HospitalInspections.org

Based on document review and staff interviews, the CAH administrative staff failed to ensure 1 of 12 employees, selected for review, repeated training for mandatory abuse reporting every 5 years, as required. (Staff O).

235 B16.5b. A person required to report cases of dependent adult abuse pursuant to sections 235B.3 and 235E.2, ... shall complete two hours of training relating to the identification reporting of dependent adult abuse within six months of initial employment and every 5 years thereafter.

Failure to ensure all staff, attending to CAH patients, receives abuse training may result in failure to report potential abusive situations placing patients at risk.

Findings include:

Review of a Health Education policy titled, "Abuse Mandatory Training", approved 9/13/2016, revealed in part "... Any employee involved in the examination, attending, counseling, and/or treatment of children and/or dependent adults will complete at least two hours of child abuse and/or dependent adult identification and reporting training every five years ..."

Review of Staff O's, education and training information revealed a certificate of completion for a course titled "Mandatory Reporting Child and Dependent Adult Abuse" on 2/16/12.

During an interview on 4/3/17, at 3:05 PM, Staff N, Employee Education/Health, confirmed Staff O's abuse training exceeded the required 5 year timeframe and assigned the task to be completed on their electronic learning system. Staff N reported Staff O's previous mandatory reporting education did not get entered into the tracking system which caused the due date for renewal to get missed.

Based on observation and patient interview, the CAH (Critical Access Hospital) failed to ensure level floor for one of one sampled patients that sustained a fall (Patient #1). The CAH identified a census of 7 at entrance (acute care and skilled care).

Failure to maintain level floor could potentially cause an injury, such as a fall, to a patient.

Findings include:

1. During an interview on 5/1/17 at 3:05 p.m., Patient #1 reported 2 falls in the bathroom, 1 which resulted in a fracture that required surgical repair at another acute care hospital. The patient reported the cause of the fall as the walker felt uneven, and got stuck going over the threshold.

2. On 5/1/17 at approximately 3:05 p.m. observation revealed approximately a 1/8th inch gap along the metal threshold between the bathroom tile and the room floor.

3. On 5/1/17 at approximately 4:12 p.m. Staff A, Chief Nursing Officer (CNO) and Staff B, Nurse Manager, confirmed the lipped area between the bathroom and patient's room as not smooth and a potential fall hazard.

4. On 5/2/17 at 1:54 p.m. Staff I, Facilities Manager, confirmed the raised area of the metal threshold between the bathroom and patient room. He measured the lipped area of the threshold as 1/8" above the bathroom tile.

Based on observation, patient interview and document review the (Critical Access Hospital) CAH failed to ensure level floor for one of one sampled patients that sustained a fall (Patient #1). The CAH identified a census of 7 at entrance (acute care and skilled care).

Failure to maintain a level floor could potentially cause an injury, such as a fall, to a patient.

Findings include:

Review of the CAH policy titled "Gait Training", effective 3/21/00, revealed in part "establish guidelines for safe and effective instruction in the gait training..." The policy reflected "If a walker is used, make sure that...the legs are even..."

1. During an interview on 5/1/17 at 3:05 p.m., Patient #1 reported a fall in the bathroom which resulted in a fracture that required surgical repair at another acute care hospital. The patient reported the walker felt uneven, and got stuck going over the threshold.

2. On 5/1/17 at approximately 3:05 p.m. observation revealed each leg of the patient's front wheeled walker were different lengths, which caused the walker to be uneven.

3. On 5/1/17 at approximately 4:12 p.m. Staff A, Chief Nursing Officer (CNO) and Staff B, Nurse Manager, confirmed each leg of the patient's front wheeled walker were set at different levels, and the walker was uneven. Staff B noted the walker looked uneven and stated you can feel it's lopsided.

4. On 5/2/17 at 9:12 a.m. Staff , physical therapist (PT) stated there is never a time a patient's walker should have uneven legs.

Based on documentation review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure the physician periodically reviewed 2 of 2 applicable mid-level practitioners' patient medical records, in conjunction with the mid-level practitioner. (Staff Q and Staff R)

The CAH administrative staff reported the volume of services provided by the selected mid-level providers from 11/1/16 to 4/30/17 included 55 patients for Staff Q and 18 patients for Staff R.

Failure to ensure a physician periodically reviewed mid-level practitioners' patient medical records in conjunction with the mid-level practitioner could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of a Quality policy titled "Peer/Mid-level Review", approved 8/10/2016, revealed in part "... A periodical chart review is completed with a physician and the mid-level practitioner together to evaluate and review the patient's record using the appropriate form. All active medical staff participates in chart review with mid-level practitioners ..."

2. Review of documentation revealed the lack of documented physician review of the mid-level practitioner's patient medical records, in conjunction with Staff Q, Advanced Registered Nurse Practitioner (ARNP) and Staff R, ARNP.

3. During an interview on 5/3/17 at 3:55 PM, Staff P, Manager of Administrative Services, confirmed the CAH had no documented evidence of a physician's periodic review of patient medical records in conjunction with Staff R.

4. During an interview on 5/3/17, at 5:00 PM, Staff P confirmed the CAH had no documented evidence of a physician's periodic review of patient medical records in conjunction with Staff Q.

Based on documentation review and staff interviews, the Critical Access Hospital (CAH) failed to ensure the mid-level practitioner participated with a physician in the periodic review for 2 of 2 applicable mid-level practitioner's patient medical records. (Staff Q and R)

The CAH administrative staff reported the volume of services provided by the selected mid-level providers from 11/1/16 to 4/30/17 included 55 patients for Staff Q and 18 patients for Staff R.

Failure to ensure the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records could potentially result in the mid-level practitioner misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of a Quality policy titled "Peer/Mid-level Review", approved 8/10/2016, revealed in part "... A periodical chart review is completed with a physician and the mid-level practitioner together to evaluate and review the patient's record using the appropriate form. All active medical staff participates in chart review with mid-level practitioners ..."

2. Review of documentation revealed the lack of documented mid-level practitioner review of patient medical records, in conjunction with a physician, for Staff Q, Advanced Registered Nurse Practitioner (ARNP) and Staff R, ARNP.

3. During an interview on 5/3/17 at 3:55 PM, Staff P, Manager of Administrative Services, confirmed the CAH had no documented evidence of a physician's periodic review of patient medical records in conjunction with Staff R.

4. During an interview on 5/3/17, at 5:00 PM, Staff P confirmed the CAH had no documented evidence of a physician's periodic review of patient medical records in conjunction with Staff Q.

Based on document review and staff interview, the critical access hospital (CAH's) administrative staff failed to ensure the surgical services staff allowed sufficient time following a surgical procedure prior to inquiring if 2 of 2 surgeons who performed surgical procedures in March 2017 had patients develop a surgical site infection. The CAH's administrative staff identified Surgeon X performed 2 surgical procedures during March 2017 and Surgeon Y performed 26 surgical procedures during March 2017.

Failure to allow sufficient time following the surgical procedure before determining if a patient had a surgical site infection could potentially result in the surgeon reporting the patient did not develop a surgical site infection but the patient later developing a surgical site infection. Failure to identify surgical site infections could potentially result in future patients developing a preventable surgical site infection.
Findings include:

1. Review of the policy "Surgical Site Infection Monitoring," effective 5/1/12, revealed in part, "A ... [surgical site infection] must meet one of the following criteria: Infection occurs within 30 days after the operative procedure..."

2. Review of returned surgical site log questionnaires from the surgeons revealed:

a. Surgeon X performed 2 surgical procedures on 3/28/17. The Infection Prevention nurse faxed the document to Surgeon X on 3/29/17. Surgeon X's office faxed the document back on 4/12/17 (14 days following the procedure). Surgeon X indicated in the documentation that neither patient developed a surgical site infection.

b. Surgeon Y performed 26 surgical procedures during March 2017. Surgeon Y performed the last procedure on 3/22/17. The Infection Prevention Nurse faxed the document to Surgeon Y on 3/29/17. Surgeon Y's office faxed the document back on 3/29/17 (7 days following the last procedure). Surgeon Y indicated in the documentation that none of the patients developed a surgical site infection.

3. During an interview at 5/2/17 at 08:00 during a tour of the operating rooms, the Infection Prevention Nurse acknowledged if they sent the surgeon a form inquiring about patients developing a surgical site infection within 30 days of the surgical procedure, the patient could develop a surgical site infection within the 30 day monitoring period required in the policy and the surgeon may not report the surgical site infection.

4. Review of the policy "Surgical Site Infection Monitoring," effective 5/1/12, revealed in part, "A deep ... [surgical site infection] must meet one of the following criteria: Infection occurs ... within one year if [an] implant is in place and the infection appears to be related to the operative procedure."

5. During an interview at 5/2/17 at 08:00 during a tour of the operating rooms, the Infection Prevention Nurse stated the Infection Prevention program lacked a process to monitor surgical implants for 1 year, as required by the CAH's policy.

Based on document review and staff interview, the critical access hospital (CAH's) Administrative Staff failed to ensure the nurse anesthetists performed a post-anesthesia evaluation after sufficient time to ensure 3 of 5 patients fully recovered from anesthesia. The operating room nurse manager identified an average of 28 surgical patients per month.

Failure to ensure nurse anesthetists performed a post-anesthesia evaluation after sufficient time to ensure patients fully recover from post- anesthesia could potentially result in the patient developing an adverse reaction to the anesthesia and the staff failing to identify and treat the adverse reaction.

Findings include:

1. Review of Patient #8's medical record revealed Patient #8 presented to the facility for repair of umbilical hernia on 1/30/2017. Patient #8 underwent the hernia repair from 08:35 AM to 08:54 AM with general anesthesia. Certified Registered Nurse Anesthetist (CRNA) U documented they transferred Patient #8 to the Post-Anesthesia Care Unit (PACU) at 09:03 AM. CRNA U documented the post-anesthesia evaluation at 9:19 AM (16 minutes after CRNA U transferred Patient #8 to the PACU).

2. Review of Patient #9's medical record revealed Patient 9 presented to the facility for removal of a cyst on 2/8/2017. Patient underwent cyst removal from 9:02 AM to 9:45 AM. Patient #9 had a spinal nerve block. CRNA U documented they transferred patient to PACU at 9:45 AM. CRNA documented post-anesthesia evaluation at 9:54 AM (9 minutes after CRNA transferred Patient #9 to PACU).

3. Review of Patient #10's medical record revealed Patient#10 presented to the facility for placement of ear tube placement in both ears on 4/10/2017. Patient #10 underwent ear tube placement in both ears from 8:07 AM to 8:15 AM. Patient #10 had general anesthesia. CRNA V documented they transferred to PACU at 8:18 AM. CRNA V documented they stopped providing anesthesia care at 8:23 AM. (5 minutes after CRNA transferred Patient #10 to PACU). The nursing staff document they discharged Patient #10 at 8:23 AM. CRNA V failed to document the time they performed post-anesthesia evaluation.

4. Review of the policy "Anesthesia Patient Care," revised on 4/01/2015, revealed the policy lacked a requirement for the anesthesia provider to allow sufficient time for recovery from anesthesia prior to performing the post- anesthesia evaluation.

5. During an interview on 5/4/2017 at 11:15 AM, the Operating Room Nurse Manager acknowledged CRNA U and CRNA V failed to allow sufficient time for Patients #8, #9, and #10 to recover from anesthesia prior to performing the post-anesthesia evaluation.

Based on documentation review and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the periodic evaluation of its total program included a representative sample of both active and closed clinical records for 11 of 15 patient care services provided. (Ambulance, Anesthesia, Sleep Study, Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Diabetic Education, Laboratory, Wound Care, and Radiology) The CAH staff identified a current census of 7 inpatients at the start of the survey.

Failure to include a representative sample of both active and closed clinical records for all patient care services provided in the annual Total Program Evaluation could potentially result in failure to identify potential changes needed in services provided.

Findings include:

1. Review of CAH policy/procedure titled "Annual Program Evaluation", dated 2/11/04, revealed in part, ". . . The hospital performs an annual evaluation of its total CAH program and services in order to determine whether the services are appropriate, adequate, effective, and efficient and determine if the established policies were followed, and if any changes are needed, to plan for those changes. . . The evaluation includes review of the following: . . . A representative sample (not less that 10%) of both active and closed clinical records. . . ."

2. Review of the "Critical Access Hospital Annual Program Evaluation July 1, 2015 - June 30, 2016 FY 2016",

lacked documentation of review of a sample of both active and closed clinical records for Ambulance, Anesthesia, Sleep Study, Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Diabetic Education, Laboratory, Wound Care, and Radiology.

3. During an interview on 5/3/2017 at 9:00 AM, Staff A, Chief Nursing Officer (CNO), verified the annual evaluation of the CAH Annual Program Evaluation only included chart review for Nursing (Acute, Swing Bed, Observation), Emergency Room, and Surgery and lacked documentation of review of a sample of both active and closed clinical records for Ambulance, Anesthesia, Sleep Study, Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Diabetic Education, Laboratory, Wound Care, and Radiology.

Based on document review and staff interview, the administrative staff failed to ensure 1 of 1 quality improvement program included patient care specific quality improvement projects for 2 of 3 contracted radiology services (MRI and Ultrasound). The administrative staff identified an average of 14 patients per month who underwent a MRI test and 55 patients per month who underwent an ultrasound procedure.

Failure to include patient care specific quality improvement projects could potentially result in the critical access hospital staff failing to identify problems related to patient care and implement corrective action to prevent the recurrence of patient care related problems.

Findings include:

1. Review of the "Quality Plan," effective 7/1/ 2016, revealed in part, "The program incorporates quality data including patient care..."

2. Review of the "Data Summary Outcome Report - Radiology," not dated, revealed in part:

a. "INDICATOR - MRI, How many MRIs were ordered and completed with [insurance company preauthorization]?"

b. "INDICATOR - Ultrasound, [high level disinfectant] test and [temperature] passes on the [internal ultrasound probe] everyday."

c. "INDICATOR - Ultrasound, How many ultrasounds are ordered and completed?"
3. During an interview on 5/3/17 at 2:30 PM, the Director of Nursing and the Quality Improvement Nurse acknowledged the MRI and Ultrasound contracted services failed to submit patient care specific information to the critical access hospital wide quality improvement program.

I. Based on documentation review and staff interviews the Critical Access Hospital (CAH) activity staff failed to ensure swing-bed patient's activity care plans were individualized to meet the patient's mental and psychosocial needs gathered from the activity comprehensive assessment in 3 of 3 open swing-bed medical records (Patient #1, #4, and #5) and 4 of 4 closed swing-bed medical records (Patient #2, #3, #6 and #7) reviewed. The facility reported a census of 3 swing-bed patients with an average daily census of 1.5 swing-bed patients. Staff A, Chief of Nursing Operations (CNO), reported the hospital provided skilled services to 36 patients from November 1, 2016 - April 30, 2017.

The activity assessment determines the content of the care plan. All swing-bed patients should have an activity care plan with individual activity-related interventions gathered from the information in the comprehensive assessment. The individualized care plans sets realistic, measurable goals, patient interventions and should be patient driven. Failure to create individualized activity care plans for swing-bed patients could potentially neglect a patient's mental and psychosocial needs that could enhance healing and lessen their stay at the CAH.

Findings include:

1. Review of CAH policy titled "Activity Program - Swing Bed", effective 7/6/00, revealed in part: "[The CAH] is an ongoing program of activities designed to meet in accordance with the comprehensive assessment, the interests and physical, mental, and psychosocial well-being of each patient.... Activity plans are developed "as soon as possible after admission..."

2. Review of 3 of 3 open swing-bed medical records (Patient #1, #2, and #3) and 4 of 4 closed swing-bed medical records (Patient # 4, #5, #6 and #7) revealed the patient's received swing-bed level of care while in the CAH. However, the medical records lacked an activity care plan that included individual activity-related interventions based on the comprehensive activities assessment.

a. Open swing-bed medical record for Patient #1 revealed he/she admitted to swing-bed level of care on 4/14/17 for Physical Therapy (PT), and Occupational Therapy (OT). Patient #1's medical record lacked a care plan that incorporated activity goals or interventions.

b. Open swing-bed medical record for Patient #4 revealed he/she admitted to swing-bed level of care on 4/22/17 for PT and OT rehabilitation. Patient #2's medical record lacked a care plan that incorporated activity goals or interventions.

c. Open swing-bed medical record for Patient #5 revealed he/she admitted to swing-bed level of care on 4/24/17 for PT, OT and Speech Therapy (ST) rehabilitation. Patient #2's medical record lacked a care plan that incorporated activity goals or interventions.

d. Closed swing-bed medical record for Patient #2 revealed he/she admitted to swing-bed level of care on 2/21/17 for PT and OT rehabilitation. Patient #2's medical record lacked a care plan that incorporated activity goals or interventions.

e. Closed swing-bed medical record for Patient #3 revealed he/she admitted to swing-bed level of care on 3/10/17 for intravenous antibiotics. Patient #3's medical record lacked a care plan that incorporated activity goals or interventions.

f. Closed swing-bed medical record for Patient #6 revealed he/she admitted to swing-bed level of care on 2/3/17 for strengthening status post pacemaker insertion. Patient #6's medical record lacked a care plan that incorporated activity goals or interventions.

g. Closed swing-bed medical record for Patient #7 revealed he/she admitted to swing-bed level of care on 2/14/17 for PT and OT rehabilitation. Patient #7's medical record lacked a care plan that incorporated activity goals or interventions

During an interview on 5/3/17 at approximately 4:15 PM, Staff B, Nurse Manager, and Staff H, Quality Assurance registered nurse (RN), stated a complete activities assessment was not completed for skilled patients.


II. Based on documentation review and staff interviews the Critical Access Hospital (CAH) activity staff failed to ensure swing-bed patient's care plans were individualized to meet the patient's mental and psychosocial needs gathered from the comprehensive assessment in 1 of 3 open swing-bed medical records (Patient #1)) and 2 of 4 closed swing-bed medical records (Patient #2 and #3) reviewed. The facility reported a census of 3 swing-bed patients with an average daily census of 1.5 swing-bed patients. Staff A, Chief of Nursing Operations (CNO), reported the hospital provided skilled services to 36 patients from November 1, 2016 - April 30, 2017. The facility reported approximately 8 patients with falls in the prior six months.

The nursing assessment determines the content of the care plan. All swing-bed patients should have an activity care plan with individual interventions gathered from the information in the comprehensive assessment. The individualized care plans sets realistic, measurable goals, patient interventions and should be patient driven. Failure to create individualized care plans for swing-bed patients could potentially neglect a patient's safety, mental and psychosocial needs that could enhance healing and lessen their stay at the CAH.

Findings include:

1. Review of CAH policy titled "Nursing", effective 6/16/10, revealed in part: "develop a plan of care which is current, comprehensive, and individualized for the patient.... A (registered nurse) "evaluates and updates the plan of care as necessary to reflect the needs of the patient..." "swing-beds weekly."

Review of the CAH policy titled "Gait Training", effective 3/21/00, revealed in part "establish guidelines for safe and effective instruction in the gait training..." The policy reflected "If a walker is used, make sure that...the legs are even..."

a. Open swing-bed medical record for Patient #1 revealed he/she admitted to swing-bed level of care on 4/14/17 for Physical Therapy (PT) and Occupational Therapy (OT) rehabilitation following a fall at home. Continued review of the clinical record revealed Patient #1 reported his/her legs gave out. Patient #1's medical record lacked a care plan that incorporated fall interventions.

Review of the patient's clinical record revealed Patient #1 sustained a fall on 5/1/17 at 3:00 a.m. The patient reported "cramping" of the left knee and right hip prior to lowering him/herself onto the floor. Patient #1's medical record lacked a care plan that incorporated fall interventions.

On 5/1/17 at 11:20 a.m. staff responded to the call light. Patient #1 was found on the floor in the bathroom which resulted in a tibia/fibula fracture which resulted in patient transfer to another acute care hospital for surgical intervention.

On 5/1/17 at 3:05 p.m. Patient #1 reported loss of control of the front wheeled walker prior to the fall. The patient was unable to recall legs gave out as before. Patient #1 reported the front wheeled walker felt uneven and the threshold between the bathroom and patient room was uneven. Patient #1 correctly stated the current date and President at the time of the interview.

Observation of the patient's front wheeled walk revealed each leg of the patient's walker was set at a different level which resulted in instability of the walker. Additionally, the threshold between the bathroom and patient's room had approximately 1/8th inch ridge between the floor tile in the bathroom and linoleum flooring in the patient's room.

On 5/1/17 at approximately 4:10 p.m. Staff A, Chief Nurse Officer (CNO), and Staff B , Medical Surgical Nurse Manger, confirmed the patient's front wheeled walker was not level. Additionally, Staff A and Staff B confirmed the area between the bathroom and patient's room was not level.

b. Closed swing-bed medical record for Patient #3 revealed he/she admitted to swing-bed level of care on 3/10/17 for intravenous antibiotics. The medical record reflected the patient was a fall risk with a Morse score of 100 (greater than 45 is high risk for fall). Patient #3's medical record lacked a care plan that incorporated fall interventions.

c. Closed swing-bed medical record for Patient #2 revealed he/she admitted to swing-bed level of care on 2/21/17 for strengthening status post bowel surgery. Patient #2 received PT and OT rehabilitative services. Patient #3's medical record lacked a care plan that incorporated activity fall interventions.

During an interview on 5/4/17 at approximately 9:25 a.m. Staff B confirmed the patient's care plans did not include fall interventions.






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Based on observation, document review and staff interviews, the Critical Access Hospital (CAH) failed to ensure outpatients who registered at the Front Registration Desk were informed of their visitation rights including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including same-sex domestic partner) and another family member for Laboratory, X-ray, Cardiac Rehab, Physical Therapy/Occupational Therapy/Speech Therapy, Diabetic Education, Wound Care, Infusion/Injection, and Senior Life Solutions outpatients. The CAH staff reported an average of 1,098 outpatients registered at the Front Registration Desk per month.

Failure to provide all outpatients, with patient rights information 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. Based on observation on 5/2/2017 at 11:15 AM of the Front Registration Desk area and 5/2/2017 at 1:45 PM of Senior Life Solutions revealed the lack of Visitor's Rights or Patient Rights and Responsibilities brochure available to outpatients that registered at that desk.

2. Review of "Outpatient/Clinic Record" document that the outpatients sign electronically at the Front Registration Desk and at Senior Life Solutions included a statement in part ". . . Our Patient Rights and Responsibilities were made available to me."

Review of CAH policy/procedure titled "Visitation Policy", dated 8/1/12, revealed in part, ". . .To ensure patients, patient's support persons, family members, significant others, domestic partners, visitors and community are informed of the Visitation Rights policy, the hospital will: 1. Include Visitation Rights references in various deemed appropriate, which may include, but is not limited to admission packets, brochures, and postings and identify a contact person/information if there is a questions on the policy. . . ."

3. During an interview on 5/2/2017 at 11:15 AM , Staff J, Front Desk Receptionist, stated Laboratory, X-ray, Cardiac Rehab, and Physical Therapy/Occupational Therapy/Speech Therapy outpatients register at the Front Registration Desk. Staff J acknowledged the outpatients electronically sign a "Outpatient/Clinic Record" document that included a statement in part ". . . Our Patient Rights and Responsibilities were made available to me." Staff J confirmed Patient Rights and Responsibilities brochures or Visitation Rights were not available to patients that registered at the Front Registration Desk.

During an interview on 5/2/2017 at 11:40 AM and 12:55 PM, Staff K, Business Office Manager acknowledged the outpatients that register at the Front Registration Desk do not receive Visitation Rights information.

During an interview on 5/2/2017 at 2:00 PM, Staff M, Office Coordinator Senior Life Solutions, acknowledged the outpatients that register at Senior Life Solutions do not receive Visitation Rights information.