HospitalInspections.org

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to periodically check all personnel who are regularly exposed to radiation for the level of radiation exposure.

Findings include:

Review on 7/10/24 of the Dosimetry Badge reports for 2024 revealed that the report did not have Dosimetry Badge results for the orthopedic surgeons that worked in the operating room.

Interview on 7/10/24 at approximately 10:30 a.m. with Staff A (Director of Medical Imaging) confirmed the above findings. Further interview with Staff A revealed that the orthopedic surgeons that worked in the operating room did not have Dosimetry Badges.

Interview on 7/11/24 at approximately 1:30 p.m. with Staff B (Director of Surgical Services) revealed that the orthopedic surgeons utilize the C-arm when they perform surgeries on patient's with fractures, total hip replacements, and pain procedures performed in the operating room. Staff B confirmed that the orthopedic surgeons did not have Dosimetry Badges.

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to have accurate records for 1 of 20 patients reviewed for inpatient records (Patient Identifier #6).

Findings include:

Review on 7/11/24 of Patient #6's physician's orders revealed an order for Full Code dated 7/3/24. Further review of Patient #6's physician's orders revealed an order for Do Not Resuscitate (DNR) signed by Staff D (Medical Doctor) on 7/6/24.

Review on 7/11/24 of Patient #6's physician's progress notes completed by Staff D revealed under Assessment/Plan that "Full Code" was documented on 7/6/24, 7/7/24, 7/8/24, 7/9/24, 7/10/24. Further review of the progress notes revealed no additional documentation regarding Resident #6's code status.

Review on 7/11/24 of Patient #6's medical record, including advanced directives, case manager notes, and nursing notes revealed no documentation regarding Resident #6's change in code status.

Interview on 7/11/24 at 11:45 a.m. with Staff E (Director of Acute Care) confirmed that there was no additional documentation for Patient #6's DNR status.

Interview on 7/11/23 at 2:45 p.m. with Staff F (Chief Medical Officer) revealed that Patient #6's above progress notes should have reflected the updated DNR status.

Review on 7/11/24 of the facility's 5/18/07 policy titled "Advanced Directives" revealed: "... 6. If a patient is capable of making decisions, then the patient's expressed preferences and decisions...should direct the patient's care plan. The patient has the right to clarify, modify, or revoke an Advance Directive at any time. If this occurs, changes need to be documented in the medical record..."