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Based on bylaws review, document review, and staff interview, the Critical Access Hospital's (CAH's) medical staff failed to recommend and the governing board failed to approve reappointment to the medical staff for 2 of 2 sampled consulting physicians (Physicians #1 and #2) providing services for the CAH. Failure to reappoint physicians to the medical staff limited the governing board's ability to ensure the CAH's patients received services from qualified practitioners.

Findings include:

Review of the "Bylaws Medical Staff Mountrail County Medical Center, Inc. [incorporated] Stanley, North Dakota" occurred on 06/17/19 at 2:15 p.m. These bylaws, adopted 11/20/13, stated,
". . . Article IV: Membership . . .
Section 5. Term of Appointment
a. Appointments to the Medical Staff shall be made by the Governing Board and shall be for a period of two years. . . .
Section 7. Credentialing from outside hospital . . .
The Medical Staff may accept credentialing information from any hospital or entity with whom it has contracted for such information . . ."

Review of the governing board's "Bylaws of Mountrail County Medical Center, Inc." occurred on 06/17/19 at 3:00 p.m. These bylaws, adopted 11/20/13, stated,
". . . Article 6 - Medical Staff . . .
6.2) Medical Staff Applications. . . . the board shall act on Medical Staff applications that have been approved by the Executive Committee. . . ."

Review of the "Rural Health Network Agreement" occurred on 06/18/19 at 7:50 a.m. This agreement, effective 08/22/07, stated, ". . . 6. Credentialing: 1.1 . . . [Name of network hospital] shall not have the right or responsibility for the initiation or denial of membership or clinical privileges at CAH to any Professional, which decision shall be the sole right and responsibility of the CAH. . . ."

Upon request on 06/18/19, the CAH failed to provide evidence the CAH's medical staff recommended and the governing body approved reappointment for Physicians #1 and #2 in the last two years.

During interview on 06/18/19 in the morning, an administrative staff member (#4) stated Physician #1 provided laboratory director services and Physician #2 provided radiology director services for the CAH.

During interview on 06/18/19 at 5:25 p.m., an administrative staff member (#2) confirmed the CAH's medical staff had not recommended and the governing board had not approved reappointment of Physicians #1 and #2.

Based on policy manual review and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel annually review the CAH's health care policies in 2018 for 2 of 11 policy manuals (Dietary and Central Supply Room) reviewed. Failure to have the required group of professional personnel annually review the policies limited the CAH's ability to ensure the policies were current and followed regulations and standards of practice.

Findings include:

Review of the policy "Quality Assurance Performance Improvement (QAPI)" occurred on 06/17/19. This policy, revised 2018, stated,
". . . Annual Review of Policy and Procedure Manuals
The Mountrail County Health Center . . . manuals will be reviewed and/or revised on an annual basis by the department manager, medical staff members, a nurse practioner [sic], administration, and governing boards. The Quality Risk Management Department will coordinate this."

Review of the CAH's policy manuals occurred on all days of the survey. The Dietary and Central Supply Room (CSR) policy manuals lacked evidence of annual review in 2018 by a physician and a physician assistant/nurse practitioner/clinical nurse specialist (required members of a group of professional personnel). Upon request on 06/18/19, the CAH failed to provide evidence of an annual policy review in 2018 for Dietary and CSR.

During interview at approximately 10:00 a.m. on 06/18/19, an administrative staff member (#3) confirmed the CAH did not have evidence of annual review of the Dietary policy manual in 2018.

During interview at approximately 2:30 p.m. on 06/18/19, a CSR staff member (#1) confirmed the CAH did not have evidence of annual review of the CSR policy manual in 2018.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications from 1 of 1 facility supply room (purchasing). Failure to remove outdated medications from the facility's supply room may result in patients receiving expired and ineffective medications.

Findings include:

Observation on 06/18/19 at 2:30 p.m. of the facility's purchasing department room showed 12 1,000 ml (milliliter) bags of 5% Dextrose (simple sugar) in LR (lactated ringers) IV (intravenous) solution expired 03/2019 and 11 bags that expired 05/2019.

During interview on 06/18/19 at 2:40 p.m., a central supply staff member (#1) stated pharmacy had failed to identify and notify central supply staff to replace the expired IV solutions.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON JANUARY 12, 2016.

Based on review of professional literature, policy and procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to assess and document the effectiveness of medications given to patients on an as needed (PRN) basis for 7 of 13 sampled patients' (Patients #2, #4, #6, #8, #9, #16 and #17) records reviewed that had received PRN medication. Failure to evaluate the patients' responses to PRN medications limited the nursing staff's ability to assess whether the medication achieved the desired effect or if the patients experienced any side effects or adverse reactions from the medication.

Findings include:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, 2012, page 862-870, states, ". . . Process of Administering Medications: When administering any drug . . . the nurse must do the following: . . . 6. Evaluate the client's response to the drug. . . . In all nursing activities, nurses need to be aware of the medications that a client is taking and record their effectiveness as assessed by the client and the nurse on the client's chart. . . . Skill 35-1 Administering Oral Medications: . . . Evaluation: Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate the effects of the medication on the client. Observe for desired effect . . ."

Review of the Hospital's policy titled "Assessment and Treatment of The Patient with Acute Pain" occurred on 06/18/19. This policy, revised January 2016, stated, ". . . The nurse will assess for the presence or absence of acute pain associated with the chief complaint as part of the initial assessment. An assessment will be repeated no more than 60 minutes after each intervention or more frequently depending on the patient's condition or the agent used. . . ." The policy failed to address assessment of other PRN medications administered.

Review of the following records occurred on 06/17/19-06/18/19.
- Patient #2's medication administration record (MAR) identified staff administered PRN Tylenol 1000 milligrams (mg) on 03/12/19 at 10:15 a.m. for upper back pain rated at 5. The follow-up assessment on the MAR identified the Tylenol was administered for a fever (no re-assessment for pain). The MAR identified the patient received PRN Ativan (anxiety medication) 1 mg times (x) 4 doses during the patient's stay. The record lacked an assessment for the effectiveness of each dose administered.
- Patient #4's MAR identified staff administered PRN Ondansetron (anti-nausea) 4 mg intravenously (IV) x 5 doses and Promethazine (anti-nausea) 25 mg IV x 6 doses. The record lacked an assessment for the effectiveness of each dose administered.
- Patient #6's MAR identified staff administered PRN Tylenol 325 mg on 03/19/19 at 2:43 p.m. with pain rated at 7. Follow-up assessment on the MAR on 03/19/19 at 3:43 p.m. failed to include the patient's pain rating. The MAR identified the patient received PRN cyclobenzaprine (muscle relaxant) 5 mg on 03/19/19 at 2:43 p.m. The record lacked an assessment for the effectiveness of the medication.
- Patient #8's MAR identified staff administered PRN Lorazepam (anti-anxiety) on 05/12/19 at 11:30 p.m. The record lacked an assessment for the effectiveness of the medication.
- Patient #9's MAR identified staff administered PRN Lorazepam 1 mg IV x 6 doses and PRN Zofran 4 mg IV x 6 doses. The record lacked an assessment for the effectiveness of each dose administered.
- Patient #16's MAR identified staff administered PRN zolpidem (to treat insomnia) 5 mg on 1/19/19 and 2.5 mg on 1/20/19. The record lacked an assessment for the effectiveness of each dose administered.
- Patient #17's MAR identified staff administered PRN Tylenol 650 mg on 03/15/19 and 03/16/19 and Lorazepam 2 mg IV on 3/16/19. The record lacked an assessment for the effectiveness of each dose administered.

During interview on 06/18/19 at 4:25 p.m., an administrative nurse (#2) confirmed staff assess the effectiveness of PRN pain medications given and no other PRN medications

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the diagnosis and treatment furnished for 3 of 4 physicians (Providers #3, #4, and #5) who provided patient treatment at the CAH in 2018. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment provided by physicians limited the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the policy "Medical Review Criteria Quality Assurance Study" occurred on 06/18/19. This policy, dated 08/2007, failed to require evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH by a network hospital or QIO or equivalent for all physicians.

Reviewed on 06/18/19, the 2018 medical staff peer review records failed to include evidence a network hospital or a QIO or equivalent evaluated the quality and appropriateness of the diagnosis and treatment furnished by Providers #3, #4, and #5.

During interview on 06/18/19 at 1:05 p.m., an administrative nursing staff member (#2) confirmed the CAH had not sent records to a network hospital or QIO or equivalent to evaluate the quality and appropriateness of the diagnosis and treatment furnished by three physicians in 2018.