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Based on observation, the hospital failed to maintain the premises in a manner that would ensure the safety of patients, by failing to ensure that hot water was maintained at a safe temperature.

Failure to ensure that hot water is maintained at a safe temperature risks injury to patients from scalding.

Findings include:

During a tour of the hospital on 12/13/10, it was found that the temperature of the hot water at the handwashing sink in the safe patient handling demonstration room on the swing bed unit was approximately 126 degrees F., which is above the safe limit of 120 degrees. F.

Inspection of the domestic hot water tanks serving this unit found that the thermostats on the tanks were set at approximately 140 degrees F.

The deficiency was corrected during the survey. Water temperature at the same sink the following day was less than 120 degrees F.

Based on observation and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings include:

Refer to deficiencies written on the
CRITICAL ACCESS HOSPITAL
MEDICARE RECERTIFICATION
LIFE SAFETY CODE SURVEY
dated 12/15/10.

Based on medical record review, the facility failed to ensure that medical records were completed to show authentication of practitioner orders for medications and other therapeutic interventions for 6 of 9 records reviewed for orders (P1, P3, P4, P9, P13, P14).

Failure to do so places patients at risk for medication errors and other errors in care.

Findings:

1. Per record review, Patient #3, was admitted on 10/26/2010. The record contained a medication telephone order on 11/12/2010 at 5:30 PM. As of 12/14/2010, the order had not been authenticated by the physician (29 days late). The record contained a medication telephone order on 11/16/2010 at 4:30 PM. As of 12/14/2010, the order had not been authenticated by the physician (25 days late). Additional telephone orders were found on 11/19, 11/25, 11/26, 11/30, 12/2, 12/4, 12/5, 12/6 and 12/7/2010 that had not been authenticated by the physician as of 12/14/2010.

2. Per record review, Patient #4, was admitted on 11/12/2010. The record contained a medication telephone order on 11/15/2010 at 3:30 PM. As of 12/14/2010, the order had not been authenticated by the physician (27 days late). The record contained a medication telephone order on 11/16/2010 at 2:40 PM. As of 12/14/2010, the order had not been authenticated by the physician (26 days late). Additional telephone orders were found on 11/17, 11/25, 11/30, and 12/8/2010 that had not been authenticated by the physician as of 12/14/2010.

3. Per record review, Patient #1, was admitted on 11/19/2010 and discharged on 11/20/2010. The record contained a medication telephone order on 11/19/2010 at 8:45 PM. As of 12/14/2010, the order had not been authenticated by the physician (23 days late). The record contained a medication telephone order on 11/20/2010 at 12:35 AM. As of 12/14/2010, the order had not been authenticated by the physician (22 days late).

4. Per record review, Patient #9, was admitted to an Observation Bed on 12/5/2010. The record contained a telephone order for a laboratory test on 12/5/2010. As of 12/14/2010, the order had not been authenticated by the physician (7 days late).

5. Per record review, Patient #13, was admitted on 11/13/2010. The record contained a telephone order for medications on 11/13/2010 at 6:15 PM. As of 12/14/2010, the order had not been authenticated by the physician (28 days late).

6. Per record review, Patient #14, was seen in the Emergency Department and subsequently admitted to Acute Care on 5/31/2010. The record contained telephone orders for medications on 5/30 and 6/1/2010. As of 12/14/2010, the orders had not been properly authenticated by the physician (more than 180 days late).

Based on medical record review, the facility failed to ensure that the medical record was completed to show practitioner orders for medications and other therapeutic interventions for 5 of 9 records reviewed for orders (P2, P8, P9, P13, P14).

Failure to do so places patients at risk for medication errors, or other errors in care, and impairs the ability to determine the timeline and course of the patient's care and response to interventions.

Findings include:

1. Per record review, Patient #2 was admitted on 5/12/2009 and discharged on 5/26/2009. The record contained a medication telephone order on 5/12/2009 at 8:10 PM. The order had been signed by the physician, but no date or time of the authentication was present in the record, as of 12/14/2010. The record contained a medication telephone order on 5/17/2009 at 7:45 PM. The order had been signed by the physician, but no date or time of the authentication was present in the record, as of 12/14/2010. The record also multiple medication and treatment telephone orders on 5/19/2009 at 11:50 AM. This order set had been signed by the physician, but no date or time of the authentication was present in the record, as of 12/14/2010. The record also had a telephone order on 5/20/2009 at 8:30 PM. This order set had been signed by the physician, but no date or time of the authentication was present in the record, as of 12/14/2010.

2. Per record review, Patient #8 was seen in the Emergency Department (ED) on 11/19/2010. The "Emergency Physician Record" form was attached to the medical record, but as of 12/13/2010, had not been completed. The "Emergency Department Physician's Orders" form was signed in the physician signature area, but the date or time of the signature was not placed on the order form. Thus, no evidence was available to show the physician was present and ordered the diagnostic tests and treatments the patient received at this time.

3. Per record review, Patient #9 was seen in the ED on 12/05/2010. The "Emergency Physician Record" form was attached to the medical record, but as of 12/13/2010, had not been completed and did not contain a signature, date or time. The "Emergency Department Physician's Orders" form was signed in the physician signature area, but the date or time of the signature was not placed on the order form. Thus, no evidence was available to show the physician was present and ordered the diagnostic tests and treatments the patient received at this time.

4. Per record review, Patient #13 was admitted on 11/12/2010. The record contained a restraint order form that was signed by the physician ordering the restraints, but had not been dated or timed, as of 12/14/2010.

5. Per record review, Patient #14 was admitted on 5/31/2010. The record contained telephone medication orders on 5/30 and 6/1/2010 that were signed by the physician ordering the restraints, but had not been dated or timed, as of 12/14/2010.

Based on review of hospital provided documents and administrative staff interview, the hospital failed to provide documentation that the comprehensive evaluation contained information showing an evaluation of its total program.

Failure to document an evaluation of the total program places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

Per review of the Critical Access Hospital (CAH) Program Evaluation, dated January 2009-December 2009, the documentation identified program services being offered to patients, such as: Medical Staff; Interpreter Services; Nursing Services; and Imaging. However, the document did not contain an evaluation of any of these services.

It was confirmed that the data and evaluation of services was being accomplished and the information was held in various departments. Per interviews with Staff #1 on 12/14-15/2010, it was stated that the program evaluation document did not contain the comprehensive evaluation, as required, but that the information was available in departmental files.

Based on review of hospital provided documents and administrative staff interview, the hospital failed to provide documentation that the comprehensive evaluation contained information from a representative sample of "open" patient records.

Failure to document the inclusion of open records places patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

Per review of the Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that open records were included in the sample. Per interview with Staff #1 on 12/14/2010, it was stated that the record review process was not set-up to ensure that open records were included in the sample.

Based on review of hospital provided documents, the hospital failed to provide documentation that the comprehensive evaluation contained information to show that health care policies had been reviewed, as a result of annual program evaluation findings.

Failure to document the review of policies that were found to need updating, as a result of the program evaluation, places all patients at risk of harm related to the potential they may not be receiving appropriate care and services that would be identified in a timely manner.

Findings:

Per review of the Critical Access Hospital (CAH) Program Evaluation, provided by administrative staff, the documentation did not identify that any policies had been reviewed, as a result of program evaluation identified issues that had a concurrent policy relation. It was evident that they were reviewed and revised, but there was no evidence that this review and revision was the direct result of program evaluation results.

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: Resident rights (?483.10(b)(3)): "The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition" for 3 of 3 swing bed patients reviewed (P10-P12).

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of Patient #'s P10-P12 medical records, the form titled "Resident's Rights" was reviewed. The form did not contain the required language identifying the right, as identified above.

No evidence was found that this right was not being supported to patients. The right was just not presented in its' entirety in the patient brochure.

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: Resident rights (?483.10(b)(4)): "The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section; and Advance directive (?483.10(b)(8)) "The facility must comply with the requirements specified in subpart I of part 489 of this chapter relating to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. If an adult individual is incapacitated at the time of admission and is unable to receive information (due to the incapacitating condition or a mental disorder) or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's family or surrogate in the same manner that it issues other materials about policies and procedures to the family of the incapacitated individual or to a surrogate or other concerned persons in accordance with State law. The facility is not relieved of its obligation to provide this information to the individual once he or she is no longer incapacitated or unable to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time." for 3 of 3 swing bed patients reviewed (P10-P12).

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of Patient #'s P10-P12 medical records, the form titled "Resident's Rights" was reviewed. The form did not contain the required language identifying the right, as identified above.

No evidence was found that this right was not being supported to patients. The right was just not presented in its' entirety in the patient brochure.

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: (1) Resident rights (?483.10(b)(5) & (6)): "(?483.10(b) (5) The facility must- (i) Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each resident when changes are made to the items and services specified in paragraphs (5)(i) (A) and (B) of this section."; and "(?483.10(b )(6) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate." for 3 of 3 swing bed patients reviewed (P10-P12).

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of Patient #'s P10-P12 medical records, the form titled "Resident's Rights" was reviewed. The form did not contain the required language identifying the right, as identified above.

No evidence was found that this right was not being supported to patients. The right was just not presented in its' entirety in the patient brochure.

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: Resident rights (?483.10(d)(2)): "[The resident has the right to-] Be fully informed in advance about...any changes in that care or treatment that may affect the resident's well-being for 3 of 3 swing bed patients reviewed (P10-P12).

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of Patient #'s P10-P12 medical records, the form titled "Resident's Rights" was reviewed. The form did not contain the required language identifying the right, as identified above.

No evidence was found that this right was not being supported to patients. The right was just not presented in its' entirety in the patient brochure.

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: Resident rights (?483.10(d)(3)): "[The resident has the right to-] Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment." for 3 of 3 swing bed patients reviewed (P10-P12).

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of Patient #'s P10-P12 medical records, the form titled "Resident's Rights" was reviewed. The form did not contain the required language identifying the right, as identified above.

No evidence was found that this right was not being supported to patients. The right was just not presented in its' entirety in the patient brochure.

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: Resident rights - work (?483.10(h)): "The resident has the right to- (1) Refuse to perform services for the facility; (2) Perform services for the facility, if he or she chooses, when- (i) The facility has documented the need or desire for work in the plan of care; (ii) The plan specifies the nature of the services performed and whether the services are voluntary or paid; (iii) Compensation for paid services is at or above prevailing rates; and (iv) The resident agrees to the work arrangement described in the plan of care." for 3 of 3 swing bed patients reviewed (P10-P12).

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of Patient #'s P10-P12 medical records, the form titled "Resident's Rights" was reviewed. The form did not contain the required language identifying the right, as identified above.

No evidence was found that this right was not being supported to patients. The right was just not presented in its' entirety in the patient brochure.

Based on review of medical records, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: Resident rights - access and visitation (?483.10(j)(1)(vii) & (viii)): "(1) The resident has the right and the facility must provide immediate access to any resident by the following: (vii) Subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and (viii) Subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident." for 3 of 3 swing bed patients reviewed (P10-P12).

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of Patient #'s P10-P12 medical records, the form titled "Resident's Rights" was reviewed. The form did not contain the required language identifying the right, as identified above.

No evidence was found that this right was not being supported to patients. The right was just not presented in its' entirety in the patient brochure.

Based on medical record review, the hospital failed to develop a comprehensive care plan for each resident that includes measurable objectives for 3 of 3 records reviewed for care plans (P5-P7).

Failure to document measurable goals in the patient care plan places all patients at risk of harm related to the potential that they will not be encouraged to improve or maintain activities of daily life.

Findings:

1. Per review of Patient #5's medical record, a patient "Plan of Care" was found, dated November 2010. The patient goal for behavioral problems was "Patient to remain free of behaviors". The patient goal for Discharge Planning was "Pt. (patient) to remain in least restrictive environment". The patient goal for Dressing Deficit was "Will Dressed Appropriately Each Day". The patient goal for Communication Deficit was "Resident Will Make Needs Known". The patient goal for Potential For Pain was "Resident Will Have Adequate Pain Control With Prescribed Methods".

2. Per review of Patient #6's medical record, a patient "Plan of Care" was found, dated July 2010. The patient goal for Mood issues was "To Be free of Mood Issues R/T Diagnosis". The patient goal for behavioral problems was "To Be Without Behaviors". The patient goal for Mobility Deficit was "Will Move Place To Place". The patient goal for Discharge Planning was "Pt. (patient) to Remain In Least Restrictive Environment". The patient goal for Dressing Deficit was "Will Dressed Appropriately Each Day". The patient goal for Communication Deficit was "Will Have Needs Met". The patient goal for Potential For Dehydration was "Will Be Well Hydrated".

3. Per review of Patient #7's medical record, a patient "Plan of Care" was found, dated November 2010. The patient goal for Dressing Deficit was "Will Dressed Appropriately Each Day". The patient goal for ROM (Range of Motion) was "Will Maintain Ability to Bear Weight". The patient goal for Medical Diagnosis was "Resident Will Be Pain Free". The patient goal for Potential For Dehydration was "Will Remain Hydrated".

In all of the above examples, the patient goals were not "measurable" or were so subjectively written that a consistent and standardized measurement of the patient's progress/decrease or maintenance could not be consistently tracked.