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Based on record review and interview, it was determined that the facility failed to ensure that discharge planning records were complete and accurately represented the individualized needs of each patient for 3 patients out of a survey sample of 20 records reviewed. (Patient identifiers are: #1, #15 and #22.)

Findings include:

Patient #1
Review on 8/22/18 of Patient #1's medical record revealed Patient #1's discharge plan of care contained generic interventions/tasks that were not patient specific for Patient #1.

Interview on 8/22/18 at approximately 8:35 a.m. with Staff B (Registered Nurse), confirmed that the discharge plan of care was a basic care plan that was not created specifically for Patient #1.

Patient #15
Review on 8/22/18 of Patient #15's discharge medical record revealed that a discharge plan of care was in place for Patient #15. Review of this plan of care identified generic discharge related tasks/interventions that would be part of an overall discharge plan. There was no documented evidence of the results of these tasks or interventions and how they would lead to a patient specific individualized discharge plan.

Patient #22
Review on 8/22/18 of Patient #22 discharge medical record revealed that a discharge plan of care was in place for Patient #22. Review of this plan of care identified generic discharge related tasks that would be part of an overall discharge plan. There was no documented evidence of the results of these tasks and how they would lead to a patient specific individualized discharge plan.

Interview on 8/22/18 with Staff D (Registered Nurse Information Technologies) confirmed that the discharge plans of care were basic care plans that were not created specifically for Patient #15 or #22.

Based on medical record review and interview, it was determined that the Critical Access Hospital failed to obtain signed consents for surgery/treatment for 3 patients in a standard survey sample of 20 patients. (Patient identifiers are: #1, #15 and #23.)

Finding include:

Patient #1
Review on 8/22/18 of Patient #1's medical record with Staff B (Registered Nurse) revealed no documented evidence of a surgical informed consent for treatment for Patient #1's date of admission which was 8/11/18.

Interview on 8/22/18 at approximately 9:35 a.m. with Staff C (RN Nurse Manager) confirmed that there was no signed surgical informed consent for treatment for Patient #1.

Patient #15
Review on 8/22/18 of Patient #15's medical record revealed that Patient #15 was admitted on 5/2/18 and underwent a surgical procedure identified no documented evidence of a signed surgical consent for the procedure that was performed.

Interview on 8/22/18 with Staff D (RN Information Technologies) confirmed that the consent for this procedure was not in the medical record.

Patient #23
Review on 8/22/18 of Patient #23's medical record with Staff A (Registered Nurse) revealed no documented evidence of a surgical informed consent for the surgical procedure done on 7/5/18 for Patient #23.

Interview on 8/22/18 at approximately 2:00 p.m. with Staff A confirmed no documented evidence of a surgical informed consent for the surgical procedure done on 7/5/18 for Patient #23.