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Based on a review of Medical Staff Bylaws, a review of Deficiency Report by Physician, and staff interview, it was determined the Hospital failed to ensure its Medical Staff enforced its Bylaws for the suspension of physicians who had delinquent records 25 days after discharge. This has the potential to affect 100% of patients serviced by the Hospital with a current average daily census of 8 patients.
Findings include:

1. The Medical Staff Bylaws (Approved May 12, 2010 and reviewed February 2013) were reviewed on 4/2/13. Both indicated "1.3 Administrative Suspension/ Revocation: 1.3-1 Medical Records: (a) Activation of Suspension: A Practitioner's patient charts shall be deemed delinquent if not completed by the fifteenth (15th) day following discharge of the patient... If a Practitioner fails to complete any delinquent charts within ten (10) days of receiving such warning, all of his or her Clinical Privileges shall be administratively suspended until all delinquent charts of his or her patients are completed to the satisfaction of the Chief of Staff and medical records department... (c) Notice: The Chief of Staff will give the affected Practitioner, CEO, and MEC Special Notice that Practitioner's admitting Clinical Privileges have been automatically suspended..."

2. The Deficiency Report by Physician for September 2012 thru March 2013 were reviewed on 4/2/13. It indicated the following Number of Drs with delinquent records between 25 but less than or equal to 30 days and the number of medical records affected.
September 2012: 8 Drs/ 15 medical records
October 2012: 1 Dr/ 2 medical records
November 2012: 4 Drs/ 9 medical records
December 2012: 8 Drs/ 14 medical records
January 2013: 5 Drs/ 7 medical records
February 2013: 3 Drs/ 5 medical records
March 2013: 7 Drs/ 8 medical records
There was no documentation to indicate any physicians had been Administratively suspended as of April 4, 2013.

3. During a staff interview, conducted with the Medical Record personnel in charge of monitoring delinquent medical records on 4/2/13 at 9:00 AM, the following was verbalized when asked to describe the Medical Staff Bylaw process related to delinquent medical records. It was verbalized that "letters are sent to physicians who have delinquent records at 15 days." When asked if there was any process after that such as suspension of privileges, it was verbalized that "no physicians have been suspended since I have been here (approximately 1 year)." On 4/2/13 at 3:15 PM, the Medical Staff Bylaws were reviewed with the Medical Staff person in charge of monitoring delinquent medical records, it was verbalized "I was unaware of any letters of suspension after the 25th day... or any letter/ notice sent by the Chief of Staff to the CEO and the affected physician." When asked how the Chief of Staff is notified of physicians with delinquent medical records, it was verbalized that "I verbally convey this to the Chief of Staff but there isn't any other follow up other than verbal reminders to the physicians." It was further clarified that "e-signatures were required and included in the delinquency finding as they are considered deficiencies."

4. During a staff interview, conducted with the CEO (assumed this position on 12/14/12) on 4/2/13 at 3:30 PM, it was verbalized that the CEO was unaware of the process delineated in the Bylaws and it was confirmed that the CEO had not received any notification of physician administrative suspension for delinquent medical records since assuming the CEO position.

5. During a staff interview, conducted with the Interim CNO on 4/3/13 at 10:00 AM, it was confirmed that no physicians had been administratively suspended due to delinquent medical records "not since probably the last 2, maybe 3 CEO's. We use to but with all the changes in the leadership, the CEO of the time stopped the suspension of privilege process for delinquent records."

6. During a staff interview, conducted with the Chief of Staff on 4/3/13 at 10:15 AM, the following was confirmed. The Chief of Staff was aware that letters were sent at 15 days and "I thought they (the Medical Record personnel in charge of monitoring delinquent medical records) sent the letters that were needed." When asked if the Chief of Staff was aware of the suspension process or aware of any physicians being suspended due to delinquent records, it was verbalized "I remember that in the past we were suspended if we didn't get our records done." It was further confirmed that the Chief of Staff was uncertain as to when this stopped and was unaware of any physicians being suspended for delinquent records.

A. Based on medical record review and staff interview, it was determined in 3 of 30 (Pts #19, #22, #28) medical records reviewed, the Hospital failed to ensure care was provided in accordance with physician orders.
Findings include:

1. The medical record of Pt #19 was reviewed on 4/3/13. Pt #19 was admitted to the Hospital on 1/14/13 with the diagnoses Renal Failure, Dehydration, Urinary Tract Infection, and Chronic Obstructive Pulmonary Disease and was discharged on 1/19/13. On 1/14/13, there were physician orders "Daily weight and Observe for Respiratory Distress... Pulse Ox every 4 hours..." There was no documentation of a weight being performed after 1/14/13 at 11:32 PM. There was no documentation to indicate a Pulse Ox was performed every 4 hours as ordered. On 1/14/13, ED documentation indicated "Stage 2 to coccyx and right heel large necrotic area to heel." There was no documentation to indicate physician orders for wound care. On 1/15/13 at 11:08 AM, nursing documentation indicated "Pressure Ulcer... telfa applied and wrapped in kerlix... Skin tear right forearm, adaptic applied and wrapped in kerlix." There was no documentation to indicate the physician was notified of the skin tear and no physician orders for skin tear wound care. On 1/15/13 at 3:51 PM, nursing documentation indicated "skin tear right forearm... dressing changed, steri strips placed times 3, telfa pad applied and wrapped in kerlix." There was no physician order.

2. The medical record of Pt #22 was reviewed on 4/3/13. Pt #22 was admitted to the Hospital on 1/14/13 with the diagnosis Right Knee Degenerative Joint Disease and underwent a knee replacement on 1/14/13. On 1/14/13, there was a physician order "Change dressing 1/16." There was no instruction as to what care to provide in relation to whether it needed to be cleaned, whether anything was to be applied, or what type of dressing to apply. On 1/16/13 at 3:04 PM, nursing documentation indicated "Change dressing on 1/16/13: Changed at 0900 20 staples intact minimal bleeding." On 1/15/13 at 11:45 AM, there was a physician order "Discontinue Foley." Nursing documentation indicated the Foley was not discontinued until 1/19/13 at 5:38 AM. There was no documentation to indicate the ordering physician was notified of the Foley not being discontinued and no order to keep the Foley.

3. The medical record of Pt #28 was reviewed on 4/3/13. Pt #28 was admitted to the Hospital on 2/15/13 with the diagnosis Left Buttock Decubitus. On 2/16/13 at 3:04 PM, nursing documentation indicated "Pressure Ulcer: left buttocks, duoderm in place." On 2/16/13 at 4:21 PM, nursing documentation indicated "Dressing Care: Dressing changed to left buttocks... duoderm placed." There was no physician order for care of the decubitus during and/or for the Duoderm.

4. During a staff interview, conducted with the Nurse Educator on 4/4/13 at 9:30 AM, it was confirmed that on Pt #19, the daily weights, and pulse ox orders were not followed as ordered. It was further confirmed that there were no orders for the wound care provided and/or documentation of physician notification concerning the occurrence of a skin tear for Pt #19. It was confirmed that physician orders were either not followed and/or were not received for the care provided on Pts #22 and #28.

B. Based on a review of Hospital policy, medical record review, and staff interview, it was determined 1 of 2 (Pt #22) medical records reviewed, in which the patient utilized PCA pain management, the Hospital failed to ensure its PCA protocol was followed.
Findings include:

1. The Hospital "PCA Dosage Protocols" (reviewed 12/12) was reviewed on 4/2/13. It indicated "Additional Orders: ... Monitor vital signs (BP, pulse, respirations), analgesia level and sedation level every 2 hours for the 1st eight hours, then every 4 hours while PCA device in use..."

2. The medical record of Pt #22 was reviewed on 4/3/13. Pt #22 was admitted to the Hospital on 1/14/13 with the diagnosis Right Knee Degenerative Joint Disease and underwent a knee replacement that day and was on a PCA pump postoperatively. Pt #22 returned to the Medical Surgical unit, from surgery, at 11:27 AM and utilized PCA for pain control until it was discontinued on 1/15/13 at 4:40 PM. There was no documentation to indicate Pt #22's vital signs and pain level were assessed, in accordance with the Hospital's policy.

3. During a staff interview, conducted with the Nurse Educator on 4/3/13 at 9:30 AM, it was confirmed that the PCA documentation of vital signs and pain level were not assessed, in accordance with the Hospital's policy and should have been. It was further verbalized that as of this time, "there isn't a PCA Flowsheet or specific documentation process" in place. "The nurses document the vital signs in the vital sign area and the pain assessment in their nursing assessment pain section."

Based on medical record review and staff interview, it was determined in 1 of 30 (Pt #19) medical records reviewed, the Hospital failed to ensure medication was administered in accordance with physician orders.
Findings include:

1. The medical record of Pt #19 was reviewed on 4/3/13. Pt #19 was admitted to the Hospital on 1/14/13 with the diagnoses Renal Failure, Dehydration, Urinary Tract Infection, and Chronic Obstructive Pulmonary Disease and was discharged on 1/19/13. On 1/14/13, physician orders indicated "... Metoprolol 100 mg by mouth daily." On 1/16/13 at 2:17 PM, MAR documentation indicated "Omitted: Hold Order." There was no physician order to hold the Metoprolol and no documentation to indicate the physician was notified the dose was held.

2. During a staff interview, conducted with the Nurse Educator on 4/4/13 at 9:30 AM, it was confirmed that on Pt #19, the Metoprolol orders were not followed as ordered. It was further confirmed that there were no orders for the holding of the Metoprolol for Pt #19.

Based on review of policy and procedure, medical record review and staff interview, it was determined in 1 of 30 (Pt #16) medical records reviewed, the Hospital failed to ensure patient forms in the medical record were properly identified.
Findings include:

1. The policy titled "Content of Medical Record" (implemented 7/12) indicated that the patient's medical record shall include all significant clinical information pertaining to the patient and all medical records "contain sufficient information to identify the patient".

2. A medical record review of Pt #16 was conducted on 4/3/13 at 2:00 PM. Pt #16 was admitted 3/13/13 for altered mental status due to kidney failure. Pt #16's medical record included a form titled "An Important Message From Medicare About Your Rights" which was signed on 3/13/13 although no patient identifier was on the form to indicate who the representative signed for. During a review of Pt #16's medical record, a Patient Progress Note by Case Management was labeled with a name, physician, allergies, age, sex, room number and medical record number which did not match the chart patient identifier being reviewed.

3. The Staff Educator and the Director of Medical records confirmed that Pt #16's chart included "An Important Message From Medicare About Your Rights" form which did not have a patient identifier and a Patient Progress Note by Case Management was misfiled.

Based on review of policy and procedure, medical records review and staff interview, it was determined the Hospital failed to ensure in 2 of 30 (Pt #5 and #16) medical records reviewed, a consent for treatment was obtained by patient or patient's representative during course of hospitalization and completed in accordance to the Hospital policy.
Findings include:

1. The review of the policy titled "Administration Policy, Authorizations and Consents" (Revised 11/12) was conducted on 4/3/13. "Policy: To the extent possible, each patient treated, except in case of emergency situation, should have an authorization for treatment signed by the patient or his legally recognized representative. In the section titled "General Information: 1. The patient must sign an authorization whenever possible. If the patient is unable to sign because of... a nearest relative may sign. Document why the patient did not sign. 3. ...Telephone authorization must be witnessed by a second person listening to the conversation. The witness and the person obtaining consent should sign the form."

2. A medical record review of Pt #5 was conducted on 4/3/13 at 2:00 PM. Pt #5 was admitted 3/31/13 for abdominal pain associated with ovarian cancer and pain control. A Consent to Treat was not signed as of 4/3/13.

3. A medical record review of Pt #16 was conducted on 4/3/13 at 11:00 PM. Pt #16 was admitted 3/13/13 for altered mental status related to kidney failure. The Telephone Authorization for Treatment dated 3/13/13 had a witness signature by the unit secretary although no indication who authorized the consent, the relationship to the patient or a second witness.

4. An interview was conducted on 4/3/13 at 2:30 PM with the Director of Medical Records and the Staff Educator who confirmed the Consent to Treat was not signed for Pt #5 prior to discharge. An interview was conducted on 4/3/13 at 11:30 PM with the Director of Emergency Services and Director of Financial Services who confirmed the Telephone Authorization for Treatment for Pt #16 did not identify the relationship or who authorized the consent, the consent was not witnessed by a second person, and the consent was not completed prior to discharge.

Based on a review of Hospital policy, medical record review, and staff interview, it was determined in 1 of 1 (Pt #30) medical records reviewed, in which the patient required VAC wound therapy, the Hospital failed to ensure its' VAC policy was followed.
Findings include:

1. The Hospital policy titled "Negative Pressure Wound Therapy" (revised 11/09) was reviewed on 4/4/13. It indicated "3. Physician's orders for negative pressure wound care should contain the following elements: a. Location, b. Dressing change frequency... c. Dressing change technique... d. Wound cleansing with specified cleanser with each dressing change, e. Continuous or Intermittent negative pressure, f. Amount of negative pressure (usually 50 to 125 ..."

2. The medical record of Pt #30 was reviewed on 4/4/13. Pt #30 was admitted to the Hospital on 1/29/13 with the diagnosis Diabetic Foot Ulcer and underwent Incision and Debridement and insertion of wound VAC device on 2/5/13. There were no physician orders as to what pressure setting, type of foam, frequency of dressing change, or mode of therapy to use with the wound VAC. There was no documentation to indicate the wound VAC was changed until 2/10/13. There was no documentation to indicate what the pressure setting, frequency of dressing change, or mode of therapy was throughout the hospitalization.

3. During a staff interview, conducted with the Interim CNO on 4/4/13 at 1:45 PM, it was verbalized that it was expected that the Negative Pressure Wound Therapy policy would be followed. The policy was retitled in place of VAC to include all forms of negative pressure wound therapy. It was further confirmed that there were no physician orders inclusive of all the elements necessary to provide VAC dressing changes for Pt #30.

Based on a review of Hospital policy, a review of Deficiency Report by Physician, and staff interview, it was determined the Hospital failed to ensure its Medical Staff completed medical records within 30 days after discharge. This has the potential to affect 100 % of patients serviced by the Hospital with a current average daily census of 8 patients.
Findings include:

1. The Hospital policy titled "Content of The Medical Record" (implemented 7/12) was reviewed on 4/4/13. It indicated "Completion of the medical record in regard to documentation and authentication shall be within 30 days following discharge."

2. The Deficiency Report by Physician for September 2012 thru March 2013 were reviewed on 4/2/13. It indicated the following Number of Drs with delinquent records greater than 30 days post discharge and the number of medical records affected with the range of days delinquent.
September 2012: 8 Drs/ 16 medical records (between 31- 121 days)
October 2012: 3 Dr/ 11 medical records (between 34- 63 days)
November 2012: 3 Drs/ 10 medical records (between 31- 92 days)
December 2012: 11 Drs/ 27 medical records (between 31- 97 days)
January 2013: 11 Drs/ 20 medical records (between 34- 113 days)
February 2013: 14 Drs/ 25 medical records (between 31- 141 days)
March 2013: 17 Drs/ 34 medical records (between 31- 92 days)

3. During a staff interview, conducted with the Medical Record personnel in charge of monitoring delinquent medical records on 4/2/13 at 3:15 PM, the following was verbalized when asked to describe the process related to delinquent medical records greater than 30 days. It was verbalized that "I verbally convey this to the Chief of Staff but there isn't any other follow up other than verbal reminders to the physicians." It was confirmed that the Medical Record personnel in charge of monitoring delinquent medical records was aware of the physicians with delinquencies greater than 30 days post discharge.

4. During a staff interview, conducted with the CEO (assumed this position on 12/14/12) on 4/2/13 at 3:30 PM, it was confirmed that the CEO was unaware of the physicians with delinquent medical records greater than 30 days post discharge since assuming the CEO position.

5. During a staff interview, conducted with the Chief of Staff on 4/3/13 at 10:15 AM, the following was confirmed. It was confirmed that the Chief of Staff was unaware of the number of physicians with delinquent medical records greater than 30 days post discharge.

Based on observation, staff interview and document review during the Life Safety portion of the Full Survey due to a Complaint survey conducted on April 2, 2013 as a follow-up to an Initital Critical Access Hospital survey conducted on December 12, 2012, the surveyor finds that the Facility is not constructed and maintained as a safe environment for patients. See Tag A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Full Survey Due to a Complaint conducted on April 2, 2013 as a Follow-up survey of an Initial Critical Access Hospital Survey conducted on December 12, 2012, the surveyors find 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 4/2/13.

Based on Review of policy and procedure, medical record review and staff interview, it was determined in 4 of 23 (Pts #16, 24, 28, 30) medical records reviewed in which the patient was discharged or transferred tp another faciltiy, the Hospital failed to ensure accurate discharge information/instructions were ordered and provided to the patient and or provider to ensure appropriate follow up care is provided.
Findings include:

1. A review of the policy titled "Medication Reconciliation" (Revised 8/12) was conducted on 4/4/13. The Nursing policy stated under "Procedure. 7. At the time of transfer, the transferring hospital informs the next provider of... reconciled medications. 8. When the patient is discharged an updated medication list is provided to the next provider... this communication is documented."

2. A review of the Pharmacy policy titled Medication Reconciliation" (dated 01/06) stated under "Procedure. 4. Whenever the patient moves to a new level of care or orders are required to be rewritten... an updated medication list will be provided to the next provider and/or the patient upon discharge."

3. A review of the policy titled "Discharge Planning" (Revised 2/13) indicated under "B. Roles in Discharge Planning... 2. Nurses...c. Provide patient, family, or caregivers with the discharge instruction sheets...1. Medication Reconciliation... 5. Home needs...8. Referrals..."

4. A medical record review of Pt #16 was conducted on 4/3/13 at 2:00 PM. Pt #16 was admitted 3/13/13 for altered mental status due to kidney failure. The patient was transferred to another facility for dialysis needs on 3/14/13 at 4:45 PM. The Medication Reconciliation Report printed and dated 3/14/13 at 5:56 PM and was signed by the physician at 6:00 PM, after the patient was transferred, and did not indicate if Current Medications ordered were to continue or discontinue.

5. A medical record review of Pt #24 was conducted on 4/3/13 at 1:00 PM. Pt #24 was admitted 3/17/13 for possible trans ischemic attack and cardiac arrhythmia. The Medication Reconciliation Report printed and dated 3/19/13 at 10:05 AM was completed by the physician 3/19/13 at 10:08 AM. The Nursing Home Patient Transfer completed by the physician 3/19/13 at 10:08 AM indicated to see the medication reconciliation for which medications to continue after discharge. The Patient Transfer Form indicated the following medications as active although discontinued on the Medication Reconciliation form: Haloperidol 5 mg/ml intramuscular injection every 4 hours as needed, Nitrostat 0.4 mg tablets sublingual every 5 minutes times three doses as needed, Lorazepam 2 mg/ml intravenous push every four hours as needed, Meloxicam 15 mg orally daily, 5% Dextrose/0.9 Normal Saline with 20 meq of Potassium to infuse at 100 ml per hour intravenously, Ferrous Sulfate 324 mg tablet orally daily and Lactulose Syrup 30 ml orally twice daily as needed. The Patient Transfer Form did not include medications which were ordered as to continue on the Medication Reconciliation Report by the physician such as: Ferrous Sulfate 325 mg orally daily, Generlac 20 ml orally twice daily, Milk of Magnesia 30 ml orally twice daily as needed and the Mupirocin 2% ointment to nares daily for 10 days did not indicate the start date or the end date. The patient was transferred to a nursing home on 3/19/13 at 1:20 PM.

6. The medical record of Pt #28 was reviewed on 4/3/13. Pt #28 was admitted to the Hospital on 2/15/13 with the diagnosis Left Buttock Decubitus. On 2/15/13 at 4:53 PM, nursing Initial Interview documentation indicated "Previous Hospitalization and/or Illness: May 5, 2012 Surgery on left buttock decubitus..." On 2/15/13 at 8:48 PM, nursing documentation indicated Pt #28 has been "going to Wound Clinic... was due to go today." The Physician's "Discharge Summary" indicated "She continues to follow up with Wound Therapy as an outpatient." On 2/18/13, Pt #28 was discharged from the Hospital with a duoderm in place; however, there were no orders to indicate what type of wound care Pt #28 was to use at home or whether the patient was to resume visits to the Wound Clinic.

7. The medical record of Pt #30 was reviewed on 4/4/13. Pt #30 was admitted to the Hospital on 1/29/13 with the diagnosis Diabetic Foot Ulcer and underwent Incision and Debridement and insertion of wound VAC device on 2/5/13. Pt #30 was discharged home with a PICC line for IV antibiotics and with the wound VAC and Home Health to follow on 2/10/13. Discharge orders and instructions failed to include orders or instructions for the care and maintenance of the PICC. It also failed to include orders or instructions for the VAC pressure setting, type of foam, and mode of therapy.

8. An interview with the Staff Educator was conducted on 4/3/13 at 2:30 PM. The Staff Educator reported that the Medication Reconciliation Report, Patient Transfer Form and the Nursing Home Transfer Form if indicated are all sent with the patient at discharge or at time of transfer. The Staff Educator confirmed the Patient Transfer Form and the Medication Reconciliation Report for Pt #16 was completed after discharge and the Medication Reconciliation Report did not indicate to continue or discontinue the current medications. The Staff Educator was unable to confirm how the information was provided to the receiving facility since it was completed after the patient had been transferred. The Staff Educator confirmed that Pt #24's Transfer Form and Medication Reconcilliation did not accurately reflect one another. On 4/3/13 at 3:15 PM the Staff Educator verified that there were no orders to indicate what type of wound care Pt #28 was to use at home or whether the patient was to resume visits to the Wound Clinic. On 4/3/13 at 1:15 AM the Staff Educator verified that there were no discharge orders or instructions for Pt #30 for the maintenance of the PICC or the Wound VAC.



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Based on a review of Hospital policy and procedures, medical records and staff interview, it was determined that in 1 of 1 (Pt # 12) medical record reviewed in which a patient required mechanical ventilation and Bi Level Positive Airway Pressure (BIPAP), the Hospital failed to ensure a physician order was obtained for ventilator settings and for the BIPAP.
Findings include:

1. The Respiratory Therapy Policy and Procedure Manual, Departmental Operations Guide (Revised 12/09) was reviewed on 04/04/13. Under "Shift report" it indicated "Respiratory care can only be administered or discontinued under a specific written, verbal, telephone, or note order from a physician."

2. The medical record of Pt #12 was reviewed on 4/2/13. It indicated Pt #12 was admitted on 02/06/13 with a diagnosis of Sepsis. The "Emergency Department Nursing Record" dated 02/06/13 indicated "BIPAP initiated by Respiratory Therapist" at 3:30 PM. There was no documentation to indicate a physician order was written for the BIPAP. The "Ventilator Flowsheet" dated 02/06/13 and 2/7/13 indicated Pt #12 was on a ventilator at 6:05 PM. There was no documentation to indicate a physician order was written for ventilator settings.

3. During an interview with the Chief Nursing Officer (CNO) on 04/03/13 at 12:00, it was determined that a physician order must be obtained prior to patients being placed on BIPAP or mechanical ventilation. The CNO indicated that during an "emergency situation" the Respiratory Technician "usually puts the patient on a ventilator with the correct settings according to the clinical status of the patient then either gets a verbal or written order from the physician".