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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 9 closed ED records (Patient #11 and #12) 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 May 9-11, 2011. This document, approved 05/18/09, stated, ". . . General Rules of Critical Access Hospital . . . 5. A physician, nurse practitioner, or physician assistant will be on call and immediately available by telephone or radio contact and available at the hospital within thirty (30) minutes. . . ."

Review of the facility's emergency department log occurred on 05/09/11. Information recorded on the ED log included, in part, the date and time of admission, patient name, age, name of health care practitioner, nature of injury, services rendered, and disposition.

Review of Patients #12 and #11 closed medical records occurred on May 9-11, 2011.

- The ED log identified Patient #12, a 72 year old male, presented to the ED on 11/27/10. The log stated, "Not seen by NP [nurse practitioner]."

Patient #12's closed medical record stated, "9:15 a [A.M.]- Pt [patient] to ER [emergency room]. Stating he would like an insulin shot. Lives 150 miles from here [and] forgot his insulin at home. States he will be home for next dose. 9:20 a- Glucoscan done. 205 mg/dl [milligrams/deciliter]. Called to [name of health care practitioner] stated he could get 1 x [time] dose here now or go to [name of pharmacy] to purchase a bottle of insulin. [Pt] states he will like to get shot here even if it is more expensive. 9:30 a- Lantus 40 units give SQ [subcutaneous] in lt [left] posterior arm. 9:35 a- Pt discharge instructions read. No further questions. Discharged home."

Patient #12's medical record lacked evidence the health care practitioner examined the patient.

During an interview on the afternoon of 05/10/11, the health care practitioner (#2) confirmed she failed to see or examine Patient #12.

- The ED log identified Patient #11, a 62 year old male, presented to the ED on 03/31/11. The ED log stated, "t.o. [telephone order] Dr. [name of provider] insert Foley."

Patient #11's closed medical record stated, "Pt reports catheter removed [at] 11 a.m. Unable to void since that time. Bladder distended. [complains of] pain. Xylocaine jelly instilled into urethra. Foley cath [catheter] inserted #16 French [without] difficulty. Initial returns of bloody urine which cleared to yellow. 1200 cc [cubic centimeters] emptied [after] 20 min [minutes]. Pt home [with] leg [and] cystoflow bag. Encourage to drink plenty of fluids [and] follow up [with] MD [medical doctor]."

Patient #11's medical record lacked evidence that a health care practitioner examined the patient.

1. Based on review of bylaws, meeting minutes, quality assurance reports, records, a professional reference, and policies and staff interview, the governing body failed to ensure the Critical Access Hospital (CAH) established policies and procedures to identify and assess patients for suicide risk, develop and implement suicide precautions, and ensure environmental safety in response to 1 of 1 outpatient (Patient #7) held for observation following a suicide attempt who also successfully eloped (left) and returned to the facility. Failure to establish and implement policies and procedures regarding patients with suicidal risk factors held for observation or admitted to the CAH places patients at risk of receiving improper care.

Findings include:

Review of the "ASHLEY MEDICAL CENTER BY-LAWS" occurred on May 9-11, 2011. These bylaws, approved 01/20/03, stated,
". . . ARTICLE VIII - Medical Staff . . .
Section 4. Medical Care: The Board of Directors, in the exercise of its overall responsibility, shall assign to the medical staff reasonable authority for ensuring appropriate professional care to the hospitals patients.
Section 5. Review: The medical staff shall conduct an ongoing review and appraisal of the quality of professional care rendered in the hospital and shall report such activities and their results to the Board of Directors."

Review of the "BY-LAWS RULES AND REGULATIONS Of the MEDICAL STAFF" occurred on May 9-11, 2011. These bylaws, approved 05/18/09, stated, "The medical staff is responsible for the quality of medical care in the hospital and must accept and assume this responsibility, subject to the ultimate authority of the hospital Board of Directors . . . The medical staff's responsibility for the quality of medical care is a delegated responsibility from the governing board, for which the medical staff shall be accountable to said board."

Review of the policy "Psychiatric Emergency Policy" occurred on 05/10/11. The CAH developed the policy in 08/07 and revised the policy in 03/11. The revised policy did not include information regarding identification and assessment of suicide risk, suicide precautions and interventions (including prevention of elopement), and environmental safety.

Reviewed on 05/10/11, the "Fire, Safety, & [and] Securities" meeting minutes from 02/08/11 stated, ". . . A peer review was done on all incident reports . . . Hospital - Outpatient - Elopement - no injury, did come back on own. . . ." The minutes did not include discussion of the incident or corrective action.

Reviewed on 05/10/11, the "Ashley Medical Center Board of Directors Meeting" minutes from 3/21/11, stated,
". . . Old Business
A. . . . The board reviewed and discussed the Medical Staff Meeting minutes of 3/16/11 . . . and the Fire, Safety and Securities Meeting minutes of 2/8/11. . . ."

Reviewed on 05/10/11, the "Ashley Medical Center Medical Staff Meeting Minutes" from 03/16/11, stated, ". . . Monthly Review and Clinical Work of the Hospital . . . [Name of director of nurses] Incident reports were reviewed and discussed. One incident was a psychiatric patient who needed to be stabilized before transfer. While the nursing staff was busy with other patients, the patient left and was then later brought back. We will now have our psychiatric patients who are awaiting transfer be monitored in the ICU [intensive care unit] room so they are hooked up to monitors. If they try to leave, alarms will then go off." Refer to C281 and C295. The minutes failed to include a determination by medical staff if the corrective action was appropriate.

Reviewed on 05/10/11, a "Yearly Quality Assurance Report" from January-March 2011 stated, ". . . Action Taken: Medical staff requested that psychiatric patients who have to be kept for stabilization be roomed in ICU and connected to cardiac monitor until discharged. . . ." The facility failed to consider safety and risk factors in using a cardiac monitor to prevent elopement of psychiatric patients. The corrective action failed to include implementation of suicidal risk factor assessments, suicide precautions, environmental safety assessments, and appropriate measures based on individual assessments.

The facility failed to provide evidence of policies and procedures established and implemented to ensure appropriate care of suicidal patients including: identification and assessment of suicide risk, suicide precautions and interventions (including prevention of elopement), and environmental safety.

During interview on 05/10/11 at 9:20 a.m., an administrative nurse (#1) stated the facility does not have a policy on suicide risk, precautions, or interventions other than the information included in their policy pertaining to the stabilization of psychiatric patients.




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2. THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON AUGUST 01, 2007.

Based on review of medical staff bylaws, review of credential files, and staff interview, the facility failed to reappoint members of the medical staff consistent with the approved medical staff bylaws for 7 of 8 practitioners reviewed (Practitioners #1, #2, #3, #4, #5, #6, and #7). Failure to reappoint and approve/delineate privileges consistent with the approved bylaws does not ensure practitioners maintain the qualifications, competency, and moral and ethical character necessary to practice at the facility and does not ensure the practitioners medical staff appointment/privileges are current and up-to-date.

Findings include:

Review of medical staff bylaws occurred May 9-10, 2011. The bylaws, approved 05/18/09, stated, "BY-LAWS RULES AND REGULATIONS . . . The Medical Staff is responsible for the quality of the medical care in the hospital and must accept and assume this responsibility, subject to the ultimate authority of the hospital Board of Directors and that the best interests of the patients are protected by concerted efforts. . .
ARTICLE II PURPOSE
The staff shall be organized to expedite the objectives of the staff in an orderly and efficient fashion. These objectives include:
1. Mutual cooperative assistance of maintaining the highest level of medical and surgical practice and care for all patients admitted to the hospital . . .
ARTICLE III MEMBERSHIP . . .
SECTION 4. PROCEDURE FOR APPOINTMENT . . .
Procedure for Reappointment
A. Application
Each current appointee who wishes to be reappointed to the Medical Staff shall be responsible for completing the reappointment application form approved by the Board. The reappointment application shall be submitted to the CEO [Chief Executive Officer] or his/her designee at least (1) month prior to the expiration of the appointee's then current appointment. Reappointment, if granted shall be for period of not more than two (2) years. . . .
Reappointment Procedure:
a. No later than two months prior to the end of the current appointment period, the CEO shall send the Medical Staff the applications of all appointees desiring reappointment during the reappointment cycle. . . .
c. The Medical Staff, after receiving the reports from the CEO will review all pertinent information available . . . for the ensuing appointment period. . . .
e. The Medical Staff shall transmit its report and recommendation to the Board through the CEO in time for the Board to consider reappointments at its final schedule [sic] meeting in each reappointment cycle. . . .
SECTION 5. TERM OF APPOINTMENT
A. Initial appointments to the medical staff shall be made by governing board of the hospital, after the recommendation of the medical staff . . . Thereafter, renewal appointments shall be for a period of time not to exceed two calendar years.
. . .
F. A term of appointment shall cease:
1. At the end of the calendar year in which the appointment is made, unless prior to such time in December of the year of appointment the governing board makes reappointment, in which case reappointment shall be for the following two calendar years . . ."

Review of individual practitioner credential files occurred on the morning of 05/11/11 and showed the following appointment/reappointment activity since 2008:

- The credential file of Practitioner #1 identified the reappointment expired on December 31, 2008. The application lacked a medical staff recommendation, and the governing board approved the practitioner for reappointment on 01/19/09. The credential file identified the practitioner's current appointment expired on December 31, 2010 and lacked evidence of an application for 2011.
During interview at 11:20 a.m. on 05/11/11, a supervisory medical records staff member (#5) stated Practitioner #1 is not currently credentialed and the organization did not have any other medical staff working at the facility in January 2009 to make the medical staff recommendation for Practitioner #1 prior to the board approval. In addition, the Board delayed credentialing Practitioner #1 nineteen days in 2009.

- The credential file of Practitioner #2 identified the reappointment expired on December 31, 2008, and the governing board approved the practitioner for reappointment on 01/19/09. The credential file identified the practitioner's current appointment expired on December 31, 2010 and lacked evidence of an application for 2011.
During interview at 11:20 a.m. on 05/11/11, a supervisory medical records staff member (#5) stated Practitioner #2 is not currently credentialed. In addition, the Board delayed credentialing Practitioner #2 nineteen days in 2009.

- The credential file of Practitioner #3 identified the practitioner's current appointment expired in December 31, 2010; medical staff recommended the reappointment 01/14/11; and the governing board approved the practitioner for reappointment on 02/21/11. The medical staff failed to recommend reappointment, and the governing body failed to reappointment Practitioner #3 prior to the expiration of the credentialing period.
During interview at 11:35 a.m. on 05/11/11, a supervisory medical records staff member (#5) agreed Practitioner #3 was not credentialed between January 1 and February 21, 2011.

- The credential file of Practitioner #4 identified the practitioner's appointment expired December 31, 2009; medical staff recommended the reappointment on 03/14/10; and the governing board approved the practitioner for reappointment on 03/15/10. The practitioner practiced a period of 74 days in 2010 before the medical staff and governing board completed the credentialing process.

- The credential file of Practitioner #5 identified the practitioner's appointment expired on December 31, 2008, and the governing board approved the reappointment on 01/19/09. The practitioner practiced a period of 19 days in 2009 without being credentialed. The credential file also identified the practitioner's current appointment expired on December 31, 2010, and lacked evidence of an application for 2011.

- The credential file of Practitioner #6 identified the practitioner's current appointment expired on December 31, 2010; the practitioner requested reappointment on 02/28/11; medical staff recommended the reappointment on 03/25/11; and the governing board approved the reappointment on 04/17/11.
During interview at 11:35 a.m. on 05/11/11, a supervisory medical records staff member (#5) agreed Practitioner #6 was not credentialed between January 1 and April 17 (107 days).

- The credential file of Practitioner #7 identified the practitioner's appointment expired on December 31, 2008, and the governing board approved the reappointment on 01/19/09. The practitioner practiced a period of 19 days in 2009 without being credentialed. The credential file also identified the practitioner's current appointment expired December 31, 2010 and lacked evidence of an application for 2011.
During interview at 11:35 a.m. on 05/11/11, a supervisory medical records staff member (#5) agreed Practitioner #7 was not currently credentialed.

Based on record review, policy review, a professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the provision of services by failing to ensure a patient received the care and services to meet her mental health needs (Refer to C281); failing to ensure a patient received a timely physical examination and assessment of health status for hypothermia (Refer to C281); and failing to ensure the provision of care in accordance with the needs of a patient following a suicidal attempt who also successfully eloped (left) the facility (Refer to C295). Failure to ensure the provision of services places the CAH patients at risk of receiving improper care.

Based on policy review, professional reference review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure 1 of 1 observation outpatient (Patient #7), admitted following a suicidal attempt who also successfully eloped from (or left) the facility, received the care and services to meet her mental health needs; and failed to ensure the patient received a timely physical examination and assessment of health status (for hypothermia) upon returning to the facility.

Failure of the health care practitioner to provide specific orders and instructions for CAH nursing staff to implement and follow immediately after admission may have contributed to the patient's elopement from the facility. Failure of the health care practitioner to perform a timely physical examination and assessment of Patient #7 had the potential for complications related to hypothermia to go undetected and untreated.

Findings include:

Review of the facility policy titled "Psychiatric Emergency Policy," occurred on 05/10/11. This policy, dated 08/2007 and revised on 03/2011, stated,
"Purpose: Care and disposition of clients with a psychiatric emergency.
What constitutes psychiatric emergency?
1. Violence . . . 2. Psychosis . . . 3. 'Bizarre' behavior by anyone which results in objectionable or unusual behavior in a public place may be due to mental illness and may be brought to the emergency room. 4. Medication problem . . .
Ashley Medical Center does not have a psychiatric unit or safe room. Patients brought to the emergency room for a psychiatric emergency will be examined and treated in the emergency room on a 1:1 observation and not left alone until transferred to another facility . . . If psychiatric emergency patient can not be transferred immediately from the emergency room due to weather or medical condition then the patient will be brought to ICU [Intensive Care Unit] and connected to a cardiac monitor. The patient will be closely observed. A determination made by the provider if 1:1 staffing is needed to maintain safety for the patient. As soon as the medical condition is stabilized the patient will be transferred to an accepting mental health facility."

Taber's Online Medical Dictionary, 21st Edition, defines hypothermia as "a core body temperature below 35 [degrees] C [Celsius] (95 [degrees] F [Farenheit]) . . . Low body temperatures are most likely to affect newborns, older adults, demented individuals, individuals exposed to wet and cold conditions outdoors. . . ."

Review of Patient #7's closed outpatient observation medical record occurred on May 9-11, 2011. Patient #7 arrived in the CAH's emergency room (ER) on 01/09/11 at 1:20 a.m. via ambulance for treatment after ingesting an undetermined amount of oral Ibuprofen tablets. The CAH admitted Patient #7 to outpatient observation status on 01/09/11 at 2:40 a.m. with admission diagnosis of bipolar disorder and history of suicidal ideation.

Patient #7's Emergency Room - Outpatient Record identified when the CAH nursing staff "questioned" Patient #7 if the ingestion of pills was an "attempt at suicide," Patient #7 "nodded" her head indicating "yes." Patient #7's vital signs obtained in the Emergency Room showed a blood pressure (BP) reading of 144/89, pulse (P) 93, respirations (R) 16, and temperature (T) of 98.5.

The on-call health care practitioner's (#2) hand-written notation on the Emergency Room -Outpatient Record stated, ". . . Had gotten in an argument with [significant other] [and] threatened to 'kill self' and grabbed bottle of Ibuprofen [and] went to bathroom and locked door. Significant other called '911' since pt [patient] didn't open door . . . Pt had 2-3 whiskey cokes this evening . . . Pt seemed to go unresponsive for police officer [and] ambulance dispatched. Pt hx [history] bipolar [disorder] [and] anxiety. Paramedic states responsive to pain - appeared more of psychotic episode . . .
O) [Objective] Alert, eyes open, nods 'yes' or 'no' to questions. Refusing to talk verbally. Eyes - PERRLA [pupils equal round reactive to light and accomodation] EOMs [extraocular eye muscles] intact. [No] nystagmus. Mouth/throat - pink moist. [Positive] gag reflex. Neck supple. Lungs CTA [clear to ausculation]. Heart S1-S2. [No] murmur. Abd [abdomen] soft, NT [nontender]
A) [Action] 1) Ibuprofen overdose. 2) Anxiety. 3) Bipolar. Medically observe 3-4 hr [hrs] to clear Ibuprofen then eval [evaluate] depression [and] suicidal concerns. May need eval [evaluation] by psychiatrist. . . ."

Patient #7's admitting history and physical stated, ". . . ASSESSMENT: 1) Ibuprofen overdose. 2) Depression with episodic suicidal ideation. 3) History of bipolar disorder. 4) Anxiety. PLAN: Patient to be admitted to hospital for medical observation for 3-4 hours to clear the effects of the Ibuprofen. Poison Control contacted and had indicated monitoring renal function which continue [sic] to be within normal limits. If any GI [gastrointestinal] upset, may administer Carafate or GI cocktail. Patient while in ER and upon admission to the hospital denied any GI upset at the time. Patient needing to be cleared medically prior to any psychiatric evaluation, therefore she was admitted for observation to our hospital. If at any time her symptoms or concern regarding suicidal ideation appears to be more than we can maintain at this hospital, we would transfer her to [Name of agency] in [Name of city] and also be followed up at [Name of hospital]. Patient however was stable and cooperative as far as answering yes and no. She is not cooperative verbally. Vitals will be q [every] 1 hour x [times] 3 hours then q 4 hours. Continue with Hep-lock (a plastic cannula inserted into a vein to provide hydration and/or medication as needed) to the right forearm. Patient will be further evaluated in regards to her anxiety and depression in the a.m. Her response to taking the Ibuprofen may have been episodic and spurred by the argument with [significant other]. Will further evaluate in the a.m. suicidal ideation and whether or not she will need immediate evaluation by the psychiatrist or if she can start management through our facility."

Patient #7's observation admission orders included diagnoses, obtaining of vital signs (as stated above), activities: "As tol [tolerated]," diet, IV (intravenous) Heplock, and "Per Poison Control - monitor for any GI upset 3-4 hrs [hours] to clear medically. Will monitor psyc [psychiatric] - anxiety, depression." These admission orders failed to identified Patient #7's level of suicidal risk and the frequency CAH staff will "monitor" the patient's "psychiatric" issues.

Patient #7's admission "Nurse's Notes," from 01/09/11 at 2:40 a.m. stated, "Admit 20 yr [year] old female . . . via w/c [wheelchair]. Was [at] home tonoc [tonight], had '2 drinks of whiskey' and took a handful of Ibuprofen. Stated 'more than 12, but less than 20.' When asked if pill ingestion was attempt at suicide, pt nodded head 'yes.' Eyes are bloodshot, no bruises anywhere on body . . . saline lock to [left] antecubital . . . Assisted to bathroom [with] standby, gait unsteady. Boyfriend was present in ER. Pt had vomited [at] home. Clothes sent home [with] boyfriend d/t [due to] lg [large] amt [amount] vomit on sleeves. Glasgow coma 13/15. Neurochecks done. Call light in reach. Rails [elevated] [times] 2 for repositioning. . . ."

A "Nurse's Note," timed at 3:00 a.m. identified Patient #7 removed the saline lock from her left antecubital area. A "Nurse's Note" timed at 4:00 a.m. stated, "Pt found in hall [with] boyfriend. She 'walked home. I brought her back.' . . . pt laughing. Pt had gown, socks, and slippers on. Temp 94.2 [degrees F]. Back in bed. Warm blankets." Facility nursing staff notified the on-call health care practitioner (#2) at 4:05 a.m. of Patient #7's elopement and subsequent return. The nursing staff was "informed to ask pt if suicidal thoughts, or plans of elopement." The nursing staff documented at 4:10 a.m., Patient #7 "denied suicidal thoughts, denies plans of elopement" and relayed this information to the on-call health care provider (#2).

Review of Patient #7's "Vital Signs, Neuro [neurological] Checks, and Hourly Urine Output," form from 01/09/11 showed:
3:00 a.m.- T 98.9, P 69, R 20, BP 119/66
4:00 a.m.- T 94.2, P 103, R 20, BP 147/93
5:00 a.m.- T 97.2, P 80, R 20, BP 138/76.

Review of the facility's incident report dated 01/09/11, identified an outside air temperature of 7 degrees F and Patient #7's home as approximately eight blocks from the facility.

Patient #7's medical record lacked evidence the on-call health care practitioner returned to the hospital upon notification of the patient's elopement and subsequent return to conduct a health assessment related to a decreased body temperature.

On the morning of 01/09/11 at 9:00 a.m., the health care practitioner (#2) completed a "Patient Health Questionnaire," (a questionnaire which screens for symptoms of depression) for Patient #7 and concluded Patient #7 "denied thoughts of suicide this AM [and] no plans of suicide. Pt states last night episode in anger to fiance. Has talked [with] fiance [and] no longer angry."

The facility discharged Patient #7 at 9:45 a.m. with instructions to take Lexapro (an antidepressant medication) 10 milligrams daily, "return to the ER or dial 911 if any thoughts or plans of suicide . . ." and to follow-up with a health care provider (#2) in two days.

During an interview on 05/10/11 at 9:20 a.m., an administrative nurse (#1) stated the facility "is not a psychiatric hospital" and the facility should not have admitted Patient #7. The administrative nurse (#1) stated she expected nursing staff to "just observe" a patient and stated the facility never considered evaluating the patient's room/environment for safety prior to admission. The administrative nurse (#1) stated the facility does not have a policy on suicide risk, precautions, or interventions other than the information contained in their policy pertaining to the stabilization of psychiatric patients.

The admitting health care practitioner failed to determine if 1:1 staffing was needed to maintain and ensure the safety of Patient #7 following admission to the CAH; failed to perform a face-to-face assessment of Patient #7 with a body temperature of 94.2 degrees F upon notification notified of the patient's elopement and subsequent return to the facility; and failed to provide specific instructions to the CAH nursing staff regarding the need to monitor Patient #7's continued elopement risk and mental health status.

Based on record review, staff interview, and policy/procedure review, the Critical Access Hospital (CAH) failed to provide care in accordance with the needs of 1 of 1 observation outpatient (Patient #7) following a suicidal attempt who also successfully eloped (left) the facility. Failure of the CAH to frequently monitor Patient #7 may have contributed to the patient's ability to elope/leave the facility. Failure of the CAH to develop and implement specific policies/procedures to identify suicide risk, the type of suicide precautions and interventions to be implemented and failure to ensure the safety of the the patient's environment, limited the CAH nursing staff's ability to provide the appropriate care for Patient #7 and did not ensure Patient #7's physical safety.

Findings include:

Review of the facility policy titled, "Psychiatric Emergency Policy," occurred on 05/10/11. This policy, dated 08/2007 and revised on 03/2011, stated,
"Purpose: Care and disposition of clients with a psychiatric emergency.
What constitutes psychiatric emergency?
1. Violence . . . 2. Psychosis . . . 3. 'Bizarre' behavior by anyone which results in objectionable or unusual behavior in a public place may be due to mental illness and may be brought to the emergency room. 4. Medication problem . . .
Ashley Medical Center does not have a psychiatric unit or safe room. Patients brought to the emergency room for a psychiatric emergency will be examined and treated in the emergency room on a 1:1 observation and not left alone until transferred to another facility . . . If a psychiatric emergency patient can not be transferred immediately from the emergency room due to weather or medical condition then the patient will be brought to the ICU [Intensive Care Unit] and connected to a cardiac monitor. The patient will be closely observed. A determination made by the provider if 1:1 staffing is needed to maintain safety for the patient. As soon as the medical condition is stabilized the patient will be transferred to an accepting mental health facility."

Review of the facility policy titled, "Elopement," occurred on 05/10/11. This policy, dated 07/2009, stated, "Elopement is defined as a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected. A patient deemed incompetent - including disoriented patients and those with psychiatric disorders - elopement has occurred as soon as the patient is discovered missing. For competent patients, elopement is considered to have occurred if more than 45 minutes have elapsed since the patient was last seen on the unit . . . ."

Review of Patient #7's closed outpatient observation medical record occurred on May 9-11, 2011. Patient #7 arrived in the CAH's emergency room (ER) on 01/09/11 at 1:20 a.m. via ambulance for treatment after ingesting an undetermined amount of oral Ibuprofen tablets. The CAH admitted Patient #7 to outpatient observation status on 01/09/11 at 2:40 a.m. with admission diagnosis of bipolar disorder and history of suicidal ideation.

Patient #7's Emergency Room - Outpatient Record identified when the CAH nursing staff "questioned" Patient #7 if the ingestion of pills was an "attempt at suicide," Patient #7 "nodded" her head indicating "yes." Patient #7's vital signs obtained in the Emergency Room showed a blood pressure (BP) reading of 144/89, pulse (P) 93, respirations (R) 16, and temperature (T) of 98.5.

The on-call health care practitioner's (#2) hand-written notation on the Emergency Room - Outpatient Record stated, ". . . Had gotten in an argument with [significant other] [and] threatened to 'kill self'' and grabbed bottle of Ibuprofen [and] went to bathroom and locked door. Significant other called '911' since pt [patient] didn't open door . . . Pt had 2-3 whiskey cokes this evening . . . Pt seemed to go unresponsive for police officer [and] ambulance dispatched. Pt hx [history] bipolar [disorder] [and] anxiety. Paramedic states responsive to pain - appeared more of psychotic episode . . .
O) [Objective] Alert, eyes open, nods 'yes' or 'no' to questions. Refusing to talk verbally. Eyes - PERRLA [pupils equal round reactive to light and accomodation] EOMs [extraocular eye muscle] intact. [No] nystagmus. Mouth/throat - pink moist. [Positive] gag reflex. Neck supple. Lungs CTA [clear to ausculation]. Heart S1-S2. [No] murmur. Abd [abdomen] soft, NT [nontender]
A) [Action] 1) Ibuprofen overdose. 2) Anxiety. 3) Bipolar. Medically observe 3-4 hr [hrs] to clear Ibuprofen then eval [evaluate] depression [and] suicidal concerns. May need eval [evaluation] by psychiatrist. . . ."

Patient #7's observation admission orders include diagnoses, obtaining of vital signs (as stated above), activities: "As tol [tolerated]," diet, IV (intravenous) heplock (a plastic cannula inserted into a vein to provide hydration and/or medication as needed), and "Per Poison Control - monitor for any GI upset 3-4 hrs [hours] to clear medically. Will monitor psyc [psychiatric]- anxiety, depression." These admission orders failed to identify Patient #7's level of suicidal risk and the frequency CAH staff will "monitor" the patient's "psychiatric" issues.

Patient #7's admission "Nurse's Notes," from 01/09/11 at 2:40 a.m. stated, "Admit 20 yr [year] old female . . . via w/c [wheelchair]. Was [at] home tonoc [tonight], had '2 drinks of whiskey' and took a handful of Ibuprofen. Stated 'more than 12, but less than 20.' When asked if pill ingestion was attempt at suicide, pt nodded head 'yes.' Eyes are bloodshot, no bruises anywhere on body . . . saline lock to [left] antecubital . . . Assisted to bathroom [with] standby, gait unsteady. Boyfriend was present in ER. Pt had vomited [at] home. Clothes sent home [with] boyfriend d/t [due to] lg [large] amt [amount] vomit on sleeves. Glasgow coma 13/15. Neurochecks done. Call light in reach. Rails [elevated] [times] 2 for repositioning. . . ."

A "Nurse's Note," timed at 3:00 a.m. identified Patient #7 removed the saline lock from her left antecubital area. A "Nurse's Note" timed at 4:00 a.m. stated, "Pt found in hall [with] boyfriend. She 'walked home. I brought her back.' . . . pt laughing. Pt had gown, socks, and slippers on. Temp 94.2 [degrees F]. Back in bed. Warm blankets." Facility nursing staff notified the on-call health care practitioner (#2) at 4:05 a.m. of Patient #7's elopement and subsequent return. The nursing staff was "informed to ask pt if suicidal thoughts, or plans of elopement." The nursing staff documented at 4:10 a.m., Patient #7 "denied suicidal thoughts, denies plans of elopement" and related this information to the on-call health care practitioner (#2). The next "Nurse's Note" entry is timed at 6:00 a.m. and identified Patient #7 "Asleep in bed, tab alarm on, call light in reach."

Review of Patient #7's "Vital Signs, Neuro [neurological] Checks, and Hourly Urine Output," form from 01/09/11 showed:
3:00 a.m.- T 98.9, P 69, R 20, BP 119/66
4:00 a.m.- T 94.2, P 103, R 20, BP 147/93
5:00 a.m.- T 97.2, P 80, R 20, BP 138/76.

The CAH nursing staff failed to obtain and/or document any further body temperatures for Patient #7.

Review of the facility's incident report dated 01/09/11, identified an outside air temperature of 7 degrees F and Patient #7's home as approximately eight blocks from the facility.

The facility discharged Patient #7 at 9:45 a.m. with instructions to take Lexapro (an antidepressant medication) 10 milligrams daily, "return to the ER or dial 911 if any thoughts or plans of suicide . . ." and to follow-up with a health care provider (#2) in two days.

During an interview on 05/10/11 at 9:20 a.m., an administrative nurse (#1) stated the facility "is not a psychiatric hospital" and the facility should not have admitted Patient #7. The administrative nurse (#1) stated she expected nursing staff to "just observe" a patient and stated the facility never considered evaluating the patient's room/environment for safety prior to admission. The administrative nurse (#1) stated the facility does not have a policy on suicide risk, precautions, or interventions other than the information contained in their policy pertaining to the stabilization of psychiatric patients.

During an interview on 05/10/11 at 3:00 p.m., an administrative nurse (#1) stated she believed Patient #7 exited through the first floor east door when the two on-duty nurses cared for another patient. This nurse reported that since this incident occurred they revised their facility policy to include placing these types of future admissions into the ICU for closer observation and monitoring. The facility's policy/procedure failed to identify or specify levels of suicide risk, suicide precautions, and interventions for staff to consider and implement as necessary related to each patient's level of risk, and failed to ensure staff assessed the physical environment of the room to ensure safety of the patient.



28086

Based on review of the facility's emergency department (ED) log and staff interview, the Critical Access Hospital (CAH) failed to maintain a record for 1 of 9 patients (Patient #21) who presented to the ED. Failure to maintain a record of the care, services, and information provided to all patients who are seen in the ED does not ensure continuity of patient care.

Findings include:

Review of the facility's ED log occurred on 05/09/11. Information recorded on the ED log included, in part, the date and time of admission, patient name, age, name of health care practitioner, nature of injury, services rendered, and disposition.

The ED log identified Patient #21, a one year old female, presented to the ED on 04/09/11 at 9:40 a.m. The written information on the ED log for Patient #21 identified the nature of injury as "pinpoint rash x [times] 2 wks [weeks]," services provided by the CAH as "Exam," and the disposition as "No charge - advised to see pediatrician." This entry in the ED log had a line drawn through it.

Following submission of a list of closed records for review to the CAH's medical record department on the afternoon of 05/09/11, a medical record staff member (#3) stated, "We don't have an emergency room record" for Patient #21, dated April 9, 2011. When shown the CAH's current ED log and entry, dated 04/09/11 for Patient #21, this medical record staff member stated her uncertainty whether a health care practitioner saw Patient #21 in the facility's ED.

During interview on the afternoon of 05/10/11, an administrative staff nurse (#1) stated she did not know if Patient #21 actually received services in the facility's ED.

During interview on 05/11/11 at 11:50 a.m., the staff nurse (#6) who worked on April 9th confirmed Patient #21 did present to the ED and received a "brief" examination by the medical doctor (MD). This staff nurse (#6) stated the MD "was familiar with the infant" as he (the MD) examined the infant prior in the week at the local clinic. This staff nurse (#6) stated the MD consulted the infant's out-of-town pediatrician by telephone and provided the infant's mother with verbal instructions to follow-up with the pediatrician the next day. The staff nurse (#6) stated the MD did not want the mother to be "charged" for the visit, so the record "was discarded" (torn up).

Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to maintain a complete medical record including health care practitioner's orders for treatment and medications administered for 2 of 9 closed emergency room (ER) records (Patients #9 and #12) and 1 of 3 closed swing bed record (Patient #17) reviewed and for medications to take upon discharge for 2 of 3 closed swing bed records (Patients #17 and #18) reviewed.

Failure to ensure the medical record included physician orders for all treatment provided limited the CAH staff's ability to ensure continuity of care. Failure of the health care practitioner to review and order all medications upon a patient's discharge from the facility does not ensure patients are aware of what medications to take upon discharge and limits the CAH staff's ability to ensure continuity of care.

Findings include:

Review of the facility policy titled "Medical Record Entries" occurred on 05/11/11. This policy, dated 09/22/04, stated, ". . . Purpose: To designate a distinct way for entries to be entered into the medical record. Description: Entries into the medical record shall be made to reflect each patient's course of care. . . ."

Review of Patients #9, #12, #17, and #18's closed medical records occurred on May 9-11, 2011.

- Patient #9's closed ER record identified the CAH nursing staff administered the following medications to the patient: baby Asprin, intravenous morphine and a nitroglycerin drip. Laboratory testing completed on Patient #9 included Prothrombin Time (PT) and Partial Thromboplastin Time (PTT). Review of Patient #9's ER record lacked written health care practitioner's orders for the administration of these medications and for the completion of the laboratory tests.

- Patient #12's closed ER record identified the CAH nursing staff administered 40 units of Lantus insulin to the patient on 11/27/10. Patient #12's ER record lacked a health care provider's written order for the administration of this medication.

- Patient #17's closed swing bed record identified the CAH admitted the patient on 02/17/11 with diagnoses of congestive heart failure, edema, and insulin dependent diabetes. Patient #17's admission physician orders included 17 oral medications, in addition to orders for "Glucoscan QID [four times a day] [with] Reg [Regular] sliding scale insulin per protocol" and "Lantus 30 u [units] [every] AM [and] 28 u SQ [subcutaneous] [every] PM." Patient #12's medical record lacked a copy of the facility's Regular sliding scale insulin protocol.

Patient #17's medication administration record (MAR) identified the CAH staff obtained Glucoscan readings at 7 a.m., 11 a.m., 5 p.m., and 9 p.m. Depending on the results, the CAH nursing staff provided Regular sliding scale insulin to the patient.

Patient #17's nurse's note for 02/20/11 showed:
5:00 p.m. - "BS [blood sugar] at this time 406. [name of doctor] notified, . . . adm [administer] 10 u Humulin R [and] recheck in 1 hr [hour] [and] notify."
6:15 p.m. - "Pt [patient] BS now 398 after light supper. [name of doctor] notified, adm [administered] 10 u Humulin R [Regular] per [name of doctor] and notify with recheck in 1 hour."
7:15 p.m. - "Rechecked BS. Now 431. [name of doctor] notified . . . to adm PM Lantus now. Recheck BS at 9 p [p.m.], and notify physician."

Patient #17's record lacked a written physician order for the Regular insulin administered to the patient at 6:15 p.m. and the medication administration record (MAR) lacked documentation of the 6:15 p.m. insulin provided to Patient #17.

The facility discharged Patient #17 on 02/21/11. Patient #17's physician order's for discharge and the patient's "Discharge Instructions," stated, "Continue home medications." Failure of the health care practitioner to specify in writing the medications for Patient #17 to take upon discharge from the facility had the potential for the patient to take the incorrect medication and/or dosage.

- Patient #18 closed swing bed record identified the CAH admitted the patient on 03/18/11 status post right hip replacement. Patient #18's health care practitioner discharged the patient home on 03/25/11, with the following order, "Discharge." This discharge order failed to list what specific medications, activity level, and follow-up precautions and/or restrictions Patient #18 needed to adhere to upon discharge.

Patient #18's "Discharge Instructions," identified CAH nursing staff printed/listed ten medications, activity level of "up with walker as instructed by the physical therapist," limitations of "no lifting," and "light exercise." The CAH nursing staff wrote this information on the "Discharge Instruction" form even though Patient #18's medical record lacked a health care practitioner's order for them.

During interview on 05/10/11 at 3:15 p.m., an administrative nurse (#1) confirmed Patients #9 and #12's ER records lacked written orders for the medications and blood tests as listed above. This administrative nurse (#1) confirmed Patient #17's swing bed record lacked a written order and documentation on the MAR by the nursing staff providing the 6:15 p.m. dose of insulin. This administrative nurse (#1) stated the practice of the health care provider to write "resume home medications," is "not allowed," and she expected the health care practitioner to write out and review all discharge medications.

Based on policy review and staff interview, the Critical Access Hospital (CAH) failed to evaluate the quality and appropriateness of the treatment furnished by 1 of 1 nurse anesthetist (#4) providing care to the CAH's patients in the past year. Failure to evaluate the quality and appropriateness of the treatment furnished has the potential to affect patient outcomes involving surgical procedures requiring anesthesia services.

Findings include:

Review of the policy titled "QUALITY IMPROVEMENT PROGRAM" occurred on May 10-11, 2011. This policy, dated 09/2010, stated, "The Quality improvement program . . . has the obligation to demand from all personnel in it's [sic] organization, an accountability for performance . . . The Medical Staff through its committee members is responsible for implementing the program as it concerns the medical staff, related services and patient outcomes.
Purpose:
The purpose and intent is to provide a comprehensive Quality Improvement program . . . through the detection and correction of factors hindering the provision of quality and appropriateness of health care. Including [sic] developing and implementing actions with periodic reassessment of the actions [sic] impact on the problems identified and to pursue opportunities to improve patient/resident care. . . .
Scope of the QI [Quality Improvement] program . . . 1. Medical Staff shall be [sic] review staff functions relating to medical records, medical care evaluation studies . . . including but not limited to: . . . Surgical Case Review; Credentials; Nursing Care Review; . . . Safety and Risk Management . . ."

The CAH failed to provide evidence a physician with experience in anesthesiology evaluated the quality and appropriateness of the treatment provided by the nurse anesthetist.

During interview on the afternoon of 05/11/11, a medical records supervisory staff member (#5) confirmed the CAH did not have a physician evaluate the quality and appropriateness of the treatment provided by the nurse anesthetist in the past year and did not have an established policy and procedure to perform an evaluation of the nurse anesthetist.

Based on policy review and staff interview, the Critical Access Hospital (CAH) failed to have a physician with the same qualifications/privileges evaluate the quality and appropriateness of the diagnosis and treatment furnished by 1 of 1 consulting ophthalmologist (Physician #6) who provided treatment to the CAH's patients in 2010. Failure to evaluate the physician has the potential to affect patient outcomes involving ophthalmology procedures.

Findings include:

Review of the policy titled "QUALITY IMPROVEMENT PROGRAM" occurred on May 10-11, 2011. This policy, dated 09/2010, stated, "The Quality improvement program . . . has the obligation to demand from all personnel in it's [sic] organization, an accountability for performance . . . The Medical Staff through its committee members is responsible for implementing the program as it concerns the medical staff, related services and patient outcomes.
Purpose:
The purpose and intent is to provide a comprehensive Quality Improvement program . . . through the detection and correction of factors hindering the provision of quality and appropriateness of health care. Including [sic] developing and implementing actions with periodic reassessment of the actions [sic] impact on the problems identified and to pursue opportunities to improve patient/resident care. . . .
Scope of the QI [Quality Improvement] program:
. . .
1. Medical Staff shall be [sic] review staff functions relating to medical records, medical care evaluation studies . . . including but not limited to: . . . Surgical Case Review . . ."

Review of a facility policy titled "ASHLEY MEDICAL CENTER PEER REVIEW" occurred on 05/11/11. The policy, dated 09/04/07, stated, ". . . A review of 5% of surgical charts consisting of emergency surgery and scheduled surgery will be done each year by a physician using the Interqual Retrospective Monitor Criteria. If some charts fall out of the criteria they will be sent on to [Network Hospital] or North Dakota Healthcare Review for further review by a surgeon. . . ."

During interview on the morning of 05/11/11, a medical records supervisory staff member (#5) confirmed the CAH did not have a sample of the consulting ophthalmologist's surgical procedures evaluated for quality and appropriateness of the diagnosis and treatment provided.