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Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a clean environment on 2 of 3 days of survey (April 25-26, 2016). Failure to ensure a clean environment may result in the spread of infection within the facility.

Findings include:

Review of the policy titled "Physical Therapy Department . . . Infection Control Guidelines" occurred on 04/27/16. This policy, dated 09/2013, stated, "PURPOSE: To provide guidelines to prevent the spread of nosocomial infections in the physical therapy department . . . 3. . . . b. HYDROCOLLATOR (a water filled tank used to warm hot packs): 1. Tank will be emptied every 4 months and cleaned with approved disinfectant, rinsed and filled with clean water. . . ."

- Observation on 04/25/16 at 11:45 a.m. showed the door between the kitchen and the staff food storage area propped open with a door stop. This area opened directly to the inpatient physical therapy room, and patients would need to walk through the staff food storage area to access physical therapy equipment. Observation also showed paint peeling on the south wall of the kitchen above food storage bins.

During an observation of the kitchen on 04/25/16 at 12:50 p.m. with two cooks (#5 and #6) the door remained propped open.

During an interview on 04/26/16 at 9:15 a.m., a dietary management staff member (#2) stated staff should not prop the door open and should not place food bins below peeling paint.

- A tour of the outpatient physical therapy department occurred on 04/26/16 at 10:20 a.m. with a physical therapist (PT) (#7). Observation during the tour showed the hydrocollator lid corroded with black material on the hinges. Observation showed the inside edges of the lid rusty with a large area of rust on the inside surface of the lid and an accumulation of rust colored flakes at the bottom of the tank. When asked, at 10:25 a.m., a physical therapy assistant (PTA) (#8) stated she cleaned it "in February maybe."

- Observation at 10:45 a.m. with a PT (#7) revealed a mop sink in the janitor closet with a hose attached to the faucet. The hose reached to the bottom of the sink and lacked a back flow device to prevent contaminated water from backing up into the water system. The staff member (#7) stated she was unaware the faucet lacked a back flow device.

Based on bylaws review, staff interview, and record review, the Critical Access Hospital's (CAH's) medical staff failed to recommend and the governing board failed to approve appointment to the medical staff for 6 of 6 practitioners' (Practitioners #1, #2, #3, #4, #5, and #6) and for 2 of 2 telemedicine entities' (Entities #1 and #2) credentialing records reviewed. Failure to appoint practitioners and telemedicine entities to the medical staff limits the governing board's ability to ensure the CAH's patients receive treatment/services from qualified practitioners.

Findings include:

Review of the "Medical Staff Bylaws Trinity Kenmare Hospital d/b/a [doing business as] Kenmare Community Hospital" occurred on 04/25/16 at 1:25 p.m. These bylaws, adopted 06/08/12, stated,
". . . Article VII: Conditions and Duration of Appointment
A. the Advisory board shall make initial appointments and re-appointments to the medical staff. The Advisory Board shall act on appointments only after there has been a recommendation from the medical staff . . .
Article IX: Appointment Process
A. Appointment/re-appointment to medical staff will be conducted in conjunction with the Administrative credentialing department at [name of parent organization]. In order to provide credentialing for Kenmare Hospital the credentialing committee will utilize the system developed by our parent organization. . . ."
These bylaws did not require medical staff appointment for practitioners providing services to the CAH's patients through telemedicine.

Review of the governing board's "Bylaws of the Advisory Board Trinity Kenmare Hospital d/b/a Kenmare Community Hospital" occurred on 04/25/16 at 5:15 p.m. These bylaws, adopted 02/13/04, stated,
". . . Article VIII Medical and Dental Staff
8.1 Organization, Appointments, and Hearings:
8.1c The Advisory Board shall act upon applications for appointment, reappointment, specific 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. . . .
8.1e The Advisory Board shall make decisions upon recommendations from the Medical Staff as to the types and extent of professional work permitted to be done by each appointee of the Medical Staff. . . ."

Reviewed on 04/26/16, the credentialing records for Practitioners #1, #2, #3, #4, #5, and #6 and Telemedicine Entities #1 and #2 lacked evidence of the CAH's medical staff recommendation and the governing body approval of appointment/reappointment and privileges.

Upon request on 04/26/16, the CAH failed to provide evidence the CAH's medical staff recommended and the governing body approved appointment/reappointment and privileges for Practitioners #1, #2, #3, #4, #5, and #6 and Telemedicine Entities #1 and #2.

During an interview on 04/25/16 at 4:10 p.m., an administrative radiology staff member (#14) confirmed Telemedicine Entity #1 provided after hours preliminary radiology interpretation for the CAH's patients.

During an interview on 04/26/16 at 3:50 p.m., an administrative staff member (#13) confirmed the CAH used the services of Telemedicine Entity #2 in the emergency department and the CAH's medical staff had not recommended and the governing body had not approved appointment/reappointment and privileges of Practitioners #1, #2, #3, #4, #5, and #6 and Telemedicine Entities #1 and #2.

Based on observation, policy review, 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 outpatient physical therapy department. Failure to disinfect the rubber stopper prior to withdrawing medication, to utilize a new syringe each time, and to use a new vial for each patient placed patients receiving Iontophoresis treatments at risk of contracting an infection.


Findings include:

Review of the CAH policy titled "Iontophoresis (delivery of medication through the skin by electrical stimulation)" occurred on 04/26/16. The policy, dated January 2006, stated, ". . . Rationale: Proper guideline for drug delivery with electrical stimulation. . . . 2. Ions include: . . .b. . . . i. Dexamethasone (cortisone) . . ."

The APIC (Association of Professionals in Infection Control and Epidemiology) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016), stated, ". . . MEDICATION VIALS . . . * Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial. * Always use a new sterile syringe and new needle/cannula when entering any vial. Never enter a vial with a syringe or needle/cannula that has been previously used. . . . * Use multidose medication vials for one patient whenever possible. . . . * Store and access multidose vials away from the immediate patient care environment and always use a sterile syringe and needle/cannula each time the vial is accessed. . . ."

Observation of the outpatient physical therapy department on 04/26/16 at 10:30 a.m. with a physical therapist (PT) (#7) identified several multi-dose vials of dexamethasone and several needles stored in a drawer in the PT office. During an interview on 04/26/16 at 10:30 a.m., a PT staff member (#7) stated staff use the dexamethasone with Iontophoresis. She stated she draws up the dexamethasone with a needle and syringe and places it on a pad for the procedure. The staff member (#7) stated she uses a new needle each time, but uses the same syringe for more than one patient and does not disinfect the rubber stopper prior to withdrawing the medication. When requested, the staff member (#7) stated the department did not have a policy and procedure for drawing up the dexamethasone.

Based on policy and procedure review, menu review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff met the nutritional needs of patients in accordance with recognized dietary practices for 1 of 1 dietary services department. Failure to develop menus and follow recipes may result in patients experiencing weight loss and/or nutritional deficiencies.

Findings include:

Review of the CAH policy titled "Food preperation [sic] and service" occurred on 04/27/16. The undated policy stated, ". . . Policy: The dietary Department shall follow food preparation procedures that will conserve nutrition value, flavor and appearance as well as meeting all Federal, State and Local laws. Procedure: 1. Menus will be the basis for all food preparation . . . 7. Portion control will be achieved through: * Portions being indicated on regular and therapeutic diet menus . . . 8. Tray cardex will provide the basis of serving sizes and the individual diets including: * Beverage * Diet and altered food texture *Food allergies . . ."

Review of the menus for the days of the survey occurred on the morning of 04/25/16. The menus lacked breakfast meals and beverages served with all meals. The menus failed to identify therapeutic diets or serving sizes.

During an interview on 04/25/16 at 3:45 p.m., a dietary manager (#2) confirmed the menus lacked therapeutic diets, serving sizes, and beverages served. The staff member (#2) stated the CAH provides regular and carbohydrate controlled diets. She stated there are also patients who receive pureed foods. The staff member confirmed the CAH had no menu for breakfast and stated the cooks decide each morning what to make for breakfast. The staff member (#2) stated the department had no recipes for staff to follow when preparing meals.

Based on record review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the evaluation of services provided through contract for 12 of 16 contracted services (accredited record technician/medical records, occupational therapy, speech therapy, electrocardiogram interpretation, specialty physician services, dietitian/nutritional services support, nurse midwifery, orthopedic services, social services support, mental health services, dentistry, and optometry). Failure to evaluate contracted services limits the CAH's ability to ensure compliance with the conditions of participation and standards for contracted services.

Findings include:

Review of the document "Services Provided by Kenmare Community Hospital" occurred on 04/26/16. This document, revised 05/30/14, stated,
". . . The following is a list of services provided to Kenmare Community Hospital through contracts or agreements with other entities.
[name of parent organization]
ART [accredited record technician] - Medical Records . . .
Occupational Therapy . . .
Speech Therapy . . .
Lab Director . . .
EKG [electrocardiogram] Interpretation . . .
Specialty physician services . . .
Radiology Director . . .
Pathology Director . . .
Dietitian, Nutritional Services Support . . .
Nurse Midwifery . . .
Orthopedic Services . . .
Social Services Support . . .
The following is a list of services provided to Kenmare Community Hospital through contracts or agreements with other entities.
[name of entity] (Mental Health Services)
Dentistry - [name of dentist]
Optometry - [name of optometrist]
[name of entity] - Ultrasound, CT Scans, Mammography van

Review of the CAH's quality assurance reporting schedule occurred on 04/26/16. This undated document listed "Contracted Services - All Departments" scheduled to report in February and "Contracted Services - Administration" scheduled to report in March.

Review of the CAH's quality assurance meeting minutes occurred on 04/26/16. The monthly minutes from January 2015 through March 2016 lacked evidence of an evaluation of the following contracted services: accredited record technician/medical records, occupational therapy, speech therapy, electrocardiogram interpretation, specialty physician services, dietitian/nutritional services support, nurse midwifery, orthopedic services, social services support, mental health services, dentistry, and optometry.

Upon request on 04/26/16, the CAH failed to provide evidence of an evaluation of the above listed contracted services.

During an interview on 04/26/16 at 3:20 p.m., an administrative nursing staff member (#4) responsible for quality assurance confirmed the CAH failed to evaluate the above listed contracted services as scheduled in 2015 and 2016.

Based on policy review and record review, the Critical Access Hospital (CAH) failed to assess and document the effectiveness of medications given to patients on an as needed (PRN) basis for 1 of 1 active swing bed patient (Patient #9) and 1 of 6 closed acute patient (Patient #18) records reviewed. Failure to document signs and symptoms experienced by the patient prior to administering PRN medication and to assess the patient's response to PRN medications may result in the patient experiencing adverse side effects from the medication and/or unrelieved pain.

Findings include:

Review of the policy titled "MEDICATIONS" occurred on 04/25/16. The policy, dated February 2015, stated, "Procedure: . . . C. PRN Medications: 1. List and chart administration of prn medication on the back of the daily MAR [medication administration record]. Note reason given and results of prn medications. . . ."

Review of the following records occurred on April 25-27, 2016:

- Patient #9's active swing bed record identified staff administered the following medications:
* Oxycodone (an opioid pain medication) 5 milligrams (mg) on 02/21/16 at 9:55 p.m. for leg pain at level 6 of 10 and on 03/06/16 at 11:25 p.m. for leg pain at level 8 of 10.
* Acetaminophen (for pain) 500 mg - two tablets on 03/08/16 at 10:45 p.m. for leg pain at level 8 of 10 and on 03/14/16 at 4:20 p.m. for leg pain at level 8 of 10.
The record lacked evidence staff assessed the patient's response to the medications.

- Patient #18's closed acute patient record identified staff administered Lorazepam (an antianxiety medication) 1 mg on 03/02/16 at 11:26 p.m., on 03/03/16 at 6:04 a.m., and on 03/06/16 at 11:40 p.m.
The record lacked evidence Patient #18 had signs or symptoms of anxiety at the times staff administered the lorazepam and lacked evidence staff assessed the patient's response to the medication.

Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure a registered nurse evaluated the use of a lower side rail for 1 of 1 active swing bed patient (#6) utilizing a lower side rail. Failure to assess the risks of utilizing the side rail may result in the patient sustaining an injury from the side rail.

Findings include:

- Review Patient #6's active medical record occurred on 04/26/16 and identified diagnoses including mental retardation with behaviors. The current care plan, dated 10/01/15, stated, "Patient will remain injury free during hospitalization . . . Patient will remain safe in bed with use of one upper rail or less . . ."

The record showed, on 04/15/16 at 5:15 a.m., staff found the patient on the floor by his bed and indicated Patient #6 had no injury from the fall. The record showed staff submitted a "work order" to have a bottom rail placed on the bed due to the patient lying on his side close to the edge of the bed. The record lacked evidence a registered nurse assessed the risks and/or benefits of utilizing the lower side rail prior to submitting the work order.

Observation, on 04/26/16 at 5:00 p.m. with a staff nurse (#3), showed upper quarter rails elevated on both sides of Patient #6's bed. The nurse picked up a lower rail which leaned against the bedside stand and placed it in position on the lower edge of the bed on the exit side. Observation showed the rail approximately 8-10 inches wide. The nurse (#3) stated staff use the rail only at night because Patient #6 lies near the edge on that side of the bed when he sleeps.

During an interview on 04/26/16 at 5:40 p.m. an administrative nurse (#4) confirmed Patient #6's current side rail assessment did not reflect use of the lower rail.

Failure to ensure a registered nurse assessed the use of the side rail prior to implementation placed Patient #6 at risk of obtaining an injury from the rail.

Based on observation, review of professional literature, policy and procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff administered medications in accordance with accepted standards of practice for 3 of 9 patients (Patient #1, #4, and #6) observed receiving medications and treatments. This failure limited the CAH's ability to ensure staff prepared and administered medications safely and within their scope of practice.

Findings include:

Berman, Snyder, and Frandsen's, "Kozier and Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 10th edition, 2016 Pearson Education Inc., page 771-772, stated, ". . . Process of Administering Medications: When administering any drug, regardless of the route of administration, the nurse must do the following: 1. Identify the client. . . . 2. Inform the client. . . . 3. Administer the drug. Read the MAR [medication administration record] carefully and perform three checks with the labeled medications . . . Then administer the medication in the prescribed dosage, by the route ordered, at the correct time. . . ."

The American Society of Consultant Pharmacists, "Geriatric Medication Handbook," 7th edition, page 148 stated, ". . . Medications should be prepared . . . immediately before administration; medications should never be prepared in advance . . . and left in unlabeled medicine cups for later use. . . ."

Review of the policy "Medication Administration" occurred on 04/27/16. This policy, revised November 2004, stated, ". . . PURPOSE: To administer medication in appropriate manner . . . PROCEDURE: 1. Gather meds to be given. . . . 2. Identify resident or patient. 3. Administer medication . . ."

- Observation on 04/25/16 at 1:30 p.m. showed two nurse aides (#11 and #12) in Patient #4's room assisting the patient from a wheelchair to a reclining chair. After assisting Patient #4 to the recliner, a nurse aide (#11) placed a mask over the patient's nose and mouth and started a machine attached to the mask to deliver a nebulizer treatment. During an interview at this time, the nurse aide (#11) stated the nurse set up the nebulizer machine in the morning, but didn't get a chance to give Patient #4 the treatment, which is the reason she started the machine at this time. She stated the aides often performed this for the nurses.

Observation of Patient #4 at 2:20 p.m. showed she remained in a recliner in her room with the nebulizer machine still running. Review of Patient #4's treatment record showed the nurse signed off this nebulizer treatment as completed at 9:00 a.m. on 04/25/16.

During an interview on 04/26/16 at 10:00 a.m., a nurse (#10) confirmed the nurse aides "sometimes" administered nebulizer treatments after the nurse set up the machine.

During an interview on the morning of 04/27/16, an administrative nurse (#1) stated the above practice as unacceptable and stated nurses must prepare and administer nebulizer treatments, not nurse aides.

- Observation of medication pass occurred on 04/26/16 at 7:40 a.m. in the dining room. The nurse (#9) responsible for administering medications during the day shift provided a medication cup containing several pills to Patient #6. The nurse (#9) stated she had all of the patients' (current hospital census identified 19 swing bed patients) medications set up in medication cups, ready to administer. Observation of the medication cart showed drawers labeled with each patient's name. The drawers contained unlabeled medication cups with pills placed inside them.

- On 04/26/16 at 11:55 a.m., observation in the dining room showed a nurse (#9) administered medications to Patient #1. The nurse (#9) stated she already had the patient's medications set up.

During an interview on the morning of 04/27/16, an administrative nurse (#1) stated nurses must prepare medications at the time of administration.

Based on record review, policy review, and staff interview, the Critial Access Hospital (CAH) failed to ensure a complete, accurately documented medical record for 1 of 1 swing bed death record reviewed (Patient #20). Failure to ensure a complete and accurate medical record limits the CAH's ability to ensure quality of care.

Findings include:

The policy titled "DEAD, CARE OF" occurred on 04/27/16. The policy, revised in February 2015, stated," . . . PROCEDURE: 1. Observe and record absence of vital signs, color, pupil dilation, etc. . . ."

Review of Patient #20's closed swing bed record occurred on 04/25/16. A family nurse practitioner (FNP) discharge note, dated 03/07/16 at 6:26 a.m., identified the patient expired from cardio pulmonary arrest. The electronic record lacked documentation from a nurse at the time of the resident's death.

During an interview on 04/26/16 at 8:30 a.m. an administrative nurse (#1) stated staff complete death documentation on paper. Later that day the nurse provided a "DEATH DOCUMENTATION CHECK LIST" for Patient #20. The checklist showed Patient #20 expired at the CAH on 03/07/16 at 1:50 a.m., but lacked evidence a nurse observed the patient or assessed vital signs, color, or pupil dilation at the time of the patient's death.

During an interview on 04/27/16 at 10:30 a.m. an administrative nurse (#1) confirmed the record lacked documentation of an assessment by a nurse at the time of Patient #20's death.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure staff developed a comprehensive and individualized care plan for 9 of 12 swingbed patients' (Patients #1, #2, #3, #5, #6, #7, #9, #10, and #11) records reviewed. This failure limited staff members' ability to ensure continuity of care for the patients.

Based on review of the North Dakota Department of Health, Division of Health Facilities provider files, this CAH has not sustained correction of this issue. The previous survey completed on May 09, 2012 found this requirement out of compliance.

Findings include:

- Patient #1's active medical record, reviewed on 04/25/16, identified the patient had diabetes. Recent orders as of 03/24/16 showed blood glucose checks twice a week and scheduled Levemir insulin administration twice a day. The patient's current care plan failed to identify diabetes and lacked individualized interventions to address this issue.

- Patient #2's active medical record, reviewed on 04/26/16, identified the patient had diabetes. Recent orders as of 02/24/16 showed blood glucose checks weekly and scheduled Metformin administration twice a day. The patient's current care plan failed to identify diabetes and lacked individualized interventions to address this issue.

- Patient #3's active medical record, reviewed on 04/27/16, identified the patient had a right knee revision. The record listed the following permitted activities for the patient: immobilizer to right knee at all times, weight bearing as tolerated, and no active range of motion to right knee for four to six weeks. The patient's current care plan failed to identify and address this issue.

During an interview on the morning of 04/27/16, an administrative nurse (#1) agreed the care plans for Patients #1, #2, and #3 failed to address identified issues and lacked individualized interventions.

- Patient #5's active medical record, reviewed on 04/26/16, identified a diagnosis of seizure disorder. The record showed Patient #5 received the following medications for the seizure disorder: Phenobarbital 64.8 milligrams (mg) twice a day and Phenytoin 100 mg twice a day. Patient #5's current care plan failed to identify the seizure disorder and lacked individualized interventions to address the disorder, including interventions to keep the patient safe if he experienced a seizure.

- Patient #6's active medical record, reviewed on 04/26/16, identified a diagnoses of diabetes. The record indicated Patient #6 received Novalin insulin and Januvia (an oral diabetic medication) daily for the diabetes. The record also showed staff performed weekly blood glucose monitoring for Patient #6. The patient's current care plan failed to identify the diabetes and lacked individualized interventions to address the diabetes and possible alterations in blood glucose levels.

- Patient #7's active medical record, reviewed on 04/26/16, identified the patient had a chronic rash on her back. Physician's notes, dated 02/14/16 and 04/21/16 addressed treatment of the rash. The patient's current care plan failed to identify the rash and lacked interventions staff should implement for the chronic rash.

- Patient #9's active medical record, reviewed on 04/27/16, identified diagnoses including congestive heart failure (CHF) and anasarca (severe generalized edema) and indicated Patient #9 had an indwelling Foley catheter. The patient's current care plan failed to identify the CHF and anasarca and lacked individualized interventions staff should implement for those diagnoses. The care plan also failed to identify use of the Foley catheter and lacked interventions for care of the catheter.

- Patient #10's active medical record, reviewed on 04/27/16, identified a diagnosis of diabetes and indicated the patient received Lantus insulin daily. The record also showed staff performed daily blood glucose monitoring. Patient #10's current care plan failed to identify the diabetes and lacked interventions staff should implement for the diabetes and for possible alterations in blood glucose levels.

- Patient #11's active medical record, reviewed on 04/27/16, identified a diagnosis of diabetes and indicated the patient received Levemir insulin twice a day and Humalog insulin three times a day for the diabetes. The record also showed staff performed twice daily blood glucose monitoring for Patient #11. Patient #11's current care plan failed to identify the diabetes and lacked interventions staff should implement for the diabetes and for possible alterations in blood glucose levels.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to prepare, review, and/or revise the comprehensive care plan for 2 of 12 active swing bed patients' (Patient #3 and #6) records reviewed. This failure limited the CAH's ability to ensure all professional disciplines worked together to develop a plan, providing the greatest benefit to the patient and ensure staff provided the necessary care and services to meet the patients' needs.

Findings include:

- Patient #3's active medical record, reviewed on 04/27/16, identified the CAH admitted the patient on 04/07/16 with revision of the right knee. Record review showed an order for physical and occupational therapy evaluations, which occurred on 04/08/16 and 04/12/16 respectively, and identified the two disciplines currently provided services to Patient #3. The patient's current care plan failed to identify the services or treatment provided to Patient #3 from the therapists and lacked collaboration from the interdisciplinary team to the therapists.

During an interview on the morning of 04/27/16, two administrative nurses (#1 and #4) confirmed staff failed to recognize the collaborated efforts for completion of an interdisciplinary comprehensive care plan for Patient #3.

- Patient #6's active medical record, reviewed on 04/26/16, identified, on 04/15/16 at 5:15 a.m. staff found the patient on the floor by his bed and indicated Patient #6 had no injury from the fall. The record showed staff submitted a "work order" to have a bottom rail placed on the bed due to the patient lying on his side close to the edge of the bed.

Observation, on 04/26/16 at 5:00 p.m. with a staff nurse (#3), showed upper quarter rails elevated on both sides of Patient #6's bed. The nurse picked up a lower rail which leaned against the bedside stand and placed it in position on the lower edge of the bed on the exit side. Observation showed the rail approximately 8-10 inches wide. The nurse (#3) stated staff use the rail only at night because Patient #6 lies near the edge on that side of the bed when he sleeps.

Patient #6's current care plan, dated 10/01/15, stated, "Patient will remain injury free during hospitalization . . . Patient will remain safe in bed with use of one upper rail or less . . ." The record lacked evidence staff revised Patient #6's care plan when they implemented the lower side rail for the patient.

During an interview, on 04/27/16 at 10:00 a.m. an administrative nurse (#1) stated staff are to update patients' care plans on a monthly basis.