HospitalInspections.org

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure proper maintenance and cleanliness of piping in 1 of 3 observed areas above the ceiling tiles (in the hallway between the elevator and nurses' station on second floor). Failure to ensure all areas of the hospital are well-maintained limits the CAH's ability to ensure a safe and clean environment for patients.

Findings include:

Observation with an administrative plant operations staff member (#3) on 11/03/15 at approximately 11:30 a.m. of a section of the chilled water supply piping above the ceiling tile in the hallway between the elevator and the nurses' station on second floor showed the pipe covering was discolored with black, brown, and tan stains.

During interview, at approximately 11:30 a.m. on 11/03/15, an administrative plant operations staff member (#3) confirmed the staining of the pipe covering and stated the pipes are probably covered in asbestos. He stated at times condensation forms on the chilled water supply piping. Staff Member #3 stated he did not know the cause of the staining and did not know if it was mold. He confirmed the facility needed to take care of the problem.

Based on bylaws review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure proper medical staff recommendation for reappointment for 1 of 1 active physician (Physician #1) in 2013. Failure to ensure proper reappointment of medical staff places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the governing board's "Constitution & Bylaws" occurred on 11/02/15. These bylaws, adopted 12/17/87, stated, ". . . Article VIII.
Medical Staff . . .
Section 4. Procedures for Board Actions Pertaining to Medical Staff Applicants or Appointees:
(a) At its next regular meeting after receipt of a recommendation from the medical staff or an appropriate committee thereof concerning an applicant for medical staff appointment or concerning a medical staff appointee, the Board shall act in the matter. . . ."

Review of the "Medical Staff By-Laws" occurred on 11/02/15. These bylaws, adopted 09/15/14, stated,
". . . ARTICLE VII Actions Affecting Medical Staff Appointees
7.1-3 Reappointment Procedure
a. The Medical Staff, after receiving the reports from the Chief Executive Officer, shall review all pertinent information available including all information provided from other committees of the Medical Staff and from Hospital management for the purpose of determining its recommendations for Staff reappointment, for change in Staff category and for the granting of clinical privileges for the ensuing appointment period. . . ."

Neither the governing board bylaws nor the medical staff bylaws included a procedure for medical staff recommendation of appointments or reappointments when the CAH has a sole physician on the active medical staff.

Reviewed the afternoon of 11/03/15, Physician #1's credentialing file indicated the physician recommended reappointment to medical staff for himself on 11/13/13. Upon this self-recommendation, the governing board approved Physician #1's reappointment on 12/02/13.

During interview at approximately 3:55 p.m. on 11/03/15, an assistant administrative staff member (#4) responsible for credentialing at the CAH stated Physician #1 was the only active physician on the CAH's medical staff at the time of his reappointment, so the CAH had Physician #1 provide the recommendation for reappointment for himself.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY CONDUCTED ON 11/16/11.

Based on medical record review, review of medical staff rules and regulations, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure complete documentation in the medical record for 2 of 5 sampled patients closed surgical records (Patient #13 and #17), 1 of 5 sampled active swing bed (SB) record (Patient #2), and 3 of 7 sampled inpatients (IP) closed medical records (Patient #8, #9 and #12).

Findings include:

Review of the CAH's Medical Staff Bylaws, Rules, and Regulations occurred on November 02-04, 2015. This document, approved 04/22/13, stated:
". . . A member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the Hospital and for the prompt completeness and accuracy of the medical record. . . . Physical examination and medical history shall be done no more than seven (7) days before admission . . . or twenty-four (24) hours after admission for each patient by the practitioner. . . .
MEDICAL RECORDS . . . The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient. . . . Operative reports . . . shall be written or dictated within twenty-four (24) hours following surgery and the report promptly signed by the surgeon and made a part of the patient's current medical record. . . . The patient's medical record should be completed at the time of discharge, including . . . final diagnosis and discharge summary. When this is not possible . . . the record is incomplete fifteen (15) days after discharge . . . SURGICAL CARE . . . there must be a complete history and physical on the patient's medical chart . . . History and physicals may be done up to thirty (30) days in advance. . . ."

Review of a facility policy "Completion Time Frames for Dictation and Transcription" occurred on 11/04/15. The policy stated, ". . . Discharge summaries need to be dictated, transcribed, and on the EHR [electronic health record] fifteen (15) days after the patient has been discharged. . . . Physicians and mid levels need to keep doing their signing on the EHR as they are currently doing on a daily basis as well as on the paper chart. . . ."

- Review of medical records occurred on November 02-04, 2015. The medical records lacked the following:
* Dictated discharge summaries for Patients #8 (discharged 08/29/15), #9 (discharged on 09/24/15), and #12 (discharged on 09/03/15), and for Patient #2 (discharged on 09/25/15) who transferred from acute to SB.
* Authentication (hand written or electronic signatures) of admission history and physical (H & P) for Patient #8 and #9.
* Operative report for Patient #17. The surgery occurred on 07/21/15.
* A history and physical completed within 30 day prior to surgery for Patient #13. The surgery (colonoscopy) occurred on 05/07/15. An entry in the medical record, dated 03/31/15, stated, ". . . We will schedule patient for colonoscopy . . . A copy of this dictation will be her preop [preoperative] history and physical . . ."
* Authentication within 15 days of a procedure note for Patient #13. The procedure occurred on 05/07/15 and authentication occurred on 06/18/15, six weeks later.

During interview on 11/03/15 between 8:20 a.m. and 9:10 a.m., a supervisory staff member of the medical records department (#5) stated providers are expected to complete medical records within 15 days of a patients discharge. On 11/03/15 at 3:20 p.m. the staff member (#5) stated physicians are required to complete operative reports within 24 hours following surgery.

During an interview on 11/03/15 at 6:16 p.m., a supervisory nurse (#2) stated Patient #2 had no discharge summary after acute stay and no H & P on SB admission.



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