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Based on bylaws review, agreement review, document review, and staff interview, the Critical Access Hospital's (CAH's) medical staff failed to recommend, and the governing body failed to approve the reappointment and privileges for 1 of 1 physician (Physician #1) reviewed who provided radiology services to the CAH through telemedicine. Failure of the medical staff to recommend and the governing body to approve reappointments/privileges of telemedicine medical staff members placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of the governing board's "Bylaws of McKenzie County Healthcare Services" occurred on the afternoon of 06/20/23. These bylaws, signed and dated 07/19/17 stated, ". . . ARTICLE VIII - MEDICAL STAFF Section 1. The Bylaws of the Medical Staff of this Corporation, together with the Rules and Regulations governing activity of the Medical Staff, shall be part of these bylaws and govern the relationship between the Medical Staff and the Board of Trustees . . . Section 2. a. . . . The Board of Trustees shall consider recommendations of the medical staff and appoint to the medical staff . . . c. All appointments to the Medical Staff shall be . . . renewable by the Board of Trustees . . ."

Review of the "MEDICAL STAFF BYLAWS" occurred on the afternoon of 06/19/23. These bylaws, dated 05/20/23, stated, ". . . 5.4 FUNCTIONS OF THE MEDICAL STAFF . . . 5.5-1 Credentialing Function. The duties of the Medical Staff with respect to credentialing shall be: a. to review the credentials of all applicants for Medical Staff appointment, reappointment and clinical privileges . . . and to make a report of its findings and recommendations . . . PROCEDURE FOR INITIAL APPOINTMENT: . . . 6.4-4 Telemedicine Credentialing: If the Hospital has a written agreement with a distant-site hospital . . . through which the distant-site hospital provides credentialing information to the Hospital and the Medical Staff concerning a physician applying for Medical Staff membership and clinical privileges and who is located at the distant-site hospital . . . the Hospital and Medical Staff may rely on the credentialing and privileging decisions of the distant-site hospital . . .7.1 PROCEDURE FOR REAPPOINTMENT . . . 7.1-3 Reappointment Procedure: . . . d. In the event the person seeking reappointment was initially credentialed through the telemedicine credentialling process, set forth in Section 6.4-4 the Medical Staff shall obtain the information set forth in Section 6.4-4 in determining the person's reappointment. . . . g. The Medical Staff shall transmit its report and recommendations to the Board through the Chief Executive Officer in time for the Board to consider reappointments at the final scheduled meeting in each reappointment cycle. . . . "

Reviewed on 06/20/23, the CAH's "Credentialing Services Agreement" with [Hospital #1] dated 08/25/16, stated, ". . . Whereas, Facility has determined that [Hospital #1's] policies and procedures for verifying credentialing information satisfy their requirement with regard to regulatory . . . standards . . . Now therefore, . . . the parties agree as follows: Services: [Name of Hospital #1] shall provide those services as set forth in this Agreement . . . A.4 [Hospital #1] will record information to include appointment, reappointment, and clinical privilege information . . . A.5 Facility shall consider the information provided to it by [Hospital #1] as part of its own process of evaluating a Practitioner's qualification to become a member of Facility. Facility shall be solely responsible for any and all determinations regarding a Practitioner's ability to be a member of Facility and for any other credentialing functions not expressly to [Hospital #1] to this Agreement. . . "

Reviewed on 06/20/23, the undated list of telemedicine providers from Hospital #1 for tele-radiology included Physician #1. Upon request on 06/21/23, the CAH failed to provide evidence the medical staff recommended and the governing body approved telemedicine reappointment and privileges for Physician #1.

During interview on the morning of 06/21/23, a staff member (#3) responsible for credentialing stated Hospital #1 approved Physician #1's reappointment/credentials for the period of 11/20/22 to 11/20/24 but confirmed the CAH's medical staff did not recommend and the CAH's governing board did not approve Physician #1's reappointment/credentials.

Based on observation, review of facility policy, Safety Data Sheet (SDS) review, and staff interview, the Critical Access Hospital (CAH) failed to safely store hazardous chemicals for 3 of 3 days of survey (June 19-21, 2023). Failure to safely store hazardous chemicals may result in patients or visitors sustaining an injury.

Findings include:

Review of the policy titled "Chemical Storage" occurred on 06/21/23. This undated policy stated, ". . . To ensure that all chemicals are kept in locked areas providing safety to of [sic] all residents and patients . . . all chemicals shall be stored in areas not accessible to residents or patients . . . When chemicals are used they may not be left unattended at any time. . . ."

Review of SDS titled "Peroxide Multi Surface Cleaner and Disinfectant" occurred on 06/21/23. This safety data sheet, dated 09/13/21, stated, ". . . Harmful if swallowed or in contact with skin. Causes severe skin burns and eye damage. . ."

Observation of the Medical Surgical Unit on all days of survey showed the following:
* 06/19/23 at 12:20 p.m., spray bottles labeled "Peroxide Undersurface Disinfectant and Cleaner" sat unattended on supply carts, in the hallway, outside the doorways of five patient rooms.
* 06/20/23 at 09:32 a.m., spray bottles labeled "Peroxide Undersurface Disinfectant and Cleaner" sat unattended on supply carts, in the hallway, outside the doorways of five patient rooms.
* 06/21/23 at 08:30 a.m., spray bottles labeled "Peroxide Undersurface Disinfectant and Cleaner" sat unattended on supply carts, in the hallway, outside the doorways of five patient rooms.

During an interview on 06/21/23 at 9:00 a.m., administrative nurse (#1) confirmed staff failed to securely store the disinfectant spray.

Based on observation, and staff interview, the Critical Access Hospital (CAH) failed to store medications in a manner that prevented unauthorized access for 3 of 6 (Surgical Unit Pediatric, Surgical Unit Adult, and Emergency Department Pediatric) crash carts observed. Failure to store all medications securely may result in unauthorized access to medications.

Findings include:

- Observation of the Surgical Unit on 06/19/23 at 3:30 p.m. showed the adult and pediatric crash carts for the surgical unit unlocked and unattended. Both carts contained emergency medications.

- Observation of the Emergency Department on 06/20/23 at 2:15 p.m. showed the pediatric crash cart located in the trauma bay unattended and unlocked. The cart contained emergency medications.

During an interview on 06/20/23 at 2:30 p.m. administrative nurses (#1 and #2) stated they expected staff to lock all crash carts when not in use.

Based on policy review, review of facility records, and staff interview, the Critical Access Hospital (CAH) failed to ensure the leader of the antibiotic stewardship program communicated the activities of the antibiotic stewardship program throughout the CAH. Failure to communicate antibiotic stewardship activities may limit the CAH's medical, nursing, and quality assurance personnel's ability to identify and address any issues with antibiotic usage and implement action plans for better patient outcomes.

Findings include:

Review of the policy titled "Antibiotic Stewardship Program" occurred 06/21/23. The policy, revised 02/28/23, stated, ". . . To improve antibiotic prescribing practices and reduce their inappropriate use. To protect our patients from the consequences of multidrug-resistant organisms . . . the approach will include the following elements: . . . Reporting data . . . Report on number of antibiotics prescribed . . . Include in a separate report . . . antibiotics that did not meet criteria for active infection . . . will report findings . . . to the Med Staff Committee . . ."

Review of the facility Medical Staff, Infection Control Committee, and Quality Assurance Committee meeting minutes from January through June of 2023 showed the minutes failed to contain reports of antibiotic stewardship activities.

During an interview on 06/20/23 at 4:00 p.m., administrative staff member (#5) agreed the meeting minutes lacked communication of antibiotic stewardship activities.

Based on policy review, report review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Assurance and Performance Improvement (QAPI) program evaluated all patient care services affecting patient health and safety for 1 of 1 year reviewed (May 2022 - May 2023). Failure to ensure all departments participate in QAPI monitoring limited the CAH's ability to ensure the provision of quality care to the CAH's patients.

Findings include:

Review of the policy titled "Quality Assurance - Performance Improvement Plan (QAPI)" occurred on 06/20/23. This policy, dated 12/14/22, stated, "1. Mission/Vision/Values . . . The program ensures implementation of processes to measure, assess, and improve the performance of the . . . clinical and support processes that respond to the health and safety needs of the patients served. . . . V. . . . The Quality Improvement Committee is responsible to . . . 11. Support departments' participation in the quality improvement process . . . the Quality Improvement coordinator's responsibilities are: . . . 7. To ensure that quality improvement activities are conducted by each department in accordance with regulatory requirements . . ."

Reviewed on 06/20/23, the CAH's QAPI reports failed to include reporting from the following departments: surgery, emergency room, central sterilizing, cardiac rehabilitation, respiratory therapy, dietary, infection control regarding nosocomial infections, pharmacy/nursing regarding medication errors, and risk management regarding adverse events.

During interview on 06/21/23 at 11:15 a.m., an administrative staff member (#4) confirmed not all departments had conducted QAPI monitors in the past year.