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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on April 18, 2012, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

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Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on April 18, 2012, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated April 18, 2012.

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A. Based on a review of Medical Staff Bylaws/ Rules and Regulations, a review of physician credential files, and staff interview, it was determined in 6 of 6 (P-1, P-2, P-3, P-5, P-6, P-7) physician and 1 of 1 Physician Assistant (PA-C #1) credential files reviewed, in which the physicians and/or PA-C provided Emergency Room (ER) coverage and/or had the potential to perform Intravenous (IV) conscious sedation, the Critical Access Hospital (CAH) failed to ensure Medical Staff who provided ER coverage and/or had the potential to perform IV conscious sedation were privileged to do so.

Findings include:

1. The Medical Staff Bylaws/ Rules and Regulations were reviewed on 3/20/12. It indicated "5.1. A. (2) The surgeon may provide conscious sedation for minor cases if appropriately credentialed. An appropriately credentialed member of the Medical Staff may provide conscious sedation in the ...(3) All ED providers, if appropriately credentialed, may provide conscious sedation or rapid induction to manage emergent cases outside the operating suite. All practitioners who provide conscious sedation or intubation shall provide documentation or proficiency at least every two years as part of the credentialing process..."

2. On 3/20/12, 6 of 6 (P-1, P-2, P-3, P-5, P-6, P-7) physician credential files, in which the physicians provided ER coverage and/or had the potential to perform IV conscious sedation, were reviewed. There was no documentation to indicate the physicians had applied for and/or were approved by the Medical Staff and/or the Governing Body to provide these services.

3. The credential file of PA-C #1 was reviewed on 3/20/12. PA-C #1 provided ER coverage and/or had the potential to perform IV conscious sedation. There was no documentation to indicate PA-C #1 had applied for and/or was approved by the Medical Staff and/or the Governing Body to provide these services.

4. During a staff interview, conducted with the Chief Executive Officer (CEO) and the Director of Quality, Safety, and Regulatory on 3/21/12 at 11:00 AM, the above findings were confirmed.

A. Based on a review of PA-C credential file, a review of CAH policy manual, a review of CAH annual Advisory Committee minutes, a review of CAH ER meeting minutes, and staff interview, it was determined in 1 of 1 (PA-C #1) midlevel credential file reviewed, the CAH failed to ensure its' PA-C participated in the development, execution, and periodic review of the written policies governing the services the CAH furnishes.

Findings include:

1. The credential file of PA-C #1 was reviewed on 3/20/12. It indicated PA-C #1 was initially hired by the CAH to provide services in the ER department on 11/94. There was no documentation to indicate PA-C #1 had participated in the development, execution, and periodic review of the written policies governing the services the CAH furnishes.

2. The CAH policy manual, the CAH annual Advisory Committee meeting minutes, and the ER meeting minutes for 2009 thru 2011 were reviewed 3/21/12. There was no documentation to indicate PA-C #1 had reviewed initially or annually the policy manual. There was no documentation to indicate PA-C #1 participated in the annual Advisory Committee meetings. The ER meeting minutes did not indicate any review of its' policies and procedures.

3. During a staff interview, conducted with the CEO on 3/21/12 at 2:30 PM, the above findings were confirmed.

A. Based on observation, a review of CAH policy, and staff interview, it was determined the CAH failed to ensure outdated drugs and/or biologicals were not available for patient use this has the potential to effect all patients serviced by the CAH.

Findings include:

1. During a tour of the CAH, conducted 3/20/12 thru 3/21/12, the following outdated drugs and/or biologicals were observed available for patient use.
In the Physical Therapy department medication cabinet, one open 30 ml vial of Dexamethasone Sodium Phosphate 4 mg/ml failed to indicate when it was opened.
In Cardiac Rehab, one open 10 ml vial of Normal Saline was observed on the stress test cart with the date of opening listed as 1/4/12.
In Operating Room #1, the Anesthesia cart contained one 40 mg syringe of Amidate with the expiration date of 3/1/12 and an open 10 French Suction Catheter.
In the Anesthesia storage room, three 21 gauge Stimquik Peri Needles expired 6/2011, two 21 gauge Polymedic UPM Needles for Electric Stimulation Cutting Bevel 45 degrees expired 12/2009, six Size 3 I-Gel Supraglottic Airway expired 1/2010, and five Endotracheal (ET) tubes ranging size 2.5 thru 8.0 expired 3/2004 thru 6/2011.
On the Recovery Room crash cart, one #4 ET tube expired 3/2004 two #7.5 ET tubes expired 10/2002, and two #8 ET tubes expired 5/2002.
In the laboratory - the following green topped Vacutainers were expired: 1 in 1/2008, 1 in 7/2011, 3 in 10/2011, 3 in 1/2012, and 1 in 2/2012. All the Vacutainers were found in laboratory tech patient draw baskets.
On the medical floor the following items were found to be outdated; 1 pint Povidone Iodine 10% Solution expired 1/2012, 2 boxes Hollister stoma cap with filter (30 count each) both expired 1/2012 and 1 box Hollister vertical Drain/Tube Attachment Device (5 count) expired 2/2012.

2. The CAH policy titled "Disposal of Medications" (Review date 6/7/11) was reviewed on 3/20/12. It indicated "As medications are found that are expired or unusable they are segregated away from active drug storage." The policy did not address biologicals. It was verbalized by the Director of Nursing (DON) that open vials are to be dated as to when opened, labeled with a sticker that indicates when the 28th day is, and discarded 28 days after opened if not used.

3. During a staff interview, conducted with the CEO on 3/21/12 at 2:30 PM, the above findings were confirmed.

A. Based on observation and staff interview, it was determined the CAH failed to ensure no food items were stored in the laboratory refrigerators that could result in possible cross contamination, this has the potential to effect all patients who receive laboratory services within the CAH.

Findings include:

1. During a tour of the CAH's laboratory, conducted on 2/20/12 at 1:45 PM, it was observed in the freezer compartment of the refrigerator that stored the lab's agar petri dishes, 1 brown bag containing approximately 6 individual ice cream cups.

2. During an interview with the Laboratory Manager, conducted on 3/20/12 at 2:30 PM, it was verbalized that no food items should be in the agar petri dish refrigerator.

3. During a staff interview, conducted with the CEO on 3/22/12 at 2:30 PM, the above findings were confirmed.

A. Based on a review of medical records and staff interview, it was determined that in 2 of 20 (Pts #11, #15) medical records reviewed, the CAH failed to ensure the administration of the medications were in accordance with pharmacy recommendations.

Findings include:

1. The medical record of Pt #11 was reviewed on 3/22/12. It indicated Pt #11 was admitted on 3/3/12 with a diagnosis of Diabetes. The medical administration record (MAR) indicated Pt #11 was to receive Digoxin every morning. The MAR indicated, "APICAL PULSE REQUIRED PRIOR TO ADMINISTRATION". There was no documentation in the medical record that reflected an apical pulse was recorded when the medication was administered on 3/4, 3/5, or 3/6/2012.

2. The medical record of Pt #15 was reviewed on 3/22/12. It indicated Pt #15 was admitted on 2/3/12 with diagnoses of Osteomyelitis of Right Ischium with Methicillin Resistant Staph Aureus. The MAR indicated that Zinc Sulfate Cap was to "AVOID GIVING WITH CALCIUM". Documentation on the MAR indicated that on numerous occasions the Zinc Sulfate cap was administered at the same time as a multivitamin that contained calcium such as on 2/7/12 when both medications were administered at 8:54 AM and on 2/8/12 when both were administered at 7:32 AM.

3. During an interview with the DON, conducted on 3/22/12 at 2:15 PM, the above findings were confirmed.

B. Based on medical record review and staff interview, it was determined that in 2 of 3 (Pts #9, #10) medical records reviewed in which the patient was receiving insulin injections, the CAH failed to ensure there was documentation that correctly identified the administration of the insulin.

Findings include:

1. The medical record of Pt #9 was reviewed on 3/21/12. It indicated Pt #9 was admitted on 3/19/12 with diagnoses of Cellulitis Both Lower Legs, Sepsis, and Congestive Heart Failure. The "Diabetic Flow Sheet" printed 3/21/12 at 6:00 AM, indicated that on 3/20/12 at 10:45 PM, Pt #9 was administered 193 units of Lantus insulin. Also the sliding scale on the document indicated the following: " if the blood glucose (BG) was between 0 and 60, give no insulin. If the BG was between 71 and 100, give no insulin. There was no indication as to what to do if the BG value was 70." The sliding scale failed to include indications for results between 61 and 70.

2. The medical record of Pt #10 was reviewed on 3/21/12. It indicated Pt #10 was admitted on 3/18/12 with a diagnosis of Confusion. The MAR printed 3/21/12 at 10:14 AM indicated Pt # 10 was to receive 28 units of Lantus Insulin subcutaneous at bedtime. Documentation on the MAR indicated that on 2/20/12 Pt #10 received 28 units of Lantus insulin at 11:05 PM, 11:05 PM, and 11:06 PM. Also, on the "Diabetic Flow Sheet", printed on 3/21/12 at 6:00 AM, it was documented that on 3/19/12 Pt #10 was administered a "28 Vial". The same was repeated on 3/20/12 at 11:05 PM and 11:05 PM.

3. During an interview with the DON, conducted on 3/21/12 at 1:45 PM, the above findings were confirmed.

C. Based on medical record review and staff interview, it was determined that in 1 of 20 (Pt #13) medical records reviewed, the CAH failed to ensure all physician's orders were carried out.

Findings include:

1. The medical record of Pt #13 was reviewed on 3/22/12. It indicated Pt #13 was admitted on 2/29/12 with a diagnosis of Diabetes. A physician's order, dated 2/29/12 at 8:51 PM, was for the nurse to "Sotolol 80 mg by mouth twice a day: MEASURE QT WITH RHYTHM STRIPS. NOTIFY DR. OF ANY CHANGE IN ECG". There was no documentation to indicate Pt #13 was ever on a cardiac monitor and no documentation of any cardiac rhythm strips in the record.

2. During an interview with the DON, conducted on 3/22/12 at 2:15 PM, the above finding was confirmed.

A. Based on medical record review and staff interview, it was determined that in 1 of 20 (Pt #7) medical records reviewed, the CAH failed to ensure all entries in the records were accurate.

Findings include:

1. The medical record of Pt #7 was reviewed on 3/21/12. It indicated Pt #7 was admitted on 3/20/12 with a diagnosis of Atrial Fibrillation. There was a physician order for Pt #7 to receive "Lorazepam 0.5 mg IV times 1." The MAR printed 3/21/12 at 2:30 PM indicated nursing was to administer, "Lorazepam Tab 0.5 mg X1 (one time) IV." It was unable to be determined which medication, oral or IV, was actually given.

2. During an interview with the DON, conducted on 3/21/12 at 10:50 AM, the above finding was confirmed.

A. Based on a review of contractual service list, a review of CAH annual Advisory Committee meeting minutes, a review of Quality Assurance Performance Improvement (QAPI) meeting minutes, a review of Infection Control Program, and staff interview, it was determined the CAH failed to ensure care and services provided by contractural services were evaluated for quality and appropriateness of the services it provided to the CAH and its' patients this has the potential to effect all patients.

Findings include:

1. The contractual service list, the CAH annual Advisory Committee meeting minutes for 2009 thru 2011, and the QAPI meeting minutes for 2011 were reviewed on 3/21/12. There was no documentation to indicate the contractual services were evaluated for quality and appropriateness in relation to the aspect of service it provided to the CAH and its' patients.

2. An example: Laundry services were listed as a contractual service thru an outside vendor. There was no documentation to indicate the laundry service were evaluated to ensure infection control standards of care related to laundry services were followed. The infection control program was surveyed on 3/21/12 at 1:45 PM. During an interview with the Infection Control Nurse, conducted on 3/23/12 at 2:00 PM, it was verbalized that no one from the CAH had ever toured the laundry processing service to ensure acceptable standards of infection control were implemented to ensure the laundry was processed in such a way as to reduce the potential for cross contamination.

3. During a staff interview, conducted with the CEO on 3/22/12 at 2:30 PM, the above findings were confirmed.