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Based on observation, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff monitored and documented the temperature and humidity of 1 of 1 Operating Room (OR). Failure to monitor and document the temperature and humidity of the OR limited the CAH's ability to ensure the temperature and humidity was within the recommended ranges to inhibit the growth of bacteria and mold and decrease floating particulate matter and electrostatic electricity.

Findings include:

A document from the Association of Perioperative Registered Nurses (AORN) titled, "Environment of Care," stated, ". . . The recommended temperature range in an operating room is between 68 [degrees] F [Fahrenheit] and 75 [degrees] F. . . . Updated March 03, 2015 . . . The recommended humidity range in an operating room is 20% to 60% . . . Updated July 18, 2013 . . ."

Observation of the OR occurred on the afternoon of 08/11/15 with an administrative nurse (#1) and an OR supervisory nurse (#9). The administrative nurse (#1) stated the CAH performed ophthalmologic surgeries in the OR once a month. The nurse (#1) stated she thought maintenance staff monitored the temperature and humidity of the OR as the OR staff did not.

During an interview on 08/12/15 at 10:30 a.m., a supervisory maintenance staff member (#3) stated maintenance staff did not monitor the temperature and humidity of the OR.

EFFECTIVENESS OF AS NEEDED MEDICATIONS

1. Based on review of professional literature, policy and procedure review, record review, 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 2 of 3 active inpatient (Patients #2 and #3) 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:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, page 862-870, states, ". . . 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. . . . In all nursing activities, nurses need to be aware of the medications that a client is taking and record their effectiveness as assessed by the client and the nurse on the client's chart. . . . Skill 35-1 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 policy "Medication Administration" occurred on 08/12/15. This policy, revised 06/30/15, stated, ". . . 19. Procedure specifics . . . h. PRN medications require additional documentation on the medication record as to why they were used and then their effectiveness. i. Nurses are encouraged to use the pain scale when documenting administration of pain medications and their effectiveness. . . ."

- Review of Patient #3's active medical record occurred on August 10-11, 2015 and identified the CAH admitted the patient on 08/07/15 with abdominal pain. The record indicated the patient used prn medications for pain and showed physician orders on 08/07/15 for Morphine 1-2 milligrams (mg) intravenous (IV) every 2 hours prn and on 08/08/15 for Morphine 4 mg IV every 2 hours prn.

Patient #3's medication administration record (MAR), pain assessment, and nurse notes showed the following administration times and patient responses for the prn medication:
*Morphine 2 mg
(08/07/15)
5:13 p.m. - response documented at 7:59 p.m., almost 3 hours later.
9:36 p.m. - no response documented.
(08/08/15)
6:45 a.m. - response documented at 8:05 a.m., almost 1 1/2 hours later.
1:29 p.m. - response documented at 3:19 p.m., almost 2 hours later.

*Morphine 4 mg
(08/08/15)
3:19 p.m. - response documented at 5:30 p.m., over 2 hours later.
9:18 p.m. - response documented on 08/09/15 at 3:59 a.m., almost 7 hours later.
(08/09/15)
9:01 a.m. - response documented at 10:30 a.m., 1 1/2 hours later.
2:26 p.m. - response documented at 4:00 p.m., 1 1/2 hours later.
5:38 p.m. - response documented at 7:00 p.m., about 1 1/2 hours later.
10:37 p.m. - response documented on 08/10/15 at 12:00 a.m., about 1 1/2 hours later.
(08/10/15)
5:30 a.m. - response documented at 7:50 a.m., over 2 hours later.
8:51 a.m. - response documented at 12:04 p.m., over 3 hours later.
9:40 p.m. - response documented on 08/11/15 at 6:09 a.m., over 8 hours later.

Review of Patient #3's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medication in a timely manner.

- Review of Patient #2's active medical record occurred on 08/11/15 and identified the CAH admitted the patient on 08/06/15 with back pain. The record indicated the patient used prn medications for pain and showed physician orders on 08/06/15 for Morphine 5 mg IV every hour prn and oxycodone 5-10 mg orally every 8 hours prn.

Patient #2's MAR, pain assessment, and nurse notes showed the following administration times and patient responses for the prn medication:
*Morphine:
(08/06/15)
10:47 p.m. - response documented on 08/07/15 at 12:30 a.m., almost 2 hours later.
(08/07/15)
4:29 a.m. - response documented at 7:52 a.m., over 3 hours later.
8:34 a.m. - response documented at 11:10 a.m., 2 1/2 hours later.
4:27 p.m. - response documented at 6:00 p.m., 1 1/2 hours later.
8:32 p.m. - response documented at 9:53 p.m., about 1 1/2 hours later.
(08/08/15)
11:00 a.m. - response documented at 4:08 p.m., over 5 hours later.
5:09 p.m. - response documented at 6:30 p.m., about 1 1/2 hours later.
(08/09/15)
2:45 p.m. - response documented at 5:00 p.m., over 2 hours later.
(08/10/15)
12:56 p.m. - response documented at 9:00 p.m., 8 hours later.

*Oxycodone
(08/08/15)
9:59 a.m. - response documented at 4:08 p.m., 6 hours later.
(08/09/15)
9:42 a.m. - response documented at 2:44 p.m., 6 hours later.
2:44 p.m. - response documented at 5:00 p.m., over 2 hours later.
(08/10/15)
8:48 a.m. - response documented at 10:30 a.m., almost 2 hours later.

Review of Patient #2's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medication in a timely manner.

During an interview on the afternoon of 08/10/15, a staff nurse (#10) stated nurses documented the patient's response to prn medications in the pain assessment section or nurse notes, but did not specify a timeframe for the response.

During an interview on the morning of 08/11/15, a staff nurse (#2) confirmed the above interview, but stated nurses must document the response within an hour after administration of the prn medication.

During an interview on the afternoon of 08/12/15, an administrative nurse (#1) stated nursing staff should evaluate the patient's response to prn medications, but did not specify a timeframe for the response or a specific area within the medical record for documentation.


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CONSCIOUS SEDATION:

2. Based on review of the North Dakota Board of Nursing practice statement, policy, personnel files, and staff interview, the Critical Access Hospital (CAH) failed to ensure the qualifications of nursing staff to administer conscious sedation for 4 of 4 registered nurses' (RNs') (RN #4, #5, #6, and #7) personnel files reviewed. Failure to ensure the competency of nursing staff to perform their clinical duties placed patients at risk of an adverse event.

Findings include:

Review of the North Dakota Board of Nursing Practice Statement "Role of Registered Nurse (RN) in the Management of Patients Receiving Moderate Sedation/Analgesia for Therapeutic, Diagnostic, or Surgical Procedures" occurred on 08/12/15. The practice statement, revised October 2012, stated, ". . . B. Qualifications . . . 6. The institution or practice setting has in place an educational/competency validation mechanism that includes a process for evaluating and documenting the individuals' demonstration of the knowledge, skills, and abilities related to the management of patients receiving sedation/analgesia. Evaluation and documentation of competence occurs on a periodic basis according to institutional policy. . . ."

Review of the CAH policy "Conscious Sedation" occurred on 08/14/15. The policy, revised February 2011, stated, "THE ROLE OF THE REGISTERED NURSE: An RN may administer drugs as ordered by a qualified anesthesia provider or attending physician. However, IV [intravenous] conscious sedation/analgesia is not written within the basic educational preparation of RNs. Nurses must seek additional education enabling them to make proper judgments in delivering safe patient care. . . ."

During an interview on 08/11/15 at 3:20 p.m., an administrative nurse (#1) stated RNs working in the emergency room administered conscious sedation and confirmed all RNs employed at the CAH worked in the Emergency Room (ER).

During an interview on 08/12/15 at 9:55 a.m., an administrative nurse (#1) stated the CAH did not provide or require specific training for nurses administering conscious sedation.

Review of personnel files occurred on 08/12/15 at 1:30 p.m. with a Human Resources staff member (#8) and identified RN #4, #5, #6, and #7's files lacked evidence of training or competency evaluations regarding administration of conscious sedation.

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to provide safeguards against loss, destruction, or unauthorized use of medical records for 1 of 2 radiology medical record storage areas (file cabinets in general radiology suite). Failure to store records in a secure manner limited the CAH's ability to prevent loss or destruction of records and to ensure the maintenance of patient confidentiality.

Findings include:

Observation on 08/11/15 at 2:20 p.m. identified medical records (mammography reports) stored in two unlocked file cabinets in the unlocked general radiology suite.

During an interview on 08/11/15 at 2:50 p.m., an administrative radiology staff member (#11) confirmed the CAH did not ensure the security of the mammography reports in the unlocked file cabinets in the general radiology suite.

Review of the health information management policy "Storage and Retrieval" occurred on 08/12/15. This undated policy failed to include storage of radiology records.

Upon request on 08/12/15, the radiology department failed to provide a policy requiring secure storage of records.

Based on bylaws review, policy review, record review, meeting minutes 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 (August 2014 - July 2015). Failure to ensure departments report to the QA Committee limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the governing board's "Bylaws of the Cavalier County Memorial Hospital Association" occurred on 08/10/15. These bylaws, approved 03/20/13, stated,
". . . Article VII. Medical Staff . . .
Section 1. Organization, Appointments and Hearings . . .
d. An interdepartmental committee of key employees and Medical Staff shall be organized to perform quality improvements and quality assurance activities, and shall make regular reports to the Board of Directors about the activities; findings and actions taken related to the quality of our hospital care, in accord with the Board approved Quality Assurance Plan. . . ."

Review of "Cavalier County Memorial Hospital Quality Assurance Plan" occurred on 08/11/15. This policy, revised 05/2013, stated,
"I. Preamble
In order to fulfill Cavalier County Memorial Hospital's responsibility to its patients, its medical and other professional staffs, and to the community it serves, the Board of Directors, the Medical Staff, and Administration have adopted and will implement the Quality Assurance Program as described in the Plan. . . .
III. Program Objectives
The program's objectives are: . . .
H. To evaluate all organized services related to patient care . . ."

Review of the 2014 and 2015 "QA Reporting Calendar Cavalier County Memorial Hospital" occurred on 08/11/15. This document indicated laundry and housekeeping should report quarterly in August, November, February, and May. The document failed to include cardiac rehabilitation (rehab) and central supply reprocessing (CSR).

Reviewed on 08/11/15, the August 2014 through July 2015 QA meeting minutes lacked evidence laundry, housekeeping, cardiac rehab, and CSR departments submitted QA reports.

During interview on 08/11/15 at 3:18 p.m., an administrative cardiac rehab staff member (#4) confirmed the cardiac rehab department had not performed QA monitoring.

During interview on 08/11/15 at 4:25 p.m., a CSR staff member (#12) confirmed the cardiac rehab department had not performed QA monitoring.

During interview on 08/12/15 at 10:30 a.m., an administrative plant operations staff member (#3) confirmed laundry and housekeeping departments had not performed QA monitoring.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the patient's right to personal privacy for 1 of 1 Swing Bed patient (Patient #7) monitored by a video camera. Failure to obtain the patient's permission for the video monitoring and to establish policies and procedures regarding the monitoring violated Patient #7's right to privacy and placed other patients at risk for violation of the right to privacy.

Findings include:

Review of Patient #7's closed medical record occurred on all days of survey and identified the CAH admitted the patient to Swing Bed on 02/06/15. Diagnoses included chronic obstructive pulmonary disease and pneumonia.

Nursing progress notes identified the following:
02/07/15 at 7:30 a.m.: ". . . Video camera remains on for patient safety. . . ."
02/08/15 at 10:00 p.m.: "Pt [patient] up out of chair on his own walking toward bathroom, this is seen on the camera. . . . Camera remains in place for pt's safety due to non compliance with using call light before getting up. . . ."
02/10/15 at 1:25 a.m.: "Pt found sitting on the floor in front of his chair. Pt had been sitting forward in the chair to use the urinal and reports sliding out of chair onto the floor. . . . Video camera has been on all shift. . . ."
02/12/15 at 8:00 p.m.: ". . . Video monitoring is in place for safety. . . ."

A Social Services note, dated 02/09/15 at 11:59 a.m. stated, ". . . Son stated that his dad makes his own decisions . . ."

The record lacked documentation regarding when staff implemented the video monitoring for Patient #7 and lacked evidence staff obtained Patient #7's or a family member's permission prior to initiating the monitoring.

During an interview on 08/11/15 at 2:45 p.m., an administrative nurse (#1) stated the CAH had no policy regarding video monitoring of patients. The nurse stated staff do not obtain a signed consent from the patient or a family member when implementing video monitoring in the room.

Staff's failure to obtain permission for the video monitoring resulted in a violation of Patient #7's expectation of privacy while in his room.