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Based on observation, interview and document review the critical access hospital (CAH) failed to ensure crash carts that contained emergency drugs were kept locked in a secure area and failed to monitor the security of the crash carts located in the emergency, medical/surgical, intensive care unit and obstetric areas. This had the potential to affect any patient and/or visitors who may receive services from the CAH.

Findings include:

During a tour of the emergency department (ED) on 3/31/14, at 1:00 p.m. a crash cart and a pediatric emergency cart containing a variety of emergency medications were stored in a patient ED room. The cart was secured with a white numbered pull-away tab. There was no documentation to identify the cart had been monitored for the security of the medications. Interview with the director of the ED during this time, confirmed the staff did not monitor the replacement of the white pull away tabs when these carts were opened and medications/items were removed.

During a tour of the surgery department on 4/1/14, at 9:00 a.m. a crash cart and a pediatric emergency cart containing a variety of emergency medications were observed in the hallway. Both carts were secured with a numbered pull-away tab. There was no documentation to identify the cart had been monitored for security of the medications. Interview with the director of surgical services, confirmed the staff did not monitor the replacement of the white pull away tabs when the carts were opened and items/medications removed. The white pull away tabs were found stored in a clear bag located on top of the crash cart.

During a tour of the intensive care unit (ICU) on 4/1/14, at 1:00 p.m. a crash cart containing a variety of emergency medications located in the hallway was noted to be unsupervised. The cart was secured with a numbered white pull-away tab. There was no documentation to identify the cart had been monitored for security of the medications. The department did not have any patients nor staff in the area during the tour. The ICU had two entry's that could be accessed by patients and/or visitors. During interview with the director of nursing (DON) at this time, she confirmed the crash cart remained unsupervised when there are no patients. She further verified patients and visitors could have access to the cart located in the ICU which contained emergency medications. The white pull away tabs were found stored in a clear bag located on top of the crash cart.

During a tour of the medical/surgical department on 4/1/14, at 1:15 p.m., a crash cart stored in the hallway and contained a variety of emergency medications was noted to be secured with a numbered white pull-away tab. There was no documentation to identify the cart had been monitored for security of the medications. Interview with the DON, confirmed the staff did not monitor the replacement of the white pull away tabs after the cart is opened and medications removed.

During a tour of the obstetrics department on 4/1/14, at 1:30 p.m. two (2) emergency carts were stored in a utility room containing a variety of emergency medications. Both carts were secured with white pull-away tabs. There was no documentation to identify the carts had been monitored for security of the medications. Interview with the director of nursing services confirmed that the staff did not monitor the replacement of the white pull away tabs after the cart is opened and medications removed.

The crash carts containing emergency medications in the ED, ICU and Med/Surg department included: 3 vials of amiodarone 150 mg; 2 vials of diazepam 10 mg; 2 vials of propranolol 1 mg; 2 vials of dopamine 400 mg; 500 cc bag of premixed Heparin; 500 cc bag of premixed lidocaine; 50 mg nipride; premixed bottle of Nitroglycerin; 100 mg bottle of activase; Solucortef 100 mg; and a vial of benadryl.

The crash cart containing emergency medications in the OR department included: 3 syringes of atropine 1 mg; 4 syringes of epinephrine 1:10,000 1 mg; 2 vials of amiodarone 150 mg; 2 syringes of valium 5 mg and 2 ampules of narcan .4 mg.

The emergency carts containing emergency medications in the OB department included: 2 vials of ephedrine 50 mg; 4 vials of pitocin 10 units and 5 vials of erythromycin 3.5 gm.

The emergency pediatric carts containing emergency medication in the OR, and ED included: 4 vials of ativan 2 mg; epinephrine 1:1000 1 ml ampule; 2 vials of Phenobarbital 130 mg and 2 vials of diazepam 10 mg.

Review of the policy for "Maintaining Integrity of the Emergency Drug System" dated 12/05, indicated the registered nurse (RN) may apply a white hasp lock seal (pull away tab) to the crash carts when opened if the pharmacy was not available. This must be documented on the restocking crash cart log. The hasp locks will be kept in the narcotic cupboards at the nurses station. The policy further stated that the integrity of the crash cart will be checked by nursing at the end of each shift.

Interview with the pharmacist on 4/3/14 at 10:00 a.m., confirmed nursing staff were not properly logging/documenting the security of the carts when replacing the red pull away tab provided by pharmacy with a white tab. He stated the pharmacy only had access to the red pull away tabs and only logged the tab number monthly when the cart was checked for expired medications. The pharmacist further stated he was unsure where nursing obtained the white pull away tabs, because pharmacy did not supply/monitor them.

Based on document review and interview, the critical access hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency or disruption of the water supply. This had the potential of affecting all patients and services provided at the CAH.

Findings include:

During a review of the agreement between the Morris Fire Department and the CAH dated 9/3/2008, it stipulated "The Morris Fire Department consents to assist Stevens Community Medical Center by furnishing transportation of potable water in the case of an emergency or a disaster. Their hospital administrator and maintenance department will determine the amount needed, depending the type of disaster/emergency".

The CAH did not have an established formula or plan as to the amount of potable and non -potable water that would be required to meet the needs of patients, staff and the various departments per day in the event of water disruption.

During an interview with the director of facility services on 3/31/14 at 2:00 p.m., he acknowledged the CAH did not have a policy which would stipulated a specific amount of potable and non potable water. The amount required during this emergency situation had not yet been determined.

Based on document review and staff interview, the critical access hospital (CAH) failed to ensure the medical doctor (MD) or the doctor of osteopath (DO) periodically reviewed and signed the records of inpatients cared for by the certified nurse practitioner (CNP) for 3 of 4 records reviewed (P1, P2 & P3).

Findings include:

P1, discharged on 1/8/14, lacked a signature by the MD/DO on the discharge summary dictated by the CNP; P2 lacked a signature by the MD on the history and physical (H&P) dictated on 1/21/14 by the CNP and P3 lacked a signature by the MD/DO on the H&P and admission orders dated 10/10/13, lacked a MD/DO signature on the discharge orders and summary dictated on 10/16/13 as well as lacking physician notification of the patients admission.

Review of the policy and procedure for " Mid-level Review of Clinical Records" dated 9/2011, indicated that all mid-level staff will work in accordance with an MD/DO for evaluation of the quality of care the mid-level provides. This included; nurse practitioners will have a physician co-signature.

During an interview with the quality assurance (QA) director, it was indicated there had not been criteria for the physicians to review progress notes or NP orders and confirmed they did not have a policy of notification of the physician when the NP admits patients.

During review of medical staff bylaws/policy's and procedures manual dated 9/12, policies and bylaws related to physician documentation and mid-level practitioners care provided were lacking.

Based on document review and interview the critical access hospital (CAH) failed to have an effective quality assurance (QA) program that evaluated on a continuous basis the quality of all patient care services, including the areas of organ tissue donation, nutrition, maintenance, medical records, emergency, surgical, pharmacy and the ambulance and anesthesia services provided by agreement. This had the potential to affect all present and future CAH patients.

Findings include:

During review of the QA documentation, which included the annual meeting minutes dated 12/10/13, it was noted that not all services were evaluated and included: organ tissue donation, nutritional, maintenance, medical records, emergency, surgical, pharmacy and the ambulance and anesthesia services.

In an interview with registered nurse (RN)-A on 4/3/14 at 10:45 a.m., regarding organ and tissue donation quality assurance activities, she stated that two years ago a labeling system had been developed to be placed into the death record book as a reminder for staff to contact the organ tissue agency. However, currently there had been no further evaluation of this activity.

The certified dietary manager (CDM) stated in an interview on 4/1/14 at 9:45 a.m. the department was collecting data on the refrigerator temperatures. Review of the data indicated there had been no problems the recorded temperatures. The CDM acknowledged this was the only measure/data collected to evaluate dietary services.

During interview on 3/31/14, at 2:00 p.m. with the director of maintenance services, it was stated the department maintains lists which contain information on the performance of various mechanical systems but did not have a current QA program in place.

During an interview with the director of medical records on 4/3/14, at 1:30 p.m. she stated a study was completed on the number of patient's history and physicals (H & P's) documented and signed by physician during a 24 hour period. This information had been documented for the past two years; however, there hasn't been any further evaluation or plans developed to improve the performance measures.


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Interview with the emergency department (ED) director on 3/31/14, at 1:00 p.m. confirmed the ED currently did not have any formal QAPI program nor did they have a program which included their ambulance services provided through agreement.

Interview with the surgical services director on 4/2/14, at 10:45 a.m. confirmed the surgical department currently did not have a formal QAPI program nor did it have a program related to anesthesia services.

Interview with the pharmacist on 4/2/14, at 1:00 p.m. confirmed the pharmacy department did not have a current formal QAPI program in place to evaluate pharmacy services.

Interview with the QAPI program director on 4/2/14 at 11:00 a.m., confirmed the CAH lacked current programs for all the identified areas listed above, including the services provided through agreements. The director indicated that each department was responsible to provide annual QA documentation. She confirmed she was aware that not all departments currently had a formal QAPI program in place to evaluate the CAH services provided.