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Based on interview and record review, the critical access hospital (CAH) failed to ensure patients right to privacy was respected during triage in the emergency room for all patients that utilized the CAH's emergency room services.

The findings include:

Minnesota statute 144.651 HEALTH CARE BILL OF RIGHTS identified the following: "Treatment Privacy- Patients shall have the right to respectfulness and privacy as it relates to their medical and personal care program. Case discussion, consultation, examination and treatment are confidential and shall be conducted discreetly. Privacy shall be respected during toileting, bathing and other activities of personal hygiene, except as needed for patient safety or assistance."

On 5/12/14, at 3:00 p.m. a tour of the emergency room was conducted. The emergency room was observed to have four bays separated by a curtain or door. A private area to triage emergency room patients was not observed. At this time, registered nurse (RN)-C stated the emergency room patients were triaged in the middle of the emergency room and then placed in the most appropriate room depending on the chief complaint of the patient. RN-C confirmed that by triaging patients in the middle of the emergency room, current emergency room patients and their visitors could see and hear other patients chief complaints and medical history.

On 5/15/14, at 12:14 p.m. the CAH's chief nursing officer confirmed the CAH's emergency room department did not have a private area to triage patients.

A policy related triaging patients in the emergency room titled "Triage" dated 12/87, and revised 8/09, was reviewed but did not include privacy as part of the policy.

Based on observation, interview and document review the critical access hospital (CAH) failed to monitor temperatures for the hydrocollator heating unit (hot moist packs) and the Therabath (paraffin wax bath). This had the potential to effect all inpatients and outpatients receiving physical therapy and occupational therapy who received treatment with the equipment.

Findings include:

On 5/13/15, at 8:00 a.m. the physical therapy (PT) and occupation therapy (OT) departments were toured. One hydrocollator lacked evidence of temperature monitoring.

The physical therapy manager (PT)-A was interviewed on 5/13/15, at 8:00 a.m. and stated they were not checking or recording any temperatures of the hydrocollator and acknowledged this should be done as preventive measure so the patients who required this hot pack treatment would not experience burns.

In review of the policy, Hydrocollator Packs, undated, specified " the water should be between 150 and 175 degrees Fahrenheit, normally kept at 165 degrees." "use caution: the packs are hot and heavy and the patient can be easily burned."

The OT department on 5/15/13, at 9:30 a.m. stated the paraffin wax bath was used for hand treatments. OT-A stated the temperature was determined by inserting her finger in the wax before starting treatment. OT-A did acknowledge the wax should have an actual temperature taken to ensure the temperature of the wax was between 126-130 degrees Fahrenheit per manufacturer guidelines. OT-A further stated that testing the temperature with her finger may not be accurate as people have different sensations to levels to heat.

In review of the policy, Paraffin Bath (undated) indicated the bath should be cleaned regularly and the temperature of the wax the mixture should be checked with a dairy or candy thermometer to ensure it is not over 130 degrees Fahrenheit.

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure the security of 2 of 3 crash carts which were located in the emergency department.

Findings include:

During a tour of the emergency department (ED) on 5/12/14, at 3:00 p.m. a crash cart and a pediatric emergency cart containing a variety of emergency medications were stored in the middle of the ED and one of the adult crash carts was pushed into an occupied patient ED room. The cart was not locked but secured with a numbered pull-away tab. There was no documentation to identify the cart had been monitored for the security of the medications. Interview with registered nurse (RN)-C during this time, confirmed staff were not always present in the ED, the crash carts were not locked and hospital staff, visitors and patients could access the medications in the emergency carts by just removing the pull away tabs.

The pharmacist was interviewed on 5/13/14, at 9:40 a.m. and confirmed 2 of 3 emergency room crash carts were not locked and not in an area that was under constant observation in the ED.

The pharmacy director provided an inventory list of the adult ED and pediatric crash carts [not an inclusive list]:
. Adenosine (used in the hospital to try to restore a normal heart rate)
. Albuterol nebs (opens bronchioles to ease breathing)
. Amiodarone (a drug used for many serious arrhythmia's of the heart )
. Aspirin 81 milligrams (mg) (a drug used to decrease platelet aggregation)
. Atropine (treats slow heart rate)
? Lidocaine (treats emergency irregular heart rate)

? Epinephrine (treats cardiac arrest)

? Naloxone (reversal agent for narcotics and treats shock)

? Amiodarone (treats life threatening heart rate)

? Adenosine (treats irregular heart rate)

? Nitroglycerine (treats chest pain)

? Metoprolol (treats high blood pressure)

? Diltiazem (treats high blood pressure & chest pain)

A total of 64 different medications were contained in each crash cart.

Review of the Bigfork Valley Hospital policy "Crash Cart Checks" dated as last revised 12/11, identified the following "Crash Carts will bed locked at all times when not in use."

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure hypodermic needles, intravenous supplies, suture kits and procedure equipment were stored in a safe manner in the emergency room on the medical/surgical unit and the procedure room in the surgical services area. This had the potential to affect all patients who utilized the emergency room and surgical services.
Findings include:
On 5/12/14, during initial tour of the medical/surgical unit from 2:25 p.m. until 3:00 p.m. an an unlocked tackle box labeled "chemo tray" was observed on the counter top in the clean utility room which registered nurse (RN)-C confirmed was accessible to patients, staff and the public. The tackle box contained a variety of needles and syringes.
On 5/13/14, during initial tour of the surgical services area from 10:30 a.m. until 11:30 a.m. in procedure room 104, located in the pre and post-operative area, unlocked, labeled cupboards and drawers which contained suture kits, syringes and needles was observed. The assistant manager of the operating room confirmed patients and their visitors are often left unattended in this room.
On 5/15/14, at 7:10 a.m. the operating room manager and the assistant operating room manager acknowledged the needles, syringes, suture kits and other supplies in procedure room 104 were not secure and stated they should be locked up.






18617

On 5/12/14, during initial tour of the emergency department (ED) from 2:50 p.m. until 3:30 p.m. unlocked emergency supplies was observed in all four bays of the ED. The supplies included many different sizes and styles of hypodermic needles, suture kits, scissors, scalpels, casting supplies, chest tubes, pericardiocentesis tray and extraction equipment. Registered nurse (RN)-C confirmed the supplies were accessible to patients, staff and the public.
Review of the undated Bigfork Valley Hospital Emergency Services Plan policy revealed it did not address the security of these items.

The chief nursing officer was interviewed on 5/13/14, at 10:00 a.m. and confirmed that these items were accessible to patients, staff and the public.

Based on observation, interview and document review the critical access hospital (CAH) failed to ensure 11 of 11 air handling ventilation systems located in patient rooms were functioning properly. This has the potential to affect all current and future inpatients and observation patients in the CAH.

Findings include:

During the environmental tour with the manager of plant operations, on 5/12/14, at 2:00 p.m. the bathroom ventilation system was checked in two patient rooms. In both rooms it was identified the ventilation system was not functioning.

In an interview with the manager of plant operations on 5/12/14, at 3:15 p.m. he stated that upon investigation by the maintenance department it was determined that the exhaust motor which operated the bathroom ventilation system for all patient rooms, 201 through 211, was burnt out and needed to be replaced. He was unaware of this problem as the computer system which monitored the systems indicated it was working. He further explained the computer system only measured if electricity was going to the exhaust motor and not if the actual motor was working properly.

The preventive maintenance log for checking the ventilation function was being conducted three times each day but the data was based on the information produced by the computer system and not actually checking for the air exchange.

Based on observation, interview and document review, the critical access hospital (CAH) failed to utilize proper infection control procedures for 1 of 1 patient (P1) observed during an epidural procedure.
Findings include:
P1 was admitted to the CAH on 5/14/14, for a scheduled outpatient epidural steroid injection.
On 5/14/14, at 2:48 p.m. upon entrance of the procedure room, P1 was observed positioned on her left side and the radiologist medical doctor (MD)-A and radiology technician (RD)-A were also in the room. MD-A washed his hands, donned a pair of sterile gloves and cleansed P1's spinal area. MD-A positioned a sterile drape and performed the time out process. Without wearing a surgical mask, MD-A proceeded to insert a needle using fluoroscopy (x-ray imaging ) guidance into P1's spine and injected the medication into the epidural space (spine canal area).
On 5/15/14, at 7:05 a.m. the operating room manager and assistant operating room manager confirmed they do not routinely require the MD to wear a mask when performing epidural steroid injections. However, they both acknowledged the benefit of requiring a mask to be worn as during the procedure the MD is injecting into the epidural space.
On 5/15/14, at 9:25 a.m. the chief nursing officer (CNO)/ infection control officer confirmed the MD should have worn a mask when performing the epidural steroid injection.
The CAH's Infection Control Practices: Standard/Transmission Based Precautions [undated] directed staff to wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space.

Based on interview and document review, the critical access hospital (CAH) failed to ensure the governing body received reports evaluating provisions of care for services provided by arrangement or agreement including: echo cardiogram, ambulance and anesthesia. Additionally, ambulance services were not currently under agreement or arrangement due to expiration of the contract. This had the potential to affect all current and future patients of the CAH.
Findings include:
On 5/13/14, at 3:15 p.m. the chief nursing officer (CNO) acknowledged anesthesia services did not have a current quality improvement project which was integrated into the CAH's quality improvement program.
On 5/15/14, at 10:45 a.m. the CNO acknowledged ambulance services did not have a current quality improvement project which was integrated into the CAH's quality improvement program.




18617

AMBULANCE

The chief nursing officer (CNO) was interviewed on 5/15/14, at 8:40 a.m. and stated the CAH ambulance services was a volunteer service provided through agreement to the CAH.

The agreement between the CAH and the Big Fork Ambulance Service Association was reviewed and under bullet point 4. the following was identified: "The term of this contract shall be one year commencing at 12:01 a.m., April 1, 2001. The term of this agreement shall be reviewed on an annual basis. A written thirty (30) day notice submitted by wither party can terminate this agreement.

Further interview with the CNO on 5/15/14, at 8:40 a.m. revealed the agreement had not been annually reviewed and updated since it's inception on April 1, 2001.

Based on interview and document review the critical access hospital (CAH) failed to ensure quality assurance/performance improvement projects were developed and integrated into the critical access hospital's (CAH) quality improvement program for the following services: dietary, cardiac rehab, physical plant, rehabilitation services, health information systems (clinical records department) and surgical services. This had the potential to affect all current and future patients of the CAH.
Findings include:
On 5/14/14, at 1:45 p.m. the assistant operating room manager acknowledged she was unaware of a current quality improvement project being done in the surgical services area besides the monitoring of surgical site infection rates. Also, on 5/15/14, the operating room manager was unable to provide evidence of a current surgical services quality improvement project.
On 5/15/14, at 10:45 a.m. the chief nursing officer (CNO) acknowledged she was unaware of a quality improvement project in place for cardiac rehab and health information systems.


15508

During interview with the registered dietician (RD) and the certified dietary manager (CDM) on 5/14/14, at 10:30 a.m. they acknowledged the Dietary department did not have a quality assurance/ performance improvement program in place at this time.

During interview with the plant manager on 5/12/2014, at 2:00 p.m. he acknowledged that aside from maintaining a variety of logs which ensured physical plant systems were operating effectively, there was not a formal quality program being conducted in this department.

In an interview with the physical therapist (PT)-A on 5/13/14, at 8:30 a.m. he stated the only QA program they were conducting at time of survey was to record if all medications and other dangerous chemicals were not accessible to patients. The only measured taken was a check to determine if the medication cabinet was locked. There was not any specific goals to attain, data analysis, any evaluation of corrective actions or measures to improve on a continuous basis.

Based on interview, and record review the critical access hospital (CAH) failed to ensure they had an arrangement with an outside entity to review the quality and appropriateness of diagnosis and treatment furnished by the CAH physicians. This had the potential to affect all current and future patients of the CAH.

The findings include:

On 5/15/14, at 8:50 a.m. chief nursing officer (CNO) verified the CAH did not have an arrangement with an outside entity to provide peer review for the quality and appropriateness of diagnosis and treatment furnished by all CAH physician's.

Review of the PEER REVIEW PROCESS policy dated November 2006, indicated the following: "If the case is rated a level 3 or 4, the case will be considered an outlier that would require external review. The case will be referred to an external peer review organization under contractual agreement with Bigfork Valley Hospital."

Review of the external peer review contracts revealed that the CAH did have a peer review process in place for the radiology and anesthesia physicians, but did not have an external peer review contract for all of the other physician's on staff including consulting physicians.

Review of the Professional Review Service Agreement dated 7/1/12, revealed the CAH entered into an agreement with a private contractor to provide professional peer review services for the CAH's Medical Executive Committee for the purpose of quality assurance, however, the contract ended on 6/30/13, and was no longer current.

On 5/15/14, at 8:50 a.m. the CNO verified she was in the process of finding a new contractor or organization to perform peer review for the CAH physicians including consulting medical staff physicians with surgical privileges.

Based on interview, and record review the critical access hospital (CAH) failed to ensure that the written policy for organ procurement organization (OPO) included a definition of "imminent death" and "timely notification." This had the potential to affect all current and future patients of the CAH.

Findings include:

The policy for tissue and eye donation dated 8/20/98, and last revised on 8/09, was reviewed and it was noted that the policy identified cardiac death, but had not defined "imminent death" and "timely notification" as it related to organ procurement.

The chief nursing officer was interviewed on 5/14/14, at 1:25 p.m. and confirmed the critical access hospital policy for OPO did not include the definition of "imminent death" and "timely notification."