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Based on observation and staff interview, the facility failed to maintain an environment free of hazards on 2 of 3 days of survey (December 13-14, 2016). Accessible hazards, including chemicals and a hot blanket warmer, places cognitively impaired and wandering patients at risk for accidents/injury.

Findings include:

Observation of the environment occurred on the afternoon of 12/14/16 and found the following chemicals stored each with hazard warning labels, and not in a secure location:
* Dirty Utility room located in a hallway on the Swingbed unit: A bottle of "Alkaline Drain Clog" remover with a label of the product being dangerous, corrosive, harmful, or fatal if swallowed; two containers of "Resolve" spot and stain cleaner with a label of keeping out of reach of children; a bottle of "HB quat" disinfectant cleaner with a label of the product causing eye, skin, nose and throat irritation, and keep out of reach of children; two containers of "Chlor Retain" with warning label of causes irritation and keeping out of reach of children; four containers of "Good Sense" sealed air-odor conteractant spray, and several bottles of liquid hand foam and hand soap sanitizers

Observation of the clean utility room in the hallway of the Swingbed unit showed storage of a blanket warmer with the door unlocked on the warmer and the internal temperature of 135 degrees.

During an interview on the afternoon of 12/14/16, a supervisory staff member (#2) and an administrative staff member (#3) agreed the above listed chemicals staff should store to prevent access to patients.

Based on observation and staff interview, the facility failed to provide safety equipment to prevent back flow of contaminated water into the potable (drinking) water system of the facility in 2 of 3 housekeeping rooms (basement and Swingbed unit). The lack of safety devices has the potential to affect the water supply for the entire facility.

Findings include:

A tour of the environment occurred on 12/14/16 at 2:40 p.m. with a supervisory environmental staff member (#2) and an administrative staff member (#3). Observation of the housekeeping room located in the basement and the housekeeping room in the west end nursing unit identified a hose connected to a faucet which reached below the flood rim of the mop sink, allowing the hose to be capable of submersion into the sink. Observation showed both faucets lacked a back flow device. An environmental staff member (#2) confirmed the faucets had no back flow device.

HOT LIQUID SPILLS

1. Based on observation, record review, and staff interview, the Critical Access Hospital (CAH) failed to assess patients and provide adequate supervision and assistance devices to prevent injuries from hot liquids, including ensuring safe coffee/hot liquids temperatures, for 1 of 4 sampled patients (Patient #4) and one patient in a closed record (Patient #21). Failure to provide adequate supervision, including an assessment of patients for risk of spills of hot liquids including coffee, and ongoing monitoring of coffee dispensing machine temperatures may have resulted in both patients experiencing injury from hot coffee.

Findings include:

Review of incident and accident reports occurred on the afternoon of 12/13/16. Two reports identified an incident/accident occurring in a unit designated for Swingbed patients. Each resident experienced coffee burns from spilling hot coffee onto themselves. The reports identified the following:
* On 6/26/2016 at 8:00 a.m., Patient #21, age 78, experienced "moderate" harm "in the dining room on the swingbed unit when was given a cup of hot coffee. [Patient] had been having jerky movements. When took the hot coffee had spilt it on himself. I [nurse's first name] was not in there at that time this happened. [A nurse by name] then brought [patient] down to his room and put cool compresses on his abdomen and thighs. [Nurse] spoke then to [provider - nurse practitioner] in regards to burn and new orders received . . . Immediate Actions Taken: Cool compresses were put onto abdomen and thighs. Did have red open blisters to abdomen and R [right] upper thigh. . . . Comments/Actions: actions taken at time of injury." The report did not include a plan to prevent reoccurrence for this patient.
* On 11/29/2016 at 8:00 a.m., Patient #4, age 96, experienced "minimal" harm when the "Resident [patient] spilled coffee in lap at breakfast table in dining room this am. Immediate Actions Taken: Res [resident] was taken to bathroom and legs assessed. Pants were changed and On call physician notified of incident. Res had no reports of pain." The report's corrective action included: "No further action needed. Resident was assessed; had initial redness which subsided and has had no further evidence of injury. Staff were educated to cool patients coffee with ice cubes or cold water. Comments/Actions: Patient with no injury from incident. Continue to work with staff on patient safety when drinking/serving hot liquids."

Observation on 12/13/16 at 5 p.m. showed an automated coffee machine located on the counter in the Swingbed dining room. A staff nurse (#11), present at the time, stated staff serve all coffee from the machine, not from the kitchen. The nurse stated staff serve the coffee to the patients, and currently no patients serve themselves from the automated coffee machine.

Observation on 12/14/16 at 8 a.m. showed two Swingbed Patients, #3 and #4, seated at the dining room table finishing breakfast. Observation showed a cup of hot chocolate at Patient #3's place setting and a cup of coffee at Patient #4's place setting. Observation showed both served in a brown hard plastic cup with a handle and no lid.

During interview on the morning of 12/15/16, the risk manager/safety team member (#9) stated after the burn incident on 06/27/16 staff turned down the coffee machine temperature six to seven degrees. The staff member stated the "direction" for addressing safety with hot liquids often comes from the acute care unit or with a swallowing evaluation. The staff member stated after the burn incident on 11/29/16 education to staff included not filling cups as full and the use of lids. She stated the facility has no process to complete burn assessment risks on patients.

During interview on 12/15/16 at 11 a.m., a supervisory nurse (#1) confirmed the CAH does not do assessments to determine whether Swingbed patients are at risk of burns from hot coffee. She expressed awareness of the burn incident on 06/27/16 and knowing the temperature of the coffee dispenser turned down following that incident. She stated after the burn incident on 11/29/16, the facility instructed staff to put ice in Patient #4's coffee, which nursing staff acknowledged doing, the facility did not implement a formal burn assessment and stated it is the nurse's judgement. The nurse (#1) supplied information from the dietary department to acknowledge all the facility's coffee machine temperatures had been set at 171 degrees Fahrenheit.

During interview on 12/15/16 at 12:20 p.m., a dietary staff member (#10) confirmed nursing staff on the units serve patients coffee out of the coffee machines on each nursing unit. She stated after the incident on 06/26/16 staff turned down the temperature of the coffee machine and readings obtained in July and August were between 172 - 174 degrees F. She stated no additional monitoring occurred after this.

On the afternoon of 12/15/16, coffee temperatures on the Swingbed nursing unit and inpatient unit occurred. Both units supply coffee from a Nescafe Alegria machine with a sign under the spout which stated "Caution Very Hot Beverage." Readings of the temperature of the coffee dispensed occurred right after dispensing them out of the machine:
* Swingbed: regular coffee temperature 177.5 degrees F; decaffeinated coffee 182 degrees F
* Inpatient unit: regular coffee temperature 180 degrees; decaffeinated coffee 177.7 degrees F



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SIDE RAIL ASSESSMENT

2. Based on observation, record review, professional literature review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate the safe use of side rails, failed to assess each patient individually prior to utilizing side rails, failed to consider side rails as a potential entrapment hazard, and failed to provide education to the patient and responsible party regarding the hazards of side rail use for 2 of 2 active swingbed patients (Patient #3 and #4) observed with side rails. Failure to assess and evaluate the use of side rails, to consider side rails as a potential entrapment hazard, and to educate patients and responsible parties regarding the hazards of using side rails, restrict a patient's movement, placed patients at risk of entrapment or injury.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated April 2003, stated, ". . . bed rails may pose increased risk to patient safety. . . . evidence indicates that half-rails pose a risk of entrapment . . . as well as falls that occur when patients climb over the rails or footboards when the rails are in use. . . . CMS [Centers for Medicare and Medicaid Services] issued guidance in June 2000 . . . One section of the guidance states, 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. Even when a side rail is not intentionally used as a restraint, patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised siderails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . . 1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize . . . those in current use should occur within the framework of an individual patient assessment. . . . 3. Use of bed rails should be based on patients' assessed medical needs and should be documented clearly . . . The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted . . . The care plan should include educating the patient about possible bed rail danger to enable the patient to make an informed decision . . . If a bed rail has been determined to be necessary, steps should be taken to reduce the known risks associated with its use. . . . Assessment of risk should be part of the individual patient's assessment, and steps to address the risk should be incorporated into the patient's care plan. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts", revised April 2010, stated, ". . . Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . . Most patients can be in bed safely without bed rails. Consider the following: Use beds that can be raised and lowered close to the floor . . . Keep the bed in the lowest position with wheels locked. When the patient is at risk of falling out of bed, place mats next to the bed . . . Monitor patients frequently. Anticipate the reasons patients get out of bed . . . meet these needs . . . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. . . . Reassess the need for using bed rails on a frequent, regular basis."

- Observation on 12/13/16 at 4:55 p.m., on 12/14/16 at 9:50 a.m., and on 12/15/16 at 12:49 p.m. identified two elevated half rails at the head of Patient #3's bed.

Review of Patient #3's medical record occurred on all days of survey and identified the CAH admitted the patient on 05/02/16 with diagnoses including tibia/fibula (leg) fracture, congestive heart failure (CHF), hyperglycemia, chronic obstructive pulmonary disease (COPD), hypertension (HTN), chronic urinary tract infections, anxiety, and depression. The nurse aide's care guide (kardex) identified the patient as up with one assist to wheelchair/walker, pressure alarm on recliner and bed, falling star on door, high risk for falls, and side rails up times two.

Review of Patient #3's nurse rounding flow sheet identified the following:
* 12/14/16 8 p.m. to 12/15/16 5:16 a.m. - Two side rails up due to Patient/Family Request. Patient sleeping in bed.
* 12/15/16 9 a.m. and 10:07 a.m. - Two side rails up due to bed controls and patient positioning.

- Observation on 12/13/16 at 5:15 p.m., on 12/14/16 at 9:50 a.m. and 12/15/16 at 12:50 p.m. identified Patient #4's unoccupied bed had two half rails at the head of the bed and not in the elevated position.

Review of Patient #4's medical record occurred on all days of survey and identified the CAH admitted the patient on 12/09/16 with diagnoses including aspiration pneumonia (10/19/16), CHF, COPD, anxiety, depression, HTN, and a cardiac pacemaker. The nurse aide's care guide (kardex) identified the patient as up with one assist to wheelchair/walker, bed/personal alarm, high risk for falls, confused at times, and side rails up times two.

Review of Patient #4's nurse rounding flow sheet identified on 12/14/16 at 9 p.m. to 12/15/16 at 3 a.m. - Two side rails up due to Patient/Family Request.

Patient #3 and #4's records lacked an individualized assessment of risk and safety for the use of side rails, lacked evidence of patient or responsible party education regarding the hazards of side rail use, and lacked a care plan for the side rails.

During an interview on 12/15/16 at 1 p.m., an administrative nurse (#1) stated nurses documented the patients' side rail usage on the rounding flow sheet by checking the following reasons:
* Bed controls
* Patient positioning
* Physician request
* Safety
* Patient/Family request
* Other (see below).
The nurse confirmed staff does not perform an initial or periodic side rail assessment for risk factors or safety for utilization of side rails, and the care plans failed to address the side rail usage.

Based on policy review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the treatment furnished by 3 of 3 active staff physicians (Physicians #1, #2 and #3) credentialed by the CAH. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the treatment furnished by the physicians limits the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the "PERFORMANCE IMPROVEMENT [PI] PLAN" occurred on 12/14/16. This plan, approved 01/20/16, identified one of the purposes of the plan as "Identify opportunities to improve processes and outcomes." The "AUTHORITY AND RESPONSIBILITY" included the "Medical Staff will actively function as the Physician Advisor to the PI program, perform peer review, communicate and support PI activities. The ultimate goal is that performance improvement opportunities are addressed, and areas of concern in patient care and safety are identified and resolved. . . ."
Review of the policy titled "Peer Review" occurred on 12/13/16. This policy, dated 05/12, stated, "PURPOSE: The purpose of physician peer review is to secure a random, structured, independent peer review of medical practices of [the CAH's] medical staff members for the purposes of . . . quality improvement . . . PROCEDURE: 1. [The CAH] has entered into an agreement with [an outside agency] for the purpose of medical staff peer review. . . . INTERNAL NON-PHYSICIAN REVIEW . . . 3. The Quality/Utilization Coordinator and Health Information Technician will screen random charts for quality using the [an outside agency] quality criteria. . . . 5. The Quality/Utilization Review Coordinator will refer charts identified with concerns of quality of care. . . . 6. Findings and recommendations from the reviewer are reported to the Medical Staff Executive Committee who will determine whether any further action is necessary. Actions may include, but are not limited to: A second review, an outside review, education, proctoring/supervision, or restriction of privileges. . . ."

On the afternoon of 12/14/16, a request occurred for the Peer Review reports within the last year for Physicians #1, #2 and #3. The review identified no outside source evaluated the quality and appropriateness of the diagnosis and treatment furnished by Physicians #1, #2 and #3.

During interview on 12/14/16 at 2:15 p.m., a quality improvement staff member (#9) stated the CAH has requested peer review to evaluate the quality and appropriateness of the diagnosis and treatment furnished by the CAH's physicians from an outside source for the surgeons and certified registered nurse anesthetists, but not for any other physicians for over a year.

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to establish a comprehensive care plan which described the services furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 4 swingbed patient (Patient #3, #4, #5, and #6) records reviewed. This failure limited the CAH's ability to ensure continuity of care and provide the greatest benefit to the patient.

Findings include:

Review of the policy "Care Plan" occurred on 12/15/16. This policy, amended October 2008, stated, "Purpose: To provide the resident/patient with appropriate treatment in order to ensure an optimal outcome during his/her stay at LAHS [Lisbon Area Health Services]. Policy: An interdisciplinary resident/patient care plan will be developed in coordination with the resident/patient and appropriate disciplines. Care plans will have measurable objectives and timetables to meet the resident/patient's medical, nursing, mental, and psychosocial needs. Procedure: 1. The plan will address resident/patient's needs, and include measures that will restore, maintain or promote their well being. . . . 4. Goals will be identified, measurable, realistic and communicated to all appropriate personnel. Swingbed: 1. An initial assessment will be completed upon admission . . . 2. The plan of care will be reviewed with weekly assessment and as the needs of the resident change. Care Conference will be held quarterly and on an as needed basis after initial care conference. 3. Care Plan Review/Revised area to be dated and initialed with each review. . . ."

- Review of Patient #5's active swingbed record occurred on 12/13/16 and identified the CAH admitted the patient on 12/01/13 with diagnoses including a cerebral vascular accident. The record showed care conferences or interdisciplinary group meetings occurred in January and October of 2016 and included nursing, dietary, activity, and social services or case management staff in attendance. Review of Patient #5's care plan showed nursing objectives, but failed to include collaboration of an interdisciplinary team such as dietary, activity, and case management.

- Review of Patient #6's active swingbed record occurred on 12/14/16 and identified the CAH admitted the patient on 12/01/13 with diagnoses including a traumatic brain injury. The record showed care conferences or interdisciplinary group meetings occurred in July and October of 2016 and included nursing, dietary, activity, and social services or case management staff in attendance. Review of Patient #6's care plan showed nursing objectives, but failed to include collaboration of an interdisciplinary team such as dietary, activities, and case management.

- Review of Patient #3's active swingbed record occurred on all days of survey and identified the CAH admitted the patient on 05/02/16 with diagnoses including tibia/fibula (leg) fracture, congestive heart failure (CHF), hyperglycemia, chronic obstructive pulmonary disease (COPD), hypertension (HTN), chronic urinary tract infections, anxiety, and depression. The current care plan showed nursing objectives, but failed to include collaboration of an interdisciplinary team such as dietary, activity, and case management and specific use/assessment of more than one side rail.

- Review of Patient #4's active swingbed record occurred on all days of survey and identified the CAH admitted the patient on 12/09/16 with diagnoses including aspiration pneumonia (10/19/16), CHF, COPD, anxiety, depression, HTN, and a cardiac pacemaker. The current care plan showed nursing objective, but failed to include collaboration of an interdisciplinary team such as dietary, activity, and case management and specific use/assessment of more than one side rail. The care plan also failed to show problem/goals/interventions after a hot coffee spill on 11/29/16.

During an interview on the morning of 12/15/16, an administrative nurse (#1) confirmed Patient #3, #4, #5, and #6's swingbed care plans were not comprehensive. The nurse also confirmed the care plan failed to address Patient #3 and #4's side rail usage/assessment and failed to address nursing staff's intervention to cool Patient #4's coffee. Refer to C294.