HospitalInspections.org

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Based on observation, review of facility floor plan and staff interview; the CAH (Critical Access Hospital) failed to provide adequate space for the provision of direct hospital services provided (Outpatient Specialty Clinics). This failed practice had the potential to affect all Outpatient Specialty Clinic patients of the CAH. Total outpatient specialty clinic patients at the CAH from 8/1/18-7/31/19 was 65.

Findings are:

A. Observation of the hospital Outpatient Specialty Clinic area (12/12/19 at 12:50 PM) revealed the 3 examination rooms (10, 11 & 12) utilized for the hospital's specialty clinics were located within the RHC (Rural Health Clinic) space.

B. Review of the facility floor plan (no date) revealed the examination rooms were located within the RHC space.

C. Interview with the CNO (Chief Nursing Officer) (12/12/19 at 1:05 PM) confirmed the specialty clinic exam rooms 10, 11 & 12 are located in the RHC area but was told "that they were carved out for hospital use."

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Based on medical record review, review of Medical Staff Rules and Regulations and staff interview; the CAH (Critical Access Hospital) failed to ensure physician orders were properly authenticated (timed, dated and signed) for 5 of 5 outpatient surgical medical records (16, 17, 18, 19 & 20) reviewed. This failed practice had the potential to affect all outpatient surgical patients of the CAH. Total outpatient surgical procedures performed at the CAH from 8/1/18-7/31/19 was 100.

Findings are:

A. Review of Patient 16's medical record (12/11/19 at 11:00 AM) revealed the patient had an EGD (endoscopy-a scope with a light and camera to look inside the upper digestive tract) on 10/22/19. Review of electronic physician orders revealed the following physician orders for the Endoscopy, IV (intravenous therapy) Access, DC (discontinue) IV & IV meds (medications) and Dismiss to Home lacked proper physician authentication (time, date and signature).

-Review of Patient 17's medical record (12/11/19 at 11:15 AM) revealed the patient had a colonoscopy (exam used to detect changes in the large intestine and rectum) on 10/29/19. Review of electronic physician orders revealed the following physician orders for the Colonoscopy, DC IV & IV meds and Dismiss to Home lacked proper physician authentication (time, date and signature).

-Review of Patient 18's medical record (12/11/19 at 11:20 AM) revealed the patient had a colonoscopy on 11/5/19. Review of electronic physician orders revealed the following physician orders for the Colonoscopy, Admit to Outpatient, IV Access, DC IV & IV meds and Dismiss to Home lacked proper physician authentication (time, date and signature).

-Review of Patient 19's medical record (12/11/19 at 11:30 AM) revealed the patient had a colonoscopy on 11/19/19. Review of electronic physician orders revealed the following physician orders for Admit to Outpatient, IV Access, DC IV & IV meds and Dismiss to Home lacked proper physician authentication (time, date and signature).

-Review of Patient 20's medical record (12/11/19 at 11:40 AM) revealed the patient had a sigmoidoscopy (exam to check the inner lining of your rectum and lower part of your colon) on 10/15/19. Review of electronic physician orders revealed the following physician orders for the Sigmoidoscopy, Admit to Outpatient, IV Access and DC IV & IV meds lacked proper physician authentication (time, date and signature).

B. Review of the Medical Staff Rules and Regulations (Effective 3/1/19) revealed "All orders...must be dated, timed and authenticated as soon as practically possible, but within 48 hours, by the physician or other practitioner ordering...".

C. Interview with the HIM (Health Information Management) Director (12/12/19 at 11:00 AM) confirmed the physician orders in the above medical records lacked proper physician authentication of time, date and signature.