HospitalInspections.org

Based on record review and interview the Critical Access Hospital failed to adhere to New Hampshire Law related to criminal background checks and annual attestation statements for 2 employees out of standard survey sample of 20.
Findings include:

New Hampshire Statutes Pertaining to Health and Human Services 2014-2015 Edition 151:2-d
"...licensee or certificate holder shall review before making a final offer of employment. An employee shall not begin work before the final offer or employment is made."

Review of personnel files on 2/25/15 revealed 2 employees had started work prior to results of criminal background check being reviewed by facility and additionally 2 employees had not completed the annual attestation as required by New Hampshire law.

Interview with Staff F (Director of Human Services) on 2/25/15 and 2/26/15 confirmed that the results of the criminal background checks had not been reviewed by facility prior to employment and that 2 other employees had not completed the annual attestation statement as required by state law.

Based on observation, review of manufacturers maintenance recommendations and interview the facility failed to have a preventive maintenance program for patient care equipment.

Findings include:

During tour of the Birthing Unit, Medical Surgical Unit and Emergency Room on 2/24/15, a piece of equipment called "Olympic Warmette Blanket Warmer" and "Blickman/blanklet /solution warmer" was observed. On the door of the Warmette it states "Clean the lint filter every three months. It is located under the bottom shelf on the left." Staff A, (RN-MSN) and Staff B (Assistant Nurse Manger/Outpatient Supervisor) had no knowledge of the staff cleaning the lint filter of the Warmette. There are no logs maintained.

Reviewing the "Olympic Warmette Models 48/49 and 55/56 manufacturer's Instruction Manual", page 4-2, revealed under the section Quarterly Maintenance,"Cleaning the Lint Filter The Warmette has a lint filter located on the inside left wall of each warming module under the bottom tray (see Figure 4.2). Clean the filter at least once every three months, or more often if it becomes blocked."

Interview with Staff C, (Director of Facilities) on 2/24/15, indicated that the Warmette's lint filters have not been cleaned since the unit's arrival.


18010

Observation during the initial tour of the Emergency Room on 2/24/15 revealed a " BLICKMAN DIGITAL WARMING CABINET ". The upper cabinet of this unit had multiple solution bottles and the lower cabinet had multiple shelves filled with patient blankets. The digital temperature for the upper cabinet showed 102 degrees and the digital temperature for the lower cabinet showed 118 degrees.

Staff D (Registered Nurse) was asked who was responsible for the cleaning and monitoring of the temperatures for this warming cabinet and Staff D responded, the "maintenance department".

During interview with Staff E (Administrative Assistant for Facilities) on 2/16/15, Staff E provided the survey team with the Blickman Digital Warming Cabinet product manual with the manufacturer's operating instructions. Review of these manufacturer's instructions during this interview revealed in the section titled "SERVICE, CAUTION, Power should be disconnected and the heaters allowed to cool prior to servicing the unit. Periodically, lint or threads may accumulate in the heater compartment. Removing the false bottom permits access to this area for vacuuming or cleaning."

Staff E also indicated during this interview that there was no documented evidence for the monitoring of the temperatures of either the upper or lower cabinet in the unit and no documented evidence that the heater compartment of this 14 year old " BLICKMAN DIGITAL WARMING CABINET " had been periodically been cleaned for lint and or threads.

Based on observation and interview the Critical Access Hospital failed to secure biohazardous sharps containers from access by unauthorized personnel.

Findings include:

Observation on 2/24/15 at 11:30 am on the Medical surgical unit revealed biohazardous sharps containers on that unit were not secure in the rooms and do not have a secure top to prevent access by unauthorized personnel.

Interview with Staff A, (RN-MS) and Staff B (Assistant Manager/Outpatient Supervisor), on 2/24/15 at 11:30 am confirmed that sharps containers on the medical surgical unit were not secure in the room and did not have a secure top to prevent access by unauthorized personnel.

Staff A and Staff B confirmed the above findings, and that some of the individual drawers did not lock and only the top drawer locked and that Staff A and B were unaware that all the drawers did not lock. All needles and syringes were removed.


18010

Observation during the initial tour of the Emergency Room on 2/24/15 with Staff D (Registered Nurse) revealed multiple biohazard sharps containers with contaminated needles and syringes and tops which were not secure to prevent access by unauthorized personnel stored in the unlocked Emergency Room dirty utility room. Staff D verbally confirmed at this time that these multiple biohazard sharps containers with contaminated needles and syringes tops were not secure and that this dirty utility room door for the storage of the Emergency Room biohazard containers was unlocked; therefore, not preventing access by unauthorized personnel and/or outside individuals.

Observation on 2/25/15 at approximately 9:30 a.m. with Staff B (Registered Nurse) of the Emergency Rooms #6 and #7 revealed unsecured biohazard sharps containers on top of the Critical Access Hospital crash carts and also unsecured biohazard sharps containers on top of the individual storage counter tops in both ER room #6 and #7. Staff B verbally confirmed at this time that these biohazard needles and sharps containers on both counter tops in ER #6 and #7 and the containers on the crash carts were not secured and accessible to unauthorized individuals.

Based on observation, Policy & Procedure review, and interview it was identified that not all staff were familiar with the Policy & Procedure relating to dating the control solution vials.

Findings include:

During tour of the inpatient care unit not all staff were familiar with the policy & procedure for the dating of blood glucose control vials and were unsure if the date on the vial were the date to be discarded at "90 days" or at "6 months".

Review of the facility policy and procedure entitled " Title: Point of Care Glucose Meter Effective Date: 5/2014... V. MANUFACTURER'S RECOMMENDATIONS: Controls Solutions: To Expire no more than 90 dates after opening solutions. Solutions are to be labeled each time a new solutions is opened..."

Interview with Staff A (RN-MSN) and Staff B (RN Assistant Manager/Outpatient Supervisor) confirmed the above findings.

Based on tour and observation of medical surgical unit and the emergency department, it was determined that the hospital failed to meet rules for the storage and handling of drugs and biological's.

Findings include:

During tour of the medical surgical unit with Staff A (RN-MS) and Staff B (RN Assistant Nurse Manager) on 2/24/15 at approximately 10:30 a.m. revealed a mobile cart stored in the hallway by a patient's room away from the nurse's desk. This mobile cart had individual drawers that contained various needles and syringes within them. The drawers where labeled as to the type of needles and syringes. The top drawer was the only drawer that was locked, the individual drawers were unlocked allowing access by unauthorized individuals.

At the time of this tour Staff A and Staff B confirmed that the cart, containing multiple needles and syringes, are stored in this area of the hallway away from the nurse's desk.


18010

Observation during the initial tour of the Emergency Department on 2/24/15 with Staff D (Registered Nurse) showed two mobile carts located in the patient care hallway outside of ER #6 and #7 with unlocked drawers containing multiple various individual needles and syringes. These mobile carts also had multiple needles, syringes and individually wrapped pre-filled syringes stored on top of each cart that were not secure and could be accessed by unauthorized individuals.

Staff D verbally confirmed at the time of this observation that the Critical Access Hospital failed to secure and lock these needle, syringes and pre-filled syringes in the Emergency Room from access by unauthorized individuals.

Based on record review, interview and review of the Critical Access Hospital (CAH) "Pain Assessment" policy and procedure it was determined that the CAH failed to ensure that the patient's medical record was complete and accurate for 5 of 10 emergency room patient's in a survey sample of 20 patients. (Patient identifier's are #2, #4, #5, #6 and #8.)

Findings include:

Review of the Critical Access Hospital (CAH) policy and procedure titled "Pain Assessment" dated "July 2002" revealed the following:

"I. PURPOSE
To provide a consistent method for conducting a systematic assessment of pain or discomfort and an objective method for quantifying pain or discomfort by utilizing a standardized pain scale.

II. POLICY
A. All patient's receiving care at .... (CAH) will have a pain assessment completed on admission, every shift and following each intervention utilized to relieve pain/discomfort...

D. Baseline pain assessment documentation will include location, intensity (present, worst, best and acceptable levels of pain), onset, duration, a qualitative description of the pain, aggravating and relieving factors and how the pain affects daily function...

III. PROCEDURES
A. On admission or first encounter with the patient a baseline rating on the pain scale will be assessed and documented

B. Assessments will be documented in the patient's medical record in accordance with the Documentation Policy and the Assessment Policy.
1. Pain as rated by the Pain Assessment Scale Bookmark
2. Measure utilized to relieve or alleviate pain
3. Response to measures
a. Document response 15 minutes after administration of intravenous medications
b. Document response 30 minutes after administration of intramuscular medications
c. Document response 60 minutes after administration of oral medications
d. Non-pharmaceutical interventions utilized will have response documented in an appropriate time frame to be determined by the nurse based on nursing judgment and the measure utilized.
e. Initiate discussion related to ongoing pain management plan of care

C. Registered Nurses will
1. Reassess and document pain assessment every shift as needed."

Patient #2.
Record review on 2/24/15 of the Emergency Room clinical record for Patient #2 revealed that Patient #2 was admitted from home on 02/24/2014. No documented evidence could be found to show that a baseline "Pain Assessment" was completed at the time of this admission for Patient #2.

Patient #4.
Record review on 2/24/15 of the Emergency Room clinical record for Patient #4 revealed that Patient #4 was admitted on 2/23/2014 complaining of "chest heaviness". Further review of this record revealed Patient #4 was administered Nitroglycerin at 18:05 with no documented evidence of a pain assessment completed before or after this medication was given. Patient #4 was also given Morphine 2 mg IV at 21:05 with no documented evidence of a pain assessment done before or after receiving this Morphine for pain.

Patient #5.
Record review on 2/24/15 of the Emergency Room clinical record for Patient #5 revealed that Patient #5 was admitted on 2/19/15 complaining of right shoulder pain with dislocation. Further record review revealed no documented evidence of a pain assessment for Patient #5 at the time of this admission. Patient #5 was administered two doses of Dilaudid 1 mg IV at different times with no documented evidence of a pain assessment done before or after this medication was administered to Patient #5.

Patient #6.
Record review on 2/25/15 of the Emergency Room clinical record for Patient #6 revealed that Patient #6 was admitted on 2/15/14 with right shoulder injury and numbness from top of shoulder to hand into fingers. Review of a Emergency Room "Pain Assessment" at this time revealed that Patient #6 rated right shoulder/humerus pain as throbbing with a pain rating of 10/10. Review of the transporting ambulance Paramedic Intercept Services "Summary of Events" revealed the following; 'IV (intravenous) Morphine titrated to the Pt (patient) pain in 4 mg doses - w/pain to the right shoulder decreasing from a 10/10 to 1/10, nausea feeling treated w/4 mg Zofran slow IV push w/ [=] result."

Review of the Emergency Room "IV/Medication Infusion Record" by the ER staff revealed that Patient #6 was given 2 individual doses of Dilaudid 1 mg and 3 individual doses of Propofol with different milligrams (mg) and no documented evidence for the monitoring of the effectiveness of these individual medications administered to Patient #6 during this Emergency Room admission.

Patient # 8.
Record review on 2/25/15 of the Emergency Room clinical record for Patient #8 revealed that Patient #8 was admitted on 12/01/14 with complaints of right shoulder dislocation. Review of the Emergency Room "Pain Assessment" at this time revealed that Patient #8 rated the right shoulder pain as a 10/10 , there was no other documentation on this Pain Assessment completed in the sections for "Character, Distribution, Radiation or Duration."

Review of the Emergency Room "IV/Medication Infusion Record" by the ER staff revealed that Patient #8 was given individual doses of Fentanyl, Ketamine and Morphine. Further review of this record revealed no documented evidence for the monitoring of the effectiveness of these individual medications administered to Patient #8 during this Emergency Room admission.

Based on observation and interview the facility failed to protect Health Care records from unauthorized access.
Findings include:

During tour of the Medical Records storage area in the basement it, was noted that there were numerous boxes of medical records that had accumulated outside the secure caged area that were accessible to anyone with basement access. There are a variety of individuals/departments that have access to these medical records, including but not limited to Hospital dministration, housekeeping, Facilities and IT (Information Technology).
Interview with Staff G, (Medical Records Director) on 2/26/15 at approximately 10:30 a.m. confirmed the boxes that were outside the secure caged area andwere in fact medical records that would not fit within the confines of the secure caged area.