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)
C0302 RECORDS SYSTEMS
CFR(s): 485.638(a)(2)

The records are legible, complete, accurately documented, readily accessible, and systematically organized.


This STANDARD is not met as evidenced by:
Based on staff interview and review of medical records and archived laboratory reports, the hospital failed to ensure 12 of 22 sample medical records (for patients #2, #4, #8, #9, #11 #12, #13, #14, #15, #18, #19, #20) were complete and accurate. Further, the hospital failed to implement a system to reliably detect medical record errors and initiate timely corrective actions. The findings were: 1. Medical record review revealed the following discrepancies: a. Two closed records (patients #11 and #13) failed to contain accurate discharge summaries. The record for patient #11 included a transcribed summary identifying the patient by name, demographic data, and hospital record number. However, the dictated summary was not consistent with the patient's clinical course or admission timeline. Detailed review of the laboratory results cited in the discharge summary did closely match the clinical course of another individual, patient #13, admitted two weeks prior to patient #11. Review of patient #13's record failed to uncover a discharge summary for an inpatient stay lasting January 5-14, 2011. b. A discrepancy was noted in the medical record for patient #19. A physician progress entry dated 1/17/11 noted the patient was placed on antibiotic therapy as a safeguard against possible Staphylococcus infection. The note further stated no cultures were necessary given the patient's condition. A subsequent progress note, entered by a different provider and dated 1/24/11, summarized the patient's diagnosis as "...MRSA [methicillin-resistant Staphylococcus aureus] positive Staph pneumonia..." Review of the record failed to uncover any evidence the patient was ever cultured or otherwise reported with a MRSA positive infection. Review of microbiology reports on 11/18/11 at 5:20 PM with laboratory technician #1 failed to show evidence patient #19 had a positive culture report in January 2011. The laboratory technician also called the reference laboratory and laboratories at the two closest medical centers to determine if the patient was cultured at any of these facilities prior to his/her admission; there were no records of specimens received from patient #19 at these facilities. c. The medical record for patient #20 failed to document vital signs during 4 of 4 blood transfusions performed on 10/16/11. Laboratory records showed emergency room staff ordered a total of 4 units of packed red blood cells (pRBC) be crossmatched for the patient. The first 2 units were released from the blood bank at 5:10 AM and 2 additional units were released at 7 AM. The medical record failed to include a record of vital signs for any of the 4 transfusion events. On 11/19/11 at 2:45 PM the CNO provided a copy of the hospital's policy and procedures for administration of blood products. According to the policy statement, staff are required to monitor and record patient vital signs (blood pressure, heart rate, temperature, patency and appearance of the infusion site) for each transfusion event. Vital signs are to be recorded prior to starting the transfusion, every 15 minutes for a half hour, every 30 minutes for the next hour, and at hourly intervals for the remainder of the transfusion. A final set of vital signs are required one hour after the transfusion is completed. The CNO stated her expectation that all nursing staff comply with the requirements to monitor and record vital signs with every transfusion event. d. The record for patient #8 contained health insurance and billing information for another patient. e. Refer to C297 for inaccuracies in medication administration for patients #2, #4, #9, #12, #14, #15, and #18. 2. Health information management clerk #1 stated in interview on 11/19/11 at 2:40 PM that the health information management supervisor retired and the vacancy was unfilled. She further stated the current staff reviewed medical records as their workload permitted, but they were not always able to review records in a timely manner. She acknowledged the errors and inaccuracies cited.