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Based on observation, interview, and document review, the facility failed to update policy and procedure manuals annually.

Findings include:

Review of the facility policy and procedure manuals revealed the following:
-Nursing Services policy and procedure manual had a signature page dated 11/21/14.
-Infection Control manual had a signature page dated 11/21/14.
-Pharmacy policy and procedure manual had a signature page dated 11/21/14.
-Administrative policy and procedure manual had a signature page dated 11/21/14.

On 8/22/17 in the afternoon, an interview with the Director of Nursing and Administrator revealed all policy and procedure manuals were supposed to be reviewed annually and presented to the Professional Advisory Board for approval. The annual had not been done since 11/21/14.

The facility Professional Advisory Board protocol indicated the following:
"B. Duties: Critical Access Hospital Advisory Board will meet at least annually to consider the following: Patient Care policies and procedures are reviewed on an annual basis by the professional group.....review organizational and administrative structure for appropriateness of current operation policies, review department policies and procedures and receive a yearly summary form the Department Supervisor. C. Responsibility: Meet the required scheduled intervals."

Based on observation, interview, and document review, the facility failed to ensure Licensed Practical Nurses (LPNs) completing initial nursing assessments were supervised and evaluated by a Registered Nurse (RN) for 3 of 20 patients (Patient #1, #3, and #4).

Findings include:

Patient #1

Patient #1 was admitted on 7/25/17, with diagnoses including diabetes mellitus, cirrhosis of liver, hyponatremia, chronic hepatitis C, and chronic pain.

The form entitled "The Nursing Assessment Restraint VS Enabling Device" was completed, signed, and dated by a LPN. "The Admission and Quarterly Data Collection Tool" was completed, signed and dated by a LPN. There was no evidence a RN had evaluated and supervised the LPN's assessments.

Patient #3

Patient #3 was admitted on 8/20/17, with diagnoses including acute pyelonephritis, acute renal failure, hypokalemia, dehydration. The patient's initial nursing assessment was completed on 8/20/17 by a LPN. There was no evidence a RN had evaluated and supervised the LPN's assessment.

Patient #4

Patient #4 was admitted on 8/21/17, with diagnoses including hypertension, renal heart disease, pre-farction syndrome, unstable angina. The patient's initial nursing assessment was completed on 8/21/17 by a LPN. There was no evidence a RN had evaluated and supervised the LPN's assessment.

On 8/23/17 in the morning, the Director of Nursing (DON) indicated LPNs were allowed to complete all assessments without supervision or oversight by a Registered Nurse. A co-signature was not required. The DON referenced the "Proposed Regulation of The State Board of Nursing LCB File No. R091-15 dated October 12, 2015 allowing LPNs to complete "focused nursing assessments" without oversight or supervision by a Registered Nurse. The assessments completed for the above three patients did not specify these assessments were "focused nursing assessments". The facility's policy and procedure had not been reviewed or updated since 2014 and had not incorporated any of the proposed regulation referenced by the DON.

The facility policy entitled Assessment and Reassessment of the Medical Surgical Patient, Page 1, under procedure stated, "At the time of admission each patient shall have an initial physical/psychological assessment completed by a Registered Nurse". It went on to explain the LPN role as follows: "LPNs may provide health teaching, utilizing the teaching plan formulated by the RN." Page 2, Each discipline's scope of assessment was defined as follows: Registered Nurse: "does all admission and subsequent assessments". LPNs: "At the direction of an RN contributes to assessment of health status by collecting, reporting and recording objective and subjective data." This policy had not been reviewed, approved or updated since 2014.

Based on observation, interview, and document review, the facility failed to ensure nursing care plans were developed, individualized and kept current for 3 of 20 patients (Patient #10, #11, and #18).

Findings Include:

Patient #10

Patient #10 was admitted on 01/08/17, with diagnoses including congestive heart failure, heart arrhythmia, chronic obstructive pulmonary disease, acute renal failure, vertebral fracture, and cardiac-respiratory failure and shock. The electronic nursing admission note dated 01/08/17 revealed an empty check box on the care plan section and no care plan initiated.

Patient #11

Patient #11 was admitted on 01/24/17, with diagnoses of acute bronchitis, altered mental status, hypomagnesemia, diabetes with acute complications, heart arrhythmias, sepsis, and lung cancer. The electronic nursing admission note dated 01/24/17 revealed an empty check box on the care plan section and no care plan initiated.

Patient #18

Patient #18 was admitted on 02/19/17, with the diagnosis of chronic renal failure. The electronic nursing admission note dated 02/19/17 revealed an empty check box on the care plan section and no care plan initiated.

On 08/22/17 in the afternoon, the Director of Nursing (DON) confirmed nursing care plans were to be initiated during the nursing admission by the admitting nurse.

The policy and procedure titled, "Assessment and Reassessment of the Medical Surgical Patient", revised 09/09/04, revealed "upon completion of the initial admission assessment, an individualized prioritized Plan of Care will be developed."

Based on observation, interview and document review, the facility failed to ensure conditions of admission forms were properly completed for 2 of 20 patients (Patient #14 and #17).

Findings include:

Patient #14

Patient #14 was admitted on 04/25/17, with diagnoses including diabetic ketoacidosis, nausea, vomiting and diarrhea. The patient's Conditions of Admission form was not dated and timed.

Patient #17

Patient #17 was admitted on 06/12/17, with diagnoses including congestive heart failure, angina, and acute retention of urine. The patient's Conditions of Admission form was not signed, dated, timed or witnessed.

On 08/22/17 in the afternoon, the Risk Manager confirmed it was hospital protocol to complete all admission forms.

Based on observation, interview, and document review, the facility failed to ensure chart entries made by the certified physicians assistant (PA-C) were co-signed by the attending physician for 1 of 20 sampled patients (Patient #19) and verbal orders were signed for 5 of 20 sampled patients (Patient #15, #16, #17, #18 and #20).

Findings include:

Patient #19

Patient #19 was admitted on 03/13/17, with diagnosis including acute exacerbation of chronic obstructive airway disease. An admission order dated 03/13/17, was entered by the Licensed Practical Nurse (LPN) and signed by the PA-C. The entry was not co-signed by the attending physician.

On 08/23/17 the Director of Nursing (DON) confirmed the attending physician must co-sign the admission orders of the PA-C.

The facility policy titled, "Acute Admissions: History & Physical's, Progress Notes, Discharge Summaries", effective 04/01/00, revealed "all chart entries made by the PA-C must be co-signed by the Attending Physician within 48 hours."

Patient #15

Patient #15 was admitted on 04/24/17, with diagnoses including deep venous thrombosis (left lower extremity), inadequate pain control and bilateral pressure ulcer buttocks. The medical record contained a verbal order given by the Nurse Practitioner (NP) dated 04/24/17 for prothrombin time every morning. The order was not signed by the NP.

Patient #16

Patient #16 was admitted on 06/21/17, with diagnoses including chest pain and acute bronchitis. The medical record contained a verbal order given by the Medical Doctor (MD) dated 06/21/17 for Solu-Medrol Intravenous (IV) 125 milligrams (mg) every six hours. The order was not signed by the MD.

Patient #17

Patient #17 was admitted on 06/12/17, with diagnoses including congestive heart failure, angina, and acute retention of urine. The medical record contained a verbal order for insertion of Foley catheter dated 06/12/17 and verbal order given by the MD dated 06/14/17 for Bumetanide IV 1 mg every 12 hours, Vancomycin/Diuretic 5:00 AM and 5:00 PM IV push. The orders were not signed by the MD.

Patient #18

Patient #18 was admitted on 02/19/17, with diagnosis including chronic renal failure. The medical record contained verbal orders given by the MD dated 02/19/17 for the following: Sodium Chloride IV 0.9% 150 milliliters (ml)/ hour, Macrobid oral 100 mg 2 times per day for 10 days, Vitamin B-12 oral 1000 micrograms (mcg) every day and Ferrous Sulfate oral 65 mg 2 times. The orders were not signed by the MD.

Patient #20

Patient #20 was admitted on 05/16/17, with diagnoses including acute pancreatitis and gallstones. The medical record contained verbal orders given by the MD dated 05/16/17 for the following medications: Sodium Chloride IV 0.9% 150 ml/ hour, Ondansetron IV 4 mg every 6 hours IV push, Protonix IV 40 mg every 24 hours IV push, Hydromorphone IV 0.5 mg every 4 hours PRN (as needed), pain IV push, Temazepam oral 15 mg HS (hour of sleep) PRN insomnia, Metronidazole IV 500 mg every 6 hours and Ampicillin-Sulbactam Sodium IV 3 grams every 6 hours. The orders were not signed by the MD.

On 08/23/17 in the afternoon, a Registered Nurse confirmed verbal orders were to be signed by the ordering practitioner. The employee confirmed the missing signatures for the five patient records.