HospitalInspections.org

Based on review of credential files, review of the agreement with a Nebraska acute care Hospital (Network Hospital) and staff interview, the Critical Access Hospital (CAH) failed to ensure that the appropriateness of diagnosis and treatment furnished by doctors of medicine and/or osteopathy was reviewed by the contracted network hospital for 10 of 10 physician credential files reviewed (Physicians A, B, C, D, E, F, H, I, J, and K). This failed practice had the potential to affect all patients of the CAH. The roster of the medical staff provided by the CAH listed 118 doctors of medicine and/or osteopathy.

Findings are:

A. Review of the Network Agreement with an effective date of 10/25/2005 and the Amendment to Network Agreement dated 1/1/2015 revealed the following:
"As necessary, and upon request of QA [Quality Assurance] representatives of the CAH, the CAH's Medical Staff, the CAH's Administrator/CEO [Chief Executive Officer], or the CAH's governing body, peer review assistance will be provided by the peer review organization currently under contract with the CAH for this service."

(Peer review is the process by which a committee and/or another physician examines the work of a peer and determines whether the physician under review has met accepted standards of care in rendering medical services.)

B. Review of the Credential and Quality files for Physicians A, B, C, D, E, F, H, I, J, and K revealed these physicians' quality files contained a summary of clinical activity at the CAH, however, none of the files contained information concerning external peer review.

C. Interview with the Compliance Officer on 12/16/15 from 9:12 AM to 9:20 AM revealed the following:
-The CAH has no contract for external peer review.
-The internal Peer Review Committee talked about a contract but have not done anything yet.
-The CAH has an internal peer review process but no external review process.

Based on record review and staff interview the facility failed to complete a comprehensive assessment within 14 days of admission for 1 of 1 (Patient 35) Swing Bed sampled patients with a length of stay longer than 14 days. This finding has the potential to cause staff to fail to identify and provide care/services to meet the needs of the resident based on a completed comprehensive assessment of their current level of functioning. The facility Swing Bed census was 2. The total Swing Bed sample size was 5, including 3 closed records.

Findings are:

A. Record review revealed Patient 35 was admitted on 10/29/15 after an acute hospital stay for bacterial infection around heart and dismissed 11/19/15. The record failed to have a comprehensive assessment completed by the 14th day (11/12/15) as required.
B. An interview on 12/16/15 at 4:00 PM with the Director of Acute Care, confirmed the facility did not have a comprehensive assessment which included all the required assessments of the patient's functional status for Patient 35. The Director of Acute Care related that the Critical Access Hospital rarely has anyone with a stay of 14 days or greater.

Based on record review and staff interview the facility failed to ensure that the Speech Therapy (ST) strategy recommendations to assist with safe swallowing for 1 of 1 (Patient 33) patients were communicated to nursing staff, care planned and implemented. This has the potential to effect any inpatient receiving a Speech Therapy evaluation.

Findings are:

A. A review of Patient 33's medical record revealed that the patient was admitted into Swing Bed status following a hospitalization in Omaha for abdominal pain and pneumonia. Speech Therapy received an order for a Bedside Swallow Evaluation (A test given by the Speech Therapist in the patients room to evaluate the patients ability to safely swallow foods and fluids.). The Speech Therapist conducted the bedside test on 12/8/15 at 1517 (3:17 PM).
The Speech Therapist Plan included:
-Patient appeared to tolerate a regular level 4 (regular diet) with thin liquids without overt s/s (signs or symptoms) of aspiration or penetration (food or fluid going down the windpipe into lungs) during the swallow evaluation.
-Aspiration Precautions- Patient is at risk for aspiration due to fatigue during meal. Recommend safe swallowing strategies of smaller meal size, smaller bite sizes, alternating bites of food with sips of liquids, as well as a secondary swallow.
-Feeding Plan Recommendations- Repetitive Dry Swallows; Alternate Liquids/Solids; Bolus size small; Small/Frequent Meals; Upright in Chair for All Meals
-Strategies-Smaller more frequent meals, smaller bite sizes, alternating bites with sips of liquids, and secondary swallow to assist in clearing pharyngeal cavity.
-Interventions- Patient Education

B. A review of Patient 33's Speech Therapist Progress Note from 12/8/15 14:30 (2:30 PM) revealed, "ST swallowing eval. (evaluation) Pt (patient) tolerated regular p.o. (oral intake) with regular thin liquids at this time. Recommend safe swallow strategies of secondary swallow, and alternating bites with sips of liquids. pt indicated a desire for smaller portions at mealtime. No overt s/s of aspiration or penetration with regular po intake with thin liquids at this time. No additional ST follow up recommended at this time."

C. Review of Patient 33's Physician Orders revealed the last dietary order received was, "Heart Healthy- Fluid Restrictions" entered into the orders on 12/10/15 at 14:59 (2:59 PM).

D. Review of the Acute Care Flowsheet documentation for 12/16/15 revealed:
-12:00 Noon "Patient reports that when (gender) was eating lunch (gender) choked on a bite of hamburger but 'was able to cough it out', patient has a dry cough at this time."
-13:47 (1:47 PM) "Pt seated up in recliner. Reports is not feeling well, as (gender) just had a coughing spell and swallowed something wrong..."

E. Review of the Respiratory Therapist Flowsheet documentation for 12/16/15 revealed:
-7:40 AM "Breath Sounds pre treatment"- Clear in upper lobes, diminished in the bases, cough; non productive
-11:41 AM "Breath sounds pre treatment" - Clear in upper lobes, diminished in the lower (bases), cough; productive, moderate amount yellow sputum
-4:23 PM " Breath sounds pre treatment" - Crackles on the rt (right), clear on the left, cough; productive, large amount yellow sputum

F. Review of the Nutrition Record from the dietary department revealed that the information that they utilized to provide the patient's meal, 12/4/15 HH ( heart health) Fluid Restriction.

G. Interview with the Registered Nurse (RN) providing care for Patient 33 on 12/17/15 at 9:50 AM revealed after reviewing the record regarding the "choking spell Patient 33 reported on 12/16/15." "I am not aware of any Speech Therapy done. Oh, yes, here (Pt 33) had a Bedside Swallowing Evaluation." When asked if the strategy recommendations the ST provided were passed on or placed on their worksheet, the RN replied, "No, I don't have anything on my Action List that gives those strategies, and I was not aware of the recommendations. I will check up on the board, no nothing written on it either."

H. An interview with a ST on 12/17/15 at 12:45 PM revealed, "Typically after a Bedside Swallowing Evaluation, we make the Progress Note in the record to communicate to nursing the recommendations. We try and catch a nurse but sometimes are not able to. It says on the eval that the patient was instructed."

I. An interview with Patient 33 on 12/17/15 at 12:20 PM revealed, the patient didn't have any recall of the Bedside Swallowing Evaluation or anyone talking to them about taking small bites and then sips. Again, (Pt 33) apologized for not recalling any of that. "I don't have a good memory."