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Based on record review and staff interview, the Critical Access Hospital (CAH) failed to assess and document the effectiveness of medications given to patients on an as needed (prn) basis for 3 of 11 active patient (Patient #3, #4, and #5) records reviewed. Failure to evaluate the patient's response to prn medications limited the nursing staff's ability to assess whether the medication achieved the desired effect or if the patient experienced any side effects or adverse reactions from the medication.

Findings include:

- Review of Patient #5's active medical record occurred on 07/23/14 and identified the CAH admitted the patient on 07/02/14 for cough and weakness. The record indicated the patient used prn medications for cough, muscle spasms, and mild pain and showed physician orders for benzonatate (used to decrease cough) 100 milligrams (mg) three times a day (TID) prn, Flexeril (a muscle relaxer, used to decrease muscle spasms) 10 mg TID prn, and acetaminophen (used to relieve mild pain) 650 mg every four hours prn.

Patient #5's medication administration record (MAR) showed the following:
*benzonatate: received on 07/05/14 at 10:58 p.m.; on 07/06/14 at 7:54 a.m. and 8:00 p.m.; on 07/07/14 at 10:27 p.m.; on 07/08/14 at 7:53 a.m.; on 07/11/14 at 9:51 p.m.; on 07/12/14 at 10:58 a.m. and 9:49 p.m.; on 07/13/14 at 8:29 a.m. and 11:06 p.m.; on 07/14/14 at 8:24 a.m. and 8:39 p.m.; on 07/15/14 at 1:55 p.m. and 10:59 p.m.; and on 07/16/14 at 11:11 p.m.
*Flexeril: received on 07/04/14 at 1:45 a.m.; on 07/06/14 at 7:54 a.m.; on 07/08/14 at 5:06 p.m.; on 07/09/14 at 9:44 a.m.; and on 07/12/14 at 8:15 p.m.
*acetaminophen: received on 07/09/14 at 9:49 a.m.; on 07/10/14 at 12:10 p.m.; on 07/12/14 at 12:44 a.m., 12:09 p.m., and 8:15 p.m.; on 07/19/14 at 1:10 p.m. and 9:40 p.m.; on 07/20/14 at 1:20 p.m. and 9:30 p.m.; and on 07/21/14 at 3:23 a.m. and 8:49 p.m.

Review of Patient #5's chart notes, adult nursing assessments, and MARs failed to include evidence nursing staff assessed and documented the effectiveness or patient's response to the prn medication.

- Review of Patient #3's active medical record occurred on July 21-22, 2014 and identified the CAH admitted the patient on 07/17/14 for therapy status post fractured right hip repair. The record indicated the patient used prn medications for mild pain and spasms and showed physician orders for acetaminophen 500 mg every six hours prn and Flexeril 5 mg TID prn.

Patient #3's MAR showed the following:
*acetaminophen: received on 07/18/14 at 2:10 p.m.; on 07/20/14 at 2:41 a.m.; on 07/21/14 at 11:08 a.m.; on 07/22/14 at 3:53 a.m. and 9:52 p.m.; and on 07/23/14 at 6:16 a.m.
*Flexeril: received on 07/18/14 at 10:37 a.m.; on 07/21/14 at 11:09 a.m.; and on 07/22/14 at 3:54 a.m.

Review of Patient #3's chart notes, adult nursing assessments, and MARs failed to include evidence nursing staff assessed and documented the effectiveness or patient's response to the prn medication.

- Review of Patient #4's active medical record occurred on July 22-23, 2014 and identified the CAH admitted the patient on 07/12/14 for therapy status post left hip replacement. The record showed a physician's order for Zofran (used to prevent/decrease nausea) 4 mg every four hours prn for nausea/vomiting. Patient #4's MAR showed the patient received Zofran on 07/14/14 at 11:30 a.m.

Review of Patient #4's chart notes, adult nursing assessments, and MARs failed to include evidence nursing staff assessed and documented the effectiveness or patient's response to the prn medication.

During an interview on 07/23/14 at 11:40 a.m., two staff nurses (#2 and #3) stated nurses reassessed patients after administration of prn medication to ensure whether the patient experienced relief from the medication and documented the patient's response in the medical record under "chart notes."

During an interview on 07/23/14 at 1:20 p.m., an administrative nurse (#1) stated she expected nursing staff to assess the effectiveness of prn medications and document the response within the patient's record. The nurse (#1) stated the CAH did not have a policy regarding administration of prn medication and stated nursing staff could document the response in a variety of sections within the patient's record.

Based on record review, review of Medical Staff Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure a complete medical record for 1 of 2 discharged observation patient records (Patient #14) and 1 of 6 discharged surgical patient records (Patient #20) reviewed. Failure to complete the medical record in a timely manner limited the CAH's ability to ensure a complete medical record and continuity of care.

Findings include:

Review of the CAH's Medical Staff Rules and Regulations occurred on 07/23/14. This document, approved on 05/17/12, stated "B. MEDICAL RECORDS . . . 20. Record Completion: . . . e. All charts for any Mercy Hospital patient are to be completed within the 30 day timeframe to include signatures. 21. . . . All medical records are to be completed within 15 days by the attending physician/allied health professional following the day of dismissal. The total chart shall be completed including signatures by all involved parties within that 30 days. . . ."

- Review of Patient #20's medical record occurred on July 22-23, 2014. The CAH admitted and discharged the patient on 12/06/13 for an outpatient surgical procedure. Health care provider (HCP) #4 dictated the operative report on 12/06/13, transcription occurred on 12/06/13, and HCP #4 signed the operative report on 04/09/14 (124 days after transcription).

- Review of Patient #14's medical record occurred on July 22-23, 2014. The CAH admitted the patient on 05/04/14 to observation status and discharged the patient on 05/05/14. HCP #5 dictated the admission history and physical (H&P) on 05/05/14, transcription occurred on 05/05/14, and HCP #5 signed the H&P on 06/11/14 (37 days after transcription).

HCP #6 dictated the discharge (D/C) summary on 05/05/14, transcription occurred on 05/06/14, and HCP #6 signed the D/C summary on 06/25/14 (50 days after transcription).

During interview on 07/23/14 at 11:00 a.m., a medical records management staff member (#7) confirmed the delay in completion of the medical records for Patient #14 and #20.