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Based on record review and staff interview, the hospital did not have the on call emergency physician in house within the thirty minute time requirement for 1 of 10 (P1) patient records who were admitted to the emergency room and who were assessed as needing to be seen by the emergency physician.

Findings include: P1 was seen in the emergency room and it took forty three minutes (43) from the time the emergency room physician was contacted to when the physician assessed the patient in person.

P1 arrived in the emergency room by ambulance at 3:50 a.m., on 7/18/11from the nursing home. The license nurse did an assessment and noted that the patient presented with complaints of abdominal pain and had received pain medication at the nursing home. The licensed nurse contacted the emergency physician at 4:07 a.m. with the assessment. The physician was then recorded on the Emergency Room Assessment to have arrived at " 0450 " or 4:50 a.m. which was forty three minutes after being contacted by the nurse. The EMERGENCY ROOM-OUTPATIENT RECORD completed by the physician stated, " Diagnosis: Ischemic Small bowel and plan is to transfer to ISJ [Immanuel St. Joseph hospital located in Mankato.] "

During an interview with the emergency room supervisor on 8/18/11 at 10:00 a.m. they agreed that the physician had not been in the hospital within the thirty minute requirement when contacted.

Based on staff interview and water agreement review, the Critical Access Hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency and how it will be distributed to all areas of the hospital. This had the potential to affect all patients, staff and visitors.

Findings include: The water agreements provided lacked specific information on how much potable and non-potable water will be needed according to patient census and hospital use. Also lacked how the water will be distributed to each department in need of potable and non-potable water.

During review of the CAH's emergency water agreement on 8/18/11 it was noted there was an agreement in place for water delivery in case of an interruption in normal water supply with Finken Water Centers, Arlington Fire Department and Geib Well and Water Services. The terms and conditions of the agreement stated, " In the event of an emergency Finken Water Center would be able to provide Sibley Medical Center with purified 5 Gallon Drinking Water Bottles and Water Dispensers. Amounts and locations would be determined at the time it is needed." The letter from the Arlington Fire Department stated, "Arlington Fire Department will supply non-potable water in a need of an emergency at the request of Sibley Medical Center." The agreement from Geib Well and Water Services stated, "In the event of a water disruption at Sibley Medical Center, Geib Well and Water Services will work to restore a temporary water supply. An above ground water line or use of a water truck would be used to supply water to the facility. At the time of the disruption we will work with the management to determine the best solution to the problem. In the event of a major catastrophe moving the patients to another hospital facility should be considered."

During interview with Maintenance Director at 8:20 A.M., on 8/18/11, he indicated he had not been aware of any plan which specified amounts of water required by the individual departments in the CAH, nor of the need to plan for specified amounts of potable versus non-potable water in the event of an emergency.

Based on staff interview and review of facility policies, the facility failed to develop and/or revise pharmacy policies with the advice of a group of professional personnel that included at least one or more doctors of medicine or osteopathy and one or more mid-level practitioner such as a physician assistant, nurse practitioner or clinical nurse specialist.

Findings include: Review of the critical access hospital (CAH) pharmacy policies related to: receipt and distribution of drugs; handling and dispensation of drugs; drug storage; system for labeling and management of outdated drugs; and administration of drugs and biologicals revealed that the policies had not been developed or reviewed by a group of professional personnel that included at least one or more doctors of medicine or osteopathy and one or more mid-level practitioner such as a physician assistant, nurse practitioner or clinical nurse specialist.

The registered pharmacist and chief nursing officer was interviewed on 8/17/11, at 3:23 p.m. during which they stated they confirmed that the pharmacy policy and procedures were not developed and signed authenticating that they had been developed and revised with the advice of a group of professional personnel that included at least one or more doctors of medicine or osteopathy and one or more mid-level practitioner such as a physician assistant, nurse practitioner or clinical nurse specialist.

Based on interview and policy review, the hospital failed to ensure the pharmacy policy related to authorized access to the pharmacy was current to the facility's practice.

Findings include: The pharmacy policy related to authorized access to the pharmacy was not current hospital practice.

Review of the policy dated as last revised 04/09 identified the following related to authorized access to the pharmacy: "1. The RN [registered nurse] pharmacy technician will be allowed to access the pharmacy prior to the pharmacist's arrival from 6:30 am to 8:30 am (limited to 2 hours) to set up patient orders for the pharmacist to verify orders and certify/check medications before they are delivered to the nursing station for patient use."

During interview with the registered pharmacist on 8/17/11, at 3:30 p.m. she stated that an RN pharmacy technician did not have access to the pharmacy. The registered pharmacist further stated that the only person that has access to the pharmacy during hours when the pharmacist is not in the pharmacy is the Registered Nurse Charge Nurse. The reregistered pharmacist confirmed that the policy related to authorized access to the pharmacy was not current.

Based on staff interview and review of facility policies, the facility failed to ensure that pharmacy policies were reviewed at least annually by the group of professional personnel required and reviewed as necessary by the CAH.

Findings include: Review of the CAH pharmacy policies related to: receipt and distribution of drugs; handling and dispensation of drugs; drug storage; system for labeling and management of outdated drugs; and administration of drugs and biological's revealed that the policies had not been reviewed and revised at least annually by a group of professional personnel.

The registered pharmacist and chief nursing officer had been interviewed on 8/17/11, at 3:23 p.m. during which they both confirmed that the pharmacy policy and procedures had not been reviewed and revised annually.

Based on record review and staff interview, the CAH failed to ensure that each medical entry by the physician and/or licensed nurse included a timed, dated and signature for 3 of 4 patients (P2, P3 and P4) reviewed who presented at the emergency room for care.

Findings include:

P2 was admitted to the emergency room on 7/22/11 at 5:00 p.m. The verbal order taken by the registered nurse had a date and signature but lacked the time of the entry. Also the emergency room physician completed the Physician ' s Signature but lacked the date and time of their entry.

P3 was admitted to the emergency room on 7/31/11 at 4:55 p.m. The physician ' s verbal order was written by a registered nurse and included the date of entry but lacked the time it was entered. It was also noted that the emergency room physician had signed the verbal order but lacked to enter the date and time of entry.

P4 was admitted to the emergency room on 8/3/11 at 9:20 a.m. The emergency room physician wrote orders, signed his/her signature however, did not include the date nor time of the entry. It is also noted that the emergency room registered nurse did not sign, date or time when the orders were completed as directed by the directions on the emergency room form which states, " nurses to check off and initial when Physician ' s orders are completed. "


On 8/16/11 at 10:00 a.m. it was verified with the emergency room supervisor that P2, P3, and P4 had entries that lacked the time and/or date the entry had been made by the author.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to identify who the responsible adult was when the patient was discharged after surgery or the surgeon who performed the surgery had a written exception in the medical record for the need of a responsible adult to accompany the patient when discharged from the hospital for 5 of 6 patients (P1, P3, P4, P5 and P6) reviewed who had surgery in the sample.

Findings include:

P1 had surgery on 7/20/11 with a local anesthesia.

P3 had surgery on 7/7/11 with general anesthesia.

P4 had surgery on 6/29/11 with a nerve block.

P5 had surgery on 7/13/11 with general anesthesia.

P6 had surgery on 6/1/11 with a nerve block.

After surgery P1, P3, P4, P5 and P6 were taken to the post anesthesia care unit (PACU). When the patients were alert and oriented in the PACU they were discharged from the hospital. However there had had been no documentation the patients were discharged in the company of a responsible adult.

During an interview on 8/18/11 at 9:14 a.m. with the operating room manager it was learned that the PACU staff generally don ' t document if the patients are discharged in the company of a responsible adult.