HospitalInspections.org

Based on observation and interview, the critical access hospital (CAH) failed to ensure routine testing for 1 of 1 telehealth machines in the emergency department (ED) had been completed as directed by the ED Telehealth Resource Manual. In addition, the CAH failed to ensure a defibrillator located in the operating room (OR) was routinely inspected and tested.


Findings include:


On 5/22/17, at 2:35 p.m. a tour of the ED was conducted with registered nurse (RN)-C. Stationed in ED room number three, a hand written sign dated 5/16/17, was taped to a telehealth monitor which indicated the ED telehealth machine was not working and a part was coming. The Telehealth Test Connection Call Log indicated the last time the machine had been functioning was 5/2/17, and on 5/16/17, it had been identified as not working. Registered nurse (RN)-C stated she thought the telehealth machine was supposed to be checked weekly to ensure it was working. RN-C confirmed the ED telehealth was utilized for any trauma, stroke, STEMI (ST elevation heart attack) or any other serious ED patient case they wanted to consult with a telehealth physician.


On 5/23/17, at 11:09 a.m. director of nursing (DON) verified the ED telehealth machine was not working and that a part had been ordered. DON stated the ED telehealth machine should be checked daily to ensure it was operational. DON confirmed the ED Telehealth Resource Manual, which was located with the ED telehealth machine, directed staff to test the machine three times a day (every shift). DON confirmed the Telehealth Test Connection Call Log had some gaps which indicated the telehealth equipment had not been tested daily or as directed by the ED Telehealth Resource Manual


Telehealth Test Connection Call Log indicated that over the last three months (2/24/17 thru 5/16/17) the ED telehealth machine had been tested ten times.


The ED Telehealth Resource Manual, dated 2/27/13, indicated the telehealth equipment should be tested on a regular basis to ensure proper operation. The CAH would initiate telehealth testing at specific times and that testing would be completed every shift between 8:00 a.m. and 10:00 a.m., 3:00 p.m. - 5:00 p.m., and 2:00 a.m. - 4:00 a.m.


34985


On 5/23/17, at 9:15 a.m. a tour of the OR with licensed practical nurse (LPN)-A revealed a defibrillator on a metal stand in the corner of the room. LPN-A reported to her knowledge the defibrillator was not checked for safe functioning and reliability on a routine basis. LPN-A stated biomedicine did perform annual preventative maintenance. However, the CAH was not able to provide documentation of completed safety checks.


On 5/24/17, at 8:10 a.m. the DON verified the defibrillator in the operating room was not routinely checked as the other defibrillators in the hospital were. DON indicated the one in the OR should also be routinely checked.

CAH policy was requested and not received.

Based on observation, interview, and document review the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: K131, K353, K372, K711, K712, K781, K900

Based on interview and document review, the critical access hospital (CAH) was found not to be in compliance with 485.627 Condition of Participation for Organizational Structure due to the failure of the governing body to assure full legal responsibility for the implementing and monitoring policies and bylaws governing the CAH's total operation related to the credentialing/recredentialing iof providors.


Findings include:


See C241: The governing body failed to assume full legal responsibility for the implementation of medical staff and governing body by-laws related to the appointment/reappointment of medical staff to ensure patients received quality care.

Based on interview and document review, the critical access hospital (CAH) failed to ensure 13 of 14 providers (MD-A, MD-B, MD-C, MD-D, MD-E, MD-F, MD-G, MD-H, MD-I, physician assistant - PA-A, PA-B, certified registered nurse anesthetist- CRNA-A, CRNA-B) had been appropriately re-credentialed. This had the potential to affect all patients served by the CAH.


Findings include:


On 5/24/17, at 10:38 a.m. the credentialing files were reviewed with the administrator and credential specialist of essential health (CS). CS explained currently the credentialing process for the CAH was coordinated through herself and the West Region Quality Board for Essential Health. The West Region Quality Board for Essential Health approved the appointment/reappointment as delegated to them by the West Region Governing Board of Directors. Prior to a provider's appointment/reappointment being approved, the request for privileges was reviewed by the credentials committee and the medical executive committee to verify competence and completeness of the privileging request. CS confirmed the West Region Board oversaw the credentialing process for the Ada CAH, Fosston CAH, Graceville CAH, and St. Mary's - Detroit Lakes CAH. The findings of this review included:


1. MD-A's request for reappointment privileges dated 4/10/15, lacked delineation for which CAH MD-A had requested family medicine privileges. MD-A's recommendation for reappointment by the medical staff dated 6/18/15, indicated they recommended MD-A for family medicine and obstetrics privileges (even though MD-A had only requested for family medicine privileges). The Essential Health West board of directors approved MD-A's request for clinical privileges "as requested" dated 7/27/15. MD-A's credentialing file lacked documentation that a background check had been completed.


2. MD-B's request for reappointment privileges dated 7/6/15, lacked delineation for which CAH MD-B had requested privileges. MD-B's credentialing file lacked documentation that a background check had been completed.


3. MD-C's request for reappointment privileges dated 10/4/15, lacked delineation for which CAH MD-C had requested privileges. MD-C's credentialing file lacked documentation that a background check had been completed.


4. MD-D's request for reappointment privileges dated 3/7/16, lacked delineation for which CAH MD-D had requested privileges. MD-D's recommendation for reappointment by the medical staff dated 6/8/16, indicated the medical staff recommended MD-D under the medical staff category as "active". However, the letter sent by the Essentia Health West Region, indicated MD-D had been approved under the "courtesy" medical staff member category. MD-D's credentialing file lacked documentation that a background check had been completed.


5. MD-E's request for reappointment privileges dated 8/11/16, lacked delineation for which CAH MD-E had requested privileges. MD-E's credentialing file lacked documentation that a background check had been completed.


6. MD-F's request for reappointment privileges dated 2/4/16, lacked delineation for which CAH MD-F had requested privileges.


7. MD-G's request for reappointment privileges dated 12/30/14, lacked delineation for which CAH MD-G had requested privileges. MD-G's credentialing file lacked documentation that a background check had been completed.


8. MD-H's request for reappointment privileges dated 9/16/15, lacked delineation for which CAH MD-H had requested privileges. MD-H's credentialing file lacked documentation that a background check had been obtained.


9. MD-I's request for reappointment privileges dated 5/29/15, lacked delineation for which CAH MD-I had requested privileges. MD-I's credentialing file lacked documentation that a background check had been obtained.


10. PA-A's request for reappointment privileges dated 10/4/16, lacked delineation for which CAH PA-A had requested privileges.


11. PA-B's request for reappointment privileges dated 8/31/15, lacked delineation for which CAH PA-B had requested privileges. PA-B's credentialing file lacked documentation that a background check had been obtained.


12. CRNA-A's request for reappointment privileges dated 8/13/15, lacked delineation for which CAH CRNA-A had requested privileges. CRNA-A's credentialing file lacked documentation that a background check had been obtained.


13. CRNA-B's request for reappointment privileges dated 3/24/15, lacked delineation for which CAH CRNA-B had requested privileges. CRNA-B's credentialing file lacked documentation that a background check had been obtained.


On 5/24/17, at 11:21 p.m. CS and administrator confirmed the above noted findings. CS verified all privilege application forms for appointment/reappointment should have a clear area for the provider to delineate which CAH the provider had requested privileges. In addition, providers should have documentation that a background check was obtained.


Medical Staff Recredentialing and Credentialing Advanced Practice Registered Nurse, Physician Assistant, Allied Health Professionals and Other Medical Professionals policies dated 9/18/15, indicated the credentials committee, the executive committee and the board of directors shall be responsible for identifying criteria, reviewing credentials, and approving clinical reappointment and scope of practice for a practitioner. In addition, one of the steps in the process for assessing and validating the qualifications of the physician/practitioner to provide patient care and service at the CAH would be based on submission of an appropriate criminal background study. The completed study results would be part of the credentialing file.


Medical Staff Credentialing and Recredentialing MD's, DO's , Foreign Medical Graduates (Physicians) with valid ECFMG certificate, DPM's , DDS policies dated 9/18/15, indicated the credentials committee, the executive committee and the board of directors shall be responsible for identifying criteria, reviewing credentials, and approving clinical reappointment and scope of practice for a practitioner. In addition, one of the steps in the process for assessing and validating the qualifications of the physician/practitioner to provide patient care and service at the CAH would be based on submission of an appropriate criminal background study. The completed study results would be part of the credentialing file.


Amended and Restated Bylaws of Bridges Medical Center (corporate governing body bylaws for ADA) dated 5/5/16, indicated Innovis had the responsibility for overseeing the medical staff credentialing in the West Region.
Bridges Medical Center Medical Staff By-Laws, Rules and Regulations dated 8/2010, indicated no person should admit or provide medical or health-related services to patients in the hospital unless they are a member of the medical staff or has been granted privileges in accordance with the procedures set forth in the bylaws.

Based on interview and document review, the critical access hospital (CAH) failed to provide documentation that the governing body had approved the appointment of the administrator.


Findings include:


On 5/25/17, at 10:01 a.m. the administrator confirmed she had accepted the administrator position at the CAH on 7/1/16, and stated this appointment should have been documented in the minutes of the 8/15/16, Board of Directors meeting minutes. The administrator confirmed the CAH lacked documentation by the CAH's Board of Directors that they had approved her appointment as the administrator for the CAH.


The CAH's organizational chart dated 2017, indicated the administrator had direct oversight for the day to day operations of the CAH.


The CAH's Board of Directors meeting minutes dated 8/15/16, lacked documentation of the Board of Directors approval for the appointment of the current administrator.

Based on observation, interview and document review, the critical access hospital (CAH) failed to ensure 4 of 4 registered nurses (RN-B, RN-C, RN-D, RN-E) who compound intravenous (IV) medication, had documentation they had been trained and determined to be competent to compound sterile preparations. In addition, the CAH failed to ensure the security of controlled medications in the pharmacy and surgical services area were maintained.
This had the potential to affect all patients served by the CAH.


Findings include:


Employee compounding competency:


On 5/22/17, at 11:22 a.m. the pharmacist confirmed the CAH recently obtained a laminar flow hood which was due to be inspected this week. Pharmacist confirmed they have not used the hood yet, however, the pharmacist and nursing staff have done simple sterile compounding of IV medications.


On 5/22/17, at 2:00 p.m. the pharmacist stated once the laminar flow hood was inspected and certified for use, the nursing staff would be expected to compound the medications under the hood during the off hours when the pharmacist was not available. The pharmacist confirmed she had not completed any training with the nursing staff to ensure they were competent with sterile compounding. The pharmacist confirmed a pharmacist was on site Monday - Friday from about 9:00 a.m. until 2:00 p.m. Any compounding of sterile IV medications after hours would have been done by the registered nurse (RN) on duty.


On 5/23/17, at 12:15 p.m. director of nursing (DON) confirmed the RN's who worked at the CAH had not received any training on sterile compounding of medications.


On 5/23/17, the pharmacist stated that once the CAH had the laminar flow hood in place, then the CAH would be more compliant with the sterile compounding regulations.


On 5/23/17, at 3:42 p.m. RN-B confirmed she had not received training with regards to the proper procedure for sterile compounding of IV medications.


On 5/24/17, at 2:13 p.m. administrator confirmed none of the RN's who worked at the CAH had been trained or deemed competent with sterile compounding of medications. Administrator stated it was her expectation that the CAH followed the most current guidelines for sterile compounding.


On 5/24/17, at 1:09 p.m. RN-B, RN-C, RN-D, and RN-E's education records were reviewed with the human resource manager (HRM) and administration assistant (AA). HRM and AA verified RN-B, RN-C, RN-D, and RN-E's educational records lacked documentation of sterile compounding training.

Pharmacist-In-Charge job description dated 11/2/15, indicated the pharmacist would ensure pharmacy standards of practice were maintained.

A policy on sterile compounding was requested, but not received.


Security of medications in the pharmacy:


On 5/22/17, at 11:10 a.m. the pharmacist confirmed nursing staff had access to the pharmacy and have accessed the pharmacy during the off hours when the pharmacist was not on duty. The pharmacist confirmed a pharmacist was on site Monday-Friday from 9:00 a.m. until 2:00 p.m.


On 5/22/17, at 1:52 p.m. during the initial tour of the pharmacy with the pharmacist, an unlocked cupboard was found to have an open/uncovered bin with the following controlled medications readily accessible:


* Seven - lorazepam 0.5 milligrams (mg) tablets (sedative used to treat anxiety)
* Two - lorazepam 2mg/milliliter (mg/ml) vials
* One - Morphine Sulfate (MS) 2mg syringe (narcotic)


The pharmacist confirmed these medications were expired and were being kept so they could be returned to the CAH's contracted medication return company, which came quarterly. The pharmacist confirmed the last time the company had come for a pick-up was 3/22/17, and stated she had no system in place to track these medications from the time they were removed out of the automated drug dispensing machine and the time they were handed over to the medication return service. The pharmacist verified these medications listed above should be double locked and the current process the CAH had in place did not provide proper security of these controlled medications.


On 5/23/17, at 1:57 p.m. the pharmacist verified there were no surveillance cameras located in the pharmacy.


Controlled Substances policy dated 7/13/16, indicated a complete physical inventory of scheduled controlled medications stored in the pharmacy should be performed monthly. All scheduled II controlled substances would be stored in a securely locked cabinet in the pharmacy. The disposal of outdated or unused controlled substances shall be performed in accordance with Federal and State regulations.



34985



On 5/23/17, at 9:15 a.m. a tour of the sterile reprocessing room with licensed practical nurse (LPN)-A revealed a medication storage cupboard. The electronic keypad did not work, which left the medications accessible to all staff that had access to the area. LPN-A explained the cupboard had not worked for about a month. LPN-A stated nurses, physicians, housekeepers, and maintenance personal had badge access to room. The cupboard contained the following medications:


-40 bottles of Xylocaine 0.5%; expiration date of 4/18.
-19 bottles of Xylocaine with epinephrine 1:100,000; expiration date of 8/18
-9 bottles of lidocaine 2%; expiration date of 2/1/18
-7 bottles of lidocaine 1%; expiration date of 6/1/18
-24 bottles Omnipaque; expiration date 12/2/19
-24 bottles of Bupivacaine 0.25%; expiration date of 4/1/18
-9 bottles of Marcaine 0.25% with epinephrine 1:200,000; expiration date 9/1/17
-23 bottles of Xylocaine 2%; expiration date of 10/18
-26 bottles of Bupivacaine HCL 0.5% with epinephrine 1:200,000; expiration date of 11/1/17
-8 bottles of epinephrine 1:1000; expiration date of 10/1/17
-22 bottles of Bupivacaine 0.5%; expiration date 6/1/18
-31 bottles Bupivacaine 0.75%; expiration date 4/18
-14 bottles Dexamethasone Sodium phosphate; expiration date 1/18
-6 bottles of Depomedrol 80mg/ml; expiration date 1/18
-6 bottles of Depomedrol 40mg/ml; expiration date of 12/17


0n 5/24/17, at 8:10 a.m. the DON stated she was not aware the lock on the cupboard had broken and indicated the medications should have been secured.

-At 1:35 p.m. the pharmacist verified the cupboard did not lock and housekeepers had access to that area for cleaning. The pharmacist was not aware of what the present inventory should be in the cupboard and there had not been a routine tracking system in place for medication usage. The pharmacist stated the medications were not secured and the system in place was not ideal.


CAH's policy, Storage of Drugs and Biologicals last revised 4/14/16 read, "All drugs and biologicals are stored within the guideline of State and Federal Law."

Based on observation, interview and record review the Critical Access Hospital (CAH) failed to ensure appropriate infection control techniques were utilized for 1 of 2 patients (P4) reviewed for isolation precautions. In addition, failed to ensure reprocessing of sterile surgical instruments included biological testing. This had the potential to affect all patients all patients served by the CAH.

Findings include:


P4's admission history and physical dated 1/26/17, indicated P4 was admitted to the CAH with diagnoses that included, but were not limited to: Influenza A (a serious and contagious respiratory illness that's caused by the influenza virus). P4's admission order's included isolation precautions used to minimize the transmission of influenza A to other patients and staff.


Review of P4's medical record revealed there was no documentation which indicated isolation precautions had been implemented as ordered by the physician's assistant (PA) who admitted P4. Additionally, P4's care plan had not identified P4 required isolation for influenza A.


The director of nursing (DON) was interviewed on 5/25/17, at 10:30 a.m. and confirmed P4's medical record had not indicated P4 had been placed in isolation as ordered by the physician's assistant at the time of admission.


The facility policy for infection control and use of isolation dated 6/10/15, identified that the CAH will use Standard Precautions and additional transmission based precautions as indicated for known, suspected or incubating infections or communicable diseases, for the protection of the hospitals patients, visitors, and staff from potential exposure to infectious, communicable and transmissible diseases.


34985


On 5/23/17, at 9:15 a.m. a tour of the sterile reprocessing room with licensed practical nurse (LPN)-A revealed all necessary components for biological testing, however, there was no record of completed biological tests. LPN-A stated currently no biological testing was performed and had never been performed as part of reprocessing of instruments. LPN-A stated, recently staff had visited a sister hospital for training and discovered they lacked biological testing of supplies, and equipment training for biological testing had been set up for 6/8/17. LPN-A reported no knowledge of infections or adverse consequences had resulted from the lack biological testing.


On 5/24/17, at 8:10 a.m. The DON confirmed the lack of biological testing and the hospital had arranged for training on 6/8/17.


CAH policy, Immediate Use Sterilization last revised 5/24/17 included: To insure that materials labeled "sterile" are in fact sterile when used on patients, three types of Quality Controls are necessary (administrative, process, and biological). The policy advised staff biological controls were to insure that conditions were met within the sterilization method chosen and to monitor the efficacy of the sterilization process

Based on interview and document review, the critical access hospital (CAH) failed to ensure the list of services furnished under arrangement or agreement included the key components of these services provided to the CAH. This had the potential to affect all patients who received services at the CAH.

Findings include:

On 5/23/17, at 2:24 p.m. the administrator provided the CAH's current list of services provided through arrangement or agreement. This list [undated] identified the company which the CAH had the agreement/arrangement with and the services which were being contracted. However, the administrator confirmed this list of services provided by arrangement/agreement lacked identification of whether the services being contracted where offered on or off-site, whether there was a limit on the volume or frequency of the service provided and when the services were available.

Based on interview, and document review, the facility failed to follow the policy and procedure to ensure a nursing plan of care was developed with identified problems and interventions for 3 or 20 patient (P1, P4, and P9) sampled inpatients. Failure to develop a nursing care plan with identified problems and interventions had the potential for provision of inadequate nursing care with appropriate interventions for all patients admitted to the facility.


Findings include:


Review of the closed medical record for P1 revealed an admission date of 12/20/16, with a diagnosis of dental abscess, and facial cellulitis. Review of the EHR (electronic health record) revealed the Registered Nurse (RN)-C had completed and electronically signed the admission care plan on 12/20/16, however, the care plan had not identified the problem area of infection, and interventions related to infection had not been developed. During an interview, on 5/24/17 at 10:20 a.m. RN-C confirmed P1's care plan had not included infection as an identified problem and specific interventions related to infection had not been developed.


Review of the closed medical record for P4 revealed an admission date of 1/26/17. P4's admission history and physical dated 1/26/17, indicated diagnoses that included, but were not limited to : Influenza A (a serious and contagious respiratory illness that's caused by the influenza virus). P4's admission order's included isolation precautions used to minimize the transmission of influenza A to other patients and staff. P4's care plan dated 1/26/17, had not identified P4 required isolation for influenza A. The director of nursing (DON) was interviewed on 5/25/17, at 10:30 a.m. and confirmed P4's medical record had not indicated P4's care plan had not included the need for isolation precautions.



Review of the closed medical record for P9 revealed a brief admission note that indicated an admission date of 2/27/17, and diagnosis of osteomyelitis (inflammation of the bone due to infection). Review of the EHR (electronic health record) revealed the Registered Nurse (RN)-F had completed and electronically signed the admission care plan on 2/28/17, however, the care plan had not identified the problem area of infection, and interventions related to infection had not been developed. During an interview, on 5/25/17 at 10:20 a.m. RN-C confirmed P9's care plan had not included infection as an identified problem and specific interventions related to infection had not been developed.


Review of the facilities policy for Interdisciplinary Plan of Care dated 9/1/16, provided the following information: The patient's overall plan of care should focus on those issues that the clinician can most influence that keep the patient from progressing to the next level of care.