HospitalInspections.org

Based on interview and record review, the facility failed to offer information regarding Advance Directives to two patients (Patient (P)14 and P16) admitted to inpatient status at the hospital. This deficient practice had the potential to adversely affect all patients admitted to the hospital by not educating the patient of their right to participate in development of a plan of care.

Findings include:

Review of Patient #14's electronic health record (EHR), revealed an admission date of 10/07/19. The EHR lacked documentation to show that P14 had been provided information or declined information on Advance Directives.

Review of Patient #16's EHR, revealed an admission date of 06/16/19. The EHR lacked documentation to show that P16 had been provided information or declined information on Advance Directives.

In an interview on 01/29/20 at 10:20 AM, the Director of Nursing said the facility was unable to locate any documentation to show P14 and P16 had been provided with information regarding Advance Directives, or documentation that P14 and P16 had declined information regarding Advance Directives. "Each time a patient enters the facility, Advance Directives should be addressed and documented. Information on Advance Directives should be addressed, and acceptance or refusal [of information] should be documented."

Review of the facility policy titled "Advance Directives," last reviewed "9/14," showed, "Purpose: Each patient, upon registration to the hospital, has a right to receive written information about his or her rights to make health care decisions, including the rights to accept or refuse treatment, as well as the right to establish an Advance Directive ... Procedure: A. ... 1. At the time of admission assessment, written information must be offered to all adult patients ... B. Documentation: At the time of admission assessment, it is the responsibility of the admitting nurse to document discussion of Advance Directives and related information within the EHR [electronic health record]."

Based on the onsite complaint investigation, completed February 25, 2020, the facility failed to comply with the regulations set forth for Life Safety, therefore, deficiencies were cited under Life Safety Code tags K211, K291, K712 and K918. See survey event ID #POB421 for full details of the cited deficiencies.

Based on record review and interview, the facility failed to develop a nursing care plan for one patient (P)15 admitted to inpatient status. This deficient practice had the potential to adversely affect the care provided to the patient.

Findings Include:

Review of P15's electronic health record (EHR) showed under "Patient Information" that he was admitted to inpatient services on 07/21/19. The EHR lacked a care plan for P15.

In in interview on 01/29/20 at 10:20 AM, the Director of Nursing said the facility had been unable to locate a care plan in the electronic record or in the hard chart for P15. She said, "There should have been a care plan. The inpatient care plan needed to be reviewed each shift," and "The goals should have been noted as to whether they had been met or not met each shift."

Review of the facility policy titled "Documentation Requirements," last revised on "02/15," showed, "Purpose: To establish documentation that fosters inter-disciplinary collaboration in patient care. The common language for documenting care needs, interventions and patient responses is by exception to established standards ... Documentation tools may consist of ... e. Care Pathway ... Procedure: ... E. Care Pathway: 1. To be selected upon admission according to diagnosis and patient care needs. 2. The pathway provides members of the health care team a tool to individualize and communicate the patient's plan of care as appropriate. 3. To be individualized: a. Throughout patient stay to reflect the patients care needs. B. As appropriate for patient's age. 4. Milliman Care Guidelines will be printed and added to patients' chart for care reference."

Based on record review and interview, the facility failed to develop a comprehensive care plan for one of three patients (patient (P)7) in Swing-bed status. This deficient practice had the potential to adversely affect the care being provided to the patient.

Findings include:

Review of P7's electronic health record (EHR) revealed an admission date to Swing bed status of 01/04/20. The facility continued to utilize the nursing inpatient care plan. Physical Therapy and Occupational Therapy documentation was present in the EHR with specific and measurable goals. There was no evidence that a comprehensive interdisciplinary plan of care that included goals and outcomes was completed within 7 days.

Review of P7's "Utilization Review/Care Conference" sheets dated 01/07/20, 01/21/20, 01/24/20, and 01/28/20, which were provided as part of the care plan, did not contain specific and measurable goals, but rather assessment statuses only.

In an interview on 01/28/20 at 2:30 PM, Registered Nurse (RN)1, in charge of Swing-bed care planning, said she had a resource titled "Critical Access Hospital Swing Bed Manual, 16th Addition" that she had already decided to utilize to build Swing-bed care plans. She said she had never developed a care plan for a Swing-bed patient and did not know it was required. In the past the facility used the acute care plan or individual plans developed by the departments, such as physical therapy, occupational therapy, or activities RN1 also said the weekly "Utilization Review/Care Conference" sheet were used by the nurses and were found in the hard charts.

In an interview on 01/29/20 at 10:21 AM, the Director of Nursing said that each department developed their own portion of the care plan. At 11:15 AM she said she did not think the current system of care planning for swing bed patients met the criteria for care planning since they did not include written measurable goals and interventions. She said the current software system was not set up for the Swing-bed patient care plans.

Review of a facility policy titled, "Scope of Services for Swing Bed," last revised 12/27/18, showed, " ... Each patient receiving rehabilitation services shall have a current written Plan of Care developed by the collaborative health care team including, but not limited to, rehabilitation services staff, nursing services, the patient's provider and other appropriate healthcare professionals. Patients shall be encouraged to make choices about their participation in rehabilitation and to develop a sense of achievement in progress ... "

Based on interview and review of the facility's Emergency Operations Plan (EOP), the facility failed to ensure there was a system to track the location of staff and patients during an emergency. This failure has the potential to negatively impact the facility's efforts to account for patients and staff during an emergency incident.

Findings include:

On 01/29/20 at 9:30 AM, an interview was conducted with the Emergency Medical Services (EMS) Director. The EMS Director stated the facility did not have a system in place to account for patients and on-duty staff in the event of an emergency. The EMS Director further stated the facility had identified the need for the EOP to include a tracking system in 2017. However, the EMS Director further stated the development of the tracking system was not complete and efforts had not been initiated until November 2019. The EMS Director stated additions to the facility's EOP were in the process of development including a section of the EOP titled, "Appendix E, Staff Recall and Survey". The EMS Director stated "Appendix E" would include a tracking system to account for patients and on-duty staff at the facility during an emergency.

A review of the facility's documentation titled, "Emergency Operations Plan", dated 01/2020, reveal no evidence of a tracking system included in the facility's EOP. In addition, a section of the EOP titled, "Appendix E, Staff Recall and Survey", was identified in the table of contents of the EOP. However, the was no evidence the EOP include a developed section of the plan titled, "Appendix E".

Based on interview and review of the facility's Emergency Operations Plan (EOP), the facility failed to ensure the emergency preparedness policies and procedures included a system to preserve patient information, protect confidentiality of patient information, and secure and maintain the availability of medical records in the event of an emergency. This failure has the potential to negatively impact the facility's efforts to preserve, protect, and maintain the health information of patients during an emergency.

Findings include:

On 01/29/20 at 9:30 AM, an interview was conducted with the Emergency Medical Services (EMS) Director. The EMS Director stated the facility had not included any provisions or system in the facility's EOP to preserve and protect the health information of patients during an emergency. The EMS Director stated the facility had a "nursing policy" to address the protection of patient health information and preservation of medical records. However, the EMS Director stated the "nursing policy" had not been included in the facility's EOP.

A review of the facility's documentation titled, "Emergency Operations Plan", dated 01/2020, revealed no evidence the EOP addressed a system to preserve patient information, protect confidentiality of patient information, and secure and maintain the availability of medical records in the event of an emergency.

A review of the facility's policy titled, "Confidentiality of Healthcare Information", dated 08/2014, revealed the facility defined healthcare information as, "any information, oral or recorded in any form, that identifies or can be readily associated with an individual patient and that directly relates to any care, service or procedure to diagnose, treat or maintain a patient's physical or mental condition or that affects the structure or any function of the body. It includes but is not limited to paper-based records, Electronic Medical Records (EMR), and medical imagery."

The facility's EOP must be based on a documented facility-based and community-based risk assessment utilizing an all-hazards approach and must include policy's and procedures that directly address protecting and maintaining healthcare information during potential emergency situations.

There was no evidence of policy's, as a part of the facility EOP, that addressed how the facility would protect and maintain healthcare information during an emergency or communicate this information to other care provider's if necessary.

Based on interview and review of the facility's Emergency Operations Plan (EOP), the facility failed to develop policies and procedures to address how the facility would ensure adequate staff to meet patient needs during emergency situations identified in the facility's risk assessment. This failure has the potential to negatively impact the facility's efforts to organize an effective response during an emergency.

Findings include:

On 01/29/20 at 9:30 AM, an interview was conducted with the Emergency Medical Services (EMS) Director. The EMS Director stated the facility had not included any procedures for the use of volunteers or for the integration of local, state, or federal emergency response staff. The EMS Director stated changes to the facility's EOP were in the process of development to include staffing strategies during an emergency. The EMS Director further stated the additions related to staffing strategies would be addressed in a section of the EOP titled, "Appendix E, Staff Recall and Survey".

A review of the facility's documentation titled, "Emergency Operations Plan", dated 01/2020, revealed no evidence the EOP addressed staffing strategies to include the use of volunteers or State and Federally designated health care professionals during an emergency. In addition, a section of the EOP titled, "Appendix E, Staff Recall and Survey", was identified in the table of contents of the EOP. However, the was no evidence the EOP included a developed section of the plan titled, "Appendix E".