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Based on record review, policy review, document review, and staff interview, the Critical Access Hospital (CAH) failed to determine if all patients admitted to the CAH had an advanced directive or provide information and/or assistance if so desired by the patients about how to obtain an Advanced Directive for five of 23 sampled patients ( Patients 12, 13, 14, 17, and 18).

Findings Include:

During medical record review on 01/07/19 at 1:09 PM, it was determined Patient 12, 13, 14, 17, and 18's medical records had no documentation that the patients were asked if they had an Advanced Directive or were offered information and if so desired, assistance to formulate an advanced directive during their admission to the CAH.

A review on 01/07/19 of the CAH policy titled, "Admission of a Patient," approved 09/25/17, showed no reference to advanced directives.

A review on 01/07/19 of an undated CAH document intended for use during the registration process titled, "TREATMENT AUTHORIZATION AND PRIVACY ACKNOWLEDGMENT," included the following: ADVANCED DIRECTIVE INFORMATION: (complete for all patients including outpatients). Do you have a living will? Do you have Medical Durable Power of Attorney (DPOA)? If yes, is the living will or DPOA on file? If no, were you given Advanced Directive Education Material? This form is to remain a part of the medical record. Patient 12, 13, 14, 17, and 18's medical records revealed this form was either missing or blank.

In an interview during medical record review on 01/07/19 at 1:12 PM, Staff B, Chief Nursing Officer (CNO) stated, "The registration clerk advised me that we do not normally do advanced directives for observation patients." It was later determined in an interview with Staff B on 01/08/19 at 2:00 PM that Obstetric (OB) and Emergency Department (ED) patients are not always asked about Advanced Directives.

Based on interview and record review, the facility failed to obtain an National Practitioner Data Base (NPDB) report for 11 of 14 medical providers (Staff I, K, L, M, N, O, P, Q, R, S, and T). The facility uses the NPDB when reviewing data for recredentialing of the provider. The facility failed to conduct a peer review, or a review of medical records, for one surgeon (Staff L) that worked on a consulting basis at the facility. This deficient practice places all patients at risk for malpractice and quality of care below standards.

Findings Include:

1. Eleven of 14 medical provider files reviewed for credentialing to include active, allied, or consulting, positions at the facility. Staff I, K, L, M, N, O, P, Q, R, S, and T's files failed to include evidence that a report from the NPDB had been obtained and reviewed when recommendations for credentialing were made by the Medical Staff, and approval by the Governing Body.

In an interview on 01/09/19 at 9:15 AM, Staff C, Executive Assistant, said the last search of the NPDB data base had been conducted in 2016, and a search of the NPDB should have been conducted in 2018, when recommendations were made by the Medical Staff.

A review of the facility, "Medical Staff Bylaws,"(undated), provided by Staff B on 01/09/19 at 9:40 AM, showed on page 13, "4. Processing Application: A. ...The Administrator, or designee, shall query the National Practitioner Data Bank as required by law. The application will then be referred to the Chief of Staff, who shall cause of the Application to be reviewed by the Medical Staff at the next regular meeting of the Medical Staff.

A review of the facility's, "Governing Board Bylaws," dated "June 18, 2018, provided by Staff B on 01/09/19 at 9:40 AM, showed, "Article X-Medical Staff, Section 1. a. ...The governing board shall consider recommendations of the medical staff and appoint to the medical staff physicians and others who meet the qualifications for membership as set forth in the bylaws of the medical staff."

2. Review of Staff L's credentialing file failed to hold evidence that Staff L's work had been peer reviewed and failed to include information that documented the medical records developed by Staff L had been reviewed as required.

In an interview on 01/09/19 at 10:15 AM, Staff A, the Chief Executive Officer (CE0) said he did not think the facility would have specific peer review data for the medical staff to review when recredentialing Staff L, as Staff L was the only surgeon. Staff A said he did not think there was a formal peer review by medical staff. Staff A said if there was not specific information that had come up through the Risk Management, there would not be information to review for Staff L.

A review of the facility's, "Medical Staff Bylaws," (undated), on page 14, provided by Staff B on 01/09/19 at 9:40 AM, showed, "6. A. Each recommendation concerning the reappointment of a Medical Staff Member and the clinical privileges to be granted upon reappointment, shall be based upon such member's professional competence and clinical judgement in the treatment of patients."

Based on observation, interview, and record review, the facility failed to implement best infection control practice when establishing an intravenous access for one surgical patient (Patient 1) of one intravenous access observed. Specifically, two nurses were observed touching the access site with gloved hands after the site had been decontaminated and prior to insertion of the intravenous catheter. The two nurses placed tape on a bedside table and on the bedrail, that would later be used to anchor the intravenous catheter.

Findings Include:

During an observation on 01/08/19 from 8:09 AM to 8:45 AM, Staff F Registered Nurse (RN) and Staff G RN each attempted to establish an intravenous access site for Patient 1 prior to surgery.

During set up to obtain intravenous access, Staff G RN pulled strips from the tape roll and stuck the strips of tape to the bedside table, with the ends flying free, to be used when the intravenous access had been established. After setting up, she changed her gloves but did not sanitize her hands. She then pulled more strips of tape, from the same roll of tape, and stuck them to the bedside table. Without changing her gloves, she used a prep pad to cleanse the areas on Patient 1's wrist where she would attempt placement of the intravenous catheter. She then continued to assess the site by touching the area several times that she had just cleansed and attempted to access the site with the catheter. The attempt failed. She then removed her gloves, washed her hands, and put on clean gloves. Staff G RN then reassessed both arms looking for a better intravenous access site. Again, she changed her gloves but did not sanitize her hands. Wearing the clean gloves, she transferred the barrier cloth from the right side of Patient 1's body to the left side of Patient 1's body. She used another prep pad to cleanse a different access site on the left forearm. Staff G RN touched the area repeatedly with her gloved fingers and attempted to obtain intravenous access. The second attempt failed. She removed her gloves, washed her hands, and went to find another staff to attempt intravenous access for Patient 1.

Staff F RN then attempted to establish intravenous access site for Patient 1. When setting up for the procedure, Staff F RN pulled two pieces of tape from the same tape roll Staff G RN had used, tore the two pieces of tape in half lengthwise, and stuck the four pieces of tape to the bed railing. The ends of the tape were flying free in the air. Staff F RN cleansed the left antecubital space and continued to assess the space with her gloved hand, touching the cleansed area. Staff F RN was able to establish the intravenous access site, clean blood away from the site, and used the tape from the bed rail to anchor the intravenous catheter.

In an interview on 01/07/19 at 10:55 AM, Staff F RN said she should have washed her hands between glove changes and not retouched the access site prior to insertion of the intravenous catheter for Patient 1. She was not sure if she should have placed the strips of tape on the bed rail.

In an interview on 01/07/19 at 11:05 AM, Staff G RN said the correct policy would be to clean the area (access site) again after she had touched it with her glove and before insertion of the intravenous catheter for Patient 1.

A review of the Critical Access Hospital policy, "Hand Hygiene," dated 04/24/15, provided by Staff B, RN Chief Nursing Officer showed Procedure ...I. Decontaminate hands after removing gloves.

A review of "Lippincott's Nursing Procedures, Sixth Edition," page 423, "Intravenous Catheter Insertion and Removal," provided by staff member B, RN Chief Nursing Officer on 01/09/19 at 10:30 AM, showed "Preparing the site...Clean the site with chlorhexidine using a back-and-forth scrubbing motion for at least 30 seconds to remove flora that would otherwise be introduced into the vascular system with the venipuncture. Allow the antiseptic to dry."

Based on medical record review, policy review, Medical Staff Rules and Regulations, and staff interview, the CAH (Critical Access Hospital) staff and/or physicians failed to time, date, or authenticate multiple entries in the medical records in keeping with the accepted standards of practice. Omissions for times, dates, or signatures included medication orders, discharge instructions, and discharge orders for eight of 12 medical records reviewed in this sample (Patients 12, 14, 15, 18, 19, 21, 22, and 23). Failure to follow standards of practive for authenticating medication orders and discharge instructions has the potential for medication errors and omissions and poor follow up care after discharge.

Findings Include:

Medical record review for Patient 12 revealed numerous orders for medications, labs, X-rays, and EKG without a date the orders were written. The same record documented medications administered to Patient 12 i.e. Aspirin 325 mg PO, Morphine 2 mg IV X 1 dose with no time, date or signature of the person giving the drugs and Brillinta (blood thinner)180 mg PO with no date or signature of the person giving the drug as required. The Advanced Practice Registered Nurse (APRN) signed the bottom of the treatment sheet but did not date the entry.

Medical record review for Patient 14 revealed standing pre-printed treatment orders for Group B streptococci (GBS) signed by the Midwife that were dated but not timed. The orders included administration of, "Ampicillin 2 grams IV initially then 1 gram IV every 4 hours until delivery." The Midwife also included standing pre-printed, "Postpartum Labor and Delivery Orders" The form includes a space for the providers signature, date and time. The provider failed to time the orders.

Medical record review for Patient 15 revealed a verbal order (VO) documented by the Registered Nurse (RN) for a Foley catheter on 01/04/18 at 11:45 PM. The VO was not authenticated by the ordering provider until 02/10/18 and did not include the time of authentication. This action is not in compliance with the CAH's policy.

Medical record review for Patient 18 revealed VOs for Calcium Carbonate 500 mg, PO (by mouth) PRN (as needed), Calcium Carbonate 1000 mg PO PRN and Tylenol 1000 mg PO every 6 hours PRN, were entered into the computer on 01/03/19 at 9:17 AM, 9:19 AM and 5:40 AM respectively. As of 01/07/19 at 4:55 PM, the order status was, "Signed: Pending" and had not been authenticated by the ordering provider. This action is not in compliance with the CAH's policy.

Medical record review for Patient 19 revealed discharge instructions written by the APRN that were signed but not dated or timed. There is a place designated at the bottom of this form, "EMERGENCY ROOM * OUTPATIENT RECORD" stating, "PATIENT'S SIGNATURE ON DISCHARGE" and, "DATE - TIME OF DISC" which were blank.

Medical record review for Patient 21 revealed discharge instructions written by the provider that were signed but not dated or timed. There is a place designated at the bottom of this form, "EMERGENCY ROOM * OUTPATIENT RECORD" stating, "PATIENT'S SIGNATURE ON DISCHARGE" and, "DATE - TIME OF DISC" which included Patient 21's signature, but no time or date of discharge. Patient 21's record also showed medication orders for Toradol (non-steroidal anti-inflammatory) 60 mg, no route and Tylenol 1000 mg PO. There was no time or date when the orders were written by the provider and no time or date when the medications were given by the RN.

Medical record review for Patient 22 revealed discharge instructions written by the provider that were signed, but not dated or timed. There is a place designated at the bottom of this form, "EMERGENCY ROOM * OUTPATIENT RECORD" stating, "PATIENT'S SIGNATURE ON DISCHARGE" and, "DATE - TIME OF DISC" which included Patient 22's signature, but no time or date of discharge.

Medical record review for Patient 23 revealed that Patient 23 received the following medications: Phenytoin (treats seizure disorders) 500 mg infusion, Ativan (sedative) 1 mg IV and Decadron (steroid) 12 mg IV. There was no documented date, time, initials, or signature of the person that administered the medications to Patient 23.

A review of the CAH's policy titled, "Medication Administration" approved 01/08/15 stated, "1. PATIENT SAFETY; Patient medications are administered using the five rights: right patient, right medication, right dose, right route and right time."

A review of the CAH's policy titled, "Verbal Orders" approved 01/06/15 stated, "PROCEDURE: ...a VERBAL ORDERS SHALL CONTAIN THE FOLLOWING: o Name of Patient o Date o Time o Prescriber...o Signature of person receiving the order...Authentication of Verbal Order The ordering practitioner must date and time the order when he or she signs the order. They must sign the verbal order as soon as possible which would be the earlier of the following: o The order must be signed within 24 hours of the initial verbal order and the next time the prescribing practitioner provides care to the patient, assesses the patient, or documents information in the patient's medical record."

A review on 01/08/19 of the CAH's undated "Medical Staff Rules and Regulations," showed, "The reasonable physician will authenticate such verbal orders at the next visit or as soon as possible, normally within 24 hours."

In an interview on 01/08/19 at 3:00 PM, with (staff B) Chief Nursing Officer (CNO) and (Staff H) Registered Nurse (RN), they had no explanation for the missing documentation to include times, and/or dates, and/or signatures for verbal or written medication orders or discharge orders and instructions.

Based on medical record review, policy review, Medical Staff Rules and Regulations, and staff interview, the CAH (Critical Access Hospital) staff and/or physicians failed to time, date, or authenticate multiple entries in the medical records in keeping with the accepted standards of practice. Omissions for times, dates, or signatures included medication orders, discharge instructions, and discharge orders for eight of 12 sampled medical records reviewed (Patients 12, 14, 15, 18, 19, 21, 22, and 23). Failure to accurately and completely complete the medical record has the potential for medical errors and omissions and poor follow up care after discharge.

Findings Include:

Medical record review for Patient 12 revealed numerous orders for medications, labs, X-rays, and EKG without a date the orders were written. The same record documented medications administered to Patient 12 i.e. Aspirin 325 mg PO, Morphine 2 mg IV X 1 dose with no time, date or signature of the person giving the drugs and Brillinta (blood thinner)180 mg PO with no date or signature of the person giving the drug as required. The Advanced Practice Registered Nurse (APRN) signed the bottom of the treatment sheet but did not date the entry.

Medical record review for Patient 14 revealed standing pre-printed treatment orders for Group B streptococci (GBS) signed by the Midwife that were dated but not timed. The orders included administration of, "Ampicillin 2 grams IV initially then 1 gram IV every 4 hours until delivery." The Midwife also included standing pre-printed, "Postpartum Labor and Delivery Orders" The form includes a space for the providers signature, date and time. The provider failed to time the orders.

Medical record review for Patient 15 revealed a verbal order (VO) documented by the Registered Nurse (RN) for a Foley catheter on 01/04/18 at 11:45 PM. The VO was not authenticated by the ordering provider until 02/10/18 and did not include the time of authentication. This action is not in compliance with the CAH's policy.

Medical record review for Patient 18 revealed VOs for Calcium Carbonate 500 mg, PO (by mouth) PRN (as needed), Calcium Carbonate 1000 mg PO PRN and Tylenol 1000 mg PO every 6 hours PRN, were entered into the computer on 01/03/19 at 9:17 AM, 9:19 AM and 5:40 AM respectively. As of 01/07/19 at 4:55 PM, the order status was, "Signed: Pending" and had not been authenticated by the ordering provider. This action is not in compliance with the CAH's policy.

Medical record review for Patient 19 revealed discharge instructions written by the APRN that were signed but not dated or timed. There is a place designated at the bottom of this form, "EMERGENCY ROOM * OUTPATIENT RECORD" stating, "PATIENT'S SIGNATURE ON DISCHARGE" and, "DATE - TIME OF DISC" which were blank.

Medical record review for Patient 21 revealed discharge instructions written by the provider that were signed but not dated or timed. There is a place designated at the bottom of this form, "EMERGENCY ROOM * OUTPATIENT RECORD" stating, "PATIENT'S SIGNATURE ON DISCHARGE" and, "DATE - TIME OF DISC" which included Patient 21's signature, but no time or date of discharge. Patient 21's record also showed medication orders for Toradol (non-steroidal anti-inflammatory) 60 mg, no route and Tylenol 1000 mg PO. There was no time or date when the orders were written by the provider and no time or date when the medications were given by the RN.

Medical record review for Patient 22 revealed discharge instructions written by the provider that were signed, but not dated or timed. There is a place designated at the bottom of this form, "EMERGENCY ROOM * OUTPATIENT RECORD" stating, "PATIENT'S SIGNATURE ON DISCHARGE" and, "DATE - TIME OF DISC" which included Patient 22's signature, but no time or date of discharge.

Medical record review for Patient 23 revealed that Patient 23 received the following medications: Phenytoin (treats seizure disorders) 500 mg infusion, Ativan (sedative) 1 mg IV and Decadron (steroid) 12 mg IV. There was no documented date, time, initials, or signature of the person that administered the medications to Patient 23.


A review of the CAH's policy titled, "Verbal Orders" approved 01/06/15 stated, "PROCEDURE: ...a VERBAL ORDERS SHALL CONTAIN THE FOLLOWING: o Name of Patient o Date o Time o Prescriber...o Signature of person receiving the order...Authentication of Verbal Order The ordering practitioner must date and time the order when he or she signs the order. They must sign the verbal order as soon as possible which would be the earlier of the following: o The order must be signed within 24 hours of the initial verbal order and the next time the prescribing practitioner provides care to the patient, assesses the patient, or documents information in the patient's medical record."

A review on 01/08/19 of the CAH's undated "Medical Staff Rules and Regulations," showed, "The reasonable physician will authenticate such verbal orders at the next visit or as soon as possible, normally within 24 hours."

In an interview on 01/08/19 at 3:00 PM, with (staff B) Chief Nursing Officer (CNO) and (Staff H) Registered Nurse (RN), they had no explanation for the missing documentation to include times, and/or dates, and/or signatures for verbal or written medication orders or discharge orders and instructions.