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Based on observation and interviews, the hospital did not ensure that all patient care equipment was safely maintained, in that, expired equipment was available for patient use in 3 of 3 patient care areas.

Findings included:

During tours of the hospital's Emergency Department (ED) at approximately 1:00 PM on 10/26/10 with the ED/Trauma Coordinator (Personnel # 19), and then the hospital's Medical/Surgical Unit at approximately 10:00 AM on 10/27/10, and the Operating Room area at 1:30 PM on 10/27/10 with the Director of Nursing (Personnel # 6), the surveyor noted the following expired equipment was available for patient use in the following areas:

Emergency Department :
2- 24 gauge Angiocath needles, expired 04/10.
1- culture swab, expired 05/10
1- culture swab, expired 09/10.
1- suction Yankauer, expired 04/10.
3- intravenous (IV) start kits, expired 09/10.

Medical/Surgical Unit:
2- Formalin fixative for Ova and Parasites, expired 09/10.
85- 20 gauge safety needles, expired 11/07.
4- 24 gauge Angiocath needles, expired 01/07.

Operating Room Area:
25- 8 gauge epidural needles, expired 06/06.
1- Foley tray, expired 08/10.
1- Skin stapler, expired 12/00.

In separate interviews at approximately 2:00 PM on 10/26/10, and approximately 10:00 AM and also at 1:30 PM on 10/27/10, both Personnel # 19 and Personnel # 6 confirmed the above expired equipment had been available for patient use in those 3 patient care areas.

Based on review of records and interviews, the Critical Access Hospital's (CAH's) medical records were not complete in that the medical record entries for 21 of 21 patients (Patients #1 through #21) discharged between 05/01/10 and 10/26/10 were not timed, dated, and/or authenticated as required by 25 Texas Administrative Code (TAC) 133.41 (j) (5). The CAH's medical record polices/procedures did not include that medical entries must be "timed."

25 TAC 133.41 (j)(5): Medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

Findings included:

The Medical Records of Patients #1 through #21 did not include the following information.

1) The "History and Physical Report" physician signatures for the following patients were not dated and/or timed.
Patient #1: Date of Admission 08/01/10, signature not dated and timed
Patient #3: Date of Admission 07/14/10, signature not dated and timed
Patient #13: Date of Admission 06/08/10, signature not dated and timed

2) The "Admission Note" physician signatures for the following patients were not dated and/or timed.
Patient #2: Date 05/30/10, signature not dated and timed
Patient #10: Date 09/6/10, signature not dated and timed

3) The "Discharge Summary" physician signatures for the following patients were not dated and/or timed.
Patient #1: Date of Discharge 08/03/10, signature not dated and timed
Patient #3: Date of Discharge 07/18/10, signature not dated and timed
Patient #4: Date of Discharge 05/24/10, signature not dated and timed
Patient #5: Date of Discharge 07/26/10, signature not dated and timed
Patient #6: Date of Discharge 07/30/10, signature not dated and timed
Patient #8: Date of Discharge 09/07/10, signature not dated and timed
Patient #9: Date of Discharge 09/22/10, signature not dated and timed
Patient #10: Date of Discharge 09/10/10, signature not dated and timed
Patient #11: Date of Discharge 06/28/10, signature not dated and timed
Patient #13: Date of Discharge 06/10/10, signature not dated and timed

4) The "Emergency Physician Record" physician and physician assistant (PA) signatures for the following patients were not dated and/or timed.
Patient #1: Date of service 08/01/10, signature not dated and timed
Patient #3: Date of service 07/14/10, signature not dated and timed
Patient #7: Date of service 09/03/10, signature for orders not timed
Patient #10: Date of service 09/05/10, signature not dated and timed
Patient #14: Date of service 07/10/10, signatures including orders not dated and timed
Patient #15: Date of service 09/19/10, signatures including orders not dated and timed
Patient #16: Date of service 09/12/10, signatures including orders not dated and timed
Patient #17: Date of service 07/30/10, signatures including orders not dated and timed
Patient #18: Date of service 07/10/10, signatures including orders not dated and timed
Patient #19: Date of service 05/30/10, signatures including orders not dated and timed
Patient #20: Date of service 05/28/10, signatures including orders not dated and timed
Patient #21: Date of service 09/17/10, signature not dated and timed

5) The "Admission Orders" physician signatures for the following patients were not dated and/or timed.
Patient #2: Admitted 05/30/10, signatures of "Admission Orders" and "Crotalid Snakebite Orders" not dated and timed
Patient #9: Admitted 09/20/10, signature not dated and timed
Patient #11: Admitted 06/24/10, signature not dated and timed

6) The "Venous Thromboembolism Prophylaxis Protocol (page 2)" signatures for the following patients were not signed, dated and/or timed.
Patient #2: Noted by nurse at "13:45" on 05/31/10, physician signature not dated and timed
Patient #4: Noted by nurse at "18:02" on 05/22/10, physician signature not dated and timed
Patient #5: Noted by nurse 07/22/10, nurse signature not timed, and 07/23/10 physician signature not timed
Patient #6: PA's signature dated 07/27/10 not timed, physician's signature not dated and timed
Patient #9: Noted by nurse at "17:10" on 09/20/10, physician's signature not dated and timed
Patient #10: Noted by nurse at "06:55" on 09/07/10, physician's signature not dated and timed
Patient #11: Date of Admission 06/24/10, physician's signature not dated and timed, nurse did not sign, date and time

7) The "Hospital Visit" report physician signatures for the following patients were not dated and/or timed.
Patient #2: Date of visit 05/31/10, signature not dated and timed
Patient #4: Date of visits 05/22/10 and 05/23/10, signatures not dated and timed
Patient #9: Date of visit 09/21/10, signature not dated and timed
Patient #11: Date of visits 06/25/10, 06/26/10, and 06/27/10, signatures not dated and timed

8) The "Instruction Sheet" physician and/or nurse signatures for the following patients were not dated and/or timed.
Patient #3: Dictated 07/18/10, physician signature not dated and timed
Patient #8: Dictated 09/07/10, physician and nurse signatures not dated and timed

9) The "Short Stay Record " report signatures for the following patients were not dated and/or timed.
Patient #6: Dated 07/26/10, signature of Physician Assistant (PA) not timed, and signature of physician not timed and dated
Patient #8: Dated 08/31/10, physician signature not timed

10) The "Inpatient Pneumococcal/Influenza Immunization Order Form" signatures for the following patients were not dated and/or timed.
Patient #6: PA signature dated 07/27/10 not timed and physician's signature not dated and timed
Patient #9: Nurse noted order on 09/20/10 at "17:05," physician signature not dated and timed
Patient #11: Nurse noted order 06/25/10, nurse signature not timed and physician's signature not dated and timed

11) The "Plan of Treatment for Rehabilitation" signatures for the following patients were not dated and/or timed.
Patient #6: Occupational therapist (OT) 07/29/10 signature not timed for 07/29/10 service, physician's signature not timed and dated for 07/30/10 physical therapy activities, and physical therapist (PT) signature dated 07/30/10 not timed
Patient #8: PT signatures dated 09/03/10 and 09/07/10 not timed, and physician's signature not dated and timed
Patient #11: OT signature dated 06/24/10 not timed, and physician's signature not dated and timed

12) The "Daily Therapy Notes" signatures for the following patients were not dated and/or timed.
Patient #6: OT signature for dates of service 07/29/10 and 07/30/10 not timed and PT signature for date of service 07/30/10 not timed
Patient #8: PT signature for dates of service 09/06/10 and 09/07/10 not timed
Patient #11: OT signatures for dates of service 06/24/10, 06/25/10, and 06/28/10 not timed

13) The "Weekly Progress Note" signature for the following patient was not dated and/or timed.
Patient #6: OT signature dated 08/05/10 for date of service 07/29/10 not timed

14) The "Exercise Flow Sheet" signatures for the following patients were not dated and/or timed.
Patient #6: PT signature for 07/30/10 not timed
Patient #11: OT signatures for 06/25/10 and 06/28/10 not timed, and PT signatures for 06/24/10, 06/25/10, and 06/28/10 not timed

15) The "Memorandum of Transfer" physician signatures for the following patients were not dated and/or timed.
Patient #8: Date of Transfer 09/07/10, signatures not dated and timed
Patient #18: Date of Transfer 07/10/10, signatures not dated and timed

16) The "Tuberculosis Skin Test (Mantoux)" reports were not timed by the nurse for the following patient.
Patient #10: Medication signatures dated 09/07/10, 48 hour results dated 09/09/10, and 72 hour results dated 09/10/10 not timed

17) The "Operative Report" physician signature for the following patient was not dated and/or timed.
Patient #12: Dictated 05/27/10, signature not dated and timed

18) The pathology report physician signatures for the following patients were not dated and/or timed.
Patient #12: Dictated 05/28/10, signature not dated and timed
Patient #13: Dictated 06/10/10, signature not dated and timed

19) The "Physician Assessment and Certification" signature was not dated and/or timed for the following patient:
Patient #18: Physician's 07/10/10 signature not timed

During an interview at 03:30 PM on 10/28/10, the Director of Nursing (Personnel #6) reviewed copies of the medical records for Patients #1 through #21. Personnel #6 was in agreement that dates, times, and/or signatures were missing.

The "Medical Staff Rules and Regulations" revised by the hospital on 11/2003 noted, "All clinical entries in the patient's medical record shall be accurately dated and authenticated ..." Time was not included in the "Medical Staff Rules and Regulations."

During an interview at approximately 02:00 PM on 10/28/10, the Medical Records Director (Personnel #3) was asked if the hospital's polices and the "Medical Staff Rules and Regulations" included that all medical record entry signatures needed to be timed. Personnel #3 said that this was not included in the CAH's medical record policies or in the "Medical Staff Rules and Regulations." Personnel #3 said that this would be added to the policies.

Based on interview and review of records, the hospital did not have drug policies that included processes for: A) pharmacy oversight of all drug storage areas in the hospital for security, or B) removing outdated drugs from patient care areas, to ensure they were not available for patient use.

Findings included:

Review of the hospital policies and procedures, "Drug Procurement" and "Recalled Drugs/Discontinued Drugs," both with a revision date of November 2001, showed the following:
A) No written process for pharmacy oversight of all drug storage areas in the hospital.
B) No written process for ongoing monitoring of expired drugs, or a system to remove expired drugs from patient care areas.

The only reference to expired drugs, noted in the hospital "Drug Procurement" policy, dated November 2001, noted that:
-"When a stocked drug expires, it will be noted on a monthly list of expired drugs. This list will be given to the consultant pharmacist. The list will be presented at the monthly Pharmacy and Therapeutics Meeting and at that time, a decision will be made as to whether the drug will be reordered or deleted from the formulary."

In an interview at 3:00 PM on 10/25/10 with the Emergency Department (ED)/Trauma Coordinator (Personnel # 19), she was asked how often the pharmacy technician checked the drug storage areas in the ED and how were expired medications removed from patient care areas. She said that the pharmacy technician checked stocked medications 2 times/week and when called by ED personnel. The ED Coordinator also stated that the pharmacy technician did not check the medications in the ED crash carts, as these were checked by the Emergency Medical Technicians (EMT's) on a monthly basis. The EMT's called the pharmacy technician if there were any expired medications to be replaced.

In an interview at 5:15 PM on 10/27/10 with the pharmacy technician (Personnel # 27), she was asked if she routinely checked the drugs in the hospital crash carts or other patient care areas that stored drugs throughout the hospital, both for security and removal of expired drugs. She said "no," and confirmed the process noted above where EMT's and/or nurses called her when they found expired medications. She also verified that the pharmacy did not have a written process where the pharmacy was responsible for providing oversight of drugs throughout the hospital.

Based on interview and review of records, the Critical Access Hospital (CAH) did not include evidence of informed consents in the medical records for a patient to be treated at the CAH by a physician assistant (PA) for 2 of 2 patients (Patient #6 and #17) who were evaluated and treated by a PA (Personnel #8) from 07/26/10 through 07/30/10.

Findings included:

Medical Record Patient #6
The "Short Stay Record" of Patient #6, age 82, noted that Patient #6 was examined by PA #8 on 07/26/10 for conditions that included hypotension and bradycardia. PA #8's plan was to admit Patient #6 to the CAH. Patient #6's treatment included, "IV fluids, ECG, labs ..." Patient #6's consent information did not indicate that Patient #6 would be evaluated or treated by a PA at any time during her hospitalization.

Medical Record Patient #17
The "Emergency Physician Record" of Patient #17, age 56, noted that Patient #17 was examined by PA #8 on 07/30/10 for conditions that included viral gastritis and nausea. PA #8 ordered medication that included Phenergan and Toradol. Patient #17's consent information did not indicate that Patient #17 would be evaluated or treated by a PA at any time during her emergency room visit.

The CAH "Medical Staff By-Laws" revised October 2002 noted, "The supervising Physician and Physician Assistant must ensure that ...Physician Assistant's scope of functions is identified ...The relationship between the members of the team and the access of the Physician Assistant to the supervising Physician is defined ..."

During an interview at 03:20 PM on 10/27/10, the Chief Executive Officer (Personnel #1) was asked if the CAH had patients sign a consent when they were evaluated and/or treated by a PA. Personnel #1 said that it was decided that this was not necessary since the PA worked under the Physician's license, but that this could be changed.

Based on interviews and review of records, the hospital did not have an interdisciplinary team who met regularly to prepare a comprehensive care plan, and that included the resident's attending physician, for 2 of 2 Swing Bed residents (Patients #22 and #23).

Findings included:

Medical Records for 2 reviewed Swing Bed residents noted the following:

Patient #22: This 88 year old female was admitted to Swing Bed status on 10/22/10. The "Physician's Order Sheet" noted an admitting diagnosis of Small Bowel Obstruction and Fatigue. The physician ordered a dietary consult and evaluation, as well as a physical therapy evaluation.

A review of the medical record did not contain a "comprehensive care plan," that had been developed by an interdisciplinary team, documenting participation from all disciplines providing services to the patient, and that included the patient's physician.

Patient #23: This 79 year old male was admitted to Swing Bed status on 10/25/10. The "Physician's Order Sheet" noted an admitting diagnosis of a fractured right patella, Arthritis, and pre-morbid contractures of bilateral lower extremities and knees. The physician ordered a physical therapy evaluation, and gave a telephone order on 10/26/10 for a pureed diet.

Review of the medical records for Patient #22 and Patient #23 did not contain a "comprehensive care plan," that had been developed by an interdisciplinary team, documenting participation from all disciplines providing services to the patient, and that included the patient's physician.

In interviews held separately on 10/26/10 at 3:30 with the Activity Director (Personnel # 21), and at 4:30 PM with the Swing Bed Coordinator (Personnel # 3), and then at 8:55 AM on 10/28/10 with the Physical Therapist (Personnel # 24), when asked if the hospital had an interdisciplinary team that included the attending physician, they each said "no." When asked if an interdisciplinary team met regularly to develop a comprehensive care plan for each Swing Bed resident, they each said "no."