HospitalInspections.org

Based on review of documents and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure medical staff approval of the Blood Supply and Services Agreement. The CAH laboratory manager reported approximately 64 inpatient blood transfusions yearly and approximately 171 outpatient blood transfusions yearly.

Failure to ensure medical staff approval of an updated blood bank agreement could potentially interrupt the availability of blood products needed for emergencies.

Findings include:

1. Review of the "Blood and Blood Product Full Service Agreement" revealed an agreement date effective on January 1, 2010. The agreement lacked documented approval by the CAH medical staff.

2. Review of the Medical Staff Meeting Minutes from 1/2010 through 7/2011 revealed the medical staff failed to approve the Blood and Blood Product Services Agreement.

3. During an interview on 12/21/11 at approximately 2:00 PM, the Administrator stated the hospital lacked policies addressing the blood bank agreement. Review of a document provided by the Administrator at the time of the interview revealed in part, "...There is not available documentation regarding the approval of the Blood Services Agreement by the Medical Staff." Additionally, the Administrator stated they had placed the Blood Services Agreement on the agenda for medical staff approval at the January 2012 medical staff meeting.

I. Based on observations, document review and staff interviews, the Critical Access Hospital (CAH) maintenance staff failed to ensure patient safety from burns related to hot water temperatures. Problems identified with hot water temperatures in patient care areas on the medical surgical unit. The Administrator identified an average daily census of 1 acute care patient and 2 swing bed patients. At the time of the survey, the patient census included 3 elderly patients (Patients #11, 25 and 42).

Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury is directly related to the temperature and duration of exposure to the water. The length of exposure required for a third degree burn to occur is 1 second at 155 degrees, 2 seconds at 148 degrees, 5 seconds at 140 degrees, 15 seconds at 133 degrees, 1 minute at 127 degrees, and 3 minutes at 124 degrees.

Findings include:

1. Observations during a tour of the medical surgical unit, accompanied by the Acute Care Nurse Manager on 12/19/11 from 2:05 PM to approximately 4:00 PM revealed the following hot water temperatures:

a. Room #2220: 133.2 degrees at 2:48 PM.

b. Room #2204: 134.1 degrees at 2:50 PM.

c. Room #2211: 132.6 degrees at 3:00 PM.

d. Room #2214: 128.7 degrees at 3:10 PM.

e. Room #2212: 128.3 degrees at 3:11 PM.

f. Shower Room #2215: 128.2 at 3:15 PM. The Acute Care Nurse Manager stated patients who have difficulty with showering independently used the shower room at least every other day.

g. Room #2209: 127.4 degrees at 3:20 PM.

h. Room #2208: 127.2 degrees at 3:35 PM

2. During an interview at the time the surveyor took the water temperatures, Maintenance Staff W stated they do not routinely check hot water temperatures in the patient rooms.

3. Review of a document provided by the Facilities Director on 12/20/11 revealed in part, "Previous to 12/19/11 the only policy we had related to hot water temps in plant ops [sic] was for general equipment room checks. I created this policy to specifically address the water temperature issue."

4. Review of policy "Domestic Hot Water Temperature Monitoring" dated 12/20/11 revealed in part, "To ensure the temperature of the hot water at all shower, bathing, and hand washing terminals is limited to a maximum temperature of 120 degrees Fahrenheit to prevent inadvertent scalding...At least once per shift, maintenance staff performs routine checks...including checks of the domestic hot water system for the acute wing of the facility."

5. Review of a document provided by Staff W on 12/21/11 revealed in part, "I had a phone call from [Staff Educator], last month worried about hot water temps in acute care...Upon further inspection we noticed temps in the mid to high 120 degrees...We made adjustments...until they were within the range, I believe around 116 degrees but did not write it down...This week I was made aware of high temps from DIA...we resolved the problem the same way as before but with documentation this time and also monitored more frequently and logged on paper."

6. Review of a document provided by Staff W on 12/21/11 revealed in part, ..."We found a faulty control mixing valve for the Acute/Med-Surg area and replaced it....and added temperature readings to our shift log sheets."

7. Review of a document provided by Staff W on 12/19/11 revealed the following hot water temperatures:

a. Room # 2201: 116.1 degrees at 4:05 PM and 112.3 degrees on 12/20/11 at 7:45 AM.

b. Room #2204: 116.1 degrees at 4:05 PM and 112.3 degrees on 12/20/11 at 7:45 AM.

8. Observations during the environmental tour on 12/20/11 from 1:30 PM to 2:30 PM from 2:05 PM to approximately 4:00 PM revealed the following hot water temperatures:

a. Room #2208: 113.5 degrees at 2:25 PM.

b. Room # 2209: 112.4 degrees at approximately 2:30 PM.



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II. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) surgical services administrative staff failed to ensure surgical services staff used 1 of 1 single patient use bottle of sterile water to humidify oxygen for a single patient in Operating Room #1. The Director of Acute Care Services and Operating Rooms stated the surgical services staff performed approximately 45 surgical procedures per month.

Failure to use a single patient use bottle of sterile water on a single patient could potentially allow micro-organisms to grow in the water, potentially resulting in patients that developed an infection from the micro-organism in the water.

Findings include:

1. Observations during a tour of the Operating Rooms on 12/20/11 at 1:10 PM revealed in 1 of 1 340 mL bottle of sterile water for inhalation connected to the oxygen port on the anesthesia machine in Operating Room #1. The bottle had a handwritten note indicating surgical services staff should change the bottle on 1/15/12.

2. Review of the manufacturer's directions on the bottle of sterile water for inhalation indicated the CAH staff should only use the bottle of sterile water for inhalation for a single patient.

3. During an interview at the time of the tour, the Director of Acute Care Services and Operating Rooms stated the surgical services staff had changed the bottle of sterile water every 30 days, and used the bottle of sterile water on multiple patients. The Director of Acute Care Services and Operating Rooms acknowledged the manufacturer required the surgical services staff to change the bottle of sterile water for inhalation after surgical servies staff used the bottle for a single patient.

Based on document review and staff interview the Critical Access Hospital (CAH) Board of Trustees failed to evaluate the competence of 10 of 11 physicians prior to recredentialing. (C-241)

Based on review of the CAH documents, Emergency Department (ED) clinical records and staff interviews, the Emergency Department staff failed to ensure all ED patients received a medical examination.
(C-241)

The cumulative effect of these systemic failures resulted the CAH's Administrative staff and Board of Trustees inability to assure the provision of quality health care in a safe environment at the CAH.

I. Based on document review and staff interview, the Critical Access Hospital (CAH) Board of Trustees recredentialed 10 of 11 physicians without the required information to evaluate the competency of the physicians. The Administrative Assistant identified 11 practitioners recredentialed since July 2011.

Failure to evaluate a physicians competency could potentially expose patients to inadequate and or inappropriate care.

Findings include:

1. Review of the "Restated Bylaws of the Board of Trustees", revised 1/26/10, revealed in part, "The Bylaws of the Medical Staff shall make provision for at least the following:...The qualifications of the members of the Medical Staff..."

2. Review of the "Bylaws of Medical Staff", approved 1/08, revealed in part, "Each recommendation concerning the reappointment of a practitioner...and clinical privileges to be granted upon reappointment shall be based upon...provision of accurate and adequate information to allow the medical staff to evaluate his competence and qualifications..."

3. Review of the policy "Ongoing Professional Practice (OPPE), dated 7/31/11, revealed in part, "The information resulting from the evaluation will be used to determine whether to continue, limit, or revoke any existing privilege(s).... The OPPE plan form and supporting data gathered during the OPPE process will be filed in the practitioner's peer review file and incorporated into the two-year reappointment process."

4. During an interview on 12/27/11 at 1:40 PM, the Administrator stated that the Board of Trustees relied on the OPPE to determine the competence of the practitioner for reappointment.

5. Review of a list of providers recredentialed since 7/11 revealed:

a. The Medical Staff approved Surgeon I for reappointment to the medical staff on 11/18/11. The Board of Trustees reappointed Surgeon I on 11/22/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

b. The Medical Staff approved Cardiologist J for reappointment to the medical staff on 10/14/11. The Board of Trustees reappointed Cardiologist J on 10/25/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

c. The Medical Staff approved Advanced Registered Nurse Practitioner K for reappointment to the medical staff on 9/16/11. The Board of Trustees reappointed Nurse Practitioner K on 9/27/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

d. The Medical Staff approved Cardiologist L for reappointment to the medical staff on 12/14/11. The Board of Trustees reappointed Cardiologist L on 12/20/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

e. The Medical Staff approved Surgeon M for reappointment to the medical staff on 11/18/11. The Board of Trustees reappointed Surgeon M on 11/22/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

f. The Medical Staff approved Radiologist N for reappointment to the medical staff on 8/12/11. The Board of Trustees reappointed Radiologist N on 8/23/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

g. The Medical Staff approved Cardiologist O for reappointment to the medical staff on 11/18/11. The Board of Trustees reappointed Cardiologist O on 11/22/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

h. The Medical Staff approved Oncologist P for reappointment to the medical staff on 10/14/11. The Board of Trustees reappointed Oncologist P on 10/25/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

i. The Medical Staff approved Cardiologist Q for reappointment to the medical staff on 8/13/11. The Board of Trustees reappointed Cardiologist Q on 8/23/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

j. The Medical Staff approved Radiologist R for reappointment to the medical staff on 11/18/11. The Board of Trustees reappointed Radiologist R on 11/22/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

k. The Medical Staff approved Oncologist S for reappointment to the medical staff on 8/12/11. The Board of Trustees reappointed Oncologist S on 8/23/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

l. The Medical Staff approved Radiologist T for reappointment to the medical staff on 8/12/11. The Board of Trustees reappointed Radiologist T on 8/23/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

m. The Medical Staff approved Pathologist U for reappointment to the medical staff on 8/12/11. The Board of Trustees reappointed Pathologist U on 8/23/11. Documentation review revealed the credential file lacked documented evidence of internal peer review.

6. During an interview on 12/21/11 at approximately 4:10 PM, the Administrator confirmed
that the practitioners credentialed by the Board of Trustees lacked the required OPPE information to allow the Board of Trustees to judge the competency of the practitioner.


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II. Based on review of the Critical Access Hospital (CAH) documents, Emergency Department (ED) medical records, and staff interviews, the ED staff failed to ensure all ED patients received an examination from the ED provider.

Failure to provide an examination for each ED patient resulted in some patients not receiving a medical evaluation in the ED. Concerns identified for 9 of 9 sampled ED patients with MediPass (a type of Medicaid) insurance (Patients # 16, 17, 18, 19, 20, 21, 22, 23 and 24). The ED manager reported a yearly average of approximately 9 MediPass patients.

Findings include:

1. Review of the CAH documents revealed:

a. The By-Laws of the Medical Staff, approved 1/22/2008, revealed a physician, physician assistant, or nurse practitioner must examine all ED patients. The initial medical examination must be performed at the hospital. ED staff may not direct an ED patient to go to a physician's office or clinic without a medical examination.

c. Policy, "Triage and Admission to the Emergency Department," reviewed 2/11, revealed all patients presenting to the emergency department will receive a medical examination.

d. Memo dated February 3, 2006, regarding MediPass Patients, revealed in part, "Effective 2/3/06, when registering MediPass patients, you place a Blue Sticker on the front sheet that the patient takes to the Emergency Room... MediPass is requiring all patients get a referral prior to being treated ..."

e. Staff H, Registered Nurse (RN)/ED manager, presented a document on 12/21/2011 at 2:50 PM, revealed in part, "...If the patient is MediPass, their primary provider is notified of their arrival to the ED..."

2. Review of the ED medical records for Patients #16, 17, 18, 19, 20, 21, 22, 23, and 24 revealed the following information.

a. Patient #16's ED medical record revealed the patient came to the ED on 1/11/11 with complaints of bilateral knee pain from a fall. The patient's discharge assessment revealed in part, "MediPass doctor did not approve ER visit, Transfer to wheel chair, assisted by spouse for follow up in clinic."
The Admission Summary Sheet revealed the patient's insurance as "Consultec/MediPass." The medical record noted the staff notified the ED provider the patient was in the ED but lacked documented evidence the ED provider examined or evaluated the patient ' s condition.

b. Patient #17's ED medical record revealed the grandparents of a 5-month-old patient came to the ED on 10/24/11 with complaints of "cranky, snotty nose and not sleeping well." Discharge assessment revealed in part, "Knowledge deficit related to inappropriate ER use. Condition unchanged...Smiling in parents arms, to office..."
The Admission Summary Sheet revealed the patient's insurance as "Consultec/MediPass." The medical record lacked documented evidence the staff notified the ED provider of the patient's presence in the ED or that the patient received an examination or evaluation of the their condition by the ED provider.

c. Patient #18's ED medical record revealed the patient came to the ED on 11/07/11 with complaints of "pain in right abd (abdominal) with bloating, also diarrhea for a week." The discharge assessment revealed in part, "Go immediately to see provider at office due to MediPass".

The Admission Summary Sheet revealed the patient's insurance as "Consultec/MediPass." The medical record lacked documented evidence the ED staff notified the ED provider patient's presence in the ED or that the patient received an examination or evaluation of the their condition by the ED provider.

d. Patient #19's ED medical record revealed the patient came to the ED on 11/18/11 with complaints of pain that comes and goes and labored respirations. Nursing assessment revealed in part, "Mom returns from registration and patient is MediPass...Patient directed to office for insurance coverage, may be seen in ER and charges will be billed to mom-no coverage for ER."
The Admission Summary Sheet revealed the patient's insurance as "Consultec/MediPass." The medical record revealed the ED staff notified the ED provider, but lacked documented evidence the ED provider provided an examination or evaluated the patient ' s condition.

e. Patient #20's ED medical record revealed a mother and her 8 month old child came to the ED on 11/09/11 after the "child fell from approximately 3 feet from the changing table to carpeted floor...small bruise right eyebrow, small bruise top of head left scalp line, and 1/2 centimeter lac [laceration] across right nares." The discharge assessment revealed in part, "Potential for injury related to fall."
The Admission Summary Sheet revealed the patient's insurance as "Consultec/MediPass." The medical record revealed the ED staff notified the ED provider of the patient's arrival, but lacked documented evidence the ED provider examined or evaluated the patient.

d. Patient #21's ED medical record revealed a mother brought her 13-year-old child to the ED on 12/05/11 with complaints the "child slipped/tripped on rug in art room at school...landing on right arm...pain to right elbow." The Discharge assessment revealed in part, "Potential for injury related to fall."

The Admission Summary Sheet identified the patient's insurance as "Consultec/MediPass." The medical record revealed the staff documented not applicable for ED provider notification. The ED medical record lacked documented evidence showing the ED provider examined or evaluated the patient's condition.

e. Patient #22's ED medical record revealed a parent brought an 11-month-old infant to the ED on 12/06/11 with complaints the "child having trouble pooping. " Nursing assessment revealed in part, "Mother informed MediPass so doctor's office contacted and wants them seen at the office..."

The Admission Summary Sheet identified the patient's insurance as "Consultec/MediPass." The medical record revealed the staff documented "MediPass to office" for ED provider notification. The ED medical record lacked documented evidence the ED provider examined or evaluated the patient.

f. Patient #23's ED medical record revealed the patient came to the ED on 12/07/11 at 7:20 AM with complaints of abdominal pain and pain worse than "10" when it came. Nursing notes revealed in part, "Patient does have Consultec/MediPass, Patient states 'I'm not going there no matter what they say, they can't help me!' I did inform patient that I did have to contact the office when they opened at 8:00 AM for visit approval." Discharge time documented the patient left at 8:25 AM, "ambulatory to clinic."

The Admission Summary Sheet identified revealed the patient's insurance as "Consultec/MediPass." The medical record revealed the staff notified the ED provider of patient's arrival to the ED, but lacked documented evidence the ED provider examined or evaluated the patient

g. Patient #24's ED medical record revealed the patient came to the ED on 12/19/11 with complaints of "left ear pain for one week, but worse today." Nursing assessment revealed in part, "Call to Physician office, visit denied due to MediPass..."
The Admission Summary Sheet revealed the patient's insurance as "Consultec/MediPass." The medical record lacked documented evidence the staff notified the ED provider of patient's arrival to the ED. The ED medical record lacked documented evidence the ED provider examined or evaluated the patient.

3. During an interview on 12/20/2011 at 11:30 AM, with Staff J, Registered Nurse (RN), Staff H, RN and ED manager and the Chief Nursing Officer (CNO) in attendance:
Staff J stated the RN would triage MediPass patients, and then the RN notifies the physician's office for approval of the ED visit. The staff offers to see the patient in the ED, but explains the patient would be responsible for the bill. Staff J stated the ED provider examines and evaluates all patients except for the MediPass patients; the ED staff had to receive approval from the patient's Physician for an ED visit.

Staff H stated the ED routine was for the ED provider to examine all patients and evaluate the patient ' s condition. Staff H stated the ED staff were updating the ED policies to reflect the present routine. Staff H stated the ED provider did a medical evaluation on all patients, except patients with MediPass insurance. The patients with MediPass insurance must have the ED visit approved by their physician. If the physician clinic denied the ED visit, the staff would send the patient to the clinic, and this could be prior the patient receiving a medical evaluation by the ED provider.

The CNO stated the policy that the provider performed the medical evaluation of the patient ' s condition had been in effect since around 2007 when the CAH started to make available 24/7 ED provider coverage.

During an interview on 12/21/11 at 1:30 PM, Staff H stated the ED provider did not always see the patient for a medical evaluation before the staff assisted the patient to the physician ' s clinic.

During an interview on 12/21/11 at 5:00 PM, Provider AAA, Physician Assistant, stated staff would notify him/her when a patient presents to the ED, and he/she gives all patients, regardless of their insurance, a medical screen to assess their medical needs. Provider AAA stated if the ED staff did not notify him/her a patient had arrived in the ED, then a medical evaluation could not be done by the provider.

During an interview on 12/21/11 at 5:45 PM, Staff I, ED RN, stated when the patient or staff takes the patient information to registration, the admitting office will call and inform ED staff the patient had MediPass for insurance. After triage, the nurse calls the patient's physician for ED visit approval, the physician dictated if patient was seen in the ED, or sent to the physician's clinic.

During an interview on 12/22/11 at 8:50 AM, Staff H reviewed all 9 ED medical records, and acknowledged the ED medical records for Patients #16, 17, 18, 19, 20, 21, 22,23, and 24 lacked documented evidence the ED provider saw these patients and/or examined the patient prior to discharge, as per the Medical Staff ByLaws.

Based on document review and staff interview the Critical Access Hospital (CAH) supervising physician failed to review patient medical records in conjunction with 1 of 1 Advanced Registered Nurse practitioner with admitting privileges (ARNP A), and 1 of 1 active Certified Registered Nurse Anesthetist (CRNA B). Additionally, the supervising physician failed to review Emergency Room (ER) patient medical records in conjunction with 1 of 1 nurse practitioner (Practitioner D) and 3 of 3 Physician Assistants (Physician Assistant C, E, F.). The health information manager stated the nurse practitioner admitted approximately 20 patients yearly. The surgical services/inpatient manager stated the CAH staff performed approximately 45 surgical procedures per month. The health information manager stated the ER nurse practitioner provided care to approximately 260 patients a year, Physician Assistant C provided care to approximately 297 patients a year, Physician Assistant E provided care to approximately 577 patients a year, and Physician Assistant F provided care to approximately 89 patients a year.

Failure to review mid-level practitioners medical records could potentially expose patients to inappropriate diagnosis and treatment.

Findings include:

1. Review of policy "Practice Guidelines: Allied Health Practitioners", dated 10/26/11, revealed in part, "Allied Health Practitioners practice with the collaboration/supervision of active medical staff at all times...A review of patient assessment, treatment orders, admission and discharge plans are completed together by the Allied Health practitioner and the collaborating/supervising physician."

2. During and interview on 12/21/11 at 3:25 PM, the Chief Nursing Officer (CNO) verified the supervising physician did not review patient medical records with ARNP A and CRNA B. Additionally, the supervising physician did not review patient medical records with ER mid-level practitioners. The CNO stated the supervising physician does not perform a face to face meeting with mid-level practitioners at all.

3. Review of a document provided by the Quality Coordinator on 12/22/11 revealed in part, "We do not monitor the interaction between the supervising physician and the [mid-level] practitioners in a structured way again it is the assumption [the supervising physicians] are following the bylaws and if there are any deviation [sic] from standards, the supervising physician has made a practice to contact administration with concerns."

Based on document review and staff interview the Critical Access Hospital (CAH) supervising physician failed to review and sign 3 of 7 closed medical records that received care by 1 of 1 Advanced Registered Nurse practitioner (ARNP A). The health information manager stated the nurse practitioner admitted approximately 20 patients yearly.

Failure to review mid-level practitioners medical records could potentially expose patients to inappropriate diagnosis and treatment.

Findings include:

1. Review of the Medical Staff Bylaws, approved 1/22/08, revealed in part, "An allied health professional (AHP) may write orders... an authorized order by an AHP must be countersigned by the responsible supervising practitioner within the time frame required in the position description or defined scope of services and, in all circumstances, 30 days following the patient's discharge."

2. Review of the policy "Practice Guidelines: Allied Health Practioners", dated 10/26/11, revealed in part, "Allied Health Practitioners will have 100% of their inpatient medical records reviewed by their collaborating/supervising physician."

3. Review of the policy "Medical Record Completion", dated 2007, revealed in part, "All medical record entries must be dated, timed and authenticated within 30 days of discharge."

4. Review of a document provided by the Health Information Manager (HIM) revealed in part, "Records are authenticated, dated and timed by Mid-Level Practioner once completed the record is then forwarded to the collaborating physician for review. Review is evidenced by Medical Doctor (MD)/Doctor of Osteopathy (DO) by authenticating, dating and time the Mid-Level Practitioner's entries."

5. During an interview on 12/21/11 at 3:25 PM, the Chief Nursing Officer (CNO) stated the CAH administrative staff expected the supervising physician to review all of the medical records for inpatient admissions by ARNP A. The supervising physician would then sign the medical record.

6. Review of closed medical records on 12/28/11 revealed the following:

a. ARNP A admitted Patient #37 on 7/21/11 for dehydration. ARNP A discharged Patient #37 on 7/24/11. The medical record lacked documented evidence the supervising physician reviewed and signed all ARNP A's medical record entries.

b. ARNP A admitted Patient #38 on 8/9/11 for acute abdominal pain. ARNP A discharged Patient #38 on 8/12/11. The medical record lacked documented evidence the supervising physician reviewed and signed all ARNP A's medical record entries.

c. ARNP A admitted Patient #41 on 6/23/11 for complications of pregnancy. ARNP A discharged Patient #41 on 6/24/11. The medical record lacked documented evidence the supervising physician reviewed and signed all ARNP A's medical record entries.

7. Review of documentation provided by the CNO on 12/22/11 revealed in part, "The records reviewed (Patient #37, #38, and #41) with copies attached lack evidence of ...physician cosigned orders. The policy 'Medical Record Completion' identifies medical record entries needing physician cosignature for mid-level practioners."

8. During an interview on 12/28/11 at noon, Physician H verified they supervised ARNP A. Physician H stated they were responsible for cosigning ARNP A's medical record entries. After reviewing the medical records for Patients #37, #38, and #41, Physician H stated they failed to cosign the medical record entries by ARNP A.

Based on document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 Advanced Registered Nurse practitioner with admitting privileges (ARNP A), and 1 of 1 active Certified Registered Nurse Anesthetist (CRNA B) participated in the review of their patient medical records with the supervising physician. Additionally, administrative staff failed to ensure 1 of 1 Emergency Room (ER) nurse practitioner(ARNP D) and 3 of 3 ER Physician Assistants (Physician Assistant C, E, F) participated in the review of their medical records with the supervising physician.

The health information manager stated the nurse practitioner admitted approximately 20 patients yearly.

The surgical services/inpatient manager stated the CAH staff performed approximately 45 surgical procedures per month that involved CRNA B.

The health information manager stated the ER nurse practitioner provided care to approximately 260 patients a year, Physician Assistant C provided care to approximately 297 patients a year, Physician Assistant E provided care to approximately 577 patients a year, and Physician Assistant F provided care to approximately 89 patients a year.

Failure to participate in the review of medical records with the collaborating/supervising physician could potentially expose patients to inappropriate diagnosis and treatment.

Findings include:

1. Review of policy "Practice Guidelines: Allied Health Practitioners", dated 10/26/11, revealed in part, "Allied Health Practitioners practice with the collaboration/supervision of active medical staff at all times...A review of patient assessment, treatment orders, admission and discharge plans are completed together by the Allied Health practitioner and the collaborating/supervising physician."

2. During an interview on 12/21/11 at 3:25 PM, the Chief Nursing Officer (CNO) verified the supervising physician did not review patient medical records with ARNP A and CRNA B. Additionally, the supervising physician did not review patient medical records with ER mid-level practitioners. The CNO stated the supervising physician does not perform a face to face meeting with mid-level practioners at all.

3. Review of a document provided by the Quality Coordinator on 12/22/11 revealed in part, "We do not monitor the interaction between the supervising physician and the practitioners in a structured way again it is the assumption [the supervising physicians] are following the bylaws and if there are any deviation [sic] from standards, the supervising physician has made a practice to contact administration with concerns."

4. During an interview on 12/28/11 at 8:00 AM, Physician G stated they supervised the supervised the Emergency Room (ER) ARNP D, and Physician Assistants C, E, and F. Physician G said they reviewed the medical records of patients cared for by the mid-level practitioners in the ER, however they did not perform a face to face review with the mid-level practitioners of the medical records.

5. During an interview on 12/28/11 at noon, Physician H verified they supervised ARNP A. Physician H stated they reviewed the medical records of inpatients cared for by ARNP A, however they did not perform a face to face review with ARNP A of the medical records.

6. During an interview on 12/29/11 at 9:00 AM, the Director of Acute Care Services and Operating Room stated a physician did not review the medical records of patients that received care from CRNA B.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 Nurse Practitioner with admitting privileges (Nurse Practitioner A) notified the physician of 4 of 4 selected patients (Patient #32, 37, and 42) directly admitted to the hospital. The Health Information Management director stated the Nurse Practitioner admitted approximately 20 patients to the CAH per year.

Failure to notify the physician when the Nurse Practitioner admitted a patient could potentially result in the physician not knowing about a patient's admission, potentially resulting in the patient needing the advanced knowledge of the physician, and the the physician not providing the additional information.

Findings include:

1. Review of closed medical records on 12/22/11 at 9:00 AM revealed the following:

a. Patient #32 presented to Nurse Practitioner A's office on 2/28/11 complaining of dehydration. Nurse Practitioner A directly admitted Patient #32 to the CAH on 2/28/11 for inpatient treatment. The medical record lacked documentation Nurse Practitioner A notified the collaborating physician of Patient #32's admission to the CAH.

b. Patient #37 presented to Nurse Practitioner A's office on 7/21/11 complaining of dehydration. Nurse Practitioner A directly admitted Patient #37 to the CAH on 7/21/11 for inpatient treatment. The medical record lacked documentation Nurse Practitioner A notified the collaborating physician of Patient #32's admission to the CAH.

c. Patient #42 presented to Nurse Practitioner A's office on 9/9/11 with symptoms of a Congestive Heart Failure Exacerbation. Nurse Practitioner A directly admitted Patient #42 to the CAH on 9/9/11 for inpatient treatment. The medical record lacked documentation Nurse Practitioner A notified the collaborating physician of Patient #42's admission to the CAH.

d. Patient #32 presented to Nurse Practitioner A's office on 11/18/11 complaining of dehydration. Nurse Practitioner A directly admitted Patient #32 to the CAH on 11/18/11 for inpatient treatment. The medical record lacked documentation Nurse Practitioner A notified the collaborating physician of Patient #32's admission to the CAH.

2. Review of the "Practice Guidelines: Allied Health Practitioners", revised 10/26/11, revealed in part, "[Nurse Practitioners] may admit patients from the medical office setting.... The collaborating/supervising MD/DO.'s [sic] clinic is notified immediately when an admission is planned."

3. During an interview on 12/27/11 at 3:00 PM, Nurse Practitioner A stated they did not notify the collaborating physician when they admitted a patient.

4. During an interview on 12/28/11 at 8:00 AM, Physician G stated they provided collaborating physician support to Nurse Practitioner A. Physician G stated the only notification they received if Nurse Practitioner A admitted a patient to the CAH was paperwork from the CAH the next day showing a list of all patients currently admitted at the CAH.

I. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) pharmacy staff failed to ensure the surgical services staff dated vials of paralytic medications when they removed 2 of 2 vials of succinylcholine, and 1 of 1 vial of rocuronium bromide from the refrigerator, and stored them at room temperature. The Director of Acute Care Services and Operating Rooms stated the surgical services staff performed an average of 45 surgical procedures involving anesthesia per month.

Failure to date the vial when anesthesia providers remove succinylcholine and rocuronium bromide vials from the refrigerator to room temperature could potentially result in the paralytic medications that lacked efficacy, required additional doses of anesthesia medications to achieve the required effects, and potentially result in side effects such as prolonged recovery from the medications, or even death.

Findings include:

1. Observations during a tour of the Operating Rooms on 12/20/11 at 1:10 PM revealed 2 Operating Rooms. Observations during a tour of Operating Room #2 revealed 1 of 1 vial of rocuronium bromide and 2 of 2 vials of succinylcholine stored at room temperature in the anesthesia cart.

2. Review of the manufacturer's instructions for rocuronium bromide, not dated, revealed in part, "Rocuronium bromide should be stored in a refrigerator... Upon removal from refrigeration to room temperature storage conditions ... use rocuronium bromide within 60 days."

3. Review of the manufacturer's instructions for succinylcholine, not dated, revealed in part, "Store in refrigerator ... The multi-dose vials are stable for up to 14 days at room temperature..."

4. During an interview at the time of the tour, the Director of Acute Care Services and Operating Rooms acknowledged the vials of rocuronium bromide and succinylcholine lacked the date surgical services staff removed the vials from the refrigerator. The Director of Acute Care Services and Operating Rooms also acknowledged if the staff did not date when they removed the vials from the refrigerator, the staff could not determine if the manufacturer specified storage time at room temperature had elapsed.


II. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) pharmacy and ambulance service administrative staff failed to ensure ambulance staff followed the manufacturer's instructions and limit the time they warmed intravenous fluids in 1 of 1 first out ambulance. The Director of the Emergency Department stated the ambulance service had approximately 1,100 ambulance calls per year.

Failure to limit the time staff warmed intravenous fluids could potentially result in micro-organisms growing in the intravenous fluids, and potentially result in a patient developing a life threatening infection.

Findings include:

1. Observations during a tour of the first out ambulance on 12/20/11 at 3:30 PM revealed 4 bags of 1000 mL intravenous fluid on a warming device. The 4 bags lacked documented evidence of the date ambulance staff placed the bags of intravenous fluids on the warming device. The ambulance staff also lacked a method to monitor the temperature of the warmed intravenous fluids.

2. Review of the manufacturer's directions for the intravenous fluids, dated 12/21/11, revealed in part, "[intravenous] solutions ... can be warmed in their plastic overwraps to temperatures not exceeding ... 104 [degrees Fahrenheit] ... for a period no longer than 14 days."

3. During an interview on 12/21/11 at 3:00 PM, the Pharmacist acknowledged the intravenous fluid manufacturer required the ambulance staff to only warm the intravenous fluids for 2 weeks. The Pharmacist also acknowledged the ambulance staff had failed to document the date they placed the intravenous fluids on the warmer, and could not determine if the manufacturer specified warming time had elapsed. Additionally, the Pharmacist acknowledged the ambulance services staff had failed to monitor the temperature of the warmed intravenous fluids.

Based on document review and staff interview the Critical Access Hospital (CAH) nursing staff failed to notify physicians of medication errors for 4 of 9 medication errors reviewed (Patients #28, 29, 30, and 31), in accordance with facility policy and procedure. The CAH administrative staff reported an average daily census of 1 acute care patient and 2 swing bed patients.

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

Findings included:

1. Review of documentation provided by Pharmacy technician Staff DD, on 12/20/11 at 2:38 PM, revealed in part, ..."Physician is notified of all med errors." Additionally Staff DD reported they did not have a medication error policy.

2. Review of medication error reports revealed:

a. A medication error report dated 2/9/11 revealed a physicians order on 2/6/11 for Flovent inhaler 250 micrograms (mcg) x 2 puffs twice daily (BID). Nursing staff administered 8 doses of Advair diskus 250/50 milligrams (mg) to Patient #28 from 2/6/11 to 2/9/11 without a physicians order. Additionally, nursing staff failed to administer the Flovent inhaler as ordered by the physician.

On 12/21/11 at 1:30 PM, the Quality Coordinator verified nursing staff failed to notify the physician of the medication error and provided documentation of their investigation. Review of the documentation revealed in part, ..."Flovent diskus order upon admission 250 mcg, Advair diskus pulled and given for 8 doses. Potential outcome - per pharmacy - could possibly increase need for short acting rescue inhaler or increased risk of asthma attack."

b. A medication error report dated 11/26/11 revealed a physicians order on 11/22/11 to flush Patient #29's Peripheral Inserted Central Catheter (PICC) with 10 millimeters (ml) of Saline BID and/or after uses (Reminder to flush all lumens after blood draw or use of lumen.) Nursing staff failed to flush Patient #29's PICC line with 10 ml of Saline BID and after blood draw or use of lumen from 11/24/11 to 11/28/11 as ordered by the physician.

On 12/21/11 at 2:50 PM, the Quality Coordinator verified nursing staff failed to notify the physician of the medication error and provided documentation of their investigation. Review of the documentation revealed in part, ..."11-22-11 order written to flush PICC lumens with 10 ml Saline each BID. Also to flush with 10 ml Saline before and after meds/labs draws. Transcribed as BID daily order to (MAR). When MAR changes activity [on 11/24/11], it was written as daily to both lumens - only one time on the MAR. Potential patient outcome - per pharmacy - may increase risk of a 'plugged line' so medication administration would be altered - plugged line could affect condition of PICC line."

c. A medication error report dated 11/21/11 revealed a physicians order on 11/19/11 for Atenolol/Chlorthiadone 100/25 mg daily. Nursing staff administered the medication BID on 11/21/11.

On 12/21/11 at 1:40 PM the Quality Coordinator verified nursing staff failed to notify the physician of the medication error and provided documentation of their investigation. Review of the documentation revealed in part, ..."Atenolol/Chlorthiadone 100/25 mg listed twice on MAR. Original order by [Physician EE] - on hold - put in MAR after being started in am. [Physician RR] ordered again. Order on med sheet and other order on MAR - 2 doses given - only one intended. Potential patient outcome - 1 additional dose - per pharmacy would not affect blood pressure levels to be threatening to life. It may drop pressure to lower than expected."

d. A medication error report dated 5/4/11 revealed a physicians order on 5/4/11 for Potassium Chloride (KCL) 20 milliequivalent (MEQ) now (6:30 PM) and before bedtime. Nursing staff failed to administer one dose of KCL to Patient #31 at bedtime.

On 12/21/11 at 1:40 PM, the Quality Coordinator verified nursing staff failed to notify the physician of the medication error and provided documentation of their investigation. Review of the documentation revealed in part, ..."[Physician K] ordered KCL 20 MEQ now and one at bedtime that same day. Now dose given - med written on MAR as needed (PRN) with 10:00 PM dose to be given - marked. 10:00 PM dose not signed off. Potential patient outcome - per pharmacy 1 missed dose would not affect potassium level to cause life-threatening level. It may show a lower than level potassium level.

I. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) radiology staff failed to follow the manufacturer's recommendation for safety practices when working with disinfecting solutions and test strips. The CAH radiology manager reported radiology staff performed approximately 10 ultrasound probe procedures monthly requiring disinfection of the probes.

Failure to follow the manufacturer's directions to verify the efficacy of the of the disinfecting solution potentially exposed patients to infectious microorganisms.

Findings included:

1. Observations during a tour of the Radiology department on 12/20/11 at 1:55 PM revealed 1 bottle of Metricide OPA solution in the ultrasound examination room. During an interview at the time of the observation, Ultrasound Technician AA said they used the Metricide OPA to soak ultrasound probes between patients. Additionally, Ultrasound Technician AA said they failed to test the solution prior to reuse.

2. Review of the manufacturer's directions for Metricide OPA solution revealed in part, ..."Concentration of this product must be verified by the Metricide OPA test strip prior to each use."

3. Review of documentation provided by the Radiology Manager on 12/21/11 revealed in part, "...No specific policy relating to Metricide OPA. Radiology staff has not been testing efficacy of solution. Going forward... no probes scheduled until testing strips are obtained and solution tested. Ordered on 12/21/11. Log sheet will be made to document testing and changing of solution."


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II. Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) surgical services administrative staff failed to ensure surgical services staff used 1 of 1 single patient use bottle of sterile water to humidify oxygen administered via cannula for a single patient in Operating Room #1. The Director of Acute Care Services and Operating Rooms stated the surgical services staff performed approximately 45 surgical procedures per month.

Failure to use a single patient use bottle of sterile water on a single patient could potentially allow micro-organisms to grow in the water, potentially resulting in patients that developed an infection from the micro-organism in the water.

Findings include:

1. Observations during a tour of the Operating Rooms on 12/20/11 at 1:10 PM revealed 2 Operating Rooms. During the tour of Operating Room #1, observations revealed 1 of 1 340 mL bottle of sterile water for inhalation connected to the external oxygen port on the anesthesia machine in Operating Room #1. The bottle had a handwritten note indicating surgical services staff should change the bottle on 1/15/12. The surgical services staff had connected an oxygen cannula to the bottle of sterile water for inhalation.

2. Review of the manufacturer's directions on the bottle of sterile water for inhalation indicated the CAH staff should only use the bottle of sterile water for inhalation for a single patient.

3. During an interview at the time of the tour, the Director of Acute Care Services and Operating Rooms stated the surgical services staff used an oxygen cannula connected to the sterile water for humidification on patients who underwent an endoscopic examination. The surgical services staff had changed the bottle of sterile water every 30 days, and used the bottle of sterile water on multiple patients. The Director of Acute Care Services and Operating Rooms acknowledged the manufacturer required the surgical services staff to change the bottle of sterile water for inhalation after surgical services staff used the bottle for a single patient.

III. Based on staff interview and document review, the Critical Access Hospital (CAH) infection control staff failed to create a system to monitor and track surgical site infections for 1 year in surgical procedures where the surgeon placed a surgical implant in a patient. The Director of Acute Care Services and Operating Rooms stated the CAH surgical services staff performed approximately 240 surgical procedures per year where the surgeon placed a surgical implant in a patient.

Failure to track surgical site infections for a full year after the surgeon placed a surgical implant in a patient could potentially result in the CAH infection control staff failing to identify all surgical site infections, potentially result in the infection control staff failing to identify a trend in surgical site infections, and intervene to prevent further surgical site infections.

Findings include:

1. During an interview on 12/21/11 at 11:00 AM, the Director of Diagnostic Services stated the CAH's infection control program followed the Center's for Disease Control and Prevention (CDC) recommendations.

2. Review of the CDC's document "Surgical Site Infection (SSI) Event", dated 8/11, revealed in part, "Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure..."

3. Review of the policy "Implant Registry", reviewed 5/11, revealed in part, "The Surgical Department will maintain an Implant Registry logbook..." The policy lacked a requirement for the CAH infection control staff to monitor patients with a surgical implant for a year to determine if the patient developed a surgical site infection.

4. During an interview on 12/21/11 at 11:00 AM, the Director of Diagnostic Services stated at the conclusion of a surgical procedure, the CAH surgical services staff gave the surgeon a form to complete and return to the CAH after the patient's first post-surgical follow-up appointment, to determine if the patient developed a surgical site infection. The CAH infection control staff would not know if the patient developed a surgical site infection in the implant unless the patient happened to return to the CAH for treatment of the infection.

During a further interview on 12/21/11 at 2:30 PM, the Director of Diagnostic Services stated they only tracked surgical surgical site infections from the time of the surgical procedure to the first post-op follow-up appointment, normally within 30 days of the surgery.
The Director of Diagnostic Services stated the system would identify if a patient developed a surgical site infection during the first 30 days after surgery.

The Director of Diagnostic Services stated if a patient developed a surgical site infection after the first post-op follow-up appointment, the infection control staff relied on the physician to inform the infection control staff. The Director of Diagnostic services stated the CAH infection control staff did not have a system to monitor patients after the first post-op follow-up appointment, and would fail to identify a surgical site infection associated with an implant for up to 1 year, as required by the CDC.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) Nutrition Services Manager failed to plan menus with defined food portions for all items on the select therapeutic menus, and failed to plan a non-select menu with defined food portions for patients unable to complete a select menu. The administrative staff reported a census of 3 swing-bed patients, and the Nutrition Services Manager reported the department serves approximately 6-9 patient meals daily.

Failure to provide a planned menu with defined food portions for dietary staff to follow could potentially result in patients receiving inadequate or excess nutrients

Findings include:

1. Review of the policy "Menu Planning", last approved on 9/28/11, revealed in part, "...Specific menus are written by the registered dietitian ... in adequate amounts at each meal to satisfy recommended daily allowances.... Menus are written to include ... amounts consistent with each patient's nutritional needs."

2. Review of the policy "Portion Control", last approved on 9/28/11, revealed in part, " Foods will be served in appropriate amounts as indicated by the therapeutic menu.... The menu should list the specific portion size for each food item. Menus should be available at the trayline for staff to refer to for proper portioning of servings for each diet.... Serving too small of portions results in the patient not receiving the nutrients needed. Servings too large of portions ... gives the patients more food than they need, want, or are allowed to have (in case of special diets)..."

3. Review of the policy "Patients Unable to Make Menu Selections", last approved on 9/28/11, revealed in part, "Purpose: To assure cognitively impaired patients are provided with a nutritionally adequate meal that meets the standards of their diet order... the diet clerk will fill out the menu for the patient by following the non select menu for the diet ordered".

4. Review of the policy "Standardized Recipes", approved on 9/28/11, revealed in part, "...Each standardized recipe will include: ... Portion size".

5. During an interview on 12/19/11 at 2:15 PM, the Nutrition Services Manager reported the CAH nutrition services staff utilized a select patient menu system for therapeutic diets, but did not have planned spreadsheets to define food portion sizes for the food selections. He/she stated the select menu had some defined food potitions on the select menu, and a department policy defined standard portion sizes. The Nutrition Services Manager reported patients unable to make menu selections received one item from each menu category of the select menu that corresponded to the diet order, as selected by the cook.

6. Review of the Nutrition Services Department Policy and Procedure Manual, last approved on 9/28/11, revealed the policy and procedure manual lacked a policy that defined standard portion sizes for foods served to patients.

7. Review of the CAH patient select menus, and recipes, revealed a lack of planned portion sizes for all food items.

8. During an interview on 12/19/11 at 8:00 AM, Cook D reported nutrition services staff had posted a portion reference chart in the kitchen to guide staff on the correct portions sizes to serve, but failed to locate it. Cook D further reported he/she had worked at the facility long enough that he/she had become familiar with the correct portion sizes.

9. During an interview on 12/20/11 at 11:45 AM, Cook C reported nutrition services staff had posted a portion reference chart in the kitchen, but was no longer available. Cook C located a reference chart for fruit juice portions, and reported the select menus specified some of the food portion sizes. Cook C further reported he/she had become familiar with the standard portion sizes over his/her length of employment, and no longer had the need for the reference chart.

10. During an interview on 12/21/11 at 9:50 AM, the Nutrition Services Manager confirmed the CAH nutrition services staff formerly used planned spreadsheets for therapeutic diets until about 2 years ago, when the facility changed to select menus. The Nutrition Services Manager confirmed nutrition services staff ahd posted a portion reference chart to guide staff on the planned portion sizes, but the reference chart was no longer available to staff. He/she acknowledged the system in place lacked clear definition of food portion sizes for all of the menu items.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) surgical services administrative staff failed to ensure 1 of 1 Certified Registered Nurse Anesthetist (CRNA B) and 1 of 1 surgeon (Surgeon BBB) present in the Operating Room (OR) during a surgical procedure that involved a C-Arm Fluoroscope wore a dosimetry badge. The Director of Acute Care Services and Operating Rooms stated the CAH OR staff performed 1 surgical procedure involving the C-Arm Fluoroscope in the prior 2 months.

Failure to provide dosimetry badges for all surgical services staff could potentially result in repeated staff exposure to unsafe levels to unintentional, and unknown amounts of x-rays, which could cause cancer or death.

Findings include:

1. Observations during a tour, on 12/20/11 at 1:10 PM, of the Operating Rooms revealed 1 of 1 C-Arm Fluoroscope in the OR Hallway.

2. Review of the policy "Radiation Protection", reviewed 6/11, revealed in part, "Badges will be worn on all ... anesthesia personnel ... All ... anesthesia personnel will wear badges if they are on duty ... where portable equipment is being used."

3. During an interview at the time of the tour, the Director of Acute Care Services and Operating Rooms stated that during the surgical procedure involving the C-Arm Fluoroscope, CRNA B and Surgeon BBB did not leave the OR while radiology staff operated the C-Arm Fluoroscope. The Director of Acute Care Services and Operating Rooms stated CRNA B and Surgeon BBB did not have a dosimetry badge to wear during surgical procedures that involved the C-Arm Fluoroscope.

Based on document review and staff interview the Critical Access Hospital (CAH) supervising physician failed to date and time all co-signatures of medical record entries in 4 of 4 closed medical records that received care by 1 of 1 Advanced Registered Nurse practioner (ARNP A). The health information manager stated the ARNP admitted approximately 20 patients yearly.

Failure to review the ARNP's medical records could potentially expose patient's to inappropriate diagnosis and treatment.

Findings include:

1. Review of the policy "Medical Record Completion", dated 2007, revealed in part, "All medical record entries must be dated, timed...within 30 days of discharge."

2. Review of closed medical records on 12/28/11 revealed the following:

a. ARNP A admitted Patient #32 on 11/18/11 for dehydration. ARNP A discharged Patient #32 on 11/20/11. The medical record lacked evidence the supervising physician dated and timed their co-signature of all ARNP A's medical record entries.

b. 3 of 3 orders written by ARNP A on 10/22/11 and 10/23/11 for Patient #36 lacked evidence the supervising physician dated and timed when the co-signed all of ARNP A's medical record entries.

c. ARNP A admitted Patient #39 on 3/11/11 for swing bed services following knee surgery. ARNP A discharged Patient #39 on 3/18/11. The medical record lacked evidence the supervising physician dated and timed when they co-signed all of ARNP A's medical record entries.

d. ARNP A admitted Patient #41 on 9/9/11 for treatment of congestive heart failure. ARNP A discharged Patient #41 on 9/16/11. The medical record lacked evidence the supervising physician dated and timed when they co-signed all of ARNP A's medical record entries.

3. During an interview on 12/28/11 at noon, Physician H verified they supervised ARNP A. Physician H stated they were responsible for dating and timing their co-signature of ARNP A's medical record entries.

4. During an interview on 12/28/11 at 2:00 PM, the Chief Nursing Officer acknowledged the medical records for Patient #32, #36, #39, and #40 lacked evidence of the dates and times Physician H co-signed ARNP A's medical record entries.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to prevent unauthorized access to patient records in the medical records department, the record storage area in the basement, the surgical department and in shred bins. The Health Information Manager reported approximately 35,000 to 40,000 medical records in the medical records department, and approximately 2,400 medical records in the basement record storage room. The Radiology Manager reported approximately 50,000 records in the basement record storage room. The Facilities Director reported the CAH had 16 shredding containers. The Director of Acute Care Services and Operating Rooms reported the surgical services staff performed approximately 45 surgical procedures per month.

Failure to secure medical records against unauthorized access could result in identity theft and/or unauthorized disclosure of personal medical information.

Findings include:

1. On 12/20/11 from 1:30 PM to 2:30 PM, during the CAH environment tour, the Facilities Director gained access to the record storage area in the basement. In an interview at the time, the Facilities Director reported medical records, radiology, and maintenance personnel had a key to the record storage area. The Facilities Director further reported medical records, and radiology staff transport their own records to and from the area, and maintenance personnel would only need to access the area in the case of an emergency. Per the Facilities Director, examples of the need to the access included a fire, a water problem, fixing a shelf, etc...

2. On 12/20/11 from 1:30 PM to 2:30 PM, during the CAH environment tour, the Facilities Director, described the procedure for handling protected health information (PHI) in the shred bins, located in various areas throughout the facility. The Facilities Director reported the contracted shredding company goes to each area to empty the bins, or if a bin was filled before their visit, housekeeping staff possessed keys to the bins, and would empty a small locked shredding bin into a large shredding bin.

3. Review of the radiology policy "Shredding", last reviewed in 6/11, revealed in part, "...This shredding shall be unlocked and gathered on a daily basis (or as needed) by the Housekeeping Department and shall be taken to the recycling room..."

4. Review of the Health Insurance Portability and Accountability Act (HIPAA) policy "Protected Health Information - Minimum Necessary Requirement", last approved on 6/29/11, revealed in part, " Policy: Jackson County Regional Health Center shall take reasonable steps to limit the use or disclosure of, and requests for, Protected Health Information (PHI) to the minimum necessary to accomplish the intended purpose.... Jackson County Regional Health Center shall take reasonable steps to limit the use or disclosure of, and requests for, PHI to the minimum necessary to accomplish the intended purpose... Workforce Requirement. Jackson County Regional Health Center must make reasonable efforts to limit workforce access to PHI by identifying the following: ... The persons or classes of persons in its workforce who need access to PHI to carry out their duties.... The category or categories of PHI that each person or class of persons in the workforce needs access to, and any conditions appropriate to such access ..."

During an interview on 12/21/11 at 3:30 PM, the Health Information Manager reviewed these portions of the policy, and acknowledged the facility had not formally defined persons, or classes of persons, who needed access to PHI to carry out their duties.

5. Review of the Health Insurance Portability and Accountability Act (HIPAA) policy "Safeguards for Protecting Protected Health Information", last approved on 6/29/11, revealed in part "... Safeguards should be designed to prevent improper access, use and disclosure by the workforce..."

6. Review of a written statement from the Health Information Manager, regarding HIPAA training, dated on 12/21/11, revealed in part "...The only authorized staff to enter into Medical Records department is through card/badge access which is set up through Environmental Service Department and includes Medical Records staff, Emergency Department nurses, Emergency Medical Technicians/paramedics, Administration and Environmental staff . . ."

During an interview on 12/21/11 at 3:30 PM, the Health Informaition Manager provided clarification on the written communication and reported the reference to Environmental Services included maintenance and housekeeping. The Health Information Manager further reported housekeeping cleaned the area, during the day when medical records staff were present, but confirmed access to the area could occur during any time of the day. He/she reported they had the ability to run a report that would provide a list of staff who accessed the area, but had not done so. The Health Information Manager acknowledged housekeeping staff did not really need independent access to the medical records department, and could access the area by knocking, like other unauthorized staff are required to do.

7. During an interview on 12/20/11 at 3:10 PM, the Health Information Manager acknowledged housekeeping employees, and maintenance employees, did not need to access medical records, or other PHI, in order to carry out their job requirements.

8. During an interview on 12/21/11 at 9:00 AM, the Facilities Director confirmed all the maintenance staff possessed keys to the basement record storage area, and possessed badge access to the Medical Records Department. The Facilities Director reaffirmed the need for maintenance staff to have the ability to access all areas in the hospital in case of an emergency, but acknowledged the maintenance staff lacked the ability to access the pharmacy.

9. During an interview on 12/21/11 at 4:00 PM, the Facilities Director reported the day shift housekeeper was scheduled to clean the Medical Records Department on Monday through Friday. The Facilities Direcor reported the maintenance department had given housekeeping staff badge access to the area for the convenience of going in and out while cleaning, without having to knock. In a follow-up interview at 4:25 PM, the Facilities Director confirmed the day shift housekeeper ,and two housekeepers trained for back-up, possessed badge access to the Medical Records Department. The Facilities Director reported he/she deleted the badge access for the two back-up housekeepers.

10. During an interview on 12/21/11 at 4:45 PM, the Director of Human Resources reported individual departments developed job descriptions for their employees, and confirmed the job descriptions did not contain specific disclosure of the need to access PHI.

11. Observations during a tour of the Surgical Services Department on 12/20/11 at 1:10 PM, revealed 6 of 6 patient medical records sitting on a cart in the Operating Room Hallway. Review of the medical records revealed the records contained the patient's name, date of service, and scheduled surgical procedure.

Additional observations during the tour revealed the following items accessable in Operating Room (OR) #2:

a. a log book labeled "Eye Implants", that contained approximately 150 patients' medical information. Further review of the log book revealed each medical record contained the patient's name, date of birth, date of service, surgical procedure performed, and insurance type.

b. a log book labeled "Implant Log", that contained 111 patients' medical information. Further review of the log book revealed each medical record contained the patient's name, date of birth, date of service, surgical procedure performed, and insurance type.

c. a log book labeled "OR Log", that contained 760 patients' medical information. Further review of the log book revealed each medical record contained the patient's name, date of service, and surgical procedure performed.

d. a log book labeled "Recovery Log", that contained 750 patients' medical information. Further review of the log book revealed each medical record contained the patient's name, surgical procedure, date of service, and any problems during the recovery period.

e. a log book labeled "Follow Up Log", that contained 20 patients' medical information. Further review of the log book revaled each medical record contained the patient's name, date of birth, date of service, surgical procedure performed, and problems during the patient's recovery period.

3. During an interview at the time of the tour, the Director of Acute Care Services and Operating Rooms stated the housekeeping staff cleaned the operating rooms after the surgical services staff had left for the day. The Director of Acute Care Services and Operating Rooms acknowledged if the housekeeping staff cleaned the surgical services department after surgical services staff had left for the day, the housekeeping staff could potentially access the log books and charts in the department. Additionally, the Director of Acute Care Services and Operating Rooms stated the housekeeping staff did not need access to the information in the log books and charts to perform their job.

Based on document review and staff interview the Critical Access Hospital (CAH) Administrative, Quality, and Credentialing staff failed:

To have systems in place to evaluate physicians for quality and appropriateness of diagnosis and treatment of patients. (C-340)

To ensure 10 of 11 physicians received internal peer review prior to recredentialing by the medical staff and Board of Trustees after July of 2011. (C-333)

To perform a peer review from a source outside the CAH for 41 of 41 physicians. (C-340)

The cumulative effect of these systemic failures resulted in the CAH ' s Administrative staffs ' inability to appropriately review and evaluate physicians and take corrective action related to the quality of care.

Based on document review and staff interview the Critical Access Hospital (CAH) administrative and quality staff failed to ensure an internal peer review occurred for 10 of 11 physicians during the two-year reappointment process after July of 2011.

Failure to perform internal peer review could potentially result in the medical staff and Board of Trustees approving a physician without information to evaluate competency and appropriateness of care provided to the patients.

Findings include:

1. Review of documentation provided by the Administrator on 12/21/11 revealed in part, "... Jackson County Regional Health Center (JCRHC) utilizes review of a range of quality data to review practioner's performance while on staff at JCRHC. This is accomplished through the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes outlined in supplemental medical staff policies."

2. Review of policy "Ongoing Professional Practice (OPPE)" dated 7/31/11, revealed in part, a. ..."A process for summary of ongoing data to be collected and documented for the purpose of assessing a practioner's clinical competence...data will be collected through...record review and monitoring of diagnostic and treatment techniques...the information gathered during this process will factor into decisions to maintain, revise, or revoke an existing privilege and/or privilege...The OPPE Plan Form and supporting data gathered during the OPPE process will be filed in the practioner's peer review file and incorporated into the two year reappointment process."...FPPE: A process whereby the organization evaluates the privilege-specific competence of practitioners for initially requested privileges for a period of time and/or when issues affecting the provision of safe, high-quality patient care are identified."

3. During an interview on 12/20/11 at 4:04 PM, the Administrator, Administrative Assistant and Quality Coordinator stated they do not complete internal peer reviews unless a quality trigger indicating a question or issue related to the provision of patient care when medical records and utilization staff review the patient's chart . The administrator said if the quality triggers were triggered the quality staff would initiate an OPPE form to identify any "deviations from the norm [sic]" for all physicians who practiced at the hospital. Additionally, the administrator stated the medical records of the 10 physicians reviewed by the medical records and utilization staff, lacked quality triggers that would activate the completion of the OPPE form by administrative and/or quality staff. The administrator confirmed the credential files for the 10 physicians identified lacked internal peer reviews.

4. Review of a list or providers recredentialed since 7/11 revealed:

a. The Medical Staff recommended Physician I, for reappointment to the medical staff on 11/18/11. The Board of Trustees reappointed Physician I on 11/22/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

b. The Medical Staff recommended Physician J, for reappointment to the medical staff on 10/14/11. The Board of Trustees reappointed Physician J on 10/25/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

c. The Medical Staff recommended Physician K, for reappointment to the medical staff on 9/16/11. The Board of Trustees reappointed Physician K on 9/27/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

d. The Medical Staff recommended Physician L, for reappointment to the medical staff on 12/14/11. The Board of Trustees reappointed Physician L on 12/20/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

e. The Medical Staff recommended Physician M, for reappointment to the medical staff on 11/18/11. The Board of Trustees reappointed Physician M on 11/22/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

f. The Medical Staff recommended Physician N, for reappointment to the medical staff on 8/12/11. The Board of Trustees reappointed Physician N on 8/23/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

g. The Medical Staff recommended Physician O, for reappointment to the medical staff on 11/18/11. The Board of Trustees reappointed Physician O on 11/22/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

h. The Medical Staff recommended Physician P, for reappointment to the medical staff on 10/14/11. The Board of Trustees reappointed Physician P on 10/25/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

i. The Medical Staff recommended Physician Q, for reappointment to the medical staff on 8/13/11. The Board of Trustees reappointed Physician Q on 8/23/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

j. The Medical Staff recommended Physician R, for reappointment to the medical staff on 11/18/11. The Board of Trustees reappointed Physician R on 11/22/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

k. The Medical Staff recommended Physician S, for reappointment to the medical staff on 8/12/11. The Board of Trustees reappointed Physician S on 8/23/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

l. The Medical Staff recommended Physician T, for reappointment to the medical staff on 8/12/11. The Board of Trustees reappointed Physician T on 8/23/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

m. The Medical Staff recommended Physician U, for reappointment to the medical staff on 8/12/11. The Board of Trustees reappointed Physician U on 8/23/11. Documentation review revealed the credential file lacked evidence of competence based OPPE review form and an internal peer review to evaluate competency and appropriateness of care provided to the patients.

4. During an interview on 12/21/11 at approximately 4:10 PM, the Administrator verified administrative and quality assurance staff failed to their systems [i.e.: FPPE and/or OPPE] for evaluating the physicians for competency and appropriateness of care provided to patients.

I. Based on review of the Critical Access Hospital (CAH) documents and staff interviews, the Emergency Department (ED) manager failed to follow the Quality Improvement (QI) process to address concerns about the CAH's process when patients covered by MediPass (a type of Medicaid) arrive at the ED.

Failure to follow the QI process resulted in separate process for ED patients with MediPass and ED patients with other types of insurance to receive care in the ED.

Concerns identified for 9 of 9 ED clinical record with MediPass insurance (Patients # 16, 17, 18, 19, 20, 21, 22, 23 and 24) reviewed. The ED manager reported a yearly average of approximately 9 MediPass patient.

Findings include:

1. "Review of the Quality Improvement (QI) Plan," revised 12/2/1010, revealed in part, "The quality improvement plan is to continuously improve the quality of care provided...through a systematic process of...identifying problems...related to patient care...
Department Directors/Managers are assigned the responsibility and accountability for implementing and documenting appropriate quality measures that establish improvement outcomes for their area of operations... "

2. Review of ED clinical records revealed Patients #16, 17, 18, 19, 20, 21, 22, 23 and 24 came to the ED and their admission summary sheet revealed the patients had Consultec/MediPass insurance. Patients #16, 17, 18, 19, 20, 21, 22, 23 and 24's ED medical records lacked evidence showing the patients received an examination and evaluation prior to their discharge from the ED. (refer to C-241, section II)

3. During an interview on 12/20/11 at 11:30 AM, the ED Nurse Manager, stated the ED provider normally evaluates and examines all ED patients except those with Medipass insurance. The CAH requires all ED patients with MediPass have their ED care approved by their own physicians prior to any evaluation or examination by the ED provider.

During a follow up interview on 12/21/11 at 1:30 PM, the ED Nurse Manager stated he/she spoke with an ED provider about the concern with separate process for ED patients with MediPass insurance. The ED Nurse Manager stated, "I am aware of the QI process, but since this had been the routine in the ED, I did not report this concern to the QI committee."



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II. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to develop a list of patient related events common to services provided to CAH patients that would identify areas of concerns with the physicians practice in 6 of 9 areas of potential peer review criteria. The CAH administrative staff identified approximately 115 members on the medical staff.

Failure to develop a list of common patient related events for peer review could potentially result in the CAH staff failing to identify inappropriate or ineffective patient care practices by the medical staff. The inappropriate or ineffective care could potentially result in patients receiving substandard care.

Findings include:

1. Review of the "PEER REVIEW LIST", dated 7/08, revealed the criteria for peer review in the surgical setting included "Organization operates on the wrong side of the individual's body. A foreign body, such as a sponge or forceps that was left in an individual after surgery. Injury to organ or body part during [operating room] or other procedure... Unexpected return to operating room or procedure room. Acute [heart attack] within 48 hours of anesthesia."

2. During an interview on 12/28/11 at 12:35 PM, the Health Information Management (HIM) Manager, and the Quality Improvement (QI) Director acknowledged due to the low volume of patients seen at the CAH, many of the events that would trigger peer review of a patient's medical records would never occur at the CAH. The HIM Manager and QI Director acknowledged they had not sent a medical record for physician peer review because an event triggered the peer review process.

Additionally, the HIM Manager and QI Director stated the physicians had participated in developing the triggers for peer review. However, the physicians at the CAH had not developed triggers to catch more common events at the CAH.

Based on document review and staff interview, the Critical Access Hospital (CAH) Quality Improvement department failed to include 1 of 1 Magnetic Resonance Imaging (MRI) contracted service and 1 of 1 Nuclear Medicine contracted service in the CAH wide Quality Improvement program. The Director of Diagnostic Services stated the contracted MRI service performed 370 MRI procedures per year, and the contracted Nuclear Medicine service performed 40 Nuclear Medicine procedures per year.

Failure to include all contracted services in the CAH wide Quality Improvement program could potentially result in CAH Quality Improvement staff failing to identify trends in the contracted services that could potentially result in patients receiving inappropriate care or treatment.

Findings include:

1. Review of the Quality Improvement committee meeting minutes from 3/24/11 to 11/17/11 revealed the meeting minutes lacked documented evidence the contracted MRI service and Nuclear Medicine reported quality improvement data to the Quality Improvement committee.

2. Review of the policy "Quality Improvement Plan", revised 12/2/10, revealed in part, "... Assure that the improvement process is hospital wide..."

3. During an interview on 12/21/11 at 2:30 PM, the Director of Diagnostic Services stated the radiology department used to report Quality Improvement data for the contracted MRI and Nuclear Medicine services to the Quality Improvement committee. The contracted services continued to send the radiology department quality improvement data. The radiology department staff reviewed the quality improvement data from the contracted services when they received it from the contracted services. However, the radiology department only would report Quality Improvement data for the contracted MRI and Nuclear Medicine services to the Quality Improvement committee if the radiology department had a problem with the contracted services.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a system was in place for a physician to review the medical records of patients that received care from 1 of 1 active Certified Registered Nurse Anesthetist (CRNA B). The Director of Acute Care Services and Operating Rooms (ACS and OR) stated CRNA B provided care to approximately 45 patients per month.

Failure to ensure a physician reviewed the records of the CRNA could potentially result in the CRNA providing inappropriate care.

Findings include:

1. Review of CRNA B's credential file on 12/21/11 revealed the credential file lacked documented evidence a physician reviewed the care CRNA B provided to patients at the CAH.

2. Review of the policy "Practice Guidelines: Allied Health Practitioners", revised 10/26/11, revealed the policy lacked a requirement for a physician to review the care provided by a CRNA to patients at the CAH.

3. During an interview on 12/29/11 at 8:50 AM, the Director of Acute Care Services (ACS) and Operating Rooms (OR) stated 1 CRNA, CRNA B, provided care to patients at the CAH. The Director of ACS and OR stated the CAH administrative staff did not have an internal, nor external, physician review the care CRNA B provided to patients at the CAH for quality and appropriateness of the diagnosis and treatment.

Based on document review and staff interview the Critical Access Hospital (CAH) administrative, quality assurance and credentialing staff failed to ensure a peer review by an outside entity occurred for 41 of 41 physicians as required. The Quality Coordinator identified approximately 1,571 outpatients, and 46 inpatients receiving services at the CAH monthly.

Failure to ensure all medical staff members received outside peer review affects the CAH's ability to assure physicians provide quality care to the CAH's patients.
Findings include:

1. During an interview on 12/21/11 at 7:30 AM, the Quality Coordinator said the hospital quality staff did not perform outside peer reviews for current medical staff members.

2. Review of documentation provided by the administrator on 12/21/11, revealed in part, " Jackson County Regional Health Center changed its policy on completion of random, periodic peer review of practitioners in January 2011 ...The Medical Staff stated they believed it no longer necessary to complete a random, periodic review as a practitioner quality check. "

3. During an interview on 12/21/11, at approximately 3:30 PM, the Administrator stated the hospital did not complete outside peer reviews on any current medical staff members. During a follow up interview on 12/27/11 at 3:05 PM, the administrator said "We are not performing external peer reviews on any physicians at our hospital during the 2 year reappointment process and have not since January 2011. "

4. Review of Medical "Staff Roster" dated 12/22/11 revealed the following information.

a. The Board of Trustees reappointed General Surgeon V on 11/24/10. Documentation review revealed the credential file lacked an outside peer review.

b. The Board of Trustees reappointed Otolaryngologist I on 11/23/11. Documentation review revealed the credential file lacked an outside peer review.

c. The Board of Trustees reappointed Ophthalmologist W on 11/23/10. Documentation review revealed the credential file lacked an outside peer review.

d. The Board of Trustees reappointed Cardiologist J on 10/26/11. Documentation review revealed the credential file lacked outside peer review.

e. The Board of Trustees reappointed Family Practice Physician G on 3/22/11. Documentation review revealed the credential file lacked an outside peer review.

f. The Board of Trustees reappointed Pathologist Y on 2/22/11. Documentation review revealed the credential file lacked an outside peer review.

g. The Board of Trustees reappointed Podiatrist AAA on 3/25/11. Documentation review revealed the credential file lacked an outside peer review.

i. The Board of Trustees reappointed Pathologist Z on 3/22/11. Documentation review revealed the credential file lacked an outside peer review.

j. The Board of Trustees reappointed Family Practice Physician AA on 7/24/10. Documentation review revealed the credential file lacked an outside peer review.

k. The Board of Trustees reappointed Radiologist BB on 3/22/11. Documentation review revealed the credential file lacked an outside peer review.

l. The Board of Trustees reappointed Ophthalmologist M on 11/23/11. Documentation review revealed the credential file lacked an outside peer review.

m. The Board of Trustees reappointed Cardiologist CC on 2/13/10. Documentation review revealed the credential file lacked an outside peer review.

n. The Board of Trustees reappointed Urology Surgeon DD on 1/27/11. Documentation review revealed the credential file lacked an outside peer review.

o. The Board of Trustees reappointed Family Practice Physician EE on 4/2/11. Documentation review revealed the credential file lacked an outside peer review.

p. The Board of Trustees reappointed Cardiologist FF on 1/31/11. Documentation review revealed the credential file lacked an outside peer review.

q. The Board of Trustees reappointed Radiologist N on 8/23/11. Documentation review revealed the credential file lacked an outside peer review.

r. The Board of Trustees reappointed Rheumatologist GG on 1/25/11. Documentation review revealed the credential file lacked an outside peer review.

s. The Board of Trustees reappointed Cardiologist O on 11/23/11. Documentation review revealed the credential file lacked an outside peer review.

t. The Board of Trustees reappointed Oral Surgeon HH on 12/8/10. Documentation review revealed the credential file lacked an outside peer review.

u. The Board of Trustees reappointed Oncologist P on 10/25/11. Documentation review revealed the credential file lacked an outside peer review.

v. The Board of Trustees reappointed Emergency Room Physician II on 8/25/09. Documentation review revealed the credential file lacked an outside peer review.

w. The Board of Trustees reappointed Cardiologist JJ on 2/17/11. Documentation review revealed the credential file lacked an outside peer review.

x. The Board of Trustees reappointed Emergency Room Physician KK on 4/26/11 Documentation review revealed the credential file lacked an outside peer review.

y. The Board of Trustees reappointed Cardiologist LL on 5/25/10. Documentation review revealed the credential file lacked an outside peer review.

z. The Board of Trustees reappointed Internal Medicine Physician MM on 3/23/11. Documentation review revealed the credential file lacked an outside peer review.

aa. The Board of Trustees reappointed Orthopedic Surgeon NN on 2/24/11. Documentation review revealed the credential file lacked an outside peer review.

bb. The Board of Trustees reappointed Emergency Room Physician OO on 1/25/11. Documentation review revealed the credential file lacked an outside peer review.

cc. The Board of Trustees reappointed Family Practice Physician PP on 12/15/10. Documentation review revealed the credential file lacked an outside peer review.

dd. The Board of Trustees reappointed Emergency Room Physician QQ on 7/31/10. Documentation review revealed the credential file lacked an outside peer review.

ee. The Board of Trustees reappointed Family Practice Physician RR on 9/11/10. Documentation review revealed the credential file lacked an outside peer review.

ff. The Board of Trustees reappointed Orthopedic Surgeon SS on 3/20/11. Documentation review revealed the credential file lacked an outside peer review.

gg. The Board of Trustees reappointed Cardiologist TT on 8/23/11. Documentation review revealed the credential file lacked an outside peer review.

hh. The Board of Trustees reappointed Oncologist S on 8/23/11. Documentation review revealed the credential file lacked an outside peer review.

ii. The Board of Trustees reappointed Psychiatrist UU on 12/21/10. Documentation review revealed the credential file lacked an outside peer review.

jj. The Board of Trustees reappointed Neurologist VV on 12/15/10. Documentation review revealed the credential file lacked an outside peer review.

kk. The Board of Trustees reappointed Family Practice Physician WW on 10/25/11. Documentation review revealed the credential file lacked an outside peer review.

ll. The Board of Trustees reappointed Urology Surgeon XX on 11/19/10. Documentation review revealed the credential file lacked an outside peer review.

mm. The Board of Trustees reappointed Family Practice Physician H on 11/20/10. Documentation review revealed the credential file lacked an outside peer review.

nn. The Board of Trustees reappointed Nephrologist YY on 6/24/10. Documentation review revealed the credential file lacked an outside peer review.

oo. The Board of Trustees reappointed Oral Surgeon ZZ on 1/23/11. Documentation review revealed the credential file lacked an outside peer review.

5. During a follow up interview on 12/27/11 at 3:05 PM, the administrator and Quality Coordinator verified the physicians identified on the Medical Staff Roster lacked a system for peer review by an outside or external entity.

Based on review of policies, Swing Bed clinical records, and staff interviews, the Critical Access Hospital (CAH) Interdisciplinary Team failed to ensure the attending physician participated in the care conferences for the development of the patient's individualized care plan.

Failure for the Interdisciplinary Team to include the attending physician could result in a lack of individualized care plan that met all the patients' medical and psychological needs of the Swing Bed patients. The lack of the attending physician's knowledge of the patient for the individualized care plan could lead to the neglect of a patient's mental and psychosocial needs that could enhance healing and lessen the stay at the hospital.

The CAH administrative staff reported a census of 3 Swing Bed patients, with a weekly average of 2 Swing Bed patients.

Concerns noted for 1 of 1 Swing Bed in-patient (Patient #11) and 4 of 4 closed Swing Bed patients (Patient #12, 13, 14, and 15) with stays in the CAH that included a Wednesday, the scheduled time of a weekly care conference.


Findings include:

1. The CAH staff used policies and procedures to provide guidance to the staff for consistency and continuity of patient care. Review of these policies and procedure revealed the following information.

a. "Provision of Social Services", revised 7/09, revealed in part, "...These care conferences will include the patient family members when possible nursing and social work staff and other ancillary departments providing services..." The Care Conference is a patient-center process by an Interdisciplinary Team, consisting of the attending physician, registered nurse with responsibility for the patient, other appropriate staff as determined by patients' needs, the patient, family, and/or patient legal representative, assessed each Swing Bed patient's individual needs and create a plan of care that enhanced healing and to lessen the patient ' s stay at the hospital

b. "Care plans", revised 10/09, revealed in part, "...ensure implementation of the practitioner's plan for medical care..."

2. Review of Swing Bed patient medical records revealed the following information.

a. Open medical record for Patient #11 revealed an admission on 12/11/11 due to renal failure, generalized weakness, and anemia. A review of the medical record revealed a care conference held on 12/14/11, but lacked documented evidence Patient #11 ' s Physician participated in the conference or the staff informed the physician on the care plan developed at the care conference.

During an interview on 12/19/11 at 2:10 PM, Registered Nurse (RN) F reviewed Patient #11's clinical record, and acknowledged the record lacked documented evidence the physician participated in the care conference or the staff informed the physician on the patient's care plan.

b. Closed medical record for Patient #12 revealed an admission on 8/27/11 for intravenous antibiotic treatment. A review of the medical record revealed a care conference held on 8/31/11 and 9/7/11, but lacked documented evidence Patient #12 ' s Physician participated in the conference or the staff informed the physician on the care plan developed at the care conference.

During an interview on 12/21/11 at 2:00 PM, RN G reviewed Patient #12's clinical record, and acknowledged the record lacked documented evidence the physician participated in the care conference or the staff informed the physician on the patient's care plan.

c. Closed medical record for Patient #13 revealed an admission on 10/17/11 for intravenous antibiotic treatment and respiratory therapy. A review of the medical record revealed a care conference held on 10/19/11, but lacked documented evidence Patient #13 ' s Physician participated in the conference or the staff informed the physician on the care plan developed at the care conference.

During an interview on 12/21/11 at 2:05 PM, RN G reviewed Patient #13's clinical record and acknowledged the record lacked documented evidence the physician participated in the care conference or the staff informed the physician on the patient's care plan.

d. Closed medical record for Patient #14 revealed an admission on 10/5/11, for intravenous antibiotic treatment due to an infection from hip surgery. A review of the medical record revealed a care conference held on 10/12/11 and 10/19/11, but lacked documented evidence Patient #14 ' s Physician participated in the conference or the staff informed the physician on the care plan developed at the care conference.

During an interview on 12/21/11 at 2:10 PM, RN G reviewed Patient #14's clinical record and acknowledged the record lacked documented evidence the physician participated in the care conference or the staff informed the physician on the patient's care plan.

e. Closed medical record for Patient #15 revealed an admission on 6/21/11 for intravenous antibiotic treatment due to pneumonia. A review of the medical record revealed a care conference held on 6/22/11, but lacked documented evidence Patient #15 ' s Physician participated in the conference or the staff informed the physician on the care plan developed at the care conference.

During an interview on 12/21/11 at 2:15 PM, RN G reviewed Patient #15's clinical record and acknowledged the record lacked documented evidence the physician participated in the care conference or the staff informed the physician on the patient's care plan.

3. During an interview on 12/19/11 at 2:10 PM, RN F stated the staff did not invite the patient's physician to weekly Care Conferences held on Wednesdays. RN F stated the staff did not call or inform the physician about the Patient's Care Plan.

During an interview on 12/21/11 at 2:05, RN G stated, "I would be surprised" if staff documented physician notification of the care plan in the medical record. RN G stated, "I have never reviewed the [patient's] care plan with the Physician."