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Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure health care services were furnished in accordance with written policy as evidenced by the CAH failing to follow hospital policy for restraints related to:
1. failing to ensure a face-to-face evaluation was conducted by a physician within an hour after restraints were applied for 1 (Patient #6) out of 2 patients (Patient #6 and Patient #7)reviewed for restraints out of a sample of 20 patients (Patient #1-#20).
2. failing to ensure every 15 minutes assessments were performed by a nurse while the patient was in restraints for 1 (Patient #6) out of 2 patients (Patient #6 and Patient #7) reviewed for restraints out of a sample of 20 patients ( Patient #1-#20).

Findings:
1. Face-to-Face Physician Evaluation

Review of the hospital's policy on Restraints revealed in part, this order should always be for the least restrictive device possible and must be followed by a face-to-face evaluation by the physician within one (1) hour after the initiation of the restraints for Behavioral Management are applied.

Patient #6
Review of the medical record for Patient #6 revealed the patient was a 32 year old female seen in the Emergency Department on 4/20/14 with the complaint of Altered Mental Status.
Review of the physician orders dated for 4/20/15 at 2:20 p.m. for Patient #6 revealed an order for Restraints. Review of the Nursing Notes revealed the restraints were applied at 2:27 p.m.. Review of the MD evaluation, dated 4/21/15 at 7:04 a.m. , revealed the physician was S14MD; patient's condition evaluated; patient is demonstrating activity that poses high risk for injury; patient is exhibiting destructive and/or violent behavior; patient is exhibiting aggressive behavior towards others; patient unable to understand at this time and family not available. I actually did not see the patient but must complete this section in order to close out the chart and have typed in what I have gleaned for the reading the chart.
Review of the Patient Reevaluation revealed Patient #6 was reassessed by S19MD on 4/20/15 at 5:41 p.m. and 10:00 p.m..
An interview was conducted with S14MD on 4/14/15 at 2:30 p.m. He reported he closed out Patient #6's medical record since it wasn't done by the previous physician. He confirmed there was not a face-to-face evaluation done by a physician one hour after the restraints were applied as per the hospital policy.
2. 15 minute Assessments
Review of the hospital policy for Restraints revealed in part, The patient in Behavioral Management Restraints will be assessed every 15 minutes for:
a. Signs of any injury associated with the application of restraints
b. Nutrition/hydration
c. Vital signs
d. Circulation and range of motion in the extremities
e. Hygiene and elimination
f. Physical and psychological status and comfort
g. Release from restraints.
Review of Patient #6's medical record revealed an order for restraints were written on 4/20/14 at 2:20 p.m.. Review of the Nursing Notes revealed the restraints were applied on 4/20/14 at 14:27. The patient was reevaluated by a nurse at 3:20 p.m., 4:20 p.m. ,and the restraints were discontinued at 5:00 p.m..
An interview was conducted with S2DON on 4/14/15 at 3 p.m. S2DON confirmed the nurses did not conduct an every 15 minute assessment on Patient #6 while the patient was in restraints for behavioral management, as specified in the hospital's policy.

Based on record review and interview the CAH (Critical Access Hospital) failed to ensure identified medication errors were documented in the patient's medical record for 1 (Patient #17) of 2 (Patient #17 and Patient #R1) hospital identified medication errors reviewed. Findings:

Review of the hospital's policy on Administration of Medications revealed in part, when a medication is ordered by the ER (Emergency Room) physician, the medication is retrieved by the nurse form the Pyxis system or other designated area...The 5 rights of medication administration are completed. The medication is recorded on the ER record including: Medication name, dose and time. This is initialed by the nurse dispensing the medication.

Review of the ED (Emergency Department) record for Patient #17 revealed the patient was a 27 year old female seen in ED on 4/3/15 for diarrhea.
Review of the Hospital's Occurrence report, dated on 4/3/15, revealed Patient #17 was given Macrobid, which was ordered for a different ED patient. S14MD was notified, patient aware of situation 130/85 BP (blood pressure), Pulse 86, Resp (Respiration) 16, Temp (Temperature) 97.6, SP02 (oxygen saturation) 100%.
Review of the ED record for Patient #17 revealed no documentation of the medication error in the medical record or that the patient was administered Macrobid.
An interview was conducted with S2DON on 4/15/15 at 2 p.m. She confirmed there was no documentation of the Macrobid being administered to the patient in the patient's medical record on 4/3/15.

Based on record reviews and interviews, the hospital failed to: 1) ensure the existing H&P (History and Physical) for the patient completed prior to admission to the hospital had updated information regarding the patient's current status for 1 (#1) of 5 (#1, #2, #3, #4, #5) medical records reviewed for swing-bed patients from a total sample of 20 records (#1-#20), and 2) failed to ensure patients admitted to the hospital had a H&P examination performed and documented on the patient's medical record within 24 hours of admission for 1 (#2) of 5 (#1, #2, #3, #4, #5) medical records reviewed for swing-bed patients from a total sample of 20 records (#1-#20). Findings:

Review of a document, Rules and Regulations of the Medical Staff of (Name of Hospital), presented by S1CEO (Chief Executive Officer) as current, revealed, in part, under the section entitled Medical Records: "The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current. This record shall include identification data; complaint; personal history; social/family history; history of present illness; physical examination; diagnostic and therapeutic orders; appropriate documentation of consent; clinical observations including results of therapy .... A complete admission history and physical examination shall be recorded within twenty-four (24) hours of admission. This report shall include all pertinent findings resulting from an assessment of all systems of the body. If a complete history has been recorded and a physical examination performed within a week prior to admission such as in the office of a physician staff member, or when appropriate, of a qualified oral surgeon staff member, a durable, legible copy of this report may be used in the patient's hospital medical record, provided there has been no change subsequent to the original examination or the changes have been recorded at the time of admission."

Review of the policy for the Swing Bed Department, entitled, Admissions Policy and Procedure, revised 03/15, revealed, in part: "Acute care documents can be copied and placed on the Swing Bed Chart or can be viewed electronically in CPSI (name of electronic health record system): Physicians History and Physical (if not greater than 30 days and include revisions)."

Review of the policy for the Swing Bed Department, entitled, Physicians, and revised on 03/15, under the section entitled, B. The Initial Physician's Progress Note Should Include the Following, revealed, in part: "1. Review and provide brief update on the patients' medical history and physical exam."

1) ensure the existing H&P (History and Physical) for the patient completed prior to admission to the hospital had updated information regarding the patient's current status.

Patient #1

Review of Patient #1's medical record revealed Patient #1 was an 86-year-old female transferred from the acute care setting and admitted to swing-bed status on 11/16/14 with a diagnosis of Pneumonia. Patient #1 was discharged from the hospital on 11/21/14.

Further review of Patient #1's medical record revealed a copy of a H&P dictated by the admitting physician on 11/10/14 and transcribed on 11/10/14. Review of the H&P under the section "Admit" (date) revealed a date of 11/10/14 typed, and the 11/10/14 date was scratched out and a date of 11/16/14 written. Further review of the H&P form and the medical record revealed no documentation updating the initial H&P performed on 11/10/14.

In an interview on 04/16/15 at 1:40 p.m., S3MR (Medical Records) Director confirmed Patient #1's medical record did not contain an update on the H&P dated 11/10/14, and the medical record should have contained documentation regarding an update to the H&P done on 11/10/14.

2) failed to ensure patients admitted to the hospital had a H&P examination performed and documented on the patient's medical record within 24 hours of admission.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was a 56-year-old female transferred from another acute care facility and admitted to the hospital on swing-bed status on 02/06/15 with a diagnosis of status-post ankle fracture surgical repair. Patient #2 was discharged from the hospital on 02/20/15.

Further review of Patient #2's medical record revealed a H&P dictated by Patient #2's admitting physician, S22MD on 03/14/15. Review of Patient #2's physician progress notes revealed the first documentation was on 02/08/15 at 8:30 a.m. by S23MD.

In an interview on 04/16/15 at 1:40 p.m., S3MR (Medical Records) Director confirmed Patient #2's medical record did not contain an H&P dictated by the admitting physician, S22MD, within 24 hours of admission, and did not contain any further documentation in Patient #2's medical record regarding an initial and/or updated H&P completed within 24 hours of admission to the hospital. S3MR Director confirmed there should have been a H&P on the medical record and/or an update within 24 hours of admission to the hospital.

Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure all medications were administered in accordance with accepted standards of practice for 1 (Patient #5) out of 5 (Patient #1-#5) swing bed patients reviewed for medication errors out of a sample of 20.
Findings:
Review of the Nursing 2015 Drug Handbook by Walter Kluwer, presented to the surveyor as the hospital's drug reference book for the nurses, revealed before administration of Digoxin an apical-radial pulse was to be monitored for 1 minute. Review of the 2015 Drug Handbook also revealed prior to administration of Lopressor always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately.
Review of the medical record for Patient #5 revealed the patient was a 58 year old male admitted to the hospital on 2/18/15 with the diagnosis of Congestive Heart Failure, Wound Care and Diabetes.
Review of Patient #5's Physician Admission Orders, dated 2/18/15, revealed an order for Lopressor 25 mg (milligrams) po (by mouth) BID (twice a day), and Digoxin .25 mg po daily.
Review of the Medication Administration Record and the Nursing Progress Notes on Patient #5 from 2/18/15 until his hospital discharge on 3/4/15 revealed the patient's pulse was not taken prior to the administration of Digoxin and Lopressor except on 2/20/15 at 09:25.
An interview was conducted with S2DON on 4/16/15 on 12 p.m. S2DON confirmed Patient #5's pulse was not taken prior to administration of the Lopressor and Digoxin administration during most of his hospital stay. S2DON revealed there was no specific hospital policy related to monitoring a patient's pulse or blood pressure prior to administration of specific medications.

Based on record review and interview the hospital failed to ensure all physician's orders were obtained and on the medical record for each patient receiving health care services. This failed practice was evidenced by verbal orders to evaluate and treat the patient for therapy not authenticated by the ordering physician for 2 (#18, #19) of 3 ( #18, #19, #20) Outpatient Therapy Records reviewed for initial orders to evaluate and treat, of a total sample of 20.
Findings:


Review of a hospital Rehabilitation Department policy, titled "Charting", revised March 2015 , and provided by S10PT as current, revealed the following, in part: I. Referrals: A. Outpatient Therapy 1. The written referral should contain: ...d. Orders, e. Physician's Signature." 2. All telephone referrals should be followed up in writing within 48 hours..."

Patient #18
Review of the medical record for Patient #18 revealed a Company A form with the name of Patient #18, a date of 2/24/15, and a diagnosis of Paraparesis. Further review of the referral/order revealed "BIW" (biweekly) and "Evaluate and Treat" had an "X" in the box next to them. Duration was documented as "4 weeks", and under "special instructions" was written a medicaid number and a phone number. Under referring the Physician's Signature line was written : S20MD (Medical Doctor)/S21 . At the top of the copied form was a printed note " 2/24/ 4:03 P.M. From: Fax to (Company A's fax number) page: 001 of."
Further review of the medical record for Patient #18 revealed an OT (Occupational Therapy) referral on Company A's letterhead, with no date. The referral for OT was for 2-3 times a week for 6-8 weeks. The diagnosis documented was Paraparesis; UE (upper extremity) residual weakness. V.O. (verbal order) S20MD, 3/16/15, and initials of S10PT. S20MD's name was printed on the next line.
Treatment records revealed Patient #18 received PT on the following dates in 2015: February 26, March 4, 5, 7, 18, 23, 25, and 27, April 7, 8, 9, 13, and 16. Further review revealed Patient #18 received OT March 18, 23, 25, and April 7, 13, and 15.


Patient #19
Review of the medical record for Patient #19 revealed she received a PT evaluation 3/26/15, and PT services 3/31, 4/2/, 4/6, /4/8, 4/10, 4/13, and 4/15/ 15. Further review revealed a referral form, with Company A's information at the top, with a request to evaluate and treat for PT three times a week, for 6-8 weeks. The diagnosis was "status post (after) bone graft, Total Knee Arthroscopy revision" " The order was documented as "V.O. S22MD/ initials of S10PT", and dated 3/25/15. Further review of the medical record revealed no authentication by S22MD of the verbal order.


In an interview 4/16/15 at 1:40 p.m S10PT verified the first request for Patient #18 to be evaluated and treated, dated 2/24/15 was signed by S20MD's office staff member. S10PT verified that neither the 2/24/15 request for PT evaluation and treatment nor the verbal order 3/16/15 to evaluate and treat Patient #18 for OT were authenticated by S20MD as of 4/16/15. S10PT verified that the verbal orders for Patient #19 were not authenticated by S24MD as of 4/16/15.

Based on record review and interviews the hospital failed to ensure all entries in the medical records were authenticated with dated and timed signatures of the provider (s), as evidenced by verbal orders not dated and/or timed for 2(#13, #14) of 4(#11, #12, #13, #14) records reviewed for orders authenticated with signature, date, and time, out of a total sample of 20.
Findings:

Review of the Medical Staff Rules and Regulations revealed, in part, under Medical Records, page 14, ... "All or orders for treatment shall be in writing... the name of the ordering practitioner with date and time dictated must accompany the (verbal) order. The responsible practitioner shall authenticate such orders by his own signature, date, and time within 10 days of the verbal order and failure to do so shall be forwarded through approved channels for appropriate corrective action."


Patient #13
Review of the medical record for Patient #13 revealed he was a 25 year old admitted 10/24/14 from the ED (Emergency Department) with complaints of epigastric abdominal pain with nausea and vomiting. Further review revealed the following orders that were not authenticated as required by the Medical Staff Rules and Regulations:
-10/25/14 at 12:01 p.m. Potassium 40 mEq in 500 cc (cubic centimeters) D5 1/2 NS (normal saline) to infuse over 4 hours. TO S16MD/S31RN. An authentication signature by S16MD was noted with no date or time.
-10/25/14 at 2:58 p.m.- Increase Demerol to 50 mg q 4h (hours) prn pain. VO (verbal order) S16MD/S31RN. An authentication signature was noted with no date or time.
-10/28/14 at 11:02 a.m.- po,D/C (discontinue) Levaquin 50 mg IVPB (IV Piggy Back), D/C Demerol 50 mg IV push, D/C Toradol 30 mg IV push, D/C Phenergan 12.5 mg IV push, D/C Zofran 8 mg IV push, Give Zofran 8 mg po q (every) 6 hours prn (as needed) , Norco 10/325 mg q 4 hours prn for pain, D/C IV fluids. Okay to leave IV out per pt request. PO (Phone orders) by S16MD (Medical Doctor)/S30LPN. No authentication signature was noted.
-10/28/14 at 11:20 a.m.- TO (telephone order) S16MD/ LPN: KCL (Potassium Chloride) 40 mEq (milliequivalents) po (by mouth) x 1 now. KCL 20 mEq po daily. The signature of S16MD was noted with no date or time.



Patient # 14
Review of the medical record for Patient #14 revealed she was a 75 year old, admitted 3/19/15 to outpatient services so that she could receive IV (Intravenous) antibiotics, then as an inpatient 3/22/15 after a fall. Her diagnoses included Pseudomonas Urinary Tract Infection, Hypertension, Diabetes, and a history of Chronic Lymphocytic Leukemia. Further review of her medical record revealed the following documented verbal orders with no time or no date and time of S20Medical Director's authentication of his signature:
-3/22/15 at 5:31 p.m-Give a 1x (time) dose of Atenolol 25 mg (milligram) tab now. Give a 1x dose of Losartan 12.5 mg tab now. TORB (telephone order, read back): S20Medical Director/S26RN (Registered Nurse). S20Medical Director's signature was noted with a date of 8/23/15 with no time.
-3/22/14 at 5:31 p.m.- Call S20Medical Director tonight for further instructions on blood pressure meds. TORB S20Medical Director/S26RN . A signature of S20Medical Doctor was dated 3/23/15 with no time.
-3/23/15 at 6:45 a.m.- O.K. to hold Humalog Insulin 6 units now. RBTO: S20Medical Director/S28RN. The signature of S20Medical Director was noted with a date of 3/23/15, and no time.
-3/23/15 at 7:51 p.m.- CT (computed tomography scan) of brain now. VORB (Verbal order/read back) S20Medical Director/S27RN. No authentication signature of S20Medical Director was noted.
-3/24/15 at 7:00 p.m.- 1/2 normal saline at 50 mls (milliliters)/hr (hour). Resume all previous orders prior to patient leaving for biopsy procedure this AM 3/24/15. RBTO (read back telephone order) S20Medical Director/S28RN. The order was signed by S20Medical Director with a signature date of 3/23/15 and no time.
-3/24/15 at 11:10 p.m.-Give a 1x dose of Atenolol 25 mg. tab now. Give a 1x dose of Losartan 12.5 mg tab now. TORB: S20Medical Director/S26RN. S20Medical Director's signature was noted with a date of 8/25/15 with no time documented.

In an interview 4/15/15 at 11:25 a.m. S3MR (Medical Record) Director, during a review of medical records, verified the above findings. S3MR confirmed that all entries in the medical record were supposed to be timed and dated.

In an interview 4/16/15 at 11:55 S2DON (Director of Nursing) verified the above noted findings in the medical record of Patients #13 and #14. S2DON verified all orders should be signed and authenticated with a date and time.

Based on record review and interview, the hospital failed to ensure there was evidence of patients being informed of their rights in the medical records for 3 (#2, #3, #5) of 5 (#1, #2, #3, #4, #5) medical records reviewed for patient's rights out of a total sample of 20. Findings:
Patient #2
Review of Patient #2's medical record revealed Patient #2 was a 56-year-old female transferred from another acute care facility and admitted to the hospital on swing-bed status on 02/06/15 with a diagnosis of status-post ankle fracture surgical repair. Patient #2 was discharged from the hospital on 02/20/15.
Further review of Patient #2's medical record revealed no documentation that she (Patient #2) had been informed of her patient's rights.
In an interview on 04/16/15 at 11:07 a.m., S3MR (Medical Records) Director confirmed there was no evidence in Patient #2's medical record that Patient #2 had been informed of her rights.
Patient #3
Review of Patient #3's medical record revealed Patient #3 was a 53-year-old male admitted to the hospital from the acute care setting into swing-bed status on 01/15/15 with diagnoses of Urinary Tract Infection, Morbid Obesity, and Paraparesis Secondary to Critical Illness. Patient #3 was discharged on 02/04/15.
Further review of Patient #3's medical record revealed no documentation in Patient #3's medical record that he had been informed of patient's rights.
In an interview on 04/16/15 at 11:07 a.m., S3MR Director confirmed there was no evidence in Patient #3's medical record that Patient #3 had been informed of his rights.
Patient #5
Review of Patient #5's medical record revealed Patient #5 was a 58-year-old male admitted to the hospital on swing-bed status on 02/18/15 with diagnoses of Congestive Heart Failure, Unhealed Wound, and Diabetes Mellitus. Patient #5 was discharged on 03/04/15.
Further review of Patient #5's medical record revealed no documentation in Patient #5's medical record that he had been informed of patient's rights.
In an interview on 04/16/15 at 11:07 a.m., S3MR Director confirmed there was no evidence in Patient #5's medical record that Patient #5 had been informed of his rights.
In an interview on 04/16/15 at 1:10 p.m., S18Admissions indicated the Admissions Department was responsible for providing patients with patient's rights information and having patients complete the acknowledgement form that they have received the information on patient's rights and understood the information. S18Admissions confirmed the Admissions Department was responsible for patient's rights for all patients seeking services at the hospital for all hospital outpatient services, for all acute care inpatients, and for all swing-bed patients. S18Admissions further confirmed there should have been documentation in the patients' medical records that they received and understood their patients' rights.