HospitalInspections.org

Based on interview and record review, it was determined that the CAH failed to ensure all staff staff exposed to radiation are monitored for the level of radiation exposure for 1 of 5 staff reviewed. (Staff Identifier is Staff E.)

Findings include:

Interview on 4/12/22 at approximately 3:20 p.m. with Staff F (Operating Room Manager) revealed that Staff E (Surgeon) ultizies the C-arm (medical imaging equipment) during procedures in the operating room but did not have a dosimetry badge.

Interview on 4/12/22 at 3:27 p.m. with Staff E confirmed that he/she did not have a dosimetry badge and he/she does use the C-arm during procedures in the operating room.

Interview on 4/13/22 at 2:54 p.m. with Staff C (Radiology Manager) confirmed that Staff E did not have a dosimetry badge.

Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to have clearly delineated swing bed orders for 2 of 2 swing-bed patients reviewed (Patient identifiers are #1 and #5.) and failed to ensure the patient medical record was complete and accurate and that care plans supported the diagnoses that meet the patients medical and psychosocial needs 3 out of 20 inpatient records reviewed. (Patient identifiers are #2, #3, and #4.)

Findings include:

Patient #1

Review on 4/13/22 of Patient #1's medical record revealed that Patient #1 had a physician's order dated 4/10/22 that read "discharge to Swing Status". The subsequent admission order for swing-bed services in Patient #1's record read as "Admit/Place ..Admission Status Inpatient Swing".

Interview on 4/13/22 a.m. with Staff B (Health Information Staff) at approximately 1:30 a.m. confirmed

Interview on 4/14/22 approximately 10:20 a.m. with Staff M (Health Information Manager) confirmed that the admission order was not clearly delineated for swing-bed services for Patient #1.

Patient #5

Review on 4/14/22 of Patient #5 clinical record revealed that Patient #5 had a physician's order dated 8/15/21 that read "discharge to Swing Status". The subsequent admission order for swing-bed services in Patient #5's record read as "Admit/Place ...Admission Status Inpatient Swing".

Interview on 4/13/22 a.m. with Staff B at approximately 1:50 a.m. confirmed that the admission order was not clearly delineated for swing-bed services for Patient #5.

Interview on 4/14/22 approximately 10:50 a.m. with Staff M confirmed that the admission order was not clearly delineated for swing-bed services for Patient #5.

Patient #2

Review on 4/13/22 of the care plans for Patient #2 revealed no documented evidence that Patient #2's admission on 6/10/21 admission that included a care plan that would address the patient's positive MRSA (Methicillin-resistant Staphylococcus aureus) and would be on precautions and isolation.

Interview on 4/13/22 at approximately 2:30 p.m. Staff B confirmed that the software program is a drop down box and only has certain diagnoses in it and that the software can not add MRSA to the care plan.

Patient #3

Review on 4/13/22 of the care plans for Patient #3 showed no documented evidence that Patient #3's admission on 10/5/21 admission had a care plan that would address the patient's need for reverse precautions and isolation.

Interview on 4/13/22 at approximately 2:30 p.m. with Staff B confirmed that Patient #3 did not have a reverse precaution care plan.

Patient # 4

Review on 4/13/22 of Patient #4's "PHYSICIAN ORDERS", dated 10/15/21 revealed documented evidence that two admit to observation orders were written by Staff I (Medical Doctor) before the patient left AMA (Against Medical Advice) after the second observation admission. In which, reviewing one observation order the order was canceled, therefore a 96 hour note would have needed to be written to cover the stay between 10/13/-10/16/21.

Interview on 4/13/22 at approximately 2:30 p.m. with Staff B confirmed above findings for Patient #4. Staff B stated that that the canceled order should have been addressed by the provider prior to 4/13/22 for clarification.

Interview 4/13/22 at approximately 3:00 p.m. with Staff M, after Staff M reviewed Patient #4's written physician orders, confirmed that the canceled order should have been addressed by the provider.

Based on observation, interview, and record review, it was determined that the CAH failed to follow manufacturer's instructions for High Level Disinfection (HLD) of ultrasound probes and warming Intravenous (IV) solutions in the radiology department; and the appropriate dishwasher rinse temperatures for sanitation of dishes in the kitchen.

Findings include:

Radiology Department

Observation on 4/12/22 at approximately 1:25 p.m. in the radiology department's ultrasound room revealed no thermometer device.

Interview on 4/12/22 at approximately 1:25 p.m. with Staff D (ultrasound technician) revealed that he/she utilized a HLD for disinfecting the ultrasound probes.

Review on 4/12/22 of the HLD solution monitoring logs from January 2022 to April 2022 revealed no recorded temperatures in the log.

Interview on 4/12/22 at approximately 3:04 p.m. with Staff D confirmed that there were no thermometer in the ultrasound room. Staff D stated that he/she does not record temperatures in the ultrasound room.

Review on 4/12/22 of the CAH's HLD manufacturer's instructions revealed
"...Directions for Use...High level disinfection is achieved when all surfaces have been contacted for eight minutes at a temperature of 20 C [degrees Celsius]/ 68 F [degrees Fahrenheit]...".

Observation on 4/12/22 at approximately 1:20 p.m. in the radiology department's CT scan room revealed multiple vials of contrast and Intravenous IV fluid bags in a warmer with no dates.

Interview on 4/12/22 at approximately 1:20 p.m. with Staff C (radiology manager) confirmed the above findings in the warmer. Staff C stated that they did not date the vials of contrast and IV solution bags on when they were placed in the warming cabinet as they use them up quickly.

Review on 4/14/22 of the manufacturer's instructions for the IV solutions revealed
"...Solutions for injections
...Once the IV Solutions in VIAFLEX Plastic Containers have been in the warming cabinet they should be identified as having been warmed and should be used within the 14 day warming period. If not use within the 14 day warming period the product should be discarded...".

Kitchen

Review on 4/12/22 of the dish machine temperature log for April 2022 revealed that there were 17 rinse temperatures recorded that was below 180 degrees Fahrenheit with no corrective actions documented.

Interview on 4/12/22 at approximately 11:30 a.m. with Staff G (cook) confirmed the above mention April 2022 dish machine temperature log. Staff G stated that rinse temperature for the dishwasher should be greater than 160 degrees Fahrenheit.

Review on 4/14/22 of the CAH's dishwasher manufacturer's instructions, revealed
"...General...dishwashers are designed to operate in one of two modes: Hot water sanitizing mode (designated by letter "H" at the end of the machine serial number)...
...Minimum water temperatures are listed below:
Sanitizing Mode...Hot Water...Rinse 180 F [degrees Fahrenheit]...".

Observation on 4/14/22 at approximately 12:00 p.m. with Staff G revealed that the dish machine had a label with an H at the end of the serial number.

Interview on 4/14/22 at approximately 12:00 p.m. with Staff G confirmed that the dish machine utilized the hot water for sanitizing dishes.

Based on interview and record review, it was determined that the Critical Access Hospital failed to ensure that the designated requestor is initiating the request to the potential donor families.

Findings include:

Interview on 4/14/22 at 9:45 a.m. with Staff A (Quality Control and Risk) revealed that the nurse and/or provider on duty would approach the family regarding organ donation, and that if nurse who knows the family would have the conversation with the family. Staff A stated that there is not one person in the facility who is the designated requester. Staff A stated that the Critical Access Hospital did not have any staff who had trained as a designated requestor.

Review on 4/14/22 of the facility's Memorandum of Understanding between the facility and the OPO (Organ Procurement Organization), dated March 25, 2022 revealed "... 1. Definitions... Designated Requestor - refers to an individual who has completed training by the OPO regarding the methodology for approaching Potential Donor families. [Organ Procurement Organization] staff shall act as the Designated Requestors for Donor Hospital... 4 Duties of the Donor Hospital... 4.3 Designate a staff member who will collaborate with [Organ Procurement Organization] to facilitate the development and implementation of an effective organ and tissue donation program...".


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Interview on 4/13/22 at 11: 30 a.m. with Staff K (Emergency Department Director) revealed that the CAH did not have a "designated requestor" for the organ procurement program and that all the nurses can approach the family after the OPO has been notified.

Interview on 4/13/22 at 11:45 a.m. with Staff N (Nurse) revealed that the CAH did not have a "designated requestor" and that all nurses can approach the families. Staff N stated that sometimes it would depend on who knows the family.