HospitalInspections.org

Based on observation, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to store medications in a manner that prevented unauthorized access for 1 of 1 off-site location (physical therapy department). Failure to store medications in a secure manner may result in unauthorized access to the medications.

Findings include:

Review of the policy titled "Medication Management" occurred on 11/30/22. This policy, revised December 2019, stated, ". . . All areas where drug products are stored will be secured. . . . Unauthorized persons may not be permitted access to medications. . . ."

Observation of the physical therapy department on 11/29/22 at 8:10 a.m. showed tubes of hydrocortisone (mild corticosteroid) and single-dose vials of dexamethasone sodium phosphate (an adrenocortical steroid anti-inflammatory drug) sitting on top of a two-drawer file cabinet located next to the unlocked door to the office.

During an interview on 11/29/22 at 8:40 a.m., a physical therapy staff member (#7) confirmed staff failed to store the hydrocortisone and dexamethasone sodium phosphate in a secure manner and indicated both physical therapy and housekeeping staff have access to the office.

Based on review of Governing Body and Medical Staff Bylaws, review of the Rural Health Network Agreement, review of provider credentialing files, review of Advisory Board meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to have a functioning governing body or written documentation that identified an individual or individuals responsible for the CAH's total operation, failed to ensure an approved governing body approved appointments/reappointments to the medical staff, and failed to ensure a functioning governing body approved the Medical Staff Bylaws. (Refer to C962)

APPROVED/FUNCTIONING GOVERNING BOARD

1. Based on review of Governing Body Bylaws, review of Advisory Board meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to have a functioning governing body or written documentation that identified an individual or individuals responsible for the CAH's total operation for 2 of 2 years reviewed (July 2020 - November 2022). Failure to ensure a functioning governing body or responsible individual(s) that assumes full legal responsibility for the CAH's total operation had the potential to affect the quality and safety of health care provided to the patients.

Findings include:

During interview at 1:30 p.m. on 11/28/22, an administrative staff member (#6) stated the local Advisory Board for Kenmare Community Hospital was no longer functioning and had not met since 2020. The administrative staff member (#6) stated the CAH was operating under the network hospital. Another administrative staff member (#4) stated the network hospital was in the process of approving the CAH under their governing board.

Review of the "Bylaws of the Advisory Board, Trinity Kenmare Hospital d/b/a [doing business as] Kenmare Community Hospital" occurred on 11/28/22 at 3:45 p.m. These bylaws, approved, adopted, and effective 02/13/2004, stated, "DEFINITIONS
1. 'Corporation' means [name of network hospital], a North Dakota corporation; which owns and operates Kenmare Community Hospital (the 'Hospital') in Kenmare, North Dakota.
2. 'Board of Directors' means the governing authority of the Corporation. Whenever the word 'Board' is used in these Bylaws, it shall mean the Board of Directors, acting through the President of the Corporation.
3. 'Advisory Board' means the local advisory board of the hospital.
4. 'Chief Executive Officer' (CEO) means the individual appointed by the Board to act on behalf of the board in the overall management of the Hospital. Whenever 'CEO' is used in these Bylaws, it shall mean the Chief Executive Officer or Administrator of the Hospital.
5. 'Medical Staff' or 'Staff' means all duly licensed physicians, dentists and other licensed professionals who have been granted privileges by the Advisory Board to attend patients in the Hospital. . . .
ARTICLE I CORPORATION
The Hospital shall have a local Advisory Board appointed by and who serve at the pleasure of the Board of Directors. . . .
ARTICLE III ADVISORY BOARD MEMBERS . . .
3.2 Governance: Unless otherwise provided herein, the Hospital shall be under the authority of the Board of Directors. . . . The Advisory Board shall establish bylaws, rules and regulations for the Medical Staff . . .
3.9 Responsibilities: The Advisory Board shall be delegated the responsibility by the Board of Directors for the functions enumerated below, subject to Corporate policies and these bylaws.
3.9a Medical Staff appointments and reappointments, and the granting of staff privileges following recommendations of the current Medical Staff. . . .
3.9c Adoption of, amendments to, or repeal of, rules and regulations governing Medical Staff.
3.9d Decisions regarding quality of service to be made available at the Hospital. . .
3.9g Review quality assurance/improvement programs on an ongoing basis. . . .
ARTICLE VIII. MEDICAL AND DENTAL STAFF
8.1 Organization, Appointments, and Hearings: . . .
8.1b . . . Only such Medical Staff Bylaws as are adopted by the Advisory Board shall be effective and the Advisory board retain the right to rescind any authority or procedures delegated to the Medical Staff by the Bylaws or otherwise, and to amend the Bylaws as necessary for the good operation of the Hospital.
8.1c The Advisory Board shall act upon applications for appointment, reappointment, specific clinical privileges and assignments of responsibilities within the Medical Staff.
8.1d The Advisory Board shall appoint only professionally competent practitioners . . .
8.1f The Advisory Board shall make decisions upon recommendations from the Medical Staff in regard to the adoption of amendments to, or repeal of, rules and regulations governing the Medical Staff. . . .
8.1h From time to time the Advisory Board shall evaluate the number, age, admissions, and hospital activities. . . ."

Reviewed on the afternoon of 11/28/22, the 2020 Advisory Board meeting minutes showed the board members last met on July 9, 2020. The meeting minutes did not indicate the Advisory Board would no longer be functioning. Upon request, the CAH failed to provide evidence the Advisory Board met after July 9, 2020.

During interview the afternoon of 11/28/22, an administrative staff member (#4) stated the network hospital's board meeting minutes lacked evidence of the Kenmore Advisory Board no longer functioning and the network hospital's governing board assuming responsibility for the CAH's operation.

During interview on the afternoon of 11/29/22, an administrative staff member (#4) stated the network hospital board meeting minutes do not include any reports regarding Kenmare Community Hospital operations.

GOVERNING BOARD APPROVAL OF MEDICAL STAFF APPOINTMENTS/REAPPOINTMENTS

2. Based on review of Governing Body and Medical Staff Bylaws, Rural Health Network Agreement review, credentialing file review, and staff interview, the Critical Access Hospital (CAH) failed to ensure an approved governing board approved appointments/reappointments to the medical staff for 9 of 9 medical staff providers' (Providers #1, #2, #3, #4, #5, #6, #7, #8, #9) credentialing records reviewed. Failure to have an approved governing board appoint/reappoint providers to the medical staff limited the governing board's ability to ensure the CAH's patients received treatment/services from qualified providers.

Findings include:

Review of the "Bylaws of the Advisory Board, Trinity Kenmare Hospital d/b/a [doing business as] Kenmare Community Hospital" occurred on 11/28/22 at 3:45 p.m. These bylaws, approved, adopted, and effective 02/13/2004, stated,
"DEFINITIONS
1. 'Corporation' means [name of network hospital], a North Dakota corporation; which owns and operates Kenmare Community Hospital (the 'Hospital') in Kenmare, North Dakota.
2. 'Board of Directors' means the governing authority of the Corporation. Whenever the word 'Board' is used in these Bylaws, it shall mean the Board of Directors, acting through the President of the Corporation.
3. 'Advisory Board' means the local advisory board of the hospital. . . .
5. 'Medical Staff' or 'Staff' means all duly licensed physicians, dentists and other licensed professionals who have been granted privileges by the Advisory Board to attend patients in the Hospital. . . .
ARTICLE I CORPORATION
The Hospital shall have a local Advisory Board appointed by and who serve at the pleasure of the Board of Directors. . . .
ARTICLE III ADVISORY BOARD MEMBERS . . .
3.9 Responsibilities: The Advisory Board shall be delegated the responsibility by the Board of Directors for the functions enumerated below, subject to Corporate policies and these bylaws.
3.9a Medical Staff appointments and reappointments, and the granting of staff privileges following recommendations of the current Medical Staff. . . .
3.9d Decisions regarding quality of service to be made available at the Hospital. . .
ARTICLE VIII. MEDICAL AND DENTAL STAFF . . .
8.1c The Advisory Board shall act upon applications for appointment, reappointment, specific clinical privileges and assignments of responsibilities within the Medical Staff.
8.1d The Advisory Board shall appoint only professionally competent practitioners meeting the personal and professional qualifications prescribed in the Medical Staff Bylaws to the Medical Staff. . . .
8.1j At its next regular meeting after receipt of a recommendation from the Medical Staff concerning an applicant for Medical Staff appointment or an appointee to the Medical Staff, the Advisory Board shall act in the matter. . . . "

Review of the CAH's "Medical Staff Bylaws Trinity Kenmare Hospital d/b/a Kenmare Community Hospital" occurred at 8:40 a.m. on 11/30/22. These bylaws, approved by the CAH Advisory Board on 07/22/04, stated, ". . .
ARTICLE IV: AUTHORITY The Medical staff is organized under authority granted by the Advisory Board pursuant to the bylaws of Kenmare Community Hospital Advisory board and policies and procedures adopted by them. . . .
ARTICLE VII: CONDITIONS AND DURATION OF APPOINTMENT
A. The Advisory board shall make initial appointments and re-appointments to the medical staff. . . .
ARTICLE X: TERMS OF APPOINTMENT & RE-APPOINTMENT
A. Appointment to Medical Staff shall be made by the advisory board and shall be for a period of two years. . . .
ARTICLE XIV: DUTIES
A. Medical Staff Duties. Duties. The duties of the Medical Staff shall be: . . .
e. To fulfill the Medical staff's accountability to the Advisory board for the medical care rendered to patients in the hospital. . . .

Review of the Rural Health Network Agreement between the network hospital and the CAH, dated 10/10/07, stated, ". . . 2. Purpose of Agreement: [name of network hospital] and CAH agree that the purpose of this Agreement is to identify and form a process to: . . . identify the process to be used for . . . credentialing. . . . 6. Credentialing: 1.1. . . [Name of network hospital] shall not have the right or responsibility for the initiation or denial of membership or clinical privileges at CAH to any Professional, which decision shall be the sole right and responsibility of CAH. . . ."

Upon request, the CAH failed to provide evidence the local Advisory Board approved appointment/reappointment for the following:Provider #1 - appointment effective 07/01/21Provider #2 - appointment effective 10/12/21
Provider #3 - appointment effective 11/09/21
Provider #4 - appointment effective 07/01/21
Provider #5 - appointment effective 07/01/21
Provider #6 - appointment effective 12/21/21
Provider #7 - appointment effective 10/31/22
Provider #8 - appointment effective 10/02/22
Provider #9 - appointment effective 10/02/22
An administrative staff member (#4) confirmed the CAH providers' appointments and reappointments were approved by the network hospital's governing board, not the local Advisory Board, which was not in agreement with the currently approved Advisory Board Bylaws, Medical Staff Bylaws, or the Rural Health Agreement.

3. GOVERNING BOARD APPROVAL OF MEDICAL STAFF BYLAWS

Based on review of Medical Staff Bylaws and staff interview, the governing board failed to approve 1 of 2 sets (February 28, 2022) of Medical Staff Bylaws provided. Failure of the governing board to approve the Medical Staff Bylaws in use had the potential to impact the quality of health care services provided to the CAH's patients.

Findings include:

Review of the "Bylaws of the Advisory Board, Trinity Kenmare Hospital d/b/a [doing business as] Kenmare Community Hospital" occurred on 11/28/22 at 3:45 p.m. These bylaws, approved, adopted, and effective 02/13/2004, stated, ". . .
ARTICLE I CORPORATION
The Hospital shall have a local Advisory Board appointed by and who serve at the pleasure of the Board of Directors. . . .
ARTICLE III ADVISORY BOARD MEMBERS . . .
3.2 Governance: Unless otherwise provided herein, the Hospital shall be under the authority of the Board of Directors. . . . The Advisory Board shall establish bylaws, rules and regulations for the Medical Staff . . .
3.9 Responsibilities: The Advisory Board shall be delegated the responsibility by the Board of Directors for the functions enumerated below, subject to Corporate policies and these bylaws.
3.9a Medical Staff appointments and reappointments, and the granting of staff privileges following recommendations of the current Medical Staff. . . .
3.9c Adoption of, amendments to, or repeal of, rules and regulations governing Medical Staff.
3.9d Decisions regarding quality of service to be made available at the Hospital. . .
3.9g Review quality assurance/improvement programs on an ongoing basis. . . .
ARTICLE VIII. MEDICAL AND DENTAL STAFF
8.1 Organization, Appointments, and Hearings: . . .
8.1b . . . Only such Medical Staff Bylaws as are adopted by the Advisory Board shall be effective and the Advisory board retain the right to rescind any authority or procedures delegated to the Medical Staff by the Bylaws or otherwise, and to amend the Bylaws as necessary for the good operation of the Hospital. . . .
8.1f The Advisory Board shall make decisions upon recommendations from the Medical Staff in regard to the adoption of amendments to, or repeal of, rules and regulations governing the Medical Staff. . . ."

Review of the "Medical Staff Bylaws, Trinity Kenmare Hospital d/b/a Kenmare Community Hospital" occurred on November 28-29, 2022. The CAH Medical Director and CAH Hospital Administrator signed these bylaws on 02/28/22.

During interview on the morning of 11/30/22, an administrative staff member (#4) stated the Advisory Board nor the network hospital board had approved the revised Medical Staff Bylaws.

Upon request on 11/30/22, the CAH provided a copy of "Medical Staff Bylaws, Trinity Kenmare Hospital d/b/a Kenmare Community Hospital," approved by the Advisory Board on 07/22/04. These bylaws were the most current, approved Medical Staff Bylaws. These bylaws stated, ". . . DEFINITIONS: . . . 2. Advisory Board means the Advisory Board of Kenmare Community Hospital . . . ARTICLE IV: AUTHORITY The Medical Staff is organized under authority granted by the Advisory Board pursuant to the bylaws of Kenmare Community Hospital Advisory board and policies and procedures adopted by them. . . .

The CAH failed to ensure the governing board approved the Medical Staff Bylaws, dated 02/28/22, currently in use.

Based on record review, review of medical staff rules and regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff notified the physician of a patient admitted to the CAH by a nurse practitioner (NP) for 6 of 6 patients (Patient #14, #18, #20, #21, #23, and #24) admitted by a NP. Failure of staff to notify the physician of a patient admitted by an NP limited the physician's ability to ensure the appropriateness of the admission and to monitor the care provided to the patient by the NP.

Findings include:

Review of the "Medical Staff Rules and Regulations" occurred on 11/30/22. These rules, updated 07/19/04, stated, ". . . All nurse practitioner or clinical nurse specialist admissions must document physician notification by the admitting nurse practitioner or clinical nurse specialist. Physician assistant notification to physician must be within four hours and must be documented that consultation occurred and the physician's approval or disapproval is placed in the patient's chart. . . . "

Review of patient medical records occurred on all days of survey. The following records of patients admitted to the facility by a NP lacked evidence they notified the physicians of the admissions:
* Patient #14 admitted on 07/02/21.
* Patient #18 admitted on 01/24/21.
* Patient #20 admitted on 01/24/22.
* Patient #21 admitted on 02/03/22.
* Patient #23 admitted on 02/02/22.
* Patient #24 admitted on 07/23/22.

During an interview on 11/30/22 at 11:00 a.m., an administrative staff member #4 confirmed the nurse practitioners failed to notify the physicians of the admissions.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications from 1 of 2 crash carts (Emergency Room) observed. Failure to remove outdated medications may result in patients receiving expired and ineffective medications.

Findings include:

Review of the policy titled "Restocking and Securing of Crash Carts Following Use (Pharm) [Pharmacy]" occurred on 11/30/22. This policy, revised June 2022, stated, ". . . 5. Crash carts will be inspected monthly for outdated/short-dated product . . ."

Review of the policy titled "Equipment, Supplies, and Medications for Emergency Services" occurred on 11/30/22. This policy, revised October 2022, stated, ". . . Monthly the crash cart is opened and checked for supplies and out-dates. . . ."

Observation of the Emergency Room crash cart occurred on 11/28/22 at 1:56 p.m. with a staff nurse (#1) and an administrative nurse (#2). The crash cart had a locked drawer containing medications used in the event of a patient cardiac or respiratory arrest. Review of the contents of the drawer showed two 1 gm (gram) Abbojects [A ready-to-use, prefilled emergency syringe] of calcium chloride (a medication used to low calcium), two 1 mL (milliliter) ampules of Epinephrine 1:1,000 (a medication to increase blood pressure), and two 1 mL Naloxone 0.4 mg/ml (mg/milliter) (a medication used to treat drug overdoses) ampules, with expiration dates of November 1, 2022.

During an interview on 11/30/22 at 2:00 p.m., the staff nurse (#1) confirmed the medications were expired, and that it is the responsibility of the night nurse to check the crash carts monthly for outdated medication. The administrative nurse (#2) agreed staff failed to remove outdated medication from the emergency room crash cart.

Based on review of the facility's Quality Assessment and Performance Improvement (QAPI) program, QAPI meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate services furnished under contracts for 1 of 1 year reviewed (October 2021 - October 2022). Failure to evaluate services furnished by contractors limited the CAH's ability to ensure the contractors provided quality services for the CAH and its patients.

Findings include:

Review of the "Trinity Kenmare Hospital Quality Plan - Clinical Excellence and Patient Safety" document for fiscal year 2022 - 2023, stated ". . . Quality Assessment and Performance Improvement Program: . . . The Administrator and Director of Nursing are responsible for the program and the quality of Trinity Kenmare services delivered. . . . This plan consists of ongoing Quality Assessment and Performance Improvement of patient care provided directly and by arrangement. . . . Quality Assessment of care processes and outcomes using data sources and indicators will include the following for 2021-2022: . . . Contracts reviewed.

Review of the CAH's list of contracted services occurred on November 28-30, 2022. This undated list identified fifteen contractors provided direct and indirect patient care services at the CAH.

Reviewed on November 28-30, 2022, quality assurance meeting minutes from the last year (October 2021 - October 2022) failed to include evidence the CAH staff had evaluated nine of the fifteen contracted services.

Upon request on 11/29/22, the CAH failed to provide evidence staff had evaluated nine of the fifteen contracted services in the past year to ensure the contractors provided quality services for the CAH and its patients.

During interview on the morning of 11/30/22, an administrative staff member (#6) confirmed CAH staff had failed to evaluate all the contracted services in the past year.

Based on record review, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to develop a care plan for 3 of 7 acute care patients (Resident #8, #13, and #14) admitted to the facility. Failure to develop and implement a care plan limits the staff's ability to provide patients with comprehensive, person-centered care.

Findings include:

Review of the policy titled "Plan of Care/Care Plan" occurred on 11/30/22. This policy, revised March 2021, stated, ". . . A Care Plan should be started for a patient upon admission and evaluated by the primary nurse and/or other members of the care team during each shift or when patient's condition changes. The patient's Care Plan should be a dynamic document developed based on the needs identified during the patient's assessment, reassessment, and/or results of diagnostic testing. . . . Measurable goals and expected outcomes should be developed with the patient and/or family if possible and should align with the medical therapy prescribed by the physician. Nursing interventions should be driven based on the goals and objectives of the care plan. . . ."

Review of patient medical records occurred on all days of survey. The following records lacked evidence staff started a care plan following the patient's admission to the facility:
* Patient #8 admitted on 09/26/21.
* Patient #13 admitted on 10/11/21.
* Patient #14 admitted on 07/02/21.

During an interview on 11/29/22 at 11:40 a.m., an administrative nurse (#2) confirmed staff failed to start a care plan following Patient #8, #13, and #14's admission to the facility.

Based on observation, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed standard infection control practices for 1 of 3 patients (Patient #1) observed during cares. Failure to perform hand hygiene after removal of gloves, after patient care, and when moving from one area of the CAH to another has the potential to spread infection to other patients, staff, and visitors.

Findings include:

Review of the facility policy titled "Hand Hygeine" [sic] occurred on 11/30/22. This policy, revised June 2021, stated, ". . . protects all patient, staff and visitors through the utilization of the 'WHO [World Health Organization] Five (5) Moments of Hand Hygiene'. . . Before touching a patient . . . Before a clean/aseptic procedure . . . After blood or body fluid exposure risk . . . After touching a patient . . . After touching patient surroundings . . . GLOVES . . . do not replace the use of hand hygiene . . . hand hygiene must be performed: . . . before donning gloves . . . after removal of gloves . . ."

Observation on 11/29/22 at 9:04 a.m., showed a certified nursing assistant (CNA) (#3) assisted Patient #1 into the communal patient restroom. The CNA (#3) donned gloves, assisted Patient #1 onto the toilet lowering the patient's incontinence brief. A small amount of incontinent bowel movement (BM) transferred from the brief to the toilet seat and Patient #1's pants. The CNA (#3) removed the soiled brief, without removing the gloves pulled the call light string, opened the cabinet drawer, retrieved a bag, and removed the patient's soiled pants. The CNA (#3) opened the bathroom door, retrieved clean supplies from another staff while wearing the same gloves. After setting the clean supplies on the patient's wheelchair cushion the CNA removed the soiled gloves, and without performing hand hygiene, donned new gloves. The CNA (#3) performed toileting hygiene for Patient #1, assisted the patient back into the wheelchair, removed the soiled gloves, and without performing hand hygiene, assisted Patient #1 to wash her hands, took her to the day room and transferred her into a recliner touching several surfaces and items. The CNA (#3) failed to perform hand hygiene until leaving the day room.

During an interview on 11/29/22 at 9:20 a.m., an administrative nurse (#2) confirmed she expected staff to perform hand hygiene before donning gloves, after glove removal, when moving from a dirty task to a clean task, and after contact with patients or patients surroundings.

Based on observation, record review, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to implement policies and procedures that included additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19 for 3 of 3 days of survey (November 28-30, 2022). Failure to implement additional precautions for staff who are not fully vaccinated may lead to increased risk of transmission and spread of COVID-19 among patients, staff, and visitors.

Findings include:

Review of the policy titled "Trinity Health COVID-19 Vaccination Mandate Requirements" occurred on 11/30/22. This policy, revised February 2022, stated, ". . . employees, volunteers, students, trainees, or other individuals providing services . . . are required to be fully vaccinated against COVID-19 . . . 6. . . . will implement additional precautions to mitigate the transmission and spread of COVID-19 for all employees. . . . Employees on a deferral or exemption will always be required to mask while at work . . ."

Review of the policy titled "Infection Prevention and Control Program" occurred on 11/30/22. This policy, revised June 2022, stated, ". . . developed and implemented an effective organization-wide Infection Prevention and Control Program for the surveillance, prevention and control of infections. This includes the coordination of organization-wide activities including all inpatient and outpatient services . . . A. The Infection Prevention and Control Program uses evidence-based national guidelines and/or recommendations from experts, such as . . . Centers for Medicare and Medicaid Services (CMS) . . . C. Risk assessment guides prioritization of infection prevention and control goals, objectives and strategies. . . ."

Review of the handout "Staff Masking Guidelines" occurred on 11/30/22. This handout, effective October 21, 2022, stated, ". . . Masks are optional for all staff regardless of vaccination status, except when providing care to a suspected or confirmed COVID-19 positive patient. . . ."

Review of employee vaccination records identified Staff A and B completed appropriate COVID-19 vaccine exemptions.

Observations showed the following:
* 11/30/22 8:00 a.m. Staff A walked throughout the facility, including the elevator, kitchen and patient care areas without a face mask.
* 11/30/22 8:05 a.m. Staff B sat at the registration desk with no face mask on and assisted patients to register for an appointment.

During an interview on 11/30/22 at 8:30 a.m., an administrative nurse (#2) stated "We've updated our infection control policy to be inclusive of all infections and it does not specifically address COVID." She agreed the current infection control policy failed to include additional precautions for staff who are not fully vaccinated against COVID-19.

Based on review of governing body and medical staff bylaws, review of the quality assurance performance improvement (QAPI) plan, and staff interview, the Critical Access Hospital (CAH) failed to report QAPI activities to the governing board for 1 of 1 year (October 2021 - October 2022). Failure to report QAPI activities to the governing board limited the governing board's ability to ensure quality of care.

Findings include:

Review of the "Bylaws of the Advisory Board, Trinity Kenmare Hospital d/b/a [doing business as] Kenmare Community Hospital" occurred 11/28/22 at 3:45 p.m. These bylaws, approved, adopted, and effective 02/13/2004, stated, "DEFINITIONS
1. 'Corporation' means [name of network hospital], a North Dakota corporation; which owns and operates Kenmare Community Hospital (the 'Hospital') in Kenmare, North Dakota.
2. 'Board of Directors' means the governing authority of the Corporation. Whenever the word 'Board' is used in these Bylaws, it shall mean the Board of Directors, acting through the President of the Corporation.
3. 'Advisory Board' means the local advisory board of the hospital. . . .
ARTICLE I CORPORATION
The Hospital shall have a local Advisory Board appointed by and who serve at the pleasure of the Board of Directors. . . .
ARTICLE III ADVISORY BOARD MEMBERS . . .
3.9 Responsibilities: The Advisory Board shall be delegated the responsibility by the Board of Directors for the functions enumerated below, subject to Corporate policies and these bylaws. . . .
3.9f Require the development of a quality assurance/improvement program . . .
3.9g Review quality assurance/improvement programs on an ongoing basis. . . .

Review of the CAH's "Medical Staff Bylaws Trinity Kenmare Hospital d/b/a Kenmare Community Hospital" occurred at 8:40 a.m. on 11/30/22. These bylaws, approved by the CAH Advisory Board on 07/22/04, stated, ". . .
ARTICLE IV: AUTHORITY The Medical staff is organized under authority granted by the Advisory Board pursuant to the bylaws of Kenmare Community Hospital Advisory board and policies and procedures adopted by them. . . .
ARTICLE XIV: DUTIES
A. Medical Staff Duties. Duties. The duties of the Medical Staff shall be: . . .
e. To fulfill the Medical staff's accountability to the Advisory board for the medical care rendered to patients in the hospital. . . .
j. . . . Medical Staff will be members of the QI Committee and reports of QI activities will be discussed at Medical Staff meetings and at the Advisory board meetings. . . ."

Review of the "Trinity Kenmare Hospital Quality Plan - Clinical Excellence and Patient Safety" document for fiscal year 2022 - 2023, stated ". . . Quality Assessment and Performance Improvement Program: . . . The Administrator and Director of Nursing are responsible for the program and the quality of Trinity Kenmare services delivered . . . Quality Assessment and Performance Improvement activities will be reported to the Administrator and the Vice President of Senior Services and Care Coordination (whom the Administrator reports to) will report to Hospital Quality Board on an annual basis. . . .
Upon request, the CAH failed to provide evidence the governing board reviewed the CAH's QAPI program for the past year. During an interview on the morning of 11/30/22, an administrative staff member (#4) confirmed the network hospital's governing board did not review the CAH's quality assurance/improvement activites.