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Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) nursing staff failed to ensure patient care supplies available for patient use, were not expired. The pediatric crash cart, an emergency cart stocked with life saving medical supplies, was located in the medical/surgical medication preparation room. The CAH had a census of 13 inpatients at the time of the survey.

Failure to assure only unexpired medical supplies were available in the pediatric crash cart placed pediatric patients at potential risk for harm due to the use of expired medical supplies that the manufacturers of the supplies determined were no longer safe for patient use.

Findings include:

1. Observation during the environmental tour of the Medical/Surgical nursing unit on 3/7/11 at 10:00 AM with Staff B, Department Manager, revealed a locked pediatric crash cart located in the medical/surgical medication preparation room. The following expired supplies were in the pediatric crash cart:

a. One purple Intravenous (IV) Delivery Module labeled with an expiration date of 8/2010;
b. One purple Intubation Module labeled with an expiration date of 2/2011;
c. One pink/red IV Delivery Module labeled with an expiration date of 8/2010;
d. One pink/red Intubation Module labeled with an expiration date of 2/2011;
e. One yellow IV Delivery Module labeled with an expiration date of 8/2010;
f. One white IV Delivery Module labeled with an expiration date of 8/2010;
g. One blue IV Delivery Module labeled with an expiration date of 8/2010;
h. One orange IV Delivery Module labeled with an expiration date of 8/2010; and
j. One green IV Delivery Module labeled with an expiration date of 8/2010.

2. During an interview on 3/7/11 at 10:00 AM, Staff B said pharmacy staff check for expired supplies and medications in the pediatric crash cart. Staff B reported speaking with pharmacy staff and the pharmacy staff said nursing staff were responsible for checking the pediatric crash cart for expired supplies. Staff B said nursing staff were not checking the crash cart for expired supplies and confirmed the supplies found in the pediatric crash cart were expired.

3. Review of the CAH policy titled (Code Blue) or Cardiorespiratory Arrest Response, reviewed 3/10 revealed in part "... i. Pharmacy is responsible for checking for expiration on all drugs. j. Each area is responsible for checking all other supplies for expiration dated."

I. Based on review of Critical Access Hospital (CAH) Medical Staff Bylaws, credential files, and staff interview, the CAH Administrative Staff failed to obtain a reference and/or competency evaluation for 8 of 15 physicians and/or mid-level practitioners reviewed (Physician or Midlevel Practitioners A, B, C, D, E, F, G, and H). The CAH had a census of 13 inpatients at the time of the survey.

Failure to obtain a reference and/or competency evaluation for a physician or mid-level practitioner could potentially result in inadequate care and treatment of patients.

Findings include:

1. Review of Medical Staff Bylaws, dated 10/14/10 by the Medical Staff and 10/19/10 by the Governing Body showed it stated in part, "...document...current clinical competence...to demonstrate that any patient treated by them will receive care of the generally recognized professional level of quality and efficiency..."

a. Review of Physician A's credential file revealed the Governing Body approved the physician's reappointment to the medical staff on 12/15/2009. The physician's credential file lacked a reference form for a competency evaluation prior to the reappointment.

b. Review of Physician B's credential file revealed the Governing Body approved the physician's reappointment to the medical staff on 12/15/2009. The physician's credential file lacked a reference form for a competency evaluation prior to reappointment.

c. Review of Physician C's credential file revealed the Governing Body approved the physician's reappointment to the medical staff on 2/15/2009. The physician's credential file lacked a reference form for a competency evaluation prior to reappointment.

d. Review of Physician D's credential file revealed the Governing Body approved the physician's reappointment to the medical staff on 12/15/2009. The physician's credential file lacked a reference form for a competency evaluation prior to reappointment.

e. Review of Physician E's credential file revealed the Governing Body approved the physician's reappointment to the medical staff on 2/16/2010. The physician's credential file lacked a reference form for a competency evaluation prior to reappointment.

f. Review of Mid Level F's credential file revealed the Governing Body approved the physician assistant's reappointment to the medical staff on 12/15/2009. The physician assistant's credential file lacked a reference form for a competency evaluation prior to reappointment.

g. Review of Mid Level G's credential file revealed the Governing Body approved the certified nurse midwife's reappointment to the medical staff on 12/15/2009. The certified nurse midwife's credential file lacked a reference form for a competency evaluation prior to reappointment.

h. Review of Mid Level H's credential file revealed the Governing Body approved the advanced registered nurse practitioner's reappointment to the medical staff on Mid Level H an approval date 2/16/2010. The advanced registered nurse practitioner's credential file lacked a reference form for a competency evaluation prior to reappointment.

2. During an interview on 3/9/11 at 9:00 AM, Staff D, Administrator Assistant, acknowledged the credential files lacked documentation of competencies. Staff D reported visiting with the identified reference professionals about the Physician and Mid levels references and competency.



II Based on review of Critical Access Hospital (CAH) Medical Staff Bylaws, credential files, and staff interview, the CAH Administrative Staff failed to obtain a reappointment approval for 1 of 4 Mid levels contracted by the CAH for Emergency Room (ER) services. (Physician Assistant I). The ER Nurse manager reported an average of 18 patients receive emergency services in the ER daily.

Failure to complete the reappointment process could potentially result in inappropriate care and treatment from unqualified practitioners.

Findings include:

1. Review of Medical Staff Bylaws dated 10/14/10 by Medical Staff and 10/19/10 by Governing Body stated in part, "...Initial appointments to the Medical Staff shall be for a period of twelve months...Subsequent reappointment shall be for a period of two (2) full Medical Staff years..."

Review of Mid Level I's credential file revealed an initial appointment of the physician assistant to the CAH's medical staff in 11/05. The physician assistant's credential file lacked documentation of reappointment approval by the Medical Staff and/or Governing Body.

2. During an interview on 3/10/11 at 9:15 AM, Staff D, Administrative Assistant, acknowledged Physician Assistant I worked routinely in CAH's ER. Staff D stated, Physician Assistant I "fell through the cracks and has not been approved by the Medical Staff or Governing Body for reappointment since the initial appointment approval in November of 2005."

Based on observation, medical record review, policy review, and staff interview the Critical Access Hospital (CAH) nursing staff failed to administer medications as ordered by the physician for 1 of 4 patients (Patient #1). The CAH had a census of 13 inpatients at the time of the survey.

Failure to administer medications as ordered by the physician resulted in a patient receiving the wrong dose of a medication .

Findings include:

1. Observation during medication administration on 3/8/11 at 8:05 AM, revealed Staff A, a Registered Nurse (RN), removed oral medications from the Pyxis including Sinemet 25/250 milligrams (mg) following the computer generated Pyxis Medication Administration Record (MAR). Staff A administered the tablet of Sinemet 25/250 mg to Patient #1. Staff A failed to reconcile the medications as documented in the Pyxis MAR with the handwritten MAR completed by nursing staff during the previous shift prior to obtaining and administering the medication.

a. Review of the Physician Admitting Orders, dated 3/7/11 at 8:00 AM, revealed an order for Sinemet 25/100 mg 1 tab (tablet), 2 times a day by mouth.

b. Review of the handwritten MAR, dated 3/8/11, showed a medication entry for Sinemet 25/100 mg 1 tab, by mouth 2 times a day.

2. During an interview on 3/8/11 at 8:05 AM, Staff A stated the pharmacy placed the wrong dose of Sinemet in the Pyxis. Staff A stated "I should have caught the error before removing and administering the Sinemet. I will complete a medication variance report and notify the physician."

Review of a Medication Variance Report Form dated 3/8/11 at 8:30 AM, revealed Staff A documented the medication entered into the Pyxis MAR was " Sinemet 25/250 mg by mouth- dose to be given/ ordered was 25/100 mg. Dose taken from Pyxis and given to patient was 25/250 mg."

3. Review of the CAH policy titled, "Administration of Medicine", reviewed 3/2010, revealed in part "... 4. The professional administering the medication may be held responsible for verifying medications to be administered with the basic order by the attending physician."

4. During an interview on 3/9/11 at 9:00 AM, Staff B, the Medical/ Surgical Department Manager, stated nursing staff write physician orders on patient MAR's by hand when pharmacy staff are not available to enter them into the Pyxis. After the pharmacy staff enter the orders into Pyxis and a computer generated MAR is produced, the nursing staff compare the computer generated MAR with the original physician order for accuracy.

5. During an interview on 3/9/11 at 9:35 AM, Staff C, Pharmacist, reported entering the Sinemet order for Patient #1 into the Pyxis. Staff C acknowledged the wrong dose for Sinemet was placed into the Pyxis by pharmacy staff.