HospitalInspections.org

Each Critical Access Hospital (CAH) is expected to be in compliance with applicable Federal laws and regulations related to the health and safety of patients.

A) Advance Directives: Based on interviews, observation, review of procedures and policies, and medical record review, it was determined that the hospital failed to comply with 42 CFR §489.102(b)(1) which requires the CAH's advance directive policy be provided at the time an individual is registered and to document in a prominent part of the patient's medical record whether or not the patient has executed an advance directive.

Findings include:

1. An interview with I6, registration personnel, on 11/08/2012 at 1350, reflected that he/she offered advance directive information to each patient who registered for an emergency department (ED) visit or inpatient admission. During the interview, I6 was observed as he/she registered a patient. The observation confirmed the correct process had taken place during a prior visit because documentation in the patient's admission screen reflected documentation of an advance directive on file for the patient.

2. Review of policy titled "ADVANCE DIRECTIVES," effective 08/2007, reflected "An inquiry will be made by the Admitting Staff during the admissions process of the patient/resident...as to whether or not the individual has executed an advance directive. A request of the patient/resident/significant other to provide a copy of the advance directive for medical record entry will be made by the Admitting Staff during the admission process...Admitting personnel will document in the medical record whether the patient/resident has completed an advance directive and that the information concerning advance directives has been given to the patient/resident/significant other during the admission process."

3. Medical record review on 11/08-09/2012 revealed 5 of 27 (#'s 13, 16, 18, 19, and 24) charts failed to document compliance with documentation of advance directive notice in the patient's electronic medical record (EMR).

B. Written Notice: The hospital also failed to comply with 42 CFR §489.20(b) which mandates that all CAHs provide written notice to all patients at the beginning of an inpatient stay or outpatient visit if there is no doctor of medicine or doctor of osteopathy present in the CAH 24 hours per day, seven days per week, in order to assist the patient in making an informed decision about his/her care. The notice must also indicate how the CAH will meet the medical needs of any patient who develops an emergency medical condition, as defined in 42 CFR 489.24(b) [the EMTALA definition], at a time when no physician is present in the CAH.

1. An interview with I1, the Director of Nursing Services (DNS), on 11/08/2012 at 1055, during a tour of the inpatient and ED patient waiting area, confirmed the hospital neglected to post a notice indicating that there was no doctor of medicine or doctor of osteopathy present in the CAH 24 hours/day, 7 days a week.

2. An interview with I2, the Assistant DNS, on 11/08/2012 at 1130, during a tour of the ED, confirmed the hospital neglected to post a notice in the ED indicating there was no doctor of medicine or doctor of osteopathy present in the CAH 24 hours/day, 7 days a week. During the same interview, I2 confirmed that the physicians scheduled to provide coverage for the ED would leave the hospital at times when there were no patients present. I2 stated that the physicians returned within 15-20 minutes if a patient arrived seeking medical assistance.

3. An interview with I6, a registration personnel, on 11/08/2012 at 1350, confirmed the hospital failed to provide a notice to all patients at the beginning of their hospital stay or outpatient visit that there was no doctor of medicine or doctor of osteopathy present in the CAH 24 hours/day, 7 days a week.

Based on interview, observation, review of crash cart checklist documentation for 2 of 3 emergency crash carts, and policy review, it was determined the hospital failed to document that its emergency crash carts were maintained to assure the integrity and availability of the contents of the carts, in accordance with hospital policy.

Findings include:

1. Review of the policy titled, "Crash Carts, Emergency," revised 01/2012 reflected the following internal requirements: "...Pharmacy Procedures...The crash cart's emergency drugs will remain inside the cart, sealed, at all times when not in use. The seal(s) will be broken only when an emergency situation arises or by Pharmacy or ICU [Intensive Care Unit] nurse or [Emergency Room] Nurse to recheck the contents...Nursing Procedure...Patient care units are responsible for checking the integrity of all equipment on top of the cart. Patient care units will check the integrity of the seal on each shift."

2. A tour of the ICU and the Emergency Department (ED) was conducted with the I1 on 11/06/2012 at 1000 and 1040, respectively. During the tour, observations of the emergency crash carts for each area were conducted. Each of the carts had a corresponding monthly checklist titled, "Defibrillator and Crash Cart Checklist." The checklist included a list of emergency equipment, and a breakaway "padlock" number for the medication storage area within the cart. The monthly checklist included directions for checking the contents of each cart as follows: "Defibrillator and Crash Cart Checklist...At the beginning of each shift, inspect the defibrillator and crash cart. First Column, AM [day] Shift, Second Column, PM [night] Shift." A defibrillator and corresponding manufacturer's instructions were also located on each cart.

3. Review of the manufacturer's instructions for the ED and ICU crash cart defibrillators, titled, "Zoll MSeries Operator's Guide," dated 10/2005, identified the following guidance, on page 9-1: "Periodic Testing...Resuscitation equipment must be maintained to be ready for immediate use...The following operational checks should be performed at the beginning of every shift to ensure proper equipment operation and patient safety. Refer to the appropriate Operator's Shift Checklist..."

4. The ED crash cart checklist was reviewed. The checklist had columns for documenting emergency equipment function, integrity, and availability for each shift. For example, "...Defibrillator...Clean, no spills, clear of objects on top, casing intact...Cables/Connectors...Inspect for cracks, broken wire or damage...Charge/Display Cycle...[oxygen] tank at least 3/4 full..." Review of the checklists for 08/2012, 09/2012, 10/2012 and 11/2012 identified that many checks were not conducted in accordance with hospital policy. For example, no checks were documented for the following dates/shifts: 08/03/2012, PM shift; 08/04/2012, AM shift; 08/12/2012, PM shift; 08/18/2012, AM shift; 08/24/2012, AM shift; 08/28/2012, PM shift; and 08/29/2012, PM shift.

Similar findings were identified during review of ED monthly crash cart checklists for 09/2012, 10/2012 and 11/2012.

5. Similar findings were identified during review of the ICU monthly crash cart checklists for 08/2012, 09/2012, 10/2012 and 11/2012. For example, review of the checklist for 08/2012, identified that 34 out of 60 shift checks were not documented as completed.

6. These findings were reviewed with I1 on 11/06/2012 at 1040. He/she stated that nursing staff were responsible for completing the crash cart checklists each shift. He/she acknowledged that the checklists lacked documentation that they were completed each shift in accordance with hospital policy.

Based on the review of documentation in 4 of 4 medical records of patients who received blood transfusion services (#s 11, 12, 13 and 14) and policy review, it was determined the hospital failed to ensure documentation of all of the elements required by the hospital's policy. Vital signs were not documented according to hospital policy.

Findings include:

1. The policy titled "Blood Transfusion," revised 01/2012 identified the following internal requirements: "Procedure for Transfusion...Obtain baseline vital signs. Document start time, vital signs and signature...Assess patient closely. Monitor vital signs every 5 minutes X 3 then every 15 minutes X 2, then every hour if stable...document observations in the medical record including vital signs."

2. Medical record #11 was reviewed. The nurse progress notes dated, 05/14/2012 at 1810, reflected the patient received a blood transfusion on 05/14/2012 which was started at 1530 and ended at 1735. Review of the "Clindoc (Patient) Report," reflected vital signs were documented on 05/14/2012 at 1535, 1550, and 2012. Review of the "Component Tag" form reflected the unit of blood was verified by the nurse on 05/14/2012 at 1535. The vital signs section of the form reflected vital signs were collected as follows: "Prior," "15 [minutes]," and "Post." However, the actual time in which the vital signs were collected was not documented on the form. The record lacked documentation that vital signs were collected every 5 minutes X 3, and then every 15 minutes X 2, and then every hour, in accordance with hospital policy.

3. Medical record #12 was reviewed. The nurse detail report dated, 07/10/2012 at 2020, reflected the patient received a blood transfusion on 07/10/2012 which was started at 1530. Review of the vitals detail report reflected vital signs were collected on 07/10/2012 at 1517, 1600, 1850, 2030, 2045, and 2300. Review of the "Component Tag" form reflected the unit of blood was verified by the nurse on 07/10/2012 at 1529. The vital signs section of the form reflected the unit was completed at 1850, and vital signs were collected as follows: "Prior," "15 [minutes]," and "Post." However, the actual time in which the vital signs were collected was not documented on the form. The record lacked documentation that vital signs were collected in accordance with hospital policy.

4. Medical record #13 was reviewed. Review of the "Component Tag" form reflected a blood transfusion was initiated by the nurse on 07/15/2012 at 1112. The vital signs section of the form reflected the nurse ended the unit of blood at 1425, and vital signs were collected as follows: "Prior," "15 [minutes]," and "Post." However, the actual time in which the vital signs were collected was not documented on the form. Review of the "Vitals Detail Report," reflected vital signs were collected on 07/15/2012 at 1112, 1127, 1142, 1230, 1430, 1440, 1455, 1520, and 1755. However, the record lacked documentation that vital signs were collected at all of the timeframes specified in the hospital policy.

5. Medical record #14 was reviewed and reflected similar findings.

Based on interview, policy review, and review of 2 of 2 medical records of patients (#s 26 and 27) who were discharged from the hospital following the provision of swing-bed services, it was determined that the hospital failed to ensure the patients were provided with a written discharge notice before transfer or discharge in accordance with hospital policy.

Findings included:

1. Review of the hospital critical access and swing bed program policy titled, "Admission, Transfer Discharge Rights Policy," reviewed by the hospital 09/26/2012, identified the following internal requirements: "...Notice Before Transfer: Before a facility transfers or discharges a resident, the facility must...Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand...Record the reasons in the residents clinical record; and...Include in the notice the items described in paragraph (a)(6) of this section..."

2. Swing-bed Patient #26: Review of the record reflected the patient was admitted to a swing-bed on 10/18/2012 and discharged from the hospital on 10/31/2012. The record lacked documentation that the patient was provided a written discharge notice before discharge.

3. Swing-bed Patient #27: Review of the record reflected the patient was admitted to a swing-bed on 08/29/2012 and discharged from the hospital on 09/12/2012. The record lacked documentation that the patient was provided a written discharge notice before discharge.

4. These findings were reviewed with I13, the Case Manager, on 11/07/2012 at 1030. He/she reviewed the medical records for Patient #s 26 and 27, and acknowledged the records lacked documentation that a written discharge notice had been provided to the patients before discharge.

Based on interview, policy review, and review of patient rights documentation, it was determined the hospital failed to fully develop and implement a policy and procedure that ensured patients were informed of their visitation rights, including any clinical restriction or limitation on such rights, and the right to receive visitors whom he or she designates, as required by this regulation.

Findings include:

1. Review of the policy titled, "Visiting Hours," effective 10/23/2003 identified it was not fully developed and implemented to address a process for informing patients of their visitation rights, including any necessary restrictions or limitations that the hospital may need to place on such rights, the reasons for the restrictions; and the right to receive visitors, including, but not limited to, a spouse, a domestic partner, another family member, or a friend, and his or her right to withdraw or deny such consent at any time, as required by this regulation.

2. A document titled, "Patient Bill of Rights," was received from I8, Admitting and Commercial Billing representative, on 11/16/2012 at 1530. He/she stated the document was provided to patients in order to inform them of their patient rights. Review of the form identified it failed to include patient visitation rights.

3. This was reviewed with I12, the Administrator, on 11/16/2012 at 1715. He/she acknowledged that the policy above was not fully developed to include a process for informing patients of their visitation rights, and that the patient rights information which was provided to patients did not include visitation rights.