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Based on observation, staff interview, facility document review and facility policy review, the facility failed to ensure emergency medications and supplies were immediately available for use when they maintained expired medications and supplies in the emergency "crash" carts. This had the potential to delay staff interventions in cardiac and respiratory emergencies for one inpatient and for all future patients presenting to the facility for emergency care.

Findings include:

During a tour of the Emergency Department (ED) with the Chief Nursing Officer (CNO) on 12/01/21 at 10:00 AM, the contents of two crash carts and the documentation of the cart checks were examined.

1. The cart defined by the CNO as "ED Acute Crash Cart," located directly adjacent to the Nurse's station contained the following expired items:

a. One vial norepinephrine bitartrate (used to increase heart pumping and blood pressure), 4mg/4ml (four milligrams per four milliliter) vial, expiration date 10/2021.
b. Two norepinephrine bitartrate 4mg/ml ampules, expiration date 10/31/21.
c. Three vials Esmolol Hydrochloride (used to increase blood pressure), expiration date November 2021.
d. One vial diphenhydramine (Benadryl) 50mg/ml, expiration date 11/2021
e. Four vials furosemide (a diuretic, used to reduce fluid overload) 40mg/ml, expiration date November 1, 2021.
f. One ampule Digoxin (used to treat heart failure), 1mg/ml, expiration date 11/21.
g. Two ampules epinephrine 1mg/ml (used to increase cardiac output), expiration date 11/21.
h. Three vials of sterile water (used to mix other medications as needed), 10ml, expiration date 09/01/21.
i. Two prefilled syringes naloxone hydrochloride (Narcan, used to reverse opioid overdose) 2mg/2ml, expiration date 11/21.
j. Two prefilled epinephrine syringes 0.3mg, expiration date September 2021.
k. One prefilled epinephrine syringe 0.15mg, expiration date November 2021.
l. Four prefilled syringes Lidocaine 1% (percent) (used for cardiac arrhythmias) 50mg/5ml, expiration date November 1, 2021.
m. Four prefilled syringes 10% calcium chloride (used in cardiac resuscitation and other disorders), 1g (gram)/10ml, expiration date 10/21.
n. Two prefilled syringes epinephrine 1mg/10ml, expiration date November 1, 2021.
o. Two bags 0.9% sodium chloride (normal saline solution used to mix and administer medications via intravenous route), 100ml, expiration date 04/21.
p. Two bags 0.9% sodium chloride 100ml, expiration date 11/21.
q. Two pairs of sterile gloves, size six and one half, expiration date 06/21.
r. One vial found in the Rapid Sequence Intubation (RSI) kit, ketamine hydrochloride (used for conscious sedation), 500mg/5ml, expiration date 07/21.
s. One stylet (used to assist a provider with intubation), contained in the facility's "Intubation Roll" which was torn open.
t. One pediatric carbon dioxide detector (used to verify correct placement of an endotracheal tube [a flexible tube inserted into the trachea to maintain an airway] in the lungs), expiration date 05/21/2019.

Review of the documents titled "Crash Cart Checklist" on top of the crash cart revealed the cart was not checked for operation of the "Zoll" brand defibrillator and the lock number on the cart (verifying the cart had not been used since the last date of checking) on the following dates:

a. August 2021: 8/5/21, 8/6/21, 8/13/21, 8/27/21, and 8/28/21.
b. September 2021: 09/01/21, 09/11/21, 09/24/21, and 09/29/21.
c. October 2021: 10/04/21, 10/07/21, 10/08/21,10/13/21, 10/14/21, 10/15/21,10/17/21, 10/18/21, 10/19/21, 10/28/21, 10/29/21, and 10/31/21.
d. November 2021: 11/01/21, 11/18/21, 11/19/21, 11/20/21, and 11/21/21.

A blank document titled, "Acute Crash Cart Inventory," listing the contents of the crash cart, was located on top of the cart. No documentation was found on the cart of a completed inventory.

2. The cart defined by the CNO as the "Big ED Crash Cart," located in a separate large ED room, contained the following expired items:

a. One prefilled syringe epinephrine 0.15mg, expiration date November 2021.
b. Four vials Esmalol, expiration date 11/30/31.
c. Five ampules epinephrine 1mg/1ml, expiration date 11/30/21.
d. One jar Nitrostat (nitroglycerin) tablets (used to treat and prevent chest pain) 0.4mg, expiration date 11/21.
e. Four prefilled syringes Lidocaine 1% 50mg/5ml, expiration date 11/21.
f. Two bags 5% dextrose 250 ml, expiration date 10/21.
g. Two vials norepinephrine bitartrate 4mg/ml, expiration date 10/21.

Review of the documents titled "Crash Cart Checklist/Main" on top of the crash cart revealed the cart was not checked for operation of the "Zoll" brand defibrillator and the lock number on the cart on the following dates:

a. August 2021: 08/05/21, 08/06/21,08/10/21, 08/13/21, 08/27/21, and 08/28/21.
b. September 2021: 09/01/21, 09/08/21, 09/11/21, 09/24/21, and 09/29/21.
c. October 2021: 10/04/21, 10/07/21, 10/08/21, 10/13/21, 10/14/21, 10/15/21, 10/17/21, 10/18/21, 10/19/21, 10/28/21, and 10/29/21.
d. November 2021: 11/01/21, 11/18/21, 11/19/21, 11/20/21, and 11/21/21.

During an interview with the CNO on 12/01/21 at 10:40 AM, the CNO stated facility and policy expectation is for the crash carts to be checked daily for defibrillator functioning and an intact lock. The CNO verified that medications maintained for emergency use on the cart cannot be considered viable after the expiration date and should be removed and replaced prior to expiration. The CNO verified that supplies packaged as sterile are considered no longer sterile if the packaging is torn or damaged. The CNO stated the facility expectation was a full examination of the crash cart contents should be conducted monthly to find and replace expired or damaged items. The CNO was unable to explain why the defibrillator and lock number were not checked daily, and stated, "I guess I'll have to start assigning this job." The CNO was asked to provide the most current policy related to checking the crash carts.

Review of the facility policy titled, "Monthly inspections of Nursing Stations, Drug Storage Areas," effective date 06/16, revealed, "The Pharmacy Department or Nursing staff shall conduct the monthly inspections. All outdated medications shall be removed and replaced with currently dated stock ...A record shall be maintained documenting the dates each department was inspected."

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure patient daily weights were obtained per providers' orders for four of seven swing bed patients (patients requiring extended skilled nursing care after an acute illness) reviewed (Patient (P)3, P5, P6, and P7). This had the potential for nursing staff and patient providers to miss patients' progressing into fluid overload, resulting in possible cardiac and/or respiratory failure, for one current swing bed patient and for all future swing bed patients in the facility.

Findings include:

The following patient medical records were reviewed in the presence of the Chief Nursing Officer (CNO) on 12/03/21:

1. Review of P3's electronic medical record (EMR) for the patient's swing bed admission from 12/09/20 through 12/14/20 revealed, in the "Physician Entered Orders" section, an order dated 12/09/21 for "daily weights x 3 days (for three days)." Review of the "Patient Progress Notes," which referred to nursing documentation of care, revealed the patient's weight was obtained only on 12/09/21, the date of admission.

2. Review of P5's EMR for the patient's swing bed admission from 12/09/20 through 12/24/20 revealed, in the "Physician Entered Orders" section, an order dated 12/09/20 for "Daily weights x 3 days." Review of the "Patient Progress Notes," revealed P5's weight was obtained only on 12/09/21, the date admission.

3. Review of P6's EMR for the patient's swing bed admission from 02/05/21 through 02/17/21 revealed, in the "Physician Entered Orders" section, an order dated 02/05/21 for "Daily weights." Review of the "Patient Progress Notes," revealed P6's weight was obtained only on 02/05/21, the date admission.

4. Review of P7's EMR for the patient's swing bed admission from 02/11/21 through 02/18/21 revealed, in the "Physician Entered Orders" section, an order dated 02/11/21 for "Daily weights." Review of the "Patient Progress Notes," revealed P7's weight was obtained only on 02/11/21, the date admission.

During an interview with the CNO on 12/03/21 at 12:45 PM, the CNO verified daily weights had not been obtained as ordered by the provider for the above medical records reviewed. The CNO stated that facility policy and expectation is for nursing staff to provide all care as ordered by the providers. The CNO was asked to provide the most current facility policy related to nursing staff providing patient care in accordance with providers' orders.

Review of the facility's policy titled, "Noting Physician Orders," last revised 07/15, revealed, "It is the responsibility of the licensed nurse to note and complete all provider orders."

Based on policy review, record review, and interview, the hospital failed to ensure:

1. Patients were assessed prior to administration of medications that were ordered "as needed" (PRN) and re-assessed for effectiveness in accordance with hospital policy for two of two patients (Patient (P)13 and P14) who were administered PRN medication from a sample of eight patient records reviewed. This deficient practice had the potential to affect one current inpatient any future patient admitted with physician orders for PRN medications.

2. Blood transfusions were verified by two staff before starting the transfusion, by checking the patient's wristband number, the unit expiration date, blood type, and appearance for one of three patients (P18) who received blood transfusion. In addition, the hospital failed to check the one-hour transfusion vital signs for two of three patients (P17 and P18) who received blood transfusions, as required by facility policy.

These findings had the potential to cause harm to all patients receiving PRN medications and blood transfusions in the facility.

Findings include:

1.Review of P14's electronic medical record (EMR), under the medication tab and progress note tab, revealed documentation that P14 received lorazepam 1 milligram (mg) Intravenous (IVP), (used to treat anxiety disorders) on 12/03/21 at 8:24 AM. There was no documentation of P14 symptoms prior to the administration of the lorazepam. In addition, there was no documentation of the effectiveness of the medication after the lorazepam was administered. On 12/05/21 at 10:02 PM, P14 was given one mg of lorazepam IVP. There was no preassessment documented to indicate the need for the medication or a post assessment to document the effectiveness of the medication. On 12/06/21 at 8:38 PM, P14 was given one mg of lorazepam IVP. There was no preassessment documented to indicate the need for the medication or a post assessment to document the effectiveness of the medication.

Review of P13's EMR, under the medication tab and progress note tab tab, revealed P13 received one tablet of hydrocodone/acetaminophen 5/325 mg (an opioid used to treat pain and as a cough suppressant) on 08/12/21 at 12:17 pm. Documentation showed P13 stated he/she could not sleep and requested pain medication. There was no documentation of the patient's pain score and there was no evidence the patient was educated on the indications for taking hydrocodone/acetaminophen. There was no documented re-assessment of the effectiveness of the medication. On 08/12/21 at 3:24 pm the staff documented P13 requested pain medication and was given one tablet of hydrocodone/acetaminophen 5/325 mg. There was no documented pain score or why the pain medication was needed There was no re-assessment of the effectiveness of the medication. On 08/12/21 at 9:50 pm, the documentation showed P13 requested pain medication and he/she was given hydrocodone/acetaminophen 5/325. There was no documented pain score or why the pain medication was needed. There was no re-assessment of the effectiveness of the medication. On 08/13/21 at 7:41 pm, the P13 was given hydrocodone/acetaminophen 5/325 for complaints of pain of 5/10 on the pain scale (a way to rate the level of pain on a zero to ten scale). There was no re-assessment of the effectiveness of the medication.

During an interview on 12/02/21 at 3:30 PM, the Chief Nursing Officer and Pharmacy Director, confirmed the staff failed to assess the patient prior to administration and assess the effectiveness of the PRN medications.

Review of the facility policy titled, "Administration of Medication" revised 5/21, showed, "After medication administration the remaining three "Rights" should be documented, Right documentation, Right reason for administration, Right patient response."

Review of the facility policy titled, "Pain scale, Admission pain History," revised 8/15, showed, "It is the policy of this facility that the Mankoski Pain Scale zero (O) to ten (10) can be used on adults to describe the subjective experience of pain on admission assessment or to evaluate pain history."

2. Review of P17's EMR, under the scanned documents tab, revealed that only one nurse signed the "certification" statement on the blood transfusion form, before giving the transfusion, that the patient's wristband numbers were identical and the unit expiration date, blood type and appearance were properly verified. In addition, there was no evidence that the one-hour post transfusion vital signs were documented after completion of the blood.

Review of P18's EMR, under the scanned documents tab, revealed there was no documentation of the one-hour post transfusion vital signs after completion of the blood at 2:00 PM on 08/10/21.

During an interview on 12/02/21 at 9:45 AM, the Chief Nursing Officer and Pharmacy Director confirmed the staff failed to check the one-hour post transfusion vital signs, and two persons failed to check the patients arm band and ensure the unit was the correct blood type, and the blood expirations and appearance was properly verified.

Review of the facility policy titled, "Blood and Blood Component Transfusion" revised 6/21, showed, "Verify the patient's identification and compatibility: Name as stated by the recipient to name on identification bracelet. Name and patient identification number to those on blood transfusion slip Blood donor number on blood transfusion slip Blood group and RH type on blood transfusion slip and bag label Expiration date to current date. Obtain vital signs one hour post transfusion."

Based on document review and interview the facility failed to ensure the Infection Control Committee reviewed the infectious reportable cases, including diagnosis of COVID-19 during a pandemic, which occurred in the critical access hospital (CAH). These finding have the potential to cause harm to all patients receiving care in the CAH, by failure to appropriately identify, track, and trend COVID-19 or any other reportable infectious disease cases identified in the CAH.

Findings include:

Review of the Infection Control Committee minutes dated May 12, 2021, June 9, 2021, July 14, 2021, August 11, 2021, September 8, 2021, October 13, 2021, and November 10, 2021 revealed the committee failed to review the reportable infectious disease tracking to include COVID-19 for just the CAH. The reports showed a total number of cases for the following, "CAH, Long Term Care (LTC) and Physician's Clinic" and was not broken down to identify the number of cases and dates that were identified in the CAH.

During a telephone interview with the Infection Control staff' #4, on 12/02/21 at 3:15 pm the Infection Control Staff #4, confirmed the state reportable infectious cases for the CAH were not trended, tracked and reported separately for the CAH. Infection Control staff #4 stated he/she collected all reportable as a total number that included the "CAH, LTC, and Physician's Clinic."

Based on document review and interview, the facility failed to ensure the Quality Assessment Performance Improvement (QAPI) program included review of the facility tracking of reportable infectious diseases, including COVID-19 during a pandemic. The failure to track, identify, and trend reportable infectious disease cases diagnosed for inpatients and staff had the potential to cause harm to all patients receiving care in the critical access hospital (CAH).

Findings include:

Review of " Quality Assurance Performance Improvement Comprehensive Committee Meeting Minutes," dated June 10, 2021, July 13, 2021, August 10, 2021, September 7, 2021, and October 12, 2021, revealed the committee did not review the infectious reportable for just the CAH. The reports showed the total number of COVID-19 cases was not specific to the CAH and included an attached Long-Term Care (LTC) facility, and Physician's Clinic. The tracking of COVID-19 did not accurately reflect the data relevant to the CAH.

During an interview on 12/03/21 at 2:30 pm, the Chief Executive Officer/Risk Management/Quality (CEO) for the confirmed the reportable infectious disease cases, including prevalence of COVID-19, were not tracked, trended, and reported as required separately from the LTC and Clinic. He/She said the cases were reported as a total for the CAH, LTC, and Physicians Clinic.