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Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to ensure that patients were given written notice of patient's rights for 1 out of 21 inpatient records reviewed (Patient identifier is #18).

Findings include:

Review on 9/19/23 of Patient #18's Admission History and Physical signed by the clinician on 8/2/23 revealed that Patient #18 was presented to the Emergency Department on 8/2/23 and was admitted to the CAH on 8/3/23.

Review on 9/19/23 of Patient #18's nursing progress note dated 8/3/23 at 5:17 p.m. revealed that Patient #18 was alert and oriented x4 (person, place, time, situation).

Review on 9/19/23 of Patient #18's medical record revealed no documentation that Patient #18 received a written Patient Bill of Rights.

Interview on 9/19/23 at 2:30 p.m. with Staff E (Nurse Manager) confirmed the above findings.

Review on 9/20/23 of the facility's policy titled "Patient Bill of Rights" last reviewed 8/2020 revealed, "... At the time of registration the registrar reviews the patient's information on the computer. If the patient has not received a copy of the Patient Bill of Rights in the last year, the registrar will offer the patient a copy, enter this in the computer, and ask the patient to signet hat they have received a copy... For inpatients, the Patient and Family guide is made available to each inpatient on admission. It includes the Patient's Bill of Rights..."

Based on observation, interview, and review of manufacturer's instruction, it was determined that the Critical Access Hospital (CAH) failed to ensure that glucometers were maintained in safe, operating condition for 2 out of 7 departments performing point of care glucose testing.

Findings include:

Review on 9/18/23 of manufacturer's instructions of StatStrip Glucose Hospital Meter Test Strips for the glucose test strips revealed, under section 11. Expiration "The expiration date is printed on the vial of test strips. Once opened, the StatStrip Glucose Hospital Meter Test Strips are stable, when stored as indicated, for up to 6 months or until the expiration date, whichever comes first."

Review on 9/18/23 of manufacturer's instructions of Nova StatStrip Glucose Control Solution, Level 1 and Level 3 for the glucose testing solutions revealed, under section Expiration, "The expiration date is printed on the control vials. Once opened, the solutions stored as indicated will be stable for up to 3 months or until the expiration date, whichever comes first."

Observation on 9/18/23 at approximately 1:00 p.m. in the Primary Care department revealed that the StatStrip Glucose Hospital Meter Test Strips and the Nova Statstrip Glucose Control Solutions (Level 1 and Level 3) had no "opened on" or "discard on" dates labeled on each opened bottle/container.

Observation on 9/18/23 at approximately 1:20 p.m. in the Internal Medicine Care department revealed that the StatStrip Glucose Hospital Meter Test Strips and the Nova Statstrip Glucose Control Solutions (Level 1 and Level 3) had no "opened on" or "discard on" dates labeled on each opened bottle/container.

Interview on 9/18/23 between 1:00 p.m. and 1:20 p.m. with Staff C (Nurse Manager) and Staff D (Senior Director of Physician Practices) confirmed the above observations.

Based on interview and record review, the Critical Access Hospital (CAH) failed to maintain records according to written policies and procedures to ensure complete records.

Findings include:

Review on 9/20/23 of the CAH's audits for complete medical records revealed that inpatient records had not been completed for August 2023. Further review revealed that surgical, outpatient, and emergency department record audits were not completed for July and August 2023.

Review on 9/20/23 of the facility's "Health Record Information/Medical Record Department" , revised on 12/2011, read, in part, " ER Physician Process For Incomplete Record", "The Emergency Department [ED] physician electronic records and/or typed reports shall be completed within 24-36 hours. The Emergency Department physicians shall not consider their duties complete until all required information is written on the printed electronic records delivered by the Health Records Information Department. The ED physicians shall not consider their duties complete until all of the addendums have been completed in the electronic record with the same information that was written on the printed electronic record."

Review on 9/20/23 of the facility's "Health Record Information/Medical Record Department" , revised on 1/2017, read, in part, " Incomplete Record Count" "Policy Statement/Purpose: Health records shall be completed in a timely manner, no later than 14 (fourteen) days from the date of discharge. The Rules and Regulations of the Medical Staff and Medicare of participation will guide this policy...HMS electronically monitors, tracks and records this based on the 14 day timeline."

Interview on 9/20/23 at approximately 10:45 a.m. with Staff B (Health Information Management (HIM) Manager) revealed that the HIM Manager had not checked the medical records to ensure the providers completed their record within the allocated time frame, which is "usually 30 days". Staff B also revealed that the emergency room records, outpatient records, and surgical records had not been reviewed for completeness for the months of July and August 2023 and that the inpatient records had not been reviewed for completeness for August 2023.

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to have complete and accurate records for 1 of 21 patients reviewed for inpatient records (Patient Identifiers is #35).

Findings include:


26364

Patient #35

Review on 9/19/23 of Patient #35's medical record revealed that Patient #35 was admitted through the Emergency Department on 9/8/23 and placed on observation status until 9/23/23, at which time Patient #35 was admitted inpatient on 9/11/23.

Further review on 9/19/23 of Patient #35's medical record revealed Patient #35 was admitted to observation status on 9/8/23 and was placed on comfort care and Do Not Resuscitate (DNR) and Do Not Intubate (DNI) due to Patient #35's diagnosis of metastatic malignant cancer.

Further review on 9/19/23 of Patient #35's medical record revealed Patient #35 was admitted to inpatient on 9/11/23 at which time the orders for DNR and DNI were not carried over or did not get reordered. The order for comfort care continued.

Interview on 9/19/23 at 10:30 a.m. with Staff E (Nurse Manager) and Staff F (Registered Nurse) confirmed the above. Staff F confirmed that the facility had no policy that defined comfort care that would include DNR/DNI.

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to ensure that the patient medical records included properly executed informed consents for 1 out of 21 inpatient records reviewed (Patient identifier is #18).

Findings include:

Review on 9/19/23 of Patient #18's Admission History and Physical signed by the clinician on 8/2/23 revealed that Patient #18 was presented to the Emergency Department on 8/2/23 and was admitted to the CAH on 8/3/23.

Review on 9/19/23 of Patient #18's nursing progress note dated 8/3/23 at 5:17 p.m. revealed that Patient #18 was alert and oriented x4 (person, place, time, situation).

Review on 9/19/23 of Patient #18's medical record revealed no signed informed consent to treat completed by Patient #18.

Interview on 9/19/23 at 2:30 p.m. with Staff E (Nurse Manager) confirmed there was no signed consent to treat.

Review on 9/20/23 of the facility's policy "Consent to Treat and Informed Consent" last reviewed 2/2020 revealed, "...Upon first contact and every visit thereafter, eery inpatient and outpatient, or Legally Authorized person for the patient, will be asked to sign... General Consent statement. The General Consent statement will include a general consent to treat... The Informed Consent must be scanned in the patient's electronic medical record...."