HospitalInspections.org

1. Based on observation, review of a professional reference, 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 during 3 of 3 days of survey (May 17-19, 2010). Failure of the CAH to adequately secure and restrict access of all drugs and biologicals allowed an opportunity for unsafe and unauthorized use of medications and has the potential to create insufficient distribution, control, and accountability of drugs.

Findings include:

The Centers for Medicare and Medicaid Services (CMS) outlined the standards of practice for the administration of pharmaceutical services. The pharmacy director is responsible for developing, implementing, and periodically reviewing and revising policies and procedures for the provision of pharmaceutical services that ensure patient safety through the appropriate control and distribution of medications. The pharmacist is to maintain control over all medications in the CAH. The CAH must lock and store all drugs and biologicals in a manner to prevent access by unauthorized individuals. Persons without legal access to drugs and biologicals cannot have unmonitored access to them. When the pharmacist is unavailable, only a designated individual may remove drugs from the pharmacy and in amounts sufficient for immediate therapeutic needs. The CAH should identify the designated individual by name and qualifications. There should be a system or process for the safeguarding, transferring, and availability of keys to the locked pharmacy area to protect unauthorized access and use. A fundamental purpose of pharmaceutical services is to ensure the safe and appropriate use of medications.

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 by the director for the provision of drugs to the medical staff and other authorized personnel of the hospital, by use of the night cabinets or floor stock, or both, and 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. . . ."

Review of facility policy "Pharmacy Access" occurred 05/18/10. This policy, revised January 2009, stated, "To define who may access the pharmacy in the absence of the pharmacist. The pharmacy shall be kept locked at all times. A pharmacist is available on an on-call basis outside of regular scheduled hours. Only those persons listed below shall have access to the pharmacy. a. Registered Pharmacist. b. Director of Patient Care. c. Registered of [sic] Licensed Practical Nurse. d. Pharmacy Technician. e. Hospital Administrator. In the absence of the pharmacist the nurse may obtain enough of the drug to last until the pharmacist is in house to dispense the necessary quantity. All drugs under the DEA [Drug Enforcement Administration] law shall be locked in the narcotic room under double lock and key. Only those persons listed below shall have access to the locked narcotic room. a. Registered Pharmacist. b. Director of Patient Care. c. Surgical Service RN's [registered nurses] . . ."

Observation during medication pass on 05/17/10 at 5:30 p.m. showed a nursing staff member (#3) entered the medication room and obtained medications for Patient #3 from this patient's drawer in the medication cart. The nursing staff member (#3) did not find the medication Metformin (a medication used to regulate blood glucose to treat diabetes) in Patient #3's drawer. The nursing staff member (#3) obtained the medication from a separate drawer, on the lower shelf of the medication cart, labeled with the name and dose of the medication. When asked about the process staff follow to obtain medication when not in the medication drawer/medication room, the staff nurse (#3) stated all nurses have access to the pharmacy by key and pointed to a set of keys on a hook on the wall in the medication room. The nurse (#3) stated all nurses on duty have access to the key and pharmacy and enter the pharmacy to obtain medications.

During an interview on 05/17/10 at 5:40 p.m., a nursing staff member (#4) stated all nurses on duty have access to a key to the pharmacy and may access and enter the pharmacy to obtain medications. The nurse (#4) identified the CAH employed two pharmacy technicians (techs), staffed to work at the CAH during daytime hours, Monday through Friday, but stated the nursing staff enter the pharmacy to access medications day or night, in the presence or absence of pharmacy staff.

During an interview on 05/18/10 at 8:10 a.m., an administrative nurse (#1) and pharmacy staff member (#2) stated only registered nurses have access to the pharmacy by key, may enter in the absence of the pharmacist or pharmacy tech to obtain medications, and must co-sign the removal of medication with another registered nurse. The pharmacy staff member (#2) specified the CAH's pharmacy policy reflected this practice. The pharmacy staff member (#2) stated, during the hours the CAH staffs pharmacy techs, it is the expectation the pharmacy techs obtain and remove medications from the CAH pharmacy.

2. Based on observation, review of a professional reference, review of the North Dakota Century Code, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff dispensed drugs and biologicals in accordance with professional principles on 3 of 3 days of survey (May 17-19, 2010). Failure to properly dispense drugs and biologicals limited the CAH's ability to prevent unauthorized use and distribution of medications, maintain control of the medications, and ensure accurate and safe medication administration. This failure allowed an opportunity for unsafe and unauthorized use of medications, and placed patients and staff at risk.

Findings include:

The Centers for Medicare and Medicaid Services (CMS) outlined the standards of practice for the administration of pharmaceutical services. A fundamental purpose of pharmaceutical services is to ensure the safe and appropriate use of medications. The pharmacy director is responsible for developing, implementing, and periodically reviewing and revising policies and procedures for the provision of pharmaceutical services that ensure patient safety through the appropriate control and distribution of medications. The pharmacist is to maintain control over all medications in the CAH. The pharmacist or pharmacy supervised personnel are to be the persons to compound, label, and dispense drugs or biologicals in accordance with State and Federal laws and regulations and accepted national principles. The pharmacist must ensure the proper dispensation of medication and appropriate supervision to provide safe and appropriate use of medications.

The North Dakota Century Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-0. Drug distribution and control. 1. General. The director of pharmacy services shall establish written procedures for the safe and efficient distribution of pharmaceutical products. . . . 2. Responsibility. The director is responsible for the safe and efficient distribution of, control of, and accountability for drugs. . . . Accordingly, the director is responsible for, at a minimum, the following: . . . f. Filling and labeling all containers from which drugs are to be administered. . . . m. Meeting all compliance and other requirements of the [name of state] board of pharmacy rules and laws and this chapter. . . . 5. Physician's orders.
. . . e. Pharmacist review. The pharmacist shall review the prescriber's order, or a direct copy thereof, before the initial dose of medication is dispensed . . . In cases when the medication order is written when the pharmacy is 'closed' or the pharmacist is otherwise unavailable, the medication order should be reviewed by the pharmacist as soon thereafter as possible, preferably within twenty-four hours. . . ."

Review of facility policy "Dispensing/Returns" occurred 05/18/10. This policy, revised January 2009, stated, "1. Physician's write orders on the Dr.'s [doctor's] order sheet for new admissions and changes of medications for present patients. The pharmacist or the tech [pharmacy technician] will pick up new orders and changes at the nurses station. 2. Pharmacist or tech will receive any of the following when he reports to the hospital to fill the days orders. a. MD [Medical Doctor] orders for new patients or for present patients with order changes. b. Patient's medication bottle returned for refill. c. Patient's medication returned because of discharge. 3. All orders are filled for a three (3) day supply with the exception of holding patient medications an [sic] medications requiring a one day stop order which are refilled daily. . . ."

Observation during medication pass on 05/17/10 at 5:30 p.m. showed a nursing staff member (#3) entered the medication room and obtained medications for Patient #3 from this patient's drawer in the medication cart. The nursing staff member (#3) did not find the medication Metformin (a medication used to regulate blood glucose to treat diabetes) in Patient #3's drawer. The nursing staff member (#3) obtained the medication from a separate drawer, on the lower shelf of the medication cart, labeled with the name and dose of the medication. Observation of the lower shelf of the medication cart showed several small, separate drawers, labeled with the type and strength of medication each drawer contained. Observation of the drawers showed multiple different types of non-emergency prescription medications supplied in unit dose packages or medication bottles.

During interview on 05/17/10 at 5:30 p.m., when asked about the process to obtain prescribed medications for patients, the nursing staff member (#3) stated nursing staff retrieve the medication from the patient's individual medication drawer in the medication cart, from the medication labeled drawers on the lower shelf of the medication cart, or the pharmacy. The nurse (#3) stated nursing staff fill patient medications on the night shift for the next day and nursing staff on the other shifts fill medications for the patient if needed.

During interview on 05/17/10 at 5:40 p.m., a nursing staff member (#4) confirmed nursing staff filled or dispensed prescribed medications for patients per doctor's orders upon admission or medication change, for example: a change in dose, an extra dose, or new medication. The nurse (#4) identified the CAH employed two pharmacy techs to work at the CAH during daytime hours, Monday through Friday. The nurse (#4) stated the pharmacy techs only order, reorder, or stock medications while present at the CAH and nursing staff fill or dispense the patient's medications.

During interview on the morning of 05/19/10, a nursing staff member (#5) stated nursing staff fill or dispense prescribed medications ordered upon admission into an individual patient medication drawer, and if a medication changes after admission, nursing staff also fill or dispense that medication for the patient. The nurse (#5) stated nursing staff obtain the medication from the pharmacy with another nurse per doctor's order, the two nurses double check the order with the medication, and co-sign the medication administration record.

During an interview on 05/18/10 at 8:10 a.m., a pharmacy staff member (#2) stated the pharmacist is present at the CAH 24 hours a month and the two pharmacy techs are present at the CAH 24 hours a week. The staff member (#2) stated the expectation is pharmacy techs fill or dispense medications to all the patients of the CAH per doctor's orders upon admission or medication changes and the pharmacist checks the medications.

Failure to follow the above facility policy limited the pharmacist's ability to ensure safe medication practices and permitted nursing staff to perform duties outside their scope of practice.

Based on record review, review of a professional reference, policy and procedure review, infection control reports and committee meeting minutes, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, and control infections and communicable diseases for all patients of the CAH for the past 12 months (June 2009-May 2010). Failure to implement an active ongoing infection control program has the potential for infections to go unreported, affecting the health of all patients of the CAH.

Findings include:

The Centers for Medicare and Medicaid Services (CMS) has outlined the standards of practice for establishing and maintaining an active tracking program to identify, investigate, report and prevent patient and employee infections and communicable diseases. The infection control officer(s) is responsible for developing this system. CMS recommends the infection control officer maintains a log of all incidents of infection and communicable diseases for patients and staff within the CAH. This log is not only limited to nosocomial infections, it must include all incidents of infection and communicable disease. The facility should identify measures for the assessment of infections in patients and staff along with measures to prevent infection. Facilities need to provide a safe environment for patients and staff. Facilities also need to provide ongoing education for patients and staff as well as methods for monitoring and evaluating asepsis. The facility needs to implement a system for corrective action and address it for effectiveness.

Review of the facility infection control policy "Introduction" occurred on 05/19/10. This policy, effective 09/14/09, stated, ". . . The sick are physiologically prone to infection and the well can inadvertently spread infection. As members of a healthcare team, the primary work for us to remember in relation to this problem is prevention. We must make every effort to prevent infection and, as the second line of defense, every possible effort should be made to detect any outbreak quickly and to contain it once it has been discovered. This means constant surveillance of the hospital environment and all who enter it. . . ."

Review of facility policy "Infection Control Committee" occurred on 05/19/10. This policy, revised 09/14/09, stated, ". . . Objectives: To establish a functional surveillance system for control of healthcare associated infections (HAIs). To identify, through the surveillance system, any specific problem areas in need of administrative or professional resolution and report to the medical staff of the hospital. Functions: Establish and implement the surveillance system for evaluating and reporting infections in patients, personnel, and discharged patients. . . ."

Review of facility policy "Infection Control Plan" occurred 05/19/10. This policy, revised 09/14/09, stated, ". . . All healthcare providers . . . are responsible for the safety, health and well being of all patients . . . This responsibility may be met by working together continuously to promote safe infection control practices, observing all rules, regulations, procedural guidelines and continually assessing the program to identify risks involved with the facility's demography of patients, in an effort to improve the quality of patient care. . . ."

Review of facility policy "Infection Control Committee Methods of Surveillance" occurred 05/19/10. This policy, revised 09/14/09, stated, "The intent of any surveillance method . . . shall be to assess the overall quality of care. Direct observation and direct contact with both patients and direct care personnel has been demonstrated to be a reliable source of data. Collection approach shall include concurrent surveillance during hospitalization and post discharge follow-up. Data cannot be limited to positive cultures and sensitivity and/or post discharge chart review. . . ."

- Patient #1's active inpatient record, reviewed on 05/18/10, identified the CAH admitted the patient on 05/16/10 with a diagnosis of urinary tract infection. Review of the emergency room report on admission identified nursing staff replaced Patient #1's existing indwelling urinary catheter with a new catheter, and sent the tip of the old catheter to the lab for a culture per physician orders. Record review showed an order for urinalysis and urine culture on admission. Review of Patient #1's lab reports, dated 05/18/10, showed multiple organisms present on the urine culture, suggested as probable contamination, and the catheter tip culture canceled due to inappropriate specimen for culture. Record review lacked any further testing. Patient #1's medication administration record showed Ciprofloxacin (an antibiotic used to treat infection) 400 milligrams (mg) intravenously (IV) ordered every 12 hours.

- Patient #4's active swing bed record, reviewed on 05/19/10, identified the CAH admitted the patient on 05/06/10 with diagnosis of pneumonia. Review of Patient #4's admission H&P (history and physical) stated, ". . . He has severe chest infection with pneumonia, streptococcus gallolyticus (bovis group). He is on multiple antibiotics. . . ." Review of the H&P assessment revealed the following diagnoses: Pneumonia Streptococcus Gallolyticus Bovis Group . . . Bronchiectasis." Review of Patient #4's current medication list showed the patient received VFend (an antifungal used to treat infection), Vancomycin (an antibiotic used to treat infection), and Zosyn (an antibiotic used to treat infection) IV. Record review lacked evidence CAH staff reported, tracked, or followed up with this infection.

- Patient #8's closed inpatient/swing bed record, reviewed on 05/19/10, identified the CAH admitted the patient on 11/23/09 with diagnosis of post, open cholecystectomy. Review of the discharge summary, dated 12/03/09, showed the patient tolerated the open cholecystectomy without any complication, progressed well initially, but then developed an ileus and a wound infection. The summary identified Patient #8 returned to the operating room and underwent debridement and packing of the infected wound after the wound dehiscenced (the layers of surgical tissue opened). The summary identified the patient received IV Zyvox (an antibiotic used to treat infection) and Zosyn, and staff collected and sent wound cultures to the lab. Review of the wound culture on the lab report, dated 12/04/09, identified escherichia coli and enterococcus faecalis (types of bacteria commonly found in the gastrointestinal tract). Record review indicated Patient #8 eventually received a wound vacuum, but this patient's health declined and the patient expired on 12/02/09. Record review lacked evidence CAH staff reported, tracked, or followed up with this infection.

- Patient #13's closed inpatient record, reviewed on 05/19/10, identified the CAH admitted the patient on 09/22/09 with diagnoses of nausea and vomiting, type A influenza, fever, and dehydration. Review of the discharge summary, dated 09/24/09, indicated Patient #13 presented to the clinic, tested positive for type A influenza, and admitted to the hospital. The summary revealed Patient #13 discharged on 09/24/09 with orders from the physician that prohibited the patient to leave the house or have visitors for seven days. Record review lacked evidence CAH staff reported, tracked, or followed up with this infection.

The CAH's infection control reports and infection control meeting minutes, reviewed on May 18-19, 2010, lacked evidence the CAH identified and recognized infections of all patients of the CAH (inpatients, swing bed, and observation). The reports revealed the CAH only tracked infections upon incidents of reported positive cultures.

During interview on 05/18/10 at 3:23 p.m., an administrative nurse (#7) stated the infection control nurse obtained information from the culture log in the CAH laboratory to track and identify infections of inpatients, swing bed, and observation patients. The nurse (#7) stated patients identified on the laboratory log with positive cultures received surveillance for infection control. When asked to clarify the process or system the CAH implemented to identify, report, and investigate infections, the administrative nurse (#7) confirmed the infection control nurse only tracked or followed patients identified as having a positive culture.

During interview on 05/19/10 at 11:45 p.m., an administrative nurse (#7) verified the CAH had no infection control log for inpatients, swing bed and observation patients, other than the log of identified patients with positive cultures. The nurse (#7) could not provide information or evidence of documented surveillance of infection for Patient's #1, #4, #8, and #13. The nurse (#7) verified the CAH had no documentation in regards to infection control on these patients.

The failure to track all possible infections among patients within the CAH limited the CAH's ability to control and prevent infections.

Based on policy and procedure review and staff interview, the Critical Access Hospital (CAH) failed to have a physician member review 9 of 12 policy and procedure manuals in 2009 (Plant Operations, Quality/Risk, Infection Control, Medical/Surgical, Swingbed and Respite, Pharmacy, Physical Therapy, Medical Records, and Intensive Care Unit). By failing to have a physician member annually review the policies and procedures, the CAH cannot ensure the policies and procedures model their current practices and are in compliance with federal and state regulations.

Findings include:

Review of the policy titled "Policy Review/Committee #110.2" occurred on 05/16/10. This policy, dated 12/02, did not include a physician member on the annual policy review committee.

Reviewed on all days of survey, the following policy and procedure manuals lacked evidence of review by a physician in 2009:

*Plant Operations *Pharmacy
*Quality/Risk *Physical Therapy
*Infection Control *Medical Records
*Medical/Surgical *Intensive Care Unit
*Swingbed and Respite

During interview on 05/19/10 at 11:15 a.m., an administrative staff member (#10) confirmed a physician had not reviewed the CAH's policy and procedure manuals in 2009.

Based on observation, record review, review of professional standards, and staff interview, the Critical Access Hospital (CAH) failed to assess each patient individually prior to utilizing side rails and failed to evaluate the safe use of side rails for 1 of 1 active inpatient (Patient #3) record reviewed and 1 of 1 active swing bed patient (Patient #4) record reviewed. Failure to assess and evaluate the use of side rails has the potential to restrict a patient's movement and has the potential to place patients at risk for injury.

Findings include:

The Food and Drug Administration (FDA) Center for Devices and Radiological Health publication titled, "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment," issued on 03/10/06, stated, ". . . FDA has received reports in which . . . patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term 'entrapment' describes an event in which a patient is caught, trapped or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in death and serious injuries . . . The current International Electrotechnical Commission (IEC) standard recognizes that the bed frame, deck, and rails are the major elements involved in entrapment . . ." The FDA's recommendation of the spacing between the inside surface of the rail and the mattress compressed by the weight of the patient's head be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. The IEC and the FDA recommend a dimension limit of less than 120 millimeters (4 and 3/4 inches) for the following: 1) within the rail; 2) under the rail, between rail supports or next to a single rail support; and 3) between the rail and mattress. . . ."

Safety Alert: Entrapment Hazards with Hospital Bed Side Rails, August 23, 1995, and Joint Commission on Accreditation of Healthcare Organization: Sentinel Event Alert, Issue 27, September 6, 2002, identified bed rail-related entrapment deaths and injuries can occur in the elderly population, who are often at risk due to limited mobility, psychoactive or sedative medications, confusion, sedation, restlessness, lack of muscle control, size and physical deformities. Death by asphyxiation or injuries to the resident's extremities can occur when the resident becomes caught between the mattress and the bed rail; the headboard and the bed rail; or getting his or her head/extremity stuck in the bed rail. Both split and full rails have the potential to cause fall-related injuries as well as entrapment. Additionally fall-related injuries or injuries to extremities can occur when confused/disoriented residents climb over the top of side rails or get an arm or leg entrapped.

Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, Hospital Bed Safety Workgroup, Food and Drug Administration, April 2003, stated,
"Guiding Principles . . . 2. Decisions to use or to discontinue the use of a bed rail should be made in the context of an individualized patient assessment using an interdisciplinary team with input from the patient and family or the patient's legal guardian. . . . Policy Considerations: 1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize or remove those in current use should occur within the framework of an individual patient assessment. . . . 3. Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team. Bed rail effectiveness should be reviewed on a regular basis. 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 and determined not to be the treatment of choice for the patient.
. . . 7. Creating a safe bed environment does not necessarily preclude the use of bed rails. However, a decision to use them should be based on a comprehensive assessment and identification of the patient's needs, which include comparing the potential for injury or death associated with use or non-use of bed rails to the benefits for an individual patient. In creating a safe bed environment, the following general principles should be applied:
Avoid the automatic use of bed rails of any size or shape. . . . Re-assess the patient's needs and re-evaluate the equipment if an episode of entrapment or near-entrapment occurs, with or without serious injury. This should be done immediately because fatal 'repeat' events can occur within minutes of the first episode. Process/Procedure Considerations . . . 1. Individualized Patient Assessment: Any decision regarding bed rail use or removal from use should be made within the framework of an individual patient assessment. . . . Risk Intervention: 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. . . . Bed Rails as Restraints: When bed rails have the effect of keeping a patient from voluntarily getting out of bed, they fall under the definition of a physical restraint. If they are not necessary to treat medical symptoms, and less restrictive interventions have not been attempted and determined to be ineffective, bed rails used as restraints should be avoided. . . . Bed Rail Safety Guidelines: If it is determined that bed rails are required and that other environmental or treatment considerations may not meet the individual patient's assessed needs, or have been tried and were unsuccessful in meeting the patient's assessed needs, then close attention must be given to the design of the rails and the relationship between rails and other parts of the bed. 1. The bars with the bed rails should be closely spaced to prevent a patient's head from passing through the openings and becoming entrapped. 2. The mattress to bed rail interface should prevent an individual from falling between the mattress and bed rails and possibly smothering. . . ."

Review of facility policy "Side Rails" occurred on 05/19/10. This policy, revised April 2009, stated, "Purpose: To provide guidance for the safe use of side rails. Policy: Side rails that are used to facilitate mobility in and out of bed, for the turning and repositioning of self are not considered restraints. Procedure/Interventions: Patients will be screened for potential risk factors during the admission process and every shift thereafter. The number of rails used and the reason for use will be documented every shift and pm [evening] on the daily nursing assessment sheet. . . . Only one side rail may be used for the purpose of facilitating mobility and repositioning. . . ." This policy failed to recognize, in accordance with standards of practice, that elevated side rails, when used for any reason and dependent on how many rails are elevated, may be considered a restraint.

Review of facility policy "Restraints" occurred on 05/19/10. This policy, revised June 2009, stated, "The patient has the right to be free from seclusion and restraints of any form, imposed as a means of coercion, discipline, convenience, or retaliation from staff. . . . A physical restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body so that he/she cannot easily remove that restricts freedom of movement or normal access to one's body. Examples of physical restraints are: Side Rails (Side rails that are used to 'facilitate mobility in and out of bed, for the turning and repositioning of self' are not considered as restraints.) . . . Methods used to protect the patient or to assist the patient in obtaining or maintaining normative body function (i.e. bed rails, tabletop chairs, bed checks, safety belts, etc.) Any time a protective devise [sic] is used as a restraint, then restraint guidelines must be used and a physician order is required. . . . The seclusion or restraint order . . . 3. Must include a written modification to the patient's plan of care. 4. Implemented in the least restrictive manner possible. 5. In accordance with safe and appropriate restraining techniques. 6. Ended at the earliest possible time. The condition of the restrained patient must be continually monitored, assessed and evaluated. Hourly notations will be noted on the task list. The physician or physician extender must see and evaluate the need for restraint or seclusion within 1 hour after the initiation of this intervention. . . ." This policy failed to recognize, in accordance with standards of practice, that elevated side rails, when used for any reason and dependent on how many rails are elevated, may be considered a restraint.

Observation of the beds utilized on the nursing unit occurred on May 17-19, 2010. The beds utilized by the current swing bed and inpatients differed in style or make and differed in the number of attached side rails. All of the beds either had four half rails, two half rails on each side, or two full rails, one rail on each side, attached to the beds. Measurements of one type of bed, located specifically in Room 212, identified five, 7 and 3/4 inch, open spaces within the rails. Measurements of a different type of bed, located specifically in Room 207, identified 5 and 1/4 to 12 and 1/4 inch open spaces within the rails.

Observations of a current inpatient, Patient #3, while the patient rested in bed on May 17-18, 2010, identified one elevated full rail on the patient's bed. Observations of a current swing bed patient, Patient #4, while the patient rested in bed on May 17-18, 2010, identified three elevated half rails on the patient's bed and on May 19, 2010, identified four elevated half rails on the patient's bed.

- Review of Patient #4's active swing bed record occurred 05/19/10. Review of Patient #4's nursing documentation from May 6-19, 2010, indicated general weakness, unsteady gait, ambulate with assist of two, and showed various fall risk assessments that identified the patient as a high risk for falls. The documentation revealed Patient #4 as confused and disoriented at times, and specified the patient required assistance to get out of bed and to reposition in bed.

Review of Patient #4's nurse note, dated 05/19/10 at 10:12 a.m., stated, "4 of 4 siderails up for patients' use of bed controls and to facilitate bed mobility." Record review lacked evidence Patient #4 exhibited any medical or behavioral need for the four elevated side rails.

Patient #4's record lacked an appropriate, individualized assessment of risk and safety for the utilization of side rails, lacked documentation of clinical interventions tried, as well as outcomes, to promote safety, lacked a care plan for side rails, lacked a physician's order and care plan for restraint, and lacked documentation of monitoring Patient #4 during the time of elevated side rails. The CAH staff failed to consider the side rails as a potential restraint and entrapment hazard.

- Review of Patient #3's active inpatient record occurred 05/19/10. Record review identified the lack of an appropriate, individualized assessment of risk and safety for the utilization of side rails. The CAH staff failed to consider the side rails as a potential entrapment hazard.

During an interview on 05/19/10 at 1:45 p.m., a nursing staff member (#6) stated nurses elevate the side rails per patient/family request for safety, positioning, and access to bed controls/call light. The staff member (#6) indicated confusion as the reason for Patient #4's elevated side rails and stated she failed to recognize the four elevated side rails as a restraint.

During interview on 05/19/10 at 2:05 p.m., an administrative nurse (#1) stated nursing staff does not perform an assessment of risk factors or safety for utilization of side rails and confirmed nurses always elevate the side rails for patient safety, positioning, and access to bed controls/call light. The administrative nurse (#1) stated the CAH failed to consider the side rails or beds a risk for safety and a potential hazard for entrapment.

Based on observation, record review, review of a professional reference, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff developed, updated, and maintained nursing care plans for 2 of 3 active inpatient (Patient #1, and #2) records reviewed. Failure to develop, update, and maintain care plans limited the CAH's ability to communicate treatment approaches, assist the patient to attain/maintain their highest physical, mental, and psychosocial well-being, and ensure continuity of care.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, pages 212-215, stated, ". . . A formal nursing care plan is a written or computerized guide that organizes information about the client's care. The most obvious benefit of a formal written care plan is that it provides for continuity of care. . . . When nurses use the client's nursing diagnoses to develop goals and nursing interventions, the result is a holistic, individualized plan of care that will meet the client's unique needs. . . . Care plans include the actions nurses must take to address the client's nursing diagnoses and produce the desired outcomes. The nurse begins the plan when the client is admitted to the agency and constantly updates it throughout the client's stay in response to changes in the client's condition and evaluations of goal achievement. . . . Regardless of whether care plans are handwritten, computerized, or standardized, nursing care must be individualized to fit the unique needs of each client. . . ."

Review of facility policy "Patient Care Plan" occurred on 05/19/10. This policy, revised June 2009, stated, "Purpose: To ensure the care, treatment and services are planned and individualized to the patient's needs. . . . The care plan will address the diagnosis and needs of the individual patient. The care plan will be updated daily or as changes occur in patient status and/or diagnosis. The care plan will address the patient needs, nursing actions/approaches/interventions, and goals. The care plan will be individualized to fit the patient needs. The care plan goals will be identified and measurable. . . ."

- Patient #1's active inpatient record, reviewed May 18-19, 2010, identified the CAH admitted the patient on 05/16/10 with diagnoses of urinary tract infection and weakness. Review of Patient #1's physician assessment on admission indicated the patient had difficulty with ambulation. Review of the physician's orders identified physical therapy for gait training and strengthening.

Patient #1's nursing documentation from May 17-19, 2010, showed several fall risk assessments identifying the patient as a high risk for falls and documented the patient was confused and disoriented at times.

Record review showed the problem "activity intolerance" initiated on the care plan on 05/16/10. The care plan lacked a goal, the patient's response to interventions, documentation of ongoing patient needs, and updating/revising the care plan in response to assessments. Review of Patient #1's care plan failed to indicate nursing staff identified infection, ambulation/gait, confusion, and the high fall risk as potential problems and failed to include these on the care plan.

- Patient #2's active inpatient record, reviewed 05/17/10, identified the CAH admitted the patient 05/14/10 with diagnoses of hyponatremia, nausea, and left hip arthritis. Review of Patient #2's medical history indicated recent right eye surgery. The patient's medication list included four different kinds of eye drop medications administered daily.

Patient #2's nursing documentation from May 14-17, 2010, showed several fall risk assessments identifying the patient as a moderate risk for falls and documented the patient had weakness and bad eyesight.

During observation on 05/17/10 at 4:55 p.m. a staff nurse (#3) assisted Patient #2 from the bed to the restroom and then to the chair for dinner. Observation showed Patient #2 appeared unsteady as she walked with the nurse. Patient #2 stated she experienced difficulty with her vision and indicated problems with blurriness, seeing colors, and sensitivity to light in her right eye. She stated the above problems made it hard for her to see and walk around.

Record review showed the problem "Risk for deficient fluid volume - Hyponatremia" initiated on the care plan on 05/14/10. The care plan lacked appropriate interventions, the patient's response to interventions, documentation of ongoing patient needs, and updating/revising the care plan in response to assessments. Review of Patient #2's care plan failed to indicate nursing staff identified weakness, poor vision, and the moderate fall risk as potential problems and failed to include these on the care plan.

During interview, on 05/19/10 at 2:10 p.m., an administrative nurse (#1) stated she expected nursing staff to initiate a care plan upon admission in accordance with the patient's medical condition(s) and review and update the care plan as the patient's condition warrants. The administrative nurse (#1) confirmed Patient #1 and #2's care plans needed work or improvement.

Based on record review, review of Medical Staff Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure accuracy of documentation regarding patient disposition on 1 of 1 emergency room (ER) log (Patient #17, #18 and #32); physician arrival times for 4 of 12 ER records (Patient #18, #24, #26, and #28); and, documentation on the correct record for 1 of 3 active acute patient records (Patient #2). Failure to ensure accuracy of documentation limited the CAH's ability to ensure appropriate care and services for patients.

Findings include:

Review of the CAH's Medical Staff Rules and Regulations occurred on May 17-19, 2010. This document, approved on 01/11/08, stated,
". . . C. MEDICAL RECORDS . . . a. Medical Record Content: The Medical Record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services. . . ."

- Review of the CAH's Log of Occurrence Reports, in the afternoon on 05/17/10, identified Patient #17, #18, and #32 left the ER against medical advice (AMA). Review of the ER Log, in the afternoon on 05/17/10, identified the ER Log showed the patients "Admit" and "AMA." During interview, at 4:30 p.m. on 05/17/10, a supervisory ER nursing staff member (#8) reported the CAH may have admitted the patients and the patients then left AMA, and the staff did not correct the ER Log.

Review of the patients' ER records, on May 18-19, 2010, identified the following:
*Patient #17 - Presented to the ER on 08/31/09, admitted to observation, and left the CAH AMA on 09/01/09.
*Patient #18 - Presented to the ER on 08/01/09, admitted to observation, and left the CAH AMA on 08/01/09.
*Patient #32 - Presented to the ER on 02/26/10, admitted to acute care, and left the CAH AMA on 02/26/10.

- Review of ER records, on May 18-19, 2010, identified the following records did not identify the physician's arrival time:
*Patient #18 - Presented to the ER on 08/01/09 at 1:10 p.m.
*Patient #24 - Presented to the ER on 11/05/09 at 3:10 a.m.
*Patient #26 - Presented to the ER on 06/04/09 at 9:25 p.m.
*Patient #28 - Presented to the ER on 09/15/09 at 4:55 p.m.

- Review of Patient #2's active acute patient record, on May 17-19, 2010, identified a nurse's note, dated 05/14/10, for another patient.

During interview, on 05/19/10 at 2:30 p.m., a health information management staff member (#9) reported staff monitored the ER records for completeness including physician arrival times. This staff member agreed staff should have corrected the ER Log, completed the physician arrival times, discovered the incomplete records during the monitoring process, and should have made entries only in the correct patient's record.

Based on record review, review of Medical Staff Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure medical records included properly executed consent forms for 3 of 12 emergency room (ER) patients (Patient #18, #20, and #31) and pertinent medical histories for 3 of 4 swing bed patients (Patient #9, #10, and #12). Failure to obtain written patient consent for treatment limited the patients' awareness of the treatment and placed the CAH at risk of providing unwanted treatment and failure to have histories and physicals for swing bed patients limited the staff's ability to ensure the continuity of care.

Findings include:

Review of Medical Staff Rules and Regulations occurred on May 17-19, 2010. This document, approved on 01/11/08, stated, "Definitions . . . Informed Consent: The disclosure of the procedure or treatment to be undertaken . . .
A. ADMISSION AND DISCHARGE OF IN-PATIENTS
2. General Duties . . . d. Admitting Information . . . A complete history and physical examination shall, in all cases, be written or dictated, within 24 hours after admission of the patient. . . .
C. MEDICAL RECORDS, 1. General Provisions
. . . b. Required Characteristics . . . Appropriate consent forms . . ."

- Review of ER patient records, on May 17-19, 2010, identified the CAH failed to obtain signed consent for treatment for the following patients:
*Patient #18 - Presented to the ER on 08/01/09, possible fractures after a fall, admitted to observation, and signed himself out of the CAH against medical advice (AMA).
*Patient #20 - Presented to the ER on 07/09/09, migraine headaches, and returned home.
*Patient #31 - Presented to the ER on 05/01/10, vaginal bleeding, approximately 14 weeks pregnant, returned home.

- Review of closed swing bed patient records, on May 17-19, 2010, identified the following records lacked pertinent medical histories:
*Patient #9 - Admitted on 09/07/09 from acute care following abdominal surgery.
*Patient #10 - Admitted on 08/04/09 from a tertiary care facility.
*Patient #12 - Admitted on 04/09/10 from a tertiary care facility.

During interview, on 05/19/10 at 2:30 p.m., a health information services management staff member (#9) agreed the records lacked consents for treatment and agreed the physicians should have completed histories and physicals or a transfer summary for the swing bed patients.

Based on record review, review of Medical Staff Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure patient records included authenticated physician orders for 1 of 12 emergency room (ER) patient records (Patient #25) and 1 of 4 closed swing bed patient records (Patient #10) reviewed. Failure to ensure physicians authenticate orders limited the physicians' and the staff's ability to ensure the accuracy and continuity of patient care.

Findings include:

Review of the Medical Staff Rules and Regulations occurred on May 17-19, 2010. This document, approved on 01/11/08, stated, ". . . A. ADMISSION AND DISCHARGE OF IN-PATIENTS . . .
2. General Duties . . .a. The practitioner admitting the patient shall: . . . ii.
be responsible to supply appropriate orders within his/her privileges . . .
B. EMERGENCY ROOM . . .
6. Emergency Room Records: The practitioner responsible for the care of the patient in the Emergency Room shall provide a complete Emergency Room medical record. Emergency Room medical records shall contain: . . . f. Record of treatment, including medications, and response . . . i. Signature or authorized authentication of the responsible practitioner . . .
C. MEDICAL RECORDS . . .
12. General Responsibilities: The attending practitioner shall be responsible for the preparation and authentication of a complete and legible medical record for each patient . . . a. Signature: All clinical entries in the patient's medical record shall be dated, timed, and properly authenticated . . ."

- Patient #25's ER record, reviewed on May 18-19, 2010, identified the patient presented to the ER on 06/17/09 complaining of nausea and vomiting after a fall. The physician (#2) gave verbal orders for laboratory and radiological studies. The medical record lacked the physician's signature for the verbal orders.

- Patient #10's closed swing bed record, reviewed on May 18-19, 2010, identified the CAH admitted the patient on 09/04/09 from a tertiary care facility and discharged her on 09/16/09. The physician's (#3) orders included occupational therapy (O.T.) evaluation and treatment. The O.T. evaluation for recommended treatment included in the medical record lacked the physician's (#3) signature.

During interview, on 05/19/10 at 2:30 p.m., a health information services management staff member (#9) agreed the physicians should have signed Patient #25's orders and Patient #10's treatment plan.

Based on record review, review of Medical Staff Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure evaluation for proper anesthesia recovery by a qualified practitioner, for 3 of 7 patient records (Patient #10, #21, and #23) reviewed who required anesthesia services. Failure to provide evaluation for post anesthesia recovery placed the patients at risk of illness and complications related to anesthesia.

Findings include:

Review of the Medical Staff Rules and Regulations occurred on May 17-19, 2010. This document, approved on 01/11/08, stated, ". . . E. ANESTHESIA PROCEDURES AND RECORDS: Whenever general, spinal or major regional anesthesia, or sedation which is expected to result in loss of protective reflexes, is to be used anywhere in the Hospital, the following requirements shall be met: . . .
3. Post-Anesthesia Care and Documentation: The person in charge of the patient's care in the immediate post-procedure period shall complete a post-anesthesia monitoring record . . ."

Review of the following closed patient records identified the Post Anesthesia Note section of the CAH's Anesthesia Evaluation form lacked completion for the post anesthesia evaluation and date:
*Patient #10 - 09/11/09, colonoscopy.
*Patient #21 - 10/15/09, bilateral knee arthroscopies.
*Patient #23 - 04/22/10, right cataract.

During interview, on 05/19/10 at 2:30 p.m., a health information services management staff member (#9) agreed these patient records lacked and should have documented post anesthesia evaluations.

Based on review of the facility's quality improvement (QI) plan, QI reporting schedule, quality assurance (QA) minutes, and staff interview, the Critical Access Hospital (CAH) failed to ensure the QA program evaluated all patient care services and other services affecting CAH patient health and safety for 12 of 12 months reviewed (April 2009-March 2010). By not ensuring all departments providing patient care participate in QA monitoring, report to the QA Committee as scheduled, perform quality of care monitoring, and establish thresholds of acceptability for QA monitoring, the CAH failed to identify risk factors affecting patient care and failed to implement corrective action if necessary.

Findings include:

Review of the "Quality Improvement Plan" occurred on 05/18/10 at 2:30 p.m. This plan, effective 12/07/07, stated,
"I. Goal of the Quality Improvement Plan
The goal of the Quality Improvement Program is to document evidence of a well defined, organized, and integrated system designed to insure [sic] that all patients treated at Pembina County Memorial Hospital receive quality care.
. . .
II. Objectives of the Quality Improvement Plan
Fulfillment of the following program objectives is recognized to be a continuous process to include all patient care services.
1. To assure the quality of patient care through objective, routine patient care evaluations and other quality improvement activities. . . .
VII. Non-Compliance . . .
All departments are required to report at least annually and more frequently as identified in the reporting schedule. . . ."

Reviewed on 05/18/10 at 2:45 p.m., the Quality Improvement Schedule for April 2009 through March 2010 included the following reporting times:
Housekeeping - March and September
Pharmacy - May and November
Plant Operations - May (follow-up) and July
Professional Staff and QA peer review reports - June, September, December, and March
Radiology - April (moved from March) and September
Swing bed activities - not on the schedule
Social Services - not on the schedule

Reviewed on May 18-19, 2010, the April 2009-March 2010 monthly QA Committee meeting minutes indicated the following departments did not submit reports to the QA Committee: swing bed activities and Social Services.
Laundry reported results to the QA Committee for the affiliated long term care facility, but did not include results of CAH monitoring activities.
The following departments did not report as scheduled by the QA Committee: Housekeeping (scheduled to report twice and reported once), Pharmacy (scheduled to report twice and reported once), Professional Staff/Peer Review (scheduled to report four times and reported twice), Plant Operations (follow-up reporting scheduled for May 2009 and reported in October 2009), Radiology (reporting rescheduled from March 2009 to April 2009 and not reported until July 2009).
The following departments did not monitor quality of care: Plant Operations, Housekeeping, and Physical therapy.
The following departments did not establish thresholds of acceptability for their QA monitoring: Business Office, Infection Control, Nursing Service, Safety/Risk, Professional Staff/Peer Review, Laboratory, Health Information, Physical Therapy, Radiology, Material Management, Diabetic Education, Cardiac Rehab, and Plant Operations.

During an interview on 05/18/10 at 5:30 p.m., an administrative staff member (#7) confirmed some departments did not report as scheduled, did not monitor quality of patient care, and did not establish thresholds of acceptability for their QA monitoring.

During an interview on 05/19/10 at 11:35 a.m., an administrative staff member (#7) confirmed swing bed activities and social services did not perform QA monitoring and laundry had not reported CAH patient monitoring.

Based on review of bylaws, network agreement, policy, peer review records, and staff interview, the Critical Access Hospital (CAH) failed to have a provider with the same qualifications/privileges review the quality and appropriateness of the diagnosis and treatment furnished by 4 of 4 physicians who performed surgical procedures at the CAH in 2009 (Physicians #4, #8, #9, and #10). By failing to perform peer review, the CAH cannot ensure the physicians performing surgical procedures provided quality and appropriate care to the CAH's patients.

Findings include:

Review of the "Restated Bylaws of Pembina County Memorial Hospital Cavalier, North Dakota" occurred May 17-19, 2010. These Bylaws, dated 04/23/02, stated, ". . . Article X - Medical Staff . . . Section 2. Medical Care and Its Evaluation . . . The medical staff shall conduct a continuing review and appraisal of the quality of professional care rendered in the hospital . . ."

Review of the "Bylaws of the Medical Staff of Pembina County Memorial Hospital Cavalier, North Dakota" occurred May 17-19, 2010. These bylaws, dated 01/11/08, stated,
"Cooperative Peer Review . . .
1.02-2 Peer Review
The Medical Staff may enter into arrangements with other Facilities or Providers to assist it in peer review activities. . . .
Article IX: Committees and Functions of the Medical Staff
Section 3 Medical Staff Review Function . . .
3-6 Peer Review Function
The peer review function of the Medical Staff shall be: (a) To develop and implement mechanisms, with approval of the Hospital administration and the Board, to review the appropriateness and medical necessity of admissions, lengths of stay, use of supportive services and discharge practices. . . ."

Review of the "CAH Network Agreement" occurred the afternoon of 05/19/10. This Agreement, effective 05/09/01, stated, ". . . 9. Credentialing and Quality Assurance. Hospital [Pembina County Memorial Hospital] and [name of network hospital] agree that Hospital will continue to follow its own physician credentialing process and quality assurance formats. . . ."

Review of the policy titled "Professional Staff/Quality Improvement Peer Review & Occurrence Review Guidelines" occurred the afternoon of 05/19/10. This policy, effective 12/07/07, stated, ". . . III. Definitions . . . D. Peer Review Panel for Specific Circumstances: . . . 2. Circumstances that require external peer review include, but may not be limited to: a) Need for specialty review, when there are a limited number or no medical staff members of the institution with the identified specialty within the organization.
. . ." This policy did not require the performance of peer review for each member of the medical staff providing care to the CAH's patients.

Reviewed at 1:50 p.m. on 05/19/10, the 2009 peer review records lacked evidence a provider with the same qualifications/privileges reviewed the quality and appropriateness of the diagnosis and treatment furnished by four physicians (#4, #8, #9, and #10) who performed surgical procedures at the CAH in 2009.

During interview at 2:05 p.m. on 05/19/10, an administrative staff member (#9) confirmed a provider with the same qualifications/privileges did not review the quality and appropriateness of the diagnosis and treatment furnished by four physicians who performed surgical procedures at the CAH in 2009.

Based on record review, professional reference review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to develop a comprehensive care plan that included measurable objectives and timetables to meet the medical, nursing, mental and psychosocial needs for 1 of 1 active swing bed (Patient #4) record reviewed. Failure to develop the comprehensive care plan limited the CAH's ability to manage patient needs, communicate treatment approaches, and to ensure continuity of care.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, pages 212-215, stated, ". . . A formal nursing care plan is a written or computerized guide that organizes information about the client's care. The most obvious benefit of a formal written care plan is that it provides for continuity of care. . . . When nurses use the client's nursing diagnoses to develop goals and nursing interventions, the result is a holistic, individualized plan of care that will meet the client's unique needs. . . . Care plans include the actions nurses must take to address the client's nursing diagnoses and produce the desired outcomes. The nurse begins the plan when the client is admitted to the agency and constantly updates it throughout the client's stay in response to changes in the client's condition and evaluations of goal achievement. . . . Regardless of whether care plans are handwritten, computerized, or standardized, nursing care must be individualized to fit the unique needs of each client. . . ."

Page 215-216 stated, ". . . Multidisciplinary (Collaborative) Care Plans: A multidisciplinary care plan is a standardized plan that outlines the care required for clients with common, predictable - usually medical - conditions. . . . Like the traditional nursing care plan, a multidisciplinary care plan can specify outcomes and nursing interventions to address client problems (including nursing diagnoses). However, it includes medical treatments to be performed by other health care providers as well. . . . Multidisciplinary care plans do not include detailed nursing activities. They should be drawn from but do not replace standards of care and standardized care plans. . . ."

Review of facility policy "Care Plan" occurred 05/19/10. This policy, revised August 2009, stated, "Purpose: To provide guidelines for conducting comprehensive accurate, standardized, reproducible assessments of each swing bed patient's functional capacity. Policy: A comprehensive care plan and resident assessment will be conducted on patients admitted to swing bed according to CMS [Centers for Medicare and Medicaid] guidelines. Procedure/Interventions: Care coordinator or designee will complete the care plan on swing bed patients. A comprehensive care plan will be initiated within 24 hours of admit. The care plan will include input from the interdisciplinary team.
. . ."

Patient #4's active swing bed record, reviewed 05/19/10, identified the CAH admitted the patient on 05/06/10 with diagnosis of pneumonia. Review of Patient #4's admission H&P (history and physical) stated, ". . . He has severe chest infection with pneumonia, streptococcus gallolyticus (bovis group). He is on multiple antibiotics. . . . He is on nasal O2 [oxygen] and at times his sat [saturation] drops below 88 . . . He did fall down there at [name of city], apparently, and he did have some rib fractures. . . ." Review of the H&P assessment revealed the following diagnoses: Pneumonia Streptococcus Gallolyticus Bovis Group, Coronary Heart Disease, COPD (Chronic Obstructive Pulmonary Disease), Chronic Kidney Disease Stage 3, Coagulopathy, Hypertension, Intermittent Atrial Fibrillation, and Bronchiectasis.

Patient #4's nursing documentation from May 6-19, 2010, indicated general weakness, unsteady gait, ambulate with assist of two and showed various fall risk assessments that identified the patient as a high risk for falls. The documentation revealed Patient #4 as confused and disoriented at times. The nursing assessments identified daily dressing changes to multiple skin tears to Patient #4's arms from a previous hospital stay.

Record review showed nursing staff initiated the problem "Ineffective Breathing Pattern" on the care plan on 05/06/10. The care plan lacked a goal, the patient's response to interventions, documentation of ongoing patient needs, and updating/revising the care plan in response to assessments.

Review of Patient #4's care plan failed to indicate nursing staff identified infection, activity, ambulation/gait, confusion, skin integrity, and the high fall risk as potential problems and failed to include them on the care plan. The care plan lacked collaboration of an interdisciplinary team, identified services or treatment furnished to Patient #4, a plan to manage risk factors and prevent declines in function, and objectives and goals for treatment.

During interview, on 05/19/10 at 2:10 p.m., an administrative nurse (#1) stated she expected nursing staff to initiate a care plan on swing bed patients upon admission in accordance with the patient's medical condition(s) and stated staff must review, add or revise, and update the care plan as the patient's condition warrants. The administrative nurse (#1) confirmed Patient #4's care plan needed work or improvement.

Based on record review, review of a professional reference, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to establish and implement a comprehensive care plan prepared by an interdisciplinary team that included periodic review for 1 of 1 active swing bed (Patient #4) record reviewed. Failure to establish the comprehensive care plan with interdisciplinary input and review limited the CAH's ability to develop a plan to improve the patient's functional abilities and provide the greatest benefit to the patient.

Findings include:

Berman, Snyder, Kozier, and Erb, "Fundamentals of Nursing, Concepts, Process, and Practice," 8th ed., Pearson Education Inc., Upper Saddle River, New Jersey, 2008, pages 215-216, stated, ". . . Multidisciplinary (Collaborative) Care Plans: A multidisciplinary care plan is a standardized plan that outlines the care required for clients with common, predictable - usually medical - conditions. . . . Like the traditional nursing care plan, a multidisciplinary care plan can specify outcomes and nursing interventions to address client problems (including nursing diagnoses). However, it includes medical treatments to be performed by other health care providers as well. . . . Multidisciplinary care plans do not include detailed nursing activities. They should be drawn from but do not replace standards of care and standardized care plans. . . ."

Review of facility policy "Care Plan" occurred 05/19/10. This policy, revised August 2009, stated, ". . . A comprehensive care plan and resident assessment will be conducted on patients admitted to swing bed according to CMS [Centers for Medicare and Medicaid] guidelines. . . . A comprehensive care plan will be initiated within 24 hours of admit. The care plan will include input from the interdisciplinary team. . . ."

Patient #4's active swing bed record, reviewed 05/19/10, identified the CAH admitted the patient on 05/06/10 with diagnoses of pneumonia. Record review showed an order for physical and occupational therapy and identified the two disciplines currently provided services to Patient #4 at the time of the survey. Review of the record also showed activities and dietary services offered to the patient.

Record review showed nursing staff initiated the problem "Ineffective Breathing Pattern" on the care plan on 05/06/10, and revealed this as the only problem identified for Patient #4. The care plan lacked identification of other problems/conditions Patient #4 exhibited and lacked identified services or treatment furnished to Patient #4, a plan to manage risk factors and prevent declines in function, and objectives and goals for treatment. The care plan lacked collaboration of an interdisciplinary team that included the attending medical doctor, physical and occupational therapy, dietary and activity services, and to the extent practicable, Patient #4 and his family. Record review lacked evidence of care plan meetings (care conference) and conversations between interdisciplinary staff in regards to the care of Patient #4.

During interview, on 05/19/10 at 2:10 p.m., an administrative nurse (#1) confirmed staff failed to recognize the collaborated efforts for completion of an interdisciplinary, comprehensive care plan for Patient #4.