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Based on observation, staff interview and policy review, the facility failed to ensure that the premises were clean and orderly on two (2) of two (2) days of survey by not ensuring a sanitary environment to avoid sources and transmission of infections and communicable disease by not ensuring that the physical environment was maintained in a sanitary manner.


Findings include:


Observations on 12/14/11 from 11:35 a.m. until 11:52 a.m. and on 12/15/11 from 10:28 a.m. until 11:00 a.m. revealed the following:


1. Black colored substances were observed on three (3) ceiling vents and five (5) ceiling tile in the storage area, food preparation area and one (1) office space in the dietary department.

2. An accumulation of dust was noted in the vents of the ice machine and in the vents over the stove.

3. Paper pieces and chipped paint were noted on the floor area behind Cooler #1.
Three (3) ceiling tiles in the dietary department were cracked or broken.

4. Room #111 - Baseboard molding was not secured to the wall; paint was peeling from the wall behind the commode, and there was a pungent smelling odor in the bathroom.

5. Room #114 - Baseboard molding was not secured to the wall; the tissue holder was rusted, and there was a pungent odor in the bathroom.

6. Room #116 - Oxygen tubing was stored on the floor of the room; there were black colored stains on the floor tiles under the air conditioner vent, and there was a pungent smelling odor in the bathroom.

7. Room #122 - The wall area near the bathroom was cracked and plastered.

8. Black colored stains were observed on floor tiles in bathrooms in Rooms #115, #116, #122 and #128.

9. An accumulation of dust was noted in wall vents and or in on over beds lights in Rooms #105, #114 and #122.

10. An accumulation of dust was observed on the hallway ceiling vent near Room #124.

11. An accumulation of dust was observed on hallway ceiling tiles near Rooms #104/#106 and #120/#122.

Interview with the Dietary Manager on 12/14/11 at 11:52 a.m. and on 12/15/11 at 1:00 p.m. confirmed the findings listed in the dietary department.

Interview and observation on 12/15/11 from 10:28 a.m. until 11:00 a.m. with the Director of Housekeeping confirmed the listed findings through out the facility.

Based on review of the CAH's (Critical Access Hospital's) policies and procedures, review of Medical Staff Rules and Regulations, review of medical records, and staff interview the facility failed to ensure that records of discharged patients are completed promptly.

Findings include:

Review of the CAH's Medical Staff Rules and Regulations revealed the requirement that a medical record be completed within 15 days of discharge.


On December 13, 2011, at 2:30 p.m., a count of incomplete medical records in the practitioners' incomplete files revealed 38 medical records that were incomplete over 15 days. Some of these medical records dated back to May, 2010. Observation revealed medical records stacked on the desk of the Director of the Medical Record Department that had been pulled for review for CORE measures. Many of these records still had flags on them for signatures, and the deficiency slip as to what the record needed for completion. An interview with the Director of the Department at that time revealed that some of the records had been worked on, but had not been checked to see if they were complete. There were over 20 records stacked on the desk. Some of these records dated back a year.


17 discharged medical records were selected at random from a list of discharges from August 1, 2011, through November 30, 2011, and reviewed. 11 of the 17 medical records were incomplete.

Based on review of the CAH's (Critical Access Hospital's) policies and procedures, review of Medical Staff Rules and Regulations, and review of medical records, the facility failed to ensure that a history and physical examination is performed within 24 hours of admission and prior to a patient having outpatient surgery, and that the physician signs all history and physical exams performed by a nurse practitioner.

Findings include:

17 discharged medical records were selected at random from a list of discharges from August 1, 2011, through November 30, 2011, and reviewed along with two (2) inpatient medical records and the last five (5) patients discharged from the hospital on 12/12/11, for a total of 24 medical records. Also reviewed were nine (9) recent outpatient surgery records.
Review of these charts revealed:

1. One (1) of seven (7) current medical records reviewed had no documented evidence of the history and physical (H&P) examination.


2. Five (5) of nine (9) recent outpatient surgery records reviewed revealed that a history and physical examination had not been documented in the medical record prior to surgery.


3. Eight (8) of 17 discharged medical records reviewed revealed that the history and physical exam performed by the nurse practitioner had not been signed by the physician

Based on review of CAH's (Critical Access Hospital's) policies and procedures, review of Medical Staff Rules and Regulations, and review of medical records, the facility failed to ensure that all entries in the medical record were timed and were signed by the person making the entry.

Findings include:

17 discharged medical records were selected at random from a list of discharges from August 1, 2011, through November 30, 2011, and reviewed along with two (2) inpatient medical records and the last five (5) patients discharged from the hospital on 12/12/11, for a total of 24 medical records.

18 of 24 medical records reviewed revealed that all physician orders had not been timed when entered into the medical record. This included those orders written by the physician, nurse practitioner and physical therapist as well as those telephone orders taken by a nurse.


20 of 24 medical records reviewed revealed that all progress notes had not been timed when entered into the medical record.


Six (6) of 17 discharged medical records reviewed revealed that the history and physical (H&P) exam had not been signed by the nurse practitioner performing the H & P.


Nine (9) of nine (9) outpatient surgery records reviewed revealed that the pre-anesthesia evaluation had not been timed by the Certified Registered Nurse Anesthetist (CRNA) performing the evaluation.


Four (4) of 17 discharged medical records reviewed revealed that verbal orders had not been signed by the person responsible for the order within 24 hours.