HospitalInspections.org

Based on medical record review, observation, staff interview and review of policy and procedure, the CAH (Critical Access Hospital) failed to ensure 1 patient (Patient 1) received medications in accordance with physician's orders during 1 of 3 medication administration passes observed.

Findings are:

A. Review of Patient 1's Medication Administration Records (MAR) dated 4/27/14, 4/28/14, 4/29/14 and 4/30/14 showed an order for Modafanil (a medication given to promote wakefulness) 100 mg (milligrams) PO (per mouth) Q (every) day. The area on the MAR where the nurse initials that the medication was administered as ordered was circled. The circling of the initials next to the Modafanil indicated that the medication was not given.

B. An observation of Registered Nurse (RN)-J on 4/30/14 at 8:40 AM revealed that while setting up the medications for Patient 1's morning medication pass, that the Modafanil was not available in the Pyxis (a medication dispensing machine) or in the container of Patient 1's home medications.

C. An interview with RN-J on 4/30/14 at 8:45 AM confirmed that the initials with a circle around it beside the Modafanil indicated that the medication was not given. RN-J stated, "I don't have it here to give either. This is a non-formulary medication and we usually have the family bring it in for us to use. I don't know why it isn't here yet, I will check with the Pharmacy and the doctor."

D. Review of Patient 1's medical record showed that the Modafanil was ordered on 4/26/14 when the patient was admitted to the hospital.

E. Interview with the Director of Ancillary Services (the director that oversees the Pharmacy Director) on 4/30/14 at 10:15 AM revealed, "We don't really have a specific policy that addresses this situation."

F. Interview with the Pharmacy Director on 4/30/14 at 10:00 AM stated, "Typically if the medication is not on the formulary, the pharmacist tells the nurse that it isn't available and to ask the family to bring it in. If they cannot or do not bring it in, then a call is made to the doctor to see if they need to continue it while here or if it can be held while at the hospital. If it is needed and the family cannot provide it the medication will be ordered from a local pharmacy. Typically the delay would be at the most 1 day."

Based on record review, review of pre-stamped progress notes and staff interview, the CAH (Critical Access Hospital) failed to ensure a physician examined the patient for the risk of the procedure immediately prior to surgery for 8 of 8 outpatient medical records (Records 18, 19, 26, 27, 28, 29, 30 & 31) reviewed. This failed practice had the potential to affect all patients of the CAH. The average number of outpatient surgical procedures performed at the CAH on a monthly basis is 52.

Findings are:

A. Review of Medical Record 18 on 4/29/14 at 9:00 AM revealed the patient had a right knee arthroscopy (examination and treatment of damage) done on 4/16/14. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 19 on 4/29/14 at 10:30 AM revealed the patient had an exploratory laparoscopy done on 2/12/14. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 26 on 5/1/14 at 8:20 AM revealed the patient had a laparoscopic cholecystectomy (removal of gallbladder) done on 4/28/14. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 27 on 5/1/14 at 8:30 AM revealed the patient had a laparoscopic cholecystectomy done on 4/28/14. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 28 on 4/29/14 at 10:20 AM revealed the patient had a tonsillectomy done on 4/23/14. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 29 on 4/29/14 at 9:20 AM revealed the patient had an excision of abdominal wall tumor done on 4/7/14. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 30 on 4/29/14 at 10:00 AM revealed the patient had a right knee arthroscopy done on 3/26/14. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.

- Review of Medical Record 31 on 4/29/14 at 11:00 AM revealed the patient had a bilateral myringotomy and tubes done on 3/12/14. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.

B. Review of the pre-stamped Progress Notes that state "Pre-Operative Evaluation by Physician: The patient was examined prior to surgery to evaluate the risk of anesthesia and the procedure to be performed. Patient condition is satisfactory for anesthesia and surgery".

C. Interview with the Surgery Director on 5/1/14 at 10:30 AM confirmed the above medical records lacked the physician documented examinations immediately before surgery that evaluate the risk of the procedure to be performed. The Surgery Director stated "We were told all the doctors had to do now was sign the H&P's (History & Physicals) and that met the requirement so the nurses stop putting the progress notes on the charts."

Based on staff interview and policy and procedure review, the Critical Access Hospital (CAH) failed to have a Policy and Procedure in place to ensure that the facility completes a 14-day comprehensive assessment when it identifies a significant change (improvement or decline) in the patient's condition. This has the potential to affect all Swing Bed Patients. The facility census was 4 acute patients and 2 swing bed patients.

Findings are:

A. Interview with the Director of Nurses on 5/1/14 at 10:00 AM verified, "No, we don't currently have a specific Policy and Procedure for a Swing Bed patient for a 14-day significant change assessment. We usually don't have patients that long here."

B. Review of the Swing Bed Policy and Procedure Book with the Utilization Nurse and the Director of Nurses, revealed the lack of a Policy and Procedure for the 14-day significant change assessment.

C. Since the facility lacked a policy and procedure regarding the 14-day significant change assessments for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive the assessment with a significant change (improvement or decline in their condition).

Based on staff interview and record reviews, the Critical Access Hospital (CAH) failed to develop a comprehensive care plan for 3 of 5 Swing Bed patients (Patients 33, 34 and 35) which would include medical, nursing, mental and psychosocial needs identified in the initial and periodic comprehensive assessments. The facility census was 4 acute patients and 2 Swing Bed patients.

Findings are:

A. A review of the Swing Bed Patient Records for Patients 33, 34 and 35 on 5/1/14, revealed the records lacked comprehensive care plans (CP).

B. An interview on 5/1/14 at 1:30 PM with the Registered Nurse that was the Health Information Manager (HIM) verified that there is not a comprehensive care plan on the medical record for Patients 33, 34 or 35.

Based on staff interview and policy and procedure review, the Critical Access Hospital (CAH) failed to have a process in place to ensure that the Swing Bed Patients' dental needs will be met. This has the potential to affect all Swing Bed Patients. The facility census was 4 acute patients and 2 Swing Bed patients.

Findings are:

A. An interview with the Director of Nurses on 5/1/14 at 10:00 AM verified, "No, we don't currently have a specific Policy and Procedure/ Process for Swing Bed patient for what to do if a Swing Bed Patient has a need for dental services. We would probably call their own dentist if from here, but otherwise probably call around to see if someone could come and see them, or we could take them to their office."

B. A review of the Swing Bed Policy and Procedure Book with the Utilization Nurse and the Director of Nurses, revealed the lack of a Policy and Procedure for dental care needs for Swing Bed patients.

C. An interview with the Executive Assistant (person in charge of keeping hard copies of facility contracts) on 5/1/14 at 8:20 AM revealed that there was not a contract for Dental Services.

D. An interview with the Medical Staff Coordinator on 5/1/14 at 8:22 AM revealed that there is no dentist on medical staff.

E. Since the facility lacked a policy and procedure regarding dental care services or a dentist on staff for the Swing Bed Patients, the CAH could not ensure that the Swing Bed Patients would receive dental care as needed.