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Based on review of the Hospital Affiliation Agreement, review of the Network Agreement, review of the Quality Assurance Plan and staff interview, the CAH (Critical Access Hospital) failed to ensure that the Network Agreement and/or Hospital Affiliation Agreement included quality assurance. This failed practice had the potential to affect all patients of the CAH. The inpatient census from 7/1/11 to 6/30/12 was 262. Census on the first day of survey was 1 Swingbed resident.

Findings are:

A. Review of the Quality Assurance Plan under the section titled TAG: C-341 (revised 3/06/2012) revealed the following "WHMH [West Holt Memorial Hospital] will provide a random sampling of charts representing Medical Staff Physicians for review by [name of a Nebraska Acute Care Hospital approximately 94 miles away from the CAH and hereafter referred to as Network Hospital]." Interview with the Quality Assurance Coordinator on 9/11/13 from 2:25 PM to 3:15 PM confirmed the Network Hospital was providing assistance with review of medical records for quality and appropriateness of diagnosis and treatment furnished by doctors of medicine or osteopathy.

B. Review of the Nebraska Critical Access Hospital Program Medicare Rural Hospital Flexibility Program Network Agreement with an effective date of 1/1/11, between West Holt Memorial Hospital and the Network Hospital revealed the agreement addressed Patient Referral and Transfers, Emergency and Non-Emergency Transportation, and Communication Systems; however, lacked any information concerning Quality Assurance.

Review of a second agreement titled Hospital Affiliation Agreement (effective date of 9/1/11) between West Holt Memorial Hospital and the Network Hospital revealed the agreement was for the Network Hospital to provide "administrator and certain management services"; however, lacked any information concerning Quality Assurance.

C. Interview with the CEO (Chief Executive Officer) on 9/12/13 from 10:45 AM to 10:48 AM confirmed the Nebraska Critical Access Hospital Program Medicare Rural Hospital Flexibility Program Network Agreement and the Hospital Affiliation Agreement both lacked any mention of Quality Assurance.

Based on Emergency Room record review from 4/21/13 through 9/7/13, policy review and staff interview the facility failed to ensure 1 (Doctor A) of 3 physicians had signed and dated their physician orders. The Critical Access Hospital (CAH) Emergency Room visit census for the last fiscal year was 668.
Findings are:

A. Review of random Emergency Room visit records from 4/21/13 through 9/7/13 revealed that eight Emergency Room Records from 6/20/13 through 6/22/13 lacked signed physician orders. Doctor A provided physician coverage from 6/20/13-6/22/13.

B. An interview with the Health Information Manager (HIM) on 9/11/13 at 3:45 PM revealed, "We had a locum tenens [a locum tenens - a physician that provides fill in coverage] for the CAH that weekend [6/20/13-6/22/13]. We had just changed to electronic records the first of June. We must have missed making sure the orders were either signed in the electronic record or wrote out and signed. Our system runs a list of unsigned orders but did not identify those orders as not being signed. It is the expectation of the facility that all the orders are signed and dated within 30 days of the visit. We will get those to the doctor and get them signed right away."

C. Review of the Policy updated 12/11/09 revealed, "The appropriate professional will sign and date in his/her own handwriting using either his initials or full name....A verbal order will be signed and dated by the practitioner."

Based on staff interview and review of policy and procedure, the CAH (Critical Access Hospital) failed to ensure a qualified professional directed the patient activities program. The total Swingbed sample was 5. The Swingbed census during survey was 1.

Findings are:

A. Interview with the Social Services/Discharge Planner on 9/10/13 at 11:30 revealed that [gender] was in charge of patient activities and had "never worked in activities" before, lacked evidence of attending a training course and did not work in collaboration with any other individual except the nurses on the floor who assisted the patients with individual activities.

B. Review of policy titled Quality of Life: Activities (no date) stated "The activities program will be directed by a qualified professional."