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Based on bylaws review, procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a physician member of the medical staff recommended the reappointment of 1 of 2 active physicians (Physician #1) to the CAH's medical staff and failed to follow the medical staff bylaws for initial appointment of 1 of 1 physician (Physician #2) providing sleep study services. Failure to ensure a physician recommends the reappointment of medical staff members and failure to follow the medical staff bylaws for appointment places the patients at risk of receiving treatment from unqualified providers.

Findings include:

Review of the "Medical Staff Bylaws" occurred on 01/07/14 at 3:35 p.m. These bylaws, effective 02/20/13, stated,
". . . Article III Membership . . .
Section 3. Conditions and Durations of Appointments
A. The Governing Body shall make initial appointments and reappointments to the Medical Staff. The Governing Body shall act on appointments, reappointments, or revocation of appointments after there has been a report from the Medical Staff as provided in these Bylaws. . . ."

Review of the governing board's "Bylaws" occurred on 01/07/13 at 5:30 p.m. These bylaws, effective 03/26/09, stated, ". . . Article VII Medical Staff
A. Organization, Appointments, and Hearings: 1. . . . The Board of Directors shall consider recommendations of the Active Medical Staff and appoint to the Medical Staff . . . physicians who meet the qualifications for membership as set forth in the bylaws of the Medical Staff. . . ."

Review of "Northwood Deaconess Health Center Procedures of the Medical Staff Credentialing" occurred on 01/08/14 at 4:10 p.m. These procedures, revised May 2012, stated, ". . . Application for Initial Appointment and Clinical Privileges: Applications for appointment to the Medical Staff shall be in writing, and shall be submitted on the appropriate forms. . . . The application shall contain a request for specific clinical privileges desired by the applicant and shall require detailed information concerning the applicant's professional qualifications . . . Submission of Application: The application for Medical Staff appointment shall be submitted by the applicant to the Chief Executive Officer or designee. After verifying the information from the primary sources . . . and collecting references . . . the Chief Executive Officer or designee shall determine the application to be complete and transmit the application and all supporting materials to the Medical Staff Committee. . . . Subsequent Medical Staff Credentials Procedure: . . . f. The Medical Staff Committee shall determine whether to recommend to the Board that the applicant be appointed to the Medical Staff . . . The recommendation of the Medical Staff Committee . . . shall be forwarded to the Board and the Chief Executive Officer. All recommendations to appoint must also specifically recommend the clinical privileges to be granted . . .
Reappointment Procedures . . . Executive Committee Action: The Executive Committee shall review the member's file . . . and either make a recommendation or reappointment or nonreappointment and for staff category . . . and clinical privileges . . ."

- Reviewed on 01/08/14, Physician #1's credentialing file lacked evidence a physician member of the medical staff reviewed the application and recommended reappointment for Physician #1.

- Reviewed on 01/08/14, Physician #2's credentialing file lacked evidence Physician #2 had submitted an application for membership on the CAH's medical staff or a request for privileges.

During an interview on 01/09/14 at 08:50 a.m., an administrative staff member (#7) and an assistant administrative staff member (#13) confirmed non-physician medical staff members had approved the reappointment of Physician #1 and agreed a physician should have reviewed the reappointment application and recommended approval. Staff members #7 and #13 confirmed Physician #2 had not submitted an application for medical staff membership and agreed the CAH should have credentialed Physician #2 following the CAH's procedures or obtained a credentialing agreement for the physician.

Based on observation, review of the North Dakota Administrative Code, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to limit access to the pharmacy in the absence of the pharmacist, ensure staff removed drugs and biologicals only in amounts sufficient for immediate therapeutic needs, and kept and maintained records to follow the flow of pharmaceuticals from the pharmacy for 1 of 1 hospital pharmacy. This failure has the potential to create insufficient distribution, control, and accountability of medications.

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 03/10/10 found this requirement out of compliance.

Findings include:

The North Dakota Administrative Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. . . . 3. Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section. One supervisory registered nurse and only one in any given eight-hour shift is responsible for removing drugs therefrom. The responsible nurse, in times of emergency, may delegate this duty to another nurse. . . . a. Removal of any drug from the pharmacy by an authorized nurse must be recorded on a suitable form showing patient name, room number, name of drug, strength, amount, date, time, and signature of nurse. b. Such form must be left with the container from which the drug was removed, both placed conspicuously so that it will be found by a pharmacist and checked properly and promptly; or, in the case of a unit dose, place an additional dose of the drug, or the box, on the form. . . ."

Review of the policy "Storage, Handling, Dispensing of Drugs and Biologicals" occurred on 01/09/14. This policy, revised November 2013, stated, ". . . 4. If the ordered medication is not available in the med [medication] room or from the med cart: a. Medication may be obtained from hospital pharmacy by the charge nurse accompanied per another healthcare professional. b. The charge nurse, in times of emergency, may delegate this duty to another nurse who also needs to be accompanied per another healthcare professional. c. Nurses obtaining medication from hospital pharmacy must complete Pharmacy Inventory Log that includes date, time, name of drug, strength, amount, patient name and room number, and signature of both nurses. d. Log will be monitored by hospital pharmacist and pharmacy tech to maintain information regarding inventory and need to order medications. . . ."

Observation of the pharmacy occurred on 01/08/14 at 3:15 p.m. with a pharmacy staff member (#4) and an administrative nurse (#3). The pharmacy staff member (#4) stated she and the pharmacist visited the hospital pharmacy daily, Monday through Friday, to accomplish their work. She stated the charge nurse accessed the pharmacy in the pharmacy staff's absence to obtain medications for patients and floor stock and documented the medication removed from the pharmacy on the pharmacy inventory log. Review of the pharmacy inventory log for the months of December 2013 and January 2014 showed nursing staff accessed the pharmacy almost daily and removed a variety of medications for patients, including medications for floor stock (examples of floor stock documentation from log: Protonix (6), Zofran (14), Vancomycin (10), Solu-Medrol (8), Lasix (7), Miralax (1), Tylenol, etc.). The log showed nursing staff failed to identify the strength and amount of medication removed and showed more than one dose of a medication removed for a patient (examples of patient medication documentation from log: Ciprofloxacin, Lorazepam, Colace, Lovenox 40 milligrams (mg) one box, Ceftriaxone (10), Nicoderm 7 mg (7), etc.).

During an interview on 01/08/14 at 3:45 p.m., a pharmacy staff member (#4) and an administrative nurse (#3) stated the CAH did not limit the amount of medication nursing staff removed from the pharmacy, allowed nursing staff to access the pharmacy to retrieve medications for floor stock, and did not realize nursing staff failed to complete the pharmacy inventory log as indicated including documentation of the drug strength and amount. The pharmacy staff member (#4) stated nursing staff accessed the pharmacy daily on the night shift to record the refrigerator temperature.

During an interview on 01/08/14 at 4:45 p.m., a staff nurse (#14) confirmed nursing staff accessed the pharmacy nightly to record the refrigerator temperature and stated nursing staff returned outdated medications found on medication carts and in the medication room to the pharmacy.

Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to monitor and document the effectiveness of medications given to patients on a pro re nata (prn) basis for 3 of 6 active patient (Patients #1, #2, and #3) records and 4 of 15 closed patient (Patients #8, #9, #11, and #12) records reviewed. Failure to evaluate the patient's response to PRN medications limited the nursing staff's ability to assess whether the medication achieved the desired effect, or if the patient experienced any side effects or adverse reactions from the medication.

Findings include:

Review of the policy "PRN Medication Record" occurred on 01/09/14. This policy, revised August 2013, stated, "The Medication Administration Record will be used to document the . . . effectiveness of PRN medication in the Acute Care, Swing Bed . . . Unit. . . . 2. The nurse will state . . . the response the patient had to the medication in the Effectiveness of Pain Medication box. . . ."

The policy failed to include the time frame for reassessment after administration of a prn medication.

During an interview on 01/08/14 at 5:04 p.m., a staff nurse (#5) stated nurses reassessed patients an hour after administration of a prn medication to ensure whether the patient experienced relief from the medication and documented the patient's response in the "medication response - prn effectiveness" section of the electronic medical record (EMR).

During an interview on 01/09/14 at 9:03 a.m., an administrative nurse (#2) stated she expected nursing staff to assess the effectiveness of prn medications within an hour of administration and document the response within the patient's record. The nurse (#2) stated nursing staff could document the response in a variety of sections within the patient's record.

- Review of Patient #1's active medical record occurred on January 07-09, 2014 and identified the CAH admitted the patient on 01/02/14 with diagnoses of pain and a left ankle fracture. The record indicated the patient required medications for left ankle pain and anxiety and showed physician orders for Dilaudid (used to treat moderate to severe pain) 2 milligrams (mg) every four hours prn, Ativan (used to treat anxiety) 0.5 mg every eight hours prn, and Ibuprofen (used to treat mild to moderate pain and inflammation) 800 mg prn daily.

Review of Patient #1's Medication Administration Record (MAR) and chart notes (including nurse notes and medication response-prn effectiveness notes) showed the following administration times and patient responses for the prn medications:
*Dilaudid: received on 01/02/14 at 4:20 p.m. - response documented at 6:30 p.m. (two hours 10 minutes later); on 01/05/14 at 10:08 p.m. - response documented at 12:29 a.m. on 01/06/14 (two hours 21 minutes later); and on 01/06/14 at 3:30 a.m. - response documented at 5:54 a.m. (two hours 24 minutes later). Received on 01/03/14 at 9:59 a.m. and 2:01 p.m.; and on 01/08/14 at 9:20 a.m. - no responses documented.
*Ativan: received on 01/03/14 at 4:50 p.m. - response documented at 6:46 p.m. (one hour 56 minutes later); at 10:29 p.m. - response documented on 01/04/14 at 1:49 a.m. (three hours 20 minutes later); and on 01/04/14 at 11:00 p.m. - response documented on 01/05/14 at 5:09 a.m. (six hours nine minutes later). Received on 01/05/14 at 10:09 p.m. - no response documented.
*Ibuprofen: received on 01/03/14 at 4:50 p.m. - response documented at 6:46 p.m. (one hour 56 minutes later); and on 01/05/14 at 2:43 p.m. - response documented at 6:39 p.m. (three hours 56 minutes later). Received on 01/06/14 at 11:30 a.m. and on 01/07/14 at 6:44 a.m. - no responses documented.

- Review of Patient #2's active medical record occurred on January 07-09, 2014 and identified the CAH admitted the patient on 12/26/13 with diagnoses including debility as well as a history of chronic pain syndrome and right inguinal wound with wound vac. The record indicated the patient required medications for back and wound pain and showed physician orders for oxycodone (used to treat moderate to severe pain) 5 mg every four hours prn and acetaminophen (used to treat mild to moderate pain) 650 mg every four hours prn.

Review of Patient #2's MAR and chart notes (including nurse notes and medication response - prn effectiveness notes) showed the following administration times and patient responses for the prn medications:
*oxycodone: received on 01/02/14 at 2:17 a.m. - response documented at 5:32 a.m. (three hours 15 minutes later); on 01/03/14 at 12:31 a.m. - response documented at 3:17 a.m. (two hours 46 minutes later); on 01/04/14 at 2:55 p.m. - response documented at 5:00 p.m. (two hours 5 minutes later); on 01/05/14 at 11:00 a.m. - response documented at 1:18 p.m. (two hours 18 minutes later); on 01/06/14 at 5:45 p.m. - response documented at 8:15 p.m. (two hours 30 minutes later); on 01/08/14 at 11:10 a.m. - response documented at 1:06 p.m. (one hour 56 minutes later); and on 01/09/14 at 12:15 a.m. - response documented at 2:40 a.m. (two hours 25 minutes later). Received on 01/01/14 at 10:15 a.m. and 2:15 p.m.; on 01/02/14 at 10:26 a.m. and 2:36 p.m.; on 01/03/14 at 4:15 p.m. and 8:17 p.m.; on 01/04/14 at 5:52 a.m., 6:55 p.m., and 11:00 p.m.; on 01/05/14 at 3:00 a.m., 7:00 a.m., 3:00 p.m., and 7:06 p.m.; on 01/06/14 at 1:53 p.m.; on 01/07/14 at 6:00 a.m., 2:03 p.m., and 10:11 p.m.; and on 01/09/14 at 4:15 a.m. - no responses documented.
*acetaminophen: received on 01/06/14 at 10:37 a.m. and on 01/07/14 at 4:02 a.m. - no responses documented.

- Review of Patient #3's active medical record occurred on January 07-09, 2014 and identified the CAH admitted the patient on 12/26/13 with a diagnosis of debility following bilateral septic knee arthritis. The record indicated the patient required medications for bilateral knee pain and showed physician orders for oxycodone 5 mg every four hours prn and acetaminophen 650 mg every four hours prn.

Review of Patient #3's MAR and chart notes (including nurse notes and medication response - prn effectiveness notes) showed the following administration times and patient responses for the prn medications:
*oxycodone: received on 01/02/14 at 11:54 a.m. - no response documented.
*combination of oxycodone and acetaminophen: received on 01/02/14 at 3:00 a.m. - response documented at 5:03 a.m. (two hours three minutes later), at 5:30 p.m. - response documented at 9:29 p.m. (three hours 59 minutes later), and at 9:37 p.m. - response documented at 11:54 p.m. (two hours 17 minutes later); on 01/03/14 at 1:39 a.m. - response documented at 3:38 a.m. (one hour 59 minutes later), and at 10:49 a.m. - response documented at 12:43 p.m. (one hour 54 minutes later); on 01/05/14 at 12:45 a.m. - response documented at 3:08 a.m. (two hours 23 minutes later); on 01/08/14 at 1:08 a.m. - response documented at 3:20 a.m. (two hours 12 minutes later); and on 01/09/14 at 2:35 a.m. - response documented at 5:32 a.m. (two hours 57 minutes later). Received on 01/03/14 at 2:50 p.m. and at 7:05 p.m.; on 01/04/14 at 12:00 a.m., 4:34 a.m., 2:32 p.m., and 6:32 p.m.; on 01/05/14 at 3:42 p.m. and 8:08 p.m.; and on 01/07/14 at 2:32 p.m. - no responses documented.

Review of Patient #8, #9, #11, and #12's closed records occurred on January 8-9, 2014.

- Review of Patient #11's record identified the CAH admitted the patient on 09/17/13 with a diagnosis of intractable back pain. Orders for Patient #11's prn medications included:
Hydrocodone/APAP (a narcotic pain medication also known as Narco) 5/325 mg one tablet every four hours prn for pain relief.
Acetaminophen (also known as Tylenol) 325 mg two tablets every six hours prn for pain relief.
Antacid Anti-Gas Suspension (an OTC medication used to treat heartburn also known as Mylanta) 200/200/20 mg/5 milliliters (ml) every four hours prn for heartburn.

Review of Patient #11's EMR, dated September 17-October 25, 2013, showed nursing staff administered prn Hydrocodone/APAP on 14 occasions in September and October 2013 and failed to document Patient #11's response to these medications. The dates and times included: 09/17/13 at 1:54 p.m.; 09/19/13 at 8:03 a.m.; 09/20/13 at 1:50 p.m.; 09/21/13 at 8:40 a.m.; 09/22/13 at 8:47 p.m.; 09/25/13 at 2:08 p.m. and 8:24 p.m.; 09/26/13 at 7:16 a.m.; 09/30/13 at 5:35 p.m.; 10/01/13 at 6:56 p.m.; 10/04/13 at 7:48 a.m.; 10/08/13 at 7:55 a.m. and 1:25 p.m.; and 10/09/13 at 5:18 a.m.

The CAH nursing staff administered prn Hydrocodone/APAP to Patient #11 on 19 occasions and failed to assess and document Patient #11's response to these medications within an acceptable time frame. The medication administration date and time and documented time of Patient #11's response (as recorded in either the patient's "Chart Notes" or "Medication Response - PRN Effectiveness" Sections of the EMR) included: 09/18/13 at 1:37 p.m. - response documented at 3:45 p.m. (two hours eight minutes later); 09/19/13 at 1:22 p.m. - response documented at 4:23 p.m. (three hours one minute later); 09/19/13 at 8:50 p.m. - response documented 09/20/13 at 12:25 a.m. (three hours 35 minutes later); 09/20/13 at 6:18 a.m. - response documented at 8:26 a.m. (two hours eight minutes later); 09/21/13 at 2:30 p.m. - response documented at 5:43 p.m. (three hours 13 minutes later); 09/22/13 at 7:38 a.m. - response documented at 11:30 a.m. (four hours eight minutes later); 09/24/13 at 6:28 a.m. - response documented at 8:47 a.m. (two hours 19 minutes later); 09/25/13 at 8:14 a.m. - response documented at 11:39 a.m. (three hours 25 minutes later); 09/26/13 at 7:54 p.m. - response documented at 12:30 a.m. (four hours 36 minutes later); 09/27/13 at 7:59 a.m. - response documented at 10:56 a.m. (two hours 57 minutes later); 09/28/13 at 9:15 p.m. - response documented 09/29/13 at 2:08 a.m. (four hours 53 minutes later); 09/29/13 at 8:20 p.m. - response documented 09/30/13 at 4:40 a.m. (eight hours 20 minutes later); 10/01/13 at 7:59 a.m. - response documented at 10:00 a.m. (two hours one minute later); 10/03/13 at 3:08 a.m. - response documented at 5:11 a.m. (two hours three minutes later); 10/09/13 at 7:50 p.m. - response documented 10/10/13 at 1:24 a.m. (five hours and 34 minutes later); 10/11/13 at 8:58 p.m. - response documented 10/12/13 at 1:05 a.m. (four hours seven minutes later); 10/12/13 at 1:45 p.m. - response documented at 6:11 p.m. (four hours 26 minutes later); 10/17/13 at 12:42 p.m. - response documented at 3:15 p.m. (two hours 26 minutes later); 10/17/13 at 5:50 p.m. - response documented at 8:30 p.m. (two hours 40 minutes later).

The CAH nursing staff administered prn Acetaminophen to Patient #11 on 09/19/13 at 11:26 a.m. and documented a response to this medication (four hours 57 minutes later) at 4:23 p.m.

The CAH nursing staff administered a prn Antacid to Patient #11 on 10/14/13 at 11:17 a.m. and failed to document how Patient #11 responsed to this medication.

- Review of Patient #12's record identified the CAH admitted the patient on 10/12/13 with a diagnoses of congestive heart failure and urinary tract infection. Patient #12's physician wrote an order for prn Acetaminophen 650 mg every four-six hours as needed for pain relief.

Review of Patient #12's EMR, dated October 12-16, 2013, showed nursing staff administered PRN Acetaminophen on 10/14/13 at 12:11 p.m. and failed to document Patient #12's response to this medication.

The CAH nursing staff administered prn Acetaminophen to Patient #12 on two occasions and failed to assess and document Patient #12's response to these medications within an acceptable time frame. The medication administration date and time and documented time of Patient #12's response (as recorded in either the patient's "Chart Notes" or "Medication Response - PRN Effectiveness" Sections of the EMR) included: 10/15/13 at 3:44 a.m. - response documented at 5:50 a.m. (two hours six minutes later) and 10/16/13 at 12:07 a.m. - response documented at 4:18 a.m. (four hours 11 minutes later).

- Review of Patient #8's record identified the CAH admitted the patient on 11/04/13 with a diagnosis of pneumonia. Orders for Patient #8's PRN medications included:
Oxycodone/Acetaminophen (a narcotic pain medication) 5/325 mg one tablet every four-six hours prn for pain relief.
Albuterol Sulfate 0.083% Nebulizer Solution (an inhaled bronchodilator medication used to help improve shortness of breath[SOB]) 2.5 mg/3 ml nebulization every three-four hours prn for SOB.

Review of Patient #8's EMR, dated November 4-8, 2013, showed nursing staff administered prn Oxycodone/Acetaminophen on three occasions on 11/05/13 at 11:02 a.m., 11/06/13 at 5:30 a.m., and 11/07/13 at 9:44 p.m. and failed to document Patient #8's response to the medication.

The CAH nursing staff administered prn Albuterol Nebulizer medication to Patient #8 on 11/08/13 at 9:12 a.m. and failed to document how the patient responded to this medication.

The CAH nursing staff administered PRN Oxycodone/Acetaminophen to Patient #8 on 11/05/13 at 5:30 p.m. and documented how the patient responded to this medication at 8:09 p.m. (two hours 39 minutes later).

The CAH nursing administered PRN Albuterol Nebulizer medication to Patient #8 on 11/07/13 at 9:25 a.m. and documented how the patient responded to this medication at 12:12 p.m. (two hours and 47 minutes later).

- Review of Patient #9's record identified the CAH admitted the patient on 11/08/13 with a diagnosis of pneumonia. Orders for Patient #9's prn medications included:
Oxycodone 5 mg two tablets every four-six hours prn for pain relief.
Albuterol Sulfate 0.083% Nebulizer Solution 2.5 mg/3 ml nebulization every three-four hours prn for SOB.
Acetaminophen 325 mg two tablets every six hours prn pain relief.
Antacid anti-gas suspension 200/200/20 mg/5 milliliters every four hours prn for heartburn.
Milk of Magnesia (MOM) (an OTC laxative medication) 7.75% 30 ml daily prn to treat constipation.

Review of Patient #9's EMR, dated November 8-16, 2013, showed nursing staff administered PRN Oxycodone on ten occasions and failed to document how Patient #9 responded to these medications on the following dates and times: 11/08/13 at 8:46 p.m.; 11/09/13 at 10:45 a.m.; 11/10/13 at 11:45 p.m.; 11/11/13 at 5:05 a.m., 10:25 a.m., and 3:43 p.m.; 11/14/13 at 9:21 a.m. and 2:06 p.m.; and 11/16/13 at 6:33 a.m. and 11:55 a.m.

The CAH nursing staff administered prn Oxycodone to Patient #9 on five occasions and failed to assess and document Patient #8's response to the medication within an acceptable time frame. The medication administration date and time and documented time of Patient #9's response (as recorded in either the patient's "Chart Notes" or "Medication Response - PRN Effectiveness" Sections of the EMR) included: 11/08/13 at 11:45 p.m. - response documented 11/09/13 at 3:44 a.m. (three hours 59 minutes later); 11/09/13 at 3:20 p.m. - response documented at 6:41 p.m. (three hours 21 minutes later); 11/11/13 at 10:25 a.m. - response documented at 12:00 p.m. (one hour 35 minutes later); 11/12/13 at 12:15 a.m. - response documented at 4:00 a.m. (three hours and 45 minutes later); 11/14/13 at 1:15 a.m. - response documented at 3:50 a.m. (two hours 35 minutes later); 11/15/13 at 3:42 a.m. - response documented at 5:42 a.m. (two hours later).

The nursing staff administered prn Albuterol Sulfate Nebulizer Solution on 11 occasions and failed to document Patient #9's response to the medication on the following dates and times: 11/08/13 at 1:40 p.m. and 3:20 p.m.; 11/10/13 at 8:02 p.m.; 11/11/13 at 3:43 p.m.; 11/12/13 at 10:20 a.m.; 11/13/13 at 3:54 a.m. and 9:37 p.m.; 11/14/13 at 3:50 a.m.; and 11/15/13 at 10:14 a.m., 3:43 p.m., and 8:45 p.m.

The CAH nursing staff administered prn Acetaminophen on 11/11/13 at 10:57 p.m., 11/13/13 at 3:55 a.m., and 11/14/13 at 3:50 a.m. to Patient #9 and failed to document how Patient #9 responded to these medications.

The CAH nursing staff administered a prn Antacid to Patient #9 on 11/11/13 at 1:46 p.m. and 8:26 p.m. and 11/15/13 at 3:30 a.m. and failed to document how Patient #9 responded to the medication.

The CAH nursing staff administered prn Acetaminophen to Patient #9 on 11/15/13 at 3:30 a.m. and documented how Patient #9 responded to the medication at 5:42 a.m. (two hours 12 minutes later).

The CAH nursing staff administered prn MOM on two occasions and failed to assess and document Patient #9's response to the medication within an acceptable time frame. The medication administration date and time and documented time of Patient #9's response (as recorded in either the patient's "Chart Notes" or Medication Response - PRN Effectiveness" Sections of the EMR) included: 11/09/13 at 4:10 p.m. - response documented at 6:21 p.m. (two hours 11 minutes later) and 11/11/13 at 8:18 a.m. - response documented at 1:32 p.m. (five hours 14 minutes later).


28086

Based on record review, staff interview, and policy and procedure review, the Critical Access Hospital (CAH) failed to maintain a complete medical record for 4 of 15 closed records (Patients #9, #11, #12, and #19) reviewed. Failure to ensure closed medical records contained an individualized and complete nursing care plan and included the results of the healthcare provider's examination/history and physical limited the CAH's ability to ensure completeness of each section of the medical record.

Findings include:

Review of the CAH policy titled "Record Services" occurred on the morning of 01/09/14. This policy dated, 08/28/12, stated, " . . . NDHC [Northwood Deaconess Health Center] will maintain a medical record for each inpatient and outpatient evaluated or treated in any part or location of the CAH. When a patient reimbursement status changes from acute care services to swing bed services, a single medical record may be used for both stays as long as the record is sectioned separately. Both sections must include admission and discharge orders, progress notes, nursing notes, graphics, laboratory support documents, and other pertinent documents, and discharge summaries . . . ."

On the afternoon of 01/07/14, the Health Information Services (HIS) manager (#12) stated the CAH utilized a separate electronic medical record (EMR) for each patient visit/admission (emergency room, acute/inpatient, observation, outpatient/observation and swing bed). This HIS manager (#12) stated upon the patient's discharge from each level of care, the CAH staff scanned all paper information from that specific patient stay into the EMR and placed it under the "images" tab in the EMR.

Review of Patient #9, #11, and #12's closed swing bed charts occurred on 01/08/14.

- Review of Patient #11's record identified the CAH admitted the patient to swing bed level of care on 09/17/13 with a diagnosis of intractable back pain. Patient #11's swing bed nursing care plan lacked nursing problems and interventions pertaining to pain management, fall risk, and level of assistance needed with activities of daily living (ADL).

- Review of Patient #9's record identified the CAH admitted the patient to swing bed level of care on 11/08/13 with a diagnosis of pneumonia. Patient #9's swing bed nursing care plan lacked nursing problems and interventions pertaining to Patient #11's medical diagnosis of pneumonia and level of assistance needed with ADLs.

- Review of Patient #12's record identified the CAH admitted the patient to swing bed level of care on 10/12/13 with diagnoses of congestive heart failure (CHF) and urinary tract infection (UTI). Patient #12's swing bed nursing care plan lacked nursing problems and interventions pertaining to Patient #12's medical diagnoses of CHF and UTI and level of assistance needed with ADLs.

On the afternoon of 01/08/14, the HIS manager (#12) provided additional nursing care plans for Patients #9, #11, and #12 which included nursing problems and interventions for each specific patient's medical diagnosis. When asked where this information was located in each patient's individual swing bed record, the HIS manager (#12) stated these care plans were in each patient's inpatient medical record.



28086

- Review of Patient #19's closed medical record occurred on 01/09/14 and identified the patient presented to the CAH's emergency department (ED) on 11/09/13 at 8:20 a.m. with signs and symptoms of a rectal bleed. The record failed to include evidence of an examination or history and physical (H&P) from Patient #19's ED provider. When asked whether the provider completed an examination or H&P on the patient, a medical records staff member (#12) indicated an H&P was in Patient #19's inpatient medical record.