HospitalInspections.org

Based on observation and staff interview, the facility failed to ensure that patient care supplies were maintained to an acceptable level of safety and quality. Findings include:

During the review of the Emergency Room on 10/19/11 beginning at 7:15 a.m., the surveyor observed the following outdated and unusable supplies.
-1 4 ounce bottle of Hibiclens solution with the manufacturer's expiration date of 5/2010.
-1 16 ounce bottle of 70% Isopropyl Alcohol with the manufacturer's expiration date of 11/2010.
-1 Kendall 1/2 inch by 5 yard sterile plain packing strip with the manufacturer's expiration date of 3/2009.
-1 Tegaderm 6 inch by 8 inch transparent dressing with the manufacturer's expiration date of 10/2010.
-39 Jelco 22 gauge by 1 inch intravenous catheters with the manufacturer's expiration date of 4/2011.
-4 Rusch 20 French 2-way Foley catheters with the manufacturer's expiration date of 5/2010.
-7 Rusch 12 French 2-way Foley catheters with the manufacturer's expiration date of 12/2008.
-2 Rusch 18 French 2-way Foley catheters with the manufacturer's expiration date of 11/2009.
-1 Shiley 5.5 French Pediatric Tracheostomy tube with the manufacturer's expiration date of 11/1997.
-2 Steri-Strips 1/4 inch by 4 inch wound closure devices with the manufacturer's expiration date of 10/2006.
-45 Jelco 24 gauge by .75 inch intravenous catheters with the manufacturer's expiration date of 10/2010.
-12 Jelco 20 gauge by 1.25 inch intravenous catheters with the manufacturer's expiration date of 12/2010.
-1 Ocean Waterseal chest drainage set with the manufacturer's expiration date of 10/2010.
-1 Kendall Adult Lumbar Puncture tray with the manufacturer's expiration date of 1/2007.
-1 Arrow-Clark Pleuraseal Thoracentesis Kit with the manufacturer's expiration date of 10/2008.
-2 Rusch 8.5 millimeter endotracheal tubes with the manufacturer's expiration date of 12/2010.
-2 Rusch 8.0 millimeter endotracheal tubes with the manufacturer's expiration date of 7/2010.
-2 Rusch 7.0 millimeter endotracheal tubes with the manufacturer's expiration date of 2/2011.
-1 Rusch 6.5 millimeter endotracheal tube with the manufacturer's expiration date of 4/2010.
-2 Rusch 2.5 millimeter pediatric endotracheal tubes with the manufacturer's expiration date of 2/2011.
-2 Rusch 3.0 millimeter pediatric endotracheal tubes with the manufacturer's expiration date of 11/2010.
-2 Rusch 3.5 millimeter pediatric endotracheal tubes with the manufacturer's expiration date of 5/2010.
-1 Rusch 4.0 millimeter pediatric endotracheal tube with the manufacturer's expiration date of 5/2010.
-3 Adult Carbon Dioxide detectors with the manufacturer's expiration date of 1/12/2009.
The surveyor noted multiple other expired or outdated supplies in the emergency room and the facility laboratory area.

During the review of the emergency room on 10/19/11 at 7:15 a.m., staff member B stated that she had been the person responsible for checking supplies for dates of expiration. Staff member B stated that staff nurses were now being assigned the responsibility for checking supplies.

Based on document review and staff interviews, the facility failed to create and utilize guidelines for the medical management of health problems that included the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH (Critical Access Hospital). Findings include:

On 10/18/11 at approximately 1:15 p.m., the surveyor provided the facility administrator with the information request list for the CAH survey. During the review of the facility policy and procedure manuals, the surveyor was unable to locate the written guidelines for management of health conditions.

During a meeting with staff member A on 1/18/11 at approximately 4:00 p.m., staff member A stated that he was not aware of the existence of the guidelines.

At 4:45 p.m., on 10/18/11, staff member C stated that the facility did not have a written policy or protocols for treatment guidelines or referrals of patients in the hospital.

Based on document review and staff interview, the facility failed to ensure that the patient care policies for the hospital were reviewed at least annually by the group of professional personnel required by the regulations. Findings include:

During the review of the facility policy and procedure manuals on 10/19/11 at approximately 2:00 p.m., the surveyor noted that the policy manual had last been reviewed by the governing board in November of 2010. The review signature sheet did not include the names of a physician or physician assistant that had also reviewed the policies.

During an interview with staff member C on 10/19/11 at approximately 4:20 p.m., staff member C stated that neither he, nor the physician medical director, had been active in the review of the facility policies and procedures.

Based on document review and staff interview, the facility failed to ensure that the clinical records for 15 (#s 1, 2, 3, 6, 10, 11, 12, 13, 14, 15, 16, 17, 18, 20, and 21) of 21 reviewed records were complete and accurately documented. Findings include:

During the review of closed critical access patient records on 10/19/11 beginning at 9:15 a.m., the surveyor noted the following incomplete records.

1. Patient #1, a 76 year old male was admitted to the emergency room on 12/7/10. Nursing assessment entries did not include the time when the entries were made into the record.

2. Patient #2, a 93 year old female was admitted to the emergency room on 2/2/11. Nursing assessment entries did not include the time when the entries were made into the record.

3. Patient #3, an 88 year old female was admitted to the emergency room on 2/10/11. Nursing assessment entries did not include the time when the entries were made into the record.

4. Patient #6 was admitted to the facility on 6/8/11. The clinical record did not include a discharge summary for the patient's stay.

5. Patient #10, a 62 year old male was admitted to the emergency room on 11/8/10. Nursing assessment entries did not include the time when the entries were made into the record. The facility transfer authorization document did not include the time that contact with the accepting physician was made.

6. Patient #11, a 58 year old male was admitted to the emergency room on 1/9/11. Nursing assessment entries did not include the time when the entries were made into the record.

7. Patient #12, a 2 month old male was admitted to the emergency room on 4/11/11. Nursing assessment entries did not include the time when the entries were made into the record.

8. Patient #13, a 15 year old female was admitted to the emergency room on 4/20/11.
A. Nursing assessment and treatment entries did not include the times when the entries were made into the record.
B. The facility transfer authority form did not include documentation of the accepting facility, accepting physician/provider, or the time of contact with the accepting facility and physician/provider.

9. Patient #14, a 26 year old female was admitted to the emergency room on 5/1/11. Nursing assessment and treatment entries did not include the times when the entries were made into the record. The facility transfer authority form did not include documentation of the name of the accepting facility.

10. Patient #15, a 67 year old male was admitted to the emergency room on 5/11/11. Nursing assessment entries did not include the time when the entries were made into the record.

11. Patient #16, a 73 year old female was admitted to the emergency room on 6/8/11. Nursing assessment entries and provider verbal orders did not include the time when the entries were made into the record, or when the verbal orders were received.

12. Patient #17, a 2 1/2 year old male was admitted to the emergency room on 7/2/11.
A. Nursing assessment entries did not include the time when the entries were made into the record.
B. The record did not include documentation of verbal orders for medications administered to the patient.

13. Patient #18, a 4 year old female was admitted to the emergency room on 7/3/11. Orders for take home medications did not include documentation of the time that the verbal orders were received.

14. Patient #20, a 17 year old male was admitted to the emergency room on 9/9/11. Nursing assessment entries did not include the time when the entries were made into the record.

15. Patient #21, a 3 year old female was admitted to the emergency room on 10/8/11. Nursing assessment and treatment entries did not include the times when the entries were made into the record.

During the end of day meeting with the facility administrative team on 10/19/11 at 4:40 p.m., staff member B noted that she was not aware that the records were incomplete.

Based on record review and staff interview, the facility failed to ensure that physician/provider orders and notes entered into the record were properly authenticated for 21 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21) of 21 reviewed clinical records. Findings include:

1. Patient #1, 76 year old male was admitted to the facility on 12/7/10. Physician orders dated 12/8/10 did not include the time when the order was written. Emergency room orders for medication and radiology test did not include a provider signature, time, and date, authenticating the order. The dictated provider emergency room/admission note did not include the date and time that the note was dictated.

2. Patient #2, a 93 year old female was admitted to the facility on 2/2/11. The diagnosis documented on the emergency room record by the provider did not include the date, time, and signature by the provider. The provider dictated admission note did not include the date and time that the note was dictated.

3. Patient #3, an 88 year old female was admitted to the facility on 2/10/11. The provider dictated emergency room note did not include the date and time that the note was dictated.

4. Patient #4, a 66 year old male was admitted to the facility on 3/2/11. Admission and discharge orders written by the provider did not include the times when the orders were written. The provider dictated history and physical and discharge summary notes did not include the times when the documents were dictated.

5. Patient #5, a 73 year old female was admitted to the facility on 5/4/11. Provider written admission orders did not include the time that the orders were written. The provider dictated history and physical and discharge summaries did not include the dates and times that the notes were dictated.

6. Patient #6, a 91 year old female was admitted to the facility on 6/8/11. Physician orders dated 6/8/11, 6/9/11, 6/10/11, and 6/12/11 did not include the time that the orders were written.

7. Patient #7, an 84 year old female was admitted to the facility on 6/27/11. Provider orders dated 6/27/11 and 6/28/11 did not include the time that the orders were written. The provider dictated history and physical did not include the date and time that the document was dictated.

8. Patient #8, 71 year old female was admitted to the facility on 9/8/11. The provider admission orders did not include the time that the orders were written. The provider dictated history and physical did not include the date and time that the document was dictated.

9. Patient #9, a 92 year old male was admitted to the facility on 9/10/11. Provider medication and laboratory testing orders dated 9/10/11 and 9/11/11, and discharge orders dated 9/12/11 did not include the times when the orders were written. The provider dictated progress note dated 9/11/11 and the discharge summary dated 9/12/11 did not include the times when the documents were dictated.

10. Patient #10, a 62 year old male was admitted to the facility on 11/8/10. The dictated provider emergency room note did not include the date and time that the note was dictated.

11. Patient #11, a 58 year old male was admitted to the facility on 1/9/11. The physician verbal order for medication did not include a date, time, and signature of the provider authenticating the order. The dictated provider emergency room note did not include the date and time that the note was dictated.

12. Patient #12, a 2 month old male was admitted to the facility on 4/11/11. The dictated provider emergency room note did not include the date and time that the note was dictated.

13. Patient #13, a 15 year old female was admitted to the facility on 4/20/11. The provider verbal order for an intravenous line, intravenous fluids, catheter insertion, and transfer did not include a date, time, and signature authenticating the orders. The dictated provider emergency room note did not include the date and time that the note was dictated.

14. Patient #14, a 26 year old female was admitted to the facility on 5/1/11. The provider verbal order for an intravenous line, intravenous fluids, catheter insertion, and medications did not include a date, time, and signature authenticating the orders. The dictated provider emergency room note did not include the date and time that the note was dictated.

15. Patient #15, a 67 year old male was admitted to the facility on 5/11/11. The clinical record did not include a written or verbal order for a diagnostic radiology study. The dictated provider emergency room note did not include the date and time that the note was dictated.

16. Patient #16, a 73 year old female was admitted to the facility on 6/8/11. The provider verbal order for an intravenous line, intravenous fluids, laboratory test, and medication did not include a date, time, and signature authenticating the orders. The dictated provider emergency room note did not include the date and time that the note was dictated.

17. Patient #17, a 2 1/2 year old male was admitted to the facility on 7/2/11. The clinical record did not include a written or verbal order for medications administered to the patient. The dictated provider emergency room note did not include the date and time that the note was dictated.

18. Patient #18, a 4 year old female was admitted to the facility on 7/3/11. The physician verbal order for medication did not include a date, time, and signature of the provider authenticating the order. The dictated provider emergency room note did not include the date and time that the note was dictated.

19. Patient #19, a 22 year old female was admitted to the facility on 7/21/11. The dictated provider emergency room note did not include the date and time that the note was dictated.

20. Patient #20, a 17 year old male was admitted to the facility on 9/9/11. The dictated provider emergency room note did not include the date and time that the note was dictated.

21. Patient #21, a 3 year old female was admitted to the facility 10/8/11. The dictated provider emergency room note did not include the date and time that the note was dictated.

During the end of day meeting with the facility administrative team on 10/19/11 at 4:45 p.m. staff member B stated that she was not aware of the missing signatures.

In a meeting with staff member H on 10/19/11 at approximately 3:45 p.m., staff member H stated that she was not aware that the date and time of the dictation of notes by the provider was not included on the note.

Based on document review and staff interview, the facility failed to complete or arrange for the completion of the Periodic Evaluation and Quality Assurance Review. Findings include:

During the review of the facility provided documentation beginning 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included;
-The periodic evaluation itself (C-0331),
-Evaluation of the utilization of the Critical access Hospital services (C-0332),
-A representative sample of open and closed clinical records (C-0333),
-The Critical Access Hospital's policies and procedures (C-0334),
-Evaluation to determine whether the utilization of services was appropriate, established policies and procedures were followed, and if changes were needed (C-0335),
-All patient care services and other services affecting patient health and safety are evaluated (C-0337),
-Nosocomial infections and medication therapy are evaluated (C-0338),
-The quality and appropriateness of the diagnosis and treatment furnished by a physician assistant at the hospital are evaluated by a member of the hospital staff that is a MD or DO (C-0339),
-The quality and appropriateness of the diagnosis and treatment furnished by a physician at the hospital are evaluated by a hospital in the network, a Quality Improvement Organization, or other qualified entity (C-0340),
-The findings of the evaluations were considered and corrective actions taken, if necessary (C-0341).

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete or arrange for the completion of a periodic evaluation of it's total program. Findings include:

During the review of the facility provided documentation beginning 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review of the total program. The documentation was requested on arrival at the facility and at the end of day meetings on 10/18/11 at 5:00 p.m. and 10/19/11 at 4:45 p.m. No documentation was provided.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included the utilization of critical access hospital (CAH) services, including at least the number of patients served and the volume of services. Findings include:

During the review of the facility provided documentation beginning on 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included utilization of CAH services, including at least the number of patients served and the volume of services.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included the utilization of critical access hospital (CAH) services, including a representative sample of both open and closed clinical records. Findings include:

During the review of the facility provided documentation beginning on 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included utilization of CAH services, including a sample of both open and closed clinical records.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included the utilization of critical access hospital (CAH) services, including the review of the hospital's health care policies. Findings include:

During the review of the facility provided documentation beginning on 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included the review of the hospital's health care policies.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation to determine whether the utilization of services was appropriate, the established policies were followed, and if changes were needed. Findings include:

During the review of the facility provided documentation beginning on 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that determined whether the utilization of services was appropriate, the established policies were followed, and if any changes were needed.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation of all patient care services and other services affecting patient health and safety are evaluated. Findings include:

During the review of the facility provided documentation beginning on 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that determined whether all patient care services and other services affecting patient health and safety were evaluated.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation of nosocomial infections and medication therapy. Findings include:

During the review of the facility provided documentation beginning on 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that determined whether nosocomial infections and medication therapy were evaluated.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation to determine whether the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialists, and physician assistants at the critical access hospital (CAH) are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH. Findings include:

During the review of the facility provided documentation beginning on 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included the quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialists, and physician assistants at the CAH were evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included an evaluation to determine whether the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the critical access hospital (CAH) are evaluated by--
(i) One hospital that is a member of the network, when applicable;
(ii) One QIO (Quality Improvement Organization) or equivalent entity;
(i) One other appropriate and qualified entity identified in the State rural health care plan. Findings include:

During the review of the facility provided documentation beginning on 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by--
(i) One hospital that is a member of the network, when applicable;
(ii) One QIO or equivalent entity;
(i) One other appropriate and qualified entity identified in the State rural health care plan.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.

Based on document review and staff interview, the facility failed to complete a periodic evaluation of the total program that included the requirement that the critical access hospital (CAH) staff considered the findings of the evaluations, including any findings or recommendations of the QIO (Quality Improvement Organization) , and took corrective action if necessary.

During the review of the facility provided documentation beginning on 10/18/11, the surveyor failed to locate or receive documentation of the completion and reporting of the required periodic evaluation and Quality Assurance Review that included the requirement for the hospital staff to consider the findings of the evaluations, including any findings or recommendations of the QIO, and take corrective action if necessary.

During an interview with staff member A on 10/19/11 at 4:45 p.m., staff member A stated that no program evaluation had been completed since prior to January of 2010.