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Tag No.: C0241
Based on staff interviews, and a review of the Medical Staff Bylaws, Rules and Regulations, the Governing Body failed to enforce the Rules and regulations regarding medical record completion by the medical staff.
Findings include:
A. A review of the current Medical Staff Rules and Regulations under Section C. Medical Records, 18. Completion of Records states, "The medical record shall be delinquent if not completed fifteen (15) days following the patient's discharge...any physician shall...automatically lose his privileges to admit new patients."
B. An interview conducted with the Director of the Medical Records Department on 7/9/14 at 10:00 AM revealed three (3) of five (5) active medical staff members had delinquent medical records (Physicians R, C and D).
C. An interview conducted with the Administrator on 7/9/14 at 12:00 noon revealed none of the medical staff with delinquent medical records had been sanctioned as the rules and regulations specified.
Tag No.: C0278
Based on random observations, review of policies and procedures, review of medical records and staff interview, the CAH (Critical Access Hospital) failed to ensure appropriate infection control practices were followed when passing/returning meal trays. Nursing staff failed to utilize appropriate hand hygiene and returned soiled trays back to the same cart which still held meal trays for other patients during 1 of 1 meal observation. These practices have the potential to spread infections to all patients receiving meal trays. Patient census on the first day of survey was 3 acute inpatients and 4 skilled patients.
Findings are:
A. Observation of the noon meal on 7/9/14 from 11:54 AM to 12 Noon with Nurse-KK passing the meal trays to patients revealed the following:
- Nurse-KK went into Room B-16 with meal tray, touched the overbed table to set up meal tray for patient and preceded to pass the meal tray for patient in Room B-20 without washing hands or using hand sanitizer.
- Nurse-KK put on gloves and gown to deliver tray to Patient 33 who was on contact isolation. The gloves and gown were removed and disposed of in the patient room. Nurse-KK left the room walked down the hallway to the medication cart and handled items on top of the cart without washing hands or using hand sanitizer. [The 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting identified the following concerning Contact isolation: precautions taken to prevent the spread of microorganisms by direct or indirect contact with a patient or patient's environment who has an infection; and, Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment.]
- Nurse-KK took a tray into the patient in Room B-20 and placed it on the over bed table in front of the patient. The patient refused the meal tray. Nurse-KK took the tray from the room and placed it in the food cart above trays that still needed to be delivered to other patients. This practice has the potential for contaminating the other trays.
Interview with Nurse-KK on 7/9/14 at 12:05 PM revealed the following:
- Aware that the soiled tray should not have been returned to the cart and placed above the other trays;
- Indicated that was going to nurses area and was going to wash hands.
B. Review of Medical Record 33 revealed a physician order dated 7/1/14 for "Contact Isolation" because of "VRE culture positive" (Vancomycin-Resistant Enterocci - a type of bacteria called enterocci that have developed resistance to many antibiotics, especially Vancomycin. VRE infections are more difficult to treat than other infections because fewer antibiotics can kill the bacteria. VRE and other bacteria can be spread from 1 person to another through casual contact or through contaminated objects.)
C. Review of the policy and procedure titled Isolation Precautions with a revised date of 2/2014 revealed the following under Contact precautions - gloves and hand washing:
- "Wear gloves when entering room."
- "Remove gloves before leaving patients environment and wash hands immediately with anti-microbial agent or a waterless antiseptic agent."
- "After glove removal and hand washing ensure that hands do not touch potentially contaminated environmental surfaces or items in patients room to avoid transfer of micro organisms to other patients or environments."
Tag No.: C0279
Based on record review and staff interview the Critical Access Hospital (CAH) failed to provide a nutritional diet as ordered by the physician for 3 patients (Patients 36, 35 and 24). The facility census was 3 acute inpatients and 4 swing bed. The total sample was 51.
Findings are:
A. Review of the medical record for Patient 36 revealed an admission to swing bed on 5/17/14 for IV (intravenous) antibiotics, IV pain medication and wound care. Review of the Patient 36's medical record revealed:
- Review of the 5/17/14 Physician Progress Note for Patient 36 revealed, "We are trying to supplement (gender) diet with some high-protein foods. I think we will ask dietary to assist us with setting up a meal plan for that. We are limited because of (gender) severe mouth and gum problems with the exposed bone of (gender) lower mandible, and that keeps (gender) from being able to chew anything, but we are going to have to figure out a way to get more proteins in if we are going to try to get the wound healed."
- Review of the 5/19/14 Dental Visit Progress noted revealed "[Patient 36] has several areas of exposed bone (lower left lingual [tongue] and buccal [inner cheek and lip] ridge) and mandibular [lower jaw] anterior. The anterior is infected; however the radiographs (xrays) do not indicate osteomyelitis (bone infection)..."
- Review of Patient 36's diet order dated 5/17/14 revealed the physician ordered a Regular Diet.
- Review of the Nutritional Assessment by the dietitian on 5/22/14 indicated that Patient 36 was receiving a Regular Diet. "Nutrition Therapy Goals as follows: Improve protein status: within 72 to 96 hours. receive adequate nutrition via nutrition support within 24 to 48 hours. Dietitian's Progress Note: Pt (patient) with wound left ankle. Will provide Juven (a dietary supplement to promote wound healing) BID (twice a day) to help promote wound healing. Goal for pt's intake to increase to 75% of meals."
- Review of 5/20/14 and 5/24/14 Trayline Report (forms that dietary use that indicates what diet specifications are used to fix the patients' trays) showed Patient 36's diet listed as Regular Diet, but in hand writing it stated "Puree" (an alteration of the texture of the food to a thick paste used for patients with trouble chewing or swallowing).
An interview with the Patient Care Coordinator on 7/8/14 at 4:40 PM, "No I don't see an order for any diet but Regular for [Patient 36]."
B. Review of the medical record for Patient 35 revealed an admission to swing bed on 3/27/14 for medication adjustment and monitoring of lab work after an ileus (bowel blockage).
a) Review of the Patient 35's medical record revealed:
- Review of Patient 35's diet order dated 3/27/14 revealed the physician ordered a Regular Diet.
Review of the Nutritional Assessment by the dietitian on 4/3/14 indicated that Patient 35 was receiving a Regular Diet. "Nutrition Therapy Goals as follows: Weight maintenance: within 7-10 days. Receive adequate nutrition via nutritional supplements or nourishments. Dietitian's Progress Note: Pt with hypokalemia (low potassium in blood) to receive orange juice with meals. Will order Boost (a nutritional drink) daily to promote adequate nutritional status."
- Review of 4/1/14 and 4/2/14 Trayline Report showed Patient 35 diet listed as Regular Diet, but in hand writing it stated "Puree".
b) Interview with the Patient Care Coordinator on 7/8/14 at 4:40 PM, "No I don't see an order for any diet but Regular for (patient 35)."
C. Review of the medical record for Patient 24 revealed an admission to swing bed on 5/21/14 for IV antibiotics following pneumonia.
a) Review of the Patient 24's medical record revealed:
- Review of Patient 24's diet order dated 5/21/14 revealed the physician ordered a Regular Diet.
- Review of the Nutritional Assessment by the dietitian on 5/22/14 indicated that Patient 24 was receiving a Regular Diet. "Goals and Plan: The patient's nutritional status is adequate. Continue current therapy."
- Review of 5/25/14 and 5/26/14 Trayline Reports showed Patient 24 diet listed as Regular Diet, but in hand writing it stated "Puree".
b) Interview with the Patient Care Coordinator on 7/8/14 at 4:40 PM, "No I don't see an order for any diet but Regular for [Patient 24]."
D. Interview with the Dietary Supervisor on 7/10/14 at 9:21 AM, "Whenever there is anything hand written on the Trayline Report it is a call from the nurses to change the diet."
E. Interview with the Patient Care Coordinator on 7/8/14 at 4:40 PM, "We are supposed to get a physician order, if we are going to need a change in the patient's diet."
Tag No.: C0297
Based on record review, staff interview and review of the Medical Staff Rules and Regulations, the facility failed to ensure verbal and telephone orders were utilized infrequently. A review of Admission orders for 12 inpatient records revealed 6 of the 12 inpatients (Patients 1, 3, 6, 7, 9 and 10) had frequent use of telephone or verbal physician orders from the health care provider. A review of Admission orders for 5 swing bed patient records revealed that 2 of the 5 patients (Patients 32 and 33) had frequent use of telephone or verbal physician orders from the health care provider. This failure had the potential to increase the risk for medication error due to the potential for misunderstanding or incorrect transcription of the providers order. The facility census was 3 inpatients and 4 swing bed on entrance. The total sample size was 51.
Findings are:
A. From a review of 51 patient records (including inpatient, swing bed, observation and outpatients) with their hospital stay ranging between 12/23/13 and 7/10/14 was completed. A random sampling of admission orders from 12 inpatient records revealed:
- Patient 1 was admitted by the health care provider on 7/3/14. The admission orders showed that 22 orders were written by the health care provider and 27 orders were taken either verbally or by phone from the health care provider.
- Patient 3 was admitted by the health care provider on 7/6/14. The admission orders showed that 0 orders were written by the health care provider and 21 orders were taken either verbally or by phone from the health care provider.
- Patient 6 was admitted by the health care provider on 4/6/14. The admission orders showed that 4 orders were written by the health care provider and 13 orders were taken either verbally or by phone from the health care provider.
- Patient 7 was admitted by the health care provider on 5/7/14. The admission orders showed that 0 orders were written by the health care provider and 21 orders were taken either verbally or by phone from the health care provider.
- Patient 9 was admitted by the health care provider on 5/21/14. The admission orders showed that 24 orders were written by the health care provider and 13 orders were taken either verbally or by phone from the health care provider.
- Patient 10 was admitted by the health care provider on 6/11/14. The admission orders showed that 0 orders were written by the health care provider and 33 orders were taken either verbally or by phone from the health care provider.
A random sampling of admission orders from 5 swing bed records revealed:
- Patient 32 was admitted by the health care provider on 7/4/14. The admission orders showed that 0 orders were written by the health care provider and 21 orders were taken either verbally or by phone from the health care provider.
- Patient 33 was admitted by the health care provider on 6/30/14. The admission orders showed that 0 orders were written by the health care provider and 24 orders were taken either verbally or by phone from the health care provider.
B. A review of the 2013 Medical Staff Rules and Regulations for the facility noted under the section titled "GENERAL CONDUCT OF CARE" that "(4) Verbal and telephone orders shall be used only when necessary and as infrequently as possible."
C. An interview with the Patient Care Coordinator on 7/8/14 at 3:30 PM revealed, "I see what you are saying about the telephone and verbal orders. Our providers have been trained in using the computer for inputting the orders. I know that some of our doctors prefer to give us the order verbally or by telephone and not put them into the computer themselves."
D. An interview with Licensed Practical Nurse (LPN)-J on 7/10/14 at 7:30 AM revealed, "When a patient switches status from acute to swing bed the doctor gives us a verbal order. We then print the orders from the acute status and send them to the pharmacy. We make the changes the doctor ordered and put them in the computer and recheck all the orders and the times."
Tag No.: C0302
Based on staff interview, record review and review of current Medical Staff Rules and Regulations, the Critical Access Hospital (CAH) failed to:
Part 1:
- Accurately document the times that the Anesthesia Services provided a pre and/or post surgery visit for 6 of 12 surgical patients (Patients 14, 15, 17, 18, 26 and 27).
Part 2:
- The medical staff failed to follow the rules and regulations related to medical record completion.
The facility census was 3 acute patients and 4 Swing Bed patients. The total sample was 51.
Findings are:
PART 1
A. Patient 14 had a Right Olecranon (the pointy bone at the back of the elbow) bursectomy (removal of the bursa-a small fluid-filled sac) on 3/31/14 from 9:23 AM -10:14 AM. The medical record showed that the pre and post anesthesia visits were completed, but were not documented in block charting (a type of charting that incorporates the activities provided to the patient in a continuous charting method, and does not identify the specific time each activity was provided) not giving the times that the visits were completed.
B. Patient 15 had a laparoscopic cholecystectomy (removal of the gall bladder through small incisions in the abdominal wall while using a scope to visualize the area) on 4/1/14 from 6:47 AM-8:36 AM. The medical record showed that the pre and post anesthesia visits were completed, but were documented in block charting, not giving the times that the visits were completed.
C. Patient 17 had an adenotonsillectomy (removal of the tonsils and adenoids) on 5/15/14 from 8:00 AM-9:08 AM. The medical record showed that the pre anesthesia visit was completed, the time the visit occurred was not documented. The post anesthesia visit was completed and documented timely.
D. Patient 18 had a laparoscopic cholecystectomy on 2/4/14 from 10:16 AM-11:20 AM. The medical record showed that the pre anesthesia visit was completed, the time the visit occurred was not documented. The post anesthesia visit was completed and documented timely
E. Patient 26 had an adenotonsillectomy (removal of the tonsils and adenoids) on 6/6/14 from 10:22 AM-10:56 AM. The medical record showed that the pre anesthesia visit was completed, the time the visit occurred was not documented. The post anesthesia visit was completed and documented timely.
F. Patient 27 had dental care requiring general anesthesia, including exam, cleaning, xrays and needed repair on 6/13/14 from 12:20 PM-2:18 PM. The medical record showed that the pre anesthesia visit was completed, the time the visit occurred was not documented. The post anesthesia visit was completed and documented timely.
G. Interview with the Certified Registered Nurse Anesthetist (CRNA) A on 7/9/14 at 4:05 PM stated, "I can see that I didn't put the times in there that the visits [pre and post anesthia] were completed. We tried that block charting and have stopped that and are doing paper charting on our Anesthesia Record forms now. I will see there is a blank for the times, I guess I just didn't get it put in there."
H. Review of the Policy for Anesthesia #2001 revealed:
- Preanesthetic Care: The CRNA must perform a preoperative evaluation of patients scheduled for surgery.... A statement on the Anesthesia Record will reflect the pre-anesthesia assessment, plan of anesthesia care and a discussion with the patient and family regarding anesthesia options, ricks and alternatives. Documentation must include date, time and signature of anesthetist.
- Post Anesthesia record shall be completed by the CRNA immediately in the postoperative care area with the information properly documented, dated and the times.
04526
PART 2
Based on staff interview and a review of the current Medical Staff Rules and Regulations, the medical staff failed to follow the rules and regulations related to medical record completion.
Findings include:
A. A review of the current Medical Staff Rules and Regulations states on page 7 under " C. Medical Records" item 18 "Completion of Records" stated, "The medical record shall be delinquent if not completed fifteen (15) days following the patient's discharge."
B. An interview conducted with the Director of Medical Records on 7/9/14 at 10:00 AM revealed a total of 11 patient medical records were delinquent. The facility reported a total annual acute inpatient census of 295 for fiscal year 2013 and an acute inpatient census of 3 on the first survey day (Record numbers 41, 42, 43, 44, 10, 46, 47, 48, 49, 50 and 51).
Tag No.: C0322
Based on record review, review of pre-stamped progress notes and staff interview, the CAH (Critical Access Hospital) failed to ensure a physician examined the patient for the risk of the procedure immediately prior to surgery for 2 of 12 (Patients 26 and 27). The facility census was 3 inpatients and 4 swing bed patients.
Findings are:
A. Review of Patient 26's medical record revealed the patient had an adenotonsillectomy (removal of the tonsils and adenoids) on 6/6/14 from 10:22 AM-10:56 AM. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.
B. Review of Patient 27's medical record revealed the patient had dental care requiring general anesthesia, including exam, cleaning, xrays and needed repair on 6/13/14 from 12:20 PM-2:18 PM. Review of the entire medical record revealed the record lacked evidence of a physician examination immediately before surgery to evaluate the risk of the procedure to be performed.
C. Review of the Policy # SUR2047 "Anesthesia Risk and Evaluation by Qualified Practitioner reviewed 6/03 was completed. The policy revealed:
- Surgical patients shall be evaluated by a physician immediately pre-operatively and post-operatively.
- Upon completion of these evaluations, the pre-op evaluation form will be signed and completed and be a part of the patients chart.
- A pre-stamped History and Physical (H&P) form stated, "PREOPERATIVE EVALUATION BY PHYSICIAN: The patient was examined prior to surgery to evaluate the risk of anesthesia and the procedure to be performed. Heart and lungs have been assessed. Patient condition is satisfactory for anesthesia and surgery. H&P REVIEWED PRIOR TO SURGERY NOTHING HAS CHANGED IN THE INTERVAL." The surgeon signs and dates and times the form.
D. An interview with the Medical Records Assistant (MR)-B on 7/8/14 at 10:20 AM revealed, "I looked in [Patient 26's] record and there isn't a pre physician visit documented before the surgery."
E. An interview with the Medical Records Director on 7/8/14 at 4:30 PM revealed, "I know why the Certified Registered Nurse Anesthetist (CRNA) did (Patient 27's) pre physician visit. The doctors at the Medical Staff meeting last year discussed it and they felt that the CRNA was more qualified then a dentist to assess the heart and lungs because they do it all the time."
Tag No.: C1001
Based on review of the Patient Bill of Rights brochure and staff interview, the Critical Access Hospital failed to inform each patient of their visitation rights. The facility census was 3 inpatients and 4 swing bed on entrance. The total sample size was 51.
Findings are:
A. Review of the Patient Education information provided to all patients on admission revealed a brochure titled "Patient Bill of Rights". The brochure revealed, "You have the right to have visitors. You have the right to refuse any visitor."
B. Review of the Patient Visitation Rights Policy and Procedure dated 9/24/13 revealed under II Policy:
(A) Statement of Patient Visitation Rights. Prior to care being provided the Hospital shall inform each patient of his or her rights (or his or her support person/representative) in writing of Patient's visitation rights, patient's right to receive the visitors who he or she designated, including, but not limited to, a spouse, a domestic partner (including a same sex partner), another family member, or a friend, patient rights to withdraw or deny such consent at any time; and any Hospital Restriction which may be imposed on patient's visitation rights, all visitors chosen by the patient (or his or her representative) must be able to enjoy "full and equal" visitation privileges consistent with the wishes of the patient (or his or her representative).
C. Interview with Social Services (SS)-B on 7/9/14 at 2:05 PM stated, "We have a policy that states the information about visitation including the domestic partner (same sex partner) verbiage, but we didn't put it into the brochure we give the patients. We will, if we have to."