HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of fourteen patients, two acute patients, ten swing bed patients, and two obstetric patients. Based on observation, staff interview, and policy review the CAH failed to maintain drugs and biologicals commonly used in life-saving procedures in one of three Emergency Department Rooms (Room #1). The CAH's failure to ensure drugs and biologicals were available for patients has the potential to cause harm and delay emergency care to patients.

Findings include:

- The CAH's Policy "DRUG RECALL AND OUTDATED DRUGS" reviewed on 9/1/15 at 2:50pm directed, "...Out dated drugs will be pulled from hospital stock and isolated 3 months prior to expiration date..."

- The CAH's policy "Medication Outdates" reviewed on 9/1/15 at 2:50pm directed, "...All medications, hospital wide will be checked for outdates. Medications will be pulled one (1) month prior to their expiration date and returned to the pharmacy. Outdated medications will be removed and isolated in the pharmacy for further disposal..."

- The CAH's policy titled "Expiration Date for Open Medication Vials" reviewed on 9/1/15 at 2:50pm directed, "...All multidose medications vials will be labeled with the date that med should be discarded. Open multidose vials will be good for 28 days, then will be discarded. All open multidose vials should be labeled with a discard date..."

- The CAH's policy "Inventory Control, Accounting for Expired and Damaged Goods" reviewed on 9/2/15 at 4:00pm directed, "...Inventory items that expired or are damaged will be removed from inventory. Expired items and potentially usable damaged items will be placed in a holding area..."


- Emergency Department Room #1 toured on 8/31/15 at 1:40pm revealed a cabinet drawer containing one "Scrub Care Surgical Scrub Brush Sponge/Nail Cleaner" with an expiration date of 12/2014.

- Emergency Department Room #1 toured on 8/31/15 at 1:45pm revealed the Emergency Crash Cart containing one unopened multi-dose vial of Procainamide (medication used to treat an irregular heart beat) 1 Gram per 10 milliliters (ml), 10 ml total volume, with an expiration date of 6/1/15.

- Emergency Department Room #1 toured on 8/31/15 at 2:00pm revealed the medication cart containing one opened multidose vial of Kenalog (used to treat inflammation) 40 milligrams per 1 ml, 5 ml total volume with discard date of 6/30/15.

Administrative Staff B interviewed on 8/31/15 at 2:00pm acknowledged the expired surgical hand scrub, the expired Procainamide, and outdated Kenalog. Administrative Staff B reported items were missed being removed from stock and the Procainamide was retained in the crash cart because it is not available for purchase at this time.

The Critical Access Hospital (CAH) reported an average daily census of 2.42 patients with a current census of 14, two acute patients, ten swing bed patients, and 2 obstetric patients. Based on observation, interview and policy review the Critical Access Hospital (CAH) failed to provide for the safety of patients and or staff in 22 of 27 patient care rooms (Room #'s 101-112 and 300-309) with biohazard (medical waste) sharps (needle and syringe) containers. This deficient practice has the potential to cause harm to patients, visitors, and staff members.



Findings include:



- The CAH's "Blood Borne Pathogen Exposure Control Plan" reviewed on 9/2/15 at 8:00am directed, "...Sharps disposable containers will be located near areas of use. The containers will be in locked compartments in patient areas..."



- Patient care rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, and 112 observed on 8/31/15 between 4:00pm and 4:10pm revealed unsecured biohazard sharps containers sitting on the counter of the patient rooms.



- Patient care rooms 300, 301, 302, 303, 304, 305, 306, 307, 308, and 309 observed on 9/1/15 between 11:00am to 11:10am revealed unsecured biohazard sharps containers sitting on the counter of the patient rooms.



Housekeeping Staff G interviewed on 8/31/15 at 4:10pm acknowledged the unsecured biohazard sharps containers sitting on the counters of the patient rooms and that unauthorized persons could access the used needles and syringes without hospital staff's knowledge.



Administrative Staff B interviewed on 8/31/15 at 4:30pm acknowledged the unsecured biohazard sharps containers in patient rooms and unauthorized persons could remove the containers allowing access which created a safety hazard and potential for the spread infections.

The Critical Access Hospital (CAH) reported an average daily census 2.42 patients with a current census of two acute, ten skilled swing bed, and two obstetric patients. Based on observation, staff interview, and policy review the CAH failed to ensure a clean and orderly environment in the physical therapy department in that the paraffin wax basin was soiled. This deficient practice had the potential to place patients at risk for exposure to dust and debris.


Findings include:


- The CAH policy "Infection Control Principles" reviewed on 9/2/15 directed staff "...all equipment as described above should be cleaned with detergent solution when visibly soiled..."


- The CAH Physical Therapy department observed on 9/2/15 between 8:30am-8:45am revealed visible dust on the paraffin wax basin (warm liquid wax used to treat pain). Visible dried wax on sides of basin, lid, and tray holding basin.


Physical Therapy Staff D interviewed 9/2/15 at 8:30am acknowledged paraffin wax basin had visible dried wax on outside of basin and tray.

The Critical Access Hospital (CAH) reported an average daily census of 2.42 patients with a current census of two acute, ten swing bed patients, and two obstetric patients. Based on staff interview and policy review the CAH failed to ensure compliance with the annual review of policies and procedures. This deficient practice had the potential to affect the safe, effective, and quality of care to all current and future patients of the CAH.

Findings include:


- The CAH's policy "Annual Review of Department Policies and Procedures" reviewed on 9/3/15 at 8:00am directed, "...policies and procedures are to be evaluated, reviewed and revised on an annual basis...submitted to the Hospital CEO for final comments, revisions, and written approval..."


- The CAH's policy and procedure manuals reviewed on 9/3/15 at 8:00am revealed the CAH's last Policies and Procedures update completed on 3/3/14.


Administrative Staff A interviewed at 8:55am acknowledged the CAH lacked evidence of annual policy and procedure review in 2015.

The Critical Access Hospital (CAH) reported an average daily census of 2.42 patients with a current census of two acute, ten skilled swing bed, and two obstetric patients. Based on observation, staff interview, and policy review the CAH failed to ensure compliance of outdated medications in one of one outpatient clinic. This deficient practice had the potential for patients to receive ineffective medications/treatments.


Findings include:

- The CAH policy "Medication Outdates" reviewed on 9/3/15 at 8:55am directed staff "...all medications, hospital wide will be checked for outdates...medications will be pulled one month prior to their expiration date and returned to the pharmacy..."

- The CAH Outpatient clinic observed on 8/31/15 from 2:15pm-2:45pm revealed the following outdated supplies:

1. One bottle of 10% Neutral Buffered Formalin (substance used for pathology of tissue sample) with an expiration of 7/14.

2. One full 16 oz bottle Dakins Solution (solution used for healing wounds) with an expiration of 3/13.

Registered Nurse Staff F interviewed on 8/31/15 at 2:45pm acknowledged outdated supplies.

The Critical Access Hospital (CAH) reported an average daily census of 2.42 patients with a current census of 14 patients, two acute patients, ten swing-bed patients, and 2 obstetric patients. Based on observation, staff interview, and document review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control program for staff practices which could contribute to healthcare acquired infections of patients and personnel in that the CAH staff failed to remove outdated or opened supplies in one of three observed Emergency Rooms (Room #1), in one of one observed outpatient clinic, in one of one observed labor/delivery/recovery/post-partum (LDRP) room, in one of one physical therapy room, and the CAH staff failed to follow manufacturer's guidelines for using cleaning products and performing hand hygiene during an observed cleaning of a discharged patient's room (Housekeeping Staff G), failed to follow the manufacturer's guidelines for using cleaning products and nationally accepted guidelines for terminal cleans in the OR during an observed cleaning of an operating room (Operating Room Staff K, L, and M), failed to follow their cleaning equipment policy during one of three observed uses of patient care equipment (Nurse Staff H), failed to place medication directly into a cup during one of five medications passes (Nurse Staff E), failed to perform hand hygiene during one of one observed intravenous starts (Nurse Staff I and Nursing Student J ), and failed to clean reusable items/supplies between patient uses during one of one observed Physical Therapy (PT) treatments (PT Staff N and PT Staff D). The CAH's failure to identify failures with infection control practices created the potential for healthcare acquired infections.



Findings include:



- The CAH's Infection Control Plan reviewed on 9/2/15 at 8:00am directed, The main focus of the plan is the prevention, detection, and treatment of infections through utilization surveillance...monitoring and surveillance establish and maintain routine activities that address patient and personnel in each area of the facility to ensure compliance with the current infection prevention standards..."


- The CAH's policy "Inventory Control, Accounting for Expired and Damaged Goods" reviewed on 9/2/15 at 4:00pm directed, "...Inventory items that expired or are damaged will be removed from inventory. Expired items and potentially usable damaged items will be placed in a holding area..."

- The CAH's policy "Single Use, Single Patient Use" reviewed on 9/2/15 at 3:10pm directed "...Single Use Device-A medical device intended to be used on an individual patient during a single procedure and then discarded. It is not intended to be reprocessed and used on another patient..."

- Emergency Department Room #1 observed on 8/31/15 at 1:30pm revealed a cabinet drawer containing one unpackaged butterfly safety blood collection set.

Administrative Staff B interviewed on 8/31/15 at 1:30pm acknowledged the blood collection set should have been disposed of when opened and not available for use.

- The Outpatient clinic observed on 8/31/15 from 2:15pm-2:45pm revealed the following breeches in infection control practices for outdated supplies:

1. One Triflex size 6 ½ sterile exam gloves with an expiration of 7/15.

2. One ¾ full 16oz (ounces) bottle of Epi-Clenz hand sanitizer with an expiration of 6/14.

3. One full container PPI Sani Cloth (clothes used for cleaning surfaces) with an expiration of 2/15.

4. One 3/4 full 8oz bottle of antibacterial soap with an expiration of 3/12.

5. One ¾ full 8oz bottle of hand sanitizer with an expiration of 2010.

6. One ½ full 8oz bottle of antibacterial soap with an expiration of 3/12.

7. One ½ full bottle of PVP prep solution (iodine solution cleansing wounds) with an expiration of 4/15.

8. One ¾ full 16oz bottle of hand sanitizer with an expiration of 10/14.

9. One ½ full 16oz bottle of hand sanitizer with an expiration of 12/11.

Registered Nurse Staff F interviewed on 8/31/15 at 2:45pm acknowledged the outdated cleaning and sanitizing products.

- Labor Delivery Recovery Postpartum (LDRP) Room #205 observed on 9/2/15 at 11:15am revealed an opened sterile 8 Fr (French) DeLee Mucus Trap one time use catheter (used to suction a newborn infant) connected to suction for neonatal use.

Administrative Staff B interviewed on 9/2/15 at 11:15am acknowledged the neonatal catheter is opened and no longer sterile. Administrative Staff B acknowledged staff could not know if the catheter had been used prior.

- Physical Therapy Department observed 9/2/15 from 8:30am-8:46am revealed the following outdated supplies:

1. One full bottle 250ml Eco-Gel 200 Ultra Sound gel (gel used between probes on ultra sound equipment and skin so sounds may be heard) with an expiration date of 6/15.

2. One ¾ full 16oz bottle Epi-Clenz hand sanitizer with an expiration date of 8/14.

3. One ¼ full 16oz bottle Epi-Clenz hand sanitizer with an expiration date of 8/14.

4. One ¾ full 32oz bottle Biofreeze (gel applied to the skin to manage discomfort) with an expiration date of 9/12.

5. One ¼ full 16oz bottle dermal wound cleanser (cleanser used to clean wounds) with an expiration date of 4/15.

6. One Medipore pad (adhesive pad used to cover wounds) with an expiration date of 9/14.

7. Thirty-five 6cm x 7cm Tegaderm dressings (clear dressing used to cover wounds) with an expiration date of 3/13.

8. Four 9cm x 10cm Tegaderm dressings with an expiration date of 5/12.

Physical Therapy Staff D interviewed on 9/2/15 at 8:35am acknowledged outdated supplies.


- The manufacturer's information sheet for "Re-Juv-Nal " reviewed on 9/1/15 at 11:30am directed when using as a disinfectant "...Let solution remain on surface for a minimum of ten minutes..."


- The CAH's policy "Hand Hygiene" reviewed on 9/2/15 at 8:00am directed, "...Indications for hand washing and hand antisepsis...decontaminate hands before having direct contact with patients...decontaminate hands before donning gloves ...decontaminate hands after removing gloves...Decontaminate hands after contact with a patient..."


- Housekeeping Staff G observed on 8/31/15 between 2:45pmto 4:25pm cleaned room 110, a discharged patient room revealing the following breaches in infection control practices for hand hygiene, disinfectant wet time per manufacturer's recommendation, and cleaning from dirty areas to a less dirty area:


- Housekeeping Staff G sprayed the patient bed, mattress, pillow, recliner, bedside stand, counter, cabinets and drawers with "Re-Juv-Nal", one-step disinfectant. While spraying the "Re-Juv-Nal" again, staff G wiped the bedside stand, recliner, and counter with a cloth wet with "Re-Juv-Nal". The surfaces remained wet five to eight minutes not the required ten minutes for disinfection as required by the manufacturer.


Staff G left room 110 and wearing the soiled gloves used to clean room 110 went down the hallway with the housekeeping cart to the housekeeping closet to change cleaning water. Staff G failed to remove their contaminated gloves or perform hand hygiene.


Staff G cleaned the bathroom in room 110 with "Re-Juv-Nal" during the cleaning process Staff G using the same cloth they cleaned the commode with to clean the trashcan, a less dirty area.


During the cleaning of room 110, Staff G reached into their scrub pocket for the cleaning cart key at least seven times with their contaminated gloves.


Staff G interviewed on 8/31/15 at 4:25pm revealed they received instructions that the surfaces must remain wet for ten minutes when using the Re-Juv-Nal to disinfect surfaces. Staff G acknowledged they left the room to go to the Housekeeping closet with soiled gloves, reached into their uniform pocket, and cleaned the trashcan after cleaning the commode.


- The CAH's infection control policy reviewed on 9/2/15 at 8:00am directed, "...items dropped on the floor are discarded or resterilized. Unsterile items should be thoroughly cleaned..."


- Association of periOperating Room Nurses (AORN) 2015 edition "Guidelines for Perioperative Practices " reviewed on 9/1/15 at 2:35pm directed, "...All floors in the perioperative and sterile processing areas should be disinfected..."


- The manufacturer's information sheet for "Top Clean" floor cleaner reviewed on 9/1/15 at 2:55pm revealed the floor cleaner was a neutralizer and failed to have disinfecting properties.



- Operating Room (OR) Staff K, Staff L, and Staff M observed on 9/1/15 between 1:00pm to 1:55pm cleaned an OR room at the end of the day revealing the following breaches in infection control practices for disinfectant wet time per manufacturer's recommendation, handling of supplies, and disinfection of the OR floor:



- OR Staff K, Staff L, and Staff M used cleaning cloths wet with "Re-Juv-Nal" one step disinfectant to wipe the back-up table, monitoring tower, refrigerator, cardiac monitor, and endoscope (a flexible tube used to view esophagus and colon) viewer. The surfaces remained wet four to seven minutes not the required ten minutes for disinfection as required by the manufacturer.



Staff M picked up a cardboard box with five intravenous (IV) extension tubing and a bag of monitoring electrodes that had sat directly on the floor and placed them on the cleaned anesthetic cart. Staff M failed to clean or discard the contaminated supplies.



Staff K using "Top Clean" floor cleaner, mopped the OR room floor. Staff K failed to disinfect the OR floor.



Staff K, Staff L, and Staff M acknowledged some surfaces in the OR failed to remain wet for the ten minutes required for disinfection that Staff M placed supplies from the floor back into use without cleaning, and the "Top Clean" failed to be a disinfecting agent.


Housekeeping Staff G interviewed on 9/1/15 at 2:55pm acknowledged "Top Clean" failed to have disinfecting properties and was a neutralizing cleaner.



- The CAH ' s policy for infection control reviewed on 9/1/15 at 8:00am directed, " ...Patient care items are cleaned after each patient use ... "



- Nursing Staff H observed on 9/1/15 at 6:30am obtained vital signs on Patient #23 then left the room and took the vital sign machine down the hallway to a storage area. Staff H failed to clean the vital sign machine used on Patient #23.



- Licensed Practical Nurse Staff E observed on 9/1/15 at 7:25am provided medication to Patient #36. Staff E obtained medication from a medication card (card with medications individually packaged) into their ungloved hand prior to placing into a medication cup (small plastic cup used to give medication).

Staff E interviewed on 9/1/15 at 7:30am acknowledged placing the medication into their hand prior to placing in a medication cup and stated "I know I'm not supposed to, but I lose them if don't."

- Policy review on 9/1/15 revealed CAH failed to develop and implement a policy and procedure for ensuring medications are placed directly into medication cups.



- Registered Nurse Staff I and Nursing Student Staff J observed on 9/1/15 between 7:30am and 7:55am provided an intravenous (IV) start to Patient #23 revealing the following breaches in infection control practices for hand hygiene. Staff I and Staff J wearing gloves inserted a 20-gauge needle and obtained blood for testing. Staff I and Staff J removed their gloves and reapplied gloves without performing hand hygiene. Staff I left Patient #23's room and failed to perform hand hygiene after patient care.



- The CAH policy "Infection Control Principles" reviewed on 9/2/15 at 8:00am directed "...reusable items/supplies...treatment tables, mat tables, wand, goniometers (used to measure angles), hand weights, etc...are wiped down with hospital approved disinfectant after each patient encounter..."

- Physical Therapy (PT) Staff N observed on 9/2/15 at 8:40am provided PT treatment to Patient #35 using a resistance band (elastic band used to add resistance to stretching). Staff N failed to clean the resistance band after Patient #35's treatment.

- Physical Therapy Staff D observed on 9/25/15 at 8:46am removed the pillow cases from two pillows used on Patient #35. Staff D failed to disinfect the pillows prior to applying new pillowcases.

PT Staff D interviewed on 9/2/15 at 8:46 acknowledged items that come into direct patient contact require cleaning and disinfecting.

The Critical Access Hospital (CAH) reported a census of fourteen patients, two acute patients, ten swing bed patients, and two obstetric patients. Based on medical record review, Medical Staff Rules and Regulations review, policy review and staff interview the Critical Access Hospital (CAH) failed to ensure medical records are complete within 30 days for five of 23 sample patients (patient's # 2, 15, 22, 24, and 26). The failure of the CAH to ensure medical records are complete has the potential to lead to poor patient outcomes for patients admitted to the CAH.

Findings include:

- The CAH's policy titled "MEDICAL STAFF RULES AND REGULATIONS" reviewed on 9/2/15 at 11:00am directed staff "...a discharge summary which includes the history of preset illness, pertinent physical findings, hospital course, results of diagnostic and therapeutic procedures, condition on discharge, special instructions to the patient, disposition and planned follow-up will be required. The patient's medical record will be complete at the time of discharge. Except in unusual circumstances, the medical record will be completed within thirty days..."

- The CAH's policy "MEDICAL RECORD CONTENT AND FORMAT" reviewed on 9/2/15 at 8:30am directed staff "...A Discharge Summary will be completed within 15 days of a patient's dismissal..."

- The CAH's policy "Verbal Orders" reviewed on 9/2/15 at 7:45am directed staff "...Verbal Orders are orders for medications, treatments, testing, intervention or other patient care that are communicated as oral, spoken communications between senders and receivers face to face or by telephone..."

- Patient #2's closed emergency room medical record reviewed on 8/31/15 revealed an admission date of 7/30/14 with a diagnosis of foot pain. Patient #2's medical record revealed the patient was admitted to the emergency room at 1:22pm and discharged at 1:57pm. Patient #2's medical record revealed a foot x-ray completed at 1:50pm. Patient #2's medical record lacked evidence a physician's order was obtained prior to the x-ray. Patient #2's medical record failed to be complete within 30 days.

Medical Records Staff C interviewed on 9/1/15 at 3:15pm confirmed Patient #2's medical record lacked evidence of a physician's order prior to the foot x-ray. Medical Records Staff C reported she did not know why the verbal order was not obtained. Medical Records Staff C acknowledged Patient #2's medical record was not complete within 30 days.

- Patient #15's medical record reviewed on 9/2/15 revealed an admission date of 7/26/15 and discharged on 7/29/15 with a diagnosis of Diabetes with Ketoacidosis (complication when the body produces too much sugar). Patient #15's medical record revealed an unsigned physician's order for Novalog 3 units (medication used to regulate insulin for a diabetic patient) to be given once on 7/29/15. Patient #15's medical record failed to be completed within 30 days after discharge.

Medical Record Staff C interviewed on 9/2/15 at 2:00pm acknowledged Patient #15's provider failed to complete their medical record within 30 days.

- Patient #22's medical record reviewed on 9/1/15 revealed an admission on 6/23/15 and discharged on 6/29/15 for a surgical procedure. Patient #22's medical record revealed a discharge summary transcribed on 6/30/15 and failed to be signed by the provider (64 days after discharge). Patient #22's medical record failed to be completed within 30 days after discharge.

- Patient #24's medical record reviewed on 9/1/15 revealed an admission on 4/10/15 and discharged on 4/17/15 for a surgical procedure. Patient #24's medical record revealed a discharge summary transcribed on 4/17/15 and failed to be signed by the provider (136 days after discharge). Patient #24's medical record failed to be completed within 30 days after discharge.

- Patient #26's medical record reviewed on 9/2/15 revealed an admission on 7/14/15 and discharged on 7/15/15 for a surgical procedure. Patient #26's medical record revealed a discharge summary transcribed on 7/15/14 and failed to be signed by the provider (46 days after discharge). Patient #26's medical record failed to be completed within 30 days after discharge.

Administrative Nurse Staff B interviewed on 9/1/15 at 4:30pm acknowledged the provider failed to complete their medical record within 30 days.

The Critical Access Hospital (CAH) reported an average daily census of 2.42 patients with a current census of 14 patients, two acute patient, ten swing bed patients, and two obstetric patients. Based on medical record review, staff interview and policy review the CAH failed to ensure four of twenty three sampled inpatient medical records (patient #'s 22, 23, 25, and 31) contained a pertinent medical history and physical (H & P) completed in a timely manner. The CAH's failure to ensure patients' medical history and physical are competed in a timely manner has the potential for poor patient outcomes.

Findings include:

- The CAH's Medical Staff Rules and Regulations reviewed on 9/2//15 at 11:00am directed, " ...A complete history and physical examination will be recorded within 24 hours of admission...If a recent completed history has been recorded and a recent physical examination performed prior to the patient's admission to the hospital may be used. The interval shall not exceed thirty days..."

- Patient #22's medical record reviewed on 9/1/15 revealed an admission date of 6/23/15 for a surgical procedure. Patient #22's medical record revealed a history and physical completed on 4/1/15 (84 days before admission). The CAH failed to ensure Patient #22's history and physical was completed within 30 days prior to admission.

- Patient #23's medical record reviewed on 9/1/15 revealed an admission date of 9/1/15 for a surgical procedure. Patient #23's medical record revealed a history and physical completed on 3/12/15 (172 days before admission). The CAH failed to ensure Patient #23's history and physical was completed within 30 days prior to admission.

- Patient #25's medical record reviewed on 9/1/15 revealed an admission date of 3/17/15 for a surgical procedure. Patient #25's medical record revealed a history and physical completed on 2/12/15 (35 days before admission). The CAH failed to ensure Patient #25's history and physical was completed within 30 days prior to admission.

- Patient #31's closed medical record reviewed on 8/31/15 revealed an admission date of 2/9/15 with a diagnosis of cerebral vascular accident (stroke) and discharged on 12/15/15. Patient #31's medical record revealed a history and physical completed on 2/12/15 (72 hours after admission). The CAH failed to ensure Patient #31's history and physical was completed within 24 hours after admission.

Administrative Staff B interviewed on 9/1/15 at 4:30pm acknowledged that Patient #31's H & P was completed two days late and Patient #'s 22, 23, and 25's surgical history and physical failed to be completed within 30 days of admission.

The Critical Access Hospital (CAH) reported a daily census of two acute, ten skilled swing bed, and two obstetric patients. Based on observation, staff interview, and policy review the CAH failed to ensure compliance of dating and timing six of twenty three sampled medical records (Patients #15, #22, #24, #25, #26, and #32) and one of one Outpatient medical record sampled (Patient #34). The CAH's failure to ensure all entries into the medical record are dated and timed has the potential to cause medication errors.

Findings included:

- The CAH policy "Legibility of Clinical Record Entries As Well As Signing, Dating and Timing All Entries In Clinical Record" reviewed on 9/3/15 at 11:00am directed staff "...when a verbal order is dictated to an RN/LPN...this order must be signed, timed and dated by the responsible physician..."

- Patient #15's medical record reviewed on 9/2/15 revealed an admission date of 7/26/15 with a diagnosis of Diabetes with Ketoacidosis (complication when the body produces too much sugar) with an order dated 7/29/15 for Novalog 3 units (medication used to regulate insulin for a diabetic patient) to be given. Patient #15's medical record lacked evidence the physician signed and dated the order.

Medical Record Staff C interview 9/2/15 at 2:00pm acknowledged Patient #15's medical record lacked required date and timing of order.

- Patient #22's medical record review on 9/1/15 revealed an admission on 6/23/15 for a surgical procedure and discharged on 6/29/15. Patient #22's medical record revealed eight written, verbal, or telephone orders that lacked a date and/or time when the provider signed the order. The Critical Access Hospital failed to assure the ordering practitioner dated and/or timed their signature.



- Patient #24's medical record review on 9/1/15 revealed an admission on 4/10/15 for a surgical procedure and discharged on 4/17/15. Patient #24's medical record revealed seven written, verbal, or telephone orders that lacked a date and/or time when the provider signed the order. The Critical Access Hospital failed to assure the ordering practitioner dated and/or timed their signature.



- Patient #25's medical record review on 9/1/15 revealed an admission on 2/17/15 for a surgical procedure and discharged on 2/21/15. Patient #25's medical record revealed four written, verbal, or telephone orders that lacked a date and/or time when the provider signed the order. The Critical Access Hospital failed to assure the ordering practitioner dated and/or timed their signature.



- Patient #26's medical record review on 9/1/15 revealed an admission on 7/14/15 for a surgical procedure and discharged on 7/15/15. Patient #26's medical record revealed four written, verbal, or telephone orders that lacked a date and/or time when the provider signed the order. The Critical Access Hospital failed to assure the ordering practitioner dated and/or timed their signature.



- Patient #32's medical record review on 9/2/15 revealed an admission on 7/16/15 with a diagnosis of anemia and discharged on 7/18/15. Patient #32's medical record revealed four written, verbal, or telephone orders that lacked a date and/or time when the provider signed the order. The medical record lacked a date and time the provider signed a consult report. The Critical Access Hospital failed to assure the ordering practitioner dated and/or timed their signature.



Administrative Nurse Staff B interviewed on 9/1/15 at 4:30pm acknowledged the providers failed to date and or time all entries into the medical records.


- Patient #34's outpatient medical record reviewed on 9/3/15 at 11:00am revealed an order dated 8/27/15 for daily wound packing and IV (medication given through vein) therapy daily for seven days. Patient #34's outpatient medical record lacked evidence the physician timed the order as required.

Registered Nurse Staff F interviewed on 9/2/15 at 11:05am acknowledged Patient #34's outpatient medical record order lacked a time when written.

The Critical Access Hospital (CAH) reported a census of ten swing bed patients with five medical records reviewed. Based on medical record review, policy review and staff interview the CAH staff failed to follow their policy/procedure to complete the required annual comprehensive assessment of swing bed patient's customary routine, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, dental status, activity interests, discharge potential and documentation of participation in assessment to meet the needs for two of two swing bed patients requiring a comprehensive assessment (Patient #'s 29 and 30). Failure to complete a comprehensive assessment had the potential to not meet the needs of swing bed patients at the CAH.



Findings include:



- The CAH's Swing Bed requirements reviewed on 9/2/15 at 3:00pm directed, "...Assessment must be done within 14 calendar days after admission...within 14 days after change in resident's condition...not less often than once every 12 months..."



- Patient #29's medical record reviewed on 8/31/15 revealed an admission date of 3/1/00 to the CAH swing bed Unit. Patient #29's medical record lacked evidence of a comprehensive assessment during the past twelve months including: customary routine, cognitive patterns, ability to communicate, mood and behavior patterns, psychosocial well-being, dental status, activity interests, discharge potential, and documentation of the patients participation in the assessment.



- Patient #30's medical record reviewed on 8/31/15 revealed an admission date of 12/28/11 to the CAH swing bed Unit. Patient #30's medical record lacked evidence of a comprehensive assessment during the past twelve months including: customary routine, cognitive patterns, ability to communicate, mood and behavior patterns, psychosocial well-being, dental status, activity interests, discharge potential, and documentation of the patients participation in the assessment.



Swing Bed Administrative Staff O interviewed on 9/1/15 at 3:45pm acknowledged CAH staff failed to complete an annual comprehensive assessment on Patient #'s 29 and 30.