HospitalInspections.org

Based on document review, observation, and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to notify patients the CAH did not have either a medical doctor (MD) or doctor of osteopathy (DO) present at the hospital 7 days a week, 24 hours a day. Failure to provide notice the CAH did not have a physician on-site 24 hours a day, 7 days a week resulted in the patients lacking sufficient information to determine if they wanted to receive care at the CAH, without a physician present at all times. The CAH identified a census of 12 patients on entrance. The CAH performs approximately 45 surgeries/month and has approximately 275 ER visits/month.

Findings include:

1. Review of the Emergency Department (ED) schedule for March 2019 revealed the CAH staff chose to utilize a mixture of physicians and Advanced Registered Nurse Practitioners (ARNPs, nurses with advanced training which allows them to diagnose, treat, and prescribe medications to patients). The ARNP was scheduled as the sole medical provider in the Emergency Department for 247 hours in March 2019 (out of 744 hours in the month).

2. Observations during a tour of the Emergency Department on 3/4/19 at 1:15 PM revealed the Emergency Department staff failed to provide notice to patients the CAH did not have a physician present at the CAH 24 hours per day, 7 days per week.

3. During an interview on 3/5/19 at 2:30 PM, the ED Manager and ED Medical Director confirmed a MD or DO does not staff the ED 24 hours per day, 7 days per week. The ED Manager revealed CAH has an ARNP who serves as the sole medical provider in the ER, and for the CAH.

4. Review of Patients' Rights brochure revealed the CAH staff failed to include a notice notifying patients that a physician is not present in the hospital 24 hours per day, 7 days a week.

I. Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to maintain hot water temperatures between 110 and 120 degrees Fahrenheit in 2 of 2 the CAH's provider-based Kanawa Medical Clinic rooms tested (Supply/Med room and Exam Room #1). Failure to maintain water temperatures between 110 and 120 degrees Fahrenheit in patient care areas could potentially result in the hot water burning patients. The CAH identified the clinic saw 92 patients a month.

Findings include:

1. Observations, during tour of the Kanawa Medical Clinic, on 3/6/2019 from 8:00 AM to 8:30 AM, with the Clinic Director, revealed the water temperature in the Supply/Med room jumped erratically between 122 - 138 degrees Fahrenheit. Water temperatures in Exam Room #1 jumped erratically between 122 and 132 degrees Fahrenheit.

2. The Clinic Director verified the water temperatures at the time of the tour of the clinic.

3. Review of the policy "ES-51 Hot Water Temp. Inspection," effective March 2005, revealed in part, "To ensure the hot water at the organization's sinks do not run ... [water temperatures] higher than 120 Degrees Fahrenheit."




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II. Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from the inpatient unit. Failure to remove outdated patient supplies from the CAH's supplies, available for use inpatient care, could potentially result in staff using the expired items for patient care after the manufacturers' expiration date, after which the manufacturer will no longer guarantee the safety and quality of the supply. The CAH identified a census of 12 patients on entrance.

Findings include:

1. Review of the policy "Removal of Outdated Supplies in Patient Care Areas," dated 02/2019, revealed in part, "All areas of the hospital ... that provide care to patients must check for and remove any outdated supplies."

2. Observations during a tour of the inpatient unit on 3/4/19 at 11:30 AM, revealed the following expired supplies in the emergency supply cart:

a. 2 of 2 ProtectIV Safety IV Catheter, 24 gauge, expired 08/2018
b. 2 of 2 ProtectIV Safety IV Catheter, 16 gauge, expired 02/2018
c. 3 of 3 BD Insyte Autoguard Winged IV Catheter, 18 gauge, expired 02/2018, 05/2018, and 07/2018
d. 2 of 3 BD Insyte Autoguard Winged IV Catheter, 20 gauge, expired 03/2018 and 05/2018
e. 2 of 3 BD Insyte Autoguard Winged IV Catheter, 22 gauge, expired 07/2018 and 10/2018
f. 1 of 2 BD Saf-T-Intima Butterfly IV Catheter, 20 gauge, expired 08/2018
g. 1 of 4 BD Saf-T-Intima Butterfly IV Catheter, 22 gauge, expired 02/2018
h. 3 of 3 BD Saf-T-Intima Butterfly IV Catheter, 24 gauge, expired 08/2017, 02/2018, and 05/2018
i. Rusch PVC Nasopharyngeal Airway, 30 French, expired 11/2018
j. Tracheal Tube, 7.5 MM (millimeter), expired 10/2018
K. Intubating Stylet, expired 11/2018

3. During an interview on 3/4/18, at the time of the tour, the Acute Care Director and RN A verified the supplies had expired and staff could use the expired supplies for patient care. RN A revealed the nursing staff failed to remove the expired supplies from the emergency cart.

Based on document review and staff interviews, the Critical Access Hospital's (CAH) Governing Board failed to appoint 3 of 4 physicians (Physician G, Physician H, and Physician I) to the CAH's medical staff. Failure of the Board of Trustees to ensure all physicians practicing at CAH are qualified to provide medical care may result in patients receiving substandard or inappropriate care. The CAH's administrative staff identified Physician G, Physician H, and Physician I saw approximately 2,148 patients without receiving the approval of Governing Board.

Findings include:

1. Review of medical staff credential files on 3/6/19 at 9:50 AM, Physician G, Physician H, and Physician I's credential files (personnel files for physicians) lacked evidence the CAH's medical staff or Board of Trustees approved Physician G, Physician H, or Physician I to provide care to the CAH's patients.

2. During an interview at the time of the review, the Credentialing Coordinator acknowledged the credential files lacked evidence the CAH's medical staff or Board of Trustees approved Physician G, Physician H, or Physician I to provide care to the CAH's patients.

3. During an interview on 3/6/19 at approximately 10:30 AM, Director of Accreditation for the CAH's network hospital confirmed Physician G, Physician H, and Physician I worked as a contracted employee of network hospital. The CAH staff relied on the network hospital's medical staff and governing body to credential Physician G, Physician H, and Physician I, instead of Hancock County Health System's medical staff and governing body credentialing them.

4. During an interview on 3/11/2018 at 4:00 PM, the CEO/CNO confirmed Physician G, Physician H, and Physician I currently provided care to patients at the CAH. The CEO/CNO acknowledged the CAH's medical staff and Board of Trustees failed to independently evaluate Physician G, Physician H, and Physician I's qualifications and experience, prior to the physicians providing care to patients at the CAH.

Based on observations, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure pharmacy oversight of sample medications in 1 of 1 Family Practice provider-based clinic. Failure of pharmacy oversight in the dispensing of sample medications could result in outdated, recalled, or otherwise unusable medications being available for physicians and mid-level providers to give to patients, as well as, the potential for theft of medications by unauthorized persons. The CAH reported the clinic saw approximately 1000 patients per month.


Findings include:

1. Observation during tour of the Family Practice provider-based clinic on 3/5/19 at 9:00 AM with the Clinic Director, revealed the sample medication supply closet stored multiple sample inhalers and oral medications. The sample medication closet included approximately 160 samples of a variety of medications, including but not limited to, medications that treat diabetes, heart conditions, and breathing problems.

2. During an interview, at the time of the tour, the Clinic Charge RN reported that when the Clinic Charge RN received sample medications, the Clinic Charge RN entered the medications on log sheets. The log sheets consisted of a separate sheet for each medication sample strength, and included documentation about the sample and a log of which patients received the sample. The Clinic Charge RN reported the CAH pharmacist did not play a role in oversight of the sample medications in the clinic. The CAH pharmacist was aware the clinic stored and disbursed sample medications, but was not involved in monitoring the sample medications.

3. During an interview on 3/5/19, at 4:30 PM, the Director of Pharmacy confirmed she knew the Family Practice provider-based clinic stored sample medications. However, the Director of Pharmacy did not provide oversight for the medications.

4. Review of a CAH Clinic policy "Sample Medications," reviewed March 2018, revealed in part, under purpose, "To provide guidelines for clinic staff in the management and tracking of sample mediations." The policy failed to include a requirement for the pharmacy staff to provide oversight for drug samples dispensed to patients of the CAH's provider based clinic.

5. During an interview on 3/7/19 at 11:00 AM, the CEO/CNO revealed the pharmacy failed to create a policy addressing how the pharmacy would provide oversight of the sample medications stored in the CAH's provider based clinic.

Based on observation, document review, and staff interviews, the Critical Access Hospital's administrative staff failed to ensure 1 out of 1 observed anesthesia providers wore head coverings which fully covered all of their hair. Failure to wear head coverings that fully cover all hair could potentially result in bacteria, fungi, or viruses on the surgical staff members' hair entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The hospital's administrative staff identified the surgical services staff performed an average of 45 surgical procedures per month.

Findings include:

1. During an interview on 3/7/2019 at approximately 1:20 PM, the OR Nurse Manager revealed the CAH their based surgical policies on the AORN (Association of peri-Operative Registered Nurses, a nationally recognized guideline agency) guidelines.

2. Review of the AORN Guideline for Surgical Attire, copyright 2018, revealed in part, "A clean surgical head covering or hood that confines all hair and completely covers the ears, scalp skin, sideburns and nape of the neck should be worn." "Hair and skin can harbor bacteria that can be dispersed into the environment. The collective body of evidence supports covering the hair and ears while in the [operating rooms]."

3. Review of the policy, "Infection Control in the Operating Room," effective July 2017, revealed in part, "To implement adequate and effective Infection Control policies in the Operating Room.... uniforms should be designed to provide maximum skin coverage and hair coverage ... "

4. Observations on 3/5/2019 at approximately 12:10 PM, revealed Patient #1 was undergoing a surgical procedure in the minor operating room. Observations revealed the Certified Registered Nurse Anesthetist (CRNA, a nurse with specialized training in administering medication to render a patient unconscious for surgery) wore a skull cap. The skull cap consisted of a cap covering the CRNA's forehead and central part of the CRNA's hair. The skull cap did not cover the lower approximately one and one half inch of the CRNA's hair on the side of the CRNA's head and 1 inch on the back of the CRNA's hair.

5. During an interview at the time of the observations, the Director of Regulatory Compliance acknowledged the skull cap did not fully cover CRNA's hair.