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800 SCHOOL ST

CARROLLTON, IL 62016

No Description Available

Tag No.: C0190

Based on document review and interview, it was determined the Governing Body failed to ensure hospital contracts/agreements for transfers were maintained and retrievable. The cumulative affect of this systemic practice demonstrates the Critical Access Hospital's inability to ensure patients are able to be transferred in a timely manner. This has the potential to affect all patients serviced by the Critical Access Hospital which has an average daily inpatient census of 3 patients and services an average of 8 patients daily in the Emergency Department.

Findings include:

1. Failed to ensure it had a contract/agreement with at least one hospital that is a member of the network for patient referral and/or transfer. See C-191.

No Description Available

Tag No.: C0191

Based on document review and interview, it was determined the Governing Body failed to ensure it had a contract/agreement with at least one hospital that is a member of the network for patient referral and/or transfer. This has the potential to affect all patients serviced by the Critical Access Hospital (CAH) which has an average daily inpatient census of 3 patients and services an average of 8 patients daily in the Emergency Department.

Findings include:

1. The CAH website was reviewed on 7/20/15 in preparation for recertification survey. The website stated the CAH had written affiliations with five hospitals for transfers.

2. A request for hospital transfer agreements was made daily from 7/21/15 thru 7/24/15. As of 7/24/15 at approximately 1:00 PM, no agreements were presented.

3. An interview was conducted with the Chief Executive Officer (E#1) on 7/24/15 at approximately 1:15 PM. E#1 verbally agreed the CAH website states they have 5 hospital affiliations for transfer "but I can't find the agreements."

No Description Available

Tag No.: C0220

Based on observation, staff interview and document review during the life safety code portion of the recertification survey conducted on August 3, 2015, the surveyor finds that the facility is not constructed and maintained as a safe environment for patients. See Tag C0231

No Description Available

Tag No.: C0222

Based on document review, observation and staff interview it was determined the Critical Access Hospital (CAH) failed to ensure mechanical and electrical equipment available for patient use was inspected and had routine preventive maintenance.This has the potential to affect all patients receiving ED services, currently approximately 8 patients per day.

Findings include:

1. A tour of the Emergency Department (ED) was conducted on 7/21/15 at 10:20 AM, with the Director of Nursing (E#4). It was observed in the ED hall way, one (1) Health-O-Meter, electronic scale without a maintenance/inspection sticker on it.

2. The CAH policy titled "Preventative Maintenance" (no revision date), was reviewed on 7/23/15 at 1:45 PM. The policy indicated "A biomed contract will be utilized to provide regular periodic maintenance and testing program for medical devices and equipment."

3. An interview with E#4 was conducted on 7/21/15 at 10:30 AM. E#4 verbalized that the scale was used to measure pediatric patients for medication dosing. E#4 also verbalized the scale had never been inspected or had regular maintenance for calibration performed on it.

4. An interview with the Chief Executive Officer (E#1) was conducted on 7/23/15 at 2:15 PM. E#1 was unable to provide evidence from the contracted biomed company that the electronic scale was calibrated or had had preventive maintenance performed on it.

No Description Available

Tag No.: C0223

Based on observation and interview, it was determined the Critical Access Hospital (CAH) failed to develop and implement a policy for the storage of biohazard chemicals and failed to ensure cleaning chemicals were not accessible to patients.

1. On 7/21/15 at approximately 10:15 AM, an observational tour of the Physical Therapy Department was conducted with Director of Quality (E#3). The unlocked cabinet under the sink in the weight room contained an opened 24 ounce bottle of glass cleaner, opened 16 ounce bottles of abrasive cleaner, and a opened 16 ounce bottle of carpet cleaner. All of the containers labels' stated, "not for human consumption" and were accessible to patients.

2. During an interview conducted with E #3 on 7/21/15 at approximately 10:30 AM, E#3 stated, "the chemicals are accessible to patients and should not be stored there".

3. During an interview conducted with Chief Executive Officer (E#1) on 7/22/15 at approximately 1:30 PM, E #1 stated, "We don't have a policy for the storage of biohazard chemicals."

No Description Available

Tag No.: C0231

Based on observation during the survey walk-through, staff interview, and document review during the life safety code portion of a recertification survey conducted on August 3, 2015 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 associated K-Tags.

No Description Available

Tag No.: C0240

Based on document/record review and interview, it was determined the Governing Body failed to ensure 6 of 6 (MDs#1, #2, #3, #4, #5 and #6) Emergency Department (ED) physicians were privileged to perform intravenous(IV) conscious sedation and were privileged in ED specific procedures. The cumulative affect of these systemic practices demonstrates the CAH's inability to ensure ED treatment was performed by physicians competent and privileged in IV conscious sedation and in the provision of ED services. This has the potential to affect all patients serviced by the ED, which currently services approximately 8 patients per day.

Findings include:

1. The Governing Body failed to ensure ED physicians applied for and were granted Medical Staff privileges to perform IV conscious sedation. See C-241A

2. The Governing Body failed to ensure ED physician specific privileges related to services being provided were applied for and approved by both the Medical Staff and the Governing Body. See C-241B

No Description Available

Tag No.: C0241

A. Based on document review and interview, it was determined for 6 of 6 (MD #1, MD#2, MD#3, MD#4, MD#5, and MD#6) physicians, who provide Emergency Department (ED) coverage and had the potential to perform intravenous (IV) conscious sedation, the Governing Body failed to ensure ED physicians applied for and were granted Medical Staff privileges to perform IV conscious sedation.

Findings include:

1. The Policy and Procedure titled "Physician Procedural Sedation" (effective 02/2014) was reviewed on 7/22/15 at approximately 11:00 AM. The policy stated "1. Any physician applying for Medical Staff privileges to do procedural sedation..."

2. Six of six ED physician credential files (MD#1, MD#2, MD#3, MD#4, MD#5, and MD#6) who performed IV conscious sedation were reviewed for application and approval of IV conscious sedation privileges on 7/21/15 at approximately 11:00 AM. Six of six lacked documentation the physicians had applied for and were approved by the Medical Staff and the Governing Body to provide IV conscious sedation.

3. An interview was conducted with the Chief Executive Officer (E#1) on 7/22/15 at approximately 11:30 AM. E#1 stated the ED physicians completed training with reappointment and took a test on IV conscious sedation "but I didn't realize they needed it spelled out in their privileges." E#1 stated "None of them (the ED physicians) will have this (privileges for IV conscious sedation) in their files."

4. A phone interview was conducted with the Chief of Staff (MD#1) on 7/25/15 at approximately 9:05 AM. When asked if MD#1 was aware the physicians (MDs #1, #2, #3, #4, #5, #6) who work in the ED and could potentially perform IV conscious sedation were not privileged to do so. MD#1 stated awareness that the physicians had taken a test on conscious sedation but verbally agreed the physicians had not applied for or been granted privileges for IV conscious sedation and that this should be done.

B. Based on document review and interview, it was determined for 6 of 6 (MD #1, MD#2, MD#3, MD#4, MD#5, and MD#6) physicians, who provide Emergency Department (ED) coverage in addition to Hospitalist services, the Governing Body failed to ensure ED physician specific privileges related to services being provided were applied for and approved by both the Medical Staff and the Governing Body. This has the potential to affect all patients serviced by the ED which currently services approximately 8 patients per day.

Findings include:

1. The Medical Staff Bylaws, Rules and Regulations (last reviewed 01/2015) were reviewed on 7/22/15 at approximately 10:15 AM. The Bylaws, Rules and Regulations stated under Article II, 2.2 A(3) "A credentials program, including mechanisms for appointment and re-appointment and the matching of clinical privileges to be exercised or of specified services to be performed with a verified credentials and current demonstrated performances... Article VIII, 8.1 Clinical privileges... Every practitioner practicing at the hospital by virtue of Medical Staff membership or otherwise, shall in connection with such practice, be entitled to exercise only those privileges specifically granted to him/her by the Board of Trustees."

2. Six of six physician credential files (MD#1, MD#2, MD#3, MD#4, MD#5, and MD#6) for physicians who provided both Hospitalist and ED coverage were reviewed for application and approval of ED specific privileges on 7/21/15 at approximately 11:00 AM. Six of six lacked documentation the physicians had applied for and were approved by the Medical Staff and the Governing Body to provide ED specific services.

3. An interview was conducted with the Chief Executive Officer (E#1) on 7/22/15 at approximately 11:30 AM. E#1 stated the ED physicians did not have ED specific privileges and "I didn't realize they needed to be spelled out in their privileges."

4. A phone interview was conducted with the Chief of Staff (MD#1) on 7/25/15 at approximately 9:05 AM. When asked if MD#1 was aware the physicians (MDs #1, #2, #3, #4, #5, #6) who work in the ED lacked privileges specific to ED services with examples of IV conscious sedation and intubation. MD#1 verbally agreed the "Medicine" privileges do not address all the privileges needed for services provided in the ED. MD#1 stated "It (the privileges) don't cover IV conscious sedation or rapid sequence intubation and other procedures we do."

No Description Available

Tag No.: C0270

Based on document review and interview, it was determined the Critical Access Hospital (CAH) failed to ensure a qualified individual provided patient nutritional/dietary care services (by employee or agreement) and failed to develop/implement polices on having a qualified dietary individual and nutritional assessments. The cumulative affect of these systemic practices demonstrates the CAH's inability to ensure patients' nutritional assessment and treatment were assessed by a qualified person in accordance with CAH policies. This has the potential to affect all inpatients serviced by the CAH with a current average daily inpatient census of 3.

Findings include:

1. Failed to develop and implement policies on a having qualified individual to provide patient nutritional/dietary care services or on nutritional assessments. See C-271A.

2. Failed to ensure a qualified individual provided patient nutritional/dietary care services. See C-279.

3. Failed to ensure a qualified individual provided patient nutritional/dietary care services. See C-289.

No Description Available

Tag No.: C0271

A. Based on document review and interview, it was determined the Critical Access Hospital (CAH) failed to develop and implement policies on having a qualified individual provide patient nutritional/dietary care services or on nutritional assessments.

Findings include:

1. On 7/24/15 at approximately 10:15 AM, the CAH policy titled "Nutritional Assessment" (effective 1/2008) was reviewed. The policy stated "A nutritional assessment will be done on every patient entering the Skilled Nursing Swing Bed Unit." The policy did not address CAH acute care inpatients.

2. During an interview conducted with the Dietary Manager (E#18) on 7/23/15 at approximately 8:30 AM, E#18 stated "Our dietitian quit a few years ago and we haven't hired another one. The menu manuals have not been updated, reviewed, or revised since the dietitian left several yeas ago. The last consultation report from E#20 was 3/8/15, that's the last time a dietitian would have looked at the menus and manuals. We have no policies on qualified dietary requirements."

3. During an interview conducted with the Chief Executive Officer (E#1) on 7/23/15 at approximately 9:30 AM, E#1 stated "The dietician quit 6/1/13 and we have tried to get another one, but no one wants to come to the CAH. The dietary manual has not been reviewed since the dietitian left. We don't have policies on having a qualified dietary individual or nutritional assessments for acute care patients."

B. Based on document review and interview, it was determined for 3 of 20 (Pts #10, #11, and #12) patients, the Critical Access Hospital failed to ensure it developed and implemented a policy on patient care planning.

Findings include:

1. Pt #10's record was reviewed on 7/22/15 at approximately 8:00 AM. Pt #10 was admitted on 7/8/15 with a diagnosis of Pneumonia (lung infection). The record noted Pt #10 was rated as high for fall and skin risk. The plan of care had no specific goals related to the high fall and skin risk.

2. Pt #11's record was reviewed on 7/22/15 at approximately 8:30 AM. Pt #11 was admitted on 7/13/15 with a diagnosis of Obstructive Bronchitis (lung fluid). The record noted Pt #11 was rated as high for fall and skin risk. The plan of care had no specific goals related to the high fall and skin risk.

3. Pt #12's record was reviewed on 7/22/15 at approximately 9:00 AM. Pt #12 was admitted on 6/8/15 with a diagnosis of Obstructive Bronchitis (lung fluid). The record noted Pt #12 was rated as high for fall risk. The plan of care had no specific goals related to the high fall risk.

4. During an interview with the Chief Executive Officer (E#1) on 5/22/15 at approximately 3:00 PM, E#1 stated, "We have no policy on patient care planning."

PATIENT CARE POLICIES

Tag No.: C0278

B. Based on document review, observation and interview, it was determined the Critical Access Hospital (CAH) failed to ensure sterile processing brushes were properly cleaned after each use, potentially affecting all patients receiving care at the CAH.

Findings include:

1. A tour of the sterile processing room was conducted on 7/21/15 at 11:00 AM with the Infection Control Nurse (E#2). It was observed on the "dirty" area of the sink, six (6) various sized scrub brushes being stored on top of each other, in a basket.

2. The CAH policy titled "Instrument Cleaning and Packaging" revised January 2009, was reviewed on 7/23/15 at 1:45 PM. The policy indicated, "2. ...instruments are cleaned of blood and debris in an open position. This is accomplished by using a scrub brush..... ."

3. On 7/21/15 at 11:15 AM, an interview with E#2 was conducted. E#2 verbalized the brushes were used to clean off debris and blood from the instruments prior to sterilization and were not being sterilized or cleaned with sanitizer after each use.

C. Based on document review, observation and staff interview, it was determined the CAH failed to ensure biological indicator (BI) ampoules were properly monitored, potentially affecting all patients receiving care at the facility.

1. A tour of the sterile processing room was conducted on 7/21/15 at 11:00 AM with the Infection Control Nurse (E#2). During the tour the "Sterile Documentation Log" dated 4/4/15 thru 7/16/15 was reviewed. The log required staff initials on the log at the 24 hour and 48 hour time frame. There were no staff initials on 5/16/15, 5/30/15 and 7/2/15, to indicate the BI's were checked at the 48 hour time frame.

2. The CAH policy "Sterilizer Biological Testing" revised January 2009, was reviewed on 7/23/15 at 1:30 PM. Under "f. The sterilizer will not be used until two (2) negative biological results have been obtained." There is no specific guidance in the policy that gives directions on how to monitor the biological indicator ampoules.

3. On 7/21/15 at 11:30 AM, an interview with E#2 was conducted. E#2 verbalized the BI's should have been checked at the 48 hour time frame. E#2 also verbalized the sterile documentation log did not have staff members initials indicating the BI's were checked at the 48 hour time frame on 5/16/15, 5/30/15 and 7/2/15.


32377

A. Based on observation, document review, and interview, in was determined that for 2 of 8 Critical Access Hospital departments toured (Laboratory, Physical Therapy), the CAH failed to ensure potentially contaminated equipment was disinfected.

Findings include:

1. On 7/21/15 at approximately 9:45 AM an observational tour was conducted in the Laboratory Department. The blood unit storage refrigerator and the specimen refrigerator doors had greater then 10 pieces of tape and tape residue on them.

2. On 7/21/15 at approximately 10:15 AM an observational tour was conducted in the Physical Therapy Department. The weight bench in the "exercise room" had two one inch size holes in the padded seat and the wall climate unit had approximately 1/16 of an inch of gray substance on the top. A bedside table in the "treatment room" contained a black substance in the shelf and the table top had greater than 10 cracks.

3. On 7/23/15 at approximately 1:00 PM, the policy titled, "Metal Cleaning" (effective 7/1998) was reviewed. The policy required "Weekly-Damp clean metal surfaces with germicidal cleaner."

4. On 7/23/15 at approximately 1:15 PM, the policy titled, "High Dusting" (effective 7/1998) was reviewed. The policy required "Normally done on a weekly basis in patient rooms, ancillary offices, etc."

5. During an interview with Director of Quality (E#3) conducted on 7/21/15 at approximately 11:00 AM, E#3 stated the "It would be difficult to disinfect the weight bench seat with the hole there. The dust and dirt should not be on the air unit or bedside table. The staff should be dusting and cleaning the areas at least weekly." .

6. During an interview with Director of Laboratory Services (E#15) conducted on 7/21/15 at approximately 11:15 AM, E#6 stated "there was no absolute way to ensure the refrigerators in the lab were disinfected, since the tape and residue are on the doors."

No Description Available

Tag No.: C0279

Based on document review and interview, it was determined for 5 of 5 patients (Pts #24, #25, #26, and #27) reviewed for nutritional assessments, the Critical Access Hospital (CAH) failed to ensure a qualified individual provided patient nutritional/dietary care services.

Findings include:

1. On 7/23/15 at approximately 12:30 PM document titled "State of Illinois-Food Sanitation Certificate" (expires 6/17/16 for E #18 was reviewed.

2. On 7/23/15 at approximately 12:45 PM document titled, "Monthly Dietician Visit...Consultation Report dated 3/8/13 and signed by Registered Dietitian (E #20). No consultation reports after 3/8/13.

3. On 7/24/15 at approximately 10:15 AM reviewed policy titled "Nutritional Assessment" ( effective 1/2008). Policy requires, A nutritional assessment will be done on every patient entering the Skilled Nursing Swing Bed Unit." The policy does not address CAH acute care inpatients.

4 Reviewed Pt # 14's clinical record on 7/24/15 at 11:00 AM. Pt. #14 was admitted on 6/3/15 with a diagnosis of diabetes mellitus.(metabolic disorder of processing calories) Pt. #14's record lacked a nutritional assessment.

5. Reviewed Pt # 24's clinical record on 7/24/15 at 9:00 AM. Pt. #24 was admitted on 3/11/15 with a diagnosis of diabetes mellitus.(metabolic disorder of processing calories) Pt. #24's record lacked a nutritional assessment.

6. Reviewed Pt # 25's clinical record on 7/24/15 at 9:15 AM. Pt. #25 was admitted on 3/8/15 with a diagnosis of diabetes mellitus.(metabolic disorder of processing calories) Pt. #25's record lacked a nutritional assessment.

7. Reviewed Pt # 26's clinical record on 7/24/15 at 9:30 AM. Pt. #26 was admitted on 4/5/15 with a diagnosis of diabetes mellitus.(metabolic disorder of processing calories) Pt. #26's record lacked a nutritional assessment.

8. Reviewed Pt # 27's clinical record on 7/24/15 at 9:45 AM. Pt. #27 was admitted on 4/20/15 with a diagnosis of diabetes mellitus.(metabolic disorder of processing calories) Pt. #27's record lacked a nutritional assessment.

9. During an interview conducted with the Dietary Manager (E#18) on 7/23/15 at approximately 8:30 AM, E #18 stated; "Our dietitian quit a few years ago and we haven't hired another one. I have a food sanitation certificate. I ' m not qualified to do nutritional assessments or menu developments. I just manage the kitchen. Our doctors don't order nutritional consults. If they order a calorie count, I do that, but that doesn't happen very often. I don't know what is done for the tube feeding patients, I guess the nurses take care of that. If there is any nutritional assessments done for the patients, maybe the nurses do them. I don't know. If we have a specialized diet order I just consult the menu manuals. The manuals have not been updated, reviewed, or revised since the dietitian left several yeas ago. The last consultation report from E #20 was 3/8/15, that's the last time a dietitian would have looked at the menus and manuals."

10. During an interview conducted with the Chief Executive Officer (E#1) on 7/23/15 at approximately 9:30 AM, E #1 stated; "The digestion quit 6/1/13 and we have tried to get another one, but no one wants to come to the CAH. I was aware that we were required to have one. I placed ads in the local papers on 9/30/13, 9/25/13, and 11/30/13. I also have consulted with the local hospitals to see if we could share a dietitian. I forgot to continue to look for a dietary person. No nutritional assessments by a qualified individual have been done since 6/1/13. The dietary manual has not been reviewed since the dietitian left. We have no policies for the qualified dietary individual or nutritional assessments for acute care patients"

10. During an interview conducted with the Registered Nurse (E#19) on 7/23/15 at approximately 10:30 AM, E #19 stated; "The nurses do not do the nutritional assessments. We get their weight and ask about food allergies and likes. If calorie counts are ordered the kitchen does them." If there is any nutritional assessments done for the patients, I guess dietary or doctors do them."

No Description Available

Tag No.: C0289

Based on document review and interview, it was determined that for 5 of 5 patients (Pts #14, #24, #25, #26, #27) reviewed for nutritional assessments, the Critical Access Hospital (CAH) failed to ensure a qualified individual provided patient nutritional/dietary care services.

Findings include:

1. On 7/23/15 at approximately 12:30 PM, the document titled "State of Illinois-Food Sanitation Certificate" (expires 6/17/16 for E #18 was reviewed.

2. On 7/23/15 at approximately 12:45 PM, the document titled, "Monthly Dietician Visit...Consultation Report dated 3/8/13 and signed by Registered Dietitian (E#20) was reviewed.

3. Pt #14's record was reviewed on 7/24/15 at approximately 11:00 AM. Pt #14 was admitted on 6/3/15 with a diagnosis of Diabetes Mellitus (a metabolic disorder of processing calories). Pt #14's record lacked a nutritional assessment.

4. Pt #24's record was reviewed on 7/24/15 at approximately 9:00 AM. Pt #24 was admitted on 3/11/15 with a diagnosis of diabetes mellitus (a metabolic disorder of processing calories). Pt #24's record lacked a nutritional assessment.

5. Pt #25's record was reviewed on 7/24/15 at approximately 9:15 AM. Pt #25 was admitted on 3/8/15 with a diagnosis of diabetes mellitus (a metabolic disorder of processing calories). Pt #25's record lacked a nutritional assessment.

6. Pt #26's record was reviewed on 7/24/15 at approximately 9:30 AM. Pt #26 was admitted on 4/5/15 with a diagnosis of diabetes mellitus (a metabolic disorder of processing calories). Pt #26's record lacked a nutritional assessment.

7. Pt #27's record was reviewed on 7/24/15 at approximately 9:45 AM. Pt #27 was admitted on 4/20/15 with a diagnosis of diabetes mellitus (a metabolic disorder of processing calories). Pt #27's record lacked a nutritional assessment.

8 During an interview conducted with the Dietary Manager (E#18) on 7/23/15 at approximately 8:30 AM, E #18 stated "Our dietitian quit a few years ago and we haven't hired another one. I have a food sanitation certificate. I'm not qualified to do nutritional assessments or menu developments. I just manage the kitchen. Our doctors don't order nutritional consults. If they order a calorie count, I do that, but that doesn't happen very often. I don't know what is done for the tube feeding patients. I guess the nurses take care of that. If there is any nutritional assessments done for the patients, maybe the nurses do them. I don't know. If we have a specialized diet order, I just consult the menu manuals. The manuals have not been updated, reviewed, or revised since the dietitian left several yeas ago. The last consultation report from E #20 was 3/8/13, that's the last time a dietitian would have looked at the menus and manuals."

9. During an interview conducted with the Chief Executive Officer (E#1) on 7/23/15 at approximately 9:30 AM, E#1 stated "The dietitian quit 6/1/13 and we have tried to get another one, but no one wants to come to the CAH. I was aware that we were required to have one. I placed ads in the local papers on 9/30/13, 9/25/13, and 11/30/13. I also have consulted with the local hospitals to see if we could share a dietitian. I forgot to continue to look for a dietary person. No nutritional assessments by a qualified individual have been done since 6/1/13. The dietary manual has not been reviewed since the dietitian left."

10. During an interview conducted with the Registered Nurse (E#19) on 7/23/15 at approximately 10:30 AM, E#19 stated "The nurses do not do the nutritional assessments. We get their weight and ask about food allergies and likes. If calorie counts are ordered the kitchen does them." If there is any nutritional assessments done for the patients, I guess dietary or doctors do them."

No Description Available

Tag No.: C0297

A. Based on document review and interview, it was determined for 1 of 2 (Pt #21) patient with orders for Lasix to be given in between units of blood, the Critical Access Hospital (CAH) failed to ensure all medication orders included the route of administration.

Findings include:

1. The policy titled "Medication Administration" (revised 12/2011) was reviewed on 7/23/15 at approximately 3:30 PM. The policy stated under "Procedure: 1. c. Orders are verified with the provider if a question is raised regarding the medication, dosage, route..."

2. The policy titled "Physician and Mid-Level Provider Orders Verbal, Faxed, and Telephone orders" (revised 08/2008) was reviewed on 7/24/15 at approximately 9:00 AM. The policy stated "Procedure: 9. All orders that are unclear must be clarified with the provider prior to carrying out the order."

3. Pt #21's record was reviewed on 7/23/15 at approximately 2:40 PM with the Chief Nursing Officer (CNO) (E#4). Pt #21 was admitted, as an outpatient, with the diagnosis of Anemia for a blood transfusion. On 7/14/15, there was a physician's order to transfuse 2 units of packed red blood cells and "40 mg Lasix between each unit." The order lacked what route the Lasix was to be administered by.

4. An interview was conducted with E#4 on 7/24/15 at approximately 2:40 PM at the time of the record review. E#4 stated the nurse and/or the pharmacist should have contacted the physician to clarify the route prior to giving the Lasix. E#4 further stated the nurse should not assume it was to be given IV although "that is the usual order".

B. Based on document/record review and interview, it was determined for 1 of 23 (Pt #19) patients, the Critical Access Hospital (CAH) failed to ensure all medications and treatments were administered in accordance with Physicain orders.

Findings include:

1. The policy titled "Oxygen Administration" (revised 02/2011) was reviewed on 7/24/15. The policy stated "Oxygen is a medication and is therefore administered by order of a physician. In emergency situations, a nurse may initiate oxygen before calling the physician."

2. The policy titled "Orders for Emergent Situations" (revised 04/2013) was reviewed on 7/24/15 at approximately 9:00 PM. The policy stated "Procedure: 3. Order sets... Respiratory distress, Tachypnea or Hypoxemia: 2. Administer oxygen... to maintain a pulse oximetry of > (greater than) 92%."

3. Pt #19's record was reviewed on 7/23/15 at approximately 12:30 PM. Pt #19 was admitted from the Emergency Department to the Medical Surgical floor on 4/17/15 with the diagnoses Metastatic Cancer, Dehydration and Hypotenstion. On 4/18/15 at 1:03 AM, the Medical Surgical nursing admission note stated Pt #19 was received to the floor with "O2 (oxygen) at 2 via nasal cannula and 8 via simple mask. Cannula removed and at 8 via simple mask..." Nursing documentation stated throughout Pt #19's stay O2 was on and was changed to nonrebreather and increased flow to 15 liters per minute. There was no physician order for the oxygen on the Medical Surgical floor and no order to initiate the standing "Orders for Emergent Situations."

4. An interview was conducted with the Chief Nursing Officer (E#4) on 7/23/15 at approximately 3:00 PM. E#4 reviewed the record of Pt #19 and verbally agreed there were no physician orders for the oxygen or to initiate the Orders for Emergent Situations on the Medical Surgical floor and there should have been,

C. Based on document/record review and interview, it was determined for 2 of 23 (Pts #19, #20) patients, the Critical Access Hospital failed to ensure telephone orders were put into writing and that all telephone orders were authenticated in accordance with its policy.

Findings include:

1. The policy titled "Physicain and Mid-Level Provider Orders Verbal, Faxed, and Telephone orders" (revised 08/2008) was reviewed on 7/24/15 at approximately 9:00 AM. The policy stated "Procedure: 4. Telephone orders are to be used sparingly, the order should be reviewed and signed (authenticated) as soon as possible. It is recommended that telephone orders be signed during the next visit to the hospital unit."

2. Pt #19's record was reviewed on 7/23/15 at approximately 12:30 PM. Pt #19 was admitted on 4/17/15 with the diagnoses Metastatic Cancer, Dehydration and Hypotenstion.
a. On 4/19/15 at 6:46 AM, nursing progress notes stated "... Telephone orders received to change IVF (intravenous fluids) to D5NS (5% Dextrose in 0.9% Sodium Chloride) rate 125 ml (milliliters)/hr (hour). Nursing documentation indicated this IV fluid was started at 6:43 AM and was discontinued at 10:14 AM when the physician changed the order to D5 1/2 NS (5% Dextrose in 0.45% Sodium Chloride) at 42 ml/hr. The telephone order was not put into writing, or entered into the computer, and signed by the physician.
b. Examples of telephone orders not signed in accordance with the CAH policy:
On 4/18/15, there were physician telephone orders for Enoxaparin 30 mg subcutaneous daily and Zantac 50 mg IV piggyback every 12 hours. On 4/19/15, there was a physician telephone order for Morphine Sulfate 3 mg IV push every 3-4 hours as needed. As of 7/24/15 at 12:00 PM, the orders had not been authenticated by the ordering physician.

3. Pt #20's record was reviewed on 7/23/15 at approximately 1:15 PM. Pt #20 was admitted on 4/5/15 with the diagnosis Hepatic Encephalopathy.
a. Examples of telephone orders not being authenticated in accordance with CAH policy:
On 4/6/15, there were Physicain telephone orders for Nexium 40 mg IV every 24 hours, Lorazepam 1 mg sublingual every 4 hours as needed and Atropine Ophthtalmic solution 1% 2 drops sublingual every 2 hours as needed. As of 7/24/15 at approximately 12:00 PM, the orders had not been authenticated by the ordering Physicain.

4. An interview was conducted with the Chief Nursing Officer (E#4) on 7/23/15 at approximately 3:00 PM. E#4 reviewed Pts #19 and #20's records and verbally agreed the D%NS at 125 ml/hr was not put into writing, or entered into the computer, for the Physicain to sign on Pt #19 and both Pts #19 and #20 had telephone orders that had not been authenticated by the Physicain and they should have been.

5. An interview was conducted with the Chief Executive Officer (E#1) on 7/24/15 at approximately 12:00 PM. E#1 stated awareness of the findings of telephone orders not being authenticated by the physicians. E#1 stated Medical Records was not aware these orders had not been signed.

No Description Available

Tag No.: C0298

A. Based on document review and interview, it was determined for 3 of 20 (Pts #10, #11, #12) patients, the Critical Access Hospital failed to ensure the plan of care (POC) included goals specific to patient care needs. (see tag 294)

Findings include:

1. Pt #10's record was reviewed on 7/22/15 at approximately 8:00 AM. Pt #10 was admitted on 7/8/15 with a diagnosis of Pneumonia (lung infection). The record noted Pt. #10 was rated as high for fall and skin risk. The plan of care had no specific goals related to the high fall and skin risk.

2. Pt #11's record was reviewed on 7/22/15 at approximately 8:30 AM. Pt #11 was admitted on 7/13/15 with a diagnosis of Obstructive Bronchitis (lung fluid). The record noted Pt #11 was rated as high for fall and skin risk. The plan of care had no specific goals related to the high fall and skin risk.

3. Pt #12's record was reviewed on 7/22/15 at approximately 9:00 AM. Pt #12 was admitted on 6/8/15 with a diagnosis of Obstructive Bronchitis (lung fluid). The record noted Pt #12 was rated as high for fall risk. The plan of care had no specific goals related to the high fall risk.

4. During an interview with Chief Executive Officer (E #1) on 5/22/15 at 3:00 PM, E #1 stated there were "no POC specific goals for Pt. 10's fall and skin risk Pt. #11's fall and skin risk, or Pt. #12's fall risk. We have no policy on patient care planning."