HospitalInspections.org

Based on review of bylaws, contracted agreement, list of contracted radiologists, and staff interview, the governing body failed to ensure approval of privileges following the Critical Access Hospital's (CAH's) bylaws for 19 of 20 contracted consulting radiologists (Physicians #1 - #19) providing services to the CAH's patients. By failing to approve privileges according to the CAH's bylaws, the governing body did not ensure the contracted radiologists providing services to the CAH's patients possessed the necessary qualifications for medical staff membership.

Findings include:

Review of the "Fifth Ammended [sic] Corporate Bylaws of Hillsboro Medical Center" occurred on the afternoon of 03/23/10. These bylaws, effective 11/19/09, stated,
"Article VII. Medical Staff . . . Section 2. . . . (A) All appointments to the membership of the Medical Staff . . . must be reviewed and approved by the Board of Trustees. . . . (D) All applications to the Medical Staff must be processed by the Medical Staff and approved by the Board of Trustees. Determination of privileges of the Medical Staff shall be in accordance with the Bylaws of the Medical Staff of Hillsboro Medical Center. . . ."

Review of the "Medical Staff Bylaws" occurred on the afternoon of 03/23/10. These bylaws, effective 01/15/09, stated, ". . . Article III Membership
Section 1. . . . Membership on the Medical Staff of Hillsboro Medical Center, is a privilege, which shall be extended only to professionally competent Practitioners who continuously meet the qualifications, standards, and requirements, set forth by these Bylaws. . . .
Section 3. . . . A. The Governing Body shall make initial appointments and reappointments to the Medical Staff. The Governing Body shall act on appointments, reappointments, or revocation of appointments after there has been a report from the Medical Staff as provided in these Bylaws
B. [Name of contracted hospital], under contract with HMC [Hillsboro Medical Center], will perform the background investigation and application process. Upon approval from [Name of contracted hospital], HMC will receive the advice and recommendation from [Name of contracted hospital], review the documentation of background studies obtained, and present the information to the Medical Staff Committee.
C. Every application for staff appointment shall be signed by the applicant and shall contain the applicants [sic] acknowledgment of every Medical Staff member's obligations . . ., a signed Provider Acknowledgment form to abide by the Medical Staff Bylaws, Rules and Regulations . . .
Article V Procedure for Appointment and Reappointment
Section 1. . . . A. Appointment to the Medical Staff is a privilege that shall be extended by the Board of Trustees to Physicians, . . . and other Practitioners judged competent under the credentialing process and who continuously meet the qualifications, standards, and requirements as set forth in these Bylaws. . . ."

Review of the "Credentialing Services Agreement" occurred the morning of 03/24/10. This agreement, effective 01/01/09, stated,
". . . Exhibit A Description of Delegated Credentialing Services . . .
2. Appointments of New Providers to the Medical Staff of Hillsboro Medical Center
[Name of contracted hospital] will perform initial credentialing verification for new providers who request membership and privileges on the medical staff of Hillsboro Medical Center. . . ."

Upon request, the facility provided no evidence the contracted hospital performed initial credentialing verification, the CAH's medical staff recommended approval of privileges and the governing body approved privileges for 19 radiologists contracted to provide services to the CAH's patients.

During interview on 03/25/10 at 8:40 a.m., an administrative staff member (#1) confirmed the CAH's medical staff had not recommended approval of privileges and the governing body had not approved privileges for the contracted radiologists providing services to the CAH's patients, except the physician serving as the radiology medical director.

During interview on 03/25/10 at 9:40 a.m., an administrative radiology staff member (#8) confirmed radiologists from a contracted hospital radiology group provided services to the CAH's patients. This staff member (#8) provided a list of the contracted radiologists currently providing services to the CAH's patients on 03/25/10 at 10:20 a.m.

1. Based on observation, review of the North Dakota Century Code, policy and procedure review, staff schedule review, and staff interview, the Critical Access Hospital (CAH) failed to limit and prevent access to 1 of 1 hospital pharmacy by unauthorized personnel during 3 of 3 days of survey (March 23-25, 2010). Failure of the CAH to adequately secure and restrict access to the pharmacy allowed an opportunity for unsafe and unauthorized use of medications and has the potential to create insufficient distribution, control, and accountability of drugs.

Findings include:

The North Dakota Century Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. 1. General. During such times as a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance by the director for the provision of drugs to the medical staff and other authorized personnel of the hospital, by use of the 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. One supervisory registered professional nurse and only one in any given eight-hour shift is responsible for removing drugs therefrom. The responsible nurse, in times of emergency, may delegate this duty to another nurse. The responsible nurse must be designated by position, in writing, by the appropriate committee of the hospital and, prior to being permitted to obtain access to the pharmacy, shall receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required. . . ."

Review of the facility policy titled "Hospital Pharmacy" occurred on 03/25/10. This policy, revised 11/09, stated, "Qualified Personnel: Pharmacist, Licensed Nurse, Nursing student under supervision of RN [registered nurse]. The Pharmacy is kept locked at all times and accessed by Licensed nursing personnel and consulting Pharmacist. . . . Purpose: The area of the hospital where drugs are stored and dispensed: oral, liquid, injectable, and topical medications. . . . Pharmacist: . . . 2. Pharmacist . . . is employed on a consulting basis to direct the management of the Pharmaceuticals. Pharmacist monitors: acute, observation bed, swing bed, treatment room, and ER [emergency room] patients. . . . Location of Medications: 1. Drug supplies are located in the medication room (Pharmacy) . . . 4. Pharmacy stock supply. Medications may be used from stock supply cupboards when a medication is not available in patient's med drawer in med cart. When ordered by HCP [healthcare provider], Licensed Nurses may get medication from Pharmacy in the absence of a pharmacist for patient use. . . . Quality Assurance . . . 3. Pharmacist monitors storage of medications . . . security. . . ."

Review of facility policy titled "Job Description: Pharmacist" occurred on 03/25/10. This policy, revised 11/09, stated, "Position Purpose: 1. To ensure drug storage area is administered in accordance with accepted professional principles. 2. Developing, supervising, and coordinating all activities of pharmacy services. . . . Scope: . . . C. Administrative Services. 1. Establish and supervise control procedures for the distribution and use of all controlled drugs, investigational medications and other drugs. . . ."

A tour of the CAH pharmacy took place on 03/24/10 at 2:05 p.m. with a pharmacy staff member (#4). Observation during the tour identified access to the pharmacy controlled by lock and key and showed one large room. The pharmacy staff member (#4) identified this room as the pharmacy and nurse medication room. Observation showed this room contained all drugs, biologicals, and pharmaceuticals included in a pharmacy and also contained a nurse medication cart, bags of non-medicated intravenous (IV) solution, IV tubing/supplies, and items nursing staff used on a regular basis. When asked which staff members have access to the pharmacy, the pharmacy staff member (#4) stated the pharmacist and the RN [registered nurse] or charge nurse on duty.

Observation during medication pass on 03/24/10 at 8:15 a.m. showed a nursing staff member (#7) entered the pharmacy and obtained medications for Patient #3 from this patient's drawer in the medication cart. The nursing staff member (#7) did not find the medication Alprazolam (a medication used to treat anxiety) in Patient #3's drawer. The nursing staff member (#7) obtained the medication from a locked cupboard within the pharmacy. Review of the staff schedule for 03/24/10 from 7:00 a.m. to 7:00 p.m. identified nursing staff member (#6) as the charge nurse on duty. Random observations of nursing staff during all days of survey showed multiple nurses on the same shift entered the pharmacy to obtain medications.

During an interview on 03/24/10 at 8:15 a.m., a nursing staff member (#7) stated all nurses have access to the hospital pharmacy by key and may enter in the absence of the pharmacist.

During an interview on 03/24/10 at 2:20 p.m., a pharmacy staff member (#4) stated the charge nurse has access to the hospital pharmacy by key and all nurses may enter in the absence of the pharmacist to obtain medications for patients.

2. Based on observation, review of the North Dakota Century Code, policy and procedure review, and staff interview, the CAH failed to ensure staff kept current and accurate records of all drugs and biologicals in accordance with accepted professional principles for 1 of 1 hospital pharmacy on 3 of 3 days of survey (March 23-25, 2010). Failure to keep and maintain adequate records/reports to follow the flow of pharmaceuticals from the pharmacy limited the CAH's ability to prevent unauthorized use and distribution of drugs and biologicals. This failure placed patients and staff at risk of unsafe and inappropriate use of drugs and biologicals.

Findings include:

The North Dakota Century Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. . . . 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. . . . The responsible nurse must be designated by position, in writing, by the appropriate committee of the hospital and, prior to being permitted to obtain access to the pharmacy, shall receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required. Such education and training must be given by the director of pharmacy, who shall require, at a minimum, the following records and procedures: a. Removal of any drug from the pharmacy by an authorized nurse must be recorded on a suitable form showing patient name, room number, name of drug, strength, amount, date, time, and signature of nurse. b. Such form must be left with the container from which the drug was removed, both placed conspicuously so that it will be found by a pharmacist and checked properly and promptly . . . 61-07-01-07. Drug distribution and control. . . . 2. Responsibility. The director is responsible for the safe and efficient distribution of, control of, and accountability for drugs. The other professional staff of the hospital shall cooperate with the director in meeting this responsibility and in ordering, administering, and accounting for pharmaceutical materials so as to achieve this purpose. Accordingly, the director is responsible for, at a minimum, the following: . . . h. Records of all transactions of the hospital pharmacy as may be required by applicable law, state and federal, and as may be necessary to maintain accurate control over and accountability for all pharmaceutical materials. . . . 9. Records and reports. The director shall maintain, and submit, as appropriate, such records and reports as are required to ensure patient health, safety, and welfare, and, at a minimum, the following: . . . e. Inventories of the pharmacy. . . ."

Review of facility policy titled "Hospital Pharmacy" occurred on 03/25/10. This policy, revised 11/09, stated, ". . . Pharmacist: 1. . . . Pharmacist maintains records of the hospital pharmacy as required by North Dakota Board of Pharmacy. 2. Pharmacist is licensed by the state of North Dakota and is employed on a consulting basis to direct the management of the pharmaceuticals. Pharmaceutical Charges . . . 1. . . . All medications prepackaged in a unit dose for in-patient use are placed in the individual patient drawer in the medication cart so the pharmacist is aware it was used . . . Quality Assurance . . . 3. Pharmacist monitors storage of medications . . . security. . . ."

Review of facility policy titled "Job Description: Pharmacist" occurred on 3/25/10. This policy, revised 11/09, stated, "Position Purpose: 1. To ensure drug storage area is administered in accordance with accepted professional principles. . . . C. Administrative Services . . . 1. Establish and supervise control procedures for the distribution and use of all controlled drugs, investigational medications and other drugs. . . . 3. Maintain and inventory of drugs and supplies to meet the routine and emergency needs of [name of facility]. . . ."

A tour of the CAH pharmacy took place on 03/24/10 at 2:05 p.m. with a pharmacy staff member (#4). Observation during the tour identified access to the pharmacy controlled by lock and key and showed one large room. The pharmacy staff member (#4) identified this room as the pharmacy and nurse medication room. Observation showed medications stocked on shelves and in cupboards. When asked what process nursing staff members follow to obtain a medication from the pharmacy in the absence of pharmacy staff, the pharmacy staff member (#4) stated nursing staff obtain the medication from the shelf, remove the medication from the pharmacy and administer to the patient, and return the medication to the counter in the pharmacy or to the patient's individual medication drawer in the nurse's medication cart. The pharmacy staff member (#4) stated the following day, pharmacy staff check the counter in the pharmacy, check the individual patient drawers of the nurse's medication cart, or check physician's orders for any medications. The pharmacy staff member (#4) confirmed this is the facility's process to track medications removed from the pharmacy.

During interview on 03/24/10 at 8:15 a.m., when asked what process nursing staff follow to obtain a medication from the pharmacy in the absence of pharmacy staff, a nursing staff member (#7) confirmed the process identified by pharmacy staff member (#4). The nursing staff member (#7) stated when removing medications from pharmacy, nursing staff record the medications on a log if staff removes a narcotic or scheduled medication.

During interview on 03/24/10 at 2:15 p.m., a pharmacy staff member (#4) stated nursing staff members do not record all medications on a log when removing medications from the pharmacy and the facility does not require the recording of all medications.

Failure to maintain accurate records and monitor inventory of the pharmacy limited the pharmacists ability to follow the flow of pharmaceuticals through the CAH and permitted nursing staff to perform duties outside their scope of practice.

Based on observation, record review, review of professional standards, and staff interview, the Critical Access Hospital (CAH) failed to assess each patient individually prior to utilizing side rails and failed to evaluate the safe use of side rails for 1 of 1 active inpatient (Patient #1) and 3 of 3 active swing bed patients (Patient #2, #3, and #4). Failure to assess and evaluate the use of side rails has the potential to restrict a patient's movement and has the potential to place patients at risk for injury.

Findings include:

The Food and Drug Administration (FDA) Center for Devices and Radiological Health publication titled, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," issued on 03/10/06, stated, ". . . FDA has received reports in which . . . patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term 'entrapment' describes an event in which a patient is caught, trapped or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in death and serious injuries . . . The current International Electrotechnical Commission (IEC) standard recognizes that the bed frame, deck, and rails are the major elements involved in entrapment . . ." The FDA's recommendation of the spacing between the inside surface of the rail and the mattress compressed by the weight of the patient's head be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. The IEC and the FDA recommend a dimension limit of less than 120 millimeters (4 and 3/4 inches) for the following: 1) within the rail; 2) under the rail, between rail supports or next to a single rail support; and 3) between the rail and mattress.

Safety Alert: Entrapment Hazards with Hospital Bed Side Rails, August 23, 1995, and Joint Commission on Accreditation of Healthcare Organization: Sentinel Event Alert, Issue 27, September 6, 2002, identified bed rail-related entrapment deaths and injuries can occur in the elderly population, who are often at risk due to limited mobility, psychoactive or sedative medications, confusion, sedation, restlessness, lack of muscle control, size and physical deformities. Death by asphyxiation or injuries to the resident's extremities can occur when the resident becomes caught between the mattress and the bed rail; the headboard and the bed rail; or getting his or her head/extremity stuck in the bed rail. Both split and full rails have the potential to cause fall-related injuries as well as entrapment. Additionally fall-related injuries or injuries to extremities can occur when confused/disoriented residents climb over the top of side rails or get an arm or leg entrapped.

Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, Hospital Bed Safety Workgroup, Food and Drug Administration, April 2003, stated,
"Guiding Principles . . .
2. Decisions to use or to discontinue the use of a bed rail should be made in the context of an individualized patient assessment using an interdisciplinary team with input from the patient and family or the patient's legal guardian. . . .

Policy Considerations
1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize or remove 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 and approved by the interdisciplinary team.
Bed rail effectiveness should be reviewed on a regular basis.
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 and determined not to be the treatment of choice for the patient.
. . .
7. Creating a safe bed environment does not necessarily preclude the use of bed rails. However, a decision to use them should be based on a comprehensive assessment and identification of the patient's needs, which include comparing the potential for injury or death associated with use or non-use of bed rails to the benefits for an individual patient. In creating a safe bed environment, the following general principles should be applied:
Avoid the automatic use of bed rails of any size or shape. . . .
Re-assess the patient's needs and re-evaluate the equipment if an episode of entrapment or near-entrapment occurs, with or without serious injury. This should be done immediately because fatal 'repeat' events can occur within minutes of the first episode.

Process/Procedure Considerations . . .
1. Individualized Patient Assessment
Any decision regarding bed rail use or removal from use should be made within the framework of an individual patient assessment. . . .

Risk Intervention
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. . . .

Bed Rails as Restraints
When bed rails have the effect of keeping a patient from voluntarily getting out of bed, they fall under the definition of a physical restraint. If they are not necessary to treat medical symptoms, and less restrictive interventions have not been attempted and determined to be ineffective, bed rails used as restraints should be avoided. . . .

Bed Rail Safety Guidelines
If it is determined that bed rails are required and that other environmental or treatment considerations may not meet the individual patient's assessed needs, or have been tried and were unsuccessful in meeting the patient's assessed needs, then close attention must be given to the design of the rails and the relationship between rails and other parts of the bed.
1. The bars with the bed rails should be closely spaced to prevent a patient's head from passing through the openings and becoming entrapped.
2. The mattress to bed rail interface should prevent an individual from falling between the mattress and bed rails and possibly smothering.
. . ."

Observation of the beds utilized on the nursing unit occurred on March 23-25, 2009. The beds utilized by the current observation, swingbed, and inpatients differed in style or make and differed in the amount of attached side rails. All of the beds either had four half rails, two half rails on each side, or two half rails, one half on each side, attached to the beds. Measurements of one type of bed, located specifically in Room 13, identified 6 to 7 inch open spaces within the rails. Measurements of another type of bed, located specifically in Room 6, identified 7 and 1/2 to 7 and 3/4 inch open spaces within the rails.

Observations of current patients (inpatient and swing bed) March 23-25, 2009, identified two elevated upper half rails on Patients #1, #2, #3, and #4's beds while the patients rested in bed.

-Review of Patient #2's active swing bed record occurred 03/24/10. The record identified the CAH admitted this 79 year old on 02/23/10 with diagnoses of Parkinson's, Alzheimer's dementia, and anxiety/depression. Record review indicated a history of recent falls.

Review of Patient #2's "Fall Risk Assessment," completed on admission, identified the patient as "high risk" for falls. Review of Patient #2's "ADL [activities of daily living] Care Plan Sheet" indicated the patient transferred with a one person assist, walker, and gait belt. A nurse's note, dated 02/28/10 at 6:30 p.m., revealed Patient #2 fell out of wheelchair in room and indicated no injury. Review of nurses' notes from 02/23/10 to 03/24/10 identified Patient #2 tried to get out of bed/chair by self several times and described the patient as restless, impulsive, and forgetful.

Patient #2's record lacked assessments and documentation for the utilization of side rails and lacked documentation of monitoring Patient #2 during the time of elevated side rails. The CAH staff failed to consider the side rails as a potential entrapment and safety hazard.

-Review of Patient #4's active swing bed record occurred 03/25/10. The record indicated the CAH admitted this 71 year old on 01/04/10 with diagnoses of left hip fracture. Record review indicated a history of cerebral vascular accident (stroke).

Review of Patient #4's "Fall Risk Assessment," completed on admission, identified the patient as "high risk" for falls. Review of Patient #4's "Admission Data," identified the patient had unsteady gait and diminished strength and indicated the patient ambulated/transferred with a two person assist and walker. A nurse's note, dated 03/23/10 at 3:30 a.m., revealed Patient #4 fell in the hallway/doorway of another patient room and obtained a small abrasion to the right lower back. Review of nurses' notes from 03/12/10 to 03/25/10 identified Patient #4 as forgetful with increased confusion.

Patient #4's record lacked assessments and documentation for the utilization of side rails and lacked documentation of monitoring Patient #4 during the time of elevated side rails. The CAH staff failed to consider the side rails as a potential entrapment and safety hazard.

-The current records for Patient #1 and Patient #3 lacked assessments and documentation for the utilization of side rails. The CAH staff failed to consider the side rails as a potential entrapment hazard.

During an interview on 03/25/10 at 10:00 a.m., a nursing staff member (#7) stated nurses elevate the two upper half rails per patient/family request for safety, positioning, and access to bed controls/call light. The staff member (#7) stated the nursing staff does not perform or document an assessment for utilization of side rails or document monitoring of side rail use.

During interview on 03/25/10 at 11:15 a.m., two administrative nursing staff members (#2 and #3) confirmed nurses elevate the two upper half rails per patient/family request for safety, positioning, and access to bed controls/call light and confirmed the nursing staff does not perform or document an assessment for utilization of side rails or document monitoring of side rail use. An administrative staff member (#1) stated the CAH failed to consider the beds a risk for safety and a potential hazard for entrapment.

Based on review of records, professional literature, policy and procedure, and ultrasound guidelines, and staff interview, the Critical Access Hospital (CAH) failed to administer medications in accordance with the physician's orders and accepted standards of practice for 1 of 1 inpatient (Patient #1) whose medication administration record (MAR) did not correspond with the physician's orders. Failure of nursing staff to ensure the MAR corresponded with the physician's orders had the potential for Patient #1 to not receive ordered medications.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, pages 841-842, stated, ". . . A drug order is written on the client's chart by the primary care provider . . . The medication order is then copied by a nurse or clerk to a Kardex or medication administration record (MAR). . . . The nurse should always question the primary care provider about any order that is ambiguous, unusual . . . or contraindicated by the client's condition. . . ."

Page 847 stated, ". . . Medication Reconciliation. Another safety issue that affects the nurse is to ensure that clients receive the appropriate medications and dosages on admission, during transfer, and at discharge. . . . As a result, the IHI [Institute for Healthcare Improvement] campaigned for medication reconciliation . . . The IHI defines medication reconciliation as 'the process of creating the most accurate list possible of all medications a patient is taking . . . and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patients at all transition points within the hospital.' . . ."

Taylor, Lillis, and LeMone, Fundamentals of Nursing, Fourth Edition, page 578, stated, "Checking the Medication Order . . . In many institutions, the order is copied onto the patient's medication record . . . The nurse is responsible for checking that the transcription of the medication order is correct by comparing it with the original order. . . ."

Review of facility policy "Orders, Doctor: Receiving and Noting" occurred on 03/25/10. This policy, dated 11/09, stated, "Purpose: To accurately transcribe and implement the provider orders. . . . 8. Complete MAR with medication . . . 10. When there is a second nurse at the time of the medication order, the second nurse will verify accuracy of the order by checking the order with the medication reconciliation sheet and the MAR. If there is not a second nurse available for verification, the verification will take place at the change of shift. . . ."

Review of facility policy "Transcription of Medication Orders" occurred on 03/25/10. This policy, dated 11/09, stated, "Purpose: To ensure proper transcription of ordered medications. . . . Procedure: 1. Transcribe medication order to include drug, order date, dose, route, time to be given on the medication administration record.
. . ."

Review of facility policy "Medication Administration Record (MAR)" occurred on 03/25/10. This policy, dated 11/09, stated, "Purpose: The MAR is used to document all medications given to a patient and serves as the current treatment and order guideline for each inpatient. Procedure: 1. Physician's orders are transcribed onto the MAR by the RN [registered nurse] or designee. . . . 5. Each scheduled medication and its time of administration is written in the spaces on the sheet. . . . 7. PRN [as needed] meds [medications] are listed on the prn sheet. . . ."

Review of facility policy "Medication Reconciliation" occurred on 03/25/10. This policy, dated 11/09, stated, "Purpose: To ensure medications are reconciled upon admission. . . . Procedure: 1. The admitting nurse will fill in top section of sheet: information source, allergies, and disposition of home medications. 2. Each entry should be dated and, if applicable, the RX # [prescription number] documented on the appropriate line. The nurse will verify all medication . . . and clarify how each med it [sic] taken by interviewing the pt [patient]. This process should be done ASAP [as soon as possible], when the pt will be an admit. Sign and date the bottom of the page. 3. Each medication that the patient is currently taking will be noted if that medication is to be continued, help/stopped or changed (Reconciliation process) by the admitting practitioner. 4. The pharmacist will also sign during next scheduled workday when medications are dispensed and note any concerns. If there are concerns/recommendations, they will be noted in space provided. Upon review of concerns the MD [medical doctor] will review the concern, sign/date and make adjustments as deemed necessary. After MD review and no changes are made with regard to the concerns, the supervisor (charge nurse, clinical coordinator or DON [director of nursing]) will also sign and date. . . ."

Review of facility policy "Medication Administration and Documentation Principles" occurred on 03/25/10. This policy, dated 11/09, stated, "Purpose: To administer medications as prescribed by the attending physician/health care practitioner. Principles and Guidelines . . . C. General Considerations: 1. Medications are given only upon physician order. . . . E. Responsibility: 1. It is the responsibility of the licensed nursing professional . . . to ensure accuracy and safety of medication administration. 2. Licensed nursing personnel . . . are to administer medications . . . in accordance with the ND [North Dakota] Board of Nursing Nurse Practice Act and applicable stated and federal regulations. . . ."

Review of Patient #1's active inpatient record occurred on 03/23/10. The record identified the CAH admitted this 72 year old on 03/22/10 with a diagnosis of gastroenteritis and ileus. Patient #1's physician's orders, dated 03/22/10 at 11:30 a.m., and medication reconciliation form, dated 03/22/10, identified medication orders for multivitamin, calcium with vitamin D, vitamin C, colace, benefiber chew, wellbutrin, ferrous sulfate, acetaminophen, fosamax, lotrel, percocet, phenergan, immodium, extra strength tylenol, and morphine. The medication reconciliation form indicated review and reconciliation by the admitting nurse, the admitting doctor, and the pharmacist.

Patient #1's medication administration record (MAR) from admission on 03/23/10, identified discrepancies with physician's orders on the medication reconciliation form. The MAR failed to include the following ten medications ordered by the physician: multivitamin, calcium with vitamin D, vitamin C, colace, benefiber chew, wellbutrin, ferrous sulfate, acetaminophen, fosamax, and percocet. This resulted in nursing staff not administering these medications to the patient on 03/22/10 and 03/23/10.

Patient #1's physician's orders, dated 03/23/10, showed an order for an abdominal ultrasound and no order to hold the patient's oral medications. The record indicated the patient had an abdominal ultrasound at 12:30 p.m. on 03/23/10.

During interview on 03/23/10 at 2:55 p.m., when asked to clarify the discrepancy between the physician's orders and those listed on the MAR, a nursing staff member (#6) stated Patient #1 did not receive the medications because of an order for an abdominal ultrasound obtained on the patient earlier in the day. The staff member (#6) then called the physician, and the physician ordered a hold on these oral medications.

Reviewed on 03/24/10, the ultrasound scheduling guidelines and preps form, provided by the facility, did not include specific instructions for holding medications prior to abdominal ultrasounds.

During interview on 03/25/10 at 11:15 a.m., an administrative nursing staff member (#3) stated nursing staff should follow physicians' medication orders. This staff member (#3) stated nursing staff uses the medication reconciliation form to help prevent medication errors and nursing staff should clarify orders with the physician as soon as possible when needed.

Based on review of quality assurance (QA) plan, QA department reporting schedule, quality improvement (QI) minutes, and staff interview, the Critical Access Hospital (CAH) failed to ensure the QA program evaluated all patient care services and other services affecting CAH patient health and safety for 12 of 12 months reviewed (February 2009 - January 2010). The CAH has the potential of failing to identify risk factors affecting patient care and failing to implement corrective action if necessary by not ensuring all departments providing patient care participate in QA monitoring, report to the QA Committee, and perform quality of care monitoring.

Findings include:

Review of the Quality Assurance Plan occurred on 03/24/10 at 5:00 p.m. This plan, approved 01/21/10, stated, "Purpose
The purpose of the Quality Assurance Program of the Hillsboro Medical Center is to deliver excellent care and key components to achieving that goal are delivering care of the highest quality possible that is safe for patients and employees. . . .
Quality Assurance Requirements . . .
C. The quality and appropriateness of patient/resident care and staff safety in the following services shall be monitored and evaluated on an ongoing basis and reported quarterly to the Quality Assurance Committee. . . . 14. Medical Record Services . . . 21. Social Services . . .
Duties of the Quality Assurance Committee
A. To identify and coordinate all interdisciplinary services of Quality Improvement action plans as specified. . . . C. To conduct routine evaluations of interdisciplinary services . . . D. To promote and assist where needed, in developing standards of care (criteria) with each interdisciplinary service . . . E. To receive, evaluate, and recommend action to problems identified in the monthly reports of all interdisciplinary services. . . ."

Review of the 2009-2010 QA department reporting schedule occurred on 03/24/10 at 4:00 p.m. The 2009 schedule stated, "January, April, July, October . . . Medical Record Services Report . . ." The 2010 schedule stated, "January Report 4th Quarter (Oct. Nov. Dec.) [for 2009] . . . Medical Record Services Report . . ."

Reviewed on 03/24/10, the 2009-2010 Quality Improvement minutes (including monthly reporting from February 2009 - January 2010) lacked evidence the medical records department reported to the QI Committee. The social services department reported results to the QI Committee for the attached long term care unit, but did not include separate results of CAH monitoring activities.

During an interview on 03/24/10 at 4:30 p.m., an administrative staff member (#1) confirmed medical records services did not report monitoring to the QI Committee and social services did not report separate results for monitoring of CAH patients in 2009.