HospitalInspections.org

Based on document review and staff interview the Critical Access Hospital (CAH) failed to implement a periodic maintenance and testing program by a qualified person for their intrarvenous (IV) infusion pumps according to the manufacturer's recommendations.

Findings included:

- On 8/4/10 the CAH provided a written document dated 8/4/10 at 12:55pm. The manufacturer B. Braun, of the IV infusion pumps "Outlook 100" recommended preventive maintenance at six months then yearly and a two year check up on the battery.

Staff A on 8/3/10 at 1:35pm acknowledged the CAH failed to have a preventative maintenance program for the IV infusion pumps and they are not periodically checked for accuracy.

Based on document review and interview the Critical Access Hospital (CAH) failed to Credential one provider to the medical staff of the Critical Access Hospital.

- Document review on 8/3/10 of the credentialing files revealed one physician, with an application date of 01/2004, lacked evidence of approval from the governing body to practice medicine in the Hanover Hospital.

Review of the Medical Record policy titled "Credentialing", revealed, "....When all information is gathered, the Medical Records designee shall forward the applications to the Governing Board for approval. All staff members must apply for re-appointment at least every 2 years..."

Interview on 8/4/10 at 1:30pm with staff I confirmed the CAH failed to credential one provider.

The hospital reported a census of 17. Based on observation, document review and interview the Critical Access Hospital (CAH) failed to ensure that outdated, mislabeled or otherwise unusable drugs are not available for patient use and failed to follow their policy for labeling of medications.

Findings include:

- Tour of the Pharmacy/Medication Room on 8/03/10 at 9:00am with Staff D revealed the following:

Three - 50milliliter (ml) bottles of Sterile Water lacked a date when each bottle was opened.
One - 20ml bottle of Acyclovir Sodium lacked a date when opened.
One - 10 milligrams (mg)/2ml bottle of Metoclopramide lacked a date when opened.
One - 5 grams/10ml of Magnesium Sulfate lacked a date when opened.
Three - 10 cubic centimeter syringes, filled with a clear liquid, lacked a label identifying the clear liquid, lacked a date when the syringes were filled and lacked the initials of the professional staff that filled the syringes.
Five - 500ml bags of Lactated Ringers with an expiration date of 4/2010.

Interview with Staff D on 8/3/10 at 9:15am confirmed the medications were outdated, mislabeled and not appropriate for patient use.

Interview with Staff T on 8/3/10 at 9:20am confirmed they filled the syringes with sterile water and forgot to appropriately label them.

Review on 8/3/10 of the Policy, "Admixture Preparation Procedure" under "Labeling of Medications", revealed "...The nurse drawing up the syringe should attach the medication label so the contents of the syringe cannot possible be mistaken for another product. The label will include the name of the medication, date, time it was drawn up, who the patient is and the time it is to be given. If the medication is a flush for IV medications, it must be labeled with the name of the medication and the time and date."

Review on 8/3/10 of the Policy, "Outdated Medications Policy" , revealed "...the outdated medication will be pulled from the stock meds at the end of the month and replaced with new ones...".


21996

- Observation of the emergency room (ER) on 8/2/10 at 11:45am revealed a cabinet that contained the following:
One-50 cubic centimeter (cc) vial of 1% Lidocaine that lacked a date when opened.
One-50 cc vial of Marcaine .5% that lacked a date when opened.
One-50cc vial of 1% Lidocaine with Epinephrine that lacked a date when opened.
One-50cc vial of Sterile Water, single use, 2/3s full.
One-50cc vial of Sterile Water, single use, 1/4 full
One-20cc vial of .9% Sodium Chloride, single use, 3/4s full.

Staff H on 8/2/10 at 11:45am acknowledged the vials of medication lacked a date when opened and the single use vials were used for more than one patient.

The facility failed to follow their policies to ensure that outdated, mislabled and unusable drugs are not available for patient use.

Based on observation, staff interview and document review, the hospital's infection control officer failed to develop a system for an active infection control program to ensure hospital personnel followed basic infection control practices during an observation in the laundry room and three of three observations of staff cleaning patient rooms (#'s 110, 111, and117).

Findings included:

- Document review on 8/3/10 of the manufactures labels for "Solid Super Star" and "Tri-Star Solar Brite" laundry soap lacked evidence of any form of sanitizer to disinfect the laundry in cold or warm water.

- Document review on 8/4/10 of the CAH's policy titled "Laundry-Washing Cycle" revised 2/9/09, directed "...It is the policy of the Hanover Hospital and ISB (intermediate swing bed) that all laundry is thoroughly cleaned and dried. It is important that all laundry is free from bacteria..."

- Observation on 8/2/10 at 10:30am revealed a home type washing machine and a commercial washing machine in the laundry room.

Interview on 8/2/10 at 10:30am with staff K revealed at times the laundry staff wash patient's personal laundry and hospital laundry in cold and warm water. Staff L verified the use of "Solid Super Star" and " Tri-Star Solar Brite" laundry soap in the washing machines.

The facility failed to prevent potential cross contamination of infectious microorganisms by not using a sanitizer when laundry is washed in cold or warm water.

- Document review on 8/4/10 of the "Ultra Quat Plus" manufacturer's guidelines for disinfection instructed staff to allow surfaces to remain wet for ten minutes to assure disinfection.

- Document review on 8/4/10 of the "Bowl Tamer RTU" and "Shower Tamer Clinging Foam" cleaners failed to identify the cleaners as a disinfecting agent.

- Document review on 8/4/10 of the CAH's policy titled "Exposer Control Hand Washing" directed "...Our facility has adopted the following work practice control for hand washing: 1. employees wash their hands immediately or as soon as possible after removing gloves..."

- Observation on 8/4/10 at 10:00am of the cleaning of patient room 110 revealed housekeeping staff G applying gloves and entering the room. Using a spray bottle of "Ultra Quat Plus" staff G sprayed the window ledge and immediately dried the ledge with a paper towel. Staff G returned to the cleaning cart removed their gloves and reapplied a clean pair of gloves. Staff G applied "Shower Tamer Clinging Foam" to the sink and faucets and dried the sink with a paper towel. Staff G returned to the cleaning cart, removed their glove and reapplied a clean pair of gloves. Staff G wet a toilet bowl brush with "Bowl Tamer RTU" cleaned the inside of the toilet bowl then the toilet seat and the outside of the toilet with the same brush. Staff G returned to the cleaning cart, removed their gloves and reapplied clean gloves and dried the toilet seat with a paper towel. Staff G returned to the cleaning cart removed their gloves, reapplied clean gloves and mopped the floor with " Ultra Quat Plus " cleaning solution. The floor dried within three minutes not the required ten minutes for total disinfection.

On 8/4/10 at 10:30am staff G acknowledged they failed to perform hand hygiene before cleaning room 110, after changing their gloves, and after completing the cleaning of the room. Staff G acknowledged the ledge and floor failed to remain wet for a contact time of ten minutes.

On 8/4/10 at 10:45am staff C verified "Bowl Tamer RTU" and "Shower Tamer Clinging Foam" were not a disinfecting agent and housekeeping staff were to apply "Ultra Quat Plus" after using the bowl and shower cleaners. Staff C acknowledged the housekeeping staff had been instructed to allow "Ultra Quat Plus" to remain on surfaces for ten minutes to achieve total disinfection.







21996

- Observation on 8/2/10 at 11:05am revealed Staff F walked out of patient room 111 with cleaning supplies in their gloved hands and placed the supplies on the cleaning cart. Staff F picked up the wet floor signs and walked down the hall to the utility room where they put the signs away. Staff F walked back to the cleaning cart, removed their gloves, applied clean gloves, and picked up cleaning supplies to clean another patient room. Staff F failed to perform hand hygiene each time they removed their gloves.

- Observation on 8/3/10 between 8:25am and 8:40am revealed Staff E with gloved hands going in and out of patient rooms removing the previous months activity calendars. Staff E removed their gloves when finished with this task and applied clean gloves. Staff F with gloved hands went from one patient's room after another patient's room and removed the activity calendars. Staff F removed their gloves and applied clean gloves, walked into the women's bathroom by the nurses station, came out, walked into the men's bathroom, came out of the bathroom with trash, picked up trash from women's bathroom, and took the trash to the cleaning cart, cleaned the bathroom by the nurses stations, removed their gloves,and applied clean gloves. Staff E and F failed to perform hand hygiene each time they removed their gloves.

- Observation on 8/3/10 at 8:50am revealed Staff E and F with gloved hands entered the hallway from the basement, removed their gloves and applied clean gloves,and began to clean the waiting room and nurses station. Staff E and F failed to perform hand hygiene when they removed their gloves.


21674


- Observations made on 8/3/10 at 10:30am revealed staff E, in the patient's room 117, with gloved hands, cleaning the outside of a toilet bowl with a wet rag, then cleaning the sink and mirror with the same rag and the same pair of gloves. With the same wet rag and wearing the same pair of gloves, Staff E proceeded into the bedroom area and began wiping down the bedroom furniture.

- Interview on 8/3/10 at 10:30am with staff E, revealed, "We do not get infection control training. I do not know what it is."

- Interview on 8/3/10 at 11:00am with staff C, revealed there was an education meeting held on March 8, 2010 with all housekeeping staff to discuss procedures on how to properly clean, control issues. Each staff member signed and dated the attendance sheet.

Document review on 8/3/10 of the housekeeping education on how to properly clean a building and Infection Control, revealed housekeeping staff E, staff F and staff G attended the meeting and signed the attendance sheet.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to designate an outpatient coordinator to be responsible for all outpatient services provided by the CAH.

Findings included:

- On 8/2/10 the "Hospital Information Sheet" (a staff roster requested by the surveyor) completed by the CAH lacked the name of a staff member in charge of the outpatient services.

Staff A on 8/3/10 at 8:00am acknowledged the CAH failed to appoint an outpatient coordinator to be responsible for all outpatient services.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to provide adequate monitoring of radiation equipment used to provide x-rays to patients.

Findings included:

- Interview on 8/4/10 at 10:30am staff J revealed the CAH did not have a system in place to ensure periodic inspections of radiology equipment. Staff J verified the CAH failed to conduct annual testing of equipment for radiation hazards.

- Document review on 8/4/10 of the last inspection conducted by the Kansas Department of Health and Environment (KDHE) Environmental Scientist on 4/24/08 revealed the CAH had been cited at K.A.R 28-35-243a?(E)(iv)(2) ...periodic measurements of the entrance exposure rate shall be taken by a qualified expert ...The measurements shall be taken annually and after any maintenance of the system ... "

The CAH failed to provide safety for patients and personnel and ensure equipment is checked for radiation leaks and the amount of radiation produced during exposure.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to develop and maintain a current list of services provided by agreement or arrangement, and the nature and scope of the services provided.

Findings included:

- On 8/2/10 at 11:05am during entrance, the surveyor requested a list of services the facility provides directly and a list of services provided through agreement or arrangement. The CAH failed to provide documentation of all services provided through agreement or arrangement, and a description of the services provided. Additional requests for documentation of services provided by agreement or arrangement were made on 8/3/10. The CAH failed to provide a complete list of services provided by agreement or arrangement and the nature and scope of the services provided.

Staff A on 8/3/10 at 11:00am acknowledged the CAH lacked a complete list of services provided by agreement or arrangement including the nature and scope of the services provided.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to ensure medical staff dated and/or timed all entries in the medical record for 10 of 31 sampled medical records (#'s14, 16, 17, 18, 20, 21,26, 27, 29, and 30).

Findings included:

- Patient #17's medical record revealed an admission date of 11/10/09 for a delivery of a baby and discharge date of 11/15/09. The medical record revealed a history and physical, a delivery note, a discharge summary and two typed progress notes between 11/11/09-11/12/09 lacked a date and/or time when authenticated (signed) by the provider.

- Patient #18's medical record revealed an admission date of 11/15/09 for a delivery of a baby and discharged 11/20/09. The medical record revealed progress notes on 1/17/09, 11/18/09, 11/19/09 and 11/20/09 lacked a time when written.

- Patient #20's medical record revealed an admission date of 11/10/09 a newborn infant and discharged on 11/15/09. The medical record revealed a discharge summary and four typed progress notes between 11/11/09-11/14/09 lacked a date and/or time when authenticated (signed) by the provider.

On 8/3/10 at 3:00pm staff I acknowledged all entries into the medical record lacked a date and/or time when authenticated.

The CAH failed to have a policy to direct staff on the requirement to date and time all entries into the medical record.

This deficient practice also affected patient #'s14, 16, 21,26, 27, 29, and 30.