HospitalInspections.org

Based on review of personnel records and interview, the facility failed to ensure background studies were completed for 2 of 10 staff (licensed practical nurse (LPN)-A, Emergency Medical Technician (EMT)-B) reviewed and 1 of 3 medical staff (MD-A) reviewed. Findings include:

Review of the credentialing file for MD-A indicated the required Minnesota background study was not completed.

LPN-A's personal record was reviewed and indicated that the required Minnesota background study was not completed.

EMT-A's personal record was reviewed and indicated that the required Minnesota background study was not completed.

On 9/29/11, at 9:28 a.m. the chief operating officer (CEO) verified the lack of background studies for MD-A, LPN-A and EMT-A. The CEO stated that credentialing files have been taken over by the corporate office located in South Dakota. The CEO stated the corporate office completed a background study, but not the required Minnesota study.

Based on interview, record review and policy review the CAH did not ensure procedures for reporting and monitoring adverse drug reactions and medication errors to prevent medication errors. Findings included:

During an interview at 10:20 a.m. on 9/27/2011 the pharmacy director (PD) stated he had not reviewed any medication errors. The PD stated he keeps a copy of the medication errors forwarded to him by nursing staff but he has not received any medication error reports since 2009. He went on to say if he discovers a medication error, he informs the director of nursing (DON). The PD stated "I am supposed to bring the medication errors to the pharmacy and therapeutics (P&T) committee for review, but how can I do that if they don't get forward to me?"

The medication error policy indicated that guidelines would be provided for quality assurance monitoring and action to be taken that will establish parameters for competent and safe nursing practice in medication administration. A review of the medication error form policy revealed the information from the medication error was to be submitted to the Pharmacy and Therapeutics Committee for review.

A review of the P & T committee meeting minutes for 2011 revealed the committee had not reviewed any medication errors.

The director of nurses, interviewed at 1:00 p.m. on 9/27/2011, "I wasn't aware we were supposed to be bringing medication errors to the P & T committee." The DON provided copies of four Medication or Treatment Error Incident reports. The DON verified the PD was aware of only one medication error. No evidence that analysis or corrective action to prevent medication errors was provided.

A review of the Quality Improvement (QI) meeting minutes dated 8/30/2011 revealed there was no QI for medication errors.

Based on interview, record and policy review, the facility did not ensure 1 of 6 physicians (MD-A) reviewed was credentialed by the critical access hospital medical staff or governing board. Findings included:

MD-A was not credentialed by the critical access hospital (CAH) medical staff or governing board.

Review of the medical staff meeting minutes for 2011 indicated that MD-A was not among the physicians credentialed by the medical staff committee.

The radiology manager (RM), interviewed at 11:20 a.m. on 9/27/2011, stated that MD-A was the director of the radiology department at the CAH.

Review of the credentialing policy indicated that Wheaton Community Hospital (Sanford Medical Center Wheaton) would obtain and secure the credentialing files of all medical staff members.

Documentation provided by the chief executive officer (CEO) revealed MD-A had been credentialed for Sanford Clinic North and Sanford Medical Center Fargo, but not for Sanford Medical Center Wheaton. The CEO was interviewed at 11:20 a.m. on 9/28/2011, and verified MD-A was not credentialed by the CAH medial staff or governing board for Sanford Medical Center Wheaton.

Based on record review, interview and policy review, the facility did not ensure 7 of 10 emergency room medical records were properly authenticated with signatures and dates of the ordering providers. Findings include:

Review of closed emergency room (ER) records revealed 5 charts with orders that were not signed by the provider and 2 charts that were not dated by the provider.

ER-1 record dated 3/26/2011, contained orders for a racemic epinephrine 2.25 % nebulizer treatment (used for airway control) and Pediapred (a pediatric steroid) 2 tsp to be given immediately. However, the ordering provider did not sign the order.

ER-2 record dated 4/24/2011, contained orders for a urinalysis and Ciprofloxacin 250 mg (antibiotic) 2 tabs by mouth twice a day. However, it was not signed by the ordering provider.

ER-3 record dated 5/8/2011, included orders for silvadene 1 % ointment (burn ointment), Toradol 60 mg intramuscular injection (anti inflammatory medication) as well as Percocet 5/325 mg (a narcotic pain medication) orally. However, the orders were not signed by the provider.

ER-4 record dated 6/19/2011, included orders for a laboratory blood draw with testing for CBC, CMP, CRP, Hgb A1C, Alcohol and urine toxicology screen. There was also an order for computed tomography (CT) of the head without contrast. The orders were not signed by the provider.

ER-5 record dated 7/7/2011, was a trauma record that indicated the patient had been intubated and received multiple medications including Versed, Atropine, sodium bicarbonate, epinephrine, and insulin. The trauma record was not signed by the provider.

ER-6 record dated 6/20/2011, included orders for amoxicillin (antibiotic) and, although the order was signed by the physician, it was not dated or timed.

ER-7 record dated 4/9/2010, included orders for laboratory blood analysis, chest Xray and nebulizer treatment. The orders were signed by the provider; however, they were not dated or timed. In addition, the consent for treatment was not signed by the patient or responsible party.

A review of the medical staff bylaws revealed all clinical entries in the patient's medical record shall be accurately dated, timed and authenticated.

During an interview at 2:50 p.m. on 9/27/2011 the director of nursing (DON) stated "the orders are supposed to be signed. I just found in July they are also supposed to be timed."

At 10:30 a.m. on 9/29/2011 the DON verified the orders were not signed and stated "with all of our quality stuff we do, we never even thought the doctors should sign the trauma record."

Based on interview, record review and policy review, the Community Access Hospital (CAH) did not ensure a quality assurance program was in effect for 4 of 18 areas reviewed for quality assurance (anesthesia, pharmacy, medication errors and physical plant). Findings include:

There was no Quality Improvement (QI) program for the anesthesia department.

Review of the Quality Improvement Meeting minutes dated August 30, 2011, indicated that the anesthesia department was continuing to work on ensuring complete documentation on forms. They were also monitoring the use of anesthesia for documentation of procedures.

Interview with the registered nurse in charge of quality assurance (RN-QA), at 9:30 a.m. on 9/28/2011, confirmed there was no currently active QI project for anesthesia.


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The pharmacy director (PD), interviewed at 10:00 a.m. on 9/27/2011, stated the current QI activity for the pharmacy consisted of monitoring "foot traffic" into the pharmacy. It was explained that every nurse coming into the pharmacy after hours needed to sign in and document the medication they were removing from the pharmacy. If the medication removed was available as floor stock he would have a conversation with the nurse about the "unnecessary trip" into the pharmacy. The PD explained he didn't do anything with the information and collection and analysis of the data is the job of the quality improvement director. The PD said he also monitors outpatient charges for medications; however, there was no data collected in regards to improvement of quality for CAH inpatients.

A review of the Quality Improvement (QI) meeting minutes dated 8/30/2011, revealed the QI for the pharmacy department was monitoring charging of medications for outpatients. If greater than $200 a note goes to the business office. A review of the sign in sheet for the meeting revealed the PD did not attend the meeting. No further information was given by the PD or the director of QI.

There was no QI program for monitoring or reducing the number of mediation errors.

The PD, interviewed at 10:20 a.m. on 9/27/2011, stated he did not review medication errors. He explained he always keeps a copy of the medication errors forwarded to him by nursing staff but there have been none forwarded to him since 2009. The PD stated that, if he discovers a medication error, he informs the director of nursing (DON). The PD stated "I am supposed to bring the medication errors to the pharmacy and therapeutics (P&T) committee for review, but how can I do that if they don't get forward to me?"

A review of the medication error policy revealed; guidelines would be provided for quality assurance monitoring and action to be taken that will establish parameters for competent and safe nursing practice in medication administration. A review of the medication error form policy revealed the information from the medication error was to be submitted to the Pharmacy and Therapeutics Committee for review.

A review of the P & T committee meeting minutes for 2011 revealed the committee had not reviewed any medication errors.

During an interview at 1:00 p.m. on 9/27/2011 the DON stated "I wasn't aware we were supposed to be bringing medication errors to the P & T committee." The DON provided copies of four Medication/ Treatment Errors or Incident reports. The DON verified the PD was aware of only one medication error. No evidence that analysis or corrective action to prevent medication errors was provided.

A review of the Quality Improvement (QI) meeting minutes dated 8/30/2011 revealed there was no QI for medication errors.

There was no QI program for the physical plant.

During an interview at 9:20 a.m. on 9/29/2011, the director of maintenance (DM) stated that the current QI project was for the clinic and not the CAH. The DM went on to say he had done some work in a closet for housekeeping. He put up some shelves and made the area more ergonomically friendly to the housekeeping staff but that was all he had done on the hospital side.

A review of the QI meeting minutes for 8/30/2011, revealed the QI for housekeeping as looking at ergonomics within the department.

Based on observation, interview, record review and policy review, the Community Access Hospital (CAH) failed to develop and implement a comprehensive care plan with directions for use of a PEG feeding tube for 1 of 1 patients (P1) in the sample reviewed for use of a PEG feeding tube. Findings include:

P1's PEG feeding tube was not checked for accurate placement prior to use and the plan of care did not direct verification of the PEG feeding tube placement.

Licensed Practical Nurse (LPN)-A was observed on 9/27/11, at 11:54 a.m. when P1 received 100 cc of water through the PEG feeding tube. LPN-A did not verify the placement of the PEG feeding tube prior to administering the water. LPN-A was interviewed after the aforementioned observation and confirmed that she should have checked for placement of the PEG feeding tube prior to its use. P1's nursing care plan dated 9/24/11, directed: "Head of Bed elevated at least 30 degrees for those with tube feedings; 9/25/11, tube feeding d/c'd." The care plan had not addressed the care and use of the feeding tube.

The CAH policy and procedure for use of PEG feeding tubes was requested at this time. The policy was provided on 9/29/11 at 10:50 a.m. The Director of Nursing Services (DNS) stated the policy had been lost in a computer file. Review of the facility policy/procedure titled "Enteral Nutritional Therapy (Tube Feeding) dated 8/26/11, identified the following " Verify tube placement prior to feeding by: Observing for Change in External Tube Length...Aspirating and Observing Feeding Tube Aspirates 60 ml syringe...Auscultate abdomen for bowel sounds..."

The DNS, interviewed on 9/29/11, at 10:50 a.m., stated that nursing staff should be following the CAH policy's related to use of PEG feeding tubes and confirmed that care plan for P1 did not address the care and use of the PEG feeding tube.