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Based on policy review and interview, the CAH (Critical Access Hospital) failed to ensure the pharmacy's policies regarding first dose review were written and implemented based on accepted professional principles. This deficient practice was evidenced by failing to ensure all prescriber's nonemergent medication orders were reviewed for appropriateness by a pharmacist before the first dose of ordered medications were dispensed in the Emergency Department.

Findings:
Review of the Louisiana Administrative Code, Title 46 Professional and Occupational Standards, Part LIII Pharmacist, Chapter 15 Hospital Pharmacy, Section: 1511: Prescription Drug Orders, Item A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency.

Review of the Hospital's policy #045-02A for the Department of Pharmacy revealed in part,"Policy: 1) All medication first does orders will be reviewed by a licensed pharmacist for appropriateness before being dispensed in the medical surgical unit of the hospital. 2) a licensed practitioner can review first dose medications in the following situations:
-in emergency/crisis situation when a pharmacist review would delay and possibly harm the patient
-an practitioner controls the ordering, preparation and administration....
Emergency Department (ED) 1) Medications ordered in Hood Memorial ED will be excluded from pharmacy first dose review since a licensed physician is on staff in that department."

An interview was conducted with S11Pharm on 7/31/19 at 2:30 p.m. He reported first dose review was not performed on medications administered in the ED since there was a physician present at all times.


30984

Based on observations and interviews, the CAH (Critical Access Hospital) failed to implement measures to ensure the provision of a safe environment consistent with nationally recognized infection control practices as evidenced by:
1. failure to ensure the hospital's glucose meter was disinfected between each patient use for 2 (#1, #2) of 2 patients observed for capillary blood glucose sampling from a total patient sample of 25 patients (#1-#25) ;

2. failure to ensure proper PPE (faceshield) was donned by nursing staff (S16RN) when removing a patient from hemodialysis for 1 (#2) of 1 patients observed receiving hemodialysis from a total patient sample of 25 (#1-#25); and

3. failure to ensure a current TB test, in accordance with the OPH guidelines, was documented for 2 (S14SO, S15SO) employee/contract staff personnel files reviewed for TB test results.

Findings:


1. Failure to ensure the hospital's glucose meter was disinfected between each patient use.

Review of CAH policy titled "Blood Glucose Monitoring" presented as current policy revealed in part, all testing shall be performed in accordance with the Standard Precautions for the handling of bloody and body fluids.

Review of the glucometer manual revealed to disinfect the glucometer, using a fresh wipe, make sure all outside surfaces of the meter remain wet for 2 minutes, remove gloves and wash hands, and let the meter air dry thoroughly before putting it away or using to test.

An observation made on 07/29/19 at 11:20 a.m. of S5LPN performing capillary blood glucose sampling on Patient #2, who was on contact isolation. S5LPN was observed entering the patients' room with gloves on and with the COW. Once she was in Patient #2's room, S5LPN placed the glucometer on the patient's bedside table. During the testing, she placed the glucometer on the patient's bed. After the capillary blood glucose sampling/testing was completed, S5LPN placed the glucometer in the nylon case on the COW. She then was observed removing her gloves and performing hand hygiene. She then cleaned the COW and entered Patient #1's room with the COW at 11:26 a.m. She applied gloves and wiped the glucometer with a disinfectant wipe. She only allowed 40 seconds after wiping the glucometer before placing the glucometer on Patient #1's bed and performing capillary blood glucose sampling on Patient #1. After the capillary blood glucose sampling/testing was completed, S5LPN placed the glucometer in the nylon case on the COW. She then was observed removing her gloves and performing hand hygiene.

In an interview on 07/29/19 with S2DON, he verified they do have a problem with not disinfecting the glucometer appropriately between each patient use. He further revealed the disinfectant should have stayed on the glucometer for 2 minutes before use on another patient in order to effectively disinfect the glucometer.


2. Failure to ensure proper PPE (faceshield) was donned by nursing staff ( S16RN) when removing a patient from hemodialysis.

Review of the CAH policy titled," Isolation Precautions", revealed in part: Masks/Face Shields/Goggles: To be worn when performing procedures that may be likely to generate splashes or sprays of blood, body fluids, secretions or excretions. These PPEs will protect the mucous membranes of the eyes, nose, and mouth.

On 7/29/19 at 10:35 a.m. an observation was made of S16RN removing Patient #2 from hemodialysis treatment. S16RN disconnected the hemodialysis bloodlines from Patient #2's central venous catheter access. S16RN failed to don a face shield when disconnecting the patient's access from the bloodlines, potentially exposing herself to blood spray/splashes.

In an interview on 7/29/19 at 10:45 a.m. with S2DON (present during the observation), he confirmed S16RN should have worn a face shield when removing Patient #2 from hemodialysis due to the potential for exposure to blood spray/spashes during the procedure.


3. Failure to ensure a current TB test, in accordance with the OPH guidelines, was documented for employee/contract staff.

Review of the Louisiana Administrative Code, "Chapter 5. Health Examinations for Employees, Volunteers and Patients at Certain Medical and Residential Facilities" revealed all persons prior to or at the time of employment at any medical or 24-hour residential facility requiring licensing by the Louisiana Department of Health shall be free of tuberculosis in a communicable state as evidenced by either: 1) a negative PPD skin test given by the Mantoux method or a blood assay for Mycobacterium tuberculosis; 2) a normal chest x-ray if the skin test or blood assay is positive; or 3) a statement from a licensed physician certifying the individual is non-infectious if the x-ray is other than normal. In order to remain employed, the individual shall be rescreened annually by one of the following methods: purified protein derivative skin test for TB given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration remains negative, or a completed questionnaire asking of the person pertinent questions related to active TB symptoms, including, but not limited to: do you have productive cough that has lasted at least 3 weeks, are you coughing up blood, have you had an unexplained weight loss recently, have you had fever, chills, or night sweats for 3 or more days. Any employee converting from a negative to a positive skin test for TB or a blood assay or having indicated symptoms of active TB revealed by the completed questionnaire shall be referred to a physician and followed as indicated.

Review of personnel files for S14SO and S15SO revealed no documented evidence of a current TB test result.

In an interview on 07/31/19 at 9:30 a.m. with S12QA and S17HR, they confirmed there were no TB test results documented in S14SO and S15SO's personnel files.


39791

Based on record review and interview the CAH failed to ensure nursing services meet the needs of the patient as evidenced by:
1. Failure to provide wound care as ordered by the physician for 2 (Patient #20 and #21) patients out of total of 13 patients with orders for wound care.
2. Failure of the nurse to perform wound assessments each time the patient's wound care was performed for 3 (#15, #20 and #21) out of 13 patients with orders for wound care.
3. Failure of the nursing staff to ensure all contracted law enforcement employees delegated the one-to-one observation of patients under a PEC received training for crisis prevention and intervention for 2 (S14SO, S15SO) out of 2 contracted law enforccement personnel files reviewed for crisis prevention and intervention.
4. Failure of the nursing staff to receive respiratory training for 4 (S5LPN, S6RN, S7RN, S8RN) out of 4 staff nurse personnel files reviewed for respiratory training.
Findings:

1. Failure to provide wound care as ordered by the physician for 2 out of 13 patients with wounds.

Review of the Hospital's Wound Assessment policy revealed in part, "Photographs and measurement will be completed within 24 hours of admission and once a week thereafter. Each time a dressing change is performed there should be documentation in the Wound Care flow sheet, after wound assessment. This can be done by the RN or LPN assigned to the patient."

Patient #20
Review of Patient #20's medical record revealed an admission date of 7/05/19 with an admit diagnosis of Stage IV sacral wound.

Review of Patient #20's physician's order revealed the following order for wound care, dated 7/26./19: Wound Care: Clean with NS, apply promogran and mepilex, every MWF and prn soiling, Mist therapy twic a week. Review of the electronic medical record, assisted with S3RN, revealed wound care was not performed as order on 7/29/19. The last wound care documented was on 7/26/19.

Patient #21
Review of Patient#21's medical record revealed an admission date of 7/17/19 with a diagnosis of Lower Extremity Wounds.

Review of the Patient #21's physician's order revealed the following order for wound care order, dated 7/29/19; Lt Lat LE: Cln W/NS, Promogran prn, Mepilex 3x/wk. Rt 1stMet/Great Toe TipL Cln w/NS, Promogram prn, Mepilex 3x/wk Santly prn. The last wound care was documented 7/26/19 and wound care was not performed on 7/29/19, Monday, as ordered.

An interview was conducted with S3RN on 7/31/19 at 9:00 a.m. She confirmed wound care was not done on the above patients due to the wound care nurse being absent on 7/29/19, but she confirmed the patients' assigned nurses should have provided the wound care.

An interview was conducted with S2DON on 7/30/19 at 2:00 p.m. He confirmed the hospital needed another wound care nurse to perform wound care when the current wound care nurse was on leave.

2. Failure of the nurse to perform wound assessments each time the patient's wound care was performed.

Patient #15
Review of Patient #15's medical record revealed an admission date of 7/17/19 with an admit diagnosis of non-healing wound to left lower extremity. The patient was admitted for wound care.

Review of Patient #15's physician's orders revealed the following order for wound care, dated 7/17/19: Cleanse with Normal Saline, Mepilex AG to fit wounds, 3 layer compression every Monday, Wednesday, and Friday.

Review of Patient #15's electronic medical record, assisted S9LPN, revealed the following wound assessment documentation: Initial assessment dated 7/17/19 at 11:00 a.m.: Wound measured, blister venous stasis ulcer.

Further review of Patient #15's medical record revealed the following wound documentation:

7/19/19 at 11:00 a.m.: Treatment performed as ordered, dressing changed. Further review revealed no documented evidence of a description of the appearance or any characteristics of the wound such as size, color, tissue type, presence/absence of drainage, or presence/absence of odor.

7/24/19 at 11:39 a.m.: Wound care provided, dressing changed. Further review revealed no documented evidence of a description of the appearance or any characteristics of the wound such as size, color, tissue type, presence/absence of drainage, or presence/absence of odor.

7/26/19 at 2:25 p.m.: Wound care provided, dressing changed. Further review revealed no documented evidence of a description of the appearance or any characteristics of the wound such as size, color, tissue type, presence/absence of drainage, or presence/absence of odor.

In an interview on 7/30/19 at 12:44 p.m. with S9LPN, she confirmed the above referenced wound dressing change documentation failed to include documentation of the appearance and characteristics of the wound.

Patient #20
Review of Patient #20's medical record revealed an admission date of 7/05/19 with an admit diagnosis of Stage IV sacral wound.

Review of the Electronic Medical Record, assisted with S3RN revealed the last wound assessment was 7/26/19.
The wound assessment revealed a sacrum pressure ulcer that measured 2.5 cm X 1.5 c.m.X 2 cm.

Patient #21
Review of Patient#21's medical record revealed an admission date of 7/17/19 with a diagnosis of Lower Extremity Wounds.

Review of the Patient #21's physician's order revealed the following order for wound care order, dated 7/29/19; Lt Lat LE: Cln W/NS, Promogran prn, Mepilex 3x/wk. Rt 1stMet/Great Toe TipL Cln w/NS, Promogram prn, Mepilex 3x/wk Santly prn.

Review of Patient #21's medical record revealed the last wound assessment was document on 7/26/19 with the last wound care treatment.

An interview was conducted with S3RN on 7/31/19 at 9:00 a.m. She reported a wound assessment should have been conducted on 7/29/19 with the ordered dressing change and treatment for Patient #20 and Patient #21.

In an interview on 7/30/19 at 3:55 p.m. with S2DON, he agreed the appearance of wounds, including drainage, odor, color, and tissue type, should have been documented with each dressing change. He indicated it appeared a description of the wound's appearance and characteristics was only being documented once a week when the wound care nurse had been assessing and measuring the wounds.

In an interview on 7/31/19 at 10:46 a.m. with S3RN, Unit Nursing Manager, she confirmed the staff nurses were not performing/documenting wound assessment when they were performing dressing changes between assessments by the wound care nurse (performed once a week). She agreed descriptions of the appearance and characteristics of wounds should have been documented with every dressing change because wound status can change quickly.


3. Failure of the nursing staff to ensure all contracted law enforcement employees delegated the one-to-one observation of patients under a PEC received training for crisis prevention and intervention.

In an interview on 7/30/19 at 11:00 a.m. with S2DON, whom is also the nurse manager of the Emergency Department, he revealed Hospital"A" has a contract with TPSO. He further stated in the event a patient in the Emergency Department had a PEC, the TPSO was assigned to watch the PEC patient.

On 7/31/19 at 9:30 a.m. a review of 2 (S14SO, S15SO) TPSO personnel files with S12QA and S17HR failed to reveal they were awarded a certificate for "De-escalation" training. S12QA and S17HR verified these findings.


4. Failure of the nursing staff to receive respiratory training.

In an interview on 7/30/19 at 11:30 a.m. with S18RT, he stated that a Respiratory Therapist is on call during the night and the nursing staff is responsible for respiratory patient cares which include oxygen therapy and breathing treatments between 11:00 p.m. to 6:00 a.m.

In an interview on 7/31/19 at 8:05 a.m. with S18RT, he stated he stopped training nurses in 2017 on respiratory treatments.

On 7/31/19 at 9:00 a.m. a review of the nurse personnel files with S12QA and S17HR revealed no documented evidence of a current respiratory competence test was presented for S5LPN, S6RN, S7RN, and S8RN. S12QA and S17HR verified these findings.



30984




39791

Based on record reviews and interviews, the CAH (Critical Assess Hospital) failed to ensure all drugs, biologicals and intravenous medications were prepared by accepted standards of practice and within the scope of practice of the RN in Louisiana as evidenced by RNs mixing and preparing IV medications/solutions in non-emergency situations, outside of their scope of practice. Findings:

Review of an opinion statement by the Louisiana State Board of Nursing in Volume 26 No. 3 of The Examiner revealed in part, "Louisiana State Board of Nursing (LSBN) has received inquiries regarding APRN 's authority to mix or compound IV solutions. The following is presented for clarification. Firstly due to current state and federal laws and rules relative to compounding, LSBN generally considers mixing or otherwise preparing IV solution in non-emergency circumstances as a prohibited act for all of its licensees. Activating/reconstituting a drug in a sterile closed system transfer device or adding diluents directly and in accordance with the direction contained in approved labeling provided by the product's manufacturer's allowed when prepared for immediate administration to an individual patient. Compounding IV therapies or adding a medication, vitamin or other substance or additive to IV solution is allowed in Louisiana when performed by registered practitioners of pharmacy, medicine, dentistry, or veterinary medicine. RNs and APRN's in Louisiana are prohibited from compounding or otherwise mixing drugs, including IV substances and solutions in non-emergent/non-life threatening circumstances as described above even when compounding or otherwise mixing such substances is prescribed or delegated by an authorized practitioner of pharmacy, medicine, dentistry or veterinary medicine."

Review of Policy # 045-018 for Compounding for the Department of Pharmacy, revealed in part: 2. All reconstitutions of sterile injectable medications will be done by the Pharmacist when on duty. When the pharmacist is not available, the RN will reconstitute and prepare medications according to current policy and procedures of the department of nursing and pharmacy.

Review of the Policy #3017 Medication Administration/ Emergency Department revealed in part: Any medication that require reconstituting, including admixtures i.e. (Piggy backs) and IM injection, may be performed by nurse on unit after competency is completed by nursing services and pharmacy. The reconstitution will be performed in clean well-lit areas using aseptic technique.

An interview was conducted with S6RN on 7/29/19 at 2:30 p.m. She reported she was the charge nurse of the Emergency Room on this current shift. She reported after pharmacy hours (usually after 4 p.m. daily) if certain medication and IV solutions needed to be prepared the registered nurse would prepare the IV solutions/medications in the medicine room on the unit. S6RN presented to the surveyor the notebook the nurses used for directions on how to mix the different medications and solutions. S6RN stated that the nurses do mix "Banana Bags" of IV fluids occasionally if ordered when the pharmacy is closed.

An interview was conducted with S11Pharm on 7/29/19 at 3:15 p.m. He reported Pharmacy hours are Monday through Friday 7:30 a.m. to 3:30 p.m. with the pharmacist on call after the pharmacy is closed.

Review of the medication mixture notebook S6RN, ED presented as the directions on how to mix specific medications revealed in part, "Banana bag- 2 grams Mag sulfate, 1 vial MVI, 100 mg Thiamine, In 1LNS over 4 hours.

An interview was conducted with S2DON on 7/29/19 at 3:00 p.m. During the interview, S2DON provided a list of medications that the emergency room nurses have mixed in the last 7 months.

Review of the list of medication/solutions emergency room nurses have had to prepare and administer in the last 7 months revealed the following medications had been prepared:

Medication Diluent/volume Rate Storage Stability
Ceftriaxone/Rocephin 1 gm NS or D5W/50 ml 20 min refrigerate 10 days
Diltiazen/Cardizem 125mg NS or D5W/100 ml titrate room temp immediate use
Piperacillin-Tazobactam/Zosyn 4.5 mg NS or D5W/100 ml 60 min refrigerate 7 days
Dobutamine/Dobutrex 500 mg NS or D5W/250ml titrate room temp 7 days
Vancomycin 2 gm NS or D5W500ml 240 min refrigerate 7days

An interview was conducted with S11Pharm on 7/31/19 at 2:30 p.m. S11Pharm confirmed the nurses were mixing medications in the Emergency Department if the medication was administered within one hour or the beginning of the administration was within one hour of preparation.

Based on record review and interview the CAH (Critical Access Hospital) failed to develop and keep a current nursing care plan for 5 (#1, #2, #3 #16, #17) of 5 patients reviewed for care plans from a total patient sample of 25 (#1-#25) .

Findings:

Patient #1
Review of Patient #1's medical record revealed an admission date of 7/11/19. Further review revealed Patient #1 was admitted for wound care and strengthening. Additional review revealed Patient #1 was being treated with hemodialysis for renal failure, was receiving Lovenox (anti-coagulant) injections for DVT prophylaxis, had an indwelling central venous catheter access for Hemodialysis, and had a co-morbid diagnosis of Diabetes Mellitus.

Review of Patient #1's plan of care revealed hemodialysis, central venous access care/maintenance, risk for bleeding related to anticoagulant therapy, and Diabetes Mellitus were not addressed as identified problems on the patient's plan of care.

Patient #2
Review of Patient #2's medical record revealed an admission date of 7/8/19. Further review revealed Patient #2 was admitted for antibiotic therapy (infected shunt) and PT/OT. Additional review revealed Patient #2 was being treated with hemodialysis for renal failure, was receiving Plavix (anti-coagulant), had an indwelling tunneled catheter access for Hemodialysis, and had co-morbid diagnoses of Diabetes Mellitus and Anemia.

Review of Patient #2's plan of care revealed hemodialysis, risk for bleeding related to anticoagulant therapy, tunneled catheter access care, Diabetes Mellitus, and Anemia were not addressed as identified problems on the patient's plan of care.

Patient #3
Review of Patient #3's medical record revealed an admission date of 7/8/19. Further review revealed Patient #3 was admitted for wound care (right lower extremity wound) and antibiotic therapy. Additional review revealed Patient #3 had co-morbid diagnoses of Diabetes Mellitus and Atrial Fibrillation. Further review revealed Patient #3 was on Eliquis (anti-coagulant) and telemetry (cardiac monitor).

Review of Patient #3's plan of care revealed impaired skin integrity and infection. Diabetes Mellitus, Atrial Fibrillation, and risk for bleeding related to anticoagulant therapy were not addressed as identified problems on the patient's plan of care.


Patient #16
Review of Patient #16's medical record revealed an admission date of 7/8/19. Further review revealed Patient #16 was admitted for treatment of altered mental status due to hepatic encephalopathy. Additional review revealed Patient #16 had a co-morbid diagnosis of Diabetes Mellitus.

Review of Patient #16's plan of care revealed altered mental status and Diabetes Mellitus were not addressed as identified problems on the patient's plan of care.

Patient #17
Review of Patient #17's medical record revealed an admission date of 7/19/19. Further review revealed Patient #17 was admitted for treatment of Hypoxia, Pulmonary Fibrosis, and acute on chronic Respiratory Failure. Additional review revealed Patient #17 had co-morbid diagnoses of Anxiety and lower extremity edema.

Review of Patient #17's plan of care revealed Anxiety and lower extremity edema were not addressed as identified problems on the patient's plan of care.

In an interview on 7/30/19 at 2:00 p.m. with S9LPN (chart navigator) she confirmed all patient diagnoses had not been addressed on the above referenced patients' plans of care.

Based on record review and staff interview, the CAH (Critical Access Hospital) failed to ensure the quality assurance (QA) program was effective. This deficient practice is evidenced by failure of the QA program to identify survey identified problems in wound care performance and wound assessments, failure to identify nurses compounding IV medications and IV's fluids with admixtures were practicing outside of their scope of practice, and failure to identify nursing staff had no documented respiratory training and skills competency evaluations for respiratory services they performed.

Findings:

Survey identified problems with wound care performance and wound assessments:

Review of sampled Patients #20 and #21 records on 7/30/19 revealed those patients' wound care was not performed as ordered on 7/29/19.

An interview was conducted with S3RN on 7/31/19 at 9:00 a.m. She confirmed wound care was not done on the above patients due to the wound care nurse being absent on 7/29/19, but she confirmed the patients' assigned nurses should have provided the wound care.

An interview was conducted with S2DON on 7/30/19 at 2:00 p.m. He confirmed the hospital needed another wound care nurse to perform wound care when the current wound care nurse was on leave.


Review of sampled Patients #15, #20 and #21 revealed wound assessments were not documented when each dressing change was performed resulting in the appearance and character of wounds only being assessed and documented on once a week when the wound care nurse performed wound care assessments and measured wounds.

An interview was conducted with S3RN on 7/31/19 at 9:00 a.m. She reported a wound assessment should have been conducted on 7/29/19 with the ordered dressing change and treatment for Patient #20 and Patient #21.

In an interview on 7/30/19 at 3:55 p.m. with S2DON, he agreed the appearance of wounds, including drainage, odor, color, and tissue type, should have been documented with each dressing change. He indicated it appeared a description of the wound's appearance and characteristics was only being documented once a week when the wound care nurse had been assessing and measuring the wounds.

In an interview on 7/31/19 at 10:46 a.m. with S3RN, Unit Nursing Manager, she confirmed the staff nurses were not performing/documenting wound assessment when they were performing dressing changes between assessments by the wound care nurse (performed once a week). She agreed descriptions of the appearance and characteristics of wounds should have been documented with every dressing change because wound status can change quickly.


Survey identified problem with nurses practicing outside of their scope of practice by compounding IV medications and IV's fluids with admixtures.


Review of an opinion statement by the Louisiana State Board of Nursing in Volume 26 No. 3 of The Examiner revealed in part, "Louisiana State Board of Nursing (LSBN) has received inquiries regarding APRN 's authority to mix or compound IV solutions. The following is presented for clarification. Firstly due to current state and federal laws and rules relative to compounding, LSBN generally considers mixing or otherwise preparing IV solution in non-emergency circumstances as a prohibited act for all of its licensees. Activating/reconstituting a drug in a sterile closed system transfer device or adding diluents directly and in accordance with the direction contained in approved labeling provided by the product's manufacturer's allowed when prepared for immediate administration to an individual patient. Compounding IV therapies or adding a medication, vitamin or other substance or additive to IV solution is allowed in Louisiana when performed by registered practitioners of pharmacy, medicine, dentistry, or veterinary medicine. RNs and APRN's in Louisiana are prohibited from compounding or otherwise mixing drugs, including IV substances and solutions in non-emergent/non-life threatening circumstances as described above even when compounding or otherwise mixing such substances is prescribed or delegated by an authorized practitioner of pharmacy, medicine, dentistry or veterinary medicine."

Review of Policy # 045-018 for Compounding for the Department of Pharmacy, revealed in part: 2. All reconstitutions of sterile injectable medications will be done by the Pharmacist when on duty. When the pharmacist is not available, the RN will reconstitute and prepare medications according to current policy and procedures of the department of nursing and pharmacy.

Review of the Policy #3017 Medication Administration/ Emergency Department revealed in part: Any medication that require reconstituting, including admixtures i.e. (Piggy backs) and IM injection, may be performed by nurse on unit after competency is completed by nursing services and pharmacy. The reconstitution will be performed in clean well-lit areas using aseptic technique.

An interview was conducted with S6RN on 7/29/19 at 2:30 p.m. She reported she was the charge nurse of the Emergency Room on this current shift. She reported after pharmacy hours (usually after 4 p.m. daily) if certain medication and IV solutions needed to be prepared the registered nurse would prepare the IV solutions/medications in the medicine room on the unit. S6RN presented to the surveyor the notebook the nurses used for directions on how to mix the different medications and solutions. S6RN stated that the nurses do mix "Banana Bags" of IV fluids occasionally if ordered when the pharmacy is closed.

Review of the medication mixture notebook S6RN, ED presented as the directions on how to mix specific medications revealed in part, "Banana bag- 2 grams Mag sulfate, 1 vial MVI, 100 mg Thiamine, In 1LNS over 4 hours.

An interview was conducted with S2DON on 7/29/19 at 3:00 p.m. During the interview, S2DON provided a list of medications that the emergency room nurses have mixed in the last 7 months.

Review of the list of medication/solutions emergency room nurses had prepared and administered in the last 7 months revealed the following medications had been prepared and administered:
Ceftriaxone/Rocephin 1 gm
Diltiazen/Cardizem 125mg
Piperacillin-Tazobactam/Zosyn 4.5 mg
Dobutamine/Dobutrex 500 mg
Vancomycin 2 gm

An interview was conducted with S11Pharm on 7/31/19 at 2:30 p.m. S11Pharm confirmed the nurses were mixing medications in the Emergency Department if the medication was administered within one hour of preparation or the beginning of the administration was within one hour of preparation.


Survey identified problem with lack of documentation of respiratory skills competency evaluations for nursing staff performing respiratory care.

Review of personnel files for selected nursing staff (S5LPN, S6RN, S7RN, S8RN) who performed respiratory care revealed no documented evidence the referenced nursing staff had received respiratory training and no documented evidence of skills competency evaluations for performance of respiratory care.

The lack of documentation of respiratory training and evidence of skills competency training was verified by HR staff who assisted with personnel record review.

Review of the hospital's performance indicators, presented as current by S12QA, revealed survey identified problems in wound care performance and wound assessments, nurses compounding IV medications and IV's fluids with admixtures resulting in nurses practicing outside of their scope of practice, and nursing staff having no documented respiratory training and skills competency evaluations for respiratory services they performed were not
identified as areas in need of improvement to be addressed through the hospital's QAPI program.

In an interview on 7/31/19 at 2:30 p.m. with S12QA, she confirmed the hospital's QA program had failed to identify the survey identified problems related to wound care performance and wound assessments, failed to identify nurses compounding IV medications and IV's fluids with admixtures were practicing outside of their scope of practice, and failed to identify nursing staff had no documented respiratory training and skills competency evaluations for respiratory services they performed as areas in need of improvement to be addressed through the hospital's QAPI program.

Based on record review and interview, the CAH failed to ensure the current Swing Bed Residents' Rights included the following rights: the right to request, refuse, and/or discontinue treatment, the right to formulate an advance directive; the right to choose his or her attending physician; the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement; the right to have access to stationery, postage, and writing implements at the resident's own expense.

Findings:

Review of the CAH's Swing Bed Residents' Rights, presented as the current document provided to Swing Bed residents, revealed no documented evidence that the following rights were included: the right to request, refuse, and/or discontinue treatment, the right to formulate an advance directive; the right to choose his or her attending physician; the right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement; the right to have access to stationery, postage, and writing implements at the resident's own expense.

In an interview on 7/30/19 at 2:00 p.m. with S2DON, he acknowledged the CAH's current Swing Bed Residents' Rights document was not inclusive of all Swing Bed Residents' Rights referenced in the CAH regulations.

Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure the Activity Director formulated activity care plans that were individualized and based upon identified preferences that supported swing bed residents' choices for activities for 3 (#1,#2, #15) of 3 (#1,#2, #15) sampled swing bed patients reviewed for activities care plans from a total patient sample of 25 (#1-#25).

Findings:

Review of the CAH policy titled," Swing Bed Activity Program", Reference: 8455, revealed in part: Purpose: To provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.
Policy: Upon admission of the patient, the Patient Activity Director will complete the Initial Activity Assessment and develop anActivity Care Plan for each patient within 7 days of admission.
The Patient Activity Director will: 1.... 2. Provide a plan of activities appropriate to the needs of the patient that includes, but is not limited to, group social activities; indoor and outdoor activities......; creative activities such as arts and crafts, music, drama, and educational programs; exercise activities; one to one attention, offered at hours convenient to the patients; reflects the cultural and religious interests of the patient population, and would appeal to both men and women, of all age groups.

Patient #1
Review of Patient #1's medical record revealed the patient was admitted to swing bed status on 7/11/19.

Further review of Patient #1's medical record revealed no documented evidence that an individualized activity care plan, based upon Patient #1's preferences for activities, had been developed.

Patient #2
Review of Patient #2's medical record revealed the patient was admitted to swing bed status on 7/8/19.

Further review of Patient #2's medical record revealed no documented evidence that an individualized activity care plan, based upon Patient #2's preferences for activities, had been developed.


Patient #15
Review of Patient #15's medical record revealed the patient was admitted to swing bed status on 7/20/19.

Further review of Patient #15's medical record revealed no documented evidence that an individualized activity care plan, based upon Patient #15's preferences for activities, had been developed.

In an interview on 7/31/19 at 10:10 a.m. with S4AD (Activities Director), she indicated she had been performing activities assessments on all swing bed patients. S4AD confirmed she had not been developing individualized activities care plans for each patient after identifying patients' activity preferences on the activity assessments.


39791