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Based on review of Medical Staff Bylaws Rules and Regulations, medical staff reappointment, and staff interview it was determined that the CAH failed to follow policy regarding reappointments of the medical staff, potentially effecting all patients receiving services.
Findings include:

1. The CAH's Medical Staff Bylaws Rules and Regulations dated March 2009 were reviewed on 10/15/12. The Rules and Regulations indicated under " Section 3. Conducting and Duration of Appointment b. ...Reappointments shall be for a period of not more than two (2) years."

2. During a review of medical staff reappointment on 10/15/12, it was noted that 2 physicians did not have reappointments completed within the 2 years. One physician was due for reappointment in February 2012 and the other was due in August of 2011.

3. During an interview with the Director of Nurses on 10/15/12 at 3:00 PM, the Director confirmed that the 2 physicians were overdue in their reappointments and that staff had been working on getting those completed.

Based on observation, policy and procedure, and staff interview it was determined that the CAH failed to ensure that food is properly stored and labeled, potentially effecting all patients and staff receiving dietary services.
Findings include:

1. During a tour of the Dietary department on 10/15/12 at 1:00 PM, it was observed in the refrigerator a container of a food item with no date, a container of lettuce undated and a lettuce salad with an appearance of a mayonnaise base with no date. Also observed in the freezer were an opened package of hot dogs and an opened package of mixed chicken pieces with no date.

2. The CAH policy and procedure titled, "DATING AND LABELING REFRIGERATED READY TO EAT POTENTIALLY HAZARDOUS FOODS" (reviewed 12/14/10) was reviewed on 10/15/12. The policy indicated under "PROCEDURE: 1. Refrigerated, ready-to-eat, potentially hazardous foods prepared and held for more than 24 hours, must be clearly marked to indicate the date by which food shall be consumed or discarded...".

3. During an interview with the Dietary Manager on 10/15/12 at 1:15 PM, the Manager confirmed that all foods are to be labeled before stored in refrigerator or freezer.

Based on observation and staff interview it was determined that the (CAH) Critical Access Hospital failed to ensure patient care radiological equipment was in safe operating condition, potentially effecting the safety of all patients and staff.
Findings include:

1. During a tour of the Radiology department on 10/15/12 at 10:00 AM, a green radiology apron was observed to have an open area along the seam, as well as, loose threads around other parts of the apron. The apron was hanging with all the other radiology aprons and was readily available for patient and staff use.

2. During an interview with the Radiology Manager on 10/15/12 at 10:00 AM, the Manager confirmed that the radiology apron should not be available for patient and staff use.

Based on a review of the CAH Medical Staff Bylaws Rules and Regulations, CAH Deficiency Report, and staff interview, it was determined that the CAH failed to ensure all medical records are completed within 30 days following discharge in accordance with written policies and procedures.
Findings include:

1. The CAH's "Medical Staff By-Laws Rules and Regulations" (dated March 2009) indicated under "B. Medical Records" 16. The patient's medical record shall be completed within a period of time that in no event exceeds 30 days following discharge."

2. A review of the Deficiency Report by Physician was reviewed on survey date 10/16/12. The report indicated a total of 48 delinquent records as of 10/16/12.

3. During an interview with the Director of Nurses on 10/16/12 at 3:00 PM, the Director confirmed the number of delinquent records as 48.

Based on policy and procedure, record review and staff interview it was determined in 1 of 4 (Pt. #13) medical records of patients receiving blood the CAH failed to ensure consents were completed as per policy.
Findings include:

1. The CAH policy and procedure titled, "CONSENT/REFUSAL BLOOD AND BLOOD PRODUCTS" (revised 5/11/11) was reviewed on 10/16/12. The policy indicated under "7. Specific Guidelines: A. Non-Surgical Procedures: 1) Obtain the Consent to Blood Components... when the first transfusion order is received."

2. The medical record of Pt. #13 was reviewed on 10/16/12. Documentation indicated Pt. #13 was admitted for oncology outpatient services on 9/28/12 with diagnosis of Metastatic Ovarian Cancer for blood transfusion. The physician telephone order written on 9/28/12 was for 2 units of packed red blood cells. "Give one today 9/28 and one tomorrow 9/29". Documentation indicated a consent was completed for the 9/28/12 transfusion. There was no consent documented for the blood transfusion that was completed on 9/29/12.

3. During an interview with the Director of Nurses on 10/17/12 at 11:00 AM, the Director confirmed a consent could not be found for the transfusion on 9/29/12. The Director confirmed that blood consents are to be signed upon each admission.

A. Based on policy and procedure, record review and staff interview it was determined in 1 of 1 (Pt. #9) restraint records reviewed that the CAH failed to ensure records were completed per policy.
Findings include:

1. The CAH policy titled, "RESTRAINT POLICY/PROCEDURE" (revised 9/12/12) was reviewed on 10/16/12. The policy indicated under "RESPONSIBILITIES OF NURSING: 1. The order must be obtained within 12 hours of initiation and signed by the attending physician....2. The following observations will be made by the certified nursing assistant and recorded on the Restraint Checklist..."

2. The medical record of Pt. #9 was reviewed on 10/16/12. Documentation indicated Pt. #9 was admitted for services on 8/6/12 with the diagnoses of Hypokalemia and Dehydration. A physician telephone order on 8/6/12 at 2135 indicated "may use soft upper limb restraints". Documentation indicated the restraints were applied at 2135. Documentation indicated a physician signature but no date or time recorded. Documentation on the "Checklist" was not clear as to the date the initial restraint was applied or the date the restraint was removed. Documentation on the Restraint Assessment/Alternatives Physician Order was not clear as to the date of the assessment. The admission date was the only date on the two assessments. Documentation indicated a physician signature on the Assessment/Alternatives Physician order, but no date and time was documented.

3. During an interview with the Director of Nurses on 10/17/12 at 10:30 AM, the Director confirmed that the only date listed on the "Checklist" and the Restraint Assessment/Alternatives Physician Order was the admission date. The Director stated she was unaware that the computer system did not have a date of the actual initial restraint or the date of discontinuance of the restraint on the checklist. The Director confirmed that the physician should have dated and timed the orders.

B. Based on policy and procedure, record review and staff interview, it was determined in 1 of 2 patients with wound care (Pt #18), the CAH failed to ensure wound care policies were followed.
Findings include:

1. The CAH policy titled "SKIN CARE POLICY" (revised 1/11/12) was reviewed on 10/17/12. The policy indicates under "POLICY: 4. Documentation of nursing interventions will be made in the patient's Daily Assessment Flowchart." The CAH policy titled "SKIN CARE-PHOTO DOCUMENTATION" (revised 1/11/12) was reviewed on 10/17/12. The policy indicated under "POLICY: Photos should be taken on admission or when wound first identified and if there is significant change..."

2. The medical record of Pt #18 was reviewed on 10/17/12. Pt #18 was admitted to the CAH with diagnoses of Abscess of Rt Thigh and Diabetes Mellitus. Documentation in the Initial Interview completed on admission on 6/5/12 at 16:02 indicated "admitted to room 8-2 from home for lesion top rt inner thigh". Documentation indicated there were no photos taken of the documented lesion. Documentation in the Patient Progress Notes dated 6/6/12 at 7:36 "resting in bed, c/o pain to right upper thigh area, area covered with 4x4 bandage, pain is 4 on 1-10 scale." Documentation failed to indicate any description of the wound or nursing interventions documented on the Daily Assessment Flowchart per the policy. No flowchart was completed during the hospital stay from 6/5/12 through Pt #18's discharge on 6/7/12.

3. During an interview with the Director of Nurses on 10/17/12 at 4:00 PM, she indicated nurses were expected to obtain photos of any wounds when first known and to chart care and description of wounds in the computer record, Daily Assessment Flowchart.

Based on Medical Staff Bylaws Rules and Regulations, record review and staff interview it was determined in 8 of 20 (Pt.#3, 4, 9, 13, 15, 16, 18 and 19) records reviewed that the CAH failed to ensure physician orders were signed, dated, and timed.
Findings include:

1. The CAH's Medical Staff Bylaws Rules and Regulations dated March 2009 were reviewed on 10/17/12. The regulations indicated under "B. Medical Records 4. All orders pertaining to patient care must be documented and signed by the physician. Telephone orders will be signed...by the physician within 48 hours. Verbal orders, other than telephone orders, shall be signed by the physician prior to leaving area."

2. The medical record of Pt #3 was reviewed on 10/15/12. Documentation indicted Pt #3 was admitted to the CAH on 10/12/12 with diagnoses of Pneumonia, Congestive Heart Failure and Pulmonary Fibrosis. Documentation indicated multiple telephone and physician written orders between 10/12/12 and 10/15/12 with no date and time of physician signature. Documentation indicated a telephone order written on 10/12/12 with no physician signature.

3. The medical record of Pt #4 was reviewed on 10/15/12. Pt #4 was admitted to the CAH on 10/13/12 with diagnoses of Congestive Obstructive Pulmonary Disease and history of Cancer of the Gall Bladder. Documentation indicated 6 telephone orders written on 10/13/12 with no date and time of physician signature.

4. The medical record of Pt. #9 was reviewed on 10/16/12. Documentation indicated Pt. #9 was admitted to the CAH on 8/6/12 with diagnoses of Hypokalemia and Dehydration. Documentation indicated multiple telephone orders between 8/6/12 and 8/10/12 were not signed, dated and timed by physician. Documentation indicated a telephone order was written for restraints on 8/6/12 at 2135. There was no date and time of physician signature documented.

5. The medical record of Pt. #13 was reviewed on 10/16/12. Documentation indicated
Pt. #13 was admitted on 9/29/12 for Oncology outpatient services with diagnosis of Metastatic Ovarian Cancer. Documentation indicated a physician telephone order for 2 units of Packed Red Blood Cells was written on 9/29/12. Documentation indicated the physician signed the order without a date and time. Documentation indicated the Blood Component Transfusion Order Form had no physician signature as of survey date 10/16/12.

6. The medical record of Pt. #15 was reviewed on 10/17/12. Documentation indicated Pt.
#15 was admitted on 6/12/12 for Oncology outpatient services with diagnosis of Metastatic Colorectal Cancer. Documentation indicated there were multiple orders dated 6/12/12 with no time of physician signature.

7. The medical record of Pt #16 was reviewed on 10/17/12. Documentation indicated Pt
#16 was admitted to the CAH on 7/31/12 with diagnoses of Advanced Metastatic Cancer of the Kidneys and Septicemia. Documentation indicated multiple telephone and written orders with no date and time of physician signature.

8. The medical record of Pt #18 was reviewed on 10/17/12. Documentation indicated Pt
#18 was admitted to the CAH with diagnoses of Abscess of Right Thigh and Diabetes Mellitus. Documentation indicated multiple orders between 6/5/12 through 6/7/12 with no date and time of physician signature.

9. The medical record of Pt #19 was reviewed on 10/17/12. Pt #19 was admitted to the CAH on 4/25/12 with diagnoses of Small Cell Lung Cancer and Gastroenteritis. Documentation indicated a telephone order and a physician written order dated 4/25/12 with no date or time of physician signature.

9. During an interview with the Director of Nurses on 10/17/12 at 11:00 AM, the Director confirmed the physician orders should be signed, dated and timed per policy.