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Based on hospital documents review, interviews, and observations, the Governing Body of this hospital failed to effectively discharge its oversight responsibility to ensure that this hospital meets all applicable Federal requirements.

Findings:


The Governing Body failed to ensure that no co-mingling of hospital and Tribal programs existed. The Audiology Tribal program was located inside the Outpatient Department of the hospital. The Tribal program is fully commingled with the hospital Out patient Department in that it utilized the same staff and patient care areas.


The Governing Body, through the approved Medical Staff Bylaws, the responsibility of Tribal programs located within the campus of the hospital. Refer to Tag A047.


The Governing Body failed to ensure that physicians provide medical care management of patients admitted to the hospital. Refer to Tag A49.


The Governing Body, through approved Policies and Procedure, and organizational structure, failed to ensure 24-hours Registered Nurse coverage in the Drug Dependency Unit. Refer to Tag A392.


The Governing Body, through Nursing Services operational management, failed to ensure that patients had current care planes that addressed the patients healthcare needs. Refer to Tag A396.


The Governing Body, through approved Policies and Procedure, failed to ensure that discharged summaries of patients were completed appropriately. Refer to Tag A468.


The Governing Body, through approved Policies and Procedure, failed to ensure that nutritional assessments and evaluation of the tolerance of patients to therapeutic diets were completed by the Registered Dietitian. Refer to A621.


The Governing Body, through approved Policies and Procedure, failed to ensure that therapeutics diets were provided to patients when ordered, and standardized recipes were followed in food preparation. Refer to Tag A628.


The Governing Body, through approved Policies and Procedure, and organizational structure, failed to ensure that the Emergency Department had the required personnel in place. Refer to Tag A1100 and A1102.

Based on documents review, interviews and observations, the hospital failed to ensure that adequate staff were available to provide patient care.

Findings:

The Drug and Dependency Unit failed to have 24-hours Registered Nurse Coverage. Refer to Tag A392.

Nursing care plans of patients failed to address the healthcare needs of patients. Refer to Tad A396.

Based on documents review, observations and interviews, the hospital failed to ensure that the dietetic and nutritional needs of patients were adequately meet.

Findings:

The registered Dietitian failed to conduct nutritional assessments and evaluation of patients' tolerance to therapeutic diets. Refer to Tag A621.

The dietary staff failed to prepare therapeutic diets as ordered by physicians, follow written pre-planned menus, and follow the hospital's standardized recipes. Refer to Tag A628,

Based on interviews with the hospital clinical director and ED nursing supervisor, there is no qualified member of the medical staff designated as the medical director for emergency services.

Findings include:

1. All medical service coverage provided in the ED is through contracted services, not by qualified members of the medical staff.

2. The clinical director of the hospital provides administrative coverage only to the ED.

3. The clinical director does not meet the hospital bylaws requirements for the director of emergency services.

4. Without an ED medical director, the hospital is unable to ensure it is meeting the needs of patients in accordance with acceptable standards of practice.

Based on the interview with the Acting CEO and the review of the Medical Staff By-laws, Rules and Regulation that was approved by the Governing Body on October 2014, the Medical Staff Bylaws placed the responsibility of Tribal programs on the Medical Staff of the hospital.


Article XII. Medical Departments, of the Medical Staff Bylaws, Section 12.01 provides "The medical Staff is to be considered non-departmentalized and shall organize itself into the following clinical services/Programs:

Dentistry - Tribal,

Optometry -Tribal Whirling Thunder Diabetes Program - Tribal

Mental Health and Psychiatric Services - Tribal,

Alcohol Counseling - Tribal"

Further, Section 17.08 Rules and Regulations for EMS (Tribal) and Clinical Services also placed the supervision and direction of the EMS Tribal program on the medical staff of the hospital.

Tribal programs are under the jurisdiction of the Tribal Council and Governing Body, not under the Governing Body of the hospital. As such, the hospital staff do not have responsibility of Tribal programs.

Based on documents review and interviews, the Governing Body failed to ensure that all patients admitted to the hospital were under the care of a physician.


Review of three (3) (Patients D1, D2 and D3) of six (6) patients in the Drug Dependency Unit (DDU) with hypertensive revealed no evidence of physician evaluation and oversight of the treatment regimen. Refer to Tag A396.


Review of four (4) (Patients MR4, MR5, MR6 and MR7) of four (4) patients discharged from the hospital revealed no evidence of physicians evaluation of the outcome of the treatment regimen of the patients. Refer to Tag A468.

Based on interviews with the hospital clinical director and ED nursing supervisor, there is no qualified member of the medical staff designated as the medical director for emergency services.

Findings include:

1. All medical service coverage provided in the ED is through contracted services

2. The Acting Clinical Director of the hospital provides administrative coverage only.

3. Review of the credential file and interview with the Acting Clinical Director revealed that he does not meet the hospital bylaws requirements for the director of emergency services.

Section 13.07 of the Medical Staff Bylaws provides "The Emergency Room Director shall be a fully credentialed active staff physician provider with a documented record providing proper Emergency Department Care according to IHS rules & regulations, and according to the guidelines of specialty organizations (i.e., ACEP, AMA). If the ER Director is not Board Certified in Emergency Medicine he/she must maintain certification in BLS-C, ACLS, and ATLS. Certification in ALSO, PALS, and NRP is considered beneficial but is not mandatory. The ER Director shall demonstrate a proven knowledge and the ability to function as a manager and/or supervisor within the Indian Health Service.

Based on record reviews and interviews, the Nursing Service failed to provide Registered Nurse coverage seven (7) days a week/24 hours a day at the Drug Dependency Unit (DDU). This finding was confirmed by the hospital Director of Nursing and the DDU Manager. The failed practice has the potential to affect 6 of 6 residents in the DDU. The census in the DDU during the survey week was 6.

Finding:
On 11/03/2014, at 10:00 am, a tour of the DDU was conducted with the Director of Nursing (DON). During the tour, the DON stated that the DDU has a Registered Nurse (RN) who works eight (8) hours a day/five days a week. The DON stated that the RN is off on Saturdays, Sundays and holidays. When asked who took care of medical issues during those days, the DON responded that the technical staff working in the unit will contact the Emergency Room nurse or the Medical unit nurse.

On 11/04/2014, at 2:00 pm, an interview was conducted with the DDU Manager. During the interview, the manager stated that the DDU has one RN five (5) days a week. The RN does not work Saturdays, Sundays and holidays. He stated that the DDU has two medication aides certified by the state of Nebraska and they can administer medications. He also confirmed that if the technicians working in the DDU cannot administer medications, they will call the Emergency Room nurse or the Medical inpatient unit nurse.

Record review of the Nursing Schedule for the DDU provided by the DON on 11/05/2014, confirmed that the Nursing Department does not have RN coverage for weekends (Saturday and Sunday) and holidays.

Provision of Medication administration (Hypertensive) monitoring/Care Plan

Based on interviews and record reviews, the Nursing Department failed to develop a care plan and monitor two (2) of three (3) hypertensive patients in the Drug Dependency Unit (DDU). This failed practice has the potential to affect patients admitted in the DDU who have hypertensive diagnosis on hypertensive medications. During the survey week there were three (3) of six (6)residents with a hypertensive diagnosis.

Findings:

Medical record reviews were conducted at the DDU on 11/05/2014.

Record # D1

Patient was admitted to the DDU on 10/07/2014. Diagnoses included hypertension, Alcoholism and Chronic pain.

Review of the Medication Administration Record (MAR) for October and November 2014, indicated that the patient was given:

a. Lisinopril 40 milligrams (mg) Per Oral (PO) daily.
b. Metoprolol, 50 mg two (2) tablets twice a day (BID).

The only Blood Pressure (BP) recorded on the patient's medical record was during the admission process: 150/86. The patient's Care Plan does not address hypertensive as a medical problem for this resident.

Record # D2


Patient was admitted to the DDU 10/06/2014. Diagnoses included hypertension, cirrhosis and drug dependency.

Review of the MAR for October and November 2014, indicated that patient was given:

a. Clonidine 0.1 mg PO BID,
b. Furosemide 40 mg PO daily.

The only Blood Pressure reading (BP) recorded on the patient's medical record were during the History and physical dated 10/01/2014 (BP 154/95) and during the admission process on 10/06/2014 (BP 129/74).

The patient's Care Plan does not address hypertension as a medical problem for this patient.

On 11/05/2014, at 10:00am, the DDU manager was interviewed. When asked about the Blood Pressure (BP) monitoring for hypertensive patients on anti-hypertensive medication, he indicated that the Medication Aides do not take BP. If any BP was taken, it is the Register Nurse's job to record it on the medical record.

On 11/05/2014, at 10:15 am, the Medication Aide on duty at the DDU, S19, was interviewed.

During the interview, S19 indicated that she has been certified as a Medication Aide by the state of Nebraska. S19 confirmed that she administered medication orally (PO), however, no BP was taken before the administration of medication. S19 stated if any BP needed to be taken the RN would do it.

On 11/05/2014, at 10:30 am, S19 telephoned the RN for the DDU. During the call, the RN indicated that she did not take BP reading for those patients. The RN only took daily BP for one (Patient D3) of 3 hypertensive patients.

On 11/05/2014, at 3:00 pm, the DON was interviewed. During the interview the DON stated that BP should be taken when the patient is hypertensive.

On 11/05/2014, at 3:30pm, the hospital Pharmacist was interviewed by the survey team. When asked who monitors the medication interaction for the DDU, the Pharmacist responded that the hospital pharmacy staff does not monitor those patients, they dispense medications as needed.

On 11/05/2014, the DDU Manager provided the job description for the Medication Aides. Review of this document found no description of the Medication Aide's responsibilities. The document was titled: Social Service Assistance.

An addendum to the position description: Medication passing of non-narcotic medication to clients dated 10/24/2014, and signed by the DDU Manager did not indicate what the medication Aides are responsible for. This was confirmed by the DON.

Based on interviews and documents review, protocols used in the emergency department were developed by the hospital medical staff and director of nursing without Pharmacy staff participation.

Findings include:

1. The Pharmacy Director confirmed that she was not involved in the development and/or review of the ED protocols during an interview on 11/5/2014 at 2:30 pm.

2. The Pharmacy Director concurred and signed off on the hospital-wide policy approval for use.

3. Pharmacy staff did not participate in the development or review of the policy to ensure that the protocols were consistent with nationally recognized and evidence-based guidelines.

4. Included in the "Emergency Department Nursing Standing Treatment Protocols Adult Patient & Pediatric Patients" at least 18 of 25 adult protocols include medication orders; 3 of 4 pediatric protocols include medication orders.

Based on medical record review for four (4) of four(4) (Patients #s MR4, MR5, MR6, MR7) discharged patients and staff interview, the facility failed to ensure that a physician completed and signed each patient's Discharge Summary. This deficient practice had the potential to affect all of the patients who are admitted to this hospital.

Findings include:

1. Review of the closed medical record for Patient MR4 revealed that she was discharged from the facility on 9/25/14, and the person who wrote and signed the Discharge Summary was Staff S20 who is a Licensed Addiction and Drug Counselor (LADC) but not a physician.

2. Review of the closed medical record for Patient MR5 revealed that he was discharged from the facility on 9/25/14, and the person who wrote and signed the Discharge Summary was Staff S21 who is a LADC but not a physician.

3. Review of the closed medical record for Patient MR6 revealed that he was discharged from the facility on 9/25/14 and the person who wrote and signed the Discharge Summary was Staff S21 who is a LADC but not a physician.

4. Review of the closed medical record for Patient MR7 revealed that she was discharged from the facility on 9/25/14 and the person who wrote and signed the Discharge Summary was Staff S20 who is a LADC but not a physician.

An interview with the Area Accreditation Compliance Specialist, Staff S22, on 11/5/14, at 3:15 PM, revealed that she was aware that it was a federal requirement for each patient to be under the supervision of a physician and that the physician is required to write and sign each patient's Discharge Summary. When interviewed about why the physician did not sign the four closed medical records for Patients MR4, MR5, MR6 and MR7, the Staff S22 stated that she was uncertain.

Based on documents review and interviews, the pharmacist failed to ensure patient safety related to drug regimen of patients of the hospital. The pharmacist failed to review medication orders for patients in the Drug Dependency Unit. The pharmacist failed to monitor the appropriateness, effectiveness and potential adverse reactions to medications ordered for patients in the Drug dependency Unit. Refer to Tag A396.

The Registered Dietitian (RD) failed to perform and document nutritional assessments and evaluate patient tolerance to therapeutic diets when appropriate.

Based on records review, review of policies and procedures and interviews, the facility failed to ensure that the RD completed nutritional assessments and diet counseling for two (2) (Patient K8 and K9) of six (6) Patients who were admitted to the Drug Dependency Unit (DDU). Patients K8 and K9 had physician ordered therapeutic diets and medications with nutritional implications. This deficient practice had the potential to affect all of the patients who are admitted to this hospital.

Findings include:

1. Review of the "Diet Order Sheet" dated 11/03/14, revealed that two (2) (Patient K8 and K9) of six (6) patients in the Drug Dependency Unit (DDU) had physician's ordered therapeutic diets. Patient K8 had a physician ordered 2 gram (gm) low sodium (Na) diet and Patient K9 had a physician ordered diabetic diet.

2. Review of the medical record for Patient K8 revealed that she was admitted to this facility on 8/26/14, with diagnoses including: Alcoholism, Vitamin D deficiency, asthma, and cirrhosis of the liver.

Review of the physician's admitting orders for Patient K8 revealed that she was ordered a therapeutic 2 gm Na diet and she was ordered some medications that could require nutritional counseling. Patient K8 was ordered Lasix and Spironolactone (diuretics for water retention), Potassium Chloride (supplement due to Potassium loss from diuretics) and Vitamin D (a fat soluble supplement).

An interview with the Director of the DDU on 11/5/14, at 9:25 am, revealed that each patient who was admitted to the DDU must completes a "Problem Statement" sheet. The Problem Statement sheet had 82 questions that the patient had to answer. Question #66 reads, "I am unaware of proper nutrition."

Review of the medical record for Patient K8 revealed that on her "Problem Statement" sheet she answered "Yes" to question #66. When interviewed on 11/5/14, at 9:25 am, about what a "Yes" answer meant to question #66, the Director of the DDU stated, "It means that she is unaware of proper nutrition."

Review of the medical record for Patient K8 revealed that the facility's full time RD did not provide individualized nutritional counseling for this patient. Review of the RD's type written note dated 8/28/14, revealed that she presented a nutrition class to the DDU patients as a group and the topics discussed included: Protein, carbohydrates, fats, food preparation, sodium, eating foods and meals slow, food portions and reasons for food portions.

There was no documented evidence that the RD counseled Patient K8 relative to her sodium restriction or potential food and drug interactions. The RD did not provide counseling relative to Patient K8's potassium supplements and foods that might be helpful, foods that have more or less water content, foods that can cause water retention or foods high in Vitamin D.

3. Review of the medical record for Patient K9 revealed that he was admitted to the DDU on 10/6/14 with diagnoses including: Diabetes, hypertension, and alcoholism.

Review of the physician's admitting orders for Patient K9 revealed that he was ordered a diabetic diet and some medications that could require nutritional counseling. Patient K9 was ordered insulin on a sliding scale regimen, multivitamins, Metformin (an oral diabetic medication) and hypertensive medications.

Review of the medical record for Patient K9 revealed that on his "Problem Statement" sheet he circled #65, "I am a diabetic" and he circled #66, "I am unaware of proper nutrition." When interviewed on 11/5/14, at 8:55 am, Patient K9 stated that the RD presented a nutrition class for the group in the DDU but she did not provide individualized nutrition counseling for his specific needs.

Review of the medication sheet dated October 06 through October 19, 2014, revealed that Patient K9 had refused his insulin injection four times. He refused his injection twice on 10/7/14 and twice on 10/8/14.

An interview with the DDU Nurse, Staff S23, on 11/4/14, at 8:30 am, confirmed that Patient K9 had refused to take his insulin because he did not "think" that he needed it.

Review of the medical record for Patient K9 revealed that the facility's full time RD did not provide individualized nutritional counseling for this patient.

Review of the RD's type written note dated 10/9/14, revealed that she presented a nutrition class to the DDU patients as a group and the topics discussed included: Protein, carbohydrates, fats, food preparation, sodium, eating foods and meals slow, food portions and reasons for food portions.

There was no documented evidence that the RD counseled Patient K9 relative to his diabetic diet or potential food and drug interactions.

The RD did not provide counseling relative to Patient K9 need for insulin and the adverse consequences when not taken as ordered, his hypertension, his oral diabetic medication and better food choices, nutritionally dense foods, or what medications need to be taken with or without food.

4. Review of the DDU's policies and procedures revealed a document titled, "Admission Assessments" reviewed and revised on 11/15/13, provided the following information:

Policy

All clients will have a history & physical assessment by a medical provided within 30 days of admission.

Procedures

"D. Nutrition assessment"

1. If nutritional needs are identified during the nursing assessment, a nutritional assessment will be done that includes:

a. Brief history regarding diet.

b. Special diet requirement, if necessary.

c. Indication of any nutritional deficiencies.

d. Proposed dietetic treatment plan signed and dated by the food service coordinator.


5. Review of the Dietary Department's policies and procedures revealed a document titled, SCOPE OF SERVICE - DIETARY DEPARTMENT dated 10/14/14 revealed the following information:

Goals and objectives:

"4. To provide nutrition services and education to patients, family members and staff as needed."


6. Review of the policies and procedures revealed a document titled, "DTR - 10 AGE SPECIFIC NUTRITION ASSESSMENT Nutritional Care Standards for Inpatients" dated 1/4/12 provided the following information:

"II. Policy

This standard focuses on providing appropriate nutritional care, including food and nutrition therapy, in a timely and efficient manner using appropriate resources ... "

"IV. Responsibilities ....

2. The nursing staff is responsible for completing the nutritional screen (attachment A). The dietitian/certified Dietary Manager is responsible for conducting assessment/reassessment to determine the nutritional care plan and for appropriately documenting in the patient's medical record... "

"7. Diabetic Patients: All diabetic patients referred to the IHS Registered Dietitian."

An interview with the RD on 11/4/14, revealed that every thirty (30) days a new group of patients entered the DDU for treatment for their addictions. She stated that she would provide a nutritional class for the group once a month and she covered the exact same topics every time; Protein, carbohydrates, fats, food preparation, sodium, eating foods and meals slow, food portions and reasons for food portions.

The RD confirmed that she did not follow the hospital policies and procedures relative to nutritional assessments and diet counseling for the DDU patients because she was told that the patients in the DDU "were different" from other in-house patients. Consequently, the RD did not council Patient # K8 or Patient # K9 when they had physician's ordered therapeutic diets, medications that could have food and drug interactions, and when both patients identified on their "Problem Statements" that they were "unaware of proper nutrition."

Based on interviews with the hospital Acting Clinical Director and ED nursing supervisor, there was no qualified member of the medical staff designated as the medical director for emergency services.

Findings include:

1. All medical service coverage provided in the ED is through contracted services.

2. The Acting Clinical Director of the hospital provides administrative coverage only to the ED.

3. The Acting Clinical Director does not meet the hospital bylaws requirements for the director of emergency services.

Section 13.07 of the Medical Staff Bylaws provides "The Emergency Room Director shall be a fully credentialed active staff physician provider with a documented record providing proper Emergency Department Care according to IHS rules & regulations, and according to the guidelines of specialty organizations (i.e., ACEP, AMA). If the ER Director is not Board Certified in Emergency Medicine he/she must maintain certification in BLS-C, ACLS, and ATLS. Certification in ALSO, PALS, and NRP is considered beneficial but is not mandatory. The ER Director shall demonstrate a proven knowledge and the ability to function as a manager and/or supervisor within the Indian Health Service.

Based on interviews with the hospital Acting Clinical Director and ED nurse supervisor, emergency services are not supervised by a qualified member of the medical staff.

Findings include:

1. The contracted medical providers working in the ED supervise emergency services on their assigned shift.

2. No qualified member of the medical staff is responsible for supervision of emergency services.

3. The Acting Clinical Director of the hospital provides administrative coverage only to the ED.

Based on observations, interviews and records review, the facility failed to:

1) prepare physician ordered therapeutic diets,

2) follow their written preplanned menus, and

3) follow their standardized recipes.

This had the potential to affect all of the patients who were admitted to this hospital.

Findings include:

Observation of the kitchen on 11/3/14 at 11:45 AM revealed that the Cook Leader, Staff S24 and Cook, Staff S25, had prepared the lunch meal for the in-house patients and the food was ready for service.

Review of the "Diet Order Sheet" dated 11/03/14, revealed that there were six (6) patients in the Drug Dependency Unit (DDU). Four (4) patients had regular (no dietary restrictions) diets, one (Patient K8) had a physician's ordered 2 gram (gm) low sodium (Na) diet and another patient (Patient K9) had a physician's ordered diabetic diet.

Review of the preplanned menu, the "Fall and Winter WK 2, Day: Monday," on 11/3/14, at 11:45 AM, revealed that the patients who had a physician's order for a "Regular" diet were to have grilled pork chops and California vegetables, and the patients that had a physician's order for a "2 gram low sodium diet" were to have low sodium baked pork chops and low sodium California vegetables. On this particular day, the diabetic diet was the same as the regular diet with one exception, they were to have fruit instead of crumb cake for their dessert.

Observation of the prepared foods on 11/3/14, at 11:45 AM, revealed that all of the food was prepared the same way, without taking therapeutic diets into consideration.

Review of the grilled pork chop recipe dated 1/3/11, revealed the ingredients included, salt, pepper and paprika. Each pork chop was to be sprinkled with the seasonings and then grilled on a well-oiled grill. Observation of the grilled pork chops revealed that they were not prepared with any of the seasonings that were listed on the recipe and no low sodium baked pork chops were prepared.

Review of the recipe for California vegetables dated 5/28/09, revealed that the ingredients included salt and margarine..

Observation of the Staff S24 on 11/3/14, at 11:50 AM, revealed that he did not add salt or margarine to the California vegetables; he added a "Durkee Vegetable Seasoning" which had dehydrated garlic and dehydrated onions among other unlisted spices. To ensure that the patients and the nutritional counselors can determine what foods and additives are being consumed, the kitchen staff should follow the written preplanned recipes. Some patients may have certain allergies or intolerances for garlic, onions and other spices so they need to know what has been added to their food.

An interview with both Staff S25 and Staff S24 on 11/3/14, at 11:55 AM, confirmed that they did not follow the preplanned menu and they did not follow the written recipes. When interviewed about why they did not prepare the low sodium baked pork chops and the low sodium California vegetables for Patient K8, Staff S24 and S25 stated that they prepared the patients foods the same way, regardless of their therapeutic diet order.

Review of the "Dietary Policies and Procedures" revealed a document titled, "DTR - 35 Following Recipes" dated 5/15/14, provided the following information:

"I. PURPOSE

To maintain the consistency and quality of food. To maintain controls on foods for ordering inventory, and production.

II. POLICY

The dietary department will follow dietary department recipes in food preparation. Any adjustments in recipes must be approved by the Certified Dietary Manager or the Supervisory Dietitian of the dietary department.

III. DEFINITIONS

None

IV. PROCEDURES

1. For proper food preparation techniques, follow the recipe selected for the food item.

2. Recipes books are kept in the dietary department.

3. Each cook is responsible for using the selected recipe in the cookbook.

4. The cook must follow the recipe completely and use proper measurements and weights to insure that the desired results are achieved ... "


Review of the "Dietary Policies and Procedures" revealed another document titled, "DTR - #37 Menu Changes" dated 5/15/14, provided the following information:

"I. PURPOSE

To maintain the consistency and quality of food served.

II. The dietary department will follow dietary department menus in food preparation. Any adjustments in menus must be approved by the Certified Dietary Manager (CDM) or the Registered Dietitian (RD) of the dietary department.

III. DEFINITIONS

NONE

IV. PROCEDURES

1. For proper food preparation techniques, follow the menu for the day/meal.

2. Menus are created and analyzed prior to serving to patients and employees.

3. Menus are created bi-annually for a two week cycle rotation for spring/summer and for fall/winter.

4. Each cook is responsible for following the menu of the day.

5. The cook must follow the menu completely.

6. Any menu changes must be approved by the CDM or Supervisory RD of the dietary department ... "


An interview with the Dietary Manager on 11/3/14, at 3:15 PM, confirmed that the facility had policies and procedures relative to following the standardized recipes and written menus. She stated that the cooks were trained to follow the recipes and the preplanned written menus but she was uncertain why they had failed to prepare the food for the therapeutic diets or follow the policies and procedures on this day.