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Based on policy and procedure review and staff interview, the facility failed to carry out an evaluation of its total program at least once a year.


Findings include:


On 12/12/12 at 10:30 a.m. the Administrator stated that he could not find documentation that the facility had conducted an annual evaluation of its total program during the past year. There were no policies and procedures available to review for an annual evaluation specifying how the Critical Access Hospital is to conduct the evaluation, who is responsible for conducting the evaluation, and what information is to be included in the evaluation.

Based on policy and procedure review and staff interview, the facility failed to review the utilization of Critical Access Hospital (CAH) services, including the number of patients served and the volume of services as part of an annual evaluation.


Findings include:


Interview with the Administrator of the CAH on 12/12/12 at 10:30 a.m. revealed that he could not find documentation that the CAH had conducted an annual evaluation of its total program during the past year.

Based on review of the facility's policies and procedures and staff interview, the facility failed to ensure that the annual evaluation included a sample of both active and closed clinical records.


Findings include:


Interview with the Administrator of the CAH on 12/12/12 at 10:30 a.m. revealed that he could not find documentation that the CAH had conducted an annual evaluation of its total program during the past year.

Based on policy and procedure review and staff interview, the facility failed to ensure that health care policies were reviewed as part of an annual evaluation.


Findings include:


Interview with the Administrator of the CAH on 12/12/12 at 10:30 a.m. revealed that he could not find documentation that the CAH had conducted an annual evaluation of its total program during the past year.

Based on policy and procedure review and staff interview, the facility failed to ensure that a yearly program evaluation was conducted that determined whether utilization of services was appropriate, that established policies were followed, and if any changes were needed.


Findings include:


Interview with the Administrator of the CAH on 12/12/12 at 10:30 a.m. revealed that he could not find documentation that the CAH had conducted an annual evaluation of its total program during the past year.

Based on observation and record review, the facility failed to ensure that the department had adequate shelving for discharged records to be filed, and that all records were promptly completed and properly filed in a timely manner after patient discharge.


Findings include:


On 12/11/12 at 11:00.a.m. observation in the Medical Record Department revealed approximately 300 acute care medical records stacked on tables, and desks in the three (3) rooms that made up the department. Because of the lack of available filing space, the open shelf files were crammed so full that medical records were observed filed half in and half out on all the shelves. Some records on the lower shelves were basically out on the floor. A person could not walk between the two (2) rows of shelving in the main room of the department.


The medical records stacked on the tables and desks had deficiency tags on them, and after reviewing these records at random, it appeared that the majority of these records had been completed by the physician, but had not been checked by medical record personnel to verify that the records were complete. These records dated back to the end of 2011.


Swing bed records were found in boxes in the third (3rd) room of the department. After reviewing several of these records at random, it was determined that these records were also incomplete. These records also dated back to the end of 2011, and had not been tagged for deficiencies.


Twenty (20) discharged records were selected at random from a list of discharges from May 1, 2012 through November 30, 2012 and reviewed along with four (4) current inpatient medical records for a total of 24 records reviewed. Fourteen (14) of the 20 discharged medical records reviewed, were found to be incomplete as to dictation and signatures.


Approximately 150 incomplete geriatric psychiatric medical records were also found in the third room of the department. These dated back to January, 2011. Many of these records had not been tagged for deficiencies.


Because of the manner in which discharged medical records were found, an accurate count could not be made of incomplete discharge records over 30 days after discharge.

Based on review of medical records, the Critical Access Hospital (CAH) failed to ensure that all entries in 24 of 24 medical records reviewed had been timed and dated.


Finding include:


Twenty (20) discharged records were selected at random from a list of discharges from May 1, 2012 through November 30, 2012 and reviewed along with four (4) current inpatient medical records for a total of 24 records reviewed.


All entries in 24 of 24 medical records reviewed had not been timed. This included history and physical examinations, physician progress notes, and physician orders. The orders not timed included those written by the physician, and in some instances verbal orders taken by a nurse. On four (4) of 24 medical records reviewed, the history and physical had not been dated.

Based on review of medical records and observation, the Critical Access Hospital (CAH) failed to ensure that medical records belonging to patients from the Senior Care Unit were protected from unauthorized use by being maintained and filed separate from other hospital medical records.
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Findings include:


Observation on 12/12/2012 revealed discharged medical records from the Senior Care Unit housed on open shelf files in the third (3rd) room of the Medical Record Department. Incomplete Geriatric Psychiatric medical records were found on an open shelf file and stacked on tables in this room.


On 12/12/12 at 11:15 a.m. the CAH's medical records in storage were observed to be filed at a locked off-site location on open shelf files and in boxes. Some of the boxes had split open and records had spilled out onto the floor. Both Geriatric Psychiatric medical records and acute care medical records were stored in this room together in no systematic order.




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