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Based on staff interviews and review of facility documents, the hospital failed to have in effect and/or utilize a current agreement with at least one hospital that was a member of the rural health network, as required.

Findings:

1. On 08/13/12 at the entrance conference for the survey, a copy of the hospital's agreement with their network resource hospital was requested. Throughout the survey, the top administrative staff were unable to locate the hospital agreement, or even to identify which hospital was that network resource hospital. The Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO)) were both newly appointed in the past few months. They acknowledged that they were not sure which hospital was the network hospital.


2. On 08/16/2012, 1:16 p.m., the CNO provided a final update, stating that they could not find any hospital network agreements, except for an old one from 2002, when the hospital became a Critical Access Hospital. S/he stated that they had no indication/knowledge that it was a currently active contract. S/he stated that the CEO was in the process of negotiating a new network resource hospital agreement with another facility that they have used informally as a resource in the past, to correct the problem. S/he stated that they were aware that the lack of an active network hospital agreement was a major gap that seems to have gotten lost in the midst of many personnel changes. She stated they were aware of the problem and actively attempting to fix it.

3. On 08/16/2012 at 4:24 p.m., the CNO provided copies of the old Critical Access Hospital network hospital agreement and the pending new agreement with Parkview.


4. On 08/17/12, just prior to the exit conference at 11:30 a.m., the CNO and the CEO brought in a copy of the new network hospital agreement, which they stated was nearly finalized. They stated that they had finally had to resort to calling the rural health network to find out who their previous network hospital had been. They acknowledged that any prior agreements had been inactive for an unknown period of time.

5. Review of meeting minutes for the governing body and medical staff for the past year revealed that the hospital had been actively utilizing several other hospitals in the network as resource for multiple issues. The survey revealed no evidence of negative consequences to the hospital for lack of an active network hospital agreement, since the hospital had multiple transfer agreements in place and actively sought consultation from other network hospitals to meet their needs.

Based on tours/observations and staff interviews, the facility failed to maintain supplies to ensure an acceptable level of safety.

Findings:

1. On 08/15/12 at 1:30 p.m., a tour of the medical/surgical department was conducted and revealed the following:
- The high quality control for the glucometer had been opened, but did not have an opened date written on the bottle.
- Date on the low quality control was 04/22/2012
- The test strips for the glucometer had been opened, but did not have an opened date written on the bottle.

During the tour those findings were confirmed with the Chief Nursing Officer (CNO) and the Manager of the Medical/Surgical department, and the items were removed.

2. On 08/15/12 at 2:20 p.m., a tour of the Labor and Delivery department was conducted and revealed the following:
- 5 Betadine swabs exp. 07/2003
- An opened bottle of Betadine with no open date
- 6 Urine transfer tubes Exp. 02/2010
- The high/low quality controls for the glucometer had been opened, but did not have an opened date.
- The test strips for the glucometer had been opened, but did not have an opened date written on the bottle.
- 12 Blue top test tubes Exp. 5&6/2012
- 6 Purple top test tubes had a sticker that said "cord blood" covering the Exp. date.

During the tour those findings were confirmed with the CNO and the Manager of Labor and Delivery department, and the items were removed.

3. On 08/15/12 at 2:55 p.m., a tour of the Surgery department was conducted and revealed the following:
- The low quality control for the glucometer had been opened, but did not have an opened date written on the bottle.
- Open bottle of Betadine with no open date.

During the tour those findings were confirmed with the Manager of the Surgical department, and the items were removed.

Based on staff interviews and review of facility documents, the hospital failed to ensure that the temperature and humidity in the surgical suites and the sterile processing area were maintained within acceptable ranges.

Findings:

1. Review on 08/16/12 of the surgical policy/procedure entitled "Temperature and Humidity in OR Rooms/ Central Supply" revealed the following, in part:
"PURPOSE:
To maintain temperature and humidity, within acceptable range, in the surgical suites and the sterile supply area.
POLICY:
The temperature in the surgical suites will be maintained between 68 and 72 degrees F. Humidity will be kept at 35% or above at all times.
EQUIPMENT:
Temperature and Humidity Logs.
PROCEDURE:
1. Every morning assigned personnel will check each room before any surgical cases are started.
2. The information will be recorded in Temperature and Humidity Log sheets, and person entering information will initial and date.
3. If temperature and humidity are not within the parameter set, personnel will inform Facilities Management and the Surgical Services Supervisor.
REFERENCES:
Perioperative Standards and Recommended Practices, AORN (Association of Operating Room Nurses) 2009."

2. Review on 08/16/12 of the Temperature and Humidity Log for August, 2012 revealed the following findings:

Because no surgeries were conducted, except in an emergency, per the Chief Nursing Officer and the surgical services supervisor, no temperature or humidity readings were recorded on the weekends of 08/04-5/12 and 08/12-12/12. The temperature and humidity checks were recorded consistently for the rest of the 08/1-16/12. Further review of the log revealed the following out-of-range temperature and humidity readings:
- the temperature in OR #1 was too low (below 68 degrees F) on 11 out of the 12 days recorded.
- the temperature in OR #2 was too low (below 68 degrees F) on 5 out of the 12 days recorded.
- the temperatures in CS (Central Processing) was too high 11 out of the 12 days recorded.
- the humidity in CS (Central Processing) was too low (35% or lower) 6 out of the 12 days recorded.
There was no indication on the log that the Surgical Services Supervisor or Facilities Maintenance had been notified or that any action had been taken to attempt to correct the out-of-range temperature and humidity readings.

3. On 08/16/2012, 11:50 a.m., the Chief Nursing Officer (CNO) was interviewed about the findings from the review of the Temperature and Humidity Log. S/he expressed concern that they were so frequently out of range, and stated that s/he would speak to the supervisor to get more information about any actions that were taken to address the problem. S/he returned very soon after the initial discussion about the issue and stated that the staff would have notified the Facilities Maintenance (FM)/Plant Operations about the out-of-range temperature and humidity readings and that the supervisor there would be able to produce reports from when staff had called to notify FM.

4. On 08/17/12 at approximately 9:40 a.m., the manger of Plant Operations was interviewed and stated that s/he was unaware of any need to maintain the specific temperature and humidity range in the surgical area. S/he stated that s/he had not been keeping records of calls about temperatures any follow-up actions taken. S/he stated that s/he was aware that the staff in the central processing area frequently complained about the temperature being too cold in their area, so his/her staff would to the area and adjust the temperature to satisfy their complaints. S/he stated that now that s/he was aware of the need to control the temperature and humidity readings in that area, s/he would begin to track calls about those issues from that department and monitor and track actions taken to maintain appropriate ranges.

5. On 08/16/12 at approximately 4:30 p.m., a brief interview was conducted with the Supervisor of Surgical Services and s/he stated that there appeared to have been a breakdown in communication about the temperature/humidity monitoring and correcting conditions that were out of range. S/he stated that s/he would speak to the manager of Plant Operations the next day to clarify expectations.

Based on staff interviews and review of facility documents, the governing body and their representative, the Chief Executive Officer (CEO), failed to ensure that the the medical staff bylaws and rules and regulations were enforced.

Findings:

1. The governing body and their representative, the CEO, failed to ensure that the mental health clinicians, who were conducting emergency psychiatric evaluations for patients in the emergency department, were credentialed, appointed and clinical privileges delineated, as part of the professional staff, as required.

a. On 08/16/12, review of the Rules and Regulations of the Medical Staff revealed the following, in part:
"VII CONSULTATION
A) Requirements for Consultation
1) The Admitting Medical Provider may ask for specialty consultation as required. All Medical Staff Members are expected to provide consults for (name of the hospital) patients; within the scope of their clinical privileges, when requested by the attending Medical Provider.
2) Other common reasons for consultation include:
(d) Where a higher level of skill or training is necessary to meet the patient's needs,
(e) Severe psychiatric problems, especially in the case of suicide attempts or chemical overdose
4) Consultants must have privileges at (name of the hospital)
D) Psychiatric Consultation
1) All patients with signs and symptoms of psychosis and all patients considered potentially suicidal must be seen in consultation by a Mental Health specialist."

b. On 08/16/2012 at 1:16 p.m. the Chief Nursing Officer (CNO) was asked about the arrangements for psychiatric evaluations for patients. S/he stated that the community mental health center provided mental health clinicians to come to the hospital to provide psychiatric evaluations when required. S/he confirmed that the mental health clinicians were not a part of the provider staff and no credential files were maintained for those clinicians. S/he was also asked if the hospital had a contractual agreement with the mental health center to provide the services. S/he later confirmed that no written agreement had been signed between the hospital and the mental health center. S/he acknowledged that the formalizing of the informal agreement with the mental health center and appointment of the clinicians were actions that would happen going forward, in order to comply with the requirements.

Based on review of facility documents and interviews the facility failed to annually review policy and procedure books.

Findings:

On 08/13/2012 through 08/16/2012 a review of the facility's policies and procedure revealed that they had not been reviewed or revised annually.

- Title: "Abbreviations", last revised/reviewed 06/2004
- Title: "Abuse Prevention", last reviewed/revised 08/2010
- Title: "Activation & Disposal of Gluteraldehyde", last reviewed/revised 12/2010
- Title: "Activities Consultant", last revised/reviewed 06/2004
- Title: "Activities Program and Expectations", last reviewed/revised 06/2004
- Title: "Adherence to 96 Hour Rule and 25 Inpatients", last reviewed/revised 06/2004
- Title: "Advance Directives", has a reviewed/revised date of 01/2011 with no signatures prior signatures were 06/2004
- Title: "Appropriate Forms for Admission to Swing Bed", last reviewed/revised 06/2004
- Title: "Assessment of Patients", last reviewed/revised 06/2004
- Title: "Authentication of Practitioners Verbal Orders", last reviewed/revised 06/2004
- Title: "Care Team", no approval
- Title: "Chronic and Terminal Pain Protocol", last reviewed/revised 01/06
- Title: "Complaints, Patient/Family/Visitor", last reviewed/revised 06/2004
- Title: "Department Function and Support", last reviewed/revised 06/2004
- Title: "Dietary Services", last reviewed/revised 06/2004
- Title: "Discharge Planning/Social Services", last reviewed/revised 06/2004
- Title: "DNR", last reviewed/revised 06/2004
- Title: "Domestic Violence/Abuse", last reviewed/revised 06/2004
- Title: "Drug Orders", last reviewed/revised 06/2004
- Title: "Ed Plan", last reviewed/revised 3/2000 no signatures
- Title: "Emergency Department Triage", last reviewed/revised 09/2010
- Title: "Fall Prevention", last reviewed/revised 06/2004
- Title: "Home Health", Referral last reviewed/revised 06/2004
- Title: "Hospital Wide policies Pertaining to Swing Bed", no signatures
- Title: "Housekeeping Service Statement", last reviewed/revised 06/2004 no signatures
- Title: "Laser Safety", last reviewed/revised 12/2010
- Title: "Medication Storage Area Inspection", last reviewed/revised 09/2010
- Title: "Medical Denials", last reviewed/revised 02/1989
- Title: "Multidose Vials", last reviewed/revised 09/2010
- Title: "Nursing Care of the Swing Bed Patient", last reviewed/revised 06/2004
- Title: "Nursing Service Requirements", last reviewed/revised 06/2004
- Title: "Nutrition Assessment", last reviewed/revised 06/2004
- Title: "Observation Services", last reviewed/revised 06/2010
- Title: "Organ and Tissue Donation", last reviewed/revised 06/2004
- Title: "Patient Communication", last reviewed/revised 06/2004
- Title: "Patient Rights", last reviewed/revised 06/2004
- Title: "Philosophy of the Swing Bed", last reviewed/revised 06/2004
- Title: "Physical Restraints", last reviewed/revised 08/2010
- Title: "Psychosocial, Spiritual and Cultural", last reviewed/revised 04/2000
- Title: "Quality Assurance for Swing Bed Unit", last revised 06/2004
- Title: "Referral Agencies", last reviewed/revised 10/1997 no signatures
- Title: "Resident Behavior and Facility Practice/Quality of life", last reviewed/revised 06/2004
- Title: "Restraints", last reviewed/revised 06/2004
- Title: "Restraints-Medical Surgical Healing", last reviewed/revised 06/2004
- Title: "Rotation/Checking Expiration Dates on Manufactured Sterile Supplies", last reviewed/revised 12/2012
- Title: "Temperature & Humidity in OR Rooms/Central Supply", last reviewed/revised 12/2010
- Title: "Transfer of Difficult Patients", last reviewed/revised 06/2004
- Title: "Transfer to Psychiatric Facility", last reviewed/revised 06/2000
- Title: "Utilization Review", last reviewed/revised 07/1994

On 08/15/2012 at 9:00 a.m. an interview was conducted with the Director of Swing Beds and the Chief Nursing Officer (CNO).The Director of Swing Beds acknowledged that most of the reviews for policies/procedures had not been done since 2004. S/he stated that for the last few years the facility has been through quite a few administrators and CNO's, but now that they had a new CNO the reviews would get done.

On 08/16/2012 at 1:16 p.m., an interview was conducted with the CNO regarding the new Centers for Medicare and Medicaid Services regulation C-1000, 1001 and 1002 related to visitor rights. The CNO said there had been no new policy developed to comply with the new regulations.

Based on review of facility documents and staff interviews, the hospital failed to maintain a complete and accurate list of all services furnished under arrangements or agreements, including the nature and scope of the services provided.

Findings:

1. On 8/16/12, a list of services provided by agreement, which had been requested during the entrance conference, was reviewed. The list appeared to be incomplete and did not included services they were acquiring through agreements, such as medical gases, pest control, biomedical waste disposal, radiation physicist, network hospital agreement, ambulance services, emergency fuel and water supplies, mental health consultation services, laundry/linen services, food and dietary supplies, to name a few.

2. On 08/16/12 at 3:33 p.m., an interview was conducted with the facility's contract manager. When asked if the list that had been provided earlier was complete, s/he acknowledged that the list was incomplete and that the facility did not currently have or maintain a complete and accurate list of all services provided by agreement. S/he stated that s/he had been hired to run the hospital's foundation, but had a strong contract management background, so had recently been given contract management as well. S/he stated that s/he was in the process of inventorying the contracts and planned to create a list as well as implement a system to review the contract annually prior to renewal. S/he stated that s/he would be utilizing a new software system to organize the contracts, including creating a list that would meet the regulations from CMS.

Based on staff interviews and review of facility documents, the hospital failed to ensure that the book in the surgery department that contained the delineation of privileges for each member of the medical staff and allied health profession staff was complete, accurate and up-to-date. The book served as the primary reference for the staff in the department to confirm that a provider had been granted the current privileges to perform a specific surgical or diagnostic procedure or to administer anesthesia, prior to scheduling or initiating the procedure.

Findings:

1. On 08/16/2012, the surveyors asked to inspect the book or log, available in the surgery department that provided information to the staff about the current privileges for each provider, to ensure that no providers were scheduling or performing procedures beyond the scope of the privileges granted to them. At approximately 3 p.m., the Chief Nursing Officer (CNO) provide a black 3-ring binder entitled " Anesthesia/ Surgery," which contained a copy of the delineation of privileges granted for each medical or allied health staff. The book had alphabetical dividers. The sections "A" through "G" were reviewed. It was evident that the book was not being kept current. It contained old delineations of privileges that had not been removed and current privileges were missing. The CNO also confirmed that many of the providers were no longer on the staff of the hospital. Of the 12 providers with delineation of privileges information in the sections reviewed, only one of them had current information. The rest had information from 2007 and 2008. When this information was reviewed later with the CNO and the Supervisor of Surgical Services, they acknowledged that the book was obviously not accurate, nor being kept up-to-date. They re-confirmed that most of the providers were no longer even on the medical staff. The CNO, who was just recently appointed to the facility, was aware of the requirements to have that information current and available to the Surgical Department staff. The Supervisor of Surgical Services was not as familiar with the requirements to provide that information to his/her staff, but stated that the book would be updated and maintained going forward to comply with the requirements.

Based on staff interviews and review of facility documents, the hospital failed to ensure that their abuse prevention policy failed to include required elements to ensure patients were protected.

Findings:

1. Review on 08/14/12 of the facility policy/procedure entitled "Abuse Prevention" revealed the following::
The abuse policy was establish to deal with abuse or potential abuse situations with in the facility related to patients, families and staff.

Review of the policy revealed that the "Protection" section of the policy only addressed activities to protect employees who reported abuse from any form of retaliation. That section did not address instituting measures to protect a patient who had made an abuse allegation from retaliation or additional abuse. No other section of the policy addressed the issue of protecting the reporting patient after allegations were made.

The policy stated that the allegations of abuse would be reported to state agencies only after an in-house investigation had been completed to determine if the allegation had occurred. That part of the policy was in direct violation of the state licensure requirement to report the allegations to the state occurrence reporting line and the local law enforcement entity immediately after receiving the allegation of abuse, rather than after an in-house investigation had been conducted and determined that the abuse did occur.

2. On 08/16/2012 at 1:16 p.m., the Chief Nursing Officer was interviewed about the missing requirement and acknowledged that the policy needed to be revised to reflect those elements.

Based on policy review and staff interviews, the facility failed to ensure patients were provided visitation rights as outlined in C 1001 and C 1002.. The facility had no written policies related to those specified visitation rights and none addressing visiting rights restrictions.

Findings:

Reference C 1001 and C 1002 - Patient Visitation Rights for findings related to the facility's failure to have written policies that ensured patients were provided visitation rights as required by this standard.

Based on policy review and staff interviews, the facility failed to have written policies that ensured patients were provided visitation rights, as required.

Findings:

1. A review of the facility policies on 08/15/12 found no written policies that addressed the following patient visitation rights: The facility did not have a policy that stated how to inform each patient of his or her visitation rights, including any clinical restriction or limitations on those rights. There was also not a policy stating how to inform each patient of the right to consent for whomever he or she chose as a visitor, and the right to withdraw the consent at any time.


2. In an interview on 08/16/2012 at 1:16 p.m., the Chief Nursing Officer confirmed the hospital did not have any policies that addressed the previously described patient visitation rights in the new regulations.

Based on policy review and staff interviews, the facility failed to have written policies that ensured patients were provided visitation rights as required.

Findings:

1. A review of the facility policies on 08/15/12 found no written policies regarding patient visitation rights. The facility did not have a policy stating how to inform each patient of his or her visitation rights including any clinical restriction or limitations on these rights. There was also not a policy stating the hospital does not restrict, limit or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. In addition, there was not a policy stating the hospital would ensure that all visitors enjoy full and equal visitation privileges consistent with patient preferences.

2. In an interview on 08/16/2012 at 1:16 p.m., the Chief Nursing Officer confirmed the hospital did not have any policies that addressed the previously described patient visitation rights in the new regulations.