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Based on observation and staff interview, the Critical Access Hospital (CAH) operating room staff failed to remove outdated supplies in 1 of 2 operating room suites, the Post Anesthesia Critical Care Unit (PACU), and the Emergency Department. The surgical nurse reported approximately 2 general surgical procedures, 17 ophthalmology surgical procedures and 17 endoscopy/colonoscopy procedures weekly.

Failure to remove outdated supplies could potentially expose patients to supplies not guaranteed sterile or potentially less effective.

Findings included:

1. Observations, during a tour of the PACU, on 1/26/11 at 8:22 AM, revealed the following outdated supplies available for patient use:
a. 12 of 18 Autoguard Insyte Intravenous needless expired 12/2010.
b. 1 of 1 sterile water multi-dose vial expired 7/2010.

2. During an interview on 1/26/11, at the time of the observation in PACU, Staff A, Registered Nurse (RN) acknowledged the outdated supplies in the PACU. Staff A stated, "We all monitor for outdates on a monthly basis. I will dispose of these right now."

2. Observations during a tour of operating room suite #1 on 1/26/11 at 8:30 AM, revealed the following outdated supplies and equipment available for patient use:
a. 6 of 6 Providine-Iodine swabstick's expired 8/09.
b. 1-3.7 ounce bottle of Providine Iodine scrub care expired 3/10. Staff A stated Providine-Iodine solutions "disinfect skin" prior to surgery.
c. 1 of 1 Ethibond excel polyester suture expired 7/10.
d. 3 of 11 Vicryl suture sets expired 7/10.
e. 1- Datex Ohmeda Gas Monitor expired 3/09.

3. During an interview on 1/26/11 at the time of the observation in operating room suite #1, Staff A stated, "All of us are responsible for checking for expiration dates, I will throw these away now. There's no excuse."

4. During an interview on 1/26/11 at 10:45 AM, the Director of Nursing (DON) stated the CAH did not have formal policies addressing outdated supplies and equipment. The DON stated, "Outdated supplies should not be available for patient use."


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5. Observations during the environmental tour of the Emergency Room (ER) on 1/24/2011 at 1:20 PM with Staff E ER Nurse Manager revealed 3 outdated boxes of sutures in the suture supply cabinet of trauma room 2. One 6-0 prolene suture box containing 1 dozen sutures expired 7/2020, one 5-0 chromic gut suture box containing 1 dozen sutures expired 7/2010 and one 5-0 coated vicryl suture box containing 1 dozen sutures expired 7/2010.

During an interview on 1/24/2010 at the time of the tour, Staff E, ER Nurse Manager agreed the 3 suture boxes were expired. Staff E said the ER hospital staff check for outdated supplies on a monthly basis and was surprised the outdated supplies were not removed from the suture supply cabinet.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the physician reviewed the CAH patient records periodically, in conjunction with the mid-level practitioner for 4 of 4 mid-level practitioners. (Practitioners E, F, G, H)

The Quality Services Director reported an average of 24 patient visits per month by Practitioner E, an average of 23 patient visits per month by Practitioner F, an average of 30 patient visits per month by Practitioner G, and 2 patient visits since 6/2010 by Practitioner H.

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioner could potentially result in mid-level practitioners misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policies/procedures on 1/26/11, revealed the CAH administrative staff failed to develop and implement policies/procedures that delineated the physician's responsibility to review the CAH patient records periodically, in conjunction with the mid-level practitioners.

2. Review of the Medical Staff Meeting minutes for the 2010 year revealed no documented evidence that showed the CAH's physicians had reviewed the patient medical records periodically and in conjunction with the mid-level Practitioners E, F, G, H.

3. During an interview on 1/26/11 at 2:45 PM, Staff F, Quality Services Director, acknowledged the CAH quality staff failed to ensure the physician reviewed the CAH patient records periodically, in conjunction with the mid-level practitioner.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the mid-level practitioners periodically reviewed patient medical records in conjunction with the physician, for 4 of 4 mid-level practitioners. (Practitioners E, F, G, H)

The Quality Services Director reported an average of 24 patient visits per month by Practitioner E, an average of 23 patient visits per month by Practitioner F, an average of 30 patient visits per month by Practitioner G, and 2 patient visits since 6/2010 by Practitioner H.

Failure of the mid-level practitioner to participate in the review of CAH patient records periodically with the physician could potentially result in mid-level practitioners misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policies/procedures on 1/26/11, revealed the CAH administrative staff failed to develop and implement policies/procedures that delineated the mid-level practitioner's responsibility to participate in the review of CAH patient records periodically with the physician.

2. Review of the Medical Staff Meeting minutes for the 2010 year revealed no documented evidence that showed the mid-level practitioner participated in the review of CAH patient records periodically with the physician.

3. During an interview on 1/26/11 at 2:45 PM, Staff F, Quality Services Director, acknowledged the CAH quality staff failed to ensure the mid-level practitioner participated in the review of CAH patient records periodically with the physician.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to develop and implement policies/procedures that delineated the physician's responsibility to review CAH patient records periodically and in conjunction with the mid-level practitioner for 4 of 4 mid-level practitioners. (Practitioners E, F, G, H)

The Quality Services Director reported an average of 24 patient visits per month by Practitioner E, an average of 23 patient visits per month by Practitioner F, an average of 30 patient visits per month by Practitioner G, and 2 patient visits since 6/2010 by Practitioner H.

Failure of the physician to review the CAH patient records periodically in conjunction with the mid-level practitioner could potentially result in mid-level practitioners misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policies/procedures on 1/26/11, revealed the CAH administrative staff failed to develop and implement policies/procedures specific to the physician's responsibility for the periodic review of the CAH's patient records, in conjunction with the clinic mid-level practitioners.

2. Review of the Medical Staff Meeting minutes for the 2010 year revealed no documented evidence that showed the CAH's physicians had reviewed the patient medical records periodically and in conjunction with mid-level Practitioners E, F, G, H.

3. During an interview on 1/26/11 at 2:45 PM, Staff F, Quality Services Director, acknowledged the CAH quality staff failed to develop and implement policies/procedures that delineated the physician's responsibility to review CAH patient records periodically, in conjunction with the mid-level practitioners listed above.


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Based on the Critical Access Hospital (CAH) policy/procedure review and staff interview, the CAH administrative staff failed to ensure swing bed activities policies were developed and implemented that delineated the staff responsibilities for initiating the activities and documenting patient participation. The CAH had a census of 4 patients with no current swing bed patients.

Failure to develop and maintain a policy that provides specific directions for initiating and documenting activities for swing bed patients could potentially result in staff failing to meet the patients ' activities social needs.

Findings include:

1. Review of the hospital policy titled "Activities of Daily Living", dated 6/01, revealed the Activity coordinator will provide activities or programs. Nursing should encourage all patients to attend these whenever possible. The policy did not address when the staff initiate activities and how to document patient participation.

2. During an interview on 1/26/2011 at 4:05 PM with Staff B, Medical/Surgical Manager, stated the hospital did not have a policy pertaining to the activities program.

I. Based on review of documents and staff interview, the Critical Access Hospital (CAH) nursing staff failed to ensure physician notification of medication errors for 14 of 22 Medication Errors/PERTS reviewed (Patients #5, 10, 11, 13, 14, 15, 16, 17, 19, 20, 21, 22, and 23). The CAH administrative nursing staff reported an average daily census of approximately 2 patients.

Failure to notify the physician of medication errors could potentially result in life threatening, or other related health conditions that could lead to serious harm.

Findings included:

1. Review of CAH policy titled "Medication Error/PERTS Form" dated 10/27/09, revealed in part:..."All medication errors will be reported to the physician by the nurse...When a nurse discovers that medication errors have occurred, the physician must be notified."

2. Review of medication errors from December 2009 to December 2010 revealed 14 of 22 medication errors lacked physician notification of the medication errors (Patients #5, 10, 11, 13, 14, 15, 16, 17, 19, 20, 21, 22, and 23).

3. During an interview on 1/24/11 at 4:30 PM, Staff C, Registered Nurse (RN) reported when a medication error is identified nursing staff are responsible for contacting and informing physicians of the medication errors. Staff C stated, "The nurse that finds the error notify's the physician, this would be in the policies and procedures and it's hospital protocol."

4. During an interview on 1/26/11 at 11:25 AM, the Director of Nursing (DON) and Medical/Surgical Nurse Manager acknowledged nursing staff had failed to notify the physician of medication errors for Patients #5, 10, 11, 13, 14, 15, 16, 17, 19, 20, 21, 22, and 23. The Medical/Surgical Nurse Manager stated, "If the nurse finds the error he/she notify's the physician, if I find the error, I would be notifying the physician."

5. During an interview on 1/25/11 at 8:00 AM, the Director of Pharmacy acknowledged nursing staff had failed to notify the physician of medication errors and indicated he/she would "follow up with this."

II. Based on review of documents and staff interview, the Critical Access Hospital (CAH) nursing staff failed to identify and document the severity of medication errors in accordance with CAH policy for 23 of 24 Medication Errors/PERTS reviewed (Patients #1-10 and #12-24). The CAH administrative nursing staff reported an average daily census of approximately 2 patients.

Failure to identify the severity of medication errors could potentially place patients at risk for inappropriate monitoring and treatment.

Findings included:

1. Review of CAH policy titled "Medication Error" dated 10/27/09, revealed in part:.."A trend of the severity of the medication error and the patient's outcome will determine the type of corrective action that will be taken."

2. Review of medication errors from December 2009 to December 2010 revealed 24 of 24 Medication Error/PERTS reports lacked identification and documentation of the severity of the medication errors (Patients #1-24).

3. During an interview on 1/26/11 at 11:25 AM, the Quality Assurance (QA) Director and the Director of Nursing (DON) acknowledged nursing staff failed to identify and document the severity of medication errors. Both reported the person filling out the report would be responsible for documenting the severity of the medication error and that this was CAH policy. The QA Director stated he/she would monitor this more closely in the future.

4. During an interview on 1/25/11 at 8:00 AM, the Director of Pharmacy acknowledged the findings and stated he/she would follow up with the DON.

5. During an interview on 1/26/11 at 11:25 AM, the Medical/Surgical Manager reported it was his/her responsibility to review the medication errors/PERTS reports initially and then submit the data to QA. The Medical/Surgical Manager stated he/she was unaware that severity codes were included on the med error forms and did not know this was CAH policy.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure surgical staff followed manufacturer's recommendation for safety practices when working with Cidex Solution testing strips. The CAH surgical staff reported approximately 8 endoscopy and colonoscopy procedures weekly.

Failure to follow manufacturer's safety practices when using Cidex testing strips could potentially result in staff using testing strips that were ineffective in verifying the minimum effective concentration of the Cidex OPA solution resulting in the spread of infectious microorganisms between patients.

Findings included:

1. Observations, during a tour of the Center Sterilization Department, on 1/26/11 at 9:02 AM, revealed 2 bottles containing Cidex OPA test strips. Staff A, Registered Nurse (RN) present at the time of the observation stated, "Both bottles are opened, neither are dated and they're suppose to be." Staff A reported that manufacturer's directions on both bottles of test strips
clearly stated the strips should be "dated when opened."

2. During a follow up interview on 1/26/11 at 9:14 AM, Staff A stated, "Hospital policy states we date the bottle of test strips when opened. We'll have to order new strips."

3. Review of CAH policy titled "Use of Cidex OPA Solution Test Strips" reviewed 10/27/09 revealed in part, "...Record the date that the bottle of Cidex OPA Test Strips was opened on the container label...Rationale: Do not use any remaining strips 90 days after opening the bottle."

Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the required group of professionals reviewed all patient care policies annually in accordance with the CAH policy for 40 of 40 patient care departments. (Ambulance, Anesthesia, Cardiac Rehabilitation, Cardiac Treadmill Stress Testing, Central Sterile, Contracted Services, Counseling Services, Emergency Department, Health Information, Infection Control, Infusion Therapy, Inpatient, Labor and Delivery, Laboratory, Maintenance and Equipment, Mammography, Medical Staff, Med/Surg, Med/Surg Respiratory Therapy, Nuclear Medicine, Nursery and Post Partum, Nutritional Services, Occupational Therapy, Pediatrics, Pediatric Therapy, Pharmacy, Physical Therapy, Pulmonary Rehabilitation, Quality Management, Radiology, Recovery Room, Respiratory Therapy, Same Day Surgery, Simplified Diet Manual, Specialty Clinics, Speech Therapy, Substance Abuse, Surgery, Swing Bed, Wound Healing Clinic. The CAH had a census of 4 patients.

Failure to ensure the required group of professionals reviewed all patient care policies annually could potentially result in failure to identify patient care needs not addressed in CAH policies/procedures.

Findings include:

1. Review of policy/procedure titled, "Policy and Procedure Development and Review", dated May 2009, revealed in part. ". . .all patient care policies will be developed and reviewed on an annual basis (485.635(a)(4)/C-280) by a group of professional personnel that includes one or more physicians and others as indicated below. At least one member of the review committee is not directly affiliated with the hospital. . . . The annual policy review meeting will be held during the last quarter of each fiscal year. Review Committee members will include: Physician, Mid-Level Practitioner, LCHC Chief Executive Officer, Quality Assurance Coordinator, Community Representative, Medical Staff Services Assistant, Medical Surgical Manager, Director of Nursing, Board of Trustee member and other members as indicated. . . . A copy of the signed Policy and Procedure Review Signature Sheet (Attachment C) will be provided to the Department Manager following the review of documents by the Policy Review Committee, Medical Staff and Board of Trustees. This sheet must be kept in the front of each policy and procedure manual."

2. Review of Policy Review Committee Meeting minutes from July 2009 through January 2011 showed the most recent committee meeting held where the committee recommended approval of the policies/procedures occurred on July 15, 2009. The Policy Review Committee Meeting minutes dated July 15, 2009 revealed in part. ". . . The Policy Review Committee recommends approval of the policies to the Medical Staff and Board of Trustees. . . "

3. During an interview on 1/26/11 at 3:10 PM, Staff F, Quality Services Director, acknowledged the Policy Review Committee last approved all of the patient care policies/procedures on July 15, 2009 and have not been reviewed since that date. Staff F verified the lack of annual review of patient care policies as required by CAH policy and the regulations.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to include all practitioners that provided care and services to the CAH patients, in their external peer review process for 4 of 10 applicable practitioners. (Practitioners A, B, C, D) The CAH reported a census of 4 patients.

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff members misdiagnosing patients and/or providing inappropriate or substandard patient care.

The Quality Services Director reported an average of 38 procedures performed per month by Practitioner A, an average of 595 tests read per month by Practitioner B, an average of 23 procedures performed per month by Practitioner C, and an average of 1 procedure performed per year by Practitioner D.

Findings include:

1. Review of policy/procedure titled, "Peer Review", dated May 2009, revealed in part. ". . .All practitioners providing diagnosis and/or treatment at LCHC will undergo the peer review process at least once per credentialing period. This peer review information will be used to monitor the performance of practitioners who have privileges at LCHC. . . At least one medical record per physician or midlevel practitioner per two year credentialing cycle will be mailed to the entity listed in the Critical Access Hospital network agreement for external peer review. . . The results of this peer review activity will be utilized at the time of medical staff reappointment and, as appropriate, in the organization's performance improvement activities. . . ."

2. Review of peer review documentation for the past credentialing period of 2 years revealed the CAH staff failed to include all Practitioners (Practitioners A, B, C, D) in the CAH's external peer review process.

3. During an interview on 1/26/11 at 10:50 AM, Staff F, Quality Services Director, stated the CAH quality staff sends out (for external peer review) patient medical records for each medical staff member that provided cared and services to patients of the CAH. Staff F acknowledged the external peer review results for Practitioners A, B, C, D were not available for review at the time of their medical staff reappointment. Staff F verified Practitioners A, B, C, D had provided services to patients of the CAH during each of their last credentialing periods.