HospitalInspections.org

I. Based on direct observation and staff interview, the Critical Access Hospital (CAH) failed to store medications appropriately. The hospital reported an average daily acute patient census of 2.88 for the most recent fiscal year. Findings include:

A. On 2/22/12 at 2:00 PM during a tour of the Radiology Department, an unlocked emergency medication storage box was observed in the radiology work room. The box contained 1 vial of 1 mg Epinephrine and 1 vial of 50 mg/ml Diphenhydramine.

During the tour of the CAT scan room, an unlocked emergency medication box was observed in a cabinet, labeled "emergency medications". The box contained 1 vial of 1 mg Epinephrine and 1 vial of 50 mg/ml diphenhydramine.

B. An interview conducted with the department manager (Employee E) confirmed the medication storage boxes were unlocked.


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II. Observation, staff interviews, and review of the CAH policies and procedures revealed the CAH failed to ensure a safe environment pertaining to the disposal of a hypodermic needle which contained a nuclear medication and had a high potential for patient harm if not disposed of or handled properly. The CAH had 1 acute care patient upon entrance. Findings include:

A.During initial tour on 2/14/12 at 11:00 AM, observation revealed the facility utilized an outpatient contracted service for the purpose of providing stress testing for patients 1 time per month. Further observation and interview with the Director of Nursing (DON) noted that Patient Room 12 was occupied by a patient for the purpose of receiving medications and a stress test. Patient Room 14 was observed to have an over-bed patient tray with lead box approximately 12 inches by 12 inches and the lid of the lead box was open. A sign attached identified the material in the lead box as "hazardous material". Interview with the DON and contracted Outpatient Representative B identified a hypodermic needle lying in the bottom of the lead box that was used to inject a radioactive material known as Cardiolite Sestamibi 99 MTC (99 Medistable Technetium) with an atomic number of 99 and had a half life of 6 hours directly into the stress patient's intravenous (IV) line. (Cardiolite allows for a view of the heart and Technetium is the radioactive portion of the mixture.) Inside the lead container was a lead oval container, referred to as a PIG. Interview with Contracted Staff B acknowledged the hypodermic needle should not have been put into the lead container, but dropped into the PIG and the lid to the lead box should have been closed.

B Interview with the DON on 2/14/12 acknowledged the CAH does admit patients with altered cognition, and minor patients that utilize the same hallway. The CAH has no active policies or procedures in place to ensure the safety of patients in case of a hazardous spill, and does not monitor the service on the Quality Assurance Program.

I. Based on review of the Critical Access Hospital's (CAH) Medical Staff By-Laws, as compared with the information available at the time of physician reappointment to the Medical Staff and staff interviews, the Governing Body failed to follow the Medical Staff By-Laws in the reappointment process. The CAH reported an average daily acute care patient census of 2.88 for the most recent fiscal year. Findings include:

A.The current Medical Staff By-Laws dated 2011 state on page 24 Section 5 Reappointment Renewal Process c. " In reviewing applications for reappointment and renewal of privileges, the Executive Committee and Board will...review ...peer review, and quality assurance records and reports; patient charts; incident reports ... and any other relevant documents..."

B. A review of the reappointment file for Physician D lacked evidence of peer review, quality assurance activity, or patient charts.

C. An interview conducted with Employee C, who oversees the reappointment process, on 2/23/12 at 10:30 AM, confirmed peer review and quality assurance information was not included in the reappointment process

II. Based on review of the CAH's Medical Staff By-Laws, as compared with the information available at the time of physician reappointment to the Medical Staff and staff interviews, the Medical Staff failed to adhere to the By-Laws in the reappointment process and failed to assure that the clinical privileges reflected the actual medical practice in the CAH. The CAH reported an average daily acute care patient census of 2.88 for the most recent fiscal year. Findings include:

A. The current Medical Staff By-Laws dated 2011 state on page 24 Section 5 Reappointment Renewal Process c. " In reviewing applications for reappointment and renewal of privileges, the Executive Committee and Board will also consider whether the practitioner has actually exercised all the requested privileges with sufficient frequency since the time of last appointment or reappointment to indicate current proficiency."

B. A review of the reappointment file for Physician D lacked evidence of the number and type of procedures performed in the CAH. In addition, the privilege list included high risk procedures such as splenectomy (removal of the spleen) and thyroidectomy (removal of the thyroid gland).

C. An interview conducted with Employee C, who oversees the reappointment process, on 2/23/12 at 10:30 AM, confirmed the number and type of procedures performed and the patient outcomes were not considered in the reappointment process and the the list of procedures granted did not reflect actual practice, as splenectomies and thyroidectomies had not been performed in the CAH for the past 7 years.