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Based on staff interview and record review the CAH failed to meet the needs of 1 of 5 ER (Emergency Room) patients reviewed, by failing to conduct an evaluation of the patient's condition to determine need for any medical stabilizing treatment, prior to transfer to another facility. (Patient #24). Findings include:

1. Per record review Patient #24 was transported by ambulance to the ER (Emergency Room), on the evening of 4/23/15, underwent diagnostic testing ordered by PA #1 (Physician Assistant), the ER medical provider on duty, and, although no ER medical provider had put eyes on or evaluated the patient, s/he was then transferred by ambulance to an outside field location to await air medical transport to another facility. ER nursing notes indicated that Patient #24 had been taken directly to CT scan upon arrival at 7:26 PM, was awake, with no signs of respiratory distress and was able to follow commands. The notes further stated that the patient had exhibited signs and symptoms of a stroke with right sided facial droop, slurred speech, left arm and leg paralysis and vital signs that included an elevated blood pressure of 151/100. PA #1's note, at 7:55 PM, stated that the ambulance had been called out at 6:52 PM for a patient with acute stroke symptoms. EMS (Emergency Medical Services) then communicated to the ER that they had contacted DHART (Dartmough Hitchcock Advanced Response Team) and would bypass the ER and connect with the medical care air transport for transport of the patient to a facility that could provide higher level care. PA #1's note further revealed that EMS again contacted the ER to request to bring the patient to the CAH to obtain a CT scan while they waited the approximate 25 minutes it would take for DHART to arrive. Patient #24 arrived in the ER and went directly to CT scan, which had been ordered by PA #1. After the scan was done the patient was immediately taken out to the ambulance and transported back to the landing area for DHART without having been seen or examined by PA #1 or any other ER medical provider. The documentation by PA #1 included the diagnosis of 'Possible CVA' (stroke) and stated that a phone call had been placed to a medical provider at the receiving hospital to alert him/her "....of the coming patient and was informed that they could not take [Patient #24] because there was not a neuro interventionist available and [Patient] might need to have the clot extracted for maximum benefit. At that point [ER Physician #1] came on and I asked if [s/he] could talk with DHMC and define what we should do with the patient. DHART was in the air with the patient at that point and a decision was made to fly [him/her] to Mass. But according to [ER Physician #1] they were not able to accept [Patient #24] either and because of fuel concerns [Patient #24] was taken to DHMC." Although the CAH's established Emergency Room Scope Of Services policy, identified by staff as the currently used policy, stated within it's scope of services...: 'The Emergency Room (ER) will provide the following services: ......Staff competencies include, but are not limited to:... Initiation of Stroke management, including administration of thrombolytics...Stabilization of patients to be transferred to a higher level of care...', the patient was taken from the ER without benefit of evaluation by a medical provider to determine need for medical treatment/stabilization prior to transfer. In addition, although the patient had not been evaluated by PA #1, or any other ER medical provider, there was a Patient Transfer Form, completed by PA #1, that identified the patient's condition as "stable."

During interview, on the afternoon of 4/28/15, Physician #2, [the ER Medical Director], confirmed that patient #24 had not been seen or examined by any ER medical provider when s/he presented, via EMS, for CT scan on the evening of 4/23/15. Physician #2 stated that Physician #1 had contacted Physician #2 on 4/24/15 to inform him/her of the incident. Physician #2 stated that s/he had interviewed PA #1 who told Physician #2 that EMS had reportedly conducted a field assessment of Patient #24, had made the determination of possible stroke and, despite the fact that the CAH did have a Stroke Protocol in place, had contacted DHART to have the patient transported via medical air transport to a hospital that could provide higher level care. EMS reportedly contacted the ER a second time to state that there would be a 25 minute waiting period for DHART arrival and requested, and were given approval by PA #1, to bring Patient #24 to the CAH to obtain a CT scan to "save time". The patient reportedly arrived at the CAH, went directly to CT scan, which had been ordered by PA #1 and was immediately put back on the ambulance stretcher and taken from the CAH by EMS. Physician #2 stated that a limited nursing assessment had been completed, and although PA #1 had reportedly attempted to evaluate the patient after the CT scan was completed, s/he was unable to do so as the patient had already been transferred from the ER without PA #1's knowledge.

The facility staff failed to follow policy in regard to the administration of an emergency involuntary medication when there was a lack of evidence of imminent threat of bodily harm to the patient or others. (Patient #1) Findings Include:

1. Per record review, Patient #1 age 84 was admitted to the CAH (Critical Access Hospital) on 4/4/15 for rehabilitation after a repair of a fractured hip. Upon admission it was noted Patient #1 had a long psychiatric history (Bipolar disorder) and dementia and recently had not been compliant with prescribed medication to include Lithium. The patient's attending physician who visited with the patient at the time of admission noted Patient #1 to be "quite manic". As a result, Patient #1 demonstrated challenging behaviors to include ongoing periodic refusal of medications, failure to maintain post surgical hip replacement precautions, ambulated without assistance although at risk for falls, refused physical and occupational therapy, was impulsive and often refused assistance with personal care. Although some nursing staff were able to provide provision of services to Patient #1, others were unable to establish a rapport that would facilitate administration of medications, incontinence care or assure patient safety. Per Nursing progress notes staff document Patient #1 was resistant when staff attempted to ambulate or transfer to bed and would slap at the nurses. Per interview on 4/29/15 at 9:50 AM, Nurse #1 acknowledged Patient #1 had reached to grab at a staff member's throat on 4/11/15, however was rapidly redirected by Nurse #1 without injury to staff or the patient. The patient expressed her/his frustration during this incident and acknowledging his/her resistance of care provided by certain staff.

On the morning of 4/12/15 during nursing attempts to administer medications, once again the patient refused and "...battered the cup of pills on the floor..". Patient #1 also intentionally spilled 2 cups of water on his/her bed and over-bed table. Staff notified the on-call hospitalist and received an order for an involuntary medication. Haldol 5 mg (psychotropic medication) IM (intramuscular) was prescribed. Per CAH policy Involuntary Procedures and Uses of Restraint last revised 1/2015 states: Definition of an emergency and validation of use: " 1. A significant change in the patient's condition or past behavior; 2. Resulting in the imminent threat of serious bodily harm to the patient or others." During interview, RN #1 also confirmed Patient #1 was agitated on 4/12/15 and staff had attempted to redirect and provide support. However, the patient's behavior had not changed significantly from admission which included on 4/12/15 to be the ongoing refusal of medication and refusal to comply with staff direction and when approached s/he would, at times, slap at staff. However, there was no indication of imminent threat of serious bodily harm to the patient or staff. In addition, staff had failed on 4/12/15 to use alternative, less restrictive interventions as directed by the General procedures for all involuntary procedures: "Such interventions may include but not be limited to the following: Crisis Prevention Intervention (CPI) de-escalation techniques.....activity changes, distraction, separate the patient from the situation/offer a quiet space, remove others that are upsetting to the patient, relaxation techniques, music, sit and talk......". Subsequently, Patient #1 had refused oral medication which was offered, the decision was made to administer the involuntary medication. On 4/12/15 at 0901, 3 staff members entered Patient #1's room. While in bed, Patient #1's arms were held by accompaning staff and Nurse #1 supported the patient's leg and administered the Haldol 5 mg. IM. Per the Certificate of Need for Involuntary Procedures, Nurse #1 notes on 4/12/15 at 10:35 AM, after 1 hour of the involuntary medication administration Patient #1 was calmer though still unable to follow instructions, still unable to keep herself safe with no insight into his/her illness or safety. Prior to the involuntary procedure, the CAH had not developed a behavioral plan to assist staff in the management and understanding of Patient #1's psychosocial needs.

The facility failed to properly store and secure expired medications within the pharmacy department and failed to securely store contrast media in the radiology department from unauthorized access. Findings include:

1. On 4/28/15 at 10:20 AM, during a tour of the Pharmacy Department accompanied by the staff pharmacist, a large quantity (100 +) of expired medications to include multi-dose and single dose vials, packaged tablets and capsules were observed overflowing in 2 boxes located in the pharmacy staff bathroom. The pharmacist stated the medications observed will eventually be picked up by a contracted pharmacy vendor for credit, however the removal was overdue. The pharmacist confirmed, although access to this location is restricted to authorized pharmacy staff, unauthorized staff do access the bathroom for housekeeping or maintenance purposes at which time continuous observation and/or supervision of such individuals could not be guaranteed. The pharmacist agreed, there was a failure to properly store expired medications.

2. Per observation, on 4/27/15 at 2:42 PM, an unlocked warming unit containing (8) 100 ml and (1) 50 ml vials of Omnipaque injectable contrast solution was unsecured in the CT room of the radiology department. The inner corridor door to the room was unlocked and accessible by a common hallway that extended to a patient waiting area. The room was not within direct sight of staff within the department. The lack of secure storage was confirmed by the director of diagnostic imaging at the time of the observation. The facility added a lock to the warming unit to secure the contrast solution after it was identified during the survey.

Based on observation and policy review, the hospital failed to assure that dietary staff consistently adhered to daily and weekly cleaning schedules to maintain sanitary food preparation and storage areas. Staff also failed to assure that all perishable foods were labeled and dated in accordance with hospital policy and accepted safe food handling practices. Findings include:

Per observations during the tour of the hospital's kitchen commencing at 10:58 AM on 4/27/15, the following perishable food item was not labeled and dated in accordance with the Dietary Policy/Procedure for "Labeling and Dating", effective 8/1/07, revised 3/22/11: a piece of cooked deli-style turkey stored in the walk-in cooler was not labeled and dated. The policy/procedure stated "Date all items the day they are prepared or opened and use the guide below to determine expiration....cooked turkey (and other cooked packaged meats) - 3 days."

Per observations of the kitchen preparation and food storage areas, the following areas were noted to be soiled with a build-up of visible dirt/debris in the corner areas: the walk-in freezer floor; the walls, under sink area, trash containers and flooring in the dish machine area; the floor perimeter and corner areas in the main kitchen, a stainless steel cart and a Rubbermaid cart used in the kitchen areas and the floor in the dry food storage pantry.
Per review of the daily and weekly cleaning schedules for dietary personnel, the areas cited are to be cleaned daily and deep cleaned, including "all crevices" and walls and floors weekly. These observations were confirmed with the Director of Dietary Services at the conclusion of the tour on 4/27/15, at 11:40 AM.

The facility nursing staff failed to develop a care plan to address behavioral factors that affected the provision of care and services for 1 patient with psychosocial and behavioral impairments. (Patient #1) Findings include:

1. Per record review, Patient #1 age 84 was admitted to the CAH on 4/4/15 for rehabilitation after a repair of a fractured hip. Upon admission it was noted Patient #1 had a long psychiatric history (Bipolar disorder) and dementia and recently had not been compliant with prescribed medication to include Lithium. The patient's attending physician who visited with the patient at the time of admission noted Patient #1 to be "quite manic". As a result, Patient #1 demonstrated challenging behaviors to include ongoing periodic refusal of medications, failure to maintain post surgical hip replacement precautions, ambulated without assistance although at risk for falls, refused physical and occupational therapy, was impulsive and often refused assistance with personal care. Although some nursing staff were able to provide provision of services to Patient #1, others were unable to establish a rapport that would facilitate administration of medications, incontinence care or assure patient safety. Per Nursing progress notes staff document Patient #1 was resistant when staff attempted to ambulate or transfer to bed and would, at times, slap at the nurses.

Although a care plan was developed which addressed Patient #1's anxiety, there was a failure to address Patient #1's behavioral needs and management. The care plan failed to address interventions to best assist both the nursing staff and the patient in approaching the patient's inability to appropriately process and comply with nursing directives due to his/her psychiatric diagnosis, dementia and cognitive impairment. On going issues with non-compliance and varied interactions which were effective with managing the above-mentioned behaviors, were not incorporated in a plan that may have provided more effective approaches with Patient #1's challenging behaviors. Per interview on the afternoon of 4/29/15, the CNO (Chief Nursing Officer) confirmed the nursing care plan for Patient #1 had failed to address behavioral factors which impacted the provision of both nursing care and rehab therapies.