HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of fourteen patients, one skilled swing bed patient and thirteen intermediate swing bed patients. Based on observation, policy review, and staff interview the CAH failed to ensure medications and biologicals are current, not outdated and available for emergency patient use for one of one Emergency Room (ER) observed, two of two crash carts observed. This failure has the potential to affect all patients who present to the ER seeking treatment for a medical condition.

Findings include:

- The CAH's policy titled, "Medication Procurement and Administration" reviewed on 8/11/15 at 7:50am directed, "...All outdated or recalled medications shall be returned to the pharmacy..."

- Observation in the ER on 8/10/15 at 1:35pm revealed the following:
One-16 ounce bottle of Isopropyl Alcohol 70% with an expiration date of 2/14.

One- 150ml (milliliter) bottle 1/4/full of Colodion Flexible, contains (pyrocylin, ether, and alcohol which is highly flammable) (used as a topical protectant applied to the skin to close small wounds, abrasions, and cuts) with an expiration date of 9/1988.

One-20ml opened bottle of sterile water lacked a date when opened.

One-1000ml single use container of sterile water with approximately 400ml of sterile water in the container.

Review of the crash cart log book revealed a date of 8/1/15 when crash cart last checked.

- Observation in the ER on 8/12/15 at 1:35pm revealed a crash cart with the following:

One-2ml vial of Solu-Medrol (a steroid) 125mg (milligrams) with an expiration date of 7/15.

One-50ml vial of 50% Dextrose with an expiration date of 8/1/15.

One-2ml vial of Verapamil (used to treat high blood pressure and some heart dysthymias) with an expiration date of 8/1/15.

One-2ml vial of Nitropress (used to treat high blood pressure) with an expiration date of 4/15.

One-10ml syringe of Epinephrine 1:10,000 (used to treat allergic reactions) with an expiration date of 1/1/15.

One-50ml IV(intravenous) bag of water with 20 milli-equivalents potassium chloride (used to treat low potassium) with an expiration date of 7/1/15.

- Observation of room 100 on the nursing unit on 8/10/15 at 3:30pm revealed a crash cart with the following:

Four-1mg syringes of Atropine Sulfate (used to treat a slow heart beat) with an expiration date of 6/1/15.

Twenty-Five- 10mg per 1ml vials of Neo-Synephrine (used to treat low blood pressure) with an expiration date of 3/15.

Four-1mg syringes of Epinephrine 1:10,000 with an expiration date of 1/1/15.

Three-50ml vials of 50% Dextrose with an expiration date of 8/1/15.

One-2ml vial of Nitropress with an expiration date of 4/1/15.

One-2ml vial of Verapamil with an expiration date of 8/1/15.

One-100ml IV bag of 0.9% Sodium Chloride (used for fluid replacement) with an expiration date of 7/15.

One-500ml bottle of sterile water with an expiration date of 3/05.

Review of the crash cart log book revealed the crash cart last checked on 4/4/15.

Staff B, RN, Administrative staff, interviewed on 8/10/15 at 3:30pm acknowledged the expired medications, and explained the nurses are to check the crash cart for expired medications once a month.

The Critical Access Hospital (CAH) reported a census of fourteen patients, one skilled swing bed patient and thirteen intermediate swing bed patients. Based on observation and staff interview the CAH failed to ensure supplies are current, not outdated and available for emergency patients use for one of one Emergency Room (ER) observed. This failure has the potential to affect all patients who present to the ER seeking treatment for a medical condition.

Findings include:

- Observation in the Emergency Room on 8/10/15 at 1:15pm revealed the following outdated supplies in a cabinet. Thirty two sterile applicators with an expiration date of 5/12 and thirty one sterile cotton applicators with an expiration date of 6/08.

Staff B, RN, Administrative staff interviewed on 8/10/15 at 1:15pm acknowledged the outdated applicators. Staff B explained the RNs are to check the ER for outdated supplies.

- Observation of the Emergency Room observed on 8/10/15 at 4:40pm revealed one Braselow Bag (used for pediatric emergency treatment) that contained the following:

One- green bag for a 30-36 kg (kilogram) pediatric patient containing one intraosseous (needle injected directly in the bone marrow) module with an expiration date of 2/10, one IV (intravenous) delivery module with an expiration date of 3/07, and one Intubation (placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) module with an expiration date of 4/08.

One- red bag for 8-9 kg pediatric patient containing one IV delivery module with an expiration date of 3/07, one Intraosseous module with an expiration date of 2/10, and one Intubation module with an expiration date of 3/08.

One- blue bag for 19-23 kg pediatric patient containing one IV delivery module with an expiration date of 3/07, one Intraosseous module with an expiration date of 2/10, and one Intubation module with an expiration date of 4/08.

One- white bag for 15-18 kg pediatric patient containing one IV delivery module with an expiration date of 3/07, one Intraosseous module with an expiration date of 2/10, and one Intubation module with an expiration date of 4/08.

One-Purple bag for 10-11kg pediatric patient containing one IV delivery module with an expiration date of 3/07, one Intraosseous module with an expiration date of 2/10, and one Intubation module with an expiration date of 4/08.

One-Yellow bag for 12-14 kg pediatric patient containing one IV delivery module with an expiration date of 3/07, one Intraosseous module with an expiration date of 2/10, and one Intubation module with an expiration date of 4/08.

Staff B, RN, Administrative staff interviewed on 8/10/15 at 4:40pm explained they are aware of the outdated supplies for the pediatric patients and are in the process of restocking them with new supplies.

Based on observation, record review, and staff interview it was determined that the Critical Access Hospital (CAH) failed to ensure outdated medications and biologicals were not available for patient use (Refer to C-0276); failed to develop an active and comprehensive infection control system which identified and investigated staff practices (Refer to C-0278); and failed to ensure outdated supplies not available for use (Refer to C-0282).

The cumulative effect of the systemic failure of the CAH to ensure outdated mediations and biologicals are not available for patient use; to develop an active and comprehensive infection control system and to ensure outdated laboratory supplies are not available for use has the potential to affect all patients in the CAH and places patients at risk for receiving ineffective drug therapies and treatments and at risk for acquiring healthcare associated infections.

The Critical Access Hospital (CAH) reported a census of fourteen patients, one skilled swing bed patient and thirteen intermediate swing bed patients. Based on observation, staff interview, and policy review the CAH failed to ensure outdated medications and biologicals were not available for patient use in one of one observed pharmacy, one of one observed Fluid Warmer, and one of one observed Delivery Room. The failure of the CAH to ensure outdated medications and biologicals were not available for patient use has the potential to affect all patients in the CAH and place them at risk for receiving ineffective drug therapies.

Findings include:

- The CAH's policy titled "Pharmaceutical Services" for all hospital departments reviewed on 8/11/15 at 7:50am directed staff, "...unused narcotics are to be returned to the Federal Narcotics Bureau or its agent...hospital returns outdated narcotics to our contracting pharmacist... "

-The CAH's policy titled "Drug Distribution and Drug Accountability" reviewed on 8/11/15 at 7:50am directed staff "...all outdated or recalled medications shall be returned to the pharmacy for credit or replacement..."

-The pharmacy observed on 8/10/15 between 12:55pm and 3:15pm revealed the following outdated medications:

1. One stock bottle of Diphenhydramine 50mg (milligrams) (medication used for allergies) with an expiration date of 8/4/15.

2. One stock bottle of GG/Codeine 100-10/5 (medication used for cough relief) with an expiration date of 5/10/15.

3. One stock bottle of Simvastatin 20mg (medication used to lower cholesterol) with an expiration date of 6/16/15.

4. One stock bottle of Lyrica 150mg (medication used for pain relief) with an expiration date of 7/13/15.

5. One stock bottle of Senna laxative (medication to treat constipation) with an expiration date of 4/15.

6. One stock bottle of Dicycloamine 10mg capsules (medication used to treat stomach pain) with an expiration date of 11/23/13.

7. One stock bottle of Vitamin D 500,000 Units with an expiration date of 10/16/14.

8. One stock bottle of Vitamin D3 2000 Units with an expiration date of 3/12/15.

9. One stock bottle of Promethazine plain syrup (medication for cough relief) with an expiration date of 9/14.

10. One stock bottle of Carafate 1gm (gram)/10ml (milliliter), 14oz (medication used to treat stomach ulcer) with an expiration date of 2/15.

11. Six stock 1-milliliter (ml) single dose vials of Atropine 0.1mg/1ml (medication used to decrease saliva) with an expiration date of 6/1/2015.

12. Five stock vials of Epinephrine 1mg (1:10,000) (medication used for emergency allergic reactions) with an expiration date of 1/1/2015.

13. One stock bottle of 50% Dextrose 25mg/50ml (solution used to provide fluids and sugar to the body) with an expiration date of 6/1/2015.

14. Twenty-one stock bottles of 50% Dextrose 25mg/50ml with expiration dates of 8/1/15.

15. Two 2ml vials of Verapamil 5mg (2.5mg/ml) (medication for treating high blood pressure) with an expiration date of 8/1/15.

16. One stock bottle of Olanzapine 5mg (medication used to treat mental illness) with an expiration date of 1/15.

17. One stock bottle of Zinc 50mg with an expiration date of 4/15.

19. One stock bottle of Hytrin 5mg (medication used to treat high blood pressure) with an expiration date of 3/15.

20. One stock bottle of Propranolol 10mg (medication to treat high blood pressure) with an expiration date of 3/15.

21. One stock bottle of Phillip's Milk of Magnesium (medication for constipation) with an expiration date of 5/15.

23. One stock bottle of glycerin suppositories (used to help with constipation) with an expiration date of 1/14.

24. Two stock bottles of Novalin R insulin (medication used for diabetes) with an expiration date of 4/15.

25. Seven stock Anucort suppositories (suppositories to help with hemorrhoids) with an expiration date of 1/14/15.

26. Five stock Hemorrhoidal rectal suppositories (suppositories to help with hemorrhoids) with an expiration date of 3/14.

27. Two stock vials of succinylcholine (medication used to sedate patients) 200mg (20mg/ml) with an expiration date of 7/1/15.

28. One stock bottle of 70% Isopropyl Alcohol with expiration date of 9/14.

29. One stock tube of Aquaphor ointment (cream to soften the skin) with an expiration date of 9/14.

30. One stock tube of Fluorouracil cream 5% cream (cream used for skin irritations) with an expiration date of 12/14.

31. Fourteen Rayon tipped applicators with an expiration date of 12/14.

32. Three Gelocast (gauze used to make a cast for broken bones) 3inch x 10 yards with an expiration date of 10/10.

34. Fifty-one adult tongue depressors with an expiration date of 5/14. Two 50-milliliter (ml) multi dose vials of Lidocaine 1% (used to numb skin) with an expiration date of 12/1/14.

35. Two Betadine Swab sticks (used to clean skin) in the IV (Intravenous) Tray with an expiration date of 10/97.

36. Two Alcohol Swab sticks (used to clean skin) in the IV Tray with an expiration date of 10/14.

37. One vial of stock Nitrostat (used for chest pain) tabs 0.4mg with an expiration date of 4/15.

38. One bottle of stock Vitamin D 50,000 USP Units with expiration date of 3/15.

39. One 500 ml glass bottle of 5% Dextrose (used for IV administration) with an expiration date of 9/14.

40. One Transsytem sterile Transport Swab for aerobes and anaerobes (culture for various microorganisms) with an expiration date of 12/2014.

41. One Transsystem sterile Transport Swab for aerobes and anaerobes (culture for various microorganisms) with an expiration date of 7/2014.

42. One Dexon 3-0 sutures, 30 inches, (used for wound closure) with an expiration date of 3/2011.

43. Two Ethilon 5/0 black monofilament sutures, 18 inches, (used for wound closure) with an expiration date of January 2013.

44. One five-milliliter multi-dose vial of Betamethasone (used for inflammation), 30mg/5ml opened with no date when opened, and an expiration date of 9/14.

45. Twenty single dose vials of 5ml Dexamethasone (steroid used to treat inflammation and other medical conditions) 4mg/ml with expiration dates of 7/15.

46. Twenty-five single dose vials of Heparin (used as anticoagulant to thin the blood) 1000 Units/ml with an expiration date of 2/1/15.

47. One 1000ml bag of 0.45% Sodium Chloride (used for IV hydration) with an expiration date of 4/1/15.

- The Intermediate Swing Bed Narcotic lock box revealed the following outdated medications:

1. Seven Clonazepam 0.5mg tablets (medication used to treat anxiety) with an expiration date of 7/9/15.

2. Thirteen Zolpidem 5mg tablets (medication to assist with sleep) with an expiration date of 7/6/15.

- The Acute Narcotic lock box revealed the following outdated medications:

1. Twenty-five 1ml vials of Phenobarbital 65mg/1ml for injection (medication used to treat seizures) with an expiration date of 7/15.

2. Twenty-two OxyContin 10mg tablets (medication used to treat pain) with an expiration date of 5/15.

3. Ten Lortab 10/325 tablets (medication to treat pain) with an expiration date of 12/20/14.

Staff RN F interviewed on 8/10/15 at 1:10pm acknowledged all of the outdated medications and reports the pharmacist had not picked them up. States, "That's the reason they're still here".

Staff RN G interviewed on 8/10/15 at 2:20pm reports she has a container she puts all the outdated medication in for the pharmacist to pick up. Staff RN G confirmed all the medications in the medication room were expired and that she is aware and working on a process for keeping track of expired medications.

Pharmacist R interviewed on 8/10/15 at 3:25pm acknowledged the outdated medications in the pharmacy. Pharmacist R did not give a reason for not picking up the outdated medications.

- Observation of the delivery room on 8/10/15 at 3:50pm revealed the following:

1. One-1000ml bottle of 0.9% Sodium Chloride for irrigation with an expiration date of 2//15.

2. One-16 ounce bottle of Hydrogen Peroxide (used as a disinfectant) with an expiration date of 6/14.

3. One-30ml bottle of 0.9% Sodium Chloride with an expiration date of 5/1/15.

- The "Braun" manufacturer's guidelines reviewed on 8/11/15 at 3:00pm directed, "... Our PIC (plastic irrigation containers)...It is recommended the product be stored at room temperature ...however, brief exposure up to 40 degrees Celsius (102 degrees Fahrenheit) does not adversely affect the product..."brief exposure can be defined as up to one month (4 weeks) storage at 40 degrees Celsius ... "

- The CAH's policy titled, "Operating Room Policy and Procedure" reviewed on 8/10/15 at 2:50pm directed, " ...It is the policy of the Operating Room (OR) to date the Normal Saline and Sterile Water for irrigation bottles as they are put into the warming cabinet. They remain stable for a period of one month, after which time they will be discarded..."

- Observation in the operating room area on 8/10/15 at 2:00pm revealed a fluid warming cabinet with a temperature of 125 degrees Fahrenheit with the temperature control set at 125 degrees Fahrenheit. The fluid warming cabinet contained; eight-1000ml of sterile water for irrigation and six-1000ml bottles of 0.9% Sodium Chloride. The bottles lacked a date when placed in the warming cabinet and exceeded the manufacturer's temperature for warming the fluids

Staff B, RN, Administrative staff interviewed on 8/10/15 at 2:00pm acknowledged the expired medications and fluids in the warming cabinet lacked a date when placed in the warming cabinet therefore staff could not determine how long the fluids remained in the warming cabinet.

Staff B, RN, Administrative staff interviewed on 8/11/15 at 3:00pm acknowledged the fluids in the warming cabinet exceeded the manufacturer's guidelines for the recommended temperature to warm the fluids.

The Critical Access Hospital (CAH) reported a census of fourteen patients, one skilled swing bed patient and thirteen intermediate swing bed patients. Based on observation, staff interview, and policy review the CAH failed to develop an active and comprehensive infection control system which identified and investigated staff practices for one of three medication passes; one of one dietary observation; one of one Solarium; two of two Waiting Rooms; one of one Commode Room; one of one observation of patient bathroom; and one of one medication refrigerator. The failure of the CAH to ensure infection control practices are followed has the potential to place all admitted to the CAH at risk for healthcare associated infections.

Findings include:

The CAH's policy titled "STANDARD PRECAUTIONS (BODY SUBSTANCE ISOLATION/UNIVERSAL PRECAUTIONS) reviewed on 8/17/15 at 11:00am directed "...Standard Precautions represents a system of barrier precautions to be used by all personnel for contact with blood, all body fluids, secretions, excretions, non intact skin, and mucous membranes on ALL patients, regardless of the patient's diagnosis. Disposable (single use) gloves shall be readily available in patient care and specimen handling areas. Wear masks in combination with eye protection devices (goggles or glasses with side shields) or chin length face shields during procedures that are likely to generate droplets, spray, or splash of body substances to prevent exposure to mucous membranes of the mouth, nose and eyes. The appropriate type of garment shall be based on the task and the degree of exposure anticipated. Gowns are worn to prevent contamination of clothing and protect the skin of personnel from blood/body/fluid exposure..."

- Observation of the north wing for acute patients on 8/11/15 between 9:20 am and 9:30 am revealed a "commode room" used to clean out commodes. The "commode room" had a sprayer for staff use and disposable masks as the only PPE (personal protective equipment) available.

Maintenance Staff D interviewed on 8/11/15 between 9:20 am and 9:30 am confirmed the "commode room" was lacking gloves, face shields, and gowns.

- Observation of the west wing Room 120 on 8/11/15 at 9:30 am revealed a bathroom with a sprayer by the toilet for staff use. The bathroom in Room 120 revealed no PPE available for staff use.

Maintenance Staff D interviewed on 8/11/15 at 9:30 confirmed the bathroom in Room 120 did not have PPE for staff use.

Administrative Staff A and Administrative Staff B interviewed on 8/12/15 at 7:55am acknowledged the commode room lacked gloves, gowns, and goggles for staff use. Administrative Staff A and Administrative Staff B acknowledged the bathroom in Room 120 did not have any PPE.

- Observation of the Solarium on 8/11/15 at 9:45 am revealed seven maroon chairs, two green flowered chairs, one green flowered couch, one blue rocking chair covered with fabric leaving the furniture surfaces as "uncleanable" .

Maintenance Staff D interviewed on 8/11/15 at 9:45 am confirmed the chairs in the solarium are covered with fabric. Maintenance Staff D reports he's unsure how the chairs are cleaned.

- Observation of the waiting room by the hospital main entrance on 8/11/15 at 9:55 am revealed four maroon chairs and three green flowered chairs covered with fabric leaving them "uncleanable".

- Observation of the waiting room on the lower level of the hospital shared by the ER (Emergency Room) and OR (Operating Room) on 8/11/15 at 10:00 am revealed thirteen maroon chairs covered with fabric leaving them "uncleanable".

Housekeeping Supervisor C interviewed on 8/12/15 at 10:58 am confirmed chairs in the Solarium and two waiting rooms have chairs covered with fabric. Housekeeping Supervisor C reports they clean the chairs regularly with Resolve Upholstery Cleaner and spray with a disinfectant. Housekeeping Supervisor C states she did not know why they got cloth chairs for use in the hospital.

Administrative Staff A and Administrative Staff B interviewed on 8/12/15 at 7:55 am acknowledged chairs in the Solarium and two waiting rooms were covered with fabric. Administrative Staff A and Administrative Staff B confirmed that fabric chairs cannot be properly cleaned. Administrative Staff A and Administrative Staff B confirmed the CAH does not have a policy for cleaning chairs.

- The CAH ' s policy titled " Standard Precautions " for all hospital departments reviewed on 8/14/15 at 9:00am directed staff, "...indications for Handwashing and Hand Antisepsis ...before having direct contact with patients..."

-Staff RN J observed 8/11/15 at 4:00pm revealed no hand hygiene performed after entering patient #46 and #47's room and prior to administering medication to them.

Staff RN J interviewed 8/11/15 at 4:20pm acknowledged hand hygiene should be performed prior to entering patient room.

- Staff RN J observed 8/11/15 at 4:23pm revealed a medication tray placed onto the bedside table of patient #48 without a protective barrier then Staff RN J took the medication tray back to the nurses station without cleaning it.

Staff RN J interviewed 8/11/15 at 4:23pm acknowledged placement of medication tray without a barrier.

Staff RN A interviewed 8/12/15 at 8:45am states "I don't think we have a policy for that".

- The Critical Access Hospital (CAH) failed to develop a policy and procedure for cleaning of general supplies.

- Pharmacy room observed on 8/10/15 at 12:55pm revealed staff food in freezer of refrigerator used for patients.

Staff LPN E interviewed on 8/10/15 at 12:55pm acknowledged there was staff food in the patient refrigerator.

- Policy review on 8/13/15 revealed the CAH failed to develop and implement a policy and procedure that ensures staff food is not placed in patient refrigerator.

Staff RN A interviewed on 8/13/15 at 1:20pm confirmed the CAH has no policy and procedure for staff food stored in the patient refrigerator.

- The Dietary kitchen observed on 8/12/15 between 9:15am and 9:30am revealed two oscillating standing fans with observable dust blowing directly onto prep table while staff prepared food, and one wall mounted fan blowing directly onto closed food cart.

Dietary Staff I interviewed on 8/12/15 at 9:20am confirmed they routinely have fans turned on in the kitchen area.

The Critical Access Hospital (CAH) reported a census of fourteen patients, one skilled swing bed patient and 13 intermediate swing bed patients. Based on emergency room (ER) medical records reviewed, policy review, medical staff rules/regulations, and staff interview the CAH failed to ensure ER medical records contained accurate and complete information for 11 of 21 ER records reviewed (patient # 's 2, 3, 4, 10, 36, 38, 40, 41, 42, 43, and 49). The CAH's failure to ensure ER patients' medical records are accurate and complete has the potential for poor patient outcomes.

Findings include:

- The CAH's ER policy titled, "Medical Records" reviewed on 8/12/15 at 4:00pm directed, "...The record from the ER will be legible, easily understandable reflection of the patient's encounter including; date and time, means of arrival, clinical impression, plans, orders, results of treatments, results of tests or procedures, disposition condition on discharge, discharge plan and patient's understanding of discharge instructions..."

- The CAH's ER policy titled, "Patient Discharge" reviewed on 8/12/15 at 4:00pm directed, "...All patients will receive written discharge instructions related to their condition which specify actions to be taken, appropriate follow up care and any contact agencies necessary..."

- The Medical Staff Rules and Regulations reviewed on 8/17/15 at 2:20pm directed, "...Records are to be completed within 30 days after the patient is discharged..."

- Patient #2's medical record reviewed on 8/11/15 revealed a 7 years old presented to the ER on 6/1/15 at 9:25pm with a complaint of headache pain, vomited once (history of migraine headaches). The medical record failed to include when the physician arrived in the ER and the condition of the patient upon arrival (Stable, Critical or Dead on Arrival) to the ER.

- Patient #3's medical record reviewed on 8/11/15 revealed they presented to the ER on 3/3/15 at 1:00am with a complaint of migraine headache. The medical record review on 8/11/15 lacked evidence of discharge instructions. The CAH failed to ensure the patient received discharge instructions for appropriate follow up care after discharge from the ER.

- Patient #4's medical record reviewed on 8/11/15 revealed they presented to the ER on 4/19/15 at 10:10am with a complaint of chest pressure. The medical record failed to include when the ER staff notified the physician, when the physician arrived in the ER and the condition of the patient on arrival to the ER.

- Patient #10's medical record reviewed on 8/11/15 revealed they presented to the ER on 7/14/15 at 8:20am with complaints of migraine headache, nausea, and pain in back left side of neck. The medical record failed to include the patient's condition on arrival to the ER and discharge instructions.

- Patient #36's medical record reviewed on 8/12/15 revealed they presented to the ER on 2/9/15 at 5:50pm with a complaint of pink/warm/indurated area size of the human hand to medial inner left thing. The medical record failed to include when the ER staff notified the physician, when the physician arrived in the ER, and the patient's condition upon arrival to the ER.

- Patient #38's medical record reviewed on 8/12/15 revealed they presented to the ER on 1/4/15 at 12:25pm with complaint of on-going cold for one week and migraine past two days. The medical record failed to include when the ER staff notified the physician and when the physician arrived in the ER.

Patient #40's medical record reviewed on 8/12/15 revealed review on 8/12/15 revealed they presented to the ER on 2/17/15 at 1:35pm by ambulance following a motor vehicle accident with complaint of right knee pain and sore chest. The medical record failed to include when the ER staff notified the physician and the condition of the patient upon arrival.

-Patient #41's medical record reviewed on 8/12/15 revealed they presented to the ER on 3/6/15 at 10:10am with a complaint of extreme shortness of breath that started that morning. The medical record failed to include when the ER staff notified the physician and when the patient arrived in the ER.

- Patient #42's medical record reviewed on 8/12/15 revealed they presented to the ED on 3/8/15 at 8:20am with complaint of bloody drainage from suture line right foot. The medical record failed to include when the ER staff notified the physician.

- Patient #43's medical record reviewed on 8/12/15 revealed they presented to the ER on 3/16/15 at 7:00am with complaint of lower back pain-rates pain at a 10 (10 meaning the greatest level of pain on the scale). The medical record failed to include when the ER staff notified the physician, when the patient arrived in the ER and the condition of the patient on admission.

- Patient #49's medical record reviewed on 8/11/15 revealed they presented to the ER on 5/3/14 with complaints of coughing, elevated temperature, and productive cough. The medical record failed to include the time of physician's arrival, and the patient's condition upon arrival to the ER.

Administrator Staff, RN, DON interviewed on 8/12/15 at 3:45pm acknowledged many ED records lack documentation and the records are not completed.

The Critical Access Hospital (CAH) reported a census of fourteen patients, one skilled swing bed patient and thirteen intermediate swing bed patients. Based on medical record review, policy review and staff interview the CAH failed to ensure all entries in the medical record are timed, dated and signed for 7 of 21 Emergency Room (ER) medical records reviewed (patient #'s 2, 4, 5, 9, 42, 44, and 45). The CAH's failure to ensure all entries in the medical record are timed dated and signed are necessary to ensure patient safety and quality of care.

Findings include:

- The CAH's ER policy titled, "Medical Records" reviewed on 8/12/14 at 4:00pm directed, "... All entries in the medical record will be signed with full signature, title, date, and time..."

- Patient #2's medical record reviewed on 8/11/15 revealed they presented to the ER on 6/1/15 at 9:25pm with a complaint of headache pain, vomited once (history of migraine headaches). Review of patient #2's medical record revealed the physician failed to date and time the ER record when they signed the medical record.

- Patient #4's medical record reviewed on 8/11/15 revealed they presented to the ER on 4/19/15 at 10:10am with a complaint of chest pressure. Review of patient #4's medical record revealed the physician failed to enter a time when they signed the medical record.

-Patient#5's medical record reviewed on 8/11/12 revealed they presented to the ER on 1/27/15 at 12:00am with complaints of rash on abdomen and back since taking one dose of Augmentin (an antibiotic) for a cat scratch on right lower leg. Review of patient #5's medical record revealed the physician failed to enter a time when they signed the medical record.

- Patient #9's medical record reviewed on 8/11/15 revealed they presented to the ER on 6/5/15 at 12:50pm with complaint of pain in right arm and not moving it after a fall out of a child sized chair. Review of patient #9's medical record revealed the physician failed to enter a time when they signed the medical record.

- Patient #42's, medical record reviewed on 8/12/15 revealed they presented to the ER on 3/8/15 at 8:20am with complaint of bloody drainage from suture line right foot. Review of patient #42's medical record revealed the physician failed to date and time the medical record when they signed it.

- Patient #44's, medical record reviewed on 8/12/15 revealed an admission to the ER on 4/13/15 at 2:30am. Nursing documentation stated "Pt awake and calling out in ISB (intermediate swing bed) room-complaints of "I hurt so bad" Pt points to right lower quadrant abdomen and also points to right hip fracture scar. Review of patient #44's medical record revealed the physician failed to sign, date, and time the medical record.

- Patient #45's medical record reviewed on 8/12/15 revealed they presented to the ED on 5/20/15 at 3:15pm by ambulance with complaint of fall landing on right hip, hit head on door or water tank. Review of patient #45's medical record revealed the physician failed to sign, date and time the medical record.

Staff B, RN, Administrative staff interviewed on 8/11/15 at 9:00am acknowledged the medical records lacked completeness including dating, timing, and signing all entries in the medical record.

The CAH failed to follow their policy to ensure the all entries in the medical record included dates, times, and physician signatures.

The Critical Access Hospital (CAH) reported an average daily census of one skilled swing bed and thirteen intermediate swing bed patients. Based on review of patient rights, staff interview and policy review the CAH failed to ensure Swing Bed patients were informed of all their patient rights for five of five swing bed records reviewed (patients #17, #18, #19, #20, and #21) in that the patients did not know they had the freedom to choose their own personal physician. This deficient practice had the potential to affect all current and future Swing Bed patients of the CAH.

Findings include:

- Patient #17's medical record reviewed on 8/11/15 revealed an admission date of 6/23/15 with a diagnosis of Urinary Tract Infection (UTI) (infection in the urine) and Coccyx Wound (wound on (wound on tailbone). Patient #17's medical record lacked evidence the CAH informed them or their representative of the patient's right to choose a personal attending MD/DO.

- Patient #18's medical record reviewed on 8/11/15 revealed an admission date of 5/17/15 with a diagnosis of Deep Vein Thrombosis (blood clot in the vein of the leg), dehydration (the body does not have enough water), UTI, Cardiac arrest (sudden loss of heart function) and respiratory arrest (sudden loss of respiratory function). Patient #18's medical record lacked evidence the CAH informed them or their representative of the patient's right to choose a personal attending MD/DO.

- Patient #19's medical record reviewed on 7/21/14 revealed an admission date of 5/10/15 with a diagnosis of UTI, Septicemia (infection in the blood) with E Coli (bacteria infection normally found in the intestine) , change in mental status, hypoxia (body is deprived of adequate oxygen), hypothyroid (when the body does not produce enough thyroid hormone), Congestive Heart Failure (when the heart is not able to pump effectively to maintain adequate blood flow in the body), Pleural effusions (excessive fluid around the lungs), Peripheral Vascular Disease (disorder of the circulatory system), Physical therapy (assistance with impairment of mobility) and Respiratory Therapy(assistance with helping patients breathe more easily). Patient #19's medical record lacked evidence the CAH informed them or their representative of the patient's right to choose a personal attending MD/DO.

- Patient #20's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of Congestive Heart Failure and Arthritis (inflammation of one or more joints that cause pain). Patient #20's medical record lacked evidence the CAH informed them or their representative of the patient's right to choose a personal attending MD/DO.

- Patient #21's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of History of Cerebral Vascular Attack (lack of blood flow that causes damage to the brain), Post Left Hip fracture (broken hip), Urinary Tract Infection, Hypertension (high blood pressure), Depression (when a patient experiences a feeling of sadness) and history of Seizures (disorder in which brain activity is disturbed). Patient #21's medical record lacked evidence the CAH informed them or their representative of the patient's right to choose a personal attending MD/DO.

- Review of the CAH's policies on 8/11/15 revealed the CAH failed to develop and implement a policy and procedure to ensure swing bed patients were informed of all their patient rights.

Staff A interviewed on 8/11/15 acknowledged swing bed patient rights lacked the required patient rights.

The Critical Access Hospital (CAH) reported an average daily census of one skilled swing bed and thirteen intermediate swing bed patients. Based on review of patient rights, staff interview and policy review the CAH failed to ensure Swing Bed patients were informed of all their patient rights for five of five swing bed records reviewed (patients #17, #18, #19, #20, and #21) in that they might not know they have the right to choose who can represent them if they are unable. This deficient practice had the potential to affect all current and future Swing Bed patients of the CAH.

Findings include:

- Patient #17's medical record reviewed on 8/11/15 revealed an admission date of 6/23/15 with a diagnosis of Urinary Tract Infection (UTI) (infection in the urine) and Coccyx Wound (wound on (wound on tailbone). Patient #17's medical record lacked evidence the CAH informed them or their representative of the right for the patient's representative, on behalf of the patient to exercise their rights if judged legally incompetent.

- Patient #18's medical record reviewed on 8/11/15 revealed an admission date of 5/17/15 with a diagnosis of Deep Vein Thrombosis (blood clot in the vein of the leg), dehydration (the body does not have enough water), UTI, Cardiac arrest (sudden loss of heart function) and respiratory arrest (sudden loss of respiratory function). Patient #18's medical record lacked evidence the CAH informed them or their representative of the right for the patient's representative, on behalf of the patient to exercise their rights if judged legally incompetent.

- Patient #19's medical record reviewed on 7/21/14 revealed an admission date of 5/10/15 with a diagnosis of UTI, Septicemia (infection in the blood) with E Coli (bacterial infection normally found in the intestine), change in mental status, hypoxia (body is deprived of adequate oxygen), hypothyroid (when the body does not produce enough thyroid hormone), Congestive Heart Failure (when the heart is not able to pump effectively to maintain adequate blood flow in the body), Pleural effusions (excessive fluid around the lungs), Peripheral Vascular Disease (disorder of the circulatory system), Physical therapy (assistance with impairment of mobility) and Respiratory Therapy(assistance with helping patients breathe more easily). Patient #19's medical record lacked evidence the CAH informed them or their representative of the right for the patient's representative, on behalf of the patient to exercise their rights if judged legally incompetent.

- Patient #20's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of Congestive Heart Failure and Arthritis. Patient #20's medical record lacked evidence the CAH informed them or their representative of their right for the patient's representative, on behalf of the patient to exercise the rights if judged legally incompetent.

- Patient #21's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of History of Cerebral Vascular Attack (lack of blood flow that causes damage to the brain), Post Left Hip fracture (broken hip), Urinary Tract Infection, Hypertension (high blood pressure), Depression (when a patient has a feeling of sadness) and history of Seizures (disorder in which brain activity is disturbed). Patient #21's medical record lacked evidence the CAH informed them or their representative of the right for the patient's representative, on behalf of the patient to exercise their rights if judged legally incompetent.

- The CAH failed to develop and implement policy and procedure to ensure swing bed patients were informed of all their patient rights.

Staff A interviewed on 8/11/15 acknowledged swing bed patient rights lacked the required patient rights.

The Critical Access Hospital (CAH) reported an average daily census of one skilled swing bed and thirteen intermediate swing bed patients. Based on review of patient rights, staff interview and policy review the CAH failed to ensure Swing Bed patients were informed of all their patient rights for five of five records reviewed (patients #17, #18, #19, #20, #21) in that the CAH did not inform them of their right to perform services for the CAH or not to perform services for the CAH. This deficient practice had the potential to affect all current and future Swing Bed patients of the CAH.

Findings include:

- Patient #17's medical record reviewed on 8/11/15 revealed an admission date of 6/23/15 with a diagnosis of Urinary Tract Infection (UTI) (infection in the urine) and Coccyx Wound (wound on tailbone). Patient #17's medical record lacked evidence the CAH informed them or their representative of the patient's right to refuse to perform services for the facility or perform services for the facility if he/she chooses.

- Patient #18's medical record reviewed on 8/11/15 revealed an admission date of 5/17/15 with a diagnosis of Deep Vein Thrombosis (blood clot in the vein of the leg), dehydration (the body does not have enough water), UTI, Cardiac arrest (sudden loss of heart function) and respiratory arrest (sudden loss of respiratory function). Patient #18's medical record lacked evidence the CAH informed them or their representative of the patient's right to refuse to perform services for the facility or perform services for the facility if he/she chooses.

- Patient #19's medical record reviewed on 7/21/14 revealed an admission date of 5/10/15 with a diagnosis of UTI, Septicemia (infection in the blood) with E Coli (bacteria infection normally found in the intestine) , change in mental status, hypoxia (body is deprived of adequate oxygen), hypothyroid (when the body does not produce enough thyroid hormone), Congestive Heart Failure (when the heart is not able to pump effectively to maintain adequate blood flow in the body), Pleural effusions (excessive fluid around the lungs), Peripheral Vascular Disease (disorder of the circulatory system), Physical therapy (assistance with impairment of mobility) and Respiratory Therapy(assistance with helping patients breathe more easily). Patient #19's medical record lacked evidence the CAH informed them or their representative of the patient's right to refuse to perform services for the facility or perform services for the facility if he/she chooses.

- Patient #20's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of Congestive Heart Failure and Arthritis (inflammation of one or more joints that cause pain). Patient #20's medical record lacked evidence the CAH informed them or their representative of the patient's right to refuse to perform services for the facility or perform services for the facility if he/she chooses.

- Patient #21's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of History of Cerebral Vascular Attack (lack of blood flow that causes damage to the brain), Post Left Hip fracture (broken hip), Urinary Tract Infection, Hypertension (high blood pressure), Depression (when a patient experiences a feeling of sadness) and history of Seizures (disorder in which brain activity is disturbed). Patient #21's medical record lacked evidence the CAH informed them or their representative of the patient's right to refuse to perform services for the facility or perform services for the facility if he/she chooses.

- Review of the CAH's policies on 8/11/15 revealed the CAH failed to develop and implement policy and procedure to ensure swing bed patients were informed of all their patient rights.

Staff A interviewed on 8/11/15 acknowledged swing bed patient rights lacked the required patient rights.

The Critical Access Hospital (CAH) reported an average daily census of one skilled swing bed and thirteen intermediate swing bed patients. Based on review of patient rights, staff interview and policy review the CAH failed to ensure Swing Bed patients were informed of all their patient rights for five of five records reviewed (patients #17, #18, #19, #20, and #21) in that the CAH failed to inform them of their right for privacy in written communications and to send and receive mail. This deficient practice had the potential to affect all current and future Swing Bed patients of the CAH.

Findings include:

- Patient #17's medical record reviewed on 8/11/15 revealed an admission date of 6/23/15 with a diagnosis of Urinary Tract Infection (UTI) (infection in the urine) and Coccyx Wound (wound on (wound on tailbone). Patient #17's medical record lacked evidence the CAH informed them or their representative of the right for privacy in written communications, send and promptly receive mail that is unopened, and have access to stationery, postage, and writing implements at the residents own expense.

- Patient #18's medical record reviewed on 8/11/15 revealed an admission date of 5/17/15 with a diagnosis of Deep Vein Thrombosis (blood clot in the vein of the leg), dehydration (the body does not have enough water), UTI, Cardiac arrest (sudden loss of heart function) and respiratory arrest (sudden loss of respiratory function). Patient #18's medical record lacked evidence the CAH informed them or their representative of the right for privacy in written communications, send and promptly receive mail that is unopened, and have access to stationery, postage, and writing implements at the residents own expense.

- Patient #19's medical record reviewed on 7/21/14 revealed an admission date of 5/10/15 with a diagnosis of UTI, Septicemia (infection in the blood) with E Coli (bacteria infection normally found in the intestine) , change in mental status, hypoxia (body is deprived of adequate oxygen), hypothyroid (when the body does not produce enough thyroid hormone), Congestive Heart Failure (when the heart is not able to pump effectively to maintain adequate blood flow in the body), Pleural effusions (excessive fluid around the lungs), Peripheral Vascular Disease (disorder of the circulatory system), Physical therapy (assistance with impairment of mobility) and Respiratory Therapy(assistance with helping patients breathe more easily). Patient #19's medical record lacked evidence the CAH informed them or their representative of the right for privacy in written communications, send and promptly receive mail that is unopened, and have access to stationery, postage, and writing implements at the residents own expense.

- Patient #20's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of Congestive Heart Failure and Arthritis (inflammation of one or more joints that cause pain). Patient #20's medical record lacked evidence the CAH informed them or their representative of their right for the patient's right to privacy in written communications, send and promptly receive mail that is unopened, and have access to stationery, postage, and writing implements at the residents own expense.

- Patient #21's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of History of Cerebral Vascular Attack (lack of blood flow that causes damage to the brain), Post Left Hip fracture (broken hip), Urinary Tract Infection, Hypertension (high blood pressure), Depression (when a patient experience a feeling of sadness) and history of Seizures (disorder in which brain activity is disturbed). Patient #21's medical record lacked evidence the CAH informed them or their representative of the right for privacy in written communications, send and promptly receive mail that is unopened, and have access to stationery, postage, and writing implements at the residents own expense.

- Policy review on 8/11/15 revealed, the CAH failed to develop and implement policy and procedure to ensure swing bed patients were informed of all their patient rights.

Staff A interviewed on 8/11/15 acknowledged swing bed patient rights lacked the required patient rights.

The Critical Access Hospital (CAH) reported an average daily census of one skilled swing bed and thirteen intermediate swing bed patients. Based on review of patient rights, staff interview and policy review the CAH failed to ensure Swing Bed patients were informed of all their patient rights for five of five records reviewed (patients #17, #18, #19, #20, and #21) in that the CAH failed to inform the patients of their right to have or not to have visitors. This deficient practice had the potential to affect all current and future Swing Bed patients of the CAH.

Findings include:

- Patient #17's medical record reviewed on 8/11/15 revealed an admission date of 6/23/15 with a diagnosis of Urinary Tract Infection (UTI) (infection in the urine) and Coccyx Wound (wound on tailbone). Patient #12's medical record lacked evidence the CAH informed them or their representative the right for the patient's right to deny or withdraw consent at any time, immediate family, other relatives of the resident or other visitors visiting the resident.

- Patient #18's medical record reviewed on 8/11/15 revealed an admission date of 5/17/15 with a diagnosis of Deep Vein Thrombosis (blood clot in the vein of the leg), dehydration (the body does not have enough water), UTI, Cardiac arrest (sudden loss of heart function) and respiratory arrest (sudden loss of respiratory function). Patient #18's medical record lacked evidence the CAH informed them or their representative of the right for the patient ' s to deny or withdraw consent at any time, immediate family, other relatives of the resident or other visitors visiting the resident.

- Patient #19's medical record reviewed on 7/21/14 revealed an admission date of 5/10/15 with a diagnosis of UTI, Septicemia (infection in the blood) with E Coli (bacteria infection normally found in the intestine) , change in mental status, hypoxia (body is deprived of adequate oxygen), hypothyroid (when the body does not produce enough thyroid hormone), Congestive Heart Failure (when the heart is not able to pump effectively to maintain adequate blood flow in the body), Pleural effusions (excessive fluid around the lungs), Peripheral Vascular Disease (disorder of the circulatory system), Physical therapy (assistance with impairment of mobility) and Respiratory Therapy(assistance with helping patients breathe more easily). Patient #19's medical record lacked evidence the CAH informed them or their representative of the right for the patient's to deny or withdraw consent at any time, immediate family, other relatives of the resident or other visitors visiting the resident.

- Patient #20's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of Congestive Heart Failure and Arthritis (inflammation of one or more joints that cause pain). Patient #20's medical record lacked evidence the CAH informed them or their representative of the right for the patient's right to deny or withdraw consent at any time, immediate family, other relatives of the resident or other visitors visiting the resident.

- Patient #21's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of History of Cerebral Vascular Attack (lack of blood flow that causes damage to the brain), Post Left Hip fracture (broken hip), Urinary Tract Infection, Hypertension (high blood pressure), Depression (when a patient experience a feeling of sadness) and history of Seizures (disorder in which brain activity is disturbed). Patient #21's medical record lacked evidence the CAH informed them or their representative of the right for the patient ' s to deny or withdraw consent at any time, immediate family, other relatives of the resident or other visitors visiting the resident.

- The CAH failed to develop and implement policy and procedure to ensure swing bed patients were informed of all their patient rights.

Staff A interviewed on 8/11/15 acknowledged swing bed patient rights lacked the required patient rights.

The Critical Access Hospital (CAH) reported an average daily census of one skilled swing bed and thirteen intermediate swing bed patients. Based on review of patient rights, staff interview and policy review the CAH failed to ensure Swing Bed patients were informed of all their patient rights for five of five records reviewed (patients #17, #18, #19, #20, and #21) in that the CAH failed to inform the patients of their right to share a room with their spouse. This deficient practice had the potential to affect all current and future Swing Bed patients of the CAH.

Findings include:

- Patient #17's medical record reviewed on 8/11/15 revealed an admission date of 6/23/15 with a diagnosis of Urinary Tract Infection (UTI) (infection in the urine) and Coccyx Wound (wound on tailbone). Patient #17's medical record lacked evidence the CAH informed them or their representative of the patient's right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

- Patient #18's medical record reviewed on 8/11/15 revealed an admission date of 5/17/15 with a diagnosis of Deep Vein Thrombosis (blood clot in the vein of the leg), dehydration (the body does not have enough water), UTI, Cardiac arrest (sudden loss of heart function) and respiratory arrest (sudden loss of respiratory function). Patient #18's medical record lacked evidence the CAH informed them or their representative of the patient's right toshare a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

- Patient #19's medical record reviewed on 7/21/14 revealed an admission date of 5/10/15 with a diagnosis of UTI, Septicemia (infection in the blood) with E Coli (bacteria infection normally found in the intestine) , change in mental status, hypoxia (body is deprived of adequate oxygen), hypothyroid (when the body does not produce enough thyroid hormone), Congestive Heart Failure (when the heart is not able to pump effectively to maintain adequate blood flow in the body), Pleural effusions (excessive fluid around the lungs), Peripheral Vascular Disease (disorder of the circulatory system), Physical therapy (assistance with impairment of mobility) and Respiratory Therapy(assistance with helping patients breathe more easily). Patient #19's medical record lacked evidence the CAH informed them or their representative of the patient's right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

- Patient #20's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of Congestive Heart Failure and Arthritis (inflammation of one or more joints that cause pain). Patient #20's medical record lacked evidence the CAH informed them or their representative of the patient's right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

- Patient #21's medical record reviewed on 8/11/15 revealed an admission with a diagnosis of History of Cerebral Vascular Attack (lack of blood flow that causes damage to the brain), Post Left Hip fracture (broken hip), Urinary Tract Infection, Hypertension (high blood pressure), Depression (when a patient experience a feeling of sadness) and history of Seizures (disorder in which brain activity is disturbed). Patient #21's medical record lacked evidence the CAH informed them or their representative of the patient's right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement.

- Review of CAH Policies revealed the CAH failed to develop and implement policy and procedure to ensure swing bed patients were informed of all their patient rights.

Staff A interviewed on 8/11/15 acknowledged swing bed patient rights lacked the required patient rights.