HospitalInspections.org

Based on review of the facility's advance directive information and staff interview, the Critical Access Hospital (CAH) failed to provide evidence of community education regarding advance directives for 3 of 3 days of survey (October 20-22, 2014). Failure to provide community education regarding advance directives limited the community's ability to gain knowledge about making informed decisions regarding advance directives.

Findings include:

Review of the facility's advance directive information occurred in the afternoon on 10/21/14. The information failed to include evidence of community education regarding advance directives.

During an interview on 10/21/14 at 4:00 p.m., an administrative nurse (#2) stated the CAH had not provided education to the community regarding advance directives.

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). 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 10/21/14 at 9:30 a.m. with an administrative nurse (#2) 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 (#2) confirmed the facility had one crash cart located in the ER.

Observation of the OR occurred on 10/21/14 at 4:30 p.m. with an administrative nurse (#5). During an interview at this time, the administrative nurse (#5) stated staff would use the crash cart from the ER in the OR for use in case of an emergency on days the CAH performed surgery.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the safety of 2 of 8 patient beds with side rails (Rooms #17 and #29). Failure to firmly secure side rails on patient beds limits the CAH's ability to ensure the safety of the patients using the beds.

Findings include:

Observation during the morning of 10/21/14 identified a half rail elevated on Patient #1's bed in Room #17 and a half rail elevated on Patient #4's bed in Room #29.

Observation on 10/22/14 at approximately 9:50 a.m. with an administrative maintenance staff member (#3) showed the side rails on the bed in Room #29 were not firmly secured allowing for movement from side-to-side and in-and-out.

During interview on 10/22/14 at approximately 9:55 a.m., an administrative maintenance staff member (#3) confirmed the side rails on the patient bed in Room #29 were not securely attached to the bed. Staff member #3 stated staff had failed to notify the maintenance department of the poorly secured side rails.

Observation on 10/22/14 at approximately 10:00 a.m. with an administrative nursing staff member (#2) showed the side rails on the bed in Room #17 were not firmly secured allowing for movement from side-to-side and in-and-out.

During interview on 10/22/14 at approximately 10:05 a.m., an administrative nursing staff member (#2) confirmed the side rails on the bed in Room #17 were not securely attached to the bed and stated she would expect securely attached side rails for the patients' safety.

1. Based on bylaws review, credentialing file review, and staff interview, the Critical Access Hospital (CAH) failed to ensure reappointments to Medical Staff followed their bylaws for 1 of 2 physician (Provider #1) and 1 of 2 nurse practitioner (Provider #2) files reviewed. Failure to follow the bylaws for reappointing staff members limits the CAH's ability to ensure their patients receive treatment from qualified providers.

Findings include:

Review of the medical staff's bylaws occurred on 10/20/14 at approximately 3:10 p.m. These bylaws, effective 02/27/13, stated,
". . . Article III Membership . . .
Section 3. Terms of Appointment
Subsection 1
Appointment to the medical and dental staff shall be made by the governing body after recommendations by the medical staff for a provisional seven-month period. After a six-month review is completed, the appointee will then be reappointed by the governing body until the next scheduled credentialing cycle. The governing body of St. Luke's Hospital may reappoint members of the staff for a further period of two years unless not recommended by the staff. . . ."

Review of the following provider credentialing files occurred on 10/21/14 at approximately 4:30 p.m.:

- Provider #1's file showed the governing board approved reappointment to courtesy staff on 06/23/11 and again on 08/28/13. The current reappointment occurred after the CAH's scheduled credentialing cycle and after the previous reappointment had lapsed.

- Provider #2's file showed the governing board approved initial appointment as a nurse practitioner on 07/26/12. The governing board approved reappointment on 08/28/13 for the timeframe of 12/30/12 through 07/30/13 (after the seven month initial provisional appointment). The governing board's approval of reappointment occurred approximately eight months after the reappointment timeframe began on 12/30/12.

During an interview on 10/22/14 at approximately 10:30 a.m., an administrative staff member (#1) stated the CAH's credentialing cycle ends June 30th of odd numbered years and is for a two year period and agreed the current reappointment for Provider #1 had occurred late. Administrative Staff Member #1 confirmed initial appointment for providers is provisional for six months and agreed the reappointment for Provider #2 had occurred late.

During an interview on 10/22/14 at approximately 10:40 a.m., a human resources staff member (#4) confirmed Provider #1 had treated CAH patients between the dates of 06/23/13 and 08/28/13 when the reappointment period had lapsed. Staff member #4 confirmed Provider #2 had treated CAH patients between the dates of 12/30/12 through 07/30/13 when the reappointment approval was late.

2. Based on bylaws review, credentialing file review, and staff interview, the Critical Access Hospital (CAH) failed to ensure their bylaws provided for credentialing of telemedicine courtesy staff for 1 of 2 telemedicine providers (Radiology Entity #3) and for accepting credentialing from a network hospital for 1 of 1 pathologist (Provider #4). Failure to include provisions in the bylaws for accepting credentialing from telemedicine entities and network hospitals limits the CAH's ability to ensure proper credentialing.

Findings include:

Review of the medical staff's bylaws occurred on 10/20/14 at approximately 3:10 p.m. These bylaws, effective 02/27/13, stated,
". . . Article IV Divisions of the Medical and Dental Staff . . .
Section 5. The Courtesy Staff
Subsection 3
Telemedicine is the use of medical information exchanged from one site to another via electronic communication for the purpose of patient care, treatment, and services in the Emergency Room. Individuals providing telemedicine services from a "distant site" must be appointed to the courtesy telemedicine staff . . . Schedule 1 and 2 of the Emergency Privileges with [name of contracted emergency telemedicine provider] also apply." The bylaws did not address credentialing of other telemedicine providers. The bylaws did not address acceptance of credentialing for providers from network hospitals.

Review of the credentialing file for a contracted pathologist (Provider #4) occurred on 10/21/14 at approximately 5:40 p.m. The file showed the CAH accepted the pathologist's credentialing from a network hospital.

Review of credentialing files for a contracted teleradiology service (Radiology Entity #3) occurred on 10/21/14 at approximately 5:45 p.m. The files showed the CAH accepted the teleradiologists' credentialing performed at the distant site.

During an interview on 10/22/14 at approximately 10:50 a.m., an administrative staff member (#1) confirmed the CAH accepted the credentialing performed at the distant site for a teleradiology group and at a network hospital for a pathologist and the bylaws did not provide for this.

Based on observation, review of the North Dakota Administrative Code, policy and procedure review, review of infection control records, review of meeting minutes, record review, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to limit access to the pharmacy in the absence of the pharmacist (Refer to C276); failed to store drugs and biologicals in a secure manner to prevent access by unauthorized personnel (Refer to C276); failed to ensure the removal of outdated medications from drug storage areas and failed to maintain drug storage in accordance with accepted professional principles in one drug storage area (Refer to C276); failed to ensure proper labeling of drugs available for patient use (Refer to C276); failed to follow professional standards of care relating to infection control practices (Refer to C278); failed to implement a system to identify, report, investigate, and control infections and communicable diseases for CAH outpatients (Refer to C278); failed to evaluate the safe use of side rails, failed to assess each patient individually prior to utilizing side rails, failed to consider side rails as a potential entrapment hazard, and failed to provide education to the patient and responsible party regarding the hazards of side rail use (Refer to C294); failed to ensure appropriate use of assistive devices to prevent accidents for patients requiring transfer assistance (Refer to C294); failed to assess and document the effectiveness of medications given to patients on an as needed basis (Refer to C294); failed to clarify physicians' orders and administer medications in accordance with physicians' orders (Refer to C297); and failed to ensure staff administered medications in accordance with accepted standards of practice and failed to ensure staff destroyed medications in a safe and secure manner (Refer to C297). Failure to ensure the provision of services places the CAH patients at risk of receiving improper care.

1. Based on observation, review of the North Dakota Administrative Code, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to limit access to the pharmacy in the absence of the pharmacist for 1 of 1 hospital pharmacy. This failure limited the CAH's ability to ensure administration of pharmaceutical services in accordance with accepted professional principles.

Findings include:

The North Dakota Administrative Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. 1. General. During such times a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance . . . for the provision of drugs . . . by use of night cabinets or floor stock, or both, and 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. . . ."

Review of the facility policy "Dispensing of Drugs" occurred on 10/22/14. This policy, revised August 2013, stated, ". . . 2. The pharmacy drug room is locked at all times. Only qualified personnel have access to it.
3. An RN [registered nurse] or LPN [licensed practical nurse] may administer single doses of medication to outpatients and emergency room patients with a physician's order . . .
6. The charge nurse is responsible for carrying the key to the drug room. . . ."

Observation of the pharmacy occurred on 10/21/14 at 2:00 p.m. with an administrative nurse (#2). The staff member (#2) stated the pharmacist does not have specific working hours, but comes to the CAH daily to fill patient's medications. The nurse (#2) stated the charge nurse accessed the pharmacy in his absence to obtain medications for patients, return outdated medications, and obtain outpatient prescription medications for emergency room (ER) patients.

During an interview on 10/21/14 at 3:15 p.m., two staff nurses (#6 and #7) confirmed the charge nurse accessed the pharmacy to obtain take-home medications for ER patients and return outdated medications found on medication carts and in the medication room.

2. Based on observation, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to store drugs and biologicals in a secure manner to prevent access by unauthorized personnel in 2 of 4 medication storage areas (Emergency Room [ER] and Operating Room [OR]). Failure of the CAH to adequately secure and restrict access of drugs and biologicals created an opportunity for unsafe and unauthorized use of medications.

Findings include:

Review of the policy "Crash Cart" occurred on 10/22/14. This policy, revised March 2003, stated, ". . . 3. Security:
a. All drugs on the crash cart are stored in a locked drawer or box.
b. Crash carts are to be secured at all times with specified locks except when in use . . .
5. Outdates:
a. Nursing is responsible for checking cart medications and drug boxes for outdates at the end of each month. . . ."

Review of the facility policy "Inventory and Control" occurred on 10/22/14. This policy, revised August 2013, stated, "1. All stock drugs will be kept in locked storage areas . . . 10. The drug room is kept locked at all times. . . ."

- Observation of the Main ER with an administrative nurse (#2) occurred on 10/21/14 at 9:30 a.m. and showed a crash cart, locked with a yellow plastic break away lock, located by the exam table. The crash cart contained various medications used in life-threatening situations and additional yellow plastic locks, used as replacements for the lock on the cart, located on the side of the cart, visible and easily accessible to anyone in the ER. The staff member (#2) stated staff do not log the unique identifier located on each plastic break away lock.

Observations on October 20-22, 2014 identified patients and those accompanying them in the ER at times without staff present.

- Observation of the OR occurred on 10/21/14 at 4:30 p.m. with a surgical nurse (#5). The nurse stated staff keep the OR door locked when not in use, but housekeeping and maintenance staff have access to the OR when needed. An unlocked cabinet in the OR contained an unopened bottle of Xylocaine (local anesthetic). Observation of a small storage room connected to the OR identified unlocked sedatives and various life-saving medications, including the following:
* Propofol 1% - 24 vials
* Ultane - 1 vial
* Atropine - 1 vial
* Ephedrine sulfate - 10 vials
* ondansetron - 3 vials
* glycopyrrolate - 25 vials
* Flumazenil - 1 vial
* Naloxone hydrochloride - 3 vials
* Neostigmine - 10 vials
* Dantrium - 24 vials
* 50% Dextrose - 2 vials
* 8.4% Sodium Bicarbonate - 2 vials
* Potassium Chloride - 2 vials

During an interview on the morning of 10/21/14, an administrative nurse (#2) stated the CAH should store medications securely to prevent unauthorized access and use.


32641


3. Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications from 2 of 4 drug storage areas (emergency room and medication cart) and failed to maintain drug storage in accordance with accepted professional principles in 1 of 4 drug storage areas (medication cart).

Findings include:

Review of the policy "Outdated Drugs" occurred on 10/22/14. This policy, revised August 2013, stated, "1. . . On the first (1st) and fifteenth (15th) day of each month, the outdated drugs will be removed by the nurses and placed in a basket in the drug room. . . ."

Review of the policy "Care and Storage of Drugs" occurred on 10/22/14. This policy, revised August 2013, stated, "GENERAL INFORMATION: 1. Keep all bottles covered tightly . . . 5. Multi-dose vials should be dated on the day opened . . . If a vial is found to be unmarked as to the date opened or if the date is illegible, the vial must be disposed of. . . ."

- Observation of the emergency room took place on 10/21/14 at 9:45 a.m. with a supervisory nurse (#6). Observation identified, in emergency room 2, a 50 milliliter (ml) used vial of Marcaine 0.25% expired 08/14 (August 2014). A handwritten date on the vial of 10/14 (October 2014) indicated staff used the vial after the expiration date.

The supervisory nurse (#6) agreed staff should ensure medications are not expired before use.

- Review of the medication cart took place on 10/21/14 at 10:55 a.m. with a staff nurse (#7). Observation identified:
* Children's Allergy 4 ounce liquid expired 09/14 (September 2014). Staff failed to identify the date opened on the bottle.
* Tums chewable bottle open with no lid.

The staff nurse (#7) agreed staff should remove expired medications from the cart and secure all medications with lids.

During an interview on 10/21/14 at 2:25 p.m., an administrative nurse (#2) stated nurses check for expired medications monthly in all medication storage areas.

4. Based on observation, staff interview, and policy and procedure review, the Critical Access Hospital (CAH) failed to ensure proper labeling of drugs available for patient use in 2 of 4 medication storage areas (pharmacy and medication cart). Failure to ensure proper labeling of drugs has the potential for medication errors and for staff to have available mislabeled or unusable medications for patient use.

Findings include:

Review of the policy titled, "Dispensing of Drugs" occurred on 10/22/14. This policy, revised August 2013, stated, ". . . 5. Any labeling, refilling, packaging or prepackaging will be done by a pharmacist. . . ."

Review of the policy titled, "Care and Storage of Drugs" occurred on 10/22/14. This policy, revised August 2013, stated, ". . . 4. Do not keep drugs in the drug cart unless properly labeled. . . ."

- Review of the medication cart took place on 10/21/14 at 10:55 a.m. with a staff nurse (#7). Observation identified a medication cassette labeled "clonazepam 1 mg [milligram]." The cassette contained ten whole tablets and one half tablet.

The staff nurse (#7) indicated nurses split the 1 mg tablet for a 0.5 mg dosage order. Nurses then place the other half tablet back into the cassette. The staff nurse (#7) agreed the cassette label did not correctly reflect the contents.

- During observation of the pharmacy on 10/21/14 at 2:50 p.m., with an administrative nurse (#2), a "Medications Removed From Pharmacy" form showed a nurse documented the removal of "sertraline 50 1/2 tab" on 10/20/14 at 1:00 p.m. Observation of the pharmacy's medication stock showed a sertraline 25 mg and 50 mg bottle. The administrative nurse (#2) verified the sertraline 50 mg bottle contained a half tablet making it incorrectly labeled and verified the nurse failed to remove the 25 mg dose from the proper bottle.

1. Based on observation, review of facility policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care relating to infection control practices observed during patient care, administration of medications, and equipment cleaning/disinfecting on 2 of 2 days (October 20-21, 2014) of observation. 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 policy "Standard Precautions" occurred on 10/22/14. This policy, revised March 2003, stated, ". . . 1. Hand washing: Routine hand washing with a plain soap is essential with patient contact whether or not gloves are worn. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. Hands must be cleansed between passing meds to different patients. HAND WASHING IS AN EXTREMELY IMPORTANT MEASURE IN PREVENTING THE TRANSMISSION OF INFECTION . . . 2. Gloves: Clean gloves are required in anticipation of touching any moist body fluids, mucous membranes or non-intact skin (i.e. blood, sputum, urine, feces, saliva). Gloves should be changed after each patient contact and between care of different body sites on the same patient. Remove gloves promptly after use and before touching non-contaminated surfaces. Wash hands after glove removal. GLOVES ARE NOT A SUBSTITUTE FOR HANDWASHING . . . 5. Patient Care Equipment: Handle all used equipment in a manner that prevents skin and mucous membrane exposure, contamination of clothing, transfer of micro-organisms to other patients and the environment . . . b. Reusable equipment: Clean and reprocess appropriately before use on another patient. . . ."

- On 10/20/14 at 2:00 p.m., observation showed a nurse (#13) entered Patient #2's room, and without performing hand hygiene, donned gloves, applied cream to the patient's legs (legs were edematous, reddened, and had scabs visible), wrapped both legs with ACE wraps, removed her gloves, and exited the room to refill the patient's water pitcher. The nurse (#13) failed to perform hand hygiene prior to making contact with the patient and after completing the leg treatment.

- Observation on 10/20/14 at 3:45 p.m. showed a nurse (#13) inserted an intravenous (IV) catheter into Patient #23's right hand. The nurse (#13) failed to perform hand hygiene prior to donning gloves for the IV insertion. The nurse (#13) tore off the tip of the glove on her right index finger to palpate the patient's vein with her exposed fingertip. After inserting the IV, the nurse (#13) removed her gloves and administered pain medication to the patient. The nurse (#13) failed to perform hand hygiene before donning gloves to insert the IV catheter, following the insertion after removing her gloves, and prior to and after administering the medication. During this observation, the nurse took Patient #23's emesis bag (containing brown liquid) with ungloved hands, bagged it in a red biohazard bag, and disposed of it in a biohazard container, located in the garage on a different wing of the CAH. The nurse washed her hands after returning to the nurse's station.

- Observation on 10/21/14 at 8:00 a.m. showed a nurse (#14) administered a medication, without wearing gloves, via an IV cannula located in the left hand of Patient #24 in the Emergency Room. Observation showed blood splattered on Patient #24's clothes and skin, including his left hand, from a bloody nose. The nurse failed to wash her hands prior to and after administering the medication and failed to wear gloves. After administering the medication, the nurse (#14) went to the nurse's station to continue charting.

- During morning medication administration on 10/21/14, observation showed a nurse (#7) prepared a patient's oral medications at the medication cart while wearing gloves, walked out of the nurse's station, down the corridor, and into the patient's room to deliver the medications. The nurse (#7) emerged from the patient's room wearing gloves. The nurse (#7) repeated this process throughout the medication pass.

- Observation on the morning of 10/21/14 identified a bin, which stored a glucometer, lancets, and alcohol pads, stored at the nurse's station. During an interview on 10/21/14 at 11:20 a.m., a nurse (#7) stated staff cleaned the glucometer (shared between patients) with an alcohol pad after each use. The nurse (#7) stated the CAH did not have any current patients requiring accuchecks.

During an interview on 10/22/14 at 1:15 p.m., an administrative nurse (#2) stated she expected staff to wash their hands with soap and water when coming in direct contact with patients and to use hand sanitizer/foam when not in direct contact with patients, such as when handing them a medication cup. The staff member (#2) stated the facility does not have a policy on disinfecting glucometers, but she personally uses high-level disinfecting wipes to disinfect the glucometer in between patients. The administrative nurse (#2) stated staff should remove gloves and perform hand hygiene prior to exiting a patient's room, including rooms in the ED.

2. Based on review of infection control reports, logs, and 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 13 of 13 months (September 2013 through September 2014) reviewed. Failure to identify and address incidents of infections among all patients and personnel 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:

Reviewed on 10/21/14, the infection control records lacked evidence the CAH identified and recognized both nosocomial and community-acquired infections of outpatients treated in the Emergency Room (ER) and those receiving outpatient rehabilitation. The infection reports/logs from September 2013 through September 2014 failed to include information and documentation of all outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on the afternoon of 10/21/14, an administrative nurse (#2) stated the facility does not receive or request infection control information from all outpatients, including outpatient rehabilitation patients and ER patients, and confirmed the CAH did not formally document and include all outpatients in infection control surveillance. During this interview, the administrative nurse (#2) confirmed the facility did not perform quality improvement audits in the area of infection control and did not perform surveillance or monitoring of staff and patients for infection control practices to evaluate the effectiveness of their infection control program.

Reviewed on 10/21/14, the CAH's infection control log, infection control reports, and infection control meeting minutes lacked evidence the CAH identified and recognized infections of employees of the CAH. The CAH failed to implement a system to track and trend infections and communicable diseases of employees.

During an interview on the afternoon of 10/21/14, an administrative nurse (#2) confirmed the CAH did not have an infection tracking system for employees.

Failure to document all incidents of infection and communicable disease, perform surveillance among all outpatients of the CAH and personnel, and evaluate the effectiveness of the infection control program limited the staffs' ability to identify, monitor, track, control, and prevent infections.

1. Based on observation, record review, professional literature review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the safe use of side rails, failed to assess each patient individually prior to utilizing side rails, failed to consider side rails as a potential entrapment hazard, and failed to provide education to the patient and responsible party regarding the hazards of side rail use for 7 of 7 active patients (Patient #1, #2, #3, #4, #6, #7, and #8) observed with elevated side rails. Failure to assess and evaluate the use of side rails has the potential to restrict a patient's movement and place the patient at risk for injury. Failure to assess and evaluate the use of side rails, to consider side rails as a potential entrapment hazard, and to educate patients and responsible parties regarding the hazards of using side rails placed patients at risk of entrapment or injury.

Based on review of the North Dakota Department of Health, Division of Health Facilities provider files, this facility has not sustained correction of this issue. The previous surveys completed on 02/28/08 and 11/02/11 found this requirement out of compliance.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated April 2003, stated, ". . . bed rails may pose increased risk to patient safety. . . . evidence indicates that half-rails pose a risk of entrapment . . . as well as falls that occur when patients climb over the rails or footboards when the rails are in use. . . . CMS [Centers for Medicare and Medicaid Services] issued guidance in June 2000 . . . One section of the guidance states, 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. Even when a side rail is not intentionally used as a restraint, patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised siderails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . . 1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize . . . those in current use should occur within the framework of an individual patient assessment. . . . 3. Use of bed rails should be based on patients' assessed medical needs and should be documented clearly . . . The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted . . . The care plan should include educating the patient about possible bed rail danger to enable the patient to make an informed decision . . . If a bed rail has been determined to be necessary, steps should be taken to reduce the known risks associated with its use. . . . Assessment of risk should be part of the individual patient's assessment, and steps to address the risk should be incorporated into the patient's care plan. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts", revised April 2010, stated, ". . . Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . . Most patients can be in bed safely without bed rails. Consider the following: Use beds that can be raised and lowered close to the floor . . . Keep the bed in the lowest position with wheels locked. When the patient is at risk of falling out of bed, place mats next to the bed . . . Monitor patients frequently. Anticipate the reasons patients get out of bed . . . meet these needs . . . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. . . . Reassess the need for using bed rails on a frequent, regular basis."

- Observation during the morning of 10/21/14 identified a half rail elevated on one side of Patient #1's bed.

Review of Patient #1's medical record occurred on all days of survey and identified the CAH admitted this patient on 10/17/14. The current care plan included shortness of breath with fatigue and weakness and extensive assist of one with a walker or wheelchair for mobility.

- Observation of Patient #2, while she rested in bed on the morning of 10/22/14, identified two elevated one-quarter rails on the bed.

Review of Patient #2's active swing bed record occurred on all days of survey and identified the CAH admitted the patient on 10/13/14 with diagnoses including general debility and chronic pain. The care plan identified the patient required extensive assistance with ambulation and toileting.

- Observation of Patient #3, while the patient rested in bed on 10/20/14 at 2:45 p.m., identified two half rails elevated on the patient's bed. On 10/21/14 at 8:00 a.m., further observation of this patient showed the two half rails remained elevated while the patient rested in bed.

Review of Patient #3's medical record occurred on all days of survey and identified the CAH admitted this patient on 10/15/14 with diagnoses including a stroke with right-sided weakness. The current care plan identified the patient required extensive to total assist with activities of daily living and transfer with a total body mechanical lift.

- Observation of Patient #4, during the morning of 10/21/14, identified one half rail elevated on the patient's bed.

Review of Patient #4's medical record occurred on all days of survey and identified the CAH admitted this patient on 10/20/14 with diagnoses including weakness and falls. The current care plan identified the patient required extensive assist with dressing and assist of one for mobility with a walker.

- Observation of Patient #6, during the morning of 10/21/14, identified two quarter rails elevated on the patient's bed.

Review of Patient #6's medical record occurred on all days of survey and identified the CAH admitted this patient on 03/09/13 with diagnoses including dementia, Alzheimer's disease, and falls with a fractured pelvis. The current care plan identified the patient with "impaired physical mobility, impaired balance, a history of falls, and diminished mental status (e.g. [for example], confusion, delirium, dementia, impaired reality testing)."

- Observation of Patient #7, while she rested in bed on the morning of 10/22/14, identified two elevated rails on the bed.

Review of Patient #7's medical record occurred on all days of survey and identified the CAH admitted this patient on 09/03/14 with diagnoses including a fall with a fractured right femur. The current care plan identified the patient required extensive assistance with all personal cares, transfers, and mobility.

- Observation on the morning of 10/21/14 identified two elevated one-quarter rails on Patient #8's bed. The patient sat in her recliner eating breakfast, but a CNA (#8) stated they remained elevated when the resident rested in bed.

Review of Patient #8's medical record occurred on October 20-21, 2014 and identified the CAH admitted this patient on 10/18/14 with diagnoses including dementia, confusion, and recurrent falls.

Patient #1, #2, #3, #4, #6, #7, and #8's records lacked an individualized assessment of risk and safety for the use of side rails, lacked evidence of patient or responsible party education regarding the hazards of side rail use, and lacked a care plan for the side rails.

During an interview on 10/21/14 at 9:50 a.m., an administrative nurse (#2) stated patients used the elevated side rails for positioning and confirmed nursing staff does not perform an assessment for risk factors or safety for utilization of side rails. The staff member (#2) confirmed staff had not educated patients or families on the risks of using side rails, including for positioning in bed.

2. Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure appropriate use of assistive devices to prevent accidents for 2 of 2 patients (Patient #2 and #6) who required staff assistance for transfers. Failure of staff to use a gait belt when transferring Patient #2 and #6 and ensure Patient #6 wore proper footwear during a transfer placed patients at risk for falls and/or injury.

Findings include:

- Review of Patient #6's medical record occurred on all days of survey and included diagnoses of dementia, Alzheimer's disease, and recurrent falls with a history of fractures. The current care plan identified Patient #6 with "impaired physical mobility, impaired balance, a history of falls, and diminished mental status (e.g. [for example], confusion, delirium, dementia, impaired reality testing)." The current nurses' notes identified Patient #6 as confused, utilized a bed alarm, and ambulated with a front-wheeled walker (FWW) and stand-by-assist of one.

During an observation on 10/21/14 at 10:30 a.m. two certified nursing assistants (CNA) (#8 and #9) physically assisted Patient #6, from the bed to a tub chair using a FWW, placing their hands under the patient's axilla, and pulling upward. Once in the tub room the CNAs put Patient #6's shoes over non-gripper socks and again physically assisted the patient to the toilet and back onto the tub chair. The CNAs failed to use a gait belt during the transfers and ensure the patient wore proper footwear.

Observation on 10/21/14 at 11:00 a.m. identified two CNAs (#8 and #9) assisted Patient #6 to stand from the bath chair by lifting under each of the patient's arms. One CNA (#8) placed her hand on Patient #6's back and ambulated beside her from the tub room to the patient's room. Observation showed Patient #6 took slow and unsteady steps as she ambulated. The CNAs (#8 and #9) failed to use a gait belt when assisting Patient #6.


27645


- Review of Patient #2's active swing bed record occurred on all days of survey and identified the CAH admitted the patient on 10/13/14 with diagnoses including general debility and chronic pain. The care plan identified the patient required extensive assistance with ambulation and toileting.

Observation on 10/21/14 at 8:20 a.m. identified a (CNA) (#9) transferred Patient #2 from the commode to the recliner using a gait belt. The CNA (#9) held the loose gait belt with one hand and lifted under Patient #2's left arm with her other hand.

During an interview on the afternoon of 10/22/14, an administrative nurse (#2) stated staff should grasp the gait belt during transfers and avoid lifting on patients' arms. The nurse (#2) stated staff should use a gait belt when transferring Patient #6.



28086

3. Based on record review, professional reference 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 7 closed inpatient (Patient #18, and #22) records reviewed. Failure to evaluate the patients' response 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 870, states, ". . . 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 #18's closed medical record occurred on 10/21/14 and identified the CAH admitted the patient on 06/08/14 with erythroderma, psoriasis, and pain. The record indicated the patient used prn medications for itchiness and pain due to a skin condition. Physician orders included Dilaudid (used to treat pain) 1-2 milligrams (mg) intravenous (IV) q (every) two hours prn, Morphine (used to treat pain) 10 mg IV q two hours prn, oxycodone (used to treat pain) 5/325 mg one to two tablets q six hours prn, and diphenhydramine (used to treat itchiness) 25 mg one to two tablets q eight hours prn.

Patient #18's online medication administration record (OMAR) and nurse progress notes showed the following administration times and patient responses for the prn medication:
*Dilaudid:
06/08/14 at 2:10 p.m. and 10:40 p.m. - no responses documented.
06/09/14 at 5:45 a.m. and 12:25 p.m. - no responses documented.
*Morphine:
06/10/14 at 8:57 a.m. - no response documented.
*oxycodone:
06/10/14 at 5:55 p.m. - no response documented.
06/11/14 at 12:30 a.m. and 8:13 a.m. - no response documented.
*diphenhydramine:
06/08/14 at 2:30 p.m. and 10:40 p.m. - no responses documented.
06/09/14 at 10:09 p.m. - no response documented.
06/10/14 at 8:58 a.m. - no response documented.
06/11/14 at 3:06 a.m. - no response documented.

Review of Patient #18's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the prn medication.

- Review of Patient #22's closed medical record occurred on 10/22/14 and identified the CAH admitted the patient on 04/23/14 with pneumonia, acute renal failure, and pain. The record indicated the patient used prn medications for pain and cough due to her condition. Physician orders included Morphine 1-2 mg IV q two hours prn, oxycodone 5 mg q four hours prn, and Phenergan with Codeine (used to decrease cough/pain) elixir 1-2 teaspoons q six hours prn.

Patient #22's OMAR and nurse progress notes showed the following administration times and patient responses for the prn medication:
*Morphine:
04/24/14 at 3:03 p.m. - failed to indicate the time of the response.
04/25/14 at 12:51 a.m. - failed to indicate the time of the response.
*oxycodone:
04/26/14 at 4:05 p.m. - failed to indicate the time of the response.
04/27/14 at 1:50 p.m. and 8:15 p.m. - failed to indicate the time of the responses.
*Phenergan with Codeine:
04/24/14 at 4:00 a.m. and 10:15 p.m. - no response documented.
04/26/14 at 3:00 p.m. - no response documented.
04/27/14 at 6:42 p.m. - no response documented.

Review of Patient #22's record failed to include evidence nursing staff documented the time of reassessment and failed to assess and document the effectiveness or the patient's response to the prn medication.

During an interview on 10/22/14 at 1:30 p.m., an administrative nurse (#2) stated staff should evaluate the effectiveness of prn medications no later than two hours after administration (which contradicted professional standards of practice) and document this in the medical record.

1. Based on observation, record review, policy and procedure review, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to clarify physicians' orders and administer medications in accordance with physicians' orders for 1 of 1 swing bed patient (Patient #1). Failure to clarify and follow physicians' orders resulted in a delay of Patient #1's medications which included an antibiotic for a urinary tract infection (UTI) and an electrolyte (potassium chloride) replacement.

Findings include:

Review of the policy "Physician's Orders' occurred on 10/22/14. This policy, revised August 2013, stated, ". . . Licensed RNs [registered nurse] or LPNs [licensed practical nurse] observe all orders and clarify when appropriate . . . Drugs may be taken from stock supply until the pharmacist is available. . . ."

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc, New Jersey, page 852 states, "The nurse should always question the primary care provider about any order that is ambiguous, unusual . . . When the nurse judges a primary care provider-ordered medication inappropriate, the following actions are required: *Contact the primary care provider. . . ."

Review of Patient #1's medical record occurred on all days of survey. The record showed a physician's order written on 10/20/14 at 9:40 p.m. for the completion of a urine culture on a previously obtained specimen or a new specimen, an increase in a potassium dosage, and to begin an antibiotic, ciprofloxacin, for a UTI. The online medication administration record (OMAR) showed nursing staff entered the antibiotic to start 10/21/14 at 9:00 p.m. and the potassium to start 10/21/14 at 9:00 p.m., almost twenty-four hours after the initial order.

Laboratory reports dated 10/20/14 showed the following:
* Blood potassium level 3.6 (Range 3.6 - 5.0)
* Urinalysis results supporting a UTI

During an interview on 10/21/14 at 3:00 p.m. a charge nurse (#6) and an administrative nurse (#2) agreed the physician's order for potassium appeared unclear and difficult to read. Both nurses verified nursing staff failed to clarify the potassium order and ensure the orders entered into the OMAR did not result in any skipped potassium doses or a delay in starting the antibiotic for the UTI. The charge nurse (#6) stated staff reported Patient #1 as currently experiencing symptoms of fever, chills, and confusion.

2. Based on observation, review of professional reference, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff administered medications in accordance with accepted standards of practice and failed to ensure staff destroyed medications in a safe and secure manner during 2 of 3 days (October 20-21, 2014) of survey. Failure to administer and destroy medications properly may result in patients receiving the wrong medication.

Findings include:

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc, New Jersey, page 860 states, " . . . Administer only medications personally prepared. . . ."

- Observation of medication administration took place on 10/21/14 at 8:10 a.m.. A nurse (#2) prepared medications for Patient #1 and #2 in two separate medication cups. After administering the medication to Patient #1 the nurse (#2) left Patient #2's medication with a charge nurse (#6) who administered the medication at 8:30 a.m.

During an interview on 10/21/14 at 10:30 a.m. an administrative nurse (#2) agreed the same nurse who prepares a medication should administer it.

- Observation at the nurses' station on 10/20/14 at 4:50 p.m., showed an unidentified patient's family member handed a white medication tablet found on the patient's floor to a certified nursing assistant (CNA) (#10). Nursing staff instructed the CNA (#10) to dispose of the medication tablet in the waste basket beside the nurses' station. Observation during that same time showed a round white medication tablet visible in the waste basket. A charge nurse (#11) indicated awareness of the missing medication tablet and identified the medication as Lasix (a potent diuretic).

During an interview on 10/21/14 at 10:30 a.m. an administrative nurse (#2) stated staff failed to dispose of the medication properly in a sharps container.

1. Based on review of medical staff rules and regulations, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a complete medical record for 1 of 2 closed emergency department (ED) patient (Patient #10) records reviewed who transferred to another facility. Failure to ensure a complete medical record limited the CAH's ability to ensure the patient received appropriate care related to the patient's medical condition.

Findings include:

Review of the CAH's Medical and Dental Staff Rules and Regulations occurred on 10/21/14. This document, adopted on 02/27/13, stated, ". . . 24. Emergency Services . . . means that all emergency patients must be screened, evaluated and then stabilized if in an emergency medical condition. The Hospital may not transfer . . . unless the patient requests a transfer or a practitioner certifies the medical necessity of the transfer. If a physician determines an appropriate transfer is necessary, the hospital must . . . b. Provide the appropriate medical records of the examination and treatment to the receiving hospital. . . . d. Ensure that the receiving facility has available space and qualified personnel for the treatment of the patient and that the receiving facility has agreed to accept the transfer and provide appropriate medical treatment. . . ."

Review of Patient #10's closed record occurred on 10/20/14 and showed the patient presented to the ED on 08/19/14 at 1:37 a.m. with suicidal ideation. The Emergency Room (ER) Nursing Documentation Record, dated 08/19/14 at 2:03 a.m., stated, ". . . NURSING ASSESSMENT FINDINGS: Patient is inebriated. He states he wants to commit suicide. He called the sheriff's department asking for help. States he wants treatment. . . . SIGNIFICANT [HISTORY]: Patient has tried to commit suicide in the past, with pills. . . ."

Review of the physician's (#15) dictated ER note identified Patient #10 as suicidal and in need of a transfer to an acute care hospital for emergency admission. The physician (#15) completed a North Dakota Supreme Court Application for Emergency Admission on 08/19/14, indicating the patient "contacted law enforcement stating he was suicidal," "told law enforcement he was going to shoot himself," and "says he is going to kill himself." The record showed a physician's order to transfer Patient #10 to [Name of Acute Care Hospital] ER via law enforcement and a nurse note, dated 08/19/14 at 2:59 a.m., stated, "Patient discharged to law enforcement. Will be taken to [Name of Acute Care Hospital] for a 24 hour hold."

Patient #10's record failed to include evidence of required transfer documents, including all components mentioned in the CAH's medical staff rules and regulations.

During an interview on 10/22/14 at 2:45 p.m., a staff nurse (#6) stated staff must complete transfer forms for all patients transferred from the ER to another hospital, including authorization for transfer (identifying the patient as stable and able to transfer, whether the receiving facility had space and personnel for treatment of the patient and agreed to accept the transfer, the name of the accepting physician, the physician's decision on how to transfer, and the provision of medical records), transfer acknowledgement (from the patient if able), and physician certification forms. The nurse (#6) confirmed Patient #10's record lacked required documents for transfer.

2. Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure a complete medical record including the date and time of the provider's order for 2 of 3 closed surgical patient (Patient #14 and #15) records and 5 of 7 closed inpatient (Patient #16, #18, #19, #20, and #21) records reviewed. Failure to ensure dating and timing of orders limited the CAH's ability to verify accurate treatment necessary for patient safety and quality of care.

Findings include:

Review of Patient #14 and #15's closed records occurred on 10/20/14 and identified the CAH admitted the patients for colonoscopy procedures on 04/10/14 and 08/28/14 respectively. Each patient record contained the same pre-printed physician orders, which included a separate section for pre-procedure, intra-procedure, and post-procedure orders. The orders failed to include the date and time the provider signed and authorized the orders.

Review of Patient #16, #18, #19, #20, and #21's closed records occurred on October 21-22, 2014 and showed the following:
*Patient #16 - admitted on 06/18/14 for pain associated with terminal cancer; orders for pain medication written on June 18 and 19, 2014 failed to include the time of the order.
*Patient #18 - admitted on 06/08/14 for erythroderma, psoriasis, and pain; two separate orders written on 06/08/14 for medications, intravenous (IV) fluids, and laboratory tests and an order containing discharge information written on 06/09/14 failed to include the time of the order.
*Patient #19 - admitted on 05/19/14 for acute pyelonephritis and fever; orders written on 05/20/14 for medication and nutritional supplements failed to include the time of the order.
*Patient #20 - admitted on 10/08/14 for congestive heart failure exacerbation; orders written on 10/10/14 for medications, activity, and laboratory tests failed to include the time of the order.
*Patient #21 - admitted on 06/17/14 for a urinary tract infection; orders for a medication written on 06/17/14 and 06/19/14 failed to include the time of the order.

During an interview on 10/22/14 at 1:23 p.m., a medical record staff member (#12) stated all orders must contain the date, time, and signature of the person writing or authorizing the order.

During an interview on 10/22/14 at 3:00 p.m., an administrative nurse (#2) confirmed the above interview.

Based on review of professional literature, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the medical record included complete instructions to the patient upon discharge for 4 of 7 closed inpatient (Patients #18, #19, #20, and #22) records reviewed. Failure to ensure patients received complete discharge instructions has the potential to place the patient at risk of improper care and has the potential to lead to readmission.

Findings include:

Berman and Snyder, "Kozier and Erb's Fundamentals of Nursing, Concepts, Process, and Practice," 9th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2012, page 262, stated, ". . . If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in layman's terms, and use of medical abbreviations . . . should be avoided. . . ."

- Review of Patient #18's closed medical record occurred on 10/21/14 and identified the CAH admitted the patient on 06/08/14 with erythroderma, psoriasis, and pain. On 06/11/14 at 8:00 a.m., the patient's provider wrote an order to discharge home and stated, "see medications per list, prednisone taper." A form titled "Medication Reconciliation Report," completed by Patient #18's provider on 06/11/14, included a list of medications the patient received while hospitalized. The provider selected whether the patient should continue the medications listed on the form upon discharge. The form did not include information on the prednisone tapering.

Patient #18's record showed the CAH provided "Patient Care Instructions" to the patient on 06/11/14 at 8:47 a.m. regarding diagnosis, treatment, follow-up, etc. The instructions stated, ". . . Medications: See medication List Prednisone Tapering dose . . ." The record failed to include an attached medication list and information on the prednisone tapering.

During an interview on 10/22/14 at 2:45 p.m., a staff nurse (#6) stated patients received a copy of Patient Care Instructions as their discharge information which included a list of medications written on the form or as a separate list. She stated the Medication Reconciliation Report was used by the provider and acted as the patient's prescription for the medications, stating the report would not suffice for patient use. The nurse (#6) confirmed Patient #18's record lacked a medication list and information regarding prednisone tapering and stated staff should have included this with the patient's discharge instructions.

- Review of Patient #19's closed medical record occurred on 10/21/14 and identified the CAH admitted the patient on 05/19/14 with pyelonephritis. On 05/22/14 at 8:45 a.m., the patient's provider wrote an order to discharge home and stated, "Encourage probiotic daily [times] 10-14 days." The record showed the CAH provided "Patient Care Instructions" to the patient on 05/22/14 regarding diagnosis, diet, activity, medications, etc. The instructions stated, ". . . Encourage probiotics daily for days . . ." The record failed to include how long the patient should take the probiotic and what dose.

- Review of Patient #20's closed medical record occurred on 10/21/14 and identified the CAH admitted the patient on 10/08/14 with an exacerbation of congestive heart failure (CHF) and discharged the patient on 10/11/14. The record showed the CAH provided "Patient Care Instructions" to Patient #20 regarding diagnosis, treatment, diet, activity, follow-up, etc. The instructions listed, ". . . 2. Meds: Lasix 20 mg [milligrams] PO [by mouth] daily. Lisinopril 5 mg 1/2 tab PO daily. Metoprolol ER [Extended Release] 25 mg 1/2 tab PO daily. Aspirin 81 mg PO daily . . . 4. Activity: Ad Lib [as able] . . ."

The CAH failed to provide discharge instructions written in terms the patient could understand.

- Review of Patient #22's closed medical record occurred on 10/22/14 and identified the CAH admitted the patient on 04/23/14 with pneumonia, acute renal failure, and pain and discharged the patient on 04/28/14. A form titled "Medication Reconciliation Report," completed by Patient #22's provider on 04/28/14, included a list of medications the patient received while hospitalized. The provider selected whether the patient should continue the medications listed on the form upon discharge. The patient's provider added additional information to several medications on the report including specific dosing, tapering, and precaution information for the medications.

The record showed the CAH provided "Patient Care Instructions" to Patient #22 regarding diagnosis, diet, activity, follow-up, etc. The instructions listed, ". . . Medications: See medication rec. [reconciliation] . . ."

During an interview on 10/22/14 at 2:45 p.m., a staff nurse (#6) stated she could not determine what information Patient #22 received upon discharge regarding medications and stated the Medication Reconciliation Report would not suffice for patient use.

During an interview on 10/22/14 at 3:15 p.m., an administrative nurse (#2) stated she expected staff to document all instructions including new medications or prescriptions for medications in terms the patient could understand with no medical abbreviations. The nurse (#2) stated the CAH's process for providing patients information regarding medications upon discharge as unclear.

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 (October 2013-September 2014). Failure to ensure departments report to the QA Committee as scheduled and establish thresholds of acceptability for QA monitoring limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the medical staff bylaws occurred on 10/20/14. These bylaws, approved 02/27/13, stated, "Preamble: Recognizing that the medical staff is responsible for the quality of medical care in the hospital and must accept and assume responsibility, subject to the ultimate authority of the hospital governing body . . ."

Review of the CAH's "Quality Assurance Plan" occurred on 10/21/14. This plan, approved 01/23/03, stated,
"Purpose
The purpose of the Quality Assurance program of St. Luke's Hospital is to ensure the delivery of optimal patient care . . .
Objectives
A. To establish an ongoing, comprehensive, and objective mechanism to monitor and evaluate the quality and appropriateness of patient care through routine data collection and analysis. . . .
Authority and Responsibility
Governing Board: The Governing Board of St. Luke's Hospital shall reaffirm its delegation of responsibility for the quality of medical care to the Medical Staff. . . .
Quality Assurance Requirements . . .
B. The quality and appropriateness of patient care in the following services shall be monitored and evaluated on an ongoing basis. Each department will report at least annually . . . 6. Pharmacy Services . . .
Duties of the Quality Assurance Committee . . .
D. To promote and assist where needed, in developing standards of care (criteria) . . ."

Reviewed on 10/21/14, the "Quality Improvement Reporting Schedule 2014," indicated Pharmacy should report in April.

Reviewed on 10/21/14, the April 2014 QA meeting minutes and department monitors lacked evidence pharmacy submitted a QA report. Upon request the CAH did not provide evidence the pharmacy department reported during the timeframe October 2013 - September 2014.

Reviewed on 10/21/14, the October 2013 - September 2014 QA monitors lacked evidence the following departments established thresholds of acceptability: operating room, dietary, swing bed activities, physical therapy, rural health clinics, administration (credentialing), maintenance, emergency department, discharge planning, housekeeping, laboratory, and radiology.

During interview on 10/22/14 at approximately 8:10 a.m., an administrative nursing staff member (#2) responsible for QA confirmed the pharmacy department had not submitted a QA report in the past year and the above listed departments had not established thresholds of acceptability for their QA monitoring.