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Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the nursing staff removed outdated medication and supplies from the Emergency Department (ED) area. Failure to remove outdated medications and supplies from the CAH's supplies, available for patient use, could potentially result in the staff using expired medications and/or supplies for patient use after the manufacturer's expiration date, potentially resulting in the staff using medication on a patient after the date which the manufacturer guaranteed the sterility and efficacy of the medication and supplies. The CAH administrative staff identified a total average of 183 ED patients per month from July 2020 until June 2021.

Findings included:

1. During a tour of the ED on 5/2/22 at 8:50 AM revealed the following outdated supplies:

a. In ED supply room, 2 of 2 ICUMed 1000 milliter (ml) intravenous (IV) bags 5% Dextrose and 0.9% Sodium Chloride solution, expired on 12/2021; 1 of 1 Hospira 1000 ml IV bag of 0.45% Sodium Chloride solution, expired on 12/2021; 2 of 2 ICUMed 1000 ml IV bags of 5% Dextrose solution; 1 of 1 Braun 1000 ml IV bag of 5% Dextrose solution; 1 of 1 Intersurgical incorporated clear-therm HMEF, luer lock port, expired 2/28/2022.

b. In ED room #2, 2 of 2 2% 400 milligram (mg) 20 ml Xylocaine injection medication, expired 11/2021.

c. In ED room #3, 1 of 1 2% 400 mg 20 ml Xylocaine injection medication, expired 11/2021.

2. Review of the CAH policy "Outdates," last revised 5/2015, revealed in part, "On a monthly basis, each department is responsible for their respective areas and will be checking inventory supplies with outdates on them."

3. During an interview on 5/2/2022 at 8:50 AM with the Ambulance Director and CNO, acknowledged these outdates in the ED.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a physician periodically reviewed the care provided for CAH patients, in conjunction with mid-level providers, for 2 of 2 Allied Health mid-level providers selected for review (Advanced Registered Nurse Practitioner A and Advanced Registered Nurse Practitioner B). Failure to ensure a physician periodically reviewed mid-level provider's patient medical records, in conjunction with the mid-level provider, could potentially result in misdiagnosing a patient and/or providing inappropriate or substandard patient care. The CAH administrative staff identified Advanced Registered Nurse Practitioner (ARNP) A and Advanced Registered Nurse Practitioner (ARNP) B treated the following patients from 5/4/2021 through 5/4/2022:

Emergency Room/Hospitalist ARNP A - 802 patients
Chronic Pain Management ARNP B - 191 patients

Findings include:

1. Review of a CAH policy titled "Peer Review", last approved 4/2022, revealed the CAH had a detailed policy to address peer review for external and internal peer review, however, the internal peer review is not done on a routine basis for all mid-level providers treating CAH patients.

2. Review of documentation revealed the CAH lacked evidence to show the identified mid-level providers participated with a physician in a periodic review of their patient's health records.

3. During an interview on 5/4/22, at 3:00 PM, the Chief Executive Officer reported a physician reviews and signs off on Emergency Room (ED)/Hospitalist ARNP A's patient charts. He reported there may be discussion on complicated patient, but not necessarily and not on a routine basis. He reported external peer review is conducted regularly for both ED/Hospitalist ARNP A and Chronic Pain Management ARNP B, which is shared with the CEO, the Chief Medical Officer and the Board of Trustee Chair but confirmed, while internal chart review may be done on a limited basis with patient care concerns, it is not conducted regularly for the ED/Hospitalist ARNP or the clinic mid-level clinic providers.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure a mid-level provider periodically participated in a review of the care provided for CAH patients, in conjunction with a physician, for 2 of 2 mid-level providers selected for review (Advanced Registered Nurse Practitioner A and Advanced Registered Nurse Practitioner B). Failure to ensure a mid-level provider participated with a physician in periodic review of the mid-level provider's patient medical records, could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care. The CAH administrative staff identified Advanced Registered Nurse Practitioner (ARNP) A and Advanced Registered Nurse Practitioner B treated the following number of emergency room patients from 5/4/2021 through 5/4/2022:

Emergency Room (ED)/Hospitalist ARNP A - 802 patients
Chronic Pain ARNP B - 191 patients

Findings include:

1. Review of a CAH policy titled "Peer Review", last approved 4/2022, revealed the CAH had a detailed policy to address peer review for external and internal peer review, however, the internal peer review is not done on a routine basis for all mid-level providers treating CAH patients.

2. Review of documentation revealed the CAH lacked evidence to show the identified mid-level providers participated with a physician in a periodic review of their patient's health records.

3. During an interview on 5/4/22, at 3:00 PM, the Chief Executive Officer reported a physician reviews and signs off on Emergency Room (ED)/Hospitalist ARNP A's patient charts. He reported there may be discussion on complicated patient, but not necessarily and not on a routine basis. He reported external peer review is conducted regularly for both ED/Hospitalist A and Chronic Pain Management ARNP B, which is shared with the CEO, the Chief Medical Officer and the Board of Trustee Chair but confirmed, while internal chart review may be done on a limited basis with patient care concerns, it is not conducted regularly for the ED/Hospitalist ARNP A or the clinic mid-level clinic providers.

Based on document review and staff interviews, the Critical Access Administrative (CAH) administrative staff failed to ensure the Laboratory Department follow the CAHs policy and procedure on the removal of cardboard boxes from the floor of the laboratory. Failure to have the boxes removed from the floor of the laboratory could potentially result in introducing harmful contaminants into the hospital environment. The CAH Administrative staff identified a census of 2 patients upon survey entry.

Findings include:

1. Review of the CAHs policy, "Corrugated/Cardboard Boxes", last approved 10/2021, revealed in part, "Corrugated/cardboard shipping boxes are potential sources of contamination as a result of their exposure to surface contaminated, such as, but not limited to dust, vectors, fluids, soil, ect." "Cardboard boxes are unable to be wiped down for cleaning/disinfecting purposes." "... Physical surveillance of compliance will be performed during monthly departmental safety rounds and will be reported to the Infection Prevention committee."

2. Observations during a tour of the Laboratory Department on 5/2/22 at 2:15 PM, with the Laboratory Director, revealed several cardboard boxes under the counters, sitting on the floor.

3. During an interivew at the time of the tour, the Laboratory Director acknowledged that the cardboard boxes under the laboratory counters. The Laboratory Director revealed that the staff had left the boxes on the floor "for some time."

4. During an interview with the Laboratory Department on 5/5/2022 at 9:40 AM, the Laboratory Director acknowledged they failed to ensure the staff removed the cardboard boxes from the lab and that the cardboard boxes posed a potential infection control hazard.

Based on observation, document review and staff interviews, Critical Access Hospital (CAH) administration failed to ensure 6 of 6 reviewed laboratory staff members (Laboratory Director, Certified Laboratory Assistant C, Medical Laboratory Technologist D, Medical Technologist E, Laboratory Phlebotomist, and Medical Laboratory Technologist F) had color vision proficiency prior to interpreting the results of fecal occult blood (blood in stool) tests for all laboratory who read the results of the test. Failure to test all laboratory staff for color blindness before performing this test may result in staff misreading the results of the fecal occult blood test which could potentially adversely affect the diagnosis and treatment plan for patients. The CAH laboratory staff performed 40 fecal occult blood tests from 7/2020 to 6/2021.

Findings include:

1. Observation on 5/2/22 at 2:15 PM, during a tour of the Laboratory, revealed the laboratory staff utilized Beckman Coulter Hemoccult slides to check stool for occult blood.

2. During an interview at the time of the tour of the laboratory, the Laboratory Director reported the laboratory staff identified a positive occult blood test result by identifying the slide turned the color blue. The Laboratory Director acknowledged the laboratory staff interpreting the test would require the ability to identify the color blue.

3. Review of the manufacturer's recommendations for Beckman Coulter Hemoccult slides, dated April 4, 2014 revealed, in part: "Because this test is visually read and requires color differentiation, it should not be interpreted by individuals with blue color deficiency (blindness) ...."

4. The CAH did not have a policy regarding staff requirements for reading a Beckman Coulter hemoccult test.

5. During an interview on 5/2/22 at 2:15 PM with the Laboratory Director acknowledged the CAH administrative staff did not currently require color blind testing of laboratory staff.

Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that the infection preventionist responsible for the infection prevention and control program had been appointed by the Governing Body, and that the appointment was based on the recommendations of medical staff leadership and nursing leadership for 1 of 1 infection preventionist. Failure to comply with regulations could potentially hinder the infection prevention and control program including surveillance, prevention, and control of hospital-acquired infections (HAI)s, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and address any infection control issues, potentially causing harm or death to patients and their safety. The CAH administrative staff identified an inpatient census of 2 patients upon entrance.

Findings include:

1. Review of the CAH's Policies and Procedures revealed that no policy existed regarding an appointment for the Infection Preventionist by the Governing Board.

2. Review of the Governing Board Meeting Minutes, from 3/24/21 to 3/23/22, revealed that an appointment had not been made by the Governing Board for the position of Infection Preventionist.

3. During an interview on 5/3/22 at 1:00 PM, with the Infection Preventionist, revealed she had been the Infection Preventionist since October 2021. The Infection Preventionist did not know if she had been appointed as the CAH Infection Preventionist by the Governing Board based on the recommendations of medical staff and nursing leadership.

4. During an interview on 5/3/22 at approximately 1:40 AM, Chief Executive Officer (CEO) confirmed the CAH did not provide recommendations to the Medical Staff nor obtain approval of the Governing Board when the new Infection Preventionist was appointed to the position.

Based on review of the Quality Improvement Plan, Quality Improvement activities, and staff interviews, the Critical Access Hospital (CAH) quality improvement staff failed to involve all departments of the CAH and services when it failed to evaluate 5 of 28 services provided by the CAH (Anesthesia, Senior Life Solutions, Pain Clinic, Pulmonary Rehab, and Health Information Management). Failure to monitor and evaluate all patient care services for quality of care and service could potentially expose patients to inappropriate and/or substantial care. The CAH administrative staff reported a census of 2 patients at the beginning of the survey. The CAH administrative staff reported the CAH staff performed the following number of procedures from July 1, 2020 to June 30, 2021 - Anesthesia services 554 procedures, Senior Life Solutions 54 patients, Pain Clinic patients 186, Pulmonary Rehab patients 12, and Health Information Management 19,930 patients .

Findings include:

1. Review of the CAH's "Quality Improvement and Patient Safety Plan," last approved 4/2022, revealed in part, "... CAH must measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital service and operations...is facility-wide, including all departments and all services..."

2. Review of the Quality Improvement Committee Meeting minutes from March 23, 2021 through April 22, 2022 revealed the meeting minutes lacked evidence that the CAH staff monitored, evaluated, and reported quality improvement activities regarding patient care services for anesthesia, Senior Life Solutions, pain clinic, pulmonary rehab, and Health Information Management (HIM).

3. During an interview on 5/4/22 at 10:00 AM, the CNO/Quality Director, acknowledged that the Quality Improvement Committee meeting minutes lacked evidence the CAH staff monitored, evaluated, and reported the quality improvement activities regarding services provided by anesthesia, Senior Life Solutions, pain clinic, pulmonary Rehab, and HIM.