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Based on review of the Critical Access Hospital (CAH) Rural Health Network agreements and staff interview, the CAH failed to have an agreement for the provision of quality assurance (QA) with a hospital that is a member of the network or a quality improvement organization or equivalent entity on 3 of 3 days of survey (07/01/13, 07/02/13, and 07/03/13). Failure to have an agreement for QA may limit the CAH's ability to ensure performance of QA.

Findings include:

Review of the CAH's current network agreement occurred on 07/01/13. The CAH's agreement, dated 02/04/13, and titled "Credentials Verification Agreement" lacked a provision or service for QA assistance the hospital would provide and the responsibilities of the CAH.

During interview on the morning of 07/03/13, an administrative member (#1) confirmed the CAH lacked an agreement for the provision of QA.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the availability of drugs and biologicals commonly used in life-saving procedures for prompt use when staff removed 1 of 1 Emergency Room (ER) crash cart containing life-saving drugs and biologicals from the ER for use on the nursing unit. Removing the crash cart from the ER limited the availability of drugs and biologicals used for treatment of life-threatening situations to patients presenting to the ER.

Findings include:

Observation of the ER occurred on 07/03/13 at 6:45 a.m. with an administrative nurse (#2) and a staff nurse (#16) and showed a crash cart containing various medications including cardiac glycosides, antiarrhythmics, antihypertensives, analgesics, anesthetics, and electrolytes and replacement solutions used in life-saving procedures.

During an interview on 07/03/13 at 7:00 a.m., an administrative nurse (#2) confirmed the crash cart contained the ER's life-saving medications needed in emergency situations such as cardiac and trauma events. On the morning of 07/03/13, a staff nurse (#16) stated when patients code (exhibited signs and symptoms of a respiratory or cardiac arrest), staff removed the crash cart from the ER for use on the patients. On the morning of 07/03/13, an administrative nurse (#2) and two staff nurses (#14 and #15) confirmed this practice.

16379

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to maintain effective housekeeping and maintenance programs to ensure the safe operation of mechanical and patient care equipment regarding placement of connecting hoses in an open drain pipe for 1 of 1 off-site physical therapy location; and stained, damaged, and sagging ceiling tiles and peeling wall paint in 1 of 1 surgical procedure room. Failure to maintain these areas and ensure an ongoing preventive maintenance program placed patients at risk of contamination during surgical procedures and exposure to unsafe water.

Findings include:

- Observation of the surgical department on 07/02/13 at 2:30 p.m., identified several ceiling tiles water stained and damaged and showed a large area of peeling paint on one of the walls located in the procedure room. The ceiling tiles located closely above the patient care area sagged and appeared as if the tiles could fall from the ceiling.

During an interview on 07/02/13 at 4:30 p.m., a maintenance department staff member (#4) stated he did not know of the damage to the ceiling tiles in the surgical department.

- Observation of the off-site outpatient physical therapy department on 07/03/13 at 9:15 a.m., identified two hoses from water supply lines placed in a sewer drain pipe.

During an interview on 07/03/13 at 9:45 a.m., a maintenance department management staff member (#4) reported he was not aware of the hoses in the drain pipe.

Based on review of the North Dakota Department of Health, Division of Health Facilities provider files, review of the Medical Staff bylaws, review of credentialing files, and staff interview, the Critical Access Hospital (CAH) failed to follow the Medical Staff bylaws regarding appointment of 2 of 2 active Allied Health Professionals (AHP) (#2 and #9); 4 of 4 courtesy staff physicians (#3, #5, #6, and #10); 1 of 1 courtesy AHP (#1) providing anesthesia services; and 2 of 2 active staff physicians (#7 and #8) providing patient care/services to the CAH patients. Failure to ensure the CAH's governing body reviewed all components for appointments and privileging placed the patients at risk of receiving treatment from unqualified providers.

Findings include:

Based on review of the North Dakota Department of Health, Division of Health Facilities provider files, this facility has not sustained correction of this issue. This requirement was found to be out of compliance during the previous survey completed in 2009.

Review of the Medical Staff Bylaws occurred on 07/01/13. The bylaws, dated 05/27/08, stated:
"PREAMBLE . . . the Medical Staff is responsible for the quality of professional services provided in the Medical Center by individuals with clinical privileges . . . ultimate authority of the Medical Center is in the Governing Body . . .
ARTICLE II, DEFINITIONS . . . Medical Staff Year commences on the first day of January and ends on the 31st day of December. . . .
ARTICLE IV: MEDICAL STAFF MEMBERSHIP . . . Section 3. CONDITIONS AND DURATION OF APPOINTMENT, A. Initial appointments and reappointments to the Medical Staff shall be made by the Governing Body . . . after there has been a report from the Medical Staff . . . B. Initial appointments shall be for a period of two years, and shall be provisional for the initial six (6) months of appointment. Reappointments shall be made for a period of time not to exceed two (2) years. All reappointments shall expire at the end of the Medical Staff Year.
C. Appointments to the Medical Staff shall confer [to give or bestow] on the appointee only such clinical privileges as have been granted by the Governing Body . . . F. Every applicant for appointment to the Medical Staff and each Medical Staff member shall maintain professional liability (malpractice) insurance . . .
ARTICLE VI, PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT . . . C. The completed application, which shall identify the Clinical Privileges for which the applicant wishes to be considered, shall be submitted . . . D. . . The hospital must also query the National Practitioner Data Bank. . . . SECTION 2. Appointment Process . . . The Medical Staff shall make recommendation to the Governing Body . . . All reports to appoint must specifically recommend the clinical privileges to be granted. . . . SECTION 3. Reappointment Process: A. At least two (2) months prior to the final scheduled Governing Body meeting in the Medical Staff year, the Medical Staff shall review all pertinent information available . . . for the purpose of determining . . . reappointments . . . and for granting of clinical privileges . . . and shall transmit its report to the Governing Body. Where non-reappointment or a change in clinical privileges is recommended, the reason for such . . . shall be stated and documented. . . . B. Each . . . reappointment . . . and the clinical privileges to be granted . . . shall be based upon . . . professional competence and clinical judgment . . .
ARTICLE VII, CLINICAL PRIVILEGES . . . A. Every practitioner . . . entitled to exercise only those clinical privileges specifically granted to him or her by the Medical Staff and approved by the Governing Body . . .
ARTICLE X, ALLIED HEALTH PROFESSIONALS . . . shall be eligible to perform within their scope of practice . . . Section 4. Applying for Allied Health Professional Membership . . . application shall be accompanied by . . . 7. Identification of the Clinical Privileges for which the applicant wished to be considered. . . . F. The Governing Body shall make the final decision to grant or deny privileges. . . ."

Review of nine provider credentialing files occurred on 07/02/13. The files review identified:
* AHP #1's (CRNA) file identified the expiration of appointment on 12/31/12. The initial appointment by Governing body, approved on 05/13/11, lacked approval of the delineated privileges. The file lacked peer review since the expired date of (re)appointment on 12/31/12.
* AHP #2's (Family Nurse Practitioner) file identified a previous approval of reappointment occurred in January 2010 and expired on 12/31/11. On 12/28/11, the applicant applied for credentialing and appointment. The Governing Body failed to grant approval for the reappointment for the next credentialing period until 04/24/12. The file lacked delineation and approval of privileges with both reappointments. During interview on the morning of 07/03/13, a staff member (#9) agreed the Governing Body failed to complete the appointment by the expiration date on 12/31/11 and stated AHP #2 saw patients between the period of expiration and renewal.
* Courtesy physician #3's file identified the expiration of liability insurance on 04/17/13. The file lacked delineation and approval of privileges by the Governing Body. During an interview on 07/03/13 at 11:20 a.m. a staff member (#9) confirmed the file lacked evidence of current liability coverage.
* Courtesy physician #5 and #6's files identified the CAH failed to query the National Practitioner Data Bank (NPDB). The file lacked delineation and approval of privileges by the Governing Body. During interview on the morning of 07/03/13, a staff member (#9) stated the CAH failed to obtain the NPDB search for the telemedicine and teleradiology services providers and stated she recently learned this is the CAH's responsibility.
* Active physician #7's file lacked delineation and approval of privileges by the Governing Body.
* Active physician #8's initial appointment occurred on 04/24/12. The file lacked evidence of how the CAH monitored the appointment after a 6 month provisional period. The file lacked delineation and approval of privileges by the Governing Body with the initial appointment.
* AHP #9's file lacked delineation and approval of privileges by the Governing Body.
* Courtesy physician #10's file lacked delineation and approval of privileges by the Governing Body.

Based on review of the Critical Access Hospital (CAH) Medical Staff bylaws, North Dakota Department of Health, Division of Health Facilities provider files, and staff interview, the CAH failed to disclose the name and address of the person responsible for medical direction (Medical Director) to the State agency in the past 9 of 9 months (August 2012 through April 2013) reviewed. Failure to disclose to the State agency the name of the medical director has the potential to affect duties as assigned within the Medical Staff bylaws including matters affecting patient care.

Findings include:

Review of the CAH's current Medical Staff Bylaws occurred on the afternoon of 07/01/13. The bylaws, approved 05/27/08, stated, ". . . ARTICLE II DEFINITIONS . . . Chief of Staff is the Medical Staff member elected in accordance with these Bylaws to serve as the President of the Medical Staff. . . . ARTICLE XI, OFFICERS SECTION 1. . . . The officers of the Medical Staff shall be: 1. President (Chief of Staff) . . . Duties of Officers . . . President . . . Report and recommend to Medical Center management when necessary with respect to matters affecting patient care . . ."

During interview on the afternoon of 07/02/13, a supervisory staff member (#2) stated a change in the medical director occurred in February 2012.

Reviewed on 07/02/13, the North Dakota Department of Health, Division of Health Facilities provider files lacked evidence the CAH disclosed to the State agency the name of the medical director.

During interview on the afternoon of 07/02/13, two administrative staff members (#1 and #2) identified lack of awareness if the CAH had notified the State agency of the person (provider/physician) responsible for medical direction.

Based on review of the critical access hospital's (CAH) policies and procedures and staff interview, the CAH failed to establish appropriate written policies and procedures for 1 of 1 cardiac rehabilitation department. Failure to provide care and services in accordance with established policies and procedures limited the CAH's ability to ensure the quality and appropriateness of care and ensure the continuity of care.

Findings include:

During review of the cardiac rehabilitation department, on 07/03/13 at 10:00 a.m., a cardiac rehabilitation department management staff member (#6) reported the CAH lacked a policy or procedure manual for the department. This staff member (#6) reported he worked in the department for approximately eight years and was not aware of a department policy or procedure manual during this time period.

16379

Based on observation and staff interview, the critical access hospital (CAH) failed to store drugs and biologicals in a secure manner to prevent access by unauthorized personnel in 1 of 1 nurses station on 3 of 3 days of survey (July 1-3, 2013) and failed to ensure safe storage of injectable medications in 1 of 1 radiology procedure room on 1 of 1 day of survey (07/03/13). Failure of the CAH to adequately secure and restrict access of drugs and biologicals created opportunities for unsafe and unauthorized use of medications.

Findings include:

- Observation of the radiology procedure room, on 07/03/13 at 8:00 a.m., identified the following injectable medications in an open box in an unsecured drawer of a cabinet:
*Two - five milliliter (ml) vials 1% Lidocaine
*Three - 30 ml vials 0.5% Sensorcaine, labeled "Nerve Blocks, Epidural Anesthesia"
*Six - one ml vials, 80 milligram per ml, Depo-Medrol, labeled "ESI [epidural steroid injection]."

The unlocked cabinet is located in the procedure room inside an unlocked door accessed from the hall.

A radiology management staff member (#3), present during observation, confirmed staff should secure the medications.

- Observation on all days of survey showed an unlocked medication refrigerator at the nurse's station. The refrigerator contained an insulin injection pen, three boxes of tetanus/diptheria toxoid immunization, and a box of Brovane respiratory inhalation solution. The nurse's station is an open area, with no doors, allowing access to staff members other than nurses. Random observations on all days of survey showed nurses not always present at the nurses station, which has the potential to allow unauthorized access to medications in the refrigerator.

Based on review of the infection log and infection prevention control reports, Quality Assurance (QA) committee meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases among CAH personnel for 5 of 5 months (January through May 2013) reviewed. Failure to identify and address infections among personnel has the potential for infections to go unreported and to spread and/or reoccur, affecting the health of all patients and personnel of the CAH.

Findings include:

The CAH's "Monthly Infection Log" and "Monthly/Quarterly Infection Prevention Control Report" (January through May 2013), reviewed on 07/02/13, lacked evidence the CAH identified and recognized infections for CAH personnel. Review of the "Quarterly QA Committee Review" meeting minutes for the fourth quarter of 2012 (dated 02/13/13) and the first quarter of 2013 (dated 05/15/13) occurred on 07/02/13 and showed the CAH failed to discuss and include incidents of infections among personnel. The CAH lacked a system or process to document and report suspected cases of infections among personnel to the infection control nurse for further investigation, monitoring, and recommendations.

During an interview on 07/02/13 at 10:05 a.m., an infection prevention staff member (#12) stated staff reported illnesses or incidents of infections to their supervisors and in turn, their supervisor reported the information to her. The staff member (#12) stated compliance with this practice is poor as the supervisors failed to follow through and report. An infection prevention nurse (#11) confirmed the CAH failed to include personnel in surveillance.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to monitor and document the effectiveness of medications given to patients on an as needed (prn) basis for 3 of 10 active patient records (Patient #3, #4, and #5) reviewed who received prn medications for pain/discomfort and nausea. Failure to evaluate the patient's response to prn medications limited the nursing staff's ability to determine whether the medication achieved the desired effect or if the patient experienced any side effects or adverse reactions from the medication.

Findings include:

- Review of Patient #3's active medical record occurred on 07/03/13 and identified the CAH admitted the patient on 06/20/13 with a diagnosis of a post open reduction internal fixation of the right hip. The record indicated Patient #3 experienced symptoms of pain and nausea throughout her hospital stay. Patient #3's record showed an order for Tylenol 325 milligrams (mg) one to two tablets every six hours prn, tramadol (used for moderate pain) 50 mg every six hours prn, Norco (used for moderate to severe pain) 5/325 mg every eight hours prn, and Zofran (used for nausea) 4 mg every six hours prn.

Review of Patient #3's Medication Administration Records (MARs) identified the following administration times for the prn medications:
*06/20/13: received tramadol at 1:00 p.m. and 8:24 p.m.; Norco at 5:13 p.m.; and Tylenol at 3:16 p.m. and 11:03 p.m.
*06/21/13: received tramadol at 2:46 p.m.; Norco at 2:44 a.m., 11:05 a.m., and 8:27 p.m.; and Tylenol at 9:17 a.m. and 5:58 p.m.
*06/22/13: received tramadol at 7:55 a.m. and 8:48 p.m.; Norco at 4:20 a.m. and 6:08 p.m.; and Tylenol at 11:50 a.m. and 11:53 p.m.
*06/23/13: received tramadol at 6:34 a.m. and 6:35 p.m.; Norco at 4:15 a.m., 2:10 p.m., and 9:50 p.m.; and Tylenol at 11:38 a.m. and 11:35 p.m..
*06/24/13: received tramadol at 2:28 a.m.; Norco at 6:34 a.m. and 7:24 p.m.; and Zofran at 10:54 a.m.
*06/25/13; received tramadol at 6:00 p.m.; Norco at 7:28 a.m. and 11:27 p.m.; and Tylenol at 10:09 p.m.
*06/26/13: received tramadol at 5:46 a.m. and 5:30 p.m.; Norco at 11:21 a.m. and 10:05 p.m.; and Zofran at 8:52 a.m.
*06/27/13: received tramadol at 2:27 a.m. and Norco at 6:00 a.m.
*06/28/13: received tramadol at 2:24 p.m. and Norco at 6:07 p.m.
*06/29/13: received Norco at 6:58 a.m., 2:50 p.m., and 11:47 p.m.
*06/30/13: received Norco at 7:19 a.m. and 1:24 p.m.
*07/01/13: received Norco at 9:01 p.m.
*07/02/13: received Norco at 12:52 p.m. and 10:01 p.m.

Nursing staff failed to document the patient's response to the prn medications on the MAR or nurses notes for the above medication administrations. Patient #3's record lacked evidence nursing staff monitored and evaluated the effectiveness of prn medications administered to the patient.


19410


- Review of Patient #4's active swing-bed record occurred on July 01-03. 2013. The CAH admitted Patient #4 on 06/07/13 status post right leg above the knee amputation. Medical diagnoses included diabetes mellitus and Methicillin Resistant Staphylococcus aureus infection in the right leg amputation site. The record indicated Patient #4 required prn medication for right leg pain and showed current orders for oxycodone/acetaminophen (Percocet) 5/325 mg 1 tablet every 4 hours prn and oxycodone 5 mg, one tablet every 4 hours prn. On June 18-20, 2013, the record showed an order for hydromorphone (Dilaudid) 0.5 mg intravenously or intramuscularly every 4 hours prn.

The prn MAR from 06/17/13 to 07/01/13 identified the following medication given for pain:
06/17/13 - Percocet and oxycodone x 4
06/18/13 - Percocet and oxycodone x 4; hydromorphone - x 1
06/19/13 - Percocet and oxycodone x 5; hydromorphone - x 2
06/20/13 - Percocet x 3; oxycodone x 4; hydromorphone - x 2
06/21/13 - Percocet and oxycodone x 3
06/22/13 - Percocet and oxycodone x 3
06/23/13 - Percocet and oxycodone x 5
06/24/13 - Percocet x 2 and oxycodone x 1
06/25/13 - Percocet and oxycodone x 3
06/26/13 - Percocet and oxycodone x 3
06/27/13 - Percocet and oxycodone x 3
06/28/13 - Percocet and oxycodone x 4
06/29/13 - Percocet and oxycodone x 2
06/30/13 - Percocet x 2 and oxycodone x 3
07/01/13 - Percocet x 3 and oxycodone x 1

Nursing staff failed to document the "Pain Response" to the medication on the MAR for the above medications and review of the nurses notes identified staff documented medication response approximately 15 out of the 58 times during the above time period.

- Review of Patient #5's active swing-bed record occurred on July 2-3, 2013. The CAH admitted Patient #5 on 06/28/13 with an admission diagnoses of status post left hip repair. The record indicated Patient #5 required prn medication for left hip pain. Orders included Norco 5/325 mg every 4 hours prn, discontinued on 06/30/13, and oxycodone/acetaminophen (Percocet) 5/325 every 4 hours prn initiated on 06/30/13.

The prn MAR from 06/29/13 to 07/02/13 identified the following medication given for pain:
06/29/13 - Norco x 1
06/30/13 - Norco x 1; Percocet x 2
07/01/13 - Percocet x 2
07/02/13 - Percocet x 3
Nursing staff failed to document the "Pain Response" to the medication on the MAR for the above medications and review of the nurses notes identified staff documented medication response two out of the 9 times during the above time period.

During an interview on 07/02/13 at 4:05 p.m., an administrative nurse (#2) stated she expected nursing staff to evaluate the effectiveness of prn medication within an hour after administration and document the result in the patient's medical record.

During an interview on 07/03/13 at 10:30 a.m., an administrative nurse (#17) confirmed Patient #3, #4, and #5's records lacked consistent documentation of patient responses after administration of prn medications.

Based on record review, review of Medical Staff Rules And Regulations, review of critical access hospital (CAH) policies and procedures, and staff interview, the CAH failed to ensure completeness, accessibility, and systematic organization for 1 of 3 sampled closed outpatient surgical records (Patient #15) and 2 of 2 open outpatient cardiac rehabilitation patient records (Patient #8 and #9). Failure to ensure complete, accurately documented, and accessible records limited the CAH's ability to ensure the quality and appropriateness of patient care.

Findings include:

Review of the CAH's Medical Staff Rules And Regulations occurred on July 01-03, 2013. This document, approved on 05/27/08, stated "SECTION I. ADMISSION AND DISCHARGE OF PATIENTS/RESIDENTS . . . 2. A member of the medical staff shall be responsible for the medical care and treatment of each patient/resident in the Medical Center and for prompt completeness and accuracy of the medical record. . . .
SECTION IV. SURGICAL RULES AND REGULATIONS,
1. A complete History and Physical shall be dictated or written prior to surgery.
2. A surgical operation shall be performed only with informed consent of the patient or his legal representative, except in case of an emergency. . . .
4. All tissues . . . will be sent to the Pathologist who shall make such examination as he or she may consider necessary to arrive at a pathological diagnosis. . . ."

Review of the CAH's policy and procedure, "Documentation," occurred on 07/03/13. This document, revised 2011, stated "1. Complete and correct information on the medical record begins with admission of the patient; admitting personnel must obtain the following information from the patient and/or responsible party. . . . This information is required on all types of admissions: inpatient, observation . . . outpatient . . .
J. Authorization for treatment - signed, dated, witnessed.
K. Surgical authorization - signed, dated, witnessed (all surgical procedures must have a separate authorization). . . .

2. Responsibility of the Admitting/Attending Physician:
A. History and Physical . . .
B. Progress Notes. . .
C. Physician's Orders . . .

3. Responsibility of the Nursing Staff:
A. Graphic charting of vital signs . . .
B. Nurses notes . . .
C. Medication Administration . . .
D. Nurses Notes . . ."

- Review of the CAH Patient Surgical Roster, on 07/01/13, identified the CAH admitted Patient #15 on 03/19/13 for an esophagogastroduodenoscopy (EGD) with a biopsy. Patient #15's medical record, reviewed July 02-03, 2013, lacked authorization for treatment, informed consent for surgical procedure, history and physical, physician's orders, nurses notes, anesthesia evaluations, intraoperative notes, and pathologist's reports.

During interview on 07/03/13 at 9:15 a.m., staff member (#7) reported the CAH staff found no additional records for Patient #15's admission and surgical procedure on 03/19/13.

- Review of the outpatient cardiac rehabilitation department occurred on 07/03/13 at 10:00 a.m. During interview at this time, a department management staff member (#6) reported staff initiate a treatment program after an initial evaluation by cardiac rehabilitation staff. The staff member reported a health care provider does not review and approve the treatment plan. At the completion of the course of treatment staff do not complete a discharge summary. The staff member (#6) reported this process had been in place for approximately eight years.

Review of Patient #8's current medical record, on July 3, 2013, identified the CAH cardiac rehabilitation program admitted Patient #8 on 06/10/13 and received treatment three times each week. The treatment record lacked a treatment plan signed by the physician including objective measurable goals, and treatment length, frequency, and duration. During interview, the morning of July 3, 2013, a cardiac rehabilitation management staff member (#6) reported the department currently had two active outpatients, Patient #8 and #9. The staff member (#6) confirmed lack of signed treatment plans.

Based on Medical Staff Bylaws review, policy review, credentialing file review, review of a roster of providers, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the quality and appropriateness of the diagnosis and treatment furnished by 1 of 1 certified registered nurse anesthetist (CRNA) (CRNA #1) reviewed providing services to the CAH's patients. Failure to evaluate the quality and appropriateness of the treatment furnished has the potential to affect patient outcomes involving surgical procedures requiring anesthesia services.

Findings include:

Review of the "Medical Staff Bylaws" occurred on 07/01/13. The bylaws, approved 05/27/08, identified the "Reappointment Process" which stated, ". . . the clinical privileges to be granted upon reappointment shall be based upon such member's professional competence and clinical judgment in the treatment of patients . . ."

Review of the "Quality/Performance Improvement Plan" occurred on 07/02/13. The plan, approved by the governing body on 03/18/13, stated,
". . . Objectives, Improve the quality of patient/resident care through the following process . . . Monitor and evaluate the quality and appropriateness of patient/resident care and the clinical performance of all individuals with clinical privileges. . . . Scope, The Quality Improvement/Risk Management program shall apply to all departments, services and practitioners whose activities within the institution have a direct influence on the quality of patient/resident care. The following is an outline of the proposed quality improvement activities: 1. Medical Staff Functions through the Professional Activities Council A. Reappointment and Credentialing . . . G. Peer Review . . ."

The CAH lacked a policy requiring evaluation of CRNAs for quality and appropriateness of the treatment provided to the CAH's patients.

Review of the CAH's current physician/provider roster occurred on 07/01/13 and identified one CRNA credentialed with courtesy staff privileges.

Review of the credentialing file of CRNA #1 occurred on the afternoon of 07/02/13. The file lacked documentation the facility evaluated the quality and appropriateness of the diagnosis and treatment provided by CRNA #1.

On the morning of 07/03/13, an administrative staff member (#1) confirmed the CAH failed to evaluate the quality and appropriateness of the treatment provided by CRNAs.

Based on Medical Staff bylaws review, policy review, review of a list of providers, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the treatment furnished in the last year by 1 of 1 courtesy staff physician (Physician #4) providing care in the emergency room (ER) for CAH patients. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the treatment furnished by the physician limits the CAH's ability to ensure the physician furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the "Medical Staff Bylaws" occurred on 07/01/13. The bylaws, approved 05/27/08, identified the "Reappointment Process" which stated, ". . . the clinical privileges to be granted upon reappointment shall be based upon such member's professional competence and clinical judgment in the treatment of patients . . ."

Review of the "Quality/Performance Improvement Plan" occurred on 07/02/13. The plan, approved by the governing body on 03/18/13, stated,
". . . Objectives, Improve the quality of patient/resident care through the following process . . . Monitor and evaluate the quality and appropriateness of patient/resident care and the clinical performance of all individuals with clinical privileges. . . . Scope, The Quality Improvement/Risk Management program shall apply to all departments, services and practitioners whose activities within the institution have a direct influence on the quality of patient/resident care. The following is an outline of the proposed quality improvement activities: 1. Medical Staff Functions through the Professional Activities Council A. Reappointment and Credentialing . . . G. Peer Review . . ."

Review of the policy "Contract Hospital Physician Peer Review Procedure" occurred on 07/03/13. The policy, undated, stated,
"1. A sample of charts will be sent to Peer Review every quarter . . ."

Review of the CAH's current physician/provider roster occurred on 07/01/13 and identified several courtesy physicians provided patient care in the CAH and/or the clinic. On 07/03/13 at 9:40 a.m., a supervisory staff member (#2) stated Physician #4, a courtesy provider, provided coverage in the emergency room on the weekends.

Review of Peer Review files completed within the last year occurred on the afternoon of 07/02/13. The files lacked evidence of peer review for Physician #4.

During interview on the afternoon of 07/02/13, a staff member (#10) confirmed the CAH failed to evaluate the quality and appropriateness of the care provided by Physician #4 within the last year.