HospitalInspections.org

Based on medical record review, hospital policy review and staff interviews, the Critical Access Hospital (CAH) failed to ensure staff were operating in compliance with their patient care policies. For four out of ten patients sampled (Patients #1, #2, #4, #10), hospital staff did not provide patient care in accordance with policy. Three patients sampled presented to the CAH with suicidal ideation, and for 3 out of 3 suicidal patients, staff failed to secure their belongings and complete safety rounding per policy. For one out of one patients sampled with risk for seizures, staff failed to implement seizure precautions as ordered, and for one out one patients sampled with a wound, staff failed to complete wound care as ordered.

Failure of hospital staff to provide care according to hospital policy placed all patients who received care at the CAH at risk of receiving not receiving care and services to meet the specific needs of each patient.

Findings include:

1. Review of the procedure "Suicidal Behavior" last revised January 2024 revealed in part:

a. "Every patient with a primary psychiatric diagnosis or complaint(s) of an emotional or substance abuse disorder will be screened for suicidal intent at the time of admission using the Columbia Suicidal Severity Rating Scale"

b. "Patient safety rounding documentation will occur no less than every 15 minutes for a moderate and high risk and every hour for low risk unless otherwise ordered by the ED Provider."

c. "Upon arrival to the Emergency Department (ED), the patient and all the patient ' s belongings will be searched for potentially harmful objects"

d. "Patient will be dressed in paper gown or paper scrubs."

2. Review of Patient #1 ' s medical record revealed:

a. Patient #1 presented to the Emergency Department on 8/4/24 at 7:22 PM for a drug and alcohol assessment.

b. On 8/4/24 at 8:29 PM Staff L (Registered Nurse) completed a Columbia Suicide Screening (a suicidal ideation and behavior rating scale to evaluate suicide risk, scores are Negative, Low, Moderate, or High) for Patient #1. Patient #1 screened low on the Columbia Suicide Screen (required hourly safety roundings).

c. Staff L (Registered Nurse) completed patient safety roundings on 8/4/24 at 7:30 PM, 8:30 PM, 10:02 PM, and on 8/5/24 at 12:30 AM and 6:31 AM.

d. Review of Patient #1 ' s chart revealed ED staff did not document patient safety roundings on 8/4/24 from 8:30 PM - 10:02 PM (a period of 1 hour and 32 minutes), from 10:02 PM - 12:30 AM (a period of 2 hours and 28 minutes), and from 12:30 AM - 6:31 AM (a period of 6 hours and 1 minute). There were no further safety roundings from 6:31 AM to when Patient #1 was discharged on 8/5/24 at 2:17 PM (a period of 7 hours and 46 minutes).

e. Review of Patient #1 ' s medical record lacked evidence that hospital staff removed personal belongings or changed Patient #1 into paper scrubs.

f. Patient #1 was discharged 8/5/24 at 2:17 PM.

3. Review of Patient #2 ' s medical record revealed the following:

a. Patient #2 was admitted to the Emergency Department on 3/29/24 at 3:18 PM for a psychiatric evaluation for worsening schizophrenia symptoms.

b. On 3/29/24 at 3:29 PM ED Staff completed a Columbia Suicide Screening for Patient #2. Patient #2 screened low on the Columbia Suicide Screen (required hourly safety roundings).

c. ED Staff completed safety roundings on 3/29/24 at 7:00 PM, 8:00 PM, 9:00 PM, 10:00 PM, 11:00 PM, and on 3/30/24 at 12:00 AM, 1:00 AM, 2:00 AM, 3:00 AM, 4:00 AM, 5:00 AM, 6:00 AM, 8:00 AM, 9:07 AM, 10:11 AM, and 11:15 AM.

d. Hospital staff did not document a safety rounding for Patient #2 on 3/30/24 from 6:00 AM - 8:00 AM (a period of two hours).

e. Review of Patient #2 ' s medical record lacked evidence that hospital staff removed personal belongings or changed Patient #2 into paper scrubs.

f. On 3/30/24 at 9:55 PM, hospital staff documented that Patient #2 reported to staff that they took their home dose of their own psychiatric medications (propranolol and aripiprazole) with dinner. Hospital staff removed medications from the room at that time. Hospital staff did not document removing any other belongings from Patient #2.

g. Patient #2 was transferred to a psychiatric facility 3/30/24 at 12:00 PM.

4. Review of Patient #4 ' s medical record revealed the following:

a. Patient #4 was admitted to the Emergency Department on 6/15/24 at 9:36 PM for a psychiatric evaluation for alcohol intoxication and suicidal ideation.

b. On 6/15/24 at 9:44 PM Staff B (Registered Nurse) completed a Columbia Suicide Screening for Patient #4. Patient #4 screened Moderate on the Columbia Suicide Screen (required every fifteen minute roundings).

c. On 6/15/24 at 9:47 PM Staff G (Nurse Practioner) ordered suicide precautions per facility policy, procedure, or guidelines.

d. Staff B (Registered Nurse) completed safety roundings on 6/15/24 at 10:47 PM and 11:57 PM and on 6/16/24 at 4:02 AM, 5:02 AM and 6:41 AM.

e. Staff A (Registered Nurse) completed safety roundings on 7:01 AM, 8:03 AM, 9:04 AM, 10:00 AM, 11:11 AM.

f. Hospital staff failed to complete fifteen minute safety roundings for Patient #4 on 6/15/24 from 9:47 PM - 10:47 PM (a period of one hour), from 10:47 PM - 11:57 PM (a period of one hour and ten minutes), from 6/15/24 at 11:57 PM - 6/16/25 at 4:02 AM (a period of 4 hours and 5 minutes), on 6/16/24 from 4:02 AM - 5:02 AM (a period of one hour), from 5:02 AM - 6:41 AM (a period of one hour and 39 minutes), from 6:41 AM - 7:01 AM (a period of 20 minutes), from 7:01 AM - 8:03 AM (a period of 1 hour and 2 minutes), from 8:03 AM - 9:04 AM (a period of 1 hour and 1 minute), from 9:04 AM - 10:00 AM (a period of 56 minutes), from 10:00 AM - 11:11 AM (a period of one hour and 11 minutes) and from 11:11 AM - the time of discharge at 11:52 AM (a period of 41 minutes).

g. Hospital staff failed to complete 47 out of 57 required roundings for Patient #4.

h. Review of Patient #4 ' s medical record lacked evidence that hospital staff removed personal belongings or changed Patient #4 into paper scrubs.

i. Patient #4 was discharged to an alcohol recovery center 6/16/24 at 11:52 AM.

5. During an interview with Staff B (Registered Nurse) on 10/2/24 at 3:51 PM they reported that for patients who screen moderate or high risk on the Columbia Suicide Screening, hospital staff try to have a 1:1 sitter, if no sitter is available, staff complete every 15 minute roundings. When asked if there was ever a time they would not complete every 15 minute rounding, Staff B reported that they were sure there are times it happens, and if they had multiple patients they would turn on the call light to alert other staff to check on the patient.

6. During an interview with Staff A (Registered Nurse) on 10/02/24 at 9:00 AM they reported that for actively suicidal patients they round every fifteen mintues but for lower level patients that are not actively suicidal, they round every hour.

7. During an interview with Staff L (Registered Nurse) on 10/2/24 at 3:15 PM they reported that for patients who screen low on the Columbia Suicide Screeing they round hourly, and for patients that screen moderate or high on the Columbia Suicide Screening they round every ten to fifteen mintues. When asked if there was ever a time they would not complete the every fifteen minute rounding for a moderate or high risk patient, Staff L stated that there were times when the ED got super busy and there was only one nurse in the ED, but that they would contact the house supervisor to get more staff.

8. Review of Patient #4 ' s medical record revealed the following:

a. Patient #4 was admitted to the Emergency Department on 6/15/24 at 9:36 PM for a psychiatric evaluation for alcohol intoxication and suicidal ideation.

b. Staff G (Nurse Practitioner) ordered seizure precautions for Patient #4 on 6/15/24 at 9:47 PM to include "bed in the lowest position, side rails up and padded, emergency equipment in the room at all times, inspect the environment for safety hazards, ensure IV access is patient and secure, and assist patient at all times with activity using a gait belt."

c. Review of the medical record including progress notes failed to show evidence that hospital staff initiated seizure precautions as ordered.

9. During an interview with Staff B (Registered Nurse) on 10/2/24 at 3:51 PM they reported that seizure precautions would include placing the patient on a monitor, having seizure pads on, making sure medications were given, frequently checking on the patient as well as having safety equipment at the bedside. Staff B reported that they would document those precautions in a progress note.

10. Review of Patient #10 ' s medical record revealed the following:

a. Patient #10 presented to the Emergency Department with a skin tear to their left hand on 6/24/24 at 9:16 PM after a fall.

b. Staff B (Registered Nurse) completed triage documentation on 6/24/24 at 9:26 PM. Staff B assigned themselves as the primary nurse caring for Patient #10 at 10:36 PM.

c. Review of the medical record lacked evidence that Staff B completed an assessment of Patient #10 ' s wound.

d. On 6/24/24 at 9:46 PM, the provider ordered wound care for Patient #10 to be completed twice daily to the left hand.

e. On 6/24/24 at 11:16 PM, Staff B placed orders to complete wound care as needed to the left hand.

f. Review of the medical record including progress notes lacked evidence that wound care was completed for Patient #10.

g. Patient #10 was discharged back to their nursing facility on 6/24/24 at 11:32 PM.

11. During an interview with Staff B (Registered Nurse) on 10/2/24 at 3:51 PM they reported that for patients that present to the ED with wounds, typical wound care would have included measuring, taking pictures, cleansing the wound, and assisting the provider to complete wound care. Staff B reported they typically documented wound care activities in a progress note.

12. In email communication with Staff O (Chief Nursing Officer) 10/3/24 at 1:27 PM, Staff O reported that they did not have a policy that specified how nursing staff were required to follow provider orders. Staff O reported that nursing staff were expected to monitor the orders throughout their shift for any changes and then ensure all orders were acknowledged before they went off shift.

Based on observation, medical record review, and staff interviews, the hospital administration failed to ensure hospital staff informed patients of their rights for 7 out of 7 patients sampled (Patients #1, #4, #5, #10, #11, #12, #13) regarding patient rights.

Failure of hospital staff to ensure patients were aware of their rights placed patients at risk for not having knowledge and the ability to protect their own rights.

Findings include:

1. Review of of the brochure entitled "Patient Rights and Responsibilities" last revised June 2019 revealed in part:

a. "As a patient, or parent or legal guardian of a patient, you have the right to: 1. Be informed in writing of your rights before patient care is furnished or discontinued whenever possible."

2. Observation of registration staff checking in 3 patients revealed the following:

a. On 10/2/24 at 1:06 PM the surveyor observed Patient #11 present to the front desk for an injection. Staff K (Registrar) verified the patient ' s information and then asked if they wanted a copy of their patient rights and responsibilities. The patient stated they did not. Staff K did not verbally inform the patient of their rights or provide any information in writing regarding patient rights.

b. On 10/2/24 at 1:10 PM the surveyor observed Patient #12 present to the registration desk for a blood draw. Staff M (Registrar) verified the patient ' s information and then asked the patient if they wanted a copy of the patient rights and responsibilities. The patient stated they did not. Staff M did not verbally inform the patient of their rights or provide any information in writing regarding patient rights.

c. On 10/2/24 at 1:16 PM the surveyor observed Patient #13 present to the front desk needing to check into the emergency department. Staff M (Registrar) verified the patient ' s name and called the ED to let them know a patient needed to be seen. While waiting for ED staff, Staff M obtained consent for treatment. Staff M asked the patient if they wanted a copy of the patient rights and responsibilities. The patient reported they did not. Staff M did not verbally inform the patient of their rights or provide any information in writing regarding patient rights.

3. Review of Patient #1 ' s medical record revealed the following:

a. Patient # 1 was admitted to the Emergency Department from 8/4/24 at 7:22 PM to 8/5/24 at 2:17 PM for a drug and alcohol assessment.

b. Review of the medical record lacked evidence Patient #1 was informed of their patient rights.

4. Review of Patient #4 ' s medical record revealed the following:

a. Patient #4 was admitted to the Emergency Department from 6/15/24 at 9:36 PM to 6/16/24 at 11:52 AM for a psychiatric evaluation for alcohol intoxication and suicidal ideation.

b. Review of the medical record lacked evidence Patient #4 was informed of their patient rights.

5. Review of Patient #5 ' s medical record revealed the following:

a. Patient #5 was admitted to the Emergency Department from 5/28/24 at 6:19 PM to 5/28/24 at 8:46 PM for a mental health evaluation.

b. Review of the medical record lacked evidence Patient #5 was informed of their patient rights.

6. Review of Patient #10 ' s medical record revealed the following:

a. Patient #10 was admitted to the Emergency Department from 6/24/24 9:16 PM to 6/24/24 at 11:32 PM for evaluation following a fall.

b. Review of the medical record lacked evidence Patient #10 or their spouse were informed of their patient rights.

7. During an interview with Staff K 10/2/24 at 1:22 PM they revealed there were four different documents the hospital used to obtain consent for treatment and acknowledgement of patient rights.

a. Staff K reported there were two versions that registration staff could print out. Review of both versions of the consent revealed that they included an acknowledgement that patients were offered a copy of their rights and responsibilities.

b. Staff K reported that when registering patients, they did not inform patients of their rights and only offered them a copy. When asked to see a copy of the rights patients were offered, Staff K gave the surveyor a notice of the hospital ' s privacy policy.

c. Staff K reported that if the computers were down and they were unable to print either of these documents, they have a hard copy they used to obtain consent. Review of this document showed it did not acknowledge informing patients of their rights or that patients were offered a copy of their rights.

d. Staff K also reported that during off hours Emergency Department staff obtained consent for treatment. The surveyor requested a copy of this document from ED staff on 10/2/24 at 1:30 PM. Review of this document revealed it did not acknowledge informing patients of their rights or that patients were offered a copy.

8. In email correspondence on 10/1/24 at 11:28 AM with Staff P (Director of Health Information Management) they revealed that they were unable to find any further documentation regarding informing Patients #1, #4, #5, and #10 of their rights.