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Based on observation and staff interview, it was determined the Critical Access Hospital was not arranged and maintained to ensure the safety of all patients including newborns.

Findings include:

A tour of the CAH's inpatient unit was conducted with the Chief Executive Officer/Chief Nursing Officer on 9/10/2012. The inpatient beds were located on two parallel hallways with a nurses station in the middle that served both hallways as well as other ancillary areas such as supply areas, medication room, etc. Rooms 223, 225, 227, 229, and 231 on the north hall were designated for medical/surgical patients. The inpatients in the medical/surgical beds included a behavioral health patient and an incarcerated patient in the custody of law enforcement. Rooms 211, 215, 217, 219 and 221 on the north hallway were designated for postpartum patients. The Newborn Nursery was located at the east end of the hallway across a public hall from Room 211. The Labor and Delivery Rooms were located at the end of the public hallway next to the surgery areas. Newborns were transferred from the labor and delivery area down the public hallway to the Newborn Nursery.

The postpartum rooms were accessible to the general public as well as non labor/delivery, postpartum or newborn nursery staff. Observations were made during the survey of occupied postpartum rooms with the doors open and newborns in isolettes near the open door. Visitors and staff for both the medical/surgical and postpartum units were observed on the unit.

The Manager of OB Services reported during interviews that the hospital utilizes a 4-band system for infant identification. She reported the mothers are directed not to release the care of their newborn to a staff member who does have a photo identification with a pink stripe. She acknowledged there was no process in place to identify and monitor visitors going in and out of the unit.

An interview was conducted with the Hospital's Director of Security on 9/14/2012. During the interview the surveyor was provided with documentation that a "Code Pink (Missing Infant/Child) drill" was conducted on 3/9/2012. The documentation included the scenario and timeline, identified areas for improvement and recommendations. There was no documentation that another "Code Pink Drill" had been conducted since 3/9/2012. The Director of Security referred to security cameras in the hospital. The surveyor asked where the cameras were located and he responded they were located at all of the entrances and exits to the facility. The surveyor asked if there were any security cameras located near or around the Labor and Delivery, Newborn Nursery or postpartum areas, and he responded, "No."

The CAH had no written policies and procedures for ensuring the safety of newborns.

Based on clinical record reviews, hospital policy and procedures review, and staff interviews, it was determined for 2 of 3 surgical patients (Patients #17 and 18), the Critical Assess Hospital failed to ensure that all physicians followed policies and procedures for writing orders and that nursing staff followed procedures for clarification of unclear orders.

Findings include:

The Hospital's policy titled, Orders for Medical Treatment, included the following: "Pre-Printed Orders and protocols are designed through an interdisciplinary process involving physicians, clinicians and ancillary personnel with a vested interested (sic) in the process and delivery of patient care for which they are intended...Noting Orders: Written acknowledgement by licensed associates that orders have been reviewed for accuracy and appropriateness prior to implementation of orders...Registered Nurse...Notes written orders, and accepts verbal, telephone, electronic, and faxed patient care/treatment orders...All orders for medical treatment shall: be written clearly, legibly and completely using only approved abbreviations...Orders that are illegible, improperly written, conditional , or ambiguous, will not be carried out until rewritten or clarified by the ordering practitioner.

-Patient #17, a pediatric patient, had pre-scheduled outpatient surgery on 3/2/2012 to repair a right inguinal hernia. The surgery was performed under general anesthesia administered and monitored by a Certified Registered Nurse Anesthetist (CRNA). Documentation in the Peri-Operative Record revealed an anesthesia start time of 11:36 a.m. and end time of 1:42 p.m. The actual surgical procedure began at 11:57 a.m. and ending at 1:28 p.m. The "Post Anesthesia Care Unit Orders (PACU) (Adults)-CHC" signed by the CRNA were dated 3/2/2012 at "0855" (8:55 a.m.), approximately three hours prior to the procedure. There was no documentation that the orders were noted by a Registered Nurse.

The surgeon also wrote orders on a Physician's Order form titled "Outpatient Surgery Post-Operative Orders & Discharge Instructions." The orders were handwritten preprinted with changes made in blue ink. The CRNA's PACU orders conflicted with the surgeon's PACU orders. The surgeon signed and dated the orders on 3/2/2012 at 1:45 p.m. The top section of the form was titled, "PACU Orders" and included an order for "Morphine 05. - 2 mg IV q 2-4 hrs, prn severe pain." The CRNA's orders included: "Morphine sulfate 2 mg IV every 5 minutes p.r.n pain. Max 10 mg." The surgeon's orders for intravenous fluids included: "LR (Lactated Ringers) @ 50/cc/hr." The CRNA's orders included "Continue IV fluids LR IV at rate 100 ml/hour." The surgeon's PACU orders did not include an order for nausea/vomiting, however, the CRNA's orders did, and the patient received Zofran 4 mg IV for nausea/vomiting in the PACU per the CRNA's orders. There was no documentation in the record that the duplicative orders were questioned or clarified with the CRNA and the physician.

The Manager of Perioperative Services acknowledged during interviews that the CRNA's orders conflicted with the surgeon's orders and that there was no documentation that the orders were clarified by the nursing staff. She later discussed the conflicting orders with the PACU nursing staff and one of the CRNA's and reported back to the surveyor that the CRNA's orders were followed rather than the surgeon's orders even though the surgeon's orders were written after the CRNA's orders.

-Patient #18, a pediatric patient, was admitted to the hospital on 9/27/2011 through the Emergency Department with a chief complaint of abdominal pain. The patient was diagnosed with acute appendicitis and was taken to the operating room for a laparoscopic appendectomy. The patient's clinical record included the surgeon's "Post-Op Orders" dated 9/27/2011 at 12:15 p.m. Portions of the orders were prewritten photocopied handwritten orders with changes made in blue ink. For example, the order the prewritten photocopied order for morphine read, "Morphine 2-6 mg IV Q 1-2 hrs, prn severe pain." The physician marked over the 6 (mg) dosage with a "4." The original prewritten order for Vicodin read: "Vicodin 5 mg 1-2 PO Q 4 hrs prn moderate pain. The physician changed the order with blue ink by crossing out the "1-2" portion of the order. The prewritten order for Tylenol read: "Tylenol 650 mg po Q 4 hrs, prn mild pain or T > 101." The physician changed the order by crossing out the "650" (mg) dose and writing in "325" in blue ink. The physician's Discharge Orders dated 9/30/2011 were also pre-handwritten and photocopied with changes made in blue ink. One of the orders for this pediatric patients was: No driving if taking pain pills."

There was no documentation that the nursing staff contacted the physician to clarify unclear and/or unacceptable orders.

The Hospital's Medical Director and the Hospital's Chief Executive Officer/Chief Nursing Officer acknowledged during an interview on 9/14/2012 that the physician did not follow policies and procedures for writing orders and that the nursing staff did not follow policies and procedures for clarifying unclear or inappropriate orders.