Garrison Memorial Hospital

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 37620 Based on bylaws review, record review, and staff interview, the Critical Access Hospital’s (CAH’s) governing board failed to ensure medical staff reappointment followed the bylaws for 1 of 1 active medical staff physician file reviewed (Provider #1). Failure to follow the bylaws for reappointment of medical staff members placed the CAH’s patients at risk of receiving services from unqualified providers. Findings include: Review of the “Bylaws of The Medical Staff of Garrison Memorial Hospital Garrison, North Dakota” occurred on 01/17/24. These bylaws, effective 12/16/08, stated, “. . . Section 5.3 Reappraisal/Reappointment Process to Medical Staff: A; appointments . . . are for a period not exceed two (2) years. At least one hundred twenty (120) days prior to the expiration of each medical staff appointee’s term of appointment or expiration of clinical privileges: . . . 4. the completed file . . . shall be forwarded to the president of the medical staff for review. The president of the medical staff shall review the file and forward a written report to the executive committee. In the event the file is that of the president of medical staff, it will be forwarded to a Representative of [acute hospital name] Medical Staff for review and a written report to the executive committee. . . .” Review of providers’ 2021-2023 credentialing files occurred on 01/17/24 and indicated the following: - Physician #1: previous appointment dated 01/27/21. Current reappointment dated 03/22/23 (over 120 days). The reappointment form dated 03/16/23 by Medical Staff identified the signature of the administrator, not Medical staff. During interview the morning of 01/18/24, an administrative staff member (#8) confirmed the CAH had not reappointed Physician #1 as per Medical Staff Bylaws.”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iii) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the CAH. This Standard is not met as evidenced by: 37620 Based on policy review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the services furnished by the CAH for 1 of 1 year reviewed (October 2022 - September 2023). Failure to evaluate the services furnished by the CAH limited the CAH’s ability to ensure the provision of quality services to meet the needs of the CAH’s patients. Findings include: Review of the policy “Quality Assurance and Performance Improvement Plan” occurred on 01/17/24. This policy, dated April 2022, stated, “. . . Evaluation: At a minimum, the executive leadership and facility management teams, along with the assistance of the QAPI [quality assurance performance improvement] Steering Committee, will conduct a facility-wide systems evaluation using the QAPI Self-Assessment. . . .” Review of the Quality Assurance Quarterly Meeting Minutes from January -October 2023 occurred on 101/17/24. The minutes failed to include a review and evaluation of the services directly provided by the CAH to ensure the services met the needs of the CAH’s patients. Upon request on 01/18/24, the CAH failed to provide evidence of review and evaluation of the services directly provided by the CAH. During interview on 01/17/24 at 3:10 p.m., a facility quality assurance staff member (#9) confirmed the CAH had not documented an evaluation of the services directly provided by the CAH.”

“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: 32641 Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications and labeling of medication syringes in 1 of 1 physical therapy medication storage area (physical therapy department). Failure to remove outdated medications and label medication syringes may result in patients receiving ineffective and inaccurate medications. Findings include: Observations on the morning of 01/17/24 in the physical therapy department’s locked medication cabinet showed the following: - 25 vials of Dexamethasone Sodium Phosphate 20 milligrams (mg) per 5 milliliters (ml) expired 02/2023 - 8 vials of Dexamethasone Sodium Phosphate 20 mg per 5 ml expired 05/2023 - 22 vials of Dexamethasone Sodium Phosphate 20 mg per 5 ml expired 10/2023 - 3 unlabeled syringes filled with 1.3 ml of a clear medication During interview, the morning of 01/17/24, a therapy staff member (#2) verified the vials of Dexamethasone as expired and agreed the syringes needed labels to identify the contents (Dexamethasone). The staff member stated therapy staff failed to ensure medications were periodically checked for outdates.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 32641 Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff developed care plans to address specific nursing and discharge needs of the patients for 5 of 20 records reviewed (Patients #1, #8, #10, #12, #13). Failure to address the needs of the patients on care plans limited the CAH’s ability to communicate treatment approaches, assist with discharge planning, and ensure continuity of care. Findings include: Review of the policy titled, “Plan of Care” occurred on 01/17/24. This policy, reviewed December 2024, stated, “Care Planning: individualized, multidisciplinary planning and provision of care, treatment, or services that addresses the needs, safety, and well-being of the patient or individual served. . . . care plans should reflect all aspects of the patients care.” Patient record review occurred on all days of survey and indicated the following: - Patient #1 admitted with a diagnosis of acute coronary syndrom with high troponins. The care plan failed to reflect problems or interventions for discharge planning. - Patient #8 admitted with a diagnosis of rib fracture. The care plan failed to reflect problems or interventions for discharge planning. - Patient #10 admitted with a diagnosis of bilateral osteoarthritic knee. The care plan failed to reflect problems or interventions for pain or discharge planning. - Patient #12 admitted with a diagnosis of tachycardia. The care plan failed to reflect problems or interventions for the patient’s current illness. - Patient #13 admitted with a diagnosis of pneumonia. The care plan failed to reflect problems or interventions for the patient’s current illness and antibiotic use. During interview on the afternoon of 01/27/24, an administrative nurse (#1) stated all care plans should address discharge planning. The nurse verified the care plans for Patients #1, #8, and #10 failed to address discharge planning, and Patients #10, #12, and #13 lacked plans for their current illness/treatment.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 32641 Based on observation, review of facility policy, review of a professional reference, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff monitored and documented the cooling process of cooked food in 1 of 1 kitchen. Failure to properly follow the cooling process for cooked foods may result in a foodborne illness. Findings include: Review of the facility policy entitled, “FOOD SAFETY Leftover Handling Activity” occured on 01/18/24. This policy, dated 02/16/11, stated, “. . . 2. Leftovers must be cooled down from 140 degrees to 70 degrees within 2 hours and from 170 [sic] degrees to 41 degrees in less than 4 hours. . . .” The SERVSAFE Manager, 7th Edition Revised, page 6.16, stated, “. . . First, cool food from 135 F [Fahrenheit] to 70 F (57 C [Celcius] to 21 C) within two hours. Then cool it from 70 F to 41 F (21 C to 5 C) or lower in the next four hours.” Observation of the kitchen on the morning of 01/17/24 with a dietary staff member (#3) showed frozen leftovers labeled in the freezer. When asked about the cooling process of cooked foods, the dietary staff member indicated staff completed no temperature monitoring during the cool down process. The dietary staff member stated staff place cooked leftover foods in shallow pans, refrigerate, freeze later in the day or the next morning, and reheat to serve to patients.”

“This survey used the 2012 edition of NFPA 101, Life Safety Code, Chapter 19-Existing Health Care Occupancies and the 2012 edition of NFPA 99, Health Care Facilities Code in compliance with 42 CFR 482.41(b)(c). The facility was located in a two-story building of Type II (000) construction with a basement. The building had a wet automatic sprinkler system designed to meet the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. An occupancy separation wall constructed to have a two-hour fire resistance rating separated a clinic building to the east from the hospital. A nursing facility occupied the second floor of the hospital. Note: At the conclusion of the 01/17/2024 Life Safety Code survey, it was determined the facility was in compliance with the provisions of NFPA 101, Life Safety Code and NFPA 99, Health Care Facilities Code.”