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Based on document review, Medical Staff Bylaws, and staff interview the Critical Access Hospital (CAH) failed to ensure a physician assistant (PA) and/or nurse practitioner (NP) member participates in developing, executing, and periodically review the CAH's written policies governing the services is furnishes. This deficient practice can affect the care provided to all patients who present to the CAH for medical care.

Findings include:

- Review of the policies and procedures presented by the CAH staff from 8/7/17 to 8/10/17 revealed the following policies were reviewed and approved by the administrator and chief of the medical staff on 6/12/17: Pharmacy, Laboratory, Radiology, Physical Therapy, Material Management, Business Office, Credentialing, Health Information Management, Emergency Operation Plan, Human Resources, Internet Technology, Dietary, Environmental services, Infection Control, Social Service, Emergency Department, Acute Nursing, and Swing Bed. Review of the Medical Staff Bylaws the Medical Staff failed to include review and approval of policies and procedures by the Medical Staff and PA and/or NP. The CAH failed to ensure the physicians included the PA and/or NP in the review and approval of the policies and procedures.

Staff B, Administration interviewed in the conference room on 8/8/17 at 7:50am explained that the PA and/or NP do not come to the Medical Staff meetings nor do they review and approve the policies and procedures.

Based on document review, Medical Staff Bylaws, and staff interview the Critical Access Hospital (CAH) failed to assure the physician assistant (PA) and/or nurse practitioner (NP) members of the CAH's staff participates in the development, execution, and periodic review of the CAH's written policies governing the services it furnishes. This deficient practice can affect the care provided to all patients who present to the CAH for medical care.

Findings include:

- Review of the policies and procedures presented by the CAH staff from 8/7/17 to 8/10/17 revealed the following policies were reviewed and approved by the administrator and chief of the medical staff on 6/12/17: Pharmacy, Laboratory, Radiology, Physical Therapy, Material Management, Business Office, Credentialing, Health Information Management, Emergency Operation Plan, Human Resources, Internet Technology, Dietary, Environmental services, Infection Control, Social Service, Emergency Department, Acute Nursing, and Swing Bed. Review of the Medical Staff Bylaws the Medical Staff failed to include review and approval of policies and procedures by the Medical Staff and PA and/or NP. The CAH failed to assure the physicians included the PA and/or NP in the review and approval of the policies and procedures.

Staff B, Administration, interviewed in the conference room on 8/8/17 at 7:50am explained that the PA and/or NP do not come to the Medical Staff meetings nor do they review and approve the policies and procedures.

Based on document review, and staff interview the Critical Access Hospital (CAH) failed to assure the policies are developed and reviewed at least annually with the advice of the CAH's professional healthcare staff including one or more doctors and one or more physician assistant (PA) and/or nurse practitioner (NP) members of the CAH's staff. This deficient practice can affect the care provided to all patients who present to the CAH for medical care.

Findings include:

- Review of the policies and procedures presented by the CAH staff from 8/7/17 to 8/10/17 revealed the following policies were reviewed and approved by the administrator and chief of the medical staff on 6/12/17: Pharmacy, Laboratory, Radiology, Physical Therapy, Material Management, Business Office, Credentialing, Health Information Management, Emergency Operation Plan, Human Resources, Internet Technology, Dietary, Environmental services, Infection Control, Social Service, Emergency Department, Acute Nursing, and Swing Bed. The CAH failed to assure the PA and/or NP are in the group of professionals that advise in the development of policies and review then at least annually.

Staff B, Administration, interviewed in the conference room on 8/8/17 at 7:50am explained that the PA and/or NP do not come to the Medical Staff meetings nor do they review and approve the policies and procedures.

Based on observation, staff interview and policy review the Critical Access Hospital (CAH) failed to ensure staff performed appropriate hand hygiene during 6 random observations (Staff C and Staff N), and disinfected patient care equipment after use during one random observation (Staff C). The cumulative effect of these deficient practices placed all patients at risk of unsafe, inadequate patient care, infection, and contraction of communicable diseases.

Findings include:

- Observation on 8/8/17 at 7:35am in patient #7's room revealed Staff C, RN (Registered Nurse) performing a blood sugar check. Staff C with glucometer (hand held machine that measures the blood sugar) case entered the patient's room, placed the glucometer on the patient's bedside table, put gloves on, performed the finger stick, placed the glucometer back in the case, removed the gloves, exited the room, and placed the glucometer case back in the medication room. Staff C failed to perform hand hygiene when entering the room, after removing the gloves, and after exiting the room. Staff C failed to disinfect the glucometer before placing back in the case and failed to disinfect the outside of the case before placing it in the medication room.

- Observation on 8/8/17 at 8:07am revealed Staff C entering patient #9's room and failed to perform hand hygiene.

- Observation on 8/8/17 at 8:35am revealed Staff N, CNA (Certified Nurse Aide) entered patient #8's room, exited the room with the breakfast tray, placed it on a cart, entered the patient's room, exited the patient's room and failed to perform hand hygiene at any time.

- Observation on 8/8/17 at 8:40am revealed Staff N entered patient #9's room, exited the patient's room, and failed to perform hand hygiene at any time.

- Observation on 8/8/17 at 8:45am revealed Staff C entered patient #8's room, exited the patient's room, retrieved some patient supplies from the supply room, entered the patient's room with the supplies and failed to perform hand hygiene at any time.

- Observation on 8/8/17 at 9:50am revealed Staff C entered patient #8's room to perform a dressing change on a stage 4 decubitus ulcer. Staff C put gloves on after entering the patient's room (failed to perform hand hygiene upon entering the patient's room) expressed the air out of the patient's colostomy (an opening in the abdomen where the large intestine is brought out to the surface to remove fecal waste), staff C then removed the gloves, put clean gloves on (without performing hand hygiene), removed the soiled dressing from the decubitus ulcer, removed the gloves (failed to perform hand hygiene), put sterile gloves on, performed the dressing change, removed the gloves, and washed their hands. Staff C failed to perform hand hygiene when entering the room and between multiple glove changes.

Staff B, Administration on 8/8/17 at 4:30pm acknowledged the failure of staff to perform hand hygiene and the disinfecting of patient care equipment after use.

- The CAH's policy titled "Hand Hygiene" reviewed on 8/10/17 at 12:45pm directed, " ...indication for hand washing ...decontaminate hands before having direct contacts with patients ...decontaminate hands after contact with a patient's intact skin ...decontaminate hands after removing gloves ..."

- The CAH's policy titled "Environmental Measures to Prevent the Spread of Infection" reviewed on 8/10/17 at 12:45pm directed, " ...non-critical equipment ...must be thoroughly cleaned and disinfected before use on another patient ..."

- The Centers for Disease Control (CDC) "Guidelines for Hand Hygiene in Health Care Settings" directed " ...indications for hand hygiene, contact with patient's skin, contact with environmental surfaces in the immediate vicinity of patient's, and after glove removal.

Based on observation, medical record review, staff interview and policy review the Critical Access Hospital (CAH) failed to ensure the patient's and/or responsible patient representative received their patient rights both verbally and in writing for two of five swing bed patient's medical record reviewed (Patient's #6 and #10). Failure to provide verbal and written rights to all patients prevents all patients from the knowledge necessary to act on those rights.

Findings include:

- Patient #6's closed swing bed medical record reviewed on 8/8/17 and 8/9/17 revealed the patient was admitted to inpatient from the ER (emergency room) on 5/30/17 at 10:55pm with diagnosis of Acute Symptomatic blood lose anemia (low blood count due to bleeding), mental status change, and hypoxemia (low oxygen level ), and on 6/2/17 the CAH discharged the patient from acute care and admitted the patient to swing bed. The CAH discharged patient #6 to home on 6/22/17. Review of the medical record revealed the patient and/or responsible patient representative did not receive the patient rights verbally or in writing when admitted to swing bed from acute inpatient.


- Patient #10's closed swing bed medical record reviewed on 8/9/17 revealed an admission date of 6/27/17 to swing bed from acute inpatient with a diagnosis of rib fractures after a fall and discharged to home on 7/3/17. Review of the medial record revealed the patient and/or responsible patient representative did not receive the patient rights verbally or in writing when admitted to swing bed from acute inpatient.

Staff F, Business office manager/health information manager interviewed on 8/10/17 at 9:am in the conference room explained that when a patient is dismissed from acute inpatient to swing bed the patients need to be given the patient rights to review and sign.

- The CAH's policy titled "Management of Swing Bed Program" reviewed on 8/10/17 directed " ...the swing bed chart shall include ...copy of patient rights-signed by the patient or his/her legal representative ..."