HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of three patients, one acute patient and two skilled swing bed patients. Based on observation, staff interview and policy review the CAH failed to ensure equipment and supplies commonly used in life-saving procedures were readily available to staff in two of three Emergency Department (ED) rooms. The CAH's failure to ensure emergency supplies were available to patients has the potential to cause harm and delay emergency care to patients.

Findings include:

Policy titled "Outdated Supplies Removal" reviewed on 6/17/15 at 1:00pm directed staff, "...if a supply is found expired it will be removed from service immediately and disposed of..."

- Emergency Department (ED) Room #1 toured on 6/15/15 at 10:05am revealed an unlocked cabinet containing one blue vacutainer tube (used to draw blood for lab testing) with expiration date 11/14 and one red speckled vacutainer tube (used to draw blood for lab testing) with expiration date 2/12. The CAH's failure to ensure proper lab drawing equipment is available has the potential for incorrect lab testing and poor patient outcomes.

Staff Registered Nurse B interviewed on 6/15/15 at 10:10am acknowledged the two expired vacutainer tubes.

- Emergency Department (ED) Room #2 toured on 6/15/15 at 10:15am revealed the Broselow Cart contained two Intubating Stylets (used to maintain airway) 10 French with expiration dates 01/2015. ED Room #2 revealed a cabinet that contained one epistaxis (balloon catheter kit) with an expiration date 4/20/13, three 5 inch Delta-lite Plus Fiberglass Cast Tape with expiration date 4/20/15 and one 4 inch Scotchcast Plus Fiberglass Cast Tape with expiration date 8/2014. The CAH's failure to ensure emergency supplies were properly maintained has the potential to cause harm for patients in an emergency.

The Critical Access Hospital (CAH) reported a census of three patients, one acute patient and two skilled swing bed patients. Based on observation, staff interview, and policy review the CAH failed to provide housekeeping and maintenance services to maintain a clean and orderly hospital.

Findings include:

- The CAH's Physical Therapy policy "Department Cleaning and Maintenance" reviewed on 6/17/15 at 3:00pm directed, "...The rehab department equipment will be maintained in and orderly, clean, and safe condition at all times...Weekly activities-contact areas of all exercise equipment cleaned...Bi-weekly activities-Hot pack unit emptied and cleaned...Paraffin bath emptied and cleaned..."

- The Physical Therapy department observed on 6/16/15 between 1:30pm to 2:00pm revealed the following:

1. A recumbent bicycle with visible dust/debris that left marks when wiped with a finger.
2. An exercise mat table with nine uncovered pillows stacked against the wall.
3. A hydrocollator (a liquid heating device that is used in physical therapy clinics to heat and store hot packs for therapeutic use) with debris.
4. A paraffin bath (used for paraffin wax treatments) with paraffin down the outside of the bath.

Physical Therapy Assistant (PTA) Staff E interviewed on 6/15/15 at 1:40pm acknowledged the dust and debris on the recumbent bicycle and indicated staff use the pillows on the exercise mat table for patients.

- Request for the Physical Therapy cleaning log for the hydrocollator and the Paraffin bath on 6/15/15 at 1:50pm revealed a February 2015 calendar that lack an entry for cleaning of the paraffin bath and a March 2015 calendar that lacked an entry for cleaning of the hydrocollar.

Certified Occupational Therapy Assistant (COTA) Staff H interviewed on /17/15 at 1:30pm acknowledged they cleaned the paraffin bath in November but failed to have documentation of the cleaning and the therapy department failed to have evidence of cleaning of the paraffin bath.

Administrative Nursing Staff A interviewed on 6/17/15 at 3:30pm indicated nursing staff cleaned the hydrocollar today 6/17/15 and on 3/12/15.

The CAH failed to provide housekeeping and maintenance services to maintain a clean and orderly hospital.

The Critical Access Hospital reported a census of three patients, one acute patient and two skilled swing bed patients. Based on observation, document review and interview, the Critical Access Hospital (CAH) failed to properly dispense drugs in accordance with acceptable professional principles and follow their policy for one of one medication room observed. The CAH failed to ensure outdated drugs were not available for patient use in one of one emergency crash cart and one of three emergency rooms. This deficient practice had the potential to affect all patients receiving medication at the CAH.

Findings include:

- Review of "Kansas State Board of Pharmacy Laws" updated August 2014 K.S.A. 68-7-11 Medical care facility pharmacy mandated "...The scope of pharmaceutical services within a medical care facility pharmacy shall conform to the following requirements: (2) Emergency outpatient service.(A) An interim supply of prepackaged drugs shall be supplied to an outpatient only by a designated registered professional nurse or nurses pursuant to a prescriber's medication order when a pharmacist is not on the premises and a prescription cannot be filled. The interim supply shall be labeled with the following information: (i) The name, address, and telephone number of the medical care facility; (ii) the name of the prescriber. The label shall include the name of the practitioner and, if involved, the name of either the physician's assistant (PA) or the advanced registered nurse practitioner (ARNP); (iii) the full name of the patient; (iv) the identification number assigned to the interim supply of the drug or device by the medical care facility pharmacy; (v) the date the interim supply was supplied; (vi) adequate directions for use of the drug or device; (vii) the beyond-use date of the drug or device issued; MISCELLANEOUS PROVISIONS 68-7-11577 (viii) the brand name or corresponding generic name of the drug or device; (ix) the name of the manufacturer or distributor of the drug or device, or an easily identified abbreviation of the manufacturer's or distributor's name; (x) the strength of the drug; (xi) the contents in terms of weight, measure, or numerical count; and (xii) necessary auxiliary labels and storage instruction, if needed. (B) The interim supply shall be limited in quantity to an amount sufficient to supply the outpatient's needs until a prescription can be filled. Adequate records of the distribution of the interim supply shall be maintained and shall include the following information: (i) The original or a copy of the prescriber's order, or if an oral order, a written record prepared by a designated registered professional nurse or nurses that reduces the oral order to writing. The written record shall be signed by the designated registered professional nurse or nurses and the prescriber; and (ii) the name of the patient; the date supplied; the drug or device, strength, and quantity distributed; directions for use; the prescriber's name; and, if appropriate, the DEA number. (3) The designated registered professional nurse or nurses may enter the medical care facility pharmacy and remove properly labeled pharmacy stock containers, commercially labeled packages, or properly labeled prepackaged units of drugs. The registered professional nurse shall not transfer a drug from one container to another for future use, but may transfer a single dose from a stock container for immediate administration to the ultimate user.

- The CAH's policy for "Emergency Room Dispensing of Take-Home Medications" reviewed on 6/16/15 at 8:05am directed, "...Only pre-packaged drugs or drugs available in unit dose will be dispensed..."

- The medication preparation room observed on 6/15/15 at 10:02am revealed a medication logbook for documentation of medications provided to patients in order for outpatients to immediately start drug therapy when the local retail pharmacy is closed.

Register Nurse (RN) Staff B interviewed on 6/15/15 at 10:02am indicated when an emergency room/outpatient required medications for use after hours of the local pharmacy the nurse would remove the medication from the CAH's medication dispensing machine and filled out a label placed on the prescription with the date, the patient's name, and how to take the medication. The nurse documented the medication dispensed on the ER record and filled out a pharmacy log with a prescription number, the date, patient's name, the drug dispensed, the dose, instructions, quantity, and the prescribing provider. Staff B verified the RNs dispensed medication to patients. The RN can only send home enough medication until the local pharmacy is open.

Registered Pharmacist (RPH) Staff D interviewed on 6/16/15 at 8:05 verified the CAH's RNs dispense medications from the CAH's medication dispensing machine and provide medication to patients when the local pharmacy is closed.

The CAH failed to properly dispense drugs in accordance with acceptable professional principles and Kansas State Board of Pharmacy Laws.

- The CAH's policy titled "Outdated Supplies Removal" reviewed on 6/17/15 at 1:00pm directed staff, "...if a supply is found expired it will be removed from service immediately and disposed of...IV solutions will returned to the manufacturer or disposed of properly...drugs will be disposed of by pharmacy..."

- The CAH's Emergency Room bay 2 crash cart observed on 6/15/15 at 10:14am revealed the following expired and/or unusable drugs:

1. One 5% Dextrose (a form of glucose) 250ml (milliliter) intravenous (IV) bag expired on 05/2015.
2. 2 single use vials Pitressin (used to raise blood pressure or treat diabetes) 20 units/ml IV,1 ml clear liquid expired 02/2015
3. 0ne 250ml glass bottle Nitroglycerin (used to widen blood vessels) in 5% Dextrose, 25mg/250ml IV expired May 2015


Registered Nurse Staff B interviewed on 6/15/15 at 10:14am acknowledged the expired medication and they were available for patient use.

- The Emergency Room bay 2 observed on 6/15/15 at 10:15am revealed a cabinet with one 0.45% normal saline 1000ml IV bag expired 4/1/15

Regisitered Nurse Staff B interviewed on 6/15/15 at 10:15am acknowledged the expired 0.45% normal saline was available for patient use.

The Critical Access Hospital (CAH) reports a census of three patients, one acute patient and two swing bed patients. Based on observation, policy review, and staff interviews the infection control officer failed to develop an active and comprehensive infection control system which identified and investigated staff practices for one of two intravenous (IV) starts, one of one dietary observation, two of two soiled utility room observations, and one of three emergency room observations.

Findings include:
- The CAH's policy "Standard Precautions" reviewed on 6/17/15 at 3:30pm directed, "...all equipment surfaces are cleaned and decontaminated (a) after contact with blood or body fluids (b) as soon as feasible after the completion of procedures...."

- Registered Nurse Staff B observed on 6/15/15 at 11:30 provided patient #43 with an Intravenous (IV) access for a CT scan. Staff B completed the IV start, cleaned up the supplies and laid the supplies on the counter. After disposing of the supplies, Staff B failed to disinfect the counter where the supplies laid.

Registered Nurse Staff B interviewed 6/15/15 at 1:20pm acknowledges they failed to disinfect the counter after contamination with blood.

- Emergency Room bay 2 observed on 6/15/15 at 10:15am revealed a cabinet with an opened and the cap removed Normal Saline Flush 0.9% 10ml (milliliter) syringe with 10ml of clear liquid and available for use.

Registered Nurse Staff B interviewed on 6/15/15 at 10:15am acknowledged the contaminated open Normal Saline syringe and available for patient use.

- The CAH's policy "Infection Control" reviewed on 6/15/15 at 3:25pm directed, "...dietary employees will practice hygienic food handling techniques...Meals-on-wheels will be sent out in disposable dishes, which are not returned to the hospital..."

- The Dietary Department observed on 6/15/15 between 2:20pm to 3:00pm revealed one large square Styrofoam container and three small, round Styrofoam containers with food placed in the north refrigerator.
Certified Dietary Manager Staff I interviewed 6/15/15 at 3:00pm acknowledges meals-on-wheels attempted to deliver the meal in the Styrofoam containers and the recipient failed to be at their home so staff retuned the meal to the kitchen.
- The Dietary Department observed on 6/15/15 at 3:00pm revealed one opened, half-full water bottle labeled "Tam" in the west refrigerator.
Certified Dietary Manager Staff I interviewed 6/15/15 at 3:00pm acknowledges the open water bottle had been drunk from and belonged to dietary staff. Staff I acknowledged the contaminated water bottle exposed patient food to contaminates.

- The CAH's policy "Standard Precautions" reviewed on 6/17/15 at 3:30pm directed, "...masks and eyewear should be worn during procedures that are likely to generate droplets/splashing...Gowns/Aprons should be worn when there is potential for soiling clothing..."
- The soiled utility room in the emergency department observed on 6/15/15 at 10:45am revealed a flush rim sink and sprayer. Observation in the room revealed the lack of cover gowns (personal protective equipment (PPE) available to protect staff and their clothing from splash and the spread of germs while using the flush-rim sink and sprayer.

Registered Nurse Staff B interviewed on 6/15/15 at 10:45am acknowledged the flush rim sink and sprayer and the CAH failed to have PPE available for uses with the sink.

- The soiled utility room on the nursing unit observed on 6/16/15 at 10:50am revealed a flush rim sink and sprayer. Observation in the room revealed the lack of cover gowns PPE available to protect staff and their clothing from splash and the spread of germs while using the flush-rim sink and sprayer.

Maintenance Staff J interviewed on 6/16/15 at 10:50am acknowledged the flush rim sink and sprayer and the CAH failed to have PPE available for uses with the sink.

The Critical Access Hospital (CAH) reported a census of three patients, one acute patient and two skilled swing bed patients. Based on observation, staff interview and policy review the CAH failed to ensure basic laboratory services essential to the immediate diagnosis and treatment of patients available in one of one blood drawing rooms adjacent to the laboratory. Failure of the CAH to provide basic laboratory services has the potential for incorrect lab testing and poor patient outcomes.

Findings include:

- The CAH's policy "Outdated Supplies Removal" reviewed on 6/17/15 at 1:00pm directed "...if a supply is found expired it will be removed from service immediately and disposed of..."

- Laboratory (Lab) toured on 6/15/15 between 11:05am and 11:30am revealed in the lower cabinet of the Lab Drawing Room two specimen collection kits containing 3 ml (milliliter) of orange-red medium for Viruses, Chlamydia, Mycoplasma and Ureaplasma (causes of infection) with an expiration date of 05/2015. The upper cabinets of the Lab Drawing Room revealed the following:
1. One 500 ml empty glass evacuated container (used to draw blood) with an expiration date of 6/1/10
2. Six 150 ml empty glass evacuated containers with expiration dates of 12/1/05
3. 14 BD Microtainer tubes (used for blood collection) with expiration dates of 05/12
4. 14 BD Microtainer plasma separator tubes (used for blood collection) with expiration dates of 02/12
5. Seven 22 gauge x1 " sterile single use needles with expiration dates of 12/2010
6. Four 3ml Normal Saline flushes with expiration dates of 04/15.

Laboratory Staff G interviewed on 6/15/15 at 11:15am acknowledged that specimen collection supplies were expired.

Laboratory Staff F interviewed on 6/18/15 at 9:10am confirmed the Laboratory lacked a policy directing disposal of expired supplies.

The Laboratory failed to follow the hospital policy directing disposal of outdated supplies.

The Critical Access Hospital (CAH) reported a census of three patients, one acute patient and two skilled swing bed patients. Based on medical record review, staff interview and policy review the CAH failed to ensure one of thirty acute medical records sampled contained a pertinent medical history and physical (H & P) completed in a timely manner. The CAH's failure to ensure patients' medical history and physical are competed in a timely manner has the potential for poor patient outcomes.

Findings include:

- The CAH's Medical Staff Rules and Regulations reviewed on 6/17/15 at 3:40pm directed, " ...a complete history and physical examination shall be written or dictated within 24 hours after admission. Short form history and physical may be used for uncomplicated admission of less than 48 hours..."

- Patient #33's medical record reviewed on 6/17/15 at 1:30pm revealed an admission date of 3/13/15 with a diagnosis of cellulitis (infection of the skin) of the left foot. Patient #33's medical record revealed a history and physical completed on 3/18/15. The CAH failed to ensure Patient #33's history and physical was completed within 24 hours after admission.

Administrative Staff A interviewed on 6/17/15 at 2:00pm acknowledged that Patient #33's H & P was completed five days late and placed the patient at risk for poor patient outcomes.

The Critical Access Hospital (CAH) reported a census of three patients, one acute patient and two skilled swing bed patients. Based on medical record review, staff interview, and Medical Staff Rules and Regulations the CAH failed to document physician's orders for one of two sampled outpatient medical records reviewed (patient #42).

Findings include:

- Patient #42's outpatient medical record reviewed on 6/17/15 revealed an admission date of 5/6/15 for outpatient series services. The care provided to patient #42 included cap changes every three days to their PICC (peripherally inserted central catheter a form of intravenous access) and a weekly dressing change to the PICC site. The medical record lacked documentation of physician's orders for the care provided.

Administrative Nursing Staff A interviewed on 6/17/15 at 3:30pm acknowledged patient #42's outpatient medical record lacked evidence the physician ordered the care provided.

The Critical Access Hospital (CAH) reported a census of three patients, one acute patient and two skilled swing bed patients. Based on observation and staff interview, the CAH failed to safeguard confidential patient information from possible destruction. This practice has the potential to affect the patients' records in 12 cardboard boxes.

Findings include:

- The Medical Records storage room observed on 6/15/15 at 11:47am revealed twelve banker boxes (cardboard boxes used to store medical records) placed directly on the floor.

- Medical Records Staff C interviewed on 6/15/15 at 11:50am acknowledged the boxes contained patients' medical records and the boxes sat directly on the floor with the potential for flooding. The CAH failed to assure protection of medical records from destruction.

The CAH failed to have a policy for protection of medical records.