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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on March 7, 2012, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

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A. Based on Critical Access Hospital (CAH) policy, observation, record review and staff interview, it was determined that the CAH failed to ensure that all therapy equipment used for patient care was maintained in a safe manner for patient use potentially affecting all patients receiving whirlpool treatment.

Findings include:

1. A review of the policies and procedures was completed on survey date 2/9/12. The policy titled "Maintenance Policy" effective 12/18/08, on page 3 under " Building Maintenance, Other ongoing preventative maintenance is completed in accordance with the preventative maintenance log in the Maintenance Department. Maintenance staff are assigned certain areas of preventative maintenance to be performed throughout the year."

2. A tour of the Therapy Department was completed on survey date 2/7/12 at 10:00 AM. During the tour it was observed that 2 whirlpool tubs were located in the therapy department with preventive maintenance tags indicating the last check was in 2005. Upon request for additional logs, documentation indicated that no preventive maintenance had been completed on the whirlpools.

3. The medical record of Pt.#21 was reviewed on survey date 2/8/12. Pt #21 was admitted to the CAH on 12/28/11 with diagnoses of Acute Respiratory Failure, Congestive Obstructive Pulmonary Disease and Right Foot Ulcer. Documentation indicated Pt#21 received a whirlpool treatment to the right foot per physician orders on 12/30/11.

4. During an interview on 2/7/12 at 3:30 PM with the Director of Nursing (DON), the above finding was confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on March 7, 2012, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated March 7, 2012.

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A. Based on policy and procedure, record review and staff interview it was determined that in 1 of 5 (Pt. #20) of death records reviewed that the CAH failed to ensure that policies were followed regarding Do Not Resuscitate (DNR).

Findings include:

1. The CAH policy titled, "Do Not Resuscitate Guidelines" effective 9/30/2004 was reviewed on 2/8/12. The policy indicated under "C. Implementation of DNR Order 1. The attending physician shall write a formal order to that effect in the patient's chart and shall write an explanation of the grounds for this decision in the patient's progress notes.

2. The medical record of Pt. #20 was reviewed on 2/8/12. Pt. #20 was admitted to the CAH on 9/8/11 with a diagnoses of Bronchitis with Right Basal Pneumonia and Metastatic Cancer of Lung. Documentation in the "Doctor's Progress Notes" indicated that on 9/25/11 the physician discussed with the patient being in a DNR status and the patient told him he was going to think about it and let the physician know. Documentation indicated that on 9/29/11 the patient expired without Cardio-pulmonary resuscitation (CPR). There was no documentation in the physician progress notes or physician orders to indicate that Pt. #20 had decided to be in a DNR status.

3. During an interview on 2/8/12 at 3:00 PM with the DON, the above findings were confirmed.




B. Based on CAH policy, document review and staff interview, it was determined in 30 of 30 medication incidents reviewed, the CAH failed to follow policies related to medication incidents..

Findings include:

1. The CAH policies and procedures were reviewed during the survey. The CAH policy titled "Review of Medication Incidents" under V. Procedures 4. "Medication incidents are classified using the following guidelines: Category: A. = Circumstances or events that have the capacity to cause error..." The CAH policy titled "Incident Disclosure Policy" under I Policy B. "Medication incidents: 1. The physician is notified of all medication incidents, immediately or as soon as possible,..."

2. A review of the Medication Incident Reports for November 2011 through January 2012 were reviewed. Documentation indicated 30 of the 30 medication incidents failed to indicate classification of the errors according to the policy guidelines. Documentation indicated the physician was not notified in 22 of 30 medication incidents.

3. During an interview with the Director of Nursing on 2/9/12 at 4:00 PM, the above findings were confirmed.

A. Based on policy and procedure, observation and staff interview it was determined that the CAH failed to ensure that all outdated drugs and biologicals were removed and not available for patient usage potentially effecting all patients.

Findings include:

1. The CAH policy titled, "Unusable and Outdated Drugs" (revised 6/07) was reviewed on 2/8/12. Documentation under " I. POLICY: All expired/outdated drugs...shall be returned to Pharmacy Services for proper disposal."

2. During a tour of the Emergency Department (ED) on 2/7/12 at 10:30 AM, it was observed in the crash cart that 1 vial of Levophed 4 mg/4ml had expired on 1/1/12. During a tour of the Radiology Department on 2/8/12 at 11:30 AM, it was observed in the emergency kit that a 500 mg bag of Dopamine had expired on 12/1/11.

3. During an interview with the DON on 2/8/12 at 3:00 PM, the above findings were confirmed.

A. Based on policy and procedure, observation, and staff interview it was determined that the CAH failed to ensure that policies are followed regarding food safety potentially effecting all patients and staff.

Findings include:

1. The CAH policy titled, "Ready -To-Eat Foods, Date Marking" effective 10/1/09 was reviewed on 2/8/12. The policy under "V. Procedures Infection Control: N/A" bullet 3 indicated "Marking the date or day the original container is opened in a food establishment...".

2. During a tour of the Dietary department on 2/8/12 at 10:00 AM, it was observed in the freezer opened bags of fish, sausage, and frozen vegetables with no dates. Also observed in refrigerator a plastic container with tomatoes was not dated.

3. During an interview with the Dietary Supervisor on 2/8/12 at 10:00 AM, the above findings were confirmed.

A. Based on Rules and Regulations, record review and staff interview it was determined that the CAH failed to ensure that all medical records are completed within 30 days after discharge.

Findings include:

1. The CAH "Medical Staff Rules and Regulations" (reviewed 3/17/11) was reviewed on 2/3/12. The Regulations under "Section 9. Medical Records 7. Medical charts must be completed in the current patient's file in the Health Information office within thirty 30 days after discharge."

2. Documentation indicated that as of 2/4/12 the CAH had 11 delinquent records past 30 days after discharge.

3. During an interview with the DON on 2/8/12 at 3:00 PM, the above findings were confirmed.

A. Based on Rules and Regulations, record review and staff interview it was determined that in 4 of 18 (Pt. #3, #17, #21, #23) patients admitted that the CAH failed to ensure that a history and physical were completed within 24 hours.

Findings include:

1. The CAH "Medical Staff Rules and Regulations" reviewed (3/17/11) was reviewed on 2/8/12. Documentation under "Section 9. Medical Records 2. A complete medical history and physical examination shall in all cases be written no more than (30) days before or (24) hours after admission."

2. The medical record of Pt. #3 was reviewed on 2/7/12. Pt. #3 was admitted to the CAH on 9/20/11 with the diagnoses of Left Mastectomy with Bleeding and Dehiscence and Anemia. Documentation indicated the History and Physical (H & P) was completed by the physician on 9/27/11.

3. The medical record of Pt. #17 was reviewed on 2/7/12. Pt. #17 was admitted to the CAH on 7/16/11 with the diagnoses of Left Lung Pneumonia and Stage 4 Coccyx Decubitus. Documentation indicated the H & P was completed on 7/20/11.

4. The medical record of Pt. #21 was reviewed on 2/8/12. Pt. #21 was admitted to the CAH on 12/28/11 with the diagnoses of Acute Respiratory Failure and Chronic Obstructive Pulmonary Disease. Documentation indicated the H&P was completed on 12/30/11.

4. The medical record of Pt. #23 was reviewed on 2/8/12. Pt. #23 was admitted to the CAH on 3/25/11 with the diagnoses of Left Leg Wound with Cellulitis and Congestive Heart Failure. Documentation indicated the H& P was completed on 3/29/11.

5. During an interview with the DON on 2/8/12 at 3:00 PM, the above findings were confirmed.

A. Based on CAH policy, record review and staff interview, it was determined in 14 of 25 (Pt. #1, 2, 3, 4, 6, 7, 11, 16, 19, 20, 21, 23, 24, and 25) records reviewed, the CAH failed to ensure all orders and physician signatures were authenticated, timed and dated.

Findings include:

1. During the survey the CAH Medical Staff Rules and Regulations dated 3/17/11 were reviewed. The CAH Rules and Regulations under Section 2. "Physician Orders" paragraph 2 indicates "The order is to be dated, timed and identified by the name of the individual who gave it and received it. These orders shall be signed before the member of the Medical Staff leaves the area."

2. The medical record of Pt. #1 was reviewed on 2/6/12. Pt. #1 was admitted to the CAH on 1/15/12 with diagnoses of Basal Pneumonitis and Congestive Heart Failure (CHF). Documentation indicated multiple orders dated from 1/15/12 through 1/21/12 with no dates or times of physician orders.

3. The medical record of Pt.#2 was reviewed on 2/6/12. Pt.#2 was admitted to the CAH on 2/6/12 with a diagnosis of Pelvic Pain. Documentation indicated no date or time on the Emergency Room orders.

4. The medical record of Pt.#3 was reviewed on 2/7/12. Pt.#3 was admitted to the CAH on 9/20/11 with diagnoses of Left Mastectomy with bleeding and dehiscence and Anemia. Documentation indicated multiple orders from 9/20/11 through 9/21/11 with no dates or times of physician signatures.

5. The medical record of #4 was reviewed on 2/7/12. Pt. #4 was admitted to the CAH on 11/15/11 with a diagnosis of Acute Congestive Obstructive Pulmonary Disease (COPD) Exacerbation. Documentation indicated orders dated 11/16/11 and 11/17/11 with no dates and times of physician signatures.

6. The medical record of Pt.#6 was reviewed on 2/7/12. Pt.#6 was admitted to the CAH on 6/29/11 with diagnoses of Pneumonia, CHF and COPD. Documentation indicated there was no time on the admission orders and no date or time on multiple physician signatures from 6/29/11 through 7/4/11.

7. The medical record of Pt #7 was reviewed on 2/7/12. Pt.#7 was admitted to the CAH with diagnoses of CHF with Exacerbation, Pneumonia and Gastrointestinal Bleed with Anemia. Documentation indicated there was no time on the admission orders and no date or time on physician signatures of verbal orders from 2/7/11 through 2/10/11.

8. The medical record of Pt #11 was reviewed on 2/9/12. Pt #11 was admitted to the CAH on 2/6/12 with diagnoses of Urinary Tract Infection, Dehydration and Dementia. Documentation indicated there was no date or time on multiple orders dated 2/6/12 through 2/9/12.

9. The medical record of Pt.#16 was reviewed on 2/8/12. Pt.#16 was admitted to the CAH on 10/13/11 with diagnoses of CHF, Anemia and Cardiomyopathy. Documentation indicated there was no date or time on physician signatures for orders on 10/13/11.

10. The medical record of Pt #19 was reviewed on 2/8/12. Pt.#19 was admitted to the CAH on 9/12/11 with diagnoses of Acute Sinusitis, Diabetes Mellitus and Respiratory Arrest. Documentation indicated there was no date or time on verbal and telephone physician orders dated 9/12/11.

11. The medical record of Pt.#20 was reviewed on 2/8/12. Pt. #20 was admitted to the CAH on 9/8/11 with diagnoses of Bronchitis, Right Basal Pneumonia and Carcinoma of the Lung with Metastasis. Documentation indicated respiratory orders failed to include date and time. Documentation failed to indicate dates and times for multiple physician signatures on orders from 9/8/11 through 9/29/11.

12. The medical record of Pt. #21 was reviewed on 2/8/12. Pt. #21 was admitted to the CAH with diagnoses of Respiratory Failure, COPD, CHF and Right Foot Ulcer. Documentation indicated there was no date or time on admission orders or on telephone orders dated 12/28/11 through 12/31/11.

13. The medical record of Pt. #23 was reviewed on 2/8/12. Pt. #23 was admitted to the CAH on 3/25/11 with diagnoses of Left Leg Wound with Cellulitis with pain, Atrial Fibrillation and CHF. Documentation indicated the respiratory orders dated 3/25/11 had no date or time of the order. Documentation indicated multiple physician orders with no date or time.

14. The medical record of Pt. #24 was reviewed on 2/8/12. Pt. #24 was admitted to the CAH on 10/6/12 with diagnoses of Pneumonia, Dehydration, Fracture/C-2, and Mental Retardation. Documentation indicated there was no time noted in the admission orders.

15. The medical record of Pt. #25 was reviewed on 2/9/12. Pt. #25 was admitted to the CAH on 8/8/11 with diagnoses of Pneumonia and CHF. Documentation indicated multiple physician orders with no date or time.

16. During an interview with the Director of Nursing on 2/8/12 at 4:00 PM, the above findings were confirmed.


B. Based on record review and staff interview, it was determined the CAH failed to ensure in 10 of 13 (Pt. #1, 2, 6, 10, 12, 13, 18, 19, 20, 24) records reviewed when patients were received through the Emergency Department, that all Medical Screening Exams (MSE) were timed.

Findings include:

1. The medical record of Pt. #1 was reviewed on 2/6/12. Pt. #1 was admitted to the CAH on 1/15/12 with diagnoses of Basal Pneumonitis and Congestive Heart Failure (CHF). Documentation indicated there was no time the MSE was completed.

2. The medical record of Pt.#2 was reviewed on 2/6/12. Pt.#2 was admitted to the CAH on 2/6/12 with a diagnosis of Pelvic Pain. Documentation indicated there was no time the MSE was completed.

3. The medical record of Pt.#6 was reviewed on 2/7/12. Pt.#6 was admitted to the CAH on 6/29/11 with diagnoses of Pneumonia, CHF and COPD. Documentation indicated there was no time the MSE was completed.

4. The medical record of Pt. #10 was reviewed on 2/7/12. Pt. #10 presented to the ED on 12/2/11 with complaint of Facial Burns 1st and 2nd Degree. Documentation indicated there was no time the MSE was completed.

5. The medical record of Pt. #12 was reviewed on 2/8/12. Pt.#12 presented to the ED on 1/8/12 with complaint of Upper Abdominal Pain and Pregnancy-24 weeks. Documentation failed to indicate the time the physician completed the MSE.

6. The medical record of Pt. #13 was completed on 2/7/12. Pt. #13 presented to the ED on 12/31/11 with complaint of Left Lower Quadrant Pain and Positive Pregnancy Test. Documentation failed to indicate the time the physician completed the MSE.

7. The medical record of Pt. #18 was completed on 2/8/12. Pt. #18 presented to the ED on 1/1/12 with complaint of Seizure Activity. Documentation failed to indicate the time the physician completed the MSE.

8. The medical record of Pt#19 was reviewed on 2/8/12. Pt.#19 was admitted to the CAH on 9/12/11 with diagnoses of Acute Sinusitis, Diabetes Mellitus and Respiratory Arrest. Documentation failed to indicate the time the physician completed the MSE.

9. The medical record of Pt.#20 was reviewed on 2/8/12. Pt. #20 was admitted to the CAH on 9/8/11 with diagnoses of Bronchitis, Right Basal Pneumonia and Carcinoma of the Lung with Metastasis. Documentation failed to indicate the time the physician completed the MSE.


10. The medical record of Pt. #24 was reviewed on 2/8/12. Pt. #24 was admitted to the CAH on 10/6/11 with diagnoses of Pneumonia, Dehydration, Fracture/C-2, and Mental Retardation. Documentation failed to indicate the time the physician completed the MSE.

11. During an interview with the DON on 2/8/12 at 4:00 PM, the above findings were confirmed.