HospitalInspections.org

Based on document review and staff interview the Critical Access Hospital (CAH) failed to ensure all physicians who ordered outpatient services were credentialed by the governing body prior to admitting and ordering outpatient services.

Findings include:

- Review of the outpatient roster revealed the CAH had 312 outpatients in the last 12 months. Review of the roster revealed 43 physicians were not on the CAH's medical staff roster.

Credentialing staff E interviewed on 5/23/11 at 1:00pm reported they did not recognize those 43 physician's names on the list provided by therapy and stated they lacked knowledge of the therapy staff accepting orders from medical staff not credentialed by the CAH. Staff E verified the names listed did not have any CAH privileges granted by their governing body.

Based on observation and staff interview the Critical Access Hospital (CAH) failed to ensure the staff properly handled medications and monitered expiration dates for medications on the nursing med surgical and ICU (Intensive Care Unit) unit, surgical suites and laboratory departments.


Findings include:


- Observation of the medication room on the med surgical and ICU units used by nursing staff on 5/15/11 at 2:30pm revealed the nursing supervisor B could not use their ID badge to gain access into the room. Housekeeping staff F was asked to try their badge to open the door. Staff F waved their badge at the door sensor and the door opened. Staff B verified the housekeepers badges should not open the medication room doors as this area is considered a restricted area.

The medication room had a automated medication dispensing unit. Observation on the adjacent counter revealed three oral medications left setting on the countertop unattended. Staff B reported the staff should not leave any medications unattended.

- Observation of the laboratory department with laboratory staff J on 5/25/11 at 9:45am revealed an unsecured fully stocked crash cart with 45 different medications. The stocked crash cart contained paralyzing medications, conscious sedation medications, cardiac medications and blood thinners.

Laboratory staff J stated they were surprised that the cart was not secure and the cart should be locked.

- Observation on 5/16/11 at 11:30am of the automated medication system in the post-operative unit revealed two 1000 militers (ml) intervenious bags (IV) of solution which expired in May 2010 and March 2011and available for patient use.

Pharmacy staff O interviewed on 5/16/11 at 11:35am reported the nursing staff were responsible for checking for outdated medications, not the pharmacy staff. Staff O reported at 3:00pm the pharmacy staff should have checked for expired medications.

- Observation of surgical suite #1 with surgical staff D on 5/16/11 at 1:00pm revealed licensed staff M and N standing at the anesthesia cart holding medications. Three medications used for anesthesia lacked the dates of when staff opened the bottles. The ansethesia cart revealed the following expired medications available for patient use.
1. Lidocaine 1% expired on March 2011
2. Atracurim 40 miligram (mg) expired on March 2011
3. Neostgmin methlysulfate expired on March 2011

- Observation in surgical suite #2 revealed a dark room with the table dressed and prepared for use; adjacent to the table was a unsecured bottle of marcaine (a medication used for anesthesia).

- The CAH's Pharmaceutical security in surgery policy dated 6/2/05, reviewed on 5/25/11 indicated all medications dispensed to the surgery area will be kept in the drug and supply carts in the surgical rooms. When the carts are not in use they will be kept locked and secured by the anesthesia staff.

Staff D reported they did not have any surgical procedures scheduled for surgical suite #2 and stated the anesthesia staff should have "put the medication away."

- Observation with staff D in a substerile room between the two surgical suites revealed an area to store extra anesthesia supplies. Staff D reported they have keys to the anesthesia room hidden in the substerile room so they can have access to the locked medications.

Administrative staff A interviewed on 5/16/11 at 2:30pm reported the anesthesia staff are responsible for securing all their medications and that nursing staff should not have access to unlock the anesthesia carts.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to appoint a director for their outpatient services to monitored, evaluated and manage the day to day operations of the department, failed to establish and implement policies and procedures to direct the services provided and failed to include out patient services in the quality assurance program to ensure the health and safety of the patients.

Findings include:

- Outpatient medical records reviewed on 5/26/11 at 10:00am for patients # 41 and # 42 revealed the outpatient therapy department accepted orders to admit patients from physicians that did not practice in Kansas and did not have admitting privileges at the CAH. See more evidence at C-0241.

Administrative staff A and B interviewed on 5/16/11 at 8:00am reported the CAH did not have a staff member appointed to the outpatient director position.

Administrative staff K interviewed on 5/16/11 at 11:00am indicated they were aware of the regulation but did not appoint a person to direct the outpatient services.

Based on medical record review of 15 acute care patients, 9 open and 6 closed records, and staff interview the CAH failed to assure the nursing staff developed individualized plans of care for 8 of the 15 patient records reviewed (patient #s 17, 19, 20, 23, 24, 26, 28, and 30).

Findings include:

- Patient #17's medical record reviewed on 5/23/11 revealed an admission date of 5/7/11 with diagnoses of urinary tract infection, urosepsis, chronic obstructive pulmonary disease and required insulin for diabetes.

Review of patient #17's plan of care identified the nursing staff failed to address the patient's medical needs; urinary tract infection, pulmonary disease, and insulin diabetes to ensure appropriate nursing care was administered.

- Patient #19's medical record reviewed on 5/23/11 revealed an admission date of 5/18/11 with diagnosis of medication overdose and required the use of a mechanical ventilator. Patient #19's admission assessment revealed nursing staff identified a moderate risk of developing skin issues.

Patient #19's plan of care on 5/19/11 lacked evidence the nursing staff developed measures to reduce the risk of developing pressure ulcers and other skin issues.

- Patient #20's medical record reviewed on 5/18/11 revealed an admission date of 5/16/11 with diagnoses of degenerative joint disease with sciatica and benign prostate hypertrophy. Patient #20 complained of right hip and back pain with risk for falls.

Patient #20's plan of care lacked documentation of nursing staff addressing the patient's pain management needs and their risk for falls.

- Patient #23's medical record reviewed on 5/18/11 revealed an admission date of 5/18/11 with diagnoses of pneumonia, myoplasma, dehydration, chronic obstructive pulmonary disease, retrotracheal mass, difficulty swallowing, coronary artery disease and required telemetry. Review of patient #23's admission assessment revealed they were at risk for developing pressure ulcers or other skin issues and at risk for falls.

Patient #23's plan of care reviewed on 5/19/11 lacked evidence of nursing staff addressing the patient's risks of developing pressure ulcers, pneumonia infection with isolation, difficulty swallowing, and their risk for falls.

- Patient #24's medical record reviewed on 5/18/11 revealed an admission date of 5/16/11 with diagnoses of urinary tract infection and had a supra pubic catheter. Patient #24's admission assessment revealed they were at risk for developing pressure ulcers or other skin issues, and at risk for developing nutrition concerns.

Patient #24's plan of care reviewed on 5/19/11 lacked evidence of nursing staff addressing the patient's risks of developing pressure ulcers, urinary tract infection, care of their supra pubic catheter, and nutrition risk.

- Patient #26's medical record reviewed on 5/18/11 revealed an admission date of 8/30/10 for a gastric band surgery. Patient #26's admission assessment revealed they were at risk for developing pressure ulcers or other skin issues, had special dietary requirement after the surgical procedure, and had mild to moderate pain.

Patient #26's plan of care reviewed on 5/19/11 lacked evidence of nursing staff addressing the patient's risks of developing pressure ulcers, pain management and their special post surgical diet.

- Patient #28's medical record reviewed on 5/18/11 revealed an admission date of 3/28/11 for surgical debriedment of their right knee and implantation of an antibiotic spacer. Patient #28's admission assessment revealed they were at risk for developing pressure ulcers or other skin issues, and at risks for falls.

Patient #28's plan of care reviewed on 5/19/11 lacked evidence of any nursing staff addressing the patient's risks of developing pressure ulcers or other skin issues and risk for falls.

- Patient #30's medical record reviewed on 5/18/11 revealed an admission date of 12/14/10 to the CAH's senior behavioral health unit with diagnoses of vascular dementia depression, cerebral arteriosclerosis, psychosis, chronic obstructive pulmonary disease, anemia, hyperthyroidism, esophageal reflux anemia coronary artery disease, severe carotid stenosis and discharge to the intensive care unit with an additional diagnosis of a right fractured femur.

Patient #30's admission assessment revealed they were at risk for falls and could remove their personal bed/chair alarm (bed/chair alarm is used to alert staff to when the patient arises without assistance).

Patient #30's plan of care reviewed on 5/19/11 lacked evidence of any revision of their plan of care for risk of falls after admission dated of 12/14/10. The plan of care lacked evidence of any revisions after the nursing staff discovery the patient could remove the bed/chair alarm without assistance to protect them from falling.

- Administrative staff A interviewed on 5/23/11 at 10:00am reported the nursing staff failed to revise the patients plans of care as their condition changed.

Base on observation and staff interview the Critical Access Hospital (CAH) failed to establish policies and procedures for terminal cleaning of the surgical suites after daily use, and failed to ensure the staff followed acceptable standards of practice for cleaning their surgical suites.

Findings include:

- Observation and interview with housekeeping staff P during terminal cleaning on 5/17/11 at 11:30am revealed they are scheduled to complete terminal cleaning on Thursdays. Staff P reported they did not use a wet-vacuum to finish the floors and stated they "just use the mop". Staff P reported they did not receive specific training to clean the suites and lacked knowledge of any policy that directed them to complete daily terminal cleaning.

Infection control staff C interviewed on 5/23/11 at 10:00am reported the CAH lacked a policy to ensure the staff completed terminal cleaning after the surgical suites were used.

Review of AORN recommendations for terminal cleaning of surgical and invasive procedure rooms, indicated the following perioperative standards:

1. Terminal cleaning and disinfection of operating and invasive procedure rooms should be done
- when the scheduled procedures are completed for the day and
-each 24-hour period during the regular work week.

2. Unused rooms should be cleaned once during each 24-hour period during the regularly scheduled work week.

3. Floors should be wet-vacuumed with an EPA-registered disinfectant after scheduled surgical cases are completed.

Staff A interviewed on 5/19/11 at 3:00pm revealed they found a copy of the CAH's AORN standard of practice manual still in the cellophane wrap unopened.