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Based on policy review, personnel record review and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure 3 of 13 employees, selected for review, received the mandatory 2 hour dependent adult abuse training within six months of their hire date (Housekeeping Staff C, Dietary Staff D and Dietary Manager). Failure to ensure all staff attending CAH patients, receive dependent adult abuse training, may result in failure to report potential abusive situations placing patients at risk for neglect, exploitation and physical, emotional and sexual abuse.

Findings include:

Review of a CAH policy, "Mandatory Reporting Training", approved 4/2022, revealed in part "...Mandatory reporters are required by law to complete two hours each of child and/or dependent adult abuse training during their first six months of employment and recertify every three years thereafter ... a mandatory reporter whose work involves the examination, attending, counseling, or treatment of adults or children on a regular basis shall ... shall complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment ... complete two hours of training relating to the identification and reporting of child abuse within six months of initial employment ... All employees working in Mandatory Reporter positions must complete training within three months of orientation and recertify within every three year period ...".

Review of Housekeeping Staff C's personnel file revealed a hire date of 10/18/21 and the file lacked documentation the employee completed the required 2 hour mandatory reporter training for children and dependent adults.

Review of Dietary Staff D's personnel file revealed a hire date of 1/24/22 and the file lacked documentation the employee completed the required 2 hour mandatory reporter training for children and dependent adults.

Review of the Dietary Manager's personnel file revealed a hire date of 6/8/19 and the file lacked documentation the employee completed the required 2 hour mandatory reporter training for children and dependent adults.

During an interview on 8/3/22, at 4:15 PM, the Human Resources Manager and Chief Financial Officer acknowledged the CAH has not required housekeeping and dietary staff to completed mandatory reporter training and confirmed Housekeeping Staff C, Dietary Staff D and the Dietary Manager have not completed the required 2 hour dependent adult and 2 hour child abuse mandatory reporter training.











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The State Agency (SA) conducted an unannounced, on-site recertification survey from 8/1/22 to 8/4/22. The survey team determined the Critical Access Hospital was operating in substantial compliance with the Conditions of Participation at the time of the survey. The survey team did identified the following standard level deficiencies.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) Board of Trustees failed to ensure 1 of 4 Affiliate Medical Staff (Physician Assistant A) and 1 of 5 Consulting Medical Staff (Radiologist B), selected for review, held approved privileges prior to providing care to CAH patients. Failure to ensure Physician Assistant (PA) A and Radiologist B had approved delineated privileges patient care could potentially result in PA A and Radiologist B providing care to CAH patients they lacked competency and skill to safely perform and result in a practitioner providing care beyond their capabilities and compromise safety of CAH patients.

The CAH administrative staff identified medical staff provided care to patients from 7/1/21 to 6/30/22 as follows:

PA A - 682 emergency room patients
Radiologist B - 2038 imaging interpretations

Findings include:

1. Review of the CAH Board of Trustees by-laws, adopted on 3/30/22, revealed in part "... The Board of Trustees shall appoint a Medical Staff comprised of physicians and other practitioners who are authorized by law and by the Board to exercise clinical privileges and render patient care services at the Hospital. The Board shall approve, on the recommendation of the Medical Staff, separate Medical Staff Bylaws, Rules and Regulations which shall outline the nature and purpose of the Medical Staff, the qualifications for membership, the responsibilities of individual Medical Staff members, the procedures and criteria for appointment, reappointment, limitation, and termination of membership or privileges, the organization and operation of the Medical Staff ...".

2. Review of the CAH Medical Staff by-laws, approved 8/12/21 revealed in part "... Privileges to practice at the Hospital are granted by the Board following recommendation of the Medical Staff ... Affiliate privileges are clinical privileges at the Hospital granted to qualified non-physician Practitioners who meet the qualification for clinical privileges ... Affiliate privileges authorize the Practitioner to provide independent clinical services to patients ... A practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws ...".

3. Review of a list of the CAH's employed personnel identified PA A as an Emergency Services provider and the CAH's Medical Staff Roster identified Radiologist B as a member of the Consulting Medical Staff.

4. Review of PA A's credential file revealed a Family Medicine delineated privilege list approved by the Board of Trustees on 1/27/21 and effective 1/28/21 to 1/27/23. The credential file lacked Emergency Medicine privileges. The credential file also failed to include Emergency Medicine Privileges for the previous credential cycle from 5/1/19 to 4/30/21.

Based on observation, document review, and interviews, the Critical Access Hospital's (CAH) administrative staff failed to ensure the surgery staff changed the sterile water flush bottles after endoscopic procedures for each patient, in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacterial growing in the sterile water and potentially causing an infection in the next patient. The hospital's administrative staff identified a total of 190 patients that had an endoscopic procedure within the fiscal year of July 2021 to June 2022.

Findings include:

1. Observations during a demonstration of an endoscopic cleaning in the surgery department on 8/4/2022 at approximately 8:30 AM with the Registered Nurse (RN) Manager of the Surgery Department revealed 1 of 1 bottle Baxter 1000 milliliter (mL) bottle of sterile water for irrigation connected to the endoscope equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract) was not changed prior to the next endoscopic procedure.

2. Review of the manufacturer's instructions indicated in part... "The contents of the opened container should be used immediately to minimize potential for bacterial growth and pyrogen formation, and the unused contents of opened containers must be discarded, since Sterile Water for Irrigation, USP does not contain an antimicrobial agent." "Sterile Water for Irrigation, USP is for single use only."

3. During an interview on 8/4/2022, at approximately 8:30 AM, with the RN Manager of the Surgery Department, acknowledged the surgery staff opened the bottles of sterile water for irrigation each day for scheduled endoscopic procedures, and connected it to the equipment. The equipment contains a one-way valve to prevent backflow between patients, to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscopic procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscope procedures. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscope procedures for the day or if the bottle ran empty.

Based on review of policy/procedure and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure a freedom of abuse, neglect, and exploitation policy was created that would contained the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency) for swing bed patients. The CAH administrative staff identified 95 skilled patients with the fiscal year of July 2021 to June 2022. Failure have a policy that included the required language and guidance could potentially prevent CAH staff from reporting alleged violations involving abuse to the CAH administrator and to other officials (including to the State Agency) in a timely manner.

Findings include:

1. Review of the CAH's policies reveal there was no policy that reflected the required language of the freedom from abuse, neglect, misappropriation of residence property, and exploitation, which is the residence right as defined by the regulations. This would include but not limited to corporal punishment, involuntary seclusion, physical or chemical restraints not required to treat the resident's medical symptoms. The facilities response to allegations of abuse, reporting procedures, timeliness, and investigative evidence.

2. During an interview on 8/8/2022 at 4:00 PM with the Quality staff member acknowledged the lack of an abuse policy which would reflect the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency). The Quality staff member verify with Administrative Assistant F that no other CAH policy existed that would contain this regulatory language.