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Based on observation, interview and record review, the Critical Access Hospital (CAH) failed to provide ongoing preventive maintenance/ safety inspections for 2 Air Vo respiratory medical devices. This failed practice had the potential to affect all patients of the CAH. The CAH had 55 inpatient admissions, 24 swing bed patients and 797 Emergency room visits for the Fiscal year 2022 statistics reported on the facility Annual Program Review.

Findings are:

A.Tour of the facility on 1/24/2023 and 1/25/2023 revealed two (2) AirVo portable units on wheels that were stored - one in the Emergency Room and one in Room 111/ the overflow/treatment room. (The AirVo2 is a humidifier with integrated flow generator that delivers high flow warmed and humidified respiratory gases to spontaneously breathing patients, with or without upper airways bypassed.) The two Air Vo's did not have a blue numerical sticker to identify any responsibility for safety/tracking of the equipment.

B. Interview with facility purchasing Manager on 1/26/2023 at 11:10am revealed that a service contract for the AirVos had not been acquired and that the BioElectronics Company completing safety inspections on other facility Durable Medical equipment had not added these two units to their workload. The facility had no initial calibration/safety inspection records, nor any record of cleaning or changing of filters per manufacturer recommendations.

-Interview with Nurse Manager during Emergency Room tour on 1/25/2023 at 11:30am revealed that the two AirVo units had been acquired sometime in the past couple years during the pandemic to assist with care of respiratory patients.

C. Review on 1/26/2023 at 11:33am of BioElectronics most recent service report of facility equipment service dates and next test due dates, generated on 1/1/2023 revealed that the Two AirVo Units were not listed on the CAH equipment file list.

Based on record review and staff interview, the facility failed to provide re-appointment/credentialing verification for one of (1) of seven (7) Medical Staff as required by medical staff by laws. Facility medical staff roster included 10 credentialed providers on the Active and Ancillary staff and 12 contracted Medical Staff to cover Weekend Emergency (ER) Room Care and hospital admissions and acute care. Facility census was three (3) patients. Physician H contracted for ER care had received temporary privileges on 12/29/2021 for 90 days, however Physician H was on facility service roster for both July, September and December 2022 schedule and provided ER care and also admitted four patients without active privileges. This failed practice had the potential to affect all patients receiving ER and inpatient care.


Findings are:

A. Review of Medical Staff Bylaws on 1/25/2023 at 2:35pm for Pawnee County Memorial Hospital last revised in 2019 noted in Article V (five) Clinical Privileges - Section 1 - A practitioner may exercise only those clinical privileges specifically granted in accordance with these Bylaws. All care rendered in the Hospital must be on the authority of a practitioner privileged to order such care.

-Review of the File provided for Physician H on 1/24/2023 at 10:30am revealed that the CEO (Chief Executive Officer) and the Medical Director (MD) had reviewed and verified credentials and signed temporary privileges on 12/27/2021 for a period of three (3) months beginning 12/31/2021 for Medical staff as a locum tenens (filling a position for a temporary assignment time).

-Review of Inpatient Admissions from 7/1/22 - 1/23/23 revealed Physician H was providing ER care and was also the admitting Physician of record for four (4) patients: with admission dates on 7/24/2022, 7/30/2022, 9/5/2022 and 12/24/2022, during a six month time span without current verification for Medical Staff privileges.

B. Interview with Clinic Manager on 1/24/23 at 10:38am revealed that Physician H did not have a completed full credentialing file processed and only had a file for temporary privileges which expired the end of March 2023.

Based on record reviews and staff interview, the facility failed to assure the policies and procedures of the CAH were reviewed biennially by a group of professional personnel of the facility. This failed practice had the potential to affect all patients of the facility. In the fiscal year of 2022 the facility had 55 inpatient admissions, 24 swing bed admissions, 70 observation admissions and 797 emergency room visits.

Findings are:

A. Record review of the following policies revealed:
Patient Rights effective date 2/19/2020
Admission of Patient review date 2/17/2020
Dental Care review date 2/17/2020
Discharge Planning review date 2/17/2020
Consent for Treatment effective date 3/1/2019
Patient Identification effective date 5/1/2018
Policy and Procedure Development review date 5/2020
Patient Access to Their Medical Record effective date 9/2013
Antibiotic Stewardship effective date 6/7/2020

B. Interview with Case Manager on 1/24/2023 at 9:00 AM confirmed that the policies of the facility were not reviewed biennially and stated "I have a folder on my computer that has the policies I need to review that are dated 2020".

Based on medical record review, review of policy and procedures, and staff interview the facility failed to (A) ensure a qualified practitioner examined 6 of 6 surgical patients (Patients 26, 27, 28, 29, 30 & 31) before surgery to evaluate the risk of anesthesia performed and (B) failed to ensure an anesthesia qualified practitioner evaluated each patient after surgery for proper anesthesia recovery before discharge for 2 of 6 surgical patients (Patients 30 & 31) reviewed. This failed practice had the potential to affect all surgical patients of the CAH. Total number of surgical procedures for Fiscal Year 2022 quarters 1-3 was 68.

Findings include:

A. Review of Patient 26's medical record (1/24/23 at 1:30 PM) revealed the patient had a colonoscopy (a procedure to look at the inside of the colon and rectum) under MAC (Monitored Anesthesia Care) with sedation on 9/13/22. The top section of the intraoperative form was checked stating "Anesthesia risks and benefits explained to the patient, procedure discussed, questions answered, consent to proceed", but lacked the signature of qualified practitioner, date and time with no evidence of time to ensure the examination took place immediately before surgery (procedure start time 9:02 AM).

-Review of Patient 27's medical record (1/24/23 at 1:45 PM) revealed the patient had a colonoscopy under MAC with sedation on 1/10/23. The top section of the intraoperative form was checked stating "Anesthesia risks and benefits explained to the patient, procedure discussed, questions answered, consent to proceed", but lacked the signature of qualified practitioner, date and time with no evidence of time to ensure the examination took place immediately before surgery (procedure start time 11:40 AM).

-Review of Patient 28's medical record (1/24/23 at 2:00 PM) revealed the patient had a colonoscopy under MAC with sedation on 11/8/22. The top section of the intraoperative form was checked stating "Anesthesia risks and benefits explained to the patient, procedure discussed, questions answered, consent to proceed", but lacked the signature of qualified practitioner, date and time with no evidence of time to ensure the examination took place immediately before surgery (procedure start time 10:44 AM).

-Review of Patient 29's medical record (1/24/23 at 2:15 PM) revealed the patient had a colonoscopy under MAC with sedation on 12/13/22. The top section of the intraoperative form was checked stating "Anesthesia risks and benefits explained to the patient, procedure discussed, questions answered, consent to proceed", but lacked the signature of qualified practitioner, date and time with no evidence of time to ensure the examination took place immediately before surgery (procedure start time 9:50 AM).

-Review of Patient 30's medical record (1/24/23 at 2:30 PM) revealed the patient had a colonoscopy under MAC with sedation on 6/14/22. The top section of the intraoperative form was checked stating "Anesthesia risks and benefits explained to the patient, procedure discussed, questions answered, consent to proceed", but lacked the signature of qualified practitioner, date and time with no evidence of time to ensure the examination took place immediately before surgery (procedure start time 10:38 AM).

-Review of Patient 31's medical record (1/24/23 at 2:45 PM) revealed the patient had a colonoscopy under MAC with sedation on 8/9/22. The top section of the intraoperative form was checked stating "Anesthesia risks and benefits explained to the patient, procedure discussed, questions answered, consent to proceed", but lacked the signature of qualified practitioner, date and time with no evidence of time to ensure the examination took place immediately before surgery (procedure start time 10:53 AM).

-Review of policy and procedure titled Anesthesia Responsibilities (effective 3/24/2021), confirmed Anesthesia Services will "Perform a thorough and complete pre-anesthesia assessment" but lacked a qualified practitioner' signature, date and time to ensure each patient's pre-anesthesia assessment to evaluate the risk of anesthesia was completed before surgery .

-Interview with QA (Quality Assurance) nurse (1/25/2023 at 1:00 PM) confirmed that 6 of 6 surgical medical records did not include qualified practitioner's signature, date or time to ensure each patient's pre-anesthesia assessment to evaluate the risk of anesthesia was completed before surgery.

B. Review of Patient 30's medical record (1/24/23 at 2:30 PM) revealed the patient had a colonoscopy under MAC with sedation on 6/14/22. The post anesthesia note lacked documentation of the time the qualified practitioner evaluated the patient for proper anesthesia recovery.

- Review of Patient 31's medical record (1/24/23 at 2:45 PM) revealed the patient had a colonoscopy under MAC with sedation on 8/9/22. The post anesthesia note lacked documentation of the time the qualified practitioner evaluated the patient for proper anesthesia recovery.

-Review of policy and procedure titled Anesthesia Responsibilities (effective 3/24/2021), lacked the evaluation for proper anesthesia recovery by a qualified practitioner before discharge.

-Interview with QA nurse on 1/25/2023 at 1:00 PM confirmed that 2 of 6 surgical medical records did not include the time the qualified practitioner evaluated the patient for proper anesthesia recovery before discharge.

Based on record review of medical records and staff interview, the facility failed to ensure 3 of 6 outpatient surgical patients (Patients 28, 29, 31) lacked documentation of discharge with a responsible adult. This failed practice had the potential to affect all surgical patients of the facility. Total number of surgical procedures for Fiscal Year 2022 quarters 1-3 was 68.

Findings include:

A. Review of Patient 28's medical record (1/24/23 at 2:00 PM) revealed the patient had a colonoscopy (a procedure to look at the inside of the colon and rectum) under MAC (Monitored Anesthesia Care) with sedation on 11/8/22 and lacked documentation of discharge with a responsible adult.

-Review of Patient 29's medical record (1/24/23 at 2:15 PM) revealed the patient had a colonoscopy under MAC with sedation on 12/13/22 and lacked documentation of discharge with a responsible adult.

- Review of Patient 31's medical record (1/24/23 at 2:45 PM) revealed the patient had a colonoscopy under MAC with sedation on 8/9/22 and lacked documentation of discharge with a responsible adult.

B. Interview on 1/25/23 at 1:00 PM with the QA (Quality Assurance) RN (Registered Nurse) confirmed the lack of documentation of discharge with a responsible adult and stated, "There is no documentation of discharge with a responsible adult."

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Based on observations, interview and record reviews, the facility failed to have a comprehensive Infection Control Surveillance Program to include monitoring of patient care medical devices that are used for internal exams as evidenced by:
Observation, interview and record review revealed the use of Ultrasound wand used for internal exams not receiving a High level disinfection after each use. 27 patients received internal ultrasound exams in the calendar year 2022. Facility did not have a contract available at time of survey to review for the Ultrasound Technologist that came to facility three days each week.
Observation of surgical services, record review of policies and procedures and staff interview, the facility failed to monitor the use of Colonoscopes (flexible camera instrument used to examine the inside of the colon) on each patient. The facility also failed to have a clear written policy defining the logging of each colonoscope used for each patient. Total number of surgical procedures for Fiscal Year 2022 quarters 1-3 was 68.
These failed practices had the potential to affect all surgical and internal ultrasound patients of the facility.


Findings include:

A. Tour of the Imaging Department on 1/25/2023 at 9:30am revealed a room housing Mammography (breast X-ray exam), Dexa Scan (bone calcium health exam) and Ultrasound (imaging for internal body structures). The Ultrasound Portable unit contained multiple wands (external exam) and probes (for internal exam). Imaging Manager stated that the Ultrasound Technician on contract was responsible for the cleaning of the equipment. The only cleaning items available for the internal probes was the gray top Disinfectant wipes used for all surface cleaning. Imaging Manager reached out to Ultrasound Tech who related - only the gray top canister wipes were used for wiping off the internal probe after each patient use.
Review of the Service Manual for the ultrasound HS50A/60A included "sufficient washing and disinfecting must be carried out to prevent infection and is the responsibility of the user who manages and maintains the disinfection procedures for the equipment. Classification of disinfectant needed for semi-critical device contacting "mucous membrane and endocavity" (internal/inside) require High level disinfectant.


-Tour of the surgery department on 1/25/2023 at 1:38pm revealed three (3) colonoscopes with serial numbers on each device, but there was no tracking mechanism in place to indicate which colonoscope had been used for each patient.

B. Record review of policy, "Colonoscopy and Endoscopy Scope Cleaning - Manual Process" review date 4/2/2021, revealed that the policy did not contain information or instruction to log each scope for patient use.
Based on observation, interview and record review, the Critical Access Hospital (CAH) failed to provide ongoing preventive maintenance/ safety inspections for 2 Air Vo respiratory medical devices. This failed practice had the potential to affect all patients of the CAH. The CAH had 55 inpatient admissions, 24 swing bed patients and 797 Emergency room visits for the Fiscal year 2022 statistics reported on the facility Annual Program Review.

C. Interview with Surgical RN on 1/25/2023 at 12:45 PM confirmed the facility did not have any system in place for tracking which colonoscope was used for each patient and stated, "We do not document which scope is used on patients."

Based on record review and staff interview, the facility failed to complete comprehensive assessments for 3 of 5 swing bed residents (32, 33 & 34) reviewed. This failed practice had the potential to affect all swing bed residents. The facility had 24 swing bed admissions for fiscal year 2022.

Findings include:

A. Record review of Resident #32 admitted 1/6/23 and currently at facility, revealed that the comprehensive assessment was not completed and not present in electronic medical chart.

-Record review of Resident #33 admitted 8/3/22-9/1/22, revealed that the comprehensive assessment was not completed and not present in electronic medical chart.

-Record review of Resident #34 admitted 9/14/22-10/6/22, revealed that the comprehensive assessment was not completed and not present in electronic medical chart.


B. Interview with QA (Quality Assurance) RN (Registered Nurse) on 1/25/23 at 3:15 PM stated, "Correct, they did not have comprehensive assessments done."