HospitalInspections.org

Based on observations and interviews, it was determined the facility failed to maintain a clean orderly Emergency Department (ED) on 2 of 3 survey days.

Findings include:

Observation on 1/18/23 at approximately 9:30 a.m., with Staff I (Director of Human Resources) and Staff J (ED Nurse Manager) present, there was an extensively dusty ED pediatric code cart, including dusty suctioning equipment.

Interview on 1/18/23 at 9:30 a.m. the surveyor inquired whose responsibility it is to ensure cleanliness of ED equipment, Staff J was not sure if it was the responsibility of ED staff or housekeeping.

Observation on 1/20/23 at approximately 10:15 a.m., with Staff K (Director of Plant Operations) present, the ED pediatric code cart was again observed with visible dust on equipment. At this time, the finding was confirmed.

Observation on 1/18/23 at approximately 9:30 a.m., with Staff I and Staff J present, surveyors observed an extensively dusty ceiling vent in ED negative pressure room 4.

Observation on 1/20/23 at approximately 10:15 a.m., with Staff K present, again ED negative pressure room 4 ceiling vent was observed extensively dusty.

Interview on 1/20/23 at approximately 10:15 a.m., Staff K stated "This [vent] definitely needs to be taken care of."

Observation on 1/20/23 at approximately 10:15 a.m., with Staff K present, there were multiple unstripped and unwaxed cracked floor tiles observed in ED rooms 1, 2, 3, 4, and 5.

Interview on 1/20/23 at approximately 12:56 p.m. with Staff E (Director of Food Nutrition and Housekeeping) stated the last time the ED floors were stripped and waxed was "about a year ago."

Observation on 1/20/23 at approximately 10:15 a.m., with Staff K present, there were water stained ceiling tiles observed in ED rooms 3 and 4, and in the Triage Room. At this time, the finding was confirmed.

Based on policy review, observation, and interview, it was determined that the Critical Access Hospital (CAH) failed to ensure medications were secured to prevent unauthorized access in the surgical department.

Findings include:

Observation on 1/19/23 at approximately 12:47 p.m. of the operating room called the "Procedure Room" within the CAH's surgical department revealed a medication box labeled "Anesthesia Emergency Medication Kit" on top of a locked Omnicell automated medication dispensing cabinet. The medication box was portable and closed with a plastic breakaway locking tag. The Procedure Room was empty and not in use. Contents of the "Anesthesia Emergency Medication Kit" are as follows:
· Atropine 1 milligram (mg) /10 milliliter (ml) injection syringe x1
· Ephedrine 50 mg/1 ml injection vial x1
· Epinephrine 1 mg/10 ml injection syringe x1
· Esmolol 100 mg/10 ml injection vial x1
· Labetalol 100 mg/20 ml injection vial x1
· Lidocaine 2% (percent) 100 mg/5 ml injection syringe x1
· Phenylephrine 10 mg/ 1 ml injection vial x1
· Rocuronium 50 mg/5 ml injection vial x1
· Sugammedex 200 mg/2 ml injection vial x2

Interview on 1/19/23 at approximately 12:50 p.m. with Staff A (Vice President Quality, Patient Safety, Compliance, and Risk) confirmed the above finding.

Review on 1/19/23 of the surgical department's schedule revealed zero scheduled procedures in the Procedure Room for 1/19/23 and for 1/20/23. Further review revealed that the most recent scheduled procedure in the Procedure Room was for 1/18/23 at approximately 3:00 p.m.

Interview on 1/19/23 at approximately 3:45 p.m. with Staff H (Pharmacy Director) revealed that the anesthesia emergency medication kits are usually left on top of the Omnicells in the surgical department as they do not fit within the Omnicells.

Observation on 1/20/23 at approximately 10:40 a.m. of the Procedure Room in the CAH's surgical department revealed the medication box labeled "Anesthesia Emergency Medication Kit" remained on top of the locked anesthesia Omnicell automated medication dispensing cabinet. The Procedure Room was empty and not in use.

Interview on 1/20/23 at approximately 10:45 a.m. with Staff B (Perioperative Services Manager) confirmed the above finding. Further interview with Staff B revealed that the expectation is that the anesthesia emergency medication kit would be secured within the Omnicell, specifically after the surgical department's hours of operation (i.e. overnight and on weekends).

Interview on 1/20/23 at approximately 12:25 p.m. with Staff E (Director of Food Nutrition Services and Environmental Services) revealed that environmental services staff have access to the four operating rooms, which includes the operating room called the Procedure Room, for overnight terminal cleaning. Terminal cleaning is typically performed by one environmental services staff member, with one environmental services supervisor checking in.

Interview on 1/20/23 at approximately 12:30 p.m. with Staff G (Certified Registered Nurse Anesthetist) revealed that the anesthesia emergency medicine kits are typically kept on top of the Omnicells in the surgical department, including after the surgical department's operating hours (i.e. overnights and weekends).

Interview on 1/20/23 at approximately 12:35 p.m. with Staff F (Operating Room Assistant), who until one month ago was an overnight environmental services staff member assigned to terminal cleaning of the operating rooms and the Procedure Room, revealed that the anesthesia emergency medication kits were stored overnight on top of the Omnicell, not inside of the Omnicell.

Review on 1/20/23 of the CAH's policy titled "Environmental Cleaning in the Surgical Suite," with approval date 4/28/22, revealed the following: "...A daily Full Terminal cleaning of the O.R. [operating room] suite will be performed by the Environmental Services Team regardless if the room has been used or not."

Review on 1/20/23 of the CAH's policy titled "Safe Storage of Drugs & Supplies," with an approval date of 9/9/22, revealed the following: "...Medication storage outside the Pharmacy: 1. All drugs are stored in a locked room, container, drawer, or cabinet. 2. All drugs are stored in a manner to prevent access by unauthorized individuals. 3. Individuals without legal access to drugs are not provided with keys or access codes to medication storage carts, cabinets or rooms."

1. Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to distinctly discharge a patient from acute status when admitted to swing-bed status for 1 of 14 patients reviewed for swing-bed status (Patient identifier is #6).

Findings include:

Review on 1/19/23 of Patient #6's medical record revealed that Patient #6 admitted to Emergency Department on 1/3/23; had a status change to inpatient on 1/4/23 and then to swing-bed status on 1/14/23.

Review on 1/19/23 of Patient #6's Inpatient Hospital Medicine - Admission Note dated 1/14/23 revealed "...Plan: Admit to Swing...".

Review on 1/19/23 of Patient #6's physician's orders revealed that there was no distinct order to discharge from inpatient care.

Interview on 1/20/23 at 11:10 a.m. with Staff A (Vice President of Quality, Patient Safety, Compliance and Risk) confirmed that there should have been a discharge order from acute inpatient care services and that there was not one for Patient #6.

Review on 1/24/23 of the facility's policy titled "Swing Bed Program" with an approval date of 11/28/22, revealed, "...c. Admission process... 1. Discharge order that states: "Discharge from Acute care..."


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2. Based on interview and record review, the hospital failed to maintain complete medical records and follow the facility's policy for completing documentation within a timely manner.

Findings include:

Review on 1/20/23 of the facility's report of delinquent records dated 01/18/23 revealed the following:

-There were a total of 105 medical records which were delinquent;
-The oldest age of deficiency was 485.
-There were 26 records from the year 2021.
-There were 11 with no dates.

Review on 1/20/23 of the facility's policy titled, "Documentation Completion, Suspension, and Reinstatement Policy-Health Information Services" with an approval date of 2/16/22, reveals under section, " A. Ambulatory Program: 1. Health Information Services (HIS) tracks only open ambulatory encounters... that identifies those providers, associates providers, mid-levels, residents, fellows, and clinical support staff who have one (1) or more open ambulatory open encounters as of 9 a.m. that morning. This report is distributed to providers and clinical leadership across all locations according to distribution lists that have been approved for each location... Affected individuals have until the following Tuesday morning at 9 a.m. to close any open encounters identified on the Friday report."

Interview on 1/19/23 at 11:25 a.m. with Staff N (Operations Managers) revealed the above 105 records were still in process of being addressed, and that all the records were personnel and not medical staff.

Staff N further revealed, that the above delinquent records are missing nursing signatures or were records created in error.

Interview on 1/19/23 at 11:30 with Staff A (Quality Patient Safety, Compliance, and Risk) confirmed the above findings.

1. Based on interview and record review, it was determined that the Critical Access Hospital (CAH) failed to ensure that all patients were given the opportunity to execute informed consent for treatment for 1 of 21 inpatient records reviewed (Patient identifier is #9).

Finding include:

Resident #9

Review on 1/20/23 of Patient #9's medical record revealed that Patient #9 admitted to the facility on 1/17/23. Further review of Patient #9's medical record revealed that there was no Consent to Treat form.

Interview on 1/20/23 at 12:10 p.m. with Staff A confirmed the above.

Review on 1/24/23 of the facility's policy titled "Informed Consent" with an approval date of 9/6/22 revealed, "...Purpose of Policy: The principle of self-determination... is the basis of informed consent The patient must give consent prior to treatment... Definitions: Informed Consent consist of two separate and distinct processes; the conversation between physician and patient (or in certain cases a designated associate provider and the patient) and the documentation that this conversation took place using written consent forms and notes in the patient record...

2. Based on interview and record review, the CAH failed to document giving the Patients' Bill of Rights to 16 of 21 inpatient and swing stay charts reviewed (Patient identifiers are #4, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20 and #21).

Findings include:

Patient #4

Review on 1/19/23 of Patient #4's medical record revealed that Patient #4 admitted to the CAH on 12/26/22 and then changed to a swing bed status on 1/3/23. Further review of the medical record revealed there was no documentation that Patient #4 received the Patients' Bill of Rights for either admission.

Patient #7

Review on 1/20/23 of Patient #7's medical record revealed that Patient #7 admitted inpatient to the CAH on 1/3/23 and changed to a swing bed status on 1/19/23. Further review of the medical record revealed there was no documentation that Patient #7 received the Patients' Bill of Rights for either admission.

Patient #8

Review on 1/20/23 of Patient #8's medical record revealed that Patient #8 admitted to the CAH on 1/5/23 and changed to a swing bed status on 1/9/23. Further review revealed there was no documentation that Patient #8 received the Patients' Bill of Rights for either admission.

Patient #9

Review on 1/20/23 of Patient #9's medical record revealed that Patient #8 admitted to the CAH on 1/17/23. Further review revealed there was no documentation that Patient #9 received the Patients' Bill of Rights.

Patient #10

Review on 1/20/23 of Patient #10's medical record revealed that Patient #10 admitted to the CAH on 1/8/23 and changed to a swing bed status on 1/11/23. Further review revealed there was no documentation that Patient #10 received the Patients' Bill of Rights for either admission.

Patient #11

Review on 1/20/23 of Patient #11's medical record revealed that Patient #11 admitted to the CAH on 1/18/2. Further review revealed there was no documentation that Patient #11 received the Patients' Bill of Rights.

Patient #12

Review on 1/20/23 of Patient #12's medical record revealed that Patient #12 admitted to the CAH on 11/30/22 and changed to a swing bed status on 12/8/22. Further review revealed there was no documentation that Patient #12 received the Patients' Bill of Rights for either admission.

Patient #13

Review on 1/20/23 of Patient #13's medical record revealed that Patient #13 admitted to the CAH on 1/18/23 and changed to a swing bed status on 1/19/23. Further review revealed there was no documentation that Patient #13 received the Patients' Bill of Rights for either admission.

Patient #14

Review on 1/20/23 of Patient #14's medical record revealed that Patient #14 admitted to the CAH on 9/13/22 and changed to a swing bed status on 9/20/22. Further review revealed there was no documentation that Patient #14 received the Patients' Bill of Rights for either admission.

Patient #15

Review on 1/20/23 of Patient #15's medical record revealed that Patient #15 admitted to the CAH on 1/13/23 as a swing bed status. Further review revealed there was no documentation that Patient #15 received the Patients' Bill of Rights.

Patient #16

Review on 1/20/23 of Patient #16's medical record revealed that Patient #16 admitted to the CAH on 1/11/23 as a swing bed status. Further review revealed there was no documentation that Patient #16 received the Patients' Bill of Rights.

Patient #17

Review on 1/20/23 of Patient #17's medical record revealed that Patient #17 admitted to the CAH on 1/14/23 and changed to a swing bed status on 1/17/23. Further review revealed there was no documentation that Patient #17 received the Patients' Bill of Rights for either admission.

Patient #18

Review on 1/19/23 of Patient #18's medical record revealed that Patient #18 admitted to the CAH on 1/11/23 to a swing bed status. Further review revealed there was no documentation that Patient #18 received the Patients' Bill of Rights.

Patient #19

Review on 1/19/23 of Patient #19's medical record revealed that Patient #19 admitted to the CAH on 10/19/22 and changed to a swing bed status on 10/23/22. Further review revealed there was no documentation that Patient #19 received the Patients' Bill of Rights for either admission.

Patient #20

Review on 1/20/23 of Patient #20's medical record revealed that Patient #20 admitted to the CAH on 10/14/22. Further review revealed that there was no documentation that Patient #20 received the Patients' Bill of Rights.

Patient #21

Review on 1/20/23 of Patient #21's medical record revealed that Patient #21 admitted to the CAH on 10/13/22. Further review revealed there was no documentation that Patient #21 received the Patients' Bill of Rights.

Interview on 1/20/23 with Staff A confirmed that the above 16 patients did not have documentation that the Patients' Bill of Rights had been given. Staff A stated the facility did not have a policy regarding the Patients' Bill of Rights.

Review on 1/23/23 of The Patients' Bill of Rights retrieved from https://www.alicepeckday.org/patients/bill-rights, revealed, "The Patients' Bill of Rights was first enacted into law as part of the Older Americans' Act of 1965. RSA [Revised Statutes Annotated] 151.21 adopts the Federal statute as law in the State of New Hampshire. It applies to all individuals in hospitals, residential care facilities, nursing homes and all other health care locations licensed under the provisions of RSA 151.21... You have the right to be informed, verbally and in writing, of your rights and of the rules and policies of the facility. You shall be fully informed of patients' rights and responsibilities and of all procedures governing patient conduct and responsibilities. This information must be provided orally and in writing before or at admission, except for emergency admissions. Receipt of the information must be acknowledged by you in writing. When a patient lacks the capacity to make informed judgments the signing must be by the person legally responsible for the patient..."