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Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the emergency department (ED) record maintained documentation of the on call provider's initial notification and arrival/respond time to the ED for 16 of 17 closed ED records (Patient #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #36,and #37) reviewed. Failure to document the time the on call provider is notified of a patient's arrival to the ED and failure to document the time the on call provider arrived to the ED, does not ensure the on call provider is available at the ED within 30 minutes of notification.

Findings include:

Review of Patient #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #36, and #37's ED records occurred on January 09-11, 2012. Review of the above ED records lacked documentation by the CAH ED staff of the time staff informed/notified the on call provider of a patient's arrival to the ED and the time the on call provider arrived at the ED.

During an interview on 01/10/12 at 9:50 a.m., an administrative staff member (#11) stated the CAH employs physicians who are directly responsible for seeing patients in the ED. The administrative staff member (#11) stated he expected these physicians to respond to the ED within 30 minutes of being notified by the ED nursing staff.

During interview on 01/10/12 at 10:00, an administrative nursing staff member (#13) stated the CAH ED nursing staff does not document the time of notification nor the time of the physician's arrival to the ED. This administrative nursing staff member (#13) confirmed all of the facility's ED records lack evidence ensuring the physician responded to the ED within 30 minutes.

Based on observation, record review, review of the Critical Access Hospital (CAH) incident reports, review of construction standards, and staff interview, the CAH failed to ensure safety of patients in 3 of 3 intensive care rooms (Room #641, #642, and #643), 1 of 6 emergency treatment rooms (Room #3), 4 of 4 public bathrooms (the men's and women's bathrooms in the basement and on the ground floor) designated for use by patients, and 1 of 1 patient bathroom at an off-site location (Mercy Therapy and Fitness). Failure to provide grab bars and call lights in toilet rooms used by patients placed the patients at risk for injury and at risk for not receiving assistance when needed.

Findings include:

Guidelines for Construction and Equipment of Hospital and Medical Facilities 1992-93, The American Institute of Architects Press, Washington, D.C., page 46 stated, "7.28.A15. Grab bars shall be provided in all patient toilets . . ." Page 61 stated, "7.32G2. A nurses emergency call system shall be provided at each inpatient toilet . . . Provisions for emergency calls will also be needed in outpatient and treatment areas where patients may be subject to incapacitation."

- Review of the CAH's incident reports, on 01/09/12, identified a report for Patient #31, dated 07/31/11 at 11:30 a.m. The report stated, "pt attempting to get off toilet in Rm [room] # [number] 643 only got half of buttocks on seat no handrails to help guide pt [patient] slid to floor unable to get up without assistance [sic]" An administrative nurse (#1) identified room 643 as an intensive care room.

Observation in the intensive care suite occurred on 01/09/12 at 5:15 p.m. with an administrative nurse (#1). Observation showed toilets in the three intensive care rooms lacked grab bars. When asked if the facility had that type of toilet in other areas, the nurse stated treatment room #3 in the emergency suite had the same toilet. Observation in emergency treatment room #3, on 01/09/12 at 5:30 p.m., confirmed no grab bars by the toilet.

Review of Patient #31's closed medical record occurred on 01/11/12. The CAH admitted Patient #31 on 07/31/11 and transferred her to an acute care hospital on 08/03/11. Patient #31's medical diagnoses include congestive heart failure and anemia. On admission, the CAH nursing staff assessed Patient #31 as a high risk for falls. Care plan interventions implemented at the time of admission by the CAH staff included ". . . Encourage handrails/safety bar as appropriate."

Failure to provide the handrails/safety bars identified in Patient #31's care plan contributed to her fall from the toilet on 07/31/11.

- A tour of the emergency department occurred on 01/09/12 at 2:30 p.m. with an administrative nurse (#1). Observation during the tour identified a bathroom equipped with a call light located within the emergency suite. When asked if patients use this toilet, the nurse stated, "only if we have to." The staff member (#1) stated emergency room staff use that bathroom and ambulatory patients use the public bathrooms located across the hall outside the emergency room suite.

Observation of the public men's and women's bathrooms located across the hall from the emergency suite occurred on 01/09/11 at 5:05 p.m. and identified both rooms lacked call lights.

On 01/10/12 at 9:10 a.m. observation of the public bathrooms near the emergency suite occurred with an administrative nurse (#1). The staff member confirmed the bathrooms lacked a means for patients to call for assistance in the public bathrooms.

- A tour of the outpatient therapy off-site location occurred on 01/10/12 at 2:30 p.m. with an administrative physical therapist (#5). When asked which bathroom patients use, the staff member identified a bathroom near the reception desk. Observation showed the bathroom lacked a call light. The staff member (#5) confirmed the bathroom lacked a means for patients to call for assistance.

- A tour of the cardiac rehabilitation (rehab) department (located in the basement of the CAH) occurred on 01/11/12 at 9:30 a.m. with an administrative nurse (#1) and a cardiac rehab nurse (#9). When asked which bathroom patients use, the nurses (#1 and #9) identified public bathrooms located down the hall and around a corner from the cardiac rehab department. Observation showed both the men's and woman's public bathrooms lacked call lights. The staff members (#1 and #9) confirmed the bathrooms lacked a means for patients to call for assistance.

Based on observation, review of North Dakota Century Code, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff disposed of trash in accordance with State regulations on 3 of 3 days of survey (January 9-11, 2012). Failure to ensure proper disposal of trash could result in infestation with insects and/or rodents.

Findings include:

North Dakota Century Code Chapter 23-16, North Dakota Administrative Code Chapter 33-07-01.1, Division of Health Facilities, North Dakota Department of Health, July 1, 2009, stated, "33-07-01.1-28. Housekeeping and related services . . . b. The hospital must be maintained free from insects and rodents. . . . 4. Garbage and trash must be stored in appropriately covered containers in areas separate from those used for the preparation and storage of food and must be removed from the premises in a timely manner . . . "

Observation of the CAH dumpsters, on 01/09/12 at 1:30 p.m. and 01/10/12 at 10:00 a.m., with an administrative dietary staff member (#10), showed one covered dumpster and one dumpster that lacked a cover. The staff member (#10) stated staff place kitchen garbage in the covered dumpster and non-food garbage in the uncovered dumpster.

A tour of the environment occurred on 01/11/12 at 8:30 a.m., with two administrative members of the environmental staff (#2 and #3) and an administrative nurse (#1). Observation during the tour identified the uncovered dumpster filled to the top with garbage. The staff members confirmed the dumpster lacked a cover.

Based on observation, review of the Critical Access Hospital (CAH) Board of Directors meeting minutes, the CAH Fire Safety policy, and staff interview, the CAH failed to provide staff training in handling emergencies, including prompt reporting of fires and extinguishing of fires specific to an off-site location for 1 of 1 off-site location (Mercy Therapy and Fitness). Failure to ensure staff training specific to the location could result in staff not responding appropriately to an emergency.

Findings include:

Review of the CAH's Board of Directors meeting minutes occurred on all days of survey. Minutes from the December 2, 2011 meeting stated, "Mercy Therapy and Fitness had a small fire originating from the clothes dryer. There was a little damage done to the facility, the dryer was damaged and the floor had burn marks."

Review of the CAH policy titled "Fire Safety" occurred on 01/11/12. The policy, revised October 2011, stated, "Fire is a constant source of danger within the hospital. It is imperative that every person employed at Mercy Hospital recognizes this fact and cooperates to prevent fire, and to participate in an efficient organization in the event of fire. . . ." The policy lacked a plan for staff response to a fire at an off-site location.

A tour of the off-site therapy location occurred on 01/10/12 at 2:30 p.m. with an administrative physical therapist (#5). Observation in the laundry area identified a discolored area on the floor, brown in color with melted tile, near the large commercial dryer. The staff member (#5) confirmed the brown area was a burn. The staff member stated a fire occurred in the dryer. He stated the ward clerk (#8) on duty that evening removed burning towels from the dryer and extinguished the fire by "stamping it out."

An interview occurred on 01/10/12 at 2:50 p.m. with the administrative physical therapist (#5). When asked if the CAH provided education to the employee (#8) regarding his response to the fire, the physical therapist stated a fire department employee educated the ward clerk immediately following the fire. When asked to provide documentation of that education, the staff member provided no further information.

On 01/11/12 at 11:05 a.m., an interview occurred with the ward clerk (#8) on duty the evening of the fire and two administrative staff members (#11 and #12). During the interview the ward clerk (#8) stated the fire occurred on 11/10/11 at approximately 7:40 p.m. The staff member (#8) stated when he discovered the fire in the dryer, he pulled the burning towels from the dryer and extinguished the fire with water. The staff member (#8) stated he then called his friend, a member of the local fire department; his friend then called 911 and the fire department responded. An administrative staff member (#12) stated the ward clerk (#8) should have immediately called 911. When asked if the facility evaluated the employee's response and provided education, the administrative staff members provided no further information.

Based on observation, record review, professional literature review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the safe use of side rails and consider side rails as a potential entrapment and safety hazard, failed to assess each patient individually prior to utilizing side rails, and failed to provide education to the patient and responsible party regarding the hazards of side rail use for 4 of 7 active patients (Patients #1, #2, #3, and #5) observed with elevated side rails. Failure to assess and evaluate the use of side rails, to consider side rails as a potential entrapment and safety hazard, and to educate patients and responsible parties regarding the hazards of using side rails placed Patients #1, #2, #3, and #5 at risk of entrapment or injury.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings," dated April 2003, stated, ". . . CMS [Centers for Medicare and Medicaid Services] . . . issued guidance in June 2000 . . . 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. Even when a side rail is not intentionally used as a restraint, patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised siderails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . . 1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize . . . those in current use should occur within the framework of an individual patient assessment. . . . 3. Use of bed rails should be based on patients' assessed medical needs and should be documented clearly . . . The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted . . . The care plan should include educating the patient about possible bed rail danger to enable the patient to make an informed decision . . . Assessment of risk should be part of the individual patient's assessment, and steps to address the risk should be incorporated into the patient's care plan. . . ."

The United States Department of Health and Human Services, Food and Drug Administration (FDA), and Center for Devices and Radiological Health (CDRH) publication titled, "Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," issued on 03/12/06, stated, ". . . FDA is recommending dimensional limits for zones 1 through 4 . . . because . . . the majority of the entrapments . . . have occurred in these zones. . . . Zone 1 is any open space within the perimeter of the rail. Openings in the rail should be small enough to prevent the head from entering. . . . FDA is recommending a measure of less than . . . 4 3/4 inches as the dimensional limit for any open space within the perimeter of a rail. Zone 2 . . . This space is the gap under the rail between a mattress . . . Preventing the head from entering under the rail would most likely prevent neck entrapment in this space. FDA recommends that this space be small enough to prevent head entrapment, less than . . . 4 3/4 inches. . . . Zone 3 . . . This area is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment . . . FDA is recommending a dimensional limit of less than . . . 4 3/4 inches for the area between the inside surface of the rail and the compressed mattress. Zone 4 . . . This space is the gap that forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of a rail. . . . The space poses a risk for entrapment of a patient's neck. . . . to prevent neck entrapment. . . . FDA recommends that the dimensional limit for this space . . . be less than . . . 2 3/8 inches. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts," revised April 2010, stated, ". . . Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . . Keep the bed in the lowest position with wheels locked. When the patient is at risk of falling out of bed, place mats next to the bed . . . Monitor patients frequently. Anticipate the reasons patients get out of bed . . . meet these needs . . . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. . . . Reassess the need for using bed rails on a frequent, regular basis."

Observation of the beds utilized in same day surgery and on the nursing unit occurred on January 09-11, 2012. The beds utilized by the current patients in these areas appeared to be the same make and model and had four half rails (two half rails on each side) attached to the beds. Measurements of the bed, located in room #643, identified 7 inch open spaces within the rails of the top half rail and 7 1/4 inch open spaces within the rails of the bottom half rail. Observation showed patients occupied the beds in other patient rooms on the nursing unit which contained the same type of bed located in room #643.

Observation of Patients #1, #2, #3, and #5 on all days of survey, while the patients rested in bed, identified two elevated upper half rails on each bed. Review of the above patients' active medical records occurred on January 09-11, 2012 and indicated "side rails up times two" throughout their stay on the nurses flowsheet progress notes. Patient #3 and #4's diagnoses included a history of falls, and their admission fall risk assessments identified them as a high risk for falls. All of the above records lacked individualized assessments of risk and safety for the use of side rails and lacked evidence of patient or responsible party education regarding the hazards of side rails use. The CAH staff failed to consider the elevated side rails a safety and entrapment hazard for Patients #1, #2, #3, and #5.

During an interview on 01/10/12 at 4:30 p.m., a nursing staff member (#16) stated patients used the elevated side rails for positioning/bed controls, and stated nursing staff does not perform or document an assessment for risk factors or safety for utilization of side rails.

During an interview on 01/11/12 at 2:00 p.m., an administrative nurse (#1) stated nursing staff usually elevated the side rails for patient positioning and access to bed controls/call light, and confirmed nursing staff does not perform an assessment of risk factors or safety for utilization of side rails at the current time. The nurse (#1) stated she did not realize the potential for the side rails as a safety hazard for entrapment or injury.

Based on record review, review of Critical Access Hospital (CAH) Medical/Dental Staff Rules and Regulations, and staff interview, the CAH failed to ensure a complete medical record for 4 of 4 active outpatient physical and occupational therapy (PT and OT) records reviewed (Patient #8, #9, #10, #11) and 1 of 1 closed outpatient PT record (Patient #13). Failure to ensure a complete and authenticated medical record could result in staff not aware of the patient's current status.

Findings include:

Review of the CAH Medical/Dental Staff Rules and Regulations occurred on 01/09/12. The rules and regulations, dated 05/02/08, stated, "Responsibility for Medical Record . . . 7. All clinical entries in the patient's medical record shall be dated and authenticated. . . ."

An entrance conference occurred on 01/09/12 at 11:25 a.m., with CAH administrative staff. During the conference, an administrative staff member (#11) stated the CAH has not yet implemented an electronic medical records system.

An interview with an administrative physical therapist (#5) occurred on 01/10/12 at 1:30 p.m. When asked about their medical records system, the physical therapist stated PT/OT staff record all progress notes electronically. He stated the notes remain on the computer, with no hard copy printed until the provider discharges the patient from therapy. The therapy ward clerk (#6) confirmed, after the provider discharges the patient from therapy, she prints the progress notes, then the PT or OT signs them.

Review of outpatient PT and OT records occurred on January 10-11, 2012. Review of Patient #8, #9, #10, #11, and #13's records identified daily progress notes recorded by the PT/OT providing services. The record showed the name of the PT/OT recording the note typed at the bottom of each note. All records reviewed lacked a hand written or electronic/authenticated signature. Review of Patient #13's record further identified the physician discharged the patient from outpatient PT on 12/06/11.

When interviewed, on 01/11/12 at 8:10 a.m., the therapy ward clerk (#6) stated the therapists type the progress notes in a "Word" document which is shared by all therapists. The staff member confirmed, although the provider discharged Patient #13 over a month ago, she printed his progress notes, and the progress notes for the active records reviewed, on 01/10/12, after the surveyor requested records for review.

An interview with a medical records staff member (#7) occurred on 01/11/12 at 11:30 a.m. The staff member (#7) confirmed the CAH has not implemented an electronic medical records system and has no policy/process for electronic signatures. The staff member (#7) stated her expectation is that the staff member recording the progress notes print and sign notes daily.

Based on policy review, review of the Performance Improvement (PI) program, review of committee meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to ensure the performance improvement program evaluated all patient care services affecting CAH patient health and safety, including the emergency room, occupational therapy, obstetrics, nursery, physical therapy, cardiac rehab, discharge planning, Swingbed, and contracted services for 4 of 4 quarters reviewed (4th quarter of 2010 through 3rd quarter of 2011), and failed to ensure the evaluation of 1 of 1 dryer fire in an offsite location (Mercy Fitness Therapy and Fitness). Failure to ensure all departments participated in PI activities placed patients at risk of not receiving appropriate care and services and limits the CAH's ability to implement corrective action when warranted. Failure to evaluate a fire, including the staff members response to the fire, causative factors contributing to the fire, and the facility's fire response plan limits the CAH's ability to protect patients from reoccurring fire hazards.

Findings include:

Review of the CAH's Performance Improvement/Patient Safety Plan 2011 occurred on the afternoon of 01/10/11. The plan, dated 06/10/11, stated,
"Policy Statement:
The purpose of the performance improvement efforts . . . is to ensure that patient care is delivered in a coordinated and collaborative effort, and that the approach to improving performance involves multiple departments and disciplines in establishing the plans . . . The organizational program, . . . has the responsibility of monitoring all aspects of patient care an (sic) services, from the time the patient interacts with any services . . . through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to improve and facilitate patient outcomes.

Scope of Performance Improvement/Patient Safety:

Performance Improvement activities encompass Mercy Hospital and Mercy Fitness and this plan provides the hospital with the mechanisms to identify opportunities for quality/performance improvement and process to improve identified deficiencies. This plan also supports that the collaborative hospital-wide approach will result in sustained quality/performance improvement in both processes and outcomes for care for our customers and will enhance the quality of the practice of the health care professionals who provide that care. . . .

The purpose of performance improvement activities is to improve patient outcomes by assessing and analyzing various dimensions of performance, including: Efficacy, appropriateness, availability, timeliness, effectiveness, continuity, safety, efficiency, and the degree of respect and caring with which services are provided. . . .
Assessment of the performance improvement/patient safety activities include: . . .
? Provision of Care, Treatment, and Services . . .
? Emergency Management . . .

Ongoing performance improvement/patient safety measures include: . . .
? Facility Safety Surveillance . . .
? Staff Perceptions Regarding Patient Safety and Willingness to Report Errors

Performance is measured through data collection and analysis:
? Ranges from no harm to sentinel event.
? Plan, Do, Study, Act (PDSA) process is utilized when opportunity for improvement is identified. . . .
? A Root Cause Analysis (RCA) will be conducted if a sentinel event has occurred as determined by the Performance Improvement/Patient Safety Committee.

Quality control data will be collected in the following areas and reported quarterly:
? Anesthesia
? Laboratory
? Nutrition Services
? Pharmacy
? Radiology
? Respiratory Care
? Surgery/Central Supply
? Infection Prevention
? Physical Therapy

Authority

The Board of Directors is ultimately responsible for the quality of care provided. . . .

Performance improvement activities are coordinated by the Performance Improvement / Patient Safety Committee. Through the ongoing application of quality and process improvement initiatives, Mercy Hospital strives to demonstrate and document that expected levels of performance be achieved. . . ."

- Review of the completed Performance Improvement reports for four quarters (4th quarter 2010, 1st, 2nd and 3rd quarter of 2011) occurred on the afternoon of 01/10/12 with a performance improvement/risk manager (#4). The reports lacked evidence of the following departments reporting on Performance Improvement (PI) activities within the last year: emergency room (ER), physical therapy (other than for Swingbed residents), occupational therapy, cardiac rehab, obstetrics, nursery, Swingbed services, discharge planning, and all contracted services. During a tour of the facility on the afternoon of 01/09/12, an administrative staff member (#11) identified the facility delivered over 300 babies per year, and saw over 1000 patients per month in the ER. Review of the contracted services list identified the facility maintained over 100 contracts.

During interview on the afternoon of 01/10/12, a performance improvement/risk manager (#4) stated the services identified above all affected patient care and agreed the facility failed to perform quality improvement monitoring on these offered services.


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- Review of the CAH policy titled "Fire Safety" occurred on 01/11/12. The policy, revised October 2011, stated, "Fire is a constant source of danger within the hospital. It is imperative that every person employed at Mercy Hospital recognizes this fact and cooperates to prevent fire, and to participate in an efficient organization in the event of fire. . . ." The policy lacked a plan for staff response to a fire at an off-site location.

Review of the CAH policy titled "Incidence Reporting (Employee/Patient/Visitor)" occurred on 01/11/12. The undated policy stated, "An incident is defined as a happening, which is of an unusual nature, an unexpected outcome, or adverse event that involves patients, visitors, medical staff, employees, and property. A "near miss" is also a reportable occurrence which is defined as a variation in process that did not have an adverse outcome, but for which a recurrence carries significant chance of serious injury or death. All employees are responsible for reporting each incident by the following procedure . . . Employee - complete paper report and give to your supervisor . . . After completion, the form will be forwarded to the Risk Manager . . . The Risk Manager will submit all incident reports to the Safety Committee for trending analysis . . ."

Review of the CAH's Board of Directors meeting minutes occurred on all days of survey. Minutes from the December 2, 2011 meeting stated, "Mercy Therapy and Fitness had a small fire originating from the clothes dryer. There was a little damage done to the facility, the dryer was damaged and the floor had burn marks." The minutes failed to identify the date the fire occurred.

Review of the Safety/Risk Committee meeting minutes occurred on January 9-10, 2012. Minutes from the 12/21/11 meeting lacked evidence the committee discussed the fire at Mercy Therapy and Fitness.

A tour of Mercy Therapy and Fitness (off-site outpatient therapy) occurred on 01/10/12 at 2:30 p.m. with an administrative physical therapist (#5). Observation in the laundry area identified a discolored area on the floor, brown in color with melted tile, near the large commercial dryer. The staff member (#5) confirmed the brown area was a burn. The staff member stated a fire occurred in the dryer. He stated the ward clerk (#8) on duty that evening removed burning towels from the dryer and extinguished the fire by "stamping it out." When asked, the staff member (#5) could not provide the date the fire occurred.

An interview occurred on 01/10/12 at 2:50 p.m. with the administrative physical therapist (#5). When asked if the CAH evaluated the employee's response to the fire and provided education regarding how staff should respond to a fire at an off-site location, the physical therapist stated a fire department employee educated the ward clerk immediately following the fire. When asked to provide documentation of that education, the staff member provided no further information.

During an interview on 01/10/12 at 4:00 p.m., a risk management staff member (#4) stated the Safety/Risk Committee did not discuss the fire. The staff member could not provide the date of the fire, stating the committee had not received an incident report regarding the fire.

On 01/11/12 at 11:05 a.m., an interview occurred with the ward clerk (#8) on duty the evening of the fire and two administrative staff members (#11 and #12). During the interview the ward clerk (#8) stated the fire occurred on 11/10/11 at approximately 7:40 p.m. The staff member (#8) stated when he discovered the fire in the dryer, he pulled the burning towels from the dryer and extinguished the fire with water. The staff member (#8) stated he then called his friend, a member of the local fire department; his friend then called 911 and the fire department responded. An administrative staff member (#12) stated the ward clerk (#8) should have immediately called 911. When asked if the facility evaluated the employee's response to the fire and provided education, the administrative staff members (#11 and #12) stated staff failed to complete an incident report, which resulted in the Safety/Risk Committee not reviewing the incident.

Based on a random review of nurse anesthetist providers, policy review and staff interview, the Critical Access Hospital (CAH) failed to evaluate the quality and appropriateness of the treatment furnished by 1 of 1 Certified Registered Nurse Anesthetist (CRNA) (Provider #1) reviewed providing care to the CAH's patients within the past year. Failure to evaluate the quality and appropriateness of the treatment furnished has the potential to affect patient outcomes involving surgical procedures requiring anesthesia services provided by the CRNA staff.

Findings include:

Review of the CAH's Performance Improvement/Patient Safety Plan 2011 occurred on the afternoon of 01/10/11. The plan, dated 06/10/11, stated,
"Policy Statement
The purpose of the performance improvement [PI] efforts . . . is to ensure that patient care is delivered in a coordinated and collaborative effort, and that the approach to improving performance involves multiple departments and disciplines in establishing the plans . . . The organizational program, . . . has the responsibility of monitoring all aspects of patient care an (sic) services, from the time the patient interacts with any services . . . through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to improve and facilitate patient outcomes.

Scope of Performance Improvement/Patient Safety

Performance Improvement activities encompass Mercy Hospital and Mercy Fitness and this plan provides the hospital with the mechanisms to identify opportunities for quality/performance improvement and process to improve identified deficiencies. This plan also supports that the collaborative hospital-wide approach will result in sustained quality/performance improvement . . .

The purpose of performance improvement activities is to improve patient outcomes by assessing and analyzing various dimensions of performance, . . .

The scope of the organizational performance improvement program includes performance of the following medical staff and organizational functions:
? The monitoring, assessment and evaluation of the patient care and the clinical performance of all individuals with clinical privileges.
? Relevant findings from the outcome of performance improvement activities performed are considered part of:
? Reappraisal/reappointment of medical staff members . . .

Authority

The Board of Directors is ultimately responsible for the quality of care provided. . . .

The medical staff, through the Medical Executive Committee, provides mechanisms to assess and evaluate the quality & appropriateness of patient care and clinical performance of all individuals with delineated clinical privileges.

Performance improvement activities are coordinated by the Performance Improvement/Patient Safety Committee. Through the ongoing application of quality and process improvement initiatives, Mercy Hospital strives to demonstrate and document that expected levels of performance be achieved. . . ."

- Review of the CAH's current list of providers occurred on the afternoon of 01/09/12. The list included two current practicing CRNAs. Review of the surgical log on the afternoon of 01/09/12 identified the nurse anesthetist administered both spinal and general anesthesia.

During interview on 01/11/12 at 9:20 a.m., a performance improvement/risk manager (#4) stated the CAH did not have an evaluation of the quality and appropriateness of the treatment and treatment outcomes provided by the CRNA (#1) or any of the CRNA staff completed within the past year. The PI policy lacked a specific plan for this process.

Based on a random sample of current practicing physicians, policy review and staff interview, the Critical Access Hospital (CAH) failed to evaluate 2 of 2 courtesy/consulting physicians (Physician #1 and #2) and 2 of 2 active physicians (Physician #3 and #4) evaluated for the quality and appropriateness of the diagnosis and treatment provided in the CAH. Failure to evaluate each physician, by physicians/providers with the same qualifications/privileges, has the potential to affect patient treatment outcomes.

Findings include:

Review of the CAH's Performance Improvement/Patient Safety Plan 2011 occurred on the afternoon of 01/10/12. The plan, dated 06/10/11, stated,
"Policy Statement:
The purpose of the performance improvement [PI] efforts . . . is to ensure that patient care is delivered in a coordinated and collaborative effort, and that the approach to improving performance involves multiple departments and disciplines in establishing the plans . . . The organizational program, . . . has the responsibility of monitoring all aspects of patient care an (sic) services, from the time the patient interacts with any services . . . through diagnosis, treatment, recovery and discharge in order to identify and resolve any breakdowns that may result in suboptimal patient care and safety, while striving to improve and facilitate patient outcomes.

Scope of Performance Improvement/Patient Safety:

Performance Improvement activities encompass Mercy Hospital and Mercy Fitness and this plan provides the hospital with the mechanisms to identify opportunities for quality/performance improvement and process to improve identified deficiencies. This plan also supports that the collaborative hospital-wide approach will result in sustained quality/performance improvement . . .

The purpose of performance improvement activities is to improve patient outcomes by assessing and analyzing various dimensions of performance, . . .

The scope of the organizational performance improvement program includes performance of the following medical staff and organizational functions:
? The monitoring, assessment and evaluation of the patient care and the clinical performance of all individuals with clinical privileges.
? Relevant findings from the outcome of performance improvement activities performed are considered part of:
Reappraisal/reappointment of medical staff members . . .

Authority

The Board of Directors is ultimately responsible for the quality of care provided. . . .

The medical staff, through the Medical Executive Committee, provides mechanisms to assess and evaluate the quality & appropriateness of patient care and clinical performance of all individuals with delineated clinical privileges.

Performance improvement activities are coordinated by the Performance Improvement/Patient Safety Committee. Through the ongoing application of quality and process improvement initiatives, Mercy Hospital strives to demonstrate and document that expected levels of performance be achieved. . . ."

- Review of the CAH's current list of providers occurred on the afternoon of 01/09/12. A selection of a random sample of these providers, both active and courtesy/consulting occurred on the morning of 01/11/12.

During interview on 01/11/12 at 9:20 a.m., a performance improvement/risk manager (#4) stated the CAH failed to ensure an evaluation of the quality and appropriateness of the treatment and the treatment outcomes provided by Physician #1, #2, #3 and #4 within the last two years occurred by another physician/provider of equal or higher service. The PI policy lacked a specific plan for this process.