Chi St Alexius Health Turtle Lake

“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principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use.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: 42397 Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of expired medications from 1 of 1 intravenous (IV) supply storage closet and 1 of 1 medication room (located on the medical floor). Failure to remove expired medications may result in patients receiving expired and ineffective medications. Findings include: Review of the policy titled “Pharmacy Expiration Date Checking” occurred on 01/31/24. This policy, revised May 2023, stated, “. . . All areas within the Medical Center that contain drug inventory will be inspected and maintained on a monthly basis . . . 2. Assigned areas will be checked for expired, short dated, damaged medication and will be returned to the pharmacy. . . .” Observation of the medical floor on 01/29/24 at 1:15 p.m. with administrative nurse (#3) showed an IV supply storage closet contained the following: * three 250 milliliter bags of normal saline 0.9% (percent) solution with an expiration date of July 2023. * nine 250 milliliter bags of dextrose 5% solution with an expiration date of October 2023. Observation of the medication room on 01/29/24 at 2:43 p.m. with administrative nurse (#3) showed one 2 milliliter vial of bebtelovimab (injectable medication to treat COVID-19) with an expiration date of 12/22/23 located in the medication refrigerator. During an interview on 01/29/24 at 2:50 p.m., administrative nurse (#3) confirmed she expected nursing staff to check the IV supply storage closet and medication room for expired medications weekly.”

“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: 42397 Based on observation, review of personnel files, review of professional reference, review of North Dakota Administrative Code (NDAC), and staff interview, the Critical Access Hospital failed to ensure all nursing staff delegated patient care to staff that possessed the specialized qualifications and competence needed to meet patient needs for 1 of 1 activity director (#1) observed feeding a patient. Failure to ensure all nursing staff delegated patient care to the staff with the training necessary to perform their duties may result in unmet patient needs. Findings include: Kozier & Erb’s “Fundamentals of Nursing, Concepts, Process and Practice,” 11th Edition e-Text, 2021, Pearson, Boston, Massachusetts, page 50, stated, “. . . Delegation is ‘allowing a delegatee to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and not routinely performed. A delegatee may be . . . assistive personnel’ . . . To perform the delegated care, the delegatee must have acquired the additional knowledge and training and validated competence to perform the delegated responsibility . . .” NDAC, Section 54-05-02-07: “Standards related to registered nurse responsibility to organize, manage, and supervise the practice of nursing” states, “ . . . In the administration and management of nursing care, registered nurses may assign and delegate the responsibility for performance of nursing interventions to other persons. . . . The registered nurse shall: . . . 2. Delegate to another only those nursing interventions for which that person has the necessary skills and competence to accomplish safely . . . In maintaining accountability for the delegation of nursing interventions, the licensed registered nurse shall: a. Ensure that the unlicensed assistive person is on a registry and has the education and demonstrated competency to perform the delegated intervention. . . .” - Observation on 01/29/24 at 12:05 p.m., showed an activity director (#1) fed Patient #2 the lunch meal which consisted of a pureed diet. Review of the activity director’s (#1) personnel file occurred on the morning of 01/31/24 and lacked evidence of nurse aide certification or specialized training required to feed patients. During interview on 01/31/24 at 10:05 a.m., an administrative staff (# 2) confirmed the activity director (#1) was not a certified nurse aide and lacked specialized training to feed patients.”

“NURSING SERVICES CFR(s): §485.635(d)(3) All drugs, biologicals, and intravenous medications must be administered by or under the supervision of a registered nurse, a doctor of medicine or osteopathy, or, where permitted by State law, a physician assistant, in accordance with written and signed orders, accepted standards of practice, and Federal and State laws. This Standard is not met as evidenced by: 42397 Based on observation, review of facility policy, review of medical record, and staff interview the Critical Access Hospital (CAH) failed to follow standards of practice for administration of medications for 7 of 7 patients (#1, #3, #23, #24, #25, #26 and #27) observed during medication pass. Failure of nursing staff to follow physician’s orders, prime insulin pens correctly, document administration of medications after administration, secure the medication cart, follow standards for self-administration of medications, and preparation of medications may result in medication errors, inaccurate dosages of medications, adverse events, and/or unauthorized access to medications by patients, staff, and visitors. Findings include: Review of the policy “Medication Administration” occurred on 01/31/24. This policy, dated 05/22/19, stated, “. . . Medications are administered only pursuant to a Provider’s Order. . . . 2. Medication Administration Record [MAR]: A. All medications administered to a patient must be recorded on the electronic MAR . . . All medications should be charted immediately after they are given by the nurse who administered them. . . . 3. Responsibilities: A. The professional nurse is responsible for the correct administration of medications as ordered by the doctor. . . .5. Preparation and Administration of Medications . . . B. The nurse will read each entry in the patient’s medication administration record and select the appropriate medication from the patient’s medication drawer. . . . the dosage strength . . . are verified before administering the medication. . . . E. It is expected that all medications be administered promptly . . . Oral medications administered by personnel must never be left at the bedside for the patient to take later. F. Medications for self-administration by inpatients must have written approval by the provider to be left at the bed side . . . 8. Procedure For Passing Medications: A. If the nurse leaves the med cart unattended for any reason, it must be locked . . . D. The nurse will prepare the medication, lock the med cart and take the medication to the patient. 1. Compare ID bracelet or Picture with ID . . . to the name on MAR and scan just prior to giving medication. 2. . . . the nurse will administer the medication. 3. The nurse will remain with the patient until all medications are swallowed. . . .” Review of the policy “Insulin Pen Use” occurred on 01/31/24. This policy, dated 05/15/19, stated, “. . . prime safety needle with 2 units prior to each administration. . . 1. Remove the safety cap from needle . . . 2. Turn dose selector to select 2 units . . . 3. Hold pen with the needle point up. . . . 4. Keep the needle point upwards; press the push button all the way in until the dose selector returns to 0. A drop of insulin should be visible at top of needle . . .” Observation of medication administration showed the following: * 01/29/24 at 1:07 p.m. nurse (#6) prepared a Novolog Flexpen for administration to Patient #1 at the medication cart, at the nurses’ station. The nurse applied a needle to the insulin pen, held the pen horizontally, and without removing the cap of the needle primed the pen with an unknown amount of insulin. When asked how many units she primed the pen with the nurse (#6) stated, “one or two units.” The nurse turned the dial of the insulin pen to six units, documented the insulin as administered for Patient #1, then administered the 6 units of insulin to Patient #1 in the patient’s room. * 01/29/24 at 1:19 p.m. nurse (#6) prepared and documented Gabapentin 300 mg (milligrams) (a pain medication) as administered for Patient #23 at the medication cart, at the nurses’ station, then administered the Gabapentin to Patient #23 in the patient’s room. * 01/29/24 at 1:48 p.m. nurse (#7) prepared and documented Acetaminophen 650 mg (a pain medication) as administered for Patient #1 at the medication cart, at the nurses’ station, then administered the Acetaminophen to Patient #1 in the patient’s room. * 01/29/24 at 1:52 p.m. nurse (#7) prepared and documented Baclofen 10 mg (a muscle relaxant medication) as administered for Patient #24 at the medication cart, at the nurses’ station, then administered the Baclofen to Patient #24 in the patient’s room. * 01/29/24 at 1:55 p.m. nurse (#7) prepared and documented Acetaminophen 500 mg as administered for Patient #25 at the medication cart at the nurses’ station, then administered the Acetaminophen to Patient #25 in the patient’s room. * 01/29/24 at 1:57 p.m. nurse (#7) prepared and documented Gabapentin 300 mg as administered for Patient #26 at the medication cart at the nurses’ station, failed to secure the medication cart, then administered the Gabapentin to Patient #26 in the patient’s room. The nurse returned to the cart 4 minutes later. * 01/30/24 at 8:05 a.m. nurse (#6) prepared and documented 1 unit of Humalog Insulin, 34 units of Glargine Insulin, a Mometasone Furoeate 200 mcg (micrograms) inhaler (asthma medication), and 13 scheduled oral medications as administered for Patient #27 at the medication cart, at the nurses’ station. The nurse (#6) took the medications to Patient #27’s room, the patient was in the bathroom. The nurse returned the medications to the medication cart. The nurse (#6) prepared and documented Acetaminophen 1000 mg as administered for patient #3, placed the pills in a plastic medication cup, labeled the medication cup with Patient #3’s name, and placed the medication cup in the medication cart. The nurse prepared eight scheduled oral medications, which included Cinnamon Bark 2000 mg (a supplement), for Patient #23, documented the medications as administered, placed the medications in a medication cup, labeled the medication cup with Patient #23’s name and placed the medication cup in the medication cart. * 01/30/24 at 8:12 a.m. nurse (#6) took the prepared medications for Patient #27 to his room, administered the two insulins and inhaler, left all the pills on the bedside table, “Work on these”, and left the room. Review of Patient #27’s medical record occurred on 01/31/24, and lacked a physician’s order for self-administration of medication. * 01/30/24 at 8:19 a.m. nurse (#6) took the medication cup labeled with Patient #3’s name from the medication cart to his room, placed it on his bedside table, stated, “These will help with your back pain”, and left the room. Review of Patient #3’s medical record occurred on 01/31/24 and lacked a physician’s order for self-administration of medication. * 01/30/24 at 8:22 a.m. nurse (#6) took the medication cup labeled with Patient #23’s name from the medication cart to her room, handed it to her, and left the room. Review of Patient #23’s medical record lacked a physician’s order for self-administration of medication, and a current physician’s order stated, “. . . Cinnamon Bark 1000 mg PO (orally) . . . “ The nursing staff failed to follow physician’s orders for self-administration of medications and medication dosages, prime insulin pens correctly, secure the medication cart at all times, document medication administration after administration, and follow standards of practice for preparation of medications by pre-dishing medications prior to administration. During an interview on 01/30/24 at 10:15 a.m., administrative nurse (#3) confirmed she expected nursing staff to follow physician’s orders, document after the medication is administered, prime insulin pens per facility policy, secure the medication cart at all times, and follow standards of practice for medication administration and not pre-dish medications.”

“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: 42397 C1206 Based on observation, review of manufacturer’s instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed manufacturer’s instructions for the use of a chemical for cleaning and disinfecting equipment and supplies for 1 of 1 equipment processing room (central processing). Failure to follow manufacturer’s instructions for cleaning and disinfection of equipment and supplies limited the CAH’s ability to ensure proper sterilization. Findings include: Observation of the central processing room occurred on 01/31/24 at 8:00 a.m. with a central processing technician (#5) showed a sink for preparation of water with quaternary solution (Mikro-Quat) for manual cleaning prior to sterilization. The sink showed a metal basin with a water fill line. The technician (#5) stated the water fill line measured two quarts of water, described the process for preparation of water with the quaternary solution and stated, “I use a 1/2 ounce of the Mikro-Quat and water to the line.” The Mikro-Quat manufacturer’s instructions, reviewed on 01/31/24 at 8:15 a.m., stated, “use 1/2 ounce of solution per one gallon of water.” During an interview on 01/31/24 at 8:15 a.m., the technician (#1) confirmed she failed to follow manufacturer’s instructions for the Mikro-Quat solution.”

“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 485.623(d)(e). The findings that follow demonstrate noncompliance with these standards. The facility was located in a two-story building of Type II (000) construction. The building had a wet automatic sprinkler system designed to meet the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. A two-hour fire resistive rated occupancy barrier separates an administrative building that is attached to the south side of the hospital. The St. Alexius Medical Center Clinic in Washburn, ND was included in this survey. Note: A Fire Safety Evaluation System (FSES) was conducted as a result of the 01/31/2024 Life Safety Code survey. The FSES was specifically used as an alternative safety method for K311, Vertical Openings. CHI St Alexius Health Turtle Lake does not meet the Life Safety Code requirements for vertical openings but does pass the FSES when all other deficiencies are corrected.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 31889 The facility failed to provide a one-hour fire resistance rated stair enclosure. Observation determined the walls of the east stair enclosure stopped at the membrane ceiling and were not extended to the roof deck. Failure to provide one-hour fire resistance rated vertical openings increases the risk of death or injury due to fire. This deficiency affected one (1) of three (3) vertical shafts in the building.”