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1. Based on observation and staff interview, the facility failed to protect the health and safety of residents, personnel, and the public, regarding oxygen storage in 1 of 1 oxygen storage area located in the basement. This failure could result in an oxygen tank falling and becoming a projectile, placing residents, staff, and visitors in the area at risk of injury.

Findings include:

On the afternoon of 09/18/12, observation identified three green "K" oxygen tanks, each holding 7050 cubic feet of gas, in the oxygen storage room in the basement. Observation showed these three tanks unsecured with a chain or other securing device.

On the afternoon of 09/18/12, a maintenance supervisory staff member (#13) confirmed the facility did not properly secure the three size "K" oxygen tanks and the unsecured tanks posed a potential hazard.

2. Based on observation and staff interview, the facility failed to ensure a safe and sanitary environment for residents, staff, and the public regarding the lack of an anti-siphon backflow valve on a hose that reached below the rim of a mop sink in 1 of 1 housekeeping room on the main level of the facility. Failure to ensure an anti-siphon backflow valve was in place created the potential for siphoning contaminated water into the potable (drinking) water system in the event of loss of water pressure, causing widespread contamination of the facility and community water system.

Findings include:

On the afternoon of 09/18/12, observation of a housekeeping room on the main floor identified a spliced garden hose hanging from a faucet into a mop sink. The hose reached below the rim of the mop sink. On the afternoon of 09/18/12, a supervisory staff member (#1) could not identify if the faucet had an anti-siphon backflow valve.

On the morning of 09/19/12, a maintenance supervisory staff member (#13) stated the faucet lacked an anti-siphon device.

Based on observation and staff interview, the facility failed to ensure a clean and orderly room for the storage of medical supplies and equipment in 1 of 1 combined medical supply and equipment room. The failure to keep supplies and equipment clean and orderly may cause infection control breaches, limit the quick access of supplies/equipment, and pose a safety hazard.

Findings include:

On the afternoon of 09/18/12, observation showed the following:
* In a hall corridor outside of the equipment/supply room (in the basement) four boxes directly on the floor. Three boxes contained mattresses, and the fourth box contained a large water tank filter. The bottom corner of one of the mattress boxes was torn and frayed.
* A cluttered main equipment/supply room with an array of medical equipment (geriatric chairs, beds, cushions, etc.) on the left side of the large room, and stocked medical supplies on the right side of the room.
* Stock medical supply boxes with dust on the top surfaces.
* At the end of the aisles on the supply side laid several large styrofoam square containers. The styrofoam boxes blocked access to supplies in that aisle including boxes of 50 cubic centimeter syringes. The syringe boxes had a heavy layer of dust over the tops of the boxes.

On the afternoon of 09/18/12, a maintenance supervisory staff member (#13) stated the facility should store everything (medical supplies including the mattresses and water filter) off the floor and agreed the room needed better organization.

Based on observation, review of a professional reference, policy and procedure review, review of infection control reports and meeting minutes, review of personnel files, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the provision of services by failing to ensure staff correctly transcribed a provider's medication order and stored all drugs and biologicals in a secure manner to prevent access by unauthorized personnel (Refer to C276); failing to follow professional standards of care relating to infection control practices, implementing a system to identify, report, investigate, and control infections and communicable diseases for outpatients, and ensuring a medical provider reviewed final culture and sensitivity reports (Refer to C278); failing to ensure all nursing staff possessed the adequate qualifications and certifications related to each of their specific roles within the CAH (Refer to C294); failing to monitor and document the effectiveness of medications given to patients on an as needed (prn) basis and provide care in accordance with the needs of patients who presented to the emergency department with suicidal ideation or attempt (Refer to C295); failing to ensure staff followed a provider's order for medication administration and blood glucose monitoring (Refer to C297); and failing to ensure staff developed, updated, and maintained nursing care plans for inpatient and swing bed patients (Refer to C298). Failure to ensure the provision of services places the CAH patients at risk of receiving improper care.

1. Based on observation, review of policy and procedure, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff correctly transcribed a provider's medication order for 1 of 1 active inpatient (Patient #2) observed receiving a medication without a provider's order. Failure of staff to ensure correct providers' orders resulted in Patient #2 incorrectly receiving hydrochlorothiazide (HCTZ) (a diuretic used for edema and/or high blood pressure) on two consecutive days (September 18-19, 2012).

Findings include:

Review of the policy "Pyxis Medstation" occurred on 09/19/12. This policy, effective 07/17/12, stated, ". . . III. Removal of Medications. A. Review of Orders. Nursing will fax the provider order sheet to pharmacy. The Pharmacist will enter the medications in the patient's pharmacy profile. . . ."

Review of the policy "Medications, Administration (OMAR/BCMA [Online Medication Administration Record/Bar Code Medication Administration])" occurred on 09/19/12. This policy, effective 12/28/10, stated, "Medications are given only per the provider' [sic] orders. . . ."

Review of the policy "Provider's Orders" occurred on 09/19/12. This policy, effective 05/14/08, stated, ". . . PURPOSE: To accurately transcribe and carry out provider's orders. POLICY: All orders for treatments shall be in writing and signed by a Provider. . . ."

Observation of medication pass on 09/18/12 at 7:45 a.m. showed a nurse (#6) administered a 12.5 milligram (mg) capsule of HCTZ to Patient #2 in his room with his morning medications.

Review of Patient #2's active record occurred on September 18-19, 2012. The CAH admitted the patient on 09/17/12 with diagnoses of coronary artery disease, peripheral artery disease, hypertension, mild anemia, and left lower extremity cellulitis. Patient #2's OMAR listed HCTZ 12.5 mg daily, but the patient's provider orders lacked an order for HCTZ. Review of the OMAR identified the patient received 12.5 mg of HCTZ on the morning of 09/18/12 and 09/19/12.

During an interview on 09/19/12 at 8:35 a.m., a nurse (#8) confirmed Patient #2's medical record lacked a provider order for HCTZ.

During an interview on 09/19/12 at 11:45 a.m., an administrative nurse (#1) stated staff faxed patient medication orders to the CAH's consulting pharmacist or the telepharmacy pharmacist for review, and the pharmacists entered the medication orders electronically into the OMAR system giving nursing staff the okay to administer the medication. The nurse (#1) stated the CAH lacked a system to "double check" patients' OMARs with provider orders to prevent medication and treatment errors.

Pharmacy staff entered HCTZ on Patient #2's OMAR without a provider's order. Failure to ensure staff followed provider orders and checked and dispensed the correct medications according to the order has the potential for patients to receive the wrong medication.

2. Based on observation, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to store drugs and biologicals in a secure manner to prevent access by unauthorized personnel in 3 of 6 medication storage areas (Main Emergency Room [ER], Overflow ER, and Central Supply). Failure of the CAH to adequately secure and restrict access of drugs and biologicals created an opportunity for unsafe and unauthorized use of medications.

Based on review of the North Dakota Department of Health, Division of Health Facilities provider files, this facility has not sustained correction of this issue. The previous survey completed on 10/08/08 found this requirement out of compliance.

Findings include:

Review of the policy "Medication Storage in the Emergency Room" occurred on 09/19/12. This policy, effective 10/27/08, stated, ". . . 1. All drugs and biologicals must be stored in a manner to prevent access by unauthorized individuals. Persons without legal access to drugs and biologicals cannot have unmonitored access to drugs or biologicals. 2. All drugs and biologicals will be kept in a locked cabinet. . . ."

- Observation of the Operating Room (OR) with a surgical nurse (#2) on 09/18/12 at 11:30 a.m., showed a door, locked with an electronic key pad, leading to the central supply room. Observation of the central supply room showed various injectable local anesthetic medications including lidocaine stored in an unlocked cupboard, and several different types of oral and injectable medications stored in two containers sitting on the floor in a narrow hallway by the door. The nurse (#2) identified the medications in the two containers as outdated medications. Two nursing assistant staff members (#10 and #11) were in the central supply room at the time of the observation. Further observation showed an anteroom located directly outside the central supply room, which led to a small sterilizing/disinfecting room, OR suite, and a door exiting the OR area out into the main hallway of the CAH. The door lacked a lock.

During an interview on 09/18/12 at 11:45 a.m., a surgical nurse (#2) stated nursing assistant, housekeeping, and maintenance staff have unmonitored access to the OR area for reprocessing, cleaning, and general maintenance.

- Observation of the Main ER with an administrative nurse (#1) on 09/18/12 at 1:20 p.m., showed a plastic, portable container labeled "RSI [Rapid Sequence Intubation] Meds [Medications] and Protocol" containing various injectable medications including midazolam (a medication used to promote sleep, relaxation, and block memory of an event), stored on the top of a supply cart. The ER included a crash cart, locked with a red plastic break away lock, located against the north wall. The crash cart contained various medications used in life-threatening situations and additional red plastic locks, used as replacements for the lock on the cart, in the top drawer of the crash cart.

During an interview on 09/18/12 at 1:40 p.m., an administrative nurse (#1) stated the ER door remained open and unlocked at all times and indicated staff monitored the ER randomly throughout the day and during the time when used for patients.

- Observation of the Overflow ER with an administrative nurse (#1) on 09/18/12 at 1:50 p.m., showed several injectable local anesthetic medications including lidocaine and Xylocaine stored in an unlocked cupboard and in an unlocked mobile cart, identified by the nurse (#1) as the "dressing cart."

During an interview on 09/18/12 at 1:55 p.m., an administrative nurse (#1) stated she did not realize all of the unsecured medications within the CAH, and confirmed the CAH should store medications securely or monitored to prevent unauthorized access and use.

1. Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care relating to infection control practices observed during patient care, administration of medications, and equipment cleaning/disinfecting on 3 of 3 days of survey (September 17-19, 2012). 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:

Review of the policy "Hand Hygiene" occurred on 09/19/12. This policy, effective 07/07/10, stated, ". . . GENERAL INFORMATION . . . Decontamination refers to the physical removal of blood, body fluids, and transient microorganisms from the hands by using hand washing and antisepsis procedures . . . Hands must be decontaminated immediately before each and every episode of direct patient contact/care, and after any activity or contact that potentially results in hands becoming contaminated . . . The use of gloves does not eliminate the need for hand hygiene, and the use of hand hygiene does not eliminate the need for gloves . . . Alcohol-based hand rubs should be used before and after each patient just as gloves should be changed before and after each patient . . . POLICY . . . Appropriate hand hygiene must occur . . . Before and after patient contact . . . After touching anything that might be dirty or contaminated . . . After removing gloves . . . Hand washing with soap and water is specifically required when: . . . Visible soiling or debris on hands . . . When contaminated with proteinaceous material . . . When contaminated with blood or body fluids. . . ."

Review of the policy "Intravenous (IV) Injection" occurred on 09/19/12. This undated policy stated, ". . . PROCEDURE: . . . 3. . . . Aseptic technique must be observed throughout the procedure . . . 5. If using a vial container, cleanse the rubber-capped vial of medication with sponge . . . 12. If IV is established, close IV tubing, clean port of IV tubing with alcohol sponge, inject medication through one of the injection sites on IV tubing . . ."

Review of the policy "Dry Dressing" occurred on 09/19/12. This policy, effective 05/07/07, stated, ". . . PROCEDURE: . . . 4. Wash hands, put gloves on - nonsterile. 5. Remove soiled dressings. Place dressings in bio-hazard plastic bag. Remove gloves. 6. Tear wrapper on dressings open. Put sterile gloves on or use sterile forceps . . . 8. Apply dressing to wound or area . . . 11. Place soiled dressing in covered garbage can in soiled utility room. 12. Wash hands. . . ."

Review of the policy "Cleaning a unit after discharge" occurred on 09/19/12. This policy, effective 12/26/05, stated, ". . . PROCEDURE: . . . 2. Clean and remove all equipment . . . 3. All utensils are to be washed and carried to Central Supply for sterilization . . . 5. Strip bed. a. Place linen in plastic sack. b. Remove pillow cover and place with dirty linen. 6. Take cleaning basin, solution, and cleaning cloths to room. 7. Clean upper surface and side of mattress with damp cloth . . . 13. Wash chairs, closet and shelves . . . 15. Wash call light cord, television control and telephone . . . 18. Restock unit with utensils. 19. Make the bed. Place pillow cover on pillow and pillowcase. . . ."

- On 09/17/12 at 4:22 p.m., observation showed a nurse (#2) walked out of the medication room, down the corridor, and into Patient #30's room. While wearing the same gloves as seen in the medication room, the nurse (#2) flushed the patient's bilateral nephrostomy tubes, removed Patient #30's dressings covering the insertion site of his nephrostomy tubes, and applied new dressings to each site. The nurse (#2) failed to remove her gloves upon entering the room, failed to wash her hands and don new gloves prior to flushing the patient's tubes, and failed to perform hand hygiene and change gloves prior to applying the new dressings.

- Observation on 09/17/12 at 4:35 p.m. in Patient #29's room showed a nurse (#4) attached an antibiotic to a secondary line on the patient's existing IV and tubing unit. Prior to hooking up the antibiotic, the nurse (#4) failed to use an alcohol pad to disinfect the exposed port on the IV tubing.

- On 09/18/12 at 7:45 a.m., in the medication room, a nurse (#6) drew up Patient #2's antibiotic and injected it into the exposed port on a bag of normal saline. The nurse (#6) failed to disinfect the exposed port with an alcohol pad prior to injecting the antibiotic.

- Observation in the Emergency Room on 09/18/12 at 9:35 a.m. showed a provider (#12) donned sterile gloves and used sterile saline to cleanse Patient #31's bleeding forehead laceration. The provider (#12) sutured the laceration, used gauze and normal saline to wipe off the blood, removed his gloves, exited the room, and charted at the nurse's station. The provider (#12) failed to wash his hands after removing his gloves, prior to exiting the room.

- In the Emergency Room on 09/18/12 at 9:45 a.m., a nurse (#3) donned gloves, cleansed Patient #31's sutured laceration with gauze and normal saline, applied antibiotic ointment with a cotton-tipped applicator, and walked the patient out of the room. While walking in the hallway, the nurse (#3) removed her gloves, finished walking with the patient, and then threw her gloves away upon returning to the nurse's station. The nurse (#3) failed to remove her gloves and wash her hands prior to leaving the patient's room and failed to wash her hands after removing her gloves in the hallway.

- Observation on 09/18/12 at 10:00 a.m. showed a nurse (#2) walked out of a kitchenette on the nursing unit with a cup of liquid, wearing a surgical hat and gloves, and backed into another room down the corridor.

- Observation on 09/18/12 at 2:54 p.m. showed an administrative nurse (#1) removed the linen used on the cart in the main emergency room (ER) following the discharge of a patient. Without disinfecting the cart, a nurse (#6) and a nurse aide (#11) placed new linen on the cart. A urinal containing urine sat on the countertop in the ER. A nurse aide (#11) removed the urinal from the room, but failed to disinfect the counter surface. Immediately after staff removed the urinal and placed the clean linen, a new patient entered the ER.

- On 09/19/12 at 8:10 a.m., in the medication room, a nurse (#9) failed to use an alcohol pad to disinfect the exposed port on a bag of normal saline prior to injecting Patient #1's reconstituted antibiotic into the bag.

- Observations on September 17-19, 2012 identified Patient #1's IV tubing lacked the date staff hung the current IV tubing unit.


28086


During an interview on 09/19/12 at 10:03 a.m., the infection control coordinator (#14) stated staff must perform hand hygiene or handwashing prior to patient care (no matter what type of contact with the patient), after patient care, after removing gloves, in between procedures on the same patient, and after eating and using the restroom. The infection control coordinator (#14) stated she expected staff to don gloves in the patient room just prior to performing care or a procedure, and stated if staff placed gloves while in a patient's room, staff must remove the gloves before leaving the patient's room. The staff member (#14) stated staff must strip patient rooms of all linens and clean after each patient use, indicating staff must clean the bed, pillows, and all used or touched surfaces with a disinfectant spray or wipe.

During an interview on 09/19/12 at 11:40 a.m., an administrative nurse (#1) confirmed the above staff member's (#14) statements. The nurse (#1) stated staff must change patient's intravenous (IV) tubing every 72 hours and document the change, and must scrub the ports of medication vials, IV bags, and IV tubing with alcohol prior to injecting/administering any type of fluid or medication.

2. Based on review of the infection control reports and meeting minutes, record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases for outpatients of the CAH for the past 8 of 8 months (January through August 2012) reviewed, and failed to ensure a medical provider reviewed a final culture and sensitivity (C/S) report for 1 of 1 closed ER patient (Patient #15) records reviewed with a culture. Failure to identify and address incidents of infections among all patients has the potential for infections to go unreported, spread, or reoccur; affecting the health of all patients, personnel, and visitors of the CAH. Failure to ensure the medical provider reviewed the final C/S report resulted in Patient #15 receiving the incorrect antibiotic to treat the infection.

Findings include:

- Reviewed on 09/19/12, the infection control program lacked evidence the CAH identified and recognized infections of outpatients. The infection reports and meeting minutes from January through August 2012 failed to include information and documentation of outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on 09/19/12 at 10:03 a.m., the infection control coordinator (#14) stated she did not receive or request infection control information from outpatients, namely, the ER, cardiac rehabilitation, physical therapy, and procedure/treatment patients. The staff member (#14) confirmed the CAH did not formally document and include outpatients in infection control surveillance.

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


21202


- Review of the facility policy title "Discharge from the Emergency Room" occurred on 09/19/12. This policy dated 10/24/09, stated "POLICY: To Ensure well-being to all patients being discharged from the Emergency Room. Responsibility: Medical Providers, Nursing Staff. PROCEDURE: . . . 6. For results of lab/diagnostics the completed reports are sent over to the McKenzie County Clinic and assigned to the provider who assessed the patient. If a locum provider assessed the patient in the Emergency Room and is not available at the clinic then the results go to the provider on call for that day or given to that patient's primary caregiver if known. The provider calls the results to the patient or directs his nurse to complete the call after documenting what is to be told to to the patient. . . ."

Review of Patient #15's closed medical record occurred on 09/18/12. The record identified Patient #15 presented to the emergency department on 08/04/12 with lesions on her back and a history of methicillin resistant staphylococcus aureus. The record identified the lesions as "draining white serous drainage." The medical doctor obtained a culture of the drainage and discharged Patient #15 home on Clindamycin (an antibiotic medication), Tylenol with Codeine (pain medication), and to follow-up in the clinic next week.

Patient #15's final C/S report dated 08/09/12, identified the organism of Escherichia (E.) coli present in the lesion. This C/S report failed to identify/list Clindamycin as a susceptible antibiotic to treat the E. coli infection.

During interview on 09/18/12 at 11:30 a.m., the facility's infection control practitioner (#14) stated she does not track infections on patients who enter the hospital's emergency department.

During interview on 09/18/12 at 2:00 p.m., an administrative nurse (#8) stated the hospital's process for monitoring C/S reports for emergency room patients consists of the hospital sending a copy of the final C/S report to the clinic for the prescribing doctor to review. If the prescribing doctor is a locum doctor, it is the responsibility of the facility's medical director to review and sign off on the report. An administrative nurse (#8) confirmed Patient #15's record lacked evidence the prescribing doctor or medical director reviewed the final sensitivity report dated 08/09/12.

Based on review of personnel files, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure all nursing staff possessed the adequate qualifications and certifications related to each of their specific roles within the CAH for 2 of 6 nurses' (#5 and #6), and 1 of 2 nursing assistant's (#7) personnel files reviewed, which lacked evidence of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) certification. Failure to ensure all nursing staff possessed the certifications, training, and competency needed to perform their clinical duties has the potential for nursing services to not meet the needs of the patients.

Findings include:

Review of the policy "Conscious Sedation (Moderate Sedation)" occurred on 09/19/12. This policy, effective 06/04/08, stated, ". . . The RN [Registered Nurse] administering these agents [moderate sedation] and monitoring of these patients are qualified and: Are competent in basic airway management and posses current ACLS certification . . ."

During an interview on 09/18/12 at 11:00 a.m., a surgical nurse (#2) stated the CAH performs endoscopy procedures about once a month and confirmed the CAH completed three procedures this morning. The nurse (#2) stated nurses working in the surgical department possessed CPR/BLS and ACLS certification and indicated two nurses (#2 and #5) currently worked in the department. The surgical nurse (#2) stated one of the nurses (#5) performed conscious sedation for the procedures.

During an interview on 09/19/12 at 7:50 a.m., an administrative nurse (#1) stated the CAH required all direct patient care staff, namely nurses and nursing assistants, to have CPR/BLS certification.

Review of personnel files occurred on 09/19/12 at 1:30 p.m. The file of a nurse (#5) currently working in the surgical department and providing conscious sedation for procedures lacked current ACLS (previous certification expired in February 2012) and CPR/BLS certification (previous certification expired in July 2012). The file of a staff nurse (#6) currently working in the CAH lacked current CPR/BLS certification (previous certification expired in November 2011). The file of a nursing assistant (#7) currently working in the CAH lacked CPR/BLS certification (previous certification expired in July 2012).

1. Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to monitor and document the effectiveness of medications given to patients on an as needed (prn) basis for 1 of 2 active inpatient (Patient #1), 1 of 1 active swing bed patient (Patient #3), 4 of 18 closed emergency room patients (Patient #9, #13, #14, and #26), 1 of 4 closed observation patient (Patient #26) and 1 of 3 closed swing bed patient (Patient #20) records reviewed who received prn medications throughout their hospital stays. Failure to evaluate the patient's response to prn medications limited the nursing staff's ability to assess whether the medication achieved the desired effect or if the patient experienced any side effects or adverse reactions from the medication.

Findings include:

Review of the facility policy title "Discharge from the Emergency Room" occurred on 09/19/12. This policy dated 10/24/09, stated "POLICY: To Ensure well-being to all patient being discharged from the Emergency Room. Responsibility: Medical Providers, Nursing Staff. PROCEDURE: . . . 4. If the patient receives something for pain such as an injection of an analgesic, documentation should be done regarding the effects of the medication . . . ."

- Review of Patient #1's active inpatient record occurred on September 17-19, 2012 and identified the CAH admitted the patient on 09/14/12 with diagnoses including left lower leg cellulitis. The record indicated Patient #1 required prn medication for left leg pain and headaches. Patient #1's Online Medication Administration Record (OMAR) for his hospital stay lacked documentation of the effectiveness of prn medication.

Patient #1's Nurse's Notes identified the following:
*09/15/12 at 4:53 a.m.: "Tylenol 650 mg [milligrams] given to patient po [by mouth] for complaints of headache." The record lacked evidence the nurse assessed the effectiveness of the prn Tylenol given for the patient's headache.
*09/15/12 at 2:43 p.m.: "Patient given Percocet 2 tabs [tablets] for a headache that has been unrelieved by Tylenol and Ibuprofen . . . Will continue to monitor."
*09/15/12 at 4:54 p.m.: "Patient resting in bed. Headache much improved . . ." Staff assessed the effectiveness of the prn medication more than two hours after administering the Percocet.
*09/16/12 at 6:15 a.m.: "Patient complaining of leg pain and headache. PRN medication given . . . Will monitor." Review of the patient's OMAR showed a nurse administered two tabs of Percocet at 6:14 a.m. The record lacked evidence the nurse assessed the effectiveness of the prn Percocet.
*09/17/12 at 12:13 a.m.: ". . . PRN Tylenol given for headache. Will continue to monitor."
*09/17/12 at 2:34 a.m.: "Patient in bed with eyes closed. No S/S [signs or symptoms] of distress . . ." Staff assessed the effectiveness of the prn medication more than two hours after administering the Tylenol.
*09/17/12 at 11:03 a.m.: "Medicated for persistent ha [headache], lt [left] side and across forehead." The patient's OMAR showed a nurse administered two tabs of Percocet at 11:01 a.m.
*09/17/12 at 12:09 p.m.: "Patient resting in bed . . . States he is having some nausea in addition to a poor appetite. Encouraged patient to just rest in bed . . . Will continue to monitor." The record lacked evidence the nurse specifically assessed the effectiveness of the prn Percocet given for the patient's persistent headache.

- Review of Patient #3's active swing bed record occurred on September 18-19, 2012 and identified the CAH admitted the patient on 09/17/12 with diagnoses including post surgical left hip fracture. The record indicated Patient #3 required prn medication for pain related to her left hip fracture and subsequent surgery. Patient #3's OMAR lacked documentation of the effectiveness of prn medication.

Patient #3's Nurse's Notes identified the following:
*09/17/12 at 11:15 p.m.: "Pt [patient] C/O [complains of] left hip pain -given hydrocodone one tab PO for same."
*09/18/12 at 1:14 a.m.: "Pt resting at this time." Staff assessed the effectiveness of the medication two hours after administering the hydrocodone.
*09/18/12 at 10:09 p.m.: "Pt requesting med [medication] for pain in left hip - med [medicated] with hydrocodone one tab PO for same . . ." The record lacked evidence the nurse assessed the effectiveness of the prn hydrocodone.

During an interview on 09/19/12 at 11:45 a.m., an administrative nurse (#1) stated she expected staff to assess the effectiveness of prn medications 30 minutes to one hour after administering the medication and then document the patient's response in the OMAR or Nurse's Progress Notes. The nurse (#1) stated the CAH's staff do not consistently assess the effectiveness of prn medications in a timely manner.



21202

Review of Patients #9, #13, #14, #20, and #26's closed medical records occurred on September 17-19, 2012.

- The CAH admitted Patient #20 to swing bed on 03/02/12 with diagnosis of renal failure, status post dehydration, and anemia. The record indicated doctor's orders for Tylenol (an over-the-counter pain medication) 1000 milligrams (mg) every 4-6 hours as needed for pain and Lorazepam (an anti-anxiety medication) 1 mg as needed. The record identified the CAH nursing staff administered seven doses of prn Tylenol (from March 04-08 and 11) and thirteen doses of prn Lorazepam (from March 03-09). Patient #20's record lacked evidence the nursing staff assessed and documented the effectiveness of the prn medications. The record identified the CAH transferred Patient #20 on 03/12/12.

- The CAH admitted Patient #26 to the emergency room on 07/23/12 at 9:27 a.m. with complaints of left leg pain. The record included health care practitioner (HCP) orders for prn pain medication of Morphine (a opioid narcotic pain medication) 3 mg intravenous push (IVP). The record identified the CAH nursing staff administered the Morphine to Patient #26 twice (at 10:00 a.m. and 11:25 a.m.). Patient #26's record lacked evidence the nursing staff assessed and documented the effectiveness of these prn medication doses.

The HCP admitted Patient #26 to observation level of care at 12:00 p.m. The record included HCP orders for Patient #26 to receive intravenous (IV) Morphine two-four mg every two-four hours PRN and Percocet (an opioid pain medication) 5/325 mg every six hours prn.

Patient #26's Medication Administration Record (MAR) showed the CAH nursing staff administered Morphine seven times and Percocet seven times to the patient during her hospital stay. Patient #26's nursing progress notes and MAR lacked evidence nursing staff monitored and documented the effectiveness of these prn pain medications administered to Patient #26.

- The CAH admitted Patient #13 to the emergency room on 08/10/12 at 7:30 p.m. with complaints of nausea and vomiting. The record included doctor's orders for Zofran (a medication used to treat nausea) 4 mg IVP and Toradal (a nonsteroidal anti-inflammatory medication) 30 mg intramuscular. The record identified the CAH nursing staff administered the above medications to Patient #13. Patient #13's record lacked evidence the nursing staff assessed and documented the effectiveness of these medications. The record identified Patient #13 left the CAH "AMA" (against medical advice) at 10:40 p.m.

- The CAH admitted Patient #14 to the emergency room on 08/11/12 at 3:24 a.m. with complaints of pain to the coccyx area. The record included doctor's orders for Morphine 3 mg IV and Zofran 4 mg IV. The record identified the CAH nursing staff administered the above medications to Patient #14. Patient #14's record lacked evidence the nursing staff assessed and documented the effectiveness of these medications. The record identified the CAH discharged Patient #14 home at 5:07 a.m.

- The CAH admitted Patient #9 to the emergency room on on 09/02/12 at 7:48 a.m. with complaints of dizziness, fast heart rate, and elevated blood pressure. The record included doctor's orders for Zofran 4 mg IVP and Ativan (an anti-anxiety medication) 1 mg IVP. The record identified the CAH nursing staff administered the Zofran at 8:14 am. and the Ativan at 9:30 a.m. Patient #9's record lacked evidence the nursing staff assessed and documented the effectiveness of these medications. The record identified the CAH discharged Patient #9 home at 11:55 a.m.

2. Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to provide care in accordance with the needs of 4 of 4 emergency room patients (#6, #7, #8, and #10) who presented to the emergency department with suicidal ideation or attempt. Failure of the CAH to implement their policy to identify suicide risk of psychiatric patients who present to the ER and specify the type of suicide precautions and interventions to be implemented, and failure to ensure the safety of the patients' environment while in the CAH, limited the CAH nursing staff's ability to provide the appropriate care and ensure the physical safety of Patients #6, #7, #8, and #10.

Findings include:

Review of the facility policy "Psychiatric Patients/Suicide Risk" occurred on 09/18/12. This policy, dated 10/25/09, stated, "POLICY . . . 'an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others, would be considered to have an emergency medical condition.' A psychiatric individual is considered stable when he or she is protected and prevented from injuring himself or others. For purposes of discharging such an individual, other than for transfer to another facility, the psychiatric individual is considered stable when he or she is no longer considered to be a threat to him or to others. Responsibility: Medical Providers, Nursing Staff. PROCEDURE: 1. All patients with a psychiatric presentation should also receive a medical screening examination to rule out other potential sources for behavioral presentation . . . 2. Emergency room patients that are determined to be a threat to self or others should be evaluated for voluntary/involuntary admission to a behavioral health unit or referred for a psychiatric evaluation. 3. Quick Assessment tool is a relatively quick and easy assessment that distills some of the more salient points of the thorough assessment into an easy-to use acronym. The acronym is "SAD PERSONS," and stands for:
S Sex . . .
A Age . . .
D Depression . . .
P Prior history . . .
E Ethanol abuse . . .
R Rational thinking loss . . .
S Support system loss . . .
O Organized plan . . .
N No significant other . . .
S Sickness . . .
The scoring of the assessment is very simple. For each finding that increases risk, a score of one is applied. The score is totaled and action is taken pursuant to the table below:
0-2 May not be a real problem, but should be followed up
3-4 May not require hospitalization, but needs follow up
5-6 Consider hospitalization, either voluntary or involuntary . . .
7-10 Definitely hospitalized voluntarily or involuntary.
4. The documentation needs to justify whatever clinical decision was reached. . . ."

This policy failed to identify/list interventions for staff to consider and implement as necessary related to each level of risk pertaining to frequency of monitoring (one-to-one monitoring versus five or ten or fifteen minute checks), and failed to ensure the safety of the patient's physical environment while in the CAH.

Review of Patients #6, #7, #8, and #10 closed medical records occurred on September 17-19, 2012.

- Patient #6 arrived at the emergency room (ER) on 08/17/12 at 9:35 a.m. after ingesting 20 tablets of Ibuprofen (an over-the-counter [OTC] non-steriodal anti-inflammatory drug). The ER Report identified the ingestion of the Ibuprofen as a suicide attempt. The record identified the medical doctor (MD) contacted the Poison Control Center, ordered an intravenous (IV) fluid bolus of normal saline solution, and arranged for transfer of Patient #6 to a psychiatric facility for evaluation and treatment. The record identified the CAH completed a medical screening examination and transferred Patient #6 at 12:00 p.m. (approximately two hours after admission).

The MD failed to identify Patient #6's level of suicidal risk while in the ER and the frequency for the CAH nursing staff to monitor the patient pending transfer. Patient #6's medical record failed to indicate whether the CAH staff assessed the safety of the physical environment of the ER while Patient #6 remained in the emergency department.

- Patient #10 arrived at the ER on 08/22/12 at 12:30 p.m. after a failed suicide attempt by ingesting 16 Nyquil (an OTC cold medicine) gel capsules and 8-10 tablets of Tylenol (an OTC pain medication also known as acetaminophen). The ER Report identified Patient #10 self-inflicted a one centimeter laceration/cut to her left wrist. The health care practitioner (HCP) ordered an IV fluid bolus of normal saline, the administration of Mucomyst (an antidotal medication for acute acetaminophen toxicity), laboratory testing, sutured the cut, and arranged transfer of Patient #10 to a psychiatric facility for evaluation and treatment. The record identified the CAH completed a medical screening examination and transferred Patient #10 at 4:06 p.m. (approximately three and one-half hours after admission).

The HCP failed to identify Patient #10's level of suicidal risk while in the ER and the frequency for the CAH nursing staff to monitor the patient pending transfer. Patient #10's medical record failed to indicate whether the CAH staff assessed the safety of the physical environment of the ER while Patient #10 remained in the emergency department.

- Patient #7 arrived at the ER on 09/07/12 at 9:40 p.m. after ingesting 25 tablets of Tramadol (a medication used to treat moderate to severe pain). The ER Report identified Patient #7 had a past history of overdose attempts. The record identified the MD ordered an IV fluid bolus and arranged for transfer of Patient #7 to a psychiatric facility for evaluation and treatment. The record identified the CAH completed a medical screening examination and transferred Patient #7 at 10:45 p.m. (one hour and five minutes after admission).

The MD failed to identify Patient #7's level of suicidal risk while in the ER and the frequency for the CAH nursing staff to monitor the patient pending transfer. Patient #7's medical record failed to indicate whether the CAH staff assessed the safety of the physical environment while Patient #7 remained in the emergency department.

- Patient #8 arrived at the ER on 09/10/12 at 1:24 p.m. with suicidal thoughts of harming himself. The record identified the MD arranged for transfer of Patient #8 to a psychiatric facility for evaluation and treatment. The record identified the CAH completed a medical screening examination and transferred Patient #8 at 5:05 p.m. (three hours and 41 minutes after admission).

The MD failed to identify Patient #8's level of suicidal risk while in the ER and the frequency for the CAH nursing staff to monitor the patient pending transfer. Patient #8's medical record failed to indicate whether the CAH staff assessed the safety of the physical environment while Patient #8 remained in the emergency department.

During interview on 09/18/12 at 9:30 a.m., an administrative nurse (#1) stated she expected nursing staff to provide one-to-one monitoring for suicidal patients and to document the monitoring in the medical record. This administrative nurse confirmed Patient #6, #7, #8, and #10's ER records lacked identification of suicidal risks by the medical provider, lacked evidence of one-to-one monitoring while in the ER by the CAH staff, and failed to ensure staff assessed the physical environment of the ER to ensure safety of the patient.

Based on observation, record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed a provider's order for 1 of 1 active inpatient (Patient #2) observed receiving a medication during medication pass which did not match the provider's order and for 1 of 1 active swing bed patient (Patient #3) with an order for blood sugar checks twice a day. Failure of staff to follow providers' orders resulted in Patient #2 incorrectly receiving hydrochlorothiazide (a diuretic used for edema and/or high blood pressure) on two consecutive days (September 18-19, 2012) and resulted in staff not checking Patient #3's blood sugar twice on 09/18/12.

Findings include:

Review of the policy "Medications, Administration (OMAR/BCMA [Online Medication Administration Record/Bar Code Medication Administration])" occurred on 09/19/12. This policy, effective 12/28/10, stated, "Medications are given only per the provider' [sic] orders. . . ."

Review of the policy "Provider's Orders" occurred on 09/19/12. This policy, effective 05/14/08, stated, ". . . PURPOSE: To accurately transcribe and carry out provider's orders. POLICY: All orders for treatments shall be in writing and signed by a Provider. . . ."

- Review of Patient #2's acute inpatient record occurred on September 18-19, 2012. The CAH admitted the patient on 09/17/12 with diagnoses of coronary artery disease, peripheral artery disease, hypertension, mild anemia, and left lower extremity cellulitis.

Observation of medication pass on 09/18/12 at 7:45 a.m. showed a nurse (#6) administered a 12.5 milligram (mg) capsule of hydrochlorothiazide to Patient #2 with his morning medications.

Review of Patient #2's OMAR identified the patient received 12.5 mg of hydrochlorothiazide on the morning of 09/18/12 and 09/19/12. Patient #2's provider orders lacked an order for hydrochlorothiazide.

During an interview on 09/19/12 at 8:35 a.m., a nurse (#8) confirmed the medical record lacked a provider order for hydrochlorothiazide.

- Review of Patient #3's active swing bed record occurred on September 18-19, 2012. The CAH admitted the patient on 09/17/12 with diagnoses of type II diabetes and post surgical left hip fracture.

A provider order, dated 09/17/12, stated to check Patient #3's blood sugar twice daily. The OMAR failed to reflect the twice daily blood sugar monitoring and identified the nursing staff failed to check the patient's blood sugar on 09/18/12.

During an interview on 09/19/12 at 11:45 a.m., an administrative nurse (#1) stated the facility lacks a system to "double check" patients' OMARs with provider orders to prevent medication and treatment errors. The administrative nurse (#1) stated a nurse incorrectly entered Patient #3's blood sugar order as PRN (as needed) on the OMAR rather than scheduled for twice a day.

Based on record review, review of a professional reference, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff developed, updated, and maintained nursing care plans for 2 of 2 active inpatient (Patient #1 and #2), 1 of 1 active swing bed patient (Patient #3), and 2 of 3 closed swing bed records (Patient #19 and #20) reviewed. Failure to develop, update, and maintain care plans limited the CAH's ability to communicate treatment approaches, assist the patients to attain/maintain their highest physical, mental, and psychosocial well-being, ensure continuity of care, and may result in failure to manage patients' needs.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 9th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2012, pages 215-216, 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. . . . When nurses use the client's nursing diagnoses to develop goals and nursing interventions, the result is a holistic, individualized plan of care that will meet the client's unique needs. . . . 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 updates it throughout the client's stay in response to changes in the client's condition and evaluations of goal achievement. . . ."

Pages 241-242 stated, ". . . After drawing conclusions about the status of the client's problems, the nurse modifies the care plan as indicated . . . Whether or not goals were met, a number of decisions need to be made about continuing, modifying, or terminating nursing care for each problem. . . . After making the necessary modifications to the care plan, the nurse implements the modified plan and begins the nursing process cycle again. . . ."

Review of the facility policy titled "Patient Care Plan" occurred on 09/19/12. This policy, effective 12/19/10, stated, "PURPOSE: To provide continuity of patient care, improve nursing care by adhering to standards for the planning and evaluation of that care . . . POLICY: 1. The patient care plan should be initiated upon the patient's admission and updated as patient's needs or providers orders change. . . ."

- Patient #1's active inpatient record, reviewed September 17-19, 2012, identified the CAH admitted the patient on 09/14/12 with diagnoses of viral syndrome, dehydration, renal insufficiency, leukocytosis, fever, nausea, vomiting, diarrhea, hyperglycemia, and cellulitis of the left lower leg. Patient #1's nurses notes for the current admission showed the patient experienced periods of nausea, headaches, and left leg pain.

Review of Patient #1's care plan showed the nursing staff failed to identify left leg cellulitis, left leg pain, headaches, and nausea. The care plan lacked documentation of ongoing patient needs and an implemented plan of established goals and interventions to meet those needs.

- Review of Patient #2's active inpatient record, reviewed September 18-19, 2012, identified the CAH admitted the patient on 09/17/12 with diagnoses of coronary artery disease, peripheral artery disease, hyperlipidemia, nicotine addiction, hypertension, left lower extremity cellulitis, mild anemia, and thrombocytopenia.

Patient #2's care plan included the problems of "cellulitis" and "infection." The care plan failed to identify all of the patient's current health needs and a plan of established goals and interventions to meet those needs.

- Review of Patient #3's active swing bed record, reviewed on September 18-19, 2012, identified the CAH admitted the patient on 09/17/12 with diagnoses of type II diabetes, hypertension, moderate aortic stenosis, post surgical left hip fracture, and post surgical anemia and hypokalemia. Patient #3's nurses notes for the current admission showed the patient experienced left hip/leg pain.

Review of Patient #3's care plan showed the nursing staff failed to identify the patient's left hip fracture, post surgical conditions (edema, anemia, etc.), left hip/leg pain, and type II diabetes. The care plan lacked documentation of ongoing patient needs and an implemented plan of established goals and interventions to meet those needs.

During an interview on 09/18/12 at 1:20 p.m., an administrative nurse (#1) stated she expected nursing staff to initiate a care plan upon admission in accordance with the patient's medical condition(s), and review and update the care plan as the patient's condition changed. This nurse (#1) confirmed the care plans lacked necessary information for the records reviewed.


21202


- Patient #19's closed medical record, reviewed on September 18-19, 2012, identified the CAH admitted the patient to swing bed from July 15-August 01, 2012, (a period of eighteen days) for respite care/services. Medical diagnoses for Patient #19 included atrial fibrillation, senile dementia, osteoporosis and frequent urinary tract infections.

Patient #19's nurse's notes for this swing bed stay identified the patient as disoriented to person, place, and time, displayed generalized weakness and the need of physical assistance of two staff members for ambulation, slight edema to bilateral lower extremities, incontinent of urine, and at risk of falling.

The record identified the medical doctor (MD) ordered Coumadin (an anti-coagulation medication) and weekly laboratory tests (prothrombin time and international normalized ratio) for Patient #19 related to her atrial fibrillation.

Patient #19's "Comprehensive Care Plan," initiated on 07/15/12, included "Swing Bed Overall Care Plan." Patient #19's care plan failed to identify all of the patient's current health needs and a plan of established goals and interventions to meet those needs.

- Patient #20's closed medical record, reviewed on September 18-19, 2012, identified the CAH admitted the patient to swing bed from March 02-10, 2010 (a period of ten days) with diagnoses of renal failure, chronic kidney disease, nausea with vomiting, and fatigue.

Patient #20's nurse's notes for this swing bed stay identified the presence of a urinary catheter, generalized weakness and the need of physical assistance of one staff member for ambulation, at risk of falling, insomnia and sleeplessness, shoulder pain, and constipation.

Patient #20's "Comprehensive Care Plan," initiated on 03/02/12, included "Swing Bed Overall Care Plan." Patient #20's care plan failed to identify all of the patient's current health needs and a plan of established goals and interventions to meet those needs.

Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure completion of written or verbal discharge instructions for 2 of 5 closed emergency room (ER) records (Patient #11 and #17) and 1 of 3 closed swing bed patient (Patient #19) and failed to ensure nursing staff completed/carried out the written orders of the health care provider for 8 of 16 closed ER patient records (Patients #6, #9, #10, #12, #13, #14, #17, and #24) reviewed.

Failure to provide written or verbal discharge instructions to ER patients limited the patients' knowledge and ability to follow the providers' follow-up care instructions. Failure to document the administration of medications and treatments limited the CAH's ability to ensure staff completed/carried out the providers' orders.

Findings include:

Review of the CAH policy titled "Discharge Instructions from the Emergency Room" occurred on 09/19/12. This policy dated 09/21/10, stated, "POLICY: To discharge patient from the Emergency Room in such a way . . . that the patient or significant other verbalizes understanding of the discharge instructions. All patients discharged from the Emergency room will be given a copy of Exit Care Instructions. This will include instructions on diet, medication, activities, and additional medical provider follow-up orders. PROCEDURE: . . . 2. Medication to be taken at home shall be listed where indicated on the instruction sheet . . . ."

Review of following closed patient records occurred on September 17-19, 2012.

- Patient #17 presented to the ER on 06/19/12, with complaints of shoulder pain. The medical doctor (MD) obtained an x-ray and determined the patient sustained a right shoulder dislocation and ordered the administration of Morphine (an opioid narcotic pain medication) 2 milligrams (mg) intravenous (IV) and Valium (a skeletal muscle relaxant) 5 mg IV. Patient #17 became unresponsive after receiving the Morphine and Valium injections. The MD wrote an order on Patient #17's ER Report form for administration of two doses of Narcan 0.4 mg IV and Flumazenil 0.4 mg IV (antidotal medications used to reverse the effects of the Morphine and Valium). The CAH nursing staff failed to observe these orders to indicate the staff completed/carried out the orders. The record identified the CAH nursing staff monitored Patient #17 for one and one-half hours.

Review of Patient #17's Emergency Room Report, dictated by the MD, identified the patient insisted on being discharged home. The MD recommended Patient #17 abstain from alcohol for 24 hours, immediately contact an ambulance if symptoms of lethargy reoccur, have someone awake him hourly throughout the night, and return to the clinic in one week.

Review of Patient #17's written discharge instructions, titled "Patient Care Instructions," completed by the CAH nursing staff failed to identify the above physician recommendations except for the need to return to the clinic in one week.

- The CAH admitted Patient #19 to swing bed from July 15-August 01, 2012, (a period of eighteen days) for respite care/services. Medical diagnoses for Patient #19 included atrial fibrillation, senile dementia, osteoporosis, and frequent urinary tract infections.

The record identified the MD ordered Coumadin (an anti-coagulation medication) and weekly prothrombin time (PT) and international normalized ratio (INR) laboratory tests for Patient #19 related to her atrial fibrillation. On 08/01/12, Patient #19's INR level returned at an elevated level of 7.02. The MD's discharge orders stated to hold (not take) the Coumadin for three days and to recheck the INR in three days.

Review of Patient #19's written discharge instructions, titled "Patient Care Instructions," completed by the CAH nursing staff stated, "Continue with home medications as attached" (referring to a copy of the computerized Scheduled Medication Orders, signed by MD), visiting nurse to see patient at home, and next lab draw for PT/INR in three days by visiting nurse. The computerized form stated, "Coumadin 5 mg - 1 tablet everyday" and "Coumadin 1 mg - 1 tablet everyday." This form lacked a notation for Patient #19 to not take the Coumadin for three days.

During interview on the morning of 09/19/12, an administrative nurse (#8) confirmed Patient #19's medical record lacked documentation of the CAH staff informing the patient to hold her Coumadin for three days and stated she expected staff to document this information on Patient #19's Patient Care Instructions.

- Patient #24 presented to the ER on 07/23/12, after falling in her home and fracturing her left tibia. The HCP wrote an order on Patient #24's ER Report for CAH nursing staff to administer Morphine 3 mg intravenous push (IVP). The CAH nursing staff failed to observe this order indicating staff completed/carried out the order.

- Patient #13 presented to the ER on 08/10/12 with complaints of nausea, vomiting, and diarrhea. The MD wrote orders on Patient #13's ER Report form for the CAH nursing staff to administer Zofran (a medication used to treat nausea) 4 mg IVP, initiate IV fluid bolus of normal saline, and Toradol (a nonsteroidal anti-inflammatory medication) 30 mg intramuscular. The CAH nursing staff failed to observe these orders to indicate staff completed/ carried out the orders.

- Patient #14 presented to the ER on 08/11/12 with complaints of intense pain to her coccyx. The MD wrote orders on Patient #14's ER Report form for the CAH nursing staff to administer IV Rocephin (an antibiotic medication) 2 grams, Morphine 3 mg IV, and Zofran 4 mg IV. The CAH nursing staff failed to observe these orders indicating the staff completed/ carried out the orders.

- Patient #12 presented to the ER on 08/15/12, with complaints of chest pain with movement and elevated blood pressure. The HCP wrote orders on Patient #12's ER Report form for Zestril (an antihypertensive medication) 10 mg orally (immediately after presenting to the ER) and 10 additional mg before discharge from the ER. The CAH nursing staff failed to observe these orders to indicate staff completed/ carried out the orders.

- Patient #6 presented to the ER on 08/17/12 after ingesting 20 tablets of Ibuprofen. The MD wrote orders on Patient #6's ER Report form for an intravenous (IV) fluid bolus of normal saline solution. The CAH nursing staff failed to observe these orders to indicate staff completed/ carried out the orders.

- Patient #11 presented to the ER on 08/19/12, with complaints of a loose tooth and an "unbearable toothache." The MD completed a medical screening examination and diagnosed a distal tooth fracture with probable abscess. The MD provided written prescriptions for Percocet (a narcotic pain medication) 5/325 mg, two tablets four times a day as needed for pain and eight tablets of Augmentin (an antibiotic medication) 875 mg, one tablet twice daily and referred Patient #11 to a dentist for further treatment.

Patient #11's written discharge instructions, titled "Patient Care Instructions," completed by the CAH nursing staff stated, "Take 1-2 Percocet every 4-6 hours for pain . . ." This contradicted with the MD's written prescription to take two tablets four times a day (or every six hours) as needed.

- Patient #10 presented to the ER on 08/22/12 after a failed suicide attempt by ingesting 16 Nyquil (an OTC cold medicine) capsules and 8-10 Tylenol (an OTC pain medication also known as acetaminophen) tablets. The HCP wrote orders on Patient #10's ER Report form for an IV fluid bolus of normal saline, the administration of Mucomyst (an antidotal medication for acute acetaminophen toxicity), and laboratory testing. The CAH nursing staff failed to observe these orders to indicate these orders were completed/ carried out.

- Patient #9 presented to the ER on 09/02/12 with complaints of dizziness, fast heart rate, and elevated blood pressure. The MD wrote orders on Patient #9's ER Report form for Zofran 4 mg IVP, Ativan 1 mg IVP, and laboratory testing. The CAH nursing staff failed to observe these orders indicating these orders were completed/ carried out.

During interview on 09/18/12 at 4:30 p.m., an administrative nursing staff member (#1) stated she expected nursing staff to observe all physician orders on the ER report form to indicate staff initiated and completed the orders as written. This administrative nurse stated she expected nursing staff to date and initial the time staff observed the order.