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Based on observation, policy review, and staff interviews, the Critical Access Hospital (CAH) maintenance staff failed to perform preventative maintenance checks on 25 of its 25 patient hospital beds. The CAH had a census of 18 inpatients.

Failure to perform routine preventive maintenance checks on all of the hospital's beds places all patients at risk from harm due to electrical or mechanical failure.

Findings include:

1. On 9/13/10 at 2:00 PM, observations made during a tour of the medical/surgical unit revealed 8 of 8 hospital beds in the unit had inspection stickers showing the maintenance staff's last preventative maintenance inspection was in August of 2009.

2. During an interview, at the time of the tour, the Chief Nursing Executive acknowledged maintenance staff failed to complete the preventative maintenance checks on the 8 beds in the medical/surgical unit and the potential risks to patients. The Chief Nursing Executive reported the maintenance staff failed to complete the preventative maintenance checks on any of the 25 hospital beds available for patient use.

During an interview, at the time of the tour, Staff E, a member of maintenance staff, reported "None of the preventative maintenance checks are done on any of the hospital beds. We are a month behind on the checks so they are not done and I am doing them right now." Staff E stated that the hospital's maintenance policies and procedures required an inspection of all CAH hospital beds annually.

3. Review of the policy, "General Electrical Safety Inspection," effective date October 2003, revealed in part, "The purpose of the General Electrical Safety Inspection is to provide a method of Electrical Safety for the whole of the Hospital environment. ... These inspections will be conducted annually or biannually depending on the equipment..."

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure that an appropriate external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors of the CAH for 9 of 9 contracted physicians (Physicians G, H, I, J, K, L, M, N, and O). The CAH had a current inpatient census of 18, an average Outpatient Clinic census of 600 patients per month, and an average Emergency Department census of 350 patients per month.

Failure to ensure the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially lead to substandard patient care.

Findings include:

1. Review of CAH policy titled "Medical Staff Ongoing Professional Practice Evaluation and Peer Review," revised August 2009, revealed the following in part. "...The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by-one hospital that is a member of the network when applicable; one QIO or equivalent entity, or one other appropriate and qualified entity identified in the state rural health care plan....Primary medical and mid-level practitioners who provide services within the confines of this facility will have a minimum of one randomly picked closed record per year evaluated by the network facility reviewing physician...."

2. The CAH ' s peer review documentation showed the committee met once monthly. Peer review documentation from September 2008 through September 2010 showed that the Quality and Performance Improvement Coordinator had failed to submit a medical record created by Practitioners G, H, I, J, K, L, M, N, and O for external peer review during the 24-month period.

3. During an interview on 9/15/10 at 11:20 AM, the Quality and Performance Improvement Coordinator and the Chief Nursing Executive both reported that they were not currently doing external peer review on any of the contracted physicians that provided care to patients of the CAH. They defined "primary medical and mid-level practitioners" as employees of the CAH that provided services to patients within the confines of the CAH. According to the Quality and Performance Improvement Coordinator and the Chief Nursing Executive, the CAH did not employ the contracted teleradiologists and emergency room physicians and these physicians were not included in the external peer review process. The contracted teleradiologists and emergency room physicians provided services to CAH inpatients, as well as, outpatients in the emergency room and clinic. Neither the CAH's policies nor bylaws for their credentialing process or their quality improvement activities required an external peer review for contracted physicians.

4. Consequently, the medical staff and governing body lacked potentially critical information regarding the quality and appropriateness of the diagnosis and treatment furnished to patients of the CAH by the contracted doctors, when considering each contracted physician for reappointment.