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Based on observation, interview and record review, the facility failed to ensure that two of four sampled patients (Patient (P) P24 and P25) receiving physical therapy (PT) services were treated with paraffin wax in a warmer that had been checked by Biomed services. This deficient practice could have resulted in the patients receiving burns from a machine that had not been inspected.

Findings Include:

During an observation and interview on 12/11/18 at 11:30 AM, while touring the PT department with the Director of the Physical Therapy (Staff O), the paraffin warming machine was plugged in and was examined with the sticker that it had been checked out by Biomed. Staff O was asked if the warmer had been checked by Biomed, Staff O stated that the warmer had been pulled out of storage four weeks ago and had not been checked by Biomed before being put into use for patients.

1. Review of P24's "Encounter Notes" dated 11/30/18, revealed P24 was being treated for bilateral carpal tunnel syndrome pain in the hands with paraffin treatment.

2. Review of P25's "Encounter Notes" revealed P25 received paraffin treatments from the dates of 11/14/18, 11/16/18, 11/21/18, 11/30/18, 12/07/18 and 12/10/18 for left hand stiffness and pain after receiving a surgical procedure.

During an interview on 12/13/18 at 9:00 AM, the Director of Nursing (Staff E) stated that the facility does not have a policy for the checking of equipment by Biomed before being used on a patient. "It had never been a problem before that someone would pull out equipment and use it before being checked."

Based on observation, interview, and policy review, the Critical Access Hospital (CAH) staff failed to secure emergency drugs in an unattended Emergency Department (ED) crash cart. Failure to appropriately secure the crash cart had the potential to cause significant harm or death to all patients entering the ED.

Findings Include:

An observation on 12/11/18 at 1:47 PM of the CAH's Emergency Department two bed trauma bay, showed the ED emergency crash cart was unlocked allowing anyone full access to multiple resuscitation and other drugs. There were no staff in the ED at the time of the observation the crash cart that was not secured.

During an interview on 12/11/18 at 1:50 PM, Staff E, RN, Director of Nursing (DON) stated, "we never lock it because of emergencies."

Document review of the CAH Drugs and Biological's policies showed the facility had no policy for securing emergency medications in the ED crash cart.

Based on interview, record review, policy review, the facility failed to ensure that eight of 25 sampled patients (Patients (P) P1, P2, P3, P4, P9, P11, P12, and P14) had a plan of care for care and treatment. This deficient practice had the potential for the patients to not receive the appropriate care and treatments for their conditions. Failure to update the patient care plans had the potential to cause harm to the patients and provide less than the standard of care expected by national healthcare standards.

Findings Include:

1. Review of P1's undated, "Patient Information" sheet revealed an admission date of 12/03/18 with a diagnoses of cerebrovascular accident (CVA) and diabetes mellitus. Review of P1's "Nursing Care Plan" undated, revealed that P1 was only care planned for falls.

During an interview on 12/11/18 at 2:16 PM, Staff J, Licensed Practical Nurse (LPN) stated when a patient becomes a swing bed patient the care plan is updated. When asked where the care plan for P1 was located she stated it should be here. Staff J stated that LPN's do not make the care plans.

During an interview on 12/11/18 at 2:24 PM, Staff I, the Assistant Director of Nursing stated the computer program creates the care plan based on diagnosis and problems. Staff I stated the Registered Nurse (RN) can edit the care plan. Staff I was asked if the care plan for P1 was an appropriate care plan that included his diagnosis and problems. Staff I stated it was not, P1 should be care planned for his diabetes, the CVA, and self-care deficit.

2. Review of P2's undated, "Patient Information" sheet revealed an admission date of 12/04/18 with the following diagnoses of total self-care deficit, diabetes mellitus, gall bladder surgery, anemia and falls. Review of P2's "Nursing Care Plan" revealed on 12/07/18 a care plan for activity intolerance and falls.

During an interview on 12/11/18 at 3:20 PM, Staff I stated that the care plan is not appropriate. Staff I stated that the care plan should have been updated and included his diabetes, anemia and his self-care deficit.

3. Review of P3's undated, "Patient Information" sheet revealed an admission date of 12/10/18 with the following diagnoses of cellulitis of lower right limb, total self-care deficit and gastroesophageal reflux disease. Review of P3's "Nursing Care Plan" revealed no care plan.

During an interview on 12/11/18 at 3:55 PM, Staff I stated that an initial care plan should be created for all new patients within 24 hours of admission. Staff I further stated P3 came in with a rash on his buttocks and back that should have been care planed as well as the cellulitis.

4. During an observation on 12/11/18 at 10:00 AM, it was revealed P4 was on contact isolation.
Review of P4's undated, "Patient Information" sheet revealed an admission date of 10/23/18 with the following diagnoses of sepsis, urinary tract infection, diabetes mellitus, and self-care deficit. Review of P4's undated "Nursing Care Plan" revealed no care plan for P4's primary diagnoses and the contact isolation.

During an interview 12/11/18 at 4:10 PM, Staff I stated that the care plan was not appropriate for P4.

5. Review of P9's undated, "Patient Information" sheet revealed an admission date of 10/27/18 with the following diagnosis of muscle weakness and pain. Review of P9's undated "Nursing Care Plan" revealed no care plan for pain.

6. Review of P11's discharged medical record on 12/11/18 at 2:30 PM, showed no updates of the patient's care plan after the initial assessment on admission. The patient was admitted on 11/05/18 and discharged on 11/08/18.

7. Review of P12's discharged medical record on 12/12/18 at 3:29 PM, showed no updates of the patient's care plan after the initial assessment on admission. The patient was admitted on 11/12/18 and discharged on 11/15/18.

8. Review of P14's discharged medical record on 12/12/18 at 2:14 PM, showed no updates of the patient's care plan after the initial assessment on admission. The patient was admitted on 12/01/18 and discharged on 12/03/18.

During an interview on 12/11/18 at 2:30 PM, Staff E, RN, Director of Nursing (DON) stated, "The care plans are generated in the electronic medical record by the diagnosis that's entered. We don't generally up-date them after the initial assessment."

During an interview on 12/12/18 at 12:03 PM, Staff G, Registered Nurse (RN) stated, "The RN generates the care plan. We started yesterday updating the care plans but before that we did not update them after the initial care plan was generated by the RN. There is no policy about care plans."

During an interview on 12/13/18 at 9:30 AM, Staff G, Registered Nurse (RN) stated, "The person that admits them [patients] to the floor generates the care plan. It's always an RN and it [the care plan] is based on assessment and diagnosis. I look at them but I haven't revised them every shift. I don't know if we have a policy on care plans, I would have to look that up in the book."

Review of the CAH's policy, "Nursing Policies," revealed, "Patient Admission ..The admitting RN will assess the patient for plan of care and begin an active problem list"

Based on interview and review, the facility failed to ensure that one of two sampled surgical patients' (Patient (P) Patient 6) charts contained the anesthesia pre and post evaluation of the procedure was in the chart. This deficient practice had the potential to harm by allowing patients to have procedures performed without being fully informed of the type of anesthesia that would be used.

Findings Include:

Review of Patient 6's "Procedure Room Nurse's Notes" dated 12/06/18 showed the patient was to receive a lumbar epidural for lower back pain. Further review of the nurses notes for medication revealed to "see the anesthesia notes." There were no anesthesia notes in the chart.

During an interview on 12/12/18 at 2:50 PM, Staff M, the Operating Room (OR) Director, stated that the anesthesiologist transcribes his notes into the recorder and the recording was taken down to Medical Records when completed.

During an interview on 12/12/18 at 3:45 PM, Staff Q, the Director of Medical Records, stated that the recording came to her earlier that morning. Staff Q stated that an outside agency transcribes the recordings with in a 24-hour period. Staff Q stated that the nurse should have brought the recording down to her at the end if the procedure.

During an interview on 12/12/18 at 4:25 PM, Staff H, Registered Nurse (RN), stated she recalled the procedure and that the notes should have been in the chart. Staff H was asked who should have taken the recording to medical records. Staff H stated that the director of the OR director usually takes the recording down medical records.

During an interview on 12/13/18 at 11:40 AM, Staff G, RN, stated that she had taken the recording to the medical records, but the medical records were locked, and she put the recording in the locker. The recording was not taken to the medical record until after 24 hours.

Review of the CAH's policy, "Surgery Manual, Anesthesia Policy," review date 01/28/10, revealed, "the anesthetist shall complete the pre-anesthesia form. The anesthetist shall check patient chart for any change in the patient's condition before induction of anesthetic...The anesthetic record will be completed by the anesthetist. Follow up visit should be made within 1 to 24 hours, documenting the time. The Surgical staff was not following their policy.

Based on interview, record review, and policy review, the facility failed to ensure that one of 23 sampled patients (Patient (P) P2) received a dietary assessment after being admitted to the hospital as a swing bed patient. This deficient practice had the potential for the patient to receive a diet that was not appropriate.

Findings Include:

1. Review of P2's undated, "Patient Information" sheet revealed an admission date of 12/04/18 with the following diagnoses of total self-care deficit, diabetes mellitus, gall bladder surgery, anemia and falls. Physician orders dated 12/04/18 revealed a "heart healthy diet." Review of the progress notes revealed no assessment or notes from the dietitian.

2. Review of P4's undated, "Patient Information" sheet revealed an admission date of 10/23/18 with the following diagnoses of sepsis, urinary tract infection, diabetes mellitus, and self-care deficit. Review of the dietary assessment dated 11/12/18 was 20 days after the initial admission.

During an interview on 12/11/18 at 3:35 PM, Staff I, Assistant Director of Nursing, stated that the "dietitian should check in weekly, but she does not always check in."

During an interview on 12/13/18 at 9:00 AM, Staff E, the Director of Nursing, stated that they do not have a policy that specifies the time frame of when the dietitian should see the patients.

Review of the CAH's policy titled, "Nursing Policies," revised 06/21/13 stated, "The dietitian or dietary manager conducts a nutritional assessment." The policy did not address a timeframe for the dietician to perform a nutritional assessment for every new admission.