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Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure Operating Room (OR) staff tested 2 of 2 high level disinfectants (Cidex OPA and Rapicide) prior to each use. The Central Supply Supervisor stated OR staff performed approximately 13 surgical procedures per month.

Failure to test high level disinfectants prior to each use could potentially result in OR staff using a disinfectant that lacked sufficient concentration of the active ingredient to kill all microorganisms on the medical device, potentially resulting in the spread of an infection between patients.

Findings include:

1. Observations during a tour of the Operating Room decontamination area on 10/18/11 at 1:00 PM revealed 1 of 1 bottle of opened Cidex OPA and 1 of 1 Rapicide endoscope reprocessor.

2. Review of the "Disinfectant Efficacy Monitoring Log" from 9/12/11 to 10/12/11 revealed OR staff tested the high level disinfectants, Cidex OPA and Rapicide, only once per day.

3. Review of the manufacturer's instructions for Cidex OPA, copywrite 2003, revealed in part, "During reuse, it is recommended that the CIDEX OPA Solution be tested with the CIDEX OPA Solution Test Strips prior to each use."

4. Review of the manufacturer's instructions for Rapicide, copyright 2011, revealed in part, "Monitor the minimum recommended concentration (MRC) ... prior to each reprocessing."

5. During an interview on 10/18/11 at 1:00 PM, the Central Supply Supervisor stated the OR staff only tested the high level disinfectants once per day, in the morning. The Central Supply Supervisor acknowledged the manufacturers' recommendations required OR staff to test the high level disinfectants prior to each use. The Central Supply Supervisor also verified the OR staff reused the Cidex OPA and Radicide more than 1 time per day and did not test the high level disinfectant prior to each use.

Based on interview, medical record review, and policy review, the Critical Access Hospital (CAH) Coordinator of Diabetes Education failed to follow CAH policy and professional standards of practice and obtain a physician order for the insulin adjustment for 1 of 5 outpatients in the diabetes education program (Patient #1).

Failure to obtain a physician order for insulin adjustment could potentially result in medical complications for the patient which may include hypoglycemia (a condition that occurs when blood sugar is too low) and lead to seizure, loss of consciousness and death or hyperglycemia (a condition that occurs when blood sugar is too high) and lead to damage to nerves, vessels, and organs, dehydration, and coma.

Findings include:

1. During an interview on 10/19/11 at 7:45 AM and a follow-up interview at 10:45 AM, Staff A, Coordinator of Diabetes Education, reported one diabetes education outpatient, Patient #1, demonstrated poor self-care skills. The patient lived with his parents and the Staff A communicated with the patient's mother via email to track blood sugar records and provide instruction on insulin adjustments. The Staff A determined a personal insulin to carbohydrate ratio for Patient #1, as ordered by physician upon hospital discharge on 7/8/11 and provided follow-up care.
Staff A reported instructing the patient on adjustments of the insulin to carbohydrate ratio following the hospital discharge, as well as adjustments to the Lantus insulin dose. Lantus is a long-acting injectable insulin given to help control the blood sugar level of patients with diabetes. Staff A reported periodically updating Patient #1's primary physician on blood sugar levels and the insulin adjustments that she made. Staff A reported believing an understanding existed between Patient #1's primary physician and herself so the insulin could be adjusted as needed. Staff A reported failing to obtain a physician order for adjustment of the Lantus insulin dose prior to instructing the patient and the patient's mother on the change. Staff A reported the CAH did not have a policy delegating this authority and acknowledged a physician order should have been obtained prior to instructing the patient and the patient's on the Lantus insulin adjustments.

2. Review of Patient #1's medical record for hospitalization from 7/5/11 to 7/8/11, revealed treatment for several medical conditions including poorly controlled Type I diabetes mellitus requiring insulin. Patient #1's discharge orders included Lantus insulin 15 units twice daily and sliding scale insulin using an insulin to carbohydrate ratio as determined by Staff A.

3. Review of Patient #1's outpatient record, maintained by Staff A, contained the following information:

a. On 6/28/11, an order for outpatient education with diabetes nurse educator for assessment and diabetes education signed by Patient #1's primary physician.

b. On 7/25/11, Staff A documented she instructed Patient #1's mother to increase Lantus insulin to 16 units. Review of subsequent blood sugar logs, verified the Lantus insulin dose adjusted up to 16 units twice daily.

c. On 9/22/11, Staff A instructed Patient #1's mother to decrease Lantus insulin to 14 units twice daily. Review of subsequent blood sugar logs, verified the Lantus insulin dose adjusted down to 14 units twice daily.

d. On 9/29/11, Staff A instructed Patient #1 to increase Lantus insulin to 15 units twice daily.

Further review of Patient #1's outpatient medical record, maintained by Staff A, showed it lacked evidence of communication with the physician regarding specific changes to the patient's insulin regimen at the time of the changes or at a later time.

4. Review of a pharmacy policy titled "Medication Orders and Administration", approved on 11/12/10, revealed in part " ... A. 1. Medications should be given only on the written order of a physician or authorized mid-level practitioner ...."

5. Review of the CAH medical staff bylaws rules and regulations revealed in part " ... 6. All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to a Registered Nurse or other authorized person ...."

6. Review of a nursing policy titled "Physician Orders", approved on 12/10/10, revealed in part " Policy: 1. All orders directing patient care must be written and/or signed by the physician ...."

Based on review of documents, review of medical records, and interview with staff, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians and midlevel providers authenticated, dated, and timed all entries in the medical record of 4 of 5 closed medical records of patients receiving swing bed level of care (Patient #5, #6, #7, and #8) and 4 of 5 closed medical records of patients receiving an acute level of care (Patient #9, #10, #11, and #12) . The CAH administrative staff reported an average monthly census of 3 patients receiving swing bed level of care and 3 patients receiving acute level of care .

Failure to authenticate, date, and/or time record entries potentially could cause harm to patients by delay in treatments, actions, or assessments.

Findings included:

1. The following medical records of patients receiving care at the swing bed level lacked a date and/or time of entries by physicians and mid-level providers.

a. Review of Patient #5's medical record revealed an admission date of 8/12/11 and a discharge date of 8/19/11. Patient #5's medical record lacked a date and time for 6 of 9 physician progress notes.

b. Review of Patient #6's medical record revealed an admission date of 8/8/11 and a discharge date of 8/17/11. Patient #6's medical record lacked a date and time for 3 of 3 progress notes and 1 of 1 medication reconciliation order form.

c. Review of Patient #7's medical record revealed an admission date of 8/5/11 and discharge date of 8/9/11. Patient #7's medical record lacked a time of the entries on 2 of 4 progress notes.

d. Review of Patient #8's medical record revealed an admission date of 10/30/11 and discharge date of 11/5/11. Patient #8's medical record lacked a time of the entries on 4 of 4 progress notes.

2. The following medical records of patients receiving care at the acute level lacked a date and/or time of entries by physicians and mid-level providers.

a. Review of Patient #9's medical record revealed an admission date of 9/13/11 and discharge date of 9/14/11. Patient #9's medical record lacked a time entry on 1 of 1 progress note, 1 of 1 medication reconciliation order form, 1 of 1 discharge summary and lacked a date and time for 1 of 1 radiology requisition form.

b. Review of Patient #10's medical record revealed an admission date of 8/29/11 and discharge date of 9/1/11. Patient #10's medical record lacked time entries on 3 of 3 progress notes and lacked a date and time for 1 of 1 radiology requisition form.

g. Review of Patient #11's medical record revealed an admission date of 9/1/11 and discharge date of 9/7/11. Patient #11's medical record lacked time entries on 5 of 5 progress notes, 1 of 1 medication reconciliation order form, 1 of 1 radiology requisition form, and 1 of 1 discharge summary.

h. Review of Patient #12's medical record revealed an admission date of 9/8/11 and discharge date of 9/10/11. Patient #12's medical record lacked time entries on 2 of 2 progress notes, 1 of 1 medication reconciliation order form, and 1 of 1 discharge summary.

3. Review of CAH policy "Policies for Charting", dated 11/10, revealed in part, "...2. Physician orders will be written by the physician with the time and date".

4. Review of CAH policy "Legal Documentation Standards", dated 11/10, revealed in part, "C. Date and Time on Entries: 1. Every entry in the medical record must include a complete date-month, day, and year and have a time associated with it. 2. Time must be included in all types of narrative notes even if it may not seem important to the type of entry...."

5. During an interview on 10/19/11 at 3:30 PM, the Director of Nursing verified the physician entries in the medical records lacked dates and/or times. The Director of Nursing reported all physician's orders and notes for these records need to be dated and timed when entered into the medical record.

Based on medical record review, staff interviews and policy/procedure review, the Critical Access Hospital (CAH) failed to ensure a qualified practitioner evaluated each patient for proper anesthesia recovery prior to discharge for 2 of 5 patients (Patient's #2 and #3). The CAH administrative staff reported completing 3 surgeries a month.

Failure to provide a proper anesthesia recovery assessment could potentially harm patients if complications occurred after surgery related to the use of the anesthesia and interventions.

Findings include:

1. Review of the Patients #2's closed medical record revealed the hospital performed surgery on 8/22/11 at 4:20 PM. The staff failed to document a post anesthesia note on the patient's condition after the surgery and prior to discharge.

2. Review of Patients #3's closed medical record revealed the hospital performed surgery on 6/15/11 at 9:15 AM. The staff failed to document a post anesthesia note on the patient's condition after the surgery and prior to discharge.

3. During an interview on 10/19/11 at 3:30 PM, the Director of Nursing stated the Certified Registered Nurse Anesthetists (CRNA's) did not complete the post anesthesia note for the surgical patients. The CAH did not have a policy or procedure addressing the need for a qualified professional to complete a post anesthesia assessment prior to the patient's discharge.

4. Review of the CAH Medical Staff Rules and Regulations dated 10/2011 revealed in part "... The physician must examine the patient immediately before surgery to evaluate the risk of anesthesia and the procedure to be performed. Before discharge, a qualified practitioner must evaluate each patient for proper anesthesia recovery. Prior to discharge, patient condition must be documented and patient must be provided with written instructions including follow-up phone numbers for emergencies."

5. Review of the CAH Operating Room Quality of Patient Care policy revealed in part "... Before discharge, the physician must evaluate each patient for proper anesthesia recovery. A post anesthesia visit shall be made by the anesthetist and documented in the anesthesia record."

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician reviewed the care provided by 1 of 1 sampled Certified Registered Nurse Anesthetist (CRNA B). The Director of Nursing stated the CAH had 8 CRNA members of the Medical Staff, and the CRNAs provided anesthesia to 45 patients per year.

Failure to provide physician review for CRNAs could potentially result in the CRNA providing inappropriate care and treatment and the CAH staff failure to recognize the inappropriate care.

Findings include:

1. Review of CRNA B's credential file on 10/20/11 revealed it lacked documented evidence that a physician reviewed the care CRNA B provided to the patients at the CAH.

2. Review of the policy "Peer Review Policy", written 11/08, revealed in part, "Health care providers/practitioners that will be included in Peer Performance Review are ... Mid-Level Practitioners [CRNAs]"

3. During an interview on 10/19/11 at 2:00 PM, the Medical Records Manager stated they did not include the CRNAs in the peer review process. The Medical Records Manager acknowledged a physician had not evaluated the care the CRNAs provided to the CAH's patients for all 8 CRNAs .

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 sampled pathologists (Pathologist C) received external peer review of the care the pathologist provided to patients at the CAH. The Director of Nursing stated the Medical Staff included 2 pathologists. The pathologists performed approximately 3 frozen sections per year.

Failure to provide external peer review could potentially allow a physician to provide inappropriate care and treatment to the patients and the CAH staff would be unaware of the inappropriate care and treatment to CAH patients.

Findings include:

1. Review of Pathologist C's credential file on 10/20/11, revealed the credential file lacked documented evidence the CAH administrative staff had requested the completion of an external peer review of the care Pathologist C provided to the CAH's patients.

2. Review of the policy Peer Review Policy, written 11/08, revealed in part, "Health care providers/professionals that will be included in Peer Performance Review are ... Physicians (all physicians that provide a service/perform surgery in our hospital)."

3. During an interview on 10/19/11 at 2:00 PM, the Medical Records Manager stated they did not include either of the pathologists in the peer review process. The Medical Records Manager acknowledged the pathologists provided diagnostic results to the CAH's patients when the pathologists performed frozen sections at the CAH, and the CAH's surgeons relied on the diagnosis by the pathologists while in the operating room.

Based on medical record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to provide an interdisciplinary care conference for 1 of 1 sampled skilled care patient (Patient #14). The CAH administrative staff reported an average monthly census of 3 skilled patients.

Failure to provide an interdisciplinary care conferences for skilled patients could result in a lack of coordination and communication for patient care during hospitalization.

Findings include:

1. Review of the medical record for Patient #14 revealed the patient admission date was 6/28/11 and the patient qualified for skilled nursing care at the CAH. The patient's medical record lacked documented evidence of any interdisciplinary care conference during the patient's stay.

2. Review of CAH policy "General Policies for SNF/ICF [Skilled Nursing Facility/Intermediate Care Facility] Patients", reviewed 11/10, revealed in part "... 16. Multidisciplinary Care Conferences will be held as required to meet the patient/residents needs and consistent with the individual plan of care'.

3. During an interview on 10/19/11 at 3:30 PM, the Director of Nursing stated "We do not do a formal interdisciplinary care conference for our skilled care patients due to the short stay of most of our skilled patients".