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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Recertification Survey conducted on May 7, 2012, the surveyors find 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 Recertifcation Survey conducted on May 7, 2012, the surveyors find 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 5/7/12.

A. Based on a review of Medical Staff Bylaws, a review of physician and Midlevel credential files, and staff interview, it was determined the CAH failed to ensure its Governing Body and Medical Staff initiated privileges to its Medical and Midlevel providers in accordance with their respective fields and then evaluated all providers upon reappointment to assure privileges were current. The cumulative effect of these systemic practices has the potential to effect 100 % of the patients serviced by the CAH.

Findings include:

1. Failed to ensure physician and midlevel privileges were initiated, updated, and maintained in respect to current services being provided by the respective provider. Please see deficiency cited at C241-A.

2. Failed to ensure the services provided by the physicians and midlevels providers was evaluated prior to reappointment. Please see deficiency cited at C241-B.

3. Failed to ensure the PA had a Collaborative Agreement with the supervising physician. Please see deficiency cited at C241-C.

4. Failed to ensure the Surgeon's privileges were updated, and maintained in respect to current surgical services being provided. Please see deficiency cited at C321-A.

5. Failed to ensure the Surgeon's privileges included the privilege to supervise the services of the CRNA, inclusive of the type and complexity of procedures they may supervise. Please see deficiency cited at C321-B.

6. Failed to ensure it designated CRNA privileges were initiated, updated, and maintained in respect to current services being provided by the CRNA. Please see deficiency cited at C323-A.

7. Failed to ensure 1 of 1 PA credential file reviewed, the CAH failed to ensure it evaluated the services provided by the PA. Please see deficiency cited at C339.

A. Based on a review of Medical Staff Bylaws, a review of physician and Midlevel credential files, and staff interview, it was determined in 8 of 8 physicians and 1 of 1 PA credential files reviewed for respective privileges, the CAH failed to ensure physician and midlevel privileges were initiated, updated, and maintained in respect to current services being provided by the respective provider.

Findings include:

1. The Medical Staff Bylaws were reviewed on 4/19/12. It indicated "Article VI. Clinical Privileges: A. Every practitioner practicing at this hospital by virtue of medical staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him by the governing body... Applications for additional clinical privileges must be in writing..."

2. Example: The credential file of P-3 was reviewed on 4/19/12. P-3 was reappointed to the Medical Staff on 3/1/11. During a staff interview, conducted with the DON on 4/19/12 at 2:00 PM, it was verbalized P-3 provided services in Family Practice on a full-time basis and ED 1 day per week. There was no documentation to indicate P-3 had been granted privileges in ED.

3. Example: The credential file of P-5 was reviewed on 4/19/12. P-5 was reappointed to the Medical Staff on 3/1/11 to provide Pathology and Nuclear Medicine services. The "Delineation of Medical Privileges Desired" was blank. There was no documentation to indicate what privileges P-5 was approved to provide.

4. Example: The credential file of P-6 was reviewed on 4/19/12. P-6 was reappointed to the Medical Staff on 3/1/11. The "Delineation of Medical Privileges Desired" was blank. There was no documentation to indicate what privileges P-6 was approved to provide.

5. Example: The credential file of P-7 was reviewed on 4/19/12. P-7 was granted initial privileges in the ED on 3/1/11. There was no "Delineation of Privileges Desired." There was no documentation to indicate what privileges P-7 was approved to provide.

6. Example: The credential file of PA was reviewed on 4/19/12. PA was reappointed to the Medical Staff on 3/1/11 to provide PA services. The "Delineation of Surgical Privileges Desired" indicated "... Intrathoracic Surgery, Gallbladder and Common Duct Surgery, Splenectomy..." During a staff interview, conducted with the DON on 4/19/12 at 2:00 PM, it was verbalized PA is an assistant to P-1 and did not perform these surgical interventions.

7. During a staff interview, conducted with the CEO on 4/19/12 at 11:00 AM, the following was verbalized in relation to the Credentialing process. The CAH looks at who the practitioner is, what area they are wanting to practice in, malpractice history, P-2 does an "in depth" review of the applicant's file, and then it goes to the Medical Staff for discussion. If it is accepted, it goes on to the Governing Body. If more information is needed, it goes for ongoing review and later discussion. The privilege list is not redone. They just sign that they want to resume the same privileges.

8. During a staff interview, conducted with P-2 (a physician who gathers and reviews all information on physicians and midlevels for appointment and/or reappointment to the Medical Staff) on 4/19/12 at 2:10 PM, the following was verbalized in relation to privileges requested, added, and/or deleted. An initial "Delineation of ....Privileges Desired" is filled out by the provider. The licensure, background, references, and all required queries are performed. Once everything is together and appears to be satisfactory, it is brought to the Medical Staff for approval and then forwarded to the Governing Body. When a provider wants to add a privilege, they submit documentation of education and the ability to provide the service and then this is discussed in Medical Staff for approval and forwarded to the Governing Body for approval. The providers do not resubmit a new "Delineation of.... Privileges Desired" form with each reappointment or with the addition and/or deletion of a privilege.

9. During a staff interview, conducted with the CEO and DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

B. Based on a review of Medical Staff Bylaws, a review of physician and Midlevel credential files, and staff interview, it was determined in 7 of 7 physicians, 1 of 1 CRNA, and 1 of 1 PA credential files in which reappointment had occurred, the CAH failed to ensure the services provided by the physicians and midlevels providers was evaluated prior to reappointment.

Findings include:

1. The Medical Staff Bylaws were reviewed on 4/19/12. It indicated "Article VI. Clinical Privileges: C. Annual redetermination of clinical privileges... shall be based upon the direct observation of care provided, review of the records of patients treated in this or other hospitals and review of the ..."

2. Example: The credential file of P-1 was reviewed on 4/19/12. P-1 was reappointed to the Medical Staff on 3/1/11. There was no documentation to indicate the services provided by P-1 had been evaluated prior to reappointment.

3. Example: The credential file of P-3 was reviewed on 4/19/12. P-3 was reappointed to the Medical Staff on 3/1/11. There was no documentation to indicate the services provided by P-3 had been evaluated prior to reappointment.

4. Example: The credential file of CRNA-1 was reviewed on 4/19/12. CRNA-1 was reappointed to the Medical Staff on 3/1/11 to provide anesthesia services. There was no documentation to indicate the services provided by CRNA-1 had been evaluated prior to reappointment.

5. Example: The credential file of PA was reviewed on 4/19/12. PA was reappointed to the Medical Staff on 3/1/11 to provide PA services. There was no documentation to indicate the services provided by PA had been evaluated prior to reappointment.

6. During a staff interview, conducted with P-2 (a physician who gathers and reviews all information on physicians and midlevels for appointment and/or reappointment to the Medical Staff) on 4/19/12 at 2:10 PM, the following was verbalized in relation to evaluation of provider services upon request for reappointment to the Medical Staff. The licensure, updated references, and all required queries are performed. Once everything is together and appears to be satisfactory, it is brought to the Medical Staff for approval and then forwarded to the Governing Body. When asked how the services of the provider are evaluated, such as numbers seen, whether policies were followed, any complications, any adverse outcomes, etc, it was verbalized that "no official" evaluation was done. "We discuss things and whether we feel the person has provided good and safe care."

7. During a staff interview, conducted with the CEO and DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

C. Based on a review of Medical Staff Bylaws, a review of credential file, and staff interview, it was determined in 1 of 1 PA credential file reviewed, the CAH failed to ensure the PA had a Collaborative Agreement with the supervising physician.

Findings include:

1. The Medical Staff Bylaws were reviewed on 4/17/12. It indicated "Article VII: Allied Health Professionals: Section 4: D: Physician Assistants: 2. a... sponsored by a member of the Medical Staff."

2. The credential file of PA was reviewed on 4/19/12. PA was reappointed to the Medical Staff on 3/1/11 to provide PA services. There was no documentation of a Collaborative Agreement between PA and a sponsoring physician.

3. During a staff interview, conducted with P-2 (a physician who gathers and reviews all information on physicians and midlevels for appointment and/or reappointment to the Medical Staff) on 4/19/12 at 2:10 PM, it was verbalized that they were unaware of the need for a Collaborative Agreement between PA and a supervising physician.

4. During a staff interview, conducted with the CEO and DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of CAH policy and procedure manual and staff interview, it was determined that the CAH failed to ensure the physicians, in conjunction with the PA, had participated in the developing, executing, and periodically reviewing the CAH's written policies governing the services it furnishes.

Findings include:

1. The CAH policy and procedure manual was reviewed on 4/20/12. There was no documentation to indicate the physicians, in conjunction with the PA, had participated in the developing, executing, and periodically reviewing the CAH's written policies governing the services it furnishes.

2. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on observation, a review of CAH policies, and staff interview, it was determined the CAH failed to ensure processes were implemented and monitored to ensure compliance with infection control was maintained. The cumulative effict of these systemic practices has the potential to effect 100% of the patients who require endoscopic services, of which the CAH averages 21 scopes/month.

Findings include:

1. Failed to ensure documentation of endoscopic scope usage and sterilization. Please see deficiency cited at C278-A.

A. Based on a review of CAH policy and procedure, medical record review, and staff interview, it was determined that in 3 of 3 (Pts #4, #5, #6) OP medical records reviewed in which the patient received a blood transfusion and medication, the CAH failed to ensure there was a proper assessment that included patient allergies prior to the administration of medications.

Findings include:

1. The CAH policy and procedure titled, "Packed Cells Administration" (revised 7/21/10) was reviewed. It indicated under "Pre-Medication Protocol (This protocol will be followed unless declined in writing by ordering physician) Tylenol 650 mg PO prior to starting blood, Benadryl 25 mg PO prior to starting blood."

2. The medical record of Pt #4 was reviewed on 4/18/12. Pt #4 was admitted on 2/17/12 with the diagnosis Myleofibrosis for an OP blood transfusion. Documentation in the nurse's note indicated that Pt #4 was administered "Tylenol 650 mg and Benadryl 25 mg". There was no documentation in the OP record that indicated the nurse performed an assessment that included Pt #4's allergies.

3. The medical record of Pt #5 was reviewed on 4/18/12. Pt #5 was admitted on 1/12/12 with the diagnosis Anemia for an OP blood transfusion. Documentation in the nurse's note indicated that Pt #5 was administered "Tylenol 650 mg and Benadryl 25 mg". There was no documentation in the OP record that indicated the nurse performed an assessment that included Pt #5's allergies.

4. The medical record of Pt #6 was reviewed on 4/18/12. Pt #6 was admitted on 10/31/11 with the diagnosis Complex Anemia for an OP blood transfusion. Documentation in the nurse's note indicated that Pt #6 was administered "Tylenol 650 mg and Benadryl 25 mg". There was no documentation in the OP record that indicated the nurse performed an assessment that included Pt #6's allergies.

5. During interviews with the DON and the CEO, conducted on 4/18/12 at 2:10 PM, the above findings were confirmed. It was verbalized that prior to the administration of any medication, the patient needs to be assessed for allergies to medications.

B. Based on a review of policy and procedure, medical record review, and staff interview, it was determined that in 2 of 3 (Pts #4, #6) medical records reviewed in which the patient received an OP blood transfusion, the CAH failed to ensure all vital signs were taken in accordance with procedures.

Findings include:

1. The CAH policy and procedure titled, "Packed Cells Administration" with a revised date of 7/21/10, was reviewed. It indicated under "PROCEDURE: ...The patient's vital signs will be taken by the nurse prior to infusion, then...1 hour post transfusion - 1 hour after saline turned on....."

2. The medical record of Pt #4 was reviewed on 4/18/12. Pt #4 received 2 units of PRBCs as an OP on 2/17/12 with the diagnosis Myleofibrosis. Transfusion documentation indicated the 2nd unit of blood was completed at 7:45 PM. The post treatment vital signs were documented at 8:18 PM, 33 minutes post transfusion.

3. The medical record of Pt #6 was reviewed on 4/18/12. Pt #6 received 2 units of PRBCs as an OP with the diagnosis Complex Anemia and was to receive one unit on 10/13/11 and one unit on 10/14/11. On 10/13/11, transfusion documentation indicated the blood infused at 5:00 PM and the post treatment vital signs were documented at 5:12 PM, 12 minutes post transfusion On 10/14/11, transfusion documentation indicated the blood infused at 1:35 PM and the post treatment vital signs were documented at 1:50 PM, 15 minutes post transfusion.

4. During an interview with the DON, conducted on 4/19/12 at 10:45 AM, the above findings were confirmed.

A. Based on a review of CAH policy and procedure, surgical C-II (narcotic) sign out sheets, and staff interview, it was determined that the CAH failed to ensure all C-II medications were properly witnessed when wasted.

Findings include:

1. The CAH policy and procedure titled, "Rules and Regulations" (effective 2/14/04) was reviewed. It indicated under, "At the end of anesthesia - daily activity: All unused and opened drugs are discarded after each case. Discarded narcotics will be recorded on the narcotic sheet as "wasted" and two (2) registered nurses will sign the sheet."

2. The surgical C-II sign out sheets were reviewed for the months of Jan and Feb 2012. There were 8 times where documentation indicated a portion of the Fentanyl ( a C-II medication) was wasted. There was no documentation that indicated the wasting of the medication was witnessed, as required.

3. During interviews with the Pharmacist and the Director of Nursing, conducted on 4/19/12 at 10:45 AM, the above findings were confirmed.

B. Based on a review of a job description, a review of CAH policy and procedure, observation, and staff interview, it was determined that the CAH failed to ensure all expired/outdated drugs and biologicals were removed from patient care areas. This has the potential to effect 100% of the patients served by the CAH.

Findings include:

1. The document titled, "Subject: JOB DESCRIPTION REGISTERED PHARMACIST" was reviewed. It indicated under, "DUTIES AND RESPONSIBILITIES: Responsibilities and duties for the Registered Pharmacist on duty are as follows: ...Removing outdated medications from all medication storage sites, i.e. pharmacy, surgery, crash carts, emergency room... and radiology."

2. The policy and procedure titled, "Beyond Use Dated Medication" (revised 8/2009) was reviewed. It indicated under, "POLICY/PROCEDURE: To ensure timely removal from patient use areas, items that are within 60 days of their beyond-use-date may be removed from patient use areas and stored in appropriate non-patient use/beyond-use-dated areas."

3. The policy and procedure titled, "Storage of Medication on Nursing Unit" (revised 7/2009) was reviewed. It indicated under, "PROCEDURE: The pharmacy staff shall make monthly inspections of all storage areas to assure compliance....Outdated medication found at the nursing station shall be returned to pharmacy...."

4. During a tour of the Pharmacy, conducted on 4/19/12 at 11:30 AM, it was observed in the hood room there was a sterile dose of Vancomycin, 1 gram, expired 3/1/12. In the ED, in room 1, there were 3 culture swabs, all expired 6/11 and 1 arterial blood sampling kit, expired 3/12. In the MRI Emergency Box, all of the following medications expired between 2/1/10 and 4/11: Nitrostat 0.4 mg bottle, 2 Epinephrine 1:10,000, 2 Lidocaine 100 mg, 1- Diphenhydramine 50 mg/ml, 2 Dexamethasone 4 mg/ml, 2 Ephedrine Sulfate 50 mg/ml, 1 - 0.9% Sodium Chloride 20 ml vial, 2 SoluCortif 100 mg, 2 Diazepam injectables 10 mg/2 ml, 2 Diphenhydramine 25 mg PO, 2 Atropine Sulfate 1 mg, 1 Calcium Gluconate 10 mg, 1 Sodium Bicarb 50 ml ampule, 1 Dopamine HCl 250 ml, 1 Aminophylline 500 mg. (The pharmacy was contacted by the Radiology staff and verbalized they were not aware of the existence of this box and had not been checking it.) In the Clinic it was observed that 7 of 7 Ecolab QuikCare waterless antimicrobial hand foams all expired 12/11. In Surgery Pre-Op room 1 the Ecolab hand sanitizer expired 2/11 and in Pre-Op room 2 the Ecolab hand sanitizer expired 2/10. In the surgical suite there were 2 ET - Tube Introducers, both expired 3/11.

5. During an interview with the DON, conducted on 4/19/12 at 3:20 PM, the above findings were confirmed.

C. Based on medical record review and staff interview, it was determined in 1 of 20 (Pt #7) medical records reviewed, the CAH failed to ensure medication and/or IV orders were clarified by pharmacy and/or nursing prior to implementation.

Findings include:

1. The medical record of Pt #7 was reviewed on 4/18/12. Pt #7 was admitted to the CAH on 9/6/11 with the diagnosis Acute DVT. On 9/6/11, there was an order "Dextrose 5% with 0.45% NS at 60 mg/ hour." There was no documentation to indicate this order was clarified by pharmacy and/or nursing. There was no time as to when the order was written. On 9/6/11 at 7:25 PM, there was a physician order "Hold Heparin for one hour and then restart at 400 ml/hr. Continue heparin at 400 ml/hr..." There was no documentation to indicate the physician was contacted to clarify the order by the pharmacist and/or nursing.

2. During a staff interview, conducted with the Pharmacist, the CEO, and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of CAH policies, observation, and staff interview, it was determined the CAH failed to ensure documentation of endoscopic scope usage and sterilization. This has the potential to effect all patients who require endoscopic services of which the CAH averages 21 scopes/month.

Findings include:

1. The policy titled "Infection Control Program Policy" (revised 7/15/05) was reviewed on 4/19/12. It indicated "Objectives... Monitoring procedures relating to .... including sterilization and disinfection procedures..."

2. The CAH policy titled "Cleaning and Disinfection of Endoscopes" (Revised 5/30/07) was reviewed on 4/18/12. It indicated "Pre-Cleaning... Leak Testing... Final Drying.." There was no documentation to indicate these processes were followed.

3. During a tour of the Surgical Suite, conducted on 4/18/12 at 1:30 PM, the scope cleaning area was observed. 2 Colonoscopes and 2 EGD scopes were observed in the Endoscope storage cabinet. It was verbalized by the Director of Surgery that no logs were maintained to monitor scope usage and/or cleaning and disinfection.

4. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

B. Based on observation, a review of CAH policy, a review of 3 sink instructions, and staff interview, it was determined the CAH failed to ensure dishwasher disinfection was monitored and recorded, as per CAH policy. This has the potential to effect 100% of the patients serviced by the CAH.

Findings include:

1. During a tour of the Dietary department, conducted on 4/17/12 at 10:30 AM, the Pro Quat test strips for the 3 compartment sink testing were observed to be outdated 2/11. The new bottle of strips, obtained by dietary staff, were also expired 2/12. There was no documentation to indicate the 3 compartment sink testing was being performed.

2. The policy titled "Infection Control Program Policy" (revised 7/15/05) was reviewed on 4/19/12. It indicated "Objectives... Monitoring procedures relating to ....food sanitation..."

3. The policy titled "Dishroom" (revised 3/08) was reviewed on 4/17/12. It indicated "Sink #3 is for sanitizing.... One minute immersion in chemical sanitizing solution." The "Third Sink Cleaning and Sanitizing" instructions posted over the 3 compartment sink area indicated "5. Immerse items in prepared solution... Note: Test prepared sanitizer solution using appropriate test strips after each water change and record results."

4. During a staff interview, conducted with the CEO and DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of job descriptions, clinical record review, and staff interview, it was determined that in 2 of 4 (Pts #13, #16) medical records reviewed for dietary involvement, the CAH failed to ensure there was a process established and implemented to ensure nutritional screenings were done on all patients and those screenings led to nutritional assessments by the RD, if necessary.

Findings include:

1. The document titled, "JOB DESCRIPTION: Registered Dietitian" was reviewed. It indicated under, "RESPONSIBILITIES: 1) Plan, direct, and evaluate food services for patients according to physician's diet orders and meeting current nutritional guidelines contained in the RDA Food and Nutrition Board, when medically appropriate....7) Interview patients regarding food habits and collect dietary histories. To use on nutritional assessment forms."

2. The document titled, "JOB DESCRIPTION: Dietary Manager" was reviewed. It indicated under, "PATIENT CARE RESPONSIBILITIES: Acute Care: Complete nutritional screening according to policy and procedure."

3. The medical record of Pt #13 was reviewed on 4/18/12. It indicated that Pt #13 was admitted on 4/17/12 with diagnoses of Fall/Pain Left Hip. There was no documentation that indicated Pt #13 received a nutritional screen or nutritional assessment.

4. The medical record of Pt #16 was reviewed on 4/18/12. It indicated Pt #16 was admitted on 4/17/12 with a diagnosis of Cholelithiasis. There was no documentation in the record that indicated Pt #16 received a nutritional screen or nutritional assessment.

5. During an interview with the RD and the DON, conducted on 4/18/12 at 2:45 PM, the above findings were confirmed.

A. Based on a review of CAH policy and procedure, medical record review, observation, and staff interview, it was determined that in 2 of 2 (Pts #11, #13) medical records reviewed in which the patient had a known or suspected communicable disease, the CAH failed to ensure isolation precautions were initiated, as per CAH policy.

Findings include:

1. The policy and procedure titled, "EMPIRIC ISOLATION" (effective 9/12/2007) was reviewed. It indicated under, "POLICY Patients with suspected infectious processes will be placed in isolation appropriate for their symptoms by the ICN or their designee... without a physician's order."

2. The medical record of Pt #11 was reviewed on 4/18/12. It indicated Pt #11 was admitted on 3/24/11 with diagnoses of Aspiration Pneumonia and Respiratory Failure. Nursing documentation on the "Initial Physical Assessment", dated 3/24/11 at 3:00 PM indicated Pt #11 had "VRE in stool since 2007." There was no documentation in the record that indicated Pt #11 was ever placed into isolation.

3. The medical record of Pt #13 was reviewed on 4/18/12. It indicated Pt #13 was admitted on 4/17/12 with a diagnosis of Fall/Pain Left Hip. A physician's order, dated 4/17/12 was for the patient to be tested for C-Difficile. There was no documentation that indicated Pt #13 was placed in isolation pending the results of the test.

4. During a tour of the medical/surgical unit, conducted on 4/18/12 at 9:45 AM, it was observed that there was no protective equipment at or near the door of Pt #13's room.

5. During an interview with the ICN, conducted on 4/19/12 at 2:15 PM, it was verbalized that the ICN was unaware of the situation with Pt #13 and that Pt #13 should have been placed in isolation pending the results of the C-Difficile culture.

6. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 4 of 20 (Pts #4, #8, #9, #12) medical records reviewed, the CAH failed to ensure care was provided in accordance with physician orders.

Findings include:

1. The medical record of Pt #4 was reviewed on 4/18/12. Pt #4 was admitted to the CAH on 2/17/12 with the diagnosis Myleofibosis for an OP blood transfusion. On 1/19/12, the physician order for the transfusion indicated "If Hemoglobin < 7.5, transfuse 2 units." The order failed to indicate 2 units of what was to be infused. There was no documentation to indicate the physician was contacted to clarify the order.

2. The medical record of Pt #8 was reviewed on 4/18/12. Pt #8 was admitted to the CAH on 9/10/11 with the diagnosis New Onset Diabetes. On 9/10/11 at 2:30 PM, nursing documentation indicated "Wound cleansed with NS, dressing changed." There was no physician order for wound cleansing and/or dressing. There was no documentation to indicate what kind of dressing was applied. On 9/11/11 at 11:10 PM, there was a physician order "Zofran 4 mg IV every 6 hours as needed." On 9/13/11, nursing documentation indicated Zofran 4 mg was given IV at 9:50 AM and 1:02 PM, which was only 3 hours and 12 minutes apart.

3. The medical record of Pt #9 was reviewed on 4/18/12. Pt #9 was admitted to the CAH on 10/10/11 with the diagnosis CHF Exacerbation. On 10/11/11 at 9:15 AM, nursing documentation indicated "POx 97% with O2 at 5 liters/ NC. Okay with Dr. to wean O2 patient uses 2 liters/NC at home 24 hours per day. O2 decreased to 4 liters/NC." It further indicated Pt #9's O2 was further decreased to 3L/NC. There was no physician order written for the O2 to be weaned and/or what parameters to use.

4. The medical record of Pt #12 was reviewed on 4/18/12. Pt #12 was admitted to the CAH on 7/19/11 with the diagnosis Pneumonia. On 7/19/11 at 4:30 PM, nursing documentation indicated "Inserted Foley catheter 16 French. Urinalysis obtained in ER..." There was no documentation to indicate an order for the Foley catheter.

5. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

B. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 1 of 1 (Pt #10) medical records reviewed, in which the patient underwent surgical intervention and was under the age of 55, the CAH failed to ensure urine pregnancy testing was performed prior to surgery, as per CAH policy.

Findings include:

1. The CAH policy titled "Preoperative Tests for Inpatients" (effective 6/1/07) was reviewed on 4/19/12. It indicated "It is the policy... for all inpatients undergoing surgery with any type of anesthesia except local... Urine pregnancy tests for female patients ages 10 to 55 unless there is a previous history of tubal ligation or hysterectomy."

2. The medical record of Pt #10 was reviewed on 4/18/12. Pt #10 was admitted to the CAH on 3/9/12 with the diagnosis Screening Follow Up Barretts and underwent EGD and Colonoscopy. There was no documentation to indicate Pt #10 was postmenopausal and/or had had a sterilization procedure in the past. There was no documentation to indicate a pregnancy test was performed.

3. During a staff interview, conducted with the Director of Surgery on 4/19/12 at 2:45 PM, it was confirmed that a urine pregnancy test should have been performed.

4. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of the CAH's Medical Staff Rules/Regulations, policy and procedure, medical record review, and staff interview, it was determined that in 1 of 20 (Pt # 20) medical records reviewed, the CAH failed to ensure a H&P was written or dictated during the first 24 hours of admission, as per CAH Rules and Regulations.

Findings include:

1. The CAH's Medical Staff Rules/Regulations were reviewed. They indicated under, "9. A complete history and physical examination shall in all cases be written or dictated during the first 24 hours of admission."

2. The CAH policy and procedure titled, "Medical Record Content", with a revised date of 1/1/06, was reviewed. It indicated under "PROCEDURE: The history and physical examination is recorded in the medical record at the time of the patient's admission...."

3. The medical record of Pt #20 was reviewed on 4/19/12. It indicated Pt #20 was admitted on 3/19/12 with diagnoses of CHF and Exacerbation of COPD. Pt #20 was discharged on 3/23/12. Documentation indicated that the H&P was dictated on 4/1/12 and transcribed on 4/2/12, 10 days after the patient was discharged.

4. During an interview with the DON, conducted on 4/19/12 at 2:10 PM, the above findings were confirmed.

A. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 6 of 20 (Pts #7, #8, #9, #10, #11, #12) medical records reviewed, the CAH failed to ensure all entries in the medical record were timed.

Findings include:

1. The CAH policies titled "Inpatient (Medical Surgical and Observation) Physician Orders" (revised 10/20/12 and 2/15/12) were reviewed on 4/18/12. Both indicated "All orders for medications/ treatments shall include the date and time of the order..."

2. The medical record of Pt #7 was reviewed on 4/18/12. Pt #7 was admitted to the CAH on 9/6/11 with the diagnosis Acute DVT. On 9/6/11, there was a physician order "Electrocardiogram..." and on 9/7/11, there were 2 physician orders, all with no documentation as to the time they were written.

3. The medical record of Pt #8 was reviewed on 4/18/12. Pt #8 was admitted to the CAH on 9/10/11 with the diagnosis New Onset Diabetes. The physician progress notes for 9/11, 9/12, and 9/13/11 failed to include the time as to when they were completed. On 9/11/11, there was a physician order for "CT of head..." and on 9/13/11, there was a physician order "Zofran... Prilosec..." There was no documentation to indicate the time as to when these orders were written.

4. The medical record of Pt #9 was reviewed on 4/18/12. Pt #9 was admitted to the CAH on 10/10/11 with the diagnosis CHF Exacerbation. The physician progress notes on 10/11 and 10/12/11 and 2 physician orders written on 10/10/11 failed to include the time as to when they were written.

5. The medical record of Pt #10 was reviewed on 4/18/12. Pt #10 was admitted to the CAH on 3/9/12 with the diagnosis Screening Follow Up Barretts and underwent EGD and Colonoscopy that day as an outpatient. The "History and Physical Examination for Day Surgery" failed to indicate the time as to when the physician completed the physical examination.

6. The medical record of Pt #11 was reviewed on 4/18/12. Pt #11 was admitted to the CAH on 3/24/11 with the diagnosis Aspiration Pneumonia. On 3/24/11, the admission orders failed to indicate the time it was written. There were 2 orders, "Add Morphine 1-2 mg..." and "Do Not Resuscitate- No Intubation" with no date or time as to when they were written. On 3/25/11, there was a physician progress note "called to see patient..." There was no documentation to indicate the time of the visit.

7. The medical record of Pt #12 was reviewed on 4/18/12. Pt #12 was admitted to the CAH on 7/19/11 with the diagnosis Pneumonia. The physician progress note for 9/20/11 and a physician order "Discontinue IV fluids..." both failed to include the time as to when they were written.

8. During a staff interview, conducted with the DON and the CEO on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of Medical Staff Bylaws, a review of Director of Surgery credential file, and staff interview, it was determined in 1 of 1 (P-1) physician credential file reviewed, in which the physician performed surgery in the CAH, the CAH failed to ensure the Surgeon's privileges were updated and maintained in respect to current surgical services being provided. This has the potential to effect all patients who require or could potentially require surgical services within the CAH.

Findings include:

1. The Medical Staff Bylaws were reviewed on 4/19/12. It indicated "Article VI. Clinical Privileges: A. Every practitioner practicing at this hospital by virtue of medical staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him by the governing body... Applications for additional clinical privileges must be in writing..."

2. The credential file of P-1 was reviewed on 4/19/12. P-1 was reappointed to the Medical Staff on 3/1/11. On 4/18/12, P-1 performed 2 surgical procedures, both Laparoscopic Cholecystectomies that progressed to Open Cholecystectomies. There was no documentation to indicate P-1 had been granted the privilege of performing Laparoscopic Cholecystectomies.

3. During a staff interview, conducted with the CEO and DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

B. Based on a review of Medical Staff Bylaws, a review of Director of Surgery credential file, and staff interview, it was determined in 1 of 1 (P-1) physician credential file reviewed, in which the physician performed supervision of the CRNA, the CAH failed to ensure the Surgeon's privileges included the privilege to supervise the services of the CRNA, inclusive of the type and complexity of procedures they may supervise. This has the potential to effect all patients who require or could potentially require anesthesia services within the CAH.

Findings include:

1. The Medical Staff Bylaws were reviewed on 4/19/12. It indicated "Article VI. Clinical Privileges: A. Every practitioner practicing at this hospital by virtue of medical staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him by the governing body... Applications for additional clinical privileges must be in writing..."

2. The credential file of P-1 was reviewed on 4/19/12. P-1 was reappointed to the Medical Staff on 3/1/11. The CAH anesthesia services are provided by a CRNA. There was no documentation to indicate P-1 had been granted the privilege of supervising the anesthesia services provided by the CRNA, inclusive of the type and complexity of procedures they may supervise.

3. During a staff interview, conducted with the CEO and DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of Medical Staff Bylaws, a review of CRNA credential file, and staff interview, it was determined in 1 of 1 CRNA, the CAH failed to ensure it designated CRNA privileges were initiated, updated, and maintained in respect to current services being provided by the CRNA.

Findings include:

1. The Medical Staff Bylaws were reviewed on 4/19/12. It indicated "Article VI. Clinical Privileges: A. Every practitioner practicing at this hospital by virtue of medical staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him by the governing body... Applications for additional clinical privileges must be in writing..."

2. The credential file of CRNA-1 was reviewed on 4/19/12. CRNA-1 was reappointed to the Medical Staff on 3/1/11 to provide anesthesia services. There was no documentation of a privilege list to indicate what anesthesia services CRNA-1 was privileged to provide.

3. During a staff interview, conducted with the CEO and DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of CAH policy, a review of CAH Annual Program Evaluation, a review of Quarterly Departmental Quality Report Summaries, a review of P&T committee meeting minutes, observation and staff interview, it was determined the CAH failed to ensure its Annual Program Evaluation included a representative sample of both active and closed clinical records, a QA program in which a process for evaluation, implementation of corrective action, and ongoing monitoring to assure compliance with CAH policies and processes, and physician review, conducted by an outside review organization was established, implemented, and maintained. The cumulative effect of these systemic practices has the potential to effect 100% of the patients serviced by the CAH.

Findings include:

1. Failed to ensure its Annual Evaluation included a review of a representative sample of both active and closed clinical records. Please see deficiency cited at C333.

2. Failed to ensure its QA program included a ongoing monitoring and evaluation to assure compliance and/or continued compliance with new and/or corrective actions. Please see deficiency cited at C336.

3. Failed to ensure there was an evaluation of the pharmacy services. Please see deficiency cited at C338.

4. Failed to ensure it's QA program included a physician review by an outside review organization to determine that the Medical Staff provided quality treatment and appropriate diagnoses to the patients served by the CAH. Please see deficiency cited at C340.

A. Based on a review of CAH policy, a review of CAH Annual Program Evaluation, a review of Quarterly Departmental Quality Report Summaries, and staff interview, it was determined the CAH failed to ensure its Annual Evaluation included a review of a representative sample of both active and closed clinical records. This has the potential to effect 100% of the CAH patients.

Findings include:

1. The CAH policy titled "Critical Access Program Evaluation" (Effective 2/2004) and (Revised 6/8/2011) were reviewed on 4/20/12. Both indicated "... will be evaluated annually..." It failed to include an evaluation of a representative sample of both active and closed clinical records.

2. The CAH Annual Program Evaluations for 2010 and 2011 were reviewed on 4/19/12. There was no documentation to indicate inclusion of a review of a representative sample of both active and closed clinical records.

3. The Quarterly Departmental Quality Report Summaries for 2011 were reviewed on 4/19/12. There was no documentation to indicate the review included a representative sample of both active and closed clinical records.

4. During a staff interview, conducted with the Safety Director (QA nurse) and the DON on 4/19/12 at 3:30 PM, it was verbalized that there is no documentation to indicate what chart reviews are open and/or closed.

5. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of Quarterly Departmental Quality Report Summaries and staff interview, it was determined the CAH failed to ensure its QA program included a ongoing monitoring and evaluation to assure compliance and/or continued compliance with new and/or corrective actions. This has the potential to effect 100% of the IP and OP patients serviced by the CAH.

Findings include:

1. The Quarterly Departmental Quality Report Summaries for 2011 were reviewed on 4/19/12. There was no documentation to indicate ongoing monitoring and evaluation to assure continued compliance with corrective actions.

2. During a staff interview, conducted with the Safety Director (the QA nurse) and the DON on 4/19/12 at 3:30 PM, it was verbalized that the departments do QA on concerns that arise and we do the Hospital Compare items. Everything does get reported to the Safety Committee, to the physicians thru the QA Committee, and to the Governing Body thru the Quarterly reports.

3. Example: The 1st, 2nd and 3rd Quarterly Departmental Quality Report Summaries were reviewed on 4/19/12. The 1st Quarter Summary indicated "Therapy Services: Pain Scale: ... Will be restudied in 6 months." The 3rd Quarter Summary failed to include a follow up of this report.

Example: The 1st Quarter Summary indicated "ED, M/S, Nursing... Family Physician or ED/Hospitalist... To provide standard guidelines for... a list developed on how and when to contact them. Policies and procedures were created and approved..." There was no documentation to indicate how these were to be monitored to ensure initial and/or ongoing compliance with the changes. There was no documentation on the 2nd or 3rd Quarter reports to indicate any follow up on these changes.

Example: The 1st Quarter Summary indicated "Infection Control, Pt Registration Safety: Registration of Pts with Known Contact Isolation Status: Pt being registered that have a notification flag of a contact isolation precaution will be identified at the time of registration..." There was no documentation to indicate how these were to be monitored to ensure initial and/or ongoing compliance with the changes. There was no documentation on the 2nd or 3rd Quarter reports to indicate any follow up on these changes.

Example: The 2nd Quarter Summary indicated "...Hospital... Holter Monitor Lease; Holter Monitor Interpretations: This quarter there was a delay receiving confirmed Holter Monitor reports and Holter Monitor kits." There was no documentation to indicate how these concerns were addressed and/or to be monitored to ensure correction, resolutions, and ongoing resolution of the concern. There was no documentation on the 3rd Quarter Summary report related to this concern.

4. During a staff interview, conducted with the ICN on 4/19/12 at 2:45 PM, it was verbalized that the IC committee meets quarterly and reviews any information that is submitted. The results do not go to QA.

5. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of Hospital P&T committee meeting minutes, Quarterly Departmental Quality Report Summaries, observation, and staff interview, it was determined that the CAH failed to ensure there was an evaluation of the pharmacy services by the pharmacy department.

Findings include:

1. The P&T committee meeting minutes for 2011 and the 1st quarter of 2012 were reviewed. The P&T committee meeting dated 4/8/11 indicated, "The need to write a policy about administration of potassium riders was discussed....but it should be clarified in a policy....As pharmacy dosing aminoglycosides is now the norm, we need to develop an internal pharmacy standard protocol to limit the variability of dosing between pharmacists....The need to write a policy on Omeprazole and Plavix concurrent therapy was discussed. Current guidelines seem to be conflicting, so we need more research and a clear policy for our facility..." The P&T committee meeting minutes for 11/14/11 indicated, "III. Look alike medication names a. Reviewed current policy - needs expansion." There was no documentation that indicated any of the policies suggested by the P&T committee were ever developed, submitted to the medical staff, or put into practice.

2. The "Quarterly Departmental Quality Report Summaries" for 1st QTR MAR, APR, May 2011 were reviewed. There was no documentation that indicated pharmacy participated in the quality evaluation.

3. During a tour of Radiology, an MRI Emergency Box was noted with the following medications expired between 2/1/10 and 4/11: Nitrostat 0.4 mg bottle, 2 Epinephrine 1:10,000, 2 Lidocaine 100 mg, 1- Diphenhydramine 50 mg/ml, 2 Dexamethasone 4 mg/ml, 2 Ephedrine Sulfate 50 mg/ml, 1 - 0.9% Sodium Chloride 20 ml vial, 2 SoluCortif 100 mg, 2 Diazepam injectables 10 mg/2 ml, 2 Diphenhydramine 25 mg PO, 2 Atropine Sulfate 1 mg, 1 Calcium Gluconate 10 mg, 1 Sodium Bicarb 50 ml ampule, 1 Dopamine HCl 250 ml, 1 Aminophylline 500 mg. (The pharmacy was contacted by the Radiology staff and verbalized they were not aware of the existence of this box and had not been checking it.)

4. During an interview with the lead pharmacist, conducted on 4/17/12 at 11:20 AM, he could not verbalize, nor produce, any statistics related to medication errors in the CAH. Upon further questioning, it was verbalized that the Pharmacy did not gather any statistics used to evaluate it's performance within the CAH. Instead, quality personnel gather the data and send it to Pharmacy. When asked what the medication error rate for the last quarter reported was, it could not be verbalized nor was any documentation produced that indicated the information.

5. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.

A. Based on a review of PA credential file and staff interview, it was determined the CAH failed to evaluate the services provided by 1 of 1 PA.

Findings include:

1. The PA credential file was reviewed on 4/19/12. The PA is the only PA that provides services in the CAH. On 3/1/11, the PA was recredentialled by the CAH. There was no documentation to indicate the PA's services had been evaluated.

2. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above finding was confirmed.

A. Based on a review of QA program and staff interview, it was determined that the CAH failed to ensure it's QA program included a physician review by an outside review organization to determine that the Medical Staff provided quality treatment and appropriate diagnoses to the patients served by the CAH. This has the potential to effect 100% of the patients served by the CAH.

Findings include:

1. The QA program was reviewed on 4/19/12. There was no documentation to indicate the CAH had included a physician review, conducted by an outside review organization to determine the Medical Staff provided quality treatment and appropriate diagnoses to the patients served by the CAH.

2. During a staff interview, conducted with the CEO on 4/18/12 at 10:00 AM, it was verbalized that the CAH is a member of ICAN; however, they have not sent any medical records out for review.

3. During a staff interview, conducted with the CEO and the DON on 4/20/12 at 2:00 PM, the above findings were confirmed.