HospitalInspections.org

The Critical Assess Hospital (CAH) reported a census of 5 acute care patients. Based on clinical record review and interview the CAH failed to ensure a complete history and physical were in the patients chart as required by the CAH's medical staff bylaws for 4 of 10 sampled acute inpatient records (#'s 1, 5, 7, and 8).

Findings included:

- Review of the clinical record for patient #3 on 1/11/10 revealed an admission date of 1/7/10 with a diagnosis of nausea/vomiting, dehydration and weakness. The record lacked a complete history and physical.

Review of the clinical record for patient #5 on 11/11/09 revealed an admission date of 1/8/10 with a diagnosis of questionable pneumonia, hypertension, and acute sinusitis. The record lacked a history and physical.

Review of the clinical record for patient #7 on 1/11/10 revealed an admission date of 10/27/09 with a diagnosis of abdominal distention and pyloric stenosis. Review of the record revealed the history and physical was transcribed 26 days later on 11/23/09.

Review of the CAH's policy titled, "Medical Staff Bylaws, page 12", under "3.5, Basic Responsibilities of Medical Staff Membership", states under "(d), Preparing and completing a medical record for all the patients to whom the member provides care in the hospital...or current records within 24 hours of admission for History and Physicals...".

Interview with staff A on 1/14/10 at approximately 8:45am, confirmed the CAH failed to complete the patient's history and physical within the CAH's bylaws and rules within 24 hours of admission. The deficient practice also affected patient #8.

Based on observation and interview the Critical Access Hospital (CAH) failed to ensure that unusable drugs and biologicals are not available for patient use stored in 1 of 1 surgical warming cabinets.

Findings included:

- Observation on 1/12/10 at 11:45am revealed a warming cabinet in the sub sterile area of the operating suite with a temperature of 96 degrees (F) Fahrenheit. The warming cabinet contained 3-1 liter bottles of sterile water used for irrigation, 5-1 liter bottles of normal saline irrigation, 3-intravenous (IV) bags of normal saline solution, 3-IV bags of D5W IV solution, and 3-IV bags of lactated ringer IV solution. These solution lacked a date when placed in the warmer or the date the fluids were to be removed from the storage area.

Document review of the information sheets provided by the manufacturer of the warmed fluids directed "...for a period no longer than two weeks (14 days)...should be used within 24 hours or discarded and should not be re-warmed or returned to stock...".

Interview with staff B on 1/12/10 at 9:30am confirmed they routinely store sterile fluids in the warmer but were unaware of the date the fluids were placed in the warmer. Staff B lacked knowledge of the length of time the manufacturer recommends warmed fluid be stored.





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Based on observation, document review and interview, the CAH (Critical Access Hospital) failed to assure medications storage according to manufacturer's guidelines in 1 of 1 warming cabinet for the storage of intervenous (IV) contrast media solution for computed tomography (CT) scans.


- Observation in the computed tomography (CT) scanner room on 1/11/10 at 10:30am revealed 5 vials and 14 boxes of injectable contrast media stored in a warmer. Additional observation of the warmer on 1/12/10 at 2:15pm revealed a thermometer reading of 102 degrees F (Fahrenheit). The manufactures' storage instructions for proper storage is at 77 degrees F with temporary storage at 59-86 degrees F.

Interview with staff A and D on 1/12/10 between 2:15pm and 3:25pm confirmed the storage of the medication exceeded manufactures' guidelines and may potential cause an adverse reaction to a patient if administered at the excessively warm temperature.