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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on September 25, 2014, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on September 25, 2014, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated September 25, 2014.

Based on CAH policy, record review and staff interview, it was determined in 1 of 17 records requiring a discharge summary (Pt #17) the physician failed to ensure the discharge summary was completed in a timely manner.

Findings:

1. A review of the hospital bylaws was conducted on 9/17/14 at 11:00 AM. The CAH bylaws reviewed 3/2014, under medical records indicated "7. Medical charts must be completed in the current patient's file in the Health Information office within thirty days after discharge."

2. Pt #17 was admitted to the CAH on 5/30/14 with diagnosis of intracranial hemorrhage and advanced dementia. Pt #17 expired while in the hospital on 6/4/14. The physician's discharge summary was not completed until 8/13/14, over 30 days late.

3. During an interview with the E #1 (Administrator) on 9/17/14 at 1:30 PM, E# 1 verbalized patient records are to be completed within 30 days and confirmed Pt #17's discharge was over the time frame expected.