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Based on observation, review of facility policy, and staff interview, the facility failed to maintain an environment free of hazards on 3 of 3 days of survey (February 13-15, 2017). Accessible hazards, including chemicals, places cognitively impaired and wandering patients at risk for accidents/injury.

Findings include:

Review of the facility "HAZARD COMMUNICATION PROGRAM," occurred on 02/15/17. The program, dated April 2016, stated, ". . . To ensure that information about the dangers of all hazardous chemicals . . . This program applies to any chemical which is known to be present in the workplace . . . Departmental Policies: Each department is responsible for developing and implementing policies and procedures for the handling of hazardous materials in their department. Departmental policies will include: . . . 2. Protection of employees, patients, visitors and community. . . . 5. Program for controlling the handling, storing . . ."

Observation of the environment occurred on the morning of 02/15/17 and showed the following chemicals, each with hazard warning labels, stored in a hallway located on the acute care/Swingbed unit, and not in a secure location:
* Clean utility room: seven 15 fluid ounce (oz) and three one liter bottles of hand sanitizer liquids
* Whirlpool tub room: in a cabinet at eye level, a gallon jug of Cavicide, a bottle of Turbo Clean, and on a bedside table just inside of the room, a jug of liquid hand sanitizer
* On a cart outside of a procedure room: Avagard instant hand antiseptic (70% ethyl alcohol), 16.9 oz (foam) bottle, with an easy removable cap
* Soiled utility room: chemicals for cleaning of scopes between procedures and jugs of chemical rapicide; two spray bottles of Cavicide spray, two gallon jugs of Isopropyl Alcohol 70%, one gallon jug of concentrated bleach, and one gallon of Asepti-Zyme in a cabinet with framed glass doors; Endozyme Triple Plus stored under a cabinet which sat below the scope cleaner

Observation of a cleaning cart in the nursing unit on the morning of 02/15/17, showed the cart unattended for, at a minimum, two minutes. An unidentified housekeeping staff member returned to the cart from a location other than a patient's room. In addition, a random observation on the morning of 02/15/17 showed the cart left unattended while the housekeeper cleaned within a patient's bathroom and room. The cart included several chemical sprays on the top including Clorox cleaning bleach, comet spray, glass cleaner, Virex 256-disinfectant, Foamy Q disinfectant cleaner, and a mop bucket with water and Virex disinfectant cleaner.

During an interview on the morning of 02/15/17, a supervisory staff member (#3) agreed staff should store chemicals to prevent access to patients.

APPOINTMENT TO MEDICAL STAFF

1. Based on bylaws review and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure appointment to the medical staff for 1 of 2 telemedicine entity's physicians (Telemedicine Entity #1) providing radiological interpretation services to the CAH's patients. Failure to appoint practitioners to the medical staff placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of Towner County Medical Center's "Medical Staff Bylaws and Rules and Regulations" occurred on 02/13/17 at 3:05 p.m. These bylaws, revised 01/26/16, stated, ". . .
Article III - Membership
Section 1. Nature of Staff Membership
Membership in the Medical Staff of the Towner County Medical Center is a privilege that shall be extended only to professionally competent physicians, dentists, chiropractors, podiatrists, physician assistants and nurse practitioners who continuously meet the qualifications, standards, and requirements set forth in these bylaws. . . .
Section 2. Qualifications
Only practitioners licensed to practice in the State of North Dakota, who can document their background, training, experience, current competence, adherence to the ethics of the medical profession, good reputation, and the ability to work with others to assure the Medical Staff and Board of Directors that any patient treated by them will receive high quality medical care, shall be qualified for membership on the Medical Staff. . . ."

During an interview on 02/14/17 at 10:10 a.m., a radiological staff member (#4) stated the CAH used the services of Telemedicine Entity #1 for radiological interpretation.

Upon request on 02/14/17, the CAH failed to provide evidence the medical staff recommended and the governing body approved appointment to the CAH's medical staff physicians from Telemedicine Entity #1.

During an interview on 02/14/17 at 1:40 p.m., an administrative staff member (#1) confirmed the CAH's medical staff had not recommended and the governing body had not approved appointment of the physicians from Telemedicine Entity #1 to the CAH's medical staff.

During an interview on 02/14/17 at 1:40 p.m., a business office staff member (#5) stated the CAH began using the services of Telemedicine Entity #1 on 09/11/15.


APPROVAL OF PRIVILEGES FOR MEDICAL STAFF

2. Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing body failed to ensure the approval of clinical privileges for 8 of 10 medical staff members' (Providers #1 - #8) credentialing files reviewed. Failure to approve clinical privileges of medical staff members placed the CAH's patients at risk of receiving services from unqualified practitioners.

Findings include:

Review of Towner County Medical Center's "Medical Staff Bylaws and Rules and Regulations" occurred on 02/13/17 at 3:05 p.m. These bylaws, revised 01/26/16, stated, ". . .
Article IV. Amended Procedure for Credentialing and Recredentialing . . .
Section 2. Initial Appointment Process
a. . . . All recommendations to appoint must also specifically recommend the clinical privileges to be granted . . .
Section 3. Reappointment (Recredentialing) Process . . .
b. . . . the Medical Staff shall review all pertinent information available on each practitioner scheduled for periodic appraisal . . . for the purpose of determining its recommendations . . . for the granting of clinical privileges for the ensuing period, and shall transmit its recommendations to the Board of Directors. . . .
Article V. Clinical Privileges
Section 1. Clinical Privileges
a. Written privileges shall be granted to physicians, dentists, chiropractors, podiatrists, nurse practitioners and physician assistants upon appointment to the Medical Staff and approved by the Board of Directors.
b. Determination of initial clinical privileges shall be based upon the applicant's training, current experience, demonstrated competence and reference. . . .
d. . . . Final determination for extension of privileges remains with the Board of Directors. . . ."

Reviewed on 02/15/17, the credentialing files for Providers #1 - #8 lacked evidence the medical staff recommended and the governing body approved specific clinical privileges for their current credentialing periods.

Upon request on 02/15/17, the CAH failed to provide evidence the medical staff recommended and the governing body approved specific clinical privileges for Providers #1 - #8 for their current credentialing periods.

During an interview on 02/15/17 at 11:00 a.m., an administrative staff member (#1) confirmed the CAH did not have evidence medical staff recommended and governing body approved specific clinical privileges for Providers #1 - #8 for their current credentialing periods.

CHIEF OF STAFF QUALIFICATIONS

3. Based on bylaws review, record review, and staff interview, the governing body failed to ensure the medical staff elected a qualified medical staff member for 1 of 3 medical staff offices (chief of staff). Failure to elect an active staff member as chief of medical staff had the potential to limit the effectiveness and accessibility of medical staff leadership.

Findings include:

Review of Towner County Medical Center's "Medical Staff Bylaws and Rules and Regulations" occurred on 02/13/17 at 3:05 p.m. These bylaws, revised 01/26/16, stated, ". . .
Article IX. Clinical Services . . .
Section 2. Qualifications of Officers . . .
The Chief of the Medical Staff shall be a physician member of the active Medical Staff. . . ."

Reviewed on 02/15/17, the credentialing file for Provider #1 (a physician) indicated the governing body approved consulting medical staff membership for Provider #1 on 03/25/15.

During an interview on 02/15/17 at 11:00 a.m., an administrative staff member (#1) confirmed the governing body approved consulting medical staff membership for Provider #1 and the medical staff had elected Provider #1 as the chief of staff.

Based on observation, review of hospital policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff securely stored medications on 1 of 2 days (02/14/17) of medication pass observation. Failure to secure all medications securely may result in unauthorized access to medications.

Findings include:

Review of the CAH policy titled "Medication Administration" occurred on 02/15/17. This policy, dated August 2015, stated, ". . . The medication cart shall be locked at all times when not in use or if unattended. . . ."

Observation on 02/14/17 at 8:27 a.m. showed a licensed nurse (#6) prepared Patient #3's morning medications. On three occasions during the preparation, the nurse (#6) left the medication cart unattended with Patient #3's medications on top of the cart. The medications included lopressor (for heart function and blood pressure), Crestor (for cholesterol), lisinopril (for blood pressure), Prilosec (for heartburn), aspirin, and iron.

Observation on 02/14/17 at 11:03 a.m. showed a medication cart in the hallway by Patient #6's room (door closed) and the drawers containing an assortment of medications opened. At 11:08 a.m., a nurse (#6) exited Patient #6's room and closed the medication drawers and locked the cart.

During an interview on 02/14/17 at 5:00 p.m., an administrative nurse (#7) stated nursing staff are expected to secure all medications in the locked medication cart.

Based on observation, record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed standard infection control practices for 3 of 3 active patients (Patient #1, #2, and #3) observed during cares. Failure to perform hand hygiene after patient care and removal of gloves and failure to sanitize the glucometer (machine used to test blood sugar) after testing a patient's blood glucose has the potential to spread infection to other patients, staff, and visitors.

Findings include:

Review of the CAH policy titled "HAND HYGIENE" occurred on 02/15/17. This policy, dated 2008, stated, "PURPOSE: To decrease the risk of transmission of infection by appropriate hand hygiene. POLICY: Hand hygiene is generally considered the most important single procedure for preventing health care-associated infections. . . . If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations . . ."

Review of the CAH policy titled "USING GLOVES" occurred on 02/15/17. This undated policy stated, ". . . Wash hands after removing gloves. Gloves do not replace hand hygiene . . ."

Review of the CAH policy titled "Blood Glucose Monitoring" occurred on 02/15/17. This policy, dated 2013, stated, ". . . The glucometer is disinfected after each patient use . . ."

- Review of Patient #1's active medical record occurred on February 13-14, 2017 and identified an admission date of 02/12/17 for pneumonia following Influenza B virus.

- Review of Patient #2's active medical record occurred on February 13-14, 2017, and identified an admission date of 02/13/17 for dehydration following Influenza B virus.

Observation on February 13, 2017 showed the following:
* 3:30 p.m. - A nurse (#6) counted Patient #2's personal money, exited the room, placed the money in a lock box on the medication cart, and without performing hand hygiene, entered Patient #1's room, turned off the call light, and assisted the patient to the bathroom. The nurse failed to perform hand hygiene before exiting Patient #2's room, after handling the patient's money, and before entering Patient #1's room.
* 3:45 p.m. - While the nurse (#6) assessed Patient #2's IV site, Patient #1's call light rang. The nurse exited Patient #2's room without performing hand hygiene and immediately entered Patient #1's room. The nurse assisted Patient #1 from the toilet to bed, washed her hands, and exited the room.
* 3:55 p.m. - The nurse (#6) sanitized her hands, assessed Patient #2's heart and lungs, exited the room, obtained an IV pump and pole, and re-entered Patient #2's room. The nurse (#6) assessed Patient #2's IV site, connected IV tubing, and began the flow of IV fluids. The nurse then exited the room without performing hand hygiene.
* 4:00 p.m. - The nurse (#6) re-entered Patient #2's room, obtained the IV starter kit left in the room earlier, exited the room, and returned the IV kit to the storage room. The nurse (#6) then sanitized her hands.
* 4:15 p.m. - Patient #2 returned from the radiology department. The nurse (#6) administered IV Protonix (a medication to prevent reflux and heartburn) to the patient and exited the room without sanitizing her hands.

- Review of Patient #3's active medical record occurred on 02/14/17 and identified an admission date of 02/13/17 for weakness, failure to thrive, and a recent fall.

Observation on 02/14/17 showed the following:
* 8:27 a.m. to 9:05 a.m. - The nurse (#6) entered Patient #3's room, applied gloves, immediately exited the room, obtained a pill cutter and cut one of Patient #3's medications in half. The nurse left the medication on the medication cart and re-entered Patient #3's room. With the same gloves, the nurse (#6) removed Patient #3's dressing from his left knee showing a large wound with sutures, approximately eight centimeters in diameter. The nurse cleansed the wound with a washcloth, removed her gloves and exited the room without performing hand hygiene. The nurse (#6) re-entered the room, applied new gloves, obtained the soiled washcloth used to cleanse the patient's wound, and exited the room. The nurse then re-entered Patient #6's room, removed her soiled gloves, washed her hands, and exited the room.
* 11:08 a.m. - The nurse (#6) obtained a glucometer from a cloth pouch and checked Patient #3's blood sugar. The nurse then placed the glucometer back in the cloth pouch without disinfecting it. The nurse (#6) stated staff use the glucometer on all the patients unless the patient provides his/her own glucometer.

During an interview on 02/14/17 at 4:15 p.m., an administrative nurse (#7) stated staff are expected to wash or use a hand sanitizer before leaving a patient's room and to disinfect the glucometer before returning it to the pouch.

Based on facility policy, review of professional literature, record review, and staff interview, the Critical Access Hospital (CAH) failed to assess and document the effectiveness of medications given to patients on an as needed (PRN) basis for 5 of 18 patients reviewed in closed records (Patient #5, #6, #16, #18 and #19). Failure to evaluate the patient's response to PRN pain medications limited the nursing staffs' 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 CAH policy titled "Medication Administration" occurred on 02/15/17. This policy, dated August 2015, stated, ". . . PRN medication administration shall include documentation of complaints or symptoms for which the drug was administered and any results achieved. . . ."

Berman and Snyder, "Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 9th ed., Pearson Education, Inc., New Jersey, page 862-870, states, ". . . Process of Administering Medications: When administering any drug, regardless of the route of administration, the nurse must do the following: . . . 6. Evaluate the client's response to the drug. . . . In all nursing activities, nurses need to be aware of the medications that a client is taking and record their effectiveness as assessed by the client and the nurse on the client's chart. . . . Skill 35-1 Administering Oral Medications: . . . Evaluation: Return to the client when the medication is expected to take effect (usually 30 minutes) to evaluate the effects of the medication on the client. . . ."

During interview on the morning of 02/14/17, an administrative staff nurse (#2) stated response to PRN medications can be found in the electronic medical record within the medication administration record (MAR), chart notes, and/or within the pain assessment section. The records reviewed for PRN response included the following:

- Review of Patient #5's closed inpatient medical record occurred on 02/13/17 and identified the CAH admitted the patient for an acute and Swingbed stay for 13 days in August of 2016 due to a cerebrovascular infarction. The record identified PRN medications administered for pain included Tylenol and Morphine Sulfate (MS) given between 08/04/16 and 08/10/16. These included:
* 08/05/16 at 8:50 p.m. a nurse administered Tylenol for pain rated a 6 on a scale of 1-10, also called "distressing" right shoulder pain. The record lacked evidence of follow-up until the following day at 8:24 a.m.
* 08/06/16 at 9:01 p.m. a nurse administered Tylenol for pain described as a #3 "bothersome shoulder" and no follow-up occurred until the following day at 8:15 a.m.
* 08/07/16 at 2:53 p.m. a nurse administered Tylenol for "bothersome" head pain. The record lacked evidence of follow-up until 5:00 p.m.
* 08/09/16 at 12:35 p.m., 2:25 p.m., and 7:38 p.m., a nurse administered MS two milligrams (mg) as the patient was "moaning," "moaning out, coughing," and "for ease of breathing." The record lacked evidence of follow-up until the following day at 12:29 a.m.

- Review of Patient #6's closed inpatient record occurred on 02/13/17 and identified the patient admitted to acute care for two days with a closed fracture of the right humerus. The record identified nursing staff administrated Celebrex for pain assessed as a #10 on 09/28/16 at 3:24 a.m. and the record lacked evidence of follow-up until 7:58 a.m.

- Review of Patient #16's closed inpatient record occurred on 02/13/17 and identified the patient admitted to acute care for two days with acute cystitis (irritation of bladder wall) with hematuria (blood in urine). The record identified nursing staff medicated the patient with Xanax (anti-anxiety medication) for "jumpy legs" on 09/07/16 at 6:28 p.m. The record lacked evidence of follow-up until the following day at 9:23 p.m.

- Review of Patient #18's closed inpatient record occurred on 02/14/17 and identified the patient admitted to acute care for four days with a urinary tract infection, acute cystitis and hematuria. The record included physician's orders for PRN Toradol (non-steroidal anti-inflammatory drug) injections, ordered for moderate pain. The electronic MAR identified nursing staff administered the medication on four occasions between November 05-08, 2016 and the record lacked evidence of follow-up.

- Review of Patient #19's closed inpatient record occurred on 02/15/17 and identified the patient admitted to acute care for two days with elevated blood sugars. The record showed nursing staff administered PRN Tylenol on two occasions and Norco (used to treat moderate to severe pain) on one occasion on 12/14/16, and the record lacked evidence of follow-up.

On 02/14/17 at 11:15 a.m., an administrative staff member (#2) stated nursing staff should generally follow-up on the effectiveness of pain medications in about an hour; stated the electronic medical record had no notification alerts to trigger nurses to complete this follow-up, and identified three locations in the electronic record to look to determine the effectiveness of PRN pain medications.

Based on bylaws review, policy review, record 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 diagnosis and treatment furnished by 3 of 5 reappointed medical staff physicians' (Providers #2, #3, and #9) credentialing records reviewed from 2015-2017. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment provided by the physicians limited the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of Towner County Medical Center's "Medical Staff Bylaws and Rules and Regulations" occurred on 02/13/17 at 3:05 p.m. These bylaws, revised 01/26/16, stated, ". . .
Article IV. Amended Procedure for Credentialing and Recredentialing . . .
Section 3. Reappointment (Recredentialing) Process
c. Each recommendation concerning the reappointment of a Medical Staff member and the clinical privileges to be granted upon reappointment shall be based upon the following: professional and clinical performance . . ."

Review of the policy "Towner County Medical Center Medical Staff Peer Review" occurred on 02/15/17. This undated policy failed to require evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH by a network hospital or QIO or equivalent for all physicians.

Reviewed on 02/15/17, the 2014-2016 credentialing files failed to include evidence of the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH by a network hospital or QIO or equivalent before the following reappointments in 2015-2017:
- Provider #2 January 2017
- Provider #3 May 2016
- Provider #9 August 2015

Upon request on 02/15/17, the CAH failed to provide evidence a network hospital or a QIO or equivalent evaluated the quality and appropriateness of the diagnosis and treatment furnished by Providers #2, #3, and #9 before reappointment in 2015-2017.

During interview on 02/15/17 at approximately 11:00 a.m., an administrative staff member (#1) confirmed Providers #2, #3, and #9 provided services to the CAH's patients 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 these physicians before reappointments in 2015-2017.