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Based on observation, policy review, and staff interview the Critical Access Hospital (CAH) failed to ensure outdated drugs and biologicals were not available for patient use in 2 of 2 crash carts and 3 medication storage cupboards.

Findings include:

- Review of the CAH's policy titled, "OUTDATED DRUGS" reviewed on 3/2/11 at 3:25pm
directed staff to remove the outdated drugs in the drug room and emergency room on the last day of the month.

- Observation on 2/28/11 at 12:15pm of the crash cart in the procedure room revealed the following outdated drugs and biologicals;
1. Four- 2 milliliter (ml) vials of procainamide Hydrochloride (a drug used to regulate the heart rate) with an expiration date of 2/1/11.
2. Five- 4 ml vials of Levophed (a drug used to treat life-threatening low blood pressure) with an expiration date of 2/1/11.
3. Two- 20 ml vials of dobutamine (a drug used to treat heart failure) with an expiration date of 11/1/10.
4. Two- 2 ml vial of Nitropress (a drug used to treat high blood pressure) with an expiration date of 2/1/11.
5. One- 250 ml bag of Dextrose 5% containing Domapine 400 milligrams (mg) (a drug used to treat shock and low blood pressure) with an expiration date of 8/1/10.
6. One- 250 ml bottle of Nitroglycerin (a drug used to dilate blood vessels) with an expiration date of 2/1/11.
7. Four- 2 ml syringes of Adenocard (a drug used to treat heart arrhythmia) with an expiration date of 1/1/2011.
8. One- 500 ml bag of 2% Lidocaine (a drug used to treat heart arrhythmia) with an expiration date of 6/1/10.

- Observation on 2/28/11 at 12:15pm of the medication storage cabinet in the procedure room revealed the following outdated and mislabeled drugs;
1. One- 50 mg opened bottle of Marcaine 5% (a drug used as a local anesthetic) labeled with a date of 7/21/10 when opened and directions that it would expire in six months (2/21/11).
2. One- 10 ml vial of Kenelog 40 mg per ml (a steroid drug used for injection).

- Observation on 2/28/11 at 1:40pm of the crash cart in the emergency room revealed the following outdated drugs and biologicals;
1. One- 10 ml syringe with Epinephrine 1:10,000 (a drug used to restore heart rhythm in cardiac arrest) with an expiration date of 4/1/10.
2. Four- 2 ml syringes of Adenocard with an expiration date of 1/1/11.
3. Two- 20 ml vials of Dobutamine with an expiration date of 11/1/10.
4. Five- 4 ml vials of Levophed with an expiration date of 2/1/11.
5. Four- syringes of Lidocaine 2% with an expiration date of 2/1/11.
6. Four- 2 ml vials of Procainamide with an expiration date of 2/1/11.
7. One- 250 ml bottle of Nitroglycerin with an expiration date of 1/1/11.
8. One- 250 ml bag of Dextrose 5% containing Dopamine 400 mg with an expiration date of 8/1/10.

- Observation on 2/28/11 at 1:40pm of a medication storage cabinet in the emergency room revealed the following;
1. One- 1 ml vial of Benadryl (a drug used to treat allergies) with an expiration date of 9/09.
2. One 50 ml bottle of 1% Lidocaine with Epinephrine with an expiration date of 9/10.

- Observation on 3/1/11 at 10:20am of a medication storage cabinet in the pharmacy revealed the following;
1. One- 10 ml open vial of Compazine (a drug used to relieve nausea) with a date when opened of 8/24/10 and a label on the vial that directs the medication expires six months after opening (2/24/10).
2. One- 20 ml vial of Labetalol (a drug used to treat high blood pressure) with a date when opened of 10/26. The staff person failed to document the year they opened the vial of Labetalol.

Staff B interviewed on 2/28/11 at 2:00pm verified the outdated drugs in the crash carts and medication storage cabinets. Staff B acknowledged the CAH staff failed to follow their policy to remove the outdated medications monthly.

Based on document review, medical record review and staff interview the Critical Access Hospital (CAH) failed to assure providers signed, dated and/or timed all entries in the medical record for 16 of 32 patient medical records reviewed (#'s 1, 2, 3, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, and 23).

Findings include:

- Review of the CAH's "Rules and Regulations of the Medical Staff", on 3/2/11 at 11:40am directed, all orders shall be in writing and signed. The CAH failed to include in the medical staff rules and regulations that all entries in the medical record when signed, include the date and time.

- Patient #20's medical record reviewed on 3/2/11 revealed an admit date of 11/8/10. Patient #20's medical record revealed between 11/8/10 and 11/9/10 six verbal orders and one order written by the provider that lacked a date and/or time when signed by the provider.

Staff E interviewed on 3/2/11 at 11:40am acknowledged the providers did not sign, date, and/or time all entries in the patient's medical record


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- Patient #9's closed medical record reviewed on 3/1/11 revealed an admit date of 9/25/10 and discharge on 9/27/10. Patient #9's medical record revealed between the dates of 9/25/10 to 9/26/10, two physician orders and three progress notes written by the provider lacked a date and/or time when signed by the provider.

- Patient #14's closed medical record reviewed on 3/2/11 revealed an admit date of 10/28/10 and discharge on 11/1/10. Patient #14's medical record revealed between the dates of 10/28/10 to 11/1/10, one physician orders written by the provider, one telephone and/or verbal orders, one set of admission orders, and two progress notes lacked a date and/or time when signed by the provider.

This deficient practice also affected patient #'s 1, 2, 3, 8, 10, 11, 12, 13, 15, 16, 17, 19, and 23.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to inform 5 of 5 swing bed patients of the right to be informed in advance about their care and treatment, of any changes in their care and treatment, and the risks and benefits that may affect their well-being (patient #'s 2, 3, 4, 5, and 6).

Findings include:

- The CAH's patient rights document reviewed on 3/1/11 at 2:00pm and given to the patients on admission revealed the CAH failed to inform patient #'s 2, 3, 4, 5, and 6 of their right to be informed in advance about their care and treatment, changes in their care and treatment and the risks and benefits that affect their well being.

- Staff A and B, interviewed on at 3/1/11 at 4:45pm confirmed the CAH failed to inform the swing bed patient #'s 2, 3, 4, 5, and 6 of their rights.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to inform 5 of 5 swing bed patients of their right to participate in planning care and treatment or changes in care and treatment unless adjudged incompetent (patient #'s 2, 3, 4, 5, and 6).

Findings include:

- The CAH's patient rights document reviewed on 3/1/11 at 2:00pm and given to the patients on admission revealed the CAH failed to inform patient #'s 2, 3, 4, 5, and 6 of their right to participate in planning care and treatment or changes in care and treatment unless adjudged incompetent.

- Staff A and B, interviewed on at 3/1/11 at 4:45pm confirmed the CAH failed to inform the swing bed patient #'s 2, 3, 4, 5, and 6 of their rights.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to inform 5 of 5 swing bed patients of their right to perform or refuse to perform work (patient #'s 2, 3, 4, 5, 6).

Findings include:

- The CAH's patient rights document reviewed on 2/1/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #'s 2, 3, 4, 5, and 6 of their right to perform or refuse to perform work.

- Staff A and B, interviewed on at 3/1/11 at 4:45pm confirmed the CAH failed to inform the swing bed patient #'s 2, 3, 4, 5, and 6 of their rights.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to inform 5 of 5 swing bed patients of their right to access writing equipment and to send and receive unopened mail (patient #'s 2, 3, 4, 5, and 6).

Findings include:

- The CAH's patient rights document reviewed on 3/1/11 at 2:00pm and given to the patient on admission revealed the CAH failed to inform patient #'s 2, 3, 4, 5, and 6 of their right to access writing equipment and to send and receive unopened mail.

- Staff A and B, interviewed on at 3/1/11 at 4:45pm confirmed the CAH failed to inform the swing bed patient #'s 2, 3, 4, 5 and 6 of their rights.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to inform 5 of 5 swing bed patients of their right to receive visitors (patient #'s 2, 3, 4, 5, and 6).

Findings include:

- The CAH's patient rights document reviewed on 3/1/11 at 2:00pm and given to the patients on admission revealed the CAH failed to inform patient #'s 2, 3, 4, 5, and 6 of their right to receive visitors.

- Staff A and B, interviewed on at 3/1/11 at 4:45pm confirmed the CAH failed to inform the swing bed patient #'s 2, 3, 4, 5, and 6 of their rights.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to inform 5 of 5 swing bed patients of their right to retain and use personal property (patient #'s 2, 3, 4, 5 and 6).

Findings include:

- The CAH's patient rights document reviewed on 3/1/11 at 2:00pm and given to the patients on admission revealed the CAH failed to inform patient #'s 2, 3, 4, 5, and 6 of their right to retain and use personal property.

- Staff A and B, interviewed on at 3/1/11 at 4:45pm confirmed the CAH failed to inform the swing bed patient #'s 2, ,3 4, 5, and 6 of their rights.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to inform 5 of 5 swing bed patients of their right to share a room with their spouse (patient #'s 2, 3, 4, 5, and 6).

Findings include:

- The CAH's patient rights document reviewed on 3/1/11 at 2:00pm and given to the patients on admission revealed the CAH failed to inform patient #'s 2, 3, 4, 5, and 6 of their right to share a room with their spouse.

- Staff A and B, interviewed on at 3/1/11 at 4:45pm confirmed the CAH failed to inform the swing bed patient #'s 2, 3, 4, 5, and 6 of their rights.

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to inform 5 of 5 swing bed patient ' s (patient #'s 2, 3, 4, 5, and 6) of their right ' s for the transfer and discharge process. The discharge transfer notice would include physician documentation in the clinical record and provide the patient/family with the written notice of items at least 30 days before their transfer and discharge. The CAH failed to provide five patients with a copy of the swing bed bill of rights to ensure sufficient preparation and orientation before transfer and discharge from the CAH.

Findings include:

- The CAH's patient right document reviewed on 3/1/11 at 2:00pm and given to the patients on admission revealed the CAH failed to inform patient #'s 2, 3, 4, 5, and 6 of the required process that includes physician documentation in the clinical record, written notice in a language the patient/family can understand at least 30 days before transfer and discharge. The patient rights lacked evidence of the written notice of items that include the reason, effective date, location, the right to appeal the action, phone numbers and addresses of the state ombudsman, contact information for patients with disabilities and mental illness.

- Staff A and B, interviewed on 3/1/11 at 4:45pm confirmed the CAH failed to inform the swing bed patient #'s 2, 3, 4, 5, and 6 of their rights pertaining to transfer and discharge.