HospitalInspections.org

1. Based upon observation of the critical access hospital (CAH), and interviews with the Maintanance personnel and Facility Director, the hospital does not have a way to provide emergency power to the hospital.

Findings include:

a. During observation of the hospital's plant, at 2:30 p.m., March 25, 2010, with the Maintanance director, it was noted that both generators that supply power to the building run on natural gas and the facility does not have a way to provide fuel to the generators in case of emergency shut-down of the natural gas, he verified that the facility does not have a way to provide emergency power to the building.

b. During interviews with the Facilities Director, at 10:30 a.m., March 29, 2010, while walking around the grounds of the hospital, following his own observations of the hospital's plant, he verified that there is no way to provide emergency power to the building, since both generators run on natural gas. He verified that the facility does not have a way to run generators if they have to be shut down. He also verified that he could provide no evidence of the hospital's compliance with these requirements.

1. Based upon review of contracts, policies and procedures and observation of the critical access hospital (CAH), and interviews with the Facility Director, the hospital does not have a way to provide emergency fuel to the hospital.

Findings include:

a. During reviews of policies and procedures and Kimble Hospital contracts at 12:00 p.m., 25 March, 2010 in the facility conference room, it was noted that the facility does not have a contract or any other arrangement for the provision of emergency fuel to the facility.

b. During observation of the hospital's plant, at 2:30 p.m., March 25, 2010, with the Maintanance director, it was noted that both generators that supply power to the building run on natural gas and the facility does not have a way to provide emergency fuel to the generators in case of emergency shut-down of the natural gas, he verified that the facility does not have a way to provide emergency fuel for the generators.

c. During interviews with the Facilities Director, at 10:30 a.m., March 29, 2010, while walking around the grounds of the hospital, following his own observations of the hospital's plant and specifically both generators that provide power to the main facility, he verified that there is no way to provide emergency fuel to the generators. He verified that the facility does not have a way to provide an alternate emergency fuel to run generators. He also verified that he could provide no evidence of the hospital's compliance with these requirements.

Based upon review of medical records and interview with staff it was determined that 13 out of 24 (54%) (MR# 9,11,12, 14,15,16,17,18,19,20,21,22, and MR#23) of medical records reviewed that were not promptly completed which included medical record that had frequent verbal orders, had history and physical that were transcribed and placed in the medical record after 24 hours of admission or had discharge summaries transcribed and placed in the medical records after 30 days of discharge. This requirement was not met as follows.

Findings:

a. Reviewed 24 medical records (MR) (MR#1-24) of emergency room, swing bed and acute care inpatient medical records it was observed that 11 out of the 24 medical records reviewed (46%) (MR# 9,12,14,15,16,18,19,20,21,22 and MR# 23) had shown frequent telephone and verbal orders being used on the average of 3 per shift per patient. It was observed that 2 out of 14 inpatient admission medical records (14%) (MR#11 and MR#17) had history and physicals documents that were transcribed, dated, timed placed in the record and signed by the physician after the 24 hours of admission of the patient. It was observed that 2 out of 14 inpatient discharge summary documents (14%) (MR#11 and MR#23) that had discharge summaries that were transcribed, dated, timed and signed by the physician later than 30 days after discharge.

b. Interviewed staff # 2, Chief Nursing Officer on March 30, 2010 @ 10:00am in the facility's conference explained and showed example of frequent use of verbal orders and told they were to be used infrequently. Staff interviewed could not show evidence that that medical records were within parameters of this requirement.