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Based on record review and staff interview, the facility failed to develop an individual abuse prevention plan for each vulnerable adult in accordance with State law for 3 of 20 (P17, P14, P1) inpatient records reviewed. Findings include:


Vulnerable adult assessment screenings were not completed on all patients admitted to the CAH.


The facility's "Abuse Prevention Plan" included screening questions to determine if a patient was susceptible to abuse.


P17 was admitted to the CAH on 4/9/10. The facility's "Abuse Prevention Plan" was blank in P17's clinical record.

P14 was admitted to the CAH on 6/14/10. The facility's "Abuse Prevention Plan" was blank in P14's clinical record.

On 6/16/10, at 1:55 p.m. LPN-B stated she only completes a vulnerable adult assessment screening if she is lead to it by concerns.

On 6/17/10, at 2:45 p.m. the DON verified P17 and P14 clinical records lacked a vulnerable adult assessment.



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P1 was admitted to an observational bed at the CAH on 6/13/10. On 6/14/10, the patient was admitted as an inpatient. The medical record lacked a Vulnerable Adult assessment.

On 6/17/10, at 2:55 p.m. the director of nursing verified this finding.

Based on interview, record review and policy review, the Critical Access Hospital (CAH) was found not to be in compliance with the Conditions of Participation for Physical Environment due to failure to ensure proper procedures were followed related to use of alcohol based skin preparation in anesthetizing locations to prevent the risk of surgical fires. This practice was evident for 3 of 7 patients (P21, P25 and P27) in the sample who required this type of surgical prep. Findings include:

The CAH did not follow the developed policies and procedures to ensure compliance with applicable federal regulations and guidelines related to the use of alcohol based skin preparations in the surgical department. CMS (Centers for Medicare and Medicaid Services) had issued a Survey and Certification Memo dated 1/12/2007, addressing risk reduction techniques to permit safe use of alcohol based skin preparations in inpatient anesthetizing locations in CAHs. The use of an alcohol based skin preparations in inpatient or outpatient anesthetizing locations is not considered safe, unless appropriate fire risk reduction measures are taken, preferable as part of a systemic approach by the CAH to preventing surgery related fires.


The Alcohol Based Skin Preps and Patient Safety policy was reviewed. Step 3.f. under to procedure was "On OR record, document skin prep, by whom, type of prep, and whether the dry time was allowed."

During record review it was noted that alcohol based skin preparation, Duraprep had been utilized for P21 during a surgery on 2/03/10, for umbilical here repair. The Operating Room Record documented that the skin prep was done by RN-A and Duraprep was used. There was a place for documentation of "> (greater than) 5 minute 'dry time' allowed after prep with the check box in front that had not been checked.

P25 had surgery on 2/19/2010, for an open umbilical hernia repair. The Operating Room Record documented that the skin prep was done by RN-B and Duraprep was used. There was a place for documentation of "> (greater than) 5 minute 'dry time' allowed after prep with the check box in front that had not been checked.

P27 had surgery on 6/16/2010, of a laparoscopic cholecystectomy. The Operating Room Record documented that the skin prep was done by RN-A and Duraprep was used. There was a place for documentation of "> (greater than) 5 minute 'dry time' allowed after prep with the check box in front that had not been checked.

On 6/17/2010, at 9:00 a.m. RN-B was interviewed and stated that she was present during the surgery on P27 and observed the dry time of greater than five minutes.

On 6/17/2010, at 9:00 a.m. an interview with the operating room supervisor indicated that the policy stated that the "dry time" was greater than five minutes and staff should document on the Operating Room Record.

Based on observation and staff interview, the CAH failed to ensure medications and other biologicals were stored securely for 1 of 1 medication refrigerator in the attached clinic, and failed to ensure outdated drugs and biologicals were not available for patient use in 1 of 1 medication cupboard in the outpatient department and 1 of 1 medication tray in a cupboard in the emergency department. Findings include:

Medications were not secured in the attached clinic.

On 6/17/10 at 9:00 a.m., the attached clinic was toured. One of the unlocked and open treatment rooms was observed to have an unlocked refrigerator that stored multiple medications and vaccines.

Medications in the unlocked refrigerator included: 35 Albuterol Inhaler solutions, 16 Ipratropium inhaler solutions, and multiple containers of insulin for injection. The refrigerator also contained multiple vaccines including MMR, Varicella, Fluzone, H1N1, Pneumococcal, Hepatitis B, Hepatitis A, and Meningococcal.

On 6/17/10 at 9:25 a.m. the clinic director stated the treatment room is never locked. She verified the refrigerator medications would be accessible to unauthorized persons.



Expired medications were available for patient use in the outpatient rehab department and emergency room.

During the tour of the outpatient rehab department on 6/17/10, at 11:15 a.m., approximately 15 dexamethasone medication containers were observed in the locked storage unit. However, the medications had expired in February 2010. At this time, the occupational therapist (and director of rehab services) verified this finding.


During the tour of the emergency room department on 6/16/10 at 10:30 a.m., expired medications were observed in a tray in the cupboard beside the attached wall medication cubicles. The tray included 2 diphenhydramine injectables that expired in April 2010. At this time, the director of nursing stated there should not be any medications in the tray and verified the findings.

Based on staff interview, and record review, the CAH failed to maintain an adequate system to identify and implement appropriate interventions to prevent the spread of infection for 2 of 2 patients (P14, P18) who received blood glucose testing by the use of a glucometer. Findings include:

The CAH failed to ensure adequate disinfection of the multi-use glucometer used for P14 and P18.

P14 was admitted to the CAH on 6/14/10 with diagnoses including acute renal failure and required glucose monitoring by nursing staff.

P18 was admitted to the CAH on 6/17/10 and required glucose monitoring by nursing staff.

On 6/17/10, at 10:40 a.m. when interviewed regarding multi-patient use glucometer testing, LPN-B stated she will use a 70% alcohol wipe to cleanse the glucometer if visibly dirty. LPN-B indicated this was directed as indicated on the facility's undated "Accu-Check Inform System Glucose Meter Competency" form used to train new employees on cleaning the multi-patient use glucometer. The form directed staff to use disinfectant of choice to cleanse at a minimum of on every 24 hours.

At 10:42 a.m. RN-B stated she would use a 70% alcohol wipe or a disinfectant wipe if cleansing the glucometer.

At 11:50 a.m. LPN-A stated she would use a 70% alcohol wipe to cleanse the glucometer, if needed.

At 2:45 p.m. the DON stated she was unsure what product was used to cleanse the glucometer, but added she would revise the competency form to use a disinfecting product after each patient use.

Based on record review and staff interview, the facility failed to develop a nursing care plan for 6 of 20 (P1, P4, P6, P14, P9, P17) inpatients reviewed. Findings include:

Patien records lacked nursing care plans.

P1 was admitted to an observational bed at the CAH on 6/13/10, with diagnoses including chronic renal failure. On 6/14/10, the patient was admitted as an inpatient. During record review on 6/16/10, the medical record was noted to lack a care plan.

P4 was admitted to the CAH on 4/25-28/2010, with diagnoses including soft tissue hematoma. The medical record was noted to include a care plan form, however, the form was blank.

P6 was admitted to the CAH on 5/26-31/10, with diagnoses including a small bowel obstruction. The medical record was observed to contain a blank care plan form.


On 6/17/10, at 2:55 p.m., the director of nursing verified these findings.



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P14 was admitted to the CAH on 6/14/10 with diagnoses including acute renal failure. The clinical record lacked a current nursing care plan.

On 6/16/10, at 11:35 a.m. LPN-A verified the patient lacked a care plan. She added on should be completed on all patients but was unsure what happened to P14's care plan.

P9 was admitted to the CAH on 5/20/10 with diagnoses of chest pain. The clinical record lacked a nursing care plan.

P17 was admitted to the CAH on 4/9/10 with diagnoses of acute coronary syndrome. The clinical record lacked a nursing care plan.

On 6/17/10, at 2:45 p.m. the DON verified these findings.

Based on staff interview and record review, the CAH failed to ensure all patients had a records are legible, complete, accurately documented, readily accessible, and systematically organized for 1 of 1 patient (P16) reviewed who had received services for cardiac arrest in the emergency room. Findings included:

P16's clinical record lacked pertinent documentation of the patient's status during the process of a code when the patient experienced a cardiac arrest.

A review of the record indicated the facility's CPR flowsheet to document the progress of CPR was blank. In addition, the nursing notes lacked consistent vital signs, documentation of treatments and assessment of the patient's status during the progress of CPR.

The record indicated:

On 3/2/10, at 10:17 p.m. P16 presented to the emergency room in cardiac arrest. No further documentation regarding P16's status was entered into the nursing documentation until 10:30 p.m.

At 10:37 p.m. nursing notes indicated a carotid, radial and pedal pulses were present, but lacked indication the rate of the pulse or further assessment of the P16's status.


At 10:48 p.m. nursing notes indicated attempts were made to transport P16 to another facility; however, the note lacked further indication or assessment of the patients's status.

At 10:50 p.m. the nursing notes indicated the physician had intubated the patient prior to 10:30 p.m. The noted lacked further detail of the intubation and how the P16 responded to the procedure.

At 10:55 p.m. the nursing notes indicated another facility was contacted to attempt to transport the patient to another hospital, but they too could not fly because of the weather. No further assessment was documented regarding the patient's status.

At 11:00 p.m. the nursing notes indicated CPR ceased and the patient passed away.

On 6/17/10, at 10:50 a.m. RN-A verified the facility has a flowsheet to fill out during CPR. She added that other disciplines can assist to fill this out during CPR.

At 2:45 p.m. the DON verified the nursing documentation was incomplete and lacked indication of the ongoing status of P16. She stated the documentation "doesn't link up." She added the CPR flowsheet should have been used.

Based on record review, policy review, and interview, the CAH (Critical Access Hospital) failed to ensure all entries made in the medical record were timed, dated, and authenticated for of 19 of 42 (P21, P22, P27, P4, P5, P7, P8, P30, P31, P32, P33, P10, P11, P12, P13, P15, P16, P18, P34) patients reviewed receiving services at the CAH. Findings include:


Rules and Regulations of the Lakewood Health Center dated 2004, stated under #8. "all clinical entries in the patient's medical record shall be accurately dated and signed. Timing of signature was not addressed.

The following inpatient records were reviewed and had incomplete entries.

P21 was admitted 2/3/10, for outpatient umbilical hernia for surgery. The Preoperative History and Physical Examination dictated on 1/29/10, was not dated of timed when the physician. The Hernia/hydrocele Orders dated 2/3/10, were not authenticated. The Operative Report form 2/3/10, by the surgeon was not dated or timed when signed.

P22 was admitted on 12/23/09, for outpatient umbilical hernia for surgery. The Preoperative History and Physical Examination dictated on 12/22/09, was not dated of timed when the physician. The Hernia/hydrocele Orders dated 12/23/09, were not authenticated. The Operative Report by the surgeon was not dated or timed when signed.

P27 had an office visit note (history and physical) on 5/27/10, lacked physician signature with a date and time.



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P4 was admitted to the CAH on 4/25/10. The history and physical dictated on 4/27/10, and the discharge summary dictated on 4/30/10, lacked a date and time of the physician signature. The physician order of 4/24/10, lacked the time of the entry.

P5 was admitted to the CAH on 4/28/10. The radiology reports supine and upright abdomen dated 4/28/10, and 4/29/10, and the AP pelvis dated 4/29/10 lacked signatures and/or dated and time of the entry. The progress note by the physician dated 4/29/10, lacked the time of the entry.

P7 was admitted to the CAH on 3/9/10. The radiology report pelvis and lateral hip dated 3/17/10, lacked the time of the entry. The physician progress note dictated 3/11/10, lacked a date and time of the physician signature.

P8 was admitted to the CAH on 3/7/10. The radiology chest report dictated 3/6/10, lacked a signature of the entry. The discharge order dated 3/9/10, lacked the time of the entry.

P30's Behavioral Health initial assessment dated 1/7/10, lacked the time of the entry.

P31 was admitted to cardiac rehab 4/22/10. The report referral report dated 5/4/10, lacked the time of the entry.

P32's occupational therapy progress note dictated 3/11/10, and the initial evaluation note dictated 2/18/10, lacked a date and time of the therapist's signature.

P33's physical therapy initial evaluation dictated 4/26/10, lacked a time of the dictation and lacked a date and time of the therapist's signature.


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P10 was admitted to the CAH on 4/22/10. Telephone orders received on 4/23/10, and 4/26/10, lacked authentication from the practitioner.

P11 was in the emergency room on 4/11/10. The consent for treatment was blank. In addition, the "emergency room nursing record" was unsigned, timed or dated. The "emergency room and outpatient physician record" was not timed and dated by the physician.

P12 was admitted on 10/6/09. The radiology report lacked a signature from the radiologist.

P13 was admitted on 4/9/10. The consent for treatment was blank.

P15 was in the emergency room on 1/31/10. The consent for treatment was blank. The "emergency room and outpatient physician record", which included medication orders, was not timed and dated by the physician. In addition, the "emergency room nursing record" lacked a discharge date and signature from nursing staff as directed on the documentation.

P16 was in the emergency room on 3/2/10. The "emergency room and outpatient physician record" which included medication orders was not timed and dated by the physician.

P18 was admitted to the CAH on 6/17/10. The physician orders lacked a time, date and signature of the physician to authenticate the orders.

P34 was seen by speech therapy through outpatient services on 6/7/10. The therapy order lacked a time of the order by the practitioner as well as orders to treat the patient as directed by the speech therapist.

On 6/17/10, at 2:45 p.m. the DON verified all physician orders and nursing documentation should be signed, timed and dated. She further verified a consent for treatment should be obtained when a patient is admitted to the hospital.

Based on record review and staff interview the facility failed to evaluate all patient care services in the quality assurance program for outpatient services which included physical therapy and occupational therapy, cardiac rehab, emergency services, behavioral health, and swing beds. Findings include:

On 6/17/10, at 11:15 a.m. during the tour of the rehab department that included physical therapy, occupational therapy, and speech therapy, the occupational therapist (and department director) stated no formal evaluation had occurred since February of 2009.

During the tour of the cardiac rehab department on 6/17/10, at 1:45 p.m. the director of nursing confirmed the CAH had no formal program evaluating these services.

During the tour of the emergency department (ED) on 6/17/10, at 3:40 p.m. the director of nursing stated the CAH had nothing being evaluated for the ED currently.

During the tour of the Behavioral Health department on 6/18/10 at 8:10 a.m. the director of the department stated the CAH was not evaluating these services.



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On 6/18/10, between 8:57 a.m. and 9:12 a.m. during review of the Swing Bed program, the director of nursing verified the CAH did not evaluate the Swing Bed services separately from the acute inpatient services. She stated the Swing Bed patients were included with the regular hospital admissions for quality assurance purposes.



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A review of the documentation for the quality assurance program indicated the following areas were not being evaluated: physical therapy and occupational therapy, cardiac rehab, behavioral health, emergency services and swing beds.

On 6/18/10, at 9:30 RN-C confirmed that the areas being evaluated did not include physical therapy and occupational therapy, cardiac rehab, behavioral health, emergency services and swing beds.