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Based on bylaws review, meeting minutes review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a physician member of the medical staff recommended the reappointment for 1 of 1 active physician (Provider #1) and the initial privileges for 1 of 1 nurse practitioner (Provider #2). Failure to ensure a physician recommends the reappointment of medical staff members and the initial privileges for nurse practitioners places the patients at risk of receiving treatment from unqualified providers.

Based on review of the North Dakota Department of Health, Division of Health Facilities provider files, this facility has not sustained correction of this issue. The previous survey completed on 05/30/13 found this requirement out of compliance.

Findings include:

Review of the governing board's "Constitution & Bylaws" occurred on 03/02/15. These bylaws, adopted 03/26/12, stated, ". . . Article VII.
Medical Staff . . .
7.1.1 . . . The governing board shall consider recommendations of the medical staff and appoint to the medical staff . . . physicians and others who meet the qualifications for membership . . .
7.2.3 The medical staff shall make recommendations to the governing board concerning: (1) appointments, reappointments
. . . (2) granting of medical staff privileges . . ."

Review of the "Medical Staff By-Laws" occurred on 03/02/15. These bylaws, adopted 07/30/13, stated,
". . . ARTICLE III Medical Staff Membership
Section 3. Conditions and Duration of Appointment
A. . . . The Board of Directors shall act on appointments, reappointments . . . after there has been a report from the Medical Staff as provided in these bylaws . . .
ARTICLE V Procedure for Appointment and Reappointment . . .
Section 3. Reappraisal/Reappointment Process
A. . . . the Medical Staff shall review all pertinent information available on each Medical Staff member scheduled for periodic appraisal, for the purpose of determining its report for reappointments to the Medical Staff and for granting of clinical privileges for the ensuing period and shall transmit its report to the Board of Directors. . . .
B. Each report concerning the reappointment of a Medical Staff Member and the clinical privileges to be granted upon reappointment shall be based upon such member's professional competence and clinical judgment in the treatment of patients/residents, his/her ethics and conduct . . .
ARTICLE VI
Section 1. Clinical privileges Restricted
A. Every individual practicing at JMHCC
. . . shall . . . be entitled to exercise only those clinical privileges specifically granted to him/her by the Medical Staff and approved by the Board of Directors . . ."

Reviewed on 03/03/15, the medical staff meeting minutes from 12/19/14 indicated the presence of one physician assistant, two nurse practitioners, and Provider #1 (a physician). The non-physician medical staff members recommended Provider #1's reappointment to active staff.

Reviewed the morning of 03/04/15, Provider #1's credentialing file indicated the governing board approved reappointment of Provider #1 to the medical staff effective 01/01/15 through 12/31/16 without the recommendation from a physician member of the medical staff.

Reviewed the morning of 03/04/15, Provider #2's credentialing file failed to include evidence a physician approved the initial clinical privileges before the medical staff recommended initial appointment of Provider #2 to the medical staff on 09/15/14. The governing board approved initial appointment of Provider #2 to the medical staff effective 09/17/14 through 12/31/15 without the approval of the clinical privileges by a physician member of the medical staff.

During interview at approximately 10:45 a.m. on 03/04/15, an administrative staff member (#1) confirmed non-physician medical staff members recommended the reappointment of Provider #1 and a physician failed to approve the clinical privileges before initial appointment of Provider #2.

Based on policy and procedure manual review and staff interview, the Critical Access Hospital (CAH) failed to have the required group of professionals annually review their health care policies for 1 of 1 year reviewed (2014). Failure to annually review their policies limits the CAH's ability to ensure staff members properly treat and care for their patients.

Findings include:

Review of the policy "Policies and Procedures - Annual Review" occurred on 03/04/15. This undated policy stated, "It is the policy of JMHCC [Jacobson Memorial Hospital Care Center] to conduct an annual review of all JMHCC policy and procedure manuals. . . ."

Reviewed on March 2-4, 2015, the following policy and procedure manuals lacked evidence of annual review in 2014 by a physician and a physician assistant, nurse practitioner, or clinical nurse specialist:
*Pharmacy
*Dietary
*Central sterilization
*Medical records

The CAH provided no other evidence of annual review in 2014 of the pharmacy, dietary, central sterilization, and medical records policies and procedures by the required group of professionals.

During an interview at 2:00 p.m. on 03/04/15, an administrative staff member (#1) confirmed the required group of professionals failed to review the pharmacy, dietary, central sterilization, and medical records policies in 2014.

Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications from 6 of 10 drug storage areas (emergency room, patient holding room, pharmacy, acute medication room, nurses' station, medication cart). Failure to remove outdated medications may result in patients receiving expired and ineffective medications.

Findings include:

Review of the facility policy "Medication Cart - Stock Medications - Checked for Out Dated Medications" occurred on 03/04/15. This policy, dated November 2005, stated, ". . . Every third Sunday of the month the medication cart stock medications will be checked . . . If there is a medication that is outdated or will be outdated at the end of the month, let Pharmacy know so the medication can be replaced."

Review of the facility policy "Multiple/Single Dose Vials" occurred on 03/04/15. This policy, revised February 2010, stated, ". . . Procedure: 1. Date and initial vial after opening . . .
2. Discard vaccine vial and multiple dose vials after 30 days from opened date, or when suspected/visible contamination occurs. . . ."

- On 03/02/15 at 2:50 p.m., observation of the "patient holding room" (observation room) occurred with an administrative nurse (#4) and identified one liter of sodium chloride expired October 2014.

- Observation of the pharmacy occurred on 03/02/15 at 4:20 p.m. with a pharmacy staff member (#13) and identified a bottle of 100 mg Gabapentin expired February 2015.

- On 03/03/15 at 7:30 a.m., observation of a nurse (#11) administering medications to Patient #25 identified an opened bottle of Azopt eye drops expired December 2014 and an unopened bottle of Azopt eye drops in the medication cart expired August 2014.

- Observation of the nurses' station and acute medication room occurred on 03/03/15 at 10:50 a.m. with an administrative nurse (#4) and identified the following:
* 10 (100 milliliter) bags of sodium chloride expired February 2015 (in a cupboard at the nurse's station)
* one opened and undated vial of bacteriostatic water (in the acute medication room)
* one opened vial of bacteriostatic water, dated 02/26 (February 26, 2015) and expired February 2015 (in the acute medication room)
* one vial of Sensorcaine opened 01/16/15 (opened greater than 30 days) (in the acute medication room)

- On the afternoon of 03/04/15, observation of the emergency room occurred with an administrative nurse (#2) and identified two opened and undated vials of sodium chloride.

During an interview on the morning of 03/03/15, an administrative nurse (#4) stated staff should date multi-use vials when opened and dispose of after 30 days. This nurse (#4) identified all staff are responsible for checking the expiration dates of medications.

Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care relating to infection control practices for 3 of 5 patients (Patient #1, #3, and #24) observed during personal cares and blood glucose monitoring. Failure to follow established infection control practices may allow transmission of organisms and pathogens from patients to staff, to other patients, or to visitors, and from one environment to another.

Based on review of the North Dakota Department of Health, Division of Health Facilities provider files, this facility has not sustained correction of this issue. The previous survey completed on 05/30/13 found this requirement out of compliance.

Findings include:

Review of the policy "Hand Hygiene" occurred on 03/04/15. This policy, revised February 2010, stated, ". . . Staff will wash their hands and use the hospital recommended hand sanitizer in the following situations: . . . Before and after patient/resident contact (for which hand hygiene is indicated by acceptable professional practice)
. . . Before and after assisting a patient/resident with personal care . . . Upon and after coming in contact with a patient/resident's intact skin . . . Before and after assisting a patient/resident with toileting . . . After removing gloves. . . ."

- On 03/02/15 at 1:00 p.m., observation showed two certified nurse aides (CNAs) (#5 and #6) transferred Patient #1 from a chair to the bed with a mechanical lift. A CNA (#5) performed perineal cares and changed the patient's incontinence brief, wet with urine and a smear of stool. Without removing her gloves and performing hand hygiene, the CNA (#5) positioned the patient with pillows, covered the patient with a blanket, bagged the garbage, and exited the room and walked down the corridor. Wearing the same gloves used during perineal cares, the CNA (#5) opened the door to the soiled utility room, disposed of the garbage bag, removed her gloves, and washed her hands at the sink.

- Observation on 03/02/15 at 1:50 p.m. identified two CNAs (#7 and #8) assisted Patient #24 with toileting. After donning gloves and performing perineal cares, a CNA (#7) assisted the other CNA (#8) to transfer the patient from the commode to the bed. After the transfer, both CNAs removed their gloves, and without performing hand hygiene, the CNA (#7) positioned the patient in bed, held a mug of water while the patient took a drink, covered the patient with a blanket, cleaned up a water spill on the bedside table, and handed the patient her newspaper and call light. The CNA (#7) washed her hands prior to exiting Patient #24's room.

- On 03/02/15 at 3:05 p.m., observation showed two CNAs (#9 and #10) assisted Patient #3 from the bed to the toilet and then to a wheelchair using a mechanical lift. After completing perineal cares, a CNA (#9) removed her gloves, bagged the garbage, and without performing hand hygiene, exited the patient's room.

During an interview on the afternoon of 03/03/15, an administrative nurse (#2) stated she expected staff to perform hand hygiene after removing their gloves and immediately after completing perineal cares.

- Observation on 03/03/15 at 7:11 a.m. showed a nurse (#11) tested Patient #24's blood glucose using a glucometer. The nurse (#11) failed to disinfect the glucometer after the procedure.

During an interview on 03/02/15 at 11:05 a.m., a nurse (#12) stated the CAH used the glucometer among multiple patients and should disinfect the machine after each use with a disinfectant wipe.

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to provide safeguards against loss, destruction, or unauthorized use of medical records for 1 of 5 medical record storage areas of the hospital (storage room within the former surgical suite). Failure to store records in a secure manner limited the CAH's ability to prevent loss or destruction of records and to ensure the maintenance of patient confidentiality.

Findings include:

Observation on 03/03/15 at 2:30 p.m. and on 03/04/15 at 1:45 p.m. identified medical records stored in an unlocked room within the former surgical suite.

During an interview on 03/04/15 at 1:45 p.m., an administrative medical records staff member (#3) confirmed the CAH did not ensure the security of the medical record storage area in the former surgical suite.

Review of the policy "Chart Location" occurred on 03/04/15 at 2:15 p.m. This undated policy failed to include a requirement to store medical records in a secure manner.

Based on bylaws review, policy review, record review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the quality assurance (QA) program evaluated all patient care services and other services affecting patient health and safety for 12 of 12 months reviewed (February 2014 - January 2015). Failure to ensure departments report to the QA Committee as scheduled limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the "Jacobson Memorial Hospital Care Center Constitution & Bylaws" occurred on 03/02/15. These bylaws, approved 03/26/12, stated, ". . . Article VII. Medical Staff . . . Section 7.2 Medical Care and its Evaluation . . . 7.2.2 The medical staff shall conduct an ongoing review and appraisal of the quality of health services within the hospital care center and shall report such activities and their results to the governing board. . . ."

Review of the CAH's "Quality Assurance and Improvement Plan" occurred on 03/03/15. This policy, revised 01/23/12, stated,
". . . Purpose
To implement a QA/QI [Quality Improvement] program designed to monitor, evaluate, maintain, and/or improve the quality and appropriateness of patient/resident/resident care within available resources. . . .
Scope
The QA/QI Programs shall be organizational wide and apply to all departments, services and practitioners whose activities within JMHCC have a direct influence on the quality of patient/resident care. . . ."

Review of the "QA/QI Program Monthly Reporting Schedule to QA/QI Committee Revised for 2014," occurred on 03/03/15. This undated document indicated the activities department should report quarterly in January, April, July, and October.

Reviewed on 03/03/15, the February 2014 through January 2015 QA meeting minutes lacked evidence the activities department submitted a QA report. Upon request, the CAH failed to provide evidence the activities department reported for the timeframe of February 2014 through January 2015.

During interview on 03/04/15 at approximately 9:45 a.m., a nursing staff member (#3) responsible for QA confirmed the activities department had not submitted a QA report in the past year.

Based on bylaws review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the treatment furnished in 2013-2014 by 1 of 2 physicians (Physician #1) with active medical staff privileges at the CAH. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the treatment furnished by the physician limits the CAH's ability to ensure the physician furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the "Jacobson Memorial Hospital Care Center Medical Staff Bylaws" occurred on 03/02/15. These bylaws, approved 07/30/13, stated,
". . . Article II Purposes
The purpose of this organization shall be: . . .
2. To strive for a high level of professional performance of all practitioners authorized by the Board of Directors to practice in JMHCC [Jacobson Memorial Hospital Care Center] through ongoing review, analysis, and evaluation of the clinical work of the members of the Medical Staff . . ."

Review of the governing board's bylaws titled "Jacobson Memorial Hospital Care Center Constitution & Bylaws" occurred on 03/02/15. These bylaws, effective 03/26/12, stated,
". . . Article VII. Medical Staff . . .
Section 7.2 Medical Care and its Evaluation . . . 7.2.2 The medical staff shall conduct an ongoing review and appraisal of the quality of health services within the hospital care center . . ."

Review of the policy titled "Peer Review Process" occurred on 03/03/15. This undated policy, stated, "HIM [Health Information Management] will be responsible for guiding the Peer Review Process based on the following criteria: . . .
3. All M.D. [Medical Doctor] Peer Review will be performed under contract with the [name of contracted agency]. . . ."

Upon request on 03/03/15, the CAH failed to provide evidence a network hospital or a QIO or equivalent evaluated the quality and appropriateness of the treatment furnished by Physician #1 in 2013 and 2014.

During interview at approximately 3:20 p.m. on 03/03/15, an administrative medical records staff member (#3) confirmed Physician #1 provided services to the CAH's patients in 2013 and 2014, and the CAH did not have a network hospital or QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment furnished by this physician.