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Based on review of policy and procedure, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff documented whether or not the patient executed an advance directive in a prominent part of the patient's medical record for 2 of 5 swingbed patient (Patient #4 and #19) records reviewed and for 9 of 15 inpatient (Patient #7, #12, #13, #14, #15, #16, #17, #18, and #20) records reviewed. This failure limits the CAH's ability to determine whether the patient had an advance directive.

Findings include:

Review of the policy "Advanced Medical Directive" occurred on 05/25/16. This policy, revised 03/01/13, stated, ". . . Upon admission to acute care, swing bed . . . patient's eighteen years of age or older are asked if they have an Advanced Medical Directive (AMD) . . . Nursing personnel shall query the patient or family member upon admission, if at all possible, as to whether the patient has executed an advanced directive. This shall be done as part of the nursing assessment. The existence or non-existence of an advanced directive shall be documented in the patient's medical record. . . ."

During an interview on the afternoon of 05/23/16, an administrative staff member (#6) stated admitting or business office personnel documented whether each patient had an advance directive upon admission to the hospital.

Review of Patient #4, #7, #12, #13, #14, #15, #16, #17, #18, #19, and #20's medical records occurred on May 23-25, 2016. The records failed to include evidence staff documented whether each patient executed an advance directive.

During an interview on the afternoon of 05/25/16, an administrative nurse (#1) stated nursing personnel documented whether each patient had an advance directive within the nursing assessment upon admission to the hospital. After the nurse (#1) reviewed Patient #4, #7, #12, #13, #14, #15, #16, #17, #18, #19, and #20's nursing assessments upon admission, she confirmed staff failed to document each patient's execution of advance directives.

Based on bylaws review, credentialing files review, and staff interview, the governing body failed to ensure reappointment to the Critical Access Hospital's (CAH's) medical staff for 1 of 3 consulting physicians (Provider #1) credentialing files reviewed. Failure to reappoint physicians providing services to the CAH's patients to the medical staff places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the "Tioga Medical Center Medical Staff By-Laws Rules and Regulations" occurred on 05/23/16 at 11:30 a.m. These bylaws, adopted 02/21/12, stated,
". . . Article IV Procedure for Appointment and Reappointment . . .
Section 3. Reappointment Process . . .
C. The reappointment process shall be completed every two years after the original appointment to the medical staff. . . ."

Review of the governing board's "03/04 Amended Bylaws of Tioga Medical Center (A Non-profit Corporation)" occurred on 05/23/16 at 3:35 p.m. These bylaws, adopted 03/15/04, stated,
". . . Article VI - Medical Staff
Section 1 - Appointment. The Board of Directors shall appoint for the Medical Center a medical staff . . .
Section 2 - Tenure. Such appointments to the medical staff shall be for one year only, commencing July 1, and may be renewed by the Board of Directors at their discretion from year to year. . . ."

Reviewed on 05/25/16 at 10:10 a.m., the credentialing file for Provider #1 showed an initial appointment on June 18, 2012. The file lacked evidence of reappointment.

Upon request on 05/25/16, the CAH failed to provide evidence their medical staff recommended and governing body approved reappointment for Provider #1 when the initial appointment ended.

During an interview on 05/25/16 at 11:20 a.m., an administrative staff member (#2) confirmed Provider #1 provided sleep study interpretation services to the CAH's patients and confirmed the CAH's medical staff and governing body had not reappointed Provider #1 when the initial appointment ended.

Based on review of professional literature, 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 5 active patient (Patient #4 and #5) records reviewed and for 5 of 15 closed patient (Patient #13, #14, #16, #17, and #20) records reviewed. Failure to evaluate the patient's response to prn medications limited the nursing staffs' ability to assess whether the medication achieved the desired effect or if the patient 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 Patient #20's closed inpatient medical record occurred on 05/23/16 and identified the CAH admitted the patient on 05/05/16 with weakness. The record indicated the patient used prn medications for anxiety and discomfort and showed physician orders on admission for Ativan (used for anxiety) 1 milligram (mg) two times a day prn and Tylenol Arthritis (used for discomfort) 650 mg every six hours prn.

Patient #20's Medication Administration Record (MAR) and chart notes showed the following administration times and patient responses for the prn medication:
Ativan
*05/07/16 at 10:59 p.m. - no response documented.
Tylenol Arthritis
*05/05/16 at 8:18 p.m. - no response documented.
*05/07/16 at 8:35 a.m. - no response documented.

- Review of Patient #16's closed inpatient medical record occurred on 05/24/16 and identified the CAH admitted the patient on 12/16/15 with abdominal pain. The record showed a physician order on admission for Reglan (used to prevent/treat nausea) 5 mg intravenous (IV) every eight hours prn. Patient #16's MAR and chart notes identified the administration of Reglan at 5:25 p.m. on 12/16/15 with no response documented.

- Review of Patient #14's closed inpatient medical record occurred on 05/24/16 and identified the CAH admitted the patient on 04/02/16 with epigastric pain and acute pancreatitis. The record indicated the patient used prn medications for pain and showed physician orders on admission for Dilaudid (used to treat pain) 2 mg IV every two hours prn and Toradol (used to treat pain) 30 mg IV every four hours prn.

Patient #14's MAR and chart notes showed the following administration times and patient responses for the prn medication:
Dilaudid
*04/02/16 at 12:34 p.m. - response documented at 2:34 p.m., two hours later; and at 3:15 p.m. - response documented at 5:27 p.m., over two hours later.
*04/03/16 at 3:25 a.m. - response documented at 7:44 a.m., over four hours later.
Toradol
*04/02/16 at 3:18 p.m. - response documented at 5:27 p.m., over two hours later.
*04/03/16 at 3:25 a.m. - response documented at 7:44 a.m., over four hours later; and at 3:05 p.m. - response documented at 11:25 p.m., over eight hours later.

- Review of Patient #17's closed inpatient medical record occurred on 05/24/16 and identified the CAH admitted the patient on 11/03/15 with weakness, pneumonia, and right shoulder pain. The record indicated the patient used prn medications for pain, fever, and nausea and showed physician orders on admission for Percocet (used to treat pain) 10/325 mg one to two tablets two times a day prn, Morphine (used to treat pain) 4 mg IV every six hours prn, Tylenol (used to treat fever) 500 mg one to two tablets every four hours prn, and Zofran (used to prevent/treat nausea) 4 mg every six hours prn.

Patient #17's MAR and chart notes showed the following administration times and patient responses for the prn medication:
Percocet
*11/04/15 at 11:16 a.m. - no response documented; 3:50 p.m. - response documented at 6:33 p.m., almost three hours later; and 10:04 p.m. - no response documented.
*11/05/15 at 12:50 p.m. - no response documented.
Morphine
*11/04/15 at 4:24 a.m. - response documented at 6:25 a.m., two hours later.
Tylenol
*11/04/15 at 8:40 a.m. - no response documented.
*11/05/15 at 5:45 a.m. - no response documented.
Zofran
*11/04/15 at 10:30 p.m. - response documented on 11/05/15 at 2:24 a.m., almost four hours later.

- Review of Patient #13's closed inpatient medical record occurred on 05/25/16 and identified the CAH admitted the patient on 05/06/16 with cough and bronchitis. The record showed a physician order on admission for acetaminophen (used to treat discomfort) 500 mg every four hours prn. Patient #13's MAR and chart notes showed the following administration times and patient responses for the acetaminophen:
*05/06/16 at 8:15 p.m. - no response documented.
*05/07/16 at 8:15 a.m. and 8:30 p.m. - no responses documented.
*05/08/16 at 8:16 p.m. - response documented at 10:31 p.m., over two hours later.

Review of Patient #13, #14, #16, #17, and #20's records failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medication and/or did so in a timely manner.


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- Review of Patient #4's inpatient medical record occurred on 05/24/16 and identified the CAH admitted the patient on 05/05/16 with vertigo. The record indicated the patient used prn medications for pain, fever, and anxiety and showed physician orders on admission for Tylenol (used to treat pain and fever) 325 mg one to two tablets every four hours prn, and Xanax (used to treat anxiety) 0.5 mg one-half tablet twice daily prn.

Patient #4's MAR and chart notes showed the following administration times and patient responses for the prn medication:
Tylenol
*05/16/16 at 9:32 p.m. - no response documented
*05/17/16 at 8:29 a.m. - no response documented
*05/18/16 at 9:41 p.m. - response documented on 05/19/16 at 2:21 a.m., almost five hours later

Xanax
*05/07/16 at 1:42 a.m. - no response documented
*05/09/16 at 12:23 a.m. - no response documented

- Review of Patient #5's inpatient medical record occurred on 05/24/16 and identified the CAH admitted the patient on 04/20/16 post right arm/shoulder fracture. The record indicated the patient used prn medications for pain and showed a physician order for Percocet (combination of oxycodone and acetaminophen) one tablet every four hours prn.

Patient #5's MAR and chart notes for the month of May showed the following administration times and patient responses for the prn medication:
Percocet
*05/01/16 at 6:51 p.m. - no response documented
*05/06/16 at 12:45 p.m. - no response documented
*05/09/16 at 6:42 a.m. - no response documented
*05/11/16 at 6:04 a.m. - no response documented
*05/12/16 at 9:20 a.m. - no response documented
*05/12/16 at 2:42 p.m. - no response documented
*05/13/16 at 9:33 a.m. - response documented at 1:02 p.m., three and a half hours later
*05/17/16 at 5:00 p.m. - no response documented
*05/18/16 at 7:15 a.m. - response documented at 11:03 a.m., almost four hours later

During an interview on 05/25/16 at 1:30 p.m., an administrative nurse (#1) stated she expected staff to reassess the effectiveness of as needed medications within one hour of administration and chart the response in the chart notes.

Based on record review, policy and procedure review, review of professional literature, and staff interview, the Critical Access Hospital (CAH) failed to ensure the medical record included complete instructions to the patient upon discharge regarding medications and self care/follow-up for 6 of 14 closed inpatient (Patient #7, #14, #15, #16, #17, and #18) records reviewed. This failure has the potential to place the patient at risk of improper care after discharge and has the potential to lead to readmission.

Findings include:

Berman, Snyder, and Frandsen's "Kozier and Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 10th edition, 2016, Pearson Education Inc., pages 114-115, stated, ". . . Preparing Clients to go Home . . . Home Health Care Teaching: Clients need help to understand their health condition, to make health care decisions, and to learn new health behaviors. Because of today's shortened hospital stays, it is often unrealistic to teach clients everything they need to know prior to discharge. . . . Essential information before discharge includes information about medications, dietary and activity restrictions, signs of complications that need to be reported to the primary care provider, follow-up appointments . . . Information needs to be provided verbally and in writing. . . ."

Review of the Institute for Healthcare Improvement's (IHI) online topic, "Reconcile Medications At All Transition Points," copyright 2016, stated, "Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking - including drug name, dosage, frequency, and route - and comparing that list against the admission, transfer, and/or discharge orders. The goal is to ensure that all correct medications are [sic] to the patient and to prevent unintended changes or omissions of medications at all transition points. . . . If this process does not occur in a standardized manner that is designed to ensure complete reconciliation, medication errors may lead to adverse events and harm. Changes for Improvement: Reconcile Admission Orders with Home Medication Lists: When a patient is admitted to the hospital, the list of all medications ordered upon admission to the hospital must be compared - or reconciled - with the list of medications the patient was taking before entering the hospital. . . . Reconcile Discharge Instructions and Prescriptions with the Medication Administration Record: After discharge from the hospital, a patient may continue taking some medications at home, but not perhaps all of them. Therefore, it is extremely important to compare the discharge medication instructions and prescriptions with the medication list collected on admission and the medication administration record (MAR) to check for any discrepancies. . . ."

Berman, Snyder, and Frandsen's "Kozier and Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 10th edition, 2016, Pearson Education Inc., pages 769-770, stated, ". . . Medication Reconciliation . . . make a complete list of the client's medications . . . on admission. This current list needs to be compared to any new medications ordered by the primary care provider on admission and during the client's hospital stay. . . . This list is also provided to clients on discharge from the facility. In addition, the client should receive, at discharge, written and oral information on each medication to be taken at home. . . ."

Review of the policy "Medication Reconciliation for Centriq Report" occurred on 05/25/16. This policy, edited 09/30/14, stated, "Policy: The Providers are to complete the Medication Reconciliation Report for these Transitions of Care. They are to inform the patient &[and]/or family if possible about the reconciled medications. . . . Inpatient to Discharge Home . . . Hospital Reconciliation Process Admission: Nurse: . . . 2. Click Update . . . 3. Review list. 4. . . . Add Home Medication . . . Provider: . . . 3. Review the patient's Home Medications. 4. Each medication needs to be addressed. . . . Discharge Reconciliation Process: Provider: . . . 4. . . . update the patient's Home Medications as well as renew any home medications that require renewal. . . . 8. . . . update the patient's home medications. 9. Check all appropriate medications on the Home Medication section. 10. Confirm and acknowledge medication reconciliation. . . ."

- Review of Patient #18's medical record occurred on 05/24/16. The record identified the CAH admitted the patient on 01/30/16 with fatigue, malaise, leukocytosis, and suspected influenza and discharged the patient on 01/31/16. A discharge summary, dated 01/31/16, stated, ". . . Discharge Diagnoses: 1. Malaise and fatigue with improvement of symptoms. 2. Leukocytosis with improvement of symptoms. . . . Hospital Course of Treatment: . . . Influenza swab was negative . . . Discharge Medications: He will continue on his normal medications which include: 1. Aspirin 325 mg [milligram] daily. 2. Coreg 3.125 mg b.i.d. [twice a day]. 3. Lisinopril 10 mg daily. 4. Simvastatin 20 mg daily. 5. Metformin 1000 mg b.i.d., this was stopped on admission but can be restarted now that he is going home. Discharge Plan/Instructions: . . . 3. Continue all current medications. No antibiotics or any other medicines were given on discharge. . . ."

Review of discharge instructions provided to Patient #18 failed to identify medications and included information on influenza, which the patient had no diagnosis of. Patient #18's record failed to include evidence of a discharge medication list.

- Review of Patient #14's medical record occurred on 05/24/16. The record identified the CAH admitted the patient on 04/02/16 with epigastric pain and acute pancreatitis and discharged the patient on 04/04/16. A discharge summary, dated 04/06/16, stated, ". . . Discharge Diagnosis: Acute pancreatitis with improvement of symptoms. . . . Discharge Plan/Instructions: . . . 2. . . . Completely remove alcohol from his diet at this point. . . . 5. He will follow up in the clinic in 1-2 weeks for recheck. . . ."

Review of discharge instructions provided to Patient #14 stated, ". . . 3. Rx [prescription] for Oxycodone . . . 4. US [ultrasound] this upcoming Thursday . . . 7. Follow up as needed." The instructions listed medical abbreviations, failed to direct the patient to remove alcohol, and failed to specify follow up in the clinic in 1-2 weeks as identified in the discharge summary rather than as needed.

- Review of Patient #15's medical record occurred on 05/24/16. The record identified the CAH admitted the patient on 04/04/16 for shortness of breath, congestive heart failure, and pneumonia and discharged the patient on 04/06/16. A discharge summary, dated 04/06/16, stated, "Discharge Diagnoses: 1. Right lower lobe pneumonia. 2. Congestive heart failure exacerbation. . . . 5. Insulin-dependent diabetes mellitus. 6. History of hypertension although running low at home recently. . . . Discharge Medications: 1. Coreg 3.125 mg b.i.d.; this is decreased 50% from his baseline per the patient's noting hypotension at home recently. 2. Digoxin 0.125 mg daily. 3. Valsartan 20 mg daily; this is also decreased 50% from his admission dosages due to the patient running low at home. 4. Change of Lasix to 60 mg twice daily for 3 days followed by resumption of 80 mg daily. 5. Aspirin 325 mg daily. 6. Atorvastatin 20 mg daily. 7. Fenofibrate 145 mg daily. 8. Spironolactone 25 mg daily. 9. Protonix is going to be discontinued and replaced with ranitidine 150 mg . . . b.i.d. 10. Lantus 70 units nightly. 11. Insulin sliding scale b.i.d. 12. Discontinue metformin secondary to renal insufficiency for the time being. 13. Lyrica 75 mg twice daily. 14. Nebulizers as needed. 15. Cefdinir 300 mg b.i.d. x 7 days. 16. Azithromycin 250 mg daily for 5 days. . . . 19. Again, the patient's metformin should be held at this current dose . . . and the patient's Lasix can be adjusted based on his symptomatology. 20. Referrals: . . . he is to return to Cardiology for cardiorenal syndrome evaluation. Discharge Plan/Instructions: The patient is to follow a low-salt cardiac/diabetic-friendly diet. . . ."

Review of discharge instructions provided to Patient #15 included information on Cefdinir, Azithromycin, and Lasix and stated, ". . . decrease carvedilol [Coreg] and valsartan by half of current dose . . ." The instructions failed to identify changes in the patient's medications such as the specific "half" dose of the Coreg and Valsartan, discontinuation of Metformin, replacement of Protonix with Ranitidine, and the specific type of insulin and dose for sliding scale. The instructions also failed to include other medications listed in the discharge summary and information about the specific diet and Cardiology follow up. Patient #15's record failed to include evidence of a discharge medication list.

- Review of Patient #17's medical record occurred on 05/24/16. The record identified the CAH admitted the patient on 11/03/15 for weakness and pneumonia and discharged the patient on 11/05/15. An admission history and physical, dated 11/03/15, stated, ". . . Current Medications: Alprazolam 0.25 mg once at bedtime. Imuran 50 mg 2 tablets at bedtime. Citalopram 40 mg daily. Nexium 40 mg daily. Oxycodone/acetaminophen 10/325 mg 2 tablets as needed at bedtime . . . Prednisone 20-mg tablets twice a day. Lyrica 150 mg 2 tablets twice a day. Warfarin 7.5 mg daily. . . ." A discharge summary, dated 11/05/15, stated, ". . . Discharge Medications: She was started on Cefdinir 300 mg 1 twice daily for an additional 7 days. . . ."

Review of discharge instructions provided to Patient #17 listed the Cefdinir, but failed to include other medications. Patient #17's record failed to include evidence of a discharge medication list.

- Review of Patient #16's medical record occurred on 05/24/16. The record identified the CAH admitted the patient on 12/16/15 with abdominal pain and small bowel obstruction and discharged the patient on 12/17/15. An admission history and physical, dated 12/16/15, stated, ". . . Current Medications: Aspirin 81 mg daily. Albuterol 1 puff 4 times daily as needed. Spiriva 1 puff daily. Saw palmetto 1 tablet daily. Cayenne pepper 1 tablet daily. . . ." A discharge summary, dated 12/17/15, stated, "Discharge Diagnoses: 1. Partial bowel obstruction. 2. Urinary tract infection [UTI]. . . . 10. Hypokalemia secondary to ostomy. . . . Discharge Medications: 1. I prescribed a 3-day course of Cipro 500 mg to be taken twice daily for the UTI. 2. I also prescribed potassium chloride 20 meq [milliequivalents] to be taken daily. 3. The patient's . . . caregivers did ask many times about whether the patient should be taking Miralax . . . it would be okay for the patient to take this to prevent further obstructions. Discharge Plan/Instructions: Followup: I would like the patient to be seen in the clinic in 1 week. I wrote an order for the patient to have a UA [urinalysis] to assess for UTI and for a BMP [basic metabolic panel] to check on his potassium . . ."

Review of discharge instructions provided to Patient #16 failed to include information concerning Cipro, postassium chloride, and Miralax or any other medications. The instructions also failed to include information about the patient's follow up appointment and laboratory tests. A discharge medication list provided to Patient #16 listed Albuterol and Spiriva, but failed to include other medications the patient previously took, as well as new medications identified in the discharge summary.

- Review of Patient #7's medical record occurred on 05/25/16. The record identified the CAH admitted the patient on 02/18/16 with nausea, vomiting, and bowel obstruction and discharged the patient on 02/19/16. A discharge summary, dated 02/19/16, stated, "Discharge Diagnoses: 1. Periumbilical hernia. 2. Resolution of partial small-bowel obstruction from the prior week. . . . 7. History of asthma. . . . Discharge Medications: 1. Albuterol nebulizers as needed. 2. Symbicort 2 puffs twice daily. 3. Stool softener. Discharge Plan/Instructions: 1. Diet: . . . liquid diet which she is to follow for the next few days, slowly advancing a minimal-residue diet and eventually a low-residue diet. I have recommended that she trial each diet for at least 3 days before advancing. . . . 3. The patient has been given ER [emergency room] precautions to return should she have unprovoked vomiting or significant abdominal discomfort, fever, or any other concerns whatsoever. . . ."

Review of discharge instructions provided to Patient #7 stated, ". . . Diet: clears-minimal residue-low residue. Advance as tolerated. . . ." The instructions failed to specify when to advance the diet as identified in the discharge summary, ER precautions, and medications. Patient #7's record failed to include evidence of a discharge medication list.

During an interview on the afternoon of 05/25/16, an administrative staff member (#6) stated the provider (physician, physician assistant, nurse practitioner) responsible for each patient's discharge must complete discharge instructions for the patient and stated they must also perform medication reconciliation to complete a discharge medication list. She stated nursing staff provided each patient with these instructions and medication list upon discharge. The staff member (#6) confirmed Patient #7, #14, #15, #16, #17, and #18's medical records failed to include complete discharge instructions and discharge medication lists upon discharge.

Based on policy review, quality improvement (QI) record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure departments reported as scheduled, monitored quality of care, and established thresholds of acceptability for QI monitoring for 11 of 11 months reviewed (May 2015-March 2016). Failure to ensure departments report as scheduled, monitor quality of care, and establish thresholds of acceptability for QI monitoring limits the CAH's ability to ensure the provision of quality care to the CAH's patients.

Findings include:

Review of the "Tioga Medical Center Acute Care/Long Term Care Quality Improvement Plan" occurred on 05/24/16 at 10:40 a.m. This plan, effective 08/17/09, stated,
". . . IV. Scope
This program is designed to coordinate all review activities pertaining to Quality Improvement issues in the Tioga Medical Center Acute Care/Long Term Care Unit. Patient services will be evaluated in the following areas: . . .
Quarterly: . . . Social Services . . .
V. Methodology
Measurable criteria will be developed by each of the involved hospital/LTC [long term care] departments that will be used to monitor identified problems. These criteria will be of adequate numbers to reach appropriate conclusions regarding problem existence, correction and monitoring. Criteria will be established at a level that is appropriate to address the identified concern.
Monthly data will be collected according to pre-set quantity and quality indicators. A written monthly report will be provided to the Quality Improvement Director that will include an overall analysis of the results of the QI studies, specific conclusions, action taken and subsequent results. . . ."

Review of QI meeting minutes, quarterly reports, and department reports occurred on 05/24/16 at 10:40 a.m. The June 2015-April 2016 QI meeting minutes, June 2015-April 2016 QI quarterly reports, and May 2015-March 2016 department QI reports revealed the following:
*Social Services - no evidence of monitoring or reporting.
*Health information management - failed to monitor quality of care.
*Plant operations - failed to include thresholds of acceptability for monitoring.
*Dietary department - failed to include the purpose of their monitoring, thresholds of acceptability, and an overall analysis of their collected data.

During an interview on 05/25/16 at 10:30 a.m., an administrative nursing staff member (#2) confirmed Social Services had not performed QI monitoring, health information management had not monitored quality of care, plant operations had not established thresholds of acceptability, and the dietary department had not included the purpose of their monitoring nor analyzed their data.