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Based on review of Critical Access Hospital (CAH) medication error reports, hospital policy/ procedure, and staff interview, the CAH failed to follow their policy for reporting medication errors for 5 of 16 medication error reports (Patients #5, #60, #61, #62 and #63). The CAH had a current census of 3 patients.

Failure to report medication errors to the physician could potentially cause harm if patients received the wrong medication, medication at the wrong time or by the wrong route.

Findings include:

Review of CAH policy titled Medication Errors dated 2/2009 revealed the following, in part. "It is the policy of RHSHC- Hospital to report all medication errors as outlined in the following procedure. The attending physician will be notified immediately upon discovery".

Review of patient medication error reports revealed:

1. The Potential Error/Event Reporting System (PEERS) for Patient #5 dated 5/6/10 at 8:15 AM showed that on 5/5/10 at 8:00 PM the nurse administered a Lidoderm transdermal patch to patient #5. On 5/6/10 at 2:30 AM, nursing staff identified the patient received the medication at the wrong time. The PEERS documentation lacked evidence that staff notified the physician of the medication error.

2. The PEERS for Patient #29 dated 5/25/20 at 9:16 AM showed that on 5/22/10 at 6:00 AM the nurse administered Mefoxin 1 gram (gm) to Patient #29. On 5/23/10 at 3:14 AM, nursing staff identified the patient received the medication at the wrong time. The PEERS documentation lacked evidence that staff notified the physician of the medication error.

3. The PEERS for Patient #30 dated 4/27/10 at 3:15 PM showed on 4/27/10 at 5:30 PM nursing staff failed to administer Mefoxin 1gm to the patient at the scheduled time. On 4/27/10 at 7:30 AM, Staff identified the patient had not received the Mefoxin. The PEERS documentation lacked evidence that staff notified the physician of the medication error.

4. The PEERS for Patient #31 dated 1/18/10 at 9:19 AM showed on 1/14/10 at 9:00 PM nursing staff administered Zantac 150mg (milligrams) to the patient without a physician order. On 1/15/10 at 2:30 AM, staff identified the medication was administered to the patient without a physician order. The PEERS documentation lacked evidence that staff notified the physician of the medication error.

5. The PEERS for Patient #32 dated 1/18/10 at 9:22 AM showed on 1/14/10 at 8:00 PM a nurse administered Glyburide 2.5mg to Patient #32. On 1/15/10 at 1:41 AM nursing staff identified the patient received the medication at the wrong time. The PEERS documentation lacked evidence that staff notified the physician of the medication error.

During an interview on 8/2/10 at 3:50 PM, the Vice President of Patient Care confirmed staff failed to notify physicians of medication errors according to the hospital policies and procedures.

Record review of the hospital policy Medication Errors 2/2009 revealed, "It is the policy of RHSHC- Hospital to report all medication errors as outlined in the following procedure. The attending physician will be notified immediately upon discovery."

Based on observation, staff interview, and document review, the Critical Access Hospital (CAH) surgical management staff failed to ensure surgical staff tested 1 of 2 disinfecting solutions for efficacy before each use, as required by the manufacturer. The CAH surgical staff identified an average of 20 endoscopic procedures per month, and each would require the use of the disinfecting solutions for cleaning after the procedure.

Failure to test the disinfecting solutions prior to each use could result in the disinfecting solution not containing a sufficient strength of the active ingredient to kill all microorganisms, potentially resulting in the spread of infectious microorganisms between patients.

Findings include:

1. Observations during a tour of the Operating Rooms Utility Room on 8/3/10 at 8:45 AM, revealed an automated endoscope reprocessor. A log sitting next to the machine revealed Operating Room staff tested the disinfectant, Cidex, once a day, when the staff used the automated endoscope reprocessor.

2. During an interview at the time of the tour, the Operating Room Director stated the Operating Room Staff test the Cidex once a day, before reprocessing any endoscopes. The Operating Room Director stated the Operating Room Staff could reprocess up to 3 endoscopes per day, without checking the disinfectant between uses.

3. Review of the policy "Disinfection of instruments using chemical germicides", effective 10/15/2009, revealed in part, "The efficacy of this product must be verified using a test strip made specifically for that product.... Test the solution according to instructions..."

4. Review of the manufacturer's directions for Cidex, revealed in part, "Reuse Period... Test the solution prior to each use."

5. Additionally, during an interview at the time of the tour, the Operating Room Director stated he/she did not know staff needed to test Cidex before each use, and would instruct Operating Room staff to test Cidex before each use in the future.

Based on observation, staff interview, review of the dietary policy/procedure manual, and cleaning records, the Critical Access Hospital (CAH) failed to ensure that dietary staff cleaned the Hobart industrial mixer, removed the carbon build-up from the cooking surfaces of sheet and cake pans, and removed the lime build-up on the inside of the Manitowoc Series 200 ice machine. The hospital reported a current census of 3 patients.

Failure to properly clean equipment, remove carbon build-up from pans prior to storing, and remove lime build-up from the inside of the ice machine could potentially result in a food borne illness.

Findings include:

1. Review of the dietary policy/procedure manual revealed a policy titled, "Pot and Pan Washing" dated 1/03 that stated in part ... "It is the responsibility of the staff to wash, rinse and sanitize the pots and pans."
A procedure titled, "Procedure for Dispensing Ice" dated 1/03 that stated in part ... "The maintenance department is responsible for cleaning the filters and repair of the motor. The ice machine is thoroughly cleaned by the maintenance department twice a year."

2. Initial dietary department tour on 8/02/10 at 2:30 p.m., with Staff A, Registered Dietitian, revealed the following:

a. The Hobart industrial mixer was stored and ready for use. Observation showed staff had stored the mixer with dried on food debris.

b. Dietary staff had stored 7 sheet pans, 6 half-sheet pans and 13 cake pans with carbon build-up on the cooking surfaces rendering the cooking surface unsanitizable.

c. The Manitowoc Series 200 ice machine had lime build-up on the interior edges rendering the interior edges unsanitizable. The Manitowoc Ice Maker Series 200 cleaning sheet for 2010 revealed completion of the de-liming process on 5/29/10.

3. During an interview, at the time of the tour and observations, Staff A verified the unclean Hobart mixer, carbon build-up on the various pans and the lime accumulation on the inside of the Manitowoc Series 200 ice machine.

Based on closed medical record review, open medical record review, medical staff policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that medical providers dated and/or timed all medical record entries in 22 of 32 closed medical records (Patients # 4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) and 5 of 5 open medical records (Patient #1, #2, #3, #33 and #34). The CAH had a census of 3 patients.

Failure to date and time medical record entries could cause harm to patients if there is a delay in treatment, actions or assessments provided.

Findings include:

1. Review of Regional Health Services of Howard County Medical Staff policy on 8/3/10 at 3:00 PM, revealed that all medical providers are required to date all entries in the medical record.

2. Review of closed medical records, on 8/3/10 at 8:15 AM revealed the medical providers failed to date and time all medical record entries in 19 of 42 closed medical records (Patients
#4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, and #26).

3. Review of open medical records, on 8/2/10 at 9:30 AM, revealed the medical providers failed to date and time all medical record entries in 5 of 5 open medical records (Patient # 1, #2, #3, #33 and #34).

4. During an interview on 8/3/10 at 1:30 PM, the Vice President of Patient Care reported that medical providers are required to date and time all entries in medical records but are not doing so on a consistent basis.

During an interview on 8/4/10 at 8:50 AM, the Vice President of Patient Care reported that medical providers are required to date and time all entries in medical records but are not doing so on a consistent basis for Obstetric and surgical medical records.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) Health Information Management (HIM) administrative staff failed to ensure all closed medical records in 4 of 4 long term storage areas were secured against unauthorized access. The CAH administrative staff identified 3 current inpatients.

Failure to secure medical records against unauthorized access could potentially result in unauthorized disclosure of patient information, including name, date of birth, or social security number.

Findings include:

1. Review of the policy "Confidentiality of patient health information," effective 7/1/2008, revealed in part, "Access to areas housing health information records shall be limited to Health Information Management personnel."

2. Observations during a tour of the Radiology Department on 8/2/10 at 11:10 AM revealed a record storage area next to the reception desk. The CAH staff secured the room with a numeric key pad lock.

3. During an interview at the time of the tour, the Radiology Director stated Environmental Services staff had the access code to the record storage room, and could access the record storage room without Radiology staff present. Environmental Services staff did not have a need to know the medical information contained in the records stored in the storage area.

4. Observations during a tour of the storage shed on 8/2/10 at 2:07 PM revealed a medical record storage area approximately 10 feet long and 4 feet high, filled with large boxes of medical records. The storage shed also contained boxes with time cards, bank statements, and budget information.

5. During an interview at the time of the tour, the HIM Director stated administration and business office staff store records in the storage shed, and have access to the storage shed. The HIM Director stated administrative or business office staff did not need to know information contained in the medical records stored in the storage shed.

6. Observations during a tour of the Community Health basement on 8/2/10 at approximately 2:45 PM revealed approximately 51 boxes containing medical records. The basement contained durable medical equipment such as wheelchairs, Human Resources records, fiscal records, and community health supplies.

7. During an interview at the time of the tour, the HIM Director stated Home Medical Equipment, Human Resources, and Community Health staff had access to the Community Health basement, and could access CAH medical records stored in the Community Health basement. The HIM Director stated Human Resources, Home Medical Equipment, and Community Health staff did not need to know information contained in the medical records stored in the Community Health basement.

8. Observations during a tour of the HIM department on 8/2/10 at approximately 3:00 PM revealed a large medical record storage area containing approximately 36,000 medical records. The HIM office also contained several desks, containing approximately 100 medical records available on the desks.

9. During an interview at the time of the tour, the HIM Director stated HIM staff do not lock the medical record storage room when HIM staff leave the office. Environmental Service staff clean the office after HIM staff leave the office for the day, and after HIM staff could supervise the Environmental Service staff. The HIM director stated the Environmental Service staff could potentially access patient medical records, and the Environmental Service staff did not need to know protected patient medical information.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure an external peer review occurred annually for each practitioner providing care to CAH patients. Problem identified with 1 (of 1) dentist providing care to CAH patients. The CAH administrative staff identified 3 procedures performed by the dentist during the past year.
Failure to ensure the evaluation of the quality and appropriateness of the diagnosis and treatment furnished by medical practitioners at the CAH could potentially lead to substandard patient care. Findings include:
1. Review of the policy "External Peer Review", effective 10/15/2008, revealed in part, "A minimum of one (1) random chart for each provider will be selected for review annually."2. Document review showed the Dentist admitted 3 patients during the previous year for procedures in the operating room.
3. Review of Dentist A's credential file showed it lacked evidence of annual external peer review related to care the Dentist provided to patients of the CAH.
4. During an interview on 8/4/10 at 9:00 AM, the Quality Director stated the CAH administrative staff had not ensured that an external peer review occurred annually for the Dentist. The Quality Director had not identified the Dentist as a practitioner providing care to patients at the CAH, and had not sent medical records of patients that received care from the Dentist for external peer review, as required by the CAH's policy.