HospitalInspections.org

Based on observation, interview and document review, the facility failed to ensure physical therapy equipment, the hydrocollator (a machine with hot water inside holding hot packs for patient use), was in safe working condition. The temperature log indicated the hydrocollator temperatures were out of range for two of two dates recorded. This deficient practice has the potential to expose patients to harm in the form of injury or burns.


Findings include:


- Observation of Physical Therapy Treatment Room on 7/5/2017 at 11:40 AM revealed the presence of a hydrocollator and a temperature log hanging on the wall titled "Cleaning and Maintenance Log". Observation revealed temperatures on the 3rd of July 2017 and 5th of July 2017 were documented at 164 degrees. Normal range on the log read "140-160 degrees F."


Physical Therapy Staff U interview on 7/5/2017 at 11:40 confirmed the temperature, and communicated that there had been no action to address the elevated temperature.


Document titled, "Moist Hot Pack Treatments" reviewed on 7/7/2017 at 3:15 PM directed, "... the hydrocollator temperature is checked to be between 140-160 F..."

Based on record review, staff interview, and policy review, the Community Access Hospital (CAH) failed to document performance of a Medical Staff annual update and review of the CAH policies. The deficient practice can lead to the delivery of unsafe, inappropriate care to all patients receiving services at the CAH.

Findings include:

- Review of the Medical Staff 2016 and 2017 meeting minutes revealed no documentation of policy review with medical staff approval for any CAH policies.

- Review of the May 2016 Policy Committee Meeting minutes revealed twenty-five policies from varying hospital departments were presented to the committee for review.

CEO Staff FF acknowledged the Medical Staff meeting minutes do not reflect the approval of policies submitted for review. S/he stated the policies are usually presented for review as they are developed or changed.

No Policy Committee Meeting minutes were available for 2017.

The CAH provided no policy directing the annual review of policies by a group of professional personnel.

Based on observation, interview and policy and procedure review, Hillsboro Community Hospital (CAH) failed to ensure expired medications and supplies were discarded from: Nursing Supply/Medication Room, Emergency Room 1 (ER), ER room 2, the Pharmacy and the Central Supply Room. The facility also failed to discard open multi-dose vials that were dated past the 28 day expiration date for 2 of 2 opened multi-dose vials observed. Failure to discard expired medications and supplies puts all patients at risk for received care and treatments that are ineffective and unsafe for use.

Findings include:


- Observation on 7/5/17 at 1:03 PM revealed Nursing Supply/Medication room with the following expired medications and supplies:

- Petrolatum Gauze Strips (a sterile dressing consisting of fine-mesh absorbent gauze impregnated with approximately three times its weight with white petrolatum (a white topical ointment used for its healing properties) 3 packages expired 5/17
- Petrolatum Gauze Strips 14 packages expired 6/17
- Tegaderm Foam Adhesive (a dressing for wound care) 1 package expired 5/17
- Tip caps for syringes 8 packages expired 5/17
- Potassium Chloride (is a composition of an electrolyte and chlorine) 1000ml (milliliter) 5 bags expired 7/1/17

Interview on 7/5/17 at 1:37 PM, Chief Nursing Office (CNO) Staff A verified the expired medications and supplies from the Nursing Supply/Medication rooms and discarded the items.



- Observation on 7/5/17 at 1:41 PM revealed ER room 2 with the following expired medicaions and supplies:

- Electrocardiogram Electrode Pads (pads to attach to a person receiving a test to the heart) 18 packages expired 1/13/17
- Triple Antibiotic 3 packages expired 1/17
- Triple Antibiotic 7 packages expired 4/17



- Observation on 7/5/17 at 1:59 PM revealed ER room 1 with the following expired supply:

- Endotracheal tube size 6.5 (a tube placed into the windpipe through the mouth or nose during a surgery or procedure) 1 expired 5/16

Interview on 6/5/17 at 1:59 PM, CNO Staff A verified the expired medications and supplies from ER rooms 1 and 2 and discarded them.



- Observation on 7/5/17 at 2:43 PM revealed the Pharmacy with the following expired medications:

- Nortriptyline Hydrochloride 25 mg tablets (a medication used for nerve pain or depression) 90 tablets expired 6/17
- Sodium Polystyrene Sulfonate 15grams (a medication used to treat elevated potassium levels) 5 bottles expired 6/17

Interview on 7/5/17 at 2:54 PM, Pharmacy Tech Staff F verified the expired medications and discarded them immediately.



- Observation on 7/5/17 at 3:47 PM revealed the Central Supply with the following expired supplies:

- Safety needles size 18 gauge (a measurement of the size of the needle) 8 expired 1/16
- Tegaderm Foam Adhesive 14 expired 5/17
- Adaptic Non-Adhering Dressings (a type of dressing used in wound care that does not stick to the skin) 2 expired 4/17

Interview on 7/5/17 at 4:16 PM, RN Staff H verified the expired supplies to be discarded.



- Observation on 7/5/17 at 11:00 AM revealed the Therapy Treatment Room with the following expired supplies and medication:
- Ultrasound Gel (used on the skin during ultrasound treatments) 1expired 9/14
- Biofreeze Lotion (medicated muscle rub) 1 bottle expired 10/11

Interview on 7/5/17 at 11:00 AM, Therapy Staff U acknowledged the items were out of date.



- Observation on 7/5/17 at 2:25 PM revealed the Surgical Crash Cart with the following expired supply:

- Electrodes (used for heart tests) 2 packages expired 1/13/17



- Policy and Procedure review on 7/5/17 revealed policy "Outdated Inventory" stated ...all items will be looked at individually for expiration dates.



- Policy and Procedure review on 7/5/17 revealed policy "Drug Storage and Stability" stated ...All stock is to be removed by expiration date to avoid outdates.



- Policy and Procedure review on 7/5/17 revealed policy "Drug Quality Program" stated ...a basic part of the Drug Quality Program is to delineate areas that are appropriate for storing medications/biologicals and establish inventory and procedures for the removal of out-dated or defective medications ...all drugs that expire will be removed from inventory and placed in the pharmacy. Expired medications will be stored in locked cabinet in pharmacy until disposed of.



- Observation on 7/5/17 at 11:45 AM revealed the Therapy Treatment Room with an unlocked cabinet containing a basket with a multi-dose vial of Lidocaine 1% (used to numb the skin) with the cap off and lacking a date of when it was opened.

Interview on 7/5/17 at 11:50 AM, Therapy Staff U acknowledged the items were unsecured and communicated they are used for Iontophoresis (using current to infuse through the skin).



- Observation on 7/5/17 at 1:03 PM revealed the Nursing Supply/Medication room with an opened multi-dose vial of Bacteriostatic Water (sterile water that contains 0.9% benzyl alcohol) lacking a date of when it was opened.

Interview on 7/5/17 at 1:37 PM, CNO Staff A verified the opened multi-dose vial of Bacteriostatic Water failed to be dated after opening and discarded the bottle.

- Policy and Procedure review on 7/5/17 revealed policy "Multi-dose Vials" stated ...all multi-dose vials must be dated and initialed upon first use.



- Observation on 7/5/17 at 11:45 AM revealed the Therapy Treatment Room had an unlocked cabinet with a vial of single use Dexamethasone (a steroid) opened and a box of 7 unopened vials in the unlocked cabinet.

Interview on 7/5/17 at 11:50 AM, Therapy Staff U communicated the opened vial of Dexamethasone was used for a half dose treatment.

- Packaging reviewed on 7/5/17 for Dexamethasone directed "Single Use Only".

- Policy and Procedure reviewed on 7/7/17 revealed policy "Physical Therapy Use of Medications" stated ...medications will be stored under proper conditions of sanitation, light, temperature, moisture, ventilation, segregation and security.



- Observation on 7/5/17 at 1:03 PM revealed the Nursing Supply/Medication Room with the following opened single use sterile supply:

- Tip Caps for Syringes 1 package of 10 caps (with 3 left in the sterile package) opened on the counter.

Interview on 7/5/17 at 1:37 PM, CNO Staff A verified the opened sterile package of tip caps for syringes and discarded them.

- Policy and Procedure review on 7/5/17 revealed policy "Storage of Supplies Policy" stated ...all sterile supplies will be checked monthly for integrity of packaging.

Based on observation, interview, and record review the Critical Access Hospital (CAH) failed to ensure staff perform appropriate hand hygiene during 1 of 1 observations (Dietary Aide Staff E), failed to ensure sufficient hair coverage in restricted kitchen areas in 1 of 2 observations (Dietary Aide Staff E), failed to ensure a sanitary environment when performing cleaning of the glucometer (point of care device used to monitor blood sugar levels) (CNA Staff CC), failed to label open food products (Dietary Manager Staff D), failed to maintain a dietary area free of dust and grease (Dietary Manager Staff D), failed to store patient care items in a clean area (Laboratory Staff C) and failed to perform appropriate patient care equipment cleaning (Therapy Staff U). These deficient practices have the potential to expose all patients and healthcare workers to hazardous waste, harmful bacteria contamination, and cross contamination resulting in bacterial, viral, and fungal illnesses.

Findings include:

- Observation on 7/5/2017 at 10:00AM revealed Dietary Aide Staff E cleaning and cutting fresh vegetables with hair visible hanging below the hairnet coverage.

Interview with Dietary Aide Staff E acknowledged the loose hair and tucked it into the hair net and proceeded to continue working with the fresh vegetables. Dietary Aide Staff E failed to wash their hands after they tucked their hair into the hair net and began cutting the vegetables again.

Interview with Dietary Aide Staff E confirmed s/he did not wash her/his hands before returning to her/his job.

Policy "Dietary Department Hair Restraints" directed "Employees shall wear hair restraints at all times while in the dietary department. Place hair restraint on: Tuck all hair under restraint, making sure to cover as much hair as possible ..."

Policy "Dietary Department Hand Washing" directed "Employees shall thoroughly wash their hands and the exposed portions of their arms with clean soap and water before starting work, during work as often as necessary to keep them clean, and after smoking, eating, drinking, using the toilet, or on contact with anything contaminated ..."



- Observation on 7/6/17 at 9:47 AM revealed Certified Nurse Assistant (CNA) Staff CC demonstrated use of the glucometer (the facility census was 0). Staff CC failed to clean the glucometer after use and placed it back in the case.

Interview on 7/6/17 at 9:49 AM, CNA Staff CC verified s/he failed to disinfect/clean the glucometer after use. Staff CC failed to have knowledge of the proper disinfectant to use to clean the glucometer.

Manufacturer's guidelines review on 7/6/17 revealed "Prodigy Auto Code Blood Glucose Meter" stated ...your Prodigy meter should be cleaned whenever it is visibly dirty by wiping the outside of the meter using a cloth dampened with either mild detergent mixed with water or 70% isopropyl (rubbing) alcohol.

Policy and Procedure review on 7/7/17 revealed the CAH failed to provide a policy concerning cleaning of the glucometer.



- Observation in the kitchen on 7/5/2017 at 9:30 AM revealed the facility failed to label opened spices being stored above the stove with an expiration date including, Italian seasoning, sage, and poultry seasoning.

Interview with Dietary Manager Staff D on 7/5/2017 at 9:30 AM acknowledged all spices have a date normally, and removed the spices from the shelf.

The CAH failed to provide a policy regarding the dating of opened food items.



- Observation of the Kitchen Dining Area on 7/5/2017 at 9:40 AM revealed a visibly dusty coffee maker and ice machine, and inside a storage cabinet, a zip-lock bag of moist used tea bags.

Interview of Dietary Manager Staff D on 7/5/2017 at 9:40 AM indicated the kitchen staff were responsible for cleaning the kitchen dining area and coffee maker. Staff D indicated they did not know who was responsible for the ice machine. Staff D acknowledged the used tea bags and disposed of them.

The CAH failed to provide a policy regarding the cleaning of the kitchen area.



- Observation of the laboratory on 7/5/2017 at 10:00 Am revealed unused patient urine collector hats (used in a toilet to collect urine samples) stored underneath a handwashing sink.

Interview of Laboratory Staff C on 7/5/2017 at 10:00 AM stated, "I wanted them [hats] out of here because we use them on patients."

The CAH failed to provide a policy regarding the storage of clean supplies.



- Observation of one of one therapy treatment room on 7/5/2017 at 11:00 revealed one container of ultrasound gel (used on the skin during ultrasound treatments) and one bottle of Biofreeze (treatment lotion) stored under the sink.


- Observation of one of one therapy treatment room on 7/5/2017 at 11:00 revealed six ice cream cups stored in the patient ice pack freezer.


- Observation of one of one therapy treatment room on 7/5/2017 at 11:00 revealed two patient water filter pitchers stored in the refrigerator with staff food.

Interview of Therapy Staff U 7/5/2017 at 11:00 acknowledged the items stored under the sink, the ice packs, and staff and patient food items stored together in the refrigerator and freezer.

Policy "Storage of Supplies Policy" reviewed on 7/7/2017 at 1:15 PM directed " ... all items will be stored in a designated section ..."



- Observation of therapy treatment room on 7/5/2017 at 11:30 AM revealed a small tear in the treatment mat.

Interview of Therapy Staff U on 7/5/2017 at 11:30 AM acknowledged the tear was present and stated they would turn over the mat.

Policy "Cleaning and Disinfection of Supplies" reviewed on 7/7/17 at 1:18 directed " ... all porous items or items that cannot be cleaned will be discarded ..."



- Observation of therapy treatment room on 7/5/3027 at 11:30 revealed no evidence of a cleaning schedule for the paraffin bath.

Interview of Physical Therapy Staff U on 7/5/2017 at 11:45 revealed the paraffin bath has no routine cleaning schedule.

Policy "Cleaning of Paraffin" reviewed on 7/7/2017 at 2:53 PM directed, "...paraffin unit will be cleaned following manufacturer's guidelines: monthly with daily use, quarterly with infrequent use."

Based on medical record review, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure the medical record included evidence of a consent for treatment was signed by the patient or the patients representative, and the patients received their patient rights for 2 of 30 patients reviewed (#16 and #20). This deficient practice has the potential to place all patients at risk to receive cares against their consent, and be unable to exercise their patient rights.


Findings Include:


- Patient #16's medical record review on 7/6/2017 at 9:30 AM revealed the patient was admitted to inpatient status on 4/27/2017 with a diagnosis of gastrointestinal obstruction (blockage in the bowels) and discharged on 4/28/2017. Medical record review revealed the facility failed to obtain signed consent for treatment and failed to document the patient received patient rights.

- Patient #20's medical record review on 7/6/2017 at 11:30 AM revealed the patient was admitted to inpatient status on 6/13/2017 with a diagnosis of carotid dissection (weakening of the blood vessel in the neck) and discharged on 6/23/2017. Medical record review revealed the facility failed to obtain signed consent for treatment and failed to document the patient received patient rights.

- Chief Nursing Officer Staff A interviewed 7/6/2017 at 11:30 confirmed both patients medical record lacked consent forms and evidence the patients received patient rights.

Policy "Consent Forms" reviewed on 7/8/2017 at 2:17 directed " ... a consent must be signed before the patient goes to surgery or before any invasive procedure is performed ..."

Based on record review and interview the Critical Access Hospital (CAH) failed to document and complete all orders for 1 of 30 patient medical records reviewed (Patient #14). Failure to complete all medical orders can result in insufficient, inadequate care for all patients.

Findings include:

- Patient #14's medical record review on 7/76/2017 at 1:00PM revealed the patient was admitted to the CAH on 3/1/2017 with a diagnosis of Multiple Sclerosis (MS) flare (damage to the insulation of the cells of the brain and spinal column resulting in a loss of communication of nerves) and was transferred to swing bed status 3/5/2017. The medical record revealed the orders for social services consult was not complete at the time of transfer.

DON Staff A interviewed 7/6/2017 confirmed the orders were not completed for the social services consult when the patient was transferred to swing bed status.

The CAH failed to provide a policy regarding completion of orders.

Based on observation, staff interview, and document review, the facility failed to wear proper surgical attire (RN Staff BB, perform adequate hand hygiene during 2 of 2 observations in the Operating Room (OR) (RN Staff I, RN Staff BB), prevent cross contamination while cleaning dirty surgical instruments (RN Staff I), provide a sanitary environment for the cleaning and decontamination of endoscopes (illuminated tube inserted into the intestinal tract) (RN Staff I), and failed to have sufficient surgical instruments available to prevent the need for immediate use sterilization (RN Staff I). Failure to wear proper attire, perform hand hygiene, failure to prevent cross contamination while cleaning dirty surgical instruments, failure to provide a sanitary environment for scope cleaning, and failure to have sufficient instruments available, can lead to cross contamination of infectious organisms including bacteria, viruses, and fungus through aerosolization (dispersing particles into the air) and direct touch contamination resulting in increased infections and adverse conditions such as TASS (Toxic Anterior Segment Syndrome - an eye condition related to poor sterilizing practices), increased morbidity, and possible death.


Findings include:

- Observation in the surgical suite on 7/6/2017 at 12:53 revealed Staff BB entering and exiting the pre-op area with a surgical mask hanging around her/his chin, wearing a dark blue long sleeved shirt underneath hospital provided surgical scrubs, and with a hospital blanket tied around her/his waist.

Interview of Surgical Supervisor Staff I on 7/6/2017 at 2:15 PM stated, "That shirt is not laundered, here. I know it is not." Staff I voiced concerns about the use of the blanket versus wearing a surgical jacket.

Policy "Operating Room Attire" reviewed on 7/7/2017 at 1:08 PM directed " ... Appropriate attire for semi-restricted areas include hospital supplied disposable cap, scrub pants and top or scrub dress, warm up jacket, disposable shoe covers" and " ... only hospital approved attire may be worn."


- Observation on 7/6/2017 at 1:30 PM revealed Surgical Staff Y exited and reentered the operating room with IV medications. Hand hygiene was not performed.

- Observation on 7/6/2017 at 1:54 PM revealed Surgical Staff BB exited and reentered the operating room with IV fluids. Hand hygiene was not performed.

Interview with Staff BB on 7/6/2017 at 1:55 PM stated, "No one told me I had to. I run all the time. We are gophers. I have not done that in 14 years".

Interview with Surgical Supervisor Staff I on 7/6/2017 at 2:15 PM stated, "Ok, I still need to mount the hand sanitizers on the wall".

Policy titled, "Hand Washing Hygiene" reviewed on 7/7/2017 at 2:30 PM directed, "...personnel should always wash their hands, even when gloves are used, after taking care of any patient. ..."

Policy "Hand Washing Hygiene" reviewed on 7/7/2017 at 2:30 PM directed, "...personnel should always wash their hands, even when gloves are used, after taking care of any patient..."


- Observation of the surgical housekeeping closet on 7/6/2017 at 3:12 PM revealed a hopper (used for flushing contaminated liquids and solids) without a protective splash guard.

Interview of Surgical Supervisor Staff I on 7/6/2017 declined the current use of PPE (personal protective equipment) when using the hopper. Staff I indicated the hopper was used to rinse out dirty cleaning supplies after cleaning the operating rooms.

The CAH failed to provide a policy regarding the use of PPE when using a hopper.


- Observation on 7/6/17 at 4:00 PM revealed Registered Nurse (RN) Staff I demonstrating cleaning of the endoscope. Staff I stated s/he removes the endoscope from the machine in the procedure room directly after patient use and hand carries it into the cleaning room, passing by the clean area to the end of the room to the dirty sink. Staff I demonstrated preparing the Medline Single Enzymatic Detergent and Presoak for the initial presoak by squirting a full push of the detergent into a small unmarked white cup and placing the detergent into the sink marked for 3 gallons of water. When asked the amount of detergent the manufacture guideline recommends, Staff I stated 1 ounce per gallon of water. Staff I measured the amount of detergent that 1 squirt was, which revealed it was less than 1 ounce. Staff I verified the facility is failing to ensure the correct amount of detergent is used in pre-cleaning the scopes. Staff I will replace the unmarked cups with marked cups and change the handwritten instructions on the bottle that states 1 squirt/gallon.

Interview on 7/6/17 at 4:00 PM, RN Staff I verified the scopes are carried by hand (failing to be in a container) through the clean area to the end of the cleaning room to the dirty sink and that the facility is failing to ensure the correct amount of detergent (1 ounce per gallon) is used in pre-cleaning the scopes.

Policy and Procedure review on 7/6/17 revealed policy "Care of the Flexible Endoscopes" stated ...transport scope and accessories in a large pan covered with a cloth ...immerse endoscope in freshly prepared warm enzymatic detergent following manufacturer's directions.


- Observation of dirty instrument central processing on 7/6/2017 at 4:25 PM revealed Surgical Supervisor RN Staff I demonstrating the cleaning of used surgical instruments. RN Staff I donned a long sleeved surgical jacket. Disposable head cover and booties remained on. RN Staff I proceeded to rinse the used surgical instruments using a large hand held faucet sprayer. The surveyor was standing approximately 6 feet from RN Staff I, and as RN Staff I rinsed the surgical instruments, splatter from water rinse reached the surveyor's clothing, causing visible water spots. When asked about using PPE (personal protective equipment), RN Staff I proceeded to don a mask with an eye shield.

Surgical Supervisor Staff I interview at 7/6/2017 at 4:45 PM reported they only change shoe covers after dirty instrument cleaning if they are wet. Staff I states they do not change the head cover after cleaning dirty instruments.

On 7/7/2017, the CAH failed to provide a policy regarding the changing of PPE in the event it becomes soiled.

Surgical Supervisor Staff I interview on 7/6/2017 at 4:57 PM during demonstration of quality controls of the autoclave sterilizer stated, "we use flash sterilization [also called immediate use sterilization] on days we do cataract surgeries" and "we only have three sets of instruments. There is no other way. We have done up to 14 [cataract] cases in a day before". Staff I reports they use a 10 minute cycle for cataract instruments instead of the normal 40 minute cycle. Staff I indicated they didn't have any cataract cases scheduled until the following week.

Association of peri-Operative Nurses (AORN) guidelines recommend the following: "Immediate use steam sterilization (IUSS) should be kept to a minimum and should be used only in selected clinical situations and in a controlled manner. Immediate use steam sterilization may be associated with increased risk of infection to patients. 1 Time constraints may result in pressure on personnel to eliminate or modify one or more steps in the cleaning and sterilization process ... ...Immediate use steam sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method intended for terminal sterilization. Immediate use steam sterilization should not be used as a substitute for sufficient instrument inventory ... ...Items to be steam sterilized for immediate use should be subjected to the same decontamination processes as described in AORN's Guideline for Cleaning and Care of Surgical Instruments. Decontamination should be performed in an area intended, designed, and equipped for decontamination activities ... ...As with terminal sterilization, proper decontamination is essential for removing bioburden and preparing an item for IUSS. Failures in instrument cleaning have resulted in transmission of infectious agents ..."

Best Practices for Processing Ophthalmic Instruments by Sterile Processing University, LLC directs: "Sterilization - Whether you are sterilizing the instruments in a conventional steam sterilizer or a table top (a table top sterilizer is defined by Association for the Advancement of Medical Instrumentation (AAMI) as a sterilizer having an internal chamber size of 2 cubic feet or less) you must read the IFUs (Instructions for Use) for exposure time, temperature and cycle time. Some eye instrument manufacturers have European temperatures only (e.g. 273oF). In the US, we are not permitted to use this temperature. You must reconcile the IFU information with your sterilizer's IFUs. You may have to separate sets to meet IFUs (e.g. some instruments require 10 minutes exposure; you cannot sterilize all instruments for 10 minutes; only those whose manufacturer recommends this time)." And "Best practices for processing ophthalmic instruments requires knowledge of the standards and recommendations to prevent TASS (Toxic Anterior Segment Syndrome - an eye condition related to poor sterilizing practices). You must have the current manufacturers IFUs for the instruments, sterilizer, cleaning agents, packaging materials, etc."

The CAH failed to provide a policy regarding immediate use sterilization, the manufacturer's guidelines for the 10-minute cycle by the autoclave, or manufacturer's guidelines or IFU's regarding the instrument's required sterilization specifications.

Based on medical record review and interview, the facility failed to ensure the medical record included a pre-anesthesia evaluation regarding choice of anesthesia, as well as evidence the anesthetist reviewed the patient's condition prior to the operation for 1 of 2 surgical charts reviewed (#30). This deficient practice has the potential to place all surgical patients at risk for adverse events during anesthesia, resulting in adverse reactions, serious complications, and or death.


Findings Include:


- Patient #30's medical record review on 7/6/2017 at 8:45 AM revealed the patient was admitted on 5/1/2017 for a same-day cataract surgery. Patient #30 was dismissed after the procedure. Medical record review revealed the record lacked evidence of a pre-anesthesia evaluation regarding choice of anesthesia, as well as evidence the anesthetist reviewed the patient's condition prior to the operation.

Chief Nursing Officer interviewed 7/6/2017 at 9:15 AM confirmed the medical record lacked the documentation.

The CAH failed to provide a policy regarding pre-anesthesia evaluation or the anesthetist review of the patient's condition prior to the procedure.

Based on document review and interview the Critical Access Hospital (CAH) failed to perform continuous quality improvement monitoring for four of six months (March, April, May, and June) of 2017. Failure to perform continuous monitoring of quality indicators places patients and employees at risk of receiving and administering poor and inefficient or unsafe care.

Findings include:

- Review of the Quality Assurance Process Improvement (QAPI) plan on 7/6/2017 at 2:00PM revealed no statistics or data were for the months of March, April, May, and June 2017 detailing the outcomes of identified indicators for any hospital department.

QA Staff DD confirmed the plan lacked statistics for every hospital department for March, April, May, and June, 2017. S/he acknowledged quality meetings are held monthly and no medical staff providers attend, however quality is presented at the quarterly Board and medical staff meetings. "I really don't have a reason the results are not present in the report except we were busy with the move."

Document "Quality Assurance/Performance Improvement (QAPI) Procedure" directed " ...All department heads, in conjunction with his or her staff, will monitor all the quality assurance activities for the respective departments as mandated by standard, bylaw, regulation, or governing body ... ...Consistent with continuous quality improvement principles, quality improvement activities at CAH will be reviewed on an ongoing basis by the Quality Committee with final assessment by the Governing Body ..."

Based on medical record review and interview, the facility failed to ensure speech therapy order for evaluation and treatment was followed for 1 of 5 swing bed medical records reviewed (Patient #22). This deficient practice has the potential to affect the rehabilitation and quality of life for all swing bed patients.


Findings include:

- Patient #22's medical record review on 7/7/2017 at 10:00 AM revealed the patient was admitted to swing bed status on 1/28/2017 and was discharged on 2/3/2017. Medical record review revealed a speech therapy evaluation and treatment order was written on the swing bed admission orders, and was signed, and noted by nursing. Medical record review revealed the patient's chart lacked evidence the patient received the speech therapy evaluation or treatment.

Therapy Receptionist Staff GG interviewed 7/7/2017 at 2:15 communicated patient #22 did not receive any speech therapy evaluations or treatments.


The CAH failed to provide a policy regarding the processing of therapy orders.