HospitalInspections.org

Based on observation, interview and policy and procedure review, the hospital failed to ensure hand hygiene was performed in 2 of 3 observations of medications passes (Staff L and Staff M). Failure to ensure hand hygiene is performed appropriately puts all patients at risk for cross-contamination of bacteria, blood borne pathogens, infections and communicable disease. The facility failed to provide a sanitary environment during the use of the glucometer (a device used to test blood sugars in a diabetic patient)(Staff M). Failure to ensure a sanitary environment to prevent infection when testing a blood sugar puts all patients at risk for acquiring blood borne pathogens, infections and diseases. The facility also failed to maintain a separate environment for staff food and patient therapy supplies in the patients' freezer and refrigerator. Failure to separate staff food from medical items used for patient care puts all patients at risk for contamination of medical supplies causing unsafe and ineffective care.

Findings include:

- Registered Nurse (RN) Staff L observed on 5/3/17 at 12:01 PM revealed them failing to perform hand hygiene after administering medications.

RN Staff L interviewed on 5/3/17 at 12:20 PM stated he/she forgot to perform hand hygiene.

- RN Staff M observed on 5/3/17 at 12:11 PM revealed them failing to perform hand hygiene during medication passes. Staff M was observed picking up the patients' medication administration record off the floor after he had stepped on it and opened the patient medication and administered it to the patient with bare hands. Staff M proceeded to open another patient's medications and administer the medications to the next patient. Staff M then took the medications back to the med room and failed to perform hand hygiene throughout the medication passes.

RN Staff M interviewed on 5/3/17 at 12:20 PM stated he/she was not aware that hand hygiene was missed.

- Policy titled "Handwashing Guidelines" reviewed on 5/3/17 directed " ... always use hand hygiene before any patient contact, after contact with patients skin, after contact with body fluids or excretions, non-intact skin or wound dressings, after removing gloves ..."


- RN Staff M observed on 5/3/17 at 11:55 AM revealed them testing a patient's blood sugar and placing the bucket containing supplies on the patient bedside table. Staff M placed the test strip bottle on the bedside table after removing a test strip and proceeded with the procedure appropriately. Staff M placed the glucometer used to test the patient blood sugar and the test strip bottle on top of a pile of lancets (small devices used to prick the skin to obtain blood for the test) contaminating them after patient use. The supply bucket was returned to the shelf in the nursing station.

RN Staff M interviewed on 5/3/17 at 12:21 PM revealed they are were not aware that the contaminated test strip bottle and glucometer used to test the blood sugar was placed on the clean lancets. Staff M removed the test strip bottle and glucometer and appropriately cleaned them.

Director of Nursing Staff B interviewed on 5/3/17 at 12:35 clarified the process of preventing spread of infection and appropriately cleaning the test strip bottle and glucometer after patient use. The facility failed to provide a policy and procedure for the use of a glucometer.


- Physical Therapy Room observed on 5/1/17 at 10:32 AM revealed an opened and re-sealed bag of broccoli in the patient freezer containing ice packs used in therapy. The patient refrigerator revealed several staff salad dressings along with a bag of electrodes used for therapy treatments. Staff D removed the staff food items immediately.

Physical Therapy Staff D interviewed on 5/1/17 at 10:32 AM stated they were not sure if food and patient items could be stored together. Food items were removed immediately. The facility failed to provide documentation of a policy in regards to staff food in patient refrigerators and freezers.

Based on interview, document review, and policy and procedure review, the hospital failed to ensure an effective Quality Assessment and Performance Improvement (QAPI) program to evaluate the quality and appropriateness of the diagnosis, treatment and treatment outcomes for the facility. Failure to ensure quality and appropriate diagnosis, treatment and outcomes puts all patients at risk for receiving inadequate care or treatment, harm, infection, or disability and outcomes resulting in further medical care, time in the hospital, costs and possibly death.

Findings include:

Quality Director Staff H interviewed on 5/2/17 at 9:27 AM stated the facility failed to have a written plan for a quality program. Staff H stated he/she is not aware of what a QAPI program should have or do.

Document titled "Medical Staff By-Laws" reviewed on 5/2/17 directed " ...Article VII Committees failed to list a QAPI committee for the facility ..."

Policy titled "Quality Assessment/Performance Improvement Program" reviewed on 5/3/17 directed " ...the organization-wide QA/PI program is to be comprehensive, well defined, and organized in such a way as to oversee the quality assurance activities of the various departments and services so that opportunities to improve care are pursued, patient safety is fostered, and identified problems are resolved. Efforts to analyze why an error has occurred (Root Cause Analysis) are an essential part of the QA/PI process so that appropriate corrective measures can be instituted ..."

Based on interview, document review and policy and procedure review, the hospital failed to ensure a Quality Assessment and Performance Improvement (QAPI) program evaluated all patient care services in the facility that affect patient health and safety. Failure to ensure all facility service areas are evaluated puts all patients at risk for harm, illness, falls, infection and disease.

Findings include:

Quality Director Staff H interviewed on 5/2/17 at 9:27 AM stated the facility failed to have a written plan for a quality program. Staff H stated he/she is not aware of what a QAPI program should have or do.

Document titled "Medical Staff By-Laws" reviewed on 5/2/17 directed " ...Article VII Committees failed to list a QAPI committee for the facility ..."

Policy titled "Quality Assessment/Performance Improvement Program" reviewed on 5/3/17 directed " ...the organization-wide QA/PI program is to be comprehensive, well defined, and organized in such a way as to oversee the quality assurance activities of the various departments and services so that opportunities to improve care are pursued, patient safety is fostered, and identified problems are resolved. Efforts to analyze why an error has occurred (Root Cause Analysis) are an essential part of the QA/PI process so that appropriate corrective measures can be instituted ..."

Based on interview, document review and policy and procedure review, the hospital failed to ensure a Quality Assessment and Performance Improvement (QAPI) program was in place to evaluate nosocomial infections and medication therapy. Failure of the facility to evaluate nosocomial infections and medication therapy puts all patients at risk for acquiring infections and diseases that could be life threatening and receiving medications resulting in poor outcomes or adverse reactions that could be life threatening.

Findings include:

Quality Director Staff H interviewed on 5/2/17 at 9:27 AM stated the facility failed to have a written plan for a quality program. Staff H stated he/she is not aware of what a QAPI program should have or do.

Document titled "Medical Staff By-Laws" review on 5/2/17 directed " ...Article VII Committees failed to list a QAPI committee for the facility ..."

Policy titled "Quality Assessment/Performance Improvement Program" reviewed on 5/3/17 directed " ...the organization-wide QA/PI program is to be comprehensive, well defined, and organized in such a way as to oversee the quality assurance activities of the various departments and services so that opportunities to improve care are pursued, patient safety is fostered, and identified problems are resolved. Efforts to analyze why an error has occurred (Root Cause Analysis) are an essential part of the QA/PI process so that appropriate corrective measures can be instituted ..."

Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) failed to follow professional guidelines for stocking the emergency medication Dantrium/Revonto (treats Malignant Hyperthermia - a condition associated with the use of succinylcholine (a medication used to relax the muscles during surgical procedures or intubation (using a device placed into the windpipe to provide airway management) and other triggering agents that causes a rapid rise in body temperature that could become life threatening) by not having the required amount of Dantrium/Revonto on hand because their rapid sequence intubation protocol included the use of succinylcholine (refer to C-0203). Failure to have the correct amount of Dantrium/Revonto could cause patient harm or death in the event of Malignant Hyperthermia

An Immediate Jeopardy (IJ) (a situation that has or is likely to cause patient harm) was identified on 5/2/2017 at 4:40 PM when the facility was found to have only 30 of the required 36 vials of Dantrium. Department Staff notified the Chief Executive Officer Staff A. Staff A immediately suspended the use of succinylcholine until the reversal agent Dantrium/Revonto could be obtained and suspended Surgical Services and Emergency Services for patients that have been given succinylcholine or may require its use for intubation. The facility also included in the plan of correction that they would begin weekly surveillance for the appropriate quantity of Dantrium.

The reversal agent Dantrium/Revonto was delivered at 5:30 PM on 5/2/2017 and the facility removed the IJ prior to the survey exit date.

Based on observations, interview and policy review, the facility failed to ensure Emergency room supplies and medications did not exceed the manufacturer's safe use date in the Pediatric Emergency Supply cart, and in the Secondary Emergency Room. This deficient practice had the potential to cause compromised medications and unsafe supplies to be used during the care and treatment of emergent patients.

Findings include:

- Pediatric Emergency Supply Cart observed between 5/1/2017 at 11:45 AM and 5/2/2017 at 3:36 PM revealed the following outdated supplies:

1. Nine Pediatric ECG electrode sets (adhesive electrodes used to monitor electrical heart rhythm) having an expiration date of 12/2009
2. Two IV securement kits (special adhesive bandages used to secure intravenous catheters) having an expiration date of 9/2016
3. Three Small bore IV extension kits (special extension tube attached to the intravenous catheter used to connect other devices) with an expiration date of 5/2015
4. One size 1.8mm X 15mm having EZ-IO kit (special needle used to access intravenous access through the bone) an expiration date of 6/2016
5. One Pedi-Padz electrode set (adhesive electrodes used to monitor electrical heart rhythm) with an expiration date of 8/1/2016
6. One size 5 Laryngeal Mask Airway (medical device that keeps a patient's airway open during anesthesia or unconsciousness) having an expiration date of 2/2017
7. One size 2.5 Laryngeal Mask Airway (medical device that keeps a patient's airway open during anesthesia or unconsciousness) having an expiration date of 1/2017
8. One Carbon dioxide detector (device for the measurement of exhaled carbon dioxide) having an expiration date of 12/2016
9. Four size 8F Stomach tubes (device used to extract substances from the stomach) having an expiration date of 4/2016
10. One size 10F Stomach tube (device used to extract substances from the stomach) with an expiration date of 4/2016
11. One size 18F Stomach tube (device used to extract substances from the stomach) with an expiration date of 5/2016
12. Two size 3.5 Endotracheal tubes (device for securing an airway that can be introduced by way of the mouth or nose) with an expiration date of 2/2017,
13. Two size 4.0 Endotracheal tubes (device for securing an airway that can be introduced by way of the mouth or nose) having an expiration date of 1/2017
14. One size 4.5 Endotracheal tube (device for securing an airway that can be introduced by way of the mouth or nose) having an expiration date of 10/2016
15. Two size 5.0 Endotracheal tubes (device for securing an airway that can be introduced by way of the mouth or nose) having an expiration date of 3/2017
16. One size 6.0 Endotracheal tube (device for securing an airway that can be introduced by way of the mouth or nose) having an expiration date of 2/2017
17. One size 6.5 Endotracheal tube (device for securing an airway that can be introduced by way of the mouth or nose) having an expiration date of 12/2016
18. One size 8F Suction catheter (device used to extract bodily secretions, such as mucus or saliva from the upper airway) with an expiration date of 9/2016,
19. Five size 10F Suction catheters (device used to extract bodily secretions, such as mucus or saliva from the upper airway) with an expiration date of 11/2016, and
20. One size 12F Suction catheter (device used to extract bodily secretions, such as mucus or saliva from the upper airway) with an expiration date of 3/2017
21. Two size 10F Stylets (a fine wire that is run through a catheter, cannula, or hollow needle to keep it stiff or clear of debris) having an expiration date of 5/2016,
22. Two size 6F Stylets (a fine wire that is run through a catheter, cannula, or hollow needle to keep it stiff or clear of debris) having an expiration date of 5/2016
23. One size 5.5 Oral/nasal tracheostomy tube with an expiration date of 4/2015
24. Three IV Kits (kit containing special bandages and equipment used to initiate and secure intravenous catheters) having an expiration date of 12/2015,
25. One IV Kit (kit containing special bandages and equipment used to initiate and secure intravenous catheters) having an expiration date of 9/2019
26. Two size 18g IV catheters (hollow sheathes remaining in the punctured vein to allow infusion of medications or fluids) with an expiration date of 9/2016
27. One size 22g IV catheter (hollow sheathes remaining in the punctured vein to allow infusion of medications or fluids) with one having an expiration date of 7/2017
28. Three Iodine swabs (single use medicated swab) having an expiration date of 1/2016


- Secondary Emergency Room observed on 5/1/2017 at 11:20 AM revealed the following expired supplies:
1. Six 22 x 1 inch Monojet needles with an expiration date of 7/2013
2. Eight 22x 1 ½ inch Monojet needles with three having an expiration date of 10/2016, two 1/2017 and three 1/2016
3. Seven 25x 5/8 inch Monojet needles with an expiration date of 7/2013
4. Two 20x1 inch Monojet needles with expiration dates of 10/0216 and 7/2013
5. Two Disposable Skin Staplers with expiration dates of 8/2014 and 1/2017
6. Four packages of Gelfoam (an absorbable gelatin compressed sponge used for wound care) with an expiration date of 1/2017
7. Three Bactiswab kits (swab used to collect cell samples for laboratory testing) with an expiration date of 3/5/2017
8. Seven Bactiswab kits (swab used to collect cell samples for laboratory testing) with an expiration date of 11/27/2016
9. One disposable staple remover with an expiration date of 12/2016
10. Five #15 scalpels with an expiration date of 11/2015


Emergency room director staff K interviewed on 5/2/2017 at 3:55 PM indicated that they had not checked the pediatric emergency cart this month for outdates, but will replace outdated supplies today.

Policy titled Outdated Products reviewed on 5/3/2017 at 10:15 AM directed " ... it shall be the policy of Harper Hospital District No 5 that outdates on all products shall be respected ..." and " ... outdated products shall be disposed of ..."

Based on observations, interview, and document review, the Critical Access Hospital (CAH) failed to ensure emergency medications were readily available in the emergency department (ED) and surgery department by failing to have medication on hand to treat Malignant Hyperthermia which is a rare life-threatening condition causing a severe high body temperature triggered by medications that act as depolarizing muscle relaxants such as succinylcholine (a muscle relaxant administered in situations when intubation (a procedure where a tube is placed into the patients airway to manage breathing)) is required. Failure to have enough Dantrium/Revonto immediately available for use has the potential for delays in responding to a medical emergency causing a worsening of a patient's condition or death.


Findings Include:

- CAH pharmacy tour conducted on 5/2/2017 at 3:49 PM revealed 30 vials of succinylcholine in the Operating Room refrigerator. Further observation of the pharmacy and review of the formulary revealed the CAH did not have Dantrium/Revonto listed as an antidote if malignant hyperthermia occurs because of the administration of succinylcholine in emergency procedures.

Pharmacy Registered Nurse Staff I interview on 5/2/2017 at 4:00 PM confirmed s/he had failed to order enough vials from their supplier.

Chief Executive Officer Staff A interviewed on 5/2/2017 at 5:00 PM confirmed the facility did not have a policy for Dantrium/Revonto administration in malignant hyperthermia situations. Documentation provided revealed the last administration of succinylcholine was 4/11/2017.

Review of Poster mounted on the wall and titled "Emergency Therapy for Malignant Hyperthermia" on 5/3/3017 at 9:30 AM directed " ...Dantrolene (Dantrium/Revonto) 2.5mg/kg Rapidly IV * Repeat until there is control of the signs of MH (Malignant Hyperthermia) ..."

Chief Executive Officer Staff A in a written statement on 5/2/2017 at 5:00 PM indicated " ...We are currently in the process of receiving 6 vials from another facility to meet the 36 vial requirement. Until those 6 vials are onsite, we will not perform any surgeries that require Succinylcholine as an anesthetic. In addition, we will not take any patients through our ER that have been given Succinylcholine as we will not be able to intubate them until we have the full required 36 vials of Dantrolene ..."

Chief Executive Officer Staff A received 36 vials of Dantrium on 5/2/2017 at 5:30 PM and placed in the Malignant Hyperthermia Cart.

Malignant Hyperthermia Association of the United States website reviewed on 5/4/2017 directs " ...The patient experiencing an Malignant Hyperthermia (MH) episode must be stabilized before being transported. Stabilization of an MH episode may take 30 minutes or more with multiple doses of Dantrolene because, in some cases, MH progresses with explosive rapidity. The full 36 vials of dantrolene is inexpensive insurance against patient injury or death and a malpractice claim, which the facility will lose. The full 36 vials of dantrolene should be available within five minutes of the diagnosis of MH ..."

Based on interview and document review, the hospital failed to ensure policy and procedures at the facility are reviewed annually by the governing body. Failure to ensure the facility policy and procedures are reviewed at least annually puts all staff and patients at risk for care given and received lacking current recommendations and changes needed to provide safe care according to State and Federal guidelines and regulations.

Findings include:

Director of Nursing Staff B interviewed on 5/3/17 at 11:45 AM stated the facility lacked documentation in the Medical Staff By-Laws and the facility's policy and procedures requiring the governing body to review the facility's policy and procedures annually.

Board of Director Meeting Minutes for 2016 and 2017 reviewed on 5/3/2017 revealed the documents lacked evidence the governing body reviewed policies and procedures annually.

Based on observation, interview and policy and procedure review, the hospital failed to ensure supplies in the 3 of 3 areas observed were discarded after expiration (2 procedure rooms, and an intravenous (IV) room). Failure to ensure outdated supplies are discarded after expiration puts all patients at risk for receiving care with ineffective medical supplies. The facility also failed to ensure 3 of 3 opened multi-dose vials in the physical therapy area were dated after opened. Failure to date opened multi-dose vials of medications puts all patients at risk for receiving medications that are ineffective and unsafe for use.

Findings include:

- Procedure room 1 observed on 5/1/17 at 1:14 PM revealed the following outdated supplies:
- 0.9% Sodium Chloride 1,000 milliliter (ml) bag (salt in water) 1 expired 4/17
- Xeroform Occlusive Gauze dressing (a sterile non-adhering protective dressing consisting of absorbent, fine-mesh gauze impregnated with a petroleum blend) 6 packages expired 3/17


- IV room observed on 5/1/17 at 1:23 PM revealed the following outdated supplies:
- 5% Dextrose 1,000 ml bag (a simple sugar made from corn and is chemically identical to glucose) 5 bags expired on 2/17
- 5% Dextrose 500 ml bag 5 expired 1/17
- CIV-Flex Transducer cover (designed specifically for ultrasound use to slide easily over transducers (a device that converts variations in a physical quantity, such as pressure or brightness, into an electrical signal or vice versa) and is a recommended alternative for latex-sensitive patients and professionals) 6 expired 11/16
- Lactated Ringers and 5% Dextrose 1000ml bag (a mixture of sodium chloride (salt electrolytes), sodium lactate (salt of lactic acid (an organic compound), potassium chloride (a metal salt) and calcium chloride (an inorganic compound of salt and calcium) in water 5 expired 3/17
- Lactated Ringers and 5% Dextrose 1000ml bag 3 expired 2/17


- Procedure room 2 observed on 5/1/17 at 1:45 PM revealed the following outdated supplies:
- 1 ml syringes 4 expired 4/17
- 1 ml syringes 7 expired 3/13

Central Supply Manager Staff E interviewed on 5/1/17 at 1:45 PM verified the expired supplies and discarded them immediately. Staff E states the supplies are checked for outdates monthly.


- Policy titled "Outdated Products" reviewed on 5/3/17 directed " ...It shall be the policy of Harper Hospital District No 5 that outdates on all products shall be respected ...outdated products shall be disposed of according to the manufacture M.S.D.S. sheet and/or such other guidelines (such as OSHA, Health and Environment, and Pharmacy), provided for the use in disposal of the product ..."


- Physical Therapy Room observed on 5/1/17 at 10:32 AM revealed the following opened multi-dose vials in the: Two multi-dose vials of Xylocaine 2% (a medication to treat irregular heartbeats, it can also relieve pain and numb the skin) and one vial of Lidocaine 2% (a medication to treat irregular heartbeats and it can also relieve pain and numb the skin).


Physical Therapist Staff D interviewed on 5/1/17 at 10:32 AM verified the opened multi-dose vials opened without dates. Staff D stated he/she is aware they should have been dated and will discard the vials.


- Policy titled "Drugs and Biologicals" reviewed on 5/1/17 directed " ...all injectables are dated and initialed the date they are opened ..."

Based on interview, record review and policy and procedure review, the hospital failed to ensure patient care plans were completed in 4 of 35 records reviewed (Patient # 21, 23, 25 and 35). Failure to ensure care plans are completed puts all patients at risk for lack of direction, continuity of care and discharge individualized for each patient according to their health care needs.

Findings include:

- Record review on 5/3/17 revealed an individualized nursing care plan lacking in the closed record review for patients # 21, 23, 25 and 35.

Medical Records Director Staff J interviewed on 5/3/17 at 10:05 AM verified the missing care plans from patients # 21, 23, 25, and 35. Staff J verified by reviewing the electronic medical record (EMR) and paper chart for each patient.

- Policy titled "Nursing Care Plans for Outpatient, Acute and Swing Bed Patients" reviewed on 5/3/17 directed " ...nursing care plans will be initiated by the registered nurse at the time of admission ...nursing care plans will be individualized for each patient according to their diagnosis and specific problems ..."

Based on interview, record review and policy and procedure review, the hospital failed to ensure patient rights and a consent to treat was signed in 2 of 35 records reviewed (patient #21 and 26). Failure to ensure patient rights and consent are signed upon admission puts all patients at risk for receiving care and treatments without their approval, knowledge, questioning and acceptance resulting in patient protection violated according to the State and Federal law. The facility also failed to ensure Discharge Summaries were signed within 30 days of discharge in 2 of 35 records reviewed (patients # 31 and 35). Failure of the physician to authenticate the discharge summary puts all patients at risk for continuity of care following discharge causing harm related to incorrect treatments, medications and re-hospitalization.

Findings include:

- Patient # 21's medical record review on 5/3/17 revealed the patient was admitted 2/7/17 with a diagnosis of pneumonia lacked evidence of patient rights and consent signed upon admission or during their acute stay at the facility. The patient was discharged on 2/8/17.

- Patient # 26's medical Record review on 5/3/17 revealed the patient was admitted on 1/9/17 with a diagnosis of dehydration and vomiting lacked evidence of patient rights and consent signed upon admission or during their stay at the facility. The patient was discharged on 1/9/17.

Medical Record Director Staff J interviewed on 5/3/17 at 10:05 AM verified the patient rights and consents were missing from the EMR (Electronic Medical Record) and paper chart for patients # 21 and 26.

- Policy titled "Admit a Patient to the Hospital" reviewed on 5/3/17 directed " ...The front desk will be notified by the NSA or nurse of the admission and room assignment ...signature for consent to treatment will be obtained ..."

- Patient # 31's medical record review on 5/3/17 revealed the facility failed to provide documentation of a discharge summary in the EMR and/or paper chart.

- Patient # 35's medical record reviewed on 5/3/17 revealed a signed discharge summary 31 days after the patient was discharged. The patient was discharged 2/6/17 and the discharge summary was authenticated by the physician on 3/9/17.


Medical Records Director, Staff J interviewed on 5/3/17 at 10:10 AM verified the lack of a discharge summary for patient # 31 and the discharge summary signed after the 30 days of the patient discharge for patient # 35.

- Document titled "Medical Staff By-Laws "reviewed on 5/3/17 directed " ...records of patients discharged shall be completed within 30 days following discharge ..."

Based on document review and staff interview the Critical Access Hospital (CAH) failed to ensure providers authenticated (signed) all orders in the medical record for 2 of 35 patients' clinical records reviewed (Patient #'s 4 and 5). The facility failed to ensure all History and Physicals (H&Ps) were signed within 48 hours of admission for 3 of 35 patients reviewed (Patient #'s 23, 25, and 33). This deficient practice had the potential to place patients at risk for receiving medications and/or treatments without confirmed orders, which could cause patient harm.

Findings include:

- Patient # 4's medical record reviewed on 5/4/2017 at 10:00 AM revealed the following orders lacking authentication by the prescribing provider (Physician Assistant Staff O):
1 verbal order was placed on 11/18/2016
4 verbal orders were placed on 11/19/2016
1 verbal order was placed on 11/20/2016

- Patient # 5's medical record reviewed on 5/3/2017 at 10:00 AM revealed the following orders lacking authentication by the prescribing provider (Physician Staff N):
1 verbal order was placed on 1/8/2016
1 verbal order was placed on 1/22/2016
1 verbal order was placed on 1/29/16
1 verbal order was placed on 2/1/2016
2 verbal orders were placed on 2/4/2016
3 verbal orders were placed on 2/5/2016
1 verbal order was placed on 2/20/2016
6 verbal orders were placed on 2/24/2016
3 verbal orders were placed on 2/28/2016
3 verbal orders were placed on 2/29/2016
1 verbal order was placed on 3/7/2016
1 verbal order was placed on 3/9/2016
2 verbal orders were placed on 3/14/2016
2 verbal orders were placed on 4/7/2016
1 verbal order was placed on 4/15/2016
1 verbal order was placed on 5/4/2016
1 verbal order was placed on 6/3/2016
1 verbal order was placed on 6/6/2016
2 verbal orders were placed on 7/8/2016
5 verbal orders were placed on 7/14/2016
1 verbal order was placed on 10/7/2016
1 verbal order was placed on 10/10/2016
1 verbal order on 11/20/2016
2 verbal orders were placed on 11/22/2016
1 verbal order was placed on 12/6/2016

Director of Nursing Staff B interviewed on 5/2/2017 confirmed the verbal orders identified in Patient #4 and 5's medical record lacked authentication by the provider.

Physician Staff N interviewed on 5/3/3017 at 1:15 PM confirmed they have placed telephone/verbal orders and do not even know how to go into the system and authenticate the orders. Staff N indicated there is not a system in place to remind them to authenticate orders and stated, "It is my responsibility to remember I made the order and I need to get them signed".

Review of the Medical Staff By-Laws on 5/3/2017 at 12:45 PM direct "A practitioner may give verbal orders for medication or treatment to personnel who are qualified ...and ... The prescribing practitioner shall authenticate the order within 24 hours ..."



- Patient #23's medical record reviewed on 5/3/17 revealed the patient was admitted on 2/17/17 with a diagnosis of abdominal pain. The physician failed to authenticate the History and Physical (H&P) within 48 hours. The physician signed the H&P on 2/24/17 (7 days after completion).

- Patient # 25's medical record reviewed on 5/3/17 revealed the patient was admitted on 3/24/17 with a diagnosis of Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The physician failed to authenticate the H&P within 48 hours. The physician signed the H&P on 3/31/17 (7 days after completion).

- Patient # 33's medical record review on 5/3/17 revealed the patient was admitted on 12/29/16 with a diagnosis of pneumonia and urinary tract infection. The physician failed to authenticate the H & P within 48 hours. The physician signed the H&P on 1/22/17 (24 days after completion).

Medical Record Director Staff J interviewed on 5/3/17 at 10:05 AM verified Patients # 23, #25, and #33 failed to have the H&P signed within the 48 hours required. Staff J stated they have attempted to obtain provider signatures.

Document titled "Medical Staff By-Laws" reviewed on 5/3/17 at 11:30 AM directs " ...no patient shall be admitted to the Hospital unless a physician or midlevel practitioner performs a physical examination and medical history with regard to such patient within 24 hours of admission. A preadmission physical examination and medical history may be included in the patient's chart in satisfaction of this requirement provided that such examination and history must have been performed no more than 7 days prior to the date of admission and an admission note is provided..."


Policy review on 5/3/2017 at 11:00 AM revealed the facility failed to provide a policy directing staff to ensure all patients receive a completed and signed medical history and physical within 48 hours of admission.

Based on review of patient rights, medical record review, and staff interview the Critical Access Hospital (CAH) failed to ensure 2 of 5 Swing Bed patients (Patient #'s 2 and 3) were informed of all of their rights. This deficient practice has the potential to cause patients to be unaware of their rights.

Findings include:

- Patient #2's medical record reviewed on 5/3/3016 at 10:30 AM revealed the patient was admitted on 2/10/2017 and discharged on 2/14/2017. The medical record lacked evidence the patient was informed of their rights.

- Patient #3's medical record reviewed on 5/3/3016 at 10:00 AM revealed the patient was admitted on 1/31/2017 and discharged on 2/3/2017. The medical record lacked evidence the patient was informed of their rights.


Director of Nursing Staff B interviewed on 5/3/2017 at 11:00 AM revealed all patients should be given their patient rights when they are admitted. Staff B indicated they would contact the medical records staff and verify the patient rights were given to each patient. Staff B failed to provide evidence patient #'s 2 and 3 received their rights.

Based on medical record review, staff interview and document review the hospital failed to provide documentation to Swing Bed Patients indicating the resident has the right to work or refuse to work at the facility for 5 of 5 swing bed patients reviewed (Patient's #1-5). This deficient practice has the potential to cause residents to perform work they may want to refuse.

Findings include:

- Patient #1's medical record reviewed on 5/3/2017 revealed they were admitted to a swing bed on 4/30/2017 and the facility provided swing bed rights to the patient during their admission which lacked the resident's right to work or refuse to work at the facility requirement.

- Patient #2's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 2/10/2017 and discharged on 2/14/2017 and the facility provided swing bed rights to the patient during their admission which lacked the resident's right to work or refuse to work at the facility requirement.

- Patient #3's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 1/31/2017 and discharged on 2/3/2017 and the facility provided swing bed rights to the patient during their admission which lacked the resident's right to work or refuse to work at the facility requirement.

- Patient #4's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 11/17/2016 and discharged on 1/22/2017 and the facility provided swing bed rights to the patient during their admission which lacked the resident's right to work or refuse to work at the facility requirement.

- Patient #5's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 3/3/2017 and the facility provided swing bed rights to the patient during their admission which lacked the resident's right to work or refuse to work at the facility requirement.

Director of Nursing Staff B interviewed on 5/3/2017 at 11:00 AM indicated the patients are given notice of their rights at upon admission.

- Document titled "Quality Care Right Here at Home" reviewed on 5/3/2017 at 4:00 PM failed to disclose to residents they had the right to perform or refuse to perform services for the facility if he or she chooses.

Based on document review, record review, and staff interview the hospital failed to include in their Swing Bed rights that the facility will provide patient notification of swing bed transfer 30 days prior to the transfer in 5 of 5 swing bed patients' records reviewed (Patient's #1-5). Failure to provide notification puts all swing bed patients at risk of inappropriate transfer.

Findings include:

- Patient #1's medical record reviewed on 5/3/2017 revealed they were admitted to a swing bed on 4/30/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #2's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 2/10/2017 and discharged on 2/14/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #3's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 1/31/2017 and discharged on 2/3/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #4's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 11/17/2016 and discharged on 1/22/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

- Patient #5's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 3/3/2017 and the facility provided swing bed rights to the patient during their admission which lacked the 30 day notification requirement.

Director of Nursing Staff B interviewed on 5/3/2017 at 11:00 AM indicated the patients are given notice of their rights at admission.

- Document titled "Quality Care Right Here at Home" reviewed on 5/3/2017 at 4:00 PM failed to include the facility will provide notice of transfer or discharge within 30 days

Based on document review, record review, and staff interview the hospital failed to include in their Swing Bed rights that the facility will provide orientation for transfer or discharge in 5 of 5 swing bed patients' medical records reviewed (Patient's #1-5). Failure to provide notification puts all swing bed patients at risk for poor transfer outcomes.

Findings include:

- Patient #1's medical record reviewed on 5/3/2017 revealed they were admitted to a swing bed on 4/30/2017 and the facility provided swing bed rights to the patient during their admission which lacked the right to orientation for transfer or discharge requirement.

- Patient #2's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 2/10/2017 and discharged on 2/14/2017 and the facility provided swing bed rights to the patient during their admission which lacked the right to orientation for transfer or discharge requirement.

- Patient #3's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 1/31/2017 and discharged on 2/3/2017 and the facility provided swing bed rights to the patient during their admission which lacked the right to orientation for transfer or discharge requirement.

- Patient #4's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 11/17/2016 and discharged on 1/22/2017 and the facility provided swing bed rights to the patient during their admission which lacked the right to orientation for transfer or discharge requirement.

- Patient #5's medical record review on 5/3/2017 revealed they were admitted to a swing bed on 3/3/2017 and the facility provided swing bed rights to the patient during their admission which lacked the right to orientation for transfer or discharge requirement.

Director of Nursing Staff B interviewed on 5/3/2017 at 11:00 AM indicated the patients are given notice of their rights at upon admission.

- Document titled "Quality Care Right Here at Home" reviewed on 5/3/2017 at 4:00 PM failed to include the right to orientation for transfer or discharge.