HospitalInspections.org

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to assure that the Registered Nurse (RN) evaluated each patient and documented clinical assessments for 4 of 20 discharged patient records reviewed (I1, I6, I9 and I10) and 1 of 4 surgical outpatient records reviewed (OP6).

Findings include: Initial and/or follow-up nursing assessments were not routinely evident in the records of I1, I6, I9 and I10 so that patient progress could be accurately assessed.

During review of the patient admission assessment documented by the nursing service department, it was noted that a 15 year (yr.) old patient (I6) had been admitted on 8/31/10 with "tightness in chest and problems breathing". The initial note documented by the RN on 8/31/10 at 0052 indicated: "complained of breathing difficulties for the last 2 days, has had asthma since childhood, no wheezing, lungs-tight - respirations very shallow at times-Bowel sounds-active x 4-no edema of extremities noted". It was noted the lungs sounds were not assessed until 0800 (7 hours later) and the RN indicated "lungs diminished throughout". The emergency room documentation of vital signs indicated that at 0040 (I6) had a respiration rate of 44 breaths/minute and heart rate of 119 beats/minute. Review of the admission nursing notes lacked an assessment of lung sounds and had not included an initial comprehensive system review and/or nurse database findings.

During review of the initial nursing assessment for patient ( I10), admitted on 4/13/10 at 1330, the following was documented: "admitted for pain control; patient here from not having radiation today due to increase pain; complained of pain on right side especially upon movement". The diagnoses included cancer with metastasis. It was not until 2130 (8 hours later) that the nurse described the patient's pain as follows "pain in bilateral sides of abdomen and lower back-pain rates at 8, using pain scale 1-10; patient has a facial grimace". It was also noted by the licensed nurse "noted small open area (no drainage) on her left buttocks-a little towards the middle". No initial comprehensive skin assessment, pain assessment and/or system review had been noted in the record of (I10).

During record review for patient (I9), it was noted the 94 yr. old patient had been admitted after two days of flu symptoms and now "seemed dehydrated and very lethargic". The initial nursing notes dated 4/21/10 at 1135 indicated " skin very dry with poor turgor and pale; has had diarrhea and vomiting in last week; none in the last 2 days". An assessment related to overall skin condition was lacking in the initial assessment. Documentation at 1315 on 4/21/10 indicated the resident exhibited "resistance, legs contracted" and at 2100 (10 hours after admission) "noted redness on foot and heels". No initial comprehensive nursing assessment related to skin condition and/or system review had been noted in the record of (I9).

Record review for (I1), an 83 yr. old patient admitted on 5/11/10, indicated the patient experienced "shortness of breath at rest, Lungs exhibit wheezes throughout, and 2+ pitting edema to entire body and 3+ pitting edema to legs and feet". The initial admission note was timed at 1230. A comprehensive assessment was lacking to indicate the overall skin condition of this resident. An entry dated the following day on 5/12/10 at 0110 by the RN stated "complained of abdominal pain wear burn marks are, otherwise "tolerable", no complains of headache or shortness of breath; lungs exhibit rhonchi with wheezing, congestion heard audibly on expiration, bowels active, abdomen soft, pain lower left where burn marks are; Edema 2+ pitting in legs, whole body appears puffy but not pitting" and documented again on 5/12/10 at 0630-"patient denies headache or pain other than lower abdominal pain where burning marks are". No further description and/or assessment related to "burn marks" was noted. It was noted this patient had a history of tobacco use prior to admission. A comprehensive review that included a systematic assessment of the patient was lacking upon admission and/or follow up.

Interview with the Director of Nurses (DON) on 9/21/10 at 3:30 p.m. revealed the facility lacked a policy regarding an admission nursing assessment. She stated she she expected their to be an initial nursing assessment to include: lung sounds, edema, bowel sounds, pain assessment, anything out of the ordinary related to skin and the reason for admission. During further interview with the DON at 5:00 p.m. on 9/21/10, she confirmed these records lacked an initial comprehensive system review assessment. The DON confirmed the records also lacked any evidence that bladder assessments had been part of the admission nursing assessment other than "bladder habits". No further comprehensive assessment had been developed for use in the CAH.

In addition, during the interview with the DON at 5:00 p.m. on 9/21/10, she confirmed the records lacked consistent documentation related to each patient's condition so that a consistent comparison could be assessed between nursing staff in order to ensure that accurate progress could be determined.










13611

The Certified Registered Nurse Anesthetist (CRNA) did not complete a comprehensive assessment for 1 of 1 outpatients who had undergone two epidural steroid injections.

Outpatient (OP-6) received an epidural steroid injection, which had been administered by the CRNA on 11/25/09. The patient's record failed to include documented consent for the procedure and there was no documentation which indicated the CRNA had discussed the risks and benefits of the procedure with the patient. There was no documentation of the location of the patient's pain or how much pain the patient was experiencing prior to the injection. There was no documentation following the procedure which indicated if the patient continued to experience pain nor any documentation of the location of the pain. Although the "Nurse Notes" indicated the patient had a driver to drive her home, there was no indication who the driver was. The only discharge instructions documented in the medical record directed the patient to call the physician immediately if pain or weakness increased in the next 4-6 hours. There was no documentation the patient had been educated to report any signs and symptoms of infection or any other complications.

According to the medical record, OP-6 had received another epidural steroid injection, administered by the CRNA, on 9/14/2010 for the diagnoses of lumbago and lumbar disc disease. The only pre-procedure notes documented by the CRNA was that the patient was "Here for Epidural", to .."see clinic list related to the patient's current medications" and the patient had ..."no known allergies". There was no documentation of the location of the patient's pain or how much pain the patient was experiencing prior to the injection. There was no consent for the procedure with the medical record nor was there any documentation to indicate whether the CRNA had discussed the risks and benefits of the procedure with the patient. There was no documentation following the procedure to indicate if the patient continued to experience pain nor any documentation of the location of pain. Although the "Nurse Notes" indicated the patient had a driver to drive her home, there was no indication who the driver was. The only discharge instructions documented in the medical record was for the patient to report to the physician if increased pain or weakness of the legs occurred. There was no documentation the patient had been informed to report any signs and symptoms of infection or any other complications.

The Director of Nursing was interviewed at 3:15 p.m. on 9/21/2010. She reviewed OP6's medical records and confirmed the pre and post-procedure assessment of the patient's condition was not comprehensive.

Based on record review and staff interview, the CAH failed to ensure that each entry was properly authenticated with a timed and dated signature for all entries for 3 of 5 surgical records reviewed (S15, S3, and S4.) Findings include:

S15's chart review indicated there was no time which indicated when a Registered Nurse had completed the "Pre-Op Assessment Sheet" dated 3/18/10. There was no date or time documented to indicate when a Registered Nurse had completed the "Surgical Procedure Checklist". There was no time documented to indicate when the Certified Registered Nurse Anesthetist (CRNA) had completed the post anesthesia assessment. There was no time documented to indicate when MD (medical doctor)-B had written the "Pre-Operative (op)Orders" or "Post op Orders" dated 3/19/10. There was no time documented to indicate when a Registered Nurse had completed the "Braden Scale-For Predicting Pressure Sore Risk" assessment dated 3/23/10, or the "John Hopkins Hospital Fall Assessment Tool" dated 3/24/10. There was no time documented to indicate when the Registered Nurse had completed the "Abuse Prevention Plan Checklist" on 3/23/10.

S3's chart review did not include a timed signature on the "Pre-Op Assessment Sheet" dated 2/27/10, to indicate when the Licensed Practical Nurse had completed it.

A review of S4's record revealed MD-B had not documented the time post operative orders had been written on 4/6/10. There was no indication of the time the Certified Registered Nurse Anesthetist had accepted a telephone order from MD-B on 4/6/10. There was no time or date documented to indicate the time the Registered Nurse had completed the "Surgical Procedure Checklist" form. There was no documentation of the time the CRNA had completed the "Post Anesthesia Comments" on 4/6/10. There was no time documented to indicate when the Licensed Practical Nurse and/or Registered Nurse had completed the "Pre-Op Assessment Sheet" on 4/1/10.

Interview with the director of nurses and with the administrator at 5:00 p.m. on 9/21/10 indicated that proper authentication of records had been identified as a problem, but had shown improvement particularly among physician providers.

Based upon interview and record review, the Certified Registered Nurse Anesthetist (CRNA) failed to complete a comprehensive post-anesthesia assessment for 2 of 4 surgical outpatients whose charts were reviewed (OP-2 and OP-4). Findings include:

Outpatient (OP-2) underwent a cystoscopy under general anesthesia on 8/9/10. The "Immediate Post Anesthesia Comment" completed by the CRNA, indicated the patient had "Tolerated anesthesia fair". An additional "Post Anesthesia Comment", completed by the CRNA at 11:00 a.m., indicated the patient had, "No complications of anesthesia". The CRNA failed to document assessment of the patient's cardiopulmonary status, level of consciousness, follow-up care and/or observations recommended related to anesthesia.

Outpatient (OP-4) underwent a laparoscopy under general anesthesia on 4/6/10. The "Immediate Post Anesthesia Comment" completed by the CRNA, indicated the patient had "Tolerated anesthesia well." An additional "Post-Anesthesia Comment" documented by the CRNA, indicated the patient had some initial nausea while in the post-anesthesia care unit. There was no other documentation by the CRNA to indicate the patient's cardiopulmonary status, level of consciousness, follow-up care and/or observations recommended related to anesthesia.

A review of the CAH policy "Postoperative Anesthesia Care" (undated) indicated each postanesthesia visit would be documented on the postanesthesia evaluation form. The policy did not address the contents of the post-anesthesia note, the type of an assessment which would be a part of the post-anesthesia visit, nor the discharge instructions which would be included with the postanesthesia visit.

The Director of Nursing (DON) was interviewed at 5:00 p.m. on 9/21/10, she verified the above findings. The DON also provided a copy of the CAH's "Specific Documentation Guidelines" and confirmed the guidelines did not indicate what should be included in the post-anesthesia note. She stated there were no other policies which addressed the composition of a comprehensive post anesthesia note.

Based upon review of Quality Assurance information and on staff interview, the Critical Access Hospital (CAH) did not ensure the patient care services including surgery, anesthesia, out patient, and the contracted radiology services were evaluated as part of the CAH's quality assurance program.

Findings include: the CAH did not ensure that surgical services, anesthesia services, outpatient services, and contracted radiology services were evaluated as part of the CAH's quality assurance program.

Surgical Services did not have an effective quality assurance program to evaluate the quality and appropriateness of the surgical services offered. Upon review of the Operating Room quality assurance program at 10:50 a.m. on 9/21/10, the current quality assurance program was noted to be monitoring the same measures evaluated since 2008. Review of the surgical services Quality indicators revealed that all indicators, with the exception of one, indicated 100% compliance over several quarters. The Operating Room Charge Nurse, the nurse in charge of quality assurance in the operating room, and the Director of Nursing were interviewed at 11:05 a.m. on 9/21/2010. They stated no other quality assurance programs had been evaluated or developed for Surgical Services.

During interview with the Director of Nursing at 11:05 a.m. on 9/21/10, she stated the Anesthesia and Outpatient services departments had not conducted quality improvement projects for over two years.




















02980

The contracted radiology services for nuclear medicine, bone density testing, and for magnetic resonance imaging (MRI) had not been evaluated by the CAH's Quality Improvement (QI) program. During review of the the CAH's QI documentation and meeting minutes it was noted the contracted radiology services had not been evaluated by the QI program for the past 2 years.

Interview was conducted with the director of nurses (DNS) on 9/21/10 at 4:30 p.m. She indicated the contracted radiology services for bone density testing, nuclear medicine, and MRI had been evaluated by the QI program in the past. It was indicated , however, there had not been quality data for those services submitted to the QI Committee for approximately the past 2 years.

Based on review of quality assurance meeting minutes, Surgical Services quality improvement plan, and staff interview, the Critical Access Hospital (CAH) failed to document the outcome of all remedial action. This had the potential to affect any patients receiving surgical services from the CAH. Findings include:

Documentation was lacking in the CAH quality assurance meeting minutes to confirm the outcome of all remedial action.

During a tour of the Surgical Suite on 9/21/2010 at 9:35 a.m., a dehumidifier machine was observed running in the operating room. The Operating Room Charge Nurse stated the operating room humidity had been too high and a humidifier was used to reduce the humidify in the operating room when surgical procedures were not scheduled. The Operating Room Charge Nurse stated she thought the humidity in the operating rooms should range between 30% and 60% humidity. A review of the CAH policy "Temperature Control in Surgery", last revised 9/18/05, indicated the humidity should be maintained between 50% and 60% in the operating room. A review of the 2010 recommendations of the American Association of Operating Room Nurses (AORN) indicated the recommended levels of humidity as recommended by the American Institute of Architects (AIA) was 30% to 60% in an operating room.

The "OR Record Sheet-Temp, Humidity, and Line Isolation Monitor" sheet was reviewed. The record indicated the humidity level was above 60%: 6 of 25 humidity checks in June, 2010; 15 of 30 humidity checks in July 2010; and 8 of 23 humidity checks in August, 2010. The humidity levels which were above 60% ranged from 62% to 72% relative humidity. The Operating Room Charge Nurse confirmed she had been aware of this problem. She also stated the problem had not been part of the discussion within the quality assurance process so that remedial action could be taken.

The Director of Nursing was interviewed on 9/21/2010 at approximately 11:10 a.m. and stated she had not been aware of the problem with excessive humidity in the operating room. She stated the problem had not been taken to the quality assurance committee and no remedial action had been taken.

Review of quality assurance meeting minutes for the past year lacked evidence of identified problems with the excessive humidity in the operating room and therefore the remedial action required to improve quality of care had not been identified.