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Based on review of patient admission information packet, review of staff education materials, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to provide information regarding the CAH's policies for advance directives to patients and their responsible parties and to its staff on 2 of 3 days reviewed (May 29-30, 2013). The policies regarding advance directives failed to identify the legal authority and a complaint process for patients and their responsible parties. Failure to include this information in the policy and failure to educate patients, responsible parties, and the CAH staff placed patients at risk of receiving undesired treatment.

Findings include:

Review of the policy "Advanced Directives" occurred on May 29-30, 2013. This policy, dated December 2012, failed to identify the following: a legal authority, a complaint process including the State Agency and staff education.

Review of the patient admission information packet occurred on May 29-30, 2013. This information lacked the CAH's policy and procedure for advance directives.

During interview, on 05/30/13 at 9:05 a.m., a supervisory staff member (#13) reported the CAH did not provide the staff with information regarding the CAH's policy on advance directives.

Based on bylaws review, record review, and staff interview, the Critical Access Hospital (CAH) failed to have a written agreement with 1 of 1 distant-site telemedicine entity (Entity #1) providing radiologic interpretation through telemedicine. Failure to have a written agreement with telemedicine entities places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the "Medical Staff By-Laws" occurred on 05/28/13. These bylaws, adopted 04/23/12, stated,
". . . Article V Procedure for Appointment and Reappointment . . .
Section G. . . . Individuals providing telemedicine services from a 'distant site' must be appointed to the Telemedicine Staff . . . Telemedicine Services which require telemedicine privileges privileges at JMHCC [Jacobson Memorial Hospital Care Center] may be processed by JMHCC's own credentialing committee or by using the following method: Credential and grant privileges to the practitioner using a written agreement . . . utilizing credentialing and privileging information from the telemedicine provider . . . provided that the hospital/group meets the Medicare Conditions of Participation for Hospitals (or Critical Access Hospitals as appropriate)."

Review of the report "JMHCC Medical Staff" occurred on 05/28/13. This report, dated 05/09/13, included a listing for Telemedicine Entity #1 with forty radiologists named. Telemedicine Entity #1 is an independent distant-site entity providing radiologic interpretation through telemedicine to the CAH. The listing included a remark, "Credentialing Agreement with [name of tertiary hospital]."

During interview at approximately 9:30 a.m. on 05/29/13, an administrative radiology staff member (#8) confirmed Telemedicine Entity #1 provided radiologic interpretation through telemedicine for the CAH.

Upon request the morning of 05/29/13, the CAH failed to provide evidence of a written agreement with Telemedicine Entity #1 for provision of radiologic interpretation through telemedicine to the CAH.

During interview at approximately 8:30 a.m. on 05/30/13, an administrative staff member (#2) confirmed the CAH did not have a written agreement for telemedicine services with Telemedicine Entity #1.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the availability for prompt use the equipment, supplies, and drugs commonly used in life-saving procedures in 1 of 1 Emergency Room (ER). Failure to store the crash cart containing life-saving drugs, biologicals, and equipment in the ER has the potential to delay treatment of life-threatening situations to patients presenting to the ER.

Finding include:

Observation of the ER occurred on 05/30/13 at 6:45 a.m. with an administrative nurse (#1) and showed the absence of a crash cart. During an interview on 05/30/13 at 6:45 a.m., the nurse (#1) stated the CAH stored the crash cart across the hall from the ER in an intensive care unit (ICU) room. The crash cart contained various medications used in life-saving procedures and a defibrillator.

Based on observation, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to ensure a safe water temperature in 1 of 2 patient restrooms (the restroom next to the front desk) at an off-site clinic. Failure to ensure and monitor safe water temperatures placed patients at risk for burns caused by hot water.

Findings include:

"Guidelines for Construction and Equipment of Hospital and Medical Facilities," 1992-93 edition, Chapter 7, Section 7.31, Subsection 7.31. E. Plumbing and Other Piping Systems. stated, ". . . 7.31.E3. The following standards shall apply to hot water systems: a. The water-heating system shall have sufficient supply capacity at the temperatures . . . indicated in Table 4. . . . Table 4 Hot Water Use. Clinical . . . Temperature [Fahrenheit] 110 . . ."

The CAH failed to provide a policy regarding safe water temperatures in patient areas.

Observation of the off-site clinic occurred on the afternoon of 05/28/13. The temperature of the water at the sink in the patient restroom next to the front desk at 1:45 p.m. measured 126 to 128 degrees Fahrenheit (F).

During an interview at approximately 1:55 p.m. on 05/28/13, a clinic staff member (#3) stated the staff did not monitor water temperatures in patient areas and did not ensure water temperatures in patient areas were 110 degrees F or less.

Based on bylaws review, meeting minutes review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a physician member of the medical staff recommended the initial appointment of 1 of 1 active physician (Provider #6) to the CAH's medical staff prior to providing treatment or services to the CAH's patients. Failure to ensure a physician recommends the appointment of medical staff members places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the governing board's "Constitution & Bylaws" occurred on 05/28/13. These bylaws, adopted 03/26/12, stated,
". . . Article VII. Medical Staff . . .
7.1.1 . . . The governing board shall consider recommendations of the medical staff and appoint to the medical staff . . . physicians and others who meet the qualifications for membership . . .
7.2.3 The medical staff shall make recommendations to the governing board concerning: (1) appointments, reappointments . . . (2) granting of medical staff privileges . . ."

Review of the "Medical Staff By-Laws" occurred on 05/28/13. These bylaws, adopted 04/23/12, stated,
". . . ARTICLE III Medical Staff Membership
Section 3. Conditions and Duration of Appointment
A. . . . The Board of Directors shall act on appointments . . . after there has been a report from the Medical Staff as provided in these bylaws; provided that in the event of unwarranted delay on the part of the Medical Staff, the Board of Directors may act without such report on the basis of documented evidence of the applicant's
. . . professional and ethical qualifications obtained from reliable sources other than the Medical Staff. . . ."

Reviewed at 1:45 p.m. on 05/28/13, the governing board meeting minutes from 11/26/12 indicated the board approved Provider #6's initial appointment to active staff pending medical staff approval.

Reviewed at 6:30 a.m. on 05/29/13, the medical staff meeting minutes from 11/26/12 indicated the presence of two physician assistants, one nurse practitioner, and Provider #6. The non-physician medical staff members recommended Provider #6's initial appointment to active staff. The minutes noted the CAH would contact [name of medical staff physician] for review and action.

Reviewed at 10:30 a.m. on 05/29/13, the CAH's emergency room log indicated Provider #6 provided treatment to CAH patients beginning on 11/26/12.

Reviewed at 1:00 p.m. on 05/29/13, Provider #6's credentialing file indicated the governing board granted initial active privileges to Provider #6 on 11/26/12.

Upon request on 05/30/13, CAH staff provided documentation of recommended initial appointment approval for Provider #6 by [name of medical staff physician] on 12/04/12 (nine days after Provider #6 started treating patients at the CAH).

During interview at approximately 8:30 a.m. on 05/30/13, two administrative staff members (#2 and #4) confirmed a physician member of the medical staff failed to recommend initial appointment approval for Provider #6 before Provider #6 began treating patients at the CAH.

Based on record review, review of medical staff rules and regulations, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the physician reviewed and signed the records of inpatients cared for by nurse practitioners or physician assistants for 2 of 3 closed swing bed patient records (Patients #8 and #13), 1 of 2 closed acute inpatient records (Patient #10), and 1 of 2 closed observation patient records (Patient #15). Failure to review and sign all inpatient records limited the CAH's ability to ensure the quality and appropriateness of patient care provided by the nurse practitioners and physician assistants.

Findings include:

Review of the Medical Staff Rules And Regulations occurred on 05/28/13. This document, approved on 01/25/11, stated, ". . . C. MEDICAL RECORDS . . . 13. Mid-Level Review:
. . . Acute: A physician will review 100% of acute records attended by a mid-level practitioner. . . . Swing Bed . . . : The physician will countersign progress notes and certification orders completed by the mid-level practitioner. . . ."

Review of the policy "Physician Notification of Admit and Review of Midlevel Provider" occurred on 05/30/13. This undated document stated ". . . The physician will review every record of the midlevel practitioner. A form will be used to document the midlevel notification of the physician and the physician review of the chart. . . ." A form titled "Review of Medical Record for Midlevel Practitioners in CAHs" accompanied this document. The form stated "I certify that I have reviewed the record of this patient/resident, admitted and/or cared for by a midlevel provider. Chart review of this admission was completed on (date) at (time). (Signature of Reviewing Physician)."

Review of closed medical records occurred on May 29-30, 2013. A physician admitted the following patients, and a midlevel provider provided care during their stays. The medical records for Patient #8, #13, and #15 lacked the CAH's "Physician Notification of Admit and Review of Midlevel Provider" form to document the physician's review of the midlevel provider's record entries and Patient #10's form lacked a physician's signature. Mid-level provider documentation for Patient #8, #10, #13, and #15 lacked the physician's signatures as follows:
*Patient #8 - admitted on 02/18/13 to swing bed status from an acute care facility, expired on 02/27/13.
- Medication and treatment orders - 02/21/13
(two orders), 02/22/13 (two orders), and
02/23/13 (two orders).
- Progress notes - 02/20/13 and 02/22/13.
*Patient #13 - admitted on 03/27/13 to swing bed status from an acute care facility, discharged to home on 04/04/13.
- Medication and treatment orders - 03/28/13,
04/02/13, and 04/04/13.
- Progress notes - 03/30/13 and 03/31/13.
*Patient #10 - admitted on 12/12/12 to acute inpatient status and discharged to home on 12/15/12.
- Medication and treatment orders - 12/13/12
- Progress notes - 12/14/12
*Patient #15 - admitted on 03/13/13 to observation status and discharged to home on 03/14/13.
- Medication and treatment orders - 03/14/13
(two orders)

During interview, on 05/30/13 at 10:00 a.m., a supervisory medical records staff member (#10) reported the medical records previously identified did not have the form and the physician did not sign the form since the physician admitted the patients. This staff member (#10) agreed the midlevel providers provided care for Patient #8, #10, #13, and #15 and the physician should have signed the records.

Based on observation, review of the North Dakota Century Code, policy review, and staff interview, the Critical Access Hospital (CAH) failed to limit and prevent access to 1 of 1 pharmacy by unauthorized personnel; failed to store medications in a secure manner in 1 of 1 medication cart; and failed to ensure staff distributed drugs and biologicals in accordance with professional principles in 1 of 1 pharmacy. Failure to adequately secure and restrict assess to the pharmacy and medication cart and keep an accurate record of drugs and biologicals removed from the pharmacy and medication room allowed an opportunity for unsafe and unauthorized use of medications and has the potential to create insufficient distribution, control, and accountability of medications.

Findings include:

The North Dakota Century Code, Chapter 61-07-01 "Hospital Pharmacy" stated,
". . . 61-07-01-05. Absence of pharmacist. 1. General. During such times as a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance by the director for the provision of drugs to the medical staff and other authorized personnel of the hospital, by use of the night cabinets or floor stock, or both, and in emergency circumstances, by access to the pharmacy . . . 3. Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section. One supervisory registered professional nurse and only one in any given eight-hour shift is responsible for removing drugs therefrom. The responsible nurse, in times of emergency, may delegate this duty to another nurse. The responsible nurse must be designated by position, in writing, by the appropriate committee of the hospital and, prior to being permitted to obtain access to the pharmacy, shall receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required. . . .
61-07-01-06. Physical requirements . . . 5. Unattended areas. In the absence of authorized personnel, and whenever any area of a hospital pharmacy is not under the personal and direct supervision of authorized personnel, such area must be locked. 6. Security. All areas occupied by a hospital pharmacy must be capable of being locked . . . so as to prevent access by unauthorized personnel. The director shall designate, in writing, by title and specific area, those persons who shall have access to particular areas within the pharmacy . . ."

Review of the policy titled "PHARMACY USE BY NURSING PERSONNEL" occurred on 05/30/13. This policy, dated 2001, stated,
". . . Medications may be removed from the Pharmacy using the following guidelines:
*Injectables in multiple dose vials: One vial may be taken.
*Injectables in single use ampules or pre-filled syringes: Take only enough to last until the next regularly scheduled Pharmacy hours.
*Topical medications: One unit may be taken.
*Oral or rectal medications not in unit dose packaging: One dose may be taken.
*Oral or rectal medications in unit dose packaging: Take enough to last until the next regularly scheduled Pharmacy hours.
Medications removed from the Pharmacy must be labeled with at least the following information:
*Name and strength of the medication
*Patient's name
*Frequency of administration . . ."

Review of the policy titled "REMOVING DRUGS AND BIOLOGICALS FROM THE PHARMACY STORAGE AREA" occurred on 05/30/13. This policy, dated 2001, stated, ". . . PROCEDURE: The following procedure should be taken for removing drugs and biologicals from the pharmacy storage area:
*Removal of any item from Pharmacy must be recorded on a suitable form showing patient's name, name of drug, strength, amount, date, and initial of physician or nurse.
*Such form shall be left with the container from which the drug was removed, both placed conspicuously so that it will be found by a pharmacist and checked properly and promptly."

- Observation of the medication room, located adjacent to the nurse's station, occurred on 05/29/13 at 1:10 p.m. with an administrative nurse (#1) and showed a large amount of medications in different doses in cassettes, including benzodiazepines and antipsychotics, multiple vials of furosemide (a diuretic), multiple bags of intravenous (IV) solutions, stock bottles of over-the-counter (OTC) medications, and various other drugs and biologicals. The nurse (#1) stated if a patient's physician orders medications stored in the medication room, scheduled or as needed (PRN), the nurses' practice included locating the bottle or cassette with the ordered dosage, removing it from the medication room, and administering it to the patient. Observation and confirmation from the nurse (#1) failed to identify a log or record of items removed from the medication room. She stated the nursing staff document the administration of narcotics to patients in the narcotic-count book.

During an interview on 05/30/13 at 8:15 a.m., the CAH pharmacist consultant (#15) confirmed the hospital does not have a log identifying the drugs or biologicals removed from the medication room.

- Observation on 05/29/13 at 3:45 p.m. and 05/30/13 at 6:40 a.m. showed an unlocked medication cart at the nurses station and no nursing staff present. During an interview on 05/30/13 at 6:45 a.m., an administrative nurse (#1) stated staff should lock the medication cart when unattended.

- Observation of the CAH pharmacy occurred on 05/29/13 at 1:40 p.m. with a pharmacy technician (#14). The technician (#14) stated pharmacy staff typically come to the hospital twice a day Monday through Friday and CAH staff can always reach the pharmacy staff by telephone. When asked who has access to the pharmacy, the technician stated the charge nurse, pharmacist, business office, and she have a key to the pharmacy and only the pharmacist has a key to the narcotic cabinet.

Review of the "PHARMACY MEDICATION SIGN-OUT" forms, dated March 25, 2013 through May 29, 2013, occurred on 05/30/13 at 8:15 a.m. with the CAH pharmacist consultant (#15). The forms showed hospital nursing staff removed a variety of medications (antiarrhythmics, antiphychotics, antidepressants, antihypertensives, inhalers, antibiotics, and OTC medications) from the pharmacy 6 of 7 days in March 2013, 26 of 30 days in April 2013, and 26 of 30 days in May 2013. The form failed to identify the amount of medication removed or the time of removal.

During interview at approximately 8:15 a.m. on 05/30/13, the CAH pharmacist consultant (#15) stated nursing staff usually take the entire bottle of the medication instead of the amount needed at the time. He stated his practice is to fill a patient's prescriptions each morning, Monday through Friday. The pharmacist consultant (#15) confirmed in the event the CAH admits a patient to the hospital on a weekend, the nursing staff obtain the prescribed medications from the pharmacy and they should only obtain the amount needed until the next pharmacy working day.

Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care related to infection control practices observed during patient care on 2 of 3 days of survey (May 28-29, 2013). Failure to follow established infection control practices may allow transmission of organisms and pathogens from patients to staff, to other patients, or to visitors, and from one environment to another.

Findings include:

Review of the policy titled "Hand Hygiene" occurred on 06/30/13. This policy, dated 2011, stated, ". . . Staff will wash their hands and use the hospital recommended hand sanitizer in the following situations: . . .
*Before and after patient/resident contact . . .
*Before and after entering isolation precaution settings; . . .
*Upon and after coming in contact with a patient/resident's intact skin, (e.g. when taking a pulse or blood pressure, and lifting a resident);
*Before and after assisting a patient/resident with toileting;
*After contact with a patient/resident with infectious diarrhea . . .
*After removing gloves or aprons . . ."

Review of the policy titled "Emergency Room Infection Control" occurred on 05/30/13. This policy, dated 2010, stated, ". . . After each case in the ER [emergency room], the ER table and all surfaces and equipment that a patient (or accompanying individual) has come in contact with, are wiped with disinfectant wipes or an approved disinfectant for cleaning . . ."

The following observations showed breaches in the hospital staff's infection control practices:
*05/28/13 at 12:28 p.m. - A licensed staff member (#5) assisted Patent #2 to bed. Observation showed a soiled soaker pad on the patient's recliner. Staff member #5 removed the soaker pad with ungloved hands and disposed of it in the soiled utility room. The staff member (#5) failed to perform hand hygiene. She then obtained a gait belt from the nurses station, applied it to Patient #3, and assisted her to a recliner in the activity room. The staff member (#5) failed to perform hand hygiene.
*05/28/13 at 1:28 p.m. - A staff member (#5) assisted Patient #2 to the bathroom. Observation showed the patient performed her own perineal cares after a bowel movement. The staff member (#5) failed to offer or encourage the patient to wash or sanitize her hands.
*05/29/13 at 6:55 a.m. - A staff member (#5) exited Patient #2's room with gloved hands, opened the clean storage closet and obtained a soaker pad. The staff member stated Patient #2 had a large incontinent bowel movement and they (staff members #5 and #7) were cleaning him. When entering the room, observation showed Patient #2 positioned on his side by the staff member (#7) while the staff member (#5) cleaned the patient. The staff member (#5) failed to remove her gloves after performing perineal cares and before exiting the room to obtain clean items from the storage room.
*05/29/13 at 7:45 a.m. - A staff member (#5) assisted Patient #4 to the bathroom. Observation showed the patient performed her own perineal cares after a bowel movement. The staff member (#5) failed to offer or encourage the patient to wash or sanitize her hands.
*05/29/13 at 11:05 a.m. - Observation showed two staff members (#6 and #8) removed the gurney from the emergency room (ER). When asked if they sanitized the gurney, the staff members said they did not, but they did change the sheet as it looked like someone had sat on it. They stated they were going to use the gurney to transport a patient to the radiology department. Observation earlier, at 10:40 a.m., showed a patient with an eye infection seated on the gurney in the ER.

During an interview on 05/29/13 at 6:45 a.m., an administrative nurse (#1) stated she expected hospital staff to sanitize or wash their hands between patients and after handing soiled items; remove their gloves before exiting a patient's room; assist patients with hand hygiene; and disinfect the ER gurney between patients.

Based on review of personnel files and staff interview, the Critical Access Hospital (CAH) failed to ensure nursing staff possessed the qualifications/certifications required for their specific roles for 1 of 3 nurses' (#7) personnel files reviewed. Failure to ensure all nursing staff possessed the required certifications, training, and competency needed to perform their clinical duties has the potential for nursing services to not meet the needs of the patients.

Findings include:

During an interview on 05/30/13 at 6:45 a.m., an administrative nurse (#1) stated the CAH required nurses working in the emergency room (ER) and as charge nurse to possess current Advanced Cardiac Life Support (ACLS), Pediatric Advance Life Support (PALS), and Trauma Nursing Core Course (TNCC) certification.

Review of three randomly selected nurses' personnel files occurred on the morning of 05/30/13. The file of a nurse (#7), currently working as a charge nurse and in the ER, lacked evidence of ACLS, PALS, and TNCC certification.

During an interview on 05/30/13 at 11:45 a.m., an administrative nurse (#1) confirmed the lack of ACLS, PALS, and TNCC certification in the nurse's (#7) personnel file. The nurse (#1) failed to provide evidence of those certifications.

Based on observation, record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to provide care in accordance with the patient's needs for 2 of 3 active swing bed records (Patients #1 and #3) reviewed. Failure to utilize a gait belt has the potential for patients to experience a fall and sustain an injury.

Findings include:

Review of the policy titled "Gait Belt Usage for One/Two Person Assist" occurred on 05/30/13. This policy, dated February 2012, stated, ". . . Implementation: 1. Check care plan/ADL [activities of daily living] plan, know the abilities of patient/resident and assist as needed . . ."

- Review of Patient #1's active swing bed record occurred on May 28-30, 2013. The CAH admitted the patient to swing bed on 04/18/13 with a diagnoses of a head injury and fractures of the dorsal and lumbar vertebrae obtained from a fall. Patient #1's current care plan failed to identify any assistive devices such as a gait belt.

Observation on 05/28/13 at 12:33 p.m. showed a nurse and a certified nursing assistant (CNA) (#1 and #5) held onto Patient #1's arms and walked with him from the dining room to his room without using a gait belt.

During an interview of the morning of 05/29/13, an administrative nurse (#1) stated the CAH required staff to utilize a gait belt while transferring Patient #1.

- Review of Patient #3's active swing bed record occurred on May 28-30, 2013. The CAH admitted the patient to swing bed on 04/16/13 with diagnoses of a fall and a head injury. Patient #3's current care plan identified a potential for injury. Interventions included a bed alarm and assistance with ambulation and transfers.

Observation on 05/28/13 at 10:55 a.m. showed a staff member (#16) assisting Patient #3 ambulating in the hall without a gait belt.

Based on observation, record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to review and revise the nursing care plan for 3 of 4 active patient (Patients #1, #2, and #4) records reviewed with a history of falls, wandering, and Clostridium difficile (C. diff) infection. Failure to review and revise care plans limited the CAH's ability to manage patients' needs, communicate treatment approaches, and ensure continuity of care.

Findings include:

Review of the policy titled "Care Planning Process CAH" occurred on 05/30/13. This policy, dated 2011, stated, "Policy, Interpretation, Implementation: The Care Planning Process is in place to ensure that a resident/patient is given appropriate treatment and provided services in order to maintain or improve his/her abilities to function with their every day activities. Procedure: . . . 5. The care plan shall reflect goals and needs based on the patient/resident status . . . 10. The care plan is updated on a continual basis. 11. Changes in patient/resident plan of care will be immediately documented on the care plan via written entry. . . ."

- Review of Patient #1's active medical record occurred on May 28-30, 2013. The CAH admitted the patient to swing bed on 04/18/13 with a diagnoses of a head injury and fractures of the dorsal and lumbar vertebrae obtained from a fall.

Observation on 05/28/13 at 12:33 p.m. showed two staff members (#1 and #5) held onto Patient #1's arms and walked with him from the dining room to his room without using a gait belt.

Patient #1's current care plan failed to identify a history of wandering and the use of a wanderguard, his recent fall, and the use of any assistive devices such as a gait belt. The care plan lacked interventions to prevent or minimize falls and wandering.

- Review of Patient #2's active medical record occurred on May 28-30, 2013. The CAH admitted the patient to swing bed on 05/14/13 with an urinary tract infection. On the morning of 05/29/13, the hospital staff placed Patient #2 in isolation precautions related to a diagnosis of C. diff.

Patient #2's current care plan, reviewed on the afternoon of 05/29/13 and the morning of 05/30/13, failed to identify isolation precautions related to the diagnosis of C. diff and interventions to prevent the spread of the infection.

- Review of Patient #4's active medical record occurred on May 28-30, 2013. The CAH admitted the patient to acute care on 05/26/13 with a diagnosis of dementia with a change in mental status. The record identified Patient #4 experienced a fall in her room on the evening of 05/28/13 and the hospital staff initiated a bed alarm.

Patient #4's current care plan, reviewed on 05/29/13, failed to identify the patient's fall on 05/28/13 and lacked interventions to prevent or minimize falls, such as the bed alarm.

During an interview on the morning of 05/29/13, an administrative nurse (#1) agreed Patient #1, #2, and #4's care plans lacked interventions related to falls, wandering, and isolation precautions.

Based on record review, review of the medical staff rules and regulations, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to maintain clinical records in accordance with written policies and procedures regarding lack of signed discharge summaries for 1 of 3 closed swing bed patient records (Patient #8) and 2 of 3 closed acute inpatient records (Patient #9 and #10). Failure to ensure signed discharge summaries limited the CAH's ability to ensure the accuracy and completeness of the medical records.

Findings include:

Review of the Medical Staff Rules And Regulations occurred on 05/28/13. This document, approved 01/25/11, stated, ". . . C. MEDICAL RECORDS, 1. Practitioners shall be responsible for the preparation of a complete and legible medical record for each patient /resident. . . . 5. All clinical entries in the patient/resident's medical record shall be . . . signed. . . . 9. A medical record shall not be permanently filed until it is completed by the the responsible practitioner . . . 12. The medical record will be complete within 30 days. . . ."

Review of the policy and procedure "Medical Record Documentation Requirements" occurred on 05/30/13. This undated document stated, "PURPOSE: To maintain records which provide caregivers with information to assist in delivering quality care and continuity of care to patient [sic]. POLICY: . . . For each patient receiving health care services, the CAH maintains a record that includes, as applicable . . . a brief summary of the episode, disposition, and instructions to the patient . . . All entries in the medical record must be . . . authenticated . . ."

Review of the policy "Deficiency Tracking" occurred on 05/30/13. This undated policy stated, ". . . The Chart Deficiency List will be utilized as a communication tool to track deficient records. Once the ward clerk has assembled the chart in the correct closed chart order, HIM [Health Information Management] will analyze the chart. Any deficiencies will be tracked on the Chart Deficiency List. . . . The chart will be ready to be filed once all deficiencies are completed . . . records will be completed and filed away within 30 days of discharge."

Review of closed medical records on May 29-30, 2013 identified the following records lacked signed discharge summaries:
*Patient #10 - admitted on 12/12/12, discharged on 12/15/12.
*Patient #8 - admitted on 02/18/13, expired on 02/27/13.
*Patient #9 - admitted on 02/25/13, discharged on 03/01/13.

During interview, on 05/29/13 at 2:15 p.m., a medical records management staff member (#10) confirmed the lack of signed discharge summaries.

Based on record review, review of the medical staff rules and regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure 4 of 10 closed emergency department (ED) records (Patient #15, #16, #18, and #23) reviewed included the times of patient arrival, provider notification, and provider arrival. Failure to include these times limited the CAH's ability to ensure the quality of patient care and monitor the appropriateness of provider response times.

Findings include:

Review of the CAH's Medical Staff Rules And Regulations occurred on 05/28/13. This document, approved 01/25/11, stated "D. GENERAL CONDUCT OF CARE . . . 12. A member of the Medical Staff shall be on duty or on-call at all times and available to respond in person to the JMHCC [Jacobson Memorial Hospital Care Center] facility within 30 minutes of being called. . . ."

Review of closed ED medical records on 05/29/13 identified records lacked response times as follows:
*Patient #15 - presented on 03/13/13, lacked patient arrival time, provider notification time, and provider arrival time.
*Patient #16 - presented on 01/15/13, lacked provider notification time, and provider arrival time.
*Patient #18 - presented on 04/14/13, lacked provider notification time, and provider arrival time.
*Patient #23 - presented on 03/21/13, lacked patient arrival time, provider notification time, and provider arrival time.

During interview, on 05/29/13 at 2:15 p.m., a supervisory medical records staff member (#13) confirmed the CAH staff failed to document the previously identified times and reported she expected the staff to document these times. This staff member (#13) also indicated the medical records department did not monitor the ED records for completeness of these times.

Based on record review, review of medical staff rules and regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure the health care practitioner (HCP) timed and signed orders within time frames established for 2 of 3 closed swing bed patient (Patient #8 and #13), 3 of 3 closed acute inpatient (Patient #9, #10, and #11), and 2 of 2 closed observation patient (Patient #14 and #15) records reviewed. Failure to ensure the HCP timed and signed treatment orders limited the CAH's ability to ensure the completeness of the medical record and the continuity of patient care.

Findings include:

Review of the CAH's Medical Staff Rules And Regulations occurred on 05/28/13. This document, approved on 01/25/11, stated "C. MEDICAL RECORDS . . . 5. All clinical entries in the patient/resident's medical record shall be timed, dated, and signed. . . . 12. The medical record will be complete within 30 days. . .
D. GENERAL CONDUCT OF CARE . . . 3. All orders must be written clearly . . . include the date and time of the entry, and signed by the practitioner within the time frames established. . . .
5. Telephone and verbal orders may be used provided they are . . . dated, timed and signed or initialed by a licensed health care practitioner responsible for the care of the patient within 48 hours unless the hospital policies and procedures for verbal and telephone orders include a process by which the reviewer of the order reads the order back to the ordering practitioner to verify its accuracy. For verbal orders and telephone orders using the read-back process, the verbal orders and telephone orders must be authenticated within 30 days of discharge or within 30 days of the date the order was given if the length of stay is longer than 30 days. . . ."

Review of closed medical records occurred on May 28-29, 2013 and identified the following records included HCP orders which lacked timing and signatures. These orders included telephone, verbal, and written orders.
*Patient #8 - admitted on 02/18/13 and expired on 02/27/13.
- lacked timing - 02/18/13, 02/19/13, 02/20/13, and 02/22/13 (two times)
- lacked signatures - 02/21/13 (three signatures), 02/22/13 (two signatures), 02/23/13 (two signatures)

*Patient #9 - admitted on 02/25/13 and expired on 03/01/13.
- lacked timing - 02/26/13, 02/27/13, and 03/01/13 (three times).
- lacked signatures - 02/25/13 (three signatures), 02/26/13, 02/28/13, 03/01/13 (three signatures).

*Patient #10 - admitted on 12/12/12 and discharged on 12/15/12.
- lacked signature - 12/13/12.

*Patient #11 - admitted on 03/18/13 and discharged on 03/22/13.
- lacked timing - 03/19/13, 03/21/13, and 03/22/13.
- lacked signatures - 03/21/13 and 03/22/13.

*Patient #13 - admitted on 03/27/13 and discharged on 04/04/13.
- lacked timing - 04/02/13 and 04/04/13.
- lacked signatures - 03/28/13, 04/02/13, and 04/04/13.

*Patient #14 - admitted on 01/30/13 and discharged on 01/31/13.
- lacked timing - 01/30/13 and 01/31/13.

*Patient #15 - admitted on 03/13/13 and discharged on 03/14/13.
- lacked timing - 03/14/13.
- lacked signatures - 03/14/13 (four signatures).

During interview, on 05/30/13 at 11:00 a.m., a medical records supervisory staff member (#13) confirmed the CAH staff should ensure the HCP completes the medical records within 30 days.

Based on bylaws review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the treatment furnished in 2012 by 5 of 5 courtesy/locum tenens physicians (Physicians #1, #2, #3, #4, and #5) at the CAH. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the treatment furnished by the physicians limits the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the "Jacobson Memorial Hospital Care Center Medical Staff Bylaws" occurred on 05/28/13. These bylaws, adopted 04/23/12, stated,
". . . Article II Purposes
The purpose of this organization shall be: . . .
2. To strive for a high level of professional performance of all practitioners authorized by the Board of Directors to practice in JMHCC [Jacobson Memorial Hospital Care Center] through ongoing review, analysis, and evaluation of the clinical work of the members of the Medical Staff . . ."

Review of the governing board's bylaws titled "Jacobson Memorial Hospital Care Center Constitution & Bylaws" occurred on 05/28/13. These bylaws, effective 03/26/12, stated,
". . . Article VII. Medical Staff . . .
Section 7.2 Medical Care and its Evaluation . . . 7.2.2 The medical staff shall conduct an ongoing review and appraisal of the quality of health services within the hospital care center . . ."

Review of the policy titled "Peer Review Process" occurred on 05/29/13. This undated policy, stated, "HIM [Health Information Management] will be responsible for guiding the Peer Review Process based on the following criteria:
1. For providers who have admitted patients to acute care during the quarter, a minimum of one chart per provider will be selected for Peer Review. . . .
3. All M.D. [Medical Doctor] Peer Review will be performed under contract with the [name of contracted agency]. . . ."

Upon request on 05/29/13, the CAH failed to provide evidence a network hospital or a QIO or equivalent evaluated the quality and appropriateness of the treatment furnished by Physicians #1, #2, #3, #4, and #5 in 2012.

During interview at approximately 4:55 p.m. on 05/29/13, an administrative staff member (#10) confirmed Physicians #1-#5 provided services to the CAH's patients in 2012, and the CAH did not have a network hospital or QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment furnished by these physicians.