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Based on policy review and staff interviews, the medical doctor (MD) or doctor of osteopathy (DO) failed to periodically review the policies governing the services provided in conjunction with the mid-level providers. Findings include:

The facilities policies were reviewed on 4/8/13 at 2:00 p.m. The policies lacked evidence of a review by a medical provider in conjunction with the mid-level provider

During an interview on 4/10/13 at 9:50 a.m., with staff member B the policies should have been updated or reviewed by the MD or DO as part of the medical oversight function for the last year.

During an interview on 4/10/13 at 11:00 a.m., staff member A stated the policies were not updated or reviewed by the MD or DO as part of the medical oversight function.

Based on document review, the facility failed to develop policies with the advice of a group of professional personnel that included a physician, a mid-level, and at least one member that was not a member of the CAH staff. Findings include:

On 4/9/13 at 2:00 p.m., staff member A stated that there was documentation that the policies of the hospital were developed and reviewed by a group of professionals including one non-CAH staff member. Staff member A did not provide verification information by the end of the survey.

On 4/10/13 at 9:50 a.m., during a meeting with the CEO, he stated that the policies should have been reviewed by a group of medical professionals, including one non-CAH staff member. Staff member B stated he would provide the documentation of the review. The documentation was not provided by the end of the survey.

The binder which contained the patient policies was reviewed on 4/8/13 at 2:00 p.m. The last update to the policies documented in the binder was 12/1/10. The binder contained a list of board of members, staff, and consultants who were expected to review the policies.

Based on record review, the facility failed to review department policies at least annually. Findings include:

1. On 4/8/13 at 2:00 p.m., the Health Information Department policies manual was reviewed by the surveyor. The Annual Review page in the manual contained documentation of an annual review of the policies for 2010 and 2011. Additionally, the annual review in 2011 lacked documentation of review of the policies by the administrator, chief of staff, mid-level provider, and an outside professional. The Annual Review page lacked documentation of an annual review in 2012.

A policy titled, Annual Review of Policies and Procedures for the Health Information Department, contained documentation as follows: "Policy: The Health Information Manager shall review all policies and procedures for the department annually. Procedure: 1. Review and revise, as necessary, each policy and procedure, for Teton Medical Center Medical and Nursing Home. Insert the revised date on each policy. Old policies are to be kept for ten (10) years. 2. Document on sheet in front of the manual, date of review of all Policies/Procedures."

Based on record review the facility failed to have a complete and accurately documented Emergency Room log for 1 (# 4) of 20 sampled patients. Findings include:

1. On 4/8/13 at 3:00 p.m., the Emergency Department log was reviewed by the surveyor. From 3/8/13 at 1540 (3:40 p.m.) to 3/10/13 at 11:26 a.m., the log was incomplete. The log contained the date and time the patient was admitted to the ER, the patient's name, and age. The log did not contain the patient's address, who they were admitted by, the name of the physician, the nature of the injury, the services rendered, whether they arrived by ambulance or not, and the disposition of the case.




26492

Based on record reviews, staff interview, and the Medical Staff By Laws the facility failed to ensure that 9(#s 3, 4, 5, 6,7, 8, 9, 10, and 14 ) of 20 sampled patients had records that were properly authenticated. Findings include:

1. Patient #3 was admitted to the facility on 4/4/13 to a swing bed for aftercare following a right hip replacement. The Admission Summary Sheet lacked a signature, date, and time by the mid-level practitioner that admitted her to the facility. A Physical Therapy Daily Progress Note for the dates of 4/9/13 and 4/5/13, was signed by the physical therapist but lacked a date and time of the signature.

2. Patient #4 came to the Emergency Room on 3/8/13 at 3:40 p.m., for a finger laceration. An Emergency Room note was dictated by the mid-level practitioner that treated patient #4 but it lacked a signature, date, and time. Patient #4 had an x-ray of his heft hand while in the ER in which the radiologist dictated two radiology reports. Both radiology reports were signed but were not authenticated with dates and times. The physician orders were reviewed and lacked a signature, date, and time.

3. Patient #5 came to the Emergency Room on 2/23/13 at 1:40 a.m., for a migraine. An Emergency Room note was dictated by the mid-level practitioner that treated patient #4 but it lacked a signature, date, and time. The physician orders were reviewed and lacked a signature, date, and time. Patient #5 had another visit to the ER on 2/28/13 at 5:01 p.m., for a fall in which she had an x-ray of her left knee. The radiology report was signed by the radiologist but was not authenticated with a date and time.

4. Patient #14 was admitted to the facility on 6/8/13 at 12:10 p.m., for acute pancreatitis. The Admission Summary Sheet lacked a signature, date, and time by the mid-level practitioner that admitted her to the facility. The Discharge Summary dictated by the mid-level practitioner that discharged patient #14 lacked a signature, date, and time. The History and Physical Examination dictated by the mid-level practitioner that admitted patient #14 to the facility lacked a signature, date, and time.


5. Patient #6 was seen in the ER on 2/13/13; the ER note lacked a time or signature of when the note was completed. The Organ Donor Inquiry form lacked a provider signature, date, or time as to when the form was completed.

6. Patient #7 was seen in the ER on 11/21/2012; the ER note was not timed or signed. The Physician's Order form was not timed or signed. The radiology report dated 11/21/12 and the Interfacility Transfer Authorization form were not timed. Patient #7 passed away on 11/21/12 and The Organ Donor Inquiry form did not have a provider signature, date, or time until 4/8/13 which was five months after the date of death.

7. Patient #8 was admitted to a swing bed on 6/4/12; the admission summary sheet was not signed, timed, or dated by the physician. The discharge summary was not timed or signed by the provider. The radiology report dated 6/6/12 was not timed to when the provider signed the form.

8. Patient #9 was admitted to acute care on 11/13/12; the Admission Summary Sheet and the History and Physical report were not signed, timed, or dated by the provider as to when the form the was completed. The Organ Donor Inquiry form did not contain a signature, or date of the staff member who completed the form.

9. Patient #10 was admitted to a swing bed on 11/24/12; the Admission Summary Sheet, Physician's Orders, Physical Therapy Initial Evaluation report, and the Occupational Therapy Initial Evaluation forms were not signed, timed, or dated by the providers as to when the forms were completed.

On 4/8/13 at 2:00 p.m., the hospital policies were reviewed and lacked a policy on authenticating chart entries.

On 4/10/13 at 11:00 a.m., staff member A stated that all entries in a medical record were to be timed, signed, and dated. She stated that the hospital did not have a policy on authenticating medical records.

On 4/10/13 at 11:00 a.m., the Medical Staff Bylaws were reviewed. Documented under section 7.5 all clinical entries in the patient's record must be accurately dated and authenticated. The Medical Staff Bylaws did not include that authenticating the medical chart included dating all entries.







26492

26492

Based on record reviews, policy review, and staff interview, the facility failed to assess the use of bed rails, and failed to obtain a complete physician's order for the use of bed rails for 5 (#s 16, 17, 18, 19, and 20) of 5 swing bed patients reviewed. Findings include:

Review of closed medical records completed on 4/9/13 at 8:00 a.m.,it was noted that side rails were used during the hospital swing bed stay for the patients.

1. Patient #16 was admitted to a swing bed on 4/6/12 with diagnoses which included congestive heart failure, aortic stenosis, and pneumonia. Noted in the closed medical record was a consent form for safety devices and restraints form signed by the patient's representative on 4/6/12.

The medical chart lacked which described that:
-Least restrictive measures were attempted prior to the placement of the side rails;
-A medical symptom documented by the physician for the use of the side rails;
-A physician's order for the restraint;
-A comprehensive assessment prior to the use of the side rails; and
-The use of the side rails was not included in the care plan.

2. Patient #17 was admitted to a swing bed on 5/17/12 with diagnoses which included anemia, hypotension, gastrointestinal bleed, history of hypertension, status-post drug-eluting stent, and status -post colonoscopy with repair of GI vascular tract. Noted in the medical record was a consent for safety devices and restraints form signed by the patient on 5/17/12.

The medical chart lacked which described that:
-Least restrictive measures were attempted prior to the placement of the side rails;
-A medical symptom documented by the physician for the use of the side rails;
-A physician's order for the restraint;
-A comprehensive assessment prior to the use of the side rails; and
-The use of the side rails was not included in the care plan.

3. Patient #18 was admitted to a swing bed on 8/30/12 with diagnoses which included total right knee replacement, MRSA positive, hypothyroidism, chronic pain, status post renal carcinoma, degenerative joint disease, an urinary tract infections. Noted in the medical record was a consent for safety devices and restraints form signed by the patient's representative on 8/30/12.

The medical chart lacked which described that:
-Least restrictive measures were attempted prior to the placement of the side rails;
-A medical symptom documented by the physician for the use of the side rails;
-A physician's order for the restraint;
-A comprehensive assessment prior to the use of the side rails; and
-The use of the side rails was not included in the care plan.


4. Patient #19 was admitted to a swing bed on 10/8/12 with diagnoses which included fall, right tibia fracture, ETOH abuse, withdrawals during hospitalization, hypomagnesemia, chronic diastolic heart failure, hypertension and history of CVA.

The medical chart lacked which described that:
-A consent for the use of restraints;
-Least restrictive measures were attempted prior to the placement of the side rails;
-A medical symptom documented by the physician for the use of the side rails;
-A physician's order for the restraint;
-A comprehensive assessment prior to the use of the side rails; and
-The use of the side rails was not included in the care plan.


5. Patient #20 was admitted to a swing bed on 11/23/12 with diagnoses which included aspiration pneumonia, sepsis and hypoxemia. Noted in the medical record was a consent for safety devices and restraints form signed by the patient on 11/23/12.

The medical chart lacked which described that:
-Least restrictive measures were attempted prior to the placement of the side rails;
-A medical symptom documented by the physician for the use of the side rails;
-A physician's order for the restraint;
-A comprehensive assessment prior to the use of the side rails; and
-The use of the side rails was not included in the care plan.

According to the restraint policy, which was reviewed on 4/10/13 at 11:00 a.m., the patient soul be assessed prior to the usage of the restraints including side rails.

On 4/10/13 at 11:00 a.m., staff member A, stated that she was not aware that a comprehensive assessment, a physician's order for the use of a restraint, a documented medical symptom by the physician, and that the restraint needed to be care planned. Staff member A stated that side rails are used for the swing bed patients.

Based on policy review and staff interviews, the facility failed to have written policies and procedures regarding visitation rights of patients. Findings include:

On 4/9/13 at 2:00 p.m., the surveyors requested the policy on the visitation rights of the patient. The policy lacked information on setting forth any clinically necessary or reasonable restrictions or limitations for visitors.

On 4/9/13 at 4:30 at p.m., staff member A, stated the facility's policy was not complete regarding the visitation rights of the patients.

Based on policy review and staff interviews, the facility lacked a policy and procedure regarding the patients' visitation rights, clinical restrictions, consent to visitors, and right to withdraw or deny consent. Findings include:

On 4/9/13 at 2:00 p.m., the surveyors requested the policy on the visitation rights of the patient.

On 4/9/13 at 4:30 p.m., staff member A, stated the facility's policy lacked visitation rights of the patients rights, clinical restrictions, consent to visitors, and the right to withdraw or deny consent.

Based on policy review and staff interviews, the facility lacked a policy and procedure regarding the visitation rights of patients which does not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation, or disability. Findings include:

On 4/9/13 at 2:00 p.m., the surveyor requested the policy on the visitation rights of the patient.

On 4/9/13 at 4:30 p.m., staff member A, stated the facility lacked a policy which addressed the restriction of visitors, limit, or deny visitations based on race, color, national origin, religion, sex, sexual orientation, disability or gender identity.