HospitalInspections.org

A.. Based on observation and staff interview, it was determined that the Critical Access Hospital (CAH) failed to ensure that all outdated biologicals were removed from the laboratory and not available for patient use.

Findings include:

1. During a tour of the CAH laboratory on 12/8/09 at 1:30 PM, the following expired items were found in the lab refrigerator: Eosinmethylene Blue (EMB) plates expired 12/4/09-- 4 packages of 10 plates each.

2. During an interview with the Director of Nursing on 12/9/09 at 1:30 PM, the above finding was confirmed.

A. Based on observation and staff interview it was determined that the CAH failed to ensure that food is properly stored and labeled.

Findings include:

1. During a tour of the dietary department on 12/8/09 at 1:00 PM, it was observed in the pantry, several opened packages of jello were inside a larger plastic sealed bag with no dates. Several canned foods had no date of receipt or an expiration date. In the freezer, it was observed that ice-cream bars were in an open box with no expiration date or date of receipt. Also, in the freezer were some frozen meats and vegetables with no date of receipt or expiration date.

2. During an interview with the Dietary Manager on 12/8/09 at 1:00 PM, when asked the procedure for labeling food items, she stated that "everything is to be labeled". When questioning the Dietary Manager about "First In First Out", she stated " all foods to be used first are put to the right".

3. During an interview with the Director of Nursing on 12/9/09 at 2:00 PM, the above findings were confirmed.

A. Based on record review and staff interview, it was determined that in 1 of 20 records reviewed (Pt.#17) the nurse failed to provide ongoing assessment of the patient's needs.

Findings include:
1. The medical record of Pt. #17 was reviewed on survey date 12/9/09. Pt. #17 was admitted to the CAH on 2/14/09 with diagnoses of Syncope, Anemia and Pleural Effusion.
Documentation on the admission assessment indicated "reason for hospitalization Unresponsive, Apnea." Documentation indicated that the admission nursing note was completed on 12/14/09 and indicated "pale,sallow color. Lungs with rales/rhonchi." There was no documentation of reassessment noted until 12/14/09 0730 AM indicating "Upon entering room Pt has no spontaneous respirations, no heart rate." Documentation indicates "Pt pronounced per (staff)." Documentation indicated Pt. #17 expired at 2/14/09 at 0750 AM.

2. During an interview with the Director of Nursing on 12/9/09 at 1:30 PM, the above finding was confirmed.

A. Based on record review and staff interview it was determined that in 1 of 20 (Pt. #15) medical records reviewed the nurse failed to ensure that medications were administered with a physician order.

Findings include:

1. The medical record of Pt. #15 was reviewed on 12/9/09. Pt. #15 was admitted to the CAH outpatient surgery department on 12/8/09 for an Esophagogastroduodenoscopy (EGD). Documentation dictated in the Operative Report indicated that Cetacaine spray was given prior to the procedure. There was no documentation in the nurses notes of the Cetacaine spray administration. There was no documentation of a physician order for the Cetacaine spray to be administered.

2. During a tour of the Surgical Department with the Circulating Nurse on 12/8/09 at 8:30 AM, she explained the normal procedure for an EGD would be to use Cetacaine spray before an EGD.

3. During an interview with the Director of Nurses and the Operating Room Nurse (ORN) on 12/9/09 at 11:00 AM, the ORN stated she felt sure that the Circulating Nurse used the Cetacaine spray before the procedure and she confirmed that there was no documentation of the Cetacaine spray being administered.

A. Based on policy, record review, and staff interview it was determined that the CAH failed to maintain medical records in accordance with policies and procedures.

Findings include:

1. The CAH policy titled, "Medical Records" under "I. PROCEDURE 3.0 All medical records are to be completed within fifteen (15) days of date of discharge."

2. A review of "Unresolved Chart Deficiencies Summary By Deficiency Type" indicated 116 delinquent records.

3. During an interview with the Director of Nursing on 12/9/09 at 2:00 PM, the above finding was confirmed.

A. Based on record review and staff interview it was determined that in 2 of 20 (Pt. #9, 19) medical records reviewed the CAH failed to ensure that the physician records are legible.

Findings include:

1. The medical record of Pt. #9 was reviewed on 12/8/09. Pt. #9 was admitted to the CAH on 10/6/09 with the diagnoses of Fever of Undetermined Origin. Documentation hand written on the "Short Stay" history and physical was illegible.

2. The medical record of Pt. #19 was reviewed on 12/9/09. Pt. #19 was admitted to the CAH on 10/9/09 with the diagnoses of Pneumonia and Dehydration. Documentation hand written on the "Short Stay" history and physical was illegible.

3. During an interview with the Director of Nurses on 12/9/09 at 2:00 PM, the above findings were confirmed.

B. Based on policy, record review, and staff interview it was determined that in 3 of 20 (Pt.s #2,5,6) medical records reviewed that the CAH failed to ensure that all "Do Not Resuscitate (DNR)" documents were completed per policy.

Findings include:

1. The policy titled, "Do Not Resuscitate Orders" under "V. PROCEDURE 1.0 Following discussion with the patient (agent), a summary of the discussion and medical order for withholding resuscitation will be written by the attending physician on the progress notes and order sheet respectively."

2. The medical record of Pt.#2 was reviewed on 12/7/09. Pt. #2 was admitted to the CAH on 12/4/09 with the diagnoses of Nausea and Congestive Heart Failure. Documentation indicated that the DNR was not completed per CAH policy.

3. The medical record of Pt. #5 was reviewed on 12/7/09. Pt. #5 was admitted to the CAH on 12/6/09. Pt. #5 was admitted to the CAH with the diagnoses of Pneumonia and Chronic Obstructive Pulmonary Disease. Documentation indicated that the DNR was not completed per CAH policy.

4. The medical record of Pt. #6 was reviewed on 12/7/09. Pt. #6 was admitted to the CAH on 12/5/09 with the diagnoses of Hypervolemia and Hyponatremia. Documentation indicated that the DNR was not completed per CAH policy.

5. During an interview with the Director of Nurses on 12/9/09 at 2:00 PM, the above findings were confirmed.

A. Based on review of policy, record review and staff interview, it was determined that in 2 of 20 (Pt. # 1, #6) records reviewed, the CAH failed to maintain records to include a pertinent medical history and physical assessment.

Findings include:

1. The CAH policy titled "History and Physical Examination" under I Procedure 1.0 Timeframe: " A medical history and physical examination shall be performed no more that thirty (30) days prior to admission or within twenty-four (24) hours after admission and shall be documented..."

2. The medical record of Pt. #1 was reviewed on 12/7/09. Pt. #1 was admitted to the CAH on 12/4/09 with the diagnosis of Acute Respiratory Disease. There was no history and physical documented in the medical record as of survey date 12/7/09.

3. The medical record of Pt. #6 was reviewed on survey date 12/7/09. Pt. #6 was admitted to the CAH on 12/5/09 with diagnoses of Hypervolemia, Diabetes Mellitus (DM) Atrial Fibrillation and Major Depression. There was no history and physical documented in the medical record as of survey date 12/7/09.

4. During an interview with the Director of Nursing on 12/9/09 at 1:30 PM, the above findings were confirmed.



B. Based on CAH policy, record review and staff interview, it was determined that in 4 of 20 closed records reviewed (Pt.# 4, #9, #12, #17), the CAH failed to maintain records to include a discharge summary.

1. The CAH policy titled "Medical Records" under I Procedure 2.0 "The attending physician shall be held responsible... a complete medical record for each patient. The policy indicates under 2.14 "discharge summary" and under 3.0 "All medical records are to be completed within fifteen (15) days of date of discharge."

2. The medical record of Pt. #4 was reviewed on survey date 12/7/09. Pt. #7 was admitted to the CAH on 8/3/09 with a diagnosis of Acute Alcohol Intoxication. Documentation failed to include a discharge summary as of survey date 12/7/09.

3. The medical record of Pt. #9 was reviewed on survey date 12/8/09. Pt. #9 was admitted to the CAH on 10/6/09 with diagnoses of Fever, Undetermined Origin. Documentation failed to include a discharge summary as of survey date 12/8/09.

4. The medical record of Pt. #12 was reviewed on survey date 12/8/09. Pt. #12 was admitted to the CAH on 6/21/09 with diagnoses of Intractable Pain, Anemia, and Status Post Below Knee Amputation, right. Documentation failed to include a discharge summary as of survey date 12/9/09.

5. The medical record of Pt. #17 was reviewed on survey date 12/9/09. Pt. #17 was admitted to the CAH on 2/14/09 with diagnoses of Syncope, Anemia and Pleural Effusion.
Documentation failed to include a discharge summary as of survey date 12/9/09.

6. During an interview with the Director of Nursing on 12/9/09 at 1:30 PM, the above findings were confirmed.

A. Based on policy and procedure, record review and staff interview it was determined in 7 of 20 ((Pt.s #2, 3, 4, 10, 14, 16, 18) records reviewed the CAH failed to ensure that physician orders were authenticated with signature, date, and time.

Findings include:

1. The CAH policy titled, "Authentication" under "I. POLICY 3rd paragraph, "To be in compliance...telephone orders should be authenticated within 48 hours. All orders should be dated, timed, and authenticated by the individual who made or authorized the entry."

2. The medical record of Pt. #2 was reviewed on 12/7/09. Pt. #2 was admitted to the CAH on 12/4/09 with the diagnosis of Nausea. Documentation indicated that three telephone orders written on 12/4/09 were not signed by the physician. Documentation indicated that a physician order written on 12/7/09 was signed by the physician but there was no time of signature.

3. The medical record of Pt. #3 was reviewed on 12/7/09. Pt. #3 was admitted to the CAH on 12/7/09 with the diagnoses of Acute/Chronic Pancreatitis and Alcohol Abuse. Documentation indicated that six telephone orders were written on 8/31/09. There was no date and time of physician signature.

4. The medical record of Pt. #4 was reviewed on 12/7/09. Pt. #4 was admitted to the CAH on 8/3/09 with the diagnosis of Acute Alcohol Intoxication. Documentation indicated physician telephone orders written on 8/3/09 were not signed.

5. The medical record of Pt #10 was reviewed on 12/8/09. Pt. #10 was admitted to the CAH on 10/26/09 with the diagnoses of Pneumonia and Influenza Type A. Documentation indicated that physician orders written on 10/26/09 and 10/27/09 were signed but there was no time recorded.

6. The medical record of Pt. #14 was reviewed on 12/9/09. Pt. #14 was admitted to the CAH on 12/7/09 with the diagnosis of Cholecystitis with Lithiasis. Documentation indicated that surgical orders were written and signed on 12/7/09 with no time recorded.

7. The medical record of Pt. #16 was reviewed on 12/9/09. Pt. #16 was admitted to the CAH on 8/17/09 with the diagnoses of Cancer of Lung and Anemia. Documentation indicated that a physician order written on 8/17/09 was signed with no time recorded.

8. The medical record of Pt. #18 was reviewed on 12/9/09. Pt. #18 was admitted to the CAH on 3/10/09 with the diagnoses of Chronic Obstructive Pulmonary Disease and Pneumonia. Documentation indicated that physician orders written on 3/11/09, 3/12/09, and 3/13/09 were signed with no time recorded.

9. During an interview with the Director of Nurses on 12/9/09 at 2:00 PM, the above findings were confirmed.