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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Sample Validation Survey conducted on November 5, 2013, the facility failed to provide and maintain a safe environment for patients and staff.
This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Sample Validation Survey conducted on November 5, 2013, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated November 5, 2013.

Based on observation, document review and interview, it was determined the Critical Access Hospital (CAH) failed to ensure outdated drugs and/or biologicals were not available for patient use. This has the potential to affect all inpatients and outpatients. Findings include:

During a tour conducted with the Quality Manager and department managers on 11/5/13 through 11/6/13, expired drugs and/or biologicals were observed available for patient care.

1) "Emergency Check Lists" were reviewed for August 2013 thru October 2013. The lists stated the crash carts were checked and stocked daily. The ED Director confirmed the following items were expired and should have been disposed of at the end of each respective month of expiration. In the Emergency Department:
a) On the ED crash cart: 1 package Adult Pad Pro (expired 10/13) and one #22 gauge Jelco (expired 9/13);
b) On the OP/ED crash cart: 1 package Pediatric Pad Pro (expired 4/13); one #18 gauge Jelco (expired 9/13); and three #22 gauge Jelco (1 expired 8/13; 2 expired 9/13);
c) On the Ortho suture cart: fifteen 2-0 Silk Suture (expired 7/13).

2. The Laboratory Director confirmed the presence of expired solutions and that one of the solutions (Gram Safranin) observed on the rack next to the microbiology sink was in use for the performance of tests and the solutions were expired and should have been removed from the laboratory by the end of the month, in which they expired. In the Laboratory:
a) Cabinet over the microbiology sink: one 250 ml bottle Stabilized Gram Iodine (expired 11/30/12) and two 250 ml bottles Gram Safranin (expired 2/28/13).
b) Rack next to the microbiology sink: an open in-use 250 ml bottle Gram Safranin (expired 2/28/13).

3. In the Respiratory Stress Lab the Respiratory Technician confirmed the supplies were expired and should have been disposed of by the end of the month in which they expired:
a) 19 packages Accu Sensors (60 sensors per package) observed stored under the sink.
b) In one of the supply cabinets: 16 Administration Set Minibore with Y-site (expired 10/12), one Chlora Prep One-Step (expired 2/13), three #20 gauge Jelco (1 expired 11/12, 1 expired 12/12, and 1 expired 2/13), three #22 gauge Jelco (1 expired 12/10 and 2 expired 1/13), and 6 packages (60 sensors per package) Accu Sensor (expired 6/13).

A. Based on document review and staff interview, it was determined the temperature and/or humidity in the Obstetrical (OB) Department were not maintained in the established parameters. This has the potential to affect all patients admitted to the OB Department.
Findings include:

1. The policy titled "Pressure Relationships" (revised 10/28/2013) was reviewed on 11/6/13. The policy stated "Temperature and Humidity: The Fahrenheit temperature and humidity parameters are as follows: Operating Room (OR) at 68-73 F & 30-60% Relative Humidity (RH)."

2. During the OB Unit tour on 11/5/13 at 1:30 PM, the logs for temperature and humidity for the OR for September 2013 thru November 5, 2013 were reviewed with the OB Director.
In the OB OR, 61 out of 97 temperature readings were out of range (60-67F); 45 out of 97 RH readings were out of range (65-72%).

3. On 11/6/13 at 2:00 PM, an interview was conducted with the OB Director. The OB Director stated the discrepancy between the policy and log temperature and humidity ranges was not known until the surveyor brought it to the attention of the OB Director.

B. Based on document/record review, observation and interview it was determined hand hygiene was not performed. This has the potential to affect all surgical patients. Findings include:

1. The policy titled "Hand Hygiene," reviewed 1/12 was reviewed 11/6/13. The policy stated to perform hand hygiene before and after direct patient contact, contact with inanimate objects in immediate vicinity of the patient and after removing gloves.

2. During a tour of the surgery department 11/6/13 at 10:30 AM, the anesthesiologist was observed to have direct patient contact, contact with patients medical equipment(pulse oximeter, cardiac monitoring devices, intravenous fluid equipment, bed, etc.) and removing gloves multiple times. There was no available alcohol-based hand rub.

3. An interview with the Director of Surgery was conducted 11/6/13 at 11:15 AM. The Director of Surgery confirmed there was no alcohol-based hand rub available for the anesthesiologist to perform hand hygiene during a procedure.

Based on observation and interview, it was determined the CAH failed to ensure food products were properly stored. This has the potential to affect all patients and visitors utilizing dietary services. Findings include:

A. The policy titled "First-In-First-Out" [FIFO](reviewed 4/13) was reviewed on 11/6/13. The policy stated "Stock will be used by the expiration date... New supplies are placed on the shelf behind the supplies on hand..." The policy did not address what procedure to follow when a container of food is opened and/or how long the container of food could be safely stored once opened to ensure it is used in the FIFO manner.

B. During g a tour of the Dietary department, conducted on 11/6/13 at 1:15 PM with the Dietary Manager, the following food items were observed stored without dates when received and/or opened.
1) In the walk-in freezer: 1 open bag of pepperoni with no date as to when opened and three 20 ounce bags of blueberries with no date as to when they were received, removed from outer packaging, or any expiration date.
2) In the walk-in cooler: various open bags of lettuce, carrots, grapes, and other vegetables and fruits with no dates to indicate when they were opened and no expiration date. When asked how it is determined that packages are opened and when to dispose of them, the Dietary Manager stated "We use everything pretty quickly. Something like the lettuce may only last a day. Other things last a lot longer. It just depends on how they are when we get them."
3) In the vegetable freezer: numerous bags of frozen vegetables (carrots, cauliflower, California blend, peas, etc.) with no dates to indicate when they were received, removed from outer packaging and no expiration dates present on the packages, When asked how they determine when food items have been opened and removed from packaging, the Dietary Manager stated "We use the stamped date of delivery on the box. Then when we open the box, they are suppose to put the date on the packages. I use a date stamper. I don't think we've ever stamped the frozen stuff." When asked about food items, such as the vegetables and fruit that do not have expiration dates, the Dietary Manager stated "We just use them until they are gone. I know that I only order blueberries once a year. The rest, we just use them until they are gone."

Based on record review and interview, it was determined for 4 of 20 patients (Pts #15, #16, #17, #19) care was not provided in accordance with physician orders. Findings include:

1. The medical record of Pt #15 was reviewed on 11/6/13 with the staff/charge nurse for the Medical Surgical unit (E6). Pt #15 was admitted on 11/5/13 with the diagnosis lower anterior resection. On 11/5/13 at 7:15 AM, "Pre-Anesthesia Evaluation" documentation stated "Epidural for post-op pain discussed and agreed with." On 11/5/13 , an untimed "Post Anesthesia Care Unit Transfer Communication Sheet" stated "Brief History:... continuous Epidural placed per Certified Registered Nurse Anesthetist (CRNA), infusing at 8 ml/hour." There was no post-op order written for the use, care, and/or maintenance of the epidural. An interview was conducted with the Clinical Educator (E#7) on 11/8/13 at 9:20AM to review the epidural order status for Pt #15. E#7 stated "I was unable to find any order. We have an epidural order form that is usually used and should have been used."

2. The medical record of Pt #16 was reviewed on 11/7/13 with a Medical Surgical Registered Nurse (E8). Pt #16 was admitted on 9/14/13 with the diagnoses pneumonia, orthostatic hypotension and fever. On 9/14/13 at 8:39 PM, there was a physician order for Albuterol nebulizer every 6 hours by Cardiopulmonary Care. On 9/15/13 at 2:00 AM, the Medication Administration Record (MAR) stated "Omit: sleeping per rn (Registered Nurse) let patient sleep." There was no documentation to indicate the physician was notified and had agreed to omit the nebulizer since the patient had just been admitted with pneumonia.

3. The medical record of Pt #17 was reviewed on 11/7/13 with E7. Pt #17 was admitted on 11/3/13 with the diagnoses right lower lobe pneumonia, chronic obstructive pulmonary disease, and atrial fibrillation.
a) On 11/3/13 at 4:10 PM, there was a physician order "Duoneb QID (four times a day). On 11/4/13 at 12:23 AM, MAR documentation indicated "Omitted: Discontinued..." On 11/4/13 at 3:15 PM, MAR documentation indicated the Duoneb was placed back on the MAR. There was no documentation to indicate the Duoneb had been discontinued. Pt #17 did not receive any Duonebs between 8:27 PM on 11/3/13 and 3:32 PM on 11/4/13. There was no documentation to indicate the physician was notified of this omission.
b) On 11/4/13 at 7:53 AM, Dietician documentation stated "Add house supplement to increase..." There was no documentation to indicate Pt #17 received and/or was offered house supplements. An interview was conducted with E7 on 11/7/13 at 2:15 PM, concerning Pt #17. E7 stated "There is no documentation that shows Pt #17 was offered or given the supplements as ordered. The supplement should have been put on the MAR or on the Med Act and it wasn't."

4. The medical record of Pt #19 was reviewed on 11/7/13 with the E7. Pt #19 was admitted on 8/13/13 with the diagnoses soft tissue infection left knee and status post left knee debridement. On 11/16/13, there was a physician's order to discharge Pt #19 on Coumadin 3 mg Tuesday, Thursday, Saturday and Coumadin 2 mg on Monday, Wednesday, Friday, and Sunday. On 8/16/13, the patient discharge instructions stated "Coumadin 3 mg by mouth daily" as well as "Coumadin 2 mg by mouth daily." There were no further directions to instruct the patient on specific days to take the doses, only to take both daily which would equal 5 mg daily. There was no physician order to change Pt #19 from the initial Coumadin 3 mg alternating with Coumadin 2 mg to Coumadin 5 mg daily. An interview was conducted with E7 on 11/7/13 at 4:10 PM concerning Pt #19. E7 stated that upon further review of Pt #19's medical record "There isn't any reason for both doses being there without further instructions being added to tell the patient to alternate the days like the physician wanted. There is a drop down option on the computer in which the nurse can input instructions like the Monday, Wednesday, Friday, Sunday so that it specifically and clearly tells the patient what to take."

Based on document review and staff interview it was determined the quality assurance program failed to effectively collect accurate data, analyze data, implement or evaluate corrective actions as needed. This has the potential to affect all patients being treated.
Findings include:

A. The policy "Performance Improvement," last reviewed 7/2012 stated the CAH's goals are to continually and systematically plan, design, measure, assess and improve performance of critical focus areas and this responsibility had been delegated to the Quality Committee.
A review of the 2012-2013 Quality Committee minutes and dashboards on 11/7/13 indicated the following examples:

1) Collect accurate date:
a) The ER (emergency room) indicator for door to TPA time for stroke stated the benchmark as less than 60 minutes. The 2nd quarter was reported as 1 patient as 62 minutes. The 3rd quarter was reported as 2 patients met criteria but did not receive TPA.
b) The indicator for door to CT (computerized tomography)/MRI (magnetic resonance imaging) for stroke stated the bench mark as less than 25 minutes. The 2nd quarter was reported as 13 patients with a 28 minute average wait time. The 3rd quarter was reported as 2 patients with a 40 minute average wait time.
c) Both indicators for the 2nd and 3rd quarters were highlighted in green which indicated the indicator met or exceeded the expectation.

2) Analyze data:
a) The core measure indicator for pneumonia antibiotic selection in an immunocompetent patient was reported for 1st, 2nd, 3rd and 4 th quarters 2012 and 1st quarter 2013 as below the national average.
b) There was no documentation to indicate an analysis was conducted since the indicator was highlighted in red which indicated the results reported were below the expectation for 1st, 2nd and 3rd quarter.

3) Implement or evaluate corrective actions:
a) The preoperative indicator for the patient medication list from the electronic medical record compares correctly with the patient's active list and the indicator for a patient having labs ordered by the physician per anesthesia as below expectation for the 1st, 2nd and 3rd quarters. The comments section stated the physician office staff needed educated as a corrective action. There was no indication as to when the recommendation was made, if the educations had been implemented or the effectiveness of the recommendation.
b) The Sleep Lab indicator for physician interpretations received within 5 days with a benchmark of 90% was reported as 1st quarter/75%, 2nd quarter/47% and 3rd quarter/49% and highlighted red which indicated the indicator was below expectation. The comments section stated the interpreting physician lost 2 partners although 2 doctors have been hired. There was no indication as to when the doctors were hired, that a corrective action was implemented or evaluated to assure the interpretations were received.

B. The Quality Committee meeting minutes dated 2/12/13 were reviewed on 11/7/13. The minutes stated 1st quarter 2012-2013 departmental quality dashboards were reviewed and a discussion of red (below expectation) indicators and corrective actions were to be taken to medical staff and the board for review. The Medical Staff minutes dated 3/26/13 stated the Quality Committee minutes were reviewed and accepted. The Board of Directors minutes dated 3/27/13 stated the 3rd quarter core measure dashboards was reviewed and an inquiry as to why the indicator for pneumonia patients was in the red. The COO was to investigate and report back. There was no documentation in the Quality Committee, Medical Staff or Board of Director meeting minutes dated between February thru November 2013, there was follow up on the pneumonia indicator or the corrective action implemented. An interview with the COO was conducted 11/7/13 during the review of the quality assurance program and meeting minutes. The COO confirmed there was no documentation to indicate the indicator was out of compliance prior to the 3/27/13 Board of Directors meeting and it was followed up on.