HospitalInspections.org

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure patients were given an advance directive notice or the right to formulate an advance directive upon admission. This had the potential to affect all patients admitted to the CAH for treatment sample was (P1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 & 13).

Findings include:

Review of patient (P)-1's medical record, indicated the patient was admitted on 8/12/16, for surgery of a left cataract extraction. The admission notes did not include the patients advance directive nor did it include it had been offered. The question on the admission form was blank.

Review of P2's medical record, indicated the patient was admitted on 11/15/16, for surgery of a right trigger finger release. The admission notes did not include the patients advance directive nor did it include it had been offered. The question on the admission form was blank.

Review of P3's medical record, indicated the patient was admitted on 12/9/16, for surgery of a left cataract extraction. The admission notes did not include the patients advance directive nor did it include that it had been offered. The question on the admission form was blank.

Review of P4's medical record, indicated the patient was admitted on 7/8/16, for surgery of a left cataract extraction. The admission notes did not include the patients advance directive nor did it include that it had been offered. The question on the admission form was blank.

Review of P5's medical record, indicated the patient was admitted on 4/8/16, for surgery of a right cataract extraction. The admission notes did not include the patients advance directive nor did it include that it had been offered. The question on the admission form was blank.

Interview with registered nurse (RN)-A on 3/7/17, at 10:00 a.m., confirmed the above patient medical records did not include advance directives and indicated advance directives were not routinely given to emergency department(ED) patients or surgical services (SS) patients, but could not explain the reason why.


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P6 was seen in the ED on 2/19/17, at 6:04 a.m. and no documentation was provided to indicate request for advance directive information, or offer to provide information to P6 or to the family.

P7 was seen in the ED on 1/5/17, at 5:34 p.m. and no documentation was provided regarding advance directive information.

P8 was seen in the ED on 3/1/17, at 9:15 p.m. and no documentation was provided regarding advance directive information.

P9 was seen in the ED on 2/18/17, at 4:24 p.m. and no documentation was provided regarding advance directive information

P10 was seen in the ED on 3/5/17, at 5:57 p.m. and no documentation was provided regarding advance directive information.

P11 was seem in the ED on 2/13/17, at 6:13 a.m. and no documentation was provided regarding advance directive information.

P12 was seen in the ED on 1/21/17, at 4:06 a.m. and no documentation was provided regarding advance directive information.

P13 was seen in the ED on 2/19/17, at 6:04 a.m. and no documentation was provided regarding advance directive information.

The director of nursing (DON) was interviewed on 3/7/17, at 3:18 p.m. and verified there was no Advance Directive information documented on patients except if they were admitted to acute care, and in the instance the patient indicated they did not have an advance directive document, that information had been offered.

On 3/8/17, at 1:00 p.m. registered nurse (RN)-B was interviewed and verified the advance directive information was not documented or information offered unless a patient was admitted to acute care services only.

Policy Healthcare Directives revised 09/2016 and reviewed 09/2016, included information regarding the procedure for asking on admission if they have an advanced directives or if they would like to complete one. This information must be documented in the patients chart. Or if they have an advanced directive it must be kept in the patients chart for quick access.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure arrangements for fuel and emergency water (potable and non-potable) were readily available in the event of an emergency and/or disruption of supply. This had the potential to affect all patients, staff, visitors and services provided in the facility.

Findings include:

During review of the CAH's emergency policies there was an agreement with Culligan for backup potable drinking water. The agreement dated 3/9/06, indicated Culligan would supply the hospital with drinking water in the event of a disaster. Although the CAH had a potable emergency supply agreement, there was no current plan specifying the amounts of water required by various CAH departments, in the event of an emergency loss of water. Further review of the facility policies there was no agreement in the event of a disaster did not include a back up fuel agreement if needed.

Interview with the director of maintenance on 3/8/17, at 1:00 p.m. confirmed there was no plan specifying the amounts of potable and non-potable water depending on patient and staff use required by various CAH departments nor was there an agreement for back up fuel supply in the event of an emergency.

Based on observation, interview and document review the critical access hospital (CAH) was found to be out of compliance with Life Safety Code (LSC) requirements. These findings have the potential to affect all patients in the CAH.

Findings include:

Please refer to Life Safety code inspection tags at: K0133, K0211, K0341, K0346, K0351 and K0354.