HospitalInspections.org

Based on document review and staff interview, the Critical Access Hospital (CAH) failed to include a mid-level practitioner (Physician Assistant or Advanced Registered Nurse Practitioner) and at least one member that is not on staff at the CAH as part of the professional group to develop and review all policies and procedures.

Findings included:

- Review of the policy and procedure manuals during the survey between 7/12/10-7/15/10 revealed the CAH lacked documented evidence of participation by a mid-level practitioner or a member not on staff at the CAH in the development and review of all policies and procedures.

On 7/13/10 at 1:15pm Administrative staff B and staff C acknowledged the annual review of policy and procedure manuals failed to include a mid-level practitioner or a reviewer not employed by the CAH.

Based on observation, document review and staff interview the Critical Access Hospital (CAH) failed to ensure that outdated drugs and biologicals were not available for patient use in two of two respiratory therapy storage cabinets, one of two crash carts, and one of one fluid warming cabinets observed containing outdated drugs and/or biologicals.

Findings include:

- Observation on 7/12/10 at 2:30pm of the nursing unit crash cart revealed the following outdated drugs;
1. One- ten milliliter vial of Procainamide hydrochloride (a drug used to treat abnormal heart rhythms) with an outdate of 7/1/10.
2. One-ten milliliter vial of pediatric 8.4% Sodium Bicarbonate (a drug used to treat metabolic acidosis) with an outdate of 7/1/10.

- Administrative staff B on 7/12/10 at 2:30pm acknowledged the Procainamide and the Sodium Bicarbonate were outdated.

- Observation on 7/14/10 at 9:15am of the respiratory treatment room revealed the following outdated drugs;
1. Two-5 dose packs of Pulmicort Respules (a steroid) with an outdate of 10/09.
2. Four vials of Albuterol Sulfate (a bronchodilator) with an outdate of 3/10.

- Staff D on 7/14/10 at 9:15am acknowledged the Pulmicort Respules and the Albuterol Sulfate were outdated.

- Observation on 7/14/10 at 9:25am of the drug cabinet in the Respiratory Therapy Office revealed the following outdated drugs;
1. Sixty-18 microgram capsules of Spirivia (used to prevent bronchospasm) with an outdate of 11/09.
2. One-7gram container of Aerobid ( used to reduce frequency and severity of asthma attacks) with an outdate of 4/10.
3. One-110 milligram container of Flovent HFA (a steroid inhaler) with an outdate of 4/09.
4. Three-10 milliliter vials of Acetylcysteine (used to break down mucous) with an outdate of 1/10.
5. Sixty-2.5 milliliter vials of Ipatropium Bromide (a bronchodilator) with an outdate of 11/08.

- Staff D on 7/14/10 at 9:25am acknowledged the Spirivia, Aerobid, Flovent, Acetylcysteine, and Ipatropium Bromide were outdated.

- Review of the CAH ' s policy titled " Destroying Outdated Drugs " on 7/14/10 revealed the policy states " ...All outdated drugs are destroyed in accordance with the State rules and regulations... All drugs in the drug room, crash carts, and ER cabinet are inspected on a monthly basis..." The CAH failed to follow their outdated drug policy.



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- Observation on 7/13/10 at 9:10am revealed a fluid warming cabinet in the recovery room. The temperature of the warming cabinet registered 180 degrees Fahrenheit. The warming cabinet contained the following:
1) One 1000 cubic centimeters (cc) container of normal saline irrigation solution;
2) One 1000 cc container of Lactated Ringer intravenous (IV) solution; and
3) Three 1000 cc containers of sterile water irrigation solution.

The warmed solutions lacked a date when placed in the warmer or when to be removed from use.

- Document review on 7/14/10 of the information sheet provided by the manufacturer of the warmed fluids directed "...fluids for injection may be warmed not to exceed 104 degrees Fahrenheit for a period no longer than two weeks (14 days)...irrigation solutions may be warmed not to exceed 150 degrees Fahrenheit for a period no longer than two weeks (14 days)..."

On 7/13/10 at 9:10am staff H acknowledged the warmed solutions lacked a date when placed in the warmer or when to be removed from use.

Based on observation, staff interview, and document review the Critical Access Hospital (CAH) failed to identify potential infection control issues and implement their policies.

Findings included:

- Review on 7/14/10 of the CAH ' s policy titled " Hand Washing " directed staff to " ... wash hands at the following times to prevent cross-contamination:
1. Before contact with a patient, the patient's environment and items that come into contact with the patient.
2. After contact with a patient, the patient's environment and items that come into contact with the patient.
3. Before handling clean supplies, sterile supplies, clean linen, medication and food.
4. After contact with excretions, secretion, or blood.
5. After contact with items contaminated by excretions, secretion, or blood ... "

- Observation on 7/13/10 at 10:40am revealed laboratory staff E performed a blood draw in the outpatient lab draw room. Staff E, wearing gloves, transferred the blood to the lab tubes and removed their gloves. Staff E exited the room and returned to work in the laboratory. Staff E failed to perform hand hygiene before returning to work.

- Observation on 7/13/10 at 3:45pm revealed laboratory staff E performed a blood draw in the outpatient lab draw room. Staff E entered the room, applied gloves and drew blood. Staff E removed their gloves and returned to the laboratory. Staff E failed to perform hand hygiene before returning to work.

- On 7/14/10 at 11:15am nursing staff F performed a dressing change. Staff F entered the patient's room, inventoried the supplies and left the room for more supplies. Staff F re-entered the patient's room, applied gloves, removed the dressing from the patient's mid-back area, removed their gloves and left the room for more supplies. Staff F re-entered room, applied gloves, cleansed the wound with saline, removed their gloves and left the room for more supplies. Staff F re-entered the room, applied gloves, applied a Duoderm dressing to the wound and another dressing over the Duoderm. Staff F removed their gloves. Staff F applied gloves after they were reminded by another staff member, and assisted with changing the patient's soiled diaper and repositioning the patient. Staff F removed their gloves, emptied the trash can, applied gloves and emptied the Foley catheter bag (a bag to collect urine). Staff F washed their hands. Staff F pulled the patient's covers up and placed the call light within reach. Staff F picked up the soiled dressing removed from the patient's wound with their bare hands, carried it out of the room to the nurses station, placed the soiled dressing in a biohazard bag and into the trash can. Staff F obtained the glucometer (a machine to test blood sugar) from the nurses station and entered another patient's room. Staff F applied gloves, performed the blood sugar test and removed their gloves. Staff F picked up the glucometer left the room, and returned the glucometer to the nurses station. Staff F failed to clean their hands or the glucometer. Staff F went to the meal cart, picked up the patient's meal, took the food into the patient's room and placed the food on the bedside table. Staff F removed the cover from the plate, left the room, went to the medication room, prepared the patient's insulin, returned to patients room and administered the insulin. Staff F failed to perform hand hygiene at least twelve times, potentially transmitting infectious microorganisms between patients and/or staff.

- Infection Control Staff C on 7/14/10 at 5:15pm acknowledged staff must perform hand washing according to policy.



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- Observation during the cleaning of the operating room (OR) on 7/13/10 at 9:30am revealed staff I and staff J, using "hdqC 2" cleaning solution, wet wiped the OR bed, walls, medication cart, and anesthesia machine. These areas remained wet for a contact time of approximately five to eight minutes not the required 10 minutes for disinfection.

The "hdqC 2" container label and manufacturer's guidelines for disinfection instructed staff to allow surfaces to remain wet for 10 minutes to assure disinfection.

Staff J on 7/13/10 at 10:00am acknowledged the "hdqC 2" cleaner required a contact time of 10 minutes to achieve disinfection. Staff H verified the surfaces on the equipment in the OR failed to remain wet for the 10 minutes required for disinfection.

Based on record review, lack of outpatient policies and procedures, and interview, the Critical Access Hospital (CAH) failed to provide services for one of one outpatient who received a blood transfusion at the CAH (patient #35).

Findings included:

- Review of patient #35's clinical record revealed an outpatient admission date of 4/25/10 with diagnoses of fever, weakness and behavior changes. A complete blood count performed on 4/25/10 revealed a hemoglobin (red blood cell count) of 7.7 gr/dL (grams/deciliters of blood) with normal range 14.0-18.0 gr/dL. The patient's hematocrit (percent of blood occupied by the red blood cells) measured 23.3% (normal range 42-52%). The provider ordered the patient to have a transfusion of two units of packed red blood cells (PRBC's) as an outpatient.

The hospital admitted the patient on 4/25/10 at 2:56pm for the blood transfusion. Review of the nurses notes, the patient arrived at 3:45pm. The nurse documented the patient's vital signs as blood pressure 95/55, pulse 101, respirations 24 and labored, oxygen saturation 98% on 2 liters of supplemental oxygen, temperature 103.0 degrees Fahrenheit and coarse lung sounds (indicates excess fluid in lungs). The nurses notes lacked documentation of additional assessment of the patient's lung status following two units of PRBC's and treatment with intravenous Lasix (a diuretic). The clinical record lacked documentation the provider received notification of the nursing assessment findings including the patient's lung sounds and temperature.

Review of the CAH's policy and procedure for blood transfusions directs staff to watch the patient closely including "b. fever- a raise of temperature ... 2 degrees Farenheit (sic) from normal of 98.6 Farenheit (sic) " .

- Staff C, interviewed on 7/13/10 at 8:50am, confirmed the CAH failed to develop and implement policies and procedures for provision of outpatient services.

- Staff B, identified as the CAH out-patient services coordinator, on 7/13/10 at 9:40am, confirmed the CAH lacked policies directing staff on the provision of outpatient services including assessment for patients receiving outpatient services. Staff B further confirmed the CAH staff should have notified the provider of the patient's assessment findings.

The CAH failed to develop and implement policies and procedures directing staff in the care of outpatients.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to develop and maintain a current list of contracted services provided. This deficient practice had the potential to effect patient services provided through contract by the CAH.

Findings included:

- Review of documentation provided during the survey between 7/12/10 and 7/15/10 revealed a lack of a contract services roster or list with the nature and scope of services provided to the CAH patients.

Administrative staff A on 7/13/10 at 11:30am acknowledged administration failed to develop and maintain a list of contract services.