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Based on interview and record review, the CAH did not ensure a physician was notified by a physician's assistant prior to the transfer of 1 of 1 patients (ER-3) who had been transferred from the Emergency Department to another hospital.. Findings include:

The physician's assistant (PA-C) did not notify a physician prior to the transfer of patient ER-3 from the Emergency Department to another hospital.

Patient ER-3 was admitted to the CAH on 7/2/2010 after swallowing a ring which had lodged in her esophagus The patient was transferred to another hospital for further treatment on 7/2/2010. The medical record lacked documentation that a physician had been notified prior to the transfer.

A review of the "Emergency Department Report" dictated by PA-C, dated 7/2/2010, did not indicate a physician had been notified prior to the transfer.

The CAH policy "Mid-Level Provider Guidelines for Emergency Room Care", last reviewed 8/2/2010, indicated the mid-level providers were to notify the consulting physician of all transfers. The policy indicated the mid-level provider could transfer a patient to another facility after contacting the consulting physician. The CAH's policy "Transfers/Referrals", dated 8/12/2008, indicated the attending physician was to order any transfer or referral of a patient from the Emergency Department.

The Patient Care Director was interviewed on 9/13/2010, at 3:30 p.m. She stated there was no documentation in the medical record a physician had been notified prior to transfer of the patient. She stated a physician is always on call for the Emergency Department and was to be notified prior to the decision to transfer a patient.

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure medications located in the operating room, in the Phase I and II Post Anesthesia Care Unit (PACU), the physical therapy department were secure and properly stored. Findings include:

During a tour of the Operating Room Suite on 9/13/2010, at 2:00 p.m., an Omnicell medication storage device, which was on wheels, was observed in the operating room. This medication storage device was used by the Certified Nurse Anesthetists (CRNA) and contained numerous anesthetic medications which included muscle relaxants and narcotics. A clear plastic container was affixed to a shelf in the PACU and had a key lock on the top of the container. A label on the plastic container indicated the medications were "Reversal Agents". This container contained a vial of Atropine, one vial of Lidocaine, two vials of Narcan, and one vial of Romazicon.

The Operating Room Coordinator was interviewed on 9/13/2010, at 2:30 p.m. and stated the Operating Room Suite and the PACU were never locked, therefore there was no way to ensure the security of these medications. The Pharmacist was interviewed on 9/14/2010, at approximately 11:45 a.m. and stated the medications were not secure as there was no way to currently lock either the Operating Room Suite or the PACU.

A review of the "Storage of Medications" policy, last revised 8/10/2010, indicated it was the policy of the hospital to provide for safe storage of all medications to ensure the integrity of the medications. The policy indicated medications were to be stored in a locked area with limited access per hospital policy.


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The physical therapy department contained stock pharmaceuticals that were opened, had outdated since the containers had been opened, and were not properly labeled and dated.

During a tour of the Rehabilitation Services Department on 9/14/10, at 10:30 a.m., it was noted there was a stock supply of Dexamethazone NaPO4 20 mg/5 ml. vials used for iontophoresis treatments. The containers were in a locked compartment; however, five of the vials were open and partially used and not dated when they had been opened. One of the vials was noted to be leaking at the seal. There was also one syringe with Dexamethazone .4 % Gel for phonophoresis treatments that was not used but was outdated with the expiration date of 9/4/10.

The Rehabilitation Director verified at 10:30 a.m., the treatments generally utilized 3 ml. of the vial per treatment and partial bottles had been utilized to perform subsequent treatments for other patients. The Director was not aware of the dates the vials had been opened and also verified the staff had not dated the vials when they had been opened.

At 11:30 a.m. the Rehabilitation Director reported the Pharmacist had verified the vials should only be used for 28 days after opening and recommended each should be discarded after the treatment session and not used between patients.


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Based on observation, interview and policy review, the Critical Access Hospital (CAH) failed to ensure meals were distributed to all inpatients in accordance with recognized dietary hygiene practices. Findings included:

Staff did not wash or sanitize their hands while passing meal trays to patients in the CAH.

During the meal tray pass on the nursing unit on 9/15/10, at 11:38 a.m., the staff that distributed the meal trays for inpatients did not properly disinfect their hands between patients served. The meal trays arrived on the unit at 11:38 a.m. and several staff were available to distribute the trays and assist in setting up the patients to eat.

Nursing Assistant (NA-A), Registered Nurses (RN-A and RN-B) were observed to take trays from the cart, carry the trays to the patient room and assist with positioning the patient and setting up of the food items. While passing and setting up the meal trays, the staff touched beds, chairs and patients directly. Staff then went back to the cart and removed the trays to serve the next patients; however, the staff did not wash or disinfect their hands with alcohol based agents. No hand disinfecting supplies were located on the cart. Although there was a foam disinfectant bottle located on the nearby wall, it was not observed to be used by staff to clean their hands.

When interviewed on 9/15/10, at 8:20 a.m., the Food Services Director verified the dietary staff delivered the cart to the nursing unit and nursing staff were responsible to distribute the meal trays.

When interviewed at 11:55 a.m., NA-A verified staff did not routinely disinfect their hands between patients while distributing trays.

The Support Services Director was interviewed at 1:00 p.m. and stated the CAH was working on changing the system to distribute the trays and have dietary be more involved with the process. The Director also verified staff were routinely disinfecting their hands between meal passes in the long term care portion of the facility and that was the accepted standard.

The CAH dietary policy, dated 7/14/10, and revised 9/13/10, only indicated, "Trays are delivered by nursing staff."

The Support Services Director was interviewed at 2:15 p.m. and verified nursing had no written policy or procedure for hand sanitization during distribution of meal trays.

Based on interview and record and policy review, the Critical Access Hospital (CAH) failed to conduct the necessary inspections of the leaded protective devices used to ensure safety for patients and personnel in the Radiology Department. Findings included:

The facility's records lacked evidence that the lead aprons, lead gloves and thyroid shields had been inspected for defects on an annual basis. The records for the last annual inspection were completed on 8/21/08. There was no evidence the equipment had been inspected in 2009 and, it was after the surveyor's intervention, that a reinspection of the protective equipment was completed on 9/13/2010.

The Radiology Technologist (RT-B) was interviewed on 9/13/10, at 1:00 p.m. and stated she did not know why there wasn't a record of the leaded equipment being inspected in 2009. She stated that it could have been that the equipment was missed for inspection or that it was conducted but not recorded as having been completed.

The facility's policy titled "Leaded Devices-Radiology", dated 7/93 with a revision on 6/5/08, specified: "At least annually, all of the following items will be physically inspected for defects and also where feasible, either radiographed or observed fluoroscopically for inadequacy or defects. Date, plus method used in the evaluation, shall be recorded and signed by the evaluator on the form provided and kept in the Quality Control Log Book."

Based upon interview, record review, and policy review, the Critical Access Hospital (CAH) did not ensure patient medical records included dated, timed and authenticated signatures of physicians and other allied health professionals for 7 of 41 (P-9, P-97, P-12, P-13, P-14, P-15, P-18) patient records reviewed. These records included inpatients, surgical patients and outpatients. Findings include:

P-9 was admitted to the CAH on 2/26/10, for abdominal pain/appendicitis. Review of the "Anesthesia Record", completed by CRNA-A, identified a hand written "Pre-anesthetic Evaluation" and "Post-Anesthetic Evaluation" which did not indicate the date or time of entry in the medical record.

P-7 was admitted to the CAH on 2/12/10, for open reduction/internal fixation of a femur fracture. Review of the surgical Anesthesia record", completed by CRNA-B, identified a hand written "Pre-Anesthetic Evaluation" and a "Post-Anesthetic Evaluation" which did not indicate the date or the time of entry in the medical record.

P-12' s chart review indicated Certified Registered Nurse Anesthetist (CRNA-C) had not indicated the time the "Pre-Anesthesia Evaluation" had been completed on 4/2/2010.

P-13's chart review indicated CRNA-C had not indicated the date or the time the "Pre-Anesthesia Evaluation" had been completed.

P-14's chart review indicated CRNA-C had not indicated the time the "Pre-Anesthesia Evaluation" and the "Post-Anesthetic Note" had been written on 4/23/2010.

P-15's chart review indicated CRNA-A had not indicated the time the "Pre-Anesthetic Evaluation" had been completed or the time the "Immediate Post-Anesthetic Evaluation" and the "Post-Anesthetic Note" had been written on 5/7/2010. There was no indication of the date or the time the "Consent for Anesthesia Services" had been signed.

P-18 was admitted to the CAH on 6/28/10, for treatment of congestive heart failure. Chart review indicated an "Admission Consent" form had been signed by the patient, however there was no date and time to indicate when the consent had been signed.


A review of the CAH policy "Legal Electronic Health Record", last revised 1/2009, indicated that scanned documents required an electronic signature and the date and time of the signature was automatically put with the signature when it was scanned into the electronic medical record.

The Nurse Educator was interviewed on 9/15/2010, at 9:30 a.m. and stated the "Anesthesia Record" chart forms were scanned into the electronic medical record. She stated that health care professionals were to document the date and time entries were made in the medical record.







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Based on interview and record review, the Critical Access Hospital (CAH) failed to ensure all patient care services and other services affecting patient health and safety were evaluated through the quality assurance program (QA). The findings included:

Organ procurement services (OPO) and the physical plant service, which would included maintenance and housekeeping, had not been evaluated through the CAH's QA program.

In an interview with the Director of Supportive Services on 9/15/10, at 1:19 p.m., she verified that these patient care services, which were part of the CAH, were lacking a comprehensive QA program.