HospitalInspections.org

Based on staffing schedules reviewed and staff interviews, the Critical Access Hospital (CAH) failed to ensure sufficient staffing to provide emergency services and/or nursing services (refer to C-0253), and failed to ensure a registered nurse (RN) or licensed practical nurse (LPN) is on duty whenever the CAH has one or more inpatients (refer to C-0255).


The cumulative effect of the systemic failure of the CAH to ensure sufficient RN staffing coverage had the potential for patients to receive inadequate care.

Based on staffing schedules reviewed and staff interviews, the Critical Access Hospital (CAH) failed to ensure sufficient staffing to provide emergency services and/or nursing services.
The CAH's failure to ensure adequate staffing by allowing the Charge RN on duty to be the Charge RN on duty for the connected long term care unit creates a potential situation of insufficient staffing for the CAH when the RN leaves to perform charge nurse duties in the long term care unit.

Findings include:

- Review of the "...Acute Care Schedule June 2015" revealed one RN and one certified nurse aide (CNA) scheduled on duty for the day shift (7am to 7pm) on 6/24/15.

Staff F, RN, interviewed on 6/23/15 at 9:30am explained the RN on duty is also responsible for the RN duties in the long term care building adjacent to the CAH if they lack a RN on duty which occurred this day on 6/23/15. Staff F explained the RN on duty at the CAH goes to the long term care building to administer insulin or other injections to the resident or at times the staff of the long term care building will bring the residents to the CAH for the RN on duty to administer insulin or other injections.

Staff G, RN, interviewed on 6/25/15 at 1:00pm explained the RN on duty at the CAH is the RN responsible for the long term care residents if the long term care does not have an RN scheduled. Staff G explained they are responsible for administering insulin or other injections, administering any narcotics to the residents if needed, and assess the residents if they fall. Staff G explained if they got busy or an emergency patient came to the CAH they would call other staff to come in to help also at times the long term care staff will bring the patients to the CAH for the RN to administer insulin or other injections to the residents. Staff G explained if the RN on duty at the CAH goes to the long term care building that leaves the scheduled CNA alone with all of the patients at the CAH.

Based on staffing schedules reviewed and staff interviews the Critical Access Hospital (CAH) failed to ensure a registered nurse (RN) or licensed practical nurse (LPN) is on duty whenever the CAH has one or more inpatients.

The failure to have a RN on duty whenever there are one or more inpatients has the potential for the lack of appropriate patient care.

Findings include:

- Review of the "...Acute Care Schedule June 2015" revealed one RN and one certified nurse aide (CNA) scheduled on duty for the day shift (7am to 7pm) on 6/23/15.

Staff F, RN, interviewed on 6/23/15 at 9:30am explained the RN on duty is also responsible for the RN duties in the long term care building adjacent to the CAH if they lack a RN on duty which occurred the day on 6/23/15. Staff F explained the RN on duty at the CAH goes to the long term care building to administer insulin or other injections to the resident or at times the staff of the long term care building will bring the residents to the CAH for the RN on duty to administer insulin or other injections.

Staff G, RN, interviewed on 6/25/15 at 1:00pm explained the RN on duty at the CAH is the RN responsible for the long term care residents if the long term care does not have an RN scheduled. Staff G explained they are responsible for administering insulin or other injections, administering any narcotics to the residents if needed, and assess the residents if they fall. Staff G explained if they got busy or an emergency patient came to the CAH they would call other staff to come in to help also at times the long term care staff will bring the patients to the CAH for the RN to administer insulin or other injections to the residents. Staff G explained if the RN on duty at the CAH goes to the long term care building that leaves the scheduled CNA alone with the patient/patients at the CAH.

The CAH failed to meet the requirement to have a RN on duty whenever the CAH has one or more patients when the RN leaves to go to the long term care building.

Based on observation, document review and staff interview, the Critical Access Hospital (CAH) failed to ensure outdated drugs and biologicals are not available for patient use in emergency rooms, the computed tomography (CT) scanner room, and medication room (refer to C-0276), failed to track and schedule outpatients separately from emergency room patients (refer to C-0280), failed to develop and maintain a current list of services provided by agreement or arrangement (refer to C-0291), failed to ensure the care and treatment of patients follow written physician orders (refer to C-0297) and failed to ensure a nursing care plan is developed and kept current for each inpatient (refer to C-0298).





The cumulative effect of the systemic failure of the CAH to have outdated medications available for use, to track outpatients and ER patients on the ER log, to keep current a list of services provided under agreement, to ensure care follows writtten physician orders, and to develop and keep current a nursing care plan had the potential for the CAH to provide services in an unsafe and ineffective manner.

Based on observation, policy review, and staff interview the Critical Access Hospital (CAH) failed to ensure outdated drugs and biologicals are not available for patient use for the emergency room, the computed tomography (CT) scanner room, and the medication room. This failure has the potential to affect all patients admitted to the CAH.

Findings include:

- The CAH's policy titled, "INSPECTION OF NURSING UNITS BY THE CONSULTING PHARMACIST" reviewed on 6/24/15 at 5:30pm directed "...Oversee outdated medications review ..."

- Observation of the emergency room on 6/22/15 at 2:10pm revealed a cabinet with one opened multiuse 20millileter (ml) vial of Lidocaine 1% (a local anesthetic) lacking a date when opened.

Staff A, pharmacy nurse, interviewed on 6/22/15 at 2:10pm acknowledged the medication lacked a date when opened and confirmed the vial of medication should have a date when it was opened.

- Observation of the Nursing Medication Room on 6/22/15 at 2:25pm revealed a blood drawing tray in a lower cabinet with one 20 ml (milliliter) vial of Lidocaine 1%(local anesthetic) 10mg/ml with an expiration date of May 1, 2015, one yellow top BD vacutainer (blood draw tube) 3.5ml with an expiration date of 05/2014 and one blue top BD vacutainer (blood draw tube) 2.7ml with an expiration date of 04/2014.

- Staff Nurse G interviewed on 6/22/15 at 2:45pm acknowledged the vial of Lidocaine and two vacutainer tubes were expired and should have been discarded.

- Observation of the CT scanning room on 6/23/15 at 9:10am revealed a cabinet with one 100ml bottle of Readi-Cat (a contrast liquid used CT scan x-rays) with an expiration date of 5/15, one vial of Epinephrine (a medication used for an allergic reaction) 1:1000/ml with an expiration date of 1/15, and one vial of Benadryl (a medication used for an allergic reaction) 50milligrams/2ml with an expiration date of 12/14.

Staff H, radiology technician, interviewed on 6/23/15 at 9:10am acknowledged the Readi-Cat, Epinephrine, and Benadryl were expired.

Based on record review and staff interview, the Critical Access Hospital (CAH ) failed to track non-urgent outpatient admissions separately from the Emergency Room (ER) Register (log) and to have scheduled outpatient appointments for 5 of 7 non-ER outpatient records reviewed (Patients # 31, #32, #34, #36, and #37). This practice had the potential for patients presenting to the ER to not receive a medical screening exam to determine whether they have an emergency medical condition.


Findings Include:


- Review of the Critical Access Hospital's (CA's) policy titled "Outpatient Services" read in part: "...Outpatients are those patients who present to the hospital property (including the hospital's dedicated emergency department) with a scheduled appointment for care or treatment and have written physician or allied health practitioner orders for such care".


- Section 489.20(r)(3) of Appendix V of the State Operations Manual Interpretive Guidelines - Responsibilities of Medicare Participating Hospitals in Emergency Cases dated 7/16/10 directed in part: "the provider agrees to maintain a central log on each individual who ¿comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged...The purpose of the central log is to track the care provided to each individual who comes to the hospital seeking care for an emergency medical condition.


Patient #31

- Review of the emergency room (ER) register (log) on 6/23/15 at 2:30 pm revealed patient #31 listed with "Nature of Injury/Illness" as "OP Procedure" and "Reason" for presentation to the CAH as "Colonoscopy". The ER log revealed the patient's status as non- urgent.

- Patient #31's closed medical record review on 6/23/15 revealed the patient appeared at the Critical Access Hospital's (CAH's) emergency department for an outpatient colonoscopy (scope to visualize large intestine). Patient #31 had the procedure and was discharged from the CAH at noon. Review of the Outpatient Schedule for 11/21/14 revealed no scheduled appointment for patient #31. Patient #31 did not come to the CAH seeking assistance for an emergency medical condition and should not have been listed on the ER log.


Patient #32

- Review of the ER log on 6/23/15 at 2:30 pm revealed patient #32 listed with "Nature of Injury/Illness" as "OP Procedure" and "Reason" for presentation to the CAH as "Colonoscopy". The ER log revealed the patient's status as non-urgent.

Patient #32's closed medical record review on 6/23/15 revealed the patient appeared at the CAH's emergency department on 11/21/14 for an outpatient colonoscopy. Patient #32 had the procedure and was discharged from the CAH at noon. Review of the outpatient schedule for 11/21/14 revealed no scheduled appointment for patient #32. Patient #32 did not come to the CAH seeking assistance for an emergency medical condition and should not have been listed on the ER log.


Patient #34

- Review of the ER log on 6/23/15 at 2:30pm revealed patient #34 listed with "Nature of Illness/Injury" as "Injections" and "Reason" for presentation to the CAH "injection". The ER log revealed the patient's status as non-urgent.

- Patient #34's closed medical record review on 6/23/15 at 9:25pm revealed the CAH staff used outpatient medical record forms and indicated an outpatient admission date of 10/20/14 at 2:10pm with a complaint of shoulder pain and a prescription from the physician for Demerol (narcotic pain medication) 50 milligrams (mg) intramuscular (IM) and Phenergan (anti-nausea medication) 25mg IM. The Registered Nurse (RN) completed vital signs assessment, injections at 2:30pm, and the patient discharged to home at 4:10pm. Review of the outpatient schedule for 10/20/14 revealed no scheduled appointment for patient #34. Patient #34 did not come to the CAH seeking assistance for an emergency medical condition and should not have been entered on the ER log.


Patient #36

- Review of the ER log on 6/23/15 at 2:30pm revealed patient #36 listed with "Nature of Injury/Illness" as "chronic back pain" and "Reason" for presentation as "Toradol' (non-narcotic pain medication). The ER log revealed the patient's status as "Non-Urgent".

- Patient #36's closed record review on 6/23/15 at 9:10pm revealed an outpatient admission date of 6/19/15 at 10:46am with a complaint of back pain and a prescription from the physician for Toradol 60mg IM for chronic back pain. RN completed a vital signs assessment, injection at 10:55am and the patient discharged to home at 11:30am. Review of the outpatient schedule for 10/20/14 revealed no scheduled appointment for patient #36. Patient #36 did not present to the CAH seeking assistance for an emergency medical condition as should not have been listed on the ER log.


Patient #37

- Review of the ER log on 6/23/15 at 2:30pm revealed patient #37 listed with "Nature of Illness/Injury" listed as "TX" (treatment) and "Reason" for presentation to the CAH "dressing change". The ER log revealed the patient's status as urgent.

- Patient #37's closed medical record reviewed on 6/23/15 at 5:47pm revealed an outpatient admission date of 6/9/15 at 5:47pm for a dressing change to a burn area on the right lower extremity. The verbal orders from the physician included dressing change with Silvadene cream 1% applied to burn area, Midazolam (anti-anxiety) medication 3mg orally, and Dilaudid (narcotic pain medication) 1 mg IM. The RN completed a nursing assessment, medications and dressing changed completed at 8:35pm and the patient discharged to home at 8:35pm. Review of the outpatient schedule for 6/9/15 revealed no scheduled appointment for patient #37. Patient #37 did not present to the CAH seeking assistance for an emergency medical condition and should not have been listed on the ER log.


Staff A, RN, interviewed on 6/23/15 at 2:30pm acknowledged the outpatients listed on the ER log, but lacked awareness that the CAH staff listed outpatients on the ER log. Staff A, after talking with some of the staff explained that if the patient's status on the ER log indicates "Referred" then they would be an outpatient. However, she acknowledged these outpatients listed on the ER log as being "Urgent" and "Non-Urgent" as outpatients not as ER patients in need of an assessment to determine whether an emergency medical condition existed.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to develop and maintain a current list of services provided by agreement or arrangement. This deficient practice had the potential to affect patient services provided through agreement or arrangement by the CAH.

Findings include:

- Review of documentation provided during the survey between 6/22/15 to 6/25/15 revealed the CAH lacked a roster or list of agreements or those services through arrangements with the nature and scope of services provided to the CAH patients.

Staff I, Administrative Assistant, interviewed on 6/23/15 at 2:00pm acknowledged the CAH failed to maintain a list of agreements or arrangement of patient care services provided.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to designate an individual to be the nurse leader in charge of the management and supervision of all of nursing services. This failure has the potential to affect the nursing care of all patients admitted to the CAH.

Findings include:

- Review of the completed Entrance Conference Information Sheet the CAH provided on 6/23/15 at 3:00pm revealed the Director of Nursing category lacked a name.

- Staff B Administrative staff, acknowledged on entrance that staff A was the assistant director of nursing.

-Staff A, RN, interviewed on 6/23/15 at 3:00pm revealed they were not the assistant director of nursing, but is assisting the nursing staff until the CAH can hire a director of nursing. The former director of nursing resigned their position at the end of May 2015.

- Staff B Administrative staff, interviewed on 6/23/15 at 3:40pm acknowledged that staff A did not except the job as assistant director of nursing or interim director of nursing, but helps out with clinical issues and staff J along with staff I, human resources director create the monthly staffing schedule for the nursing staff.

The CAH failed to employ or name a director of nursing to oversee nursing services.

Based on policy review, record review and staff interview the CAH failed to ensure the care and treatment of patients follow written physician orders for two of 37 medical records reviewed (patient # 8 and #15).

This deficient practice has the potential for patients to receive inaccurate lab tests, procedures, or medications.

Findings include:

- The CAH's policy titled "PHYSICIAN'S ORDERS" reviewed on 6/24/15 at 5:30pm directed "...All orders for medication, treatments, etc., are to be in writing to a licensed nurse ..."

- Patient #8's medical record reviewed on 6/24/15 at 11:30am revealed the patient presented to the emergency room (ER) on 1/16/15 at 3:00am with a complaint of back pain. Patient #8 received Demerol (narcotic pain medication) 50mg intramuscular (IM) and Soma (a muscle relaxant) 350milligrams (mg) orally. Patient #8's medical record lacked a physician's order for the Demerol or Soma that patient #8 received in ER for their back pain.

Staff D, Administrative staff, interviewed on 6/24/15 at 11:30am confirmed patient #8's ER record lacked physician orders for the Demerol 50mg IM and Soma 350mg the patient received.

- Patient #15's medical record reviewed on 6/24/15 at 8:00am revealed an admission date of 4/11/15 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CAD (Coronary Artery Disease) and ASHD (Atherosclerotic Heart Disease). Patient #15, initially seen in the emergency room, had an EKG (electrocardiogram to monitor the heart), Chest X-Ray (CXR) and the following lab: CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), BNP (B-type Natriuretic Peptide, a heart test), Free T4 (Thyroid test), TSH (Thyroid Stimulating Hormone), cardiac enzymes, D-Dimer (check for blood clot), Magnesium and ABG's (Arterial Blood Gases). Patient #15 had an echocardiogram while in acute care and a 2-Gram Low Sodium Diet. Patient #15's medical record lacked evidence that a licensed nurse processed the orders for the EKG, CXR, CBC, CMP, BNP, Free T4, TSH, cardiac enzymes, D-Dimer, Magnesium, ABG's, Echocardiogram and 2 Gram Low Sodium Diet.

Staff A & Staff C interviewed on 6/23/15 at 4:15pm acknowledged that Patient #15's medical record lacked evidence a licensed nurse processed orders for an EKG, CXR, CBC, CMP, BNP, Free T4, TSH, cardiac enzymes, D-Dimer, Magnesium, ABG's, Echocardiogram and 2 Gram Low Sodium Diet. Staff C reports she does not know why the orders were not processed properly.

Based on observation, policy review, and staff interview the Critical Access Hospital (CAH) failed to ensure a nursing care plan is developed and kept current for each inpatient for nine of 20 sampled inpatients reviewed (patient #12, #13, #14, #15, #16, #18, #19, #20 and #26).
The failure of the CAH to identify the nursing needs of patients has the potential to put all patients admitted to the CAH at risk for inadequate care.

Findings include:

- The CAH's policy titled, "PATIENT CARE PLANS" reviewed on 6/24/15 at 5:30pm directed "...to ensure each patient has a nursing care plan initiated within eight hours of admission, based on the identified patient needs and utilizing the nursing process. To ensure each patient/significant other shall be involved in, as appropriate, and informed about the nursing plan of care developed by the nursing staff. The nursing care plan shall be reviewed, updated and revised as appropriate and necessary every twelve hours with the appropriate changes dated and initialized ..."

- Patient #12's closed medical record reviewed on 6/23/15 at 9:30am revealed an admission date of 3/25/15 with a diagnosis of abdominal pain. Patient #12's medical record lacked an individualized nursing care plan.

- Patient #13's closed medical record reviewed on 6/23/15 at 10:30am revealed an admission date of 2/27/15 with a diagnosis of abdominal pain. Patient #13's medical record lacked an individualized nursing care plan.

- Patient #14's closed medical record reviewed on 6/23/15 at 11:00am revealed an admission date of 3/27/15 with diagnoses of syncope (fainting) and renal failure (kidneys not functioning). Patient #14's medical record lacked an individualized nursing care plan.

- Patient #15's closed medical record reviewed on 6/24/15 at 8:00am revealed an admission date of 4/11/15 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CAD (Coronary Artery Disease) and ASHD (Atherosclerotic Heart Disease). Patient #15's medical record lacked an individualized nursing care plan.

- Patient #16's closed medical record reviewed on 6/24/15 at 8:30am revealed an admission date of 2/27/15 with a diagnosis of acute renal failure. Patient #16's medical record lacked an individualized nursing care plan.

- Patient #18's closed medical record reviewed on 6/24/15 at 9:30am revealed an admission date of 5/14/15 with diagnoses of abdominal pain and vomiting. Patient #18's medical record lacked an individualized nursing care plan.

- Patient #19's closed medical record reviewed on 6/24/15 at 10:00am revealed an admission date of 5/20/15 with a diagnosis of possible CVA (cerebrovascular accident). Patient #19's medical record lacked an individualized nursing care plan.

- Patient #20's closed medical record reviewed on 6/23/15 at 10:30am revealed an admission date of 12/14/14 with a diagnosis syncope (fainting). Patient #20's medical record lacked an individualized nursing care plan.

- Patient #21's closed medical record reviewed on 6/24/15 at 10:45am revealed an admission date of 12/16/14 with diagnoses of vomiting, headache and fever. Patient #21's medical record lacked an individualized nursing care plan.

- Patient #26's closed medical record reviewed on 6/24/15 at 10:30am revealed an admission date of 12/30/15 with diagnoses of Diabetes Mellitus Type 2 (chronic high blood sugar), Herpes Syndrome (sexually transmitted disease), Genital Warts (sexually transmitted disease). Patient #13's medical record lacked an individualized nursing care plan.

Staff C interviewed on 6/23/15 at 4:15pm acknowledged that patient #'s 12, 13, 14, 15, 16, 18, 19, 20 and 26 lacked an individual nursing care plan. Staff C states she does not know why care plans are not being done.

Based on observation, Medical Staff Bylaws review, policy review and staff interview the Critical Access Hospital (CAH) failed to ensure medical records are complete within 30 days (refer to C-0302), failed to ensure patients receiving health care services received a properly executed consent or had a discharge summary by the physician (refer to C-0304), failed to ensure a History and Physical was completed (refer to C-0305), failed to ensure the physician timed, dated and authenticated orders (refer to C-0307) and failed to maintain and provide the appropriate safeguards needed to protect stored medical records from destruction (refer to C-0308).

The cumulative effect of the CAH's systemic failure to ensure records are completed promptly, to ensure patients had a properly executed consent, to ensure patient's had a discharge summary and History and physical in the required timeframes and with authenticated orders, and to ensure the records are stored in such a manner to protect from destruction resulted in the potential for delays or inability to obtain pertinent medical information necessary to care for patients or for patients to make decisions about their healthcare.

Based on observation, Medical Staff Bylaws review, policy review and staff interview the Critical Access Hospital (CAH) failed to ensure medical records are complete within 30 days for 14 of 37 sampled patients (patients #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #27, #28, #29, and #30).
The failure of the CAH to ensure medical records are complete has the potential for providers to not have the information necessary to treat patients.

Findings include:

- The CAH's Medical Staff Bylaws and Rules and Regulations reviewed on 6/24/15 at 10:00am directed "...members of the Medical Staff are required to complete medical records within a reasonable time which may not in any event exceed 30 days ..."

- The CAH's policy titled "PATIENT CARE PLANS" reviewed on 6/24/15 at 5:30pm directed "...nursing care plans shall be initiated by a Registered Nurse. Updates may be done by RN or LPN ..."

- The CAH's policy titled "SWING BED COMPREHENSIVE ASSESSMENT, reviewed on 6/24/15 directed staff to ensure all swing bed patients receive a comprehensive assessment upon admission to swing bed and to complete timely reviews of the assessment within 24 hours of admission with other disciplines completing their portions within 72 hours of admission ... "

- The CAH's policy titled " SWING BED CRITERIA FOR ADMISSION, reviewed on 6/24/15 directed "... admitting provider to write orders for admission and the registered nurse (RN) starts a new chart. The RN completes the comprehensive assessment within 24 hours of admission ..."

- The CAH's policy titled, "SWING BED COMPREHENSIVE PLAN OF CARE " reviewed on 6/24/15 directed the interdisciplinary team to develop the comprehensive plan of care for each swing bed patient that includes measurable objectives and time table to meet the patient needs. The comprehensive plan of care will be completed within seven days of admission .

- The CAH's policy titled "TRANSFER AND DISCHARGE REQUIREMENTS, SWING BED " reviewed on 6/24/14 directed staff to complete a swing bed patient's discharge consistent with the discharge process of the CAH .

- The CAH's policy titled, "PHYSICIAN SERVICE STATEMENT" directed "...the Physician's responsibility to include the discharge summary at discharge, transfer or death... "

- Patient #12's closed medical record reviewed on 6/23/15 at 9:30am revealed an admission date of 3/25/15 with a diagnosis of abdominal pain. Patient #12's medical record lacked a History & Physical and a Discharge Summary completed by the physician. Patient #12's medical record lacked an individualized nursing care plan. Patient #12's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #12's medical record lacked a History & Physical, Discharge Summary and an individualized nursing care plan. Staff C states she does not know why they were not done.

- Patient #13's closed medical record reviewed on 6/23/15 at 10:30am revealed an admission date of 2/27/15 with a diagnosis of abdominal pain. Patient #13's medical record lacked an individualized nursing care plan. Patient #13's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #13's medical record lacked an individualized nursing care plan. Staff C states she does not know why it was not done.

- Patient #14's closed medical record reviewed on 6/23/14 at 11:00am revealed an admission date of 3/27/15 with diagnoses of syncope (fainting) and renal failure (kidneys not producing). Patient #14's medical record lacked an individualized nursing care plan. Patient #14's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #14's lacked an individualized nursing care plan. Staff C states she does not know why it was not done.

- Patient #15's closed medical record reviewed on 6/24/15 at 8:00am revealed an admission date of 4/11/15 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CAD (Coronary Artery Disease) and ASHD (Atherosclerotic Heart Disease). Patient #15's medical record lacked a Discharge Summary by the physician, physician orders signed, dated and authenticated and informed consents prior to treatment. Patient #15's medical record lacked evidence the patient received patient rights. Patient #15's medical record was incomplete. What treatment did he need a consent for? what orders were not authenticated?

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #15's medical record lacked a Discharge Summary by the physician; physician orders signed, dated and authenticated informed consents prior to treatment and patient rights. Staff C states she does not know why they were not done.

- Patient #16's closed medical record reviewed on 6/24/14 at 8:30am revealed an admission date of 5/8/15 with a diagnosis of acute renal failure. Patient #16's medical record lacked a Discharge Summary by the physician and an individualized nursing care plan. Patient #16's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged that Patient #16's medical record lacked a Discharge Summary by the physician and an individualized nursing care plan. Staff C states she does not know why they were not done.

- Patient #17's closed medical record reviewed on 6/24/15 at 9:00am revealed an admission date of 5/5/15 with diagnoses of renal and ureteral disease. Patient #17's medical record lacked a History & Physical and a Discharge Summary completed by the physician. Patient #17's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #17's medical record lacked a History & Physical and a Discharge Summary by the physician. Staff C states she does not know why they were not done.

- Patient #18's closed medical record reviewed on 6/24/15 at 9:30am revealed an admission date of 5/20/15 with diagnoses of abdominal pain and vomiting. Patient #18's medical record lacked an individualized nursing care plan. Patient #18's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #18's medical record lacked an individualized nursing care plan. Staff C states she does not know why it was not done.

- Patient #19's closed medical record reviewed on 6/24/15 at 10:00am revealed an admission date of 5/20/15 with a diagnosis of possible CVA (cerebrovascular accident). Patient #19's medical record lacked a History & Physical by the physician and an individualized nursing care plan. Patient #19's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #19's medical record lacked a lacked a History & Physical by the physician and an individualized nursing care plan. Staff C states she does not know why they were not done.

- Patient #20's closed medical record reviewed on 6/24/15 at 10:15am revealed an admission date of 12/14/14 with a diagnosis of syncope (fainting). Patient #20's medical record lacked a Discharge Summary by the physician, an individualized nursing care plan and informed consents prior to treatment. Patient #20's medical record lacked evidence that the patient received patient rights. Patient #20's medical record was incomplete. what treatment did he need a consent for?

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #20's medical record lacked a Discharge Summary by the physician, an individualized nursing care plan and informed consents prior to treatment and lacked evidence that the patient received patient rights. Staff C states she does not know why they were not done.

- Patient #21's closed medical record reviewed on 6/24/15 at 10:45am revealed an admission date of 12/16/14 with diagnoses of vomiting, headache and fever. Patient #21's medical record revealed the History & Physical dictated by the physician 12/19/14 and signed by the physician 3/30/15. Patient #21's medical record revealed the Discharge Summary dictated by the physician 12/19/14 and signed by the physician 3/30/15. Patient #21's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #21's medical record lacked a History & Physical and Discharge Summary completed within 30 days. Staff C states she does not know why they were not done.

- Patient #27's closed medical record reviewed on 6/23/15 and 6/24/15 revealed an admission date of 4/7/15 as a direct admit to swing bed from Hospital AA for skilled services with a diagnosis of left hip fracture. Patient #27's record revealed a discharge on 5/22/15, 46 days later. Review of the closed medical record lacked evidence of a comprehensive care plan with interventions, a discharge summary that included the recapitulation of the stay, a final summary of the patient status at the time of discharge and a post-discharge plan of care with the participation of the patient, his or her family. Patient #27's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:00pm acknowledged Patient #27's medical record lacked a comprehensive care plan, discharge summary, a final summary and post-discharge plan of care. Staff C states she does not know why they were not done.

- Patient #28's closed medical record review revealed an admission date of 3/8/15 with a diagnosis of hypoxia (lack of oxygen). On 3/12/15 at 2:00pm, the physician wrote an order for "Swing Bed if qualified". Patient #28's medical record revealed a discharge date of 3/16/15 or four days after admission to swing bed. Review of the closed medical record lacked evidence of a swing bed comprehensive assessment completed by members of the interdisciplinary team, a comprehensive care plan with interventions completed by the interdisciplinary team and a discharge summary at discharge that included the recapitulation of the stay, a final summary of the patient status at the time of discharge and a post-discharge plan of care with the participation of the patient, his or her. Patient #28's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:00pm acknowledged that Patient #28's medical record lacked a comprehensive assessment, comprehensive care plan, a discharge summary, a final summary and a post-discharge plan of care. Staff C states she does not know why they were not done.

- Patient #29's closed medical record reviewed on 6/24/15 revealed a direct admission to swing bed from Hospital AA on 4/8/15 with a diagnosis of aftercare following repair of fractured ankle, diabetic with hypertension. The record revealed a discharge date of 4/24/15, 17 days later. Review of the closed medical record lacked evidence of a comprehensive care plan with interventions completed by the interdisciplinary team, a charge summary at discharge that included the recapitulation of the stay, a final summary of the patient status at the time of discharge and a post-discharge plan of care with the participation of the patient, his or her family. Patient #29's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:00pm acknowledged that Patient #29's medical record lacked a comprehensive care plan, a charge summary, a final summary and a post-discharge plan of care. Staff C states she does not know why they were not done.

- Patient #30's closed medical record reviewed on 6/24/15 revealed an admission date of 5/17/15 to swing bed with a diagnosis vomiting (cause unknown) and right flank pain (cause unknown). Patient #30's record revealed a discharge date of 5/21/15, four days after admission to swing bed. Review of the closed medical record lacked evidenced of an initiated comprehensive assessment by members of the interdisciplinary team, a complete discharge summary that included the recapitulation of the stay, a final summary of the patient status at the time of discharge and a post-discharge plan of care with the participation of the patient, his or her family. Patient #30's medical record was incomplete.

Staff C interviewed on 6/24/15 at 4:00pm acknowledged that Patient #30's medical record lacked a comprehensive assessment, a discharge summary, a final summary and post-discharge plan of care. Staff C states she does not know why they were not done.

Based on observation, Medical Staff Bylaws and Rules and Regulations, policy review and staff interview the Critical Access Hospital (CAH) failed to ensure that patients receiving health care services received a proper executed consent or had a discharge summary by the physician for seven of 37 sampled medical records (Patients #11, #12, #15, #16, #17, #20 and #36).

The failure of the CAH to ensure medical records are complete has the potential for providers to not have the information necessary to treat patients.

Findings include:

- The CAH's policy titled "GENERAL CONSENT" reviewed on 6/24/15 at 5:30pm directed, "...All consent forms must be signed and witnessed. The completed consent form shall be a permanent part of the chart and shall accompany the patient to surgery or to the location where the treatment or procedure is being performed ..."

- The CAH's "MEDICAL STAFF BYLAWS AND RULES AND REGULATIONS", reviewed on 6/24/15 at 10:00am directed " ...members of the Medical Staff are required to complete medical records within a reasonable time which may not in any even exceed 30 days ... "

- Patient #11's closed medical record reviewed on 6/23/15 at 9:00am revealed an admission date of 6/20/15 with a diagnosis of syncope (fainting). Patient #11's medical record lacked an informed consent prior to health care services provided.

- Patient #12's closed medical record reviewed on 6/23/15 at 9:30am revealed an admission date of 3/25/15 with a diagnosis of abdominal pain. Patient #12's medical record lacked a Discharge Summary by the physician.

- Patient #15's closed medical record reviewed on 6/24/15 at 8:00am revealed an admission date of 4/11/15 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CAD (Coronary Artery Disease) and ASHD (Atherosclerotic Heart Disease). Patient #15's medical record lacked a Discharge Summary by the physician and informed consents prior to health care services provided.

- Patient #16's closed medical record reviewed on 6/24/14 at 8:30am revealed an admission date of 5/8/15 with a diagnosis of acute renal failure. Patient #16's medical record lacked a Discharge Summary by the physician.

- Patient #17's closed medical record reviewed on 6/24/15 at 9:00am revealed an admission date of 5/5/15 with diagnoses of renal and ureteral disease. Patient #17's medical record lacked a Discharge Summary completed by the physician.

- Patient #20's closed medical record reviewed on 6/24/15 at 10:15am revealed an admission date of 12/14/14 with a diagnosis of syncope (fainting). Patient #20's medical record lacked a Discharge Summary by the physician, and informed consents prior to health care services provided.

- Patient #36's closed outpatient medical record reviewed on 6/23/15 at 9:10pm revealed an outpatient admission date of 6/19/15 at 10:46am with a complaint of back pain. The RN treated the patient appropriately and discharged the patient on 6/19/15 at 10:51am. Patient #36's medical record lacked evidence that the patient signed an informed consent.

Staff C interviewed 6/24/15 at 4:30pm acknowledged the following: Patient #11's medical record lacked and informed consent prior to health care services provided; Patient #12's medical record lacked a Physician's Discharge Summary; Patient #15's medical record lacked a Physician's Discharge Summary and informed consent prior to health care services provided; Patient #16's medical record lacked a Physician's Discharge Summary; Patient #17's medical record lacked a Physician's Discharge Summary and Patient #20's medical record lacked a Physician's Discharge Summary and informed consent prior to health care services provided.

Based on Medical Staff Bylaws review and staff interview the Critical Access Hospital (CAH) failed to ensure a History and Physical was completed for four of twenty sampled inpatients (Patients #12, #17, #19 and #23). The failure of the CAH to ensure History and Physicals are completed has the potential for providers not to have the information needed to treat patients admitted to the CAH.

Findings include:

- The CAH's Medical Staff Bylaws and Rules and Regulations reviewed on 6/24/15 at 10:00am directed "...A physical examination and medical history shall be done no more than 7 days before or 48 hours after an admission for each patient by a doctor of medicine or osteopathy ..."

- Patient #12's closed medical record reviewed on 6/23/15 at 9:30am revealed an admission date of 3/25/15 with a diagnosis of abdominal pain. Patient #12's medical record lacked a History & Physical by the physician.

- Patient #17's closed medical record reviewed on 6/24/15 at 9:00am revealed an admission date of 5/5/15 with diagnoses of renal and ureteral disease. Patient #17's medical record lacked a History & Physical by the physician.

- Patient #19's closed medical record reviewed on 6/24/15 at 10:00am revealed an admission date of 5/20/15 with a diagnosis of possible CVA (cerebrovascular accident). Patient #19's medical record lacked a History & Physical by the physician.

- Patient #23's closed medical record reviewed on 6/24/15 at 11:45am revealed an admission date of 5/26/15 with diagnoses of Weakness, Headache, Generalized Ill Feeling. Patient #23's medical record lacked a History & Physical by the physician.

Staff C interviewed on 6/24/15 at 4:00pm acknowledged the medical records lacked a Physician's History and Physical on Patients #12, #17, #19 and #23. Staff C states "the doctor just didn't do them."

Based on policy review, record review and staff interview the Critical Access Hospital (CAH) failed to ensure the physician timed, dated and authenticated orders for one of 20 sampled closed medical records reviewed (patient #15). This failure has the potential to affect all patients admitted to the CAH.

Finding include:

- Patient #15's closed medical record reviewed on 6/24/15 at 8:00am revealed an admission date of 4/11/15 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CAD (Coronary Artery Disease) and ASHD (Atherosclerotic Heart Disease). Patient #15, initially seen in the emergency room, had an EKG (electrocardiogram to monitor the heart), Chest X-Ray (CXR) and the following lab: CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), BNP (B-type Natriuretic Peptide, a heart test), Free T4 (Thyroid test), TSH (Thyroid Stimulating Hormone), cardiac enzymes, D-Dimer (check for blood clot), Magnesium and ABG's (Arterial Blood Gases). Patient #15 had an echocardiogram while in acute care and a 2-Gram Low Sodium Diet. Patient #15's medical record lacked signed physician orders for the EKG, CXR, CBC, CMP, BNP, Free T4, TSH, cardiac enzymes, D-Dimer, Magnesium, ABG's, Echocardiogram and 2 Gram Low Sodium Diet.

Staff C interviewed on 6/23/15 at 4:15pm acknowledged that Patient #15's medical record lacked signed physician orders for an EKG, CXR, CBC, CMP, BNP, Free T4, TSH, cardiac enzymes, D-Dimer, Magnesium, ABG's, Echocardiogram and 2 Gram Low Sodium Diet. Staff C states "he just didn't do it."

Based on observation and staff interview the Critical Access Hospital (CAH) failed to maintain and provide the appropriate safeguards from destruction for 27 boxes of medical records stored on the floor of the off-site medical record storage room.

Findings include:

- The offsite medical record storage room observed on 6/25/15 at 10:30am revealed 27 boxes of the CAH's patient closed medical records stored in the middle of the room on the linoleum floor. The floor had dirt and paper debris swept to the center of the room. The room appeared un-kept.

Director of Medical Records Staff C interviewed on 6/25/15 at 10:45am verified the medical records are stored offsite on the second floor of a county building. Staff C confirmed 27 boxes containing approximately 10 to 15 medical records each were stored directly on the linoleum floor without the required space between the box and the floor. Staff C acknowledged they could not find a policy for the storage of medical records and said the building is maintained by the county but the CAH is to maintain the cleanliness and overall appearance of the room.

Based on staff interview the Critical Access Hospital (CAH) failed to conduct or arrange a periodic evaluation of its total program at least once a year. This deficient practice has the potential to affect all patients who present to the CAH for services.

Findings include:

- On entrance to the CAH on 6/22/15 requested documentation of the CAH's annual program evaluation. The CAH failed to provide evidence of an annual program evaluation.

Staff A, RN interviewed on 6/24/15 at 4:15pm acknowledged the CAH failed to conduct a periodic evaluation of their total hospital program.

The CAH failed to carry out or arrange for a periodic evaluation of their total program at least once a year.

Based on observation, document review and staff interview, the Critical Access Hospital (CAH) failed to be substantially in compliance with the skilled nursing requirement for comprehensive assessment, comprehensive care plan and discharge planning for swing bed patients (refer to C-0360); failed to ensure staff followed the policies and procedures to complete the comprehensive assessments within 24 hours of admission (refer to C-0388); failed to ensure staff followed the policies and procedures to develop a comprehensive care plan for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, mental and psychosocial needs (refer to C-0395); failed to ensure the interdisciplinary team followed policies and procedures to develop a comprehensive care plan within seven days after the completion of the comprehensive assessment (refer to C-0396); and failed to ensure the swing bed patients had a discharge summary that included a recapitulation of their stay, a final summary of their status at the time of discharge and a post discharge plan of care developed with the participation of the patient and his or her family (refer to C-0399).




The cumulative effect of the CAH's systemic failure to meet the skilled nursing requirements for swing bed patients had the potential for patients to receive inadequate care and for the patient's needs to not be met.

The Critical Access Hospital (CAH) reported a census of 1 patient. Based on medical record review, document review and staff interview the CAH failed to be substantially in compliance with the skilled nursing requirement for comprehensive assessment, comprehensive care plan and discharge planning for two of four closed swing bed patients reviewed (patients #28 and #30).

The failure to comply with skilled nursing requirements for the comprehensive assessment, comprehensive care plan and discharge planning has the potential to affect all patients admitted for swing bed care to lack appropriate patient cares.

- CAH policy titled "SWING BED COMPREHENSIVE ASSESSMENT, dated: 8/14/2010" reviewed on 6/24/15 directed staff to ensure all swing bed patients receive a comprehensive assessment upon admission to swing bed and to complete timely reviews of the assessment. The policy directed nursing to complete the Comprehensive Assessment within 24 hours of admission with other disciplines completing their portions within 72 hours of admission.

The policy titled "SWING BED CRITERIA FOR ADMISSION, dated: 8/19/10" reviewed on 6/24/15 directed the patient has met the three days as an in-patient or returned to hospital with the same diagnosis in the past 30 days. Met the qualifying care needs criteria: a) need for daily Skilled care, b) other services that are appropriately provided in the in-patient setting, such as physical therapy. The admitting provider writes orders for admission and the registered nurse (RN) starts a new chart. The RN completes the comprehensive assessment within 24 hours of admission. The comprehensive care plan will be completed by the seventh day of admission.

- Patient #28's closed medical record review revealed an admission date of 3/12/15 to swing bed with a diagnosis of hypoxia (lack of oxygen). The physician ordered a consult for physical therapy to evaluate for strengthening and ambulation." Review of the medical record lacked evidenced of social services participation, a comprehensive assessment, a comprehensive care plan and discharge planning. The medical record review lacked evidence of a separate section for the swing bed chart for patient #28.

- Patient #30's closed medical record reviewed on 6/24/15 revealed an admission date of 5/17/15 to swing bed with a diagnosis of vomiting (cause unknown) and right flank pain (cause unknown). Review of the medical record lacked evidence of social services participation, a comprehensive assessment, a comprehensive care plan and discharge planning. The medical record review lacked evidence of a separate section for the swing bed chart for patient #30.

RN Staff A interviewed on 6/23/15 at 3:30pm acknowledged the CAH swing bed computer medical record lacked evidence of a separate swing bed chart for patients #28 and #30 that included social services participation, the swing bed comprehensive assessment, the swing bed comprehensive care plan and the swing bed discharge planning. Staff A verified they use the same chart for an admission to observation, acute care and swing bed care instead of opening a separate chart for swing bed services.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical records for swing bed patients #28 and #30 lacked the required social services participation, the swing bed comprehensive assessments, the swing bed comprehensive plan of care and the swing bed discharge planning. Staff C confirmed the CAH failed to create a separate swing bed section of the chart when the patient transfers from an acute care level of care into the swing bed level of care.

The Critical Access Hospital (CAH) reported a census of 1 patient. Based on medical record review, document review and staff interview the CAH failed to ensure staff followed the policies and procedures to complete the comprehensive assessments within 24 hours of admission for two of four closed swing bed patients reviewed (patients #28 and #30). The assessments need to include the patient's customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, dental status, activity interests, discharge potential and document participation of the patient and other disciplines.

The failure to complete swing bed patients' comprehensive assessments has the potential to not meet the needs of the patients.

Findings included:

- CAH policy titled "SWING BED COMPREHENSIVE ASSESSMENT, dated: 8/14/2010" reviewed on 6/24/15 directed staff to ensure all swing bed patients receive a comprehensive assessment upon admission to swing bed and to complete timely reviews of the assessment. The policy directed the nursing portion of the Comprehensive Assessment to be completed within 24 hours of admission with other disciplines completing their portions within 72 hours of admission.

The policy titled " SWING BED CRITERIA FOR ADMISSION, dated: 8/19/10 " reviewed on 6/24/15 directed the admitting provider to write orders for admission and the registered nurse (RN) starts a new chart. The RN completes the comprehensive assessment within 24 hours of admission.

- Patient #28's medical record review on 6/24/15 revealed an admission date of 3/8/15 to observation status from the long term care unit with a diagnosis of hypoxia (lack of oxygen). On 3/9/15 nursing order to change the patient status to inpatient medical. On 3/12/15 the physician wrote an order to " Evaluate for swing bed, move if needed and consult to physical therapy for strengthening and ambulation. " Review of the medical record lacked evidenced of a comprehensive assessment completed within 24 hours of admission to a swing bed that included the following: identification and demographic information, customary routine, cognitive patterns, ability to communicate, mood and behavior patterns, psychosocial well-being, dental status, activity interests, discharge potential and documentation of the patient and other disciplines participation within 72 hours of the comprehensive assessment.

- Patient #30's medical record reviewed on 6/24/15 revealed an admission date of 5/14/15 at 12:39am to observation with a diagnosis vomiting (cause unknown) and right flank pain (cause unknown). On 5/14/15 at 9:35am the physician wrote an order to "Change the patient to acute". On 5/16/15 at 8:15pm the physicians order directed the patient "go to Swing bed tomorrow." Review of the medical record lacked evidenced of a comprehensive assessment completed within 24 hours of swing bed admission that included the following: identification and demographic information, customary routine, cognitive patterns, ability to communicate, mood and behavior patterns, psychosocial well-being, dental status, activity interests, discharge potential and documentation of the patient and other disciplines participation within 72 hours of the comprehensive assessment.

RN Staff A interviewed on 6/23/15 at 3:30pm acknowledged the CAH swing bed computer medical record lacked evidence of swing bed patient's #28 and #30 comprehensive assessments that included participation of all disciplines and the patient or family members. Staff A verified they use the same chart for an admission to observation, acute care and swing bed care.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical records for swing bed patients #28 and #30 lacked the required comprehensive assessments with participation of all disciplines and the patient/families members. Staff C confirmed the CAH failed to create a separate swing bed section of the chart when the patient transfers from an acute care level of care into the swing bed level of care.

Based on medical record review, document review and staff interview the Critical Access Hospital (CAH) failed to ensure staff followed the policies and procedures to develop a comprehensive care plan for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for four of four sampled swing bed patients (patients #27, #28, #29 and #30).

The failure to develop swing bed patients comprehensive care plan and identify their care needs has the potential for patients needs not to be met.

Findings include:

- CAH policy titled, "SWING BED COMPREHENSIVE PLAN OF CARE, dated 8/17/2010" reviewed on 6/24/15 directed the interdisciplinary team to develop the comprehensive plan of care for each swing bed patient the includes measurable objectives and timetable to meet the patient needs. The comprehensive plan of care will be completed within seven days of admission.

CAH policy titled, "MANAGEMENT OF SWING BED PROGRAM: dated 8/14/2010" reviewed on 6/24/15 revealed under " Procedure: ... 13. Nursing Care Plan indicating patient's needs/problems, a. Goals set to guide each practitioner and patient, b. Approaches used to accomplish the goals, and c. Evaluations of plan with appropriate adjustments.

- Patient #27's closed medical record reviewed on 6/23/15 and 6/24/15 revealed an admission date of 4/7/15 as a direct admit to swing bed from Hospital AA for skilled services with a diagnosis of left hip fracture. Patient #27's record revealed a discharge on 5/22/15, 46 days later. Review of the medical record lacked evidence of a comprehensive care plan developed by the interdisciplinary team that included measurable objectives and timetables for medical, nursing, mental and psychosocial needs identified in the comprehensive assessment.

Registered Nurse (RN) Staff A interviewed on 6/24/15 at 1:30pm acknowledged the CAH swing bed patient #27's record lacked a comprehensive care plan that included measurable objectives and timetables for their care needs and evidence of participation of all disciplines and the patient or family members. Staff A verified the CAH's medical records are computerized and since the change from paper charts to computerized charting nursing staff are using the acute chart problem list. Nursing staff failed to create a separate swing bed chart section, and to initiate and complete the required swing bed comprehensive care plan.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical record for swing bed patient #27 lacked a comprehensive care plan. Staff C shared they were unable to find or explain why the computer record lacked a comprehensive care plan.

- Patient #28's closed medical record review on 6/24/15 revealed an admission date of 3/8/15 with a diagnosis of hypoxia (lack of oxygen). On 3/12/15 the physician wrote an order for "Swing Bed if qualified". Patient #28's medical record revealed a discharge date of 3/16/15 or four days after admission to swing bed. Review of the medical record lacked evidenced the CAH initiated a comprehensive care plan that included measurable objectives and timetables for medical, nursing, mental and psychosocial needs identified in the comprehensive assessment after admission to swing bed.

RN Staff A interviewed on 6/24/15 at 1:30pm acknowledged the CAH swing bed patient #28's record lacked a comprehensive care plan that included measurable objectives and timetables for their care needs and evidence of participation of all disciplines and the patient or family members. Staff A verified the CAH's medical records are computerized and since the change from paper charts to computerized charting nursing staff are using the acute chart problem list. Nursing staff failed to create a separate swing bed chart section, and to initiate and complete the required swing bed comprehensive care plan.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical record for swing bed patient #28's record lacked a comprehensive care plan. Staff C shared they were unable to find or explain why the computer record lacked a comprehensive care plan.

- Patient #29's closed medical record reviewed on 6/24/15 revealed a direct admission to swing bed from Hospital AA on 4/8/15 with a diagnosis of aftercare following repair of fractured ankle, diabetic with hypertension. The record revealed a discharge date of 4/24/15, 17 days later. Review of the medical record lacked evidenced the CAH initiated a comprehensive care plan that included measurable objectives and timetables for medical, nursing, mental and psychosocial needs identified in the comprehensive assessment after admission to swing bed.

RN Staff A interviewed on 6/24/15 at 1:30pm acknowledged the CAH swing bed patient #29's record lacked a comprehensive care plan that included measurable objectives and timetables for their care needs and evidence of participation of all disciplines and the patient or family members. Staff A verified the CAH's medical records are computerized and since the change from paper charts to computerized charting nursing staff are using the acute chart problem list. Nursing staff failed to create a separate swing bed chart section, and to initiate and complete the required swing bed comprehensive care plan.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical record for swing bed patient #29's record lacked a comprehensive care plan. Staff C shared they were unable to find or explain why the computer record lacked a comprehensive care plan.

- Patient #30's closed medical record reviewed on 6/24/15 revealed an admission date of 5/17/15 to swing bed with a diagnosis vomiting (cause unknown) and right flank pain (cause unknown). Patient #30's record revealed a discharge date of 5/21/15, four days after admission to swing bed. Review of the medical record lacked evidenced of the initiation of a comprehensive care plan that included measurable objectives and timetables for medical, nursing, mental and psychosocial needs identified in the comprehensive assessment after admission to swing bed.

RN Staff A interviewed on 6/24/15 at 1:30pm acknowledged swing bed patient #30's record lacked a comprehensive care plan that included measurable objectives and timetables for their care needs and evidence of participation of all disciplines and the patient or family members. Staff A verified the CAH's medical records are computerized and since the change from paper charts to computerized charting nursing staff are using the acute chart care plan. Nursing staff failed to create a new, separate swing bed chart section, and to initiate and complete the required swing bed comprehensive care plan.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical record for swing bed patient #30's record lacked a comprehensive care plan. Staff C shared they were unable to find or explain why the computer record lacked a comprehensive care plan.

Based on medical record review, document review and staff interview the Critical Access Hospital (CAH) failed to ensure the interdisciplinary team followed policies and procedures to develop a comprehensive care plan within seven days after the completion of the comprehensive assessment for two of four sampled swing bed patients (patients #27 and #29).

The failure to have the interdisciplinary team participate in the development of the comprehensive care plan has the potential for the lack of appropriate patient care.

Findings include:

- CAH policy titled, "SWING BED COMPREHENSIVE PLAN OF CARE, dated 8/17/2010" reviewed on 6/24/15 directed the interdisciplinary team to develop the comprehensive plan of care for each swing bed patient the includes measurable objectives and timetable to meet the patient needs. The comprehensive plan of care will be completed within seven days of admission.

- Patient #27's closed medical record reviewed on 6/23/15 and 6/24/15 revealed an admission date of 4/7/15 as a direct admit to swing bed from Hospital AA for skilled services with a diagnosis of left hip fracture. Patient #27's record revealed a discharge on 5/22/15, 46 days later. Review of the medical record lacked evidence the interdisciplinary team followed the CAH's policy and procedure to develop a comprehensive care plan that included measurable objectives and timetables for medical, nursing, mental and psychosocial needs identified in the comprehensive assessment after admission to swing bed.

Registered Nurse (RN) Staff A interviewed on 6/24/15 at 1:30pm acknowledged the CAH swing bed patient #27's closed record lacked a comprehensive care plan developed by the interdisciplinary team that included measurable objectives and timetables for their care needs and evidence of participation of all disciplines and the patient or family members. Staff A verified the CAH's medical records are computerized and since the change from paper charts to computerized charting the interdisciplinary team are using the acute chart care plan. The interdisciplinary team failed to create a new separate swing bed chart section, and to initiate and complete the required swing bed comprehensive care plan.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the closed medical record for swing bed patient #27 lacked a comprehensive care plan developed by each member of the interdisciplinary team. Staff C shared they were unable to find or explain why the computer record lacked a comprehensive care plan.

- Patient #29's closed medical record reviewed on 6/24/15 revealed a direct admission to swing bed from Hospital AA on 4/8/15 with a diagnosis of aftercare following repair of fractured ankle, diabetic with hypertension. The record revealed a discharge date of 4/24/15, 17 days later. Review of the closed medical record lacked evidence the interdisciplinary team followed the CAH's policy and procedure to complete a comprehensive care plan that included measurable objectives and timetables for medical, nursing, mental and psychosocial needs identified in the comprehensive assessment after admission to swing bed. The medical record lacked documentation of participation by the social worker and the activities designee.

Social Worker Staff E interviewed on 6/23/15 at 4:00pm verified they have failed to participate in the development of Swing Bed patients' comprehensive care plans since 2010 when they were told they no longer needed to complete any social assessments for swing bed patients.

RN Staff A interviewed on 6/24/15 at 1:30pm acknowledged swing bed patient #29's closed record lacked a comprehensive care plan that included measurable objectives and timetables for their care needs and evidence of participation of all disciplines and the patient or family members. Staff A verified the CAH's medical records are computerized and since the change from paper charts to computerized charting nursing staff are using the acute chart care plan. The interdisciplinary team failed to create a new separate swing bed chart section, and to initiate and complete the required swing bed comprehensive care plan.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical record for swing bed patient #29's record lacked a comprehensive care plan. Staff C shared they were unable to find or explain why the computer record lacked a comprehensive care plan.

Based on medical record review, document review and staff interview the Critical Access Hospital (CAH) failed to ensure the swing bed patients had a discharge summary that included a recapitulation of their stay, a final summary of their status at the time of discharge and a post discharge plan of care developed with the participation of the patient and his or her family for 4 of 4 sampled swing bed patients (patients #27, #28, #29 and #30).

The failure to have a discharge summary that included a recapitulation of their stay, a final summary of their status at the time of discharge and a post discharge plan of care developed with the participation of the patient and his or her family has the potential to delay a provider from having information needed to care for a patient.

Findings include:

- CAH policy titled "TRANSFER AND DISCHARGE REQUIREMENTS, SWING BED, dated 8/20/10", directs staff to complete a swing bed patient's discharge consistent with the discharge process of the CAH.

CAH policy titled, "PHYSICIAN SERVICE STATEMENT, dated 8/19/2010" directed the Physician's responsibility to include the discharge summary at discharge, transfer or death.

- Patient #27's closed medical record reviewed on 6/23/15 and 6/24/15 revealed an admission date of 4/7/15 as a direct admit to swing bed from Hospital AA for skilled services with a diagnosis of left hip fracture. Patient #27's record revealed a discharge on 5/22/15, 46 days later. Review of the closed medical record lacked evidence of a discharge summary that included the recapitulation of the stay, a final summary of the patient status at the time of discharge and a post-discharge plan of care with the participation of the patient, his or her family to assist with the adjustment of a new living situation.

Registered Nurse (RN) Staff A interviewed on 6/24/15 at 1:30pm acknowledged the CAH swing bed patient #27's closed record lacked a discharge summary that included the recapitulation of the patient's stay, a final summary of the patient status and the patient or family members, and a post-discharge plan of care with participation by the patient and their family for the adjustment to their new living situation. Staff A verified the CAH's medical records are computerized and since the change from paper records to computerized charting all required components of the swing bed medical record are not completed.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical record for swing bed patient #27 lacked a discharge summary. Staff C shared they were unable to find or explain why the computer record lacked a complete discharge plan and will need to talk to the software vendor.

- Patient #28's closed medical record review on 6/24/15 revealed an admission date of 3/8/15 with a diagnosis of hypoxia (lack of oxygen). On 3/12/15 at 2:00pm the physician wrote an order for "Swing Bed if qualified". Patient #28's medical record revealed a discharge date of 3/16/15 or four days after admission to swing bed. Review of the closed medical record lacked evidence of a discharge summary at discharge that included the recapitulation of the stay, a final summary of the patient status at the time of discharge and a post-discharge plan of care with the participation of the patient, his or her family to assist with the adjustment of a new living situation.

RN Staff A interviewed on 6/24/15 at 1:30pm acknowledged the CAH swing bed patient #28's closed record lacked lacked a discharge summary that included the recapitulation of the patient's stay, a final summary of the patient status and the patient or family members, and a post-discharge plan of care with participation by the patient and their family for the adjustment to their new living situation. Staff A verified the CAH's medical records are computerized and since the change from paper records to computerized charting all required components of the swing bed medical record are not completed.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical record for swing bed patient #28 lacked a discharge summary. Staff C shared they were unable to find or explain why the computer record lacked a complete discharge plan and will need to talk to the software vendor.

- Patient #29's closed medical record reviewed on 6/24/15 revealed a direct admission to swing bed from Hospital AA on 4/8/15 with a diagnosis of aftercare following repair of fractured ankle, diabetic with hypertension. The record revealed a discharge date of 4/24/15, 17 days later. Review of the closed medical record lacked evidenced of a discharge summary at discharge that included the recapitulation of the stay, a final summary of the patient status at the time of discharge and a post-discharge plan of care with the participation of the patient, his or her family to assist with the adjustment of a new living situation.

RN Staff A interviewed on 6/24/15 at 1:30pm acknowledged the CAH swing bed patient #29's record lacked lacked a discharge summary that included the recapitulation of the patient's stay, a final summary of the patient status and the patient or family members, and a post-discharge plan of care with participation by the patient and their family for the adjustment to their new living situation. Staff A verified the CAH's medical records are computerized and since the change from paper records to computerized charting all required components of the swing bed medical record are not completed.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical record for swing bed patient #29 lacked a discharge summary. Staff C shared they were unable to find or explain why the computer record lacked a complete discharge plan and will need to talk to the software vendor.

- Patient #30's closed medical record reviewed on 6/24/15 revealed an admission date of 5/17/15 to swing bed with a diagnosis vomiting (cause unknown) and right flank pain (cause unknown). Patient #30's record revealed a discharge date of 5/21/15, four days after admission to swing bed. Review of the closed medical record lacked evidenced of a discharge summary at discharge that included the recapitulation of the stay, a final summary of the patient status at the time of discharge and a post-discharge plan of care with the participation of the patient, his or her family to assist with the adjustment of a new living situation.

RN Staff A interviewed on 6/24/15 at 1:30pm acknowledged swing bed patient #30's closed record lacked a discharge summary that included the recapitulation of the patient's stay, a final summary of the patient status and the patient or family members, and a post-discharge plan of care with participation by the patient and their family for the adjustment to their new living situation. Staff A verified the CAH's medical records are computerized and since the change from paper records to computerized charting all required components of the swing bed medical record are not completed.

Director of Medical Records Staff C interviewed on 6/24/15 at 3:00pm verified the medical record for swing bed patient #30 lacked a discharge summary. Staff C shared they were unable to find or explain why the computer record lacked a complete discharge plan and will need to talk to the software vendor.

Based on document review, medical record review and staff interview the CAH failed to inform each patient or the patient's support person of their visitation rights and their right to designate whom they wish to have as visitors upon admission for 3 of 20 sampled inpatients medical records (Patients #11, #15, and #20) and 17 of 4065 outpatients (from Jan. 2014 to Dec. 2015) medical records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #31, #32, #33, #34, #35, #36, and #37). The failure to inform patients of their visitation rights has the potential to affect all patients admitted to the CAH.

Findings include:

- The CAH's policy titled "PATIENT VISITATION" reviewed on 6/25/15 directed "...To ensure contact and support of family members and friends during hospitalization ...."

- Patient #1's closed emergency room (ER) medical record reviewed on 6/24/15 revealed an admission date of 4/10/15 at 6:56am in a code blue (critical condition) situation from severe congestive heart disease. The ER staff performed appropriate code blue protocols. Patient #1 died on 4/10/15 at 9:10am. The CAH failed to inform patient #1's daughter of the patient's visitation rights.

- Patient #2's closed ER medical record reviewed on 6/24/15 revealed an admission date of 2/12/15 at 7:2am with complaints of nausea, vomiting, headache, and dizziness. The ER staff treated the patient appropriately and discharged the patient on 2/12/15 at 1:20pm. The CAH failed to inform patient #1 of their visitation rights.

- Patient #3's closed ER medical record reviewed on 6/24/15 revealed an admission date of 9/21/14 at 12:05pm with complaints of a fall and knee pain. The ER staff treated the patient appropriately and discharged the patient on 9/21/14 at 1:37pm. The CAH failed to inform patient #3 of their visitation rights.

- Patient #4's closed ER medical record reviewed on 6/24/15 revealed an admission date of 10/15/14 at 2:00pm with a complaint of accidental poisoning. The ER staff treated the patient appropriately and discharged the patient on 10/15/14 at 1:37pm. The CAH failed to inform patient #4 of their visitation rights.

- Patient #5's closed ER medical record reviewed on 6/24/15 revealed an admission date of 10/10/14 at 3:00pm with complaints of nausea, and abdominal pain. The ER staff treated the patient appropriately and transferred the patient to an acute care hospital on 10/10/14 at 5:13p with appropriate transfer documents. The CAH failed to inform patient #5 of their visitation rights.

- Patient #6's closed ER medical record reviewed on 6/24/15 revealed an admission date of 10/18/14 at 11:24pm with a complaint of possible active labor. The ER staff treated the patient appropriately and discharged the patient on 10/19/14 at 1:25am. The CAH failed to inform patient #6 of their visitation rights.

- Patient #7's closed ER medical record reviewed on 6/24/15 revealed an admission date of 9/16/14 at 8:55pm with complaints of cough and shortness of breath. The ER staff treated the patient appropriately, but the patient signed out of the ER Against Medical Advise (AMA) on 9/16/14 when the physician wanted them to be admitted to acute care. The CAH failed to inform patient #7 of their visitation rights.

- Patient #8's closed ER medical record reviewed on 6/24/15 revealed an admission date of 1/16/16 at 3:00am with a complaint of back pain. The ER staff treated the patient appropriately and discharged the patient on 1/16/15 at 4:55am. The CAH failed to inform patient #8 of their visitation rights.

- Patient #9's closed ER medical record reviewed on 6/24/15 revealed an admission date of 1/19/15 at 10:03am with a complaint of allergic reaction. The ER staff treated the patient appropriately and discharged the patient on 1/19/15 at 11:20am. The CAH failed to inform patient #9 of their visitation rights.

- Patient #10's closed ER medical record reviewed on 6/24/15 revealed an admission date of 3/8/15 at 3:58am with complaint battery to face and bite to left upper thigh. The ER staff treated the patient appropriately and admitted the patient to acute care on 3/8/15 at 6:30am. The CAH failed to inform patient #10 of their visitation rights.

- Patient #11's closed medical record reviewed on 6/23/15 at 9:00am revealed an admission date of 6/20/15 with a diagnosis of syncope (fainting). Patient #11's medical record lacked evidence the patient received patient rights. The CAH failed to inform Patient #11 of their rights.

- Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #15's medical record lacked evidence the patient received patient rights.

- Patient #15's closed medical record reviewed on 6/24/15 at 8:00am revealed an admission date of 4/11/15 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease), CAD (Coronary Artery Disease) and ASHD (Atherosclerotic Heart Disease). Patient #15's medical record lacked evidence the patient received patient rights.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #15's medical record lacked evidence the patient received patient rights.

- Patient #20's closed medical record reviewed on 6/24/15 at 10:15am revealed an admission date of 12/14/14 with a diagnosis of syncope (fainting). Patient #20's medical record lacked evidence that the patient received patient rights.

Staff C interviewed on 6/24/15 at 4:30pm acknowledged Patient #20's medical record lacked evidence that the patient received patient rights. Staff C states she does not know why they were not done.

- Patient #34's closed outpatient medical record reviewed on 6/23/15 at 9:25pm revealed an outpatient admission date of 10/20/14 at 2:10pm with a complaint of shoulder pain. The registered nurse (RN) treated the patient appropriately and discharged the patient on 10/20/14 at 2:50pm. The CAH failed to inform patient #34 of their visitation rights.

- Patient #35's closed outpatient medical record reviewed on 6/23/15 at 8:45pm revealed an outpatient admission date of 3/25/15 at 11:06am with orders for a portacath (an intravenous catheter to administer fluids) flush scheduled monthly. The RN treated the patient appropriately and discharged the patient on 3/25/15 at 11:50am. The CAH failed to inform patient #35 of their visitation rights.

- Patient #36's closed outpatient medical record reviewed on 6/23/15 at 9:10pm revealed an outpatient admission date of 6/19/15 at 10:46am with a complaint of back pain. The RN treated the patient appropriately and discharged the patient on 6/19/15 at 10:51am. The CAH failed to inform patient #36 of their visitation rights.

- Patient #37's closed outpatient medical record reviewed on 6/23/15 at 5:4pm revealed an outpatient admission date of 6/9/15 at 5:47pm for a dressing change to a burn area on the right lower extremity. The RN treated the patient appropriately and discharged the patient on 6/23/15 at 8:35pm. The CAH failed to inform patient #37 and their father of their visitation rights.

Staff J interviewed on 6/23/15 at 9:50am explained the patient signs the consent to treatment electronically and the statement in the consent to treatment states they have received their patient rights. However Staff J confirmed they do not have paper patient rights to give to the patients to review and no outpatients receive information regarding their patient rights.

Staff I interviewed on 6/24/15 at 7:30am acknowledged the outpatients do not receive information regarding their patient rights because they do not have the patient rights in paper form for them to review at the registration area.