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Record review and staff interview revealed the Critical Access Hospital (CAH) failed to document admission and discharge vitals, physician medication order was properly signed, and failed to ensure discharge instructions for 1 of 6 outpatient medical records reviewed. The CAH is licensed for 24 beds and had a census of 2 acute care patients and 3 custodial patients upon entrance. Findings include:

A. Record review on 10/26/11 at 1:00 PM revealed Patient A presented to the CAH on 10/3/11 as an outpatient with a pertinent diagnosis of breast cancer requiring a peripheral vascular access, IV infusion of the following:

1. Herceptin 6mg/kg, 420 MG IV q (every) 3 weeks, start 3 wks (weeks) post-loading dose, (Nursing 2010 Drug Handbook, page 1237, identified Herceptin as being indicated for patients with Metastatic Breast Cancer in patients whose tumors over express the human epidermal growth factor receptor 2 (HER2) protein.)

2. Zometa 3mg, IV, q 3 weeks, and Herceptin 8mg/kg, 567mg IV, loading/1st dose X (time) 1. (Nursing 2010 Drug Handbook, Page 792, identified Zometa as indicated for Hypercalcemia caused by malignancy, and multiple myeloma and bone metastases of solid tumors in conjunction with standard antineoplastics). Review of the patient's checklist for the administration for Herceptin identified 18 steps necessary to administer and document Herceptin. Check list Sections 16, 17, and 18 reads:
16. Complete discharge instructions and VS (vitals).
17. Pt (patient) is instructed to contact their provider if any problems, pain, tenderness or adverse reactions. Give patient information sheet at initial dose.
18. Document on outpatient form.

All 18 items on the checklist for patient procedure instructions had been checked. Review of the nurses notes and discharge instructions lack documentation that the patient was properly informed of discharge instructions.

B. Interview with the Health Information Manager (HIM) and the Director of Nurses (DON) acknowledged the lack of discharge instructions and discharge vitals were properly documented in Patient A's medical record.

C. Record review on 09/13/11 at 1:30 PM revealed Patient A presented to the CAH on 9/13/11 as an outpatient for an IV of Zometa 4/mg/5m? (unsure as to what ? was to mean); gave 3mg/5ml pump, and Herceptin 440 mg IV per pump. Record review lacked a physician's signature for the medication administered to Patient A, a complete set of discharge vital signs and documentation that discharge instructions were given to Patient A.

Review of the patient's checklist for the administration for Herceptin identified 18 steps necessary to administer and document Herceptin. Check list steps 16, 17 and 18 read:
16. Complete discharge instructions and VS (vitals).
17. Pt (patient) is instructed to contact their provider if any problems, pain, tenderness or adverse reactions. Give patient information sheet at initial dose.
18. Document on outpatient form.

All 18 steps on the checklist had been checked. Review of the nurses notes and discharge instructions lacked documentation that the patient was properly informed of discharge instructions and a complete set of discharge vital signs ensuring that Patient A was stable upon discharge.

D. Interview with the Health Information Manager (HIM) and the Director of Nurses (DON) acknowledged the lack of discharge instructions or discharge vital signs were properly documented in Patient A's medical record and lacked a physician signature for the medication order for Patient A.

E. Record review on 09/13/11 at 1:30 PM for Patient A presented to the CAH with a pertinent diagnosis of breast cancer on 08/22/11 as an outpatient for an IV of Zometa 4mg/5ml, gave 3mg per pump, and Herceptin 420 mg, 19 ml given. Record review revealed a lack of a signed physician order for the medication administered to Patient A, a complete set of discharge vital signs and documentation that discharge instructions were given to Patient A.

Review of the patient's checklist for the administration for Herceptin identified 18 steps necessary to administer and document Herceptin. Check list steps 16, 17 and 18 read:
16. Complete discharge instructions and VS (vitals).
17. Pt (patient) is instructed to contact their provider if any problems, pain, tenderness or adverse reactions. Give patient information sheet at initial dose.
18. Document on outpatient form.

All 18 checklist steps had been checked. Review of the nurses notes and discharge instructions lacked documentation that the patient was properly informed of discharge instructions and a complete set of discharge vital signs ensuring that Patient A was stable upon discharge.

F. Interview with the Health Information Manager (HIM) and the Director of Nurses (DON) acknowledge the lack of discharge instructions or discharge vital signs were properly documented in Patient A's medical record and a signed physician order for the medication administered to Patient A.