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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on February 26 - 27, 2013, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on February 26 - 27, 2013, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated February 27, 2013.

Based on a review of Critical Access Hospital (CAH) policy and procedure, medical record review and staff interview, it was determined that in 1 of 3 (Pt #15) medical records reviewed in which the patient received blood transfusions, the CAH failed to ensure the physician signed the informed consent for transfusion of blood and/or blood component form to indicate the physician had explained the benefits, risks, and alternatives to the patient.
Findings include:

1. The Hospital policy and procedure revised 9/25/12 titled, "Blood/Blood Product Transfusion & Adverse Reaction" was reviewed on 02/05/13. It indicated under "III. Responsibilities 2.0 Physician ordering transfusion explains the risks and benefits to the patient."

2. The medical record of Pt #15 was reviewed on 02/05/13. It indicated that Pt #15 was admitted on 01/28/13 with a diagnosis of Abnormal Labs. Documentation indicated that on 01/29/13, at 1:25 AM, Pt #15 signed an INFORMED CONSENT FOR TRANSFUSION OF BLOOD AND/OR BLOOD COMPONENTS form. Documentation indicated on 01/29/13 that Pt #15 received 2 units of packed red blood cells. The INFORMED CONSENT indicated "As the physician ordering the transfusion(s), I have explained the risks, benefits, and alternatives of blood or blood product transfusions to this patient." The signature line for the physician to sign, date, and time was blank.

3. During an interview with the Quality Manager on 02/5/13 at 2:00 PM, it was confirmed that the informed consent form was not signed by the physician and that the physician should have signed it.









31195

Based on a review of Critical Access Hospital (CAH) policy, observation, a request for inspection logs and staff interview, it was determined the CAH failed to follow their policy at its offsite locations related to the inspection and removal of expired drugs and biologicals. This failure has the potential to affect 100% of patients receiving care at offsite locations.
Findings include:

1. The CAH policy with a revision date of 9/07, titled "Monthly Inspection Records" was reviewed on 2/6/13. The policy indicated under "Procedure 1.0 The pharmacy technician conducts monthly inspections of all nursing care units and other areas of the hospital where medications are dispensed, administered or stored. 3.0 Areas that have limited access are monitored by designated personnel and supervised by pharmacy. 3.1 The following areas are monitored: Medication are stored...Expiration dates... After the Pharmacy Manager reviews the inspection results, the pharmacy technician then initials and dates the sheet which is filed in the Pharmacy."

2. During an inspection of the Center for Medical Arts (CMA) offsite location for laboratory and imaging on 2/5/13 at 8:30 AM, it was observed in the imaging department Computed Tomography scan room, multiple bags of Normal Saline (NS) which were expired and available for patient use. The following items were observed: NS 50 ml - 5 bags expired 9/12 and 4 bags expired 1/13.
During an inspection of the St. Joseph Outpatient Rehab offsite location on 2/5/13 at 3:30 PM, it was observed in a supply storage area that 5 bottles of Sterile Water-50 ml expired 10/1/12 and were available for patient use.

3. A request for the completed logs indicating inspection of the offsite locations was made on 2/7/13 at 9:00 AM. The Director of Quality indicated there were no logs maintained to indicate the inspections were completed.

4. In a staff interview conducted with the Quality Manager on 2/7/13 at 9:10 AM, she reported there had been no implementation of the inspection logs at the offsite locations in the past. The Quality Manager indicated the managers at the offsite locations as well as Pharmacy staff, Environmental staff and Quality staff would begin to monitor the progress regarding the inspections.

Based on a review of Critical Access Hospital (CAH) policy, record review and staff interview, it was determined in 2 of 12 (Pt #9, 14) patient records indicating verbal or telephone orders were received, the CAH failed to ensure the physician followed their policy for signature, date and timing of the orders.
Findings include:

1. The CAH policy titled "Medical Record Completion", revised 9/24/12, was reviewed. The policy indicated on page 5, under "Verbal/Telephone Order- Dated/Timed/Signed within 48 hours after order given."

2. The medical record of Pt #9 was reviewed on 2/5/13. Pt #9 was admitted to the CAH on 1/31/13 with diagnoses Pancreatitis-resolved and Dementia. Documentation indicated multiple telephone orders dated 1/31/13 through 2/2/13 which were unsigned as of 2/5/13.

3. The medical record of Pt #14 was reviewed on 2/6/13. Pt #14 was admitted to the Out Patient area of the CAH with diagnoses of Chronic Anemia and Menorrhagia and was scheduled for blood transfusions. Documentation indicated a telephone order for "T&C, 4 units" dated 1/29/13 was unsigned as of 2/6/13.

4. During an interview with the Director of Patient Care Services on 2/7/13 at 11:30, she indicated physicians are expected to follow the policy to sign orders and when orders are not signed they are flagged so physicians are aware. She indicated some physicians are better than others and confirmed the orders reviewed were unsigned.

Based on a review of Critical Access Hospital (CAH) policy and staff interview, it was determined the CAH failed to ensure medical records were completed within 22 days, as per the CAH's policy This has the potential to affect 100% of the patients who receive services at the CAH.
Findings include:

1. The CAH policy revised on 9/24/12, titled "Medical Record Completion" was reviewed on 2/6/13. The policy indicated on page 5 of 6 under "Document...All other documents needing Signed/Dated/Timed" under "Completion Timeframe...Within 22 days from discharge/service date".

2. During an interview with the Quality Manager on 2/6/13 at 3:00 PM, it was reported that there were 13 delinquent medical records as of 2/5/13.