HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of 5 patients with 33 medical records reviewed. Based on observation, staff interview and review of policy and manufacturer ' s guidelines the CAH failed to develop a policy to ensure staff clean equipment according to manufacturer ' s instructions. The infection control officer failed to develop an active infection control system to identify, report, investigate, monitor and implement infection control practices for one of one Hydrocollators.

Findings include:

- The CAH ' s policy titled " Cleaning Hydrocollator " reviewed on 1/8/13 at 2:20pm directs " The Hydrocollator will be cleaned once a month, or more often if needed, to maintain cleanliness of hot packs " .

- The manufacturer's guidelines for maintenance of the " Hydrocollator Mobile Heating Units " reviewed on 1/7/13 at 4:00pm directed, "...The tank should also be drained and cleaned systematically, at minimum intervals of every two weeks " .

- Observation of the physical therapy department on 1/7/13 at 3:30pm revealed a Hydrocollator (a tank with warm water in it to warm hot packs used on patients). A log labeled "Hydrocollator Pack Machine Monthly Cleaning Record" located in the physical therapy office and revealed the last date the staff cleaned the Hydrocollator was 12/7/12.

Staff A, Infection Control Officer interviewed on 1/9/13 at 11:15am acknowledged the CAH failed to develop a policy to ensure staff clean equipment according to manufacturer ' s instructions and the infection control plan failed to develop an active infection control system to identify, report, investigate, monitor and implement infection control practices for one of one Hydrocollators.

Staff B, Physical Therapy Aide interviewed on 1/7/13 at 4:00pm acknowledged the CAH staff failed to clean the Hydrocollator according to the manufacturer's guidelines.

The Critical Access Hospital (CAH) reported a census of 5 patients with 33 medical records reviewed. Based on medical record review, policy review, and staff interview the CAH failed to follow their policy to ensure a physician recorded a complete admission history and the physical examination within twenty-four hours of admission for 5 of 10 patients requiring a history and physical examination (patients # 5, 19, 20, 21, and 23).

Findings include:

- The CAH policy titled " Rules and Regulations of the Medical Staff " reviewed on 1/8/12 at 4:00 pm directs " A complete admission history and physical examination is to be recorded within twenty-four (24) hours of admission " .

Patient #5 medical records reviewed on 1/9/13 revealed an admission date of 1/3/13 with diagnoses of shortness of breath, weakness, and arrhythmias (irregular heart beats). Patient #5 ' s medical record revealed history and physical dictated on 1/9/13, six days after admission.

Patient #19 ' s medical record reviewed on 1/7/13 revealed an admission date of 10/5/12 with diagnosis of influenza with respiratory manifestation. Patient #19 ' s medical record revealed history and physical dictated on 11/2/12, 28 days after admission.

Patient #20 ' s medical record reviewed on 1/7/13 revealed an admission date of 11/23/12 with diagnosis of obstructive chronic bronchitis (long-term lung problems). Patient #20 ' s medical record revealed history and physical dictated on 11/30/12, seven days after admission.

Staff C, medical records director interviewed on 1/9/13 at 11:00pm acknowledged the medical records lacked history and physical dictation completed within the twenty-four hour requirement.

This deficient practice also affected patients # 21 and 23.

The Critical Access Hospital (CAH) reported a census of 5 patients with 33 medical records reviewed. Based on medical record review, policy review, and staff interview the CAH failed to ensure providers authenticate (sign) entries in the surgical record for 5 of 5 surgical patient ' s medical records reviewed (patients # 9, 15, 16, 17, and 18).

Findings include:

- The CAH ' s policy titled " Anesthesia Services " reviewed on 1/9/13 at 11:10am directs, "...the name and qualifications of the individual administering the anesthesia ...shall be documented in the medical record by the nurse anesthetist."

- The CAH ' s policy titled " Assessment Prior to Induction " reviewed on 1/9/13 at 11:10am directs " Documentation of above noted evaluations ...is required by the anesthetist providing anesthesia services " .

- Patient #9's medical record reviewed on 1/9/13 at 3:15pm revealed an admission date of 1/8/13 with a diagnosis of right hip replacement. Patient #9's medical record revealed a pre-anesthesia evaluation dated 1/8/13, and a post-anesthesia evaluation dated 1/8/13. The pre-anesthesia evaluation lacked a signature of the anesthesia provider, and the post-anesthesia evaluation lacked a signature of the anesthesia provider.

- Patient #15's closed medical record reviewed on 1/8/13 revealed an admission date of 10/23/12 with a diagnosis of left total knee arthroplasty (surgical repair). Patient #15's medical record revealed a pre-anesthesia evaluation dated 10/23/12, and a post-anesthesia evaluation dated 10/23/12. The pre-anesthesia evaluation lacked a signature of the anesthesia provider, and the post-anesthesia evaluation lacked a signature of the anesthesia provider.

- Patient #16 ' s closed medical record reviewed on 1/8/13 revealed an admission date of 10/22/12 with a diagnosis of Esophagoscopy Gastroscopy Duodenoscopy (exam of the upper bowel) and Colonscopy (exam of the lower bowel). Patient #16's medical record revealed a pre-anesthesia evaluation dated 10/22/12, and a post-anesthesia evaluation dated 10/22/12. The pre-anesthesia evaluation lacked a signature of the anesthesia provider, and the post-anesthesia evaluation lacked a signature of the anesthesia provider.

Staff C, medical records director interviewed on 1/9/13 at 11:00pm acknowledged the surgical records lacked the signature of the anesthesia providers.

This deficient practice also affected patients # 17 and 18.