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)
C0304 RECORDS SYSTEMS
CFR(s): 485.638(a)(4)(i)

For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient;


This STANDARD is not met as evidenced by:
Based on staff interview and review of medical records, the facility failed to ensure 3 of 3 sample patient records (#13, #20, and #21) involving blood transfusions had properly executed consents for transfusion. In addition, acknowledgements of privacy and information regarding emergency services were not timed or dated for sample patient #6. The findings were: 1. Of 3 medical records selected for review of blood transfusion documentation, all 3 (patients #13, #20, and #21) failed to include timed signatures to verify the patient's understanding of the transfusion procedure before it was initiated. These records were reviewed on 11/16/11 at 2:15 PM. Health information clerk #1 acknowledged in interview on 11/16/11 at 3:30 PM that consent forms should be signed and both the date and time annotated in the space provided on the consent form. She further stated it was the facility's policy to date and time signatures in the medical records. 2. Record review further showed that patient #6's signatures on the acknowledgements of privacy and information regarding emergency services were not dated or timed. Patient #6 had multiple visits to the emergency room and an inpatient admission within a 10 day period. It was not clear at what time or during which visit(s) the patient acknowledge the information contained on the privacy and emergency services forms.