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Based on interview, record review, and review of facility policy, the Critical Access Hospital (CAH) failed to ensure the staff notified the physician of a change in condition for one of 20 sampled patients, (Patient 12). The staff failed to notify the physician when Patient 12 experienced an episode of choking and bleeding from the nose. The failure of the CAH to ensure the staff notified the physician of a change in patient condition had the potential to affect all 19 currently admitted patients by potentially causing a delay in the evaluation and treatment of a newly developed or worsening condition.

Findings Include:

On 04/30/19, the DON provided a copy of an untitled document and indicated it was the facility's policy and procedure for physician notification of changes in condition. Review of the untitled document, dated 09/01/16, showed the following, "Purpose: To provide a policy and procedure for notifying [the] physician of [a] patient change of condition. Procedure: 1. [The] Charge nurse will do a head to toe assessment of [the] patient with any change of condition. 2. [The] Charge nurse will notify [the] practitioner of changes in condition, after [an] assessment [is] done, of all swing bed and acute care patients."

During a review of Patient 12's electronic medical record, the undated "Face Sheet" showed the CAH admitted the patient on 11/13/15 with diagnoses of congestive heart failure, Parkinson's disease, diabetic neuropathy
(condition affecting the nerves supplying the arms and legs), diabetes mellitus, type II, and shortness of breath. Review of the "Assessment," dated 08/14/18, showed the resident was oriented to self, exhibited no behaviors, and required the assistance of one staff to feed herself.

Review of the nursing "Progress Notes," dated 08/14/18, showed the nurse documented, "Reported by day staff [that the] pt [patient] 'felt bad' after [a] choking episode [that occurred] during [her] meal and epistaxis [nose bleed]. No complaints during this shift, states 'I feel better'." Further review of the medical record provided no documentation to show the staff notified the physician of Patient 12's choking event.

During an interview on 04/30/19 at 2:30 PM, the Director of Nursing (DON) was asked to review Patient 12's clinical record and locate the documentation that showed the staff notified the physician of the patient's change in condition related to her episodes of choking and a nosebleed. The DON stated she could not find where the staff notified the physician, and when asked if the staff should have notified the physician, the DON stated, "Yes."

Based on interview and document review, the facility failed to ensure the activities program was directed by a qualified individual. This failure had the potential to affect the quality of life for the 18 swing bed status patients currently admitted in the facility.

Findings Include:

During an interview on 04/29/19 at 11:05 AM, when asked about the qualifications of the facility's Activity Director, the Director of Nursing (DON) provided a certificate of completion in a course titled, "Social Services Designee," dated 09/08/17, and a job description for the facility's Activities Director position. When asked if the facility had a policy regarding the qualifications for the Activities Director, the DON stated, "No."

On 04/29/19 at 1:05 PM, the DON provided another "Social Services Designee" certificate and a separate "Activity Director" course certificate. The DON stated she did not realize it was two different courses, and that these certificates were for the Activities Director that, "left in January 2019."

A review of the facility's undated job description titled, "Activity Director/Social Service Designee (AD/SSD)," showed the following qualifications: "JOB QUALIFICATIONS:

Experience: Preferred but not necessary

Education: High School Graduate, CNA certification preferred

Certification: 36 hour AD/SSD training course

Registration: CPR Course reviewed every two years (You may be asked to complete a CNA course)."

Based on interview, record review, and review of facility policy, the Critical Access Hospital (CAH) failed to ensure the staff completed an activity assessment, as part of the comprehensive assessment, for one of 20 sampled patients, (Patient 18), to determine the patient's preferred activity interests. The CAH's failure to ensure the staff completed an assessment of the patient's activity preferences had the potential to impair the patient's ability to reach their optimal state of psychosocial well-being.

Findings Include:

Review of Patient 18's "Face Sheet" located in the electronic medical record (EMR), showed the CAH admitted the patient on 04/08/19 with a diagnosis of an impacted fractured left hip. Further review of Patient 18's EMR provided no documentation to show the staff completed an assessment of Patient 18's activity interests and skills.

During an interview on 05/01/19 at 2:15 PM, when asked to locate Patient 18's activities assessment, the Director of Nursing (DON) stated, "There is none."

Review of the facility's policy titled, "Activities Program," with an effective date of 06/07/18, showed, "Statement Purpose: It is the policy of [Name of facility] to provide activities which are suited to the intellectual, social, spiritual, creative, and physical needs and capabilities of patients. It encourages involvement and allows the patient to function as an important part of our treatment programs and coordinates with the overall plan of care. Procedure: . . . 2. An Activity Care Plan will be developed for each patient based on a total patient assessment, including, but not limited to past and current interests, skills, medical limitations, cognitive functioning and emotional state."

Based on interview and review of the facility's documentation, the facility failed to ensure compliance for the Condition of Participation (CoP) for the Emergency Preparedness Plan (EPP) as evidenced by the failure to 1. Included policies and procedures for the provision of subsistence needs addressing pharmaceutical supplies for patients and staff during an emergency or disaster; 2. To establish policies and procedures to address a means to shelter in place in the facility; 3. Include an identified system of medical documentation that secured and maintained the availability of patient records; 4. To establish policy and procedures to address for the use of volunteers in an emergency; 5. Maintain a current list of names and contact information in the "Emergency Preparedness Communication Plan" that included facility staff members, entities providing services under arrangement, patient physicians, and/or a list of other facilities; 6. Include contact information for the federal and state emergency preparedness staff, and/or agencies in the communication plan; 7. Have a written policy and/or procedure for sharing information and medical documentation for patients; 8. Identify a method of communication with the authority having jurisdiction in cases of emergency to provide information regarding the CAH's ability to provide emergency assistance during a disaster or emergency; and 9. Identify a written training and testing program based on the facility's "Emergency Plan and Risk Assessment

The cumulative affects of these deficient practices have the potential to place all patients at risk for unsafe care and potentially hindered the facility's ability to provide and ensure safe care during an emergency or disaster situation.

Findings Include:

1. The facility's staff failed to establish policies and procedures to address subsistence needs addressing pharmaceutical supplies for patients and staff during an emergency or disaster situation. Refer to tag E0015.

2. The facility's staff failed to establish policies and procedures to address sheltering in place for an emergency. Refer to tag E0022.

3. The facility's staff failed to establish policies and procedures to address preserving patient information, protecting confidentiality of patient information, and securing and maintaining availability of patient records in the event of an emergency. Refer to tag E0023.

4. The facility's staff failed to establish policies and procedures for the use of volunteers in the event of an emergency. Refer to tag E0024.

5. The facility's staff failed to maintain a current list of names and contact information in the "Emergency Preparedness Communication Plan" that included facility staff members, entities providing services under arrangement, patient physicians, and/or a list of other facilities. Refer to tag E0030.

6. The facility failed to include contact information for the federal and state emergency preparedness staff, and/or agencies in the communication plan. Refer to tag E0031

7. The facility failed to have a written policy and/or procedure for sharing information and medical documentation for patients under their care in the CAH's "Emergency Preparedness Communication Plan. Refer to tag E0033.

8. The facility failed to identify a method of communication with the authority having jurisdiction in cases of emergency to provide information regarding the CAH's ability to provide emergency assistance during a disaster or emergency. Refer to tag E0034

9. The facility failed to identify a written training and testing program based on the facility's "Emergency Plan and Risk Assessment." Refer to tag E0036


During an interview on 05/01/19 between 10:05 AM and 10:32 AM, the Operations Manager confirmed the CAH had no provider for emergency pharmaceutical supplies included in the emergency plan, and stated, "We don't have a shelter in place policy."; upon review of the CAH's EPP to locate the required policy or procedure that identified the required system for preserving and ensuring the confidentiality of medical documentation, the Operations Manager stated, "I don't recall having anything in here [the EPP] that specifically identifies this [system]."; the Operations Manager confirmed that the facility's EPP did not cover the use of volunteer healthcare professionals or identify emergency staff strategies. The Operations Manager stated, "I don't have anything in here [the emergency plan]."; the Operations Manager stated, "No names and contact information are included in the emergency plan."; the Operations Manager confirmed the facility's "Emergency Preparedness Communication Plan" did not include contact information for the state and federal emergency agencies listed in the plan; confirmed that a method for sharing patient information and medical documentation was not covered in the CAH's emergency plan; and stated, "[There is] nothing referenced in the communication plan about the ability to provide assistance."; and the Operations Manager stated the facility had ". . . no written training program based on the emergency plan."

Based on interview and record review, the Critical Access Hospital (CAH) failed to ensure the facility's "Emergency Preparedness Plan" included policies and procedures for the provision of subsistence needs addressing pharmaceutical supplies for patients and staff. This failure had the potential affect any of the 19 patients receiving care in the facility, plus any staff on duty caring for them, in the event of an emergency.

Findings Include:

A review of the CAH's "Emergency Preparedness" plan on 05/01/19 at 9:10 AM, showed a plan for emergency water, food, and alternative energy sources; however, no alternative source for resident and staff emergency pharmaceutical needs was identified.

During an interview on 05/01/19 at 10:05 AM, the Operations Manager confirmed the CAH had no provider for emergency pharmaceutical supplies included in the emergency plan.

Based on interview and review of the facility's "Emergency Preparedness Plan (EPP)," the Critical Access Hospital (CAH) failed to develop and implement emergency preparedness policies and procedures regarding sheltering in place in the case of an emergency and/or natural disasters that could threaten the health or safety of the participants, staff, or the public that might be in the facility at the time of an emergent occurrence. This failure had the potential affect any of the 19 patients receiving care in the facility plus any staff on duty caring for them in the event of an emergency or natural disaster.

Findings Include:

Review of the facility's EPP on 05/01/19 at 9:10 AM showed the plan did not include policies and procedures for sheltering in place in case of an emergency and/or natural disaster.

During an interview on 05/01/19 at 10:01 AM, the Operations Manager stated, "We don't have a shelter in place policy."

Based on interview, and a review of the facility's Emergency Preparedness Plan (EPP), the Critical Access Hospital (CAH) failed to include an identified system of medical documentation that secured and maintained the availability of patient records. This failure had the potential to affect the 19 patients receiving care in the facility, and hinder the facility's ability to provide care and services and keep patients safe during an emergency.

Findings Include:

Review of the facility's EPP on 05/01/19 at 9:10 AM showed no evidence of a policy or procedure that identified the system of medical documentation that would preserve, secure, and provide for the confidentiality of patient information, yet maintain the availability of patient records in the case of an emergent event.

During an interview on 05/01/19 at 10:10 AM, upon review of the CAH's EPP to locate the required policy or procedure that identified the required system for preserving and ensuring the confidentiality of medical documentation, the Operations Manager stated, "I don't recall having anything in here [the EPP] that specifically identifies this [system]."

Based on interview and review of the facility's "Emergency Preparedness Plan (EPP)," the Critical Access Hospital (CAH) failed to ensure the EPP included a policy regarding the use of State and Federally designated healthcare professional volunteers to care for the facility's patients in the case of an emergency. This deficient practice had the potential to affect the continuity of care for all 19 of the facility's patients.

Findings Include:

A review of the facility's EPP on 05/01/19 at 9:10 AM showed the plan did not include a policy regarding the use of State and/or Federal healthcare professional volunteers in an emergency, or other emergency staffing strategies.

During an interview on 05/01/19 at 10:21 AM the Operations Manager confirmed that the facility's EPP did not cover the use of volunteer healthcare professionals or identify emergency staff strategies. The Operations Manager stated, "I don't have anything in here [the emergency plan]."

Based on interview and review of the facility's "Emergency Preparedness Plan (EPP)," the Critical Access Hospital (CAH) failed to maintain a current list of names and contact information in the "Emergency Preparedness Communication Plan" that included facility staff members, entities providing services under arrangement, patient physicians, and/or a list of other facilities. This failure had the potential to affect the 19 patients receiving care in the facility and could delay the facility's ability to respond to an emergency. This failure had the potential to prevent the facility from providing care and services to patients during an emergency event and to keep the patients safe.

Findings Include:

Review of the facility's "Emergency Preparedness Communication Plan" on 05/01/19 at 9:10 AM showed the plan did not include identification of the facility's staff and their contact information, did not identify the entities that would provide services under arrangement and their contact information, nor did it include a list of patient physicians and their contact information, or a list of other facilities.

During an interview on 05/01/19 at 10:30 AM, the Operations Manager stated, "No names and contact information are included in the emergency plan."

Based on interview, and review of the facility's "Emergency Preparedness Communication Plan," the Critical Access Hospital (CAH) failed to include contact information for the federal and state emergency preparedness staff, and/or agencies in the communication plan. This failure had the potential affect the 19 patients receiving care in the facility and could delay the facility's ability to respond to an emergency. This failure had the potential to prevent first responders and other sources of assistance from providing care and services to the facility and its patients during an emergency event.

Findings Include:

A review of the facility's "Emergency Preparedness Communication Plan" on 05/01/19 at 9:10 AM showed the plan did not include emergency contact information for the emergency agencies listed in the plan.

During an interview on 05/01/19 at 10:32 AM, the Operations Manager confirmed the facility's "Emergency Preparedness Communication Plan" did not include contact information for the state and federal emergency agencies listed in the plan.

Based on interview and review of the facility's "Emergency Preparedness Plan," the Critical Access Hospital (CAH) failed to have a written policy and/or procedure for sharing information and medical documentation for patients under their care in the CAH's "Emergency Preparedness Communication Plan." This failure had the potential to affect the 19 patients receiving care in the CAH, and could potentially prevent the CAH from ensuring the provision of care and services to patients during an emergency.

Findings Include:

A review of the facility's "Emergency Preparedness Communication Plan" on 05/01/19 at 9:10 AM showed the plan did not include a written policy or procedure for sharing patient information and medical documentation with another provider in an emergent event.

During an interview on 05/01/19 at 10:33 AM, the Operations Manager confirmed that a method for sharing patient information and medical documentation was not covered in the CAH's emergency plan."

Based on interview, and review of the facility's "Emergency Preparedness Communication Plan," the Critical Access Hospital (CAH) failed to identify a method of communication with the authority having jurisdiction in cases of emergency to provide information regarding the CAH's ability to provide emergency assistance during a disaster or emergency. The CAH's failure to identify the means of communication with the authority having jurisdiction, had the potential to affect all 19 patients receiving care in the facility, and to hinder the facility's ability to keep patients safe, and to render assistance during an emergency event.

Findings Include:

Review of the facility's "Emergency Preparedness Plan (EPP) Communication Plan" on 05/01/19 at 9:10 AM showed the plan did not include a method for providing information about the facility's ability to provide assistance to the authority having jurisdiction, or to the Incident Command Center, or designee in the event of an emergency.

During an interview on 05/01/19 at 10:36 AM, the Operations Manager stated, "[There is] nothing referenced in the communication plan about the ability to provide assistance."

Based on interview, and review of the facility's "Emergency Preparedness Plan (EPP)," the Critical Access Hospital (CAH) failed to identify a written training and testing program based on the facility's "Emergency Plan and Risk Assessment." The CAH's failure to identify a written facility EPP-based training and testing program had the potential to affect the 19 patients receiving care in the facility and hinder the facility's ability to keep patients and staff safe during an emergency event.

Findings Include:

Review of the facility's "Emergency Preparedness Plan" on 05/01/19 at 9:10 AM showed the plan did not include a written description, with an annual update and review, of a training and testing program based upon the facility's "All Hazards Risk Assessment" and EPP.

During an interview on 05/01/19 at 10:39 AM, the Operations Manager stated the facility had ". . . no written training program based on the emergency plan."