HospitalInspections.org

The hospital reported a census of six patients. Based on document review and staff interview, the Critical Access Hospital failed to assure the staff followed the Medical Staff's Rules and Regulations for credentialing the hospital's Physician Assistant (PA) staff.

Findings include:

- Review of Physician Assistant H's credentialing record on 7/15/10 revealed the hospital accepted their Medical Staff application on 9/25/09. The record lacked evidence of any specific clinical privileges requested by the PA.

Review of the hospital's on-call schedule for the emergency department revealed the PA began to see emergency department and hospital patients after 9/25/09.

Review of the Hospital's Medical Staff's By-laws, rules and regulations dated 8/9/88 directed the credentialing staff to obtain a request for specific clinical privileges from all medical staff applicants. The document directs the governing body to review the request and determine which privileges they will grant the staff to perform prior to providing patient care.

Interview with credentialing staff G on 7/15/10 at 9:30am reported the hospital failed to follow their established by-laws and failed to complete the credentialing process for medical staff H.

The hospital reported a census of six patients. Based on observation, document review and staff interview, the Critical Access Hospital failed to assure the staff properly stored controlled medications and monitor for out of date drugs and supplies.

Findings include:

- Observation of the medication room on 7/13/10 at 8:00am revealed a shelf with the following narcotic medications stored in a un-lockable storage bin:
1. One full bottle of Morphine Sulfate 10 milligrams (mg) in each milliliter (ml).
2. MS Contin 60mg - 86 tablets
3. One full bottle of Roxanol 20mg/ml, 30ml.

Interview with licensed staff I on 7/13/10 at 8:00am acknowledged the hospital failed to double lock the narcotic medications.

Interview with licensed staff C on 7/13/10 at 2:00pm reported the hospital required double locks for all narcotic medications and stated, "it's good practice." Staff D and E reported the hospital lacked a policy to direct the staff on how to store narcotic medications.

- Observation of the emergency department on 7/13/10 at 11:00am revealed the following expired medications and supplies available for patient use:

1. Anesthetic medications (medications to numb sensation):
One- bottle of Sensorcaine 0.5% expired on 1/21/10.
One- bottle of Lidocaine expired on 1/24/10.
2. Intervenous solution:
One 1000 ml bag of D5W expired on 2/10.
3. Sutures:
Ten- Vicryl expired on 1/10.
Four- 3-0 Silk expired on 1/07.

Interview with licensed staff C on 7/13/10 at 2:00pm reported the hospital staff were required to check the department periodically for expired medications and supplies. Staff D and E reported the hospital lacked a policy to direct the staff to monitor for expired medications and supplies.

The hospital reported a census of six patients. Based on document review and interview, the Critical Access Hospital failed to meet the Condition of Participation to conduct a periodic evaluation.

Findings include:

- Review of the hospital's Governing Body meeting minutes lacked documentation of a periodic evaluation. The hospital could not produce evidence of a periodic evaluation on 7/13/10.

- Staff A, B, C and D, interviewed on 7/13/10 at 2:50pm acknowledged the Governing Body failed to perform a periodic evaluation.

- The Critical Access Hospital (CAH) failed to complete a periodic evaluation of it's total program as required C-330.

- The CAH failed to ensure it carried out or arranged for a periodic evaluation of its total program as required at C-331.

- The CAH failed to perform the utilization of services including the number of patients served and the volume of services as required at C-332.

- The CAH failed to review not less than 10% of both active and closed patient records as required at C-333.

- The CAH failed to provide evidence that the health care policies are evaluated, reviewed and/or revised as part of the annual program evaluation as required at C-334.

- The CAH failed to acknowledge the purpose of the evaluation to determine whether the utilization of services is appropriate, the established policies are followed and any changes are needed as required at C-335.