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Based on record review, review of Medical Staff Rules and Regulations, and staff interview, the Critical Access Hospital (CAH) failed to ensure a physician or physician assistant was available on site within 30 minutes after patients presented to the emergency department (ED) for treatment for 6 of 21 sampled ED records (Patients #1, #33, #34, #35, #36, and #37). Failure to ensure the availability of a physician or physician assistant delayed treatment, may have placed patients at risk of pain and worsening illness due to delayed treatment, and limited the CAH's ability to ensure the appropriateness of patient care.

Findings include:

Review of the CAH Medical Staff Rules and Regulations occurred on February 28 - March 2, 2011. This document, approved on 07/22/09, stated, "D. GENERAL CONDUCT OF CARE . . . 6. On call Physicians must be available for response and direct patient care within 30 minutes or sooner if the clinical situation warrants."

Review of patient ED records occurred on March 1-2, 2011 and identified the following:
*Patient #1 - presented on 02/25/11 at 2:10 p.m. for shortness of breath. The record lacked documentation of the time the physician/physician assistant saw the patient.
*Patient #33 - presented on 12/28/10 at 12:38 p.m. with abdominal pain. The physician/physician assistant saw the patient at 1:50 p.m. (72 minutes after the patient's arrival).
*Patient #34 - presented on 01/03/11 at 1:50 p.m. with elevated blood pressure. The physician/
physician assistant saw the patient at 3:00 p.m. (70 minutes after the patient's arrival).
*Patient #35 - presented on 01/13/11 at 7:17 a.m. with a kidney stone. The physician/physician assistant saw the patient at 8:30 a.m. (73 minutes after the patient's arrival).
*Patient #36 - presented on 01/17/11 at 7:14 a.m. with abdominal pain. The physician/physician assistant saw the patient at 8:00 a.m. (46 minutes after the patient's arrival).
*Patient #37 - presented on 01/18/11 at 3:28 p.m. for shortness of breath. The physician/physician assistant saw the patient at 5:00 p.m. (92 minutes after the patient's arrival). The CAH admitted the patient.

During interview, on 03/02/11 at 2:30 p.m., an administrative staff member (#3) reported the CAH expects a physician or physician assistant to see patients within 30 minutes after presenting to the ED.

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 1 of 6 compressed gas tanks (nitrogen tank behind partial wall) in Operating Room #3. 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 "Compressed Gases, Storage and Handling" occurred on 03/02/11 at 3:55 p.m. This policy, dated 02/13/08, stated, ". . . III. General Handling Procedures
1. Cylinders must be securely fastened to prevent them from falling or being knocked over. Suitable racks, straps, chains, stands or other devises [sic] are required to support cylinders. . . ."

Observation, on 03/02/11 at 3:50 p.m., identified one nitrogen tank stored unsecured on the floor behind a partial wall in Operating Room #3.

During interview on 03/02/11 at 3:50 p.m., an administrative maintenance staff member (#2) confirmed the CAH staff failed to store the nitrogen tank in a secure manner.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to repair damaged surfaces in 1 of 2 shower rooms on second floor (Room #208). Failure to repair damaged surfaces prevents the CAH from ensuring the cleanliness of the surfaces and safety from injury from rough edges.

Findings include:

Observation, on 03/02/11 at 10:00 a.m., identified the following damaged surfaces in Room #208:
- the entrance to the shower had an approximate 6 inch by 10 inch area near the floor with crumbling sheet rock and exposed, rusted metal framework on the outer edge
- the wall between the shower area and the linen storage area had an approximate 1 inch by 12 inch area gouged and stripped of paint
- the outer door had an approximate 2 inch splinter of wood covered with two to three layers of plastic surgical tape

During interview at 10:00 a.m. on 03/02/11, an administrative maintenance staff member (#2) confirmed the above listed areas needed repair; the CAH could not ensure the cleanliness and safety of the damaged areas; and the maintenance department had not received a work order reporting the damaged areas.

Based on observation, record review, policy and procedure review, review of professional standards, and staff interview, the Critical Access Hospital (CAH) failed to ensure the provision of services by failing to follow acceptable professional standards of care relating to infection control practices (Refer to C278), failing to provide dietary services in accordance with recognized dietary practices (Refer to C279), failing to ensure a means of patient identification (Refer to C294), failing to provide care in accordance with the patient's needs regarding pain management and fall preventions (C295), failing to assess and implement interventions for side rail use (Refer to C295), and failing to ensure nursing staff confirmed patient identification prior to medication administration and tests (Refer to C297). Failure to ensure the provision of services places all of the CAH's patients at risk.

Based on observation, review of professional literature, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to follow acceptable professional standards of care relating to infection control practices for 1 of 1 active swing bed patient (Patient #40) observed receiving a blood glucose test. Failure to follow infection control practices may allow transmission of organisms from equipment to patients, to other patients, to staff, or to visitors.

Findings include:

Centers for Disease Control and Prevention, "Diabetes and Viral Hepatitis: Important Information on Glucose Monitoring", updated 02/23/11, stated, ". . . Any time blood glucose monitoring equipment is shared between individuals there is a risk of transmitting viral hepatitis and other bloodborne pathogens. . . . Following are specific infection control recommendations targeting diabetes care procedures . . . anyone performing fingerstick procedures should review the following recommendations to assure that they are not placing persons in their care at risk. . . . Diabetes Care Procedures And Techniques: . . . Decontaminate environmental surfaces such as glucometers regularly and any time contamination with blood . . . occurs or is suspected. . . . Glucose test meters approved for use with more than one person must be cleaned and disinfected following disinfection guidelines. . . . Hand Hygiene and Glove Recommendations: . . . Change gloves that have touched potentially blood-contaminated objects or fingerstick wounds before touching clean surfaces. . . . Perform hand hygiene . . . immediately after removal of gloves and before touching other medical supplies intended for use on other residents . . ."

Review of the policy "Blood Glucose Monitoring System: Abbott Precision Xceed Pro" occurred on 03/02/11. This policy, dated November 2010, stated, ". . . Patient Glucose Test Procedure: . . . 11. Clean meter after each patient use. . . .Decontamination/Isolation: After every patient use, each meter must be cleaned with Super Sani-Cloth wipes. . . ."

Review of the policy "Standard Precautions" occurred on 03/02/11. This policy, revised June 2008, stated, ". . . Standard Precautions apply to all patients . . . Standard Precautions include the following: . . . 2. Alcohol Hand Rub: . . . use . . . before and after direct patient contact . . . after removing gloves, after contact with . . . equipment in the patient's immediate vicinity . . ."

Review of the policy "Hand-Hygiene" occurred on 03/02/11. This policy, revised October 2010, stated, "I. Purpose: The purpose of this policy is to reduce the risk of transmission of infection to patients and employees. II. Policy: Hand washing is the single most effective way to prevent the spread of organisms and potential infection. . . ."

Observation of blood glucose testing occurred on 02/28/11 at 4:25 p.m. with a nurse (#9). The nurse entered Patient #40's identification information into the blood glucose testing machine in the medication room, picked up the machine and entered Patient #40's room, donned gloves, and performed a blood glucose test on the patient with the machine. The nurse (#9) left Patient #40's room with the blood glucose machine in hand, walked into the medication room, removed gloves, placed the blood glucose machine into its case, and left the medication room. The nurse (#9) failed to disinfect the blood glucose machine after using it on Patient #40 and prior to placing the machine back in its case for use on other patients and failed to wash her hands or perform hand hygiene prior to moving on to other tasks.

During an interview on 03/02/11 at 9:07 a.m., the infection control officer (#19) stated staff must clean and disinfect the blood glucose meter after each patient use and stressed staff must wash their hands or perform hand hygiene after removing gloves to prevent the spread of bloodborne pathogens.

Based on review of the North Dakota Department of Health, Division of Health Facilities provider files, this facility has not sustained correction of this issue. The issue was found to be out of compliance during the previous survey completed in 2008.

Based on observation, review of dietary standards, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the CAH provided dietary services to patients in accordance with recognized dietary practices regarding kitchen sanitation/food preparation and food storage for 2 of 3 (kitchen and nursing unit kitchenette) food preparation storage areas. Failure to follow recognized dietary practices in these areas places patients, staff, and the public who consume food items stored, prepared, and served in the CAH, at risk of food borne illness.

Findings include:

The North Dakota Requirements For Food And Beverage Establishments, North Dakota Administrative Code, Chapter 33-33-04, adopted 01/01/08, states,
". . . 33-33-04-52. Manual warewashing - Sink compartment requirements. 1. A sink with at least three compartments shall be provided for manually washing, rinsing, and sanitizing equipment and utensils. . . . 2. Manual washing, rinsing, and sanitizing must be conducted in the following sequence: a. Sinks must be cleaned prior to use. b. Equipment and utensils must be thoroughly washed in the first compartment with a hot detergent solution that is kept clean and maintained not less than one hundred ten degrees Fahrenheit . . . c. Equipment and utensils must be rinsed free of detergent and abrasives with clean water in the second compartment. d. Equipment and utensils must be sanitized in the third compartment according to one of the methods included in section 33-33-04-53.4. . . . 33-33-04-52.1. Warewashing equipment - Cleaning frequency. . . . the compartments of sinks used for washing and rinsing equipment . . . shall be cleaned: 1. Before use; 2. Throughout the day at a frequency necessary to prevent recontamination of equipment and utensils . . . 3. If used, at least every twenty-four hours. . . . 33-33-04-52.4. Warewashing equipment - Cleaning agents. When used for warewashing, the wash compartment of a sink . . . shall contain a wash solution of soap, detergent, acid cleaner, alkaline cleaner, degreaser, abrasive cleaner, or other cleaning agent according to the cleaning agent manufacturer's label instructions. 33-33-04-52.5. Warewashing equipment - Clean solutions. The wash, rinse, and sanitize solutions shall be maintained clean. 33-33-04-52.6. Manual warewashing equipment - Wash solution temperature. The temperature of the wash solution in manual warewashing equipment shall be maintained at not less than one hundred ten degrees Fahrenheit . . . or the temperature specified on the cleaning agent manufacturer's label instructions. . . . 33-33-04-53.1. Manual warewashing equipment - Hot water sanitization temperatures.* [Note: * indicates a critical item] If immersion in hot water is used for sanitizing in a manual operation, the temperature of the water shall be maintained at one hundred seventy-one degrees Fahrenheit . . . or above. . . . 33-33-04-53.5. Warewashing equipment - Determining chemical sanitizer concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. . . . 33-33-04-107. Storage of materials.* 1. Poisonous or toxic materials consist of the following four categories: a. Pesticides. b. Detergents, sanitizers, and related cleaning or drying agents. . . . 2. . . . All poisonous or toxic materials shall be stored in cabinets or in a similar physically separate place used for no other purpose. To preclude contamination, poisonous or toxic materials shall be separated by spacing or partitioning and shall not be stored above food, food equipment, utensils, or single-service articles . . ."

Review of the policy "Infection Control Practices In Dietary Department" occurred on 03/02/11. This policy, revised December 2010, stated, "Purpose: To control the spread of infectious disease through the use of proper sanitation practices in accordance with state and local health department standards. Policy: Adherence to and implementation of established standards for sanitation and infection control shall be the policy of the Dietary Services Department. Food Handling: . . . Proper handling of foods . . . the use of clean, sanitary equipment, tools . . . and the storage of toxic materials away from all foods will be standard practices. . . . Equipment and Utencils [sic]: 2. All cooking utensils, equipment and work surfaces used in the preparation of food shall be cleaned and sanitized with an effective sanitizing agent after each usage. . . ."

Upon request on 03/02/11, the facility failed to provide a policy regarding monitoring of the concentrations of the solutions and the water temperature in the three compartment sink.

- Observation of the nursing floor kitchenette occurred on 03/01/11 at 8:20 a.m. and identified a cupboard located under the sink labeled "cleaning supplies only." Observation of the contents in the cupboard showed multiple paper products (cups and cup covers, plates, straws, paper towels, and coffee filters) and individual sugar packets available for patient use, stored with an open container of Sani-Cloths (a type of disinfecting wipe) and a bottle of Nickel Safe Ice Machine Cleaner.

- Observation of the kitchen on 03/01/11 at 10:05 a.m., with a dietary staff member (#6), identified a three compartment sink, which the staff member (#6) stated the CAH used regularly every day to wash, rinse, and sanitize equipment and utensils. The three compartment sink included a pre-measured chemical dispenser, which staff member (#6) stated a supplier services on a monthly basis.

During an interview on 03/01/11 at 10:05 a.m., a dietary staff member (#6) reported dietary staff do not regularly monitor the concentrations of the solutions in the three compartment sink or the water temperature, do not maintain a record of solution or temperature monitoring, and do not keep test strips/kits in the kitchen area. The staff member (#6) reported the kitchen staff have relied on the chemical supplier's monthly visits to monitor the three compartment sink solutions and stated the CAH does not have a policy or procedure for monitoring these solutions.

During the same interview, the staff member (#6) stated staff must store chemicals and cleaners separate from patient food or paper products.

Based on observation, review of professional literature, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the identity of hospitalized patients by failing to have a means of identification on the patient throughout their stay in the CAH for 2 of 6 patient (Patients #40 and #41) observations during treatment and medication administration. Failure to ensure identification of patients has the potential to place the patient at risk of improper care or treatment, therefore, risking patient safety.

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, page 712 stated, ". . . Client safety problems can include a variety of errors such as . . . mistaken identity . . ."

Beyea's "Patient Identification: A Crucial Aspect of Patient Safety-Patient Safety First," AORN (Association of Perioperative Registered Nurses) Journal, dated September 2003, stated, ". . . Concern for proper patient identification is evidenced in the 2003 National Patient Safety Goals. One of the six identified goals is to improve the accuracy of patient identification. . . . This basic ritual and routine is integral to the medication administration process, treatments, and procedures. . . . All clinicians need to be concerned with the processes and systems that support correct identification of patients. . . . The importance of this basic practice cannot be minimized. No assumptions about identity can be made. Every clinician providing care for the patient must make it a routine practice to verify identity. . . . a patient has the right to be identified correctly."

Review of the policy "Patient Identification For Clinical Care and Treatment" occurred 03/02/11. This policy, revised July 2009, stated, "Policy: It is the policy of Mercy Hospital to ensure that all patients are properly identified prior to any care, treatment or services provided. . . . Principles Of Identification: A system for positive identification of all patients fulfills two basic functions: To reliably identify the patient as the person for whom the care, treatment, and service is intended . . . To match the care, treatment and service to that person and their medical record. Initial Patient Identification: Mercy Hospital's two patient identifiers to ensure that the right patient receives the right procedure/treatment and report are: Patient name, Patient date of birth . . . The permanent identification band includes the patient's full name, hospital, identification number, medical record number, date of birth, age, gender, primary insurance, & [and] patient status (type). . . . Defective or missing bands are replaced with new bands. . . . Verification For Delivery Of Ongoing Care: The two patient identifiers (name and date of birth) are also used to verify identification for providing ongoing care. . . . Whenever possible, staff verbally assess the patient to assure proper identification, asking the patient's name and date of birth and matching the verbal confirmation to the written information on the identification band . . ."

- Observation of blood glucose testing occurred on 02/28/11 at 4:25 p.m. with a nurse (#9). The nurse performed a blood glucose test on Patient #40 and failed to identify the patient prior to performing the test. Patient #40's wrists lacked an identification band to ensure proper identification of the patient. Upon further observation, Patient #40's room lacked any other means to identify the patient.

- Observation of medication pass occurred on 03/02/11 at 7:45 a.m. with a nurse (#8). The nurse (#8) administered oral medications including Coreg (used to decrease blood pressure and treat heart failure), Lasix (used to decrease swelling or blood pressure), isosorbide (used to treat or prevent chest pain), and K-Lor (used to treat or prevent low potassium levels); and an intravenous medication of hydromorphone (used to treat moderate to severe pain) to Patient #41. The nurse (#8) failed to identify Patient #41 prior to medication administration. Patient #41's wrists lacked an identification band to ensure proper identification of the patient. Upon further observation, Patient #41's room lacked any other means to identify the patient.

During an interview on 03/02/11 at 8:30 a.m., a nurse (#8) stated all patients admitted to the hospital received a name band containing their full name, birthdate, and medical record number and confirmed staff must check a patient's identity prior to administering any medications or treatments. The nurse (#8) stated if the patient wished not to wear the name band, staff would place the band on the bed siderail in the patient's room, as staff could easily access the band to confirm the patient's identity. The nurse (#8) stated she did not confirm Patient #41's identity before medication administration because she knew the patient. She did not realize the patient was not wearing a name band, nor was the name band attached to the patient's siderail. The nurse (#8) admitted the practice as unsafe, adding patients are not always confined to their room, as they may be walking the hallway, in therapy, or in another department for a test/procedure.

During an interview on 03/02/11 at 10:43 a.m., the surveyor informed two administrative nurses (#4 and #5) of the observations and interviews on 02/28/11 and 03/02/11, involving the identification of Patients #40 and #41. The administrative nurses (#4 and #5) stated the CAH's policy is to identify admitted patients by a nameband placed around the patient's wrist, to include name, birthdate, and patient identification number. A nurse (#5) confirmed the CAH utilized travel nurse staff at times and other staff members have contact with patients including providers, laboratory, radiology, and therapy staff. The administrative nurses (#4 and #5) stated they expected staff to place identification bands on all patients and all staff to confirm identification of patients prior to any care, treatment or procedure, regardless of knowing the patient.

1. Based on record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff provided care in accordance with the patient's needs regarding pain for 1 of 1 closed swing bed patient record with an admission diagnosis of back pain (Patient #9). Failure to assess the patient's pain and offer pain medications as ordered may have resulted in Patient #9 experiencing unnecessary pain.

Findings include:

Review of the CAH policy and procedure "Pain Management" occurred on 03/02/11. This document, dated 09/10, stated, ". . . II. POLICY, It is the policy of Mercy Hospital to outline a holistic and multidisciplinary approach to the management of patients experiencing anxiety, discomfort, pain, and/or suffering. . . .
V. QUALIFIED PERSONNEL, This policy applies to direct patient care personnel. . . .
IX. OVERVIEW. . . Through a comprehensive pain assessment, the caregiver can begin to understand the impact of pain on a patient's life. . . .
XIII. ASSESSMENT . . . 6. Assess for physical, behavioral, and emotional signs and symptoms of pain. . . . 7. Assess characteristics of pain . . . d. . . . 1). Be sure to assess patients' pain when they are moving, not just lying in bed or sitting in a chair. Pain intensity often changes with movement. . . .
XXI. PAIN ASSESSMENT . . . To sustain improvements in pain management, a systematic interdisciplinary approach must be implemented and monitored. . . . Standard, At the time of initial evaluation and at least once every 8 hours, all patients will be asked about the presence and intensity of pain. . . . Intervention, Initial and subsequent pain assessments will be documented in the patient's medical record. . . . Standard, A pain rating greater than the patient's comfort goal will trigger an . . . additional analgesic, or other pain relief intervention. . . . Intervention, The patient's medical record will show evidence of the use of a pain relief intervention. . . ."

Review of Patient #9's closed medical record occurred on March 1-2, 2011. The CAH admitted the patient to observation status on 10/05/10, transferred the patient to swing bed status on 10/06/10, and transferred the patient to a tertiary care center on 10/11/10. Admission diagnoses included chronic back pain. The patient's history included two previous spinal compression fractures treated with vertebroplasties.

Patient #9's admission physician orders, dated 10/05/10 at 1:30 p.m., included pain medications Ultram, two, four times each day, and Percocet 5/325, one every four hours as needed. The physician's orders stated, ". . . encourage to take . . ." Physician's orders, dated 10/05/10 at 3:30 p.m., included a reduction of the Ultram to three times each day.

Patient #9 received a magnetic resonance imaging (MRI) study of the lumbar spine on 10/08/10. The MRI report, dated 10/08/10, stated, "IMPRESSION: 1. New inferior endplate compression fracture at L1 [first lumbar vertebrae] with approximately 50% to 55% loss of vertebral body height. . . ." The MRI report identified degenerative changes in the lumbar spine which had progressed from previous studies.

Patient #9's medical record including the Graphic Sheet, Nurse's Notes, Swing Bed Assessment, and medication administration record (MAR) showed the facility staff administered Ultram to Patient #9 at 8:00 a.m., 12:00 noon, and 8:00 p.m. as scheduled. These documents showed the following:
*10/06/10, 7:20 p.m. - pain "8/10 with movement," provided scheduled Ultram, and did not offer or encourage Percocet.
*10/07/10, 8:00 a.m. - back pain radiating to abdomen. Provided scheduled Ultram and did not offer or encourage Percocet.
8:00 p.m. - pain with movement. Provided scheduled Ultram and did not offer or encourage Percocet.
*10/08/10, 11:15 a.m. - pain "5/10," provided scheduled Ultram, and did not offer or encourage Percocet.
*10/08/10, 5:00 p.m. - pain "3/10," offered pain medication, and patient declined.
*10/09/10 - lacked evidence of pain assessments or offer of Percocet after 9:00 a.m.
*10/10/10 - lacked evidence of pain assessments or offer of Percocet.
*10/11/10, 12:20 a.m. - Percocet administered, pain not assessed.
6:10 a.m. - Percocet administered, pain not assessed.
12:00 noon - no pain, as indicated on Graphic Sheet.
4:20 p.m. - Percocet administered at time of discharge.

The CAH staff failed to assess Patient #9's pain at least every eight hours per facility policy during a 51 hour time period and failed to offer Percocet for pain as ordered by the physician for a period of 39 hours.


2. Based on record review, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure care provided in accordance with the patients' needs regarding prevention of falls for 2 of 3 closed patient records (Patient #11 and #12) who experienced falls in the CAH. Failure to provide care according to the patients' needs may have contributed to the patients' falls and related injuries.

Findings include:

Review of the CAH policy and procedure "FALLS," occurred on 03/02/11. This document, dated 10/09, stated, ". . . II. POLICY, For patients identified at risk for falls, interventions will be implemented to prevent falls and maintain safety. At a minimum: . . .
B. Implement Required Fall Prevention Interventions and as appropriate the interventions from the Recommended Fall Prevention Interventions. . . . 2. Universal Interventions - required and recommended interventions for all patients . . .
III. QUALIFIED PERSONNEL, In a broad sense, this policy applies to all employees as active participants in the prevention of patient falls. . . .
V. STAFF EDUCATION, All facility staff should be educated about universal fall preventions and their role as a patient advocate in preventing falls and related injuries. Education for patient care staff should include the specific requirements of this policy in assessing and caring for the patient and their environment. . . .
IX. PROCEDURE, This procedure serves as a guideline to assist personnel in accomplishing the goals of the policy. . . .
H. Implement Fall Prevention Interventions: . . .
2. Required Universal Fall Prevention Interventions: . . .
f. Gait belt where appropriate when patient
requires assistance with balance for
ambulation or transfer. . . .
m. Supervision and assistance with
elimination, transfer and ambulation
activities. . . ."

- Review of Patient #12's closed medical record occurred on March 1-2, 2011. The CAH admitted the patient to swing bed status on 12/16/10 with orthostatic hypotension, weakness, and deconditioning after heart valve replacement and pacemaker placement.

Patient #12's care plan, updated 12/17/10, stated, ". . . PROBLEM, 5. Potential for fall related to hospitalization and Autonomic Syncopy [sic] R/T [related to] hypotention [sic] (orthostatic) . . . INTERVENTION . . . 3) Assist all [sic] all times [with] gait belt & [and] waker [sic] . . ."

Patient #12's nurse's notes, dated 12/31/10 at 1:50 a.m., stated, "(D) [Data] Pt. [Patient] up to BR [bathroom] [with] SBA [standby assistance] of i [one]. When ambulating from BR, pt. lost balance & fell forward. Hit bedside table. CNA [Certified Nursing Assistant] [name] present & called for help. Upon arrival to room there was a pool of blood. . . . Relates pain to (Lt) [left] eye. . . .;" and at 2:10 a.m., stated, "(D) Pt. transferred to ER [emergency room] for CT [computerized tomography] & continued assess . . ." The nurse's notes lacked information the CNA assisted Patient #12 with a gait belt as required in the care plan.

Patient #12's CT report, dated 12/31/10, stated, "CERVICAL SPINE: Noted are fractures of the proximal 1st rib on the left and the proximal 2nd rib on the right. Question of some callous formation on the left side which would indicate an old injury and not necessarily one related related to the acute trauma."

Patient #12's Discharge Summary, dated 12/31/10, stated, "FINAL DIAGNOSIS: Extensive left forehead injury with left forehead laceration, 4 cm [centimeters], with left upper eyelid injury with laceration. T1 [First thoracic vertebrae] transverse [process] fracture, unclear if it is new or old. . . .
SUMMARY . . . HISTORY AND PHYSICAL . . . The patient this evening had gotten up to go to the bathroom. Was being assisted back to bed and attendant had turned around and had not watched the patient for just a moment, was with him and the patient had fallen to the floor and he hit his head on the bedstand with hyperflexion of his neck. . . .
DAY OF DISCHARGE . . . The patient did have suctioning that was required of his mouth due to extensive nasal bleeding . . ." The medical record identified the CAH transferred Patient #9 to a tertiary care center by ambulance.

Review of the CAH's Incident Reporting Information System documentation confirmed the CNA left the patient unattended for a brief period and lacked information regarding use of a gait belt. Failure to provide assistance to Patient #12 during ambulation and use of a gait belt may have resulted in the patient's fall and injuries.

- Review of Patient #11's medical record occurred on March 1-2, 2011. The CAH admitted the patient on 11/22/10 with diagnoses including weakness. Physician orders on admission included, "BRP [Bathroom privileges] [with] help."

Patient #11's care plan, dated 11/22/10, stated, ". . . PROBLEM, 5. Potential for fall related to . . . weakness . . . INTERVENTIONS . . . 2. Implement universal fall prevention interventions . . . Assist of i [one] when up . . ."

Patient #11's nurse's notes, dated 11/23/10 at 12:05 a.m., stated, "Pt. [Patient] A/O [alert/oriented], color pale. . . . Is [sic] generalized weakness . . .;" and at 5:15 a.m., identified a staff member assisted the patient to the bathroom, visited with the patient while the patient was on the toilet, the patient became weak, and Patient #11 fell off the toilet. The CAH's Fall Event Report, dated 11/23/10 at 5:15 a.m., stated, "Description of Event: Pt. [Patient] assisted to the bathroom with nurse. Nurse helped pt. to toilet. Nurse went to straighten pt.'s bed. Pt. was sitted [sic] on the toilet and fell to the side of the toilet. Bruise noted to left eye and laceration by left ear. Pt. denies any pain or discomfort."

Patient #11's admission diagnoses, care planning, and assessment of weakness identified the patient was at risk of falls. Failure to monitor Patient #11 in the bathroom may have resulted in her fall from the toilet and resultant injuries.

During interview, on 03/02/11 at 2:30 p.m., an administrative staff member (#3) reported the CAH did not have additional information available regarding Patient #11's and Patient #12's falls.


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3. Based on observation, record review, policy and procedure review, review of professional literature, 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 4 of 4 active patient (Patient #1, #2, #3, and #4) records reviewed. Failure to assess and evaluate the use of side rails has the potential to place patients at risk for injury and restrict a patient's movement.

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, have 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 the policy "Siderail Policy" occurred on 03/02/11. This policy, reviewed 04/01/10, stated, "Siderails are considered protective devices. Top siderails are used on all beds to enhance mobility and to ease use of bed controls. Beds are to be in the 'low' position except when nursing care is being provided. Policy: Use of full siderails at any time will be based on assessed patient needs, and not be used routinely in any nursing unit. Siderail use is documented . . . for all patients. Full siderails may be used when a patient shows judgment/behavior which indicates his/her safety may be jeopardized. Under these circumstances the Restraint Policy and Procedure is followed. When a patient requests full siderails be used the request is documented . . ."

Review of the policy "Restraint Policy and Procedure" occurred on 03/02/11. This policy, undated, stated, "Purpose: To protect patient rights, dignity, safety, and well-being. To provide guidelines/criteria for appropriate utilization of restraints. To comply with CMS [Centers for Medicare and Medicaid] -COP [Conditions of Participation], State Department of Health Standards. Policy: Patients have the right to be free from any physical or chemical restraint . . . that is not required to treat the patient's current assessed needs. . . . It is the policy of Mercy Hospital to treat all patients with the least restrictive measures consistent with patient . . . safety, and to reduce the use of restraints through alternative or preventive measures. The use of restraints will be limited to clinically appropriate and justified situations as identified by utilization of the approved criteria and through comprehensive assessment of the patient and plan of care. Restraints should only be utilized when least restrictive measures have been ineffective or not a viable option. . . . The order for restraints must include: Date and time of order; Duration of restraint (time limited); Type of restraint; Reason for restraint (clinical justification); . . . When a patient is restrained, an RN [registered nurse] documents . . . while the restraint is in place. . . . Education of Qualified Staff: Purpose is to decrease the use of restraints and provide awareness of appropriate and justified use of restraints for emergency situation where there is imminent risk of a patient harming themselves, or others. . . . Examples Of Types Of Restraints: . . . Side rails . . . Full side rails . . ."

Review of the facility's "Safety Committee" meeting minutes occurred 03/02/11. The minutes, dated 03/09/10, stated, ". . . New Business: Bedrail Safety: In response to alerts that have been published about bedrail safety, it was reported that an assessment was made of Mercy's patient beds. It was found that beds likely do not meet the standards for bedrail safety. Shared was the research into the cost of bedrail modification (~$400/each). Following discussion and considering our typical patient type, committee felt that the cost of modifications outweighs the practicality of modifying all beds and alternatively suggest to Nursing and Risk Management that one set of the modification pads be ordered and available for instances when patient is identified as at risk of this safety alert and further recommended that Nursing and Risk work on developing an assessment tool to trigger identification of patients at risk. . . ."

Observation of the beds utilized on the nursing unit occurred on February 28 - March 1, 2011. The beds utilized by the current inpatient and swing bed patients differed in style or make, but all had four half rails, two half rails on each side, attached to the beds. Measurements of one type of bed, located specifically in Patient #4's room (Room 202) identified 5 1/4 to 7 1/4 inch open spaces within the rails. Measurements of another type of bed, located specifically in Patient #3's room (Room 218) identified 7 1/4 to 9 inch open spaces within the rails.

Observations of two current swing bed patients (Patients #3 and #4) and one inpatient (Patient #1) while they rested in bed, on February 28 - March 2, 2011, identified two elevated upper half rails on their beds. Observations of another inpatient (Patient #2) while resting in bed, identified three elevated half rails on the patient's bed on February 28 - March 1, 2011, and four elevated half rails on the patient's bed on 03/02/11. The CAH staff implemented side rails without risk and safety or restraint assessments.

- Review of Patient #2's active inpatient record occurred on February 28 - March 2, 2011 and identified the CAH admitted the patient on 02/23/11. Patient #2's Fall Risk Indicator section on the "Daily Assessment" form, from February 28 - March 2, 2011, identified the patient at high risk for falls. The Neurological section on the "Daily Assessment" form, from February 28 - March 2, 2011, indicated Patient #2 as disoriented, lethargic, and unresponsive at times, and the activity section revealed the patient as bedfast.

The record lacked an individualized assessment of risk and safety for the utilization of side rails. The record lacked evidence Patient #2 exhibited any medical or behavioral need for the four elevated side rails on 03/02/11 and clinical interventions tried, as well as outcomes, to promote safety, lacked a physician's order for the four elevated side rails, and documentation of monitoring Patient #2 during the time of elevated side rails. The CAH staff failed to consider the side rails as a potential entrapment and safety hazard, and as a restraint during the time of elevation of all four half rails.

- Review of Patient #1's active inpatient record occurred on February 28 - March 1, 2011 and identified the CAH admitted the patient on 02/25/11. Review of Patient #1's "Morse Fall Risk Assessment" upon admission and during the hospital stay, identified the patient at high risk for falls. The record lacked an 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 and safety hazard.

- Review of Patient #3's active swing bed record occurred on February 28 - March 1, 2011 and identified the CAH admitted the patient on 02/22/11. Review of Patient #3's "Morse Fall Risk Assessment" upon admission and during the hospital stay, identified the patient at high risk for falls. The record lacked an 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 and safety hazard.

- Review of Patient #4's active swing bed record occurred on 03/02/11 and identified the CAH admitted the patient on 02/22/11. The record lacked an 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 and safety hazard.

During an interview on 02/28/11 at 4:30 p.m., a nursing staff member (#9) stated staff elevate the two upper half side rails to protect patients from falling out of bed and per patient/family request for positioning and access to bed controls/call light. The nurse (#9) stated staff does not perform or document an assessment for the utilization of side rails.

During an interview on 03/02/11 at 10:43 a.m., two administrative nursing staff members (#4 and #5) confirmed staff elevate the two upper half rails per patient/family request for safety, positioning, and access to bed controls/call light and staff does not perform or document an assessment for utilization of side rails. The nurses (#4 and #5) confirmed the CAH considers four elevated half rails as a restraint and staff should use only when clinically necessary. An administrative nurse (#5) stated the CAH failed to consider the bedrails a risk for safety and a potential hazard for entrapment.

Based on observation, review of professional literature, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure nursing staff administered medications and performed tests according to accepted standards of practice during 6 of 6 medication administration observations (Patients #1 on 02/28/11 and 03/01/11, #3, #41, #42, and #43) and 1 of 1 test observations (Patient #40). Failure to confirm identification of a patient prior to medication administration and tests, risked patient safety and has the potential for staff to administer medication or perform tests on the wrong 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, page 712 stated, ". . . Client safety problems can include a variety of errors such as . . . mistaken identity . . ."

Pages 848-849, stated, ". . . Process of Administering Medications. When administering any drug, regardless of the route of administration, the nurse must do the following: 1. Identify the client. Errors can and do occur, usually because one client gets a drug intended for another. One of the . . . National Patient Safety Goals is to improve the accuracy of client identification. This goal requires a nurse to use at least two client identifiers whenever administering medications. Neither identifier can be the client's room number. Acceptable identifiers may be the person's name, assigned identification number, telephone number, photograph, or other person-specific identifier . . . In hospitals, most clients wear some sort of identification, such as a wristband with name and hospital identification number. Before giving the client any drug, always check the client's identification band. . . . 3. Administer the drug. . . . There are aspects of medication administration that are important for the nurse to check each time a medication is administered. These are referred to as the 'rights.' Traditionally there were five rights to medication administration. More rights have been added . . . with the latest being the ten rights."

Page 850, Box 35-4 stated, "Ten 'Rights' of Medication Administration . . . Right Client. Medication is given to the intended client. Check the client's identification band with each administration of a medication. . . ."

Page 852-854, Skill 35-1 stated, "Administering Oral Medications . . . Performance . . . 6. Prepare the client. Check the client's identification band. Rationale: This ensures that the right client receives the medication. . . ."

Review of the policy "Medication: Safe Administration" occurred on 03/02/11. This policy, dated 04/01/10, stated, "Policy: To ensure accurate, safe, and efficient administration of medication. . . . Medication Safety Principles: 1. Every dose of medicine is potentially dangerous. . . . 5. Follow 'The Five Rights of Medication Safety': . . . b. Right patient - Check the room and bed number as well as identify patient with at least two identifiers, such as stated name and date of birth. . . . Administering Medication Protocol: . . . 3. Check patient identification by checking patient's name band and asking patient to state name and date of birth. . . ."

Review of the policy "Blood Glucose Monitoring System: Abbott Precision Xceed Pro" occurred on 03/02/11. This policy, reviewed November 2010, stated, ". . . Patient Glucose Test Procedure: . . . 4. Identify patient according to Patient Identification Policy. 5. At the Patient ID [identification] screen, manually enter patient ID number via the keypad . . . 6. At the 'Confirm Patient ID' screen, reenter Patient ID using the keypad. ***Both Patient ID entries must match before testing continues*** . . ."

Review of the policy "Patient Identification For Clinical Care and Treatment" occurred 03/02/11. This policy, revised July 2009, stated, "Policy: It is the policy of Mercy Hospital to ensure that all patients are properly identified prior to any care, treatment or services provided. . . . Initial Patient Identification: Mercy Hospital's two patient identifiers to ensure that the right patient receives the right procedure/treatment and report are: Patient name, Patient date of birth . . . The permanent identification band includes the patient's full name, hospital, identification number, medical record number, date of birth, age, gender, primary insurance, & [and] patient status (type). . . . Verification For Delivery Of Ongoing Care: The two patient identifiers (name and date of birth) are also used to verify identification for providing ongoing care. . . . Patient identification is confirmed using the two-identifier system prior to conducting any medication . . . obtaining . . . specimens from the patient, performing a treatment, performing a diagnostic test . . . Whenever possible, staff verbally assess the patient to assure proper identification, asking the patient's name and date of birth and matching the verbal confirmation to the written information on the identification band . . ."

- Observation of medication pass occurred on 02/28/11 at 3:45 p.m. A nurse (#10) prepared to administer intravenous (IV) medications of fentanyl (used to treat persistent, moderate to severe pain) and ondansetron (used to prevent or treat nausea and vomiting) to Patient #42. The nurse (#10) entered Patient #42's room and administered the medications through an IV line to the patient. Observation showed the nurse (#10) failed to identify the patient prior to medication administration.

- Observation of medication pass occurred on 02/28/11 at 4:15 p.m. A nurse (#9) prepared to administer IV medications of Levaquin (used to treat infections) and Solu-medrol (used to decrease inflammation) to Patient #1. The nurse (#9) entered Patient #1's room and administered the medications through an IV line to the patient. Observation showed the nurse (#9) failed to identify the patient prior to medication administration.

- Observation of medication pass occurred on 03/01/11 at 7:55 a.m. A nurse (#12) prepared to administer Librium (used to treat anxiety) orally to Patient #3. The nurse (#12) entered Patient #3's room, administered the medication in pudding, and witnessed the patient swallow the medication. Observation showed the nurse (#12) failed to identify the patient prior to medication administration.

- Observation of medication pass occurred on 03/01/11 at 8:15 a.m. A nurse (#12) prepared to administer oral medications including Cymbalta (used to treat depression or anxiety), Senna Plus (used to treat or prevent constipation), Ferrous Sulfate (used as an iron supplement), aspirin (used as a mild blood thinner to prevent clots), Thera-plus Vitamin (used as a multivitamin), metoprolol tartrate (used to decrease blood pressure), and furosemide (used to decrease fluid or blood pressure); an IV medication of Solu-medrol; and a transdermal patch of nitroglycerin (used to prevent or treat chest pain) to Patient #1. The nurse (#12) entered Patient #1's room, handed the patient a medication cup containing the oral medications and witnessed the patient swallow the medications, administered the IV medication through an IV line, and applied the transdermal patch to Patient #1. Observation showed the nurse (#12) failed to identify the patient prior to medication administration.

- Observation of medication pass occurred on 03/02/11 at 7:38 a.m. A nurse (#13) prepared to administer a subcutaneous medication of Humulin R (used to treat diabetes) to Patient #43. The nurse (#13) entered Patient #43's room and injected the medication into the patient's abdomen. Observation showed the nurse (#13) failed to identify the patient prior to medication administration.

- Observation of medication pass occurred on 03/02/11 at 7:45 a.m. A nurse (#8) prepared to administer oral medications including Coreg (used to decrease blood pressure and treat heart failure), Lasix (used to decrease swelling or blood pressure), isosorbide (used to treat or prevent chest pain), and K-Lor (used to treat or prevent low potassium levels); and an intravenous medication of hydromorphone (used to treat moderate to severe pain) to Patient #41. The nurse (#8) entered Patient #41's room, handed the patient a medication cup containing the oral medications, and witnessed the patient swallow the medications. Observation showed the nurse (#8) failed to identify the patient prior to medication administration.

- Observation of blood glucose testing occurred on 02/28/11 at 4:25 p.m. with a nurse (#9). The nurse entered Patient #40's identification information into the blood glucose testing machine in the medication room, picked up the machine and entered Patient #40's room, donned gloves, and performed a blood glucose test on the patient with the machine. The nurse (#9) failed to identify the patient prior to performing the test and failed to enter Patient #40's identification information into the machine in the presence of the patient. Patient #40's wrists lacked an identification band to ensure proper identification of the patient. Upon further observation, Patient #40's room lacked any other means to identify the patient.

During an interview on 03/02/11 at 8:30 a.m., a nurse (#8) stated she forgot to identify Patient #41 during medication pass on 03/02/11 at 7:45 a.m., before medication administration because she knew the patient and confirmed CAH policy requires staff to identify patients prior to medication administration.

During an interview on 03/02/11 at 10:43 a.m., two administrative nurses (#4 and #5) stated the CAH's policy is to identify patients with two identifiers, including name and birthdate, prior to performing tests or medication administration. The nurses (#4 and #5) stated they expected staff to obtain identification information from the patient (have the patient speak their name and birthdate) or by the patient's medical record (medication administration record, test order form) and compare the information with the patient's nameband.

Based on record review, review of Medical Staff Rules and Regulations, and staff interview, the Critical Access Hospital (CAH), failed to ensure accurate documentation of operative reports for 2 of 7 closed sampled surgical patient records (Patients #25 and #26) and discharge summaries for 2 of 11 closed sampled acute and swing bed records (Patients #11 and #12). Failure to ensure the operative reports included complications experienced during the procedures and failure to include pertinent information in the discharge summaries did not provide a true and accurate record of the patients' hospitalizations and limited the CAH's ability to ensure quality patient care.

Findings include:

Review of the CAH's Medical Staff Rules and Regulations occurred on February 28 - March 2, 2011. This document, approved 07/22/09, stated, "B. MEDICAL RECORDS, 1. The attending practitioner shall be responsible for the preparation of a complete . . . medical record for each patient. Its contents shall be pertinent . . . 6. Operative reports shall include a detailed account of the findings at surgery as well as the details of the surgical technique. . . . 12. A discharge summary shall be written or dictated on all medical records of patients hospitalized under acute, observation or swing bed services. The content of the discharge summary shall be sufficient to justify the diagnosis, treatment, and end results. . . ."

- Review of Patient #25's closed surgical medical record occurred on March 1-2, 2011. The CAH admitted the patient to same day surgery on 11/15/10 for a screening colonoscopy.

Patient #25's IV [intravenous] Sedation Flowsheet, dated 11/15/10, stated, "Vagal response [with] HR [heart rate] 30's [beats per minute] [arrow down - decreased] BP [blood pressure]. . . . Procedure stopped. . . ." The Flowsheet identified medications administered, heart rate and blood pressure returned to pre-operative levels.

Patient #25's operative report, dated 11/15/10, lacked any information regarding the patient's reduced heart rate and blood pressure.

- Review of the CAH's surgical procedure log occurred on 02/28/11. This document identified the CAH admitted Patient #26 on 11/09/10 for an esophagogastroduodenoscopy with complications of "bronchospasm" (smooth muscle contraction of the bronchi causing obstruction of the airway).

Review of Patient #26's closed surgical medical record occurred on March 1-2, 2011. The patient's IV Sedation Flowsheet, dated 11/09/10 at 10:18 a.m., stated, "Stridor [noisy breathing which may be associated with airway obstruction]. Jaw thrust. Lidocaine given to [arrow down - decrease] spasm. [Arrow up - increased] air movement. . . ."

Patient #26's operative report, dated 11/09/10, lacked any information regarding the patient's bronchospasm and stated, ". . . Patient tolerated the procedure well. . . ."

- Review of Patient #11's medical record occurred on March 1-2, 2011. The patient experienced a fall in the CAH on 11/23/10 resulting in a bruise to the left eye and a laceration at the left ear. Patient #11's discharge summary, dated 11/26/10, lacked information regarding the fall and injuries.

- Review of Patient #12's medical record occurred on March 1-2, 2011. The CAH admitted the patient to the swing bed unit on 12/16/10. The patient received dressing changes to his left knee for a draining wound. The wound culture was positive for methicillin resistant staphylococcus aureus (MRSA). The patient experienced a fall in the CAH on 12/31/10 resulting in a forehead laceration and possible fractures of the first thoracic ribs.

A physician staff member (#15) treated Patient #12 in the CAH's emergency department (ED) after the fall and coordinated the patient's transfer. This staff member (#15) completed a discharge summary, dated 12/31/10, which focused on Patient #12's fall, his injuries, and the treatment provided in the ED. The discharge summary lacked information regarding Patient #12's knee wound and positive culture for MRSA.

Patient #12's medical record included a handwritten note, undated and unsigned, to the patient's attending swing bed physician (#16) which stated "[Physician staff member (#15)] dictated on the ER [emergency room] visit before transfer but we need you to do a disch. [discharge] summary to give patients [sic] course while in swing bed. . . . Please include info on knee wound & [and] 'bug.' "

During interview, on 03/02/11 at 2:00 p.m., a medical records management staff member (#14) reported the CAH did not monitor the content of the operative reports. This staff member agreed the operative reports and discharge summaries for these patients failed to accurately document the patients' stays at the CAH.

This staff member (#14) confirmed a medical records department staff member wrote the note to the staff member (#16) regarding the need for more information on Patient #12's discharge summary. This staff member (#14) reported administration staff reviewed Patient #13's discharge summary and determined it adequate.

Failure to document complications in the operative reports did not allow the CAH to track and trend these complications and the possible effects on patient recovery or outcome. Failure to include information regarding Patient #11's fall and Patient #12's knee wound and MRSA did not provide accurate summaries of the patients' stays. Failure to correct Patient #12's record after identification by the CAH staff did not comply with the Medical Staff Rules and Regulations.

Based on review of policy and 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 1 of 1 physician peer record reviewed who performed ophthalmological procedures at the CAH in 2010 (Physician #1). By failing to perform peer review, the CAH cannot ensure the physician performing ophthalmological procedures provided quality and appropriate care to the CAH's patients.

Findings include:

Review of the policy titled "Medical Staff Performance Improvement/Risk Management/ Utilization Review Activities Process" occurred the morning of 03/02/11. This policy, revised 12/2010, stated, ". . . Medical Staff Performance Improvement Activities:
1. The Medical Staff Performance Improvement/ Risk Management/Utilization Review Committee (MSPI) fulfills the Medical Staff Bylaws, Rules and Regulations and Mercy Hospital's Performance Improvement/Risk/Management/Utilization Management Plan regarding continuous quality monitoring and evaluation of Medical Staff functions that contribute to the preservation and improvement of the quality, appropriateness, timeliness, efficiency, and efficacy of the patient care provided in the hospital. The Medical Staff utilizes the outcome of the quality of care reviews to recommend appointment and reappointment, determine clinical privileges, plan for continuing education, and change or revise patient care processes or services."

Reviewed at 2:30 p.m. on 03/02/11, the 2010 peer review records lacked evidence a provider with the same qualifications/privileges reviewed the quality and appropriateness of the diagnosis and treatment furnished by a physician (#1) who performed ophthalmological procedures at the CAH in 2010.

During interview at approximately 2:40 p.m. on 03/02/11, an administrative nursing staff member (#3) confirmed a provider with the same qualifications/privileges did not review the quality and appropriateness of the diagnosis and treatment furnished by Physician #1 who performed ophthalmological procedures at the CAH in 2010.

Based on observation, review of policy and procedure, record review, and staff interview, the Critical Access Hospital (CAH) failed to provide an on-going program of activities for 2 of 2 swing bed patients (Patient #3 and #4) currently hospitalized, and failed to ensure a qualified professional directed the activities program for swing bed patients. Failure to provide meaningful activities with respect to each patient's individualized interests, physical, mental, and psychosocial needs, does not allow patients the opportunity to maximize their highest practicable quality of life and overall well-being.

Findings include:

Review of the policy "Recreation Therapy (Activities)" occurred on 03/02/11. This policy, revised September 1993, stated, "I. Scope of Program: A. The activities program shall provide for a balance of activities to meet the inter-related needs and interests of the Swing Bed patients . . . B. Activities shall be designed to promote the personal growth and improve the self-image and functioning level of participants by providing opportunities . . . C. Activities shall respond to individual differences in health status, lifestyle, intensity, religious affiliations, values, experiences, needs, interests, abilities, skills and age by providing opportunities for a variety of types and levels of involvement. Activities shall include but not be limited to the following: small and large group activities, individualized activities, individual activities for bed-confined patients, active and spectator participation, intergenerational experiences . . . E. Activities shall emphasize individual strengths and abilities . . . F. All program activities shall be supervised by program staff. . . . II. Planning: A. Recreational activities are available (and strongly encouraged) to all swing bed patients in the hospital. B. These services are available on third floor . . . Monday through Saturday . . . C. It is desired that patients participate in activities at least 3 times weekly, but ideally on a daily basis. D. Activities are planned by the Activities Coordinator, with the assistance of the Activities Aide, and approved by the physician. E. The plan for, and conduct of, the activities plan is an ongoing process and shall be reviewed, revised, and evaluated as necessary. F. Nursing staff are available during scheduled periods for activities to meet any physical needs of the patient. III. Scheduling: A. A monthly calendar of activities shall be prepared and posted. . . . B. Daily activities and services shall be posted in a visible location within the unit and in each patient room. C. Patients . . . shall have the opportunity to evaluate activities and plan future activities on a monthly basis. D. Planned activities are provided 6 days per week on a regular basis. Occasional evening/Sunday events are scheduled as appropriate. IV. Staffing: A. One full time Activity Coordinator B. One full time Restorative Aide/Activity Assistant C. Activity Director to consult with Activity Coordinator on a weekly basis. V. Charting: A. The Activities Coordinator shall be responsible for initiating and maintaining a record of the patients involvement and attendance in specific activities. B. Within 7 days of admission to Swing Bed, the Activities Coordinator does an assessment of the patient . . . C. A monthly progress note and ongoing revision of the patients' recreational therapy plan of care is included in the record. 1. The 'Recreational Activities Attendance and Progress Record' is used, which shows attendance in specific areas of activities on a daily basis. 2. A progress summary is made on a monthly basis. 3. Both the Activities Coordinator and Activities Aide chart on this form. . . . D. The Activities Coordinator and/or Activities Aide actively participates in the multi-disciplinary care plan conferences for each Swing Bed patient."

- Review of Patient #3's active swing bed record occurred on February 28 - March 1, 2011. The record identified the CAH admitted the patient on 02/22/11 for wound care to multiple fingers post amputation and rehabilitation with occupational therapy. Patient #3's physician ordered a restorative therapy aide upon admission. A certified nursing assistant (CNA) performed an activities assessment on 02/23/11. Review of the "Activities Assessment Form" showed Patient #3 enjoyed movies, news, radio, visiting, walking, and cards. A note written by the CNA on the assessment stated, "hard to do activities re: hands are bandaged."

Patient #3's medical record lacked the development and implementation of a care plan regarding individualized activities to ensure the patient received or participated in activities appropriate for the patient. The progress notes lacked documentation of outcomes/responses to activity interventions.

Review of nurse notes identified the following:
02/22/11 at 3:20 p.m.: "Pt. [patient] very beligerant [sic] threatening to go home. . . ."
02/22/11 at 4:15 p.m.: "Pt. up walking had pulled his dressing off Lt [left] hand. . . . Asking if police have been called. Still wanting to go home."
02/22/11 at 7:00 p.m.: "Awake [and] pacing around the floor. Pulled dressing to Rt [right] hand off . . . Keeps saying he has to go home."
02/23/11 at 9:30 a.m.: ". . . Confused but only slightly irritated. . . ."
02/23/11 at 3:30 p.m.: "Pt. up walking around. Restless . . ."
02/24/11 at 8:30 p.m.: "Pt. pacing in hallway unsure of why he is still in Hospital. Attempting to pack suitcase. Also chewing on drsgs [dressings] and trying to take off. . . ."
02/26/11 at 11:00 a.m.: ". . . Pacing in halls and agitated about going home and unable . . ."
02/28/11 at 12:35 p.m.: "Dr. [doctor] . . . notified of . . . how he really wants to drive downtown to go get a pack of cigarettes. Also relates to when drinking his coffee, he wants to be smoking. . . ."
03/01/11 at 8:30 a.m.: "Alert but forgetful. . . . Is skeptical about taking his meds [medications]. Thinks he's going home today."
03/01/11 at 10:00 p.m.: ". . . 'I'm not taking any of these pills' . . . he cont. [continued] to refuse. He is confused and does not believe that he had his fingers amputated. . . . he became frustrated . . ."

Observation throughout the day on February 28 - March 1, 2011 showed staff interacting with Patient #3 during cares, but often showed Patient #3 alone in his room, pacing the hallways and his room, and standing at the nurses station. Patient #3's room lacked a calendar for planned monthly activities.

Review of Patient #3's "Activity Therapy Service Record Log" from February 22-March 01, 2011 indicated the following: walking (20 minutes to an hour daily), TV/Radio/Movie (1 to 4 hours a day), Sensory-Lotion Rubs (5 minutes for 3 days), Visiting 1:1 (15 to 30 minutes a day), and Company (30 minutes for 4 days).

Review of the above activity participation records for Patient #3 showed CAH staff failed to provide a meaningful activity program for the patient including suitable in-room activities, one on one activities, and group activities to ensure the CAH met the patient's everyday physical, mental, and psychosocial needs. A lack of structured activities may have contributed to Patient #3's behaviors of agitation and irritability.

- Review of Patient #4's active swing bed record occurred on 03/02/11. The record identified the CAH admitted the patient on 02/22/11 for recovery from a perinephric hematoma with additional diagnoses of schizoaffective disorder, chronic depression, and bipolar disorder. Patient #4's physician ordered a restorative therapy aide upon admission. A certified nursing assistant (CNA) performed an activities assessment on 02/23/11. Review of the "Activities Assessment Form" showed Patient #4 enjoyed TV, radio, visiting, walking, crafts, one on one activities, rosary, singing, getting hair washed, and group cards.

Patient #4's medical record lacked the development and implementation of a care plan regarding individualized activities to ensure the patient received or participated in appropriate activities. The progress notes lacked documentation of outcomes/responses to activity interventions.

Observation throughout the day on February 28 - March 1, 2011 showed staff interacting with Patient #4 during cares, but often showed Patient #4 alone in her room lying in bed and walking in the hallways. Patient #4's room lacked a calendar for planned monthly activities.

Review of Patient #4's "Activity Therapy Service Record Log" from February 22 - March 2, 2011 indicated the following: walking (15 to 30 minutes daily), Pastor Visits (10 minutes for 4 days), TV/Radio/Movie (2 to 3 hours a day), Cards/Games/Puzzles (30 minutes for 2 days), Sensory-Lotion Rubs (5 minutes for 2 days), Visiting 1:1 (10 to 15 minutes a day), and Company (1 to 3 hours a day).

Review of the above activity participation records for Patient #4 showed CAH staff failed to provide a meaningful activity program for the patient including suitable in-room activities, one on one activities, and group activities to ensure the CAH met the patient's everyday physical, mental, and psychosocial needs.

During an interview on 02/28/11 at 5:50 p.m. a nurse (#10) stated the CAH is currently developing an activity program directed by a CNA. The nurse (#10) stated at the present time, nursing staff (nurses and nurse aides) offered activities to patients and stated every now and then a volunteer visited the CAH and provided crafts for those patients who wished to participate.

During an interview on 03/01/11 at 5:30 p.m. a nurse (#7) showed the surveyor an activity room down the hall from the nurse station, but stated the CAH had not used the room. The nurse (#7) reported the CAH had no formal activity program, patients most often stay in their rooms alone, and stated patients do not receive activities as they should. The nurse (#7) reported Patient #3 could benefit from a formal activity program to keep him preoccupied helping to control his behaviors.

During interview, on 03/02/11 at 7:30 a.m., a licensed occupational therapy staff member (#1) reported she had been responsible for the activities program until approximately one year ago. This staff member reported the CAH did not have a designated responsible individual for the activities program. This staff member reported she did not provide consultation or direction nor was she aware of any consultant for the activities program. This staff member (#1) reported the CNAs were responsible for the swing bed activities program, including assessment of individual patient interests, providing the activities program to the patients, and documentation of the patient activities program.

During an interview on 03/02/11 at 10:43 a.m., two administrative nurses (#4 and #5) reported a designated CNA is responsible to perform the swing bed activity assessments on patients and stated nursing staff is responsible to provide activities to the patients. An administrative nurse (#5) admitted the CAH's activity program has been inactive for the last year and confirmed the CAH lacked a qualified staff member as director of the program. The administrative nurse (#5) agreed Patient #3 and other swing bed patients would benefit from activities outside their room where the patients could interact with other people, especially when the patients were hospitalized for several weeks or months.


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