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Based on record review, review of Medical Staff Rules and Regulations, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the emergency department (ED) record maintained documentation of the on call provider's initial notification and/or arrival/respond time to the ED for 6 of 11 closed ED records (Patient #14, #16, #17, #18, #22, and #23) reviewed. Failure to document the time staff notified the on call provider of a patient's arrival to the ED and failure to document the time the on call provider arrived to the ED, does not ensure the on call provider is available at the ED within the required timeframe.

Findings include:

Review of the CAH's Medical Staff Rules and Regulations occurred on May 07-09, 2012. This document, approved on 07/24/04, and revised on 12/19/08, stated, " . . . 3. For all Medial Staff personnel required to serve as emergency room practitioners as defined in the Medical Staff Bylaws, specific maximum response time limit must be twenty (20) minutes or less . . . ."

Review of the CAH policy titled, "Admitting Patient to Emergency Room" occurred on 05/09/12. This policy dated 11/2011, stated, " . . . PROCEDURE: . . . B. Document time provider was called and the time he/she arrived . . . ."

Review of Patient #14, #16, #17, #18, #22, and #23's ED records occurred on May 08-09, 2012. Review of the above ED records lacked documentation by the CAH ED staff of the time staff informed/notified the on call provider of a patient's arrival to the ED and the time the on call provider arrived at the ED.

During an interview on 05/08/12 at approximately 4:00 p.m., a nursing administrative staff member (#2) stated she expected the on call provider to respond to the ED within 20 minutes of being notified by the ED nursing staff. Administrative nursing staff member (#2) confirmed Patient #14, #16, #17, #18, #22, and #23's ED records lack evidence of the time ED nursing staff members initially contacted the on call provider of a patient's presentation to the ED and the time the on call provider actually arrived to the ED.

Based on review of bylaws and meeting minutes, review of agreements, review of credentialing files, and staff interview, the Critical Access Hospital (CAH) failed to appoint a Medical Director for 8 of 12 months (April 2011 through March 2012) reviewed, failed to ensure the complete credentialing of 2 of 2 family nurse practitioners (Practitioner #1 and #2) prior to reappointment, and failed to accurately credential 1 of 1 physician identified as a locum tenens (Practitioner #3). Failure to establish a Medical Director of the Medical Staff, failure to appoint/reappoint without all required information to determine qualifications, and failure to accurately credential a physician could compromise the care provided within the CAH, result in the lack of availability of needed services, and does not ensure practitioners' qualifications and competency to practice at the CAH.

Findings include:

Review of medical staff bylaws occurred May 7-9, 2012. The bylaws, approved 07/24/04, and revised on 12/19/08, stated, "Medical Staff Bylaws . . .
ARTICLE III. CATEGORIES OF THE MEDICAL STAFF
The Medical Staff shall be divided in active, consulting and locum tenens categories.
A. The active Medical Staff shall consist of providers who are located closely enough to the hospitals to provide continuous care of their patients, and who assume all the functions and responsibilities of membership on the active Medical Staff, including where appropriate, emergency service care and consultation assignments and granted privileges as requested . . . shall be eligible to vote, to hold office, and to serve on Medical Staff committees, and expected to attend Medical Staff meetings. . . .
C. The locum tenens Medical staff are those who are not regularly employed by the hospital and who do not live in the local community and work only for a specifically designated time periods . . . are not eligible to vote or hold office in the Medical staff organization. . . .
ARTICLE VIII: APPLICATION FOR MEMBERSHIP & PRIVILEGES
Applications for membership . . . shall be in writing . . . for medical staff request for appointment and privileges. . . . I. . . . DEA [drug enforcement agency] license will be included and copies will be obtained for provider records . . .
ARTICLE IX: APPOINTMENT PROCESS
A. The completed applications shall be submitted to the administrator . . . who shall after collecting references and other materials deemed pertinent, transmit the application and all supporting materials to the credential committee . . . The credential committee shall review and they will then make a recommendation, in writing as to approval . . .
B. The application will be then transmitted to the active staff for their recommendation to then be presented to the advisory by the Administrator.
C. The Advisory Board shall then make an appointment decision in agreement with the Credentialing committee . . . It shall be the hospital's policy to credential all medical staff including the mid-levels (FNP/PA) [family nurse practitioners/physician assistants] . . ."
ARTICLE XII. OFFICERS . . . The officers of the Medical Staff shall be: 1. Chair - Medical Director 2. Vice Chair B. Qualifications of Officers, Officers must be members of the active Medical Staff . . . Only the active Medical Staff shall be eligible to vote. . . . The Medical Director shall serve as the chief administrative officer of the Medical Staff . . ."

An amendment to the medical staff bylaws regarding the appointment process and terms occurred on 12/19/08, which stated:
"ARTICLE IX & X: APPOINTMENT PROCESS & TERMS OF APPOINTMENT & REAPPOINTMENT
Appointment/reappointment to medical staff will be conducted in conjunction with the Administrative credentialing department at [network hospital]. In order to provide credentialing for Kenmare Hospital the credentialing committee will utilize the system developed by our parent organization. All records for physicians/mid levels will be shared in order to provide paperwork needed in the credentialing process."

Review of the "Bylaws of the Advisory Board" occurred on 05/07/12. The bylaws, dated June 2004, stated,
". . . Responsibilities: The Advisory Board shall be delegated the responsibility by the Board of Directors for the functions . . . subject to Corporate policies and these Bylaws. 3.9a. Medical Staff appointments and reappointments, and the granting of staff privileges following recommendations of the current Medical Staff. . . ."

Review of the CAH's Rural Health Network Agreement occurred on 05/09/12. The Agreement, dated October 2007, stated,
". . . Credentialing:
l.l [Network hospital] shall provide credential verification services to CAH according to prevailing health care organizations accreditation standards, for all physicians and health care professional ("Professional (s)") who have been credentialed by [network hospital] for medical staff membership and clinical privileges at [network hospital] and who are seeking the initiation or renewals of medical staff privileges at CAH, in order to provide periodic professional services at CAH . . . [network hospital] shall have the right and responsibility for the initiation or denial of membership or clinical privileges at CAH to any Professional, which decision shall be the sole right and responsibility of CAH. . . ."
1.2 [Network hospital] service shall include: . . . other items relevant to Professionals' credentials and qualifications . . ."

A list of Medical and Professional Staff, dated 05/07/12, provided by an administrative staff member (#1) on the afternoon of 05/07/12, showed a locum tenens physician (#3) (a physician who temporarily fulfills the duties of another physician) as the only medical physician capable of supervising the family nurse practitioners for patient's in the emergency department/ inpatient and outpatient department. The list identified one other active physician as a dentist (#4).

During an interview with the administrative staff member (#1) on the afternoon of 05/07/12, the staff member stated the locum tenens physician (#3) is acting as the Medical Director of the CAH.

Review of the last year's (April 2011 through March 2012) medical staff meeting minutes and board advisory meeting minutes occurred on the afternoon of 05/07/12. The medical staff meeting minutes showed a nurse practitioner (#1), an active member of the medical and professional staff at the CAH, chaired all meetings beginning in August of 2011. The minutes lacked evidence the CAH appointed Physician (#3) as the new Medical Director.

During interview on the afternoon of 05/07/12, an administrative staff member (#1) stated the CAH failed to appoint a medical director. According to the CAH's medical staff bylaws, a locum tenens physician is not eligible for Medical Director duties.

- Review of individual practitioner credential files occurred on the morning of 05/09/12 and showed the following:

- The credential file of Practitioner #1 lacked signed and dated Medical Staff approval and Governing Body approval documentation. The credentialing file showed a re-appointment occurred for the time period from February 28, 2011 through January 31, 2013.

- The credential file of Practitioner #2 lacked evidence of a current DEA license. The credentialing file showed a re-appointment for February 28, 2011 through January 31, 2013.

- A list of Medical and Professional Staff, dated 05/07/12, provided by an administrative staff member (#1) on the afternoon of 05/07/12, identified Practitioner #3 as a locum tenens at the CAH. The credential file of Practitioner #3 identified the practitioner credentialed as active staff at the network hospital. The facility failed to accurately credential Practitioner #3 for the CAH services provided.

Based on review of the Medical Staff bylaws and meeting minutes, record review and staff interview, the Critical Access Hospital (CAH) failed to disclose the name and address of the person responsible for medical direction, and the absence of a medical director, to the State agency the past 8 of 12 months (August 2011 through March 2012). Failure to disclose to the State agency the name of the medical director, and appoint, a Medical Director has the potential to affect continuity of care, and adversely affect patient care.

Findings include:

Review of the CAH's current Medical Staff Bylaws occurred on the afternoon of 05/07/12. The bylaws, approved 07/22/04, revised 12/19/08, stated, ". . . ARTICLE III. CATEGORIES OF THE MEDICAL STAFF . . . C. The locum tenens Medical staff are those who are not regularly employed by the hospital or who do not live in the local community and work only for a specifically designated time periods . . . are not eligible to vote or hold office in the Medical Staff organization. . . . ARTICLE XII. OFFICERS . . . The officers of the Medical Staff shall be: 1. Chair - Medical Director 2. Vice Chair B. Qualifications of Officers, Officers must be members of the active Medical Staff . . . Only the active Medical Staff shall be eligible to vote. . . . The Medical Director shall serve as the chief administrative officer of the Medical Staff . . ."

A list of Medical and Professional Staff, dated 05/07/12, provided by an administrative staff member (#1) on the afternoon of 05/07/12, showed a locum tenens physician (#3) as the only medical physician capable of supervising the family nurse practitioners for patient's in the emergency department/ inpatient and outpatient department. According to the CAH's medical staff bylaws, a locum tenens physician is not eligible to be Medical Director. The list identified one other active physician as a dentist (#4).

During an interview with the administrative staff member (#1) on the afternoon of 05/07/12, the staff member stated the locum tenens physician (#3) is the acting Medical Director. The staff member stated the locum tenens provided services at the CAH on average seven days a month.

Review of the last years (April 2011 through March 2012) medical staff meeting minutes and board advisory meeting minutes occurred on the afternoon of 05/07/12. The medical staff meeting minutes showed a nurse practitioner (#1) (granted Active staff designation at the CAH) chaired the meetings beginning in August of 2011.

During interview on the morning of 05/09/12, an administrative staff member (#1) stated mid-level providers can call the network hospital emergency room physician for medical direction when the locum tenens physician (#3) is unavailable.

During interview on the afternoon of 05/09/12, an administrative staff member (#1) stated the CAH lacked a policy or procedure to notify the State agency when the person responsible for medical direction changes. The CAH failed to ensure the appointment of a Medical Director.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure a doctor of medicine or osteopathy periodically reviewed and signed the records of all inpatients cared for by Allied Health Professionals (AHP) (nurse practitioners, clinical nurse specialists, certified nurse midwives, or physician assistants) for 1 of 1 closed inpatient record (Patient #8) reviewed. Failure to periodically review and sign records of inpatients cared for by the AHP limited the CAH's ability to ensure the quality and appropriateness of patient care provided by the AHPs.

Findings include:

On the afternoon of 05/07/12, the CAH provided the survey team with a list of all inpatient/acute admissions from November 2011-April 2012. Review of this list identified one acute admission (Patient #8) from 11/08/11.

Patient #8's medical record identified an AHP admitted this patient to the CAH with diagnosis of cellulitis of right upper arm, leukocytosis, hyperkalemia, chronic kidney disease, and anemia. Review of Patient #8's medical record lacked evidence a physician reviewed and signed this record.

During interview on 05/09/12 at 8:15 a.m., an administrative nurse (#2) failed to provide evidence of the physician review for Patient #8's inpatient stay dated 11/08/11.

Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff dispensed medication in accordance with a provider's medication order for 1 of 1 active swing bed patient (Patient #3) observed receiving a medication during medication pass which did not match the provider's order. The failure of staff to dispense the correct medication upon a provider's order resulted in Patient #3 receiving the wrong type of medication over the past two years.

Findings include:

Observation during medication pass on 05/08/12 at 12:00 p.m., showed a staff nurse (#10) standing at the medication cart in the patient dining room preparing to administer potassium chloride (KCL) capsules to Patient #3. Review of Patient #3's medication administration record (MAR) showed, "KCL Sprinkles 20 meq [miliequivalents] po [by mouth] TID [three times a day] [with] meals". The nurse (#10) picked up the KCL medication bottle which read, "Potassium CL [chloride] ER [extended release] 10 meq [two] po", placed two KCL ER capsules into a medication cup, opened the capsules and poured the contents of the capsules (small granules) out into the medication cup, added applesauce to the contents in the medication cup and mixed all together, and then administered the medication and applesauce to Patient #3.

Review of Patient #3's active swing bed record occurred on 05/09/12 and identified a provider order, dated 03/25/10 at 9:15 a.m., which stated, "[increase] KCL 20 meq sprinkles po tid [with] meals . . ." The record showed this order still in effect as the most recent provider order, dated 04/17/12, stated, "KCL Sprinkles 20 meq TID [with] meals".

During a telephone interview on 05/09/12 at 11:50 a.m., a pharmacist (#18) stated she did not recognize the term "sprinkles" or know what the term referred to, and confirmed the contents of the extended release KCL capsules remained extended release when poured out and administered outside of the capsule. The pharmacist (#18) stated KCL comes in tablet or capsule form, varies in strengths, and can be administered for immediate or extended release.

During a telephone interview on 05/09/12 at 1:45 p.m., a consulting pharmacist (#19) stated the term "sprinkles" referred to a medication contained in a packet consisting of a powder or crystal substance which can be poured out and mixed with fluid or food for administration. The pharmacist (#19) stated KCL is available in immediate or extended release and stated staff must confirm questions about a medication order with the provider who wrote the order.

The pharmacy staff dispensed extended release KCL to Patient #3 despite the provider order which indicated administration of immediate release KCL. The pharmacy staff also dispensed capsules of KCL to Patient #3 despite the provider order which indicated administration of sprinkles of KCL. Record review lacked evidence pharmacy staff questioned or clarified the provider order regarding sprinkles, capsules, immediate or extended release. Failure to ensure staff followed provider orders and dispensed correct medications has the potential for patient's to receive the wrong medication dose, strength, frequency, route and/or the wrong medication all together.

1. Based on observation, review of professional literature, policy and procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care relating to infection control practices during observations of patient care, administration of medications, disposal of trash, and equipment cleaning/disinfecting on two of three days of survey (May 07-08, 2012). Failure to follow established infection control practices may allow transmission of organisms and pathogens from patients to staff, to other patients, or to visitors, and from one environment to another.

Findings include:

The Centers for Disease Control and Prevention's (CDC) publication titled "Guideline for Hand Hygiene in Health-Care Settings," issued on 10/25/02, stated, ". . . Recommendations: 1. Indications for handwashing and hand antisepsis . . . F. Decontaminate hands after contact with a patient's intact skin . . . G. Decontaminate hands after contact with body fluids or excretions, mucous membranes . . . I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . . . J. Decontaminate hands after removing gloves . . . 2. Hand-hygiene technique: A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry . . . 6. Other Aspects of Hand Hygiene . . . D. Remove gloves after caring for a patient. . . ."

The CDC's publication titled "Guidelines for Environmental Infection Control in Health-Care Facilities", issued on 06/06/03, stated, ". . . inadvertent exposures to environmental pathogens . . . or airborne pathogens . . . can result in adverse patient outcomes and cause illness among health-care workers. Environmental infection-control strategies . . . can effectively prevent these infections. The incidence of health-care-associated infections . . . can be minimized by 1) appropriate use of cleaners and disinfectants . . . I. Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas: A. Select EPA-registered disinfectants . . . and use them in accordance with the manufacturer's instructions . . ."

Review of the policy "Isolation Precautions" occurred on 05/09/12. This policy, revised October 2010, stated, ". . . The most important tier is 'Standard Precautions' designed for the care of all patients regardless of diagnoses or infection status. . . . All personnel are responsible to comply with Standard Precautions . . . 1. Standard Precautions: Precautions apply to: 1) blood, 2) all body fluids, secretions and excretions . . . regardless of whether there is visible blood . . . and 4) mucous membranes. . . . Standard precautions will apply to all patients at all times and are designed to prevent transmission of antibiotic resistant organisms from unrecognized sources. A. Hand Hygiene: Wash hands after touching . . . body fluids . . . excretions, and contaminated items, regardless of whether gloves are worn. Wash hands after gloves are removed when worn for care activities . . . and when otherwise indicated to avoid transfer of microorganisms to other patients/residents or environments. It may be necessary to wash hands between tasks and procedures on the same patient/resident to prevent cross contamination . . . B. Gloves: Wear gloves . . . when touching . . . body fluids . . . excretions and contaminated items. . . . Change gloves between tasks and procedures on the same patient/resident or after contact with materials that may contain a high concentration of microorganisms. Remove gloves after use for care activities, before touching non-contaminated items and environmental surfaces . . ."

Review of the policy "Hand Washing/Hand Hygiene" occurred on 05/09/12. This policy, revised November 2011, stated, ". . . Hand washing has long been considered the most important measure to prevent the transmission of disease causing microorganisms. Hand hygiene refers to the acceptability of waterless hand antiseptics for routine use when hands are not visibly soiled. . . . Soap and water washing is always required after contact of hands with gross body fluids or substances. . . . When is hand hygiene required: Because of the increase incidence of antibiotic resistant organisms in healthcare facilities and more recently in the community, we need to consider that all residents and personnel could be 'colonized' and so hand hygiene has become increasingly important to prevent transmission in the facility. . . . After: . . . 3. After handling trash . . . 4. After removing gloves. 5. After contact with resident. 6. After contact with environment. . . . 8. After handling any contaminated materials . . . 11. After contact with a 'dirty' body site - before contact with another body site. (Removal of gloves may be adequate). . . . Waterless hand antiseptic: . . . Apply sufficient amount to wet hands thoroughly. Rub hands together, covering entire surface . . . Allow to dry. . . ."

Review of the policy "Gloves" occurred on 05/09/12. This policy, reviewed November 2011, stated, "PURPOSE: To prevent transfer of contaminants from one area to another. . . . 2. Hands are to be washed using proper hand washing techniques prior to and immediately after the use of gloves. . . ."

Review of the policy "Infection Control Barriers (Gloves, Gowns, Masks)" occurred on 05/09/12. This policy, reviewed February 2011, stated, ". . . 2) Removing the gown: a) Untie the waist tie. b) Wash your hands. c) Untie the neckties. d) Grasp the neck fastener or the inside of the gown at the shoulder area. Bring the neck of the gown forward and draw it over your arms and hands. e) Hold your arms away from your body and fold the gown . . . inward and rolled into a bundle. . . . h) Wash your hands or use waterless hand antiseptic. . . . Procedure for Removing Barriers and Leaving an Isolation Room . . . 5) Remove the gloves. 6) Wash your hands. . . . 8) Untie your gown, remove it and discard . . . 9) Use gloves to take the . . . garbage to the carts. Avoid having the bags touch your clothing. 10) Remove gloves and wash your hands or use waterless hand antiseptic. . . ."

Review of the policy "Hazardous Communication" occurred on 05/09/12. This policy, revised 02/14/01, stated, ". . . Original chemical product containers or packaging containing hazardous chemicals will be labeled with the following information: Trade name or chemical name of the hazardous substance. Name and address of the chemical product manufacturer. Appropriate hazard warnings in the form of words, pictures, or symbols that convey the hazard of the substance in the container. . . . All containers should have the name of the material, appropriate hazard warnings . . ."

- The following observations showed staff failed to perform proper hand hygiene; failed to perform hand hygiene or hand washing after peri-cares, after removing gloves, and prior to moving onto other tasks; and failed to remove an isolation gown according to facility policy:
*Observation on 05/07/12 at 2:30 p.m. showed two nursing staff members (#3 and #4) entered Patient #2's room, used hand sanitizer, donned gloves, and removed the patient's soiled brief. One nursing staff member (#3) cleansed Patient #2's peri-area of urine with a wipe, turned the patient to her side, cleansed a smear of stool from the patient's buttocks, threw the soiled brief and wipes in the garbage, and removed gloves. The staff member (#3) applied hand sanitizer and placed gloves, failing to thoroughly rub the hand sanitizer all over her hands and allow the sanitizer to dry prior to placing new gloves (observation showed hand sanitizer foam remained on the nursing staff member's hands when new gloves placed). The nursing staff member (#3) placed a new brief on Patient #2, removed gloves, continued to dress and transfer the patient to the geri-chair, removed the garbage, and left the patient's room. Observation showed the nursing staff member (#3) failed to perform proper hand hygiene or hand washing after performing peri-cares and removing gloves, prior to moving onto other tasks and leaving Patient #2's room.
*Observation on 05/07/12 at 2:45 p.m. showed two nursing staff members (#3 and #5) entered Patient #25's room, used hand sanitizer, donned gown and gloves, and assisted the patient to the toilet in the bathroom. Patient #25 voided in the toilet and when finished, the two nursing staff members (#3 and #5) assisted the patient to stand. One nursing staff member (#5) cleansed Patient #25's peri-area of urine, opened the bathroom door and left the bathroom to obtain an incontinence pad from the bedside stand, returned to the bathroom and closed the door, pulled up the patient's pad and pants, flushed the toilet, and assisted the patient to the wheelchair. The staff member (#5) removed the gait belt from Patient #25, adjusted the patient's legs in the wheelchair, and opened the door to the bathroom. He then removed his gloves, grasped the waist area of the gown and tugged it loose, untied the necktie of the gown, removed the gown, and washed his hands. The nursing staff member (#5) failed to remove the isolation gown according to the CAH policy and failed to perform hand hygiene or hand washing after performing peri-cares and prior to moving onto other tasks.
*Observation on 05/08/12 at 9:15 a.m. showed two nursing staff members (#6 and #7) entered Patient #2's room, washed hands, donned gloves, assisted the patient to bed with a hoyer lift, and removed the patient's soiled brief. One nursing staff member (#7) cleansed Patient #2's peri-area of urine with a wipe, turned the patient to her side, cleansed a smear of stool from the patient's buttocks, threw the soiled brief and wipes in the garbage, removed gloves, and immediately placed new gloves. The nursing staff members (#6 and #7) placed a new brief on Patient #2, removed gloves, pulled up the patient's pants, and continued to situate the patient in bed. The staff members (#6 and #7) replaced the garbage and washed their hands in the patient's room. Observation showed the nursing staff member (#7) failed to perform hand hygiene or hand washing after performing peri-cares and removing gloves, prior to placing new gloves and moving onto other tasks.
*Observation on 05/08/12 at 9:35 a.m. showed a nursing staff member (#7) disposed of garbage in the soiled utility room and used hand sanitizer upon leaving the room. The staff member (#7) rubbed the hand sanitizer on hands, but immediately wiped the sanitizer off with a paper towel stating, "this stuff is so slimy". Observation showed the nursing staff member (#7) failed to perform proper hand hygiene.
*Observation on 05/08/12 at 11:30 a.m. showed a nursing staff member (#10) entered Patient #26's room, donned gloves, and assisted the patient to the bathroom. Observation showed the patient's pants and the disposable pad on his bed saturated with urine. The nursing staff member (#10) removed her gloves after she provided incontinence cares for Patient #26 and bagged the wet clothing and brief. She noticed the wet disposable pad on the patient's bed and placed it into the trash can with her un-gloved hand. The staff member (#10) exited the patient's room with the bagged garbage and clothing and disposed of them in the soiled utility room. As she obtained a floor mop, a nursing staff member (#17) handed her the portable telephone and the staff member (#10) placed it in her pocket. The nursing staff member (#10) mopped Patient #26's floor, returned the mop, and then sanitized her hands.

During an interview on 05/08/12 at 3:15 p.m., a nursing staff member (#3) stated staff must use hand sanitizer or wash hands upon entering and leaving patient rooms, after removing gloves, and after touching bodily fluids. The staff member also stated staff must wear gowns for all hands-on cares, such as peri-cares, when providing care for a patient with Methicillin-resistant Staphylococcus Aureus (MRSA).

During an interview on 05/08/12 at 3:25 p.m., an administrative nurse (#2) stated staff must wash their hands or use hand sanitizer upon entering and leaving a patient room, before and after placing gloves, after peri-cares, and after touching body fluids whether staff applied gloves or not. The nurse (#2) stated staff must apply hand sanitizer all over their hands and rub the sanitizer in for effectiveness.

- The following observations showed staff failed to perform proper cleaning of patient care equipment, labeling of cleaning products, and disposal of trash:
*Observation on 05/07/12 at 3:08 p.m. showed a nursing staff member (#9) assisting a patient from an exercise machine in the designated physical therapy (PT)/restorative care room in the lower level of the CAH. The staff member (#9) obtained a bottle of cleaning solution and a wash cloth from a desk cupboard located in the room, sprayed the cleaning solution on the handles and seat of the exercise machine, and immediately wiped the solution off with the wash cloth. The nursing staff member (#9) then placed the bottle of cleaning solution and soiled wash cloth back in the desk cupboard and left the room with the patient. Observation of the cleaning solution label listed the name of the cleaner as "Coverage Plus" and lacked instructions for use.
*Observation of the off-site PT department occurred on 05/07/12 at 4:00 p.m. with a PT staff member (#15). Observation of two spray bottles of cleaning solution lacked labels to identify the contents and instructions for use.
*Observation on 05/08/12 at 9:15 a.m. showed two nursing staff members (#6 and #7) entered Patient #2's room, assisted the patient to bed with a hoyer lift, and changed the patient's soiled brief. A staff member (#7) replaced the garbage can liner and placed the soiled garbage bag on top of Patient #2's bedside stand.
*Observation on 05/08/12 at 9:40 a.m. showed two nursing staff members (#7 and #8) entered Patient #3's room, changed the patient's soiled brief, and prepared to assisted the patient to the wheelchair with a hoyer lift. A staff member (#7) replaced the garbage can liner and placed the soiled garbage bag in Patient #3's wheelchair.
*Observation on 05/08/12 at 11:20 a.m. showed two nursing staff members (#7 and #11) entered Patient #2's room and assisted the patient to the wheelchair with a hoyer lift. A staff member (#7) replaced the garbage can liner and placed the soiled garbage bag on top of Patient #2's bed.

During an interview on 05/07/12 at 3:45 p.m., a nursing staff member (#9) stated staff used a cleaning solution called coverage plus to clean equipment after each patient use, and indicated staff must use a new wash cloth each time to wipe the cleaning solution off. The staff member (#9) seemed unsure and couldn't state how long to leave the cleaning solution on the equipment to clean or disinfect between patients.

During an interview on 05/07/12 at 4:00 p.m., two PT staff members (#15 and #17) stated staff used a cleaning solution to clean equipment and beds after each patient use and pointed to two different spray bottles containing solution which lacked labels. A staff member (#15) stated the receptionist mixed up the solution according to manufacturer's instructions from a large container called coverage plus. The PT staff members (#15 and #17) seemed unsure, stating once staff spray the cleaning solution on the bed or equipment, the solution must stay on the surface for 10 seconds before wiping off. Observation of the instructions on the large container of coverage plus stated, ". . . thoroughly wet . . . remain wet for 10 minutes . . . wipe dry with cloth or air dry . . ."

During an interview on 05/08/12 at 3:25 p.m. an administrative nurse (#2) stated all cleaning solutions must contain a label which included the name of the solution and instructions for use, and stated staff must follow instructions for use when cleaning and disinfecting patient care items between patients. The infection control nurse (#16) stated staff must never place soiled garbage bags on bedside tables, patient beds or wheelchairs.

- The following observations on 05/08/12 at 11:10 a.m., showed staff failed to perform sanitary medication administration:
*Observation showed a staff nurse (#10) standing at the medication cart in the patient dining room preparing to administer a hydrocodone tablet to Patient #27. Review of the medication administration record (MAR) showed hydrocodone, 10/500 milligram (mg), 1/2 tablet. The nurse (#10) picked up the hydrocodone tablet with her bare hands, broke the tablet in half, placed half of the tablet in a medication cup and the other half back into the medication bottle, and administered the half tablet to Patient #27.
*Observation showed a staff nurse (#10) standing at the medication cart in the patient dining room preparing to administer an ibuprofen tablet to Patient #28. The ibuprofen tablet fell on the top of the medication cart as the nurse (#10) tried to place the tablet in a medication cup. The nurse (#10) picked up the ibuprofen tablet with her bare hands, placed the tablet in the medication cup, and administered the tablet to Patient #28.

During an interview on 05/08/12 at 3:25 p.m., an administrative nurse (#2) stated she expected staff to use hand sanitizer or wash their hands prior to touching medications.

2. Based on review of the infection control log, infection control committee meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases among personnel of the CAH for 8 of 8 months (August 2011 to March 2012) reviewed. Failure to identify and address infections among personnel has the potential for infections to go unreported and to spread or reoccur, affecting the health of all patients and personnel of the CAH.

Findings include:

The CAH's Infection Control Log and Infection Control Meeting Minutes (August 2011 to March 2012), reviewed on 05/08/12, lacked evidence the CAH identified and recognized infections for personnel of the CAH. The CAH failed to maintain a log of infections among personnel for the past 8 months (August 2011 to March 2012). The CAH lacked a system or process for personnel to document and report suspected cases of infections to the infection control nurse for further investigation, monitoring, and recommendations.

During an interview on 05/08/12 at 3:25 p.m., the infection control nurse (#16) stated the CAH failed to include personnel in their infection control surveillance and confirmed the CAH had no infection control log for personnel.


22495

1. Based on observation, review of professional literature, record review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the safe use of side rails and consider side rails as a potential entrapment and safety hazard for 2 of 4 active patients (Patient #2 and #3) observed with elevated side rails. Failure to evaluate the safe use of side rails and consider side rails as a potential entrapment and safety hazard placed Patient #2 and #3 at risk of entrapment or injury.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings," dated April 2003, stated, ". . . CMS [Centers for Medicare and Medicaid Services] . . . issued guidance in June 2000 . . . 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. Even when a side rail is not intentionally used as a restraint, patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised siderails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . ."

The United States Department of Health and Human Services, Food and Drug Administration (FDA), and Center for Devices and Radiological Health (CDRH) publication titled, "Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," issued on 03/12/06, stated, ". . . FDA is recommending dimensional limits for zones 1 through 4 . . . because . . . the majority of the entrapments . . . have occurred in these zones. . . . Zone 1 is any open space within the perimeter of the rail. Openings in the rail should be small enough to prevent the head from entering. . . . FDA is recommending a measure of less than . . . 4 3/4 inches as the dimensional limit for any open space within the perimeter of a rail. Zone 2 . . . This space is the gap under the rail between a mattress . . . Preventing the head from entering under the rail would most likely prevent neck entrapment in this space. FDA recommends that this space be small enough to prevent head entrapment, less than . . . 4 3/4 inches. . . . Zone 3 . . . This area is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment . . . FDA is recommending a dimensional limit of less than . . . 4 3/4 inches for the area between the inside surface of the rail and the compressed mattress. Zone 4 . . . This space is the gap that forms between the mattress compressed by the patient, and the lowermost portion of the rail, at the end of a rail. . . . The space poses a risk for entrapment of a patient's neck. . . . to prevent neck entrapment. . . . FDA recommends that the dimensional limit for this space . . . be less than . . . 2 3/8 inches. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts," revised April 2010, stated, ". . . Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . ."

Observation of the beds utilized on the nursing unit occurred on May 07-08, 2012. The beds differed in make and model, but included two half rails attached to each side of the upper half of the beds. Measurements of the bed located in room 110, identified seven and a half inch spaces within the top half of the rails. Observation showed Patient #2 occupied the bed located in room 110 and Patient #3 occupied the same type of bed located in room 108.

- Review of Patient #2's record occurred on May 08-09, 2012 and identified the CAH admitted the patient on 04/13/05 with a diagnosis of Alzheimer's dementia. The care plan, reviewed by CAH staff on 05/03/12, identified Patient #2 as a potential risk for falls due to decreased mobility and confusion. Review of provider progress notes from December 2011 to April 2012, identified Patient #2 as non-responsive and requiring total assistance from nursing staff with all activities of daily living (ADL's). A side rail evaluation form, dated 05/03/12, identified the use of side rails for safety reasons due to the patient's episodes of "jerkiness". The form indicated the side rail will not assist Patient #2 with bed mobility and transfer, but will assist to avoid rolling out of bed and is recommended for safety. Observation of Patient #2 on all days of survey while resting in bed, showed elevation of two upper half side rails. The CAH staff failed to consider the side rails as a potential safety and entrapment hazard for Patient #2.

- Review of Patient #3's record occurred on May 08-09, 2012 and identified the CAH admitted the patient on 11/30/09 with a diagnosis of dementia. A side rail assessment, dated 03/29/12, identified the use of side rails for repositioning and security and stated, "Staff will continue to put 1/2 side rail up [times one or two] as resident uses side rails to assist with turning." Observation on 05/08/12 at 9:35 a.m. showed two staff members (#7 and #8) utilized a full body mechanical lift, transferred Patient #3 to her bed, and provided incontinence cares. The staff members rolled the patient from side to side to provide cares. Patient #3 did not assist with repositioning and her hands remained at her side. Observation showed Patient #3's side rails remained elevated when the staff members exited the room. The CAH staff failed to consider the side rails as a potential safety and entrapment hazard for Patient #3.

During an interview on 05/08/12 at 3:20 p.m., an administrative nurse (#2) stated facility staff place Patient #3's hand on the side rail during cares and she would expect the staff to lower the side rail after the completion of cares.

During an interview on 05/09/12 at 10:35 a.m., an administrative nurse (#2) stated the CAH is trialing new patient beds which meet the safety standards in regards to spacing within the side rails, and agreed the patient beds in current use contain large spaces within the rails which could lead to entrapment or injury. The administrative nurse (#2) confirmed Patient #2 is immobile and relied on staff for complete assistance with ADL's and stated staff should not elevate the patient's side rails.


21202


2. Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to monitor and document the effectiveness of pain medications given to patients on a prn (as needed) basis for 1 of 3 closed swing bed records (Patient #7) reviewed. Failure to evaluate Patient #7's response to prn pain medications limited the nursing staff's ability to assess whether the medications achieved the desired effect, or if the patient experienced any side effects or adverse reactions from the medications.

Findings include:

Review of the CAH policy titled, "Pain Assessment and Management" occurred on 05/09/12. This policy, dated 12/2011, stated, "PURPOSE: To diagnose, assess, and start pain management program for the best comfort relief for patients and residents . . . Management Program: . . . Monitor effects of medications . . . ."

Review of Patient #7's closed swing bed record occurred on 05/07/12, and identified the CAH admitted the patient on 09/08/11 following an open reduction internal fixation (ORIF) of her left femur. The record indicated a doctor's order for Patient #7 to receive prn pain medications of Oxycodone (an opioid pain medication) 5 milligrams every 4 hours (hrs) prn and Tylenol (also known as Acetaminophen, an over the counter pain medication) 650 mg every four hrs prn.

Patient #7's Medication Administration Record (MAR) from September-October 2011 showed the CAH nursing staff administered Oxycodone three times (on September 9, 11, and 13), and Tylenol twice (on October 1 and 13). Patient's #7's Nurse's Notes and PRN Pain Flowsheet lacked evidence nursing staff monitored and documented the effectiveness of these prn pain medications administered to Patient #7.

During interview on 05/08/12 at approximately 10:00 a.m., an administrative nurse (#2) confirmed nursing staff failed to assess and document the effectiveness of above prn pain medications administered to Patient #7.


22495


3. Based on record review and staff interview, the Critical Access Hospital (CAH) failed to provide care in accordance with the patient's needs for 1 of 1 swing bed record (Patient #3) who required frequent use of suppositories for a bowel movement. Failure to notify the physician regarding Patient #3's bowel habits and implement less invasive interventions, as well as implement dietary interventions, resulted in inconsistent bowel management and has the potential for pain and constipation.

Findings included:

Review of Patient #3's record occurred on May 08-09, 2012 and identified the CAH admitted the patient on 11/30/09. Diagnoses included dementia and constipation. Medications administered to assist in stool elimination included a dulcolax suppository as needed (PRN). The current care plan related to constipation identified the interventions, "Encourage fluids. Administer laxatives per provider order." Review of the nurses notes and PRN medication administration record (MAR) from February 2012 through May 8, 2012 identified the nursing staff administered a PRN suppository four times in February, four times in March, five times in April, and three time from May 1st to May 8th.

During an interview on 05/09/12 at 11:05 a.m., an administrative nurse (#2) stated the CAH does not have a written protocol related to bowel elimination and the nursing staff administer a suppository to Patient #3 on her third or fourth day without a bowel movement.

Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed a provider's medication order for 1 of 1 active swing bed patient (Patient #3) observed receiving a medication during medication pass which did not match the provider's order. The failure of staff to follow a provider's medication order resulted in Patient #3 receiving the wrong type of medication over the past two years.

Findings include:

Observation during medication pass on 05/08/12 at 12:00 p.m., showed a staff nurse (#10) standing at the medication cart in the patient dining room preparing to administer potassium chloride (KCL) capsules to Patient #3. Review of Patient #3's medication administration record (MAR) showed, "KCL Sprinkles 20 meq [miliequivalents] po [by mouth] TID [three times a day] [with] meals". The nurse (#10) picked up the KCL medication bottle which read, "Potassium CL [chloride] ER [extended release] 10 meq [two] po", placed two KCL ER capsules into a medication cup, opened the capsules and poured the contents of the capsules (small granules) out into the medication cup, added applesauce to the contents in the medication cup and mixed all together, and then administered the medication and applesauce to Patient #3.

Review of Patient #3's active swing bed record occurred on 05/09/12 and identified a provider order, dated 03/25/10 at 9:15 a.m., which stated, "[increase] KCL 20 meq sprinkles po tid [with] meals . . ." The record showed this order still in effect as the most recent provider order, dated 04/17/12, stated, "KCL Sprinkles 20 meq TID [with] meals".

During a telephone interview on 05/09/12 at 11:50 a.m., a pharmacist (#18) stated she did not recognize the term "sprinkles" or know what the term referred to, and confirmed the contents of the extended release KCL capsules remained extended release when poured out and administered outside of the capsule. The pharmacist (#18) stated KCL comes in tablet or capsule form, varies in strengths, and can be administered for immediate or extended release.

During a telephone interview on 05/09/12 at 1:45 p.m., a consulting pharmacist (#19) stated the term "sprinkles" referred to a medication contained in a packet consisting of a powder or crystal substance which can be poured out and mixed with fluid or food for administration. The pharmacist (#19) stated KCL is available in immediate or extended release and stated staff must confirm questions about a medication order with the provider who wrote the order.

The nursing staff administered extended release KCL to Patient #3 despite the provider order which indicated administration of immediate release KCL. The nursing staff also administered the contents of the capsules of KCL to Patient #3 despite the provider order which indicated administration of sprinkles of KCL. Record review lacked evidence nursing staff questioned or clarified the provider order or the pharmacists dispensing (sprinkles, capsules, immediate or extended release). Failure to ensure staff followed provider orders and administered correct medications has the potential for patient's to receive the wrong medication dose, strength, frequency, route and/or the wrong medication all together.

Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to maintain a complete medical record including health care practitioner (HCP) orders for instruction and medications to the patient upon discharge from the facility for 3 of 3 closed observation patient (#9, #10, and #11) records and 2 of 11 closed emergency department (ED) patient (#16 and #17) records reviewed. Failure of the CAH to ensure the patient received written discharge instruction and medication orders from the HCP limited the patients' ability to ensure consistent follow-up of instructions and limited the CAH staff's ability to ensure continuity of care.

Findings include:

Review of the facility policy titled, "Medical Record Documentation" occurred on 05/09/12. This policy dated 04/2004, stated, "POLICY: The attending practitioner shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall contain sufficient information to . . . facilitate continuity of care among health care providers. The record shall include: . . . discharge instructions to patient/family . . . EMERGENCY RECORDS An appropriate medical record shall be kept for every patient receiving emergency service . . . Final disposition, including instruction giving to the patient and/or his family . . . relative to necessary follow-up care . . . ."

Review of the following closed medical records occurred on May 07-08, 2012.

- Patient #11 presented to the ED on 10/31/11 with complaints of severe left shoulder and arm pain. The CAH admitted Patient #11 to observation status. During her hospital stay, Patient #11 received Cataflam (an nonsteroidal anti-inflammatory medication) 50 milligrams (mg) and Lisinopril (an antihypertensive medication) 10 mg (both of these medications were new for the patient.)

Patient #11's HCP orders for discharge stated, ". . . cont. [continue] [with] current Rxs [prescriptions]."

Patient #11's written discharge instructions completed by the CAH nursing staff, stated, ". . . Continue with current medications . . . ." These written discharge instructions failed to specify the dosage, frequency and type of medications Patient #11 was to take upon discharge from the CAH and placed Patient #11 at risk of receiving incorrect instructions and taking the wrong medications.

- Patient #16 presented to the ED on 01/08/12 at 3:31 p.m. with complaints of heavy menstrual bleeding, lightheadedness and headaches. Patient #16's HCP note identified home medications of calcium carbonate, multivitamin with minerals, Zyprexa, and Paxil. Review of the health care providers orders identified Patient #16 received 400 mg Ibuprofen while in the ED and additional instructions for the patient to ". . . repeat in 3-4 hours PRN [as needed]." The CAH discharged Patient #16 from the ED at 6:44 p.m. Review of Patient #16's computerized discharge instructions, signed by Patient #16 and the HCP on 01/08/12, failed to include instructions for the use of PRN Ibuprofen.

Failure of the HCP to provide written orders for medications to take upon discharge from the CAH ED, placed Patient #16 at risk of receiving incorrect instructions and taking the wrong medications.

- Patient #17 presented to the ED on 01/21/12 at 2:09 p.m. with complaints of painful respirations, pain to the left side of his upper chest wall, and difficulty raising his right arm. Patient #17's HCP order stated "Pt [patient] instructed that we are unable to provide x-ray at this time and he is encouraged to go to [name of another facility] for further evaluation."(The CAH was unable to conduct radiology testing due to an equipment breakdown.) Patient #17's ED record lacked evidence that the CAH ED staff provided written discharge instructions informing him to go immediately to another facility to obtain radiology testing.

- Patient #10 presented to the ED on 01/23/12 and the CAH admitted her to observation status. Patient #10's diagnoses included dehydration, weakness, status post total knee replacement, diabetes, depression, and anxiety. The HCP wrote orders for Patient #10's to continue with her home medications of Metformin, Glipizide, Paxil, Lisinopril, Hydralazine, and Omeprazole upon admission to the hospital. On 01/25/12 at 1:00 p.m., the HCP ordered the CAH staff to administer a dose of oral Alprazolam 0.25 mg to Patient #10.

Patient #10's HCP orders for discharge, dated 01/25/12 at 4:10 p.m., stated, ". . . Continue home medications . . . Alprazolam 0.25 mg orally twice daily."

Review of Patient #10's written discharge instructions, completed by the CAH nursing staff, stated, ". . . Xanax 0.25 mg, Hydralazine 25 mg, Metformin 500 mg, Paxil 40 mg, Lisinopril 40 mg, Glipizide 5 mg, Hydrochlorothiazide 25 mg, Aspirin 325 mg, and Lovastatin 40 mg . . . ."

Failure of the HCP to provide written orders for medications to take upon discharge from the CAH, placed Patient #10 at risk of receiving incorrect instructions and taking the wrong medications.

- Patient #9 presented to the ED on 03/03/12 and the CAH admitted him to observation status. Patient #9 sustained a fall at an assisted living facility. Admitting diagnoses for Patient #9 included head injury, chronic anticoagulation and unsteady gait. Patient #9's HCP orders for discharge identified the following medications of: enteric-coated aspirin 81 mg daily, Hydrochlorothiazide 25 mg daily, calcium 600 mg plus Vitamin D daily, garlic supplement 500 mg daily, Metformin extended-release 500 mg daily, Digoxin 250 micrograms (mcg) four days a week and 375 mcg on Monday-Wednesday- Friday, Tylenol arthritis one tab daily, Metoprolol 50 mg in the evening, artificial tears, and warfarin 6 mg two days a week (Monday and Friday).

On 03/05/12, the CAH discharged Patient #9 to an assisted living facility. Review of Patient #9's Transfer Record listed the following medications as "See Copy of MAR [medication administration record], resume home meds [medications] except reduce HS [evening] Metoprolol to 50 mg."

The CAH failed to send a signed HCP order to the assisted living facility indicating the specific medications for Patient #9 to take upon discharge.

During interview on the morning of 05/10/12, an administrative nurse (#2) stated she expected the providers to identify the medications for all patients to take at the time of discharge from ED/hospital by writing each medication, dosage and frequency as an order and for the CAH nursing staff to list these specific medications on the CAH's discharge instruction form or transfer sheet if patient is discharged to another health care facility.

Based on record review, review of admission information provided to swing bed patients, and staff interview, the Critical Access Hospital (CAH) failed to provide swing bed patients and their families/legal guardians with access to the current version of the printed resident rights and responsibilities booklet for 4 of 4 active swing bed patients (Patient #1, #2, #3, and #4) and 2 of 2 closed swing bed patients (Patient #6 and #7). Failure of the CAH to provide patients and/or their families/legal guardians with the current and correct resident rights/responsibilities booklet does not ensure or allow the resident and family/legal guardian to fully execute these rights and responsibilities.

Findings include:

On the afternoon of 05/07/12, the CAH provided a copy of the written information provided to swing bed patients regarding their rights (Swing Bed Admission Packet).

Review of the CAH's Swing Bed Admission Packet, included a booklet titled "Resident's Rights - A Guide To Your Rights as a Resident of a Nursing Facility in North Dakota," dated December 1998. The current version of this booklet is dated August 2009.

During interview on 05/08/12 at 9:00 a.m., a social service staff member (#13) stated the CAH informs all swing bed patients of their rights /responsibilities by providing and reviewing the above Resident's Rights booklet dated 1998 with each swing bed patient and/or family/legal guardian. When informed this booklet was revised in 2009, the staff member (#13) stated her unawareness of this revision.

Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff revised, updated, and maintained nursing care plans for 2 of 2 closed swing bed patient (Patient #6 and #7) records reviewed. Failure to update, revise, and maintain care plans limited the CAH's ability to manage patient needs, communicate treatment approaches, assist the patient to attain/maintain their highest physical, mental, and psychosocial well-being, and ensure continuity of care.

Findings include:

Review of the CAH policy titled "Care Plans" occurred on 05/09/12. This policy, dated 11/2011, stated, "PURPOSE: 1. To identify resident problems. 2. To set goals for dealing with these problems . . . PROCEDURE: Care plans are initiated on all Swing Bed and Long Term Care within 24-hours of admission and completed within 7 days following . . . B. Identify Problems . . . C. Set Goals . . . D. Plan Approaches . . . ."

Review of the CAH policy titled "Pain Assessment and Management" occurred on 05/09/12. This policy, dated 12/2011, stated, "PURPOSE: To diagnose, assess, and start pain management program for the best comfort relief for patients and residents . . . Charting . . . 5. Include pain management/assessment on care plan."

- Review of Patient #7's closed swing bed record occurred on 05/07/12, and identified the CAH admitted the patient on 09/08/11 following an open reduction internal fixation (ORIF) of her left femur.

Physician orders for Patient #7 included:
09/08/11 - prn (as needed) pain medication of Oxycodone (an opioid pain medication)
09/21/11 - prn pain medication of Tylenol (also known as Acetaminophen, an over the counter pain medication)
12/15/11 - DuoDerm (a type of dressing) to right buttock wound

Patient #7's September 2011 Medication Administration Record (MAR) identified the CAH staff provided the patient with prn pain medications for left leg pain.

A nurse's note, dated 12/15/11, for Patient #7 identified ". . . open area to [right] buttock . . . [left] [lower] extremity-- 3-4 + [plus] edema thigh to toes, [no] complaints pain, [increased] warmth compared to [right] . . . ." The CAH staff notified Patient #7's Allied Healthcare Provider and received an order to obtain an ultrasound of left lower extremity. Patient #7's ultrasound, completed on 12/21/11, identified a "DVT [deep venous thrombus] throughout the left leg . . . ."

Review of Patient #7's care plan identified CAH staff failed to identify, set goals, and implement interventions to address pain management, impaired skin integrity, and the development of a DVT.

- Review of Patient #6's closed swing bed record occurred on 05/07/12 and identified the CAH admitted the patient to swing bed on 11/03/11 and discharged her to a long-term care facility 11/07/11 (four days later).

Review of Patient #6's medical record identified the CAH staff failed to initiate a care plan for this patient.

During interview on 05/08/12 at 11:45 a.m., an administrative nurse (#2) confirmed Patient #7's medical record lacked a care plan for pain management, impaired skin integrity, and the presence of the DVT. This staff member stated she expected the CAH staff to implement care plans to address Patient #7's issues of pain, impaired skin integrity, and a positive DVT and complete a temporary or initial plan of care for Patient #6 even though her stay at the CAH was "short-term."