HospitalInspections.org
Bringing transparency to federal inspections
KOHALA HOSPITAL
PATIENT CARE POLICIES
Tag No.: C0982
Based on interviews and record review, the facility failed to monitor polices governing the total operation and ensure policies are administered to provide quality health care in a safe environment.
Findings include:
An interview and record review were done on March 17, 2022, at 11:10 AM. The administrator provided the bylaws of the facility to this surveyor. The bylaws Governing Body approval was dated 08/21/2008. The administrator stated, "I know it's outdated, and it's being reviewed at this time". Upon review of the bylaws, there was no signature of an individual identifying who assumes responsibility or ownership of the bylaws.
An interview was done on March 17, 2022, at 12:45 PM with the Director of Nursing (DON). Several policies were requested. Policy reference #2076, #1980, 2350, #2234 and #2466 were approved on the days they were requested, i.e., 03/17/22 and 03/18/22. Queried why the policies were updated when requested in which DON responded that they were being updated.
This deficient practice demonstrates the lack of participation in the development and review of policies governing the Critical Access Hospital (CAH).
RECORDS SYSTEM
Tag No.: C1110
Based on interviews and record review, the facility failed to maintain records of a discharge summary for all 21 of 21 residents discharged from the facility into the swing unit.
Findings include:
A concurrent record review and interview was done on 03/18/22 at 09:30 AM with Registered Nurse (RN)1. This surveyor queried regarding the discharge summaries for all the residents in the swing unit. RN1 confirmed that there were no discharge summaries dictated when all the patients were transferred from the long term facility to the Swing beds in the Critical Access Hospital.
SPECIAL REQUIREMENTS FOR CAH PROVIDERS LTC
Tag No.: C1600
Based on interviews and record review, the facility failed to maintain documentation in the medical records of efforts for nursing facility placement for 21 out of 21 patients in the swing unit.
Findings:
Record review was done on 03/18/22 at 0900 AM of the patient's charts. There was no documentation regarding efforts to place the Critical Access Hospital (CAH) patient's to nursing facilities.
On 03/18/22 at 10:15 AM, query was made with administrator regarding documentation for patient's in the swing beds to nursing facility placement. Administrator stated that he was not aware that the facility needed to document attempts for nursing facility placement.