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Based on policy and procedure review and staff interview, the Critical Access Hospital (CAH) failed to maintain an infection prevention program which included identifying, reporting and investigating infections and monitoring of hand hygiene and other health care practices of direct patient care staff. This failed practice had the potential to affect all patients of the facility. The CAH reported in the fiscal year of April 2014 - March 2015 a total of 988 patients were admitted to acute care; 38 patients were admitted to swing bed and 77 were admitted to observation.

Findings are:

A. A review of the "Infection Prevention Plan" Policy and Procedure with an effective date of 4/21/09 and last revised on 8/2011 revealed, "...The Infection Prevention Coordinator is the person assigned the task of accountability and coordination of the Infection Prevention Program...The responsibilities of the Infection Preventions Coordinator will be in accordance with the job description developed by administration." The policy identified the following as part of those responsibilities:
- Developing and implementing policies and procedures and governing asepsis (state of being free from disease-causing contaminants like bacteria, viruses, fungi and parasites) and control of infections.
- Developing a system for identifying, investigating and reporting and preventing spread of infections among patients and staff.
- Identifying, investigating, reporting and preventing spread of hospital acquired infections (HAI) and communicable diseases among patients and staff.
- Maintains all records of everything that pertains to infection prevention, including minutes of the Infection Prevention Committee meetings.

B. During an interview with the Infection Control Prevention Coordinator on 4/27/15 at 2:05 PM, it was identified that there currently is no log or system to track the infections and communicable diseases since July of 2014. The Infection Control Prevention Coordinator did identify that the lab results were looked at, and information was written on sticky notes or notes here and there but no real system was currently going on. When asked what the facility measures for preventions of infections, it was identified that currently there is not any percentage rates calculated or comparisons made to that of the facility and the national average. When inquired about any health care staff surveillance going on in the facility, the Infection Control Prevention Coordinator stated, "nothing that is documented."

Failure of direct patient care staff to perform hand hygiene before and after direct patient care and immediately preceding any invasive procedure, is the primary cause of health care acquired infection, according to the Centers for Disease Control.

Based on review of administrative documents, policy and procedure and staff interview, the Critical Access Hospital (CAH) failed to include 1 of the 3 elements (an analysis of the number of patients using the services offered at the CAH) in the last periodic evaluation. This has the potential to affect all services provided to patients at the CAH.

Findings are:

A. Upon request for the last periodic evaluation the facility provided the document titled CAH Quality Meeting Policy Review and Signing dated 2/25/14. Review of this document revealed no information concerning the number of patients using the different services at the hospital.

B. Interview with the DON (Director of Nursing) on 4/27/15 from 1:35 PM to 1:45 PM revealed the DON was not working for the facility at the time of this meeting and could not guarantee utilization of services was talked about.

After request of the Administrator during the exit conference on 4/27/15 from 5:00 PM to 5:20 PM for any additional information that might be available concerning an evaluation of the utilization of services, nothing was provided.

C. Review of the policy and procedure titled Quality Improvement Plan revealed the following under the section titled Annual Evaluation by the Board of Directors: "The report includes...Patient related quality concerns and outcomes which impact patient care and clinical performance, including utilization of services pertaining to the number of patients served and the volume of clinical services...."

Based on review of the Quality Improvement Plan (QIP), review of Continuous Quality Improvement (CQI) Dashboard report, review of meeting minutes and staff interview, the Critical Access Hospital (CAH) failed to ensure that 10 of 24 disciplines (Anesthesia, Cardiac Rehabilitation, Central Processing, Discharge Planning/Social Services, Medical Records, Occupational Therapy, Oncology, Physical Therapy, Pulmonary Rehabilitation and Speech Therapy) identified in the QIP reported to the CAH Quality Improvement Program. This has the potential to affect patients receiving services from these 10 disciplines.

Findings are:

A. Review of the QIP dated 8/2012 revealed the following:
- Quality Improvement Coordinator is responsible for maintaining departmental quality improvement reports;
- The plan identified 24 disciplines that participate in the quality improvement program;
- Identified the Medical Staff Meetings and the CAH Committee as the established committees for quality improvement; and,
- Indicated that specialty meetings could be scheduled at the discretion of the Administrator or the Quality Improvement Coordinator.

B. Interview with the Quality Improvement Coordinator (QIC) and the Director of Nursing on 4/27/15 from 1:35 PM to 3:00 PM revealed the following:
- QIC started in position on 2/2/15;
- Department Head Meeting minutes, Safety-Infection Prevention meeting minutes and Medical Staff meeting minutes contain information about the QIP; and,
- Indicated that just recently started a CQI (Continuous Quality Improvement) Dashboard for the different disciplines.

C. Review of monthly Department Head meeting minutes from 4/15/14 through 3/17/15 revealed Quality was listed as an agenda item for 3 of the 13 meeting held. Meeting minutes dated 4/21/15 stated "Each department needs Quality goals quarterly."; no other information regarding Anesthesia, Cardiac Rehabilitation, Central Processing, Discharge Planning/Social Services, Medical Records, Occupational Therapy, Oncology, Physical Therapy, Pulmonary Rehabilitation and Speech Therapy's participation in the QIP was found.

D. Review of the monthly Medical Staff meeting minutes from 5/2/14 through 4/3/15 revealed the only discussion from any of the 10 disciplines identified as not reporting quality activity happened at the 8/1/14 meeting. The 8/1/14 meeting minutes under the Quality Improvement Committee report section documented "Information was presented...on 'Clinical Considerations for HF [Heart Failure] patients and Cardiac Rehab [Rehabilitation].' " However, this report lacked any information regarding Cardiac Rehabilitation quality information happening at the CAH.

E. Review of 6 Safety-Infection prevention meeting minutes held between 8/5/14 and 4/13/15 revealed no quality information concerning Anesthesia, Cardiac Rehabilitation, Central Processing, Discharge Planning/Social Services, Medical Records, Occupational Therapy, Oncology, Physical Therapy, Pulmonary Rehabilitation and Speech Therapy.

F. Review of the CQI Dashboard with the measurement period identified as April 2015 revealed no information regarding Anesthesia, Cardiac Rehabilitation, Central Processing, Discharge Planning/Social Services, Medical Records, Occupational Therapy, Oncology, Physical Therapy, Pulmonary Rehabilitation and Speech Therapy.

G. Interview with the Quality Improvement Coordinator on 4/17/15 at 3:45 PM confirmed lack of any further information regarding the CAH's quality assurance for the last year.

Based on staff interview and record review the Critical Access Hospital (CAH) failed to have an activity program that identified and incorporated the interests of 5 of 5 (Patients 32, 33, 34, 35 and 36) swing bed patients into their daily plan of care. This failed practice had the potential to affect all patients admitted to swing bed . The CAH reported from April 2014 to March 2015 a total of 38 swing bed admissions.

Findings are:

A. Review of Patient 32 medical record admitted 3/28/15 and dismissed 4/3/15, lacked an Activity Assessment, daily charting related to an individualized activity program, and the Plan of Care lacked an Activity Care Plan.

An interview with the Activity Director (AD) on 4/27/15 at 11:00 AM revealed, that the AD had looked in Patient 32's medical record over the weekend and was not able to locate the Activity Assessment either.

B. Review of Patient 33's medical record admitted 2/6/15 and dismissed 2/27/15, revealed two documents that mentioned activities. The Swing Bed Comprehensive Assessment for Nebraska Critical Access Hospitals dated 2/20/15 and an undated Social History Form for Skilled Care. The record lacked an Activity Assessment from 2/6/15 through 2/20/15, daily charting related to an individualized activity program, and the Plan of Care lacked an Activity Care Plan.

C. Review of Patient 34's medical record admitted 11/4/14 and dismissed 12/5/14, revealed two documents that mentioned activities. The Swing Bed Comprehensive Assessment for Nebraska Critical Access Hospitals dated 12/6/14 and an undated Social History Form for Skilled Care. The record lacked an Activity Assessment from 11/4/14 through 12/5/14, daily charting related to an individualized activity program, and the Plan of Care lacked an Activity Care Plan.

D. Review of Patient 35's medical record admitted 2/6/15 and dismissed 2/10/15, lacked an Activity Assessment, daily charting related to an individualized activity program, and the Plan of Care lacked an Activity Care Plan.

E. Review of Patient 36's medical record admitted 3/17/15 and dismissed 3/24/15, lacked an Activity Assessment, daily charting related to an individualized activity program, and the Plan of Care lacked an Activity Care Plan

F. An interview with the Director of Nurses on 4/22/15 at 11:00 AM and verified by phone call on 5/4/15 at 9:21 AM revealed, Patient 35 and 36's medical record lacked an Activity Assessment, daily charting related to an individualized activity program, and the Plan of Cares lacked an Activity Care Plan.

G. Review of the adopted 2/12 form titled Oakland Mercy Hospital with verbiage stating, "Welcome to the Swing Bed Program at Oakland Mercy Hospital....The purpose of the Swing Bed Program is to provide hospital beds for patients requiring skilled (SNF) until they can be discharged home or to another facility....MEMBERS OF YOUR HEALTH CARE TEAM....Patient activities: The Activity Director or designee will meet with you soon after admission to SNF care to assess your needs and preferences in the area of Patient Activities. After the first visit, the Patient Activities Provider will meet with you for a planned activity three times a week and can provide options for activities on other days if you wish."

Based on record review, staff interview and review of policy and procedures the Critical Access Hospital (CAH) failed to ensure that a physician order for discharge was obtained from the provider/surgeon prior to dismissal for 6 of 6 surgical records sampled (Patients 26, 27, 28, 29, 30 and 31). This failed practice had the potential to affect all surgical patients of the CAH. The CAH reported from April 2014 to March 2015 a total of 138 surgical procedures were performed at the CAH including: inpatient and outpatient surgery and scopes.

Findings are:

A. Review of Patient 26's record dated 3/18/15 revealed the patient had a laparoscopic cholecystectomy (removal of the gallbladder through several small incisions in the abdomen). Review of the Doctor (Dr) N's order sheets lacked a discharge order. Review of the record revealed that Patient 26 was dismissed on 3/18/15 at 1525 (3:25 PM).

B. Review of Patient 27's record dated 11/19/14 revealed the patient had a laparoscopic cholecystectomy. Review of the Dr N's order sheets lacked a discharge order. Review of the record revealed that Patient 27 was dismissed on 11/19/14 at 1400 (2:00 PM).

C. Review of Patient 28's record dated 10/8/14 revealed the patient had umbilical hernia (tissue bulges out through an opening in the muscles of the abdomen near the belly button) repair . Review of the Dr N's order sheets lacked a discharge order. Review of the record revealed that Patient 28 was dismissed on 10/8/14 at 1620 (4:20 PM).

D. Review of Patient 29's record dated 1/21/15 revealed the patient had a colonoscopy (a procedure that allows the Dr to look at the inside of the large intestine). Review of the Dr N's order sheets lacked a discharge order. Review of the record revealed that Patient 29 was dismissed on 1/21/15 at 1120 (11:20 AM).

E. Review of Patient 30's record dated 2/18/15 revealed the patient had a EGD (Esophagogastroduedenoscopy - a procedure that allows the Dr to look at the inside of the esophagus/food pipe, stomach and upper duodenum). Review of the Dr N's order sheets lacked a discharge order. Review of the record revealed that Patient 30 was dismissed on 2/18/15 at 1400 (2:00 PM).

F. Review of Patient 31's record dated 9/10/14 revealed the patient had a EGD. Review of the Dr N's order sheets lacked a discharge order. Review of the record revealed that Patient 31 was dismissed on 9/10/14 at 1100 (11:00 AM).

G. Review of the "Dismissal of a patient" Policy and Procedure with an effective date of 5/3/94 and revision date of 11/14/09 revealed, "1. Obtain the dismissal order and instructions from the physicians written orders....."

H. An interview with the Director of Nurses on 4/21/15 at 4:55 PM verified that the surgical charts lacked a discharge order.

Based on review of medical records, review of policy and procedures and staff interview, the Critical Access Hospital (CAH) failed to ensure that 2 of 2 Specialty Physician/Outpatient records reviewed contained physicians' signature on the transcribed progress note and that the nursing entries on the Admission Summary Sheet contained signatures of the nurse making the entry. This failed practice has the potential to affect all patients seen in the Specialty Physician/Outpatient Clinic. In the past year (4/1/14 through 3/30/15) the Specialty Physician/Outpatient Clinic had 598 patients.

Findings are:

A. Review of Medical Record 39 revealed the patient was seen in the Oncology Clinic on 10/4/14. The Admission Summary Sheet contained a height, weight, temperature, blood pressure, pulse and oximetry reading (measure of the oxygen in the blood stream). This entry contained no signature of the individual completing this information. The record also contained a typed progress note that indicated the note had been dictated by Physician B but lacked a signature of Physician B.

Review of Medical Record 40 revealed the patient was seen in the Cardiology Clinic on 12/23/14. The Admission Summary Sheet contained hand written vital signs, height and weight, a list of 17 medication and reason for the visit. This entry contained no signature of the individual completing this information. The record also contained a typed progress note with the physicians name at the top of the note but lacked a signature of the physician.

B. Interview with the Surgical Services Coordinator (also works in the Specialty/Outpatient Clinic) on 4/21/15 between 10:30 AM and 11:30 AM confirmed the entries of vital signs, height, weight and medications were the nurses entries and confirmed they lack a signature of the nurse completing the entry.

Interview with the HIM (Health Information Management) Director on 4/21/15 at 1:15 PM confirmed that HIM lacked copies of the progress notes for Medical Records 39 and 40 that contained signatures of the physician.

C. Review of the policy and procedure titled Authentication (identification of the author of a medical record entry by that author and confirmation that the contents are what the author intended) of Medical Record Entries revealed "Entries will be confirmed by written signatures, initials or electronic signatures."