HospitalInspections.org

Based on document review and staff interview it was determined the Critical Access Hospital (CAH) failed to ensure quality data for reporting of unusual occurrances in order to track and trend performance was completed per policy. This failure has the potential to affect all patients and staff.

Findings include:

1. On 7/11/22, the CAH policy dated, 11/20, titled, "Incident and Improvement Reporting" was reviewed. Under "POLICY: ...Upon discovery, all incidents or improvement opportunities should be reported to the department manager immediately...The report will be entered into the reporting system or called into the hot line by the employee as soon as possible and preferably no later than end of the employee's shift...Updates will be provided to the Quality Management Committee."

2. On 7/11/22-7/12/22, the medical record of Pt #1 was reviewed. On 6/16/22 at 11:51 AM, Pt #1 presented to the emergency department (ED) via emergency medical services (EMS) from a nursing home. Pt #1's chief complaint was right side weakness and right shoulder pain. Documenation in the triage notes indicated Pt #1 was alert and oriented time 3 (person, place, time) and was able to give verbal consent for treatment. The medical screening exam (MSE) completed by a physician indicated Pt #1 was "alert, disoriented x3. Documentation in the "Patient Summary" "spoke with Pts daughter (HCPOA) Advised that mother was being returned to SNF Daughter wished to speak to the ER MD. ER MD agreed to speak to her. Transferred call the ERMD. On 6/16/22 at 3:00 PM, Pt #1 was discharged in stable condition.

3. On 7/11/22 at 2:40 PM, an interview was conducted with the ED manager (E#1). E#1 recalled Pt #1's daughter (HCPOA) calling the ED multiple times while her mother was being assessed wanting to speak with the ED physician. The HCPOA also called and spoke with a couple of nurses. E#1 verbalized, the HCPOA was very demanding, yellling and was upset. She wanted the physician to call Pt #1's specialist. E#1 stated, "I know one of the nurses hung up on her because they couldn't get a word in to try and explain her mother's care." E# 1 was asked about getting verbal consent when Pt #1 had a HCPOA. E#1 verbalized, Pt #1 was alert and oriented when she came in. If she would, have been incapacitated, we would have called the HCPOA. E#1 was asked about completing an incident report. E#1 stated, "I did not report it, but I probably should have." E#1 was able to transfer a call the ED physician from the HCPOA, but did not know the outcome of the conversation.

4. On 7/11/22 at 3:15 PM, a telephone interview was conducted with the ED nurse (E#2). E#2 recalled Pt #1's HCPOA calling the ED multiple times. E#2 stated, "I attempted to give her information, but I couldn't get 2 words out, extremely rude. She just kept yelling she wanted to speak to doctor. She would not listen to anything I tried to say. I finally told her I had to go and take care of my patients and hung up the phone." E# 2 was asked if the incident was reported? E#2 stated, "I reported it to the manager." E#2 stated,, " I don't believe I documented the incident."

5. On 7/12/22 at 1:15 PM, an interview was conducted with the records clerk (E#3). E#3 recalled Pt #1's HCPOA calling several times. The first time was to set up patient portal. E#3 verbalized I requested the HCPOA and legal guardianship papers. The HCPOA wanted to make sure these documents were on file at the hospital so she could be notified. E#3 recalled the HCPOA called back on the day Pt #1 was being brought into the ED. The HCPOA wanted to make sure she was notified so she could answer any questions,since her mother had dementia. E#3 physically, walked the HCPOA forms to the ED so they would be readily available. E#3 reported the HCPOA called back a few days later and was upset with the hospital, because she was unable to talk with doctor at time of the exam. E#3 apologized and gave her contact information to report the incident. E#3 was asked, did you report the incident? E#3 replied, "no, I didn't know I would need to."

6. On 7/12/22 at 2:00 PM, an interview was conducted with quality manager (E#4). E#4 reviewed the documents and confirmed the incident should have been reported and follow-up should have been completed with Pt #1's HCPOA.