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Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure criminal background checks were completed in a timely manner for 2 of 10 non-credentialed employees (E-5 and E-7) reviewed, who had been hired since the previous survey had been conducted 9/16/10.

Findings include:

On 6/25/14, at 9:00 a.m. personnel records were reviewed with the human resource (HR) manager who was responsible for the non-credentialed personnel records. The HR manager verified background checks were not conducted in a timely manner for the following employees:
? E-5, a physical therapist, had been hired 8/5/13, and did not have a background check completed until 12/23/13.
? E-7, a speech therapist, had been hired 6/20/13, and did not have a background check completed until 6/5/14.

The CAH's Background Check policy dated 1/2005, indicated criminal background checks would be required for all employees.

During interview with the HR director at 9:30 am. on 6/25/14, the HR director stated both of these staff had worked directly with patients prior to their background checks having been completed.

Based on the Life Safety Code Substantial Allegation survey completed on 6/26/14, the facility was found not in compliance with Life Safety from Fire found at CFR 485.623(d).

Refer to Life Safety Code deficiencies at K45, K50, K52 and K144.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure intravenous (IV) solutions stored the emergency department (ED)'s warming cabinet, were stored under safe temperatures in accordance with the manufacturer guidelines. This had the potential to affect any patients who received IV solutions as part of their treatment in the CAH's ED .
Findings include:
On 6/24/14, at 8:40 a.m. during the initial tour of the ED with the director of nursing (DON) and registered nurse (RN)-F a two compartment warming cabinet was observed in the open storage room adjacent to the trauma room. On the top shelf of the lower compartment there was observed:
? One 1000 milliliters (ml) of 0.9% sodium chloride intravenous (IV) solution in a plastic over pouch with a "discard 7/8" written on the over pouch.
? One 1000 ml of lactated ringers (LR) IV solution in a plastic over pouch with a discontinued date of 6/27/14, written on the over pouch.
? One 1500 ml of normal saline irrigation solution in a plastic pour bottle. The bottle was observed to be bulging and the expiration date on the bottle was April 2014. The bottle lacked a discard date.
The DON confirmed the temperature of the top compartment of the warming cabinet read 124 degrees Fahrenheit (F) and the bottom compartment read 117 degrees F. There was a small sticker adhered to the outside of the warming cabinet that indicated IV fluids were good for two weeks and to please label the solutions. The DON verified the 1500 ml normal saline solution was expired and she immediately removed it from the warming cabinet. The DON and RN-F also confirmed the temperatures for the warming cabinet were not monitored by nursing nor were they aware of the appropriate temperature range.
On 6/24/14, at 1:00 p.m. the DON verified the CAH lacked a policy and procedure for storing IV solutions in the warming cabinet.
On 6/25/14, at 9:00 a.m. RN-B confirmed the ED warming cabinet's temperature was 122 degrees F on the top compartment and 116 degrees F on the lower compartment. On the top shelf of the lower compartment was the 1000 ml of 0.9% sodium chloride IV solution with a discard date of 7/8/14; and the 1000 ml of LR IV solution with a discontinued date of 6/27/14.
On 6/25/14, at 11:05 a.m. the maintenance manager stated the maintenance staff did not monitor the temperatures of the ED warming cabinet.
On 6/25/14, at 11:25 a.m. the pharmacist was interviewed and acknowledged being unaware of the product guidelines for the IV solutions observed in the ED warming cabinet.
On 6/26/14, at 8:05 a.m. the DON provided the manufacturer's guidelines from Baxter Healthcare Corporation with regards to storing irrigation and IV solutions in warming cabinets. The manufacturer guidelines indicated IV solutions of 150 mls or greater can be warmed in their plastic over pouches to temperatures not exceeding 104 degrees F and for a period no longer than 14 days. The DON stated at that time, the temperatures of the warming cabinet had been turned down to meet the manufacturer guidelines.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure an intravenous (IV) medication, Mannitol (medication used to treat acute sudden kidney failure or reduce intracranial pressure), was safely stored in the emergency department (ED) warming cabinet, in accordance with the manufacturer guidelines. This had the potential to affect any patient who might be treated with the IV Mannitol in the CAH's ED.
Findings include:
On 6/24/14, at 8:40 a.m. during the initial tour of the ED with the director of nursing (DON) and registered nurse (RN)-F a two compartment warming cabinet was observed in the open storage room adjacent to the trauma room. On the top shelf of the lower compartment there was a 500 ml IV solution of 20 % Mannitol in a plastic pouch. There was no discard date identified on the medication.
During the intial tour, the DON confirmed the temperature of the top compartment of the warming cabinet read 124 degrees Fahrenheit (F) and the bottom compartment read 117 degrees F. There was a small sticker adhered to the outside of the warming cabinet that indicated IV fluids were good for two weeks and Mannitol was good for 2-3 months and to please label the solutions. The DON and RN-F confirmed the temperatures for the warming cabinet were not monitored by nursing nor were they aware of the appropriate temperature range.
On 6/24/14, at 1:00 p.m. the DON verified the CAH lacked a policy and procedure for storing IV medication in the warming cabinet.
On 6/25/14, at 9:00 a.m. RN-B confirmed the ED warming cabinet's temperature was 122 degrees F on the top compartment and 116 degrees F on the lower compartment. The 500 ml of 20% Mannitol IV medication [undated] remained on the top shelf of the lower compartment.
On 6/25/14, at 11:05 a.m. the maintenance manager confirmed maintenance staff did not monitor the temperatures of the ED warming cabinet.
On 6/25/14, at 11:25 a.m. the pharmacist was interviewed and acknowledged being unaware of the product guidelines for the IV Mannitol medication observed in the ED warming cabinet.
On 6/26/14, at 8:05 a.m. the DON provided the manufacturer's guidelines from Baxter Healthcare Corporation with regards to storing IV medications in warming cabinets. The manufacturer guidelines indicated IV medications of 150 mls or greater can be warmed in their plastic over pouches to temperatures not exceeding 104 degrees F and for a period no longer than 14 days. The DON stated at that time, the temperature of the warming cabinet had been turned down to meet the manufacturer's guidelines.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure an adequate system for maintaining the cleanliness of the facility's ice machines had been established in accordance with manufacturer's guidelines for 3 of 3 ice machines. This had the potential to affect any patients and personnel of the CAH who consumed beverages cooled with ice.

Findings include:

During the environmental tour on 6/23/14, at 2:00 p.m., the ice machine located in the nursing kitchen was found to have a significant deposit of a white flaky substance built up on in the spout cover, chute and drip tray. At 2:30 p.m., the ice machine located in the cafeteria was observed. This ice machine also had deposits of a white flaky substance in the spout cover.

During a tour of the surgical suite on 6/24/14, at 1:00 p.m., the ice machine located in the Phase II patient care area was found to have a significant deposit build up of a white substance in the spout cover and in the storage tray.

The manufacturer's guidance was reviewed for each ice machine. According to the manufacturer's directions for the ice machines located in the surgical suite and the nursing kitchen: "cleaning should be scheduled at a minimum of twice per year. Sanitization of the ice storage bin should be scheduled for a minimum of 4 times a year." The manufacturer's guidelines for the ice machine located in the cafeteria stipulated the maintenance "should be scheduled at least two times per year."

The most recent maintenance log for cleaning and sanitizing the ice machines reflected the ice machine located in the surgical suite had last been cleaned and sanitized 12/10/13; the nursing kitchen ice machine had last been cleaned and sanitized 11/22/13, and the cafeteria's ice machine had last been cleaned and sanitized 5/9/12.

During an interview with the plant manager on 6/23/14 at 3:00 p.m., he verified the maintenance logs provided were the only available records of the cleaning and sanitizing the ice machines.

Based on interview and document review, the Critical Access Hospital (CAH) failed to maintain the Computerized Tomography (CT) equipment as recommended by the physicist. This has the potential to affect all persons who had a physician's order for a CT scan.

Findings include:

In review of the physicist report dated as surveyed 2/25/14, and reported 3/10/14, two areas assessed for pass/fail, were marked as "Fail". The report, "CT Scanner Performance Report", indicated the report "summarizes the results of tests performed in accordance with the American College of Radiology CT QC Manual." Two areas were identified as Fail: A.) Review of CT Protocols and L.) Acquisition Display Callibration.

During interview with the radiology department manager on 6/24/14 at 9:00 a.m., he stated he was aware these areas had been identified as "Fail" on the physicist's report. The radiology department manager verified his department had not yet addressed, or determined corrective action for the areas identified as "Fail".

Based upon interview and record review, the hospital did not ensure a nursing care plan had been developed for 9 of 20 inpatients (P1, P2, P3, P10, P12, P13, P14, P16 & P19) whose records were reviewed.

Findings include:

P1 was admitted to the critical access hospital (CAH) on 6/24/2014, with diagnoses (dx) which included pneumonia, insulin dependent diabetes mellitus, and a history of colitis. The admission nursing assessment, dated 6/24/2014, indicated the patient had a history of diabetes with some episodes of hypoglycemia, colitis and cardiac disease with subsequent angina, hypertension and angina.

The care plan, dated 6/24/2014, did not address interventions and goals related to the patient's insulin dependent diabetes, colitis, or cardiac disease.

Registered nurse (RN)-C was interviewed on 6/24/2014, at 9:40 a.m. and verified the care plan did not include interventions and goals related to diabetes, colitis, or cardiac disease with angina and hypertension. She stated the only intervention in the care plan related to the patient's history of diabetes was the frequency of monitoring blood glucose measurements.

P2 was admitted to the CAH on 6/21/2014, with diagnoses which included small bowel obstruction, history of cardiac arrhythmia which included ventricular tachycardia, and insulin dependent diabetes mellitus. The patient's record also indicated P2 had an internal pacemaker-defibrillator. The admission nursing assessment, dated 6/21/2014, indicated the patient had diabetes, required airway support for sleep apnea, had an internal pacemaker and defibrillator, had a dx of hypertension and edema of the lower extremities.

The patient care plan did not include any identified problems, interventions and goals related to the patient's insulin dependent diabetes mellitus, sleep apnea, hypertension, edema or the presence of an internal pacemaker-defibrillator.

RN-C was interviewed on 6/24/2014, at 10:20 a.m. and verified the care plan did not include interventions and goals related to the patient's history of diabetes, sleep apnea, hypertension, edema and the presence of an internal pacemaker-defibrillator.

P3 was admitted to the CAH on 6/21/2014, with diagnoses of renal insufficiency, insulin dependent diabetes mellitus and mild dehydration. The admission nursing assessment, dated 6/21/2014, indicated the patient had diabetes mellitus, dementia and incontinence.

The nursing care plan did not include any identified problems, interventions and goals related to the patient's insulin dependent diabetes mellitus, dementia or incontinence.

RN-C was interviewed on 6/24/2014, at 10:20 a.m. and verified the care plan did not include interventions and goals related to the patient's diabetes, dementia nor incontinence.

P10 was admitted to the CAH on 1/29/2014, to undergo a bilateral mastectomy. The admission nursing assessment, dated 1/29/2014, indicated the patient had breast cancer. The nursing care plan, dated 1/29/2014, did not include any identified problems, interventions or goals related to the surgical procedure the patient had undergone.

RN-C was interviewed on 6/24/2014, at 10:40 a.m. and verified the patient did not have a care plan which included interventions and goals to direct nursing care following her surgical procedure.

The Director of Nursing was interviewed on 6/26/2014, at 10:20 a.m. and stated the CAH did not have a policy related to care plan development.



32601

P12 had been admitted to the CAH on 1/6/14, for post-operative care following a transurethral resection of the prostate (TURP). The history and physical dated 12/17/14, indicated P12 had a history of hypertension, hyperlipidemia, and diabetes. The admission nursing assessment dated 1/6/14, indicated P12 had a history of sleep apnea, peripheral neuropathy, constipation, gastric reflux and diabetes.

On 6/25/14, at 8:51 a.m. RN-B verified the record lacked the development of a care plan for P12.

P13 was admitted to the CAH on 1/10/14, with diagnoses which included possible deep vein thrombosis (DVT), history of atrial fibrillation and severe pain in her lower extremity. The admission nursing assessment dated 1/10/14, indicated P13 had a history of peripheral neuropathy, rheumatoid arthritis, urinary tract infection (UTI), incontinence and cataracts. During the hospital episode P13 was diagnosed and treated for a UTI .

P13's care plan dated 1/10/14, lacked interventions and goals related to pain control, UTI, atrial fibrillation or possible DVT.

On 6/25/14, at 8:36 a.m. RN-B verified P13's care plan lacked interventions and goals related to P13's diagnosis of UTI, possible DVT, pain or atrial fibrillation.

P14 had been admitted to the CAH on 5/20/14, with diagnoses which included cerebral atherosclerosis, transient ischemic attack (TIA), diabetes, hypertension and gout. The admission nursing assessment dated 5/20/14, indicated P14 had been admitted to rule out a cerebrovascular accident (CVA) and TIA. In addition, the assessment indicated P14 utilized a continuous positive airway pressure (CPAP) machine, had a history of arthritis, and had diabetes.

P14's care plan dated 5/20/14, lacked interventions and goals related to diabetes, hypertension, pain control and obstructive sleep apnea for which P14 utilized a CPAP.

On 6/25/14, at 1:15 p.m. RN-B verified P14's care plan lacked interventions and goals related to P14's diagnosis of hypertension, diabetes, gout, pain control and obstructive sleep apnea.

P16 had been admitted to the CAH on 1/9/14, with diagnoses which included hypoglycemia secondary to congenital hyperinsulinemia and mild dehydration. The admission nursing assessment dated 1/9/14, indicated P16 had a history of hypoglycemia, hyperinsulinemia and diarrhea.

P16's care plan dated 1/9/14, lacked interventions and goals related to P16's hypoglycemic episode, and diarrhea.

On 6/25/14, at 1:50 p.m. RN-B verified P16's care plan lacked interventions and goals related to P16's diagnosis of hypoglycemia. RN-B stated nursing had been monitoring P16's blood sugars frequently.

P19 had been admitted to the CAH on 4/17/14, with diagnoses which included dizziness, weakness, hypotension, anemia, atrial fibrillation, dehydration, non-insulin dependent diabetes. The admission nursing assessment dated 4/17/14, indicated P19 had a history of diabetes, glaucoma, and vertigo.

P19's care plan dated 4/17/14, lacked interventions and goals related to P19's diagnoses of diabetes, glaucoma, hypotension, atrial fibrillation, anemia and dehydration.

On 6/25/14, at 2:00 p.m. RN-B verified P19's care plan lacked interventions and goals related to P19's diagnoses of diabetes, glaucoma, hypotension, atrial fibrillation, anemia and dehydration.

Based on inteview and document review, the Critical Access Hospital (CAH) did not ensure the following patient care services had developed a quality assurance (QA) process which was integrated into the CAH's QA program: radiology, anesthesia, ambulance service, cardiac rehab, and mental health/counseling services. This had the potential to affect all patients who received care from any of these departments.

Findings include:

The certified registered nurse anesthetist (CRNA) was interviewed on 6/25/14, at 10:45 a.m. and verified there was no current quality assurance process related to anesthesia services being conducted in the CAH.


15508

In an interview with the manager of the Radiology department on 6/24/14, at 9:00 a.m. he stated that neither the contracted service for nuclear medicine, nor ultrasound had provided the CAH with any QA processes or data.

During an interview with the manager of cardiac rehabilitation on 6/26/14, at 9:05 a.m., she confrimed her department was working on developing a QA program with regards to monitoring patient weights that it had not yet been fully established for implementation.

The director of the Mental Health Counseling department stated in an interview on 6/26/14, at 10:00 a.m., that there was not a QA program in place for their service. However, he stated the intent was to use patient satisfaction surveys to develop a future QA program.


32601

On 6/24/14, at 1:10 p.m. the director of nursing (DON) stated she was unaware of any QA project for the CAH's ambulance services. The DON confirmed the ambulance services should have a QA project as they were considered a department of the CAH.