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Based on record review, policy and procedure review, review of a professional reference, staff interview, and review of State Agency provider files, the Critical Access Hospital (CAH) failed to ensure CAH staff documented whether or not patients had an advance directive for 2 of 2 active swing bed patient (Patient #1 and #2) records reviewed, and 3 of 3 closed observation patient (Patient #13, #14, #21) records reviewed. Failure to determine and record whether or not the patient had advance directives placed the patients at risk of receiving undesired treatment and limited the CAH's ability to honor the patient's wishes if a life threatening event occurred.

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 02/28/08 found this requirement out of compliance.

Findings include:

The Centers for Medicare and Medicaid Services (CMS) has outlined the standards of practice regarding advance directives which state the CAH patient (inpatient or outpatient) has the right to formulate advance directives, and to have the CAH staff implement and comply with the individual's advance directive. Furthermore, this requirement specifies the rights of a patient (as permitted by State law) to formulate, at the individual's option, advance directives. The CAH is required to provide written notice of its policies regarding the implementation of patients' rights to make decisions concerning medical care, such as the right to formulate advance directives. The CAH shall provide notice of their advance directive policy at the time an individual is admitted as an inpatient and should also consider providing the advance directive notice, at the time of registration to outpatients (or their representatives) who are in the emergency department, in an observation status, or undergoing same-day surgery. The CAH shall document in a prominent part of the patient's medical record whether or not the patient has executed an advance directive. The CAH shall provide for staff education concerning its policies and procedures on advance directives and provide community education regarding advance directives. All education efforts must be documented by the CAH.

Review of the policy "Advance Directives" occurred on 11/01/11. This policy, undated, stated, ". . . 1. Written information regarding Advance Directives will be given to each patient or their representative on admission. . . . 3. A patient who has formulated an Advance Directive will be asked to provide copies of the documents to St. Luke's Hospital. . . . 4. The front sheet of each chart will be marked in the appropriate boxes to indicate if the patient has Advance Directives and who the information was given to. . . ."

Review of Patient #1 and #2's active medical records occurred on all days of survey. These records lacked evidence/documentation the CAH staff determined whether the patients had executed an advance directive.

During an interview on 11/01/11 at 1:15 p.m., an administrative nurse (#2) confirmed Patient #1 and #2's medical records lacked documentation of advance directive information.


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- Review of Patient #13's closed medical record occurred on 11/01/11. Patient #13 presented to the emergency room (ER) on 01/22/11 at 7:50 a.m. and the CAH admitted her to observation status at 8:40 a.m. Patient #13 remained in the hospital for over 24 hours (discharged on 01/23/11 at 10:45 a.m.). The CAH staff failed to assess at the time of admission to observation level of care whether or not Patient #13 had an Advance Directive and whether they provided the patient with information regarding Advance Directives.

- Review of Patient #14's closed medical record occurred on 11/01/11. Patient #14 presented to the ER on 01/29/11 at midnight and the CAH admitted her to observation status at 1:30 a.m. Patient #14 remained in the hospital for over eight hours (discharged on 01/29/11 at 10:00 a.m.). The CAH staff failed to assess at the time of admission to observation level of care whether or not Patient #14 had an Advance Directive and whether they provided the patient with information regarding Advance Directives.

- Review of Patient #21's closed medical record occurred on 11/02/11. Patient #21 presented to the ER on 09/30/11 at 11:30 a.m. and the CAH admitted her to observation status at 12:30 p.m. Patient #21 remained in the hospital for over four hours (discharge on 09/30/11 at 4:55 p.m.). The CAH staff failed to assess at the time of admission to observation level of care whether or not Patient #14 had an Advance Directive and whether they provided the patient with information regarding Advance Directives.

During an interview on 11/01/11 at 1:15 p.m., an administrative nurse (#2) stated the CAH nurses must assess on admission whether or not patients have an advance directive and document this in the medical record.

Based on observation, interview, and record review, the Critical Access Hospital failed to maintain a safe physical plant and environment by failing to ensure anti-siphon backflow valves were in place (Refer to C222), failing to ensure the availability of an emergency water supply (Refer to C229), and failing to maintain the building in compliance with the Life Safety Code (Refer C231). Failure to maintain a safe physical plant and environment places all patients at risk.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure a safe and sanitary environment for patients, staff, and the public regarding the lack of anti-siphon backflow valves on 1 of 1 sinks with attached hoses in a housekeeping storage room and on 1 of 1 shower head with an attached hose in a shower stall. Failure to ensure anti-siphon backflow valves were 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:

Observation during an environmental tour of the facility on the morning of 11/02/11 identified the following:
* a hose connected to a faucet, coiled up in the sink, located in the housekeeping storage room. Observation failed to identify a backflow prevention device on the faucet.
* a room with a shower stall, and a reverse osmosis (RO) unit set-up. A y-connector with a 25 foot garden hose hung off a second y-connection. Observation identified a hose attached to the shower head, which lacked a back flow valve.

During interview on 11/02/11 at 9:30 a.m., an administrative maintenance staff member (#7) stated the sink and shower head did not, and should have backflow prevention devices.

Based on observation, review of policies and procedures, review of contract agreements, and staff interview, the Critical Access Hospital (CAH) failed to ensure the availability of an emergency water supply for non-medical emergencies, for 3 of 3 days of survey (October 31-November 2, 2011). Failure to develop agreements and policies and procedures to ensure the availability of an emergency water supply places patients at risk in the event of a loss of water supply.

Findings include:

Review of the CAH emergency water agreement occurred on 11/02/11. The agreement, dated 06/06/90, stated, "This agreement is between St. Luke's Hospital and the [name of a city] whereby the [name of a city] agrees to supply water needs as necessary to St. Luke's Hospital during an emergency situation."

A tour of the physical plant occurred on the morning of 11/02/11. Observation during the tour did not identify an emergency supply of potable or nonpotable water within the facility.

The CAH's policies and procedures and contract agreements failed to identify estimations of water needs for an emergency water supply, and define the need for both potable and nonpotable water in the event of an emergency.

During interview, on 11/02/11 at 1:45 p.m., an administrative staff member (#8) stated the CAH was unable to obtain emergency water for a period of three days this past spring from "the city" they had contracted. The staff member stated "the city" lost power and was unable to provide emergency water for the CAH. The staff member reported CAH staff arranged for bottled water from the store and nonpotable water from farmers to flush the toilets. This staff member stated the facility made no changes in agreements since this occurred. This staff member reported he was not aware of any estimation of the amount of potable and non-potable water necessary for the CAH's operations, at that time, or for future occurrences in the event of a loss of water supply.

Based on observation, interview and record review, the critical access hospital failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. Refer to CMS-2567 for K tags cited as a result of the on-site survey completed 11/15/2011.

Based on review of a list of providers, review of medical staff bylaws, review of credential files, review of the surgical log, staff interview and review of State Agency provider files, the Critical Access Hospital (CAH) failed to appoint 1 of 1 Allied Health Provider (Provider #1) as a member of the medical staff consistent with the approved medical staff bylaws, and failed to ensure completed delineation of privileges prior to appointment for 1 of 7 providers (Physician #2) reviewed. Failure to appoint and delineate privileges consistent with the approved bylaws does not ensure practitioners maintain the qualifications, competency, and moral and ethical character necessary to practice at the facility and does not ensure the practitioners' medical staff appointment/privileges are current and up-to-date.

Findings include:

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 02/28/08 found this requirement out of compliance.

Review of medical staff bylaws occurred October 31, 2011. The bylaws, approved 03/27/08, defined the purpose of the organization as "To strive that all patients admitted to the hospital or treated as outpatients receive the optimal achievable levels of care. . . ."

ARTICLE III, Subsection 4 under Terms of Appointment stated:
"Appointment to the medical and dental staff shall confer on an appointee only such privileges as are listed in the form 'Medical Staff Privileges' herein after provided."

Article III, Section 4 of the bylaws define the "Procedures for Appointment

Subsection I
Application for membership on the medical and dental staff shall be presented in writing, on the prescribed form, which shall state the qualifications and references of the applicant and shall also signify his agreement to abide by the bylaws, rules, and regulations of the medical and dental staff. The application for membership on the medical and dental staff shall be presented to the administrator of the hospital, who shall transmit it to the secretary of the medical staff.

Subsection 2
The medical staff shall investigate the character, qualifications, and standing of the applicant and shall submit a report of the findings at the regular meeting of the staff, or as soon as possible.

Subsection 3
At the first regular meeting thereafter the chief of staff shall present the application to the staff members. . . .

Subsection 6
When the final action has been taken by the governing body, the administrator shall be authorized to transmit this decision to the candidate for membership, and if he is accepted, to secure his signature to the bylaws, rules, and regulations. Such a signature shall constitute his agreement to governed by the said bylaws, rules and regulations. . . .

Section 7. Allied Health Staff

The medical staff will approve credentials on professional staff relating to patient care in allied health fields, etc. physical therapy, CRNA's [Certified Registered Nurse Anesthetists], PA/NP's [Physician Assistants/Nurse Practitioners] and speech therapy. The Credential Committee will check privilege list to verify appropriated privileges for levels of education, experience, and training and give delineated list to appropriate hospital departments. . . .

ARTICLE VI: DETERMINATION OF QUALIFICATIONS AND PRIVILEGES

Section 1. Classification of Privileges

Privileges granted to medical and dental staff members shall be recommended by the active staff and be referred to the governing body for approval.

Section 2. Determination of Privileges

Subsection 1
Determination of initial privileges shall be based upon an applicant's training, experience, and demonstrated competence. This determination shall be the responsibility of the active staff, and shall become a part of the applicant's permanent record by filling out the form 'Medical Staff Privileges.'

Subsection 2
Determination of extension of further privileges shall be based upon demonstrated competence which shall be evaluated by the active staff and approved by the governing body. . . .

Credentials
To investigate the credentials of all applicants for membership or reappointment to the medical staff, dental staff, or allied health staff, and to make recommendations in conformity with Article III, Section 4, Subsection 4, of these bylaws,

The credential files shall include, but not be limited to the following:
a) completed application forms
b) Chief of Staff evaluation at end of provisional period
c) letters of appointment/reappointment
d) board approved privileges
e) DEA #'s [drug enforcement agency numbers]
f) insurance coverage
g) data practitioner database checked
If applicable, the credential files shall include the following:
a) documentation of interviews
b) notes on telephone reference checks . . . "

Review of the CAH's current list of providers occurred on the afternoon of October 31, 2011. The list identified one CRNA (Provider #1) under the "ALLIED HEALTH PERSONNEL" list; and identified Physician #2 as a Courtesy Staff Physician.

Review of individual physician/provider credential files occurred on the afternoon of 11/01/11 and showed the following appointment/reappointment activity since 2008:

- Review of Provider #1's credentialing file identified the following:
* Provider #1 practiced as an Allied Health Staff member, specifically a contracted CRNA staff member.
The file lacked:
- an application to the medical staff for credentialing
- Chief of Staff evaluation at end of a provisional period
- letters of appointment/reappointment
- board approved privileges
- DEA #'s
- data practitioner database check
- documentation of interviews
- notes on telephone reference checks

Review of the medical staff provider list identified the CAH initially granted Provider #1 practice privileges January 1992.

Review of the "Register of Operations" identified Provider #1 administered anesthesia services for surgical procedures including colonoscopy and esophagogastroduodenoscopy (EGDs) procedures between March 2008 and September 2011.

During interview on the morning of 11/02/11, a management staff member (#8) stated Allied Health Staff are not credentialed the same as the other medical staff and was not aware of the medical staff bylaws regarding the credentialing process requirement.

- The credentialing file of Physician #2 showed evidence of a reappointment of the physician's courtesy privileges with an application on file dated 05/23/11. The application included an "Intent of Reappointment" statement "To abide by my personal 'Delineation of Privileges' on file as approved by the Governing Board." The file showed evidence of medical staff and governing staff approval of the reappointment in June of 2011. Review of Physician #2's file lacked evidence of a "Delineation of Privileges" form.

During interview on the morning of 11/02/11, a management staff member (#8) stated he was unable to find Physician #2's completed "Delineation of Privileges" form, and stated the form had been removed from the file and misplaced.

Based on observation, record review, policy and procedure review, professional literature review, review of admission information provided to acute patients, and staff interview, the Critical Access Hospital (CAH) failed to ensure the provision of services by failing to monitor and document the effectiveness of medications given to patients on an as needed (prn) basis; failing to evaluate the safe use of side rails, assess each patient individually prior to utilizing side rails, consider side rails as a potential entrapment hazard, and provide education to the patient and responsible party regarding the hazards of side rail use; failing to establish and implement interventions to manage or prevent patient falls; failing to ensure the documentation of fetal heart tones; and failing to accurately assess and identify patient drug allergies (Refer to C295). Failure to ensure the provision of services places the CAH patients at risk of receiving improper care.

1. Based on record review, review of admission information provided to acute patients, and staff interview, the Critical Access Hospital (CAH) failed to monitor and document the effectiveness of medications given to patients on a prn (as needed) basis for 2 of 2 active swing bed patient (Patient #1 and #2), 2 of 2 closed inpatient (Patient #9 and #27), 1 of 3 closed swing bed patient (Patient #25), and 1 of 15 closed emergency room patient (Patient #22) records reviewed who received various 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:

On 10/31/11, the facility provided a copy of the information given to all acute patients at the time of admission to the CAH. Review of this information included a form titled, "PATIENT'S RIGHTS AND RESPONSIBILITIES." Review of this undated form stated, "All patients have a right to pain management.
Patient Rights: As a patient at St. Luke's Hospital, you can expect:
* information about pain and pain relief measures;
* a concerned staff committed to pain prevention and management;
* health professionals who respond timely to reports of pain; and
* your reports of pain will be believed.
Patient Responsibilities: As a patient at St. Luke's Hospital, we expect that you will:
* ask your doctor or nurse what to expect regarding pain and pain management;
* discuss pain relief options with your doctor or nurse;
* work with the doctor and nurse to develop a pain management plan;
* ask for pain relief when pain first begins;
* help your doctor and nurse to assess your pain;
* tell your doctor or nurse if your pain is not relieved; and
* tell your doctor or nurse about any worries you have about taking pain medications."

The back side of this form included three commonly used pain scale assessment tools:
"0-10 Visual Analog Scale" which identifies the number of "0" as "no pain" and "10" as the "worst possible pain,"
"Non-Communicative" which identifies the numbers of "0-1" as "sleeping calm/relaxed, not agitated" and "8-9" as "constant moaning without stimuli" and,
"Smile-Sad Faces Scale" where a smiling face indicates the number zero and no pain; while a sad face with tears indicates the number ten and the worst possible pain.

- Review of Patient #1's active swing bed record occurred on October 31 - November 1, 2011 and identified the CAH admitted the patient on 09/23/11 with diagnoses including post left hip surgery. The record indicated Patient #1 required prn medication for pain related to her left hip and for anxiety. Review of Patient #1's Medication Administration Records (MARs) for her hospital stay lacked documentation of the effectiveness of prn medication.

Patient #1's Nurse's Notes included the following:
*09/24/11: ". . . Medicated [with] Oxycodone 5 mg [milligrams] . . . @ [at] [10:00 a.m.], [3:00 p.m.] and Tylenol at [1:00 p.m.] for c/o [complaints of] pain. Obtained some relief. . . ." It is unclear when nursing staff monitored the effectiveness of the Oxycodone and Tylenol as the time on the nurse note indicated 9:00 a.m. to 5:10 p.m.
*09/25/11 at 6:30 a.m.: "Pt [patient] requested pain medication x [times] 2 during the noc [night] [with] relief . . ." It is unclear when nursing staff monitored the effectiveness of the pain medication as staff administered the medication during the night and documented the nurse note in the morning.
*09/25/11: ". . . Medicated [with] Oxycodone 5 mg at [11:15 a.m.] and [4:50 p.m.] for c/o pain obtains some relief. . . ." It is unclear when nursing staff monitored the effectiveness of the Oxycodone as the time on the nurse note indicated 9:00 a.m. to 7:00 p.m.

Further review of Patient #1's Nurse's Notes included the following:
*09/26/11 at 5:30 a.m.: ". . . Pt had pain medication x 2 [and] Tylenol x 1 . . ."
*09/29/11 at 10:40 p.m.: "C/O h/a [headache] now . . . Tylenol 650 mg given . . ."
*10/01/11 at 3:15 p.m.: ". . . C/O pain in [left] hip @ this time. Oxycodone given . . ."
*10/08/11 at 6:40 p.m.: "Pt c/o leg pain. . . . Tylenol 325 [2] . . . given @ this time. . . ."
*10/20/11 at 9:00 p.m.: ". . . Gave Ativan 0.5 mg [2] . . . for anxiety. . . ."
*10/21/11 at 5:30 a.m.: ". . . Pt given 1 mg Ativan during the noc for anxiety . . ."
*10/23/11 at 4:30 a.m.: ". . . Pt was given Ativan around [11:00 p.m.] for anxiety . . ."
*10/26/11 at 5:30 a.m.: "Pt c/o pain to hip earlier in shift. . . . medicated . . . given Ativan . . ."
*10/30/11: ". . . Tylenol given . . ." The nursing staff indicated the time on the nurse note as 9:00 a.m. to 8:00 p.m.
*11/02/11 at 6:00 a.m.: ". . . Medicated [with] Tylenol for pain . . ."
The above nurse notes, as well as all subsequent nurse notes, lacked evidence nursing staff monitored and documented the effectiveness of the pain and anti-anxiety medications administered to Patient #1.

- Review of Patient #2's active swing bed record occurred on October 31 - November 1, 2011 and identified the CAH admitted the patient on 08/27/11 with diagnoses including low back and hip pain. The record indicated Patient #2 required prn medication for pain and for anxiety and behaviors. Review of Patient #2's Medication Administration Records (MARs) for her hospital stay lacked documentation of the effectiveness of prn medication.

Patient #2's Nurse's Notes included the following:
*08/28/11 at 5:00 a.m.: ". . . Pt given Ativan [and] Tramadol for aggitation [sic] [and] pain . . ."
*09/03/11 at 5:30 p.m.: ". . . Ativan [1] . . . given @ [11:10 a.m.]. Pt then offered c/o stomach pain . . . Ultracet [2] . . . given @ [11:15 a.m.]. No further c/o pain or agitation. . . ." It is unclear when nursing staff monitored the effectiveness of the Ativan and Ultracet as the time on the nurse note indicated 5:30 p.m. The medications were administered about 6 hours prior to this documentation.
*09/07/11: ". . . Medicated [with] Ativan 0.5 mg @ [3:15 p.m.] for hollering, Ultracet [2] tabs [tablets] @ [6:30 p.m.] for c/o headache, [and] Ativan 0.5 mg @ [8:25 p.m.] for continued hollering. . . ." The nursing staff indicated the time on the nurse note as 9:00 a.m. to 9:00 p.m.
*09/08/11 at 7:00 p.m.: "pt medicated [with] Ativan 0.5 mg . . ."
*09/11/11 at 2:00 p.m.: ". . . Ativan 0.5 mg . . . given . . ."
*09/11/11 at 3:00 p.m.: ". . . Order received for IM [intramuscular] Valium - given . . ."
*09/12/11 at 2:50 p.m.: "Pt c/o pain. Call the doctor my arm hurts I hurt all over. Medicated [with] Ultracet 2 tabs . . ."
*09/16/11 at 8:00 p.m.: ". . . Ativan [1] mg . . . given for anxiety. . . ."
*09/18/11 at 12:30 p.m.: ". . . Tramadol [2] . . . given for pain [and] Ativan 0.5 mg given for anxiety. . . ."
*09/18/11 at 8:25 p.m.: ". . . Ativan 1 mg . . . given. . . ."
*10/01/11 at 7:20 p.m.: ". . . Ultracet [2] given for c/o back pain [and] Ativan 0.5 mg [1] . . . given for cont [continuing] to holler. . . ."
*10/04/11 at 7:45 p.m.: "Pt given Tylenol 500 mg [2] . . . for c/o headache. . . ."
*10/08/11 at 1:55 p.m.: "Pt c/o back pain. Tramadol 50 mg [2] . . . given . . ."
*10/10/11 at 9:00 p.m.: ". . . Pt. anxious [and] agitated, given Tramadol for pain, Pt. reported, 'Pain in back'. . . ."
*10/14/11: ". . . tylenol given for shoulder discomfort @ [1:10 p.m.]. . . ." The nursing staff indicated the time on the nurse note as 12:45 p.m. to 6:00 p.m.
*10/17/11 at 6:00 a.m.: ". . . medicated [with] Ativan 1 mg . . ."
*10/20/11: ". . . Tylenol 500 mg [2] . . . given . . ." The nursing staff indicated the time on the nurse note as 9:00 a.m. to 7:45 p.m.
*10/22/11 at 4:15 a.m.: ". . . Pt given tramadol [and] Ativan . . ."
*10/22/11, untimed: ". . . Tramadol [1] given @ [8:00 p.m.] for pain. Ativan 0.5 mg [2] . . . given for hollering [and] [increased] anxiety. . . ."
*10/24/11 at 7:05 p.m.: ". . . gave Tramadol [2] . . . Ativan 1 mg . . . at [7:00 p.m.]. . . ."
*10/28/11 at 8:30 p.m.: ". . . Ativan [2] . . . given @ [8:15 p.m.] for [increased] hollering/agitation. . . ."
*10/30/11: ". . . C/O leg pain @ [4:15 p.m.]. Tylenol 500 mg [2] . . . given @ [4:30 p.m.] along [with] Ativan 0.5 mg [2] . . . for pain [and] [increased] anxiety. . . ." The nursing staff indicated the time on the nurse note as 9:00 a.m. to 7:15 p.m.
*10/31/11 at 8:30 p.m.: ". . . Ativan 1 mg . . . given. . . ."
The above nurse notes, as well as all subsequent nurse notes, lacked evidence nursing staff monitored and documented the effectiveness of the pain and anti-anxiety medications administered to Patient #2.

- Review of Patient #9's closed inpatient record occurred on 10/31/11, and identified the CAH admitted the patient 12/29/10 with diagnoses of pneumonia, fever, gastroenteritis, and dehydration. The record indicated Patient #9 required prn medication for nausea (Phenergan) related to his gastroenteritis. Review of Patient #9's Medication Administration Records (MARs) from December 29-January 04, 2011 lacked documentation of the effectiveness of the prn medication.

Review of Patient #9's MARs showed that on 12/29/10 at 10:00 p.m. the patient received Phenergan 25 milligrams (mg) intravenous (IV).

Patient #9's Daily Flow Sheets included the following:
*12/29/10 at 10:00 p.m.- ". . . Pt [patient] wretching [sic]. Given Phenergan 25 mg IV."
*12/30/10 at 12:30 a.m.- "Wretching [sic] at this time. Repositioned." (CAH nursing staff documented effectiveness 2 1/2 hours later).
*12/30/10 at 6:40 a.m. "[no] further wretching [sic] noted. [no] further diarrhea noted. Pt confused [at] all times [throughout] noc [night]."

The above Daily Flow Sheets from 12/29/10, lacked evidence nursing staff monitored and documented the effectiveness of the anti-nausea medication administered to Patient #9 in a timely fashion.

- Review of Patient #25's closed swing bed record occurred on 11/01/11, and identified the CAH admitted the patient 04/18/11 with diagnoses of respiratory distress and congestive heart failure. The record indicated Patient #25 required prn medication for pain and dyspnea (Dilaudid). Review of Patient #25's MARs from April 18-21, 2011 lacked documentation of the effectiveness of the prn medication.

Review of Patient #25's MARs showed the patient received Dilaudid three times on April 18 (at 9:40 a.m., 2:00 p.m., and 11:00 p.m.,); four times on April 19 (at 3:45 a.m., 1:35 p.m., 8:45 p.m., and 10:45 p.m.); and four times on April 20 (at 2:30 a.m., 12:40 p.m., 5:05 p.m., and 11:55 p.m.).

Patient #25's Nurse's Notes included the following:
*04/18/11 at 10:00 a.m.: ". . . Pt comfort care for respiratory distress . . . Dilaudid give as needed for resp [respiratory] attacks . . . pt checked Q [every] [hour] [and] PRN."
*04/18/11 at 2:00 p.m.: "Pt restless holding chest [complained of] SOB [shortness of breath] . . . medicated with Dilaudid 1 mg IV. Will continue to monitor."
*04/19/11 from 9:00 a.m.-9:00 p.m.: ". . . medicated [with] Dilaudid [one] mg IVP at 1325 [1:35 p.m.]. [and] 2045 [8:45 p.m.]. Pt lungs sound more wet this evening. [complained of] dry mouth [and] hunger . . . Awake most of day . . . ."
*04/19/11 from 9:00 p.m. - 6:30 a.m. on 04/20/11: "Pt remain frail . . . Dilaudid given per agitation . . . ."
*04/20/11 from 9:00 a.m.-9:00 p.m.: ". . . Dilaudid [one] mg given IV at 1240 [12:40 p.m.] [and] 1705 [5:05 p.m.] for restlessness [and] [increased] resps [respiratory rate] . . . ."
*04/21/11 at 6:00 a.m.: "Pt rested much of noc. Medicated [times] [one] [with] Dilaudid 1 mg for restlessness, gasping resps . . . ."

The above Nurse's Notes from April 18-21, lacked evidence nursing staff monitored and documented the effectiveness of the pain medication administered to Patient #25.

- Review of Patient #27's closed inpatient record occurred on 11/01/11, and identified the CAH admitted the patient 06/03/11 with diagnoses of pneumonia, septicemia, and congestive heart failure. The record indicated Patient #9 required prn medication for pain (Oxycodone). Review of Patient #27's MARs from June 03-05, 2011 lacked documentation of the effectiveness of the prn medication.

Review of Patient #27's MARs showed the patient received Oxycodone 15 mg orally on 06/03/11 at 8:00 p.m. and 06/05/11 at 11:10 a.m. and 8:45 p.m.

Patient #27's Daily Flow Sheets included the following:
*06/03/11 for the twelve hour day shift identified Patient #27 experienced "[left] shoulder pain - chronic."
*06/05/11 - for the twelve hour day shift identified "[complaints of] chronic pain."
*06/05/11 - for the twelve hour day shift identified "prn meds [medications] [at] 2100 for chronic pain."

The above Daily Flow Sheets from June 03 and 05, 2011, lacked evidence nursing staff monitored and documented the effectiveness of the pain medication administered to Patient #27.

- Review of Patient #22's closed emergency room (ER) record occurred on 11/01/11. The patient presented to the ER 09/18/11 at 3:35 p.m. with diagnosis of comminuted fracture of the ulnar shaft. The record indicated Patient #22 required prn medication for pain (Dilaudid). Review of Patient #22's ER record identified he received Dilaudid 1 mg IV at 5:45 p.m. and the nursing staff failed to document the effectiveness of this medication. The CAH transferred Patient #22 to another facility at 6:05 p.m.

During interview on the afternoon of 11/01/11, an administrative nurse (#1) was asked to provide the facility's pain management policy/procedure for review. This staff member stated the CAH does not have a specific policy/procedure relating to pain management. An administrative staff member (#1) confirmed Patient #9, #22, #25, and #27's records lacked documentation by the nursing staff of the effectiveness of prn medications administered. This staff member stated she expected nursing staff to evaluate the effectiveness of PRN medications within 30 minutes depending on the type of and route of the medication administration.

Failure of the CAH nursing staff to utilize the pain scales (provided to patients at the time of admission) to evaluate the effectiveness of prn pain mediations during all levels of care (ER, inpatient, or swing bed) may have contributed to these patients (#1, #2, #9, #22, #25, and #27) unresolved pain issues and did not allow the CAH nursing staff to ensure the prn medication achieved its desired effect.

2. Based on observation, record review, professional literature review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the safe use of side rails, failed to assess each patient individually prior to utilizing side rails, failed to consider side rails as a potential entrapment hazard, and failed to provide education to the patient and responsible party regarding the hazards of side rail use for 2 of 4 active patients (Patient #1 and #2) observed with elevated side rails and 1 of 1 closed inpatient (Patient #9) record reviewed who experienced an entrapment due to elevated side rails.

Failure to assess and evaluate the use of side rails, to consider side rails as a potential entrapment hazard, and to educate patients and responsible parties regarding the hazards of using side rails placed Patients #1 and #2 at risk of entrapment or injury and contributed to Patient #9's entrapment.

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 02/28/08 found this requirement out of compliance.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated April 2003, stated, ". . . bed rails may pose increased risk to patient safety. . . . evidence indicates that half-rails pose a risk of entrapment . . . as well as falls that occur when patients climb over the rails or footboards when the rails are in use. . . . CMS [Centers for Medicare and Medicaid Services] . . . CMS issued guidance in June 2000 . . . One section of the guidance states, 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. Even when a side rail is not intentionally used as a restraint, patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised siderails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . . 1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize . . . 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 . . . 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 . . . The care plan should include educating the patient about possible bed rail danger to enable the patient to make an informed decision . . . If a bed rail has been determined to be necessary, steps should be taken to reduce the known risks associated with its use. . . . 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. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts", revised April 2010, stated, ". . . Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . . Most patients can be in bed safely without bed rails. Consider the following: Use beds that can be raised and lowered close to the floor . . . Keep the bed in the lowest position with wheels locked. When the patient is at risk of falling out of bed, place mats next to the bed . . . Monitor patients frequently. Anticipate the reasons patients get out of bed . . . meet these needs . . . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. . . . Reassess the need for using bed rails on a frequent, regular basis."

- Observation of Patient #2 while she rested in bed on the mornings of 11/01/11 and 11/02/11, identified two elevated upper half rails on the bed.

Review of Patient #2's active swing bed record occurred on October 31 - November 1, 2011 and identified the CAH admitted the patient on 08/27/11 with diagnoses including low back and hip pain, psychiatric problems with aggressive behaviors, and urinary stress incontinence. The Admission Nursing Assessment showed Patient #2 transferred with one person assist, and ambulated with two person assist; required assistance with toileting (incontinent of bowel and bladder), bathing, grooming, eating, and oral hygiene; identified the patient as having poor vision and hearing, and indicated disorientation. Patient #2's Fall Risk Assessment, dated 08/27/11, identified her as a high risk for falls. Review of Patient #2's Daily Care Sheets from September 1 to October 31, 2011 indicated two side rails up.

Patient #2's Nurse's Notes stated the following:
*09/02/11 at 6:15 a.m.: ". . . During NOC [night] pt [patient] was found sitting at edge of bed confused . . ."
*09/05/11 at 6:00 a.m.: ". . . Pt. found trying to get out of bed @ [at] 0500 [5:00 a.m.]. . . ."
*09/10/11 at 3:15 p.m.: ". . . Attempts to get up out of chair/bed on her own. . . ."
*09/11/11 at 6:00 a.m.: ". . . Pt trying to crawl out of bed @ this time. . . ."
*09/12/11 at 3:30 p.m.: "Pt found attempting to crawl out of bed . . ."
*09/13/11 at 11:00 p.m.: "Pt yelling out [and] sitting @ side of bed. . . ."
*09/16/11 at 7:11 p.m.: "Pt found on knees [with] face on bed frame. States 'nose is sore' bruising noted to [bilateral] knees [with] tenderness. . . . Placed in recliner . . ."
*09/17/11 at 5:00 a.m. to 2:45 p.m.: ". . . Pt found on floor @ 1445 [2:45 p.m.] laying on her back at end of chair beside the bed . . ."
*09/17/11 at 8:30 p.m.: "pt crawled onto floor - took blankets from bed [and] covered herself up . . ."
*09/27/11 at 1:30 a.m.: "Pt found on floor lying on her left side yelling out for help. Blood noted on floor. . . . Direct pressure applied to wound on [left] side of head. . . . Bed alarm applied. Floor matt [sic] also placed beside bed. . . ."
*09/27/11 at 6:00 a.m.: "Pt yelling out [and] trying to crawl out of bed x [times] 3 . . ."
*10/10/11 at 1:50 p.m.: "Pt found on the floor up on her knees [with] her head under the bed [and] partial bed rail. . . . Pt. states 'I was going to the BR [bathroom]. . . ."
*10/14/11 at 10:45 a.m.: "pt found on floor. Laceration to [left] eye. . . ."

Patient #2's medical record lacked an individualized assessment of risk and safety for the use of side rails, and lacked evidence of patient or responsible party education regarding the hazards of side rail use. Given Patient #2's multiple occasions of getting up out of the bed by herself, history of falls, and injuries from falling, the CAH staff failed to consider the elevated side rails a safety and entrapment hazard for the patient.

- Observation of Patient #1 while she rested in bed on the morning of 11/02/11, identified one elevated upper half rail on the bed.

Review of Patient #1's active swing bed record occurred on October 31 - November 1, 2011 and identified the CAH admitted the patient on 09/23/11 with diagnoses including post left hip surgery, legal blindness, pain, gait and balance abnormality, and recurrent falls. The record indicated Patient #1 required assistance with activities of daily living and ambulation due to her legal blindness. Patient #1's Fall Risk Assessment, dated 09/23/11, identified her as a high risk for falls. Review of Patient #1's Daily Care Sheets from September 23 to October 31, 2011 indicated two side rails up.

Patient #1's medical record lacked an individualized assessment of risk and safety for the use of side rails, and lacked evidence of patient or responsible party education regarding the hazards of side rail use. The CAH staff failed to consider the side rails as a potential safety and entrapment hazard for the patient.

- Review of Patient #9's closed inpatient record occurred on 10/31/11, and identified the CAH admitted the patient 12/29/10 with diagnoses of pneumonia, fever, gastroenteritis, and dehydration.

Patient #9's Fall Risk Assessment, completed on 12/29/10, identified a score of "13." Printed instructions on the top of this form state, " . . . If the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan."

Review of Patient #9's care plan included the safety inventions of "bed to lowest position," and every one hour checks by staff.

Patient #9's Medication Administration Record (MAR) identified the patient received the following prn (as needed) medications:
* Phenergan (anti-nausea medication) 25 milligrams (mgs) intravenously (IV) on 12/29/10 at 10:00 p.m. and 12/31/10 at 8:50 p.m.
*Haldol (an antipsychotic medication) 0.5 mg orally (po) on 01/01/11 at 9:30 p.m.

Patient #9's Daily Flow Sheet stated:
12/29/10 - generalized weakness, unable to ambulate.
12/30/10 - generalized weakness, hallucinating "majority of day."
01/01/11- generalized weakness, hallucinating at times.

Review of Patient #9's Daily Flow Sheet, dated 01/02/11, stated, "0000 [midnight]- Pt [patient] found on floor next to bed. [right] arm stuck between repositioning bar [and] bed - echymotic [sic] area to inner [right] wrist [and] outer [right] hand. [no] open skin ares. Pt very diaphoretic, color dusky. VS [vital signs] [blood pressure] 113/80, P [pulse] 113, R [respirations] 28, SpO2 [oxygen saturation] 95%, R/A [room air], T [temperature] 97.9 [degrees fahrenheit]. Pt alert, disoriented to place, time. Attempts to make appropriate comments - 'Thank you' repeatedly but then speech is garbled. [complained of] some pain to [right] knee [no] injury noted. Will cont [continue] to monitor. When pt assisted back to bed her color improved to pink, [no] more diaphoresis. Calmed now. Bed in low position, tab alarm placed. Call button in reach."

A physician Progress Note, dated 01/02/11 at 9:14 a.m., for Patient #9 stated, "S: [subjective] [Patient #9] is currently awake, alert, pleasant, and not at all agitated. However, during the night she had hallucinations. She was crying out and actually fell out of bed and bruised her arm. She was given Haldol and then was able to sleep . . . ."

After Patient #9's entrapment with the repositioning bar, CAH staff placed a tab alarm to her bed.

Patient #9's medical record lacked an individualized assessment of risk and safety for the use of her repositioning side rail and lacked evidence of patient or responsible party education regarding the hazards of side rail use. Given Patient #9's history of generalized weakness and hallucinations, the CAH staff failed to consider the elevated repositioning rail a safety and entrapment hazard for the patient. Following the incident on 01/01/11, the CAH staff failed to assess the safety of the repositioning rail which resulted in Patient #9's right arm, wrist, and hand entrapment.

During an interview on 11/01/11 at 1:15 p.m., an administrative nurse (#2) stated patients used the elevated side rails for positioning, and confirmed nursing staff does not perform or document an assessment for risk factors or safety for utilization of side rails.

During an interview on 11/02/11 at 10:00 a.m., an administrative nurse (#1) confirmed nursing staff does not perform an assessment of risk factors or safety for utilization of side rails. The nurse (#1) stated nursing staff usually elevated the side rails for patient positioning and access to bed controls/call light, and stated she did not realize the potential for the side rails as a safety hazard for entrapment.

3. Based on record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to establish and implement interventions to manage or prevent falls for 1 of 1 closed inpatient (Patient #9) record reviewed who experienced a fall and entrapment with a repositioning rail. Failure to recognize the risks associated with falls and take action to manage or prevent falls caused an unsafe environment for Patient #9 and contributed to the patient's entrapment in the repositioning rail.

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 02/28/08 found this requirement out of compliance.

Findings include:

Review of the policy "Patient Falls: Prevention Protocol and Post Fall Interventions" occurred on 11/01/11. This policy, developed on 08/25/08, stated, "DEFINITION: A fall is defined as 'a sudden unanticipated change in body position in a downward direction which may or may not result in a physical injury'. (This does not include assisting a patient to a chair or to the floor.) ASSESSMENT: 1. All patients will have a fall risk assessment upon admission by a licensed nurse. A reassessment may be done if the patient's orientation or alertness changes and will be done after a fall occurs. 2. Monitor gait, balance and fatigue with ambulation. 3. Monitor after change in medication for possible side effects. 4. Patients determined to be at fall risk will have safety precautions implemented to meet their individual needs such as being placed in a room near the nurses' station or using a tab alert. See 'Fall Prevention Protocol' for interventions. 5. If a patient is determined to be at risk, the 'Fall Prevention Protocol' will remain in place for the duration of the hospitalization unless documented otherwise by an RN [Registered Nurse] or physician.
INTERVENTIONS: Are chosen based on assessment of patient need and appropriateness. Interventions that may be considered for an individualized plan of care include: 1. Place a fall risk sign in a highly visible area outside the patient's room on the door. 2. Make a notation on the Kardex. 3. Patients benefit from having family or close friends at the bedside to provide comfort and reassurance. Discuss fall risk status with patient and/or family/responsible person. 4. Use gait belt to transfer patients to a commode, chair or when ambulating. Keep a gait belt at bedside for patients identified as a fall risk. 5. Maintain bed in low position (one of the special low beds) when occupied by a patient and may place a mattress on the floor beside the low bed. 6 Maintain equipment with wheels in locked position at all times. 7. Remove any environmental obstacles from the patient's walking path. 8. Consider bed or chair alarm or tab alert as appropriate. 9. Reorient to surroundings and environment as needed. 10. Be alert to investigate noises from patient rooms. 11. Place call light and frequently used items within reach. Utilize night light in patient room. 12. Offer bedpan, urinal, or assistance to bathroom at mealtime, at bedtime, and upon awakening. 13. Patients identified as a 'Fall Risk' will be supervised while on the commode. 14. Provide non-skid slippers for patients without footwear. 15. Obtain assistive devices as needed for mobilization. Assist with/supervise transfers and ambulation. Arrange for Physical Therapy evaluation if appropriate. 16. Consider placement in a room or area of high visibility. 17. Discuss benefits of continuous supervision with family/responsible person as appropriate. 18. Communicate fall risk status at shift report and upon patient transfer to another department or facility. 19. Safety issues will be discussed at interdisciplinary team meetings.
CARE PLAN: 1. The plan of care will reflect the appropriate interventions individualized to patient's needs and will be updated as needed.
DOCUMENTATION: 1 Interventions used to prevent falls. 2. Notification of patient and/or family/responsible person regarding high fall risk status and any teaching done. 3. 'High Risk for Falls' on the Kardex and on the care plan and the frequency of monitoring.
POST FALL FOLLOW UP: . . . 4. Assess and document circumstances of the fall: location, medications, vital signs and the patient's response to the fall. 5. Notify the physician of the fall. 6. Notify the family or responsible person of the fall. 7. Implement fall risk precautions if not already in force. 8. Perform baseline neuro checks for potential head injury every 4 hours for 24 hours post fall. 9. Evaluate the need for every 15 to 30 minute safety checks . . . ."

Review of Patient #9's closed inpatient record occurred on 10/31/11, and identified the CAH admitted the patient 12/29/10 with diagnoses of pneumonia, fever, gastroenteritis, and dehydration.

Patient #9's Fall Risk Assessment, completed on 12/29/10, identified a score of "13". Printed instructions on the top of this form state, " . . . If the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan."

Interventions to prevent falls in place for Patient #9 implemented at the time of admission included "bed to lowest position," and every hour one checks by staff.

Patient #9's Medication Administration Record (MAR) identified the patient received the following prn (as needed) medications:
* Phenergan (ant

Based on record review, review of facility policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to maintain a complete medical record including health care practitioner (HCP) orders for instruction and medications to the patients upon discharge from the facility for 3 of 3 closed observation patient (Patient #13, #14, and #21) records reviewed. Failure of the CAH to ensure the patient received written discharge instruction and medication orders from the HCP limited the patients' ability to ensure consistent follow-up of instructions and limited the CAH staff's ability to ensure continuity of care.

Findings include:

Review of the facility policy "Discharge of a Patient" occurred on 11/02/11. This policy dated, 02/2009, stated, "Patients are discharged from St. Luke's Hospital upon direct orders of a physician . . . Procedure: 1. An order must be obtained from the physician for discharge of the patient . . . 4. Complete the "Discharge Instruction Sheet." The nurse on duty . . . reviews the instructions for follow-up care with the patient or responsible person to assure understanding . . . Teaching sheets are available for several educational needs. The nurse must document these sheets were given to the patient or responsible person on the "Discharge Instruction Sheet" or in the nurses' notes . . . ."

- Review of Patient #13's closed medical record occurred on 11/01/11. Patient #13 presented to the emergency room (ER) on 01/22/11 at 7:50 a.m. and the CAH admitted her to observation status at 8:40 a.m. Patient #13's diagnosis included acute chest pain. The CAH discharged the patient on 01/23/11.

Review of Patient #13's history and physical, dated 01/22/11, identified the medications of Diovan, Asprin, Atenolol, Simvastatin, and Celexa.

Patient #13's HCP order's for discharge stated, "Discharge home. . . F/U [follow-up] [name of health care practitioner] . . . Meds [medications] as at home [with] increased isosorbide as 60 mg [milligrams] Q [every] AM [morning], 30 mg Q PM [evening]."

Review of Patient #13's written discharge instructions, completed by the CAH nursing staff stated, ". . . ACTIVITIES: . . . Same kind of activity as in hospital . . . EXERCISE: Light (walking, etc.) . . . DIET: . . . Drink at least 8-10 glasses of fluid daily . . . MEDICINES: Isosorbide 60 mg every morn [morning], Isosorbide 30 mg every eve [evening], Diovan 160 mg daily, ASA [Asprin] 325 mg daily, Atenolol 50 mg daily, Simvastatin 80 mg daily, Celexa 40 mg daily SPECIAL ADVICE [and] TREATMENTS: No work for 2 [two] days OTHER INSTRUCTIONS: Follow-up with [name of health care practitioner] on . . . ."

Failure of the HCP to provide written exercise, activity, and diet instructions and medication orders at the time of discharge, placed Patient #13 at risk of receiving incorrect instructions and taking the wrong medications.

- Review of Patient #14's closed medical record occurred on 11/01/11. Patient #14 presented to the ER on 01/29/11 and the CAH admitted her to observation status at 1:30 a.m. Patient #14's diagnoses included tachycardia with heart palpitations and hypertension. The CAH discharged the patient at 10:00 a.m.

Review of Patient #14's history and physical, dated 01/29/11, identified the medications of Metoprolol 25 mg daily, Enalapril 20 mg daily, and Lipitor 20 mg 1/2 tablet daily.

Patient #14's HCP order's for discharge stated, "Discharge home."

Review of Patient #14's written discharge instructions, completed by the CAH nursing staff stated, ". . . ACTIVITIES: . . . Same kind of activity as in hospital . . . EXERCISE: Light (walking, etc.) . . . DIET: No restrictions Drink at least 8-10 glasses of fluid daily . . . MEDICINES: Metoprolol 50 mg twice daily (new prescription) - otherwise continue other home meds - Enalapril and Lipitor SPECIAL ADVICE [and] TREATMENTS: Limit smoking to none OTHER INSTRUCTIONS: Please call clinic or hospital with questions or comments. Return to hospital as needed."

Failure of the HCP to provide written exercise, activity, and diet instructions and medication orders at the time of discharge, placed Patient #14 at risk of receiving incorrect instructions and taking the wrong medications.

- Review of Patient #21's closed medical record occurred on 11/02/11. Patient #21 presented to the ER on 09/30/11 and the CAH admitted her to observation status at 12:30 p.m. Patient #21's diagnoses included closed-head injury and confusion. The CAH discharged the patient at 4:55 p.m.

Review of Patient #21's history and physical, dated 09/30/11 identified the medications of Levothyroxine, Toprol, Hyzaar, Nexium, Neurontin, Clonazepam, and Vitamin B 12.

Patient #21's physician orders for discharge stated, "D/C [discharge] home. Resume regular diet [after] 24 [hours]; clear liquid until then. Activity as tolerated. Continue home meds. Add KCL [potassium] 20 mEq [milliequivalent] [one] po [orally] daily. F/U [at] clinic 1-2 weeks [and] return here prn [as needed]."

Review of Patient #21's written discharge instructions, completed by the CAH nursing staff stated, ". . . EXERCISE: Light (walking, etc.) . . . DIET: No restrictions Drink at least 8-10 glasses of fluid daily . . . MEDICINES: Continue all previous home medications plus KCL 20 mEq [one] po (qd) [everyday] daily." Patient #21's record lacked evidence the CAH nursing staff provided the patient with educational information such as "Teaching Sheets" (as per facility policy) regarding instructions following a head injury.

Failure of the physician to provide written medication orders for all medications at the time of discharge, placed Patient #21 at risk of taking the wrong medications.

Failure to provide Patient #21 with specific discharge instructions of the signs/symptoms a patient with a closed head injury should report (such as difficulty awakening, seizures, vomiting that continues and/or worsens, and/or unequal pupils) has the potential for a worsening head injury to go unreported and may result in permanent disability or death.

During an interview on 11/01/11 at 1:15 p.m., an administrative nurse (#1) stated she believed the nurses "copied" all of the patient's (Patient #13, #14, and #21) medications as they appeared on the CAH's medication administration records and confirmed the CAH's health care practitioners failed to write out all of the medications and treatments for each patient to continue upon discharge from the facility.

Failure of the HCP and physician to provide written exercise, activity, and diet instructions and medication orders at the time of discharge for Patient #13, #14, and #21, may result in these patients' delayed recovery or unnecessary return for treatment.

Based on policy review, Quality Assurance (QA) record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the quality assurance program evaluated all patient care services affecting CAH patient health and safety, including Swingbed (including activities and social services), pharmacy, discharge planning, and the contracted services of laundry and pharmacist for 12 of 12 months reviewed (November 2010-October 2011). Failure to participate in quality assurance activities places patients at risk of not receiving appropriate care and services and limits the CAHs ability to implement corrective action if necessary.

Findings include:

Review of the CAH's "QUALITY ASSURANCE PLAN" occurred on the morning of November 1, 2011. The plan, dated 08/11/04, stated,
"Purpose . . . to ensure the delivery of optimal patient care in the most appropriate setting . . .
Ongoing and systemic monitoring through objective criteria to evaluate the quality and appropriateness of patient care, pursue opportunities to improve patient care, and resolve identified problems.
Documentation of the level of care delivered. . . .
Quality Assurance Requirements . . .
B. The quality and appropriateness of patient care in the following services shall be monitored and evaluated on an ongoing basis. Each Department will report at least annually or as directed by the QI [Quality Improvement] Coordinator. . . .
3. Nursing Services including Discharge Planning . . .
6. Pharmacy Services including Pharmacy and Therapeutic functions . . .
10. Swingbed Activities
11. Swingbed Social Services . . .
Contracted Services . . ."

The 2011 QI reporting schedule identified annual reporting of the contracted services of Laundry and the Pharmacist to the QA committee should occur in April.

Review of the QA Committee Meeting Minutes occurred on the morning of 11/01/11. The minutes lacked reporting in April of 2011 from the contracted services of Laundry and Pharmacist. The minutes lacked reporting in August of 2011 from the following departments: Swingbed, Swingbed Activities, and Pharmacy. In addition, the minutes lacked reporting of Discharge Planning by nursing services and Swingbed Social Services (as identified by the QA plan).

During interview, on 11/01/11 at 1:30 p.m. and 11/02/11 at 11:00 a.m., a management staff member (#1) stated, within the last year, Swingbed, Swingbed Activities, Swingbed Social Services, Pharmacy, Discharge Planning, and the contracted services of Laundry and Pharmacist, did not report QA activities to the QA committee as required according to the QA plan.

Based on review of a list of providers, policy review and staff interview, the Critical Access Hospital (CAH) failed to evaluate the quality and appropriateness of the treatment furnished by 1 of 1 nurse anesthetist (Provider #1), 1 of 1 Family Nurse Practitioner (FNP) (Provider #2), and 1 of 1 Physician's Assistant-Certified (PA-C) (Provider #3) providing care to the CAH's patients within the past year. Failure to evaluate the quality and appropriateness of the treatment furnished has the potential to affect patient outcomes involving surgical procedures requiring anesthesia services provided by the CRNA and involving patient care provided by the FNP and PA.

Findings include:

Review of the QUALITY ASSURANCE PLAN occurred on November 01, 2011. The plan, dated 08/11/04, identified "Quality Assurance Requirements" of:
"A. Requirements for Medical Staff services evaluation will be met by:
1. Monitoring and evaluating the quality and appropriateness of patient care and the clinical performance of all individuals with delineated privileges encompassing all major clinical activities in the hospital on an ongoing basis. . . .
3. Other Medical Staff responsibilities included in QA [Quality Assurance] consists of: . . .
c. Appraisal of the competence of all practitioners not permitted to provide care independently. . . .
5. The information collected during these various reviews shall be assessed to identify important problems in patient care. . . .
c. A physician will review all cases pulled for review . . ."

Review of the CAH's current list of providers occurred on the afternoon of October 31, 2011. The list identified one CRNA (Provider #1), one FNP (Provider #2), and one PA-C (Provider #3).

During interview on the morning of 11/02/11, a management staff member (#8) stated the CAH did not have a physician evaluate the quality and appropriateness of the treatment provided by the consulting nurse anesthetist (Provider #1), the FNP (Provider #2), or the PA-C (Provider #3) in the past year.

Based on review of a list of providers, review of agreements, policy review and staff interview, the Critical Access Hospital (CAH) failed to have 1 of 1 active medical staff physician who provided treatment to the CAH's patients (Physician #1) evaluated for the quality and appropriateness of the diagnosis and treatment furnished. Failure to evaluate the physician, by physicians/providers with the same qualifications/privileges, has the potential to affect patient outcomes.

Findings include:

Review of the CAH's current list of providers occurred on the afternoon of October 31, 2011. The list identified one active medical staff physician.

An administrative staff member (#8) provided a copy of the facility Peer Review agreement on the afternoon of 10/31/11. The agreement, dated 04/18/11, identified an avenue for the CAH to have medical staff cases reviewed by an outside entity through the use of the Rural Health Network.

Review of the QUALITY ASSURANCE PLAN occurred on November 01, 2011. The plan, dated 08/11/04, identified "Quality Assurance Requirements" of:
"A. Requirements for Medical Staff services evaluation will be met by:
1. Monitoring and evaluating the quality and appropriateness of patient care and the clinical performance of all individuals with delineated privileges encompassing all major clinical activities in the hospital on an ongoing basis. . . .
4. Included with these functions is the routine collection of information about important aspects of patient care provided through medical staff peer review/quality assurance activities.
5. The information collected during these various reviews shall be assessed to identify important problems in patient care. . . .
c. A physician will review all cases pulled for review (see Addendum of the Rural Health Network Agreement). . . ."

During interview on the morning of 11/02/11, a management staff member (#8) stated no peer review had occurred for Physician #1.