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Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure documentation of medication errors or drug reactions, including notification to the practitioner, must be in the patient's medical record for the occurrence of a medication error for 7 of 8 medication errors reviewed (Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7). Failure to document medication errors or drug reactions in the medical records could potentially result in the provider not knowing about the medication error and failing to take steps to address the consequences of the medication error, possibly resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff reported a census of 4 on entrance to the facility and an average daily census of 4 patients per day.

Findings include:

1. Review of the policy "Medications", effective 10/2020, revealed in part "All med errors will have the date and time of physician notification documented ... [medication errors and drug reactions] are charted on the medical record."

2. Review of policy "Incident Reports", effective 5/2020, revealed in part "The physician/ provider must be notified whenever an incident involves his/her patient ...The person completing the report will record the date and time the physician/provider was notified ..."

3. Review of medication errors from February 2021 to May 2021 revealed:

a. On 05/25/2021 at approximately 11:44 AM, the Operating Room (OR) staff administered Patient #1 a pre-op IV antibiotic in 14 minutes, which was supposed to be infused over an hour. Patient #1's medical record lacked documentation of the time nursing staff notified the practitioner responsible for Patient #1's medical care.

b. On 05/15/2021 at approximately 9:00 PM, the nursing staff administered Patient #2 the wrong dose of medication. Patient #2's medical record lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #2's medical care.

c. On 04/24/2021 at 8:27 AM, the nursing staff omitted a medication for Patient #3. Patient #3's medical record lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #3's medical care.

d. On 05/07/2021 at approximately 2:00 PM, the nursing staff omitted 2 medications for Patient #4. Patient #4's medical record lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #4's medical care.

e. On 04/13/2021 at approximately 9:00 AM, the nursing staff failed to hold an ordered medication for Patient #5 prior to an ordered procedure. Patient #5's medical record lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #5's medical care.

f. On 02/21/2021 at approximately midnight, the nursing staff omitted a medication for Patient #6. Patient #6's medical record lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #6's medical care.

g. On 02/15/2021 at approximately 6:00 PM, the nursing staff missed 3 doses of medications for Patient #7. Patient #7's medical record lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #7's medical care.

4. During chart review and an interview on 06/02/2021 at 8:55 AM, the Quality and Risk Manager acknowledged the medical records of Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7, lacked documentation of the date/time the nursing staff notified the patient's physician of the medication error.

5. During an interview on 06/02/2021 at 3:30 PM, the CNO acknowledged the medical records of Patient #1, Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, and Patient #7, lacked documentation of the medication errors and the date/time the nursing staff notified the patient's physician of the medication error.

Based on review of policies/procedures, medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure examination of the patient by a physician immediately before surgery to evaluate the risks prior to the performance of the procedure in 5 of 5 closed medical records (Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14) reviewed. Failure of a physician to examine a patient immediately before surgery could result in surgery performed on an unstable patient. The hospital's administrative staff identified the surgical services staff performed an average of 76 surgical procedures per month.

Findings include:

1. Review of closed surgical records revealed the following:

a. Patient #10 had their tonsils removed on 6/1/21 at 7:02 AM. Patient #10's medical record lacked evidence that a physician examined Patient #10 on the day of surgery, prior to the surgical procedure, to ensure Patient #10 could still safely undergo surgery.

b. Patient #11 had a colonoscopy with biopsy on 5/28/21 at 6:51 AM. Patient #11's medical record lacked evidence that a physician examined Patient #11 on the day of surgery, prior to the surgical procedure, to ensure Patient #11 could still safely undergo surgery.

c. Patient #12 had an esophagogastroduodenoscopy (EGD) with biopsy procedure (EGD is an endoscopic procedure that allows the doctor to examine the esophagus, stomach and duodenum (part of the small intestine)) on 5/26/21 at 9:39 AM. Patient #12's medical record lacked evidence that a physician examined Patient #12 on the day of surgery, prior to the surgical procedure, to ensure Patient #12 still could safely undergo surgery.

d. Patient #13 underwent gallbladder removal surgery on 5/25/21 at 6:54 AM. Patient #13's medical record lacked evidence that a physician examined Patient #13 on the day of surgery, prior to the surgical procedure, to ensure Patient #13 could still safely undergo surgery.

e. Patient #14 underwent a toe amputation on 5/25/21 at 1:05 PM. Patient #14's medical record lacked evidence that a physician examined Patient #14 on the day of surgery, prior to the surgical procedure, to ensure Patient #14 could still safely undergo surgery.


2. During an interview on 6/2/21 at 4:10 PM, the Surgery Nurse Manager acknowledged Patient #10, Patient #11, Patient #12, Patient #13, and Patient #14's medical records lacked evidence that a physician examined the patient on the day of surgery, prior to the surgery, to ensure the patient could still safely undergo surgery. The Surgery Nurse Manager revealed that they lacked knowledge of the requirement for a physician needed to examine a patient prior to surgery, to ensure the patient could safely undergo surgery. As the Surgery Nurse Manager lacked knowledge of the requirement for a physician to examine a patient prior to surgery, the Surgery Nurse Manager failed to develop and implement a policy requiring physicians to assess the patients prior to surgery.

Based on observation, document review, and staff interviews, the hospital's administrative staff failed to ensure 2 out of 2 observed surgeons and anesthesia providers (CRNA E and Surgeon G) wore head coverings which fully covered all of their hair. Failure to wear head coverings that fully cover all hair could potentially result in bacteria, fungi, or viruses on the surgical staff members' hair entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The hospital's administrative staff identified the surgical services staff performed an average of 76 surgical procedures per month.

Findings include:

1. Observations on 06/02/2021 at approximately 6:50 AM, during an Esophagogastroduodenoscopy (EGD) with Biopsy procedure (EGD is an endoscopic procedure that allows your doctor to examine the esophagus, stomach and duodenum (part of the small intestine)), revealed Patient #8 was undergoing a surgical procedure in operating room #1. Observations from inside the operating room revealed CRNA E (Certified Registered Nurse Anesthetist) (a registered nurse with specialized training in administering medication to render a patient unconscious for surgery) wore a skull cap. The skull cap consisted of a cap covering CRNA E's forehead and central part of CRNA E's hair. The skull cap did not cover the lower approximately one inch of CRNA E's hair on the side of CRNA E's head and the back of CRNA E's hair.

2. Observations on 06/02/2021 at approximately 9:52 AM, during a Cholecystectomy Laparoscopic procedure (The gallbladder is removed with instruments placed into small incisions in the abdomen), revealed Patient #9 was undergoing a surgical procedure in operating room #2. Observations from inside the operating room revealed Surgeon G and CRNA E wore a skull cap. The skull cap consisted of a cap covering Surgeon G's forehead and central part of Surgeon G's hair. The skull cap did not cover the lower approximately one inch of Surgeon G's back of Surgeon G's hair. The skull cap consisted of a cap covering CRNA E's forehead and central part of CRNA E's hair. The skull cap did not cover the lower approximately one inch of CRNA E's hair on the side of CRNA E's head and the back of CRNA E's hair. Nearing the end of the procedure Registered Nurse (RN) F was asked by CRNA E to push his hair that had fallen out of his cap at the front of his skull cap.

3. During an interview on 06/02/2021 at approximately 9:15 AM, the Surgery Manager revealed that most of the hospital's male surgeons and CRNAs all wear skull caps. The Surgery Manager reported the hospital followed the AORN (Association of peri-Operative Registered Nurses, a nationally recognized guideline agency) guidelines and American College of Surgeons (a professional organization for surgeons) statement for surgical attire.

4. Review of the AORN Guideline for Surgical Attire, copyright 2020, revealed in part, "The revision stated that the scalp and hair should be covered when entering the semi-restricted and restricted areas ..."

5. Review of the hospital's Attire, Non-Patient Entering Restricted Areas in The Operating Room, reviewed on 10/2020, revealed the policy in part, "Surgical attire consists of: ... Head covering that confines all hair and scalp, disposable preferred."

6. During an interview on 06/02/2021 at approximately 3:10 PM, the hospital's Vice President acknowledged the surgeons and CRNA's currently wear skull caps.