HospitalInspections.org

Based on observation and staff interview, the CAH (Critical Access Hospital) failed to keep the hallway by radiology clean and free of construction dust and debris and failed to keep the portable X-ray machine free of construction dust. Census on the first day of survey was 3 acute care inpatients and 1 swingbed patient. Findings include:

A. On 6/7/11 from 2:40 PM to 3:00 PM Radiology Technologist N was observed returning the portable X-ray machine to the storage area in the West hallway. Radiology Technologist N was observed wiping off the knobs on the control panel with disinfectant wipes after using the portable X-ray machine for a patient in the emergency department. The control panel for this machine appeared to be dusty even after the knobs were wiped off. When the surveyor wiped fingers across the control panel fingers had white residue on them. Surveyor's finger wipes were observable in the dust remaining on the control panel.

B. On 6/7/11 from 2:40 PM to 3:00 PM observation in the hallway outside the radiology department revealed a blue rug that was soiled with small white particles of drywall and a white powder substance. The wall to the west of the door leading into the radiology department was under repair/remodeling.

C. Interview with the Radiology Director on 6/7/11 from 2:40 PM to 3:00 PM revealed that the day before (6/6/11) they had been working on the wall to create a door for a storage area in the West hallway and confirmed that the area and X-ray machine needed to be cleaned.

Based on review of Practitioner Credential files, review of Medical Staff Bylaws, review of the Credentialing Agreement, review of Medical Staff meeting minutes and Governing Body meeting minutes and staff interview, the CAH failed to follow the Medical Staff Bylaws and the Credentialing Agreement by not:
- Ensuring that the Medical Staff reviewed and made recommendations for the appointment/reappointment of practitioners applying/reapplying for membership on the Medical Staff prior to the Governing Body approving appointment to the Medical Staff for 3 of 7 credential files reviewed (Practitioners D, F and G);
- Ensuring that the Medical Staff meeting minutes reflected the recommendation for appointment/reappointment of practitioners and that the Governing Body meeting minutes reflected appointment/reappointment of practitioners to the Medical Staff for 4 of 7 credential files reviewed (Practitioners A, B, C and E).
- Ensuring that the credential files included privileges specific for Morrill County Community Hospital for 6 of 7 credential files reviewed (Practitioners A, B, D, E, F and G);
- Ensuring that the credential file for 1 of 7 Practitioners reviewed (Practitioner B) contained a signed application for membership and contained evidence of investigating the education and background for this practitioner;
- Ensuring that 1 of 7 credential files reviewed contained evidence of professional competence, clinical judgement and relations with staff, physicians and patients in the CAH (Practitioner D);
- Ensuring that 3 of 7 credential files contained evidence of current Liability Insurance (Practitioners E, F and G); and,
- Ensure that 1 of 7 credential files contained evidence of the practitioner having a current license to practice in the State of Nebraska (Practitioner E);

The list of members on the Medical Staff provided by the CAH contained 131 physicians and/or allied health practitioners. Findings include:

A. Review of the Medical Staff Bylaws approved by the Governing Body on 6/1/09 revealed the following concerning appointments to the Medical Staff under Article III, Section C, "The Board of Trustees shall act on appointments only after there has been a recommendation from the Medical Staff..." Further review of the Medical Staff Bylaws revealed the following concerning reappointments to the Medical Staff under Article VI, Section B "...the Medical staff shall review the application and act to recommend, or not to recommend, appointment to the Medical staff and the privileges to be granted....When the recommendation of the Medical staff is favorable to the applicant, the hospital Administrator shall promptly forward the application, together with all supporting documentation, to the Board of Trustees."

Review of the Board of Directors Monthly Meeting minutes date 6/15/10 revealed the following: "June appointments were presented. See attachment." A motion was made and seconded to approve the attached appointments. Practitioners D, F and G were included on the attachment along with 20 other practitioners. Review of the Medical Staff meeting minutes dated 7/26/10 revealed under the section titled Credentialing that a motion was made and seconded "to accept those presented for appointment and reappointment to the medical staff. Motion carried. Please see attached list of physicians." The attached list was the same list attached to the Board of Directors meeting minutes dated 6/15/10. he Governing Body acted on these appointments/reappointments 41 days prior to recommendation from the Medical Staff.

Interview with the Administrator and Administrative Assistant on 6/8/11 from 11:20 AM to 12:15 PM and 1:50 PM to 3:05 PM confirmed the above information for Practitioners B, C and E.

B. Review of the credential files for Practitioners A, B, C and E revealed no information in the file concerning when the Medical Staff had last made the recommendation for appointment/reappointment to the Medical Staff or when the Governing Body had last approved the appointment to the Medical Staff.

Interview with the Administrator and Administrative Assistant on 6/8/11 from 11:20 AM to 12:15 PM and 1:50 PM to 3:05 PM revealed the following:
- Were unable to provide the Medical Staff meeting minutes where Practitioners A, B, C and E were recommended by the Medical Staff for appointment/reappointment to the Medical Staff;
- Were unable to provide the Governing Body meeting minutes where Practitioners A, B, C and E were approved for appointment/reappointment to the Medical Staff;
- Practitioners B and C are employed by the CAH;
- Practitioner C was not reviewed by the Medical Staff for reappointment because it would be like appointing self (the list of Active Medical Staff listed 3 other Active members);
- Practitioner C receives an annual evaluation by the Board at which time salary increase is approved and that they thought this evaluation satisfied reappointment to the Medical Staff;
- Indicated that Practitioner B was hired by the CAH and that the Board approved and signed the contract during the 4/20/10 meeting and started on 9/22/10;
- Indicated that Practitioner A was initially appointed to the Medical Staff in 2009 but also retired from practicing later in 2009 and then came back to the hospital even later in 2009; however, no specific dates were available for these changes.

Review of the Board of Directors meeting minutes dated 5/17/11 revealed that Practitioner C received an "annual evaluation" with approval for a cost of living increase. The meeting minutes contained no information concerning appointment to the Medical Staff.

Review of the Board of Directors meeting minutes dated 4/20/10 documented the signing of the contract for Practitioner B with an arrival date of 7/1/10 or within 90 days. The 4/20/10 meeting minutes did not reflect appointment to the Medical Staff.

C. Review of the Medical Staff Bylaws approved by the Governing Body on 6/1/09 revealed the following concerning Clinical Privileges under Article VI Section A:
"Every Physician/Allied Health Professional practicing at this hospital by virtue of Medical Staff membership or otherwise, shall, in the practice, be entitled to exercise only those clinical privileges specifically granted to him by the Board of Trustees...Every initial application for staff appointment must contain a request for the specific clinical privileges desired by the applicant."

Review of the credential file for Practitioner B revealed no listing of privileges. Practitioner B is a CAH employed physician and started work on 9/22/10.

Review of the credential file for Practitioner E revealed no listing of privileges. The physician was listed as a consulting member of the Medical Staff on the list provided by the CAH.

Review of credential files for Practitioners A, D, F and G revealed there were no privilege forms specific to Morrill County Community Hospital. The only privilege forms present had other hospital's or CAH's names on the form. Interview with the Administrator and Administrative Assistant on 6/8/11 from 11:20 AM to 12:15 PM and 1:50 PM to 3:05 PM confirmed these privilege forms were not for Morrill County Community Hospital and contained privileges not provided at this CAH.

D. Review of the Medical Staff Bylaws approved by the Governing Body on 6/1/09 revealed the following under Article VI Section A Application for Appointment:
"All applications for appointment to the Medical Staff shall be submitted on a form prescribed by the Board of Trustees. The application shall require detailed information concerning the applicant's professional qualifications, his/her membership in local, state, or national medical societies and license to practice. She/He shall be required to give Three (3) references pertaining to the applicant's professional competence and ethical character....By applying for appointment to the Medical Staff....authorizes the hospital to consult with members of Medical Staffs of other hospitals with which the applicant has been associated, and with others who may have information bearing on his/her competence, character, and ethical qualifications; consents to the hospital's inspection of all records and documents that may be material to an evaluation of his/her professional qualification for staff membership...."

Review of the Credential Agreement with a commence date of 9/1/99 revealed the following "For each Morrill Physician's application for appointment or reappointment to Memorial's medical staff that is provided to [credentialing organization] pursuant to this Agreement, [credentialing organization] shall verify the information that is in the medical staff application - with primary sources and will indicate the date of verification."

Review of the credential file for Practitioner B revealed no completed applications for membership with signature. The credential file contained no references that documented the applicant's competence and ethical character or contact with other hospitals Practitioner B was associated with.

Interview with the Administrator and Administrative Assistant on 6/8/11 from 11:20 AM to 12:15 PM revealed the following:
- Practitioner B did not go through the credential organization contracted with the CAH but through a recruiting firm;
- The recruiting firm did the research on Practitioner B and provided this information to the CAH but this information was not kept by the CAH;
- Administrator called the Program Director for Practitioner B's residency program but did not document this conversation;
- Practitioner B was interviewed by the Medical Staff, then the Governing Board and then the Medical Staff and Governing Board came together for discussion, before the decision was made to hire Practitioner B.

The CAH failed to maintain documented evidence of investigation of Practitioner B's education, competence and ethical character.

E. Review of the Medical Staff Bylaws approved by the Governing Body on 6/1/09 revealed the following under Article VI, Section C Reappointment Process:
"Each recommendation concerning the reappointment of a Medical Staff member, and the clinic privileges to be granted, upon reappointment, shall be based upon such member's professional competence and clinical judgement in the treatment of patients, his ethics and conduct, his attendance at Medical Staff meetings and participation in staff affairs, his compliance with the hospital Bylaws, Rules and Regulations, his cooperation with hospital personnel, his use of the hospitals's facilities for his patients, his relations with other practitioners, and his general attitude toward patients...."

Review of the credential file for Practitioner D revealed reference checks with 2 other hospitals/CAHs where Practitioner D held Medical Staff membership and references from 4 peers; however, the credential file contained no information on: compliance with this CAH's Bylaws, Rules and Regulations, i.e., completion of medical records; attendance at Medical Staff meetings; peer review of patients attended to evaluate competence; and/or number of patients attended, or procedures completed to evaluate use of hospital's facilities.

Interview with the Administrator on 6/8/11 from 1:50 PM to 3:05 PM confirmed the credential file contained no data concerning Practitioner D's practice at Morrill County Community Hospital.

F. Review of the Medical Staff Bylaws approved by the Governing Body on 6/1/09 revealed the following under Article III, Section A Qualifications for Membership:
"Each member of the Medical Staff is required to have a minimal amount of Liability Insurance, as required by the Nebraska Excess Liability Fund. The Liability insurance must be with a company licensed or approved by the State of Nebraska. Members will submit annually a Certificate of Insurance that verifies compliance with this requirement."

Review of credential files for Practitioners E, F and G revealed expired certificates of insurance as follows:
- Practitioner E's insurance expired on 5/18/11;
- Practitioner F's insurance expired on 3/1/11; and
- Practitioner G's insurance expired on 7/15/10.

Interview with the Administrator and Administrative Assistant on 6/8/11 from 1:50 PM to 3:05 PM confirmed the expiration dates for insurance for Practitioners E, F and G.

G. Review of the Medical Staff Bylaws approved by the Governing Body on 6/1/09 revealed the following under Article III, Section A Qualifications for Membership:
"The applicant for membership on the Medical Staff shall be a graduate of a professional school approved by each health professional's national governing organization and legally licensed to practice in the State of Nebraska..."

Review of the credential file for Practitioner E revealed Nebraska license expired on 10/1/10.

Interview with the Administrator and Administrative Assistant on 6/8/11 from 1:50 PM to 3:05 PM revealed the following:
- Confirmed the expiration date on the copy of the license for Practitioner E that was in the credential file; and
- Indicated they had no way of tracking expired Nebraska Licenses.

Based on staff interviews, record review and lack of documentation, the CAH (Critical Access Hospital) failed to have a policy and procedure for the reporting of adverse drug reactions. The census on entrance for the survey was 3 acute care inpatients and 1 swingbed patient. Findings include:

A. Review of the Pharmacy Policy and Procedure manual failed to discover a policy for reporting adverse drug reactions.

B. An interview with the Consultant Pharmacist and the Director of Nursing on 6/8/2011 beginning at 12:15 PM confirmed they do not have one.

Based on observation, record reviews, lack of documentation and staff interviews, the CAH (Critical Access Hospital) failed to have an active infection control program and surveillance plan in place. The census on entrance for the survey included 3 acute inpatients and 1 swingbed patient. Findings include:

A. Review of the Infection Control Policy & Procedure Manuel revealed the cover noted "REVISED NOVEMBER 1999". Review of the policies and procedures within the manual identified they were outdated. An interview with the current ICC (Infection Control Coordinator) on 6/7/11 beginning at 3:30 PM found she had taken on the ICC position on 4/1/11. She revealed she had worked at this CAH for several years in the late 1990s. She had been the ICC at that time and had developed the Infection Control Program then. When she first looked at the manual again she recognized her own writing and immediately realized the policies were outdated, much of them from 1998. She stated she needs to start from the beginning and has joined APIC (Association for Professionals in Infection Control), as well as gone to the Internet for current information. She has not been able to do much because she is allotted 4 to 8 hours a week to work on infection control. She confirmed that is not enough time to bring the program up to current standards.

B. In the interview with the ICC on 6/7/11 at 3:30 PM, the ICC admitted they do not have a surveillance program. She was able to identify the need for rounds for surveillance, but only had some forms she had gotten from the Internet that she was considering for documenting surveillance rounds. When asked about tracking of infections and antibiotic therapy (ABT) she was able to explain what needed to be done, but there had not been any tracking since November of 2010. Review of the documentation in the manual of the infection and ABT confirmed the last month of tracking was November 2010.

C. On 6/8/11 at 1:25 PM, observation of an RN setting up and starting an intravenous (IV) antibiotic medication for a new patient revealed the RN gathered together the IV bag of antibiotic, the bag of normal saline, the IV tubing sets for both the IV antibiotic and the bag of normal saline. She labeled the tubing with the date, labeled the bags of antibiotic, and normal saline, and put the bags on the tubing, hung the bags from a shelf in the medication room, went down the hall to the linen closet where they store their pumps, obtained an IV pump and took the pump to the patient's room and plugged it into a wall socket. Then she returned to the medication room, opened the door, obtained the IVs and supplies, took them to the patient's room, set them down by the sink in the room, hung the bags on the IV pole, checked the patient's identification, went to a cabinet in the room and obtained an alcohol wipe, returned to the patient, wiped the hub of the IV port and connected the IV tubing to the port. Then she programmed and started the pump to infuse the IV solution. The patient requested more water, so she took the water container to get it filled and left the room. Walking with her, she was asked when she washed her hands, and she responded she washed her hands before she started collecting her supplies and medication to administer the IV antibiotic. She admitted not washing her hands since and said she probably should have washed her hands again when she was finished with the IV but she was going to get the patient's water then wash her hands, touching multiple surfaces while setting everything up to administer the IV antibiotic, which indicates need for handwashing, and she did not wear gloves while working with the IV connecting it to the patient's IV site.

Based on review of the Policy and Procedure meeting minutes, review of policies and procedures and staff interview, the CAH (Critical Access Hospital) failed to ensure that the group of professional personnel reviewed 7 of 7 required types of policies and procedures. The policies not reviewed were:
- Description of the services the CAH furnishes directly and those furnished through agreement or arrangement;
- Polices and procedures for emergency medical services;
- Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral;
- The maintenance of health care records;
- Procedures for the periodic review and evaluation of the services furnished by the CAH;
- Rules for the storage, handling, dispensation and administration of drugs and biologicals;
- Procedures for reporting adverse drug reactions and errors in the administration of drugs;
- System for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel; and
- Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices.
Census on the first day of survey was 3 acute care inpatients and 1 swingbed patient. Findings include:

A. Review of the policy titled Policy and Procedure Committee with a reviewed date of 2/14/06 revealed the following:
"Morrill County Hospital shall maintain a policy and procedure committee for the purpose of reviewing, updating and changing policies as needed at least on an annual basis." This policy did not identify whether all policies would be reviewed by this committee or just certain policies.

B. Review of the Policy and Procedure Meeting minutes dated December 2010 revealed a listing of policies that had been updated but did not include information about which policies and procedures were reviewed. These meeting minutes indicated policies were updated for:
- HIPAA (Health Insurance Portability and Accountability Act - privacy of your personal health information);
- IV (intravenous) updated with current information;
- The illegibility, refusal by nurse to give medication or follow orders was updated;
- New policy for bone marrow aspiration, assisting with;
- Cervical and pelvic traction policies were removed; and
- New groshong catheter was updated.
The meeting minutes included no information at all concerning review of the following policies and procedures:
- Description of the services the CAH furnishes directly and those furnished through agreement or arrangement;
- Polices and procedures for emergency medical services;
- Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral;
- The maintenance of health care records except the HIPAA policies;
- Procedures for the periodic review and evaluation of the services furnished by the CAH;
- Rules for the storage, handling, dispensation and administration of drugs and biologicals except for IV and policies for nurse refusal to give medication because of illegibility;
- Procedures for reporting adverse drug reactions and errors in the administration of drugs;
- System for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel; and
- Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices.

C. Interview with the Administrator on 6/9/11 from 10:25 AM to 10:35 AM confirmed that the policy and procedure committee only looked at and approved policies that had been changed in the last year and that the meeting minutes failed to reflect which types of policies had been reviewed.

Based on review of the Program Evaluation and staff interview, the CAH (Critical Access Hospital) failed to include a review of the CAH's health care policies in the annual Program Evaluation. Census on the first day of survey was 3 acute care inpatients and 1 swingbed patient. Findings include:

A. Review of the document titled Critical Access Hospital Program Evaluation for Period Ending December 31, 2010, revealed the following opening statement "One of the requirements is the annual program evaluation that is completed each year and contains the following, but not limited to the following list." This list included "Review of health care policies"; however, review of the written narrative completed by the Administrative Assistant and signed by the Administrator revealed no information concerning the review of the CAH's health care policies.

The attachments to this Program Evaluation included a document titled Policy and Procedure meeting dated December 2010. Review of this Policy and Procedure Meeting minutes dated December 2010 revealed a listing of policies that had been updated but did not include information about which policies and procedures were reviewed. These meeting minutes indicated policies were updated for:
- HIPAA (Health Insurance Portability and Accountability Act - privacy of your personal health information);
- IV (intravenous) updated with current information;
- The illegibility, refusal by nurse to give medication or follow orders was updated;
- New policy for bone marrow aspiration, assisting with;
- Cervical and pelvic traction policies were removed; and
- New groshong catheter was updated.
The meeting minutes included no information at all concerning review any of the CAH's Patient Care policies.

B. Interview with the Administrator on 6/9/11 from 10:25 AM to 10:35 AM confirmed that the policy and procedure committee only looked at and approved policies that had been changed in the last year and confirmed that the Program Evaluation included no other information on review of patient care policies.

Based on record review, lack of documentation and staff interview, the CAH (Critical Access Hospital) failed to ensure nosocomial infections were being tracked and evaluated. The census at the time of entrance for the survey was 3 acute inpatients and 1 swingbed patient. Findings include:

A. Review of the documentation for investigating, tracking, and reporting of nosocomial and communicable diseases failed to find anything written since November of 2010. An interview with the ICC (Infection Control Coordinator) on 6/7/11 beginning at 3:30 PM, noted the ICC revealed she had only been doing infection control for 6 to 7 weeks and was trying to learn the current standards, update their plan, and their system for tracking & reporting of nosocomial infections was still being developed. She confirmed they had not been tracking and evaluating the infections, nosocomial or community-acquired. They do not have an actual quality improvement plan developed for this topic at this time.


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Review of the Quality Assurance meeting minutes from November 2010 through May 2011 revealed no information concerning nosocomial infections and/or medication therapy, specifically antibiotic therapy. Interview with the Quality Assurance Coordinator on 6/8/11 confirmed that the Quality Assurance program failed to include a review of nosocomial infections and medication therapy, specifically antibiotic therapy since taking over the Quality Assurance Coordinator position in September 2011.