HospitalInspections.org

Based on observation and staff interview, the facility failed to assure adequate housekeeping services to maintain cleanliness in one of one air vents in the surgical suite's equipment clean-up room. The findings were:

Observation on 1/5/11 at 2:48 PM revealed the ceiling air vent located in the surgical suite clean-up room was encrusted in dirt and dust. The vent was approximately 12 inches by 16 inches and was located directly over an equipment washing machine. The door to the machine was open and multiple endoscopy tools were resting on the open door. Interview with the plant operations manager at that time confirmed the observation.

Based on observation, medical record review, staff interview, and review of policies and procedures, the facility failed to ensure staff reported 1 medication error out of 14 observed medication passes as required per their policies and procedures. The findings were:

Observation on 1/4/11 showed RN #10 prepared and administered Glipizide to patient #5 at 8:42 AM after s/he had finished breakfast. Reconciliation of the medication pass with the physician's 1/1/11 orders showed Glipizide was to be administered thirty minutes prior to meals. Review of the MAR showed the appropriate instructions were included, but the medication administration time was entered on the MAR as 9 AM. Interview with the RN on 1/5/11 at 3:30 PM revealed she did not notice the specified time for administration until she gave the medication. She confirmed she administered the medication as indicated on the MAR. She further stated that pharmacy entered administration times onto the MARs and that they were occasionally incorrect. Interview with pharmacist #3 on 1/5/11 at 10:40 AM confirmed the pharmacy department entered administration times onto the MARs.
According to the facility's policy and procedure entitled "Pharmacy Services: Medication Occurrences," last reviewed on 5/13/2010, a medication occurrence was "A lapse in the medication process during...administration of a medication...whether an adverse consequence occurs or not." The list of reportable occurrences included "Computer entry:...medication name (may include labeling)...Performance deficit...Procedure/protocol not followed." Review of the policy and procedure entitled "Incident Reporting, Serious and Sentinel Event Reporting", effective 6/11/09, showed the purpose of reporting incidents was to "...prevent/reduce potential recurrence of similar incidents." Interview with the CNO on 1/7/11 at 10:23 AM revealed an incident report for the medication error should have been submitted, but was not.

Based on medical record review, interviews with staff and a contracted employee, and review of policies and procedures, staff failed to complete required assessments to identify potential nutritional needs for 3 of 22 sample patients (#2, #4, #5) in order to ensure those needs were met. The findings were:

Review of the medical records for patients #2, #4, and #5 showed the Admission Health Profile assessment was completed for each patient. However, upon reviewing the individual items included in the assessment, a nutrition screen had not been completed for any of the patients. On 1/7/11 at 8:45 AM RN #8 identified the screen as part of the admission profile screen. Further review of the individual medical records showed patient #2 had physician's orders for a cardiac diet. Patient #4 was hospitalized for throat pain that was determined to be cardiac pain, and also had order for a cardiac diet and strict intake and output. Patient #5 had orders for a diabetic diet. Interview with the RD on 1/6/11 at 8:48 AM revealed the RD was in the facility weekly and assessed any referral of patients still hospitalized. The RD stated referrals came from the nutrition screening process or verbally, but he did not complete an assessment if he had not received a referral.
According to the facility's policy and procedure, "Admission Forms in the Electronic Medical Record (EMR)," effective 6/1/07, staff were to initiate and complete the admission health profile within 24 hours. Further review showed "Ancillary consults not requiring a physician's order (i.e., Nutrition,...) will be sent automatically when indicated" based on the admission health profile Interview with RN #8 while reviewing each record confirmed the individual nutrition screens in the admission health profile were not completed.

Based on observation, medical record review, staff interview, and review of policies and procedures, the facility failed to ensure medications were administered according to accepted standards of practice. One medication error out of 14 opportunities for error resulted in a medication error rate of 7.14%. In addition, staff failed to notify the physician when medication was held for patient #5. The findings were:

1. Observation on 1/4/11 showed RN #10 prepared and administered Glipizide to patient #5 at 8:42 AM after the patient had finished breakfast. However, reconciliation of the medication pass with the physician's 1/1/11 orders showed Glipizide was to be administered thirty minutes prior to meals. During an interview on 1/5/11 at 3:30 PM, the RN confirmed she administered the medication incorrectly. Refer to C277 for additional details.

2. Review of physician's orders dated 1/1/11 showed patient #5 was to receive metformin twice daily with morning and evening meals. Review of the January 2011 MAR revealed the medication was not administered until the morning of 1/3/11. The documentation when each routinely scheduled dose of metformin was not given indicated the patient's blood sugar was too low. Further review of the record with RN #8 failed to show evidence staff notified the physician when the medication was held. On 1/5/11 at 10:35 AM the CNO stated that nurses could withhold a medication based on prescribed parameters or on their judgment of the patient's clinical condition, but they were required to nofity the physician. She further stated there was no evidence the physician was notified when any of the doses of metformin were held.

Based on medical record review and staff interview, the facility failed to ensure the care plan for 1 of 20 sample acute care patients (#4), whose records were reviewed for care plans, included all identified concerns. The findings were:

According to the medical record, patient #4 came to the emergency department on 1/2/11 for throat pain. The patient was admitted with diagnoses that included chest pain and was placed on a cardiac diet and strict intake and output. Review of the 1/2/11 history and physical showed the patient had three stents placed four days prior to his/her admission. Review of the nursing notes, dated 1/3/11, showed nursing staff informed the patient that his/her laboratory tests "...had gotten worse since [s/he] was in the ED..." and the physician wanted him/her on telemetry (cardiac monitoring). However, review of the care plan on 1/6/11 showed the only issue that had been addressed was the patient's initial complaint of throat pain. On 1/6/11 at 8:55 AM, RN #8 confirmed the care plan was incomplete.

Based on medical record review, staff interview, and review of the medical staff rules and regulations, the facility failed to ensure post-anesthesia evaluations included complete assessments to determine proper anesthesia recovery for 5 of 7 sample patients (#7, #12, #13, #19, #33) who required that evaluation. In addition, the medical staff rules and regulations failed to identify the person in charge of the patient's post-anesthesia recovery. The findings were:

1. According to information related to anesthesia services published by the Centers for Medicare and Medicaid Services, revised on 2/5/2010, the post-anesthesia evaluation "...is required any time general, regional, or monitored anesthesia has been administered...generally would not be performed immediately at the point of movement from the operative area to the designated recovery area...may not begin until the patient is sufficiently recovered from the acute administration of the anesthesia so as to participate in the evaluation...conform to current standards of anesthesia care, including: Respiratory function... Cardiovascular function... Mental status... Temperature... Pain... Nausea and vomiting... Postoperative hydration..." Medical record reviews showed failure to conform to these guidelines as follows:
a. Patient #19 had surgery under general anesthesia on 7/3/10 and was transferred to the post-anesthesia care unit (PACU) at 11:30 AM. The post-anesthesia evaluation was completed at 11:35 AM; the only information provided was "VSS" (vital signs stable).
b. Surgery for patient #33 was conducted on 6/2/10 under general anesthesia, and the patient was transferred to PACU. However, the post-anesthesia evaluation documentation consisted of one word,"uneventful." The note was dated 6/2/10, but the time was not indicated.
c. Surgery for patient #7 ended at 2:22 PM on 7/21/10, and the patient was transferred to PACU for recovery from general anesthesia. The anesthetist documented he completed the post-anesthesia evaluation at 2:45 PM, but the required information was not included.
d. Review of the medical records for surgical patients #12 and #13 showed the post-anesthesia notes failed to include any information other than "uneventful." Surgery for patient #12 was conducted on 8/2/10 under general anesthesia. The post-anesthsia evaluation was completed at 1927, but the documentation was incomplete. Surgery for patient #13 was conducted on 10/15/10 at 8 AM. Time for the post-anesthesia evaluation was not indicated.
While reviewing each record, RN #8 confirmed the absence of required post-anesthesia information.

2. Review of the 2009 "Washakie Medical Center Medical Staff Rules and Regulations," revealed that "...the person in charge of the patient's care in the immediate post-procedure period shall complete a post-anesthesia monitoring record..." The medical staff rules and regulations continued to describe the information required in the record and ended with "...the patient's condition upon release from the area (or termination of special post-anesthesia monitoring). Discharge will be based on the Aldrete Score." This verbiage failed to indicate who was in charge of the patient's care, resulting in the possibility that it could be the PACU nurse, a person not identified by federal regulation as a qualified practitioner to administer anesthesia.


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Based on review of policies and procedures and staff interview, the facility failed to ensure their policy for abuse included all required elements. The findings were:

Review of the facility's 9/17/08 policy and procedure entitled "Abuse Prevention" showed it failed to include immediate notification of the administrator for all allegations specified in the federal regulation. Interview with the CNO on 1/7/11 at 8:10 AM confirmed this failure.

Based on medical record review and staff interview, the facility failed to ensure the discharge summary for 1 of 2 swing bed patients (#15) included a recapitulation of stay. The findings were:

Review of the medical record showed patient #15 was admitted to swing bed status on 10/22/10 and discharged on 11/3/10. Further review showed the form for the recapitulation of stay had not been completed. On 1/6/11 at 2:30 PM RN #8 confirmed the discharge summary lacked a recapitulation of stay.