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A. Based on observation and staff interview, it was determined that the Critical Access Hospital (CAH) failed to ensure all medications were appropriately stored.

Findings include:

1. During a tour of the CAH's Emergency Department (ED), conducted on 11/3/10 at 11:00 AM, it was observed in the Omnicell storage room that there was one 1ml Carpuject syringe of 250mcg/ml of digoxin (injectable) that was laying on medication trays and not secured/stored in any manner.

2. During an interview with the CNO, conducted on 11/3/10 at 11:15 AM, the above finding was confirmed.

A. Based on a review of CAH policy, observation, and staff interview, it was determined the CAH failed to ensure outdated drugs/biologicals were not available for use in patient care areas.

Findings include"

1. The CAH policy titled "System to Control Dated/Perishable Medications" was reviewed on 11/4/10. It indicated "Medications stocked in the Pharmacy storage areas shall be checked for expiration dates... Procedure: The program for checking and removing outdates involves monthly Pharmacy storage area checks."

2. During a tour of the CAH, conducted on 11/3/10 at 10:30 with the Laboratory Manager, 1- 70 ml Toomey Syringe with expiration date of 10/09 and 1-5 ml Lidocaine Jelly 2% with expiration date of 9/10 were observed in the Medical Surgical Medication Room. In both Operating Room #1 and #2, 1- 10 ml vial of Esmolol Hydrochloride with expiration dates of 9/10 were observed in the Anesthesia medication boxes.

3. During a staff interview, conducted with the CNO on 11/5/10 at 10:00 AM, the above findings were confirmed.

A. Based on policy and procedure review, medical record review, unusual occurrence review, and staff interview, it was determined that in 1 of 2 (Pt #8) medical records reviewed in which a medication was not administered, the CAH failed to ensure the occurrence was reported per policy and procedure.

Findings include:

1. The CAH policy and procedure titled, "Medication Event" was reviewed. It indicated under, "Definitions: 7. Omitted Medication - The failure to give an ordered dose." and under "A medication event includes but is not limited to: 3. Any medication omitted in error." Under "Policy: 1. The hospital encourages reporting of errors, adverse drug events...to assess and improve mediation processes and to provide a safe environment for patient care."

2. The medical record of Pt #8 was reviewed on 11/3/10. It indicated Pt #8 was admitted on 11/2/10. The record indicated that the patient was not administered Albuterol per physician's orders due to the medication not being available.

3. A review of the CAH's unusual occurrence reports was conducted. There was no documentation that indicated an unusual occurrence report was completed that indicated a medication was not administered as ordered.

4. During an interview with the CNO, conducted on 11/3/10 at 2:15 PM, the above finding was confirmed.

A. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 2 of 20 (Pts #1, #3) medical records reviewed, the CAH failed to ensure Intravenous (IV) sites were changed, in accordance with CAH policy, to decrease the potential for IV related infections.

Findings include:

1. The CAH policy titled "Peripheral Intravenous Infusions and Saline Lock" was reviewed on 11/4/10. It indicated "Policy: 6. Infection Control: d. Tubing Change: 1) The IV sit, tubing, and dressing are changed every 96 hours... 8. Pre-Hospital IV- an IV established by an ambulance/ Emergency Management System (EMS) service, not an IV established in another BroMenn facility or another hospital prior to transfer to BroMenn... are changed as soon as possible and at least within 48 hours of admission."

2. The medical record of Pt #1 was reviewed on 11/3/10. Pt #1 was admitted to the CAH on 11/1/10 with the diagnoses Fever, Mental Status Change, and Leukocytosis. Emergency Room documentation indicated Pt #1 had two IV sites started by the EMS service, not established by another BroMenn facility, upon arrival to the Emergency Department (ED). As of 11/4/10 at 3:30 PM, there was no documentation to indicate the above sites had been changed, as per CAH policy.

3. The medical record of Pt #3 was reviewed on 11/4/10. Pt #3 was admitted to the CAH on 10/30/10 with the diagnosis Pneumonia. ED documentation indicated that Pt #3's IV was started in the ED. As of 11/4/10 at 3:30 PM, there was no documentation to indicate that the IV site had been changed, as per CAH policy.

4. During a staff interview, conducted with the CNO on 11/5/10 at 10:00 AM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 1 of 20 (Pt #6) medical records reviewed, the CAH failed to ensure physician orders were followed.

Findings include:

1. The medical record of Pt #6 was reviewed on 11/4/10. Pt #6 was admitted to the CAH on 10/27/10 with the diagnoses Fall with Multiple Fractures. On 10/27/10 at 5:15 PM, there was a physician's order "Neurological checks every 4 hours for 24 hours, Vital Signs every 4 hours, and Occupational Therapy (OT) consult." On 10/28/10, there was no documentation of a neurological check between 12:10 AM and 9:30 AM or between 9:30 AM until 4:32 PM. On 10/28 and 10/19/10, nursing documentation failed to include vital signs every 4 hours. As of 11/4/10 at 3:30 PM, there was no documentation to indicate that OT had completed the consultation.

3. During a staff interview, conducted with the CNO on 11/5/10 at 10:00 AM, the above findings were confirmed.

B. Based on a review of policy and procedure, medical record review, and staff interview, it was determined that in 1 of 2 (Pt #11) medical records reviewed in which the patient had an ulcer, the CAH failed to ensure the ulcer was always properly measured.

Findings include:

1. The CAH policy and procedure titled, "Wound Care" was reviewed on 11/4/10. It indicated under, "Policy: 8. Measure wounds upon admission, weekly..."

2. The medical record of Pt #11 was reviewed on 11/4/10. It indicated Pt #11 was admitted on 10/3/10 with a diagnosis of Urosepsis. Documentation indicated that Pt #11 had a stage 1 ulcer in the groin area. There was no documentation that indicated the ulcer was ever measured.

3. During an interview with the CNO, conducted on 11/4/10 at 12:30 PM, the above finding was confirmed.

A. Based on medical record review and staff interview, it was determined that in 3 of 20 (Pts #3, #8, #10) medical records reviewed, the CAH failed to ensure all medications were administered in accordance with physician's orders.

Findings include:

1. The medical record of Pt #3 was reviewed on 11/4/10. It indicated Pt #3 was admitted on 10/30/10 with a diagnosis of Pneumonia. A physician's order, dated 10/30/10 was for Ducolax 2 tabs to be administered "now and every day as needed". Documentation indicated that only 1 Ducolax tab was administered to complete the "now" order.

2. The medical record of Pt #8 was reviewed on 11/3/10. It indicated Pt #8 was admitted on 11/2/10. A physician's order was for Albuterol 1 puff. A nursing note indicated that the medication was not administered as ordered due to the medication not being available.

3. The medial record of Pt #10 was reviewed on 11/4/10. It indicated Pt # 10 was admitted on 10/30/10. A physician's order was for Xanax 0.5mg to be administered at bedtime (9:00 PM). A nurses note on 11/2/10 indicated that the medication was not administered as the patient was asleep. However, the record indicated that the nurse administered Coreg that day at 2100.

4. During an interview with the CNO, conducted on 11/4/10 at 2:25 PM, the above findings were confirmed. It was also verbalized that in the case of the Albuterol not being administered, the medication is always available in the Hospital.

A. Based on medical record review and staff interview, it was determined in 5 of 20 (Pts #1, #2, #5, #6, #11) medical records reviewed, that the CAH failed to ensure that documentation was complete.

Findings include:

1. The medical record of Pt #1 was reviewed on 11/3/10. Pt #1 was admitted to the CAH on 11/1/10 with the diagnoses Fever, Mental Status Change, and Leukocytosis. There was no documentation to indicate the time the Medical Screening Exam (MSE) was completed.

2. The medical record of Pt #2 was reviewed on 11/4/10. Pt #2 was admitted to the CAH on 11/1/10 with the diagnosis Aspiration Pneumonia. There was no documentation to indicate the time the MSE was completed.

3. The medical record of Pt #5 was reviewed on 11/4/10. Pt #5 was admitted to the CAH on 5/9/10 with the diagnoses Congestive Heart Failure and Ground Level Fall. There was a "Patient Progress/Variance Note" which indicated "1330: Patient... wheezing. More alert... he agrees to intravenous (IV) injection." The entry was not legible and there was no date as to when the entry was made.

4. The medical record of Pt #6 was reviewed on 11/4/10. Pt #6 was admitted to the CAH on 10/27/10 with the diagnoses of Fall with Multiple Fractures. There was no documentation to indicate the time the MSE was completed. On 10/28/10, there was a physician telephone order that had not been signed by the physician as of 11/4/10. On 10/29/10, there were 2 physician orders which lacked the time as to when they were written.

5. The medical record of Pt #11 was reviewed on 11/4/10. Pt #11 was admitted to the CAH on 10/3/10 with the diagnosis Urosepsis. There was no documentation to indicate the time the MSE was completed.

6. During a staff interview, conducted with the CNO on 11/5/10 at 10:00 AM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 5 of 20 (Pts #1, #2, #5, #6, #11) medical records reviewed, that the CAH failed to ensure that documentation was complete.

Findings include:

1. The medical record of Pt #1 was reviewed on 11/3/10. Pt #1 was admitted to the CAH on 11/1/10 with the diagnoses Fever, Mental Status Change, and Leukocytosis. There was no documentation to indicate the time the Medical Screening Exam (MSE) was completed.

2. The medical record of Pt #2 was reviewed on 11/4/10. Pt #2 was admitted to the CAH on 11/1/10 with the diagnosis Aspiration Pneumonia. There was no documentation to indicate the time the MSE was completed.

3. The medical record of Pt #5 was reviewed on 11/4/10. Pt #5 was admitted to the CAH on 5/9/10 with the diagnoses Congestive Heart Failure and Ground Level Fall. There was a "Patient Progress/Variance Note" which indicated "1330: Patient... wheezing. More alert... he agrees to intravenous (IV) injection." The entry was not legible and there was no date as to when the entry was made.

4. The medical record of Pt #6 was reviewed on 11/4/10. Pt #6 was admitted to the CAH on 10/27/10 with the diagnoses of Fall with Multiple Fractures. There was no documentation to indicate the time the MSE was completed. On 10/28/10, there was a physician telephone order that had not been signed by the physician as of 11/4/10. On 10/29/10, there were 2 physician orders which lacked the time as to when they were written.

5. The medical record of Pt #11 was reviewed on 11/4/10. Pt #11 was admitted to the CAH on 10/3/10 with the diagnosis Urosepsis. There was no documentation to indicate the time the MSE was completed.

6. During a staff interview, conducted with the CNO on 11/5/10 at 10:00 AM, the above findings were confirmed.

A. Based on policy and procedure review, medical record review, unusual occurrence review, and staff interview, it was determined that in 1 of 2 (Pt #8) medical records reviewed in which a medication was not administered, the CAH failed to ensure the occurrence was reported per policy and procedure.

Findings include:

1. The CAH policy and procedure titled, "Medication Event" was reviewed. It indicated under, "Definitions: 7. Omitted Medication - The failure to give an ordered dose." and under "A medication event includes but is not limited to: 3. Any medication omitted in error." Under "Policy: 1. The hospital encourages reporting of errors, adverse drug events...to assess and improve mediation processes and to provide a safe environment for patient care."

2. The medical record of Pt #8 was reviewed on 11/3/10. It indicated Pt #8 was admitted on 11/2/10. The record indicated that the patient was not administered Albuterol per physician's orders due to the medication not being available.

3. A review of the CAH's unusual occurrence reports was conducted. There was no documentation that indicated an unusual occurrence report was completed that indicated a medication was not administered as ordered.

4. During an interview with the CNO, conducted on 11/3/10 at 2:15 PM, the above finding was confirmed.

A. Based on internal documentation and staff interview, it was determined that the CAH failed to ensure it's Quality Assurance program included a program review by an outside review organization to determine that the Medical Staff provided quality treatment and appropriate diagnoses to the patients served by the Critical Access Hospital.

Findings include:

1. The internal documentation dated "November 5, 2010, was reviewed. It indicated that the CAH sent 1 record for peer review to ICAHN on 11/2/10 and one to the Primus Emergency group for review in early 2010. Other than those 2 records, the documentation indicated that no other records were sent out for peer review since 2006.

2. During an interview with the Quality Analyst, conducted on 11/5/10 at 9:5 AM, the above finding was confirmed.