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Based on review of Critical Access Hospital (CAH) employee files and staff interview, the CAH failed to provide education to staff for 8 of 8 staff records (Staff Member #4, #5, #6, #7, #8, #9, #10, and #11) reviewed regarding policies on advance directives. Failure to educate the staff regarding the CAH's policies and procedures on advance directives may result in patients receiving undesired healthcare services.

Findings include:

Review of eight randomly selected employee files (Staff Member #4, #5, #6, #7, #8, #9, #10, and #11) occurred on the morning of 05/01/14 and identified the facility failed to educate these staff members on the CAH's policies and procedures for advance directives.

During an interview on 05/01/14 at 10:40 a.m., an administrative staff member (#4) confirmed the CAH failed to educate all staff on the CAH's policies and procedures for advance directives and identified new employees do not receive education on advance directives during orientation.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the availability of drugs, biologicals, and equipment commonly used in life-saving procedures for prompt use when staff removed 1 of 1 Emergency Room (ER) crash cart from the ER for use in the operating room (OR) and cardiac rehabilitation department. Removing the crash cart from the ER limited the availability of drugs, biologicals, and equipment used for treatment of life-threatening situations to patients presenting to the ER.

Findings include:

Observation of the ER occurred on 04/30/14 at 1:00 p.m. with an administrative nurse (#3) and showed a crash cart containing a defibrillator and various medications including cardiac glycosides, antiarrhythmics, antihypertensives, analgesics, anesthetics, and electrolytes and replacement solutions used in life-saving procedures. The nurse (#3) confirmed this crash cart was the only one located in the ER.

Observation of the cardiac rehabilitation department occurred on 04/30/14 at 8:20 a.m. with an administrative nurse (#4) and identified oxygen and nitroglycerin (cardiac medication) located in the department. The nurse (#4) stated in case of an emergency, she would obtain the crash cart located in the ER for any additional equipment, such as a defibrillator.

Observation of the OR occurred on 05/01/14 at 9:18 a.m. with an administrative nurse (#3). During an interview at this time, the administrative nurse (#3) stated staff brought the crash cart from the ER to the OR for use in case of an emergency on days the CAH performed surgery. The nurse (#3) confirmed the ER crash cart contained life-saving equipment and medications needed in emergency situations such as cardiac and trauma events.

Based on observation, review of manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure proper maintenance of 1 of 1 water/ice dispenser used for patients and located in the staff lounge. Failure to ensure proper maintenance occurred on a regular basis, such as cleaning, sanitizing, and de-mineralizing to prevent the development of mold and the production of corrosion, has the potential to affect the health of patients consuming the water/ice from the dispenser.

Findings include:

Review of manufacturer's instructions for the water/ice dispenser occurred on 05/01/14. The instructions, dated June 1986, stated, ". . . Maintenance and Cleaning should be scheduled at a MINIMUM of twice per year. . . ."

Observation of the staff lounge occurred on 05/01/14 at 9:00 a.m. with a physical plant staff member (#12) and identified the facility's water/ice dispenser used for patients on the counter.

During an interview on 05/01/14 at 9:00 a.m., a physical plant staff member (#12) stated the CAH did not have an established process for staff to clean, sanitize, and de-mineralize the water/ice dispenser. The physical plant staff member (#12) stated the facility replaced their ice machine last week, but confirmed the CAH had not cleaned, sanitized, or de-mineralized the prior water/ice dispenser.

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 within the recommended ranges to inhibit the growth of bacteria and mold, and decrease floating particulate matter and electrostatic electricity.

Findings include:

An article from the Association of Perioperative Registered Nurses (AORN), updated 06/30/09, stated, ". . . The recommended temperature range in an operating room is between 68 [degrees] F [Fahrenheit] and 73 [degrees] F . . . The recommended humidity range in an operating room is between 30% [percent] to 60%. Both the temperature and humidity should be monitored and recorded daily using a log or electronic documentation of the heating, ventilation, and air conditioning (HVAC) system. . . ."

Observation of the OR occurred on 05/01/14 at 9:18 a.m. with an administrative nurse (#3) and showed one OR suite and one procedure room. The nurse stated the CAH performed general, orthopedic, and podiatry surgery cases within the OR. A monitoring device located in the OR suite identified a temperature of 62 degrees F and humidity of 47%. The nurse (#3) stated staff noted the temperature and humidity of the OR on the days the CAH performed surgery, but failed to monitor and document the temperature and humidity daily.

Based on review of an agreement, review of the Medical Staff bylaws, and staff interview, the Critical Access Hospital (CAH) failed to ensure the agreement identified the responsibility of credentialing and privileging for 2 of 2 physicians (Physician #1 and #2) providing services to the CAH through the agreement. Failure to designate responsibility including credentialing and privileging of these physicians providing the contracted service placed the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the CAH's "SLEEP LABORATORY SERVICES AGREEMENT" occurred on 05/01/14. The agreement, dated November 2007, stated:
". . . A. Hospital seeks to provide its patients and the greater community sleep laboratory services including, but not limited to, polysomnography [the study of sleep] sleep studies.
B. Hospital desires that [laboratory-lab], as an independent contractor, provide certain sleep testing services to address the Hospital's needs with respect to sleep laboratory services. . . .
The services to be provided under this Agreement are reasonable and necessary for the legitimate business purposes of the Hospital. . . ."

The agreement identified the responsibilities of the hospital as:
". . . Hospital will provide a qualified Medical Director to assist [contractor] as may be required to facilitate the Services provided . . . Medical Director shall have control of the Sleep Lab and [contractor] shall manage and control the technical and administrative duties of the Sleep Lab. Hospital shall be responsible for monitoring the credentialing and licensing of the Medical Director and Medical Director's compliance with applicable standards, quality control measures, policies, procedures, laws, and regulations. . . ." The agreement failed to identify the responsibility of monitoring the credentialing and licensing of the physicians providing the service.

Review of the CAH's current Medical Staff Bylaws occurred on the afternoon of 04/30/14. The bylaws, approved 08/21/13, identified the requirements for Medical Staff Membership. The bylaws stated:
"ARTICLE III: MEDICAL STAFF MEMBERSHIP . . . Membership on the medical staff of the hospital is a privilege granted by the Board of Directors . . . which shall be extended only to professionally competent physicians . . . who continuously meet the qualifications, standards and requirements set forth in these bylaws, rules and regulations. . . .
In order to qualify for appointment and reappointment to the medical staff and to be granted clinical privileges to practice at the hospital, each practitioner must continually meet all the following standards: . . . credentials for staff appointment and reappointment and for the specific clinical privileges requested . . ."

On the morning of 04/30/14, the review of the roster of physicians providing the medical interpretation/review for Sleep lab studies identified two physicians (Physician #1 and #2) provided the service.

Review of the CAH's agreements occurred on the morning of 04/30/14 and 05/01/14. The agreement with the Sleep Laboratory failed to state the contract included credentialing and granting of privileges for the providers/physicians interpreting the results of the sleep studies performed at the CAH.

During interview on the afternoon of 04/30/14, an administrative staff member (#2) confirmed the sleep laboratory service is provided within the hospital and the physicians doing the interpretation are provided by the Sleep Laboratory. The staff member stated the CAH's medical staff and governing body do not appoint these physicians which included credentialing and granting of privileges.

Based on review of the Critical Access Hospital (CAH) Medical Staff bylaws, North Dakota Department of Health, Division of Health Facilities provider files, and staff interview, the CAH failed to disclose the name and address of the person responsible for medical direction (Medical Director) to the State agency in the past 4 of 4 months (January 2014 through April 2014). Failure to disclose to the State agency the name of the medical director has the potential to affect duties as assigned within the Medical Staff bylaws including matters affecting patient care.

Findings include:

Review of the CAH's current Medical Staff Bylaws occurred on the afternoon of 04/29/14. The bylaws, approved 08/21/13, included the roles and responsibilities of the Medical Staff officers. The bylaws stated, ". . . ARTICLE VIII: OFFICERS . . . Duties of Officers a. Chief: The Chief shall serve as the highest elected official of the medical staff and shall: 1. Act in coordination and cooperation with the Administrator/CEO [chief executive officer] in all matters of mutual concern with the hospital . . . Be responsible for the enforcement of medical staff bylaws, rules and regulations, for implementation of sanctions where they are indicated, and for the medical staff's compliance with procedural safeguards in all instances where corrective action has been requested against a practitioner . . ."

During interview on the afternoon of 04/30/14, an administrative staff member (#1) stated a change in the medical director occurred in January 2014.

Reviewed on 05/01/14, the North Dakota Department of Health, Division of Health Facilities provider files lacked evidence the CAH disclosed to the State agency the name of the medical director.

During interview on the afternoon of 04/30/14, an administrative staff member (#2) identified the CAH had no policy on the reporting or notifying the State agency of the person (provider /physician) responsible for medical direction.

Based on review of infection control reports, meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases for outpatients of the CAH for the past 7 of 7 months (October 2013 - April 2014) reviewed. Failure to identify and address incidents of infections among all patients has the potential for infections to go unreported, spread, or reoccur; affecting the health of all patients, personnel, and visitors of the CAH.

Findings include:

The infection control program, reviewed on 04/30/14, lacked evidence the CAH identified and recognized infections of outpatients (excluding surgery/procedure patients). The infection reports and meeting minutes from October 2013 through April 2014 failed to include information and documentation of outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on 04/30/14 at 4:10 p.m., the infection control coordinator (#4) stated she did not receive or request infection control information from outpatients, namely, the Emergency Room, cardiac rehabilitation, and occupational/physical therapy patients. The staff member (#4) confirmed the CAH did not formally document and include outpatients in infection control surveillance.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure the development of comprehensive care plans for 2 of 2 cardiac rehabilitation patient records (Patient #3 and #4) reviewed. Failure to develop, implement, and individualize care plans for cardiac rehabilitation limited the CAH's ability to manage patients' needs and communicate treatment approaches and goals.

Findings include:

Review of Patient #3 and #4's records occurred on 04/29/14 and lacked care plans with specific focus areas, measurable goals, and interventions related to cardiac rehabilitation.

During an interview on 04/30/14 at 3:30 p.m., an administrative nurse (#4) confirmed Patient #3 and #4's records lacked care plans related to their cardiac rehabilitation.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to provide safeguards against loss, destruction, or unauthorized use of medical records for 1 of 3 medical record storage areas of the hospital (storage room across from the radiology department). 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 05/01/14 at 9:30 a.m. identified an unlocked storage room containing medical records across from the radiology department.

During an interview on the morning of 05/01/14, a maintenance staff member (#12) stated staff should keep the door locked.