The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

KENMARE COMMUNITY HOSPITAL PO BOX 697 KENMARE, ND 58746 Nov. 1, 2017
VIOLATION: POLICIES - INFECTION CONTROL Tag No: C0278
Based on review of infection control reports and logs, review of facility policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases for all inpatients and outpatients of the CAH for the past 11 of 11 months (November 2016 through September 2017) reviewed. Failure to identify and address incidents of infections among all patients and personnel has the potential for infections to go unreported, spread, or reoccur; affecting the health of all patients, personnel, and visitors of the CAH.

Findings include:

Review of the facility's policy titled "Infection Control Surveillance" occurred on 10/31/17. This policy, reviewed September 2013, stated, "PURPOSE: To collect data for the purpose of reducing the risk of Healthcare Associated infection among patient/residents receiving care at Kenmare Community Hospital and to reduce infectious risk to hospital employees. POLICY: The Infection Control Nurse or designee will routinely and systematically perform surveillance for Healthcare Associated infections for all units in the hospital. . . ."

Reviewed on 10/31/17, the infection control records lacked evidence the CAH identified and recognized both nosocomial (hospital acquired) and community-acquired infections of inpatients in acute care and observation and outpatients receiving care in the emergency room and in physical therapy. The infection reports/logs from November 2016 through September 2017 failed to include information and documentation of all inpatients and outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on the morning of 10/31/17, two supervisory nurses (#1 and #3) stated the facility does not receive or request infection control information from all inpatients, including acute care and observation, and all outpatients, including physical therapy and the emergency department.

Failure to document all incidents of infection and communicable disease, and perform surveillance among all inpatients and outpatients of the CAH limited the staffs' ability to identify, monitor, track, control, and prevent infections.
VIOLATION: PATIENT CARE POLICIES Tag No: C0275
Based on record review, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to follow its policy on notification of a provider/physician regarding the death of a patient for 2 of 3 sampled patients (#1 and #23) death records reviewed. Failure to notify the provider does not allow the provider to obtain specific information regarding the death including family notification.

Findings include:

Review of the CAH policy "DEAD, CARE OF" occurred on 11/01/17. The policy, dated 02/15, stated, ". . . PROCEDURE: . . . 2. Notify provider. 3. Provider will pronounce death. . . . 7. Check to see if an autopsy has been ordered or if the coroner needs to be notified. If an autopsy is ordered . . ."

- On the morning of 11/01/17 observation showed a medical provider (#7) asked a staff nurse (#2) if a death occurred last night and if the nurse needed to call a provider to pronounce the death. The staff nurse stated a death had occurred but failed to know if the night nurse needed to call a provider to pronounce the death. The provider stated no one had called her to pronounce the death.

Review of Patient #1's "Death Documentation Checklist" completed by the nurse on duty at the time of death, identified the date, time of death and "Pronounced by [provider's name]." This is the provider who, from the above observation, stated the nurse had not contacted her regarding the death.





- Review of Patient #23's medical record occurred on 11/01/17. Patient #23's "Death Documentation Checklist" identified the provider pronounced the death, including "Diagnosis or cause of death: cardiac arrest." The checklist identified the physician notified. A "Final Report" note, dictated by the provider eight days later, stated, ". . . expired on [DATE and time]. I was contacted by the RN [registered nurse] taking care of [patient's name], [the nurse at time . . .] reported that he had expired. The patient was admitted late yesterday to the swing bed . . . TIME OF DEATH: Pronounced by [first and last name of a staff nurse] . . ."

During an interview on the morning of 11/01/17, a nurse supervisor (#1) stated she expects a provider to pronounce deaths.
VIOLATION: POLICIES - DRUG MANAGEMENT Tag No: C0276
SECURE MEDICATION STORAGE/DELIVERY/DISPOSAL

1. Based on observation, review of facility policy, review of the North Dakota Century Code, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff securely stored medications in 1 of 1 medication storage areas (Main Nursing Station). This failure allowed an opportunity for unsafe and unauthorized access and/or use of medications and had the potential to create insufficient distribution, control, and accountability of medications.

Findings include:

Review of the facility policy titled "Destroying Medications" occurred on 11/01/17. This policy, reviewed February 2015, stated, ". . . All outdated and discontinued medications are to be returned to the Director of Nursing. She or her designee will then inventory and return them to Trinity pharmacy for destruction. . . ."

Review of the facility policy titled "Medication Delivery" occurred on 11/01/17. This policy, reviewed February 2015, stated, "It is the policy of Kenmare Community Hospital that medications delivered from Kenmare Drug are to be physically handed to a nurse by the pharmacist or pharmacy tech [technologist]. If no nurse is available, the medications are to be taken to the Acute Nurses Station and placed inside the pharmacy locked box."

Review of the facility policy titled "Administration of Medications" occurred on 11/01/17. this policy, revised December 2016, stated, ". . . Duties of Nurse 1. Controlled substances will be inventoried and count verified with each removal/counted and witnessed at each shift change. . . ."

The North Dakota Century Code, Chapter 61-07-01 "Hospital Pharmacy" stated, ". . . 61-07-01-06. Physical requirements. . . . 3. Storage. All drugs must be stored in designated areas . . . which are sufficient to ensure proper . . . security. . . . 6. . . . so as to prevent access by unauthorized personnel. . . ."

- Observation on 10/30/17 at approximately 11:30 a.m. showed the main nurses' station door open, no staff present, and the following medications located on the counter:
* 1 - 100 milliliter (ml) container of lidocaine hydrochloride oral/topical solution with approximately 35 ml remaining in the bottle
* 32 - 30 ml containers of lidocaine hydrochloride solution
* 32 - 5 ml containers of Nystatin oral suspension

During an interview on the afternoon of 10/31/17, a staff nurse (#6) stated she failed to secure the above medications scheduled for return to the pharmacy.

- Observation/inspection on the morning of 11/01/17 of the main nurses' station medication area, with a staff nurse (#6) and a nursing supervisor (#1) present, showed a locked cabinet used to store discontinued medications prior to pharmacy disposal and identified:
* Hydrocodone 5/325 - 30 tablets discontinued 10/04/17 with the count verification sheet
* Hydrocodone 5/325 - 3 tablets discontinued 08/28/17 with the count verification sheet
* Tramadol 25 mg - 150 tablets discontinued 09/25/17 with the count verification sheet
* Lorazepam 0.5 mg - 32 tablets discontinued 10/04/17 with the count verification sheet
* Lorazepam 2 mg/ml injectable - 7 cartridges discontinued 10/04/17 with the count verification sheet
* Tylenol #3 (with codeine) - 12 tablets discontinued 10/03/17 with the count verification sheet
* Various other medications discontinued and no count verification sheet required

During the above observation, the nurses (#1 and #6) stated after nurses placed the medications in the tub for disposal, the nursing staff made no further count or verification of the discontinued and/or controlled medications to ensure accuracy and accountability before pharmacy came to pick them up. The nurse (#1) agreed Schedule II controlled medications (hydrocodone) always needed a double lock system.

- Observation/inspection on the morning of 11/01/17 of the main nurses' station medication area with a staff nurse (#6) and a nursing supervisor (#1) present showed a padlocked wooden box located on the work counter area. The nurse (#6) stated pharmacy placed medications delivered to the facility in the box and used the key located in an unlocked drawer near the box to open and lock it. The nurse (#6) confirmed pharmacy delivered Schedule II controlled medications in the same manner. The nurse (#1) agreed this process failed to ensure secure storage of medications.

Failure to secure and account for controlled medications prior to disposal or during pharmacy delivery may result in unauthorized access to medications and/or drug diversion.

UNLOCKED TREATMENT CART

2. Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure 1 of 1 treatment carts remained locked and inaccessible to unauthorized persons. Failure to secure physician ordered medications for patient treatments may result in unauthorized access to medications.

Findings include:

Observation on all days of survey showed an unlocked treatment cart containing various patient eye drops and topical skin creams for pain or other skin issues located in a small open area between patient hallways.

During an interview on the morning of 11/01/17, a nurse supervisor (#1) agreed staff should lock the treatment cart containing patient medication/treatments.
VIOLATION: GOVERNING BODY Tag No: C0241
THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON APRIL 24, 2016.

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

Findings include:

Review of the "Medical Staff Bylaws Trinity Kenmare Hospital d/b/a [doing business as] Kenmare Community Hospital" occurred on 10/30/17 at 1:55 p.m. These bylaws, adopted 06/08/12, stated,
". . . Article VII: Conditions and Duration of Appointment
A. the Advisory board shall make initial appointments and re-appointments to the medical staff. The Advisory Board shall act on appointments only after there has been a recommendation from the medical staff . . .
Article IX: Appointment Process
A. Appointment/re-appointment to medical staff will be conducted in conjunction with the Administrative credentialing department at [name of parent organization]. In order to provide credentialing for Kenmare Hospital the credentialing committee will utilize the system developed by our parent organization. . . ."

Review of the governing board's "Bylaws of the Advisory Board Trinity Kenmare Hospital d/b/a Kenmare Community Hospital" occurred on 10/30/17 at 2:40 p.m. These bylaws, adopted 02/13/04, stated,
". . . Article VIII Medical and Dental Staff
8.1 Organization, Appointments, and Hearings:
8.1c The Advisory Board shall act upon applications for appointment, reappointment, specific privileges and assignments of responsibilities within the Medical Staff.
8.1d The Advisory Board shall appoint only professionally competent practitioners meeting the personal and professional qualifications prescribed in the Medical Staff Bylaws to the Medical Staff. . . .
8.1e The Advisory Board shall make decisions upon recommendations from the Medical Staff as to the types and extent of professional work permitted to be done by each appointee of the Medical Staff. . . ."

Review of the "Rural Health Network Agreement" occurred on 10/30/17 at 4:15 p.m. This agreement, effective 10/10/07, stated, ". . . 6. Credentialing: 1.1 . . . [Name of network hospital] shall not have the right or responsibility for the initiation or denial of membership or clinical privileges at CAH to any Professional, which decision shall be the sole right and responsibility of the CAH. . . ."

Reviewed on 10/31/17, the credentialing records for Practitioners #1 and #2 lacked evidence of the CAH's medical staff recommendation and the governing body approval of appointment/reappointment and privileges.

Upon request on 11/01/17, the CAH failed to provide evidence the CAH's medical staff recommended and the governing body approved appointment/reappointment and privileges for Practitioners #1 and #2.

During an interview on 11/01/17 at 8:35 a.m., an assistant administrative staff member (#5) confirmed the CAH's medical staff had not recommended and the governing body had not approved appointment/reappointment and privileges of Practitioners #1 and #2.
VIOLATION: NURSING SERVICES - DRUG ADMINISTRATION Tag No: C0297
Based on observation, record review, review of facility policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to ensure nursing staff administered patient medication in accordance with physician orders and accepted standards of practice for 1 of 3 swing bed patients (Patient #6) observed during medication administration. Failure to ensure the medication label matched the physician's order and medication administration record (MAR) and clarify any discrepancies has the potential to place patients at risk of medication errors.

Findings include:

Review of the policy titled "Labeling of Medications" occurred on 11/01/17. This policy, reviewed February 2015, stated, ". . . All drugs and biologicals must be properly labeled and legible at all times. . . ."

Review of the policy titled "Administration of Medications and roles of Nursing Personnel" occurred on 11/01/17. This policy, revised December 2016, stated, " . . . All medications, as ordered by the physician, are administered or supervised by a Registered Nurse. . . ."

Review of the policy titled "Administration of Medications" occurred on 11/01/17. This policy, revised December 2016, stated, ". . . Only the pharmacist fills medications and changes labels . . . Follow the 'Five Rights' for correct drug administration: . . . Right time - Medications are administered within 30 min [minutes] before or after prescribed time to ensure intended therapeutic effect . . . Compare drug label listing on unit dose med [medication] of patient; name of drug, dosage, method and time of administration with those on MAR. . . ."

Berman, Snyder, and Frandsen's, "Kozier and Erb's Fundamentals of Nursing: Concepts, Process, and Practice," 10th edition, 2016 Pearson Education Inc., pages 768, 771-772, stated, ". . . four main types of medication errors that occur with hospitalized clients: . . . (4) administration errors (e.g. [example given] wrong dose, wrong time . . . Most medication errors occur during the administration stage. . . . Process of Administering Medications: When administering any drug, regardless of the route of administration, the nurse must do the following: . . . 3. Administer the drug. Read the MAR carefully and perform three checks with the labeled medications . . . Then administer the medication in the prescribed dosage, by the route ordered, at the correct time. . . ."

Observation on 10/30/17 at 2:59 p.m. showed a registered nurse (#4) administered Seroquel 25 milligrams (mg) to Patient #6. Before administration of Seroquel, the nurse (#4) checked the medication label which stated to administer at "1300" (1:00 p.m.) and at "HS" (hour of sleep) against the MAR which stated to administer at "1500" (3:00 p.m.) and at "HS." The nurse (#4) stated, "We give it at 3 [3:00 p.m.]."

Review of Patient #6's current physician order sheet identified "Seroquel 25 mg by mouth at 1500 et [and] 2000 [8:00 p.m.]."

The nurse (#4) failed to clarify and/or have pharmacy correctly label the medication.

During an interview on the morning of 11/01/17, a nursing supervisor (#1) agreed the label failed to match the MAR or physician's order, and nursing staff failed to clarify the order and/or have the medication relabeled by pharmacy.
VIOLATION: RECORDS SYSTEM Tag No: C0302
Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure a complete, accurately documented medical record for 9 of 16 swing bed patient (Patient #6, #7, #8, #9, #10, #11, #12, #13, and #14) treatment administration records (TAR) reviewed. Failure to ensure a complete and accurate medical record by documenting patient treatments as completed limits the CAH's ability to ensure quality of care.

Findings include:

Review of the October 2017 TAR for swing bed Patient #6, #7, #8, #9, #10, #11, #12, #13, and #14 identified numerous days (up to seven days for some patients) nursing staff failed to initial/document the physician ordered treatments as completed.

During an interview on the morning of 11/01/17, a nursing supervisor (#1) agreed nursing staff should document on the TAR after completing treatments.