HospitalInspections.org

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Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports. "

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Based on interview, observation, review of policy and documents, the facility failed to assure proper handling, storage and control of medications.

Failure to do so creates risk for inadequacies in quality and quantity of medications available for patient care.
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Findings:
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Item #1 After-Hours Pharmacy Access
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1. In review of facility pharmacy policy titled, "Emergency Access" (revised 12/5/2014) it stated, "In the absence of a pharmacist, access to the Pharmacy Department Room shall be controlled to one designated nurse per shift."
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2. On 12/9/2014 at 3:00 PM Surveyor #2 interviewed the newly appointed Director of Pharmacy (Staff Member #6) about after-hours pharmacy access by nursing. S/he stated that to date, nursing staff had access to the pharmacy with their individual key card badges. That system allowed for potential access of more than one nurse in any after-hours period. In addition, s/he stated that there was no active system to validate that access occurred by only the designated RN.
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Item #2 Labeling of Opened Medications
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Findings:
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1. Upon review of the facility policy titled, Nursing Unit Inspection report (6/10/14) the fourth bulleted item stated, "Each Department will be inspected for proper medication storage, outdates, degraded medications ...proper labeling and inventory."

2. On 12/10/2014 at 9:30 AM during a tour of the Emergency Department, Surveyor #2 asked an RN (Staff Member #7) about the system for labeling multi-dose oral medications after they had been opened. S/he stated that they were available for 30 days from the date opened and that they were labeled with the date that they were opened.

3. At that time, the following medications located in the unit stock section were noted as opened and labeled accordingly:
Folic acid 5 mg/10 ml, labeled "[upward pointing arrow] 11-29"
Q-Dry (diphenhydramine) 12.5 mg/5 ml, labeled "ER stock 6-14-14"
Ibuprofen 100 mg/5 ml (children's): labeled "exp 1-15"
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The pharmacy staff was not able to provide information about the documentation standard for labeling multi-dose oral medications for expiration, once opened.

A recent Nursing Unit Inspection report completed by pharmacy staff on 11/30/2014 for the Emergency Department medications was reviewed. It indicated that that all areas were checked off as up-to-date through 12/26/2014.
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Item #3 Security of Medications
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Findings:
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1. On 12/09/2014 at 3:00 PM Surveyor #2 entered the operating area and gained access to the "GI Lab" (where endoscopic procedures are performed) with the Director of Nursing (Staff Member #10) and the Pharmacy Director (Staff Member#11) after patient care had concluded. The two doorways used to gain access to the area were not secured (open to the public). On the floor inside the procedure room, was an unsecured 5-gallon red biohazard container. The top of the container box was propped half -opened allowing easy access to its contents.

The container was almost completely filled with discarded (used and partially used) medication vials; some of which contained significant quantities of medication. Of note, there was significant quantity of dantrolene and propofol solution in two of the vials located near the top of the container.

2. During a discussion at that time, the Director of Nursing stated that the doors to the operating room area and GI Lab were not locked from staff and public access. S/he acknowledged that the current system did not prevent unauthorized access to the space and medications located there. According to the Director of Pharmacy, the disposal of vials containing medications was not authorized to occur in the red biohazards container.

3. The facility did not have a policy in place and provided a draft copy of the policy as the most current staff reference. According to the draft policy titled, "Pharmaceutical Waste Management" provided by the Director of Pharmacy, a black topped hazardous waste container for non-viable pharmaceutical waste would be the approved receptacle for the viewable type of medication waste located in the biohazards container.

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Item #1 Disinfection and Sterilization of Medical Equipment

Based on observation, interview and document review, the hospital failed to implement policies and procedures designed to prevent exposure to infectious agents during the processing of medical equipment.

Failure to adhere to manufacturer's guidance for processing medical equipment puts patients at risk from infection caused by improper disinfection and sterilization.

Findings:

1. The instructions printed on the "Rapacide Glutaraldehyde Test Strips" bottle, under the sub-heading "Shelf Life" indicated that once opened, the strips must be discarded after 90 days and there is an open space on the outside of the bottle for staff members to mark the "open date".

2. On 12/9/2014 at 10:35 AM, Surveyor #1 interviewed a surgical technician (Staff Member #5) about their process for cleaning and disinfecting endoscopes. Staff Member #5 explained that prior to using the automated endoscope reprocessor (AER), s/he uses a rapacide test strip to determine the efficacy of the glutaraldehyde disinfectant. The surveyor observed that the opening date of the bottle had not been marked in the designated space on the outside of the bottle. During concurrent interview with the staff member, s/he indicated they were unaware that the manufacturer's directions indicated the strips could only be used for 90 days once opened.

3. On 12/9/2014 at 11:15 AM, Surveyor #1 toured the sterile processing area with Staff Member #5. The staff member indicated that the biologic indicators are run weekly and with every implantable. The staff member indicated that the biologic indicators were read 12-24 hours after incubation. The surveyor noted that several read times logged were under 24 hours in duration. Upon review of the manufacturer's directions for use with steam sterilizers, the surveyor noted that the instructions indicated a validated incubation time of 24 hours. Staff Member #5 confirmed that the results were recorded prior to the 24 hour completion time.

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Based on review of policy and procedure and record review, the facility failed to assure that 3 of 3 patients receiving peri-operative nursing services had nursing assessments and care plans completed for their care episode.

Failure to do so creates risk that patients will receive sub-standard quality of care.
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Item #1 Readiness for Discharge from the Post-Anesthesia Care Unit (PACU) After Surgery
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Findings:
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1. Upon review of policy titled "Routine Patient Care in the PACU" (reviewed 06/2014), the final item stated, "The Modified Aldrete PACU Scoring System for discharge will be used: Documentation of the Modified Aldrete score will be completed prior to patient discharge. The score must return to the baseline assessment before the patient may be released from the procedure area. Evidence that the patient has met discharge criteria must be clearly documented in the medical record."

2. In review of 3 of 3 medical records for Patients #8-10 who had surgery at the facility and received PACU nursing care, there were no post-operative Modified Aldrete scores located in the records. Patients #9 and 10 also did not have a pre-operative baseline score recorded as a reference for the post-operative assessment period.
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#2 Nursing Assessments and Care Plans for Surgery Patients
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Findings:

1. Upon review of policy titled "Nursing Care documentation-Carenet (06/5/2014) in the section titled "Menu Tabs" it stated "For Admission complete all of the following Forms, these items are considered our 'MINIMUM' documentation." The list included 15 required items, some of which were: Adult or Pediatric Admission History, Adult or Pediatric Admission Assessment (Head to Toe assessment); Care Plan and Fall Risk.

2. In review of 3 of 3 medical records for Patients #8-10 who had same-day surgery at the facility and received peri-operative nursing care, there were no pre-operative nursing assessments (head to toe) in the record including, but not limited to, the Adult Ambulatory Care Intake form. Additionally, there were no nursing care plans located in the records.

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Based on record review and review of policy and procedures, the facility failed to demonstrate that post-anesthesia documentation was adequate in 2 of 3 post-anesthesia patient records.

Failure to do so creates risk that patient recovery from anesthesia may be incompletely assessed.
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Findings:
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1. Upon review of facility document titled, "Post Operative Anesthesia Care" (reviewed 5/22/09) it stated under item 6, "At least one post-anesthetic visit will be recorded, describing the presence or absence of anesthesia related complications."

2. In the review of 2 of 3 medical records for Patients #8 and #10 who had same-day surgery at the facility, the post-anesthesia evaluation note was recorded as "SPAC." There was no documentation related to the patients' cardiopulmonary status, level of consciousness, follow-up care or complications related to anesthesia.

3. In a follow-up interview with the Director of Nursing (Staff Member #10) on 12/10/2014 at 2:15 PM s/he stated she was unfamiliar with the term "SPAC" and the nomenclature could not be located on the facility document of accepted abbreviations. Subsequently, the meaning of the author's abbreviation was determined as "stable post anesthesia care."

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Based on record review and interview the facility failed to demonstrate that it notified swing bed residents in writing about discharge plans prior to discharge in 3 of 3 records.
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Failure to do so creates risk that residents may not have the opportunity to participate in their discharge plans including, but not limited to, appealing the plan developed by the facility.
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Findings:
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1. In review of the following policies and procedures there was no information about notifying swing bed residents in writing in advance of discharge plans: "Discharging of Patients," "Discharging Patients to a Skilled Nursing Facility" and "Patient Transfers-Skilled Units/Intrafacility."

2. In review of medical records of 3 of 3 swing bed patients (Patients #5, 6 & 7) there was no indication that the patients had received written notification about their discharge plan prior to discharge, despite documentation in the record about the plan by the Discharge Planner (Staff Member #9).

3. During an interview between Surveyor #2 and the Discharge Planner (Staff Member #9) on 12/9/2014 at 10:00 AM, s/he stated that s/he did not notify swing bed residents in writing about their discharge or transfer in advance of it occurring.

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Based on review of policy and procedure, record review and staff interview, the facility failed to demonstrate that it developed and implemented activity plans for 3 of 3 swing bed residents.

Failure to do so creates risk that swing bed residents' recreational and therapeutic program needs will be neglected which may result in lower quality care.
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Findings:
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1. According to facility policy titled, "Swing Bed Activities" (revised 8/20/13), item 2 stated the "Activities Assessment" would be conducted by the "Activities Coordinator, Occupational Therapist or nursing staff." It also stated under the "Activities Plan " section that "Activities will be planned and coordinated" by certain individuals on staff including, but not limited to the Swingbed Activities Coordinator. It further defined elements of the activities plan and the time frame for plan completion.

2. In review of swing bed resident records, the following omissions were noted:

a. Patient #2 was a swing bed patient admitted on 8/9/2014 for recovery after a left total hip repair. The "Activities Assessment" was half completed and the sections for the patients "leisure needs and interests" and "Plan" were left blank. There was no indication in the medical record that an activities plan had been developed or implemented.

b. Patients #3 was admitted on 7/5/2014 for care following a stroke and Patient #4 was admitted on 6/2/2014 for care for congestive heart failure. In both medical records the activities assessment was not completed and there was no indication that an activities plan had been developed or implemented.

3. On 12/10/2014 at 4:00 PM Surveyor #2 interviewed an occupational therapist (Staff Member #8). S/he stated that s/he speaks regularly (at least 5 times per week) with Activities Coordinator. However, sometime in the past year s/he became less involved in overseeing the activities program and was not aware that activity plans were not being developed and implemented.