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Based on observation, interview, record review and policy review, the hospital failed to ensure that:
- Full-time oversight of nursing practices of the hospital was provided by the Chief Nursing Officer (CNO).
- A list of all services provided under arrangement or agreement that described the nature and scope of services provided was maintained.
- The Chief Executive Officer (CEO) provided oversight of contracted services and that all services furnished by the hospital through contracted services and agreements complied with the applicable requirements of the Conditions of Participation (COPs).
- Twenty-two out of 22 contracted services and agreements were reported to the Quality Assurance Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program for evaluation.
- Three out of 22 contracted services and agreements were executed specifically and solely for the hospital.
- Three out of 22 contracted services and agreements were updated to reflect the correct legal name of the hospital.
- Separate policies were developed for Hospital A, the surveyed critical access hospital (CAH) and Hospital B, a nearby CAH with a separate provider number.
- Patient #1 received a physician-ordered medication.
- Intravenous (IV, in the vein) tubing and peripheral IV dressings were labeled per hospital policy.

The cumulative effects of these failed practices resulted in the hospital's non-compliance with requirements of 485.635 COP: Provision of Services. The hospital census was six.

Based on interview, record review and policy review, the hospital failed to ensure separate policies were developed for Hospital A, the surveyed critical access hospital (CAH) and Hospital B, a nearby CAH with a separate provider number.

This had the potential to affect all patients treated or admitted to the hospital by failing to direct appropriate care and services specific to Hospital A. The hospital census was six.

Findings included:

Even though requested, the hospital failed to provide a policy on policy implementation and review process.

Review of the hospital's document titled, "Medical Executive Committee Review and Approval Policy Review - No Changes," showed the following:
- On 01/11/21, there were 58 policies with Hospital A and Hospital B listed on the same policy that were reviewed and approved with no changes.
- On 02/08/21, there were 82 policies with Hospital A and Hospital B listed on the same policy that were reviewed and approved with no changes.
- On 03/08/21, there were 54 policies with Hospital A and Hospital B listed on the same policy that were reviewed and approved with no changes.
- On 04/12/21, there were 63 policies with Hospital A and Hospital B listed on the same policy that were reviewed and approved with no changes.
- On 05/10/21, there were 113 policies with Hospital A and Hospital B listed on the same policy that were reviewed and approved with no changes.
- On 06/14/21, there were 30 policies with Hospital A and Hospital B listed on the same policy that were reviewed and approved with no changes.

During an interview on 07/13/21 at 3:03 PM, Staff L, Administrator, stated that the policies were reviewed annually and were combined because staff work at both hospitals.

Based on record review and interview, the hospital failed to maintain a list of all services provided under arrangement or agreement that described the nature and scope of services provided. The hospital census was six.

Findings included:

Review of the undated hospital-provided document titled, "Table of Contents, Contracted Services & Agreements - Aurora," showed a listing of 22 individuals or entities that provided contracted services. The listing failed to show the following:
- The service(s) offered;
- Whether the service(s) were offered onsite or offsite;
- Whether there was any limit on the volume or frequency of the service(s) provided; and
- When the service(s) were available.

During a telephone interview on 07/15/21 at 1:35 PM, Staff L, Administrator, stated that she assumed the position of administrator on 11/01/20, and the format for the current list of contracted services and agreements was the format that the previous administrator had used and that she had continued to use. She stated that the list needed to be more complete and include the missing information to clearly show what each contract entailed.

Based on record review and interview, the Chief Executive Officer (CEO) failed to ensure that all services furnished by the hospital through contracted services and agreements complied with the applicable requirements of the Conditions of Participation (CoPs) when they failed to ensure that:
- Twenty-two out of 22 contracted services and agreements were reported to the Quality Assurance Performance Improvement (QAPI, process for reporting and/or identifying adverse events, near misses or review of high risk, problem prone areas for patient safety) program for evaluation;
- Three out of 22 contracted services and agreements were executed specifically and solely for the hospital; and
- Three out of 22 contracted services and agreements were updated to reflect the correct legal name of the hospital.
These failed practices placed the health of all patients at risk for the quality, safety, and/or appropriateness of services provided. The hospital census was six.

Findings included:

1. Review of the 2021 Quality and Patient Safety Performance Improvement Plan showed it was the Quality/Patient Safety Committee's responsibility to ensure the regular evaluation of the quality, patient safety, and/or appropriateness of services provided.

Review of the hospital-provided document titled, "Department Performance Improvement Studies 1st Quarter 2021," showed no evaluation of the quality, patient safety, and/or appropriateness of contracted services provided.

During an interview on 07/14/21 at 12:55 PM, Staff L, Administrator, stated that review of contracted services was not reported to the QAPI program.

2. Review of the contracted services and agreement titled, "Service Agreement-Nuclear Medicine Imaging Services," dated 04/01/18, showed that an agreement was entered into between Hospital A and Hospital B (collectively and individually the "Health Center") and a company for the provision of diagnostic nuclear medicine imaging services.

Review of the memorandum of understanding (MOU, an expression from two parties to mark a business relationship) for contracted services agreement titled, "MRI Services at Hospital A and Hospital B," dated 06/17/05, showed that an agreement was entered into between Hospital A for mobile Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) services on Mondays and Hospital B on Wednesdays. The MOU was acknowledged, accepted and signed on 06/24/05.

Review of the contracted services and agreement titled, "Medical Coverage Agreement," dated 03/01/07, showed that an agreement was entered into between Hospital B and a company ("Company") for radiology services. An attachment titled, "First Amendment Medical Coverage Agreement," dated 12/23/09, showed that an agreement was entered into between Hospitals A/B ("Hospital") and "Company" that amended the terms of the original agreement. An attachment titled, "Exhibit A," showed that the "Company" would provide coverage/services Monday through Friday, on a rotating basis between Hospital A and Hospital B.

Review of the contracted services and agreement titled, "Medical Director Services Addendum," effective 05/01/20, showed that an agreement was entered into between Hospital B, Hospital A (collectively the "Hospital") and Clinic C ("Clinic"), for the services of Medical Director, Radiology Department.

During an interview on 07/13/21 at 11:20 AM, Staff L, Administrator, stated that since Hospital A and Hospital B were both part of the same health system, all contracts were reviewed and approved by the health system's Legal Department, and since she was the administrator of both hospitals, she thought it was acceptable to have both hospitals listed on the same contracts and agreements that pertained to both hospitals.

3. Review of the hospital-provided document titled, "Articles of Amendment for a Nonprofit Corporation," date filed with the Missouri Secretary of State 11/15/11, showed that an amendment was adopted on 10/31/11, that changed the name of the corporation from Hospital Z to Hospital A.

Review of the hospital-provided document titled, "Certificate of Amendment of a Missouri Nonprofit Corporation," dated 11/15/11, showed that the Missouri Secretary of State certified that Hospital A had delivered its Articles of Amendment of its Articles of Incorporation and complied with the requirements of law governing the Amendment of Articles of Incorporation under The Missouri Nonprofit Corporation Law, and that the Articles of Incorporation were amended accordingly, and that Hospital A was formerly known as Hospital Z.

Review of the contracted services agreement titled, "Ultrasound Technologist Agreement," dated 01/31/05, showed that an agreement was entered into between Hospital Z, and a company and that the agreement would automatically renew from year to year thereafter unless 60 days' written notice was provided by either party. No update or revision to the contract had been made to reflect a change to the hospital's name that occurred on 10/31/11.

Review of the contracted services agreement titled, "Purchase Order for Teleradiology and Related Services," showed that an agreement was entered into between Clinic J ("Client") and a virtual radiologic company and Health System S ("System"), effective 06/08/11, and that the agreement would automatically renew from year to year after the initial two year period. No update or revision to the contract had been made to reflect a change to the hospital's name that occurred on 10/31/11.

Review of the MOU titled, "MRI Services at Hospital Z and Hospital Y," dated 06/17/05, showed that an agreement was entered into between Hospital Z for mobile MRI services on Mondays and Hospital Y on Wednesdays. The agreement would be continued indefinitely unless terminated by either party upon 30 days' advance written notice. The MOU was acknowledged, accepted and signed on 06/24/05. No update or revision to the contract had been made to reflect a change to the hospital's name that occurred on 10/31/11.

During an interview on 07/13/21 at 11:50 AM, Staff L, Administrator, stated that Hospital Z was the previous name of Hospital A and that the hospital's Legal Department had advised her that the contracts and agreements were still in effect because they had the Articles of Amendment for a Nonprofit Corporation and the Certificate of Amendment of a Missouri Nonprofit Corporation from the Secretary of State's Office that showed where the hospital's name had officially been changed from Hospital Z to Hospital A.

Based on interview, record review and policy review, the hospital failed to ensure full-time oversight by a Chief Nursing Officer (CNO) who was responsible for nursing practices of the hospital. This failure placed all patients at risk for their health and safety. The hospital census was six.

Findings included:

Review of the untitled and undated hospital-provided document showed that Staff C, Registered Nurse (RN), Chief Nursing Officer (CNO), was designated as the Director of Nursing and Director of Operations for Hospital A.

Review of the undated CNO job description showed that the position was responsible for the following: serves as the Administrative Director for the identified areas and service lines to develop and enforce policies and procedures, to operationalize budgetary decisions for areas of responsibility and participate in strategic planning for the hospital. Primary functions of the role are: (1) serve as a co-chair in the management and leadership of the service line; (2) work directly with department and medical director(s) and others to position the service line as a regional center of excellence; (3) work directly with department managers to provide leadership and guidance in planning, organizing, directing, controlling, staffing, and evaluating each department; (4) oversee the implementation of the hospital's philosophy, goals, and objectives; (5) establish standards for clinical and management competency; and (6) represent the areas of responsibility in the strategic planning process.

During an interview on 07/13/21 at 2:40 PM, Staff C, RN, CNO, stated that she was responsible for the oversight of nursing practices for Hospital A. She stated that she was at Hospital A four days a week and went to Hospital B one time a week to oversee one of her staff who also worked at Hospital B.

Based on observation, interview and policy review, the hospital failed to follow their policy related to labeling intravenous (IV, in the vein) tubing for two current patients (#1 and #8) of three current patients observed and labeling peripheal IV catheter dressings for four current patients (#1, #2, #4 and #8) of four current patients observed. To ensure Patient #1 received a physician-ordered medication for four days.This had the potential to affect all patients who were prescribed medications that were not available from the pharmacy.The hospital census was six.

Findings included:

1. Review of the hospital's policy titled, "AUR CAS NUR Peripheral Catheter and Intravenous Administration Set Change," dated 02/09/21, showed that both sets of tubing and flush bags are labeled with a patient label and the date, time, and initials of the person who changed the tubing.

Review of IV Catheter Maintenance within the Lippincott Manual of Nursing Practice showed that the dressing should be labeled with the date it was changed or the date it next needed to be changed as directed by the facility.

Observation on 07/13/21 at 8:30 AM, showed that Patient #8's IV tubing did not have a label with the date, time or initials of staff. The patient's peripheral IV dressing did not have the date, time or initials of staff.

During an interview on 07/13/21 at 11:40 AM, Staff M, Registered Nurse (RN), stated that she saw that there was no label on the tubing and she went back and put a label on the tubing.

Observation on 07/13/21 at 8:45 AM, showed that Patient #1's IV tubing did not have a label with the date, time or initials of staff. The patient's peripheral IV dressing did not have the date, time or initials of staff.

Observation on 07/12/21 at 2:30 PM, showed that Patient #2's peripheral IV dressing did not have the date, time or initials of staff.

Observation on 07/13/21 at 9:25 AM, showed that Patient #4's peripheral IV dressing did not have the date, time or initials of staff.

During an interview on 07/13/21 at 2:40 PM, Staff C, Chief Nursing Officer (CNO), stated that all tubing and peripheral site dressings should have the date, time and the initials of staff.

2. Review of the hospital's policy titled, "AUR CAS NUR Medication Administration," dated 05/12/21, showed that:
- Licensed nursing personnel or allied health personnel will administer medications as prescribed by the practitioner.
- If a home medication is ordered by the physician and pharmacy does not carry the medication, licensed nursing personnel need to have the patient/family bring the home medication in and labeled by pharmacy.
- If the patient/family is unable to bring in a home medication, the ordering physician needs to be notified immediately.

Review of Patient #1's medical record showed that the 94-year-old female was admitted from the Emergency Department (ED) on Saturday, 07/10/21, with a diagnosis of acute cystitis without hematuria (sudden inflammation of the urinary bladder without blood), weakness and falls. She had a history of high blood pressure (BP, a measurement of the pressure of blood flow in two different parts of the heart, normal is approximately 90/60 to 120/80) of slight to moderate severity of long duration. Her blood pressure on admission was 135/64 in her right arm. Her home medications included Inderal LA (a medication used to treat high blood pressure, chest pain, uneven heartbeat, and tremors) 80 milligrams (mg, a measure of dosage strength) daily and Norvasc (a medication used to treat high blood pressure and chest pain) 10 mg daily.

Observation on 07/13/21 at 8:45 AM, showed Staff P, Registered Nurse (RN), administered daily medications to Patient #1, except for the Inderal LA.

During an interview on 07/13/21 at 9:05 AM, Staff P stated that she was unable to give the medication because it was not available through the hospital pharmacy. She stated that the Medication Administration Record (MAR) showed that the patient had not been given the medication since admission, which was four days. She stated that the physician should have been called on admission to inform him that the medication was not available.




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