Meeker Memorial Hospital

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 40948 Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings include: Please refer to the Life Safety Code inspection tags: K0291, K0351, K0353, K0372, K0712, K0761, K0901, K0906, K0909, K0918 and K0926.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 48583 Based on interview and document review, the facility failed to ensure all scheduled II medications were appropriately accounted for and were routinely reconciled within the Critical Access Hospital (CAH) to prevent potential diversion. Findings include: On 9/9/25 at 9:00 a.m. review of facilities variance reports and medication errors from 2/1/25 to 9/7/25, revealed the following scheduled medications had discrepancies errors: - Fentanyl (used to treat moderate to severe pain) - 32 times - Lorazepam (used to treat anxiety and agitation) - 3 times - Midazolam (used for sedation) - 14 times - Codeine with Guaifenesin (narcotic cough suppressant) - 1 time - Ketamine (used during anesthesia for sedation) - 3 times - Tramadol (used to treat moderate to severe pain) - 2 times - Hydromorphone (used to treat moderate to severe pain) - 4 times - Gabapentin (used to treat nerve pain) - 4 times - Morphine (used to treat moderate to severe pain) - 2 times - Oxycodone (used to treat moderate to severe pain) -1 time - Methylphenidate (used as a central nervous system stimulant) - 1 time - Unknown controlled substances with only dosages listed - 3 times Review of facilities Omnicell (automatic medication dispensing machine) Transaction Detail daily report dated 8/17/25 to 9/7/25, revealed 8 schedule II medication errors which required resolution by licensed staff in the Omnicell. During an interview on 9/9/25 at 1:57 p.m., RN-D identified medication errors were documented on a computerized record, and they were forwarded to the department manager. When the department manager was made aware, immediate actions with RN who performed the errors, were completed. RN-D stated the provider would be notified immediately for ordered interventions. During an interview on 9/9/25 at 2:12 p.m., RN-E revealed all medication errors would go to charge nurse. The error would be documented in the system and the provider would be notified. During an interview on 9/10/25 at 8:19 a.m., RN-F revealed narcotic counts were verified in Omnicell to ensure count was accurate when the medication was removed from the drawer. Medications were to be given within 30 minutes of removal from the Omnicell. from drawer. If medications were not given they were to be returned to bin on side of Omnicell and 2 nurses were needed to verify the medication was returned. The process was the same if medications needed to be wasted and required 2 nurses during the medication wasting. RN-F indicated Relias (company) online training was provided on medication administration completed annually. During an interview on 9/10/25 at 8:31 a.m., RN-G stated if narcotics were to be administered and needed to be wasted 2 nurses would need to provide signatures and both would need to observe the waste. RN-G was not certain if there was a policy for wasting medication. Training on medications was provided online on an annual basis. During an interview on 9/10/25 at 8:43 a.m., RN-H stated if narcotics were to be given, they needed to be removed from the Omnicell and administered within 30 minutes of removal. If a narcotic medication not given within 30 minutes, it was to be logged as a discrepancy and forwarded to the nurse manager for investigation. If a medication needed to be wasted, 2 nurses were required to observe the waste and document in the Omnicell. RN-H could not recall recent training on medications, but thought it was completed on an annual basis online and with the nurse educator. There was a policy for wasting of medications located on policy stat (online policy locator). If a medication was not wasted timely the manager would receive a discrepancy report and they would be required to follow up with the nurse. During an interview on 9/10/25 at 8:55 a.m., RN-I stated all narcotics were stored in either the Omnicell or refrigerated Omnicell. All narcotics required a count prior to removal of medications. A discrepancy report was pulled at end of each shift for licensed staff to review for any discrepancies they had prior to the end of their shift. There was information for wasting medications included in the policy. Education was provided at time of on-boarding. If there was a narcotic error it would have been entered into safety reporting systems, which was recently changed to Safe Qual from RL solutions. During an interview on 9/10/25 at 9:15 a.m., RN-J stated the Omnicell would prompt the licensed nurse for a count prior to pulling medication. If the count was off a second RN would have had to verify the medication count. For any incorrect count, the Omnicell would print out the discrepancy and it was to be given to the charge nurse. If a medication needed to be wasted, it would have required 2 nurses to log into Omnicell and identify the patient for whom the medication was to be wasted for. The Omnicell auto-populated the need for waste. 2 RN’s were needed to confirm the medication administered and amount that needed to be wasted. During an interview on 9/10/25 at 9:43 a.m., registered nurse (RN)-B stated if a nurse only administered a partial dose of a scheduled II medication, the remaining partial dose needed to be wasted in the proper designated “bin” with another licensed nurse. The medication also needed to be wasted in the Omnicell. It was the facilities policy to waste scheduled II medications in the proper area and Omnicell, with two licensed nurses. Every time a nurse logged into the Omnicell it would alert the nurse of a partial dose that needed to be wasted and would continue to show until it was resolved. The Omnicell printed a report 2 times per day, and showed if a nurse had a medication to waste. Nursing staff were responsible to waste medications prior to the end of their shift. Yearly training was completed on medication administration. RN-B had not received any additional training regarding medications. During an interview on 9/10/25 at 9:56 a.m., the emergency room paramedic (ERP) indicated scheduled II medications were removed from the Omnicell and documented for each patient. Medications were wasted in the Omnicell if the full dose was not given. 2 staff were required to waste schedule II medications. A report was generated every 12 hours for staff to review to see if they had a medication that needed to be wasted. The Omnicell reported a required waste, each time the staff member logged into the Omnicell. Training was completed annually for medications and would be completed on an as needed basis. The ERP did not have any additional medication training other than the annual training. During an interview on 9/10/25 at 10:05 a.m., RN-C revealed pharmacy was in charge of the Omnicell’s and Omnicell counts. A report was generated daily for staff to see if they had a medication that needed to be wasted within the system. If there were any discrepancies, RN-C would be notified by pharmacy the next day. RN-C worked Monday through Friday so if a discrepancy happened over the weekend, they would be notified on Monday when they returned to work. All discrepancies that had not been resolved in 24 hours were reported to them through a report. If a scheduled II medication had a discrepancy, they would discuss the discrepancy with the licensed staff who had the discrepancy and the licensed staff who witnessed the waste, to ensure the medication was wasted properly. RN-C would then require the RN to document the waste in the Omnicell. RN-C would expect this process to happen within 24 hours. Once the waste was recorded in the Omnicell, RN-C would report the correction to the director of quality (DOQ) who would then resolve the medication discrepancy in the variance reporting system. During an interview on 9/10/25 at 9:45 a.m., certified registered nurse anesthetist (CRNA) stated medications that were needed for surgery were scanned out of the anesthesia cart and pharmacy was alerted on what medications were removed. The medications that were not opened or used were scanned back into the anesthesia cart. Medications that were given during surgery needed to be charted in the electronic health record (EHR) with the dose and time given. At the end of the procedure, the remaining medications were wasted with another nurse. Wasting narcotic medications always required 2 nurses. When the surgery was finished, a list of the medications removed from the anesthesia care was compared to the patient’s EHR and/or waste record. During an interview on 9/10/25 at 2:35 p.m., the pharmacy manager (PM) stated printouts were printed automatically each day for pharmacy to review for any medication discrepancy. If a partial dose of a narcotic was given, 2 nurses would be required to waste the medication in the proper waste receptacle and document it in the Omnicell. It was the facility’s policy to have 2 licensed nurses observe wasting the narcotic into the medication destruction box. The facility had a control-check drug diversion software in place that generated a report at midnight as a control check. The PM reviewed the dashboard and investigated each medication discrepancy. Many times, it was staff forgetting to document the wasted medication in the Omnicell. The same process took place for any medication errors. The PM would receive the report, investigate it, send it to the department manager and DOQ. Once the medication error was resolved, the DOQ would resolve the issue in the variance reporting system. During a follow-up email on 9/19/25 at 3:09 p.m., the DOQ stated the facility was unable to generate the twice daily reports. They were generated in real-time for each department. The report was a tool to remind staff of waste requirements and/or prompt completion of missing documentation before the end of each staff’s shift. The daily report from pharmacy was the only report available. During an interview on 9/10/2025 at 5:53 p.m., DOQ and chief nursing officer (CNO), confirmed the above findings and indicated the facilities current process was to receive the generated report from the Omnicell, investigate the licensed staff involved with the medication discrepancy, and the licensed staff were required to document the discrepancy in the Omnicell within 24 hours of being notified of the discrepancy. The investigation involved asking each staff to verify the medication was wasted properly and having both staff sign the medication off. The facility lacked accountability and relied on staff assurance for medication wasting. Her expectations were for staff to waste the unused medication as soon as possible, with 2 staff witnessing the medication destruction following the facilities policy. The importance of monitoring medication waste was to ensure patient safety. Review of facility policy titled Controlled Substance Management, last reviewed June 2025, identified: 1. The procedure for documenting Unused Controlled Substance (“Waste”): a. Controlled substances should be wasted immediately or as close to the time of administration as possible. b. All wasted Schedule II-V substances shall be witnessed and co-signed by a licensed staff. 2. Discrepancy Discovery and Reporting: a. A discrepancy occurs anytime the expected count of a controlled substance held by Omnicell does not match the actual count verified by the user. b. Discrepancies must be resolved prior to the end of the shift of the user that verified the count. The discrepancy must be resolved prior to the next patient procedure. 3. Discrepancy Resolution and Reporting: a. Discrepancies are resolved through investigation of the actions that lead to the differences between the expected and actual counts. b. Most discrepancies will be easily resolved upon chart review and interviewing the parties involved. c. The user should immediately take steps to resolve the discrepancy by checking with the last person to access that compartment. d. If necessary call the previous user at home. Review of facility policy titled Controlled Substance Pharmacy Procedures last reviewed 4/25, identified pharmacy will review an Epic Report daily to assure that all narcotics have been documented on the e-MAR [electronic medication record]. If there are discrepancies, the Pharmacy Technician will contact the Nursing Manager as soon as possible. Staff were to fill out a Safety Event Reporting system report. The pharmacy technician was to investigate, and if unable to resolve, immediately contact the pharmacy and nursing manager. Pharmacy would consider any unresolved discrepancies to be consistent with drug diversion and take appropriate actions as outlined in Hospital policy and State and Federal regulations.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 48583 Based on interview and document review, the facility failed to identify and continually monitor the identified concern to promote patient care according to the facilities Quality Assessment and Performance Improvement (PI) plan. This had the potential to affect all the patient’s residing in the facility. Findings include: Dietary: During joint interview with the Director of Quality Improvement (QI)-A and the Dietary Manager (DM)-A on 9/10/25 at 3:15 p.m., QI-A stated in 2024, the facility identified patient concerns regarding hot/cold food. In 2025, the facility initiated a PI plan to monitor the food temperature by randomly selecting 2 patient trays per week and temping the food to ensure the food was within recommended ranges. During Q1, 37/37, or 100%, of the random patient trays temperature checks were within range. The DM-A stated during Q2 (April, May and June), staff had not completed any random testing. In July ‘25 (the start of Q3), the goal of temping 2 trays per week was re-implemented, however, the goal was not reached. Audits reinstated to 2 per month. The DM-A stated the completed patient surveys for Q2 identified satisfaction with the patient food and since there was no longer a problem with the food, they stopped doing random temp checks. The facilities 2025 Nutrition Patient Tray Temperature Compliance form; the analysis, conclusions and recommendations sections, identified the following: - April-June 2025: 0 random patient trays were logged. The analysis/conclusions and recommendations/actions sections were blank. - July 8 through August 2025: There were no notes in the measure section. The analysis/conclusions section identified: a goal to pull at least 2 patient trays, measure and assess the temperature of the food, and document thermometer calibration. The recommendations/actions section identified education with the management staff to have the process put in place for continuation of the project. The facility failed to continually monitor the patient’s concerns of cold food to ensure the concern was resolved. Infection Prevention: Review of the facilities 2025 Q2 MMHC Dept PI, identified gaps in hand hygiene practice existed and the goal was to improve the gaps in monitoring by completing and documenting audits monthly and quarterly. The benchmark was 75%. The form indented zero’s during the months of January through March (Q1), N/A in April, zero’s for May through June (Q2), and August. September identified 1 audit. On 9/9/25 at 2:12 p.m., registered nurse (RN)-E stated RN-E was not aware of any audits being completed on the nursing unit. On 9/9/25 at 2:33 p.m., RN-F indicated RN-F was familiar with the QAPI process. RN-F indicated the nursing unit was working on falls and assessments. RN-F revealed RN-F was unaware of any other areas being implemented. On 9/10/25 at 2:00 p.m., registered nurse (RN)-A, who is also the Infection Preventionist, stated hand hygiene was started as a PI project because hand hygiene was very important to prevent the spread of infections. RN-A stated although the facility had not identified an issue with hand hygiene and no audits were completed in Q1 and Q2, she thought hand hygiene would be a good place to start for a PI project. The facility failed to identify an ongoing concern and monitor the identified concern. Laboratory Services: Review of the facilities 2025 Q2 MMHC Dept PI identified the facilities laboratory’s project was to identify urine analysis (UA)s that did not meet criteria for culture. The facilities laboratory’s action plan indicated the laboratory talked with clinical staff and stated they do not reject high epitheal counts for culture. Clinic staff indicated providers wanted the UAs anyway. The target was 25%. The PI lacked any documentation for Q1 2025 and Q2 2025. During an interview on 9/10/25 at 1:30 p.m., Labaratory Manager (LM) on at identified the facilities laboratory PI project for 2025 was urine culture studies. LM stated if there was less than 10 epi’s the culture should not have been flagged. LM further stated the facility found a trend that urine cultures were being ordered without meeting the criteria for a urine culture. LM revealed the PI project went to medical staffing last month and education needed to be established for providers. LM stated even if urine culture criteria was not met providers were requesting the laboratory to complete the culture anyway. LM further stated the project was created to prevent the use for unnecessary antibiotic treatments for patients. LM confirmed no data had been collected at this time. Imagining Services: Review of the facilities 2025 Q2 MMHC Dept PI identified the facilities imaging services project was to implement physician and insurance verification on outside orders. The imaging services action plan was for scheduling staff to make sure they have all the correct insurance information prior to or during scheduling of all exams. The target was 25%. The PI lacked any documentation for Q1 2025 and Q2 2025. During an interview on 9/10/25 at 2:00 p.m., Imaging Services Manager (ISM) identified the imaging services PI project included looking at outsider orders that came in, reviewing them for the proper information, reviewing them for prior authorizations and ensuring they are approved prior to scanning them into the system. ISM stated during monthly meetings it was discovered that many orders were coming in and did not have all the information for the prior authorization. ISM further stated this was causing a delay in the authorization and scheduling process. ISM indicated the current PI project began around the first of the year. ISM confirmed no documentation had been reported for Q1 and Q2 2025.”

“QAPI CFR(s): (d) Standard: Program activities. For each of the areas listed in paragraph (b) of this section, the CAH must: (3) Set priorities for performance improvement, considering either high volume, high-risk services, or problem prone areas. This Standard is not met as evidenced by: 48583 Based on interview and document review, the facility failed to identify and incorporate the high volume, high-risk services, or problem prone areas related to pharmacy services into their quality assurance and improvement (QAPI) program. In addition the facility failed to complete an annual periodic evaluation of its total program. Findings include: Review of facilities 2024 Q4 2.0 MMHC Department PI virtual representation undated, indicated the facilities goal for pharmacy was Narcotic RL’s (Administration/Waste Documentation). Quarter one was 7.0 100% of target, quarter two was 4.00 100% of target, quarter three was 14 less than 75% of target and quarter four was 5 100% of target. Action plan indicated goal was met. Facilities QAPI (quality assurance and performance improvement plan) failed to continue the pharmacy project of narcotic RL’s (Administration/Waste Documentation). Additionally, the facilities QAPI project lacked documentation regarding the facility’s periodic evaluation. Review of facilities 2024 Q4 2.0 MMHC Department PI virtual representation undated, indicated the facilities goal for pharmacy was Hospital barcode compliance. It further indicated the goal stated there were several DME products that were changed in Epic to not require a bar code scan. It stated pharmacy manager (PM) would coordinate with nursing leadership on processes for non-compliance with RN scanning. Quarter one was 93.6%, 75%-99% of goal met, quarter two was 94.3%, 75%-99% of goal met and quarter three was 95%,75%-99% of goal met. The QAPI failed to continue the pharmacy project of narcotic RL’s (Administration/Waste Documentation). Additionally, the QAPI project lacked documentation regarding the facility’s periodic evaluation. During an email request on 9/9/25 at 11:47 a.m., director of quality (DOQ) stated the facility no longer completed periodic evaluations based on documentation received from the facilities CCH Quality Network group. DOQ further stated the group supported the discontinuation of annual program evaluations. During an interview on 9/10/25 at 2:35 p.m., pharmacy manager (PM) indicated the facility pharmacy QAPI project for 2025 was bedside barcoding. PM further indicated the Omnicell (electronic medication dispenser) printed reports in real time and was being used as the tool for drug discrepancies. PM stated the report is printed at midnight and pharmacy reviewed it the next day. PM further stated if there was a discrepancy, the facility would determine what happened. PM indicated there was no drug diversion issues at this time, so the project changed after the real time tool was implemented. During an interview on 9/10/25 at 5:53 p.m., DOQ and chief nursing officer (CNO) confirmed the above findings and DOQ was unaware periodic evaluations needed to be complete annually. DOQ and CNO the facility was watching reports more closely for medication discrepancies. DOQ and CNO indicated medication discrepancies should be included back into QAPI. DOQ and CNO both stated the importance of having QAPI was for patient safety and reliability.”