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Based on review of professional literature, observation, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed acceptable surgical standards of practice regarding the temperature and humidity of 1 of 1 Operating Room (OR) used for procedures requiring general anesthesia. Failure to document, monitor, and ensure the temperature and humidity of the OR are within the recommended ranges may result in the growth of bacteria and an increase in patient infections.

Findings include:

An article from the Association of Perioperative Registered Nurses (AORN), updated 06/30/09, stated, ". . . The recommended temperature range in an operating room is between 68 [degrees] F [Fahrenheit] and 73 [degrees] F . . . The recommended humidity range in an operating room is between 30% [percent] to 60%. Both the temperature and humidity should be monitored and recorded daily using a log or electronic documentation of the heating, ventilation, and air conditioning (HVAC) system . . . The potential risk of microbial growth increases in areas where sterile supplies are stored when the humidity is too high. . . ."

Observation of the OR occurred on 09/17/13 at 4:15 p.m. with an administrative nurse (#2). A thermometer and hygrometer (gauge used to measure the amount of humidity (moisture) in the air) located in the OR identified a temperature of 67 degrees F and humidity of 65%. The nurse (#2) stated she expected the OR staff to contact the maintenance supervisor if the humidity measured lower than 50% or higher than 60%. She stated the OR staff checked the temperature and humidity on procedure days and did not keep a log of the measurements.

During an interview on 09/17/13 at 4:45 p.m., the maintenance supervisor (#7) stated the CAH staff had not reported any concerns regarding the temperature and humidity of the OR all summer.

During an interview on 09/18/13 at 7:50 a.m., an OR staff member (#8) stated the temperature and humidity of the OR before the first procedure that morning measured 67 degrees F and 65% humidity.

Based on policy review, minutes review, and staff interview, the Critical Access Hospital (CAH) failed to have the required group of professionals annually review their health care policies for 1 of 1 year reviewed (July 2011 - June 2012). Failure to annually review their policies limits the CAH's ability to ensure staff members properly treat and care for their patients.

Findings include:

Review of the policy "Critical Access Periodic Evaluation" occurred on 9/17/13. This policy, written 5/03/01, stated, "Policy: On an annual basis . . . 3. The following policy and procedure manuals will be reviewed by the Policy Review Committee. General Facility, Business Office/Health Information Management, Dietary, Laboratory, Radiology, Nursing/Critical Care, Emergency Department, Infection Control, Pharmacy, OR [operating room]/CS [central supply]/Anesthesia, Environmental Services, Performance Improvement, Swing Bed, Safety/Risk Management, Material Management, Social Services."

Review of the Oakes Community Hospital Policy Committee Minutes occurred on 9/17/13. These minutes, dated 5/10/13, lacked evidence of annual policy review by the required group of professionals including a physician; a physician assistant, nurse practitioner, or clinical nurse specialist; and a non-staff member.

Reviewed on September 17-18, 2013, the Radiology and Laboratory policy and procedure manuals lacked evidence of annual review by a non-staff member and a physician assistant, nurse practitioner, or clinical nurse specialist.

The CAH provided no other evidence of annual review of their policies and procedures by the required group of professionals.

During an interview at 11:45 a.m. on 09/18/13, an administrative staff member (#3) confirmed the required group of professionals had not reviewed their policies during fiscal year 2012.

1. Based on review of professional literature, observation, review of patient care event reports, and staff interview, the Critical Access Hospital (CAH) failed to ensure the identity of hospitalized patients for 1 of 1 active patient (Patient #2) observed on 09/16/13; and for 2 of 2 patient care event reports (Patients #7 and #8) reviewed regarding mistaken patient identity. Failure to ensure identification of patients has the potential to place the patient at risk of improper care or treatment, risking patient safety.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, page 712, stated, ". . . Client safety problems can include a variety of errors such as . . . mistaken identity . . ."

Beyea's "Patient Identification: A Crucial Aspect of Patient Safety-Patient Safety First," AORN (Association of Perioperative Registered Nurses) Journal, dated September 2003, stated, ". . . All clinicians need to be concerned with the processes and systems that support correct identification of patients. . . . The importance of this basic practice cannot be minimized. No assumptions about identity can be made. Every clinician providing care for the patient must make it a routine practice to verify identity. . . . a patient has the right to be identified correctly."

- Observation of patient care occurred on 09/16/13 at 1:45 p.m. with a nurse (#9). The nurse entered Patient #2's room with her medications, observed the patient's name bracelet, and found it saturated with water and unreadable. The nurse (#9) exited the room and obtained a new name bracelet. The nurse failed to confirm Patient #2's identity before she placed the new bracelet on the patient's wrist.



28086

- Review of Patient Care Event Reports (the CAH's incident reporting system) occurred on 09/16/13 and showed the following:
*03/22/13 at 3:30 a.m. - ". . . Description of the Event: Pt [patient] is on telemetry and the monitor leads off. Went in to replace leads and leads and telemetry unit were not on the patient. Asked for help from another nurse to look for leads and telemetry unit. Unit was not in patient's bed or on patient. . . . Patient Name: [Patient #7] . . . Immediate Actions Taken: Took telemetry unit off patient in room 114-1 and immediately placed telemetry unit on [initials of Patient #7] . . . Comments: Name confusion for telemetry placement with patients having the same first name. . . . Initial Contributing Factors: Two patients had the same first name and possible that when telemetry unit was asked to be placed only first name of the patient was used."
*06/01/13 at 8:00 a.m. - ". . . Description of the Event: patient received wrong tray. . . . Patient Name: [Patient #8] . . . Comments: Same first name last initial mix up. . . . Comments: Name confusion. Need to verify ID [identification] with verbal acknowledgement and 2 patient identifiers. . . . Special Notification Comments: 2 patients with same first name and very similar last name, both admitted same day. Fortunately diet was appropriate. . . . Initial Contributing Factors: not reading the full name and room number on the tray card. both patiens [sic] have the same first name. . . ."

During an interview on 09/18/13 at 2:00 p.m., an administrative nurse (#1) stated all patients admitted to the hospital received a name band containing their name, birthdate, and medical record number, and she expected staff to place a new nameband when the patient's identifying information is unreadable. The nurse (#1) stated she expected staff to confirm patient identity prior to implementing treatment, and staff must check the patient's nameband against their stated name and birth date.



20497

2. Based on personnel record review and staff interview, the Critical Access Hospital (CAH) failed to ensure proper training and orientation for 2 of 4 registered nurses' (Staff Members #4 and #5) files reviewed. Failure to perform and document training and orientation limits the CAH's ability to ensure staff members can meet the needs of the patients.

Findings include:

Review of personnel records occurred on 09/18/13 and indicated the following start dates:
- Staff Member #4 began working in Cardiac Rehabilitation (Rehab) in May 2012.
- Staff Member #5 began working at the CAH in November 2011.
Upon request, the CAH failed to provide evidence of orientation for Staff Members #4 and #5.

During interview the afternoon of 09/18/13, a human resources staff member (#6) stated Staff Member #4 began working in Cardiac Rehab in May 2012. Staff Member #6 confirmed Staff Member #5 ended employment with the CAH on 07/06/08 and started again on 11/16/11.

During interview the afternoon of 09/18/13, an administrative nursing staff member (#1) stated the CAH should have documented Cardiac Rehab orientation for Staff Member #4, and they did not orientate Staff Member #5 since she had worked at the CAH previously.

1. Based on review of professional reference, record review, observation, and staff, patient, and family interview, the Critical Access Hospital (CAH) failed to verify a patient's allergies and document the allergies in the patient's medical record for 1 of 1 active patient (Patient #3) record reviewed. Failure to verify and document a patient's allergies may result in adverse reactions, allergic responses, or death.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 9th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2012, page 859, stated, "The nurse should always assess a client's health status and obtain a medication history prior to giving any medication. . . . An important part of the history is clients' knowledge of their drug allergies. . . . The nurse should clarify with the client any side effects, adverse reactions, or allergic responses due to medications. . . ."

Review of Patient #3's active medical record occurred on all days of survey and identified the CAH admitted the patient to acute care 09/10/13 and transferred to swing bed on 09/16/13. Diagnoses included weakness with acute exacerbation of congestive heart failure (CHF). The patient's arm bracelet and medical record identified an allergy to penicillin. The "Mini Nutritional Assessments," dated 09/11/13 and 09/17/13, identified Patient #3 had no known allergies.

Observation on 09/16/13 at 2:20 p.m. showed a nurse (#9) entered Patient #3's room with medications. The nurse (#9) asked the patient if he had any allergies. The patient stated yes and identified allergies to penicillin, sulfa, and oysters. The nurse (#9) observed the patient's arm bracelet and stated the bracelet only identified penicillin as an allergy. The nurse (#9) asked what kind of a reaction he had from sulfa. Patient #3 and his spouse both identified a rash as the reaction. Review of Patient #3's medical record on 09/17/13 and 09/18/13 indicated the CAH staff nurse failed to update the patient's allergies.

During an interview on 09/16/13 at 4:35 p.m., a dietician (#10) stated the CAH nursing staff notify the dietary department of patients' food allergies.

During an interview on 09/17/13 at 5:50 p.m., Patient #3 and his spouse stated the two times the patient tried oysters his throat swelled and he could not breath.

2. Based on record review and staff interview, the Critical Access Hospital (CAH) failed to monitor and document the effectiveness of medications given to patients on an as needed (prn) basis for 2 of 3 active patient (Patients #1 and #2) and 3 of 6 closed inpatient/swingbed patient (Patients #9, #10, and #11) records reviewed who received prn medications for pain/discomfort and anxiety. Failure to assess and document the patient's need for a prn medication and evaluate the patient's response to prn medications limited the nursing staff's ability to determine whether the medication achieved the desired effect or if the patient experienced any side effects or adverse reactions from the medication.

Findings include:

- Review of Patient #1's active medical record occurred on all days of survey and identified the CAH admitted the patient to acute care on 09/04/13. Diagnoses included chronic back pain and osteoporosis. Medication included a fentanyl transdermal patch (an opioid analgesic for moderate to severe chronic pain) 12.5 micrograms (mcg) every 72 hours, tramadol (an analgesic for moderate to moderately severe chronic pain) 50 milligrams (mg) at bedtime (HS) as needed (PRN), Tylenol 650 mg every 4 to 6 hours PRN, and clonazepam (an anticonvulsant administered for seizure activity, restless legs syndrome, or panic disorder) 0.5 mg at HS PRN.

Review of Patient #1's medication administration record (MAR) from 09/04/13 to 09/09/13 showed the following medications administered:
*09/04/13 at 11:15 p.m. - tramadol and clonazepam simultaneously. The MAR failed to identify the reason for administration and the patient's response to the medications.
*09/05/13 at 9:00 p.m. - tramadol and clonazepam administered simultaneously per patient request for sleep. The MAR failed to identify the patient's response to the medication.
*09/06/13 at 8:30 p.m. - tramadol and clonazepam simultaneously. The MAR failed to identify the reason for administration and the patient's response to the medications.
*09/09/13 at 5:00 a.m. - Tylenol. The MAR failed to identify the reason for administration and the patient's response to the medication.
*09/09/13 at 9:00 p.m. - tramadol and clonazepam administered simultaneously for sleep. The MAR failed to identify the patient's response to the medications.

- Review of Patient #2's active medical record occurred on all days of survey and identified the CAH admitted the patient to swing bed on 09/02/13. Diagnoses included chronic back pain, spinal stenosis, and a history of back surgery. Medications included oxycodone IR (an immediate release opioid analgesic for moderate to severe pain) 7.5 mg every 4 hours PRN.

Review of Patient #2's MAR from 09/02/13 to 09/17/13 showed the CAH nursing staff failed to identify the reason for administering PRN Oxycodone IR and the patient's response to the medication on 12 occasions.

- Review of Patient #11's closed medical record occurred on 09/18/13 and identified a swing bed admission from 07/11/13 to 07/26/13. Diagnoses included chronic pain, end stage renal disease, blindness, diabetes mellitus, and mood disorder. Medications included Ativan (antianxiety) 1 to 2 mg three times a day (tid) PRN.

Review of Patient #11's MAR from 07/18/13 to 07/25/13 showed the CAH nursing staff administered PRN Ativan on 17 occasions and failed to identify the reason for administration and the patient's response to the medication.

During an interview on the afternoon on 09/18/13, an administrative nurse (#1) stated she expected nursing staff to document patients' responses to a PRN medications.


28086


- Review of Patient #9's closed medical record occurred on 09/17/13 and identified the CAH admitted the patient on 07/16/13 with a diagnosis of a post abdominal hysterectomy. The record indicated Patient #9 experienced symptoms of pain and itching throughout her hospital stay. Patient #9's record showed an order for morphine sulfate (used to treat pain) 2 milligrams (mg) intravenous (IV) every three hours prn, Ultracet (used to treat pain) one tablet orally every three hours prn, and diphenhydramine (used to treat itching) 25 mg orally or IV every six hours prn.

Review of Patient #9's Medication Administration Record (MAR) identified the following administration times for the prn medications:
*07/17/13: received diphenhydramine orally at 6:15 a.m. and 10:00 p.m., and IV at 11:52 a.m..
*07/18/13: received oral diphenhydramine at 8:40 a.m.; Ultracet at 12:30 p.m., 4:00 p.m., and 9:00 p.m.; and morphine at 10:50 p.m.
*07/19/13: received morphine at 5:00 a.m.; and Ultracet at 3:00 a.m., 6:25 a.m., and 10:45 a.m.

Review of Patient #9's patient progress sheet for the 3:00 p.m. to 11:00 p.m. shift on 07/18/13; and the 11:00 p.m. to 7:00 a.m. and 7:00 a.m. to 3:00 p.m. shifts on 07/19/13, showed the patient identified a pain rating of 5-6 on a scale from 0-10 (10 indicated the worst pain). Nursing staff failed to document the patient's response to the prn medications on the MAR or patient progress sheets for the above medication administrations. Patient #9's record lacked evidence nursing staff monitored and evaluated the effectiveness of prn medications administered to the patient.

- Review of Patient #10's closed medical record occurred on 09/18/13 and identified the CAH admitted the patient on 09/02/13 with a diagnosis of a post femur fracture of the right hip. The record indicated Patient #10 experienced symptoms of discomfort throughout her hospital stay. Patient #10's record showed an order for Tylenol (used to treat mild pain) 500 mg two tablets every six hours prn.

Review of Patient #10's MAR identified staff administered Tylenol at the following times:
*09/02/13 at 8:30 p.m.
*09/03/13 at 6:15 p.m.
*09/04/13 at 7:30 a.m., 12:20 p.m., and 9:40 p.m.

Nursing staff failed to document the patient's response to the prn Tylenol on the MAR or patient progress sheet for the above medication administrations. Patient #10's record lacked evidence nursing staff monitored and evaluated the effectiveness of prn medications administered to the patient.

During an interview on 09/18/13 at 2:00 p.m., an administrative nurse (#1) confirmed the process for assessing and documenting prn medication responses as inconsistent. The nurse (#1) stated she expected nursing staff to assess the effectiveness of prn medications within an hour of administration and document the patient's response on the patient progress sheet.

22495

Based on review of professional literature, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure nursing staff read back and verified verbal and/or telephone orders received from the patient's provider for 3 of 4 active patient (Patients #1, #2, and #4) and 7 of 14 closed patient (Patients #6, #7, #8, #9, #11, #12, and#13) records reviewed. Failure of nursing staff to repeat and verify verbal or telephone orders to ensure accuracy may result in medication and/or treatment errors.

Findings include:

Berman and Snyder, "Kozier and Erb's Fundamentals of Nursing, Concepts, Process, and Practice," ninth edition, Pearson Education Inc., Upper Saddle River, New Jersey, 2012, page 269, stated, ". . . Telephone Orders: Primary care providers often order a therapy (e.g. [for example], a medication) for a client by telephone. . . . While the primary care provider gives the order, write the complete order down on the physician's order form and read it back to the primary care provider to ensure accuracy. . . . Have the primary care provider verbally acknowledge the read-back of the verbal/telephone order. Then indicate on the physician's order form that it is a verbal order (VO) or telephone order (TO). . . ."

- Review of Patient #1, #2, and #4's active medical records occurred on September 16-18, 2013. The record showed nursing staff received verbal and telephone orders from patients' providers throughout their hospital stay. The nursing staff did not specify whether they read back and verified the verbal and telephone orders.

- Review of Patient #6, #7, #8, #9, #11, #12, and #13's closed medical records occurred on September 16-18, 2013. The records showed nursing staff received verbal and telephone orders from the patients' providers throughout their hospital stays. The nursing staff did not specify whether they read back and verified the verbal and telephone orders. The nursing staff did not identify several orders as a verbal or telephone order.

During an interview on 09/18/13 at 2:00 p.m., an administrative nurse (#1) stated nursing staff must specify orders received from the patient's provider as verbal or telephone and must perform the "read back and verified" process to ensure accuracy of the order. The nurse (#1) stated nursing staff must document this process within the patient's medical record.

Based on review of patient care event reports, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure complete medical records with accurate documentation of care for 3 of 3 closed patient (Patients #7, #8, and #14) records reviewed with patient care incidents. Failure to accurately document patient care limited the CAH's ability to investigate incidents and perform quality monitoring.

Findings include:

Review of Patient Care Event Reports (the CAH's incident reporting system) and closed medical records occurred on September 16-18, 2013 and showed the following:

*03/20/13 at 9:00 a.m. - ". . . Description of the Event: Pt [patient] extubated during tonsillectomy procedure. . . . Patient Name: [Patient #14] . . . Immediate Actions Taken: Re-intubated by anesthesia after noted by surgeon and staff, but still cyanotic. Pt bagged to restore [oxygen] sats and successfully reintubated. . . ."

- Patient #14's medical record identified the CAH admitted the patient on 03/20/13 for a T&A procedure. The anesthesia record identified the patient's vital signs within normal limits and indicated the surgical case as uneventful, other than documentation on the record which stated,
". . . [8:50 a.m.] Surgeon extubated Pt. reintubated, [bilateral breath sounds] . . ." Review of the operating room nurse's notes and the operative report identified the surgical case as uneventful. Patient #14's record failed to match the above incident report and identify concerns with the patient's care.

*03/22/13 at 3:30 a.m. - ". . . Description of the Event: Pt is on telemetry and the monitor leads off. Went in to replace leads and leads and telemetry unit were not on the patient. . . . Patient Name: [Patient #7] . . . Immediate Actions Taken: . . . placed telemetry unit on [initials of Patient #7]. New [3:00 a.m.] strips run and placed in chart. . . ."

- Patient #7's medical record identified the CAH admitted the patient on 03/21/13 with diagnoses including questionable congestive heart failure and tachycardia. An electrocardiograph report, dated 03/21/13 at 12:54 p.m., identified an abnormal test and stated, "Wide QRS [series of deflections in an electrocardiogram] tachycardia and left bundle branch block." The patient's admission orders identified placement of telemetry. Patient #7's record failed to include documentation related to the above incident report.

*06/01/13 at 8:00 a.m. - ". . . Description of the Event: patient received wrong tray. . . . Patient Name: [Patient #8] . . ."

- Patient #8's medical record identified the CAH admitted the patient on 06/01/13 with diagnoses including abdominal pain. Patient #8's record failed to include documentation related to the above incident report.

During an interview on 09/18/13 at 2:00 p.m., an administrative nurse (#1) stated staff must document all incidents of patient care in the medical record and confirmed the above patient records lacked documentation of their incidents.

Based on review of medical staff rules and regulations, review of professional literature, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the medical record included documentation of informed consent and written discharge instructions including post-operative medications for 2 of 4 closed surgical patient (Patients #12 and #13) records reviewed. Failure to ensure informed consent limited the patient's ability to make an informed decision regarding the surgical procedure. Failure to ensure patients received written discharge instructions including post-operative medications has the potential to place the patient at risk of improper care.

Findings include:

Review of the CAH's Medical Staff Rules And Regulations occurred on 09/16/13. This document, adopted on 09/21/11, stated, ". . . 2. MEDICAL RECORDS . . . 2.4 DOCUMENTATION OF SURGICAL/INVASIVE PROCEDURES 2.4.1 Informed consent for any procedure shall be obtained and documented by the Medical Provider before the procedure, and before administration of pre-anesthetic/anesthetic agents. Informed consent shall include risks and benefits and any alternatives to the planned procedure. . . ."

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, pages 127 and 257, stated,
". . . Essential information before discharge includes information about medications . . . Information needs to be provided verbally and in writing. . . . If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications . . . should be written in layman's terms, and use of medical abbreviations (such as t.i.d.) should be avoided.
. . ."

- Review of Patient #12's closed medical record occurred on 09/17/13 and identified the CAH admitted the patient on 09/04/13 for a rotator cuff repair. The record listed Patient #12's current medications as levothyroxine (used to treat the thyroid) 175 micrograms (mcg) daily. Review of post-operative documentation showed Patient #12 received intravenous (IV) Zofran (used to treat nausea) and intramuscular (IM) Tordal (an anti-inflammatory used to treat pain) at 12:45 p.m. A photocopy of post-operative medication prescriptions included in the record identified Tordal 10 milligram (mg) tablets one every six hours until gone, vistaril (used to treat pain or nausea) 50 mg tablets one every four to six hours as needed (prn), and hydrocodone (used to treat pain) 5/325 mg one to two tablets every three to four hours prn.

Review of Patient #12's record showed post-operative orders and discharge instructions included on the same form signed by the patient's physician. The form included treatment orders intended for nursing staff and instructions for the patient to follow upon discharge. The medication section of the form listed, ". . . Hydrocodone 5/325 mg [medical abbreviation for one] to [medical abbreviation for two] p.o. [by mouth] q [every] 2-3 hrs [hours] PRN . . ."

The CAH failed to provide discharge instructions written in terms the patient could understand. Patient #12's discharge instructions failed to indicate whether the patient should resume previous medications taken at home (levothyroxine), include the newly prescribed medications Tordal and Vistaril, and specify the last time of medication administration (Tordal).

- Review of Patient #13's closed medical record occurred on 09/17/13 and identified the CAH admitted the patient on 04/17/13 for a colonoscopy. The record lacked evidence Patient #13's medical provider obtained and documented informed consent or discussion of the risks, benefits, and alternatives to the procedure with the patient.

The record listed Patient #13's current medications as Synthroid (used to treat the thyroid) 100 mcg daily, Lipitor (used to treat high cholesterol) 20 mg daily, Premarin (used to treat menopause) 0.625 mg daily, aspirin 81 mg daily, calcium daily, vitamin D daily, multivitamin daily, and Ibuprofen 200 mg six to eight tablets as needed daily. Review of Patient #13's discharge instructions failed to indicate whether the patient should resume these medications at home. The discharge instructions stated, ". . . see post anesthesia discharge instructions . . . see discharge instructions sheet . . ." Patient #13's record failed to include a copy of the specified patient instructions.

During an interview on 09/18/13 at 2:00 p.m., an administrative nurse (#1) stated medical providers performing surgical procedures must document informed consent in the medical record prior to the procedure and confirmed Patient #13's record lacked a copy of the documentation. The administrative nurse (#1) stated nursing staff must document post-operative medications on the patient's discharge instructions in terms the patient could understand and provide instruction on whether to resume medications previously taken. The administrative nurse (#1) confirmed Patient #13's record lacked a copy of the discharge instructions.

Based on review of medical staff rules and regulations, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure all patients received a medical history and physical assessment (H&P) prior to and within 30 days of the procedure for 1 of 4 closed surgical patient (Patient #13) records reviewed. Failure to complete an H&P prior to the planned procedure has the potential to place the patient at risk if there is anything in the patient's overall condition that would affect the procedure.

Findings include:

Review of the CAH's Medical Staff Rules And Regulations occurred on 09/16/13. This document, adopted on 09/21/11, stated, ". . . 2. MEDICAL RECORDS . . . 2.4 DOCUMENTATION OF SURGICAL/INVASIVE PROCEDURES . . . 2.4.3 The Medical Record shall document a current pertinent physical examination prior to the performance of a procedure. . . . All ambulatory procedures . . . performed in the operating suite require a complete . . . H&P prior to the procedure. This requirement is met if: 1. The H&P was performed within 30 days prior to the surgery . . . 2.4.3.1 Ambulatory procedures not performed in the operating suite . . . require a brief H&P consisting of the following . . . examination of heart, lungs . . ."

Review of Patient #13's closed medical record occurred on 09/17/13 and identified the CAH admitted the patient on 04/17/13 for a colonoscopy. The record identified an H&P completed on 03/13/13. Review of the H&P lacked evidence of a heart and lung assessment and identified the examination occurred 35 days prior to the scheduled procedure. The record lacked evidence of a complete H&P performed within 30 days of Patient #13's procedure.

During an interview on 09/18/13 at 2:00 p.m., an administrative nurse (#1) stated all surgical patients required a complete H&P including a heart and lung assessment within 30 days of their procedure and confirmed the lack of a current H&P in Patient #13's medical record.

Based on review of medical staff rules and regulations, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure all medical records contained provider orders, including the date and time of the order and the signature of the person authorizing the order, for 1 of 2 active inpatient (Patient #4) and 4 of 10 closed patient (Patients #6, #7, #10, and #13) records reviewed. Failure to ensure dated, timed, and signed provider orders limited the CAH's ability to verify accurate treatment necessary for patient safety and quality of care.

Findings include:

Review of the CAH's Medical Staff Rules And Regulations occurred on 09/16/13. This document, adopted on 09/21/11, stated, ". . . 2. MEDICAL RECORDS . . . 2.3 CONTENTS OF THE MEDICAL RECORD . . . 2.3.3 Clinical Entries . . . All clinical entries in the chart shall be accurately timed, dated, and signed. . . . 2.3.6 All orders for treatment shall be written, dated, and signed by the Medical Provider responsible for them. . . ."

- Review of Patient #4's active medical record occurred on 09/17/13 and showed the following provider orders:
*Adult Standing Orders (written orders regarding patient care which authorizes the nurse to carry out specific actions under certain circumstances when a provider is not immediately available) - lacked the date, time, and signature of Patient #4's provider.
*09/16/13: "Discharge . . . today. [Right] knee injection before discharge [with] DepoMedrol [an anti-inflammatory] 40 mg [milligrams] [and] Marcaine [a local anesthetic] 0.5%." - lacked the time and signature of the person authorizing the order.

- Review of Patient #6's closed medical record occurred on 09/18/13 and showed the following provider orders:
*Pneumonia Admission Orders - lacked the time.
*Pneumonia Antibiotic Orders and Adult Standing Orders - lacked the date, time, and signature of the provider.

- Review of Patient #7's closed medical record occurred on 09/18/13 and showed the following provider orders:
*Adult Standing Orders, Telemetry Protocol Orders, Insulin Orders, and Congestive Heart Failure (CHF) Orders - lacked the date and time of the order.
*Deep Vein Thrombosis (DVT) Prophylaxis Orders - lacked the time of the order.

- Review of Patient #10's closed medical record occurred on 09/18/13 and showed the following provider orders:
*Adult Standing Orders and DVT Prophylaxis Orders - lacked the date, time, and signature of the provider.

- Review of Patient #13's closed medical record occurred on 09/17/13 and showed the following provider orders:
*Pre-Operative Orders - lacked the date and time of the order.

During an interview on 09/18/13 at 2:00 p.m., an administrative nurse (#1) stated orders for treatment must include the date, time, and signature of the person ordering the treatment.

Based on policy review, minutes review, and staff interview, the Critical Access Hospital (CAH) failed to annually review their health care policies as part of the annual program evaluation for 1 of 1 year reviewed (July 2011 - June 2012). Failure to annually review their policies limits the CAH's ability to ensure staff members follow the CAH's policies.

Findings include:

Review of the policy "Critical Access Periodic Evaluation" occurred on 09/17/13. This policy, written 05/03/01, stated, "Policy: On an annual basis, Oakes Community Hospital (Hospital) will review information related to services provided by the Hospital during the previous twelve months. . . . Procedure: . . . 3. The following policy and procedure manuals will be reviewed by the Policy Review Committee. General Facility, Business Office/Health Information Management, Dietary, Laboratory, Radiology, Nursing/Critical Care, Emergency Department, Infection Control, Pharmacy, OR [operating room]/CS [central supply]/Anesthesia, Environmental Services, Performance Improvement, Swing Bed, Safety/Risk Management, Material Management, Social Services."

Review of the Oakes Community Hospital Annual Critical Access Program Review Minutes occurred on 09/17/13. These minutes, dated 05/10/13, lacked evidence of annual policy review during fiscal year 2012 (July 2011 - June 2012).

Review of the Oakes Community Hospital Policy Committee Minutes occurred on 09/17/13. These minutes, dated 05/10/13, lacked evidence of annual policy review.

During an interview at 11:45 a.m. on 09/18/13, an administrative staff member (#3) confirmed the CAH had not reviewed their policies during fiscal year 2012.