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Based on interview, and document review the critical access hospital (CAH) failed to ensure criminal background checks had been completed for 4 of 12 providers (medical doctor-MD-A, MD-B, certified registered nurse anesthetist-CRNA-A, and physician assistant-PA-A). In addition, the CAH failed to ensure 3 of 8 supplemental nursing services agencies (Supplemental Healthcare, Specialty Nurses-Minnesota, Inc., and Travel Nurse Solutions) the CAH had contracted, were properly registered with the Minnesota commissioner as required. Also, the CAH failed to ensure all inpatients received vulnerable adult screenings in accordance with state law for 6 of 20 inpatients (P16, P17, P18, P19, P20, P12) reviewed.


Findings include:


Criminal background checks had not been completed on all providers.


On 2/11/15, at 2:10 p.m. the credentialing records were reviewed with the director of patient experience and the director of quality and compliance. The director of patient experience verified the following background check information on the following providers:

· MD-A's request for privileges had been approved by the governing board (GB) on 6/23/14; MDA's credentialing file lacked a background check.
· CRNA-A's request for privileges had been approved by the GB on 6/23/14; CRNA-A's credentialing file lacked a background check.
· MD-B's request for privileges had been approved on 8/24/14; MD-B's credentialing file lacked a background check.
· PA-A's request for privileges had been approved on 5/27/14; PA-A's credentialing file lacked a background check.


The directors of patient experience and quality and compliance confirmed the above providers were currently working at the CAH.


The Credentialing Policy dated 10/2013, indicated the purpose of the policy was to assure all providers met the qualifications for medical staff appointment for privileges. In addition, one of the sources queried for information regarding each provider would be a criminal background check.


The CAH's Human Resources Background Study policy dated 3/2014, indicated all current employees or contractors who have direct contact with persons served by the program would be required to have a background study.


Sanford Medical Center Thief River Falls Medical/Professional Staff Bylaws dated 12/2014, indicated the specifics of the application, credentialing and privileging processes were contained in the credentialing policy.



Some of the supplemental nursing services agencies (SNSA) contracted by the CAH had not been registered with the state of Minnesota.


On 2/9/15, at 4:10 p.m. the director of quality and compliance provided the list of the CAH's contracted services. This list included SNSA's which the CAH had current contracts with to provide services as needed.


On 2/11/15, at 8:30 a.m. the director of nursing (DON) confirmed the following SNSAs were not on the approved directory of registered SNSAs:

· Specialty Nurses-Minnesota, Inc
· Travel Nurse Solutions (Jackson Nurse Professionals)
· Supplemental Healthcare


The DON confirmed the CAH had utilized at least one of these services within the last month.


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Vulnerable adult (VA) assessment screenings were not completed at the time of admission for all patients admitted to the CAH.


Review of the following CAH's inpatient medical records which included the psychosocial assessment and flow sheets revealed the following:


P16 was admitted to the CAH on 2/9/15, P16's medical record identified on 2/5/15, during a pre-op phone call P16's psychosocial needs were assessed. One of the probes of the psychosocial assessment included the following: "Does patient display any signs/symptoms of abuse or neglect?" It was unclear how this area could have been accurately assessed via a telephone call. P16's medical record lacked documentation of the completion of a vulnerable adult assessment and screening at the time of admission to the CAH on 2/9/15.


P17 was admitted to the CAH on 2/9/15, P17's medical record identified on 2/5/15, during a pre-op phone call P17's psychosocial needs were assessed. One of the probes of the psychosocial assessment included the following: "Does patient display any signs/symptoms of abuse or neglect?" It was unclear how this area could have been accurately assessed via a telephone call. P17's medical record lacked documentation of the completion of a vulnerable adult assessment and screening at the time of admission to the CAH on 2/9/15.


P18 was admitted to the CAH on 2/2/15, P18's medical record identified that on 1/30/15, during a pre-op phone call P18's psychosocial needs were assessed. One of the probes of the psychosocial assessment included the following: "Does patient display any signs/symptoms of abuse or neglect?" It was unclear how this area could have been accurately assessed via a telephone call. P18's medical record lacked documentation of the completion of a vulnerable adult assessment and screening at the time of admission to the CAH on 2/2/15.


P19 was admitted to the CAH on 2/10/15, P19's medical record identified that on 2/9/15, during a pre-op phone call P19's psychosocial needs were assessed. One of the probes of the psychosocial assessment included the following: "Does patient display any signs/symptoms of abuse or neglect?" It was unclear how this area could have been accurately assessed via a telephone call. P19's medical record lacked documentation of the completion of a vulnerable adult assessment and screening at the time of admission to the CAH on 2/10/15.


P20 was admitted to the CAH on 2/10/15, P20's medical record identified that on 2/9/15, during a pre-op phone call P20's psychosocial needs were assessed. One of the probes of the psychosocial assessment included the following: "Does patient display any signs/symptoms of abuse or neglect?" It was unclear how this area could have been accurately assessed via a telephone call. P20's medical record lacked documentation of the completion of a vulnerable adult assessment and screening at the time of admission to the CAH on 2/10/15.


The registered nurse (RN) director of quality/compliance was interviewed on 2/12/15, at 12:00 noon and stated that psychosocial assessment (also known as a vulnerable adult assessment) should be completed in person at the time of admission to the CAH. The RN director of quality/compliance stated the CAH did not have a policy related to assessment of vulnerable adults but they used current nursing manuals to provide direction for assessment practices and provided the following reference materials for assessments: "Fundamentals of Nursing 7th Edition by Mosby, Elsevier, Potter and Perry" which provided the following direction: "Client abuse: Abuse of children, women, and older adults is a growing health problem. Obvious physical injury or neglect are signs of possible abuse (e.g., evidence of malnutrition or presence of bruising on the extremities or trunk). Assess for the client's fear of the spouse or partner, caregiver, parent, or adult child. Note if the partner or caregiver has a history of violence, alcoholism, or drug abuse..."


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P12 was admitted to the CAH on 12/9/14. P12's medical record identified the inpatient admission navigator was partially completed on 12/9/14. The navigator included questions which required the nurse to ask the patient, "Have you been hit, slapped, kicked or otherwise physically hurt by someone?" Additional questions included, "Has anyone put you down, called you names or made your feel bad about yourself," and "Has anyone forced you to have sexual activities?" P12's record lacked documentation of the completion of a vulnerable adult assessment and screening at the time of admission to the CAH on 12/9/14.


The DON completed a review of P12's chart on 2/11/15, at 1:40 p.m. The DON verified P12's vulnerable adult screening had not been completed and should have been completed by the admitting nurse on 12/9/14.


The facility policy and procedure entitled Patient Bill of Rights and Responsibilities last revised on 7/14, was reviewed. The procedure directed staff to provide the Patient Bill of Rights and Responsibilities in advance to any individual planned admission to the hospital and also in the new patient packet which was provided on admission.

No policy related to VA assessment screening completion was provided.

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure the security for 2 of 3 crash carts which were located in the emergency department (ED). This had the potential to affect all patients seen in the CAH's ED.

Findings include:

On 2/9/15, during the initial tour of the ED from 2:30 p.m. until 3:10 p.m. adult crash carts were observed located in both of the trauma rooms (trauma room #1 and #2). Each crash cart had a white and red numbered breakaway lock attached to the medication drawer.

On 2/9/15, at 2:50 p.m. registered nurse (RN)-C confirmed patients and visitors were left unattended in the ED rooms.

On 2/10/15, at 11:00 a.m. the ED manager, RN-E confirmed patients and visitors were left alone in the trauma rooms with the curtain closed, which would leave the adult crash carts unattended and out of constant supervision of the ED staff.

On 2/11/15, at 9:30 a.m. the pharmacy manager (PM) confirmed the adult crash carts in the two trauma rooms in the ED were not as secure as they could be and that they were not in constant view of the ED staff.

The PM provided an inventory list of the adult ED crash carts [not an inclusive list]:
· Atropine (treats slow heart rate)
· Lidocaine (treats emergency irregular heart rate)
· Epinephrine (treats cardiac arrest)
· Naloxone (reversal agent for narcotics and treats shock)
· Amiodarone (treats life threatening heart rate)
· Adenosine (treats irregular heart rate)
· Verapamil (treats high blood pressure, chest pain, irregular heart rate)
· Procainamide (treats life threatening heart rate)

The CAH's Crash Cart Standardization and Restocking Procedures policy dated 1/2013, indicated the CAH's pharmacy and nursing staff would provide security of medications contained in the crash carts at all times.

Based on observation and interview, the critical access hospital (CAH) failed to assure hypodermic needles and intravenous (IV) supplies were stored in a safe manner for 6 of 6 (ER- 1, ER-2, ER-3, ER-4, ER-trauma 1, ER-trauma 2) emergency department (ED) rooms. This had the potential to affect all patients and visitors to the ED.

Findings include:

On 2/9/15, during the initial tour of the ED from 2:30 p.m. until 3:10 p.m. there was observed in all four ED treatment rooms (ER-1, ER-2, ER-3, ER-4) and the two ED trauma rooms (ER-trauma 1, ER-trauma 2) unlocked cupboards and drawers which contained syringes and needles in a variety of sizes and IV start kits. A key lock was observed to be located on the door of each cupboard and drawer. Registered nurse (RN)-C stated the cupboards and drawers were not usually locked and that visitors and family members were left unattended in these rooms.

On 2/9/15, at 3:15 p.m. the manager of the ED, RN-E, confirmed the cupboards containing the IV supplies and needles were currently unlocked and stated "they should be locked."

On 2/10/15, at 10:55 a.m. RN-E verified the CAH did not have a policy on assuring the security of medical supplies which included needles, syringes and IV start kits.

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure intravenous (IV) solutions were stored in the emergency department's (ED) warming cabinet according to manufacturer's guidelines. This had the potential to affect all patients who are treated in the CAH's ED.

Findings include:

On 2/9/15, during the initial tour of the ED from 2:30 p.m. until 3:10 p.m. there was observed in an alcove by the ED treatment rooms a two chamber warming cabinet. The temperature of the upper chamber of the warming cabinet, as indicated by the outside thermometer, was 100 degrees Fahrenheit (F). Blankets and patient gowns were located in the lower chamber, and the following IV solutions were observed in the upper chamber:

· Four undated 1000 milliliter (ml) bags of 0.9% sodium chloride IV solution in clear plastic covered pouches.
· Two undated 1000 ml bags of lactated ringers (LR) IV solutions in clear plastic covered pouches.

On 2/9/15, at 3:00 p.m. registered nurse (RN)-C stated he was unsure of how long the IV solutions had been in the warming cabinet or the ED's policy on how long IV solutions could be kept in the warming cabinet.

On 2/9/15, at 3:10 p.m. the ED manager, RN-E, stated she was unable to confirm how long the IV solutions had been in the top compartment of the ED cabinet warmer.

On 2/10/15, at 9:20 a.m. RN-E confirmed the ED lacked a policy for storing and maintaining IV solutions in the warming cabinet.

On 2/11/15, at 9:40 a.m. the pharmacy manager (PM) stated she was unaware of the product guidelines for the IV solutions observed in the ED warming cabinet.

On 2/11/15, at 3:00 p.m. the PM provided the manufacture guidelines from Baxter Healthcare Corporation and Hospira Inc. These guidelines indicated IV solutions of 150 mls or greater could be warmed in their plastic over pouches for periods no longer than 14 days and not to exceed 104 degrees F.

Based on interview and document review, the critical access hospital (CAH) failed to assure a comprehensive list of services furnished under agreement or arrangement had been maintained. This had the potential to affect all patients who received services at the CAH.

Findings include:

On 2/9/205, at 4:10 p.m. the director of quality and compliance provided the CAH's current list of services provided through agreements or arrangements. The CAH's Contracts list [undated] identified the contract name, department and subject of the service.

On 2/11/15, at 8:05 a.m. the director of quality and compliance confirmed the contract list provided was not an inclusive list. She verified some of the agreements or contracted services missing from the list were: CardinalHealth (after hour pharmacy services) and general electric (bio-medical services).

In addition, on 2/11/15, at 10:20 a.m. the director of nursing (DON) confirmed the following contracted nursing services were not on the CAH's Contracts list provided by the director of quality and compliance:

· Onward Healthcare
· Travel Nurse Across America
· Supplemental Healthcare

Based on interview and document review, the critical access hospital (CAH) failed to ensure a comprehensive care plan was developed to include individualized nursing diagnosis, expected outcomes and/or interventions for 9 of 20 (P6, P7, P13, P15, P16, P17, P18, P19, P20) inpatient records reviewed.

Findings include:

Each care plan was automatically populated by the computer program used for the electronic medical records and included a psychosocial care plan, multiple possible "nursing diagnoses," multiple possible "evidenced by" statements and multiple possible "related to" statements that were not edited or made appropriate to the individual patient's condition.

P6's history and physical (H&P) dated 3/12/14, identified active diagnoses which included complex endometrial hyperplasia and cystocele. The H&P identified that P6 was to have multiple surgical procedures on 3/12/14, which included a hysterectomy and cystocele repair. Review of P6's care plan dated 3/12/14, revealed one entry entitled, "Risk for injury." On 3/13/14, one additional care plan problem was added which was, "Impaired Gas Exchange." There were no further care plan entries.

P7's H&P dated 5/17/14, identified P7 was admitted to the obstetrics unit for childbirth. P7's care plan had only one entry which identified a problem of a, "Risk for injury" related to postpartum pain control.

P13's H&P dated 1/14/15, identified diagnoses which included metastatic breast and bone cancer with radiation treatments in progress, dysphagia related to throat surgery and bilateral pulmonary embolisms. P13's care plan initiated on 1/14/15, only identified a care area related to, "Impaired Gas Exchange."

P15's face sheet identified and admission date of 12/22/14, to the obstetrics unit. A discharge summary dated 12/24/14, identified P15 had been admitted for a scheduled cesarean section. P15's care plan was initiated on 12/22/14 and only included entries related to the problem area of, "Risk for injury."

The director of nursing was interviewed on 2/11/15, at 1:40 p.m. and stated care plans should be initiated on admission and should be comprehensive to include all things a patient may need help with. The DON reviewed the records of P6, P7, P13 and P15 and verified the care plans were not comprehensive based on the level of care and assistance needed. The DON gave examples of areas that should have been added which included psychosocial needs, risks for infections with surgical patients, education, comfort and phases of care.


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P16 was admitted to the hospital on 2/9/15, with primary diagnoses that included prolapse of a pelvic organ and was status post (s/p) vaginal hysterectomy with bilateral salpingo-oophorectomy. The post operative care plan dated 2/9/15, and timed 3:31 p.m. had addressed one identified problem which included "RISK FOR INJURY" and addressed P16's pain management interventions that included using patient controlled analgesia (PCA)which was working well for P16 and identified that P16 had low urine output and the medication Lasix had been administered. The care plan had not included goals or interventions related to airway management, discharge planning, emotional support, family involvement, diet, fluid/electrolyte management, nausea management, oxygen therapy, pain management, post-anesthesia care (vital signs and neurological check protocol for post-operative), skin surveillance, and wound care.


P17 was admitted to the hospital on 2/9/15, with primary diagnoses that included dysmenorrhea with post-ablation syndrome and was status post (s/p) total abdominal hysterectomy bilateral salpingo-oophorectomy. The post operative care plan dated 2/9/15, and timed 5:05 p.m. had addressed one identified problem which included "RISK FOR INJURY" and addressed P17's low blood pressure,low urine output, and management of pain via epidural until the morning of post-op day 2 when P17 had been successfully switched to oral pain medications (the type and dosage of oral pain medications was not identified on the care plan.) The care plan had not included goals or interventions related to airway management, discharge planning, emotional support, family involvement, fluid/electrolyte management, nausea management, oxygen therapy, diet, pain management, post-anesthesia care (vital signs and neurological check protocol for post-operative), skin surveillance, and wound care.


P18 was admitted to the hospital on 2/2/15, with primary diagnoses that included endometrial cancer and was s/p total abdominal hysterectomy bilateral salpingo-oophorectomy. The post operative care plan dated 2/2/15, and timed 5:06 p.m. had addressed two identified problems which included "RISK FOR INJURY" and "ACUTE PAIN" these care planned areas addressed P18's high blood pressure concerns and treatments and pain management interventions using the medication vicodin (the dose and amount was not identified).The care plan had not included goals or interventions related to airway management, diet, discharge planning, emotional support, family involvement, fluid/electrolyte management, nausea management, oxygen therapy, pain management, post-anesthesia care (vital signs and neurological check protocol for post-operative), skin surveillance, and wound care.



P19 was admitted to the hospital on 2/10/15, with primary diagnoses that included osteoarthritis and was status post (s/p) left total hip arthroplasty. The post operative care plan dated 2/10/15, and timed 4:59 p.m. had addressed identified problems which included "RISK FOR INJURY", "RISK FOR FALLS", "RISK FOR INFECTION", and "SELF-CARE" and addressed P19's mobility deficit, self-care deficit, and hemovac drain, use of PCA pump, and oxygen saturation level on 2 liters of oxygen per nasal cannula. The care plan had not included goals or interventions related to airway management, discharge planning, emotional support, family involvement, fluid/electrolyte management, nausea management, diet, post-anesthesia care (vital signs and neurological check protocol for post-operative), skin surveillance, and wound care.


P20 was admitted to the hospital on 2/10/15, with primary diagnoses that included degenerative joint disease and was status post (s/p) right total knee arthroplasty. The post operative care plan dated 2/11/15, and timed 3:13 p.m. had addressed identified problems which included "ACTIVITY INTOLERANCE", and "SELF-CARE", and had not addressed any of P20's mobility deficit, self-care deficit, hemovac drain, use of PCA pump for pain management, and oxygen saturation level on 2 liters of oxygen per nasal cannula. The care plan had not included goals or interventions related to airway management, discharge planning, emotional support, family involvement, fluid/electrolyte management, nausea management, diet, post-anesthesia care (vital signs and neurological check protocol for post-operative), skin surveillance, and wound care.


The facility policy, "Guidelines for Documentation of Nursing Plan of Care or Making Changes in", last revised 9/14, was reviewed. The policy identified a plan of care would be created for each patient that was individualized and comprehensive and should include identified standards which are derived from nursing assessment and diagnosis. Further, the nursing care plan should address each patients physical, psychological and emotional status.


The registered nurse (RN) director of quality/compliance was interviewed on 2/12/15, at 12:00 noon and stated that patient care plans should be completed and give the reader a picture of the nursing care required for each individual patient. The RN director of quality/compliance confirmed the aforementioned patients (P15, P16, P17, P18, P19, and P20) had care plans that were not comprehensively completed.

Based on interview and document review, the critical access hospital (CAH) failed to ensure 2 of 6 surgical inpatients (P15, and P16) had a completed history and physician (H&P) in the medical record.


Findings include:


P15 was admitted to the hospital on 12/22/14, for a scheduled cesarean section. P15's medical record lacked documentation that a H&P had been completed 30 days of P15's schedule operation.


The director of nursing (DON) was interviewed on 2/11/15, at 1:40 p.m. and after review of P15's medical record confirmed it lacked a H&P.


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P16 was admitted to the hospital on 2/9/15, for vaginal hysterectomy and bilateral salpingo oophorectomy. P16's medical record lacked documentation that a H&P had been completed within 30 days of P16's scheduled operation.


Review of the medical staff by-laws effective December 2014, the following was identified in section 3.4: "If a complete H&P [history and physical] was performed by a practitioner...up to 30 calendar days prior to the patient's admission to the Medical Center (including an H&P from the patient's prior admission to the Medical Center), a reasonable durable, legible copy of the H&P report may be used in the patient's medical record in lieu of an admission H&P report, provided a Practitioner with appropriate Privileges performs a physical assessment and updates the H&P report in writing (regardless of whether there have been any changes to the patient's status) within 24 hours of the patient's admission, unless the patient will be taken to surgery before that time, in which case the H&P report and updates must be placed in the patient's chart before the patient is taken to surgery.


Review of P16's medical record revealed that an H&P had not been completed 30 days prior to P16's surgical procedure and hospital admission. There was a dictation which identified an H&P update had been completed on 2/9/15, however a full H&P had not been completed within 30 days of P16's surgery.


The registered nurse (RN) director of quality/compliance was interviewed on 2/12/15, at 12:00 noon and confirmed that P16 did not have a full H&P completed within 30 days prior to surgery on 2/9/15.

Based on interview and document review the critical access hospital (CAH) failed to ensure quality assurance/performance improvement projects were developed and integrated in the hospitals quality improvement program for the following services: organ tissue, eye procurement, ambulance services and swing bed. This had the potential to affect all current and future patients of the CAH.


Findings include:


The director of nursing (DON) was interviewed on 2/12/15, at 9:30 a.m. and established that the CAH had correctly implemented their policy regarding notifcation of the organ procurement agency within 60 minutes of the time of patients death 80% of the time during the 2014, year. The DON confirmed the CAH had not completed a root cause analysis of the barriers to timely reporting and developed a quality improvment project related to timely notifcation to the organ procurement agency within 60 minutes from the time of a patients death. The DON confirmed that the CAH had not developed any ongoing quality improvement projects related to organ procurement.


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During interview on 2/12/15 at 10:15 a.m., the DON stated the facility had not done any work in quality improvement related to the Swing Bed portion of the CAH. The DON stated the focus had recently been on moving into the new building and waiting to see how the inpatient numbers worked out before putting any focus into the Swing Bed part of the CAH.


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On 2/10/15, the emergency department (ED) manager, registered nurse (RN)-E, stated she was unaware of any quality assurance/performance improvement (QA/PI) project being conducted by the ambulance service.

On 2/12/15, at 8:50 a.m. the director of quality and compliance confirmed ambulance services did not have a current quality improvement project which was integrated into the CAH's quality improvement program. She confirmed the ambulance service was a contracted service and they should be reporting to the quality committee at least twice a year.

The 2014 Sanford Health Critical Access Hospital (CAH) Quality Management Plan indicated ambulance services was scheduled to report to the quality management committee four times a year (February, May, August and November). In addition, a goal of the quality management plan was to assure all services, including contract services, were evaluated.

Based on interview the facility failed to ensure there was an ongoing activity program for any patient admitted to a Swing Bed.

Findings include:

During interview on 2/12/15, at 10:15 a.m., the director of nursing (DON) stated the Swing Bed portion of the facility had not been a staff focus for quite some time and the facility was waiting to see how the inpatient numbers were once they were settled in the new building before deciding how to proceed with the Swing Bed patients. Further, the DON confirmed that although the facility did not currently have any Swing Bed patients, there was no plan in place to provide an ongoing program of activities for any Swing Bed patients the facility may receive.

A policy was requested related to activities for Swing Bed patients, however none was provided.

Based on interview, the mental health unit of the critical access hospital (CAH) failed to develop and follow a utilization review plan which included psychiatric services. This had the potential to affect all psychiatric patients admitted to the mental health unit.


Findings include:


On 2/10/15, at 2:14 p.m. the manager of the psychiatric unit, registered nurse (RN)-F confirmed the ten bed inpatient psychiatric unit did not have a utilization review plan. RN-F stated she just worked with a clerical staff member and they communicated with the patient's insurance company as needed.


On 2/12/15, at 10:05 a.m. the manager of utilization review, RN-G, verified the inpatient psychiatric unit did not have a utilization review plan. RN-G stated she was aware they needed one and it was a "work in progress."