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Based on observation and interview, the facility failed to provide services in accordance with appropriate written policies. Findings include:

1. Per observation on 7/27/10 at 4:15 PM, the Adult Code Cart and Pediatric Code Cart located in the Howell Pavilion nursing unit were not checked daily per the facility policy labeled Crash Cart Checks. Per the facility policy, crash carts should be checked daily for lock integrity, medication expiration date, supply expiration date, defibrillator charges, and battery powered equipment. The policy further states that the procedure for the cart checks includes; recording the lock number, date, defibrillator check and signature of person checking on the designated log sheet daily.

Per review of the Adult Code Cart Daily Check sheet for May 2010, 28 of 31 days contained no documentation for the daily checks. Per review of the sheet for June 2010, 20 of 30 days contained no documentation, and for July 2010, 15 of 27 days contained no documentation.

Per review of the Pediatric Code Cart Daily Check sheet for May 2010, 28 of 31 days contained no documentation for the daily checks. Per review of the sheet for June 2010, 22 of 30 days contained no documentation, and for July 2010, 15 of 27 days contained no documentation. Per interview on 7/27/10 at 4:30 PM, the Charge Nurse confirmed that the code cart daily checks for the Adult and Pediatric code carts were incomplete for the months of May, June, and July 2010.

Based on observation and staff interview the facility failed to assure that outdated drugs were not available for patient use, that all drugs and biologicals were stored in a secure manner, and that pharmaceutical services were in accordance with accepted professional principles. Findings include:

1. During a tour of the PACU (Post Anesthesia Care Unit) on 7/27/10 at 9:55 AM 1 ampule of Epinephrine 1:1000 and a 5ML vial of Lidocaine 1.5% and Epinephrine 1:200,000 were left unsecured on a counter. A 30 ML vial of Bupivacaine 0.5% and a open bottle of Asprin 81 mg were observed stored in an unlocked cabinet. At the time of observations it was confirmed by PACU staff and the VP of Surgical Services, all drugs must be stored in the Pyxis (medication dispensing station).

2. On 7/27/10 at 3:50 PM during a tour of the CAH's on campus pediatricians' office, bottles of hydrogen peroxide were observed stored in unlocked cabinets. The office practice manager confirmed at the time of observation, the biologicals should not have been stored unsecured in the pediatric exam rooms.

3. On 7/27/10 at 9:30 AM during a tour of the CAH's off-site Urology office in White River Junction, multiple medications, including antibiotic injectable, epinephrine injectable, and chemotherapeutic drugs, were observed stored in an unlocked drawer and/or in an unlocked refrigerator within an unsecured area of the practice. The office manager of the practice confirmed that the medications were kept in an unsecured room in unlocked areas at the time of the observation.

4. On 7/27/10 at 1:50 PM during a tour of the Radiology Department, a bottle of gas relief drops was observed in an unlocked drawer in 1 of 2 x-ray rooms. Further, the bottle, which was available for patient use, was labeled with an expiration date of 05/08. In addition, there was a large open container of liquid Barium Sulfate suspension, as well as several packages of Barium Sulfate tablets and powder, stored in an unlocked cabinet in the unsecured room. The manager of the Radiology Department confirmed the above at the time of observation.

5. Per observation on 7/27/10 at 3:00 PM, the Code Cart located in the Pulmonary Rehabilitation room failed to contain 2 medications required by facility standards. Per direct observation of the medications available in the Code Cart, the cart did not contain any Narcan (a narcotic reversal agent) or Furosemide (a diuretic). Per review of the Adult Crash Cart Check List, the 2 medications were marked as "out" during the last check of the cart, dated 7/4/10. At the time of observation, the absence of these 2 medications was confirmed by the Cardiopulmonary Services Supervisor.

6. Per observation during tour of the CAH's off -site physician practice in Berlin, at 8:10 am on 7/27/10,
medications available for patient use included 8 expired vials of injectable Ceftriaxone (an antibiotic) 1 gm. The expiration dates noted on the vials were between 5/2010 and 7/1/2010. In addition, a vial of injectable Lidocaine, 10mg/ml solution, was found opened and undated in an unlocked drawer of an unsecured patient exam room utilized by the nurse midwifery practice. All observations were confirmed by the RN Office Manager at the time tour.

Based on observation and staff interview, the CAH staff failed to maintain appropriate infection control measures when handling and storing used patient instruments, and the use of sterile solutions for urology procedures. Findings include:

1. During a tour of the physician offices on the CAH campus, on 7/27/10 at 4:30 PM, a 1000 cc bag of sterile water was observed hanging on an IV pole with tubing attached without appropriate labeling identifying the date and time the bag was spiked and hung. There was approximately 500 cc of the solution left in the bag. A plastic bottle containing sterile water was also noted to have been opened and without appropriate label noting date and time the bottle had been opened for use. At the time of the observation, the practice manager contacted the urology staff responsible for the solutions and was informed the solutions were opened during office use on 7/23/10 for urology procedures. The V.P. of Hospital Services confirmed on the afternoon of 7/27/10, it is the expectation that all solutions should have been labeled when hung or opened.

2. During a tour and interview with the office manager of the Gifford Medical Center OB/GYN office on 7/28/10 at 10:00 AM, the office manager stated that used patient instruments are stored in open, uncovered bins in patient exam rooms. S/he stated that in each patient exam room, a bin is partially filled with water that includes an enzyme liquid, placed in the sink, and is used to store used speculums throughout the day. S/he confirmed that multiple speculums are stored in the bin in the sink while multiple patients are seen in the exam rooms, and that the speculums are not removed from the room after each patient. Per observation of the available unoccupied exam room, the only sink available for hand washing contained an uncovered pink plastic bin partially filled with a solution, ready for storage of used patient instruments. During an interview on 7/28/10 at 1:45 PM, the Vice President of Patient Care Services, who provides oversight to the office, confirmed that the above practice is not acceptable to maintain proper infection control.

Based on observations and staff interview, dietary staff failed to ensure that all sanitation processes were in accordance with the facility's dishwashing requirements. Findings include:

During observations of the manual dishwashing area on 7/26/10 at 10:30 AM, the sanitizer levels in the sink used for manual dishwashing registered as less than the required levels. The staff member washing dishes in the 3 compartment sink unit measured the level of sanitizer present in the last sink (used for sanitization) as less than 200 PPM (parts per million). He verified that the color change on the test strip indicated that the level of sanitizer was less than required, as stated on the manufacturer's chart located on the wall above the sink and per facility procedures. In addition, the level of water in the sanitizer sink was not deep enough to cover the pot being washed in the 1st sink, per observations at that time. The staff member assigned to dishwashing was asked to put the pot into the sanitizer sink. The pot's height was observed to be higher than the water level and not completely covered by the sanitized water. These observations were confirmed with the Director of Hospitality and Food Services and the Chef on 7/27/10 at 10:15 AM.

Based on record review and confirmed through staff interview the facility failed to assure complete and accurate documentation of the medical record for 1 applicable patient ( #27 ). Findings include:

1. Per review, on the afternoon of 7/28/10, the medical record for Patient #27 did not include complete documentation of an ER (Emergency Room) visit. Per review of the ER Log on the afternoon of 7/26/10 Patient #27 was listed as presenting to the ER on 2/8/10. However, the only medical record for Patient #27, dated 2/8/10, identified the visit as "Clinic" and included a physician 'Office Note' which stated; "........patient is seen 3 days post, partial nail avulsion medial margin great toenails bilaterally. The patient presented to the emergency department complaining of increased discomfort. They kindly referred on to our care...". During interview, on the afternoon of 7/28/10, the VP of Patient Care Services agreed that it appeared that the patient had presented to the ER on 2/8/10 and was referred to the office practice. S/he confirmed that there should have been some documentation of the patient's visit by ER staff.

Based on interview and record review, the CAH failed to assure: that a properly executed informed consent for anesthesia was obtained for 1 applicable patient (Patient #7); and that the medical record included all pertinent information for 2 applicable patients (Patients #26 and #29) . Findings include:

1. Per review, on 7/27/10, the medical record for Patient #7, who underwent exam and surgical repair of a laceration under spinal anesthesia on the evening of 1/7/10, lacked informed consent for the anesthesia. This was confirmed by the Operating Room Nurse Manager during interview, at 2:20 PM on the afternoon of 7/28/10.

2. Per review, on the morning of 7/28/10, the medical records for Patients #26 and #27 both lacked documentation that the patients, who each presented to the ER with suicidal and/or homicidal ideation were placed in an environment that reduced the potential for self harm or harm to others during their stay. Patient #26 presented to the ER on 7/22/10 with a chief complaint of Suicidal ideation and Patient #27 who presented to the ER on 6/9/10 had a physician assessment that stated: "acute alcohol intoxification and likely polysubstance abuse with suicidal and homicidal ideation". Both patients had undergone a Suicide Risk Assessment, which identified each patient at moderate risk.. Although the facility's Suicide Assessment and Prevention Policy, dated 6/9/09, identifies interventions to assure a safe environment, which include: removal of potentially harmful equipment and removal of patient clothing and personal belongings from the room, there was no documented evidence that these interventions had been implemented for either patient. This was confirmed by the VP of Patient Care Services during interview on the afternoon of 7/28/10.

Based on record review and confirmed through staff interview the facility failed to include in the medical record the results of consultative screening conducted for 1 applicable patient. (Patient #22) Findings include:

Per review, conducted on the afternoon of 7/28/10, the medical record for Patient #22 lacked documentation of the results of a mental health screening evaluation conducted in the ED (Emergency Department) on 2/21/10. The patient, who was brought to the ED by law enforcement, presented with a chief complaint, "........drinking and expressing suicidal ideas." During the course of treatment a nurse's note, at 8:10 PM, identified that the patient had been "Examined by Clara Martin Screener", (the area's mental health agency). The patient was subsequently discharged in police custody, however there was no documentation of the evaluation by the mental health provider to reflect the decision for disposition at discharge. This was confirmed by the VP of Patient Care Services during interview on the afternoon of 7/28/10.

Based on staff interview and record review Anesthesia services failed to ensure a post-anesthesia evaluation report was conducted by a practitioner qualified to administer anesthesia for each patient receiving anesthesia for 2 applicable patients. (Patients #7 and #10) Findings include:

1. Per record review on 7/28/10, Patient #10 underwent general anesthesia for orthopedic surgery on 1/26/10 and was discharged on 1/30/10. There was no evidence in the medical record that a post anesthesia evaluation was conducted. This was confirmed by the Operating Room Nurse Manager on 7/28/10 at 2:20 PM.

2. Per record review, on the afternoon of 7/27/10, Patient #7 underwent an exam and surgical repair of a laceration under spinal anesthesia on the evening of 1/7/10. Although the patient was not discharged until 3 days later on 1/10/10, there was no evidence that a post anesthesia evaluation had been completed to determine proper recovery from the anesthesia. This was confirmed by the Operating Room Nurse Manager during interview at 2:20 PM on 7/28/10.

Based on staff interview and record review, the CAH failed to assure that all remedial actions taken related to an event report were summarized and accurately documented. Findings include:

Per review of an event report dated 5/17/10 and confirmed during interview with the Vice President (VP) of Patient Care Services and the Director of Quality on 7/28/10 at 3:30 PM, there was not accurate, documented evidence of all remedial actions taken by hospital staff subsequent to this event report. The event report involved infection control issues, surgical, nursing and laboratory services as well as environmental services. There was no written summary and analysis of all facts and actions taken regarding the areas of quality deficiencies identified as a result of the event. The VP of Patient Care services stated at 3:30 PM that there were factual errors in the report that should have been noted and corrected and agreed there was no documented evidence of the summarization of action and analysis of the event for quality tracking purposes.