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Based on observation and interview the Critical Access Hospital (CAH) failed to install an Air Gap for the kitchen sink used for the preparation of food in accordance with Food and Drug Administration and the Kansas Food Code 5-202.13 and 5-202.14. Failure to install an Air Gap placed all patients, visitors and staff members at risk for contaminated food in the event there was a backflow from the sewer into the preparation sink.

Findings included:

- According to the Food and Drug Administration and the Kansas Food Code 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).



- According to Food Code 5-202.14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device.



An interview was conducted with a kitchen staff member on 5/23/2016 at 3:00 p.m. The staff member was asked which sink was used to wash vegetables. The staff member pointed to a kitchen sink attached to a wall on the opposite side of the oven. The staff member stated that the area of the kitchen did have a history of backflow in the remote past (date unknown).



- Observation of the pipes that drained from the prep sink revealed there wasn't an air gap in place.



Interview with the maintenance staff member on 5/24/2016 at approximately 8:30 a.m. revealed s/he wasn't sure how to install an air gap for that sink.



- Review of the policies and procedures for the Critical Access Hospital revealed here was no policy and procedure that addressed air gap installation for the kitchen prep sink.

The Critical Access Hospital (CAH) reported a census of two skilled swing bed patients.

Based on policy review, observation, and interview the CAH failed to provide for the safety of patients in two of two Emergency Department (ED) patient care rooms (ED trauma room #1 and ED room # 2 ) when keys ( which unlocked the cabinets above the drawers containing lidocaine (a local anethetic and anti-arrhythmic) were found in an unlocked drawer and accessible to anyone in the rooms. The ED Pediatric Crash Cart was also unlocked and contained Sodium Bicarbonate (a salt which is used in the bloodstream to regulate the body's acid-base balance).

The CAH failed to secure potentially hazardous solutions from patients and visitors.

This deficient practice has the potential to cause harm to patients.

Findings include:

1. Emergency Department trauma room #1 and Emergency Department room #2 observed on 5/24/2016 at 12:30 PM revealed the CAH failed to secure keys to locked cabinets.


- Emergency Department trauma room # 1 observed on 5/24/2016 at 11:30 PM revealed the CAH failed to have the Pediatric Crash Cart locked that contained Sodium Bicarbonate 10ml (milliliters) 4.2% (0.5mEq-milliequalivent/ml).


Director of Nursing Staff B interviewed on 5/24/2016 at 1:00 PM acknowledged the keys to the locked cabinet should have been placed in their Pyxis (electronic dispensing of patient's medications) and not in the drawer. Staff B stated she did not know the Pediatric crash cart needed to be locked.


- Policy reviewed on 5/25/2016 at 3:00 PM revealed the CAH failed to develop a policy to ensure the CAH secures lock cabinet keys.


2. During a tour of the CAH patient area of the clean and dirty utility rooms revealed the rooms were unlocked and accessible to patients and visitors. Cleaning solutions, nail polish remover, shampoo and hemoccult solution were unsecured and accessible to patients and visitors.


- Policies reviewed on 5/25/2016 at 3:30 p.m. revealed the CAH failed to develop and implement a policy to ensure the CAH secured potentially harmful substances.

Based on observation and interview the Critical Access Hospital (CAH) failed to ensure all patients would have a supply of water during an emergency.


Findings include:


An interview was conducted on 5/25/2016 with the CAH maintenance staff member # J regarding emergency supplies of water and fuel. Staff member J stated that there was a supply of fuel for the generator but that s/he was unaware of a supply of water.


Interview on 5/25/2016 with a kitchen cook staff member stated the Critical Access Hospital kept a supply of bottled water on hand at that currently one 12 ounce bottle was in the refrigerator. Additional drinking water would be delivered the following day.


- A policy that included information regarding the amount of fuel and water to have available during an emergency could not be located in the Critical Access Hospital policy and procedure manual.

Based on interview, observation and record review, it was determined that the Critical Access Hospital's (CAH) governing body failed to ensure the organizational structure requirements were met. The governing body failed to be responsible for the total operation of the CAH and ensure the quality of care provided to patients.


Failure to ensure the provision of quality health care in a safe environment placed all patients at risk for potential complications.


Findings include:

Refer to Tag C-0241.

Based on interview, observation and record review the Critical Access Hospital (CAH) failed to ensure that the medical staff was held accountable to the governing body that was responsible for the total operation of the CAH for the quality of care provided to patients. Failure to determine, implement and monitor current CAH practices included in their policies that ensured the provision of quality health care in a safe environment placed all patients at risk for potential complications.

Findings include:

1. According to the Malignant Hyperthermia Association of America. Hospitals that provide general anesthesia to patients are required to have a sufficient supply of Dantrolene in stock to treat Manlignant Hyperthermia.

- Malignant hyperthermia (MH) is a potentially fatal, inherited disorder usually associated with the administration of certain general anesthetics and/or the drug succinylcholine.


- The CAH failed to ensure the necessary supply of emergency medication (Dantrolene) and sterile water for reconstituting the drug for surgical patients experiencing a Malignant Hyperthermia (MH) episode. Failure to stock the necessary amount of Dantrolene placed all surgical patients at risk for harm including death. Refer to Tag C-0320.


2.The CAH failed to install an Air Gap for the kitchen sink used for the preparation of food. Failure to install an Air Gap in accordance with the Food and Drug Administration and the Kansas Food Code 5-202.13 and 5-202.14 placed all patients, visitors and staff members at risk for contaminated food in the event there was a backflow from the sewer into the preparation sink. Refer to Tag C-0151.


3.The CAH failed to ensure all patients would have a supply of water during an emergency. Refer to Tag C-0229.


4.The CAH failed to provide for the safety of patients in two of two ED patient care rooms (ED trauma #1 room and ED # 2 room) with keys in lower drawer accessible to locked cabinet containing lidocaine ( a numbing medication and an anti-arrythmic) and one of one ED Pediatric Crash Cart unlocked containing Sodium Bicarbonate (a salt that regulates your acid-base balnce in your bloodstream). Refer to Tag C-0221.


5.The CAH failed to secure potentially hazardous solutions from patients and visitors. Cleaning solutions, hemocult solutions, shampoo, nail polish and lotions were unsecured and were accessible to patients and visitors. Refer to Tag C-0221.


6. The CAH failed to perform a periodic evaluation and QA review of its program annually for the past 5 years. Refer to Tags C-0330 - 0343.


7. The CAH failed to ensure all supplies are maintained to safely meet patients' needs for both day-to-day operations and during emergencies in one of one Emergency Crash Cart, and one of one Pediatric Broselow (pediatric emergency supply) cart. Refer to Tag C-0276.


8. The CAH failed to ensure pharmacy services were provided with oversight of a pharmacist in accordance with regulations for all medication ordering, stocking, and repackaging of medication. Refer to Tag C-0276.

9. The CAH failed to ensure the infection control officer had education and/or experience and training in the principles and methods for infection prevention and control. Refer to Tag C-0278.

Based on policy review, observations, and staff interviews the Critical Access Hospital (CAH) failed to ensure that drugs and biologicals are managed in a safe manner (Refer to C-0276) and the CAH failed to provide an effective and active infection control program including a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel (Refer to C-0278).


The cumulative effect of the CAH's failures resulted in the potential for medication errors to occur and all patients receiving services to be administered ineffective medications and to be exposed to healthcare associated infections.

The Critical Access Critical Access Hospital (CAH) reported a census of two skilled swing bed patients.

Based on policy review, observations and staff interviews the CAH failed to ensure all supplies are maintained to safely meet patients' needs for both day-to-day operations and during emergencies in one of one Emergency Crash Cart, and one of one Pediatric Broselow (pediatric emergency supply) cart. The CAH failed to ensure pharmacy services were provided with oversight of a pharmacist in accordance with regulations for all medication ordering, stocking, and repackaging of medication.

The CAH's failure to dispose of expired supplies placed all patients at risk for receiving ineffective supplies. The CAH's failure to provide pharmacy oversight in accordance with accepted regulations placed all patients at risk for medication errors.


Findings include:

EXPIRED SUPPLIES

- The Emergency Trauma Room #1 observed on 5/24/2016 at 11:45 AM and revealed the following outdated supplies in the Emergency Crash Cart:

1) Two Endotracheal tube (maintains airway) sterile packets 7.3cm (centimeter) had an expiration date of 3/2016.


- The Emergency Trauma Room #1, observed on 5/24/2016 at 11:45 AM, revealed the following outdated supplies in the Pediatric Broselow cart:

1) Two IV (Intravenous- giving fluids or meds through a vein) Transfer sets (extension tubing) had expiration dates of 4/2016.

The Director of Nursing, Staff B, was interviewed on 5/24/2016 at 12:00 PM and acknowledged the outdated supplies should have been disposed.

- Emergency Room #2 was observed on 5/24/2016 at 1:15 PM and revealed the following outdated supply in the wall cabinet:

1) One Betadine (skin disinfectant) swab stick with expiration date of 9/2015.

The Director of Nursing, Staff B, was interviewed on 5/24/2016 at 12:00 PM and acknowledged the outdated supplies should have been disposed.

- The CAH Policy, reviewed on 5/24/2016 at 3:00 PM, revealed the CAH failed to develop a policy to ensure all outdated supplies are disposed properly.


DISPENSING MEDICATIONS

- Kansas Pharmacy regulation 68-7-11. Medical care facility pharmacy. (3) The designated registered professional nurse or nurses may enter the medical care facility pharmacy and remove properly labeled pharmacy stock containers, commercially labeled packages, or properly labeled prepackaged units of drugs. The registered professional nurse shall not transfer a drug from one container to another for future use, but may transfer a single dose from a stock container for immediate administration to the ultimate user.

Interview with the Director of Nursing Services on 5/23/2016 revealed all medication ordering, stocking, and repackaging of medication was performed by designated nursing staff. Observation of the pharmacy stock room and interview with the Director of Nursing Services on 5/23/2016 revealed that the pharmacist was present only when notified by the nursing staff of need for oversight. The function of all medication ordering, stocking, and repackaging is performed by designated nursing staff.

- During an observation with the staff B and staff C on 5/23/2016, it was stated that medications are removed from original packaging when a container is low. The medication is placed in zip lock bags, labeled with medication name, dose, and expiration date. The medications are then placed in a pharmacy general stock bin. All of the functions are performed by designated nursing staff without direct oversight by the pharmacist.

- There was no CAH policy and procedure that addressed pharmacy services pertaining to pharmacy oversight related to standards of practice for dispensing medications.

Based on observation, interview, record review and review of the Critical Access Hospital (CAH) policies and procedures, the CAH failed to ensure the infection control officer had education and/or experience and training in the principles and methods for infection prevention and control. The CAH's Infection control and prevention program did not ensure staff members followed standards of practice for infection control as evidenced by:

1. The CAH failed to complete a infection control risk assessment prior to remodeling.
2. Staff (Registered Nurse (RN) Staff B and RN Staff D) failed to perform appropriate hand hygiene.
3. Staff (RN Staff D, Physician Staff F and Staff H) actions caused the potential for cross-contamination.
4. Improper use of personal protective equipment/surgical attire (Staff H).
5. Staff (RN Staff F and RN Staff P) failed to performa a proper terminal clean of the operating room after a procedure.
6. Opened food jar was kept in the refrigerator for more than two months.
7. Kitchen drain had potential for backflow of sewage and cross-contamination of food.

Failure to have an infection control officer with education and/or experience with training resulted in an infection control program that did not monitor staff member infection control practices, did not track identified infections or monitor antibiotic medication therapy. This failure placed all patients at risk for hospital acquired infection and/or cross contamination.


Findings include:


INFECTION CONTROL PROGRAM

1. Interview on 5/24/2016 at 2:40 to 3:40 p.m. with the CAH's infection control officer revealed s/he did not receive infection control education or had experience or training in infection control methods. The Infection Control officer stated that s/he was filling in for the past three months since the previous infection control officer retired.

2. Review of the CAH reportable communicable diseases did not list up to date reportable communicable diseases.


3. The CAH did not track or monitor multi-drug resistant organisms. The CAH did not track antibiotic use.


REMODELING POLICY AND PROCEDURE
1. According to the infection control officer, the hospital did not have a policy and procedure to address actions taken during remodeling or construction to protect patients and visitors from air pollution that could potentially spread infections. It was learned that the hospital had recently remodeled the entire hospital and was completed in September 2015.


HAND HYGIENE
According to the Center for Disease Control and Prevention hand hygiene should be performed:
1. Before eating. 2. Before and after having direct contact with a patient's intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed). 3. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. 4. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. 5. If hands will be moving from a contaminated-body site to a clean-body site during patient care. 6. After glove removal. 7. After using a restroom.

The CAH Policy for Nosocomial Infection Prevention-Hand washing stated, "Health Care Workers will wash their hands to prevent the spread of nosocomial infections: Before applying and after removing gloves."


1. Director of Nursing, RN, Staff B observed on 5/24/2016 at 12:45 PM revealed Staff B failed to perform hand hygiene after removing gloves while in patient #8's room after administrating IV antibiotic.

Director of Nursing, RN, Staff B interviewed on 5/24/2016 at 1:00 PM acknowledged they should have done hand hygiene after removing their gloves.

2. Director of Nursing, RN, Staff B observed on 5/24/2016 at 3:10 PM revealed Staff B failed to perform hand hygiene when entering the nursing medication room prior to preparing the Toradol (anti-inflammatory pain) injection for patient #8.

Director of Nursing, RN Staff B observed on 5/24/2016 at 3:15 PM revealed Staff B failed to perform hand hygiene when entering patient #8 room and after touching the computer in the patient's room prior to giving patient #8 pain medication.

Director of Nursing, RN, Staff B, interviewed on 5/24/2016 at 4:00 PM acknowledged they should have done hand hygiene when entering the patient's room and prior to giving the pain medication to the patient.

3. Registered Nurse Staff D observed on 5/25/2016 at 8:40 AM revealed Staff D failed to perform hand hygiene when entering patient #19's room (205), then proceeded to pick up an IV bag and left the room and entered in the nursing medication room.

Registered Nurse Staff D interviewed on 5/25/2016 at 8:42 AM acknowledged they did not performed hand hygiene when entering and exiting patient #19's room. Staff D stated they should have.

4. Registered Nurse (RN) Staff D was observed on 5/25/2016 at 9:38 a.m. during the insertion of an Intravenous (IV) catheter for the infusion of fluid.

RN Staff D washed his/her hands and approached patient #23 and completed a physical assessment.

After touching the patient and documenting on a computer keyboard s/he donned latex gloves and inserted the IV catheter. No hand hygiene was performed before donning the latex gloves and inserting the IV catheter.


CROSS CONTAMINATION
1. Registered Nurse Staff D observed on 5/25/2016 at 9:15 AM revealed Staff D failed to dispose of sterile IV extension tubing after the first unsuccessful attempt to place an IV in patient #19. Staff D placed the sterile IV extension set without capping off the end of the tubing, placing it back in a plastic container that had been contaminated with Staff D hands.

2. During an observation of a colonoscopy procedure on 5/25/2016 at 1:00 p.m. a physician (staff member #H) was observed donning a glove that had fallen on the floor of the treatment room, then continued to perform the colonoscopy.


Interview after the procedure with the Nursing Director of Surgery who was attending the procedure stated that s/he did not observe the incident but would have asked staff member #H to change the glove.


3. During the colonoscopy procedure Staff member #H adjusted his/her face mask and shield with a contaminated gloved hand.


SURGICAL ATTIRE
1. During the colonoscopy procedure on 5/25/2016, observation of Staff member #H revealed s/he wore a skull cap that did not cover all the hair on his/her head.

2. During the colonoscopy procedure on 5/25/2016 Staff H was observed performing the procedure without a cover gown (a gown worn during surgery or procedure that covers and protects attire from contamination).

After the colonoscopy procedure, Staff H left the procedure room. When the Nurse Director of Surgery was asked where Staff H was going, s/he answered to visit a patient on the floor that had a prior procedure performed. Staff H did not change the attire worn during the procedure prior to leaving the area and visiting with a patient.


TERMINAL CLEANING
1. During an operating Room observation on 5/25/2016 at 3:30 PM Staff F and Staff P failed to ensure the terminal cleaning was done properly.

Registered Nurse Staff F interviewed on 5/25/2016 at 4:00 PM revealed that they did not know the proper terminal cleaning procedure. Staff F stated they cleaned thoroughly from ceiling to floor, once a month.

FOOD STORAGE
1. Observation of the patient refrigerator in the patient care area revealed a jar of applesauce that had mold growing in it. The jar was initially opened in March 2016 (2 months prior). Review of the cleaning report for the refrigerator indicated the refrigerator was to be cleaned out each month. The last time the refrigerator was cleaned was 3/18/2016.

FOOD PREPARATION
1. Observation of the CAH kitchen revealed there was no air gap installed in the prep sink. Failure to prevent a backflow of sewage into the prep sink potentially placed all patients and visitor to the cafeteria at risk for contamination of food.

Based on medical record review and staff interview the Critical Access Hospital (CAH) failed to ensure that a History and Physical (H&P) was completed for 1 of 20 patients' (Patient #21) records reviewed.

Failure to include an H&P in the medical records results in incomplete information/documentation regarding medical history, assessment of the health status and health care needs of the patient.

Findings include:

1. Review of the medical record of Patient #21 on 5/24/16 revealed s/he was admitted to the CAH on 3/24/2016 with pneumonia (an infection in the lungs). There was no H&P found in the medical record.

2. On 5/25/2016 at 10:00 a.m. staff member #O confirmed/verified there was no H&P in patient #21's medical record for the admission date of 3/24/2016.

3. Review of the CAH Medical Records policy and procedures manual on 5/26/2016 revealed the policy for History and Physical included "The history and physical sheet" that was used to record the history and physical examination report about a certain patient. The form is utilized by Medical Record personnel when transcribing dictation done by a medical staff professional, usually an attending physician, nurse practitioner, or med student, about the patient. The history and physical information may consist of present illness, past medical and surgical history, family history, allergies, medication's being taken by the patient, review of systems, vital signs, physical examination and an assessment of the patient's condition. The dictation and the examination should be accomplished the day of admission of that patient. The form must then be signed by the physician.

The Medical Record Department policy states, "The medical record shall contain, when applicable, identification data, chief complaint, present illness, past history, physical examination, provisional diagnosis, ..."

Based on observation, document review, and staff interview, it was determined that the Critical Access Hospital failed (CAH) to ensure the necessary supply of an emergency medication (Dantrolene) and sterile water for reconstituting the drug for surgical patients experiencing a Malignant Hyperthermia (MH-a potentially fatal inherited disorder in response to certain general anesthetics or succinylcholine) episode.



The CAH's failure to stock the necessary amount of Dantrolene placed all surgical patients at risk for harm including death.



Findings include:



- The Malignant Hyperthermia Association of the United States stated that a stock of 36 vials of Dantrolene is recommended. "The patient experiencing an MH episode must be stabilized before being transported. Stabilization of an MH episode may take 30 minutes or more with multiple doses of dantrolene because, in some cases, MH progresses with explosive rapidity ... The full 36 vials of dantrolene should be available within five minutes of the diagnosis of MH."



- Observation of the operating and treatment areas of the Critical Access Hospital and through interview with staff member #A on 5/25/2016 at 4:00 p.m. revealed the CAH failed to ensure a supply of the required 36 vials of 20 milligrams of Dantrolene. The CAH had a supply of 24 vials. The CAH failed to ensure that there was a supply of sterile water required for reconstitution of the Dantrolene. Failing to have a supply of sterile water for reconstitution resulted in the inability to administer the Dantrolene. This failure placed all patients at risk of not surviving malignant hyperthermia reaction from general anesthesia.



According to the Nurse Director of Surgery on 5/25/2016, s/he was unaware that the Critical Access Hospitals required 36 vials of Dantrolene and sterile water for reconstitution.




- The surveyors as representatives of the Centers for Medicare and Medicaid Services notified the CAH Administrator that they identified an Immediate Jeopardy situation on 5/25/2016 at 5:10 pm when an insufficient amount of medication (Dantrolene-an emergency drug used for treating malignant hyperthermia-a rare reaction to drugs used for general anesthesia) and sterile water to reconstitute the medication was discovered and the Critical Access Hospital (CAH) had performed recent surgeries requiring general anesthesia and had planned future surgeries requiring general anesthesia.



- The CAH provided a plan to correct the failed practice including obtaining the twelve vials of dantrolene and the sterile water required to reconstitute the drug, halting any surgical procedures until the medication was obtained, and putting a system of checks and balances into place to ensure that the proper amount of dantrolene and sterile water was available at all times. 12 - 20 milligram vials of Dantrolene and 2 liters of sterile water arrived at the hospital and were inspected and the immediate jeopardy was removed at 6:30 p.m on 5/25/16.



- CAH policies and procedures were reviewed without locating a policy and procedure that addressed the hospital's pharmacy services ensured a required amount of Dantrolene or other similar drug was available at all times.

Based on interview and review of documents, it was determined that the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis.

This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.

Findings include:

- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March 2011.
Refer to Tag C-0331 - 0343 for further details.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis.

This failure resulted in outdated policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.

Findings include:

1. The Critical Access Hospital failed (CAH) to ensure the necessary supply of emergency medication (Dantrolene) and sterile water for reconstituting the drug for surgical patients experiencing a Malignant Hyperthermia (MH-a rare life-threatening reaction to drugs used for general anesthesia) episode. Failure to stock the necessary amount of Dantrolene and sterile water to reconstitute the drug placed all surgical patients at risk for harm including death.

Through interview and review of policies and procedures no policy and procedure was located that related to the CAH ensuring an addequate amount of Dantrolene or equivalent was available during surgery requiring general anesthesia.


2. Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.

Review of Infection Control policies show they were last reviewed in March of 2011 and the manual contained outdated materials to include; reportable communicable diseases and failure to monitor antibiotic use in identified multidrug resistant organisms.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including the utilization of CAH services, including at least the number of patients served and the volume of services.

This failure resulted in outdated policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.

Findings include:

- Document titled "2015 Combined Statistics Report" revealed the number of visits in the past three years to all areas including ED, Acute beds, Swing beds indluding average length of stay.


- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that the statistics report had been reviewed or the information used to address the adequacy of the CAH's services for the community.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including a review of a representative sample of both active and closed clinical records.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:


- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that representative samples of open and closed records had been reviewed annually or the information used to address the adequacy of the CAH's services for the community.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including the CAH's healthcare policies.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:


- Review of the CAH policies and procedures manual including the healthcare policies showed the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a total program review occurred annually to evaluate the CAH's healthcare policies.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including determining whether the utilization of services was appropriate, whether established policies were followed, and whether any changes were needed.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.



Findings Include:


- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a yearly evaluation had occurred to determine whether revisions of any of the policies was necessary to address the changing clinical practice guidelines and to meet the needs of the community.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including reviewing the effectiveness of their quality assurance (QA) program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and the treatment outcomes.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:


- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a review of the CAH's QA program occurred to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and the treatment outcomes.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including evaluating all patient care services and other services affecting patient health and safety.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:



- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a review of the CAH's QA program occurred annually to evaluate all patient care services and services affecting patient health and safety.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including evaluation of nosocomial infections and medication therapy.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:

- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a total program review occurred annually to evaluate nosocomial infections and medication therapy.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including evaluating the quality and appropriateness of treatment furnished by the nurse practitioners and physician assistants at the CAH.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:


- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a total program review occurred annually to evaluate the quality and appropriatenss of the treatment by nurse practitioners and physician assistants.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including evaluating the quality and appropriateness of the diagnosis and treatment furnished by medical doctors and doctors of osteopathy at the CAH.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:


- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a total program review occurred annually to evaluate the care provided by the medical doctors and doctors of osteopathy at the CAH.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including considering the findings of the evaluations and taking corrective actions if necessary.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:


- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a total program review occurred annually including considering the evaluation and taking corrective action.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including taking appropriate remedial action to address any deficiencies found through the quality assurance (QA) program.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:


- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a total program review occurred annually to address any deficiencies found in the QA program.

Based on interview and review of documents, the Critical Access Hospital (CAH) failed to carry out a periodic evaluation of its total program on a yearly basis including documenting the outcome of all remedial actions.


This failure resulted in policies and procedures that did not reflect current CAH practice. This resulted in the CAH failing to develop and implement necessary and updated policies to ensure quality care, consistent with standards of practice and the provision of services in a safe environment.


Findings Include:


- Review of the CAH policies and procedures manual indicated the last time the policies and procedures were reviewed was in March of 2011. This was confirmed by the CAH administrator in an interview on 5/25/16 at 8:40 am.


- There was no evidence provided that a total program review occurred annually including documentation of the outcome of any remedial actions taken.

Based on review of medical records and observation the Critical Access Hospital (CAH) failed to ensure that 1 of 2 Swing bed patients (patient #6) was provided the Notice of Patient Rights.

By not providing the patients with Notice of Rights, the CAH fails to ensure that patients know their rights and responsibilities while a patient in the CAH.

Findings include:

- Medical Record Review of swing bed patient #6 admitted in 2009 with advanced age revealed no documentation that the patient or responsible party received notice of Patient Rights.

- The CAH ' s policy and procedure for Patient Rights was reviewed on 5/26/2016 and revealed; " Upon admission to Washington County Hospital each patient will receive a copy of the "Patient ' s Rights." A signed acknowledgement of the patient's receipt of the Patient's Rights document will be made a permanent part of the medical record... "