HospitalInspections.org

Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to the Life Safety Code inspection tags: F321, F324, F353, F702, and F920 for additional information.

Based on interview and document review, the critical access hospital (CAH) failed to ensure policies and procedures in the nursing department were reviewed every two years. In addition, the facility failed to ensure policies were reviewed for clinical records and radiology biannually.

Findings include:

Review of clinical record policies and radiology policies revealed the following were not reviewed biannually:

Clinical Records Policies
-Access, Use, and Disclosure of Protected Health Information last review date 6/14/2022.
-Electronic Signatures last review date 2/14/2022.
-Retention of Non-Electronic Medical Records last review date 9/10/2019.
-Physician Orders-Telephone, Verbal Order last review date 11/17/2021.

Radiology Policy
-Radiation Safety (ALARA) last review dated 2/9/2021.









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Review of nursing policies and procedures revealed the following:

NURSING
-Reportable Events-Adverse Health Events and TJC Sentinel Events last review date 5/22/22.
-Employee Orientation last review date 2/27/22.
-Staff Competence last review date 10/23/20

During an interview on 6/25/24 at 10:05 a.m., the director of nursing (DON) stated clinical policies were reviewed internally every two years however any policies which were administrative were not part of this review process. The DON verified the above policies had not been reviewed in the two year time frame.

During an interview on 6/27/24 at 8:25 a.m., the administrator verified the above policies were not part of the every two year review process.

Based on interview and medical record review, the hospital failed to ensure patients received the Important Message from Medicare (IMM) for 4 of 6 (P1, P6, P9, P13) patients who were admitted to inpatient status or swing bed status.

Findings include:

A review of medical records and interview was completed on 6/27/24 at 12:00 p.m. with registered nurse (RN)-A and administrator present. The review revealed the following:

P1 was admitted on 6/23/24, as an inpatient with weakness and fever. A review of the medical record with RN-A and with the administrator revealed the IMM was not found in P1's medical record. Administrator verified the record lacked an IMM.

P6 was admitted on 4/12/24, in a swing bed status for wound care. A review of the medical record with RN-A and with the administrator revealed the IMM was not found in P6's medical record. Administrator verified the record lacked an IMM.

P9 was admitted on 5/8/24, as an inpatient for urinary tract infection with an indwelling urinary catheter. A review of the medical record with RN-A and with the administrator revealed the IMM was not found in P9's medical record. Administrator verified the record lacked an IMM.

P13 was admitted on 6/26/24, as an inpatient for upper gastrointestinal bleed. A review of the medical record with RN-A and with the administrator revealed the IMM was not found in P13's medical record. Administrator verified the record lacked an IMM.

According to the Centers for Medicare and Medicaid, "Hospitals are required to deliver the Important Message from Medicare (IM), formerly CMS-R-193 and now CMS-10065, to all Medicare beneficiaries (Original Medicare beneficiaries and Medicare Advantage plan enrollees) who are hospital inpatients. The IM informs hospitalized inpatient beneficiaries of their hospital discharge appeal rights."