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Based on document review and and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure timely physician notification for the occurrence of a medication error for 2 of 7 medication errors reviewed. (Patient #8 and Patient #9). Failure to notify the physician of medication errors could potentially result in the provider not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the provider making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff reported a census of 1 patient on entrance, and an average daily census of 3 patients per day.

Findings include:

1. Review of "Incident Reporting" last approved 09/2019, revealed in part: "...if there are incidents...and/or medication variances...fill out Section A...and Section D (Medication Variance)...to ensure that all field in this sections are completed", and "notify... as soon as possible".

2. Review of medication errors from November 2018 to August 2019 revealed:

a. The nursing staff administered Patient #8's antibiotic late on 12/22/18 at 20:50 PM. Patient #9's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #9's medical care of the medication error.

b. The nursing staff infused Patient #8's intravenous (IV) fluids at the wrong rate on 6/10/19 at 20:00 PM. Patient #8's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #8's medical care of the medication error.



3. During an interview on 10/02/19 at 12:38 PM, the Chief Executive Officer acknowledged the medication error paperwork for Patient #8 and Patient #9 lacked documentation that the nursing staff notified the patient's provider of the medication error.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure surgical staff sanitized their hands after glove use during 1 of 1 observed surgical procedures (Patient #1). Failure to ensure surgical staff followed approved infection control standards of practice in accordance with the Centers for Disease Control (CDC) recommendations could potentially result in the surgical staff failing to remove bacteria which contaminated their hands during a procedure and potentially transmit the bacteria to another patient, potentially causing a life-threatening infection. The CAH's administrative staff identified the surgical staff performed 129 surgical procedures for the fiscal year 2019 (July 1, 2018 to June 30, 2019).

Findings include:

1. Review of the "Handwashing Policy," reviewed 05/2019, revealed in part. "All employees are responsible for preventing the spread of infection by practicing effective handwashing (sic)."

2. Review of the policy "Infection Control for Nursing," reviewed 08/2019, revealed in part "Purpose: To minimize patient, employees and customer exposure to pathogenic bacteria, viruses and parasites, the nursing personnel will follow the Hospital-Wide Control policies..." "Indications for hand washing (soap and water) and hand antisepsis (alcohol-based hand rub) are: ... Before having direct contact with patients...before donning sterile gloves for an invasive (i.e. insertion of indwelling urinary catheters, etc) procedure... After removing gloves ..."

3. Observations on 09/30/19, beginning at 1:30 PM during Patient #1 cataract surgery, revealed the following:

--1:39 PM CST B failed to perform hand hygiene prior to donning sterile gloves prior to performing the facial prep on Pt #1.

--2:13 PM Medical Doctor (MD) Q removed their sterile gloves and failed to perform hand hygiene before administering eye medication to Pt #1.

--2:14 PM Certified Surgical Technician (CST) A removed their sterile gloves and failed to perform hand hygiene.

--2:14 PM CST B removed their sterile gloves and failed to perform hand hygiene.

--2:16 PM Registered Nurse (RN) C removed their non-sterile gloves and failed to perform hand hygiene.

--2:18 PM CST A and CST B removed their sterile gloves and failed to perform hand hygiene.

--2:19 PM CRNA E (a nurse with specialized training to administer medication used during surgery to ensure patients do not feel pain during surgery) B removed their non-sterile gloves and failed to perform hand hygiene.


Observation on 9/30/2019, beginning at 2:20 PM following Patient #1 cataract surgery, revealed the following:

2:53 PM CST D removed their non-sterile gloves and failed to perform hand hygiene.

3:02 PM CST D removed their non-sterile gloves and failed to perform hand hygiene.


4. During an interview on 10/01/2019 at 12:55 PM, Operating Room (OR) Manager revealed they expected the surgical staff to perform hand hygiene according to the hospital Handwashing policy and Surgical Hand Hygiene Standards.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure Surgeon Q completed the medical record with a pre-operative review and update to the History & Physical (H&P) for 5 of 9 reviewed patient charts (Patient #1, Patient #2, Patient #10, Patient #11, and Patient #12). Failure to assess the patient pre-operatively for any changes in their condition since the patient's H&P was completed might result in Surgeon Q failing to detect a change in the patient's condition between the H&P examination and the surgical procedure, potentially resulting in the patient experiencing a life-treating complication during surgery. The CAH's administrative staff identified the surgical staff performed 129 surgical procedures for the fiscal year 2019 (July 1, 2018 to June 30, 2019).

Findings include:

1. Review of the "Medical Staff: Rules and Regulations Policy" reviewed 07/2019, revealed in part. " ...the surgeon must document they have reviewed the History and Physical and concurs with the findings and recommendations ..."

2. Review of medical records revealed the following:

a. Patient #1 underwent a surgical procedure on 9/30/19. Surgeon Q failed to document, prior to the surgical procedure, that they evaluated Patient #1, and Patient #1 could still safely undergo the surgical procedure.

b. Patient #2 underwent a surgical procedure on 6/03/19. Surgeon Q failed to document, prior to the surgical procedure, that they evaluated Patient #2, and Patient #2 could still safely undergo the surgical procedure.

c. Patient #10 underwent a surgical procedure on 6/03/19. Surgeon Q failed to document, prior to the surgical procedure, that they evaluated Patient #10, and Patient #10 could still safely undergo the surgical procedure.

d. Patient #11 underwent a surgical procedure on 6/03/19. Surgeon Q failed to document, prior to the surgical procedure, that they evaluated Patient #11, and Patient #11 could still safely undergo the surgical procedure.

e. Patient #12 underwent a surgical procedure on 9/30/19. Surgeon Q failed to document, prior to the surgical procedure, that they evaluated Patient #12, and Patient #12 could still safely undergo the surgical procedure.


3. During an interview on 10/02/2019 at 2:15 PM, the OR (Operating Room) Manager, verified that Surgeon Q failed to document in the medical records, prior to the surgical procedure, for Patient #1, Patient #2, Patient #10, Patient #11, and Patient #12, that Surgeon Q assessed the patient for changes between the completion of the H&P examination and the surgical procedures.

I. Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to develop a comprehensive activities care plan for 1 of 1 open swing bed patient medical record (Patient #3) and 4 of 4 reviewed closed swing bed patient medical records (Patient #4, Patient #5, Patient #6, and Patient #7). Failure to develop a comprehensive activities care plan that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well-being and independence possible. The CAH administrative staff identified an average of 4 swing bed patient admissions per month and a census of 1 swing bed patient on entrance.

Findings include:

1. Review of the policy, "Activity Program," effective 04/2019, revealed in part, "...Activity assessment, goals and care plans are developed as soon as is practical following admission to the Swing Bed program, but within 7 days...Activities are provided based on the comprehensive assessment and care plan and the preferences of each resident...."

2. Review of medical records revealed the following:

a. The CAH staff admitted Patient #3 to swing bed status on 09/27/2019. Registered Nurse I completed an initial activities assessment for Patient #3 on 09/27/2019. Patient #3's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.

b. The CAH staff admitted Patient #4 to swing bed status on 12/12/2018. The CAH staff discharged Patient #4 from swing bed status on 01/11/19. Registered Nurse H completed an initial activities assessment for Patient #4 on 12/12/2019. Patient #4's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.

c. The CAH staff admitted Patient #5 to swing bed status on 04/10/2019. The CAH staff discharged Patient #5 from swing bed status on 04/11/19. Registered Nurse F completed an initial activities assessment for Patient #5 on 04/10/2019. Patient #5's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.

d. The CAH staff admitted Patient #6 to swing bed status on 05/22/2019. The CAH staff discharged Patient #6 from swing bed status on 05/30/19. Registered Nurse G completed an initial activities assessment for Patient #6 on 05/24/2019. Patient #6's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.

e. The CAH staff admitted Patient #7 to swing bed status on 04/30/2019. The CAH staff discharged Patient #7 from swing bed status on 05/25/2019. Registered Nurse F completed an initial activities assessment for Patient #7 on 05/01/2019. Patient #7's medical record lacked evidence the CAH staff created an activity care plan that directed staff to provide individual or group activities chosen by the patient.


3. During an interview on 10/01/2019 at 11:30 AM, the Medical-Surgical Nurse Manager acknowledged Patient #3's, Patient #4's, Patient #5's, Patient #6's, and Patient #7's medical records lacked an activities care plan.



II. Based on policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure qualified staff directed group, individual, and independent activities provided to swing-bed patients. Failure to ensure qualified staff member directed swing-bed activities designed to meet the patients' interests and encourage independence and interaction could potentially impede patients' progression toward attaining goals and achieving the highest level of well-being and independence possible. The CAH administrative staff identified an average of 4 swing bed patient admissions per month and a census of 1 swing bed patient on entrance.

1. Review of policy, "Activity Program," revised 04/2019, lacked language identifying the swing bed activity director's responsibilities for directing the development, implementation, supervision, and ongoing evaluation of the swing bed activities program.

2. During an interview on 10/01/2019 at 11:30 AM, the Medical-Surgical Nursing Manager revealed Occupational Therapist M provides oversight for the swing bed activities program. The Medical-Surgical Nursing Manager revealed Occupational Therapist M's only responsibility is co-signing a monthly swing bed activities calendar (a calendar listing available activities for swing bed patients).

3. During an interview on 10/02/2019 at 03:40 PM, Certified Nurse Assistant (CNA) R revealed responsibility for preparing a monthly calendar of swing bed activities. CNA R revealed no specialized education or training in recreational therapy and no additional responsibilities for swing bed activities development.

4. During an interview on 10/01/2019 at 11:58 AM, Occupational Therapist M revealed co-signing the monthly swing-bed activities calendar developed by CNA R and answering occasional questions from nursing staff regarding swing-bed patients as the extent of oversight for activities provided to swing bed patients. Occupational Therapist M acknowledged no review/oversight of the development, implementation, supervision, and ongoing evaluation of the activities program.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation services for 2 of 5 swing bed patients (Patient #4 and Patient #5). Failure to ensure a physician ordered specialized rehabilitation services could result in swing bed patients not receiving specialized rehab services appropriate to their medical condition. The CAH administrative staff identified an average of 4 swing bed patient admissions per month and a census of 1 swing bed patient on entrance.

Findings included:

1. Review of the swing bed policy, "Specialized Rehabilitative Services-Swing Bed," revised 04/2019, revealed in part, "...The specialized rehabilitative services must be provided under the order of a physician...."

2. Review of Patient #4's closed medical record revealed the CAH staff admitted Patient #4 for swing bed level care on 12/12/2018. The CAH staff discharged Patient #4 on 01/11/19. Advanced Registered Nurse Practitioner (ARNP, a nurse with advanced training who may prescribe therapies) L wrote an order on 12/12/2018 at 07:52 PM for the Physical Therapist to evaluate and treat Patient #4 and for the Occupational Therapist to evaluate and treat Patient #4.

3. Review of Patient #5's closed medical record revealed the CAH staff admitted Patient #5 for swing bed level care on 04/10/2019. The CAH staff transferred Patient #5 on 04/11/2019. ARNP L wrote an order on 04/10/2019 at 04:57 PM for the Physical Therapist to evaluate and treat Patient #5 and for the Occupational Therapist to evaluate and treat Patient #5.

4. During an interview on 10/01/2019 at 09:00 AM, the Medical-Surgical Nursing Manager acknowledged that ARNP L wrote the therapy orders for Patient #4 and Patient #5 when the patients received swing bed services. The Medical-Surgical Nursing Manager acknowledged a physician did not write the therapy orders for Patient #4 and Patient #5.

5. During an interview on 10/01/2019 at 09:58 AM, Physician J confirmed ARNP L wrote therapy orders for Patient #4 and Patient #5.