Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 531311 (X3) Date Survey Completed 11/17/2011
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)
C0151 COMPLIANCE WITH FEDERAL LAWS & REGULATIONS
CFR(s): 485.608(a)

The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients.


This STANDARD is not met as evidenced by:
Based on medical record review, staff interview, and review of policies and procedures, the facility failed to obtain and/or implement advance directives for 3 of 20 sample patients (#2, #4, #9) with those directives in place. The findings were: 1. Medical record review showed patient #2 was admitted to swing bed status on 11/8/11 and unexpectedly passed away on 11/9/11. Review of the physician's 11/9/11 discharge summary showed the patient was improving and, on the morning of 11/9/11, the patient "began to eat [breakfast] at about 8:10 a.m...was found dead at 8:25 a.m." According to the "Advanced Directives, Living Will and/or Healthcare POA Status" form included in the medical record, the patient had a durable power of attorney (DPOA) that did not go into effect until the patient's supervising physician determined the patient lacked the capacity to make health decisions. At that time the patient's agent was authorized to make decisions according to the patient's "Durable Power Of Attorney for Health Care and Health Care Directive" and "in accordance with my other wishes to the extent known to my agent." In addition, the DPOA authorized any of the health care providers to "disclose and release my complete health records...to my agent." Review of the admission orders showed the physician wrote "DNR" (do not resuscitate) when the patient was admitted to swing bed status from acute care. However, there was no evidence this was the patient's wish; nor was there evidence the physician discussed the matter with the patient's power of attorney (POA). Furthermore, there was no evidence the POA had been notified by the supervising physician that the patient lacked the mental capacity to make health care decisions. On 11/15/11 at 2 PM the CNO confirmed the DNR order and lack of documentation that the POA had been notified. The CNO stated the patient was not DNR while in acute care. During an interview on 11/16/11 at 11:52 AM, the physician who wrote the DNR order stated "...someone..." on staff told her the patient was DNR in the past so she wrote the order based on that comment. According to the facility's policy and procedure entitled "Advance Directives", last revised 8/19/08, the attending physician "will incorporate the provisions of the advance directive into the patient medical treatment plan." 2. According to Policy #AC184, "Advance Directives", the employee processing the admission will ask the patient for a copy of the advance directive, which will become a permanent part of the patient's medical record. The policy also stated the attending physician will incorporate the provisions of the advance directive into the patient's medical treatment plan. Review of the 11/2/11 facility form entitled "Advanced Directives, Living Will and/or Healthcare POA Status" for patient #4 revealed staff indicated the patient had previously established his/her advance directive wishes. Interview with the DON on 11/14/11 at 3:15 PM revealed staff failed to obtain a copy of the advance directives for this patient. She further stated as soon as staff were aware of the existing advanced directive, they should have done the necessary follow up to obtain a copy and placed it in the patient's medical record. Review of the medical record for the patient showed that as of 11/17/11, a copy of his/her advance directives had not be placed in the medical record. Further review showed the provisions of the patient's advanced directives had not been incorporated into his/her medical treatment plan in accordance with the facility's policy. 3. Review of the facility's "Advanced Directives, Living Will and/or Healthcare POA Status" showed a copy of the directive for patient #9 had been placed in the active medical record. However, detailed review of the acute care record showed it was lacking. On 11/15/11 at 2 PM the CNO confirmed the directive was not in the record. She stated staff probably moved the directive to the swing bed record instead of copying it and leaving the original on the acute care record as was correct.