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Based on record review and interview, the provider's governing body failed to offer institutional oversight by not:
*Following medical staff and board of trustees bylaws to grant practitioners privileges to provide care for hospital patients.
*Ensuring quality assurance and program improvement (QAPI) activities were shared by the medical staff with the governing board.
*Preparing an institutional budget and plan.
*Reviewing contracted services for quality of care.
Findings include:

1. Review of medical staff bylaws signed 8/15/01 and board of trustees bylaws signed 8/15/01 revealed the board of trustees was to approve all medical staff appointments based upon recommendations received from the medical staff. Review of medical staff and board of trustees meeting minutes from January 2009 through April 2010 revealed that process was not followed for appointment and reappointment of practitioners to care for patients in the hospital. Refer to A046 and A341.

2. Review of the provider's governing board minutes from January 26, 2009, through April 2010, revealed there was no mention of any reports shared from the QAPI committee. Interview with the director of nursing at 9:30 a.m. on 4/15/10 revealed nothing had been discussed with the medical staff or governing board regarding QAPI program activities in "a long time." Refer to A049.

3. Interview on 4/15/10 at 9:30 a.m. with the administrator and review of governing board minutes revealed the provider did not have a budget for the years 2009 and 2010. Refer to A073.

4. Interview on 4/15/10 at 3:30 p.m. with the administrator and review of the book of contracted services revealed there was no provision for the governing board to evaluate the contracted services. Refer to A084.

Based on interview and record review, the provider failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program. The provider failed to ensure:
*The QAPI program reflected the complexity of the hospital's organization and services.
*All hospital departments and services were involved in the QAPI program.
*Contracted services were reviewed for quality of services furnished.
*Quality indicators related to improved health outcomes, and the prevention and reduction of medical errors were the focus of a QAPI program.
Findings include:

1. Review of the provider's May 2002 quality assurance plan revealed:
*The QAPI program was designed to furnish quality patient care while reducing hospital and medical staff liability.
*The projected outcomes of the QAPI program were to:
- Improve quality of patient care.
- Improve care delivery through problem identification, problem solving, problem prevention, and problem monitoring.
- Increase cost containment through problem prevention.
- Increase employee awareness of risk management, legal aspects of health care delivery, confidential matters, and acceptable methods used in problem solving.
*The goals of the QAPI program were defined as:
-Demonstrating that, given available resources, patient care was maintained at optimal, achievable levels of quality. That care was to have been delivered in an efficient and safe manner.
-Ensuring patient care practices and professional performances were regularly, validly, and reliably evaluated.
- Ensuring evaluation results were integrated as appropriate into the hospital and medical policies, procedures, and operations.
- Ensuring the hospital and care environment and equipment met standards of safety for patients, employees, and visitors.
- Demonstrating the QAPI program's procedures, methods, and systems were efficient and effective.
- Providing a means for fulfilling and integrating the QAPI responsibilities of all professional, managerial, technical, and support personnel.
- Providing a foundation for fulfillment of regulatory standards.

Continued review of that quality assurance plan revealed:
*The governing board's responsibility for the QAPI program was to have:
- Reviewed and approved or required changes in procedures, methods, systems for gathering, analyzing, and using information.
- Reviewed and accepted or rejected periodic reports on the findings, actions, and results.
- Assessed the QAPI program's effectiveness and efficiency and required necessary modification in organizational structure and systems to have improved program performance.
*The medical staffs' responsibility for the QAPI program was to have:
- Implemented the program.
- Actively participated in the program.
- Monitored all QAPI activities and reported them to the governing board.
*The responsibility of the administrator in the QAPI program was to have:
- Assured all hospital departments directly related to patient care have managers and directors participate in the program.
- Ensured all departments perform at least the minimum number of monitoring evaluation activities as required by regulatory standards.
- Established reporting mechanisms so the findings and recommendations from those activities were shared with the medical staff.
- Provided necessary administrative assistance to support and facilitate the continued operation of the program.
- Analyzed information and acted upon problems.
- Appointed a QAPI program coordinator.
*The QAPI program coordinator was to have been responsible for:
- Overall integration and coordination of all QAPI functions.
- Maintaining identified time parameters for reporting.
- Maintaining a current log of activities and reports of all departments, services, and committees.
- Preparing quarterly reports and presenting them to the administrator and medical staff.
- Communicating the results of the problem solving to all departments, services, and committees.
- Assisting the medical staff, committees, and departments in the development of written criteria to have been used in assessing problems.
- Distributing the governing board's yearly appraisal of the QAPI program to all departments, services, and committees involved.
- Evaluating the QAPI program and recommending changes to the medical staff, administration, or governing board.
- Maintaining copies of all minutes, reports, worksheets, and other data in a manner to ensure confidentiality.

Review of the provider's bylaws of the medical staff adopted on 10/29/90 and signed by the governing board chairman on 8/15/01 revealed the medical staff were responsible for:
*Implementing the overall quality assurance program.
*Providing professional direction to the information gathering components and analysis of data pertaining to medical care given within the facility.
*Reporting its findings to the governing board and the facility's administration.

Interview with the director of nursing (DON) at 9:30 a.m. on 4/15/10 revealed there had not been any QAPI meetings since the coordinator had left in August 2009. She confirmed nothing had been discussed with the medical staff or governing board regarding QAPI program activities in "a long time."

Review of a file folder of quality assurance activities provided by the DON revealed multiple departments had participated in QAPI activities at various times from March 25, 2006 through December 31, 2009 as follows:
*Cardiac care quality assurance (QA) indicated one patient chart was reviewed on 9/16/09 for various documentation components. No action plan or interventions were indicated.
*Nursing care QA was completed for most quarters in 2006 through 2009. Various areas were reviewed with an action plan for most of the assessment findings being to follow-up the next quarter.
*Business office QA activities were last completed on 10/29/08 with problem areas identified and action plans defined.
*Laundry QA was last completed on 9/29/08 with an indication the pounds of laundry being washed had increased. No action plan was defined.
*Pharmacy QA was last completed in June 2009. An action plan for each problem area was included.
*Emergency room QA was last completed in September 2009 with a chart audit. No action plan was included with that audit.
*Housekeeping QA was last completed in September, no year indicated. No action accompanied those findings.
*Laboratory QA was last completed in October 2008. An action plan was included with the findings.
*Maintenance QA was last completed in July 2007. A checklist of items reviewed was included. No action plan was found regarding any of those items.
*Medical records QA was last completed in June, 2007. A checklist of indicators had been completed. No action plan was included with that checklist.
*Radiology QA was last completed on 10/1/08. No action plan was included with those findings.
*Kitchen QA was last completed in September 2008 with a checklist of indicators completed. No action plan was included with that checklist.

Interview with administrator 4 at 10:00 a.m. on 4/15/10 revealed she had started in her position on 1/26/10. She stated she was not aware of any QAPI program activities having been conducted since her hire date. She further stated she had planned to have a QAPI meeting in the near future.

Review of the provider's governing board minutes from January 26, 2009, through April 12, 2010, revealed there was no mention of any reports shared from the quality assurance and program improvement committee.

Based on record review and interview, the provider failed to ensure laboratory services were available and adequate to meet the routine and emergency services of its patients. Findings include:

1. Review of monthly on-call schedules and nterview on 4/15/10 at 8:10 a.m. and at 2:10 p.m. with laboratory person 1 revealed there currently was no on-call schedule for laboratory personnel. The above interview also revealed:
*Emergency laboratory services were not available 24 hours daily in the facility.
*The medical staff did not have a designated set of emergency laboratory services to be immediately available.
Refer to A583.

Based on interview, bylaws review, and record review, the provider failed to ensure a utilization review (UR) plan was maintained to provide for review of services furnished by the provider and by members of the medical staff. Findings include:

1. Interview at 9:30 a.m. on 4/15/10 with the director of nursing revealed nothing had been done regarding UR "in a long time."

Review of the 8/15/01 bylaws, rules, and regulations of the medical staff revealed the medical staff were responsible for reviewing and evaluating the quality of medical care given to a patient. Further review revealed a UR committee was to have been established to conduct UR studies to evaluate:
*The appropriateness of admissions to the hospital.
*Lengths of stay within the hospital.
*Discharge practices.
*Use of medical and hospital services.
*All related factors which may have contributed to the effective utilization of hospital and physician services.
*How under-utilization and over-utilization of each of the hospital's services affected the quality of patient care provided at the hospital.
*Patterns of care and obtain criteria related to average or normal lengths of stay by specific disease category.
*The availability of other suitable health care facilities and services outside the hospital.

Review of the provider's 8/15/01 bylaws of the board of trustees revealed:
*The medical staff were responsible for conducting an ongoing review and appraisal of the quality of medical care provided at the hospital.
*The medical staff were responsible for reporting those activities and their results to the governing board.

Review of the provider's governing board minutes from January 26, 2009, through April 12, 2010, revealed there was no mention of any reports shared from the UR committee.

Interview at 10:30 a.m. on 4/15/10 with the administrator revealed she was not aware of any UR activities having been done since her hire date on 1/26/10.

Based on observation, interview, record review, and policy review, the provider failed to ensure:
*A sanitary environment and practices to avoid sources and transmission of infections and communicable diseases was maintained throughout the facility.
*An active program was maintained for the prevention, control, and investigation of infections and communicable diseases.
Findings include:

1. Interview with the director of nursing (DON) at 9:15 a.m. on 4/15/10 revealed:
*The provider did not have a policy and procedure manual specific to infection prevention and control.
*There were a few policies related to infection prevention control within the nursing policy and procedure manual.
*The DON used to receive monthly reports from the laboratory regarding cultures that had been completed that month.
*Those laboratory culture reports had not been received since August 2009.
*The DON used those laboratory reports to ensure the swing bed patients were receiving appropriate antibiotics.
*The DON did not utilize any other data collection or monitoring tools.
*The DON would monitor staff practices regarding infection prevention and control when she worked on the floor.
*Education provided to staff regarding infection prevention and control consisted of providing them with articles from nursing journals.
*An annual inservice on topics related to infection prevention and control was provided for staff.
*The DON had not received any formalized training in infection control for quite some time.
*If a patient acquired an infection, sources from the internet would have been used to determine protocols for care.
*The provider did not have an infection control committee designated to discuss concerns related to infection prevention and control.

Review of the provider's February 2002 infection control program policy revealed the infection control program would consist of:
*Identification of healthcare acquired infections.
*Prevention, surveillance, and control of policies and procedures relating to infections within the hospital environment.
*A system of reporting, evaluating, and maintaining records of healthcare acquired infections.
*A review and evaluation of policies and procedures that involved the control of infections.
*The responsibility of monitoring the infection control program should have been under the Control Committee.
*Universal precautions were to have been followed.

Review of the provider's undated personnel policy manual revealed an infection control committee had been established for the:
*Surveillance of inadvertent hospital infection potentials.
*Review and analysis of actual infections.
*Promotion of a preventative and corrective program designed to minimize infection hazards.
*Supervision of infection control in all phases of the hospital activities.

Refer to A749, finding C1.

Based on record review and interview, the provider failed to ensure the governing board was fully involved in evaluating and making final decisions on appointments for five of eight sampled practitioners (A, B, F, G, and H) to the medical staff. Findings include:

1. Review of the physician call schedule for October 2009 revealed physician A was on call the first time from 10/8/09 to 10/13/09. Review of the call schedules from November 2009 through February 2010 revealed physician A was on call in each of those months.

Review of physician A's application for appointment to the medical staff revealed it was dated 9/1/09. The above application was dated and signed by administrator 4 indicating the appointment was recommended, the physician was appointed to the medical staff, and requested privileges were approved effective 9/1/09.

Review of the medical staff meeting minutes revealed there were no meetings of the medical staff between 2/12/09 and April 2010.

Review of the board of trustees meeting minutes from August 2009 through April 2010 revealed for the following meetings physician A:
*8/18/09, Was not licensed in South Dakota.
*8/24/09, Was not yet licensed.
*10/21/09, Was mentioned during a doctor search discussion.
*1/4/10, Was mentioned as a possible hire as medical director.
*1/17/10, Was mentioned in relation to salary level and release from locum company.
*2/15/10, Was included in a motion to approve additions to the medical staff as the medical director.
The first written record indicating physician A was approved by the board of directors to practice in the facility was in the minutes of the 2/15/10 board of trustees meeting. At that meeting physician A was designated as the medical director.

2. Review of the physician call schedule for December 2009 and January 2010 revealed certified nurse practitioner (CNP) H was on call during each of those months.

Review of CNP H's credential files revealed there was no application for appointment to the medical staff.

Review of the board of trustees meeting minutes from August 2009 through April 2010 revealed there was no discussion of CNP H.

3. Review of the physician call schedule for January 2010 revealed physician assistant-certified (PA-C) F worked 1/29/10 through 1/31/10.

Review of (PA-C) F's application for appointment to the medical staff revealed it was dated 1/29/10. The above application was signed by administrator 4 indicating the appointment was recommended, the (PA-C) was appointed to the medical staff, and requested privileges were approved effective 1/29/10.

Review of the board of trustees meeting minutes from August 2009 through April 2010 revealed (PA-C) F was appointed to the medical staff on 2/15/10.

4. Review of physician B's provider reappointment questionnaire dated 2/18/09 revealed he was requesting reappointment for staff privileges in pathology. The appointment sheet was dated as approved by the medical staff in February 2009, and there was no date for the board meeting. Administrator 14 had signed the appointment sheet to indicate requested medical privileges were approved effective 5/1/09.

Review of the medical staff meeting minutes dated 2/12/09 revealed there was no discussion of physician B's request for reappointment.

Review of the board of trustees meeting minutes from January 2009 through April 2010 revealed there was no discussion of physician B's request for reappointment.

5. Review of chiropractor G's credentialing file revealed he had an application for full hospital privileges in the specialty of chiropractic. He had applied for appointment to the medical staff as attending staff in the department of general practice with other appointment specified as chiropractic. Medical privileges desired included differential diagnosis of certain diseases, medical pediatric care for uncomplicated infections, allergic disorders for uncomplicated and complicated asthma, endocrine and metabolic disorders for uncomplicated diabetes, and orthopedic care for dislocations. The above application was signed by administrator 14 indicating the appointment was recommended, and the chiropractor was appointed to the medical staff effective 10/21/09. Administrator 14 also dated the form to indicate the requested medical and orthopedic privileges were approved effective 10/21/09, but the approval check boxes were not completed.

Review of the board of trustees meeting minutes dated 9/29/09 revealed the chiropractor was going to start practice on 11/1/09. Room rent was specified, and it was noted he could also do therapy.

Review of the hospital's website revealed an undated announcement stating the above chiropractor was an addition to the staff of the hospital starting on 11/5/09. The announcement also stated he was considered a primary care physician and had been approved for hospital privileges at the hospital.

Interview on 4/15/10 at 11:45 a.m. with administrator 4 and the president of the board of trustees revealed they were not aware of the chiropractor having staff privileges at the hospital. The president stated he thought the arrangement made with the chiropractor was for a lease of space for the chiropractor to see patients. The president did not recall the board of trustees approving the chiropractor for hospital privileges.

During the above interview the president of the board of trustees stated the board might have considered the above practitioners for medical privileges. He stated those actions might not have been recorded in the minutes. The president also stated many of the members of the board of trustees were new and not completely familiar with the processes required for medical staff appointment.

6. Review of the minutes of the 2/15/10 board of trustees meeting revealed the motion "Additions to medical staff ok'd by board: PA-C D, CNP C, PA-C E, and PA-C F." The above motion was not clear if the intent of the board of trustees was to:
*Appoint the practitioners to the medical staff (an action not allowed in the medical staff and board of trustees bylaws.)
*Approve the practitioners' practice agreements with the supervising physician.

Review of the medical staff bylaws dated 8/15/01 revealed:
*Only physicians, doctors of osteopathy, and dentists were qualified for membership on the medical staff.
*Only the governing board made appointments to the medical staff of the hospital.
*Appointments were for one year or until the end of the fiscal year of the hospital.
*The governing board reappointed medical staff members upon recommendation of the credentials committee of the medical staff.
*Initial application for appointment to the medical staff was to be reviewed by the medical staff with recommendations to go to the governing board for final action.
*In the case of an emergency the administrator of the hospital, after consulting with the medical chief of staff, could grant temporary privileges for no more than 30 days.
*Physician assistants and nurse practitioners were employees of physicians, and the physicians were responsible for their actions. The administrator and board of trustees were to approve the duties assigned by the physicians.
*Only members of the medical staff were able to admit patients to the hospital.

Review of the board of trustees bylaws dated 8/15/01 revealed the board was to appoint a medical staff composed of physicians. Specific provisions related to appointments mirrored the requirements outlined in the above medical staff by-laws.

Based on interview, bylaws review, and record review, the provider failed to ensure quality assurance and program improvement (QAPI) activities were shared by the medical staff with the governing board. Findings include:

1. Review of the provider's governing board minutes from January 26, 2009, through April 12, 2010, revealed there was no mention of any reports shared from the QAPI committee.

Review of the provider's bylaws of the medical staff adopted 10/29/90 and signed by the governing board chairman 8/15/01 revealed the medical staff were responsible for:
*Implementing the overall quality assurance program.
*Providing professional direction to the information gathering components and analysis of data pertaining to medical care given within the facility.
*Reporting its findings to the governing board and the facility's administration.

Review of the provider's May 2002 quality assurance plan revealed:
*The medical staff were responsible for implementing the QAPI program.
*The medical staff would actively participate in the QAPI program.
*The medical staff would monitor all QAPI activities and report them to the governing board.

Interview with the director of nursing at 9:30 a.m. on 4/15/10 revealed there had not been any QAPI meetings since the coordinator had left in August 2009. She confirmed nothing had been discussed with the medical staff or governing board regarding QAPI program activities in "a long time."

Interview with the administrator at 10:00 a.m. on 4/15/10 revealed she had started in her position on 1/26/10. She stated she was not aware of any QAPI program activities having been conducted since her hire date. She further stated she had planned to have a QAPI meeting in the near future.

Based on interview and record review, the provider failed to ensure an institutional plan and annual operating budget were prepared. Findings include:

1. Interview on 4/15/10 at 9:30 a.m. with administrator 4 revealed the provider did not have a budget for the years 2009 and 2010. Administrator 4 revealed she had requested the financial books for the year 2009 be closed, because they could not reconcile those expenses. She stated it would be better to close the books and start fresh in 2010. Administrator 4 revealed there were no plans for capital expenditures for the current year nor the next three years. Continued interview with administrator 4 revealed the governing board had met on 4/12/10. She had presented the provider's clinic and hospital losses, trends, and indicated a decision was needed immediately regarding the provider's financial situation.

Review of the following governing board meeting minutes revealed:
*1/4/10 - A financial company had been hired to reconcile the books but had not been successful as of yet. A motion was approved to pursue plans laid out for operating the hospital for one year.
*2/15/10 - The balance sheets were at a dead end, and the books could not be reconciled. It was approved to end the 2009 year and make a fresh start. There was no budget presented or approved at that meeting.
*From 1/26/09 through 4/12/10 revealed discussions regarding finances had been conducted, but no budget had been presented for approval.

Based on record review and interview, the provider failed to:
*Evaluate contracted services to ensure services were provided in a safe and effective manner.
*Develop and implement a quality assessment and performance improvement program (QAPI) regarding contracted services.
*Ensure contracted services were renewed upon expiration as appropriate.
Findings include:

1. Interview on 4/15/10 at 3:30 p.m. with administrator 4 revealed the book of contracts provided to the survey team contained all current hospital contracts used by the provider. Administrator 4 revealed no quality assurance provisions had been implemented for evaluating contracted services. There were no reports provided to QAPI regarding contracted services.

Review of the following listed contracts revealed they had expired:
*Nova Fire Protection expired on 5/22/07.
*School Health Nursing Services on expired 6/30/08.
*Full Service Contract expired on 1/5/09.
*South Dakota Special Health Services Participating Provider Agreement and Clinic expired on 9/30/09.

Based on observation, record review, policy review, and interview, the provider failed to assess and reassess the need for physical restraints for two of two sampled patients (2 and 5). Findings include:

1. Random observation of patient 2 on 4/13/10 and on 4/15/10 revealed when out of bed she was seated in a geriatric chair (geri-chair) with a lap tray. During breakfast and noon mealtimes the lap tray was not removed.

Review of patient 2's Informed Consent For Physical Restraints form dated 4/23/08 revealed:
*The physician had signed that form for a geri-chair with a lap table.
*The proposed duration of the restraint was indefinite unless the patient's condition improved.
The restraint was recommended for personal safety and comfort.
*The restraint form had been signed by the patient's power of attorney.

Review of patient 2's Intermediate Swingbed Recertification Orders signed by the physician on 4/12/10 revealed there was no order for a restraint or a chair that prevented the patient from rising. A checkmark had been placed in the "No" response box for restraints.

Review of patient 2's care plan last updated 4/15/10 revealed the geri-chair had not been addressed as a problem.

Review of patient 2's care conference note dated 3/24/10 revealed the geri-chair and restraints had not been discussed.

Interview with registered nurse (RN) 13 confirmed patient 2 was in a geri-chair with a lap tray. RN 13 revealed her review of the patient's medical record confirmed the physician had ordered the geri-chair on 4/23/08. She was not able to locate monthly assessments or a reevaluation for the continued need for the geri-chair with a lap tray. RN 13 revealed patient 2's physical and mental condition had deteriorated, and she was less mobile now than in 2008.

2. Random observation of patient 5 on 4/13/10 and on 4/15/10 revealed when out of bed she was seated in a geri-chair with a lap tray. During breakfast and noon mealtimes the lap tray was not removed.

Review of patient 5's Informed Consent For Physical Restraints form dated 9/28/06 revealed:
*The physician had signed that form for a geri-chair with a lap table.
*The proposed duration of the restraint was for one year.
*The restraint was recommended for personal safety and the safety of other residents and staff.
*The restraint form had been signed by the patient's power of attorney.

Review of patient 5's Intermediate Swingbed Recertification Orders signed by the physician on 4/2/10 revealed there was no order for a restraint or a chair that prevented the patient from rising. A checkmark had been placed in the "No" response box for restraints.

Review of patient 5's care plan last updated 3/24/10 revealed the the geri-chair had not been addressed as a problem.

Review of patient 5's care conference note dated 3/24/10 revealed the geri-chair and restraints had not been discussed.

Interview with RN 13 confirmed patient 5 was in a geri-chair with a lap tray. RN 13 revealed her review of the patient's medical record confirmed the physician had ordered the geri-chair on 9/28/06. She was not able to locate a current physician's order for the geri-chair with lap tray. RN 13 stated she was not able to locate monthly assessments or a reevaluation for the continued need for the geri-chair with a lap tray. RN 13 revealed patient 5's physical and mental condition had deteriorated, and she was less mobile now than in 2006.

3. Review of the provider's restraint policy approved July 2009 revealed:
*The purpose was to use the least restrictive, provide safety, prevent injury, and enable and promote the highest practicable level of independence.
*The procedure for initiating a restraint included:
-Discussing the use of the restraint with the resident and family, explain the risks and benefits of the restraint, and document that discussion in the patient's medical record.
-Obtain a physician's order for the least restrictive device. That order must include the medical symptoms for the restrictive device.
-The restraint would be checked every 30 minutes, released, and the patient would be repositioned every two hours.
*Patients with physical restraints would be reevaluated at least monthly, and the care plan would be updated to reflect the patient's current restraint status.

Based on record review and interview, the provider failed to ensure four of eight of practitioners (A, B, F, and H) who had practiced in the facility or acted as a consultant were reviewed by the medical staff and approved by the governing board on a timely basis. Findings include:

1. Review of the medical staff bylaws dated 8/15/01 and board of trustees bylaws dated 8/15/01 revealed the board was to appoint a medical staff based upon recommendations of the medical staff.

Review of the medical staff meeting minutes revealed there was only one meeting of the medical staff (2/12/09) between January 2009 and April 2010. During the 2/12/09 meeting of the medical staff there was no discussion of medical staff appointments.

Review of the board of trustees meeting minutes from January 2009 through April 2010 revealed the only discussion of appointments to medical staff was made at the 2/15/10 meeting. The discussion did not include any references to recommendations made by the medical staff. During the meeting:
*Physician A was appointed to the medical staff. He had already practiced in the facility since October 2009.
*Physician assistant-certified F was appointed to the medical staff. She had practiced in the facility from 1/29/10 through 1/31/10.
*Physician B was not discussed. He was the consultant for laboratory services and had applied for renewal of staff privileges on 2/18/09.
*Certified nurse practitioner H was not discussed. She had practiced in the facility during December 2009 and January 2010.

Interview on 4/15/10 at 11:45 a.m. with administrator 4 and the president of the board of trustees revealed the governing board did not document all decisions made concerning appointments to the medical staff.

Refer to A046.

Based on observation, interview, record review, and policy review, the provider failed to ensure care plans were updated to reflect changes in the care provided for three of eight sampled swing-bed patients (2, 5, and 11). Findings include:

1. Interview on 4/13/10 at 3:10 p.m. with swing bed patient 11 revealed she felt she could have benefited from physical therapy or occupational therapy services. She further revealed she had not received those services for quite some time. Interview with that same patient on 4/15/10 at 1:10 p.m. revealed she did refuse the above services from time to time due to pain and fear that staff were not well enough trained to provide those services.

Interview with registered nurse (RN) 13 at 9:10 a.m. on 4/14/10 revealed patient 11 had been given several exercises to do on her own or with staff help, a neck brace to wear, and a special pillow to use. Patient 11 had refused all of those options. RN 13 also stated that patient had seen the chiropractor. She was not aware if he had any recommendations for any type of rehabilitative services to have been provided.

Review of patient 11's nursing care plan revealed an entry on 4/15/09 indicating an order had been received for physical therapy for strengthening. There were no other entries on that care plan regarding the need for exercises or patient 11's preferences regarding rehabilitative care.

Review of the provider's April 2002 restorative/rehabilitative nursing policy revealed all restorative/rehabilitative nursing cares should have been included in a patient's overall plan of care.

2. Review of patient 11's 6/12/09 physician's orders revealed an order for the implementation of methicillin resistant staphylococcus aureus (MRSA) protocols. Refer to A749, finding C1.

Interview at 10:10 a.m. on 4/14/10 with RN 13 revealed care plans were to have been updated at least monthly. She confirmed nothing was found on patient 11's care plan regarding her needs/problems with rehabilitative services or the nursing approaches/solutions to those concerns. She further confirmed nothing was found on patient 11's care plan regarding implementation of the MRSA protocols.

Review of the provider's May 2002 nursing care plan policy revealed:
*The purpose of the care plan was to have developed an individual plan of care for each patient that would enable that patient to reach his/her optimum health potential.
*An individualized care plan was to have been maintained on all patients.
*The care plan should have outlined statements of the patient's needs or problems and the nursing approaches or solutions to those needs/problems.
*Whenever possible goals were to have been mutually set with the patient or family.
*Care plans were to have been reviewed and revised as the patient's condition changed.

Review of the provider's August 2005 policy on intermediate care for swing bed patients revealed:
*For continuity of care a nursing care plan that included long and short term goals was to have been completed on each individual.
*Those care plans were to have been reviewed and revised weekly.
*Those care plans were to have included input from all disciplines.

The above policies apply to all findings.



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3. Random observation of patients 2 and 5 revealed when out of bed the patients were seated in a geriatric chair (geri-chair) with a lap tray across the front. Observation of both patients at the breakfast and noon meals on 4/14/10 and 4/15/10 revealed the lap trays were not removed during those meals.

Review of the care plans for patients 2 and 5 revealed restraints/geri-chair had not been addressed as a problem.

Refer to A154 findings 1 and 2.

4. Review of the nursing flow sheet for patient 2 revealed an asterisk had been placed in the block for ulcer assessment and a note "Refer to Wound Assessment" had been handwritten on that form.

Review of the wound assessment form dated 4/9/10 for patient 2 revealed a two centimeter by one-point seven centimeter round stage 2 pressure ulcer had been identified on her right heel.

Review of the care plan for patient 2 last updated 4/15/10 revealed the pressure ulcer had not been addressed. There were no interventions listed for the pressure ulcer identified on the 4/9/10 wound assessment form.

Interview on 4/14/10 at 9:00 a.m. with RN 13 regarding patient 2 revealed:
*The wound assessment form documentation identified a stage 2 pressure ulcer on the patient's right heel.
*The patient's care plan dated 3/14/10 did not address the pressure ulcer as a problem. There were no interventions listed for prevention of a pressure ulcer.
*The nursing staff did not know how the pressure ulcer had started; they thought maybe her shoe was to blame. The staff had stopped putting shoes on her, a padded heel protector had been placed on the right foot, her heels were elevated on pillows to prevent pressure on them, and the bed had a built-in eggcrate mattress.

Based on observation, interview, and policy review, the provider failed to ensure:
*Nursing staff used clean technique when administering medications to one of ten sampled patients (2).
*Medication waste did not occur during medication administration for one of ten sampled patients (2).
Findings include:

1. Observation on 4/13/10 at 11:56 a.m. of the medication pass revealed registered nurse (RN) 18 prepared and administered patient 2 her medications. Observation at that time revealed RN 18:
*Removed a bottle of TUMS from the medication cart and placed two tablets in a medication cup.
*From a medication cassette placed one carbamazepine tablet in the medication cup.
*Without wearing gloves broke the two TUMS tablets in half and placed the halves back into the medication cup.
*With her bare fingers she placed each TUMS half and the carbamazepine tablet into patient 2's mouth.

Interview on 4/13/10 at 2:15 p.m. with RN 18 regarding patient 2 confirmed she had broken the patient's TUMS tablets in half. She had used her bare fingers to administer resident 2 her medication. RN 18 said she should have worn gloves to administer patient 2 her medications.

Review of the provider's Rules for Giving Medications reviewed July 2009 revealed "When giving pills, tablets or capsules, place in proper container directly from bottle or cap of bottle. Do not touch them with your hands."

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, MO., 2005, p. 852, revealed "Do not touch medications with fingers." The use of clean technique was required for medication administration.

2. Observation of the medication pass for patient 1 on 4/13/10 at 12:08 p.m. revealed RN 18:
*Crushed two pills in a small bowl.
*Removed a cotton ball from a covered container on the medication cart. With that cotton ball pushed the crushed medications into a medication cup.
*Placed the patient's meal tray on top of the medication cart and added the crushed medications to a serving of cubed potatoes with gravy.
*Placed the food tray in front of the resident and encouraged her to begin eating.
*Continued with her medication pass. She did not ensure the patient ate all of her potatoes and gravy.

Observation of patient 1 during the meal revealed:
*She picked up her paper napkin and blotted up the leftover gravy on her plate.
*Several chunks of potatoes were on the floor next to her chair.

Interview with RN 18 on 4/13/10 at 2:15 p.m. regarding patient 1 revealed:
*She had placed the medication into the patient's serving of potatoes and gravy. The full dose of each medication might not have been received if the patient did not eat the full serving, wasted some on the floor, or soaked up gravy with her napkin.
*She had no concerns about the medication being trapped in the cotton ball fibers. She tapped the cotton ball to ensure all the medication went into the cup.
*There was a low potential for cotton fibers getting into the patient's medication.
*She used a clean cotton ball each time. The cotton balls were kept in a covered container on top of the medication cart and were accessible to other individuals.
*The food tray was clean, it came directly from the food cart, and contamination of the medication cart was not an issue.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, MO., 2005, revealed:
*Page 843: One of the patients six rights for safe medication administration included the right to have the correct drug dose.
*Page 853:
-If the patient required crushed medications the ground medications could have been placed in a small amount of soft food like custard or applesauce to make it easier to swallow.
-The nurse should have stayed with the patient until all the medication was completely swallowed. It was the nurse's responsibility to ensure the patient received the ordered medication dose.

Based on record review and interview, the provider failed to implement a system of coding and indexing medical records. Findings include:

1. Review of the medical records system revealed there was no procedure to retrieve medical records by diagnosis and procedure codes. The provider used a system where each patient was identified by number, and medical records could be retrieved by patient name only. There was no indexing system that categorized patients by diagnosis and procedure codes.

Review of the provider's medical records policy and procedue manual reviewed 1/2/02 revealed:
*A major responsibility and duty of the medical records manager was to code and index the medical record.
*Indexing was defined as the listing on a card for a specific disease or operation entity according to a recognized nomenclature (name).

Interview at the above time with the medical records manager confirmed the provider did not have an indexing system to retrieve medical records in a timely manner when looking for certain diagnosis or procedure codes.

Interview on 4/13/10 at 2:40 p.m. with the director of nursing confirmed the above information.

Based on record review, interview, bylaws review, and policy review, the provider failed to ensure:
*Accurate and complete information was documented regarding restorative and rehabilitative care provided for one of eight sampled swing bed patients (11).
*All sampled medical record entries from different patient service areas were authenticated with either signatures, dates, or times. A sample of 658 medical record entries revealed 380 instances where either the signature, date, or time of the entry was not recorded.
Findings include:

1. Interview on 4/13/10 at 3:10 p.m. with swing bed patient 11 revealed she felt she could have benefited from physical therapy or occupational therapy services. She further revealed she had not received those services for quite some time. Interview with that same patient on 4/15/10 at 1:10 p.m. revealed she did refuse the above services from time to time due to pain and fear that staff were not well enough trained to provide those services.

Interview at 9:10 a.m. on 4/14/10 with registered nurse (RN) 13 revealed patient 11 had been given several exercises to do on her own or with staff help, a neck brace to wear, and a special pillow to use. Further interview revealed patient 11 had refused all of those options. RN 13 also stated that patient had seen the chiropractor. She was not aware if he had any recommendations for any type of rehabilitative (rehab) services to have been provided.

Review of patient 11's nurses' notes from March 2009 through April 2010 revealed nothing was documented regarding any exercises or rehab services provided to or with patient 11. Review of the physicians' progress notes revealed no entries from the chiropractor regarding services he had provided for patient 11.

Review of two rehab flow sheets dated February 2010 and March 2010 revealed initials were placed in boxes for each day of the month. No indication was found on those flow sheets as to what the initials in those boxes meant.

Review of the provider's April 2002 restorative/rehab nursing policy revealed progress notes were to have been written by nursing staff. Those progress notes were to have documented the restorative/rehab aspect of care as needed according to the patient's progress.

Review of the provider's May 1990 policy on general rules for charting revealed the purpose of charting was to:
*Keep a detailed record of the patient's treatment, progress, and care.
*Aid the physician in diagnosis, evaluation, and treatment.
*Aid the nurses in planning individual nursing care.
*Provide a legal record of the patient's treatment.
Further review of that policy revealed the patient's record or chart was to have been considered:
*A written record of the patient's history, examinations, tests, diagnosis, prognosis, therapy, and responses to therapy.
*A means of communication among those who provided care to the patient.
Continued review of that policy revealed nurses' notes were to have contained:
*The patient's mental or emotional condition.
*The patient's reaction to therapeutic procedures.
*Any abnormalities in the patient's activity or function.

Interview with RN 13 at the 9:20 a.m. on 4/13/10 confirmed nothing was documented within patient 11's chart regarding any rehab care provided to or with her.

2. Review of 131 written physicians' orders during review of medical records on all patient care areas revealed 32 were not dated, and 92 were not timed.

3. Review of 77 telephone physicians' orders during review of medical records on all patient care areas revealed 2 were not signed, 32 were not dated and 47 were not timed.

4. Review of 49 physicians' progress notes during review of medical records on all patient care areas revealed 18 were not dated, and 46 were not timed.

5. Review of 401 miscellaneous forms regarding physician or nurse contact with the patient during review of medical records on all patient care areas revealed 1 was not signed, 11 were not dated, and 109 were not timed.

Interview on 4/14/10 at 9:00 a.m. with RN 13 revealed:
*A note had been placed at the nurse's station that read: "When writing verbal orders from providers we need to write time taken under date-that is time provider gave us the order. Also remind providers to time when orders written."
*There was no place on the recertification form for a time.
*They were not aware the physician's signature needed to be dated and timed with authenticating verbal orders until two weeks ago when a traveling staff member informed them they were not dating and timing medical entries.

Interview on 4/14/10 at 9:35 a.m. with the director of nursing confirmed medical record entries were not always dated and timed.

Review of the provider's undated policy on the receiving and noting of doctors' orders revealed the date and time the order was written should have been included after all orders.

Review of the provider's May 1990 policy on general rules for charting revealed all entries were to have been dated and timed.

Review of the provider's August 2005 intermediate care policy for swing bed patients revealed nurses were to have charted on admission, weekly, and then as needed in the nurses' notes. Any observations in those notes were to have included the date and time of occurrence.

Review of the provider's 8/15/01 medical staff bylaws, rules, and regulations revealed all entries in the medical record should have been dated and authenticated. The rules did not include a requirement for the above entries to have been timed.

The above interviews, policy reviews, and bylaws review apply to findings 2 through 5.

Based on record review and interview, the provider failed to ensure one of two radiology technicians (7) was checked periodically for the amount of radiation exposure. Findings include:

1. Review of radiology records for exposure badges revealed there was a report for radiology technician 17 but no report for radiology technician 7.

Interview on 4/14/10 at 11:35 a.m. with radiology technician 17 revealed there was no radiology exposure badge record for radiology technician 7. She stated radiology technician 7 did not have an exposure badge reading, because he was a back-up technician. Radiology technician 7 was not in the facility very often.

Based on record review and interview, the provider failed to have a radiologist with medical staff privileges in either a full-time, part-time, or consulting capacity. Findings include:

1. Interview on 4/14/10 at 11:35 a.m. with radiology technician 17 revealed it was her understanding that physician A supervised the radiology department. She stated the provider had a contract with a medical imaging consulting group to interpret x-rays. She felt she could consult with the radiologist who was the head of that group if there were radiology problems. She was not sure if that radiologist had an official relationship with the hospital.

Interview on 4/15/10 at 11:00 a.m. with credentialing coordinator 16 revealed the above radiologist did not have privileges with the provider. She offered an undated letter signed by the radiologist stating he was voluntarily resigning his courtesy privileges with the provider. The letter stated those privileges were not needed to read radiology studies that were sent from the hospital. The letter did not state anything about supervising the provider's radiology department.

Review of the 2/15/10 minutes of the governing board revealed no radiologist was included as a physician with staff privileges at the hospital.

Based on record review and interview, the provider failed to ensure:
*Emergency laboratory services were available 24 hours a day.
*The medical staff determined a list of laboratory services immediately available to meet emergency needs.
Findings include:

1. Review of monthly on-call schedules revealed starting with February 2010 there were no laboratory personnel listed on the on-call schedule. From August 2009 through January 2010 laboratory personnel had been listed as being on-call.

Interview on 4/15/10 at 8:10 a.m. and at 2:10 p.m. with laboratory person 1 revealed there currently was no on-call schedule for laboratory personnel. If there were emergency laboratory services needed when the laboratory was not open they could have been sent to facilities in neighboring communities. She also stated the medical staff did not have a designated set of emergency laboratory services to be immediately available. She stated other hospital personnel would have been able to perform tests exempted by the clinical laboratory improvement act when laboratory personnel were not present. She stated there was no specific list of those exempted tests.

Based on observation and interview, the provider failed to ensure medical supplies held in two of four observed storage/use areas were free from outdated or deteriorated products. Findings include:

1. Observation on 4/13/10 at 4:05 p.m. of an unmarked storage room in the west hall of the ground floor revealed:
*One container of Nu Gauze with an expiration date of April 2002.
*One container of Nu Gauze Iodoform with an expiration date of February 2006.
*One bottle of sterile water for irrigation with an expiration date of October 2009.
*One container of Nu Gauze Iodoform with an expiration date of November 2009.

2. Observation on 4/14/10 at 2:00 p.m. of the 1st floor emergency room revealed:
*Four different disposable cannula low pressured cuffed tracheostomy tubes with expiration dates from July 1995 through November 1996.
*Eight different packages of sutures with expiration dates ranging from July 2003 through July 2009.
*One multi-lumen catheter kit with an unreadable expiration date and broken packaging compromising the contents.
*One container of Nu Gauze Iodoform with an expiration date of November 2009.

3. Interview on 4/14/10 at 10:10 a.m. with central supply coordinator 18 revealed she maintained the above unmarked storage room and delivered supplies to the emergency room as needed. She stated she removed outdated supplies from stock when they were identified.

A. Based on record review and interview, the provider failed to ensure appropriate actions were maintained to contain methicillin resistant staphylococcus aureus (MRSA) infection for one of eight sampled swing bed patients (11). Findings include:

1. Review of patient 11's medical record revealed she was diagnosed with a presumptive MRSA infection on 6/12/09. Review of patient 11's 6/12/09 physician's orders revealed treatment protocols for MRSA infection were to have been instituted on that day. Review of the provider's 6/12/09 physician's progress report revealed:
*A culture had been done on patient 11's lesion, and it showed MRSA.
*"In the past, we had been plagued with MRSA infection in this institution because of difficulty carrying out our MRSA protocol."
*The MRSA protocol was to have been implemented.
*Hibiclens antibacterial soap was to have been used for cleansing three times each day.
*Patient 11 was to have been maintained on isolation until further notice.

Review of patient 11's care plan revealed there were no entries between 6/6/09 and 6/30/09. Further review of that care plan found nothing regarding the implementation of MRSA protocols.

Interview with RN 13 on 4/15/10 at 1:30 p.m. revealed the MRSA protocols were obtained from another provider's website. She confirmed nothing was found on the care plan regarding the implementation of the MRSA protocols.




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B. Based on observation and interview, the nursing staff failed to ensure clean scissors were used during one of one patient's (1) dressing change. Findings include:

1. Observation on 4/14/10 at 11:15 a.m. of patient 1's dressing change revealed registered nurse (RN) 13 did the following:
*Obtained a sterile gauze pad, Kling, sterile Q-Tip, and ointment from the medication cart.
*Opened the Kling, went to the nurses station, opened a drawer, and removed a pair of scissors.
*Without cleaning the scissors cut a portion off the Kling roll to use during patient 1's dressing change.
*Entered the patient's room, opened the gauze packet, placed it on the overbed table, and laid the Kling on that surface.
*Obtained a pair of clean gloves, exited the room, entered the soiled utility room with the gloves in hand, and returned to the patient's room with a red garbage bag.
*Without washing her hands put on the gloves she had carried to the soiled utility room, opened the red bag, assisted the patient to turn to her left side.
*Removed the old dressing, measured the wound area, and removed her contaminated gloves.
*Without washing her hands or using hand sanitizer tore off a piece of tape and put on clean gloves.
*Put ointment with a Q-tip on the wound, placed the gauze pad on the wound, and wrapped the area with the Kling bandage.
*Exited the room and entered the soiled utility room for trash disposal.

Interview on 4/14/10 at the time of the above dressing change with RN 13 revealed patient 1's dressing change was considered a clean procedure not sterile. She only had to maintain a clean environment. RN 13 revealed she:
*Should have cleaned the scissors with alcohol prior to using them to cut patient 1's bandage.
*Was not sure who had used the scissors prior to or what they had been used for.
*Had not washed her hands after leaving the soiled utility room. She had carried the gloves to the soiled utility room, had not put the gloves down, and they were still clean.
*Was not sure if the provider had a protocol or policy for completing a dressing change.

Interview on 4/15/10 at 10:00 a.m. with the director of nursing revealed there was no policy for cleaning patient care equipment used during dressing changes or a policy for completing dressing changes.




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C. Based on observation and interview, the provider failed to ensure the cleanliness and prevention of potential infection for one of one observation of the ice scoop in the patient dining room. Findings include:

1. Observation on 4/13/10 at 3:30 p.m. revealed a randomly observed patient took the ice scoop from on top of the ice machine in the patient dining room. The patient was holding the ice scoop with both hands by the scoop portion and not the handle while walking in the hallway. The ice scoop was out of its plastic bag. An unidentified staff person took the ice scoop from the patient and placed it back in the dining room on top of the ice machine. The ice scoop was placed on top of the plastic bag on top of the ice machine at that time. The ice scoop was not cleaned prior to returning it to the top of the ice machine.

Interview with the dietary manager on 4/14/10 at 2:10 p.m. revealed the dietary department did not clean the ice scoop or replace it when necessary. She stated the ice scoop and storage of it was taken care of by the nursing department.

Interview on 4/14/10 at 3:20 p.m. with licensed practical nurse 15 and registered nurse 13 revealed the ice scoop was cleaned with bleach and water periodically. There was no specific time frame for cleaning the ice scoop. There was no specific policy and procedure for the cleaning of the ice scoop or replacement of the plastic bag which contained the ice scoop.

Based on interview and job description review, the provider failed to ensure the activity program was directed by a qualified designee or activities professional. In addition the provider failed to ensure an activity consultant was on staff or contracted to assist with the activities program as needed. Findings include:

1. Interview on 4/14/10 at 9:50 a.m. with the director of nursing (DON) revealed she was the director for the swing bed program. However she was not responsible for the swing bed activity program. The activity program had been assigned to a licensed practical nurse (LPN) on staff. The DON revealed she was not aware of the qualifications needed to become an activity coordinator. She did not know what training the LPN had taken to become the activity coordinator.

Interview on 4/15/10 at 10:15 a.m. with LPN 15 revealed she was responsible for the provider's swing bed activity program. Continued interview with LPN 15 revealed:
*She had not been certified by a national or state program for the activity coordinator position.
*She did not have an activity consultant to provide guidance regarding activities issues. If she had questions she would call another healthcare activity coordinator as needed.
*She had become the activity coordinator many years ago and was not certified or taken an activity coordinators course for certification.

Review of the provider's Activity Coordinator Job Description revealed:
*Requirements and qualifications: A high school diploma or equivalent, and be qualified or eligible for the activity coordinator as required by the South Dakota Department of Health.
*The activity coordinator duties involved planning and implementing the activity program to meet the physical, spiritual, mental, and psychosocial needs and interests of the patients. The activity coordinator developed the activity care plan for all patients and participated in care plan meetings.
*The activity coordinator was accountable to the DON.