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Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure community education regarding advance directives had been completed. This had the potential to affect all current and future patients of the CAH.

Findings include:

The director of nursing (DON) provided all information regarding how the CAH informs it's patients on making advanced directives which included a pamphlet provided on admission that described Advanced Care Planning. The pamphlet dated 11/16/00, offered that a one to one appointment could be made with a trained facilitator to assist with making advanced directives.

The DON was interviewed on 8/30/17, at 9:45 a.m. during which she stated that any member of the community could schedule a one to one appointment to be assisted with making advanced directives; however, community education had not been provided to explain what advanced directives were and how they could be formulated with the assistance of the CAH.

The facility policy for Resuscitation Status dated as reviewed on 8/22/17, had not included ensuring community education regarding advance directives to be completed.

Based on observation and interview, the critical access hospital (CAH) failed to perform preventive maintenance for 2 therapy exercise equipment. This had the potential to effect all patients who utilized those pieces of equipment.

Findings included:

During a tour of the rehabilitation department with exercise physiologist (EP)-A on 8/29/17, at 1:00 p.m. two cable weight exercise machines lacked preventative maintenance (PM) stickers. EP-A verified the absence of the PM stickers, and stated to her knowledge, the CAH's maintenance department was performing the preventative maintenance.

On 8/29/17, at 2:00 p.m. rehabilitation manager (RM) stated she believed the CAH's maintenance department was performing the routine preventative maintenance.

On 8/30/17, at 2:30 p.m. the CAH's maintenance engineer (ME) stated the two cable weight exercise machines were not on the inventory list, and had the maintenance department had not completed preventative maintenance on the equipment.

The facility was unable to provide a policy on preventative maintenance.

Based on the Life Safety Code (LSC) survey. A Medicare-participating Critical Access Hospital (CAH), including all component parts or facilities of the CAH, must comply with the applicable LSC requirements.

Please refer to the life safety code deficiencies cited at: K0291, K0321, K0341, K0901, K0914, K0923

Based on interview and document review, the critical access hospital (CAH) failed to ensure policies and procedures in the emergency department and laboratory were reviewed annually.

Findings include:

During review of laboratory policies and procedures, it was revealed the CAH's policy Release of Blood in Emergency Situations was dated 2/28/11, and had not been reviewed annually. On 8/31/17, at 10:00 a.m. the laboratory manager (LM) verified all laboratory policies were not currently up to date with the annual review. LM stated she was working towards reviewing all of the policies.

During review of the emergency department (ED) policies and procedures, it was revealed the CAH's policy Chest Pain or Myocardial Infarction-Standard of Care was dated 1/29/14, and had not been reviewed annually. On 8/30/17, at 1:00 p.m. the emergency department manager (EDM) verified not all policies were currently up to date with the annual review. EDM stated she was working towards reviewing all of policies.

The CAH's Policy and Procedure Management Policy dated 8/9/17, directed policies will be reviewed by the responsible person, for accuracy and continued appropriateness annually.

Based on interview and document review, the critical access hospital (CAH) failed to ensure 11 of 12 registered nurses (RN-A, RN-B, RN-C, RN-D, RN-E, RN-F, RN-G, RN-H, RN-I, RN-J, and RN-K) who compounded intravenous (IV) medication, had documentation they had been trained and deemed to be competent to compound sterile preparations.

Findings include:

On 8/29/17, at 11:01 a.m. RN-L (nurse manager) confirmed all charge nurses compounded medications in the pharmacy during the times a pharmacist was not available.

On 8/29/17, at 2:19 p.m. the pharmacy director (PD) stated all RN charge nurses compounded medications in the pharmacy, under the laminar hood, after hours and on weekends. The PD stated that all charge nurses had initially been trained on compounding. The PD stated the charge nurses had not been evaluated annually to assure continued competency with compounding and they should be evaluated annually to assure they remain competent with the IV compounding procedure. The certified pharmacy technician (CPT) confirmed they had not kept very good records of when the charge nurses had been initially competency tested for compounding. The CPT stated she had just posted a list of the charge nurses names in the pharmacy, and when they came in to be tested she would just cross their names off.

8/30/17, at 1:40 p.m. RN-L and the director of patient care services provided the list of RN charge nurses and confirmed the CAH lacked documentation that all of the RN charge nurses had been initially trained on compounding medications, and that annual competency testing had not been completed. RN-L provided a list of the charge nurses and any educational records they had regarding competency for compounding.

Review of these records indicated:
-The following charge nurses lacked documentation for initial Sterile IV Product Preparation Competency Assessments: RN-A, RN-B, RN-C, RN-D, RN-G, RN-H, and RN-J.
- The following charge nurses lacked documentation of annual Sterile IV Product Preparation Competency Assessments: RN-A, RN-B, RN-C, RN-D, RN-E, RN-F, RN-G, RN- H, RN-I, RN-J, and RN-K

Safe Admixture of Parenterals Sterile Compounding Preparation policy dated 3/28/17, directed initially pharmacy compounding personnel should review a video on sterile compounding, pass a written test, be observed by a pharmacist and pass the Sterile IV Product Preparation Competency Assessment, pass the gloved fingertip sampling and media-fill testing of aseptic manipulative skills initially, and annually thereafter.

Based on observation, interview, and document review, the critical access hospital (CAH) failed to implement protocols for appropriate cleaning/disinfection of the surgical environment to minimize risk of infection. This had the potential to affect any surgical patients. In addition, the CAH failed to develop and implement a program to reduce the risk of a Legionella (a bacterium) in the facility water system to prevent cases and outbreaks of Legionnaires' disease (a serious type of pneumonia). This had the potential to affect all patients, visitors, and staff.

Findings include:

A tour of the surgical services area was completed on 8/29/17, at 9:30 a.m. during which registered nurse (RN)-N established the hospital performed surgeries and diagnostic colonoscopys. During interview with RN-N, regarding the cleaning and disinfection of the surgical suites and procedure rooms where colonoscopy's were performed between patients, she identified the product the facility used was Virex II 256 and did not identify any further products used for disinfection of the floor of the procedure rooms or surgical suites. RN-N stated she was unaware whether the Virex II 256 was effective against Clostridium Difficile (C-Diff: a contagious bacterial organism that is prevalent in the gastrointestinal track).

When reviewed, the diversy care products data sheet of the Virex II 256 (provided by RN-N) lacked indication of effectiveness against Clostridium Difficile.

A policy and procedure for disinfection of the surgical suites and procedure room was requested but not provided.



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During interview on 8/31/17, at 9:00 a.m. the environmental service director (ED) was asked if the facility had completed a risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. ED confirmed the facility had not completed a risk assessment which identified Legionella and other opportunistic waterborne pathogens and the CAH was in the process. ED indicated the program, policies, and procedures would be developed based on the Centers for Disease Control's tool kit.

Based on interview and document review, the critical access hospital (CAH) failed to ensure a comprehensive list of services furnished under agreement or arrangement had been maintained. This had the potential to affect all patients who received services at the CAH.

Findings include:

On 8/29/17, at 11:00 a.m. the administrator and the Director of Quality and Health Information Services (DQHIS) provided the CAH's current list of services provided through agreements or arrangements, in the form of a 8/26/17 policy titled "Contracted Services." The policy identified 6 company names and the services they provided.

On 8/31/17, at approximately 10:00 a.m. the DQHIS confirmed the policy was not an inclusive list. The DQHIS verified some of the agreements or contracts services missing from the list were: Wilderness (telemedicine), St. Luke's Hospital (after-hour pharmacy), Wapiti (emergency room physician coverage), a dentist, a traveling surgical technician, and a biomedical company. In addition, the CAH's contracted services list lacked information regarding whether the services were offered on or off site, whether there was any limit on the volume or frequency of the services provided; and when the services were available.

The facility was unable to provide a policy on agreements.

Based on interview and document review, the critical access hospital (CAH) failed to ensure notification to the organ procurement organization (OPO) in a timely manner for 1 of 3 emergency department (ED) patients (P21) who died at the facility.

Findings include:

P21 was admitted to the CAH ED on 10/15/16 at 12:44 p.m., for cardiopulmonary resuscitation (CPR) and died on 10/15/16, at 2:03 p.m.
In P21's undated Critical Care flowsheet indicated P21 died on 10/15/16, at 2:03 p.m. The Patient Record entry at 4:53 p.m. indicated the organ procurement organization had been called, but did not indicate a time.

On 8/29/17, at 2:35 p.m. the director of patient care services (PCS) confirmed there was no time listed in P21's medical record as to the time the OPO was called; it only indicated "yes." The PCS confirmed the facility did not know when the OPO was called, and she needed to contact the OPO to determine when they received the referral.

On 8/31/17, at approximately 10:30 a.m. the PCS provided a Referrals by Hospital Report from the OPO. On the referrals by hospital report, the OPO was notified of P21's death at 6:09 p.m. 4 hours and five minutes after the time of death.

The PCS confirmed the CAH's expectation for notification of a patient's death to the OPO was within one hour.