HospitalInspections.org

Based on policy and procedure review, review of professional literature, review of personnel files, review of patient logs, record review, medical staff rules and regulations review, and staff interview, the Critical Access Hospital (CAH) failed to ensure emergency care provided met the needs of the CAH' patients by failing to ensure the professionals staffing the emergency room (ER) and providing care for 5 of 16 closed ER records (Patients #8, #9, #20, #25, and #28) reviewed furnished care within their scope of practice and possessed the appropriate skills, education, certifications, and specialized training to provide the care; and by failing to ensure the availability of a health care practitioner for patients presenting to the emergency department (ED) on a 24-hour a day basis for 2 of 16 closed ED records (Patients #8 and #28) reviewed (Refer to C201). Failure of the CAH to ensure professionals caring for patients in the ER delivered care within their scope of practice and possessed the appropriate training limited the CAH's ability to ensure ER patients received the necessary and appropriate emergency care, services, and follow-up care; and failure to ensure the availability of 24 hour emergency services for patients presenting to the ED placed patients seeking emergency treatment at risk of not receiving appropriate care and treatment.

Findings include:

- During an interview on 11/14/11 at 12:30 p.m., an administrative nurse (#2) stated paramedics staffed the ER Monday through Friday from 7:00 a.m. to 9:00 p.m., Saturday and Sunday from 7:00 a.m. to 3:00 p.m., are on call 24 hours a day, and stated the charge nurse on duty cared for all patients who presented to the ER beyond the hours of the paramedics. The administrative nurse (#2) stated the paramedics triaged all patients presenting to the ER during the above identified hours and determined the priority level of each patient according to the patient's condition; and stated the paramedics must notify the charge nurse upon determining a patient is a level one or two priority. The administrative nurse (#2) stated the CAH requires the charge nurse to come to the ER, assess the patient, and document this assessment in the patient's medical record or cosign the paramedic's assessment if in agreement.

Review of the policy "Staffing Of The Emergency Room" occurred on 11/15/11. This policy, dated 07/30/11, stated, "POLICY: Staffing of the Emergency Room Department shall be done in such a manner so as to facilitate optimum care of the patient in any emergency situation. PROCEDURE: 1. The Emergency Department is under the direction of the Director of Nursing or her assistant. 2. An RN [Registered Nurse] . . . or a Paramedic will triage and assess all patients treated in the Emergency Room. . . . 3. All patients coming to be seen in ER will be triaged by a Paramedic or an RN Monday through Friday, 7:00 am to 9:00 pm and Saturday/Sunday 7:00 am to 3:00 pm a Paramedic will triage each patient. If the patient is a Triage Level 1 or 2 the Paramedic will notify the Charge Nurse and an RN will need to go to ER to assess and help care for the patient. The Charge Nurse will be required to co-sign all Triage Level 1 and 2 ER patient charts. . . ."

Review of the policy "Patient Triage" occurred on 11/15/11. This policy, dated 05/22/09, stated, "POLICY: Triage is an assessment of acuity using guidelines to determine the presenting patient's priority level to ensure the optimal outcome for the patient. . . . If paramedic doing triage determines patient to be a Level I, the charge nurse must be called down to ER. TRIAGE PROTOCOL:
EMERGENCY MEDICAL CONDITIONS (Level One Priority): These conditions involve acute, urgent, potential life threatening conditions. The following is a NON-INCLUSIVE list of emergency medical conditions that require immediate intervention . . . and should be addressed by a physician as soon as possible. 1. Difficulty maintaining an airway. 2. Breathing problems. 3. Penetrating chest or abdominal wounds. 4. Chest pain suspicious of cardiac source. 5. Coma or altered level of consciousness. 6. Multiple trauma. 7. Hemorrhage from any site. 8. Anaphylaxis. 9. Burns . . . 10. Hypothermia or Hyperthermia. 11. Severe laceration. 12. Hyperglycemia/hypoglycemia. 13. Pregnant woman with bleeding or abdominal pain. 14. Pregnant patient with: a. Labor or suspected labor. b. Ruptured membranes. c. Decreased fetal movement. 15. Seizure. 16. Suspected CVA [Cerebral Vascular Accident]. URGENT MEDICAL CONDITIONS (Second level priority): The following is a NON-INCLUSIVE list of urgent medical condition (these are symptomatic with non emergent needs) which require a physician's evaluation. 1. Fever: a. Birth of 6 months: 101.6. b. 6 months-60 years: 103. c. Over 60 years, diabetic or whit chronic medical problems: 100. 2. Multiple fractures. 3. Vomiting and/or diarrhea . . . 4. Lacerations. 5. Trauma to the eye, foreign body in eye or severe pain in the eyes. 6. Suspected fracture. 7. Shortness of breath . . . 8. Possible rape. 9. Possible child/spousal abuse or neglect. 10. Burns (other than those listed in emergency medical conditions above). 11. Possible assault. 12. Abdominal pain. 13. Dehydration . . . 14. Soft tissue injury with controlled bleeding. 15. Severe headache, unrelieved by Tylenol or aspirin. 16. Drug or alcohol withdrawal [sic]. 17. Suicidal attempt or intent.
MINOR MEDICAL CONDITIONS (Third priority): The following is a NON-INCLUSIVE list of medical conditions that will be treated after patients with emergency or urgent conditions have been stabilized. (These are conditions that could potentially have been seen in the clinic setting.) 1. Upper respiratory conditions. 2. Otitis media. 3. Brief vomiting. 4. Migraines. 5. UTI [Urinary Tract Infection]. 6. First degree burn. 7. Infected wound. 8. Back pain.
LOWEST LEVEL PRIORITY CONDITIONS: The following is a NON-INCLUSIVE list of medical conditions that will be treated after patients with all above prior levels have been treated/stabilized. 1. DOA [Dead On Arrival]. 2. Obvious mortal wounds where death appears inevitable . . . 3. Med's [Medications] needing refilled. 4. Pregnancy test or other non emergent testing. Evaluations after the initial contact: Evaluation is a fluent, ongoing and continuous process in which the ER staff must constantly re-evaluate and continuously triage all patients based on condition. Patients may become a higher or lower priority and providers must be prepared to address changes in patient priority and status. . . . The Emergency Room/Charge Nurse or paramedic shall use his/her discretion as to the utilization of other staff in the event of a critically ill patient or in the event of multiple patients. . . ."

- During an interview on 11/16/11 at 9:20 a.m., an administrative paramedic staff member (#3) confirmed the same process for triaging and caring for patients in the ER as stated by an administrative nurse (#2), and added only the paramedics see the level three or four priority patients in the ER (CAH policy states paramedics must notify the charge nurse for level one and two priority patients). The staff member (#3) stated the paramedics cared for the level three and four priority patients and discharged the patients home, confirming the paramedics provided patients with education and discharge instructions. The administrative paramedic staff member (#3) stated all paramedics currently employed by the CAH worked in the ER, and prior to working in the ER, all received and completed education/training to their role, adding the paramedics followed the scope of practice guidelines for paramedics set forth by the state and the CAH's own scope of practice guidelines for paramedics.

During an interview on 11/16/11 at 9:25 a.m., an administrative nurse (#2) stated once the charge nurse assessed the level one and two priority patients in the ER, the nurse could make the determination to leave the paramedic to care for the patient until the CAH transferred or discharged the patient from the ER; and confirmed a nurse does not see some patients, according to their priority level, in the ER.

Review of the state's practice guideline "Emergency Medical Technician [EMT]-Paramedic Division of Emergency Medical Services Scope of Practice Guidelines" occurred on 11/16/11. This guideline, revised February 2006, stated, ". . . The skills described in the Scope of Practice are only meant to provide guidelines to specific care providers. All skills must be approved by the services Medical Director and if necessary additional training be provided by service and monitored by Medical Director.
AIRWAY/VENTILATION/OXYGENATION Skill: Airway-Nasal, Airway-Oral, Airway-Multi Lumen, Intubation-Digital, Intubation-Retrograde, Intubation-Lighted Stylet, Intubation-Medication Assisted, Intubation-Paralytic (RSI [Rapid Sequence Intubation]), Intubation-Nasotracheal, Intubation-Orotracheal, Bag-Valve-Mask (BM), End Tidal CO2 [Carbon Dioxide] Monitoring/Capnometry, Chest Decompression-Needle, Chest Tube Placement, Chest Tube-Monitoring & [and] Management, BiPAP [Bilevel Positive Airway Pressure], CPAP [Continuous Positive Pressure], Cricoid Pressure (Sellick), Cricothyroidotomy-Needle, Cricothyroidotomy-Surgical, Gastric Decompression-NG [Nasogastric] Tube, Gastric Decompression-OG [Orogastric] Tube, Jaw-thrust, Jaw-thrust-Modified (trauma), Mouth-to-Barrier, Mouth-to-Mask, Mouth-to-Nose, Mouth-to-Stoma, Obstruction-Manual, Obstruction-Direct Laryngoscopy, Oxygen Therapy-Humidifiers, Oxygen Therapy-Nasal Cannula, Oxygen Therapy-Simple Face Mask, Oxygen Therapy-Partial Non-rebreather, Oxygen Therapy-Venturi, Oxygen Therapy-Regulators, PEEP [Positive End-Expiratory Pressure]-Therapeutic (>5cm [centimeters] H2O [water] pressure), Pulse Oximetry, Suctioning-Upper Airway, Suctioning-Tracheobronchial, Ventilators-Automated Transport
CARDIOVASCULAR/CIRCULATION Skill: Cardiac Monitoring-Multi Lead (non-interpretive), Cardiac Monitoring-Multi Lead (interpretive), Cardiac Monitoring-Single Lead (interpretive), Cardiopulmonary Resuscitation (CPR), Cardioversion-Electrical, Carotid Massage, Defibrillation-Automated/Semi Automated (AED [Automated External Defibrillator]), Defibrillation-Electrical, Hemorrhage Control-Direct Pressure, Hemorrhage Control-Pressure Point, Hemorrhage Control-Tourniquet, Internal Cardiac Pacing-Monitoring Only, MAST/PASG [Military Anti-Shock Trousers/Pneumatic Anti-Shock Garment], Mechanical CPR Device, Transcutaneous Pacing-Automated, Transcutaneous Pacing-Manual
IV [Intravenous] INITIATION/MAINTENANCE/FLUIDS Skill: Arterial Line-Monitoring, Arterial Line-Access, Arterial Line-Initiation, Peripheral-Initiation, Intraosseous-Initiation, Central Line-Monitoring & Access, Crystalloids (D5W [Dextrose in 5% Water], R/L [Ringers Lactate], NS [Normal Saline]), Colloids-(Albumin, Dextran), Blood/Blood By-Products, Maintenance-Medicated IV Fluids, Peripheral Inserted Central Catheter (PICC), Central Line-Initiation, Maintenance-Non-Medicated IV Fluids
MEDICATION ADMINISTRATION-ROUTES Skill: Aerosolized/Nebulized, Buccal, Endotracheal Tube (ET), Intramuscular (IM), . . . (IV) Piggyback . . . (IV) Push, Nasogastric, Oral, Rectal, Subcutaneous, Sub-Lingual
IMMOBILIZATION Skill: Spinal Immobilization-Assessment Based, Spinal Immobilization-Cervical Collar, Spinal Immobilization-Long Board, Spinal Immobilization-Manual Stabilization, Spinal Immobilization-Manual Stabilization, Spinal Immobilization-Seated Patient (KED [Kendrick Extrication Device]), Splinting-Manual, Splinting-Rigid, Splinting-Soft, Splinting-Traction, Splinting-Vacuum
MISCELLANEOUS Skill: Assisted Delivery (Child-birth), Blood Glucose Monitoring, Blood Pressure-Manual/Automated, Epi-Pen-Carrying & Administration (By Protocol), Eye Irrigation, Hemodynamic Monitoring, ICP [Intracranial Pressure] Monitoring, Initiation of IV at Central Line Port, Thrombolytic Therapy-Initiation, Thrombolytic Therapy-Monitoring, Urinary Catheterization, Venous Blood Sampling-Obtaining, Implanted Artificial Venous Access Device (Access Only)."

Review of the policy "EMT Paramedic Scope of Practice" occurred on 11/16/11. This policy, undated, included the following not listed in the state's paramedic scope of practice guidelines, "1. Perform initial, focused and on-going patient assessments. . . . 3. Apply bandages and dressings. 4. Apply . . . immobilization devices. . . . 7. Provide ordinary and reasonable care for ill and injured patients in accordance with generally accepted standards. . . . 10. Medication administration of approved drugs: . . . f. Topical . . . i. Intradermal . . . A Paramedic's main responsibility I [sic] the hospital will be to help in the Emergency Room . . . The Paramedic may also be utilized in all other area [sic] of the hospital in which they are qualified to work (within their scope of practice). After successful completion of orientation process, skills must be signed off by the DON [Director of Nursing] to show competency level. The Paramedics will work in the hospital setting under the supervision of the hospital's patient service management (Director of Patient Care). . . ."

Review of the "St. Aloisius Paramedic Unit 1.0 Job Description" occurred on 11/16/11. This document, undated, stated, ". . . JOB DESCRIPTION . . . revised 04/20/08 . . . Summary: A Paramedics main responsibility in the hospital setting will be to help in the emergency room . . . Essential Duties and Responsibilities: include the following, other duties may be assigned. Provide ordinary and reasonable care for ill and injured patients that present to the emergency room. Provide care based on the approved Paramedic scope of practice signed and reviewed by the Medical Director and the Director of Patient Care (Director of Nursing) and attached to this job description. . . ."

During an interview on 11/16/11 at 11:20 a.m., an administrative nurse (#1) stated the CAH developed and implemented the process of using paramedics in the ER approximately three years ago to assist with staffing and stated the CAH developed scope of practice guidelines and policies for the paramedics and nursing staff to follow regarding the care of patients in the ER. The nurse (#1) stated the CAH employed four paramedics and stated the paramedics all worked in the ER and received training and orientation to the ER.

- Review of the personnel files for four Paramedics currently on staff at the CAH occurred on 11/16/11 at 1:20 p.m. The date of hire for the staff members ranged from April 2002 to September 2010. Review of the orientation forms included information on: tour of ER, location of policy and medical books, emergency physician on call routines and schedules, triage procedures, patient documentation, review of ER forms, procedures for acute and observation patient admissions, narcotic counts, medication procedures, location of general supplies, contents of emergency packs and equipment, communication equipment, procedures for trauma codes and code blues, ER checklist, direction when a procedure is out of scope of practice, calling charge nurse to hand off report and for female pelvic exams, and physician standing orders. The forms included a checkmark in front of each area mentioned above indicating completion of the task, and a section at the end of the form for a completion date, signature of paramedic, and signature of supervisor. The orientation form failed to include specific information on performing assessments (initial, focused, and on-going); applying bandages, dressings, and immobilization devices; providing ordinary and reasonable care to patients in accordance with generally accepted standards; and administration of topical and intradermal medications as indicated in the CAH's scope of practice for paramedics.

Three staff members' (#3, #8, and #9) ER orientation forms identified a completion date of 06/06/11. The personnel files lacked ER orientation forms or other evidence of ER orientation and approval of skills prior to June 2011. Two staff members' (#8 and #9) forms failed to include DON sign-off of the skills and one staff member's (#10) file failed to include evidence of ER orientation or DON sign-off of skills. The paramedic staff members' (#3, #8, #9, and #10) files failed to include evidence each staff member received and completed ER orientation to the specific items listed in the CAH's paramedic scope of practice guidelines.


21202

- Review of Patients #8, #9, #20, #25, and #28 closed medical records occurred on November 14-16, 2011. The ER log identified Patient #9, a 19 year old female, presented to the ER on 01/10/11. The log identified the "Nature of Injury" as "Suicide Attempt."

Review of Patient #9's closed medical record showed the admitting ER staff member (#8) (a paramedic) identified a "Chief Complaints/Injury" of "Suicidal tendency," and assigned/determined a "Triage Level" of "II (Urgent)." The staff member (#8) obtained vital signs at 7:30 p.m. and 8:43 p.m. and documented the following:
7:23 p.m. - "Pt [patient] presents pedis [ambulatory] to ER with parents. Pt agitated - stating she doesn't want to go into treatment. Pt's mom states she came home from Fargo today very agitated and told her mom she was going to slice her arm. Pt's left arm has several cuts from a razor on wrist area. Pt was in [name of acute psychiatric hospital] for suicidal tendencies and was released on Friday- Jan [January] 7th. . . . Pt became agitated [and] called her mom."
7:36 p.m. - "Dr. [doctor] called. Told me that [name of physician assistant] was on call. Got ahold of [name of physician assistant]. Pt's mom states that she became agitated this evening and went for a walk. Pt's mom followed in car. Once pt got in car she stated to her mom that she 'wished she had ended it today'."
8:23 p.m. - "Labs ordered."
8:53 p.m. - "Pt admitted to med [medical] floor for observation."

The paramedic (#8) determined Patient #9's "Triage Level" as "II - Urgent." The record lacked evidence a registered nurse (RN) conducted an assessment and/or concurred with the paramedic's assessment/findings.

- The ER log identified Patient #8, a 44 year old female, presented to the ER on 01/11/11. The log stated, ". . . Services Rendered 'Not Seen By Dr'. . . ."

Review of Patient #8's closed medical record identified a "Chief Complaints/Injury" of "Large round lump on vaginal opening." The record identified a paramedic (#8) obtained vital signs and documented the following:
2:07 p.m. - "Pt presents pedis to ER complaining of a large quarter [sized] bump in her vaginal area. She noticed it this morning and tried putting hot wash rags on it but it did not help. It is painful."
2:15 p.m. - "Dr notified of pt."
2:38 p.m. - "Pt talked with [name of on-call doctor's physician assistant] and decided to go to Dr. [name of doctor] office instead of being seen in the ER."
2:41 p.m. - "Pt left ER to be seen at Dr. [name of doctor] office."

Patient #8's record lacked evidence the admitting ER staff (#8) (a paramedic) documented a "Triage Level," and evidence a RN conducted an assessment and/or concurred with the paramedic's assessment/findings.

- The ER log identified Patient #20, a 14 year old male, presented to the ER on 03/11/11. The log identified the "Nature of Injury" as "abd [abdominal] pain."

Review of Patient #20's closed medical record showed the admitting ER staff member (#9) (a paramedic) identified a "Chief Complaints/Injury" of "[right] sided abd pain," and assigned/determined a "Triage Level" of "II (Urgent)." The staff member (#9) obtained vital signs at 9:00 a.m., 9:10 a.m., and 9:47 a.m. and documented the following: "Pt to ER complaining of abd pain. Pt relates that he noticed the pain when he got up this AM. Pt relates his pain is on his [right] side of lower abd. Pt denies any nausea or fever. Pt relates he had normal BM [bowel movement] yesterday. Pt denies any back pain. Pt denies any trouble passing his urine. Pt has increase in pain with palpation. Pt has normal bowel sounds. Pt lab work came back normal. Pt pain is 1/10. Pt discharged in care of his mother. Pt advised to watch for fever, increased in pain, nausea, or vomiting. If symptoms become worse pt with contact Dr . . . ."

Staff member (#9) determined Patient #20's "Triage Level" as "II - Urgent." The record lacked evidence an RN conducted an assessment and/or concurred with the paramedic's assessment/findings.

- The ER log identified Patient #25, a 23 year old male, presented to the ER on 08/08/11. The log identified the "Nature of Injury" as right hand pain.

Review of Patient #25's closed medical record showed the admitting ER staff member (#10) (a paramedic) identified a "Chief Complaints/Injury" of "[right] wrist/hand pain" which originated on 08/06/11 and assigned/determined a "Triage Level" of "III (Minor)". The staff member (#10) obtained vital signs at 3:46 p.m. and 4:12 p.m., documented the patient's "Pain Level" as "9/10," and stated, the "Description of Injury" as "Tactor rollover on 08/06/11. Was hauling hay when a front tire blew out on the tractor. Tractor [and] trailer of big round bales rolled. Was seen in the ER that evening. No x-rays taken. Given pain med [medication] in hospital ER. Current Ibuprofen and Tylenol not working to keep the pain down."

Review of Patient #25's record showed the medical doctor (#21) ordered an x-ray. Review of the dictated ER Note, completed by the doctor (#21), failed to identified an order for any pain medications upon discharge from the ER.

Patient #25's written discharge instructions, completed by a staff member (#10), identified the patient received a printed handout regarding wrist sprains and the new medication of "Oxycodone 10 mg [milligrams] po [orally] q [every] 4 hrs [hours] for pain," and instructed to return to the ER if he developed "fever, change in finger sensation, circulation."

Review of Patient #25's medical record lacked evidence of a written physician order from the doctor for the patient to take Oxycodone for pain. The Emergency Room Note, dated 08/08/11 stated, ". . . PLAN: The patient will wear his . . . splint and take OTC pain meds [medications]. Apply cast if fracture is identified."

- Review of Patient #28's closed medical record showed the patient presented to the ER on 09/05/11. The admitting ER staff member (#10) (a paramedic) identified a "Chief Complaints/Injury" of "high fever, chills, cough and wheezing," and assigned/determined a "Triage Level" of "III (Minor)." The staff member (#10) obtained vital signs at 9:43 a.m., 10:17 a.m., 11:15 a.m., and 11:45 a.m., and stated the "Description of Injury: Sore throat, fever, [and] chills, cough, SOB [shortness of breath]. Also had diarrhea for 1 wk [week]. Headache now and again. 2 wks ago 'mini-stroke'. Father [and] brother had asthma and stroke on father's side of family. C-spine fusion. [right] 3rd finger tendon repair, lumbar disc surgery in 2011" and
10:50 a.m. "Dr . . . here."
11:05 a.m. "IV [intravenous] . . . [left hand]."
11:25 a.m. "IV meds given."

Patient #28's written discharge instructions, completed by a staff member (#10), identified the patient received handouts on sinusitis and pneumonia, instructions to return to the ER if he developed a high fever, shortness of breath, chest pain or if IV site begins to hurt, smell or get red, and return on 09/06/11 for more IV antibiotics. Patient #28's medical record lacked a written physician order for the patient to return for IV antibiotics on 09/06/11.

The CAH utilized paramedics for triaging patients who presented to the ER and caring for patients during their stay in the ER from admission to transfer or discharge. The state's and CAH's scope of practice guidelines for paramedics do not specify this practice. The CAH utilized paramedics to perform skills/tasks beyond the specified tasks included in the state's scope of practice guidelines for paramedics. The CAH failed to ensure that paramedics who worked in the ER practiced within their scope of practice. According to policy, the CAH failed to ensure an RN assessed all ER patients triaged as Level II - Urgent patients.

Based on record review, medical staff rules and regulations review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the availability of a health care practitioner for patients presenting to the emergency department (ED) on a 24-hour a day basis for 2 of 16 closed ED records (Patients #8 and #28) reviewed. Failure to ensure the availability of 24 hour emergency services for patients presenting to the ED placed patients seeking emergency treatment at risk of not receiving appropriate care and treatment.

Findings include:

Review of the CAH's Medical Staff Bylaws, Rules, and Regulations occurred on November 14-16, 2011. This document, approved 10/15/07, stated, ". . . RULES AND REGULATIONS . . . J. EMERGENCY SERVICE . . . 3. The Hospital . . . shall develop a policy for on-call practitioners in the emergency services area. The policy shall require such call coverage to be scheduled twenty-four (24) hours per day, seven (7) days per week. The on-call practitioner must respond within (30) minutes of receiving the emergency call.
4. . . . any individual who presents to the Emergency Room requesting an examination or treatment for a medical condition will be provided an appropriate medical screening examination within the capabilities of the emergency room in order to determine whether an emergency medical conditions [sic] exists. Medical personnel who are qualified to provide an initial screen examination include the following medical or nursing personnel: physician, physician assistant, nurse practitioner. Registered Nurses, specially trained in obstetrics, are authorized to perform a medical screening examination of an obstetrical patient to determine she is in labor."

- The ED log identified Patient #8, a 44 year old female, presented to the ED on 01/11/11. The log stated, ". . . Services Rendered 'Not Seen By Dr' . . . ."

Review of Patient #8's closed medical record identified a "Chief Complaints/Injury" of "Large round lump on vaginal opening." The record identified a staff member (#8) obtained vital signs and documented the following:
2:07 p.m. - "Pt [patient] presents pedis [ambulatory] to ER [emergency room] complaining of a large quarter [sized] bump in her vaginal area. She noticed it this morning and tried putting hot wash rags on it but it did not help. It is painful."
2:15 p.m. - "Dr [doctor] notified of pt."
2:38 p.m. - "Pt talked with [name of on-call doctor's physician assistant] and decided to go to Dr. [name of doctor] office instead of being seen in the ER."
2:41 p.m. - "Pt left ER to be seen at Dr. [name of doctor] office."

Patient #8's closed ER record lacked evidence a health care practitioner completed and documented a medical screening examination prior to sending the patient to the clinic.

- Review of Patient #28's closed medical record showed the patient presented to the ED on 09/05/11. The admitting ER staff member (#10) identified a "Chief Complaints/Injury" of "high fever, chills, cough and wheezing," and assigned a "Triage Level" of "III (Minor)." The staff member (#10) obtained vital signs at 9:43 a.m., 10:17 a.m., 11:15 a.m., and 11:45 a.m., and documented, "Description of Injury: Sore throat, fever, [and] chills, cough, SOB. Also had diarrhea for 1 wk [week]. Headache now and again. 2 wks ago 'mini-stroke.' Father [and] brother had asthma and stroke on father's side of family. C-spine fusion. [right] 3rd finger tendon repair, lumbar disc surgery in 2011" and at
10:50 a.m. "Dr . . . here."
11:05 a.m. "IV [intravenous] . . . [left hand]."
11:25 a.m. "IV meds given."

Review of Patient #28's record showed a medical doctor ordered laboratory testing and IV medications of Solumedrol and Rocephin. The record lacked evidence a health care practitioner performed a medical screening examination of Patient #28.

During interview on 11/16/11 at 11:00 a.m., administrative nurses (#1 and #2) confirmed the records of Patient #8 and #28 failed to show evidence that a qualified provider (either the on-call doctor or a physician assistant) performed a medical screening examination when these patients presented to the CAH's ED.

Based on review of professional literature, observation, and staff interview, the Critical Access Hospital (CAH) failed to ensure a safe water temperature in 1 of 1 patient restroom in the emergency department (next to the treatment room on the west side). Failure to ensure and monitor safe water temperatures placed patients at risk for burns caused by hot water.

Findings include:

"Guidelines for Construction and Equipment of Hospital and Medical Facilities," 1992-93 edition, Chapter 8, Section 8.12, Table 8, Hot Water Use, stated, ". . . Temperature (Fahrenheit), Resident Care Areas, 110 (max.) [maximum] . . ."

Upon request on 11/16/11, the CAH did not provide a policy regarding safe water temperatures in patient areas.

Observation of the emergency department occurred in the morning on 11/16/11. The temperature of the water at the sink in the patient restroom next to the treatment room at 10:20 a.m. measured 125 degrees Fahrenheit (F). An administrative nursing staff member (#2) confirmed the temperature.

During interview at approximately 10:40 a.m. on 11/16/11, an administrative environmental services staff member (#12) stated the CAH did not monitor water temperatures in patient areas and did not ensure water temperatures in patient areas were 110 degrees F or less.

Based on observation, record review, policy and procedure review, professional literature review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the provision of services by failing to provide the medical and/or mental health management of problems in patients admitted to the CAH with suicidal attempts (Refer to C275); failing to evaluate the safe use of side rails, assess each patient individually prior to utilizing side rails, consider side rails as a potential entrapment and safety hazard, and provide education to the patient and responsible party regarding the hazards of side rail use; and failing to evaluate the plan of care for patients experiencing falls, pressure ulcers, and suicide attempts (Refer to C295). Failure to ensure the provision of services places the CAH patients at risk of receiving improper care.

Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to provide the medical and/or mental health management of problems for 2 of 2 closed observation records (Patients #9 and #23) reviewed and admitted to the CAH with diagnosis of suicide attempt. Failure to provide admitted patients with medical and mental health management of all problems placed Patients #9 and #23 and all CAH patients at risk of receiving improper care.

Findings include:

Review of the policy "Suicide Patients, Handling of" occurred on 11/16/11. This policy, dated 08/1997, stated, "POLICY: Suicide patients present special problems in terms of care and prevention of self-inflicted harm. The hospital has a duty to protect patients from harm and self-inflicted injury and must take proper precautions to assess the anticipate [sic] suicidal tendencies in patients. PROCEDURE: A. Procedure in Emergency Room: 1. The patient must be kept under constant surveillance . . . B. Procedure on Medical Floor: 1. Admission precautions: a. Do not leave newly admitted patients unattended until all articles from their pockets have been removed. b. Attempt to establish a relation [sic] early on. Allow freedom to express feelings through verbal communication. 2. The patient should be placed in a private room near the Nurse's Station. 3. All objects with which the patient could further injure himself should be removed. These include plastic bags, matches or cigarette lighters, power cords, telephone wires, unused restraints, wire clothes hangers, all sharp or protruding objects and all objects which can be ingested such as aerosol sprays and glass objects should be removed. 4. The patient should be dressed in a hospital gown and all personal clothing items, especially belts and shoelaces, should be removed. 5. All staff members who have contact with the patient should be informed about the possibility of a repeat suicide attempt. 6. The patient may not require 24 hour continuous observation, but should be observed by nursing personnel at least once per hour . . . 7. The patient should be supervised one-to-one whenever he leaves his room. . . ."

Information attached to this policy titled "Suicide Risk: A Guide for ED [Emergency Department] Evaluation and Triage" stated, ". . . High risk patients . . . Made a serious or nearly lethal suicide attempt; persistent suicide ideation or intermittent ideation with intent and/or planning; psychosis, including command hallucinations; recent onset of major psychiatric syndromes, especially depression; been recently discharged from a psychiatric inpatient unit, history of acts/threats of aggression or impulsivity.
Moderate risk patients . . . Suicide ideation with some level of suicide intent, but who have taken no action on the plan; no other acute risk factors; a confirmed, current and active therapeutic alliance with a mental health professional.
Low risk patients . . . Some mild or passive suicide ideation, with no intent or plan; no history of suicide attempt; available social support. . . ."

- The ED log identified Patient #9, a 19 year old female, presented to the ED on 01/10/11. The log identified the "Nature of Injury" as "Suicide Attempt." Review of Patient #9's closed medical record identified a "Chief Complaints/Injury" of "Suicidal tendency", and showed a "Triage Level" of "II (Urgent)."

Patient #9's Nurse Notes as documented on the ED Record by the paramedic stated:
7:23 p.m. - "Pt [patient] presents pedis [by foot] to ER with parents. Pt agitated - stating she doesn't want to go into treatment. Pt's mom states she came home from Fargo today very agitated and told her mom she was going to slice her arm. Pt's left arm has several cuts from a razor on wrist area. Pt was in [name of acute psychiatric hospital] for suicidal tendencies and was released on Friday- Jan [January] 7th. . . . Pt became agitated [and] called her mom."
7:36 p.m. - "Dr. called. Told me that [name of physician assistant] was on call. Got ahold of [name of physician assistant]. Pt's mom states that she became agitated this evening and went for a walk. Pt's mom followed in car. Once pt got in car she stated to her mom that she 'wished she had ended it today'."
8:23 p.m. - "Labs ordered."
8:53 p.m. - "Pt admitted to med [medical] floor for observation."

Patient #9's medical record lacked evidence the CAH's ER staff kept the patient under constant supervision while the patient remained in the ER.

Patient #9's history and physical identified diagnoses of "1). Acute anxiety/depression 2) acute suicidal, 3) acute cutting episode."

Other than restricting Patient #9's visitors and telephone calls, the facility failed to implement and monitor specific interventions and failed to specify the patient's level of suicide risk (high, moderate, or low) at the time of admission.

- Review of Patient #23's closed medical record identified a "Chief Complaints/Injury" of "Feels depressed Suicidal tendency," and showed a "Triage Level" of "III (Minor)." The ER staff obtained Patient #23's vital signs at 1:00 p.m., 2:17 p.m., 3:52 p.m., 4:30 p.m. and 4:55 p.m.

Patient #23's Nurse Notes as documented on the ED Record stated,
12:29 p.m. - "To ER per cart, alert et [and] oriented . . . Pt [patient] reports feeling [increased] depression et 'want to kill myself' lately. Reports 'mother didn't show up for family picnic . . . Reports 'feeling this way since Sat [Saturday] it gets worse everyday.' Reports she would kill herself [with] poison et scissors if she were to carry through [with] plan."
2:50 p.m. - "Called to notify acceptance of pt at [name of acute hospital] . . . Was informed of a shortage of beds in the psych [psychiatric] area [and] that the pt can come up [and] be evaluated but that she most likely not be admitted. Called Dr. [name of provider's] clinic with the info. Waited for return call. . . ."
4:20 p. - "Dr. [name of provider] called back [and] stated he would admit her for observation."

Patient #23's medical record lacked evidence the CAH's ER staff kept the patient under constant supervision while the patient remained in the ER.

Patient #23's medical record failed to specify the patient's level of suicide risk (high, moderate, or low) at the time of admission and specific interventions implemented and monitored while the patient remained hospitalized in the CAH.

During interview on 11/16/11 at 11:10 a.m., an administrative nurse (#1) confirmed the facility failed to identify the levels of suicide risk for Patients #9 and #23 at the time of admission.

1. Based on observation, record review, professional literature review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the safe use of side rails and consider side rails as a potential entrapment and safety hazard, failed to assess each patient individually prior to utilizing side rails, and failed to provide education to the patient and responsible party regarding the hazards of side rail use for 3 of 3 active patients (Patients #1, #2, and #3) observed with elevated side rails. Failure to assess and evaluate the use of side rails, to consider side rails as a potential entrapment and safety hazard, and to educate patients and responsible parties regarding the hazards of using side rails placed Patients #1, #2, and #3 at risk of entrapment or injury.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings," dated April 2003, stated, ". . . CMS [Centers for Medicare and Medicaid Services] . . . issued guidance in June 2000 . . . 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. Even when a side rail is not intentionally used as a restraint, patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised siderails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . . 1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize . . . those in current use should occur within the framework of an individual patient assessment. . . . 3. Use of bed rails should be based on patients' assessed medical needs and should be documented clearly . . . The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted . . . The care plan should include educating the patient about possible bed rail danger to enable the patient to make an informed decision . . . Assessment of risk should be part of the individual patient's assessment, and steps to address the risk should be incorporated into the patient's care plan. . . ."

The United States Department of Health and Human Services, Food and Drug Administration (FDA), and Center for Devices and Radiological Health (CDRH) publication titled, "Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," issued on 03/12/06, stated, ". . . FDA is recommending dimensional limits for zones 1 through 4 . . . because . . . the majority of the entrapments . . . have occurred in these zones. . . . Zone 1 is any open space within the perimeter of the rail. Openings in the rail should be small enough to prevent the head from entering. . . . FDA is recommending a measure of less than . . . 4 3/4 inches as the dimensional limit for any open space within the perimeter of a rail. Zone 2 . . . This space is the gap under the rail between a mattress . . . Preventing the head from entering under the rail would most likely prevent neck entrapment in this space. FDA recommends that this space be small enough to prevent head entrapment, less than . . . 4 3/4 inches. . . . Zone 3 . . . This area is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment . . . FDA is recommending a dimensional limit of less than . . . 4 3/4 inches for the area between the inside surface of the rail and the compressed mattress. Zone 4 . . . This space is the gap that forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of a rail. . . . The space poses a risk for entrapment of a patient's neck. . . . to prevent neck entrapment. . . . FDA recommends that the dimensional limit for this space . . . be less than . . . 2 3/8 inches. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts," revised April 2010, stated, ". . . Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . . Keep the bed in the lowest position with wheels locked. When the patient is at risk of falling out of bed, place mats next to the bed . . . Monitor patients frequently. Anticipate the reasons patients get out of bed . . . meet these needs . . . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. . . . Reassess the need for using bed rails on a frequent, regular basis."

Observation of the beds utilized on the nursing unit occurred on November 14-16, 2011. Most of the beds utilized by the current observation, inpatient, and swing bed patients had four half rails, two half rails on each side, attached to the beds. The beds and side rails all differed in shape, size, or make. Measurements of one type of bed, located specifically in room #235, identified 7 1/2 to 8 inch open spaces within the rails of the top half rail and 7 1/2 to 9 inch open spaces within the rails of the bottom half rail. Observation showed other patient rooms on the nursing unit contained the same type of bed located in room #235 and identified patients occupied some of the beds.

Observation of Patients #1, #2, and #3 on all days of survey, while the patients rested in bed, identified two elevated upper half rails on the bed. Review of the above patients' active medical records occurred on November 14-15, 2011. The records indicated two side rails up for patient safety. The records lacked individualized assessments of risk and safety for the use of side rails and lacked evidence of patient or responsible party education regarding the hazards of side rails use. The CAH staff failed to consider the elevated side rails a safety and entrapment hazard for Patients #1, #2, and #3.

During an interview on 11/16/11 at 10:50 a.m., a nursing staff member (#4) stated patients used the elevated side rails for positioning and confirmed nursing staff does not perform or document an assessment for risk factors or safety for utilization of side rails. The nurse (#4) stated she did not realize the potential for the side rails as a safety hazard for entrapment or injury.

During an interview on 11/16/11 at 11:20 a.m., an administrative nurse (#1) confirmed the CAH utilized beds for patients which contained large spacing gaps within the side rails and stated the CAH is in the process of obtaining new side rails or changing existing ones. The nurse (#1) stated nursing staff usually elevated the side rails for patient positioning and access to bed controls/call light and confirmed nursing staff does not perform an assessment of risk factors or safety for utilization of side rails at the current time.


21202


2. Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the plan of care for 1 of 1 closed swing bed record (Patient #6) with pressure ulcers and who experienced a fall and 2 of 2 closed observation records (Patients #9 and #23) admitted with a diagnosis of suicide attempt. Failure to assess and evaluate pressure ulcers had the potential to impede the healing process of Patient #6's pressure ulcers. Failure to implement interventions and a plan of care to prevent falls limited the CAH's ability to ensure Patient #6's safety. Failure to develop and implement specific suicide precautions and interventions and failure to ensure the safety of the patient's environment, limited the CAH's ability to provide the appropriate care for and ensure the physical safety of Patients #9 and #23.

Findings include:

Review of the following policies occurred on 11/16/11.

The policy titled "Pressure Ulcers," dated 05/26/11, stated, ". . . I. Weekly Wound Assessment: A. Done daily for acute care and Medicare patients and weekly on chronic ulcers. Assess and record: pressure sore characteristics . . . signs of local infection . . . signs of systemic infection . . . II. Risk Factors for all stages: A. Assess and record: activity/movement, presence or absence of sensory deficits, diagnoses, medications, mental status, age, nutritional and circulatory status. . . ."

The policy titled "Nursing Care Plan," dated 09/04/03, stated, ". . . POLICY: In order to meet nursing service's goal of comprehensive quality care, each patient admitted to the hospital should have an individualized Plan of Care based on his needs and problems. PROCEDURE: 1. Nursing histories are obtained by a RN [registered nurse] or LPN [licensed practical nurse], supervised by an RN on admission of the the patient. This collected information is used to make an individualized Nursing Care Plan. 2. The Nursing Care Plan is part of the chart. It is outlined by statements of patient's needs and problems with nursing approaches and solutions . . . 5. The Care Plan should be done for all patients who are hospitalized for more than 24 hours and should be completed within 24 hours."

The policy titled, "Suicide Patients, Handling of," dated 08/1997, stated, "POLICY: Suicide patients present special problems in terms of care and prevention of self-inflicted harm. The hospital has a duty to protect patients from harm and self-inflicted injury and must take proper precautions to assess the anticipate [sic] suicidal tendencies in patients. PROCEDURE: A. Procedure in Emergency Room: 1. The patient must be kept under constant surveillance . . . B. Procedure on Medical Floor: 1. Admission precautions: a. Do not leave newly admitted patients unattended until all articles from their pockets have been removed. b. Attempt to establish a relation [sic] early on. Allow freedom to express feelings through verbal communication. 2. The patient should be placed in a private room near the Nurse's Station. 3. All objects with which the patient could further injure himself should be removed. These include plastic bags, matches or cigarette lighters, power cords, telephone wires, unused restraints, wire clothes hangers, all sharp or protruding objects and all objects which can be ingested such as aerosol sprays and glass objects should be removed. 4. The patient should be dressed in a hospital gown and all personal clothing items, especially belts and shoelaces, should be removed. 5. All staff members who have contact with the patient should be informed about the possibility of a repeat suicide attempt. 6. The patient may not require 24 hour continuous observation, but should be observed by nursing personnel at least once per hour . . . 7. The patient should be supervised one-to-one whenever he leaves his room. . . ."

Information attached to this policy titled "Suicide Risk: A Guide for ED [Emergency Department] Evaluation and Triage" stated, ". . . High risk patients . . . Made a serious or nearly lethal suicide attempt; persistent suicide ideation or intermittent ideation with intent and/or planning; psychosis, including command hallucinations; recent onset of major psychiatric syndromes, especially depression; been recently discharged from a psychiatric inpatient unit, history of acts/threats of aggression or impulsivity.
Moderate risk patients . . . Suicide ideation with some level of suicide intent, but who have taken no action on the plan; no other acute risk factors; a confirmed, current and active therapeutic alliance with a mental health professional.
Low risk patients . . . Some mild or passive suicide ideation, with no intent or plan; no history of suicide attempt; available social support. . . ."

- Review of Patient #6's closed swing bed medical record occurred on November 14-15, 2011. The CAH admitted Patient #6 to swing bed on 09/08/11 and discharged him on 09/21/11 (21 days later). Patient #6's medical diagnoses included herpes simplex virus, encephalitis, diabetes mellitus, and morbid obesity.

Patient #6's admission history and physical, dictated by a mid level practitioner, identified the patient had two open areas to coccyx each measuring one and one-half centimeters in size.

Patient #6's nursing progress notes stated:
09/08/11 at 4:43 p.m. - "Wound Assessment Findings: ABNORMALS: WOUND LENGTH/WIDTH/DEPTH (SEE NOTES), WOUND - BLISTER, WOUND- PRESSURE ULCER STAGE II INTERVENTIONS: Charge nurse notified, Provider notified. Blister to right medial heel measures 1.2 cm [centimeter] x [by] 2 cm. Open area to left buttock 3 cm x 2 cm. Open area to coccyx 3 x 7 cm . . . Morse Fall Scale Findings: . . . SCORE 25-50 - LOW RISK INTERVENTIONS: Implement standard safety protocol . . . Musculoskeletal Findings: ABNORMALS: BEDRIDDEN, GENERALIZED WEAKNESS . . . ."
09/12/11 at 1:33 a.m. - ". . . nurse sitting at station heard noise ran to [room] 211 and found resident on floor with bed turned on side. Pt [patient] rolled over in bed and ? flipped. Pt denied any injuries, covered with warm blanket. Assistance from LTC [Long Term Care], maintenance. Pt hoyed [sic]. Pt denies hitting head, stated pillow was below head when he fell."

Patient #6's closed medical record lacked evidence the CAH's nursing staff assessed the patient's pressure ulcers daily or on a weekly basis as per their facility policy.

Patient #6's medical record identified the presence of pressure ulcers upon admission to the CAH on 09/08/11. Review of a Patient #6's care plan identified "Risk for impaired skin integrity," dated 09/13/11 (five days after admission), and lacked evidence of specific interventions to aid in the healing and further prevention of pressure ulcers.

Review of Patient #6's computerized care plan lacked evidence CAH nursing staff identified the problem and implemented interventions regarding prevention of falls and safety in response to the fall from bed the patient experienced on 09/12/11.

During interview on the morning of 11/15/11, an administrative nurse (#1) stated she expected nursing staff to have immediately re-evaluated Patient #6's fall risk assessment (Morse Fall Scale) after his fall and confirmed no care plan for falls and/or safety existed for Patient #6. This administrative nurse (#1) confirmed the CAH admitted Patient #6 with pressure ulcers and the CAH nursing staff should have immediately implemented a care plan aimed at interventions to promote healing of the pressure ulcers.

- The ED log identified Patient #9, a 19 year old female, presented to the ED on 01/10/11. The log identified the "Nature of Injury" as "Suicide Attempt." The CAH admitted Patient #9 to observation level of care at 8:53 p.m. on 01/10/11 and discharged the patient on 01/11/11 at 10:00 a.m.

Review of Patient #9's closed medical record showed the admitting Emergency Room (ER) staff member (a paramedic) identified a "Chief Complaints/Injury" of "Suicidal tendency" and assigned/determined a "Triage Level" of "II (Urgent)."

Patient #9's Nurses Notes as documented on the ED Record by the paramedic stated:
7:23 p.m. - "Pt presents pedis to ER with parents. Pt agitated - stating she doesn't want to go into treatment. Pt's mom states she came home from Fargo today very agitated and told her mom she was going to slice her arm. Pt's left arm has several cuts from a razor on wrist area. Pt was in [name of acute psychiatric hospital] for suicidal tendencies and was released on Friday- Jan [January] 7th. . . . Pt became agitated [and] called her mom."

Patient #9's history and physical identified diagnoses of "1). Acute anxiety/depression 2) acute suicidal, 3) acute cutting episode."

Other than restricting Patient #9's visitors and telephone calls, the facility failed to implement and monitor specific interventions and failed to specify the patient's level of suicide risk (high, moderate, or low) at the time of admission.

Review of Patient #9's care plan, dated 01/10/11, identified the problem of "Actual/potential risk for violence: self directed" and interventions of "1. Assess for suicide potential 2. Provide safe environment by removing potentially harmful substances and objects 3. Spend time with patient to provide sense of security, reinforce self-worth." Patient #9's medical record lacked evidence the CAH nursing staff implemented the above care plan interventions of assessing the patient's suicide potential and providing a safe environment. Patient #9's record lacked evidence the CAH staff removed potentially harmful substances and objects from the environment.

The CAH nursing staff failed to ensure the safety of the patient's environment.

- The ED log identified Patient #23, a 22 year old female, presented to the ED on 06/15/11. The CAH admitted Patient #23 at 4:55 p.m. to observation level of care and discharged the patient on 06/16/11 at 11:20 a.m.

Review of Patient #23's closed medical record identified a "Chief Complaints/Injury" of "Feels depressed suicidal tendency" and showed a "Triage Level" of "III (Minor)."

Patient #23's Nurses Notes as documented on the ED Record stated,
12:29 p.m. - "To ER per cart, alert et [and] oriented . . . Pt [patient] reports feeling [increased] depression et 'want to kill myself' lately. Reports 'mother didn't show up for family picnic . . . Reports 'feeling this way since Sat [Saturday] it gets worse everyday.' Reports she would kill herself [with] poison et scissors if she were to carry through [with] plan."
4:20 p. - "Dr. [name of provider] called back [and] stated he would admit her for observation."

Admission orders included a diagnosis of "suicide gesture," and failed to indicate specific suicide precautions and interventions to implement and monitor while the patient remained hospitalized at the CAH and failed to specify the patient's level of suicide risk (high, moderate, or low) at the time of admission.

Review of Patient #23's medical record lacked evidence the CAH nursing staff ensured the safety of the patient's environment by the removal of potentially harmful substances and objects from the environment.

During an interview on 11/16/11 at 11:10 a.m., an administrative nurse (#1) stated she requires care plans for patients admitted as an "inpatient or swing bed" and for those patients who "remain hospitalized for longer than 24 hours" and stated she did would expect nursing staff to have initiated a care plan for Patients #9 and #23. This staff member confirmed the records of Patients #9 and #23 lacked evidence the CAH staff assessed each patient's environment and removed potentially harmful substances and objects.

Based on record review, review of medical staff rules and regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure the accessibility of medical records (Refer to C303) and failed to ensure complete documentation in the medical record (Refer to C304). The cumulative effect of these systemic problems resulted in the CAH's inability to ensure medical records provided continuance of quality health care to the CAH's patients.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 03/27/08.

Based on record review, review of medical staff rules and regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure the accessibility of medical records for 1 of 4 closed inpatient surgical records (Patient #30) reviewed. Failure of the CAH to ensure the accessibility of medical records limited the CAH's ability to ensure complete and accurate documentation, placed the medical record at risk of loss or damage, and limited the CAH's access to the medical record for quality improvement review.

Findings include:

Review of the CAH's Medical Staff Bylaws, Rules, and Regulations occurred on November 14-16, 2011. This document, approved 10/15/07, stated, ". . . RULES AND REGULATIONS . . . C. RELEASE OF INFORMATION . . . 2. Records may be removed form the Hospital's jurisdiction and safekeeping only in accordance with Hospital's polices and with the court orders, subpoenas, or pursuant to state and federal law. All records are property of the Hospital and shall not otherwise be taken away. In case of readmission of a patient, all previous records shall be available for the use of the attending physician. . . ."

Review of the CAH's Operating Room Log identified Patient #30 underwent a vaginal hysterectomy on 09/15/11. The surveyor requested this chart from an administrative staff member (#11) on the morning of 11/16/11.

On 11/16/11 at 11:55 a.m., an administrative staff member (#11) stated she could not locate Patient #30's "original" chart from the inpatient hospital stay dated 09/15/11. This staff member provided scanned "copies" of some of Patient #30's information retained in the CAH's electronic medical record system (history and physical, discharge summary, operative report, physician progress notes, pathology report, and laboratory reports) and stated the handwritten doctor's orders, anesthesia record, and post anesthesia care record, nurse's notes, and care plan are missing. This staff member stated she "believed" the doctor removed the record from the hospital and does not know how long this chart has been unaccounted for.

When asked to review the CAH policy/procedure pertaining to the removal of patient records from the premises, an administrative staff member (#11) stated the CAH has no such policy/procedure.

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY CONDUCTED ON 04/02/03 and 03/27/08.

Based on medical record review, review of medical staff rules and regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure complete documentation in the medical record for 5 of 16 closed emergency room (ER) records (Patient #8, #20, #24, #28 and #25), 3 of 4 closed inpatient (IP) surgical records (Patient #13, #14, and #32), 3 of 5 closed outpatient (OP) surgical records (Patient #15, #16 and #17), and 1 of 3 closed swing bed patient records (Patient #12) reviewed.

Findings include:

Review of the CAH's Medical Staff Bylaws, Rules, and Regulations occurred on November 14-16, 2011. This document, approved 10/15/07, stated, ". . . RULES AND REGULATIONS A. ADMISSION AND DISCHARGE . . . 2. A member of the Medical Staff shall be responsible for the medical care and treatment of each patient in in Hospital and for the prompt completeness and accuracy of the medical record . . .
B. MEDICAL RECORDS B1. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current. 2. Pertinent progress notes shall be recorded at the time of assessment, sufficient to permit continuity of care and transferability . . . 3. Operative reports shall include a detailed account of the findings at surgery as well as the details of the surgical technique and estimated blood loss. Operative reports shall be written or dictated within 24 hours following surgery and the report promptly signed by the surgeon and made a part of the patient's current medical record . . . 5. All clinical entries in the patient's medical record shall be accurately dated and authenticated by the person (identified by name and discipline) who is responsible for ordering, providing or evaluating the service furnished . . .
D. GENERAL CONDUCT OF CARE D1. All orders for treatment shall be in writing. . . . The responsible practitioner shall authenticate orders . . .
J. EMERGENCY SERVICE . . . 2. An appropriated medical record shall be kept for every patient receiving emergency service . . . The record shall include:
(a) adequate patient identification;
(b) information concerning the time of the patient's arrival, means of arrival and by who transported;
(c) pertinent history of the injury or illness including details relative to first aid or emergency care given the patient prior to his arrival;
(d) description of significant clinical, laboratory and roentgenologic findings;
(e) diagnosis;
(f) treatment given;
(g) condition of the patient on discharge;
(h) final disposition, including instruction given to the patient and/or his family relative to necessary follow-up care . . .
3. The Hospital . . . shall develop a policy for on-call practitioners in the emergency services area. The policy shall require such call coverage to be scheduled twenty-four (24) hours per day, seven (7) days per week. The on-call practitioner must respond within (30) minutes of receiving the emergency call.
4. . . . any individual who presents to the Emergency Room requesting an examination or treatment for a medical condition will be provided an appropriate medical screening examination within the capabilities of the emergency room in order to determine whether an emergency medical conditions exists. Medical personnel who are qualified to provide an initial screen examination include the following medical or nursing personnel: physician, physician assistant, nurse practitioner. Registered Nurses, specially trained in obstetrics, are authorized to perform a medical screening examination of an obstetrical patient to determine she is in labor. . . ."

- Review of a sample of the CAH's closed IP and OP surgical records occurred on November 14-16, 2011 and identified the CAH Health Information Management (HIM) department failed to promptly transcribe dictated operative reports as follows:
* Patient #13, underwent an IP abdominal hysterectomy procedure on 01/26/11. The CAH discharged the patient on 01/30/11. Review of the Operative Report, identified a dictation note of 01/30/11 (four days after the operation) and the CAH's HIM department transcribed the report on 02/01/11 (two days after discharge).
* Patient #15, underwent an OP laparoscopic cholecystectomy procedure on 04/06/11 and the CAH discharged the patient the same day. Review of the surgeon's operative report titled "Surgery/Procedure/Tests" included a date of "04/18/11" which identified when the surgeon authenticated/signed the note. This form lacked the dictation and transcription date.
* Patient #14, underwent an emergency Cesarean Section procedure on 04/14/11. The CAH discharged the patient on 04/17/11. Review of the Operative Report identified a dictation date of 04/14/11 (the day of the operation) and the CAH's HIM department transcribed the report on 04/29/11 (11 days after discharge).
* Patient #32, underwent a Cesarean Section procedure on 07/14/11. Review of the Operative Report, identified a dictation date of 07/14/11 (the day of the operation) and the CAH's HIM department transcribed the report on 08/05/11 (21 days later).
* Patient #16, underwent an OP inguinal hernia repair procedure on 08/03/11 and the CAH discharged the patient the same day. Review of the surgeon's operative report titled "Surgery/Procedure/Tests" included a date of "08/06/11" which identified when the surgeon authenticated/signed the note. This form lacked a dictation or transcription date.
* Patient #17, underwent an OP excision of the labium majus procedure on 09/20/11 and the CAH discharged the patient on the same day. Review of the Operative Report, identified a dictation date of 09/20/11 (the day of the operation) and the CAH's HIM department transcribed the report on 10/03/11 (13 days after discharge).

During an interview on 11/15/11 at 4:30 p.m., an administrative staff member (#11) stated the HIM department lacked a policy regarding the timeframe for transcription of operative reports; she expected staff to transcribe the operative report in a "timely" manner; and the CAH staff should have access to the report in accordance with Medical Staff Rules and Regulations. This staff member confirmed Patients #13, #14, #15, #16, and #32's operative reports were not accessible during their respective hospital stays and this information was not available to healthcare providers had these patient's experienced a healthcare emergency.

- Review of a sample of CAH's closed medical records occurred on November 14-16, 2011 and identified records lacked clinic notes, physician orders, pertinent medical history, and assessment of the health status and health needs as follows:
* Patient #8, a 44 year old female, presented to the Emergency Department (ED) on 01/11/11. An ER Note, dictated on 01/29/11 (18 days after the patient presented to the ED), stated, ". . . The patient was seen by [name of physician assistant] and went to my office to be seen. For details of the exam and the procedure please see the office notes." During review of this closed record, the clinic note mentioned was not available for review.
* Patient #20, a 14 year old male, presented to the ED on 03/11/11 with right sided abdominal pain. Patient #20's record indicated an ER note dictation date of 03/19/11 (eight days after the patient presented to the ED) and the CAH's HIM department transcribed it on 04/22/11 (31 days later). This physician ER Note located on Patient #20's closed ER record lacked evidence of authentication.
* Patient #15, a 81 year old male, presented to the CAH for an OP surgery on 04/06/11. Review of Patient #15's physician orders, dated 09/20/11 at the time of admission and at 10:00 a.m., lacked authentication.
* Patient #16, a 73 year old male, presented to the CAH for an OP surgery on 08/03/11. Review of Patient #16's admission orders, dated 08/03/11, lacked authentication. * Patient #24, a 10 year old male, presented to the ED on 06/24/11 with left elbow pain. Patient #24's record indicated an ER note dictation date of 08/29/11 (more than two months after the patient presented to the ED) and the CAH HIM department transcribed it on 09/11/11 (12 days later).
* Patient #16, a 73 year old male, presented to the CAH for an OP procedure on 08/03/11. Review of Patient #16's admission orders, dated 08/03/11, lacked authentication
* Patient #25, a 23 year old male, presented to the ED on 08/08/11 with right hand pain. Review of Patient #25's record showed orders for an x-ray. Review of the dictated ER Note failed to identify an order for any pain medications upon discharge from the ER. Patient #25's written discharge instructions identified the patient received a printed handout regarding wrist sprains and the new medication of "Oxycodone 10 mg [milligrams] po [orally] q [every] 4 hrs [hours] for pain," and instructed to return to the ER if he developed "fever, change in finger sensation, circulation." Review of Patient #25's medical record lacked evidence of a written physician order for the patient to take Oxycodone for pain. The Emergency Room Note, dated 08/08/11 stated, ". . . PLAN: The patient will wear his . . . splint and take OTC [over-the-counter] pain meds [medications]. Apply cast if fracture is identified."
* Patient #28, a 27 year old male, presented to the ED on 09/05/11, with a high fever, chills, cough of productive white/green sputum, and wheezing. This record identified Patient #28 received intravenous (IV) Solumedrol and Rocephin. Patient #28's written discharge instructions instructed the patient to return on 09/06/11 for IV antibiotics. Patient #28's record lacked evidence the health care provider completed a pertinent progress note (ER Note) for this stay and lacked written orders for the patient to return the next day for additional IV antibiotics.
* Patient #17, a 72 year old female, presented to the CAH for an OP procedure on 09/20/11. Review of the discharge orders, dated 09/20/11 lacked authentication.
* Patient #12, a 81 year old male, admitted to swing bed on 10/25/11 and expired on 11/02/11. Patient #12's diagnoses included acute myocardial infarction, congestive heart failure, type 2 diabetes, and chronic obstructive pulmonary disease. Review of Patient #12's Discharge Summary (used as the history and physical (H&P) for this swing bed stay) identified a dictated discharge summary on 11/10/11 (16 days after transferring the patient to swing bed level and after the patient's death.) Patient #12's swing bed stay of 10/25/11 lacked a completed assessment of his health status at the time of admission to swing bed.

During an interview on 11/15/11 at 4:30 p.m., an administrative staff member (#11) stated she expected providers to dictate an ER Note immediately after seeing the patient. This administrative staff member stated the CAH allowed providers to use the discharge summary from an acute/inpatient stay as the H&P for a swing bed stay and if doing so would expect the provider to complete the discharge summary on the day the CAH transferred the patient to swing bed. This administrative staff member confirmed the provider completed Patient #12's acute discharge summary/swing bed H&P late, and the information contained in this document remained unavailable to staff during Patient #12's hospitalization. Administrative staff member (#11) confirmed Patients #15, #16, #17, and #20's records lacked evidence of physician order authentication.

During interview on 11/16/11 at 11:25 a.m., an administrative nurse (#1) stated she expected the doctors to clearly write all medications and discharge orders within the medical record.

Based on policy review, reporting schedule review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure all departments affecting patient health and safety evaluated quality of patient care and reported to the Quality Improvement (QI) Committee as scheduled for 12 of 12 months reviewed (November 2010 - October 2011). Failure to ensure all departments evaluated quality of care and reported to the QA Committee as scheduled limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the policy titled "St. Aloisius Medical Center Quality Improvement Peer Review Plan" occurred on 11/15/11. This policy, revised 02/25/11, stated,
"1. Quality Improvement/Peer Review Goals: . . .
B. To assess the effectiveness of efforts taken to monitor, assess and improve care and departmental services. . . .
D. . . . QI/Peer Review activities are to be ongoing and should result in a positive impact on care and departmental services. . . .
2. Objectives: . . .
B. Department Services:
1. All departments are required to monitor and evaluate key aspects of their service. . . .
3. All departments . . . are required to prepare a written report which must be presented to the committee quarterly. . . ."

- Reviewed on 11/15/11, the monthly Quality Improvement Committee meeting minutes from November 2010 - October 2011 lacked evidence the following departments reported quality of patient care evaluations to the facility wide QI Committee: physical therapy, occupational therapy, and central supply.

Review of the "Quality Improvement/Peer Review Department Reporting Schedule" occurred on 11/15/11. This schedule, revised 12/03/08, included the following reporting times:
Cardiac Rehabilitation: December, March, June, and September.
Environmental Services: January, April, July, and October.
Obstetrics: February, May, August, and November.

- Reviewed on 11/15/11, the November 2010 - October 2011 monthly QI Committee meeting minutes indicated the following departments did not report as scheduled by the QI Committee:
Cardiac Rehabilitation: no report in December, March, and September.
Environmental Services: no report in July.
Obstetrics: no report in February and August.

During an interview at approximately 3:30 p.m. on 08/24/11, an administrative staff member (#7) confirmed physical therapy, occupational therapy, and central supply did not report quality of care monitoring to the QI Committee in the past year; and cardiac rehabilitation, environmental services, and obstetrics did not report as scheduled in the past year.

Based on policy review, medical staff roster review, register review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the quality and appropriateness of the treatment furnished by 1 of 1 Family Nurse Practitioner (FNP) (Provider #1), and 1 of 1 Physician's Assistant (PA) (Provider #2), and 18 of 18 Certified Registered Nurse Anesthetists (CRNAs) (Providers #3-#20) providing care to the CAH's patients in 2010. Failure to evaluate the quality and appropriateness of the treatment furnished has the potential to affect patient outcomes involving patient care provided by the FNP and PA and surgical procedures requiring anesthesia services provided by the CRNAs.

Findings include:

Review of the "St. Aloisius Medical Center Medical Staff Bylaws" occurred on 11/14/11. These bylaws, approved 10/15/07, stated,
". . . Article I Definitions
The following definitions shall apply to terms used in these bylaws:
(1) 'Allied Health Professionals' shall mean healthcare professional other than physicians, podiatrists and dentists, optometrists: i.e. [id est - in other words]: Nurse Practitioners, Physician Assistants, Chiropractors and Certified Registered Nurse Anesthetist's.
. . . Article V Committees of the Medical Staff . . .
5.4-8 Quality Improvement/Peer Review Functions. . . .
The Medical Staff shall also work with the Hospital in analyzing the quality and appropriateness of services provided by Allied Health Professionals and other healthcare givers at the Hospital. . . ."

Review of the CAH's medical staff roster occurred on the afternoon of 11/15/11. The roster, revised 11/10/09, included Providers #1 and #2.

Upon request the afternoon of 11/15/11, the CAH failed to provide evidence a physician evaluated the quality and appropriateness of the treatment provided by Providers #1 and #2 and a physician with experience in anesthesiology evaluated the quality and appropriateness of the treatment provided by the nurse anesthetists (Providers #3-#20).

Review of the CAH's "Register of Operations" occurred in the morning of 11/16/11. The register indicated the following CRNAs provided services to the CAH's patients in 2010:
January: Providers #13, #4, #19, and #8.
February: Providers #15, #6, and #17.
March: Provider #11.
April: Providers #16, #9, and #20.
May: Providers #7 and #5.
June: Providers #15, #17, #13, and #10.
July: Providers #16, #12, #4, #14, and #8.
August: Providers #19, #5, and #3.
September: Providers #12, #3, and #4.
October: Providers #7, #20, and #16.
November: Provider #8.
December: Providers #12, #18, and #16.

During interview at approximately 3:00 p.m. on 11/15/11, an administrative nursing staff member (#1) confirmed Providers #1 and #2 provided care to the CAH's patients in 2010, and the CAH did not have a physician evaluate the appropriateness of the diagnosis and treatment furnished by Providers #1 and #2. Administrative nursing staff member #1 confirmed the CAH did not have a physician with anesthesiology experience evaluate the quality and appropriateness of the treatment provided by the CRNAs.