HospitalInspections.org

Based on review of a selected sample of new employees hired within the past 2 years and a
lack of documented evidence, the Critical Access Hospital (CAH) failed to ensure patient safety in non-medical emergencies. The hospital is licensed for 12 acute beds. Findings include:

A. 5 of 5 orientation records of newly hired employees lacked dates of training in non-medical emergencies. The records failed to reflect specific training to ensure, prior to the first day of patient care, new employees were educated in non-medical emergencies, nor did the records reflect the individuals' specific responsibilities in non-medical emergencies.

Based on a review of practitioners' performance evaluations, staff interviews and a comparison of the Medical Staff By-Laws, Rules and Regulations to actual practice, the Governing Body failed to ensure or enforce the current rules governing physician and mid-level practitioners performance in medical record completion. The Medical Staff consists of 2 physicians, 1 physician assistant (PA) and 1 nurse practitioner. The hosptial is licensed for 12 beds. Findings include:

A. On 5/21/12 the Health Information Manager reported 3 clinicians had a total of 34 delinquent medical records. All of these patient records were incomplete past 30 days, after the patient was discharged from the hospital. Physician-A had 22 delinquent medical records, Mid-level practitioner-B had 9 delinquent records and nurse practitioner-C had 3 delinquent medical records.

B. A review of all Active Medical Staff members' reappointment files revealed 1 physician had a history of failure to complete medical records in a timely fashion. The summary report indicated "NO" for timely medical record completion; however, in the section labeled Disciplinary Action nothing was documented.

C. The Medical Staff Rules and Regulations specified that in the event of medical record delinquency, the Practitioner was to receive a letter from the Administrator stating their admitting privileges were revoked pending medical record completion.

D. An interview with the Administrator on 5/22/12 at 1:30 PM confirmed disciplinary action was not taken against all 3 individuals who failed to complete medical records in a timely manner.

Staff interviews, observation, and review of the medication formulary revealed the Critical Access Hospital (CAH) failed to ensure all medications and biologicals are secured/locked up, and failed to ensure outdated or unusable medications and biologicals were not available for patient use pertaining to the crash cart located in Patient Room E, identified as an Intensive Care Unit (ICU-E). The CAH is licensed for 12 beds and had a census of 2 Swingbed patients and 1 acute care patient at survey entrance. Findings include:

A. Observation while on bed count of the CAH with Registered Nurse/Charge Nurse (RN)-1) on 5/21/12 at 11:30 AM revealed ICU-E to have a red 5-drawer crash cart. The crash cart was unlocked holding 37 various medications and biologicals, identified by RN-1 as "being used for patients in case of an emergency." RN-1 then identified the crash cart in ICU-E to have last been used on 5/1/12, allowing the ICU-E crash cart to be unlocked for a total of 21 days. RN-1 stated "the crash cart is only checked and restocked if the lock is broken and medications are used" and is unsure why it isn't locked.

B. Review/ inventory of the medication formulary on 5/21/12 at 11:15 AM with RN-1 of the ICU-E crash cart found the following medications to be outdated and available for patient use.
1. 2-syringes Sodium Bicarbonate 8.4% 50 ml (milliliters) which is an alkalinizer--Expiration date 4/1/;12
2. 2- vials Pronestyl (Procainimide HCL) 500 mg/ml (milligrams per milliliters) which is an antiarrhythmic--Expiration date 4/1/12.

C. Interview on 5/21/12 at 1:00 AM with the Director of Nurses (DON) revealed the medications were outdated but very hard to find/replace. During the survey it was noted the DON disposed of the outdated medications and contacted another facility which replaced the outdated medications.

Based on medical record reviews, staff interviews, review of the Medical Staff Rules and Regulations, and an internal audit of the medical records, the Critical Access Hospital (CAH) failed to ensure 34 closed patient medical records (1-34) were complete and accurately documented within the 30 days allotted in the Medical Staff Rules and Regulations. The 34 delinquent closed medical records included acute care patients, Swingbed patients, observation patients, and emergency room patient records. Medical Doctor (MD)-A had a total of 22 delinquent closed medical records for lack of documentation pertaining to history and physicals, discharge summariess, progress notes, failure to co-sign progress notes and physician medical orders. Physician Assistant Certified (PAC)-B had 9 delinquent closed medical records for lack of documenting final diagnoses, discharge summaries, and dictating history and physicals. Advanced Practice Registered Nurse (APRN)-C had 3 delinquent closed medical records pertaining to the lack of documenting final diagnosis, lack of signatures on history and physicals, co-signing of doctor orders, and progress notes.
The CAH is licensed for 12 beds with 2 Swingbed patient's and 1 acute care patient at survey entrance. Findings include:

A. Review on 5/21/12 at 2:00 PM of the Medical Staff Rules and Regulations #12 reads: "Any medical chart which remains incomplete for fifteen days after dismissal of the patient, shall be called to the attention of the CEO who shall promptly notify the physician that his/her record will become delinquent in 15 days. A medical record is considered delinquent when it has not been completed within 30 days following the patient's discharge.

B. Initial interview with the Health Information Manager (HIM) on 5/21/12 at 3:00 PM presented this surveyor a computer-generated list of 34 delinquent closed patient medical records ranging from 30 days to 94 days delinquent.

Closed delinquent medical record examples for MD-A include:
1. HIM identified closed acute care Patient 1 admitted on 3/25/12 with discharge date of 3/28/12 with pertinent diagnosis of partial bowel obstruction. HIM identified the acute care medical record lacked a history and physical, physician progress notes, co-signing of progress notes dated 3/26/12, and a discharge summary - placing this medical record at 54 days delinquent.
2. HIM identified a closed observation medical record for Patient 3 admitted on 3/13/12 with a discharge date of 3/14/12 with pertinent diagnosis of chest pain. HIM identified the closed medical record lacked a history and physical, and progress notes for 3/14/12 - placing this medical record at 68 days delinquent.
3. HIM identified a closed Swingbed medical record for Patient 8 admitted on 2/21/12 and discharged on 2/27/12. HIM identified the closed Swingbed medical record for Patient 8 lacked a discharge summary, co-signing of doctor's orders and progress notes (dates not identified by HIM)- placing this medical record at 84 days delinquent.

Closed delinquent medical records for PAC-B include:
1. HIM identified closed acute care Patient 23 admitted on 3/07/12 and discharged on 3/13/12 with pertinent diagnoses of poor control of DM ll, stasis ulcer left lower extremity, and rheumatoid arthritis. HIM identified the closed acute care medical record for Patient 23 lacked a final diagnosis, discharge summary and dictated history and physica - placing this medical record at 69 days delinquent.
2. HIM identified closed Swingbed Patient 28 admitted on 3/07/12 and discharged on 3/21/12 with pertinent diagnoses of lower respiratory infection and IV ABX (intravenous antibiotics) with general weakness. HIM identified the Swingbed medical record lacked a history and physical, final diagnosis and discharge summary - placing this Swingbed medical record at 61 days delinquent.
3. HIM identified Patient 30 admitted to an acute care status though the emergency department on 3/30/12 and discharged on 4/4/12 with pertinent diagnosis of acute exacerbation COPD (Chronic Obstructive Pulmonary Disease). HIM identified the closed acute care medical record for Patient 30 lacked a final diagnosis, discharge summary , and signatures on the emergency room form and history and physical - placing this emergency room/acute care medical record at 47 days delinquent.

Closed delinquent medical record examples for APRN-C include:
1. HIM identified Patient 21 admitted on 2/20/12 with discharge date of 2/27/12 with pertinent diagnosis of S/P left hip fracture with pinning, and identified the closed Swingbed medical record as lacking a history and physical, discharge summary and co-signing of progress notes - placing this medical record at 84 days delinquent.
2. HIM identified Swingbed Patient 33 admitted on 2/01/12 and discharged on 2/12/12 with pertinent diagnosis of S/P ORIF right hip fracture, osteoporosis, HTN, and GERD and identified the closed signed medical record as lacking a discharge summary and co-signatures on progress notes - placing this medical record at 94 days delinquent.

Based on staff interview and a lack of documented evidence, the Critical Access Hospital (CAH) Quality Assurance Program failed to include that all services affecting patient health and safety were evaluated. The hospital reported 224 acute care patients for the most recent fiscal year and is licensed for 12 beds. Findings include:

A. An interview conducted with the Administrator on 5/23/12 at 2:30 PM revealed the Quality Assurance program did not include housekeeping services, as required.

B. A review of the most recent Quality Assurance summary of activity failed to include housekeeping.