HospitalInspections.org

Based on observation, interview, record review and policy review, the Critical Access Hospital (CAH) was found not to be in compliance with the Conditions of Participation for Physical Environment (CFR 485.623) due to failure to ensure proper procedures were followed related to use of alcohol based skin preparation in anesthetizing locations to prevent the risk of surgical fires. This practice was evident for 4 of 5 surgical patients (S1, S2, S3 and S4) in the sample who utilized an alcohol based prep for surgery.

Findings include: The CAH did not implement policies and procedures to ensure compliance with applicable federal regulations and guidelines related to the use of alcohol based skin preparations in the surgical department. CMS (Centers for Medicare and Medicaid Services) had issued a Survey and Certification Memo dated 1/12/2007, addressing risk reduction techniques to permit safe use of alcohol based skin preparations in inpatient anesthetizing locations in CAHs. The use of an alcohol based skin preparations in inpatient or outpatient anesthetizing locations is not considered safe, unless appropriate fire risk reduction measures are taken, preferable as part of a systemic approach by the CAH to preventing surgery related fires.

On 6/9/10, at 1:15 p.m. an interview was conducted with both the Registered Nurse-(D) and the surgery manager RN-(E) regarding policy/procedure for use of alcohol based skin preparation. They verified the CAH had been using the alcohol based skin prep, DuraPrep, as preferred by the surgeons. Although the staff indicated they routinely checked to assure the alcohol had completely dried, these CAH staff verified they had not documented in the patient records verifying that appropriate procedures were followed ensuring the proper use of the alcohol based skin preparation prior to the surgical procedure.

During record review it was noted that alcohol based skin preparation had been utilized during 4 of 5 surgeries on the following dates: (S1) 2/26/10, (S2) 3/9/10, (S3) 1/21/10 and (S4) 9/25//09. Review of the Nursing Operative Report for each of these four records confirmed that alcohol skin preparation had been utilized as indicated by the surgical staff. No documentation was evident to indicate the alcohol based skin prep had been dried and/or the appropriate procedure implemented.

The River's Edge CAH surgical skin preparation policy indicated "for duraprep instructions, please see the attached instructions for applications." The attached literature included: " ...Once a uniform coating is applied, allow DuraPrep surgical solution to dry thoroughly (approximately 2-3 minutes) before incision or use of electrocautery/laser..."

The Director of Nursing (DON) and Administrator were made aware of these findings on 6/9/10 at approximately 3:15 p.m. They confirmed their was no system currently in place to ensure documentation was evident in the patient records regarding drying of the prep prior to draping, even though the facility's practice had been to check for thorough drying of the alcohol based prep.

Based on observation, interview and policy review, the facility failed to ensure that medications were stored securely in the Emergency Room, at the hospital's nursing station in the inpatient area, and in a hallway of the attached clinic. This had the potential to affect any patients and the public who utilized these areas. The findings include:

During a tour of the attached clinic on 6/9/2010 at 9:55 a.m. with the Environmental Services Director and again on that date 11:10 a.m., with the Clinical Services Director of the clinic, it was noted that there were medications unlocked in a cabinet in the center hallway. Included were the following medications: 2 vials of Solumedrol 40 mg; 5 ampules of Epinephrine 1 mg/ml; Diphenhydramine eight 25 mg capsules; Xylocaine 1% 10 ml of 10 mg/ml; Prednisone ten 10 mg tablets; Loratidine ten 10 mg tablets; Hydroxyzine two 1 ml vials 50 mg/5 ml; Zantac two 2 ml vials of 50 mg/ml; Depomedrol one 1 ml vial of 40 mg/ml; Albuterol Sulfate for inhalation nineteen 3 ml doses.

The Clinical Director of the clinic verified by interview at 11:10 a.m. on 6/9/10 that these medications should have been stored more securely.

In addition, there were medications observed to have been stored on a counter in the emergency room on 6/8/10 at 3:40 p.m. in a small portable unlocked container. The container was labled: RSI meds. Medications in the box included: Etomidate 40 mg/20 ml vial; Versed seven vials of 10 mg/2ml and ten vials of 2 mg/2 ml; Rocuronium three vials of 100 mg/10 ml; and Succinylcholine four vials of 200 mg/10 ml. Registered Nurse (RN)-A confirmed during interview at that time, that the medications were unlocked so that the staff would have quick access to them. In addition, RN-A confirmed there was not always someone sitting at the desk.



10155

During the medication administration on the nursing unit on 6/9/2010 at 8:00 a.m., a set of medication keys was observed to be taken from a red box container and used to open up a medication cart. The keys were returned to the red box container after the medications were taken from the cart. The red box container was located on top of the pyxis cell cabinet, out in the open of the nursing station. Licensed Practical Nurse (LPN)-A was interviewed and indicated the keys were for the medication cupboards above the pyxis machine and the cart that held overflow medication that did not fit into the pyxis cell.

On 6/10/2010 at 1:15 p.m., RN Manager- A was interviewed. She stated some of the patient's own medications were in the medication cart and other medication that did not fit into the pyxis cell. Other medications were stored in a cupboard above the pyxis cell that was locked and required use of that set of keys. The nurse manager found the medication keys in the red box container on top of the pyxis cell. She used the keys to open the locked cupboards above the pyxis cell . Medications in the cupboards included; intravenous medications, antibiotics, Tylenol tablets and Tylenol liquid, lovenox, lidoderm patches and prednisone.

RN Manager-A verified at that time that the charge nurse should have been carrying the medication keys on her person.

The facility's policy/procedure for Medication Keys dated as revised 7/09 included: "To ensure the safety of medications. All cupboards, carts, and refrigerators which contain medications will be locked at all times."

Based on record review and staff interview the CAH failed to ensure that each medical entry by the physician included authentication of dates/time of the medical entry for 4 of 10 Emergency Room records (E1, E2 E3 and E4) reviewed; 20 of 22 inpatient records (P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, P19, P20 and P21) reviewed; and 4 of 5 surgical patient records (S1, S2, S3 and S4) reviewed. The findings include:

Medical records that included in-patient, surgical, and emergency patient records, lacked physican signature authentication including date and/or time the entries had been made. Physician signatures were not consistently authenticated with the date and/or time in the following types of documents contained in medical records: physician progress notes, physician orders, operative reports, transfers, and discharge summaries.

Examples of this deficient practice include: S1 had a surgical procedure completed on 2/26/10. The physician's operative note and discharge summary lacked dates and time of the physician's signature. S2 had a surgical procedure completed on 3/9/10. The physician's orders, perioperative report, operative note and operative report were not dated and timed.
S3 had a surgical procedure completed on 1/21/10. The physician's operative report was not dated or timed. S4 had a surgerical procedure completed on 9/25/09. The history and physical exam, progress notes and discharge summary lacked the time of the physician's signature. In addition, there was no date or time on the physician's diagnosis sheet.
E1, E2 and E3 each had received emergency room services in June 2010. The physician orders and notes were not consistently dated and timed. E4 had been seen in the emergency room 2/8/10 and the physician's admit orders were not dated or timed. P2, P3, P4, P5, P6, P7, P8, P9, P10, P11, P12, P13, P14, P15, P16, P17, P18, P19, P20 and P21, had been inpatients. Their medical records lacked consistent dates and times of physician signatures for progress notes, physician orders, history and physicals, and/or discharge summaries.

Upon interview with the Administrator on 6/10/2010 at 3:30 p.m. it was verified that entries in the medical records reviewed lacked consistent authentication of the date/time the entry had been made by the author. The Administrator confirmed the CAH was aware of this issue and had been working to correct it.







10155