HospitalInspections.org

Based on policy review, document review, state law and regulation review, and interview, the Critical Access Hospital (CAH) failed to ensure nursing policies and procedures were available and implemented with the nursing staff affecting 4 (Patient 1, 3, 4, and 5) of 5 patients reviewed. This deficient practice has the potential to affect all patients and may lead to harm or other adverse outcomes.

Findings Include:

Review of Kansas regulation §28-34-7 (g) Nursing policies and procedures. Nursing care policies and procedures shall be in writing and consistent with generally accepted practice and shall be reviewed and revised as necessary.

Review of the CAH's policy titled, "Scope of Service Rehabilitation Services," dated 08/03/22, showed "Speech therapy services also include the care and services provided by a Speech Therapist (ST) including, but not limited to fluency, speech production, language, cognition, voice, resonance, feeding and swallowing, and auditory habilitation and rehabilitation."

Patient 1

Review of Patient 1's medical record showed that Patient 1 was admitted on 12/23/22 at 10:43 AM for the treatment of congestive heart failure (CHF, a progressive heart disease that affects pumping action causing fatigue and shortness of breath) and respiratory syncytial virus (RSV, a viral infection of the respiratory tract that causes mild flu-like symptoms).

Review of Patient 1's medical record showed that Patient 1's vital signs and pain were not assessed every four hours as per interview, for acute care patients.

The hospital failed to provide a policy for vital signs or a policy for pain assessments and management.


Patient 3

Review of Patient 3's medical record showed that Patient 3 was admitted on 11/20/22 at 9:51 for the care and treatment of bilateral cellulitis (infection of the skin on both sides) of the lower extremities. Patient 3 was placed on sepsis protocol (the body's extreme response to an infection). Patient 3 has been diagnosed with type 2 diabetes mellitus (when the body does not control the amount of glucose in the blood), morbid obesity (a chronic condition in which a person has a body mass index of 40 or higher), and lymphedema (swelling due to build-up of lymph fluid in the body).

Review of Patient 3's medical record showed that Patient 3 fell on 11/23/22 during a transfer from a recliner to the bed caused by slipping in the fluid draining from his leg wounds.

The hospital failed to provide a policy for transfers, weight limits, or special care for bariatric patients or wound care.

Review of Patient 3's medical record showed that Patient 3 experienced high and low glucose levels (blood sugar below 70 is considered low and higher than 100 is considered a high.

The hospital failed to provide a policy for diabetes management.

Review of Patient 3's care plan showed that Patient 3 had "nutritional imbalance r/t [related to] swallowing difficulty.

The hospital failed to provide a policy for bedside swallow screening or altered diets.

Review of Patient 3's medical record showed that Patient 3 was using a CPAP (continuous positive airway pressure) machine (device for treating sleep apnea, pauses or stopping of breathing).

The hospital failed to provide a policy for the setup or inspection of patient owned CPAP machines.

Review of Patient 3's medical record showed that Patient 3 was not assessed for pain every four hours, as per interview, for acute care patients. Patient 3 was not assessed regularly for pain relief after receiving pain medication.

The hospital failed to provide a policy for pain assessments and management.

Review of an email dated 01/18/23 at 4:46 PM, Staff B, Risk Manager (RM), wrote, "We don't have a specific policy just for transfers, but this gait belt policy speaks to them. Our on-staff speech therapist performs our bedside swallow studies and many other services, she's housed in the Rehabilitation Services department and this policy speaks to their scope of service.


Patient 4

Review of Patient 4's medical record showed that Patient 4 was admitted on 01/11/23 after reporting dyspnea (an intense tightening in the chest, difficulty breathing) and atrial fibrillation (heart racing or beating irregularly). Patient 4 has a history of degenerative joint disease of shoulders and knees, CHF,

Review of Patient 4's medical record showed that Patient 4 was not assessed for pain every four hours, per interview, for acute care patients.

The hospital failed to provide a policy for pain assessments and management.


Patient 5

Review of Patient 5's medial record showed that Patient 5 was admitted on 10/31/22 due to aggressive behaviors toward housemates after using amphetamine (a stimulant that affects the chemicals in the brain and nerves that contribute to hyperactivity and impulse control) and marijuana (cannabis). Patient 5 has an extensive mental health history.

Review of Patient 5's medical record showed that Patient 5 was provided Tylenol (a medication used to treat fever and pain) several times and failed to follow up on the effectiveness of the medication in a timely manner (usually an hour per nursing standards).

The hospital failed to provide a policy for pain assessments and management.

During an interview on 01/20/23 at 9:07 AM, Staff H, Chief Nursing Officer (CNO), stated that she realized they did not have a policy on pain assessments. Staff H stated that there is no policy that addresses when or how vital signs are to be obtained. Staff H stated that patients in the ED and acute care have their vitals assessed every four hours. Staff H acknowledged that nursing policies and procedures were lacking and that she needed to work on that.

Based on policy review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure appropriate nursing care for pain management, reassessment after as needed (PRN) medications are administered, and blood sugar control for 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5). This deficient practice has the potential to place patients at risk for ineffective pain management and blood sugar control which could cause harm, or other adverse outcomes.

Findings Include:

Review of the CAH's document titled, "Job Description," for the Chief Nursing Officer (CNO), dated 10/2020, showed, "The CNO is responsible for all day-to-day activities consistent with providing optimal patient care.

Review of the CAH's policy titled, "Documentation," dated 06/06/22 showed, "Vital signs will be obtained and recorded per provider and/or nursing order. The following measurable data will be collected and recorded as vital signs: temp, heart rate, respirations, systolic B/P [ventricle force of blood being pumped out of the heart], diastolic B/P [heart at rest between beats], B/P location [extremity], B/P position, SPO2% [oxygen in blood], O2 [oxygen] delivery mode [room air, nasal cannula or mask], height, weight, and pain scale rating [how would you rate your pain on average?" is scored on a 0 to 10, in which 0 [is] no pain and 10 [is] worst imaginable pain]."

Review of www.wongbakerfaces.org showed that the "Wong-Baker Faces Pain Rating Scale," is a set of faces, also known as the "1 through 10 scale." The scale goes from 0, no hurt; 2, hurts a little bit; 4, hurts little more; 6, hurts even more; 8, hurts whole lot; and 10, hurts worst. The scale was developed to improve assessment so that pain management can be addressed.

Review of the CAH's policy titled, "Medication Management," dated 08/09/22, showed, "the effect of the PRN (as needed) medication on the patient must be documented in the medical record. PRN orders should be written to include the symptoms or indication for use . . . unless there is only one use for the medication.

Review of the CAH's "Nursing Unit Meeting Minutes," dated 08/26/22, showed "Be sure that if you are unable to get routine VS on an inpatient make sure to let the patient's nurse know so that she can obtain them. It is imperative that we get vital signs as ordered."

During an interview on 01/19/23 at 10:31 AM, Staff D, RN, stated that vital signs are completed every four hours for acute care patients and as needed. Staff D stated that vitals include temp, pulse, respiration, blood pressure, oxygen saturation, pain, and initial vitals would include height and weight. Staff D stated that a pain assessment would be more in depth if the patient was admitted to care for pain, but that typically she did not go into depth with it, just the 1-10 pain scale. Staff D stated that after a PRN (as needed) pain medication was provided to the patient she would check on the patient in thirty minutes to an hour and contact the provider for further orders if needed.


Patient 1

Review of Patient 1's medical record showed that Patient 1 was admitted on 12/23/22 at 10:43 AM to Acute Care Services for the treatment of congestive heart failure (CHF, a progressive heart disease that affects pumping action of the heart muscles causing fatigue and shortness of breath) and respiratory syncytial virus (RSV, a viral infection of the respiratory tract that causes mild flu-like symptoms).

Patient 1 was admitted to Acute Care Services where vital signs and pain are to be assessed every four hours, per interview with Staff D on 01/19/23 at 10:31 AM, for acute care patients. The hospital could not provide a policy for pain assessment or management.

Review of Patient 1's "Nursing Orders" and "Physician Entered Orders" showed that Patient 1 did not have an order for vital signs.

Review of Patient 1's "Nursing Physical Assessment," dated 12/24/22 at 8:34 AM, showed that Staff I, Registered Nurse (RN), failed to assess Patient 1 for pain.

Review of Patient 1's "Nursing Physical Assessment," dated 12/27/22 at 8:22 AM, showed that Staff I, RN, failed to assess Patient 1 for pain.

Further review of Patient 1's medical record showed that vital signs were not documented every four hours as required for acute care patients and that pain was not assessed every four hours:

On 12/23/22 at 6:30 PM, Staff L, RN, assessed Patient 1's vital signs more than six hours from the previous assessment. Staff L failed to assess Patient 1 for pain.

On 12/23/22 at 10:28 PM, Staff L, RN, failed to assess Patient 1 for pain.

On 12/24/22 at 2:25 AM, Staff L, RN, failed to assess Patient 1 for pain.

On 12/24/22 at 10:15 AM, Staff X, Nurse Aide (NA), failed to assess Patient 1 for pain.

On 12/25/22 at 2:37 PM, Staff X, NA, failed to assess Patient 1 for pain.

On 12/25/22 at 6:09 PM, Staff W, Certified Nurse Aide (CNA), failed to assess Patient 1 for pain.

On 12/25/22 at 10:05 PM, Staff W, CNA, failed to assess Patient 1 for pain.

On 12/26/22 at 2:15 AM, Staff W, CNA, failed to assess Patient 1 for pain.

On 12/26/22 at 8:24 AM, Staff X, NA, assessed Patient 1's vital signs more than six hours from the previous assessment. Staff X failed to assess Patient 1 for pain.

On 12/26/22 at 10:41 AM, Staff X, NA, failed to assess Patient 1 for pain.

On 12/26/22 at 2:30 PM, Staff X, NA, failed to assess Patient 1 for pain.

On 12/26/22 at 6:20 PM, Staff H, Chief Nursing Officer (CNO), failed to assess Patient 1 for pain.

On 12/26/22 at 10:08 PM, Staff H, CNO, failed to assess Patient 1 for pain.

On 12/27/22 at 3:04 AM, Staff L, RN, assessed Patient 1's vitals four hours and 56 minutes after the previous assessment. Staff L failed to assess Patient 1 for pain.

On 12/27/22 at 7:03 AM, Staff X, NA, failed to assess Patient 1 for pain.

On 12/27/22 at 10:20 AM, Staff I, RN, failed to assess Patient 1 for pain.


Patient 2

Review of Patient 2's medical record showed that Patient 2 was admitted on 12/01/22 at 3:17 PM to Acute Care Services for the treatment of COVID-19 and congestive heart failure (CHF). Patient 2 has the following diagnoses: down syndrome (a genetic disorder caused when abnormal cell division results in an extra full or partial copy of chromosome 21), hepatic steatosis (fatty liver), sinus bradycardia (a heart rate that is less than 60 beats per minute), dyspnea (shortness of breath) on exertion, heart murmur (an unusual 'whooshing' heart sound), dependent edema (gravity-related swelling in the lower body), obesity (overweight), gastroesophageal reflux disease (GERD, when stomach acid repeatedly flows back into the throat), and hypothyroidism (when the thyroid gland doesn't produce enough of certain crucial hormones). Patient 2 was pronounced deceased on 12/02/22 at 5:10 PM.

Review of Patient 2's "Physician Entered Orders," showed that on 12/01/22 at 6:17 PM the physician ordered Fentanyl (medication used to help relieve severe ongoing pain) 50 micrograms per 1 milliliter (mcg/mL) PRN (as needed) Q4H (every four hours)."

Review of Patient 2's "Pain Assessment Flowsheet," showed that only one pain assessment was completed for Patient 2 during her acute care stay. Patient 2 was alert and able to verbally communicate if she had pain. Patient 2's pain was not assessed every four hours.


Patient 3

Review of Patient 3's discharged medical record showed that patient 3 was admitted on 11/20/22 at 9:51 PM to Acute Care Services for the treatment of painful bilateral cellulitis (skin infection) of the lower extremities and pressure sore on the right big toe. Patient 3 had the following diagnoses: Type 2 diabetes mellitus (the body's inability to control the amount of sugar in the blood), morbid obesity (a complex chronic condition in which a person has a body mass index of 40 or higher), and lymphedema (swelling due to build-up of lymph fluid in the body). Patient 3 was placed on sepsis protocol (the body's extreme response to an infection).

Patient 3 was admitted to Acute Care Service where, per interview with Staff D on 01/19/23 at 10:31 AM, pain is to be assessed every four hours.

Review of Patient 3's "Physician Orders," dated 11/20/22 at 10:44 PM, showed vital signs were ordered every four hours.

Review of Patient 3's "Physician Entered Orders," showed the following pain medications:

1. Tylenol (medication used to treat pain or fever) adult tab 650 mg every four hours.
2. Ultram (medication used to treat pain) 100 mg as needed every four to six hours.

Review of Patient 3's medical record showed that on 11/20/22 at 5:48 PM, Staff E, RN administered Ultram (a pain reliever used to treat moderate to moderately severe pain) 100 mg. Staff E failed to use a pain scale to assess Patient 3's pain. Staff E failed to reassess effectiveness of pain intervention within an hour (the standard nursing reassessment of pain occurs 30 minutes after IV pain medication and 60 minutes after oral medications).

Review of Patient 3's "Nurses Physical Assessment." dated 11/20/22 at 10:31 PM, Staff J, RN, assessed Patient 3's pain at seven. Staff J failed to contact the physician to address Patient 3's pain level to obtain further orders.

Review of Patient 3's medical record showed that on 11/21/22 at 8:34 AM, Staff E, RN, administered Tylenol 650 mg. Staff E failed to use a pain scale and failed to reassess the effectiveness of pain intervention within an hour.

Review of Patient 3's medical record showed that on 11/21/22 at 1:12 PM, Staff E, RN, administered Tylenol 650 mg. Staff E failed to use the pain scale and failed to reassess the effectiveness of pain intervention within an hour.

Review of Patient 3's medical record showed that on 11/22/22 at 5:00 AM, Staff Q, RN, administered Tylenol 650 mg. Staff Q failed to use the pain scale and failed to reassess the effectiveness of pain intervention within an hour.

Review of Patient 3's medical record showed that on 11/22/22 at 2:14 PM, Staff D, RN, administered Tylenol 650 mg. Staff D failed to use the pain scale and failed to reassess the effectiveness of pain intervention within an hour. At 3:29 PM Staff D, documented that the medication was partially effective but failed to use a pain scale for the reassessment.

Review of Patient 3's medical record showed that on 11/22/22 at 6:34 PM, Staff L, RN, administered Tylenol 650 mg. Staff L failed to use the pain scale and failed to reassess effectiveness of pain intervention within an hour.

Review of Patient 3's medical record showed that on 11/22/22 at 11:54 PM, Staff L, RN, administered Tylenol 650 mg. At 11:58 PM Staff L recorded Patient 3's pain at seven, left neck. Staff L failed to reassess pain effectiveness of the Tylenol within an hour. At 1:50 AM, Staff L, recorded the pain reassessment as effective but failed to use the pain scale during reassessment.

Review of Patient 3's "Nursing Physical Assessment" dated 11/23/22 at 10:32 AM, Staff E, LPN, recorded pain at five, left neck. Staff E failed to provide interventions for Patient 3's pain.

Review of Patient 3's medical record showed that on 11/23/22 at 5:03 PM, Staff E, LPN, administered Tylenol 650 mg. Staff E failed to use the pain scale and failed to reassess effectiveness of the intervention within an hour.

Review of Patient 3's medical record showed that on 11/23/22 at 8:43 PM, Staff L, RN, administered Tylenol 650 mg. Staff L failed to use the pain scale with her assessment prior to administration. At 9:27 PM Staff L reassessed the effectiveness of the Tylenol at a pain level six, left hip. Staff L failed to provide other nursing interventions to Patient 3.

Review of Patient 3's medical record showed that on 11/24/22 at 1:50 AM, Staff L, RN, administered Tylenol 650 mg. Staff L failed to use the pain scale and failed to reassess the effectiveness of the medication within an hour.

Review of Patient 3's "Nursing Physical Assessment" dated 11/24/22 at 8:08 AM, Staff R, RN, administered Tylenol 650 mg for pain level six, left hip. Staff R failed to reassess the effectiveness of the pain intervention within an hour. At 9:53 AM, Staff R, documented the Tylenol as partially effective. Staff R failed to use the pain scale with reassessment.

Review of Patient 3's "Nursing Physical Assessment" dated 11/24/22 at 6:45 PM, Staff S, LPN, assessed Patient 3's pain at six, left hip. Staff S failed to provide pain medication or other nursing interventions for pain.

Review of Patient 3's "Nursing Physical Assessment" dated 11/24/22 at 10:14 PM, Staff S, LPN, assessed Patient 3's pain at eight, left hip. Staff S administered Tylenol 650 mg. Staff S failed to administer appropriate medication for pain higher than a five or provide additional nursing interventions. Staff S failed to reassess the effectiveness of the pain intervention within an hour. At 11:43 PM, Staff S recorded that the Tylenol was effective but failed to use the pain scale.

Review of Patient 3's medical record showed that on 11/25/22 at 9:21 AM, Staff E, LPN, administered Ultram 50 mg. Staff E failed to use a pain scale prior to the medication administration. Staff E failed to reassess effectiveness of the pain intervention within an hour. At 11:18 AM, Staff E recorded the pain reassessment was effective but failed to use the pain scale.

Review of Patient 3's "Nursing Physical Assessment" dated 11/26/22 at 12:30 AM, Staff T, RN, failed to assess Patient 3's pain with the pain scale.

Review of Patient 3's "Nursing Physical Assessment" dated 11/26/22 at 6:40 AM, Staff D, RN, assessed Patient 3's pain at three, left hip. Staff D failed to administer any pain medication or offer any other pain management strategies for Patient 3's pain.

Review of Patient 3's medical record showed that on 11/26/22 at 8: 51 AM, Staff D, RN administered Ultram 50 mg. Staff D failed to use the pain scale during her assessment. Staff D failed to reassess the effectiveness of the pain intervention within an hour. At 11:59 AM, Staff D, documented pain intervention was partially effective but failed to use the pain scale.

Review of Patient 3's medical record showed that on 11/26/22 at 1:20 PM, Staff D, RN, administered Ultram 50 mg. Staff D failed to use a pain scale during her assessment. Staff D failed to reassess the effectiveness of the pain intervention within an hour. At 4:11 PM, Staff D documented that the pain intervention was partially effective but failed to use a pain scale.

Review of Patient 3's "Nursing Physical Assessment" dated 11/26/22 at 6:59 PM, Staff J, RN, assessed Patient 3's pain at five, left hip, left ankle. Staff J failed to administer medication for pain .

Review of Patient 3's medical record showed that on 11/27/22 at 12:03 AM, Staff D, RN, administered Ultram 50 mg. Staff D failed to use a pain scale during her assessment. Staff D failed to reassess effectiveness of pain intervention within an hour.

Review of Patient 3's "Nursing Physical Assessment" dated 11/27/22 at 8:30 AM, Staff D, RN, documented Patient 3's pain at a five, left hip, left ankle. Staff D failed to administer medication for pain.

Review of Patient 3's medical record showed that on 11/27/22 at 3:25 PM, Staff D, RN, recorded effective pain reassessment. Staff D failed to use a pain scale during her reassessment.

Review of Patient 3's "Nursing Physical Assessment" dated 11/27/22 at 6:45 PM, Staff L, RN, documented Patient 3's pain at a three, left hip. Staff L failed to administer pain medication for pain .

Review of Patient 3's "Nursing Physical Assessment" dated 11/28/22 at 7:26 AM, Staff D, RN, documented Patient 3's pain at a six, left hip. At 7:32 AM, Staff D administered Ultram 50 mg. Staff D failed to reassess the effectiveness of the pain intervention within an hour.

Review of Patient 3's "Nursing Physical Assessment" dated 11/28/22 at 6:30 PM, Staff L, RN, documented Patient 3's pain at a four, left hip. Staff L failed to administer pain medication for pain .

Review of Patient 3's medical record showed that on 11/28/22 at 11:39 PM, Staff S, LPN, administered Tylenol 650 mg. Staff S failed to use a pain scale during her assessment. Staff S failed to reassess the effectiveness of the pain intervention within an hour.

Review of Patient 3's medical record showed that on 11/29/22 at 7:57 AM, Staff E, LPN, administered Ultram 50 mg. Staff E failed to use the pain scale during her assessment. Staff E failed to reassess the effectiveness of the pain intervention within an hour.

Review of Patient 3's medical record showed that on 11/29/22 at 5:48 PM, Staff E, LPN, administered Ultram 50 mg. Staff E failed to use a pain scale during her assessment.

Review of Patient 3's "Physician Orders," showed Patient 3 receives fast acting insulin on a sliding scale: Call Physician for blood sugar of 0 to 60. No insulin needed for blood sugar of 61-150. Give 3 units for blood glucose results of 151 to 200, give 6 units for blood glucose results of 201 to 250.

Review of Patient 3's care plan showed that nursing staff failed to develop long and short-term goals for the management of Patient 3's diabetes. Further review showed the medical record failed to include interventions for Patient 3's low blood sugars.

Review of Patient 3's medical record showed that nursing staff failed to document nursing interventions for low (blood sugar result lest than 70) or high (blood sugar result of 99 or higher) on the following dates and times:

Review of Patient 3's "Diabetic Record" dated 11/22/22 at 6:47 AM, and Patient 3's Medication order to call the Physician if blood sugar is below 60. Patient 3's blood sugar level was 56. Nursing staff failed to document interventions provided for low blood sugar.

Review of Patient 3's "Diabetic Record" dated 11/25/22 at 7:50 PM, Patient 3's blood sugar level was 66. Nursing staff failed to document interventions provided for low blood sugar.

Review of Patient 3's "Diabetic Record" dated 11/26/22 at 7:45 PM, Patient 3's blood sugar level was 160. Staff J, RN, failed to administer insulin to Patient 3.

Review of Patient 3's "Diabetic Record" dated 11/27/22 at 6:16 PM, Patient 3's blood sugar level was 179. Staff Q, RN failed to administer insulin to Patient 3.


Patient 4

Review of Patient 4's medical record showed that Patient 4 was admitted on 01/11/23 to Acute Care Services for the care and treatment of atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat) after reporting an intense tightening of her chest and difficulty breathing. Patient 4 has been diagnosed with CHF, hypertension (high blood pressure), urinary incontinence (leaking of urine), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), degenerative joint disease of shoulders and knees, syncope syndrome (fainting), and history of partial hip replacement surgery.

Patient 4 was admitted to Acute Care Services, per interview with Staff D on 01/19/23 at 10:31 AM, pain is to be assessed every four hours.

Review of Patient 4's "Physician Entered Orders," showed that there were no orders placed for vital signs.

Review of Patient 4's medical record showed that nursing staff failed to assess pain levels every four hours. Further review showed that Patient 4 was assessed for pain four of 12 times during her acute care stay.


Patient 5

Review of Patient 5's discharged medical record showed that Patient 5 was admitted on 10/31/22 due to aggressive behaviors towards housemates after taking amphetamines and marijuana. Patient 5 has a history of manic-depressive disorder (also known as bipolar disorder, a mental health condition that causes extreme mood swings that include emotional highs [mania] and lows [depression]) and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior).

Review of Patient 5's "Physician Entered Orders," showed that Patient 5 has the following PRN medication orders:

1. Benadryl (medication used to treat allergies or as a mild sedative) 50 mg PRN HS (hour of sleep, bedtime).

2. Tylenol adult tab 650 mg PRN every four hours.

Review of Patient 5's care plan showed that it failed to address, through short and long term goals, the pain that Patient 5 was experiencing. Further review showed that the plan did not include other modalities of treatment for Patient 5's pain.

Review of Patient 5's "Medical Administration Record (MAR)," showed the following as needed (PRN) medications were provided and nursing staff failed to provide a reassessment within an hour or implement further nursing interventions:

On 10/31/22 at 5:52 PM, Staff L, RN, administered Tylenol 650 mg. Staff L failed to document the effectiveness of the medication.

On 10/31/22 at 10:21 PM, Staff L, RN, administered Benadryl 50 mg (a medication used to treat allergies or restlessness). Staff L failed to document the effectiveness of the medication.

On 11/01/22 at 8:55 PM, Staff L, RN, administered Tylenol 650 mg. On 11/01/22 at 11:49 PM, Staff L documented that the Tylenol was partially effective. Staff L failed to provide follow up in a timely manner and failed to notify the physician or offer other nursing interventions.

On 11/01/22 at 8:54 PM, Staff L, RN, administered Benadryl 50 mg. On 11/01/22 at 11:49 PM, Staff L documented that the Benadryl was noneffective. Staff L failed to provide follow up in a timely manner and failed to notify the physician or offer other nursing interventions.

On 11/02/22 at 1:13 AM, Staff L, RN, administered Tylenol 650 mg. On 11/02/22 at 3:00 AM, Staff L documented that the Tylenol was partially effective. Staff L failed to provide follow up in a timely manner, failed to notify the physician, and failed to offer other nursing interventions.

On 11/02/22 at 9:23 PM, Staff L, RN administered Tylenol 650 mg. On 11/02/22 at 11:49 PM, Staff L documented that the medication was effective. Staff L failed to follow up in a timely manner.

On 11/03/22 at 6:02 AM, Staff L, RN administered Tylenol 650 mg. Staff L failed to follow up and document the effectiveness of the Tylenol.


During an interview on 01/19/23 at 8:32 AM, Staff A, Chief Executive Officer (CEO), stated that a pain assessment is completed when there is complaint of pain. Staff A stated pain medication is provided, and nursing would follow up one to two hours, offer comfort measures, and follow up with the physician. Staff A was unsure if the pain scale can be documented with a set of vitals with location and description of the pain.

During an interview on 01/19/23 at 2:50 PM, Staff E, LPN, stated that pain assessments are completed based on a scale of 1 to 10, with ten being the higher pain level. Staff E stated that she is bad about going back and reassessing pain with patients. Staff E stated that she forgets to document the type of pain a patient is having. Staff E stated that she charts pain by exception. Staff E stated that if a patient is not experiencing pain, it's not charted again or re-evaluated.

During an interview on 01/20/23 at 9:07 AM, Staff H, CNO, stated that she realized they did not have a policy on pain assessments. Staff H stated that there is no policy that addresses when or how vital signs are to be obtained. Staff H stated that patients in the ED and acute care have their vitals assessed every four hours.

Based on policy review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure the implementation of patient care plans with measurable short - and long-term goals, intervention to address patient's individual needs, and reviewed and updated as needed, for 5 of 5 patients reviewed (Patient 1, 2, 3, 4, and 5). This deficient practice has the potential to affect all patients and may lead to harm and other adverse outcomes.


Findings Include:


Review of the CAH's policy titled, "Care Plan," dated 09/16/22, showed, "An individualized, multidisciplinary care plan for all patients will be implemented at the time of admission . . . based upon the diagnosis and patient assessment . . . using best practice and updated care plans through the EHR (electronic health record): relevant diagnosis will be selected or created; pertinent outcomes and interventions will be chosen or created; related tasks and activities will be selected or created and appear on the Med act. The activities will be addressed accordingly . . . a minimum of two patient specific problems must be selected. Appropriate and relevant outcomes, interventions and activities will be chosen for this diagnosis. The activities will be addressed on the [EHR] each shift or per activity frequency. The care plan will be reviewed at a minimum of every 24 hours."

Review of the CAH's policy titled, "Documentation," dated 06/06/22, showed "A care plan will be generated within eight hours of admission. The plan will be individualized and multidisciplinary for each patient. The plan will be based upon the diagnosis and patient assessment. The care plan shall address the learning needs of the patient and/or family. After the initiation of the care plan by RN, those disciplines consulting in the care shall contribute to the plan as appropriate to the patient's needs. Care plans shall be reviewed daily at a minimum, with the revisions reflecting the assessment and reassessment of needs of the patient. Nursing diagnosis will be selected from the EHR database, or created to meet that patient's individual needs, along with attainable goals." Further review showed that care plans and the "documentation of goals and interventions [are completed by] RN [Registered Nurse], LPN [Licensed Practical Nurse], PT [Physical Therapist], RT [Respiratory Therapist], Diet [sic, dietician], SS [social services], [and] ACT [undefined]."


Patient 1

Review of Patient 1's medical record showed that Patient 1 was admitted on 12/23/22 at 10:43 AM for the treatment of congestive heart failure (CHF, a progressive heart disease that affects pumping action of the heart muscles causing fatigue and shortness of breath) and respiratory syncytial virus (RSV, a viral infection of the respiratory tract that causes mild flu-like symptoms).

Review of Patient 1's Morse fall assessment (a rapid and simple method of assessing a patient's likelihood of falling) showed he scored a 35 and is considered to have a moderate fall risk.

Review of Patient 1's "Problems/Goals (care plan)," initiated 12/23/22 at 11:18 AM showed the following problems:

1. At risk for decreased cardiac output secondary to CHF.
2. Isolation R/T (related to) RSV.
3. Age related care: older adult (65 + years-old).

Further review showed that there were no measurable objectives, implemented activities or interventions, and short- and long-term goals related to the identified problems. Patient 1's moderate fall risk was not addressed on the care plan with interventions per policy.

Further review showed that on 12/27/22 at 11:11 AM, after Patient 1 was discharged, the following goals were added:

1. Pt (patient) will be able to make informed decisions.
2. Pt will understand lifestyle impact of illness.
3. Pt and visitors will comply with [CAH] procedures for isolation and visitation.
4. Pt educated on isolation and verbalized understanding of need for isolation.
5. Lab values WNL (within normal limits).
6. Lung sounds clear no peripheral edema (swelling).
7. Pt's I & O (input and output) balanced.
8. Pt/family assisted with appropriate and indicated services for return home.

Further review showed nursing staff failed to document interventions and progress on Patient 1's care plan during his acute care stay.


Patient 2

Review of Patient 2's medical record showed that Patient 2 was admitted on 12/01/22 at 3:17 PM for the treatment of COVID-19 (patient is unvaccinated) (a mild to severe respiratory illness that is caused by the coronavirus and presents as flu-like symptoms) and congestive heart failure (CHF). Patient 2 has the following diagnoses: down syndrome (a genetic disorder caused when abnormal cell division results in an extra full or partial copy of chromosome 21), hepatic steatosis (fatty liver), sinus bradycardia (a heart rate that is less than 60 beats per minute), dyspnea (shortness of breath) on exertion, heart murmur (an unusual 'whooshing' heart sound), dependent edema (gravity-related swelling in the lower body), obesity (overweight), gastroesophageal reflux disease (GERD, when stomach acid repeatedly flows back into the throat), and hypothyroidism (when the thyroid gland doesn't produce enough of certain crucial hormones).

Review of Patient 2's Morse fall assessment showed she scored a 45 and is considered to have a high fall risk (a high fall risk is a score of 45 or higher). Further review of Patient 2's medical record showed that Patient 2 would take off her oxygen and pull at other wires and tubing.

Review of Patient 2's "Problems/Goals (care plan)," initiated on 12/01/22 at 3:00 PM showed the following problems were identified:

1. Breathing pattern, ineffective r/t covid.
2. Gas exchange impaired r/t covid.

Review showed that there were no measurable objectives, implemented activities or interventions, and short- and long-term goals related to the identified problems. Patient 2's high fall risk was not addressed on the care plan with interventions per policy. Further review of Patient 2's medical record showed that goals and interventions were not implemented for the removal of oxygen, leads, and IVs.

On 12/02/22 at 6:10 PM, after Patient 2 was deceased (12/02/22 at 5:10 PM), the following goals were added to the care plan:

1. Pt lung sounds, and respiratory efforts return to patient baseline.
2. Pt skin will remain warm, pink, and dry and vital signs will be WNL.
3. Pt will request breathing assistance when needed.
4. Dyspnea at rest and on exertion not present/within Pt normal.
5. Neurological status within normal range.
6. PaCO2 (Partial pressure of carbon dioxide, test often performed on people with lung diseases), arterial pH (Power of hydrogen), O2 (oxygen) saturation within normal limits.

Further review showed nursing staff failed to document interventions and progress on Patient 2's care plan during her acute care stay.


Patient 3

Review of Patient 3's discharged medical record showed that patient 3 was admitted on 11/20/22 at 9:51 PM for the treatment of painful bilateral cellulitis (skin infection) of the lower extremities and pressure sore on the right big toe. Patient 3 had the following diagnoses: Type 2 diabetes mellitus (the body's inability to control the amount of sugar in the blood), morbid obesity (a complex chronic condition in which a person has a body mass index of 40 or higher), and lymphedema (swelling due to build-up of lymph fluid in the body). Patient 3 was placed on sepsis protocol (the body's extreme response to an infection).

Review of Patient 3's Morse fall assessment showed he scored a 60 and is considered to have a high fall risk.

Review of Patient 3's "Problems/Goals (care plan)," initiated on 11/20/22 at 11:19 PM showed the following problems were identified:

1. Age related care (41-65 years-old).
2. Nutrition - more than body requirements.
3. Nutritional Imbalance related to swallowing difficulty.

Review of Patient 3's medical record showed that Patient 3 fell on 11/23/22 while transferring from the recliner to the bed.

Review of Patient 3's "Problems/Goals (care plan)," showed that on 11/23/22 at 7:11 AM the following goal was added:

1. At risk injury/fall related to decreased mobility.

And at 1:00 PM added:

2. Skin integrity, actual impairment.

Review of Patient 3's Problem/Goals (care plan)," showed that on 11/29/22 at 5:15 PM the following problems/goals were added and resolved:

1. age care guidelines will be implemented.
2. Pt will be able to make informed decisions.
3. Pt will understand lifestyle impact of illness.
4. Pt actively participate in exercise program with OT/PT (occupational and physical therapies).
5. Pt decreases caloric intake, monitored calorie intake.
6. Pt verbalizes satisfaction of behavior modification and weight loss.
7. Intake and output balanced.
8. Pt will maintain body mass, weight within normal limits.
9. Pt will participate in OT.
10. Modify lifestyle to reduce risk.
11. Pt will remain injury/fall free.
12. Pt/staff will follow PT/OT prescribed regimens.
13. Pain management as ordered.
14. Decrease signs and symptoms of cellulitis.
15. Pt regains skin integrity evidenced by warm, dry, intact skin.

Review of Patient 3's medical record showed that Patient 3 was transferred to higher care on 11/29/23 at 6:00 PM.

Further review showed that there were no measurable objectives, implemented activities or interventions, and short- and long-term goals related to the identified problems. Patient 3's high fall risk was not addressed until after his fall. Patient 3's diabetes and wound care were not addressed in his care plan. The use of a gait belt and walker were not addressed in the care plan. Nursing staff failed to document interventions and progress on Patient 3's care plan during his acute care stay.


Patient 4

Review of Patient 4's medical record showed that Patient 4 was admitted on 01/11/23 for the care and treatment of atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat) after reporting an intense tightening of her chest and difficulty breathing. Patient 4 has been diagnosed with CHF, hypertension (high blood pressure), urinary incontinence (leaking of urine), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), degenerative joint disease of shoulders and knees, syncope syndrome (fainting), and history of partial hip replacement surgery.

Review of Patient 4's Morse fall assessment showed a score of 60, a high fall risk.

Review of Patient 4's "Problems/Goals (care plan)," initiated on 01/11/23 at 4:08 PM showed the following problems were identified:

1. Age related care (65 years and older).
2. At risk for decreased cardiac output secondary to tachycardia (a heart rhythm disorder with heartbeats faster than usual, greater than 100 beats per minute).

Review of Patient 4's medical record showed that Patient 4 was discharged on 01/13/23 at 3:36 PM.

Review of Patient 4's "Problem/Goals (care plan)," showed on 01/13/23 at 4:15 PM, the following goals were added and resolved due to patient discharge:

1. Age care guidelines will be implemented.
2. Pt will be able to make informed decisions.
3. Pt will understand lifestyle impact of illness.
4. Lab values within normal limits.
5. Lung sounds clear, no peripheral edema.
6. Pt's input and output balanced.
7. Pt/family assisted with appropriate and indicated services for return home.

Further review showed that there were no measurable objectives, implemented activities or interventions, and short- and long-term goals related to the identified problems. Patient 4's high fall risk was not addressed. Nursing staff failed to document interventions and progress on Patient 4's care plan during her acute care stay.


Patient 5

Review of Patient 5's discharged medical record showed that Patient 5 was admitted on 10/31/22 due to aggressive behaviors towards housemates after taking amphetamines and marijuana. Patient 5 has a history of manic-depressive disorder (also known as bipolar disorder, a mental health condition that causes extreme mood swings that include emotional highs [mania] and lows [depression]) and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior).

Review of Patient 5's "Problems/Goals," initiated on 11/03/22 at 10:52 AM, showed a goal to complete assessment with a note that Patient 5 is on list for placement at state hospital.

Review showed that a nursing care plan was not implemented upon arrival to the ED, did not address her aggression, inability to sleep, or 1:1 status with law enforcement officer (LEO ).

Further review showed nursing staff failed to document interventions and progress on Patient 5's care plan during her stay.


During an interview on 01/20/23 at 9:07 AM, Staff H, CNO, stated that she has had difficulty getting staff to update and document on patient care plans. Staff H stated that we have them, we just need to get the staff to document on them.

Based on policy review, record review, and interview, the Critical Access Hospital (CAH) failed to ensure appropriately executed consents were obtained for 3 of 5 patients reviewed (Patient 2, 4, and 5). This deficient practice has the potential to affect all patients and may cause harm or other adverse outcomes.

Findings Include:

Review of the CAH's policy titled, "Informed and Implied Consent," dated 08/29/22, showed, "Verbal consent is valid and shall be authenticated by the signature of two witnesses."


Patient 2

Review of Patient 2's medical record showed a "Consent for Medical Treatment," dated 12/01/22 at 10:44 AM, Staff M, Admissions Representative, witnessed a "verbal consent." Further review showed that the consent did not have a second witness. The document failed to show who the verbal consent was obtained from.

Review of Patient 2's medical record showed a "Consent for Medical Treatment," dated 12/01/22, untimed, showed Staff N, Admissions Representative witnessed the "VC [verbal consent] by mother." Further review showed that the consent did not have a second witness.

Review of Patient 2's medical record showed "Important Message from Medicare," dated 12/01/22 at 3:26 PM, Staff N, Admissions Representative witnessed "VC [verbal consent]." Further review showed that the acknowledgement did not have a second witness.


Patient 4

Review of Patient 4's medical record showed "Consent for Medical Treatment," was left undated and unsigned. The consent form had a patient sticker dated 12/06/22 and was scanned to the medical record. There was no note explaining why the form was left unsigned.

Review of Patient 4's medical record showed "Important Message from Medicare," dated 01/11/23 at 9:24 AM, showed Staff N, Admissions Representative, witnessed the form and noted "VC [verbal consent] by [patient name]."


Patient 5

Review of Patient 5's medical record provided by the CAH failed to show evidence that a consent for treatment was obtained for Patient 5 upon his admission on 10/31/22.


During an interview on 01/19/23 at 10:31 AM, Staff D, RN, stated that if a patient was unable to sign consents and the durable power of attorney was present, they could sign the consents. Staff D stated that if verbal or phone consents were obtained, two hospital staff would need to hear and witness the consents. Staff D stated that the DPOA would be kept on the chart.

During an interview on 01/19/23 at 2:50 PM, Staff E, LPN, stated that if a patient is unable to sign their consents, two nurses will witness the verbal consent and sign the document.