Russell Regional Hospital

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 52950 Based on observation, policy review, document review and interview, the Critical Access Hospital (CAH) failed to ensure staff provided care within their scope of practice. The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) situation. On 09/30/25 at 4:08 PM, Surveyors notified hospital administration Staff E, Chief Executive Officer, and Staff C, Director of Nursing that an IJ existed at §485.635(d)(1), Nursing Services, under 42 CFR 485.635, Condition of Participation: Provision of Services. The hospital submitted a plan of removal (POR) on 09/30/25 at 4:40 PM. On 10/01/25 at 3:53 PM the hospital was notified the written POR was accepted. The POR included the following: “The lack of properly trained staff providing care created a finding of immediate jeopardy for patients presenting to the Emergency Department. This had the potential to affect all patients entering the Emergency Department. On 09/30/2025 Orientation Checklists, Daily Checklists, and Competency check off forms were created by Director of Nursing to be reviewed with all staff prior to their next scheduled shift. LPN job description will be updated to include the requirement of BLS. Administration will develop policies related to Human Resources [HR] maintaining accurate and complete documentation of certifications, licensure, and job descriptions. Each position will have specific documentation guidelines to ensure accurate record keeping by HR department. HR department will after approval of this plan of removal ensure that all files are up to date. HR Director will be the main person responsible for making sure that once a position is filled or a change request form is completed that the needed documents are obtained. Education regarding verbal orders will be provided to all personnel prior to their next shift after the acceptance of this removal plan with the understanding that only Licensed Personnel can take verbal orders from providers and can only be entered by the Licensed Personnel. This will be covered in the Orientation Checklist, Competency checklist, and again during annual employee education for continued department education. All staff will obtain and/or maintain certifications pertinent to their position as outlined in the policies. Director of Nursing will develop and implement orientation, competency, and daily check offs to be reviewed with all staff prior to next shift after acceptance of the plan of removal. Education will focus on ER specific training, competencies specific to position, and daily checklists. Staff who do not present for competency review and training will be unscheduled until training has been completed. ER providers will be updated regarding changes going forward by Administration as well as the Medical Director of the Emergency Department. Communication about the changes will be posted in the necessary departments and sent out via employee emails. Emails sent out by Director of Nursing/Administration/HR will include ‘read receipt’ a signature form will also be requested to be signed by employees stating they have read updates and completed requested education. The Director of Nursing/Administration will complete weekly chart audits. Review process will also be reviewed with the HIM [Health Information Management] department to ensure double check is completed and appropriately documented. Upon discovery of discrepancy, staff will notify the Director of Nursing immediately of error. Monthly chart audits by ER nursing staff will be implemented and checklist developed to ensure accurate and appropriate documentation is followed. Human resources will conduct monthly audits of staff certifications, licensure, and job descriptions for all current and new staff. Human resources will be responsible for maintaining accurate employee files. After acceptance of this plan of removal Human Resources will ensure staff files are updated appropriately.” The hospital’s plan of removal validated prior to survey exit on 10/02/25 at 1:20 PM. Finding Include: 1. The CAH failed to ensure that hospital policies and procedures were reviewed at least biennially. (Refer tag C-1008) 2. The CAH failed to ensure that staff provided care within their scope of practice of 3 of 10 sampled patients. (Refer tag C-1046)”

“PATIENT CARE POLICIES CFR(s): §485.635(a)(2) The policies are developed with the advice of members of the CAH’s professional healthcare staff, including one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of §485.631(a)(1). §485.635(a)(4) These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section, and reviewed as necessary by the CAH. This Standard is not met as evidenced by: 52950 Based on policy review, email review and interview, the Critical Access Hospital (CAH) failed to ensure that CAH policies and procedures were reviewed at least biennially by a group of professional personnel required under paragraph (a)(2) of this section and reviewed as necessary by the CAH. Failure to ensure the CAH reviews and/or updates policies and procedures has the potential to place patients and/or employees at risk for inconsistent care and outdated practices, causing poor patient outcomes and further safety concerns. Findings Include: Review of the CAH’s policies and procedures provided by the CAH showed the following policies were not reviewed and/or revised by the group of professional personnel at least biennially: “Radiation Safety/Protection,” approval date 05/18/23. “Charting Requirements-Swing Bed,” approved date 08/22/23. “Discharge Planning,” approval date 02/10/22. “Discharge of Patient-Nursing Acute,” approval date 03/14/18. “Emergency Room Visitation,” approval date 02/28/18. “Falls,” approval date 05/18/23. “Patient Grievance Process,” approval date 05/18/23. “Resolving Conflicts of Care/Complaints,” approval date 03/27/19. “Non-Punitive, System-Based Medication Error Reporting- MM.6.22,” approval date 04/24/17. “EMTALA [Emergency Medical Treatment and Labor Act] Medical Screening Exam,” approval date 05/18/23. “Admission to Swing bed Services,” approval date 05/18/23. “Nursing Triage in the ED,” approval date 05/18/23. “Precipitate (Emergency OB) Delivery,” approval date 05/18/23. “Nursing Standard of Care,” approval date 05/18/23. “EMTALA Kansas Transfer Policy,” approval date 03/27/19. “Verbal & Written Orders-MM.3.13,” approval date 06/21/19. Review of an email sent by Staff C, Director of Nursing (DON), on 09/30/25 at 8:48 AM, showed, “All policies were pulled from policy tech so they would be most current ...” Review of an email sent to Staff E, Chief Executive Officer (CEO) on 10/01/25 at 8:36 AM, surveyors requested a policy on policies. Staff E, CEO, asked for clarification, stating “ I am not sure what you are asking for.” Surveyors responded requesting their policy on how to write policies, approve, and manage their policies and procedures. Response from Staff E, CEO, “Not that I can locate.””

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 52950 Based on record review, policy review, document review and interview, the Critical Access Hospital (CAH) failed to ensure staff provided care within their scope of practice for 3 (Patients 2, 6, and 9) of 9 patients reviewed. The cumulative effects of this deficient practice resulted in an Immediate Jeopardy, (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death). Findings Include: Review of the CAH policy titled, “Nursing Standards of Care,” dated 05/18/23, showed, “ ...The nursing standards of care provide guidelines for assessment, nursing diagnosis, planning, and implementation ... Scope; Registered nurses and licensed practical nurses employed by Russell Regional Hospital ...” Review of the CAH policy titled, “Verbal & Written Orders- MM.3.13,” dated 06/21/19, showed, “ ...Verbal/telephone orders of medication shall be received and recorded by the Pharmacist or licensed nurse ...” Review of the CAH policy titled, “Medication Timely Administration -MM.5.11,” dated 01/02/24, showed, “ ...Personnel Authorized to Administer Medications: a; Includes RNs [Registered Nurse], LPNs [Licensed Practical Nurse], MICTs [Mobile Intensive Care Technician], Physicians, APRNs [Advanced Practice Registered Nurse], Pas [Physician Assistant], CRNAs [Certified Registered Nurse Anesthetist]. IV certified LPNs [License Practical Nurse] may administer medications in accordance with 60-16-102 of the Kansas Nurse Practice Act ...” Review of the CAH policy titled, “Falls,” dated 05/18/23, showed, “Purpose; To observe, assess, document and report any condition change from a fall. Scope; Nursing staff ...” Review of the CAH policy titled, “Nursing Triage in the ED [emergency department],” dated 05/18/23, showed, “ ...All patients who present to Russell Regional Hospital Emergency Room will receive timely triage and medical screening by an RN and physician, who will prioritize patient care and ensure prompt and appropriate treatment ...” Review of a CAH document titled, “ER Tech I Job Description,” dated 03/12/18, showed, “ ...Certified Nurses Aid ...Must maintain current BLS [Basic Life Support] certification ... Under supervision of ER [Emergency Room] staff nurse or physician, performs EKGs [Electrocardiogram]; Accurately documents interventions and assessments in nursing documentation ... Demonstrates ability to provide patient care skills and maintains proficiencies as outlined in orientation check sheet ...May notify physician on-call of patient arrival to ER to include subjective complaint and objective symptoms ... Provides high quality, compassionate care within scope of practice and as delegated by ER staff nurse ...” Patient 2 Review of Patient 2’s medical record showed a 27-year-old presented to the ED on 08/28/25 at 2:39 PM with a complaint of headache and discharged on 08/28/25 at 4:00 PM with a diagnosis of acute migraine headache (a severe, throbbing headache),without aura (a type of migraine that is not proceeded by visual, sensory, or other neurological symptoms), with status migrainosus (migraine that last longer than 72 hours), Acute viral syndrome (a short-term infection caused by a virus). Review of “Triage,” on 08/28/25 at 2:41 PM, showed, Staff B, CNA (Certified Nurse Assistant), completed fall risk assessment, physical assessment, nursing progress notes. The CAH failed to ensure a Registered Nurse (RN) completed required fall risk assessment, physical assessment, and nursing progress note. The medical record showed Staff B, CNA performing assessments and tasks that are to be completed by a licensed nurse and furthermore, there was no record of RN supervision or oversight of the CNA. Patient 6 Review of Patient 6’s medical record showed a 47-year-old presented to the ED on 08/28/25 at 12:10 PM with a complaint of vomiting and discharged on 08/28/25 at 3:35 PM with a diagnosis of Intractable vomiting (vomiting that is difficult to control) with nausea (queasy sensation including an urge to vomit) and dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake). Review of “Medication/IV/Drip/Fluid Orders,” dated 08/28/25 at 12:43 PM, showed, Staff B, CNA, took verbal orders from Staff D, ARNP, for the following medications, IV [Intravenous] NS [Normal Saline] 1000 milliliters (ml), and Zofran (anti-nausea medication) 4 milligrams (mg) IV. Review of Staff B, CNA’s “Nursing Progress Notes,” dated 08/28/25 at 2:45 PM, showed, “ ...IV Fluids Phenergan via IV site #1 Discontinued: bag #1 completed. Total amount infused: 25 mg mL(sic). IV patency established. IV site checked: no pain, redness, or swelling. IV flushed thoroughly ...”. Review of Staff B, CNA (Certified Nurse Assistant) personnel file on 09/30/25 at 9:40 AM, with start date of 03/12/24 failed to show any orientation check sheet, competency check sheet, or Basic Life Support (BLS) in the file. The CAH failed to ensure a Registered Nurse (RN) completed the process of taking verbal orders. Staff B, CNA, documented in the medical record that he discontinued intravenous (IV) lines and flushed IV lines without RN oversight which is not a part of his job description or within his scope of practice. Patient 9 Review of Patient 9’s medical record showed a 44-year-old presented to the ED on 09/16/25 at 8:29 PM with a complaint of migraine headache and was discharged on 09/16/25 at 9:24 PM with a diagnosis of chronic migraine headache without aura (sensory, visual, or motor disturbances) - poorly controlled. No status migrainosus. Review of “Medication/IV/Drip/Fluid Orders,” on 09/16/25 at 8:34 PM, showed, Staff K, Paramedic Tech, took verbal orders from Staff M, M.D, for the following medications, IM [Intramuscular] Phenergan (anti-nausea medication) 25 mg, IM Ketorolac (anti-inflammatory medication to treat pain) 30 mg, and PO [Oral] Tramadol (pain medication) 50 mg. The CAH failed to ensure a Registered Nurse (RN) completed the process of taking verbal orders for Patient 9. During an interview on 09/29/25 at 3:53 PM, Staff B, CNA, stated that his role in the emergency department includes triaging patients by asking about their presenting concern and duration of symptoms. He places patients in the room and notifies the provider. For patients with chest pain, the provider will give him verbal orders to do cardiac labs and EKGs. During an interview on 09/29/25 at 4:52 PM, Staff C, RN, Director of Nursing (DON), stated that it is out of the scope of practice for a CNA to take verbal orders, flush an IV, triage a patient, complete fall and physical assessments. During an interview on 09/30/25 at 2:30 PM, Staff E, Chief Executive Officer (CEO), stated that Staff B, CNA is performing tasks outside of his scope of practice, by administering medications. During an interview on 10/01/25 at 12:08 PM, Staff D, Advanced Register Nurse Practitioner (ARNP), stated that only registered nurses can take verbal orders for medication.”