HospitalInspections.org

Based on document review and interview, the CAH (Critical Access Hospital) failed to maintain current credentialing files with state background studies for 2 of 16 medical staff (MD-A, DO-A) records reviewed. In addition, the facility failed to maintain state background studies for 2 of 16 (E-1, E-2) direct care staff reviewed.

Findings include.

A review of credentialing files for MD-A and DO-A were found to lack State background studies.

A review of personnel files for E-1 and E-2 were found to lack State background studies.


On 2/1/12, at 10:40 a.m. the human resources director stated E-1 and E-2 did not have background studies completed or filed.

At 11:45 a.m. the Chief Executive Officer (CEO) verified the missing documents in the files and stated all the credentialing files for providers should have a background study completed.

Based on document review and interview, the CAH (Critical Access Hospital) failed to maintain current credentialing files with current licensure, certifications or registrations for 2 of 16 medical staff (MD-B and DDS-A) credentialing files reviewed and 6 of 6 contracted staff (E-2, E-3, E-4, E-5, E-6 and E-7) personnel files reviewed.

Findings include.

The personnel files of MD-B and DDS-A lacked documentation of current State licensure.

E-2's personnel record lacked verification of a current Registered Dietician license.

E-3 and E-4's personnel record lacked verification of a current Occupational Therapist license.

E-5's personnel record lacked verification of a current Speech Therapist license.

E-6's personnel record lacked verification of a current Dietetic Technician license.

E-7's personnel file lacked verification of a current Social Work license.

On 2/1/12, at 10:40 a.m. the human resources director stated they did not have personnel files for the contracted staff with current verification of license.

At 11:45 a.m. the Chief Executive Officer (CEO) verified the missing documents in the files and stated all the credentialing files should have verification of a current licensure.

The By-Laws of the Medical Staff dated 1/9/02, indicated all medical staff shall present copies of their current State license.

Based on observation and interview, the CAH (Critical Access Hospital) failed to ensure the BiPAP machine (bi-level positive airway pressure-a type of non invasive ventilation) was on a preventive maintenance program to ensure the device was in working order to promote patient safety. This practice had the potential to effect all patients in the CAH.

Findings include:

During tour of the emergency department with the director of nursing (DON) on 1/31/12, at 1:00 p.m. the BiPAP machine was observed to lack identification of an equipment function check by the maintenance/biomed department.

At 1:25 p.m. the DON verified the BiPAP machine was used in the emergency department as needed. The DON also stated the BiPAP machine had not been checked for function and safety, nor added to the routine preventative maintenance check list. The DON stated it had been missed. Additionally, the DON stated the BiPAP machine had not been checked since purchased a couple of years ago. The DON stated the biomed company that performed the CAH's equipment preventative maintenance checks was coming to check the machine.

Based on document review and interview, the CAH (Critical Access Hospital) failed to ensure all personnel were trained to manage non-medical emergencies for 6 of 6 (E-2, E-3, E-4, E-5, E-6 and E-7) contracted staff reviewed.

Findings include:

E-2, E-3, E-4, E-5, E-6, and E-7's personnel records lacked documentation of training related to non-medical emergency procedures.


On 2/1/12, at 10:40 a.m. the human resources director stated they did not have personnel files for the contracted staff and lacked documentation of training provided to contact staff for non-medical emergency procedures.

Based on interview, and document review, the CAH (Critical Access Hospital) failed to develop an emergency plan to ensure adequate water availability and distribution to all areas of the hospital. This had the potential to affect all patients of the CAH.

Findings include:

Review of the CAH's "Emergency Water Provisions" policy dated 10/07, lacked the required specifications and calculations regarding the amount of potable and non-potable water needed according to patient census and hospital use, and how it would be distributed in the case of an emergency. Additionally, the policy lacked an identified source of the potable water in the event of an emergency.

During interview, on 1/31/12, at 10:05 a.m. the director of maintenance (DOM) stated the Warren Fire Dept. would supply emergency water for flushing only and not consumption. Additionally, the DOM verified the policy lacked the required calculations of the specified water needs required for non potable and potable water, as well as a method of distribution, and source.

Based on document review and interview, the CAH (Critical Access Hospital) failed to ensure the Governing Body monitored the implementation of policies related to credentialing for 4 of 11 medical staff's (DO-A, MD-A, MD-B, MD-C, and DDS-A) credentialing files reviewed.

Findings include.

MD-A and DO-A did not have complete credentialing file which included a completed State background study on file.

MD-B and DDS-A did not have a complete credentialing file which included a current State license to practice on file.

MD-B, MD-C and DDS-A had not completed the credentialing process which included approval to practice at the facility from the Medical Staff and Governing Body in accordance with the Medical Staff By-Laws.

On 2/1/12, at 11:45 a.m. the Chief Executive Officer (CEO) stated all the credentialing files should be complete according to the By-Laws and verified the missing documents in the files. The CEO stated DDS-A had signed a contact but had not gone through the credentialing process. The CEO stated MD-C was new to the facility but had not gone through the credentialing process. The CEO further added that MD-B had been missed the last time the MD should have had reappointment, and verified the previous appointment by the Governing Body was 10/21/08. The CEO stated all the medical staff should have appointment from the Medical Staff and Governing Body.

The By-Laws of the Medical Staff dated 1/9/02, indicated all medical staff should present copies of their current state license and should complete an application for Medical staff membership. The By-Laws indicated appointments to the medical staff should be made by the board.

Based on observation, interview, and document review, the CAH (Critical Access Hospital) failed to ensure the infection control program was being implemented related to ongoing monitoring and trending of infection rates from the surveillance program according to the established policies. In addition, the CAH failed to follow manufacturer guidelines to ensure proper monitoring of a disinfectant solution used in radiology and did not consistently implement policies regarding the use of the tabletop autoclave. This practice had the potential to effect all patients who were treated at the CAH.

Findings included:

Infection Control Program

On 1/30/12, at 3:05 p.m. the assistant director of nurses (ADON) and infection control lead, stated the CAH did not have a separate infection control committee. She added the infection control issues were reported through the quality assurance (QA) committee. The ADON verified she did not have hospital-acquired infection rates for the CAH from the past year.

On 2/1/12, at 9:10 a.m. the QA (quality assurance) coordinator stated that infection control quality indicators were reported at the QA meetings and if there was something unusual. She added she was not sure of any monthly infection rates being reported.

On 2/1/12, at 1:35 p.m. the director of nurses (DON) stated the previous infection control nurse had incorporated everything in her QA notes because the monthly rates were so low. The DON reviewed the facility infection control policies regarding reporting on infection control rates and stated, "We just need to follow our policies."

Review of Quality Improvement Committee (QIC) minutes from 2011 through the time of survey revealed the following:
-On 1/14/11, a report from infection control on quality indicator rates with no report of health care acquired infection rates or other infection control concerns.
-On 3/15/11, no report from infection control
-On 6/1/11, a report from infection control on quality indicator rates with no report of health care acquired infection rates or other infection control concerns.
-On 9/27/11, no report from infection control
-On 10/27/11, no report from infection control
-On 11/17/11, no report from infection control
-On 1/17/12, no report from infection control

Review of the policy titled Healthcare Associated Infection Identification and Tracking dated 3/08, indicated the Infection Control Officer would report the number of infections monthly to the infection control committee and note any nosocomial (facility-acquired) infections. Review of the facility policy titled Infection Control Committee dated 9/08, indicated the committee would report to the QA committee via the Infection Preventionist (infection control officer).


Disinfection

On 1/30/12, at 1:30 p.m. during a tour of the ultrasound room, the ultrasound (U/S)technologist stated that she currently used Cidex OPA (disinfectant/sterilant) for disinfection of the vaginal probe. The U/S technologist stated she did monitoring of the mixed Cidex OPA solution using Cidex OPA solution test strips and provided the surveyor the current bottle of test strips in use. The bottle of test strips indicated they expired 2/2011, and there was no date in the space on the label to record date opened. The U/S technologist verified there were approximately 20 strips remaining with the bottle labeled as originally containing 60 strips and that this was the bottle she had been using. The U/S technologist did not know when it had been opened.

Review of the "Cidex Solution Chart" log indicated the Cidex solution had been tested with the strips for a total of 75 days after the date of expiration on the bottle of 2/2011.

Review of the policy titled US Procedure for Disinfecting Vaginal Probe dated 2/11, indicated the probe was to be soaked in the Cidex OPA solution for 12 minutes after the exam as part of the disinfecting process.

The manufacturer's instructions for Cidex OPA solution test strips directed, "do not use any remaining strips 90 days after opening the bottle" and that the open date was to be recorded in the space provided on the label of the bottle. Expired strips were to be disposed of per facility policy.


Sterilization

On 2/1/12, at 11:30 a.m. the materials management director (MMD) indicated the tabletop steam autoclave was used about 1-2 times week to sterilize instruments. The MMD stated she also used an Attest biological indicator (to monitor for the effectiveness of the sterilization process) about once a month.

Review of the Attest-Monitoring of Autoclaves log indicated the Attest biological indicator usage was documented on 1/6/11, 3/2/11, 4/11/11, 6/6/11, 7/21/11, 8/29/11, 10/10/11, 11/29/11 and 1/30/12.

Review of the undated policy CSR indicated the Attest Steam Indicator was recommended every 3 months. The policy included the statement, "I feel it is unnecessary to do monthly checks unless a problem with the indicator strips."

According to the Center for Disease Control's (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, the use of a biological indicator to monitor the effectiveness of sterilizers at least weekly is a 1B recommendation (strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies, and by strong theoretical rationale).

On 2/1/12, at 1:35 p.m. the DON stated the facility did not have a policy regarding the provision of disinfection or sterilization of patient care items and equipment.

Based on interview and document review, the CAH (Critical Access Hospital) failed to provide an effective quality assurance program to evaluate the quality and appropriateness of the treatment and services furnished in the CAH related to 3 of 12 departments (occupational therapy (OT), speech therapy (ST), Pharmacy) reviewed.

Findings include:

A review of the QA program indicated 3 departments lacked quality indicators determined by problem identification, ongoing monitoring, data analysis, corrective actions and evaluation of corrective actions.

Occupational Therapy

A review of the undated 2011 Year End OT (occupational therapy) Review indicated the QA indicators for 2011 included timeliness of referrals, OT evaluations completed within 48 hours of referrals and activities assessed for swing bed patients within 48 hours of referrals. The goal of the QA indicator was to achieve 100% and the results of the indicator was 100%.

The QA for OT lacked problem identification or data analysis as well as ongoing monitoring or data collection details related to the QA indicator. No further data, monitoring or analysis of the QA indicators throughout the year was provided upon request.

Speech Therapy

A review of the undated 2011 Year End Speech Therapy (ST) Review indicated the QA indicators for 2011 included timeliness of referrals and the initial visit made within 48 hours of referral. The goal of the QA indicator was to achieve 100% and the results of the indicator was 100%.

The QA for ST lacked problem identification or data analysis as well as ongoing monitoring or data collection details related to the QA indicator. No further data, monitoring or analysis of the QA indicators throughout the year was provided upon request.



On 2/1/12, at 9:10 a.m., registered nursing (RN)-A and the director of medical records (the Quality Improvement Coordinators) stated they were going to implement new documentation for 2012 and recognized that complete documentation of the QA program for each of the departments were lacking. They added the QA program indicators are discussed at the meetings; however, this information is not always documented. RN-A indicated no further data or analysis of the QA indicators for OT or ST could be provided. She stated they had identified past problems with referrals but stated the QA documentation provided did not reflect any concerns. RN-A stated documentation was missing related to the identification of the problem and the ongoing monitoring of the indicator. RN-A stated they would be starting new indicators in February 2012.




29440


Pharmacy

On 2/1/12, at 12:40 p.m. the director of nurses (DON), who had oversight of the pharmacy services for the CAH, stated a quality assurance project that involved the contracted pharmacy services was lacking.

Review of the policy titled Quality Improvement Plan for North Valley Health Center dated as revised 1/1/12, indicated that each department would determine their own quality indicators. Review of the facility "QI Meeting Schedule" dated 1/1/12, indicated reporting on the pharmacy occurred in April and October with nursing and tissue donation. Review of Quality Improvement Committee minutes from 1/14/11, 3/15/11, 6/1/11, 9/27/11, 10/27/11, 11/17/11, and 1/17/12, included no reporting of pharmacy indicators.

Based on document review and interview, the CAH (Critical Access Hospital) failed to ensure policies and procedures had been developed which clearly delineated the procedure for peer review related to appropriateness of medical diagnosis and treatment when a potential "outlier" was identified. This practice had the potential to effect all patients treated in the CAH.

Findings include:

Review of the 2010 Peer Review documentation was conducted and revealed a physician, not employed at the facility, reviewed patient records based on criteria which included an acute patient stay of greater than five days and whether the stay was deemed medically necessary. No other criteria was evaluated in the documentation and no other peer review to evaluate "outliers" was included in the peer review process.

On 2/1/12, at 9:55 a.m. registered nurse (RN)-A (the Quality Improvement Coordinator) stated medical staff will suggest what they want to review through peer review on an annual basis. She added a physician who is retired provides the peer review. RN-A stated for 2010 the peer review was based on whether a patient had an acute stay of longer than 5 days and if the stay was medically necessary.

At that time, the medical records director (MRD) (and Quality Improvement Coordinator) stated the goal of the peer review would have been to evaluate if the patient should have been transferred out to another facility. The MRD stated this was only found as a concern in one of the evaluations.

At 2:50 p.m. the MRD stated the facility had no policy or criteria documented to conduct peer review. She added they just let the physicians decide what to do.