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Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure CAH staff documented the provision of the CAH's advance directive information to each patient for 20 of 20 patients' records reviewed (Patients #1-#20). Failure to document in the patients' records the provision of advance directive information limited the CAH's ability to ensure patients were aware of the CAH's advance directive policies and their right to make decisions regarding their care.

Findings include:

Review of the policy "Advance Directives" occurred on 10/31/18. This policy, revised 11/2015, stated, ". . . Each patient or their immediate family will be provided with information regarding Advance Directives and the patient's right to make decisions concerning his/her medical care. . . ." The policy did not require CAH staff to document the provision of the information in the patients' records.

Reviewed October 29-31, 2018 the records for Patients #1-#20 failed to include evidence the CAH staff provided the patients with the CAH's advance directive information.

During interview in the afternoon of 10/30/18, an administrative nurse (#1) stated the CAH did not require staff to document the provision of the CAH's advance directive information in the patients' records.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure dietary services provided in accordance with recognized dietary practices regarding warewashing, cooling and reheating of foods, and sanitary practices in 1 of 1 kitchen. Failure to follow sanitary practices in the kitchen placed patients and staff at risk of contracting a food borne illness.

Findings include:

Review of the facility policy titled "Sanitation Methods" occurred on 10/30/18. This policy, updated November 2013, stated, ". . . Cool cooked foods quickly, uncovered. Refrigerate immediately, keep refrigerated . . . Employee should be responsible for having a clean and orderly work area. . . ."

Review of the facility policy titled "Sanitary Food Handling" occurred on 10/30/18. This policy, updated November 2013, stated, ". . . Thaw frozen foods in the refrigerator, cooler, or cold water . . . Leftover cooked foods must be cooled rapidly to 45 degrees Fahrenheit or lower and stored covered in the refrigerator. . . ."

Observation on 10/29/18 at 11:00 a.m. of the facility's main kitchen with the dietary manager (DM) (#2) showed the following:
* A cloth covered plate warmer located on the kitchen counter showed stains and debris on the cover
* An open package of Styrofoam cups for patient use stored on a shelf above the janitor's closet floor sink
* A frozen container of soup containing beef placed on a tray to thaw located on a shelf above the stove

During the observation, the DM (#2) stated staff had not laundered the cloth plate warmer since acquired and had not placed the warmer on a cleaning schedule; the kitchen had no schedule for cleaning the kitchen areas; staff restocked the inpatient unit's kitchenette with the Styrofoam cups stored in the kitchen's janitor closet which nursing staff used for patient in-room water containers; and staff failed to properly thaw the frozen soup per posted procedure.

Further interviews on the mornings of 10/29/18 and 10/31/18, the DM (#2) indicated the kitchen staff had no system in place for monitoring the temperatures in the dishmachine. On the afternoon of 10/30/18, the DM (#2) received a communication from the representative of the company that serviced the dishmachine and supplied the sanitizer who indicated for the dishmachine to properly sanitize with the chlorine, the temperature should be at least 120 degrees Fahrenheit (F) but no greater than 165 degrees F with the ideal range at 160 degrees F.

On the morning of 10/31/18 when asked for policies regarding warewashing equipment temperatures and kitchen cleaning schedules, the DM (#2) stated the facility had no policies for these areas.

Based on professional reference review, policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to assess the effectiveness of medications given to patients on an as needed (PRN) basis within the expected timeframe for 8 of 16 patient records reviewed (Patients #6, #9, #10, #13, #17, #18, #19, and #20) who received PRN medications. Failure to evaluate the patients' responses to PRN medications within the expected timeframe limited the nursing staffs' ability to assess whether the medications achieved the desired effect.

Findings include:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 10th ed., Pearson Education, Inc., New Jersey, pages 771-778, stated, ". . . Process of Administering Medications: When administering any drug, regardless of the route of administration, the nurse must do the following: . . . 6. Evaluate the client's response to the drug. . . . Skill 35-1 . . . 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. . . ."

Review of the CAH's policy titled "PRN Management" occurred on 10/31/18. This policy, dated 01/2005, failed to include the timeframe staff should assess the effectiveness of PRN medications after administration.

Reviewed October 29-31, 2018 the following records indicated CAH staff failed to assess the efficacy of PRN medications within the expected 30-60 minutes after administration:
- Patient #6 received Zofran on 06/13/18 at 7:59 a.m. Staff completed a follow-up assessment at 10:13 a.m. (2 hours and 14 minutes later).
- Patient #9 received Tylenol on 08/23/18 at 8:20 p.m. Staff completed a follow-up assessment at 10:13 p.m. (1 hour and 53 minutes later). Patient #9 received Tylenol on 08/24/18 at 9:30 a.m. Staff completed a follow-up assessment at 11:44 a.m. (2 hours and 14 minutes later).
- Patient #10 received Morphine on 08/29/18 at 2:15 a.m. Staff completed a follow-up assessment at 3:45 a.m. (1 hour and 30 minutes later). Patient #10 received Morphine on 08/30/18 at 3:15 p.m. Staff completed a follow-up assessment at 5:11 p.m. (1 hour and 58 minutes later).
- Patient #13 received Norco on 09/15/18 at 5:51 p.m. Staff completed a follow-up assessment at 7:43 p.m. (1 hour and 52 minutes later). Patient #13 received Norco on 09/16/18 at 2:10 a.m. Staff completed a follow-up assessment at 4:23 a.m. (2 hours and 13 minutes later). Patient #13 received Dilaudid on 09/17/18 at 12:55 a.m. Staff completed a follow-up assessment at 2:45 a.m. (1 hour and 50 minutes later).
- Patient #17 received Norco on 06/21/18 at 8:47 p.m. Staff completed a follow-up assessment at 10:16 p.m. (1 hour and 29 minutes later). Patient #17 received Norco on 06/21/18 at 3:48 p.m. Staff completed a follow-up assessment at 5:46 p.m. (1 hour and 58 minutes later).
- Patient #18 received Neurontin on 07/06/18 at 9:49 p.m. Staff completed a follow-up assessment at 11:30 p.m. (1 hour and 41 minutes later). Patient #18 received Zofran on 07/05/18 at 7:00 p.m. Staff completed a follow-up assessment at 9:30 p.m. (2 hours and 30 minutes later).
- Patient #19 received Dilaudid on 07/09/18 at 2:59 p.m. Staff completed a follow-up assessment at 4:29 p.m. (2 hours later).
- Patient #20 received Norco on 07/30/18 at 8:18 p.m. Staff completed a follow-up assessment on 07/31/18 at 12:24 a.m. (4 hours and 6 minutes later). Patient #20 received Norco on 08/01/18 at 2:26 a.m. Staff completed a follow-up assessment at 3:58 a.m. (1 hours and 32 minutes later).

During interview on 10/30/18 at 2:00 p.m., an administrative nurse (#1) stated she would expect staff to assess the effectiveness of PRN medications within 30-60 minutes of administration.









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Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff developed nursing care plans to address the needs of the patients for 6 of 20 records reviewed (Patients #6, #7, #9, #11, #13, and #20). Failure to address the needs of the patients on nursing 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.

Findings include:

Review of policy titled, "Care Plans and the Nursing Process" occurred on 10/30/18. This policy, revised 04/2013, stated, "Policy: The nursing process, including assessment, planning, intervention, and evaluation, will be documented for each hospitalized patient from admission through discharge. . . . The Nursing Care Plan will be completed for patients admitted to ER [emergency room], observation, inpatient, or swingbed. . . . The careplans will be reviewed on the night shift and any changes will be addressed. The plan will include nursing measures that will restore, maintain, or promote the patient's well being. These measures should include: Physiological, Psychosocial, Environmental, Patient/family education, Patient discharge plan. . . . Nursing care plans will be revised as needs of the patient change. . . ."

Patient record review occurred October 29-31, 2018 and indicated the following:
- Patient #6 had diagnoses of hematuria, flank pain, atrial fibrillation, and diabetes mellitus during hospitalization from June 12-14, 2018. The nursing care plan failed to address these diagnoses.
- Patient #7 had diagnoses of confusion, uncontrolled blood glucose, and possible urinary tract infection during hospitalization from June 12-14, 2018. The record failed to include a nursing care plan.
- Patient #9 had diagnoses of pneumonia, hypotension, and Alzheimer's disease during hospitalization from August 22-24, 2018. The record failed to include a nursing care plan.
- Patient #11 had diagnoses of pneumonia, pleural effusion, hypertension, generalized weakness, and diabetes mellitus during hospitalization from September 3-6, 2018. The nursing care plan failed to address these diagnoses.
- Patient #13 had diagnoses of acute pancreatitis, gastroesophageal reflux, and chronic headaches during hospitalization from September 14-17, 2018. The record failed to include a nursing care plan.
- Patient #20 had diagnoses of pulmonary embolus to the right lower lung, possible pneumonia, and hypertension during hospitalization from July 28-August 1, 2018. The nursing care plan failed to address these diagnoses.

During interviews on 10/30/18 at 4:00 p.m. and 10/31/18 at 10:00 a.m., an administrative nurse (#1) confirmed the above listed records failed to include evidence staff completed care plans and addressed the patients' diagnoses on the care plans.














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