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Based on Medical Staff Meeting minutes, Governing Body Meeting minutes and staff interview, the Critical Assess Hospital (CAH) failed to ensure that the Governing Body maintained complete records (privileges, medical license, malpractice insurance and health) of Contracted Staff. This occurred in 3 of 5 (Staff N, O, P) contracted staff personnel files reviewed.
Findings:
1. On the morning of October 14, 2014 Surveyors requested and reviewed Medical Staff Meeting minutes and Governing Body minutes.
2. On the morning of October 15, 2014 Surveyors requested and reviewed five contracted staff files.
3. Three of Five files (Staff N, O, P,) reviewed did not contain current privileges, Medical license, malpractice insurance, and health records.
4. The finding was verified by Staff U on the afternoon of October 15, 2014.

Based on policy and procedure review, infection control surveillance review, personnel file review, staff interview and observation, the Critical Access Hospital (CAH) failed to maintain a system for identifying, reporting, investigating and controlling infections and communicable dieseases of patients and personnel.

Findings:

1. On the morning of 10/14/2014, surveyors requested all infection control surveillance reports, infection control meeting minutes, infection control policies and procedures and the personnel file of the infection control practitioner. No infection control meeting minutes were provided.

2. On the morning of 10/14/2014, surveyors were told that staff L was the designated infection control practitioner.

3. Review of medical staff meeting minutes, and governing body meeting minutes contained no documentation that staff L had been designated in writing as the infection control practitioner.

4. On the afternoon of 10/15/2014, surveyors reviewed the personnel file of staff L. There was no evidence of any infection control training and/or education.

5. On the afternoon of 10/15/2014, staff L told surveyors that she had not had any infection control training.

6. On the morning of 10/14/2014, surveyors reviewed medical staff meeting minutes. There was no documentation that disinfectants and chemicals used in the CAH had been reviewed and approved by the infection control officer, infection control committtee, and medical staff.

7. On the morning of 10/14/2014, staff L told surveyors that she had only been the infection control practitioner for a few months but she had not reviewed and approved all disinfectants and chemicals used in the CAH.

8. There was no documentation that the CAH had an infection control risk assessment. Staff L told surveyors there was not an infection control risk assessment.

9. There was no documentation that the CAH had a tuberculosis risk assessment. Staff L told surveyors there was not a tuberculosis risk assessment.

10. There was no documentation that employee illnesses are tracked and investigated. Staff L told surveyors that she had not tracked and investigated employee illnesses.

11. The CAH did not have a reportable disease list and process consistent with state requirements.

12. There was no documenation of environmental rounds to include all departments of the CAH such as dietary, laboratory, radiology, laundry, and housekeeping. Staff L told surveyors she had not made environmental rounds to all departments of the CAH and had not monitored infection control processes in all departments of the CAH.

13. Infection control policies and procedures were outdated and contained information not pertaining to the CAH.

14. Staff L told surveyors that the CAH was in the process of painting old cabinets. There was no documention that an infection control risk assessment was done regarding the renovations.


Observations:

1. On the morning of 10/14/2014, surveyors toured the Criticial Access Hospital (CAH).

2. Surveyors observed a hallway that contained gurneys already covered with a sheet and wheelchairs. Surveyors asked staff L how she would know if the equipment was clean. She stated she didn't know for sure but the nurses were to clean the equipment before it was stored.

3. Surveyors observed a patient room, room #24 that contained multiple equipment. Surveyors could not determine if the equipment was clean or dirty.

4. Surveyors observed in all patient rooms a squeeze bottle of soap located on the sinks. The rooms did not contain hands free soap systems and did not contain hands free alcohol hand rub.

5. Surveyors observed a room that contained three refrigerators. The refrigerators contained laboratory equipment. The door to the room was wide open allowing free access to the refrigerators.

6. Surveyors observed a room in the main hallway that was labled as "patient shower" that contained multiple oscillating fans. Staff L told surveyors that the fans are used for multiple patient use. Surveyors asked staff L how the fans were cleaned. Staff L told surveyors the fans were taken apart and cleaned. Staff L told surveyors that not all parts of the fan can be cleaned.

7. Surveyors observed the Emergency Room. There was an Obstetric "precipitous delivery pack" that is used for an emergency delivery pack. The preciptious delivery pack was dated to expire 01/12/2012.

There were multiple supplies stored in drawers in the Emergency Room. Many of the supplies were still in original packaging but the packaging had turned yellow.

8. Surveyors observed the crash carts in the Emergency Room. The laryngoscope blades in the crash cart were stored uncovered. Staff L told surveyors that the laryngoscope blades were cleaned with HDQ which is the disinfectant that is used on everything. HDQ is not high level disinfection. A CAH policy, titled, "Infection Control in the Emergency Room," documented, "...Laryngoscope blades should be washed in detergent solution, soaked in 70% alcohol for 10 minutes, rinsed, dried, and kept in dustprrof envelope until reuse..."

Based on medical record review, hospital document review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that nutritional screening met the nutritional needs of the patients. This occurred in 2 of 2 (# 4 & # 6) swing bed medical records reviewed and occurred in 3 of 9 (#7, 12, & #14) inpatient medical records reviewed.
Findings:
1. On the afternoon of October 15, 2014, surveyors reviewed 2 (#4 & #6) swing bed medical records and 9 (#5, 7, 8, 9, 10, 11, 12, 13, 14, & #15) inpatient medical records.
2. 2 of 2 swing bed patients (Patient #4, & #6) did not contain a nutritional screening done by the dietician.
3. The medical record for patient #7 documented, "...possiblity for decreased appetite" There was no documentation of a nutritional screen done by the dietician.
4. The medical record for patient #14 documented an order from the physicain for a nutritional consult. There was no documentation that the dietician had seen the patient.
5. The medical record for patient #12 dcoumented that the patient had Crohn's disease, several loose stools, nausea and decreased potassium levels. There was no documentation that the dietician had seen the patient. There was no documentation of a nutritional screen done by the dietician.
6. A document titled " Protocol for Notification of RD " documented "...Dietary manager fills out assessment sheet including meds and lab work and faxes to RD for evaluation; RD returns to the facility with recommendations ...."

Based on hospital Governing Body meeting minute review, Medical Staff meeting minute review and staff interview, the hospital failed to maintain a list of all services provided through arrangements, contracts or agreements that described the nature and scope of the services provided.
Findings:
1. On the morning of October 14, 2014, surveyors reviewed Governing Body and Medical Staff meeting minutes for 2013/2014. There was no documentation of a list of Contracted Services and the nature of the services provided.
2. On the morning of October 14, 2014 Surveyors requested a list of contracted services. No list was provided.
3. The findings were verified upon Exit on the afternoon of October 15, 2014.

Based on Governing body meeting minute review, medical staff meeting minute review and staff interview, the hospital failed to ensure contracted services were furnished to comply with all applicable condition of participation.
Findings:
1. On the morning of October 14, 2014 Surveyors reviewed Governing Body and Medical Staff meeting minutes for 2013/2014. There was no documentation of a Contracted Services Evaluation.
2. On the morning of October 14, 2014 Surveyors requested a list of contracted services. No list was provided.
3. Staff S told surveyors that he had evaluated Contracted Services but not formally.
4. Staff L told surveyors that respiratory therapy is a contracted service.
5. Staff L told surveyors that she provided the nursing staff with respiratory therapy training.
6. On the afternoon of 10/15/2014, surveyors reviewed nursing personnel files. The last documented respiratory training by the contracted Respiratory Therapist was in 2006.
7. On the morning of 10/15/2014, staff L told surveyors that the dietician was a contracted service.
8. On the afternoon of 10/15/2014, staff L told surveyors that the dietician had not provided nursing staff with any dietary training.
9. The findings were verified upon Exit on the afternoon of October 15, 2014.

Based on medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure medical records for emergency room patients contained complete health status assessments.
This occurred in 3 of 3 (#15, 16, & #17) emergency room patient's medical records reviewed.

Findings:

1. On the afternoon of 10/15/2014, surveyors reviewed medical records. Three of three (#15, 16 & #17) emergency room medical records reviewed did not contain documentation of a complete head to toe health assessment.

2. At the time of medical record review staff L told surveyors that since the CAH started using the electronic health record some of the nurses will only document a "focused" health assessment.

Based on Medical Staff meeting minute, Governing Body meeting minute review, and staff interview, the Critical Access Hospital (CAH) failed to:
a. perform a periodic evaluation of its total program at least once a year;
b. ensure a yearly program evaluation included the number of patients served and the volume of services;
c. ensure a yearly program evaluation included review of both active and closed clinical records;
d. review and revise the health care policies as part of the annual program evaluation.
Findings:
1. On the morning of October 14, 2014 Surveyors requested the hospital's Program Evaluation. No evaluation was given.
2. On the morning of October 14, 2014 Surveyors reviewed Governing Body and Medical Staff minutes for 2013/2014. There was no documentation of a Program Evaluation.
3. Review of all CAH policies and procedures contained documentation of policies and procedures reviewed annually but many CAH policies and procedures were outdated.
4. Emergency room policies and procedures were last revised in 2000.
5. Infection Control policies and procedures were last revised in 1989.
6. Some Nursing policies and procedures were last revised in 1989.
7. Staff S verified the findings at Exit on the afternoon of October 15, 2014.

Based on Governing Body meeting minute review, Medical Staff meeting minute review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that a Program Evaluation was conducted at least once a year.
Findings:
1. On the morning of October 14, 2014 Surveyors requested the hospital's Program Evaluation. No evaluation was given.
2. On the morning of October 14, 2014 Surveyors reviewed Governing Body and Medical Staff minutes for 2013/2014. There was no documentation of a Program Evaluation.
3. Staff S verified the findings at Exit on the afternoon of October 15, 2014.

Based on hospital document review, medical record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure each swing bed resident was informed both orally and in writing of his or her rights and all rules and regulations. This occurred in 2 of 2( #4 & #6) swing bed resident's medical records reviewed.

Findings:

1. On the morning of 10/15/2014, staff L told surveyors that the CAH had recently started using the electronic health record (EHR).

2. On the afternoon of 10/14/2014 surveyors reviewed a policy, titled.."Procedure Patient Bill of Rights." The policy documented, "...Each patient, or member of the patient's famly, admitted to Swing Bed will be given a copy of the following: A copy of the patient Bill of Rights..."

3. Staff L told surveyors that since the CAH had been utilizing the EHR, swing bed residents have not received their rights in writing.

4. On the afternoon of 10/15/2014, surveyors reviewed two swing (#4 & #6) bed resident's medical records. Both swing bed resident's medical records contained no documentation that the patient received their rights.

Based on hospital document review, medical record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure each swing bed resident was notified in writing of each item and service that the CAH provided and notified of each item and service that the resident would be charged. This occurred in 2 of 2 (#4 & #6) swing bed resident's medical records reviewed.

Findings:

1. On the morning of 10/14/2014, surveyors reviewed a hospital policy, titled, "Procedure Patient Bill of Rights." The policy, documented "...each patient, or member of the patient's famly, admitted to a swing bed will be given a copy of the following: a letter explaining all covered and non-covered services of swing bed..."

2. On the morning of 10/14/2014, Staff L told surveyors that swing bed resident's did not receive a letter explaining all covered and non-covered services of swing bed.

3. On the afternoon of 10/15/2014, surveyors reviewed two (#4 & #6) swing bed resident's medical records. Both swing bed resident's medical records contained no documentation that the residents received a letter explaining all covered and non-covered services of swing bed.

Based on hospital document review, medical record review, and staff interview the critical access hospital (CAH) failed to ensure swing bed residents were provided activities to meet the needs of the residents based on a comprehensive assessment, resident's interests, and the physical, mental, and psychosocial well being of each resident. This occurred in 2 of 2 (#4 & #6) resident's medical records reviewed.

Findings:

1. On the morning of 10/14/2014, Staff L told surveyors that the CAH had recently started using the electronic health record (EHR).

2. On the morning of 10/14/2014, Staff L told surveyors that since the CAH had been utilizing the EHR she had not performed activities assessments on swing bed patients. Staff L told surveyors that there is no where on the EHR to document an activities assessment.

3. On the afternoon of 10/15/2014, surveyors reviewed two (#4 & #6) swing bed resident's medical records. Both swing bed resident's medical records did not contain documentation of an activities assessment.

3. On the afternoon of 10/15/2014, surveyors reviewed a swing bed admission packet. The admission packet contained an activities assessment. The activities assessment was in paper form. Staff L told surveyors that when documentation was on paper this was the form used for activities assessments.

4. On the afternoon of 10/15/2014, surveyors reviewed 2 swing bed resident's medical records. Both swing bed resident's medical records contained no documentation of an activities assessment and both swing bed resident's medical records contained no documentation of any activities performed with the patients.