HospitalInspections.org

Based on staff interview and record review, the Critical Access Hospital (CAH) failed to have accurate documentation that surgical patient medical records contained the pre-surgical physical examination to evaluate for the risk of the procedure to be performed by the physician for 2 (Patients 27 and 30) of 6 surgical patients. This failed practice had the potential to affect all surgical patients of the CAH. The Critical Access Hospital (CAH) provided 783 patient surgical services in 2014.

Findings are:

A. Review of Patient 27's record dated 10/22/14-10/26/14 revealed the patient had a left total knee replacement. Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

B. Review of Patient 30's record dated 1/6/15 revealed the patient had a bunionectomy (surgery to remove the bump/enlargement of the joint at the base of the big toe) and hammertoe repair (surgery to straighten a curled or flexed deformity of the toes). Review of the entire medical record revealed no evidence of the physician documentation of the pre-surgical examination for the risk of the procedure to be performed.

C. An interview with the Director of Nurses (DON) on 3/23/15 from 8:50-9:10 AM revealed the following:
- The facility staff reviewed the medical records for Patients (27 and 30) and was not able to find the documentation that the surgeon saw the patient before the surgery;
- Surgeons would have done the assessment on their patients immediately before surgery because in both these cases the surgery was on a limb in which the surgeon would initial before the patients were taken back to surgery;
- The surgery staff has a stamp that is placed on the patient record which the surgeon signs and dates after their assessment of the patient immediately before surgery; and,
- The charts for Patients 27 and 30 both had the stamp, but the surgeons failed to document seeing their patients.

D. An interview with the DON on 3/24/15 at 11:15 AM revealed, "I have looked in the Policies and Procedures and in the Medical Staff Bylaws/ Rules and Regulations and we don't have a policy that states that the surgeons are to see the patient immediately before surgery. We expect our surgeons to see the patients before surgery. We know they do, we just need to be sure they get it documented."

Based on review of medical records, Medical Staff Rules and Regulations and staff interview; the CAH (Critical Access Hospital) failed to ensure that the patient medical records contained documentation of the form containing general consent to admission and to the conditions of admission for 6 (Patients 2, 18, 21, 33, 34, and 35) of 40 patients. This failed practice had the potential to affect all patients receiving care at the CAH. The CAH reported in 2014: 220 acute inpatient admissions, 195 observation admissions, 67 swing bed admissions, 3333 emergency department visits and 783 surgical cases.

Findings are:

A. Review of Patient 2's record dated 2/17/15-2/21/15 revealed the patient was admitted to the hospital for treatment of pyleonephritis (a bacterial infection of the kidneys). Review of the entire medical record revealed a lack of a signed general consent to admission and to the conditions of admission (a form that the patient or the responsible party for the patient signs to give the hospital and staff permission to provide the patient care and treatment while in the hospital).

B. Review of Patient 18's record dated 2/28/15-3/1/15 revealed the patient was admitted to the hospital for treatment of anemia (low blood count). Review of the entire medical record revealed a lack of a signed general consent to admission and to the conditions of admission.

C. Review of Patient 21's record dated 3/6/15 revealed the patient was treated in the emergency room at the hospital for for a head laceration (cut to the head requiring stitches). Review of the entire emergency room record revealed a lack of a signed general consent to admission and to the conditions of admission.

D. Review of Patient 33's record dated 2/27/15-3/6/15 revealed the patient was admitted to the hospital for swing bed for continued intravenous antibiotic treatment and therapy. Review of the entire medical record revealed a lack of a signed general consent to admission and to the conditions of admission.

E. Review of Patient 34's record dated 2/9/15-2/18/15 revealed the patient was admitted to the hospital for swing bed for continued intravenous antibiotic treatment and therapy. Review of the entire medical record revealed a lack of a signed general consent to admission and to the conditions of admission.

F. Review of Patient 35's record dated 11/26/14-12/3/14 revealed the patient was admitted to the hospital for swing bed for continued intravenous antibiotic treatment and therapy. Review of the entire medical record revealed a lack of a signed general consent to admission and to the conditions of admission.

G. Review of the Medical Staff Rules and Regulations approved 11/30/10 stated the following:
"ADMISSION CONSENT-An admission form containing general consent to admission and to the conditions of admission shall be signed by the patient or by one authorized to consent for the patient at the time of admission...Except in an emergency, no procedures or treatment may be performed in the Hospital without the signed admission form or other written consent of the patient or of one authorized to consent for the patient..."

H. An interview with the Director of Nurses (DON) on 3/23/15 from 8:50-9:10 AM revealed, that the facility staff reviewed the medical records for Patients (2, 18, 21, 33, 34, and 35) and was not able to find a consent. "We believe the consents were obtained, some of the staff remember getting the consents, but cannot find them in the computer. We have called our electronic medical record vendor to see if they can help us retrieve them. So far, we have not been able to produce the forms."

Based on staff interview and review of 5 of 5 patient records (Patients 32, 33, 34, 35 and 36), the CAH (Critical Access Hospital) failed to:
Part I:
Have a qualified professional to direct the patient activities program.
Part II:
Document the individual activities the patient participated in while a swingbed patient for 3 of 5 patients ( Patients 32, 35, and 36).
The failed practice had the potential to affect all patients admitted to swingbed. The CAH had a total of 67 swingbed admissions for 2014.

Findings are:

A. An interview with the Swing Bed Coordinator-Registered Nurse (RN)-AA on 3/23/15 at 12:45 PM verified that [gender] did not attended the training course for activities. RN AA stated, "I complete the patient activity assessments for the Swing Bed patients. The nursing staff on the floor frequently assist the patients with their individual activities. I don't think we always capture in the charting all the activities that are provided to the patients like we should."

B. The patient record review for Patients 32, 33, 34, 35 and 36 showed an Activity Assessment completed by RN AA, (who did not have the training to be a qualified professional to direct the activity program for the Swing Bed patients).

C. Review of the swingbed patient records for Patients 32, 35 and 36 lacked the individual activity documentation during their stay in swing bed.