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Based on policy review and staff interview, the Critical Access Hospital (CAH) failed to ensure compliance with Federal regulations regarding advance directives at CFR 489.102 for 1 of 1 advance directive policy. Failure to include required information regarding potential conscience objections placed patients at risk of receiving undesired treatment.

Findings include:

Review of the CAH's policy titled "Advance Directives" occurred on April 25-26, 2012. The policy, revised 12/03, lacked a precise statement of limitation if the provider or the CAH could not implement the patient's advance directive on the basis of conscience, and failed to describe the range of medical conditions or procedures affected by the conscience objection.

During an interview, on the morning of 04/26/12, a social services staff member (#7) confirmed the CAH policy lacked a statement regarding conscience objections.

Based on review of records, medical staff rules and regulations, meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to ensure the availability of a health care practitioner 24 hours a day for 2 of 11 closed emergency room (ER) records (Patients #22 and #23) reviewed. Failure to ensure the availability of emergency services 24 hours a day placed patients seeking emergency care at risk of not receiving appropriate treatment.

Findings include:

Review of the CAH's "Rules and Regulations of the Medical Staff" occurred on 04/24/11. The document, adopted on 09/16/08, stated, "General Conduct of Care . . . 7. On Call Procedure: If a practitioner's name appears on the 'Call List', it is implied that the practitioner is available for contact by the hospital concerning inpatients and is available to handle emergency care for patients . . . d. The practitioner will respond within 30 minutes. . . ."

Review of the CAH's Medical Executive Committee meeting minutes occurred on 04/24/11. Minutes from the 05/24/11 meeting stated, "NEW BUSINESS . . . When patients present to the ER they have to be assessed before they can be brought to the clinic. . . ."

- Review of Patient #23's ER record occurred on all days of survey. The record identified the one year old patient presented to the ER on 10/19/11 at 7:39 a.m. The record showed the child "awakened with cough, heavy breathing et [and] was restless during noc [night]." The record indicated the physician arrived at 8:04 a.m. and "Talked to parent et [and] instructed them to have child seen in clinic. Appt [appointment] made for [Patient #23] at 9 AM at [local clinic] [with] [practitioner's name]. Parent agreeable but somewhat upset appearing." The record lacked evidence the physician performed a medical screening examination (MSE) prior to recommending the patient be seen at the clinic.

- Review of Patient #22's ER record occurred on all days of survey. The record identified the patient presented to the ER on 12/13/11 at 9:34 a.m. with right ankle, knee, thigh, and great toe pain following a fall which occurred the day before. The record stated, "0940 [9:40 a.m.]: provider aware. Provider recommended that pt [patient] be given the option to be seen in clinic. 0945: Brought patient to clinic in wheelchair [without] incidence [sic]. . . ." The record lacked evidence of a MSE performed in the ER.

On 04/26/12 at 7:40 a.m. an administrative nurse (#7) provided information regarding Patient #22 and #23. She stated Patient #23's parent did not keep the clinic appointment scheduled for 9:00 a.m. on 10/19/11. The nurse (#7) confirmed neither Patient #22 nor #23 had a MSE while in the ER.

Based on observation, review of the North Dakota Century Code, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to limit and prevent access to the hospital pharmacy by unauthorized personnel in 1 of 1 pharmacy. Failure of the CAH to adequately secure and restrict access of all medications allowed an opportunity for unsafe and unauthorized use of medications and has the potential to create insufficient distribution, control, and accountability of medications.

Findings include:

The North Dakota Century Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. 1. General. During such times as a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance by the director for the provision of drugs to the medical staff and other authorized personnel of the hospital, by use of the night cabinets or floor stock, or both, and in emergency circumstances, by access to the pharmacy . . . 3. Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section. One supervisory registered professional nurse and only one in any given eight-hour shift is responsible for removing drugs therefrom. The responsible nurse, in times of emergency, may delegate this duty to another nurse. The responsible nurse must be designated by position, in writing, by the appropriate committee of the hospital and, prior to being permitted to obtain access to the pharmacy, shall receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required. . . ."

Review of the policy "Access To Pharmacy In Absence Of Pharmacist" occurred on 04/25/12. This policy, revised December 1995, stated, "One supervisory registered professional nurse is responsible for removing drugs from the hospital pharmacy in any given 8-hour shift. . . ."

A tour of the hospital pharmacy took place on 04/25/12 at 10:38 a.m. with an administrative nurse (#1). Observation showed the pharmacy locked and lacking the presence of a pharmacist or pharmacy personnel. The administrative nurse (#1) stated the charge nurse on duty had access to the pharmacy with a key and could enter the pharmacy to obtain medications for patients.

An observation on 04/25/12 at 11:13 a.m. showed a staff nurse (#6), identified as the medication nurse on duty, entered the pharmacy and removed a bottle of medication.

During an interview on 04/25/12 at 11:25 a.m., a staff nurse (#6) stated she entered the pharmacy and removed a bottle of oral antibiotics for a patient. The nurse (#6) stated all nurses on duty had access to the pharmacy with a key and could enter the pharmacy to obtain medications if needed.

During another interview on 04/26/12 at 11:25 a.m., an administrative nurse (#1) confirmed all nurses on duty may access the pharmacy and remove medications needed for patients in the absence of the pharmacist or pharmacy personnel. The administrative nurse (#1) stated the nurses must only remove the immediate dose needed for the patient rather than the whole bottle or multiple doses.

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 for 3 of 4 active swing bed patients (Patients #3, #4, and #29) observed receiving toileting assistance, catheter care, and peri-cares. 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 . . . 6. Other Aspects of Hand Hygiene . . . D. Remove gloves after caring for a patient. . . ."

Review of the policy "Hand Hygiene" occurred on 04/25/12. This policy, revised March 2007, stated, ". . . II. PURPOSE: To protect healthcare workers and others from harmful microorganisms; to promote patient safety by preventing transmission of infection from one patient to another via the healthcare worker; and to remove transient bacteria on hands contaminated after handling patients, objects and surfaces. . . . C. Decontaminate hands before and after having direct contact with patients. . . . F. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin and wound dressings if hands are not visibly soiled. . . . H. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. I. Decontaminate hands after removing gloves. . . ."

Review of the policy "Peri-Care" occurred on 04/26/12. This policy, reviewed September 2009, stated, ". . . Good hand washing is essential before and after procedures involving body fluids. Use Standard (Universal) Precautions for all situations of peri-care. . . ."

Review of the policy "Nursing Assistants: General Duties" occurred on 04/26/12. This policy, reviewed and revised November 2009, stated, "1. Use diligent handwashing before and after cares of each patient. Also use appropriate hand hygiene between cares. . . ."

- The following observations showed staff failed to perform hand hygiene or hand washing after toileting, performing peri-cares, and prior to moving onto other tasks:
*Observation on 04/24/12 at 11:17 a.m. showed two nursing staff members (#4 and #8) entered Patient #4's room, donned gloves, and assisted the patient to the toilet in the bathroom with the EZ Stand (a mechanical device used by staff to transfer patients). Patient #4 voided in the toilet and when finished, the two nursing staff members (#4 and #8) assisted the patient to stand. One nursing staff member (#4) cleansed Patient #4's peri-area of urine, removed gloves, and pulled up the patient's pants; then both staff members (#4 and #8) assisted the patient out of the bathroom to the wheelchair, removed Patient #4's arm sling, and removed the EZ stand pad and leg strap. A staff member (#4) obtained a washcloth, wet the cloth with water under the sink, handed the washcloth to Patient #4 to wash her face and hands, then handed the patient a glass of water, and placed gloves and combed Patient #4's hair. At this time, the nursing staff member (#4) removed gloves, performed hand washing, and left the patient's room.
*Observation on 04/24/12 at 2:25 p.m. showed a nursing staff member (#5) entered Patient #3's room, donned gloves, and assisted the patient to stand from the toilet in the bathroom. The staff member (#5) wiped Patient #3's peri-area of stool, removed gloves, pulled up the patient's pants, and assisted the patient out of the bathroom to the recliner. Next, the nursing staff member (#5) removed the gait belt from Patient #3, assisted the patient to place her legs up in the recliner, attached the patient's urine catheter bag to the side of the recliner, placed pillows underneath Patient #3's back and legs, placed the call light next to the patient, and straightened up the room. At this time, the nursing staff member (#5) performed hand washing and left the patient's room.
*Observation on 04/25/12 at 7:40 a.m. showed a nursing staff member (#5) donned gloves, assisted Patient #4 to stand in the bathroom with the EZ Stand after using the toilet, cleansed the patient's peri-area of urine, removed gloves, and assisted the patient out of the bathroom with the EZ Stand to the bed. The staff member (#5) donned gloves, assisted Patient #4 with a bed bath, placed clothing on the patient's upper half and placed a brief, assisted the patient to stand with the EZ Stand, performed peri-cares with a washcloth, pulled up the patient's brief, and assisted the patient to the wheelchair. Next, the nursing staff member (#5) placed Patient #4's pants, socks, and shoes, assisted the patient to stand with the EZ Stand, pulled up the patient's brief and pants, and assisted the patient to sit in the wheelchair. The nursing staff member (#5) then performed hand washing and left the patient's room.

- Observation upon entering Patient #29's room on 04/24/12 at 1:00 p.m. showed a nursing staff member (#8) donned with gloves, emptying urine from a catheter bag into a container. The staff member (#8) took the container of urine into Patient #29's bathroom and closed the door. A few moments later, the staff member (#8) exited the bathroom, removed gloves, left the patient's room, and walked down the hall toward the nurse station. Observation showed Patient #29's bathroom lacked a sink or evidence of hand sanitizer. Observation showed the nursing staff member (#8) failed to perform hand hygiene or hand washing after performing urine catheter cares, removing gloves, and leaving Patient #29's room.

- The following observations showed staff failed to perform hand hygiene or hand washing after removing their gloves and prior to donning new gloves or completing other tasks:
*Observation on 04/24/12 at 11:17 a.m. showed two nursing staff members (#4 and #8) entered Patient #4's room, donned gloves, assisted the patient to the toilet in the bathroom with the EZ Stand, and removed gloves. The staff members (#4 and #8) immediately donned gloves again, assisted the patient to stand, and one of the nursing staff members (#4) cleansed Patient #4's peri-area of urine and removed gloves. The other nursing staff member (#8) removed gloves and both staff members (#4 and #8) assisted the patient out of the bathroom to the wheelchair. Observation showed both staff members (#4 and #8) completed multiple tasks with the patient and in the patient room after removing their gloves.
*Observation on 04/25/12 at 7:40 a.m. showed a nursing staff member (#5) donned gloves, assisted Patient #4 to stand in the bathroom with the EZ Stand after using the toilet, cleansed the patient's peri-area of urine, removed gloves, and assisted the patient out of the bathroom with the EZ Stand to the bed. The staff member (#5) donned gloves again and continued to assist Patient #4 with bathing, peri-cares, and dressing. Observation showed the nursing staff member (#5) completed multiple tasks and failed to perform hand hygiene or hand washing after removing gloves and prior to donning new gloves.

- Observation on 04/24/12 at 11:17 a.m. showed two nursing staff members (#4 and #8) assisted Patient #4 to the toilet in the bathroom with the EZ Stand. A staff member (#8) grabbed Patient #4's pillow (the pillow used under the patient's head for sleep) from the bed and placed the pillow behind the patient for support while she sat on the toilet. The nursing staff members (#4 and #8) assisted the patient from the bathroom to her wheelchair, and a staff member (#8) placed the same pillow used to support Patient #4 on the toilet under the patient's arm for support while in the wheelchair.

During an interview on 04/25/12 at 1:45 p.m., a nursing staff member (#5) stated staff must wash hands or use hand sanitizer after removing gloves and upon leaving patient rooms.

During an interview on 04/25/12 at 5:25 p.m., a nursing staff member (#10) hesitantly stated staff must wash hands or use hand sanitizer upon entering patient rooms, after dealing with body waste, and after removing gloves.

During an interview on 04/26/12 at 10:38 a.m., an administrative nurse (#1) stated staff must wash their hands or use hand sanitizer after emptying a catheter, removing gloves, before placing gloves, and after peri-cares. The nurse (#1) stated after staff completed toileting a patient in the bathroom or commode, she expected staff to secure the patient and then perform hand washing or hand hygiene as soon as possible prior to moving onto other tasks or patients.

Based on observation, review of policy and procedure, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure nursing staff followed current patient care instructions to meet the individualized needs for 2 of 4 active patient (Patients #3 and #4) records reviewed. Failure to follow current patient care information to meet each patient's individualized needs has the potential for patients to receive inappropriate care and treatment or not receive care.

Findings include:

Review of the policy "Day Shift - 2nd Floor Duties Of Nursing Assistants" occurred on 04/26/12. This policy, reviewed and revised September 2009, stated, ". . . [6:00 a.m.] Both aides report to the nurse's station. Pick up daily assignments and aide worksheet and review while getting report. . . ."

Review of the policy "Nursing Assistants: General Duties" occurred on 04/26/12. This policy, reviewed and revised November 2009, stated, ". . . 35. Refer to aide worksheet for patient care information. 36. If any questions about anything, ask the nurse."

- Review of Patient #3's active swing bed record occurred on 04/26/12 and identified the CAH admitted the patient on 11/17/11 with diagnoses of post urinary tract infection and encephalopathy. Patient #3's care plan, dated 11/21/11, identified staff must place a clip alarm (a chair and/or bed alarm) on the patient at all times. During an observation on 04/24/12 at 2:25 p.m., a nursing staff member (#5) entered Patient #3's room to assist the patient from the recliner to the bathroom and as the staff member (#5) started assisting the patient to stand, she stated the patient lacked a clip alarm. The nursing staff member (#5) stated staff must always place a clip alarm on the patient when in bed or in the recliner as Patient #3 has a history of falls and tends to get up on her own rather than call staff to assist her.

- Observation on 04/25/12 at 7:40 a.m. showed two nursing staff members (#5 and #9) assisted Patient #4 to stand with the EZ Stand (a mechanical device used by staff to transfer patients) and transferred the patient to the bathroom. A sign hanging on the bathroom wall stated, "When transferring resident with the EZ stand please use the arm sling at all times." After toileting, a nursing staff member (#5) transferred Patient #4 out of the bathroom to the bed, and a few moments later, transferred the patient from the bed to the wheelchair with the EZ stand. During the above transfers, observation showed the staff members (#5 and #9) failed to provide Patient #4 with an arm sling.

Review of Patient #4's active swing bed record occurred on April 25-26, 2012 and identified the CAH admitted the patient on 12/09/11 with a diagnosis of a right sided stroke and left sided paralysis. Patient #4's care plan lacked information regarding the arm sling.

An interview with a physical therapy staff member (#3) occurred on 04/26/12 at 9:20 a.m. The staff member (#3) stated the most recent orders for Patient #4, ordered on 03/19/12, included using the left arm sling when up in the EZ stand for comfort and support.

During an interview on 04/25/12 at 1:45 p.m., a nursing staff member (#5) stated staff passed along patient care information during report prior to each shift, and all staff received "aide work sheets" which contained specific patient information, but stated staff did not always keep the work sheets current or updated.

During an interview on 04/26/12 at 11:25 a.m., an administrative nurse (#1) stated the nurses and nurse assistants participated in report together prior to each shift change and exchanged patient care information. The nurse (#1) stated all staff members (nurses, nurse assistants, ward clerks, etc.) are responsible for updating the kardex (patient care information) and the aide work sheets when staff receives new orders or patient care information. The administrative nurse (#1) stated she expected staff to follow patient care instructions included on the aide work sheets, so all staff members know how to care for each patient.

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 closed swing bed record (Patient #7) who spilled hot coffee on himself. Failure to implement interventions placed Patient #7 at risk of sustaining a burn from hot liquids.

Findings include:

Review of Patient #7's closed swing bed record occurred on all days of survey. The record showed the hospital admitted Patient #7 on 03/14/12 with diagnoses of prostatic cancer with metastasis. Nurses notes, dated 03/25/12, identified the following:
2:30 p.m. - "NA [nursing assistant] reported that Pt. [patient] was holding coffee cup drinking coffee when Pt accidentally spilled the coffee on himself. Red area from mid abdomen to (L) [left] waist. No blisters noted. Area tender to touch. Red area measuring 8 cm [centimeters] in height and 23 cm in width. 2 small red areas noted to Pt. upper (L) thigh, unsure if these areas are related to the coffee spill. Areas are not tender to touch and no blisters noted. Clothing was changed and a cool cloth applied to red areas."
6:00 p.m. - "Red area on abdomen has decreased in size. Red area is on (L) abdomen measuring 0.5 cm in height and 8 cm in width. Area is not tender to touch. No blisters noted. Pt does not remember spilling coffee. The 2 small red areas on Pts (L) upper thigh are no longer present. No blisters noted on (L) upper thigh. (L) upper thigh is not tender to touch. . . ."
Nurses notes contained no further documentation regarding the red areas.

A "General Event Report," dated 03/25/12, also described the event. The report stated, "FOLLOW UP/ACTION TAKEN: Educated NA about giving Pt hot coffee." The record lacked evidence the facility provided education to staff members other than the nursing assistant on duty at the time of the incident.

Patient #7's care plan identified a problem, dated 03/25/12: "Alteration in skin integrity skin tear (L) forearm coffee burn thigh." Approaches to the problem stated, "1. Cleanse area as ordered. 2. Clear absorbent tegaderm to left forearm [change] weekly et [and] prn [as needed]." Patient #7's care plan failed to identify the potential for injury from spilling hot liquids and lacked interventions to prevent another spill from occurring.

During an interview on 04/25/12 at 4:15 p.m. an administrative nurse (#7) agreed the care plan lacked interventions to prevent future spills of hot liquids.

Based on record review, review of professional literature, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff revised, updated, and maintained nursing care plans for 3 of 4 active patient (Patients #2, #3, and #4) records reviewed. Failure to update, revise, and maintain care plans limited the CAH's ability to communicate treatment approaches, assist the patient to attain/maintain their highest physical, mental, and psychosocial well-being, and ensure continuity of care. Failure to maintain current care plans could result in failing to manage patient's needs.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, pages 212-215, stated, ". . . A formal nursing care plan is a written or computerized guide that organizes information about the client's care. The most obvious benefit of a formal written care plan is that it provides for continuity of care. . . . Care plans include the actions nurses must take to address the client's nursing diagnoses and produce the desired outcomes. The nurse begins the plan when the client is admitted to the agency and constantly updates it throughout the client's stay in response to changes in the client's condition and evaluations of goal achievement. . . . care must be individualized to fit the unique needs of each client. . . ."

Review of the policy "Swing Bed Resident Care Plans" occurred on 04/26/12. This policy, undated, stated, "PURPOSE: The purpose of the care plan is to assess the problems and needs of each resident and develop a plan of caring for that resident so that he/she may attain the highest practicable level of functioning during his/her stay. The resident care plan is developed in coordination with . . . appropriate health care personnel consistent with the . . . provider's orders. PARTS OF THE CARE PLAN: The plan of care shall include . . . time oriented and measurable goals for resolution of each problem and specific approaches for resolution of each problem. CARE PLAN TEAM: . . . representatives from nursing, activities, dietary, physical therapy/restorative care, and social services. . . . CARE PLAN TIME FRAMES: . . . 4. Care plans will be reviewed monthly for . . . three months . . . and quarterly thereafter. Care plans will be reviewed as a team at regularly scheduled care conferences. . . . UPDATES: Resident care plans must be kept current. Revisions can be made at any time by all professional personnel involved in the care of the resident. RESPONSIBILITIES OF CARE PLAN TEAM MEMBERS: All Participating Disciplines: . . . 2. Report care plans back to other staff in your department to ensure continuity of care by all staff. . . ."

- Review of Patient #3's active record occurred on 04/26/12 and identified the CAH admitted the patient on 11/17/11 for post urinary tract infection and encephalopathy. Patient #3's medical history included a recent right ankle fracture with surgical repair. The record included the following:
*A physician consultation order from Patient #3's orthopedic surgeon, dated 11/10/11, stated no weight bearing on the right leg for six weeks and use cam walker (a boot used to provide support, protection, and immobilization) at all times. The care plan identified the problem, "2. [status post] [right] ankle fx [fracture] NWB [non weight bearing] status unable to stand on [left] without bearing weight on [right]" on 11/21/11. Another problem identified on the care plan on 11/21/11, stated, "4. Pain fractured ankle" and listed "1. WBAT [weight bearing as tolerated] NWB [right leg] - keep elevated. 2. Cam walker on . . ." The care plan lacked specific information or instruction about the cam walker and identified conflicting information about Patient #3's weight bearing status.
*A physician consultation order from Patient #3's orthopedic surgeon, dated 12/12/11, stated, "1. Start WB [weight bearing] and gait training - may do 25% WB week 1, 50% WB week 2, 75% WB week 3, 100% WB week 4. 2. Continue cam boot . . ." The care plan failed to include this information.
*A provider order, dated 12/15/11 at 9:50 a.m., stated, ". . . use Dicem [a type of mat] under resident in geri chair to prevent sliding forward . . ." The care plan lacked this information.
*A provider order, dated 01/03/12 at 7:55 a.m., stated, "PT [physical therapy] to initiate gait training. WBAT [weight bearing as tolerated] in cam boot per physician consult dated 12/12/11." This order is dated more than three weeks after the physician consult order on 12/12/11. Another provider order, dated 01/03/12 at 9:25 a.m., stated, "Staff to utilize EZ stand [a mechanical device used by staff to transfer patients] for transfers". On 01/10/12, staff added the problem, "10. [decreased] ambulation status [related to] NWB [secondary to] [right] ankle fx. [decreased] transfer status", and listed a goal which stated, "Initiate ambulation weight bearing as tolerates wearing cam book walker [increase] distance as tolerates up to 80 [feet] increase ability to transfer sit [arrow over to the right] stand [independent] [with] SBA [stand by assist] of 1 [and] verbal cues." The care plan failed to include the order regarding the EZ stand.
*A provider order, dated 01/09/12, stated, "Ted hose [compression stocking used to reduce or prevent swelling in the lower extremities] to [bilateral] L/E [lower extremities], may be off [at] noc [night] prn [as needed]." The care plan failed to include this information.
*A physician consultation order from Patient #3's orthopedic surgeon, dated 01/11/12, stated, "Continue compression hose for swelling, D/C [discontinue] cam boot, swedo ankle brace [used for support] prn." A provider order, dated 01/12/12 at 8:30 a.m., stated, ". . . Swedo ankle type brace for [weight bearing] off [at] noc. . . ." The care plan failed to include this information.
*A provider order, dated 01/17/12 at 4:00 p.m., stated, "Calmoseptine to open area under breast [and] 4x4 [gauze dressing] daily." The care plan failed to include this information.
*A provider order, dated 01/18/12 at 12:25 p.m., stated, "Staff may transfer pt. [patient] to/from toilet and bed [with] FWW [front wheeled walker] or may ambulate pt. to/from toilet . . ." The care plan failed to include this information.
*A provider order, dated 02/01/12 at 8:40 a.m., stated, "Staff to pin alarm to pts clothing rather than use clip [at] all times." The care plan failed to include this information.
*A provider order, dated 02/01/12 at 2:30 p.m., stated, "DC scheduled calmoseptine and gauze for under breasts. May continue to use prn." The care plan failed to include this information.
*A provider order, dated 03/16/12, stated, "D/C [left] AFO [a brace used for foot drop] and [right] ASO (a brace used for support and/or stabilization]". The care plan failed to include this information.
*A provider order, dated 04/24/12 at 1:25 p.m., stated, "Use foot/calf board in addition to standard leg rest to support legs when in w/c [wheelchair]." The care plan failed to include this information.

The staff failed to review and revise Patient #3's care plan as changes occurred in order to maintain an accurate account of the patients' current health status and care needs.

Patient #3's record indicated the patient's vision as significantly impaired due to macular degeneration. Observation of Patient #3's room on 04/24/12 at 2:25 p.m., showed multiple tools to assist the patient with poor vision (i.e. talking book machine, large print books and papers with instructions, lighting, etc.) and objects placed close to the patient and in the same area so the patient could find them. The care plan instructed staff to assist the patient with reading mail and other materials, identifying oneself, explaining tasks and routines, menu selection, identifying foods and liquids on meal trays and in room, and using colored plates for meals. Observation showed the location of Patient #3's room as the last room on the north side of the hallway, down the hall to the left of the nurse station (the farthest room from the nurse station).

Patient #3's record indicated a history of falls. Upon admission, staff completed a fall risk assessment and identified the patient as a "potential risk for falls". The fall risk assessment form failed to include interventions used to minimize Patient #3's risk for falling. The care plan identified a problem of "8. Restless at times" on 11/21/11 and stated, "1. Clip alarm [at] all times 2. EZ Lift/Ceiling lift transfers if needed 3. NWB [right] leg. WBAT 4. Do not leave resident alone when toileting 5. Low bed in lowest position" as approaches or interventions. The record identified Patient #3 as weak and needing assistance of one to two staff members along with the EZ stand lift for all transfers and ambulation. Review of nurse notes from admission to 04/25/12, identified Patient #3 as confused at times and indicated the patient made multiple attempts at transferring and ambulating by herself. The record identified the following:
*On 02/01/12, staff found the patient hunched over the bed on her knees.
*On 03/31/12, staff found the patient walking in the hallway by herself.
*On 04/13/12, two staff members lowered the patient to the floor as her legs gave out from under her.
*On 04/20/12, staff found the patient standing alone in her room beside her bed.
*On 04/21/12, staff found the patient on the floor in her room as she fell over her wheelchair pedals while trying to get out of the chair on her own.

The staff completed another fall risk assessment on 02/20/12, which still identified Patient #3 as a "potential risk for falls", but the assessment failed to include interventions used to minimize the patient's risk. The care plan lacked updated or revised approaches and/or interventions to problem number eight as stated above. The staff failed to consider all potential contributing factors (poor vision, room location, confusion, weakness, etc.) relating to Patient #3's falls, and failed to include new approaches or interventions to address Patient #3's falls on the care plan.

During an interview on 04/26/12 at 11:25 a.m., an administrative nurse (#1) stated multiple disciplines developed swing bed patient care plans and met as a committee weekly to update the care plans in addition to a utilization review nurse who updated the care plans daily. The nurse (#1) stated she expected staff to keep care plans current and encouraged all staff members to update and revise the care plans as needed, stressing staff must include and add new orders or treatments to the care plan.


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- Review of Patient #2's active swing bed record occurred on April 24-26, 2012 and identified the CAH admitted the patient on 04/20/12 with a diagnosis of type II diabetes. Patient #2's care plan, dated 04/20/12, identified the patient received Novolog sliding scale insulin based on accuchecks taken four times daily. A nursing staff member discontinued this approach and included a resolution date of 04/24/12 on the care plan. The care plan also identified the resident received propanolol twice daily for hypertension. Review of Patient #2's physician's orders showed an order, dated 04/24/12, to discontinue his propanolol medication, but lacked an order to discontinue the accuchecks and Novolog sliding scale.

During an interview on 04/26/12 at 9:55 a.m., a nursing staff member (#2) stated she incorrectly discontinued the accuchecks and sliding scale insulin on Patient #2's care plan instead of discontinuing the propanolol.

- Review of Patient #4's active swing bed record occurred on April 25-26, 2012 and identified the CAH admitted the patient on 12/09/11 with a diagnosis of a right sided stroke and left sided paralysis. Patient #4's current care plan, stated, "12/12/11 Problem: Potential for decline of overall ROM [range of motion] [and] strength. Potential for contractures of [left] U/E [upper extremity] . . . [left] hand/wrist edema . . . Approaches . . . 02/13/12 Initiate use of white left hand splint when up; [with] Isotoner glove . . . 12/13/11 Problem: Weakness CVA [cerebrovascular accident] . . . Approaches . . . EZ stand [with] buttock strap for all transfers or lift . . . 12/15/11 Problem: Edema - esp [especially] left hand . . . Approaches . . . Isotoner glove on left . . . Wrist cock up splint on left when up . . ."

Review of Patient #4's physician's orders showed a physical therapy order, dated 03/19/12, stating, "Initiate use of left arm sling when up in E-Z stand. Initiate arm protectors bilaterally when up." Patient #4's care plan lacked this most recent therapy order.

During an interview on 04/26/12 at 9:20 a.m., a physical therapy staff member (#3) stated she expected staff to use the left arm sling and bilateral arm protectors when getting Patient #4 up and identified the Isotoner glove and left hand splint as PRN (as needed) interventions. The staff member (#3) verified Patient #4 no longer used the buttock strap on the E-Z stand and stated she "forgot to discontinue it."

The facility failed to review and revise Patient #2 and #4's care plans as changes occurred in order to maintain an accurate account of the patients' current health status and care needs.

Based on policy and record review and staff interview, the Critical Access Hospital (CAH) failed as part of an annual program evaluation to determine the appropriateness of the utilization of services and the following of its policies for 2 of 2 years (2011 and 2012) reviewed. Failure to determine the appropriateness of the utilization of services and whether the CAH followed its policies limited the CAH's ability to determine the need for changes.

Findings include:

Reviewed on 04/26/12, the CAH's performance improvement policy, revised September 1999, stated, ". . . XI. Quality Improvement Annual Evaluation and Reappraisal: . . . Components of the annual evaluation include utilization of services, including the number of patients served and volume of services provided. The annual evaluation will include review of policy and procedures, findings and recommendations of sources from contractual agreements/arrangements related to quality. Resultant recommendations when instituted should assure that the program is ongoing, comprehensive, effective in improving patient care, clinical performance and conducted with cost efficiency. . . ."

Reviewed on 04/26/12, the "Annual Review Meeting" records from 02/15/11 and 02/21/12 lacked evidence the CAH determined the appropriateness of the utilization of services and whether the CAH followed its policies.

During an interview on 04/26/12 at approximately 10:00 a.m., an administrative staff member (#11) confirmed the CAH did not determine the appropriateness of the utilization of services and whether the CAH followed its policies as part of the annual program evaluations in 2011 and 2012.

Based on review of policy and procedure, professional reference, and records, and staff interview, the Critical Access Hospital (CAH) failed to ensure the resident's right to be free of physical and/or chemical restraints not required to treat the resident's medical symptoms for 1 of 1 closed swing bed patient record (Patient #8) receiving antipsychotic medication on an as needed (PRN) basis and for 2 of 2 closed swing bed patient records (Patients #7 and #8) physically restrained. Failure to ensure adequate indication for the use of antipsychotic medication placed Patient #8 at risk for side effects related to its use. Failure to attempt the least restrictive device resulted in staff utilizing four point restraints (a restraint which involves tying the arms and legs of the patient) and geriatric chairs (geri-chairs) with trays for Patients #7 and #8.

Findings include:

Review of the CAH's "Restraint Policy" occurred on April 25-26, 2012. The policy, revised July 2009, stated,
"PHILOSOPHY: Garrison Hospital and Nursing Facility are committed to the appropriate use of protective restraints as a mechanism to support and protect patients/residents from injury to self and others . . . we promote the health, dignity and well-being of the patient/resident through use of the least restrictive methods possible . . .
PURPOSE: The policy and procedure provides guidelines for the appropriate and safe use of restraints . . . All patients have the right to be free from restraints that are not medically necessary or are used for purposes other than patient safety and benefit . . .
DEFINITIONS:
A. A physical restraint is any physical method of restricting a person's freedom of movement, physical activity, or normal access to his or her body.
B. A chemical restraint is defined as a psycho-pharmacologic drug that is used to control behavior or restrict the patient's/resident's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition . . .
POLICY: . . .
2. Nursing staff will always implement least restrictive measures. Early assessment and intervention may eliminate the need for more restrictive measures . . .
4. The patient and /or responsible party is educated on the reason for the restraints and problems that can occur as a result of them.
5. A consent to use restraints is received from the patient or family member . . .
6. The reason for the treatment must be clearly stated in the nurses notes and the patient care plan . . .
9. Staff must have ongoing education regarding restraints (physical and chemical).
10. Type of restraint used must be specified . . .
PROTOCOL: . . .
2. The following are interventions to be utilized when appropriate to the patient situation in an attempt to maintain patient safety and freedom of movement and prior to the use of restraints. . . .
BEHAVIOR: . . .
B. Combative: . . .Time out and rest periods . . . Control visual and auditory stimuli . . . Speak softly . . . Don't attempt to reorient or argue facts . . . medication adjustments . . .
In spite of the foregoing interventions the patient's risk status/behavior persist, and RN [Registered Nurse] may decide to apply a restraint (geri-chair . . . soft limb holders). The device chosen will permit the greatest freedom of movement consistent with patient safety . . .
PROCEDURE: . . .Obtain physician order per protocol . . .
TYPES OF RESTRAINTS:
Wrist Restraints: 1. Loop around wrists, then make single tie at wrist level. 2. Tie ends to mattress frame with bow, making sure patient is comfortable . . ."

Wolters and Kluwer, Nursing 2011 Drug Handbook, Lippincott, Williams, and Wilkins, Philadelphia, page 548 stated, "Exelon Patch . . . Adverse Reactions: . . . anxiety, aggressive reaction . . ."
Page 663 - 664 stated, "Haldol . . . Indications & Dosages: Psychotic disorders . . .Adverse Reaction: . . . sedation, drowsiness, lethargy . . . insomnia, confusion . . . Contraindications & Cautions: . . . Use cautiously in elderly and debilitated patients . . ."
Page 696 - 697 stated, "Ativan . . . Indications & Dosages: Anxiety . . . Elderly patients: 1 to 2 mg [milligrams] P.O. [orally] in divided doses . . . Adverse Reactions: . . . drowsiness, sedation . . . insomnia, agitation, dizziness, weakness, unsteadiness, disorientation . . ."

- Patient #8's closed swing bed record, reviewed on all days of survey, identified the CAH admitted the patient on 10/18/11 with diagnoses including dementia. A nurses note, dated 10/18/11 at 10:00 a.m., stated, "Gait steady. Is alert et [and] oriented, but forgetful et has periods of confusion." The record showed, on 10/23/11, the physician ordered an Exelon [a medication for dementia] patch 4.6 milligrams/24 hours to be applied daily. The record indicated Patient #8 experienced an adverse reaction to the Exelon.

A physician's order, dated 11/9/11, stated, ". . . had Exelon patch applied 10/27 & 10/28. Had total Behavioral change, was previously pleasant slightly confused but redirectable - to violent and non redirectable. Had to be medicated [with] Ativan and Haldol . . ."

Patient #8's nurses notes identified the following:
10/26/11 at 3:00 p.m. - "Seems more sleepy today, requiring many cues to carry out ADL's [Activities of Daily Living]."
10/27/11 at 4:30 p.m. - "Pt [patient] showing more signs of confusion. Needs assist of [one] [with] cares. . . ."
10/28/11:
1:45 p.m. - "pt difficult to redirect. pt had pushed aide against the wall holding her upper arms et [and] states to her 'I'm going to wring your neck.' pt tried to slap another aide this AM [morning] et pt walking the halls [with] walker [with] angry expression. [Social Worker's name] 1:1 [one to one] [with] pt. pt chased after this RN just a few steps [with] arms outreach [sic] stating 'I'm going to wring your neck . . .'"
2:10 p.m. - "[Nurse's name] administered IM [intramuscular] Ativan 2 mg to pt . . ."
2:18 p.m. - "pt up in hall [with] no walker et was outside room 207 arguing [with] family of that room. pt was able to be redirected back to his room. All resident room doors now closed for safety. pt in bedside chair [with] call light in reach."
4:25 p.m. - "Notified pt family [name] of pt fall at 1545 [3:45 p.m.] . . . pt to ER [emergency room] for treatment et eval [evaluation]" The nurses notes lacked any details regarding this fall which occurred two hours after administration of the Ativan. A "General Event Report," dated 10/28/11 at 3:45 p.m., stated, "Pt found lying on floor in doorway of room. Pt had hit head. Fall unwitnessed."
7:30 p.m. - Pt is in bed [after] being in ER for laceration to posterior head . . . Neurocheck done with little improvement in cognition or strength. Unable to understand commands consistently."
9:10 p.m. "Haldol 5 mg given IM as pt is trying to get up is confused."
10/29/11:
1:25 a.m. - "Pt very restless. One time order for Haldol 5 mg give IM (L) [left] deltoid for restlessness & confusion." The record lacked an indication for administering the second dose of Haldol or evidence staff attempted non-pharmacological interventions prior to administering the Haldol.
2:45 a.m. - "Pt continues to be restless and unable to comprehend staying in bed. 4 point restraints initiated."
4:00 a.m. - "Pt pulling brief down. Voided incontinently . . . 4 point restraints released for cares then restarted . . . neuro checks done. Some strength increase and cognition more responsive to questions."
6:00 a.m. - "Restraints released and pt turned . . . Restraints applied. Pt continues to want to get up . . ."
6:00 p.m. - "Restraints released at 0800 [8:00 a.m.]. Pt observed to no longer be combative or aggressive. Lethargic. Throughout the day, his LOC [level of consciousness] improved . . ."
10/30/11 at 4:00 a.m. - "Resident continues to attempt to get up and out of bed. Discussed time of day and encouraged to return to bed. Sleeping @ present."

A physician's order, dated 10/28/11 at 9:02 p.m. stated, "Haldol 5 mg po or IM TID [three times a day] PRN." The order failed to identify the specific medical symptoms for which staff should administer the Haldol.

The record lacked evidence staff attempted behavior interventions prior to administering the IM Ativan on 10/28/11 at 2:10 p.m. and lacked an indication for administration of the Haldol on 10/28/11 at 9:10 p.m., and on 10/29/11 at 1:25 a.m. Administration of the Haldol could mask symptoms of a head injury. In addition, the record lacked an indication for use of the 4 point restraints, lacked evidence staff attempted less restrictive interventions prior to placing Patient #8 in the restraints, and lacked evidence staff attempted to discontinue the restraints on 10/29/11 at 4:00 a.m., when the patient's strength and cognition increased. The record showed, on 10/30/11 at 4:00 a.m., when staff used redirection when the resident attempted to get out of bed, the resident returned to bed and slept.

A physician's order, dated 10/28/11 at 9:02 p.m., stated, "Four point Restraints as needed." The order failed to give specific behaviors for which staff could apply the restraints for Patient #8 and failed to identify the medical symptom for which staff should use the four point restraints.

A "General Event Report," dated 10/29/11 at 8:00 a.m., stated, "DESCRIPTION OF EVENT: Patient in four point restraints. Upon entry to room, all 4 restraints wrapped a few times around the siderails. Three of the restraints were not secured to the bed frame. Three restraints secured with several knots . . . FOLLOW UP/ACTION TAKEN: Restraints removed. Patient's aggressive nature dissolved [sic]. Restraints remained off."

Patient #8's nurses notes identified additional doses of Haldol administered without indication or attempts at behavior interventions prior to administration:
10/30/11 at 5:30 p.m. - "He is continually trying to stand up with no agenda of what he wants to do. He declines need to use the bathroom. As this past hour has passed, he is beginning to aggressively push the dining room table, throw newspaper on floor & verbal irritation. Haldol 5 mg IM given per PRN orders."
11/03/11 at 3:40 p.m. - "Pt showing increased signs of agitation. Gave PRN Haldol but agitation continues. Pt. continues to self transfer. . . . Placed in geri-chair [with] lap tray . . ."
11/03/11 at 8:30 p.m. - "Pt given 5 mg haldol PO for increased agitation et behavior . . ."
11/04/11 at 5:55 a.m. - ". . .Pt is becoming agitated. Trying to pull apart his bipap machine. Pt also trying to crawl over side rails. Pt medicated [with] haldol PO."

Patient #8's "PRN PAIN MEDICATION RECORD" identified the following doses of Haldol not recorded in the nurse's notes:
10/30/11 at 7:25 p.m. for "uncooperative, restless, confusion"
11/01/11 at 11:40 p.m. for "restless/agitation"
11/07/11 at 10:15 p.m. for "restless"
11/08/11 at 8:35 p.m. for "Restless"

The record failed to identify Patient #8's specific behavior symptoms for which staff administered the Haldol. Administration of the Haldol without adequate indications for use or attempts at behavior intervention prior to administration placed Patient #8 at risk for experiencing side effects from the medication.

A physician's order, dated 11/03/11, stated, "May use Geri chair [with] lap tray as a restraint for safety." The order failed to identify the medical symptom for which staff should use the geri-chair. The record lacked evidence staff obtained consent from the patient or family member prior to initiating the geri-chair with lap tray on 11/03/11. The record identified staff continued to utilize the geri-chair with lap tray for Patient #8 through 11/24/11, when his condition began to decline.

Review of Patient #8's care plan identified a problem, dated 10/28/11: "Restlessness poor judgement [with] ambulation, transfer - very unsteady . . ." Approaches to the problem included: ". . . Lap tray as needed for safety. Haldol for severe restless . . ." The care plan failed to identify the geri-chair with lap tray as a restraint or identify specific indications for its use or for the administration of Haldol.

During interviews on 04/25/12 at 4:15 p.m. and on 04/26/12 at 7:40 a.m. and 1:45 p.m., an administrative nurse (#7) provided no additional information regarding the Haldol administration or the four point restraints. The nurse stated she provided one-on-one staff education regarding proper application of four point restraints, but could not provide the date or an attendance roster from that education.

Review of Restraint Committee meeting minutes occurred on April 25-26, 2012. Minutes, dated 11/18/11, stated, ". . . Re-training with aides done on 11/17/11." The notes failed to specify what type of training the CAH provided. This training occurred three weeks after staff incorrectly applied the four point restraints and failed to include licensed staff.

- Patient #7's closed swing bed record, reviewed on all days of survey, identified the CAH admitted the patient on 03/14/12 with diagnoses including prostatic cancer with metastasis. The record identified Patient #7 had an implanted pain pump and experienced significant break through pain. Physician's orders, dated 03/14/12, stated, "Pad and clip alarm when in bed, clip alarm attached short when in chair. Geri chair [with] lap tray for all sitting." The physician's order failed to identify the medical symptom for which staff should use the geri-chair.

Review of Fall Committee meeting minutes occurred on April 25-26, 2012. The minutes, dated 03/16/12, indicated staff implemented alarms, a hi/lo bed in the low position, and a mat at the bedside on admission due to Patient #7's fall risk.

Patient #7's nurses notes identified the following:
03/31/12:
7:50 a.m. - "pt in geri chair [with] lap tray . . . pt very restless et takes clothes off while in chair et fighting the lap tray et efforts to calm the pt . . . pt is 1:1 at this time . . ."
4:15 p.m. - "pt restless in geri chair et attempted to climb out. Then pt stops et closes both eyes et is quiet . . ."
04/01/12:
2:45 p.m. - "pt woken up for straight cath [catheterization] et started pulling on catheter. pt combative et resistant. [four] assist for pt safety . . ."
9:00 p.m. - "Pt is awake @ intervals trying to get up and out of bed. He is agitated and slapping @ staff and occasionally kicking @ staff. Periods of restlessness are approximately 2-3 minutes followed by five to ten minutes of being asleep . . ."
10:30 p.m. - ". . . pt was attempting to kick the staff, grab and gouge with his fingernails and bite staff . . ."
04/02/12:
(no time recorded) - "This RN sat with pt one on one until shortly after midnight. During this time pt was again attempting to kick, bite grab and dig in his fingernails. [Physician's name] on call provider was notified . . . "
2:45 a.m. - "Thorazine [an antipsychotic medication] 25 mg given IM . . . for agitation. Pt was also placed in soft wrist and ankle restraints as ordered. Pt continues to attempt to grab and gouge staff with fingernails and bite . . . Pt is unable to comprehend what the staff was telling him at this time. . . ."
3:00 a.m. - ". . . He was observed trying to bite at the wrist restraints and bit himself on the right hand . . ."
5:30 a.m. - "While pt continues to agitated [sic] and restless at intervals he is resting at longer intervals."
8:00 a.m. - "[Staff member's name] removed soft wrist and ankle restraints. Skin around (R) [right] and (L) wrist red but blanchable. Pt is laying in bed. Bed in low position. Clip alarm is on. Music is playing in the background."

Patient #7's care plan, dated 03/20/12, identified a problem: "Actual fall & potential for more R/T [related to] confusion & restlessness. Approaches to the problem included: ". . . Geri chair [with] lap tray when up & alone.. . ." The care plan failed to identify the geri-chair as a restraint for Patient #7.

The record lacked evidence staff obtained consent from the patient or a family member prior to implementing the four point restraints or informed the family the next day that the restraints had been in use. The record identified staff continued to use the geri-chair for Patient #7 until his transfer to another hospital on 04/02/12 at 7:42 p.m. Failure to reassess the safety of the geri-chair after Patient #7 fought using the chair and attempted to crawl out of it created a risk for entrapment in the chair.

When asked, during an interview on 04/26/12 at 1:45 p.m., why staff used the four point restraints for Patient #7 when he had a low bed, alarms, and a mat beside the bed, an administrative nurse (#7) stated staff thought if the resident rolled out of bed onto the mat, he would attempt to ambulate. She stated Patient #7 only ambulated with physical therapy.