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Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

Refer to K-011 - The hospital failed to provide two (2) hour fire separation between nonconforming building.

Refer to K-025 - The hospital failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.6, and 19.1.6.4.

Refer to K-027 - The hospital failed to provide doors with self-closing or automatic-closing in accordance with 19.2.2.2.6.

Refer to K-029- The hospital failed to provide one (1) hour fire rated construction (with a 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Refer to K-144- The hospital failed to provide the required monthly generator testing in accordance with NFPA99.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

Refer to K-011 - The hospital failed to provide two (2) hour fire separation between nonconforming building.

Refer to K-025 - The hospital failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.6, and 19.1.6.4.

Refer to K-027 - The hospital failed to provide doors with self-closing or automatic-closing in accordance with 19.2.2.2.6.

Refer to K-029- The hospital failed to provide one (1) hour fire rated construction (with a 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Refer to K-144- The hospital failed to provide the required monthly generator testing in accordance with NFPA99.

Based on observation and record review, the hospital failed to ensure that
the overall CAH environment is developed and maintained in a manner to ensure the safety and well being of patients.


Findings include:

Refer to K-144- The hospital failed to provide the required monthly generator testing in accordance with NFPA99.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings include:

Refer to K-011 - The hospital failed to provide two (2) hour fire separation between nonconforming building.

Refer to K-025 - The hospital failed to provide the required 30 minute fire resistance rating for smoke barrier walls in accordance with 19.3.7.3, 19.1.6.6, and 19.1.6.4.

Refer to K-027 - The hospital failed to provide doors with self-closing or automatic-closing in accordance with 19.2.2.2.6.

Refer to K-029- The hospital failed to provide one (1) hour fire rated construction (with a 45 minute fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4.

Refer to K-144- The hospital failed to provide the required monthly generator testing in accordance with NFPA99.

Based on medical record review, policy and procedure review, observation and staff interview, the Critical Access Hospital (CAH):
1. failed to ensure 10 of 10 inpatient, outpatient, acute and swing bed patient's medical records reviewed were accurately documented, entries timed, consents properly executed, and promptly completed following discharge.
2. failed to ensure that 10 of 10 emergency records reviewed were accurately documented with times on nurses signatures and on the physician signatures for discharge.


Findings include:

Ten (10) random medical records were reviewed. These records included inpatient, outpatient, acute and swing bed patients.

Three (3) of 10 medical records reviewed did not contain a properly executed "Conditions of Admission". The consent either did not contain a patient signature with the reason the patient was unable to sign, responsible party signature or a complete witness signature.

Eight (8) of 10 medical records reviewed did not contain a properly executed "Authorization for Medical Treatment". The consent either did not contain a patient signature with the reason the patient was unable to sign, a responsible party signature or a complete witness signature.

Five (5) of 10 medical records reviewed did not contain documentation of a living will, durable power of attorney or patient signature with reason patient unable to sign on the "Information for Our Patients on Advance Directives".

Three (3) of 10 medical records reviewed did not contain documented times on all entries in the medical record. This included patient "Orders", "Inpatient and Outpatient Progress Notes and/or Evaluation and Plan of Care" for Physical, Occupational and Speech therapy.

Two (2) of 10 medical records reviewed did not contain complete documentation that physician's orders were noted with a date, time, and signature of staff member noting order.

One (1) of 10 medical records reviewed had an incomplete "Fall Assessment".

Six (6) of 10 medical records reviewed had no documentation of discharge planning.

10 of 10 random emergency records reviewed were not accurately documented with times on nurses signatures and on the physician signatures for discharge.

On 03/19/13 at 1:05 p.m. a tour of the Medical Records Department revealed an observation of approximately 62 incomplete medical records which included dietary, physical, speech or occupational therapy which ranged from January to February 2013. This count was conducted and confirmed by the Medical Record Director (MRD). Interview with the MRD revealed records were considered incomplete for physician's 15 days after discharge. When asked what the policy was for completion of the entire medical record, she stated "We only have a policy for the physician's to complete the records." There were no incomplete physician's records.

On 03/20/13 at 9:15 a.m. the MRD stated, "The incomplete medical records have been completed." At 11:00 a.m. observation of the medical records reviewed on 03/19/2013 confirmed the incomplete records had been completed.

On 3/20/13 at 9:30 a.m. the Medical Staff Coordinator was asked about their policies for the completion of medical records and medical record entry requirements. She stated, "There are no written policies." The Director on Nurses (DON) was asked about policies concerning discharge planning. She stated, "Discharge planning is documented on the initial nursing assessment/interview."

In an interview on March 20, 2013 at 11:00 a.m. the Quality Director stated that Joint Commission did not put emphasis on times. She stated that they (CAH) had upgraded their policies to include it.

Review of the CAH's "Documentation of Care" policy (revised on 10-2012) revealed, "...20.: All written orders must be dated and timed when written."

Review of Doctor's Orders Worksheet #2 revealed, "All doctors orders must be timed."

Review of the CAH's "Delinquent Chart Reporting" policy revealed, "The physicians ...are to complete all of the medical records that they are responsible for within 15 days of a patient's discharge ...".

Review of the CAH's "Consent for Treatment-Adult Policy" revealed, "Purpose: ...obtain appropriate patient or patient representative consent prior to providing treatment ...Consent to Treat: Before care is rendered, a consent form will be completed and sign by the patient or person authorized to consent on behalf of the patient ...Consent Form: The consent form will include the signature, date and time of the patient or the name of the person providing consent ...Unable to Obtain Consent: If the patient is competent and able to verbalize consent, but unable to sign a consent form ...staff will write the words "Patient Unable to Sign" and document the reason for the inability to sign on the consent form. A family member or other staff member will sign the form as a witness ...".

Review of the CAH's "Documentation" policy revealed, "Documentation of Care ...19. All written orders must be noted by the nurse. The nurse must sign, date and time when the order is noted. 20. All written orders must be dated and timed when written. 21. All signatures should state title ...".

Review of the CAH's "Discharge Planning" policy revealed, "Discharge Planning: Nursing shall assist in discharge planning ...Discharge screening is done as a part of the Initial Patient Assessment ...".

Review of the CAH's "Medical Staff Bylaws" policy (approved 2/28/13) revealed "...Article XIII: Committees Section I. Executive Committee: ...1. Medical Records: The committee shall be responsible for assuring that all medical records meet the highest standards of patient care ...and that they are sufficiently complete at all times ...".

Review of the CAH's "Rules and Regulations of the Medical Staff " policy (approved 8/29/06) revealed, "Appendix A: Rules and Regulations of the Medical Staff ...13. Medical Record Requirements: ...The attending physician shall direct the preparation of a complete medical record ...Each medical record contains at least the following: ...9) Evidence of known advance directives; 10) Evidence of informed consent ...16) clinical observations ...No medical record shall be filed until it is complete, except on order of the medical records committee ...35. Physician Responsibility For Obtaining Informed Consent: A. Informed Consent: Each patient's medical record must contain evidence of the patient's or his legal representative's general consent for treatment during hospitalization ...C. Informed Consent, Signatures: An informed consent must be signed by the patient (or on the patient's behalf by the patient's authorized representative), and witnessed by a legally competent third party ...". This policy was scheduled to be discussed at the next meeting in March 2013.

In exit conference, no further documentation was offered.

Based on medical record review, policy and procedure review, observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all medical records reviewed were complete and accurately documented.

Findings include:

Cross Refer to C300 for the CAH's failure to ensure all medical records are complete and accurately documented.

Based on medical record review, policy and procedure review, observation and staff interview, the Critical Access Hospital (CAH) failed to ensure consent forms are properly executed.

Findings include:

Cross Refer to C300 for the CAH's failure to ensure consents are properly executed.

Based on record review, staff interview and policy review, the Critical Access Hospital (CAH) failed to ensure documentation of times and dates on signatures in 10 of 10 emergency records reviewed.

Findings include:

Cross Refer to C300 for the CAH's failure to ensure all entries in the medical record are dated and timed.




30232

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure that a periodic annual evaluation of its total program was conducted.

Findings include:

On 03/20/13 at 9:00 a.m. the Administrator was asked about the facility's annual program evaluation. The Administrator stated, "I will look for it."
At 10:10 a.m. the Administrator stated, "I cannot find it. I have been here four (4) months. We have the 12 months of data, but the data has not been summarized." A copy of the CAH's policy/procedure for the annual program review was requested. No documentation was submitted. At 1:20 p.m. the Administrator stated, "We have been evaluating and summarizing one department at a time including contract services." He submitted several policies, but none were regarding a periodic annual evaluation.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure an annual evaluation of its total program was conducted.

Findings include:

Cross Refer to C330 for the CAH's failure to ensure that an annual evaluation of its total program was conducted.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure that the utilization of services (number of patients served and volume of services) was included in an annual program evaluation.

Findings include:

Cross Refer to C330 for the CAH's failure to provide documentation of its utilization of services (number of patients served and volume of services) in an annual program evaluation.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to conduct a representative sample review of its active and closed clinical records in an annual program evaluation.

Findings include:

Cross Refer to C330 for the CAH's failure to provide documentation of a sample review of its active and closed clinical records in its annual program evaluation.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to ensure utilization of services is appropriate, policies are followed or if policies need to be changed in its annual program evaluation.

Findings include:

Cross Refer to C330 for the CAH's failure to determine if utilization of services was appropriate, if policies were followed or if policies needed to be changed in its annual program evaluation.