HospitalInspections.org

Based on observation and staff interview the facility failed to ensure that 1 of 2 satellite clinics (Jasper Family Clinic) had a supply of commonly used life-saving drugs available for use.

Findings include: Staff were unable to locate the vial of epinephrine that had been identified as an essential medication, and part of the emergency kit, located at the satellite Jasper Family Clinic.

During a tour of the Jasper Family Clinic on 4/22/2010 at 2:00 p.m. it was noted the clinic had an emergency kit located in the medication room. It was observed that the procedure "Emergency Medical Protocol for Management of Anaphylactic Reactions in Children and Teens and Adults" had been placed in the emergency supply kit. The protocol had been signed by the medical director on 11/28/2008 and stated, "these standing orders for the medical management of vaccine reactions in child, teenage and adult patients shall remain in effect for patients of the Pipestone Family Clinic to include Jasper satellite clinic." However, it was noted the emergency bag/kit lacked the injectable epinephrine medication, listed on the protocol as necessary for anaphylactic treatment. The kit had a Diphenhydramine (Benadryl) capsule available for use but the PA (physician's assistant) could not locate a vial of epinephrine that would be necessary for treatment of signs and symptoms of anaphylactic reaction. Both the PA (staff A) and the medical assistant (staff B) confirmed on 4/22/2010 at 2:30 p.m. the emergency bag had not been properly stocked. These were the only two staff available in the clinic at the time.

Interview with the Director of Nurses' on 4/26/2010 at 3:00 p.m. confirmed it was a "problem" that the necessary emergency medication had not been readily available for use and that staff had been unable to locate the medication.

Based observation and staff interview the facility failed to ensure that the required emergency equipment had been readily available to staff at 1 of the 2 satellite clinics (Jasper Family Clinic).

Findings include: Staff were unable to locate the Automated External Defibrillator (AED) equipment located in the satellite clinic in Jasper.

Prior interview with the Clinic Services Manager on 4/22/2010 at 11:00 a.m. revealed that both satellite clinics (Jasper and Edgerton) had emergency equipment including an AED available for use if needed during clinic hours. During subsequent observation at the Jasper Family Clinic on 4/22/2010 at 2:00 p.m. neither of the two staff available were able to locate the AED equipment. Both the PA (staff A) and medical assistant (staff B) were unable to locate the emergency equipment. Both staff (A) and (B) indicated on 4/22/2010 at 2:15 p.m. that they were unsure whether or not the clinic had an available AED on site.

During interview with physician (C) on 4/22/2010 at 3:30 p.m. it was learned the AED had been available on a shelf in the closet in the back room of the Jasper clinic. He indicated the Jasper Family Clinic had not routinely kept a log that verified the AED equipment had been monitored, but indicated a log had been maintained for the AED at the Edgerton Family clinic. Physician (C), who was located at the Edgerton clinic at the time of the interview, indicated he also staffed the Jasper clinic at various times so was aware of the AED availability.

Upon further interview with the Clinic Services Manager on 4/26/2010 at 2:05 p.m. it was learned that the Jasper Family Clinic had recently been equipped with newly purchased AED equipment.

Interview with the Director of Nursing on 4/26/2010 at 2:15 p.m. confirmed that it was a "problem" that staff were not knowledgeable at the clinic as to the location of the AED.

Based on observation, interview, record review and policy review, the Critical Access Hospital (CAH) was found not to be in compliance with the Conditions of Participation for Physical Environment (CFR 485.623) due to failure to ensure proper procedures were followed related to use of alcohol based skin preparation in anesthetizing locations to prevent the risk of surgical fires. This practice was evident for 5 of 5 patients (P1, P2, P3, P4 and P5) in the sample who required this type of surgical prep.

Findings include: The CAH did not implement policies and procedures to ensure compliance with applicable federal regulations and guidelines related to the use of alcohol based skin preparations in the surgical department. CMS (Centers for Medicare and Medicaid Services) had issued a Survey and Certification Memo dated 1/12/2007, addressing risk reduction techniques to permit safe use of alcohol based skin preparations in inpatient anesthetizing locations in CAHs. The use of an alcohol based skin preparations in inpatient or outpatient anesthetizing locations is not considered safe, unless appropriate fire risk reduction measures are taken, preferable as part of a systemic approach by the CAH to preventing surgery related fires.

On 4/23/2010, at 10:00 a.m. an interview was conducted with both the scrub tech (D) and the circulating nurse (E) regarding policy/procedure for use of alcohol based skin preparation. They verified the CAH had been using alcohol based skin preps with a limited number of surgicals (total hip replacements) as preferred by the surgeon. Although the staff indicated they routinely checked to assure the alcohol had completely dried, the CAH staff had not documented in the patient record verifying that appropriate procedures were followed ensuring the proper use of the alcohol based skin preparation prior to the surgical procedure.

During record review it was noted that alcohol based skin preparation had been utilized during five (5) hip surgeries on the following dates: (P1) 9/15/09, (P2) 11/10/09, (P3) 11/24/09, (P4) 12/14/09 and (P5) 1/5/2010. Review of the Nursing Operative Report for all five (5) records confirmed that alcohol skin preparation had been utilized as indicated by the surgical staff. No documentation was evident to indicate the alcohol based skin prep had been dried and/or the appropriate procedure implemented. When queried as to the method of alcohol skin prep application, interview with the scrub tech (D) on 4/23/2010 at 10:10 a.m. revealed the alcohol had been poured into a sterile medication cup, applied with a Kelly and prep sponge and then air dried prior to DuraPrep application.

The Pipestone County Medical Center(PCMC) CAH surgical skin preparation policy indicated the following procedure for orthopedic preps (#7 thru #11):
7. Alcohol prep is located in OR 2 in the locked fireproof cupboard;
8. Allow the alcohol prep to dry completely to reduce the risk of fire;
9. When alcohol prep is used inspect for areas of pooling. If pooling is noted replace linens and be sure all areas are dry of alcohol;
10. Perform alcohol prep prior to draping so pooling can be noted; and
11. Document on the Nursing Operative Report what prep was used.

Interview with the RN circulating nurse (D) on 4/22/10, at 11:50 a.m. revealed the staff would document on the Nursing Operative Report the need for any replacement linens due to pooling.

During review of the the PCMC fire safety policy the following had been noted: "Minimize liquid alcohol solutions in pools around the patient or in open containers, allowing time for thorough drying of applied solutions before draping and ensure dissipation of alcohol vapors before using any heat source near the patient".

The Director of Nursing (DON) was interviewed at 3:15 p.m. on 4/26/2010. The DON confirmed their was no documentation evident in the patient records regarding drying of the prep prior to draping, even though the facility's practice had been to check for thorough drying of the alcohol based prep.

Based on record review and staff interview the CAH failed to ensure that each medical entry by the physician included a timed signature for 11 of 20 inpatient records reviewed. (Records P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, and P16.)

Findings include: Eleven inpatient records reviewed lacked signatures that included the time of the medical entry. The timed signature enry was lacking on the following types of medical documents: physician progress notes, history and physicals, pathology reports and discharge summaries.

Upon interview with the Director of Health Information at 2:00 p.m. on 4/26/2010, it was verified that entries in the medical records reviewed lacked consistent authentication of the time the entry had been made by the author.