HospitalInspections.org

Based on observation, staff interview, and document review, the Critical Access Hospital (CAH) administrative staff failed to ensure the CAH had 25 or less beds available for inpatient use. Failure to ensure the CAH staff maintained 25 or less inpatient beds could potentially result in the CAH staff potentially admitting more patients than they had the staff capacity to care for, potentially resulting in the CAH staff failing to ensure each patient received the necessary care. The CAH administrative staff identified a census of 9 inpatients on entrance.

Findings include:

1. Observations during a tour of the inpatient unit on 3/19/19 at 10:30 AM revealed 25 inpatient beds available for patient care. Further observations, at the time of the tour, revealed 1 crib stored in room 1746, a supply room on the inpatient care unit.

2. Review of CAH's "Critical Access Oversight Plan," approved 4/2018, revealed, in part, "[CAH] may not have more than 25 beds occupied for hospitalized patients... Any hospital-type bed located in or adjacent to any location where the bed could be used for inpatient care counts towards the 25 bed limit."

3. During at interview on 3/19/19 at 2:00 PM, Chief Executive Officer (CEO) and Inpatient Nurse Manager acknowledged the crib, plus the 25 inpatient beds, resulted in 26 beds available for inpatient use.

Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the staff removed outdated medication from 2 of 6 Emergency Department rooms. Failure to remove outdated medications from the CAH's supplies, available for patient use, could potentially result in the staff using expired medications for patient use after the manufacturer's expiration date, potentially resulting in the staff using medication on a patient after the date which the manufacturer guaranteed the sterility and efficacy of the medication. The Emergency Department administrative staff identified an average of approximately 500 patients per month who requested Emergency Medical Care,.

Findings included:

1. Observations on 3/18/2019 during a tour of the Emergency Department, revealed outdated 0.9 % Sodium Chloride 10 ml syringes for injection (used to administer saline solution in intravenous lines before and after medication administration), readily available for patient use, in 2 locked medication/supply cabinets in patient treatment areas:

a. Exam Room 4, 0.9% Sodium Chloride 10 ml syringes for injection, 39 total syringes, 13 syringes expired 2/1/2019, 2 expired 3/1/2019

b. Trauma Bay #1, 0.9% Sodium Chloride 10 ml syringes for injection, 32 total syringes, 4 expired 1/1/2019, 2 expired 2/1/2019, 2 expired 3/1/2019

2. Review of "Outdated Medication Policy," effective 3/2018, revealed in part, "effective for: ... Emergency Dept.... Outdated medications will be removed from stock and disposed of ..."

3. During an interview on 3/18/19, at the time of the observation, the Emergency Department Nurse Manager acknowledged the nursing staff failed to remove the expired medication from the locked supply cabinets.

Based on observation, staff interview, and document review, the Critical Access Hospital (CAH) administrative staff failed to ensure the nursing staff notified the patients' physician following the discovery of a medication error for 7 of 23 medication errors reviewed (Patient #5, Patient #6, Patient #12, Patient #13, Patient #14, Patient #15, and Patient #16). Failure to notify the physician of medication errors could potentially result in the physician lacking knowledge of the medication error and failing to potentially modify the patient's treatment plan, potentially resulting in a life-threatening complication. The CAH administrative staff reported a census of 9 patients on entrance.

Findings include:

1. Review of the CAH Adverse Drug Reaction/Medication Error Reporting policy/procedure stated, in part, "Upon discovery of a medication error, or near miss incident, the staff member must report the event to the physician."

2. Review of medication errors on 3/20/19 revealed the following:

a. On 2/19/19 at 4:30 PM, the nursing staff discovered they failed to administer Sirolimus (a medication to prevent organ rejection) to Patient #5. The medication error record lacked documentation the nursing staff notified Patient
#5's physician of the medication error.

b. On 10/17/18 at 12:00 PM, the nursing staff discovered they administered 2 flu shots (vaccines to prevent the flu) to Patient #6. The medication error record lacked documentation the nursing staff notified Patient #6's
physician of the medication error.

c. On 8/7/18 at 11:30 AM, the nursing staff discovered they failed to administer an antibiotic to Patient #12. The
medication error record lacked documentation the nursing staff notified Patient #12's physician of the medication error.

d. On 7/11/18, the nursing staff discovered they almost made a medication error for Patient #13. The medication
error record lacked documentation the nursing staff notified Patient #13's physician of the medication error.

e. On 6/24/18 at 9:30 AM, the nursing staff discovered they administered an extra liter of fluids intravenously to Patient #14. The medication error record lacked documentation the nursing staff notified Patient #14's physician of the medication error.

f. On 6/5/18 at 6:30 PM, the nursing staff discovered they administered the incorrect dose of Lasix (a medication to
help patients remove fluid from their body) to Patient #15. The medication error record lacked documentation of the
date or time the nursing staff notified Patient #15 's physician of the medication error.

g. On 3/1/18 at 7:30 PM, the nursing staff discovered they administered Patient #16 a dose of Dilaudid (a strong pain relieving medication) and Patient #16 was allergic to the medication. The medication error record lacked
documentation of the date or time the nursing staff notified Patient #16's physician of the medication error.

4. During an interview on 3/20/2019 at 3:05 PM, the Director of Quality verified the medical records lacked documentation the nursing staff notified the physician when they made a medication error for Patient #5, Patient #6, Patient #12, Patient #13, and Patient #14. The Director of Quality also verified the medical records lacked the date and time the nursing staff notified the physician when they made a medication error for Patient #15 and Patient #16.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the Radiology staff in 1 of 1 Computed Tomography room (CT - computer processed x-rays that produce tomographic images or 'slices' of specific areas of the body) used intravenous (IV) solution bags labeled "single dose container" and transfer set IV tubing (used to transfer the IV solution to a syringe) for only 1 patient per IV bag. The radiology staff performed an average of 66 CT scan procedures per month which used the IV solution bag and IV tubing. The radiology staff performed 6 CT scan procedures which used the IV solution bag and IV tubing during the survey. Failure to ensure staff used a separate single-dose bag of IV solution and IV tubing for each patient could potentially result in bacteria, viruses, or fungi contaminating the IV bag or tubing, potentially transmitting the bacteria, viruses, or fungi between patients, and potentially resulting in the next patient developing a life-threatening infection.

Findings included:

1. Observations during a tour of the Radiology area - CT Room on 3/19/19 at 11:35 AM, with the Radiology Manager, revealed 1 of 1 500 ml "single dose container" bag of IV 0.9% normal saline (a solution of sodium chloride and water used for IV infusion) dated by Radiology staff as hung on 3/18/19 at 7:17 PM. Additional observation showed a tubing (transfer set) attached to the IV bag (a piece of tubing which transfers the fluid from the IV bag to the contrast infusion set used to inject contrast media into a patient's vein). The IV bag had approximately 250 ml of 0.9% normal saline remaining in the bag out of 500 ml initially.

2. Review of the product label printed directly on the 500 ml 0.9% normal saline IV solution bag showed the bag of IV solution was "single dose container" (Single-dose IV solutions were intended for use on a single patient for a single case, procedure, or injection. Single-dose solutions are labeled as such by the manufacturer and typically lack an antimicrobial preservative).

Review of the manufacturer's product insert for the IV tubing revealed the following in part, "...Single Use Only...For use with one container of media only...."

3. Review of facility policies revealed the CAH lacked a policy requiring the CAH staff to follow the manufacturer's directions and use single dose IV bags for only 1 patient.

4. During an interview on 3/19/19 at 11:35 AM, the Radiology Manager confirmed Radiology staff used the same 500 ml 0.9% normal saline IV solution bag and tubing hanging in the CT room for more than 1 patient and may use the same set up for 24 hours. On further interview, the Radiology Manager confirmed he was not aware the IV solution bag stated 'single dose container' and the manufacturer's instructions for use of the transfer set tubing stated 'single use only'.

Based on policy/procedure, document review, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure surgical services staff discharged a patient who received anesthesia to the company of a responsible adult for 4 of 5 surgical patients reviewed (Patients #1, Patient #2, Patient #3, and Patient #4). The facility staff reported an average of 61 surgical patients that received anesthesia per month. Failure to ensure surgical services staff discharged patients who received anesthesia in the company of a responsible adult could potentially result in the patient discharging and lacking someone to monitor them following surgery, and potentially allowing a life-threatening complication to occur unnoticed.

Findings included:

1. Review the policy "Conscious Sedation Protocol", revised 3/2019, revealed in part, "...Patient Discharge: Outpatients receiving IV conscious sedation will need a responsible person, aged 18 years or older to accompany them at discharge...."

2. Review of patient medical records revealed the following:

a. Patient #1 received anesthesia for a surgical procedure on 2/5/19. The surgical services staff discharged Patient #1 on 2/5/19 at 1:30 PM. Patient #1's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

b. Patient #2 received anesthesia for a surgical procedure on 2/12/19. The surgical services staff discharged Patient #2 on 2/12/19 at 3:35 PM. Patient #2's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

c. Patient #3 received anesthesia for a surgical procedure on 2/13/19. The surgical services staff discharged Patient #3 on 2/13/19 at 10:44 AM. Patient #3's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

d. Patient #4 received anesthesia for a surgical procedure on 2/14/19. The surgical services staff discharged Patient #4 on 2/14/19 at 4:00 PM. Patient #4's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

3. During an interview on 3/21/19 at 9:10 AM, the Operating Room Manager confirmed Patient #1's, Patient #2's, Patient #3's, and Patient #4's medical record lacked documentation the surgical services staff discharged the patients in the company of a responsible adult after the patients received anesthesia.