HospitalInspections.org

Based on review of provider files and staff interview, the Critical Access Hospital (CAH) failed to confirm the notification/disclosure of the name and address of the person responsible for medical direction to the State agency for 3 of 3 days of survey (April 12-14, 2016).

Findings include:

Based on the review of the North Dakota Department of Health, Division of Health Facilities provider files, the CAH failed to notify the department of a change in the medical director.

On the afternoon of 04/13/16, a supervisory staff person (#6) stated the CAH lacked documentation to indicate notification of the state agency upon change in the medical director.

On the afternoon of 04/14/16, a quality assurance staff member (#5) stated the CAH's current medical director assumed the position/duties on September 1, 2013.

Based on record review, review of facility policy, 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 1 of 1 active patient (Patient #1) record reviewed and 6 of 8 closed patient (#11, #13, #14, #16, #17, and #18) records reviewed. 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:

Review of the policy "Medication Administration" occurred on 04/14/16. The policy, dated 07/24/15, stated, "Procedure: . . . 9. Pro Re Nata (PRN) medications administered will be qualified by designating the times of administration, the reason for the medication; response to medication will be documented in the chart notes by the administrator of the medication. . . ."

- Patient #11's closed record, reviewed on 04/12/16, identified staff administered the following PRN medications on 11/08/15:
* lorazepam (an antianxiety) at 3:30 a.m.
* Fentanyl (an opioid analgesic) at 12:16 p.m.
The record failed to identify the reason staff administered the lorazepam and lacked evidence staff assessed the patient's response to the medications.

- Patient #13's closed record, reviewed on 04/13/16, identified staff administered Morphine (an opioid analgesic) on 03/25/16 at 5:19 a.m., 3:26 p.m., and 8:56 p.m. and failed to assess the patient's response to the medication.

- Patient #14's closed record, reviewed on 04/13/16, identified staff administered acetaminophen (an analgesic) on 10/14/15 at 7:29 p.m. and failed to assess the patient's response to the medication.

- Patient #16's closed record, reviewed on 04/13/16, identified staff administered the following PRN medications:
* ibuprofen (an analgesic) on 11/10/15 at 8:15 a.m.; 11/11/15 at 2:41 a.m. and 9:56 p.m.; and on 11/12/15 at 10:02 p.m.
* alprazolam (an antianxiety) on 11/12/15 at 10:02 p.m. and on 11/13/15 at 9:14 a.m.
The record lacked evidence staff assessed the patient's response to the medications and failed to identify the reason staff administered the alprazolam.

- A second closed record for Patient #16, reviewed on 04/14/16, identified staff administered the following PRN medications:
* acetaminophen on 11/13/15 at 9:44 p.m.; 11/15/15 at 9:00 p.m.; and on 11/17/15 at 6:32 p.m.
* ibuprofen on 11/14/15 at 12:59 a.m.
The record lacked evidence staff assessed the patient's response to the medications and failed to identify the reason staff administered the medications.

- Patient #17's closed record, reviewed on 04/14/16, identified staff administered oxycodone (an opioid analgesic) on 11/15/15 at 3:21 a.m. and failed to assess the patient's response to the medication.

- Patient #18's closed record, reviewed on 04/14/16, identified staff administered the following PRN medications:
* atropine (to dry secretions) on 11/26/15 at 9:33 a.m. and 4:08 p.m.
* lorazepam on 11/25/15 at 3:27 p.m.; 11/27/15 at 8:35 a.m., 1:23 p.m., and 4:40 p.m.; and 11/28/15 at 9:31 a.m., 1:27 p.m., and 4:32 p.m.
The record lacked evidence staff assessed the patient's response to the medications.

During an interview on 04/13/16 at 7:40 a.m., an administrative nurse (#1) stated staff documented the response in the nurse's notes or other sections of the record.



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- Patient #1's active record, reviewed on 04/14/16, identified staff administered the following PRN medications during the month of April:
* acetaminophen on 04/02/16 at 1:00 a.m., 04/03/16 at 1:30 a.m., 04/04/16 at 12:57 a.m., 04/07/16 at 12:40 a.m., 04/08/16 at 12:11 a.m., 04/10/16 at 12:08 a.m., 04/12/16 at 12:01 a.m., and on 04/13/16 at 12:09 a.m.
* trazodone (an antidepressant used for sleep) on 04/02/16 at 1:00 a.m., 04/03/16 at 1:30 a.m., 04/04/16 at 12:57 a.m., 04/07/16 at 12:40 a.m., 04/08/16 at 12:11 a.m., 04/10/16 at 12:08 a.m., 04/12/16 at 12:01 a.m., and on 04/13/16 at 12:10 a.m.
The record lacked evidence staff assessed the patient's response to the medications and failed to identify the reason staff administered the medications.

During an interview on 04/14/16 at 10:00 a.m., an administrative nurse (#6) stated he expected staff to assess the effectiveness of PRN medications no more than one hour after administration and to document the results in the nurse's notes.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all drugs, biologicals, and intravenous medications were administered by or under the supervision of a registered nurse for 1 of 1 patient (Patient #3) observed receiving medications from a paramedic. This failure limited the CAH's ability to ensure staff prepared and administered medications safely, accurately, and within their scope of practice.

Findings include:

Observation on 04/12/16 at 3:45 p.m. identified a paramedic (#8) dispensed a Wellbutrin (an antidepressant) tablet from the medication cart located at the nurse's station, administered the medication to Patient #3, and signed off the medication as given on the electronic medication administration record.

During an interview on the afternoon of 04/12/16, a nurse (#7) stated the paramedic (#8) worked on the nursing unit when needed and answered call lights, assisted patients, and administered medications.

During an interview on the morning of 04/14/16, an administrative nurse (#6) stated the paramedic (#8) worked on the nursing unit as needed for approximately the past two and a half years. On this same afternoon, the nurse (#6) stated the paramedic accessed the Omnicell (an automated medication dispensing system) and administered all routes of medications, except intramuscular.