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Based on observation, record review, policy and procedure review, and interviews of administrative staff, the Critical Access Hospital (CAH) failed to provide for emergency care necessary to meet the needs of its patients by:

1. Failing to ensure required equipment and supplies used in life-saving procedures, such as tracheotomy set, cricothyrotomy kit, and chest tubes were readily available for use to treat emergency cases in the facility; and

2. Failing to ensure practitioners and CAH staff were trained and evaluated for competency to respond to emergency medical needs, such as utilizing life-saving equipment to provide for airway access, management and protection including tracheotomy, cricothyrotomy, chest tubes and medications required to perform rapid sequence intubation.

These findings presented a serious and immediate threat to the health and safety of all patients presenting with or developing an obstructed or compromised airway or collapsed lung either as an inpatient or when presenting to the CAH emergency department.

CAH Administration was notified of the Immediate Jeopardy (IJ) deficient practice on 9/20/11 at 3:30 PM.

The IJ was determined to be abated on 9/22/11 at 11:30 AM based on the CAH's providing required life-saving equipment and supplies and providing training/competency for practitioners and CAH staff.

The Condition of Participation for Emergency Services is out of compliance due to the seriousness of the deficiencies cited at C 0202, C 0204 and C 0207.

The facility census at the time of the survey was 3 swing bed patients and 2 private pay patients. The CAH had 136 patients present to the emergency department in the 6 months prior to the survey.

Based on observation, record review, policy and procedure review, interviews of administrative staff and medical staff, the Critical Access Hospital (CAH) failed to ensure required life saving equipment (tracheotomy set, cricothyrotomy kit, and chest tubes) as well as trained/competencied practitioners and staff to utilize life saving equipment including tracheotomy, cricothyrotomy and chest tubes were present in the emergency department to provide emergency interventions for airway access, management and protection.

Two medications required for rapid sequence intubation were not readily available potentially delaying or preventing emergency life-saving intubation for airway management and protection.

These findings presented a serious and immediate threat to the health and safety of all patients presenting with or developing an obstructed or compromised airway or a collapsed lung either as an inpatient or presenting to the emergency department. The Administration was notified of the Immediate Jeopardy on 9/20/11 at 3:30 PM. The facility census was 3 swing bed patients and 2 private pay patients. The CAH had 136 patients present to the emergency department in the 6 months prior to the survey. Findings are:

A. During a review of the CAH's emergency services on 9/20/11 beginning at 9:45 AM, it was determined the hospital did not have in the facility a tracheotomy set, a cricothyrotomy kit, or chest tubes with thorocotomy set and other supplies needed for life-saving treatment for patients presenting with obstructed airway or a collapsed lung. Interview with the Director of Nursing (DON) during this review revealed the hospital had those supplies until about 1.5 to 2 plus years ago when that equipment was removed from the hospital. The DON stated the physician that was their primary provider at that time told them to get rid of the supplies because they would not use them and the Physician Assistants (PAs) they had working the emergency department on call then said they were not adequately trained to use that equipment and they would not. The PAs also refused to attend a trauma class that the DON recommended they attend. DON said she did not feel comfortable about removing those supplies from the hospital, but she did not have the support to fight it, so she followed the physician's demands. That physician is no longer with the hospital, and the DON stated she had forgotten about the situation. DON was asked what would happen if they had a patient with an obstructed airway and they could not intubate the patient. She replied, "The patient would die. There's nothing else we could do."

B. During observations while touring the emergency department beginning at 10:30 AM, a television was noted to be mounted high on the wall opposite the emergency room patient bed. DON stated they have telemedicine connecting the CAH to 3 different hospitals in 3 different cities, including Norfolk, Lincoln and Omaha. They test the equipment every month and have not had any problems with the communications. She responded in the positive when asked if they could obtain help/direction for managing a patient with an obstructed airway or collapsed lung. DON also agreed a patient with an impaired airway or chest injury that required chest tubes would not have time to make it to another hospital that could provide this level of care.

C. Review of the policies and procedures for the emergency department found there was a policy for a cricothyrotomy, but no policy for a tracheotomy, and no policy for insertion of chest tubes. They also did not have a policy on the privileges and training required to work in the emergency department.

D. During the tour of the emergency department beginning at 10:30 AM, it was determined that the medications immediately available in the emergency department did not include all of the medications necessary for rapid sequence intubation should the facility practitioners need to access, manage and protect the airway of a patient presenting to the emergency department with an obstructed airway, a comatose patient requiring airway protection, or other condition requiring airway access, management and protection until transfer could be completed to another hospital. Interview with the DON beginning at 9:45 AM revealed she thought they had a dosing guide somewhere for rapid sequence intubation, and found the guide in a box of cards on the emergency cart. Looking over the guide, the DON said they had the Atropine and Lidocaine in the medication drawers in the cart, but the Etomidate (a short acting sedative, induction agent) and Midazolam (AKA Versed - also a sedative, induction agent) were kept in the scope anesthesia cart which was in a locked room down the hall from the emergency room. DON stated that not all CAH staff would know where the key to that room was, and it would take time to access the medication, if they could get to it.

E. An interview was completed on 9/21/11 between 2:35 and 3:20 PM by telephone with a Physician Assistant (PA) that works on call in the emergency department. He discussed a case that came through the emergency department on 1/24/11 that had an emergency medical condition with potential airway complications. The PA said intubation would have been difficult due to the patient's anatomical neck structure. The patient was transferred to another hospital with a higher level of care in Norfolk without being intubated. The PA revealed he was the only one in the facility at that time with the training to do intubation, and made the comment that he knew if the facility had any trach or cricothyrotomy supplies they would be very rudimentary. If unable to intubate, availability of a tracheotomy set or a cricothyrotomy kit would be critical to access a compromised airway, or for a patient paralyzed by drugs used to attempt rapid sequence intubation

F. It was determined that because of the lack of this life-saving equipment to access, manage and protect a patient's airway and the unavailability of 2 medications used for rapid sequence intubation there was a serious and immediate threat to the health and safety of patients requiring these services. Administrator and DON were notified of the Immediate Jeopardy (IJ) deficient practice on 9/20/11 at 3:30 PM.

On 9/22/11 at 11:30 AM, the IJ was abated based on confirmation of the CAH's response to comply with the requirements. CAH had obtained all of the equipment needed to provide the life-saving services including a tracheotomy set, a cricothyrotomy kit, chest tubes and supplies necessary to insert and use chest tubes. CAH had written the necessary policies for these services, but policies still needed to be approved by the medical staff which would occur at their next meeting. CAH had provided training and competencies through "Just in Time Training" to the physician assistants and nursing staff. See C0207.

Based on observation, policy and procedure review, and interviews of administrative staff, the facility failed to ensure required life-saving equipment, such as, tracheotomy set, cricothyrotomy kit, and chest tubes were present and readily available for use in the hospital to provide emergency interventions for airway access, management and protection. The facility census was 3 swing bed patients and 2 private pay patients. The CAH had 136 patients present to the emergency department in the 6 months prior to the survey. Findings are:

A. During a review of the Critical Access Hospital's (CAH) emergency services on 9/20/11 beginning at 9:45 AM, it was determined the hospital did not have in the facility a tracheotomy set, a cricothyrotomy kit, or chest tubes with thorocotomy set and other supplies needed for life-saving treatment for patients presenting with obstructed airway or a collapsed lung.

B. Interview with the Director of Nursing (DON) during this review, revealed the hospital had those supplies until about 1.5 to 2 plus years ago when that equipment was removed from their hospital. DON stated the physician that was the primary provider at that time told them to get rid of the supplies because they would not use them. The Physician Assistants they had working the emergency department on call then had said they were not adequately trained to use that equipment and they would not.

C. Review of the policies and procedures for the emergency department found there was a policy for a cricothyrotomy, but no policies for a tracheotomy and for insertion of chest tubes.

Based on review of credential files, review of Medical Staff Bylaws and Rules and Regulations, review of policies and procedures, review of on call schedule for physicians and/or midlevel practitioners for September 2011 and staff interviews, the CAH (Critical Access Hospital) failed to ensure that:

1. 3 of 4 physicians (Physicians B, C and H) listed on the on-call schedule for the ER (Emergency Room) for September 2011 had the necessary training and/or granted privileges to perform life saving airway management and protection;

2. 5 of 6 midlevel practitioners (Physician Assistants I, N and P and Advanced Practiced Registered Nurses K and O) listed on the on-call schedule for the ER for September 2011 had the necessary training and/or granted privileges to perform life saving airway management and protection; and

3. 7 of 14 RNs (Registered Nurses) had the necessary experience and training for set up and assisting physicians and/or midlevel practitioners in the emergency room for life saving airway management and protection.

NOTE: The American College of Surgeons Committee on Trauma dated September 2002 developed criteria concerning Management of the Airway which included the following information:
- The purpose of airway management is to provide and maintain a secure airway, ensure adequate oxygenation and ventilation, prevent aspiration and protect the cervical spine.
- Patients at risk for airway problems are head injury, direct airway injury, shock, facial fractures, thoracic injury and drugs/alcohol.
- Management techniques included simple techniques oropharngeal and nasopharyngeal airway (plastic tubes inserted in the mouth or nose to aid breathing), tracheal intubation (placement of a tube into the windpipe), and needle or surgical cricothyroidotomy (a hole is cut or made with a needle through the membrane in the neck into windpipe in order to allow air into the lungs).

Due to the lack of trained/privileged providers covering the emergency department, and trained/competencied nursing staff to set up and assist the medical staff providers in the emergency department to perform life saving airway management and protection, it was determined that an Immediate Jeopardy (IJ) to patient health and safety situation existed. The Administrator and the Director of Nursing were notified of the IJ deficiencies on 9/20/11 at 3:30 PM.

The facility census at the time of the survey was 3 swing bed patients and 2 private pay patients. The CAH had 136 patients present to the emergency department in the 6 months prior to the survey. Findings are:

A. Review of the Medical Staff Bylaws with a revised date of June 2006, review of the Medical Staff Rules and Regulations with an approved date of 3/26/08 and review of the Emergency Department policy and procedure manual revealed the CAH had no written policy available that spelled out the necessary training that a physician and/or midlevel practitioner needed in order to provide coverage in the emergency department at the hospital.

B. Interview with the DON (Director of Nursing) on 9/21/11 at 12:20 PM confirmed the policy and procedure manual for the emergency department contained no policy regarding the necessary training and/or experience for a physician and/or midlevel practitioner in order to provide coverage in the emergency department.

C. Review of the credential file for Physician B revealed this physician was granted temporary privileges for 9/1 and 2, 2011. Review of the on-call schedule for the emergency department for September 2011 revealed Physician B was on call from 9:00 PM on 9/1/11 to 5:00 PM 9/2/11. Review of the privilege list for Physician B revealed the form had no section designated Emergency Room; however, under medical condition placement of chest tubes was checked and also endotracheal (oral and nasal) was checked. This physician had not been granted temporary privileges for more advanced airway management, i.e. cricothyroidotomy; however, the credential file contained a copy of ATLS Certification (Advanced Trauma Life Support - this certification would include training in cricothyroidotomy).

D. Review of the credential file for Physician C revealed a delineation of privilege list dated 5/20/10 with request for cricothyroidotomy but the privileges for introduction of chest tube and tracheotomy had been crossed through. Interview with the Administrator on 9/22/11 at 12:15 PM revealed that these procedures were crossed through since the CAH did not have the equipment to perform those procedures. This privilege form also indicated that Physician C did not have ACLS (Advanced Cardiac Life Support) Certification). The credential file contained no information on whether this Physician had ATLS training and/or experience in airway management. Review of the September 2011 on-call schedule revealed this physician was scheduled for 9/19 and 20/11.

E. Review of the September 2011 physician on-call schedule revealed Physician H was scheduled to be on call on 9/30/11. Review of the credential information for this physician revealed no completed privilege form and no evidence of training for emergency airway management.

F. Review of the credential file for PA (Physician Assistant)-I revealed this PA did have privileges for endotracheal intubation and insertion of oropharyngeal airway; however, no privileges had been granted for cricothyroidotomy, chest tube or tracheotomy. The privilege form and credential file contained evidence of ACLS but no evidence of training/experience in airway management. Review of the on call schedule for September 2011 revealed this PA was scheduled for 9/1, 6, 7, 13, 14, 15, 16, 17, 18, 21, 22, 27, 28 and 29/11.

G. Review of the credential file for PA-N revealed the PA had received temporary privileges for 9/11-13/11. Review of the privilege list revealed privileges for endotracheal (oral and nasal); however, there were no privileges for more advanced airway management or for chest tube insertion. The file lacked evidence of training and/or experience in advanced airway management. Review of the September 2011 on-call schedule revealed PA-P worked 9/11 and 12/11.

H. Review of the credential file for PA-P revealed the PA was given temporary privileges for 9/8-10/11. The file contained a Scope of Practice Agreement with the PA and the Medical Director signed 9/8/11. There was no delineation of privileges form in this file. The file did contain an email from PA-P indicating certification in ATLS, however, no evidence of this was present. Review of the September 2011 on call schedule revealed PA - P worked 9/8-10/11.

I. Review of the credential file for APRN (Advanced Practice Registered Nurse)-K revealed a Scope of Practice Agreement with Physician C. The file contained no delineation of privilege, no evidence of training and/or experience in airway management and no letter granting temporary privileges. Review of the September 2011 on call schedule revealed this APRN was scheduled to work 9/26/11.

J. Review of the credential file for APRN-O revealed the file contained no delineation of privileges form and no evidence of training and/or experience in airway management. Review of the September 2011 on-call schedule revealed this APRN worked 9/2, 3, 4 and 5/11.


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K. Review of the nursing employee list revealed the facility had 14 RNs employed at the facility. According to the DON during the emergency room review, all 14 RNs had their ACLS (Advanced Cardiac Life Support) and PALS (Pediatric Advanced Life Support) certifications. An interview with the DON on 9/22/11 at 1:00 PM revealed 7 of the RNs had also taken the Trauma Nursing Core Course and were knowledgeable about airway assessment, management and appropriate interventions. The DON said those nurses would be able to perform the necessary services required. The other 7 nurses would eventually have the course, but they were not signed up at the time of the survey since sessions fill up quickly and were not offered very often. Upon notification of the IJ deficiencies, DON contacted their network hospital in Norfolk to get JIT (Just in Time) training at the end of the week for the remaining 7 nurses.

L. The CAH provided an action plan to abate the IJ that included:
- documentation of the required certifications and training of the medical providers contracted to cover the emergency department;
- privileging of all those providers approved by the medical director and the plan to present these at the next medical staff meeting for their approval, followed by board approval;
- policies for training and privileging developed by the Administrator for any provider prior to their being able to cover the emergency department;
- all RNs scheduled to work were provided JIT training prior to their being allowed to work;
- additional JIT training scheduled for the day after the survey was completed for all nursing staff ; and
- Medical Director determined additional training would be provided to the nursing staff as well as training provided 2 times per year to keep nursing staff up to date and comfortable with the services of airway management and protection.

Based on confirmation of this information, the IJ was determined to be abated on 9/22/11 at 11:30 AM.

Based on review of policy and procedure manuals, review of Medical Staff meeting minutes and staff interview, the CAH (Critical Access Hospital) failed to ensure that all required members of the group of professionals (physician, physician assistant and someone not on staff at the hospital) reviewed 7 of 7 required types of policies and procedures in the past year. The policies not reviewed were:
- Description of the services the CAH furnishes directly and those furnished through agreement or arrangement;
- Polices and procedures for emergency medical services;
- Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral;
- The maintenance of health care records;
- Procedures for the periodic review and evaluation of the services furnished by the CAH;
- Rules for the storage, handling, dispensation and administration of drugs and biologicals and procedures for reporting adverse drug reactions and errors in the administration of drugs (Pharmacy policies and procedures);
- System for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel (Infection Control policies and procedures; and
- Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices (Dietary Policies and Procedures).

The facility census at the time of the survey was 3 swing bed patients and 2 private pay patients. The CAH had 136 patients present to the emergency department in the 6 months prior to the survey. Findings are:

A. During the entrance conference on 9/19/11 from 11:00 AM to 11:20 AM the DON (Director of Nursing) indicated that not all of the policy and procedure manual would show review of the policies by the Medical Director due to the Medical Director wanting to review policies and procedure in more depth before signing off on the policies. DON also indicated that the person not on staff involved in the review was a member of the governing body.

B. On 9/22/11 at 1:30 PM surveyor requested a copy of the description of the services the CAH furnishes directly and those furnished through agreement. The Administrator printed a copy off of the computer with a revised date of January 2011 and indicated that this revised policy had not been taken to the Medical Staff for review. The Administrator also provided a 3-ring notebook titled Administrative Policies. The copy of provided services in this manual was dated December 2009. The CAH could provide no evidence that this policy had been reviewed by the group of professionals in the last year.

C. Review of the Emergency Room policy and procedure manual revealed a signature sheet in the front of the manual which indicated that the Chief of the Medical Staff had approved the policies and procedures on 8/1/11 and that the Governing Board President had approved the policies and procedure on 8/3/11. Review of the Medical Staff meeting minutes dated 7/21/11 revealed there was a request for the Chief of the Medical Staff for approval of the ER (Emergency Room) policies and procedures with the documentation that this was addressed further after the meeting was adjourned. PA (Physician Assistant)-I attended this meeting; however, there was no documentation that the policies and procedures were reviewed and there was no evidence that PA-I was involved in the review after the meeting.

D. During the entrance conference on 9/19/11 from 11:00 AM to 11:20 AM a request was made for a copy of the last Annual Program Evaluation. On 9/19/11 at 4:00 PM the Director of HIM (Health Information Management) provided an undated policy titled Periodic Evaluation for CAH. Review of the Administrative policy and procedure manual revealed a different policy for the Periodic Evaluation for CAH. There was no documentation available to show which was the most current policy and procedure and to show that this policy had been reviewed by the group of professionals in the past year.

E. Review of the HIM policy and procedure manual revealed a signature sheet in the front of the manual which indicated that the Chief of the Medical Staff had approved the policies and procedures on 2/15/10 and that the Governing Board President had approved the policies and procedures on 2/15/10. Review of the Medical Staff meeting minutes dated 7/21/11 revealed there was a request for the Chief of the Medical Staff for approval of the HIM policies and procedures with the documentation that this was addressed further after the meeting was adjourned. PA-I attended this meeting but there was no evidence of involvement in the review of the policies and procedures. Facility could provide no evidence that the policies and procedures for HIM had been reviewed by the group of professionals in the past year.

F. Review of the Pharmacy policy and procedure manual revealed a signature sheet in the front of the manual which indicated that the Chief of the Medical Staff had approved the policies and procedures on 6/17/10 and that the Governing Board President had approved the policies and procedures on 6/30/10. Review of Medical Staff meeting minutes for the past year revealed no documentation of review of Pharmacy policies and procedures. The CAH could provide no evidence that Pharmacy policies and procedures were reviewed by the group of professionals in the past year.

G. Review of the Infection Control policy and procedure manual revealed a signature sheet in the front of the manual which indicated that the Chief of the Medical Staff had approved the policies and procedures on 3/17/10 and that the Governing Board President had approved the policies and procedures on 6/30/10. Review of the Medical Staff meeting minutes dated 8/18/11 under section titled policy and procedure books revealed the Chief of the Medical Staff "has completed...review of Infection Control...and has signed...approval." However, the CAH could provide no evidence that the Infection Control policies and procedures had been reviewed by the PA or the Governing Body President.

H. Review of the Dietary Department policy and procedure manual revealed a signature sheet titled Policy & Procedure Manual and Diet Manual Approval with the signature of the Medical Director dated 1/20/11. Review of the Medical Staff meeting minutes dated 1/20/11 revealed the following under Dietary Manual: "The dietary Manual was brought to the meeting for approval. [Chief of the Medical Staff] kept the manual for more thorough review following the meeting, to be signed and returned to the Dietary Department with any recommendations." There was no documentation provided to indicate that the PA and Governing Body President were involved in the review of the Dietary Department policies and procedures.

Based on record review, review of facility policy and staff interviews the facility failed to ensure nursing staff developed a nursing plan of care for 4 of 17 inpatients (Patients 4, 33, 34 and 35) reviewed. The total sample size was 33. The facility census at the time of the survey was 3 swing bed patients and 2 private pay patients. The CAH had 136 patients present to the emergency department in the 6 months prior to the survey. Findings are:

A. Record review of the medical record for Patient 4 admitted 7/23/11 and discharged 7/26/11 failed to find any evidence the nursing staff developed a nursing plan of care. Staff interview on 9/21/11 at 4:35 PM with Licensed Practical Nurse (LPN)-F confirmed this finding.

B. Record review of the medical record for Patient 33 admitted 8/31/11 and discharged 9/10/11 failed to find any evidence the nursing staff developed a nursing plan of care. Staff interview with LPN-G on 9/20/11 at 1:10 PM confirmed this finding.

C. Record review of the medical record for Patient 34 admitted 5/20/11 and discharged 5/28/11 failed to find any evidence the nursing staff developed a nursing plan of care. Staff interview with Director of Nursing (DON) on 9/20/11 at 10:20 AM confirmed this finding.

D. Record review of the medical record for Patient 35 admitted 7/12/11 and discharged 7/22/11 failed to find any evidence the nursing staff developed a nursing plan of care. Staff interview with LPN-G on 9/20/11 at 1:10 PM confirmed this finding.

E. Review of facility policy titled "Procedure: Care Planning" last revised 12/18/07 states "A plan of care should be placed on the patient's chart upon the admission process and no later than 24 hours after admission."