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Based on document review, observation and interview, it was determined the Hospital failed to maintain and inventory sample medication supplied to the Hospital by a contractual physician. This has the potential to effect all patients in the Cardio-Pulmonary Department.

Findings include:

1. Hospital policy 730-064 (revised 2/19/07), was reviewed on 1/21/14 at 1:30 PM. It indicated "Those areas which do maintain an inventory of sample medications shall list them on a Quality Sample Medication Inventory Sheet. A copy of the Quarterly Sample Medication Inventory Sheet shall be submitted to Pharmacy on a quarterly basis."

2. A tour of the Cardio-Pulmonary Department with Registered Respiratory Therapist (E #2) on 1/20/15 at 11:00 AM was conducted. 17 boxes of patient education kits containing Xarelto (anti-embolism medication) 20 milligrams, (5) oral tablets with a expiration date of 12/14 were located in the Cardio-Pulmonary work area.

3. On 1/20/15 at 11:15 an interview with E #2 was conducted. E #2 verbalized the Xarelto 20 milligrams had expired and should have been removed from the patient care area.

4. An interview with Pharmacist (E #3) on 1/20/15 at 2:45 PM was conducted. E #3 verbalized that medications brought into the Hospital by specialty physicians are not put on a log. E #3 stated "I have no idea what medications are brought into the hospital or dispensed by specialists."

Based on direct observations during the survey walk-through, staff interviews, and document reviews during the Life Safety portion of a Medicare Critical Access Hospital Recertification Survey conducted on January 27, 2015, the surveyor found that the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231

Based on document review, observation and interview it was determined the Hospital failed to ensure mechanical and electrical equipment available for patient use was inspected and had routine maintenance. This has the potential to affect all patients receiving care at the Hospital.

Findings include:

1. The policy titled "GE Clinical Services Medical Management Program" (revised 11/10) was reviewed on 1/21/15 at 10:00 AM. The policy indicated, "Procedure: Inspect medical equipment prior to initial use, and,...at intervals not to exceed twelve (12) months...".

2. A tour of the Medical-Surgical unit was conducted on 1/20/15 at 10:30 AM with the Medical-Surgical Clinical Manager (E #5). It was observed in the clean utility room two (2) Covidien Kangaroo E Pumps with Pole Clamp. The pumps did not have a maintenance sticker or an inspection sticker.

3. An interview was conducted on 1/21/2015 at 2:00 PM with Nursing Administrator (E #4). E #4 stated the Kangaroo Pumps were purchased on 1/28/13 and were taken to the unit without a maintenance check. Also there is no documentation a routine maintenance check was ever performed.

4. The policy titled "Casualty Prevention-Electrical Safety-Employee-owned Equipment" (Effective date April 24,1995) was reviewed on 1/21/15 at 1:30 PM. Under page "2. #7" it indicated "If the equipment will be used in the facility on a permanent basis, then the equipment/appliance will be entered into the Scheduled Maintenance Program (SMP) and a regular date of inspection and inspection criteria will be assigned to it".

5. A tour of the Medical-Surgical unit was conducted on 1/20/15 at 10:30 AM with E #5. It was observed in the clean utility room a Remington hair dryer without a maintenance tag.

6. An interview was conducted on 1/21/15 at 2:00 PM with E #4. E #4 stated the hair dryer was purchased and taken directly to the unit without being checked by maintenance.

Based on direct observations during the survey walk-through, staff interviews, and document reviews during the Life Safety portion of a Medicare Critical Access Hospital Recertification Survey conducted on January 27, 2015, the surveyor found that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567.

A. Based on document review, observation and interview it was determined the Hospital failed to ensure expired medication and biological's were not available for patient use. This has the potential to affect all patients receiving care at the Hospital.

Findings include:

1. On 1/20/2015 at 10:30 AM an observation tour was conducted with the Medical-Surgical Clinical Manager (E #5). The following expired biological's were found in the medication room on the Medical-Surgical Unit.

18 - BD Vacutainer blue top 2.7 ml (milliliter) vial expired 12/2014
38 - BD Vacationer green top 4.5 ml vial expired 9/2014
5 - FloQ Swabs Respiratory Syncytial Virus (RSV) CoPan Flocked Swabs- expired 9/2014
14 - Pur Wraps Sterile Foam Tipped Applicator (Rapid Flu) expired 9/2014
11 - Classio Swabs by CoPan (Strep) expired 9/2014

2. An interview was conducted with E #5 on 1/22/2015 at 09:30 AM. E #5 stated the items were expired and should have been removed from the patient care area.

3. Hospital Policy "Expired, Damaged, Contaminated Medications" (dated 3/26/14) indicated "It is the responsibility of the Pharmacy Department to remove all expired medications from all areas in the Hospital.

4. An observational tour of the Cardio-Pulmonary Department with Registered Respiratory Therapist (E #2) on 1/20/15 at 11:00 AM was conducted. 17 boxes of educational resource kits containing Xarelto (anti embolus medication) 20 milligrams, of (5) oral tablets per box were found with an expiration date of 12/14 in the department work area.

5. An interview with E #2 on 1/20/15 at 11:30 AM was conducted. E #2 stated medication samples were left in the Cardio-Pulmonary Department by one of the contractual physicians. E #2 verbalized expired medication should not be available for patient use.

Based on document review, observation and interview, it was observed in 3 (E #1, E #7, E #8) of 5 surgical staff, they failed to perform surgical services in accordance with acceptable standards of practice and recommendations promoted by the Association of peri-Operative Registered Nurses (AORN). This has the potential to effect all patients receiving surgical services at the Hospital.

Findings:

1. Pt #6 was admitted on 1/20/15 for eye surgery. An observation in Operating Room Suite B on 1/20/15 at 11:00 AM found Surgery Manager (E #5), Certified Registered Nurse Anesthetist (E #7), and Registered Nurse (E #8) provided patient care during surgery without shoe coverings.

2. An interview with Chief Executive Officer (E #9) was conducted on 1/21/15 at 3:45 PM. E #9 verbalized that all staff working in the Operating Room should wear acceptable operating room attire per AORN standards; which included wearing shoe coverings.

3. Hospital policy "Surgical Procedure (revised 8/13) indicated "Contain all jewelry, including earrings, necklaces, watches and bracelets within the surgical attire."

4. Pt # 6 was admitted 1/20/15 for eye surgery. During an observation in Operating Room Suite B on 1/20/15 at 11:00 AM, Surgery Manager (E #1) provided patient care during surgery with three (3) rings exposed.

3. An interview with the Chief Executive Officer (E #9) was conducted on 1/21/15 at 3:45 PM. E #9 verbalized that all staff working in the Operating Room should wear acceptable operating room attire per AORN standards; which included covering rings.