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Based on review of documents, observation and staff interview the Critical Access Hospital (CAH) staff failed to ensure the maintenance staff monitored the hot water temperatures at the handwashing sinks in the patient rooms. Hot water temperatures were identified at greater than 120 degrees Fahrenheit in 8 of 20 patient rooms and 1 of 1 Nursery. (Patient rooms 119, 120, 126, 131, 133, 140, 143, and Nursery)

Failure to ensure the maintenance staff monitored the hot water temperatures at the handwashing sinks could potentially cause serious scalding burns to patients. (The depth of injury directly related to the temperature and duration of exposure to the water. The length of exposure required for a third degree burn to occur is 15 seconds at 133 degrees, 1 minute at 127 degrees, and 3 minutes at 124 degrees.)

Findings include:

1. Observations on 11/16/15 beginning at 10:00 AM during tour of the nursing unit, the Chief Nursing Officer (CNO) verified the hot water flowing from the handwashing sinks in 8 of 20 patient rooms and nursery were the following:

Room 119 - 129.0 degrees Fahrenheit
Room 120 - 128.3 degrees Fahrenheit
Room 126 - 126.1 degrees Fahrenheit
Room 131 - 123.4 degrees Fahrenheit
Room 133 - 123.1 degrees Fahrenheit
Room 140 - 126.5 degrees Fahrenheit
Room 143 - 123.8 degrees Fahrenheit
Nursery - 127.6 degrees Fahrenheit

2. According to the Centers for Medicare and Medicaid Services, the acceptable range for water temperature in patient care areas is 110-120 degrees Fahrenheit.

3. Review of the CAH policies and procedures revealed the lack of a policy/procedure that addressed the acceptable range for hot water temperature in patient care areas.

4. During an interview on 11/16/15 at 11:20 AM Staff E, Facilities Manager verified the hot water temperatures in patient rooms and nursery were greater than 120 degrees Fahrenheit. Staff E stated maintenance staff did not monitor the hot water temperature in patient rooms.

During an interview on 11/19/15 at 10:10 AM Staff S, Maintenance stated maintenance staff tests the hot water temperature in 1 random patient room per day but did not document the patient room.

Based on review of policies, procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the physician periodically reviewed mid-level practitioner's patient medical records in conjunction with the mid-level practitioner.

Failure to ensure the physician periodically reviewed 2 of 5 mid-level practitioner's patient medical records in conjunction with the mid-level practitioners could potentially result in misdiagnosing of patients and/or providing inappropriate or substandard patient care. (Staff J, Physician Assistant (PA) and Staff K, PA)

Findings include:

1. Review of CAH policy titled "Medical Record Review, Physician Assistant and Nurse Practitioner" dated July 2011 stated in part, "...All mid-level practitioners providing diagnosis and/or treatment at LCHC [Lucas County Health Center] will periodically undergo the medical record review process...The mid-level practitioner involved in the care will be required to attend the Quality Management Committee meeting either in person or via the phone. At the Quality Management Committee meeting, a physician member of the Quality Management Committee will review the record and any findings in conjunction with the mid-level practitioner involved in the patient's care..."

2. Review of documents titled, "Quality Management Minutes" from January 2013 to September 2015 lacked evidence the physician performed periodical reviews of PA J's patient medical records in conjunction with PA J.

Review of documents titled, "Quality Management Minutes" from January 2013 to July 2015 lacked evidence the physician performed periodical reviews of PA K's patient medical records in conjunction with PA K and prior to when PA K was recredentialed on 7/1/2015.

3. During an interview on 11/19/15 at 9:50 AM Staff H, Ancillary Services Operations Officer acknowledged the documents lacked evidence the physician periodically performed reviews of PA J's patient medical records, in conjunction with PA J. Staff H stated the last physician reviewed PA K's patient medical records, in conjunction with PA K on 5/21/13. Staff H reported PA K should of had a physician chart review since then.

Based on review of policy, procedure, document, and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure the mid-level practitioners participated with a physician in periodic reviews of the mid-level practitioners patient medical records.

Failure to ensure 2 of 5 mid-level practitioners participated with a physician in periodic reviews of the mid-level's patient medical records could potentially result in the mid-level practitioners misdiagnosing patients and/or providing inappropriate or substandard patient care (Staff J, Physician Assistant (PA) and Staff K, PA).


Findings include:

1. Review of CAH policy/procedure titled "Medical Record Review, Physician Assistant and Nurse Practitioner", dated July 2011, revealed in part, ". . . All mid-level practitioners providing diagnosis and/or treatment at LCHC [Lucas County Health Center] will periodically undergo the medical record review process. . . The mid-level practitioner involved in the care will be required to attend the Quality Management Committee meeting either in person or via the phone. At the Quality Management Committee meeting, a physician member of the Quality Management Committee will review the record and any findings in conjunction with the mid-level practitioner involved in the patient's care. . . ."

2. Review of documents titled, "Quality Management Minutes" from January 2013 to September 2015 lacked evidence PA J participated with a physician to perform periodical reviews of PA J's patient medical records.

Review of documents titled, "Quality Management Minutes" from January 2013 to July 2015 lacked evidence PA K participated with a physician to perform periodical reviews of PA K's patient medical records or prior to when PA K was recredentialed on 7/1/2015.

3. During an interview on 11/19/15 at 9:50 AM Staff H, Ancillary Services Operations Officer acknowledged the documents lacked evidence the physician periodically performed reviews of PA J's patient medical records, in conjunction with PA J. Staff H stated the last physician reviewed PA K's patient medical records, in conjunction with PA K on 5/21/13. Staff H reported PA K should of had a physician chart review since then.

I. Based on observation, review of policy and procedure, and staff interview the Critical Access Hospital (CAH) failed to ensure staff cleansed the IV (Intravenous) line port and the rubber septum on the top of medication vials prior to the insertion of a needle and withdrawal of medication.

Failure to ensure staff cleansed the IV line port rubber septum on the top of 1 of 1 new medication vials prior to the insertion of a needle and withdrawal of medication could result in introducing micro-organisms into the medication vial affecting the efficacy of the medication and potentially harming the patient. (Certified Registered Nurse Anesthetist (CRNA) Staff F)

Findings include:

1. Review of the policy and procedure titled, "Intravenous: Intravenous Push IVP" dated 6/2001 included in part, "...Open alcohol pad and wipe the injection port of heplock..." The policy and procedure lacked evidence of a procedure to cleanse the rubber septum on top of medication vials prior to insertion of a needle and withdrawal of medication.

2. Observations on 11/17/15 beginning at 9:40 AM in the operating room showed Staff F, CRNA removed the protective caps on 3 of 3 vials of medication. Without wiping the rubber septum, Staff F inserted the needles attached to the syringes into each of the medication vials and withdrew the medication into the syringes.

3. During an interview on 11/17/15 at 11:05 PM, Staff F, CRNA acknowledged he failed to cleanse the rubber septum on the top of each of the 3 medication vials prior to inserting the needles into the medication vials and withdrawal of the medication into the syringes.

During an interview on 11/17/15 at 12:10 PM, Staff G, Infection Control Preventionist stated it is expected that staff cleanse the rubber stopper on the medication vial prior to inserting a needle to draw up medication.



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II. Based on observation, review of policy, manufacturer's instructions, and staff interview the Critical Access Hospital (CAH) staff failed to date the Nova StatStrip glucose test strips and high/low glucose control solutions upon opening for use in 2 of 2 ambulances located in the emergency department (ED) ambulance garage.

Failure to ensure staff documented the opened date on 2 of 2 Nova StatStrip glucose test strips and 2 of 2 sets of high/low glucose control solution bottles could result in the use of glucose test strips and high/low glucose control solution beyond the 3 months after the bottles were opened. The use of expired glucose test strips and/or high/low glucose control solutions could potentially alter the performance of the Nova StatStrip blood glucose machine and/or patient glucose test results.

Findings include:

1. Review of document titled, "Lucas County Health Center Ambulance Inspection" showed staff tested the accuracy of the Nova StatStrip blood glucose machine 2 times a day.

2. Review of the manufacturer's instructions titled, "Nova StatStrip Glucose Test Strip For Use ONLY with the Nova StatStrip Family of Meters" Dated 3/2012, included in part, "...Once opened, the StatStrip Test Strips are stable... up to 180 days or until the expiration date, whichever comes first...Control solution is good for only 3 months after opening..."

3. During an interview and observation on 11/16/15 at 2:35 PM, Staff I, ED Paramedic acknowledged both sets of Nova StatStrip blood glucose test strips and high/low control solution bottles for the Nova StatStrip blood glucose machine in the ambulances lacked an open date on all the containers. Staff I stated he did not generally date the glucose test strip bottles or the glucose control solution bottles when opening them for use.

Based on review of policy, documents, and staff interviews, the Critical Access Hospital (CAH) failed to ensure 1 of 1 teleradiologists, 2 of 7 physicians, 3 of 34 consulting physicians and 1 of 1 associate applicable physicians received an outside entity peer review per credentialing cycle and prior to the physicians reappointment to the Medical Staff. (Staff L through R).

The CAH administrative staff identified the practitioners provided services to patients, from 1/1/15 to 10/31/15, as follows:

Staff L M.D. Orthopedics - 12 patients
Staff M M.D., Otolaryngology - 25 patients
Staff N D.P.M., Podiatrist - 41 patients
Staff O, D.O., Emergency Medicine - 393 patients
Staff P, M.D., Family Medicine - 395 patients
Staff Q D.O., Family Practice - 356 patients
Staff R M.D., Teleradiologist - 58 radiology film reads

Failure to ensure all medical staff members received an outside entity peer review per credentialing cycle and prior to the physicians reappointment to the Medical Staff in accordance with the CAH policy to evaluate the appropriateness of diagnosis and treatment furnished to patients at the CAH could potentially affect the CAH's ability to assure the physicians provided quality care to their patients.

Findings include:

1. Review of a Quality Improvement policy titled "Peer Review", dated 5/09 included in part, "...At least one medical record per physician...per credentialing cycle will be mailed to the entity listed in the Critical Access Hospital network agreement for external peer review....The results of this peer review activity will be utilized at the time of medical staff reappointment..."

2. Review of the document titled, "Amendment to Critical Access Hospital Network Agreement" dated September 24, 2008 included in part, "...shall assist hospital in reviewing quality and appropriateness of the diagnoses and treatment furnished by Hospital's physicians and practitioners...carrying out requirements of...quality assurance plan...shall be accomplished through external peer review...on a quarterly basis..."

Review of CAH documentation on 11/19/15 revealed the CAH failed to ensure administrative staff performed outside entity peer reviews during the identified physician's credentialing cycle and prior to the physicians reappointment to the Medical Staff.

3. During an interview on 11/19/15 at 9:00 AM Staff H, Ancillary Services Operations Coordinator acknowledged the identified physicians lacked evidence of an outside entity peer review during the physician's credentialing cycle and prior to the physicians reappointment to the Medical Staff.