or through a process developed in cooperation with the pharmacy and the institution's appropriate patient care committee, subject to oversight by the pharmacy . . ."

9. Review of the Iowa Code 2014, Chapter 147 titled "General Provisions, Health-Related Professions" revealed in part ". . . 147.107 Drug dispensing, supplying, and prescribing - limitations. 1. A person, other than a pharmacist, physician, dentist, podiatric physician, or veterinarian . . . shall not dispense prescription drugs or controlled substances . . ."

I. Based on observation, document review, and staff interviews, the Critical Access Hospital(CAH) failed to have a system in place that assured Radiology staff in the Computed Tomography room (CT- computer-processed X-rays that produce tomographic images or 'slices' of specific areas of the body) used intravenous (IV) solution bags labeled "single-dose" for only 1 patient per bag. The Radiology Department had an average of 30 CT procedures, using the IV solution and tubing set, per month.

Failure to ensure staff uses a separate single-dose or single-use bag of IV solution for each patient increases the risk of transmitting infectious diseases between patients or between a patient and healthcare personnel during preparation and administration of IV solutions.

Findings include:

1. Single-dose or single-use vials and/or IV solutions are intended for use in a single patient for a single purpose such as procedure or injection. Single-dose or single-use vials and solutions are labeled as such by the manufacturer and typically lack an antimicrobial preservative.

According to the Centers for Disease Control (CDC), healthcare staff may not administer medications from single-dose or single-use vials, ampules, bags or bottles of intravenous solutions to more than one patient (e.g. do not use a bag of saline as a common source supply for multiple patients). The CDC also directs clinicians not to use fluid infusion or administration sets (e.g., intravenous tubing) for more than one patient.

2. Observation, during tour of the Radiology Department on 7/29/14 at 9:00 AM, with Staff A, Radiology Leader, revealed 1 of 4, 250 milliliter (ml) " single-dose " bags of intravenous (IV) 0.9% normal saline (A solution of sodium chloride and water used for IV infusion.).

3. Review of CAH policies showed there was no policy that addressed single-dose IV solutions.

4. During an interview on 7/29/14 at 9:00 AM, Staff B, CT technologist confirmed staff used the 250 ml 0.9% Sodium Chloride IV solution bag in the CT room for more than one patient and may use the same bag of IV solution for 24 hours prior to changing it. Staff used the IV solution in the Stellant Medrad injector to inject contrast into patients. Staff change the syringes and tubing with the syringes between patients and cleanse the 0.9% IV solution tubing with alcohol prior to connecting it to the new syringes. Staff do not change the 0.9% IV solution until the bag is empty, usually after injecting 3 to 4 patients.


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II. Based on document review, policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to establish a consistent system to identify and prevent transmission of infections and communicable diseases for contracted employees and failed to follow the established system for employees and volunteers. Problems were identified for 2 of 3 contracted staff , 3 of 3 volunteers, and 4 of 21 employees selected for review.

Failure to identify infections and communicable diseases could potentially result in causing harm to patients through exposure and transmission of communicable diseases.

Findings include:

1. During an interview on 7/30/14 at 11:00 AM, Staff L, RN/Occupational Health Nurse reported a pre-employment health exam and 2-step TB test are completed upon hire and a health exam is repeated every 4 years and documented on a form titled "Four-Year Employee Tuberculosis Health Risk Screening".

2. Review of the employee health file for Staff N, Registered Nurse (RN)/Wound Nurse, revealed a document titled "Annual Employee Health Assessment", dated 12/29/08, with an incomplete blood pressure assessment section.

Review of the employee health file for Staff O, RN/Emergency Room (ER) Coordinator, revealed a document titled "Annual Employee Health Assessment", dated 11/21/08.

Review of the employee health file for Staff K, Pharmacy Director, revealed a document titled "Four-Year Employee Health Examination Form", dated 1/19/10.

Review of the employee health file for Staff D, RN/Cardiac/Pulmonary Rehab nurse, revealed a document titled "Employee Pre-Placement Physical", dated 6/22/09.

Review of volunteer health information for Staff T, Volunteer, revealed a document titled "Four-Year Employee Health Examination Form", dated 1/27/10.

Review of volunteer health information for Staff W, Volunteer, revealed a document titled "Four-Year Employee Health Examination Form", dated 1/13/10.

Review of the Occupation Health tracking sheet for Volunteers/Auxiliary revealed Staff U, Volunteer, revealed a new hire physical completed on 1/19/09.

Review of the health information files for 2 of 3 contracted staff selected for review revealed a lack of documentation to show Staff X, Physical Therapy Receptionist had a recent health exam and Staff Y, Sleep Tech, had a recent tuberculosis test (TB) and health exam.

3. During follow-up interviews on 7/30/14, at 2:00 PM, and 7/31/14, at 9:15 AM, Staff L confirmed the 4 identified employees lacked a health exam within the past 4 years. She explained she had gotten behind, had recently identified the employees that were past due and had planned to get them all caught up in August and September. Staff L said she did not have any health information on the contracted employee, Staff Y and unaware the person provided any services at the CAH. Staff L confirmed she had documented evidence of a TB test for Staff X and but lacked documented evidence of a recent health exam.

Staff L reported the CAH had been completing health exams on contracted employees but discontinued doing them a few months ago. She relayed she contacted another entity to obtain a copy of a recent health exam for Staff X and hoped to provide a copy the following day. Staff L confirmed she completed the TB tests and health exams for the Volunteers/Auxiliary members and acknowledged the health exams for the volunteers, Staff T, U, and V were completed more than 4 years ago.

4. Review of a CAH policy titled "Pre-Placement Post Offer Health Screen", currently in the process of being approved, revealed in part " . . . Every 4 years a high risk assessment is performed by the Employee Health Nurse for TB for all employees . . ."

During an interview on 7/31/14, at 8:30 AM, Staff L confirmed the policy titled "Pre-Placement Post Offer Health Screen", reflected the CAH's current practice, despite being presented as a draft. She relayed the form titled "Four-Year Employee Tuberculosis Health Risk Screening" served to review for any symptoms of TB and documented a health exam, which is used for employees and volunteers subsequent to their new-hire exam and completed every 4 years.

During an interview on 7/30/14, at 11:50 AM, Staff M, Administrative Services Director, reported the specialty services recently became his responsibility and acknowledged there had been a gap in the process for ensuring required health information was obtained for contracted employees.

During follow-up interviews on 7/31/14 at 9:45 AM and 11:40 AM, Staff M produced a fax from the contracted company for Staff Y, which revealed dates for a TB test on 1/2/13 and a health exam on 1/30/14, but had still not received any documentation of a recent health exam for Staff X. In addition, he reported the CAH did not have a policy to ensure contracted staff met all the requirements to work in the CAH and be involved in patient care.

Based on review of policies, procedures, meeting minutes, and interview with staff, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals, including a Physician and a Mid-Level provider, reviewed all patient care policies annually for 18 of 24 patient care departments (Clinics, Infection Prevention, Quality Management, Surgery, Anesthesia, Laboratory, Obstetrics, Environment of Care, Environmental Services, Materials Management, Medical/Surgical, Health Information Management, Information Technology, Patient Rights, Utilization Review, Rehab Services, Respiratory Services, and Medical Staff. The CAH administrative staff identified a current census of 9 inpatients.

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs that are not addressed in CAH policies and procedures or the need for any revisions in the policies and procedures.

Findings include:

1. Review of policy/procedure titled, "Document Management Policy and Procedure", dated 4/4/14, revealed in part. ". . .Policies are developed with the advice of a group of professional personnel, the Policy Committee that includes one or more doctors of medicine or osteopathy and one or more mid-level providers appointed by the medical staff. At least one member is not a member of the CAH staff. The Policy Committee participates in the development, execution and periodic review of the written policies. Policies are reviewed at least annually by appropriate leaders and the Policy Committee. . . ."

2. Review of the CAH Policy Committee Meeting minutes for August 15, 2013 included documentation of the absence of the mid-level provider at the meeting. The committee approved policies for Health Information Management, Information Technology, Patient Rights, Utilization Review, Rehab Services, Respiratory Services, and Medical Staff at the meeting.

Review of CAH Policy Committee Meeting minutes for February 27, 2014 included documentation of the absence of the physician at the meeting. The committee approved policies for Clinics, Infection Prevention, Quality Management, Surgery, Anesthesia, and Laboratory at the meeting.

Review of CAH Policy Committee Meeting minutes for May 22, 2014 included documentation of the absence of the physician and the mid-level provider at the meeting. The committee approved policies for Obstetrics, Environment of Care, Environmental Services, Materials Management, and Medical/Surgical.

3. During an interview on 7/30/14 at 11:30 AM, Staff A, Chief Operating Officer, acknowledged the physician was not present at the CAH Policy Committee meetings on February 27, 2014 or May 22, 2014 for annual review of the stated policies/procedures but they were approved. Staff A acknowledged mid-level provider was not present at the CAH Policy Committee meeting on May 22, 2014 for annual review of the stated policies/procedures but they were approved.

Based on policy/procedure review, document review, and staff interview, the critical access hospital (CAH) staff failed to a provide dosimeter badge (small devices used to measure a staff member's exposure to radiation) for 1 of 3 practitioners (Practitioner P) while performing procedures in the operating room that involved a C-Arm fluoroscope (a portable device creating real-time radiological images). Practitioner P completed 4 procedures during the past 6 months using the C-Arm with fluoroscopy.

Failure to provide staff with dosimeter badges could potentially allow a staff member to receive unrecognized large quantities of radiation, and result in health hazards for the staff person.

Findings include:

1. Review of undated CAH policy/procedure titled "Radiation Protection Policy and Procedure", revealed, in part ". . . All personnel that perform x-ray, fluoro, CT and mammography are monitored on a monthly basis as to the amount of radiation exposure they receive on the job. . . ."

2. Review of dosimeter badge reports for April, May, and June 2014 lacked evidence of monitoring of radiation exposure for Practitioner P.

3. During an interview on 7/30/14 at 4:10 PM, Staff P, Radiation Safety Officer, stated the CAH does not provide Practitioner P a dosimeter badge to monitor their radiation exposure while using the C-Arm fluoroscope during procedures in the operating room.



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Based on observation, staff interview and policy review, the Critical Access Hospital (CAH) failed to ensure 1 of 2 radiation exposure cords were secured to not allow staff access into the x-ray room during testing of patients. The CAH staff reported completing an average of 250 to 300 x-rays a week.

Failure to secure radiation exposure cords could allow staff access to the x-ray room while performing a procedure and exposing staff to unnecessary radiation.

Findings include:

During tour of the radiology department on 7/29/14 at 9:00 AM with Staff C, Radiology technologist, revealed 1 of 2 radiation exposure cords in general x-ray room 2 was not secured and reaching approximately 8 feet into the x-ray room. This would allow staff access to the x-ray rooms during the procedures.

During an interview on 7/29/14 at 9:00 AM, Staff C agreed the radiation emitting cord was not secured and would allow staff access to the x-ray room during x-ray procedures. Staff C said the cords should be secured at a short length not allowing staff access to the x-ray room during procedures.

Review of the CAH's undated policy "Radiation Protection Policy and Procedure", revealed in part... "All people that are not directly in performing the exam, (ex: doctor, nurse, etc.) must step behind the shield or 6 feet back during the exposure."

Based on review of policies/procedures, patient medical records, and staff interview, the Critical Access Hospital (CAH) staff failed to obtain physicians' order for admission to Cardiac and Pulmonary Rehabilitation (rehab) services for 2 of 3 active patient's receiving cardiac rehab services (Patient #1 and #23) and 1 of 2 active patient's receiving pulmonary rehab services (Patient #2).

The Cardiac Pulmonary Registered Nurse identified a current census of 3 Phase II cardiac rehab patients and 5 Phase II Pulmonary rehab patients. The Cardiac Pulmonary Registered Nurse reported an average monthly census of approximately 50 cardiac rehab patients and 20 pulmonary rehab patients.

Failure to obtain physician's orders for Cardiac and Pulmonary Rehabilitation services prior to the start of care and initial assessment could potentially affect the provision of appropriate care services when not ordered by the patient's physician.

Findings included:

1. Review of policy titled "Cardiac Rehab", dated 5/15/14 revealed the following in part, ..."The following baseline information and testing is required for admission to the Cardiac Rehabilitation Outpatient Programs (Phase II) and will be obtained prior to the initial interview...A physician's order..."

2. Review of policy titled "Pulmonary Exercise Prescription", dated 11/21/13 revealed the following in part, ..."Phase II...programs or extensions may be initiated as determined by goal attainment physician orders..."

3. Review of Patient #1's medical record revealed a cardiac rehab referral dated 4/26/14 with diagnosis including but not limited to coronary artery stent insertion (a small, metal mesh tube that keeps the artery open), and acute myocardial infarction (a heart attack). The patient started the cardiac rehab program on 6/3/14. The medical record lacked documented evidence of a physician's order prior to completion of the cardiac rehab exercise program (a program in which the physician orders the maximum heart rate, blood pressure and rate of energy and metabolic rate during a specific activity as determined by the physician.)

Review of Patient #23's medical record a cardiac rehab referral dated 5/27/14 with diagnosis including but not limited to coronary artery stent insertion. The patient started the cardiac rehab program on 6/4/14. The patient exercised on 6/4/14 at 9:00 AM. The medical record lacked a physician's order prior to completion of the exercise program.

Staff P, Registered Nurse (RN) and Cardiac/Pulmonary Rehab Nurse Coordinator failed to obtain a physician's order until 3:00 PM on 6/4/14. At the time of the review of the cardiac rehab patient's medical records, Staff P acknowledged she failed to follow policy and procedure for obtaining physician's orders prior to exercising and implementing the cardiac rehab Phase II exercise sessions.

Review of Patient #2's medical record revealed a pulmonary rehab order dated 3/27/14 for chronic obstructive pulmonary disease. The patient started the pulmonary rehab program on 4/22/14 at 10:00 AM. Staff P, failed to obtain a physician's order for outpatient pulmonary rehab exercises until 2:00 PM on 4/22/14. At the time of the review of pulmonary rehab patient medical records, Staff P acknowledged she failed to follow and procedure for obtaining physician's orders prior to exercising and implementing the pulmonary rehab Phase II exercise sessions.

4. During an interview on 7/30/14 at 3:45 PM, the Director of Nursing (DON) reviewed the records for the 3 patients identified (Patient #1, #2, and #23) and acknowledged Staff P failed to follow hospital policy and failed to obtain a physician's order for outpatient cardiac and pulmonary Phase II rehab exercises. The Director of Nursing said there would be steps taken to remedy this "immediately".

Based on document review and staff interview, the critical access hospital (CAH) failed to delineate privileges for 1 of 1 Registered Nurse, who was not an employee of the hospital, to assist with surgical procedures at the hospital. The RN assisted with 19 of 19 surgical procedures in 2013 and 14 of 14 surgical procedures completed by associated practitioner from January through July 2014 . (Other staff AA)

Failure to privilege all assistants that accompany physicians to assist with surgical procedures are not CAH employees or contracted employees could result in surgical patients receiving surgical intervention from a person without the necessary qualifications.

Findings include:

1. Review of Medical Staff Bylaws, dated December 12, 2012, revealed, in part, ". . . Every practitioner of other professional providing clinical services at this Hospital by virtue of his or her Staff appointment or otherwise, shall, in conjunction with such practice and except as provided in Section 7.5 [Emergency Privileges], be entitled to exercise only those clinical privileges or specified services specifically granted to him or her by the board. . . ."

Review of the Operating Room Log on 7/29/14 at 2:00 PM revealed Other Staff AA, Registered Nurse, provided surgical assistance for Practitioner O, a surgeon, during surgical interventions for patients. The surgical technician assisted with 19 of 19 surgical procedures in 2013 and 14 of 14 surgical procedures completed by Practitioner O
from January through July 2014. Review of the Surgical Procedures Manual kept in the Surgery area on 6/3/14 showed it lacked documentation of privileges for Other Staff AA to assist Practitioner O with surgical procedures in the operating room.

Review of Other Staff AA's, Registered Nurse, personnel file on 7/30/14 at 12:10 PM, showed it lacked documentation of privileges for Other Staff AA.

2. During an interview on 7/29/14 at 2:00 AM, Staff BB, Surgery Coordinator, verified that Other Staff AA lacked surgical privileges to provide assistance during surgical procedures with Practitioner O. Staff BB stated Other Staff AA scrubbed in and assisted Practitioner O during surgical procedures.

During an interview on 7/29/14 at 3:00 PM, Staff CC, Executive Assistant responsible for credentialing, verified that Other Staff AA lacked surgical privileges to provide assistance during surgical procedures with Practitioner O.

Based on review of the Quality Improvement Plan, Quality Improvement activities and interview with staff, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for 10 of 21 patient care services offered at the CAH. The services not evaluated included: Nutrition, Cardiac/Pulmonary Rehabilitation, Imaging, Environmental Services, Wound Care, Respiratory, Nuclear Medicine, Bone Density, Physical/Occupational/Speech Therapy, and Sleep Study.
The contracted services were Respiratory, Nuclear Medicine, Bone Density, Physical/Occupational/Speech Therapy, and Sleep Study The CAH administrative staff reported a census of 9 inpatients at the time of the survey and the number of outpatients vary from day to day. These services also included outpatient services.

Failure to monitor and evaluate all patient care services for quality of care could potentially expose CAH patients to inadequate or less than optimal care.

Findings include:

1. Review of CAH policy titled "CQI Plan", dated 3/17/10, revealed, in part. "The purpose of this plan is to act as a guide and to provide a method for continuous quality improvement (CQI) at Knoxville Hospital & Clinics. . . The committee reviews summaries data from Measurement, Monitoring, and Analysis of quality across the organization. . . ."

2. Review of CQI/Risk Management Committee Meeting minutes from July 10, 2013 through July 9, 2014 showed a lack of evidence that Nutrition Services, Cardiac/Pulmonary Rehabilitation, Imaging Services, Environmental Services, Wound Care, Contracted services - Respiratory, Nuclear Medicine, Bone Density, Physical/Occupational/Speech Therapy, and Sleep Study were monitored, evaluated and included quality improvement activities regarding these patient care services.

3. During an interview on 7/31/14 at 10:40 AM, Staff A, Chief Operating Officer, acknowledged the lack of reports to the CQI committee for Nutrition Services, Cardiac/Pulmonary Rehabilitation, Imaging Services, Environmental Services, Wound Care, and the contracted services of Respiratory, Nuclear Medicine, Bone Density, Physical/Occupational/Speech Therapy, and Sleep Study.

During an interview on 7/28/14 at 2:15 PM, Staff I, Clinical Dietitian, and Staff Q, Manager of Nutritional Services, reported the lack of quality information for food service or clinical nutrition.

During an interview on 7/29/14 at 9:00 AM, Staff R, Contracted Respiratory Services Practitioner, acknowledged the lack of quality information for respiratory services.

During an interview on 7/29/14 at 9:15 AM, Staff R, Contracted Respiratory Services Practitioner, acknowledged the lack of quality information for sleep study.

During an interview on 7/30/14 at 10:40 AM, Staff P, Nuclear Medicine Technician, stated Nuclear Medicine or Bone Density have not reported quality information to the quality committee for quite some time.

During an interview on 7/31/14 at 12:50 PM, Staff I, Chief Clinical Officer, acknowledged Physical Therapy, Occupational Therapy, or Speech Therapy have not reported quality information to the quality committee.

Based on review of documents and medical record, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure the activity coordinator developed and implemented an activity program in the multidisciplinary care plan for 6 of 6 open swing bed patients (Patient #3, #5, #6, #7, #8, and #9), and 6 of 6 closed swing bed patients (Patient #10, #11, #12, #13, #14, and #15).

The Medical Surgical Nurse Manager identified a census of 6 swing bed patients at the time of the survey.

Failure to provide an activity program that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well being and independence possible.

Findings include:

1. Review of document titled "Resident Rights", revised 8/13, revealed the following in part, ..."the resident has the right to choose activities...consistent with his or her interests...and plans of care...the facility must provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment..."

2. Review of active medical records revealed the following information.

a. A physician ordered swing bed services for Patient #3 on 7/21/14. Staff G, an occupational therapist designated as the activity coordinator, completed the activity assessment on 7/21/14. Patient #3's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

b. A physician ordered swing bed services for Patient #5 on 7/17/14. Staff G completed the activity assessment on 7/18/14. Patient #5's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

c. A physician ordered swing bed services for Patient #6 on 7/17/14. Staff G completed the activity assessment on 7/18/14. Patient #6's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

d. A physician ordered swing bed services for Patient #7 on 7/24/14. Patient #7's medical record lacked evidence of an activities assessment, an activity and/or activity progress notes and an activity care plan directing staff to provide individual or group activities chosen by the patient.

e. A physician ordered swing bed services for Patient #8 on 7/19/14. Staff G completed the activity assessment on 7/21/14. Patient #8's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

f. A physician ordered swing bed services for Patient #9 on 7/17/14. Staff G completed the activity assessment on 7/18/14. Patient #9's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

3. Review of closed medical records revealed the following information.

a. A physician ordered swing bed services for Patient #10 on 7/10/14. Staff G completed the activity assessment on 7/10/14. Patient #10's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

b. A physician ordered swing bed services for Patient #11 on 7/19/14. Staff G completed the activity assessment on 7/12/14. Patient #11's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

c. A physician ordered swing bed services for Patient #12 on 7/7/14. Staff G completed the activity assessment on 7/16/14. Patient #12's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

d. A physician ordered swing bed services for Patient #13 on 7/25/14. Patient #13's medical record lacked evidence of an activities assessment, an activity and/or activity progress notes and an activity care plan directing staff to provide individual or group activities chosen by the patient.

e. A physician ordered swing bed services for Patient #14 on 7/14/14. Patient #14's medical record lacked evidence of an activities assessment, an activity and/or activity progress notes and an activity care plan directing staff to provide individual or group activities chosen by the patient.

f. A physician ordered swing bed services for Patient #15 on 7/9/14. Staff G failed to complete an activity assessment until 7/18/14. Additionally, Patient 15's medical record lacked evidence of an activity care plan directing staff to provide individual or group activities chosen by the patient.

4. During an interview on 7/30/14 at 8:50 AM, Staff G acknowledged she was responsible for completing an activity assessment and providing an activity program for swing bed patients. Staff G said in addition to activity calendars there were a variety of various activities available for swing bed patients at the hospital.
Staff G acknowledged she failed to develop an activities care plan after reviewing both the open and closed patient medical records identified and said she was unaware that this was her responsibility. Staff H, the Director of Physical and Occupation Therapy services said they did not understand their staff (including Staff G) were responsible for assessing, implementing, and revising an interdisciplinary activity care plan for swing bed patients.

During an interview on 7/30/14 at 9:15 AM, Staff F, Registered Nurse (RN) and the Medical/Surgical Nurse Manager said Staff G was responsible for developing an activity care plan and she knew Staff G offered swing bed patients alternatives for activities daily however she said she was unaware Staff G failed to develop an activity care plan. Staff F acknowledged the open and closed records identified lacked an activity assessment and progress notes in some instances and an activity care plan was a part of the patient's interdisciplinary care plan in all cases and reviewed by the interdisciplinary team during care plan conferences.

During an interview on 7/31/14 at 7:15 AM, the Director of Nursing (DON) said they did not have a policy for swing bed activity care plans. The DON verified hospital protocol would direct staff responsible for overseeing the activity program for swing bed patients to develop and implement a care plan specific to activities. The DON acknowledged the open and closed records identified they lacked an activity assessment and progress notes in some instances and lacked an activity care plan as a part of the patient's interdisciplinary care plan to be reviewed by the interdisciplinary team at care plan conferences in all cases. The DON said that she was not aware this was not being done and they would be addressing the situation.

Based on review of documents, review of medical record, and staff interviews, the Critical Access Hospital (CAH) swing bed interdisciplinary team failed to ensure the attending physician participated in the interdisciplinary care conferences for the development of the patient's individualized care plan for 6 of 6 open swing bed patients (Patient #3, #5, #6, #7, #8, and #9), and 5 of 5 closed swing bed patients (Patient #10, #12, #14, #15 and #23).

The Medical Surgical Nurse Manager identified a census of 6 swing bed patients at the time of the survey.

Failure to obtain input from the attending physician while formulating and revising the patient's individualized care plan could result in delays in implementing treatment modalities to improve the patient's functional abilities, to enhance healing, and to shorten the hospital stay.

Findings include:

1. Review of 6 of 6 swing bed in-patients medical records revealed the following:

a. A physician ordered swing bed services for Physical Therapy (PT) and Occupational Therapy (OT) services for Patient #3 on 7/21/14. A history and physical dated 7/17/14 revealed admitting diagnosis including but not limited to acute gastrointestinal bleeding, renal failure syndrome, diabetes, congestive heart failure and chronic obstructive lung disease.

A review of the patient's medical record revealed care conferences occurred on 7/21, 7/23, 7/25, and 7/27/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

b. A physician ordered swing bed services for PT services for Patient #5 on 7/14/14. A history and physical dated 7/14/14 revealed admitting diagnosis including but not limited to acute gastrointestinal bleeding and anemia.

A review of the patient's medical record revealed care conferences occurred on 7/16, 7/18, 7/21, 7/23, 7/25, and 7/27/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

c. A physician ordered swing bed services for PT and OT services for Patient #6 on 7/17/14. A history and physical dated 7/14/14 revealed admitting diagnosis including but not limited to iron deficiency anemia, severe chronic obstructive pulmonary disease and bacterial pneumonia.

A review of the patient's medical record revealed care conferences occurred on 7/16, 7/18, 7/22, 7/23, 7/25, and 7/27/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

d. A physician's order dated 7/24/14 for swing bed services for PT and OT services for Patient #7. A history and physical dated 7/24/14 revealed admitting diagnosis including but not limited to left total hip replacement.

A review of the patient's medical record revealed care conferences occurred on 7/24, 7/25, and 7/27/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

e. A physician ordered swing bed services for PT and OT services for Patient #8 on 7/21/14. A history and physical dated 7/16/14 revealed admitting diagnosis including but not limited to acute heart failure, acute confusion, acute bronchitis and atrial fibrillation with cardiac pacemaker.

A review of the patient's medical record revealed care conferences occurred on 7/22, 7/23, 7/25, and 7/27/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

f. A physician ordered swing bed services for PT and OT services for Patient #9 on 7/21/14. A history and physical dated 7/17/14 revealed admitting diagnosis including but not limited to right lower lobe pneumonia, urinary tract infection, history of malignancy with liver metastasis and Parkinson's.

A review of the patient's medical record revealed care conferences occurred on 7/18, 7/21, 7/23, 7/25, and 7/27/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

2. Review of 5 of 5 closed swing bed patients medical records revealed the following:

a. A physician ordered swing bed services for PT and OT services for Patient #10 on 7/7/14. A history and physical dated 7/7/14 revealed admitting diagnosis including but not limited to anemia, Acute CVA (stroke). osteoporosis with pathological fracture, and seizure disorder.

A review of the patient's medical record revealed care conferences occurred on 7/9, 7/11, 7/14, and 7/16/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

b. A physician ordered swing bed services for PT and OT services for Patient #12 on 7/7/14. A history and physical dated 7/7/14 revealed admitting diagnosis including but not limited to motor vehicle collision with multiple trauma, chronic obstructive lung disease and pleural effusion (a condition in which excess fluid builds around the lung).

A review of the patient's medical record revealed care conferences occurred on 7/9, 7/11, 7/14, 7/16, 7/18 and 7/21/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

c. A physician ordered swing bed services for intravenous antibiotic therapy for Patient #14 on 7/7/14. A history and physical dated 7/11/14 revealed admitting diagnosis including but not limited to cellulitis (a common skin infection caused by bacteria) of the left arm.

A review of the patient's medical record revealed care conferences occurred on 7/14 and 7/16/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

d. A physician ordered swing bed services for PT and OT services for Patient #15 on 7/10/14. A history and physical dated 7/10/14 revealed admitting diagnosis including but not limited to iron deficiency anemia, muscular deconditioning and hypokalemia (low potassium blood levels), and generalized weakness.

A review of the patient's medical record revealed care conferences occurred on 7/9, 7/11, 7/14, 7/16, 7/18, 7/21, 7/22, and 7/23/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

e. A physician ordered swing bed services for intravenous antibiotic therapy services for Patient #23 on 7/8/14. A history and physical dated 7/8/14 revealed admitting diagnosis including but not limited to cystitis (a urine infection in the bladder), dehydration and dementia.

A review of the patient's medical record revealed care conferences occurred on 7/9, and 7/11/14. The interdisciplinary team meeting minutes lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

3. During an interview on 7/28/14 at 2:10 PM, Staff V, RN/Utilization Review/Care Plan Manager, reported being responsible to coordinate and manage interdisciplinary care conferences. Staff V confirmed the physicians did not attend the care conferences or attest in signature they reviewed care conferences.

Staff V said she reviewed the patient's hospital stay to ascertain if the the physician had additional thoughts or changes in orders or therapies and acknowledged the open and closed medical records identified with concerns lacked evidence of physician involvement. Staff V said in the 2 years she had coordinated interdisciplinary care conferences she had never documented physician involvement and was unaware that this was a requirement.

During an interview on 7/31/14 at 7:15 AM, Staff D, the DON, acknowledged the CAH lacked a policy specific to physician involvement with interdisciplinary care plan conferences. Staff D said interdisciplinary team members review the patient's plan of care with the physician routinely but are not documenting this information in the patient's medical record currently. Staff D acknowledged nursing and interdisciplinary team members failed to document or provide evidence of physician involvement in care plan meetings and this would be addressed by the hospital immediately.