HospitalInspections.org

Based on Medical Staff Bylaws review, credential file review, and staff interview, the critical access hospital's (CAH's) Governing Body failed to ensure 4 of 6 members of the Professional Staff (Staff ID #'s C, I, L and Q) were reappointed to the medical staff every two years according to the Hospital's Bylaws and failed to ensure 5 of 6 members had an approved / signed Delineation of Privileges form (ID #'s C, I, K, L, and Q)

Findings include:

The "Medical Staff Bylaws" dated 12/17/14 reviewed on 9/9/15 in section 4.3 directed "Appointment Authority: Appointments, denials and revocations of appointments to the Medical Staff shall be made by the Board as set forth is these Bylaws..." 4.4 "Duration of Appointment and Reappointment: Reappointments and appointments after the completion of provisional status shall be for a period of two years..." 5.2 "Delineation of Privileges: each application for appointment to the Medical Staff must contain a request for the specific Clinical Privileges desired by the applicant..."

Record review of credential files on 9/10/15 revealed the following:

ID# C is a Medical Doctor / Family Medicine. The physician was last reappointed to medical staff on 9/14/11. The appointment expired 9/14/13. The credential file lacked a delineation of privileges form.

ID# I is a Podiatrist. The Podiatrist was last reappointed to medical staff on 11/21/12. The appointment expired 11/21/14. A form titled "Request and Approval of Privileges for Podiatry" dated 1/18/11 was not signed / approved by the Governing Board.

ID# K is a Medical Doctor / Cardiology. The Cardiologist was last appointed to medical staff on 11/19/14. A form titled "Request and Approval of Privileges for General Cardiology" dated 8/12/14 was not signed / approved by the Governing Board.

ID# L is a Medical Doctor / Pathology. The Pathologist was last appointed to medical staff on 6/19/13. The appointment expired 6/19/15. The credential file lacked a delineation of privileges form.

ID# Q is a Physician Assistant. The Physician assistant did not have an appointment to medical staff or a delineation of privileges form. The file did contain copies and verification of licensure.

Interview with a staff member responsible for the credential files (ID# H) on 9/10/15 at 10:30 a.m. revealed acknowledgement that she would need to have the above providers reappointed to medical staff at the next Governing Board meeting and ensure all the proper documents are in place.

Based on observation, record review, policy review, and staff interview, the critical access hospital (CAH) failed to designate in writing an individual or group of individuals, qualified through training, as an infection control officer and failed to place 1 of 7 current swing bed patients sampled (Patient ID# 6) on contact isolation per policy after a positive culture result for Methicillin Resistant Staphylococcus Aureus (MRSA) microorganism. These deficient practices have the potential to place all patients and CAH staff at risk for infections or spreading infections.

Findings include:

Interview on 9/9/15 at 9:10 a.m. with the Director of Nursing (DON)(ID# B) revealed the hospital has not designated in writing an individual or group of individuals, qualified through education / training, as an infection control officer or officers. The DON stated that the infection control committee members (mostly department heads) assist with the infection control program but acknowledged there has been no specific training / requirements for the staff members of the committee.

Patient ID #6's record review on 9/9/15 at 9:15am revealed a Lab Report collected 9/2/15 "Culture MRSA Screen: Nares (nose) Result = (MRSA) Staphylococcus aureus" Resistant microorganism. Contact precautions required." Final report was dated 9/5/15 at 8 p.m. "

Observation 9/9/15 at 9:30 a.m. revealed patient ID# 6 was in her bed in room 113. The room did not have a contact precaution sign posted on the door. The surveyor inquired at this time with the DON as to why there was no contact precaution sign posted on the patient's door. The DON stated she would look into the matter.

Interview on 9/9/15 at 12:20 p.m. with the DON revealed she contacted the Physician Assistant (PA) about the positive MRSA culture for patient ID# 6 and the PA wrote a progress note and a new order.

Patient ID# 6's record review further revealed a progress note dated 9/8/15 that read in part: "Admission swab of nares on 9/2/15 revealed positive MRSA. Treatment initiated 9/8/15. Bactroban (antibacterial used to treat skin infections) Nasal each nare twice daily x 5 days. Repeat nasal swab seven days from start of treatment. Wear gloves when in contact with patient. "A Physician Order dated 9/9/15 stated " Wear gloves when in contact with patient."

Review of the CAH's policy on 9/9/2015 titled "Contact Isolation" (no date) stated " Visitors - report to Nurse's station before entering room. Diseases requiring contact isolation: Multiple - resistant bacteria infection or colonization (any site) with any of the following: 2. Staphylococcus aureus resistant to methicillin..." General Instructions: Door will be labeled "Contact Isolation." All visitors to check with RN before entering room..."

Review of Infection Control meeting minutes for 2015 (dated 1/6/15, 4/7/15, and 7/7/15) revealed only one mention of infection control training. On 1/7/15 the meeting stated "There is a webinar Thursday at 1 p.m. on C-Diff (clostridium difficile-a bacterium that causes diarrhea and more serious intestinal conditions) if anyone is interested."