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Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to clarify a physician's order for 1 of 2 active swingbed patients (Patient #6) observed during a dressing change. Failure to clarify a physician's order may result in Patient #6 receiving inconsistent and incorrect treatment.

Findings include:

Observation on 06/22/15 at 10:05 a.m. showed a nurse (#2) changed Patient #6's surgical incision dressing on her left hip/leg. During an interview on the morning of 06/22/15, the nurse (#2) stated the medical record lacked clear physician's orders regarding changing the patient's dressing. The nurse (#2) stated she needed direction, so she consulted with another nurse working on the floor and looked at previous nursing progress notes to see what other staff used on the wound.

Review of Patient #6's medical record occurred on 06/22/15 and identified the CAH admitted the patient on 06/09/15 with a post surgical left hip/leg incision. A physician's order, dated 06/09/15, stated, "Daily drsg [dressing] change of LLE [left lower extremity]."

During an interview on 06/22/15 at 3:45 p.m., a nurse (#3) confirmed the medical record lacked a specific order for the dressing change to Patient #6's left hip/leg incision. The nurse (#3) stated, "I wasn't here when the patient was admitted, but I assume our staff continued changing the dressing like how it was when the patient came from [name of a different hospital]."

During an interview on 06/22/15 at 3:50 p.m., an administrative nurse (#1) stated staff should call the medical provider and obtain specific dressing change orders for Patient #6.

Based on record review the Critical Access Hospital (CAH) failed to ensure a complete and accurate medical record for 2 of 6 active patient records (Patient #1 and #2) reviewed. Failure to accurately document residents' falls limited the CAH's ability to track and trend the falls and implement appropriate interventions.

Findings include:

- Review of Patient #2's medical record occurred on 06/22/15. A progress note, dated 03/21/15 at 10:46 p.m., stated, "was called to resident room by CNA [Certified Nursing Assistant] found resident on floor Charge nurse [name] also in room call [sic] provider [name] was here to assess resident. was taken to ER [Emergency Room] per w/c [wheelchair] vitals taken with to ER to be charted." The record lacked documentation of the circumstances surrounding the fall, the patient's vital signs, any signs/symptoms of injury, and the reason staff transported the patient to the ER.

Review of Patient #2's ER record occurred on 06/22/15. The record, dated 03/21/15 at 10:46 p.m. stated, "Resident was found on the floor in her room, the Charge Nurse [name] and [another nurse's name] went to the room and transferred her to the ER. Resident was conscious, no change in mentation. She has pain in the right arm. She was found at 2145 [9:45 p.m.]. She was then taken to the ER. . . . She has a laceration on the top of her head above the forehead. The laceration measures 1.34 [inches] x 1/2 [inch] wide. . . ."

Provider notes, dated 03/21/15 (no time recorded), stated, ". . . Per nursing staff, she was trying to get in bed and she was caught by the bed sheets and then she fell face down on her face where she had a laceration of the middle forehead. She was conscious. She also stated that she had pain and then refused to come sit back in bed. I was in the hospital and she was still laying face down on the left side with her bedspread under her head with minimal bleeding. I did help get her off the floor and put her on a wheelchair to go to the ER. All along she was very agitated, cursing, yelling, refused for anyone to touch her except if there is a healthcare provider present and I told her I was and then she said okay and we went to the ER and put her on the gurney."

Patient #2's medical record failed to identify the patient had become caught in the bedding, had sustained a laceration to her forehead, and the results of the vital signs obtained at the bedside. The record also failed to identify if the patient was alone at the time of the fall, if she complained of pain, and/or had any other symptoms of a potential injury.

Failure to document the complete circumstances of the fall limited staff's ability to evaluate the cause of the fall and implement interventions to prevent additional falls.

- Review of Patient #1's medical record occurred on 06/22/15. A progress note, dated 04/18/15 at 10:52 p.m., stated, "No injury from previous fall." The record lacked documentation of the fall.

An incident report, dated 04/18/15 at 4:38 p.m. stated, "I heard alarms going off and I went to his room and found him on the floor resting his head on his hand and smiling. I asked what happened, he told me he was trying to get up and tripped on the fall matt [sic]."

Review of Patient #1's current care plan, dated 03/06/15 identified a problem: "Risk for falls." Approaches to the problem included: "Fall mat on floor at bedside while in bed." The lack of documentation of the circumstance surrounding the fall contributed to staff's failure to evaluate the continued use of the fall mat to determine if the mat was a safety hazard and may result in additional falls for Patient #1.

Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff maintained individualized care plans for each patient for 3 of 7 active swingbed patient records (Patient #2, #3, #6) reviewed. Failure to develop care plans based on the patients' current needs limited staffs' ability to ensure continuity of care for the patients.

Findings include:

- Patient #3's medical record, reviewed on 06/22/15, identified the patient had a current stage two pressure ulcer to her left ear. The patient's current care plan failed to identify the pressure ulcer and lacked individualized interventions to address this issue.

- Patient #6's medical record, reviewed on 06/22/15, identified the CAH admitted the patient with an indwelling catheter and left post surgical hip/femur incision. The patient's current care plan failed to identify the indwelling catheter and post surgical incision and lacked individualized interventions to address these issues.

- Review of Patient #2's medical record occurred on 06/22/15 and identified the patient experienced a fall on 03/21/15 which resulted in a fractured right patella (knee). Observation on 06/22/15 at 9:20 a.m. showed Patient #2 seated in the dining/activity area with a splint on her right leg. The patient's care plan failed to identify the fracture and lacked individualized interventions to address this issue.

The record also identified a diagnosis of breast cancer. A progress note, dated 05/15/15 at 9:11 p.m., stated, "R) [right] breast is draining yellowish discharge. Nipple hard and red. This is not new occurrence." A physician's order, dated 11/13/14, stated, "Apply dressing to nipple/breast area. Apply guaze [sic] with vaseline to the nipple area on breasts when draining. Then apply a telfa over that area, use paper tape. Document PRN [as needed]" Patient #2's care plan failed to identify the drainage from her right breast and lacked individualized interventions for this issue.

During an interview on 06/22/15 at 3:20 p.m., an administrative nurse (#1) agreed the care plans for Patient #2, #3, and #6 lacked individualized diagnoses/care areas and interventions. The nurse (#1) stated the CAH's electronic medical record generated the patient care plans, but staff have the ability to individualize interventions.