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Based on observation, record review, policy and procedure review, review of the outpatient procedure log, and staff interview, the Critical Access Hospital (CAH) failed to ensure the availability of all equipment, supplies, and medication used in treating emergency cases when using 1 of 1 Emergency Room (ER) for scheduled outpatient procedures. Failure of the CAH to ensure the ER, or an alternate room including all life saving equipment, supplies, and medications was available for all patients, especially cardiac and trauma patients arriving to the ER has the potential to affect the CAH's ability to treat all emergency cases.

Findings include:

Review of the facility policy "Emergency Medical Services Plan" occurred on 12/01/10. This policy, undated, stated, "[name of hospital] offers Level IV emergency medical services 24 hours a day . . . Equipment, supplies, and medication used in treating emergency cases are readily available for treating emergency cases. . . ."

During a tour of the ER on the morning of 11/30/10 with three administrative nurses (#2, #4, and #5), observation of the ER showed one large room identified by a staff member (#4) as the main and only ER room within the CAH, containing all of the facility's emergency supplies, medications, and equipment.

During an interview on 11/30/10 at 10:10 a.m., an administrative nurse (#2) stated the CAH routinely performed outpatient procedures such as lesion removals, knee/hip/shoulder injections, spinal taps, and complicated sutures in the ER. The nurse (#2) stated the CAH also used alternate rooms such as the ultrasound and critical care unit rooms for outpatient procedures, but confirmed the majority of the procedures took place in the ER. The administrative nurse (#2) stated clinic staff schedule or set up the procedures upon determination from providers that a procedure is indicated. When asked about the time frame of the procedures and the number performed, the staff member (#2) estimated 20-30 minutes per procedure and stated providers performed several procedures.

Review of the outpatient procedure log occurred on 12/01/10 and identified CAH staff utilized the ER for outpatient procedures. The log identified the CAH performed 4 to 11 outpatient procedures in the ER each month, which included a total of 73 procedures performed from January through November 2010. Review of the outpatient procedure log identified the length of the procedures from 10 minutes to seven and a half hours.

Review of the outpatient procedure record for Patient #6 occurred 11/30/10. The record showed the patient underwent a left great toenail removal in the ER on 11/17/10. The record identified the patient's admission occurred at 9:30 a.m. and discharge at 10:00 a.m. Review of this record showed access to the ER limited for 30 minutes.

Review of the outpatient procedure record for Patient #7 occurred on 11/30/10. The record showed the patient underwent three lesion removals in the ER on 10/19/10. The record identified the patient's admission occurred at 12:53 p.m. and discharge at 13:50 p.m. Review of this record showed access to the ER limited for 57 minutes.

During an interview on 11/30/10 at 10:40 a.m., an administrative nurse (#2) stated the ER included all life saving equipment, supplies, and medications, and agreed occupying the ER for an outpatient procedure could create unsafe conditions for a patient arriving at the ER who required emergency care. The nurse (#2) stated the CAH lacked a formal plan to ensure the treatment of patients upon arrival to the ER needing lifesaving measures during the time an outpatient procedure is in progress in the ER.

Based on bylaws review, record review, and staff interview, the Critical Access Hospital (CAH) failed to follow the medical staff bylaws for appointment to medical staff for 2 of 11 providers' files reviewed (Providers #1 and #2). By failing to approve privileges according to the CAH's bylaws, the governing body and Chief Executive Officer (CEO) did not ensure the providers possessed the necessary qualifications for medical staff membership and /or locum tenens privileges.


Findings include:

Review of the [name of hospital] HOSPITAL-CLINIC ASSOCIATION [Governing Board] BYLAWS occurred on 11/29/10. These bylaws, approved 05/13/08, stated, ". . . ARTICLE IX. DUTIES OF BOARD OF DIRECTORS . . . Section 8. Medical Staff Members. The appointment to, termination of, or modification of membership on the Medical Staff and the approval, withdrawal or other modification of clinical privileges in accord with the Bylaws, rules and regulations of the Medical Staff of the Association after first having received the recommendation by the Medical Staff all in accordance with the Medical Staff Bylaws, rules and regulations. . . ."

Review of the MEDICAL STAFF BYLAWS [name of hospital] HOSPITAL-CLINIC ASSOCIATION occurred on 11/29/10. These bylaws, approved 12/16/08, stated, ". . . Article III: Membership . . .
Section 3. Conditions and Duration of Appointment
1. . . . The Board of Directors shall act on appointments, re-appointments, or revocation of appointments only after there has been a recommendation from the Medical Staff as provided in these Bylaws . . .
Section 5. Temporary Privileges
1. The CEO of the Hospital after conference with the Chief of Staff shall have the authority to grant temporary privileges to a practitioner who is not a member of the Medical Staff.
2. The CEO of the Hospital may permit a practitioner serving as a locum tenens for a member of the Medical Staff to attend patients without applying for membership on the Medical Staff . . . providing all of his/her credentials have first been approved by the Chief of Staff . . ."

Reviewed on 11/29/10, the CAH's credentialing file for Provider #1 lacked evidence the medical staff recommended reappointment of Provider #1 before the Governing Board approved reappointment on 06/15/10.

Reviewed on 11/29/10, the CAH's credentialing file for Provider #2 lacked evidence the Chief of Staff approved Provider #2's credentials before the CEO and Governing Board granted locum tenens privileges for Provider #2 on 09/28/10.

During interview at approximately 4:45 p.m. on 11/30/10, an administrative staff member (#3) confirmed medical staff did not recommend reappointment of Provider #1 before the CEO and Governing Board approved reappointment and the Chief of Staff did not approve the credentials of Provider #2 before the CEO and Governing Board granted locum tenens privileges.

Based on record review, review of a professional reference, policy and procedure review, infection control reports and committee meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, and control infections and communicable diseases for all patients and personnel of the CAH for 9 of 9 months reviewed (March to November 2010); failed to report an infection for 1 of 3 active patient (Patient #1) records reviewed; and failed to follow acceptable professional standards of care relating to infection control practices in patients with Methicillin Resistant Staphylococcus aureas (MRSA) for 1 of 26 closed patient (Patient #25) records reviewed. Failure to identify and address all incidents of infections among patients and personnel has the potential for infections to go unreported, and to spread or reoccur, affecting the health of all patients and personnel of the CAH. Failure to follow infection control practices may allow transmission of organisms/bacteria from patients to staff, other patients, or visitors.

Findings include:

The Centers for Medicare and Medicaid Services (CMS) has outlined the standards of practice for establishing and maintaining an active tracking program to identify, investigate, report and prevent patient and employee infections and communicable diseases. The infection control officer(s) is responsible for developing this system. CMS recommends the infection control officer maintain a log of all incidents of infection and communicable diseases for patients and staff within the CAH. This log is not only limited to nosocomial (facility acquired) infections, it must include all incidents of infection and communicable disease. The facility should identify measures for the assessment of infections in patients and staff along with measures to prevent infection. Facilities need to provide a safe environment for patients and staff. Facilities also need to provide ongoing education for patients and staff as well as methods for monitoring and evaluating asepsis (germ-free). The facility needs to implement a system for corrective action and address it for effectiveness.

Review of the facility policy "Infection Control Monitoring" occurred on 12/01/10. This policy, reviewed/revised August 2010, stated, "POLICY: [name of hospital] & [and] Clinics strive to keep a safe and infectious free environment for both the hospital personnel and its consumers. It is the goal of this institution to maintain a nosocomial-free work place. . . . PROCEDURE: A. Prior to administering antibiotics as ordered by the medical provider, every patient admitted to the [name of hospital] will be assessed for signs and symptoms of infection by the medical/nursing staff. B. Appropriate measures will be taken in precaution of an identified organism; if the organism is identified, precautions will be taken according to current Centers for Disease Control (CDC) guidelines/recommendations to protect all hospital personnel and its consumers. C. All nosocomial infections will be reviewed by the Infection Control Committee at scheduled meetings. D. All nosocomial infections will be reported to the Medical Staff Committee by the Compliance Coordinator at scheduled meetings. . . ."

Review of the facility policy, Infection Control, occurred on 12/01/10. This document, undated, stated, "CONTACT PRECAUTIONS (In addition to Standard Precautions), Visitors - Report to Nurses' Station Before Entering Room
1. Private Room . . .
2. Gloves - wear gloves when entering room. Change gloves after contact with infective material. Remove gloves before leaving patient's room.
3. Wash hands - with antimicrobial agent immediately after glove removal and before leaving the patient's room.
4. Gown - wear when entering room to protect clothes from items in patient's room or if the patient has any of the following: Incontinent . . . Remove gown before leaving the patient's environment.
5. Transport - Limit the movement/transport of patients from room to essential purposes only. During transport, ensure that all precautions are maintained at all times.
6. When possible, dedicate the use of noncritical patient care equipment to a single patient. If common equipment is used, clean and disinfect between patients."

- Patient #1's active inpatient record, reviewed on November 29-30, 2010, identified the CAH admitted the patient on 11/26/10. Patient #1's record included a copy of a urine culture laboratory report, dated 11/28/10, which indicated mixed gram positive isolates. The record identified a physician order, dated 11/28/10 at 1:00 p.m., for Ciprofloxacin (an antibiotic) 200 milligram (mg) intravenous (IV) daily. The CAH discharged Patient #1 on 11/30/10 at 11:45 a.m. Record review lacked evidence CAH staff reported, tracked, or followed up with this infection during Patient #1's hospital stay.

- Review of Patient #25's medical record occurred on November 30-December 01, 2010. The CAH admitted the patient to swing bed status on 10/01/10 and discharged the patient to her home on 11/03/10.

Patient #25's medical record included a urinary culture laboratory report, dated 10/23/10, which identified MRSA and recommended "Contact Isolation." The health care provider ordered antibiotics for this infection.

Patient #25's medical record identified episodes of urinary incontinence. During the hospital stay, the CAH staff provided physical therapy services and activities services to the patient.

During interview, on 11/30/10 at 2:00 p.m., a physical therapy management staff member (#10) reported the department staff follow nursing department precautions when treating patients with infections. This staff member reported these precautions include the use of gowns, gloves, treating patients in their rooms, leaving equipment in patients' rooms, and handwashing.

Patient #25's medical record lacked orders for "Contact Isolation" or progress notes indicating consideration for these orders. The patient's care plan, dated 10/01/10, stated, "INFECTIONS/POTENTIAL . . . 1. Standard Precautions . . ."

Patient #25's medical record lacked evidence the CAH staff considered the recommendation for "Contact Isolation" or implemented infection control precautions greater than "Standard Precautions." Failure to implement "Contact Precautions" limited the CAH staff's ability, including physical therapy and activities staff, to implement appropriate infection control measures. These failures placed all patients, staff, and visitors at risk of infection and illness related to Patient #25's MRSA.

The CAH's Infection Control Data Collection reports and infection control meeting minutes (March to November 2010), reviewed on 11/30/10, lacked evidence the CAH identified and recognized infections of all patients (inpatients, swing bed, and observation) and personnel of the CAH. The reports revealed the CAH only tracked infections upon incidents of reported positive cultures, and lacked the inclusion of personnel. The CAH failed to maintain a complete log of all incidents of infections among patients and personnel for the past nine months (March to November 2010).

During interview on 11/30/10 at 3:00 p.m., an administrative nurse (#5) stated the infection control nurse obtained information from all patients upon admission and culture reports to track and identify infections of inpatients, swing bed, and observation patients. The nurse (#5) stated only patients identified with infections on admission, or those with positive cultures, received surveillance for infection control.

The CAH lacked a system or process for staff to document and report suspected cases of infections to the infection control nurse/officer for further investigation, monitoring, and recommendations.

During an interview on 11/30/10, when asked to clarify the process or system the CAH implemented to identify, report, and investigate infections, two administrative nurses (#2 and #5) confirmed the infection control nurse tracked or followed patients with known infections determined on admission or upon a positive culture. An administrative nurse (#2) stated the CAH failed to include personnel in their infection control surveillance. The nurse (#2) stated the CAH had no infection control log for inpatients, swing bed, observation patients, and outpatients, or personnel.

The failure to track all possible infections among patients and personnel within the CAH limited the CAH's ability to control and prevent infections.


16379

Based on observation, professional literature review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to meet the nutritional needs of patients in accordance with recognized dietary practices regarding the storage of employee food with patient food and storage of supplies (ice packs) with food items in 1 of 1 nourishment station refrigerator/freezer. These practices have the potential to increase the risk of foodborne illness and can affect all patients who eat food stored in these conditions.

Findings include:

Observation of the side by side refrigerator/freezer located in the nourishment station, on 11/29/10 at 4:40 p.m., showed food items of ketchup, relish, mustard, salad dressing, Hershey's chocolate syrup, multiple coffee mate creamers, sandwiches, soda, fruit, etc. stored in the two bottom drawers and two bottom shelves in the door of the refrigerator. Facility staff did not label the food items with a name or date. A staff member (#7) identified the items as employee food items. Observation of the upper shelves of the refrigerator and door contained various food items of juice, jello, bread, pudding, milk, ensure, soda, applesauce, and fruit cups identified by the staff member (#7) as patient food items.

Observation of the freezer showed various food items of frozen dinners, prepackaged coffee filters containing coffee grounds, and individual icee pops contained in plastic sleeves. The freezer also showed multiple coffee items which included: two unlabeled plastic containers of coffee grounds, one contained a spoon; and two unlabeled, opened bags of coffee grounds. Observation showed five reusable frozen gel-ice packs used by patients stored within and on top of the food items. The staff member (#7) identified the food items as belonging to employees and patients.

During interview on 11/29/10 at 4:40 p.m., a staff member (#7) stated staff have designated the bottom two drawers of the refrigerator and door for employee food storage, and stated employees stored food items in the refrigerator/freezer per hospital policy. The staff member (#7) stated staff should label the food items.

During an interview on 11/30/10 at 9:05 a.m., a dietary staff member (#9) stated she expected employees to store their personal food items separately from patient food, and stated the CAH designated two full size and one small sized refrigerator/freezers, located in the lower level of the CAH, for employee use. The staff member (#9) stated employees must never store patient care items (the ice packs) in direct contact with patient food items.

Based on observation, record review, policy and procedure review, review of a professional reference, and staff interview, the Critical Access Hospital (CAH) failed to assess each patient individually prior to utilizing side rails and failed to evaluate the safe use of side rails for 3 of 3 active patient (Patient #1, #2, and #3), and 4 of 26 closed patient (Patient #13, #15, #25, and #31) records reviewed. Failure to assess and evaluate the use of side rails has the potential to restrict a patient's movement and place patients at risk for injury.

Findings include:

The Food and Drug Administration (FDA) Center for Devices and Radiological Health publication titled, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," issued on 03/10/06, stated, ". . . FDA has received reports in which . . . patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term 'entrapment' describes an event in which a patient is caught, trapped or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in death and serious injuries . . . The current International Electrotechnical Commission (IEC) standard recognizes that the bed frame, deck, and rails are the major elements involved in entrapment . . ." The FDA's recommendation of the spacing between the inside surface of the rail and the mattress compressed by the weight of the patient's head be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. The IEC and the FDA recommend a dimension limit of less than 120 millimeters (4 and 3/4 inches) for the following: 1) within the rail; 2) under the rail, between rail supports or next to a single rail support; and 3) between the rail and mattress."

Safety Alert: Entrapment Hazards with Hospital Bed Side Rails, August 23, 1995, and Joint Commission on Accreditation of Healthcare Organization: Sentinel Event Alert, Issue 27, September 6, 2002, have identified bed rail-related entrapment deaths and injuries can occur in the elderly population, who are often at risk due to limited mobility, psychoactive or sedative medications, confusion, sedation, restlessness, lack of muscle control, size and physical deformities. Death by asphyxiation or injuries to the resident's extremities can occur when the resident becomes caught between the mattress and the bed rail; the headboard and the bed rail; or getting his or her head/extremity stuck in the bed rail. Both split and full rails have the potential to cause fall-related injuries as well as entrapment. Additionally fall-related injuries or injuries to extremities can occur when confused/disoriented residents climb over the top of side rails or get an arm or leg entrapped.

Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, Hospital Bed Safety Workgroup, Food and Drug Administration, April 2003, stated,
"Guiding Principles . . . 2. Decisions to use or to discontinue the use of a bed rail should be made in the context of an individualized patient assessment using an interdisciplinary team with input from the patient and family or the patient's legal guardian. . . . Policy Considerations: 1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize or remove those in current use should occur within the framework of an individual patient assessment. . . . 3. Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team. Bed rail effectiveness should be reviewed on a regular basis. The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of choice for the patient.
. . . 7. Creating a safe bed environment does not necessarily preclude the use of bed rails. However, a decision to use them should be based on a comprehensive assessment and identification of the patient's needs, which include comparing the potential for injury or death associated with use or non-use of bed rails to the benefits for an individual patient. In creating a safe bed environment, the following general principles should be applied:
Avoid the automatic use of bed rails of any size or shape. . . . Re-assess the patient's needs and re-evaluate the equipment if an episode of entrapment or near-entrapment occurs, with or without serious injury. This should be done immediately because fatal 'repeat' events can occur within minutes of the first episode. Process/Procedure Considerations . . . 1. Individualized Patient Assessment: Any decision regarding bed rail use or removal from use should be made within the framework of an individual patient assessment. . . . Risk Intervention: Assessment of risk should be part of the individual patient's assessment, and steps to address the risk should be incorporated into the patient's care plan. . . . Bed Rails as Restraints: When bed rails have the effect of keeping a patient from voluntarily getting out of bed, they fall under the definition of a physical restraint. If they are not necessary to treat medical symptoms, and less restrictive interventions have not been attempted and determined to be ineffective, bed rails used as restraints should be avoided. . . . Bed Rail Safety Guidelines: If it is determined that bed rails are required and that other environmental or treatment considerations may not meet the individual patient's assessed needs, or have been tried and were unsuccessful in meeting the patient's assessed needs, then close attention must be given to the design of the rails and the relationship between rails and other parts of the bed. 1. The bars with the bed rails should be closely spaced to prevent a patient's head from passing through the openings and becoming entrapped. 2. The mattress to bed rail interface should prevent an individual from falling between the mattress and bed rails and possibly smothering. . . ."

Review of the policy "Patient Safety" occurred 12/01/10. This policy, reviewed/revised August 2010, stated, "POLICY: Safety of the patient is of constant concern to the nurse who is functioning at all times as a liaison between departments of the hospital and the patients. The following safety precautions will be utilized as indicated: A. All adult beds are equipped with siderails for the purpose of safety as well as an aid for self-turning of the patient. . . ."

Observation of the beds utilized on the nursing unit occurred on 11/29/10. The beds utilized by the current observation, swingbed, and inpatients differed in style or make, but all had four half rails, two half rails on each side, attached to the beds. Measurements of one type of bed, located specifically in Rooms 173-2 and 167-2, identified 5 to 7 inch open spaces within the rails. Measurements of another type of bed, located specifically in Rooms 175 and 178, identified 7 1/2 to 9 inch open spaces within the rails.

- Observation on November 29-30, 2010 identified two elevated upper half rails elevated on Patient #1's bed. Review of Patient #1's active inpatient record occurred November 29-30, 2010 and identified the CAH admitted the patient on 11/26/10. Review of Patient #1's "Risk for Falls Assessment Tool" upon admission, identified the patient at risk for falls. The "Patient Care Flow Sheet & (and) Nurse's Notes" for Patient #1's hospital stay identified side rails times two. Record review lacked an individualized assessment of risk and safety for the utilization of side rails. The CAH staff failed to consider the side rails as a potential entrapment and safety hazard.

- Observation on November 29, 2010 identified two elevated upper half rails elevated on Patient #2's bed. Review of Patient #2's active swing bed record occurred 11/29/10 and identified the CAH admitted the patient on 11/28/10. Review of Patient #2's "Risk for Falls Assessment Tool" upon admission, identified the patient at risk for falls. The "Patient Care Flow Sheet & Nurse's Notes" for Patient #2's hospital stay identified side rails times two. Record review lacked an individualized assessment of risk and safety for the utilization of side rails. The CAH staff failed to consider the side rails as a potential entrapment and safety hazard.

- Observation on November 29, 2010 identified two elevated upper half rails elevated on Patient #3's bed. Review of Patient #3's active observation record occurred 11/30/10 and identified the CAH admitted the patient on 11/29/10. Review of the "Patient Care Flow Sheet & Nurse's Notes" for Patient #3's hospital stay identified side rails times two. Record review lacked an individualized assessment of risk and safety for the utilization of side rails. The CAH staff failed to consider the side rails as a potential entrapment and safety hazard.

- Review of Patient #15's medical record occurred on November 30 - December 01, 2010. The CAH admitted the patient to the emergency department (ED) on 08/12/10 after a fall at a long term care (LTC) facility and transferred the patient to observation status. The patient's history included a recent hip surgical procedure.

Patient #15's Risk for Falls Assessment Tool, undated, stated ". . . Guidelines: A client who has check mark in front of an element with an asterisk (*) or four or more of the elements would be identified as at risk for falls. . . ." This tool identified six elements, two with (*), "History of falls before admission" and "Confusion/disorientation."

Patient #15's Patient Care Flow Sheet & (and) Nurse's Notes, for the patient's hospital stay, August 12 -13, 2010, identified "Siderails: . . . x [times] 2 . . ." and August 12 - 13, 2010, 7:00 p.m. to 7:00 a.m., identified "Siderails: . . . x 4 . . ."

Nurse's Notes, dated 08/12/10, identified the following:
*6:00 p.m. - "Pt. [Patient] found lying on floor even though siderails up x 4 and camera monitor on. Pt. assisted back to bed c [with] assist x 4, [physician extender] assesses pt., no injuries noted."
*10:35 p.m. - "Pt. found sitting on floor beside bed. Pt. assessed for injuries. None found. Pt. reports pain to mid sternal area. Pt. assisted back into bed c assist of 3. [Physician] present during transfer."

Patient #15's medical record lacked physician orders for use of side rails, lacked assessment for use of side rails, lacked assessment for use of four side rails as a potential restraint, lacked evidence of consideration for least restrictive alternatives, and lacked care planning intervention for use of four side rails.

The CAH admitted Patient #15 after a fall at the LTC facility. The CAH's Fall Risk Assessment identified the patient at risk for falls. The CAH staff implemented side rails without risk or restraint assessments and continued the use of four side rails after Patient #15 fell from the bed despite the four side rails. Patient #15 experienced two falls from the bed while the CAH staff implemented four side rails which placed him at risk of injuries related to possible entrapment, crawling over and between the side rails, and crawling around the side rails at the head or the foot of the bed.

- Review of Patient #31's medical record occurred on November 30-December 01, 2010. The CAH admitted the patient to observation status on 06/07/10 and discharged the patient on 06/12/10. The patient's diagnoses included hyposmality/hyponatremia and detoxification. The medical record identified the CAH staff implemented two side rails.

Patient #31's Nurse's Notes stated the following:
*06/08/10, 1:46 a.m. - "Pt. [Patient] up to edge of bed shaking siderail . . ."
*06/08/10, 9:35 a.m. - "Pt. heard yelling 'help.' Pt. found on one knee, kneeling. . . . unable to say what happened. . . ."
*06/09/10, 2:30 a.m. - "Crash heard from outside pt.'s room. Pt. found on floor by head of bed c [with] head in garbage can. Pt. has 3 cm. [centimeter] laceration to above (L) [left] eyebrow and 1 cm. laceration to below (L) eyebrow. . . ." It is unknown how Patient #31 fell to the floor.
*06/09/10, 3:10 a.m. - "Pt. attempting to climb out of bed. . . . Pt. continues to be very agitated. . . ."
*06/09/10, 3:20 a.m. - "Pt. attempting to climb out of bed. . . ."
*06/09/10, 4:40 a.m. - "Pt. found on knees on floor in front of sink. . . ."

The CAH staff identified Patient #31's agitation and falls. It is unknown if the patient climbed over or around the side rails to exit the bed resulting in his falls. This placed Patient #31 at risk of entrapment or injury related to the side rails. The CAH staff continued to implement the side rails without risk or restraint assessments.

- Review of Patient #13's medical record occurred on November 30-December 01, 2010. The CAH admitted the patient on 04/14/10 and the patient expired on 04/18/10.

Patient #13's medical record identified the CAH staff implemented the top two side rails on the patient's bed. The patient's medical record lacked an assessment regarding the side rails as potential restraints or possible entrapment hazards.

- Review of Patient #25's medical record occurred on November 30-December 01, 2010. The CAH admitted the patient to swing bed status on 10/01/10 and discharged the patient on 11/03/10.

Patient #25's physician orders included "Siderails." Patient #25's medical record identified the CAH staff implemented the top two side rails on the patient's bed. The patient's medical record lacked an assessment regarding the side rails as potential restraints or possible entrapment hazards.

During an interview on 11/30/10 at 2:50 p.m., a staff nurse (#6) stated nurses and nurse aides elevate the two upper half side rails per patient/family request for positioning and access to bed controls/call light and stated staff also use the side rails to prevent patients from falling or falling out of bed. The nurse (#6) stated nursing staff does not perform or document an assessment for risk factors or safety for utilization of side rails.

During an interview on 11/30/10 at 4:00 p.m., two administrative nurses (#2 and #5) confirmed nursing staff elevate the two upper half side rails per patient/family request for safety, positioning, and access to bed controls/call light. The two nurses (#2 and #5) confirmed nursing staff does not perform or document an assessment for utilization of side rails, or document monitoring of side rail use. An administrative nurse (#2) stated the CAH failed to consider the beds a risk for safety and a potential hazard for entrapment.


16379

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 issue was found to be out of compliance during the previous survey completed in 2007.

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 1 of 3 active patient (Patient #1) and 3 of 26 closed patient (Patient #15, #27, and #31) records reviewed. Failure to develop, update, and maintain care plans limited the CAH's ability to communicate treatment approaches, assist the patient to attain/maintain their highest physical, mental, and psychosocial well-being, and ensure continuity of care. Failure to maintain current care plans could result in failing to manage patient's needs.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, pages 212-215, 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 constantly updates it throughout the client's stay in response to changes in the client's condition and evaluations of goal achievement. . . . Regardless of whether care plans are handwritten, computerized, or standardized, nursing care must be individualized to fit the unique needs of each client. . . ."

Page 237-239 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 facility policy "Care Plans and the Nursing Process" occurred 12/01/10. This policy, reviewed/revised August 2010, stated, "POLICY: The nursing process, including assessment, planning, intervention, and evaluation, will be documented for each hospitalized patient from admission through discharge. . . . C. The nursing care plan will be completed for patients whose stay extends 24 hours from time of admission by the admitting nursing personnel. 1. The plan will include nursing measures that will restore, maintain, or promote the patient's well being. These measures should appropriately include: a. Physiological. b. Psychosocial. c. Environmental. d. Patient/family education. e. Patient discharge plan. 2. The plan of care will reflect current standards of nursing practice. D. Contributions to the nursing care plan will be received from all nursing team members. Nursing care plans will be revised as needs of the patient change and subsequently are to be dated and initialed by the nurse. PURPOSE: To provide a means by which to plan for and communicate appropriate patient care while providing a framework for establishing the standard of care in a given situation. Furthermore, it provides validation of the appropriateness of care given . . ."

- Patient #1's active inpatient record, reviewed November 29-30, 2010, identified the CAH admitted the patient on 11/26/10 with diagnoses of bradycardia, hypotension, hyperkalemia, renal failure, and diabetes. Review of Patient #1's medical history included chronic back pain.

Review of Patient #1's physician admission orders included an order for blood sugar checks before meals and at bedtime, and for treatment of blood sugars less than 110 as hypoglycemia (low blood sugar) with administration of 4 ounces of apple juice. The physician orders also included medication orders for insulin; Levamir 15 units in the morning, and Humalog 8 units in the morning and 4 units with supper. Review of Patient #1's Glucometer Log from November 26-30, 2010, identified blood sugar results ranging from 64 to 256.

Patient #1's record included a copy of a urine culture laboratory report, dated 11/28/10, which indicated mixed gram positive isolates. The record identified a physician order, dated 11/28/10 at 1:00 p.m., for Ciprofloxacin (an antibiotic) 200 mg (milligram) IV (intravenous) daily.

Review of Patient #1's Nurse's Notes included the following:
*11/27/10 at 7:20 p.m.: ". . .Reports pain to lower back. . . ."
*11/28/10 at 7:40 p.m.: ". . . Pt [patient] c/o [complains of] lower back pain . . ."
*11/29/10 at 9:30 p.m.: ". . . does c/o lower back pain et [and] states back pain 'has been a chronic problem' for her. . . ."
*11/29/10 at 9:50 p.m.: ". . . Pt requests analgesic for back pain. . . ."
A progress note, dated 11/29/10 at 8:25 a.m., stated, ". . . Her only complaint this morning is of back pain and this is a chronic problem for this lady. . . ." Review of Patient #1's medication administration record for the hospital stay identified the patient received scheduled morphine sulfate and Vicodin as needed for back pain.

Review of Patient #1's nursing documentation from November 26-30, 2010, identified two open sores to the patient's left buttock, indicating the sores were stage two ulcers. During an interview on 11/30/10 at 8:30 a.m., Patient #1 stated, "I've had a problem with open sores on my bottom. I have a sore on my bottom right now that has been there for a while. I have trouble healing the sores. I just hope it doesn't get any worse."

Review of Patient #1's care plan indicated nursing staff failed to identify hypoglycemia and hyperglycemia (high blood sugar), urinary tract infection, chronic back pain, and skin integrity as problems and failed to include them on the care plan. The record lacked documentation of ongoing patient needs, and an implemented plan of established goals and interventions to meet those needs.

- Review of Patient #31's medical record occurred on November 30-December 01, 2010. The CAH admitted the patient to observation status on 06/07/10 and discharged the patient on 06/12/10. The patient's diagnoses included hyposmality/hyponatremia and detoxification.

The patient's medical record identified he experienced several falls from the bed, he was agitated, and the CAH staff implemented side rails, and administered an anti-anxiety medication, Ativan. The CAH staff failed to identify these issues and interventions on Patient #31's care plan.

- Review of Patient #27's medical record occurred on November 30-December 01, 2010. The CAH admitted the patient on 08/12/10 to observation status, transferred the patient to acute inpatient status on 08/14/10 and discharged the patient to swing bed status on 08/17/10. The patient's admission diagnoses included urinary tract infection (UTI), a history of depression, anxiety, and schizophrenia with current psychiatric therapy, and a history of lung cancer and chemotherapy.

The medical record included a copy of a urinary culture laboratory report obtained prior to admission, dated 08/13/10. This culture identified "Klebsiella pneumoniae" and the physician ordered antibiotics for treatment. The medical record also identified Patient #27 experienced back pain and radiological tests identified probable bone cancer.

Patient #27's care plan, dated 08/12/10, failed to identify the patient's UTI, psychiatric problems, or cancer, failed to identify interventions or approaches available to CAH staff, and failed to show any revisions or updates regarding these problems.

- Review of Patient #15's medical record occurred on November 30 - December 01, 2010. The CAH admitted the patient to the emergency department (ED) on 08/12/10 after a fall at a long term care (LTC) facility and transferred the patient to observation status.

Patient #15's care plan, dated 08/12/10, stated, "SAFETY . . . 1. Side rails up x [times] 2. . . ."

Patient #15's Patient Care Flow Sheet & (and) Nurse's Notes, dated August 12 - 13, 2010, 7:00 p.m. to 7:00 a.m., stated, "Siderails: . . . x 4 . . ."

Nurse's Notes, dated 08/12/10, identified the following:
*6:00 p.m. - "Pt. [Patient] found lying on floor even though siderails up x 4 and camera monitor on. Pt. assisted back to bed c [with] assist x 4, [physician extender] assesses pt., no injuries noted."
*10:35 p.m. - "Pt. found sitting on floor beside bed. Pt. assessed for injuries. None found. Pt. reports pain to mid sternal area. Pt. assisted back into bed c assist of 3. [Physician] present during transfer."

Patient #15's care plan lacked accurate information regarding the number of side rails used, lacked criteria for use of the side rails, and failed to identify the use of side rails as a potential restraint and injury hazard.

During an interview on 11/30/10 at 4:00 p.m., an administrative nurse (#2) 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. Another administrative nurse (#5) stated nursing staff failed to include all pertinent diagnoses and current problems Patient #1 experienced on the care plan. The nurse (#5) agreed staff must keep care plans current to assess and meet patient needs, and stated nursing staff improved in establishing and implementing care plans, but still needed work or improvement.


16379

Based on record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure records included written instructions to the patient for 1 of 4 sampled closed surgical patient records (Patient #6) and 7 of 15 sampled closed emergency department (ED) patient records (Patient #12, #17, #18, #20, #21, #22, and #23). Failure to provide written discharge instructions limited the CAH's ability to ensure patient compliance with follow-up care and placed the patients at risk of complications and recurrent illness related to inaccurate or failure to recall verbal instructions.


Findings include:

Review of the CAH's policy and procedure Outpatient & (and) Emergency Room Chart Order, occurred on 12/01/10. This document, revised 01/06, stated, "POLICY: All records filed in the HIM [Health Information Management] Department are to be arranged in a specific order after the patient is discharged. . . . PROCEDURE: . . . 3. Assemble the records in the following order: . . . See Discharge Chart Order - Inpatient/Observation Bed . . ."

Review of the CAH's policy and procedure, Discharge Chart Order - Inpatient/Observation Bed, occurred on 12/01/10. This document, revised on 07/10, stated, ". . . PROCEDURE: . . . 2. Assemble the records in the following order . . . Discharge Instructions . . ."

- Review of Patient #6's medical record occurred on November 30 - December 01, 2010. The CAH admitted the patient for removal of an ingrown toenail as an outpatient on 11/17/10. The patient received a local anesthetic. Review of the medical record showed the CAH staff failed to provide written post-operative instructions to the patient on discharge.

- Review of ED patient records occurred on November 30 - December 01, 2010. The following patient records, including date admitted and reason for admission, lacked written discharge instructions:
*Patient #12 - 11/14/10 - migraine
*Patient #17 - 08/06/10 - head laceration, refused inpatient admission
*Patient #18 - 10/21/10 - 5 years old, sore throat, fever
*Patient #20 - 06/11/10 - wrist laceration
*Patient #21 - 09/15/10 - possible early labor, transferred by private vehicle
*Patient #22 - 10/01/10 - positive pregnancy test, vaginal bleeding
*Patient #23 - 10/24/10 - assault, domestic violence

During interview, on 12/01/10 at 12:15 p.m., an administrative nursing staff member (#2) confirmed CAH staff should provide written instructions to patients discharged from the ED.

Based on review of policy and peer review records and staff interview, the Critical Access Hospital (CAH) failed to have a provider with the same qualifications/privileges review the quality and appropriateness of the diagnosis and treatment furnished by 2 of 2 physicians who performed surgical procedures at the CAH in 2009-2010 (Physicians #1 and #2). By failing to perform peer review, the CAH cannot ensure the physicians performing surgical procedures provided quality and appropriate care to the CAH's patients.

Findings include:

Review of the policy titled "[name of hospital] Community Hospital Policy and Procedure" occurred the morning of 12/01/10. This policy, revised 08/10, stated, "Policy: It is the policy of [name of hospital] Community Hospital & Clinics to conduct physician peer review of the following issues: . . . appropriateness of care reviews . . . Purpose: To perform periodic evaluation . . . and quality assurance reviews of medical staff members employed within [name of hospital] Community Hospital & Clinics. . . . Peer Review The duty of the healthcare organization and its medical staff is to assure that the clinical performance of all members of the medical staff are subject to internal and/or external quality assurance monitoring peer review. . . ."

Reviewed at 8:00 a.m. on 12/01/10, the 2009-2010 peer review records lacked evidence a provider with the same qualifications/privileges reviewed the quality and appropriateness of the diagnosis and treatment furnished by two physicians (#1 and #2) who performed surgical procedures at the CAH in 2009-2010.

During interview at approximately 8:10 a.m. on 12/01/10, two nursing staff members (#2 and #4) confirmed a provider with the same qualifications/privileges did not review the quality and appropriateness of the diagnosis and treatment furnished by the two physicians who performed surgical procedures at the CAH in 2009-2010.

Based on policy review, quality assessment record review, and staff interview, the Critical Access Hospital failed to consider the Quality Assessment and Performance Improvement (QAPI) findings and take corrective action if necessary as part of the QAPI program for 1 of 1 year reviewed (4th quarter 2009-3rd quarter 2010). Failure to take corrective action for deficiencies found through the QAPI program puts the facility at risk of providing inappropriate care to its patients.

Findings include:

Review of the policy titled "Quality Assessment and Performance Improvement Plan," occurred on November 30-December 1, 2010. This policy, revised 02/10, stated, "PURPOSE: . . . This includes developing and implementing actions with periodic reassessment of the action impact on the problems identified and to pursue opportunities to improve patient care. . . . PROCEDURE: . . . Each supervising Department Manager shall be responsible for implementation of quality improvement activities to improve customer satisfaction and effectively identify and resolve high priority patient care problems. . . ."

Reviewed on 11/30/10, the 2010 (4th quarter 2009-3rd quarter 2010) QAPI Committee Meeting minutes indicated the facility failed to identify problem areas and implement corrective actions to continually improve patient quality in the following areas where the department did not meet the established goal:
- Discharge Planning - Discharge plan documented on careplan
Goal: 100%
Performance level: 4th quarter 83%
- Discharge Planning - Completion of discharge planning for all Social Services referrals
Goal: 100%
Performance level: 3rd quarter 89%
- Emergency Medical Services - Runs logged in log book
Goal: 100%
Performance level: 4th quarter 92%
- Health Information Management - Medical staff dictation compliance with regulations and bylaws
Goal: 100%
Performance level: 4th quarter 69%, 1st quarter 86%, 2nd quarter 78%, 3rd quarter 76%
- Cardiac Care Unit - Testing cardiac defibrillator daily
Goal: 100%
Performance level: 1st quarter 84%
- Central Supply - Reduce the amount of rusty instruments
Goal: 0 items
Performance level: 1st quarter - 3 items
- Dietary Services - Monitoring infectious materials that are on meal trays returned to dietary
Goal: 100%
Performance level: 1st quarter 97%, 2nd quarter 90%, 3rd quarter 99%
- Emergency Medical Services - Trip tickets will be completed within 24 hours
Goal: 100%
Performance level: 1st quarter 95%
- Emergency Room - Completion of log book
Goal: 100%
Performance level: 1st quarter 98%, 2nd quarter (April 97% and June 98%), 3rd quarter 99%
- Radiology Services - Orders must contain diagnosis and demographics
Goal: 100%
Performance level: 1st quarter 96%, 2nd quarter 13/681 non-compliant (98%), 3rd quarter 84%
- Swing Bed - completion of activity assessments prior to discharge
Goal: 100%
Performance level: 1st quarter 93%, 2nd quarter 87%, 3rd quarter 92%
- Pharmacy - Monitoring the use of PPI's [proton pump inhibitors]
Goal: 100%
Performance level: 1st quarter 47%, 2nd quarter 40%

During interview at approximately 8:10 a.m. on 12/01/10, two nursing staff members (#2 and #4) confirmed the facility failed to implement corrective actions for the above areas not meeting the established goals.

Based on record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to develop a comprehensive care plan to meet the medical, nursing, and psychosocial needs for 1 of 2 sampled closed swing bed patient records (Patient #25). Failure to develop a comprehensive care plan limited the CAH staff's ability to ensure continuity of care and ensure the patient attained the highest practicable physical, mental, and psychosocial well-being.

Findings include:

Review of the CAH's policy and procedure "Care Plans and the Nursing Process" occurred on 12/01/10. This document, revised 08/10, stated, "POLICY: The nursing process, including assessment, planning, intervention, and evaluation, will be documented for each hospitalized patient from admission through discharge. . . .
C. The Nursing Care Plan will be completed for patients whose stay extends 24 hours from time of admission by the admitting nursing personnel.
1. The plan will include nursing measures that will restore, maintain, or promote the patient's well being. These measures should appropriately include:
a. Physiological
b. Psychosocial
c. Environmental
d. Patient/family education
e. Patient discharge plan
2. The plan of care will reflect current standards of nursing practice.

D. Contributions to the nursing care plan will be received from all nursing team members. Nursing care plans will be revised as needs of the patient change and subsequently are to be dated and initialed by the nurse.

PURPOSE: To provide a means by which to plan for and communicate appropriate patient care while providing a framework for establishing the standard of care in a given situation. Furthermore, it provides validation of the appropriateness of care given, and to adjust staffing levels. . . ."

Review of Patient #25's medical record occurred on November 30-December 01, 2010. The CAH admitted the patient to swing bed status on 10/01/10 and discharged the patient to her home on 11/03/10. The patient's admission diagnoses included post hip fracture with open reduction internal fixation. During the hospital stay, the CAH staff provided physical therapy services and activities services.

Patient #25's medical record included a urinary culture laboratory report, dated 10/23/10, which identified Methicillin Resistant Staphylococcus Aureus (MRSA) and recommended "Contact Isolation." The health care provider ordered antibiotics for this infection.

Patient #25's care plan, dated 10/01/10, failed to identify the physical therapy treatment program or the activities program or interventions available for implementation by CAH staff. The care plan "INFECTIONS/POTENTIAL" identified "Standard Precautions" and lacked revisions or updates regarding the MRSA or Contact Precautions.

Failure to develop a comprehensive care plan for Patient #25 which included the physical therapy program and any precautions, the activities preferences and possible interventions by staff, and the MRSA infection and Contact Precautions, limited the CAH staff's ability to communicate and ensure the appropriateness of care provided. This failure placed the patient at risk of not attaining her highest functional level and placed all patients, staff, and visitors at risk of infection.