HospitalInspections.org

Based on review of records and interview, the Critical Access Hospital failed to ensure that the verbal physician orders were dated, timed, and authenticated within 48 hours by the prescriber or another practitioner/physician who was responsible for the care of 4 of 19 patients (Patients #15, #16, #22, and #24) who received treatment and/or services at the hospital from 11/24/10 through May 2011.

Findings included:

Patient #15 -
1) The physician's verbal order for "250 ml ns (normal saline) bolus..." was received on 02/26/11 at 02:00 AM. The physician authenticated the 02/26/11 verbal order on 03/20/11 at 04:45 PM, approximately 23 days after the verbal order was received.

2) The physician's verbal orders that included "stop all medications...remove ventilator...continue comfort measures..." were received on 02/27/11 at 01:00 PM. The physician authenticated the 02/27/11 verbal orders on 03/20/11 at 04:45 PM, approximately 22 days after the verbal orders were received.

Patient #16 -
1) The physician's verbal orders that included "Zofran...Morphine..." were received on 12/07/10 at 11:45 AM. The physician authenticated the 12/07/10 verbal orders on 12/17/10 at 08:00 AM, approximately 10 days after the verbal orders were received.

2) The physician's verbal orders that included "...Physical Therapy: Evaluation and Treatment...Occupational Therapy..." were received on 12/09/10 at 09:40 AM. The physician authenticated the 12/09/10 verbal orders on 12/17/10 at 08:00 AM, approximately 8 days after the verbal orders were received.

Patient #22 -
1) The physician's verbal order for daily physical therapy was received on 03/25/11 at 04:30 PM. The physician authenticated the 03/25/11 verbal order on 05/02/11 at 05:00 PM, approximately 38 days after the verbal order was received.

Patient #24 -
1) The physician's verbal order to discontinue physical therapy was received on 03/22/11 at 02:00 PM. The physician authenticated the 03/22/11 verbal order on 04/05/11 at 11:15 AM, approximately 14 days after the verbal order was received.

During a joint interview at approximately 11:00 AM on 05/26/11, the Interim Chief Nursing Officer (Personnel #3), Emergency Room/Intensive Care Unit Director (Personnel #4), and Medical Records Director (Personnel #25) reviewed the above medical records with the surveyors and agreed that the physician's verbal orders were not authenticated within the required 48 hours from when the verbal order was received.

The "Authorized Entries in the Medical Record" policy revised by the Critical Access Hospital March 2011 noted, "...Verbal/telephone orders should be authenticated, dated, and timed within 48 hours..."

Based on observation, review of records, and interview, the pharmacy failed to inspect the Critical Access Hospital's crash cart emergency drug storage areas in that 2 of 4 emergency crash carts did not contain a listing of drugs that were available for use during a medical emergency and the Pharmacist failed to review and initial the "Medication Storage Area Evaluation" that included the inspection of these two crash carts. This practice could present a risk of potential harm for all patients, visitors, and staff that were in need of emergency services while in the hospital. The Critical Access Hospital did not follow their own policy and procedure.

Findings included:

During a tour of the Critical Access Hospital at approximately 10:00 AM on 05/24/11, the surveyors observed that there was no medication listing of the medications available in the two medical/surgical emergency crash carts. When this was brought to the nursing staff's attention, the medication lists were requested from and produced by the pharmacy department to be added to the emergency stock of medications available on each of the two medical/surgical crash carts.

The Pharmacy's "Medication Storage Area Evaluation" forms noted the "MS" and "MS2" (Medical/Surgical) units were inspected monthly from January 2011 through April 2011. The "Medication Storage Area Evaluation" had signature lines that were not signed by the nurse and initialed by the pharmacist. There was no documentation on these forms that the "Emergency Medication Supply (crash cart)" medication listings were missing from the two crash carts surveyed on 05/24/11.

During an interview at approximately 03:00 PM on 05/24/11, the Pharmacist (Personnel #15) was asked if she had reviewed the pharmacy's "Medication Storage Area Evaluation" for January 2011 through April 2011. The Pharmacist said that she did not review these forms and agreed that she had not initialed the forms as part of the hospital's inspection of the drug storage areas that included inspection of the hospital's crash carts.

The Critical Access Hospital's "Emergency Drugs (Crash Carts)" policy PS-08-02 effective August 2010 noted, "The Director of Pharmacy should ensure the availability of a sufficient inventory... approved emergency drugs in the...patient care areas...A list of the approved drugs should be maintained in the pharmacy and will be readily available wherever the emergency drug containers are stored..."

Based on review of records and interview, the Critical Access Hospital's medical records were not complete in that the medical record entries for 13 of 19 patients (Patients #1 through #5, Patients #7 through #10, Patient #12, Patient #21, Patient #23, and Patient #24) who received medical services at this Critical Access Hospital from November 24, 2010 through April 23, 2011 were not timed, dated, and/or signed according to their own policy.

Findings included:

The "History and Physical" physician's signature was not dated and timed for the following patients:
Patient #4 - Transcribed 03/14/11 10:35 AM, signature not dated and timed.
Patient #21 - Transcribed 12/13/10 09:18 AM, signature not dated and timed.
Patient #23 - Transcribed 12/13/10 01:48 PM, signature not dated and timed.

The "Progress Note" physician's signature was not dated and/or timed for the following patients:
Patient #4 - Progress note 03/13/11 transcribed 03/14/11 10:15 AM, signature not dated and timed.
Patient #21 - Progress note 12/12/10 transcribed 12/13/10 01:02 PM, signature not dated and timed.
Patient #23 - Signature dated 12/13/10, physician did not time.

The "Fluid Restriction" form was not signed and/or timed by the person entering the information for the following patients:
Patient #21 - Dated 12/11/10 at 08:00 PM, not signed.
Patient #24 - Dated 03/20/11, not signed and timed.

The "Fall Risk Assessment Scoring Tool" nurse's signature was not timed for the following patient:
Patient #10 - Assessed 04/13/11, signature not timed.

The Radiology "Contrast Media Questionnaire Form" was not signed, dated, and/or timed by the physician, registered nurse, and/or radiology technician for the following patient:
Patient #4 - Radiology Technician signature dated 03/13/11 was not timed. There was no signature by a physician or registered nurse with date and time of signatures as required.

The Radiology "Contrast Media Authorization" witness signature was not dated and timed for the following patient:
Patient #4 - Patient signed 03/13/11 at 11:15 AM, witness signature was not dated and timed.

The "RRRH Surgery Discharge Instructions" form was not signed by the nurse with date and time noted for the following patient:
Patient #1 - "EGD" 03/25/11, nurse did not sign, date, and time the form as required.

The "Perioperative Nursing Assessment" nurse and/or physician signatures were not dated and/or timed for the following patient:
Patient #2 - Surgical procedure left 5 th digit 04/04/11, "Pre-OP RN" and Circulator RN signatures were not dated and timed, Physician's signature was not timed.

The "Out Patient Nursing Care Plan" nurse signatures were not dated and timed for the following patient:
Patient #2 - Surgical procedure left 5 th digit 04/04/11, "Pre-OP" and "Post-OP" nurse signatures were not dated and timed.

The "Certificate of Medical Necessity" physician's signature was not timed for the following patient:
Patient #3 - Physician's signature dated 04/01/11 was not timed.

The "Certification of Medical Screening Examination (MSE)" physician's signature was not dated and/or timed for the following patients:
Patient #3 - Date In 04/01/11, Physician's signature timed 10:00 AM with no date.
Patient #5 - Date In 04/16/11, Physician's signature dated 04/16/11 not timed.

The "Emergency Department" template physician's signature was not dated and/or timed for the following patients:
Patient #5 - Patient label dated 04/16/11, Physician's signature not dated and timed.
Patient #9 - Patient label dated 04/06/11, Physician's signature not dated and timed.
Patient #12 - Patient label dated 12/03/10, Physician's signature not dated and timed.

The "Order Procedure Form Medical Emergencies" physician's signature was not dated and timed for the following patient:
Patient #9 - Date of visit 04/06/11, Physician's signature not dated and timed.

The "Order Procedure Form Genitourinary Emergencies" physician's signature was not dated and timed for the following patient:
Patient #12 - Nurse signature 12/03/10 11:40 AM, Physician's signature not dated and timed.

The "Plan of Care" nurse's signature was not timed for the following patient:
Patient #12 - Nurse signed implementation of plan 12/03/10, signature not timed.

The "Restraint Flow Chart" nurse's signature was not dated and timed for the following patient:
Patient #12 - Dated 12/04/10, Nurse's signature was not dated and timed.

The "Physician's Admit Orders" nurse's signature was not dated and timed for the following patient:
Patient #10 - Date ordered 04/09/11, nurse's signature not dated and timed.

The "Physician Orders" were not signed, dated, and timed by the physician for the following patient:
Patient #23 - Orders dated and timed 12/12/10 10:40 AM, physician did not sign with date and time of signature.

The "Inpatient Pneumococcal/Influenza Order Form" nurse's signature was not dated and timed for the following patient:
Patient #10 - Patient label dated 04/09/11, Nurse signatures were not dated and timed.

The form "Provided by American Heart Association's National Registry of CardioPulmonary Resuscitation" signatures were not dated and timed for the following patient:
Patient #7 - Time event recognized in Emergency Room was 12:33 PM on 12/01/10, the Recorder, Nurse, and individual "ICU/Code Team" signatures were not dated and timed. The Physician's signature was not dated and timed.

The "Transfusion Record" nurse signatures were not dated and timed for the following patient:
Patient #8 - Date blood issued 03/03/11 02:40 PM, the nurse signatures were not dated and timed by the nurse obtaining the blood and the two nurses identifying the blood when administered. Date blood issued 03/03/11 05:00 PM, the nurse signatures were not dated and timed by the nurse obtaining the blood and one of the two nurses identifying the blood when administered.

The "Initial Assessment Form" nurse signature was not dated and timed for the following patient:
Patient #24 - Date of visit 03/20/11, nurse's signature was not dated and timed.

The "Disclosure and Consent Medical and Surgical Procedures" witness signature was not dated and timed for the following patient:
Patient #24 - Patient signed 03/20/11 10:55 AM, witness signature was not dated and timed.

The "Pre-op and Post-op Check list" was not signed by the nurse with date and time of signature for the following patient:
Patient #24 - Patient label dated 03/20/11, nurse did not sign with date and time of signature.

During a joint interview at approximately 11:00 AM on 05/26/11, the Interim Chief Nursing Officer (Personnel #3), Emergency Room/Intensive Care Unit Director (Personnel #4), and Medical Records Director (Personnel #25) reviewed the above medical records with the surveyors and agreed that the medical records were not complete in that signatures were missing and/or the signatures were not dated and/or timed.

The "Authorized Entries in the Medical Record" policy revised by the Critical Access Hospital March 2011 noted, "Medical record entries will be legible and complete...All entries in the medical record are dated, timed, its author identified, and when necessary, authenticated.."

Based on record review and interview, the facility did not provide an ongoing program of activities for 1 of 2 patients (Patient #16), in that there was no evidence in the medical record of activities being provided to the patient.

Findings included:

1) Review of the medical record for Patient #16, a Swing Bed patient, who was in the facility in February of 2011, did not include any documentation that Patient #16 was assessed or offered activities.

2) Review of the personnel file for the Activities Director (Personnel #21) included that she had been with the facility since November of 2010.

3) In an interview at 09:00 AM on 05/25/11, the Quality Assurance/Risk Manager (Personnel #1) was asked if there was any other documentation of activities for Patient #16. Personnel #1 stated that there was none and confirmed the surveyors' findings.