HospitalInspections.org

Based on review of credential files, review of a diagnostic imaging report, review of Medical Staff Bylaws and staff interview, the CAH (Critical Access Hospital) failed to ensure that 1 of 1 radiologist reviewed (Physician Radiologist-D) performed only the clinical privileges specifically granted by the Board. The specific privilege the Board had not granted to Physician Radiologist-D was MRI (Magnetic Resonance Imaging) interpretation. The list of physicians provided by the CAH contained 5 radiologists. Review of the Radiology Statistics in the 2012 Annual Meeting report revealed 105 MRIs were completed in 2012. This failed practice has the potential to affect any patient having an MRI at the CAH.

Findings are:

A. Review of the Medical Staff Bylaws approved by the Board on 12/18/08 revealed the following under Article VIII Clinical Privileges, Section 1 Nature of Privileges:
"A member of the Medical Staff may exercise only those clinical privileges specifically granted in accordance with these Bylaws."

B. Review of the Delineation of Radiological Procedures dated 3/9/12 located in Physician Radiologist-D's credential file revealed the privilege form lacked the privilege for interpretation of MRI studies. Review of a Diagnostic Imaging Report for Patient 45 revealed an MRI of the right shoulder was completed on 8/6/13 and the interpreting physician was Physician Radiologist-D.

C. Interview with the Administrator and Compliance Officer on 10/2/13 from 11:30 AM to 11:45 AM confirmed that Physician Radiologist-D had not been granted the privilege of interpretation of MRI studies by the Board.

Based on record review, staff interview and review of the CAH (Critical Access Hospital) Policy and Procedures, the facility failed to ensure that 4 of the 20 inpatient records (Patients 3, 4, 8 and 20) reviewed contained complete physician/provider orders when the patient changed from Observation Status to Acute Inpatient Status. The total sample was 42 and the CAH census was 1 inpatient and 1 swing bed patient.

Findings are:

A. Review of Patient 3's medical record dated 5/22/13 revealed the patient had been admitted on 5/21/13 in Observation Status. (Observation status is hospital outpatient services to help the doctor decide if the patient needs to be admitted as an inpatient or can be discharged.)

On 5/22/13 the physician/provider wrote the following orders at 7:40 AM:
1) "Switch to Acute care diagnosis Pneumonia [infection in lungs], hyponatremia [low salt level in the blood], fluid retention [an excess buildup of fluids in the body], A fib [atrial fibrillation-a heart rhythm disorder], mental changes, congestive heart failure [the heart cannot keep up with the workload and fluid can build up]."
2) Levaquin (an antibiotic) 750 mg (milligrams) IV (intravenous) daily.
3) Continue previous orders and medications.
4) Discontinue feet elevations q (every) 2 hours.
5) Keep feet elevated when in chair.

The 5/22/13 Acute Care medical record for Patient 3 did not indicate the specific physician/provider orders to continue in Acute Care Status. The record lacked what other medications to continue, what diet to provide the patient and any other orders the physician/provider desired to continue to care for the patient.

Interview with the DON (Director of Nurses) on 10/3/13 at 10:15 AM revealed, "Yes they [the Physician/Provider] are supposed to write all new orders when they change the patient's status."

B. Review of Patient 4's medical record dated 7/14/13 revealed the patient had been admitted on 7/12/13 in Observation Status.

On 7/14/13 the physician/provider wrote the following orders at 1320 (1:20 PM):
- Admit Pt (patient) to Acute Status at 1400 (2:00 PM).
- Transfer Dx (diagnoses): Reoccurring N/V/D (nausea/vomiting/diarrhea)
- ileus (an obstruction of the intestinal bowel muscles)
- when given laxatives has had only liquid, inappropriate digestion.
- Continue all medications except laxatives as noted below: Dulcolax pills, Dulcolax suppository, Miralax, mag citrate (all laxatives to promote bowel movements).

On 7/14/13 at 1430 (2:30 PM) the physician/provider wrote the following orders:
- Continue all orders from observations.
- Give Benadryl (medication for allergic reactions) 25 mg IV 1/2-1 hour before Scan.

The 7/14/13 Acute Care medical record for Patient 4 did not indicate the specific physician/provider orders to continue in Acute Care Status. The record lacked what other medications to continue, what diet to provide the patient and any other orders the physician/provider desired to continue to care for the patient.

Interview with the DON on 10/7/13 at 1:50 PM revealed, "I looked at the Medication Reconciliation Record on the computer. They are supposed to list out all the medications the physician wants to continue when they admit the patients from one status to the other and circle if continuing or discontinuing them. There isn't a Medication Reconciliation Record for that date. Otherwise they should rewrite them."

C. Review of Patient 8's medical record dated 8/23/13 revealed the patient had been admitted directly to an Inpatient/Acute Status.

The physician/provider utilized the Heart Failure (the heart cannot keep up with the workload and fluid can build up) Standing Admission Orders (a typed set of orders with care orders for a specific disease that the physician/provider can pick from or add to) and signed them 8/23/13. The Orders included the following categories: Diagnoses, Condition, Allergies, Vital signs, Activity, Treatment, Food and Nutrition, Respiratory Services. Also Insulin Infusion Orders were initiated for this patient (insulin is provided to treat diabetes-elevated blood sugars).

The physician/provider indicated what of the standing orders (gender) wanted for Patient 8's care.

The physician/provider orders lacked a Food and Nutrition order (a diet order that the physician wants the patient to follow while in the hospital).

Interview with the DON on 10/7/13 at 4:30 PM revealed, "I wasn't able to find the doctor order for the diet for [Patient 8] either."

D. Review of Patient 20's medical record dated 3/23/13 revealed the patient had been admitted on 3/21/13 in Observation Status.

On 3/23/13 the physician/provider wrote the following orders at 1410 (2:10 PM):
- Change patient to acute.
- Obtain H/H (hemoglobin - lab test that identifies the component of the red blood cells that carries oxygen and hematocrit - lab test that shows the amount of red blood cells in the blood), PT (prothrombin time- a test that checks the blood clotting ability and time), PTT (partial thromboplastin time - another lab test that checks for blood clotting ability and times) at 10 PM tonight.

On 3/23/13 the physician/provider lacked further instructions related to the physician/providers desire of what orders to continue in Acute Care Status. The record lacked what other medications to continue, what diet to provide the patient and any other orders the physician/provider desired to continue to care for the patient.

Interview with the DON on 10/7/13 at 4:30 PM revealed that they are supposed to rewrite the orders when the patient changes from Observation Status to Inpatient/Acute Status or Swing Bed Status. The DON confirmed that this was not being done.

E. Review of the undated "Procedure for Admitting a Patient to Swing Bed Care" revealed the following:
"1)The physician must write a discharge order from Acute Care and then admit to swing bed/skilled nursing if this is applicable. This will be done on separate doctor's order sheets.
2)The acute care record is then closed out as any other discharge and a new record made for the swing bed with appropriate admission orders written..."

Interview with the DON on 10/8/13 at 9:50 AM revealed, "This is what I would expect when admitting from any status - from Observation to Acute Inpatient Status or from Inpatient Status to Swing Bed Status."