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Tag No.: C0225
A. Based on review of Critical Access Hospital (CAH) policy, observational tours of the Medical/Surgical Unit and operating rooms in the Surgical Department and staff interview, it was determined that for 11 of 11 ( R #100 - R #109 and R #111) patient rooms in the Medical/Surgical Unit; and 1 of 2 (O #1) Operating Rooms in the Surgical Department, the Hospital failed to ensure patients rooms were free from chipped paint and rust which could affect all patients serviced on the Medical Surgical Unit and Operating Room.
Findings include:
1. The CAH policy entitled, "Environmental Rounds Inspections" (revised 1/5/09), was reviewed on 11/7/11 at approximately 9:00 AM and included, "...Environmental rounds have been established to routinely provide a check and balance system for continual improvement of (CAH's healthcare environment..."
2. An observational tour of the Medical/Surgical Unit was conducted on 11/7/11 between approximately 9:45 AM and 10:45 AM. During the tour, the edges of the sink basins in R #100 - R #109 were found to contain rust and bathroom wall in R #111 contained chipped paint.
3. A tour of the Surgical Department was conducted on 11/8/11 between approximately 6:45 AM and 8:45 AM. During this tour, the walls in O #1 contained chipped paint.
4. The above findings were confirmed with the Director of Nursing during an interview on 11/8/11 at approximately 3:15 PM.
Tag No.: C0271
A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 1 (Pt #1) clinical record reviewed of a patient with tube feedings, the Critical Access Hospital (CAH) failed to ensure the patient's gastric residual was checked as required by policy.
Findings include:
1. CAH policy entitled, "MPC-10-ENT, Enteral Feedings," with review date 9/9/11, reviewed on 11/7/11 at approximately 11:00 AM required, "Policy:..5.0. Gastric residuals will be checked every 4 hours, unless specifically ordered by the physician."
2. The clinical record of Pt #1 was reviewed on 11/7/11 at approximately 10:00 AM. Pt #1 was an 81 year old female admitted on 11/1/11 with a diagnosis of Right Hip Fracture. Clinical documentation included that Pt #1 received Gastric Tube Feedings on 11/6/11 but lacked documentation of residual checks from 10:03 AM 11/6/11 until 7:32 AM (7 hours) and from 7:32 AM until 3:27 PM (8 hours), and from 3:27 PM until 8:00 PM.
3. The findings were verified by the Nursing Coordinator during an interview on 11/7/11 at approximately 10:45 AM.
B. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 3 (Pt #14)clinical records reviewed, the Critical Access Hospital (CAH) failed to ensure less restrictive interventions were attempted prior to the application of restraint devices and justification for the restraint.
Findings include:
1. CAH policy entitled,"G-03-Restraint-Non Violent," with review date 5/4/11 reviewed on 11/7/11 at approximately 10:10 AM required, "1.0 General Concepts. 1.1.1 A restraint can only be used if needed to improve the patient's well being and less restrictive interventions have been determined to be ineffective."
2. The clinical record of Pt #14 was reviewed on survey date 11/9/11 at approximately 11:00 AM. Pt #14 was a 71 year old female admitted on 1/26/11 with a diagnosis of Diverticulitis of the Colon. The clinical record of Pt #14 contained a physician's order for restraint dated 1/26/11. The Restraint Order Sheet dated 1/26/11 lacked documentation that less restrictive intervention had been attempted prior to the application of the restraint devices. Pt. #1 Restraint Monitoring Flowsheet dated 1/26/11 at 12:00 PM lacked justification for the application of restraint and Pt #14's Observations and Level of Consciousness at 12:00 PM included "Sedated, Sleeping, and Quit/Calm/Resting".
3. The findings were verified with the Chief Nurse Executive during an interview on 11/9/11 at approximately 11:15 AM.
C. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 3 (Pt #1) clinical records reviewed, the Critical Access Hospital (CAH) failed to ensure new physician orders for restraints were authorized after 24 hours.
Findings include:
1. CAH policy entitled, "GA-03-Restraint-Non Violent," with review date 5/4/11 reviewed on 11/7/11 at approximately 10:10 AM, required, "5.0...When in use for non-violent/non-self destructive behavior (Medical Necessity)...5.4.4 Continued use of restraint use beyond the first 24 hours is authorized by a physician issuing a new order if restraint use continues to be clinically justified."
2. The clinical record of Pt #1 was reviewed on 11/7/11 at approximately 10:00 AM. Pt #1 was an 81 year old female admitted on 11/1/11 with a diagnosis of Right Hip Fracture. The clinical record of Pt #1 included documentation that Pt #1 was restrained on 11/3, 11/4, 11/5, 11/6, and 11/7/11. The record lacked a physician's orders for restraint usage on 11/5 and on 11/6/11.
3. The findings were verified by the Nursing Coordinator during an interview on 11/7/11 at approximately 10:45 AM.
Tag No.: C0279
A. Based on review of Hospital policy, observation, and staff interview, it was determined that the Critical Access Hospital (CAH) failed to ensure that the patient's refrigerator in the Medical/Surgical Unit contained only patients' nourishments which could affect all patients serviced on the Medical Surgical Unit.
Findings include:
1. The CAH policy entitled, "Refrigerator Temperature Monitoring - Medications and Patient Nutrition" (revised 10/6/11) was reviewed on 11/7/11 at approximately 9:00 AM and included, "...Employee food will not be kept in patient care refrigerators..."
2. During a tour of the Medical/Surgical Unit conducted on 11/7/11 between approximately 9:45 AM and 10:45 AM, F #1 (refrigerator) located in the nutrition room had two unlabeled food containers identified by the Medical/Surgical Unit Manager as belonging to an employee.
3. The above findings were confirmed during an interview with the Medical/Surgical Unit Manager on 11/7/11 at 10:15 AM and the Chief Nursing Executive during interviews on 11/7/11 at approximately 9:30 AM and 3:15 PM.
B. Based on review of Critical Access Hospital (CAH) policies, observational tour and staff interview, it was determined that the CAH failed to ensure all food items were labeled with date of opening which could affect the food being served to 3 current patients as of 11/9/11.
Findings include:
1. CAH policy entitled, "NUTR 05 Dating/Labeling of Stored Food Items, "with review date of 4/14/11 reviewed on 11/8/11 at approximately 12:00 PM required, "Procedure:...3. Prepared food items...3.5 All condiment containers will be clean..labeled with both a received and open date."
2. On 11/9/11 between 8:45 AM and 9:30 AM, an observational tour was conducted of the CAH's dietary department. During the tour, the CAH's dry food storage area, multiple opened containers of condiments were not labeled with the date of opening. Examples included: Lemon Pepper, Dill Weed, Ginger, Herb Seasoning, Nutmeg, Clove, Cinnamon, and Baking Powder.
3. The findings were verified by the Food Service Supervisor during an interview on 11/9/11 at approximately 9:30 AM.
Tag No.: C0295
A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined that in 1 of 3 (Pt#1) patients receiving blood product transfusions, the Critical Access Hospital (CAH)failed to ensure patient's vital signs were reassessed 15 minutes after transfusion was initiated.
Findings include:
1. CAH policy entitled, "MPC0-02-Blood Administration," with review dated 9/15/11 reviewed on 11/7/11 at approximately 10:00 AM required, "Policy:..18.0 Check the patient's vital signs 15 minutes after the blood begins infusing."
2. The clinical record of Pt #1 was reviewed on 11/7/11 at approximately 10:00 AM. Pt #1 was an 81 year old female admitted on 11/1/11 with a diagnosis of Right Hip Fracture. The clinical record contained a physician's order dated 11/4/11 that required Pt #1 receive two (2) units packed red blood cells. On 11/4/11, unit # 04411 110016 was started at 12:15 PM and vital signs documented. The clinical record however, lacked a 15 minute reassessment of Pt #1's temperature as required.
3. The findings were verified by the Nursing Coordinator during an interview on 11/7/11 at approximately 10:45 AM.
Tag No.: C0298
A. Based on review of Hospital policy, Medical Unit Guidelines, clinical records, and staff interview, it was determined that in 3 of 19 (Pt's #1, 14 and 17) inpatient clinical records reviewed, the CAH failed to ensure patients' care plans were updated/revised to accurately reflect patients' health status.
Findings include:
1. CAH policy entitled, "GA-03-Restraint-Non Violent," with review date 5/4/11 reviewed on 11/7/11 at approximately 10:10 AM required, "...5.0 When in use for non-violent/non-self destructive behavior (medical necessity): 5.1 Anytime restraints are used in the care of a patient, it must be addressed in that patient's plan of care."
2. The "Medical Unit Guidelines for Care" was reviewed on 11/7/11 at 10:20 AM, the Guidelines included, "II Plan of Care... B. Review and revise patient plan of care and education at least once every 12 hours..."
3. The clinical record of Pt #1 was reviewed on 11/7/11 at approximately 10:00 AM. Pt #1 was an 81 year old female admitted on 11/1/11 with a diagnosis of Right Hip Fracture. The clinical record of Pt. #1 contained a physician's restraint order dated 11/3/11. Pt #1's plan of care failed to include Pt #1's restraint usage from 11/3/11 to 11/6/11.
4. The clinical record of Pt #14 was reviewed on 11/9/11 at approximately 11:00 AM. Pt #14 was a 71 year old female admitted on 1/26/11 with a diagnosis of Diverticulitis of the Colon. The clinical record of Pt #14 contained a physician's order dated 1/26/11 that included the use of restraint devices. Pt #14's plan of care failed to include Pt #14's restraint usage on 1/26/11.
5. The findings related to Pt's. # 1 & 14 were verified by the Nursing Coordinator during an interview on 11/7/11 at approximately 10:45 AM and the Chief Nurse Executive during an interview on 11/9/11 at approximately 11:15 AM.
6. The clinical record of Pt #17 was reviewed on 11/9/11 10:40 AM. Pt #17 was a 21 year old male, admitted on 5/16/11 with a diagnosis of Cellulitis. A physician's order dated 5/18/11 at 1:17 PM, required contact isolation and a nursing note indicated that contact isolation was initiated on 5/18/11 at 11:36 AM. The Care Plan, dated 5/18/11 was not updated to include contact isolation.
7. This finding was confirmed by the Nursing Supervisor/Team Leader during an interview on 11/9/11 at 10:50 AM.
surveyors: 15168 & 19843
Tag No.: C0306
A. Based on review of Critical Access Hospital (CAH) Medical Staff Rules and Regulations, Letter of Attestation, and staff interview, it was determined that the CAH failed to ensure that medical records were completed within 30 days for 35 medical records as of 11/08/2011.
Findings include:
1. The CAH's "Medical Staff Rules and Regulations" (updated 6/2011) was reviewed on 11/7/11 at approximately 9:30 AM and included, "...Charts that are incomplete beyond 30 days will result in suspension from the medical staff..."
2. The CAH's Director of Support Services provided documentation entitled, "Delinquent Medical Record Letter of Attestation" for review on 11/8/11 at approximately 8:00 AM which included, "...As of today, Tuesday, November 08, 2011, the total number of delinquent medical records was 35."
3. The above findings were confirmed with the Chief Nursing Executive on 11/8/11 at approximately 3:15 PM.