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The Critical Access Hospital (CAH) reported a census of ten inpatients including five skilled swing bed patients, three acute patients, one obstetrical and one newborn patient. Based on observation, medical record review, policy review, and staff interview the CAH failed to develop a system to identify and control infections or staff practices which could contribute to healthcare acquired infections of patients and personnel (C-0278), failed to meet the needs of patients (C-0294), failed to provide nursing care to meet the needs of patients (C-0295), failed to supervise and evaluate nursing care (C-0296), and failed to properly label intravenous tubing (C-0297).

The cumulative effect of the systematic failure to ensure the CAH develop a system to identify and control infections or staff practices, failure to meet the needs of patients, failure to provide nursing care to meet the needs of patients, failure to supervise and evaluate nursing care, and to properly label intravenous tubing resulted in the CAH's inability to provide care in a safe and effective manner.

The Critical Access Hospital (CAH) reported a census of ten inpatients including five skilled swing bed patients, three acute patients, one obstetrical and one newborn patient. Based on observation, document review and staff interview, the CAH's Infection Control Nurse failed to develop a system to identify and control infections or staff practices which could contribute to healthcare acquired infections of patients and personnel. Observations included two patients with a urinary catheter, one patient with a dressing change, one patient in contact isolation, one cleaning of a patient room, and staff administering intravenous (IV) medications to one patient. The CAH's failure to identify issues with infection control practices created the potential for healthcare acquired infections.

Findings include:

- The CAH's policy for the role of Infection Control Nurse reviewed on 5/6/14 at 11:35am directed, "...The Infection Control Nurse will be responsible for coordinating...surveillance, prevention, and management activities throughout the building..."

- The Catheter-associated Urinary Tract Infection (CAUTI) Toolkit core prevention strategies from the Center for Disease Control specific recommendations reviewed on 5/8/14 at 2:40pm recommended "...keep catheter collecting bag below level of bladder at all times (do not rest bag on floor)..."

- Observation on 5/5/14 at 10:00am in room 112 revealed a patient with their urinary catheter bag lying directly on the floor.

- The CAH's policy for Maintenance of IV solutions, reviewed on 5/6/14 at 3:35pm directed, "...Change IV tubing every 72 hours...Tag IV lines both primary and secondary with dates to facilitate proper changing..."

- Observation on 5/5/14 at 10:30am in room 110 revealed a patient with their urinary catheter bag lying directly on the floor and the patient's IV tubing lacked a label indicating when the tubing was started or when it need to be discontinued.

- Registered Nurse staff A, interviewed on 5/5/14 at 10:50am acknowledged the IV tubing lacked a label.

- The CAH's policy for hand hygiene reviewed on 5/6/14 at 11:35am directed, "...Hands should be decontaminated by washing with soap and water or use of alcohol hand rubs...before and after the use of gloves...between different wounds on the body..."

- Observation on 5/5/14 at 11:00am in room 110 revealed a urine spill on the floor. Housekeeping staff B entered the room with gloves and a mop to clean up the spill. Staff B mopped the urine off the floor, touched the urine soaked mop head with their gloved hands, placed the mop head in a bag and returned to the room without changing their gloves. Staff B touched the over-the-bed table, finished cleaning up the urine spill, returned to the cleaning cart in the hallway, placed the mop head in a bag, and removed their gloves without performing hand hygiene.

- Registered Nurse staff C, observed on 5/6/14 at 9:45am provided a dressing change to patient #5's back wound. Wearing gloves staff C checked the scrotum area, provided peri-care, removed the soiled gloves and reapplied glove without performing hand hygiene. Staff C removed the three soiled dressing from patient #5's back. The patient had a blister on the right lower back, a blackened area approximately two inches by one inch without drainage or odor on the lower mid back, and another blister type area above the blackened area. Staff C changed gloves without performing hand hygiene between glove changes then cleaned all areas with normal saline. Staff C changed gloves without performing hand hygiene and applied new dressings as ordered. Staff C dated the dressing change removed their gloves and performed hand hygiene.

- The CAH's directions for contact precautions posted at the door when contact isolation is required reviewed on 5/7/14 at 8:00am directed, "...gown upon entering...gloves upon entering..."

- Nurse Aide staff D, observed on 5/7/14 at 7:35, in room 103 a contact isolation room, with gown and gloves on sitting on a chair feeding patient #1. Staff D's gown covered the front of their scrubs but failed to cover the backside of their scrubs where they sat on a chair in the isolation room.

Registered Nurse staff E interviewed on 5/7/14 at 7:35am acknowledged staff D failed cover all their scrubs with a protective gown.

- Nurse Aide staff D observed on 5/7/14 at 11:15am in room 103 a contact isolation room, providing cares to patient #1 without the use of the required gloves and gown to enter the room. Staff D acknowledged they failed to have the required protective equipment on to be in an isolation room.

The Critical Access Hospital (CAH) reported a census of ten inpatients including five skilled swing bed (SSB) patients, three acute patients, one obstetrical and one newborn patient. Based on observation, document review and staff interview the CAH staff failed to meet the needs of patients and ensure nursing staff followed physician orders for monitoring vital signs for two of ten sampled patients (patient #'s 1 and 2), failed to complete nursing assessments of wounds/skin for one of five skilled swing bed sampled patients (#5), failed to follow the CAH's policy following a patient fall for one sampled patient with a fall (#5), and failed to answer a call light timely for one of five swing bed patients (#3). This deficent practice places patients at risk for inadequate care.

Findings include:

- Patient #1's medical record review on 5/5/14 revealed an admission to skilled swing bed (SSB) on 4/30/14 with diagnosis of congestive heart failure (CHF). Medical record review revealed a physician order on 4/30/14 at 9:40am for vital signs four times a day. The medical record revealed CAH staff obtained vital signs twice on 5/2/14 and three times on 5/3/14 not the ordered four times a day.

- Patient #2's medical record review on 5/5/14 revealed an admission to SSB on 4/20/14 with diagnosis of urinary tract infection (UTI). Medical record review revealed a physician order on 4/20/14 at 12:51pm for vital signs four times a day. The medical record revealed CAH staff obtained vital signs twice on 4/30/14, and three times on 5/3/14, not the ordered four times a day.

- Registered Nurse staff F interviewed on 5/5/14 at 2:45pm acknowledged CAH nursing staff failed to follow physician orders for vital sign four times a day to meet the needs of patient #1 and patient #2.

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. The medical record revealed an admission skin assessment "Has red area on right upper arm, patient states it is from last hospital stay at another hospital due to tape". The next skin assessment on 3/16/14 at 7:28pm noted "Abnormals: skin flushed, contusion, poor skin turgor". The skin assessment on 3/18/14 at 6:50pm noted, "Skin extremely dry, poor skin turgor". Patient #5's skin assessment throughout his acute admission remained the same. On admission to SSB on 3/19/14 patient #5's skin assessment indicated, " Skin pale, poor skin turgor". The skin assessment remained the same until 4/5/14 at 2:15pm with a nurses note indicating "wound, mucous membranes dry, tongue dry" and dressings applied, skin care protocol followed, wound to the lower right back, superficial, measures approximately 3cm x 2cm, red bed with minimal fibrin, cleaned with normal saline, covered with mepilex dressing. Old dressing has grayish/green and serous drainage with no odor. Patient #5's medical record lacked physician orders for a dressing change to the back on 4/5/14 and physician progress notes on 4/5/14 failed to indicate they were aware of the wound to patient #5's back. The next entry into the medical record regarding a wound on the back was on 4/19/14 at 8:55pm noting "daughter came out of room complained "my dad has a sore to his lower back". The note indicated sore to right lower back which is approximately half dollar size open area, black leathery in the middle and red raw around edges, and identified a new dime size reddened area above the wound. The nurse cleaned and redressed the wound. On 4/20/14 a consult was order with Physician staff G. Staff G's consult note on 4/20/14 indicated the patient developed a necrotic area on the right lower back 3cm x 2.5cm "likely due to heating pad" and indicated due to the patient's poor health would not do anything at this time. The wound care nurse ordered a Mepilex foam dressing and changed every 72 hours. Documentation in the medical record indicated patient #5 received a heating pad from staff to assist in pain management multiple times.

- Registered Nurse staff H, interviewed on 5/6/14 at 11:15pm, acknowledged they were the nurse on duty 4/19/14 when patient #5's family member came to the nurses' station and reported the dressing was off patient #5's back. Staff indicated there had been a dressing on patient #5's back and they had not seen the wound since the day shift did dressing changes. Staff H did monitor the dressing. When the dressing came off on 4/19/14 they cleaned the wound with normal saline and placed a Mepilex dressing. The next morning the patient had a consult with a doctor and the wound care nurse. Staff H indicated at times staff gave patient #5 "a heating pad" to help with their pain. Staff H indicated they do not have heating pads and staff used a towel and warm water from the faucet wrapped in another towel and a blue incontinence pad for a heating pad. Staff H acknowledged the medical record lacked appropriate skin assessment for patient #5.

- The CAH's policy for falls reviewed on 5/5/14 at 4:00pm directed, "...If a patient should fall: A. Assess the patient for injury. B. Notify the physician of the fall. C. Complete an incident report and a fall analysis report..."

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. Patient #5's fall risk assessment on 4/21/14 at 4:00 indicated the patient was a high risk for falls. Documentation included Confusion/disorientation (3), Incontinence (3), Uses assistive devices/has weakness (2) Analgesic (3), other (3). High risk 6+ points. The next fall risk assessment on 4/21/14 at 6:50am included incontinence (3), analgesic (3), recent history of fall (not slip/trip) (7). The medical record failed to contain information regarding a fall on 4/21/14.

- Nurses' Aide staff I interviewed by phone on 5/7/14 at 12:45pm, remembered patient #5 sustained a fall in the shower but could not remember the exact date of the fall. Staff I indicated they placed patient #5 in a shower chair in the shower then went to make the bed. Patient #5 slipped out of chair on to the floor. Staff I indicated she reported the fall to Registered Nurse staff J.

- Risk Manager staff K, interviewed on 5/7/14 at 12:50pm, indicated they had not received a variance report on patient #5 for a fall during this admission.

- Registered Nurse staff J, interviewed on 5/8/14 at 8:52am by phone, acknowledged they provided nursing care for patient #5 on 4/21/14 and he sustained a fall in the shower around 5:00am. Staff J acknowledged they did not document the fall in the nurses' notes, notify the physician, or fill out an incident report and did not follow the CAH's policy for falls.

- Nurse Aide staff D observed on 5/5/14 at 2:30pm, answered the call light system at the nurses station, told a patient it would be a few minutes before they could help them and they would need to get some help. Staff D continued to work at the computer. At 2:47pm the patient placed a second call to the nurses' station and staff D, repeated it would be a few minutes and she would need to find some help. During the request for help from the patient there were three other staff members at the nurses' station.

Register Nurse staff F interviewed on 5/5/14 at 2:50pm acknowledged the delay when a patient called for help.

- Nurse Aide staff D interviewed on 5/6/14 at 2:20pm acknowledged the call light incident on 5/5/14 involved patient #3 a SSB patient.

The Critical Access Hospital (CAH) reported a census of ten inpatients including five skilled swing bed (SSB) patients, three acute patients, one obstetrical and one newborn patient. Based on observation, document review and staff interview the CAH staff failed to provide nursing care to meet the needs of patients and ensure nursing staff followed physician orders for monitoring vital signs for two of ten sampled patients (patient #'s 1 and 2), failed to complete nursing assessments of wounds/skin for one of five skilled swing bed sampled patients (#5), failed to follow the CAH's policy following a patient fall for one sampled patient with a fall (#5), and failed to answer a call light timely for one of five swing bed patients (#3). This deficent practice places patients at risk for inadequate care.

Findings include:

Patient #1's medical record review on 5/5/14 revealed an admission to skilled swing bed (SSB) on 4/30/14 with diagnosis of congestive heart failure (CHF). Medical record review revealed a physician order on 4/30/14 at 9:40am for vital signs four times a day. The medical record revealed CAH staff obtained vital signs twice on 5/2/14 and three times on 5/3/14 not the ordered four times a day.

- Patient #2's medical record review on 5/5/14 revealed an admission to SSB on 4/20/14 with diagnosis of urinary tract infection (UTI). Medical record review revealed a physician order on 4/20/14 at 12:51pm for vital signs four times a day. The medical record revealed CAH staff obtained vital signs twice on 4/30/14, and three times on 5/3/14, not the ordered four times a day.

- Registered Nurse staff F interviewed on 5/5/14 at 2:45pm acknowledged CAH nursing staff failed to follow physician orders for vital sign four times a day to meet the needs of patient #1 and patient #2.

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. The medical record revealed an admission skin assessment "Has red area on right upper arm, patient states it is from last hospital stay at another hospital due to tape". The next skin assessment on 3/16/14 at 7:28pm noted "Abnormals: skin flushed, contusion, poor skin turgor". The skin assessment on 3/18/14 at 6:50pm noted, "Skin extremely dry, poor skin turgor". Patient #5's skin assessment throughout his acute admission remained the same. On admission to SSB on 3/19/14 patient #5's skin assessment indicated, " Skin pale, poor skin turgor". The skin assessment remained the same until 4/5/14 at 2:15pm with a nurses note indicating "wound, mucous membranes dry, tongue dry" and dressings applied, skin care protocol followed, wound to the lower right back, superficial, measures approximately 3cm x 2cm, red bed with minimal fibrin, cleaned with normal saline, covered with mepilex dressing. Old dressing has grayish/green and serous drainage with no odor. Patient #5's medical record lacked physician orders for a dressing change to the back on 4/5/14 and physician progress notes on 4/5/14 failed to indicate they were aware of the wound to patient #5's back. The next entry into the medical record regarding a wound on the back was on 4/19/14 at 8:55pm noting "daughter came out of room complained "my dad has a sore to his lower back". The note indicated sore to right lower back which is approximately half dollar size open area, black leathery in the middle and red raw around edges, and identified a new dime size reddened area above the wound. The nurse cleaned and redressed the wound. On 4/20/14 a consult was order with Physician staff G. Staff G's consult note on 4/20/14 indicated the patient developed a necrotic area on the right lower back 3cm x 2.5cm "likely due to heating pad" and indicated due to the patient's poor health would not do anything at this time. The wound care nurse ordered a Mepilex foam dressing and changed every 72 hours. Documentation in the medical record indicated patient #5 received a heating pad from staff to assist in pain management multiple times.

- Registered Nurse staff H, interviewed on 5/6/14 at 11:15pm, acknowledged they were the nurse on duty 4/19/14 when patient #5's family member came to the nurses' station and reported the dressing was off patient #5's back. Staff indicated there had been a dressing on patient #5's back and they had not seen the wound since the day shift did dressing changes. Staff H did monitor the dressing. When the dressing came off on 4/19/14 they cleaned the wound with normal saline and placed a Mepilex dressing. The next morning the patient had a consult with a doctor and the wound care nurse. Staff H indicated at times staff gave patient #5 "a heating pad" to help with their pain. Staff H indicated they do not have heating pads and staff used a towel and warm water from the faucet wrapped in another towel and a blue incontinence pad for a heating pad. Staff H acknowledged the medical record lacked appropriate skin assessment for patient #5.

- The CAH's policy for falls reviewed on 5/5/14 at 4:00pm directed, "...If a patient should fall: A. Assess the patient for injury. B. Notify the physician of the fall. C. Complete an incident report and a fall analysis report..."

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. Patient #5's fall risk assessment on 4/21/14 at 4:00 indicated the patient was a high risk for falls. Documentation included Confusion/disorientation (3), Incontinence (3), Uses assistive devices/has weakness (2) Analgesic (3), other (3). High risk 6+ points. The next fall risk assessment on 4/21/14 at 6:50am included incontinence (3), analgesic (3), recent history of fall (not slip/trip) (7). The medical record failed to contain information regarding a fall on 4/21/14.

- Nurses' Aide staff I interviewed by phone on 5/7/14 at 12:45pm, remembered patient #5 sustained a fall in the shower but could not remember the exact date of the fall. Staff I indicated they placed patient #5 in a shower chair in the shower then went to make the bed. Patient #5 slipped out of chair on to the floor. Staff I indicated she reported the fall to Registered Nurse staff J.

- Risk Manager staff K, interviewed on 5/7/14 at 12:50pm, indicated they had not received a variance report on patient #5 for a fall during this admission.

- Registered Nurse staff J, interviewed on 5/8/14 at 8:52am by phone, acknowledged they provided nursing care for patient #5 on 4/21/14 and he sustained a fall in the shower around 5:00am. Staff J acknowledged they did not document the fall in the nurses' notes, notify the physician, or fill out an incident report and did not follow the CAH's policy for falls.

- Nurse Aide staff D observed on 5/5/14 at 2:30pm, answered the call light system at the nurses station, told a patient it would be a few minutes before they could help them and they would need to get some help. Staff D continued to work at the computer. At 2:47pm the patient placed a second call to the nurses' station and staff D, repeated it would be a few minutes and she would need to find some help. During the request for help from the patient there were three other staff members at the nurses' station.

Register Nurse staff F interviewed on 5/5/14 at 2:50pm acknowledged the delay when a patient called for help.

- Nurse Aide staff D interviewed on 5/6/14 at 2:20pm acknowledged the call light incident on 5/5/14 involved patient #3 a SSB patient.

The Critical Access Hospital (CAH) reported a census of ten inpatients including five skilled swing bed (SSB) patients, three acute patients, one obstetrical and one newborn patient. Based on observation, document review and staff interview the CAH registered nurse (RN) failed to supervise and evaluate nursing care and ensure nursing staff followed physician orders for monitoring vital signs for two of ten sampled patients (patient #'s 1 and 2), failed to complete nursing assessments of wounds/skin for one of five skilled swing bed sampled patients (#5), failed to follow the CAH's policy following a patient fall for one sampled patient with a fall (#5), and failed to answer a call light timely for one of five swing bed patients (#3). This deficent practice places patients at risk for inadequate care.

Findings include:

Patient #1's medical record review on 5/5/14 revealed an admission to skilled swing bed (SSB) on 4/30/14 with diagnosis of congestive heart failure (CHF). Medical record review revealed a physician order on 4/30/14 at 9:40am for vital signs four times a day. The medical record revealed CAH staff obtained vital signs twice on 5/2/14 and three times on 5/3/14 not the ordered four times a day.

- Patient #2's medical record review on 5/5/14 revealed an admission to SSB on 4/20/14 with diagnosis of urinary tract infection (UTI). Medical record review revealed a physician order on 4/20/14 at 12:51pm for vital signs four times a day. The medical record revealed CAH staff obtained vital signs twice on 4/30/14, and three times on 5/3/14, not the ordered four times a day.

- Registered Nurse staff F interviewed on 5/5/14 at 2:45pm acknowledged CAH nursing staff failed to follow physician orders for vital sign four times a day to meet the needs of patient #1 and patient #2.

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. The medical record revealed an admission skin assessment "Has red area on right upper arm, patient states it is from last hospital stay at another hospital due to tape". The next skin assessment on 3/16/14 at 7:28pm noted "Abnormals: skin flushed, contusion, poor skin turgor". The skin assessment on 3/18/14 at 6:50pm noted, "Skin extremely dry, poor skin turgor". Patient #5's skin assessment throughout his acute admission remained the same. On admission to SSB on 3/19/14 patient #5's skin assessment indicated, " Skin pale, poor skin turgor". The skin assessment remained the same until 4/5/14 at 2:15pm with a nurses note indicating "wound, mucous membranes dry, tongue dry" and dressings applied, skin care protocol followed, wound to the lower right back, superficial, measures approximately 3cm x 2cm, red bed with minimal fibrin, cleaned with normal saline, covered with mepilex dressing. Old dressing has grayish/green and serous drainage with no odor. Patient #5's medical record lacked physician orders for a dressing change to the back on 4/5/14 and physician progress notes on 4/5/14 failed to indicate they were aware of the wound to patient #5's back. The next entry into the medical record regarding a wound on the back was on 4/19/14 at 8:55pm noting "daughter came out of room complained "my dad has a sore to his lower back". The note indicated sore to right lower back which is approximately half dollar size open area, black leathery in the middle and red raw around edges, and identified a new dime size reddened area above the wound. The nurse cleaned and redressed the wound. On 4/20/14 a consult was order with Physician staff G. Staff G's consult note on 4/20/14 indicated the patient developed a necrotic area on the right lower back 3cm x 2.5cm "likely due to heating pad" and indicated due to the patient's poor health would not do anything at this time. The wound care nurse ordered a Mepilex foam dressing and changed every 72 hours. Documentation in the medical record indicated patient #5 received a heating pad from staff to assist in pain management multiple times.

- Registered Nurse staff H, interviewed on 5/6/14 at 11:15pm, acknowledged they were the nurse on duty 4/19/14 when patient #5's family member came to the nurses' station and reported the dressing was off patient #5's back. Staff indicated there had been a dressing on patient #5's back and they had not seen the wound since the day shift did dressing changes. Staff H did monitor the dressing. When the dressing came off on 4/19/14 they cleaned the wound with normal saline and placed a Mepilex dressing. The next morning the patient had a consult with a doctor and the wound care nurse. Staff H indicated at times staff gave patient #5 "a heating pad" to help with their pain. Staff H indicated they do not have heating pads and staff used a towel and warm water from the faucet wrapped in another towel and a blue incontinence pad for a heating pad. Staff H acknowledged the medical record lacked appropriate skin assessment for patient #5.

- The CAH's policy for falls reviewed on 5/5/14 at 4:00pm directed, "...If a patient should fall: A. Assess the patient for injury. B. Notify the physician of the fall. C. Complete an incident report and a fall analysis report..."

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. Patient #5's fall risk assessment on 4/21/14 at 4:00 indicated the patient was a high risk for falls. Documentation included Confusion/disorientation (3), Incontinence (3), Uses assistive devices/has weakness (2) Analgesic (3), other (3). High risk 6+ points. The next fall risk assessment on 4/21/14 at 6:50am included incontinence (3), analgesic (3), recent history of fall (not slip/trip) (7). The medical record failed to contain information regarding a fall on 4/21/14.

- Nurses' Aide staff I interviewed by phone on 5/7/14 at 12:45pm, remembered patient #5 sustained a fall in the shower but could not remember the exact date of the fall. Staff I indicated they placed patient #5 in a shower chair in the shower then went to make the bed. Patient #5 slipped out of chair on to the floor. Staff I indicated she reported the fall to Registered Nurse staff J.

- Risk Manager staff K, interviewed on 5/7/14 at 12:50pm, indicated they had not received a variance report on patient #5 for a fall during this admission.

- Registered Nurse staff J, interviewed on 5/8/14 at 8:52am by phone, acknowledged they provided nursing care for patient #5 on 4/21/14 and he sustained a fall in the shower around 5:00am. Staff J acknowledged they did not document the fall in the nurses' notes, notify the physician, or fill out an incident report and did not follow the CAH's policy for falls.

- Nurse Aide staff D observed on 5/5/14 at 2:30pm, answered the call light system at the nurses station, told a patient it would be a few minutes before they could help them and they would need to get some help. Staff D continued to work at the computer. At 2:47pm the patient placed a second call to the nurses' station and staff D, repeated it would be a few minutes and she would need to find some help. During the request for help from the patient there were three other staff members at the nurses' station.

Register Nurse staff F interviewed on 5/5/14 at 2:50pm acknowledged the delay when a patient called for help.

- Nurse Aide staff D interviewed on 5/6/14 at 2:20pm acknowledged the call light incident on 5/5/14 involved patient #3 a SSB patient.

The Critical Access Hospital reported a census of ten inpatients including five skilled swing bed, three acute, one obstetrical and one newborn patient. Based on observation, document review and interview CAH nursing staff failed to properly label intravenous tubing for one of five skilled swing bed patients (#5). This deficient practice places patients at risk for improper administration of drugs.

Findings include:

- The CAH's policy for Maintenance of IV solutions, reviewed on 5/6/14 at 3:35pm directed, "...Change IV tubing every 72 hours...Tag IV lines both primary and secondary with dates to facilitate proper changing..."

- Observation on 5/5/14 at 10:30am in patient #5's room revealed the patient's IV tubing lacked a label indicating when the tubing was started or when it need to be discontinued.
Registered Nurse (RN) staff A interviewed on 5/5/14 at 10:50am acknowledged the IV tubing lacked a label and a dated label is required.

The Critical Access Hospital(CAH) reported a census of ten inpatients including five skilled swing bed, three acute, one obstetrical and one newborn patient. Based on document review and staff interview, the CAH failed to assure all medical records are accurately and completely document orders, treatments, care provided and response to those treatments for one of one sampled patient requiring skin and wound assessments and had a fall (patient #5). The CAH's failure to maintain an accurate and complete medical record places patients at risk for inadequate patient care.

Findings include:

- The CAH's policy for wound assessment reviewed on 5/6/14 at 3:35pm directed, "...asses the wound location and its size, measure the length, width, and depth...assess the color of the wound bed...drainage...odor...stage the wound...assess the surrounding skin...evaluate the response to treatment..."

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. The medical record revealed an admission skin assessment "Has red area on right upper arm, patient states it is from last hospital stay at another hospital due to tape". The next skin assessment on 3/16/14 at 7:28pm noted "Abnormals: skin flushed, contusion, poor skin turgor". The skin assessment on 3/18/14 at 6:50pm noted, "Skin extremely dry, poor skin turgor". Patient #5's skin assessment throughout his acute admission remained the same. On admission to SSB on 3/19/14 patient #5's skin assessment indicated, " Skin pale, poor skin turgor". The skin assessment remained the same until 4/5/14 at 2:15pm with a nurses note indicating "wound, mucous membranes dry, tongue dry" and dressings applied, skin care protocol followed, wound to the lower right back, superficial, measures approximately 3cm x 2cm, red bed with minimal fibrin, cleaned with normal saline, covered with mepilex dressing. Old dressing has grayish/green and serous drainage with no odor. Patient #5's medical record lacked physician orders for a dressing change to the back on 4/5/14 and physician progress notes on 4/5/14 failed to indicate they were aware of the wound to patient #5's back. The next entry into the medical record regarding a wound on the back was on 4/19/14 at 8:55pm noting "daughter came out of room complained "my dad has a sore to his lower back". The note indicated sore to right lower back which is approximately half dollar size open area, black leathery in the middle and red raw around edges, and identified a new dime size reddened area above the wound. The nurse cleaned and redressed the wound. On 4/20/14 a consult was order with Physician staff G. Staff G's consult note on 4/20/14 indicated the patient developed a necrotic area on the right lower back 3cm x 2.5cm "likely due to heating pad" and indicated due to the patient's poor health would not do anything at this time. The wound care nurse ordered a Mepilex foam dressing and change every 72 hours. The first primary care physician ' s progress note acknowledging awareness of a wound to patient #5's back on 4/21/14 indicated that patient #5 "was found to have a sacral burn from heating pad". Documentation in the medical record indicated patient #5 received a heating pad from staff to assist in pain management multiple times. Patient #5's medication administration record (MAR) indicated patient #5 received dressing changes on 4/4/14, 4/11/14, 4/25/14, and 5/3/14. The medical record lacked notes describing wound location and its size, length, width, depth, color of the wound bed, drainage, odor, stage of the wound, assess the surrounding skin, and evaluate the response to treatment. Nurses' notes on 5/2/14, 5/3/14, and 5/5/14 indicated patient #5 received a dressing change but the documentation failed to include a description of the wound size, length, width, depth, color of the wound bed, drainage, odor, stage of the wound, assess the surrounding skin, and evaluate the response to treatment.

- Registered Nurse staff H, interviewed on 5/6/14 at 11:15pm, acknowledged they were the nurse on duty 4/19/14 when patient #5's family member came to the nurses' station and reported the dressing was off patient #5's back. Staff indicated there had been a dressing on patient #5's back and they had not seen the wound since the day shift did dressing changes. Staff H did monitor the dressing. When the dressing came off on 4/19/14 they cleaned the wound with normal saline and placed a Mepilex dressing. The next morning the patient had a consult with a doctor and the wound care nurse. Staff H indicated at times staff gave patient #5 "a heating pad" to help with their pain. Staff H indicated they do not have heating pads and staff used a towel and warm water from the faucet wrapped in another towel and a blue incontinence pad for a heating pad. Staff H acknowledged the medical record lacked appropriate skin assessment and a physician order for dressing changes prior to 4/20/14 for patient #5.


- The CAH's policy for falls reviewed on 5/5/14 at 4:00pm directed, "...If a patient should fall: A. Assess the patient for injury. B. Notify the physician of the fall. C. Complete an incident report and a fall analysis report..."

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. Patient #5's fall risk assessment on 4/21/14 at 4:00 indicated the patient was a high risk for falls. Documentation included Confusion/disorientation (3), Incontinence (3), Uses assistive devices/has weakness (2) Analgesic (3), other (3). High risk 6+ points. The next fall risk assessment on 4/21/14 at 6:50am included incontinence (3), analgesic (3), recent history of fall (not slip/trip) (7). The medical record failed to contain information regarding a fall on 4/21/14.

- Nurses' Aide staff I interviewed by phone on 5/7/14 at 12:45pm, remembered patient #5 sustained a fall in the shower but could not remember the exact date of the fall. Staff I indicated they placed patient #5 in a shower chair in the shower then went to make the bed. Patient #5 slipped out of chair on to the floor. Staff I indicated she reported the fall to Registered Nurse staff J.

- Risk Manager staff K, interviewed on 5/7/14 at 12:50pm, indicated they had not received a variance report on patient #5 for a fall during this admission.

- Registered Nurse staff J, interviewed on 5/8/14 at 8:52am by phone, acknowledged they provided nursing care for patient #5 on 4/21/14 and he sustained a fall in the shower around 5:00am. Staff J acknowledged they did not document the fall in the nurses' notes, notify the physician, or fill out an incident report and did not follow the CAH's policy for falls.

The Critical Access Hospital(CAH) reported a census of ten inpatients including five skilled swing bed, three acute, one obstetrical and one newborn patient. Based on document review and staff interview, the CAH failed to maintain medical records that includes all orders, reports of treatments, and pertinent information mecessary to monitor the patient progress for one of one sampled patient requiring skin and wound assessments and had a fall (patient #5). The CAH's failure to maintain an accurate and complete medical record places patients at risk for inadequate patient care.

Findings include:

- The CAH's policy for wound assessment reviewed on 5/6/14 at 3:35pm directed, "...asses the wound location and its size, measure the length, width, and depth...assess the color of the wound bed...drainage...odor...stage the wound...assess the surrounding skin...evaluate the response to treatment..."

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. The medical record revealed an admission skin assessment "Has red area on right upper arm, patient states it is from last hospital stay at another hospital due to tape". The next skin assessment on 3/16/14 at 7:28pm noted "Abnormals: skin flushed, contusion, poor skin turgor". The skin assessment on 3/18/14 at 6:50pm noted, "Skin extremely dry, poor skin turgor". Patient #5's skin assessment throughout his acute admission remained the same. On admission to SSB on 3/19/14 patient #5's skin assessment indicated, " Skin pale, poor skin turgor". The skin assessment remained the same until 4/5/14 at 2:15pm with a nurses note indicating "wound, mucous membranes dry, tongue dry" and dressings applied, skin care protocol followed, wound to the lower right back, superficial, measures approximately 3cm x 2cm, red bed with minimal fibrin, cleaned with normal saline, covered with mepilex dressing. Old dressing has grayish/green and serous drainage with no odor. Patient #5's medical record lacked physician orders for a dressing change to the back on 4/5/14 and physician progress notes on 4/5/14 failed to indicate they were aware of the wound to patient #5's back. The next entry into the medical record regarding a wound on the back was on 4/19/14 at 8:55pm noting "daughter came out of room complained "my dad has a sore to his lower back". The note indicated sore to right lower back which is approximately half dollar size open area, black leathery in the middle and red raw around edges, and identified a new dime size reddened area above the wound. The nurse cleaned and redressed the wound. On 4/20/14 a consult was order with Physician staff G. Staff G's consult note on 4/20/14 indicated the patient developed a necrotic area on the right lower back 3cm x 2.5cm "likely due to heating pad" and indicated due to the patient's poor health would not do anything at this time. The wound care nurse ordered a Mepilex foam dressing and change every 72 hours. The first primary care physician ' s progress note acknowledging awareness of a wound to patient #5's back on 4/21/14 indicated that patient #5 "was found to have a sacral burn from heating pad". Documentation in the medical record indicated patient #5 received a heating pad from staff to assist in pain management multiple times. Patient #5's medication administration record (MAR) indicated patient #5 received dressing changes on 4/4/14, 4/11/14, 4/25/14, and 5/3/14. The medical record lacked notes describing wound location and its size, length, width, depth, color of the wound bed, drainage, odor, stage of the wound, assess the surrounding skin, and evaluate the response to treatment. Nurses' notes on 5/2/14, 5/3/14, and 5/5/14 indicated patient #5 received a dressing change but the documentation failed to include a description of the wound size, length, width, depth, color of the wound bed, drainage, odor, stage of the wound, assess the surrounding skin, and evaluate the response to treatment.

- Registered Nurse staff H, interviewed on 5/6/14 at 11:15pm, acknowledged they were the nurse on duty 4/19/14 when patient #5's family member came to the nurses' station and reported the dressing was off patient #5's back. Staff indicated there had been a dressing on patient #5's back and they had not seen the wound since the day shift did dressing changes. Staff H did monitor the dressing. When the dressing came off on 4/19/14 they cleaned the wound with normal saline and placed a Mepilex dressing. The next morning the patient had a consult with a doctor and the wound care nurse. Staff H indicated at times staff gave patient #5 "a heating pad" to help with their pain. Staff H indicated they do not have heating pads and staff used a towel and warm water from the faucet wrapped in another towel and a blue incontinence pad for a heating pad. Staff H acknowledged the medical record lacked appropriate skin assessment and a physician order for dressing changes prior to 4/20/14 for patient #5.


- The CAH's policy for falls reviewed on 5/5/14 at 4:00pm directed, "...If a patient should fall: A. Assess the patient for injury. B. Notify the physician of the fall. C. Complete an incident report and a fall analysis report..."

- Patient #5's medical record review between 5/5/14 to 5/7/14 revealed an admission on 3/16/14 to acute care and a SSB admission on 3/19/14 with a diagnosis of metastatic cancer of the liver and intractable pain. Patient #5's fall risk assessment on 4/21/14 at 4:00 indicated the patient was a high risk for falls. Documentation included Confusion/disorientation (3), Incontinence (3), Uses assistive devices/has weakness (2) Analgesic (3), other (3). High risk 6+ points. The next fall risk assessment on 4/21/14 at 6:50am included incontinence (3), analgesic (3), recent history of fall (not slip/trip) (7). The medical record failed to contain information regarding a fall on 4/21/14.

- Nurses' Aide staff I interviewed by phone on 5/7/14 at 12:45pm, remembered patient #5 sustained a fall in the shower but could not remember the exact date of the fall. Staff I indicated they placed patient #5 in a shower chair in the shower then went to make the bed. Patient #5 slipped out of chair on to the floor. Staff I indicated she reported the fall to Registered Nurse staff J.

- Risk Manager staff K, interviewed on 5/7/14 at 12:50pm, indicated they had not received a variance report on patient #5 for a fall during this admission.

- Registered Nurse staff J, interviewed on 5/8/14 at 8:52am by phone, acknowledged they provided nursing care for patient #5 on 4/21/14 and he sustained a fall in the shower around 5:00am. Staff J acknowledged they did not document the fall in the nurses' notes, notify the physician, or fill out an incident report and did not follow the CAH's policy for falls.