HospitalInspections.org

Based on review of policies and procedures, review of Medical Staff Bylaws, review of Medical Staff meeting minutes, review of Governing Board meeting minutes, review of nursing staff schedules, and staff interview, the CAH (Critical Access Hospital) failed to ensure the Governing Board approved changes to the Medical Staff Bylaws that were approved by the Medical Staff that allowed EMT-Paramedics (Emergency Medical Technician-Paramedics) to perform emergency medical screening in the Emergency Department. The CAH's list of employees contained 2 EMT-Paramedics. The Emergency Department provided services to 3364 patients in 2012. On the first day of survey patient census was 7 acute inpatients, 3 skilled inpatients and 1 newborn. This failed practice has the potential to affect all patients seen in the emergency department.

Findings are:

A. Review of the nursing staff schedule for January and February 2013 revealed EMT - Paramedic-A was listed on the schedule and worked 1 day in the emergency room - 1/7/13. The person scheduled in the emergency room would potentially perform the emergency medical screen and report this information to the PA (physician assistant) and or physician.

Review of the policy and procedure titled Paramedics - Scope of Practice (approved and effective date of 8/9/12) revealed the purpose of the policy was "To define scope of practice and/or authority for all Paramedics practicing at Sidney Regional Medical Center." Review of a second policy titled Paramedic (Revised date 1/2013) revealed the following: "It shall be the policy of Sidney Regional Medical Center (SRMC) to allow an Emergency Medical Technician-Paramedic (EMT-P) to perform all qualified practices and procedures defined within the State of Nebraska Department of Health and Human Services Statutes, Rules and Regulations relating to Emergency Medical Services as defined in Title 172 Nebraska Administrative Code (NAC) 12 in acute care nursing areas, including the emergency department and critical care unit." This policy went on to describe this procedure: "An Emergency Medical Technician-Paramedic (EMT-P), while functioning with an advanced life support emergency medical service, may perform all of the practices and procedures of 172 NAC 11-006.04 (pages 24 - 29) as approved by Sidney Regional Medica [SIC] Medical Center Medical Staff."

B. Review of the Medical Staff meeting minutes for 7/17/12 revealed the following:

"[Name of Vice President Patient Care Services] requested that the Medical Staff Rules and Regulations change under Medical Staff Rules and Regulations, Section 3, Paragraph 4 'Qualified Medical Personnel'. The Medical Staff was asked to approve adding Paramedics as qualified medical personnel to perform the initial medical screening assessment.

It was moved and seconded to approve changing the Rules and Regulations to add Paramedics as qualified medical personnel. Motion carried."

On 2/28/12 at 11:30 PM the Vice President of Patient Care Services provided a one-page document with Medical Staff Rules and Regulations in the upper right hand corner and at the bottom right hand corner was the date July 2012 with the following documentation: "A medical screening/assessment shall be performed by a physician, physician assistant, registered nurse or paramedic qualified in emergency room care." However, the copy of the Medical Staff Bylaws Rules and Regulations that was provided to the surveyor as requested during the entrance conference on 2/26/13 from 12:00 Noon to 12:20 PM (Mountain Time) had a revised date of June 2011 with the following documentation "A medical screening/assessment shall be performed by a physician, physician assistant, or registered nurse qualified in emergency room care."

C. Review of the Board of Directors meeting minutes dated 7/24/12 revealed no documentation that the Medical Staff Rules and Regulation changes approved by the Medical Staff on 7/17/12 were approved by the Governing Board.

D. Interview with the CEO (Chief Executive Officer) on 2/28/13 at 2:45 PM confirmed there was no documentation to reflect that the Governing Body had approved this change in the Medical Staff Bylaws.

Based on review of the computerized index for policies and procedures, and staff interview, the CAH (Critical Access Hospital) failed to ensure that the group of professionals developed 1 of the 9 required types of policies and procedures (Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral).

On the first day of survey, patient census was 7 acute inpatients, 3 skilled inpatients and 1 newborn. The Emergency Department provided services to 3364s patient in 2012. This failed practice has the potential to affect all patients seen in the CAH.

Findings are:

A. Review of the computerized indexes for all the CAH polices and procedures revealed no listing of policies and procedures for guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral.

B. Telephone interview with the CCO (Corporate Compliance Officer) on 3/5/13 from 11:35 AM to 11:55 AM confirmed the CAH had no policies and procedures guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral.

Based on observation, staff interview and review of policies and procedures, the CAH (Critical Access Hospital) failed to ensure confidentiality of medical record information for outpatients seen in the Rehabilitation Services area. There were 890 outpatients seen in the Rehabilitation Services area in 2012. This failed practice has the potential to affect all outpatients seen in the Rehabilitation Services area.

Findings are:

A. Interview with the Director of Rehabilitation Services on 2/26/13 from 1:40 PM to 2:30 PM revealed the following:
- Therapists keep some paper copies of current outpatient records on their desks which generally includes the initial assessment, any recertification assessment, diagnostic imaging reports, and exercise flow sheets;
- When outpatients are discharged the patient records mentioned above are kept in a file cabinet in the reception office area but the file cabinet is not locked;
- The Rehabilitation Department is locked when staff leave for the day; however, housekeeping staff comes in after hours to clean the area and would have access to the patient records that are left on therapists' desks and also the discharged records kept in the file cabinet in the reception office.

B. Observation of the Rehabilitation Department on 2/26/12 from 1:40 PM to 2:30 PM revealed a door that leads from the rehabilitation therapy area into the reception office/therapist office area that could be locked; however, there was a reception window that has no locking mechanism.

C. Review of the policy and procedure titled Security, Access and Confidentiality of Medical Records (reviewed date of 12/12) revealed the following procedures:
"Medical Records shall be maintained in a secure location at all times...All information contained in a medical record is considered confidential and shall only be accessed by hospital staff with a need to know...."