HospitalInspections.org

Based upon interview and record review, the facility failed to ensure the records are legible, complete, accurately documented, readily accessible, and systematically organized related to Patient Code Status for Life Sustaining Treatment for one patient [Patient #14] of 20 sampled patients.
Findings include:

Review of Medical Records for Patient #14 treated at Porter Medical Center [PMC] reveal the patient signed a Do Not Resuscitate/ Clinician Orders for Life Sustaining Treatment [DNR/COLST] form dated 11/5/21 which listed the patient as "DNR/Do Not Attempt Resuscitation (allow natural death)" with the order signed by a physician.
The DNR/COLST order was electronically entered into the Porter Medical Center electronic medical record system on 11/12/21, and the same order again entered into the system on 1/3/22.
Review of Medical Records for Patient #14 for Porter Medical Center [PMC] include the patient's Code Status History.
The PMC Code Status History for Patient #14 records:
11/11/21: Limitation of Treatment. The history records the order changed to 'inactive' on 12/10/21, though there is no new written order to replace/change it.
12/10/21: Full Code. The history records the order as then 'inactive' on 12/13/21. Next on the Code Status History, on the same date, 12/13/21, the Full Code is then listed as 'active', then 'inactive' on 12/31/21.
Review of Advance Care Planning Documents for Patient #14 record on 1/3/22 PMC 'received' the patient's DNR/COLST form, which was the physician's order dated 11/5/21 [and first 'received' on 11/12/21] that ordered the patient as "DNR/Do Not Attempt Resuscitation (allow natural death)".
The PMC Code Status History records on the same date, 1/3/22, that Patient #14's code status is "Full Code", with the status 'active' until 1/25/22.
On 1/25/22, the PMC Code Status History records the patient's status as 'Limitation of Treatment" and the status 'active'.
Review of Hospitalist notes from Porter Medical Center, dated 1/25/22 record Patient #14's code status as "Full Code", noting the patient is returning to the nursing home the following day.
Review of Palliative Care Physician notes from Porter Medical Center on the same day, 1/25/22, record "This visit included a regular follow up visit and an advance care planning visit discussing CODE status and reaffirming DNR, DNI status". Further review of the Palliative Physician notes reveals Patient #14 "understands that if he is very sick he would want to be left alone to a peaceful death and not end up on machines."

Further review of Patient #14's medical record reveals on 1/28/22, at approximately 8:30 PM, "patient was found unresponsive. Unable to determine code status at this time. Provider on call notified. Stated to follow last code status order."
Per review of Patient #14's Medical Record on 3/16/22, listed under Questions for Most Recent Historical Code Status (Order 224847216-dated 1/25/22):
"Question-
When the patient has NO PULSE: Answer- DNR
When the patient HAS A PULSE and is in respiratory distress/failure: Do not intubate (DNI)
Who Made the Decision? Patient".
Further review of Patient #14's medical record for 1/28/22 reveals "Administrator on call notified, stated due to current circumstances to initiate CPR [Cardiopulmonary Resuscitation] and call 911. Initiated CPR at approximately 8:45. Transferred to PMC ER @ 9:10 via ambulance."
The PMC Emergency Room Physician writes: "Per report, pt had previously been DNR/DNI but then had reverse it and was full code." The physician records the patient was then intubated, and later expired at 9:24 PM. The Physician also includes "After the patient's death, the patient's chart was reviewed more extensively, and it appears that as of 1/25/2022, his CODE STATUS was LLST [Limited Life Saving Treatment]/DNR/DNI."
The PMC Code Status History for Patient #14 records the patient's Limitation of Treatment status, initiated on 1/25/22, now listed as 'inactive' on 1/26/22.

Review of PMC's medical record for Patient #14 reveals on 1/26/22, a Physician attending the patient at the nursing home recorded regarding the patient's Code Status "He does not want to talk about it. FULL." And "COLST Complete? No". There is no accompanying order recording the patient as a Full Code.
Further review of PMC's medical record for Patient #14 reveals Physician notes regarding the patient being found unresponsive on 1/28/22 record "[staff] from [nursing home] calls on call at 8:43 PM on 1/28/22 stating that [Patient #14] has been unresponsive for the last 6 minutes. We have reviewed available COLST form. [Staff] reports Patient is a DNR."

An interview was conducted with PMC's Chief Nursing Officer [CNO] and the Director of Quality Safety and Performance Improvement [DQS] on 3/16/22 at 12:35 PM. The CNO and DQS confirmed that Patient #14's medical record included conflicting documentation regarding the patient's code status on the same date[s] on multiple occasions and from multiple sources.

Based on observation and staff interview the Critical Access Hospital (CAH) failed to store medical records in a manner that safeguarded against loss, destruction, and unauthorized use at three locations (Main Campus, Clinic A, and Clinic B). Findings include:

1. During a tour on 3/14/2022, at 3:00 PM of the attic area of Porter Hospital where paper medical records were stored, piping with sprinkler heads were noted to be hanging above the shelving. These records were uncovered and there was a potential for water damage from the sprinkler system and/or damage from fire. During an interview with the Director of Health Information Management (HIM) on 03/15/22 at 3:00 PM, S/He confirmed that the medical records were not stored in a maintained location where records must be protected.

2. During a tour of primary care Clinic A on 3/14/2022 at 3:30 PM accompanied by the Practice Manager, paper medical records were observed to be stored in the basement on open wooden shelves underneath copper piping and valves. The Practice Manager confirmed the records were not stored in a protected manner to assure they sustained no damage from water or fire.

3. During a tour of a podiatry Clinic B on 3/14/2022 at 10:30 AM and accompanied by a staff technician, x-ray medical records were observed in an unprotected wooden shelf behind the front office space. Office staff confirmed the records were not stored in a manner to protect them from fire or water damage.

Based on observation and interview the CAH failed to ensure that the methods for preventing and controlling the transmission of infections were followed during the cleaning and disinfecting of patient equipment. Findings include:

Per observation on 3/15/22 at 12:50 PM, a Registered Nurse (RN) began cleaning a scope that was used to perform a colonoscopy (A procedure in which a flexible fiber-optic instrument is inserted through the anus to examine the colon.) in a treatment room. The RN finished cleaning the scope, removed his/her gloves and without sanitizing his/her hands, donned a new pair of gloves. The nurse left the treatment room with the soiled scope, brought it into the dirty utility area of central sterile supply, touched several areas in the dirty utility area and then removed his/her gloves and washed his/her hands. Per interview on 3/15/22 with the RN at that time, S/He confirmed that hand hygiene needs be done each time gloves are removed and prior to new gloves being donned.

Per interview on 3/15/22 at 3:55 PM with the Infection Preventionist, S/He also confirmed that hand hygiene must be done after gloves are removed.

Per review of the policy "Guidelines for Hand Hygiene"-approved 9/2020, it states "2. If hands are not visibly soiled, use alcohol-based hand rub for routinely decontaminating hands ...or alternatively wash hands with antimicrobial soap and water ...: a. Before having direct contact with patients. b. Before donning gloves ...g. after contact with inanimate objects (including medical equipment) ...h. After removing gloves".

Based on interview and record review the CAH failed to develop policies and procedures that ensured the implementation of additional precautions and contingency plans intended to mitigate the transmission and spread of COVID-19 for all staff who were not fully vaccinated for COVID-19. Findings include:

Per review of the policy, "COVID-19 Vaccine Policy"-effective 11/12/21, it states, "Monitoring and Documentation ...Employee Health or Human Resources will notify employees' leaders of approved reasonable accommodations, including weekly testing, as necessary. They will not share any additional information with the leader". There was no evidence of what the additional approved reasonable accommodations and contingency plans would be to mitigate the transmission and spread of COVID-19 for staff who are not fully vaccinated for COVID-19.

Per interview on 3/16/22 at approximately 9:30 AM with the Director of Quality, Safety, and Performance Improvement, S/He stated that the CAH had "other COVID-19" policies that guided the mitigation and contingency plans for unvaccinated staff. During an interview 3/16/22 at 1:29 PM, with the Director of Accreditation and Regulatory Affairs for the Jeffords Institute for Quality, S/He confirmed that the staff vaccination policies did not contain the required elements of the regulation.

Based on interview and record review the CAH failed to develop comprehensive policies and procedures for Swing Bed residents that prohibit and prevent, abuse, neglect, exploitation, and misappropriation of property. Findings include:

Per review of the policy, "Identification and Reporting of Suspected Abuse (Domestic, Child, and Vulnerable Adult)"-approved 11/2020. There was no evidence that the policy and/or procedure contained the time frame in which allegations involving abuse, neglect, exploitation, or mistreatment, to include injuries of an unknown origin and misappropriation of residents' property were reported, and to the required officials. There was also no indication of the process in which these allegations were to be fully investigated and if substantiated the appropriate corrective action that would be taken.

Per interview on 3/16/22 at 1:52 PM with the Chief Medical Officer (CMO), S/He stated that the CAH policies govern the Swing Bed residents and confirmed that the above policy did not "align" with the regulations.