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Based on record review and interview, the provider failed to ensure:
*The medical staff and sections conducted ongoing monitoring and evaluation of the quality and appropriateness of care for 3 of 11 hospital departments (food and nutrition services, pharmacy, and nursing services to include emergency department, intensive care unit, medical/surgical/pediatrics, operating room, and same day surgery).
*Fifty-eight medication errors identified from January 2013 through October 2013 had been evaluated for process changes to reduce potential medication errors and provide feedback to staff.
Findings include:

1. Review of the provider's quality coordinating council committee minutes for 4/3/13, 7/10/13, 8/10/13, 9/4/13, 10/17/13, and 11/6/13 revealed the following hospital departments had no on-going monitoring or evaluation of quality and appropriateness of patient care. Review of the above listed minutes revealed:
*Food and nutrition services had no identified indicators, bench marking, or goals established. Information had been reported on staff replacements, open dietary positions, number of people served at the facility picnic, and which staff member was responsible for food purchases.
*Pharmacy had included a review of medication errors, but there was no indication any actions had been implemented to prevent potential medication errors, changes in medication administration processes, or feedback to staff related to the review of medication errors or the prevention of medication errors.
*Nursing services had reported monitoring data collected during a 2012 chart review audit for the emergency department, intensive care unit, medical/surgical/pediatrics units. There was no data reported for quality assurance and performance improvement. Information reported by nursing service included the number of patients seen and staffing issues.

Refer to A273, finding 1.

2. Review of the provider's 2013 medication occurrences report revealed documentation of numerous medication errors that had been categorized as patient impact, process type, and outcome type errors. A total of fifty-eight medication errors had been identified.

Review of the Pharmacy and Therapeutics meeting minutes dated 2/16/13, 3/26/13, 4/23/13, 5/28/13, 6/25/13, 7/23/13, and 8/27/13 revealed:
*Medication occurrences had been reported and categorized as patient impact, process type, and outcome type.
*A request had been made for the medication reconciliation process to be reviewed by the Medication Administration Team at the 2/26/13 meeting.
*There was no documentation in the provider's quality assurance and performance improvement program meeting minutes that requested review had been conducted.
*There was no documentation in the provider's quality assurance performance improvement program meeting minutes feedback to the nursing staff had been conducted to decrease the potential for future medication errors.

Refer to A286, finding 1.

Based on record review, interview, and policy review, the provider failed to ensure 3 of 11 hospital services (food and nutrition, pharmacy and therapeutics, and nursing services to include emergency department, intensive care unit, medical/surgical/pediatrics, operating room, and same day surgery) had reported measurable outcomes based on data provided to the quality assurance performance improvement (QAPI) plan. Findings include:

1. Review of the provider's quality coordinating council committee minutes from July 2013 through November 2013 revealed information had been reported for the following hospital departments:
*Food and nutrition services had no identified indicators, bench marking, or goals established. Information had been reported on staff replacements, open dietary positions, number of people served at the facility picnic, and which staff member was responsible for food purchases.
*Pharmacy and therapeutics had included a review of medication errors, but there was no indication any actions had been implemented to prevent potential medication errors, changes in medication administration processes, or feedback to staff related to the review of medication errors or the prevention of medication errors.
*Nursing services had reported monitoring data collected during a 2012 chart review audit for the emergency department, intensive care unit, medical/surgical/pediatrics units. There was no data reported for quality assurance and performance improvement. Information reported by nursing service included the number of patients seen and staffing issues.

Review of the quality coordinating council meeting minutes from July 2013 through November 2013 revealed:
*No summary and analysis of report findings, department recommendations and/or action plans, and no quality improvement committee recommendations or comments.
*Food and nutrition, pharmacy and therapeutics had none of the above related to medication errors, and nursing services to include emergency department, intensive care unit, medical/surgical/pediatrics, operating room, and same day surgery.

Interview on 11/13/13 at 10:15 a.m. with vice president of outcomes and service excellence staff A and quality improvement and risk management staff B revealed:
*Each department would have set their own priorities, monitoring, and goals.
*Each department would have reported on those areas on a yearly or bi-yearly basis.
*Each department submitted reports that might or might not have included a status report on which areas were being monitored.
*All reports from departments were given to the governing body on a monthly basis.
*The governing body had not made any recommendations for any QAPI projects.
*The core measures for congestive heart failure, acute myocardial infarction, and pneumonia were monitored.
*The quality care council had been asked to monitor processes in the past, but they could not remember which ones.

Interview on 11/14/13 at 9:00 a.m. with the chief nursing officer revealed:
*She had just started that position in August 2013.
*She was aware the QAPI program did not identify opportunities for improvement and changes for all hospital services.

Review of the provider's revised 6/20/13 Performance Improvement Plan revealed the medical staff committees and sections should have conducted ongoing monitoring and evaluation of the quality and appropriateness of care for the following hospital services:
*Food and nutrition services, pharmacy, respiratory care, social services, anesthesia, TCU/Maryhouse, Avera Medical Group services, rehabilitation (rehab) services (cardiac rehab, speech therapy, physical therapy, and occupational therapy), and nursing services (emergency department, operating room, same day surgery, kidney dialysis, intensive care, obstetrics/family practice, medical/surgical/pediatric, out-patient treatment services, and diabetes education).
*The quality coordinating council would meet once a month and was responsible for:
-Identifying areas for process or performance improvement.
-Ideas for teams were generated from but not limited to the following areas:
--Employee/department requests.
--Performance improvement monitors.
--Patient satisfaction surveys.
--Core measure reports.
--Bench marking.
-Developing, monitoring, and follow-up of all total quality management teams.
-Reviewing departmental status reports.
-Serve as a resource to all departments.

Based on record review and interview, the provider failed to ensure all medication occurrences had been reviewed and acted upon by the quality assurance/performance improvement (QA/PI) committee. Findings include:

1. Review of the provider's medication occurrences from January 2013 through October 2013 revealed:
*There had been a total of fifty-eight medication occurrences.
*Four had been classified as an adverse drug reaction-other (no explanation of what other was).
*Fifty-seven of those occurrences had been classified as a medication error with no harm to the patient.
*One had been classified as increased patient monitoring.
*The process types of those occurrences included:
-Four prescribing occurrences.
-Twenty-four transcribing occurrences.
-Twenty-eight administration occurrences.
-Two monitoring occurrences.
*The outcome types of those occurrences included:
-Twenty-five omissions.
-Three wrong patient.
-Ten wrong time.
-Four wrong medication.
-One wrong route.
-Seven extra dose of medication.
-One under dose of medication.
-One unordered medication.
-One wrong dose and wrong rate of medication.
-Two protocol not followed.
-Three with no outcome type.
*Occurrences by departments included:
-Thirty-seven occurrences for medical/surgical.
-Four occurrences for obstetrics.
-Three occurrences for emergency department/acute care unit.
-Two occurrences for the operating/recovery rooms.
-Three occurrences for the intensive care unit (ICU).
-Three occurrences for the pharmacy.
-One occurrence for the nursery.
-Five occurrences for the kidney dialysis unit.

Review of the quality coordinating councils meeting minutes from July 2013 through November 2013 revealed:
*Pharmacy and therapeutics reported in August 2013.
*That report had not included any medication occurrences.
*Pharmacy and therapeutics were scheduled to report to the quality coordinating council in February and August 2013.

Review of the pharmacy and therapeutics committee meeting minutes from 2/26/13 through 10/22/13 revealed:
*Medication occurrences were reviewed at each meeting.
*At the 2/26/13 meeting the medication occurrences were to have been forwarded to the medication administration team for further discussion on processes and possible thresholds.
*There was no further documentation in the meeting minutes indicating a goal and processes had been recommended.
*Medication occurrences were tracked, but no trending was noted.

Interview on 11/12/13 at 3:00 p.m. with pharmacist D revealed:
*She determined what type of error had occurred and what the severity of each was.
*Those were looked at by the medication administration team on a monthly basis.

Based on record review, interview, and policy review, the provider failed to ensure nursing services was organized to provide oversight and competency validation completion for three of three newly hired registered nurses (RN) (E, F, and G) related to one of one sampled patient (1) medication error. Findings include:

1. Review of patient 1's grievance dated 10/25/13 revealed:
*An initial identification band had been placed on patient 1's wrist by the patient access staff.
*A second identification band had been placed on his wrist by RN E when he had reached the medical floor.
*RN E had given patient 1 a medication without checking his identification band or asking his name and date of birth.
*Patient 1 had two different identification bands on, one with his name on it and one with patient 2's name on it.
*He had been given patient 2's medication on 10/15/13.
*He had been told that medication was "like taking a Tums."

Review of patient 1's entire medical record for his admission on 10/15/13 revealed:
*No mention he had received the medication that was for patient 2.
*No mention his physician had been notified of the medication error.

Review of patient 2's medication administration record for 10/15/13 revealed:
*He was to have received calcium acetate 667 milligrams three times daily.
*That was the medication patient 1 had received.
*That medication was used for the control of increased phosphates for patients with end stage renal disease.
*He had received that medication on 10/15/13 at 8:00 a.m., 12:00 noon, and 6:00 p.m.

Review of the provider's undated departmental orientation record for new employees revealed what was required on the first day and for the first week. That orientation included the provider's revised November 2011 Patient Identification policy. That policy included:
*Two identifiers would have been used prior to any treatment/procedure/medication administration.
*The two identifiers would have been the patient's full name and date of birth.
*All patients would have an identification band placed on the their wrist by the patient access staff or the emergency room staff.
*When a patient reached the assigned unit a different staff member would have verified the identification band accuracy.
*That policy was reviewed during the first day of orientation.

Review of RN E's personnel record revealed:
*Her date of hire was 6/6/13.
*Her initial orientation had been started on 6/6/13.
*There was no record of her nursing orientation to the medical/surgical/pediatrics unit.

2. Review of RN F's personnel record revealed:
*Her date of hire was 9/3/13.
*There was no record of her initial orientation.
*Her nursing orientation to the medical/surgical/pediatrics unit had not been completed.
*There was only the date of 10/23/13 documented for some of the orientation skills.
*The nursing orientation to the medical/surgical/pediatric unit did not contain a patient identification section.

3. Review of RN G's personnel record revealed:
*Her date of hire was 6/25/12.
*Her initial orientation had been started on 6/25/12.
*There was no record of her nursing orientation to the medical/surgical/pediatrics unit.

4. Interview on 11/13/13 at 4:00 p.m. with RN C revealed:
*When a new RN started they had a general orientation on day one.
*They then had a week of other general orientation that was completed.
*They had ninety days to complete the unit specific orientation.
*They were assigned a preceptor to work with them when they were on the floor. That preceptor changed from day-to-day.
*The new RNs would meet weekly with the nursing coordinators for education.
*There was no record of that education for the RNs.
*The new RNs were responsible to ensure their nursing orientation to the units was completed by ninety days.
*The new RNs kept their orientation sheets until they were completed.
*The nursing coordinators did not review those orientation sheets or keep track of where each RN was in their orientation.

Based on record review, interview, and policy review, the provider failed to ensure medication verification was completed for one of one sampled patient (1) prior to administration of medication by one of one registered nurse (RN) E. Findings include:

1. Review of patient 1's grievance dated 10/25/13 revealed:
*An initial identification band had been placed on patient 1's wrist by the patient access staff.
*A second identification band had been placed on his wrist by RN E when he had reached the medical floor.
*RN E had given patient 1 a medication without checking his identification band or asking his name and date of birth.
*Patient 1 had two different identification bands on; one with his name on it and one with patient 2's name on it.
*He had been given patient 2's medication on 10/15/13.
*Had been told that medication was "like taking a Tums" by a staff pharmacist.

Review of patient 1's entire medical record for his admission on 10/15/13 revealed:
*No mention he had received the medication that was for patient 2.
*No mention his physician had been notified of the medication error.

Review of patient 2's medication administration record for 10/15/13 revealed:
*He was to have received calcium acetate 667 milligrams three times daily.
*That was the medication patient 1 had received.
*That medication was used for the control of increased phosphates for patients with end stage renal disease.
*He had received that medication at 8:00 a.m., 12:00 noon, and 6:00 p.m.

Review of the provider's revised November 2011 Patient Identification policy revealed:
*Two identifiers would have been used prior to any treatment/procedure/medication administration.
*The two identifiers would have been the patient's full name and date of birth.
*All patients would have had an identification band placed on their wrist by the patient access staff or the emergency room staff.
*When a patient reached the assigned unit a different staff member would have verified the identification band accuracy.

Interview on 11/13/13 at 2:00 p.m. with the chief nursing officer revealed:
*RN E was still completing her orientation.
*The medical unit had been very busy with seven admissions and four discharges on 10/15/13.
*Patient 1 was a direct admission and should not have received a new identification band.
*The process was if a patient had been admitted from the emergency department a new identification band was placed due to billing number changes.
*If a patient was a direct admission no new identification band was applied.
*RN E had applied patient 2's identification band on patient 1.
*She agreed the patient identification policy had not been followed.