HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to ensure that all facility and medical equipment is listed in an inventory which includes a record of maintenance activities.

Failure to maintain a complete inventory of equipment deemed safe to use and with record of preventative maintenance puts patients and staff at risk of injury or harm.

Findings included:

1. Document review of the hospital's policy titled, "Environment of Care Annual Assessment," PolicyStat ID 10468393, effective 12/12 and approved 12/21, showed that an annual review of all medical equipment will be conducted by Maintenance and that preventative maintenance on equipment is performed and documented.

2. On 01/04/22 between 9:15 and 11:00 AM, Surveyor #4 inspected the Emergency Department (ED) and hospital medical units with the Facilities Director (Staff #401). The surveyor observed the following patient equipment without preventative maintenance stickers:
a. Patient lift, #133287
b. Blanket warmer, #001736
c. Halyard Pain Management Generator, no tag #

3. On 01/05/22 at 10:15 AM, Surveyor #4 conducted a BioMed Equipment Review meeting with Staff #401. Staff #401 confirmed the above listed items were not included in the hospital inventory and did not have documented preventative maintenance.
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Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection report found at Shell 1ELC21.
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Based on interview, medical record review, and review of Medical Staff Bylaws, Rules and Regulations, the hospital failed to ensure that they followed their approved Medical Staff Bylaws for medical records documentation.

Failure to ensure the hospital had processes in place to ensure that healthcare providers are properly documenting places patients at risk for substandard care and adverse outcomes.

Findings included:

1. Review of the Critical Access Hospital's (CAH) document titled, " Medical Staff Bylaws, Rules and Regulations" dated 07/20, showed the following:

a. Medical records are considered delinquent if they remain incomplete for more than 30 days following the patients discharge form the hospital. Incomplete medical record items include missing dictation or reports, such as discharge summaries, history and physicals, and unsigned dictation reports.

b. History and Physical documentation are considered delinquent if not dictated with 24 hours from admission.

c. When possible, authentication should be made at the time of the creation of the record. All authentication must be made within 30 days of the creation of the record.

d. The Providers for whom medical records are delinquent will be notified via written notice that records must be completed within one week from the date which the notice is sent. If the records are not complete within one week, admitting Privileges will be suspended.

2.Review of the Critical Access Hospital's document titled, " Documentation Deficiencies List," no date, showed that 22 patient medical charts dated 03/21 through 09/21 were deficient in documentation.

3. On 01/05/21 at 2:45 PM, Surveyor #10 interviewed the Revenue Cycle Manager (Staff #1014) regarding the deficient documentation. Staff # 1014 confirmed the findings and stated that her team is working on trying to get caught up with the deficiencies and she regularly reports to the executive team.

4.On 01/06/21 at 9:30 AM, Surveyor #10 interviewed the District Superintendent/Hospital Administrator (Staff #1012) about the delinquent medical records. Staff #1012 stated the following:

a. The executive team is aware of the delinquent medical records and are on the disciplinary track for one provider. Staff #1012 stated that it is a delicate path due to the availability of providers being very limited in the rural counties.

b. Surveyor #10 asked Staff #1012 about his role in overseeing the providers. Staff #1012 stated that the providers report directly to him.

c. Review of the organizational chart shows that the medical staff including the Chief of Staff report to the District Superintendent/Hospital Administrator (Staff #1012).

d. Surveyor #10 asked Staff #1012 what evidence the hospital can provide of the Chief Medical Officers involvement in overseeing the providers. Staff #1012 stated the Chief of Medical Officer was not very involved.
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Based on interview and document review, the Critical Access Hospital (CAH) failed to develop and implement policies and procedures for directing the care of pain procedures.

Failure to ensure that policies and procedures for pain procedures are developed and implemented risks inadequate care from potentially contradictory patient care procedures.

Findings included:

1. Document review of the Critical Access Hospital's policies and procedures showed no evidence that policies and procedures were developed and implemented for pain procedures performed at the hospital.

2.On 01/05/22 at 2:30 PM, Surveyor #10 interviewed the Chief Nursing Officer (CNO) (Staff #1010). During the interview, Surveyor #10 requested copies of pre-established policies and procedures for the pain procedures performed at the hospital. The CNO was unable to provide evidence of established policies and procedures for the pain procedures performed at the hospital.
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Based on interview, medical record review for current and discharged patients,the Critical Access Hospital failed meet the requirements for Conditions of Participation for Medical Records.

Failure to maintain complete patient medical records that are readily accessible to healthcare providers involved in patient care impairs the facility's ability to provide quality care in a safe environment.

Findings included:

1.Failure to ensure that patients medical records were accurate, complete and finalized.

Cross Reference C-1102

2.Failure to maintain medical records that were complete for discharge summaries

Cross Reference C-1110

3.Failure to ensure that patient medical records included documentation of a History and Physical

Cross Reference C-1114

4.Failure to ensure that medical providers documented progress notes

Cross Reference C-1116
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Based on interview, record review, review of hospital policy and procedures, and Medical Staff Bylaws, Rules and Regulations, the Critical Access Hospital failed to ensure that patients medical records were accurate, complete and finalized.

Failure to do so creates risk for an inaccurate, unfinalized medical record and a record that can be altered because it was not finalized by the provider. Quality and continuity of care could be compromised based upon the quality of the medical record.

Findings included:

1.Review of the Critical Access Hospital's (CAH) document titled, "Timely Encounter Documentation and Closure," policy # 9904316, last approved 06/21, showed that documentation would be completed at the time of service or shortly thereafter. The reasonable time frame for delayed entry is 24 hours from time of service.

2. Review of the Critical Access Hospital's (CAH) document titled, " Medical Staff Bylaws, Rules and Regulations" dated 07/20, showed the following:

a. Medical records are considered delinquent if they remain incomplete for more than 30 days following the patients discharge form the hospital. Incomplete medical record items include missing dictation or reports, such as discharge summaries, history and physicals, and unsigned dictation reports.

b. History and Physical documentation are considered delinquent if not dictated with 24 hours from admission.

c. When possible, authentication should be made at the time of the creation of the record. All authentication must be made with in 30 days of the creation of the record.

3. Medical record review for 4 patients showed the following:

a. On 01/01/20 Patient #1011 was admitted for a Urinary Tract Infection. The review showed the following:

- The first progress note was documented on 02/20/21, 50 days after the patient was admitted by the Physician Assistant (Staff # 1015).

-The progress note was signed on 10/04/21 at 10:38 AM, 226 days after admission.

b. On 07/02/21 Patient #1027 was admitted for Cerebral Vascular Attack (stroke). The review showed the following:

-An admission note recorded on 07/03/21 at 9:00 AM. The Physician Assistant (Staff # 1015) signed the note on 11/18/21 at 11:56 AM, 139 days after admission.

-A progress note was recorded on 10/05/21 at 8:30 AM and was signed by the Physician Assistant (Staff # 1015) on 01/04/22 at 9:29 AM, 91 days later

-A progress note was recorded on 11/09/21 at 9:00 AM and was signed by the Physician Assistant (Staff # 1015) on 01/04/22 at 9:33 AM, 56 days later.

c. On 05/18/21 Patient #1019 was admitted for status post Coronary Artery Bypass (open heart surgery). The medical record review showed a discharge note was recorded on 05/14/21 at 12:00 PM and signed by the Physician Assistant (Staff # 1015) on 09/24/21 at 10:00 AM, 133 days later.

d. On 04/06/21 Patient #1035 was admitted for Acute and Chronic Heart Failure. The review showed that the admission note was recorded on 04/09/21, three days after the patient was admitted by the Physician Assistant (Staff #1015).

4. On 01/04/21 at 3:00 PM, Surveyor #10 interviewed the Chief Nursing Officer (Staff #1010) regarding the timely documentation by the providers. Staff #1010 confirmed that the documentation had not been completed in a timely manner and stated that the executive team is aware, and they are working on improving it.

5. Surveyor #10 requested a copy of the Critical Access Hospitals chart deficieny list. The review of the Critical Access Hospital's document titled, " Documentation Deficiencies List," no date, showed that 22 patients medical charts dated 03/21 through 09/21 are deficient in documentation. (Patient # 1014, 1016, 1017, 1018, 1020, 1021, 1022, 1023, 1024, 1026, 1028, 1029, 1030, 1031, 1032, 1033, 1034, 1036, 1037, 1038, 1039, and Patient #1040)

6. On 01/05/21 at 2:30 PM, Surveyor #10 interviewed the Revenue Cycle Manager (Staff #1014) regarding the deficient documentation. Staff #1014 confirmed the findings and stated that her team is working on trying to get caught up with the deficiencies and she regularly reports to the executive team.
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Based on interview, record review, and review of the Medical Staff Bylaws, Rules and Regulations, the facility failed to maintain medical records that were complete for discharge summaries for 11 of 30 patients (Patient # 1015, 1018, 1022, 1025, 1026, 1028, 1031, 1032, 1035, 1040 and #1041).

Failure to have discharge summaries impairs communication and continuity of care between health care providers and results in an incomplete medical record.

Findings included:

1. Review of the Critical Access Hospital's (CAH) document titled, " Medical Staff Bylaws, Rules and Regulations" dated 07/20, showed the following:

a. Each medical record shall include a discharge summary with outcome of hospitalization, disposition of case and provisions for follow-up care and final diagnosis.

2. Review of closed medical records showed that 2 of 12 patients were missing discharge summaries (Patient #1015 and #1035).

a. On 09/26/21 Patient #1015 admitted for COVID 19 pneumonia. The review showed that the patient was transferred to a higher level of care on 09/29/21. There was no evidence that a discharge summary was documented.

b. On 04/06/21 Patient #1035 admitted for Acute and Chronic Heart Failure. The review showed that the patient was discharged on 04/07/21. There was no evidence that a discharge summary was documented.

3. Review of the Critical Access Hospital's document titled, " Documentation Deficiencies List," no date, showed that 9 of 30 patients medical records, dated 03/21 through 09/21, are missing discharge summaries (Patient #1018, 1022, 1025, 1026, 1028, 1031, 1032, 1040 and #1041).

4. On 01/05/22 at 10:00 AM, Surveyor #10 interviewed the Chief Nursing Officer (Staff #1010) regarding the missing discharge summaries. Staff #1010 confirmed the missing discharge summaries.

5. On 01/05/22 at 2:55 PM, Surveyor #10 interviewed the Revenue Cycle Manager (Staff #1014) about the deficiency list and the missing discharge summaries. Staff #1014 confirmed that Patients #1018, 1022, 1025, 1026, 1028, 1031, 1032, 1040 and #1041 were missing discharge summaries. Staff #1014 showed Surveyor #10 the follow up emails sent to Physicians, Physician Assistants, the Chief Executive Officer (Staff #1012) and the Chief Nursing Officer (Staff #1010) attempting to correct the deficiencies.
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Based on interview, record review, review of hospital policy and procedures, and Medical Staff Bylaws, Rules and Regulations, the Critical Access Hospital failed to ensure that patient medical records included documentation of a History and Physical for 7 of 11 patients (Patient # 1010, #1011, #1012, #1014, #1015, #1016 and Patient #1019).

Failure to ensure a complete and timely documented History and Physicals puts patient at risk for unrecognized and unmet care needs, and inconsistent and unsafe care due to the lack of complete and accurate information that is readily accessible to hospital personnel.

Findings included:

1. Review of the Critical Access Hospital's (CAH) document titled, " Medical Staff Bylaws Rules and Regulations" dated 07/20, showed the following:

a. A medical history and physical examination must be completed and documented twenty-four hours after admission.

b. The medical history and physical examination must be placed in the patient's medical record with in twenty-four hours after admission.

2. Review of the Critical Access Hospital's (CAH) document titled, "Patient Status Guidelines for Admissions," policy #10191197, last approved 12/21, showed that required documentation includes a provider history and physical.

3. Record review for 7 of 11 patients (Patient # 1010, #1011, #1012, #1014, #1015, #1016 and Patient #1019) showed the following:

a. On 09/08/21 Patient #1010 was admitted for decrease mobility and custodial care. The medical review showed no evidence that a History and Physical was documented.

b. On 01/01/20 Patient #1011 was admitted for a Urinary Tract Infection. The medical record review showed no evidence that a History and Physical was documented.

c. On 11/18/21 Patient #1012 was admitted for Chronic Obstructive Pulmonary Disease, Sepsis. Weakness and Acute Respiratory Failure. The medical record review showed no evidence that a History and Physical was documented.

d. On 11/23/21 Patient #1014 was admitted for Chronic Obstructive Pulmonary Disease, falls and foot fracture. The medical review showed no evidence that a History and Physical was documented.

e. On 09/26/21 Patient #1015 was admitted for COVID 19 pneumonia. The medical record review showed no evidence that a History and Physical was documented.

f. On 09/24/21 Patient #1016 was admitted for hyperkalemia (elevated potassium) and leukocytosis ( elevated white blood cells). The medical record review showed no evidence that a History and Physical was documented.

e. On 05/18/21 Patient #1019 was admitted for status post Coronary Artery Bypass (open heart surgery). The medical record review showed no evidence that a History and Physical was documented.

4. Review of the Critical Access Hospital document titled, " Documentation Deficiencies List," no date, showed that 16 patients medical charts dated 03/21 through 09/21 are missing a History and Physical (Patient # 1017, #1018,1#020, #1021, #1022 ,#1023, #1024, #1025, #1026,#1028, #1029, #1030, #1031,#1032, #1033 and Patient #1034).

5. On 01/04/21 at 3:00 PM, Surveyor # 10 interviewed the Chief Nursing Officer (Staff #1010) regarding the missing history and physicals. Staff #1010 confirmed the missing History and Physicals and stated that there should be a History and Physical recorded for every patient admitted to the hospital.

6. On 01/05/21 at 3:45 PM Surveyor #10 interviewed Revenue Cycle Manager (Staff #1014) about the deficiencies. Staff #1014 confirmed the 16 missing History and Physical and showed Surveyor #10 the follow up emails sent to Physicians, Physician Assistants and Chief Executive Officer (Staff #1012) Chief Nursing Officer (Staff #1010) to correct the missing documentation.
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Based on interview, record review, review of hospital policy and procedures, and Medical Staff Bylaws, Rules and Regulations, the Critical Access Hospital failed to ensure that medical providers documented progress notes for 8 of 30 patients ( Patient # 1010, #1015, #1025, #1035, #1036,#1037, #1038, and #1039)

Failure to ensure progress notes are present in the patient record risks inadequate and/or inappropriate care and treatment during emergencies and on subsequent hospital admissions.

Findings included:

1. Review of the Critical Access Hospital's document titled, " Medical Staff Bylaws, Rules and Regulations" dated 07/20, showed that each medical record shall include all providers orders, reports of treatments, medication records, radiology, laboratory results, vital signs and other information necessary to monitor the patient's condition.

2. Review of the Critical Access Hospital's document titled, " Patient Status Guidelines for admission," policy # 10191197, last approved 12/21, showed that provider progress notes are required for each day of the patient's hospital stay.

3. Medical Record review for 2 of 12 patients (Patient # 1015 and #1035) showed no progress notes recorded during their hospital admission.

a. On 09/26/21 Patient #1015 was for COVID 19 pneumonia. The medical record review showed no evidence of progress notes during her admit and prior to her transfer to a higher level of care on 09/29/21.

b. On 04/06/21 Patient #1035 admitted for Acute and Chronic Heart Failure. The medical record review showed no evidence of any progress notes being documented during the patients admit form 04/06/21-04/07/21.

4. Review of the Critical Access Hospital's document titled, " Documentation Deficiencies List," no date, showed that 6 patients medical charts dated 03/21 through 09/21 had no and/or are missing progress notes (Patient #1010, #1025, #1036, #1037, #1038 and #1039)

5. On 01/05/21 at 10:00 AM, during chart review, Surveyor # 10 interviewed the Chief Nursing Officer (Staff #1010) regarding the missing progress notes. Staff # 1010 confirmed the missing progress notes for Patient's # 1010 and #1035. Staff #1010 stated that progress notes should be completed on a routine basis.

6. On 01/05/21 at 3:45 PM, during document review of the hospital's deficiencies list, Surveyor #10 interviewed the Revenue Cycle Manager (Staff #1014) about the missing progress notes. Staff #1014 confirmed that there are missing and/or no progress notes for Patients # 1010, 1025, 1036, 1037, 1038 and #1039. Staff #1015 showed Surveyor #10 the follow up emails sent to Physicians, Physician Assistants and Chief Executive Officer (Staff #1012) Chief Nursing Officer (Staff #1010) attempting to correct the deficiencies.
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Based on observation, document review, and interview, the Critical Access Hospital (CAH) failed to implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer expiration date.

Failure to follow a systematic process for ensuring patient care supplies do not exceed their expiration date risks deteriorated or potentially contaminated supplies being available for patient care.

Findings included:

1. Document review of the hospital's policy titled, "Outdated Supply Disposal," PolicyStat ID 6797547, approved 09/19, showed that outdated items will be disposed of.

2. On 01/05/22 at 12:40 PM, Surveyor #4 observed the Radiology/Imaging area of the hospital. The observation showed 2 bottles of MediChoice Ultrasound Gel with an expiration date of 01/20.

3. At the time of the observation Surveyor #4 asked the CT Technician (Staff #404) about the expired ultrasound gel. Staff #404 stated the bottles should have been discarded and would dispose of the items.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop and maintain an emergency preparedness plan that is evaluated and updated at least every 2 years per CMS (Center for Medicare and Medicaid) Appendix Z emergency preparedness requirements.

Failure to develop and maintain an emergency preparedness plan that is evaluated and updated at least every 2 years risks patient harm related to an emergency plan that does not meet the needs of patients.

Findings included:

1. Document review of the hospital's Emergency Preparedness Plan titled, "EARH Emergency/Disaster Response Plan," PolicyStat ID 4990722, last approved 05/19, showed that the plan was last revised 01/18 and expired 05/20.

2. On 01/05/22 at 11:30 AM, Surveyor #4 interviewed and reviewed the hospital's emergency response plan with the hospital's Facilities Maintenance Manager (Staff #401). Staff #401 confirmed the emergency plan provided was last revised on 01/18 and expired on 05/20. Staff #401 stated an updated plan is currently being reviewed by management.
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Based on interview and document review the Critical Access Hospital (CAH) failed to include in the Emergency Disaster/Response Plan a process to cooperate and collaborate with agencies to assure an integrated response to an emergency.

Failure to prepare an integrated response could result in a less effective response to an emergency causing a delay and an inability to provide patient care.

Findings Included:

1. Document review of the hospital's Emergency Preparedness Plan titled, "EARH Emergency/Disaster Response Plan," PolicyStat ID 4990722, last approved 05/19, showed no planned or ongoing activities with local, tribal, regional, state, and federal agencies to maintain a cooperative and collaborative response to an emergency.

2. On 01/05/22 at 11:30 AM, Surveyor #4 interviewed and reviewed the hospital's emergency response plan with the hospital's Facilities Maintenance Manager (Staff #401). Staff #401 was unable to provide policy and procedures for cooperation and collaboration efforts as required in CMS regulation.

3. On 01/06/22 at 8:00 AM, Staff #401 stated he had discussed the missing elements of the Emergency Preparedness Plan with the hospital safety officer who was out sick and confirmed these policies and procedures are missing from the provided emergency plan.
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Based on document review and interview, the Critical Access Hospital (CAH) failed to develop policies and procedures for the hospital's emergency preparedness plan to include provisions for food, water, medical and pharmaceutical supplies for patient, staff, and visitors in an event of an emergency.

Failure to provide provisions for subsistence needs, places patients, staff, and visitors at risk of harm during an emergency event.

Findings included:

1. Document review of the hospital's Emergency Preparedness Plan titled, "EARH Emergency/Disaster Response Plan," PolicyStat ID 4990722, last approved 05/19, showed no provisions for food, water, medical supplies and pharmaceuticals.

2. On 01/05/22 at 11:30 AM, Surveyor #4 interviewed and reviewed the hospital's emergency response plan with the hospital's Facilities Maintenance Manager (Staff #401). Staff #401 was unable to provide policy and procedures for provisions for food, water, medical supplies and pharmaceuticals as required in CMS regulation.

3. On 01/06/22 at 8:00 AM, Staff #401 stated he had discussed the missing components of the Emergency Preparedness Plan with the hospital safety officer who was out sick and confirmed these policies and procedures are missing from the provided emergency plan.
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Based on interview and document review, the hospital failed to identify contact information for Federal, State, tribal, regional, and local emergency preparedness staff or other sources of assistance for use in the event of an emergency as per CMS (Center for Medicare and Medicaid Services) Appendix Z emergency preparedness requirements.

Failure to develop a communication plan including contact information for official agencies for use in an emergency, places patients, staff, and the community at risk of harm due to ineffective communication.

Findings included:

1. Document review of the hospital's Emergency Preparedness Plan titled, "EARH Emergency/Disaster Response Plan," PolicyStat ID 4990722, last approved 05/19, showed no contact information for outside agencies as required.

2. On 01/05/22 at 11:30 AM, Surveyor #4 interviewed and reviewed the hospital's emergency response plan with the hospital's Facilities Maintenance Manager (Staff #401). Staff #401 confirmed the emergency plan provided did not include outside agency contact information.

3. On 01/06/22 at 8:00 AM, Staff #401 stated he had discussed the missing elements of the Emergency Preparedness Plan with the hospital safety officer who was out sick and confirmed these policies and procedures are missing from the provided emergency plan.
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