The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

POCAHONTAS COMMUNITY HOSPITAL 606 N W 7TH STREET POCAHONTAS, IA 50574 Sept. 28, 2011
VIOLATION: PROVISION OF SERVICES Tag No: C0270
Based on review of documentation, policy/procedures, observation, patient and staff interviews, the Critical Access Hospital (CAH) staff failed to implement systems that assured provision of services accommodated the needs of their patients.

The CAH administrative staff reported an average daily census of approximately 2 swing bed patients and a daily average of 2 inpatients.

The following examples confirm this determination.

The CAH staff failed to consistently implement or follow their policy for skin assessment, skin flow sheet, removal of Ted hose, and individualized care plans for patients receiving care at the CAH. This failure resulted in patients developing skin ulcers. (Refer to tag C-293, C-395)

The CAH nursing staff failed to identify unusual skin occurrences including but not limited to necrotic skin areas and pressure ulcers/wounds. (Refer to tag C-337)

The CAH staff failed to utilize employees with specialized education (Enterostomal (wound) nurse and/or Dietary staff) for the care of their patients admitted with pressure ulcers or developed hospital-acquired pressure ulcers. (Refer to tag C-295)

The CAH staff failed to follow physician's orders for medications and or treatments. (Refer to tag C-297)

The CAH staff failed to obtain Physician orders prior to the start of patient medication and/or treatment. (Refer to tag C-297)

The CAH staff failed to complete the admission assessment for the acute patients and comprehensive assessment for the swing bed patients for patients receiving care and/or treatment at the CAH, therefore staff did not identify all of the patients' medical, mental and psychosocial needs. (Refer to tag C-298 C-395)

The CAH staff failed to develop and update care plans to implement individualized interventions for patients receiving medical care and treatment at the CAH, the staff use the care plan interventions for consistent and individualized care to enhance the patient's healing while in the CAH. (refer to tag C-298 C-395)

The CAH staff failed inspect a Laminar Flow Hood in the pharmacy two times a year.
(Refer to tag C-276)

The cumulative effect of these systemic failures and deficient practices resulted in the avoidable pressure ulcers to compromised patients breakdown in the hospital's ability to provide safe care and monitoring to all patients.
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to consistently follow physician ' s orders and/or established policies and procedures when assigning patient ' s level of care, performing skin assessments, admission nursing assessments, completing incident reports, providing therapies, administering medications or treatments, and developing patient care plans for 2 of 2 current Swing-Bed (SWB) patients (#'s 26 and 27) and 8 of 12 discharged patients (closed medical records #25, 28, 29, 30, 31, 32, 37, and 50) reviewed.

The CAH administrative staff reported a current census of 2 swing bed patients and a daily average of approximately 2 inpatients.

Failure to follow established patient care policies and procedures resulted in staff failing to meet a patient's needs causing harm.

Findings include:

1. Review of Patient #26's medical record revealed, nursing staff failed to remove the patient's Ted hose when they performed the complete skin assessment, in accordance with CAH policy. Failure to remove the patient's Ted hose prevented the nursing staff from identifying significant changes in the patient's skin and resulted in the patient suffering hospital acquired pressure ulcers.

a. Review of 2 of 2 inpatient medical records (Patients #26 and 27) and 8 of 12 closed medical records for Patients #28, 29, 30, 31, 32, 25, 37, and 50 revealed nursing staff failed to develop and implement nursing care plans individualized to each patient's specific medical needs, in accordance with CAH policies.

b. Review of 2 of 2 inpatients (Patients #26 and 27) and 8 of 12 closed medical records for Patients #28, 29, 30, 31, 32, 25, 37, and 50 revealed nursing staff failed to document all portions of the admission nursing assessment, in accordance with CAH policy.

c. Review of Patients #26, 31 and 32's medical records revealed nursing staff failed to obtain Physician orders that delineated the patient's level of care, treatment and/or medications the patients received during their hospitalization , in accordance with CAH policy.

d. Review of Patients #26 and 30's medical records revealed staff failed to follow Physician orders for medications, Physical and/or Occupational therapy, and oxygen therapy, in accordance with CAH policies.

2. During an interview on 9/12/11 at 4:15 PM, Staff H acknowledged, in these instances, the nursing staff failed to follow nursing policies for wound/ulcer care, skin assessments, admission nursing assessments, Ted Hose, physician orders, and/or care plans.

a. During an interview on 9/14/11 at 9:00 AM, Staff X, Quality Assurance, stated, the nursing staff needs to fill out an incident report for hospital-acquired ulcers and wounds or QA would not have any way to know of the ulcers. Staff X stated the nurses were educated on the incident policy during their orientation. Staff X stated, "I would expect an incident report to be made out for any wounds developed in the hospital." Staff X reviewed the incident reports and confirmed there were no incident reports for hospital-acquired ulcers in the past year.

b. During an interview on 9/14/11 at 10:50 AM, Staff E, Registered Nurse (RN) stated, "Yes, I am aware of the online policy manual." Staff E stated Staff H, RN Director of Patient Care, informed the nursing staff of the online policy manual approximately 6 months ago. Staff E demonstrated and printed copies of policies for Care Plans, Decubitus (pressure ulcers) and Foley catheter irrigation.

c. During a follow up interview on 9/14/11 at 11:05 AM, Staff H stated the nurse's trainer instructed nursing staff on the computer online policy at their orientation. Staff H stated the nurses signed a statement they were aware and could access the online hospital wide and department policy manual.

d. During an interview on 9/19/11 at 9:45, Staff H, Director of Patient Care Services, acknowledged that nursing staff failed to implement nursing care plan in accordance with hospital policy stating, "Apparently, the staff did not always do this."

3. Policy and procedure review revealed the following information.

a. "Application of Antiembolic Stockings" not dated revealed, " ... ASSESSMENT: ...condition of skin of lower extremities; ...Hose should be removed daily for inspection of skin and hygiene .... "

b. "Comprehensive Resident Assessment" revised, 2/06 revealed, "...The comprehensive assessment must include at least the following information...Physical functioning and structural problems ...nutritional status ...Skin condition....Medications ...Special treatment and procedures ...Documentation of summary information regarding the additional assessment performed ....Comprehensive Resident Assessments will be conducted within 24 hours of admission .... "

C. " Guide to completing Admission Assessment " revealed, " Braden Risk Assessment: Check if the patient is bedfast, chairfast of unable to reposition themselves. If any are checked complete the Braden Risk Assessment Scale on the back of the Skin NCP [Nursing Care Plan] ....Nursing Care Concerns ...the Care Concerns " Sheet is to be complete by the nurse during or as he/she completes the Admission Assessment. 1) A check in any of the boxes means that specific nursing diagnosis category that requires being included on the Nursing Care Plan. If more than one nursing diagnosis is available in the category, the nurse will check the appropriate diagnosis. "

d. " Interdisciplinary Care Plan ...Swing bed " revised,
2/06 revealed, " ...An Interdisciplinary Care Plan will be formulated on each Swing bed patient based on the admission assessment and any other pertinent problems or needs identified within 14 calendar days after admission .....The Nursing Care Plan will be completed within 24 hours of admission to PCH [Pocahontas Community Hospital] and will be utilized in the development of the Interdisciplinary Care Plan. The Nursing Care plan will be reviewed by each shift .... "

e. " Care Planning ...Medical surgical Unit " revised, 2011 revealed, " ...within eight hours of acute, swing bed or hospitality admission all patients shall have a Plan of Care generated by the Registered Nurse ...The plan of care shall be individualized, based on the diagnosis and patient assessment ...The plan of care shall be updated daily, with revisions reflecting the reassessment of needs of the patient .... "

f. " Medication Administration Procedure " revised, 2/2010 revealed, " ...Check medication with physician ' s orders and with the MAR [Medication Administration Record] ...Physicians shall be notified if medications must be held for any reason .... "

g. " Medication orders - Processing " revised, 4/07 revealed, " ...The pharmacist shall review and verify the entry against the original order before the drug is dispensed ... "

h. " Orders (General and Medication) " revised 2/06 revealed, " ...All medical tests and procedures completed in PCH require an order from a physician or mid-level practitioner. Physical Therapy orders require a signature of a physician .... "

i. " Incident Reports " revised, 2/09 revealed, " The form must be completed for ALL unusual occurrences involving patients ...an unusual occurrence is defined as any occurrences involving patients ...which is not consistent with the regular hospital routine, REGARDLESS, of whether or not there was an apparent injury or other damage .... "
VIOLATION: POLICIES - DRUG MANAGEMENT Tag No: C0276
Based on observation, review of policies, and staff interview, the Pharmacist failed to ensure inspections of the Laminar Airflow Hood occurred in accordance with manufacturer's recommendations.

The CAH administrative staff reported an average daily average of approximately 2 inpatients.

Failure to inspect the Laminar Flow Hood according to manufacturer's direction could result in the laminar flow hood malfunctioning flow hood potentially resulting in patients receiving contaminated IV medications.

Findings include:

1. Initial tour of the pharmacy conducted on 9/7/11 at 2:10 PM with the Pharmacist, revealed
an inspection date of 12/27/10 on the Laminar Flow Hood. The Pharmacist stated independent contractors inspected the Laminar Hood every 6 months. The Pharmacist acknowledged that he failed to ensure the independent contractors conducted the six month inspection due June of 2011.

2. Review of the "Biological Safety Cabinet Test Report" revealed the following in part. "... the purpose of field testing this equipment is to assess whether it is functioning as designed in compliance with the specifications...." Additionally, the report verified the last inspection occurred on 12/27/2010.

3. Review of the "Laminar Flow Hood" policy, revised 12/10, stated in part, "...The Laminar Flow Hood shall be inspected by an independent contractor...for operational efficiency at least every 6 months..."
VIOLATION: NURSING SERVICES Tag No: C0294
Based on review of policies and medical records and staff interviews, Critical Access (CAH) nursing staff failed to complete all portions of the admission nursing assessment that addressed actual and potential risks for impaired skin integrity, nursing care concerns, nutritional screening, and skin wound flow sheets for 3 of 5 discharged acute patients. (Patient #25, #37, and #50).

The CAH administrative staff identified an average daily census of approximately 2 inpatients.

Failure to complete all portions of the admission nursing assessment could potentially interrupt continuity of nursing care services, evaluation of the care and treatment of patients, development of the interdisciplinary care plan used to meet the physical needs of all patients admitted to the CAH.

Findings include:

1. The CAH staff used policies and procedures to provide guidance to the staff for consistent and continuity of care. A review of these policies and procedure revealed:

a. "Comprehensive Resident Assessment" revised 2/06 revealed in part,..."To gather information necessary to provide appropriate care and services for each...patient...Pocahontas Community Hospital will conduct an initial comprehensive assessment of the patient's capability to perform daily life functions and to assess significant impairment in functional capacity...The comprehensive assessment must include...physical functioning and structural problems...nutritional status...skin condition...special treatments and procedures..."

b. "Guide to completing Admission Assessment", no date, revealed in part ...To provide the medical and nursing staff with information regarding past and current health problems. The physical assessment portion of the "Admission Assessment" serves as the baseline and helps identifies the patient's needs. The information is used by the nursing staff to develop an appropriate nursing care plan and to communication with other members of the health team the special needs of the patient use the information."
...Check if patient is bedfast, chair fast or unable to reposition themselves. If any are checked, complete the Braden Risk Assessment Scale on the back of the skin NCP (Nursing Care Plan)...
...The nursing "Care Concerns" sheet is to be completed by the nurse during or as he/she completes the Admission Assessment. A check in any of the boxes means that specific nursing diagnosis category that requires being included on the nursing care plan. If more than one nursing diagnosis is available in the category, the nurse will check the appropriate diagnosis."

c.. "Guide to completing Patient Care Flow Sheet" dated 9/07 revealed in part, ...To document physical assessment findings, changes in condition, nursing care provided, treatments, evaluation of the care and treatment, patient education and communication with other health team members...Each shift would complete assessment at start of shift..."

d. "Guide to completing admission update" review date 2/11 revealed in part...The assessment is used to update the physical finding when a patient changes from one level of care to another. The nursing care plan revision is based on the information...nursing care plan: check reviewed or revised after completion of the Care Concerns list...New care plans must be used...Braden Risk Assessment...needs to be reviewed and updated...The Nursing care plan needs to reflect the findings...Care Concerns update...check appropriate box and initiate nursing care plan on updated assessment....nursing care concerns...help identify the appropriate nursing diagnosis for each patient...a check in any of the boxes means that specific nursing diagnosis category that requires being included in the nursing care plan...please make sure the dietary section is complete on all admissions and if a referral is needed make sure that dietary gets the information..."

2. Review of Patient #25's closed acute medical record revealed:

a. Nursing staff documented the patient arrived to the hospital with a red rash areas covering the patients left antecubital space and hands and arms. Additionally the patient's perineal and buttock area was red.

b. Nursing staff failed to complete a skin/wound flow sheet addressing the rash and red areas documented on the admission assessment.

c. Nursing staff failed to complete the nursing screening portion of the admission assessment.

d. Nursing staff complete a Braden risk assessment.

e. Nursing staff failed to complete the nursing care concern portion of the admission assessment. This portion identified areas that required nursing staff to develop a care plan individualized for Patient #25's specific needs.

During an interview on 9/19/11 at 2:10 AM, Staff H reviewed Patient #25's medical record and confirmed the nursing staff did not complete all portions of the Admission Assessment. Nursing staff failed to complete; the Braden Scale, nutritional screening, nursing care concerns, and skin wound flow sheets. Staff H confirmed that nursing staff failed to complete the nutritional screening and request additional assessment by the Dietitian, in accordance with CAH policies and procedures.

3. Review of Patient #37's closed acute medical record revealed:

a. Nursing staff documented the patient arrived to the hospital with red areas in both groin folds and perineal area with opened areas of skin partially gone. Additionally nursing staff documented red/rash areas on both of the patient's lower legs.

b. Nursing staff failed to complete a skin/wound flow sheet addressing the rash and red areas documented on the admission assessment.

c. Nursing staff documented the patient arrived to the hospital " chair fast " on the Braden Risk Assessment. Nursing staff failed to complete a Braden Assessment Scale.

d. Nursing staff failed to complete a nutritional screening and request additional assessments by the dietician in accordance with CAH policies and procedures.

During an interview on 9/19/11 at 1:30 PM, Staff H reviewed Patient #37 ' s medical record and acknowledged nursing staff failed to complete skin/wound flow sheet to monitor improvements and /or declines in the groin folds, perineal areas and opened areas. Staff H verified nursing staff failed to complete a Braden Assessment scale and request notify the dietician to determine if additional nutritive supplement would assist in the healing process of the areas and/or prevent further breakdown.


4. Review of Patient #50's closed acute medical record revealed:

a. emergency room Physician EEEE documented Patient #50 arrived to the hospital with necrotic toes bilaterally (both) with dry gangrene.

b. Nursing staff failed to document the necrotic toes bilaterally with dry gangrene.

c. Nursing staff documented the patient arrived to the hospital with bruising to both arms.

d. Nursing staff failed to complete a skin/wound flow sheet addressing the necrotic toes and bruising on the admission assessment.

e. Nursing staff documented the patient had a poor appetite and chewing/swallowing problems on the nutritional screening however failed to request additional assessments by the dietician in accordance with CAH policies and procedures.

f. Nursing staff failed to complete the nursing care concern portion of the admission assessment. This portion identified areas that required nursing staff to develop a care plan individualized for Patient #50 ' 's specific needs.

During an interview on 9/12/11 at 4:15 PM, Staff H stated the nurses did not address wounds consistently on the "skin/wound flow sheet" or in the Daily Patient care sheet as per policy. The nursing staff failed to follow nursing policies for wound/ulcer care, admission assessments, and/or interdisciplinary care plans.
During an interview on 9/19/11 at 2:00 PM Staff H reviewed Patient #50's medical record and acknowledged nursing staff failed to document the necrotic toes and bruised areas and failed to complete skin/wound flow sheets to monitor for improvements and/or declines in the altered skin areas. Staff H verified nursing staff failed to complete a Braden Assessment scale and request notify the dietician to determine if additional nutritive supplement would assist in the healing process of the areas and/or prevent further breakdown. Additionally, Staff H acknowledged the nursing staff failed to complete the nursing care concerns portion for development of a plan of care for Patient #50. Staff H stated the CAH had 2 Enterostomal nurses and a dietician that nursing staff failed to notify when they noted problems in accordance with policies and procedures.
VIOLATION: NURSING SERVICES - DRUG ADMINISTRATION Tag No: C0297
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


I. Based on review of the Critical Access Hospital (CAH) documents, medical records and staff interviews, nursing staff failed to obtain physician orders for, level of care and or treatments/medications received for 1 of 2 inpatient swing bed patient (Patient #26) and 2 of 5 discharged swing bed patients (Patient's #31 and #32).
The CAH administrative staff identified an average daily census of approximately 2 inpatient swing bed patients.

Failure to obtain a physician's order for level of care, medications, and treatments resulted in nursing and therapy staff administering mediations and providing treatments not approved by the physician that could impact the patient's quality of life, health status and lengthen their hospital stay.

Findings include:

1. Review of inpatient #26's In patient Swing Bed medical record revealed:

a. Physicians orders for admission on 8/15/11. The physician failed to identify the level of care on patient #26 admission orders from 8/15/11 to 9/7/11.

b. An admission nursing assessment dated [DATE] documented a Foley catheter. The physician failed to sign a Foley catheter protocol form from 8/18/11 through 9/7/11 delineating the diagnosis and rational for continuation of the Foley catheter.

During an interview on 9/7/11 at 10:50 AM, Staff S, Registered Nurse (RN) stated, nursing staff are responsible for completing the Foley catheter protocol form and having the physician sign it within three days after admission. Staff S stated, "I was instructed by the nursing supervisor to fill out the Foley catheter protocol form." During a follow up interview on 9/10/11 at 10:50 AM, Staff S confirmed she had failed to complete the Foley Catheter form, and obtain a physician's signature for diagnosis and continuation of the Foley Catheter on 8/18/11 stating, "It was just one of those things missed."

During an interview on 9/6/11 at 3:45 PM, Staff H, Director of Patient Care Services, reviewed Patient #26's medical record, and acknowledged the physician failed to identify the level of care, and the physician failed to sign a Foley catheter protocol form from 8/18/11 to 9/7/11.

2. Review of patient #31's discharged Swing Bed medical record revealed:

a. Nurses notes stated admitted to swing bed on 6/21/11. The medical record lacked a physicians order for admission to swing bed level of care from 6/21/11 through 7/1/11 when the physician discharged the patient from the hospital.

b. The Medication Administration Record documented nursing staff administered and or provided the following medications and treatments, without a physicians order, to Patient #31, from 6/21/11 through 7/1/11:

i. Allopurinol 100 mg po once daily

ii. Aquaphilic ointment to bilateral (both) legs topically twice daily.

iii. Daily weight.

iv. Enalapril Mal 20 mg twice a day.

v. Fentanyl Patch 25 mg topically every 72 hours.

vi. Furosemide Tablet 40 mg 2 tablets once a day.

vii. Levaquin 5000/1000 ml inject once a day.

viii. Nifedical XL 30 mg 1 tab once a day.

ix. Potassium Chloride 10 nonequivalent (meq) 1 capsule once a day.

x. Vision Formula 1 tab once daily.

xi. Wound care-dressing change bilateral lower legs once daily:

1. Cleanse with Normal Saline.
2. Apply Hydrogel.
3. Cover with dry gauze and roll gauze.
4. After performing steps above to both legs apply TubiGrip during day and remove stockings at HS.
5. Report if any increase in drainage, redness, warmth, swelling, or odor).

xii. Tylenol/codeine tablet #3- 1 to 2 tabs as needed every 4 hours.

xiii. Milk of Magnesia 10 millimeters (ml) as needed.

c. During an interview on 9/8/11 at 10:45 AM Staff V, RN, reviewed Patient #31's medical record and acknowledged the physician failed to identify the patients level of care and nursing staff failed to obtain physician's orders for the medications and treatments identified on the medication administration records from 6/21/11 through 7/1/11.

d. During an interview on 9/19/11 at 7:00 AM, Staff H acknowledged the swing bed medical record lacked a physician's order for level of care. Additionally, Staff H acknowledged nursing staff failed to obtain a physician's order for medications administered and treatments provided to the patient from 6/21/11 to 7/1/11.

3. The CAH staff used policies, procedures, and medical staff bylaws to provide staff with guidance, consistency, and continuity of patient care. Review of these documents revealed:

a. Medical Staff Rules and Regulations, revised 4/29/10, revealed in part:

"...vi. All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to a registered professional nurse...and signed by the attending practitioner..."

b. Policy/Procedure review revealed the following in part:

i. "SNF" [Skilled Nursing Facility], revised 2/02 ...The patient's physician is an active member of the Pocahontas Community Hospital medical Staff...admission process...Admission orders are written and signed by the attending physician..."

ii. "Prevention of Catheter Associated Urinary Tract Infections (CAUTI)", dated 8/25/10... Document indications for catheter insertion and continuation of catheter beyond 3 days. Assess daily the need for continuation of the catheter. Complete the Foley insertion/removal protocol form and place in chart. Insert urinary catheters only when necessary and leave them in place for the shortest time possible..."

iii. "Orders" revised 2/06, ...all medical tests and procedures completed in PCH [Pocahontas Community Hospital] require an order from a physician..."

"...iv. Medication Orders-Processing" revised 4/07, ...All medication for patients shall be ordered in writing by the attending healthcare practitioner. The ordering practitioner must date and sign the order at the time he or she writes the order. The pharmacist shall review and verify the entry against the original order before the drug is dispensed..."


4. Review of Patient #32's discharged Swing Bed medical record revealed:

a. PT initial evaluation/plan of treatment forms, documented the patient received PT sessions, 1 to 2 sessions per day, Monday through Friday for one month (5/21/11 through 6/29/11). The medical record lacked a physician's order for PT services.

b. OT initial evaluation/plan of treatment forms, documented the patient received OT sessions, 5 times a week for 4 weeks (5/31/11 through 6/30/11). The medical record lacked a physician's order for OT services.

c. Admission nursing assessment notes dated 5/31/11, documented an incision located on Patient #32's left hip due to postoperative hip repair.

d. Nursing staff documented dressing changes to the patient's left hip incision on 6/1/11, 6/2/11, 6/4/11, and 6/7/11. The medical record lacked a physician's order for dressing changes and/or care of the incision.

e. During an interview on 9/8/11 at 8:10 AM, Staff V reviewed Patient #32's medical record and acknowledged nursing staff failed to obtain a physician's order for dressing changes and/or care of the incision as well as PT and OT services.

f. During an interview on 9/8/11 at 1:00 PM, Staff U, Physical Therapy Aide (PTA) stated the PT department received an order for PT and OT to evaluate and treat via computer on 5/31/11. Staff U stated nursing staff are responsible for entering the PT and OT orders into the computer system. Additionally, Staff U stated therapy staff failed to review Patient #32's medical record to confirm a physician's order for PT and OT, stating they rely on nursing staff to enter the physicians order in the computer.

g. During an interview on 9/14/11 at 10:00 AM, Staff BB, Physical Therapist, acknowledged the patients orders for PT and OT services were not from a physician credentialed at the Pocahontas Community Hospital.

h. During an interview on 9/19/11 at 8:00 AM, Staff H acknowledged nursing staff failed to obtain a physicians order for dressing changes to the incision on patient #32's left hip. Additionally, Staff H stated the orders for PT and OT services were not from a physician credentialed at the Pocahontas Community Hospital.

5. The CAH staff used policies, procedures and other documents to provide guidance to the staff for consistency and continuity of patient care. Review of these documents revealed:

a. "Orders" revised 2/06, ...Physical Therapy orders require a signature of a physician...The practitioner must date and sign the order at the time he or she signs the order."

b. "Medical Staff Meeting minutes" dated 6/23/2010, revealed in part... iv. Admitting orders for Rehab services for skilled care patients need to be written by a MD/DO [Medical Doctor/Doctor of Osteopath]."

c. "Agreement between Pocahontas Community Hospital and Sports Rehab and Physical Therapy, Inc." dated 3/12/1998, ....Performs patient evaluations and administers therapy treatments according to orders received from the physician. Treats patients under doctor's orders."

II. Based on review of the Critical Access Hospital (CAH) policies, medical records and staff interviews nursing staff failed to follow the physician's order for medication administration for 1 of 2 inpatient swing bed patients (Patient #26) and failed to follow physician's orders for oxygen therapy for 1 of 5 discharged swing bed patients (Patient #30).

The CAH administrative staff identified an average daily census of approximately 2 inpatient swing bed patients.

Failure to follow physician's orders could potentially result in a decline in the patient's quality of life, health status and lengthen their hospital stay.

1. Review of Patient #26's Inpatient swing bed medical record revealed:

a. Medication reconciliation-physician orders dated 8/15/11 showed a physician's order for Doxylamine 25 mg PO at hours of sleep daily. Nursing staff failed to administer the Doxylamine 25 mg from 8/15/11 through 9/6/11.

b. A medication error/incident form dated 9/13/11 showed the patient should have received Doxylamine 25 mg by mouth at bed time daily starting with the admission on 8/15/11. Doxylamine had not been unavailable since admission. Nursing staff failed to notify the physician the medication was unavailable. The medication was discontinued from non-use and unavailability on 9/6/11. Patient #26's physician signed the medication error/incident form on 9/16/11.

c. During an interview on 9/6/11 at 3:45 PM, Staff H reviewed Patient #26's medical record, and acknowledged nursing staff failed to follow the physician's order for Doxylamine 25 mg. from 8/15/11 to 9/6/11.

2. Review of Patient #30's discharged swing bed medical record revealed:

a. A physician's order for Oxygen 2 L (liters) per NC (nasal cannula) dated 4/12/11, revealed the following: The flow sheets showed nursing staff delivered the oxygen at 3 liters from 4/16/11 through 4/18/11 and 4 liters from 4/19/11 through 4/20/11. The nurses failed to follow the physician's orders for oxygen therapy.

b. During an interview on 9/8/11 at 10:45 AM, Staff V reviewed Patient #30's medical record and confirmed the physician's order stated Oxygen 2 Liters. Staff V acknowledged the nurses failed to follow the physician's orders for oxygen therapy stating that he/she was "Not sure why the nurses increased the Oxygen without getting a Physician order."

c. During an interview on 9/14/11 at 11:30 AM, Staff H acknowledged nursing staff failed to follow the physician's orders for oxygen therapy stating nursing staff should have notified the physician if they felt the oxygen needed to be increased. Staff H stated the hospital did not have a policy for oxygen use.

3. The CAH staff use policies, procedures and other documents to provide guidance to the staff for consistency and continuity of patient care. Review of these documents revealed:

a. "Medication Administration Procedure" revised 12/10 revealed in part, "...It is the policy of Pocahontas Community Hospital to implement a procedure for the safe and uniform distribution of medication...check medication with physician's orders...check route with physician's order...check dose with physician's order..."

b. "Summary of Notes from Communication Board" dated 3/23/11 revealed in part, "...12. Please make sure we are following through with Dr's order. If there is an order that needs to be discontinued or updated...leave a note on the front of the chart so when the provider makes rounds they can see it and change the order..."
VIOLATION: NURSING SERVICES - CARE PLANS Tag No: C0298
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of policies, clinical records, care plans and staff interviews the Critical Access Hospital (CAH) nursing staff failed to develop and update individualized care plans for patients in accordance with CAH policy for 3 of 5 (Patients #25, 37, and 50) closed acute medical records reviewed.

The CAH administrative staff reported a census of 2 Swing Bed in-patients with a daily average of 3 patients.

Failure to develop and update individualized care plans could potentially result in disruption of the patient's continuity of care services which may impact the patient's medical, mental and psychosocial needs.

Findings for include:

1. The CAH staff used policies, procedures to provide guidance to the staff for consistency and continuity of care. Review of these policies and procedures revealed:

a. "Care Planning" revised 2011, revealed in part, "It is the policy of Pocahontas Community Hospital to provide an individualized, interdisciplinary plan of care for all patients. Within 8 hours of acute...admission all patients shall have a Plan of Care generated by the Registered Nurse... The Plan of Care shall be individualized, based on the diagnosis and patient assessment. The Plan of Care shall be updated daily, with revisions reflecting the reassessment of needs of the patient..."

b. "Decubitus Ulcer, Prevention and Care of" revised 2011 per DON (Director of Nursing) revealed in part, "...a skin integrity problem Plan of Care will be completed within 24 hours as part of the Plan of Care..."

2. Review of the medical records for Patients #50, 25,and 37 revealed in part:

a. Patient #50's acute medical record revealed Patient #50's admission to acute care from 6/21/11 through 6/25/11 for acute exacerbation of COPD with weakness, Oxygen and steroid dependent and diabetes mellitus type II.

Patient #50's medical record lacked a care plan for the skin issues on admission and new skin (coccyx and heel break down) issues that developed during the patient's hospitalization .

"Medication Reconciliation" dated 6/21/11 revealed in part, "...Betadine-apply to toes daily..."

"Admission Assessment" dated 6/21/11 revealed in part, "...gangrene of toes...removal of toes left foot 2010..."

"Admission Assessment" dated 6/21/11 lacked a Braden risk assessment, areas of skin issues identified, and nursing concerns checked for development of the plan of care.

Review of the "Patient Care Flow Sheet" revealed in part:

6/21/11 at 7:30 PM, "...Toes brown from Betadine with sores..."
6/22/11 at 7:00 AM, "...Remaining toes dry with black orange discoloration..." 11:15 AM, "...complains of heel discomfort, left heel has quarter size black area with red indurations..."
6/23/11 at 7:00 AM, "...Remaining toes dry and black red and blackened area, scabbed over noted to left heel. Betadine to mentioned areas..."
6/24/11 at 6:50 AM, "...Pedal pulse palpable. Dark area left heel remains with pink surrounding..." 4:00 PM, Wife states patient has open area on bottom. Wife applied Sween cream and positioned patient on side." 8:00 PM, "...Toes on feet dark rotten-chronic problem/issue..." 10:00 PM, "...left of coccyx-has a broken down area 0.5 cm X 2 cm. Multiple small areas open...Sween cream applied..."

Patient #50's medical record lacked a care plan for the skin issues on admission and new skin (coccyx and heel break down) issues developed during the patient's 5-day stay in the CAH.
During an interview on 9/19/11 at 2:00 PM Staff H reviewed Patient #50's medical record and acknowledged the lack of a Braden scale, skin/wound flow sheet to monitor skin issues on admit and new skin issues that developed during patient's stay at the CAH. Staff H stated the nursing staff should have started a skin care plan at admission and updated the care plan for the development of the coccyx and heel breakdown for Patient #50.

b. Patient #25's acute medical record revealed Patient #25's admission to acute care from 4/23/11 through 4/27/11 for severe low back pain and dehydration.

Nursing staff failed to update the patient's care plan to include new concerns that developed during the patient's hospitalization .

Patient #25's "Admission Assessment" revealed nursing staff documented a red rash located on the left antecube (inside of the elbow), arms, hands, and perineal-buttocks area red. Staff failed to complete the "Nutritional Screening" to help identify interventions for dehydration and the "Nursing Care Concerns" that nursing staff used to complete a nursing care plan. Nursing staff also failed to complete the Braden scale and a skin sheet for monitoring the skin areas identified on the assessment.

"Patient Care Flow Sheet" revealed in part, 4/23/11 at 8:00 PM, "...Patient has a reddened circular area on the anterior side of elbow in the crease...." The nurse notified the Physician of the areas. At 8:20 PM, the Physician visited the Patient and gave orders for Lotrisone cream BID (twice daily).

4/27/11 at 8:50 AM, "...Red non-raised excoriated areas noted under breasts, around stoma, bilateral groin and peri-rectal area, Lotrisone applied.

Patient #25's medical record lacked a care plan that addressed all the patient needs at admission. Nursing staff failed to update the care plan to include new concerns that developed during the patient's 5 day stay at the CAH. Patient #25's Care Plan lacked nutritional interventions related to the patient's diagnosis of dehydration on admission and updated information on the new excoriated areas under the breast, around the stoma, bilateral groin and the peri-rectal area.

During an interview on 9/19/11 at 2:10 AM, Staff H reviewed Patient #25's medical record and acknowledged the care plan lacked interventions for nutrition for the dehydration. Staff H confirmed the nursing staff failed to update the care plan to address the new excoriated areas under the patients breast, around the stoma, bilateral groin and the peri-rectal area developed during the patients 5 day stay.


c. Patient #37's acute medical record revealed Patient #37's admission to acute care from 11/15/10 through 11/18/10 for Pneumonia, COPD (Chronic Obstructive Pulmonary Disease), Candida Intertrigonitis and senile dementia.

Nursing staff failed to include nutritional interventions to help in healing the excoriated and/or open areas on the patient's care plan. Nursing staff failed to update the care plan interventions related to the increased reddened and excoriated areas that developed during the patient's hospitalization .

Patient #37's "History and Physical Report" dated 11/15/10 revealed in part, "...circular hive like areas in the lower extremities. Abdominal fold also showed an open excoriated rash across the waist to the crest of the hips and then down into the groin...a rash near the buttock...couple spots were open...circular slightly-raised reddened hive-like areas scattered over the lower extremities from knees on down..."

The Braden Scale dated 11/15/10 revealed a score of 11, "High Risk" and noted to include nutritional interventions. The medical record lacked dietary interventions to increase the patient's healing ability.

Physician orders dated 11/15/10 at 1:10 revealed "Lotrisone cream BID PRN, (Candida) groin.

The Admission assessment dated [DATE] revealed in part, "...applying Lotrisone, Redness bilateral groin folds, redness of perineal area with 1 cm areas of skin partially gone, few blood spots in diaper. Bilateral lower legs red rash, not warm..." Pictures taken of perineal areas and lower legs confirmed the above assessment.

"Patient Care Flow Sheets" revealed in part, 4/18/10 at 4:15 AM, "...protective ointment applied to very red bottom with open areas noted...red area noted under abdominal fold, protective ointment applied to area will notify Physician of area..."; 6:45 AM, "...Bilateral redness pinkness groin, was incontinent peri-anal buttock area red to dark pink with few areas. More redness today then yesterday... " 9:30 AM, "...Sween cream to peri-anal area, Lotrisone Cream to bilateral groin area... " 10:40 "Transfer back to manor (nursing home) ..."

Patient #37's care plan lacked nutritional interventions to help in healing the excoriated and/or open areas. Also, the care plan lacked updated interventions related to the increased reddened and excoriated areas that developed during the patients 4 day stay in the CAH.

During an interview on 9/19/11 at 1:30 PM, Staff H reviewed Patient #37's medical record and acknowledged the Care Plan did not address nutritional needs to increase healing and the nursing staff did not update the care plan to address the change in skin conditions.

3. During an interview on 9/19/11 at 9:45, Staff H stated the nursing staff develops a care plan from the admission assessment and diagnosis. The patients' care plans should be complete and address the individual needs of the patient. Staff H stated, the nursing staff updates the patient's care plan when new issues develop, apparently, the staff did not always do this.

4. During an interview on 9/12/11 at 4:15 PM, Staff H stated the nurse did not address wounds consistently on the skin sheets or in the Daily Patient care sheet. The nursing staff did not routinely measure and document the pressure ulcers when developed on patient in the CAH. Staff H stated, the nursing documentation on the wounds was confusing, "I would expect the nurses to document changes in condition, dressing changes and any treatment changes." Staff H stated, the CAH has 2 Enterostomal (wound) nurses and a dietician that were not utilized as they should have been. Staff H stated, "The current process is lacking."

5. During an interview on 9/14/11 at 9:00 AM, Staff X, Quality Assurance, stated QA did not address CAH acquired pressure ulcers or wounds unless they become a trend. Staff X went on to say, the incident reports for the pressure ulcers and wounds need to be filled out by the nursing staff or QA would not have any way to know of the pressure ulcers. Staff X stated, "I would expect any wounds developed in the hospital, an incident report to be made out." Staff X stated the nurses were educated to fill out an incident report for all sudden changes in a patients' condition. Staff X stated there were no incident reports for hospital-acquired pressure ulcers in the past year.
VIOLATION: RECORDS SYSTEM Tag No: C0304
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of documents, medical records, and staff interview, the CAH administrative staff failed to ensure Emergency Department (ED) physicians dated and timed all orders in the medical record.

The CAH administrative staff reported an average daily census of approximately 15 emergency room patients.

Failure to date and or time record entries could potentially cause harm to patients by delay in treatments, actions or assessments provided.

Findings include:

1. Review of CAH policy, "Orders (General and Medication)" dated 7/11 revealed in part, "...Minimum Information required on the order sheet: ... Date of Order, Time of Order...".

2. Review of Patient #38's ED medical record revealed an admission date of [DATE] for emergency medical treatment.

Patient #38's medical record lacked a date and time for 2 of 2 physician's orders.

3. Review of Patient #39's ED medical record revealed an admission date of [DATE] for emergency medical treatment.

Patient #39's medical record lacked a time for 2 of 2 physician's orders.

4. Review of Patient #40's ED medical record revealed an admission date of [DATE] for emergency medical treatment.

Patient #40's medical record lacked a time for 8 of 8 physician's orders and 1 of 1 physicians' entry on the transfer sheet.

5. Review of Patient #41's ED medical record revealed an admission date of [DATE] for emergency medical treatment.

Patient #41's medical record lacked a time for 10 of 11 physician orders.

6. Review of Patient #42's ED medical record revealed an admission date of [DATE] for emergency medical treatment.

Patient #42's medical record lacked a time for 7 of 7 physician orders.

7. Review of Patient #43's ED medical record revealed an admission date of [DATE] for emergency medical treatment.

Patient #43's medical record lacked a time for 2 of 2 physician orders.

8. Review of Patient #44's ED medical record revealed an admission date of [DATE] for emergency medical treatment.

Patient #44's medical record lacked a date and time for 1 of 1 physician orders.

9. Review of Patient #51's ED medical record revealed an admission date of [DATE] for emergency medical treatment.

Patient #51's medical record lacked date and time for 4 of 4 physician orders.

10. During an interview on 9/19/11 at 9:40 AM, Staff F, Utilization Review and Charge Capture Analyst, verified the physician entries in the medical records lacked dates and times when the physician wrote orders. Staff Q stated, according to policy all physician's orders and notes for these records need to be dated and timed.
VIOLATION: PROTECTION OF RECORD INFORMATION Tag No: C0308
Based on observation, policy review, and staff interviews, the Critical Access Hospital (CAH) (Health Information, Radiology and Laboratory) staff failed to secure all medical record information in the radiology and laboratory departments and basement area against unauthorized access.

The Director of Patient Services reported an average daily census of approximately 3 patients.

The laboratory director reported an average monthly census of approximately 250 inpatients and 900 outpatients.

The radiology director reported an average yearly census of approximately 100 inpatients and 4,400 outpatients.

Failure to secure medical records against unauthorized access could result in identity theft or unauthorized disclosure of personal medical information.

Findings include:

1. During an interview on 9/6/11 at 2:15 PM, Staff K, the Laboratory Manager stated, housekeeping staff cleaned the laboratory department in the morning unsupervised. Staff K acknowledged housekeeping services staff could access patient medical record information and did not have a need to know the patient's medical information to perform their job duties.

2. Tour of the laboratory department on 9/6/11 from 1:35 PM to 3:05 PM, revealed:

a. 1 of 1 box, located on the north wall next to the laboratory desk area, which contained information including but not limited to patient names, date of birth, medical record number, and copious confidential laboratory test and/or procedures. During an interview, at the time of the observation, Staff K stated the box contained approximately 250 patient order sets. Staff K acknowledged that housekeeping services staff could access information contained in the box and did not have a need to know the patient's medical information.

b. 3 standing shelving units, located on top of the island in the middle of the lab, which contained outpatient order sheets. Staff K stated the outpatient order sheets contained information including but not limited to patient names, date of birth, medical record number, and laboratory tests and/or procedures. During an interview, at the time of the observation, Staff K stated the shelving units contained approximately 30-50 outpatient order sheets "daily". Staff K acknowledged that housekeeping services staff could access information contained in the box and did not have a need to know the patient's medical information.

3. During an interview on 9/7/11 at 7:20 AM, Staff M, housekeeping services staff, acknowledged he/she cleaned the laboratory department daily at approximately 6:00 AM unsupervised by laboratory staff. Staff M stated, laboratory personnel "usually" arrive at approximately 7:00 AM. During a follow up interview on 9/12/11 at 10:10 AM, Staff M stated, "I heard this might be an issue and the lab manager said I needed to [speak] with her and see what needed to be done."

4. Review of hospital policy, "Patient Record Security" dated 2/11, revealed the following in part, "...Hardcopy (paper) records which are being stored temporarily in departments be accessible for patient care...will be secured in a non-public area with patient information no visible to the casual eye. These records will be in a locked area when staff is not present..."

5. During an interview on 9/6/11 at 3:15 PM, Staff N, the Radiology Manager stated housekeeping staff cleaned the radiology department in the evening unsupervised. Staff N
acknowledged housekeeping services staff could access patient medical record information and did not have a need to know the patient's medical information to conduct their job duties.

6. Tour of the radiology department on 9/6/11 from 3:15 PM to 4:00 PM revealed:

a. 4 upright shelving units, located in the radiology departments film room which contained approximately 700 film-file folders. During an interview, at the time of the observation, Staff N stated the folders contained the patients name, date of birth, and the physician's report [for the radiological film study] and diagnosis. Staff N acknowledged that housekeeping services staff could access information contained on the shelving units and did not have a need to know the patient's medical information.

b. 1 of 3 unsecured shred bins, located in the radiology file room. During an interview, at the time of the observation, Staff N acknowledged the unsecured shred bin and stated "anyone" including "housekeeping services staff" could access information stored in the shred bin. Staff N stated the shred bins contained documents that are to be discarded or destroyed that have patient information contained within the documents. Staff N stated, "I wasn't aware that it wasn't locked."

c. 1 upright shelving unit, located in the dictation room which contained approximately 1,500 mammogram and x-ray reports. During an interview, at the time of the observation, Staff N stated the shelving units contained information including but not limited to radiological reports, patient's names, date of birth, phone number and diagnosis. Staff N acknowledged that housekeeping services staff could access information contained on the shelving unit and did not have a need to know the patient's medical information.

d. 1 of 1 shelving unit located in the control room area, which contained approximately 50 outpatient forms. During an interview, at the time of the observation, Staff Q, Radiology technician, stated the shelving unit contained information including but not limited to patient's names, date of birth, phone number and address, insurance information and radiological procedures. Staff Q acknowledged that housekeeping services staff could access information contained on the shelving unit and did not have a need to know the patient's medical information.

7. During an interview on 9/6/11 at 3:46 PM, Staff P, housekeeping services staff, acknowledged he/she cleaned the radiology department daily at approximately 4:30 PM unsupervised by radiology staff. Staff P stated, "The radiology staff are gone, I'm here alone."

8. During an interview on 9/13/11 at 7:15 AM, Staff Y, Maintenance Director stated the shred bins located in the radiology department contained "patient information" and "a multitude" of additional information. Staff Y acknowledged the shred bin was unsecured and when he became aware of the situation he placed a lock on the bin immediately. Staff Y stated shred bins "should never be unlocked" and "nobody needs to see" the information contained in the bins".

9. Review of hospital policy, "Disposal of Confidential or Patient Related Documents" dated 9/11, revealed the following in part,..."This policy addresses what to do with those documents that do not belong in the patient's medical record or documents that are to be discarded or destroyed that have patient information contained within those documents...any documents with patient information that need to be destroyed will be taken to a locked receptacle within the facility...The receptacles will remain locked."





10. During a tour of the Health Information area on 9/7/11 at 8:45 AM, Staff G, Health Information supervisor (HIM), stated a basement room held the inactive and deceased patient medical records. A tour of the basement on 9/7/11 at 8:50 with Staff G revealed an unsecured room with shelving units that held approximately 80 plus boxes of inactive and/or deceased medical records. An open box revealed approximately 17 medical records that contained patient information including name, address, social security numbers, phone numbers, and medical services performed while in the hospital. Staff G confirmed the inactive and deceased patients' medical records contained the above medical and personal information.

a. Staff G acknowledged the room remained unlocked as several departments utilized the room for storage. Staff G confirmed all personal had access to the unlocked room and therefore, also to the information in the medical records. Staff G acknowledged the door to the room had a lock mechanism, but "staff does not use it."

b. Review of CAH policy, "Patient record security" dated 2/11 revealed in part,"...Pocahontas Community Hospital will secure patient health information throughout the facility ...
Inactive hard copy (paper) records will be stored in the basement area of the medical building ..."
VIOLATION: QA - MD/DO OVERSIGHT Tag No: C0339
Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician at the CAH evaluated the quality and appropriateness of the diagnoses and treatment of patient care furnished by 4 of 4 mid-level practitioners. (Practitioners A, B, O, and P) CAH administrative staff reported an inpatient census of 3 patients.
Failure to ensure the physicians evaluated the quality and appropriateness of the diagnosis and treatment of patient care furnished by the mid-level practitioners could potentially result in mid-level practitioners misdiagnosing patients and/or providing inappropriate or substandard patient care.
Findings include:
1. Review of the CAH's "Quality Improvement Plan", revised 10/09, lacked evidence of a requirement for the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by mid-level practitioners (Practitioners A, B, O, and P) by a physician at the CAH.
2. Review of the CAH's "Medical Staff Bylaws and Rules and Regulations", revised 4/10, lacked evidence of a requirement for the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by mid-level practitioners (Practitioners A, B, O, and P) by a physician at the CAH.
3. Review of Quality Improvement Committee Meeting minutes and Medical Staff Meeting minutes for September 2010 to September 2011 lacked evidence of evaluation of the quality and appropriateness of the diagnosis and treatment furnished by mid-level practitioners (Practitioners A, B, O, and P) by a physician at the CAH.
4. During an interview, on 9 /19/1 at 10:45 AM, the Director of Patient Care Services, acknowledged the lack of evaluation of the quality and appropriateness of the diagnosis and treatment furnished by mid-level practitioners (Practitioners A, B, O, and P) by a physician at the CAH. "The Mid-levels and their supervising physician do sit down and discuss patient care informally. But, these conversations are not documented and there is no way to know if there is an ongoing evaluation."
VIOLATION: QUALITY ASSURANCE Tag No: C0340
I. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 1 of 1 general surgeon selected for review received external peer review from an equivalent peer. The CAH administrative staff identified 7 general surgeons on courtesy staff.

The CAH administrative staff identified 46 general surgery procedures yearly.

Failure to ensure all medical staff members received external peer review from a equivalent peer could potentially expose patients to inappropriate medical care.
Findings include:
1. Review of credential Files from 9/7/11 to 9/12/11 revealed: General Surgery Physician H credential file lacked documented evidence of external peer review by a doctor of General surgery.
2. During an interview at the time of the credential file review, Staff H, Director of Patient Services/Credential files coordinator stated they sent medical records to their network hospital. The outside network hospital had the medical records reviewed by an Internal Medicine Physician/Hospitalist (Physician DDDD). The outside network did not have physicians with General Surgery privileges review medical records of patients that received care from Physician H. Staff H acknowledged that they failed to ensure the physician reviewer for Physician H had enough knowledge to appropriately evaluate the medical records presented. Staff H stated, "I wasn't aware that the external peer review needed to be completed by a physician from a respective practice or speciality."
3. Review of Physician DDDD's privileges, dated 7/31/09 revealed Physician DDDD was not credentialed to perform surgical procedures requiring general anesthesia.

4. Review of the policy "Medical Staff Peer Review" revision date 2/11, revealed in part, ..."Pocahontas Community Hospital and its medical staff are responsible for the quality of care provided to the patient...therefore it is the policy of Pocahontas Community Hospital to support the medical staff peer review process...Trinity Regional Medical Center will review 10% of those physicians...recredentialing by the hospital." The policy failed to address medical staff members selected for review received external peer review from an equivalent peer.

5. Review of "Summary of Peer Review Process for Pocahontas Hospital" dated and signed 9/8/11, by Staff H, revealed in part, ..."We have had a network agreement with Trinity Regional Medical Center (TRMC)...for many years. As part of this network agreement, TRMC is to provide for peer review for our physicians who perform hands on care to our patient or interpretation of testing performed here at our hospital...Our issues with this in the past have be related to what is considered "peer to peer"...This has been a broken process in the past but TRMC and Pocahontas Community Hospital have recommitted to the process...from a regulatory perspective to see that we are meeting our CAH regulations. It continues to be a work in progress."

II. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 9 of 23 medical staff members selected for review received external peer review prior to reappointment. The Director of Patient Care Services identified 92 active physicians.

The CAH administrative staff identified 618 initial interpretation of Teleradiological procedures yearly, 37 urology - Cystology procedures yearly and 2 Ears Nose and Throat (ENT) surgical procedures yearly.

Failure to perform peer review could potentially result in physicians providing inappropriate or dangerous care to patients.

Findings include:
1. Review of credential Files from 9/7/11 to 9/12/11 revealed:
a. Physician C, Teleradiologist, credential file lacked documented evidence of external peer review prior to Medical staff approving reappointment on 8/18/11. Additionally the Medical Staff recommended reappointment to the Board of Trustees on 8/18/11.
b. Physician D, Teleradiologist, credential file lacked documented evidence of external peer review prior to Medical Staff approving reappointment on 2/15/11 and Board of Trustees approving reappointment on 2/28/11.
c. Physician E, Urologist, credential file lacked documented evidence of external peer review prior to Medical Staff approving reappointment on 10/28/09 and Board of Trustees approving reappointment on 11/30/09.
d. Physician F, Cardiologist, credential file lacked documented evidence of external peer review prior to Medical Staff approving reappointment on 2/13/11 and Board of Trustees approving reappointment on 2/28/11.
e. Physician I, Teleradiologist, credential file lacked documented evidence of external peer review prior to Medical Staff approving reappointment on 4/19/11 and Board of Trustees approving reappointment on 4/25/11.
f. Physician K, Teleradiologist, credential file lacked documented evidence of external peer review prior to Medical Staff approving reappointment on 12/23/09 and Board of Trustees approving reappointment on 12/23/09.
g. Physician L, Teleradiologist, credential file lacked documented evidence of external peer review prior to Medical Staff approving reappointment on 6/21/11 and Board of Trustees approving reappointment on 6/28/11.
h. Physician M, Teleradiologist, credential file lacked documented evidence of external peer review prior to Medical Staff approving reappointment on 4/19/11 and Board of Trustees approving reappointment on 4/19/11.
i. During an interview on 9/7/11 at 3:00 PM, Staff H stated Teleradiologists would do preliminary readings after hours and on weekends. Staff H continued, "There would be a potential that a physician would treat a patient at our hospital based on that preliminary reading."
j. Physician N, Ears-Nose-Throat surgeon (ENT) credential file lacked documented evidence of external peer review prior to Medical Staff approving reappointment on 12/22/09 and Board of Trustees approving reappointment on 12/23/09.
2. During an interview on 9/8/11 at 9:32 AM, Staff H acknowledged Physician's C, D, E, F, I, K, L, M, and N's credential files lacked documented evidence of external peer review prior to Medical Staff and Board of Trustees approval for reappointment. Staff H stated medical staff is informed at the time of reappointment verbally "by myself that everything is OK". Staff H verified the Medical Staff Committee "have been aware that external peer reviews were not back at the time of reappointment." Staff H stated, "They [Medical Staff] still sign off that physician for reappointment." Staff H continued, "If there was an issue with that late external peer review, I would address it immediately with the medical staff president."
3. During an interview on 9/8/11 at 9:55 AM, Physician CCCC, Chief of Medical Staff stated the purpose of credential review for reappointment of a physician "is to identify any care concerns with the practitioner." Physician CCCC continued, "We [Medical Staff] would approve that providers reappointment even if there was no external peer review report." Physician CCCC stated he was unaware that the "external peer review reports needed to be present and reviewed by medical staff" prior to reappointment. Physician CCCC acknowledged Staff H provided a verbal review of physicians that "are going to be approved" to the medical staff committee and "our decision to either approve or disapprove the physician for reappointment would go on to the Board of Trustees."
4. During a follow up interview on 9/8/11 at 9:45 AM, Staff H acknowledged external peer review "is a part of the recredentialing process". Staff H stated, "I have not discussed the late external peer review reports with the administrator." Staff H continued, "The bylaws state the physician up for reappointment must furnish information for external peer review. If we [Pocahontas Community Hospital] don't have this information we shouldn't approve that physician."
5. During an interview on 9/8/11 at 3:00 PM, Staff X, Director of Patient Quality stated, "We discovered late last year that we [Pocahontas Community Hospital] were not meeting the requirements for credentialing."
6. During an interview on 9/12/11 at 1:15 PM, Physician EEEE, Medical Staff/Credentialing Committee Member acknowledged the Medical Staff committee failed to review external peer review reports prior to reappointment. Physician EEEE stated [Staff H] verbally informed the medical staff committee "if there were any problems." Physician EEEE stated, External peer review was "A quality of practice if you have questions on the care and services provided to a patient by a physician." Physician EEEE acknowledged the medical staff failed to comply with external peer review requirements, "I would say we're on the outs."
7. During an interview on 9/13/11 at 1:30 AM, the Chief Executive Officer (CEO) acknowledged the CAH failed to ensure medical staff members received external peer review prior to reappointment. The CEO stated he "became" aware of "the situation" when the survey team identified concerns "last week". The CEO stated the hospital intended to address the "obvious mistakes" with external peer review and "implement" a new process.
8. Review of "Position Description for the Director of Patient Services" revealed in part, "...Coordinates Continuous Quality Improvement (CQI)...ensures department standards and monitoring procedures are consistent with goals and objectives of Pocahontas Community Hospital CQI programs, relevant legal and regulatory requirements...Coordinates hospital compliance to...CAH regulations...Coordinates Medical Staff Meetings (Agenda...quality audits)."
9. Review of "Agreement for Chief of Services" with Physician CCCC, revealed in part, "...Accept committee appointments...to serve on various hospital committees relating to In-patient services...Reviews Total Quality Management Programs...Provide consultation and direction to staff and physician members of Medical Staff concerning In-patient services...serve as a consultant to physicians...on clinical issues related to patient care...as well as on issues concerning compliance within the In-patient services...with hospital Medical Staff Bylaws, rules and regulation."
10. Review of "Pocahontas Community Hospital Medical Staff Reappointment Flow Sheet" revealed in part, "...charts pulled/sent for peer review...completed reappointment packet is received and report from peer review...completed packet reviewed by Pocahontas Community Hospital Administrator and Medical Staff Executive/Credential Committee...Reappointment Form presented to full Medical Staff for opinion...Medical Staff recommendation taken to Hospital Board of Trustees...Final decision made by Hospital Board of Trustees."
11. Review of CAH policy "Medical Staff Peer Review" dated 2/11, revealed in part, "...It is the policy of Pocahontas Hospital to support the medical staff peer review process...all cases undergoing peer review will have a worksheet completed that lists the ration for the conclusion made by the peer reviewer...results of peer review are utilized at the time of the medical staff reappointment."
12 . Review of "Pocahontas Community Hospital Bylaws" dated 12/18/07, revealed in part, ..."The medical staff shall conduct review and appraisal of the quality of professional care rendered by the hospital, and shall report such activities and their results to the Board of Trustees...The Medical Staff shall make recommendation to the Board of Trustees concerning...Reappointments...and granting of Clinical Privileges."
13. Review of "Pocahontas Community Hospital Medical Staff Bylaws and Rules and Regulations" dated 4/29/10, revealed in part, ...This Medical Staff is organized to...establish an organization to which the Board of Trustees can initially delegate medical care and peer review responsibilities, and which can assist the Board in over-seeing the provision of medical care services at the hospital, delineating the clinical privileges that each physician may exercise in the hospital, and evaluating each practitioner's performance...The following shall be express conditions on the application for, or the holding or exercise of, membership and privileges at the hospital. Each applicant and each member hereby expressly...authorizes this hospital, its Board of Trustees...and this Medical Staff...to request, receive, furnish, consider, and act upon all relevant information bearing upon such practitioner's qualifications or performance...agrees to furnish upon request all information in his or her procession which may be relevant to peer review." The Medical Staff Bylaws failed to address a requirement for external peer review as a condition for physician reappointment to Medical Staff.
14. Review of "Summary of Peer Review Process for Pocahontas Hospital" dated and signed by Staff H on 9/8/11, revealed in part, "...As per our hospital bylaws, it is our process to have the peer review completer prior to reappointment we continue to try to come up with a better schedule for this process to get our charts turned around in a more timely manner."

III. Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure all physicians that provided care and services to CAH patients were members of Pocahontas Community Hospital's medical staff. The Director of Patient Care identified 20 Holter monitor tests yearly and 5 Event monitor tests yearly.
Failure to appoint physicians to the medical staff potentially places patients at risk of misdiagnosis and inappropriate treatment.

Findings include:

1. Review of medical records and documentation dated 9/8/11 showed 17 of 17 physician's ordered and interpreted Holter and event monitor testing for 27 CAH patients. The governing body and medical staff failed to credential and privilege these physician's to provide patient diagnosis and treatment at Pocahontas Community Hospital. According to Staff H Pocahontas CAH staff sends the Holter and event monitors to outside cardiology groups for interpretation. However, Pocahontas Community Hospital does not credential some of the physicians providing interpretations.

2. Review of "Pocahontas Community Hospital Bylaws" dated 12/18/07, revealed in part, "...Only an appropriately licensed physician with clinical privileges shall be directly responsible for a patient's diagnosis and treatment within the area of his/her privileges."
VIOLATION: RESIDENT ASSESSMENT (483.20(B)(1)) Tag No: C0388
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of the Critical Access Hospital's (CAH) documents, medical records and staff interviews, the CAH Activity and Nursing staff failed to complete comprehensive assessments for 2 of 2 Swing Bed in-patients (Patient #26 and 27) and 5 of 5 closed Swing Bed patient (Patient #28, 29, 30, 31 and 32) medical records reviewed.

The CAH administrative staff reported a census of approximately 2 Swing Bed patients.

Failure to complete the comprehensive nursing assessments prevented the nursing staff from identifying significant changes in a patient's skin and resulted in the patient suffering hospital acquired pressure ulcers.

Failure to complete the comprehensive activities assessment could potentially result in staff failing to identify a patient's interests in order to provide activities that encourage the patient's physical and psychological well-being potentially resulting in longer recovery time.

Findings include:

1. Review of Patients #26, 27, 28, 29, 30, 31 and 32's medical records revealed the patients received Swing Bed care treatment while in the CAH. However, the medical records lacked complete nursing and/or activity comprehensive assessments during the Swing Bed patient's hospital stay.

a. Patient #26's Swing Bed medical record revealed Patient #26's admission to the Swing Bed care unit on 8/15/11 for wound care, antibiotic treatment, Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) due to an incision from an infected right hip replacement and swallowing difficulties. Staff failed to remove the patient's Ted hose and complete a comprehensive skin assessment, that included the patient's legs, causing the patient to suffer hospital aquired pressure ulcers.

Patient #26's Swing Bed initial assessment dated [DATE] revealed in part, "...surgical site right hip with staples superficial abrasion right elbow, red right heel. Red excoriated groin area..."

Patient Care Flow sheets dated 8/15, 18, 19, 20, and 21/11 lacked documented evidence that staff removed Patient #26's ted hose for a complete skin assessment.

Patient Care Flow sheets revealed:

8/17 at 8:45 AM pain medication given for "C/O [complained of] heel and coccyx pain..." the nursing notes lacked documented evidence of an assessment of the heel pain
8/18 at 4:00 PM "rash on upper legs abdomen looks same..." The nursing notes failed to note removal of ted hose for the assessment of the lower legs.
8/20/11 at 9:00 PM, "uses triangle above head to re-adjust self often..."
8/21/11 at 1:25 AM, "continues to move a lot in bed, pulls on triangle frequently...2:00 abductor pillow remains in place and secured with ace wrap..."
8/21/8:30 AM "air mattress on and working...1:20 PM Partial bed bath given. Bottom remains red, superficial, no open areas noted...3:00 PM, Air mattress on...5:00 PM bed lowered pillow placed under legs for comfort..."
8/22/11 at 7:30 AM "foam splint in place between legs...10:30 AM Dressing changed to buttocks - Polymem replaced- 1 inch diameter serous sanguinous drainage noted on chux. Sore area on buttock remains raw..."
8/22/11 at 7:00 PM "C/O pain in the tail-bone area. C/O pain above right ear, ulcerated area noted approximately 3 cm in size above right ear. Some oozing with dried crusted areas noted..."
8/22/11 at 11:30 PM, "Ted hose removed...area around coccyx reddened and broken down - appears much worse than yesterday-more beefy red with deeper areas white in color. Pictures taken. Several areas dark purple to black in color on ankles/feet. Abductor pillow removed - rolled on to left side and propped with 3 pillows. 2 pillows in-between legs. Incision site to right hip well approximated without drainage, staples intact.
Areas to feet/ankles are as follows:
1. Right outer ankle 5.5 cm X 5 cm purple in color, intact
2. Right lower leg outer aspect 6 cm X 2.5 cm and intact
3. Area right above #2 1.5 cm X 0.8 purple, intact
4. Right lower leg anterior side 5.5 X 0.5 cm dark purple and intact
5. Right foot 5 th digit (small toe) 1.3 cm X 0.2 cm dark purple and intact
6. Right great toe 2.5 cm X 0.2 cm dark purple and intact
7. Right lower leg posterior aspect is 1.6 X 0.4 cm and 2.1 X 1.5 cm
8. Right foot inner aspect 1.9 cm X 3.7
cm (area by great toe/base of great toe) area is dark black in color with dark red surrounding the edges
9. Inner aspect of right foot between ankle and foot 4.0 cm X 3.0 cm, odd shape dark red in color with overlay of a blister area
10 Inner right ankle 1.8 cm X 2 cm, dark purple with blistered area covering area
11 Left foot 5 th digit (pinkly toe) outer side 2 X 1.2 CM light purple in color
12 Left outer heel reddened in color
Info given to supervisor re: area will notify next shift to notify [Physician]
8/23/11
6:00 AM another area on right heel #13 5 cm X 6 cm dark purple to black in color - currently not open
Add: pictures taken of all areas documented

Patient #26's "Skin/Wound Flow sheet" revealed the following:

8/15 through 8/21 (lacked notation for 8/19/11) two areas reviewed by nursing, the coccyx and right heel. Nursing note on skin sheet revealed daily documentation, the heel to be "motioned and off bed"

8/22/11 documentation notes:
1. Right outer ankle 5.5 cm X 5 cm purple in color, intact
2. Right lower leg outer aspect 6 cm X 2.5 cm and intact
3. Area right above #2 1.5 cm X 0.8 purple, intact
4. Right lower leg anterior side 5.5 X 0.5 cm dark purple and intact
5. Right foot 5 th digit (small toe) 1.3 cm X 0.2 cm dark purple and intact
6. Right great toe 2.5 cm X 0.2 cm dark purple and intact
7. Right lower leg posterior aspect is 1.6 X 0.4 cm and 2.1 X 1.5 cm
8. Right foot inner aspect 1.9 cm X 3.7 cm dark black, dark red surrounding the edges
9. Inner aspect of rt foot between ankle and foot 4.0 cm X 3.0 cm, dark red & a blister area
10 Inner right ankle 1.8 cm X 2 cm, dark purple with blistered area covering area
11 Left foot 5 th digit (pinkly toe) outer side 2 X 1.2 CM light purple in color
12 Left outer heel reddened in color
13 Right heel 5 cm X 6 cm dark purple to black in color not open

Observation on 9/12/11 at 1:00 PM, Staff S, Registered Nurse (RN), completed the treatment to Patient #26's pressure ulcers. Patient #26 sat in a recliner with a pillow under both feet and a pressure-relieving boot covered the right foot. Removal of the boot revealed skin pressure ulcers on the lateral and inner side of lower leg, inner and lateral side of right foot, around the inner and outer ankle areas and toe areas. Left foot noted pressure ulcers on the toe area and above left outer ankle area. Staff cleansed each area with normal saline then applied Betadine to each area. Each ulcer measured and photographed during the treatment. Coccyx area covered with dressing after treatment in the AM prior to surveyor's arrival.

During an interview on 9/12/11 at 2:30 PM, Staff I, RN confirmed Patient #26's did not have any pressure ulcers on right lower leg and/or foot. Staff I stated the patient had a foam wedge between the legs to keep hips in alignment. The patient rubbed the right leg up and down on this wedge; this may have caused the pressure ulcers on the inner right leg. Staff I was not aware of anything placed between leg and wedge for protection.
Staff I stated staff placed a bed trapeze Patient #26's bed for the patient to use when repositioning in bed. Staff I stated, "The patient would push with the heels of the feet to rise up in bed, this could have helped cause the heel ulcer." Staff I confirmed the ted hose would cover the heel of the foot. Staff I stated the ted hose were not removed every shift as per the daily flow show sheet instructed. Staff I stated removal of the ted hose caused Patient #26 pain, so the nurses, "were not always removing the ted hose every shift."

During an interview on 9/12/11 at 3:13 PM Staff E, RN, stated when Patient #26 arrived to the CAH, the Physician ordered "Non-weight bearing". Staff E stated the patient had a foam wedge between the legs to keep hips in alignment. Staff E stated the patient would rub legs on the wedge and this may have contributed to the pressure ulcers on the inner legs. Staff E stated the patient pushed with both heels to help raise self in bed. Staff E unaware of when staff placed or removed the trapeze. Staff E stated the nursing documentation did not reflect the removal of the hose every shift as the daily sheet instructed.

During an interview on 9/12/11 at 3:45 PM, Staff S, RN, stated at admission Patient #26 did not have pressure ulcers on the lower right leg or foot. Staff S stated at admission the patient had ted hose and a wedge between the legs for hip alignment. Staff S a nurse placed an ace wrapping around the patient's legs and wedge to keep the wedge in place. Staff S stated the patient rubbed the right leg against the wedge, "this may have caused the inner right leg pressure ulcers". Staff S unaware of any prevention measure placed between legs and wedge for prevention.
Staff S stated a bed trapeze placed over the patient's bed to assist with self-reposition. Staff S stated the patient used both heels to push self up in bed and "probably caused the heel ulcer".

During an interview on 9/13/11 at 7:00 AM, Staff J, RN, stated during routine care of Patient #26 the coccyx appeared more reddened and after removal of the ted hose, Staff J found the lower leg and feet pressure ulcers. Staff J stated she notified, Staff H, Director of Patient Care. Staff J stated both of the nurses looked at the pressure ulcers and Staff J documented and photographed the ulcer areas. Staff J stated reported the pressure ulcers to the oncoming nurse for Physician notification.
Staff J stated the patient's wedge between the legs was cumbersome and caused the patient pain. Staff J stated the treatment or did the pedal pulse assessment require the staff to remove the ted hose. The nurses did not remove the ted hose routinely due to the pain it caused the patient.
Staff J unaware of a policy for wounds or ted hose. Staff J unaware of policies on the computer or how access them. Staff J unaware of when staff placed the long brace, short boot or bed trapeze for the patient.
Staff J stated, "I have learned the ted hose must come off" for a skin assessment.
Staff J stated when the pressure ulcers were found, I told Staff H, "I felt like we [nurses] failed the patient." when the nursing staff failed to remove the ted hose to a complete skin assessment.

During an interview on 9/6/11 at 3:45 PM, Staff H, Director of Patient Care, reviewed Patient #26's Swing Bed medical record and acknowledged the lack of a comprehensive activity assessment. Staff H stated the nursing daily assessment did not reflect the consistent removal of the ted hose as per the daily sheet instructs. The care plan did not provide added interventions for pressure reducing measures after the pressure ulcers developed.

Follow up interview on 9/12/11 at 4:15 PM, Staff H stated Patient #26's pain issues were the concern when the patient arrived. Patient #26 had a foam wedge between legs and ted hose on when arrived at the CAH. Staff H stated the patient rubbed right leg against the wedge due to the pain. Staff H stated the nursing charting did not reflect consistent removal of the ted hose. Staff H stated the nurse found the pressure ulcers when she removed the ted hose on 8/22/11. Staff H stated straps on the wedge held it in place, when the patient pulled the right leg up the friction may have caused the outer leg pressure ulcers. Staff H stated the leg rubbed against the wedge could have caused inner leg pressure ulcers, "the patient was restless."

Staff H stated a bed trapeze placed over the patient's bed to assist with self-reposition. Staff H unaware how long the patient had the trapeze, but used it to assist with raising self in bed by pushing with the heels of feet, this may have added to the cause of the heel ulcer. Staff H stated staff tried several preventive measures, a bed trapeze, long brace, short boot, float heels off the bed and special mattresses. Staff H unaware of when each of these preventative measures started or stopped. Staff H stated the medical record does not reflect when measures started or stopped. Staff H unaware of preventive measures applied between leg and wedge to decrease friction.

During an interview on 9/14/11 at 7:45 AM, Practitioner CCCC stated Patient #26 arrived at the CAH in poor condition, with ted hose and a foam wedge between his legs. The patient moved the right leg against the wedge and caused friction on the inner leg and foot. This friction caused the inner pressure ulcers. Practitioner CCCC stated "the pressure ulcers to the inner leg and foot were unavoidable" due to the orthopedic physician wanted the wedge to remain. Practitioner CCCC stated he was unaware if staff placed preventive measure to reduce the friction between wedge and legs. Practitioner CCCC unaware if the CAH had a wound and/or ted hose policy to follow. Practitioner CCCC stated if the CAH did not have a ted hose policy, then they should follow the daily care sheet of ted hose off 1 hour every 8, "I would think that would be adequate."

Practitioner CCCC stated when Patient #27 arrived at the CAH, the nursing staff noted a soft spongy heel, care should have been taken to prevent this ulcer, and this ulcer was avoidable.

b. Patient #27's Swing Bed medical record revealed Patient #27's admission to Swing Bed care from 8/5/11 for strengthening therapy and Antibiotic treatment from pneumonia.

The admission assessment stated ecchymosis of hands and arms healed, low back laminectomy scar pink and intact with 8 cm ecchymosis right hip.

Review of the Patient care Flow Sheets revealed the following

8/24/11 at 8:00 PM "...left heel has red area 1/2 dollar size, place pillow under legs to float heels..."
8/26/11 at 6:45 AM, "...small amount incontinent in brief. Buttock pink with very shallow open area right buttock..." 9:00 PM, "Patient noted to be incontinent of urine...peri cares provided..."
8/28/11 at 6:50 PM, "Assessment completed. Patient sitting up in chair, Patient complains bottom being sore from sitting..."
8/29/11 at 5:15 AM, "...Noted two open areas to buttock. Area on right cheek measure 1.2 cm X 0.8 cm. Area on left check measures 0.4 X 0.2 cm. Barrier cream applied..."
8/30/11 at 5:00 PM, " open area right buttock dime size. White barrier cream applied..."
9/1/11 at 9:15 AM, "...Incontinent of mod amount of urine...Polymem applied with paper tape to dime sized decubitus..."
9/8/11 at 9:00 AM, "...Patient told Physical Therapist he/she had a sore spot on the left lateral heel...1 cm red area patient states is tender to touch, obtained heel protector to apply after shower..."
9/12/11 at 7:45 PM, "...lotion applied to legs and feet, heel protectors reapplies..."

Patient #27's "Skin/Wound Flow Sheet" revealed the following:

8/29/11 site 1-Right buttock cheek stage 2 measured at 1.2 X 0.8 cm, site 2- left buttock cheek stage 1 measured at 0.4 X 0.2 cm
8/30/11 and 8/31/11 lacked documentation
9/1/11 site 1 "dime sized" stage 2 Polymem applied with paper tape, site 2- 1 cm stage 1
9/2/11 site 1 stage 2 1 cm yellow shallow center Polymem opsite
9/3/11 site 1 "...same as above entry Polymem with paper tape..."
9/6/11 site 1 "...same as above..."
9/8/11 site 1 Polymem - opsite around,
9/8/11 site 3 stage 1 1 cm heel slow to heal

Review of the remaining of the skin sheets dated until 9/12/11 revealed no changes to site 1 or site 3.

Although, according to the Patient Daily sheet, Patient #27 complained of pain in left heel, that nurse noted area red, and tender to touch on 8/24/11. The skin flow sheet lacked documentation of the heel until 9/8/11 when, according to the nurse's note, the patient complained of a sore left heel to the Physical Therapist.

Review of the Physician progress notes from 8/1/11 through 9/12/11 lacked documentation that showed the Physician was aware of the patient's sore heel. Review of the Physician progress note dated 9/1/11 revealed in part, "I did stand patient to look at the pressure sores. The one pressure sore is about 5 mm and the other 2 mm. We will go ahead and put duoderm on those..."

During an interview on 9/19/11 at 9:45 AM, Staff H, RN Director of Patient Care, stated Patient #27 did not have skin break down or complaints of heel pain on admission. Staff H stated the medical record lacked documented evidence the staff notified the Physician of the coccyx area until 9/1/11 when the Nurse Practitioner noted the pressure sores in the progress notes. Staff H confirmed the medical record lacked documented evidence the staff notified the Physician of the sore heel.

Staff H stated, "The coccyx continues to be treated and the wound nurse has taken over."
Staff H stated the care plan needed updated to reflect the pressure area on the coccyx and the sore heel. Staff H stated, the nursing staff should have updated the care plan when the patient had a change in condition. Staff H stated the nursing staff is to notify the Physician of patients' change of condition.

Staff H reviewed the medical record and confirmed the Patient #27's updated care plan was incomplete and not individualized to their needs. Staff H confirmed the care plan lacked additional information on the developed pressure ulcers on the coccyx and reddened heel areas.



c. Patient #31's Swing Bed medical record revealed Patient #31's admission to the Swing Bed care from 6/21/11 through 7/1/11. Review of the History and Physical dated 6/21/11 revealed in part, "...open wounds...left lower leg of about 2 cm in size...oozing clear serous drainage. Wound measured 2.4 x 0.5 x 0.1 cm...slight exudative material over the surface as well as small amount of necrotic tissue...debrided wound...There were a couple of smaller areas that were barely open on the right leg and were not addressed..."

Patient #31's uncompleted admission assessment dated [DATE] with addendum dated 6/21/11 revealed in part, "cellulites bilateral legs, bruises on right leg purple in color painful right leg..." The medical record lacked the 4 th page to the admission assessment, revised 10/10, this page held information on the systems for urinary issues of continence, muscular issues of weakness/muscle cramps/swelling/deformities, Neuro issues of fainting/convulsion/orientation/memory loss/behaviors/depression/numbness/walking. The area for Nursing Care Concerns for nursing diagnosis addressed a quick short summary of the issues the admitting nurse found on the patient. Without this information, the nursing staff failed to complete a comprehensive assessment for Patient #31.

Patient #31's Patient Care Flow sheets revealed the following:

6/21/11 at 11:00 AM, "Wound Care completed as ordered. Ted stocking on as ordered..." 12:30 PM, "...Patient not wanting to go for a walk due to leg hurting..." 1:30 PM, "...Patient complains of right knee pain..." 10:15 PM, "...stockings removed bilateral legs..."
6/22/11 at 10:00 AM, Dressing changed completed after shower, scant amount of serous drainage noted from legs, warmth and swelling. Complains of pain with touch." 8:15 PM, "...Aquaphilic applied to bilateral lower legs..."
6/23/11 at 6:45 AM, "...Dressing to bilateral legs intact..." 10:45 AM, "Dressing change completed as ordered..." 7:50 PM, "...Dressing to right lower leg noted to be saturated. Dressing changed and feet elevated on pillows..."
6/24/11 at 7:00 AM, "...complains pain in sores on legs. Right leg undressed, left has gauze dressing which is dry..." 11:15 AM, Wounds on legs cleansed with normal saline, Aquaphilic applied to dry skin. Wound gel to open areas, covered with 4 X 4 and wrapped with Kerlix and thin Tubigrip applied...still feels a tingling in legs..." 1:00 "[Practitioner EEEE} in to look at patient's leg wounds, redressed as done before today..." 10:30 PM, wound treatment to bilateral legs complete, drainage noted on stockinet area cleaned and re-wrapped as order. Patient tolerated procedure will. Legs up on pillow for comfort..."
6/25/11 at 4:30 PM "...Drainage - moderate amount light yellow drainage noted on right lower leg. New dressing applied and re-wrapped with Kling and Adaptic applied..."
6/26/11 at 3:30 AM, "...patient started in complaints of leg pain and how worse the area on right calf was. Advise patient that spot is getting smaller and is getting better. Patient then started on some other problem..." 9:00 AM "Dressing changed to lower legs, unwrapped ace at 3:00 PM..." 10:00 PM, dressing change done...daughter was able to observe condition of legs. Left leg had large amount of seepage on dressing. Patient asked when this would stop, advised patient as soon as the fluids disappear then it will quit. Advised patient and daughter that the swelling has decreased, the spot on right calf is getting smaller. Patient legs up on pillows for comfort..."
6/27/11 at 7:00 AM, "...patient states 'legs hurt' but could not specify pain level. Denies need for medication. Gauze dressing intact to bilateral lower extremities, scant, dry serous drainage noted to both dressings..."
6/28/11 at 6:50 AM, "...No dressing on legs. 8 inch diameter area of drainage on Chux under right leg. More redness noted in left leg than right." 9:45 AM, "...More swelling in lower legs, skin is tight and shiny. Wounds rinsed with normal saline. Wound gel applied to each. Covered with 4 X 4, wrapped with Kerlix then wrapped with 6-inch ace bandages. Serous drainage noted from right wound. Aquaphilic ointment applied to both legs before dressing..." 10:40 PM, "...Ace wraps taken off bilateral lower legs. Right leg saturated with serous drainage, changed dressings to right leg with dry fluff..."
6/29/11 at 2:20 AM, "...Dressing to right leg changed due to previous dressing saturated with serous drainage..." 7:00 AM, "...Serous drainage from both leg wounds noted on dressing. More edema noted in lower legs and feet this am." 11:00 AM, "Wounds on both legs cleansed with normal saline. Wound gel applied. ABD placed to cover dark scabbed area posterior right leg. 4 X 4's to wound on left leg. Both wrapped with Kerlix then wrapped with ace bandage. Edema is less in right leg...more redness in left leg then right." 8:00 PM, "Assessment complete, dressing change to legs bilateral. Right leg with dark red/black silver dollar wound to lateral calf. Cleansed with normal saline, wound gel applied, covered with ABD and wrapped with puff roll. Left leg with sore to skin with serous drainage, Cleansed with normal saline and wound gel applied. Covered with ABD and wrapped in puff. Aquaphilic applied to both calves bilateral..."
6/30/11 at 10:00 AM, "Dressing change done to bilateral lower legs as per protocol (Tegaderm) wound gel, Aquaphilic, Telfa, Kling and Adaptic applied..." 7:10 PM, "...Assessment done, bandage intact with some drainage noticed bilateral legs..." 8:00 PM, "Stockings removed bilateral legs. Bandage removed, wound cleansed bilateral legs, new Telfa on drainage sites. Aquaphilic and new bandage wrap around bilateral legs..."
7/1/11 at 7:20 AM, "Dressing removed from lower legs. [Practitioner EEEE] injected xylocaine 3 ml to right lower leg hematoma site. Skin removed and small pieces of clotted blood, irrigated vigorously with normal saline. Wound gel 4 X 4 and Kerlix...tolerated with small amount of discomfort...wound measures 3.3 cm X 2.3 cm and 0.2 cm deep." 9:00 AM "...Aquaphilic to lower legs. Wound gel to superficial open area 1.5 cm X .75 cm left anterior lower leg. Covered with 4 X 4, leg wrapped with Kerlix, Ace wraps to lower legs."

Patient #31's medical record lacked Physician admitting orders with treatment orders for lower legs. Although the History and Physical dictated by the Physician did note open wounds, the documentation lacked measurement of the wounds treated during patient stay until 7/1/11, date of discharge. Nursing documentation on admit stated, "Wound Care completed as ordered. Ted stocking on as ordered..." the medical record lacked a physician order.

Patient #31's medical record lacked a comprehensive nursing and/or Activity assessment during the patient admission to swing-bed level care.

During an interview on 9/8/11 at 10:45 AM Staff V, RN, reviewed the medical record and confirmed the medical record lacked admission orders for Patient #31. Staff V confirmed the medical record lacked documentation of open wounds on admit. Staff V stated the Physician wound treatment order would be on the admit orders, since there is no admit orders, we have no treatment order. Staff V stated, "The Physician orders start on 6/22/11, it is like some pages are missing." At 1:05 PM, Staff V returned and stated the Health Information (HIM) supervisor reported the HIM staff found no other papers for this patient.

On a follow up interview on 9/14/11 at 9:50 AM, Staff V reviewed Patient #31's medical records and confirmed the record did not contain skin/wound flow sheets. Staff V stated, "I do not remember this patient having an open area." Staff V stated if staff documented they performed dressing changes then "this patient must have had an open wound." Staff V confirmed the last page of the nursing admission assessment and stated, "The nurses are to complete the full nurse assessment". Staff V stated the nursing staff reviews all patient issues for a complete assessment and document nurse/patient concerns on the "Admission Assessment".

During an interview on 9/8/11 at 8:10 AM, the Activity Coordinator reviewed Patient #31's Swing Bed medical record and confirmed the medical record lacked an Activity comprehensive assessment.

d. Patient #32's Swing Bed medical record revealed Patient #32's admission to the Swing Bed care from 5/31/11 through 6/23/11 for weight bearing as tolerates, due to post op left hip hemiarthroplasty regards to left femoral neck fracture.

Patient #32's "Admission Assessment" lacked the completion of the second page that reviewed living arrangements, fall assessment, History of wandering, assistive device used, weight bearing, nutritional screening, infection control screening and functional status for feeding, oral care toileting, positioning and transferring.

Review of the Patient Care flow Sheet revealed in part,

5/31/11 at 7:00 PM, "...Patient has abrasion left knee..."
6/1/11 at 8:00 AM, "...Incision dressing change moderate amount of serosanguineous drainage noted."
6/2/11 at 8:30 AM, "...moderate amount of serosanguineous drainage noted on dressing...Bruising noted on left leg dorsal aspect from thigh all the way down to knee."
6/4/11 at 8:15 PM, "...4+ pitting edema to left leg and ankle/foot, 3+ to right leg/ankle/foot..."
6/8/11 at 9:00 AM, "Sutures removed..." 9:10 AM, "Wound dry, approximate with no drainage"
6/9/11 at 7:00 AM, "...Moderate amount of bright red drainage from surgical site, band aid applied..."
6/10/11 at 3:00 AM, "Incision site drainage dark red blood area cleaned, new bandage put on. The drainage stopped..." 7:00 AM, "...Small amount of serous drainage from surgical site, band-aid intact." 7:10 PM, "...Dressing changed on left hip, still small amount of dark red drainage..."
6/11/11/ at 11:00 AM, "...Dressing change done to left hip, small pea-size" area drainage, red drainage-scant amount...no new areas of drainage noted..."
6/12/11 at 7:30 AM, "...Dressing saturated with moderate amount of bright red blood..." 10:40 AM, "...New steri-strips applied X [times] 3 to left hip wound, small amount of drainage noted."
6/12/11 through 6/21/11 the nurses documented incision dry and intact or small amount of red bloody drainage.
6/22/11 at 7:30 AM, "Physician in. Left hip open area probed...dark sanguineous drainage expressed, Hydroperoxide swabbed into opening, covered with 4x4s...assisted up to drain incision, healed except for pea size open area distal end..."
6/23/11 at 7:15 AM, "...Left hip with scant dark bloody drainage covered with 4x4." 8:35 AM, "Patient discharged ..."
Patient #32's medical record lacked skin/wound flow sheets, comprehensive nursing and activity assessments during the patient admission to swing-bed level care.

During an interview on 9/14/11 at 7:50 AM, Staff H, reviewed Patient #32's medical record and confirmed the nursing staff failed to complete the "Admission Assessment". Staff H stated the nurses filled out the assessment for a complete and comprehensive assessment to identify all issues and concerns of the nurse and patient.

During an interview on 9/8/11 at 8:10 AM, the Activity Coordinator reviewed Patient #32's Swing Bed medical record and confirmed the medical record lacked an Activity comprehensive assessment.

A follow up interview on 9/8/11 at 8:30 AM, the Activity Coordinator stated it was their responsibility to fill out the "Plan of Activities" form for all Swing Bed Patients as the comprehensive assessment. The Activity Coordinator acknowledged the closed Swing Bed medical records review did not have a Plan of Activity form and stated, "I am not sure why the closed records do not have an activity assessment, I know I fill one [Plan of Activity form] for each patient."

During an interview on 9/12/11 at 4:15 PM, Staff H stated the nurse did not address wounds consistently in the Daily Patient care sheet and the skin/wound flow sheet. The nursing staff failed to follow nursing policies for wound/ulcer care, admission assessments, Ted Hose and/or care plans. The nursing staff did not routinely measure and document the pressure ulcers when developed on patient in the CAH. The nursing staff did not routinely start a skin/wound flow sheet on pressure ulcers/wounds on admit or pressure ulcers/wounds acquired while in the hospital.
Staff H stated the nursing documentation on the wounds was confusing, "I would expect the nurses to document changes in condition, dressing changes and any treatment changes." Staff H stated, the CAH has 2 Enterostomal (wound) nurses that were not utilized as they should have been. Staff H stated, "The current process is lacking".

During an interview on 9/14/11 at 9:00 AM, Staff X, Quality Assurance, stated QA did not address CAH acquired pressure ulcers or wounds unless they become a trend. Staff X went on to say, the incident reports for the pressure ulcers and wounds need to be filled out by the nursing staff or QA would not have any way to know of the pressure ulcers. Staff X stated, "I would expect an incident report to be made out for any wounds developed in the hospital." Staff X stated the nurses were educated to fill out an incident report for all sudden changes in a patients' condition. Staff X stated there were no incident reports for hospital-acquired pressure ulcers in the past year. (Refer to C-337)

e. Patient #28's Swing Bed medical record revealed Patient #28's admission to the Swing Bed care from 5/13/11 through 5/16/11 for Oxygen therapy maintain a SaO2 at 90% due to hypoxia probably from pneumonia. Review of Patient #28's medical record lacked a comprehensive activity assessment during the patient admission to swing-bed level care.

During an interview on 9/8/11 at 8:10 AM, the Activity Coordinator reviewed Patient #28's Swing Bed medical record and confirmed the medical record lacked an Activity comprehensive assessment.

f. Patient #29's Swing Bed medical record revealed Patient #29's admission to the Swing Bed care from 2/3/11 through 2/14/11 for PT, OT and for uncontrolled hypertension. Review of Patient #29's medical record lacked a comprehensive activity assessment during the patient admission to swing-bed level care.

During an interview on 9/8/11 at 8:10 AM, the Activity Coordinator reviewed Patient #29's Swing Bed medical record and confirmed the medical record lacked an Activity comprehensive assessment.

g. Patient #30's Swing Bed medical record revealed Patient #30's admission to the Swing Bed care from 4/12/11 through 4/21/11 for PT, OT, IV Antibiotics and Oxygen therapy due to pneumonia. Review of Patient #30's medical record lacked a comprehensive activity assessment during the patient admission to swing-bed level care.

During an interview on 9/8/11 at 8:10 AM, the Activity Coordinator reviewed Patient #30's Swing Bed medical record and confirmed the medical record lacked an Activity comprehensive assessment.

2. The CAH staff used job description and the policies and procedures to provide guidance to the staff for consistent and continuity of care. A review of these policies and procedure revealed:

a. "Guide to completing Admission Assessment", no date, revealed in part, "To provid
VIOLATION: MAINTENANCE Tag No: C0222
I. Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) nursing staff failed to remove outdated supplies in 1 of 1 Broselow/Hinkle Pediatric Emergency System carts. Staff G, Director of Patient Care, reported approximately 10 pediatric emergency cases per month.

Failure to remove outdated supplies could potentially expose pediatric patients to supplies not guaranteed to be sterile or as effective.

Findings included:

1. Observations during a tour of the emergency department, on 9/6/11 at 3:00 PM, revealed the following outdated supplies in the Broselow/Hinkle Pediatric Emergency System cart:

a. 2 of 2 Green Intravenous (IV) Delivery Modules (2 IV catheters, 1 IV prep kit, and 1 IV extension tubing kit per module) expiration date 6/11. Staff V reported at the time of the observation, Emergency Department staff used the IV modules during pediatric emergency treatment.

b. 1 of 1 Purple Intravenous (IV) Delivery Modules (2 IV catheters, 1 IV prep kit, and 1 IV extension tubing kit per module) expiration date 7/11. Staff V reported at the time of the observation, Emergency Department staff used the IV modules during pediatric emergency treatment.

c. 1 of 1 White Intravenous (IV) Delivery Modules (2 IV catheters, 1 IV prep kit, and 1 IV extension tubing kit per module) expiration date 6/11. Staff V reported at the time of the observation, Emergency Department staff used the IV modules during pediatric emergency treatment.

d. 1 of 1 Blue Intravenous (IV) Delivery Modules (2 IV catheters, 1 IV prep kit, and 1 IV extension tubing kit per module) expiration date 6/11. Staff V reported at the time of the observation, Emergency Department staff used the IV modules during pediatric emergency treatment.

e. 4 of 4 Bard brand Premature Infant feeding tubes expiration date 5/11. Staff V reported at that time of the observation, Emergency Department staff used the feeding tubes during pediatric emergency treatment.

2. During an interview, on 9/6/11, at the time of the observation in the Emergency Department, Staff V acknowledged the outdated supplies in the Broselow/Hinkle Pediatric Emergency System cart. Staff V stated, "It is the responsibility of the nursing staff to check all supplies for outdates monthly. I will throw all of these items away immediately".

3. CAH policy titled "Inventory Control", approved 2/11, stated in part: "Supplies: Each department is responsible for maintaining supplies needed to provide services. Supplies will be checked monthly for outdates".







II. Based on observation, policy review and staff interview, the Critical Access Hospital (CAH) failed to ensure patient care supplies, in the diabetes education program storage areas, were not outdated. The Diabetes Education Registered Nurse reported 5-10 patients are seen in the diabetes education program in a 3-6 month period.

Failure to retain current medical supplies for patient care could potentially harm patients by using supplies that the manufacturer determined may be ineffective due to being outdated.

Findings include:

Review of a house wide policy titled "Inventory Control", approved in 3/11, stated in part " ...supplies will be checked monthly for outdates ".

Review of an Out-Patient clinic policy titled "Clinical Policies-Drug Samples", approved on 3/7/11, stated in part "... 3. Cupboard space is available at the Specialty Outpatient Clinic. Specialists are allowed to stock their own supplies " ... It will be the sole responsibility of the specialist &/or his/her staff to check for outdates and destroy them accordingly".
Observation during a tour of the diabetes education program storage area, located in the Specialty Clinic, on 9/7/11 at 3:00 PM, revealed 9 expired BD Getting Started Take Home Kits. One kit revealed an expiration date of 4/3/08, 2 kits revealed an expiration date of 6/27/10 and 6 kits revealed an expiration date of 8/8/10. During an interview at the time, Staff D, Outpatient Clinic Coordinator, confirmed the products were expired and reported Staff C, Diabetes Education RN, stocked the supplies in the cabinet and responsible to check for expired supplies.
During an interview on 9/8/11 at 8:00 AM, Staff C, Diabetes Education RN, reported a supply cabinet, in the CAH Specialty Clinic, utilized to store blood glucose monitoring kits and insulin starter kits to supply to patients. He/she further reported he/she checked for expired products periodically and did not have a formal system in place to ensure expired products are removed from the cabinet.
VIOLATION: ORGANIZATIONAL STRUCTURE Tag No: C0240
Based on document review, physician, Board of Trustee and staff interviews, the Director of Patient Care Services/Peer Review Coordinator failed to monitor policies governing the peer review process for appointment to the medical staff to ensure quality of health care for patients. The Director of Patient Care services identified 92 active physicians.

The following examples confirm this determination.

The Board of Trustees failed to ensure the medical staff preformed external peer review before recommending physicians for reappointment. (refer to C 241)

The CAH administrative staff failed to ensure a physician at the CAH evaluated the quality and appropriateness of the diagnoses and treatment of patient care furnished mid-level practitioners. (refer to C 339)

The CAH administrative staff failed to ensure all physicians that provided care and services to CAH patients were members of Pocahontas Community Hospital's medical staff. (refer to C 340)

The CAH administrative staff failed to ensure physicians received external peer review prior to reappointment. (refer to C 340)

The CAH administrative staff failed to ensure external peer review from an equivalent peer. (refer to C 340)

The cumulative effect of these systemic failures resulted the CAH's inability to provide quality health care in a safe environment.
VIOLATION: GOVERNING BODY Tag No: C0241
I. Based on review of the Critical Access Hospital (CAH) documents and staff interview, the Board of Trustees failed to ensure the medical staff preformed external peer review before recommending 9 of 23 physicians for reappointment.

Failure to perform external peer review before recommendation to the Board of Trustees could potentially result in the medical staff recommending a physician for reappointment that had provided inadequate or inappropriate care to patient's at the CAH.

Findings include:

1. Review of policy "Organizational Compliance Policy" dated 2/15/11, revealed in part, "...Responsibility for compliance with applicable laws and regulations ultimately rests with the Board of Trustees...The Pocahontas Community Hospital Board shall...hold management responsible for its efforts for results in implementing the Organization Compliance Program...exercise final authority in compliance matters."

2. Review of "Bylaws" dated 12/18/07, revealed in part , "...The Board of Trustees shall...delegate responsibility to the Medical Staff...the responsibility for providing appropriate professional care to the hospital's patients, within the following policies:...The Medical staff shall conduct a continuing review and appraisal of the quality of professional care rendered in the hospital, and shall report such activities and their results to the Board of Trustees...The medical staff shall make recommendations to the Board of Trustees concerning...reappointments."

3. Review of "Medical Staff Bylaws and Rules and Regulations" revised 4/29/10, revealed in part, "...The Medical Staff is organized to...establish an organization to which the Board of Trustees can initially delegate Medical care and peer review responsibilities."

4. During an interview on 9/8/11 at 9:32 AM, the Director of Patient Care Services stated the medical staff was aware of problems with the external peer review process. In addition, the Director of Patient Care Services stated the medical staff approved the physicians for reappointment despite the problems with the external peer review process. During a follow up interview on 9/12/11 at 2:30 PM, the Director of Patient Care Services stated the Medical Staff and "myself" failed to present information to the board about ongoing problems with the external peer review process.

5. During an interview on 9/8/11 at 9:55 AM, the Chief of Medical Staff stated the
medical staff was aware of problems with the external peer review process and they would approve reappointment "even if there was no external peer report." The Chief of Medical Staff was unaware that the medical staff needed to perform external peer review prior to reappointment.

For additional information refer to C-340 II

II. Based on document review and Board of Trustee interview, the Board of Trustees failed to ensure administrative staff provided an equivalent peer review for 1 of 7 general surgeons.

Failure to ensure a general surgeon received external peer review from another general surgeon could potentially result in inadequate or inappropriate care to patient's at the CAH.

Findings include.

1. Review of "Summary of Peer Review Process" dated 9/8/11, revealed in part, "..Our issues with [peer review] in the past have been related to what is considered peer to peer...this has been a broken process in the past."

2. During an interview on 9/13/11 at 1:00 PM, Board of Trustee member DD, stated the board was not aware of any problems with the external peer review process. The Board of Trustee member DD stated they approve physician appointment and reappointment based on the recommendation of the Medical Staff.

For additional information refer to C-340 I

III Based on document review and staff interview, the Board of Trustees failed to enforce CAH policies and procedures when credentialing of 17 of 17 physicians.

Failure to credential physicians at the CAH could potentially result in physicians that lacked the appropriate professional qualifications providing care to patients at the CAH, potentially exposing patients to inappropriate care or misdiagnoses.

Findings include:

1. Review of "Bylaws" dated 12/18/7, revealed in part, "...Only an appropriately licensed practitioner with clinical privileges shall be directly responsible for a patient's diagnosis and treatment with the area of his/her privileges...The Medical staff shall conduct a continuing review and appraisal of the quality of professional care rendered in the hospital, and shall report such activities and their results to the Board of Trustees."

2. Review of "Summary of Peer Review Process" dated 9/8/11, revealed in part, "...During the investigation [survey] and discussion of this peer review process...and physicians that interpret studies or tests...we realized today that the Cardiac Holter and Event Monitors, that are sent to cardiology groups...were read by physicians not currently credentialed here."

For additional information refer to C-340 III

IV. Based on document review and staff interview, the Board of Trustees failed to ensure Quality Assurance/Quality Improvement (QA/QI) staff monitored, and corrected problems identified with the external peer review process. Problems included, the medical staff failed to ensure an external peer review occurred and/or that an equivalent peer conducted the external review prior to reappointment, and physicians providing patient care services were members of the CAH's medical staff.

Failure of the QA/QI staff develop and implement plans to correct problems identified with the external peer review process resulted in the Board of Trustees inability to evaluate the information and implement remedial action, if necessary, in respect to appropriate review and reappraisal of the quality of care provided to patients.

Findings include:

1. Review of CAH policy "Quality Improvement Plan" dated 2/15/11, revealed in part, "..."Ensure communication and reporting of Continuous Quality Improvement outcomes on a regular basis to...Board of Trustees...Board of Trustee functions...receives information form the medical and hospital management staff regarding medical staff credentialing monthly and outcomes of Continuous Quality Improvement quarterly."

2. Review of policy "Organizational Compliance Policy" dated 2/15/11, revealed in part, "...prepare and present periodic reports to the Board of Trustees regarding compliance and the activities undertaken and the activities planned in order to assure compliance."

3. Review of "Medical Staff Bylaws and Rules and Regulations" revised 4/29/11, revealed in part, "...This Medical Staff is organized to...establish an organization to which the Board of Trustees can initially delegate...peer review responsibilities,...and which can assist the Board in overseeing the provision of Medical Care Services at the hospital,...The specific functions to be carried out include...Conduct quality assurance activities in accordance with the Hospital's QA plan, and exercise such responsibility and authority provided therein."

4. During an interview on 9/13/11 at 1:00 PM, Board of Trustee member DD, acknowledged they reviewed Quality improvement reports and the reports did not include any concerns regarding external peer review. Board of Trustee member DD stated, if CAH Quality Improvement staff failed to inform the Board of problems with the external peer review process, the Board could not identify and take corrective action to resolve the problem.

For additional information refer to C-195, C-336 and C-340
VIOLATION: EVALUATIONS - PRE-OP & POST-OP Tag No: C0322
Based on review of policies, patient medical records, and staff interviews, the Critical Access Hospital (CAH) surgical staff failed to ensure a qualified practitioner evaluated each patient for proper anesthesia recovery prior to discharge for 5 of 5 closed surgery patient records (Patient's #45, #46, #47, #48, and #49). The ambulatory surgery department staff reported approximately 10 surgical procedures performed per month.

Failure to provide a proper anesthesia recovery assessment, by a qualified practitioner, could potentially harm patients if complications, related to the use of anesthesia, occur after surgery and the patient has returned home.

Findings include:

1. Review of the CAH documents:
a. Policy, "Duties and Responsibilities of the Anesthesia Provider", approved 3/11, revealed in part, "...E. Post-Anesthesia Record...5. A post-operative evaluation of each patient will be done by the anesthesia provider, who administered the anesthetic within 48 hours."

b. "Medical Staff Rules and Regulation," revised 4/29/2010, revealed in part, "...E. Surgery: ...6. A post-anesthesia note must be written by the anesthesiologist or Certified Registered Nurse Anesthetist (CRNA) who administers the anesthesia on all inpatients and outpatients prior to discharge from surgery and anesthesia services...."

c. Review of policies revealed that the CAH staff had failed to follow established policies and procedures that required the anesthesia provider to evaluate each patient, who had received anesthesia, for appropriate recovery prior to discharge from the CAH.

2. Review of medical records for Patient's #45, #46, #47, #48, and #49 revealed the following:

a. Patient #45's closed medical record revealed an admission on 6/21/2011 for a laparoscopic cholecystectomy.

Patient #45's Anesthesia Record, dated 6/21/11, revealed anesthesia start time at 8:00 AM and stop time 10:00 AM. Last documented anesthesia assessment done at 10:00 AM.

Patient #45's Post Anesthesia Assessment section revealed the CRNA failed to document a post-anesthesia exam following the surgery and prior to the patients' discharge from the CAH.

b. Patient #46's closed medical record revealed an admission on 7/11/2011 for gastric resection surgery.

The Anesthesia Record, dated 7/11/11, revealed anesthesia start time at 8:28 AM and stop time 8:59 AM. Last documented anesthesia assessment done at 8:55 AM.

Patient #46's Post Anesthesia Assessment section revealed the CRNA failed to document a post-anesthesia exam following the surgery and prior to the patients' discharge from the CAH.

c. Patient #47's closed medical record revealed an admission on 6/1/2011 for laparoscopic cholecystectomy.

The Anesthesia Record, dated 6/1/11, revealed anesthesia start time at 10:10 AM and stop time 11:27 AM. Last documented anesthesia assessment done at 11:27 AM.

Patient #46's Post Anesthesia Assessment section revealed the CRNA failed to document a post-anesthesia exam following the surgery and prior to the patients' discharge from the CAH.

d. Patient #48's closed medical record revealed an admission on 7/11/2011 for a tonsillectomy.

The Anesthesia Record, dated 7/11/11, revealed anesthesia start time at 9:57 AM and stop time 10:34 AM. Last documented anesthesia assessment done at 10:30 AM.

Patient #48's Post Anesthesia Assessment section revealed the CRNA failed to document a post-anesthesia exam following the surgery and prior to the patients' discharge from the CAH.

e. Patient #49's closed medical record revealed an admission on 6/13/2011 for a laparoscopic appendectomy.

The Anesthesia Record, dated 7/11/11, revealed anesthesia start time at 10:19 AM and stop time 11:10 AM. Last documented anesthesia assessment done at 11:07 AM.
Patient #49's Post Anesthesia Assessment section revealed the CRNA failed to document a post-anesthesia exam following the surgery and prior to the patients' discharge from the CAH.

3. During an interview, on 9/7/11 at 1:15 PM, the Director of Outpatient Services stated, the CRNA's do not perform a post anesthesia assessment prior to a patient's discharge from the CAH. She reported that the CRNA's do their final assessment when the patient is transferred to the Post Anesthesia Care Unit (PACU) from surgery for recovery. The patient is then monitored by the Registered Nurses (RN) until the patient is discharged . The patient's discharge may be up to twenty four (24) hours after surgery.
VIOLATION: PERIODIC EVALUATION & QA REVIEW Tag No: C0330
Based on review of the Critical Access Hospital (CAH) documents, policy/procedures and staff interview, the Director of Patient Care Services/Coordinator of External Peer Review failed to ensure an effective quality assurance program was in place to identify and correct problems with the external peer review process. Additionally, the Director of Patient Care Services/Coordinator of External Peer Review failed to implement quality assurance policies and procedures to trend and evaluate for appropriate care and services provided to patients.

The CAH administrative staff identified 92 active physicians.

The CAH Quality Assurance staff failed to ensure that a system was in place to identify, track, and trend significant changes in patients skin condition. (Refer to tag C-337)

The Governing Board failed to ensure an external peer review occurred before the medical staff recommended physician's for reappointment. (refer to C 241)

The CAH administrative staff failed to ensure an equivalent peer conducted the external physician peer reviews. (refer to C 340)

The CAH Quality Improvement/Quality Assurance staff failed to ensure an effective quality assurance program was in place to identify and correct problems with the external peer review processes. (refer to C 336)

The CAH Director of Patient Care Services and the Quality Assurance Director failed to ensure nursing staff followed policies and procedures for trending and evaluating appropriate services and treatment for patients. (refer to C 337)

The CAH administrative staff failed to ensure a physician at the CAH evaluated the quality and appropriateness of the diagnoses and treatment of patient care furnished by mid-level practitioners. (refer to C 339)

The CAH administrative staff failed to ensure all physicians that provided care and services to CAH patients were members of Pocahontas Community Hospital's medical staff. (refer to C 340)

The cumulative effect of these systemic deficiencies resulted the CAH's inability to appropriately review and reprise the quality of care provided to patients in a safe environment.
VIOLATION: ANNUAL PROGRAM EVALUATION Tag No: C0331
Based on review of the Critical Access Hospital (CAH) policy and procedures, documents, and staff interviews, the Administrator failed to include the external peer review process in their total program evaluation in accordance to policy and procedure.

Failure to include the external peer review process and provide full disclosure of the information derived from the annual program evaluation to the Board of Trustees resulted in the Board of Trustees lack of access to the information. Failure to have access to the information resulted in the Board's inability to evaluate the information and implement remedial action, if necessary, in respect to appropriate review and reappraisal of the quality of care provided to patients.

Findings include:

1. Review of policy "Annual Program Evaluation" revised 2/03, revealed in part, "...Pocahontas Community Hospital (PCH) will perform an annual evaluation of its services in order to determine whether the services is appropriate...the established policies were followed and if any changes are needed...the evaluation will review indicators as follows...Peer review (Medical Staff Minutes)...The PCH Board of Trustees will review the written report of the findings of the Annual Program Evaluation."

2. Review of policy "Organizational Compliance Policy" dated 2/15/11, revealed in part, "...This organizational Compliance Policy outlining the components of an organizational compliance program shall be adopted by the Board of Trustees...the compliance officer shall be responsible for the oversight and monitoring of compliance activities...undertake the following duties...prepare and present periodic reports to the Board of Trustees regarding compliance and the activities undertaken in order to assure compliance."

3. Review of PCH Annual Program Evaluations dated 7/1/09 to 6/30/10 lacked documentation of the external peer review process.

4. Review of "Bylaws" revised 12/18/07, revealed in part, "...The business and affairs of the hospital shall be managed by its Board of Trustees. Furthermore, all affairs of the hospital should be vested in the Board of Trustees, who shall have control ...of business and operation of the institution..."

5. During an interview on 9/12/11 at 3:05 PM, the Director of Patient Care Services
acknowledged the annual CAH Total Program Committee reviewed internal and external peer review, and any problems associated with the peer review process. The Director of Patient Care Services stated the Medical Staff and "myself" failed to present information to the committee about ongoing problems with the external peer review process.

6. During an interview on 9/13/11 at 1:00 PM, Board of Trustee member DD, stated the Board of Trustees reviewed the annual CAH Program Evaluation, and relied on CAH staff to inform the Board of Trustees of any problems in the CAH.
VIOLATION: QA - QUALITY OF PATIENT CARE Tag No: C0336
Based on review of the Critical Access Hospital (CAH) documents, policy/procedures, and staff interview, the Director of Patient Care Services and the Director of Patient Quality failed to ensure an effective quality assurance program was in place to identify and correct problems with the external peer review processes.

Failure to ensure an effective quality assurance program was in place to identify and evaluate problems in the external peer review process and provide full disclosure of the information derived through the quality assurance program to the Medical Staff and Board of Directors resulted in the Medical Staff and Board of Director's not having full access to the information. Failure to have access to the information resulted in Medical Staff and Board's inability to evaluate the information and implement remedial action, if necessary, in respect to appropriate review and reappraisal of the quality of care provided to patients.

Findings include:

1. Review of Job Description "Director of Patient Quality" (Quality Compliance Director) revealed in part, "...Provides joint leadership...with the Director of Patient Care Services. Responsible for Patient Quality. Provides consultation to...hospital staff to assist them in meeting the organization's quality goals...Monitors State and Federal Regulations...and assists departments to remain in compliance...serves as a liaison between the hospital and medical staff in issues related to peer review, credentialing and as requested...in collaboration with the Director of Patient Care coordinate Continuous Quality Improvement (CQI) activities..."

2. Review of Job Description "Director of Inpatient Services" revealed in part, "...Coordinates CQI activities for assigned areas; ensures that department standards and monitoring procedures are consistent with the goals and objectives of Pocahontas Community Hospital CQI programs...and regulatory requirements...Member of Quality Assurance (QA)...coordinates hospital compliance to CAH regulations."

3. Review of the facility's policy "Organizational Compliance Policy" dated 2/15/11 revealed in part, ..."Organizational Compliance Policy or Compliance Policy refers to all...activities...to assess...monitor, and correct organizational practices to minimize the risk of noncompliance with applicable statutes and regulations...assure that each person in the Organization carrying out tasks, which have the potential to violate applicable laws or regulations...periodically determine those areas of risk for which compliance activities should be undertaken...develop and implement periodic monitoring and evaluation programs to effectively access compliance."

4. Review of facility's policy "Quality Improvement Plan" dated 2/15/11, revealed in part, "...Quality Improvement (QI) is a cooperative effort of all personnel working together to improve operational effectiveness and efficiency by continually improving performance of systems that directly...support and facilitate delivery of care...The Board of Trustees has the overall responsibility for the QI Program. This program shall be governed in accordance with the hospital and Medical Staff bylaws, policies, and procedures; and comply with conditions of participation for a CAH...Objectives:...Establish a mechanism to identify and solve problems that impact directly and indirectly on patient care...evaluate activities to ensure that desired results have been achieved...ensure communication and reporting of CQI outcomes on a regular basis to hospital management, Medical Staff, Board of Trustees

4. Review of Medical Staff Bylaws dated 4/29/10, revealed in part, ..."The specific functions to be carried out include the following:...QA)/CQI...conduct Quality activities in accordance with the Hospital's QA/CQI plan, and exercise such responsibility and authority as are provided therein."

5. During an interview on 9/12/11 at 9:45 AM, Staff X, Quality Compliance Director, acknowledged the problems with the external peer review process originated in 2009. Staff X stated, "It's been ongoing for the past 2 years." Staff X confirmed the Quality Committee failed to "formally" identify and implement corrective actions to resolve the problems with the external peer review process and stated, "I'm not certain if any of us understood the external peer review process." Staff X stated, "We've visited about this, but have never implemented an action plan."In addition, Staff X acknowledged failure to correct problems with the external peer review process resulted in the Medical Staff and Board of trustees, "Would not have all relative information to determine if all physicians could be reappointed."

6. Review of Quality Improvement (QI) committee meeting minutes from 9/10 to 8/11 revealed the meeting minutes lacked documented evidence the committee identified and implemented a plan to correct problems with the external peer process.

7. During an interview on 9/12/11 at 1:45 PM, Staff H, Director of Patient Quality, acknowledged the hospital failed to identify problems with the external peer review process and stated, "when I inherited the responsibility for external peer review in 2009." Staff H confirmed the hospital administrative staff failed to identify and correct problems with the external peer review processes as a QI issue and the hospital administrative staff failed to take "formal steps" to resolve external peer review problems. Staff H acknowledged hospital administrative staff failed to provide full disclosure of the information related to problems with the external peer review process to the Board of Directors. However, Staff H stated, the problem with external peer review processes were discussed at a Medical Staff meeting approximately 6-9 months ago, "verbally and informally" and "there would be no documentation of this."

8. During an interview on 9/13/11 at 1:30 AM, the Chief Executive Officer (CEO) acknowledged the hospital administrative staff failed to identify problems with the external peer review process. The CEO stated, "I agree this is a quality issue and the QA director, the Director of Patient Quality and myself should be responsible for this." The CEO continued, "Now that we [the hospital administrative staff ] are aware of the problem, we will implement a new [external review] process and re-evaluate wether it is effective."

For additional information refer to C-340.
VIOLATION: QUALITY ASSURANCE Tag No: C0337
Based on review of the Critical Access Hospital (CAH) documents, medical records, observation, and staff interviews, the Quality Assurance staff failed to ensure that a system was in place to identify, track, and trend significant changes in patients skin condition.

The survey team identified one hospital acquired pressure ulcer while onsite. (Patient # 26)

The CAH administrative staff identified an average daily census of approximately 2 swing bed patients and 2 acute patients.

Failure to identify, track and trend significant changes in patient skin conditions resulted in avoidable pressure ulcers/wounds that affected patients quality of life and health status.

1. For skin issues and assessment findings for Swing Bed Patients #26, 27, 31, and 32 Refer to tag C-388. For skin issues and assessment findings for acute Patients #25, 37, and 50 Refer to tag C-294

2. The CAH staff used job descriptions, policies and procedures to provide guidance to the staff for consistent and continuity of care. Review of these documents revealed:

a. Review of job descriptions revealed in part:

i. "Director of Nursing (Director of In-patient Services)" revised 4/2011 "...Coordinates CQI (Continuous Quality Improvement) activities for assigned areas; ensures that department standards and monitoring procedures are consistent with goals and objectives of Pocahontas Community Hospital CQI...Member of QA...coordinates hospital compliance to ...CAH regulations..."

ii. "Director of Patient Quality" revised 9/08 " , General Summary: Provides joint leadership to the Nursing Department... Responsible for Patient Quality... Provides consultation, education, and direction to departments and hospital staff to assist them in meeting the organization's quality, risk and patient safety goals...

Managerial Responsibilities/Competencies: reviews all unusual occurrence reports, assess seriousness and potential liability and initiate follow-up circumstances warrant...collect and analyze data, which can be utilized in identifying am minimizing risk exposure..."

b. Review of the CAH "Quality Improvement Plan" revised 10/2009 revealed in part, "Quality Improvement is a cooperative effort of all personnel working together...
by continually improving performance of systems that directly...support and facilitate delivery of care...this effort included a unified process of monitoring and evaluating patient care...

Objectives:...Establish a mechanism to identify and solve problems that directly and indirectly on patient care..."

c. Review of the Board of Trustee Bylaws revised 4/10, revealed in part,..."Quality Assurance/Continuous Quality Improvement. conduct quality assurances activities in accordance with the Hospital Quality Assurance/continuous Quality Improvement Plan, and exercise such responsibility and authority as are provided therein. The committee shall review and evaluate the plan..."

d. Review of policy "Incident Reports" revised 2/09, revealed in part,..."The hospital incident report form is used as part of the facilities...CQI programs. The form must be completed for all unusual occurrences involving patients...unusual occurrence is defined as any occurrences involving patients...which is not consistent with the regular hospital routine...The completed form is handed into the Director of Patient Quality. The information obtained from the reports will be categorized in a "patterns over time" manner and submitted to the Quality Assurance Committee for the purpose of...improving the management of patient care and treatment by assuring the appropriate and immediate intervention occurs for the patient's safety... and to assure the prevention of occurrences... Providing a database for the facility so that the care being given can be analyzed, evaluated, and acted upon."

3. During a interview on 9/14/11 at 7:20 AM, Staff CC, Certified Nurse Aide (CNA), stated that incident forms were located at the nurses station for nursing staff to use. Staff CC demonstrated where the incident reports were stored and observation revealed the incident report forms were clearly labeled for identification. Staff V, Registered Nurse (RN) present at the time of the interview and observation stated nursing staff placed the incident forms and various other forms in the drawer for "easy access".

4. During an interview on 9/14/11 at 9:30 AM, Staff S, RN stated the incident forms in the drawer at the nursing station were for nursing staff to use as needed. Staff S stated the nurses filled out the incident forms for medication errors, falls, and "out of the ordinary problems". Staff S stated, QA trended skin issues from the incident reports and stated, "I have never filled out an incident form for skin integrity (changes)."

5. During an interview on 9/14/11 at 10:15 AM, Staff E, RN verified nursing staff filled out the incident forms for medication errors and injuries however he/she was "unaware" nursing staff "were responsible" for completing an incident report from for significant skin changes. Staff E stated when Patient #26's heel changed from being red in color on admission to necrotic that this would be a significant change in skin condition. Staff E denied completing a incident form for significant changes in skin conditions for the past 1 and 1/2 years.

6. During an interview on 9/14/11 at 10:25 AM, Staff V, Patient Care Coordinator, acknowledged the QA committee reviewed and evaluated information on the incident reports. Additionally, Staff V verified changes from red in color to necrotic to skin areas would be an example of a significant change in skin condition. when a skin area changed from red in color to necrotic. Staff V stated nursing staff would complete an incident form if staff "bumped" a patient and caused injury to their skin however they would not fill out an incident report for pressure ulcers. Staff V stated, "I wouldn't have thought to do this." Staff V acknowledged if nursing staff failed to complete an incident form for significant changes in skin conditions the QA committee would be unable to evaluate for patterns, trends, or hospital acquired pressure ulcers.

7. During an interview on 9/14/11 at 9:00 AM, Staff X, QA director acknowledged the QA committee failed to monitor hospital acquired pressure ulcers or wound. Staff X stated in order for QA to identify, track, and trend significant changes in skin or pressure ulcers/wounds nursing staff would need to fill out an incident form. Staff X stated nursing staff "were educated" to fill out an incident report for "all" sudden changes in a patient's condition that would include necrotic changes and hospital acquired pressure ulcers/wounds.