HospitalInspections.org

Based on observation and interview, the CAH failed to ensure the physical environment was maintained for the safety of the patients. This deficient practice is evidenced by:
1) failing to ensure the behavioral health unit did not contain safety risks for the psychiatric patients; and
2) failing to ensure call bells located on hospital bed rails were functional for 15 of 15 hospital beds in use.

Findings:

1) Failing to ensure the behavioral health unit did not contain safety risks for the psychiatric patients.

Observations of the behavioral health unit on 8/7/17 at 2:00 p.m. revealed the following safety risks:
a) garbage can liners in the trash cans located in the hall had plastic liners which could pose a risk for suffocation.
b) mirrors in patient rooms were made of breakable glass.
c) round light covers located on the ceiling of patients' bathrooms were able to be pulled from the ceiling which would provide access to screws, light bulbs and electrical wiring.
d) fluorescent light covers in the patients' rooms were not secured allowing access to the bulbs.
e) screws located in an electrical outlet in room 20 did not have safety screws.
f) air conditioning vents in patients' rooms had grates with spaces large enough to present a ligature risk.
g) screws in bathroom door hardware in patients' rooms were not all of the safety type.
h) air return vents in patients' rooms were able to be opened allowing for ligature risks or areas to conceal contraband.
i) patients' shower room had an air conditioning vent with grates with spaces large enough to present a ligature risk.
j) patients' shower room had a handle on a door that was not secured tightly allowing a gap between it and the door that presented a ligature risk.
k) hand rails in the patient hallways were 2 ¼ inches from the wall presenting a ligature risk.
l) temperature thermostat covers portruded from the wall far enough to present an injury risk and the square shaped metal covers were easily removed, presenting an item that could be used for self injury or as a weapon.
m) 3 hinges on the bathroom doors in all patient rooms were separated widely enough to presnet ligature risk. The top hinge also protruded enough to provide a ptential ligature point.
o) all mattresses had zippered covers that were not secured to prevent potential risk for suffocation and for hiding contraband.
p) patient hallway in an area where patients were allowed to walk, unsupervised, potentially out of sight of staff had a large "V" shaped hinge that could provide a potential ligature anchor point. This area also had a door handle that was opened and could also provide a potential ligature anchor point. These findings were confirmed with S13RN during the observation. She also confirmed the patients were allowed to walk, unsupervised, potenitally out of sight of staff in the above referenced hallway.

In an interview on 8/7/17 at 2:30 p.m. with S13RN, she verified the above listed safety risks in the psychiatric unit.

2) Failing to ensure call bells located on hospital bed rails were functional.

In an observation on 8/7/17 at 1:55 p.m. of patient room #8, the bed rail had a button with a red silhouette image of a nurse indicated it could be pushed to call for a nurse. When the button was pushed, it did not activate any feature to notify staff the patient needed assistance.

In an interview on 8/7/17 at 1:56 p.m. with S2DON, she verified the button with an image of a nurse on the side rail of the beds was a call button to summon the nursing staff in an emergency or if the patient needed assistance. S2DON also verified the button on the bedrail was not functional. She said the hospital had 15 hospital beds and none of the call buttons on the side rails worked She said there was also a call bell connected to the wall, but could not guarantee that a confused patient or a visitor would not mistakenly press the button on the side rail in an emergency thinking it was functional.



30984

30984


Based on credentialing file review, medical staff bylaw review and interview, the CAH failed to ensure the governing body privileged medical staff members as part of the reappointment process, according to the Medical Staff Bylaws, for 3 (S7MD, S8MD, S9MD) of 3 physicians' credentialing files reviewed.

Findings:

Review of the CAH's Medical Staff Bylaws revealed in part: Section3. Terms of Appointment: 1. Appointments shall be made by the Medical Staff with final approval made by the Governing Body of the Hospital and shall be made for the period of two years. Re-appointments may be made following the two year period upon recommendation of the Medical Staff and Approval of the governing Board of the hospital. 2 ..... 3. Appointment to the Medical Staff shall confer on the appointee only such privileges as may hereinafter be provided.

S7MD
Review of S7MD's credentialing file revealed he was reappointed to the medical staff on 7/27/16 for a period of 2 years. Further review revealed no current documentation of delineation of privileges.

S8MD
Review of S8MD's credentialing file revealed he was reappointed to the medical staff on 2/3/17 for a period of 2 years. Further review revealed no current documentation of delineation of privileges.

S9MD
Review of S9MD's credentialing file revealed he was reappointed to the medical staff on 4/27/16 for a period of 2 years. Further review revealed no current documentation of delineation of privileges.

In an interview on 8/10/17 at 10:40 a.m. with S12MedRecords, she said her department was responsible for reappointments. She said a request for clinical privileges should have been submitted with their application for reappointment and the privileges should have been approved by the medical staff and the board. She verified the 3 above mentioned physicians did not get mailed the form to request privileges when they had been mailed their application packet. She verified they did not have delineated privileges for their most recent appointments to the medical staff.

Based on record review and interview, the CAH failed to ensure there was a system in place for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel. This deficient practice was evidenced by:
1) failure of the CAH to maintain a sanitary environment; and
2) failure of the CAH to maintain documentation of a log for disinfection of the washing machine between patient loads of laundry on the Behavioral Health Unit.

Findings:

1) Failure of the CAH to maintain a sanitary environment.

On 7/7/17 at 1:55 p.m. - 2:45 p.m. an observation was conducted of the hospital. The following infection control breaches were observed:

Inpatient Unit:
Linens stored in the linen room uncovered.
Patient bedside commodes and patient lifts stored in the patient shower room which also housed a toilet.
The above referenced findings were confirmed, during the observation on 8/7/17 at 1:55 p.m. with S2DON.

Behavioral Health Unit:
Group Room:
8 chairs in the patient group room noted to be in disrepair, coverings on the arms and seats of the chairs with rips and tears making them difficult to disinfect due to being non-intact.

MHT Room:
Ice scoop was noted to be housed in the container where ice used for patient consumption was stored.
A patient food tray was observed on the counter in the MHT room which also housed patient supplies and paper goods.
8 - 3 liter opened, partially consumed soft drinks, unlabeled with date and time of opening, were noted on the counter in the MHT desk area.
2 box fans observed on the floor, coated with a layer of gray, dust-like residue
Clean supply of patient towels were observed stacked on top of a patient bedside table, uncovered and unprotected from potential contamination with dust and/or dirt.
Refrigerator temperature log was missing entries for 8/5/17-8/7/17.
The above referenced findings were confirmed during the observation on 8/7/17 at 2:35 p.m. with S13RN.


2) Failure to maintain documentation of a log for cleaning of the washing machine between patient loads of laundry.

Review of the Behavioral Health Unit Washing Machine Log revealed the following instructions for disinfection of the washing machine following each patient wash load: A cycle of hot water and 1 cup of bleach is run per staff following each patient wash load.

Review of the Behavioral Health Unit washing machine logs from 12/2016 -7/2017 revealed the following:
12/2016 entries documenting disinfection of the washing machine were documented for the following dates: 12/6/16, 12/13/16, 12/14/16, 12/16/16, 12/17/16, 12/22/16, 12/24/16, 12/25/16;
1/2017 entries documenting disinfection of the washing machine were documented for the following dates: 1/3/17, 1/4/17, 1/5/17, 1/10/17, 1/12/17, 1/13/17, 1/14/17, 1/25/17
2/2017: entries documenting disinfection of the washing machine were documented for the following dates: 2/8/17
3/2017: no entries
4/2017: 4/20/17, 4/25/17
5/2017: no entries
6/2017: 6/5/17, 6/6/17, 6/7/17
7/2017: 7/30/17
8/2017: no entries
The above referenced findings were confirmed during the observation on 8/7/17 at 2:45 p.m. with S13RN.

Based on record review and interview, the CAH failed to ensure the RN assigned nursing care duties to appropriate personnel (licensed practical nurse, nursing assistant, nurse's aide, surgical technician) with the qualifications and competence to perform the assigned tasks. This deficient practice was evidenced by failure of the CAH to ensure competency evaluations were performed for 2 (S4SurgeryTech/ActDir, S5RN) of 2 hospital personnel reviewed for assisting in diagnostic procedures.

Findings:

S4SurgeryTech/ActDir
Review of S4SurgeryTech/ActDir revealed no documented evidence of surgical tech skills competencies since 2010.

In an interview on 8/7/17 at 2:40 p.m. with S2DON, she confirmed S4SurgeryTech/ActDir was the hospital staff member responsible for decontamination, sterilization, and packaging of instruments and equipment used in the hospital's procedures.

In an interview on 8/9/17 at 2:30 p.m. with S4SurgeryTech/ActDir she confirmed she was a surgical case tech and was responsible for decontamination, sterilization, and packaging of instruments and equipment used in the hospital's procedures.

In an interview on 8/10/17 at 12:30 p.m. with S3ADON (ICO), she confirmed S4SurgeryTech/ActDir had no documented case tech skills competencies since 2010. S2ADON (ICO) indicated S5RN was the hospital staff member responsible for assessing S4SurgeryTech/ActDir's surgical case tech skills competencies. S3ADON (ICO) reported she had verified, with S5RN, that there were no case tech skills competencies for S4SurgeryTech/ActDir since 2010.


S5RN

Review of the Louisiana State Board of Nursing, "Declaratory Statement on the Role and Scope of Practice of the Registered Nurse in the Administration of Medication and Monitoring of Patients During the Levels of Procedural Sedation (Minimal, Moderate, Deep, and Anesthesia) as Defined Herein" revealed in part the following: Position Statement, March 17, 2004.....The Registered nurse (non-CRNA) (Certified Registered Nurse Anesthetist) shall have documented education and competency to include: A. Knowledge of sedative drugs and reversal agents, their dosing and physiologic effects. Advanced Cardiac Life Support....Skill in establishing an open airway, head-tilt, chin lift, use of bag-valve-mask device, oral and nasal airways, and emergency procedures. This includes rescuing a patient that may progress beyond deep sedation. Demonstration of the acquired knowledge of anatomy, physiology, pharmacology, and basic cardiac arrhythmia recognition; recognize complications of undesired outcomes related to sedation/analgesia; demonstrated appropriate interventions in compliance with standards of practice, emergency protocols, or guidelines....
B. Competencies will be measured initially during orientation and on an annual basis....


Review of the hospital policy titled Conscious Sedation by the Registered Nurse revealed in part:
B. Competencies will be measured initially during orientation and on an annual basis.

Review of the personnel folder for S5RN revealed her last annual competency for the administration of conscious sedation was dated 3/31/15.

In an interview on 8/9/17 at 3:30 p.m. with S5RN, she confirmed she assisted with procedures requiring Conscious Sedation. S5RN indicated the physician would initiate the patient's Conscious Sedation, attain the desired level of sedation and would periodically instruct her to "push 1 mg or 2mg of Propofol" during the procedure.

In an interview on 8/10/17 at 11:15 a.m. with S2DON, she verified Conscious Sedation annual competencies should have been done annually. She also verified S5RN administered conscious sedation to patients receiving procedures at the hospital.

30984


Based on record review and interview, a registered nurse failed to supervise and evaluate the care of each patient as evidenced by:
1) failing to document safety observations of patients every 15 minutes as ordered for 5 (#8, #9, #10, #11, #12) of 5 current psychiatric patients on census; and
2) failing to ensure the registered nurse that delegated patient care to a LPN documented an assessment of a patient with a worsening change in condition for 2 (#14, #18) of 2 patient transfers reviewed.

Findings

1) Failing to document safety observations of patients every 15 minutes as ordered.

Review of the hospital policy titled Levels of Patient Observation revealed in part:
A) 1. All patients are monitored a minimum of once every 15 minutes.

Review on 8/7/17 at 2:35 p.m. of the 15 Minute Checks Patient Observation sheets from the behavioral health unit dated 8/7/17 revealed the following:
Patient #8 did not have documented evidence of q 15 minute observations from 8:00 a.m. until 9:00 a.m., 9:30 a.m. until 10:00 a.m. and from 1:00 p.m. until 2:30 p.m. (3 hours 45 minutes total).
Patient #9 did not have documented evidence of q 15 minute observations from 2:00 p.m. until 2:30 p.m. (45 minutes total).
Patient #10 did not have documented evidence of q 15 minute observations from 8:00 a.m. until 8:45 a.m., 9:30 a.m. until 10:00 a.m. and from 1:15 p.m. until 2:30 p.m. (3 hours and 15 minutes total).
Patient #11 did not have documented evidence of q 15 minute observations from 8:00 a.m. until 8:45 a.m., 9:30 a.m. until 10:15 a.m. and from 11:45 p.m. until 2:30 p.m. (5 hours total).
Patient #12 did not have documented evidence of q 15 minute observations from 8:00 a.m. until 8:45 a.m., 9:30 a.m. until 10:00 a.m. and from 1:15 p.m. until 2:30 p.m. (3 hours and 15 minutes total).

In an interview on 8/7/17 at 2:40 p.m. with S14MHT, she said she had been responsible for documenting the q 15 minute observations on the patients in the behavioral health unit. She verified she should have been documenting every 15 minutes that she had observed the patients for safety. S14MHT said she had not documented on the patients since lunch because she had been busy.

In an interview on 8/7/17 at 2:45 p.m. with S13RN, she verified S14MHT should have been documenting on the psychiatric patients every 15 minutes but had not.

In an interview on 8/10/17 at 12:19 p.m. with S15RN, he verified it was the RN's responsibility to ensure the q 15 minute observation sheets had been completed by the MHTs..


2) Failing to ensure the registered nurse that delegated patient care to a LPN documented an assessment of a patient with a worsening change in condition.

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice Delegating Nursing Interventions revealed the RN retains the accountability for the total nursing care of the individual. The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Any situation where tasks are delegated should meet the following criteria: a) the person has been adequately trained for the task; b) the person has demonstrated that the task has been learned; c) the person can perform the task safely in the given nursing situation; d) the patient's status is safe for the person to carry out the task; e) appropriate supervision is available during the task implementation; f) the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. The RN may delegate to LPNs the major part of the nursing care needed by individuals in stable nursing situations, that is, when the following three conditions prevail at the same time in a given situation: a) nursing care ordered and directed by the RN or MD requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; b) change in the patient's clinical conditions is predictable; and c) medical and nursing orders are not subject to continuous change or complex modification.

Review of the CAH policy titled Job Description Charge Nurse revealed in part:
Job tasks:
2. Monitor, record and report signs, symptoms and changes in patient conditions.
4. Modify patient treatment plans as indicated by patient's responses and conditions.

Patient #14
Review of Patient #14's medical record revealed she had been admitted to the CAH on 3/8/17 at 5:20 p.m. and discharged on 3/15/17 at 6:00 p.m. to an acute care hospital for a possible stroke.

Review of Patient #14's medical record revealed the following entries by S11LPN:
4:00 p.m. - Entered pts room. Pt sleeping with mouth open repositioned and sweating. Checked cbg 154 b/p 147/87, p- 73 O2% 97, called S9MD. Awaiting call back.
4:34 p.m. - Patient not responding, eyes fixed, tried Ammonia, did not respond. B/P 160/87 O2 98%, cbg 137, placed on cardiac monitor. HR and pulses and rhythm within normal limits.
4:50 p.m. - S9MD called back, CT of head without contrast ordered stat and placed on stretcher, will continue to monitor b/p 181, pulse 60, respirations O2% 98. Respirations 12 unlabored.
5:02 p.m. - S9MD visits, at bedside speaking with family, called Hospital "A" ER to transfer. Documentation noted and sent with pt.
5:59 p.m. - Air med arrives to transfer patient.

Further review revealed no documentation of RN involvement in patient care after 4:00 p.m. or an assessment by the RN.

In an interview on 8/8/17 at 2:00 p.m. with S2DON, she verified a RN did not document an assessment in Patient #14's medical record when she had a change in condition and had to be sent to another hospital.


Patient #18
Review of Patient #18's medical record revealed the patient was admitted on 6/2/17. Further review revealed the patient was transferred out of the hospital as an "acute out" transfer to a higher level of care due to symptoms of worsening shortness of breath, anemia, and acute/chronic kidney disease on 6/9/17 at 2:26 p.m.

Further review of Patient #18's medical record revealed the following nursing note "q 2 hour rounding" entries:
6/9/17 2:26 p.m. pt. sitting in wheelchair watching tv, scheduled medication administered as ordered. C/O (complains of) "aching", pain "all over" rated at 6 on the pain scale. States," I just feel bad and weak". 7.5 mg of Norco administered by mouth. Tolerated well. No other needs voiced. Call button within reach. Attempting to notify FNP of patient's status.
6/9/17 3:43 p.m.: called to pt. room. "I feel weak and I feel like I'm smothering". Denies chest pain/pressure. Lungs sound diminished. Respiratory Department notified. Pt. placed on BiPAP at this time. FNP notified of pt. status and agreed to come to see pt.
6/9/17 4:12 p.m.: pt. lying in bed with HOB (elevated) 35 degrees. BiPAP in place.
6/9/17 5:01 p.m. new orders received from FNP to transfer pt. with dx of "worsening shortness of breath, anemia and acute/chronic kidney disease".
Further review revealed no documented evidence of a RN Assessment with the change in the patient's condition.

In an interview on 8/817 at 1:41 p.m. with S6LPN, he confirmed, after review of the patient's electronic medical record, that there was no documented evidence of an assessment by a RN with the patient's change in condition requiring an "acute out" transfer to a higher level of care.

Based on record review and interview, the CAH failed to ensure nursing care plans were developed and kept current for each inpatient for 5 (#4, #5, #6, #10, #13) of 20 sampled patients.

Findings:

Review of the hospital policy titled Plans of Care, revealed in part:
A nursing plan of care shall be developed based on identified nursing diagnosis and/or patient care needs.
5. Select nursing interventions to attain outcomes by checking the appropriate interventions and/or by developing additional interventions and writing them in on the lines provided.


Patient #4
Review of Patient #4's medical record revealed medical diagnoses which included diabetes mellitus. Further review revealed Patient #4 was ordered to have blood glucose levels obtained before meals and before bedtime with ordered sliding scale insulin.

Review of Patient #4's nursing care plan revealed no problem identified for diabetes.

In an interview on 8/8/17 at 10:05 a.m. with S6LPN, he verified there was no problem identified on Patient #4's nursing care plans for diabetes.

Patient #5
Review of Patient #5's medical record revealed medical diagnoses which included diabetes mellitus. Further review revealed Patient #5 was ordered to have blood glucose levels obtained before meals and before bedtime with ordered sliding scale insulin.

Review of Patient #5's nursing care plan revealed no problem identified for diabetes

In an interview on 8/8/17 at 10:30 a.m. with S6LPN, he verified there was no problem identified on Patient #5's nursing care plans for diabetes.

Patient #6
Review of Patient #6's medical record revealed medical diagnoses which included status post panniculectomy with wound dehiscence and necrotizing fasciitis, Hypertension, and Diastolic Heart Failure. Further review revealed impaired skin integrity actual, impaired gas exchange, risk for injury: falls related to decreased mobility, and nutrition imbalance less then body requirement related to malnourishment were care planned as identified problems. Further review revealed no documented interventions regarding the above referenced problems.

In an interview on 8/8/17 at 10:55 a.m. with S6LPN, he verified there were no documented interventions for the above referenced identified problems.

Patient #10
Review of Patient #10's medical record revealed medical diagnosis which included diabetes mellitus. Further review revealed Patient #10 was ordered to have blood glucose levels obtained before meals and before bedtime.

Review of Patient #10's nursing care plan revealed no problem identified for diabetes.

In an interview on 8/8/17 at 10:10 a.m. with S13RN, she verified there was no problem identified on Patient #10's nursing care plans for diabetes.

Patient #13
Review of Patient #13's medical record revealed problems had been identified on the nursing care plan for falls, nutritional imbalance, and risk for impaired skin integrity. There were no goals or interventions developed for the identified problems.

In an interview on 8/8/17 at 10:10 a.m. with S2DON, she said the computer charting system would not allow the staff to enter interventions for problems identified on the care plans.

Based on record review and interview, the CAH failed to ensure medical records were complete. This deficient practice is evidenced by the staff failing to ensure post anesthesia instructions were completed for 3 (#3, #19, #20) of 3 patients receiving procedures.

Findings:

Review of a document titled Post Operative Instructions revealed there were boxes to be checked by the nursing staff to indicate which instructions were applicable. There was a question with check boxes to indicate whether or not the patient had anesthesia by selecting "yes" or "no". If "yes" was selected there were 6 instructions for the patient post anesthesia. Further review revealed a section titled Patient's Activity with the appropriately ordered activity level to be selected from a preprinted list.

Patient #3
Review of Patient #3's medical record revealed the patient had a colonoscopy with biopsy procedure performed on 7/13/17. Further review revealed patient Post Operative Instructions, dated 7/13/17, which had choices of "yes" or "no" to indicate whether the patient had anesthesia. Additional review revealed both the 'yes" and "no" choices had been left blank and no post procedure activity level had been selected.

Patient #19
Review of Patient #3's medical record revealed the patient had an EGD (upper GI) with biopsy procedure performed on 3/9/17. Further review revealed patient Post Operative Instructions, dated 3/9/17, which had choices of "yes" or "no" to indicate whether the patient had anesthesia. Additional review revealed both the 'yes" and "no" choices had been left blank and no post procedure activity level had been selected.

Patient #20
Review of Patient #20's medical record revealed the patient had an EGD (upper GI) with biopsy procedure performed on 3/30/17. Review of the Post Operative Instructions dated 3/30/17 revealed neither "yes" nor "no" had been selected for whether or not Patient #20 had anesthesia. There was also no activity level selected.

In an interview on 8/9/17 at 3:30 p.m. with S5RN, she verified the Post Operative Instructions forms had not been properly completed.

Based on record review and interview, the CAH failed to ensure the medical record of each patient receiving health care services was complete and accurate. This deficient practice was evidenced by:

1) failure of the CAH to ensure informed consent forms were completed with an authentication, date, and time for 3 (#3, #19, #20) of 3 patients reviewed for consents.; and
2) failure of the CAH to ensure the medical record of each patient transferred from acute inpatient status to swingbed status had a discharge summary recapitulaing the patients' acute inpatient stay for 2 (#15, #16) of 2 total patients reviewed who were admitted acute inpatient and transferred to swingbed status out of a total patient sample of 20.

Findings:

1) Failure of the CAH to ensure informed consent forms were completed with an authentication, date, and time.

Review of the hospital policy titled Medical Records revealed the following in part:
All entries in the medical record must be timed, dated and authenticated to ensure accuracy of each entry.

Patient #3
Review of Patient #3's medical record revealed the patient had a colonoscopy with biopsy procedure performed on 7/13/17. Further review revealed a Consent for Conscious Sedation that had been dated by the physician but had not been timed. Additional review revealed a Consent for Medical School Student that had been dated by the nurse but had not been timed.

Patient #19
Review of Patient #19's medical record revealed the patient had an EGD (Upper GI) with biopsy procedure performed on 3/9/17. Further review revealed a document titled," Consent for Medical/Surgical Procedure and Acknowledgement of Receipt of Information', that had been obtained by S8MD. The consent was authenticated by S8MD but not dated or timed.

Patient #20
Review of Patient #19's medical record revealed the patient had an EGD (Upper GI) with biopsy procedure performed on 3/30/17.

Review of Patient #20's medical record revealed documents titled Patient Request Form and Patient Consent for Conscious Sedation that been dated and signed by the physician but had not been timed.

Review of Patient #20's medical record revealed a documents titled Authorization/Consent Form and Patient Consent Form that been dated and signed by the nurse but had not been timed.


2) Failure of the CAH to ensure the medical record of each patient transferred from acute inpatient status to swingbed status had a discharge summary recapitulaing the patients' acute inpatient stay.

Patient #15
Review of Patient #15's medical record revealed an acute inpatient admit date of 7/18/17 from the hospital's emergency department. Further review revealed Patient #15 was transferred to swingbed status on 7/22/17 at 11:30 a.m. Additional review revealed no documented evidence of a discharge summary recapitulating the patient's acute inpatient hospital stay.

In an interview on 8/8/17 at 12:24 p.m. with S6LPN, he confirmed Patient #15 had been transferred from acute inpatient status to swingbed status on 7/22/17 at 11:30 a.m. S6LPN also confirmed there was no discharge summary recapitulating Patient #15's acute inpatient hospital stay as of 8/8/17 (date of chart review).

Patient #16
Review of Patient #16's medical record revealed an acute inpatient admit date of 7/24/17. Further review revealed Patient #16 was transferred to swingbed status on 7/27/17 at 1:40 p.m. Additional review revealed no documented evidence of a discharge summary recapitulating the patient's acute inpatient hospital stay.

In an interview on 8/8/17 at 12:51 p.m. with S6LPN, he confirmed Patient #16 had been transferred from acute inpatient status to swingbed status on 7/27/17 at 1:40 p.m. S6LPN also confirmed there was no discharge summary recapitulating Patient #16's acute inpatient hospital stay as of 8/8/17 (date of chart review).

Based on record review and interview, the CAH failed to ensure all medical record entries for patient's receiving health care services at the hospital were complete. This deficient practice was evidenced by failure of the CAH to ensure all medical record entries were authenticated, dated, and timed for 3 (#3, #19, #20) of 20 patients sampled for timing medical record entries.

Findings:

Patient #3
Review of Patient #3's medical record revealed the patient had a colonoscopy with biopsy procedure performed on 7/13/17. Further review revealed the following incomplete medical record entries:

Physician's orders for Outpatient Endoscopy Procedures. The document had been dated 7/12/17 but had not been timed by the physician.

A document titled,"Patient Classification Status" for determination of anesthesia type had been signed by the physician but had not been dated or timed.

A document titled, "Modified Aldrete Scoring System" that had not been authenticated or dated.

A procedure note dictated on 7/13/17 and transcribed on 7/14/17. Further review revealed the document had been electronically reviewed and signed by S8MD but the authentication had not been dated and timed.

Post Operative Instructions that had been authenticated and dated but had not been timed.


Patient #19
Review of Patient #19's medical record revealed the patient had an EGD (Upper GI) with biopsy procedure performed on 3/9/17. Further review revealed the following incomplete medical record entries:

A document titled, "Orders and Treatment for S18MD Outpatient Surgery" were authenticated by S18MD, but not dated or timed.

A document titled," Patient Classification Status" indicating the classification of the type of anesthesia the patient was to receive for the procedure was authenticated by S18MD, but was not dated or timed.

A document titled, "Modified Aldrete Scoring System" for discharge appropriateness from post anesthesia care unit revealed the RN performing the assessment had not dated the assessment.

A document titled, "Post-Operative Instructions" dated 3/9/17, had been authenticated but not timed.

A document titled, "Procedure Note", revealed the note was electronically signed by S8MD but was not dated or timed.

A document titled," Endoscopy Form", revealed S8MD had authenticated the form but had failed to date and time his authentication.

Patient #20
Review of Patient #19's medical record revealed the patient had an EGD (Upper GI) with biopsy procedure performed on 3/30/17.

Review of Patient #20's medical record revealed documents titled Patient Request Form and Patient Consent for Conscious Sedation that been dated and signed by the physician but had not been timed.

Review of Patient #20's medical record revealed a documents titled Authorization/Consent Form and Patient Consent Form that been dated and signed by the nurse but had not been timed.

In an interview on 8/7/17 at 3:30 p.m. with S2DON, she confirmed all medical record entries should be authenticated, dated and timed. .

Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure swing bed patients had individualized activity care plans, based upon activities assessments, for 4 ( #4, #5. #6. #7) of 4 swing bed patients reviewed for activities care plans out of a total patient sample of 20 (#1-#20).

Findings:

Patient #4
Review of Patient #4 's medical record revealed the patient was admitted to swing bed status on 8/4/17. Further review of Patient #4's medical record revealed no documented evidence of an activities care plan based upon needs identified in the patient's activities assessment.

In an interview on 8/8/17 at 10:00 a.m. with S6LPN confirmed there was no activities care plan in Patient #4's medical record.


Patient #5
Review of Patient #5 's medical record revealed the patient was admitted to swing bed status on 6/23/17. Further review of Patient #5's medical record revealed no documented evidence of an activities care plan based upon needs identified in the patient's activities assessment.

In an interview on 8/8/17 at 10:30 a.m. with S6LPN confirmed there was no activities care plan in Patient #5's medical record.

Patient #6
Review of Patient #6 's medical record revealed the patient was admitted to swing bed status on 5/31/17. Further review of Patient #6's medical record revealed no documented evidence of an activities care plan based upon needs identified in the patient's activities assessment.

In an interview on 8/8/17 at 1:00 p.m. with S6LPN confirmed there was no activities care plan in Patient #6's medical record.

Patient #7
Review of Patient #7 's medical record revealed the patient was admitted to swing bed status on 7/6/17. Further review of Patient #7's medical record revealed no documented evidence of an activities care plan based upon needs identified in the patient's activities assessment.

In an interview on 8/8/17 at 1:40 p.m. with S6LPN confirmed there was no activities care plan in Patient #7's medical record.

In an interview on 8/9/17 at 2:30 p.m. with S4SurgeryTech/ActDir, she confirmed each swingbed status patient had an activities assessment on admit. S4SurgeryTech/ActDir reported she was the hospital staff member responsible for performing swingbed patient activities assessments. S4SurgeryTech/ActDir confirmed there were no activities care plans for the above referenced swing bed patients.