HospitalInspections.org

Based on policy review, observations, and staff interview, the Critical Access Hospital (CAH) staff failed to maintain accounting records that tracked requisition and dispensing of narcotic drugs and controlled substances for patient use in the Emergency Department. The CAH had a census of approximately 12 patients daily in the Emergency Department.

Failure to maintain a record system tracking receipt and disposition of medications could result in unauthorized access, usage, and distribution of medications.

Findings included:

1. Review of hospital policy Dispensing of "Starter Pack" #12.035 (Revision date 3/09) revealed the following, in part:
" ... Records and receipt and disbursement: The director of pharmacy is responsible for maintaining accurate records of all receipts and disbursements of controlled substances to nursing services. The pharmacist shall periodically inspect drug administration records and narcotic inventory records for proper record keeping ... Perpetual inventory form at nursing units: At all nursing units a standardized form will be utilized to record the use, and waste of controlled substances. The name of the patient, patient location, provided, amounts used and waste, if any and the signature of the person administering the drug shall all be filled out ... "

2. Observation on 3/31/10 at 10:30 AM, in Emergency/Treatment room #2 revealed a locked cabinet containing the following narcotic medications:

6 - Bottles of Tylenol with codeine Elixir, 120 milliliters (ml).

9 - Unit dose packets, containing 10 tablets of Acetaminophen with codeine.

5 - Bottles of Robitussin with codeine Elixir, 118 ml.

14 - Unit dose packets, containing 10 tablets of Hydrocodone 5/500 milligrams (mg).

16 - Unit dose packets, containing 10 tablets of Darvocet N 100 mg. Staff A, Paramedic and EMS supervisor accompanied the surveyor at the time of the observation and assisted in unlocking the cabinet.

3. Staff A, confirmed the findings at the time of the observation. Staff A stated, " Those are starter packs. We do not document starter pack medications on an inventory sheet, we fill out slips when the packs are given to patients, and send them to the pharmacy. I will check into this. "

4. During an interview on 3/31/10 at 11:00 AM the Pharmacist Director stated, " We do not have an inventory or count sheet here at the hospital for the narcotic starter pack medications. I have been the director of pharmacy for three years and we have never kept an accountable form here. We would not be able to track on paper for missing medications, no. I have written down each drug that is a controlled medication and the quantity for each starter pack on a control form. When something is removed, it will need to be recorded on the inventory ER sheet. I will implement this immediately. "

5. During an interview on 3/31/10 at 11:10 AM, Staff B, Registered Nurse (RN) and supervisor of the emergency room confirmed the findings. Staff B stated, " The starter packs are not monitored. I have been the supervisor for 10-years and as nursing staff; we have never monitored or inventoried starter medications here at the hospital. "

6. On 3/31/10 at 11:30 AM, the Pharmacist Director presented the survey team with a copy of a medication dispensation control form titled "ER Starter Packs" dated 3/31/10. The Pharmacist Director stated, "Medications will be recorded on a daily basis by the ER nurses on this inventory sheet when the starter packs are dispensed in the ER. It will be a part of my monthly inventory checks hospital wide."

Based on observation, document review, and staff interview, the Operating Room Supervisor failed to ensure a system was in place that showed the Operating Room staff verified the efficacy of the Cidex OPA prior to each use in accordance with the manufacturer ' s directions for use. The Critical Access Hospital (CAH) staff identified a current census of 7 patients.

Failure to have a system in place that monitors and/or tracks the tests performed to ensure the minimum effective concentration of Cidex OPA's active ingredient could potentially allow operating room staff to use Cidex OPA below the minimum effective concentration. Using the disinfectant below the minimum required concentration could potentially result in the disinfectant solutions failure to kill all infectious organisms on the equipment/instruments allowing infectious organisms to transfer to another patient, possibly resulting in the spread of infectious diseases.

Findings include:

1. Observations during a tour of the Operating Rooms on 3/30/10 at 3:15 PM, revealed an opened bottle of Cidex OPA, and an opened bottle of Cidex OPA test strips. Observations also revealed the hospital lacked documentation of when Operating Rooms staff tested reused Cidex OPA to ensure the Cidex OPA contained the minimum effective concentration of the active ingredient.

2. Review of the manufacturer's directions for Cidex OPA, removed from the open bottle of Cidex OPA, revealed in part, "Concentration of this product during its reuse life must be verified by the Cidex OPA solution test strip prior to each use to determine that the concentration of [the active ingredient] is above the [minimum effective concentration] of 0.3%."

3.During an interview, at the time of the tour, the Operating Rooms Supervisor stated the Operating Room (OR) staff tested the Cidex OPA disinfecting solution before each reuse. However, the OR staff did not maintain a system, that showed documented evidence that OR staff performed the tests or the results of the tests to ensure the Cidex OPA contained the minimum effective concentration of the active ingredient. The Operating Rooms Supervisor acknowledged the lack of documentation that showed OR staff tested the Cidex OPA for the minimum effective concentration of the active ingredient before each reuse.

Based on observation, document review, and staff interview, the Operating Room Supervisor and the Director of Health Information failed to ensure the operating room staff had access to a list of current operating room privileges for 2 of 2 reviewed surgeons (Surgeons G and F). The Critical Access Hospital (CAH) identified 9 anesthesia providers, 9 surgeons, and 2 family practice physicians with current operating room privileges.

Failure to provide operating room staff with current operating room privileges could potentially allow physicians or anesthesia providers to perform procedures, for which the medical staff had not evaluated their competence, potentially resulting in physicians performing procedures in an unsafe manner.

Findings include:

1. Observations and review of the Privilege list, during a tour of the Operating Rooms, on 3/30/10 at 3:10 PM, revealed the following information.

a. Review of Surgeon G's "medical staff privileges" list revealed Surgeon G signed the privilege list on 11/12/1997. Review of the most recent documents placed with the privilege list showed the "Reappointment Period: 2008-2009". The privilege list did not contain a current list of Surgeon G's operating room privileges.

b. Review of Surgeon F's medical staff privileges" list revealed Surgeon F signed the privilege list on 2/27/2004. Review of the most recent documents placed with the privilege list showed the "Reappointment Period: 2008-2009". The privilege list did not contain a current list of Surgeon F's operating room privileges.

2. During an interview, at the time of the tour, the Operating Room Supervisor acknowledged the privilege list for all anesthesia providers, surgeons, and family practice physicians with operating room privileges lacked a current list of operating room privileges.

3. During an interview on 3/31/10 at 11:30 AM, the Director of Health Information stated the CAH's medical staff reappointed all members, including the anesthesia providers, surgeons, and family practice physicians with operating room privileges in December 2009. "I have not sent a copy of the privileges requested, [form stating a medical staff member did not with to change privileges], or the current privileges list to the Operating Room." "If Operating Room staff needed to verify [an anesthesia provider's or physician's] privileges after hours, the Operating Room staff would have to call me at home. I would have to tell the staff where to look for the privileges. If [the Operating Room staff] couldn't find [the current privileges], I would have to come in and locate [the current privileges]." The Director of Health Information acknowledged the CAH lacked a policy requiring the Operating Room staff to receive a copy of the current privilege list for anesthesia providers and physicians with operating room privileges. The Director of Health Information also acknowledged the CAH lacked a system to provide the Operating Room staff with a current copy the privileges for anesthesia providers or physicians with operating room privileges.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure that an appropriate external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors of the CAH for 6 of 9 physicians (Physicians A, B, C, D, E, and F) credential files reviewed. The CAH administration reported a current census of 8 inpatients.

Failure to ensure the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially lead to medical staff providing substandard patient care.

Findings included:

1. Review of the Medical Staff Bylaws, revised September 2005 revealed the following, in part. " ...Section 12. 6 Quality Assessment and Improvement Committee ... 12.6-1 Members Duties ... (b) Review and act upon, on a regular basis, factors affecting the quality and efficiency of patient care provided in the Hospital, including surgical care, mortality, drug use, and blood usage studies, and fulfillment of consultation requirements, applicable Peer Review Organization (PRO) criteria, norms standards, and actions .... "

3. Review of peer review documentation for the past 24 months showed that CAH staff had failed to submit medical records created by Practitioners A, B, C, D, E, and F for external peer review.

4. During an interview on 3/31/10 at 10:30 AM, the Director of Health Information Management stated that the CAH administration did not require an external peer review as part of their quality or credentialing process.

5. During an interview on 3/31/10 at 10:30 AM, the Quality Assurance and Improvement Coordinator acknowledged that an external peer review was not required as part of the CAH's quality improvement activities.

Therefore, the medical staff and governing body lacked information from an external peer review process, regarding the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH, in the physician's credential files at the time of reappointment for 6 of 9 physicians.