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Based on observation, document review and interview, it was determined the Critical Access Hospital (CAH) failed to ensure outdated biologicals were not available for patient care use. This has the potential to affect all patients who present to the Emergency Department (ED), which currently services approximately 666 patients per month.

Findings include:

1. An observational tour of the ED was conducted on 9/22/15 at approximately 10:00 AM with the Director of Outpatient Services (E#2). In ED Room #7, the following outdated supplies were observed:
a. In the emergency crash cart- two Quik A.B.G. (arterial blood gas) samplers expired 01/2015 and one 6.0 millimeter Shiley expired 03/2015.
b. In the respiratory bag- one 30 French Nasopharyngeal Airway expired 08/2014.
c. In the negative pressure room, one open 12 fluid ounce bottle of SAF-Clens AF with date of opening of 6/3/15.

2. The CAH policy titled "Patient Care Manual... Subject Solution Dating" (reviewed 07/2015) was reviewed on 9/22/15 at approximately 11:45 AM. The policy stated "Procedure: C. Solutions used in the Emergency Department... are discarded after each patient's use."

3. The CAH policy titled "Infection Control... Subject: Department Tours" (Originated 05/2015) was reviewed on 9/22/15 at approximately 1:35 PM. The policy stated "Procedure VI: F. Supplies are not expired. Anything marked with an expiration date... will not be stored beyond the expiration date."

4. An interview was conducted with E#2 on 9/22/15 at approximately 10:30 AM. E#2 observed the outdated arterial blood samplers, Shiley, and Nasopharyngeal Airway and verbally agreed they should have been removed and/or replaced prior to their expiration date and the SAF-Clens AF should have been discarded..

Based on record review and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure care and services were provided based on a complete physician order. This has the potential to affect all patients being served by the CAH (both inpatient and outpatient).

Findings include:

1. The clinical record of Pt #1 was reviewed on 9/22/15 at approximately 12:00 PM. Pt #1 presented to the Emergency Department (ED) with complaints of a migraine on 12/31/14.
a. The patient progress note dated 12/31/14 noted Phenergan 50 mg (milligram) was administered at 11:46 PM. The patient progress note dated 1/1/15 noted Sublimaze 100 mcg/2 ml (micrograms/milliliter) was administered at 3:57 AM and Toradol 60 mg was administered at 3:58 AM. The record lacked a physicians order to administer Phenergan 50 mg, Sublimaze 100 mcg and Toradol 60 mg.
b. The physician order sheet dated 12/31/14 at 11:30 PM ordered Dilaudid 2 mg IM (intramuscular), Phenergan 25 mg IM, Benadryl 50 mg IM and Solumedrol 125 mg IM. The order lacked a frequency to administer the medications. Dilaudid 2 mg was administered on 1/1/15 at 12:50 AM and 1:02 AM (4 mg in 12 minutes), Phenergan was administered on 12/31/14 at 11:50 PM and on 1/1/15 at 7:05 AM, Benadryl 50 mg was administered on 12/31/14 at 11:45 PM and 11:51 PM (100 mg in 6 minutes) and on 1/1/15 at 7:06 AM, Solumedrol 125 mg was administered on 12/31/14 at 11:47 PM and 11:51 PM (250 mg in 4 minutes).
c. The physician order sheet dated 12/31/14 at 11:30 PM noted "1 L (liter) (0.9 NS) (normal saline) Bolus - Cancel Mag (magnesium) Sulfate (26 m) Rider- Cancel. The patient progress note documented on 1/1/15 at 6:40 AM Magnesium Sulfate 2 gm/50 ml and Normal Saline 1000 ml were infused.
d. A radiology report noted a CT (computerized tomography) scan was completed on 1/1/15 at 2:55 AM. The record lacked a physicians order for a CT scan.

2. The clinical record of Pt #4 was reviewed on 9/23/15 at approximately 12:00 PM. Pt #4 presented to the ED with complaints of migraine on 9/2/15. The patient progress notes noted the nurse administered Sublimaze at 2:59 AM. The physicians order noted a phone order was obtained for Sublimaze at 3:36 AM, 37 minutes after administration.

3. During an interview on 9/23/15 at approximately 2:30 PM, E#4 (Clinical System Specialist) verbally agreed with the findings above for Pt #1 and Pt #4. E#4 stated "Orders should have been received prior to administering the medications and conducting the CT scan and the medication frequency should have been clarified prior to administration."

Based on document/record review and staff interview, it was determined in 4 of 10 (Pt #2, #3, #4, #9) records reviewed, the Critical Access Hospital (CAH) failed to ensure medical records were accurate and complete.

Findings include:

1. The CAH Rules and Regulations (effective 1/1/2014) were reviewed on 9/22/15 at approximately 2:00 PM. They stated "4. Medical Records" which lacked all the required entries were considered "incomplete" after seven days following the patient's discharge and were considered "delinquent" after thirty days following the patient's discharge.

2. Pt #2's record was reviewed on 9/22/15 at approximately 11:30 AM. Pt #2 presented to the ED on 7/3/15 at approximately 3:54 AM with the chief complaint (CC) of Abdominal Pain. The record stated the ED physician's (MD#2) assessment was completed at 5:38 AM, seven minutes prior to Pt #2 being discharged. Pt #2 re-presented to the ED on 7/3/15 at approximately 6:50 PM with the CC of Abdominal Pain. The record stated the ED physician's (MD#3) assessment was completed at 9:35 PM, seventeen minutes prior to Pt #2 being discharged.

An interview was conducted with MD#2 on 9/24/15 at approximately 10:15 AM. When asked about the process for assessing and documenting patient care in the ED, MD #2 stated the nurses triage the patients and then call the physician with a report, laboratory/radiology and/or medication orders may by given at that time, the physician goes to see the patient, and "I try to chart right after I see them." When asked about Pt #2's record and the timing of the physician assessment, MD#2 stated "I'm not surprised if there isn't documentation in the records. This computer system has been challenging and I've lost things I've put in. I try to chart after I see a patient, but I just put the time I'm charting and not when I did it (saw the patient)... I didn't think to put the time I actually saw them, so it may very well look like I didn't see them until just before they lift. I just hit the time I'm charting."

3. Pt #3's record was reviewed on 9/22/15 at approximately 12:30 PM. Pt #3 presented to the ED on 8/4/15 at approximately 1:32 PM with the CC of Left Jaw Pain and was discharged at approximately 4:14 PM. At the time of the record review, there was no documentation to indicate Pt #3 was assessed by MD #4 who was the attending physician.

4. The clinical record of Pt #4 was reviewed on 9/23/15 at approximately 12:00 PM. Pt #4 presented to the ED with complaints of migraine on 8/27/15 and 9/2/15. The ED summary report noted Pt #4 was triaged on 8/27/15 at 12:30 AM and discharged at 1:35 AM. A physician order for pain medication, anti nausea medication and an antibiotic was electronically signed by the physician on 8/27/15 at 1:13 AM. The ED summary report noted the medical screening exam was conducted at 5:43, greater than 4 hours after discharge although the physician had examined the patient prior to discharge. The ED summary report noted Pt #4 was triaged on 9/2/15 at 10:52 PM. Physician orders for laboratory tests were electronically signed by the physician at 11:40 PM. The ED summary report noted "0205 EDMD (emergency department medical doctor) at bedside speaking with PT (patient)." The medical screening exam was documented as completed at 3:16 AM, 4 hours after triage.

5. Pt #9's record was reviewed on 9/23/15 at approximately 11:30 AM. Pt #9 presented to the ED on 9/7/15 at approximately 2:03 AM with the CC of Right Flank Pain and was discharged at approximately 5:20 AM with a script from MD #4. As of the time of the record review, there was no documentation to indicate Pt #9 was assessed by MD #4.

6. An interview was conducted with the Director of Medical Records (E#5) on 9/22/15 at approximately 2:45 PM. When asked the process for reporting and tracking Emergency Department (ED) delinquent/incomplete records, E#5 stated with the implementation of the new electronic record on 6/22/15, the CAH was not disciplining physicians for incomplete records. E#5 stated each ED physician is given a list weekly, or the next day the physician works, of records which are incomplete and what is lacking. When asked if the Medical Executive Committee (MEC) and Governing Body was aware of the delinquent/incomplete ED records, E#5 stated ED physician delinquent/incomplete records was not reported to the Medical Executive Committee and wasn't sure if the Governing Body was aware.

7. An interview was conducted with the Executive Assistant/Medical Staff Services (E#6) on 9/22/15 at approximately 2:55 PM with E#5 present. When asked about the process for tracking/reporting ED delinquent/incomplete records, E#6 stated being unaware that this was not reported to the MEC or Governing Body.

8. An interview was conducted with the Chief Executive Officer (E#11) and the Director of Outpatient Services (E#2) on 9/22/15 at approximately 2:55 PM. E#2 stated ED delinquent/incomplete records were not reported to E#2. E#11 stated being unaware this was not being tracked/reported to MEC and Governing Body. E#11 stated "I thought it (ED delinquent/incomplete records) was reported with the rest of the physicians." Both E#2 and E#11 verbally agreed this should have been done and wasn't.

Based on document review and interview, it was determined for 4 of 10 (Pts #2, #4, #7, #9) patients, the Critical Access Hospital (CAH) failed to ensure telephone orders were authenticated by the physician in accordance with its policy.

Findings include:

1. The CAH policy titled "Physician's Orders" (revised 01/2014) was reviewed on 9/23/15 at approximately 11:00 AM. The policy stated a process for both written and electronic telephone orders. Under the written procedure, the policy stated the physician should sign the order upon the next physician visit to the unit, or within 24 hours if they are unable to sign them at that time. Under the electronic telephone procedure, the policy stated the Registered Nurse (RN) would enter the order into the computer "which allows the physician to sign using electronic signature".

2. Pt #2's record was reviewed on 9/22/15 at approximately 11:30 AM. Pt #2 presented to the Emergency Department (ED) on 7/3/15 at approximately 3:54 AM with the Chief Complaint (CC) Abdominal Pain. At 4:20 AM, there were electronic phone orders for Dilaudid 2 milligrams intramuscular times one and Phenergan 50 milligrams intramuscular times one entered by the RN. The orders were not electronically signed by the physician until 7/19/15.

3. The clinical record of Pt #4 was reviewed on 9/23/15 at approximately 12:00 PM. Pt #4 presented to the ED with complaints of migraine on 8/27/15 and 9/2/15. The physician orders noted telephone orders were obtained on 9/3/15 at 12:05 AM for laboratory testing and at 3:36 AM for medications. The physician orders were electronically signed by the physician on 9/6/15 at 8:51 AM, although the physician was in the unit as evidenced by multiple entries into Pt #4's electronic record following the receipt of the telephone orders.

4. Pt #7's record was reviewed on 9/23/15 at approximately 12:30 PM. Pt #7 presented to the ED on 7/3/15 at approximately 1:28 AM with the CC Right Foot Pain. At 1:47 AM, there was an electronic phone order for an X-ray of the right foot entered by the RN. The order was not electronically signed by the physician until 7/19/15.

5. Pt #9's record was reviewed on 9/23/15 at approximately 11:30 AM. Pt #9 presented to the ED on 9/7/15 at approximately 2:03 AM with the CC Right Flank Pain. At 2:16 AM, there was an electronic phone order for a urinalysis with culture if indicated entered by the RN. The order was not electronically signed by the physician until 9/9/15.

6. An interview was conducted with the Clinical Services Specialist (E#4) on 9/23/15 at approximately 1:15 PM. E#4 stated all phone orders, written and electronic, were expected to be signed by the physician when they come to the unit or within 24 hours if they are unable to sign them at that time. E#4 had reviewed the records of Pt #2, #7 and #9 and verbally agreed the phone orders were not authenticated by the physicians in accordance with the CAH policy and they should have been.