HospitalInspections.org

Based on record review and staff interview, the critical access hospital (CAH) failed to ensure compliance with Federal regulations regarding advance directives for 7 of 14 closed patient records (Patients #7, #11, #14, #15, #17, #18, and #19) reviewed and for education of CAH staff regarding the facility's policies and procedures for advance directives. Failure to determine if patients have an advance directive at the time of admission and failure to educate CAH staff placed the patients at risk of receiving undesired treatment and limited the staff's ability to respond regarding advance directives.

Findings include.

- During review of the CAH's electronic medical records (EMR), on March 26-27, 2013, a medical records management staff member (#16) reported the CAH staff identify patients with an advance directive on the "face sheet" or on the "Authorization for Treatment" form. This staff member reported the CAH maintained the authorization form in the CAH while the patient is in the CAH and then "scanned" into the EMR after discharge.

Reviewed on March 26-27, 2013, the following closed medical records failed to identify if patients did or did not have advance directives:
- Patient #11, admitted 01/17/13, discharged 01/18/13.
- Patient #7, admitted 02/12/13, discharged 02/14/13.
- Patient #14, admitted 01/27/13, discharged 02/21/13.
- Patient #15, admitted 03/20/13.
- Patient #17, admitted 01/23/13.
- Patient #18, admitted 02/14/13
- Patient #19, admitted 10/18/12.

- Reviewed on 03/27/13, the staff education records lacked evidence of education provided to the staff regarding the CAH's policies and procedures for advance directives.

During interview, on 03/27/13 at 8:00 a.m., an administrative nursing staff member (#2) reported the CAH has been attempting to determine if the CAH should use the "face sheet" or "Authorization for Treatment" to document the advance directive information. This staff member confirmed the education provided to staff lacked information on the facility's advance directives policies and procedures.

1. Based on observation, review of manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure proper maintenance of 1 of 1 water/ice dispenser located in the kitchenette on the nursing unit. Failure to ensure proper maintenance occurred on a regular basis, such as cleaning, sanitizing, and de-mineralizing to prevent the development of mold and the production of corrosion, has the potential to affect the health of patients consuming the water/ice from the dispenser.

Findings include:

Review of manufacturer's instructions for the water/ice dispenser, Scotsman Model MDT3F12 and MDT4F12, occurred on 03/27/13. The instructions, dated May 2001, on page 14, stated, "Maintenance: . . . the water and ice vending systems will need to be periodically sanitized and de-mineralized. The air cooled condenser will also need to be kept clean. Schedule the sanitation, cleaning and de-mineralization on a regular basis to keep the ice clean and the machine operating efficiently. SANITATION and CLEANING: Water System: This ice machine requires periodic sanitation and de-mineralization. . . ."

Observation of the kitchenette on the nursing unit occurred on 03/26/13 at 2:45 p.m. and showed a water/ice dispenser on the counter. A dietary staff member (#18) confirmed the water/ice dispenser is for patient use and stated she did not know if staff maintained the dispenser.

During an interview on 03/26/13 at 2:45 p.m., a physical plant staff member (#17) stated the CAH did not have an established process for staff to clean, sanitize, and de-mineralize the water/ice dispenser. The physical plant staff member (#17) confirmed the CAH had not cleaned, sanitized, or de-mineralized the water/ice dispenser since installation of the dispenser on 05/08/09.




20497

2. Based on observation and staff interview, the Critical Access Hospital (CAH) failed to install a backflow prevention device on 1 of 1 water supply line with an attached hose in the off-site clinic (former radiology processor room) and failed to securely cap 1 of 1 open sewer pipe in the off-site clinic (former radiology processor room). Failure to have backflow prevention devices on water supply lines placed the patients and the public at risk of contamination of the public water supply and failure to cap open sewer pipes placed the patients and staff at risk of exposure to sewer gas.

Findings include:

Observation of the former radiology processor room at the off-site clinic at 2:10 p.m. on 03/25/13, revealed the following:

- A water supply line with an attached hose draped in the sink. Observation failed to identify a backflow prevention device on the water supply line.

- An uncapped sewer pipe protruding from the floor next to the water supply line.

During interview at 2:20 p.m. on 03/25/13, a radiology/laboratory clinic staff member (#12) confirmed the off-site clinic did not have a backflow prevention device on the water supply line in the former radiology processor room and the off-site clinic had an open sewer pipe in the former radiology processor room.

Based on bylaws review, record review, and staff interview, the Critical Access Hospital (CAH) failed to follow the medical staff bylaws for appointment and reappointment of medical staff for 1 of 1 certified registered nurse anesthesist (Provider #1), 33 of 33 teleradiologists (Providers #9 - #41), 4 of 4 active staff (Providers #2, #4, #5, and #7), 1 of 1 consulting staff (Provider #3), and 2 of 2 associate staff (Providers #6 and #8) files reviewed of providers furnishing services to the CAH's patients. Failure to approve appointments and reappointments according to the CAH's bylaws, limited the medical staff's and governing body's ability to ensure the providers possessed the necessary qualifications for medical staff membership.

Findings include:

Review of Sanford Mayville's medical staff bylaws occurred on 03/25/13. These bylaws, adopted 12/19/11, stated,
" . . . ARTICLE II
The purpose of this organization shall be:
3 To insure a high level of professional performance of all physicians, dentists, or allied health professionals authorized to practice in the hospital, through the appropriate delineation of the clinical privileges, that each physician, dentist, or allied health professional may exercise in the hospital . . .
ARTICLE III Medical Staff Membership . . .
Section 1. Nature of Medical Staff Membership
Membership on the medical staff of Sanford Mayville is a privilege which shall be extended only to professionally competent physicians, dentists, or allied health professionals . . .
Section 2. Conditions and Duration of Appointments . . .
C. Appointment of the medical staff shall confer on the appointee only such clinical privileges as have been granted by the governing body, in accordance with these bylaws. . . .
ARTICLE V Procedure for Appointment and Reappointment . . .
Section 2. Appointment Process. . . .
A. . . . All recommendations to appoint must also specifically recommend the clinical privileges to be granted . . .
Section 3. Reappointment Process.
A. . . . The medical staff shall review all pertinent information available on each applicant . . . for the purpose of determining is [sic] recommendation . . . for granting of clinical privileges for the ensuing period, and shall transmit its recommendation, in writing, to the governing body. . . .
Section 4. Provisional Appointments
A All initial appointments to any category of the medical staff shall be provisional. . . .
Section 7. Allied Health Professional
Request to perform specified patient care services from allied health professionals (such as family nurse practitioner, physician assistant or certified nurse anesthesist) shall be processed in the manner specified in Article V, Section 4. . . .
ARTICLE VI Clinical Privileges
Section 1. Clinical Privileges Restricted
A Every physician, dentist, or allied health professional practicing at Sanford Mayville shall, by virtue of medical staff membership, or otherwise, in connection with such practice, shall be entitled to exercise only those clinical privileges specifically granted to him/her by the governing body . . .

Review of Sanford Mayville's governing board bylaws occurred on 03/26/13. These bylaws, adopted 01/24/11, stated,
". . . X. Medical Staff . . .
10.2.2 Medical Staff Recommendations. The medical staff shall make recommendations to the Board of Directors concerning; (1) appointments, reappointments . . . (2) granting of clinical privileges . . ."

Review of Sanford Mayville's governing board bylaws occurred on 03/26/13. These bylaws, adopted 07/09/12, stated,
". . . IV. Board of Directors
Section 4.1 Authority and Responsibility. . . . The authority delegated to the Board of Directors includes . . . the following:
d. Credentialing and granting privileges to medical staff members and other health care professionals providing services at the corporation . . ."

Reviewed on 03/27/13, the CAH's credentialing files indicated the following:

- The CAH failed to provide evidence of credentialing Provider #1, a certified nurse anesthesist. Review of the CAH's Operating Room Register indicated Provider #1 had furnished services to the CAH's patients since 2006.

- Upon request on 03/27/13, an administrative staff member (#1) provided a list of 33 teleradiologists (Providers #9 - #41) providing services to the CAH's patients. The CAH's credentialing files lacked evidence the CAH credentialed the 33 teleradiologists.

- The medical staff and governing board failed to approve the specific clinical privileges for four active staff members (Providers #2, #4, #5, and #7), one consulting staff member (Provider #3), and two associate staff members (Providers #6 and #8) who furnished services to the CAH's patients. The CAH provided no other evidence medical staff recommended or the governing board approved clinical privileges for Providers #2 - #8.

During interviews, at approximately 9:50 a.m. and 11:30 a.m. on 03/27/13, an administrative staff member (#1) confirmed the following: the CAH had not credentialed Provider #1 who had furnished anesthesiology services to the CAH's patients; the CAH had not credentialed the teleradiologists providing services to the CAH's patients; and the medical staff and governing board had not approved the specific clinical privileges for Providers #2-#8.

Based on observation, record review, facility policy/procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a provider assessed 1 of 3 patients (Patient #33) observed in the Main Emergency Room (ER) prior to the patient receiving medication. Failure to ensure a provider examined a patient prior to administering medication may result in the patient receiving inappropriate treatment for their symptoms and diagnosis.

Findings include:

Review of the facility policy titled "ER POLICY" occurred on 03/26/13. This policy, revised 02/20/12, stated, ". . . F. The nurse notifies the provider regarding the patient. The time the provider is notified and the time arrived are both entered. . . ."

Observation on 03/25/13 at 5:40 p.m. showed a nurse (#13) administered six milligrams (mg) of sumatriptan succinate (Imitrex - a medication used to treat migraine headaches) intramuscularly (IM) to Patient #33 in the Emergency Room. The nurse (#13) stated the provider had not seen the patient yet. Before assessing the patient, the provider gave a telephone order for six mg IM Imitrex. The nurse (#13) revealed Patient #33 had not received Imitrex previously.

Review of Patient #33's ER record identified the following:
*Patient arrived at the hospital at 5:14 p.m.
*Patient taken into the ER at 5:18 p.m.
*Vitals taken at 5:20 p.m.
*ER Provider notified at 5:32 p.m.
*Imitrex six mg IM, per provider's telephone order, administered at 5:35 p.m. (Observation showed a nurse administered the medication at 5:40 p.m.)
*Provider arrived to examine the patient at 6:00 p.m.
*Patient discharged at 6:19 p.m.
*ER nurse's note: "Patient arrived in ED [Emergency Department] with complaint of migraine headache that started around 0700 [7:00 a.m.]. Took Advil Migraine without relief. Headache worsened about 1300 [1:00 p.m.] today. Patient doesn't have prescription meds. [medications] for migraine, [sic] usually they give me a 'shot'."

During an interview on 03/26/13 at 1:45 p.m., an administrative nurse (#2) stated she expected the ER providers to examine patients prior to ordering treatments/medications.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 04/22/09.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to store drugs and biologicals in a secure manner to prevent access by unauthorized personnel in 1 of 2 Emergency Rooms (ER) (Main ER). Failure of the CAH to adequately secure and restrict access of drugs and biologicals created an opportunity for unsafe and unauthorized use of medications.

Findings include:

Observation of the Main ER with an administrative nurse (#2) occurred on 03/26/13 at 1:15 p.m. and showed a locked medication storage cabinet and a small locked medication storage refrigerator. Observation showed the CAH kept the keys to both medication storage units in a small magnetic box attached to the bottom of the medication cabinet. This method of storing the keys resulted in easy access to medications by unauthorized personnel, patients, and visitors in the ER.

During an interview on 03/26/13 at 1:30 p.m., an administrative nurse (#2) stated the ER door remained open and unlocked at all times and confirmed the current method of storing the keys for the medication cabinet and refrigerator allowed for unauthorized access to the medications.

Based on review of infection control reports and 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 for outpatients of the CAH for the past 14 of 14 months (January 2012 through February 2013) reviewed. Failure to identify and address incidents of infections among all patients has the potential for infections to go unreported, spread, or reoccur; affecting the health of all patients, personnel, and visitors of the CAH.

Findings include:

Reviewed on 03/26/13, the infection control program lacked evidence the CAH identified and recognized infections of outpatients. The infection reports and meeting minutes from January 2012 through February 2013 failed to include information and documentation of outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on 03/26/13 at 2:10 p.m., two administrative staff members responsible for the infection control program (#2 and #8) stated they do not receive or request infection control information from outpatients. The staff members (#2 and #8) confirmed the CAH did not formally document and include outpatients in infection control surveillance.

Failure to document and perform surveillance among all patients of the CAH limited the staffs' ability to identify, monitor, track, control, and prevent infections.

Based on policy and procedure manual review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the required members of a group of professional personnel annually reviewed the CAH's health care policies and procedures in 2012 for 5 of 20 policy and procedure manuals (Cardiac Rehabilitation, Physical Therapy, [name of off-site clinic], Laboratory, and Radiology) reviewed. Failure to have the required group annually review the policies and procedures limits the CAH's ability to ensure the policies and procedures model the CAH's current practices and were in compliance with federal regulations.

Findings include:

Review of the policy titled "Sanford Mayville Critical Access Annual Program Evaluation" occurred on 03/26/13. This undated policy stated,
"Policy: An annual review will be done to evaluate the total critical access program. . . . 2. Currrent health care policies related to provision of critical access hospital status have been reviewed . . ."

Review of the CAH's policy and procedure manuals occurred on all days of the survey. The following manuals lacked evidence of annual review in 2012 by the required members of a group of professional personnel (a physician; a physician assistant, nurse practitioner, or clinical nurse specialist; and a non-staff member): Cardiac Rehabilitation, Physical Therapy, [name of off-site clinic], Laboratory, and Radiology.

Reviewed on 03/26/13, the 2012 Annual Program Evaluation lacked evidence of annual policy and procedure review for the departments listed above. The CAH provided no other evidence of policy and procedure annual review in 2012 for the departments listed above.

During interview, at 1:00 p.m. on 03/26/13, an administrative cardiac rehabilitation staff member (#5) reported she was unaware when the CAH reviewed the manual.

During interview at 1:50 p.m. on 03/26/13, two administrative laboratory staff members (#3 and #14) confirmed the CAH had not reviewed the laboratory policies and procedures in 2012.


16379

During interview, at 2:30 p.m. on 03/26/13, an administrative radiology staff member (#3) confirmed the CAH had not reviewed the radiology policies and procedures in 2012.

During interview, at 2:00 p.m. on 03/26/13, an administrative physical therapy staff member (#4) confirmed the CAH had not reviewed the physical therapy policies and procedures annually.

During interview the afternoon of 03/27/13, an administrative nursing staff member (#2) confirmed the CAH had not reviewed the [name of off-site clinic] policies and procedures in 2012.

1. Based on record review, review of professional reference, and staff interview, the Critical Access Hospital (CAH) failed to provide care according to patient needs for 1 of 3 closed inpatient records (Patient #13) regarding administration of psychoactive medications and opioid pain medications. Provision of these medications placed Patient #13 at risk of falls, injuries, and decreased responsiveness related to excessive medication.

Findings include:

Nursing 2011, "Drug Handbook," 31st edition, Lippincott, Philadelphia, reviewed on on 03/27/13, stated the following:
*pages 663-664 - "Haloperidol, Haldol . . . Incompatibilities: . . . morphine . . . ADVERSE REACTIONS, CNS [Central Nervous System] . . . sedation . . . INTERACTIONS . . . CNS depressants: May increase CNS depression. . . ."
*pages 696-697 - "Ativan . . . ADVERSE REACTIONS, CNS . . . sedation . . . INTERACTIONS . . . CNS depressants: May increase CNS depression. . . ."
*pages 760-763 - "Morphine . . . Incompatibilities: . . . haloperidol . . . ADVERSE REACTIONS, CNS . . . sedation . . . INTERACTIONS . . . CNS depressants . . . May cause respiratory depression, hypotension, profound sedation, or coma. . . ."

The National Institutes of Health internet website, nih.gov, "Daily Med," reviewed on 03/27/13, stated ". . . NORCO (hydrocodone with acetaminophen) . . . is an opioid analgesic . . . Drug Interactions: Patients receiving other narcotics . . . antipsychotics, antianxiety agents, or other CNS depressants . . . with NORCO may exhibit an additive CNS depression. . . ."

- Reviewed on 03/26/13, Patient #13's closed inpatient medical record identified the CAH admitted the patient on 01/22/13 and discharged the patient on 01/26/13 with diagnoses including fractured ribs, congestive heart failure, and atrial fibrillation.

Physician medication orders included the following:
*Ativan (an antianxiolytic) 2 milligrams (mg)/milliliter (ml), 1 mg, intravenously (IV), ordered 01/23/13, one time dose.
*Haldol (an antipsychotic) 2 mg, IV, every four hours (q4h), as needed (prn), for agitation, ordered 01/22/13.
*Hydrocodone-acetaminophen (NORCO) (an opioid pain medication) 5/325 mg, 1-2 tablets, (q4h) prn for pain, ordered 01/22/13.
*Ativan 2 mg/ml, 1 mg, IV, q8h, prn, for anxiety and agitation, ordered 01/24/13.
*Morphine (an opioid pain medication) 4 mg/ml, 1-2 mg, IV, q4h, prn, for pain, ordered 01/23/13, discontinued 01/24/13.
*Morphine 4 mg/ml, 2-4 mg, IV, q4h, prn, for pain, ordered 01/24/13.

Patient #13's Medication Administration Report (MAR), for the period 01/22/13 through 01/26/13, showed the CAH staff administered the following antipsychotics, antianxiety, and opioid analgesic medications:
*01/22/13-
4:15 p.m. - NORCO, 5/325, 2 tablets
8:35 p.m. - NORCO, 5/325, 2 tablets
10:45 p.m.- Haldol, 2 mg, IV
*01/23/13-
2:45 a.m. - Haldol, 2 mg, IV
10:00 a.m. - Haldol, 2 mg, IV
3:54 p.m. - Morphine, 2 mg, IV
5:45 p.m. - NORCO, 5/325, 2 tablets
9:00 p.m. - Morphine, 2 mg, IV
9:00 p.m. - Haldol, 2 mg, IV
11:10 p.m. - Ativan, 1 mg, IV
*01/24/13-
4:40 a.m. - Haldol, 2 mg, IV
4:40 a.m. - Morphine, 2 mg, IV
11:22 a.m. - Morphine, 4 mg, IV
2:37 p.m. - Ativan, 1 mg, IV
3:57 p.m. - Morphine, 4 mg, IV
*01/25/13-
1:15 a.m. - Ativan, 1 mg, IV
1:49 a.m. - Morphine, 4 mg, IV
5:22 a.m. - Morphine, 4 mg, IV
6:36 a.m. - Ativan, 1 mg, IV
11:15 p.m. - Morphine, 4 mg, IV
*01/26/13-
12:15 a.m. - Ativan, 1 mg, IV
3:30 a.m. - Morphine, 4 mg, IV
9:45 a.m. - NORCO, 5/325, 2 tablets
10:20 a.m. - Morphine, 4 mg, IV

The MAR shows the CAH staff administered the medications as follows:
*NORCO, orally, four times and Morphine, IV, 10 times
*Morphine and Haldol (Incompatible) at the same time, IV, twice in the same eight hour period, 01/23/13 at 9:00 p.m. and 01/24/13 at 4:40 a.m.
*Ativan IV on 01/25/13 at 1:15 a.m. and 6:36 a.m., 5 hours 21 minutes between doses instead of 8 hours as ordered.

During interview, on 03/27/13 at 2:30 p.m., an administrative nursing staff member (#2) reported Patient #13 did have some behaviors during her stay, however, this staff member was not aware of the patient's medications. Following the exit conference, at approximately 3:30 p.m., the staff member (#2) and a consulting pharmacy staff member (#19) reported the consultant pharmacist was not aware of the medications administered to Patient #13.



28086

2. Based on record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to monitor and document the effectiveness of medications given to patients on an as needed (prn) basis for 4 of 9 patient records (Patient #2, #3, #4, and #34) reviewed who received prn medications for pain/discomfort. Failure to evaluate the patient's response to prn medications limited the nursing staff's ability to determine 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 the policy "Pain Management" occurred on 03/27/13. This policy, revised and effective June 2012, stated, ". . . POLICY: . . . 5. The patient's right to appropriate assessment and management of pain will be recognized. . . . 1. Initial Assessment . . . a comprehensive assessment of pain quality and intensity is done which includes location, and the patient's acceptable level of pain. 2. Reassessment: A. Is the evaluation of the effectiveness of a pain intervention within a clinically appropriate time frame. B. Is completed at a minimum, within 60 minutes of pharmacological interventions. . . . DOCUMENTATION: 1. Document the following in the medical record: Pain assessment and reassessments . . ."

- Review of Patient #4's active swing bed record occurred on 03/26/13 and identified the CAH admitted the patient on 02/24/13 with diagnoses including a prosthetic joint infection in the left hip. The record indicated Patient #4 required prn medication for left hip pain and showed an order for hydrocodone/acetaminophen 7.5/325 milligrams (mg) one to two tablets (tabs) every four hours prn. Review of Patient #4's Medication Administration Records (MARs) and daily flowsheet documentation showed the following administration times and patient responses for the hydrocodone/acetaminophen:
*02/24/13 at 10:58 p.m.: received two tabs for pain rating eight out of ten (8/10) on a zero to ten scale (the scale represented zero as no pain and ten as the most pain), no response documented until 4:45 a.m. the next morning (about six hours later).
*02/25/13 at 4:45 a.m. and 6:40 p.m.: received two tabs for pain rating 5-6/10, no responses documented.
*02/26/13 at 4:46 a.m. and 6:24 p.m.: received two tabs for pain rating 5-6/10, no responses documented.
*02/27/13 at 7:58 a.m., 1:10 p.m., and 9:45 p.m.: received two tabs for pain rating 3-6/10, no responses documented.
*02/28/13 at 5:00 p.m.: received two tabs for pain rating 6/10, no response documented.
*03/01/13 at 8:30 a.m.: received two tabs for pain rating 6/10, no response documented. Received two tabs at 10:27 p.m. with no response documented until 6:00 a.m. the next morning (over seven hours later).
*03/02/13 at 8:59 a.m., 2:00 p.m., and 9:15 p.m.: received two tabs for pain rating 4-6/10, no responses documented.
*03/03/13 at 8:47 a.m.: received one tab for pain rating 4/10, no response documented until 12:01 p.m. (over three hours later).
*03/04/13 at 8:50 a.m., 12:11 p.m., and 9:11 p.m.: received one tab for pain rating 3-4/10, no responses documented.
*03/05/13 at 9:18 a.m.: received one tab for pain rating 3/10, no response documented.
*03/06/13 at 8:16 a.m.: received one tab for pain rating 2/10, no response documented.

- Review of Patient #3's active swing bed record occurred on 03/26/13 and identified the CAH admitted the patient on 03/19/13 with diagnoses including a pathological fracture of the right humerus. The record indicated Patient #3 required prn medication for right arm pain and showed an order for hydrocodone/acetaminophen 5/325 mg one to two tabs every six hours prn. Review of Patient #3's MARs and daily flowsheet documentation showed the following administration times and patient responses for the hydrocodone/acetaminophen:
*Received for pain rating 1/10 on 03/19/13 at 9:46 a.m. with no response documented until 12:45 p.m. (three hours later). Received for mild pain at 9:15 p.m., no response documented.
*Received for mild pain on 03/22/13 at 8:00 a.m. with no response documented until 10:00 a.m. (two hours later).
*Received for mild pain on 03/24/13 at 8:00 a.m. with no response documented until 10:03 a.m. (two hours later).

- Review of Patient #34's closed swing bed record occurred on 03/25/13 and identified the CAH admitted the patient on 11/02/12 with diagnoses including left total knee replacement. The record indicated Patient #34 required prn medication for left knee pain and showed an order for hydrocodone/acetaminophen 5/325 mg one to two tabs every four hours prn. Review of Patient #34's MARs and daily flowsheet documentation showed the following administration times and patient responses for the hydrocodone/acetaminophen:
*11/02/12 at 9:00 p.m.: received two tabs with no response documented until 10:54 p.m. (almost two hours later).
*11/03/12 at 1:00 a.m.: received two tabs with no response documented until 3:00 a.m. (two hours later). Received two tabs at 7:02 a.m., 3:53 p.m., and 9:00 p.m. with no responses documented.
*11/04/12 at 1:04 p.m.: received two tabs with no response documented until 3:00 p.m. (almost two hours later). Received two tabs at 5:51 p.m. and 9:58 p.m. with no responses documented.
*11/05/12 at 2:29 a.m. and 5:45 p.m.: received two tabs, no responses documented.
*11/06/12 at 1:44 a.m.: received two tabs, no response documented. Received two tabs at 6:00 a.m. with no response documented until 9:00 a.m. (three hours later). Received two tabs at 10:32 a.m., 2:00 p.m., and 6:30 p.m. with no responses documented.
*11/07/12 at 4:01 a.m.: two tabs given, no response documented.

Patient #3, #4, and #34's records lacked evidence nursing staff monitored and evaluated the effectiveness of the patient's prn pain medication and/or did so within sixty minutes per the CAH's policy.

- Review of Patient #2's active inpatient record occurred on March 25-27, 2013 and identified the CAH admitted the patient on 03/23/13 with diagnoses including pneumonia.

Patient #2's MAR lacked documentation the staff assessed the effectiveness of the following prn medications administered:
*03/24/13 - 1,000 mg of Tylenol administered at 12:11 p.m. and 9:00 p.m.
*03/25/13 - 1,000 mg of Tylenol administered at 4:40 p.m.

During an interview on the morning of 03/26/13, an administrative nurse (#2) confirmed Patient #2, #3, #4, and #34's records lacked consistent documentation of patient responses after administration of prn medications. The nurse (#2) stated she expected nursing staff to evaluate the effectiveness of prn medication within an hour after administration and document the result in the patient's medical record.


27645

Based on record review, review of policy and procedure, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to develop nursing care plans within a timely manner, individualize the care plan according to each patient's specific needs, and implement interventions listed on the care plan for 6 of 12 patient records(Patients #3, #4, #5, #7, #14, and #34) reviewed who experienced limited mobility, pain, falls, skin breakdown, and infection. Failure to develop, implement, and individualize care plans limited the CAH's ability to manage patients' needs, communicate treatment approaches, and ensure continuity of care.

Findings include:

Review of the Centers for Disease Control and Prevention internet site, cdc.gov, occurred on 03/27/13. The internet site stated, ". . . Healthcare-associated Infections (HAIs) . . . Clostridium difficile [C. difficile] infection . . . patients can get sick from C. difficile picked up from contaminated surfaces . . . Patients Can: . . . Wash your hands after using the bathroom. Try to use a separate bathroom if you have diarrhea, or be sure the bathroom is cleaned well if someone with diarrhea has used it. . . ."

Review of the policy "Documentation Guidelines" occurred on 03/27/13. This policy, revised June 2011, stated,
"PURPOSE: DOCUMENTATION GUIDELINES-INPATIENT, The patient chart will: . . . 7. Be integrated whereby the plan of care and patient chart are complementary and will reflect on-going evaluation of progress toward achieving expected outcomes. . . .
POLICY: . . . DOCUMENTATION BY PERSONNEL: . . . The Registered Nurse [RN] . . . 2. The RN's documentation reflects the nursing plan of care based on a continuum from admission to discharge; this documentation also reflects the RN's evaluation of the client family's responses to nursing interventions. . . ."

Review of the policy "Documentation Standards" occurred on 03/27/13. This policy, dated 02/27/12, stated, ". . . 7. Learning assessments and care plans will be initiated by the RN. Care plan notes should be entered each shift by the licensed nurse. Care plans and education should be resolved at the time of discharge or transfer. . . ."

- Review of Patient #3's medical record identified the CAH admitted the patient to swing bed status on 03/19/13 after he experienced a fall and "pathologic" fracture of the right humerus. The patient's admission physician orders, dated 03/19/13, regarding the right upper extremity, included: ice, elevation, and an occlusive dressing for four days.

Patient #3's current care plan regarding Activities of Daily Living (ADLs) stated the patient required assistance with hygiene, bathing, and feeding; and, required assistance with ambulation, active mobility, and passive mobility.

Patient #3's care plan lacked information regarding mobility restrictions of his right upper extremity during activities such as bathing and dressing, and scheduled wearing of the right upper extremity immobilizer.

During interview, on 03/26/13 at 4:00 p.m., an administrative nursing staff member (#2) agreed Patient #3's nursing care plan lacked information that provided direction to the nursing staff regarding Patient #3's right upper extremity mobility restrictions.

Further review of Patient #3's active swing bed record identified the patient required "as needed" (prn) medication for pain related to the right arm fracture and showed an order for hydrocodone/acetaminophen 5/325 mg (milligrams) one to two tablets every six hours prn. Review of Patient #3's Medication Administration Record (MAR) showed the patient received one to two doses of hydrocodone/acetaminophen approximately every other day from March 19-24, 2013 for mild pain. Patient #3's care plan, dated 03/19/13, identified the problem "Acute Pain" and indicated "Pain Control" as the goal. Interventions stated on the care plan included the following, "1. Pain Management . . . Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. 2. Medication Management . . . Facilitation of safe and effective use of prescription and over-the-counter drugs. 3. Non-pharmacological Pain Management . . ." The care plan interventions failed to include specific information regarding Patient #3's individualized needs (such as the patient's tolerable or acceptable level of pain, type of prescription and over-the-counter medication, type of non-pharmacological treatments, etcetera) to guide staff in assisting the patient achieve his pain control goal.

Patient #3's record showed nursing staff completed a fall risk assessment on admission and identified the patient as a high fall risk. Patient #3 wore an immobilizer or sling on his right arm due to a fracture, which limited his mobility. Transfers and ambulation required stand by assistance from staff. The patient's care plan, dated 03/19/13, identified the problem "Risk for Falls" and indicated "Falls Occurrence" as the goal. Interventions listed on the care plan included the following, "1. Fall Prevention . . . Instituting special precautions with patient at risk for injury from falling. . . . 6. Refer to therapies, as appropriate . . . 7. Surveillance: Safety . . . 8. Provide appropriate level of supervision/surveillance to monitor patient and to allow for therapeutic actions . . ." The care plan interventions failed to include specific information regarding Patient #3's individualized needs to guide staff in assisting the patient and preventing falls.

- Review of Patient #7's closed observation patient record occurred on 03/26/13. The CAH admitted the patient on 02/12/13 and discharged the patient to her home on 02/14/13. The patient's admitting diagnoses included diarrhea and dehydration.

Patient #7's laboratory stool culture test report identified "Clostridium difficile." Nurse's notes, dated 02/13/13, stated, "C. diff. [Clostridium difficile] (+) [positive]. Precautions in place. . . ." The medical record failed to identify the precautions.

Patient #7's nursing care plan failed to include "C. diff." or any precautions implemented, including handwashing instructions, isolation, or ensuring the patient used one toilet.

During interview, on 03/27/13 at 2:30 p.m., an administrative nursing staff member (#2) agreed staff should have included C. difficile precautions and instructions on Patient #7's care plan.

- Reviewed on 03/25/13, the CAH's accident and incident reports identified Patient #14 experienced falls on 01/25/13, 01/31/13, and 02/01/13.

Review of Patient #14's closed inpatient and swing bed medical records occurred on 03/26/13. The CAH admitted the patient on 01/25/13, transferred the patient to swing bed status on 02/09/13, and discharged the patient on 02/21/13. Admission diagnoses included nausea, vomiting, and urinary tract infection.

Patient #14's Risk Management Worksheets, provided by the CAH, identified the following falls:
*01/25/13, 12:00 p.m. - ". . . Pt. [Patient] states able to ambulate to BR. [bathroom]. Pt. assisted by 2. Halfway to BR pt. unable to stand. Pt. lowered by staff of 2. . . .
Fall Inter [Interventions]: Commode by bed; High Risk Signage; Observation bed/close to RN [Nurse's] Station . . . Fall Prevent [Prevention]: Communicate to Staff . . ."
*01/31/13, 11:00 a.m. - ". . . Patient had unobserved fall at 1100 [a.m.]. . . . she was asleep in bed and 'woke up to the crash, and I was on the floor.' Patient had 1 bedside rail up and rolled out of bed on the side she did not have the rail up. . . .
Fall Prev [Prevention] Pgm [Program] - Y [Yes] . . ." The Worksheet lacked any other Fall Prevention or Interventions.
*02/01/13, 9:00 p.m. - ". . . CNA [Certified Nursing Assistant] found patient lying on left side on floor. . . . States just 'slid nicely to the floor.' Was heading for the bathroom with 4 wheel walker . . . Had call bell lying on bedside table . . . in front of her when sitting in the chair. . . .
Fall Prevent: Alarms; Commode by Bed; Hourly Rounds; Personal items w/in [within] reach; Side rails up x [times] 2; Observation bed close to RN station. . . ."

Patient #14's care plan identified the following approaches/interventions regarding the resident's risk for falls:
*02/01/13, 8:31 a.m. - ". . . Patient has had 2 falls during this hospitalization (01/25 and 01/31) - use bed alarm at night, offer reminders, be certain room is free of clutter, have access to call light."
*02/04/13, 2:43 p.m. - ". . . Patient had 2 falls last week - use bed alarm and chair alarm. Monitor for ongoing safety, is close to nurses station."
*02/11/13, 1:55 p.m. - ". . . Patient remains at high risk for falls - has had 3 falls since acute admission. Use bed alarm and chair alarm. Remind patient frequently of limitations."
Staff modified Patient #14's care plan ten days after her fall. The care plan lacked the fall prevention approaches/interventions identified on the Risk Management Worksheets.

During interview, on 03/27/13 at 2:30 p.m., an administrative nursing staff member (#2) agreed staff should have included fall prevention approaches/interventions on Patient #14's care plan in a timely manner after the falls.


28086


- Review of Patient #4's active swing bed record occurred on 03/26/13 and identified the CAH admitted the patient on 02/24/13 with diagnoses including a prosthetic joint infection of the left hip and a history of right below the knee amputation. Patient #4's admission history and physical (H&P) indicated the patient as non-ambulatory at the present time. Review of nursing assessments showed Patient #4 required stand by assistance of staff or one staff member for bed mobility and required transfers from the bed to the chair with a sliding board and one to two staff members. Physical therapy staff performed an evaluation on 02/25/13 and recommended further treatment one to two times a day. Occupational therapy staff performed an evaluation on 02/26/13 and recommended further treatment five times a week. Patient #4's record lacked evidence of a multidisciplinary care plan as physical and occupational therapy staff failed to develop a care plan relating to their treatment. The record lacked a care plan to address Patient #4's limited mobility and activity.

Patient #4's record showed nursing staff completed a fall risk assessment on admission and identified the patient as a high fall risk. The patient's care plan, dated 02/26/13, identified the problem "Risk for Falls" and indicated "Falls Occurrence" as the goal. Interventions listed on the care plan included the following, "1. Fall Prevention . . . Instituting special precautions with patient at risk for injury from falling. . . . 4. Surveillance: Safety . . . 5. Provide appropriate level of supervision/surveillance to monitor patient and to allow for therapeutic actions . . ." The interventions failed to include specific information regarding Patient #4's individualized needs to guide staff in assisting the patient to help prevent falls.

A physician's progress note, dated 03/04/13 at 8:05 a.m., stated, ". . . PLAN: . . . 2. For pressure sore-continue dressings, modified positioning, encourage Ensure, multivitamin to supplement nutrition. . . . Physical Exam: . . . Skin: . . . Buttocks: There is a duoderm in place over the entire lower back and coccygeal area. He [sic] erythema and about 2nd degree skin breakdown at the inferior border of the duoderm. . . ." The patient's care plan, dated 02/26/13, identified the problem "Risk for/and Impaired Skin Integrity" and indicated "Tissue Integrity: Skin and Mucous Membranes" as the goal. Interventions listed on the care plan included the following: "1. Skin Surveillance . . . 2. Promote adequate nutrition and hydration . . . 3. Consider specialty bed, mattress, or positioning aids . . ." The interventions failed to include specific information regarding Patient #4's individualized needs to guide staff in assisting the patient repair and maintain skin integrity.

- Review of Patient #5's active swing bed record occurred on 03/26/13 and identified the CAH admitted the patient on 03/21/13 with diagnoses including a cerebral vascular accident (CVA) or stroke. The record showed nursing staff completed a fall risk assessment on the patient upon admission and identified him as a high fall risk. The admission nursing assessment showed Patient #5 as forgetful, impulsive, weak, and unsteady, but able to ambulate and transfer independently. The patient's care plan, dated 03/21/13, identified the problem "Risk for Falls" and indicated "Falls Occurrence" as the goal. Interventions listed on the care plan included the following: "1. Fall Prevention . . . Instituting special precautions with patient at risk for injury from falling. . . . 4. Surveillance: Safety . . . 5. Provide appropriate level of supervision/surveillance to monitor patient and to allow for therapeutic actions . . ." The interventions failed to include specific information regarding Patient #5's individualized needs to guide staff in assisting the patient to help prevent falls.

- Review of Patient #34's closed swing bed record occurred on 03/25/13 and identified the CAH admitted the patient on 11/02/12 with diagnoses including left total knee replacement. The record indicated Patient #34 required prn medication for pain related to her left knee and showed an order for hydrocodone/acetaminophen 5/325 mg one to two tablets every four hours prn. Review of Patient #34's MAR indicated the patient received two tablets of hydrocodone/acetaminophen during each administration and showed administration of the medication one to four times a day from November 2-7, 2012. Patient #34's care plan, dated 11/05/12, identified the problem "Acute Pain" and indicated "Pain Control" as the goal. Interventions listed on the care plan included the following, "1. Pain Management . . . Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. 2. Medication Management . . . Facilitation of safe and effective use of prescription and over-the-counter drugs. 3. Non-pharmacological Pain Management . . ." The interventions failed to include specific information regarding Patient #34's individualized needs to guide staff in assisting the patient achieve her pain control goal.

During an interview on the afternoon of 03/26/13, an administrative nurse (#2) stated Patient #3, #4, #5, and #34's care plans lacked specific information about the patients' needs and she expected staff to individualize the care plans.

Based on policy review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure all departments affecting patient health and safety reported to the Quality Assurance (QA) Committee for 12 of 12 months reviewed (January-December 2012). Failure to ensure all departments report to the QA Committee, limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the "Quality Assurance Plan" occurred on 03/26/13 at 3:55 p.m. This undated policy stated,
". . . Scope
. . . Each department that has an impact on patient care will be included in the program . . ."

Reviewed at approximately 4:05 p.m. on 03/26/13, the 2012 QA Committee meeting minutes lacked evidence the off-site clinic reported to the QA Committee.

During interview at 8:55 a.m. on 03/27/13, an administrative nursing staff member (#2) confirmed the off-site clinic did not report to the QA Committee in 2012.

Based on record review and staff interview, the critical access hospital (CAH) failed to ensure notification of the organ procurement organization (OPO) for 1 of 2 patient records (Patient #10) reviewed of a patient who died in the CAH. Failure to notify the OPO prevented the opportunity to determine the medical suitability for organ donation.

Findings include:

Reviewed on 03/26/13, Patient #10's emergency department (ED) record identified the CAH admitted the patient on 10/22/12. The patient expired in the ED. The ED record lacked evidence the CAH staff contacted the OPO regarding potential organ donation.

During interview, on 03/27/13 at approximately 9:00 a.m., an administrative nursing staff member (#2) confirmed the CAH staff should have contacted the OPO.