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Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all patient care equipment was maintained in safe operating condition as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the CAH patient beds.
Findings:

On 3/19/18 at 11:15 a.m., during a tour with S4Charge Nurse, observation revealed all patient rooms had a lighted nurse call button on the bed side rails. Upon pressing the nurse call button on these beds, observation revealed they were inoperable.

During an interview on 3/19/18 at 11:20 a.m., S4Charge Nurse acknowledged the call bell feature on the side rails does not function for 25 of 25 patient beds used in the CAH.

During an interview on 3/19/18 at 3:30 p.m., S1DON acknowledged the call bell feature on the side rails does not function for 25 of 25 patient beds used in the CAH.

Based on interview and record review, the CAH failed to ensure drugs and biologicals were dispensed according to accepted pharmacy principles as evidenced by all prescribers' orders for first dose medications in non-emergent situations not being reviewed for appropriateness by a pharmacist before the first dose was dispensed for 3 of 3 (#21, 22, 23) patients reviewed for first dose verification.
Findings:

Review of the CAH's Policy and Procedures revealed, in part, the following:
Section 2 - Care of Patients
Subject: Pharmacist Order Verification
Policy: The pharmacist will review each prescription or order for medications.
Procedure: The pharmacist reviews the encoded prescription and if appropriate will confirm the order. Orders requiring clarification will be discussed with the prescriber before verification.

Review of patient # 21's medication administration record revealed the patient's first dose of Ceftriaxone 1 gram, given on 3/4/18 at 3:10 p.m., was administered prior to review by the pharmacist.

Review of patient # 22's medication administration record revealed the first dose of Clindamycin 600 milligrams in 50 milliliters of normal saline, given on 3/18/18 at 11:44 a.m., was administered prior to review by the pharmacist.

Review of patient #23's medication administration record revealed the first dose of Levothyroxine 0.088 milligrams, given on 3/17/18 at 6:41 a.m., was administered prior to review by the pharmacist.

During an interview on 3/20/18 at 2:30 p.m., S3Pharmacist acknowledged the medications for patient #21, patient #22 and patient #23 were administered prior to review by the pharmacist.

Based on record review and interview, the CAH failed to ensure identified medication errors were documented in the patient's electronic medical record for 2 patients (#11 and #20) of 3 patients (#11, #19, and #20) hospital identified medication errors reviewed.
Findings:

Patient #11
Review of the CAH's CHOR (Confidential Hospital Occurrence Report) revealed Patient #11 had received a 10 milligram dose of Norvasc on 1/17/18 at 3:54 a.m. instead of the ordered dose of Norvasc 5 milligrams. Review of the patient's electronic medical record failed to reveal documentation of the medication error.

During an interview on 3/21/18 at 9:30 a.m., S8Medical Records Director confirmed, after review of patient #11's medical record, that the medication error was not documented in the patient's electronic medical record.

Patient #20
Review of the CAH's CHOR revealed Patient #20 had a missed dose of Phenobarbital 400mg on 1/29/18 at 9:21, that was ordered but not administered. Review of the patient's electronic medical record failed to reveal documentation of the medication error.

During an interview on 3/21/18 at 9:30 a.m., S8Medical Records Director confirmed, after review of patient #20's medical record, that the medication error was not documented in the patient's electronic medical record.

I. Based on observation and interview, the CAH failed to maintain a system for controlling infections and communicable diseases of patients as evidenced by 1) failing to ensure that housekeeping sanitized patient care equipment; 2) having expired containers of enteral feedings and dressings available for patient use; and 3) administering normal saline intended for single dose use to multiple patients during procedures in the radiology department.
Findings:

On 03/19/18 at 10:45 a.m., a tour of the nurse's station and patient's equipment and supplies area with S4Charge Nurse revealed the following observations:
1. The clean utility equipment room contained 2 tube feeding pumps and 3 intravenous (IV) infusion pumps that were dirty. There was a large spider web observed in the corner of the room that was hanging on clean tube feeding pumps.
2. The billable-items storage room contained: 12 Pulmocare, 2 Newborn Enfamil and 1 Infant Enfamil cans of liquid nutrition labeled with an expiration date of 3/1/18 and 8 packages of Caltostat 2x2 dressings labeled with an expiration date of 11/2017.

During an interview on 3/19/18 at 10:50 a.m., S4Charge Nurse acknowledged the expired liquid nutrition, the expired dressing and the dirty equipment was an infection control issue and should not have been available for patient use.

3. On 03/19/18 at 2:45 p.m., a tour of the radiology department with S7Radiology Director revealed a partially used bag of normal saline with attached tubing was hanging from an IV pole in the computed tomography (CT) room. The bag of saline was labeled "for single use."
An interview at this time with S7Radiology Director confirmed that the normal saline was dated and timed when initially punctured, used for multiple patients during procedures, and discarded after 24 hours.


II. Based on observation and interview, the CAH failed to maintain a system for controlling infections and communicable diseases of patients as evidenced by having an unsanitary kitchen environment, which included improper sanitization procedures of food preparation and serving items along with unlabeled and undated stored foods.
Findings:

On 3/19/18 at 2:00 p.m., a tour of the dietary department with S5Dietary Manager revealed the following:
patient serving plates, plate warmers, and steam table pans stored wet;
shelf mounted can opener blade and interior mechanism covered with with dried and caked-on food;
two deep fryer strainers with dried food particles coating the webbing and 1 cheese grater with food particles dried on the inside and outside of the grater hanging on the utensil rack above a food preparation table;
one pedestal fan in the kitchen prep area covered with dust and circulating air into the kitchen food preparation area.

Further observation revealed an open cool whip container that was not dated and a container with "bacon grease" that was not labeled or dated in the upright cooler.

During an interview on 3/19/18 at 2:20 p.m., S5Dietary Manager acknowledged that storing food preparation items wet or with food particles remaining on utensils was unsanitary. S5Dietary Manager also acknowledged that the dirty fan and containers that had been opened, unlabeled, and/or undated was an infection control issue.





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Based on record review and interview, the registered nurse failed to supervise and evaluate the care provided to patients by 1) failing to ensure an ongoing observation for 2 patients of 2 patients (#9, #10) diagnosed with suicidal thoughts and 2) failing to assess the complete vital signs of a patient who presented to the emergency department (ED) and was admitted with pneumonia for 1 of 5 ED records reviewed (#11).
Finding:

1) Failing to ensure an ongoing observation for 2 patients of 2 patients (#9, #10) diagnosed with suicidal thoughts

Review of the CAH (Critical Access Hospital) Procedure/Policy Number N.4.106 revealed, in part, the following:
Subject: Suicide Precautions/Preventions
Purpose: To delineate procedures to be undertaken when suicide precautions/prevention must be initiated.
Policy: ...to implement interventions by the staff for patients with suicidal ideation.

15 Minute Observation
Symptoms: 1. Evidence of suicidal ideation and Patient has a Plan.
Interventions: 1. Safety / Precautions checks recorded every 15 minutes on the PEC/Suicide Observation Flow Sheet

30 minute Observation
Symptoms: 1. Evidence of suicidal ideation of intent is present but patient sates no intent of action: Patient is without a Plan
Interventions: Safety / Precautions checks recorded every 30 minutes on the PEC/Suicide Observation Flow Sheet.

Patient # 9
Review of patient #9's medical record revealed, in part, the following:
Admit date of 1/12/18 at 1:07 p.m. with diagnoses of depression and suicidal thoughts.
Physician Clinical Report - Chief complaint: Suicidal Thoughts (thoughts of harm to self but no specific plan) ...
Nursing - Self Harm Assessment: The patient answered "no" to the question "do you have thoughts of harming or killing yourself?"
Continued review of patient #9's medical record failed to reveal safety/precaution checks recorded every 30 minutes.

During an interview on 3/21/18 at 2:30 p.m., after reviewing patient #9's medical record, S6Nurse Manager acknowledged patient #9 was not monitored every 30 minutes as was stated in the policy.

Patient # 10
Review of patient #10's medical record revealed, in part, the following:
Admit date of 1/20/18 at 6:38 p.m. with a diagnosis of suicidal thoughts.
Physician Clinical Report - Chief complaint: Suicidal thoughts ... ( ...has had thoughts of harm to self ...).
Nursing Physical Assessment - ...He describes suicidal thoughts and has a specific plan (with access to the planned method). Prior history of suicidal thoughts.
Continued review of patient #10's medical record failed to reveal safety/precaution checks recorded every 15 minutes.

During an interview on 3/21/18 at 2:30 p.m., after reviewing patient #10's medical record, S6Nurse Manager acknowledged patient #10 was not monitored every 15 minutes as was stated in the policy.


2) Failing to assess the vital signs of a patient who presented to the emergency department (ED) and was admitted with pneumonia for 1 of 5 ED records reviewed (#11)

Review of the record for Patient #11 revealed he presented to the ED on 03/06/18 at 1:05 a.m. with complaints of dyspnea and low oxygen saturation. Review of the ED nurses notes dated 03/0618 at 1:10 a.m. revealed the patient's blood pressure was 164/110, heart rate 45 and temperature was 95.7 (axillary).

Review of the ED nurses notes dated 03/06/18 at 3:31 a.m. revealed "Blood Pressure: deferred due to patient condition". Heart rate 54. Temperature 95.7 (axillary).

Review of the ED nurses notes dated 03/06/18 at 3:55 a.m. revealed "Blood Pressure: unable to obtain due to patient condition". Heart rate 45, Temperature 95.7 (axillary).

Further review of the ED nurses notes revealed the patient admitted to the hospital and was transported by stretcher to the floor on 03/06/18 at 3:59 a.m. No blood pressure had been assessed and documented on the patient since he was triaged at 1:10 a.m. (approximately 3 hours prior). Further review revealed no ongoing assessments or interventions related to the patient's low body temperature.

Review of the inital nuring assessment when the patient arrived to the inpatient floor dated 03/06/18 at 0349 revealed "skin cool to touch, temp 92 degrees axillary. Heater on in room and blankets applied. Unable to get vitals due to patient's condition. Patient is do not recusitate (DNR)."

Review of the record revealed that that first blood pressure was obtained on 03/06/18 at 6:20 a.m., (over 2 hours after arriving on the floor) with a result of 112/88 and temperature documented as 93 degrees axillary.

Further review of the patient's medical record revealed no documentation regarding the reason why the patient's blood pressure could not be obtained. Further review revealed no further assessments of the patient's low body temperature upon arrival to the inpatient floor.

On 03/20/8 at 11:30 a.m., S1DON and S6Nurse Manager reviewed patient #11's medical record. They revealed that they were usure why the patient's blood pressure was not assessed in the ED or on the inpatient floor on 03/06/18. They further confirmed that that patient's low body temperature should have been further assesed.


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