HospitalInspections.org

Based on review of policies/procedures, meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure all patient care policies were approved by the Governing Board annually, in accordance with facility policy prior to . There were 22 of 25 patient care departments (Anesthesia, Surgery, Emergency Room, Pharmacy, Laboratory, Behavioral Health, Skilled Care, Radiology, Computed Tomography (CT), Dexa scan, Ultrasound, Mammography, Dietary, Nursing Services, Obstetrics, Sleep Study, Maintenance, Health Information Management, Patient Registration, Quality, Environmental Services, and Infection Control, as well as 10 of 13 contracted services (Infusion/Chemotherapy, Magnetic Resonance Imaging (MRI), Nuclear Medicine, Echocardiogram, Pain Clinic, Physical Therapy, Speech Therapy, Occupational Therapy, and Respiratory Therapy). The CAH administrative staff identified a census of 5 patients at the beginning of the survey. Failure to ensure all patient care policies were approved by the Governing Board annually, prior to the policies becoming in effect could potentially result in the CAH's staff inappropriately acting on or enforcing a policy that may not address patient care needs or cause patient harm.

Findings include:

1. Review of the CAH policy, "Policy and Procedure Development, Revisions, Approval and Retention," approved 5/11/22, revealed in part, " ...Policy owner (typically the department leader) begins revision/creation process and submits for approval electronically which will begin the approval workflow." " ...Workflow consists of the department leader, senior leader, CAH representatives."
" ...Upon the completion of all approvals, the policy will become active and the previous version will automatically be archived..."

2. The CAH's policy does not include the Governing Board's approval prior to the implementation of the review/revised or created policies. The policy reveals in part, " Critical Access Hospital Committee, Medical Staff, Board of Trustees Approval ...a report of departmental policies and revisions, creations and retired policies will be printed and brought before the above mentioned committees for review and discussion.

3. During an interview on 10/11/2022 at 3:10 PM, with the Quality Data Specialist and the Director of Organizational Excellence revealed they have been activating all policies that had been reviewed and approved by department leaders, senior leaders, and CAH representatives. They further acknowledged the CAH's policy does not include the Board of Trustees as part of the workflow for final approval prior to the policies becoming active.

Based on document review, medical record review and staff interview, the Critical Access Hospital (CAH) staff failed to ensure physician notification of a medication error was documented in a patient's medical record for 4 of 12 medication errors reviewed. (Patient #5, Patient #6, Patient #7, and Patient #8). Failure to notify and document physician of medication errors, in the medical record, could potentially result in a practitioner not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the practitioner making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff identified a census of 5 patients at the beginning of the survey.

Findings include:

1. Review of the CAH policy, "Medication Error Report," approved 2/4/22, revealed in part, "... Medication errors that reach the patient and cause harm and errors that reach the patient and do not cause harm and reported to the physician as well as the patient".

2. Review of medication errors from October 2021 to October 2022 revealed the following:

a. The nursing staff made a medication error (wrong route) on 4/05/22 at 11:24 AM which involved Patient #5. Patient #5's medical record lacked documentation to show the nursing staff notified the practitioner responsible for Patient #5's medical care of the medication error.

b. The nursing staff made a medication error (wrong dosage) on 4/18/22 at 9:52 PM which involved Patient #6. Patient #6's medical record lacked documentation to show the nursing staff notified the practitioner responsible for Patient #6's medical care of the medication error.

c. The nursing staff made a medication error (wrong dosage) on 4/18/22 at 9:25 PM which involved Patient #7. Patient #7's medical record lacked documentation to show the nursing staff notified the practitioner responsible for Patient #7's medical care of the medication error.

d. The nursing staff made medication errors (not administered) on 7/4/22 at 9:00 PM which involved Patient #8. Patient #8's medical record lacked documentation that the nursing staff notified the practitioner responsible for Patient #8's medical care of the medication error.

3. During an interview on 10/13/22, at 10:10 AM, the Senior Director of Nursing acknowledged she could not find anywhere in the patient's charts that the practitioners were notified and the medication error reports does have a spot to write when the practitioner was notified but was not filled out.

4. During an interview on 10/13/22, at 10:10 AM, the Director of Organizational Excellence acknowledged the CAH policy requires nursing staff to document medication error notification to the practitioner responsible for a patient's care, in the patient's medical record. The Director of Organizational Excellence confirmed the medical records of Patient #5, Patient #6, Patient #7, and Patient #8 lacked documentation of medication error notification to the practitioner responsible for the patient's care.

Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure physicians ordered specialized rehabilitation services for 1 of 1 open swing bed patients (Patient #1), and 3 of 4 closed swing bed patients (Patient #2, Patient #3, and Patient #4). Failure to ensure a physician ordered specialized rehabilitation services could result in swing bed patients not receiving specialized rehab services appropriate to their medical condition. The CAH administrative staff identified 59 swing bed patient admissions in fiscal year 2022 and a census of 1 swing bed patient on entrance.

Findings included:

1. Review of Patient #1's open medical record revealed the CAH staff admitted Patient #1 for swing bed level care on 10/6/2022, diagnosis: weakness secondary to urinary tract infection and significant peripheral neuropathy. Advanced Registered Nurse Practitioner A (ARNP, a nurse with advanced training) wrote orders on 10/6/2022 at 09:11 AM for the Physical Therapist to evaluate and treat Patient #1 and for the Occupational Therapist to evaluate and treat Patient #1. The Physical Therapist evaluated Patient #1 on 10/6/2022 at 9:45 AM. The Occupational Therapist evaluated Patient #1 on 10/6/22 at 1:45 PM.

2. Review of Patient #2's closed medical record revealed the CAH staff admitted Patient #2 for swing bed level care on 08/08/2022, diagnosis status post right total knee arthroscopy. The CAH staff discharged Patient #2 on 08/23/2022. ARNP B wrote orders on 08/08/2022 at 11:37 AM for the Physical Therapist and the Occupational Therapist to evaluate and treat Patient #2 for weakness secondary to condition. The Physical Therapist evaluated Patient #2 on 8/9/2022 at 3:20 PM. The Occupational Therapist evaluated Patient #2 on 9/9/2022 at 2:23 PM.

3. Review of Patient #3's closed medical record revealed the CAH staff admitted Patient #3 for swing bed level care on 06/23/2022, diagnosis: physical deconditioning status post ascending aortic aneurysm repair. The CAH staff discharged Patient #3 on 07/10/2022. ARNP A wrote orders on 06/23/2022 at 2:31 PM for the Physical Therapist and the Occupational Therapist to evaluate and treat Patient #3. The Physical Therapy Evaluation was completed on 6/23/2022 at 4:41 PM and the Occupational Therapist evaluation was completed Patient # 3 on 6/24/2022 at 1:01 PM. ARNP A ordered Respiratory Therapy to assess and treat Patient #3 on 6/23/2022 at 2:23 PM. The Respiratory Therapy evaluation was completed on 6/23/2022 at 2:23 PM.

4. Review of Patient #4's closed medical record revealed the CAH staff admitted Patient #4 for swing bed level care on 08/17/2022, diagnosis: central cord syndrome following a traumatic cervical spine injury. The CAH staff discharged Patient #4 on 08/27/2022. ARNP A wrote orders on 8/17/22 at 2:27 PM for the Occupational Therapist to evaluate and treat Patient #4, at 3:32 PM for the Physical Therapist to evaluate and treat Patient #4., and at 10:53 PM for the Respiratory Therapist to evaluate and treat Patient #4. The Physical Therapy Evaluation was completed on 8/18/2022 at 07:45 AM. The Respiratory Therapy Evaluation was completed on 8/18/2022 at 8:19 AM. The Occupational Therapy Evaluation was completed on 8/18/2022 at 2:11 PM.

5. During an interview on 10/12/2022, at the time of the record review, the Compliance Officer acknowledged that ARNP's A and B wrote the therapy orders for Patient #1, Patient #2, Patient #3, and Patient #4 when the patients received swing bed services. The Compliance Officer acknowledged a physician did not write the therapy orders for Patient #1, Patient #2, Patient #3, and Patient #4. The Compliance Officer acknowledged the CAH was not aware a physician must write the order for specialized rehabilitation services.

6. During an interview on 10/12/2022 at 3:10 PM, ARNP A verbalized ARNP A was not aware of the requirement of physicians, both MD and DO, to order specialized rehabilitation therapies for swing bed patients and acknowledged that the facilities ARNP hospitalists order the specialized therapies for the CAH swing bed patients. ARNP A verbalized the CAH does not have a policy identifying which providers may order specialized rehabilitation services for swing bed patients.