HospitalInspections.org

Based on review of personnel files, policy review, and staff interview, the Critical Access Hospital's (CAH's) governing body failed to ensure the CAH followed its policy for annual performance reviews for 4 of 11 employee records (#1, #2, #3 and #4) reviewed. Failure to ensure staff received annual appraisals limited the CAH's ability to assess and evaluate the employee's performance and competency and has the potential to affect patient care.

Findings include:

Review of the policy "PERFORMANCE APPRAISAL" occurred on 04/04/18. This policy, dated 01/07/98, stated, "Northwood Deaconess Health Center (NDHC) requires that performance appraisals be conducted for all employees, annually. . . . PROCEDURE: . . . ALL employees shall be appraised annually for each position held, during the employee's anniversary month for that position. . . . Performance appraisals become a permanent part of the employee's personnel file and are to be turned over to the Executive Secretary for filing in the employee's Central Personnel File. . . ."

Review of personnel files occurred during the morning of 04/04/18 and identified the following information:
Staff #1: Hire Date: 06/02/04. No performance appraisal available.
Staff #2: Hire Date: 01/07/13. Last performance appraisal: 12/09/15.
Staff #3: Hire Date: 05/01/00. Last performance appraisal: 12/11/15.
Staff #4: Hire Date: 04/02/97. Last performance appraisal: 12/09/15.

Upon request on 04/04/18, the CAH failed to provide a performance appraisal for Employee #1.

During an interview on the afternoon of 04/04/18, an administrative therapy staff member (#5) confirmed he/she failed to complete the annual appraisals for employees #2, #3, and #4.

Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the CAH staff notified a doctor of medicine (MD) or doctor of osteopathy (DO) of a patient's admission to the CAH for 3 of 20 records (Patient #2, #6, and #15) reviewed. Failure to notify the MD/DO of a patient's admission limited the MD/DO's ability to monitor the care provided to the patients by the CAH staff.

Findings include:

Review of the policy titled "MD [Medical Doctor] Review of Mid-Level Providers" occurred on 04/04/18. This policy, dated August 2012, stated, ". . . Whenever a patient is admitted to the CAH by a nurse practitioner, physician assistant, or clinical nurse specialist, a doctor of medicine or osteopathy on the staff of the CAH is notified of the admission. This will be documented in the record by the Mid-Level Provider."

- Review of Patient #2's record identified a nurse practitioner (NP) admitted Patient #2 on 03/19/18. The record lacked evidence the CAH staff notified the MD of the admission.

- Review of Patient #6's closed record identified a NP admitted Patient #6 on 12/28/17. The record lacked evidence the CAH staff notified the MD of the admission.


37620


- Review of Patient #15's record identified a NP admitted Patient #15 on 02/20/18. The record lacked evidence the CAH staff notified the MD of the admission.

During an interview at 11:00 a.m. on 04/04/18, supervisory staff member (#4) confirmed the above records lacked documentation of MD notification.







19410

RECORDING OF MEDICATIONS REMOVED FROM PHARMACY

1. Based on record review, policy review, and review of the North Dakota Administrative Code, the Critical Access Hospital (CAH) failed to accurately and completely record medication removal in the absence of a pharmacist or pharmacy technician for 1 of 1 CAH pharmacy. This failure limited the CAH's ability to ensure administration of pharmaceutical services in accordance with accepted professional principles.

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. . . . 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. . . ."

Review of the policy "Storage, Handling, Dispensing of Drugs and Biologicals" occurred on 04/03/18. This policy, revised May 2016, stated, ". . . If the ordered medication is not available in the med [medication] room or from the med [medication] cart: . . . c. Nurses obtaining medication from hospital pharmacy must complete Pharmacy Accessed Log that includes date, time, name of drug, strength, amount, patient name and room number, and signature. . . ."

Reviewed on 04/03/18 at 3:00 p.m., the "Pharmacy Accessed Log" showed multiple entries lacking the time staff removed medications from the pharmacy.

FIRST DOSE VERIFICATION

2. Based on policy review, review of the North Dakota Administrative Code, and staff interview, the Critical Access Hospital (CAH) failed to have a pharmacist review initial doses of medications for patients using home medications. Failure to verify patients' home medications for correct medication and dosage, according to provider orders, may cause medication errors and injury to the patient.

Findings include:

The North Dakota Administrative Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-07. Drug distribution and control. . . . 5. Physician's orders. . . . e. Pharmacist review. The pharmacist shall review the prescriber's order, or a direct copy thereof, before the initial dose of medication is dispensed . . . "

Review of the policy "Procedure for Medication Order Verification" occurred on 04/03/18. This policy, revised February 2018, stated, "Policy: all first dose medication orders for acute, swing bed and observation patients will be verified for accuracy and appropriateness by [hospital] Telepharmacy. . . . 4. If a dose is scheduled prior to [facility] pharmacist filling the order, a video first dose verification is necessary. . . . d. Medication bottle/package/IV [intravenous] bag/vial will be placed under camera eye for pharmacy at [hospital] to view. . . . 5. Nurses will check that medications have been verified by [hospital] Telepharmacy within one hour of submission. . . ."

During an interview on 04/04/18 at 9:45 a.m., two supervisory nurses (#1 and #3) confirmed CAH staff failed to obtain a pharmacist verification of first dose home medications used for CAH patients.



32641

Based on observation, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed professional standards for administration of medications in 1 of 1 Physical Therapy department. Failure to utilize a new syringe each time staff prepared the medication placed patients receiving Iontophoresis (delivery of medication through the skin by electrical stimulation) at risk of contracting an infection from potential contamination of the medication/syringe.

Findings include:

The APIC (Association of Professionals in Infection Control and Epidemiology) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016) stated, ". . . * Always use a new sterile syringe . . . when entering any vial. Never enter a vial with a syringe . . . that has been previously used. . . . * Store and access multidose vials away from the immediate patient care environment and always use a sterile syringe . . . each time the vial is accessed. . . ."

- Observation of the Physical Therapy department occurred on 04/03/18 at 9:30 a.m. with an administrative therapy staff member (#5). A locked cabinet in the therapy office contained a multi-dose bottle of dexamethasone and a syringe on the shelf next to the medication.

During an interview at approximately 9:30 a.m. on 04/03/18, Staff Member #5 stated therapy staff used the dexamethasone for iontophoresis. The staff member stated therapy staff re-use the same syringe when drawing up the dexamethasone and disinfect the outside of this syringe with a Sani-Cloth immediately prior to entering the medication bottle.

Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the prescribing medical provider signed verbal/telephone orders for 2 of 17 patient (Patient #4 and #7) closed records reviewed. Failure to ensure medical providers signed verbal/telephone orders placed the patients at risk for medication and/or treatment errors.

Findings include:

Review of the policy "Verbal Orders" occurred on 04/04/18. This policy, revised May 2013, stated, ". . . The verbal order must be documented in the patient's medical record immediately and be reviewed and countersigned by the prescriber. a. Within thirty (30) days of discharge or within thirty (30) days of the date the order was given if the length of stay is longer than thirty (30) days."

- Review of Patient #4's medical record showed a telephone order, dated 02/08/18. The prescribing medical provider had not countersigned the order.

- Review of Patient #7's medical record showed a telephone order, dated 01/23/18. The prescribing medical provider had not countersigned the order.

During an interview, on the morning of 04/04/18, a supervisory staff member (#4) confirmed the prescriber failed to electronically sign the above orders.