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Based on record reviews and interview, the Critical Access Hospital failed to ensure each patient received a psychiatric evaluation that described the total appraisal and assessment of the patients illness that included: reaction to the hospitalization, describes attitudes and behaviors, estimates intellectual functioning, memory functioning and orientation, inventory of patients assets in descriptive not interpretive fashion, and strengths and disabilities for 4 (#6, #7, #8, #9) of 4 records reviewed for psychiatric evaluation from a total sample of 20.

Findings:

Review of the policy titled BHU- Psychiatric Evaluation, Number OLG.BHU.0338, dated 05/2022, revealed in part: A. Psychiatric Evaluation should include: 11. Past history of any psychiatric problems and treatment; including previous precipitating factors, diagnosis, and course of treatment. 12. Social and development history. 13. Appearance/behavior, emotional response, verbalization, thought content and cognition of the behavior. 14. Disorders of the perception. 15. Intellectual functioning, memory functioning and orientation. 16. Assets and strengths; in descriptive not interpretive fashion. 17. A provisional or admitting diagnosis at the time of admission and must include the diagnosis of incurrent diseases as well as psychiatric diagnosis. 18. Preliminary treatment plan. 19. Tentative discharge and aftercare.

Patient #6
Review of Patient #6's medical record revealed patient #6 was admitted to the psychiatric unit on 12/02/2022 with a diagnosis of SI, and Anxiety. Review of the Psychiatry Evaluation for patient #6 dated 12/03/2022 revealed no documentation of a total appraisal and assessment of the patients illness that included reaction to the hospitalization, describes attitudes and behaviors, estimates intellectual functioning, memory functioning and orientation, inventory of patients assets in descriptive not interpretive fashion, and strengths and disabilities.

Patient #7
Review of Patient #7's medical record revealed patient #7 was admitted to the psychiatric unit on 12/09/2022 with a diagnosis of Depression. Review of the Psychiatry Evaluation for patient #7 dated 12/09/2022 revealed no documentation of a total appraisal and assessment of the patients illness that included reaction to the hospitalization, describes attitudes and behaviors, estimates intellectual functioning, memory functioning and orientation, inventory of patients assets in descriptive not interpretive fashion, and strengths and disabilities.

Patient #8
Review of Patient #8's medical record revealed patient #8 was admitted to the psychiatric unit on 12/09/2022 with a diagnosis of Depression. Review of the Psychiatry Evaluation for patient #8 dated 12/09/2022 revealed no documentation of a total appraisal and assessment of the patients illness that included reaction to the hospitalization, describes attitudes and behaviors, estimates intellectual functioning, memory functioning and orientation, inventory of patients assets in descriptive not interpretive fashion, and strengths and disabilities.

Patient #9
Review of Patient #9's medical record revealed patient #9 was admitted to the psychiatric unit on 12/11/2022 with a diagnosis of Bipolar, and Depression. Review of the Psychiatry Evaluation for patient #9 dated 12/11/2022 revealed no documentation of a total appraisal and assessment of the patients illness that included reaction to the hospitalization, describes attitudes and behaviors, estimates intellectual functioning, memory functioning and orientation, inventory of patients assets in descriptive not interpretive fashion, and strengths and disabilities.

In an interview on 12/13/2022 at 10:15 a.m. with S5CR confirmed Patients #6, #7, #8, and #9 Psychiatric Evaluation did not contain documentation of a total appraisal and assessment of the patients illness that included reaction to the hospitalization, describes attitudes and behaviors, estimates intellectual functioning, memory functioning and orientation, inventory of patients assets in descriptive not interpretive fashion, and strengths and disabilities.

Based on record review and staff interview, the Critical Access Hospital failed to ensure documentation of a History and Physical examination which included a descriptive neurological examination indicating what tests were performed to assess neurological functioning for 4 (#6, #7, #8, #9) of 4 records reviewed for History and Physical from a total sample of 20. The absence of this information limits the clinician's ability to accurately diagnose the patient's condition and to provide a measure of baseline function, thereby potentially adversely affecting care.

Findings:

Patient #6
Review of Patient #6's medical record revealed patient #6 was admitted to the psychiatric unit on 12/02/2022 with a diagnosis of SI, and Anxiety. Review of the History and Physical dated 12/03/2022 failed to reveal a detailed cranial nerves assessment.

Patient #7
Review of Patient #7's medical record revealed patient #7 was admitted to the psychiatric unit on 12/09/2022 with a diagnosis of Depression. Review of the History and Physical dated 12/10/2022 failed to reveal a detailed cranial nerves assessment.

Patient #8
Review of Patient #8's medical record revealed patient #8 was admitted to the psychiatric unit on 12/09/2022 with a diagnosis of Depression. Review of the History and Physical dated 12/10/2022 failed to reveal a detailed cranial nerves assessment.

Patient #9
Review of Patient #9's medical record revealed patient #9 was admitted to the psychiatric unit on 12/11/2022 with a diagnosis of Bipolar, and Depression. Review of the History and Physical dated 12/12/2022 failed to reveal a detailed cranial nerves assessment.


In an interview on 12/13/2022 at 10:15 a.m. with S5CR confirmed Patients #6, #7, #8, and #9 History and Physical did not contain a detailed cranial nerves assessment.

Based on record review and interview the Critical Access Hospital failed to develop a comprehensive current nursing care plan for 1 (#12) of 4 (#11, #12, #13, #14) patients reviewed for care plans from a total patient sample of 20.

Findings:

Review of the policy titled Documentation of Outcomes and the Nursing Plan of Care, Number OHS.NURS.OS.044, dated 02/07/2022, revealed in part: B. Each patients care plan should address their specific needs.

Patient #12
Review of Patient #12's medical record revealed an admission date of 12/09/2022. Further review revealed Patient #12 was admitted for SOB. Further review revealed Patient #12 had a history of DM. Review of Physicians orders dated 12/09/2022 revealed an order for CBG before meals and nightly, and Insulin U-100 per sliding scale. Review of the plan of care for patient #12 revealed no documentation to identify DM as a problem on the patient's plan of care.

In an interview on 12/13/2022 at 10:15 a.m. with S5CR confirmed patient #12's care plan did not include goals or interventions that addressed DM.

Based on record review and interview the hospital failed to document a properly executed informed consent for anesthesia for surgical patients. This deficiency is evidenced by failure of the medical staff to specify the name of planned anesthesia for 1 (#10) of 1 reviewed anesthesia consent. Findings:

Review of hospital policy OLG.RM.016, "Procedural Informed Consent," revealed in part, "V.B. 2. A properly executed Informed Consent form contains at least the following: . . .c. Name, description and purpose of the specific procedure(s) for which consent is being given."

Review of the surgical record for Patient #2 revealed an esophagogastroduodenoscopy (EGD) was performed on 11/16/2022 under monitored anesthesia care (MAC).

Review of the anesthesia consent revealed "Part 1. Treatment / Procedure- Anesthesia. Description, nature, purpose of anesthesia and/or anesthetic procedure: To provide anesthesia for proposed surgical/ medical procedure. "

Further review of the consent revealed "10. Consent- I hereby authorize and direct the Authorized Physician named and designated in Part 8, together with associates, assistants, and residents of his/her choice, to administer or perform the anesthesia or Anesthetic Procedure described in Part 1, including any additional procedures . . ."

In interview on 12/13/2022 at 2:50 p.m., S4DR verified the name and description of the specific type of anesthesia was not on the consent. S4DR stated it was a system wide policy that the type of anesthesia planned would not be named on the anesthesia consent. The name of the planned anesthesia would only be in the provider's note at the time consent was obtained.



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