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Based on observation, staff interview and administrative policy review, the critical access hospital (CAH) failed to ensure their total number of beds available for inpatients did not exceed 25. The CAH reported a current census of 12 inpatients at the time of the survey.

Failure to ensure the CAH maintained only 25 beds available for inpatient care could potentially result in the CAH's ability to provide care and services as a CAH.

Findings include:

Observation during tour of the inpatient care area with Nurse Manager of Inpatients, on 2/23/15 at 11:30 AM revealed 25 beds and 2 cribs (total 27 beds), were set up and available for inpatient use.

During at interview on 2/23/15 at 11:30 AM, Nursing Manager of Inpatients acknowledged the hospital's total number of beds available for inpatients was 27 including 25 med/surg/OB beds and 3 cribs stored in a room adjacent to the inpatient area.

Review of the administrative policy titled 25 Acute and Skilled care beds Critical Access Hospital, dated 6/11, stated in part...Critical Access Hospitals are limited to a maximum of 25 beds that can be used for inpatient care.

Based on observation and staff interview, the Critical Access Hospital (CAH) ultrasound staff failed to document the date 1 of 1 bottle of Cidex OPA test strips was opened in accordance with the manufacturer's requirements. The facility reported an average of 5 ultrasound procedures were performed daily.

Failure to document the date staff opened the bottle of Cidex OPA test strips could potentially allow staff to use the test strips after the manufacturer's shortened expiration date, potentially resulting in inaccurate test results, which could lead to patients receiving inappropriate treatment.

Findings include:

1. Observation on 2/24/15 at 2:35 PM, during tour of the Ultrasound Room with Staff Q, Ultrasound/Radiology Technician, revealed 1 of 1 opened bottle of Cidex OPA test strips available for use. The bottle of Cidex OPA test strips lacked documented evidence of the date the staff first opened the bottle.

2. Review of the manufacturer's instruction for the Cidex OPA test strips stated in part, ". . . Do not use any remaining strips 90 days after opening the bottle. . . Improper storage or use of test strips may result in false readings. . . ."

3. During an interview at the time of the tour, Staff Q acknowledged the Cidex OPA test strips lacked documented evidence of the date the staff opened the bottle to reflect the shortened expiration date, as required by the manufacturer.

Based on document review, policy/procedure review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician, in conjunction with the physician assistant and/or nurse practitioner members, periodically reviewed the Emergency Department (ED) patient records for 3 of 3 Advanced Registered Nurse Practitioners (ARNP) and 1 of 1 Physician Assistant (PA) evaluating and providing care to patients in the ED.

The administrative staff at the CAH identified approximate numbers of patients evaluated and provided care and services by mid-level physicians in the ED were as follows:

- Practitioner C, PA: 74 patients in 20015
- Practitioner A, ARNP: 71 patients in 20015
- Practitioner B, ARNP: 15 patients in 20015
- Practitioner D,ARNP: 98 patients in 20015

Emergency room staff identified an average of 100 patient visits a week in the ED.

Failure to ensure a physician periodically reviews, in conjunction with the mid-level providers, the care provided by the mid-level practitioners affects the facility's ability to assure mid-level providers are consistently providing quality care to patients.

Findings include:

Review of the "Cherokee Regional Medical Center Medical Staff Bylaws", amended 12/2013, revealed the Bylaws lacked a requirement for a physician to review in conjunction with the mid-level providers the patient care provided at the facility by the mid-level providers in the ED.

Review of the CAH's policies revealed no policy for a physician to review in conjunction with the mid-level providers the patient care provided at the facility in the ED.

During an interview on 2/25/15 at 9:50 AM, Staff C, Director of Health Information Manager stated the mid-level providers in the ED send all patient medical records electronically to the on call physician review following evaluation of the patient. The on call physician reviews the mid-level's care and treatment for the patient and co-signs the medical record electronically at the time of review. Staff C said she did not know if physicians review the mid-level ED patient medical records in conjunction with the mid-levels.

During an interview on 2/25/15 at 10:00 AM, the Chief Executive Officer, CEO stated the CAH had initiated monthly mid-level meetings 3 months ago. All 4 mid-level providers and 1 physician attend the meetings monthly. The CAH started these meetings to keep communication open between the mid-level providers and the physicians. The CEO said staff discuss ED patient medical records for appropriate care, but staff do not select specific patient medical records records for the 4 mid-level providers and document the review was completed for the mid-levels. The CEO stated the CAH did not have a policy for physician to mid-level provider medical record review.

Based on observation, policy review and staff interviews, the Critical Access Hospital (CAH) dietary staff failed to use sanitary practices during food handling and patient meal service. The administrative staff identified a census of 12 inpatients and the Dietary Manager identified dietary staff provided approximately 30 patient meals daily.

Failure to maintain sanitary practices during meal service and food handling could potentially result in contamination of the patient's food leading to foodborne illness.

Findings include:

1. Observation during breakfast food preparation and meal service on 2/24/15, from 7:45 AM to 8:25 AM, identified the following concerns:

Staff K, cook, initiated the observation period with clean hands. Staff K put a glove on one hand on 3 separate occasions to handle ready-to-eat foods, but failed to wash her hands before donning the gloves. In addition she touched a variety of surfaces, with the gloved hand, including, but not limited to, a container of grated potatoes, pre-portioned bags of chopped vegetables, carton of liquid eggs, squeeze bottle of liquid margarine, refrigerator door handles, microwave door, package of bread and English muffins and toaster handle. This resulted in Staff K serving ready-to-eat foods to patients, including an English muffin, toast and an omelet, with a contaminated glove.

Observation during lunch food preparation and meal service on 2/24/15, from 11:20 AM to 12:30 PM, identified the following concerns:

Staff K, initiated the observation period with clean hands. Staff K put a glove on one hand on 3 separate occasions, to handle ready-to-eat foods. On 2 occasions, she obtained a glove from the box and laid it on the food preparation counter prior to donning. Staff K failed to wash her hands before donning the gloves. In addition, she touched a variety of surfaces, with the gloved hand, including, but not limited to, refrigerator door handles, raw chicken breast, mayonnaise container, bread and hamburger bun package, package of ham and microwave door. This resulted in Staff K serving ready-to-eat foods to patients, including sandwiches, sliced tomato, onion and pickles, leaf lettuce with a contaminated glove.

2. During an interview on 2/25/15 at 8:15 AM, Staff J, Clinical Dietitian, acknowledged Staff K should have washed her hands prior to donning a glove.

During an interview on 2/25/15 at 8:50 AM, Staff I, Dietary Manager, confirmed Staff K, handled several surfaces with a gloved hand and then handled ready-to-eat food with a contaminated glove. In addition, she confirmed Staff K should have washed her hands prior to donning a clean glove. Staff I reported she talked to Staff K, after the observation period, to ensure she was aware of the problems her food handling techniques.

3. Review of a dietary policy titled " Disposable Glove Use", reviewed and approved in 8/2014, revealed in part ". . . When gloves are worn, they must be changed between tasks. Proper handwashing procedures must be used . . ."

Review of a dietary policy titled "Hand Washing", reviewed and approved in 8/2014, revealed in part ". . . To control the spread of harmful bacteria, all employees are responsible to wash hands . . . The following events indicate when hand washing is necessary . . . After hand contact with unclean equipment and work surfaces, soiled clothing and rags . . "
The Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, in both the 2005 and 2013 editions, requires gloves to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. Food employees must clean their hands after handling soiled equipment and utensils, during food preparation, as often as necessary to remove soil and prevent cross contamination when changing tasks and before donning gloves for working with food.

Based on review of policies/procedures, open and closed acute patient medical records, and staff interview, the Critical Access Hospital (CAH) failed to ensure the nursing care plan was individualized for patients at risk for falls in 2 of 3 open acute patient medical records (Patients # 8 and 9) and 2 of 4 closed acute patient medical records (Patients # 10 and 11). The facility identified an average of 11 acute patients per day.

Failure to individualize care plans for patients at risk for falls could potentially result in disruption of the patient's continuity of care and services which could impact the patient's needs and care provided.

Findings include:

1. Review of CAH policy/procedure titled "Care Plan Preparation", dated April 4, 2014, revealed in part, ". . . A care plan directs a patient's nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings. . . Implementation. . . Based on an analysis of the data, determine which nursing diagnoses will guide your patient care. Be sure to address all of the patient's significant needs when determining nursing diagnoses. . . ."

Review of CAH policy titled "Fall Prevention", dated January 9, 2015, revealed in part, ". . . A risk assessment for falls should be performed for all admitted patients. When performing a fall risk assessment, use a standardized, facility-approved assessment tool, such as the . . . Morse Fall Scale. . . ."

Review of an undated document provided by the CAH titled "Morse Fall Scale for Identifying Fall Risk Factors" noted the patient's fall risk score greater than 45 as high risk for falls.

2. Review of 2 of 3 open patient medical records of patients identified as high risk for falls lacked risk for falls identified on the patient's care plan as follows:

a. Patient # 8 was admitted 2/23/15 and was assessed with a fall risk score of 70. The care plan for the patient lacked the risk for falls.

b. Patient # 9 was admitted 2/22/15 and was assessed with a fall risk score of 100. The care plan for the patient lacked the risk for falls.

3. Review of 2 of 4 closed patient medical records of patients identified as high risk for falls lacked risk for falls identified on the patient's care plan as follows:

a. Patient # 10 was admitted 10/16/14 and was assessed with a fall risk score of 50. The care plan for the patient lacked the risk for falls.


b. Patient # 11 was admitted 11/7/14 and was assessed with a fall risk score of 75. The care plan for the patient lacked the risk for falls.

4. During an interview on 2/25/15 at 2:20 PM, Staff W, Utilization Review Manager, acknowledged Patients # 8, 9, 10, and 11 were assessed with fall risk scores greater than 45 and the care plan for the patients did include their risk for falls.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to delineate privileges for 1 of 1 Registered Nurses Staff B, who was not an employee of the hospital, to assist with surgical procedures. The Registered Nurse (RN) assisted with 3 to 4 surgical procedures a month provided by an associated practitioner, Practitioner G.

Failure to privilege all assistants that accompany providers could result in patients receiving surgical interventions from unqualified professionals.

Findings include:

1. Review of Medical Staff Bylaws, dated December 2013, revealed, in part, ". . . 6.2 Each member and applicant for membership and clinical privileges in all categories shall, upon application or reapplication and continuously thereafter, meet each of the qualifications listed below. b. Competence. Possess and maintain demonstrated clinical competence, including current knowledge, judgement and technique in his or her specialty area and for all privileges held or applied for. . ."

Review of the Operating Room Log on 2/24/15 at 10:40 AM with Staff E, Operating Room Manager revealed Staff B provided surgical assistance for Practitioner G during surgical interventions for patients. Staff B assisted with 3 to 4 surgical procedures a month completed by Practitioner G.

Review of the Surgical Privileges Manual kept in the Surgery area on 2/24/15 lacked documentation of privileges for Staff B.

Review of Staff B's personnel file on 2/24/15 lacked documentation of privileges.

2. During an interview on 2/25/15 at 7:45 AM, Staff A, Vice President of Regulation and Compliance, stated Staff B lacked surgical privileges to provide assistance during surgical procedures with Practitioner G. Staff A stated the CAH ensured Staff B had a current RN license, but did not privilege Staff B for assisting Practitioner G with surgical procedures. Unless Staff B worked with patients independently, the CAH would not privilege her.

Based on review of documents and staff interview the critical access hospital (CAH) failed to complete the external entity review for all physicians credentialed at the hospital. The hospital administrative staff identified 9 of 88 credentialed providers files included external entity review.

Failure to complete external entity review for all providers could potential result in the CAH's ability to verify the physicians provided appropriate care for the patients of the CAH.

Findings include:

The review of 10 providers credentialing files revealed 3 (Providers H, I and J) of 10 files lacked an external entity review. The external entity review is completed by providers of the network hospital and provides information related to the quality and appropriateness of the diagnoses and treatment furnished by the CAH ' s providers.

The review of the Critical Access Network Agreement, dated 3/17/10 states in part ...the network hospital shall assist the CAH in reviewing the quality and appropriateness of the diagnoses and treatment furnished by the CAH ' s physicians and other practitioners on an annual basis for purposes of assisting the CAH in carrying out the requirements of its quality assurance plan.

During an interview on 2/25/15 at 9:45 AM with Staff L, Registered Nurse Utilization Review acknowledged external peer review is completed on our 5 active providers (Providers E, F, K, L and M) and our 4 active mid-level providers (Mid-levels A, B, C and D). The Vice-President of Regulatory/Compliance verified this information.

Based on review of policies/procedures, open and closed swing bed patient medical records, and staff interview, the Critical Access Hospital (CAH) failed to ensure the nursing care plan was individualized for patients at risk for falls in 2 of 2 open swing bed patient medical records (Patients # 6 and 7) and 6 of 6 closed swing bed patient medical records (Patients # 2, 3, 4, 5, 12, and 13). The facility identified a current census of 4 swing bed patients and an average of 13 swing bed patients per month.

Failure to individualize care plans for patients at risk for falls could potentially result in disruption of the patient's continuity of care and services which could impact the patient's needs and care provided.

Findings include:

1. Review of CAH policy/procedure titled "Care Plan Preparation", dated April 4, 2014, revealed in part, ". . . A care plan directs a patient's nursing care from admission to discharge. This written action plan is based on nursing diagnoses that have been formulated after reviewing assessment findings. . . Implementation. . . Based on an analysis of the data, determine which nursing diagnoses will guide your patient care. Be sure to address all of the patient's significant needs when determining nursing diagnoses. . . ."

Review of CAH policy titled "Fall Prevention", dated January 9, 2015, revealed in part, ". . . A risk assessment for falls should be performed for all admitted patients. When performing a fall risk assessment, use a standardized, facility-approved assessment tool, such as the . . . Morse Fall Scale. . . ."

Review of an undated document provided by the CAH titled "Morse Fall Scale for Identifying Fall Risk Factors" noted the patient's fall risk score greater than 45 as high risk for falls.

2. Review of 2 of 2 open swing bed patient medical records of patients identified as high risk for falls lacked risk for falls identified on the patient's care plan as follows:

a. Patient # 6 was admitted 2/15/15 and was assessed with a fall risk score of 85 lacked risk for falls identified on the patient's care plan.

b. Patient # 7 was admitted 2/16/15 and was assessed with a fall risk score of 50 lacked risk for falls identified on the patient's care plan.

3. Review of 6 of 6 closed swing bed patient medical records of patients identified as high risk for falls lacked risk for falls identified on the patient's care plan as follows:

a. Patient # 2 was admitted 10/30/14 and was assessed with a fall risk score of 80. The care plan for the patient lacked the risk for falls.

b. Patient # 3 was admitted 11/16/14 and was assessed with a fall risk score of 45. The care plan for the patient lacked the risk for falls.


c. Patient # 4 was admitted 11/27/14 and was assessed with a fall risk score of 60. The care plan for the patient lacked the risk for falls.

d. Patient # 5 was admitted 12/21/14 and was assessed with a fall risk score of 55. The care plan for the patient lacked the risk for falls.

e. Patient # 12 was admitted 12/9/14 and was assessed with a fall risk score of 100. The care plan for the patient lacked the risk for falls.

f. Patient # 13 was admitted 9/6/14 and was assessed with a fall risk score of 100. The care plan for the patient lacked the risk for falls.

4. During an interview on 2/25/15 at 2:20 PM, Staff W, Utilization Review Manager, acknowledged Patients # 8, 9, 10, and 11 were assessed with fall risk scores greater than 45 and the care plans for the patients lacked their risk for falls.
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Based on review of documents, medical records, and staff interview, the Critical Access Hospital (CAH) swing bed interdisciplinary team failed to ensure the attending physician participated in the interdisciplinary care conferences for the development of the patient's individualized care plan for 2 of 2 applicable open swing bed patients (Patients # 6 and 7) and 4 of 4 closed swing bed patients (Patients # 2, 3, 4, and 5). The facility identified a current census of 4 swing bed patients and an average of 13 swing bed patients per month.

Failure to obtain input from the attending physician during the formulation and revision of the patient's individualized care plan could result in the delay of implementation of treatment modalities to improve the patient's functional abilities, to enhance healing, and to shorten the patient's hospital stay.

Findings include:

1. Review of 2 of 2 applicable open swing bed patients medical records revealed the following:

a. Patient # 6 admitted to swing bed 2/15/15 for physical therapy. Discharge Planning and Rehabilitation documentation lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

b. Patient # 7 admitted to swing bed 2/16/15 for IV antibiotics and physical therapy. Discharge Planning and Rehabilitation documentation lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

2. Review of 4 of 4 closed swing bed patients medical records revealed the following:

a. Patient # 2 admitted to swing bed from 10/30/14 to 11/14/14 with congestive heart failure and intractable back pain due to lumbar fracture and for physical therapy. Discharge Planning and Rehabilitation documentation lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

b. Patient # 3 admitted to swing bed from 11/16/14 to 11/25/14 for IV antibiotics. Discharge Planning and Rehabilitation documentation lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

c. Patient # 4 admitted to swing bed from 11/27/14 to 12/4/14 for occupational and speech therapy. Discharge Planning and Rehabilitation documentation lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

d. Patient # 5 admitted to swing bed from 12/21/14 to 12/29/14 for IV antibiotics. Discharge Planning and Rehabilitation documentation lacked evidence showing the physician participated, signed, and/or was updated by the interdisciplinary team on the care plan developed and reviewed at the care conferences.

3. Review of CAH policy titled "General Policies for Swing/Inn Care Patients (SWG)", dated 8/09, revealed in part, ". . . Interdisciplinary Care Conferences will be held as required to meet the patient/resident needs and consistent with the individual plan of care. . . ."

The policy failed to include the physicians involvement with the interdisciplinary care plan conferences.

4. During an interview on 2/23/15 at 3:35 PM, Staff W, Utilization Review Manager, acknowledged the policy failed to include physician involvement with interdisciplinary care plan conferences. Staff W confirmed the lack of physician involvement with the interdisciplinary care plan conferences.

Based on document review, observations, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure patients (or support persons where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients. The CAH staff identified a current census of 12 patients - 8 acute patients and 4 swing bed patients.

The CAH staff identified an average number of patients served in the following areas:
- Inpatients: 11 patients per day
- Skilled patients: 13 patients per month
- Emergency Room: 100 patients per year
- Laboratory: 9,256 inpatient tests per year; 45,189 outpatient tests per year
- Radiology: 1,122 inpatients tests per year; 10,221 outpatient tests per year
- Surgery (inpatient and outpatient): 20 per week
- Physical Therapy: 2,039 inpatient visits per year; 6,706 outpatient visits per year; 954 Holstein outpatients per year
- Occupational Therapy: 700 inpatient visits per year; 686 outpatient visits per year
- Speech Therapy: 67 inpatients visits per year; 203 outpatient visits per year
- Respiratory Therapy (inpatient and outpatient): 440 treatments per month
- Infusion Therapy Area: 130 outpatients per month
- Cardiac Rehabilitation: 30 outpatient visits per month
- Pulmonary Rehabilitation: 12 outpatient visits per month
- EKG: 100 per month
- Holter Monitors: 10 outpatients per month
- Diabetic Education: 35 outpatients per year
- Nutrition Consults: 27 outpatients per year
- Sleep Study: 8 outpatients per month

Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of "Patient Rights and Responsibilities" patient handout, revised 2/05, revealed the document lacked the current patient visitation rights information regarding consent to receive visitors he or she has designated, either orally or in writing, including but not limited to, spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time.

2. During an interview and observation during tour of the Radiology area on 2/24/15 at 8:55 AM, Staff U, Patient Registration Clerk, stated the Radiology outpatients are registered in Radiology. Staff U acknowledged the Patient Rights Information was not provided to the outpatients.

During an interview and observation during tour of the admissions area on 2/24/15 at 11:05 AM, Staff R, Admitting Clerk, stated the following patients were registered at the admissions desk: Physical Therapy, Occupational Therapy, Speech Therapy, EKG, Holter Monitor, Diabetic Education, Nutritional Consults, Emergency Room, Surgery, and Inpatients. Staff R acknowledged only inpatients, not outpatients, were given the patient handout titled "Patient Rights and Responsibilities".

During an interview and observation during tour of the Laboratory area on 2/24/15 at 2:20 PM, Staff S, Laboratory Clerk, stated the Laboratory outpatients are registered in the Lab and the patient handout titled "Patient Rights and Responsibilities" was available to the patients in a wall-mounted brochure holder.

During an interview and observation during tour of the Specialty Clinic area on 2/24/15 at 3:40 PM, Staff T, Receptionist Specialty Clinic, stated the following patients were registered at the Specialty Clinic desk: Cardiac Rehabilitation, Pulmonary Rehabilitation, Respiratory Therapy, Infusion/Chemotherapy, Stress Test, and Sleep Study.

During an interview and observation during tour of the Holstein Physical Therapy Clinic on 2/25/15 at 9:20 AM, Staff V, Manager Physical Medicine and Rehabilitation, stated the outpatients are registered over the telephone and the patient handout titled "Patient Rights and Responsibilities" was posted in the Holstein Clinic area.

During an interview on 2/25/15 at 10:55 AM, Staff A, Vice President Regulatory/Compliance, acknowledged the CAH's Visiting Policy had been updated to include the current visitation rights. Staff A further acknowledged the patient handout titled "Patient Rights and Responsibilities", available to patients, had not been updated to include the current visitation rights.