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Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure the emergency equipment commonly used in life saving procedures was monitored according to the CAH policy for 1 of 1 emergency rooms (ER).

Findings include:

During a tour of the emergency department on 8/28/13, at 1:05 p.m. the ER crash cart (a cart containing emergency supplies commonly used during life saving procedures) was observed. The DON stated that the defibrillator automatically went through an auto check for function daily and printed the results which were then placed in an envelope and saved. When the DON was asked about monitoring other equipment in the crash cart used in emergencies she stated that the crash cart supplies were supposed to be checked weekly. The DON stated that these weekly checks were documented on a Crash Cart Checklist. Review of the checklists from 4/1/13-8/28/13, indicated the following items should be checked weekly to ensure availability during an emergency: intubation kit, pediatric intubation kit, adult and pediatric ambu bags, algorithm cards, advanced cardiac life support handbook, defibrillator pad, quick combo adult and pediatric, blue CPR sheets with clipboard, Broslow tape, electrode gel, pocket mask, defibrillator paper, portable suction, oxygen tank, Yankauer suction kit, oxygen non-rebreather mask, oral airways, multiple needles, syringes, and IV tubing for fluids and blood and suction catheters. Review of the documentation recorded on the Crash Cart Checklists revealed the supplies had been checked on 2 occasions dated 5/11/13, and 8/17/13.

Review of the CAH policy Crash Cart Stocking, Security, and Maintenance reviewed on 7/11/11, indicated the "Crash carts will be checked on a regular basis as follows: ...2. Weekly medication, equipment, and supply check; and after each crash cart use."

On 8/28/13, at 1:35 p.m. the director of nursing confirmed the emergency room crash carts had not been been checked and monitored according to the CAH policy.

Based on interview and documentation review the Critical Access Hospital (CAH) failed to ensure physician/physician extender signatures were timed and dated for 6 of 21 patient (P3, P4, P7 P8, P9, P10) medical records reviewed.


Findings included:


P3 was admitted on 3/24/13. The admission physician's orders were signed by the physician but not dated or timed.


P4 was admitted on 9/26/12. Physician orders dated 9/26 and 9/27/12, were signed by the physician but not dated or timed.


P7 was admitted on 10/1/12. The admission physician orders were signed by the physician but lacked the time and date of the signature.


P8 was admitted on 5/17/13, and discharged on 5/22/13. The discharge summary dictated on 5/23/13 was signed by the physician; however, lacked the time and date of the signature.


P9 was admitted on 12/10/12, and discharged on 12/14/12. The discharge summary dictated on 12/16/13, was signed by the physician; however, lacked the date and time of the signature.



P10 was admitted on 12/11/12, and transferred to another hospital for further care on 12/13/12. The discharge summary dictated on 12/13/13, was signed by the physician; however, lacked the date and time of the signature.


The CAH policy for Authentication of Signature, Time, Date, reviewed January 2012, indicated that all CAH staff entering information into any medical record will sign, date and time all entries into the medical record.


On 8/28/13, at approximately 11:00 a.m. the health information manager (HIM) verified the medical record entry signatures lacked the required dates and times.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the certified registered nurse anesthetist (CRNA) provided and documented a post-anesthesia evaluation for each surgical patient which included: cardiopulmonary status, level of consciousness, complications during the procedure and recovery and follow up care and/or observations for 2 of 4 patients (P20, P21) whose surgical records were reviewed.

Findings include:

P20 had surgery for a bowel resection with intravenous (IV) general sedation. The CRNA's post-anesthesia discharge note dated 4/14/11, at 6:00 p.m. indicated what R20 had no anesthesia related complications, however, did not include P20's cardiopulmonary status, or level of consciousness.

P21 had surgery for an umbilical hernia with IV general sedation. The CRNA's post-anesthesia discharge note dated 8/8/13, at 10:30 a.m. indicated what R21 had no anesthesia related complications, however, did not include P20's cardiopulmonary status, or level of consciousness.

On 8/28/13, at 3:15 p.m. the registered nurse, surgical supervisor verified the post anesthesia evaluation and discharge records did not address cardiopulmonary status nor the level of consciousness for P20 and P21.

The Post-Anesthesia Evaluation policy reviewed 8/26/12, indicated the post-anesthetic evaluation would be completed after the patient returned to the floor. The policy also indicated the CRNA would check for homeostatic functioning of body systems, current vital signs, and the presence of any untoward conditions which may have resulted from the administration of anesthesia and document the results.

Based on review of facility policies, quality assurance documentation and interview, the Critical Access Hospital (CAH) failed to ensure periodic evaluation and quality review of their services was completed as required. The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to maintain effective quality assurance processes in order to ensure provision of quality health care. Therefore, the CAH was unable to meet this condition of participation. These deficient practices have the potential to impact all patients receiving services from the CAH.

Findings include:

See C337-Based on document review and staff interview, the CAH failed to have an effective program that evaluated on a continuous basis, the quality of all patient care services. This has the potential to affect all CAH patients.

See C340-Based on interview, contract review, and policy review, the CAH failed to ensure that they had an arrangement with an outside entity to review the quality and appropriateness of diagnosis and treatment furnished by CAH physicians and one mid-level provider. This practice had the potential to affect all current and future patients of the CAH.

Based on document review and interview, the Critical Access Hospital (CAH) failed to have an effective quality assurance (QA) program that evaluated on a continuous basis, the quality of all patient care services. This deficient practice has the potential to affect all CAH patients.

Findings include:

Evidence was lacking to indicate that QA activity had been reported on an ongoing basis in the following areas: emergency services, ambulance, radiology, organ procurement, sleep studies, anesthesia, swing bed, cardiac rehab, diabetes clinic and nutrition services.

Review of the 2013, Total Quality Management Meeting committee minutes dated 7/30/13, 4/17/13, and 2/6/13, lacked reports of projects and/or activities that had occurred to evaluate CAH services provided for departments which included: emergency services, ambulance, radiology, organ procurement, sleep studies, anesthesia, swing bed, cardiac rehab, diabetes clinic, and nutrition services. No ongoing discussions were evident related to ongoing quality assurance activities for these aforementioned areas.

Review of the CAH Quality Improvement Policy and Plan revised 12/7/12, indicated the following related to "Participation" in quality assurance and process improvement of the CAH. "All patient care services and other services affecting patient health and safety, including services relating to patient care that are furnished by a contractor, must be evaluated. These are: Activities, Acute Care Nursing, including ER and Outpatient, Anesthesia, Behavioral Health, Bodyworks Fitness Center, Cardiac/Pulmonary Rehab. Clinic, Central Service and Receiving (CSR), Diabetes Resource Center, Dietary, Emergency Medical Services (EMS/Ambulance), Employee Health, Environmental Services, Infection Control, Laboratory and Blood Utilization, Long-Term Care Nursing, LakeWood Nursing Service, Laundry, Maintenance, Medical Records, Medical Staff appropriateness and quality of diagnosis and treatment (peer review), Pharmacy, Radiology Services, Social Services, Surgical Services, Swing Bed, Therapies, including Physical, Occupational, and Speech Therapy, Tissue Review, Utilization Review (UR), including Discharge Planning." The policy identified the following related to: Ongoing Monitoring of Data Collection: "Department/service areas will maintain a method of ongoing monitoring and data collection based on indicators developed from practices that are high volume, high risk, problem-prone, and/or high cost. Indicators will be monitored at least monthly and the assessment documented and kept on file in the respective department/service are quarterly."
The policy indicated the following procedures related to quality improvement approaches "Rapid Cycle Improvement," ... "Unexplained variations or trends identified during periodic monitoring are addressed through the Rapid Cycle Improvement Process. Identified areas for improvement, which may be outside the scope of the reporting department, are also captured using this process. Collaboration with other departments/service areas is expected and encouraged. A systematic approach is used to implement improvements to resolve problems. Define situation. Apply quick fix, if necessary. Identify root causes. Implement corrective action. Evaluate and follow-up."

The following departments lacked ongoing quality assurance or process improvement activities:

Emergency Room/Ambulance

Review of the Rapid Cycle Improvements QI Quarterly report for April-June 2013, lacked quality assurance or process improvement activities identified for the Emergency room or Ambulance. On 8/28/13, at 1:35 p.m. the director of nursing (DON) verified the ambulance and emergency room departments currently did not have any ongoing QA projects.

Nursing Services/Swing Bed/Organ, Tissue, and Eye Procurement

The Rapid Cycle Improvements QI Quarterly report for April-June 2013, lacked evidence of quality assurance or process improvement activities for Nursing Services, Swing Bed, or Organ, Tissue, Eye Procurement. On 8/28/13, at 1:55 p.m. the DON stated the nursing department utilized several methods of monitoring problems, however, stated they, "Could to a better job" with data being used to identify improvement or not with the systems being monitored. There was no hospital QA/PI activity for Organ, Tissue, and Eye Procurement, only the data reports supplied by LifeSource.

SURGERY and ANESTHESIA
Interview with surgical manager on 8/28/13, at 3:40 p.m. stated that they are monitoring their services but have not completed a quality assurance project in the last year. She stated that they were monitoring the time out process being completed correctly in the operating room but had no documentation of that monitoring. She further stated she didn't know of any QA program anesthesia services are doing.

CARDIAC REHABILITATION SERVICES and the DIABETIC CLINIC are run by the same staff. Interview on 8/27/13, at 9:14 a.m. registered nurse (RN)-A stated that they have monitored the percentages of patients goals that have been met, but they have not done a QA project in the last year.

RADIOLOGY SERVICES and LABORATORY SERVICES
On 8/27/13, at 9:45 a.m. the manager of radiology and laboratory services stated that she has no documentation of any QA for radiology services. She stated that she had been involved in the falls assessments and the proper use of mechanical lifts, however, had no documentation that indicated this was completed or that it was a QA program. At 10:30 a.m. when the manager was asked about the laboratory QA she stated that the facility as whole does the QA and basically each department doesn't do QA anymore.

FOOD AND DIETETIC SERVICES
On 8/27/13, at 3:00 p.m. the food service assistant (FSA)-A said that they did do customer satisfaction questionnaires but didn't know of any QA program that was completed as a result of the questionnaires.

SLEEP STUDY
On 8/27/13, at 3:45 p.m. the director of nursing (DON) was interviewed regarding the type of QA program the sleep study program had completed with in the last year. The DON stated that the sleep study program did not have a QA program in the last year.

On 8/19/13, at 8:30 a.m. t registered nurse (RN) quality manager (RN/QM) confirmed the QA/PI (quality assurance performance improvement) process had not been all inclusive nor had it been an ongoing process. The RN/QM stated she was rather new to the role of RN/QM and did not understand that each identified department needed to have ongoing performance improvement projects.

Based on interview, contract review and policy review, the Critical Access Hospital (CAH) failed to ensure they had an arrangement with an outside entity to review the quality and appropriateness of diagnosis and treatment furnished by CAH physician's and one mid-level provider. This practice had the potential to affect all current and future patients of the CAH.

Findings include:

On 8/29/13, at 9:00 a.m. registered nurse (RN)-D verified the CAH did not have an arrangement with an outside entity to provide peer review for the the quality and appropriateness of diagnosis and treatment furnished by all CAH physician's and one mid-level provider. RN-D stated the CAH physicians including consulting medical staff physicians with surgical privileges and those that provided telemedicine, had not been evaluated since August of 2011.

Review of the Quality Improvement Policy and Plan dated revised 12/7/12, indicated the following under the subtitle "VII. ORGANIZATIONAL FRAMEWORK...3. Medical Staff...d. Ensures that the following functions are performed within the medical staff quality improvement program:..Peer Review..."

Review of the INDEPENDENT CONTRACTOR AGREEMENT dated 6/1/10, revealed the CAH entered into an agreement with a private contractor to provide professional peer review services for the CAH's Medical Executive Committee for the purpose of quality assurance.

On 8/29/13, at 10:30 a.m. the CAH Administrator verified the contractor that provided professional peer review services for the CAH's Medical Executive Committee had not performed peer review for the CAH physician's and one mid-level provider (a nurse practitioner) since August 2011. The Administrator stated the private contractor had retired and was no longer under contract by the CAH to perform peer review. The Administrator also stated he was in the process of finding a new contractor or organization to perform peer review for the CAH physicians including consulting medical staff physicians with surgical privileges, those that provided telemedicine and one mid-level provider.