HospitalInspections.org

Based on review of documents and staff interview, it was determined the facility failed to ensure the group of professional personnel included one (1) or more physician assistants. This has the potential to negatively affect the development of policies and procedures by not having the professional input of all disciplines working within the facility.

Findings include:

1. Based on review of the members of the "Policy Oversite Committee", it was determined the facility employs physician assistants who take call and write orders under the direction of a physician. These physician assistants are not included in the annual review of Policy and Procedures.

2. During an interview with the Administrative Secretary on 6/5/12 at 1400, she provided a list of the members of the "Policy Oversight Committee" and this list did not include any of the employed physician assistants on staff.

3. During an interview with the Chief Executive Officer (CEO) on 6/6/12 at 1030 he revealed there are no physician assistants on the Policy Oversite Committee.

Based on document review and staff interview it was determined the hospital failed to ensure there is an active infection control program that reports on monitoring/surveillance projects and staff compliance with infection control performance standards. Additionally, there were no documented corrective measures that were taken relative to the findings of any infection control activities. Failure to have an active infection control surveillance program with analysis of findings and the institution of corrective actions can result in the spread of infections/diseases among patients or staff.

Findings include:

1. Review of the Infection Control Committee Minutes from January 2011 to present revealed no reports on monitoring or surveillance projects that were conducted by infection control except for the number of health care associated infections. There were no findings, recommendations or actions that were enacted relative to the infection control as a result of the analysis of infection control projects.

2. During interview with the Infection Control Nurse on 6/6/12 at 1350 hours she was questioned as to the lack of reports in infection committee minutes about the findings and analysis of surveillance/ monitoring projects. The Infection Control Nurse stated she does conduct some surveillance activities but really doesn't document anything.

Based on review of documents and staff interview, it was determined the facility failed to ensure the policies were reviewed annually by a group of professional personnel. This has the potential to limit the quality of care rendered to patients through out dated policies.

Findings include:

1. The Policy and Procedure manual for the Emergency Department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

2. The Policy and Procedure manual for the Health Information Management Department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

3. The Policy and Procedure manual for Anesthesia Department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

4. The Policy and Procedure manual for the Radiology Department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

5. The Policy and Procedure manual for the Personnel Department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

6. The Policy and Procedure manual for the Safety and Disaster Department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

7. The Policy and Procedure manual for Infection Control was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

8. The Policy and Procedure manual for the Operating Room was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

9. The Policy and Procedure manual for the Critical Access Hospital was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

10. The Policy and Procedure manual for the Social Service Department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

11. The Policy and Procedure manual for the Medical Surgical Unit was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

12. The Policy and Procedure manual for the Special Care Unit was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

13. The Policy and Procedure manual for the Respiratory Therapy Department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

14. The Policy and Procedure manual for the Laboratory was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

15. The Policy and Procedure manual for Nutrition Services was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

16. The Policy and Procedure manual for the Physical Therapy department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

17. The Policy and Procedure manual for the Housekeeping department was last reviewed and approved by the "Policy Oversite Committee" for calendar year 2011 which is from 1/1/11 through 12/31/11.

18. The Policy and Procedure manual for the Behavioral Health Department revealed none of the policies had been dated or signed.

19. These manuals were reviewed with the Chief Executive Officer (CEO) on 6/6/12 at 1030 and he agreed the Committee has not met to review the policies. He stated there are no meeting minutes to his knowledge indicating there has been any meetings of the Policy Oversite Committee.

Based on review of documents and staff interview the hospital failed to have a list of services furnished under arrangements or agreements including their nature and scope of service. This deficient practice has the potential to allow such services to function with limited over-site and "outside" the federal certification regulations for Critical Access Hospitals.

Findings include:

1. After review of the hospital's Administrative Policy Manuel for 2012 and various other hospital papers and documents presented to the surveyors for their review, there was no documented evidence of a list of services furnished under arrangement.

2. During interview with the Administrative Assistant on June 7, 2012 at approximately 9:30 a.m. she indicated she was not aware of a list of services provided by agreement and that she would investigate further. At the time of exit there was no evidence of any such document.

3. During the exit conference on June 7, 2012 at 11:30 a.m. the Chief Executive Officer (CEO) stated that he had asked key staffers as to whether the hospital had a list of services provided by agreement. He said he agreed the hospital does not have a list of these services.

Based on document review and staff interview it was determined that infection control failed to report to quality assurance any monitoring projects which includes medication therapy evaluations such as antibiotic usage and staff compliance with infection control performance standards. Additionally there was no documented corrective measures that were taken relative to the findings of infection control activities. Failure to have an active infection control surveillance program with analysis of findings and the institution of corrective actions can result in the spread of infections/diseases among patients or staff.

Findings include:

1. Review of Quality Assurance Control Committee Minutes from January 2011 to present revealed no reports on monitoring or surveillance projects that were conducted by infection control except for the number of health care associated infections. There were no findings, recommendations or actions that were enacted relative to the infection control as a result of the analysis of infection control projects.

2. During interview with the Infection Control Nurse on 6/7/12 at 0930 hours she was questioned as to the lack of reports to Quality Assurance about the findings and analysis of surveillance/monitoring projects such as medication therapy evaluation or staff compliance with infection control performance standards. The Infection Control Nurse stated she does conduct some surveillance activities but really doesn't document anything.

Based on review of documents, medical records and staff interview, it was determined the facility failed to ensure an activity program was developed for the residents in six (6) of six (6) swing bed records reviewed (#1, 2, 5, 18, 19 and 20). This has the potential to negativity affect the residents by leaving them feeling isolated and removed from emotional stimulation.

Findings include:

1. Resident #1 was admitted to swing bed on 4/12/12 and discharged on 4/15/12. There was no documentation in the medical record to indicate the resident had been involved in or offered any type of activity.

2. Resident #2 was admitted to swing bed on 5/6/12 and discharged on 5/20/12. There was no documentation in the medical record to indicate the resident had been involved in or offered any type of activity.

3. Resident #5 was admitted to swing bed on 5/14/12 and discharged on 5/24/12. There was no documentation in the medical record to indicate the resident had been involved in or offered any type of activity.

4. Patient #18 was admitted to swing bed on 5/22/12 and is currently still an inpatient. There was no documentation in the medical record to indicate the resident had been involved in or offered any type of activity.

5. Patient #19 was admitted to swing bed on 5/24/12 and is currently an inpatient. There was no documentation in the medical record to indicate the resident had been involved in or offered any type of activity.

6. Patient #20 was admitted to swing bed on 5/30/12 and is currently an inpatient. There was no documentation in the medical record to indicate the resident had been involved in or offered any type of activity.

7. During an interview with the Social Worker on 6/5/12 at 1320, she revealed there are no organized activities for swing bed residents. She revealed there are calendars placed in the patient room with activities scheduled on the long term care unit and if the patients would like to attend, then they will transport them to the long term care unit. She also stated she does not offer reminders of the daily activities. She revealed when a patient is admitted to swing bed status, she will notify the activity department for the long term care unit in hopes they will take over the activities.

8. During an interview on 6/5/12 at 1400 with the Clinical Manager of the Medical/Surgical and Specialty Care Unit, she revealed there will be no documentation of activities in the resident medical record, as activities for the residents do not occur on the unit.