HospitalInspections.org

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on May 25, 2021, the surveyor finds 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 C930.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Recertification Survey conducted on May 25. 2021, the surveyor finds that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated May 25, 2021.

Based on document review and staff interview it was determined for 1 of 6 (Pt #5) records of patients with do not resuscitate (DNR) status, the critical access hospital (CAH) failed to ensure policies related to advance directives were followed. This has the potential to affect all patients receiving services.

Findings include:

1. On 5/20/21 at 9:30 AM, the policy dated 4/20, titled, "Patient Self-Determination Act"was reviewed. The policy under "Procedure...Step 3 If the patient has an advance directive, it will be followed once a copy is obtained." Under "Step 5...DETERMINATION OF VALIDITY OF ADVANCE DIRECTIVE...Signature of patient, Witness(s) signature(s)".

2. On 5/18/20-5/20/21, the medical record of Pt #5 was reviewed. Pt #5 presented to the emergency department (ED) on 11/5/20 at 10:43 PM, with chief complaint of confusion and combative behavior. Pt #5 was living at home and was accompanied by spouse. On 11/6/21 at 2:45 AM, Pt #5 was admitted for acute care. On 11/6/21 at 3:18 AM, documentation on the "Initial Interview"completed by a registered nurse (RN) indicated wife was HCPOA (health care power of attorney) and Pt #5 was a "DNR" (do not resuscitate). After review of the medical record, there was no other documentation to indicate a discussion of DNR or POLST (practitioner orders for life sustaining treatment) was found. Pt #5 was discharged in stable condition to a long term care facility on 11/9/21 at 4:13 PM.

3. On 5/20/21 at 2:00 PM, an interview was conducted with the chief nursing officer (E#1) and utilization review coordinator (E#4). E#1 and E#4 both reviewed Pt #5's medical record and could not find any documentation of a discussion with wife or family regarding DNR. There was no documentation of a physician order or POLST.