HospitalInspections.org

Based upon review of medical records and interview with staff it was determined that 14 electronic medical records reviewed of acute and swing bed patients (MR# 11,12, 13, 14,15,16,17,18,19,20,21,22, 23 and MR#24) these records did not have well developed care plans. This requirement was not met as follows.

Findings:

a. Reviewed 14 electronic medical records of Acute care and Swing bed patients (MR # 11-24) there were 14 out of 14 (100%) which included (MR# 11,12,13,14,15,16,17,18,19,20,21,22,23 and MR#24), that did not have nursing care plans that were well developed. Problems were being addressed on a daily basis but there was not evidence of a well developed care plan that was measurable in the medical record reviewed initiated after 24 hours of admission.

b. Interviewed staff #2, chief nursing officer at 3:00pm on March 24, 2010 in an office on the 2nd floor who also reviewed these electronic medical records with the surveyor and observed the incomplete entries. Staff member interviewed could not provided evidence that the medical record reviewed met the requirements of this regulation.

Based upon review of medical records and interview with staff it was determined that 21 out of 24 (83%) (MR# 3,4,5,6,7,8,10,11,12, 13, 14,15,16,17,18,19,20,21,22, 23 and MR#24) of electronic medical records reviewed that were incomplete which included medical record entries that were either not dated, timed or authenticated in written or electrical form by the person responsible for providing or evaluating the services provided, consistent with hospital policies and procedures. This requirement was not met as follows.

Findings:

a. Reviewed 24 electronic medical records (MR # 1-24) there were 21 out of 24 (83%) of the medical records reviewed (MR# 3,4,5,6,7,8,10,11,12,13, 14,15,16,17,18,19,20,21,22, 23 and MR#24) that had medical entries or authentications that were either not dated and/or timed and/or authenticated, had incomplete medical entries after 30 days of discharge of patient. These medical entries ranged from history and physicals being transcribed and placed in the electronic records after the required 24 hours- 10 out of 24 records (42%) which included medical record (MR) # 11,12,13,14,15,16,17,18,20 and ,MR#24) , Acute care and Swing bed patients not having well developed care plans that were measurable 14 out of 14 (100%) which included (MR# 11,12,13,14,15,16,17,18,19,20,21,22,23 and MR#24), X ray results not being dated, time and authenticated by the radiologist within 30 days of discharge 11 out of 24 (46%) which included medical record (MR#3,4,5,6,7,8,19,20,21,22,and MR#24), Swing bed medical records not showing evidence that a multidisciplinary care meeting held 4 out of 6 (67%) swing bed patients electronic medical records reviewed which included( MR #11,14,15 and MR#18.) There were 2 out of 10(20%) MR# 3 and MR#10 emergency department medical records reviewed that had method of transportations forms that were not fully filled out by the witness.

b. Interviewed staff #2, chief nursing officer at 3:00pm on March 24, 2010 in an office on the 2nd floor who also reviewed these electronic medical records with the surveyor and observed the incomplete entries. Staff member interviewed could not provided evidence that the medical record reviewed met the requirements of this regulation.

Based upon review of medical records and interview with staff it was determined that the 6 electronic records of swing be patient did not meet this requirement as follows.

Findings:

a. Reviewed 6 electronic medical records of swing bed patients (MR # 11,14,15,16, 17 and 18) there were 6 out of the 6 (100%) of the electronic medical records of swing bed patients reviewed that did not have developed comprehensive care plans that included measurable objectives.

b. Interviewed staff #2, chief nursing officer at 3:00pm on March 24, 2010 in an office on the 2nd floor who also reviewed these electronic medical records with the surveyor and observed the incomplete entries. Staff member interviewed could not provided evidence that the medical record reviewed met the requirements of this regulation.

Based upon review of medical records and interview with staff it was determined that the 6 electronic records of swing bed patients did not meet this requirement as follows.

Findings:

a. Reviewed 6 electronic medical records of swing bed patients (MR # 11,14,15,16, 17 and 18) there were 6 out of the 6 (100%) of the electronic medical records of swing bed patients reviewed that did not have developed comprehensive care plans that included measurable objectives.

b. Reviewed 6 electronic medical records of swing bed patients (MR#11,14,15,16, 17 and MR #18). There were 4 out of the 6 medical records (MR # 11, 14, 15 and MR# 18) (67%) reviewed that did not have evidence of an interdisicplinary team meeting being held which included the attending physician, registered nuse with responsibility for the resident, and other appropriate staff in disciplines as determined by the residents needs,and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative.

c. Interviewed staff #2, chief nursing officer at 3:00pm on March 24, 2010 in an office on the 2nd floor who also reviewed these electronic medical records with the surveyor and observed the incomplete entries. Staff member interviewed could not provided evidence that the medical record reviewed met the requirements of this regulation.

1. Based upon observation of the critical access hospital (CAH), and interviews with the hospital's staff, the hospital does not have signs, posted conspicuously, specifying the rights of individuals under Section 1867 of the Social Security Act, with respect to examination and treatment for emergency medical conditions and women in labor.

Findings include:

a. During observation of the hospital's emergency department (ED), at 9:30 a.m., March 23, 2010, with the ED nurse manager, it was noted that there were no signs specifying the rights of individuals under Section 1867 of the Social Security Act, with respect to examination and treatment for emergency medical conditions and women in labor, posted in any of the ED's treatment rooms (two, two-bed treatment rooms, and a trauma treatment room), at the nurse's station, or at the admitting station There was only one sign in any area of the ED, in a short hallway through which patients traveled only briefly.

b. During interviews with the ED nurse manager, at 9:30 a.m., March 23, 2010, in the ED, following his own observations of the hospital's ED, ED treatment rooms, ED nursing station, ED admitting area, and ED waiting room, he verified that the ED had not posted conspicuously, a sign specifying the rights if individuals under Section 1867 of the Social Security Act with respect to examination and treatment for emergency medical conditions and women in labor. He also verified that he could provide no evidence of the hospital's compliance with these requirements.