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Based on staff interview, review of employee files, and review of North Dakota Administrative Code (NDAC), the Critical Access Hospital (CAH) failed to comply with federal and state regulations to ensure current registration with the North Dakota Board of Nursing (NDBON) for 2 of 2 surgical technicians (#4 and #5). Failure to ensure unlicensed assistive persons are on the NDBON registry limited the CAH's ability to ensure staff were qualified to assist with patient care/procedures.

Findings include:

The NDAC 54-01-03-01 stated, ". . . 79. 'Technician' means an unlicensed assistive person who may perform limited nursing functions within the ordinary, customary, and usual roles in the person's field. Examples may include surgical and dialysis technicians and medical assistants. . . . 54-07-02-02.1. Unlicensed assistive person registry status. Unlicensed assistive persons who carry out delegated nursing interventions must hold current registry status either on the board registry or on another state registry recognized by the board.
. . ."

During an interview on the afternoon of 03/21/18, a director of surgery (#3) identified two surgical technicians (#4 and #5) utilized in the surgical department failed to register with the NDBON.

Review of the employee files showed no registration with the NDBON for both surgical technicians (#4 and #5).

During an interview on 03/21/18 at 3:30 p.m., an administrative nurse (#1) confirmed two surgical technicians (#4 and #5) lacked registration with the NDBON.

Based on observation, policy review, review of the North Dakota Administrative Code, and staff interview, the Critical Access Hospital (CAH) failed to limit access to the pharmacy in the absence of the pharmacist for 1 of 1 hospital pharmacy. This failure limited the CAH's ability to ensure administration of pharmaceutical services in accordance with accepted professional principles.

Findings include:

The North Dakota Administrative Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. 1. General. During such times a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance . . . for the provision of drugs . . . by use of night cabinets or floor stock, or both, and in emergency circumstances, by access to the pharmacy. . . . 3. Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section. . . ."

Review of the policy titled "Pharmacy Access" occurred on 03/20/18. This policy, revised June 2017, stated, ". . . Removal of any drug from the pharmacy by an authorized RN [registered nurse] must be recorded on the log showing date, time, patient name, room number, drug name, strength, amount taken, time dose needed, reason pulled and RN signature. . . . Pharmacy can only be accessed for the required medications and only the dose needed at that time. Medications cannot be signed out for later doses. 8. The sign out log will be monitored by the pharmacist weekly. . . ."

Observation on the afternoon of 03/20/18 showed the following inaccurate and incomplete entries in the "After Hour Sign Out Sheet:"
* "Date: [Blank], Time: 2100/0645 [9:00 p.m./6:45 a.m.], Patient Name: [Patient #1], Room #: 205, Drug: Risperidone, Dose: 0.5 mg [milligrams], Amount: 2, Time Dose Needed: [Blank], Reason Needed: None on floor, RN Sign: [Nurse initials]"
* "Date: [Blank], Time: 2100 [9:00 p.m.], Patient Name: [Patient #5], Room #: 204, Drug: Levothyroxine, Dose: 112 mg, Amount: 1, Time Dose Needed: [Blank], Reason Pulled: None on floor, RN Sign: [Nurse initials]"

A pharmacy technician (#4), interviewed during the observation, identified the following:
* The staff nurse failed to date the above two entries and document Time Dose Needed.
* The staff nurse failed to sign out one dose of risperidone at a time.
* The staff nurse signed out 2 doses of risperidone in one entry at two different times and changed the "Amount" column from 1 to 2.
* Patient #1 received one dose of risperidone on 03/17/18 at 8:40 p.m. and the other dose on 03/18/18 at 8:40 p.m.
* The pharmacy technician checked all weekend entries on Monday.
* Pharmacy staff failed to report the inaccuracy of the above entries.

The facility failed to review the pharmacy's "After Hour Sign Out Sheet" for completion and accuracy and to ensure nurses signed out only the dose needed at that time.

MULTIDOSE VIALS

1. Based on observation, policy review, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed professional standards for administration of medications in 1 of 1 Physical Therapy department. Failure to disinfect the rubber septum prior to withdrawing medication and to utilize a new syringe and needle each time staff drew up the medication placed patients receiving Iontophoresis (delivery of medication through the skin by electrical stimulation) at risk of contracting an infection.

Findings include:

The APIC (Association of Professionals in Infection Control and Epidemiology) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016), stated, ". . . MEDICATION VIALS . . . * Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial. * Always use a new sterile syringe and new needle/cannula when entering any vial. Never enter a vial with a syringe or needle/cannula that has been previously used. . . . * Use multidose medication vials for one patient whenever possible. . . . * Store and access multidose vials away from the immediate patient care environment and always use a sterile syringe and needle/cannula each time the vial is accessed.
. . ."

Review of the policy titled "EXPIRATION Dates of Pharmaceuticals" occurred on 03/20/18. This policy, revised June 2017, stated, ". . . If a Multi-dose vials has been opened or accessed (needle-puncture), it should be dated. . . . All Multi-dose vials will be dated and initialed when opened. . . ."

- Observation of the Physical Therapy department occurred on 03/20/18 at 9:00 a.m. with a physical therapist (PT) (#7). Observation of a cabinet in the therapy office showed two multi-dose vials of dexamethasone (cortisone) with puncture marks on the septums. The labels failed to identify the date staff first accessed the vials. Observation showed no alcohol wipes available to disinfect the septum prior to withdrawing the medication and no supply of needles and syringes in the cabinet. The PT (#7) confirmed staff use the dexamethasone during iontophoresis treatments and do not use a new needle and syringe to withdraw each dose.

DIETARY INFECTION CONTROL PRACTICES

2. Based on observation and staff interview, the Critial Access Hospital (CAH) failed to ensure staff used appropriate infection control practices when serving food for 1 of 2 meals observed (lunch on 03/20/18). Failure to follow infection control practices during meal service may result in the spread of a food borne illness within the hospital.

Findings include:

Observation of meal service occurred on 03/20/18 at at 11:30 a.m. and showed a dietary staff member (#8) in the kitchenette preparing to serve the meal. The staff member (#8) wore a hooded sweatshirt with stains on the front. The sweatshirt fit very loosely with the body of the shirt at mid-thigh level and the sleeves falling below the staff member's hands. During meal service the staff member used her gloved hands to push up the sleeves and continued to serve food without changing her gloves.

The staff member (#8) dropped a pen and a felt tip marker on the floor, picked them up with her gloved hands, and placed them in the sweatshirt pocket. Wearing the same gloves, the staff member (#8) opened the oven door, removed several plates from a shelf, and placed them in the oven. The staff member (#8) removed the felt tip marker (that had fallen to the floor) from her pocket, labeled milk cartons, then removed her gloves, washed her hands, and put on new gloves.

During an interview on 03/21/18 at 9:10 a.m., two administrative dietary staff members (#9 and #10) stated the staff member (#8) serving food on 03/20/28 should have removed her sweatshirt prior to serving food and should have removed her gloves and washed her hands after picking up items from the floor.

Based on observation, review of menus, policy review, and staff interview, the Critical Access Hospital (CAH) failed to follow recognized dietary practices during meal service for 1 of 2 meals observed (lunch on 03/20/18). Failure to provide serving sizes in accordance with the CAH menus may not provide the complete nutritional requirements for the patients.

Findings include:

Review of the policy titled "Portion Control" occurred on 03/21/18. The policy, dated 2008, stated, "Individuals will receive the appropriate portions of food as planned on the menu. Control at the point of service is necessary to assure that only the standard portion is served. . . . The menu should list the specific portion size for each food item. Menus should be posted at the tray line for staff to refer to for proper portioning of servings for each diet. . . ."

Observation of meal service, on 03/20/18 at 11:30 a.m., showed no menu posted at the tray line. Prior to beginning food service, the dietary staff member (#8) stated that a size 8 scoop equaled 1/2 cup. She stated the menu called for 3/4 cup of creamed chipped beef. She said she did not have a 3/4 cup scoop, so would use a size 8 which was 2/3 cup.
The dietary aide (#8) served the following inappropriate serving sizes:
* Brussels sprouts - size 6 scoop (2/3 cup) - menu stated 1/2 cup
* Chipped beef - size 8 scoop (1/2 cup) - menu stated 2/3 cup
* Spinach casserole - size 6 scoop (2/3 cup) - menu stated 1/2 cup
* The menu indicated patients should receive a dinner roll with the meal. The staff member (#8) failed to provide the dinner roll. Observation showed no dinner rolls available in the kitchenette.

During an interview on 03/21/18 at 9:10 a.m., two administrative dietary staff members (#9 and #10) confirmed the dietary aide (#8) did not follow the menu when serving lunch on 03/20/18 and stated they did not know why staff failed to provide the dinner roll for lunch on 03/20/18.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to assess and document the reason for and/or the effectiveness of medications given to patients on an as needed (PRN) basis for 2 of 4 observation patient records (#2 and #3) reviewed. Failure to evaluate the patient's response to PRN pain medications limited the nursing staffs' ability to assess whether the medication achieved the desired effect or if the patient experienced any side effects or adverse reactions from the medication.

Findings include:

- Review of Patient #2's observation medical record occurred on 03/20/18. Diagnosis included cellulitis of finger left hand. Pain medications included Tylenol 650 milligrams (mg) every 8 hours PRN (as needed). The record identified Patient #2 received Tylenol on 03/18/18 at 3:00 p.m. The record lacked a follow-up assessment of the medication's efficacy.

- Review of Patient #3's observation medical record occurred on 03/20/18. Diagnosis included chest pain. Pain medications included Ketorolac (nonsteroidal anti-inflammatory) 15 mg IV (intravenous) every 6 hours PRN. The record identified Patient #3 received Ketorolac on 03/19/18 at 12:56 p.m. The record lacked a follow-up assessment of the medication's efficacy.

During an interview on 03/21/18 at 3:55 p.m., an administrative nurse (#2) stated PRN medication should have follow-up documentation completed one hour after administration of the medication.

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the diagnosis and treatment furnished by 1 of 2 active medical staff physicians' (Provider #1) peer review records reviewed from 2017. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment provided by the physicians limited the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the policy "Professional Staff/Quality Improvement Peer Review & Occurrence Review Guidelines" occurred on 03/21/18. This policy, dated 12/07/07, failed to require evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH by a network hospital or QIO or equivalent for all physicians.

Upon request on 03/21/18, the CAH failed to provide evidence a network hospital or a QIO or equivalent evaluated the quality and appropriateness of the diagnosis and treatment furnished by Provider #1 in 2017.

During interview on 03/21/18 at approximately 3:30 p.m., an administrative staff member (#11) confirmed Provider #1 provided services to the CAH's patients and the CAH did not have a network hospital or QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment furnished by this physician in 2017.