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Based on document review and interview, the critical access hospital (CAH) did not ensure the contracted nursing service was registered with the state agency. In addition there was no criminal background study completed for 1 of 1 registered nurse (RN)-E contracted for on call shifts in the CAH.


Findings include:


The CAH contract with the nursing service included provision of nursing staff for the medical, surgical, ICCU (intensive coronary care unit) and OB units as needed.


RN-E's personnel record was reviewed on 9/26/13, at approximately 9:00 a.m. with employment coordinator (EC) who was responsible for personnel records. The EC verified the lack of criminal background check for RN-E, the owner and sole employee of the nursing service. CAH did not complete criminal background checks as directed by MN Statute 144.057 Subdivision 1 that reads, "Background studies required. The commissioner of health shall contract with the commissioner of human services to conduct background studies of (1) individuals providing services which have direct contact...with patients and residents in hospitals... (4) individuals employed by a by a supplemental nursing services agency, ...".


Further review indicated the contracted nursing service was not registered with the state agency. RN-E had worked 285 hours from October 1, 2012 though September 1, 2013 under the nursing service contract.

The nursing agency contract, dated 2012, indicated RN-E agreed to submit criminal background checks or drug testing as per CAH policy.

Based upon observation, interview and record review, the critical access hospital (CAH) did not ensure hazardous chemicals were appropriately stored in 2 of 2 clean supply rooms and in 2 of 2 dirty utility rooms in the medical surgical nursing unit.


Findings include:


During a tour of the medical surgical nursing unit on 9/24/2013 at 10:30 a.m., numerous cleaning supplies and other hazardous chemicals were observed in unlocked clean supply and soiled utility rooms which were accessible to pediatric and adult patients and visitors.


One container of Buckeye Quat 256 was observed in an unlocked lower cupboard in clean supply room #1.

A large container of premixed Quat 256 was located on the counter in soiled utility room #1. Two 1 gallon containers of bleach were observed in an unlocked lower cupboard. One sixteen ounce bottle of 70% Isopropyl alcohol and 1 container of Buckeye Blue all purpose cleaner were observed on the counter.

Two containers of 70% isopropyl alcohol were observed on the counter and one container of Buckeye Quat 256 was observed in the unlocked cupboard in clean supply room #2.

Two containers of Lysol disinfecting sprays were observed on the counter and 2 one gallon containers of Sun Brite bleach, 1 bottle of Betco Bol Maid toilet cleaner and 2 quarts of Buckeye Quat 256 were observed in the unlocked lower cupboard in soiled utility room #2.

The clean supply and soiled utility rooms were located a distance from the nursing desk, which was not always occupied, and had lever door handles with no potential for being locked.

The director of inpatient nursing was interviewed on 9/24/2013 at 11:10 a.m. and verified both pediatric and adults patients, including the cognitively impaired, were placed on the medical-surgical nursing unit. She verified the cupboards in the clean supply and the dirty utility rooms were not able to be locked. She also stated there was no way to lock the doors on the soiled utility and the clean supply rooms to prevent access to the unlocked hazardous chemicals by patients or visitors.

A review of the Material Safety Data Sheets (MSDS) for Sun Brite bleach indicated ingestion of the material could cause corrosion of the mucous membranes, skin contact could cause chemical burns, and the poison control center or a physician should be called if exposure to eyes occurred.

The MSDS sheet for Bol Maid toilet cleaner indicated the product could cause severe respiratory tract, eye and skin burns. The product contained a material which could cause organ damage.

The MSDS sheet for Buckeye Blue all purpose cleaner indicated the material should be kept out of reach of children. The MSDS also indicated protective safety glasses and rubber gloves should be used with the product.

The Buckeye Sanicare Quat 256 MSDS indicated the material caused irreversible eye damage and skin burns. It also indicated the product should be kept out of reach of children.

The Professional Lysol Brand III Disinfectant Spray MSDS indicated the product was a hazard to humans and should be kept out of reach of children. A physician or the Poison Control Center should be called if the product was swallowed or inhaled.

The Ethyl Rubbing Alcohol 70% MSDS indicated the product was harmful if inhaled and ingestion could cause gastrointestinal irritation or central nervous depression.

The environmental service supervisor was interviewed by telephone on 9/27/2013 at 12:45 p.m. The supervisor confirmed the hazardous chemicals found in the clean and soiled utility rooms were chemicals frequently used by housekeeping staff. He stated housekeeping staff were required to keep these chemicals in a locked room, however, other staff had requested availability to some of these products when housekeeping staff were not available. He stated he was unable to find a policy relating to the security of hazardous products.

Based on observation, interview and documentation review the community access hospital (CAH) failed to ensure appropriate temperatures were maintained in 2 of 3 refrigerators in the emergency room. This had the potential to affect patients being seen in the emergency room.


Findings include:


During tour of the emergency room (ER) on 9/24/13, at 9:30 a.m. with the emergency room director (ERD), there were 2 refrigerators without thermometers. Refrigerator temperatures were not monitored or tracked. The ERD stated she didn't believe that they had a policy for checking and recording temperatures of the refrigerators.


On 9/26/13, at 3:00 p.m. RN-D provided a list of food and medications in the ER refrigerators. The food refrigerator contained five cartons of milk, 2 containers of apple sauce, fruit juice, garlic bread and instant food thickener. The medication refrigerator contained 12 different medications including rabies immune globulin, hepatitis B vaccine for children, hepatitis B vaccine for adults, and tuberculin purified protein (TB Mantoux test). RN-D stated that vaccines required refrigerators. There was no thermometer in the refrigerator and no log of refrigerator temperatures.


Review of the manufacturer's instructions for tuberculin purified protein and rabies immune globulin directed storage between 35 to 46 degrees Fahrenheit and not to freeze.


The pharmacist (P-A) was interviewed on 9/25/13, at 1:40 p.m. verified the temperature range for vaccines and stated that medication refrigerator temperatures were to be checked and recorded daily. ER staff was responsible for checking and recording the daily refrigerator temperatures.


The CAH policy dated 12/2012, with no review date indicated vaccines shall be stored in refrigerator and freezer units which can maintain the appropriate temperature range and are large enough to maintain the years largest inventory without crowding. The refrigerator and freezer temperature shall be read and documented twice a day,

Based on interview and document review the Critical Access Hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency and /or disruption of supply. This had the potential of affection all patient staff, visitors and services provided.


Findings include:


The CAH policy for Emergency Water Plan last revised 11/7/2012, lacked a calculation of the amount of potable water that would be need for staff and visitor use during the emergency. Although the policy specified the amount of potable water required per patient in a 24 hour period it did not specify the amount of water that should be allocated for staff and visitors use.


In an interview with the Director of Building and Grounds on 9/24/13 at 1:30 he verified this was the only policy the CAH had in place regarding emergency water use.

Based upon observation, interview and document review, the critical access hospital (CAH) did not ensure medication had been disposed of in a secure manner in 3 of 3 operating rooms, the Day Surgery Unit and the intensive care unit.

Findings include:


Medications were observed to be accessible in unsecured areas of the hospital where patients, visitors and other persons without legal access to drugs and biological were present.


SURGICAL SUITE

During a tour of the surgical suite on 9/25/2013 at 9:00 a.m., Certified Registered Nurse Anesthetist (CRNA-A) was observed disposing of a vial of medication into a container labeled hazardous waste. The container was attached to the anesthesia machine with a Velcro strap which could be easily removed. The container measured approximately 12 inches in height and 8 inches in depth and had an opening in the top of the container which measured approximately 4 inches in diameter. The opening on the top of the container would allow free access to the contents in the container. Many vials, syringes and bottles which contained discarded medications were visible in the container.


During a tour of the surgical suite on 9/25/2013 at 10:30 a.m., containers labeled hazardous waste were observed in operating rooms 1, 2 and 3. Some of the medications observed in the containers included syringes of Propafol (an anesthetic agent), Toradol (pain medication), and Lidocaine (a local anesthetic).


CRNA-A was interviewed on 9/25/2013 at approximately 11:00 a.m. and stated all unused medications, except controlled medications, were disposed of in these containers.


The director of surgical services was interviewed on 9/25/2013 at 11:00 a.m. and verified the discarded medications would be accessible to unlicensed staff. The director stated housekeeping personnel cleaned the operating rooms when unlicensed staff were not present.


DAY SURGERY UNIT


During a tour of the Day Surgery Unit, a container labeled hazardous waste was observed in the cupboard under a sink. The container measured approximately 12 inches in height and 8 inches in depth and had an opening in the top of the container which measured approximately 3 inches in diameter. Numerous containers of eye drops, vials and bottles, which contained discarded medications, were observed in the container. Some of the medications which had been discarded in the container included Toradol, Lidocaine and various eye drops.


Registered Nurse (RN-A) was interviewed on 9/25/2013 at 10:15 a.m. and stated all unused medications, except controlled medications, were discarded in the hazardous waste container. RN-A stated persons without legal access to medications cleaned the day surgery unit when unlicensed staff were not present.


INTENSIVE CARE UNIT


During a tour of the intensive care unit (ICU) on 9/24/2013 at 11:20 a.m., a container labeled hazardous waste was observed in the intensive care unit. The container measured approximately 12 inches in height and 8 inches in depth and had an opening in the top of the container which measured approximately 3 inches in diameter. The opening on the top of the container would allow free access to the contents in the container. Many vials, syringes and bottles which contained discarded medications were visible in the container. The director of inpatient services was interviewed on 9/24/2013 at 11:20 a.m. and verified the ICU was unlocked, even when patients were not present, which would allow access to unlicensed persons as well as visitors and patients to discarded medications.


The hospital policy, Managing Hazardous Waste, (last revised 12/15/2009), indicated all unused pharmaceuticals would be treated as hazardous waste and would be placed in marked collection containers. The policy indicated the containers, when full, would be transported by custodial or pharmacy staff to the hazardous waste storage area where they would be transferred into 55 gallon, covered barrels. Unlicensed staff would have access to medications during transport of the hazardous waste containers.


Pharmacist-A was interviewed on 9/25/2013 at 1:10 p.m. and stated unlicensed staff, patient and visitors should not have access to the medications which had been discarded in the hazardous waste containers. The pharmacist also confirmed the storage room where the unused medications were stored prior to removal by the contracted service should be locked. The pharmacist confirmed unlicensed staff have access to this storage room.


Biohazardous Storage Room:

During the physical plant tour on 9/24/13 at 1:00 p.m. the room which stored the CAH's biohazard wastes, which included pharmaceutical wastes was found to be unsecured. On a subsequent observation on 9/25/13 at 7:45 a.m. this room was again found to be unsecured.

The Director of Building and Grounds confirmed, on 9/25/13 at 3:05 p.m. these findings and stated the expectation was for it to be secured at all times.

15508

Based on preventive maintenance review, policy review and staff interview, the Critical Access Hospital (CAH) failed to inspect their lead aprons and thyroid shields in a timely manner as designated per facility policy. This deficient practice had the potential to affect all patients who required X-Rays.


Findings includes:


It was noted during review of the preventive maintenance records, 3 wrap-around aprons, and 2 aprons and 3 thyroid shields had not been inspected for leaks since April, 2011.


The facility's policy IMS-0225 lasted revised 09/2013, indicated the following "Lead aprons, thyroid shields, gloves and barrier curtains shall be inspected at intervals not to exceed 24 months. This also includes protective lead used by the OR (operating room) and ED (emergency department) ."


In an interview with a radiology technician, (RT)-A, on 9/24/13 at 10:10 a.m., she confirmed these items had not been fluoroscoped (CAH's method for examining for leaks/cracks in protective lead equipment) as she is the only person in the radiology department who performs inspections on protective lead equipment and she knew she had never tested these particular items.

13611

Based upon observation, interview and record review, the critical access hospital (CAH) did not ensure hospital policies were followed for 1 of 1 inpatients (P-1) observed while ambulating without a gait (transfer) belt.


Findings include:


P-1 was observed on 9/23/13 at 3:15 p.m. ambulating without a transfer belt. Nursing assistant (NA) assisted P1 with a gentle hold on the patient's arm.


P-1 was observed on 9/24/2013 at 10:25 a.m. ambulating in the hallway with the assistance of a NA. The NA had her left arm looped loosely through the patient's right arm and a transfer belt was not used.


P1 had diagnoses which included a history of a traumatic brain injury due to a cerebral aneurysm and a history of seizures.


The admission nursing assessment, completed 9/23/2013 at 11:10 a.m., indicated the patient had a history of falling within the last 6 months, an unsteady gait and a history of violent temper outbursts. The care plan, dated 9/23/2013, indicated the patient was at risk for falls but did not direct staff to utilize a gait belt (a safety device) when ambulating the patient.


NA-A was interviewed on 9/25/2013 at 1:30 p.m. and stated staff did not use a transfer belt when ambulating the patient.


RN-A was interviewed on 9/25/2013 at approximately 2:30 p.m. and stated the patient had not exhibited any aggressive behavior during this hospitalization and enjoyed ambulating. The registered nurse stated staff ambulated the patient frequently and did not use a transfer belt.

The hospital policy Safe Patient Handling (last revised 3/2011) indicated transfer/gait belt usage was mandatory for all patient handling with the exception of bed mobility and medical contraindications.

Based on interview and documentation review the Critical Access Hospital (CAH) failed to ensure physician signatures were timed and dated for 9 of 22 patient (P8, P10, P11 P13, P16, P17, P18, P19, P22).


Findings include:


P8 was admitted to the CAH on 12/24/12. The physician's progress notes from 12/26, 12/27 and 12/28/12 had been signed by not timed by the physician.


P10 was admitted 3/1/13. Physician's progress notes from 3/1/13 and 3/6/13 had been signed but not timed. The orders from 3/5/13 had been signed but not timed.


P11 was admitted 3/23/13. The telephone orders from 3/25/13, was not dated or timed when the physician signed the orders.


P13 was admitted 4/4/13. The telephone orders from 4/4/13 and 4/7/13 and not been dated or timed when the physician signed the orders.


P16 was admitted 6/25/13. Telephone orders from 6/27/13 and written orders from 6/29/13 were signed but not timed.


P17 was admitted 6/18/13. The physician's orders from 6/19/13 were not been timed when signed.


P18 was admitted 7/29/13. The verbal orders from 7/29/13 and 7/30/13 had not been time or dated when physician signed the orders.


P19 was admitted 6/1/13. Telephone orders from 6/1/13 had not been timed or dated when physician signed orders.


P22 was admitted 8/20/13. The physician orders dated 8/20/2013 were signed and dated by the physician but lacked the time of the signature. The physician orders to stop the Epidural (drugs used to decrease pain in the lower part of the body), and use a Bipap as needed, and to give a fluid bolus 500 ml lactated ringers now, dated 8/20/2013 by the physician but lacked the time the order was written. The physician orders dated 8/22/2013 were signed and dated by the physician but lacked the time of the signature.


In review of the CAH's policy HIS 0015 with the last revision 09/13, this policy indicated "all entries in the medical record should be timed, dated and authenticated ....".


Interview with the Director of Health Information Services on 9/26/13 at 3:35 p.m. verified noted orders and progress notes lacked dates and/or timed physician signatures (P8, P10, P11, P13, P16, P17, P18, P19 & P22).

Based on document review and staff interview, the critical access hospital (CAH) failed to have an effective quality assurance (QA) program. This had the potential to affect all CAH patients.


Findings include:


Evidence was lacking to indicate that QA activity was reported on an ongoing basis in the following areas: infection control, maintenance, pharmacy, medication errors, and swing beds. Review of the 2012, and 2013, quality council meeting minutes with the, Health Information Manager/Quality Manager (HIM/QM), confirmed that reports, projects and/or activities were missing or did not include information about what these services were doing to evaluate and improve CAH services.


The undated Quality Improvement Plan indicated the CAH had a system to report on their QA plans for each service. The CAH system informed staff how to evaluate and document their QA for each of their department. The plan used "plan, do, study and act". The plan indicated the service areas should document the perceived problem, should state the objective or goal, should collect data that is measurable and to develop a plan. The 'do' was to carry out the plan, document and begin to analysis of the data. The 'study' was to complete, compare and summarize. The 'act' was the modification of the plan if needed and to add a new plan as needed. All services listed above were missing this information.


Interview with the Health Information Manager/Quality Manager (HIM/QM) on 9/24/13, at 2:45 a.m. confirmed the QA/PI (quality assurance/performance improvement) process was not always completed by each service. HIM/QM stated there was a schedule when each department were to report on their QA/PI monitoring and projects. The HIM/QM stated that the infection control was to report on QA/PI on 9/17/13. Review of the report indicated the director of staff education and infection control (DSE&IC) had not reported on infection control QA/PI. She further verified that pharmacy had reported numbers of medication error but had no evaluations of trends or plans to reduce medication errors. The pharmacy lacked a QA improvement project. She confirmed documentation was lacking in the minutes and confirmed physical environment and swing beds did not complete a QA/PI plan.


Infection Control:
The DSE&IC was interviewed on 9/25/13, at 11:45 a.m. regarding the infection control QA/PI plan during the last year. The DSE&IC stated that she did surveillance on hand washing about a year ago but had not documented it. There were not start/stop dates for the activity. On 9/26/13, an undated and unsigned document for, "Hand Hygiene" was presented in PI format with a start date of May 2008. The hand washing project was not reported to QA/PI in the last year.


Medication Errors:
Interview with the pharmacist on 9/25/13, at 1:25 p.m. stated that medication errors were not analyzed for trending. There was no policy for follow up of medication errors. Review of medications errors indicated recurring missed dose/wrong dose of medications.





15508

Physical Environment:
Interview with the Director of Building and Grounds, on 9/24/13 at 2:10 p.m. indicated the department did not had a current Quality Assurance activity.


Swing Bed:
In an interview with Patient Care Services Administrator on 9/26/13 at 9:00 a.m. she confirmed this department does not have a quality assurance study in place and has not had one in the past two years. This administrator stated one main reason for the lack of a quality assurance program was due to the low census in the Swing Bed department, which made it difficult to identify areas for study.


Pharmacy:
The Director of Pharmacy, interviewed on 9/25/13 at 1:10 p.m., stated the last quality study conducted in the department was 11/2011, and there was no current quality assurance activity.

Based on document review and staff interview, the critical access hospital (CAH) failed to address medication therapy utilized for hospital acquired infections (HAI) as part of the quality assurance/performance improvement plan or activity. This had the potential to affect all CAH patients.


Findings include:


The infection control meeting minutes for 2012, and 2013, were reviewed and noted to lack evidence of analysis of medication therapy in relation to hospital acquired infections.


The Health Information Manager/Quality Manager (HIM/QM), interviewed on 9/24/13, at 2:45 a.m., stated quality assurance/performance improvement (QAPI) process was not always completed by each service. On 9/17/13, the schedule indicate an infection control report; however, the practitioner reported on the nature of the position as opposed to any QAPI information.


Interview with the director of staff education and infection control (DSE&IC) registered nurse on 9/25/13, at 10 a.m., stated she did not have any documented quality assurance assurance improvement plan for infection control. She had done surveillance of staff hand washing and completed did follow up teaching but it was not documented. Regarding evaluation of medication therapy for hospital acquired infections, the DSE&IC stated she went out to the floor once a month and reviewed all inpatient records for that day. If a patient was receiving an antibiotic she determined if the patient was on the appropriate antibiotic and wrote a summary. The summary documentation provided was dated 2008 and 2010. Interview with DSE&IC on 9/26/13, at 9:30 a.m. indicated there was no documentation of the antibiotics utilized or of culture results.