HospitalInspections.org

Based on staff interview, review of employee files, and review of North Dakota Administrative Code (NDAC), the Critical Access Hospital (CAH) failed to comply with federal and state regulations to ensure current registration with the North Dakota Board of Nursing (NDBON) for 1 of 1 surgical technician (#2) reviewed. Failure to ensure unlicensed assistive persons (UAPs) applied to the NDBON registry limited the CAH's ability to ensure qualified staff to assist with patient care/procedures.

Findings include:

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

Review of the employee files on 11/06/19 showed a surgical technician (#2) lacked registration with the NDBON.

During an interview on 11/06/19 at 11:15 a.m., a human resources staff member (#11) stated the surgical technician (#2) utilized in the surgical department had not registered as a UAP with the NDBON.

During interview on 11/06/19 at 11:45 a.m., an administrative nurse (#1) stated she had no knowledge of the requirement for registration of surgical technicians with the NDBON.


32641

Based on policy review, record review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Improvement (QI) program evaluated all patient care services and other services affecting patient health and safety for 4 of 4 quarters reviewed (3rd quarter 2018, 4th quarter 2018, 1st quarter 2019, and 2nd quarter 2019). Failure to ensure departments submitted QI monitoring reports to the QI Committee as required limited the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the policy titled "Facility Quality Improvement Plan" occurred on 11/06/19. This policy, revised 01/2019, stated,
"Purpose:
First Care Health Center has an ongoing, comprehensive Quality Assurance/Quality Improvement Program to strive to ensure that patient care/relations are continually improved . . .
Each department involved directly or indirectly in patient care areas shall be included in Quality Improvement and Quality Control activities according to the frequency assigned. (See report schedule) . . .
Organization: . . .
6. The Quality Coordinator is responsible for the integration and coordination of pertinent aspects of the QI program. These responsibilities include: . . .
g. . . . obtaining reports for presentation to the QI Committee. . . .
7. . . . Responsibilities of the QI Committee include:
a. Reviewing reports from patient care services . . .
b. Assessing data . . .
c. Providing feedback . . .
d. Monitoring resolution of problems. . . .
8. . . . Information collected and action taken to resolve identified problems must be reported to the QI Committee as per established reporting schedule. . . ."

Reviewed on 11/06/19, the CAH's 2018 and 2019 QI Reporting Schedule indicated Nutritional Services, Respiratory Therapy, and Social Services should report every quarter.

Reviewed on 11/06/19, the 3rd quarter 2018, 4th quarter 2018, 1st quarter 2019, and 2nd quarter 2019 QI Committee's quarterly meeting minutes from October 2018 through October 2019 lacked evidence Nutritional Services, Respiratory Therapy, and Social Services submitted reports to the QI Committee.

Reviewed on 11/06/19, the October 2018 through October 2019 QI monitors submitted to the QI Committee failed to include reports from Nutritional Services, Respiratory Therapy, and Social Services.

During interview on 11/06/19 at approximately 11:50 a.m., an administrative staff member (#1) confirmed Nutritional Services, Respiratory Therapy, and Social Services had not submitted their QI monitoring reports to the QI Committee the past year.