HospitalInspections.org

Based on observation, interview and document review, the CAH failed to maintain hot water temperatures below 120 degrees in patient rooms. The CAH identified a census of 1 inpatient at entrance.

Failure to maintain water temperatures below 120 degrees in patient rooms could potentially cause burns to patient skin, elevated water temperatures to newborns and elderly patients are likely due to the fragileness of the skin.

Findings include:

Observation on 10/24/16 at 11:45 AM, during the initial nursing tour, with Staff A, Director of Nursing (DON); revealed the following hot water temperatures in patient rooms.
Room 140-125.6 degrees
Room 148-125.1 degrees

Review of the policy titled, Water Temps, dated 8/13/01; reads in part...Policy: To maintain safe water temperatures in rooms and areas which patient have access. The temperatures to be maintained: 110 degrees to 120 degrees +/- 2 degrees. Procedure: Once a month, during the week of our monthly Safety Committee a work order is given to a maintenance worker with a list of areas to check water temperatures. If any of the temps fall out of range, adjustments are made to the water heaters and re-tested the following day.

An interview on 10/26/18 at 9:25 AM, with Staff D, Chief Engineer, revealed daily water temperatures are taken at the mixing valve. Daily water temperatures are not taken in the patient wing unless there is a problem. Staff D, re-checked the water temperatures on the patient wing on 10/26/16 all reading were below 120 degrees.

I. Based on review of quality plan and quality committee meeting reports that are presented to the governing body of the CAH (Critical Access Hospital), and administrative staff interviews the CAH failed to present all information discussed at the quality committee meetings to the governing body. The CAH identified a census of 1 inpatient at entrance.

Failure to present all quality information to the governing body could potentially result in a lack of information needed by the governing body to make decisions, and appropriate decisions for the CAH.

Findings include:

Review of the Quality Improvement Plan, revised 3/10; reads in part...II D. Departmental Studies Departments choose at lease one Q.A. (Quality Assessment) indicator that relates to an aspect of care or service. Each department will report quarterly to the Q.A. Committee...E. Program Organization 1. Hospital Governing Board The governing board is the final authority and bears ultimate responsibility for the hospital-wide, comprehensive Quality Improvement Program. It receives, for review and comment, reports on all program activities and findings from the Quality Assessment Committee... F. Flow of Quality Improvement Information. 1. Quality Assessment Reports a. Each department will submit reports on quality assessment activities on a quarterly basis to the Q.A. Coordinator. These reports will the be presented to the committee. These reports are then presented to the Medical Staff in Quality Assessment session and to the Board of Directors.

Review of the Board of Director Meeting minutes from 12/15 to present, revealed Continuous Quality Improvement (CQI) minutes presented quarterly to the board. The minutes lacked complete information from all departments reporting. Information found in the minutes included a summation of the departments activities, and failed to include the total quality activities of the departments.

An interview on 10/26/16 at 1:35 PM, with Staff C, Chief Executive Officer (CEO), revealed the governing body failed to receive all information discussed in the quarterly quality committee meetings. The CQI quarterly minutes are presented to the governing body, these minutes contain a summation of the information discussed at the quarterly meetings. Individual department quality reports are not part of the CQI minutes.

An interview on 10/27/16 at 9:00 AM, with Staff F, Director of Quality, revealed the governing body does not receive all of the information presented at the CQI quarterly meetings. The board is given a summation of the meeting and department information.


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II. Based on document and credential file review and staff interview, the CAH's Governing Body failed to ensure the recredentialing process occurred within the required time-frame for 1 of 1 pathologists selected for review (Staff C).

Failure to complete the credentialing process in the defined period of time could potentially result in a physician impacting patient care without verification the practitioner meets all state, federal and CAH requirements,

Findings include:

Review of the credential file for Staff C, Pathologist, revealed the last approval for reappointment to the CAH medical staff, by the governing body, occurred on 8/26/14. Documentation of approval notification to Staff C, on 9/2/2014, revealed his membership and clinical privileges were due for review no later than September 2016 and his credential file lacked documentation of approval for temporary privileges.

During an interview on 9/26/16, at 3:40 PM, Staff B, Chief Executive Officer, reported Staff C fulfilled oversight and consultation duties, to the CAH laboratory, as the director of the pathology group. She acknowledged his last credentialing cycle had ended and his re-appointment approval should have been done by now. Staff B attributed the lapse to difficulty with practitioners turning in required materials in a timely manner.
During a follow-up interview on 9/27/16, at 10:20 AM, Staff B, reported the CAH utilizes a Credentialing Verification Organization (CVO) to gather data and verify the credentials for the appointment to the medical staff. Staff B reported the CAH has not yet received the re-credentialing packet for Staff C and again acknowledged his re-appointment to the medical staff was past due.
Review of the CAH's Medical Staff By-laws, approved by the governing body on 9/24/13, revealed in part, "... on or before October 1 of the year in which the practitioner's privileges will expire, each practitioner with clinical privileges ... must submit a signed, completed application for reappointment and renewal of privileges to the Administrator ..."
During an interview on 10/27/16, at 10:20 AM, Staff B reported the Medical Staff By-laws need to be updated, as they no longer re-credential everyone in October, and explained each practitioner is re-credentialed for a 2 year period based on the date of their last re-appointment approval date. She confirmed Staff C's should have been sent to medical staff and governing body for re-appointment approval in September.
Review of the CAH's Quality Improvement Plan, revised 3/10, revealed the scope of quality assessment includes credentialing of personnel to ensure the quality of medical staff services.

Based on review of Medical Staff Rules and Regulations and administrative staff interviews, the administrative staff failed to ensure that Emergency Department physicians documented periodic medical record reviews they completed in conjunction with the midlevel providers. The CAH reported 44 of 198 ED visits were covered by a midlevel for 9/2016.

Failure to review patient medical records in conjunction with the midlevel providers that delivered the care could potentially result in inadequate medical care, and communication to the provider for ED patients.

Findings include:

Review of Rules and Regulations of the Medical Staff, approved on June 23, 2015; reads in part...Section G-Emergency Services 2. The Allied Health Provider (AHP) will participate with the physician in the periodic review of both open and closed patient clinical records.

The CAH lacked documentation that showed Staff I, DO (Doctor of Osteopathic Medicine) provider, reviewed 44 ED patient medical records in conjunction with Staff H, PA-C midlevel provider, who had delivered the care.

During an interview on 10/26/16 at 3:00 PM, Staff G, Chief Nursing Officer, acknowledged the CAH lacked documentation that showed Staff I had reviewed 44 ED records in conjunction with Staff H in 9/2016.

Based on review of Medical Staff Rules and Regulations and administrative staff interviews the administrative staff of the CAH failed to document the inconjuncture meetings between the midlevel and the provider in the ED (Emergency Department). The CAH reported 44 of 198 ED visits were covered by a midlevel for 9/2016.

Failure to conduct the inconjuncture meetings between the midlevel and provider in the ED could potentially result in a lack adequate medical care, and communication to the provider for ED patients.

Findings include:

Review of Rules and Regulations of the Medical Staff, approved on June 23, 2015; reads in part...Section G-Emergency Services 2. The Allied Health Provider (AHP) will participate with the physician in the periodic review of both open and closed patient clinical records. The CAH lacked documentation of the inconjuncture meetings between the Staff H , PA-C midlevel, and Staff I, DO provider, for review of the 44 ED records completed by the Staff H in the ED.

An interview on 10/26/16 at 3:00 PM, with Staff G, Chief Nursing Officer, acknowledge the CAH lacked documentation of the inconjuncture meetings between the Staff H and Staff I for chart review of the 44 ED records completed by the Staff H in 9/2016.

Based on observation, review of CAH (Critical Access Hospital) policy and procedures and other associated documentation the CAH nursing staff failed to document the open date on the controls used for 4 of 4 Accu-Chek Inform II machines found in the nurse/OB station and the ambulatory surgery unit. The CAH identified 5 of 113 patients from the nursing and surgery departments used the Accu-Check Inform II machines during 10/16.

Failure to document the open date on the controls used for the Accu-Chek Inform II machines could potentially result in inaccurate blood sugar results.

Findings include:

Observation on 10/24/16 at 2:45 PM, during the initial tour of the nursing unit, with Staff A, Director of Nursing, revealed; 3 Accu-Chek Inform II machines in the nurse/OB station. Staff A verified all 3 machines used the same controls, the controls lacked an open date. Staff A acknowledge the lack of an open date on the control solution at the time of the observation.

Observation on 10/25/16 at 1:30 PM, during the initial tour of the surgery department, with Staff E, Director of Surgery, revealed; 1 Accu-Chek Inform II machine in the ambulatory surgery unit. The controls lacked an open date. Staff E acknowledged the lack of an open date on the control solution at the time of the observation.

Review of the manufacture's information for Accu-Chek Inform II controls, undated, reads in part...Note: Write the date the bottle was opened on the bottle label. The control solution is stable for 3 months from that date or until the "Use by" date on the bottle label, whichever comes first.

Review of the policy titled, Glucometer testing, undated, reads in part...2. Analytical Control Storage and Use 2. Use before the unopened expiration date shown on the bottle and within three (3) months after first opening.

Based on policy review, medication error record review and staff interview the Critical Access Hospital (CAH) administrative staff failed to ensure nursing staff notified the medical provider when a medication error occurred for 3 of 11 patients medication errors reviewed (Patient #3, 4, and 7). The nursing staff failed to date and/or time the notification of provider for 7 of 11 patients medication errors reviewed (Patient #1, 2, 3, 4, 5, 6, and 7).

The Director Of Nursing reported a census of 0 inpatients at entrance.

Failure to ensure nursing staff notified the provider and date/time when the staff notified the provider of medication errors could potentially result in medications being given/or not given to the patient.

Findings include:

A review of medication errors on 10/26/16 revealed 3 of 11 patients (Patient #3, 4, and 7) errors selected for review lacked provider notification of the medication error, 6 of 11 patients (Patients #1, 2, 3, 4, 6, and 7) lacked a date when the staff notified the provider and 7 of the 11 (Patient #1, 2, 3, 4, 5 6, and 7) reviewed lacked a time for provider notification.

Review of policy titled Nursing Service Policy and Procedure for Medication/Procedure Incident Reporting, revised on 2/07, reads in part ...1. All medication error occurrences shall be reported to the employee's immediate supervisor and the attending physician, or physician on call if unable to reach the attending physician or if the incident occurs after hours...

An interview on 10/26/16 at 2:15 PM, with Staff A, RN DON, acknowledged the nursing staff are to notify the medical provider of a medication error. Staff A, RN DON confirmed (Patient #3, 4, and 7) lacked provider notification of the medication error, 6 of 11 (Patients #1, 2, 3, 4, 6, and 7) lacked a date for provider notification and 7 of the 11 (Patient #1, 2, 3, 4, 5 6, and 7) lacked a time for provider notification.
Staff A, RN DON stated the Patients medical records, also, lack documentation of provider notification of the medication errors.

Based on policy review, Critical Access Hospital (CAH) Review 2015 and administrative staff interview the CAH review failed to include information related to reviews of a sample of active and closed clinical records. The CAH review is completed annually.

Failure of the CAH Review 2015 to include active and closed record reviews could potentially result in audits and audit criteria not being appropriate for the population served, and important results going unnoticed and unmentioned.

Findings include:

Review of document titled, CAH Review, dated 2015; reads in part...Open Chart Review Done monthly by utilization review and daily on all current acute patients records for completeness and appropriateness of diagnosis and treatment, surveillance for infections, length of stay, signature for verbal orders, history and physical and proper consents on the record. 100% of the acute charts are looked at daily. Closed chart review Audit of closed records on present criteria is done in Health Information. This audit involves criteria from different departments. Each department is also responsible to audit records for inpatients and outpatients with the criteria that have been set by the manager.

The review lacks information related to a representative sample of both active and closed clinical records, how records are selected and reviewed, how does the sample represent all services furnished, and what criteria is used in the review process.

Review of the policy titled, Periodic Evaluation of CAH Program, dated 3/2001 reads in part...Procedure 3. The evaluation will include a representative sample of both active and closed clinical records. A representative sample of both active and closed clinical records is defined as not less than 10 percent of both active and closed patient records.

An interview on 10/26/16 at 1:35 PM, with Staff B, Chief Operating Officer (CEO); revealed the review is completed by the CEO and lacks the criteria used for the completion of open and closed chart review.

Based on policy review, Critical Access Hospital (CAH) Review 2015 and administrative staff interview the CAH annual review failed to include all health care policies, even those requiring no changes. The CAH review is completed annually.

Failure of the CAH Review to include review of all CAH policies, even those requiring no change,could potentially result in those policies lacking an annual review.

Findings include:

Review of document titled, CAH Review, dated 2015; reads in part...Health Care Policies: New policies are presented to the policy review committee. Manager presents revised policies at the time of the annual policy review to the committee. The review lack information regarding the review of policies needing no change at the time of the review process.

Review of the policy titled, Periodic Evaluation of CAH Program, dated 3/2001 reads in part...Procedure 4. The evaluation will include a review and/or revision of the hospitals health care policies.

An interview on 10/26/16 at 1:35 PM, with Staff B, Chief Operating Officer (CEO); revealed the review is completed by the CEO and lacks information regarding approval of health care policies that require no revisions.

Based on review of Patient Rights Document , medical records and staff interview, the Critical Access Hospital (CAH) failed to ensure inpatients and outpatients were informed of their visitation rights including the ability to receive designated visitors, but not limited to a spouse, a domestic partner (including same-sex domestic partner) and another family member or friend for Swing bed patients, Acute patients and all outpatients.

The Director Of Nursing reported a census of 0 inpatients at entrance.

Failure to provide all inpatients, skilled patients and outpatients, with patient rights information could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person present when they are provided any type of care services or treatment modalities.

Findings include:

Review of the document titled "Patient rights and responsibilities for Swing Bed" dated February 2007, provided to swing bed patients, revealed a lack of documentation regarding his or her consent to receive visitors whom he or she designates, including but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member or friend.

Review of the CAH Annual Review for 2015 noted the number of patients served in the following areas:
- Average monthly inpatient (acute and swing bed) census - 39
- 1,444 acute patients for 2015
- 109 swing bed patients for 2015
- 40,696 outpatients for 2015

Review of the document titled "Patient rights and responsibilities" not dated, provided to acute care patients, observation patients and outpatients on admit to the CAH, lack of documentation regarding his or her consent to receive visitors whom he or she designates, including but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member or friend.

During an interview on 10/25/16 at 4:30 PM, Staff A, Director of Nursing, (DON) Registered Nurse (RN) acknowledged the Patient Rights provided to swing bed patients, acute care patients and outpatients lacked information for same sex and domestic partner. Staff A, DON RN confirmed the Patient Rights provided to the patients should have this language in them. Staff A, DON RN stated the updated Abuse policy had the required language but did not update the Patient Rights/Resident Rights paper given to the Acute, Skilled patients and outpatients.