The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GIFFORD MEDICAL CENTER 44 SOUTH MAIN STREET RANDOLPH, VT 05060 Feb. 15, 2011
VIOLATION: RECORDS SYSTEM Tag No: C1114
Based on record review and confirmed by staff interview, the hospital failed to include in the medical record the results of consultative screening for 2 of 2 applicable patients. (Patients # 9 and #16 ) Findings include:

1. Per record review on 2/14/11, Patient #9 presented to the Emergency Department (ED) on 1/10/11 expressing suicidal ideation with a plan to hang his/herself. A request was made by the ED physician to have a psychiatric counselor come to the ED to evaluate and screen Patient #9 for admission to an inpatient psychiatric facility. A psychiatric social worker from a mental health agency came to the ED, evaluated Patient #9 and recommended the patient be transferred to an inpatient psychiatric unit. Arrangements were made and a transfer was facilitated. The results of the consultative screening, to reflect the decision to transfer the patient, was not found in the patient's record.

2. Per review, conducted on the morning of 2/14/11, the medical record for Patient #16 lacked documentation of the results of a mental health screening evaluation conducted in the ED (Emergency Department) on 2/7/11. The patient presented to the ED, on that date, with a chief complaint of, "vomiting'......drank half gallon of rum over past 12 hours." The patient who had an elevated blood alcohol level of 231 mg/dL at that time, had a final diagnosis of Acute and Chronic Alcoholism. During the course of treatment a nurse's note at 2:20 PM identified that " ......from Clara Martin here to talk with patient.." (the area's mental health agency). The patient was subsequently discharged to home, however there was no documentation of the evaluation by the mental health provider to reflect the decision for disposition at discharge.

Per interview on the afternoon of 2/14/11 the VP of the Hospital Division confirmed the documentation was not found in the records for Patients #9 and #16 and acknowledged that although this issue has been identified in the past, the mental health agency continues not to provide the consultative screening information and the hospital has been inconsistent with requesting the information at the time of the consultation.
VIOLATION: PATIENT CARE POLICIES Tag No: C1006
Based on record review and staff interview nursing staff failed to provide health care services in accordance with facility policies during the provision of care in the Emergency Department for 2 of 21 records reviewed. (Patients #3 and #14). Findings include:

1. Per review on 2/14/11, Patient #3 was treated in the Emergency Department (ED) on 11/10/10 for an allergic reaction. The patient's vital signs were recorded at 2220 when triaged. At 2300 the patient was examined by the ED physician who prescribed Pepcid 20 mg. IVP (intravenously push); Solu-Mederol 125 mg. IVP and Benadryl 50 mg. IVP for symptoms that included ".....a wheal and flare reaction particularly on the forearms and the anterior chest where h/she has been scratching". Over the course of the 2 hours the patient received treatment, nursing staff failed to monitor the patients vital signs especially after medication administration or prior to discharge. Per review of the "Emergency Department Nursing Standards of Care", effective 07/06/2010, states "All patients will be re-assessed prior to discharge (including vital signs). No vital signs were recorded prior to discharge of this patient.

2. Per record review Patient #14 presented on the evening of 1/1/11 complaining of "severe" dental pain. The patient's vital signs were documented at 11:40 PM, during triage assessment, and revealed an elevated BP reading of 152/97 as well as elevated pulse rate of 109. Although the patient was discharged just 30 minutes later, at 12:10 AM on 1/2/11, nursing staff failed to reassess the vital signs prior to discharge, in accordance with the facility's policy, "Emergency Department Nursing Standards of Care". The policy states: "H. Documentation will include; 3. Patients with abnormal vital signs on admission to the ED will have vital signs repeated prior to being discharged , admitted or transferred."
During interview, at 1:01 PM on 2/14/11, the VP of Hospital Services confirmed the lack of reassessment of the patient's vital signs prior to discharge.
VIOLATION: NURSING SERVICES Tag No: C1049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review nursing staff failed to administer medications in accordance with physician orders for 2 patients. (Patients #23 and #26). Findings include:

1. Per record review, on 2/7/11, Patient #23 was admitted on [DATE] with multiple health issues including a psychiatric diagnosis for which s/he routinely received Depakote (used in the treatment of some mood disorders). Although there was a physician order, dated 2/4/11, that stated to administer Depakote 125 mg orally at HS (hour of sleep) the patient had only received the medication on one occasion as of 2/7/11. This was confirmed by the Clinical Nurse Manager during interview at 3:30 PM on 2/7/11. The nurse who had reconciled the physician orders had documented, in red ink, next to the Depakote order on the order sheet; "as a x 1 (ch)". The hospital pharmacist stated, during interview at 3:35 PM on 2/7/11, that the order form, which was then faxed to the pharmacy, did not differentiate colored ink and appeared to be a "one time only" order and therefore was only given one time.

2. Per review of Patient #26''s medical records, for 2 separate inpatient stays on 11/22/10-11/24/10 and 12/14/10-12/17/10, respectively, nursing failed to administer a physician ordered daily medication. The patient was admitted to the facility on [DATE], from a local nursing home, with a diagnosis of right Middle Lobe Pneumonia. A physician order, dated 11/22/10, directed nursing staff to administer Namenda 10 mg PO (by mouth) daily. Review of the patient's MARs for 11/23/10 and 11/24/10 revealed that the medication had been omitted on each of those days. Staff had documented the reason for omission as; "med not here" and "need to get from....." The patient was discharged on [DATE], back to the nursing facility, and did not receive the physician ordered daily dose of Namenda during the 2 days of hospitalization .

Patient #26 was re-admitted to the facility on [DATE] with a diagnosis of; Change in Mental Status, Bronchitis and Prostate Enlargement. A physician order, dated 12/14/10, directed staff to administer Namenda 10 mg PO BID. Review of the patient's MARs for 12/15/10, 12/16/10 and 12/17/10 revealed that each dose of the medication had, again, been omitted for the following documented reasons; "med not available", and "absent from unit". The patient was discharged back to the nursing facility on 12/17/10 and had not received the physician ordered medication for the 3 days of hospitalization . There was no evidence that nursing staff had contacted the physician, during either inpatient stay, to inform him/her that the medication had not been administered.

The Director of Pharmacy services stated, during interview at 1:50 PM on 2/7/11, that when a drug is not available for patient use in the facility's pharmacy the drug is obtained through 3 possible routes including; samples obtained from an affiliated physician office, from a local pharmacy or use of a patient's own medication brought in from home. The Pharmacy Director further stated that, if a patient's own medication is to be used the family will bring the medication to the hospital where it is appropriately identified and labeled by the hospital's pharmacy and then made available for patient use. The pharmacist stated they "Do not have good process for follow up when patients bring in own meds to assure meds are available and given." S/he stated that although there is a process within the pharmacy for assuring timely delivery of non-formulary medications for patient use, it is not a formal process, is not included in any policy and not all pharmacists are aware of it. The Clinical Nurse Manager confirmed, during interview at 3:00 PM on 2/7/11, that it appeared the medication had never been administered to Patient #26 during either of the aforementioned hospital stays. S/he further confirmed the lack of evidence that the physician had been notified that the medication had not been administered. The VP of Hospital Services stated, during the same interview, that the expectation for nursing staff is to notify the physician if a medication is not available within 24 hours of the order.
VIOLATION: PATIENT CARE POLICIES Tag No: C1016
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews and record review Pharmacy failed to develop an effective process for assuring timely dispensation and administration of all physician ordered medications for patient use. Findings include:

Per review of medical records, for 2 separate inpatient stays from 11/22/10-11/24/10 and from 12/14/10-12/17/10, Patient #26 did not receive a physician ordered daily medication during either of the respective hospital stays. The patient who was admitted to the facility on [DATE], had a physician order, dated 11/22/10, that directed nursing staff to administer Namenda 10 mg PO (by mouth) daily. Review of the patient's MARs (Medication Administration Records) for 11/23/10 and 11/24/10 revealed that the medication had been omitted on each of those days. Staff had documented the reason for omission of the med as: "med not here" and "need to get from....." The patient was discharged on [DATE], and did not receive the physician ordered daily dose of Namenda during the 2 days of hospitalization .

Patient #26 was re-admitted to the facility on [DATE] and had a physician order, dated 12/14/10, that stated to administer Namenda 10 mg PO BID (twice a day). Review of the patient's MARs for 12/15/10, 12/16/10 and 12/17/10 revealed that each dose of the medication had, again, been omitted for the following documented reasons; "med not available", and "absent from unit". The patient was discharged back to the nursing facility on 12/17/10 and had not received the physician ordered medication for the 3 days of hospitalization . There was no evidence, during either inpatient stay, that nursing staff had contacted the physician to inform him/her that the medication had not been administered.

The Director of Pharmacy services stated, during interview at 1:50 PM on 2/7/11, that when a drug is not available for patient use in the facility's pharmacy the drug is obtained through 3 possible routes including; samples obtained from an affiliated physician office, from a local pharmacy or use of a patient's own medication brought in from home. The Pharmacy Director further stated that, if a patient's own medication is to be used the family will bring the medication to the hospital where it is appropriately identified and labeled by the hospital's pharmacy and then made available for patient use. The pharmacist stated they "Do not have good process for follow up when patients bring in own meds to assure meds are available and given." S/he stated that although there is a process within the pharmacy for assuring timely delivery of non-formulary medications for patient use, it is not a formal process, is not included in any policy and not all pharmacists are aware of it. The Clinical Nurse Manager confirmed, during interview at 3:00 PM on 2/7/11, that it appeared the medication had never been administered to Patient #26 during either of the aforementioned hospital stays. S/he further confirmed the lack of evidence that the physician had been notified that the medication had not been administered. The VP of Hospital Services stated, during the same interview, that the expectation for nursing staff is to notify the physician if a medication is not available within 24 hours of the order.
VIOLATION: RECORDS SYSTEM Tag No: C1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review, the hospital failed to ensure complete and accurate documentation of the medical record for 3 applicable patients (Patients # 9, 16, 23 ) Findings include:

1. Per record review, on 2/7/11, Patient #23 was admitted on [DATE] with multiple health issues including a psychiatric diagnosis for which s/he routinely received Depakote (used in the treatment of some mood disorders). Although there was a physician order, dated 2/4/11, that stated to administer Depakote 125 mg orally at HS (hour of sleep) the patient had only received the medication on one occasion as of 2/7/11. This was confirmed by the Clinical Nurse Manager during interview at 3:30 PM on 2/7/11. The nurse who had reconciled the physician orders had documented, in red ink, next to the Depakote order on the order sheet; "as a x 1 (ch)". The hospital pharmacist stated, during interview at 3:35 PM on 2/7/11, that the order form, which was then faxed to the pharmacy, did not differentiate colored ink and appeared to be a "one time only" order and therefore was only given one time.

2. Per record review on 2/14/11, Patient #9 presented to the Emergency Department (ED) on 1/10/11 expressing suicidal ideation with a plan to hang his/herself.. A request was made by the ED physician to have a psychiatric counselor come to the ED to evaluate and screen Patient #9 for admission to an inpatient psychiatric facility. A psychiatric social worker from a mental health agency came to the ED, evaluated Patient #9 and recommended the patient be transferred to an inpatient psychiatric unit. Arrangements were made and a transfer was facilitated. The results of the consultative screening, to reflect the decision to transfer the patient, was not found in the patient's record.

3. Per review, conducted on the morning of 2/14/11, the medical record for Patient #16 lacked documentation of the results of a mental health screening evaluation conducted in the ED (Emergency Department) on 2/7/11. The patient presented to the ED, on that date, with a chief complaint of, "vomiting'......drank half gallon of rum over past 12 hours." The patient who had an elevated blood alcohol level of 231 mg/dL at that time, had a final diagnosis of Acute and Chronic Alcoholism. During the course of treatment a nurse's note at 2:20 PM identified that " ......from Clara Martin here to talk with patient.." (the area's mental health agency). The patient was subsequently discharged to home, however there was no documentation of the evaluation by the mental health provider to reflect the decision for disposition at discharge.

Per interview on the afternoon of 2/14/11 the VP of the Hospital Division confirmed the documentation was not found in the records for Patients #9 and #16 and acknowledged that although this issue has been identified in the past, the mental health agency continues not to provide the consultative screening information and the hospital has been inconsistent with requesting the information at the time of the consultation
VIOLATION: QA - QUALITY OF PATIENT CARE Tag No: C0336
Based on staff interviews and record review the facility failed to identify and implement measures to improve quality and correct a previously identified deficient practice regarding documentation of consultative findings for patients presenting in the ED. Findings include:

Per review of medical records conducted on 2/9/11, 2/10/11 and 2/14/11 the medical records for 2 patients lacked documentation of consultative screenings conducted as part of the ED treatment and decision for discharge disposition for each of the respective patients. The following information was obtained:

1. Per record review on 2/14/11, Patient #9 presented to the Emergency Department (ED) on 1/10/11 expressing suicidal ideation with a plan to hang themselves. A request was made by the ED physician to have a psychiatric counselor come to the ED to evaluate and screen Patient #9 for admission to an inpatient psychiatric facility. A psychiatric social worker from a mental health agency came to the ED, evaluated Patient #9 and recommended the patient be transferred to an inpatient psychiatric unit. Arrangements were made and a transfer was facilitated. The results of the consultative screening, to reflect the decision to transfer the patient, was not found in the patient's record.

2. Per review, conducted on the morning of 2/14/11, the medical record for Patient #16 lacked documentation of the results of a mental health screening evaluation conducted in the ED (Emergency Department) on 2/7/11. The patient presented to the ED, on that date, with a chief complaint of, "vomiting'......drank half gallon of rum over past 12 hours." The patient who had an elevated blood alcohol level of 231 mg/dL at that time, had a final diagnosis of Acute and Chronic Alcoholism. During the course of treatment a nurse's note at 2:20 PM identified that " ......from Clara Martin here to talk with patient.." (the area's mental health agency). The patient was subsequently discharged to home, however there was no documentation of the evaluation by the mental health provider to reflect the decision for disposition at discharge.

Per interview on the afternoon of 2/14/11 the VP of the Hospital Division confirmed the documentation was not found in the records for Patients #9 and #16 and acknowledged that, although this issue had been identified by surveyors during the survey on 7/28/10, the mental health agency continues not to provide the consultative screening information and the hospital has been inconsistent with requesting the information at the time of the consultation