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Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure the nursing staff documented the shortened expiration date for 7 of 7 Stanley Healthcare Sensormat Pads located in the Medical/Surgical unit. Failure to document the shortened expiration date on the pads could potentially result in the nursing staff utilizing a Sensormat Pad after the manufacturer guaranteed the pad would function as expected, potentially resulting in the Sensormat Pad failing to notify the nursing staff a patient got out of a chair, and the patient potentially sustaining a fractured hip or a life-threatening injury. The CAH administrative staff reported a census of 9 inpatients on entrance to the facility and an average daily census of 11 patients per day.

Findings include:

1. Observations on 01/27/2020 at 09:00 AM, during a tour of the Medical/Surgical Unit, revealed 7 of 7 Stanley Healthcare Chair Sensormat Pads (pads that sense patient movement off a chair, triggering an audible alarm) and the Pad transmitters (the device connected to the pad to enable the pads to activate the alarm) lacked documentation of the shortened expiration date (180 days from the first day of use by the nursing staff).

2. Review of the manufacturer's recommendations for the Stanley Healthcare Chair Sensormat Pads revealed in part, "On first use, record the expiry date (180 days from [the first use] date) on the [pad] ...."

3. During an interview on 1/27/2020 at the time of the tour, the Chief Nursing Officer verified the nursing staff failed to document the shortened expiration date 180 days after the nursing staff first used the Sensormat Pad.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure timely physician notification for the occurrence of a medication error for 6 of 13 medication errors reviewed (Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5). Failure to notify the physician of medication errors could potentially result in the provider not knowing about the medication error and either failing to take steps to address the consequences of the medication error, or the provider making a medical decision without the knowledge of the medication error, either way potentially resulting in inappropriate treatment or even a fatal reaction. The CAH administrative staff reported a census of 9 patients on entrance to the facility and an average daily census of 11 patients per day.

Findings include:

1. Review of the policy "Medication Errors," revised 10/2019, revealed in part, "Documentation of the error ... including notification to the practitioner, must be in the patient's medical record, including notification time and interventions ...."

2. Review of medication errors from January 2019 through December 2019 revealed:

a. The nursing staff administered Patient #1 the wrong medication on 11/12/19 at 08:12 PM. Patient #1's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #1's medical care of the medication error.

b. The nursing staff administered Patient #2 the wrong dose of medication on 10/03/19 at 08:14 PM. Patient #2's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #2's medical care of the medication error.

c. The nursing staff administered Patient #3 the wrong medication on 09/17/19 at 09:30 PM. Patient #3's medication error paperwork lacked documentation of the date and time nursing staff notified the practitioner responsible for Patient #3's medical care of the medication error.

d. The nursing staff administered Patient #4's intravenous antibiotic too rapidly on 09/04/19 at 11:00 PM. Patient #4's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #4's medical care of the medication error.

e. The nursing staff administered Patient #5 the wrong dose of medication on 08/08/19 at 08:58 PM. Patient #5's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #5's medical care of the medication error.

f. The nursing staff failed to administer Patient #3's medication on 01/20/19 at 05:36 PM. Patient #5's medication error paperwork lacked documentation the nursing staff notified the practitioner responsible for Patient #5's medical care of the medication error.

3. During an interview on 01/28/19 at 4:30 PM, the Director of Organizational Performance acknowledged the medication error paperwork for Patient #1, Patient #2, Patient #3, Patient #4, and Patient #5 lacked documentation the nursing staff notified the patient's physician of the medication error or lacked documentation of the date/time the nursing staff notified the patient's physician of the medication error.