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Based on observation, interview, and record review, the facility failed to ensure the three and two hour barriers separating buildings were free of penetrations, to ensure each corridor door with self-closing and latching hardware closed and latched the door, to ensure the rated, protective construction surrounding its stairways were free of penetrations, to ensure access to exits were clearly marked by approved, readily visible signs and doors likely to be mistaken for an exit had a sign designating they were not an exit, failed to ensure penetrations in smoke barriers were properly sealed, to ensure its doors located in rated barriers self-closed and where installed with latching hardware, latched, to ensure penetrations in construction protecting hazardous areas were sealed and doors self closed, to ensure its corridors were free and clear of paraphernalia, to include a transmission of a fire alarm signal during each of its fire drills, to ensure its sprinkler system complied with NFPA 25, 1999 edition, and to ensure its emergency electrical system complied with NFPA 99, 1999 edition. (C 231)

Based on observation, interview, and record review, the facility failed to ensure it complied with the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association, 101, issued January 14, 2000. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 22 patients.

Findings include:

K11 Failed to ensure the three and two hour barriers separating buildings were free of penetrations

K18 Failed to ensure each corridor door with self-closing and latching hardware closed and latched the door.

K20 Failed to ensure the rated, protective construction surrounding its stairways were free of penetrations.

K22 Failed to ensure access to exits were clearly marked by approved, readily visible signs and doors likely to be mistaken for an exit had a sign designating they were not an exit

K25 Failed penetrations in smoke barriers were properly sealed

K27 Failed to ensure its doors located in rated barriers self-closed and where installed with latching hardware, latched

K29 Failed to ensure penetrations in construction protecting hazardous areas were sealed and doors self closed

K39 Failed to ensure its corridors were free and clear of paraphernalia.

K50 Failed to include a transmission of a fire alarm signal during each of its fire drills.

K62 Failed to ensure its sprinkler system complied with NFPA 25, 1999 edition.

K106 Failed to ensure its emergency electrical system complied with NFPA 99, 1999 edition.

Based on review of the Medical Staff Bylaws, medical record review, and staff interview; the facility failed to ensure timely documentation of History and Physicals and Operative Reports. This affected two of 21 medical records reviewed (Patients #10 and #11). The facility census was 22.


Findings include:


Review of the Medical Staff Bylaws approved by the Board of Governors revealed a complete History and Physical (H&P) was to be dictated or written no more than seven days prior to admission or 24 hours after admission. Operative reports would be dictated immediately following surgery and will be authenticated by the surgeon after transcription.


1. Review of the medical record for Patient #10 revealed an admission date of 08/03/16. The medical record lacked documentation of an H&P as of 08/25/16. This finding was verified on 08/25/16 at 9:45 AM by Staff E.


2. Review of the medical record for Patient #11 revealed an admission date of 08/18/16. The patient had a left proximal total nailing of the hip on 08/19/16 after a fall at home. The medical record contained an operative note dictated on 08/22/16. This finding was verified on 08/25/16 at 9:45 AM by Staff E.

Based on staff interview, medical record review, and review of policies and procedures, it was determined the critical access hospital failed to ensure a physician's order was written for nursing interventions (C294) failed to ensure medication orders were signed by a physician (C297) failed to ensure care plans were appropriate to each patient's diagnoses (C0298) and therapy services frequency and duration were signed by a physician (C299). This cumulative effect of these systemic practices resulted in the hospital's inability to ensure the safe delivery of healthcare. The active census was 22.

Based on review of the medical record and staff interview, the facility failed to have physician orders for all nursing interventions provided. This affected one of 21 medical records reviewed (Patient #8). The facility census was 22.


Findings include:


Review of the medical record for Patient #8 revealed an admission date of 08/19/16. The medical record contained documentation that nursing was cleansing the patient's hip incision with Betadine and covering it with a Mepore dressing. In addition nursing documented the patient was on oxygen two liters per nasal cannula from 08/19/16 through 08/22/16. The medical record lacked documentation of orders for wound care or oxygen use.


This finding was verified on 08/25/16 at 9:45 AM by Staff E. Staff E stated an order for the dressing change and oxygen use should have been documented.

Based on medical record review, staff interview, and review of the medical staff bylaws it was determined nursing staff failed to ensure a valid physician's order was written prior to administration of medications. This affected one (Patient #5) of twenty one medical records reviewed. The active census was 22.


Findings include:


Review of the Medical Staff ByLaws approved by the Board of Governors states standing orders may be formulated by individual practitioners on the Medical Staff. A copy of these orders will be placed in the patient's chart on order of the attending practitioner and signed by the practitioner.



Review of the medical record for Patient #5 revealed the infant was born on 08/21/16 to the Labor/Delivery unit without complications. Nursing documentation revealed Vitamin K 1 mg was administered intramuscularly and the Erythromycin 0.5 cm ribbon was applied to both eyes following a vaginal delivery.


Routine newborn orders include Aquamephyton (Vitamin K) 1 mg intramuscularly once and Erythromycin ophthalmic ointment 0.5 cm to both eyes once. Staff A confirmed on 08/24/16 at 12:45 PM both medications were administered without a written physician's order.


Staff A stated in an interview on 08/25/16 at 1:22 PM the staff nurse is required to enter the standing newborn protocol into the electronic health record and the physician is to sign off on the order.

Based on policy review, staff interview, and medical record review; the facility failed to ensure care plans were complete with all diagnoses and interventions based on assessment of patient condition. This affected three (Patients #5,#11 and #17) of twenty one medical records reviewed. The active census was 22.


Findings include:

Review of the "Nursing Care Plans" policy revealed nursing care plans would be implemented upon admission according to the patient's nursing diagnoses and assessment. Care plans would be individualized and updated based on the response to nursing assessments.


During interview on 08/22/16 at 3:30 PM, Staff D and E stated the nurses are required to have at least one diagnosis on the care plan and chart against that at least every 24 hours.

1. Review of the medical record for Patient #11 revealed an admission date of 08/18/16. The patient had a left proximal total nailing of the hip on 08/19/16 after a fall at home. The History & Physical (H&P) dated 08/18/16 documented a left intertrochanteric fracture, a urinary tract infection, hyponatremia, hypothyroidism, meneiere's disease, chronic kidney disease, osteoarthritis, urge incontinence, gastroesophageal reflux disease, high blood pressure, and memory loss. The patient had transfusions of four units of packed red blood cells, incentive spirometrey four times a day, and physical and occupational therapy.

The care plan created on 08/18/16 was for acute pain with interventions of analgesic administration, anxiety reduction, and bed rest. The care plan lacked additional diagnosis or areas of care or additional interventions. This finidng was verified on 08/25/16 at 9:45 AM by Staff E.


2. Review of the medical record for Patient #5 revealed the newborn was delivered by vaginal birth on 08/21/16 weighing 5 lbs. 11 oz. The patient's apgars were 8/9 at one and five minutes following birth.

Review of the care plan revealed a nursing diagnosis with interventions for breastfeeding. The care plan lacked all appropriate newborn care interventions for a small for gestational age infant. This finding was confirmed with Staff F on 08/25/16 at 2:50 PM.


3. Review of the medical record for Patient #17 revealed an admission date of 08/20/16. The H&P dated 08/21/16 documented the patient had a laproscopic ventral hernia repair the previous week and had a history of chronic lung disease, heart disease, cerebral vascular disease, high blood pressure, obstructive sleep apnea, osteoarthritis, and osteoporosis. The patient was admitted for pain control and dehydration. The patient was receiving physical and occupational therapy.

The care plan created on 08/20/16 was for risk of injury with interventions for allergy management, energy management, and fall prevention. The care plan created 08/23/16 was for risk for deficient fluid volume with interventions of electrolyte monitoring and fluid management. The care plan created 08/24/16 was for risk for falls with the intervention of fall prevention. The care plan lacked additional diagnosis or areas of care or additional interventions. This finding was verified on 08/25/16 at 9:45 AM by Staff E.

Based on policy review, staff interview, and medical record review; the facility failed to ensure therapy services had a frequency and duration ordered by a physician. This affected two (Patients #11 and #17) of twenty one medical records reviewed. The active census was 22.


Findings include:


Review of the "Physical Therapy" policy revealed inpatient therapy services would be provided per physician orders. The physician order should include the frequency and duration of therapy.


During interview on 08/24/16 at 11:00 AM, Staff G stated that for inpatient therapy evaluation orders for the frequency and duration of services would be entered into the electronic medical record for physician signature or the physician would need to sign the therapy evaluation and plan of treatment form. Staff G stated he/she was not aware this was not happening currently.


1. Review of the medical record for Patient #11 revealed an admission date of 08/18/16. The patient had a left proximal total nailing of the hip on 08/19/16 after a fall at home. The medical record contained orders dated 08/19/16 for physical and occupational therapy to evaluate and treat. The medical record contained documentation of a physical therapy evaluation dated 08/20/16 with the recommendation to treat the patient one to two times per day for six to seven days per week. The medical record contained an occupational therapy evaluation dated 08/22/16. No additional therapy orders were documented, however, therapy was provided per the therapists recommendations. This finding was verified on 08/25/16 at 9:45 AM by Staff E.


2. Review of the medical record for Patient #17 revealed an admission date of 08/20/16. The medical record contained orders dated 08/20/16 for physical and occupational therapy to evaluate and treat. The medical record contained documentation of a physical therapy evaluation dated 08/21/16 with the recommendation to treat the patient one to two times per day for five to six days per week. The medical record contained an occupational therapy evaluation dated 08/22/16 with the recommendation to treat the patient one to two times per day for five days per week. No additional therapy orders were documented, however, therapy was provided per the therapists recommendations. This finding was verified on 08/25/16 at 9:45 AM by Staff E.

Based on policy review, staff interview, and medical record review; the facility failed to ensure care plans were complete with all diagnoses and interventions based on assessment of patient condition with input from all disciplines involved. This affected three of three swing bed medical records reviewed (Patients #8, #9, and #10). The facility census was three swing bed patients.


Findings include:


Review of the "Nursing Care of Swing Bed Patients" policy revealed a nursing care plan will be developed based on the diagnosis for swing bed admission. All departments involved in the patient's care will have input into the care plan including the patient and family. The care plan will be updated weekly with input from all disciplines.


During interview on 08/22/16 at 3:30 PM, Staff D and E stated the nurses are required to have at least one diagnosis on the care plan and chart against that at least every 24 hours.


1. Review of the medical record for Patient #8 revealed an admission date of 08/19/16 as a swing bed patient. The History & Physical (H&P) dated 08/16/16 documented the patient fell at home and fractured his/her right hip and right elbow. The patient also had mitral valve prolapse, osteoarthritis, osteoporosis, high blood pressure, and hyperlipidemia. The patient had surgery on 08/17/16 for a hip nailing to repair the fracture. The patient also had physical and aoccupational therapy.

The care plan created 08/19/16 was for risk for infection with an intervention of incision site care. The care plan lacked additional diagnosis or areas of care or additional interventions. The care plan lacked interventions by all staff involved in the patient's care. This finding was verifed on 08/25/16 at 9:45 AM by Staff E.


2. Review of the medical record for Patient #9 revealed an admission date of 08/18/16 as a swing bed patient. The H&P dated 08/12/16 documented the patient had diabetes, high blood pressure, coronary arteriosclerosis, acid reflux, and was scheduled for a left total knee replacement due to severe osteoarthritis. The patient had the left knee replacement on 08/15/16. The patient received a transfusion of two units of packed red blood cells, an ultrasound to rule out a blood clot due to extreme pain in the left leg which was negative, was on a blood thinner, and received physical and occupational therapy.

The care plan listed activity intolerance with interventions of assisting with activities of daily living, energy management and exercise promotion. The care plan lacked any additional diagnosis or areas of care or any additional interventions. This finding was verifed on 08/25/16 at 9:45 AM by Staff E.


3. Review of the medical record for Patient #10 revealed an admission date of 08/03/16. The medical record contained documentation the patient was admitted for weakness, a uringary tract infection, high blood pressure, and benign prostatic hypertrophy. The patient was receiving physical and occupational therapy, and had a foley catheter. The care plan listed activity intolerance with interventions of activity therapy and exercise promotion. The care plan lacked additional diagnosis or areas of care or additional interventions. This finding was verifed on 08/25/16 at 9:45 AM by Staff E.

Based on policy review, staff interview, and medical record review; the facility failed to ensure therapy services had a frequency and duration ordered by a physician. This affected three of three swing bed medical records reviewed (Patients # 8, #9, and #10). The facility census was three swing bed patients.


Findings include:


Review of the "Physical Therapy" policy revealed inpatient therapy services would be provided per physician orders. The physician order should include the frequency and duration of therapy.


During interview on 08/24/16 at 11:00 AM, Staff G stated that for inpatient therapy evaluation orders for the frequency and duration of services would be entered into the electronic medical record for physician signature or the physician would need to sign the therapy evaluation and plan of treatment form. Staff G stated he/she was not aware this was not happening currently.


1. Review of the medical record for Patient #8 revealed an admission date of 08/19/16. The medical record contained orders dated 08/19/16 for physical and occupational therapy to evaluate and treat. The medical record contained documentation of a physical therapy evaluation dated 08/19/16 with the recommendation to treat the patient one to two times per day for six to seven days per week for six weeks. The medical record contained an occupational therapy evaluation dated 08/19/16 with the recommendation to treat the patient two times per day, five days per week for six weeks. No additional therapy orders were documented, however, therapy was provided per the therapists recommendations. This finding was verified on 08/25/16 at 9:45 AM by Staff E.


2. Review of the medical record for Patient #9 revealed an admission date of 08/18/16. The medical record contained orders dated 08/18/16 for physical and occupational therapy to evaluate and treat. The medical record contained documentation of a physical therapy evaluation dated 08/19/16 with the recommendation to treat the patient one to two times per day for six to seven days per week for three weeks. The medical record contained an occupational therapy evaluation dated 08/19/16 with the recommendation to treat the patient two times per day, five days per week for four weeks. No additional therapy orders were documented, however, therapy was provided per the therapists recommendations. This finidng was verified on 08/25/16 at 9:45 AM by Staff E.


3. Review of the medical record for Patient #10 revealed an admission date of 08/03/16. The medical record contained orders dated 08/03/16 for physical and occupational therapy to evaluate and treat. The medical record contained documentation of a physical therapy evaluation dated 08/03/16 with the recommendation to treat the patient one to two times per day for five to six days per week for two to four weeks. The medical record contained an occupational therapy evaluation dated 08/03/16 with the recommendation to treat the patient two times per day, five days per week for four weeks. No additional therapy orders were documented, however, therapy was provided per the therapists recommendations. This finding was verified on 08/25/16 at 9:45 AM by Staff E.