HospitalInspections.org

Based on interview and document review, the critical access hospital (CAH) failed to provide the required Important Message from Medicare About Your Rights (IM Message) form for 4 of 20 inpatients (P9, P12, P15, P17) and for 1 of 5 swing bed (SB4) patients reviewed. This had the potential to affect all patients served by the CAH.

Findings include:

Review of the following CAH's inpatient medical records revealed the following:

P9 was admitted to the CAH on 6/12/15, and discharged on 6/14/15. P8's medical record lacked the signed IM message.

P12 was admitted to the CAH on 7/21/15, and discharged on 7/24/15. P12's medical record lacked a signed IM message.

P15 was admitted to the CAH on 4/23/15, and discharged on 4/26/15. P15's medical record lacked a signed IM message.

P17 was admitted to the CAH on 3/25/15, and discharged on 3/28/15. P17's medical record lacked a signed IM message.

SB4 was admitted to the CAH on 5/23/15, and discharged on 6/1/15. SB4's medical record lacked a signed IM message.

On 8/13/15, at 1:15 p.m. the director of nursing (DON) confirmed the aforementioned patients had likely not received the IM message. The DON verified the IM message was required to be given to all inpatients who are medicare eligible.

Based on observation, interview, and record review the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.
Findings include:

Please refer to Life Safety Code inspection tags: K50, K52, K154, K155.

Based on interview and document review, the critical access hospital (CAH) failed to provide documentation that the governing body had approved the appointment of the chief executive officer (CEO).
Findings include:
On 8/11/15, at 8:50 a.m. the compliance officer (CO) confirmed the current CEO had started at the CAH on 4/1/14. However, the CO stated they were unable to find the minutes of the Board of Trustees meeting which would have approved the CEO's appointment.
The 1/28/14, Board of Trustees Meeting Minutes indicated a resolution had been approved for the CAH's trustees to move forward with recruitment for a CEO.
The 7/29/14, Board of Trustees Bylaws indicated the governing board would select and employ a competent CEO who would direct the management of the CAH.

Based on interview and document review, the critical access hospital (CAH) failed to ensure the operative report was completed immediately following surgery for 1 of 7 patients (P4) reviewed for surgical records.

Findings include:

P4 was admitted to the CAH 5/29/15, for a cesarean section. The anesthesia record indicated anesthesia started on 5/19/15, at 7:50 a.m. and the procedure ended at 9:15 a.m. The operative note was dictated 5/30/15, at 10:14 a.m.

On 8/13/15, at 1:15 p.m. registered nurse (RN) verified the operative report was not done immediately following surgery.

The Medical Staff Bylaws dated 12/14, indicated all operations performed would be fully described by dictation or in writing immediately following surgery.

Based on interview and document review, the critical access hospital (CAH) failed to ensure appropriate notification, investigation and follow up interventions had been developed to minimize the reoccurrence of further medication errors for 6 of 6 patients (P21, P22, P23, P24, P25, P26) who had a medication error . This had the potential to affect all patients treated at the CAH.
Findings include:
Medication variance dated 5/13/15, indicated a lesser dosage of intravenous (IV) Vancomycin (antibiotic) had been administered to P21 than what was ordered (1 gram given instead of the 1250 milligrams which was ordered). The "action taken/notification" section of the medication variance was blank. This section included an area to document the date and times of when the physician was notified, examination of the patient and when the family was notified.
Medication variance dated 5/21/15, indicated P22's Heparin (medication used to eliminate or reduce the risk of blood clots - considered a high risk medication) IV drip was to have been discontinued at 1:00 p.m. on 5/21/15, however, was not discontinued until 7:00 p.m. (6 hours past the order for discontinuation). The "action taken/notification" section of the medication variance was blank.
Medication variance dated 6/20/15, indicated a lesser dosage of IV Vancomycin had been administered to P23 than what was ordered (1 gram given instead of 2 grams which had been ordered). The "action taken/notification" section of the medication variance was blank.
Medication variance dated 7/7/15, indicated P24's morning dose of Vancomycin and solumedrol (steroid) was omitted. The order was to administer the Vancomycin and solumedrol at 8:00 a.m. however, these medications were not given until 2:00 p.m. The "action taken/notification" section of the medication variance was blank.
Medication variance dated 7/12/15, indicated a lesser dosage of IV Vancomycin had been administered to P25 than what was ordered (1 gram given instead of the 1250 milligrams which had been ordered). The "action take/notification" section of the medication variance was blank.
Medication variance dated 7/13/15, indicated a lesser dosage of IV Vancomycin had been administered to P25 than what had been ordered (1 gram given instead of the 1500 milligrams which had been ordered). The "action taken/notification" section of the medication variance was blank.
Medication variance dated 8/4/15, indicated an IV dose of Ceftriaxone was hung for administration for P26, however, the clamp on the IV tubing was not opened and as a result of this, the antibiotic was not administered. The "action taken/notification" section of the medication vriance was blank.
On 8/11/15, at 1:45 p.m. the pharmacy director (PD) stated the pharmacy department collected the number of medication errors and sent those numbers to the pharmacy and therapeutics committee. The PD stated the process for medication variance review was that the medication variance forms were sent to the pharmacy for review and then a copy of the review was forwarded to the nursing managers who were responsible to conduct the follow up. The PD confirmed she was unaware of the follow up on medication variances or the action plans that may have been taken as a result of the above noted medication variances. The PD confirmed the pharmacy department tracked the number of medication errors and trended the category of errors, however, the pharmacy had not been analyzing the trends of errors and had not developed action plans for improvement to help minimize the risk of repeated errors.
On 8/11/15, at 2:35 p.m. the director of nursing (DON) confirmed the expectation was that all medication variances would be followed up on and the physician would be notified of the error. The DON confirmed the "action taken/notification" section of the above medication variance forms were blank. The DON also stated she was unaware of any tracking, trending, analysis or follow up action plans with regards to the medication variance reviews.
On 8/11/15, at 2:50 p.m. registered nurse (RN)-B (nurse manager) confirmed the nurse managers were not tracking, trending or conducting analysis of medication variances. RN-B verified if the staff had followed up with the physician they would have documented in the "action taken/notification" section of the medication variance form and not in the patient's medical record.
The Medication/Transcription Errors: Reporting policy dated 6/19/12, directed staff to report the medication error to the physician who ordered the medication or the physician on-call. In addition, all medication errors were to be documented on the Variance Report. The compliance officer, DON and pharmacy would then review the medication variances for a potentially serious nature or trends which indicated repeated errors and after review, appropriate actions would be developed and taken to ensure improved medication distribution safety.
The Quality and Performance Improvement Plan dated January 2015 - December 2015, indicated the CAH tracked medication variances, analyzed causes, implemented preventive actions and evaluated improvement efforts for sustainability.

Based on observation, interview and document review, the critical access hospital (CAH) failed to follow safe medication administration practices for 1 of 3 patient (P27) medication administration observations.
Findings include:
On 8/11/15, at 8:07 a.m. emergency department patient (P27) presented to the CAH with complaints of right sided flank pain.
On 8/11/15, at 10:01 a.m. registered nurse (RN)-C was observed to successfully place an intravenous (IV) line in P27's left hand. RN-C had brought into the emergency department patient room two correctly labeled injectable pain medications which were Morphine Sulfate (MS) 4 milligrams (mg) and toradol 30 mg. At 10:07 a.m. RN-C informed P27 that she was going to give her some pain medicine through the IV. RN-C proceeded to administer MS 4 mg IV push (IVP). At 10:07 a.m. RN-C administered toradol 30 mg IVP. Prior to the administration of the MS 4 mg IVP and the toradol 30 mg IVP, RN-C was observed to not verify the identification of P27 by asking P27 her name and date of birth, nor did RN-C check the identification armband which was located on P27's right wrist.
On 8/11/15, at 10:12 a.m. RN-C stated prior to administering medications the patient should be identified by asking them their name and date of birth or looking at their armband. RN-C confirmed she had not done this prior to the administration of the MS and toradol IVP she had just given to P27.
On 8/11/15, at 1:22 p.m. the pharmacy director (PD) verified nursing staff should follow the CAH's policy on administration of medications which included proper verification of the patient by asking the patient their name and date of birth and that should be correlated with what was on the patient's armband prior to the administration of any medication.
On 8/11/15, at 2:32 p.m. the director of nursing (DON) confirmed her expectation was for staff to follow the Administration of Drugs policy which directed staff to properly identify patients prior to the administration of any medications.
The Administration of Drugs policy dated 7/2012, directed staff to correctly identify patients prior to the administration of any medication by asking the patient their first and last name, and birth date. This information then would be checked against the patient's identification band.

Based on observation and interview, the critical access hospital (CAH) failed to ensure medical records were stored in a safe environment in order to prevent damage. This had the potential to affect all patients of the CAH.

Findings include:

During a tour of the medical record storage area for inactive records on 8/11/15, at 2:05 p.m. until 2:45 p.m. with the director of health information management (HIM) revealed a locked storage room which, according to the HIM director, held boxes of medical records, accounting records and other patient information from expired patients. Observation of the room revealed banker boxes stacked on the floor, on shelves and on pallets. The room had shelving units which also held banker boxes of patient information. The HIM director stated the medical records were not usually stored on the floor and were in the process of being moved to shelves in the room which would then be encased in locked cages and organized by department.

On 8/13/15, at 8:10 a.m. the HIM director verified the boxes on the floor were inactive patient medical records, which numbered over 100, and had been there for a couple of weeks. The HIM director confirmed the patient records were not stored in a manner in which to prevent damage.

Based on interview and review of facility policies and quality assurance documentation, it was determined the critical access hospital (CAH) failed to ensure periodic evaluation and quality review of their services. The cumulative effect of these systemic problems resulted in the CAH's inability to maintain effective quality assurance processes in order to ensure provision of quality health care. Therefore, the CAH was unable to meet this condition of participation. These deficient practices have the potential to impact all patients receiving services from the CAH.

Findings include:


See C332- The CAH failed to include a comprehensive utilization of services review in the CAH's annual program evaluation.

See C335- The CAH failed to review and evaluate the CAH's utilization of services to determine whether changes needed to be made in order to promote quality patient care during the annual CAH evaluation.

See C336- The CAH failed to develop, maintain and promote an ongoing, hospital-wide quality assurance performance improvement (QAPI) program to continuously evaluate, the quality and appropriateness of the diagnosis and treatment furnished so that corrective actions could be implemented and evaluated to improve the quality of patient care.

See C337- The CAH failed to ensure quality assurance/performance improvement (QAPI) projects were current, comprehensive and incorporated into the CAH's QAPI program for the following departments: dietary, infection control, surgery, anesthesia, pharmacy, medication variances, emergency department, nursing, swing bed, clinical records and radiology.

See C338- The CAH failed to evaluate medication therapy utilized for nosocomial infections. This had the potential to affect all CAH patients.
See C341 - The CAH failed to analyze and evaluate findings, and failed to consider appropriate actions to address concerns related to medication errors.

Based on interview and document review, the critical access hospital (CAH) failed to include a comprehensive utilization of services review in the CAH's annual program evaluation.
Findings include:
The minutes of the 3/5/15, Quality/Compliance Committee Meeting included "annual CAH review" as one of the agenda items. The minutes reflected that a written utilization of CAH services report had been distributed at the 3/5/15 meeting. The compliance officer (CO) provided this report and it included:

· Number of acute care admissions
· Number of swing bed admissions
· Acute care days
· Swing bed days
· Highest census days
· Number of zero census days
· Number of emergency room visits
· Number of deliveries and cesarean sections

On 8/12/15, at 9:41 a.m. the compliance officer (CO) confirmed the utilization of services report lacked information of other service lines which had been provided by the CAH in 2014 such as: newborn days, physical therapy, occupational therapy, speech therapy, categories of surgical procedures, diagnostic radiology and out-patient chemotherapy along with the financial impact they had made on the CAH.
The Annual Review of the CAH program policy dated 12/14, indicated an annual CAH program evaluation would be conducted to ensure appropriate utilization of services was conducted and to determine if any changes were needed. In addition, a statistical report of the CAH services would be compiled annually and submitted for the CAH's annual review.

Based on interview and document review, the critical access hospital (CAH) failed to review and evaluate the CAH's utilization of services in order to determine if changes needed to be made during their annual CAH evaluation. This had the potential to affect all CAH patients.
Findings include:
The minutes of the 3/5/15, Quality/Compliance Committee Meeting included "annual CAH review" as one of the agenda items. The minutes reflected that a written utilization of CAH services report had been distributed at the 3/5/15 meeting. The compliance officer (CO) provided this report and it included:

· Number of acute care admissions
· Number of swing bed admissions
· Acute care days
· Swing bed days
· Highest census days
· Number of zero census days
· Number of emergency room visits
· Number of deliveries and cesarean sections

The 3/5/15, Quality/Compliance Committee Meeting minutes lacked discussion regarding an evaluation of the services provided by the CAH and whether the utilization of services remained appropriate or if changes needed to be made.
On 8/12/15, at 9:41 a.m. the compliance officer (CO) confirmed the utilization of services report lacked information of other service lines which had been provided by the CAH in 2014 such as: newborn days, physical therapy, occupational therapy, speech therapy, categories of surgical procedures, diagnostic radiology and out-patient chemotherapy along with the financial impact they had made on the CAH. The CO verified what had been presented to the Quality/Compliance Committee for the CAH annual review was not an inclusive list of services for them to review.
The Annual Review of the CAH program policy dated 12/14, indicated an annual CAH program evaluation would be conducted to ensure appropriate utilization of services was conducted and to determine if any changes were needed. In addition, a statistical report of the CAH services would be compiled annually and submitted for the CAH's annual review.

Based on interview and document review, the critical access hospital (CAH) failed to develop, maintain and promote an ongoing, hospital-wide quality assurance performance improvement (QAPI) program. This had the potential to affect all patients seen at the CAH.
Findings include:
On 8/13/15, at 8:12 a.m. registered nurse (RN)-E (quality coordinator) stated about a year ago the CAH's quality committee had been restructured and the quality committee and the infection control committee were combined. RN-E stated the committee currently did not have a scheduled time to meet as it just "depended on the schedule of others." The compliance officer (CO) stated the CAH has had in place for over 20 years the plan-do-check-act (PDCA) methodology process which was supposed to be followed by the departments when working on QAPI projects.
On 8/13/15, at 8:15 a.m. the CO stated the nurse managers had routinely been invited to attend the hospital quality/compliance committee where they shared their current quality projects. The CO verified over the last year no departmental manager had attended nor presented to the quality and compliance committee.
On 8/13/15, at 8:20 a.m. RN-E confirmed all departments and contracted services were required to have a current, relevant quality project which should have been incorporated into the hospital-wide QAPI program. However, RN-E verified the CAH did not have a departmental reporting schedule developed nor a schedule for departments to submit their QAPI projects progress following the PDCA process. RN-E stated even though there were some quality indicators which the departments should always collect, each department should have selected a new QAPI project once they have "topped off" with their numbers. RN-E confirmed some managers submitted data to the benchmark report, however, this report was a data collection tool and lacked evidence of analysis of the data collected, action plans for improvement, checks to assure improvement plans had made a difference and interventions to assure continued improvement. RN-E stated she had sent out a request to departments in January regarding their QAPI projects and had not yet received a response back from the departments.
The 2/17/15, Quality and Infection Control Team (QICT) meeting minutes indicated under the Quality Coordinator Report the request for approval of the quality and performance improvement plan, departments were no longer expected to submit a power point presentation of their QAPI projects, however, had been asked to send the name of their project and an overview to RN-E (which as noted above RN-E had not received as of 8/13/15).
The 5/8/15, QICT meeting minutes indicated under the Quality Coordinator Report that the benchmark report (data driven - stoplight report) had been presented.
The QICT meeting minutes for 2/17/15, and 5/8/15, lacked documentation of an update with regards to the progression of the individual QAPI projects, analysis of current QAPI projects, identification of corrective action plans, action plan implementation and evaluation to determine if the measures of improvement identified improved quality. In addition, when direction had been provided by the QICT committee with problem areas identified and how the PDSA methodology had been followed and guided the departments through the QAPI process.
The Quality and Performance Improvement Plan approved 4/28/15, indicated the purpose of the quality plan was to outline the systematic, organizational wide approach to continuous and sustained improvement. In addition, the plan also indicated that all disciplines and services collaborated to carry out performance improvement activities. The goals and objectives outlined in the plan was for the development, implementation and maintenance of an effective, ongoing, organizational, data-driven quality assessment which included:
· Emphasized the role of leadership in improved performance
· Utilized QAPI tools and methodology to facilitate improvement (PDCA)
· Approached in an interdisciplinary manner
· Sustained improvement over time
· Provided a mechanism for employees to be engaged in the QAPI activities
· Meet the regulatory requirements
The scope outlined in the plan indicated it was a continual program that would identify opportunities for improvement and demonstrate measurable improvements associated with improved health outcomes.

Based on interview and document review, the critical access hospital (CAH) failed to ensure quality assurance/performance improvement (QAPI) projects were current, comprehensive and incorporated into the CAH's QAPI program for the following departments: dietary, infection control, surgery, anesthesia, pharmacy, emergency department, nursing, swing bed, clinical records and radiology. This had the potential to affect all patients receiving services from the CAH.

Findings include:

Clinical Records:

On 8/11/15, at 2:40 p.m. the health information manager (HIM) stated she had one current project for QA regarding the scanning of medical records into the electronic medical record (EMR) system. The HIM director was unable to provide data collected, analysis of data nor an evaluation of any data collected. The HIM director was unable to provide evidence of performance improvement.

On 8/13/15, at 8:10 a.m. the HIM director verified the facility did not have an ongoing QA/PI program for clinical records.

Nursing:

On 8/11/15, at 10:45 a.m. registered nurse (RN)-G stated nursing services was working on an alarm management for the QA program to address alarms in the emergency room. RN-G verified there was no current system in place for the program as they were working on a policy, therefore the alarm QA had not been implemented.

On 8/12/15, at 3:20 p.m. RN-G stated nursing services was also working on a falls prevention program. RN-G confirmed this program had been in place since 2011. RN-G verified nursing services had not developed new QA initiatives for the nursing department.


29433

Dietary Services:

On 8/10/15, at 2:05 p.m. housekeeper (H)-A stated the CAH collected temperatures of food trays that were delivered by a contracted service. H-A stated once a month, the CAH checked the temperature of food trays for one week. H-A stated the facility kept this data, however, there was no system for data analysis and the CAH did not have a QA program with the contracted dietary service.

On 8/13/15, at 8:10 a.m. RN-E verified the facility did not have an ongoing QA program for dietary services.

Infection Control:

On 8/12/15, at 2:00 p.m. RN-H stated she performed audits of handwashing by nurses caring for patients in isolation rooms and had a goal of 85%. RN-H verified there was no system for data analysis and she had not identified any further problems with infection control and had no corrective action.

On 8/13/15, at 8:10 a.m. RN-E verified the facility did not have an ongoing QA program for infection control.

Surgery:

On 8/13/15, at 8:10 a.m. RN-E who was in charge of QA and was also the head of the surgery department verified the facility did not have an ongoing QA program for surgical services.

Anesthesia:

On 8/13/15, at 8:10 a.m. RN-E stated anesthesia services were compiling data on hospital readmissions following surgery. RN-E verified there were no futher evaluations on what was done with this data and there were no other QA programs for the anesthesia department.

Radiology:

On 8/12/15, at 2:30 p.m. the director of radiology stated the radiology department had no ongoing QA program. On 8/13/15, at 8:10 a.m. RN-E verified the facility did not have an ongoing QA program for the radiology department.


32601

Emergency Department:
On 8/12/15, at 9:15 a.m. RN-F (emergency department nurse manager) stated for the last 12 years he had been collecting data on the number of returns to the hospital, deaths within 48 hours of being seen in the emergency department (ED) and the number of patients who left without being seen. In addition, RN-F submitted data into the trauma registry. RN-F stated these numbers were submitted to the director of nursing (DON). RN-F was unaware of any data analysis being done on this information or how it was incorporated into the CAH's quality program. RN-F stated the ED was not working on a current QAPI project beyond the routine data collection of quality indicators.
On 8/13/15, at 8:30 a.m. RN-E verified the facility did not have an ongoing QA program for emergency services.
Pharmacy Services:
On 8/11/15, at 1:50 p.m. the pharmacy director (PD) stated pharmacy services had been working on barcode scanning since 2009. In addition, since 2010 the pharmacy department maintained a log of what medications were taken out of the pharmacy after hours. The PD confirmed pharmacy services did not have a more current QAPI project. The PD also stated medication variance numbers and the category of the types of medication variances were reported to the pharmacy and therapeutics committee monthly. However, the PD confirmed pharmacy services had not been analyzing the trends of medication variances nor had developed action plans for improvement to which would minimize the risk of a repeated variances. The PD verified pharmacy services currently had no QAPI project being conducted which focused on medication variances.
On 8/13/15, at 8:38 a.m. the compliance officer (CO) verified the facility did not have an ongoing QA program for pharmacy.
On 8/13/15, at 8:41 a.m. RN-E verified the facility did not have an ongoing QA program for medication variances.
The Quality and Performance Improvement Plan dated January 2015 - December 2015, indicated the purpose of the quality plan was to outline the systematic, organizational wide approach to continuous and sustained improvement. The plan also indicated that all disciplines and services collaborated to carry out performance improvement activities. The scope of the quality program included medication variance identification and reduction. In addition, indicated the CAH tracked medication variances, analyzed causes, implemented preventive actions, and evaluated improvement efforts for sustainability.

Based on interview and document review, the critical access hospital (CAH) failed to evaluate medication therapy utilized for nosocomial infections. This had the potential to affect all CAH patients.
Findings include:
Medication therapy had not been evaluated with regards to utilization for nosocomial infections as part of the quality assessment/performance improvement (QAPI) program in 2015. The 2/17/15, and 5/8/15, Quality and Infection Control Team (QICT) meeting minutes lacked discussion related to the medication management and therapy for infections.
On 8/11/15, at 1:50 p.m. the pharmacy director (PD) stated the QAPI projects pharmacy had been working on for the last several years included barcode scanning and monitoring inventory of what medications were being removed from the pharmacy after hours. The PD confirmed pharmacy services had no QAPI project in place to look at medication therapy for infection control prevention.
On 8/13/15, at 8:10 a.m. registered nurse (RN)-E verified the facility did not have an ongoing QAPI program for medication therapy for infection control prevention.
On 8/13/15, at 8:38 a.m. the compliance officer (CO) verified the facility did not have an ongoing QA program for pharmacy related to medication therapy for infection control prevention.

Based on interview and document review, the critical access hospital (CAH) failed to analyze, evaluate the findings and consider appropriate actions to address the concerns related to medication errors. This had the potential to affect all CAH patients.
Findings include:
On 8/11/15, at 1:45 p.m. the pharmacy director (PD) stated the pharmacy department collected the number of medication errors and sent these numbers to the pharmacy and therapeutics committee. The PD confirmed the pharmacy department tracked the number of medication errors and trended the category of errors, however, pharmacy staff had not been analyzing the trends of errors nor had they developed action plans for improvement to which would minimize the risk of a repeated error.
The 1/2015, 4/2015, and 7/2015, pharmacy and therapeutics committee meeting minutes indicated the number of medication errors had been presented. However, lacked discussion regarding the tracking, trending, analysis, and development of action plans to prevent further medication errors.
The Quality and Infection Control Team (QICT) meeting minutes dated 2/17/15, and 5/8/15, lacked discussion regarding medication error analysis, trending, action plan development to minimize the risk of repeated medication errors.
The Medication/Transcription Errors: Reporting policy dated 6/19/12, indicated the compliance officer, DON and pharmacy would review the medication variances for a potentially serious nature or trends which indicated repeated errors and after review, appropriate actions would be developed and taken to ensure improved medication distribution safety. In addition, the pharmacy/nursing analysis with recommendations would be reported to the pharmacy and therapeutics committee and the pharmacy and therapeutics committee would make the final recommendations to be instituted by pharmacy/nursing.
The Quality and Performance Improvement Plan dated January 2015 - December 2015, indicated the purpose of the quality plan was to outline the systematic, organizational wide approach to continuous and sustained improvement. The scope of the quality program included medication variance identification and reduction. In addition, indicated the CAH tracked medication variances, analyzed causes, implemented preventive actions, and evaluated improvement efforts for sustainability.

Refer to C0277 for medication variances.