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Based on observation and interview, the emergency room had expired sterile supplies readily available for patient use. Patient and cleaning supplies were stored under the sink in the trauma room.

Findings included

On 9/4/2018, in the trauma emergency room, in the drawer of the counter were found 16 packages of 6" Q-tips that were expired. On the counter, was a tube of Triple Antibiotic Ointment that had an expiration date of 12/2014.

Under the sink, inside the cabinet were multiple items stored under the sink. The items stored under the sink included bed pans, specimen hats (to set inside the commode to measure urine output), suction containers, green under pads, blue Chux pads, Adult briefs (open package), blue bags, Ready Bath Towels, along with Comet and Air Freshener. With that many items stored in that small cabinet, all of the supplies were opened and not able to be used. All the supplies stored under the sink were discarded.

After finding these items in the Trauma room, this surveyor went to get Personnel #5 so he could see what was found under the sink and the expired supplies. Personnel #5 said the nurses are suppose to be stocking the room and pulling expired supplies. Personnel #5 did not know who put all the supplies under the sink but, Personnel #5 said he would get them removed from under the sink as they were not to be stored there.

Based on observation, record review, and interview, the facility failed to ensure all essential mechanical, electrical, and patient care equipment is maintained in safe operating condition, in that,

2 of 2 in-house Laundry washer's daily, quarterly, and annual maintenance requirements were not documented/completed.

Findings included

During a tour of the in-house Laundry area on 9/04/19 ending at 10:24 AM, Personnel #20 explained the Laundry process. Two industrial washers and dryers were present.

The facility's Biomedical testing records did not include annual maintenance of either washer.

There were no daily or quarterly maintenance records of the required items.

During an interview on 9/04/19 ending at 10:50 AM, Personnel #1 stated there were no maintenance records for the washers and provided one washer manual for review.

The undated, "Industrial Washer" manual reflected, "Dexter Model T-600...Preventative maintenance requirements...daily...quarterly..."

Based on record review and interview, the governing body failed to execute their credentialing process, in that,

the Governing body failed to document approval of delineation of privileges for 8 of 11 credentialed staff (Personnel #25, Personnel #42, Personnel #43, Personnel #44, Personnel #45, Personnel #46, Personnel #47, and Personnel #49); and

the governing body failed to send letters of notification of appointment to the medical staff for 11 of 11 credentialed staff (Personnel #24, Personnel #25, Personnel #42, Personnel #43, Personnel #44, Personnel #45, Personnel #46, Personnel #47, Personnel #48, Personnel #49, and Personnel #50) to notify the medical staff personnel, they had been appointed to the medical staff by the governing body and the term of their appointment and approval of privileges.

Findings included

Personnel #25, Personnel #42, Personnel #43, Personnel #44, Personnel #45, Personnel #46, Personnel #47, and Personnel #49 did not have documentation of delineation of privileges that was approved by the governing body.

Personnel #24, Personnel #25, Personnel #42, Personnel #43, Personnel #44, Personnel #45, Personnel #46, Personnel #47, Personnel #48, Personnel #49, and Personnel #50 did not get notified by letter that they had been appointed to the medical staff by the governing body and the term of their appointment.

An interview with Personnel #1 on 9/5/2019 confirmed that the delineation of privileges were not approved for the newly credentialed medical staff and an appointment letter was not sent to the credentialed staff advising them of their approval to the medical staff and their length of term. Personnel #1 stated the hospital was sending out letters to the staff but cannot find for the last few reappointments. Personnel #1 stated he did not know when they stopped doing the letters.

Review of the facility's medical staff bylaws on 9/4/2019, the bylaws stated at least 90 days before the end of their term on the medical staff that the physician is to submit a reapplication to the medical staff with a request for privileges indicating the specific privileges they were requesting...When the packet had been completed and approved by the medical staff then it would be forwarded to the Governing Body and they would approve the appointment to the medical staff and the delineation of privileges...The physician would be notified of his appointment and delineation of privileges.

Based on record review and interview, Personnel #51 provided and assisted patient care and assisted with wound care on Patient #26 on 9/4/2019, without being a member of the nursing staff or credentialed staff of the hospital. Provider #51 is an LVN that assists Personnel #42 in the clinic with patient care.

Findings included

A Personnel file was requested for Personnel #51 on 9/4/5029. Personnel #1 advised that Personnel #51 did not have a Personnel file as she was not a member of the hospital nursing staff.

An interview with Personnel #1 on the morning of 9/5/2019 at 10:30 AM confirmed that Patient #51 was an LVN that was employed at the clinic next door to the hospital. Personnel #1 stated that Personnel #51 works for Personnel #42 as her nurse in the clinic. Personnel #1 stated that Personnel #51 was sent to wound care training with Personnel #42. Personnel #51 also had training in wound infection. Personnel #1 stated "I am trying to get over this. I will get this fixed."

Based on record review and interview, the physician failed to ensure participation in developing, executing, and periodically reviewing the (critical access hospital) CAH's written policies governing the furnished services, in that, the policies were not reviewed or approved by Medical Staff or Governing Body.

Findings included

The facility policies did not reflect an annual review. They did not reflect they were developed and reviewed by the required group of professionals (MD, PA, NP)

The facility polices were not reviewed/approved in the 2019 Quality, Medical Staff, or Governing Board meeting minutes.

Many facility policies had not been reviewed since 2002, 2006, 2010, 2013, and 2016.

Many facility policies had been reviewed/revised in March, April, and August of 2018. They had not been reviewed for 2019.

During an interview on 9/04/19 ending at 3:58 PM, Personnel #2 was asked about policy review. Personnel #2 stated, "We have begun to review and revise them. Some have been updated and the rest we will be getting to." Personnel #2 was asked who was completing the changes. Personnel #2 stated, "I am." Personnel #2 was asked who was approving the changes. Personnel stated, "the CEO."

During an interview on 9/04/19 ending at 4:15 PM, Personnel #1 was asked if the policies had been approved thru the hospital meeting structure (Governing Body, Medical Staff, Quality Assurance). Personnel #1 stated, "No."

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Based on record review and interview, the physician failed to ensure medical orders for each patient, in that,

A) 3 of 4 Swing patient (Patient #5, #6, and #7) records did not reflect physician swing bed admission orders at admission;

B) 3 of 3 outpatient surgical procedure patient (Patient #10, #11, and #12) records did not reflect pre-operative/procedure orders prior to pre-operative nursing care of the patient; and

C) 1 of 3 acute/inpatient (Patient #5) pain medication orders did not reflect physician directed parameters (pain scale) for pain medication administration with 2 or more pain medications ordered.

Findings included

A) Patient #5's, #6's, and #7's records did not reflect physician swing bed admission orders at admission.

B) Patient #10's, #11's, and #12's records did not reflect pre-operative/procedure orders prior to pre-operative nursing care of the patient.

C) Patient #5's pain medication orders did not reflect physician directed parameters (pain scale) for pain medication administration with 2 pain medications ordered.

During an interview and electronic record review ending 9/05/19 at 3:25 PM, Personnel #2 navigated the records and confirmed the above findings.

The 6/05/06 last revised/reviewed "Medical Record Documentation" policy required, "Physician orders - completed at the time of admission..."

The 8/02/06 last revision "Physician Services" policy required, admitted...only upon recommendation of, and remain under the care a physician approved by the Medical Staff..."

The 1/03/13 last revised/reviewed "IV Policy" required, "All IV's administered, will be by the order of physician..."

The facility's 10/17/18 effective "Plan for the Provision of Care Treatment and Services" policy required, "Patients are admitted to the hospital in one of two ways: By written or verbal order from a physician or provider with admitting privileges...presenting to the Emergency Department for treatment, with subsequent orders for admission..."

Based on observation, record review, and interview, the Personnel #42 failed to provide services according to the Critical Access Hospital's policies, in that, Personnel #42 performed wound care including deep tissue debridement of eschar on Patient #26 on 9/4/2019 without washing her hands between regular disposable gloves and changing gloves to sterile procedure.


Findings included

Personnel #42 accessed the wound of Patient #26 with bare hands. Patient #26 had "road rash" with bare skin from a fall. The right shoulder had brown speckled small scabs over the tissue on the right shoulder with no drainage or exudate. There were areas of bare skin where the top layer of skin had been removed during his fall. Personnel #51 was instructed by Personnel #42 to scrub the brown "speckled road rash" to try to remove some of the scabs that were on the area. Personnel #51 scrubbed the "brown speckled road rash:" with a 4 x 4 gauze with saline. Some of the "brown speckled road rash" were removed.

Personnel #51 removed her gloves without washing her hands or using alcohol hand wash and donned another pair of gloves to apply a dressing. Personnel #42 removed her gloves, did not wash her hands or alcohol and helped to apply the dressing with bare hands. Two (2) Mepilex sponges and a large tegaderm were used for the shoulder wound care.

Personnel #42 left the room to obtain supplies to prepare for a sterile procedure without washing her hands. Personnel #21 was the patients assigned Nurse for the day and she helped gather supplies and helped hold the patient in position while applying bandage. The patient had a square shaped eschar covering a wound on his right lateral hip just below the hip joint. Personnel #42 obtained supplies and opened her sterile tray with her unwashed, bare hands. (A sink with soap and an alcohol dispenser were on the wall behind Personnel #42 and Personnel #51 in Patient's #26 room).

Personnel #42 and Personnel #26 opened up sterile supplies onto the sterile field without washing hands. Personnel #51 never washed her hands between procedures and donned non sterile gloves and opened up sterile supplies during the procedure. Personnel #42 donned sterile gloves and used sterile 4 x 4's and betadine to prep the area of the hip where the square eschar wound was located. The size of the wound was approximately 2.5" x 3" in a rectangle shape. This area was where the patient laid on his wallet after his fall. Personnel #42 numbed the area of eschar with Lidocaine 1%.

Personnel #42 then took a scalpel and cut horizontal lines in the eschar and then vertical lines. Then Personnel #42 started to pull areas of the eschar off of the wound. The eschar was extremely tough and some areas had to be cut from the wound bed. After the procedure, Personnel #42 cleaned the edges of the wound. She removed her gloves and did not wash her hands. She then started to apply a layered dressing onto the wound. She used white tape to hold the top edge of the dressing in place. Then Personnel #42 gathered up all the 4x4's used during the procedure (some were blood covered) and put them on top of the sterile tray. She picked out the 4 disposable blades she used during the procedure with her bare hands and discarded the sterile tray in the garbage and disposed of the blades/scalpels in the sharps container.

The facility's "Hand Hygiene and Glove Guidelines" Effective Date 12/30/2016 stated, "It is the purpose of Muenster Hospital District to ensure that all hospital personnel will perform hand hygiene as recommended by the CDC in order to prevent transmission of bacteria, germs and infections."

An interview on 5/9/2019 at 9:30 AM shared with Personnel #1 the happenings of the lack of hand hygiene during the procedure as documented above. Personnel #1 was shocked by the details of the lack of handwashing and the breach of Infection control by Personnel #42. Personnel #21 and Personnel #26 (Personnel #26 had on non-sterile gloves and would take off her gloves when she left the room and go get the supplies and come back without washing her hands and done more gloves.) Personnel #1 stated, "We have had annual training and on-line training. I sent Personnel #42 and Personnel #51 to training so they could both become Certified wound care nurses and wound infection nurses. I am just trying to get over this. Personnel #1 stated: "I will get it fixed."

Based on record review and interview, the facility failed to ensure policies were developed with the advice of members of the (Critical Access Hospital) CAH's professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists;
and reviewed annually by the group of professional personnel required under paragraph (a)(2) of this section, and by the CAH.

Findings included

The facility policies did not reflect an annual review and did not reflect developed and reviewed by the required group of professionals.

The facility polices were not reviewed/approved in the 2019 Quality, Medical Staff, or Governing Board meeting minutes.

Many facility policies had been reviewed/revised in March, April, and August of 2018. They were not reviewed for 2019.

Many facility policies had not been reviewed since 2002, 2006, 2010, 2013, and 2016.

During an interview on 9/04/19 ending at 3:58 PM, Personnel #2 was asked about policy review. Personnel #2 stated, "We have begun to review and revise them. Some have been updated and the rest we will be getting to." Personnel #2 was asked who was completing the changes. Personnel #2 stated, "I am." Personnel #2 was asked who was approving the changes. Personnel stated, "the CEO."

During an interview on 9/04/19 ending at 4:15 PM, Personnel #1 was asked if the policies had been approved thru the hospital meeting structure (Governing Body, Medical Staff, Quality Assurance). Personnel #1 stated, "No."

Based on record review and interview, the Chief Executive Officer (CEO) failed to ensure contracted services were evaluated for compliance with conditions of participation and standards for the service provided, in that,

2 of 2 contracted services (Tele Radiology and Nuclear Medicine) were not evaluated for quality of care metrics for the provided services.

Findings included

There was no conditions of participation and standards evaluation for the Tele Radiology and Nuclear Medicine services available for review.

The 2019 Quality, Medical Staff, and Governing Body meeting minutes did not reflect a conditions of participation and standards evaluation for the Tele Radiology and Nuclear Medicine services.

During an interview on 9/04/19 at 8:35 AM, Personnel #1 confirmed the evaluations have not occurred.

Based on record review and interview, the facility failed to ensure a registered nurse (RN) supervised and evaluated the nursing care for each patient, including patients at a SNF (skilled nursing facility) level of care in a swing-bed (critical access hospital) CAH, in that,

A) 2 of 3 acute/inpatient (Patient #4, and #5) records did not document an RN (registered nurse) assessment within/every 24 hours period;

B) 2 of 3 acute/inpatient (Patient #5 and #9) records did not document pain medications given when the patient complained of pain;

C) 3 of 4 Swing patient (Patient #5, #6, and #7) records did not reflect physician swing bed admission orders at admission prior to nursing care of the patient and there was no NURSING ACTION to secure orders prior to care;

D) 3 of 3 outpatient surgical procedure patient (Patient #10, #11, and #12) records did not document pre-operative/procedure orders prior to pre-operative nursing care of the patient and there was no NURSING ACTION to secure orders prior to care; and

E) 1 of 3 acute/inpatient (Patient #5) pain medication orders did not reflect physician directed parameters (pain scale) for pain medication administration with 2 or more pain medications ordered. There was no warning about the maximum dose for Tylenol in a 24 hour period.

Findings included

A) Patient #4's and #5's records did not document an RN assessment within/every 24 hours period;

Patient #4 did not have an RN assessment on 8/08/19, and 8/09/19.

Patient #5 did not have an RN assessment on 6/04/19, 6/05/19, and 6/06/19.

B) Patient #5's and #9's records did not document pain medications given when the patient complained of pain;

Patient #5 had pain scale of 7 on 6/03/19 at 22:19 PM, 8 on 6/04/19 at 8:53 AM, and 5 on 6/04/19 at 20:17 PM.

There were no pain medication administrations documented for the patient. There was no indication the patient did not want pain medication.

Patient #9 had a pain scale of 6 on 6/04/19 at 22:17 PM. T

here were no pain medication administrations documented for the patient. There was no indication the patient did not want pain medication.

C) Patient #5's, #6's, and #7's records did not reflect physician swing bed admission orders at admission prior to nursing care of the patient and there was no nursing action to secure orders prior to care;

Patient #4 was discharged as an acute patient to the swing bed status at 13:35 PM on 8/12/19.

The provided Nursing care including 15:39 PM Assessment, 17:00 PM fingerstick blood glucose, and serving a meal at 18:00 PM was completed prior to the physician orders for care. The physician swing bed orders were at 18:12 PM.

Patient #5 was discharged as an acute patient to the swing bed status at 16:52 PM on 6/06/19.

The provided Nursing care including 17:07 PM Assessment, serving a meal at 18:00 PM was completed prior to the physician orders for care. The physician swing bed orders were at 18:29 PM.

Patient #6 was discharged as an acute patient to the swing bed status at 12:12 PM on 8/28/19.

The provided Nursing care including 12:46 PM Assessment, 16:00 PM turning, and serving a meal at 18:00 PM was completed prior to the physician orders for care. The physician swing bed orders were at 18:58 PM.

Patient #7 transferred into the hospital for a swing bed at 17:00 PM on 8/07/19.

The provided Nursing care including 17:24 PM Assessment, serving a meal at 18:00 PM was completed prior to the physician orders for care. The physician swing bed orders were at 20:02 PM.

D) Patient #10's, #11's, and #12's outpatient surgical procedure records did not document pre-operative/procedure orders prior to pre-operative nursing care of the patient and there was no nursing action to secure orders prior to care;

Patient #10 came for a colonoscopy on 6/21/19. At 9:49 AM, the nursing care included placing an IV catheter (intravenous). There were no pre-operative physician orders until 12:00 PM.

Patient #11 came for an EGD on 6/21/19. At 9:32 AM, the nursing care included placing an IV catheter (intravenous). There were no pre-operative physician orders until 11:17 AM.

Patient #12 came for an EGD and colonoscopy on 6/21/19. At 9:03 AM, the nursing care included placing an IV catheter (intravenous). There were no pre-operative physician orders until 10:05 AM.

E) Patient #5's pain medication orders did not reflect physician directed parameters (pain scale) for pain medication administration with 2 pain (or more) medications ordered.

Patient #5 pain medication orders included (milligrams every 6 hours as needed) "Norco 7.5 mg Q6H PRN pain" and "Tylenol 1000 mg Q6H PRN headache/pain/Temp."

There were no pain scale parameters to direct the nurse which medication to use with moderate or severe pain.

There was no warning about the maximum dose for Tylenol in a 24 hour period with both these medications ordered every 6 hours as needed.

Patient #5 on 6/05/19 at 20:20 PM received Tylenol and 6/06/19 at 8:06 AM received Norco.

americanpainsociety.org/uploads/about/position-statements/ps-opioid-dosage.pdf

During an interview and electronic record review ending 9/05/19 at 3:25 PM, Personnel #2 navigated the records and confirmed the above findings. Personnel #2 confirmed there was no documentation by nursing that indicated they called/received/clarified orders with medical staff prior to the care of each patient.

The facility's 6/05/06 last revised/reviewed "Medical Record Documentation" policy required, "Physician orders - completed at the time of admission..."

The facility's 8/02/06 last revision "Physician Services" policy required, admitted...only upon recommendation of, and remain under the care a physician approved by the Medical Staff..."

The facility's 1/03/13 last revised/reviewed "IV Policy" required, "All IV's administered, will be by the order of physician..."

The facility's 8/02/18 "Pain Management" policy required, "Right to optimal pain management...reassessment...following any pain relief interventions, and a minimum of one time each shift...administer analgesics in accordance with the physician's orders..."pain scale 0 no pain...1-3 mild pain...4-6 moderate pain...7-10 severe pain..."

The facility's 10/17/18 effective "Plan for the Provision of Care Treatment and Services" policy required, "Patients are admitted to the hospital in one of two ways: By written or verbal order from a physician or provider with admitting privileges...presenting to the Emergency Department for treatment, with subsequent orders for admission...page 7...Reassessment...at least every 24 hours by a RN..."

Based on record review and interview, the facility failed to ensure a nursing care plan was developed and kept current for each inpatient, in that,

3 of 3 acute/inpatient (Patient #4, #5, and #9) records did not reflect a complete and up-to-date care plan.

Findings included

Patient #4's, #5's, and #9's records did not reflect a complete and up-to-date care plan.

~Patient #4's care plan did not reflect an altered mental status, and a cardiac plan.

Patient #4's physician emergency room assessment reflected Limitations: Altered Mental Status and current visit diagnosis for admission as Paroxysmal Atrial Fibrillation, Hypertension, and Coronary Artery Disease.

Patient #4's Discharge Summary reflected Parkinson's Disease.

~Patient #5's care plan did not reflect a cardiac plan.

Patient #5's physician emergency room assessment reflected current visit diagnosis for admission as Hypertension and Paroxysmal Atrial Fibrillation.

~Patient #9's care plan did not reflect a respiratory plan.

Patient #9's physician emergency room assessment reflected current visit diagnosis for admission as a COPD Exacerbation. (Chronic Obstructive Pulmonary Disease)

During an interview and electronic record review ending 9/05/19 at 3:25 PM, Personnel #2 navigated the records and confirmed the above findings.

Based on record review and interview, the quality assurance program failed to evaluate quality metrics for conditions of participation and standards all patient care services and other services affecting patient health and safety, in that,

6 of 6 services (Respiratory, Housekeeping, In-house Laundry, Outpatient Surgery/GI Procedures, Anesthesia/CRNA, Tele Radiology, and Nuclear Medicine) were not evaluated for conditions of participation and standards.

Findings included

There was no conditions of participation and standards evaluation for the Respiratory, Housekeeping, In-house Laundry, Outpatient Surgery/GI Procedures, Anesthesia/CRNA, Tele Radiology, and Nuclear Medicine available for review.

The 2019 Quality, Medical Staff, and Governing Body meeting minutes did not reflect a conditions of participation and standards evaluation for the Respiratory, Housekeeping, In-house Laundry, Outpatient Surgery/GI Procedures, Anesthesia/CRNA, Tele Radiology, and Nuclear Medicine.

During an interview on 9/04/19 at 8:35 AM, Personnel #1 confirmed the contract evaluations have not occurred.

During an interview on 9/05/19 at 10:00 AM, Personnel #3 explained the Quality Metrics, Quality meeting schedule of departments, Meeting Agenda and Meetings. Personnel #3 confirmed there were not quality metrics on the above named departments/services. Personnel #3 confirmed there wasn't a physician in the Quality Meetings. Personnel #3 reviewed the 2019 meeting minutes for participation and confirmed the number of times the CEO had not participated. Personnel #3 explained the CEO does have access to the online quality metrics and many metrics go to the Medical Staff Meeting for presentation. Personnel #3 confirmed all department quality metrics do not go to the Medical Staff for review.