HospitalInspections.org

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to assure all physicians that provided services for the CAH are licensed and credentialed. The CAH failed to verify the license and credentials of one of six physicians who provided services for the CAH (staff F).


Findings include:

- Clinical records reviewed between 2/2/11 and 2/8/11 revealed Staff F interpreted a diagnostic test. The license verification and credentialing information provided by the CAH on 2/9/11 revealed a current license for medical staff F, but lacked any other professional data. Staff C confirmed the CAH failed to credential medical staff F.

Staff C interviewed on 2/9/11 at 9:40am revealed the CAH failed to assure Staff F held a physician's license prior to the interpretation of the diagnostic testing.

The failure to credential Staff F and verify the physician's current licensure prior to the provision of services has the potential to have an unqualified person interpret medical information and participate in the health care of a patient.

Based on medical record review and staff interview, the Critical Access Hospital, (CAH) failed to ensure the physician reviews and signs all records for patients cared for by the mid-level practitioner. The deficient practice effected five of five patients seen by the mid-level practitioner in the emergency department (ED) (patient #'s 1, 2, 5, 6 and 7).

Findings include:

- Patient #1's clinical record revealed an ED visit on 12/9/10 with assessment and treatment by the mid-level practitioner. The clinical record lacked evidence of the physician reviewing the clinical record.

- Patient #2's clinical record revealed an ED visit on 11/8/10 with assessment and treatment by the mid-level practitioner. The clinical record lacked evidence of the physician reviewing the clinical record.

- Patient #5's clinical record revealed an ED visit on 6/21/10 with assessment and treatment by the mid-level practitioner. The clinical record lacked evidence of the physician reviewing the clinical record.

- Administrative staff C, interviewed on 2/9/11 at 2:30pm confirmed the CAH lacks a policy requiring the physician to review the clinical records of out-patients or emergency department patients cared for by the mid-level practitioner.

- The Medical Staff Bylaws, reviewed on 2/9/11 at 3:30pm directs "2.5 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP", "(e) periodically reviewing and signing the records of patients care for by nurse practitioners,...".

The CAH failed to ensure the physician reviewed and signed all clinical records of patients who received care and treatment provided by the mid-level practitioner. The deficient practice also affected patient's #'s 6 and 7.

Based on document review and interview, the Critical Access Hospital (CAH) failed to assure all clinical records are complete and failed to assure all clinical records are protected from possible destruction or or unauthorized.

Findings include:


- The CAH failed to assure clinical records are complete and accurately documented as evidenced at
C-302, CFR 485.638(a)(2).

- The CAH failed to follow written physician orders and failed to notify the physician when the orders not in accordance with manufacturers' recommendations as evidenced at C-306 CFR 485.638(a)(4)(iii).

- The CAH failed to endure providers dated and timed all entries in the medical record when authenticated (signed) as evidenced at C-307 CFR 485.638(a)(4)(iv).

- The CAH failed to maintain confidential patient information and protect from unauthorized use or destruction as evidenced at C-308 CFR 485.638(b)(1).

Based on clinical record review and staff interview, the Critical Access Hospital (CAH) failed to assure clinical records are complete and accurately documented. The deficient practice of incomplete clinical records affected two of two patients who received blood transfusions (patient #'s 13 and 19).

Findings include:

- Patient #13's clinical record revealed an admission date of 9/24/10 with diagnosis of pregnancy. The physician ordered a blood transfusion to be administered on 9/27/10. The blood administration record lacked evidence identifying the nurse that administered the blood.

- Patient #19's clinical record revealed an admission date of 1/6/11 with diagnoses including pneumonia and congestive heart failure. The physician ordered a blood transfusion on 1/7/11. The blood administration record lacked evidence identifying the nurse that administered the blood.

- Staff D, interviewed on 2/8/11 at 12:30pm, confirmed the lack of signatures of a nurse on the transfusion record of the staff member that administered the blood.

- CAH policy titled "Blood/Components Transfusion" lacked instruction to identify the staff member accountable for the blood transfusion.

The CAH failed to assure complete documentation of the blood transfusions including the nurse(s) responsible for the transfusion.

Based on clinical record review and staff interview, the Critical Access Hospital (CAH) failed to follow written physician orders and failed to notify the physician when the order is not written in accordance with manufacturers' recommendations.

Findings include:

- Patient #3's clinical record, reviewed on 2/2/11 at 1:25pm, revealed the patient was admitted to the Emergency Department on 9/16/10 with diagnoses including short of air and pain. A unidentified CAH staff member created a list of medications the patient takes at her home. The list includes Duragesic Patch 125mg (milligrams) changed daily, last changed 9/15/10. Physician G ordered the patient to be admitted and to continue with medications given at home. The Medication Administration Record, created upon admission, directed staff to administer Duragesic Patch 125mcg (micrograms), and to change the patch every 72 hours. The licensed CAH staff failed to notify the physician of the failure to follow the orders. A nurse changed the patch 9/18/10. The patient discharged from acute care to swing bed status on 9/19/10.

Review of the manufacturer's prescribing information revealed the patch is available in microgram dosing and is continuous dosing for 48 to 72 hours while patient is wearing the patch.

Staff D, interviewed on 2/9/11 at 11:40am confirmed the CAH failed to transcribe the physician orders as written and failed to notify the physician the orders were not followed as ordered.

Based on policy review, medical record review and staff interview the Critical Access Hospital (CAH) failed to ensure providers dated and timed all entries in the medical record when authenticated (signed) for 33 of 33 patient medical records reviewed
# 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,
32,and 33.

Findings include:

- Review of Health Information's policy,"Confidentiality of Patient's Records", on
2/9/11 at 3:15pm directed, all entries will be signed and dated. The CAH failed to include in their policy that all entries in the medical record are timed.

- Patient #20's medical record reviewed on 2/2/11 revealed an admit date of 1/26/11 to swing bed status. Patient #20's medical record revealed between 1/26/11 and 2/2/11, two verbal orders and one progress note that lacked a date and time when signed by the provider.

- Patient #21's medical record reviewed on 2/2/11 revealed an admit date of 11/19/10 to
swing bed status. Patient #21's medical record revealed between 11/19/10 to 11/23/10,
admission orders on 11/19/10 signed by the provider and dated and timed by some one else,
one telephone order on 11/22/10, signed by the provider and dated and timed by some one else, one telephone order on 11/22/10 lacked a date and time when signed by the provider, and on 11/23/10 one verbal order signed by the provider and dated and timed by some one else.

Staff C interviewed on 2/3/11 at 10:30pm acknowledged the providers did not date and time
their signature's, some one else dated and timed the provider's signature.

- Patient #31's medical record reviewed on 2/3/11 revealed an admit date of 12/25/10.
Patient #31's medical record revealed between 1/25/11 to 1/27/11, a History and Physical signed by the provider, dated and timed by some one else, admission orders signed and dated by the provider, not timed, and three verbal orders signed by the provider, dated and timed by someone else.

Staff E interviewed on 2/7/11 at 3:15pm verified the provider signs the entries in the medical
record and health information management staff dated and timed the signature when the provider hands them the medical record.

- Patient #10's clinical record revealed an admission date of 8/5/10 with diagnoses including
heart and respiratory problems. The entire clinical record was previously reviewed during a
complaint survey 8/30/10- 9/2/10. Comparison of the previously reviewed record and the clinical record presented 2/3/11 at 3:00pm revealed the addition of a discharge summary to the record. The summary, dictated and transcribed on 8/30/10, was signed by the practitioner and dated by someone else on 8/6/10 at 3:46pm- 26 days before it was dictated and transcribed.

Medical record supervisor staff C, interviewed on 2/3/11 at 9:50am confirmed the document
appeared to be signed before it was created.

Physician C, interviewed on 2/3/11 at 12:05pm confirmed his/her signature on the document and the discrepancy of when the document created and the date and time authenticate, which was written by someone else.

Progress note, "Date 8/5/10 8:20am" was added to the clinical record after the record had been reviewed on 8/30/10-9/2/10. The progress note, signed by the physician, lacked the date and time authenticated. Medical record supervisor staff C, interviewed on 9/2/11 at 9:50am stated the document was dictated sometime in November 2010 and typed.

Progress note "Dated 8/6/10", reviewed during the previous survey, was presented by the CAH in the complete clinical record. The progress note had been changed with the signature
appearing in a different place in the document. The practitioner failed to date and time the
authenticating signature. An addendum was made to the 8/6/10 entry. The addendum lacked
the date of dictation and transcription. The practitioner signed the addendum, but failed to
date and time the entry into the clinical record.

- Patient #1's clinical record revealed an Emergency Department (ED) admission on
12/9/10. A mid-level practitioner H performed the Medical Screening Examination and determined the patient did not have an emergency medical condition. The CAH provided treatment and discharged the patient home. Mid-level practitioner H failed to date and time the authenticating signature on the ED record.

- Patient #2's clinical record revealed an ED admission on 11/8/10. Mid-level practitioner H
performed a medical screening examination and determined the patient had an emergency
medical condition. The CAH provided treatment and transferred the patient to another hospital. Practitioner H failed to date and time the authenticating signature on the ED record.

- Patient #10's clinical record revealed an admission date of 8/5/10 with diagnoses including heart and respiratory problems. The entire clinical record was previously reviewed during a complaint survey 8/30/10- 9/2/10. Comparison of the previously reviewed record and the clinical record presented 2/3/11 at 3:00pm revealed the addition of a discharge summary to the record. The summary, dictated and transcribed on 8/30/10, was signed by the practitioner and dated by someone else on 8/6/10 at 3:46pm- 26 days before it was dictated and transcribed.

Medical record supervisor staff C, interviewed on 2/3/11 at 9:50am confirmed the document appeared to be signed before it was created.

Physician C, interviewed on 2/3/11 at 12:05pm confirmed his/her signature on the document and the discrepancy of when the document created and the date and time authenticate, which was written by someone else.

Progress note, "Date 8/5/10 8:20am" was added to the clinical record after the record had been reviewed on 8/30/10-9/2/10. The progress note, signed by the physician, lacked the date and time authenticated. Medical record supervisor staff C, interviewed on 9/2/11 at 9:50am stated the document was dictated sometime in November 2010 and typed.

Progress note "Dated 8/6/10", reviewed during the previous survey, was presented by the CAH in the complete clinical record. The progress note had been changed with the signature appearing in a different place in the document. The practitioner failed to date and time the authenticating signature. An addendum was made to the 8/6/10 entry. The addendum lacked the date of dictation and transcription. The practitioner signed the addendum, but failed to date and time the entry into the clinical record.

- Patient #1's clinical record revealed an Emergency Department (ED) admission on 12/9/10. A mid-level practitioner H performed the Medical Screening Examination and determined the patient did not have an emergency medical condition. The CAH provided treatment and discharged the patient home. Mid-level practitioner H failed to date and time the authenticating signature on the ED record.

- Patient #2's clinical record revealed an ED admission on 11/8/10. Mid-level practitioner H performed a medical screening examination and determined the patient had an emergency medical condition. The CAH provided treatment and transferred the patient to another hospital. Practitioner H failed to date and time the authenticating signature on the ED record.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to maintain confidential patient information and protect from unauthorized use or destruction.

Findings include:

- Observation of a storage area in the basement on 2/7/11 at 12:25pm and random observations during the survey revealed an unsecured door to a room with 13 boxes of patient information including diagnoses, laboratory testing results and identifying information. Random observations from the hallway by the door revealed several community members using the hall as a walking area without staff present.

Staff C, interviewed on 2/8/11 at 12:30pm confirmed patient information is to be protected from authorized loss, use or destruction. Staff C confirmed the storage of patient information is in an unsecured area. Staff C confirmed community members use the hallway to walk.

Administrative staff A, interviewed on 2/9/11 at 9:45am, confirmed the CAH failed to protect the confidential patient information placed in the unlocked, unattended room from potential loss, misuse or destruction.

- Observation of the CAH's laboratory, on 2/8/11 at 3:40pm revealed the door to the room was unlocked with a sign on the door handle directing to "push". The room was unattended at the time the observation was made. Observation in the laboratory work area revealed patient information including names, other identifying information and laboratory results on a work table and hanging on the wall.

Supervisory staff I interviewed on 2/9/11 at 9:15am confirmed the laboratory failed to protect patient information and lacked a procedure to assure patient information is protected.

Based on policy review, medical record review and staff interview the Critical Access Hospital (CAH) failed to assure a written History and Physical (H&P) was placed on the medical record prior to surgery and signed by the surgeon for 3 of 5 sampled surgical patient records reviewed (#'s 25, 27, and 28).

Findings include:

- Review of the CAH's policy, "Outpatient Surgery Requirements", on 2/9/11 at 2:50pm directed a History and Physical (H&P) is one of the requirements that must be completed before outpatient surgery is performed. The CAH failed to include in their policy the requirement that the H&P is on the medical record prior to surgery and signed by the surgeon.

- Patient #25's medical record reviewed on 2/8/11 revealed an admit date of 12/15/10 for a simple mastectomy surgical procedure. Patient #25's medical record revealed the patient was in the operating room on 12/15/10 at 8:34am. The record revealed an H&P typed on 12/15/10 at 9:36am an hour and two minutes after the patient entered the operating room. Staff H, mid-level practitioner, signed the H&P and someone else dated and timed the H&P an hour and 33 minutes before it was typed. The surgeon failed to review and sign the H&P.

- Patient #27's medical record reviewed on 2/8/11 revealed an admit date of 11/10/10 for a left inguinal hernia repair surgical procedure. Patient #27's medical record revealed the patient was in the operating room on 11/10/10 at 8:10am. The record revealed an H&P typed on 11/10/10 at 9:22am an hour and 12 minutes after the patient entered the operating room. Staff H, mid-level practitioner, failed to date and time the H&P when signed. The surgeon failed to review and sign the H&P.

- Patient #28's medical record reviewed on 2/8/11 revealed an admit date of 11/10/10 for a left breast biopsy surgical procedure. Patient #28's medical record revealed the patient was in the operating room on 11/10/10 at 9:55am. The record revealed an H&P from the clinic dated 10/15/10. The surgeon signed they reviewed the H&P on 11/10/10 at 3:21pm, four hours and 26 minutes after the patient entered the operating room.

Staff E interviewed on 2/8/11 at 11:50am acknowledged staff H, mid-level practitioner, performed and dictated the H&P for patient #25 and #27 the morning of their surgery. Staff E confirmed the medical record lacked the typed H&P on it before the patient went to surgery and the surgeon failed to sign they reviewed the H&P for patient #25 and #27.

- Medical Staff Bylaws, reviewed on 2/9/11 at 3:30pm fail to direct the physician to assure a History and Physical examination is documented, signed by the surgeon and included in each non-emergent surgical patient's clinical record prior to surgery.