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Based on record review, policy review and employee interview, the hospital facility failed follow their own policy for updating care plans for Patient #1 and #2, two (2) of two (2) swing bed patients reviewed.


Findings include:



Record review for swing bed Patients #1 and #2 revealed that their care plan had been entered upon admission but had not been updated since although they had received multiple changes in treatment and care since admission.

Review of the hospital's "Patient Care Plans" policy revealed, "Procedure (3) The plan of care will be problem oriented and new problems will be added when they develop."

During interview on 03/27/13 at 11:15 a.m. Registered Nurse (RN) #3was asked to show how a care plan was updated. After the RN pulled up the care plan for Patient #1 on the computer she was unable to show documentation that the patient's care plan had been updated after removal of a ventilator. She stated, "The goal should have been completed and the care plan updated."

Based on record review, policy review and staff interview, the hospital failed ensure that orders for three (3) of four (4) patients currently admitted to swing bed and acute care were countersigned by the physician on his next visit to the station within 24 hours. Patient's #1, #2 and #4.


Findings include:


Review of the hospital's "Verbal and Telephone Orders" policy revealed, "The physician's verbal or telephone orders may be taken by the Registered nurse or Licensed Practical Nurse read back for verification and should be countersigned by the physician on his next visit to the station within 24 hours."

Review of records for Patients #1, #2, and #4 revealed multiple telephone and verbal orders taken by nursing staff since the patients admission to the hospital that had not be countersigned by the physician.

During an interview on 03/26/13 at 2:15 p.m. Registered Nurse (RN) #2 was asked what the hospital's policy was regarding the physician signing their verbal orders. She stated, "I don't know what the time frame is, but they are supposed to come back and sign them."

Based on review of the Critical Access Hospital's (CAH's) policies and procedures, and review of medical records, the facility failed to ensure that the general consents for medical treatment signed on admission were properly executed.


Findings include:


19 discharged medical records were selected at random from a list of discharges from July 1, 2012 through March 25, 2013, and reviewed along with three (3) inpatient medical records and the last five (5) discharges from the hospital for a total of 27 medical records.

Review of 27 of 27 medical records revealed that the general consent for medical treatment signed on admission had not been timed.

Based on review of the Medical Staff Rules and Regulations, and review of medical records, the Critical Access Hospital (CAH) failed to ensure that the physician signs the history and physical examination performed by a nurse practitioner on six (6) of 12 records reviewed.


Findings include:


19 discharged medical records were selected at random from a list of discharges from July 1, 2012 through March 25, 2013, and reviewed along with 3 inpatient medical records and the last five (5) discharges from the hospital for a total of 27 medical records.

Review of 27 medical records revealed that a nurse practitioner had performed the history and physical examination on 12 of the 27 discharged medical records reviewed. The physician had not signed the history and physical exam on six (6) of these 12 records.

Based on review of the Medical Staff Rules and Regulations and review of medical records, the hospital failed to ensure that all entries in the medical record are timed and that verbal orders are signed by the physician within 24 hours.


Findings include:


Review of the facility's Medical Staff Rules and Regulations revealed that verbal orders from a physician are required to be signed by the physician within 24 hours.


19 discharged medical records were selected at random from a list of discharges from July 1, 2012 through March 25, 2013, and reviewed along with 3 inpatient medical records and the last five (5) discharges from the hospital for a total of 27 medical records.

Five (5) of eight (8) current medical records reviewed [three (3) inpatient and the last five (5) discharges from the hospital], contained unsigned verbal orders that were more that 24 hours old. These verbal orders had been given by a nurse practitioner and by a physician.

Three (3) of the three (3) medical records reviewed that contained "Do not Resuscitate" orders had orders that had not been timed.