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Based on observation, record review and staff interview, the facility failed to keep an accurate record system to account for and ensure the control of the distribution, use and disposition of the scheduled/controlled medications (classifications of medications based on their "potential for abuse"). The facility census was 1 swing bed and 2 acute care patients.

Findings are:

A. An observation in the pharmacy with the Pharmacist on 6/4/14 from 1:15 PM to 2:00 PM revealed a locked cupboard with the Scheduled Medication supplies in the pharmacy. The Pharmacist had 2 books (Count Books) that were used to count the controlled medications. (The Count Books possessed a separate page for each medication with the name of the medication, strength of the medication and the balance of the current medication on hand in the pharmacy.) Random Scheduled Medication counts were completed with the Pharmacist which revealed:
- Demerol (a narcotic pain medication) 50 mg (milligrams) 1 ml (milliliter) carpujects (a prefilled cartridge that is loaded into a syringe holder). The Count Book showed a balance of 137; the Cupboard had 10 boxes of 10 carpujects (equaling 100 carpujects) with a balance of 37 carpujects not being accounted for on the Count Book sheet.
- Morphine Sulfate (a narcotic pain medication) 30 mg (1 mg/ml - 1 milligram per milliliter) vials in boxes for PCA pump. The Count Book showed a balance of 32 boxes; the Cupboard had 29 boxes; with a balance of 3 boxes not being accounted for on the Count Book sheet.

B. An interview with the Pharmacist on 6/4/14 at 1:55 PM revealed, "I did the complete Annual Inventory of Controlled Substances, Schedule II on March 31, 2014 and the count was correct. We also do a cycle count with the Scheduled/Control Medications in the Pyxis (a medication dispensing machine). The Pyxis machines keep a perpetual count. I, the Director of Nurses, Assistant Director of Nurses and the Administrator are the only ones that have access to the keys to the pharmacy. I and the Administrator only have keys to the locked cupboard in the pharmacy." "I am sure it is an addition or subtraction issue. I haven't had time to input all the deliveries and send backs, but I keep the forms here in the book. So I think that is where the discrepancies came from..." "I have been getting ready for a computer rollout with medications." " I will do a complete count again and track it all down."

C. Review of the Controlled Drug System policy dated 11-04 and 6-10 for Schedule II Controlled Substances revealed:
- Receiving, record the date and quantity received in the proper columns of the narcotic inventory records.
- Dispensing, The medication is placed in the Pyxis equipment for removal as needed. All Pyxis transactions are recorded. The pharmacist/pharmacy technician will verify the controlled substance counts remaining in the automated dispensing machine and record the number of doses added when refilling the machine.
- Return of Drug to the Pharmacy, Unused Schedule II drugs may be returned from the patient care areas. The drug must be counted. The Pharmacist verifies the quantity returned and signs the appropriate blank and dates the corresponding line. The Pharmacy department carefully signs in these returns so that the narcotic record will accurately reflect the pharmacy inventory.
- Pharmacy Inventory: 1) Periodic inventory checks will be made approximately every 6 months. The received/issue records will be balanced with the inventory at this time. Disposition records will also be checked periodically to verify that all supplies of Schedule II drugs are present and secured in the designated areas. 2) A recorded physical inventory is required by the Drug Enforcement Administration (DEA) every 2 years and must be kept on file.

Based on staff interview and record review the Critical Access Hospital (CAH) failed to have accurate documentation for the times that the Anesthesia Services provided a pre and/or post surgery visit for 9 of 9 surgical patients ( Patients 16, 17, 18, 26, 27, 28, 29, 30 and 31). The facility census was 2 acute patients and 1 Swing Bed patients.

Findings are:

A. Patient 16 had an Umbilical Hernia Repair (repair of a weakness in the muscle wall by the belly button) on 12/10/13 from 1359 (1:59 PM) -1538 (3:38 PM). The medical record showed that the pre and post anesthesia visits were completed, but were not documented until 12/10/13 at 2129 (9:29 PM).

B. Patient 17 had a Cesarean Section (delivery of a baby surgically from the uterus) on 12/10/13 from 1159 (11:59 AM) -1307 (1:07 PM). The medical record showed that the pre and post anesthesia visits were completed, but were not documented until 12/10/13 at 2147 (9:47 PM).

C. Patient 18 had a left knee arthroplasty (total left knee joint replacement) on 3/17/14 from 1028 (10:28 AM) -1154 (11:54 AM). The medical record showed that the pre and post anesthesia visits were completed, but were not documented until 3/17/14 at 1935 (7:35 PM).

D. Patient 26 had a right knee arthroscopy with meniscectomy (right knee scope to repair the knee cartilage) on 4/14/14 from 1738 (5:38 PM) -1827 (6:27 PM). The medical record showed that the pre and post anesthesia visits were completed, but were not documented until 4/18/14 at 1010 (10:10 AM).

E. Patient 27 had a tonsillectomy (removal of the tonsils) and uvulopalatopharyngoplasty (reshaping and tightening of tissue of the uvula [tissue that dangles in the back of the mouth], soft palate (muscular part of the roof of the mouth) and throat) on 2/3/14 from 1201 (12:01 PM) -1314 (1:14 PM). The medical record showed that the pre anesthesia visit was completed, but was not documented until 2/3/14 at 1438 (2:38 PM). The post anesthesia visit was completed and documented timely.

F. Patient 28 had an appendectomy (surgical removal of the appendix (a worm-like appendage of the large bowel) through the abdominal wall) on 12/13/13 from 2233 (11:33 PM) -0215 (2:15 AM) on 12/14/13. The medical record showed that the pre anesthesia visit was completed, but was not documented until 12/14/13 at 0330 (3:30 AM). The post anesthesia visit was completed and documented timely.

G. Patient 29 had a tubal ligation (surgical procedure to cut the fallopian tube of a woman to achieve sterilization) on 4/2/14 from 1102 (11:02 AM) -1205 (12:05 PM). The medical record showed that the pre and post anesthesia visits were completed, but were not documented until 4/2/14 at 1722 (5:22 PM).

H. Patient 30 had a laparoscopic cholecystectomy (removal of the gall bladder through small incisions in the abdominal wall while using a scope to visualize the area) on 4/17/14 from 0830 (8:30 AM) -1030 (10:30 AM). The medical record showed that the pre and post anesthesia visits were completed, but were not documented until 4/18/14 at 1159 (11:59 AM).

I. Patient 31 had a left myringotomy and placement of ventilation tubes (a tiny incision in the eardrum and placement of tubes) on 3/10/14 from 1045 (10:45 AM) -1105 (11:05 AM). The medical record showed that the pre and post anesthesia visits were completed, but were not documented until 3/10/14 at 1616 (4:16 PM).

J. Interview with the Certified Registered Nurse Anesthetist (CRNA) A on 6/4/14 at 9:40 AM stated, "The reason the times and dates in the computer record is different than when we do the assessments and the pre and post anesthesia visits is that it dates and times it when we put it in the computer. My partner and I write all the information down on paper forms at the time of our services, and complete it all timely, but on busy days we don't input it into the computer until later that day or even up to a few days later. The computer documents those times and we can't put in the time we did the service." "We don't keep the written information because the hospital doesn't want double information in the chart, so after we input the information we shred the written forms." "I can see the confusion when it comes to the time documented, but the services are provided per protocol."

Based on review of the Network Agreement, review of policies and procedures, review of the semiannual reviews by the Network Hospital Representative and staff interview, the CAH (Critical Access Hospital) failed to ensure that the quality and appropriateness of diagnosis and treatment furnished by doctors of medicine or osteopathy was evaluated by the Network Hospital as spelled out in the Network Agreement. The CAH Medical Staff included 4 Active Staff and 38 Consulting Staff. This failed practice has the potential to affect all patients treated by active and consulting members of the medical staff. The 2013-2014 Annual Program Review reported 374 acute inpatients, 15,135 outpatients, 81 swingbed patients, 89 newborn babies and 332 outpatient observations.

Findings are:

A. Review of the agreement for Nebraska Critical Access Hospital Medicare Rural Hospital Flexibility Program or Network Agreement entered into on 3/6/2007 revealed the following under Quality Assurance:
"Members of the CAH's medical staff, mid-level practitioners, nursing staff, and administration participate in implementing the QA [Quality Assurance] Plan. The parties agree that [name of Network Hospital] through participating members of its medical staff or other personnel designated by [name of Network Hospital] shall meet with the CAH's QA representative no less than on a semi-annual basis to provided objective oversight and assistance to the CAH in reviewing the quality and appropriateness of the diagnosis and treatment furnished by CAH's doctors of medicine or osteopathy....As necessary, and upon request of QA [Quality Assurance] representatives of the CAH, The CAH's Medical Staff, the CAH's Administrator/CEO, or the CAH's governing body, peer review assistance will be provided by [name of Network Hospital] the peer review organization currently under contract with the CAH for this service."

(Peer review is the process by which a committee and/or another physician examines the work of a peer and determines whether the physician under review has met accepted standards of care in rendering medical services.)

B. Review of the Physician Peer Review Policy/Procedure last revised 10/6/11 revealed a process where patient medical records are screened. If any patient medical record met the screening criteria the record would be reviewed during the monthly medical staff meeting (internal peer review). The policy and procedure explained the circumstances for external peer review which included:
"Ambiguous or conflicting recommendation from internal reviewers or QA Committee or when reviewers or committee cannot reach consensus for a particular recommendation.
When no physician on the medical staff has expertise in the specialty under review, or when the only physicians on the medical staff with that expertise do not feel comfortable in reviewing the case.
Where there may be a likelihood of legal action.
When a physician under review reports peer reviewer or committee as biased.
When there is only one physician group."

C. Review of the Semi-Annual Program Visit report dated 10/21/13 from the Network Hospital Representative revealed no mention of Peer Review (review of quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy. Review of the Annual Program Evaluation and Semi-Annual Visit report dated 5/8/14 revealed the following concerning Medical Staff Peer Review: "This activity continues as outlined in the Medical Staff Bylaws and Quality Assurance Plan."

D. Interview with the QA Coordinator on 6/4/14 from 3:10 PM to 3:40 PM revealed the CAH's internal peer review process followed the policy and procedure and indicated that no records were send for external peer review in last year. The QA Coordinator pulled the last record for external peer review, which was sent for review on 10/1/2010. The QA Coordinator also indicated that the Network Hospital Representative did not look at any of the peer review documents during the semiannual visits. Interview with the CEO (Chief Executive Officer) on 6/4/14 from 3:40 PM to 3:50 PM confirmed that the CAH completed internal peer review at medical staff meetings that included 2 different medical groups and a pathologist, but, no external peer review was completed by Network Hospital.

Based on review of personnel files, review of policies and procedures, review of employee handbook and staff interview, the CAH (Critical Access Hospital) failed to check the State Nurse Aide Registry prior to hiring 2 of 2 NAs (Nursing Assistants: NA - D and NA - F) reviewed. The CAH had hired 5 NAs from 6/1/13 through 5/31/14 and had a total of 13 NAs on staff. This failed practice has the potential to affect all swingbed patients. The 2013-2014 Annual Program Review reported 81 swingbed patients.

Findings are:

A. Review of the information on background checks and registry checks from the personnel files for NA-D and NA-F revealed no information that the State Nurse Aide Registry had been checked. Interview with CFO (Chief Financial Officer)/Business Manager on 6/3/14 at 4:15 PM confirmed the lack of checking the State NA registry for adverse findings prior to hiring these 2 NAs. Interview with the DON (Director of Nursing) on 6/3/14 at 5:20 PM confirmed that the State NA registry was not checked prior to hiring these 2 NAs.

B. Review of the policy and procedure titled Abuse and Neglect Reporting last revised January 2011 revealed the following concerning abuse prevention:
"Before hiring a new patient care employee....inquire the State nurse aide registry..."

Review of the employee handbook (with no date) under the section titled Applications and Background Checks revealed the following:
"The hospital will conduct such background check on new applicants, as deemed appropriate under the circumstances. All applicants may be required, as a condition for their application to be considered, to execute authorizations to conduct background checks, including but not limited to checks of criminal background, state adult abuse and child abuse registries."

Based on staff interview and review of 5 of 5 patient records (Patients 32, 33, 34, 35 and 36), the CAH (Critical Access Hospital) failed to ensure a qualified professional directed the patient activities program. The total Swingbed sample was 5. The Swingbed census during survey was 1.

Findings are:

A. An interview with the Swing Bed Liaison-Registered Nurse (RN)-AA on 6/3/14 at 5:30 PM verified the Licensed Practical Nurse (LPN)-BB that is in charge of patient activity assessments for the Swing Bed patients, lacked evidence of attending a training course. The LPN did the assessment and notified the nursing staff on the floor who assisted the patients with individual activities of the completed assessments.

B. The patient record review for Patients 32, 33, 34, 35 and 36 showed an Activity Assessment completed by LPN-BB, which did not have the training to be a qualified professional to direct the activity program for the Swing Bed patients.

Based on staff interview and medical record review, the Critical Access Hospital (CAH) failed to ensure that an order for Physical Therapy evaluation and treatment for 1 of 5 swing bed patients (Patient 36) was completed. The facility census was 2 acute patients and 1 Swing Bed patients.

Findings are:

A. Review of Patient 36's medical record revealed the following orders on 4/25/14 Swing Bed Admission Order form:
- "1. Admit to Swingbed for: "Physical Therapy (PT) with restorative goals."; "Medication requiring frequent lab work and physician monitoring." and "Skilled Nursing Observation."
- "5. Physical Therapy consult and treat."

B. The medical record for Patient 36 lacked a PT evaluation and treatment document.

C. An interview with the Swing Bed Liaison-Registered Nurse (RN)-AA on 6/4/14 at 4:15 PM verified, "There was nothing done related to the PT evaluation order. We did not do one - for some reason it was missed."

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have a process in place to ensure that the Swing Bed Patients' dental needs will be met. This has the potential to affect all Swing Bed Patients. The facility census was 2 acute patients and 1 Swing Bed patient.

Findings are:

A. An interview with the Swing Bed Liaison-Registered Nurse (RN)-AA on 6/3/14 at 5:30 PM verified, "No, we don't currently have a Dentist on staff or under arrangement for our Swing Bed patients."

B. Review of the Swing Bed Patient Bill of Rights dated 8/12 revealed, "22. The patient will be assisted to obtain routine and 24 hour emergency dental care as needed."

C. Since the facility lacked a dentist on staff or under agreement/contract for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive dental care as needed.