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Based on document review and interview, it was determined in 2 of 2 (Pt #12, Pt #13) patients' records reviewed, the Hospital failed to ensure Patient Rights and Responsibilities information was provided or explained to the patient or the patient's representative. This has the potential to affect all patients served by the CAH (Critical Access hospital) with a current census of 5 patients.

Findings include:

1. The Code of Federal Regulation (CFR) Title 42- Public Health, Volume 5 dated 10/1/18 was reviewed on 4/25/19. The document required that, "Title: PART 489 - PROVIDER AGREEMENTS AND SUPPLIER APPROVAL; Context: Title 42 - Public Health. CHAPTER IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES: SUBCHAPTER G - STANDARDS AND CERTIFICATION: § 489.102 Requirements for providers. (a) Hospitals, critical access hospitals... (and for Medicaid purposes, providers of personal care services), hospices, and religious nonmedical health care institutions must maintain written policies and procedures concerning advance directives with respect to all adult individuals receiving medical care, or patient care in the case of a patient in a religious nonmedical health care institution, by or through the provider and are required to: (1) Provide written information to such individuals concerning-(i) An individual's rights under State law (whether statutory or recognized by the courts of the State) to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate, at the individual's option, advance directives. Providers are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. Providers are to update and disseminate amended information as soon as possible, but no later than 90 days from the effective date of the changes to State law..."

2. The policy titled "Patient Rights and Responsibilities" (reviewed by the Hospital on 7/3/18) was reviewed on 4/25/19. The policy noted; "4. ... inform each patient and/or the patient's personal representative... of the patient's rights and responsibilities, prior to providing or discontinuing patient care whenever possible. 5. Patient rights and responsibilities information is provided and explained in a language or manner that the patient and/or patient's personal representative can understand..."

3. Pt #12 Admission: 4/10/19
Diagnosis: Cellulitis and Abscess of left great toe. The record was reviewed on 4/25/19 at approximately 9:15 AM. The record lacked documentation that Pt #12 was provided with or explained the Patient Rights and Responsibilities.

4. Pt #13 Admission: 11/29/18
Diagnosis: Left shoulder and elbow fracture. The record was reviewed on 4/25/19 at approximately 10:45 AM. The record lacked documentation that Pt #13 was provided with or explained the Patient Rights and Responsibilities.

5. On 4/25/19 at approximately 11:00 AM, during an interview and demonstration of the process for informing the patients about their rights and responsibilities; Patient Access Lead (E#4) submitted the document titled, "An Important Message from Medicare about your Rights", but was unaware of what the patients rights and responsibilities were. E#4 went to inquire with the Registration Department, then E#4 submitted the pamphlet/document titled, "Patient Rights and Responsibilities (Illinois)" E#4 stated "The pamphlet is suppose to be given to the patient during the registration process. They (the patients) usually don't take it (the pamphlet). They just leave it in the room or throw it away. I know the nurses don't ask upon admission if they (the patients) have received a copy of their rights and responsibilities or ensure the patient understands their rights. We don't document that rights were provided. I just assumed the registration staff offered it (the pamphlet) and that's all that was required."

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on May 7, 2019 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code therefore the requirements of 42 CFR Subpart 485.623, Physical Plant and Environment are NOT MET.

See the life safety code deficiencies on the associated K-tags

Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure all electrical equipment used in the Sleep Laboratory was checked for safety, prior to use. This has the potential to affect all patients serviced by the Sleep Laboratory, which performs an average of eleven sleep studies monthly.

Findings include:

1. An observational tour, with concurrent interview, of the Sleep Laboratory was conducted on 4/23/19 at approximately 11:35 AM, with the Vice President of Support Services (E#7). A Tower Fan in the sleep study patient room; lacked any identifying information, as to any preventive maintenance was conducted for electrical safety, prior to use. E#7 verbally agreed with the above finding and stated, "I will have to look into this (whether the fan had been checked for electrical safety prior to use)."

2. The policy titled "Standard Operating Procedure" (last revised by the Facility 4/23/18) was presented and reviewed on 4/25/19 at approximately 10:10 AM. The policy stated, "5. Procedure A. Adding individual equipment.. For equipment located during sweeps or discovered through conversation sometime after installation, do your best to provide proper purchasing information...Incoming inspection work order... Technician will open inspection for each owned device within the AIMS (name of program) application." The "Risk/Critical and AEM (alternate equipment management)/Maintenance Strategy Determination" attachment to the policy listed a rating procedure to determine what the patient risk was and the frequency, or strategy, to be utilized for ongoing preventive maintenance.

3. An interview was conducted with the Director of Quality and Safety (E#8) on 4/25/19 at approximately 11:15 AM. E#8 stated, "Yes, they (the Facility) should have had that (the fan) checked (for electrical safety) before using it. That's what we do on the fans we purchase for using (for patients). From what I understand, no one knows for certain where the fan came from, so it wasn't checked (and put into the system for inventory/preventive maintenance rating)."

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on May 7, 2019 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies on the associated K-tags.

Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure all biologicals available for patient use were not expired. This has the potential to affect all patients served by the CAH with a current census of 5 patients.

Findings include:

1. A tour of the surgical department was conducted on 4/24/19 at approximately 9:00 AM with the Director of Acute Care/ Surgical Services (E #9). During the tour,the following items were expired:
a) anesthesia room, nine 40 mls of 10% neutral buffered formalin bottles were expired (one dated 5/2014, six dated 1/2017, one dated 6/2017 and one dated 12/2013)
b) OR (operating room) one culture swab, which expired on 2/28/19

2. The Hospital policy titled "Outdated Drugs, Biological's and Supplies ( last reviewed or revised: 2/11/2019)", was reviewed on 4/25/19 at approximately 9:15 AM. The policy required "...Process:..3. Review of supplies is conducted with items appropriately disposed no later than the expiration date listed on the packaging. 4. Department manager , or designee, conduct periodic check of the are to ensure no outdated items are present. 5. Periodic checks will be conducted no less than quarterly..."

3. During the tour with E#9, it was verbally confirmed the formalin bottles and culture swab were outdated and should have been removed.

Based on document review and staff interview, it was determined for 1 of 2 (Pt # 16) patient that received a blood transfusion, the Critical Access Hospital (CAH) failed to ensure blood product administration was performed per policy. This has the potential to affect all patients served by the CAH with a current census of 5 patients.

Findings include:

1. The medical record of Pt #16 was reviewed on 4/24/19 at approximately 11:00 AM. Pt #16 was admitted on 3/14/19 with the diagnosis of blood loss/anemia. On 3/14/19, Pt #16 received one unit of red blood cells. The transfusion record lacked verification of a second nurse, as required by policy.

2. The CAH submitted document titled, "Lippincott Procedure: Blood and Blood Product Administration Policy" was reviewed on 4/24/19 at approximately 1:00 PM. The procedure required on page 6, "Use a two-person verification process in the presence of the Patient to match the blood or blood product to the practioner's order and the patient to the blood product."

3. An interview was conducted with the Acute Care Unit-Charge Nurse (E#6) on 4/24/19 at approximately 2:00 PM. E #6 confirmed the above findings and stated that all blood products require a second nurse signature for verification prior to administration.