Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 531311	(X3) Date Survey Completed 04/28/2022
Name of Provider or Supplier Crook County Hospital	Street Address, City, State 713 Oak Street, Sundance, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
C0000	A recertification survey was conducted by Healthcare Licensing and Surveys from 4/25/22 to 4/28/22. Also reviewed in the course of the survey was complaint intake WY00003241. In addition, a review for compliance with the Omnibus COVID-19 Health Care Staff Vaccination requirements was conducted. It was determined, based upon the findings of the survey team, that no deficiencies were identified pertaining to these requirements. The following common abbreviations are used throughout this document: CNA- Certified Nurse Aide DNS- Director of Nursing Services Less commonly used abbreviations will be annotated in each deficiency.
C1008	PATIENT CARE POLICIES §485.635(a)(2) The policies are developed with the advice of members of the CAH's professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This STANDARD is not met as evidenced by: Based on policy and procedure review, staff interview, and medical staff meeting minutes review, the facility failed to ensure policies were reviewed every 2 years in a variety of areas (dietary, emergency, acute care). The findings were: 1. Review of the 1/25/22 medical staff meeting minutes showed the facility had an organized medical staff team. The following concerns were identified: a. Review of the 1/25/22 medical staff meeting minutes showed no documentation regarding review of facility policies and procedures. b. Review of facility policies and procedures revealed the following policies were not reviewed at least every 2 years: "Heparin (Thromboembolism)" effective 11/21/19 and last reviewed 11/21/19, "EMTALA Guideline" effective and last reviewed 12/18/18, "Trauma Activation Patient Guideline" effective and last reviewed 3/21/19, "Employee Health-Infection Control" effective and last reviewed 1/23/19, "OSHA Exposure to Blood borne Pathogens Standard" effective and last reviewed 8/1/16, "Discharge Planning" last reviewed 8/19/08, and with 1 exception ("Diet/Nutrition Care Manual"approved March 2022) the dietary policies in the electronic system had review dates of 2018 and 2019. c. Interview with the DNS on 4/27/22 at 1:38 PM confirmed the policies were not all up to date or reviewed every two years. The process was to have each department include their policies in an electronic program to then be revised, reviewed and retrieved as needed. The DNS verified there was not a specific committee that reviewed hospital policies, instead there was a policy review approval workflow that showed who reviewed each department's policies for approval. She also confirmed the Acute Care policies were out of date and had not yet been included in the electronic program for review. d. Review of the undated policy approval workflow information showed the Acute Care policies were managed by the DNS and reviewed and approved by the medical director; Emergency Department policies were managed by the DNS and the ED director and were reviewed and approved by the medical director. The Dietary policies were managed by the dietary supervisor and the dietitian, there was no one included to further review or approve these policies.
C1056	PATIENT VISITATION RIGHTS §485.635(f) Standard: Patient visitation rights. A CAH must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the CAH may need to place on such rights and the reasons for the clinical restriction or limitation. A CAH must meet the following requirements: (1) Inform each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, in advance of furnishing patient care whenever possible. (2) Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. This STANDARD is not met as evidenced by: Based on medical record review, staff interview, and policy review, the facility failed to ensure policies and procedures were documented to address the visitation rights for 20 of 20 inpatient sample records (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #20, #21). The findings were: Review of the medical records sample patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #20, #21 which included 5 current patients who were in swing bed status showed a lack of evidence they were provided information on patient visitation rights. The following concerns were identified: a. Review of the medical records for the 20 sample patients revealed there was no documentation regarding patient visitation rights in the medical record. b. Review of the facility policies and procedures showed the facility had no policy to address patient visitation rights. c. Interview with the DNS on 4/28/22 at 9 AM confirmed the facility failed to formulate a policy regarding patient visitation rights. She further stated there was no documentation in the medical record to show patients were informed of their visitation rights, and she confirmed no documentation regarding patient visitation was provided to patients or families. She stated her expectation was for staff to inform patients of their visitation rights upon admission.
C1404	DISCHARGE PLANNING PROCESS The CAH's discharge planning process must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient's representative, or patient's physician. This STANDARD is not met as evidenced by: Based on medical record review, staff interview, review of the facility strategic plan, and review of policy and procedures, the facility failed to implement a process to identify patient risk and needs for discharge planning at an early stage of hospitalization. The process was lacking for a sample of 20 inpatient records (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #20, #21). The findings were: 1. Review of the medical records showed a lack of discharge planning documentation for the following inpatients who were admitted/discharged within the past year: #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, #15, #16, #17, #18, #19, #20, #21. 2. Interview with the DNS on 4/27/22 at 12 PM revealed there was an open position for a discharge planner. There was a CNA/Activity aide who was helping out with discharge planning to the extent possible and the medical records were lacking any initial screening to identify discharge planning needs. She further confirmed the information related to post-acute care needs and resource information was not always documented in the medical records. Many times the information was documented in emails between the staff. 3. Review of the policy and procedures for discharge planning showed it was last revised August 19, 2008. The policy showed the facility "...will identify at an early state of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate Discharge Plan." The policy included the need for social services, director of nursing or other appropriately qualified staff to conduct the discharge planning and for the discharge planning form to be completed "on a timely basis so appropriate arrangements for post hospital care are made before discharge and to avoid unnecessary delays in discharge." The policy further showed the facility "...will include the Discharge Planning Form in the patient's medical record..." and "...Advanced Directives Forms and Home Health/Hospice Agency Referral Forms will be discussed with the patient or the person acting on the patient's behalf..." 4. Review of the June 2021 Strategic Plan showed developing a discharge planning process was included. Review of the February 10, 2022 Manager Meeting Minutes showed the position for a "care manager" had been posted. The plan was to have the position filled and then do further work on the discharge planning process.
C1626	NUTRITION Nutrition (§483.25(g)(1) and (g)(2) of this chapter). " §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- (1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; (2) Is offered sufficient fluid intake to maintain proper hydration and health. This STANDARD is not met as evidenced by: Based on review of patient records, policy review, and staff interview, the facility failed to ensure a registered dietitian (RD) was utilized by the facility to provide dietetic services and assess nutritional needs of the patients. The census was 5. The findings were: 1. Interview with the dietary supervisor on 4/26/22 at 2 PM revealed there was not currently an RD available for the facility. She stated she was in the process of completing a course to become a certified dietary manager and had an expected graduation date of January 2023. When asked about the department policies and the diet manual, the dietary supervisor was not familiar or aware of how these items were updated or reviewed. Review of the menus showed there were planned diets including Diabetic, Cardiac, 2 gram sodium (low sodium), finger foods and mechanically altered diets. The following concerns were identified: a. Interview with the DNS on 4/27/22 at 4:10 PM verified there was not any documentation to show a nutritional screen or assessment was completed for the current Swing Bed patients (#1, #2, #3, #5, #6). Further she confirmed there was not an RD available, however, there was a plan for a new graduate to start in June 2022. Additionally, the facility was working on contracting with an RD from another state who was in the process of seeking Wyoming licensure. The DNS was unaware of how long it would be for this contract to be in place. b. Review of the 4/22/22 physician history and physical for patient #5 showed the plan to address the diagnoses of Type 2 diabetes, hyperlipidemia, and essential hypertension included an order for an 1800 -calorie ADA (American Diabetes Association) diet, 2 gram sodium diet. c. Review of the 4/20/22 physician admission orders showed patient #3 had orders for a "Cardiac Diet." 2. Review of the Dietary department policies and the Acute Care/Swing Bed policies showed the following concerns: a. There was no policy or procedure on how nutritional assessments would be completed. In addition, there was nothing in place to identify the need for an RD to be utilized as the diet/nutrition professional. b. Review of the policies in the electronic program showed the only current policy was for the "Diet/Nutrition Care Manual" this was dated as last approved March 2022. However, review of this policy showed it was not specific to which manual was to be utilized, and did not address the need for approval by the medical staff who ordered therapeutic diets. c. The remainder of the dietary policies in the system had review dates of 2018 and 2019.