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Based on document review, observational tour, and interview it was determined for 2 of 2 Cardiopulmonary Resuscitation Cart (CPR) daily checklist forms, the Hospital failed to ensure proper documentation of the CPR cart daily checklist.
Findings include:
1. Hospital policy titled "CPR CART and Defibrillator-Security and Maintenance" effective 1/24/13 stated, "all CPR Carts are to be inspected daily (when clinical unit is open operationally) and initialed against the daily checklist by departmental staff. CPR Carts with a numbered breakaway lock are to be inspected for the integrity of the lock, and the equipment stored on the outside of the cart must be inventoried on the approved checklist every shift by designated responsible staff. The daily check is documented on a CPR Cart Log Form."
2. An observational tour was conducted on 9/8/2014 at 9:40 AM of the acute care unit. Upon inspection of the CPR cart daily checklist log, for the months of August and September 2014, there were several blank spaces.
3. On 9/8/2014 at 10:10 AM, an interview was conducted with the Quality Coordinator (E #2), who stated she was unsure is to why the spaces were left blank.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on September 17-18, 2014, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on September 17-18, 2014, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated September 18, 2014.

Based on document review and staff interview, it was determined for 1 (Pt #11) of 2 clinical records reviewed for patients with suicidal ideation, the Critical Access Hospital (CAH) failed to ensure observation precautions were conducted in accordance with CAH policy.

1. The CAH's policy entitled "Suicide Precaution" (revised 4/2008) was reviewed on 9/10/14 at approximately 11:00 am and required, "...NURSING CARE 1. Close observation, within visual range every fifteen (15) minutes while awake...3. Every fifteen (15) minutes check while asleep..."

2. The clinical record for Pt #11 was reviewed on 9/9/14 at approximately 1:00 pm. Pt #11 was a 33 year old male admitted to the hospital on 7/6/14 with a diagnosis of bipolar disorder with suicidal ideation. The physician's admitting orders included, "suicide watch". The suicide precaution checklist dated 7/7/14 lacked 15 minute safety checks from 7:00 am -7:30 am and 10:00 am - 11:15 am.

3. During an interview with the Chief Nursing Officer (E #1) on 9/10/14, E #1 stated the suicide precaution checklist should have been completed every fifteen minutes per policy.

Based on document review and interview, it was determined that in 1 of 18 (Pt. #14) records reviewed, the Critical Access Hospital (CAH) failed to ensure the clinical record was complete and contained accurate documentation.

Findings include:

1. The clinical record reviewed 09/09/14 included Pt. #14 was a 77-year-old male admitted 06/27/14 with diagnoses of urosepsis, dehydration, and gastroenteritis. The medical screening exam, dated 06/25/14 at 9:30 A.M. inaccurately included documentation that Pt. #14 was discharged home in "fair, stable" condition. The clinical record included documentation that Pt. #14 had actually been admitted to the medical surgical unit on 06/25/14 and discharged on 06/27/14.

2. In an interview conducted on 09/09/14 at approximately 9:10 A.M. with the Chief Nursing Officer (CNO), the CNO stated the emergency department physician "should have charted [the patient was] admitted".

3. The CAH's policy entitled, "Patient assessment," reviewed 4/02 included, "Physical Assessment: Patient is assessed by review... Assessment is completed at least once per eight hour shift."

4. The CAH's "Patient shift assessment" form required documentation of various systems including: skin, genitourinary, and Morse fall risk score.

5. The "Patient shift assessment" dated 6/27/14 at 7:40 A.M., in the clinical record for Pt. #14, lacked documentation that an assessment of skin, genitourinary, and Morse fall risk score had been completed. There was no documentation of this information elsewhere in the record.

6. In an interview conducted on 09/09/14 at approximately 9:10 A.M. the CNO stated, "It's all missing."

Based on documentation review and staff interview, it was determined for 5 of 18 clinical records reviewed (Pts. #7, 10, 11, 14 & 18), the Critical Access Hospital (CAH) failed to ensure physician discharge orders and a complete discharge summary were completed for a discharged patient.

Findings include:

1. The CAH's policy titled, "Discharge Procedure" revised on 12/2008 was reviewed on 9/10/14 at 2:00 PM. The policy required, "1. Obtain discharge order from physician."

2. The CAH's policy titled, "Medical Records, Contents and Completion of" revised on 11/2010 was reviewed on 9/10/14 at 2:05 PM. The policy required, "1. Inpatient Acute Care Charts a. This record shall include... discharge summary (including condition on discharge, instructions, follow-up, final diagnosis)..."

3. On 9/9/14 at 3:00 PM, Pt. #18's clinical record was reviewed. Pt. #18 was an 83 year old female, admitted on 8/25/14, with diagnoses of chronic obstructive pulmonary disease, chronic heart failure, and legally blind. Pt. #18's telephone follow-up report dated 8/29/14, included Pt. #18 was discharged to a swing bed on 8/29/14 at 4:00 PM. A physician's order for discharge from the CAH was not found.

4. Pt. #18's discharge summary dated 8/29/14 at 11:49 AM, did not include a summary of the treatment provided during or follow-up after hospitalization.

5. On 9/10/14 at 11:35 AM, an interview was conducted with the Hospital Information Manager (E #3). E #3 stated she was unable to locate Pt. #18's discharge order and the Physician, who wrote Pt. #18's discharge summary, told E #3 that discharge summaries include more information using dictation over typing into the medical record, which the CAH prefers.


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6. The clinical record for Pt #10 was reviewed on 9/9/14 at approximately 12:50 PM. Pt #1 was a 32 year old male admitted to the hospital for observation on 3/13/14 with a diagnosis of alcohol intoxication. Pt #1 was discharged on 3/14/14, and the clinical record lacked a discharge summary.

7. The clinical record for Pt #11 was reviewed on 9/9/14 at approximately 1:00 PM. Pt #11 was a 33 year old male admitted to the hospital on 7/6/14 with a diagnosis of bipolar disorder with suicidal ideation. Pt #11 was discharged on 4/7/14, and the clinical record lacked a discharge summary.

8. The clinical record for Pt #7 was reviewed on 9/9/14 at approximately 1:15 PM. Pt #7 was a 32 year old female admitted to the hospital on 1/11/14 with a diagnosis of pneumonia. Pt #7 left against medical advice on 1/13/14, and the clinical record lacked a discharge summary.

9. The findings for Pts. #7, 10, & 11 were discussed with the Chief Nursing Officer (E #1) during an interview on 9/10/14 at approximately 9:30 AM.




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10. The clinical record reviewed 09/09/14 included Pt. #14 was a 77-year-old male admitted 06/27/14 with diagnoses of urosepsis, dehydration, and gastroenteritis. The clinical record included Pt. #14 was discharged on 06/27/14, but lacked documentation of a discharge summary for this patient.

11. In an interview conducted on 09/09/14 at approximately 9:10 A.M. the CNO stated, "I do not see an official discharge summary written or dictated."