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Based on document review and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to:

Create medical record documentation policies and procedures that clearly outline and define documentation expectations to assure each patient's medical record contained all physician orders, nursing notes, and other pertinent information necessary to monitor a patient's progress and provide appropriate care by following the CAH's written policies.
Please refer to C-1006 for additional information.

The cumulative effect of these failures and deficient practices resulted in the CAH's inability to ensure the nursing staff provided health care services in accordance with the CAH's policies to ensure the CAH staff provided safe and appropriate patient care, which could potentially result in patient harm or death. The hospital's administrative staff identified a census of 8 patients upon entrance.




II. During the investigation of incident 90745-I, the survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patient's at risk) related to the Condition of Participation for Provision of Services (42 CFR 485.635).

1. The administrative staff failed to initially develop and implement a corrective action plan to ensure all patients had a complete medical record with all pertinent information for other care providers to access/retrieve to provide safe and appropriate care of all CAH patients.

2. The survey team identified an Immediate Jeopardy (IJ) situation and notified the administrative staff on 5/4/2020 at 3:00 PM. The administrative staff took action to remove the immediacy of the situation. The hospital staff removed the immediacy prior to the survey team exiting the complaint investigation when the administrative staff took the following actions:

a. The administrative staff updated the procedure for all nursing staff to consistently document in the medical record, under the provider notification tab in IVIEW, any notification from staff to an attending provider that the patient's family or friends have information or a concern that the patient has exhibited suicidal ideation and/or may harm herself or himself. Upon notification, the provider will evaluate the patient and document findings. After evaluation is completed, appropriate interventions will be carried out.

b. On 5/5/2020, the administrative staff educated staff on this process. Emails were sent to all staff.

c. The administrative staff updated procedures for patients who have a current substance abuse issue, regardless of the admission diagnosis, the Hospital expectations of staff (nursing and/or providers) will be as follows: Providers will document their assessment in the EMR per the provider preference. Nursing: the Depression Screening Questionnaire/EMR tool will be completed. If positive, the Detailed Depression Screening Questionnaire/EMR tool will be completed. Appropriate notification and/or referrals will be made if needed.

d. On 5/5/2020, the hospital educated staff on this process. Emails were sent to all staff.

e. The hospital documented that staff are aware of the process and staff have acknowledged the review of the same.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure 2 of 5 patients (Patient #1 and Patient #2) had a complete and accurate medical record when the CAH staff failed to provide policies and procedures that clearly defined documentation expectations and guidelines to assure a patient's record contained appropriate documentation of a practitioners' orders, interventions, findings, assessments, records, notes, reports and other information necessary to monitor a patient's condition and when staff failed to follow existing CAH policies. Failure to provide clearly defined documentation policies and procedures could result in incomplete and inadequate documentation needed for a patient's health care providers to provide for appropriate care, potentially resulting in patient harm or death. The CAH's administrative staff identified an inpatient census of 8 on entrance.

Findings included:

1. Review of the Medical Staff Rules and Regulations - 2019, revealed in part, "Medical Staff shall be responsible ... for the prompt completeness and accuracy of the medical record ... a completed medical record shall include ... orders; progress notes ... Pertinent progress notes shall be recorded at the time of observation sufficient to permit continuity of care and transferability..."

2. Review of the Health Information Policy "Contents of a Completed Medical Record", effective 12/2019, revealed in part, "Purpose ... assure content of the medical record is sufficiently detailed ... to enable the practitioner responsible for the patient to provide continuing care ... determine later what the patent's condition was at a specific time ... the patient's response to treatment.... assure adequate documentation for another practitioner to assume care of the patient at any time ... assure adequate documentation for retrieval of pertinent information ... items to be contained in a completed medical record..physician orders ... progress notes ... sufficient to show clear chronological picture of patient's condition ... any changes and results ... Nursing Notes ... contain pertinent, meaningful information and observations ..."

3. Review of the Nursing Policy "Clinical Documentation in the Electronic Medical Record (EMR)", effective 11/2019, revealed in part, "Documentation of patient care .. [should be] done in real time (e.g. immediately following provision of that care) ... Clinical documentation is done in the EMR as defined per department-specific policies...Procedure: Documentation- Complete required forms, document assessment in the EMR." The policy failed to provide any guidance to the nursing staff regarding information the hospital expected the nursing staff to document.

4. Review of Nursing Policy "Documentation of Nursing Care", effective 10/2019, revealed in part "purpose of documenting patient care ... communicate the patient's progress to personnel involved in the patient's care, provide a legal record ... Procedure: Use the most current documentation form ... Make all entries concise and timely..." The policy failed to provide any guidance to the nursing staff regarding information the hospital expected the nursing staff to document.


5. During an interview on 5/5/2020 at 2:20 PM, Registered Nurse (RN) B the CAH staff admitted Patient #1 to the hospital 4/20/20. RN B revealed Patient # 1's family member came to the hospital in the afternoon on 4/22/2020. Patient #1's family member informed RN B that a bottle of pills and an illegible note written by Patient #1 was found in Patient #1's residence. Patient #1's family member had concerns that Patient #1 may have intended to hurt themselves or still intend to hurt themselves.

Patient #1's family member spoke with RN B and requested that RN A, Patient #1's nurse, call Patient #1's family member when RN A finished providing care to Patient #1. RN A provided care to Patient #1 the day prior, and Patient #1's family member had previously spoken with RN A. RN B informed RN A about Patient #1's family member's concerns and that Patient #1's family member requested that RN A contact them.

Physician C, Patient #1's doctor, visited Patient #1 after Physician C's office closed for the day. RN B and RN A notified Physician C about Patient #1's family member's concerns prior to Physician C visiting Patient #1.

RN B acknowledged they failed to document the conversation RN B had with Patient #1's family members, that Patient #1's family member had concerns that Patient #1 might harm themselves, and Physician C visited Patient #1 in the evening in Patient #1's medical record.


6. During an interview on 4/30/20 at 3:00 PM, RN A verified that RN B told RN a that Patient #1's family member had visited the hospital on the afternoon of 4/22/20. RN B informed RN A that Patient #1's family member had requested RN A to call Patient #1's family member when RN A had time. When RN A called Patient #1's family member, Patient #1's family member informed RN A they had concerns about a bottle of pills and a note found in Patient #1's residence. Patient #1's family member had not read the note yet, but was concerned the note was possibly a suicide note.

RN A called Physician C, Patient #1's doctor, and informed Physician C about Patient #1's family member's concerns that Patient #1 may have suicidal thoughts. Physician C ordered RN A to enter a consult order for the CAH's social services to assess Patient #1 and informed RN A that Physician C would visit Patient #1 after Physician C's office hours. RN A contacted behavioral health and left a voicemail notifying the Social Worker about the consult order for Patient #1.

Physician C visited Patient #1 late on 4/22/20, after Physician C's office hours. Physician C spoke with Patient #1 about the bottle of pills and directly asked Patient #1 if they tried to hurt themselves. Patient #1 denied trying to harm themselves.

The Social Worker called RN A late on 4/22/20. The Social Worker informed RN A they had spoken with Patient #1's family member on the afternoon of 4/22/20 and Patient #1's family member indicated the note found in Patient #1's residence was not a suicide note. The Social Worker agreed to try to see Patient #1 on 4/23/20 (the next day).

RN A acknowledged they failed to document the phone conversation with Patient #1's family member, Patient #1's family member's concerns about Patient #1 possibly having suicidal thoughts, the phone conversation with Physician C, notifying Physician C about Patient #1's family member's concerns, that Physician C visited Patient #1 on 4/22/20 after clinic hours, the content of Physician C's conversation with Patient #1, the phone call with the Social Worker, or the content of RN A's call with the Social Worker in Patient #1's medical record.


7. During an interview on 4/28/20 at 1:42 PM, Physician C revealed RN A notified Physician C that Patient #1's family member expressed concern about the bottle of pills and note found in Patient #1's residence, and that Patient #1's family member was concerned Patient #1 would harm themselves. Physician C ordered RN A to consult the Social Worker and informed RN A that Physician C would visit Patient #1 after Physician C's office hours that day. Physician C arrived at the hospital around 6:30 PM to 7:00 PM on 4/22/20. Physician C spoke with Patient #1 and discussed the pill bottle and note found at Patient #1's residence. Patient #1 assured Physician C they were not trying to harm themselves. Patient #1 requested Physician C order the nursing staff to remove Patient #1's Foley catheter. After leaving Patient #1's room, Physician C ordered RN A to remove Patient #1's Foley catheter.

Physician C acknowledged they failed to document the conversation with Patient #1 about Patient #1 wanting to hurt themselves or document the order for the nursing staff to remove Patient #1's Foley catheter.


8. Review of Patient #1's medical record revealed the CAH staff admitted Patient #1 on 4/20/20 for treatment of possible pneumonia. Patient #1's medical record lacked documentation of the information described by RN A, RN B, and Physician C, including the concerns of Patient #1's family member that Patient #1 may have had suicidal thoughts. Patient #1's medical record also lacked documentation of Physician C's order to remove Patient #1's Foley catheter.


9. During an interview on 5/8/20 at approximately 10:00 AM, the Acute Care Director expected the nursing staff to document the care they provided to Patient #1, document the information the nursing staff received from Patient #1's family member, and the interactions between Patient #1 and Physician C. The Acute Care Director acknowledged the nursing staff failed to document this information in Patient #1's medical record.


10. During an interview on 4/28/20 at approximately 10:49 AM, the CNO/Assistant Administrator revealed the CAH nursing staff used "documentation by exception." (Documentation or Charting by Exception (CBE) is a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail.) The CNO/Assistant Administrator felt the use of documentation by exception for the nursing documentation did not provide sufficient information to allow someone reading the patient's medical record to understand what care the CAH staff provided to the patient.


11. During an interview on 5/7/20 at approximately 1:00 PM, the CNO/Assistant Administrator and Acute Care Director acknowledged the CAH lacked a policy instructing the CAH nursing staff to utilize the "documentation by exception" method of charting patient care.

12. During an interview on 5/8/20 at approximately 10:00 AM, CNO/Assistant Administrator and Acute Care Director acknowledged the CAH lacked documentation policies and procedures that provided clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. The CAH's existing policies and procedures failed to provide direction to the CAH staff regarding how to document patient care/assessments or exceptions to the CAH's predefined normal ranges for patient assessments. The CAH's administrative staff had not created a written expectation for how the CAH staff should document patient care or assessments.

13. Review of Patient #2's open medical record on 5/7/20 at approximately 3:00 PM, facilitated with Acute Care Director and CNO/Assistant Administrator, revealed the nursing staff completed a Detailed Depression Screening Questionnaire on Patient #2, with a total screening score of 6. The screening tool's guidance revealed for scores of "5-9 = notify Social Services of potential depression".

At the time of the record review, the CNO/Assistant Administrator revealed the CAH's electronic medical record provider created the guidance for the CAH's staff in the Detailed Depression Screening Questionnaire. The CAH staff could not change the verbiage in the scoring section, and the CAH did not have Social Services available to assess patients for depression. Since the CAH lacked the ability to perform a depression screening by Social Services, the CNO/Assistant Administrator did not expect the nursing staff to notify anyone if the Questionnaire indicated the staff should notify Social Services.

The CNO/Assistant Administrator and Acute Care Director acknowledged the CAH lacked any written procedure or guidance for the nursing staff on how to complete the Detailed Depression Screening Questionnaire or what actions they expected the nursing staff to take if the patient had possible signs of depression.


14. During an interview on 5/7/20 at approximately 3:00 PM, the Acute Care Director acknowledged the CAH lacked a policy that identified what type of information required physician notification, such as elevated depression scores, changes in a patient's condition, or critical lab values. The CAH also lacked a policy identifying where the nursing staff should document the information in the patient's medical record.


15. During an interview on 5/8/20 at 9:14 AM, the HIM Manager (Health Information Management, the department ultimately responsible for a patient's medical record at the CAH) revealed they expected the CAH staff to document the care provided to patients at the CAH. If the CAH staff failed to document the care they provided to a patient, the staff were assumed to not have provided that care to the patient.