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Based on interview, the critical access hospital failed to obtain a written agreement for credentialing services provided by another hospital.

Findings include:

On 9/5/13, at 2:15 p.m. credentialing of medical staff review was completed with the administrator and credentialing specialist (CS). The CS stated that she works at Essentia Health - Fosston but provides credentialing services for several of the Essentia facilities in the northern part of MN, including Essentia Health Ada critical access hospital. The administrator indicated credentialing of medical staff was done by CAH staff until approximately nine months ago. CS verified it had been since that time that she took over the role of credentialing services.

The administrator verified on 9/6/13, at 10:30 p.m. there was no agreement related to credentialing services, and the CAH did not have a policy specific to agreements for credentialing.

Based on interview, the critical access hospital failed to obtain a written agreement for telemedicine services provided for patients at the CAH.

Findings include:

On 9/5/13, at 2:00 p.m. the director of nursing and administrator verified the CAH has been providing radiology services via telemedicine for some time, and within the past week began providing telemedicine through the emergency department. The DON stated the physicians and nurses were educated on how to provide these services last week, but staff have not used the service at that time. A physician at Essentia Health in Fargo could be available to assist the CAH's medical staff in assessing and treating patients with an emergent condition. Telemedicine equipment was observed in the emergency department on 9/5/13, at 9:00 a.m..

On 9/6/13, at 10 a.m. the administrator verified there was no written agreement with Essentia Health - Fargo to provide telemedicine services, which would address credentialing and privileges of the medical staff providing these services.

Based on interview, the governing body of the critical access hospital (CAH) failed to ensure a written agreement for telemedicine services provided for patients at the CAH was obtained.

Findings include:

On 9/5/13, at 2:00 p.m. the director of nursing and administrator verified the CAH has been providing radiology services via telemedicine for some time, and within the past week began providing telemedicine through the emergency department. The DON stated the physicians and nurses were educated on how to provide these services last week, but staff have not used the service at that time. A physician at Essentia Health in Fargo could be available to assist the CAH's medical staff in assessing and treating patients with an emergent condition. Telemedicine equipment was observed in the emergency department on 9/5/13, at 9:00 a.m..

On 9/6/13, at 10 a.m. the administrator verified there was no written agreement with Essentia Health - Fargo to provide telemedicine services, which would address credentialing and privileges of the medical staff providing these services.

Review of the Governing Board Minutes from the last meeting held on July 24, 2013, failed to address telemedicine services through the emergency department being approved.

Based on interview and document review, the critical access hospital (CAH) failed to ensure the governing body approves reappointment of physicians and midlevels to the medical staff for 3 of 10 (MD-B, MD-C, MD-D) credential files reviewed.

Findings include:

On 9/5/13, at 2:15 p.m. credentialing of medical staff review was completed with the administrator and credentialing specialist (CS). The CS stated she had taken over the credentialing services for the CAH approximately nine months ago. She stated there were some providers who have not been reappointed timely during the transition. The previous credential files had been scanned into files on the computer by the staff person responsible for credentialing (who is no longer employed by the CAH), and the hard copy of the files could not be located. The CS stated she is working on getting the timing of the reappointments to coincide with other facilities. She had developed a spread sheet and was working on getting the credentialing files current.

Physician (MD)- B was due for reappointment to the medical staff in 4/13. The CS provided a copy of the application for reappointment which included requested privileges and other background information which will be presented at the next medical staff meeting in October 2013. She verified on 9/5/13, at 2:30 p.m. the reappointment was not timely.

MD-C was due for reappointment to the medical staff in 6/13. The CS stated on 9/5/13, at 2:30 p.m. the application for reappointment and credentialing information will be presented to medical staff in October 2013.

MD-D was recommended for reappointment to the medical staff on 10/26/11, but the governing body did not approve the reappointment. The Governing Board (GB) minutes for 10/26/11, failed to address reappointment of MD-D. The administrator verified on 9/6/13, at 10:00 a.m. there was no documentation of the GB approving MD-D for reappointment.

Based on interview and document review, the critical access hospital (CAH) failed to provide appropriate emergency services during a cardiac arrest for 1 of 1 patient (P12) death record reviewed.

Findings include:

P12 had been admitted to the CAH on 2/4/13, with complaints of nausea, vomiting and diarrhea. P12 was diagnosed with gastroenteritis, dehydration and had a history of congestive heart failure. Review of P12's medical record revealed he was administered various medications, intravenous (IV) fluids, and nasal oxygen on admission to the facility. P12 was weak, shaky and required assistance with repositioning and transferring. P12 reported intermittent nausea, abdominal discomfort and had episodes of vomiting. On 2/5/13, at 4:40 p.m. P12 reported worsening abdominal cramping pain and spit up brown/green sticky phlegm. P12 spit up again, foul odor material which tested positive for blood at that time. At 8:00 p.m., P12 continued to complain of abdominal pain and at 8:10 p.m., P12 was noted to be pale, did not feel good and had dark brown liquid coming from his mouth. P12 was suctioned for dark brown liquid, was noted not to be breathing and had no pulse. The attending physician was present, emergency services personnel (paramedics) were called for assistance and cardiopulmonary resuscitation (CPR) started at that time. CPR continued, defibrillation done for ventricular tachycardia with no successful return of pulse or respirations noted at 8:27 p.m. At 8:38 p.m., CPR continued, P12 again had emesis and suctioning done. At 8:44 p.m. the physician intubated P12's airway, (a total of 34 minutes after cardiac arrest began.) P12 was suctioned for copious amounts of vomit during and after intubation. CPR continued with frequent shocking done for ventricular fibrillation without return of pulse. At 9:05 p.m., asystole was observed with no pulse noted, CPR stopped and P12 was pronounced dead. The record lacked documentation of oxygen levels immediately before and during cardiac arrest episode.

Review of the Hospital Progress Note/Death Summary dictated 2/6/13, revealed a summary of P12's hospital course and cardiac arrest. The summary identified on 2/5/13, at 8:00 p.m., P12 had complained of abdominal pain, attempted to void, had emesis and became unresponsive. Family present with P12 called for assistance and physician entered room and CPR initiated at that time. The summary identified four (4) paramedics responded quickly to help with the CPR. P12 had no pulse or respirations, placed on a cardiac monitor which demonstrated ventricular tachycardia and cardioversion was attempted. CPR continued, IV emergency medications were administered and further cardioversion attempted without success. The summary indicated further emesis occurred and vigorous suctioning was done. The summary identified P12 had been intubated after P12 experienced further emesis, however lacked documentation of the actual time P12 had been intubated and lacked documentation of oxygen levels for P12. CPR was stopped at 9:05 p.m., when asystole with only occasional electrical capture of pacemaker spikes occurred. The summary indicated the physician had close communication with the family and had persisted vigorously with resuscitative efforts at their request.

Review of P12's Ramsey County Medical Examiner's Office form completed by the physician on 2/6/13, identified the cause of death as acute aspiration secondary to emesis.

Review of the American Heart Association algorithm, advanced cardiovascular life support (ACLS) for cardiac arrest revealed placement of a endotracheal intubation was routine procedure for cardiac arrest response.

On 9/6/13, at 10:25 a.m., the director of ambulance services (DAS) confirmed the usual CAH practice was to call paramedics on duty to assist with acute emergencies in the hospital. She confirmed paramedics were ACLS certified, trained to intubate patients and also followed the American Heart Association protocol for cardiac arrest. The DAS indicated maintaining compressions and the patient's airway was the most important aspects of CPR. She indicated when vomiting occurs, the airway could not be protected and the vomitus could be forced into the patient's lungs with routine rescue breathing done. The DAS indicated suctioning and intubation "right away is the gold standard."

On 9/6/13 at 1:50 p.m., the director of nursing (DON) indicated there is increased potential for aspiration when patients are vomiting and confirmed vomiting and or aspiration could compromise oxygenation levels. The DON confirmed the facility followed the American Heart Association guidelines for cardiac arrest. The DON confirmed the physician and paramedics were present throughout the cardiac arrest and both the paramedics and hospital staff were ACLS certified. He confirmed the paramedics were trained in intubation techniques and also indicated the physician was trained in intubation technique. The DON confirmed no oxygen levels had been documented during P12's cardiac arrest, and the usual practice would be to confirm adequate oxygen levels during cardiac arrest. He confirmed P12 had not been intubated for 34 minutes after cardiac arrest occurred and stated he would of liked to see P12 intubated to protect his airway sooner however, he trusted his physician's decisions.

The physician (MD)-A was no longer working at the CAH and unavailable for interview.

The CAH was unable to provide policies related to CPR or intubation.

Based on interview and document review, the critical access hospital (CAH) failed to maintain clinical records in a manner to prevent alteration of patient information for 2 of 19 (P10, P11) closed patient records reviewed in the sample.

Findings include:

P10 had been admitted to the CAH on 3/18/13, with diagnosis of diabetic ketoacidosis. Review of P10's Hospital Admission History and Physical report, dictated on 3/18/13, revealed the report had been altered. The typed report included handwritten words under crossed out words in the report. However, the report lacked identification of the author of the handwritten words and lacked identification of origination of the crossed out words.

P11 had been admitted to the CAH on 6/24/13 with diagnoses of vomiting and headache. Review of P11's Hospital Admission History and Physical report, transcribed on 6/24/13, revealed the report had been altered. The typed report included a handwritten word over a typed word in the report. However, the report lacked identification of the author of the handwritten word and lacked identification of the origination of the written words of the report.

Review of the CAH policy titled Medical Record Signatures, dated 5/4/06, identified all entries in the medical record should include time, date and authentication.

On 9/6/13, at 1:05 p.m., the director of nursing confirmed the above findings and confirmed the current facility policy.

Based on interview and document review, the critical access hospital (CAH) failed to maintain medical records for all admitted patients that included a discharge summary of the hospital episode for 3 of 19
(P12, P13, P14) closed inpatient records reviewed.

Findings include:

P12 was admitted to the CAH on 2/4/13, with diagnosis of gastroenteritis. P12 expired after cardiac arrest on 2/5/13. P12's record lacked documentation of a discharge summary of the events of hospital stay.

P13 was admitted to the CAH on 2/11/13, with diagnoses of hypoxemia and influenza like illness. P13 was discharged from the hospital on 2/14/13, however, the record lacked documentation of a discharge summary of events of the hospital stay.

P14 was admitted to the CAH on 11/23/12, with diagnosis of buttocks boil. P14 was discharged from the hospital on 11/24/13, however, the record lacked documentation of a discharge summary of events of the hospital stay.

Review of the CAH policy titled Medical Records , dated 5/4/06, identified every medical record would include documentation of a discharge summary.

Review of the CAH policy titled Medical Records Analysis, revised 6/30/10, identified a discharge summary would be required on all inpatients and would be written or dictated as soon as possible, but no later than 20 days following discharge.

On 9/5/13, at 4:27 p.m., the director of nursing (DON) confirmed the current policy and confirmed P12, P13 and P14 lacked documentation of a discharge summary of the inpatient stay.

Based on interview and document review, the critical access hospital (CAH) failed to ensure the physician assumed full responsibility for history and physicals completed by mid level practitioners for 6 of 11 patients (P8, P17, P15, P19, P20, P14) admitted to the CAH. In addition, the CAH failed to ensure all diagnostic reports were signed timely by the appropriate personnel for 3 of 19 patients (P19, P21, P22) closed records reviewed.

Findings include:

History and Physicals

P8 was admitted to the CAH on 8/15/13, for a tonsillectomy. P8's History and Physical (H&P) dated 8/9/13, was completed by physician assitant (PA)-A, however, the H&P lacked the surgeons signature to indicated he/she had assumed full responsibility of the H&P.

P17 was admitted to the CAH on 9/28/12, by PA-A. PA-A completed the admission history and physical on 9/28/12, however, the record lacked a signature of a physician.

P15 was admitted to the CAH on 4/18/13, by PA-A. PA-A completed the history and physical on 4/18/13, however, the record lacked a signature of a physician.

P19 was admitted to the CAH on 11/8/12, by PA-A. PA-A completed the history and physical on 11/9/12, however, the record lacked a signature of a physician.

P20 was admitted to the CAH on 9/29/12, by PA-A. PA-A completed the history and physical on 9/30/12, however, the record lacked a signature of a physician.

P14 was admitted to the CAH on 11/23/12, by nurse practitioner (NP)-A. NP-A completed the admission history and physical on 11/24/12, however the record lacked a signature of a physician.

Diagnostic Tests

P19 had a magnetic resonance image (MRI) of the left foot done on 4/19/13. The report identified the results as preliminary, however, the record lacked documentation of a final report and lacked authentication by the radiologist.

P21 had a computed tomography (CT) scan of the neck soft tissue with contrast done on 5/16/13. The report identified the results as preliminary, however, the record lacked documentation of a final report and lacked authentication by the radiologist. In addition, P21 had a CT of the chest with contrast, two xrays of the abdomen and an xray with two views of the chest on 4/15/13. The reports identified the results as preliminary, however, the record lacked documentation of the final reports and lacked authentication by the radiologist.

P22 had a 12 lead electrocardiogram (EKG) done on 6/17/13. The documentation identified the results of the EKG had been authenticated on 6/25/13, a total of 8 days after the EKG had been performed.

Review of the CAH medical records polity titled Analysis, revised 6/30/13, revealed all patients admitted to acute care by a mid level provider would have the history and physical completed by the mid level practitioner counter signed by the MD/DO. Further, the policy identified medical records should be completed within 30 days after discharge and any records not completed within 30 days are considered delinquent.

On 9/5/13, at 8:50 a.m., the director of nursing (DON) confirmed the diagnostic results findings and stated he would expect the EKG should have been interpreted within a few hours of the test performed.

On 9/6/13, at 12:10 p.m. the DON confirmed the current facility policy and confirmed the above findings.


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Based on interview and document review, the critical access hospital (CAH) failed to ensure that each medical record entry had been properly authenticated with a timed and dated signature for 18 of 18 closed inpatient /emergency room /surgical records (P1, P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P13, P14, P19, P20, P23, P24, P25) reviewed in the sample.

Findings include:

P1 was admitted to the CAH's Emergency Department (ED) on 8/11/13. The Emergency Room record lacked the date and time of the physician assistant's (PA) signature.

P2 was admitted to the CAH's emergency department (ED) on 8/22/13. The Emergency Room Note dated 8/22/13, lacked the date and time of the physician's signature.

P3's physician order for an outpatient lower extremity x-ray dated 8/28/13, lacked the date and time of the physician's signature.

P4's physician order for an outpatient C (cervical)-spine Magnetic Resonance Imaging (MRI) dated 8/19/13, lacked the date and time of the physician's signature.

P5 was admitted to the CAH's ED on 7/19/13. The Emergency Room record lacked the date and time of the physician's signature.

P6 was admitted to the CAH on 5/23/13, for a hemorrhoidectomy. The general surgery office note dated 5/23/13, lacked the date and time of the physician's signature. P6's anesthesia record dated 5/23/13, lacked the physician's signature. P6's surgical instructions, section titled, Post-Op (operative) instructions for surgical patients lacked the time and date of the physician's signature.

P7 was admitted to the CAH on 6/6/13, for hernia repair. P7's History and Physical (H&P) dated 5/7/13, lacked the date and time of the physician's signature. P7's Surgical Instructions, section titled, Post-Op instruction for surgical patients dated 6/6/13, lacked the date and time of the physician's signature. P7's Standing Orders for post anesthesia care form dated 6/6/13, lacked the time of the physician's signature. The anesthesia record dated 6/6/13, lacked a physician's signature. In addition, the physician progress note titled Follow-up colonoscopy dated 5/7/13 lacked a dated physician signature.

P8 was admitted to the CAH on 8/15/13, for a tonsillectomy. P8's H &P dated 8/9/13, lacked the date and time of the PA's signature. P8's Surgical Instructions, section titled Post-Op instructions for surgical patients lacked a date and time of the physician's signature.

P9's physician order for an outpatient lumbar spine MRI dated 8/19/13, lacked the date and time of the physician's signature.

P10's telephone physician's orders dated 3/19/13, 3/18/13, 3/19/13, did not include a date and time of the physician's signature. Additionally, the Hospital Admission H & P (history and physical) dated 3/18/13, lacked the date and time of the physician's signature.

P11's hospital admission H &P dated 6/24/13, lacked the date and time of the physician's signature. The physician's telephone orders dated 6/24/13, (three), 6/25/13, lacked the date and time of the physician's signature. Additionally, the discharge summary dated 6/25/13, lacked the date and time of the physician's signature.

P13's clinic note/hospital admission H &P dated 2/11/13, lacked the date and time of the physician's signature. The telephone order dated 2/11/13, lacked the date and time of the physician's signature.

P14's telephone orders (three) dated 11/24/12, lacked a date and time of the physician's signature. The Chief Complaint form dated 11/23/12, lacked the date and time of the physician's signature.

P19's hospital admission H &P dated 11/8/12, lacked the date and time of the physician's signature. The Informed Consent for Advanced Directives For Medical Treatment dated 11/2, lacked the time of the physician's signature. Additionally, the discharge summary dated 11/9/12, lacked the date and time of the physician's signature.

P20's hospital admission H&P dated 9/29/12, lacked the time and date of the physician's signature. The hospital progress notes both dated 9/30/12, lacked the time and date of the physician's signature. Additionally, the telephone orders both dated 9/29/12, lacked the time and date of the physician's signature.

P23's physician medical entry note dated 1/1/13, and 1/2/13, lacked the time of the physician's signature. The physician order dated 1/1/13, lacked the time of the physician's order. The office note, admission note dated 12/31/12, lacked the date and time of the physician's signature.

P24's hospital admission H &P dated 1/10/13, lacked the date and time of the physician's signature. The progress note dated 1/12/13, lacked the date and time of the physician's signature. The discharge summary dated 1/13/13, lacked the date and time of the physician's signature.

P25's discharge summary dated 2/7/13, lacked the date and time of the physician's signature. The telephone physician order dated 1/25/13, lacked the dated and time of the physician's signature.

Review of the CAH policy titled Medical Record Signatures, dated 5/4/06, identified all entries in the medical record would include time, date and authentication.

Review of the CAH policy titled Acceptance of Verbal/Telephone Orders, effective 2/13, identified all orders verbal or telephone shall be authenticated as soon as possible by the responsible provider.

On 9/3/13, at 3:10 p.m. the director of radiology verified the physician orders were not dated and times and should have been.
On 9/6/13, at 12:10 p.m., the director of nursing (DON) confirmed the current facility policy and confirmed the above findings. The DON indicated he was aware the medical records lacked proper authentication.


28035