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A. Based on policy, record review and staff interview, it was determined that in 1 of 5 patients who received blood transfusion(s) (Pt. #12), the Critical Access Hospital (CAH) failed to ensure that written policies for blood administration were followed.

Findings include:

1. The policy titled "Blood/Blood Product Transfusion and Suspected Adverse Reaction" under "1.1 M. The RN administering the blood and one other staff member (RN, LPN, NP, PA, MD, DO) verify the patient armband, blood recipient ID number... at the bedside prior to attaching the blood to the tubing."

2. The medical record of Pt. #12 was reviewed on survey date 10/06/09. Documentation indicated that Pt. #12 was admitted to the CAH on 8/24/09 with diagnosis of Anemia. Documentation indicated that the physician's office faxed orders on 8/24/09 at 12:57 PM for "Type and Cross match for 2 units PRBC's and transfuse over 3 hours." Documentation on the" Blood Component Transfusion Form" indicated that on 8/25/09 the second unit of blood was started at 0505 by the registered nurse. There was no documentation to indicate that another staff member witnessed the bedside verification.

3. During an interview with the Director of Patient Care Services on 10/8/09 at 12:00 PM, the above finding was confirmed.


B. Based on policy, record review and staff interview, it was determined that in 1 of 21 records reviewed (Pt. #15), the CAH failed to ensure that policies were followed regarding medication administration related to patients with known drug allergies.

Findings include:

1. The policy titled "Medication Administration, Adult, under V. Procedure, 1.3 Check for patient allergies, contra-indications..."

2. The medical record of Pt. #15 was reviewed on survey date 10/7/09. Documentation indicated that Pt. #15 was admitted to the CAH on 6/28/09 with diagnoses of Fever, Anemia, Testicular Cancer with metastasis and Sepsis. Documentation on the "Orders- General Admission" indicated allergy to morphine. Documentation in the "History and Physical" dated 6/28/09 at 1335 also indicated "Allergies: Morphine." Documentation indicated an order was written by the physician on 7/2/09 for "Morphine Sulfate 10 mg IV q 2 hr prn." Documentation on the "Medication Administration Record" indicated that Morphine Sulfate 10 mg/ml was given at 0846. There was no documentation to indicate that Pt. #15's allergy status had changed prior to the time of morphine administration.

3. During an interview with the Director of Patient Care Services on 10/8/09 at 12:00 PM, the above finding was confirmed.

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A. Based on policies and procedures, record review,and staff interview it was determined that the CAH failed to ensure that clinical records were maintained in accordance with policies and procedures.

Findings include:

1. The policy titled, "Rules and Regulations of the Medical Staff" under "X. Medical Record Completion 3.b. Delinquent status: iv. Any records missing signatures thirty (30) days after discharge."

2. The "Delinquency Rate Report" was reviewed on 10/07/09. Documentation indicated that there were 80 delinquent records between 9/1/09 thru 9/30/09.

3. During an interview with the Director of Patient Care Services on 10/8/09 at 12:00 PM, the above findings were confirmed.

A. Based on medical record review and staff interview it was determined that in 3 of 21 (Patient (Pt.) #16, 17, 20) records reviewed, the Critical Access Hospital (CAH) failed to ensure that physician orders were complete and accurate.

Findings include:

1. The medical record of Pt. #16 was reviewed on 10/7/09. Pt. #16 was admitted to the CAH on 8/18/09 with the diagnosis of Anemia. Documentation indicated that admission orders were written on 8/18/09 and signed by the physician on 8/19/09 with no time. Documentation indicated that a physician order for "CT of abdomen..." was written on 8/18/09 and signed by the physician on 8/19/09 with no time.

2. The medical record of Pt. #17 was reviewed on 10/7/09. Pt. #16 was admitted to the CAH on 8/3/09 with the diagnoses of Hepatocellular Carcinoma and Hypertension. Documentation indicated that a physician order "Sonogram liver, GB...) was written and signed on 8/4/09 with no time. Documentation indicated that on 8/4/09 the Deep Vein Thrombosis (DVT) prophylaxis was signed and dated by the physician with no time.

3. The medical record of Pt. #20 was reviewed on 10/7/09. Pt. #20 was admitted to the CAH on 7/17/09 with the diagnoses of Fractured Right Femur and Right Hip Pain. Documentation indicated that a physician order "Admit pt. to Med-Surg..." written on 7/17/09 with no time.

4. During an interview with the Director of Patient Care Services on 10/8/09 at 12:00 PM, the above findings were confirmed.