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Based on observation, policy review and interview, the facility failed to ensure the condition and overall environment of the facility was maintained to ensure the safety of the patient by failing to: 1) ensure medical equipment was being monitored and maintained and 2) ensure the shower/tub room floor was free of risk and hazards. In addition, the CAH failed to ensure freezer temperatures were being monitored for the refrigerator/freezer in the activities room. Findings:

Medical Equipment

Observation on 9/20/11 at 1200 noon in the Physical Therapy Department, revealed the Total Gym 1500 and the NuStep TRS 4000 and the Original Seated Stepper had no preventive maintenance (PM) sticker on them.

During an interview on 9/20/11 at 2:30 pm with the Building Services Manager, he confirmed South Central Biomed (the biomedical contract company) had not checked Physical Therapy's patient equipment. He further revealed the facility did not have any documentation from South Central Biomed for their last inspection of October 2010.

Observation and interview on 9/21/11 at 8:15 am in the Outpatient Clinic with employee #10 revealed one (1) Zoll M Series Biphasic 200 joules max defibrillator used for both pediatric and adult patients, and one (1) blood pressure and pulse monitor with finger probe oxygen capability, had no biomedical sticker on them. During the interview Employee #10 confirmed no biomedical sticker was on the equipment and no biomedical check had been done.

During an interview on 9/22/11 at 9:30 am with the Human Resource Manager he confirmed there was no biomedical policy in place.

Shower/Tub Room

During the initial environmental tour on 9/19/11 of the patient shower/tub room, a floor tile located on the outer edge of the tile area, (tile number 8 out of 16 tiles) was chipped, leaving a sharp edge. The tiled area was in the shower area and created a potential hazard for the shower chair wheel or an uncovered patient foot during a shower.

During an interview on 9/20/11 at 2:30 pm with the Building Services Manager, he acknowledged the shower tile area was a concern.

Review on 9/22/11 at 9:30 am of the policy #ES 203, "Environmental Services-Maintenance ...Daily Walk-Thru"; "PROCEDURE REVISED: July 6, 2011"; "Procedure: ...3. Repairs and replacements for any unusual findings will be done in a timely manner. Major problems will be addressed and repaired at once."

Activities Room Freezer

During the initial environmental tour on 9/21/11 at 9:45 am, an observation was made of the activities room refrigerator/freezer. It had a refrigerator temperature log posted but not a freezer temperature log.

During an interview on 9/20/11 at 5 pm with Employee #11 she confirmed the activities room freezer temperature was not being recorded. Employee #11 further stated the CNA's were responsible for monitoring the activities refrigerator temperature and the refrigerator/freezer did store items for the patients.

During an interview on 9/21/11 at 2:15 pm with the DON (Director of Nursing) she confirmed the activities room freezer temperature was not being monitored. She further stated there was no policy for taking freezer temperatures.

Based on observation, record review, and interview the facility failed to ensure medications and supplies were securely maintained. As a result medications and supplies stored in the respiratory room and in the 2 emergency rooms were readily accessible to unauthorized personnel. Findings:

Observation on 9/19/11 at 9:45 am revealed Emergency Room #'s 1 and 2 had unsecured, individually packaged needle/syringe units sitting on the counters in open-topped plastic bins and on shelves in unlocked glass-door cabinets, within view and easily accessible to the general public.

Observation on 9/19/11 at 10:00 am in the room next to ER #1, referred to as the "RESPIRATORY ROOM" by the Director of Nursing (DON), revealed a small locked under-the-counter refrigerator that contained, among other items, vials of Tetanus vaccine, Influenza vaccine, 29 vials of Diltiazem 25mg/5ml (a medication used to treat high blood pressure), and 9 vials of Anectine 200mg/10ml (a paralytic drug used to induce muscle relaxation and short term paralysis). The key to unlock the refrigerator was hanging on a small hook directly next to the refrigerator.

During an interview on 9/20/11 at 1:45 pm with the DON she confirmed the hospital did not lock the respiratory room door. The DON confirmed the hospital did not have a policy or procedure for securing medications and supplies.

Based on record review and interview the critical access hospital failed to ensure their policies and procedures were reviewed on an annual basis.

Review of the hospitals' policies 9/19-22/11 revealed not all the policies had not been reviewed on an annual basis to ensure the policies and procedures were being implemented and to determine if policies and procedures needed revision. Findings:

Review of the "Continuous Quality Improvement Plan" on 9/19-22/11 revealed, "The Quality Management Committee (QMC) consists of the following individuals: The CEO, Chief of Staff/designee, Department Managers as well as the CFO. The members of the QMC are responsible for: Ensuring that the review functions for each department and sub-committee are completed...The sub-committees are responsible for policy and procedure review and development as well as utilization review activities."

During an interview with the Administrative Assistant on 9/20/11 at 1:30 pm, she confirmed the hospital had not done an annual review of all of their policies. She further stated the hospital had no policy or procedure for the hospital to review their policies.

Based on interview and contract reviews Cordova Critical Access Hospital (CCAH) failed to ensure there were contracts in place with 2 suppliers who provided services for inspecting hospital equipment used for patient care. As a result, CCAH could not produce documentation of delineation of services provided by the 2 suppliers. Without delineation of the contractors' responsibilities, the critical access hospital is limited in their ability to evaluate the services to ensure they are provided in accordance with critical access hospital conditions of participation. Findings:

During review of CCAH contracts 9/19-22/11, two supplier contracts, Advanced Diagnostics, Inc. (ADI) and South Central Biomed could not be found. According to the ADI Website, ADI is a company that "provides repairs, preventive maintenance, and inspections for medical instruments and electronic biomedical equipment..." This service is provided by biomedical technicians. ADI offers "a complete range of X-Ray and Diagnostic Imaging Equipment and Supplies."

During an interview on 9/20/11 at 2:30 pm, the Building Services Manager stated South Central Biomed was the supplier who provided an annual onsite inspection of the hospital equipment. South Central Biomed technicians inspected equipment used by patients. Biomedical technicians were responsible for maintenance, installation, calibration, and repair of biomedical equipment designed to diagnose and treat medical conditions.

During an interview on 9/20/11 at 3:15 pm with the Human Resource Director, he confirmed CCAH did not have a contract with ADI or with South Central Biomed.

Based on record review and interview the critical access hospital failed to conduct an annual review and evaluation of all hospital services. As a result, there was not documented evidence of an annual evaluation that included determining appropriateness of utilization of services, adherence to facility policies and procedures, and changes in facility practices. Without reviewing and evaluating all services, deficient practices cannot be detected and corrected and maintained. Findings:

On 9/21/11 at 11:15 am the DON (Director of Nursing) provided the "2010 Annual Report of Pharmaceutical Services at CCMC".

During an interview on 9/22/11 at 7:50 am, the Administrator Assistant confirmed the hospital had not reviewed or evaluated its hospital services. She further stated the members of the Quality Management Committee (QMC) were responsible for conducting the review and evaluation.

Review of the "Continuous Quality Improvement Plan" 9/19-22/11 revealed, "The members of the QMC are responsible for: Ensuring that the review functions for each department and sub-committee are completed..."

Based on interview and record review, the facility failed to provide written notice of its policies regarding the implementation of patient's rights to make decisions concerning medical care, such as the right of advance directives, for 1 of 4 sampled swing bed patients and to have those advanced directives placed in a prominent part of the medical record. This created a risk for initiating CPR in the event of cardiopulmonary arrest against the patient's wishes. Findings:

Review of Patient #1's medical record on 9/19/11 revealed the Patient was admitted on 9/7/2011 with diagnoses that included pelvic fracture, hypertension, atrial fibrillation (an irregular and rapid heart rate) and COPD (chronic obstructive pulmonary disease). The Patient's medical record did not have a signed "Acknowledgement of Receipt of Patient Rights and Information on Advanced Directives".

Review of the facility's policy and procedure "Advanced Directives" (policy #NSG 125, effective date 1-24-08, reviewed, 7/25/11) revealed, "All patients/residents admitted to Cordova Community Medical Center (CCMC) ...will be given the booklet entitled "Alaska Advance Directives" which explains the healthcare legal documents and the patient/resident will be asked to sign that they have been given the booklet "Alaska Advanced Directives". It was further stated in the policy and procedure, "Full Resuscitation" or "Full Code" will be attempted for any resident or patient who is found to have no palpable pulse and/or no discernible respirations, unless there is a written Medical Provider order to the contrary."

During an interview on 9/21/2011 at 9:00 am with Employee #5, a nurse assigned to the swing bed unit, revealed she did not know the code status of swing bed Patient #1. After reviewing Patient #1's medical record that was located at the nurse's station, she confirmed there was no advanced directive in the Patient's medical record and that in the absence of an advanced directive she would be considered a "Full Code".

During an interview on 9/21/11 at 11:00 am with the Medical Director, he stated he had clarified Patient #1's code status. Record review confirmed he had written an order in the medical record dated 9/21/11 (1030 AM) that Patient #1's advanced directives were in her outpatient chart. He documented her code status as: "Do not intubate, no chest compressions. May: use cardiac drugs, IVF (intravenous fluids) and IV (intravenous) antibiotics, mask, (or briefly) bag-mask O2 (oxygen)."

Interview on 9/22/11 at 9:30 am with the DON (Director of Nursing) revealed staff were unable to locate a copy of any advanced directives in the Patient's medical record. In addition they were not able to locate the signed form "Acknowledgement of Receipt of Patient Rights and Information on Advanced Directives".

Based on interview and policy review the facility failed to have policies and procedures in place regarding inpatient and outpatient visitation rights, including any restrictions or limitations, and how the hospital staff would be trained to appropriately deal with the visitation rights of the patient. This deficient practice created the potential for unnecessarily restricting visitation for staff not knowing what restrictions or limitations are clinically necessary. Findings:

Review of the policies and procedures 9/19-22/11 revealed no policy or procedure on patient visitation rights.

During an interview on 9/21/11 at 2:15 pm the DON (Director of Nursing) confirmed there was no policy and procedure on patient visitation rights and confirmed no staff education had been done.