HospitalInspections.org

Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) failed to implement and maintain emergency care necessary to meet the needs of its patients in the Emergency Department.

Findings include:

1. The CAH failed to provide emergency care necessary to meet the needs of 1 of 34 patients (#29). The CAH failed to provide emergency care to treat Patient #29's fast heart rate, failed to perform a septic workup for fever, and failed to treat dehydration with sufficient intravenous fluids.

Please refer to C271.

2. The CAH failed to ensure the adult and pediatric laryngoscope lights for emergency intubation were functional, and failed to ensure that expired supplies were replaced on the Pediatric code cart in the Emergency Department (ED).

Please refer to C204.

Based on observation and interview, the Critical Access Hospital (CAH) failed to ensure the laryngoscope lights for emergency intubation were functional, and failed to ensure that expired supplies were replaced on the Pediatric code cart in the Emergency Department (ED). In addition, the CAH failed to ensure the Medical Surgical Department code cart had been checked for supplies and equipment function. Findings include:

1. During review of the Code Cart Meeting minutes of 11/19/14, they indicated that a new committee was formed to evaluate the pediatric and adult code cart contents (8 months ago). During review of the minutes of 12/18/14, they indicated that Pharmacy is responsible for the entire code cart contents.

During tour on 7/7/15 at 9:45 A.M. in the ED Trauma Room, with the ED Unit Manager and the Nursing Director of the ED, the Adult and Pediatric Code Carts were evaluated for life saving equipment. On the Pediatric Cart, Surveyor #4 observed the following outdated supplies and equipment:

- 1 Pediatric emergency intubation set, dated 2/20/15 (expired over 4 months ago).
- 2 oxygen delivery modules with an oral airway and non-rebreather bag, dated 5/2015 (expired 2 months ago).
- 16 intravenous start sets, dated 6/20/15 (expired 17 days ago).
- A round measuring device with yellow tubing (an indicator of being old) to measure the pressure with manual resuscitation with an ambu bag.

During an interview on 7/7/15 at 10:30 A.M., the Nursing Emergency Department Director stated that the supplies in the pediatric cart were outdated and the respiratory measuring device with the yellow tubing was obsolete. She said that the Pharmacy department unlocks the carts and ensures the supplies are not outdated. When she was asked who ensures that the laryngoscope lights for emergency intubation were functional, she did not know.

During an interview and document review on 7/8/15 at 9:00 A.M. with the Chief of Pharmacy, she stated that her department checks the adult code cart monthly, and that she checks that the laryngoscope light works. This cart is also checked by another Pharmacist and then by students during the summer. When asked who checks the pediatric code cart, she said they only check for outdated medications not the supplies. The laryngoscope light also is not checked to see if it works.

Review of the pharmacy adult code cart inventory sheets (for the Trauma Room) indicated this cart was not consistently checked monthly as follows:
- Checked on 12/19/14
- Not checked in 1/2014 and 2/2015 (2 months)
- Checked on 3/6/15
- Checked on 3/25/15
- Not checked in 4/2015 and in 5/2015 (2 months)
- Checked on 6/4/15
- Checked on 7/6/15

Review of the pharmacy adult code cart inventory sheets on 7/8/15 with the Chief of Pharmacy indicated it lacked documentation to ensure the laryngoscope light was checked and works.

During an interview with the Chief of Pharmacy on 7/8/15 at 9:03 A.M., she stated that for 4 of the past 7 months the adult code cart in the Trauma Room was not checked.

During an interview with the Chief of Pharmacy on 7/8/15 at 9:03 A.M., she stated that there were 4 months during the past 7 months in which the adult code cart in the Trauma Room was not checked.




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2. On 7/7/15 at 10:50 A.M., the Surveyors observed Emergency Code Cart #6 (Medical Surgical Unit), locked. There was a log/inventory check book stored on the cart.

During interview with Staff Education Nurse (SEN) #1, she said that the only time the Code Cart is unlocked and inventory checked/replaced is when there is a Code, a Mock Code, or during staff education/orientation. SEN #1 said that staff are required to check the Code carts every day, and initial that the cart has been checked and emergency equipment functional.

Upon further review of Emergency Code Cart #6's log data from 6/2014 to 7/7/15, the following dates were not checked by nursing, to ensure all supplies/equipment were available and functioning in the event of an emergency:

- 6/2014: 6/4, 6/5 and 6/6/14.
- 7/2014: 7/3, 7/4, 7/11, 7/21 and 7/22/14
- 8/2014: 8/9, 8/10, 8/11, 8/15 and 8/18/14.
- 9/2014: 9/8, 9/9 and 9/18/14.
- 10/2014: 10/1, 10/3, 10/4 and 10/19/14.
- 11/2014: 11/3, 11/7 and 11/23/14.
- 12/2014: 12/2, 12/12 and 12/31/14.
- 1/2015: 1/8 and 1/18/15.
- 2/2015: 2/10 and 2/11/15.
- 3/2015: 3/4, 3/5, 3/11, 3/25 and 3/31/15.
- 4/2015: 4/1, 4/3, 4/23, 4/24, 4/28 and 4/29/15.
- 6/2015: 6/24/15.
- 7/2015: 7/1/15.

During interview on 7/7/15 at 11:05 A.M., SEN #1 said that daily checks of Emergency Code Cart have to be checked to ensure safe, operational equipment, and storage of supplies in the event of an emergency/code.

Based on observation and interview, the Critical Access Hospital (CAH) failed to ensure compliance with applicable Federal laws and regulations, related to the health and safety of patients regarding elevated hot water temperatures.

Findings include:

During a tour of the Second Floor Medical Surgical Patient Unit on 7/7/15 at 10:10 A.M., the Surveyors identified that the hot water temperature in the hand sink (located in the corridor of the Unit) and the hot water temperatures in the Patient's Shower Rooms felt very hot to touch.

Plant Engineer #1 came to the Second Floor Unit with a thermometer he said was routinely used to test hot water temperatures. However, the Plant Engineer said that he only tested hot water temperatures in the Boiler Room, and not on the patient care units. He said that the temperature is typically 118 degrees Fahrenheit (F).

Plant Engineer #1 tested the hot water in the hand sink to be at 139 degrees F, and the Patients' shower room to be at 126 degrees F. He said that he was not aware there was a regulation/requirement to ensure the hot water temperatures in patient care areas did not exceed 110 degrees, and that hot water temperatures had never been tested in patient's sink/bathing areas, or logged.

Based on observations and interview the Critical Access Hospital (CAH) failed to maintain proper storage of trash.

During a tour on 7/7/15 at 4:00 P.M., the surveyor observed three dumpsters outside of the CAH. All three dumpsters were open on top, exposing the contents of each one. Additionally, one of them had open door panels on either side, and two of them had broken lid panels.

During a second tour on 7/8/15 at 8:30 A.M., all three dumpsters were again observed open, exposing the contents.

During an interview on 7/8/15 at 8:30 A.M., the Director of Environmental Services said the dumpster lids should be closed when not in use and, the broken lids would be replaced.

Based on record/document review and interview, the Critical Access Hospital (CAH)/Governing Body failed to ensure that Surgeon (Surgeon #1) had been appointed/designated as the Chief of Surgery. Findings include:

During the Entrance Conference on 7/7/15 at 9:00 A.M., the Chief Executive Office (CEO) told the Surveyors that Surgeon #1 was the "Chief of Surgery."

Review of a consent for "Suspension of Do Not Resuscitate Orders During Surgical Procedures" indicated that Surgeon #1 signed (9/2012) that he was the "Chief of Surgery."

Review of the "Credentialing Files for May, 2014" indicated that Surgeon #1 was appointed an "Active" staff member for "Surgery."

Review of Surgeon #1's personnel file, indicated that Surgeon #1 was re-appointed by both the President and CEO of the Hospital, effective 5/22/14 - 5/31/16, for the Department of Surgery. There was no appointment/re-appointment indicating that Surgeon #1 was designated in the role as Chief of Surgery.

Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) failed to implement and maintain the provision of services for delivery of emergency services, pharmacy oversight with code carts and high alert/risk medications, and for documentation related to physician orders and patient allergies. Findings include:

1. The CAH failed to ensure that a Physician followed emergency department policies and standards of practice for 1 of 34 patients (#29) related to providing emergency care to treat a fast heart rate, failed to perform a septic workup for fever, and failed to treat dehydration with sufficient intravenous fluids.

Please refer to C271.

2. The CAH failed to review and revise their Emergency Department policies annually.

Please refer to C272.

3. The CAH failed to ensure that there were Physician orders for emergency medications and procedures (defibrillation) for 2 of 34 Patients (#15 and #16) in the Emergency Department.

Please refer to C297, Example #1.

4. The Facility failed to have a list of high alert/high risk medications along with appropriate instructions posted in the Emergency Department.

Please refer to C297, Example #2.

5. The CAH failed to document why a patient's allergies were not obtained and/or efforts to obtain them for 1 of 33 patients (#17) in the Emergency Department.

Please refer to C297, Example #3.

6. The CAH failed to have 2 of 2 Nurse Practitioners Clinical Privileges signed by the Chief Nursing Officer.

Please refer to C297, Example #4.


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7. The CAH failed to ensure that a PTA (Physical Therapy Aide) properly disinfected a unit per Manufacturers Directions for Use (MDFU) of disinfection wipes after an unidentified patient left.

Please refer to C278.


8. The CAH failed to ensure that 2 nurses inserted intravenous lines per policy for 3 patients (#26, #27 and #34).

Please refer to C278.

9. The CAH failed to ensure that the Paraffin heating machine in the Occupational Therapy Room was cleaned per MDFU.

Please refer to C278.

10. The CAH failed to ensure that nursing staff followed the facility's policy and Physician's orders to instill eye drops prior to surgery and putting patients at risk for cross contamination.

Please refer to C278.

11. The CAH failed to ensure that the Sterilizing/Disinfecting Solution Metrocide 28 was not being stored in a clean area and kept at the correct temperature per MDFU.

Please refer to C278.

12. The CAH failed to ensure that Physician #3 followed facility protocol during a surgical scrub.


13. The CAH failed to ensure that the circulating nurse in the OR did not contaminate the sterile field by leaning over the table and dropping sterile objects onto the sterile surface.

Please refer to C278.

14. The CAH failed to ensure decontamination of the surgeon's gloves after Physician #3 dropped a contaminated surgical sponge on the floor, bent over, picked it up with his sterile gloves and disposed of it in the trash. The Physician did not wash/clean his hands after donning new sterile gloves.

Please refer to C278.

15. The CAH failed to properly store 5 glass IV bottles of Balanced Salt Solution (BBS) with 0.3% Epinephrine (one for each surgery of the day). On 7/7/15 at 10:45 A.M., the surveyors observed that all of the BBS IV bottles were being stored in the operating room (OR) in a cart at the foot of the surgical bed during surgeries.

During interview on 7/7/15 at 11:45 A.M., the Surgical Manager said that the bottles should have been stored in a place outside of the operating room and one bottle at a time brought in for each surgery as needed.

Please refer to C278.

16. The CAH failed to ensure that Physician #1 wore his surgical gown appropriately during a colonoscopy procedure, and that proper hand washing techniques were followed.

Please refer to C278.

17. The CAH failed to ensure that Physician's removed and disposed of surgical masks following each surgery and did not wear them hanging around the neck in common areas.

Please refer to C278.

18. The CAH failed to ensure that the Dietary Department that sanitary practices were maintained to minimize the risk of food borne illnesses.

Please refer to C278.

19. The CAH failed to ensure that staff was monitored for communicable diseases per policy for 3 staff members.

Please refer to C278.

Based on record review and interview, the Critical Access Hospital (CAH) failed to provide emergency care necessary to meet the needs of 1 of 34 patients (#29). The CAH failed to provide emergency care to treat Patient #29's fast heart rate, failed to perform a septic workup for fever, and failed to treat dehydration with sufficient intravenous fluids. Findings include:

Review of an unresolved grievances on 7/8/15 indicated there was a written grievance filed on 4/23/15 related to the quality of care that Patient (#29) received in the Emergency Department (over 2 months ago).

Review of the CAH's Emergency Department Manual dated 3/20/2012, under Scope and Complexity of care needs, it stated that all patients that present to the (CAH) shall receive services in a timely manner along with appropriate treatment modalities.

Patient #29 was admitted to the Emergency Department on 4/3/2015 at 11:56 P.M. with a diagnosis of dehydration secondary to nausea and vomiting. This Patient was short of breath and in respiratory distress. Pertinent diagnoses included; Atrial fibrillation, chronic obstructive pulmonary disease (O2 dependent) and treated with Bipap (a machine to assist with breathing) at home, congestive heart failure, insulin dependent diabetes mellitus, renal failure, and hypertension.

Record review indicated Bipap was started on 4/4/15 at 12:15 A.M. by the Respiratory Therapist for this patient's respiratory distress.
An EKG (electrocardiogram) on 4/4/15 at 12:20 A.M., indicated this Patient had Atrial Fibrillation with a heart rate of 144 bpm (beats per minute) (normal heart rate is 60-100 bpm).

Review of the Emergency Nursing Record dated 4/4/2015 at 12:25 A.M. indicated a fever of 101.7 degrees (tympanic) (normal is 96.3 to 99.5 degrees), heart rate of 128 bpm, and respiratory rate of 27 breaths per minute (normal is 12 to 20). The triage Emergency Severity Index (ESI) was left blank. The ESI is an acuity rating.

Review of an untimed Physician's order on 4/4/15 indicated only 2 medications were ordered Zofran intravenously (for nausea and vomiting) and a Tylenol Suppository 650 mg (milligrams) per rectum (for pain or fever). There was no documentation indicating that medications were ordered to control the fast heart rate or an empiric antibiotic to treat a possible infection.

Patient #29 was seen by Physician #5 on 4/4/15 at 12:30 A.M. and diagnosed with dehydration secondary to vomiting and diarrhea. In addition, this Patient had shortness of breath and was in respiratory distress.

Review of the laboratory work on 4/4/15 at 12:25 A.M. indicated that this Patient's white blood cells (WBC) were elevated 17,500 per mcl (microliter) (normal is 3,500 to 10,000 per mcl) and high immature white blood cells. These WBC values can be indicative of an infection. A Chest X-Ray was negative for an acute infiltrate.

Record review indicated on 4/4/15 at 3:00 A.M.(approximately 3 hours after this patient was admitted), intravenous (IV) fluids were administered, Dextrose 5% with 1/2 normal saline at 150 cc (cubic centimeters) an hour.

Review of the Emergency Nurses Record of 4/4/15 indicated an untimed entry which stated, "MD (Medical Doctor) made aware of elevated heart rate, stated he was not concerned." Under area to indicate whether this patient was on a cardiac monitor (telemetry), it was left blank, indicating that this patient was not on a cardiac monitor.

Record review indicated this Patient's heart rate was monitored via a vital sign machine and progressively increased as follows:
- At 1:00 A.M. - 143 bpm
- At 1:10 A.M. - 144 bpm
- At 1:20 A.M. - 151 bpm
- At 1:50 A.M. - 158 bpm
- At 2:30 A.M. - 165 bpm
- At 2:40 A.M. - 173 bpm
- At 3:00 A.M.- 181 bpm
- At 3:20 A.M. - 183 bpm
- At 3:40 A.M. - 188 bpm
- At 3:50 A.M. - 186 bpm

This Patient was transferred via ambulance at 3:55 A.M. to a Community Hospital and immediately admitted to the Intensive Care Unit. This patient's atrial fibrillation with rapid ventricular response was treated with intravenous cardiac medications (digoxin, cardiazem, and levophed) and fluid boluses for volume depletion. For this patient's acute on chronic respiratory failure, he/she was intubated (on 4/4/15 at 3:30 P.M.) and received ventilator support. Blood cultures initially collected on 4/4/15 were negative for infection, and blood cultures collected on 4/11/15 were positive for infection, and this patient was treated with antibiotics.

This Patient died on 4/14/15 at 11:15 P.M. from a cardiopulmonary arrest, septic shock, acute respiratory failure and acute renal failure.

A Physician Peer Review (for Physician #5) regarding the ED quality of care complaint of 4/23/15 regarding the ER admission at the CAH on 4/3/15 was completed on 7/9/15 at 10:01 A.M. This Review indicated that this patient's rapid heart rate should have been treated, that a septic workup with empiric antibiotics and blood cultures should have been done, and that the physician's treatment for this Patient's dehydration was not aggressive enough with fluids.

During an interview on 7/9/15 at 11:55 A.M., with the Physician Director of Emergency Services he stated that (Patient #29's) dehydration was not adequately treated, and the heart rate control and septic workup was not conducted as the standard of practice would have indicated.

Please refer to C384, Example #1.

Based on document review and interview the Critical Care Access Hospital (CAH) failed to review and revise their Emergency Department and clinical nutrition policies annually. Findings include:

1. Review of the Emergency Department Manual dated 3/20/12, indicated it had not been reviewed for over 3 years.

During an interview with the Nursing Director of the Emergency Department on 7/7/15 at 4:30 P.M., she said it was outdated.



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2. Review of the Clinical Nutrition Policy Manual indicated the following policies were in place for hospital-wide use:

-Clinical Nutrition Manual Locations.
-Ordering of Diets and Diet Changes.
-Diet Order Reports.
-Kardex and Diet Change Sheets for Computer Down Time.
-Nonspecific Diet Orders.
-Patient Food Preferences.
-Meal Delivery.
-Aspiration Risk Policy.
-Calorie Counts.
-Nutritional Supplements-Delivery.
-Nutrition Support-Enteral Feedings.
-Inpatient Diet Instructions.
-Nutritional Assessments.
-Outpatient Medical Nutrition Therapy.
-Nutrition Coverage.

Further review of these policies indicated the most recent updates were between 4/2011 and 5/2012.

During an interview on 7/8/15 at 12:00 P.M., the
Clinical Dietitian said the current nutritional policies in place had not been updated annually.

Based on observation and staff interview, the CAH (Critical Access Hospital) failed to ensure that drugs were stored in a drug storage area in accordance with accepted professional standards.
Findings included:
1. A tour of the CAH pharmacy was conducted on 7/8/15 at 1:00 P.M. with the Chief of Pharmacy. The following observations were made:
The floor in the drug storage area was observed to have dirt, dust, and debris on it, especially under the desk situated in the drug storage room.
One of the bottom shelves in the drug storage area was observed to have dirt and dust on the ledge.
A window sill was observed to have a dirty dust pan and brush resting on it.
A pharmacy storage room situated across the hall from the main pharmacy was observed to have 7 cases of D5W (5 % Dextrose and water) solution resting directly on the floor.
A hole was observed on the outside wall of the pharmacy, above and to the left of a security alarm. The hole passed through the entire wall exposing broken plaster and wall construction material. The Chief of the Pharmacy was not sure how long the hole had been there or what created it. The Chief of the Pharmacy told the Surveyor she would contact someone from maintenance about the hole in the wall. However, no follow-up information was provided prior to the exit interview.
The Chief of the Pharmacy said she understood the Surveyors concerns regarding the uncleanly condition of the drug storage area of the Pharmacy along with the other findings by the Surveyors.

2. On 7/7/15 at 10:35 A.M. an inspection of the medication room on the Medical-Surgical Unit was conducted. A vial of the medication Hyelenex was observed in the medication refrigerator. The vial was not labeled or dated with when the vial was opened. According to the manufacturer the medication is dispensed in single dose vials.
An air conditioning unit was observed mounted on the wall towards the ceiling at the nurses station of the Medical-Surgical unit. The air conditioner was observed to have condensation dripping down onto the medication cart situated directly below it. The water was observed to have damaged packages of dressing material resting on the medication cart below it.
Interview with SEN #1 (Staff Education Nurse) at that time said that the air conditioning unit should not be dripping water onto the medication cart and supplies. She removed the wet supplies from the top of the medication cart, discarded them, and said she would call maintenance to fix the problem.

Based on observation and staff interview, the facility failed to conduct preventative techniques to ensure proper infection control practices for patients in the Surgical Operating Rooms, Same Day Surgery Department (intravenous {IV} therapy and instilling eye drops per Physician's order), Physical Therapy and Occupational Therapy Departments, Housekeeping Services, Infusion Center, Kitchen Sanitation, and staff immunizations affecting 6 of 7 outpatients (#25, #26, #27, #32, #33 and #34) as well as 3 staff members (#4, #29 and #30) regarding immunizations. Findings include:

1. On 7/7/15 at 2:20 P.M., the surveyors observed PT Aide #1 clean a unit that was used by an unidentified PT patient in the PT Therapy Room. PT Aide #1 took a disinfectant wipe (2 minute dry time to be effective) and wiped down the pillow that was on the bed. She next placed the disinfected pillow on the contaminated cloth chair next to the therapy bed. PT Aide #1 effectively wiped down the vinyl covered bed with a new disinfectant wipe, then used the cloth to disinfectant the metal table and 1 and 2 pound weights on top of a metal table.

Because the weights were made of a material that will not stay wet for the required 2 minutes, they do not get properly disinfected between patients.

During interview on 7/7/15 at 2:30 P.M., the Rehab Director and PT Aide #1 said that they would develop a plan to properly disinfect the weights between patients and that the pillow was re-contaminated after being placed after being placed on a contaminated surface.

2. On 7/7/15 at 2:45 P.M., the surveyor observed there was a Paraffin (wax) heating machine on one of the metal tables in the Occupational Therapy (OT) Room. At present, the paraffin machine was not turned on. The surveyor also observed a cleaning schedule hanging on a cabinet that indicated the machine was cleaned monthly.

Review of the Manufacturer's Directions for Use (MDFU)included:
"Clean the unit after every 40 treatments, when the paraffin is no longer clear, or whenever sediment accumulates on the bottom."

During interview on 7/7/15 at 3:00 P.M., the Director of Rehab said that the paraffin heater is cleaned and documented on the schedule every 30 days (and not every 40 treatments per MDFU), regardless if the paraffin is no longer clear, or whenever sediment accumulates on the bottom per MDFU. The Rehab Director said that the schedule would be revised to ensure that MDFU are followed.

3. Review of the hospital's policy and procedure regarding Intravenous Therapy (revised 1/2015) included:
- Tighten tourniquet, above intended site.
- Don gloves.
- Cleanse site with 70% alcohol -Use friction and work from center to periphery.
- Perform, venipuncture. Two attempts per licensed nurse.
- Release tourniquet and secure with tape.

On 7/8/15 at 9:50 A.M., the surveyor observed Nurse #7 insert a peripheral line (intravenous line) for Patient #26 in one of the Same Day Surgery rooms. Nurse #7 applied a tourniquet, then palpated the patient's right hand. After locating a site to insert the IV, Nurse #7 used an alcohol wipe to clean the area. Nurse #7 wiped the area up and down several times and not per policy going from the center to the periphery of the insertion site. Then she fanned the site with her hands to dry the alcohol (possibly introducing dust and contaminates from the air to the insertion site.) Before inserting the IV, Nurse #7 recontaminated the site by touching the insertion site with her contaminated gloved hand. The IV was inserted and taped in place, then covered with a clear dressing.

4. On 7/8/15 at 12:00 P.M., the surveyor observed Nurse #7 insert an intravenous line for Patient #27 in one of the Same Day Surgery rooms. Nurse #7 applied a tourniquet, then palpated the patient's right hand. After locating a vein to insert the IV, Nurse #7 used an alcohol wipe and again disinfected the area up and down several times and not per policy, as above. Then, as previously, she fanned the site with her hands to dry the alcohol. Before inserting the IV, Nurse #7 recontaminated the site by touching the insertion site again with her gloved hand. The IV was inserted and taped in place then covered with a clear dressing.

During interview on 7/8/15 at 2:50 P.M., the Surgical/Same Day Manager 2:50 P.M., said that Nurse #7's technique was not conducted per policy.

5. On 7/9/15, at 8:45 A.M., the surveyor observed the Infection Control/Infusion Manager (ICIM) conduct a Venipuncture procedure for an Iron Infusion for Patient #34 in the Infusion Center.

The ICIM used an alcohol prep pad to disinfect the insertion area using up and down strokes and not from the center to the periphery per policy. The ICIM also recontaminated the insertion site by touching it with gloved hand prior to inserting the needle. The ICIM reprepped the area with a clean alcohol prep pad. This time, a side to side disinfection was done and not from the center to the periphery per policy. As above the ICIM touched the disinfected insertion site with her contaminated gloved hand and inserted the needle. There was no blood return and entire reprepping procedure was repeated as above.

During interview with the ICIM on 7/9/15 at 9:10 A.M., the ICIM said that disinfection of an insertion site should be from the center of the site to the periphery and then inserting the needles without touching the site.

6. Review of the hospital's policy and procedure regarding "Instillation of Eye Drops" (reviewed 4/29/15) included:
- Review physician's medication order for number of drops and the correct eye to instill the drops.
- Wash hands, don gloves.
- Hold a gauze pad in the non-dominant hand on patient's cheekbone just below lower eyelid. Gently press downward with thumb or forefinger against bony orbit retracting lower lid. Turn head slightly in direction of eye that is receiving the medication.
- Ask patient to look at ceiling.
- With dominant hand resting on patient's forehead, hold ophthalmic solution container approximately 1-2 centimeters above the lower conjunctiva sac.
- Drop number of drops in the conjunctival sac (center of lid). Instruct patient to close eyes gently.
- Wipe off excess sterile gauze working inner to outer eye.
- Remove and dispose of gloves. Wash hands.

For Patient #33, Nurse #5 failed to follow physician's orders and facility policy regarding the administration of eyedrops prior to surgery.

On 7/8/15 at 9:30 A.M., the surveyor observed Nurse #5 administering eyedrops. The Physician's order said to administer 4 different eyedrops 5 minutes apart. Nurse #5 donned clean gloves without performing hand hygiene first. The eyedrops were instilled every 2 minutes and not 5 minutes as ordered.

During the administration of the eyedrops facility policy was not followed:
- Hands were not consistently washed before donning gloves or when gloves were removed.
- Nurse #5 did not use gauze per policy on the patient's cheek. The patient was handed a tissue to wipe the affected eye.
- During the instillation, Nurse #5 was very close to touching the lower conjunctival sac with the tip of the medication bottle, and not 1-2 centimeters per policy.

During interview on 7/9/15 at 12:10, the Manager of Same Day Surgery/Operating Room told the surveyors that staff did not follow the facility's policy on the proper instillation of eyedrops and hand hygiene.

7. During a tour of the Operating Rooms on 7/8/15 at 7:40 A.M., the surveyors observed a long blue rectangular plastic box in a clean area across from the surgical scrub sink. The OR Manager said the tub was used for high disinfection of flexible endoscopes after surgery. She told the surveyors that the solution in the tub contained the Sterilizing and Disinfection solution Metricide 28.

According to Manufacturer's Directions for Use (MDFU) the solution is viable for 28 days and that the solution needs to be kept at 25 degrees Centigrade (equivalent to 77 degrees Fahrenheit {F}) to be effective. Review of the temperature log indicated the temperatures were not consistently recorded. From 4/28/15 to 7/8/15 there were 36 entries. The temperatures ranged from 65.1-81.6 F. There were no days that the temperatures were 77 degrees F.

During interview on 7/8/15 at 8:00 A.M., the OR Manager said the high disinfectant container should not be kept in a clean area due to the risk of cross contamination. She also said that temperatures were not being consistently documented and that the temperatures were not kept at 77 Degrees F. per MDFU.

8. Review of the facility's policy and procedure, Hand Scrubbing Technique (Operating Room) was issued in 3/2014. It included:
- Perform Prewash.

Brush Scrub:
- Scrub hands and forearms, with disposable brush, to 2 inches above elbow, using counted brush stroke method (physician scrubbed to mid forearm.
- Fingernails of hand #1 - Using 15 strokes.
- Fingernails of hand #2 - Using 15 strokes.
- Begin with palm of hand #1 and apply 9 strokes to each of the three areas of fingers and hand.
- Repeat above strokes for hand #2.
- Scrub backside of hand #1 applying 9 strokes to each of three areas of fingers and hand, then repeat for backside of hand #2.
- Scrub arm #1 from wrist to forearm and repeat for arm #2.
- Scrub arm #1 from forearm to elbow and repeat for arm #2.
- Discard brush into sink or waste receptacle.
- Rinse hands and arms thoroughly, keeping hands raised.
- Proceed to OR, keeping hands above the elbows and out from scrub clothes.

The Principle of the surgical hand scrub is to ensure that areas that were previously scrubbed, are not gone over again during the scrub per "Association of periOperative Registered Nurses "(AORN) recommendations.

On 7/8/15 at 9:00 A.M. and 10:25 A.M., the surveyors observed Physician #2 incorrectly scrubbing for surgical procedures.

The surveyors observed Physician #2 perform the Pre-Scrub, but only going to mid forearm and not 2 inches above the elbow per policy. The surveyors observed the Physician during the Surgical Brush Scrub. Instead of going through the specific steps above for scrubbing sections at a time and working from fingertips to elbows, Physician #2 scrubbed both hands and then both wrists, then up and down the forearms to the fingertips several times, each time re-contaminating the section below. Physician #2 walked into OR #2, dried his hands on a sterile towel, then waved his hands in the air (stirring up dust and other particles in the room) before donning a surgical gown, gloves and mask.

9. Patient #25 was admitted to the Same Day Surgical Unit on 7/8/15 for removal of a right eye cataract and lens implant.

According to AORN (Association of periOperative Registered Nurses) in the Perioperative Standards and Recommended Practices 2012 Edition of standards.

On Page 89, under Recommendation IV, included:
- "All items introduced to a sterile field should be opened, dispensed, and transferred by methods that maintain item sterility and integrity."
- "All items should be delivered to the surgical field in a manner that prevents nonsterile objects or people from extending over the the sterile field. Skin is a source of bacteria and scurf (small shreds of exfoliating skin) and shredding; therefore, maintaining distance from the sterile field can decrease the potential for contamination when items are passed from a nonsterile area to a sterile area."

Prior to the patient coming into the room, the surveyor observed the Circulating Nurse (#6) opening sterile supplies and leaning over the sterile field, then dropping the contents; syringes, prep cup and sterile gloves onto the sterile field.

On 7/8/15 at 9:15 A.M., after Patient #25's right eye was prepped with Betadine for cataract removal, the Betadine was blotted from the eye. Physician #2 dropped the contaminated surgical sponge on the floor, bent over, picked it up with his sterile gloves and disposed of it in the trash.

Instead of cleaning his hands first, Physician #2 went directly to the Surgical Technician who applied new sterile gloves.

During interview on 7/8/15 at 9:20 A.M., the Surgical Manager (SM) told the surveyors that the Physician should have re-scrubbed before donning new sterile gloves and that the Circulating Nurse should never lean over a sterile field and items on the table. The SM said that the Circulating Nurse may open the supplies without touching anything inside, and then the Surgical Technician takes the items with sterile gloves.

10. After the above surgical procedure, the surveyors observed 4 glass IV bottles of Balanced Salt Solution (BBS) with 0.3% Epinephrine (one for each surgery of the day) All of the bottles were being stored on a metal cart at the foot of the surgical bed, which a risk of cross contamination when each surgical patient is in the room. Closer observation of the bottles indicated the time that the medication was mixed by the Pharmacy was not on the medication.

During interview on 7/8/15 at 9:40 A.M., the Surgical Manager said that one bottle of BBS was for each of the 5 surgical patients. She said that all the bottles and other supplies for other patients should never be stored in the operating room due to the risk of cross contamination by splashes, etc.

11. For Patient #32, admitted 7/9/15 to Same Day Surgery for a colonoscopy, had a diagnosis of sleep apnea.

On 7/9/15 at 9:45, the patient was brought into Operating Room #1. Physician #1 came into the room wearing a yellow surgical gown that was not fastened at the neck, but was tied loosely at the waist. At 10:00 A.M., the surveyors observed that the arms of the Physician's surgical gown had slipped down off the shoulders and were at his elbows. At 10:05-10:20 A.M., the arms of the gown had slipped to almost the wrists and the gown had slipped to just below the waist. There was no attempt made by the Circulating Nurse (Nurse #6) to secure the gown during the procedure. At the conclusion of the procedure, neither Physician #1 nor Physician #3 (Anesthesiologist) performed hand hygiene after removing their gloves, they went directly to the medical record to enter documentation (risk of cross contamination).

During interview on 7/9/15 at 1:00 P.M., the Surgical Manager said that Nurse #6 should have tied the Physician's gown at the neck at the beginning of the procedure to prevent the Physician's scrubs from rubbing against the patient and risking cross contamination.

12. On 7/9/15 at 10:30 A.M. the surveyors observed Surgical Technician (ST) #1 clean the endoscope used in the above procedure in the appropriate sink. His technique was adequate, however, Nurse #6 came into the room, and the surveyor asked where the serial number of the endoscope was documented for this patient per facility policy. Nurse #6 said that the surgical forms that are used now, do not have a place to document the serial number, so it is not documented anywhere.

During interview on 7/9/15 at 1:00 P.M., the Surgical Manager (SR) said that serial numbers of the endoscopes must be documented whether or not there is a line to write it on. The SR said the form would be revised to ensure a space would be provided to document the serial number, otherwise it needs to be written in the medical record.

13. On 7/7/15 at 3:20 P.M., 2 surveyors observed Physician #1 standing at the elevator after pushing the button. He was wearing a surgical mask which was hanging down around his neck.

According to AORN Recommendation VI b.1., surgical masks should not be worn hanging down from the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross-contaminate the surgical attire top (scrub top).

On 7/8/15 the surveyors observed three surgical procedures conducted by Physician #2. After each surgical procedure, Physician #2 did not remove and dispose of his mask. Instead, the mask was slipped down from on the head (still tied) and hung around the neck.

On 7/9/15 at 10:30 A.M., the surveyors observed Physician #2 sitting at the nurses' station with the mask hanging down around the neck.


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14. The Dietary Department of the Critical Access Hospital failed to ensure sanitary practices were maintained to minimize the risk of food borne illnesses.

During an initial tour of the kitchen on 7/7/15 at 9:40 A.M., the following concerns were observed:

-In the walk-in freezer, one large box of hamburger patties and one box of blueberries were left open to air.

-In the walk-in refrigerator, a box of hamburger meat was stored directly on the floor.

-On the bread storage rack, two bags of bread and one bag of rolls were open to air.

-The flour bin, which was approximately half full, was unlabeled and undated. Additionally, there was a scoop sitting directly in the flour.

-The sugar bin, which was approximately one third full, was unlabeled and undated. There was a metal bowl, used to scoop sugar, placed directly in the sugar.

-The floors between the cooking equipment and underneath work tables were dirty with dried food, dust and papers.

-Ceramic wall tiling around work areas were dirty with dried food splatters.

-Two drawers, below a work station, were dirty with dry food particles. These drawers contained utensils used for food preparation and service.

-Twenty bottles of spices/seasonings not in use, were open to the air.

During a tour of the second floor Nutrition Kitchenette on 7/7/15 at 10:15 A.M., the following concerns were observed:

-The inside of the microwave was dirty with dried food splatters.

-Four storage containers used for holding condiments and crackers were dirty.

During a second tour of the Dietary Department and Nutrition Kitchenette on 7/8/15 at 11:15 A.M., the following were observed:

-Three trash buckets were uncovered and not being used.

-The spice and seasoning bottles remained open to air.

-The two drawers below the work areas remained dirty with food particles.

-The floors and wall tiles remained dirty with dried food particles, papers and dust.

-Both the flour and sugar bins had the scoop and bowl still stored directly in the bins.

-One bag of bread was open to air on the bread rack.

-The inside of the microwave and food storage bins in the kitchenette remained dirty.

During an interview on 7/8/15 at 11:55 A.M., the Food Service Director said he would implement improved cleaning assignments for the dietary staff.

15. The Critical Access Hospital failed to monitor staff for communicable diseases.

Review of the facility Physical Assessment Policy with a review date of 9/2013, indicated the following:

-Physical assessments are required of all qualified job applicants after an offer of employment has been made.
-Pre-placement physical assessments include but are not limited to; Rubella titer, Hepatitis B titer and PPD (Tuberculosis Testing).

Review of Employee Record #4, indicated the only documented Tuberculosis (TB) test was 9/1/97.

Review of Employee Record #29, indicated no current evidence of Influenza Vaccination, and no evidence of Measles, Mumps, Rubella (MMR), Varicella and Hepatitis B immunizations.

Review of Employee Record #30, indicated no current evidence of Influenza Vaccination, and no evidence of MMR, Varicella and Hepatitis B immunizations.

During an interview on 7/9/15 at 12:10 P.M., the Infection Control Manager said not all staff had been screened for communicable diseases, but should have been. She said evidence of Influenza vaccination or declination should be maintained in the employee files.

Based on observation, record review, and staff interview, the CAH (Critical Access Hospital) failed to ensure that for 1 patient, (#10), of a total sample of 34 patients, that the CAH staff documentation of the assessment, treatment, and interventions of the patient during a Rapid Response was conducted in accordance with accepted professional standards and the CAH policy.
Findings included:
On 7/7/15 at approximately 2:55 P.M., a Rapid Response was called for Patient #10, who was admitted earlier that morning with diagnoses which included hypertension and acute headache.
Interview with the DON on 7/7/15 revealed that the patient had displayed seizure like activity during attempts to place a central line, with the patient's eyes rolling back in his/her head. The Patient's blood sugar at that time was 635 mg/dl, the patient was anoxic and hypotensive, with a systolic blood pressure in the 80's, according to the physician's progress note.
Review of physician orders and physician progress notes, indicated that the patient was given 500 cc of Normal Saline, Stat, x 2 followed by 150 ml/hr, multiple doses of regular insulin, multiple doses of IV (intravenous) Labetalol (beta-blocker for heart rate and blood pressure control), laboratory tests for blood sugar, and assessments of vital signs and medical status by physicians and nurses at the time of the Rapid Response.
Review of the SBAR (Situation Background Assessment Recommendation) form for the Rapid Response, provided by the DON on 7/8/15 at 10:15 A.M., revealed no documentation of any of the events, assessments, or interventions provided to the patient during the Rapid Response on the previous day.
Interview with the DON confirmed that, the Hospital failed to document the events/circumstances surrounding the change in the patient's medical condition per the Hospital policy on Rapid Response, to include assessment of the patient (including vital signs, level of consciousness, neurological status, etc) and any interventions provided to the patient by the physicians, nurses, and other health care professionals providing care and treatment to the patient.
The DON said that it would be impossible to accurately capture the events of the Rapid Response, or when interventions were initiated, an entire day after the event occurred. The DON also said there should have been someone in the patient's room responsible for documenting an accurate assessment of the entire event.

Based on observations and staff interviews, the Critical Access Hospital (CAH) failed to ensure that there were physician orders for emergency medications and procedures (defibrillation) for 2 of 33 patients (#15 and #16). In addition, the CAH failed to post a list of high risk/high alert medications in the Emergency Department and failed to document a patient's allergies for 1 of 33 patients (#17). For 2 of 2 Nurse Practitioners (NP #1 and NP #2), the CAH failed to have their clinical privileges signed by the Chief Nursing Officer. Findings include:

1. Review of the Procedure for Code Blue Team (a cardiac/respiratory arrest), revised 4/2014, under Drugs and Intravenous for code team member #4, it states, "Read back all verbal orders and report to recorder every drug and dose given." Under Code Blue Points of Emphasis, it states, "The Code Blue Flow Sheet will be completed and signed by the assigned recorder. He/she will be responsible for obtaining the M.D.(Medical Doctor's) signature and to review all the information with the Code Coordinator."

A. For Patient #15, the CAH failed to have physician's orders for medications and procedures (defibrillation) administered during a cardiac and respiratory arrest.

Patient #15 was admitted to the Emergency Department on 6/1/15 at 11:55 A.M., this patient was actively being resuscitated by the EMS (Emergency Medical Service) who witnessed this patient's respiratory arrest that progressed to cardiac arrest. The Patient's Emergency Severity Index was 1, a triage acuity index scale from 1 (indicating resuscitation) to 5 (nonemergent). These Intravenous push (IVP) medications were given; Atropine (to stimulate the heart) 1 milligram (mg) one dose, Epinephrine (to stimulate the heart and blood vessels) 1:10,000 1 mg for 4 doses, Levophed (to stimulate heart and blood vessels) intravenous drip and defibrillation with 200 joules, the code ended on 6/2/15 at 1:28 A.M.

Review of Patient #15's record indicated there was no Code Blue Flow Sheet. (This is the signed record for the verbal orders given during the code).

During an interview with Nurse #11 on 7/8/15 at 4:05 P.M., she stated that the verbal orders during the code were written on a blank piece of paper and they were suppose to be transcribed onto the code sheet later. Nurse #11 had delegated this to be done by another Nurse, but there was no evidence that this was done. She said it is hard to document on the code sheet because the boxes are so small and the inpatient nursing staff (who come to help) are not familiar with the code sheets. Therefore the code sheets are usually filled out after the code (not in real time) and then signed by the Physician.

B. For Patient #16, the CAH failed to have the Physician's verbal orders for medications administered during a cardiac arrest signed by the Physician.

Patient #16 was admitted to the Emergency Department on 6/9/15 at 7:17 A.M. in cardiac arrest. Cardiopulmonary Resuscitation was administered. These IVP medications were given; Epinephrine 1:10,000 0.5 mg for 4 doses and Sodium bicarbonate (decrease an acidosis) 5 milliequivalents for 2 doses. The code ended on 6/10/15 7:36 A.M.

Review of Patient #16's Code Blue Documentation sheet on 7/7/15 indicated the Physician's signature at the bottom of this sheet was left blank.

During an interview with the Nursing Director of the Emergency Department on 7/7/15 at 3:20 P.M., she stated that code sheet (for Patient #16) did not have a physician's signature for the verbal orders given during the code.

2. The CAH failed to have a list of high alert/high risk medications along with appropriate instructions, posted in the Emergency Department.

Review of the Policy on High Risk Medication Management, revised 2/24/15, stated, "Special standardized procedures and processes shall be employed to minimize the potential for serious adverse events related to the use of high-risk medications. High-Risk Drugs (are defined) as a medication that has an inherent narrow therapeutic index and/or has the potential to cause serious adverse events when not used appropriately."

During an interview with the Chief of Pharmacy on 7/7/15 at 3:20 P.M., in the Emergency Department by the medication preparation area, she said that high alert/risk medications are posted on the wall by the automated medication dispensing system. She check this wall and then stated that they should be there but were probably removed in October of 2014 with the renovations.

3. For Patient #17, the CAH failed to document why a patient's allergies were not obtained and/or efforts to obtain them.

Patient #17 was admitted to the ED on 7/5/15 at 9:34 P.M., with shortness of breath and a fever.

According to the CAH's policy on Medication Management, revised on 2/25/15, it stated under procedure, "The nurse will check for medication allergies prior to administration of all medications."

Record review on 7/7/15 under this patient's allergies it stated, "unable to obtain." There was no documentation explaining why there were no allergies listed, and no documentation of any efforts to obtain them.

Record review indicated that this patient received 6 medications in the ED. These medications were Albuterol 2.5 mg nebulizer (for difficulty breathing), Lorazepam 1 mg IVP (for anxiety), Tylenol 975 mg by mouth (for fever or pain), Cardizem 20 mg IVP (for heart rate and blood pressure), Solumederol 125 mg IVP (for respiratory inflammation), and Levaquin 500 mg IV piggyback (an antibiotic).

During an interview on 7/8/15 at 9:15 A.M. with the Emergency Department Unit Manager, she said she spoke to this patient's nurse and was informed that this patient said (he/she) did not remember the allergies but was allergic to mostly everything.



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4. Review of employee record for NP #1 indicated there were signed Clinical Privilege Forms for Palliative Care and Pain Management. Both forms were signed by the Department Chair, the President/Medical Staff, and the President/Chief Executive Officer. Neither of the forms were signed by the Chief Nursing Officer.



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5. Review of employee record for NP #2 indicated there was a signed Clinical Privilege Form for the appointment of an Affiliate Provisional Medical Staff (for 3/2015 - 3/2016) that was signed by the President/Chief Executive Officer. The form was not signed/approved by the Chief Nursing Officer, as required.

Based on observation, record review, patient and staff interview, the Critical Access Hospital (CAH) failed to ensure a care plan had been developed for 1 of 34 sampled patients (#6) related to psycho-social well-being/needs. Findings include:

Patient #6 was admitted to the Facility in 7/2015. The Patient's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) exacerbation, pneumonia, depression and anxiety.

During observation and interview (on 7/8/15 at 10:00 A.M.), the Surveyor observed Patient #6 resting in bed. The Patient's hair was disheveled. The room was dark and the privacy curtain was pulled to the end of the bed.

Patient #6 became very tearful during the interview process, and described several issues to the Surveyor, as they related to his/her emotional well-being, home-life and frame of mind. Patient #6 said that he/she did not want to return to his/her home, and that she had no idea what the discharge plan was, nor when the Facility anticipated the discharge. Patient #6 said that he/she was fearful of being discharged related to the following expressed concerns:

- No food, nor a way to obtain food.
- Adult family members living in the Patient's home are verbally abusive toward the Patient.
- Home conditions deplorable due to clutter, filth, and several animals living there and pet excrement.
- Family members coerce/belittle Patient into relinquishing social security disability income.
- No transportation to and from appointments.
- No Primary Care Physician available, close by, for follow-up care upon discharge.
- Family members took over Patient's bed and room, and Patient now has to sleep on sofa.
- Concerned about appearance, having no teeth, due to removal a year ago due to mouth problems, no way to get to appointment to have teeth made.
- No community services or the knowledge on how to obtain assistance. No support system from family or friends.
- Lack of activities in Hospital to keep occupied during day.

Record review indicated a Social Service note (dated 7/6/15), whereby, Social Worker (SW) #1 indicated that Patient #6 lived at home, without community services; and that Patient #6 had been referred to Social Services by Nursing, related to "emotional state and assessment of need." SW #1 indicated that Patient #6 had outpatient services, prior to being admitted, with a psychiatric outpatient organization, but had been discharged from that organization.

SW #1 documented that Patient #6 had been stressed about "many social issues." SW #1 indicated that Patient #6 had no formal and informal support.

SW #1 indicated that Patient #6 would need follow-up (f/u), and that the Patient has agreed to outpatient counseling with services and medication evaluation. SW #1 indicated that Nursing was informed, and the SW would f/u to re-assess and refer to outpatient services.

SW #1 indicated in a second note (dated 7/7/15 at 2:36 P.M.) that she met with Patient #6, who was tearful, and agreed to community outpatient for psycho-social needs "after" discharge. SW #1 indicated that she left a message for the Patient's "former therapist" to clarify options.

During interview on 7/8/15 at 10:30 A.M., SW #1 said that she is aware that Patient #6 has social concerns, and that she is trying to reach out to the Patient's former therapist to assist the Patient when he/she is discharged to home.

SW #1 said that SW #2 has also met with Patient #6. SW #2 was present, turned and looked at the Surveyor, but made no comment as to what extent she assisted Patient #6 with support services regarding psycho-social concerns.

The Surveyor indicated to both SW #1 and SW #2 several concerns regarding the Patient's alleged home situation, follow-up care, no PCP locally, no food, deplorable living conditions and lack of transportation or support, and inquired what the discharge plan was relative to the Patient-described conditions. SW #1 said that she wasn't aware of all of these issues, but perhaps the Facility could check with the Community Hospital Acceleration, Revitalization & Transformation (CHART) program (a grant program) to assist Patient #6.

Review of SW #2's note, dated 7/8/15 at 10:54 A.M., indicated that SW #2 received a telephone call from Patient #6's former therapist, who said that the therapist would not be able to pick Patient #6 up for therapy again, as Patient #6 has "transportation issues." SW #2 documented that Patient #6 would be referred to another agency, and maybe referred to CHART program due to extent of f/u needs.

During interview on 7/8/15 at 3:10 P.M., the Case Manager (CM) said that she is aware of Patient #6's needs, but "backed off," when the Patient's issues became psycho-social in nature. The CM said that her responsibility is discharge planning and coordination of care. The CM said that the "Team" meets 3 times a week to discuss plans and management for Patient's who are in the acute care setting. The CM said that she, nor other multidisciplinary staff documented on Patient #6 and concerns discussed at each meeting. The CM said that she deferred Patient #6 to the Social Services Department, and did not know what the discharge plan was at this time.

The Surveyor inquired about Nursing, as Patient #6 was admitted with several medical issues as well. The CM said that a Nurse is present during Team and Multidisciplinary meetings, but that she did not know what the Nurse actually does or documents, only that a Nurse is present.

The CM then printed a CM note (dated 7/8/15 at 8:05 A.M.), indicating that Patient #6 lives at home with family members; has no outside services, Patient states he/she "has very little - Not even a bed," and that Patient #6 had been referred to Social Services.

During interview on 7/8/15 at 3:17 P.M., the Director of Nursing (DON) said that a representative from Nursing is in attendance at each of the meetings the CM was referring to. The Surveyor inquired about a care plan being completed with interventions to address the Patient's concerns. The DON said that Nursing should have completed a care plan, relative to Patient #6's psycho-social well-being.

Upon further review, the DON said that there was no care plan, with interventions, nor a discharge plan for Patient #6, and that the facility should have initiated one.

The DON said that according to the Nursing Assessment on admission (7/3/15), Patient #6 had several "triggers" that indicated a care plan should have been developed. The DON said that the triggers included: "depression, anxiety, stress, impaired coping and being withdrawn." The DON said that he was "shocked" at all the triggers, and the fact that a care plan had not been developed with interventions to address these concerns for Patient #6.

Further review of the clinical record on 7/8/15 at 4:30 P.M. indicated that SW #1 met with Patient #6 today after meeting with the Surveyor, when it was reported Patient #6 was tearful. SW #1 indicated that Patient #6 agreed to the CHART program and to f/u with outpatient mental health referral, home issues, resource referral, dental and PCP f/u. SW #1 indicated in the note that Patient #6 requested activities to keep his/her mind occupied while in-patient, a service that had not been provided to Patient #6 since being admitted.

Please refer to C360.

Based on record review and staff interview, the facility failed to ensure that patients' records contained an assessment of health status, a brief summary of the episode, disposition, and discharge instructions to the patient for 2 of 7 outpatients (#30 and #32.) in a total sample of 34 patients. Findings include:

1. Patient #30 was admitted to the facility on 7/8/15 for outpatient cataract surgery. Review of the clinical record had no evidence that an updated History and Physical was completed and documented by Physician #2 as required by hospital policy.

2. Patient #32 was admitted to the facility in 7/9/15 for an outpatient colonoscopy. Review of the clinical record indicated there was no evidence that an updated History and Physical was completed and documented by Physician #1.

During interview on 7/9/15 at 12:30 P.M., the Surgical Manager said that the Physician must complete an updated history and physical prior to any surgical procedure.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to properly maintain medical records in a location that was protected from fire and water damage. Findings include:

Closed Record Maintenance:

Observation of the closed record rooms on the CAH's First Floor, on 7/7/15 and on 7/8/15 at 9:30 A.M. with the Director of Medical Records revealed 20 rows of closed medical records stored in two rooms, on open-faced metal cabinets. The closed medical records were not totally enclosed in a cabinet. As a result, medical records were not stored so as to prevent their destruction from fire or water sprinkler damage.

During interview on 7/8/15 at 9:30 A.M., the Director of Medical Records said that the current storage of medical records did not provide an effective protection of closed records if a fire occurred when Administrative staff were unavailable (such as nights, weekends and holidays.)

:

Based on staff interview the facility failed to ensure there was a current roster listing each practitioner's specific surgical privileges which must be posted in the surgical suite and area/location where the scheduling procedures are done. A current list of surgeons suspended from surgical privileges or whose surgical privileges have been restricted must be retained in these area/locations as well. The Critical Access Hospital (CAH) must delineate the surgical privileges of all practitioners performing surgery and surgical procedures.

During interview on 7/8/15 at 8:15 A.M., the Surgical/OR Manager told the surveyors that she did not have an available and updated copy of a surgical delineation in the surgical suite as required. She also said that the CAH has been on the intranet for 2 years, but that she does not know how to retrieve the information. The Surgical Manager said that surgeries are being performed without a posted/updated delineation list.

Based on record review and staff interviews, the Critical Access Hospital (CAH) failed to provide evidence that patients and/or their authorized persons were contacted with the option of being donors of anatomical gifts on admission or in a timely manner. Findings include:

The CAH's 6/2014 Organ and Tissue Donation Policy indicated that the Organ Procurement Organization (OPO) collaborated with facility staff prior to the discussion of donation with the legal next of kin. The OPO staff informed every family of a decedent's documented donation decision or in the absence of designated consent, their right to consider organ and tissue donation whenever death occurred. Physicians and nurses will work with the contracted agency to develop an appropriate family approach by the OPO.

Review of the Organ Procurement (OP) Hospital Performance Summary for 2014 and for 1/2015-3/2015, reviewed on 7/8/15, indicated the CAH had 49 deaths, but no family approaches for pre-referral for organ, eye and tissue donations in 2014, and the first three months of 2015.

Review of the CAH's Admissions Packet indicated no information about how patients and/or their authorized family members could learn about and contact CAH staff about the OP process and options.

During interviews on 7/7/15 at 10:30 A.M. with the Director of Case Management, and on 7/8/15 at 3:00 P.M. with the Director of Nursing Services, who was designated as the CAH's OP requester, both said that the facility did not inform or collaborate with potential donors and their families about the option to either donate or not donate organs, tissues, or eyes, at the time of admission or thereafter. Both staff indicated that the OPO contacted families about the option to donate or not donate, only at the time of immanent death.

Please refer to C348.

Based on record review and staff interviews, the Critical Access Hospital (CAH) failed to provide evidence that CAH staff were trained in approaching, contacting and informing potential family donors with the option of being donors of anatomical gifts on admission or in a timely manner. Findings include:

The CAH's 6/2014 Organ and Tissue Donation Policy indicated that the contracted Organ Procurement Organization (OPO) collaborated with CAH staff prior to the discussion of donation with the legal next of kin. The OPO staff informed every family of a decedent's documented donation decision or in the absence of designated consent, their right to consider organ and tissue donation whenever death occurred. Physicians and nurses will work with the contracted agency to develop an appropriate family approach by the contracted agency.

Review of the Organ Procurement (OP) Hospital Performance Summary for 2014 and for 1/2015-3/2015 on 7/8/15 indicated the CAH had 49 deaths, but no family approaches for pre-referral for organ, eye and tissue donations in 2014/2015.

The CAH's Admissions Packet review indicated no evidence that patients and/or their authorized family members could obtain contact information about the OP process and options.

During interviews on 7/7/15 at 10:30 A.M. with the Director of Case Management, and on 7/8/15 at 3:00 P.M. with the Director of Nursing Services (DNS), designated as the facility's OP requester, both said that they were not trained in the OP procedures for approaching potential donors or their legal representatives at admission or thereafter. Staff said they did not approach patients or their families about OP donations, and knew of no other CAH staff (Physicians and Nurses) who had been trained in a course designated by the OPO in approaching families in conjunction with organ, tissue or eye donation requests.

Based on observation, record review, patient and staff interview, the Critical Access Hospital (CAH) failed to ensure Skilled Nursing Facility (SNF) requirements had been provided for 1 of 34 sampled patients (#6) related to Activities and Dental services. Findings include:

During the initial tour of the Unit on 7/7/15 at 9:10 A.M., the Director of Nursing (DON) said that Patient #6 had sores either on the lips or in the mouth and that testing was being done.

Patient #6 was admitted to the CAH in 7/2015. The Patient's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) exacerbation and pneumonia.

During interview on 7/8/15 at 10:00 A.M., Patient #6 was teary, and described several issues to the Surveyor, that included lack of activities to keep his/her mind occupied and dental care/services. Patient #6 said that he/she had to have all teeth removed due to a genetic condition about a year ago, and would love to get dentures to improve eating and his/her appearance.

Patient #6 said that he/she has nothing to do but sit and think about all that is wrong, his/her illnesses and upsetting home life. Patient #6 said that there is nothing to read, and would love puzzle books or magazine materials if any were available or offered.

Review of the clinical record, after the Surveyor met with Patient #6, SW #1 indicated in a note (7/8/15 at 10:54 A.M.) that a referral would be made for dental f/u. In addition, SW #1 indicated in this note that Patient #6 requested activities to keep the Patient's mind occupied while a patient in the Facility.

Please refer to C385.

Based on record review, patient, Health Care Proxy designee and staff interviews, the Critical Access Hospital (CAH) failed to ensure that 1 of 7 outpatients (#5) and 4 sampled in-patients (#1, #2, #3, and #4) and/or their legal representatives (Health Care Proxy/Legal Guardian) out of a total sample of 34 patients, were given the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives. Findings include:

Review of the Swing Bed Program's Resident Rights policy, the CAH's Patient Rights and Ethics Policy and Procedures, dated 2/2014, indicated that patients (and their Health Care Proxies) had the individual's right under state law to make decisions concerning medical care, including the right to accept or refuse medical treatment.

1. For Patient #1, the CAH failed to allow the patient to refuse treatment and/or formulate an Advanced Medical Directive.

Patient #1 was admitted as a swing bed patient in 7/2015 with diagnoses that included Pneumonia and Congestive Heart Failure.

During interview on 7/7/15 at 9:40 A.M., Patient #1 said that he/she wished to be designated as Do Not Resuscitate (DNR)/Do Not Intubate (DNI) status. Patient #1 said he/she did not remember that he/she was given the opportunity by CAH staff or his/her Physician, either verbally or in writing, to formulate an Advance Medical Directive since admission. The patient said that he/she had designated in writing a family member to be the Health Care Proxy (HCP).

Chart record review on 7/7/15 at 10:00 A.M. indicated no written evidence the patient had been allowed to formulate an Advanced Medical Directive. Physician orders, from the date of admission to 7/7/15, indicated the resident had a "Full Code" status. There was no evidence that the patient's HCP form was in the clinical record, nor any documented discussion with the patient by CAH staff including the patient's Physician, about the patient's refusal of treatment wishes.

During interviews with the Director of Nursing Services and the Director of Social Services on 7/7/15 at 1:30 P.M., both said the patient was capable of signing an Advanced Medical Directive, and that the CAH failed to provide the patient the right to refuse care as stipulated in a DNR/DNI directive.

2. For Patient #2, the CAH failed to allow the patient to refuse treatment and/or formulate an Advanced Medical Directive.

Patient #2 was admitted as a swing bed patient in 6/2015 with diagnoses that included right Total Knee Replacement, Osteoporosis, Osteoarthritis and Anthropophagi Reflux Disease.

During interview on 7/7/15 at 9:50 A.M., Patient #2, with spouse present, said that he/she was supposed to be designated as DNR/DNI status. Patient #2 also said that he/she notified the facility that he/she was donating his/her body to a local medical school when the time came for such donation. Patient #2 said he/she had not been approached or been given the opportunity by CAH staff or his/her Physician, either verbally or in writing, to formulate an Advance Medical Directive. Patient #2 said that his/her spouse was his/her Health Care Proxy designee.

Chart record review on 7/7/15 at 10:00 A.M. indicated no evidence the patient had been allowed to formulate an Advanced Medical Directive. Physician orders, from the date of admission to 7/7/15, indicated the resident had a "Full Code" status. There was no evidence that the patient's HCP form was in the clinical record, nor any documented discussion with the patient by CAH staff including the patient's Physician, about the patient's refusal of treatment.

During interviews with the Director of Nursing Services and the Director of Social Services on 7/7/15 at 1:30 P.M., both said the patient was capable of signing an Advanced Medical Directive, and that the CAH failed to provide the patient the right to refuse care as stipulated in a DNR/DNI directive.

3. For Patient #3, the CAH failed to allow the patient to formulate an advanced medical directive.

Patient #3 was admitted as a swing bed patient in 7/2015 with diagnoses that included Right Hip Fracture, Cerebrovascular Accident, Dementia, Hypertension, and anemia.

During interview on 7/7/15 at 10:40 A.M., the Health Care Proxy (HCP) alternate for Patient #3 said that the patient was alert and confused with increasing periods of lethargy. The HCP alternate said that CAH staff had frequently consulted with him/her and that he/she had signed patient admission form(s.) The HCP said that he/she was unaware of the patient's Advanced Medical Directive and/or HCP status. The HCP alternate produced a HCP form indicating the patient's family member was the primary HCP, and that the facility did not have a copy of the patient's HCP form until 7/7/15.

Chart record review on 7/7/15 at 10:50 A.M. indicated on 7/3/15 that the patient was described by the Director of Case Management as "unable" to verbalize goals. There was no documented evidence the patient had formulated an Advanced Medical Directive. Physician orders, from the date of admission to 7/7/15, indicated the resident had a "DNR/DNI Code" status. There was no documented evidence that the patient had a discussion with facility staff including the patient's Physician, about the patient's refusal of treatment, nor was there written documentation as to the patient's wishes for a DNR/DNI directive. Additionally, there was no evidence that the patient's HCP had been invoked by the patient's Physician. There was evidence that the CAH had allowed the HCP alternate to sign a facility "Waiver of Responsibility" form in error for the patient on 7/1/15.

During interviews with the Director of Nursing Services and the Director of Social Services on 7/7/15 at 1:30 P.M., both said the patient was legally responsible for signing any Advanced Medical Directive since admission, and that the CAH failed to provide the patient the opportunity to formulate an advanced medical directive. Staff said that the CAH was unaware of the patient's HCP designates up until 7/7/15, when it received the written HCP form from the HCP al;ternate. Staff also said that the HCP status had not been invoked by the patient's Physician, and that the patient's HCP alternate should not have signed any admission forms. Staff said that the Physician should not have ordered the patient to be a DNR/DNI status without patient's discussion or an invocation of the HCP, if appropriate.

4. For Patient #4, the CAH failed to allow the patient to formulate an Advanced Medical Directive.

Patient #4 was admitted as a swing bed patient in 6/2015 with diagnoses that included traumatic osteoporosis thoracolumbar compression fracture, Parkinson's Disease, lumbar spinal fracture and bilateral lower extremity edema.

During interview on 7/7/15 at 1:00 P.M., Patient #4 said that he/she wished to be designated a DNR/DNI status. Patient #1 said he/she had no knowledge that he/she was given the opportunity by CAH staff or his/her Physician, either verbally or in writing, to formulate an Advance Medical Directive since admission. The patient said that he/she had designated in writing a family member out of state to be his/her primary HCP designate.

Chart record review on 7/7/15 at 1:15 P.M. indicated no evidence the patient had been allowed to formulate an Advanced Medical Directive. Physician orders, from the date of admission to 7/7/15, indicated the resident had a "Full Code" status. Although there was no evidence that the patient's HCP had been invoked, the CAH staff had the patient's alternate HCP designee sign a facility "Waiver of Responsibility" form for the patient on 6/10/15.

During interviews with the Director of Nursing Services and the Director of Social Services on 7/7/15 at 1:30 P.M., both said the patient was capable of signing an Advanced Medical Directive, and that the CAH failed to provide the patient the right to refuse care as stipulated in a DNR/DNI directive. Staff also said that the patient's alternate HCP designee should not have signed a waiver of responsibility form on admission, as this was the right of the patient only, unless the patient instructed CAH staff otherwise.


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5. Review of the hospital's policy and procedure entitled "Suspension of Do Not Resuscitate Orders During Surgical Procedure" of 9/2012 included:

If a patient has the capacity, he or she has the right to refuse medical intervention including, but not limited to cardio-pulmonary resuscitation. In the event of incapacity, substituted judgement by the agent/surrogate applies. However, in cases where the patient, agent/surrogate consents to a surgical procedure, the Do Not Resuscitate (DNR) order, as with all pre-surgical orders, will be suspended and rewritten postoperatively. Exceptions to the suspension of the DNR may occur on a "case by case basis" and only if:
- The particular anesthetic agent, by it's usual action, is not expected to compromise the patient's cardio-pulmonary status, i.e., local anesthesia, and the patient, agent/surrogate agree to sustain the DNR order during the surgical procedure.
- The discussion will be documented in the physician progress notes.

This policy was:
- Reviewed on 9/7/12 by the Ethics Committee Co-Chairperson,
- Issued by the Chief Nursing Officer/PI/RM on 9/7/12,
- Approved by the Chief of Surgery (9/19/12), the Chief of Anesthesiology (9/18/12), Interim Chief Operations Officer (9/7/12) and the President, Medical Staff (9/13/12).

Patient #25 was admitted to the Same Day Surgical Center on 7/8/15 for a right eye cataract extraction with an Intraocular lens implant using a topical/local anesthetic. Other pertinent diagnoses include: Insulin dependent diabetes mellitus,

Review of Patient #30's medical record indicated the patient had a physician's order (4/10/14) for Do Not Resuscitate, Do Not Intubate, No Artificial nutrition, No non-invasive ventilation, No dialysis, Yes to Hospitalization and Yes to short term intravenous hydration. The medical record also contained a MOLST form (Medical Orders for Life-Sustaining Treatment) dated 4/10/14, which stated the same information as the above order. The form was signed by the patient and a Nurse Practitioner.

Further review of the clinical record found no evidence that a discussion was held with the patient regarding the patient's wishes about withdrawing the DNR orders during the surgical procedure per policy.

During interview on 7/9/2015 at 12:10 P.M., the Surgical Manager (SM) said the Physician must have a discussion with the patient prior to surgery regarding the patient's options regarding the suspension of the DNR during the surgical procedure. The Surgical Manager said there was no evidence in the patient's clinical record which would indicate there was a discussion on this matter (i.e., Physician's Progress Note).

Based on observation and staff interview, the hospital failed to provide privacy for a patient following surgery.

For Patient #33 admitted to the Same Day Surgery Unit on 7/9/15 for a right eye cataract removal.

On 7/9/15 at 9:30 A.M., the surveyor walked past Patient #33's room. The patient's bed was next to the door in full view of anyone walking in the corridor.

The patient was wearing a hospital gown, however, the patient was exposed up to the groin area.

During discussion at 9:30 A.M., Nurse #5 said, "Well he/she has underwear on." The surveyor intervened on the patient's behalf, and suggested that the nurse should pull the privacy curtain so the patient would not be exposed to staff, patients and visitors walking by the room.

During interview on 7/9/15 at 1:00 P.M., the Surgical Manager said that the patient's privacy curtain should have been pulled over to afford the patient privacy and dignity.

Based on record review and staff interviews, the Critical Access Hospital (CAH) failed to follow its specific time frames for the review and response to complaints/grievances of staff neglect to patients for 2 of 8 sampled discharged patients (#28 and #29). Additionally, the CAH failed to provide the patient/family member with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the complaint, the results of the complaint process and date of completion for 2 of 8 sampled patients (#28 and #29.) in a total sample of 34 patients. Findings include:

Review of the CAH's Complaints and Grievances Policy (dated 11/18/14) indicated that complaints/grievances were to be acknowledged by the Quality Improvement/Risk Management Coordinator (QI/RMC) as soon as possible, but no later than 7 business days from the QI/RMC's receipt of the complaint. If resolution of the complaints/grievances is completed at the time of the letter, the following information will be included: the name of the hospital, contact person, steps taken to investigate the grievance, results of the grievance process, and date of completion. If resolution is not completed at the time of the letter, the following information will be included: the name of the hospital, contact person, and expected date of resolution. If the complaint concerns Medical staff, a request will be made to the appropriate Chief of Service/designee to review the complaint. The findings of the Chief of Service/designee will be reported to the RM and to the Chief Operating Officer (COO). If indicated, the COO and /or the RM will confer with the Chief of Service to discuss the complaint and investigation with the involved physician. If circumstances warrant the information will be submitted to the Medical Staff Executive Committee for review and consideration of future action. Physician-related complaints and follow up recommendations are filed in Physician Practice Profiles as well as in Risk Management files. A final letter will be sent upon completion of the investigation but no later than 30 days from the receipt of the grievance. Any investigation that exceeds 30 days will be reported to the Hospital Performance Improvement Committee for action/recommendations, and the patient will be contacted with an update and expected date of resolution. The final letter will include the name of the hospital, contact person, steps taken to investigate the grievance, results of the grievance process, and date of completion. The hospital must provide adequate information to address each item stated above. All complaint follow up letters include contact information for patients to pursue if they are not satisfied with the resolution by the hospital.

1. For Patient #29, the CAH failed to acknowledged to receipt of the family member's grievance on behalf of the patient by the QI/RMC within 7 business days, failed to provide the expected date of resolution in the initial response to the patient's family, and failed to provide any final letter to the patient's family in 30 days or thereafter from the receipt of the grievance, with any information such as the name of the hospital, contact person, steps taken to investigate the grievance, results of the grievance process, and date of completion.

Patient #29 was admitted to the hospital's ED (Emergency Department) on 4/3/15, and discharged from the Ed on 4/4/15.

A family member of Patient #29 called the QI/RMC on 4/23/15 and made a verbal complaint regarding Medical staff neglect to Patient #29. Specifically the complaint alleged:

-the patient's heart rate was very high, had trouble breathing, and that the attending ED Physician "didn't treat (Patient #29," that the patient did not receive respiratory treatment, no IV (Intravenous), no fluids, that the patient "just laid there getting worse, and the attending ED Physician hardly ever came into the room,

-that the ED Physician wanted to admit the patient to the CAH's Medical/Surgery (unit) for observation, but that Ed nurses seemed "nervous" about this (because the CAH had no ICU (Intensive Care Unit) there, and the nurses suggested the family member talk to the ED Physician about having the patient transferred to another hospital instead. When the family member talked to the ED Physician, the ED Physician agreed to the transfer,

-that when the patient arrived at the transfer hospital, staff there were surprised that the patient did not have an IV started,

-and that the patient was intubated at the transfer hospital's ICU, never improved, and died several days later. This verbal complaint was recorded by the QI/RMC on 4/23/15 on a Patient Complaint Report, and referred to the Chief of Service for investigation of Medical staff conduct on 4/23/15.

A letter was sent to Patient #29's family member (the Complainant) on 5/12/15 acknowledging the family member's concern about patient care in the CAH's ED on 4/3/15. The letter did not indicate the expected date the investigation would be completed as required. It indicated "When the investigation of this case is complete, you (family member) will receive another letter from us informing you of the outcome." This first and only CAH letter sent to the family member (acknowledging the complaint) was, per CAH policy, to be sent out no later than 5/4/15 (7 business days after the receipt of the complaint.) However, this initial letter was 8 days beyond the initial 7 day letter requirement.

Review on 7/8/15 of the complaint file for Patient #29 indicated the family member of Patient #29 did not receive any 30 day or 60 day communication about the CAH's investigation after the complaint receipt (4/23/15), per CAH policy.

During interview on 7/8/15 at 2:45 P.M., the QI/RMC and Chief Quality Assurance Officer said that the CAH's policy and procedures were not followed for investigating Patient #29's complaint, nor communicating in a timely manner the receipt of the complaint, the lack of an investigation and outcome with the family member of Patient #29.

2. For Patient #28, the CAH failed to acknowledge receipt of the patient's grievance within 7 business days, failed to investigate the patient's complaint, and failed to provide any final letter to the patient in 30 days or thereafter from the receipt of the grievance, with any information such as the name of the hospital, contact person, steps taken to investigate the grievance, results of the grievance process, and date of completion.

Patient #28 was admitted to the hospital's ED (Emergency Department) on 5/11/15.

Review of the Patient Grievance/Complaint Report, dated 5/12/15, the patient called staff from another local hospital the day after the patient's ED admission at the CAH. Patient #28 reported a verbal complaint of Medical staff mistreatment regarding the CAH's ED Medical staff. Specifically, the complaint alleged:

-an Ed Physician asked the patient to stand and try to walk to which the patient told the Physician that his/her gait was not steady. The patient fell against a curtain and into some medical equipment, resulting in pain to the patient's back and neck. The ED Physician allegedly said to the patient: "Oh, that was my fault,"

-and the patient also stated the ED Physician grabbed the patient's shoulder and came face to face with the patient, saying "you better knock this shit off, these fake seizures or I'll stick a tube down your throat and put you out, I know you know what I'M talking about."

Review of the Grievance/Complaint Report indicated the investigation was assigned to the Chief of Service on 5/12/15 and also reported to the CAH's QI/RMC.

Review of the Complaint Investigation on 7/8/15 indicated no CAH acknowledgement of the complaint with Patient #28, seven (7) business days after receipt of the complaint (i.e., 5/21/15.) There was no evidence the CAH provided any final letter/communication to the patient in 30 days or thereafter from the receipt of the grievance (i.e., 6/13/15), with any information such as the name of the hospital, contact person, steps taken to investigate the grievance, results of the grievance process, and date of completion.

During interview on 7/8/15 at 2:45 P.M., the QI/RMC and Chief Quality Assurance Officer said that the CAH's policy and procedures were not followed for investigating Patient #28's complaint, nor communicating in a timely manner the receipt of the complaint, the lack of an investigation and outcome with Patient #29.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to provide an ongoing program of activities directed by a qualified activities professional, as required. Findings include:

Review of the CAH's Admission Packet and listing of key CAH personnel indicated no reference to an ongoing program of activities for patients, swing bed or otherwise, nor identification of the person coordinating CAH activities.

During interview on 7/7/15 at 9:15 A.M., during the initial CAH tour, the Director of Nursing Services said the CAH did not have an ongoing schedule of activities for patients nor a person assigned to coordinate an activity program.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure a comprehensive assessment for allergic reactions for 1 of 25 sampled in-patients (#2). Findings indicate:

Patient #2 was admitted as a swing bed patient in 6/2015 with diagnoses that included right Total Knee Replacement, Osteoporosis, Osteoarthritis and Gastroesophageal Reflux Disease.

Chart documentation included a facsimile History and Physical (H&P) letter, dated 5/27/14, by the patient's Primary Care Physician. The Primary Care Physician's letter was received by the facility on 6/26/15. The H&P listed Patient #2's allergies, including the antihypertensive medication Hydrochlorothiazide and Latex.

Review of the CAH's list of Patient #2's allergies did not include Hydrochlorothiazide and Latex.

During interview on 7/7/15 at 10:00 A.M., the Director of Nursing Services said that the CAH had not included all of the patient's documented allergies in Patient #2's assessment.