HospitalInspections.org

Based on review of information provided to patients on admission, record review, and staff interview, the Critical Access Hospital (CAH) failed to provide admitted patients written information concerning advance directives and notice regarding the on-site presence of a doctor of medicine or osteopathy for 15 of 15 inpatient (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #15, #17 and #18) records reviewed. Failure to provide this information limited the patients' ability to make informed decisions regarding medical treatment.

Findings include:

Review of information provided to patients at the time of admission occurred on 03/02/16. The information failed to include evidence the CAH provided inpatients with written information regarding advance directives including notice of the CAH's advance directive policies and of no doctor of medicine or osteopathy present in the CAH 24 hours per day, seven days per week. Review of Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #15, #17, and #18's inpatient medical records occurred on all days of survey. The records failed to include evidence of the above information.

During an interview on 03/02/16 at 2:30 p.m., an administrative nurse (#1) confirmed the CAH failed to provide written notice of advance directive information/policies to the patient and the lack of on-site presence of a doctor of medicine or osteopathy 24 hours a day, seven days a week.

APPOINTMENT TO MEDICAL STAFF

1. Based on bylaws review, staff interview, and record review, the Critical Access Hospital's (CAH's) governing board failed to ensure appointment to the medical staff for 6 of 7 physicians (Physicians #1, #2, #3, #4, #5, and #6) providing electrocardiogram (EKG) interpretation services through telemedicine and for 1 of 2 locum tenens practitioner's record reviewed (Provider #9) providing emergency department treatment/services. Failure to appoint practitioners to the medical staff providing treatment/services places the CAH's patients at risk of receiving treatment/services from unqualified practitioners.

Findings include:

Review of the "Bylaws of the Medical Staff of Garrison Memorial Hospital Garrison, North Dakota" occurred on 02/29/16 at 10:40 a.m. These bylaws, adopted 09/16/08, stated, ". . . Article Three Membership
Section 3.1 Nature of Medical Staff Membership: Membership on the staff of Garrison Memorial Hospital is a privilege which shall be extended only to those licensed under Chapter 43-17, Chapter 43-28, or Chapter 43-12.1, N.D.C.C. [North Dakota Century Code], and who continuously meet the qualifications, standards, and requirements set forth by these bylaws. . . ."
These bylaws did not require medical staff appointment for practitioners providing services to the CAH's patients through telemedicine.

Review of the governing board's "Amended and Restated Bylaws of Garrison Memorial Hospital" occurred on 02/29/16 at 1:35 p.m. These bylaws, effective 10/01/14, stated,
". . . Article IX Medical Staff
Section 9.2 Applications and Appointments. The Board of Directors shall consider recommendations of the Medical Staff and appoint to medical staff membership and/or grant privileges to such Practitioners who meet the qualifications set forth in the Medical Staff Bylaws, Rules and Regulations and related documents. . . .
Section 9.3 Patient Care Responsibilities. Each Practitioner shall have appropriate authority and responsibility for the care of his or her patients, subject to the scope of his or her licensure and clinical privileges, as delineated by the Board of Directors . . ."

During an interview on 02/29/16 at 4:20 p.m., an administrative radiology staff member (#5) confirmed [Name of Entity] physicians provided EKG interpretation for the CAH's patients. During an interview on 03/01/16 at 2:15 p.m., an administrative radiology staff member (#5) confirmed the CAH transmitted EKG results to [Name of Entity] electronically for interpretation and provided a list of physicians from [Name of Entity] who provided EKG interpretation for the CAH's patients.

Upon request on 03/02/16, the CAH failed to provide evidence the CAH's medical staff recommended and the governing body approved appointment/privileges for the following physicians providing EKG interpretation through telemedicine for the CAH's patients: Physicians #1, #2, #3, #4, #5, and #6.

During an interview on 03/02/16 at 1:15 p.m., an assistant administrative staff member (#6) responsible for credentialing confirmed the CAH's medical staff had not recommended and the governing body had not approved appointment of Physicians #1, #2, #3, #4, #5, and #6.

Reviewed on 03/01/16 the providers' call schedule from November 2015 - February 2016 listed Physician #9 on call from December 24, 2015 through January 3, 2016.

Reviewed on 03/01/16 the emergency department patient logbook indicated Physician #9 treated patients from December 24, 2015 through January 3, 2016.

Reviewed on 03/02/16, Physician #9's credentialing file lacked evidence of appointment from December 24, 2015 through January 3, 2016.

During an interview on 03/02/16 at 1:15 p.m., an assistant administrative staff member (#6) responsible for credentialing confirmed the CAH's medical staff had not recommended and the governing body had not approved appointment of Physician #9 for the period of December 24, 2015 through January 3, 2016.


APPROVAL OF CLINICAL PRIVILEGES

2. Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure the medical staff recommended and the governing board approved the specific clinical privileges for appointment/reappointment of 2 of 4 physician's assistant/nurse practitioners' credentialing files reviewed (Providers #7 and #8). Failure to ensure the approval of specific clinical privileges for appointments/reappointments places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the "Bylaws of the Medical Staff of Garrison Memorial Hospital Garrison, North Dakota" occurred on 02/29/16 at 10:40 a.m. These bylaws, adopted 09/16/08, stated,
". . . Article Three Membership
Section 3.3 Conditions and Duration of Appointment: . . .
f. Appointment to the medical staff shall confer on the appointee only such clinical privileges as have been granted by the board of directors, in accordance with these bylaws. . . .
Article Five Procedure for Appointment and Reappraisal/reappointment . . .
Section 5.4 Licensed Health Practitioners [physician assistants and nurse practitioners] . . .
4. Application and Designation of Licensed Health Practitioners: . . .
g. . . . The recommendation for the licensed health practitioner must specifically state the recommendations for delineating the licensed health practitioner's functions to be performed and any limitation thereon. . . .
5. Reappointment . . . of licensed health practitioners:
a. The executive committee shall periodically, at least biennially, review the licensed health practitioner's performance and submit its recommendation thereof in writing to the administrator. . . .
c. The administrator shall make the final decision of any further performance of designated functions by a licensed health practitioner based on the recommendations of the medical staff . . ."

Review of the governing board's "Amended and Restated Bylaws of Garrison Memorial Hospital" occurred on 02/29/16 at 1:35 p.m. These bylaws, effective 10/01/14, stated,
". . . Article IX Medical Staff
Section 9.2 Applications and Appointments. The Board of Directors shall consider recommendations of the Medical Staff and appoint to medical staff membership and/or grant privileges to such Practitioners who meet the qualifications set forth in the Medical Staff Bylaws, Rules and Regulations and related documents. . . ."

Reviewed on March 2-3, 2016, the following providers' credential files lacked evidence the medical staff recommended and the governing board approved specific clinical privileges for appointment/reappointment:
- Provider #7 appointed on 01/25/16
- Provider #8 reappointed on 01/25/16.

During an interview on 03/02/16 at 1:15 p.m., an assistant administrative staff member (#6) responsible for credentialing confirmed the CAH's medical staff had failed to recommend and the governing board had failed to approve specific clinical privileges for Providers #7 and #8.


TEMPORARY/LOCUM TENENS PRIVILEGES

3. Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing body failed to ensure the granting of temporary/locum tenens privileges followed the medical staff bylaws for 1 of 2 consulting physician's (Physician #10) and 1 of 2 locum tenens practitioner's (Provider #11) records reviewed. Failure to ensure the granting of temporary/locum tenens privileges follows the medical staff bylaws places the CAH's patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the "Medical Staff Bylaws" occurred on 07/14/15 at 2:40 p.m. These bylaws, adopted 04/12/13, stated,
". . . Article Six Clinical Privileges and Functions . . .
Section 6.2 Temporary Privileges
a. . . . temporary clinical privileges may be granted for a limited period of time by the administrator on the recommendation of the president of the medical staff. . . .
c. The administrator may permit a physician serving as a locum tenens for a member of the medical staff to attend patients without applying for membership on the medical staff, providing all of such person's credentials have first been approved by the president of the medical staff. . . ."

Review of Physician #10's and Provider #11's credentialing files occurred on 03/02/16 and indicated the following:
- The administrator failed to approve Physician #10's temporary privileges granted on 11/17/15.
- The administrator and chief of medical staff approved locum tenens privileges for Provider #11 on 03/01/16 for the period beginning 11/01/15 (four months earlier) and for the period beginning 01/31/16 (one month earlier).

During an interview on 03/02/16 at 1:15 p.m., an assistant administrative staff member (#6) responsible for credentialing confirmed the CAH's administrator failed to approve Physician #10's temporary privileges granted on 11/17/15, and the administrator and chief of staff approved Provider #11's locum tenens privileges late for the periods beginning 11/01/15 and 01/31/16.

Based on observation, review of the North Dakota Century Code, policy and procedure review, record review, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the provision of services by failing to limit access to the pharmacy in the absence of the pharmacist (Refer to C276); failing to remove outdated medications and intravenous fluids from drug storage areas (Refer to C276); failing to follow professional standards of care relating to infection control practices (Refer to C278); failing to ensure proper storage of patient supplies (Refer to C278); failing to ensure appropriate use of assistive devices to prevent accidents for patients requiring transfer assistance (Refer to C296); failing to conduct a risk analysis and evaluation of all incidents for a patient with a wheelchair positioning device (Refer to C296); failing to ensure the availability of medications and administer them in a timely manner (Refer to C297); and failing to update, revise, and maintain patients' care plans (Refer to C298). Failure to ensure the provision of services places the CAH patients at risk of receiving improper care.

PHARMACY ACCESS

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 04/26/12.

1. Based on observation, review of the North Dakota Century Code, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to limit and prevent access to the hospital pharmacy by unauthorized personnel in 1 of 1 pharmacy. This failure allowed an opportunity for unsafe and unauthorized use of medications and has the potential to create insufficient distribution, control, and accountability of medications.

Findings include:

The North Dakota Century Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. . . . 1. General. During such times as a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance . . . for the provision of drugs . . . in emergency circumstances, by access to the pharmacy. . . . 3. Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section. One supervisory registered professional nurse and only one in any given eight-hour shift is responsible for removing drugs therefrom. . . . a. Removal of any drug from the pharmacy by an authorized nurse must be recorded on a suitable form showing patient name, room number, name of drug, strength, amount, date, time, and signature of nurse. b. Such form must be left with the container from which the drug was removed, both placed conspicuously so that it will be found by a pharmacist and checked properly and promptly; or, in the case of a unit dose, place an additional dose of the drug, or the box, on the form. . . ."

Review of the policy "Access To Pharmacy In Absence Of Pharmacist" occurred on 03/01/16. This policy, revised May 2012, stated, "One supervisory registered professional nurse and only one in any given eight-hour shift is responsible for removing drugs from 2nd floor pharmacy. . . . Only the amount of medication needed for the immediate dose needed for the patient is removed from the multi-dose vial, do not take the whole bottle or multiple doses. The form must be left by the container from which the drugs were removed and will be checked by the Pharmacist on his/her next visit. . . ."

Observation of the hospital pharmacy took place on 03/01/16 at 9:15 a.m. with a pharmacy staff member (#2). The staff member (#2) stated the charge nurse on duty had access to the pharmacy with a key and could enter the pharmacy to obtain medications for patients in the absence of pharmacy staff and stated the nurse must document the medication removal on a form kept in the pharmacy.

Review of the "record of removal of drugs from pharmacy" form for January-February, 2016, identified nurses from second floor (hospital), third floor (long term care facility), and the clinic removed medications for "floor stock" and in amounts greater than one dose.

During an interview on 03/01/16 at 9:15 a.m., the pharmacy staff member (#2) confirmed the charge nurse from all units could access the pharmacy and remove medications needed for floor stock.


27645


OUTDATED MEDICATIONS

2. Based on observation, policy review, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications from 3 of 4 rooms in the emergency room (ER) (#1, #3, and #4). Failure to remove outdated medications may result in patients receiving expired and ineffective medications.

Findings include:

Review of the policy titled "Medication/Narcotic Outdates" occurred on 03/02/16. This policy, dated October 1999, stated, ". . . It is the policy of Garrison Memorial Hospital to ensure that all medications are taken off the shelf and sent to Pharmacy for disposition . . . Plan: Nursing Service will check monthly . . . Medications that are outdated will be removed from stock and replaced by pharmacy . . ."

Review of an article titled "Questions about Multi-dose vials" found on the Centers for Disease Control and Prevention (CDC) website, revised February 2011, stated ". . . If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days . . ."

Observation of the emergency department occurred on 03/02/16 at 10:00 a.m. with an administrative nurse (#1) and identified the following:
* two 1,000 milliliter (ml) bags of sodium chloride intravenous fluid, one expired in June 2015 and the other in April 2015, in a cupboard in Room #1
* two opened 20 ml vials of xylocaine, one undated and one dated as opened on 01/27/16, located in the suture cart in Room #3
* two three ml vials of amiodarone, both expired February 2016, in the crash cart located in Room #4

During an interview on the morning of 03/02/16, an administrative nurse (#1) stated staff should date multi-use medication vials and discard 30 days after opening. The nurse confirmed the expiration dates of the medications found in the emergency rooms.

HAND HYGIENE AND GLOVE USAGE

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 04/26/12.

1. Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care relating to infection control practices for 7 of 8 patients (Patients #6, #7, #8, #19, #20, #21, #22) observed receiving toileting assistance, catheter insertion, perineal cares, and blood draws. Failure to follow established infection control practices may allow transmission of organisms and pathogens from patients to staff, to other patients, or to visitors, and from one environment to another.

Findings include:

Review of the facility policy titled "Specimen Collection and Handling - Phlebotomy" occurred on 03/02/16. This policy, revised January 2016, stated, ". . . Standard Precautions . . . Gloves when touching or coming in contact with blood or body fluids . . . It is also imperative that hand washing is done adequately and frequently . . ."

Review of the facility policy titled "Hand Hygiene/Hand Washing occurred on 03/02/16. This policy, revised December 2015, stated, ". . . Good basic personal hygiene and Hand washing are critical to help prevent the spread of illness and disease . . . Specific Indications for Hand Hygiene
* If your hands are visibly soiled
* Before and after assisting a patient or resident with toileting
* If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands in all other clinical situations . . .
* Before and after patient contact
* Donning/removing gloves
* Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters or other invasive devices that do not require a surgical procedure . . ."

Review of the facility policy titled "Peri-Care" occurred on 03/02/16. This policy, dated September 2009, stated, ". . . Precautions . . . A. Disposable gloves should be used when handling body fluids. Good hand washing is essential before and after procedures involving body fluids. Use Standard (Universal) Precautions for all situations of peri-care . . ."

- Observation on 02/29/16 at 11:00 a.m. identified two nurse aides (#13 and #14) changed Patient #7's incontinent product. Wearing gloves, an aide (#14) cleansed stool from the resident's perineal area. Without changing her gloves, the aide (#14) proceeded to apply the patient's left compression stocking and adjusted her bed. The aide (#14) removed her gloves and without performing hand hygiene, exited the room to get the mechanical lift. The aide (#14) returned to Patient #7's room and did not perform hand hygiene upon re-entering with the mechanical lift. The other aide (#13) donned gloves, emptied the patient's urinary catheter bag, and used a wet wash cloth to cleanse the catheter tubing. Wearing the same gloves, the aide (#13) wet a wash cloth and washed the patient's face and mouth, including inside her mouth to remove residue from the patient's lips. The aide (#13) applied petroleum jelly to the patient's lips, removed her gloves, assisted the other aide (#14) to transfer the patient, gathered the soiled linen with her ungloved hands, and then exited the patient's room without performing hand hygiene. The aide (#13) disposed of the linen in the soiled utility room and then entered another patient's room to answer a call light.

- Observation on 02/29/16 at 3:30 p.m. identified two nurses (#10 and #15) changed Patient #8's indwelling urinary catheter after two attempts. During both attempts, a nurse (#15) failed to perform hand hygiene prior to donning sterile gloves and inserting the catheter into Patient #8's bladder.

- Observation on 03/01/16 at 8:50 a.m. identified a nurse (#10) entered an outpatient room, and without performing hand hygiene, donned gloves, and inserted an intravenous (IV) catheter to Patient #19's left wrist. The nurse (#10) washed her hands after inserting the IV.

- Observation on 03/01/16 at 9:25 a.m. identified two nurse aides (#14 and #16) transferred Patient #20 from her wheelchair into bed and checked her incontinent product. The patient was incontinent of urine and stool. Wearing gloves, a nurse aide (#14) completed perineal care, placed a clean brief, pulled up the patient's pants, repositioned the patient with pillows, clipped the call light to the patient, and moved the patient's water and phone closer to her on the bedside table. The nurse aide (#14) then removed her gloves and washed her hands prior to exiting the patient's room. The aide (#14) failed to remove her gloves and perform hand hygiene after performing perineal care and prior to completing other tasks.

- Observation on 03/01/16 at 10:00 a.m. identified a laboratory staff member (#18) gathered needed blood draw supplies for Patient #6, and set his phlebotomy tray on the floor in the corridor outside of the patient's room. Without performing hand hygiene, the staff member (#18) donned gloves, drew the patient's blood, and wearing the same gloves, exited the patient's room to get a band aid. The staff member (#18) re-entered, continued to wear the same gloves used for the blood draw, applied the bandage to the patient's arm, and exited the room without performing hand hygiene and wearing the same gloves used throughout the procedure.

- Observation on 03/01/16 at 11:35 a.m. identified a laboratory staff member (#17) entered the emergency department (ED) to draw a blood sample from Patient #22. Without performing hand hygiene, the staff member (#17) donned gloves, drew three blood samples, removed her gloves, and exited the ED without performing hand hygiene.

- Observation on 03/01/16 at 4:05 p.m. identified a nurse (#11) changed an outpatient's (Patient #21) indwelling urinary catheter. The nurse (#11) failed to perform hand hygiene prior to donning sterile gloves and inserting the catheter into Patient #21's bladder.

An interview with two administrative nurses (#1 and #3) occurred on 03/02/16 at 2:40 p.m. The nurses stated staff should perform hand hygiene before and after patient contact, before and after blood draws and intravenous catheter insertion, prior to donning sterile gloves, and immediately after completing perineal cares. One nurse (#3) stated staff should not place a phlebotomy tray on the floor.








28086


STORAGE OF PATIENT SUPPLIES

2. Based on observation, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed professional standards of care related to infection control practices for proper storage of patient supplies in 3 of 3 crash carts (cardiac rehab, Room #2 in the Emergency Room (ER), and Room #4 in the ER). Failure to follow established infection control practices may allow transmission of organisms and pathogens from staff to patients.

Findings include:

Review of the Association of Perioperative Registered Nurses (AORN) clinical practice guideline, "Anesthetic Equipment," updated January 28, 2013, stated, ". . . Laryngoscope blades should be . . . protected from contamination until used. . . . blades should be stored in packages . . . to ensure the blade is protected from contamination. The storage of unpackaged laryngoscope blades is unreliable and leads to questions regarding the safe use of the blades. . . ."

Review of the American Association of Nurse Anesthetists (AANA) document, "Infection Control Guide for Certified Registered Nurse Anesthetists [CRNA]," revised November 2012, stated, ". . . This guide offers procedural recommendations based on the latest evidence. . . . Oral Airways . . . and Laryngoscope Blades: Most oral airways . . . are disposable and should be treated as clean objects. . . . Reprocessed laryngoscope blades . . . should then be packaged and stored in a manner so that recontamination is prevented. . . . leaving such equipment loose and unpackaged in the drawer of the . . . cart is not considered an appropriate method of packaging and storage. . . . Preventive Measures: Environmental . . . Infection transmission . . . can be reduced or prevented when appropriate safeguards and precautions are implemented and must be a priority in all settings where patient care is provided. . . ."

- Observation of the cardiac rehab department occurred on 02/29/16 at 4:05 p.m. with an administrative nurse (#1) and showed a crash cart. The crash cart contained unpackaged patient supplies including several disposable oral and nasal airways and two laryngoscope blades.

- Observation of the emergency department occurred on 03/02/16 at 10:00 a.m. with an administrative nurse (#1) and showed crash carts located within Room #2 and Room #4. Each crash cart contained several unpackaged and uncovered laryngoscope blades throughout the drawers of the carts.

Staff failed to contain patient supplies (nasal and oral airways and laryngoscope blades) in a manner to prevent contamination.

During an interview on 03/02/16 at 1:30 p.m., an administrative nurse (#1) confirmed staff should store patient supplies in a manner to prevent contamination.

ICE DISPENSING

3. Based on observation, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed professional standards of care related to infection control practices for dispensing ice water to patients on 2 of 3 days (02/29/16 and 03/01/16) of survey. This failure placed patients at risk of consuming contaminated water.

Findings include:

Review of guidelines from the "North Dakota Requirements for Food and Beverage Establishments" handbook, adopted 04/01/12, page 30, stated, ". . . 33-33-04-22. Ice dispensing. Ice for consumer use must be dispensed only by employees with scoops, tongs, or other ice-dispensing utensils or through automatic self-service, ice-dispensing equipment. Ice-dispensing utensils must be stored on a clean surface or in the ice with the dispensing utensil's handle extended out of the ice. Between uses, ice transfer receptacles must be stored in a way that protects them from contamination. . . ."

Observation of the nourishment room, located on the nursing unit, occurred on 02/29/16 at 11:00 a.m. with a dietary staff member (#4). The room contained two full sized refrigerators, one designated for patient use and one designated for staff use. The staff refrigerator contained a white bucket filled with ice, which had a small styrofoam cup stored inside of it.

During an interview at this time, the dietary staff member (#4) stated staff used the cup to scoop the ice out of the bucket to provide ice water to the patients, but stated staff should not store the styrofoam cup inside of the bucket as it could contaminate the ice and eventually the ice water. The staff member (#4) stated staff should not store the bucket of ice in the refrigerator designated for staff use.

Further observations of the staff refrigerator in the nourishment room on 02/29/16 at 3:50 p.m. and on 03/01/16 at 10:30 a.m., identified the styrofoam cup remained stored in the white bucket of ice.

SAFETY RISKS INCLUDING USE OF POSITIONING HARNESS/FALL FROM WHEELCHAIR/SIDE RAIL

1. Based on observation, record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the nursing care on an on-going basis for 1 of 1 inpatient (Patient #2) using a positioning device in a wheelchair and failed to utilize footpedals for 1 of 5 patients (Patient #10) observed being propelled by staff. Failure to conduct a risk analysis and evaluation of all incidents places patients at risk of harm from reoccurrences. Failure of staff to utilize footpedals when transporting patients in wheelchairs may result in avoidable injuries.

Findings include:

Review of the "INCIDENT/EVENT REPORTING" policy occurred on 03/02/16. The policy, dated March 2009, defined an "event" as "any happening which is not consistent with the routine operation of the facility or routine care of a particular patient. . . provides a method for discovery and a means for investigation of causes . . . to assist . . . to reduce morbidity/mortality and improve quality of care. OBJECTIVES . . . To improve the management of patient care and treatment by assuring that appropriate and immediate intervention occurs for the patients safety and to assure the prevention of recurrences. . . . so that the care being given can be analyzed and evaluated. . . . Physical therapy is notified of all falls. . . . They will identify any problems and see that corrections are done."

- Review Patient #2's medical record occurred on 03/01/16. Diagnoses included traumatic brain injury, cervical dystonia (abnormal muscle tone affecting the neck muscles), and seizure disorder.

Observation on 03/01/16 at 1:50 p.m., showed Patient #2 on his back in bed with his knees flexed, a pillow placed between the wall and the patient's right lateral knee, bilateral grabs bars with bed controls positioned within the bars on the upper quarter of the bed, bed in the low position, a clip alarm attached to the patient's clothing, a fall mat on the floor of the exit side of the bed, and the patient's room located at the distant end of the hall from the nurse's station.

Patient #2's current "Aide Work Sheet" stated ". . . Clip alarm on pt. [patient] when in bed and in w/c [wheelchair]. Place alarm on the wall side of the bed. Keep alarm cord short to alert staff promptly of pt activity in bed. . . . Lock bed in low position. Mat at bedside. Pt to have no more than 2 hours of sitting at a time. . . . Pt has w/c with straps for positioning. Straps to be used during transportation and for positioning. MUST have foot pedals on at all times when pushing pt in wheelchair. . . . STRAPS OFF WHEN UP TO TABLE. STRAPS TO BE USED FOR NO LONGER THAN 1 HOUR INTERVALS AND CHECK PT FOR REDNESS AFTER LOOSENING." The work sheet identified the patient on "FALL PRECAUTIONS."

* An event identified that on 11/01/15 at 4:00 p.m.: "Pt [patient] found in room, had been in w/c [wheelchair]. Pts positioning vest was unzipped & [and] pt. suspended from arm portion of vest. Buttocks almost to floor." Corrective action included "Reinforced to not leave pts. vest unzipped & to monitor pt. more closely when in his room." The report identified the patient "last seen/observed/assisted" one to two hours prior; no witnesses to the fall, fall intervention prior to the fall as no chair alarms; and contributing factors included the patient's confusion and memory impairment. Follow-up from nursing included a notification to the physical therapy department with the details of the incident which identified the patient's chair alarms not in place, and brakes on the wheelchair not locked. During interview on 03/01/16 at 3:30 p.m. a physical therapist (#8) stated the incident occurred because staff failed to remove the positioning straps across the patient's shoulders after unzipping the harness, however, as noted above, the report included the corrective action of not to leave the patients vest unzipped. The therapist stated the care plan should have included the intervention when staff remove the positioning device the straps should also be removed from around the patient's shoulders. The care plan failed to include how often the monitoring in the room should occur. The therapist said "maybe" we need to do more education.

On 03/01/16 at 2:05 p.m. an unidentified staff member stated the vest utilized in Patient #2's wheelchair is considered a positioning device and physical therapy would assess. Upon request, staff failed to show evidence of an assessment.

Failure of the CAH to inform and educate all staff on the removal of the shoulder harness when unzipping the positioning device placed the patient at risk for harm.

* An event identified that on 12/18/15 at 11:30 a.m.: "Staff pushing patient in wheelchair. Foot pedals not on. Patient fell forward out of chair. Broke fall with his head. Laceration to left forehead. The follow-up/action taken stated the patient taken to the emergency room "where sutures were placed to the forehead laceration. CT Head done. Routine crani-checks." The report lacked a notification of the fall to the physical therapy department.

During interview on 03/01/16 at 1:50 p.m., a staff nurse (#10) stated staff received specific instruction after the fall from the wheelchair to utilize foot pedals on all patients transported in a wheelchair by staff members. The nurse provided a communication sheet given out after the incident, "SAFE PATIENT HANDLING RECOMMENDATIONS FOR WHEELCHAIR USE." The procedure, also posted in a kitchenette in a hall near the nurse's station, stated, "1. When patients are being transported by wheelchair by staff, the wheelchair leg rests must be in place.
* If patient is able to push wheel chair part way and staff assists with the rest of the transport the wheel chair leg rest will need to be put on the chair. . . ."

A "Nursing communication," form, dated 12/21/15, stated "May use chest straps/vest to position pt when he is being pushed in his w/c, but must be released when not pushing as previously ordered."

During an interview on 03/01/16 at 2:45 p.m., a nurse (#1) stated the fall from the wheelchair occurred with the positioning vest off and stated the vest is used only during meal times. This contradicts the care plan of "STRAPS OFF WHEN UP TO TABLE."

- Review of Patient #10's record occurred on 03/02/16 and identified diagnoses of status post toe amputation and deconditioning.

An observation on the morning of 03/01/16 identified a staff member (#9) propelled Patient #10's wheelchair without using footpedals.

During an interview on 03/02/16 at 2:40 p.m., a nurse (#1) stated staff should apply footpedals to wheelchairs when assisting patients to propel.

* An event identified that on 01/03/16 at approximately 4:30 a.m.: "Pt found with right lateral knee through the side rail pressed against the wall. An area of redness about 2 inches around an area that appeared to be a shearing type abrasion 3/4 cm [centimeter] located on right knee." Follow-up/action taken included cleansing of the abrasion and applying antibiotic ointment. The report failed to identify if any interventions occurred following for the patient's safety and to assure the prevention of recurrences, including an analysis of contributing factors.

During interview on 03/01/16 at 1:50 p.m., while observing Patient #2 resting in his bed, a nurse (#10) stated Patient #2 moves about easily within the bed. The nurse then located the patient's wheelchair and described the wheelchair as custom fit to assist the patient's positioning.

During an interview on 03/01/16 at 2:00 p.m., a charge nurse (#11) stated Patient #2 is unable to ambulate at all, and is not able to sit upright without assistance. The nurse stated, to her knowledge, Patient #2 has had the same bed and grab bar attached since August 2015, and lacked awareness of the siderail incident.

During an interview on 03/01/16 at 2:45 p.m. a staff nurse (#1) lacked awareness of new interventions put in place after the side rail incident regarding the incident.

The most current side rail assessment for Patient #2, dated 04/01/13, identified the patient with confusion, with poor "very poor" balance or trunk control, does use the siderails for positioning or support, and does not understand how to use the bed controls. The final recommendation included the use of "Quarter-rails up to access bed controls/mobility," with a plan for "Evaluation ongoing."

On 03/01/16 at 3:40 p.m., a physical/restorative therapy assistant (#12) stated staff should include safety measures of utilizing the wheelchair harness correctly (off the shoulders when not in use), when to use the harness (i.e. meal times and/or transport), and the use of the side rail for positioning in the patients' care plan.


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MECHANICAL LIFT TRANSFER

2. Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to provide safe and comfortable transfers for 1 of 1 patient (Patient #7) observed during a sit-to-stand mechanical lift transfer. Failure to ensure proper use of the sit-to-stand mechanical lift may result in avoidable accidents, falls, pain, and injuries.

Findings include:

Review of Patient #7's medical record occurred on March 1-2, 2016 and identified diagnoses of a recent left hip fracture, history of back compression fractures, and back and leg pain. Patient #7's current Aide Work Sheet (the care plan used by direct care staff) stated, ". . . E-Z (brand of lift) stand or lift with assist . . . Shoe to right foot and use blue block in EZ stand to keep NWB [non-weight bearing] status to left leg . . ."

Observation on 02/29/16 at 11:00 a.m. identified two nurse aides (#13 and #14) transferred Patient #7 from the bed to a wheelchair using a sit-to-stand mechanical lift. The nurse aides put the patient's right shoe on and placed a block to the base of the lift, as per the care plan. During the transfer, Patient #7 bent both legs back and rested both knees on the pad designed to cushion patients' shins during transfers. While holding on to both handle bars, the patient leaned to the right and rested her head on a handle bar. Observation showed the patient's elbows extended and raised above her ears as the mechanical lift sling slid up and under the patient's elbows. During the transfer, the patient verbalized pain and stated, "Ow! Ouch!" The patient furrowed her eyebrows and her body and face tensed. One nurse aide (#13) stated, "This has been happening all the time when transferring [Patient #7] with the lift."

During an interview on 03/01/16 at 9:15 a.m., a physical therapist (#8) stated staff should not transfer Patient #7 with the sit-to-stand mechanical lift if she is unable to bear weight to her right leg. The physical therapist (#8) stated if staff are unable to transfer the patient appropriately and safely, they need to notify the nurse.

Based on record review, facility policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure the delivery of medications occurred consistent with physicians' orders for 2 of 8 patients (Patients #12 and #15) reviewed in closed records. Failure to administer medications within the specified time frame/period and ensure the availability of medications may alter the therapeutic effect of the medication.

Findings include:

Review of the policy "Medication Administration" occurred on 03/02/16. This policy, dated February 2008, stated, "Policy: Medications are administered only pursuant to a Provider's Order. Procedure: . . . 2. A. . . . Accurate times of administration are essential for monitoring responses and pharmacokinetic calculations. . . . D. If a scheduled medication is administered early or late (1 hour from scheduled time), the time of administration is noted on the MAR [medication administration record] . . . 3. Responsibilities: A. The professional nurse is responsible for the correct administration of medications as ordered by the doctor. . . . 5. Obtaining Meds [medications] from the Pharmacy during business hours. A. . . . A copy of all provider's orders are sent promptly to the Pharmacy via computer. B. A sufficient supply of the new medication will be dispensed by the pharmacy or available in accu-dose . . . 6. Obtaining Meds from Pharmacy after business hours: . . . Find medication ordered. C. Check label for correct drug, dose, route . . . Check this with Provider's order. Telepharmacy oversees. . . . 8. Preparation and Administration of Medications. . . . The name of the medication . . . and the dosage schedule are verified before administering the medication. . . . E. It is expected that all medications be administered promptly as prescribed. . . . G. Some medications may require assessment and verification of patient condition before and/or after dosing. When such a situation exists, the results of the assessment and verification will be noted on the medication administration record at the time of the medication administration. . . . H. . . . If a medication is unavailable in the patient's medication drawer, the medication shall be obtained from the pharmacy or from accu-dose depending upon the situation. . . ."

- Review of Patient #15's closed record occurred on all days of survey. The record identified an inpatient stay for four days in November 2015. On 11/17/15 the physician ordered the intravenous administration of Solu-Cortef (hydrocortisone sodium succinate) 100 milligrams (mg) every eight hours "For 2 days, six doses." Solu-Cortef is an anti-inflammatory drug used for severe inflammation and adrenal insufficiency.

Review of the electronic medication administration record (eMAR) identified nursing staff administered the medication inconsistent with the physician's order:
* 11/17/15 at 1:50 p.m., first dose
* 11/17/15 at 8:23 p.m., 6 hours and 33 minutes following the first dose
* 11/18/15 at 6:42 a.m., 10 hours and 19 minutes after the previous dose
* 11/18/15 at 1:00 p.m., 5 hours and 18 minutes after the previous dose
* 11/18/15 at 8:09 p.m., 7 hours and 9 minutes after the previous dose
* 11/19/15 scheduled dose for 6:36 a.m.; not administered as medication not available (this scheduling would have spaced the administrations 10 hours and 27 minutes if given)
* 11/19/15 at 1:49 p.m., 17 hours and 40 minutes between doses, due to not administering the 6:36 a.m. dose

- Review of Patient #12's closed record occurred on all days of survey. The record identified an inpatient stay in September 2015 for four days.

The record identified the physician ordered Ampicillin-Sulbactam Sodium (Unasyn) (an antibiotic) 1.5 grams every eight hours intravenously on 09/12/15. Review of the eMAR identified nursing staff administered the medication on an approximate schedule of every eight hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The eMAR showed nursing staff failed to administer the 6:00 a.m. dose on 09/14/15 and lacked an explanation for the missed dose.

The eMAR identified several medications ordered on 09/12/15 at 9:00 a.m. and staff's failure to administer the first dose that day or document the reason this did not occur. This included:
* Lovenex (enoxaparin) (an anti-coagulant) 30 mg subcutaneous (sq) injection once daily; first dose administered on 09/13/15 at 9:43 a.m.
* Pepcid (famotidine) (acid reducer taken by mouth) 20 mg two times daily; first evidence of administering the medication documented on 09/12/15 at 11:56 p.m. and showed the medication not administered due to the patient's condition
* Proscar (finasteride) (used to treat enlarged prostate and improve urinary flow) once daily documented as "due" on the eMAR on 09/12/15; the following two days the record reflected the medication not administered due to the patient's condition and discontinued after those two days
* Norco (hydrocodone-acetaminophen) (narcotic pain medication for moderate pain) three times a day and documented as "due" at 7:00 a.m. and 12:00 noon on 09/12/15. The eMAR reflected the scheduling of this medication for the following two days and not administered due to the patient's condition and then discontinued on 09/14/15
* Xopenex (levalbuterol) (treats and prevents airway tightness) nebulizer solution four times a day, ordered at 6:00 a.m. The eMAR identified the medication due at 6:00 a.m. and 11:00 a.m. on 09/12/15 and not administered. The eMAR showed the medication administered consistently per orders the following two days until discontinued.
* Namenda (memantine) (used for treatment of Alzheimer's dementia) 10 mg two times a day, the eMAR identified the medication due at 9:00 a.m. on 09/12/15 and could not be administered due to the patient's condition on 09/12/15 at 11:58 p.m.
* Protonix (pantopraxole) (stomach acid reducer) injection intravenously not administered until 09/13/15 at 9:45 a.m.
* Zoloft (sertraline) (antidepressant) and Flomax (tamsulosin) (given for urinary flow problems) scheduled for once daily. The eMAR showed the medications not administered on 09/12/15 and indicated on 09/13/15 not administered due to the patient's condition.

During interview on 03/02/16 at 1:00 p.m., a staff nurse (#1) lacked knowledge on what occurred with the missed doses of medications for Patients #15 and #12. The nurse stated after pharmacy hours medications are available through an accu-dose system, with verification through a pharmacy staff member via the telepharmacy system.

During an interview on 03/02/16 at 1:35 p.m., a nurse (#7) stated staff should start any medications entered onto the eMAR at that time, and if a resident/patient cannot take the medication, staff should identify that on the eMAR. The nurse lacked knowledge of why staff failed to administer scheduled medications for Patients #12 and #15.

THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 04/26/12.

Based on record review, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff revised, updated, and maintained nursing care plans for 2 of 6 acute care patients' (Patient #9 and #12) records reviewed. Failure to update, revise, and maintain care plans limits 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. Failure to maintain current care plans could result in failing to manage patients' needs.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice, "8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, pages 212-215, stated, ". . . A formal nursing care plan is a written or computerized guide that organizes information about the client's care. The most obvious benefit of a formal written care plan is that it provides for continuity of care. . . . Care plans include the actions nurses must take to address the client's nursing diagnoses and produce the desired outcomes. The nurse begins the plan when the client is admitted to the agency and constantly updates it throughout the client's stay in response to changes in the client's condition and evaluations of goal achievement. . . . care must be individualized to fit the unique needs of each client. . . ."

- Review of Patient #12's closed medical record occurred on 03/01/16. The record identified Patient #12 hospitalized in acute care in September 2015 for four days due to aspiration pneumonia and dehydration. The record lacked a care plan for this stay.


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- Review of Patient #9's acute inpatient record occurred on 02/29/16. The record identified the CAH admitted the patient on 02/26/16 with diagnoses including cellulitis of the right leg, rheumatoid arthritis, and anxiety. Patient #9's record lacked evidence of an inpatient care plan.

On the morning of 03/01/16, an administrative nurse (#1) confirmed staff failed to develop care plans for Patients #9 and #12.

Based on record review, review of professional literature, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff revised, updated, and maintained nursing care plans for 3 of 9 sampled inpatient swingbed (SB) residents (Residents #2, #6, and #7). Failure to update, revise, and maintain care plans limits the CAH's ability to communicate treatment approaches, assist the resident to attain/maintain their highest physical, mental, and psychosocial well-being, and ensure continuity of care. Failure to maintain current care plans could result in failing to manage patients' needs.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice, "8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, pages 212-215, stated, ". . . A formal nursing care plan is a written or computerized guide that organizes information about the client's care. The most obvious benefit of a formal written care plan is that it provides for continuity of care. . . . Care plans include the actions nurses must take to address the client's nursing diagnoses and produce the desired outcomes. The nurse begins the plan when the client is admitted to the agency and constantly updates it throughout the client's stay in response to changes in the client's condition and evaluations of goal achievement. . . . care must be individualized to fit the unique needs of each client. . . ."

Review of the "Swing Bed Resident Care Plans" policy occurred on 03/02/16. This policy, dated May 2012, stated, "PURPOSE: The purpose of the care plan is to assess the problems and needs of each resident and develop a plane [sic] of caring for that resident so that he/she may attain the highest practicable level of functioning during his/her stay. The resident care plan is developed in coordination with . . . appropriate health care personnel consistent with the . . . provider's orders. PARTS OF THE CARE PLAN: . . . Identification of real and potential problems, time orientated and measurable goals for resolution of each problem and specific approaches for resolution of each problem. CARE PLAN TEAM: . . . representatives from nursing, activities, dietary, physical therapy/restorative care, and social services. . . . CARE PLAN TIME FRAMES: . . . 1. Initial assessment must begin upon admission . . . Care plan entries must be signed or initialed and dated. . . . Care plans will then be reviewed monthly for . . . three months . . . and quarterly thereafter. Care plans will be reviewed as a team at regularly scheduled care conferences. . . . UPDATES: Resident care plans must be kept current. Revisions can be made at any time by all professional personnel involved in the care of the resident. All interventions involving resident care issues initiated by nursing or other disciplines need to be care planned. . . . Therapy issues . . . Safety devices . . . RESTORATIVE CARE/PHYSICAL THERAPY 1. Provide complete physical assessment . . . 4. All seating and positioning issues . . ."

Review of the "FALL PREVENTION AND REDUCTION PROGRAM" policy occurred on 03/02/16. This policy, dated October 2013, stated, "PURPOSE: To enhance patient safety through a fall prevention program. Definition of a fall . . . An intercepted fall is a fall. . . . PROCEDURE: . . . The care plan is updated to reflect interventions identified and put into place . . ."

- Review of Resident #2's inpatient swingbed (SB) record occurred on 03/01/16. Diagnoses included traumatic brain injury. The record identified an incident where staff found the resident hanging from a positioning device in his wheelchair on November 1, 2015. The care plan failed to identify the specific problem and include an intervention to avoid repeat occurrences. During interview on 03/01/16 at 3:30 p.m. a physical therapist (#8) stated the care plan should include the intervention when staff remove the positioning device, staff should remove the straps from around the resident's shoulders.

Resident #2's current "Aide Work Sheet," utilized by direct caregivers, stated, ". . . Clip alarm on pt. [patient] when in bed and in w/c [wheelchair]. Place alarm on the wall side of the bed. Keep alarm cord short to alert staff promptly of pt activity in bed. . . . Lock bed in low position. Mat at bedside. Pt to have no more than 2 hours of sitting at a time. . . . Pt has w/c with straps for positioning. Straps to be used during transportation and for positioning. MUST have foot pedals on at all times when pushing pt in wheelchair. . . . STRAPS OFF WHEN UP TO TABLE. STRAPS TO BE USED FOR NO LONGER THAN 1 HOUR INTERVALS AND CHECK PT FOR REDNESS AFTER LOOSENING." The work sheet identified the patient on "FALL PRECAUTIONS."

The multi-disciplinary care plan addressing the problem of "SAFETY - FALL" included the following interventions not identified on the "Aide Work Sheet:"
* "Staff to check resident [every] hour" and "Position resident in the middle of the bed."

A report identified on 11/01/15 at 4:00 p.m.: "Pt [patient] found in room, had been in w/c [wheelchair]. Pts positioning vest was unzipped & pt. suspended from arm portion of vest. Buttocks almost to floor." Corrective action included "Reinforced to not leave pts. vest unzipped & to monitor pt. more closely when in his room." The current "Aide Work Sheet" stated to not use the straps longer than one hour intervals, failed to include how to position the straps when not in use, and failed to identify how often the monitoring in the room should occur. The report identified notification to physical therapy department with the details of the incident. During interview on 03/01/16 at 3:30 p.m. a physical therapist (#8) stated the incident occurred because staff had not removed the positioning straps across the resident's shoulders after unzipping the harness. The therapist stated the care plan should include the intervention when staff remove the positioning device, staff should remove the straps from around the resident's shoulders. The therapist said "maybe" we need to do more education.

On 03/01/16 at 3:40 p.m., a physical/restorative therapy assistant (#12) stated the care plan should include safety measures of utilizing the wheelchair harness correctly (off the shoulders when not in use), when to use the harness (i.e. meal times and/or transport), and the use of the side rail for positioning.

- Review of Patient #6's inpatient SB record occurred on 03/02/16. Nursing progress notes, dated 12/26/15, showed staff identified a stage II pressure ulcer to Patient #6's left buttock. The progress notes identified the ulcer healed on 01/08/16.

Review of Patient #6' current care plan stated, ". . . Compromised skin integrity . . . resident has open area left buttock . . ." Staff failed to revise the care plan after the ulcer healed.

During an interview on the afternoon of 03/02/16, an administrative nurse (#1) confirmed Patient #6's pressure ulcer to his left buttock healed.

- Review of Patient #7's inpatient SB record occurred on 03/01/16 and identified the patient required staff assistance for transfers. Review of the patient's current orders identified a physical therapy order, dated 02/25/16, stating, "1-1.5 hour sitting maximum as tolerated." Review of a physical therapy progress note, dated 02/25/16, stated, ". . . advised charge nurse that pt [patient] should not sit up for more than ~1 [approximately one] hour . . ."

Review of Patient #7's care plan and Aide Work Sheet failed to identify staff should ensure the patient does not sit up for greater than 1.5 hours.

On the morning of 03/02/16, an administrative nurse (#1) confirmed the care plan lacked the physical therapy instructions to lay Patient #7 down after 1-1.5 hours.