HospitalInspections.org

Based on document review, policy review and staff interviews, the Critical Access Hospital (CAH) failed to comply with applicable federal regulations regarding their emergency preparedness plan for potable water needs and have an emergency water agreement with an outside entity, structured to meet their needs, to ensure the availability of adequate water in the event of an interruption in the water supply. The administrative staff identified a census of 3 patients at the time of the survey, an average daily census of 3 patients and generally staffed for 12 patients.

Failure to ensure emergency water is available to meet the facility's critical functions during an emergency/crisis situation inhibits the facility's ability to ensure patient safety and quality of care while responding to and recovering from a situation that resulted in disruption of water.

Findings include:

1. Review of an undated document titled "Disaster Relief Water for Consumption" revealed a local retail grocery store agreed to supply the CAH with potable water during an emergency and maintain enough water on hand to supply the CAH for the duration of an emergency. The agreement lacked any details regarding the CAH's potential need related to quantity and timeframe for delivery.

2. Review of an agreement with [City] Water Works Trustees, dated 6/6/21, revealed in part "... The [City] Water Works will allow the [CAH] use of the Water Works' 550-gallon bulk tank and water for emergency situations ... Due to how this water is transported, it cannot be deemed as potable water. Other measures should be taken to insure potable water is available for consumption ...".

3. Review of a CAH policy titled "Water Distribution System Failure", dated 10/2016, revealed in part "... [City] Water Works will provide a bulk tank supply of drinkable water when needed ...", which conflicts with the language in the [City] Water Works agreement.

4. Review of a CAH policy titled "Disaster Plan for Meal Service", last approved 10/2019, revealed in part "... [Local retail grocery store] is the designated vendor to supply and deliver water as needed ...".

5. During an interview on 4/5/22, at 9:30 AM, the Facilities Management Director, acknowledged the agreement with the City Water Works identified the water would be considered nonpotable and the agreement with the local retail grocery store lacked detail regarding the quantity the CAH might need and/or the quantity the store would be able to provide and in what time frame.

6. During an interview on 4/6/22, at 4:15 PM, the Chief Clinical Officer (CCO), thought the CAH had additional details for emergency water needs as part of their emergency preparedness planning and would check to provide additional details.

7. During an interview on 4/7/22, at 8:00 AM, the Chief Clinical Officer provided an undated document titled "Potable Emergency Water Supply", which contained a short statement which identified the CAH stored 9 - 5 gallon containers on site, is maintained at all times and stored in multiple locations within the facility to eliminate the risk of damage in the event of disaster and identified as adequate to meet the CAH's need until the local retail grocery store can deliver more water. The document failed to included any planning details of how the CAH arrived at their assessment of the adequacy of the quantity currently stored.

8. The CCO provided another document with the same title at 10:30 AM, dated 4/7/22, which included details regarding the CAH's estimated needs for potable water and available potable water supply on hand. The CCO acknowledged the Chief Financial Officer put together the document after consultation with the Food Service Director and Facilities Management Director during the survey and confirmed the details regarding the potential quantity of emergency water the CAH may need, had not been included as part of their emergency water planning and associated agreements.

Based on document review and staff interviews the Critical Access Hospital (CAH) administrative staff failed to ensure state employment requirements were met for the individual responsible for the operation of the Nutrition Services Department. The administrative staff identified a census of 3 inpatients at the time of the survey and an average census of 3 patients. The Food Service Director reported the department serves an average of 9-15 patient meals daily. Failure to ensure a qualified person manages the food service department could potentially result in poor dietary practices impacting the health and nutritional needs of the patients.

Findings include:

1. Review of a document titled [Healthcare Facility Management Provider] - [CAH] Master Services Agreement, dated 5/1/21, identified an agreement for a Food Service Management Program which included a contracted Food Service Director.

2. Review of the role summary for the Director of Nutritional Services, written/revised 3/2021, revealed the position identified the required knowledge, skills and abilities to include a Certified Dietary Manager (CDM) or Registered Dietitian.

3. Review of the Food Service Director's resume identified an Associates of Arts Degree and 20+ years of retail foodservice but failed to show completion of a Certified Dietary Manager training.

4. During an interview on 4/4/22, at 10:45 AM, the Food Service Director reported he had multiple years of experience in retail foodservice but acknowledged he is not a CDM.

5. During an interview on 4/4/22 at 2:00 PM, the Food Service Director reported he is responsible for the Nutrition Services Department operations and confirmed he has looked into completing the dietary manager certification but has not yet enrolled in a program.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician periodically reviewed the care provided for CAH patients, in conjunction with mid-level providers, for 2 of 2 applicable Emergency Department mid-level providers selected for review (Advanced Registered Nurse Practitioner A and Advanced Registered Nurse Practitioner B). Failure to ensure a physician periodically reviewed mid-level provider's patient medical records, in conjunction with the mid-level provider, could potentially result in misdiagnosing a patient and/or providing inappropriate or substandard patient care. The CAH administrative staff identified Advanced Registered Nurse Practitioner (ARNP) A and Advanced Registered Nurse Practitioner (ARNP) B treated the following number of emergency room patients from 4/1/2021 through 4/6/2022:

Advanced Registered Nurse Practitioner A - 126 patients
Advanced Registered Nurse Practitioner B - 639 patients

Findings include:

1. Review of a CAH policy titled "Performance Improvement" last approved 2/2022, revealed in part "... The Quality Director, in tandem with the Inpatient/ED Director, actively identify and delegate a minimum of 10% of the active and closed patient care records for auditing. ... Included in this audit are 10% of emergency records ... 10% of all allied health provider charts ...".

2. Review of Peer Review Committee Meeting minutes from 2/22/22 revealed patients of ARNP A and ARNP B had been reviewed but the committee meeting minutes showed neither ARNP in attendance at the meeting.

3. The CCO provided examples of ARNP A's and ARNP B's documentation in some of their patient's medical records which revealed communication between them and a physician but failed to document a comprehensive review of the patient's ED care.

4. During an interview, on 4/6/22, at 4:00 PM, the CCO reported the Peer Review committee consisted of physicians and the mid-level providers do not attend. She explained if there are any concerns regarding any of the charts reviewed, a physician would contact the mid-level provider and the case discussed. The CCO reported the ED mid-level providers and physicians frequently discuss patient care, while the patient is in the ED, and the information would be documented in the medical record.

5. During an interview on 4/7/22, at 9:00 AM, the CCO reported she is confident that physicians are evaluating the ED mid-level providers CAH patient care for appropriateness of treatment, but confirmed capturing that the review and evaluations of charts in conjunction with each other is difficult to document in the chart and confirmed it does not occur at another point in time.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a mid-level provider periodically participated in a review of the care provided for CAH patients, in conjunction with a physician, for 2 of 2 applicable Emergency Department mid-level providers selected for review (Advanced Registered Nurse Practitioner A and Advanced Registered Nurse Practitioner B). Failure to ensure a mid-level provider participated with a physician in periodic review of the mid-level provider's patient medical records, could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care. The CAH administrative staff identified Advanced Registered Nurse Practitioner (ARNP) A and Advanced Registered Nurse Practitioner B treated the following number of emergency room patients from 4/1/2021 through 4/6/2021:

Advanced Registered Nurse Practitioner A - 126 patients
Advanced Registered Nurse Practitioner B - 639 patients

Findings include:

1. Review of a CAH policy titled "Performance Improvement" last approved 2/2022, revealed in part "... The Quality Director, in tandem with the Inpatient/ED Director, actively identify and delegate a minimum of 10% of the active and closed patient care records for auditing. ... Included in this audit are 10% of emergency records ... 10% of all allied health provider charts ...".

2. Review of Peer Review Committee Meeting minutes from 2/22/22 revealed patients of ARNP A and ARNP B had been reviewed but the committee meeting minutes showed neither ARNP in attendance at the meeting.

3. The CCO provided examples of ARNP A's and ARNP B's documentation in some of their patient's medical records which revealed communication between them and a physician but failed to document a comprehensive review of the patient's ED care.

4. During an interview, on 4/6/22, at 4:00 PM, the CCO reported the Peer Review committee consisted of physicians and the mid-level providers do not attend. She explained if there are any concerns regarding any of the charts reviewed, a physician would contact the mid-level provider and the case discussed. The CCO reported the ED mid-level providers and physicians frequently discuss patient care, while the patient is in the ED, and the information would be documented in the medical record.

5. During an interview on 4/7/22, at 9:00 AM, the CCO reported she is confident that physicians are evaluating the ED mid-level providers CAH patient care for appropriateness of treatment, but confirmed capturing that the review and evaluations of charts in conjunction with each other is difficult to document in the chart and confirmed it does not occur at another point in time.

Based on document review, medical record review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to follow their policy and ensure a medication error, the condition of the patient, physician notification and subsequent action taken to address the medication error, were documented in the patient's medical record for 8 of 8 medication errors involving 7 of 7 patients reviewed (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7). Failure to document medication errors in the medical record, including the condition of the patient, physician notification and subsequent action taken to address the medication error could potentially result in the practitioner or other staff not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the practitioner making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff identified a census of 3 patients at the beginning of the survey.

Findings include:

1. Review of the CAH policy, "Medication Errors," approved 8/2021, revealed in part, "Documentation in the medical record shall include what drug/dose was or was not administered, the time, the condition of the patient as appropriate to the patient's condition and medication, the notification of the provider, and any subsequent action ordered and taken."

2. Review of medication errors 4/1/21 to 4/7/22 revealed:

a. The nursing staff made a medication error on 4/1/21 at 9:00 AM (missed medications) which involved Patient #1. Patient #1's medical record lacked any documentation of the medication error as required by policy.

b. The nursing staff made a medication error on 5/10/21 at 7:55 PM (wrong administration route) and at on 5/10/21 at 11:45 PM (wrong intravenous fluid rate) which involved Patient #2. Patient #2's medical record lacked any documentation of the medication error as required by policy.

c. The nursing staff made medication errors on 5/27/21 at 3:00 PM (missed medications) which involved Patient #3. Patient #3's medical record lacked any documentation of the medication error as required by policy.

d. The nursing staff made a medication error on 6/27/21 at 2:00 PM (wrong intravenous fluid) which involved Patient #4. Patient #4's medical record lacked any documentation of the medication error as required by policy.

e. The nursing staff made a medication error on 10/29/21 at 5:00 PM (missed doses) which involved Patient #5. Patient #5's medical record lacked any documentation of the medication error as required by their policy.

f. The nursing staff made a medication error on 11/21/21 at 8:00 PM (wrong medication) which involved Patient #6. Patient #6's medical record lacked any documentation of the medication error as required by policy.

g. The nursing staff made a medication error on 2/17/22 at 3:00 AM (missed dose) which involved Patient #7. Patient #7's medical record lacked any documentation of the medication error as required by policy.

3. During an interview on 4/7/22 at 11:00 AM, the Chief Clinical Officer confirmed the CAH staff do not document anything related to an medication occurrence report in the patient's medical record.

Based on observation, review of policies/procedures, and staff interviews, the Critical Access Hospital (CAH) Laboratory Department, Radiology Department, and Cardio-Pulmonary Services Department staff failed to protect all confidential patient information from unauthorized access in 3 of 3 Departments. Failure to secure medical records against unauthorized access could result in identity theft and/or unauthorized disclosure of personal medical information. The CAH clinic administrative staff identified a combined average of 50 out-patient Cardio-Pulmonary Rehabilitation Services visits, an average of 3694 outpatient Laboratory visits, and an average of 338 outpatient Radiology visits (07/01/2020-06/30/2021) over the past fiscal year.

Findings include:

1. Observation on 4/5/2022 at 2:05 PM, during a tour of Laboratory Services Department, revealed 1 of 1 FAX machines located in an unlocked area of office space.

2. Observation on 4/5/2022 at 1:35 PM, during a tour of Radiology Services Department, revealed 1 of 1 FAX machines located in an unlocked area of office space.

3. Observation on 4/6/2022 at 2:05 PM, during a tour of Cardio-Pulmonary Services Department, revealed 1 of 1 FAX machines located in an unlocked area of office space.

4. During an interview on 4/5/2022 at 2:25 PM, Director of Laboratory Services Department revealed the Laboratory Department areas are locked when the departments are closed, however, housekeeping and maintenance staff have access to the locked departments when Laboratory staff are not present. Fax machines are not secured and private patient information is received after hours and sit on the Fax machines until staff retrieves the information. The Director of Laboratory Services acknowledged that the private patient information on the FAX machine and in the file cabinets is available for unauthorized personnel access. The Director of Laboratory Services indicated the department receives an average of 10-15 faxes daily during times when Laboratory staff are not present.

4. During an interview on 4/5/2022 at 1:35 PM, Director of Radiology Services Department revealed the Radiology Department areas are locked when the departments are closed, however, housekeeping and maintenance staff have access to the locked departments when Radiology staff are not present. Fax machines are not secured and private patient information is received after hours and sit on the Fax machines until staff retrieves the information. The Director of Radiology Services acknowledged that the private patient information on the FAX machine and in the file cabinets is available for unauthorized personnel access. The Director of Radiology Services indicated the department receives an average of 2-3 faxes daily during times when Radiology staff are not present.

5. During an interview on 4/6/2022 at 3:10 PM, Supervisor of Cardio-Pulmonary Services Department revealed the Cardio-Pulmonary Services Department areas are locked when the departments are closed, however, housekeeping and maintenance staff have access to the locked departments when Cardio-Pulmonary Department staff are not present. Fax machines are not secured and private patient information is received after hours and sit on the Fax machines until staff retrieves the information. The Supervisor of Cardio-Pulmonary Services acknowledged that the private patient information on the FAX machine and in the file cabinets is available for unauthorized personnel access. The Supervisor of Cardio-Pulmonary Services indicated the department receives and average of 8-10 faxes per month during times when Cardio-Pulmonary staff are not present.

6. Review of policy "Information/Data Classification," approved 6/2020, revealed in part, "All information, regardless ... must be protected from unauthorized access, modification, disclosure, and/or destruction."

Based on observation, document review, and staff interviews the Critical Access Hospital (CAH) staff failed to ensure it maintained a clean and sanitary environment to avoid sources and transmission of infection when it failed to adequately wipe down all areas of the hospital bed during a terminal clean in 1 of 1 patient rooms observed (room 220). Failure to remove sources of infection could result in the transmission of the infectious organism(s) to the next patient exposed to the contaminated item leading to illness or potentially death. The CAH administrative staff identified an average daily census of 3 inpatients who utilized its services in Fiscal year 2021.

Findings include:

1. Review of CAH Terminal Room/Construction Cleaning policy, last revised 11/2019, revealed in part, "Terminal unit cleaning is provided by Environmental Service personnel ... Environmental Services Responsibility for a patient care room ... Wash topside of mattress. Turn mattress sideways on bed. Slide to the foot of the bed. Wash top of frame and wash all supporting rods, rails and braces. Turn mattress over and slide to opposite end of bed and repeat process..."

2. Observations of a terminal clean on 4/4/2022 at approximately 1:10 PM, room #220 of medical surgical unit revealed Environmental Services Staff C failed to wipe both sides of the mattress and the metal mattress support.

3. During an interview on 4/4/2022, at the time of the observation, Environmental Staff C indicated they are to wipe down all surfaces with the provided disinfectant, with the wiped surfaces remaining wet for 10 minutes prior to using the Ultraviolet (UV) light for 30 minutes.

4. During an interview on 4/4/2022 at 3:30 PM, the Director of Inpatient and Emergency Services acknowledged the Environmental staff did not clean the hospital bed per hospital policy.

Based on review of policy/procedure and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 abuse policy 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 Survey Agency) for swing bed patients. The CAH administrative staff identified a monthly average of 3 skilled patients per month from September 21, 2021 until February 22, 2022. Failure to include the required language in the abuse policy could potentially prevent CAH staff from reporting alleged violations involving abuse to the CAH administrator and to other officials (including to the State Survey Agency) in a timely manner.

Findings include:

1. Review of the CAH's policy "Identifying, Assessment and Reporting of Suspected Domestic Abuse" approved date, 12/2020, failed to include 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).

2. During an interview on 4/7/2022 at 10:30 AM, the Chief Clinical Officer (CNO) acknowledged the abuse policy failed to include 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).