HospitalInspections.org

Based on policy review, medical record review and interview the facility failed to ensure staff:
- Completed a History and Physical (H&P), within 30 days of two surgical procedures (#28 and #33) of four reviewed.
- Completed informed consents for two surgical procedures (#31 and #33) of four reviewed.
- Performed one full patient assessment (#31) prior to a surgical procedure of four reviewed. These failures had the potential to affect the quality of care for all patients that presented for surgical procedures. The facility census was five Acute Care patients, one Swing Bed patient, and two Observation patients for a total census of eight.

Findings included:

1. Review of the hospital's bylaws, last reviewed 05/23/19, showed that failure to complete an H&P shall render the medical record incomplete and if a complete H&P has been recorded not more than 30 days prior to the procedure, a durable, legible copy of the report may be used in the patient's record.

2. Review of Patient #28's medical record dated 06/19/23, showed Staff AA, Gynecologist, failed to provide a date and time of signature that showed the completion of the H&P in a timely manner prior to a total hysterectomy (the removal of the entire uterus and the cervix).

3. Review of Patient #33's medical record dated 07/10/23, showed Staff Y, Gastrointestinal (GI) Physician, failed to provide a date and time of signature that showed the completion of the H&P in a timely manner prior to an Esophagogastrodueodenoscopy (EGD, a test to examine the lining of the esophagus, stomach and first part of the small intestine) procedure.

4. Review of the facility's policy titled, "Informed Consents," last reviewed on 02/2023, showed that the consent for surgical treatment may be obtained by the physician to explain the procedure, risks, benefits and alternatives associated with the procedure or operation.

5. Review of Patient #31's medical record dated 06/12/23, showed Staff Y, GI Physician, failed to provide a date and time of signature that showed the completion of the informed consent to perform the procedure and failed to document a pre-operative assessment.

6. Review of Patient #33's medical record dated 07/10/23, showed Staff Y, GI Physician, failed to provide a date and time of signature that showed the completion of the informed consent to perform the procedure.

7. During an interview on 09/09/23 at 11:30 AM, Staff BB, Director of Surgical Services, stated the physicians should have signed and dated the H&P's, informed consents and the assessments.

Based on record review and interview the facility failed to ensure privileges requested by supervising physicians included administration of anesthesia by Certified Registered Nurse Anesthetists (CRNA) for one (#1) of one credentialing packets for surgeons reviewed. The facility census was five Acute Care patients, one Swing Bed patient, and two Observation patients for a total census of eight.

Findings included:

1. Review of Staff #1, surgeon, credentialing file showed that the privilege for supervision of CRNA's was not selected.

2. Review of the facility's policy titled, "Rules and Regulations for Medical Staff," dated 12/15/22, showed when the operating/anesthesia team consists of non-physicians, a physician shall be immediately available in case of an emergency, such as cardiac standstill or cardiac arrhythmia and the health system permits physicians to supervise a CRNA administering anesthesia for outpatient procedures performed in an Ambulatory Surgical Center setting.

3. During an interview on 08/08/23 at 3:15 PM, Staff M, Credentialing stated the CRNA is under the supervision of the anesthesiologist at the facility in Joplin. The medical staff rules and regulations addressed the supervision of the CRNA but only for the ambulatory surgical setting.

4. During an interview on 08/09/23 at 11:10 AM, Staff E, Chief Operating Officer stated there are four surgeons at the facility.

Based on policy review, record review and interview the facility failed to develop a comprehensive activity care plan that provided specific individualized activity interest and interventions to stimulate the patient's physical and mental well-being for one current Swing Bed (Swing Bed - a Medicare program in which a patient can receive acute care services, then if needed Skilled Nursing Home Care) patient (#6) and for three discharged Swing Bed patients (#14, #15, and #16) reviewed for a comprehensive quality of life activities care plan.
This failed practice had the potential to affect all Swing Bed patients by failing to stimulate their minds, body and social interests. The facility census was five Acute Care patients, one Swing Bed patient, and two Observation patients for a total census of eight.

Findings included:
1. Review of the facility's policy titled, "Resident's Rights," dated 06/29/22, showed staff directive: The resident is involved in the assessment and care planning process and is allowed choices based on information given.

Review of the facility's policy titled, "Documentation Guidelines," dated 03/08/22, showed staff directives for Nursing Plan of Care:
- Initiated when admission assessment completed;
- Identify problem list;
- Goals identified and reviewed with patient/family input;
- Physiological, psychosocial, emotional and educational factors included;
-Revised with needs of patient;
- RN (Registered Nurse) will review and update the Plan of Care every shift, completing/inactivating interventions as appropriate and documenting Outcomes as Met, Partially Met, or Not Met. Some outcomes may have identified unique assessments to document the status of the outcome; and
- Review Plan of Care each shift for revisions and updating.

2. Review of Patients' Electronic Medical Health Records (EMHR) showed:
- Patient #6 was admitted to the facility's Swing Bed program on 08/04/23, for left leg fracture, weakness and hypertension (high blood pressure);
- Patient #14 was admitted to the facility's Swing Bed program on 07/06/23, for left hip fracture and weakness;
- Patient #15 was admitted to the facility's Swing Bed program on 05/04/23, for metabolic acidosis (buildup of acid in the body due to either kidney disease or kidney failure); and
- Patient #16 was admitted to the facility's Swing Bed program on 06/28/23 for fractured ribs.

Patient #6's, #14's, #15's and #16's EMHR showed staff failed to develop a comprehensive activity plan of care for the patients during their stay in the facility's Swing Bed program.

3. During an interview on 08/08/23 at 9:47 AM, Staff S, Social Services, Swing Bed Coordinator, stated she performed an activity assessment on all patients admitted to the facility's Swing Bed program, however, Staff S stated she did not include activities in the Swing Bed patients' Plan of Care.