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Based on bylaws review, record review, and staff interview, the governing body failed to ensure the Critical Access Hospital (CAH) followed the medical staff's rules and regulations regarding admission orders for 11 of 20 patient records (Patients #1, #3, #4, #11, #14, #15, #17, #19, #21, #25, and #26) reviewed. Failure to follow the rules and regulations may have limited the CAH's ability to provide the necessary services to meet patient needs.

Findings include:

Review of the governing body's "Bylaws of Carrington Health Center" occurred on 11/30/15. These bylaws, effective 05/19/09, stated, ". . . Article IX
Medical Staff . . .
Section 9.2 Medical Staff Bylaws. There shall be bylaws, rules and regulations for the Medical Staff setting forth its organization and government. Bylaws, rules and regulations shall be adopted by the Medical Staff, but only those approved by the Board of Directors shall become effective. . . ."

Review of the "Carrington Health Center Medical Staff Bylaws" occurred on 11/30/15. These bylaws, approved by the governing board on 03/21/02, stated, ". . . Article VIII
Rules and Regulations of the Medical Staff
(a) Medical staff Rules and Regulations, as may be necessary to implement more specifically the general principles of conduct found in these bylaws, shall be adopted in accordance with this Article. . . . Rules and Regulations shall have the same force and effect as the bylaws and are incorporated herein. . . ."

Review of the "Rules and Regulations of the Medical Staff Carrington Health Center" occurred on 11/30/15. These undated rules and regulations stated, ". . . Admissions
1. A physician's order is required for a patient admission to the hospital. . . ."

The following patient records, reviewed from November 30 - December 2, 2015, failed to include evidence of a physician's order for admission:
* Patient #1 - admitted 11/29/15
* Patient #3 - admitted 11/28/15
* Patient #4 - admitted 11/28/15
* Patient #11 - admitted 10/07/15
* Patient #14 - admitted 06/04/15
* Patient #15 - admitted 06/22/15
* Patient #17 - admitted 10/08/15
* Patient #19 - admitted 06/12/15
* Patient #21 - admitted 06/11/15
* Patient #25 - admitted 11/26/15
* Patient #26 - admitted 09/28/15

During an interview on 12/01/15 at 2:30 p.m., a nurse manager (#1) indicated a physician's order was not required for the admission of a patient to the CAH which failed to follow the facility's rules and regulations.


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Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to clarify a physician's order for 1 of 4 active patient (Patient #4) records reviewed. Failure to clarify a physician's order after identifying a high risk for venous thromboembolism (VTE) [blood clot] resulted in Patient #4 not receiving treatment related to this risk factor.

Findings include:

Review of the policy "Venous Thromboembolism Prevention" occurred on 12/02/15. This policy, revised December 2014, stated, ". . . Procedure: All observation, acute, and SwingBed patients, over the age of 18, will have a risk assessment completed and proper prophylaxis for VTE will be ordered within 24 hours of admission. 1. When patient is admitted to the hospital a risk assessment will be completed. 2. The physician can either order the prophylaxis from eHR [electronic health record] order sets, Admission Basic or Admission Med/Surg [Medical/Surgical] order sets or as an individual order. . . ."

Review of Patient #4's medical record occurred on all days of survey. The record showed an admission date of 11/28/15 and identified the patient on bedrest, weak, unsteady, confused, and a transfer assist of 1-2 staff. An undated "Venous Thromboembolism Risk Assessment and Orders (VTE)" form showed Patient #4 as a high risk for deep vein thrombosis (DVT) due to "Medical patient currently on bed rest - w/c [wheelchair] . . . Age 75 years or more. . . ." The physician signed the form, but failed to include a prophylactic [prevention] regimen.

During an interview on 12/02/15 at 9:50 a.m., two supervisory nurses (#2 and #4) agreed nursing staff failed to ensure the physician addressed the patient's need for DVT prophylaxis.