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Based on policy/procedure review, observation and staff interview, the Critical Access Hospital (CAH) failed ensure that the daily defibrillator checks were consistently recorded on the Checklists.

Findings include:

Review of the facility's "Daily Crash Cart and Defibrillator Checks" policy/procedure (Effective 6/05) revealed, "...The defibrillator must be checked on each shift for operational readiness by the Charge Nurse. A check list is available on the crash cart for the nurse to sign."

Review of the facility's Station B Checklist revealed that from January 1, 2012 through August 6, 2012 there were approximately 56 signatures missing from the Checklist. Review of the Geriatric Psychiatric Unit Checklist revealed that from February 1, 2012 through July 31, 2012 eleven (11) signatures were missing.

Interview with the Station B Charge Nurse on 08/07/2012 at approximately 10:00 a.m and the Geriatric Psychiatric Unit Charge Nurse on 08/07/2012 at 12:15 p.m. revealed that the checklists were to be completed according to their policy/procedure.

On 03/09/2012 an in-service had been conducted concerning Crash Cart checks each shift.

Based on observation, policy/procedure review, pharmacist job description review, review of Narcotic Count Logs and staff interview, the Critical Access Hospital (CAH) failed to maintain control over medications in all CAH locations.

Findings include:

Review of the facility's "Expired Medications" policy, revised 05/01/1998, revealed, "Procedure: 1. Routine inspections of all medication storage areas are to be performed on a monthly basis by the pharmacist or his appointed designee for outdated/expired medications. 2. When expired medications are found in the Pharmacy or any other medication storage area, those medications shall be immediately removed from stock."

Review of the "Director of Pharmacy Job Description" policy, dated 05/01/1998 and signed by the Administrator and Director of Pharmacy, revealed, "The following duties are reprensentative of the position; 2. Supervise drug storage and preparation areas throughout the hospital; 3. Maintain strict control and accountability for medications dispensed to patients and for floor stock; 4. Conducts monthly inspections of all areas where drugs are stored or dispensed."

On 08/07/12 at approximately 10:30 a.m. review of the Narcotic Log Book on Station B revealed that from February 1, 2012 through August 6, 2012 approximately 126 nurse signatures were missing.

On 08/07/12 at approximately 1:30 p.m. tour of the Emergency Department revealed that the Medication Refrigerator Logs for February and March, 2012 were lying beside the refrigerator. No other Logs could be located by the nurse. A vial of Lantus insulin U-100 had been dated as opened on 02/22/12. TNKase, Tenecteplase used for stroke patients was dated August, 2011. Zantac for injection 40ml (milliliters) was not dated when opened.

On 08/07/12 at approximately 2:30 p.m. an interview was held in the Pharmacy with the Pharmacist. The Pharmacist stated that he offered to assist the hospital with pharmacy duties following the death of the hospital's other Pharmacist. He stated that he lives close to the facility and is in the hospital in the mornings, around noon, and in the evening each day. The Pharmacist was not aware of the hospital's Pharmacy Policy/Procedure on Expired Medications or of the Pharmacist Job Description.

Based on record review, policy review and staff interview, the facility failed to have a current personalized care plan for Patient #1, one (1) of two (2) patients reviewed.

Findings include:

Record review for Patient #1 revealed that he was a 35 year old admitted to Station B on 08/06/12 for observation. His diagnoses included Extreme Hyperglycemia, Type II Diabetes, and new onset of Chest Pain. He was switched to Acute Care on 08/08/12. A Nursing Care Plan was present on the record but did not address the patient's chest pain.

On 08/08/12 at 1:30 p.m. the nurse responsible for Patient #1's care confirmed that the patient's chest pain should have been addressed in his careplan.

Based on record review, the facility failed to ensure that all entries in the medical record are timed.


Findings include:


Twenty (20) medical records were selected at random from a list of discharges from January 1, 2012, though July 31, 2012 and reviewed along with six (6) inpatient medical records for a total of 26 medical records.


Nine (9) of 26 medical records reviewed revealed that all entries had not been timed when entered into the medical record. This included both progress notes and orders written by the physician.