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Based on observation and staff interview, the Critical Access Hospital (CAH) failed to repair torn carpet outside 1 of 2 patient shower rooms (located at the end of the north hallway on the nursing unit). Failure to repair torn carpet prevents the CAH from ensuring the patients' safety from injury due to tripping or getting caught in the torn carpet.

Findings include:

Observation on 06/05/12 at 3:15 p.m. showed a nursing staff member (#5) assisting Patient #2 from the shower room, located at the end of the north hallway on the nursing unit. Patient #2 ambulated independently with the staff member (#5) at her side. Observation of the carpet immediately outside the door of the shower room, showed an approximate 16 inch tear where part of the carpet had lifted from the floor.

A tour of the CAH occurred on 06/05/12 at 3:40 p.m. with an administrative maintenance staff member (#3). Observation of the above hallway and carpet outside the shower room took place during the tour. During an interview on 06/05/12 at 3:40 p.m., the administrative maintenance staff member (#3) identified the hallway outside the shower room as a high traffic area for patients and staff. The staff member (#3) confirmed the carpet needed repair as the torn carpet could pose a safety concern for patients and stated the maintenance department had not received a work order reporting the torn carpet.

Based on review of the infection control log and meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases for outpatients of the CAH for the past 6 of 6 months (December 2011 through May 2012) reviewed. Failure to identify and address incidents of infections among all patients has the potential for infections to spread or reoccur; affecting the health of all patients, personnel, and visitors of the CAH.

Findings include:

Reviewed on 06/05/12, the infection control program lacked evidence the CAH identified and recognized infections of outpatients. The infection incidence forms (infection control log) and safety meeting minutes (including infection control information) from December 2011 through May 2012, failed to include information and documentation of outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on 06/05/12 at 10:00 a.m., the infection control nurse (#2) stated she did not formally document her daily review of the emergency room (ER) log and the records of ER patients with known or suspected cases of infection or communicable diseases and did not include the ER patients in surveillance. The nurse (#2) stated she did not receive or request infection control information from the surgery department manager for procedure and surgery outpatients or from a physical therapist (PT) for wound care outpatients. The infection control nurse (#2) confirmed the CAH did not formally document and include outpatients in infection control surveillance.

The failure to document and perform surveillance among all patients of the CAH, limited the CAH's ability to identify, monitor, track, control, and prevent infections.

Based on record review, and staff interview, the Critical Access Hospital (CAH) failed to provide care in accordance with the patients needs for 1 of 1 closed Swing Bed record (Patient #9) who experienced falls at the facility. Failure to implement interventions to prevent further falls could result in the patient sustaining an injury.

Findings include:

Patient #9's closed Swing Bed record, reviewed on June 5-7, 2012, identified the CAH admitted the patient to Swing Bed on 04/17/12 with diagnoses including dementia, debility, and weakness. A Physical Therapy Evaluation, dated 04/18/12, stated, ". . . seen in physical therapy today for general weakness and decline in overall mobility . . . the patient does have right lower extremity radiculopathy/myopathy [disease of the nerve root/muscle weakness] from an injury well into the past. This has left him with no right hip flexion. . . . today demonstrating significant decline in overall mobility and requiring significant assist with transfers and unable to fully stand by bedside upon evaluation. The patient does have right lower extremity myopathy from a previous injury/pathology also causing difficulties with transfers. . . . The patient is a candidate for physical therapy secondary to the deficits noted specifically the need to improve supine to sit to stand transfers to help with nursing care and to avoid injuries to the staff as well as the patient and caregivers."

A progress note dated, 04/19/12 at 4:27 p.m., stated, "Staff was called to room per wife at 1600 [4:00 p.m.]. Staff found patient laying on floor in front of recliner. Wife stated that patient was trying to use the urinal and the chair was put up to high with the control and he slid out onto floor. Patient was instructed by Physical Therapy to stand up with assist of 4, gait belt, and a walker. Resident was then helped off of floor and into recliner. . . . No injuries noted at time of fall. . . . Alert and confused. . . ."

An event report, dated 04/19/12, stated, ". . . wife stated, 'He was trying to use the urinal, and we put the chair up, and he slid out onto the floor.' Risk manager comments for the event report, dated 04/20/12, stated, ". . . Wife informed that staff must be called to assist and to not do it herself. Alarms are in place and were sounding . . . No changes made."

Progress notes identified a second fall on 04/23/12 at 2:07 p.m. The note stated, "Physical Therapy found [patient's name] on the floor sitting with his legs out in front of him, L) [left] leg bent some straightened without difficulty, recliner had raised up and he slid out of chair. 4 assist and hoyer lift used to transfer pt [patient] to bed, no bruises noted and able to move extremeity [sic] without difficulty. . . ."

An event report, dated 04/23/12, stated, "Heard patient yelling for help. Went into room and found patient on floor in front of left recliner which was elevated to highest position. . . ." Supervisor comments for the report, dated 04/24/12, stated, ". . . Recliner was found in highest position, pt had remote in hand. Pt screams out and hollers frequently due to dementia. Pt is reminded to use call light for help. Chair and bed alarm in place. . . ." Risk Manager comments for the report, dated 04/26/12, stated, "Staff will assist with recliner and try to keep remote out of his reach due to increase in Dementia. . . ."

Patient #9's care plan, dated 04/17/12, identified "Falls/Safety Risk/Elopement Risk." The care plan identified interventions of "Keep call light within reach and encourage use. Instruct resident on safety measures. Keep room clutter free. Keep a light on at night. Non-skid slippers/shoes for transfers and ambulation." The care plan failed to address Patient #9's need for "significant assistance with transfers" identified by the physical therapist and lacked evidence staff implemented the intervention of keeping the lift chair remote out of Patient #9's reach.

An interview with an administrative nurse (#2) occurred on 06/06/12 at 12:40 p.m. The nurse stated the chair alarm failed to sound when the patient fell on 04/23/12. She stated the alarm may have malfunctioned or the patient may have turned it off.

The record lacked evidence staff removed the chair remote from Patient #9's reach until 04/26/12, three days after the second fall involving the lift chair. The facility failed to provide evidence of an investigation of the reason the chair alarm did not sound on 04/23/12. Failure to promptly implement interventions to prevent further falls and to investigate why the alarm failed to function placed Patient #9 at risk for further falls and possible injury.

Based on record review, review of medical staff rules and regulations, and staff interview, the Critical Access Hospital (CAH) failed to maintain a complete medical record including physician's orders for treatment for 1 of 1 closed outpatient record (Patient #22) reviewed; and reports of ordered laboratory (lab) tests and physician's orders for medications for 2 of 11 closed emergency room (ER) records (Patients #18 and #23) reviewed. Failure to ensure the medical record included reports of lab tests and physician orders for medications and treatment limited the CAH's ability to provide quality care to outpatients and ER patients.

Findings include:

The Medical Staff Rules and Regulations, approved on 12/17/07 and 02/21/12, stated, "Section 2. Medical Records . . . A. The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient . . . This record shall include . . . special reports . . . clinical laboratory . . ."

- Review of Patient #22's closed outpatient record occurred on June 4-5, 2012 and identified the 17 month old patient presented to the local clinic on 12/12/11. The record showed the physician referred Patient #22 to the hospital after evaluation at the clinic. The outpatient record lacked physician's orders for treatment at the hospital.

- Review of Patient #18's closed ER record occurred on June 4-5, 2012 and showed the patient presented to the ER on 12/10/11 after a motor vehicle accident. Discharge instructions stated, "Percocet [a pain medication] 5/325 every 6 hrs [hours] as needs for pain." and "Keflex [an antibiotic] 500 mg 2 times a day for 1 week." Patient #18's record lacked physician's orders for the medications.

- Review of Patient #23's closed ER record occurred on June 4-5, 2012 and showed the patient presented to the ER with "burning pain on voiding x [times] 1 week." The record identified physician's orders for a urine culture and sensitivity, but lacked evidence staff completed the test. Discharge instructions for Patient #23 stated, "Pyridium [a medication used for burning with urination] 200 mg 3 times a day for 2 days." and "Ciprofloxin [an antibiotic] 500 mg 2 times a day for 20 days." Patient #23's record lacked physician's orders for the medications.

During an interview on 06/05/12 at 9:20 a.m., a medical records staff member (#6) stated staff failed to enter the order for Patient #23's urine culture in the computerized ordering system, so the lab did not perform the test. The staff member did not provide physician's orders for Patient #22 or for the medications listed on the discharge instructions for Patients #18 and #23.

Based on record review, review of the Medical Staff Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure a qualified practitioner examined each patient immediately before surgery to evaluate the risk of the procedure performed for 3 of 3 closed surgical records (Patients #5, #6, and #7) reviewed. Failure to perform an assessment prior to surgery placed the patients at risk for complications.

Findings include:

The Medical Staff Rules and Regulations, approved on 12/17/07 and 02/21/12, stated, "Section 2. Medical Records . . . C. There will be a completed history and physical work up in the medical record of every patient prior to surgery . . . the physician or other individual qualified to perform the history and physical writes an update note addressing the patient=s [sic] current status and/or changes in the patient=s [sic] status . . . within 7 days prior to the outpatient surgery . . ." This statement conflicts with federal requirements which state the assessment must be completed immediately prior to the surgery.

Review of Patients #5, #6, and #7's closed outpatient surgical records occurred on June 5-6, 2012 and identified the patients had surgical procedures performed on 03/08/12, 01/13/12, and 11/10/11 respectively. Patients #5, #6, and #7's records lacked an assessment by a qualified practitioner immediately prior to their surgical procedures to evaluate the risk of the procedure.

When interviewed on 06/06/12 at 10:30 a.m., an administrative nurse (#1) confirmed the practitioner failed to perform the pre-surgical assessments for the above patients.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the discharge of patients with a responsible adult for 2 of 3 closed surgical records (Patients #5 and #6) reviewed. Failure to ensure the discharge of patients with a responsible adult placed the patients at risk if complications occurred.

Findings include:

- Patient #5's closed surgical record, reviewed June 5-6, 2012, identified the CAH admitted the patient on 03/08/12 at 6:00 a.m. for outpatient surgery. The record showed the CAH discharged Patient #5 at 11:30 a.m., but failed to identify the discharge of the patient with a responsible adult.

- Patient #6's closed surgical record, reviewed June 5-6, 2012, identified the CAH admitted the patient on 01/13/12 at 9:41 a.m. for outpatient surgery. The record showed the CAH discharged Patient #6 at 1:30 p.m., but failed to identify the discharge of the patient with a responsible adult.

When interviewed, on 06/06/12 at 10:30 a.m., an administrative nurse (#1) stated it is the CAH's policy to discharge all surgical patients with a responsible adult.

Based on and policy review, quality assurance (QA) record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the establishment of thresholds of acceptability for QA monitoring for 12 of 12 months reviewed (May 2011-April 2012). Failure to ensure the establishment of thresholds of acceptability for QA monitoring limited the CAH's ability to determine and implement corrective action if necessary.

Findings include:

Review of the "Tioga Medical Center Acute Care/Long Term Care Quality Improvement Plan" occurred on 06/05/12 at 12:40 p.m. This plan, effective 08/17/09, stated,
". . . V. Methodology
Measurable criteria will be developed by each of the involved hospital/LTC [long term care] departments that will be used to monitor identified problems. These criteria will be of adequate numbers to reach appropriate conclusions regarding problem existence, correction and monitoring. Criteria will be established at a level that is appropriate to address the identified concern. . . ."

Reviewed at 3:00 p.m. on 06/05/12 the June 2011-May 2012 (including data collected from May 2011-April 2012) "CAH/QA Reports" failed to include thresholds of acceptability for
monitoring performed by the following departments: dietary, discharge planning, health information, clinic, transfers, AMA (against medical advice), trauma, nursing service, ER (emergency room), physical therapy, occupational therapy, and radiology.

Reviewed at 3:30 p.m. on 06/05/12 the 2011-2012 departmental QA monitors indicated the following failed to include thresholds of acceptability: anesthesia, OR (operating room)/CSR (central supply room), housekeeping, plant operations, pharmacy, cardiac rehab, and the departments listed above.

During an interview at approximately 10:00 a.m. on 06/06/12, an administrative nursing staff member (#2) confirmed the CAH's QA monitors did not include thresholds of acceptability.