HospitalInspections.org

Based on observations and staff interviews, the facility staff failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality. Findings include:

1. During the review of the emergency department on 6/6/11 beginning at 11:00 a.m., the surveyor observed the following expired patient care supplies available for use:
-1 Tincture of Benzoin swabstick with the manufacturer's expiration date of 12/2008.
-2 Normal Saline wipes with the manufacturer's expiration date of 3/2011.
-2 18 French red rubber straight catheters with the manufacturer's expiration date of 4/2006.
-1 20 French red rubber straight catheter with the manufacturer's expiration date of 6/2005.
-5 6 French pediatric Foley catheters with the manufacturer's expiration date of 6/2008.
-1 Cardinal Health Adult Lumbar Puncture tray with the manufacturer's expiration date of 1/2011.
-1 Sherwood Thoraseal III closed chest drainage system with the manufacturer's expiration date of 11/2009.
-2 Becton-Dickinson EZ-Scrub 3% Chg (Chlorhexadine) scrub brushes with the manufacturer's expiration date of 2/2009.
-1 Adaptic 3 inch by 3 inch sterile Petrolatum dressing with the manufacturer's expiration date of 10/2008.
-1 4-0 Ethilon suture on an FS-2 needle with the manufacturer's expiration date of 1/2011.
-31 Povidone-Iodine sterile prep pads with the manufacturer's expiration dates of 10/2010 (21) and 11/2010 (10).
-2 Jamshidi bone marrow aspiration needles with the manufacturer's expiration date of 11/2010.
-2 Illinois bone marrow aspiration needles with the manufacturer's expiration date of 11/2010.
-5 Portex arterial blood gas kits with the manufacturer's expiration date of 7/2010.
-11 Becton-Dickinson 4.0 milliliter green top Vacutainer blood collection tubes with the manufacturer's expiration dates of 9/2010 (8) and 2/2011 (3).
-2 Becton-Dickinson 4.0 milliliter blue top Vacutainer blood collection tubes with the manufacturer's expiration date of 2/2011.
-3 Becton-Dickinson 6.0 milliliter red top Vacutainer blood collection tubes with the manufacturer's expiration date of 3/2011.
-7 Becton-Dickinson 4.0 milliliter purple top Vacutainer blood collection tubes with the manufacturer's expiration date of 3/2011.
-50 Hemaprompt Fecal and gastric occult blood testing cards with the manufacturer's expiration date of 12/2010.
-1 1 gram foil pack Iodophor PVP ointment with the manufacturer's expiration date of 2/2007.
-1 Curity sterile 1/4 inch by 5 yard Iodoform packing strip with the manufacturer's expiration date of 4/2010.
-7 Merocex Epistax Pack with the manufacturer's expiration date of 2/27/2011.
-6 Nephron Pharmaceuticals 3 milliliter normal saline for irrigation with the manufacturer's expiration date of 12/2010.
-1 1 ounce tube Vaseline Petroleum Jelly with the manufacturer's expiration date of 1/2010.

During an interview with staff member I on 6/6/11 at approximately 12:15 p.m., the nurse stated that nursing staff did not routinely check supplies for expiration dating except when the supplies were pulled for use.

During an interview with staff member D on 6/6/11 at approximately 2:00 p.m., staff member D stated that the supplies were checked by the staff of central stores. The staff checked dates of expiration during the annual inventory, but had missed the identified items.


27821


2. On 6/7/11 at 1:30 p.m., the pharmacy room was inspected by the surveyor for outdated supplies. The following were found:

-2 Filterflow filtered extension sets with the manufacturer's expiration date of 1/2009.

3. On 6/8/11 at 7:35 a.m., the clean utility room on the second floor of the facility was inspected by the surveyor for outdated supplies. The following were found:

-5 bottles of roll-on Antiperspirant/Deodorant with the manufacturer's expiration date of 4/2010.

Based on document review and staff interviews, the facility governing body failed to ensure that the Critical Access Hospital organizational structure requirements were met. The Governing body failed to ensure that health care providers on staff were granted membership and privileges in a timely manner (see Tag C-241), and that the change of responsible individual was reported to the State Agency appropriately (see Tag C-243). Findings include:

1. During the review of provider credential files on 6/7/11, beginning at 3:00 p.m., the surveyor noted that the credential files for 11 of 11 sampled providers were incomplete. The surveyor also noted that all providers on staff had not completed the application/reapplication process, did not receive recommendations for membership and privileges from the medical executive committee, or receive membership and privileges from the governing board according to the approved medical staff bylaws. (C-241)

2. During the entrance conference with the facility administrator on 6/6/11 at 9:30 a.m., the surveyor noted that the administrator listed for the facility was not the administrator currently in the facility. Staff member A, the current chief executive officer, stated that she had been in the position as administrator since December 2010. The change of responsible individual had not been reported to the state agency. (C-243)

Based on document reviews and staff interview, the facility governing body and responsible individual failed to ensure that all policies for operation of the Critical Access Hospital were followed. Findings include:

1. During the review of provider credential files on 6/7/11, beginning at 3:00 p.m., the surveyor noted that the credential files for 11 of 11 sampled providers were incomplete. The individual provider files did not contain information necessary to make decisions about suitability for membership in the Medical Staff according to the approved Medical Staff Bylaws. The credential files lacked documentation of education, experience, personal and professional references, peer review data, documentation of a recommendation by the Medical Executive committee, and current requests for clinical privileges. The surveyor also noted that all providers on staff had not completed the application/reapplication process, did not receive recommendations for membership and privileges from the medical executive committee, or receive membership and privileges from the governing board according to the approved medical staff bylaws. The last documented reappointment in the files was dated 2008. The approved Medical Staff bylaws require the reappointment process be conducted every two years. The prior documentation of reappointment was 2005. There were three year intervals between provider reappointments for both periods.

Article III of the facility Medical Staff Bylaws: Medical Staff Membership; Section III; Conditions and Duration of Appointment; subheading A; reads as follows. " All appointments and reappointments to the medical staff shall be made by the Board of Directors. The Board of Directors shall act on appointments, reappointments, or revocation of appointments only after there has been a recommendation from the medical staff as provided by these bylaws;"

2. The files of three providers that had received initial membership into the medical staff were a part of the initial review. All three of the provider files did not indicate that the provider had been re-evaluated for full membership into the medical staff of the facility. Initial membership and privileges were granted. There was no documentation that the re-evaluation of the three providers had occurred, or that action by the Medical Staff or Board of Directors had taken place to grant full membership into the facility medical staff.

Article III of the facility Medical Staff Bylaws: Medical Staff Membership; Section III; Conditions and Duration of Appointment; subheading B reads as follows. "All initial appointments to the medical staff shall be 'provisional' for a period of 6 months. Reappointments to provisional membership may not exceed (1) one full medical staff year, at which time the failure to advance an appointee from provisional to regular staff status shall be deemed a termination of his/her staff appointment. Initial appointments to the medical staff for provisional staff shall be governed by the provisions of Article IV, Section 2. Reappointments to regular staff membership shall be for a period not exceeding 24 months, and shall be determined in accordance with Article V, Section 3, of these bylaws."

During an interview with staff members A and C on 6/8/11 at approximately 9:15 a.m., staff member C stated that the credentialing process was currently being done and that the process had not been done in 2010.

Based on document review and staff interview, the facility failed to provide the State Agency with the name and address of the person principally responsible for the operation of the Critical Access Hospital. Findings include:

During the entrance conference with the facility administrator on 6/6/11 at 9:30 a.m., the surveyor noted that the administrator listed for the facility was not the administrator currently in the facility. Staff member A, the current chief executive officer, stated that she had been in the position as administrator since December 2010. The change of responsible individual had not been reported to the state agency. Staff member A stated that there had been an interim administrator between the documented responsible individual, and the current administrator. The appointment of the interim administrator had not been reported to the State Agency.

Based on observations and a staff interview, the facility failed to ensure that outdated, mislabeled, or otherwise unusable drugs were not available for patient use. Findings include:

1. During the review of the emergency department on 6/6/11, beginning at 11:00 a.m., the surveyor observed the following expired or unusable medications available for patient care use:
-3 1000 milliliter bags of 5% Dextrose with Lactated Ringers intravenous solution with the manufacturer's expiration date of 3/2011.
-1 open 30 milliliter vial of 1% Lidocaine with Epinephrine marked as opened on 3/22/2011.

During an interview with staff member I on 6/6/11 at approximately 12:15 p.m., the nurse stated that opened vials were to be discarded 28 days after having been first accessed. Staff member I stated that nursing staff did not routinely check medications for expiration dates except when the medications were pulled for use.


27821


2. On 6/7/11 at 1:30 p.m., the pharmacy room was inspected by the surveyor for outdated or unusable medications. The following was found during the inspection:

-1 Albuterol Sulfate inhaler, 0.5% solution, 5 milligrams (mg)/milliliter (mL), with the manufacturer's expiration date of 12/2010;
-2 bags of 5% Dextrose Injection fluid, 100 mL, with the manufacturer's expiration date of 10/2010; and
-1 bottle of Sodium Polystyrene Sulfonate Suspension, 15 grams/60 mL, a 473 mL bottle which was a third full, was opened on 3/24/10 and was available for use.

Based on observations and staff interview, the facility failed to ensure that recognized dietary practices were followed in regards to kitchen sanitation. Findings include:

1. On 6/6/11 at 10:15 a.m., an initial observation of the kitchen was made. At that time, staff member N was observed in the kitchen standing in front of the stove. Staff member N was not wearing a hair restraint or beard restraint and he was lighting the stove during the observation. Staff member N had short growth of a beard on his face.

On 6/6/11 at 11:50 a.m., observation of the lunch meal was done. Staff member N was working the tray line for lunch but did not have a beard restraint on. During this observation, staff member N opened a bag of sliced bread and used his gloved hand to remove two pieces of bread from the bag instead of using tongs to remove the pieces of bread.

2. On 6/6/11 at 2:00 p.m., the inspection of the kitchen was performed. At 2:15 p.m., one of the freezers was inspected which contained leftover food stored in containers which originally contained whipped topping and sour cream. When the surveyor asked staff member M what was in the containers she stated it was leftover food and one of the containers had hash browns written on the lid of the whipped topping container. A bottle of water that belonged to a staff member, was found in a refrigerator used to store snacks and meal service items for the patients/residents. Staff member M confirmed that the bottle of water belonged to another staff member. Coffee cups were stored in the dining room with the open side facing up, not inverted.

On 6/7/11 at 7:20 a.m., observation of the breakfast tray line service was performed. Staff member M was conducting the tray line service. She had gloves on and was collecting all of the supplies she needed while touching refrigerator handles, drawer and cabinet pulls, and put trash in the garbage all with her gloved hands. At no time during this initial observation did staff member M remove her gloves, wash her hands, and put on a new pair of gloves.

During the meal service observation on 6/7/11 at 7:20 a.m., staff member M touched several ready to eat items with her gloved hands such as a pancake, toast, and cooked bacon when tongs were readily available. When the surveyor asked staff member M if she usually used tongs to plate the breakfast items, she stated that she should use the tongs but that she wasn't consistent.

3. On 6/7/11 at 8:00 a.m., after observing the breakfast tray line, a bottle of raspberry iced tea was found in the refrigerator used to store snacks and meal service items for the patients/residents. Staff member M confirmed that the bottle of tea belonged to another staff member and she also stated that staff have a refrigerator in the break room down the hall where staff may put their beverages.

On 6/7/11 at 1:00 p.m., the refrigerators in the clean utility room on the second floor of the facility and in the swing bed nurses station on the first floor of the facility were inspected. Neither refrigerator contained a thermometer, and no temperature log could be found for either refrigerator. Staff member T, a Certified Nurses Assistant, was interviewed at 1:10 p.m., regarding both of the refrigerators. She stated that the temperature in the refrigerator on the first floor was checked by the maintenance staff. That refrigerator contained snacks and condiments for the residents, such as carafes of cranberry juice, apple juice, lemonade, and fruit punch. There were also containers of applesauce, yogurt, ketchup, and mustard. The freezer compartment of that refrigerator contained frozen cooked shrimp. The refrigerator on the second floor of the facility contained snacks for the residents such as bottles of Ensure, applesauce, a package of deli meat, and a cheese slice. The freezer contained ice cream bars and frozen wild berry nutritional treats.

On 6/8/11 at 10:45 a.m., staff member U was interviewed and he stated the maintenance staff did not check the temperature of the two refrigerators. He stated that he thought the kitchen staff or the nursing staff did the temperature checks. The surveyor then went in the dining room at 10:50 a.m., and asked staff member V about who checked the temperature of the two refrigerators. Staff member V stated she thought it was the kitchen staff that checked it. At that time, the surveyor asked the kitchen staff if they checked the temperature of the refrigerators and they stated that they didn't check them and thought it was the maintenance staff that checked them. Staff member B, the Director of Nursing, was interviewed at 11:00 a.m., regarding the refrigerators and the temperature logs. Staff member B stated there were no temperature logs for either refrigerator and that no staff were assigned to monitor the temperature of the refrigerators.

Based on the absence of a required document and a staff interview, the facility failed to maintain a list of all services furnished under arrangements or agreements. The list should describe the nature and scope of the services provided. Findings include:

During the initial meeting with staff member A, the facility administrator, on 6/6/11 at 10:30 a.m., staff member A was reviewing the survey information request form. Staff member A stated that the facility was unable to provide the requested information. Staff member A stated that the facility did not have a list of contracts with the scope and nature for each contract.

Based on document review, the facility failed to ensure that the clinical records of 13 (#s 1, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, and 17) of 19 sampled patients/residents were complete and accurate. Findings include:

1. Patient #1 came to the emergency department on 5/4/10. The facility form labeled Emergency Department Registration and Medical Record did not include documentation of the date and time when the provider signed the form. The facility form labeled Transfer Consent did not include documentation of the time that the consent was obtained.

2. Patient #5 came to the emergency department on 6/28/10. The facility form labeled Emergency Department Registration and Medical Record did not include documentation of the time when the provider signed the form.

3. Patient #6 came to the emergency department on 7/9/10. The facility form labeled Emergency Department Registration and Medical Record did not include documentation of the times of physician notification and arrival, a nursing assessment, or physician orders.

4. Patient #7 came to the emergency department on 7/31/10. The facility form labeled Emergency Department Registration and Medical Record did not include the time when the provider signed the form. The facility form labeled Emergency Department Discharge Instructions did not include documentation of the date or time when the signature of the patient/guardian was obtained.

5. Patient #8 came to the emergency department on 8/11/10. The facility form labeled Emergency Department Registration and Medical Record did not include documentation of the time when the provider signed the form. The facility form labeled Patient Rights and Responsibilities did not include documentation of the time when the signature of the patient/guardian was obtained. The facility form labeled Emergency Department Discharge Instructions did not include documentation of the time when the signature of the patient/guardian was obtained.

6. Patient #9 came to the emergency department on 9/15/10. The facility form labeled Emergency Department Registration and Medical Record did not include documentation of the date or time when the provider signed the form. The facility form labeled ER Flowsheet contained entries at 1603 (4:03 p.m.), 1609 (4:09 p.m.), 1613 (4:13 p.m.), 1623 (4:23 p.m.), 1628 (4:28 p.m.), 1637 (4:37 p.m.) and 1642 (4:42 p.m.) that did not include the signature or initials of the individual that made the entries on that clinical record. The facility form labeled Patient Rights and Responsibilities did not include documentation of the time when the signature of the patient/guardian was obtained.

7. Patient #10 came to the emergency department on 9/16/10. The facility form labeled Patient Rights and Responsibilities did not include documentation of the time when the signature of the patient/guardian was obtained. The facility form labeled Emergency Department Registration and Medical Record did not include documentation of the date or time when the provider signed the form.

8. Patient #11 came to the emergency department on 10/10/10. The facility form labeled Consent for Services did not include documentation of the times when the patient and witness signatures were obtained. The facility form labeled Emergency Department Registration and Medical Record did not include documentation of the time when the provider signed the form.

9. Patient #12 came to the emergency department on 11/16/10. The facility form labeled Emergency Department Registration and Medical Record did not include documentation of the time when the provider signed the form. The facility form labeled Transfer Authorization did not document the name of the facility that the patient was being transferred to. The form did not include documentation of the time when the provider's signature was obtained. The facility form labeled Trauma Flowsheet did not include the signature of the nurse providing care to the patient, or a date or time for the signature of that nurse. The form did not include documentation of the time when the provider signed the form.

10. Patient #14 came to the emergency department on 12/28/10. The facility form labeled Emergency Department Registration and Medical Record did not include documentation of the time when the provider signed the form.

11. Patient #15 came to the emergency department on 5/8/11. The facility form labeled Consent for Services did not include documentation of the times when the patient/guardian and witness signatures were obtained. The facility form labeled Emergency Department Discharge Instructions did not include documentation of the date and time when the signature of the patient/guardian was obtained.

12. Patient #16 came to the hospital on 6/2/11. The facility form labeled Consent for Services did not include documentation of the date and times when the patient and witness signatures were obtained. The facility form labeled Patient Rights and Responsibilities did not include documentation of the time when the signature of the patient was obtained. The facility form labeled Notice: Emergency Services did not include documentation of the time that the signature of the patient was obtained.

13. Patient #17 came to the hospital on 6/4/11. The facility form labeled Patient Rights and Responsibilities did not include documentation of the time when the signature of the patient was obtained. The facility form labeled Consent for Services did not include documentation of the date and times when the patient's signature was obtained. The form was not witnessed by a member of the staff.