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Based on a record review, staff interview and policy review, the facility failed to have policies in place to care for Patient #6, a psychiatric patient that presented to the Emergency Room (ER). Patient #6 was one (1) of seven (7) emergency records reviewed.

Findings include:


Record review for Patient #6 revealed that she was a 16 year-old brought into the ER via ambulance. The patient had texted her Mom stating that she did not want to go on, life was hopeless and she was taking some pills. Patient #6 had taken Tylenol by mouth and was described in the record as non-verbal. The patient's Tylenol level was 21.0. (30 is considered an overdose) The patient was given intravenous (IV) fluids wide open. She began talking. The record indicated that it was discussed that she should be admitted to an inpatient treatment center for depression. The patient wanted to go home and staff allowed her to leave.


On 06/26/2012 at 1:00 p.m. the Director of Nursing (DON) was asked for the facility's ER policies for psychiatric patients. After searching for the policies, the DON stated there were none.


On 06/26/2012 at 1:15 p.m. the DON stated that both the Registered Nurse (RN) on duty and she felt that Patient #6 should have been held at least 24 hours for observation for the safety of the patient, but the Nurse Practitioner released her.
These findings were presented in exit and no other documents were provided.

Based on observations during a tour of the facility, staff interview and policy review, the facility failed to ensure that outdated medications are removed from the refrigerator and shelves and failed to have medications stored safely in the Emergency Room (ER).


Findings include:


On 06/26/12 at 11:15 a.m. observations made with the DON (Director of Nurses) revealed a refrigerator located on the ER floor which contained an opened bottle of Lantus insulin dated 05/22/2012.

Review of the manufacturer's instructions revealed that insulin should be discarded 28 days after opening. Review of the agency's undated and unreviewed "Insulin Floor Stock Procedure: Pharmacy Procedure Insulin" policy revealed, "Each container of insulin shall be dated and initialed upon opening." Handwritten on the policy was the statement, "Vials will be discarded after 30 days from initial opening to ensure (?)...Manufactures recommend 28 days." The DON stated that she would correct this.


Observation of stored IV (intravenous) fluids revealed:
a) Three (3) bags of D10W with an expiration date of March 2012;
b) Two (2) LR (Lactate Ringers) 1000 cc (cubic centimeter) bags dated December 2011.


Observation at 11:30 a.m. on 06/26/12 revealed that the medication refrigerator located in the third (3rd) bay of the ER did not have a lock on it.


On 06/27/12 all findings were discussed with the DON. No other information was provided regarding these issues.

Based on record review, policy review and staff interview, the facility failed to have a current personalized care plan for Patient #1 and #2, two (2) of two (2) patients reviewed.


Findings include:


Record review that Patient #1 was a 73 year old admitted on 06/21/2012 with diagnoses which included Bronchitis, altered mental status and an elevated blood pressure. Generic care plans, which had been placed in the chart on 06/22/12, showed no documented evidence that they had been reviewed and/or updated.

Record review that Patient #2 was a 92 year old admitted 06/22/2012 with the diagnosis of Respiratory Difficulties. There was no documented evidence of a care plan on the patient's chart.

Review of the facility's "Patient Admission Procedures" policy (undated) revealed: " 9. An interdisciplinary care plan will be prepared during the first regularly scheduled weekly care plan meeting after admission. 10. Nursing service will write the nursing care plan and it will be reviewed weekly after the regular discharge planning meeting."

These findings were discussed with the DON during exit. She stated that she understood. No further documentation was provided.

Based on review of the Critical Access Hospital/s (CAH's) policies and procedures and record review, the facility failed to ensure that two (2) of two (2) medical records that contained a consent for blood transfusions had consents which were not properly executed.

Findings include:


20 discharged medical records were selected from a list of discharges from January 1, 2012 through June 25, 2012. They were reviewed along with three (3) inpatient medical records, and the last four (4) discharges from the hospital, for a total of 27 medical records.


Review of two (2) of two (2) medical records that contained a consent for blood transfusions revealed that the consent had not been timed or dated. None of the blanks for recording the name of the hospital, patient name or physician's name had been completed.

Based on review of the Critical Access Hospital's (CAH's) policies and procedures and record review, the facility failed to ensure that all entries in nine (9) of 27 medical records were timed by the person making the entry.


Findings include:


Twenty discharged medical records were selected from a list of discharges from January 1, 2012 through June 25, 2012. These records were reviewed along with three (3) inpatient medical records and the last four (4) discharges from the hospital, for a total of 27 medical records.


On nine (9) of 27 medical records reviewed, all physician orders had not been timed when entered into the medical record. This included verbal orders taken by a nurse, and as well as those orders entered into the record by a nurse practitioner and a physician.

Based on observations and staff interview, the facility failed to protect the confidentiality of the patient's medication records. Four (4) of four (4) carts located in the facility's hallways had medication records and narcotic records left open on top of carts.


Findings include:


Observations made during tour of the facility on 06/26/2012 at approximately 12:00 p.m. revealed that medication records and narcotics records were lying on top of four (4) medication carts out in four (4) hallways. While examining the carts and the records on the carts, none of the staff asked who I (surveyor) was or what I was looking at or for. All four (4) medication/narcotic records contained patients' names, medications, and other identifiers and were out for anyone to open and look at.


During an interview on 06/26/2012 the Director of Nursing (DON) stated that she thought they (the medication records) should not be there. Observations made on 06/27/2012 at 1:30 p.m. revealed that the medication/narcotic records remained on top of all four (4) carts out in the hallways. The facility policy was requested on 06/27/12 at 1:30 p.m. No policy was provided regarding the medication records.

Based on review of the the facility's policies and procedures, review of Quality Assurance minutes, review of Medical Staff meeting minutes and staff interview, the facility failed to carry out an evaluation of its total program at least once a year.


Findings include:


Document review revealed that the facility had no policies and procedures to review for an annual evaluation specifying how they are to conduct the evaluation, who is responsible for conducting the evaluation, and what information is to be included in the evaluation.


Interview with the Administrator and the Chief Financial Officer, the facility had not conducted an annual evaluation of its total program during the past year.

Based on policy and procedure review, Quality Assurance meeting minutes review and Medical Staff meeting minutes review, the facility failed to review the utilization of services, including the number of patients served and the volume of services as part of an annual evaluation.


Findings include:


Review of the facility's policies and procedures, review of the Quality Assurance meeting minutes and review of the Medical Staff meeting minutes revealed that the facility had not performed a yearly annual evaluation that included all services, the number of patients served, and the volume of services provided.

Based on review of the facility's policies and procedures, review of minutes of Medical Staff meetings and Quality Assurance review, the facility failed to ensure that a representative sample of both active and closed clinical records were reviewed as part of the annual evaluation.


Findings include:


Review of the facility's policies and procedures, Quality Assurance review and minutes of the Medical Staff meetings revealed no documented evidence that the facility had performed a clinical record review of both active and closed records as part of an annual evaluation.

Based on review of the facility's policies and procedures, Quality Assurance review and review of the minutes of the Medical Staff meetings, the facility failed to ensure that the review of their policies and procedures was done in conjunction with an annual evaluation.


Findings include:


Review of the facility's policies and procedures, Quality Assurance review and review of the minutes of the Medical Staff meetings revealed that the
facility had reviewed its policies and procedures on October 25, 2011, but this was not done in conjunction with an annual evaluation.

Based on policy and procedure review and review of minutes of the Quality Assurance and Medical Staff meetings, the facility failed to ensure that an annual evaluation had been done to determine if utilization of services was appropriate, if established policies were followed, and if any changes were needed.


Findings include:


Review of the facility's policies and procedures and review of minutes of the Quality Assurance and Medical Staff meeting revealed that the facility had not determined whether the utilization of services was appropriate, the established policies were followed and any changes were needed as a result of a program evaluation.

Based on staff interview and record review, the agency failed to have a personalized comprehensive current care plan for Patient #3, one (1) of one (1) patients in the Swing Bed Unit.


Findings include:


Record review revealed that Patient #3 was the only patient in the Swing Bed Unit. Review of the patient's care plan revealed that it was not a comprehensive care plan. The generic care plan in the patient's chart had no details or notes regarding the patient. The care plan contained a plan for wound care. Review of the patient's chart revealed that she did not have a wound. Review of the wound care sheet in the chart revealed that it was blank, showing no wounds present.


On 06/27/12 these finding were present to the Director of Nursing and the Director of the Swing Bed Unit. No further information was provided.