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Based on review of credential files, review of Medical Staff Bylaws, review of the agreement with a Nebraska hospital (Network Hospital) for quality, review of the Central Nebraska Critical Access Hospital Network Peer Review Process Guidelines and staff interview, the governing body of the Critical Access Hospital (CAH) failed to ensure that:
1. The Medical Staff Bylaws were followed in the privileging and/or reappointment of 9 of 10 physicians (Physicians H, J, K, L, M, N, O, P, Q) and 4 of 5 non-physician practitioners (Certified Registered Nurse Anesthetist [CRNA] - R; Advanced Practice Registered Nurse [APRN] - S; APRN - T; and APRN - U) reviewed (Refer to C-0241);
2. The quality and appropriateness of diagnosis and treatment and of the treatment outcomes furnished by physician at the CAH was evaluated by the Network Hospital (Refer to C-0340).

The cumulative effect of these systemic problems resulted in the CAH's inability to ensure the provision of quality health care to all patients of the CAH.

A. Review of the Medical Staff Bylaws approved by the CAH governing body on 6/21/2004 revealed the following concerning membership, reappointment process and clinical privileges:

Article IV, Section 3 - Reappointment Process
"Reappointment shall be based upon such member's professional competence and clinical judgment in the treatment of patients, his/her ethics and conduct, attendance at medical staff meetings, and participation in staff affairs. Also consideration will be given to compliance with hospital bylaws, medical staff bylaws, and rules and regulations. As well as, the practitioner's cooperation with hospital personnel, use of hospital facilities and his/her patients, relations with other practitioners and his/her general attitude towards patients, the hospital, and the public...."

Article VI, Section 1 - Clinical Privileges Restricted
"Every practitioner practicing at this hospital by virtue of medical staff membership shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him by the governing board...."

Review of credential files for Physicians J, L, O, P and Q revealed no evidence that the governing board had granted any privileges for these physicians to practice at the hospital. Interview with Radiologist Technologist-G (responsibilities included maintenance of the credential files) on 10/12/15 from 10:45 AM to 11:25 AM confirmed the above credential files lacked a listing of privileges.

Review of the credential file for Physician H (last reappointment by Governing Board 5/19/14), Physician K (last reappointment by Governing Board 10/19/15, Physician M (last reappointment by Governing Board 2/17/14), Physician N (last reappointment by Governing Board 1/20/14), CRNA-R (last reappointment by Governing Board 6/16/14), APRN-S (last reappointment by Governing Board 12/16/13), APRN-T (last reappointment by Governing Board 5/19/14) and APRN-U (last reappointment by Governing Board 11/17/14) revealed no information on: professional competence and clinical judgment in the treatment of patients; attendance at medical staff meetings and participation in staff affairs; compliance with hospital bylaws, medical staff bylaws, and rules and regulations; cooperation with hospital personnel, use of hospital facilities and his/her patients,and his/her general attitude towards patients, the hospital, and the public. Interview with the Administrator on 10/21/15 from 10:45 AM to 11:25 AM confirmed the credential files lacked information in regards to activity and quality of the individual at the CAH.

B. Review of the Network Agreement effective 8/1/2009 under section V Quality Assurance revealed the following:
"As necessary, and upon request of QA [Quality Assurance] representative of Rock County Hospital, the Rock County Hospital Medical Staff, Rock County Hospital Administrator/CEO [Chief Executive Officer], or Rock county Hospital governing body, peer review assistance may be provided by the network's peer review process or another service under contract by BCH [sic should be RCH for Rock County Hospital]"

(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.)

Review of a document titled Central Nebraska Critical Access Hospital Network Peer Review Process Guidelines dated 01/01/2015 provided by the CAH's Administrator revealed the purpose of the guidelines was "The Central Nebraska Critical Access Hospital Network Peer Review Process is a non-bias confidential activity performed by the physicians within the network's critical access hospitals. The peer review process will facilitate safe, timely, effective, efficient and equitable patient centered (STEEP) outcomes through the identification of opportunities for improving processes and delivery of patient care." The guidelines continues to list the responsibility and procedure for this process as:
"1. Each critical access hospital will have an established quality plan for review of appropriate care and treatment of the patients at their facility....
2. The critical access hospital may use the Central Nebraska Critical Access Hospital Network Internal Peer Review process template or establish their own internal peer review process.
3. Charts that are identified for external peer review will be sent for peer review through the external peer review process utilizing the Central Nebraska Critical Access Hospital External Peer Review process template.
4. Peer Review Rotation schedules will be maintained and distributed to the Critical Access Hospitals by the network hub hospital."

C. Interview with the Administrator on 10/21/15 from 9:05 AM to 9:35 AM revealed the following concerning the evaluation of quality and appropriateness of diagnosis and treatment furnished by the physicians:
-Medical records are reviewed against specific criteria, usually by the nurses;
-If the record meets any of the criteria then it is sent out for external peer review;
-They send the records out according to the rotation set by the Network Hospital;
-The HIM (Health Information Management) Director takes care of sending the records out.

Interview with the HIM Director on 10/21/15 at 9:45 AM and again at 11:00 AM revealed the following:
-No audits have been completed for 2015;
-None of the records audited met the criteria to send out for external peer review in 2014; and,
-Unable to find the results of the 1 record send out for external peer review in 2013.

Based on review of credential files, review of the Medical Staff Bylaws, review of patient's diagnostic reports and staff interview, the Critical Access Hospital (CAH) failed to ensure that the Medical Staff Bylaws were followed in regards to:
-Ensuring that reappointment of 4 of 10 physicians reviewed (Physician H, K M and N) and 4 of 5 non-physician practitioners (Certified Registered Nurse Anesthetist [CRNA] - R; Advanced Practice Registered Nurse [APRN] - S; APRN - T; and APRN - U) was based on competence, clinical judgement in treatment of patients, attendance at medical staff meetings, compliance with hospital bylaws and rules and regulations, cooperation with hospital personnel, and use of the hospital facilities.
-Ensuring that 5 of 10 physicians (Physicians J, L, O, P and Q) had been granted clinical privileges (defines the procedures and patient care services a practitioner is deemed competent to perform).

This failed practice had the potential to affect all patients of the CAH. The roster of the medical staff provided by the CAH listed 51 physicians and 24 non-physician practitioners.

Findings are:

A. Review of the Medical Staff Bylaws approved by the CAH governing body on 6/21/2004 revealed the following concerning membership, reappointment process and clinical privileges:

Article III, Section 1 - Nature of Medical Staff Membership
"Membership of the Medical Staff of Rock County Hospital is a privilege which shall be extended only to professionally competent physicians, dentists, physician's assistants, nurse practitioners and certified nurse anesthetists who continuously meet the qualifications, standards and requirements set forth in these bylaws."

Article IV, Section 3 - Reappointment Process
"Reappointment shall be based upon such member's professional competence and clinical judgment in the treatment of patients, his/her ethics and conduct, attendance at medical staff meetings, and participation in staff affairs. Also consideration will be given to compliance with hospital bylaws, medical staff bylaws, and rules and regulations. As well as, the practitioner's cooperation with hospital personnel, use of hospital facilities and his/her patients, relations with other practitioners and his/her general attitude towards patients, the hospital, and the public...."

Article VI, Section 1 - Clinical Privileges Restricted
"Every practitioner practicing at this hospital by virtue of medical staff membership shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him by the governing board...."

B. Review of credential files for Physicians J, L, O, P and Q revealed no evidence that the governing board had granted any privileges for these physicians to practice at the hospital. These physicians had provided the following services for the CAH:
-Interview with the Laboratory Manager on 10/15/15 from 8:25 AM to 8:45 AM revealed Physician J came to the CAH quarterly and provided oversight for blood transfusions patients received.
-Review of diagnostic reports revealed Physician L provided x-ray interpretations for Patient 19 on 4/3/15, Patient 22 on 9/15/15 and 9/23/15, and Patient 6 on 7/23/15.
-Review of diagnostic reports revealed Physician O provided x-ray and/or CT scan interpretations for Patient 7 on 6/26/15, Patient 17 on 9/11/15, Patient 18 on 7/9/15, Patient 21 on 10/7/15 and Patient 3 on 10/6/15.
-Review of diagnostic reports revealed Physician P provided CT scan interpretations for Patient 30 on 6/27/15 and Patient 35 on 5/8/15.
-Review of diagnostic reports revealed Physician Q provided x-ray interpretations for Patient 14 on 7/22/15, Patient 26 on 9/29/15 and Patient 27 on 9/29/15.

Interview with Radiologist Technologist-G (responsibilities included maintenance of the credential files) on 10/12/15 from 10:45 AM to 11:25 AM confirmed the above credential files lacked a listing of privileges.

(A physician credential file contains the information gathered at the time of appointment/reappointment to the hospitals medical staff and includes information such as: an application; list of privileges requested; verifications of education, training, work experience licenses, registrations and references; background checks; and, quality and activity at the CAH.)

C. Review of the credential file for Physician H (last reappointment by Governing Board 5/19/14), Physician K (last reappointment by Governing Board 10/19/15, Physician M (last reappointment by Governing Board 2/17/14), Physician N (last reappointment by Governing Board 1/20/14), CRNA-R (last reappointment by Governing Board 6/16/14), APRN-S (last reappointment by Governing Board 12/16/13), APRN-T (last reappointment by Governing Board 5/19/14) and APRN-U (last reappointment by Governing Board 11/17/14) revealed no information on: professional competence and clinical judgment in the treatment of patients; attendance at medical staff meetings and participation in staff affairs; compliance with hospital bylaws, medical staff bylaws, and rules and regulations; cooperation with hospital personnel, use of hospital facilities and his/her patients,and his/her general attitude towards patients, the hospital, and the public.

D. Interview with the Administrator on 10/21/15 from 10:45 AM to 11:25 AM confirmed the credential files lacked information in regards to activity and quality of the individual at the CAH.

Based on review of the agreement with a Nebraska hospital (Network Hospital), review of the Telemedicine Credentialing and Privileging Agreement, review of a letter from the Network Hospital and staff interview, the Critical Access Hospital (CAH) failed to ensure that 2 of 2 credentialing services (Telemedicine Credentialing and Privileging Agreement and Network Agreement) provided through agreement were followed to ensure that the CAH followed the medical staff bylaws for credentialing and privileging their physician and non-physician practitioners (Refer to C-0241). This failed practice had the potential to affect all patients of the CAH.

Findings are:

A. Review of the Network Agreement with an effective date of 8/1/2009 revealed the following concerning credentialing:
"Rock County Hospital and [Network Hospital] hereby enter into a Credentialing Agreement for purposes of providing credentials verification oversight. This will involve an analysis by the appropriate personnel at [Network Hospital] of Rock County Hospitals's credentialing process. This process results in the verification of credential by Rock County Hospital for determination of privileges that can be afforded at the facility. Credentialing process overview documentation shall be provided by [Network Hospital] to Rock County Hospital for purposes of evaluation its credentialing process."

Interview with the Radiology Technologist - G on 10/21/15 from 10:45 AM to 11:25 AM revealed responsibilities include verification of all credential information and requests for peer reference evaluations and affiliated hospital evaluations.

The Administrator provided the most recent documentation of oversight in the credentialing and privileging process at the CAH by the Network Hospital. Review of this letter revealed the last time the Network was at the CAH for a review of the credentialing and privileging process was 8/26/2004 and documented "you have made a good effort in some of the identified areas but there are many more areas that need improvement."

B. Review of the Telemedicine Credential and Privileging Agreement effective 8/1/2014 revealed the following:
"....The governing body of the Receiving Site [Rock County Hospital] has chosen to rely on the Hospital's [Network Hospital's] credentialing and privileging decisions for purposes of the Receiving Site's medical staff determining whether or not to recommend that privileges be granted to a Practitioner....Hospital shall send a letter stating each provider has met all of the requirements to be on staff and shall provide Receiving Site copies of the applicable clinical privileges delineations."

Review of the credential files for Physicians J, L, O, P and Q (who were credentialed through the Telemedicine Credentialing and Privileging Agreement) revealed no delineation of privileges. Interview with Radiologist Technologist-G (responsibilities included maintenance of the credential files) on 10/12/15 from 10:45 AM to 11:25 AM confirmed the above credential files lacked a listing of privileges.

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have documentation of the pre dismissal nursing discharge assessment for 2 of 6 (Patients 26 and 27) surgical patient medical records; and 1 of 6 (Patient 26) surgical patient medical records lacked a discharge order. This failed practice had the potential to affect all surgical patients of the CAH. The Critical Access Hospital (CAH) provided 59 outpatient scope procedures in the fiscal year of 7/1/14-6/30/15.

Findings are:

A. Review of Patient 26's outpatient surgical record dated 5/27/15 admission at 1200 Noon and dismissed at 1445 (2:45 PM) revealed the patient had a colonoscopy (looking at the inside of the lower bowel with a lighted tube) with biopsies (tissue samples). Review of the Patient Procedure Observation Form lacked the nursing documentation for pre dismissal assessment by identifying Yes/No/NA (not applicable) for the following information: Vital signs stable; Return to pre-op (pre-operation) mental status; Absence of resp.(respiratory) distress; Swallow/cough/gag reflex present; Able to ambulate (walk); Oral fluids retained; Pain control by meds; Drsg (dressing) checked/no drng (drainage); Voided; Pt given instructions; Escorted by; Driven home by; Discharge Criteria Met: Time discharged and how discharged (walked, wheelchair, carried) and nurses' signature.

Review of Patient 26's outpatient surgical record dated 5/27/15 lacked a physician order for discharge.

B. Review of Patient 27's outpatient surgical record dated 10/01/15 admission at 0630 AM Noon and dismissed [No time listed] revealed the patient had a colonoscopy. Review of the Patient Procedure Observation Form lacked the nursing documentation for pre dismissal assessment by identifying Yes/No/NA for the following information: Vital signs stable; Return to pre-op mental status; Absence of resp. distress; Swallow/cough/gag reflex present; Able to ambulate; Oral fluids retained; Pain control by meds; Drsg checked/no drng; Voided; Pt given instructions; Escorted by; Driven home by; Discharge Criteria Met: Time discharged and how discharged (walked, wheelchair, carried) and nurses' signature.

C. An interview with the Director of Nurses (DON) on 10/21/15 from 11:30 AM verified that there was not a discharge order on (Patient 26's) medical record and that the dismissal assessment section of the "Patient Procedure Observation Form" for (Patients 26 and 27) lacked the nurses documentation. The DON also shared that there was not specific instructions or policies for the dismissal assessment section of this form.

Based on review of medical records, policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to:
Part I: Ensure that 4 of 5 (Patients 39, 40, 41 and 42) Outpatient Clinic records reviewed contained signatures of the nurse making the entry on the "Outpatient Clinic Form."
Part II: Ensure that 3 of 5 (Patients 34, 35 and 36) Swing Bed records reviewed contained the date the nurse completed the recapitulation (A summary of the hospital stay) form in the record.
Part III: Ensure that 5 of 6 (Patients 26, 27, 28, 29 and 30) Outpatient Surgical records reviewed identifed the time the Anesthesia pre operative visit was completed and 4 of (Patients 27, 28, 29 and 30) Outpatient Surgical records reviewed identified the time the Anesthesia post operative visit was completed.
This failed practice has the potential to affect all patients seen in the Outpatient Clinic, patients provided anesthesia for surgery and patients dismissed from Swing Bed status at the CAH.

Findings are:

Part I
A. The Outpatient Clinic Record review revealed the following patient medical records lacked authentication of the nurse completing an entry in the record:
-Review of the medical record for Patient 39 revealed the patient was seen in the Cardiology Clinic on 4/17/15. The Outpatient Clinic Form contained a weight, blood pressure and pulse. This entry contained no signature of the individual completing this information.
-Review of the medical record for Patient 40 revealed the patient was seen in the Cardiology Clinic on 9/18/15. The Outpatient Clinic Form contained a weight, blood pressure, pulse and oximetry reading (measure of the oxygen in the blood stream). This entry contained no signature of the individual completing this information.
-Review of the medical record for Patient 41 revealed the patient was seen in the Cardiology Clinic on 8/21/15. The Outpatient Clinic Form contained a weight, blood pressure, pulse and oximetry reading. This entry contained no signature of the individual completing this information.
-Review of the medical record for Patient 42 revealed the patient was seen in the Surgical Clinic on 8/19/15. The Outpatient Clinic Form contained a temperature, respirations, blood pressure, pulse and oximetry reading. This entry contained no signature of the individual completing this information.

Part II
B. The Swing Bed record review revealed the following patient medical records lacked a date the nurse completed the recapitulation form in the record:
-Review of the medical record for Patient 34 revealed the patient was dismissed from Swing Bed Status on 7/23/15. The Recapitulation form was completed by RN S, and lacked the date the form was completed.
-Review of the medical record for Patient 35 revealed the patient was dismissed from Swing Bed Status on 5/11/15. The Recapitulation form was completed by RN S, and lacked the date the form was completed.
-Review of the medical record for Patient 36 revealed the patient was dismissed from Swing Bed Status on 6/9/15. The Recapitulation form was completed by RN S, and lacked the date the form was completed.

Part III
C. The Outpatient Surgical record review revealed the following patient medical records lacked a time of the Anesthesia provided the pre operative and post operative visits for the following:
-Review of the medical record for Patient 26 revealed the Anesthesia Form dated 5/27/15 lacked a time the pre operative visit was provided by Certified Registered Nurse Anesthetists (CRNA-provide anesthetic to patients receiving surgery or procedures) -M.
-Review of the medical record for Patient 27 revealed the Anesthesia Form dated 6/17/15 lacked a time the pre operative and post operative visit was provided by CRNA J.
-Review of the medical record for Patient 28 revealed the Anesthesia Form dated 9/3/15 lacked a time the pre operative and post operative visit was provided by CRNA J.
-Review of the medical record for Patient 29 revealed the Anesthesia Form dated 6/17/15 lacked a time the pre operative and post operative visit was provided by CRNA J.
-Review of the medical record for Patient 30 revealed the Anesthesia Form dated 7/15/15 lacked a time the pre operative and post operative visit was provided by CRNA M.

D. Review of the undated Pre-Anesthesia Care Policy revealed, "...The responsibility of the nurse anesthestist (CRNA) begins before the actual administration of the anesthetic. The anesthetist has an obligation to determine that an appropriate pre-anesthesia evaluation with relevant tests have been completed by the physician. The nurse anesthetist (CRNA) shall also visit the patient and make a pre-anesthetic evaluation of the patient..."
The Post-Anesthesia Care Policy revealed, "...Post anesthetic visits will be made on all patients receiving ...anesthetic. A post anesthetic note shall be made early in the postoperative period after recovery from anesthesia. The post anesthesia note should be dated, and describe the presence or absence of anesthesia-related complications..."

E. Interview with the HIM (Health Information Management) Director on 10/20/15 at 2:25 PM confirmed that HIM lacked having had a policy talking about staff authenticating and dating entries in medical records, only located a policy for the Medical Staff.

Interview with the HIM on 10/20/15 at 3:00 PM revealed, "I do not have a policy." The HIM Manager had researched if the CAH had a policy for nursing authenticating and dating their entries in the medical records.

Based on review of the agreement with a Nebraska hospital (Network Hospital) for quality assurance, review of the Central Nebraska Critical Access Hospital Network Peer Review Process Guidelines, review of completed External Peer Review Audit Sheets, review of credential files and staff interview, the CAH (Critical Access Hospital) failed to ensure that the quality and appropriateness of diagnosis and treatment and of the treatment outcomes furnished by physicians was evaluated by the Network Hospital's process for 4 of 10 physicians (Physicians H, K, M and N) reviewed. This failed practice had the potential to affect all patients of the CAH. The roster of the medical staff provided by the CAH listed 51 physicians.

Findings are:

A. Review of the Network Agreement effective 8/1/2009 under section V Quality Assurance revealed the following:
"As necessary, and upon request of QA representative of Rock County Hospital, the Rock County Hospital Medical Staff, Rock County Hospital Administrator/CEO [Chief Executive Officer], or Rock county Hospital governing body, peer review assistance may be provided by the network's peer review process or another service under contract by BCH [sic should be RCH for Rock County Hospital]"

(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 a document titled Central Nebraska Critical Access Hospital Network Peer Review Process Guidelines dated 01/01/2015 provided by the CAH's CEO revealed the purpose of the guidelines was "The Central Nebraska Critical Access Hospital Network Peer Review Process is a non-bias confidential activity performed by the physicians within the network's critical access hospitals. The peer review process will facilitate safe, timely, effective, efficient and equitable patient centered (STEEP) outcomes through the identification of opportunities for improving processes and delivery of patient care." The guidelines continues to list the responsibility and procedure for this process as:
"1. Each critical access hospital will have an established quality plan for review of appropriate care and treatment of the patients at their facility....
2. The critical access hospital may use the Central Nebraska Critical Access Hospital Network Internal Peer Review process template or establish their own internal peer review process.
3. Charts that are identified for external peer review will be sent for peer review through the external peer review process utilizing the Central Nebraska Critical Access Hospital External Peer Review process template.
4. Peer Review Rotation schedules will be maintained and distributed to the Critical Access Hospitals by the network hub hospital."

C. Interview with the Administrator on 10/21/15 from 9:05 AM to 9:35 AM revealed the following concerning the evaluation of quality and appropriateness of diagnosis and treatment furnished by the physicians:
-Medical records are reviewed against specific criteria, usually by the nurses;
-If the record meets any of the criteria then it is sent out for external peer review;
-They send the records out according to the rotation set by the Network Hospital;
-The HIM (Health Information Management) Director takes care of sending the records out.

D. The HIM Director provided the completed External Peer Review Audit Sheets for 2013 and 2014. Review of the 2014 file revealed 54 audits with none identified for external peer review. Review of the 2013 revealed 112 audits with 1 identified for external peer review. Interview with the HIM Director on 10/21/15 at 9:45 AM and again at 11:00 AM revealed the following:
-No external peer review audits have been completed for 2015; and,
-The nurses have not completed the audits since 2011 when it became the responsibility of HIM Director;
-The external peer review completed for 2013 could not be found.

E. Review of the credential files for Physicians H, K, M and N revealed no evidence that the quality and appropriateness of diagnosis and treatment and of the treatment outcomes furnished by physicians was evaluated. Interview with the Administrator on 10/21/15 from 10:45 AM to 11:25 AM revealed the lack of any information concerning the evaluation of the physician's competence in treating patients at the CAH.