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Based on review of the hospital's medical staff bylaws, medical staff credentialing files, and interview, the Critical Access Hospital failed to confirm that physicians appointed to the hospital's medical staff were currently licensed for 1 of 4 physicians reviewed (Physician #1).

Failure to ensure that all professional healthcare staff members are currently licensed risks provision of care and services by unqualified individuals.

Findings:

1. On 11/2/2011 at 1:00 PM during review of the hospital's medical staff credentialing and appointment process, Surveyor #13692 observed that the Washington State DOH license for Physician #1 had expired in March 2011.

2. The hospital's medical staff bylaws (Effective 11/8/2010) under Section 3.2-1 General Qualifications read as follows: "Physicians...shall be qualified for Medical Staff membership only if they (a) document their licensure..."

3. An interview with the hospital's medical staff credentialing coordinator (Staff Member #1) confirmed that the hospital had not verified that Physician #1's license had been renewed according to the medical staff bylaws.

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Based on review of contracts and agreements with the hospital's healthcare contractors, the Critical Access Hospital failed to include language in the contract with their teleradiology service provider that met the requirements for credentialing, privileging, and quality monitoring as identified in the regulation.

Failure to ensure that telemedicine healthcare providers and entities are in compliance with standards set by CMS risks poor quality of care and adverse patient outcomes.

Findings:

On 11/2/2011, review of the hospital's contract with their teleradiology service provider (Contractor #1) revealed that the contract language did not include credentialing, privileging, and quality monitoring requirements as directed by CMS in July 2011.
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1. Based on observation the hospital failed to maintain the laboratory equipment in safe operating condition to prevent possible cross contamination of the hospital's water supply.

Failure to maintain the laboratory plumbing and equipment in safe operating condition places the patients at risk for possible exposure to chemical and biological contaminates.

Findings:

On 11/2/2011 Surveyor #00210 found a plumbing cross connection between the chemical analyzer ( Unicel DXC 600) in the laboratory and the hospital's drinking water. There was no reduce pressure backflow assembly installed on the water line before the water filters on the wall and under the lab sink to protect from possible chemical or biological contaminates entering the drinking water from the chemical analyzer. Any piece of equipment added to the drinking water supply needs the required level of protection for that type of equipment added.


2. Based on observation the hospital failed to maintain patient lavatory equipment in safe operating condition.

Failure to maintain patient lavatory equipment in safe operating condition places the patients at risk for injury while using damaged equipment.

Findings:

On 11/2/2011 Surveyor #00210 observed the ring cover on the hot water faucet in patient room 112 was damaged with a hole through the ring cover and sharp metal edges were exposed around the faucet handle.


3. Based on observation the hospital failed to maintain the walls in good condition to provide smooth and cleanable surfaces.

Findings:

During environmental round on 11/2/2011 Surveyor #00210 observed holes through the tile wall of the central processing area into the adjoining general storage room. The damaged wall needed repair to provide smooth and cleanable surface and to prevent possible harborage of pests.

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Based on observation, the hospital failed to maintain the corridors to be orderly and free from obstructions.

Failure to maintain the hallways to be orderly and without obstructions places the patients at risk for injury from obstructed hallways in the case of an emergency.

Finding:

On 11/1-2/2011 Surveyor #00210 observed patient equipment (walker), a linen hamper, a bio waste container and a large garbage container stored in the exit corridor next to the emergency department.

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Based on observation, and record review the Critical Access Hospital (CAH) failed to meet the provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Refer to the Fire Life Safety report for deficiencies found during the survey on 11/1/2011.

CONDITION NOT MET

Based on observation, document review and staff interviews, the Critical Access Hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure.

Failure to meet established organizational structure requirements and responsibilities impaired the hospital's ability to provide quality care in a safe environment.

Reference: CFR 485.627(a) "The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing, and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment."

Findings:

Due to the cummulative effect of deficiencies detailed under the Conditions of Participation at 42 CFR 485.641 Periodic Evaluation and Quality Monitoring ; and 42 CFR 485.635, Provision of Services, the Condition of Participation for Organizational Structure was NOT MET.

Cross-refer to C0241, C0278, C0336, C0337, C0338, and C0342

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Based on review of the hospital's medical staff bylaws, medical staff credentialing files, and interview, the Critical Access Hospital failed to identify practice privileges for a contracted physician working in the hospital's ED for 1 of 1 physician reviewed (Physician #2).

Failure to identify practice privileges for physicians risks provision of services by unqualified individuals.

Findings:

1. Physician #2, an employee of patient care Contractor #2, started working in the hospital's ED on 11/1/2011. On 11/2/2011 at 1:00 PM during review of the hospital's medical staff credentialing and appointment process, Surveyor #13692 observed that Physician #2 had been appointed to the hospital's medical staff in October 2011. The physician's credentialing files did not include a list of privileges that identified the physician's scope of practice in the ED.

2. The hospital's medical staff bylaws (Effective 11/8/2010) under Section 4.6-2 Provisional Staff read as follows: "The prerogatives of a Provisional Staff Member shall be to (a) exercise such Clinical Privileges as are granted to him pursuant to Credentialing Manual."

3. An interview on 11/2/2011 at 1:00 PM with the hospital's medical staff credentialing coordinator (Staff Member #1) confirmed that the hospital had not identified the physician's ED practice privileges according to the medical staff bylaws.

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CONDITION NOT MET

Based on review of hospital policies and procedures; staff interviews; and review of the hospital's infection control program and infection surveillance documentation; the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Provision of Services.

Failure to develop and implement an effective infection prevention and control program impaired the hospital's ability to provide quality care in a safe environment.

Findings:

Due to the cummulative effect of deficiencies detailed under the Condition of Participation at 42 CFR 485.635 Provision of Services, the Condition was NOT MET.

Cross-refer to C0278
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1. Based on interview and record review the Critical Access Hospital failed to limit access to the pharmacy in the absence of a pharmacist to one designated registered nurse according to hospital policy and Washington State Board of Pharmacy regulations.

Failure to do so prevents the hospital from controlling access and accountability for the pharmacy supplies, and inhibits the ability to account for discrepancies and other supply issues.

Reference: WAC 246-873-050 "Absence of a pharmacist. (2) Access to the pharmacy. Whenever a drug is required to treat an immediate need and not available from floor stock when the pharmacy is closed, the drug may be obtained from the pharmacy by a designated registered nurse, who shall be accountable for his/her actions. One registered nurse shall be designated in each hospital shift for removing the drugs from the pharmacy. (a) The director of pharmacy shall establish written policy and recording procedures to assist the registered nurse who may be designated to remove drugs from the pharmacy, when a pharmacist is not present, in accordance with Washington State Pharmacy Practice Act, RCW 18.64.255(2), which states that the director of pharmacy and the hospital be involved in designating the nurse.

Findings:

a. During tour of hospital on 11/1/11 Staff #5 informed Surveyor #18001 that two nurses routinely had custody of keys to the pharmacy, for use when the pharmacist was absent. One was the assigned Charge Nurse in the Emergency Department, and the other was the Director of Nursing. This was in contradiction to the regulatory requirement that only one designated registered nurse was to be given access at any given time. Interview with the Pharmacy Director by surveyor #13692 on 11/2/11 revealed that the Director was unaware of this arrangement.

b. Hospital policy entitled " Authorized Access to Pharmacy " (Policy #7170-400; revised 7/11/2011, reads in part: " 1. Entry into pharmacy when a Pharmacist is NOT present: l Designated registered nurse: l. Another nurse may enter pharmacy ONLY if accompanied by the designated registered nurse who is responsible for the pharmacy. "


2. Based on interview and record review, the Critical Access Hospital failed to ensure that nurses who accessed the pharmacy when the pharmacist was absent recorded removal of medications according to hospital policy and Washington State Board of Pharmacy regulations.

Failure to do so risks administering incorrect medications to patients and could result in patient harm.

Reference: WAC 246-873-050 "Absence of a pharmacist. (b) The stock container of the drug or similar unit dose package of the drug removed shall be left with a copy of the order of the authorized practitioner to be checked by a pharmacist, when the pharmacy reopens, or as soon as is practicable."

Findings:

a. On 11/2/2011, review by Surveyor #13692 of the log of medications removed from the pharmacy when the pharmacist was not on site for the month of October 2011 revealed the following:

The pharmacy was accessed 41 times by nursing staff, and 51 medications were removed. The log indicated that a sample of the drug was not left, nor was the NDC number written on the log, for the pharmacist to review for 10 of these 51 medications. The log indicated that 37 of these 51 medications were removed for specific patients. There was no physician ' s order for the pharmacist to review for 10 of 37 medications removed.

b. The hospital's policy and procedure entitled " Authorized Access to Pharmacy " (Policy #7170-400; Revised 7/11/2011) reads in part: " Procedure: 8. The copy of the medication order will be placed on the counter, a proper notation of the quantity taken, time of day, and the signature of the Nursing Supervisor will be inscribed [on the Medication Disposition Log]. When possible, a unit of the same item will be placed theron so that a proper check by a pharmacist can be affected ... 11. The Nursing Supervisor shall log each time of entry, patient name and room, medication name, NDC [National Drug Code] if sample not left, number of doses, the reason for accessing the mediation from the pharmacy ...and his/her signature on the Night Log. "

c. An interview with the Pharmacy Director on 11/2/2011 by Surveyor #13692 confirmed that nurses did not follow hospital policy and procedure when removing these drugs from the pharmacy when the pharmacist was absent.


3. Based on observation and interview, the Critical Access Hospital failed to follow acceptable standards and their hospital policy for positively identifying patients prior to administration of medications.

Failure to do so places patients at risk of debility related to medication errors.

Findings include

a. On 11/2/11, Surveyor #18001 observed Staff Member #9 administer medications to two patients. In each situation, staff #9 told the surveyor that s/he had examined the patient ' s wristband for proper identification on an earlier visit to the patient ' s room. However Staff Member #9 did not do so when entering the room just prior to administering medications.

b. On 11/1/11 and 11/2/11, Surveyor #18001 interviewed three patients and their family member(s) as to whether staff members positively determined their identity by some means before administering medications, such as examining their name bands or asking name and another identifier, such as birth date. All those interviewed indicated that this did not occur.

c. Facility policy #7170-704, " Medication Administration", revised 7/11/11 reads in part: "11. The medication nurse will positively identify the patient by reading the identification wrist band and following the organizational Patient Identification for Clinical Care and Treatment policy, which requires the use of two (2) additional patient identifiers prior to administration of all medications. "

4. Based on record review, the Critical Access Hospital failed to follow state regulation and hospital policy for authenticating verbal, verifying, and writing complete orders.

Failure to do so risks patients receiving unintended medications or dosages, with potential risks to the patient.

Reference: "WAC 246-873-090 Administration of drugs. (1) General. Drugs shall be administered only upon the order of a practitioner who has been granted clinical privileges to write such orders. Verbal orders for drugs shall only be issued in emergency or unusual circumstances and shall be accepted only by a licensed nurse, pharmacist, or physician, and shall be immediately recorded and signed by the person receiving the order. Such orders shall be authenticated by the prescribing practitioner within 48 hours. "

Findings:

a. On 11/1/11 Surveyor #18001 reviewed the medical record for Patient #3 who had been admitted on 7/30/11 with multiple diagnoses including having sustained a stroke. Reviewing the physician ' s orders, 20 verbal/telephone orders were documented between 7/27/11-10/28/11. None of them were designated as " TOV " or " VOV " , indicating that the staff taking the order had confirmed the order with the practitioner. Of those 20 orders, 2 had not been authenticated, though the 48 hour requirement according to regulation and policy had been exceeded. The remaining verbal/telephone orders had been signed by the practitioner, but no date or time had been documented, rendering it impossible to know when the authentication had taken place.

On 11/1/11 the surveyor reviewed the medical record of Patient #4 who had been admitted on 10/23/11 with diagnoses including respiratory failure. Reviewing the physician ' s orders, 8 verbal/telephone orders were documented between 10/25/11-10/28/11. None of them were designated as " TOV " or " VOV " as previously. Of those 8 orders, none were dated and timed when authenticated, again preventing a determination as to when the authentication had taken place.

Similar incompleteness in terms of the date and time orders were signed were found for five of five other records reviewed by surveyor 13692 for this issue (Patients #7 - 11).

Hospital policy #8721-014, " Organizational Verbal Order Acceptance, Transcription and Implementation " , revised 4/19/10 reads in part that " All verbal orders must be written with TOV (telephone order verified) or VOV (voice order verified) time and order received, complete documentation of order on the medical record order sheet, with signature ... "


b. On 11/2/11 Surveyor #18001 reviewed a cross-section of ten Emergency Department patient records. Patients #12 - 15 received intravenous medications. However, there was no order found for any of these patients directing staff to initiate an intravenous access device. For patient #15, the patient had orders for six medications for which the route was not specified, resulting in an incomplete order. The patient was admitted for abdominal pain and vomiting, and was ultimately transferred to another hospital for care.

Hospital policy #7170-309, " Physician's Verbal and Telephone Orders", revised 7/11/11 reads in part: " All Physician orders will be: ... complete ... 6. Telephone/verbal orders are signed/and authenticated according to policy. 8. All verbal or telephone orders will be signed by the prescriber within 48 hours
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Based on interview, observation, medical record review; review of hospital policies and procedures; review of the hospital's infection control log, infection control committee meeting minutes, and quality committee meeting minutes; the Critical Access Hospital failed to develop and implement an effective infection control and prevention program.

Failure to develop and implement an effective infection control and prevention program risks transmission of communicable diseases to patients, staff, and visitors.

Reference: CDC Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. V.B.1 - "Use Contact Precautions as recommended in Appendix A for patients with know or suspected infections or evidence of syndromes that represent risk for contact transmission."

Findings:

1. An interview with the hospital's quality program coordinator (Staff Member #1) on 11/1/2011 at 11:00 AM revealed that the hospital's previous infection control coordinator had not submitted a departmental report to the Quality Committee as required by the hospital's quality plan since 3rd quarter 2009.

2. Review of the hospital's infection control log on 11/1/2011 revealed that healthcare associated infections had been logged but had not been analyzed. No action plans had been developed to reduce the chance of infection reoccurrence.

3. Review of the Infection Control Committee meeting minutes for July 2011 included recommendations made by a physician member for tracking and trending upper respiratory infections, urinary tract infections, and MRSA. No action plans had been developed to address these recommendations as of November 1, 2011.

There was no evidence in Infection Control Committee meeting minutes of environmental rounds being performed to monitor for infection control breeches, such as cross-contamination between soiled and clean items and areas.

4. An interview with the hospital's current infection control coordinator (Staff Member #2) on 11/2/2011 at 11:00 AM revealed that the coordinator had no formal training in infection control and prevention principles and practices, such as surveillance methodology, identification of healthcare-associated infections, analysis of infection incidence and prevalence, benchmarking, and action plans for performance improvement.

The interview also revealed that the hospital had not performed an Infection Risk Assessment, to include occurrences of MRSA,VRE, and Clostridium difficile, according to hospital policies and procedures #8740-1001 and #8740-1002 (Effective 7/18/2011).

5. An interview with the assistant nurse manager (Staff Member #3) on 11/2/2011 at 11:00 AM revealed that patients were not asked regarding history of MRSA and other MDROs per hospital policy and procedure #8740-4018 (Effective 8/1/2011).

6. On 11/2/2011, review of the medical records of two patients identified on the hospital's infection log for 2010 as being diagnosed with Clostridium difficile (Patients #1 and #2) revealed that both patients had uncontrolled diarrhea for two to twenty-seven days prior to diagnosis. The medical records lacked evidence that the patients had been placed in contact precautions when the uncontrolled diarrhea began nor after the diagnosis of Clostridium difficile was made as recommended by the CDC.

On 11/2/2011, review of the medical records of Patient #22, who had been admitted on 8/19/2011 for a blood transfusion, revealed that the patient had a draining wound and been diagnosed with MRSA The patient's medical record lacked evidence that the patient had been placed in contact precautions as recommended by the CDC.

7. Surveyor #18001 observed the follow breaches of infection control procedures:

a. On 11/1/11 patient care supplies were stored in cardboard boxes directly on the floor in the south wing supply room and central supply room. They were subject to contamination due to their pervious nature. These supplies consisted of 3 bottles of tube feeding solution, 2 boxes of paper towels, and multiple boxes of disposable tourniquets. Staff Member #5 made the same observation.

b. On 11/1/11 in the Emergency Department, a pillow and a casting bucket were stored below a sink. Staff Member #5 made the same observation..

c. On 11/1/11 a bottle of Betadine brand skin cleanser had expired in May 2011, which made it subject to bacterial overgrowth. Staff Member #5 made the same observation.

d. On 11/2/11 Staff Member #9 administered an injection to a patient without first cleansing the skin at the injection site.

e. On 11/2/11 in two patient rooms, nebulizer equipment, including used (contaminated) mouthpieces were stored in the open air, unprotected from cross-contamination.

8. Surveyor #00210 observed the follow breaches of infection control procedures:

a. During the kitchen inspection on 11/2/2011 at 10:30 AM the surveyor observed three solution-filled containers in the kitchen that the kitchen staff used to sanitize food contact surfaces. The surveyor asked the kitchen manager (Staff Member #10) for the test strips that staff used to measure the level of sanitizer in the containers and was given the quaternary chemical test strips. The surveyor dipped the test strips into the solution, but test strips did not show any level of sanitizer present in the containers.

The kitchen manager reported that chlorine was used as a sanitizer solution in the containers. There were no chlorine test strips in the kitchen at that time to measure the concentration of the chlorine sanitizer in the containers. The quaternary chemical test strips used in the kitchen were chemical-specific for quaternary ammonia sanitizer solutions and did not test for chlorine levels.

The kitchen staff did not use the correct chemical test strips in the kitchen that were specific for the chemical sanitizer in use at the time and therefore could not ensure the correct concentration of the sanitizer used.


b On 11/3/2011 at 10 AM, the surveyor dressed in a head cover, a lab coat and shoe covers and toured the clean Central Supply (CS) area where patient instruments were cleaned, packaged and sterilized. The surveyor observed a red line on the counter space which divided the dirty area of the room from the clean area of the room. The surveyor used a light-weight tissue and observed that the air pressure in the room was positive, blowing out into the corridor, which is the correct environmental design for a clean work space to keep contaminates out of the room. In a soiled work space the air pressure should be negative, blowing in from the corridor or adjoining space to keep contaminates in the room. The hospital was mixing dirty and clean operations in the same clean air space.

The CS manager reported to the surveyor that the dirty instruments were brought into CS from the emergency department to be first soaked and cleaned in an enzymatic solution to remove any blood or tissue on the instruments. This was done on the "dirty" side of the red line in CS. The cleaned instruments were later wrapped and sterilized in the autoclave on the "clean" side of the red line. Dirty instrument cleaning and packaging and sterilizing patient instruments were performed in the same space. When dirty and clean duties are mixed in the same space there is potential for cross contamination to occur.

There was no evidence that the environment in the CS department was evaluated by the hospital to ensure there was no possible cross contamination of patient instruments by mixing clean with dirty.
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Based on interview and patient record review, the facility failed to implement a system to plan and document an individualized plan of care for every patient served.

Failure to do so places patients at risk of unrecognized care needs and failure to meet them.

Findings include:

1. Patient #5 was admitted in observation status on 11/2/11. Surveyor #18001 reviewed the patient's medical record and found no evidence that an individualized plan of care had been developed for the patient. Staff Member #5 stated it was not facility policy to develop care plans for observation patients, who could stay up until 24 hours.

2. On 11/3/11, Surveyor 13692 reviewed medical records for eight adult acute care patients, finding that four of eight did not include a patient plan of care (Patients #16 -19). Review of two pediatric patients on 11/3/11 by Surveyor 13692 revealed that the records included standardized patient care plans for adult long-term care patients, and not been individualized to reflect the needs of pediatric acute care patients (Patients #20 - 21).
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CONDITION NOT MET

Based on review of hospital policies and procedures; staff interviews; review of the hospital's quality assurance program and quality assurance documentation; review of the hospital's infection control program and infection surveillance documentation; and review of deficiencies cited during the 2006 Critical Access Hospital survey and the hospital's attestation of correction of these deficiencies; the Critical Access Hospital failed to meet the requirements for the Condition of Participation for Periodic Evaluation and Quality Assurance Review.

Failure to develop and implement an effective quality assurance program impaired the hospital's ability to provide quality care in a safe environment.

Reference: 485.641(b) "The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes."

Findings:

Due to the cummulative effect of deficiencies detailed under the Condition of Participation at 42 CFR 485.641 Periodic Evaluation and Quality Monitoring, this Condition was NOT MET.

Cross-refer to C0336, C0337, C0338, and C0342

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Based on interview and review of the hospital's quality assurance plan and quality program documentation, the Critical Access Hospital failed to implement its plan to monitor, evaluate, and improve the quality of patient care services through routine data collection and analysis.

Failure to systematically collect and analyze facility performance data limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings:

1. The hospital's policy entitled "Performance Improvement Plan" (#8611-040; Effective 9/7/2011) read in part as follows:

"Scope and Integration: ...All personnel and departments are expected to be actively involved in the program. Contract services providing direct patient care or affecting the health and safety of patients are also included in the on-going monitoring activities and as appropriate the PI team process ... The PI program evaluated the quality of the diagnosis and treatment outcomes. The program includes ... Nosocomial infections."

"Roles and Responsibilities: The governing board has the ultimate responsibility for the quality of care and service provided. The Board's accountability for quality is discharged through its performance of four major responsibilities ...[including] Ensuring that quality management programs are in place and working effectively to monitor and improve quality ...Leaders play a central role in fostering improvement through planning, educating, setting priorities ... The Board receives a quarterly report from the Performance Improvement Committee. The content of all reports to the Governing Board contain sufficient detail and analysis to allow the Board to effectively meet its responsibility for quality oversight."

"Performance Improvement Committee (PIC): ...The responsibilities of the PIC include: Oversight of staff education and training for performance improvement and the facilitation of the PI process ... Prioritize quality improvement projects and commission teams ... Identify organizational trends or opportunities for improvement projects from reports received throughout the organization. Sources of data and information include reports from infection control studies, utilization review studies; risk management reports, and corporate compliance audits."

"Departmental Responsibilities: Each department is responsible for assessing and improving performance within the department. Quality assessment studies are conducted on an ongoing basis and reported to the PIC on an ongoing basis."

2. Interviews with quality program coordinator (Staff Member #1) and review of the hospital's quality assurance plan and quality program documentation, on 11/1/2011 at 11:00 AM; and 11/2/2011 at 8:30 AM) revealed that the hospital's quality program and plan had been revised 9/7/2011 but had not implemented as of 11/1/2011:

a. 4 of 21 department were delinquent in submission of quality indicator monitoring results to the hospital's quality improvement committee.

1) The quarterly reports for the infection control and employee health programs were missing for 4th quarter in 2009, for all four quarters in 2010, and for the first and second quarters of 2011.

2) The quarterly reports for the housekeeping department and Corporate Compliance were missing for the 2nd, 3rd, and 4th quarters of 2010 and the first and second quarters 2011

There was no plan evident in the quality committee meeting minutes for improving reporting compliance.

b. The hospital had had not developed a process for evaluating the performance of all patient care contractors. Patient care contractors were not evaluated as part of the CAH annual program review.

c Healthcare associated infections had been logged but had not been analyzed. No action plans had been developed to reduce the chance of infection reoccurrence.

d. There was no systematic process for reporting, tracking of progress of departmental performance improvement projects.

e. The hospital did not prioritize performance improvement activities to ensure achievement of those with the greatest impact on patient care quality and safety.

Cross-Refer to C0337, C0338, and C0342
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Based on review of the hospital's list of patient care contractors and interview, the Critical Access Hospital failed to develop a process for evaluating the performance of contractors who provided clinical services to hospital patients.

Failure to determine whether contractors meet all Medicare conditions of participation and standards risks provision of ineffective and unsafe healthcare to patients.

Findings:

On 11/1/2011 at 9:00 AM during the entrance conference, Surveyor #13692 received a list of contracted patient care services that included telepharmacy services; dietician services; a reference laboratory; and teleradiology services.

Interviews with quality program coordinator (Staff Member #1) on 11/1/2011 at 11:00 AM; and 11/2/2011 at 8:30 AM) revealed that the hospital had had not developed a process for evaluating the performance of these patient care contractors. Patient care contractors were not evaluated as part of the CAH annual program review.

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Based on review of the hospital's infection control log and review of infection control committee meeting minutes, the Critical Access Hospital failed ensure that incidents of healthcare acquired infections were analyzed and action plans developed for infection prevention according to hospital policy.

Failure to develop and implement an effective infection control and prevention program risks transmission of communicable diseases to patients, staff, and visitors.

Findings:

1. Review of the hospital's infection control log on 11/1/2011 revealed that healthcare associated infections had been logged but had not been analyzed. No action plans had been developed to reduce the chance of infection reoccurrence.

2. Review of the Infection Control Committee meeting minutes for July 2011 included recommendations made by a physician member for tracking and trending upper respiratory infections, urinary tract infections, and MRSA. No action plans had been developed to address these recommendations as of November 1, 2011

Cross-refer to C0278
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Based on interview and review of the hospital's quality assurance plan and quality program documentation, the Critical Access Hospital failed to develop and sustain action plans to improve hospital performance.

Failure to systematically collect and analyze facility performance data limited the hospital's ability to identify problems and formulate action plans. This reduced the likelihood of sustained improvements in clinical care and patient outcomes.

Findings:

1. Review of quality committee meeting minutes for 2010 and 1st quarter 2011 on 11/1/2011 revealed that the committee reviewed reports of quality indicators from 17 hospital departments. The committee nor the departments did not formulate action plans to address indicators that did not meet quality goals.

2. Interviews with quality program coordinator (Staff Member #1) on 11/1/2011 at 11:00 AM; and 11/2/2011 at 8:30 AM) revealed that adverse occurrences such as medication errors and patient falls reported through the hospital's Quality Management Memo system. These occurrences were analyzed individually and reported to the Quality Committee by numbers of incidents only. Aggregate data regarding these occurrences were not analyzed for common causes to facilitate development of action plans to reduce the chance of recurrence.

3. An interview with contracted pharmacy director (Contractor #3) on 11/2/2011 at 9:00 AM revealed that medication errors were tracked by the telepharmacy service provider. No information regarding these errors, such as types and number of errors, was shared with the hospital.

4. This CMS Critical Access Hospital recertification survey resulted in 2 repeat deficiencies cited during its 2006 recertification survey (C0336, C0337). The hospital's plans of correction for these deficiencies were not effective and sustainable.

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Based on interview, the Critical Access Hospital failed to develop and policy and procedure for a comprehensive assessment of the needs of swing bed patients.

Failure to perform an comprehensive assessment of the patient's needs risks provision of inadequate or ineffective patient care and discharge to a harmful living environment.

Findings:

Interviews with the assistant nurse manager (Staff Member #3) on 11/1/2011 at 1:15 PM and the hospital's social worker (Staff Member #4) on 11/2/2011 at 10:40 AM revealed the following:

1. Admission assessments of swing bed patients did not include the resident's customary routine nor a psychosocial assessment of the resident. The assessments did not document the patient's participation in the assessment.

2. The hospital had no policy and procedure for a comprehensive assessment of the healthcare needs of swing bed patients was to be conducted, including the required elements of the assessment, which disciplines were to perform which parts of the assessment, and the frequency and conditions for reassessment of the patient.
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