HospitalInspections.org

Based on hospital by-law review, policy and procedure manual review, Medical Staff meeting minute review, and staff interview the governing body and the designated administrator failed to ensure the Critical Access Hospital (CAH) develop/review/review policies to direct and support the responsibilities of medical staff, the CAH medical staff failed to participate in the development and periodic review of the CAH's policies, failed to review policies with the advice of a group of professional personnel that included at least one physician, one physician assistants or nurse practitioners, and an outside reviewer, for the CAH's policy and procedure manuals, failed to develop emergency department policies and procedures with specific guidelines for the scope of practice, to develop emergency department policies and procedures with specific guidelines to meet all medical conditions that present to the emergency department.

Findings include:

- Review of CAH policy and procedure manual review and Medical Staff meeting minutes for the last year lacked evidence of an annual review, revision or approval by the medical staff of the CAH policies.

Administrative staff A interview on 9/25/13 at 8:10am acknowledged the CAH lacked evidence of medical staff involvement in the development and periodic review of the CAH's policies.

- Review of the policy and procedure manuals provided during the survey between 9/23/13 to 9/26/13, the Medical Staff meeting minutes for the last year, and the CAH's annual program evaluation lacked evidence that a physician, a physician assistant or nurse practitioner, and an outside reviewer was included as part of a group of professional personnel that annually review and/or revise the CAH's policy and procedure manuals.

Administrative staff A interviewed on 9/25/13 at 8:10am acknowledged the CAH lacked evidence a physician, a physician assistant or nurse practitioner, and an outside reviewer reviewed and/or revised the CAH's policy and procedure manuals within the last year.

- After multiple requests by the surveyor on 9/24/13 to 9/26/13 the hospital failed to provide policies and procedures that described the scope of medical acts that may be preformed by their Advanced Practice Registered Nurse (APRN).

- Review of Medical Staff By-laws dated 4/14/03 lacked guidelines for the medical management of health problems that included a description of the scope of medical acts that may be preformed by their Advanced Practice Registered Nurse (APRN). The Medical Staff By-laws lacked evidence of EMTALA considerations within the document.

- Hospital emergency department policies were requested on 9/24/13 at 2:00pm. Administrative staff A and Corporate staff J on 9/24/13 at 4:45pm reported the hospital had hospital polices and corporate policies available to staff for use. Staff J reported the hospital staff should be used the management company's policies to limit the amount of confusion as to what policies were to be provided. Corporate vice president of clinical services indicated the hospital should be using the policies that the management company provided.

- Review of Governing Body By-laws dated 6/1/08 lacked evidence of who can cover the medical needs of patients who present to the Emergency Department and lacked evidence of EMTALA considerations within the document.

- The hospital lacked policies for review to direct to care for probable conditions that present to the Emergency Department such as: a precipitous delivery of a newborn, resuscitation of a child, how to care for a mentally unstable patient, emergency care for a snakebite victim, how to care for a prisoner.

The CAH's Governing Body By-Laws and Medical Staff By-Laws lacked guideline for development/revision/review of CAH policies.

The Critical Access Hospital (CAH) reported a census of no patients with an average daily census of 2.6 acute patients. Based on policy and procedure manual review, Medical Staff meeting minute review and staff interview the CAH medical staff failed to participate in the development and periodic review of the CAH's policies to ensure sound patient care.

Findings include:

- Review of CAH policy and procedure manual review and Medical Staff meeting minutes for the last year lacked evidence of an annual review, revision or approval by the medical staff of the CAH policies.

Administrative staff A interview on 9/25/13 at 8:10am acknowledged the CAH lacked evidence of medical staff involvement in the development and periodic review of the CAH's policies.

The Critical Access Hospital (CAH) reported a census of no patients with an average daily census of 2.6 patients. Based on medical record review, policy review, periodical evaluation review, and staff interview the CAH failed to develop/revise/review policies with the advice of a group of professional personnel that included at least one physician, one physician assistants or nurse practitioners, and an outside reviewer (C-0272), failed to develop emergency department policies and procedures with specific guidelines for the scope of practice, to develop emergency department policies and procedures with specific guidelines to meet all medical conditions that present to the emergency department (ED)(C-0275), failed to ensure the nursing staff in their emergency department met patient needs for pain control (C-0294).

The cumulative effect of the systematic failure to ensure the CAH develop/revise/review policies and procedures and failed to ensure the nursing staff met patient needs for pain control resulted in the CAH ' s inability to provide care in a safe and effective manner.

The Critical Access Hospital (CAH) reported a census of no patients with an average daily census of 2.6 acute patients. Based on policy and procedure manual review, Medical Staff meeting minute review, CAH annual program evaluation and staff interview the CAH failed to develop/revise/review policies with the advice of a group of professional personnel that included at least one physician, one physician assistants or nurse practitioners, and an outside reviewer, for the CAH's policy and procedure manuals.

Findings include:

- Review of the policy and procedure manuals provided during the survey between 9/23/13 to 9/26/13, the Medical Staff meeting minutes for the last year, and the CAH's annual program evaluation lacked evidence that a physician, a physician assistant or nurse practitioner, and an outside reviewer was included as part of a group of professional personnel that annually review and/or revise the CAH's policy and procedure manuals.

Administrative staff A interviewed on 9/25/13 at 8:10am acknowledged the CAH lacked evidence a physician, a physician assistant or nurse practitioner, and an outside reviewer reviewed and/or revised the CAH's policy and procedure manuals within the last year.

The Critical Assess Hospital (CAH) reported 476 patients received emergency medical care from the hospital's emergency department and transferred 63 patients onto other health facilities for follow up emergency care. The survey included a sample of 20 emergency department patient records for review. Based on document and policy review, medical record review and staff interview the CAH failed to develop emergency department policies and procedures with specific guidelines for the scope of practice that may be performed by the hospital's Advanced Practice Registered Nurse (APRN). The hospital failed to develop and implement policies and procedures to meet all medical conditions that present to the Emergency Department (ED).The hospital failed to extend their definition of a qualified medical provider (QMP) to the hospital's Advanced Practice Registered Nurse (APRN) to allow them to perform medical screening exams (MSE). Failure to update policies and procedures lead to 1 of 20 selected emergency department patients (patient #17) to receive a medical screening examination (MSE) from a unqualified medical provider. The CAH failed to ensure the Medical Staff completed medical screening exams (MSE) and documented the existence of emergency medical conditions for 7 of 20 emergency department patients (patient #'s 2, 3, 4, 5, 15, 17, and 20).

Findings include:

- After multiple requests by the surveyor on 9/24/13 to 9/26/13 the hospital failed to provide policies and procedures that described the scope of medical acts that may be preformed by their Advanced Practice Registered Nurse (APRN).

- Review of Medical Staff By-laws dated 4/14/03 lacked guidelines for the medical management of health problems that included a description of the scope of medical acts that may be preformed by their Advanced Practice Registered Nurse (APRN). The Medical Staff By-laws lacked evidence of EMTALA considerations within the document.

- Hospital emergency department policies were requested on 9/24/13 at 2:00pm. Administrative staff A and Corporate staff J on 9/24/13 at 4:45pm reported the hospital had hospital polices and corporate policies available to staff for use. Staff J reported the hospital staff should be used the management company's policies to limit the amount of confusion as to what policies were to be provided. Corporate vice president of clinical services indicated the hospital should be using the policies that the management company provided.

- Review of Governing Body By-laws dated 6/1/08 lacked evidence of who can cover the medical needs of patients who present to the Emergency Department and lacked evidence of EMTALA considerations within the document.

- The hospital lacked policies for review to direct to care for probable conditions that present to the Emergency Department such as: a precipitous delivery of a newborn, resuscitation of a child, how to care for a mentally unstable patient, emergency care for a snakebite victim, how to care for a prisoner.

- Hospital Medical Staff by-law and rules and regulations dated 4/14/2003, reviewed on 9/25/13 revealed the hospital required all active medical staff members to live within 30 minutes of the hospital to ensure the emergency department had continuous and timely care ....and participate in emergency department coverage.

Administrative staff A on 9/23/13 at 10:20am during entrance conference stated the hospital used locums to help cover emergency room and that the hospital also used a Advanced Practice Registered Nurse (APRN) F covered the ED one day a week.

- Hospital/ Corporate policy for Emergency Medical Treatment and Labor Act (EMTALA)-Medical Screening Exam and Stabilization policy stated the purpose of the policy is to establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition (EMC), any necessary, stabilization treatment or an appropriate transfer for the individual as required by EMTALA.

The EMTALA policy stated "An appropriate Medical Screening Exam (MSE), within the capabilities of the hospital (including ancillary services) shall be performed by a physician in order to determine whether an EMC exists ....If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment with the capacity and capability of the hospital, or an appropriate transfer as required by EMTALA.

The EMTALA policy stated the Extent of the Medical Screening Examination:
1. Determination is an EMC exists. The hospital is obligated to perform the MSE in order to determine if an EMC exists. It is not appropriate to merely "log in" or triage an individual with a medical condition and not provide an MSE.
2. Judgment by Physician. The extent of the necessary examination to determine the presence or absence of an EMC is within the discretion of the examining physician. However, the elements of an appropriate MSE should include:
a. Log entry with disposition.
b. Triage record
c. Ongoing recording of vital signs
d. Oral history
e. Physical exam
f. Use of all available/necessary testing resources
g. Discharge and transfer vital signs and
h. Adequate documentation of the above.

Who may perform a MSE:
1. Only a physician may perform an MSE at the hospital ...
2. The Emergency Department (ED) physician on duty is responsible for the general care of all individuals presenting to the ED.
3. The responsibility remains with the ED physician until the individual is admitted, transferred or discharged.

- Patient #17's (an 11 year-old child) medical record reviewed on 9/25/13 revealed they presented to the emergency department with a church camp staff member on 7/25/13 at 10:03am with a chief complaint of a laceration to their upper left lip. Registered Nurse E documented the patient refused a nursing assessment until their parents arrived. Patient #17 reported their pain was at a "2" (on a scale of 1-10) at 10:03am.

Registered Nurse E called Advanced Practice Registered Nurse 10:05am (the assigned on-call ED provider) and documented the APRN arrived at 10:10am.

Patient #17's medical record revealed the APRN notified a physician Z office in a near by town of the patient's need for sutures on the left upper lip. Administrative staff B on 9/25/13 at 4:00pm reported physician Z was not credentialed at the hospital and stated physician G was APRN F's sponsoring physician.

Patient #17's medical record lacked evidence of a completed triage with ongoing recording of vital signs and lacked evidence the APRN consulted with their sponsoring physician prior to transferring the patient to a doctor ' s office for repair of their laceration.

Patient #17's medical record lacked evidence of a completed MSE by a QMP during their ED visit.

Administrative staff A on 11/26/13 at 9:00am reported APRN staff F provided emergency room coverage for 50 days during the last year and cared for 102 emergency department patients.

- Hospital/ Corporate policy for Emergency Medical Treatment and Labor Act (EMTALA)-Medical Screening Exam and Stabilization policy stated the purpose of the policy is to establish guidelines for providing appropriate medical screening examinations and, if the individual is determined to have an emergency medical condition (EMC), any necessary, stabilization treatment or an appropriate transfer for the individual as required by EMTALA.

The EMTALA policy directed Medical Staff Member to ensure they patient assessments to ensure the Extent of the Medical Screening Examination:???
1. Determination is an EMC exists. The hospital is obligated to perform the MSE in order to determine if an EMC exists. It is not appropriate to merely "log in" or triage an individual with a medical condition and not provide an MSE.
2. Judgment by Physician. The extent of the necessary examination to determine the presence or absence of an EMC is within the discretion of the examining physician. However, the elements of an appropriate MSE should include:
a. Log entry with disposition.
b. Triage record
c. Ongoing recording of vital signs
d. Oral history
e. Physical exam
f. Use of all available/necessary testing resources
g. Discharge and transfer vital signs and
h. Adequate documentation of the above.

- Patient #2's medical record reviewed on 9/24/13 revealed they presented to the Emergency Department on 11/26/12 at 2:15pm with a chief complaint of right foot pain for 3 weeks. Patient #2 rated their pain at a "7" (on a scale of 1-10). Registered Nurse E noted their right foot had a trace of edema on the top of the foot and great toe.

Patient #2's was seen by physician Y at 2:35pm, per RN documentation. Physician Y "hurt foot 3 weeks ago not deformed no open wound no signs of infection alert and oriented medical screening exam done will see if pre-pay not medical emergency."

Patient #2's medical record lacked evidence of diagnostic testing such as, an x-ray to determine if an emergency existed and did not receive treatment for their reported pain.

Registered Nurse E noted at 2:40pm they took the patient via wheelchair to the physician's adjacent doctor's office. Patient #2's medical record lacked evidence of an order to discharge the patient to the office.

The record lacked evidence of a completed MSE to the capabilities of the hospital discharge orders/instructions and lacked evidence of an order to transfer the patient to the physician's office.

- Patient #3's medical record reviewed on 9/24/13 revealed they presented to the Emergency Department on 12/16/12 at 1:18am with the chief complaint of "not feeling right" low reported blood sugar and light sensitivity. Registered Nurse Z initial patient assessment noted patient#2 also voiced complaints of tightness in chest without chest pain and visual disturbances. Registered Nurse Z's notes revealed patient stated "not feeling right" reports visual disturbances seeing spots left eye, light sensitivity. Patient is diabetic, blood sugar at home was 85, patient reported they ate some candy canes and had changes to a high dose of blood pressure medications. Patient #2 reported their blood pressure is lower than normal and stated their systolic blood pressure is 140's. Registered Nurse Z documented patient #2's blood pressure was 110/60, blood sugar is 152 and placed patient on oxygen.

Registered Nurse Z noted on-call physician T at with patient in emergency department at 1:30am. The staff performed an EKG to assess patient's heart function, with normal results.

Physician T completed the following discharge instructions form for patient #2 that noted their primary diagnosis or reason for visit was "vision changes" The exam and treatment you have received has been on an emergent basis. Close follow up with your primary care provider for continued monitoring of you symptoms is important. Please follow the instructions given below until your follow up is obtained. In the event you are unable to contact your primary provider, or it your symptoms continue, worsen, or new symptoms arise; please return to the emergency department. If you feel that you have a life threatening emergency, do not hesitate to call 911 for emergency medical assistance. Follow up instructions:
1. Talk to your doctor on Monday about recent vision changes.
2. Please return to the ED with continued or worsening symptoms.
3. Monitor blood sugars closely as well as blood pressure.

Physician T's examination and progress notes lacked evidence of a MSE that addressed patient #2's blood pressure concerns and diagnostic testing, such as a CT scan to evaluate their neurological status. Physician T's documentation lacked evidence if patient #2 had an emergency medical condition prior to their discharge at 2:10am.

- Patient #4's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 12/17/12 at 5:40pm with a chief complaint of migraine and nausea. Registered Nurse AA completed Patient #4's initial assessment and noted the patient reported a pain level of "8" (1 to 10 scale).

Registered Nurse AA noted physician Y in the emergency department with patient #4 at 5:50pm. Physician Y noted patient #4 complaint of a migraine headache. "No different than other migraine headaches they have had." Except patient #4 reported their pain was not relieved by their routine migraine medication and that they had vomited the medication after taking the doses.

Physician Y's exam stated "A febrile, vital signs, generally well groomed, moderate distress, and alert oriented times three." Review of the medical decision making portion and diagnostic testing portions of the physician exam were left blank. Physician Y ordered an injectable pain medication prior to patient discharge at 6:50pm. Physician Y's documentation lacked evidence of documentation to determine if a emergency medical condition existed.

Physician Y completed the following discharge instructions for patient #4:
Discharge instructions directed:
1. Follow up with your primary care provider
2. Rest-get plenty of sleep
3. Try to keep a food journal. Sometimes foods may trigger a migraine such as cheddar cheese, bacon, alcohol, processed and cured meats.
4. Recommend seeing internal medicine physician at clinic who may be able to help you avoid emergency department.

- Patient #5's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 12/25/13 at 11:45pm with a chief complaint of shooting pain in vagina. Registered Nurse D completed an initial nursing assessment and noted patient #5 reported pain at a "6" (on a 1-10 scale) at 11:45pm and was discharged without pain management at 12:55am with a report of pain at "5" (on a scale of 1-10).

Registered Nurse D noted physician T in emergency department if see patient #5 at 11:45pm. Patient #5 reported they had vaginal pain since this afternoon. Patient reported having normal menstrual cycles. Patient reported having vaginal pain and bleeding on 12/19/13. Patient is sexually active and reports unprotected sex last week. Physician T completed a pelvic exam and ordered labs for urine analysis, sexual transmitted disease and pregnancy test. All results reported were negative.

Physician T completed discharge instructions and directed patient #5 to:
1. Take Tylenol and/or Advil for pain.
2. Results of STD test to be sent to primary physician.
3. If pain/bleeding/discharge continue recommend a pelvic ultra sound. Which can be ordered by your physician.
4. Return to emergency department for fevers over 100.4 continued vaginal pain, bleeding.

Patient continued to report their pain was elevated at "5" at discharge was discharged at 12:55am. Patient did not receive any pain medications during emergency department visit. Physician T's documentation lacked evidence of an evaluation and determination if an emergency medical condition existed.

- Patient #15's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 6/18/13 at 7:35pm with a chief complaint of migraine unresolved by current medications. Registered Nurse M assessment revealed patient reported pain at
10+ (on a scale of 1-10) and an elevated blood pressure of 145/97.

Physician Y arrived at the emergency department at 7:56pm. Physician Y documented patient #15 complained of a history of migraines and noted the patient took two doses of maxalt but has not had any relief, becomes nauseated if moves around.

Physician Y's examination noted patient had general moderate distress; eye pupils are equal and lacked evidence of infection. No edema noted on eyelids and ordered the following medications: Toradol 60 milligrams (mg) injection for pain and zofran 4mg tablet by mouth for nausea.

Review of physician orders lacked evidence of diagnostic tests to determine the cause of the patient report of pain and lacked evidence of a physician evaluation of their elevated blood pressure. Patient #15's medical record lacked evidence of an evaluation and determination if an emergency medical condition existed.

Patient discharge instructions directed:
1. Follow up with physician about migraines not relieved by current medication. Doctor may be able to have you take something else or something to prevent migraine headaches.
2. Your blood pressure was high and you need follow up about blood pressure also. There are preventative treatments for migraines that are blood pressure medications.
3. Return as needed, rest get enough sleep, avoid triggers may be able to find trigger by keeping a food diary- some foods may cause you to have migraines- processed meat and cheese.

- Patient #20's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 9/10/13 at 4:35pm with a chief complaint of a toothache. Registered Nurse O completed patient assessment and noted patient #20 reported their pain was at a "10" (on a scale of 1-10).

Physician Y arrived in the emergency department at 4:43pm and documented the patient reported having a toothache for 1.5 weeks, can't see their dentist for an additional 1.5 weeks. Physician Y documented "the patient's teeth appear normal to me no obvious gingivitis swelling of gum not emergency medical problem." Patient reported a crack tooth was the cause of the pain to the nurse.

Discharge instructions: directed the patient to see a dentist and to contact primary care doctor for any routine treatment - they may be able to call in prescription for you. The record lacked evidence the patient received any treatment for their tooth pain rated at a "10" and lacked evidence the staff used the hospital capabilities and a contracted dentist.

- Administrative staff B on 9/24/13 at 10:00am reported the patients medical records lacked evidence of a completed MSE to determine if a EMC existed and stated the hospital did not include EMTALA concerns of who completed the medical screens and if the patient's primary concerns were addressed by the physician.

The Critical Assess Hospital reported 476 patients received emergency medical care from the hospital's emergency department and transferred 63 patients onto other health facilities for follow up emergency care for the last 12 months. The survey included a sample of 20 emergency department patient records for review. Based on document and policy review, medical record review and staff interview the hospital failed to ensure the nursing staff in their emergency department met patient needs for pain control for 8 of 20 emergency department patients (patient #'s 2, 4, 5, 6, 8, 9, 16 and 29).

Findings include:

- Critical Access Hospital nursing policy for pain management dated 7/13 and reviewed on 9/24/13 directed nursing to assess patient pain upon admission (including the emergency department) and stated if a patient reports it is unacceptable if a patient reports a pain at of above "5" on a 1- to 10 pain scale. The policy directed nursing staff to contact the physician to obtain order ' s to treat patient pain within 15 minutes of the pain report. The policy directed nursing staff to administer medications as ordered and reassess patient's including vital signs and pain levels as follows:
1. Every 10 minutes after intravenous (IV) pain medication.
2. Every 30 minutes after a pain medication injection.
3. Every hour after oral pain medications.


- Patient #2's medical record reviewed on 9/24/13 revealed they presented to the ED on 11/26/12 at 2:15pm with a chief complaint of right foot pain for 3 weeks, rated at "7" (on a scale of 1-10). Registered Nurse E documented patient #2 had a trace amount of swelling on the top of their right foot and great toe. Patient #2's medical record lacked evidence on any pain medication and further pain assessment.

Patient #2's medical record lacked evidence of any further vital sign assessment and lacked discharge pain assessment at their discharge at 2:40pm.

- Patient #4's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 12/17/12 at 5:40pm with a chief complaint of migraine and nausea. Registered Nurse AA completed Patient #4's initial assessment and noted the patient reported a pain level of "8" (1 to 10 scale). Physician Y ordered an injectable pain medication and Nurse AA administered the medication at 6:10pm.

Patient #4's vital sign and nursing assessment revealed their next assessment occurred at 6:30pm, 20 minutes after the medication.

- Patient #5's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 12/25/13 at 11:45pm with a chief complaint of shooting pain in vagina. Registered Nurse D completed an initial nursing assessment and noted patient #5 reported pain at a "6" (on a 1-10 scale) at 11:45pm.

Patient #5's medical record lacked evidence of any pain management during their emergency department visit. Patient #5 continued to complain of pain of at a "5" upon discharged at 12:55am.

- Patient #6's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 1/18/13 at 10:47pm with a chief complaint of a headache, chest pain and vomiting with stomach ache. Registered Nurse E documented patient #6 reported pain at a 10 (on a 1-10 scale) at 10:47pm. Patient #6 ' s medical record lacked evidence of an ongoing patient assessment and medication administration.

Patient #6's medical record lacked evidence of any pain management during their emergency department visit and lacked a discharge assessment.

- Patient #8's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 1/26/12 at 11:09pm with a chief complaint of a smashed right hand. Registered Nurse K documented patient #8 reported pain at "7" (on a 1-10 scale). Registered Nurse K reassessed patient pain at 12:10am and patient #8 reported their pain was between "6-7" Patient #8 reported their pain at discharge continued and rated it at a "5" . Patient #8's medical record lacked evidence of further patient pain reported to the emergency department physician.

- Patient #9's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 3/30/13 at 7:50am with a chief complaint of neck pain with a headache and arm pain after an auto accident. Patient #9 reported their pain rated at "6" (on a 1-10 scale).

Physician W ordered an IV pain medication at 8:00am and Registered Nurse P administered their pain medication at 8:35am. Registered Nurse reassessment paint #9's pain medication at 9:15am and patient reported pain rated at "7". Physician W ordered a second IV pain medication at (an unknown time) and Registered Nurse P administered their pain medication at 9:15am.

Patient #9's medical record lacked evidence of a follow up pain assessment and patient #9 complained of pain rated at "7" upon discharge at 10:40am.

- Patient #16's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 7/21/13 at 5:56pm with a chief complaint of right side abdominal pain rated at "8" (on scale of 1-10). Physician W ordered IV pain medication at 6:20pm and at 7:10pm. Registered Nurse H administered the first dose at 6:44pm. Patient # 16's medical record lacked evidence of a follow up pain assessment for the first pain medication dose. Registered Nurse H administered the second dose of pain medication at 7:12pm. Registered Nurse H reassessed and patient reported pain at "6" and at "5" at 7:45. The medical record lacked evidence of additional pain management medication and reassessments until their discharge at 8:38pm.

- Patient #20's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 9/10/13 at 4:35pm with a chief complaint of a toothache and pain rated at "10" (on a scale of 1-10).

Patient #20's medical record lacked evidence of a physician order for pain management and lacked additional pain assessments until their discharge at 4:55pm.

- Administrative staff A and B on 9/25/13 at 4:30pm reported the nursing staff failed to follow the policy for patient pain management and verified the medical records lacked appropriate patient pain assessments and interventions.

The Critical Access Hospital (CAH) reported a census on no patients with an average daily census of 2.6 acute patients. Based on medical record review, policy review and staff interview, the CAH failed to accurately complete medical records for 14 of 42 sampled medical records (patient #'s 2, 4, 9, 10, 11, 14, 15, 17, 18, 20, 26, 27, 28, and 32).

Findings include:

- The CAH's policy "Health Information Review" reviewed on 9/25/13 at 3:00pm directed, "...The medical record must be reviewed to insure accuracy and completeness of the record ...accuracy of: 1. Name, 2. Dates, 3. Hospital number, 4. Absence of reports ordered, 5. Reports or orders lacking signatures...Records shall be complete within 14 days of discharge..."

- Patient #2's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 11/26/12 at 2:15pm with a chief complaint of right foot pain for 3 weeks. Patient #2's patient history form, physician decision making and treatment/course section of the physician exam and disposition revealed physician Y left the information spaces blank. Review of the nursing assessment from the emergency department revealed Registered Nurse E left patient #2's discharge vital signs blank.

- Patient #4's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 12/17/12 at 5:40pm with a chief complaint of a migraine and nausea. Patient #4's physician decision making and patient disposition revealed physician Y left the information spaces blank.

- Patient #9's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 3/30/13 at 7:50am with a chief complaint of neck pain with a headache and arm pain after an auto accident. Physician W failed to complete emergency department transfer form which lacked evidence of documented which acute hospital the physician sent patient #9 to for additional care.

- Patient #10's medical record reviewed on 9/24/13 revealed they presented to the emergency department on4/28/13 at 8:54pm with a chief complaint of chest pain. Physician V failed to complete emergency department transfer form and lacked evidence of documented which acute hospital the physician sent patient #10 for additional care and the name of the ambulance services used for transport. Patient #10's physician orders revealed physician V failed to cosign a phone order from 4/29/13 for an EKG and pain medication.

- Patient #11's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 5/28/13 at 7:42pm with a chief complaint of falling out of highchair with bump and scratches to forehead. Patient #11's physician decision-making and treatment/course section of the physician exam and disposition revealed physician Y left the information spaces blank.

- Patient #14's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 6/9/13 at 8:14am with a chief complaint of a laceration to forehead. Patient #14's physician order sheet revealed a voice order for topical and injectable pain medications and lacked evidence of a physician signature to authenticate the order.

- Patient #15's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 6/18/13 at 7:35pm with a chief complaint of migraine unresolved by medications. Patient #15's physician decision making and patient disposition revealed physician Y left the information spaces blank.

- Patient #17's (11-year-old child) medical record reviewed on 9/25/13 revealed they presented to the emergency department with a church camp staff member on 7/25/13 at 10:03am with a chief complaint of a laceration to their upper left lip. Patient #17's physician decision-making and treatment/course section of the physician exam and patient disposition revealed physician Advance Practice Registered Nurse (APRN) F left the information spaces blank.

- Patient #18's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 8/7/13 at 1:15am with a chief complaint of being "assaulted at 5:00pm. Hit in the head and body, slammed off porch onto head and neck, nausea, vomiting and right arm pain" Patient #18's physician decision-making section of the physical exam revealed Physician Y left the section blank.

- Patient #20's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 9/10/13 at 4:35pm with a chief complaint of a toothache and discharged at 4:50pm. Patient #20's past patient history form, physician decision-making and treatment/course section of the physician exam and disposition revealed physician Y left the information spaces blank.

- Administrative staff B on 9/26/13 at 1:00pm acknowledged the emergency department medical records lacked completion by the physician's and staff and reported the hospital lacked a system to track and trend EMTALA documentation.

- Patient #26's medical record reviewed on 9/24/13 revealed an admission date of 6/10/13 with a diagnosis of Aortic Stenosis (an abnormal narrowing of the aortic valve in the heart) and acute respiratory failure and transferred to a higher level of care on 6/13/13. Patient #26 received an echocardiogram on 6/13/13. The medical record lacked a report for the echocardiogram.

Administrative staffs I, interviewed on 9/24/13 at 4:30pm, acknowledge the medical record lacked the results of an echocardiogram performed on patient #26.

- Patient #27's medical record reviewed on 9/24/13 revealed an admission date of 6/14/13 with a diagnosis of multiple rib fractures and discharged on 6/17/13. The last documented nurse ' s notes on 6/17/13 indicated patient #27's received medications and sitting up in the chair. Patient #27's medical record lacked documentation of discharge and/or the patient ' s condition at discharge. Patient #27's medical record contained a discharge summary dictated by the physician and typed on 7/23/13, thirty-six days after discharge.

Administrative staffs I, interviewed on 9/24/13 at 4:30pm, acknowledge the medical record lacked nursing documentation of discharge and/or the patient's condition at discharge.

Medical records staff K interviewed on 9/25/13 at 12:00pm indicated they were unaware of any delinquent medical records.

- Patient #28's medical record reviewed on 9/24/13 revealed an admission date of 7/10/13 with a diagnosis of cerebral vascular accident (stroke) and discharged on 7/13/13. Patient #28's medical record contained a discharge summary dictated by the physician and typed on 8/16/13, thirty-four days after discharge.

Medical records staff DD interviewed on 9/25/13 at 12:00pm indicated they were unaware of any delinquent medical records.

- Patient #32's medical record reviewed on 9/25/13 revealed an admission date of 3/25/13 with a diagnosis of Intractable pain shoulder and hip and discharged on 3/29/13. The last documented nurse ' s notes on 3/29/13 indicated patient #32's received a pain assessment and staff would continue to monitor patient #32. Patient #27's medical record lacked documentation of discharge and/or the patient's condition at discharge.

Administrative staffs I, interviewed on 9/25/13 at 5:00pm, acknowledge the medical record lacked nursing documentation of discharge and/or the patient's condition at discharge.

The Critical Access Hospital (CAH) reported a census of no patients with an average daily census of 2.6 acute patients. Based on medical record review, policy review, Medical Staff By-Laws/Rules and Regulations and staff interview the staff of the CAH failed to date and/or time all authenticated (signed) entries in the medical record for 38 of 42 medical records reviewed (patient #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, and 40).

Findings include:

- Patient #2's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 11/26/12 at 2:15pm with a chief complaint of right foot pain for 3 weeks. Physician Y failed to complete emergency room form that indicated the time they arrived to the emergency department to care patient #2. Patient #2's physician exam form laced evidence of a date and time that physician Y signed the form.

- Patient #3's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 12/16/12 at 1:18am with the chief complaint of "not feeling right" low blood sugar, light sensitivity. Physician T failed to complete emergency room form that indicated the time they arrived to the emergency department to care patient #3. Patient #3's discharge instructions lacked a date and time to authenticate physician T's signature.

- Patient #4's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 12/17/12 at 5:40pm with a chief complaint of a migraine and nausea. Physician Y failed to complete emergency room form that indicated the time they arrived to the emergency department to care patient #4. Patient #4's discharge instructions lacked a date and time to authenticate physician Y's signature.

- Patient #5's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 12/25/13 at 11:45pm with a chief complaint of shooting pain in vagina. Physician T failed to complete emergency room form that indicated the time they arrived to the emergency department to care patient #5. Patient #5's physical exam, physician orders and discharge instructions lacked a date and time to authenticate physician T's signature.

- Patient #6's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 1/18/13 at 10:47pm with a chief complaint of a head ache, chest pain and vomiting with stomach ache. Physician U failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #6.

- Patient #7's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 3/23/13 at 11:32am with a chief complaint of a possible blood clot. Physician R failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #7.

- Patient #8's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 1/26/12 at 11:09pm with a chief complaint of a smashed right hand. Physician S failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #8.

- Patient #9's medical record reviewed on 9/24/13 revealed they presented to the emergency department on 3/30/13 at 7:50am with a chief complaint of neck pain with a headache and arm pain after an auto accident. Physician W failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #9.

- Patient #10's medical record reviewed on 9/24/13 revealed they presented to the emergency department on4/28/13 at 8:54pm with a chief complaint of chest pain. Physician V failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #10.

- Patient #11's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 5/28/13 at 7:42pm with a chief complaint of falling out of highchair with bump and scratches to forehead. Physician Y failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #11. Patient #11's discharge instructions lacked a date and time to authenticate physician Y's signature.

- Patient #12's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 5/31/13 at 10:02pm with a chief complaint of a dog bite to left ankle. Physician S failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #12. Patient #12's physician orders lacked evidence of a time and discharge instructions lacked a date and time to authenticate physician S's signature.

- Patient #13's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 6/7/13 at 1:39am with a chief complaint of right eye pain. Physician Y failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #13. Patient #13's discharge instructions lacked a date and time to authenticate physician Y's signature.

- Patient #14's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 6/9/13 at 8:14am with a chief complaint of a laceration to forehead. Physician R failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #14. Physician assessment and physical exam form and patient discharge instructions lacked a date and time when authenticated by physician R.

- Patient #15's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 6/18/13 at 7:35pm with a chief complaint of migraine unresolved by medications. Physician Y failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #15. Patient #15's discharge instructions lacked a date and time to authenticate physician Y's signature.

- Patient #16 medical record reviewed on 9/25/13 revealed they presented to the emergency department on 7/21/13 at 5:56pm with a chief complaint of right side abdominal pain. Physician Y failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #16.

- Patient #17's (11-year-old child) medical record reviewed on 9/25/13 revealed they presented to the emergency department with a church camp staff member on 7/25/13 at 10:03am with a chief complaint of a laceration to their upper left lip. Advance Practice Registered Nurse (APRN) F failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #17.

- Patient #18's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 8/7/13 at 1:15am with a chief complaint of being " assaulted at 5:00pm. Hit in the head and body, slammed off porch onto head and neck, nausea, vomiting and right arm pain. " Physician Y failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #18. Physician order sheet lacked evidence of the time they ordered intravenous fluids for patient #18.

- Patient #19's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 8/12/13 at 4:09pm with a chief complaint of being suicidal. Physician Y failed to complete emergency room form that indicated the time they arrived to the emergency department to care for patient #19. Physician order sheet lacked evidence of the time they ordered intravenous fluids for patient #19.

- Patient #20's medical record reviewed on 9/25/13 revealed they presented to the emergency department on 9/10/13 at 4:35pm with a chief complaint of a toothache and discharged at 4:50pm. The physician Y failed to document the time they arrived at the hospital emergency department.

Administrative staff B interviewed on 9/26/13 at 1:00pm acknowledged patient records from the emergency department were incomplete.

- Patient #22's medical record review on 9/24/13 revealed an admission date of 3/25/13 with a diagnosis of Metastatic Prostate Cancer (cancer of the prostate gland) and discharged on 3/28/13. Patient #22's medical record revealed a history and physical dictated on 4/7/13, typed on 4/8/13, and authenticated, a discharge summary dictated on 4/7/13, typed on 4/8/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary. Patient #22's medical record lacked a time the physician wrote progress notes on 3/26/13.

- Patient #23's medical record reviewed on 9/24/13 revealed an admission on 4/1/13 with a diagnosis of pneumonia and discharged on 4/4/13. Patient #23's medical record revealed between 4/1/13 to 4/4/13, four telephone/verbal orders lacked a date and/or time when authenticated by the provider. Patient #23's medical record revealed a history and physical dictated on 4/1/13, typed on 4/2/13, and authenticated, a discharge summary dictated on 4/6/13, typed on 4/8/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #24's medical record reviewed on 9/24/13 revealed an admission on 4/9/13 with a diagnosis of chronic anemia and discharged on 4/12/13. Patient #24's medical record revealed between 4/9/13 to 4/12/13, four telephone/verbal orders and two progress notes lacked a date and/or time when authenticated by the provider. Patient #24's medical record revealed a history and physical dictated on 4/10/13, typed on 4/11/13, and authenticated, a discharge summary dictated on 5/9/13, typed on 5/10/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #25's medical record reviewed on 9/24/13 revealed an admission on 5/14/13 with a diagnosis of congestive heart failed and discharged on 5/18/13. Patient #25's medical record revealed between 5/14/13 to 5/18/13, three telephone/verbal orders and a progress note lacked a date and/or time when authenticated by the provider. Patient #25's medical record revealed a history and physical dictated on 5/15/13, typed on 5/15/13, and authenticated, a discharge summary dictated on 5/18/13, typed on 5/20/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #26's medical record reviewed on 9/24/13 revealed an admission date of 6/10/13 with a diagnosis of Aortic Stenosis (an abnormal narrowing of the aortic valve in the heart) and acute respiratory failure and transferred to a higher level of care on 6/13/13. Patient #26's medical record revealed a history and physical dictated on 6/11/13, typed on 6/11/13, and authenticated, a discharge summary dictated on 6/13/13, typed on 6/13/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #27's medical record reviewed on 9/24/13 revealed an admission date of 6/14/13 with a diagnosis of multiple rib fractures and discharged on 6/17/13. Patient #27's medical record revealed a history and physical dictated on 6/15/13/13, typed on 6/17/13, and authenticated, a discharge summary dictated on 7/22/13, typed on 7/23/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #28's medical record reviewed on 9/24/13 revealed an admission date of 7/10/13 with a diagnosis of cerebral vascular accident (stroke) and discharged on 7/13/13. Patient #28's medical record revealed a history and physical dictated on 7/11/13, typed on 7/12/13, and authenticated, a discharge summary dictated on 8/16/13, typed on 8/16/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #29's medical record reviewed on 9/24/13 revealed an admission date of 8/12/13 with a diagnosis of septic shock (an infection through out the body) and transferred to a higher level of care on 8/13/13. Patient #29 ' s medical record revealed a discharge summary dictated on 8/15/13, typed on 8/16/13, and authenticated. The physician failed to date and time when they authenticated the discharge summary.

- Patient #30's medical record reviewed on 9/24/13 revealed an admission date of 3/8/13 with a diagnosis of renal failure and discharged on 3/11/13. cranial osteomylitis Patient #30's medical record revealed a history and physical dictated on 3/8/13, typed on 3/8/13, and authenticated, a discharge summary dictated on 4/7/13, typed on 4/8/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #31's medical record reviewed on 9/25/13 revealed an admission date of 3/25/13 with a diagnosis of pancreatitis (an infection of the pancreas) and transfer to a higher level of care on 3/25/13. Patient #31's medical record revealed a history and physical dictated on 3/25/13, typed on 3/26/13, and authenticated, a discharge summary dictated on 3/27/13, typed on 3/27/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #32's medical record reviewed on 9/25/13 revealed an admission date of 3/25/13 with a diagnosis of intractable pain shoulder and hip and discharged on 3/29/13. Patient #32's medical record revealed a history and physical dictated on 3/26/13, typed on 3/27/13, and authenticated, a discharge summary dictated on 3/29/13, typed on 3/30/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #33's medical record reviewed on 9/25/13 revealed an admission date of 4/18/13 with a diagnosis of hypoxia (the body is deprived of adequate oxygen) and discharged on 4/20/13. Patient #33's medical record revealed a history and physical dictated on 4/18/13, typed on 4/18/13, and authenticated, a discharge summary dictated on 4/24/13, typed on 4/24/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #34's medical record reviewed on 9/25/13 revealed an admission date of 5/10/13 with a diagnosis of cranial osteomylitis (infection in the bones of the skull) and discharged on 5/14/13. Patient #34's medical record revealed a history and physical dictated on 5/30/13, typed on 5/30/13, and authenticated, a discharge summary dictated on 3/30/13, typed on 3/30/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #35's medical record reviewed on 9/25/13 revealed an admission date of 5/23/13 with a diagnosis of hyponatremia (low sodium blood level). Patient #35's medical record revealed a history and physical dictated on 5/24/13, typed on 5/24/13, and authenticated. The physician failed to date and time when they authenticated the history and physical.

- Patient #36's medical record reviewed on 9/23/13 revealed an admission on 4/29/13 with a diagnosis of kidney disease and discharged on 5/13/13. Patient #36's medical record revealed between 4/29/13 to 5/13/13, eight telephone/verbal orders lacked a date and/or time when authenticated by the provider. Patient #36's medical record revealed a history and physical dictated on 4/30/13, typed on 4/30/13, and authenticated, a discharge summary dictated on 5/30/13, typed on 5/30/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #37's medical record reviewed on 9/23/13 revealed an admission on 7/1/13 with a diagnosis of gait/balance disturbance and discharged on 7/16/13. Patient #37's medical record revealed between 7/1/13 to 7/16/13, six telephone/verbal orders and eleven progress notes lacked a date and/or time when authenticated by the provider. Patient #37's medical record revealed a history and physical dictated on 6/28/13, typed on 7/1/13, and authenticated, a discharge summary dictated on 8/16/13/13, typed on 8/16/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #38's medical record reviewed on 9/24/13 revealed an admission on 7/19/13 with a diagnosis of fractured hip and discharged on 8/16/13. Patient #38's medical record revealed between 7/19/13 to 8/16/13, two telephone/verbal orders and four progress notes lacked a date and/or time when authenticated by the provider. Patient #38's medical record revealed a history and physical dictated on 7/20/13, typed on 7/22/13, and authenticated, a discharge summary dictated on 9/12/13/13, typed on 9/13/13, and authenticated. The physician failed to date and time when they authenticated the history and physical and the discharge summary.

- Patient #40's medical record reviewed on 9/24/13 revealed an admission on 8/6/13 with a diagnosis of subdural hematoma (blood gathers within the outermost meningeal layer, between the dura mater, which adheres to the skull) and discharged on 8/15/13. Patient #40's medical record revealed between 8/6/13 to 8/15/13, one telephone/verbal order and five progress notes lacked a date and/or time when authenticated by the provider. Patient #40's medical record revealed a discharge summary dictated on 9/2/13, typed on 9/3/13, and authenticated. The physician failed to date and time when they authenticated the discharge summary.

Medical records staff DD interviewed on 9/25/13 at 12:00pm they did not monitor through quality assurance for dating/timing entries into the medical record.

The CAH failed to have a policy directing staff of the requirement to date and time entries into the medical record. The CAH Medical Staff By-Laws/Rules and regulations failed to direct staff to date and time entries into the medical records.

Based on Quality Improvement Plan review, Quality Committee meeting minutes reviewed and staff interview the Critical Access Hospital (CAH) failed to effectively develop and monitor policy and procedure review/revision/appropriateness for CAH services, to effectively develop and monitor emergency department staff and patient care practices, to effectively develop and monitor medical records for completeness and staff dating/timing entries into the medical record, to effectively monitor staff providing patient rights to all patients receiving services in the CAH, and failed to include these issues/problems in their Quality Improvement (QA/PI) program.

Findings include:

- The CAH's Performance Improvement Plan reviewed on 9/26/13 at 1:00pm directed, " ...The Quality Improvement Program at the hospital is about creating high quality patient care and strong organizational outcomes through a systematic approach that continuously monitors, develops, and improves out health care delivery services, professional practices ...The desired outcomes of the program are: 1. To assure the existence of strong internal operations that lead to the delivery of the highest possible level of safe patient care and service. 2. To assure the continuous identification of opportunities to drive a higher level of quality, efficiency and effectiveness into everything that impacts the delivery of patient care and the relationships with our communities ...

- Review of the Quality Assurance Performance Improvement (QAPI) Committee meeting minutes on 9/26/13 at 1:15pm lacked evidence of the identification or monitoring of policy and procedure review/revision/appropriateness for CAH services, emergency department staff and patient care practices, medical records for completeness and staff dating/timing entries into the medical record, and staff providing patient rights to all patients receiving services in the CAH.

- Hospital's QA calendar for the last 15 months reviewed on 9/26/13 revealed the hospital failed to identify indicators and lacked QA data from their anesthesia, central sterile, surgical department and practitioners at the hospital. Administrative staff B verified the departments failed to identify areas of improvement and failed to report any data collection.

Review of QA calendar revealed the business offices and outpatient department had identified indicators and had " N/A " on the calendar. QA calendar had red indicators for administration, dietary, emergency department, environment, medical records, infection control, laboratory, materials management, pharmacy, radiology, utilization review, swing bed, medical and surgical patient care departments to indicate poor performance with their identified indicators.

Review of their QA action plan lacked data enter and interventions implemented to correct, monitor and evaluate their identified problem indicators. The action plan failed to include monitoring of policy and procedure review/revision/appropriateness for CAH services, emergency department staff and patient care practices, medical records for completeness and staff dating/timing entries into the medical record, and staff providing patient rights to all patients receiving services in the CAH.

Administrative staff B interviewed on 9/26/13 at 1:00pm reported the hospital departments have not been held accountable for their parts of the hospital's QA program and that the program is " not an effective program. "

Medical records staff DD interviewed on 9/25/13 at 12:00pm indicated they did not have a formal tool to assist them in monitoring patient records for completeness or staff dating/timing entries into the medical record and were unaware of any delinquent medical records.

The Critical Access Hospital (CAH) reported a census of no swing bed patients with one swing bed admission during the survey. Based on medical record review and staff interview the CAH failed to provide patient rights to one of five Swing Bed patients medical record review (patient #40)

Findings include:

- Patient #40's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 8/6/13. The medical record lacked evidence patient #40 received patient rights.

Office staff CC interview on 9/25/13 at 3:05pm acknowledged the medical record of patient #40 lacked evidence that the patients were informed of their rights.

The Critical Access Hospital (CAH) reported a census of no swing bed patients with one swing bed admission during the survey. Based on Patient Rights review and staff interview the CAH's Swing Bed Patient Rights provided to all swing bed patients failed to inform swing bed patients of his or her right to choose a personal attending physician for five of five swing bed patients reviewed (patient #'s 36, 37, 38, 39, and 40).

Findings include:

- The CAH's Patient's Rights provided as the rights given to Swing Bed patients, reviewed on 9/25/13 at 11:00am directed, "...You will be told the name of the physician who has primary responsibility for coordinating your care..." The Patient Rights lacked the patient rights information that the resident had the right to choose a personal attending physician.

- Patient #36's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 4/29/13. The medical record revealed the patient received patient rights that failed to inform them of their right to choose a personal attending physician.

- Patient #37's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 7/1/13. The medical record revealed the patient received patient rights that failed to inform them of their right to choose a personal attending physician.

- Patient #38's medical record, reviewed on 9/24/13 revealed a swing bed admission date of 7/19/13. The medical record revealed the patient received patient rights that failed to inform them of their right to choose a personal attending physician.

- Patient #39's medical record, reviewed on 9/24/13 revealed a swing bed admission date of 9/23/13. The medical record revealed the patient received patient rights that failed to inform them of their right to choose a personal attending physician.

- Patient #40's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 8/6/13. The medical record lacked evidence patient #40 received patient rights.

Swing Bed Coordinator staff BB interviewed on 9/25/13 at approximately 11:00am acknowledged the swing bed patient rights failed to include the right to choose a personal attending physician.

The Critical Access Hospital (CAH) reported a census of no swing bed patients with one swing bed admission during the survey. Based on Patient Rights review and staff interview, the CAH failed to inform swing bed patients of his or her right to be informed in advance about care and treatment and changes in their care and treatment for five of five skilled swing bed patient records reviewed (#'s 36, 37, 38, 39, and 40).

Findings include:

- The CAH's Patient's Rights provided as the rights given to Swing Bed patients, reviewed on 9/25/13 at 11:00am failed to inform swing bed patient of his or her right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #36's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 4/29/13. The medical record revealed the patient received patient rights that failed to inform them of the right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #37's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 7/1/13. The medical record revealed the patient received patient rights that failed to inform them of the right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #38's medical record, reviewed on 9/24/13 revealed a swing bed admission date of 7/19/13. The medical record revealed the patient received patient rights that failed to inform them of the right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #39's medical record, reviewed on 9/24/13 revealed a swing bed admission date of 9/23/13. The medical record revealed the patient received patient rights that failed to inform them of the right to be informed in advance about care and treatment and changes in their care and treatment.

- Patient #40's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 8/6/13. The medical record lacked evidence patient #40 received patient rights.

Swing Bed Coordinator staff BB interviewed on 9/25/13 at approximately 11:00am acknowledged the swing bed patient rights failed to include the right to be informed in advance about care and treatment and changes in their care and treatment.

The Critical Access Hospital (CAH) reported a census of no swing bed patients with one swing bed admission during the survey. Based on Patient Rights review and staff interview, the CAH failed to inform swing bed patients of his or her right to work or refuse to perform work for five of five skilled swing bed patient records reviewed (#'s 36, 37, 38, 39, and 40).

Findings include:

- The CAH's Patient's Rights provided as the rights given to Swing Bed patients, reviewed on 9/25/13 at 11:00am failed to inform swing bed patient of his or her right to work or refuse to perform work for the facility.

- Patient #36's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 4/29/13. The medical record revealed the patient received patient rights that failed to inform them of his or her right to work or refuse to perform work for the facility.

- Patient #37's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 7/1/13. The medical record revealed the patient received patient rights that failed to inform them of his or her right to work or refuse to perform work for the facility.

- Patient #38's medical record, reviewed on 9/24/13 revealed a swing bed admission date of 7/19/13. The medical record revealed the patient received patient rights that failed to inform them of his or her right to work or refuse to perform work for the facility.

- Patient #39's medical record, reviewed on 9/24/13 revealed a swing bed admission date of 9/23/13. The medical record revealed the patient received patient rights that failed to inform them of his or her right to work or refuse to perform work for the facility.

- Patient #40's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 8/6/13. The medical record lacked evidence patient #40 received patient rights.

Swing Bed Coordinator staff BB interviewed on 9/25/13 at approximately 11:00am acknowledged the swing bed patient rights failed to include the right to work or refuse to perform work for the facility.

The Critical Access Hospital (CAH) reported a census of no swing bed patients with one swing bed admission during the survey. Based on Patient Rights review and staff interview, the CAH failed to inform swing bed patients of his or her right to share a room with their spouse for five of five skilled swing bed patient records reviewed (#'s 36, 37, 38, 39, and 40).

Findings include:

- The CAH's Patient's Rights provided as the rights given to Swing Bed patients, reviewed on 9/25/13 at 11:00am failed to inform swing bed patients of his or her right to share a room with their spouse.

- Patient #36's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 4/29/13. The medical record revealed the patient received patient rights that failed to include right to share a room with their spouse.

- Patient #37's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 7/1/13. The medical record revealed the patient received patient rights that failed to include right to share a room with their spouse.

- Patient #38's medical record, reviewed on 9/24/13 revealed a swing bed admission date of 7/19/13. The medical record revealed the patient received patient rights that failed to include right to share a room with their spouse.

- Patient #39's medical record, reviewed on 9/24/13 revealed a swing bed admission date of 9/23/13. The medical record revealed the patient received patient rights that failed to include right to share a room with their spouse.

- Patient #40's medical record, reviewed on 9/23/13 revealed a swing bed admission date of 8/6/13. The medical record lacked evidence patient #40 received patient rights.

Swing Bed Coordinator staff BB interviewed on 9/25/13 at approximately 11:00am acknowledged the swing bed patient rights failed to include the right to share a room with their spouse.

The Critical Access Hospital (CAH) reported a census of no swing bed patients with one swing bed admission during the survey. Based on personnel file review and interview the Critical Access Hospital (CAH) failed to provide a qualified professional to direct the activities program. Failure to provide a qualified activity director had the potential to affect all skilled swing bed patients.

Findings include:

- Document review on 9/26/13 at 9:00am of the personal file for Swing Bed Coordinator staff BB, listed as the activity director for swing bed, revealed the file lacked evidence of professional qualifications for the position.

Swing Bed coordinator staff BB interview on 9/25/13 at approximately 11:00am acknowledged they failed to complete a training course to meet qualifications for activity director and thought being a Register Nurse qualified them for the position.

The Critical Access Hospital (CAH) reported a census of no swing bed patients with one swing bed admission during the survey. Based on contracted service review and staff interview the CAH failed to have a contract or agreement for provision of routine and emergency dental care for the swing bed patients. Non-compliance with this requirement had the potential to affect all swing bed patients.

Findings include:

- Review of list of contracted services provided by the CAH and reviewed on 9/25/13 failed to include an agreement for the required dental services for swing bed patients.

Administrative staff A interviewed on 9/25/13 at 4:00pm acknowledged the CAH failed to have an agreement or contract with a dentist for provision of routine and emergency dental care for swing bed patients.