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Based on review of credential files, review of Medical Staff Bylaws and staff interview, the CAH (Critical Access Hospital) failed to follow the Medical Staff Bylaws in the reappointment of 6 of 10 sampled physician/non-physician credential files reviewed (Physicians K, L, M, N and O and Non-physician P) by not ensuring that granting of privileges was based on continued qualifications as spelled out in the Medical Staff Bylaws. This failed practice has the potential to affect all patients of the hospital. The list of physicians/non-physician on the medical staff roster (no date) provided by the HIM (Health Information Management Director) listed: 3 active staff (practitioners who admit patients to the hospital); 6 active affiliate staff (non-physician practitioners who qualify for co-admitting privileges); 10 affiliate staff (non-physician practitioners who have clinical privileges at the CAH but do not co-admit patients); and, 73 consulting staff (practitioners who are recognized specialists willing to serve in a consulting capacity).

Findings are:

A. Review of the Medical Staff Bylaws approved by the Governing Board on 3/27/13 revealed the following under Article IV Clinical Privileges, 4.2 Qualifications:
"The following constitute continuing qualifications for the exercise of privileges at the Hospital. Each member and applicant for membership shall....Demonstrate current competence, including current knowledge, judgment, training, and technique, in his or her specialty area and for all privileges held or applied for....Perform a sufficient number of procedures, manage a sufficient number of cases, and have sufficient patient care contact with the Hospital to permit the proctor or Medical Staff to assess current competency for all requested privileges...."

The Medical Staff Bylaws under Article VI Appointment and Privileging, 6.6 Reappointment/Renewal Process states:
"...the Executive Committee and Board...may review and consider any other records and information deemed relevant to their review. Without limitation, this may include review of such items as...utilization review, quality assurance, and other peer review records and reports; patient charts; incident reports...complaints or comments from other members of the Hospital staff, the CEO [Chief Executive Officer], patients, or members of the public; and any other relevant documents or correspondence."

B. Review of credential files for Physician K (last reappointment by Governing Board 9/24/14), Physician L (last reappointment by Governing Board 5/22/13), Physician M (last reappointment by Governing Board 1/28/15), Physician N (last reappointment by Governing Board 9/24/14), Physician O (last reappointment by Governing Board 10/23/13) and Non-physician P (last reappointment by Governing Board 6/25/14) revealed no information regarding:
- Current competence;
- Number of procedures performed, number of patient care contact and/or number of admissions to evaluate competence and use of CAH;
- Utilization review information;
- Quality assurance and other peer review records and reports;
- Pertinent incident reports; and,
- Pertinent complaints or comments from other members of the Hospital staff, the CEO, patients, or members of the public.

(A physician credential file contains the information gathered at the time of appointment/reappointment to the hospital medical staff and includes information such as: an application; list of privileges requested; verifications of education, training, work experience, licenses, registrations and references; background checks; and, activity and quality at the CAH.)

C. Interview with the CEO on 3/12/15 from 10:00 AM to 10:30 AM confirmed that the credential files lacked any information concerning current practices at the CAH including quality assurance, peer review complaints and utilization of CAH; however, the CEO could not verify whether the Director of PI ( Performance Improvement) maintained a Quality file on the physicians.

Interview with the HIM Director (responsibilities included maintenance of the credential files) on 3/12/15 at 8:45 AM confirmed the files provided were the only files available for the reappointment process.

Interview with the Director of PI on 3/12/15 at 11:50 AM confirmed having no physician quality files; however, indicated was working on a form which included quality information concerning physician/non-physician on the CAH's medical staff.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to maintain an infection prevention program which included monitoring of hand hygiene practices of direct patient care staff. This failed practice had the potential to affect all patients of the facility. The CAH reported in the fiscal year of 5/1/13 - 4/30/14 a total of 438 patients were admitted to acute care; 165 patients were admitted to swing bed and 48 births.

Findings are:

A. A review of the "Introduction to Infection Prevention and Control Program" Policy and Procedure with an effective date of 7/2005 and last revised on 3/2015 revealed, "...The Infection Prevention and Control Plan defines the structure and activities for surveillance, prevention and control of infections among patients, residents, employees and all others who may come into contact with patients and establishes responsibility for over site of these activities... To reduce the risks of endemic and epidemic health care-associated infections in patients, residents, and healthcare workers...The Infection Prevention and Control Program at this health system incorporates the following in a continuing cycle: surveillance, prevention and control of infections throughout the organization. Development of alternative techniques to address the real and potential exposures. Selection and implementation of the best techniques to minimize adverse outcomes. Evaluate and monitor the results and revise techniques as needed...."

B. An interview with the Infection Control Nurse on 3/12/15 at 8:30 AM, when asked what are the measures in place for prevention of infections, stated, "I currently only go over handwashing with new hires. I am not currently doing any other surveillance with staff such as handwashing or anything. I am relatively new in the position and have not developed that whole program yet."

Failure of direct patient care staff to perform hand hygiene before and after direct patient care and immediately preceding any invasive procedure, is the primary cause of health care acquired infection, according to the Centers for Disease Control.

Based on review of Medical Staff Rules and Regulations, review of the 2013-2014 Annual Program Evaluation and staff interview; the CAH (Critical Access Hospital) failed to ensure practitioners completed their medical records within 30 days of the patients' discharge. Patient census on the first day of survey was 13 (4 acute inpatient, 7 swingbed patients, 1 private pay patient and 1 observation patient).

Findings are:

A. Interview with the Director of Health Information Management (HIM) on 3/11/15 at 3:10 PM revealed, "I don't know if there are medical records over 30 days of a patient's discharge. We can't run a report to check for incomplete records. Before we went to the electronic medical records in 1/2013 we were able to keep track but this computer program does not let us run a report to check if all the orders are signed, so we aren't able to know. We currently have no providers that are suspended."


B. Review of the Medical Staff Rules and Regulations approved 3/27/13 stated the following:
"Delinquent Charts: The patient's medical record shall be completed within thirty days following the patient's discharge. If the record remains incomplete thirty days after discharge, or if any part of the record is otherwise delinquent, the CEO (Chief Executive Officer), or his or her designee, shall notify the practitioner in writing that his or her clinical privileges, including admitting privileges, will be automatically suspended five days from the date of notice, unless the practitioner completes such records within such period or provides evidence and the Executive Committee concurs that there is good cause for such delinquency."

C. Review of the 5/1/13 - 4/30/14 Annual Program Evaluation revealed the following data:
- Acute Inpatient Admissions 438
- Swing Bed Admissions 165
- Surgeries/procedures performed 339
- Emergency Room visits 1083

It is unknown if the medical record documentation for the above data was completed within 30 days due to changing to electronic medical records on 1/2013.

Based on record review, staff interview and review of policy and procedures the Critical Access Hospital (CAH) failed to:
Part I: Ensure that upon discharge from same day surgical procedures a physician order for discharge was obtained from the provider/surgeon prior to dismissal for 3 of 6 surgical records sampled (Patients 27, 28 and 31); and
Part II: Ensure that upon discharge from same day surgical procedure that complete discharge instructions were provided to 6 of 6 surgical patients sampled (Patients 26, 27, 28, 29, 30 and 31) related to information regarding prescription pain medications sent with the patients upon dismissal.

This failed practice had the potential to affect all surgical patients of the CAH. The CAH reported in the fiscal year of 5/1/13 - 4/30/14 a total of 339surgical procedures were performed at the CAH including: inpatient and outpatient surgery, scopes, and cataract surgeries.

Findings are:

Part I
A. Review of Patient 27's record dated 1/13/15 revealed the patient had a laparoscopic cholecystectomy (removal of the gallbladder through several small incision in the abdomen). Review of Doctor (Dr) N's order sheet titled "Laparoscopic Choleycystectomy [sic] /Appendectomy POST-OP Orders" lacked a discharge order. Review of the record revealed Patient 27 was dismissed on 1/13/15.

B. Review of Patient 28's record dated 12/23/14 revealed the patient had a laparoscopic cholecystectomy. Review of Dr N's order sheet titled "Laparoscopic Choleycystectomy [sic] /Appendectomy POST-OP Orders" lacked a discharge order. Review of the record revealed Patient 28 was dismissed on 12/23/14.

C. Review of Patient 31's record dated 11/11/14 revealed the patient had bilateral inguinal hernia (tissue pushes through a weak spot in the groin muscle) repair and umbilical hernia (tissue bulges out through an opening in the muscles of the abdomen near the belly button) repair. Review of Dr N's order sheet titled "Hernia POST-OP Orders" lacked a discharge order.

D. Review of the "Discharge from PACU (Post-anesthesia care unit)" Policy and Procedure with an effective date of 11/2006 and last revised on 10/2014 revealed, "Discharge procedures prior to discharge are as follows: The nurse determines if the patient adequately meets all discharge criteria. The nurse will verify discharge order with the physician order sheet..."

E. An interview with the Chief Nursing Officer on 3/12/15 at 11:45 AM verified that the discharge order was lacking from Patients 27, 28 and 31's medical records following their surgical procedures.

Part 2
A. Review of Patient 26's record dated 2/23/15 revealed the patient had a left knee medical meniscectomy (repair of a torn meniscus/cartilage in the knee joint). Review of the form titled "(Dr O) Discharge Instructions" revealed under the category DISCOMFORT: "You have been given a prescription for:" a blank line followed. The dismissing nurse did not fill in what prescription medication Dr O sent home with Patient 26. The dismissal instructions were signed by Patient 26 on 2/23/15.

B. Review of Patient 27's record dated 1/13/15 revealed the patient had a laparoscopic cholecystectomy (removal of the gallbladder through several small incisions in the abdomen). Review of the form titled "Laparoscopic Gallbladder Removal Discharge Instructions" provided by Dr N revealed, "...You will have a prescription pain pill to take every 4 hours as needed for severe pain. Always take with food - never on an empty stomach..." The dismissing nurse did not indicate on the discharge instruction sheet what prescription medication Dr N sent home with Patient 27. The dismissal instructions were signed by Patient 27 on 1/13/15.

C. Review of Patient 28's record dated 12/23/14 revealed the patient had a laparoscopic cholescstectomy. Review of the form titled "Laparoscopic Gallbladder Removal Discharge Instructions" provided by Dr N revealed, "...You will have a prescription pain pill to take every 4 hours as needed for severe pain. Always take with food - never on an empty stomach..." The dismissing nurse did not indicate on the discharge instruction sheet what prescription medication Dr N sent home with Patient 28. The dismissal instructions were signed by Patient 28 on 12/23/14.

D. Review of Patient 29's record dated 11/24/14 revealed the patient had removal of hardware status post healed right patellar (kneecap) fracture. Review of the form titled "(Dr O) Discharge Instructions" revealed under the category DISCOMFORT: "You have been given a prescription for: percocet as needed. The dismissing nurse did not fill in what strength of percocet or the instructions on taking the medications. The dismissal instructions were signed by Patient 29 on 11/24/14.

E. Review of Patient 30's record dated 10/22/14 revealed the patient had bilateral subcutaneous mastectomy (removal of excess breast tissue). Review of the form titled "Dismissal Instructions for Outpatient Surgery" provided by Dr J revealed, "Pain control as follows as prescribed by your physician:percocet as needed." The dismissing nurse did not fill in what strength of percocet or the instructions on taking the medications. The dismissal instructions were signed by Patient 30 on 10/22/14.

F. Review of Patient 31's record dated 11/11/14 revealed the patient had bilateral inguinal hernia repair and umbilical hernia repair. Review of the form titled "Hernia Discharge Instructions" provided by Dr N revealed, "...Your doctor may have prescribed a pain pill you can take every 4 hours for more severe pain. Always take with food - never on an empty stomach..." The dismissing nurse did not indicate on the discharge instruction sheet what prescription medication Dr N sent home with Patient 31. The dismissal instructions were signed by Patient 31 on 11/11/14.

G. Review of the "Discharge from PACU (Post-anesthesia care unit)" Policy and Procedure with an effective date of 11/2006 and last revised on 10/2014 revealed, "Discharge procedures prior to discharge are as follows: The nurse determines if the patient adequately meets all discharge criteria. The nurse will verify discharge order with the physician order sheet. Give the patient and significant other (if available) instructions for self-care, medications, appointments or supplies; document these instructions...Give instructions to have take-home prescriptions filled immediately..."

H. An interview with the Chief Nursing Officer on 3/12/15 at 11:45 AM verified that the discharge instructions for Patients 26, 27, 28, 29, 30 and 31 lacked complete information regarding narcotic pain medication prescribed by the surgeon upon discharge from the same day surgery procedures.

Based on review of medical records, Medical Staff Rules and Regulations and staff interview; the CAH (Critical Access Hospital) failed to ensure that surgical patient medical records contained documentation of the pre-surgical physical examination to evaluate for the risk of the procedure to be performed by the physician for 2 (Patients 26 and 29) of 6 surgical patients. This failed practice had the potential to affect all surgical patients of the CAH. The Critical Access Hospital (CAH) reported in the fiscal year of 5/1/13 - 4/30/14 a total of 339 procedures were performed at the CAH including: inpatient and outpatient surgery; scopes and cataract surgeries.

Findings are:

A. Review of Patient 26's record dated 2/23/15 revealed the patient had a left knee medical meniscectomy (repair of a torn meniscus/cartilage in the knee joint). Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

B. Review of Patient 29's record dated 11/24/14 revealed the patient had removal of hardware status post healed right patellar (kneecap) fracture. Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

C. Interview with Surgical Nurse/Registered Nurse (RN) J on 3/11/15 at 10:15 AM revealed that the surgeons do an assessment on their patients immediately before surgery. "The orthopedic surgeon also marks the limb in which the surgery will occur and answers questions. We have a stamp for the record that most of the physicians use that identifies that they have examined the patient and found no changes since the History and Physical (H&P) was completed within 30 days, they sign and date that after their assessment. We must have missed the documentation of the orthopedic surgeon seeing those patients (Patients 26 and 29) before their surgery because I know that the surgeon did see them."

D. Review of the Medical Staff Rules and Regulations approved 3/27/13 stated the following:
"...When the History and Physical is conducted within 30 days before admission or registration, an updated examination of the patient, including any changes in the patient's condition, must be completed and documented within 24 hours after admission but prior to surgery or a procedure requiring anesthesia services. The updated examination of the patient, including any changes in the patient's condition, must be completed and documented in the medical record. The update note must document an examination for any changes in the patient's condition since the patient's H&P was performed that might be significant for the planned course of treatment. If, upon examination there are no changes in the patient's condition since the H&P was completed, the provider must indicated in the patient's medical record that the H&P was reviewed, the patient was examined, and that "no change" has occurred in the patient's condition since the H&P was completed..."

Based on review of the electronic and paper record system used for Cardiac Pulmonary Rehabilitation, review of policies and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure confidentiality and potential unauthorized use of medical records information for 1 of 1 sampled Pulmonary Rehabilitation record reviewed (Medical Record 38). The CAH currently had 8 Cardiac Pulmonary Rehabilitation outpatients. The Annual Evaluation for fiscal year 2014 (5/1/2013 - 4/30/14) identified 446 cardiac pulmonary rehabilitation sessions for that time period.

Cardiac and Pulmonary Rehabilitation helps patients improve their health and live a more active life after major or ongoing heart or lung problems.

Findings are:

A. Tour of the Cardiac and Pulmonary Rehabilitation area with the Director of Ancillary Services (this individual was also licensed as a Respiratory Therapist) on 3/10/15 from 3:00 PM to 4:00 PM revealed the following:
- The Cardiac Pulmonary Rehabilitation area and Physical, Occupational and Speech Therapy Services share an entrance door and waiting area with Cardiac Pulmonary Rehabilitation located to the right of the waiting area.
- The technician workroom has a identification badge activated entrance.
- There were no other employee or patients in this area upon entrance to the technician workroom.
- Upon entrance to the workroom the computer monitor was on and displayed the names of 8 patients.
- The Director of Ancillary Services demonstrated how to open up the electronic medical record for Patient 38.

Interview with the Director of Ancillary Services on 3/10/15 at 3:15 PM revealed the following:
- Cardiac Pulmonary Rehabilitation uses a computer system to monitor patients vital signs and heart rhythm during the patients exercise session.
- Respiratory therapists (individuals who conduct the cardiac or pulmonary rehabilitation sessions with patients) usually get out of the program when rehabilitation sessions are done.
- Indicated that the computer system requires no log on identification or password to access the program that contains the patient medical record information.
- At the end of each session the respiratory therapist prints off a daily report of the session for the patient to put into the patients paper medical record.

B. Interview with the Human Resource Executive (responsibility includes maintenance of who has access to identification badge access doors) on 3/10/15 at 4:10 PM and again on 3/11/15 at 12:20 PM revealed laundry/housekeeping, maintenance and security, surgery LPNs (licenses practical nurses) and Surgery RNs (registered nurses) identification badges were coded to provide access to the Cardiac Pulmonary Rehabilitation technician room.

C. Review of the paper record for Patient 38 revealed Daily Reports printed off from the computer, which contained information such as blood pressure heart rate, weight, breath sounds, education provided and comments concerning how the patient did during the session. This would be the information that anyone who could access this room would be able to view on the computer monitor.

D. Interview with the Director of Information Technology on 3/10/15 a 3:20 PM in the Cardiac Pulmonary Rehabilitation technician room, after checking security on the computer, revealed the computer had "no security on it".

E. Review of the policy and procedure titled Workstation Administration with an effective date of 4/2014 revealed the following:
"PURPOSE: To provide guidance on protecting access to all workstations, and to provide confidentiality of information and e-PHI [electronic-personal health information]. POLICY: Workstations shall be protected and used in a manner to safeguard the confidentiality and integrity of PHI and confidential Information. APPLICABILITY: This policy covers any and all workstations owned or operated by [name of the CAH]."

Review of a second policy and procedure titled Access Control with an effective date of 4/2014 revealed the following:
"PURPOSE: To provide guidance on limiting access to the [name of CAH] computer system or any other electrical device....GUIDELINES FOR THE DEVELOPMENT OF PROCEDURES....Each user of the system should have a unique identification. The system should provide a method to accurately identify each user through a directory system, password or other means."

Based on record review and staff interview the facility failed to ensure the swing bed patient records included a recapitulation (a concise summary) of their swing bed stay in 3 of 3 (Patients 34, 35 and 36) discharged swing bed records reviewed. The Critical Access Hospital (CAH) had 160 swing bed dismissals from 5/1/13 - 4/30/14. This has the potential to effect all discharged swing bed patients.

Findings are:

A. Review of Patient 34's medical record revealed a lack of a recapitulation of the patient's swing bed stay from 2/17/15-2/20/15.

B. Review of Patient 35's medical record revealed a lack of a recapitulation of the patient's swing bed stay from 1/21/15-1/23/15.

C. Review of Patient 36's medical record revealed a lack of a recapitulation of the patient's swing bed stay from 12/3/14-12/9/14.

D. An interview with the Social Services Director on 3/12/15 at 11:15 AM revealed, "I do a summary of the discharge planning and interdisciplinary team meeting while in swing bed. The nurses do a summary of the services they provide the patient during their swing bed stay. If therapy is involved they do a summary of their services. We don't do a combined summary of their swing bed stay that brings all the disciplines summary into one form or note."

E. The CAH did not identify a specific policy and procedure that addressed the recapitulation of the swing bed patient's stay.