CINXE.COM

<!DOCTYPE html>     <html lang="en-us">  <head><script type="text/javascript" src="/_static/js/bundle-playback.js?v=HxkREWBo" charset="utf-8"></script> <script type="text/javascript" src="/_static/js/wombat.js?v=txqj7nKC" charset="utf-8"></script> <script>window.RufflePlayer=window.RufflePlayer||{};window.RufflePlayer.config={"autoplay":"on","unmuteOverlay":"hidden"};</script> <script type="text/javascript" src="/_static/js/ruffle/ruffle.js"></script> <script type="text/javascript"> __wm.init("https://web.archive.org/web"); __wm.wombat("http://www.nebraskahospitals.org:80/about_us/member_services/cah/cah_top10_deficiencies/list_of_deficiencies_2013.html","20140620222244","https://web.archive.org/","web","/_static/", "1403302964"); </script> <link rel="stylesheet" type="text/css" href="/_static/css/banner-styles.css?v=S1zqJCYt" /> <link rel="stylesheet" type="text/css" href="/_static/css/iconochive.css?v=3PDvdIFv" />  <title>NHA Listing of Deficiencies for 2013</title>  <meta http-equiv="content-type" content="text/html; charset=UTF-8"/> <meta name="keywords" content="Nebraska, hospital, association, deficiencies, critical, access, hospital, cited"/> <link rel="stylesheet" href="https://web.archive.org/web/20140620222244cs_/http://cdn.firespring.com/cache/core.1402970906.css" type="text/css" charset="UTF-8"/> <link rel="stylesheet" href="https://web.archive.org/web/20140620222244cs_/http://cdn.firespring.com/designs/np_bulwark/css/stylesheet.css" type="text/css" charset="UTF-8"/> <link rel="stylesheet" href="https://web.archive.org/web/20140620222244cs_/http://cdn.firespring.com/designs/np_bulwark/subdesigns/3625/css/stylesheet.css" type="text/css" charset="UTF-8"/> <script src="https://web.archive.org/web/20140620222244js_/http://cdn.firespring.com/core/js/jquery-1.10.2.min.js" type="text/javascript"></script> <script src="https://web.archive.org/web/20140620222244js_/http://cdn.firespring.com/core/js/jquery-migrate-1.2.1.min.js" type="text/javascript"></script>   <script src="https://web.archive.org/web/20140620222244js_/http://cdn.firespring.com/designs/np_bulwark/js/jquery.dropdownPlain.js"></script>  </head> <body id="internal"> <div id="placeholder" class="wrap"> <div class="row clearfix 99 headerArea"> <div id="top_nav" class="col span16"> <div id="search"><div class="fdpc_search_form_10461324" class="fdpc_search_form"> <form> <input type="text" id="fdpc_search_form_input_10461324" class="fdpc_search_form_input"/> </form> <div id="fdpc_search_results_10461324" class="fdpc_search_results"></div> <script type="text/javascript"> var Swiftype = window.Swiftype || {}; (function () { if (!Swiftype.key) { Swiftype.key = 'rcyvkq3yVqdWpzKJwUMp'; Swiftype.inputElement = '#fdpc_search_form_input_10461324'; Swiftype.resultContainingElement = '#fdpc_search_results_10461324'; Swiftype.attachElement = '#fdpc_search_form_input_10461324'; Swiftype.renderStyle = "overlay"; Swiftype.disableAutocomplete = true; } else { var inputs = Swiftype.additionalInputElements || []; inputs.push('#fdpc_search_form_input_10461324'); Swiftype.additionalInputElements = inputs; } var stScript = document.createElement('script'); stScript.type = 'text/javascript'; stScript.async = true; stScript.src = "//web.archive.org/web/20140620222244/http://swiftype.com/embed.js"; var entry = document.getElementsByTagName('script')[0]; entry.parentNode.insertBefore(stScript, entry); }()); </script> </div></div><div id="quick_links" style="left:0;"> <ul class="content_collection_items spacing_default"> <li id="item3890083"> <div class="collection_item_label"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/events/upcoming.html">Upcoming Events</a> </div> </li> <li class="Alt" id="item4506273"> <div class="collection_item_label"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/nha_member_services.html">NHA Member Services</a> </div> </li> <li id="item4361498"> <span class="collection_item_label"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/staff.html">Contact Us</a></span> </li> </ul> </div> </div> <header class="col span16"> <div id="logo"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/"><img src="https://web.archive.org/web/20140620222244im_/http://cdn.firespring.com/images/766d2431-7263-4f2c-be44-a84ea31c5fa5.jpg" alt="Nebraska Hospital Association"/></a> </div> <div id="resize"></div> <ul id="skipnav"> <li><a href="#nav">Skip to area navigation</a></li> <li><a href="#content">Skip to content</a></li> </ul> <nav class="topnav dropdown pnav"> <ul class="fdpc_level_0 topnav dropdown pnav"> <li class="fdpc_level_0 fdpc_odd fdpc_section fdpc_here about_us"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/" class="fdpc_level_0">About Us</a> <ul class="fdpc_level_1 about_us"> <li class="fdpc_odd fdpc_page history"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/history.html">History of NHA</a></li> <li class="fdpc_even fdpc_page mission"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/mission.html">Mission and Vision</a></li> <li class="fdpc_odd fdpc_page staff"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/staff.html">Staff Contacts</a></li> <li class="fdpc_even fdpc_page board_members"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/board_members.html">Board Members</a></li> <li class="fdpc_odd fdpc_page districts"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/districts.html">Districts & District Chairs</a></li> <li class="fdpc_even fdpc_page member_hospitals"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_hospitals.html">Member Hospitals</a></li> <li class="fdpc_odd fdpc_section fdpc_here member_services"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/">Member Services</a> <ul class="fdpc_level_2 member_services"> <li class="fdpc_odd fdpc_page nha_member_services"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/">NHA Member Services</a></li> <li class="fdpc_even fdpc_section fdpc_here cah"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/">Critical Access Hospitals</a> <ul class="fdpc_level_3 cah"> <li class="fdpc_odd fdpc_page cah"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/">Critical Access Hospitals</a></li> <li class="fdpc_even fdpc_page cah_contacts"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_contacts.html">CAH Contacts List</a></li> <li class="fdpc_odd fdpc_section fdpc_here cah_top10_deficiencies"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_top10_deficiencies/">CAH Top 10 Deficiencies</a> <ul class="fdpc_level_4 cah_top10_deficiencies"> <li class="fdpc_odd fdpc_page cah_top10_deficiencies_6302013"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_top10_deficiencies/">Top 10 Deficiencies list Oct. 1, 2012 through June 30, 2013</a></li> <li class="fdpc_even fdpc_page cah_top10_deficiencies_6302012"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_top10_deficiencies/cah_top10_deficiencies_6302012.html">Top 10 Deficiencies list through June 30, 2012</a></li> <li class="fdpc_odd fdpc_page fdpc_here fdpc_last list_of_deficiencies_2013"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_top10_deficiencies/list_of_deficiencies_2013.html">Listing of Deficiencies for 2013</a></li> </ul> </li> <li class="fdpc_even fdpc_page fdpc_last state_operations_manuals"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/state_operations_manuals.html">State Operations Manuals</a></li> </ul> </li> <li class="fdpc_odd fdpc_section all_members"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/all_members/">All NHA Members</a> <ul class="fdpc_level_3 all_members"> <li class="fdpc_odd fdpc_page fdpc_last member_guide"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/all_members/">Member Guide</a></li> </ul> </li> <li class="fdpc_even fdpc_page fdpc_last faq"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/faq.html">Frequently Asked Questions</a></li> </ul> </li> <li class="fdpc_even fdpc_page affiliate_members"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/affiliate_members.html">Affiliate Members</a></li> <li class="fdpc_odd fdpc_page subsidiaries"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/subsidiaries.html">Subsidiaries</a></li> <li class="fdpc_even fdpc_page fdpc_last sponsorship"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/sponsorship.html">Sponsorship</a></li> </ul> </li> <li class="fdpc_level_0 fdpc_even fdpc_section communications"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/" class="fdpc_level_0">Communications</a> <ul class="fdpc_level_1 communications"> <li class="fdpc_odd fdpc_section publications"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/">Publications</a> <ul class="fdpc_level_2 publications"> <li class="fdpc_odd fdpc_section electronic"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/electronic/">E-Publications</a> <ul class="fdpc_level_3 electronic"> <li class="fdpc_odd fdpc_page the_advocate"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/electronic/">The Advocate</a></li> <li class="fdpc_even fdpc_page newslink"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/electronic/newslink.html">Newslink</a></li> <li class="fdpc_odd fdpc_page ep_news"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/electronic/ep_news.html">Emergency Preparedness News</a></li> <li class="fdpc_even fdpc_page fdpc_last e-bulletin"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/electronic/e-bulletin.html">e-Bulletin</a></li> </ul> </li> <li class="fdpc_even fdpc_section fdpc_last print"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/print/">Print Publications</a> <ul class="fdpc_level_3 print"> <li class="fdpc_odd fdpc_page health_neb"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/print/">Healthier Nebraska</a></li> <li class="fdpc_even fdpc_page cbr"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/print/cbr.html">Community Benefits Report</a></li> <li class="fdpc_odd fdpc_page fdpc_last mvr"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/publications/print/mvr.html">Member Value Report</a></li> </ul> </li> </ul> </li> <li class="fdpc_even fdpc_page nebraska-healthcare-marketers"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/nebraska-healthcare-marketers.html">Nebraska Healthcare Marketers</a></li> <li class="fdpc_odd fdpc_page social_media"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/social_media.html">Social Media</a></li> <li class="fdpc_even fdpc_section calendar"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/calendar/">Health Care Observances Calendar</a> <ul class="fdpc_level_2 calendar"> <li class="fdpc_odd fdpc_page fdpc_last observances-calendar-2014"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/calendar/">Health Care Observances Calendar</a></li> </ul> </li> <li class="fdpc_odd fdpc_section fdpc_last communications_resources"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/communications_resources/">Resources</a> <ul class="fdpc_level_2 communications_resources"> <li class="fdpc_odd fdpc_page electronic_archive"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/communications_resources/">E-Publications Archive</a></li> <li class="fdpc_even fdpc_page print_archive"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/communications_resources/print_archive.html">Print Publications Archive</a></li> <li class="fdpc_odd fdpc_page links"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/communications_resources/links.html">Important Links</a></li> <li class="fdpc_even fdpc_page newslink_archive_dec13"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/communications_resources/newslink_archive_dec13.html">Newslink December 2013</a></li> <li class="fdpc_odd fdpc_page fdpc_last newslink_archive_april14"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/communications/communications_resources/newslink_archive_april14.html">Newslink April 2014</a></li> </ul> </li> </ul> </li> <li class="fdpc_level_0 fdpc_odd fdpc_section advocacy"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/" class="fdpc_level_0">Advocacy</a> <ul class="fdpc_level_1 advocacy"> <li class="fdpc_odd fdpc_page be_an_advocate"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/">Be an Advocate</a></li> <li class="fdpc_even fdpc_section state_issues"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/state_issues/">State Issues</a> <ul class="fdpc_level_2 state_issues"> <li class="fdpc_odd fdpc_section fdpc_last legislature_2013_14"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/state_issues/legislature_2013_14/">103rd Legislative Session 2013-14</a> <ul class="fdpc_level_3 legislature_2013_14"> <li class="fdpc_odd fdpc_page state_issues"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/state_issues/legislature_2013_14/">Issues</a></li> <li class="fdpc_even fdpc_page state_bills"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/state_issues/legislature_2013_14/state_bills.html">Bills of Interest</a></li> <li class="fdpc_odd fdpc_page state_testimonies"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/state_issues/legislature_2013_14/state_testimonies.html">Testimonies</a></li> <li class="fdpc_even fdpc_page regulatoryhearing_testimony"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/state_issues/legislature_2013_14/regulatoryhearing_testimony.html">Regulatory Hearing Testimonies</a></li> <li class="fdpc_odd fdpc_page 2014_legislative_wrapup"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/state_issues/legislature_2013_14/2014_legislative_wrapup.html">2014 Legislative Wrap-Up</a></li> <li class="fdpc_even fdpc_page fdpc_last 2013_legislative_wrapup"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/state_issues/legislature_2013_14/2013_legislative_wrapup.html">2013 Legislative Wrap-Up</a></li> </ul> </li> </ul> </li> <li class="fdpc_odd fdpc_section federal_issues"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/federal_issues/">Federal Issues</a> <ul class="fdpc_level_2 federal_issues"> <li class="fdpc_odd fdpc_page fdpc_last federal_tracker"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/federal_issues/federal_tracker.html">Tracking Federal Issues</a></li> </ul> </li> <li class="fdpc_even fdpc_section action_center"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/action_center/">Action Center</a> <ul class="fdpc_level_2 action_center"> <li class="fdpc_odd fdpc_page current_state_legislation"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/action_center/">Current state legislation</a></li> <li class="fdpc_even fdpc_page advocacy_alerts"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/action_center/advocacy_alerts.html">Advocacy alerts</a></li> <li class="fdpc_odd fdpc_page fdpc_last presentations"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/action_center/presentations.html">Presentations</a></li> </ul> </li> <li class="fdpc_odd fdpc_page nhapac"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/nhapac.html">NHA Political Action Committee</a></li> <li class="fdpc_even fdpc_page advocacyday2014"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/advocacyday2014.html">Advocacy Day </a></li> <li class="fdpc_odd fdpc_page fdpc_last advocacy_resources"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/advocacy/advocacy_resources.html">Resources</a></li> </ul> </li> <li class="fdpc_level_0 fdpc_even fdpc_section quality_and_safety"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/" class="fdpc_level_0">Quality & Safety</a> <ul class="fdpc_level_1 quality_and_safety"> <li class="fdpc_odd fdpc_section quality_initiatives"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/">Quality Initiatives</a> <ul class="fdpc_level_2 quality_initiatives"> <li class="fdpc_odd fdpc_section quest_for_excellence"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/">Quest for Excellence</a> <ul class="fdpc_level_3 quest_for_excellence"> <li class="fdpc_odd fdpc_page quest_for_excellence"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/">Quest for Excellence Award</a></li> <li class="fdpc_even fdpc_section fdpc_last questforexcellence_archive"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/questforexcellence_archive/">Quest for Excellence Awards Archive</a> <ul class="fdpc_level_4 questforexcellence_archive"> <li class="fdpc_odd fdpc_page questforexcellence_archive_2012"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/questforexcellence_archive/">2012 Quest for Excellence Awards</a></li> <li class="fdpc_even fdpc_page questforexcellence_archive_2011"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/questforexcellence_archive/questforexcellence_archive_2011.html">2011 Quest for Excellence Awards</a></li> <li class="fdpc_odd fdpc_page questforexcellence_archive_2010"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/questforexcellence_archive/questforexcellence_archive_2010.html">2010 Quest for Excellence Awards</a></li> <li class="fdpc_even fdpc_page questforexcellence_archive_2009"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/questforexcellence_archive/questforexcellence_archive_2009.html">2009 Quest for Excellence Awards</a></li> <li class="fdpc_odd fdpc_page questforexcellence_archive_2008"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/questforexcellence_archive/questforexcellence_archive_2008.html">2008 Quest for Excellence Awards</a></li> <li class="fdpc_even fdpc_page questforexcellence_archive_2007"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/questforexcellence_archive/questforexcellence_archive_2007.html">2007 Quest for Excellence Awards</a></li> <li class="fdpc_odd fdpc_page fdpc_last questforexcellence_archive_2005"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/quest_for_excellence/questforexcellence_archive/questforexcellence_archive_2005.html">2005 Quest for Excellence Awards</a></li> </ul> </li> </ul> </li> <li class="fdpc_even fdpc_page med_reconciliation"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/med_reconciliation.html">Medication Reconciliation</a></li> <li class="fdpc_odd fdpc_page hen"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/hen.html">Hospital Engagement Network (HEN)</a></li> <li class="fdpc_even fdpc_page fdpc_last color_coded_wristbands"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_initiatives/color_coded_wristbands.html">Color Coded Wristbands for Safety</a></li> </ul> </li> <li class="fdpc_even fdpc_page leaders_in_quality"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/leaders_in_quality.html">Leaders in Quality Videos</a></li> <li class="fdpc_odd fdpc_page rural_qi"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/rural_qi.html">Rural QI Steering Committee</a></li> <li class="fdpc_even fdpc_section emergency_preparedness"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/emergency_preparedness/">Emergency Preparedness</a> <ul class="fdpc_level_2 emergency_preparedness"> <li class="fdpc_odd fdpc_page fdpc_last emergency_preparedness"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/emergency_preparedness/">Emergency Preparedness</a></li> </ul> </li> <li class="fdpc_odd fdpc_section fdpc_last quality_resources"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_resources/">Resources</a> <ul class="fdpc_level_2 quality_resources"> <li class="fdpc_odd fdpc_page patient_safety"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_resources/">Patient Safety Links</a></li> <li class="fdpc_even fdpc_page fdpc_last quality_improvement"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/quality_and_safety/quality_resources/quality_improvement.html">Quality Improvement Links</a></li> </ul> </li> </ul> </li> <li class="fdpc_level_0 fdpc_odd fdpc_section education"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/" class="fdpc_level_0">Education</a> <ul class="fdpc_level_1 education"> <li class="fdpc_odd fdpc_section events"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/events/">Events</a> <ul class="fdpc_level_2 events"> <li class="fdpc_odd fdpc_page upcoming"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/events/">Upcoming Events</a></li> <li class="fdpc_even fdpc_page webinars"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/events/webinars.html">Webinars</a></li> <li class="fdpc_odd fdpc_page in_person_events"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/events/in_person_events.html">In-Person Events</a></li> <li class="fdpc_even fdpc_page member_meetings"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/events/member_meetings.html">Member Meetings</a></li> <li class="fdpc_odd fdpc_page midyearmeeting"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/events/midyearmeeting.html">Mid-Year Meeting & Golf Tournament</a></li> <li class="fdpc_even fdpc_page fdpc_last nha_annual_convention"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/events/nha_annual_convention.html">NHA Annual Convention</a></li> </ul> </li> <li class="fdpc_even fdpc_page research_education"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/research_education.html">Research & Educational Foundation</a></li> <li class="fdpc_odd fdpc_page care_learning"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/care_learning.html"> careLearning</a></li> <li class="fdpc_even fdpc_section leadership_institute"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/leadership_institute/">Leadership Institute</a> <ul class="fdpc_level_2 leadership_institute"> <li class="fdpc_odd fdpc_page li_overview"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/leadership_institute/">Overview</a></li> <li class="fdpc_even fdpc_page program_components"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/leadership_institute/program_components.html">Program Components</a></li> <li class="fdpc_odd fdpc_page current_participants"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/leadership_institute/current_participants.html">Current Participants</a></li> <li class="fdpc_even fdpc_page fdpc_last alumni_main"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/leadership_institute/alumni_main.html">Alumni</a></li> </ul> </li> <li class="fdpc_odd fdpc_page trustee_education"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/trustee_education.html">Trustee Education Certification Program</a></li> <li class="fdpc_even fdpc_page western_regional_trustee_symposium"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/western_regional_trustee_symposium.html">Western Regional Trustee Symposium</a></li> <li class="fdpc_odd fdpc_page scholarships"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/scholarships.html">Health Care Career Scholarships</a></li> <li class="fdpc_even fdpc_section one_book"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/one_book/">One Book One Hospital</a> <ul class="fdpc_level_2 one_book"> <li class="fdpc_odd fdpc_page fdpc_last book_overview"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/one_book/">Overview</a></li> </ul> </li> <li class="fdpc_odd fdpc_page e_store"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/e_store.html">Education e-Store</a></li> <li class="fdpc_even fdpc_page fdpc_last education_resources"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/education/education_resources.html">Resources</a></li> </ul> </li> <li class="fdpc_level_0 fdpc_even fdpc_section health_data"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/health_data/" class="fdpc_level_0">Health Data</a> <ul class="fdpc_level_1 health_data"> <li class="fdpc_odd fdpc_page nhis"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/health_data/nhis.html">Nebraska Hospital Information System</a></li> <li class="fdpc_even fdpc_page databank"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/health_data/databank.html">DATABANK</a></li> <li class="fdpc_odd fdpc_page hipaa"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/health_data/hipaa.html">HIPAA</a></li> <li class="fdpc_even fdpc_page nehii"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/health_data/nehii.html">NeHII</a></li> <li class="fdpc_odd fdpc_page fdpc_last data_resources"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/health_data/data_resources.html">Resources</a></li> </ul> </li> <li class="fdpc_level_0 fdpc_odd fdpc_section fdpc_last resources"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/" class="fdpc_level_0">Resources</a> <ul class="fdpc_level_1 resources"> <li class="fdpc_odd fdpc_section communications"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/communications/">Communications</a> <ul class="fdpc_level_2 communications"> <li class="fdpc_odd fdpc_page res_archive"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/communications/">E-Publications Archive</a></li> <li class="fdpc_even fdpc_page res_news_archive"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/communications/res_news_archive.html">Print Publications Archive</a></li> <li class="fdpc_odd fdpc_page fdpc_last res_links"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/communications/res_links.html">Important Links</a></li> </ul> </li> <li class="fdpc_even fdpc_section advocacy"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/advocacy/">Advocacy</a></li> <li class="fdpc_odd fdpc_section quality"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/quality/">Quality & Safety</a> <ul class="fdpc_level_2 quality"> <li class="fdpc_odd fdpc_page res_qsres"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/quality/">Partnering Agency Resources</a></li> <li class="fdpc_even fdpc_page fdpc_last res_qs_links"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/quality/res_qs_links.html">Important Links</a></li> </ul> </li> <li class="fdpc_even fdpc_section education"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/education/">Education</a></li> <li class="fdpc_odd fdpc_section health_data"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/health_data/">Health Data</a></li> <li class="fdpc_even fdpc_section workforce"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/workforce/">Workforce</a> <ul class="fdpc_level_2 workforce"> <li class="fdpc_odd fdpc_page fdpc_last nursingschools"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/workforce/">Nursing School Programs</a></li> </ul> </li> <li class="fdpc_odd fdpc_section fdpc_last member_services"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/member_services/">Member Services</a> <ul class="fdpc_level_2 member_services"> <li class="fdpc_odd fdpc_section fdpc_last critical_access_hospitals"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/member_services/critical_access_hospitals/">Critical Access Hospitals</a> <ul class="fdpc_level_3 critical_access_hospitals"> <li class="fdpc_odd fdpc_page critical_access_hospitals"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/member_services/critical_access_hospitals/">Critical Access Hospitals</a></li> <li class="fdpc_even fdpc_page cah_contacts_list"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/member_services/critical_access_hospitals/cah_contacts_list.html">CAH Contacts List</a></li> <li class="fdpc_odd fdpc_page fdpc_last cah_top_10_deficiencies"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/resources/member_services/critical_access_hospitals/cah_top_10_deficiencies.html">CAH Top 10 Deficiencies</a></li> </ul> </li> </ul> </li> </ul> </li> </ul> </nav>  </header> </div> <div id="content" class="row clearfix"><div id="secondary-nav" class="col span-one-third"> <nav class="subnav"> <ul class="fdpc_level_0 subnav"> <li class="fdpc_level_0 fdpc_odd fdpc_page history"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/history.html" class="fdpc_level_0">History of NHA</a></li> <li class="fdpc_level_0 fdpc_even fdpc_page mission"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/mission.html" class="fdpc_level_0">Mission and Vision</a></li> <li class="fdpc_level_0 fdpc_odd fdpc_page staff"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/staff.html" class="fdpc_level_0">Staff Contacts</a></li> <li class="fdpc_level_0 fdpc_even fdpc_page board_members"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/board_members.html" class="fdpc_level_0">Board Members</a></li> <li class="fdpc_level_0 fdpc_odd fdpc_page districts"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/districts.html" class="fdpc_level_0">Districts & District Chairs</a></li> <li class="fdpc_level_0 fdpc_even fdpc_page member_hospitals"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_hospitals.html" class="fdpc_level_0">Member Hospitals</a></li> <li class="fdpc_level_0 fdpc_odd fdpc_section fdpc_here member_services"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/" class="fdpc_level_0">Member Services</a> <ul class="fdpc_level_1 member_services"> <li class="fdpc_odd fdpc_page nha_member_services"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/">NHA Member Services</a></li> <li class="fdpc_even fdpc_section fdpc_here cah"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/">Critical Access Hospitals</a> <ul class="fdpc_level_2 cah"> <li class="fdpc_odd fdpc_page cah"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/">Critical Access Hospitals</a></li> <li class="fdpc_even fdpc_page cah_contacts"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_contacts.html">CAH Contacts List</a></li> <li class="fdpc_odd fdpc_section fdpc_here cah_top10_deficiencies"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_top10_deficiencies/">CAH Top 10 Deficiencies</a> <ul class="fdpc_level_3 cah_top10_deficiencies"> <li class="fdpc_odd fdpc_page cah_top10_deficiencies_6302013"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_top10_deficiencies/">Top 10 Deficiencies list Oct. 1, 2012 through June 30, 2013</a></li> <li class="fdpc_even fdpc_page cah_top10_deficiencies_6302012"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_top10_deficiencies/cah_top10_deficiencies_6302012.html">Top 10 Deficiencies list through June 30, 2012</a></li> <li class="fdpc_odd fdpc_page fdpc_here fdpc_last list_of_deficiencies_2013"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/cah_top10_deficiencies/list_of_deficiencies_2013.html">Listing of Deficiencies for 2013</a></li> </ul> </li> <li class="fdpc_even fdpc_page fdpc_last state_operations_manuals"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/cah/state_operations_manuals.html">State Operations Manuals</a></li> </ul> </li> <li class="fdpc_odd fdpc_section all_members"> <a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/all_members/">All NHA Members</a> <ul class="fdpc_level_2 all_members"> <li class="fdpc_odd fdpc_page fdpc_last member_guide"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/all_members/">Member Guide</a></li> </ul> </li> <li class="fdpc_even fdpc_page fdpc_last faq"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/member_services/faq.html">Frequently Asked Questions</a></li> </ul> </li> <li class="fdpc_level_0 fdpc_even fdpc_page affiliate_members"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/affiliate_members.html" class="fdpc_level_0">Affiliate Members</a></li> <li class="fdpc_level_0 fdpc_odd fdpc_page subsidiaries"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/subsidiaries.html" class="fdpc_level_0">Subsidiaries</a></li> <li class="fdpc_level_0 fdpc_even fdpc_page fdpc_last sponsorship"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/about_us/sponsorship.html" class="fdpc_level_0">Sponsorship</a></li> </ul> </nav> </div> <div class="col offset1 span9"> <h1 class="page_title">Listing of Deficiencies for 2013</h1> <p><font face="Verdana" size="2"><b>CRITICAL ACCESS HOSPITALS<br/> Listing of Deficiencies for 2013<br/> Nebraska DHHS Licensure Unit<br></p> <p><font face="Verdana" size="2">CRITICAL ACCESS HOSPITALS<br/> <u>C-195 - AGREEMENTS</u></b><br/> Each CAH that is a member of a rural health network shall have an agreement with respect to credentialing and quality assurance with at least:<br/> 1. One hospital that is a member of the network;<br/> 2. One QIO or equivalent entity; or<br/> 3. One other appropriate and qualified entity identified in the State Rural Health Care Plan.<br/> <b>Reason Cited:<br/> 1. The facility failed to ensure that the network agreement and/or hospital affiliation agreement included Quality Assurance.<br></p> <p><font face="Verdana" size="2"><u>C-0197 – AGREEMENTS</u></b><br/> The Facility must ensure that when telemedicine services are furnished to the CAH’s patients through an agreement with a distant – site telemedicine entity, the agreement is written and specifics that the distant-site telemedicine entity is a contractor of services to the CAH, and as such, in accordance with 485.635(c) (4)(ii), furnishes the contracted services in a manner that enables the CAH to comply with all applicable conditions of participation for the contracted services, including, but not limited to, the requirements in this section with regard to its physicians and practitioners providing telemedicine services.<br></p> <p><font face="Verdana" size="2">The Governing Body of the CAH may elect to rely upon the credentialing and privileging decisions made by the governing-body of the distant-site telemedicine entity regarding individual distant-site physicians or practitioners.<br/> <b>Reasons Cited:<br/> 1. Facility failed to have an agreement for credentialing teleradiology physicians.</p> <p><font face="Verdana" size="2"><u>C-0222 – MAINTENANCE</u></b><br/> The CAH has housekeeping and preventive maintenance programs to ensure that –</p> <p><font face="Verdana" size="2"><ul><li>All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition.</li></ul> <p><b>Reasons Cited:<br/> 1. Failure to ensure patient care equipment received routine preventive maintenance.<br/> 2. Evidence hospital device was safe for patient use.</p> <p><font face="Verdana" size="2"><u>C-0225 – MAINTENANCE</u></b><br/> The premises are clean and orderly.<br/> <b>Reasons Cited:<br/> 1. Leaking pipe in dietary area.<br/> 2. Ceiling tiles stained and/or broken in food storage, aide’s work area, above storage shelf.<br/> 3. Failed to ensure bed linens were clean and in good repair.</p> <p><font face="Verdana" size="2">C-0240 – ORGANIZATIONAL STRUCTURE<br/> <u>C-0241 – GOVERING BODY</u></b><br/> Medical Staff credentialing/privileging not completed per bylaws and practitioners not functioning within the scope of privileges granted.</p> <p><font face="Verdana" size="2"><b>Reasons Cited:<br/> 1. The facility failed to ensure that the Medical Staff Bylaws, Rules and Regulations were followed in the appointment and/or reappointment of Medical Staff physicians and allied health professionals. Facility failed to ensure that external peer review policies were followed.<br/> 2. The Governing Body failed to ensure that the Medical Staff Bylaws were followed.<br/> 3. The facility failed to follow Medical Staff Bylaws to ensure physicians were trained and qualified for additional surgical privileges requested and granted by the governing body for physician/practitioners and for the reappointment and continuation of privileges for physicians/practitioners.<br/> 4. The facility failed to ensure the Medical Staff Bylaws, Rules and Regulations were followed in the appointment / reappointment of Medical Staff Physicians and Alli8ed Health Professionals and failed to follow the policy and procedure for external peer review.<br/> 5. The facility failed to ensure that the Medical Staff followed their bylaws in regard to reappointment for Physicians and Affiliate Staff.<br/> 6. The Governing Body failed to follow the Medical Staff Bylaws in regard to granting new surgical privileges for Physicians/Practitioners; reappointment and continued privileges for Physicians/Practitioners and appointment for Physicians / Practitioners.<br/> 7. The facility failed to ensure the Governing Board approved changes to the Medical Staff Bylaws allowing EMT-Paramedics to perform emergency medical screening in the emergency room.</p> <p><font face="Verdana" size="2"><u>C-0272 – PATIENT CARE POLICIES</u></b><br/> The policies are developed with the advice of a group of professional personnel that includes one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of at least one member is not a member of the CAH staff.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure that the group of professionals developed the required types of policies and procedures.</li> <p>2. The facility failed to include the required members in the group of professionals responsible for the development of patient care policies (Mid-Level Practitioner).</p> <p><font face="Verdana" size="2"><u>C-0276 – PATIENT CARE POLICIES</u></b><br/> Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs re not available for patient use.<br/> <b>Reasons Cited:<br/> 1. The facility failed to keep an accurate record system to account for and ensure the control of the distribution, use and disposition of scheduled/controlled medications.</p> <p><font face="Verdana" size="2"><u>C-0280 – PATIENT CARE POLICIES</u></b><br/> These policies are reviewed at least annually by the group of professionals required under paragraph (a) (2) of this section, and reviewed as necessary by the CAH.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure that the group of professionals reviewed the required types of policies and procedures in the last year.<br/> 2. The facility failed to include the required members in the group of professionals responsible for the annual review of patient care policies (Midlevel).</p> <p><font face="Verdana" size="2"><u>C-0304 – RECORDS SYSTEM</u></b><br/> For each patient receiving health care services, the CAH maintains a record that includes: Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure each surgical patient had a complete history and physical examination documented for surgical medical records.</p> <p><font face="Verdana" size="2"><u>C-0305 – RECORDS SYSTEM</u></b><br/> Reports of physical examinations, diagnostic and laboratory test results, including clinical laboratory services, and consultative findings.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure each surgical patient had a complete history and physical examination documented for surgical medical records.</p> <p><font face="Verdana" size="2"><u>C-0337 – RECORDS SYSTEM</u></b><br/> Dated signatures of the doctor of medicine or osteopathy or other health care professional.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure that physicians had signed and dated their physician orders.</p> <p><font face="Verdana" size="2"><u>C-0308 – PROTECTION OF RECORDS INFORMATION</u></b><br/> The CAH maintains the confidentially of record information and provides safeguards against loss, destruction, or unauthorized use.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure confidentiality of medical records information for outpatients seen in the rehabilitation services area.</p> <p><font face="Verdana" size="2"><u>C-0322 – Anesthetic Risk & Evaluation</u></b></p> <ul><li>A qualified practitioner must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed.</li> <li>A qualified practitioner must examine each patient before surgery to evaluate the risk of anesthesia.</li> <li>Before discharge each patient must be evaluated for proper anesthesia recovery by a qualified practitioner.</li></ul> <p><font face="Verdana" size="2"><b>Reasons Cited:<br/> 1. No evidence of examination of patient by a qualified practitioner immediately prior to surgery.<br/> 2. No evidence of examination by a qualified practitioner to evaluate risk of anesthesia.<br/> 3. No evidence of examination by a qualified practitioner for proper anesthesia recovery.</p> <p><font face="Verdana" size="2"><u>C-0337 – Quality Assurance</u></b><br/> All patient care services and other services affecting patient health and safety are evaluated.<br/> <b>Reasons Cited:<br/> 1. Failure to evaluate radiological impressions by Active Medical Staff with Radiologist interpretations.<br/> 2. Failure to include in Quality Improvement program contracted services.<br/> 3. Housekeeping Services were not included in Quality Assurance program.<br/> 4. The facility failed to ensure that contracted medical maintenance service provided quality reports to ensure the safety or critical patient care equipment could be evaluated.</p> <p><font face="Verdana" size="2"><u>C-0339 – QUALITY ASSURANCE</u></b><br/> The quality and appropriateness of diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure that the quality and appropriateness of diagnosis and treatment furnished by mid-level practitioners was evaluated by a physician member of the CAH staff based on a review of the facility Quality Assurance plan.</p> <p><font face="Verdana" size="2"><u>C-0340 – QUALITY ASSURANCE</u></b><br/> The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by –<br/> (i) One hospital that is a member of the network, when;<br/> (ii) One QIO or equivalent entity;<br/> (iii) One other appropriate and qualified entity identified in the State rural health care plan;<br/> (iv) In the case of distant-site physicians and practitioners providing telemedicine services to the DCAH’s patients under a written agreement between the CAH and a distant-site hospital, the distant-site hospital; or<br/> (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (b)(4)(i) through (iii) of this section;</p> <p><font face="Verdana" size="2"><b>Reasons Cited:<br/> 1. The CAH failed to follow their policy for external peer review provided by the network hospital.<br/> 2. The facility failed to follow the network hospitals plan for review of quality and appropriateness of diagnosis and treatment by physicians at the CAH.<br><br/> <br><br/> <u>SKILLED NURSING FACILITIES REQUIREMENTS<br/> C-0361 – RESIDENT RIGHTS</u></b><br/> The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must protect and promote the rights of each resident.<br/> <b>Reasons Cited:<br/> 1. Failed to provide each patient with a notice of the swing bed rights. The rights that were provided lacked the swing-bed resident rights.</p> <p><font face="Verdana" size="2"><u>C-0363 RESIDENT RIGHTS</u></b><br/> The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of –<br/> (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;<br/> (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and Inform each resident when changes are made to the items and services specified in paragraphs (5) (i) (A) and (B) of this section.<br/> <b>Reasons Cited:<br/> 1. The swing bed patient records failed to have evidence of written resident notification of expected benefits under Medicare/Medicaid and what items the resident may be responsible for either at admission or during their stay.</p> <p><font face="Verdana" size="2"><u>C-0373 – TRANSFER AND DISCHARGE DEFINITION</u></b><br/> Definition: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility.<br/> <b>Reasons Cited:<br/> 1. The facility failed to have a policy and procedure in place to ensure the facility does not initiate a discharge or transfer of swing bed patients due to difficulty with their care or due to their level of care.<br/> 2. The facility failed to have a policy and procedure regarding facility initiated transfers and discharges for the swing bed patients to ensure the facility does not initiate a discharge or transfer due to the level or difficulty with care.</p> <p><font face="Verdana" size="2"><u>C-0374 – TRANSFER AND DISCHARGE</u></b><br/> Transfer and discharge requirements. The facility must permit each resident to remain in the facility, and not transfer or discharge the resident without cause.<br/> <b>Reasons Cited:<br/> 1. The facility failed to have a policy and procedure in place to ensure the facility does not initiate a discharge or transfer of swing bed patients without cause.</p> <p><font face="Verdana" size="2"><u>C-0376 – TRANSFER AND DISCHARGE REQUIREMENT</u></b><br/> When a facility transfers or discharges a resident under any circumstances specified in paragraphs (a) (2) (i) through (v) of this section, the resident’s clinical record must be documented<br/> <b>Reasons Cited:<br/> 1. The facility failed to have a policy and procedure in place to ensure the physician completes the required documentation of a facility initiated transfer and discharge.</p> <p><font face="Verdana" size="2"><u>C-0377 – TRANSFER AND DISCHARGE NOTICE</u></b><br/> Before a facility transfers or discharges a resident, the facility must –<br/> (i) Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move, in writing and in a language and manner they understand.<br/> (ii) Record the reasons in the resident’s clinical record; and<br/> (iii) Include the notice the items described in paragraph (a) (6) of this section.<br/> <b>Reasons Cited:<br/> 1. The facility failed to have a policy and procedure in place to ensure proper procedures for notification of transfers.</p> <p><font face="Verdana" size="2"><u>C-0378 – TIMING OF TRANSFERS AND DISCHARGE NOTICE</u></b><br/> The notice of transfer or discharge required under paragraph (a) (5) (ii) of this section must be made by the facility at least 30 days before the resident is transferred or discharged.<br/> <b>Reasons Cited:<br/> 1. The facility failed to have a policy and procedure in place to ensure the resident is given timely notice of a facility initiated discharge or transfer.</p> <p><font face="Verdana" size="2"><u>C-0379 – CONTENTS OF TRANSFERS AND DISCHARGE NOTICE</u></b><br/> Contents of the notice must include:<br/> (i) The reason for transfer or discharge<br/> (ii) The effective date of transfer or discharge<br/> (iii) The location to which the resident is transferred or discharged;<br/> (iv) A statement that the resident has the right to appeal the action to the State;<br/> (v) The name, address and telephone number of the State Long Term Care Ombudsman<br/> (vi) For nursing facility residents with development disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established un Part C of the Development Disabilities Assistance and Bill of Rights Act; and<br/> (vii) For nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act.<br/> <b>Reasons Cited:<br/> 1. The facility failed to have policies and procedures in place to ensure that residents are given timely notice of the facility initiated discharge or transfer.</p> <p><font face="Verdana" size="2"><u>C-0382 – ABUSE</u></b><br/> The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.<br/> <b>Reasons Cited:<br/> 1. The facility administrative staff failed to take steps to prevent and protect patients from staff physical abuse.</p> <p><font face="Verdana" size="2"><u>C-0383 – STAFF TREATMENT</u></b><br/> The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.<br/> <b>Reasons Cited:<br/> 1. The facility failed to develop policies and procedures prohibiting the mistreatment, neglect, and abuse of patients and prohibiting the misappropriation of patient property.</p> <p><font face="Verdana" size="2"><u>C-0384 – STAFF TREATMENT</u></b><br/> The facility must not employ individuals who have been –<br/> (A) Found guilty of abusing, neglecting or mistreating residents by a court of law; or<br/> (B) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure that allegations of mistreatment, neglect, or abuse including injuries of unknown origin and misappropriation of property were reported immediately to the administrator of the CAH and to the State Survey Agency and failed to investigate those allegations and send in a report within 5 days of the incident per facility policy and procedure.<br/> 2. The facility failed to check the nurse aide registry prior to hiring ward clerks / nursing assistants over the period of one year.</p> <p><font face="Verdana" size="2"><u>C-0385 – RESIDENT ASSESSMENT</u></b><br/> The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure a qualified professional directed the patient activities program.</p> <p><font face="Verdana" size="2"><u>C-0388 – RESIDENT ASSESSMENT</u></b><br/> The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity.<br/> <b>Reasons Cited:<br/> 1. The facility failed to initially assess swing bed patients to ensure the nutritional needs were met within 7 days as directed by the nutritional screen policy and procedure.<br/> 2. The facility failed to fully complete initial and periodic comprehensive assessments for swing-bed patients.</p> <p><font face="Verdana" size="2"><u>C-0389 – RESIDENT ASSESSMENT WHEN REQUIRED</u></b><br/> A facility must conduct a comprehensive assessment of a resident in accordance with the time frames specified. The time frames prescribed in 413.343 (b) of this chapter do not apply to CAHs:<br/> (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition.<br/> <b>Reasons Cited:<br/> 1. The facility failed to ensure that patients who had been in the facility for 14 day or more had a comprehensive, accurate, standardized, assessment completed.</p> <p><font face="Verdana" size="2"><u>C-0395 – COMPREHENSIVE CARE PLANS</u></b><br/> The facility must develop a comprehensive care plan for each resident that includes measurable objectives and time tables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following:<br/> (i) The services that are to be furnished to attain or maintain the resident’s highest practicable, physical, mental, and psychosocial well-being as required;<br/> (ii) Any services that would otherwise be required, but are not provided due to the resident’s exercise of rights, including the right to refuse treatment.<br/> <b>Reasons Cited:<br/> 1. The facility failed to develop a comprehensive care plan for swing bed patients that included medical, nursing, mental and psychosocial needs identified.</p> <p><font face="Verdana" size="2"><u>C-0396 – COMPREHENSIVE CARE PLANS</u></b><br/> A comprehensive care plan must be:<br/> (i) Developed within 7 days after the completion of the comprehensive assessment;<br/> (ii) Prepared by an interdisciplinary team, that includes the attending MD/DO, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident’s needs, and, to the extent practicable, the participation of the resident, the resident’s family or the resident’s legal representative; and<br/> (iii) Periodically reviewed and revised by a team of qualified persons after each assessment.<br/> <b>Reasons Cited:<br/> 1. The facility failed to develop an interdisciplinary comprehensive care plan for swing-bed patients.</p> <p><font face="Verdana" size="2"><u>C-0399 – DISCHARGE SUMMARY</u></b><br/> When the facility anticipates discharge, a resident must have a discharge summary that includes:<br/> (1) A recapitulation of the resident’s stay;<br/> (2) A final summary of the resident’s status to include items in paragraph (b)(2) of this section, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or legal representative; and<br/> (3) A post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to her or her new living environment.<br/> Reasons Cited:<br/> 1. The facility failed to ensure discharged swing-bed patients had a discharge summary that included a recapitulation of the patient’s stay.</p> <p><font face="Verdana" size="2"><b>State Operations Manual, Appendix W, Survey Protocol, Regulations and Interpretive Guidelines for Critical Access Hospitals and Swing-Beds in CAH</b></p> <p><font face="Verdana" size="2"><a href="https://web.archive.org/web/20140620222244/http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_w_cah.pdf<br />">http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_w_cah.pdf</a><br><br/> <br></p> <p><font face="Verdana" size="2"><b>TITLE 175 HEALTH CARE FACILITIES AND SERVICE LICENSURE / CHAPTER 9 – HOSPITALS<br/> Deficiencies Cited in 2013</p> <p><font face="Verdana" size="2">9-006.05 Quality Assurance/Performance Improvement</b><br/> Each hospital must have an effective, hospital-wide quality assurance/performance improvement program to evaluate care and treatment provided to patients. This program, must include, but is not limited to:<br/> 1. Establishment of appropriate committees such as a medical staff and utilization review committee for the purpose of reviewing the medical and hosp0ital care as required under <u>Neb. Rev. Stat. 71-2047;</u><br/> 2. A written plan of implementation;<br/> 3. All services provided including contracted services;<br/> 4. The tracking of outpatient surgical procedures that result in unplanned patient admissions to a hospital within 72 hours of a procedure, due to post-surgical complications;<br/> 5. Evaluation of care and treatment provided both by staff and through contract;<br/> 6. Appropriate action to address problems found through the program;<br/> 7. Evaluation of the outcome for any action taken; and<br/> 8. Reporting to the governing authority.<br/> <b>Reason Cited:<br/> 1. The facility failed to incorporate active monitoring / tracking for Action Plans reviewed.</p> <p><font face="Verdana" size="2">9-006 Plan of Care</b><br/> A plan of care must be established, implemented and kept current to meet the identified needs for each inpatient. The plan of care must be interdisciplinary when appropriate to meet individual needs of the patients.<br/> <b>Reasons Cited:<br/> 1. The facility failed to identify and establish a plan of care related to nutritional risks for patients.<br/> 2. The facility failed to develop a plan of care for patients and to keep the care plan current for patients.<br/> 3. The facility failed to develop and implement a plan of care for patients to meet their identified needs.</p> <p><font face="Verdana" size="2">9-006.7A1 Medical Records – Content</b><br/> Each medical record must contain, when applicable the following information:<br/> 1. Identification Data<br/> 2. Chief Complaints<br/> 3. Present Illness<br/> 4. History and Physical Examination<br/> 5. Admitting Diagnosis<br/> 6. All Pathology / Laboratory and Radiology reports<br/> 7. Properly executed informed consent forms<br/> 8. Consultation Reports<br/> 9. Medical Practitioner Orders<br/> 10. Documentation of all care and treatment, medical and surgical<br/> 11. Tissue Report<br/> 12. Progress notes of all disciplines<br/> 13. Discharge Summary and Final Diagnosis<br/> 14. Autopsy Findings<br/> 15. Advance Directives, if available<br/> <b>Reason Cited:<br/> 1. The facility failed to have physician sign orders in medical record. Record only contained verbal orders.</p> <p><font face="Verdana" size="2">9-006.03A3b Registry Checks</b><br/> The hospital must check for adverse findings with each of the following registries:<br/> 1. Nurse Aide Registry<br/> 2. Adult Protective Services Central Registry<br/> 3. Central Register of Child Protection Cases<br/> 4. Nebraska State Patrol Sex Offender Registry<br/> <b>Reason Cited:<br/> 1. The Critical Access Hospital failed to complete a check for adverse findings on the Nurse Aide Registry for unlicensed direct care staff reviewed.</p> <p><font face="Verdana" size="2">9-006.01A Governing Authority</b><br/> The governing authority responsibilities include:<br/> 1. Ensuring the quality of all services, care and treatment provided to patients whether those services, care or treatment are furnished by hospital staff or through contract with the hospital.<br/> 2. Determining which categories of practitioners are eligible candidates for appointment to the medical staff.<br/> 3. Appoint and reappointment of medical staff members and delineating their clinical privileges, according to the procedures for credentials review established by the medical staff and approved by the governing authority.<br/> <b>Reason Cited:<br/> 1. The Critical Access Hospital failed to ensure the governing board approved changes to the Medical Staff Bylaws and failed to ensure that the governing body was responsible for determining if EMT-Paramedics could perform activities within their scope of practice as an employee in the hospital.</p> <p><font face="Verdana" size="2">9-006.03B1 Orientation</b><br/> Each hospital must provide and maintain evidence of an orientation program for all new staff and, as needed, for exiting staff who are given new assignments. The orientation program must include an explanation of the:<br/> 1. Job Duties and Responsibilities<br/> 2. Hospital’s Sanitation and Infection Control Programs<br/> 3. Organizational Structure within the Hospital<br/> 4. Patient Rights<br/> 5. Patient Care Policies and Procedures<br/> 6. Personnel Policies and Procedures<br/> 7. Emergency Procedures<br/> 8. Disaster Preparedness Plan<br/> 9. Reporting Requirements for abuse, neglect or exploitation in accordance with the Adult Protective Service Act. Neb. Rev. Stat 28-372, or in the case of a child in accordance with Neb. Rev. Stat. 28-711, and with hospital policies and procedures<br/> <b>Reasons Cited:<br/> 1. The Critical Access Hospital failed to ensure that employees reviewed received orientation on reporting requirements for abuse, neglect or exploitation.<br/> 2. The facility failed to ensure that Physicians and Physician Assistants involved in the supervision of EMT-Paramedics were oriented to the scope of practice of an EMT-Paramedic and the supervision requirements as determine by the Medical Staff of the Critical Access Hospital and failed to ensure that Registered Nurses were oriented to the supervision requirements for EMT-Paramedics.</p> <p><font face="Verdana" size="2">9-006.01B Administration</b><br/> The administrator is responsible for planning, organizing, and directing the day to day operation of the hospital. The administrator must report and be directly responsible to the governing authority in all matters related to the maintenance, operation, and management of the hospital. The administrator’s responsibilities include:<br/> 1. Developing procedures which require the reporting of any evidence of abuse, neglect, or exploitation of any patient served by the hospital in accordance with Neb. Rev. Stat. 28-732 or the Adult Protective Services Act or in the case of a child, in accordance with Neb. Rev. Stat. 28-7111;<br/> 2. Ensuring an investigation is completed on suspected abuse, neglect or exploitation and that steps are taken to prevent and protect patients.<br/> <b>Reason Cited:<br/> 1. The facility Failed to take steps to protect patients from abuse.</b></p> </div> </div> <footer class="wrap"> <div class="footer_links"> </div>  <div class="locations"> <div class="locations_website_title"> Nebraska Hospital Association </div> <div class="location location1"> <div class="location_addresses"> <div class="location_address location_address1"> 3255 Salt Creek Circle, Suite 100 </div> <div class="location_address location_address2"> Lincoln, NE 68504-4778 </div> <div class="location_end"></div> </div> <div class="location_phones"> <div class="location_phone location_phone1"> <span class="location_phone_label">Phone</span> <span class="location_phone_number">(402) 742-8140</span> </div> <div class="location_phone location_phone2"> <span class="location_phone_label">Fax</span> <span class="location_phone_number">(402) 742-8191</span> </div> <div class="location_end"></div> </div> <div class="location_email"> <span class="location_email_label">E-mail</span> <span class="location_email_link"><a href="https://web.archive.org/web/20140620222244/http://www.nebraskahospitals.org/contact.html">info@NebraskaHospitals.org</a></span> </div> <div class="location_info"> <p>Monday-Friday, 8:30 a.m. - 5:00 p.m.</p> </div> <div class="location_social_media"> <div class="location_facebook"> <span class="location_facebook_label">Facebook</span> <span class="location_facebook_link"><a href="https://web.archive.org/web/20140620222244/http://facebook.com/NEhospitals" target="_blank">NEhospitals</a></span> </div> <div class="location_twitter"> <span class="location_twitter_label">NebHospitals</span> <span class="location_twitter_link"><a href="https://web.archive.org/web/20140620222244/https://twitter.com/#!/NebHospitals" target="_blank">NebHospitals</a></span> </div> <div class="location_end"></div> </div> <div class="location_end"></div> </div> </div> <p class="copyright">© Copyright 2014</p>   <div class="fdpc_design_footer"> </div>  </footer> </div> <script src="https://web.archive.org/web/20140620222244js_/http://cdn.firespring.com/designs/np_bulwark/js/anythingslider/jquery.anythingslider.js"></script> <script type="text/javascript" src="https://web.archive.org/web/20140620222244js_/http://cdn.firespring.com/designs/np_bulwark/js/scripts.js"></script> <script src="https://web.archive.org/web/20140620222244js_/http://cdn.firespring.com/cache/core.1402970906.js" type="text/javascript"></script> <script type="text/javascript"> var firespring = { log: function(){ return; }, goal: function(){ return; }}; var firespring_site_id = 66415578; (function() { var s = document.createElement('script'); s.type = 'text/javascript'; s.async = true; s.src = ( document.location.protocol == 'https:' ? 'https://web.archive.org/web/20140620222244/https://analytics.firespring.com/js' : 'https://web.archive.org/web/20140620222244/http://analytics.firespring.com/js' ); ( document.getElementsByTagName('head')[0] || document.getElementsByTagName('body')[0] ).appendChild( s ); })(); </script> <noscript><p><img alt="Firespring Analytics" width="1" height="1" src="https://web.archive.org/web/20140620222244im_/http://analytics.firespring.com/66415578ns.gif"/></p></noscript> <script type="text/javascript"> var _gaq = _gaq || []; _gaq.push(['_setAccount', 'UA-1394851-12'],['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://web.archive.org/web/20140620222244/https://ssl' : 'https://web.archive.org/web/20140620222244/http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); </script> </body> </html>