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Based on review of the blood bank agreement, Medical Staff Meeting minutes, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH's Medical Staff approved the updated blood bank agreement. The Laboratory administrative staff reported the laboratory had 20 units of blood products available to CAH patients at the beginning of the survey.

Failure to ensure a current, approved blood bank agreement was in place could potentially interrupt the availability of blood products needed for emergencies resulting in patient harm and/or death.

Findings include:

1. Review of the "Blood Supply and Services Agreement", dated September 1, 2011, signed by the Chief Nursing Officer on 9/30/2011, revealed the agreement lacked approval by the CAH's Medical Staff.

2. Review of the CAH's Medical Staff Meeting minutes for September 2011 revealed the Blood Bank Agreement Amendment lacked approval by the CAH's Medical Staff.

3. During an interview on 11/28/18 at 10:10 PM, the Laboratory Supervisor acknowledged the Blood Bank Agreement dated September 1, 2011 lacked approval by the CAH's Medical Staff.

Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from 1 of 1 Medical/Surgical Nursing Unit emergency supply crash cart, 1 of 1 Emergency Department emergency supply crash cart, and 1 of 1 Specialty Clinic Orthopedic supply closet.. The CAH staff reported furnishing patient care for approximately 2 medical surgical patient's per day, 400 emergency patients per month, and 46 orthopedic patients visits per month in the Specialty Clinic. Failure to remove outdated patient supplies from the CAH's supplies, available for use in patient care, could potentially result in staff using the expired items for patient care after the manufacturers' expiration date, indicating the staff should not use the supplies for patient care.

Findings include:

1. Observations on 11/26/18 at 11:45 AM, during a tour of the Medical/Surgical Unit, revealed the following expired supplies in the emergency supply crash cart:
a. 3 of 3 18 Gauge BD Insyte Autoguard Intravenous (IV) needles, expired 4/2018
b. 3 of 3 20 Gauge BD Insyte Autoguard IV needles, expired 7/2018
c. 3 of 5 18 Gauge Safety Glide IV needles,expired 12/2016
d. 2 of 5 18 Gauge Safety Glide IV needles, expired 9/2017
e. 3 of 3 18 Gauge BD Insyte Autoguard IV needles, expired 12/2016
f. 1 of 1 24 Gauge BD Insyte Autoguard IV needles, expired 10/2018

During an interview on 11/26//2018 at the time of the tour, the Inpatient and ED Nurse Manager verified the outdated supplies in the Medical Surgical emergency supply cart and reported staff should have checked the supplies monthly.

2. Observations during a tour of the Emergency Department (ED) on 11/27/2018 at approximately 9:30 AM, revealed 1 of 1 7.5 mm endotracheal tube (a tube placed through the mouth into the windpipe to help a patient breath) that expired in 9/2018.

During an interview on 11/27/2018 at the time of the tour, the Inpatient and ER Nurse Manager verified the outdated supplies in the ED emergency supply crash cart.

3. Observations 11/28/2018 at 8:50 AM, during a tour of the Orthopedic Specialty Clinic, revealed the following expired supplies in the Orthopedic supply closet:

a. 1 of 1 # 15 disposable scalpel (a small and extremely sharp bladed instrument), expired 4/2016
b. 3 of 5 22 Gauge 3.5 inch Spinal needles, expired 1/2017
c. 1 of 5 22 Gauge 3.5 inch Spinal needles, expired 2/2018

During an interview on 11/28/2018 at the time of the tour, the Director of Support Services verified the outdated supplies in the Orthopedic supply closet.

4. During an interview on 11/29/18 at 8:40 AM, the Director of Support Services revealed the hospital lacked a policy instructing the staff to check supplies for expiration.

Based on observation, document review, and staff interviews, the Critical Access Hospital's (CAH) staff failed to follow the manufacturer's directions when staff utilized the FreeStyle Freedom Lite Blood Glucose Monitoring System for more than one patient on the Medical Surgical Unit and the Emergency Department (ED). Failure to follow the FreeStyle Freedom Lite Blood Glucose Monitoring System manufacturer's instructions for use may result in inadequate instrument cleaning leading to inadequate disinfection of the FreeStyle blood glucose monitor and the potential for infections. The CAH reported the Medical Surgical Unit monitored blood glucose levels on approximately 6 patients per month and the ED staff monitored blood glucose levels on approximately 3 patients per month.

Findings include:

1. Observation on 11/27/2018 at 10:00 AM in the ED revealed ED staff utilized the FreeStyle Freedom Lite Blood glucose monitor to check an ED patient blood sugar.

2. Review of the FreeStyle Freedom Lite manufacturer's booklet, dated 6/23/2016 revealed in part, "Important Information About Your Blood Glucose Monitoring System"Intended Use ... Important: The device must not be used on more than one person including other family members due to the risk of spreading infection. All parts of the device and its accessories are considered biohazardous and can potentially transmit infectious diseases, even after performing the cleaning procedure."

2. Review of Policy "Routine Cleaning of General Equipment," reviewed 7/19/2018, revealed in part, "Manufacturer ... recommendations will be followed in the handling, cleaning, and decontaminating general equipment."

3. During an interview on 11/27/2018 AM while on tour in the ED, the Inpatient and ED Nurse Manager reported a single FreeStyle Freedom Lite Blood Glucose Monitor was utilized in both the ED and on the Medical Surgical Unit to monitor the blood glucose levels on multiple patients.

Based on review of the Quality Improvement Plan, Quality Improvement activities, and staff interview, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for 2 of 4 contracted patient care services (MRI - Magnetic Resonance Imaging and Nuclear Medicine). The CAH administrative staff reported a census of 1 patient at the beginning of the survey. The CAH administrative staff reported the contracted services performed 161 MRI procedures and 25 Nuclear Medicine procedures from July 1, 2018 to June 30, 2018.

Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care.

Findings include:

1. Review of the CAH Performance Plan, dated 7/192/017, revealed, in part, "...The Medical Staff meets with representatives from all clinical departments and hospital and administration. Medical staff is responsible for the identification, approval, and oversight of clinically related performance improvement initiatives throughout the hospital. This includes ... reviews of internal departmental and interdisciplinary initiatives and contracted services ...."

2. Review of the Board Quality Committee Meeting minutes from February 15, 2018 through November 15, 2018 lacked evidence that the MRI (Magnetic Resonance Imaging) and Nuclear Medicine contracted services monitored, evaluated, and reported quality improvement activities regarding patient care services.

3. During an interview on 11/29/18 at 9:15 AM, the Chief Clinical Officer (CCO) acknowledged that the MRI and Nuclear Medicine contracted services monitored, evaluated, and reported quality improvement activities regarding patient care services. The CCO confirmed the Nuclear Medicine contracted service monitored how frequently patients failed to show up for their procedures, and did not monitor any items related to the quality of patient care.

Based on policy/procedure review and staff interview, the Critical Access Hospital (CAH) staff failed to update the visitation rights policy to ensure all patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients. The CAH staff identified a current census of 1 patient at the start of the survey.

The CAH staff identified the served the following numbers of patients from 7/1/2017 to 6/30/2018:

- Inpatients (Acute and Swing Bed) discharged - 157
- Surgeries - 610
- Radiology exams - 4187
- Mobile Services Outpatient visits (Echo, Nuclear Medicine, MRI - Magnetic Resonance Imaging) - 285
- Laboratory tests - 33389
- Therapy Outpatient visits (Physical Therapy, Occupational Therapy, Speech Therapy) - 22188
- Respiratory Therapy Outpatient visits - 514
- Cardiac Rehabilitation visits - 573
- Pulmonary Rehabilitation visits - 108
- Sleep lab visits - 88
- Emergency Room visits - 4848
- Ambulatory care visits (Antibiotics, Chemotherapy, Blood Transfusions) - 1235

Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of CAH policies/procedures revealed the CAH lacked a policy requiring staff to inform all inpatient and patients undergoing an outpatient procedure (or their support person when appropriate) of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member ,or a friend for all inpatients and outpatients.

2. During an interview on 11/28/18 at 11:40 AM, the Chief Clinical Officer acknowledged the Patient Rights Policy lacked a requirement for staff to inform all inpatient and patients undergoing an outpatient procedure (or their support person when appropriate) of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member ,or a friend for all inpatients and outpatients.

Based on document review and staff interviews, the Critical Access Hospital (CAH) staff failed to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member or a friend for all inpatients and outpatients. The CAH staff identified a current census of 1 patient at the start of the survey.

The CAH staff identified the served the following numbers of patients from 7/1/2017 to 6/30/2018:

- Inpatients (Acute and Swing Bed) discharged - 157
- Surgeries - 610
- X-ray exams - 4187
- Mobile Services Outpatient visits (Echo, Nuclear Medicine, MRI - Magnetic Resonance Imaging) - 285
- Laboratory tests - 33389
- Therapy Outpatient visits (Physical Therapy, Occupational Therapy, Speech Therapy) - 22188
- Respiratory Therapy Outpatient visits - 514
- Cardiac Rehabilitation visits - 573
- Pulmonary Rehabilitation visits - 108
- Sleep lab visits - 88
- Emergency Room visits - 4848
- Ambulatory care visits (Antibiotics, Chemotherapy, Blood Transfusions) - 1235

Failure to provide all patients with current visitation rights could potentially result in limiting/restricting access of visitors to patients that infringed on their right to have a support person when they are provided any type of care, services, or treatment modalities.

Findings include:

1. Review of CAH policies/procedures revealed the CAH lacked a policy requiring staff to inform all inpatient and patients undergoing an outpatient procedure (or their support person when appropriate) of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member ,or a friend for all inpatients and outpatients.

Review of an undated brochure, available in Patient Care areas and Registration, "Patient Rights and Responsibilities," lacked information to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients.

Review of undated document "Your Rights and Responsibilities as a Patient," lacked information to ensure patients (or support person where appropriate) were informed of their visitation rights, including the ability to receive designated visitors, but not limited to a spouse, domestic partner (including a same-sex domestic partner), another family member, or a friend for all inpatients and outpatients.

2. Interviews with the CAH staff who register inpatients and outpatients included the following:

a. During an interview on 11/27/18 at 3:00 PM, Staff A, Patient Access Registration, stated they provided a copy of the undated brocure "Patient Rights and Responsibilities" to all inpatients and outpatients registering for laboratory, radiology, the emergency department, surgery, and cardiac rehabilitation services.

b. During an interview on 11/28/18 at 2:50 PM, Staff B and Staff C, Patient Access Representatives, stated when they registered patients for their outpatient therapy appointments, Staff B and Staff C offered the patients a copy of the undated document "Patient Rights and Responsibilites as a Patient."