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I. Based on observations, document review, and staff interviews, the facility failed to have a system in place to monitor hot water temperatures at 1 of 2 offsite clinics (Noah Clinic) to ensure they were in an acceptable range of 110 to 120 degrees. The facility reported approximately 70 patient visits per week at the Noah Clinic.

Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury is directly related to the temperature and duration of exposure to the hot water. The length of exposure required for a third degree burn (destroys the outer layer of skin and the entire layer beneath) to occur is 15 seconds at 133 degrees Fahrenheit, one minute at 127 degrees Fahrenheit, and 3 minutes at 124 degrees Fahrenheit.

Findings include:

1. Observations on 10/1/12 from 2:55 PM to 3:15 PM, during the environmental tour of the Noah Clinic with Staff E, Director of Clinic Operations, revealed the following hot water temperatures at the hand washing sinks in 3 of 3 patient exam rooms:

a. Exam Room 1400 - 126.0 degrees Fahrenheit
b. Exam Room 1399 - 126.5 degrees Fahrenheit
c. Exam Room 1396 - 126.3 degrees Fahrenheit

2. Review of a facility document titled "Plan Services Task Request", dated 10/1/12, revealed, in part, ". . . Check water temperatures throughout the building Every Friday. If there are any temps that are not within the ranges indicated, contact the manager; Clinical - 110 - 120 degrees. . . ."

The Noah Clinic did not have a system in place to track and trend their hot water temperatures.

3. During an interview on 10/1/12 at 3:10 PM, Staff D, Clinic Registered Nurse, stated it took a while for the hot water to get hot but then the water was hot - not like burning hot, but hot. Staff D further stated she did not know if anyone monitored the hot water temperatures at the Noah Clinic.

- During an interview on 10/1/12 at 3:20 PM, Staff E, Director of Clinic Operations, stated the maintenance staff did not monitor hot water temperatures at the Noah Clinic.

- During an interview on 10/1/12 at 10:15 AM, Staff F, Director of Facilities, stated the maintenance staff did not monitor the hot water temperatures at the Noah Clinic.


II. Based on observation, document review, and staff interviews, the facility failed to have a system in place to monitor the hot water temperature in 1 of 1 hydrocollator (Physical Therapy Department) to ensure the water was in a safe range for patient use and failed to clean the hydrocollator monthly in accordance with the facility policy. The facility reported Physical Therapy staff used a hot pack from the hydrocollator on approximately 10 patients per day.

Failure to monitor water temperature in the hydrocollator could potentially cause serious burns to patients during hot pack therapy. Failure to clean the hydrocollator could result in equipment failure related to rust and/or calcium build-up and potentially void the manufacturer warrantee.

Findings include:

1. Observation during a tour of the Physical Therapy department on 10/3/12 at 8:45 AM, with Staff G, Physical Therapist, revealed 1 of 1 Hydrocollator unit (a liquid heating device used in physical therapy to heat and store hot packs for patient use.) that contained approximately 2 small and 4 large hot packs immersed in hot water.


2. Review of Physical Therapy policies/procedures revealed no evidence of a policy/procedure that addressed monitoring the water temperature in the hydrocollator. Additionally, the Physical Therapy department did not have a system in place to document and track the hot water temperature in the hydrocollator.

- Review of Physical Therapy undated policy/procedure titled "Hydrocollator Cleaning Guidelines" revealed, in part, "Policy: Hydrocollator will routinely be cleaned monthly. . . ."

The policy also included space for staff to document the date they cleaned the hydrocollator, their initials, and comments. Review of this documentation showed staff failed to clean the hydrocollator 6 of 12 months in 2011 (January, April, May, June, July, and September) and 5 of 9 months in 2012 (January, March, June, July, and September).

3. During an interview on 10/3/12 at 9:00 AM, Staff H, Physical Therapy Technician, stated the Physical Therapy technicians clean the hydrocollator but do not check the water temperature in the hydrocollator. Staff H further stated maintenance staff monitored the water temperature in the hydrocollator. Staff H was not aware of any documentation of the water temperatures in the hydrocollator.

Staff H acknowledged the documentation on the "Hydrocollator Cleaning Guidelines" policy/procedure showed staff did not clean the hydrocollator monthly in accordance with the policy/procedure.

-During an interview on 10/3/12 at 1:55 PM, Staff G, Physical Therapist, acknowledged the facility lacked a policy/procedure that addressed monitoring the water temperature in the hydrocollator. Staff G further stated no one is monitoring the water temperatures in the hydrocollator.

Staff G acknowledged documentation on the "Hydrocollator Cleaning Guidelines" policy/procedure lacked evidence the hydrocollator was cleaned monthly in accordance with the policy/procedure.

- During an interview on 10/1/12 at 10:15 AM, Staff F, Director of Facilities, stated the maintenance staff did not monitor the water temperature in the hydrocollator.

Based on observation, review of policies/procedures, and staff interviews, the pharmacy staff failed to develop and maintain a system to track and account for the receipt and distribution of sample drugs used in 3 of 4 offsite clinics. Problem identified in the Shell Rock, General Surgery, and Orthopedic Clinics.

The Director of Clinics reported an average of 220 patient visits per week for the Shell Rock Clinic and 30 patient visits per week for the General Surgery and Orthopedic Clinics.

Failure of pharmacy staff to provide oversight of sample medications could result in outdated, recalled, or otherwise unusable medications being available for physicians and mid-level providers to give to patients, as well as, the potential for theft of medications by unauthorized persons.

Findings include:

1. Observation during tour of the Shell Rock Clinic on 10/2/12 at 10:05 AM with Staff B RN (Registered Nurse), revealed 2 of 2 locked sample medication rooms containing approximately 771 boxes and 218 bottles of sample medications. Categories of sample medications included in the room were to control blood pressure, prevent stroke, treat cardiac conditions, replace hormones, treat mood disorders, and treat and manage diabetes.

Observations during tour of the General Surgery/ Orthopedic Clinic on 10/2/12 at 4:00 PM with Director of Clinic Services revealed 2 of 2 locked sample medication rooms containing 235 boxes and 57 bottles of sample medications. Categories of sample medications included in the rooms were to treat breathing disorders, memory disorders and stomach disorders with other miscellaneous medications available for distribution.

2. Review of Pharmacy policies/procedures titled "Medication Handling, Storage and Control," revised 5/11 and the clinic policy titled "Drug Storage and Security" revised 5/12 showed the facility had a system in place to track all medications "ordered and obtained only from wholesalers authorized to manufacture and/or distribute medications by law." The policies did not address sample medications obtained through the facility's off-site clinics and lacked information regarding the pharmacy staff's responsibly for specification as to quality, quantity and source of supply for sample medications used in the clinics.

3. During an interview on 10/2/12 at 10:05 AM, Staff B, RN (Registered Nurse) at the Shell Rock Clinic stated pharmacy staff do not have oversight of the sample medications available for patient use. The clinic staff do send outdated medications back to the hospital pharmacy for disposal, but pharmacy staff do not come to the clinic to oversee the sample medications.

- During an interview on 10/2/12 at 4:00 PM, Staff A, RN at the General surgical/Orthopedic clinic stated pharmacy staff do not have oversight of the sample medications at the clinic.

- During an interview on 10/2/12 at 2:30 PM, Staff C, Pharmacist stated the pharmacy staff do not have oversight of the sample medications in the offsite clinics but should oversee the medications at the offsite clinics.

Based on document review and staff interview, the facility failed to have a system in place that ensured a physician evaluated the care provided to patients for 1 of 1 sampled Certified Registered Nurse Anesthetists (CRNA I). The facility identified 3 CRNA members of the medical staff at the facility.

Failure to ensure a physician reviewed the care provided by the CRNAs (a nurse with advanced training to administer anesthesia to patients for surgery) to patients at the facility inhibits the facility's ability to assure CRNAs provide quality care to its patients.

Findings include:

1. Review of CRNA I's credential file (a personnel file for CRNAs) on 10/2/12 at 2:30 PM revealed the credential file lacked evidence a physician evaluated the medical care provided by the CRNA to determine if the CRNA provided quality diagnosis and care of the CAH's patients.

- Review of the policy "Physician Oversight of Midlevel Providers," effective 12/11, revealed the policy lacked a requirement for a physician to review the care CRNAs provided to patients at the Critical Access Hospital.

2. During an interview on 10/3/12 at 7:40 AM, the Quality Director stated a physician did not review the medical care provided by CRNA I. The Quality Director stated they had failed to consider the 3 CRNAs that provided care to patients at the Critical Access hospital as Mid-Level providers.

Based on document review and staff interview the facility failed to include 8 of 9 sampled physicians that provided care and services to the CAH patients, in their outside peer review process as required. The facility identified 114 physician members of the Medical Staff.

Failure to ensure all physicians that practice at the CAH receive outside peer review of the care they provided to patients at the CAH by a physician peer from an outside source inhibits the facility's ability to assure physicians consistently provide quality care.

Findings include:

1. Review of physician credential files (personnel files for physicians) on 10/2/12 at 2:30 PM, revealed the following:

- Pathologist J's (a physician that specialized in examining body tissue to make a diagnosis) credential file lacked evidence an outside physician had reviewed the care Pathologist J provided to patients at the CAH.

- Family Practitioner K's credential file lacked evidence an outside physician had reviewed the care Family Practitioner K provided to patients at the CAH.

- Family Practitioner L's credential file lacked evidence an outside physician had reviewed the care Family Practitioner L provided to patients at the CAH.

- Tele-Radiologist M's (a physician that specialized in interpreting x-rays) credential file lacked evidence an outside physician had reviewed the care Tele-Radiologist M provided to patients at the CAH.

- Cardiologist N's (a physician that specialized in diseases of the heart) credential file lacked evidence an outside physician had reviewed the care Cardiologist N provided to patients at the CAH.

- Surgeon O's credential file lacked evidence an outside physician had reviewed the care Surgeon O provided to patients at the CAH.

- Radiologist Q's (a physician that specialized in interpreting x-rays) credential file lacked evidence an outside physician had reviewed the care Radiologist Q provided to patients at the CAH.

- Emergency Physician R's credential file lacked evidence an outside physician had reviewed the care Emergency Physician R provided to patients at the CAH.

2. Review of the "REVISED BYLAWS OF THE MEDICAL STAFF," approved 4/12, revealed the bylaws lacked a requirement for an outside physician to review the medical care of all the physicians that practiced at the CAH.

- Review of the policy "Professional Peer Review", effective 7/09, revealed the policy lacked a requirement for an outside physician to review the medical care of all the physicians that practiced at the CAH.

3. During an interview on 10/3/12 at 7:40 AM, the Quality Director stated the CAH administrative staff used a system to routinely provide internal review of the medical care the physicians at the CAH provided to the patients at the CAH. The Quality Director stated the internal review process could result in the CAH administrative staff requesting an outside physician review the care provided by the physicians at the CAH. The process did not result in all physicians that practiced at the CAH receiving an outside review of the care they provided to patients at the CAH. The Quality Director acknowledged the regulations required all physicians that practiced at the CAH to have the care they provided to patients at the CAH reviewed by an outside physician.