HospitalInspections.org

Based on observation and interview, the facility staff failed to post a sign in the emergency department (ED) informing individuals there was not a medical doctor on site 24 hours a day seven days per week. The facility staff failed to provide written notice to inpatients and outpatients, at the beginning of their stay, informing them the facility does not have a medical doctor on site 24 hours a day 7 days per week. The facility staff failed to post the required EMTALA rights sign for all individuals to see who enter the emergency room.
Findings include:

During an observation on 6/30/15 at 7:05 a.m., an initial tour of the emergency room was completed. The required EMTALA and MD/DO 24/7 On-Site Presence signs were not posted for all individuals to view who entered the ED.

In an interview on 6/30/15 at 8:30 a.m., staff member B, QA director, stated the signs must be in the old hospital. New signs would be ordered and posted.

In an interview on 6/30/15 at 1:00 p.m., staff member D, the director of nursing, stated there was not a written notice provided to inpatients or outpatients regarding the lack of a medical doctor on site 24 hours a day 7 days per week.

33810


Based on observation, interview and record review, the facility failed to verify that patients ingested their medications, were given the correct medication dose, and clarified discrepancies for 2 (#21 and #22) of 22 sampled patients. Findings include:

1. During an observation on 6/30/15 at 8:30 a.m., staff member F, LPN, reviewed the electronic medication administration record for patient # 21, which reflected calcium 500 mg plus D. The Calcium bottle reflected 600 mg plus D. The Calcium 600 mg plus D was poured into a medication cup and placed on the bedside table in patient #21's room. Staff member F left the room prior to watching patient #21 ingest the calcium.

Review of patient #21's electronic orders reflected Calcium 500 mg plus D.

During an observation on 6/30/15 at 9:30 staff member G, RN obtained a verbal clarification order for patient #21's calcium from 500 mg to 600 mg, to match the product available in the facility.

During an interview on 6/30/15 at 9:45 a.m., non-staff member/consultant H, PharmD, stated after the doctor placed a medication order, the pharmacy reviewed and verified the medications. Non-staff member/consultant H stated pharmacy had not noticed that the calcium dosage order had not matched the calcium product supplied to the facility and had not gotten a clarification from the physician. Non-staff member/consultant H stated either the nurses had not noticed the difference between the calcium dose order and calcium product dose, or just did not request a physician clarification.

During an interview on 6/30/15 at 10:15 a.m., staff member F stated she was aware that the calcium dose given to patient #21 was different than the calcium dose written in the medication administration record. Staff member F stated her nurse colleagues had instructed her to use calcium 600 mg, because that was the dose the facility stocked for patient use. Staff member F stated she should have clarified the medication discrepancy with the medical provider prior to giving the medication.

Review of the facility's Medication Administration policy under section C/Number 11 reflected, "Special care shall be taken in identifying the patient for whom the medication has been ordered. Patients can expect to have their medications given according to the five rights - right patient, right dose, right route, and right time. If this comparison reveals any discrepancies, withhold the med until the discrepancy is cleared up. If a patient questions or doubts any of his/her meds, always double-check the orders and the med dose before administering the med."

2. During an observation on 6/30/15 at 8:45 a.m., staff member F poured patient #22's medications into a med cup and placed the cup on the bedside table in patient #22's room. Staff member F left the room prior to watching patient #22 ingest the medications.

During an interview on 6/30/15 at 10:35 a.m., staff member F stated if a patient had been at the facility for a long time and she knew they were capable of taking their own meds independently, she would give those patients their meds to take at their own time.

During an interview on 6/30/15 at 10:40 a.m., staff member D, DON, stated her expectations for medication administration by the facility nurses were to observe each patient's medication ingestion.

Review of the facility's Medication Administration policy under section C, number 12 reflected, "Care should be taken to verify that the patient has actually ingested the med."

Based on interview, the facility failed to comply with §485.641 for the years 2013 and 2014, specifically, there was no completion of an annual evaluation of the total program for the years 2013 and 2014 (see C331); there was no completion of an annual evaluation of the number of patients served and the volume of services for the year 2013 and year 2014 (see C332); there was no completion of an annual evaluation which included a representative sample of active and closed clinical records for 2013 and 2014 (see C333); there was no completion of an annual evaluation which included a review of the CAH's health care policies for the year 2013 and year 2014 (see C 334); there was no completion of an annual evaluation which included a review of utilization of services for year 2013 and year 2014 (see C 335); there was no maintenance of an effective and on going quality assurance program since 2012 (see C336); there was no evaluation of the health care services and safety for patients in the quality assurance program since the year 2012 (see C337); there was no evaluation of the quality assurance program for nosocomial infections and medication therapy for patients (see C338); there was no evaluation by an outside entity of the diagnosis and treatment by doctors of medicine or osteopathy in the quality assurance program since 2012 (see C340); there was no inclusion of an outside entity's recommendations for the quality assurance program (see C341); there was no evaluation of the health care services and safety for patients in the quality assurance program since the year 2012 (see C342); and, there was no remedial action by the staff to address deficiencies found through the quality assurance program (see C343).

Based on interview, the facility failed to complete an annual evaluation of the total program for the years 2013 and 2014.
Findings include:

In an interview on 6/30/15 at 7:50 a.m., staff member B, QA director, stated there has not been a periodic annual evaluation since 2012.

Based on interview, the facility failed to complete an annual evaluation of the number of patients served and the volume of services for the year 2013 and year 2014.
Findings include:


In an interview on 6/30/15 at 7:50 a.m., staff member B, QA director, stated there has not been an annual evaluation since 2012.

Based on interview, the facility failed to complete an annual evaluation which included a representative sample of active and closed clinical records for 2013 and 2014.
Findings include:

In an interview on 6/30/15 at 7:50 a.m., staff member B, QA director, stated there has not been a periodic annual evaluation since 2012.

Based on interview, the facility failed to complete an annual evaluation which included a review of the CAH's health care policies for the year 2013 and year 2014.
Findings include:

In an interview on 6/30/15 at 7:50 a.m., staff member B, QA director, stated there has not been an annual evaluation since 2012.

Based on interview, the facility failed to complete an annual evaluation which included a review of utilization of services for year 2013 and year 2014.
Findings include:

In an interview on 6/30/15 at 7:50 a.m., staff member B, QA director, stated there has not been an annual evaluation since 2012.

Based on interview, the CAH failed to maintain an effective and on going quality assurance program since 2012.
Findings include:

In an interview on 6/30/15 at 4:30 p.m., staff member B, QA director, stated there has not been an update to the quality assurance since 2012.

Based on interview, the quality assurance program failed to evaluate the health care services and safety for patients since the year 2012.
Findings include:

In an interview on 6/30/15 at 4:30 p.m., staff member B, QA director, stated there has not been a quality assurance plan since 2012.

Based on interview, the quality assurance program did not evaluate the nosocomial infections and medication therapy for patients since the year 2012.
Findings include:

In an interview on 6/30/15 at 4:30 p.m. staff member B, QA director, stated there has not been an update to quality assurance since 2012.

Based on interview, the quality assurance program did not have an outside entity evaluate the diagnosis and treatment by doctors of medicine or osteopathy since 2012.
Findings include:

In an interview on 6/30/15 at 4:30 p.m., staff member B, QA director, stated there has not been an updated quality assurance plan since 2012.

Based on interview, the quality assurance program did not encompass an outside entity's recommendations for the QA program.
Findings include:

In an interview on 6/30/15 at 4:30 p.m., staff member B, QA director, stated there has not been an update to the quality assurance plan since 2012.

Based on staff interview, quality assurance program did not evaluate the health care services and safety for patients since the year 2012.
Findings include:

In an interview on 6/30/15 at 4:30 p.m., staff member B, QA director, stated there has not been an updated quality assurance plan since 2012.

Based on staff interview, the CAH staff failed to take remedial action to address deficiencies found through the quality asurance program. Findings include:

In an interview on 6/30/15 at 4:30 p.m. staff member B, QA director, stated there has not been an update to the quality assurance plan since 2012.

33810

Based on record review and interview the facility failed to provide:
- A discharge summary, discharge instructions or discharge disposition for patient #16,
- Evidence of discharge instruction for patient's #19 and #20, and
- Supervision of the facility's discharge process, and the initiation and completion of a post-discharge plan for 8 (#s 15 - 22) of 22 sampled patients. Findings include:

1. Patient #15 was admitted to an acute care bed on 1/9/15 with the diagnosis of cerebral concussion, and was discharged and then transferred to a swing bed on 1/13/15. Patient #15 was discharged from the facility on 2/3/15 to a nursing home with physical therapy, nutrition and wound care.

2. Patient #17 was admitted to an acute care bed on 12/31/14 with diagnosis of pneumonia, and was discharged and transferred to a swing bed on 1/5/15. Patient #17 was discharged from the facility on 1/26/15 to a nursing home.

3. Patient #18 was admitted on 6/29/15 to a swing bed with diagnosis of generalized weakness after a hospitalization. Patient #18 was a current patient at the facility during the recertification survey.

4. Resident #21 was admitted to a swing bed on 6/19/15 for skilled wound care for diagnosis of stasis ulcers. Patient #21 was a current patient at the facility during the recertification survey.

Review of patients #15, #17, #18 and #21's electronic records reflected a lack of discharge planning notes, and a post-discharge plan.

5. Patient #16 was under observation from 3/17 - 3/19/15, admitted to an acute care bed on 3/19/15 with diagnoses of back/pelvic pain, weakness and non-operative compression fracture. Patient #16 was discharged & then transferred to a skilled swing bed from 3/22 - 4/8/15. On 4/8/15, patient #16 was discharged and transferred to private pay swing bed after the patient's skilled needs were met. Patient #16 was discharged from the facility on 5/22/15.

Review of the electronic records for patient #16 reflected a lack of discharge planning notes, a post-discharge plan, discharge disposition, and a discharge summary (for 5/22/15).

6. Patient #19 was admitted to an acute care bed on 3/5/15 with diagnoses of congestive heart failure and pneumonia, and was discharged and transferred to a swing bed on 3/9/15. Patient #19 was discharged from the facility on 3/23/15 to home.

Review of the electronic records for patient #19 reflected a lack of discharge planning notes, a post-discharge plan, and discharge instruction details including medications, Coumadin labs and medical provider follow-up.

7. Patient #20 was admitted to a swing bed on 4/7/15 after a hospitalization for diagnoses of hydrocephalus and a peritoneal shunt replacement. Patient #20 was discharged to home on 4/17/15.

Review of the electronic records for patient #20 reflected a lack of discharge planning notes, a post-discharge plan, signed discharge instructions from the patient or designee, and lacked guidance on a time frame on when to follow-up with the primary medical provider.

8. Patient #22 was admitted to a swing bed on 6/10/15 after a hospitalization in Billings for a motor vehicle accident and resulting diagnoses of right tibia and fibula fractures. Patient #22 was discharged to home on 6/30/15.

During an interview on 6/29/15 at 3:55 p.m., patient #22 stated he was planning on returning to his home on 6/30/15 with Meals on Wheels. Patient #22 stated he had a home evaluation with occupational therapy and his son was making home modifications. Patient #22 stated he had been given written physical therapy exercises and he knew he had to increase his protein intake.

Review of the electronic records for patient #22 reflected a lack of discharge planning notes, a post-discharge plan, signed discharge instructions by the resident or designee, details including Meals on Wheels, occupational home evaluation, increased protein, physical therapy exercises, and information regarding the status of Patient #22's home modifications.

Review of the facility's Discharge Summary policy and procedure reflected:

"Social Services will assure when [the facility] anticipates discharge of a patient {sic} that a discharge summary is completed that includes:
1. A recapitulation of the patient's stay.
2. A final summary of the patient's status that is available for release to authorized persons and agencies, with the consent of the patient or legal representative.
3. A post-discharge plan of care that is developed with the participation of the patient and his or her family, which will assist the patient to adjust to his or her new living environment.
Social Services will assist the family in arranging transportation and for assistance and/or care supplies at home, when needed. Social Services will also assist the family in relocating the patient, as needed."

On 6/30/15 at 3:15 p.m., staff member D, DON, facilitated the review of the electronic medical records in the computer for patients #s 15 - 22. The title 'post-discharge plan' were listed as a title in the electronic medical record care plans for patients #s 15 - 22, but there were no details listed under the plans.

On 7/1/15 at 8:55 a.m., staff member D was given a written request for copies of the following electronic documents for patients #s 15 - 22:

- Discharge planning notes,
- Referral notes for durable medical equipment, home health, and follow-up appointments,
- Discharge dispositions (home, assisted living, nursing homes, other); and,
- Discharge Summaries.

The printed electronic medical records provided for patients #s 15 - 22 reflected a lack of discharge planning notes and whether the patient and/or family were included in the discharge plan.

During an interview on 7/1/15 at 9:00 a.m., staff member E, RN, stated the electronic post-discharge plan was a new program at the facility and was not currently being used because of insufficient staff education on the program. The facility did not have a social service staff member to supervise the discharge planning process, but currently was suppose to be supervised by the QA staff coordinator. Currently, to understand where the discharge planning progress was for any one patients, the progress notes from the different departments would need to be reviewed. Staff member E said that was not an efficient way of finding the discharge planning information.

On 7/1/15 at 9:20 a.m., staff member B, QA, stated that discharge planning happens through-out the facility by the different disciplines. The floor nurses sum up the discharge plan prior to the patient discharge, and that it was her job to supervise the process, but she did not currently have the time.

Based on staff interview, the facility did not have written policies and procedure regarding visitation rights of patients. Findings include:

In an interview on 7/1/15 at 9:30 a.m., staff member C, Outpatient Director, stated there were no policies developed for visitation rights. Staff member C stated there was not a written form provided to inpatients or outpatients regarding visitation rights.

Based on staff interview, the facility did not have written policies and procedure regarding visitation rights and possible clinical restrictions of visitation. Findings include:

In an interview on 7/1/15 at 9:30 a.m., staff member C, Outpatient Director, stated there were no policies developed for visitation rights or clinical limitations.

Based on staff interview, the facility did not have written policies and procedures for patient visitation rights which included not discriminating against race, color, national origin, religion, sex, gender identity, sexual orientation, disability of patient, or patient representative, or patients visitors. Findings include:

In an interview on 7/1/15 at 9:30 a.m., staff member C, Outpatient Director, stated there were no policies developed for patient visitation rights.