HospitalInspections.org

Based on observation, policy review, review of product labels, and staff interview, the Critical Access Hospital (CAH) failed to safely store hazardous chemicals on 4 of 5 floors (First, Second, Third, and Fifth Floor) of the facility. Failure to safely store hazardous chemicals may result in cognitively impaired patients sustaining an injury.

Findings include:

Review of the policy titled "Hazard Communication Program" occurred on 03/01/23. This undated policy stated, ". . . Ensure personnel use, transport, and store hazardous materials in a safe manner. . . ."

An observation on 02/28/23 at 1:20 p.m. showed an unlocked therapy gym on the fifth floor
with a "Pro Lysol Disinfectant" spray can on top of a desk and an "Ace Pure Silicone Lubricant" spray can, a "Food Grade Silicone" spray can, and a container of "PRV Super Strength Cleaner" in an unlocked cupboard.

Observations on 03/01/23 at 3:00 p.m. showed the following:
* An unlocked ambulatory care area on the first floor with a "Lysol Disinfectant" spray can in a bin hanging on the wall in the stress test room and another spray can on the railing in the bathroom.
* An unlocked laundry room on the second floor with a container of "Scotchguard," two "Spray and Wash" spray bottles, and two containers of "Clorox Germicidal Bleach" on top of the counter.
* Two unlocked shower rooms on the second floor with a "3M Disinfectant Cleaner RCT Concentrate" spray bottle on top of the counter.
* An unlocked tub room on the second floor with a "3M Disinfectant Cleaner RCT Concentrate" spray bottle on top of the counter, and a container of "Clorox Germicidal Bleach" and a container of "Gen Keen IV 1 Step Disinfectant" on the floor.
* An unlocked utility room on the third floor with an "Award Furniture Polish" spray can, a bottle of "Comet Cleaner with Bleach," a "Glass Cleaner Fortified with Amnonia RTV" spray bottle, three "Linen 9000" spray bottles, four "Lysol Disinfectant" spray cans, a "Neutral Quat Disinfectant Cleaner" spray bottle, a bottle of "Ready-to-Use 3M Phosphoric Acid Restroom Cleaner," and a "Stainless-Steel Cleaner" spray can sat in two unlocked cupboards.
* The unlocked therapy gym on the fifth floor with the same chemicals accessible to patients.

Review of the product labels identified the following:
* "causes eye irritation" - Comet Cleaner with Bleach and Scotchguard
* "causes moderate eye irritation" - 3M Disinfectant Cleaner RCT Concentrate, Lysol Disinfectant, and Pro Lysol Disinfectant
* "causes serious eye irritation" - Linen 9000
* "causes eye and skin irritation" - Award Furniture Polish and Glass Cleaner Fortified with Amnonia RTV
* "causes eye, skin, nose, and throat irritation" - Neutral Quat Disinfectant Cleaner
* "harmful if swallowed, causes skin irritation" - PRV Super Strength Cleaner
* "causes eye and skin irritation, may be harmful if directly inhaled" - Spray and Wash
* "vapors harmful, irritant to eyes, skin, and respiratory tract" - Food Grade Silicone
* "causes eye, skin, and digestive tract burns, may cause nose and throat irritation" - Ready-to-Use 3M Phosphoric Acid Restroom Cleaner
* "causes irreversible eye damage and skin burns, harmful if swallowed" - Clorox Germicidal Bleach
* "corrosive, causes irreversible eye damage and skin burns" - Gen Keen IV 1 Step Disinfectant
* "harmful or fatal if swallowed" - Ace Pure Silicone Lubricant and Stainless-Steel Cleaner

During interview on 03/01/23 at 3:30 p.m., a maintenance staff member (#1) confirmed, "Chemicals should be locked, especially if harmful with exposure."

Based on record review, review of the facility's "Medical Staff Bylaws," and staff interview, the Critical Access Hospital (CAH) failed to ensure a doctor of medicine or osteopathy periodically reviewed and signed the records of all inpatients cared for by Allied Health Professionals (AHP) (nurse practitioners, clinical nurse specialists, certified nurse midwives, or physician assistants) for 2 of 4 closed records (Patient #12 and #19) reviewed. Failure to periodically review and sign records of inpatients cared for by the AHP limited the CAH's ability to ensure the quality and appropriateness of patient care provided.

Findings include:

Review of the CAH's current "Medical Staff Bylaws" occurred on 03/09/23. The bilaws stated, ". . . Any AHP who functions under the supervision/collaboration of a duly licensed physician, must be supervised by or practice in collaboration with a Member that has an Appointment to the Medical Staff at the Hospital. . . ."

On the afternoon of 02/27/23, the CAH provided a list of inpatient admissions from August 1, 2022-January 31, 2023. Review of the medical records also occurred on 02/27/23. The records identified a nurse practioner admitted the following patients to the CAH, but lacked evidence a physician reviewed and signed the records:
* Patient #12 admitted on 09/02/22.
* Patient #19 admitted on 10/07/22.

During an interview on 03/01/23 at 2:00 p.m., an administrative staff member (#7) confirmed she was unable to locate evidence a physician reviewed and signed Patient #12 and #19's inpatient records.

Based on record review, review of the facility's "Medical Staff Rules and Regulations," and staff interview, the Critical Access Hospital (CAH) failed to ensure staff notified the medical doctor (MD) or doctor of osteopathy (DO) when a nurse practitioner (NP), physician's assistant, or clinical nurse specialist admitted a patient to the CAH for 2 of 4 patients (Patient #12 and #19) admitted by an NP. Failure of staff to notify the MD/DO of patients admitted by a NP, physician's assistant, or clinical nurse specialist limited the physician's ability to ensure the appropriateness of the admission and to monitor the care provided to the patients by the NP,
physician's assistant, or clinical nurse specialist.

Findings include:

Review of the CAH's current "Medical Staff Rules and Regulations" occurred on 03/01/23. These rules, updated 11/19/15, failed to address the need for a physician to be notified of the
NPs', physician's assistants', or clinical nurse specialists' admissions to the CAH.

Review of patient medical records occurred on 02/27/23. The records identified a NP admitted the following patients to the CAH, but lacked evidence staff notified a physician of the admissions:
* Patient #12 admitted on 09/02/22.
* Patient #19 admitted on 10/07/22.

During an interview on 03/01/23 at 2:00 p.m., an administrative staff member (#7) confirmed she was unable to locate evidence staff notified the physician when a NP admitted Patient #12 on 09/02/22 and admitted Patient #19 on 10/07/22.

Based on plan review, meeting minutes review, document review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Assurance and Performance Improvement (QAPI) program evaluated all patient care services/departments affecting patient health and safety for 4 of 4 quarters reviewed (3rd Quarter 2022, 4th Quarter 2022, 1st Quarter 2023, and 2nd Quarter 2023). Failure to ensure all departments report monitoring to the QAPI committee limited the CAH's ability to ensure the provision of quality care to the CAH's patients.

Findings include:

Review of the CAH's "Performance Improvement (PI) Risk Management Plan," dated 03/02/22, stated, ". . . The Medical Staff and employees . . . will participate in ongoing and systematic performance improvement efforts and identify actual and potential risks to patient safety. . . . Scope: To achieve the goal of delivering high quality of care, all Medical Staff and employees are given the responsibility and authority to participate in the performance improvement program. The Performance Improvement Program includes the following activities: All direct and indirect services affecting patient health, treatment and safety . . . The members of the Quality and Value Committee are responsible for: Assuring that the review functions outlined in this plan are completed . . . Department Staff Responsibility: . . . implementing performance improvement activities. . . . Department managers are responsible for identifying performance indicators, collecting and analyzing data, developing and implementing changes to improve service delivery, and monitoring to assure that improvement is made and sustained. . . ."

Reviewed on February 28 - March 1, 2023, the CAH's "Quality and Value" committee meeting minutes (3rd and 4th Quarters 2022 and 1st and 2nd Quarters 2023) lacked evidence the departments providing dietary, cardiac rehabilitation, and social services submitted PI monitoring reports for all four quarters.

During interview on 02/28/23 at 11:00 a.m., an administrative staff member (#2) indicated the dietary department is currently not performing PI monitoring.

During interview on 03/01/23 at 1:40 p.m., a quality improvement staff member (#6) confirmed the departments providing dietary, cardiac rehabilitation and social services failed to submit PI monitoring reports to the Quality and Value committee for the last four quarters.