HospitalInspections.org

Based on observation and staff interview, the CAH failed to store sterile equipement used inthe administration of vaccines in accordance with accepted professional principals in the pediatric practice and failed to ensure 3 vials of outdated medication were not available for patient use in the general surgery practice.

Findings include:

Observation in the laboratory cabinet located in the pediatric office on 8/4/2021 at 1:15 p.m. revealed approximately 40 pre-assembled 1 mL syringe/needle sets stored in a non-sterile environment. Further observation found syringe and needles not yet assembled together were stored in separate individually wrapped sterile packaging.

Interview with Staff C (Practice Coordinator) on 8/4/2021 at 1:15 p.m. confirmed the above observation and revealed pre-assembly of the syringe and needles was performed to save time when administering vaccines. Staff C confirmed that the syringes and needles are received separately in sterile packaging.

The CAH could not provide a reference to professional standards during the remainder of the survey, that outlines the practice of pre-assembly and non-sterile storage of syringe/needle sets for later use with vaccine administration.

Observation of the storage room in Internal Medicine on 8/4/2021 at 2:10 p.m. revealed two single dose vials (1 mL each) of Diphenhydramine (lot 6020128) expired July 2021 and were stored with other medications available for patient use.

Interview with Staff D (Clinical Manager) on 8/4/2021 at 2:10 p.m. confirmed the above observation.

Observation of the medication storage area in General Surgery on 8/5/2021 at 8:30 a.m. revealed one single dose vial (5 mL) of 1% Lidocaine (lot AF44259) expired on 8/1/2021 and was stored with other medications available for patient use.

Interview with Staff D (Clinical Manager) on 8/5/2021 at 2:10 p.m. confirmed the above observation.

Based on interview and record review the Critical Access Hospital failed to accurately write an admission order for swing-bed services (after a discharge order from acute inpatient care services) for 1 of 3 swing-bed patients reviewed that were admitted to swing-bed status. (Patient identifier is #27).

Findings include:

Review on 8/4/21 of Resident #27's clinical record revealed that Resident #27 had a physician's order dated 6/18/21 that read "DISCHARGE TO: Swing stay from acute stay." There was not a subsequent admission order for swing-bed services in Resident #27's record.

Interview on 8/5/21 at approximately 10:20 a.m. with Staff B (Electronic Medical Record Manager) confirmed that there was not an admission order for swing-bed services for Resident #27.

Interview on 8/5/21 at approximately 10:30 a.m. with Staff A (Registered Nurse, Director of Quality/Compliance/Risk Safety) confirmed that there was not an admission order for swing-bed services for Resident #27.

Based on interview and record review the Critical Access Hospital failed to maintain completed closed medical records and follow the hospital medical staff's rules and regulations for deficiencies in delinquent chart documentation between 1/1/21 to 8/3/21.

Findings include:

Review on 8/3/21 of the facility's Deficiency Report (requested for the timeframe of 1/1/21to 8/3/21), printed on 8/3/21, revealed the following:
-There were a total of 31 medical records that were delinquent over 30 days;
-There were 13 providers listed with deficient records;
-Twenty-three records were missing dictation and 8 records were missing signatures;
-Deficient documentation included: procedures, orders, diagnoses, dates, consultations, progress notes and reports;
-The oldest age of deficiency was 167 days old;
-All delinquent documentation was from the Emergency Department.

Review on 8/3/21 of the facility's Medical Staff Rules/Regulations, reviewed on 9/10/20, read, in part, " ...Medical Records ... E. Documentation Requirements and Definitions. 1. A completed chart has all documentation and signatures completed .... 5. Progress notes, outpatient notes, consultation notes, diagnostic tests or procedure notes must be completed in the electronic health record (EHR) or otherwise recorded within 24 hours. 6. Telephone orders are to be signed within 48 hours .... 8 EHR orders are to be signed within 15 days. F. Deficiencies in Documentation. 1. A medical record with be determined to be deficient when any of the above requirements are not met. 2. Health Information Management personnel will inform the Practitioner about the deficiency at the time of discovery. 3. A chart will become delinquent if a deficiency is not correct within 15 days from the date of deficiency and a written warning will be issued at that time. 4. If the record delinquency is not corrected 72 hours after the written warning the Practitioner will be automatically assessed a fine of $50 per chart ... and each week until the delinquency is corrected. 5. If the delinquency is not corrected, or the fine is not paid, within 30 days the Practitioner's clinical privileges will be deemed to have been voluntarily indefinitely relinquished ..."

Interview on 8/3/21 at approximately 1:20 p.m. with Staff E (Health Information Management Tech/Hospital Medicine Practice Coordinator) revealed that he/she did not document when the practitioners were notified of delinquent documentation. Staff E stated he/she placed the deficiency reports in the practitioner's bins weekly. Staff E could not provide documentation that the practitioners listed in the above report had been notified of the deficiencies.

Interview on 8/3/21 at 3:15 p.m. with Staff A (Registered Nurse, Director of Quality/Compliance/Risk Safety) confirmed that the facility did not track or log notifications to the practitioners in the above deficiency report. Staff A also stated that the facility had not issued written warnings and/or monetary fines to any of the 13 providers listed on the above Deficiency Report.