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Based on bylaws review, agreements review, and staff interview, the governing body failed to ensure appointment/reappointment to the Critical Access Hospital's (CAH's) medical staff for 3 of 3 telemedicine entities (Entities #1, #2, and #3). Failure to appoint/reappoint physicians to the medical staff providing telemedicine services to the CAH's patients places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the "Medical Staff Bylaws" occurred on 01/05/16 at 1:40 p.m. These bylaws, adopted 03/21/13, stated, ". . .
Article V. Divisions of the Medical Staff
Section 6. Telemedicine Staff
a. . . . Individuals providing telemedicine services from a 'distant site' must be appointed to the Telemedicine Staff . . . Telemedicine Services which require telemedicine privileges at the hospital may be processed by the hospital's credentialing committee or by using the following method: Credential and grant privileges to the practitioner using a written agreement . . . utilizing credentialing and privileging information from the telemedicine provider or practitioner's primary hospital/group or from a credentialing verification organization . . . Telemedicine privileges shall be for a period of not more than two years. . . . All telemedicine providers and practitioners will be categorized as 'telemedicine staff' . . ."

Review of the governing board's "Bylaws of Mountrail County Medical Center, Inc. [Incorporated]" occurred on 01/05/16 at 2:20 p.m. These bylaws, adopted 11/20/13, stated,
". . . Article 6 - Medical Staff
6.1) Organization and Responsibility. The Board of Directors shall establish a medical staff, which shall be organized and governed pursuant to bylaws, rules and regulations adopted by the medical staff and approved by the directors. . . .
6.2) Medical Staff Applications. . . . the Board shall act on Medical staff applications that have been approved by the Executive Committee. . . ."

Review of the CAH's telemedicine agreements occurred on 01/06/16 at 8:25 a.m.
*Telemedicine Entity #1 - "Radiology Interpretation Services Agreement," dated 01/01/12, stated, "[name of entity] hereby agrees to provide imaging interpretative services (Services) to Mountrail County Health Center (Referring Facility) to begin 01-01-2012. . . . The parties agree and acknowledge that Referring Facility has chosen to rely on [name of entity's] credentialing and privileging decisions for purposes of Referring Facility's medical staff determining whether or not to issue privileges to [name of entity] Physician. . . ."
*Telemedicine Entity #2 - "Electro Cardiogram (EKG) Interpretation Services Agreement," dated 02/11/13, stated, "[name of entity] hereby agrees to provide (EKG) interpretative services (Services) to _[sic]Mountrail County Health Center (Referring Facility) to begin 3/4/2013. . . . The parties agree and acknowledge that Referring Facility has chosen to rely on [name of entity's] credentialing and privileging decisions for purposes of Referring Facility's medical staff determining whether or not to issue privileges to [name of entity] Physician. . . ."
*Telemedicine Entity #3 - "Agreement For Credentialing and Privileging of [name of entity] Telemedicine Practitioners," dated 02/18/13, stated, "This Agreement for Credentialing and Privileging of [name of entity] Telemedicine Practitioners ('Agreement') is made this 18th day of February, 2013 between [name of entity] . . . ('Distant Site') and Mountrail County Medical Center . . . ('Hospital'). . . . 2. . . . Distant Site and Hospital agree to use the credentialing and privileging policies and protocols of Distant Site so Hospital can grant telemedicine privileges to Distant Site's [name of entity] Telemedicine Practioners [sic] who will be providing telemedicine services to Hospital's patients through the use of this Agreement. . . ."

Upon request on 01/06/16, the CAH failed to provide evidence the CAH's medical staff recommended and the governing body approved the following:

* Appointment for physicians from Telemedicine Entity #1 in 2012.
* Appointment for physicians from Telemedicine Entity #2 in 2013.
* Reappointment for physicians from Telemedicine Entity #3 in 2015.

During an interview on 01/06/16 at 10:45 a.m., an administrative staff member (#1) confirmed Telemedicine Entity #1 physicians provided radiology interpretation and Telemedicine Entity #2 physicians provided electrocardiogram interpretation to the CAH's patients. This staff member (#1) confirmed the CAH's medical staff had not recommended and the governing body had not approved appointment of the physicians from Telemedicine Entities #1 and #2.

During an interview on 01/06/16 at 4:15 p.m., an administrative staff member (#1) confirmed Telemedicine Entity #3 physicians provided emergency services through telemedicine to the CAH's patients. This staff member (#1) confirmed the CAH's medical staff had not recommended and the governing body had not approved reappointment of the physicians from Telemedicine Entity #3 in 2015.

Based on record review, review of a professional reference, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure nursing staff documented the patient's assessment prior to administration of as needed (PRN) medications and/or the patient's reassessment after administration of PRN medications for 6 of 20 patient records (Patient #6, #7, #8, #9, #15, and #16) reviewed. Failure to document a patient's assessment and/or reassessment limited the nursing staff's ability to determine whether the medication achieved the desired effect in a sufficient time frame.

Findings include:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, page 870, stated, ". . . 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. . . ."

Review of the CAH's policy and procedure titled "Pain Management" occurred on 01/06/16. This policy, revised April 2010, stated, ". . . 1. Each client will have a pain assessment completed . . . c. At 1/2 and 2 hours after pain medication given. d. If any new report of pain. 2. Assessment includes: a. Location b. Quality c. Intensity . . . Assess pain systematically - using appropriate 0-10 [0 equals no pain; 10 equals worst pain] pain scale . . . Document response to interventions."

The following patient records, reviewed January 5-7, 2016, failed to include an assessment prior to administering PRN medications and/or a reassessment after administering PRN medications:
* Patient #6 from 07/30/15 to 08/28/15 - Clonazepam (anti-anxiety) administered 30 times, oxycodone (pain) administered 13 times, Norco (pain) administered 2 times, and Percocet (pain) administered 3 times.
* Patient #7 from 07/07/15 to 07/24/15 - Oxycodone administered 38 times and diazepam (anti-anxiety) administered 1 time.
* Patient #8 from 11/10/15 to 12/06/15 - Dilaudid (pain) administered 5 times and lorazepam (anti-anxiety) administered 1 time.
* Patient #9 from 10/28/15 to 11/16/15 - Tramadol (pain) administered 8 times.
* Patient #15 from 09/30/15 to 10/01/15 - Morphine (pain) administered 2 times.
* Patient #16 from 08/17/15 to 08/20/15 - Morphine (pain) administered 11 times and oxycodone administered 4 times.

During an interview on 01/06/16 at 4:35 p.m., an administrative nurse (#1) indicated nurses should complete a patient reassessment within one hour after administering PRN medications. The nurse also verified the policy stated at 1/2 and 2 hours.


22495

Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to complete consent forms and transfer authorization forms for 2 of 20 patient records (Patient #12 and #17) reviewed. Failure to complete all legal forms and obtain consents for procedures limits the CAH's ability to provide a clear account of the patient's activity while a patient at the CAH and places patients at risk of receiving unwanted treatment.

Findings include:

Review of the policy "PATIENT TRANSFER AUTHORIZATION" occurred on 01/07/16. This policy, revised in 2006, stated, "PURPOSE: To assure and [sic] orderly transfer of a patient to another facility in accordance with federal law. . . . The transferring nurse will check the transfer form to ensure that is is complete. . . ."

Kozier & Erb's "Fundamentals of Nursing, Concepts, Process, and Practice", 9th ed., Pearson Education, Inc., New Jersey, pages 59-62 stated, "Informed consent is an agreement by a client to accept a course of treatment or a procedure after being provided complete information, including the benefits and risks of treatment . . . Three groups of people cannot provide consent. . . . persons who are unconscious or injured in such a way that they are unable to give consent. In these situations, consent is usually obtained from the closest adult relative . . . Often the nurse is asked to obtain a signed consent form. . . . The nurse's signature confirms three things: *The client gave consent voluntarily. *The signature is authentic. *The client appears competent to give consent. . . ."

- Review of Patient #12's medical record occurred on all days of survey and identified an admission date of 10/17/15. The CAH transferred the patient to another facility on 10/18/15. The CAH failed to complete "SECTION II - MEDICAL NECESSITY QUESTIONNAIRE" of the "CERTIFICATE OF TRANSFER" form.

Review of Patient #12's "CT [computed tomography] SCREENING FORM" showed CAH personnel failed to complete the form and obtain consent from the patient or the closest adult relative.

- Review of Patient #17's medical record occurred on all days of survey and identified an admission date of 08/15/15. The CAH transferred the patient to another facility on 08/18/15. The CAH failed to complete "SECTION II - MEDICAL NECESSITY QUESTIONNAIRE" of the "CERTIFICATE OF TRANSFER" form.

During an interview on the morning of 01/07/16, an administrative nurse (#1) stated CAH staff should complete all transfer and consent forms completely.

32641

Based on record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure complete documentation for 3 of 15 closed inpatient records (Patients #8, #12, and #20) reviewed with no discharge summary. Failure of the provider to include a discharge summary in the medical record does not provide a summary of the patient's CAH stay.

Findings include:

Review of the policy and procedure entitled "Discharge Summary" occurred on 01/06/16. This undated policy stated, ". . . A discharge summary shall be dictated for all patients staying more than 48 hours . . . The discharge summary shall be dictated within 30 days. . . ."

Review of medical records occurred on all days of survey and lacked the following:
* Patient #8 - Admitted 11/10/15 and discharged 12/6/15. No discharge summary.
* Patient #12 - Admitted 10/17/15 and transferred to another facility 10/18/15. No discharge summary.
* Patient #20 - Admitted 07/26/15 and transferred to another facility 04/28/15. No discharge summary.

During an interview on 01/06/16 at 4:35 p.m., an administrative nurse (#1) verified a provider should dictate a discharge summary within 30 days of the patient's discharge.

Based on policy review, meeting minutes review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Assurance (QA) program evaluated all patient care services and other services affecting patient health and safety for 12 of 12 months reviewed (October 2014-September 2015). Failure to ensure departments report quality of patient care monitoring to the QA Committee as scheduled limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the policy titled "Quality Assurance Program" occurred on 01/05/16. This policy, revised in 2012, stated,
"Purpose: To implement a quality assurance program designed to monitor, evaluate, maintain and/or improve the quality and appropriateness of patient/resident care within available resources.
. . .
Scope: The Quality Assurance Program shall be facility wide, apply to all departments, services and practitioners whose activities within the facility have direct influence on the quality of patient/resident care. . . . Each department representative will be responsible for reporting to the Quality Assurance Committee on a quarterly basis. The following services will participate in quality assurance activities. All department representatives shall submit quarterly reports. . . . i. Medical Records . . .
Authority and Responsibilities: . . . As specified in the plan, each clinical discipline and service will participate in the review of the patient/resident care it provides. . . ."

Reviewed on January 5-6, 2016, the 2015 Quality Assurance Quarterly Meeting minutes indicated the medical records department did not submit reports in July and November for the timeframe of April 2015-September 2015.

Reviewed on January 5-6, 2016, the October 2014-September 2015 QA records indicated the medical records department did not report monitoring regarding the quality of patient care from October 2014-March 2015 and lacked evidence of reporting monitors from April 2015-September 2015.

During interview on 01/06/16 at 4:15 p.m., an administrative staff member (#1) confirmed the medical records department had failed to submit monitoring reports to the QA Committee the past two quarters and reports related to quality of patient care the previous two quarters.