HospitalInspections.org

Surveyor #1

Based on medical record review, the hospital failed to ensure that evidence existed to show that Medicare patients received a copy of the standardized notice "An Important Message from Medicare" upon or within two (2) days of admission and/or prior to discharge for 4 of 4 Medicare patients reviewed for the beneficiary notice (Patient #'s 2-5).

Failure to ensure that patients receive their rights, as required, places these patients at risk of harm related to a discharge that may be accomplished prior to the patient being ready for discharge.

Findings:

1. Per review of Patient #2's medical record, the patient was admitted with Medicare benefits on 5/3/2012. The record did not contain the notice titled "An Important Message from Medicare" that was signed by the patient.
The record did not contain the same document or evidence that the information was given to the patient prior to discharge.

2. Per review of Patient #5's medical record, the patient was admitted with Medicare benefits on 5/11/2012. The record did not contain the notice titled "An Important Message from Medicare" or evidence that the information was given to the patient, prior to discharge.

3. Per review of Patient #4's medical record, the patient was admitted with Medicare benefits on 3/16/2012. The record did not contain the notice titled "An Important Message from Medicare". The record did not contain the same document or evidence that the information was given to the patient prior to discharge.

4. Per review of Patient #3's medical record, the patient was admitted with Medicare benefits on 1/20/2012 at 2:00 AM. The record contained the notice titled "An Important Message from Medicare" that was signed by the patient at that time. The record did not contain the same document or evidence that the information was given to the patient prior to discharge.
The patient was re-admitted with Medicare benefits on 1/27/2012. The record did not contain the notice titled "An Important Message from Medicare" that was signed by the patient. The record did not contain the same document or evidence that the information was given to the patient prior to discharge on 2/1/2012.

Based on observation the hospital failed to implement cross-connection controls to maintain the hospital's drinking water supply in safe condition.

Failure to maintain cross connection controls on laboratory equipment and scope washers places the patients and staff at risk for possible exposure to chemical and biological contaminates.

Findings:
1. On 5/16/2012 at 2:30 PM while conducting a tour of the laboratory, the surveyor observed a Millipore water filter system that supplied treated water to a chemical analyzer. There was no backflow preventer on the Millipore filter system to prevent possible back siphoning of chemicals or biological contaminates into the drinking water system.

2. On 5/17/2012 at 3:45 PM the surveyor found that the Steris (System 1E Processor) peracetic acid endoscope processor in the endoscopy surgical suite #5 was not installed with a reduce pressure backflow assembly. The scope washer was connected to the hospital's domestic water supply at the wash sink which also supplied water to an eye wash station. The scope washer could possible contaminate the hospital's drinking water and the eye wash station with biological and chemical contaminates during a loss of water pressure without the proper backflow equipment installed.

Any equipment added to the hospital's water supply system will need a level of backflow protection specific for the piece of equipment installed on the domestic water line.

Based on observation the hospital failed to ensure that proper ventilation was maintained in the laboratory and adjoining patient care areas. Failure to maintain correct ventilation and air flow patterns in the hospital places the patients at risk for the spread of infections.

Findings:

On 5/16/2012 at 2:00 PM during the environmental tour with hospital engineering staff, the surveyor observed a soiled utility room next to the laboratory that was separated by a shared common door. The surveyor used a strip of tissue paper to observe the direction of air flow from the lab and found the tissue strip blew out from the laboratory through the soiled utility room and out into the adjoining hallway. The air pressure in the lab was positive to the corridor and to the soiled utility room. Air balancing was needed to ensure the air pressure in the soiled utility room and the laboratory was negative to the corridor.

Based on observation the Critical Access Hospital (CAH) failed to meet the provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.

Refer to the Fire Life Safety report for deficiencies found during the survey on 5/15-17/2012.

Surveyor #1

Based on review of hospital infection control documents and administrative interview, the infection control program did not include a mechanism for collecting and reviewing infections and communicable diseases from non-patient care staff, contract staff and volunteers.

Failure to collect information pertaining to individuals that could place themselves in a position to infect hospital patients places all patients at risk of harm.

Findings:

Per interview with Staff #2 on 5/17/2012, it was stated that there was no policy and procedure, nor was the program designed to provide information to the infection control program concerning any infections and communicable diseases from such persons as: non-patient care staff; contract staff; and volunteers.

Surveyor #1

Based on medical record review, the hospital's Rehabilitation Services failed to ensure that a policy and procedure was developed and implemented requiring that patients will have an individualized plan of treatment that includes measurable short-term and long-term goals for 1 of 1 records reviewed for swing bed rehabilitative services (Patient #1).

Failure to ensure that short- and long-term measurable goals are incorporated in the treatment plan places patients at risk of not having their rehabilitation needs recognized or met.

Findings:

Per record review, Patient #1 was admitted on 1/20/2012 and started receiving Physical Therapy (PT) services on 1/21/2012. As stated by Staff #1, the patient's plan of treatment is written after each therapy session and documented in the electronic record. Per review of the "Physical Therapy Goals" section, goals were identified but there was no way to determine if these were "short-term" or "long-term" goals".
In addition, there was no documentation in the plan that showed any incorporation of "patient, family and caregiver goals".

Surveyor #1

Based on medical record review, the hospital failed to ensure that medical records contained a history and physical for 3 of 3 records reviewed for completeness (Patient #'s 4, 6, 7).

Failure to ensure that medical records are promptly completed places all patients at risk of harm related to the possibility that the information would not be available in a timely manner.

Reference: per review of Medical staff policy and procedure titled "Documentation: Medical Record", #D-10, last revised 4/2012, it states, "All medical records are to be completed and authenticated within thirty (30) days of date of discharge".

Findings:

1. Per record review, Patient # 4 was a patient in the hospital in March 2012. Per review of the "Incomplete Record" documentation form, the patient's "History and Physical" had not been completed by the physician, as of 5/16/2012.

2. Per record review, Patient # 6 was a patient in the hospital in March 2012. Per review of the "Incomplete Record" documentation form, the patient's "History and Physical" and "Discharge Summary" had not been completed by the physician, as of 5/16/2012.

3. Per record review, Patient # 7 was a patient in the hospital in February 2012. Per review of the "Incomplete Record" documentation form, the patient's "Discharge Summary" had not been completed by the physician, as of 5/16/2012.

Surveyor #1

Based on medical record review, the hospital failed to ensure that documentation existed to show each patient was evaluated for proper anesthesia recovery by a qualified practitioner for 3 of 3 records reviewed for surgical service recovery (Patient #'s 8, 9, 10).

Failure to document assessments of cardiopulmonary status; level of consciousness; any follow-up care and/or observations; and any complications occurring during post-anesthesia recovery places patients at risk of harm related to the potential that their post-surgery course might be compromised by un-assessed areas.

Findings:

1. Per medical record review, Patient #8 was admitted on 5/8/2012 for surgery. Per review of the "Anesthesia Record", a "Post-Anesthesia Note" section was on the form that contained a "check box" for "No post-anesthesia complications" and "Specific post-anesthesia complication noted". There was no documentation of any assessments of "cardiopulmonary status; level of consciousness; any follow-up care and/or observations". The anesthesia provider stated that this is the only place for the post-anesthesia evaluation to be documented.

2. Per medical record review, Patient #9 was admitted on 4/22/2012 for surgery with general anesthesia. Per review of the "Anesthesia Record", there was no documentation of any assessments of "cardiopulmonary status; level of consciousness; any follow-up care and/or observations".

3. Per medical record review, Patient #10 had surgery, including general anesthesia,
on 5/7/2012. Per review of the "Anesthesia Record", there was no documentation of any assessments of "cardiopulmonary status; level of consciousness; any follow-up care and/or observations".

Surveyor #1

Based on review of hospital documents and administrative interview, the written agreement with an Organ Procurement Organization (OPO) did not include a mechanism for integration into the hospital Quality Assurance (QA) Program..

Failure to have QA oversight of the OPO agreement places patient's families at risk of not having their wishes followed regarding patient organ and tissue donations in a timely manner.

Findings:

Per review of the OPO agreement, no information was found to show that specifics of the agreement were being monitored within the QA Program. Per interview with Staff #3 on 5/17/2012, it was stated that there was no documentation that the QA program had been monitoring any specifics from the written agreement.

Surveyor #1

Based on review of hospital-provided documentation, the hospital failed to ensure that the resident rights document given to the patient upon admission contained the following: "The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section; and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law.

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of the "Swing Bed Services Patient Information Packet", the identified section pertaining to patient rights did not contain the required language identifying the right, as identified above.

Surveyor #1

Based on review of hospital-provided documents, the hospital failed to ensure that Swing Bed patients were given their resident rights information upon admission, to include: "The resident has the right to be fully informed in advance about...any changes in that care or treatment that may affect the resident's well-being".

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of the "Swing Bed Services Patient Information Packet", the identified section pertaining to patient rights did not contain the required language identifying the right, as identified above.

Surveyor #1

Based on review of hospital-provided documents, the hospital failed to ensure that Swing Bed patients were given their resident rights information upon admission, to include: "The resident has the right to personal privacy and confidentiality of his or her personal and clinical records".

Failure to ensure that all required resident rights are given to patients places them at a risk of potential harm related to their ignorance of their rights as residents.

Findings:

Per review of the "Swing Bed Services Patient Information Packet", the identified section pertaining to patient rights did not contain the required language identifying the right, as identified above.

Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident; and the resident may approve or refuse the release of personal and clinical records to any individual outside the facility;