HospitalInspections.org

At the time of revisit on March 5, 2015 this deficiency was not corrected.

Based on review of hospital documents and interviews with hospital staff, the governing body failed to ensure that all practitioners providing patient care are qualified and have current privileges granted, orientation and health histories. This occurred in three (H, I and J) of three contract personnel credential files reviewed.

Findings:

On the afternoon of 03/05/15, surveyors requested and reviewed three contracted staff files.

The personnel files for Staff H and I did not contain documentation of complete health histories and hospital orientation.

Staff J was the contracted dentist for the hospital. The hospital contract with Staff J was dated March 2009. Staff A and C was asked for the current contract, none was provided.

There was no documentation of a current credential file for Staff J.

The above findings were presented to the administrative staff during the exit conference on the afternoon of 03/05/15.

At the time of revisit on March 5, 2015 this deficiency was not corrected.

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

Findings:

1. On the morning of March 5, 2015, surveyors requested all infection surveillance reports, infection control meeting minutes, and infection control policies and procedures. Surveyors were given quality committee meeting minutes. There was no documentation of infection control meeting minutes.

2. On the morning of March 5, 2015, surveyors requested documentation of review and approval of all disinfectants and chemicals used in the CAH. Surveyors were provided a list of disinfectants and chemicals used in the CAH but there was no documentation of the disinfectants and chemicals being approved by the infection control officer, infection control committee, medical staff, and governing body.

3. On the afternoon of March 5, 2015, the Chief Nursing Officer(CNO) told surveyors that the chemicals and disinfectants used at the CAH had not been reviewed and approved by the infection control officer, infection control committee, medical staff, and governing body.

4. On the morning of March 5, 2015, surveyors requested documentation of employee illness tracking and analysis. No documentation was provided. The CNO told surveyors the employee health nurse keeps track of the employee illnesses but did not analyze for trends in employee illnesses.

5. On the morning of March 5, 2015, infection control surveillance data was provided to the surveyors. The infection control surveillance data only identified problems but no action plan or analysis of the problems. Surveyors reviewed the dietary infection control surveillance data. A problem was identified as "...Dishwashing machine "wash" water is 140 degrees..." The data noted this was non compliant. The dietery infection control surveillance documented a note "...chemical dish machine reaches 120 degrees..." There was no documentation of an action plan or analysis of the data.

Observations:

1. On the afternoon of March 5, 2015, surveyors toured the Criticial Access Hospital (CAH).
2. Surveyors observed a room in the main hallway that was labled as "patient shower" that contained multiple oscillating fans. This was a finding from the recertification survey conducted on October 15, 2014. The CAH's plan of correction documented "...All fans have been removed..."

At the time of revisit on March 5, 2015 this deficiency was not corrected.
Based on Governing body meeting minute review, medical staff meeting minute review and staff interview, the Critical Access Hospital (CAH) failed to ensure contracted services were furnished to comply with all applicable condition of participation.
Findings:
1. On the morning of March 5, 2015, Surveyors reviewed Governing Body and Medical Staff meeting minutes. There was no documentation of a Contracted Services Evaluation.
2. On the morning of March 5, 2015, the Chief Executive Officer(CEO) told surveyors that he reviewed and evaluated all contracts when they were due for renewal. The CEO told surveyors he documented in the CAH's electronic quality system.
3. On the afternoon of March 5, 2015, surveyors requested documentation from the CAH's electronic quality system of contract review. No documentation was provided.
4. On the afternoon of March 5, 2015, surveyors reviewed a contract the CAH had with a local dentist. The contract with the dentist expired in 2009.

At the time of revisit on March 5, 2015 this deficiency was not corrected.

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 4 of 4 (#3, 4, 5, & #6) emergency room patient's medical records reviewed.

Findings:

1. On the afternoon of March 5, 2015 , surveyors reviewed medical records. Four of Four (#3, 4, 5, & #6) 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 the Chief Nursing Officer(CNO) verified that the nurses did not perform complete head to toe assessments on Emergency Room patients. The CNO told surveyors that the nurses only document a "focused" health assessment.

At the time of the revisit on March 5, 2015 this deficiency was not corrected.
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 it's 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;
Findings:
1. On the morning of March 5, 2015 Surveyors requested the CAH's program evaluation. No program evaluation was provided.
2. On the morning of March 5, 2015 Surveyors reviewed Governing Body and Medical Staff minutes. There was no documentation of a Program Evaluation.
3. On the afternoon of March 5, 2015 the Chief Executive Officer verified that the CAH did not have an annual program evaluation.

At the time of the the revisit on March 5, 2015 this deficiency was not corrected.

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 March 5, 2015, surveyors requested the CAH's annual program evaluation. None was provided.
2. On the morning of March 5, 2015, surveyors reviewed Governing Body meeting minutes and Medical Staff meeting minutes. There was no documentation of an annual program evaluation.
3. On the afternoon of March 5, 2015, surveyors requested the CAH's annual program evaluation. The Chief Executive Officer verified that the CAH did not have an annual program evaluation.

At the time of revisit on March 5, 2015 this deficiency was not corrected.

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( #1 & #2) swing bed resident's medical records reviewed.

Findings:

1. On the afternoon of March 5, 2015, surveyors reviewed medical records. Two of two swing bed ( #1 & #2) resident's medical records reviewed did not contain documentation that the resident received their resident's rights.

2. On the afternoon of March 5, 2015, the Chief Nursing Officer told surveyors that swing bed resident's received a swing bed packet upon admission to swing bed.

3. On the afternoon of March 5, 2015, surveyors reviewed the swing bed admission packet that swing bed resident's receive. The admission packet did not contain the resident's rights. The admission packet documented "...upon admission, or on request prior to admission, you will receive a copy of the patient's bill of rights and the rules and regulations governing patient stays..."

4. The Chief Nursing Officer verified at the time of medical record review that swing bed resident's did not receive their resident's rights.