Bringing transparency to federal inspections
Tag No.: C0205
Based on direct observation, staff interview, and record review, the Critical Access Hospital (CAH) Laboratory Blood Bank failed to ensure appropriate storage of blood products, as the refrigeration storage monitoring system failed to accurately and quickly respond to temperature fluctuations. The laboratory reported 54 patient blood transfusions for the most recent fiscal year. Findings include:
A. Records of testing the blood bank storage refrigerator visual and audible temperature monitoring alarm system for the previous 2 quarters revealed the continuous recording thermometer audible alarm responded at 8 degrees Celsius(C) and 11 C degrees respectively.
B. A review of the visual monitoring graphs for these tests lacked any evidence of documented response.
The Food and Drug Administration (FDA) Code of Federal Regulations (CFR) specifies at 610.53 and 610.40, "Blood and blood products must be stored at temperatures between 1 and 6 C. Continuous monitoring must include audible and visual alarm of the storage system."
C. On 4/20/11 at 1:00 PM the blood bank temperature monitoring system was challenged. The audible alarm responded at 1 degree C, and at 6.5 C; however, the visual recording monitor failed to respond to the 1 degree Celsius challenge. The elevated temperature challenge to the visual alarm system responded approximately 10 minutes later.
D. On 4/21/11 at 10:30 AM a retrospective review of the visual recording monitor revealed the recorder did not re-equilibrate for approximately 2 hours. The internal thermometer registered 4 degrees C during this same time period.
E. Interviews on 4/20/11 and 4/21/11 with the Laboratory General Supervisor confirmed the visual alarm monitoring system failed to respond quickly and accurately, as required.
Tag No.: C0225
Observations and interviews with Registered Dietitians (RD)-A and -B, Dietary Manager (DM), and Maintenance Personnel (MP), revealed the Critical Access Hospital (CAH) failed to ensure the premises were in good repair in the kitchen. The CAH is licensed for 21 beds and had a census of 3 acute care patients upon survey entrance. Findings include:
A. Observation of the kitchen and interviews with RD-A, RD-B, and the DM on 4/12/11 at 11:00 AM revealed wood cabinets of various sizes located along the west, north and south walls, and directly under a metal food prep area (kitchen center island) to be worn, chipped and lacking the manufacturer's finish. Interviews and observations with RD-A, RD-B, and the DM, identified the wood shelves to store dry foods, dishes, and pots and pans which are used for the preparation of patient meals. The wood cabinets and shelving in all above cabinets are worn, chipped and lacking the manufacturer's finish, making it difficult to clean and sanitize properly. Interview with the MP identified the wood cabinets in the kitchen as "the original ones installed when the hospital was built in 1959, and that plans to upgrade the kitchen have been made several times, but something else always comes up."
B. Observation of the heat and air conditioning ventilation duct system that hangs from the ceiling, located directly above the dishwashing station in the kitchen, displays chipped and peeling white paint.
C. Observation of the wood shelving located in the kitchen dry goods station #1 revealed it is chipped and lacks the manufacturer's finish, making it difficult to clean and sanitize properly.
D. The walk-in cooler measuring approximately 6 feet x 8 feet located in storage room #2 lacks the baseboard seals, exposing the underlying metal and old glue. This does not allow for a smooth, cleanable surface.
E. Observation of the cement floors located in dry food storage areas #1 and 2 in the kitchen revealed they are sealed with a gray epoxy (used in adhesives and surface coatings). In both food storage areas, the gray epoxy is scratched and rusted, making it difficult to clean and sanitize the floors. Interview with the MP revealed the epoxy was put down on the floors in the dry food storage areas #1 and 2 some time in 1979, and they have not been upgraded since.
F. Observation of the main entrance door into the kitchen, which is constructed of wood and measures approximately 6.7 feet x 3 feet, revealed it is marred and discolored, exposing the underlying wood. This makes it difficult to clean and sanitize properly.
G. The following kitchen baking pans and pots and pans were inventoried by RD-A, RD- B, and DM, and they were observed/identified to be dented, blackened along the edges with food debris, and missing the manufacturer's seal, exposing the underlying metal:
1. 2 - 11 1/4 x 20 inch roasters;
2. 4 - skillets measuring 8,10,12 and 14 inches;
3. 3 - 12-cup metal muffin pans;
4. 1 - shallow roaster measuring 19 1/2 x 11 inches;
5. 2 - 16 inch metal pizza pans;
6. 1 - 12 quart double boiler/stock pot;
7. 1 - 6 quart stock pot with strainer lid;
8. 2 - 8 quart metal stock pots;
9 1 - Teflon cake pan;
10. 1 - 3 quart saucepan with lid;
11. 1 - 4 1/2 quart metal saucepan;
12. 1 - 4 quart metal saucepan;
13. 2 - 2 quart metal saucepans;
14. 1 - 7-8 quart covered roaster with rack;
15. 1 - Teflon-coated tilt and drain griddle; and
16. 2 - 23 inch by 13 1/2 inch metal shallow roasters .
H. Observation on 4/12/11 at 1:00 PM noted all dirty dishes returned to the kitchen were deposited in a plastic tub located directly on top of the steam table that is used to cook and store food that is served to CAH patients. Observation noted the steam table top did appear clean; however, this practice presents a risk for food cross contamination. Interview with the RDs and DM revealed there was no other place to put the dirty dishes. Interview with the MP revealed the facility had not put in an area/window for dirty dishes.
I. Observation of dry goods storage area #2 showed a ceiling exhaust vent measuring approximately 24 inches x 36 inches with grids coated with a dust/dirt substance. Interview with RD-A, RD-B and DM revealed the vent is to be cleaned by MP but was not sure when it was last cleaned.
J. Observation of a grey painted steel food prep station in the middle of the kitchen revealed the paint chipped and peeling, exposing the underlying metal. This does not allow for a smooth, cleanable surface.
K. Observation of a white metal food prep and formica-top storage cabinet located on the north wall of the kitchen revealed the metal to be heavily scratched, exposing the underlying metal, and the formica top displaying large chips and dents. This does not allow for a smooth, cleanable surface.
Tag No.: C0298
Record reviews, review of the Nursing Care Plan Policy, and staff interviews revealed the Critical Access Hospital (CAH) failed to ensure the nursing staff develops and keeps current the nursing care plans for 2 of 3 acute care patients (Patients 1 and 2). The CAH is licensed for 21 beds and had a census of 3 acute care patients upon entrance. Findings include:
A. Review of the Policies and Procedures for Nursing Care Plans on 4/12/11 at 1:00 PM reads: Purpose: The Care Plan identifies the patient's usual or potential problems, goals (or outcomes), nursing interventions and evaluation. Care Plans provide a means of communication among nurses and other health care providers. All Care Plans shall have a nursing diagnosis, goal, intervention and evaluation for each problem identified, with Acute Nursing Care Plans done within 24 hours, and updated daily and/or as needed. Procedure 111 A reads: All patients shall have an individualized plan of care even though a standard care plan is used. The Care Plan shall be individualized by identifying unusual problems or needs, or by activating only those problems that pertain to a particular patient.
B. Record review on 4/12/11 at 2:48 PM revealed Patient 1 admitted to an inpatient status on 4/9/11 with pertinent diagnoses of UTI (urinary tract infection) with dizziness, hypomagnesemia, chronic diarrhea associated with radiation proctitis, history of rectal cancer with resection, chemotherapy and radiation, severe arthritis, anemia and mild congestive heart failure. The admit orders plan read: Admit to acute. Plan on starting to treat for UTI. Draw blood cultures X 2 prior to that. Place on telemetry to monitor heart rhythm and repeat a cardiac enzyme panel in the morning. Levaquin to be dosed by pharmacy for UTI. We are already replacing magnesium. Follow closely. Patient voices understanding.
Review of the current nursing care plan on 4/12/11 for Patient 1 addressed only "bowel incontinence".
Interview with Registered Nurse (RN)-A and -B revealed the nursing care plan for Patient 1 should also include the following:
1. Decreased cardiac output R/T (related to) arrhythmias, and hypertension requiring the need for a telemetry;
2. Impaired physical mobility R/T risk for falls;
3. Excessive fluid volume R/T bilateral lower extremities and need for TEDS; and
4. Impaired skin integrity R/T chronic diarrhea.
Interview with the Director of Nursing (DON) on 4/12/11 at 3:00 PM acknowledged the nursing care plan was not complete for Patient 1.
C. Record review on 4/12/11 at 4:20 PM revealed Patient 2 admitted to an inpatient status on 4/10/11 with pertinent diagnosis of hypoxemia, etiology uncertain. Major concern at this point would be pulmonary emboli with recent leg swelling, hypoxemia with markedly elevated D-dimer, 3 times normal: with negative PE per CT, history of hypertension, hyperlipidemia, dementia with agitation, depression, degenerative arthritis, history of peptic ulcer disease, urinary incontinence, renal insufficiency. The admission orders/plan read: "Get a chest CT scan. We will have to premedicate to avoid increasing renal insufficiency. Start on Lovenox and Coumadin." Review of current nursing care plan on 4/12/11 addressed only "impaired gas exchange."
Interview with RN-A and RN-B revealed the nursing care plan for Patient 2 should also include the following:
1. Risk for infection. Lacks what related to;
2. Decreased cardiac output. Lacks what related to;
3. Fluid volume excess R/T Lasix and edema; and
4. Activity intolerance R/T weakness, fatigue and hypoxemia
Interview with the DON on 4/12/11 at 4:30 PM acknowledged the nursing care plan was not complete for Patient 2.
Tag No.: C0301
Staff interview and review of the Rules and Regulations of the Medical Staff revealed the Critical Access Hospital (CAH) failed to maintain a medical record system in accordance with the written policies and procedures for the completion of the medical records for 13 patients (Patients 1-13) within the allotted time frame. The CAH is licensed for 21 beds and had a census of 3 acute patients upon survey entrance. Findings include:
A. Review on 4/14/11 at 8:00 AM of the Rules and Regulations of the Medical Staff section G. Medical Records, Page 9, Paragraph 5, dated 10/26/10 reads: "The Medical Record shall be completed by the physician or his/her designee within 15 days after discharge of the patient. If not so completed, the physician will be notified by the Medical Records Department. If not completed within 30 days, the physician's admitting privileges may be suspended by the Hospital Administrator until the incomplete records are all completed. Repeated infractions of this regulation shall be cause for review of the physician's staff privileges, with recommendations by the Credentials Committee for action by the Governing Body."
Interview with the Health Information Manager (HIM) on 4/14/11 at 9:08 AM identified a total of 13 delinquent medical records. Following is the list of practitioners and reasons for delinquent records:
1. Practitioner 1 had 4 delinquent medical records lacking 1 consultation note, 1 attestation and face sheet with diagnosis, and 2 attestations and diagnosis;
2. Practitioner 2 had 1 delinquent medical record lacking an order sheet;
3. Practitioner 3 had 1 delinquent medical record lacking an order sheet;
4. Practitioner 4 had 1 delinquent medical record lacking clinic dictation;
5. Practitioner 5 had 6 delinquent medical records with 1 lacking a CT report and 5 lacking X-Ray reports.
Interview with the HIM acknowledged the delinquent medical records are from visiting physicians and there are no procedures for obtaining physician signatures/reports to assist with the completion of the medical records within the time allotted by the Rules and Regulations. At the time of the survey, no delinquent notices for the medical records had been sent out to the physicians or disciplinary action taken.
Tag No.: C0361
Based on record reviews, staff interviews, review of patient rights, and review of Advance Directive/Durable Power of Attorney (POA) Policy and Procedure, the Critical Access Hospital (CAH) failed to ensure patient rights pertaining to Advance Directives were followed for 2 of 5 closed Swing Bed patients (Patients 33 and 34). The CAH is licensed for 21 beds and had a census of 3 acute care patients upon entrance. Findings include:
A. Review on 4/13/11 at 8:30 AM of the CAH's Swing Bed Resident Rights #2 reads: "The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive." Review of the CAH's Advance Directive/Durable Power of Attorney Policy and Procedure, Page 1, Section 11-A reads: "At the time of admission (within 24 hours of admission), the Nursing staff shall provide the adult client, aged 19 and older, with written information regarding the client's rights under State law, to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives as permitted by the State and Federal Regulations. Clients of any age, or their guardian or representative shall sign a Code Status Sheet." Section 11-B reads: "Nursing staff should complete the Advance Directive Acknowledgement form and obtain client's signature." Section 11-E reads: "If the Client has an Advance Directive or Durable Power of Attorney, a copy of this legal document is attached to the active medical record by medical records/office personnel."
B. Record review on 4/13/11 at 9:00 AM revealed Patient 33 admitted to a Swingbed status on 12/27/10 and discharged on 1/1/11 with pertinent diagnoses of right lower lobe pneumonia, history of ground level falls, chronic atrial fibrillation, history of renal insufficiency and history of congestive heart failure. The patient's admission/orders plan read: Admit to swing bed care for further strengthening and rehab with PT, will continue on oral Levaquin for pneumonia and home meds. Will adjust therapy as needed. Patient voices understanding.
The comprehensive assessment tool dated 1/1/11 identified Patient 33 as requiring no assist with ADLs and is alert, orientated, no issues with short or long term memory, and plans on returning home upon discharge.
Review of record revealed Patient 33 signed the following forms in the medical record 1-8:
1. Condition of Treatment form - signed 12/27/10;
2. Advance Directive index and payer responsibility questionnaire - signed 12/27/10, noting that patient has advance directives and would not like any more information on advance directives;
3. Notice of Medicare provider non-coverage - signed 12/30/10;
4. Facility directory consent - signed 12/27/10;
5. Dental services authorization - signed 12/27/10;
6. Bed hold policy - signed 12/27/10;
7. Discharge instructions - signed 1/1/11; and
8. Inventory of personal effects - noted to be "verbal permission" for patient signature - dated 12/28/10.
The Advance Directives Acknowledgement is noted to have been filled out by a staff member with patient verbal permission for signature and dated 12/23/10. Patient 33 has advance directives, but the facility does not have a copy, acknowledging a family member or significant other is aware that Patient 33 has advance directives. The CAH's "Dear client" letter identified Patient 33 as acknowledging verbally "I do not want CPR done. I want my doctor to order a DNR (Do not resuscitate)." This form was identified as "verbal permission by patient" and dated 12/23/10 while patient was hospitalized in an acute status.
C. Interview with the Director of Nursing (DON) on 4/14/11 at 1:38 PM acknowledged Patient 33 did have a Power of Attorney (POA) but POA was out of town at the time of the incident requiring the patient to be hospitalized and was not sure if the patient had an Advance Directive or where it was, and if Patient 33 could sign all the other forms, then should have signed the DNR status form. DON was not sure staff attempted to get a copy of the Advance Directive.
D. Record review on 4/14/11 at 1:35 PM revealed Patient 34 admitted to a Swing Bed status on 1/12/11 and discharged on 1/21/11 with pertinent diagnoses of pancreatitis and colitis. Orders/plan to admit was for strengthening with PT/OT. Patient assessed by nursing staff as verbal, alert, capable of making own decisions, with good long and short term memory.
E. Record review noted Patient 34 signed the following medical record forms 1-7:
1. Condition of Treatment - signed 1/13/11;
2. Notice of Medicare provider non-coverage form - signed 1/19/11;
3. Facility Directory Consent - signed 1/13/11;
4. Vaccination form - signed 1/11/11;
5. Dental services authorization - signed 1/12/11;
6. Bed hold policy - signed 1/12/11;
7. Inventory of personal effects - signed 1/21/11.
8. Advance Directive Index and Payer Responsibility Questionnaire acknowledging that Patient 34 does not have Advance Directives and does not want information on Advance Directives was filled out by a nurse per phone conversation with Patient 34's family member and dated 1/10/11. Advance Directive Acknowledgement form states: "I HAVE NOT executed an Advance Directive was signed by a different family member on 1/10/11. Record lacked documentation that Patient 34 was asked or Advance Directives discussed with the patient. Interview with the DON on 4/14/11 acknowledged there was no proof the family members had POA authority for Patient 34 or the Advanced Directives issue was even discussed with the patient.