HospitalInspections.org

The Critical Access Hospital (CAH) reported an average daily census of 2.87 with a current census of five skilled swing bed patients. Based on Medical Staff Credentialing file review, Medical Staff Bylaws review, and staff interview the CAH medical staff failed to examine credentials and make recommendation to the Governing Body on appointment to the medical staff for one of eleven medical staff credentialing files reviewed (Physician Staff G). The failure of the CAH to examine credentials and make recommendations on medical staff can lead to poor patient outcomes and affect all patients in the CAH.

Findings include:

- The CAH's policy titled "MEDICAL STAFF BYLAWS OF DECATUR HEALTH SYSTEMS, INC." reviewed on 9/10/15 at 10:15am directed "...reappointments and appointments after the completion of provisional status shall be for a period of two Medical Staff years... "

- Physician Staff G's credentialing file reviewed on 9/10/15 at 1:10pm revealed a reappointment date of 8/20/12. The Governing Body failed to ensure Physician Staff G, listed as the hospital's Chief of Staff, had a current reappointment to the medical staff.

Medical Records Staff H interviewed on 9/10/15 at 2:20pm acknowledged Physician Staff G's reappointment was missed in 2014. Medical Records Staff H reported that Physician staff reappointment is done at the annual meeting in November.

The Critical Access Hospital (CAH) reported a current census of five skilled swing bed patients. Based on observation, staff interview, and policy review the CAH staff failed to ensure compliance with hand hygiene for one of one observed dressing change (Staff C) and the CAH failed to have personal protective equipment (PPE) available for one of three flushable basins (used to rinse soiled items) located in the utility room in surgical services. This deficient practice had the potential for spread of infection to patients of the CAH.

Findings include:

- The CAH policy titled "Isolation Precautions" reviewed on 9/9/15 at 1:30pm directed staff "...mask, eye protection, face shield-wear mask and eye protection ...activities that are likely to generate splashes...Gown-wear a gown to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, sections and excretions...hand hygiene is again performed when changing gloves, after taking off gloves..."

- Observation during a tour of surgical services on 9/9/15 between 11:00am and 11:45am revealed a utility room with a flushable basin. The utility room lacked PPE including gowns, gloves, and masks.

Registered Nurse Staff B interviewed on 9/9/15 at 11:45pm acknowledged the lack of accessible PPE near the flush basin.

- Registered Nurse Staff C observed on 9/10/15 at 10:00am performed a dressing change on Patient #33. Staff C failed to perform hand hygiene between glove changes.

Registered Nurse Staff C interviewed on 9/10/15 at 10:15 acknowledged they failed to perform hand hygiene between glove changes.

The Critical Access Hospital (CAH) reported an average daily census of 2.87 with a current census of five skilled swing bed patients. Based on medical record review, Medical Staff Bylaws, and staff interview the CAH failed to ensure medical records are complete within 30 days for five of twelve sample patients (patient's # 18, 20, 21, 25, and 30). The failure of the CAH to ensure medical records are complete has the potential to lead to poor patient outcomes for patients admitted to the CAH.

Findings include:

- The CAH's "MEDICAL STAFF BYLAWS OF DECATUR HEALTH SYSTEMS, INC." reviewed on 9/10/15 at 10:15am directed "...a notification of delinquent medical records will be given to the practitioner and the Board of Trustees after warning of delinquency for failure to complete medical records within thirty (30) days of a patient's discharge... "

- Patient #18's medical record reviewed on 9/9/15 revealed an admission date of 5/11/15 with a diagnosis of Cellulitis of Right Knee (infection of the skin) with a discharge on 5/15/15. The medical record revealed a discharge summary dated 7/19/15 (66 days after discharge). Patient #18's medical record failed to be completed within 30 days after discharge.

- Patient #20's medical record reviewed on 9/2/15 revealed an admission date of 7/2/15 with a diagnosis of New Onset Progressive Decubitus Ulcer (deterioration of the skin causing open wound) with a discharge on 7/6/15. The medical record lacked a discharge summary. Patient #20's medical record failed to be completed within 30 days after discharge.

- Patient #21's medical record reviewed on 9/9/15 revealed an admission date of 6/25/15 with a diagnosis of acute hypoxic respiratory failure (sudden loss of sufficient oxygen in the body) with a discharge on 6/30/15. The medical record lacked a discharge summary. Patient #21's medical record failed to be completed within 30 days after discharge.

- Patient #25's closed medical record reviewed on 9/9/15 revealed an admission on 6/26/15 and discharged to skilled swing bed on 6/30/15 with a diagnosis of Left Lower Lobe Pneumonia. Patient #25's medical record revealed a History and Physical dictated by the provider on 8/18/15 (49 days after discharge). Patient #25's medical record failed to be completed within 30 days after discharge.

- Patient #30's closed medical record reviewed on 9/9/15 revealed an admission on 7/6/15 and discharge on 7/9/15 with diagnoses of decreased mental status and hypoglycemia (low blood sugar). Patient #30's medical record revealed a history and physical completed on 8/10/15 (31 days after discharge). Patient #30's medical record failed to be completed within 30 days after discharge.

Administrative Staff A interviewed on 9/9/15 at 2:45pm acknowledged Patient #'s 18, 20, 21, 25, and 30 charts were not complete within 30 days. Administrative Staff A reported they have been having difficulty getting providers to dictate History and Physicals on time as well as Discharge Summaries.

The Critical Access Hospital (CAH) reported an average daily census of 2.87 patients with a current census of five swing bed patients. Based on medical record review, staff interview and lack of policy for review the CAH failed to ensure ten of twenty sampled inpatient medical records (patient #'s 13, 15, 18, 21, 24, 25, 26, 27, 28, and 30) contained a pertinent medical history and physical (H & P) completed in a timely manner. The CAH's failure to ensure patients' medical history and physical are competed in a timely manner has the potential for poor patient outcomes.

Findings include:

- Patient #13's closed medical record reviewed on 9/9/15 revealed an admission date of 4/9/15 with a diagnosis of hyperglycemia and discharged on 4/13/15. Patient #13's medical record revealed a history and physical completed on 4/13/15 (96 hours after admission). The CAH failed to ensure completion of Patient #13's history and physical within the required 48 hours after admission.

- Patient #15's closed medical record reviewed on 9/9/15 revealed an admission date of 8/20/15 with diagnoses of fever and vomiting with a discharge on 8/21/15. Patient #15's medical record revealed a history and physical completed on 9/6/15 (17 days after admission). The CAH failed to ensure completion of Patient #15's history and physical within the required 48 hours after admission.

- Patient #18's medical record reviewed on 9/9/15 revealed an admission date of 5/11/15 and discharge date of 5/15/15 with diagnoses of right knee cellulitis (infection in the cells), nausea, vomiting, and left jaw pain. Patient #18's medical record revealed a history and physical dictated 7/19/15 (69 days after admission). The CAH failed to ensure completion of Patient #18's history and physical within the required 48 hours after admission.

- Patient #21's medical record reviewed on 9/9/15 revealed an admission date of 6/25/15 and discharge date of 6/30/15 with a diagnosis of acute hypoxic respiratory failure. Patient #21's medical record revealed a History and Physical dictated on 6/29/15 (4 days after admission). The CAH failed to ensure completion of Patient #21's history and physical within the required 48 hours after admission.

- Patient #24's closed medical record reviewed on 9/9/15 revealed an admission on 4/2/15 and discharged to skilled swing bed on 4/7/15 with a diagnosis of PE (Pulmonary Embolism - blood clot in the lung). Patient #24's medical record revealed a history and physical dictated by the provider on 4/24/15 (22 days after admission). The CAH failed to ensure completion of Patient #24's history and physical within the required 48 hours after admission.

- Patient #25's closed medical record reviewed on 9/9/15 revealed an admission on 6/26/15 and discharged to skilled swing bed on 6/30/15 with a diagnosis of Left Lower Lobe Pneumonia. Patient #25's medical record revealed a history and physical dictated by the provider on 8/18/15 (53 days after admission). The CAH failed to ensure completion of Patient #25's history and physical within the required 48 hours after admission.

- Patient #26's current medical record reviewed on 9/8/15 revealed an admission to skilled swing bed on 9/4/15 with diagnoses of fever, mental status change, and abnormal x-ray. Patient #26's medical record lacked a History and Physical by the provider (4 days after admission). The CAH failed to ensure completion of Patient #26's History and Physical within the required 48 hours after admission.

- Patient #27's current medical record reviewed on 9/8/15 revealed an admission to skilled swing bed on 9/4/15 with diagnoses of urinary tract infection, pyelonephritis (kidney infection), and fever. Patient #27's medical record lacked a history and physical by the provider (4 days after admission). The CAH failed to ensure completion of Patient #27's history and physical within the required 48 hours after admission.

- Patient #28's current medical record reviewed on 9/8/15 revealed an admission to skilled swing bed on 8/30/15 with diagnoses of chest pain and bradycardia (slow heart rate). Patient #28's medical record lacked a history and physical by the provider (8 days after admission). The CAH failed to ensure completion of Patient #28's history and physical within the required 48 hours after admission.

- Patient #30's closed medical record reviewed on 9/9/15 revealed an admission date of 7/6/15 with diagnoses of decreased mental status and hypoglycemia (low blood sugar) with a discharged on 7/9/15. Patient #30's medical record revealed a history and physical completed on 8/10/15 (35 days after admission). The CAH failed to ensure completion of Patient #30's history and physical within the required 48 hours after admission.

Administrative Nursing Staff A interviewed on 9/9/15 at 2:35pm indicated the facility was aware they had a problem getting history and physicals as well as discharge summaries completed timely.

- The CAH's Medical Staff Rules and Regulations reviewed on 9/10/15 failed to direct practitioners on the requirement to complete medical history and physicals within 48 hours after admission.

The Critical Access Hospital (CAH) reported an average daily census of 2.87 with a current census of five swing bed patients. Based on medical record review, staff interview, and lack of policy for review the CAH failed to ensure compliance of dating and timing twelve of twenty sampled inpatient medical records (Patients #'s 11, 13, 16, 17, 18, 19, 20, 21, 22, 24, 25, and 29). The CAH's failure to ensure all entries into the medical record are dated and timed has the potential to cause medication errors.

Findings include:

- Patient #11's medical record reviewed on 9/9/15 revealed an admission date of 8/15/15 with a diagnosis of probable Pulmonary Embolism (blood clot in the lung). The medical record revealed two telephone/verbal orders that lacked a date and/or time when the practitioner co-signed the order.

- Patient #13's medical record reviewed on 9/9/15 revealed an admission date of 4/9/15 with a diagnosis of hyperglycemia (elevated blood sugar). The medical record revealed five physician orders written on 1/19/15 that lacked a time when written and six telephone/verbal orders that lacked a date and/or time when the practitioner co-signed the order.

- Patient #16's medical record review on 9/9/15 revealed an admission on 1/10/15 with a diagnosis of hemorrhagic stroke and discharged on 1/27/15. Patient #16's medical record revealed fifteen verbal or telephone orders that lacked a date and/or time when the practitioner co-signed the order.


- Patient #17's medical record review on 9/9/15 revealed an admission on 12/8/14 with a diagnosis lung cancer and discharged on 1/4/15. Patient #17's medical record revealed nine verbal or telephone orders that lacked a date and/or time when the practitioner co-signed the order.


- Patient #18's medical record reviewed on 9/9/15 revealed an admission date of 5/11/15 with diagnoses of Cellulitis of Right Knee (infection of the skin) and a discharge on 5/15/15. The medical record revealed seven written physician orders that lacked a time when written and four telephone/verbal orders that lacked a date and time when the practitioner co-signed the order.

- Patient #19's medical record reviewed on 9/9/15 revealed an admission date of 8/25/15 with a diagnosis of acute blood loss anemia (condition where a person quickly loses blood in the body) and discharged on 8/28/15. The medical record revealed two written physician orders that lacked a time when written and six telephone/verbal orders that lacked a date and/or time when the practitioner co-signed the order.

- Patient #20's medical record reviewed on 9/2/15 revealed an admission date of 7/2/15 with a diagnosis of New Onset Progressive Decubitus Ulcer (deterioration of the skin causing open wound) with a discharge on 7/6/15. The medical record revealed three written physician orders that lacked a time when written.

- Patient #21's medical record reviewed on 9/9/15 revealed an admission date of 6/25/15 with a diagnosis of acute hypoxic respiratory failure (sudden loss of sufficient oxygen in the body) and discharged on 6/30/15. The medical record revealed two written physician orders that lacked a time when written and twenty seven written, telephone/verbal orders that lacked a date and/or time when the practitioner co-signed the order.

- Patient #22's medical record reviewed on 9/9/15 revealed an admission date of 3/25/15 with diagnoses of Leukocytosis (condition when the body produces too many white blood cells due to an infection) and discharged on 3/29/15. The medial record revealed three written physician orders that lacked a time when written and one standing order that lacked a date and/or time when the practitioner co-signed the order.


- Patient #24's closed medical record reviewed on 9/9/15 revealed an admission date of 4/2/15 and discharged on 4/7/15 with a diagnosis of PE (Pulmonary Embolism - a blood clot in the lungs). Patient #24's medical record revealed one physician order that lacked a time when written and two telephone/verbal orders that lacked a date and/or time when the practitioner co-signed the order.

- Patient #25's closed medical record reviewed on 9/9/15 revealed an admission date of 6/26/15 and discharged on 6/30/15 with a diagnosis of Left Lower Lobe Pneumonia. Patient #25's medical record revealed six telephone/verbal orders that lacked a date and/or time when the practitioner co-signed the order.

- Patient #29's closed medical record reviewed on 9/9/15 revealed an admission date of 3/7/15 and discharged on 3/24/15 with diagnoses of CHF (Congestive Heart Failure), Atrial Fibrillation (irregular heart rate), and acute fall with closed head trauma. Patient #29's medical record revealed two physician orders that lacked a time when written and four telephone/verbal orders that lacked a date and/or time when the practitioner co-signed the order.

Administrative Nurse Staff A interviewed on 9/9/15 at 2:35pm acknowledged the practitioners failed to date and or time all entries into the medical records.


- The CAH failed to have a policy and procedure directing staff of the requirement to date and time all entries into the medical record. The CAH's Medical Staff By-Laws, Rules and Regulations failed to direct practitioners on the requirement to date and time all entries into the medical record.

The Critical Access Hospital failed to assure the ordering practitioners dated and/or timed their signature.