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Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure timely physician notification for the occurrence of a medication error for 5 of 19 medication errors reviewed. (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5). Failure to notify the physician of medication errors could potentially result in the provider not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the provider making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff reported a census of 13 patients on entrance, and an average daily census of 5.09 patients per day.

Findings include:

1. Review of "Medication Incident and Adverse Drug Reaction Reporting" last approved 12/10/2019, revealed in part: "Any medication error or adverse reaction will be reported on the Incident Report Form....The Medication Incident report on the intranet will be filled out and submitted online with all pertinent data that is known. The Medical Provider must be notified of the incident in all instances as soon as possible to determine if therapy should be altered or other means of action should be taken."

2. Review of medication errors from January 2019 to December 2019 revealed:

a. The nursing staff made a medication error on 07/31/2019 at11:30 AM which involved Patient #1. Patient #1's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #1's medical care of the medication error.

b. The nursing staff made a medication error on 04/28/2019 at 06:00 AM which involved Patient #2. Patient #2's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #2's medical care of the medication error.

c. The nursing staff made a medication error on 01/24/2019 at 11:48 AM which involved Patient #3. Patient #3's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #3's medical care of the medication error.

d. The nursing staff made a medication error on 02/22/2019 at 22:00 PM which involved Patient #4. Patient #x4's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #4's medical care of the medication error.

e. The nursing staff made a medication error on 02/15/2019 at 06:00 AM which involved Patient #5. Patient #5's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #5's medical care of the medication error.

3. During an interview on 02/05/2020 at 12:31 PM, the Chief Nursing Officer and Nursing Director acknowledged the medication error paperwork for Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5 lacked documentation the nursing staff notified the patient's provider of the medication error.

Based on observation, document review and staff interviews, Critical Access Hospital (CAH) administration failed to ensure 2 of 2 reviewed laboratory staff members (Medical Technologist A and Medical Technologist B), 1 of 1 reviewed registered nurses (RN C), 1 of 1 reviewed Advanced Registered Nurse Practitioner (ARNP) D, and 1 of 1 reviewed Emergency Department (ED) physician (ED Physician E) had color vision proficiency prior to interpreting the results of fecal occult blood (blood in stool) tests for all laboratory, nursing and medical staff who read the results of the test. Failure to test all laboratory, nursing and medical staff for color blindness before performing this test may result in staff misreading the results of the fecal occult blood test which could potentially adversely affect the diagnosis and treatment plan for patients. The CAH performed 109 fecal occult blood tests from March 2019 to February 2020.

Findings include:

1. Observation on 02/03/2020 at 10:54 AM, during a tour of the Laboratory revealed the laboratory staff utilized Beckman Coulter Hemoccult slides to check stool for occult blood.

2. Observation on 02/02/2020 at 1:00 PM, during a tour of the Emergency Department (ED), revealed staff utilized Beckman Coulter Hemoccult slides to check stool for occult blood.

3. During an interview at the time of the laboratory tour, the Laboratory Director reported the CAH staff did not receive testing for color blindness upon hire or any time later. The Laboratory Director acknowledged that interpretation of the Hemoccult test would require the staff member to utilize blue/green color vision proficiency to interpret the test.

4. During an interview on 02/04/2020 at 1:00 PM, the Emergency Services manager confirmed all physicians working in the ER used Beckman Coulter Hemoccult slides to check stool for occult blood in the ED.

5. Review of manufacturer's recommendations from March 2015 for Beckman Coulter Hemoccult slides revealed, in part: "Because the test is visually read and requires color differentiation, it should not be interpreted by individuals with blue color deficiency (blindness)."

6. Review of personnel files revealed the following:

a. Medical Technologist A started working at the CAH on 03/18/2019. Medical Technologist A's personnel file lacked documentation the CAH staff tested Medical Technologist A for blue color vision proficiency upon hire or at any time after hire.

b. Medical Technologist B started working at the CAH on 03/10/2011. Medical Technologist B's personnel file lacked documentation the CAH staff tested Medical Technologist B for blue color vision proficiency upon hire or at any time after hire.

c. Registered Nurse (RN) C started working at the CAH on 03/18/2019. RN C's personnel file lacked documentation the CAH staff tested RN C for blue color vision proficiency upon hire or at any time after hire.

d. Advanced Registered Nurse Practitioner (ARNP) D initially apply to start working at the CAH in 2014. ARNP D's personnel file lacked documentation the CAH staff tested ARNP D for blue color vision proficiency upon hire or at any time after hire.

e. Emergency Department (ED) physician E initial apply to start working at the CAH in 20005. ED physician E's personnel file lacked documentation the CAH staff tested ED physician E for blue color vision proficiency upon hire or at any time after hire.

7. During an interview on 02/04/2020, at 3:57 PM, the Infection Control Director confirmed CAH staff did not perform testing for color blindness on any of the CAH employees, including the physicians and Advance Practice Practitioners.

Based on document review, policy review and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH staff received regular health examinations as part of the CAH's system to identify and prevent transmission of infections and communicable diseases. The problem was identified for 6 of 18 employees reviewed (Lab Technician F, Inaging Services Director G, Registered Dietician H, Registered Nurse I, Cook J, and Pharmacy Technician K). Failure to identify infections and communicable diseases among employees could potentially result in the transmission of a communicable disease to patients.

Findings include:

1. Review of employee health information revealed:

a. Lab Technician F had an associate health screening performed on 3/18/11. Lab Technician F's employee health information lacked documentation the CAH staff performed an associate health screening on Lab Technician F after 3/18/11.

b. Imaging Services Director G had an associate health screening performed on 2/23/13. Imaging Services Director G's employee health information lacked documentation the CAH staff performed an associate health screening on Imaging Services Director G after 2/23/13.

c. Registered Dietician H had an associate health screening performed on 4/10/12. Registered Dietician H's employee health information lacked documentation the CAH staff performed an associate health screening on Registered Dietican H after 4/10/12.

d. Registered Nurse I had an associate health screening performed on 8/19/11. Registered Nurse I's employee health information lacked documentation the CAH staff performed an associate health screening on Registered Nurse I after 8/19/11.

e. Cook J had an assocate health screening performed on 8/14/13. Cook J's employee health information lacked documentation the CAH staff performed an associate health screening on Cook J after 8/14/13.

f. Pharmacy Technician K had an associate health screening performed on 5/13/14. Pharmacy Technician K's employee health information lacked documentation the CAH staff performed an associate health screening on Pharmacy Technician K after 5/13/15.


2. Review of the CAH policy "Employee Health Program," dated 6/11/19, revealed in part " ... New associates will be required to have an employment health screen prior to an offer of employment ... Employee health screens are required on all associates every four years .... "

3. During an interview on 2/4/20 at 11:30 AM, Human Resource Assistant L reported the CAH policies did not require the CAH staff to perform an associate health screening, except for the initial associate health screening completed upon hire.

4. During an interview on 2/4/20 at 11:50 AM, the Quality/Infection Control Director reported she did not know about the requirements to perform an associate health screening every 4 years. The Quality/Infection Control Director confirmed that she had never performed an associate health screening, except for the screening performed upon hire of a new associate.