HospitalInspections.org

Based on interview and record review the facility failed to have criminal background studies completed on 2 of 21 (P-8, CRNA-1) physicians and or mid level practitioners. Findings included:

Physician (P-8) and a Certified Registered Nurse Anesthetist (CRNA-1) did not have a criminal background study on file.

During interview with the administrative assistant on 8/27/10, at 1:30 p.m. she acknowledged these had been missed in the credentialing process.

Based on interview and record review the facility failed to obtained the necessary medical staff and governing board approval for the right to practice in the CAH for 1 of 2 (CRNA-1)certified registered nurse anesthetist (CRNA).
Findings included:

In the credentialing review on 8/26/10, at 10:00 a.m. the personnel record for CRNA-1 did not have either medical staff or governing board approval which would have authorized CRNA-1 to practice in the facility.

In an interview with the administrative assistant on 8/27/10, at 1:30 p.m. confirmed the approval process was missing for CRNA-1.

Based on interview and observations the facility failed to ensure vaccines and insulins and a emergency box in radiology were adequately secured. Findings include:

During the physical plant tour on 8/25/10 at 10:00 a.m. a refrigerator located in the Northside Medical clinic had vaccines and insulins that were not secured. Interview with the clinic manager indicated that the refrigerator was not secured and that housekeeping personal did clean that area after clinic hours.

At 3:10 p.m. on 8/25/10, the radiology room contain the CT scanner had an emergency box that has portable. The room has unlocked and no staff were present in the room or the adjoined room. Both rooms had doors that were open to the hallway. Medications contained in the emergency box were all in syringes: Epinephorine 1:10,000 and 1:1,000; Solu-Cortef 100 ml (milligram); Benadryl 50 ml.

At 3:15 p.m. on 8/25/10, interview the director of radiology verified that the emergency box was unsecured.

Patient (P)-9 did not have an initial nursing assessment which was complete and comprehensive.

Chart review on 8/25/2010 indicated P-9 was admitted to the hospital on 8/21/2010. The "Initial Patient Assessment" form (unsigned) had not been fully completed. Patient history related to respiratory status, genitourinary, endocrine, and pain had not been assessed.

Although the assessment indicated the patient had a history of high blood pressure and coronary artery disease, there had been no nursing assessment of cardiac or circulatory status. The assessment indicated the patient had a history of a poor appetite, however, there was no nursing assessment of his nutrion, bowel sounds, last bowel movement and condition of his abdomen. The assessment indicated the patient had osteoarthritis and a left leg amputation, however, there was no nursing assessment of his mobility status, muscular status or ability to transfer. The assessment also indicated the patient had a history of dementia, however, the nursing assessment did not include an assessment of the patients's cognition.

RN-C was interviewed on 8/25/2010 at 2:30 PM. She stated the assessment had not been completed because the patient could not provide the information due to confusion. She stated the patient's spouse had left the hospital prior to completion of the initial nursing assessment. She stated the assessment should have been completed by nursing staff as soon as the patient's spouse was available to provide the relevant patient information.

Chart review indicated Patient-10 did not have a comprehensive assessment completed upon admission to the hospital.

P-10 was admitted to the hospital on 7/14/2010 with weakness and nausea. The "Initial Patient Assessment" (unsigned) was dated 7/14/2010 at 4:10 PM. Although the patient history obtained by nursing staff indicated concerns related to respiratory status, cardiovascular status, gastrointestinal status, musculoskeletal status, and pain, there had been no further nursing assessment of these identified concerns. There had been no nursing assessment of any patient history of emotional or psycho/social concerns.

The DON was interviewed on 8/26/2010 at 10:30 AM. She verified the "Initial Patient Assessment" form was incomplete and lacked a comprehensive nursing assessment of identified concerns.

Chart review indicated Patient-11 did not have a comprehensive initial nursing assessment completed upon admission to the hospital and prior to a surgical procedure which required a scheduled inpatient hospitalization following surgery..

P-11 was admitted to the hospital on 8/18/2010 at 7:30 AM just prior to a scheduled surgical procedure which required inpatient admission following surgery. The only nursing admission assessment which had been completed was the "Outpatient Surgery" nursing form. The "Initial Patient Assessment" form, which was a comprehensive nursing assessment tool used following inpatient admission, had not been completed during the patient's hospital stay.

The Director of Nursing was interviewed on 8/26/2010 at 10:30 AM. She stated the hospital had identified a concern related to patients who were admitted the same day of a major surgical procedure and scheduled to remain inpatients postoperatively. She stated the "Initial Patient Assessment" tool was not always being completed upon admission of these patients to the hospital. She stated nursing staff had been educated regarding the appropriate use of the nursing admission forms. She verified a comprehensive patient assessment utilizing the "Initial Patient Assessment" form should have been completed upon admission of the patient to the hospital and prior to surgery.

Patient-12 did not have a comprehensive nursing assessment completed upon admission to the hospital and prior to a surgical procedure which required inpatient hospitalization following surgery.

P-12 was admitted to the hospital on 6/2/2010 at 8:00 AM prior to a surgical procedure which required a scheduled inpatient hospitalization following surgery. The only nursing assessment which had been completed was documented on the "Outpatient Surgery" nursing assessment form.

The hospital "Admission of a Patient Policy", last revised 3/99, indicated a complete patient history should be obtained and a physical assessment should be completed. The policy did not indicate which nursing assessment form should be completed when patients were admitted as an inpatient to the hospital.

The Director of Nursing (DON) was interviewed on 8/26/2010 at 10:30 AM. She stated the hospital had identified a concern related to patients who were admitted the same day of a major surgical procedure and scheduled to remain inpatients postoperatively. She stated the "Initial Patient Assessment" tool was not always being completed upon admission of these patients to the hospital. She stated nursing staff had been educated regarding the appropriate use of the nursing admission forms. She verified a comprehensive patient assessment utilizing the "Initial Patient Assessment" form should have been completed upon admission of the patient to the hospital and prior to surgery. The DON also stated the hospital did not have a policy related to the completion of a comprehensive nursing assessment.

Based upon interview and record review, the hospital did not ensure a comprehensive care plan had been developed for 1 of 2 inpatients whose records were reviewed on 8/24/2010 (P-8). Findings include:

P-8 was admitted to the hospital on 8/22/2010 with right flank and abdominal pain and a urinary tract infection. Chart review on 8/24/2010 indicated an "Initial Patient Assessment" had been completed on 8/22/2010 at 6:20 PM. The assessment indicated the patient had a history of confusion and memory loss, back pain and an unsteady gait. A "Morse Fall Risk Assessment Scale" (undated) indicated the patient was at high risk for falls. The scale indicated a fall score above 45 indicated high risk for falling and the patient's score was 100.

The care plan did not indicate the patient had a urinary tract infection nor did the care plan include goals and interventions related to the care and treatment of the symptoms of her urinary tract infection. The care plan also did not indicate the resident was at high risk for falls nor did it include any goals and interventions to decrease the risk of the resident falling. The care plan also did not address the patient's confusion and memory loss.

The policy provided by the hospital titled "Care Plans/Standards of Care Policy", last revised 9/2008, indicated that each patient would have an individualized care plan initiated/supervised by a registered nurse as soon as possible after admission. The policy also indicated that problems and needs of the patient were determined by the admission assessment. The care plans were to be reviewed each shift and updated by a registered nurse as the patient's health status changed.

RN-C was interviewed on 8/25/2010 at 2:30 PM and stated interventions related to the patient's diagnosis of a urinary tract infection and her high risk for falls should have been included in the plan of care.

Based on record review, medical staff rules and regulation, and interview, the CAH (Critical Access Hospital) failed to ensure all entries made in the medical record were timed, dated, and authenticated for of 16 of 39 patients (P1, P2, OP1, P3, P4, P5, P6, P7, P8, P9, P10, P13, P17, ER4, P20, OP2) reviewed receiving services at the CAH. Findings include:

P1's chart review indicated the patient had been admitted to the hospital from the Emergency Department on 8/5/2010. Physician-A had not indicated the date or the time physician orders had been written in the Emergency Department. "Physician Progress Notes", dated 8/6/2010 and 8/7/2010, did not indicate the time the physician had written the progress notes.

P2 was admitted 8/5/10. P-2's chart review indicated Physician-2 had not indicated the time "IV Patient Controlled Analgesia (PCA) Medication Orders" and "Intrapartum Cesarean Orders" had been written.

OP-1 was admitted on 8/25/10 as an outpatient. OP-1's chart review indicated Physician-6 had not indicated the time "Postoperative Orders" and the "Consent to Medical/Surgical Treatment or Procedure" had been signed. There was no indication of the time the "Pre-Op Interview" form had been completed by RN-A.

P3 was admitted 12/28/10. P-3's chart review indicated Physician-4 had not signed the physicians's affirmation of discussion portion of the "Consent to Medical/Surgical Treatment or Procedure" form. The physician also had not indicated what time an operative note, dated 12/28/2009, had been written on the "Physicians's Progress Notes". Physician-1 had not indicated the time a physician progress note had been written on 12/30/2009.

P4's chart review indicated consultant Physician-7 had dictated a "Surgical Pathology Report" (reported 1/25/2010) which had been electronically signed by the physician. However, there was no indication of the date or the time the physician had electronically signed the report.

P5's chart review indicated Physician-3 had not indicated the time orders for "Sliding Scale Insulin Protocol" had been signed. A "Blood Glucose Flow Sheet" indicated the results of the patient's blood glucose test results on 1/4/10 at 5:00 PM and 9:00 PM and on 1/5/10 at 7:00 AM, however, there was no indication who had completed the blood glucose testing. The Director of Nursing was interviewed on 8/26/2010, at 10:30 AM and stated laboratory personnel performed blood glucose tests and verified there was no documentation of who had completed the testing on the flowsheet.

P6's chart review indicated Physician-5 had not indicated the time "Post-op IP Orders" had been written. There was no indication the time the physician had signed the "Consent to Medical/Surgical Treatment for Procedure" form. Although a "Surgery Scheduling Form" had been completed, there was no indication who had completed the form nor the time and date the form had been completed. RN-B had not indicated the time a "Pre-Op Checklist" had been completed on 4/21/2010.

P7's chart review indicated an "Initial Patient Assessment" form had been completed, however there was no signature present to indicate who had completed the form nor was there a date or time documented to indicated when the form had been completed. Physician-1 had written "Physician Progress Notes" on 7/24/10 and 7/26/10 but did not indicate what time the notes had been written.

P8's chart review indicated an "Initial Patient Assessment" form had been completed on 8/22/2010, at 6:20 PM. However, there was no signature present to indicate who had completed the assessment. A "Skin Risk Assessment Scale", a Morse Fall Risk Assessment Scale", and a "Daily Fall Risk Assessment Scale" had been completed, however, there was no signature present to indicate who had completed the forms nor a time or date to indicate when the forms had been completed.

P9's chart review indicated an "Initial Patient Assessment", a "Skin Risk Assessment Scale" and a "Morse Fall Risk Assessment Scale" had been completed. There was no indication who had completed the forms nor the time and date the forms had been completed.

P10's chart review indicated an "Initial Patient Assessment" form, a "Skin Risk Assessment Scale" and a "Morse Fall Risk Assessment Scale" had been completed. There was no indication who had completed the forms nor the date and time they had been completed. A "Daily Skin Risk Assessment" form had been completed on 7/14/2010, however, there was no indication who had completed the assessment or the time the assessment had been completed. A "Berg Balance Scale" had been completed by a member of the contract physical therapy staff on 7/15/2010, however there was no indication who had completed the assessment.


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P13, who had been in a swing bed had an Initial Patient Assessment dated 6/10/10. This assessment did not have a signature of the individual who had complete the assessment. In addition, this patient had a physician's progress note of 6/15/10, that did not have a time or date of physician signature.

P17's chart review had an Initial Patient Assessment dated 1/31/10 however, there was no signature of who had completed the assessment or the time it had been conducted.

ER4 was seen in the ER on 4/20/10. There was no signature, date or time by physician-7 on the order form. Physician-9 did not date or time the cardiology consult dictated on 4/20/10, when the signature was authenticated.

P20 was admitted 6/1/10. There was no time on the skin risk assessment dated 6/1/10.

OP2 was admitted as an outpatient on 6/25/10. A G.I. consult dictated on 6/25/10 by physician-10 did not have a date or time when signed.

Based upon interview and record review, the hospital did not ensure a current roster listing each practitioners specific surgical privileges were available in the surgical suite and in the Outreach area where surgery scheduling occurred for 13 of 13 (S-1, S-2, S-3, S-4, S-5, S-6, S-7, S-8, S-9, S-10, S-11, S-12, S-13) surgeons on staff at the Critical Access Hospital (CAH). Findings include:

During a tour of the surgical suite on 8/25/2010 at 3:10 PM, the Operating Room Coordinator verified that a current roster listing each practioner's specific surgical privileges was not available in the surgical suite and in the Outreach area where surgery scheduling occurred.

S-1, S-2, S-3, S-4, S-5, S-6, S-7, S-8, S-9, S-10, S-11, S-12, and S-13 all had surgical privileges at the CAH.

Based on interview and record review the CAH failed to ensure all patient care services affecting patient health and safety are evaluated through the quality assurance program. Findings include:

In an interview on 8/24/10, at 2:30 p.m. with the registered dietitian it was determined this department did not have a quality assurance program in place. She stated that in the past they conducted a study on timeliness of tray delivery to patients but currently there is not an active QA study being conducted.

During an interview with the director of Quality Assurance on 8/26/10, at 8:30 a.m. she stated that the Swing Bed unit is currently collecting data regarding patient satisfaction and activity programs but they had not developed a specific QA program at the time of the survey.