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Based on observation, record review, policy review, document review, and interview, the Critical Access Hospital (CAH) failed to have an adequate inventory of available necessary medications used for life-saving measures and failed to ensure expired emergency medications were removed from potential use. Failure to maintain a current supply of life-saving medications and life-saving equipment, places all patients receiving services at this hospital at risk for harm.


Findings Include:

1. The Critical Access Hospital (CAH) failed to ensure it maintained an adequate supply of medication to reverse the potential life-threatening side effect, malignant hyperthermia (MH) (dangerously high body temperature, rigid muscles or spasms, and a rapid heartrate) resulting from the use of Succinylcholine (a medication used to provide muscle relaxation while inserting a breathing tube) in emergencies and failed to ensure inspection of an emergency defibrillator (equipment used in cardiac arrest) was current. (Refer to tag C0884)

2. The Critical Access Hospital (CAH) failed to ensure expired medications, commonly used in life-saving procedures for use in emergencies, were removed from potential use and failed to ensure oxygen supply was readily available on the crash cart. (Refer to tag C0886)

Based on observation, document review, and interview, the Critical Access Hospital (CAH) failed to ensure it maintained an adequate supply of medication to reverse the potential life-threatening side effect, malignant hyperthermia (MH) (dangerously high body temperature, rigid muscles or spasms, and a rapid heartrate) resulting from the use of Succinylcholine (a medication used to provide muscle relaxation while inserting a breathing tube) in emergencies and failed to ensure inspection of an emergency defibrillator (equipment used in cardiac arrest) was current. Failure to maintain a supply of medication to reverse the potential life-threatening side effect of succinylcholine and failure to inspect life-saving equipment for safety places all patients receiving services at this hospital at risk for harm.

Findings Include:

Review of the Malignant Hyperthermia Association of the United States (MHAUS) showed, ...All facilities, including ambulatory surgery centers and offices, where MH triggering anesthetics (isoflurane, desflurane, and sevoflurane) and depolarizing muscle relaxants (succinylcholine) are administered, should stock dantrolene as indicated below, along with the other drugs and devices necessary to treat an HG reaction. If none of these agents are ever in use in the facility, then dantrolene need not be kept on hand ...

...To treat an MH episode, an initial dose of dantrolene at 2.5 mg/kg is recommended, with a suggested upper limit of 10 mg/kg. If a patient of average weight (approximately 70 kg) were to require dantrolene at the upper dosing limit, then at least 700 mg of dantrolene would be needed.

DANTRIUM/REVONTO - stock a minimum of 36-20 mg vials
RYANODEX- stock a minimum of 3 - 250 mg vials

In addition, a review of cases has shown that in a "worse case" scenario of a very large person (i.e., about 100-110 kg or 220 - 250 pounds) having an acute MH incident, as much as 8-10 mg/kg will be needed for treatment; higher doses may be required on rare occasions. This regimen of dantrolene will allow for initial stabilization and treatment while more vials are being acquired to continue treatment, as needed.

Review of a hospital document titled, "Malignant Hyperthermia and Dantrium (medication used to treat malignant hypothermia) Administration," undated, showed, " ...Immediately obtain Dantrium and sterile water ...Dantrium needs to be administered immediately .... The RN (Registered Nurse) or RNs should begin to mix the 20 milligram (mg) vials by adding 60 milliliter (ml) sterile water to each vial and shake vigorously ..."

During an observation on 04/11/23 at 08:50 AM, a crash cart showed the defibrillator maintenance inspection tag with a completed date of 02/2022 with the next inspection due date of 02/23. The hospital failed to ensure that life-saving emergency equipment inspections were up to date.

During an observation on 04/11/23 at 9:28 AM, the operating room showed a total of 35 vials of Dantrolene, no sterile water and no syringes were available. The hospital failed to ensure necessary supplies were available to dilute and administer life-saving medication. During the observation, Staff H, RN, verified the hospital did not have the required amount of Dantrolene, sterile water, and syringes available to meet requirements.

During an interview on 04/11/23 at 1:00 PM, Staff A, Chief Nursing Officer (CNO), stated that Staff C, RN/Pharmacy Technician, went to another facility to pick up one bottle of Dantrolene, sterile water, and syringes. Staff A, CNO, stated that Staff C, RN, was currently enroute back to the facility with the supplies.

Based on observation, document review, and interview, the Critical Access Hospital (CAH) failed to ensure expired medications, commonly used in life-saving procedures for use in emergencies, were removed from potential use and failed to ensure oxygen supply was readily available on the crash cart. Failure to remove expired medications used to treat potentially life-threatening emergencies and have a readily available oxygen supply on the crash cart places all patients at risk for harm.


Findings Include:


Review of a hospital policy titled, "Medications in the Emergency Department," revised 09/2019, showed, " ...Medication cabinets will be stocked by Pharmacy: Pharmacy or nursing staff will periodically check for outdates. Emergency ACLS (Advanced Cardiac Life Support) drugs are locked in crash cart ..."

Review of a hospital policy titled, "Crash Cart Checks and Cart Security," revised 12/2022, showed, " ...Nursing staff will be responsible for ensuring that the crash carts are properly secured with a keyed lock or numbered security tag after verifying contents of cart are fully stocked and within expiration dates ...A monthly check will be completed by pharmacy staff to ensure all medications are within expiration date use ...Daily check and/or test of the functionality of the following equipment: Defibrillator/monitor; Suction; Oxygen Supply ...Documentation of the inspection should be recorded on "daily log" located on the crash cart. The documentation shall include the following: Date; Proper function of the equipment (pass/fail); Initials of the person performing the inspections; any malfunction or absent item should be documented on the inspection log and central supply notified ...Monthly medication out-date check: If medication tray has been unused for current month - Monthly check will be done by the fourth week of each month and medications expiring within the next month will be removed and replaced ...When checking for medication expiration out-dates, the pharmacy staff or designated staff is expected to verify the medication stored is the correct amount and route."

Review of a hospital policy titled, "Crash Cart Checks," revised 06/2019, showed, " ...Nursing should check all drugs and items on the emergency cart at the beginning of each month. Expired drugs and biologicals should be replaced ..."

During an observation on 04/11/23 at 8:50 AM, the crash cart revealed the following expired medications:

Solumedrol (medication used to treat severe allergies); 4 vials expired 02/2023 and 0 unexpired

Lasix (medication used to treat fluid overload); 4 vials expired 08/2022 and 0 unexpired

Aspirin (medication used to reduce the risk of heart attack) 81 milligram (mg) tab; 8 packages (pkg) expired 08/2022 and 0 unexpired

Adenosine (medication used for cardiac emergency); 12 vials expired 03/2023 and 0 unexpired

Magnesium Sulfate (medication used to treat cardiac emergency); 8 vials expired 08/2022 and 0 unexpired

Narcan (medication used to treat opioid overdose emergency); 2 vials expired 03/2023 and 0 unexpired

Decadron (medication used to treat severe allergic reaction); 1 vial expired 03/2023 and 0 unexpired

Dexamethasone (medication used to treat severe allergic reaction); 1 vial expired 11/2022 and 0 unexpired
8.4% Sodium Bicarb (medication used to treat metabolic acidosis); 8 vials expired 10/2022 and 0 unexpired

Epi Pen Adult (medication used to treat severe allergic reaction); 3 expired 03/2023 and 0 unexpired

Epi Pen Pediatric (medication used to treat severe allergic reaction); 3 expired 02/2023 and 0 unexpired

50% Dextrose (medication used to treat low blood glucose levels); 3 vials expired 04/2023 and 0 unexpired

Epinephrine (medication used to treat severe allergic reaction); 17 vials expired 11/2022 and 0 unexpired

Further observation, showed there was no supply oxygen on the crash cart.


During an observation on 04/11/23 at 9:28 AM, the operating room anesthesia medication cart showed the following expired medications:

Glucagon (medication used to treat low blood sugar); 1 vial expired 03/2023

Bloxiverz (medication used to treat reverse anesthesia); 1 vial expired 02/2023

Naloxone (medication used to treat overdose in emergency situations); 1 vial expired 02/2023

Oxytocin (medication used in childbirth; control bleeding; increase contractions); 3 vials expired
11/2022


During an observation on 04/11/23 at 9:25 AM, Staff C, RN/Pharmacy Technician, was in the medication room removing expired emergency medications from trays taken out of the hospital's crash cart. Staff C verified that at the time of the survey, the crash carts contained expired emergency medications and contained no unexpired emergency medications as listed above. Staff C stated that the hospital had trouble getting medication from the current vendor and that the hospital was trying to transition to another vendor within the next month or two. Staff C stated that it is the responsibility of the RNs to check medication expiration dates and that, " ...they obviously had not been doing that ..."

During an interview on 04/14/23 at 10:22 AM, Staff E, Director of Pharmacy, stated that he oversees the pharmaceutical needs of the hospital. He stated that he was made aware of surveyor findings in which multiple rescue medications in the crash carts were found to be expired. He stated that the hospital's policy required nurses to check crash cart medications weekly for outdates and, "we discovered that obviously was not being done as expected." He stated that the failure to ensure expired medications were removed from stock was, "ultimately my responsibility."

Based on policy review and interview, the Critical Access Hospital (CAH) failed to ensure that hospital policies and procedures were reviewed at least biennially by a group of professional personnel required under paragraph (a)(2) of this section and reviewed as necessary by the CAH. Failure to ensure the hospital reviews and/or updates policies and procedures at least biennially places any patient or employee at this hospital at risk for non-compliance related to failure to comply with new laws and regulations, which can result in inconsistent outdated practices resulting in poor patient outcomes and safety concerns.

Findings Include:

Review of the Hospital's Policy and Procedure Manual on "PolicyStat" showed the following policies were not reviewed and/or revised at least biennially:

"Medications in the Emergency Department," revised 09/2019, with next review due 09/2020
"Crash Cart Checks," revised 06/2019, with next review due 07/2020
"Assigning Nursing Care of Patients," revised 06/2019, with next review due 06/2020
"Scope of Service," revised 09/2019, with next review due 09/2020
"Competency of Staff-Credentials and Continuing Education," revised 09/2019, with next review due 09/2020
"Nursing Documentation," revised 07/2019, with next review due 08/2020
"Discharge Planning," revised 07/2019, with next review due 07/2020
"Patient Care Team Meeting," revised 07/2019, with next review due 07/2020
"Nursing Care Delivery Model," revised 05/2019, with next review due 05/2020
"Standards of Practice," revised 09/2019, with next review due 09/2020
"Admission of a Swing Bed Patient," revised 07/2019, with next review due 08/2020
"Patient Rights and Responsibilities," revised, 02/2019, with next review due 11/2022
"Photographing/Videotaping Patients" revised 09/2019, with next review due 09/2020
"Activities Program," revised 07/2019, with next review due 07/2020

During an interview on 04/12/23 at 8:54 AM, Staff A, CNO, stated they look over their policies and procedures, but they are not routinely updating or revising them.

Based on policy review, document review, and interview, the Critical Access Hospital (CAH) failed to ensure nursing care for each patient was supervised and evaluated by a Registered Nurse (RN) for eight of 12 patients (Patients 3, 4, 5, 7, 9, 10, 11, and 12), failed to ensure that an RN completed an assessment on five of 12 patients (Patient 3, 4, 5, 7, and 8). Failure to ensure that each patient receives a daily comprehensive physical assessment and evaluation of care by a RN places any patient receiving care at this hospital at risk for unidentified care needs and harm.

Finding Include:

Review of a hospital policy titled, "Assigning Nursing Care of Patients," revised 06/2019, showed, " ...Planning, supervision, and evaluation of the nursing care of each patient is done by a Registered Nurse (RN). The charge RN is responsible for assessing the patient needs and assigning duties to professional and non-professional personnel according to the needs of the patient and qualifications of available staff ...The RN assigns nursing personnel best qualified to meet the needs of each individual patient. She/he is responsible for planning, supervising, and evaluating the nursing care of each patient regardless of the category of personnel assigned to the patient ..."

Review of a hospital policy titled, "Nursing Documentation," revised 07/2019, showed that a Registered Nurse (RN) and Licensed Practical Nurse (LPN) may complete patient assessments, however, an RN must complete the patient assessment on all acute care patients and Swing bed patients at least once every 24 hours.

Review of a document titled, "Job Description Paramedic," revised 02/2023, showed, " ...Under the direction and supervision of the professional nurse in charge of the department, the paramedic assists the nurses in providing quality patient care and informs the nurse about any significant changes. This includes taking vital signs, transporting patients, and helping the professional nurse with interventions."


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was admitted on 02/15/23 at 11:30 PM for vomiting and fever.

On 02/16/23 at 12:26 AM, the Initial Nursing Assessment was completed by a Licensed Practical Nurse (LPN). Further review of Patient 2's medical record failed to show documented evidence that the initial assessment was reviewed and/or evaluated by an RN as required per hospital policy.


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 was admitted on 03/20/23 at 5:48 PM for cellulitis (bacterial infection) of leg. On 03/27/23 at 11:37 AM, Patient 3 was admitted to Swing Bed status (a service that rural hospitals and CAH's provide that allows a patient to transition from acute care to a Skilled Nursing Unit without leaving the hospital) for continuation of wound care.

Review of Patient 3's medical record failed to show documented evidence that a licensed nurse completed a comprehensive admission assessment when Patient 3 was admitted to Swing Bed status as required per hospital policy. Further review of Patient 3's medical record showed that the first nursing assessment completed was a shift assessment on 03/27/23 at 7:00 PM by Staff T, LPN.

Review of Patient 3's medical record failed to show documented evidence that an RN completed a daily physical assessment on Patient 3, as required per hospital policy, for the following dates: 03/21/23; 03/24/23; 03/27/23; 03/28/23; 03/29/23; 03/30/23; 04/1/23; 04/2/23; and 04/3/23.

Review of Patient 3's medical record failed to show documented evidence that an RN supervised or evaluated the care of Patient 3 that was provided by an LPN, specifically the completion of a physical assessment, for 20 of 29 completed Nurse Shift assessments.


Patient 4

Review of Patient 4's active medical record showed that Patient 4 was admitted on 04/28/23 at 2:00 PM with a diagnosis of septic diverticulitis (an inflammation or infection in one or more small pouches in the digestive tract.) Patient 4 was started on IV (intravenous) fluids and IV antibiotics and placed NPO (no food/fluids by mouth) for gut rest.

On 04/8/23 at 7:58 PM, the initial admission nursing assessment was completed by Staff S, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN, as required per hospital policy.

On 04/9/23 at 6:40 AM, Patient 4's physical assessment was completed by Staff R, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN, as required per hospital policy.

On 04/9/23 at 7:24 PM, Patient 4's physical assessment was completed by Staff S, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN, as required per hospital policy.


Patient 5

Review of Patient 5's active medical record showed that Patient 5 was admitted on 04/8/23 at 6:35 AM with a chief complaint of right sided weakness, right facial drooping, and slurred speech.

On 04/8/23 at 10:10 AM, Patient 5's initial triage Emergency Department nursing assessment was completed by Staff R, LPN. At 6:41 PM, the initial admission nursing assessment was completed by Staff S, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/9/23 at 10:10 AM, Patient 5's physical assessment was completed by Staff R, LPN. At 6:29 PM, the physical assessment was completed by Staff S, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/10/23 at 6:48 PM, Patient 5's physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN as required per hospital policy.


Patient 7

Review of Patient 7's active medical record showed that Patient 7 was admitted to Swing Bed on 03/30/23 after an acute hospitalization for a stroke. Patient 7's active secondary diagnosis included the following: Type 2 diabetes mellitus (a chronic disease process of high blood glucose levels), Atrial fibrillation (irregular/rapid heart rate), Long term use of insulin (medication used to treat high blood sugar), Hyperlipidemia (high levels of fat in the blood), Essential hypertension (high blood pressure), left above the knee amputation, and Hypomagnesemia (low magnesium levels in the blood.)

On 04/01/23 at 8:21 AM, Patient 7's physical assessment was completed by Staff U, LPN. At 6:55 PM, the physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/02/23 at 8:57 AM, Patient 7's physical assessment was completed by Staff U, LPN. At 7:03 PM, the physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/03/23 at 6:50 AM, Patient 7's physical assessment was completed by Staff R, LPN. At 7:30 PM, the physical assessment was completed by Staff S, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/06/23 at 6:16 PM, Patient 7's physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN as required per hospital policy.

On 04/07/23 at 7:31 AM, Patient 7's physical assessment was completed by Staff K, LPN. At 6:45 PM, the physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/08/23 at 6:57 AM, Patient 7's physical assessment was completed by Staff R, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN as required per hospital policy.

On 04/09/23 at 6:45 AM, Patient 7's physical assessment was completed by Staff R, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN as required per hospital policy.

On 04/10/23 at 7:06 PM, Patient 7's physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN as required per hospital policy.

On 04/11/23 the medical record failed to show documented evidence that a PM nursing assessment was completed on Patient 7.


Patient 8

Review of Patient 8's discharged medical record showed that Patient 8 was admitted on 01/14/23 at 7:22 PM for acute dehydration, weakness, and failure to thrive. Patient 8 was discharged from acute care to swing bed status on 01/14/23.

The Initial Nursing Assessment on 01/11/23 at 12:20 PM for Patient 8's acute stay was completed by an LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN and an RN failed to document a daily assessment on 01/11/23 as required per hospital policy.

Further review Patient 8's medical record failed to show that an Initial Admission Nursing Assessment or follow up physical assessments were completed from 01/14/23 through 01/31/23 while Patient 8 was in Swing Bed status.

During an interview on 4/13/23 at 10:45 AM, Staff A, Chief Nursing Officer (CNO) verified that Patient 8 did not have a nursing assessment in the medical record form 01/14/23 through 01/31/23.


Patient 9

Review of Patient 9's medical record showed the patient presented to the Emergency Department (ED) on 04/10/23 at 7:18 AM, with a chief complaint of difficulty breathing and chest pain. Patient 9 was transferred to a higher level of care at 11:45 AM due respiratory failure. The record review showed the initial triage assessment completed by Staff P, Paramedic, was not reviewed or evaluated by the RN as required per hospital policy. Record review failed to show documented evidence that an assessment was completed by a RN as required per policy.


Patient 10

Review of Patient 10's medical record showed the patient presented to the ED on 02/16/23 at 3:18 PM, with a chief complaint of chest pain. The record review showed the initial triage assessment completed by Staff P, Paramedic, was not reviewed or evaluated by the RN as required per hospital policy. Record review failed to show documented evidence that an assessment was completed by a RN as required by policy.


Patient 11

Review of Patient 11's medical record showed the patient presented to the ED on 03/20/23 at 4:45 PM with a chief complaint of sinus pain. The record review showed the initial triage assessment completed by Staff P, Paramedic, was not reviewed or evaluated by the RN as required per hospital policy. The record review failed to show documented evidence that an assessment was completed by an RN as required by policy.


Patient 12

Review of Patient 12's medical record showed the patient presented to the ED on 02/21/23 at 1:30 PM, with a chief complaint of chest pain, and was transferred to a higher level of care at 3:40 PM due to Cardiac intensive care need. The record review showed the initial triage assessment completed by Staff P, Paramedic, was not reviewed or evaluated by the RN as required per hospital policy. The record review failed to show documented evidence that an assessment was completed by an RN as required by policy.


During an interview on 04/12/23 at 11:15 AM, Staff D, Paramedic, stated, "My role is a paramedic. I just work in the ER [Emergency Room]. I basically do what an RN would do; assessment, let the provider know the patient is here, and do orders on patients. I do all my charting independently."

During an interview on 04/12/23 at 8:54 AM, Staff A, CNO, stated that a Paramedic or an RN completes the initial screen which includes the vital signs and chief complaint for Emergency Department patients. The paramedic can admit an Emergency Department patient which includes the initial assessment of the chief complaint and take the vital signs. The paramedic is on his own unless he requests help, or it is a complicated patient.

During an interview on 04/12/23 at 8:54 AM, Staff A, CNO, stated that the statement "EMTALA screening to be completed by RN" in the Paramedic job description meant the RN does the screening for EMTALA to ensure no EMTALA violations occur. Staff A, CNO, was unable to further elaborate or give further details.

Based on policy review, document review, and interview, the Critical Access Hospital (CAH) failed to implement a comprehensive plan of care for 4 of 12 patients (Patient 2, 4, 7, and 8) as required per hospital policy. The failure to implement a comprehensive plan of care for every patient places any patient receiving care at this hospital at risk for unidentified care needs and harm.


Finding Include:

Review of a hospital policy titled, "Admission of Patient," approved 11/2021, showed that each patient will have a plan of care initiated within eight hours of admission.

Review of a hospital policy titled, "Nursing Care Delivery Model," revised 05/2019, showed, " ...RNs are accountable for an individually tailored plan of care for the patient ..."

Review of a hospital policy titled, "Standards of Practice," revised 09/2019, showed, " ...Present/potential patient problems are documented in the patient's medical record to facilitate the development of patient outcomes and the nursing care plan to achieve those outcomes ..."


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was admitted on 02/15/23 at 11:30 PM for vomiting and fever.

Review of Patient 2's medical record failed to show documented evidence that a comprehensive plan of care was developed or implemented to address nursing concerns/goals for Patient 2 as required per hospital policy.

Review of Patient 2's medical record, showed that nursing staff failed to ensure that present/potential problems that might include but not limited to the following: IV fluids and antibiotics, and/or IV invasive lines/devices, skin integrity/monitor for pressure injury were considered to facilitate the development of patient outcomes and the nursing care plan to achieve those outcomes as required per hospital policy.


Patient 4

Review of Patient 4's active medical record showed that Patient 4 was admitted on 04/28/23 at 2:00 PM with a diagnosis of septic diverticulitis (an inflammation or infection in one or more small pouches in the digestive tract.) Patient 4 was started on IV (intravenous) fluids and IV antibiotics and placed NPO (no food/fluids by mouth) for gut rest.

Review of Patient 4's medical record, "Problems/Goals" [Plan of Care] dated 04/9/23 - 04/10/23, showed, "Pain Acute R/T (related to) abdominal pain." Nursing staff failed to ensure that present/potential problems that that might include but not limited to the following: nutrition/diet for a patient on NPO status, IV fluids and antibiotics, and/or IV invasive lines/devices, were considered to facilitate the development of patient outcomes and the nursing care plan to achieve those outcomes as required per hospital policy.


Patient 7

Review of Patient 7's active medical record showed that Patient 7 was admitted to Swing Bed on 03/30/23 after an acute hospitalization for a stroke. Patient 7's active secondary diagnosis included the following: Type 2 diabetes mellitus (a chronic disease process of high blood glucose levels), Atrial fibrillation (irregular/rapid heart rate), Long term use of insulin (medication used to treat high blood sugar), Hyperlipidemia (high levels of fat in the blood), Essential hypertension (high blood pressure), left above the knee amputation, and Hypomagnesemia (low magnesium levels in the blood.)

On 03/31/23 at 9:46 AM, an order showed, "Wound Care: apply Duoderm (a brand of dressing to treat a wound) to open areas on lower bil [bilateral] buttocks."

Review of Patient 7's medical record, "Problems/Goals" [Plan of Care] dated 03/30/23 - 04/12/23, showed, "Falls Injury Risks For Pt [patient]" and "Difficulty with Gait". Nursing staff failed to ensure that present/potential problems that might include but not limited to the following: diet for patient with Type 2 Diabetes (the body has high sugar levels for prolonged periods of time), impaired skin integrity/wound care, cardiac assessment for medication administration of high-risk medications, were considered to facilitate the development of patient outcomes and the nursing care plan to achieve those outcomes as required per hospital policy.


Patient 8

Review of Patient 8's discharged medical record showed that Patient 8 was admitted on 01/14/23 at 7:22 PM for acute dehydration, weakness, and failure to thrive. Patient 8 was discharged from acute care to swing bed status on 01/14/23.

Review of Patient 8's medical record, showed nursing staff failed to ensure that present/potential problems that might include but not limited to the following: skin integrity; pain management; nutrition; spiritual; and emotional needs were considered to facilitate the development of patient outcomes and the nursing care plan to achieve those outcomes as required per hospital policy.


During an interview on 4/13/23 at 10:45 AM, Staff A, CNO, stated that Patient 8 was admitted to swing bed for "end of life care." Staff A, CNO verified that Patient 8 did not have an Initial Admission nursing assessment, did not have daily shift nursing assessments, and did not have a nursing care plan implemented through-out the swing bed hospitalization.

Based on policy review, document review, and interview, the Critical Access Hospital (CAH) failed to ensure that discharge planning was completed for 5 of 8 patients (Patient 2, 4, 5, 7 and 8) as required per hospital policy. Failure to ensure discharge planning was completed has the potential to interrupt the continuity of care, delay of placement, post-care services, and/or increases risk for rehospitalization for patients receiving services at this hospital.

Findings Include:

Review of a policy titled, "Discharge Planning," revised 7/19, showed, "Discharge planning is a process and service where patient needs are identified, evaluated, and assistance given in preparing him/her to move from one level of care to another. Nursing personnel will collaborate with all members of the healthcare team to plan events within a given setting which enables the patient to regain as normal and productive a role as possible, providing for efficient, compassionate, and economical methods for the delivery of health services. Discharge planning shall be initiated on admission and continue through discharge, with education and patient planning for the home care environment. During the admission assessment, patient planning will be initiated to identify problems and make appropriate entries on the problem list or plan of care. Interaction with appropriate members of the healthcare team will occur throughout the patient's hospitalization to enable a comprehensive plan for patient care to be developed ..."


Review of the Critical Access Hospital's (CAH) Quality Assurance Performance Improvement (QAPI) Minutes dated 01/16/23, showed, "Readmissions within 30 days are higher than average. We had 2 [two] Readmissions attributed to Swing bed discharges that come back as acute."

Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was admitted on 02/15/23 at 11:30 PM for vomiting and fever.

Review of Patient 2's medical record, including admission, progress notes, plan of care, and discharge documentation, failed to show documented evidence of a discharge plan that includes an assessment of needs including, but not limited to post-hospitalization care services, home health or hospice services, and any other non-healthcare services and community-based care providers, as well as the patient's access to those services.


Patient 4

Review of Patient 4's active medical record showed that Patient 4 was admitted on 04/28/23 at 2:00 PM with a diagnosis of diverticulitis (an inflammation or infection in one or more small pouches in the digestive tract.)

Review of Patient 4's medical record, including admission, progress notes, plan of care, and discharge documentation, failed to show documented evidence of a discharge plan that includes assessment of needs including, but not limited to post-hospitalization care services, home health or hospice services, and any other non-healthcare services and community-based care providers, as well as the patient's access to those services.


Patient 5

Review of Patient 5's active medical record showed that Patient 5 was admitted on 04/08/23 at 6:35 AM with a chief complaint of right-sided weakness, right facial drooping, and slurred speech.

Review of Patient 5's medical record, including admission, progress notes, plan of care, and discharge documentation, failed to show documented evidence of a discharge plan that includes assessment of needs including, but not limited to post-hospitalization care services, home health or hospice services, and any other non-healthcare services and community-based care providers, as well as the patient's access to those services.


Patient 7

Review of Patient 7's active medical record showed that Patient 7 was admitted to Swing Bed on 03/30/23 after an acute hospitalization for a stroke (blood supply to the brain is interrupted).

Review of Patient 7's medical record, including admission, progress notes, plan of care, and discharge documentation, failed to show documented evidence of a discharge plan that includes assessment of needs including, but not limited to post-hospitalization care services, home health or hospice services, and any other non-healthcare services and community-based care providers, as well as the patient's access to those services.


Patient 8

Review of Patient 8's discharged medical record showed that Patient 8 was admitted on 01/14/23 at 7:22 PM for acute dehydration, weakness, and failure to thrive. Patient 8 was discharged from acute care to Swing Bed status on 01/14/23 with a change of diagnosis to comfort care only. Patient 8 was transferred to a Skilled Nursing Facility on 01/31/23 at 11:15 AM.

Review of Patient 8's medical record, including admission, progress notes, plan of care, and discharge documentation, failed to show documented evidence of a discharge plan that includes assessment of needs including, but not limited to post hospitalization care services, skilled nursing placement, home health or hospice services, and any other non-health care services and community-based care providers, as well as the patient's access to those services.

During an interview on 04/12/23 at 8:54 AM, Staff A, Chief Nursing Officer (CNO) stated that she was currently responsible for discharge planning, and she is aware discharge planning is lacking and hasn't been completed.

Based on record review, policy review and interview, the Critical Access Hospital (CAH) failed to complete discharge planning as required per 483.15(c)(3) and 483.15(c)(5) to ensure the discharge rights; notice of discharge and/or transfer for a Swing Bed patient (Patient 8) were met. Failure of the hospital to provide a patient and/or patient representative with appropriate notice of discharge and/or transfer has the potential to interrupt the continuity of care, delay placement, and post-care services, and/or increase the risk for rehospitalization for any patient receiving Swing Bed services at this facility.

Findings Include:

Review of a hospital policy titled, "Discharge Planning" revised 07/2019, showed "Discharge planning is a process and service where patient needs are identified, evaluated, and assistance given in preparing him/her to move from one level of care to another. Nursing personnel will collaborate with all members of the healthcare team to plan events within a given setting which enables the patient to regain as normal and productive a role as possible, providing for efficient, compassionate, and economical methods for the delivery of health services ..."


Patient 8

Review of Patient 8's discharged medical record showed that Patient 8 was admitted on 01/14/23 at 7:22 PM for comfort care. Patient 8 was transferred to a Skilled Nursing Facility on 01/31/23 at 11:15 AM.

Review of Patient 8's medical record failed to show documented evidence that Patient 8 and/or a patient representative was provided with written documentation in a language that could be understood of Patient 8's transfer that included the following: reason for transfer; effective date of transfer; and location to which patient is transferred.

During an interview on 04/12/23 at 8:54 AM, Staff A, Chief Nursing Officer (CNO), stated that she was currently responsible for discharge planning, and she is aware discharge planning is lacking and hasn't been completed.

Based on policy review, document review, and interview, the Critical Access Hospital (CAH) failed to ensure that nursing staff completed a comprehensive assessment for 3 of 3 Swing Bed patients (Patient 3, 7, and 8), failed to ensure that nursing care for each patient was supervised and evaluated by a Registered Nurse (RN) for 2 of 3 Swing Bed patients (Patient 3 and 7), and failed to complete discharge planning as required for 2 of 3 Swing Bed patients (Patient 7 and 8). Failure of the Hospital to ensure that each Swing Bed patient receives a daily comprehensive physical assessment and evaluation of care by a Registered Nurse and the failure to develop and implement a thorough plan of care for every patient places any patient receiving care at this hospital at risk for unidentified needs and adverse outcomes.

Findings Include:

Review of a policy titled, "Patient Care Team," revised on 7/2019, showed, "There will be a Patient Care Team Conference which will represent the various disciplines which will be providing care to the Swing-Bed patient. The goal of the committee is to provide quality patient care to swing-bed patients by maximizing communication among care givers. Team Conferences will be held weekly, and as needed. Also, QA issues will be addressed as needed in these meetings ...Discussion and input from each discipline regarding those residents currently in the swing-bed program: A. Planning of care; B. Discharge goals and methods of obtaining those goals (develop a discharge plan); C. Recommendations for an alternate plan of care ..."

Review of a policy titled, "Admission of a Swing Bed Patient," revised 7/2019, showed, " ...A Swing Bed Admission Assessment must be completed within 8 hours of arrival or status change ...Care plans should be completed within 24 hours of admission to Swing Bed. The Care Plan is reviewed and updated every 24 hours by Nursing and reviewed and updated weekly at the Multidisciplinary Swing Bed Conference ..."

Review of a hospital policy titled, "Admission of Patient," approved 11/2021, showed that each patient will have a plan of care initiated within eight hours of admission.

Review of a hospital policy titled, "Nursing Care Delivery Model," revised 05/2019, showed, " ...RNs are accountable for an individually tailored plan of care for the patient ..."

Review of a hospital policy titled, "Assigning Nursing Care of Patients," revised 06/2019, showed, " ...Planning, supervision, and evaluation of the nursing care of each patient is done by a Registered Nurse (RN). The charge RN is responsible for assessing the patient needs and assigning duties to professional and non-professional personnel according to the needs of the patient and qualifications of available staff ...The RN assigns nursing personnel best qualified to meet the needs of each individual patient. She/he is responsible for planning, supervising, and evaluating the nursing care of each patient regardless of the category of personnel assigned to the patient ...

Review of a hospital policy titled, "Standards of Practice," revised 09/2019, showed, " ...Present/potential patient problems are documented in the patient's medical record to facilitate the development of patient outcomes and the nursing care plan to achieve those outcomes ..."

Review of a policy titled, "Discharge Planning," revised 7/2019, showed, " ...During the admission assessment, patient planning will be initiated to identify problems and make appropriate entries on the problem list or plan of care. Interaction with appropriate members of the healthcare team will occur throughout the patient's hospitalization to enable a comprehensive plan for patient care to be developed ..."

Review of a hospital policy titled, "Patient Care Team Meeting," revised 7/2019, showed that Swing Bed patients will have a weekly "Patient Care Team Conference" [Nursing, Social Services, Activities Coordinator, Dietician, Utilization Review, and Pharmacy Technician] to discuss the patient's planning of care, discharge goals, and recommendations for an alternate plan of care. The team should also address quality issues regarding patient care, including appropriate utilization of services.

Review of a hospital policy titled, "Nursing Documentation," revised 7/2019, showed that a Registered Nurse (RN) and Licensed Practical Nurse (LPN) may complete patient assessments, however, an RN must complete the patient assessment on all acute care patients and Swing bed patients at least once every 24 hours.


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 was admitted on 03/20/23 at 5:48 PM for cellulitis (bacterial infection) of leg. On 03/27/23 at 11:37 AM, Patient 3 was admitted to Swing Bed status for continuation of wound care.

Review of Patient 3's medical record failed to show documented evidence that a licensed nurse completed a comprehensive admission assessment when Patient 3 was admitted to Swing Bed status as required per hospital policy. Further review of Patient 3's medical record showed that the first nursing assessment completed was a shift assessment on 03/27/23 at 7:00 PM by Staff T, LPN.

Review of Patient 3's medical record failed to show documented evidence that an RN completed a daily physical assessment on Patient 3, as required per hospital policy, for the following dates: 03/27/23; 03/28/23; 03/29/23; 03/30/23; 04/1/23; 04/2/23; and 04/3/23.

Review of Patient 3's medical record failed to show documented evidence that an RN supervised or evaluated the care of Patient 3 that was provided by an LPN, specifically the completion of a physical assessment, for 14 of 16 completed Nurse Shift assessments.

Review of Patient 3's care plans showed nursing staff failed to review Patient 3's care plans on 03/31/23, 04/01/23, and 04/02/23.


Patient 7

Review of Patient 7's active medical record showed that Patient 7 was admitted to Swing Bed on 03/30/23 after an acute hospitalization for a stroke. Patient 7's active secondary diagnosis included the following: Type 2 diabetes mellitus (a chronic disease process of high blood glucose levels), Atrial fibrillation (irregular/rapid heart rate), Long term use of insulin (medication used to treat high blood sugar), Hyperlipidemia (high levels of fat in the blood), Essential hypertension (high blood pressure), left above the knee amputation, and Hypomagnesemia (low magnesium levels in the blood.)

On 04/01/23 at 8:21 AM, Patient 7's physical assessment was completed by Staff U, LPN, and at 6:55 PM, the physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessments completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/02/23 at 8:57 AM, Patient 7's physical assessment was completed by Staff U, LPN and at 7:03 PM, the physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessments completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/03/23 at 6:50 AM, Patient 7's physical assessment was completed by Staff R, LPN and at 7:30 PM, the physical assessment was completed by Staff S, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessments completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/06/23 at 6:16 PM, Patient 7's physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN as required per hospital policy.

On 04/07/23 at 7:31 AM, Patient 7's physical assessment was completed by Staff K, LPN and at 6:45 PM, the physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessments completed by the LPN and an RN failed to document a daily assessment as required per hospital policy.

On 04/08/23 at 6:57 AM, Patient 7's physical assessment was completed by Staff R, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN as required per hospital policy.

On 04/09/23 at 6:45 AM, Patient 7's physical assessment was completed by Staff R, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN as required per hospital policy.

On 04/10/23 at 7:06 PM, Patient 7's physical assessment was completed by Staff T, LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN as required per hospital policy.

On 04/11/23 the medical record failed to show documented evidence that a PM nursing assessment was completed on Patient 7.

On 03/31/23 at 9:46 AM, an order showed, "Wound Care: apply Duoderm (a brand of dressing to treat a wound) to open areas on lower bil [bilateral] buttocks."

Review of Patient 7's medical record, "Problems/Goals" [Plan of Care] dated 3/30/23 - 4/12/23, showed, "Falls Injury Risks For Pt [patient]" and "Difficulty with Gait." Nursing staff failed to ensure that present/potential problems that included: diet for patient with Type 2 Diabetes ((the body has high sugar levels for prolonged periods of time), impaired skin integrity/wound care, cardiac assessment for medication administration of high-risk medications, were considered to facilitate the development of patient outcomes and the nursing care plan to achieve those outcomes as required per hospital policy.

Review of Patient 7's medical record, including admission, progress notes, plan of care, and discharge documentation, failed to show documented evidence of a discharge plan that includes assessment of needs including, but not limited to: post hospitalization care services, home health or hospice services, and any other non-health care services and community-based care providers, as well as the patient's access to those services.


Patient 8

Review of Patient 8's discharged medical record showed that Patient 8 was admitted on 01/14/23 at 7:22 PM for acute dehydration, weakness, and failure to thrive. Patient 8 was discharged from acute care to swing bed status on 01/14/23 with a change in diagnosis to comfort care only. Patient 8 transferred to a Skilled Nursing Facility on 01/31/23 at 11:15 AM.

The Initial Nursing Assessment on 01/11/23 at 12:20 PM for Patient 8's acute stay was completed by an LPN. The medical record failed to show documented evidence that an RN supervised and/or evaluated the assessment completed by the LPN and an RN failed to document a daily assessment on 01/11/23 as required per hospital policy.

Further review of the medical record failed to show that an Initial Nursing Assessment or follow up physical assessments were completed from 01/14/23 through 01/31/23 for Patient 8 when admitted to Swing Bed status.
During an interview on 4/13/23 at 10:45 AM, Staff A, CNO verified that Patient 8 did not have a nursing assessment in the medical record from 01/14/23 through 01/31/23.

Review of Patient 8's medical record, showed that nursing staff failed to ensure that present/potential problems that might include but not limited to the following: skin integrity; pain management; nutrition; spiritual; and emotional needs were considered to facilitate the development of patient outcomes and the nursing care plan to achieve those outcomes as required per hospital policy.

Review of Patient 8's medical record, including admission, progress notes, plan of care, and discharge documentation, failed to show documented evidence of a discharge plan that includes assessment of needs including, but not limited to post hospitalization care services, skilled nursing placement, home health or hospice services, and any other non-health care services and community-based care providers, as well as the patient's access to those services.

Based on policy review, document review, and interview, the Critical Access Hospital (CAH) failed to ensure that it had a written process or procedure to inform each patient whom to contact to file a grievance and ensure prompt grievance resolution. Failure to ensure a written process is established for the prompt resolution of a patient grievance could potentially violate any patient's right to have concerns addressed in a timely manner and failure to provide the correct contact information for the State Licensing Agency places any patient and/or patient representative at risk of not being able to anonymously report a complaint or grievance.

Findings Include:

Review of a hospital policy titled, "Patient Rights and Responsibilities," revised, 09/2019, showed that a patient has a right to, " ...be advised of the hospital grievance process, should he or she wish to communicate a concern regarding the quality of the care he or she receives or if he or she feels the determined discharge date is premature. Notification of the grievance process includes whom to contact to file a grievance, and that he or she will be provided with a written notice of the grievance determination that contains the name of the hospital contact person, the steps taken on his or her behalf to investigate the grievance, the results of the grievance and the grievance completion date.

Review of a document titled, "[The Hospital] Patient's Rights & Responsibilities," dated 02/2019, showed, " ...They [the patient] may also contact the Kansas Department of Health and Education at 785-296-4999 ..." The Hospital provided incorrect contact and phone information for contacting the State Licensing Agency.

During an interview on 4/13/23 at 3:05 PM, Staff V, Revenue Cycle Manager, verified the hospital did not have a written policies that address grievances, the grievance process, or grievance resolution and only addresses the filing of a grievance in the Patient Rights policy.