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Based on observations and interviews by Deputy State Fire Marshal, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings include:

Refer to deficiencies written on the Critical Access Hospital Recertification Life Safety Code Survey.
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Based on observation, interview, and review of hospital policies and procedures, the hospital failed develop and implement policies and procedures that ensured intravenous medications prepared in pre-drawn syringes were labeled according to accepted standards of practice, as demonstrated by 1 of 1 anesthesia providers observed (CRNA #1).

Failure to label pre-drawn syringes of medications risks medication errors and transmission of communicable diseases to patients.

References: "Safe Injection Practices to Prevent Transmission of Infections to Patients" (Centers for Disease Control and Prevention; April 2011); "APIC Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care" (Association for Professionals in Infection Control and Prevention; 2010); ASA Statement on the Labeling of Pharmaceuticals for Use in Anesthesiology (American Society of Anesthesiologists, October 2009)

Findings:

1. On 10/19/2012 at 7:50 AM, Surveyor #1 inspected the anesthesia cart the hospital's surgical suite Two unlabeled 20 ml syringes of white fluid were on top of the cart. During an interview at the time of the observation, CRNA #1 stated that the unlabeled syringes contained the anesthetic medication propofol.

2. Review of the hospital's anesthesia services and pharmacy policies and procedures revealed the hospital did not have a policy and procedure for preparing and labeling pre-drawn syringes of medication.
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1. Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that anesthesia providers followed CDC guidelines for use of multi-dose medication vials.

Failure to implement appropriate and effective infection control measures risks transmission of communicable diseases to patients, staff, and visitors.

Findings:

a. On 10/10/2012 at 8:20 AM, Surveyor #1 observed and interviewed a certified registered nurse anesthetist (CRNA #1) who was providing anesthesia to Patient #7 during a surgical procedure. The CRNA's anesthesia cart contained two multi-dose vials of medication, Robinul and neostigmine. The vials were open and dated. CRNA #1 confirmed that medication from the vials had been withdrawn and the open vials of medication returned to the anesthesia cart for future use.

b. CDC guidelines for safe injection practices dated 2/9/2011 state that if a multi-dose vial enters the immediate patient treatment area, including operating rooms, the vial should be dedicated to that patient only and discarded after use.

c. Review of hospital policies and procedures revealed there was no written policy for safe use of multi-dose medication vials.


2. Based on observation and interview, the hospital failed to ensure that patient care supplies were not subject to cross contamination from unclean items and surfaces for 1 of 1 staff member observed (Staff Member #2).

Failure to prevent cross-contamination risks transmission of infectious disease.

Findings:

On 10/10/201 at 8:15 AM, Surveyor #1 observed the surgical team preparing Patient #7 for surgery. RN #3 used battery-operated clippers to shave Patient' #1's genital area. RN #2 then picked up the clippers with ungloved hands and placed the clippers on the bottom shelf of a supply cart next to clean supplies. After the clippers were removed from the surgery suite, a bottle of saline irrigation solution was placed on the site where the clippers had been placed. The shelf had not been sanitized after the clippers were removed.


3. Based on observation, interview, and review of hospital policies and procedures, the hospital failed to ensure that surgery staff members performed hand hygiene in accordance with accepted standards of practice.

Failure to perform hand hygiene after contact with contaminated items risks transmission of communicable diseases.

Findings:

a. The hospital's policy and procedure entitled, "Hand Hygiene" (Reviewed 3/2012) stated that all hospital personnel would wash or sanitize their hands before and after each direct contact with patients or the patient's environment. Hand hygiene was to be performed before and after using gloves.

b. On 10/10/2012, Surveyor #1 observed the following in the hospital's surgical suite:

At 8:10 AM, CRNA #1 placed an endotracheal tube into Patient #1's airway. After intubation, CRNA #1 removed his/her gloves and donned another pair without performing hand hygiene between glove changes.

At 8:15 AM, RN #2 removed his/her gloves, then did not perform hand hygiene prior to touching clean items. RN #2 then touched clippers used to prep Patient #1's genital area without wearing gloves, set the clippers on the bottom shelf of a supply cart, then did not perform hand hygiene prior to touching clean items.

At 8:25 AM, RN #3 removed his/her gloves, then did not perform hand hygiene prior to donning new gloves.

c. An interview with the Surgical Nurse Manager at 8:25 AM confirmed that the staff members had not performed hand hygiene according to hospital policy and procedure.
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4. Based on interview and record review, the CAH failed to implement a system to identify and control infections and communicable diseases, by failing to establish a robust system for analyzing surgical site infections, failing to conduct a tuberculosis risk assessment, and failing to review antimicrobial susceptibility.

Failure to implement a system to identify and control infections and communicable diseases risks spread of communicable disease to patients, staff and visitors.

Findings include:

a, Record review and interview with the CAH infection preventionist on 10/11/2012 found that the CAH infection control program did not include analysis and review of common factors identified in surgical site infections during the prior 22 months.

b. An interview with the CAH infection preventionist on 10/11/2012 found that the CAH infection prevention program did not include review of pathogen distributions and antimicrobial susceptibility profiles. The profiles were available in the form of an antibiogram, but this was not provided to the CAH infection preventionist.

c. Interviews with the CAH human resources manager on 10/10/2012 and CAH infection preventionist on 10/11/2012 found that the CAH had elected to restrict tuberculosis skin testing to new hires and exposed employees, rather than conducting annual testing. The CAH infection preventionist confirmed that the CDC Tuberculosis Risk Assessment had not been completed as part of the decision to restrict tuberculosis skin testing.
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Based on interview and record review, the critical access hospital failed to ensure that the quality assurance program was effectively evaluating the quality, appropriateness and outcomes of the diagnosis and treatment furnished in the CAH, by failing to analyze mortality, patient injuries, patient satisfaction, peer review recommendations and departmental changes to performance improvement plans.

Failure to ensure an effective quality assurance program risks provision of patient care that does not meet the quality expectations of the CAH.

Findings include:

1. An interview with the CAH quality coordinator on 10/11/2012 found that the CAH did not aggregate and analyze mortality or patient satisfaction data as part of the CAH performance improvement program.

2. An interview with the CAH director of nursing and review of quality program documentation on 10/11/2012 found that the CAH collected data on patient falls, including date, time, unit, injury and patient name, but did not analyze this and other available data, such as fall risk scores, environmental and equipment factors and other Fall Incident Report data fields for factors that could illuminate opportunities for performance improvement to reduce the overall incidence of falls in the CAH.

3. Review of medical staff peer review documentation on 10/10/2012 and an interview with CAH quality coordinator on 10/11/2012 found that the CAH performance program did not incorporate recommendations made by the peer review physician for CAH system and policy review and changes.

4. An interview with the CAH quality coordinator and review of quality data on 10/11/2012 found that the CAH performance improvement process did not track and monitor some actions taken, or planned but not taken, to improve performance. Specifically, the CAH pharmacy had developed a plan for policy changes to be taken to two CAH committees, but this plan was modified to no longer include policy changes. The CAH performance improvement department had not been included in the modification of the plan or informed of the outcome.
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Based on interview, the Critical Access Hospital failed to develop and a policy and procedure for a comprehensive assessment of the needs of swing bed patients.

Failure to perform an comprehensive assessment of the patient's needs risks provision of inadequate or ineffective patient care and discharge to a harmful living environment.

Findings:

On 10/9/2012 at 2:30 PM, an interview with the Director of Nursing Services, the hospital's social worker, and the charge nurse of the Transitional Care unit (RN #1) revealed that admission assessments of swing bed patients did not include the resident's customary routine.

The hospital had no policy and procedure for how a comprehensive assessments of the healthcare needs of swing bed patients were to be conducted, including the required elements of the assessment, which disciplines were to perform which parts of the assessment, and the frequency and conditions for reassessment of the patient.
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