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A. Based on observation, a review of Critical Access Hospital (CAH) policy, and staff interview, it was determined the CAH failed to ensure outdated drugs and/or biologicals were not available for use in the patient care areas which has the potential to effect all patients who receive services at the CAH .

Findings include:

1. During a tour of the CAH, conducted 11/29/11 thru 11/30/11, the following outdated biologicals and/or undated open vials of drugs were observed available for use in the patient care areas. In the Physical Therapy department: in the medication cabinet: 1 open undated 10 ml vial of Marcaine 0.5% and 1 open undated 5 ml vial of Betamethasone; in the treatment area: 1 thirty ml Germ X expired 9/11; under the main sink: 5 sixteen ounce bottles of 70% Isopropyl Alcohol all expired 12/10. In the Cardiac Rehabilitation area, 4 four ounce Hand Sanitizers with Aloe expired 9/11 and one 12 ounce Germ X expired 9/10. In the Cardiopulmonary Crash Cart: 1 Blue Line Tracheal Tube 6.0 mm expired 12/97; 2 Laryngeal Mask Airways (1 size 4 expired 2/09 and 1 size 5 expired 1/09); 2 Intravenous start kits (1 expired 2/08 and 1 expired 4/10); 6 BD Saf-T-Intima catheters (2 expired 2/10, 3 expired 5/10, and 1 expired 6/10); 11 BD Angiocaths (3 expired 5/08, 2 expired 6/08, 3 expired 8/08, and 3 expired 3/09). In the Obstetrical Unit blanket/fluid warmer, 2 liters of Sterile Water expired 11/7/11.

2. The CAH policy titled "Expiration Dates" was reviewed on 11/30/11. It indicated "Inventory supplies with expiration dates are monitored as they are issued. Certain categories of supplies will be checked at nursing units monthly." It was verbalized by the Director of Quality that all multi-dose vials are to be dated when opened and discarded after 28 days.

3. During a staff interview, conducted with the Director of Quality on 11/30/11 at 1:00 PM, the above findings were confirmed.

A. Based on observation and staff interview, it was determined the CAH failed to ensure patient care areas were maintained in a fashion to prevent the potential for cross contamination which has the potential to effect all patients who receive services at the CAH.

Findings include:

1. During a tour of the CAH, conducted on 11/29/11 thru 11/30/11, the following were observed: In the PT department under the main sink: one open container of paper towels. In the dietary department, 4 cases of assorted sodas were observed on the floor in the dry storage area. In the Radiology Nuclear Medicine room, one cushion that could be used for positioning of patients was observed under the sink.
In Cardiac Rehabilitation area, 6 dirty drinking cups under the sink. In the Emergency Room patient refrigerator on 11/30/11, three 236 ml boxes of milk expired 11/29/11.

2. During a staff interview, conducted with the Director of Quality on 11/30/11 at 3:00 PM, the above findings were confirmed.

A. Based on medical record review and staff interview, it was determined in 4 of 20 (Pts #1, #3, #7, #9)
medical records reviewed, the CAH failed to ensure care was provided as per physician orders.

Findings include:

1. The medical record of Pt #1 was reviewed on 12/1/11. Pt #1 was admitted to the CAH on 11/28/11 with the diagnosis Antepartum Check and was admitted to the Labor and Delivery Unit. The "Vaginal Delivery Admission" orders indicated "Diagnostic Tests: Fetal Vibroacoustic Stimulation Test... Oxytocin/ Pitocin Administration: 500 ml of Lactated Ringers with 30 units of Pitocin to infuse..." There was no documentation to indicate that the Fetal Vibroacoustic Stimulation Test was completed. Nursing and Pharmacy documentation indicated 500 ml of Normal Saline instead of Lactated Ringers with 30 units of Pitocin was administered. Nursing documentation indicated that Pt #1's intravenous site was discontinued at 1:14 AM on 11/29/11. There was no physician order to discontinue the IV.

2. The medical record of Pt #3 was reviewed on 12/1/11. Pt #3 was admitted to the CAH on 11/25/11 with the diagnoses Bilateral Pulmonary Emboli and Atrial Fibrillation. On 11/25/11, there was a physician order for Vital Signs with Pulse Oximeter every 4 hours, which would equal 6 sets per day. Nursing documentation indicated the initial vital signs with pulse oximeter as 4:15 PM on 11/25/11. There was no documentation to indicate that Pt #3's vital signs with pulse oximeter were monitored every 4 hours as ordered. Nursing documentation indicated 1 set of vital signs with pulse oximeter on 11/25/11; 4 sets on 11/26/11 and 11/27/11; 3 sets on 11/28/11; and 2 sets on 11/29/11 thru 12/1/11.

3. The medical record of Pt #7 was reviewed on 12/1/11. Pt #7 was admitted to the CAH on 11/29/11 with the diagnosis Active Labor 39 3/7 weeks and had intact membranes. The "Vaginal Delivery Admission" orders indicated "Laboratory: Urine Dipstick unless Rupture of Membranes... Diagnostic Tests: Fetal Vibroacoustic Stimulation Test... Oxytocin/ Pitocin Administration: 500 ml of Lactated Ringers with 30 units of Pitocin to infuse..." Pt #7 Nursing documentation indicated Pt #7's membranes were intact.
There was no documentation to indicate that the Urine Dipstick or Fetal Vibroacoustic Stimulation Test were completed. Nursing and Pharmacy documentation indicated 500 ml of Normal Saline instead of Lactated Ringers with 30 units of Pitocin was administered. A Urinalysis was performed. There was no order for the Urinalysis. Nursing documentation indicated that Pt #7's intravenous site was discontinued at 7:00 PM on 11/30/11. There was no physician order to discontinue the IV.

4. The medical record of Pt #9 was reviewed on 12/1/11. Pt #9 was admitted to the CAH on 11/30/11 with the diagnosis Active Labor 39 weeks and intact membranes. The "Vaginal Delivery Admission" orders indicated "Laboratory: Urine Dipstick unless Rupture of Membranes. Urinalysis if more than trace of protein on urine dipstick... Diagnostic Tests: Fetal Vibroacoustic Stimulation Test... Oxytocin/ Pitocin Administration: 500 ml of Lactated Ringers with 30 units of Pitocin to infuse..." Pt #9's nursing documentation indicated Pt #9's membranes were intact. There was no documentation to indicate that the Urine Dipstick or Fetal Vibroacoustic Stimulation Test were completed. A Urinalysis was performed, in which was not ordered to be done unless trace of protein on urine dipstick. Nursing and Pharmacy documentation indicated 500 ml of Normal Saline instead of Lactated Ringers with 30 units of Pitocin was administered. Nursing documentation indicated that Pt #9's intravenous site was discontinued at 2:03 AM on 12/1/11. There was no physician order to discontinue the IV.

5. During a staff interview, conducted with the Director of Quality on 12/1/11 at 3:00 PM, the above findings were confirmed.

A. Based on a review of the CAH's Bylaws, Rules/Regulations, a review of the medical records list of overdue medical records, and staff interview, it was determined that the CAH failed to ensure all physicians completed their records within 30 days for 13 medical records as of 11/30/11.

Findings include:

1. The CAH's Bylaws, Rules/Regulations were reviewed. They indicated under "III. Medical Records A. Entries 4. The patient's medical record should be complete at the time of discharge...If the records shall remain incomplete after 23 days, a notice shall be mailed to each physician stating that he has 7 days to complete his record or he shall have admitting privileges suspended until the records are complete...."

2. The document titled, "ChartFact Medical Record Delinquency Report" was reviewed. It indicated that there were 13 records that exceeded the 23/7 day time limit for completion as of 11/30/11.

3. During an interview with the Director of Quality Services, conducted on 12/2/11 at 8:15 AM, the above findings were confirmed..

Based on medical record review and staff interview, it was determined in 1 of 3 (Pt #1) medical records reviewed, in which the patient received Epidural Anesthesia services, the CAH failed to ensure a post anesthesia evaluation was conducted prior to discharge to evaluate for proper anesthesia recovery.

Findings include:

1. The medical record of Pt #1 was reviewed on 12/1/11. Pt #1 was admitted to the CAH on 11/28/11 with the diagnosis Antepartum Check, was admitted to the Labor and Delivery Unit, received an Epidural on 11/29/11 at 6:30 AM, delivered a viable infant, and was discharged on 12/1/11. There was no documentation to indicate a post anesthesia assessment was completed.

2. During a staff interview, conducted with the Director of Quality on 12/1/11 at 2:30 PM, the above finding was confirmed.

A. Based on a review of CAH policy, a review of CAH annual program evaluation, and staff interview, it was determined the CAH failed to ensure its annual program evaluation (inclusive of the Professional Practice Committee and the Quality Committee meeting minutes) included a review of at least 10% of both active and closed patient records of both inpatient and outpatient records.

Findings include:

1. The CAH policy titled "Critical Access Hospital Annual Evaluation" was reviewed on 11/29/11. It indicated "A. Annual Evaluation Includes: 2. Audit of active and closed medical records for compliance and quality of the record."

2. The CAH annual program evaluation for 2009 thru 2010 were reviewed. There was no documentation to indicate that 10% of both active and closed patient records of both inpatient and outpatient records were reviewed. It indicated that only closed records of patients who had expired were reviewed.

3. During a staff interview, conducted on 11/29/11 at 3:00 PM, it was verbalized by the Director of Quality that the annual program evaluation included both the minutes of the Professional Practice Committee and the Quality Care Committee. It was further verbalized that inpatient records were reviewed daily; however, there was no documentation to indicate this and no documentation in either of the sets of minutes to indicate that these results were discussed.

4. During a staff interview, conducted with the Director of Quality on 11/29/11 at 3:00 PM, the above findings were confirmed.