HospitalInspections.org

Based on policy review, observation, and staff interview, the Critical Access Hospital (CAH) failed to ensure the safety of patients, staff, and the public by not securely storing 2 of 17 oxygen K-tanks (close to the doorway) in the oxygen storage room. Failure to secure oxygen tanks places any person in the vicinity at risk for injury should the tank fall or become damaged.

Findings include:

Review of the policy titled "Storage of Oxygen" occurred on 10/24/12 at approximately 2:45 p.m. This policy, dated 05/13/11, stated, ". . . Purpose: Proper storage of oxygen. . . . Procedure: . . . 4. Oxygen tanks will be kept in a carrier at all times, or secured with chains to the wall. . . ."

Observation, at approximately 10:20 a.m. on 10/24/12, identified two oxygen K-tanks stored unsecured on the floor by the doorway in the oxygen storage room.

During interview at approximately 10:20 a.m. on 10/24/12, an administrative maintenance staff member (#10) confirmed the CAH staff failed to store two oxygen tanks in a secure manner.

Based on bylaws review, meeting minutes review, record review, and staff interview, the Critical Access Hospital (CAH) failed to follow the medical staff bylaws for appointment and reappointment of medical staff for 8 of 9 providers' files reviewed (Providers #1, #2, #3, #4, #5, #6, #7, and #8) and for 27 of 28 teleradiologists (Providers #9-#35) providing services to the CAH. By failing to approve appointments and reappointments according to the CAH's bylaws, the medical staff and governing body did not ensure the providers possessed the necessary qualifications for medical staff membership.

Findings include:

Review of the "Cooperstown Medical Center Medical Staff Bylaws" occurred on 10/22/12. These bylaws, adopted 08/30/11, stated,
". . . Article III Medical Staff Membership . . .
Part B: Conditions of Appointment
Section 1. Conditions and Duration of Appointments . . .
Initial appointments shall be for a period of 90 days from the date of the applicant's approval by the Medical Staff and governing Board. At that point, the applicant's file will be reviewed again by the Medical Staff and if approved, appointment shall continue for a period of 2 years from the 90 day review date. Reappointment shall be for a period of not more than two (2) years. Appointments to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Board of Directors in accordance with these Bylaws. . . .
Article IV Initial Appointment
Part A: Application
Section 1. Information
Applications for appointment to the Staff shall be in writing, and shall be submitted on a form prescribed by the Board of Directors. The application shall require detailed information concerning the applicant's professional qualifications, which shall include:
a. The names of at least three (3) Health Care Providers or dentists who have had experience in observing and working with the applicant and who can provide adequate references pertaining to the applicant's professional competence and ethical character . . .
Part B. Procedure
a. The Medical Staff shall examine evidence of the professional competence, qualifications, character and ethical standing of the applicant and review the information from references given by the applicant and form other sources available, and shall determine whether the applicant has established and meets all the necessary qualifications for the category of Staff membership and clinical privileges requested. . . .
c. When the recommendation of the Medical Staff is favorable to the applicant, the Medical Staff shall make a written report and recommendations to appoint must also specifically recommend the clinical privileges to be granted . . .
Part C. Provisional Clause/Credentialing
a. All initial appointments to any category . . . of the Medical Staff shall be provisional for a period of 90 days. . . .
c. The performance of provisional staff members shall be observed by the Chief of Staff or a peer member of the Medical Staff appointed by him/her, to determine the clinical privileges provisionally granted to them. . . .
Article VI Scope of Clinical Privileges
Section 1. Application for Clinical Privileges
Every Health Care Provider practicing at this Hospital . . . shall . . . be entitled to exercise only those clinical privileges specifically granted to him/her by the Board of Directors. . . ."

Review of the governing board's "Amended Bylaws of the Cooperstown Medical Center" occurred on 10/23/12. These bylaws, effective 11/05/08, stated,
". . . Article VII. Medical Staff . . .
The medical staff shall make recommendations to the Board of Directors concerning the following:
a. Appointments, reappointments . . .
b. Granting of clinical privileges. . . ."

Review of the September 2011-2012 governing board's meeting minutes occurred on 10/23/12. The minutes, dated 01/30/12, stated Provider #1 started seeing patients on January 27, 2012.

Reviewed on October 23-24, 2012, the CAH's credentialing files indicated the following:

- For Provider #1, the medical staff approved appointment on 02/16/12 and the governing board approved appointment on 02/27/12 after Provider #1 had begun to treat patients on January 27, 2012.

- The CAH failed to initially appoint two providers for a provisional 90 day time period. Provider #1's file indicated the governing board approved appointment on 02/27/12. There was no evidence of reappointment after 90 days. Provider #2's file indicated the governing board approved appointment on 10/25/11. There was no evidence of reappointment after 90 days.

- The medical staff and governing board failed to approve the specific clinical privileges for initial appointment of Providers #1, #2, #4, and #5 and for reappointment of Providers #3, #5, #6, #7, and #8. There was no evidence in Provider #1, #2, #3, #4, #5, #6, #7, and #8's credentialing files of medical staff's recommendation or governing board's approval for clinical privileges.

- The CAH failed to obtain 2 of 3 required references for initial appointment of Provider #4.

- The CAH's credentialing files lacked evidence of credentialing for 27 teleradiologists (Providers #9 - #35). Upon request, the CAH's Radiology Supervisor provided a list of 28 teleradiologists providing services to the CAH's patients. The CAH did not provide evidence of credentialing 27 teleradiologists on the list.

During interview, at approximately 1:05 p.m. on 10/24/12, an assistant administrative staff member (#11) confirmed the following: Provider #1 had started treating the CAH's patients before the governing board approved initial appointment; the CAH did not appoint Providers #1 and #2 to a provisional 90 day initial appointment; medical staff and governing board did not approve the specific clinical privileges for Providers #1-#8; the CAH failed to obtain 2 of the required references before appointing Provider #4; and the CAH did not credential 27 teleradiologists.

1. Based on observation, review of medication error reports, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff safe and accurate distribution of drugs and biologicals on 3 of 3 days of survey (October 22-24, 2012). Failure to properly dispense drugs and biologicals limited the CAH's ability to ensure accurate and safe medication administration, prevented the pharmacy from maintaining control of medications, and allowed an opportunity for unsafe distribution of medications.

Findings include:

Review of the policy "Omnicell" occurred on 10/24/12. This policy, effective 09/15/10, stated, ". . . The Omnicell System will be used to store, distribute . . . medications stocked in the Hospital. . . . C. Medication Dispensing. 1. Use the global list to choose a patient. Verify that you have chosen the correct patient . . . and select remove meds. . . . 3. When Overriding Medications: No medications will be removed by a nurse from the Omnicell prior to entering . . . verbal order or verifying a written order is present for that drug in the medical record. . . . G. Stock Replenishment. 1. The Pharmacy will be responsible for maintaining adequate inventory of all medications in the Omnicell. 2. . . . The medications that are recorded as being low will be collected in the Pharmacy and will be delivered and refilled into the Omnicell. . . ."

Review of the CAH's medication error reports from the last six months (April through September 2012) occurred on 10/23/12. A report, dated 06/08/12, showed an incident in which a nursing staff member administered the wrong medication to a patient. The report stated, "Pt [patient] was given Amoxicillin [an antibiotic] instead of Azithromycin [another type of antibiotic]. Pt is listed as having an allergy to Amoxicillin, with symptoms being a rash. . . ."

- Observation during medication pass on 10/22/12 at 1:40 p.m., showed a nursing staff member (#8) entered the medication room and attempted to obtain a medication for Patient #1 from the Omnicell (an automated medication dispensing system). Patient #1's medication administration record (MAR) listed hydrocodone/APAP (acetaminophen) (a medication used to treat pain) 5/325 milligrams (mg) every four hours as needed. The nurse (#8) selected Patient #1's name in the Omnicell, approved an override function, typed in hydrocodone, and the Omnicell brought up two options for the medication: a 5/500 mg and 10/650 mg tablet. The nurse (#8) realized the two doses differed from what Patient #1's provider ordered, so she checked the medication cart and entered the pharmacy to see whether the patient had his own supply of hydrocodone/APAP within the CAH. Unable to find the ordered dose of the hydrocodone/APAP, the nurse (#8) chose to administer Patient #1 a different pain medication ordered by his provider.

Review of Patient #1's record occurred on October 22-23, 2012 and identified the CAH admitted the patient on 10/17/12. Patient #1's MAR showed he received one to three doses of hydrocodone/APAP 325 mg daily from October 18-21, 2012. On 10/24/12 at 2:45 p.m., an administrative nurse (#4) stated staff split a 10/650 mg tablet of hydrocodone/APAP in half to achieve the 5/325 mg dose administered as above, but provided no documentation to verify this took place.

- Observation during medication pass on 10/23/12 at 11:15 a.m., showed a nursing staff member (#9) entered the medication room and obtained medications for Patient #4 from the Omnicell. The nurse (#9) selected Patient #4's name in the Omnicell, approved an override function, and typed in the name of each medication to administer. The Omnicell brought up the name of the medication, but listed the medication in different doses and routes, leaving the decision up to the nurse as to which medication to choose.

During an interview on 10/22/12 at 1:45 p.m., a nurse (#8) stated the nurses performed an override on the Omnicell to pick and choose the correct medications for administration to patients. The nurse (#8) stated the CAH did not use the Omnicell properly or for its intended purpose.

A tour of the pharmacy took place with two administrative nurses (#3 and #4) on 10/23/12 at 2:35 p.m.. An administrative nurse (#4) stated staff faxed provider's medication orders to the consulting pharmacist for review, transcribed the medication order to the patient's MAR, and obtained the medication from the Omnicell for administration. The nurse (#4) confirmed staff dispensed medications for patients from the Omnicell by overriding the system, picking and choosing which medications to administer according to the order.

During an interview on 10/23/12 at 3:05 p.m., an administrative nurse (#3) stated the pharmacist does not enter each patient's ordered medications under the patient's name or profile into the Omnicell system as the process is lengthy. The nurse (#4) stated the pharmacist placed medications into unit doses marked with a barcode and left the medications in the pharmacy for the nurses to place or re-stock in the Omnicell and stated nurses re-stocked other medications which lacked the ability to be unit dosed in the Omnicell as well.

Allowing nursing staff to override and specifically choose the patient's medications from the Omnicell and re-stock medications in the Omnicell system limited the pharmacists' ability to ensure safe medication practices

2. Based on observation, review of the North Dakota Century Code, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to limit and prevent access to the hospital pharmacy by unauthorized personnel and document the removal of medications from the pharmacy for 1 of 1 hospital pharmacy. Failure of the CAH to adequately secure and restrict access to medications and document medication removal activity from the pharmacy allowed an opportunity for unsafe and unauthorized use of medication. This failure has the potential to create insufficient distribution, control, and accountability of medications.

Findings include:

The North Dakota Century Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-05. Absence of pharmacist. 1. General. During such times as a hospital pharmacy may be unattended by a pharmacist, arrangements must be made in advance . . . for the provision of drugs . . . in emergency circumstances, by access to the pharmacy . . . 3. Access to pharmacy. Whenever any drug is not available from floor supplies or night cabinets, and such drug is required to treat the immediate needs of a patient whose health would otherwise be jeopardized, such drug may be obtained from the pharmacy in accordance with the requirements of this section. One supervisory registered professional nurse and only one in any given eight-hour shift is responsible for removing drugs therefrom. The responsible nurse, in times of emergency, may delegate this duty to another nurse. The responsible nurse must be designated by position, in writing, by the appropriate committee of the hospital and, prior to being permitted to obtain access to the pharmacy, shall receive thorough education and training in the proper methods of access, removal of drugs, and records and procedures required. Such education and training must be given by the director of pharmacy, who shall require, at a minimum, the following records and procedures: a. Removal of any drug from the pharmacy by an authorized nurse must be recorded on a suitable form showing patient name, room number, name of drug, strength, amount, date, time, and signature of nurse. b. Such form must be left with the container from which the drug was removed, both placed conspicuously so that it will be found by a pharmacist and checked properly and promptly; or, in the case of a unit dose, place an additional dose of the drug, or the box, on the form. . . ."

Review of the policy "Pharmacy" occurred on 10/24/12. This policy, effective and revised on 12/14/10, stated, ". . . The Pharmacy is kept locked at all times. The Hospital Charge Nurse has a key, as well as the Unit Coordinator, DON [Director of Nursing], and facility Consultant Pharmacist. Hospital nurses will only access medications from the Pharmacy if they are unable to obtain them from the Omnicell. . . ."

Observation during medication pass on 10/22/12 at 1:40 p.m., showed a nursing staff member (#8) entered the medication room and attempted to obtain a medication for Patient #1 from the Omnicell. The nurse (#8) realized the Omnicell did not contain the medication she needed, nor did the medication cart, so she entered the pharmacy to obtain the medication. The nurse (#8) stated nurses used a key, kept on a key ring with other keys located in the medication cart, to enter the pharmacy and obtain medications when the medication is not available in the Omnicell or medication cart.

A tour of the pharmacy occurred on 10/23/12 at 2:35 p.m. with two administrative nurses (#3 and #4). Observation showed several different medications packaged in different doses in bottles, vials, and intravenous (IV) bags stored on the shelves and in the cupboards of the pharmacy. A nurse (#4) stated when a medication is unavailable in the Omnicell, the CAH allowed nursing staff to enter the pharmacy and remove medications.

During an interview on 10/23/12 at 3:05 p.m., an administrative nurse (#3) confirmed nursing staff removed medications from the pharmacy and did so in any amount and stated the CAH did not require the nurses to log (name/dose/amount of medication, name of person removing medication, etc.) removal of the medications from the pharmacy.

1. Based on observation, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care related to infection control practices observed during patient care on 2 of 3 days of survey (10/22/12 and 10/24/12). Failure to follow established infection control practices may allow transmission of organisms and pathogens from patients to staff, to other patients, or to visitors, and from one environment to another.

Findings include:

Review of the policy "Handwashing" occurred on 10/24/12. This policy, revised 03/16/11, stated, ". . . PURPOSE: The single most important measure in the prevention of spreading infections is handwashing. Proper handwashing helps prevent the spread of infection from person to person or from one part of the body to another. POLICY: Indications for Handwashing: . . . 3. Before and after resident/patient contact . . . 8. Before and after assisting a resident/patient with person care . . . 14. Before and after assisting a resident/patient with toileting . . . 17. After contact with a resident's/patient's mucous membranes and body fluids or excretions. 18. After handling soiled or used linens, dressings, bedpans, catheters and urinals . . . 20. After performing personal hygiene actions; 21. After removing gloves or aprons . . . 22. After completing duty . . . Sanitizing hand gel may be used in addition to proper handwashing . . . Hand gel is NOT APPROPRIATE when hands are visibly soiled. . . ."

Review of the policy "Glove Use" occurred on 10/24/12. This policy, revised 03/15/10, stated, ". . . PROCEDURE: . . . 4. Begin procedure. Remember that gloves should be removed and hands washed when the procedures are completed . . . It may also be necessary to change gloves and wash hands during the care of a single resident/patient . . . 7. Never wear clean or contaminated gloves in the hallway or away from resident/patient care areas. . . ."

- The following observations showed staff failed to perform hand hygiene after performing perineal cares and prior to moving onto other tasks and after patient contact:
*Observation on 10/22/12 at 1:02 p.m. showed two nurses (#7 and #8) entered Patient #1's room, donned gloves, and assisted the patient to transfer to the bedside commode. Patient #1 had a bowel movement on the commode and when finished, one nurse (#8) performed perineal cares and then both nurses (#7 and #8) assisted the patient to stand and walk back to his bed. One nurse (#8) changed her gloves, assisted the patient to a lying position, removed her gloves, boosted the patient up in bed, positioned him onto his right side, removed his slippers, covered the patient with a blanket, placed his nasal cannula, picked up a heat pack off the patient's bed, and then washed her hands prior to exiting the patient's room. The nurse (#8) failed to perform hand hygiene after performing perineal cares.
*Observation on 10/22/12 at 1:48 p.m. showed a nurse (#8) entered Patient #1's room, donned gloves, administered an intravenous medication, removed her gloves, and then exited the patient's room. The staff member (#8) failed to perform hand hygiene prior to exiting the patient's room.
*Observation on 10/24/12 at 8:45 a.m. showed a nurse (#6) donned gloves and assisted Patient #29 to the bathroom. The patient was incontinent of stool and had a bowel movement in the toilet. The nurse (#6) performed perineal cares, removed her gloves, assisted Patient #29 back to her bed, applied her stockings, handed the patient her glasses, assisted her to dress, donned gloves, bagged the garbage and soiled linen, and then exited the patient's room with the garbage bags and her gloves still on. The nurse (#6) failed to perform hand hygiene after performing perineal cares and prior to exiting the patient's room.

During an interview on 10/24/12 at 11:06 a.m., the infection control coordinator (#4) stated she expected staff to perform hand hygiene immediately after completing perineal cares and prior to moving on to other tasks.

2. Based on review of infection control reports and meeting minutes, record review, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases for outpatients of the CAH for the past 6 of 6 months (April 23, 2012 - October 23, 2012) reviewed. Failure to identify and address incidents of infections among all patients has the potential for infections to go unreported, spread, or reoccur; affecting the health of all patients, personnel, and visitors of the CAH.

Findings include:

- Reviewed on 10/24/12, the infection control program lacked evidence the CAH identified and recognized infections of outpatients (excluding procedure/treatment patients). The infection reports and meeting minutes from April through October 2012 failed to include information and documentation of outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on 10/24/12 at 10:30 a.m., the infection control coordinator (#4) stated she did not receive or request infection control information from outpatients, namely, the Emergency Room, cardiac rehabilitation, and occupational/physical therapy patients. The staff member (#4) confirmed the CAH did not formally document and include outpatients in infection control surveillance.

The failure to document and perform surveillance among all patients of the CAH, limited the CAH's ability to identify, monitor, track, control, and prevent infections.


28086

Based on observation, review of professional literature, policy and procedure review, record review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the safe use of side rails and consider side rails as a potential safety hazard for 4 of 4 active patients (Patients #1, #2, #3, and #4) observed with elevated side rails, and 8 of 22 closed patient (Patients #7, #8, #9, #11, #12, #13, #14, and #15) records reviewed; and failed to recognize the risks associated with falls and implement appropriate interventions to manage or prevent falls for 3 of 4 active patient (Patients #1, #3, and #4) records reviewed with a history of falls or who experienced a fall. Failure to evaluate the safe use of side rails, consider side rails as a potential safety hazard, recognize the risks associated with falls, and take action to manage or prevent falls caused an unsafe environment and placed Patients #1, #2, #3, #4, #7, #8, #9, #11, #12, #13, #14, and #15 at risk of injury.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings," dated April 2003, stated, ". . . CMS [Centers for Medicare and Medicaid Services] . . . issued guidance in June 2000 . . . 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. . . . patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over . . . may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised siderails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . . Use of bed rails should be based on patients' assessed medical needs and should be documented clearly . . . The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted . . . The care plan should include educating the patient about possible bed rail danger to enable the patient to make an informed decision . . . If a bed rail has been determined to be necessary, steps should be taken to reduce the known risks associated with its use. . . . Assessment of risk should be part of the individual patient's assessment, and steps to address the risk should be incorporated into the patient's care plan. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts," revised April 2010, stated, ". . . Potential risks of bed rails may include: . . . bodily injury . . . when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . . Most patients can be in bed safely without bed rails. Consider the following: Use beds that can be raised and lowered close to the floor . . . Keep the bed in the lowest position with wheels locked. When the patient is at risk of falling out of bed, place mats next to the bed . . . Monitor patients frequently. Anticipate the reasons patients get out of bed . . . meet these needs . . . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. . . . If patients or family ask about using bed rails . . . Reassure patients and their families that in many cases the patient can sleep safely without bed rails. Reassess the need for using bed rails on a frequent, regular basis."

Review of the policy "Acute Care Side Rail Use," occurred on 10/24/12. This policy, dated 12/02/08, stated, ". . . PURPOSE: To ensure side rails are used appropriately for all patients and that required documentation is complete. POLICY: Nurses . . . will complete a Side Rail Assessment on every patient admitted to the facility under Acute Care, Observation, Swing Bed . . . status. This assessment shall be initiated within 4 hours of the patient's admission. PROCEDURE: 1. Upon patient admission . . . nurses will begin assessing the need for side rails to be up or down on the patient's bed. . . . 3. Upon completion of the assessment form, the nurse . . . will place the decision made for side rail use on the Care Plan. Care Plan will include whether side rails are used per patient preference, for bed mobility, as seizure precautions, etc. . . . 5. Side Rail Assessment will be repeated if patient experiences an entrapment situation. . . ."

The "Acute Care Side Rail Assessment Form" included a decision tree with a track on the left side of the form stating, "Patient wants side rails UP x [times] 1, x2, x3, x4 (circle one). Is there a risk to the patient if side rails are up? . . ." If staff identified no risk, the form stated, ". . . 1. Side rails to remain UP x1, x2, x3, x4 (circle one). . . ." If staff identified risk, the decision tree moves to a track on the right side of the form which stated, ". . . Assess RISKS for side rails DOWN . . ." The Assessment Form failed to identify a more specific assessment of the side rails as potential safety issue for patients.

- Review of Patient #1's acute record occurred on October 22-23, 2012. The CAH admitted the patient on 10/17/12 with a diagnosis of pneumonia, including a history of a subdural hematoma and left chest wall contusion from a fall on 10/13/12 at the facility where Patient #1 resided. Patient #1's admission orders indicated staff assistance with activity and ambulation. Observation on 10/22/12 at 1:05 p.m., showed two nurses (#7 and #8) assisted Patient #1 from the commode in his room to the bed and identified the patient required extensive assistance from the nurses (#7 and #8) to reposition in bed comfortably due to pain. Upon settling Patient #1 into bed, the nurses (#7 and #8) elevated the upper two half side rails, which remained elevated while the patient rested in bed throughout the day. Review of a side rail assessment completed upon admission showed elevation of two side rails per Patient #1's wishes and indicated the elevated side rails were no risk to the patient, therefore, failing to assess the use of side rails any further. The CAH staff failed to consider the side rails as a risk and potential safety hazard for Patient #1.

Review of Patient #1's admission orders included a physical and occupational therapy consult and indicated "fall precautions." The admission history and physical (H&P) indicated a history of falls and subsequent provider progress notes showed Patient #1 as oriented to person, but not to place and time. Review of nursing assessments and patient care notes throughout Patient #1's hospital stay indicated the patient as weak, unsteady, and needing assistance with activity. The record lacked evidence of a fall risk assessment, interventions to prevent or minimize falls, and implementation of specific "fall precautions" as ordered by Patient #1's provider on admission.

- Review of Patient #2's observation record occurred on October 22-23, 2012 and identified the CAH admitted the patient on 10/21/12. Observation of Patient #2 on 10/22/12 while the patient rested in bed showed two elevated upper half side rails. A side rail assessment completed upon admission showed elevation of two side rails per Patient #2's wishes and indicated the elevated side rails were no risk to the patient, therefore, failing to assess the use of side rails any further. The CAH staff failed to consider the side rails as a risk and potential safety hazard for Patient #2.

- Review of Patient #3's acute record occurred on October 23-24, 2012 and identified the CAH admitted the patient on 10/07/12. Patient #3's chief complaints listed on the admission H&P included confusion, chronic pain, and falls. The admission H&P stated, ". . . he has been falling, unstable with difficulty for son to manage him with worsening confusion. . . . States chronic edema to the lower extremities with difficulty walking very far . . . is not completely oriented to day, date, and place and sone [sic] says that has been worsening over the past days. . . . Alert, but somewhat disoriented . . . history of falls the last few days. . . . his son . . . states he will likely leave AMA [against medical advice] as soon as he is capable of functioning; standing and walking without assistance." Review of nursing assessments throughout Patient #3's acute hospital stay indicated the patient as weak, confused at times, disoriented to place, and on bedrest.

Review of nurses notes included the following:
*10/08/12 at 6:15 a.m., ". . . Pt [patient] very weak, unable to ambulate, hx [history] of falls prior to admission . . ."
*10/08/12 at 7:30 p.m., ". . . confused at times . . ."
*10/09/12 at 12:45 a.m., "Pt found on knees on floor by bedside. Pt. states he didn't know what happened . . . Skin tear x [times] 2 present to [right] fa [forearm]. . . . Pt assisted back to bed. Gait unsteady. . . ."

Observation of Patient #3 on October 23-24, 2012 while the patient rested in bed showed two elevated upper half side rails. Review of a side rail assessment completed upon admission showed elevation of two side rails per Patient #3's wishes and indicated the elevated side rails were no risk to the patient, therefore, failing to assess the use of side rails any further. The CAH staff failed to consider the side rails as a risk and potential safety hazard for Patient #3. The record lacked evidence of a fall risk assessment and interventions to prevent or minimize falls upon admission and after Patient #3 fell.

- Review of Patient #4's swing bed record occurred on October 23-24, 2012 and identified the CAH admitted the patient on 09/21/12 with diagnoses of shortness of breath and weakness. Review of nurses notes included the following:
*10/07/12 at 1:00 p.m., ". . . When sat up on EOB [edge of bed], this nurse noted sm [small] amt [amount] blood on the sheet. Found 2 cm [centimeter] long skin tear to [right] outer forearm. . . . Pt states it may have happened when he sat up - thinks its from side rail. . . ."
*10/14/12 at 3:40 a.m., ". . . Note sm skin tear x 2 to RFA [right forearm] (below elbow region) . . ."
*10/14/12 at 4:15 a.m., "Pt remains restless and agitated. . . ."
*10/14/12 at 9:00 a.m., "Pt is agitated - very uncomfortable. Cannot sit for more than a few seconds. . . . Pt is from bed to chair to standing [with] walker repeatedly. . . ."
*10/17/12 at 11:25 p.m., "This nurse . . . heard crash and found pt. on floor in room. Pt. lying on floor face down. . . . asked pt if he fell he states 'I was pushing table to walk with it and I slipped so I went down to the floor.' . . ."
*10/19/12 at 5:15 a.m., "Small skin tear, 1/3 [inch] long, round, noted on lateral side of [left], 5th finger. Moderate amount bright red blood noted. . . ."

Observation of Patient #4 on October 23-24, 2012 while the patient rested in bed showed two elevated upper half side rails. Review of a side rail assessment completed upon admission showed elevation of two side rails per Patient #4's wishes and indicated the elevated side rails were no risk to the patient, therefore, failing to assess the use of side rails any further. The CAH staff failed to consider the side rails as a risk and potential safety hazard for Patient #4. The record lacked evidence of a fall risk assessment and interventions to prevent or minimize falls upon admission and after Patient #4 fell.

- Review of Patient #7, #8, #9, #11, #12, #13, #14, and #15's closed acute and observation patient records occurred on October 23-24, 2012. These patient records included the CAH's Side Rail Assessment upon admission and indicated the CAH staff elevated the top two side rails at the patient's request. The medical records identified the CAH staff elevated the top two side rails of these patients' beds during their stays. The CAH staff failed to assess these patients for safety risk factors regarding elevation of the top two side rails.

Failure to assess patients for risk of injury including when patients request elevation of the top two side rails, placed patients at risk of entrapment, falls, and other injuries related to side rails; and, placed patients at risk of limited mobility and may have limited their potential to reach their maximum physical, mental, and psychological well-being.

During an interview on 10/24/12 at 11:20 a.m., a nurse (#9) stated staff asked patients whether they wanted elevated side rails upon admission and elevated the side rails per patient request and stated most patients desired elevated side rails for safety and bed positioning. The nurse (#9) stated staff assessed patients for a risk of falling upon admission by taking the patient's condition and past history into account, but did not formally document this assessment and stated staff implemented fall interventions or fall precautions (chair/bed alarm, room close to nurse station) if needed. Another nurse (#6) agreed with the above processes and confirmed the nurse's (#9) statements.

During an interview on 10/24/12 at 12:55 p.m., two administrative nurses (#3 and #4) stated staff performed a side rail assessment on patients upon admission, but agreed the assessment lacked appropriate means to identify risks if patients desired to elevate the side rails. A nurse (#3) stated staff must document interventions to prevent falls and confirmed the CAH lacked a formal fall risk assessment.


16379

Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff developed and implemented a nursing care plan for 2 of 4 active patient (Patients #3 and #4) records reviewed with a history of falls and/or who experienced a fall. Failure to develop and implement care plans limited the CAH's ability to manage patient's needs, communicate treatment approaches, and ensure continuity of care.

Findings include:

Review of the policy "Care Plans - Initiation and Updating" occurred on 10/24/12. This policy, effective 12/07/08, stated, "Initiation and updating of patient Care Plans will be the responsibility of the Registered Nurse. Care Plans must be initiated within 24 hours of admission . . ."

- Review of Patient #1's acute record occurred on October 22-23, 2012. The CAH admitted the patient on 10/17/12 with a diagnosis of pneumonia, including a history of a subdural hematoma and left chest wall contusion from a fall on 10/13/12 at the facility where Patient #1 resided. Patient #1's admission orders indicated staff assistance with activity and ambulation, included a physical and occupational therapy consult, and indicated "fall precautions." The admission history and physical (H&P) indicated a history of falls and subsequent provider progress notes showed Patient #1 as oriented to person, but not to place and time. Review of nursing assessments and patient care notes throughout Patient #1's hospital stay indicated the patient as weak, unsteady, and needing assistance with activity. The record lacked a care plan which included interventions to prevent or minimize falls and specific "fall precautions" as ordered by Patient #1's provider on admission.

- Review of Patient #3's acute record occurred on October 23-24, 2012 and identified the CAH admitted the patient on 10/07/12. Patient #3's chief complaints listed on the admission H&P included falls. The admission H&P stated, ". . . he has been falling, unstable with difficulty for son to manage him with worsening confusion. . . . States chronic edema to the lower extremities with difficulty walking very far . . . history of falls the last few days. . . ." Review of nursing assessments throughout Patient #3's acute hospital stay indicated the patient as weak and nurses notes included the following:
*10/08/12 at 6:15 a.m., ". . . Pt [patient] very weak, unable to ambulate, hx [history] of falls prior to admission . . ."
*10/09/12 at 12:45 a.m., "Pt found on knees on floor by bedside. Pt. states he didn't know what happened . . . Skin tear x [times] 2 present to [right] fa [forearm]. . . . Pt assisted back to bed. Gait unsteady. . . ."
The record lacked a care plan which included interventions to prevent or minimize falls upon admission and after Patient #3 fell.

- Review of Patient #4's swing bed record occurred on October 23-24, 2012 and identified the CAH admitted the patient on 09/21/12 with diagnoses of shortness of breath and weakness. Review of nurses notes included the following:
*10/17/12 at 11:25 p.m., "This nurse . . . heard crash and found pt. on floor in room. Pt. lying on floor face down. . . . asked pt if he fell he states 'I was pushing table to walk with it and I slipped so I went down to the floor.' . . ."
The record lacked a care plan which included interventions to prevent or minimize falls upon admission and after Patient #4 fell.

During an interview on 10/24/12 at 12:55 p.m., an administrative nurse (#3) stated she would expect staff to initiate a care plan for patients with a history of falls and especially for those who experienced a fall.

Based on record review and staff interview, the critical access hospital (CAH) failed to ensure records were complete regarding care plans for 2 of 3 closed swing bed patient records (Patients #12 and #16) and 4 of 6 closed acute inpatient records (Patients #9, #11, #12, and #13); and, failed to accurately document on the CAH's emergency department (ED) log patients who leave without being seen or against medical advice (AMA). Failure to ensure the closed records included the complete care plan limited the CAH's ability to ensure the quality of care provided. Failure to identify patients who present to the CAH's ED for treatment and leave without being seen or AMA limited the CAH's ability to track and trend patterns of care and ensure quality of care.

Findings include:

- Review of the CAH's ED log identified the staff used codes to show the disposition of patients who presented to the ED for treatment. During interview, on 10/22/12 at 3:05 p.m., a medical records staff member (#1) reported the CAH did not have a code for patients who left the ED without being seen or who left AMA. This staff member (#1) reported these patients are coded as returning "home." This staff member reported she was aware of patients who left the ED without being seen or AMA, but could not provide dates or names. This staff member (#1) reported she thought this occurred approximately "four" times each year.

During interview, on 10/24/12 at 1:30 p.m., an administrative management staff member (#2) reported he is aware of patients leaving the ED without being seen or AMA approximately "two-three" times each year. This staff member (#2) reported being unaware the CAH staff failed to document this on the ED log.

- Review of closed medical records on October 23-24, 2012 identified incomplete care plans for the following acute inpatients and swing bed patients:
ACUTE-
*Patient #11 - admitted on 03/13/12 and expired on 03/16/12. Diagnoses included sepsis. Admission physician orders included "comfort cares" and an indwelling urinary catheter. The patient's care plan failed to include approaches for comfort cares or the urinary catheter.
*Patient #9 - admitted on 04/19/12 and discharged on 05/04/12. The medical record identified falls, speech-language pathologist recommendations to monitor for potential aspiration during eating, and the patient demonstrated aggressive behaviors toward staff requiring antipsychotic medications. The patient's care plan failed to include approaches for these issues.
*Patient #13 - admitted on 07/15/12 and discharged on 07/17/12. Admission diagnoses included fever, cellulitis, and an open wound. The patient received antibiotics. The patient's care plan failed to identify approaches regarding the patient's infection.
ACUTE/SWING BED
*Patient #12 - admitted on 05/07/12, transferred to Swing Bed on 05/10/12, and discharged on 05/12/12. Admission diagnoses included malignant neoplasm with metastases and the patient received pain medication. The patient's care plan failed to identify approaches for the metastases and approaches for pain control.
SWING BED
*Patient #16 - admitted on 07/05/12 and discharged on 08/03/12. Diagnoses included diabetes mellitus and the patient received insulin injections. The patient's care plan lacked approaches for monitoring the patient's blood glucose levels and potential insulin reactions.

During interview, on 10/24/12 at 2:00 p.m., an administrative nursing staff member (#3) reviewed the patient records previously identified and confirmed the care plans lacked the information indicated.

Based on bylaws review, procedure review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the treatment furnished in 2011 by 1 of 1 active physician (Physician #36) and 2 of 2 courtesy physicians (Physicians #2 and #3) at the CAH. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the treatment furnished by the physicians limits the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the "Cooperstown Medical Center Medical Staff Bylaws" occurred on 10/22/12. These bylaws, adopted 08/30/11, stated,
". . . Article IV Initial Appointment . . .
Part D: Reappointment . . .
Section 2. Reappointment Process . . .
b. Each recommendation concerning the reappointment of a Medical Staff member and the clinical privileges to be granted upon reappointment shall be based upon such member's professional competence and clinical judgment in the treatment of patients . . ."

Review of the governing board's "Amended Bylaws of the Cooperstown Medical Center" occurred on 10/23/12. These bylaws, effective 11/05/08, stated,
". . . Article VII Medical Staff . . .
Section 2. Medical Care and its Evaluation . . . The Medical Staff shall conduct an ongoing review and appraisal of the quality of professional care rendered in the Cooperstown Medical Center . . ."

Review of the procedure titled "Peer Review Procedure" occurred on 10/24/12. This policy, effective 01/07/09, stated, "Cooperstown Medical Center has an agreement with an outside facility to participate in a process for reviewing the care provided by members of their respective Medical Staffs." The procedure did not include a requirement to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the treatment furnished by the physicians.

Upon request on 10/24/12, the CAH failed to provide evidence a network hospital or a QIO evaluated the quality and appropriateness of the treatment furnished by Physicians #2, #3, and #36 in 2011.

During interview at approximately 12:50 p.m. on 10/24/12, an administrative staff member (#12) confirmed the CAH did not have a network hospital or QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment furnished by Physicians #2, #3, and #36.