HospitalInspections.org

Based on observation and staff interview the Critical Access Hospital (CAH) failed to ensure the outdated emergency supplies were unavailable for use in one of one Post Anesthesia Care Unit (PACU) mini carts. This deficient practice has the potential to expose patients to unsafe supplies resulting in inadequate results.

Findings include:

- PACU mini cart observed on 9/26/2017 at 10:20 AM revealed the following outdated supplies:

1. Two Glide Scope blades #1 (a device used to assist in placing a tube in the windpipe to provide an airway) with an expiration date 2/27/2017.

2. Two Glide Scope blades #2 with an expiration date of 2/21/2016.

Registered Nurse Staff G interviewed on 9/26/2017 at 10:40 AM confirmed the expired Glide Scope blades and stated, "They were on backorder so Respiratory Therapy told us to keep them."

Policy review on 9/27/2017 at 4:00 PM revealed the facility failed to provide a policy directing staff to ensure expired emergency supplies are discarded in the Post Anesthesia Care Unit.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure one of one laboratory chemical decontamination showers was in safe operating condition to avoid splashing and spreading of chemical contamination and failed to ensure physical therapy equipment, the hydrocollator (a machine with hot water inside holding hot packs for patient use), and Paraffin wax bath (hot therapeutic wax) were in safe working condition. The temperature log indicated the hydrocollator temperatures are measured only on a weekly basis, and no temperature log was provided for the paraffin wax bath. These deficient practices have the potential to expose staff and patients to chemical contamination, and placed patients at risk for harm in the form of injury or burns.

Findings include:

- Laboratory observed on 9/26/2017 at 10:58 AM revealed an eyewash station and decontamination shower combination. The decontamination station failed to contain a curtain or splashguard to prevent the spreading of contaminants during use.

Laboratory Director, Staff K interviewed on 9/26/2017 at 10:58 AM explained that this shower is what lab personnel would use if they were exposed to chemicals. Staff K reported there is no shower curtain or splash guard to protect laboratory staff or the laboratory environment from contamination.

Policy review on 9/27/2017 revealed the CAH failed to provide a policy regarding safe operation of the chemical decontamination station.


- Physical Therapy Area observed on 9/26/2017 at 10:33 AM revealed a hydrocollator with a temperature log revealing weekly temperatures.

Physical Therapy Director Staff J interviewed on 9/26/2017 confirmed the temperatures are only checked weekly.


Policy titled, "Hydrocollator and Hot Packs" reviewed on 9/27/2017 directed, ...water temperature should be ~71 degrees C...


- Occupational Therapy Treatment Area observed on 9/26/2017 at 10:30 AM revealed a paraffin wax bath without a corresponding temperature log.

Physical Therapy Director Staff J interviewed on 9/26/2017 confirmed the paraffin bath temperatures are not monitored.

Policy titled, "Paraffin Bath" reviewed on 9/27/2017 directed, Check paraffin wax temperature. It should be set at 126 degrees F. Do not apply paraffin if temperature is over 130 degrees F...

Based on observation, staff interview, and policy review the Critical Access Hospital (CAH) failed to ensure the outdated medications and biologicals were unavailable for use in the freezer located in the Post Anesthesia Care Unit (PACU) and in the Nursing medication room Omnicell (automated medication dispensing machine). This deficient practice has the potential to expose patients to unsafe, ineffective medications and supplies resulting in inadequate results.

Findings include:

- Freezer located in the PACU observed on 9/26/2017 at 10:50 AM revealed the following outdated medications:

1. Forty Four Acetaminophen (a medication used to treat pain) 650 milligram suppositories with an expiration date of 1/2017.
2. Twelve vials of Lidocaine 0.9% (a medication used to numb the skin) with an expiration date of 7/12/2017.
3. Nine tubes filled with RPMI with PSN and FBS (used for cell cultures) with an expiration date of 10/2015.

Registered Nurse (RN), Staff G confirmed the medications and supplies were outdated and indicated the physician that used the medications stored in the freezer no longer comes to their facility and they had forgotten the items were in the freezer.

Policy titled "Medication/Supplies Outdate Policy" reviewed on 9/27/2017 at 7:00 PM directed ...items that are outdated will be logged in the outdate log book, removed and replaced with an in date item...


- Nursing Medication Room Omnicell observed on 9/26/2017 at 2:24 PM revealed one, 1000 ml bag of 5% IV Dextrose (sugar water) in normal saline (salt water) with an expiration date of 8/1/2017, and three vials of rabies vaccine with an expiration date of 6/17/2017.

Pharmacy Nurse, Staff C interviewed on 9/26/2017 at 2:24 PM acknowledged the IV bag was expired. Staff C reported the rabies vaccines were ordered special for a family, but they never came to get the injections. Staff C added that the expiration date was incorrectly put into the Omnicell machine.

Policy titled, "Pharmacy Outdates and Recalls" reviewed on 9/27/2017 directed, ...Medications with a specific date such as, (1 Dec 17) will be outdated the prior month (1 Nov. 17)... and ...all expired meds and recalls will be placed in the appropriately labeled bins an sent with the licensed pharmacy disposal company EXP every 3 months...

Based on interviews and document review, the Critical Access Hospital (CAH) failed to provide evidence of a system to monitor for Adverse Drug Reactions (ADRs). This deficient practice places patients at risk for adverse drug reactions.

Findings include:

- Pharmacy Nurse, Staff C interviewed on 9/27/2017 at 1:29 PM reported the facility has had ADRs in the past and indicated they were reported to the Quality Manager and the Pharmacist, but was unable to show evidence of ADR tracking. Staff C stated they were not able to recall the patient's names that have had these reactions and because they did not keep a paper copy of the report sent to the pharmacist, they could not provide evidence of tracking.

- Quality Nurse, Staff D interviewed on 9/27/2017 at 2:30 PM reported that the ADR reports are placed in risk management and discarded after one year. Staff D shared there was one ADR about two years ago, but was not able to recall who the patient was.

Policy review on 9/27/2017 revealed the CAH failed to provide a policy directing staff to track and maintain records of ADRs.

Based on observation, staff interview and policy review the Critical Access Hospital (CAH) failed to ensure single use sterile supplies remain unopened prior to use in the Post Anesthesia Care Unit (PACU); failed to ensure infection control practices were followed for one of two observed medication administrations; failed to ensure the ice machine was clean; failed to ensure therapy equipment surfaces were cleanable for 2 of 4 Therapy treatment rooms (rooms 2 and 3); and failed to ensure staff food and patient food were stored separately in the Occupational Therapy (OT) refrigerator. These deficient practices have the potential to cause hospital-associated infections.


Findings include:

- Post Anesthesia Care Unit's Glide Scope Mobile Unit observed on 9/26/2017 at 10:30 AM revealed three nasal tracheal tubes cuffed (a device placed in a patients airway to provide oxygen) sizes 6.5, 7.0, and 7.5 open and available for use.

Registered Nurse (RN), Staff G interviewed on 9/26/2017 at 10:40 AM confirmed the Nasal Tracheal tubes are single use sterile items that should be discarded after opening.

Policy review on 9/27/2017 at 4:00 PM revealed the CAH failed to provide a policy directing staff to ensure single use sterile items were discarded if the packaging was not intact.


- Certified Registered Nurse Anesthetist (CRNA), Staff F observed on 9/26/2017 at 9:45 AM revealed them removing the top off an unidentified vial of medication and withdrawing the medication without cleaning the rubber septum.

CRNA, Staff F interviewed on 9/26/2017 at 10:10 AM confirmed they did not clean the septum and agreed they should have.

Policy review on 9/27/2017 at 4:00 PM revealed the CAH failed to provide a policy directing staff to ensure they clean the septum of medication vials prior to piercing and withdrawing the medication.


- Post Anesthesia Care Unit's Ice Machine observed on 9/26/2017 at 10:35 AM revealed it to have a whitish buildup on the ice dispenser and a blue/green build up with rust on the bottom of ice machine tray.

RN, Staff H interviewed on 9/26/2017 at 10:35 AM confirmed the whitish and blue/green buildups on the ice machine and indicated they do not use it because the ice tastes "funny".

Policy review on 9/27/2017 at 4:00 PM revealed the facility failed to provide a policy directing staff to ensure the ice machine was clean and without buildup.


- Therapy Treatment Rooms observed on 9/26/2017 at 10:28 AM revealed the therapy treatment mats in room 2 and 3 had multiple small tears in the plastic coating, rendering the surface un-cleanable.

- OT Treatment area observed on 9/26/2017 at 10:30 revealed a refrigerator containing bottled water and personal staff food items.

- Therapy Director, Staff J interviewed on 9/26/2017 at 10:30 acknowledged the tears in the mat. Staff J also communicated the refrigerator stored bottled water for therapy patients as well as the staff's food.

Policy review on 9/27/2017 revealed the facility failed to provide a policy directing staff to store patient food separately from staff foods.


- Housekeeping Staff, Staff I observed performing a terminal cleaning of a discharged patients room on 9/27/2017 at 12:59 PM revealed Staff I cleaning the bathroom and then placing the used rag into a trash bag. Staff I then took a dry clean mop rag and submerged it in to the clean soap and water container without changing the dirty gloves. This deficient practice has the potential to contaminate the clean soap and water mixture reducing its effectiveness. Staff I failed to change their gloves between cleaning dirty surfaces and soaking a new cleaning rags on three more occasions during the observation.

- Policy titled "Environmental Services/ Housekeeping Cleaning the Patient Room Dismissal" reviewed on 9/27/2017 directs, ...Remove gloves upon completion of bathroom cleaning and discard..."