HospitalInspections.org

Based on record reviews and interviews, the Governing Body failed to discharge its oversight responsibilities effectively.

Findings:

Review of the Medical Staff Bylaws revealed under Section 2, Credentialing Process, "The Governing Body of the Crownpoint Service Unit has delegated to the Clinical Director, Co-Chiefs of Staff, and CEO the authority to grant expedited appointment to the Medical/Dental Staff and approve privileges if an applicant's application is "routine", as defined by the following criteria." Further it says, "Decisions to approve credentials and privileges made by the MDSEC under the expedited authority become effective at the time of their approval. Applicants may exercise privileges granted to them immediately upon MDSEC approval."

In 5 of 5 medical staff credential files reviewed, the medical staff application for memebership to the Crownpoint Medical/Dental Staff and privileges were not approved by the Governing Body by by the Chief Executive Officer of the hospital. The regulation specifically requires that only the GOverning Body of a hospital can appoint members of its medical staff and grant privileges.

In 2 of 5 medical staff credential files, the Governing Bodyy failed to ensure that practitioners have the necessary credentials to render emergent care to patients to preserve life in that an emergency room physician and a nurse-midwife only have Basic Cardiac Life Support certification.


The Governing Body failed to ensure the quality of care provided to patients. An emergency patient with symptoms of a gastro-intestinal bleeding was transfused 4 units of blood over a short period of time but the patient was not assessed for trassfusion-associated circulatory overload. The Blood Transfusion Record failed to ensure consistent assessment of a transfusion reaction in that there were no parameters specified for staff to assess the signs and symptoms of a transfusion reaction consistently. A pregnant in labor presented to the emergency department and was placed on fetal monitoring but no staff assessed the monitor strips to ensure the health of the unborn Child. Refer to Tag A115 for details.

Based on record reviews and interviews, the hospital failed to ensure that patients recieved care in a safe setting.


Review of the clinical record of patient DG1 revealed, a 26-year old woman who was 36-weeks pregant presented to the Emegency Department (ED) on 3/22/2019. She informed the ED staff that she felt less movement of her unborn child 6 hours prior to presentation. She denied having any contraction, vaginal bleeding, or water leakage. This woman is a Gravida 4 Para 3. She gave a history or pre-ecampsia during her first pregnancy. The vital signs taken during triage were: BP 145/95, Pulse 88, Respiration 20, Temperatur 97.6. The woman was placed on fetal heart rate monitoring. The initial reading showed a fetal heart rate of 148. Review of the fetal heart rate monitoring stips showed that a staff reviewed the strip during the first 15 minutes when a troublesome rhythm was seen; the staff noted that the patient was simply coughing causing the aberrant strip reading. No further assessment were done particlarly when the strip showed very troubling rhythm. The Chief of Staff informed the surveyor that care provided to this patient was not reviewed by the medical staff to assess the quality of care provided and/or identify opportunities of improvement in the care of pregnant women who presents to the ED.


Review of the clinical record of patient DG2 revealed, a 54-year old man presented to the ED on 4/20/2019. He informed the ED staff that he was vomiting blood at home an hour prior to presentation. He had a history of cirrhosis of the liver and gastro-intestinal bleeding in the past. The triage note revealed that the patient vomitted appoximately 500 ml of blood during the triage assessment. The vital signs taken during triage were: BP 133/90, Temperature 97.7, Pulse 94, Respiration 22. The physician assessment revealed that the patient had no abdominal tenderness, rebound tenderness, guarding, or masses. The laboratory test results showed a hematocrit of 36.40 (reference rate is 42 - 52) and hemoblobin of 11.40 (reference rate is 14 - 18). The patient had 4 units of Packed Red Blood Cells, the 3 units was transfused within 30 minutes or less and the 4th unit was infusing during transport to another hospital. There was no phsyician's order for the units of blood to be transfused found in the electronic medical record. Hospital staff tried to locate a hard copy the physician's order but was unable to find it. There was no assessment done to assess for reactions to blood component transfusion which can range from mild to potentially fatal. Transfusion-associated circulatory overload (TACO) is a common transfusion reaction in which pulmonary edema develops primarily due to volume excess or circulatory overload. TACO typically occurs in patients who receive a large volume of a transfused product over a short period of time.

The American Association of Blood Banks (AABB) recommended a restrictive RBC transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than a liberal threshold when the hemoglobin level is 10 g/dL (strong recommendation, moderate quality evidence). For patients undergoing orthopedic surgery or cardiac surgery and those with preexisting cardiovascular disease, the AABB recommends a restrictive RBC transfusion threshold (hemoglobin level of 8 g/dL; strong recommendation, moderate quality evidence). The restrictive hemoglobin transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but RCT evidence is not available for all patient categories. These recommendations apply to all but the following conditions for which the evidence is insufficient for any recommendation: acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological disorders who at risk of bleeding), and chronic transfusion–dependent anemia.


Review of the clinical record of patient DG3 revealed, 42-year old man who was brought to the ED from one of the off campus out patient department of the hospital on 04/07/2019. The triage note indicated that the patient was vomitting blood at home prior to going to the outpatient department located off campus. The vital signs during triage were: BP 107/79, Pulse 121, Respiration 16. The patient was transfused with 2 units of PRBC; first unit was tarnsfused within 35 minutes and the secodn unit was transfused within 30 minutes. No assessent was done for potential TOCO prior to transfer to another hospital. There was no physicia's order tor the blood transfusion found in the medical record. The laboratory test result showed: hematocri of 38.70 (reference range of 42 - 52) and hemoglobin of 13.20 (reference range of 14 - 18).

The AABB recomended that transfusion practices for RBCs should be designed to optimize clinical outcomes and to avoid transfusions that are not clinically indicated. Physicians should consider the risk of transfusion-transmitted infections and noninfectious adverse events, such as transfusion-related acute lung injury and transfusion-associated circulatory overload in their decision making to transfuse a patient.

Based on record review and interview, the hospital administration failed to have an abuse and neglect policy and procedure that included all the elements necessary for effective abuse prevention such as prevention of abuse, screening of staff, identification of events and occurrences that may contribute to abuse and neglect, training, protection of patients, investigation of all allegations of abuse and neglect, reporting of all incidents of abuse/neglect/harrassment and analyzes of data for apporpaite corrective action development and implementation. The failed practice can negatively affect inpatients and outpatients receiving care and services at the hospital and outpatient clinics.


On 07/09/2019, the hospital abuse and neglect policy and procedure was requested for review. At 1:30 PM the hospital Education and Training Officer provided several documents related to the abuse and neglect of the elderly and children.The title of the documents were:

1. Neglect, Exploitation of the Elderly and Disabled Adult.

2. Infant/Child Abduction and

3. Elder/Domestic/Child Abuse and Neglect Policy.

These policies focus on how to respond to victims of abuse when the abuse occurs outside of the hospital setting.


On 07/10/2019 at 8:30 AM, an interview was conducted with four staff members from the Inpatient Unit: Certified Nurse Aide #1, Certified Nurse Aide #2, Certified Nurse Aide #3 and Registered Nurse #1. During the interview, the staff indicated they have never seen an abuse and neglect policy that instructed the staff on how to proceed if a patient complained that a staff member committed abuse. The Registered Nurse stated that there are a few policies and procedures in the computer program that the hospital uses for training addressing abuse. However, the Registered Nurse #1 was not sure if any of the policies or procedures addressed how to protect the patient or what to do in case a patient complains of being abuse by a hospital staff member.


On 07/10/2019 at 11:00 AM, the Inpatient Unit Manager, Registered Nurse #2, was interviewed concerning the abuse and neglect policy and procedure. The Manager stated that it is in the computer. At 11:20 AM, the Manager provided the same policy and procedure that the Education and Training Officer had previously provided.


On 07/10/2019 at 2:30 PM, the Chief Medical Officer (CMO) was interviewed. The CMO stated that the hospital has the policy and procedure that was provided to them by Indian Health Services. The CMO stated "I am going to be honest with you; we do not have an abuse and neglect policy and procedure that covers all the seven components of the federal regulation. However, we just started today to put something together".

Based on observation, record review, and interviews, the hospital Nursing Services failed to:

1. Become familiarized with emergency resuscitation equipment, and

2. Have pediatric resuscitation equipment in the pediatric crash cart.


Findings:


On 07/11/2019 at 8:35 AM, an inspection was conducted in the hospital Inpatient Unit. The Unit takes care of adults and pediatric patients. On 07/09/2019, the hospital census for the Inpatient Unit was 2 (one adult and one pediatric). The Unit had one adult crash cart and one pediatric crash cart.


Registered Nurse #3 opened the adult crash cart to demonstrate if all the supplies were in the cart and available for use in case of an emergency. When Registered Nurse #3 was asked to connect the adult laryngoscope blade with the handle, the nurse was not able to perform that task. Registered Nurse #3 stated, "I can't do it, I am not an intensive care nurse."


On 07/11/2019 at 8:45 AM, an inspection of the pediatric crash cart was performed with Registered Nurse #3. During the inspection, the pediatric laryngoscope blade was not found in the crash cart. A scenario was presented to Registered Nurse #3 of a pediatric patient needing to be intubated. When asked how long would it take for the nurses to locate a pediatric blade for the laryngoscope, the Registered Nurse responded, "It will take a while".


On 07/11/2019 at 8:50 AM, an interview was conducted with Registered Nurse #4, working in the Inpatient Unit. The Registered Nurse was asked where she would locate a pediatric laryngoscope blade in case of a pediatric emergency. Registered Nurse #4 responded "In the crash cart". Registered Nurse #4 added, "I thought the blades were in the large box on the pediatric crash cart".


On 07/11/2019 at 8:55 AM, an interview with the Inpatient Unit Manager Registered Nurse #2 was conducted. The Unit Manager stated that he expects all Registered Nurse's to be familiar with the use of all the equipment that is in the crash cart, including connecting the laryngoscope handle to the blade. The Unit Manager also stated, "I am not sure how they had been checking for the batteries and the light of the laryngoscope when they are checking the cart". Registered Nurse #2 indicated that he thought the pediatric crash cart was "ready to be used".


On 07/11/2019 at 9:10 AM, the surveyor exited the Inpatient Unit and the nurses were trying to locate the pediatric laryngoscope blade.


On 07/11/2019 at 9:15 AM, the Inpatient Unit Manager approache the surveyor and stated, "The nurses found the pediatric blades". The surveyor stated, "It took 30 minutes to find the pediatric laryngoscope blade". Registered Nurse #2 stated, "We will work on training".


Record review of the pediatric crash cart inspection log for the Inpatient Unit confirmed that the crash cart was last check on 07/07/2019 by Registered Nurse #3. The surveyor asked Registered Nurse #3 if she remembered checking the pediatric laryngoscope with the pediatric blade when she check the cart on 07/07/2019. The nurse replied, "I don't remember".

Based on interview and record review, the hospital failed to have all medical records promptly completed. The hospital failed to comply with their own policy and procedures for medical record documentation. This hospital's failed practice can potentially affect the integrity of patient medical records.


On 07/10/2019 at 10:30 AM, an interview with the Medical Records Director was conducted. The Director stated that the hospital is going through a cycle of incomplete medical records that is affecting the way the department functions. During the interview the Director stated that the Medical Record Department release a list three days a week with all patient medical records that are delinquent, missing doctors' or providers' signatures, providers' progress notes after a patient visit, missing patient consents for procedures, et cetera. The Director indicated that in the morning directors meet with the Medical Record staff to discuss the reports to ensure everyone is aware of the deficiency in completing medical records documentation. When asked about how many delinquent medical records the department has, the Director stated more than 100. The Director stated that because her department runs a deficiency report three times a week, the providers that are involved with the deficiency will be notified within 48 hours of the encounter with the patient, and then weekly afterward.


On 07/11/2019 at 2:45 PM, the hospital CMO was interviewed concerning the number of incomplete medical records. During the interview the CMO stated that medical records does not have an effective system in place and when some of the providers go to clear the deficiency, most of the time the medical record staff can't find what is missing. The CMO is aware of the number of delinquent medical records since her office gets the reports from the Medical Records Department. The CMO stated, "I can't take negative action towards the provider and send them to sit in the Medical Records office because we need them to take care of patients". "I can't cut their salary. I may have to cancel their request for leave until the job is done". The CMO was aware that there were 488 delinquent patient medical records.


On 07/11/2019 at 3:10 PM, a confidential interview with an administrative staff member was conducted. During the interview the staff member stated that the number of patient medical records is correct. They run the reports three times a week and the Medical Records Department sends letters to the providers and they choose not to take action. The staff stated, "I am here to tell you that the medical records department system is correct". "Sometimes there are 400 or 500 deficient records".


Review of the Medical Record Deficiency Report for the month of April, May, June, and the first week of July 2019 were 488.

Of the 488 delinquent medical records, the surveyor reviewed 51. Each of the 51 patient medical records was confirmed to be incomplete. Medical Record Technician #1 and the surveyor opened all 51 patients' electronic medical records to verify the information provided by the Medical Record Director. They were missing patient consents for medical procedures, provider signatures, patient visit progress notes, procedures notes, emergency department providers progress notes, transferred notes, provider consultation evaluation, electrocardiogram reports, dental visits reports, providers titles, patient consent signatures and medical evaluation reports.


On 07/11/2019 at 4:00 PM, a second interview with the CMO was conducted. The findings of the patient sample selected for record reviews were discussed. The CMO stated that the Governing Body will meet and discuss the medical record deficiencies and come up with a plan to reduce the number of delinquent medical records at the hospital.


Record review of the Quality Management Council for the month of April 2019 noted, "Where are the consent forms?" "Consent forms need to have date and time".


Record review of the Quality Management Council for the month of May 2019 noted, "We are not receiving consent forms for vaccinations. Cannot give immunizations without signing consents forms".


A review of the Medical Record, Erroneous Documentation Correction Policy and Procedure was completed. The policy has guidance on how the providers can enter the electronic system to correct an event related to "A visit has not exceeded 30 days".


A review of the Verbal Orders Policy and Procedures was conducted. According to the policy verbal orders will be electronically signed by the physician within twenty-four (24) hours.


A review of the hospital Patient Documentation Requirements Policy and procedure dated 4/2016 stated:

"Record deficiencies: 1. Weekly notices are provided to each provider with incomplete records in order that they make arrangements to complete their records to avoid delinquent records.

2. Medical Records delinquent in the reporting period will be identified and action taken by the Chief of Staff as prescribed in the Medical Staff Rules and Regulations".


The patient Documentation Requirement Policy and Procedure also indicates:" F Progress Notes: 1. Progress Notes will be written within adequate frequency to document the patient's course in the hospital to reflect any changes in condition and the results of treatments rendered. Progress notes will be written in three days or less."

Based on observation, interviews, and records review, the Infection Control Program Coordinator failed to:

1. Have a system in place to ensure the microscope in the Women Health Clinic is sanitized according to manufacturer's recommendations. This failed practice can create cross contamination between users and can compromise the results of the microscopic test.

2. The hospital Dental Clinic failed to maintain dental supplies in the original packaging, exposing these items to the environment with the potential for cross contamination. The Dental Clinic also has expired supplies in a ready to use cart.


Findins:


1. Women's Health Clinic:

On 07/08/2019 at 3:15 PM, an observation was made of the Women's Health Clinic. A microscope was observed in the Dirty Utility Room. The microscope was sitting on a countertop and covered with a bag. Alcohol pads approximately 2.0 x 1.5 inches in size were located on the countertop to the right of the microscope. MD #1 was asked to explain how the microscope is cleaned and sanitized after use. MD #1 stated, alcohol pads were used to "wipe down the deck and lens". MD #1 stated that the alcohol pads were also used to "wipe countertops and surrounding areas". MD #1 did not state how the rest of the microscope was cleaned and no germicidal wipes were observed in the room.


Definition:

Dirty utility room- A room where soiled and used supplies and equipment are discarded or kept until they are transferred for sterilization.


On 07/09/2019 at 10:40 AM, a second observation of the microscope located in the Women's Health Clinic was made. According to the Clinic Charge Nurse, Registered Nurse #5, the lens of the microscope are cleaned after every use by the provider. The Charge Nurse indicated that the microscope is used to verify amniotic fluid, yeast and any other microscopic test that the provider chooses to perform. When asked how the base of the microscope is cleaned and when, the Charge Nurse stated, she did not know. Registered Nurse #5 stated that the laboratory staff cleaned the microscope once a month. When asked if the table where the microscope is located gets cleaned and sanitized, the Charge Nurse replied, "housekeeping comes and cleans this room, but I am not sure when they come". When asked if the housekeeper cleaned the surface of the table after the provider completed the test, the Charge Nurse stated, "I don't think so".


On 07/09/2019 at 10:45 AM, an interview was conducted at the Women's Health Clinic with MD #2. MD #2 indicated that after she use the microscope, she cleans the lens with one or two alcohol pads. When asked if she cleans the stage or the condenser of the microscope, the MD stated, "no, I was just told to clean the lens and sometimes I clean the stage with an alcohol pad". MD #2 stated, "I try to clean the microscope after every use". When asked how many alcohol pads she used to clean the base of the microscope, the MD stated "I don't know how many alcohol pads I use, maybe one or two." The alcohol pads MD #2 was referencing are approximately 2.0 x 1.5 inches in size and sat to the right of the microscope.


On 07/09/2019 at 11:00 AM, the Clinical Laboratory Supervisor was interviewed concerning the cleaning and disinfecting of the microscope in the Women's Health Clinic. The Supervisor stated that the laboratory technician goes to the clinic and cleans the microscope once a month. The supervisor indicated that she conducted training on how to clean the lens of the microscope but not on how to clean the base of the microscope.


On 07/09/2019 at 11:45 AM, an interview was conducted with the Infection Control Coordinator. During the interview, the Coordinator stated that she did not know that the microscope in the Women's Health Clinic was not sanitized according to guidance.


The review of the Clinical Laboratory Policy and Procedure for the microscope sanitation provided by the Laboratory Supervisor on 07/09/2019 stated, to:

1. Moisten the tip of a swab or piece of lens paper with lens cleaning.

2. Working from the center out, in a circular motion, gently clean oculars and objectives.

3. Dry with a clean, dry swab or lens paper.

4. Clean the stage of the microscope with a suitable cleanser.

5. Thoroughly dry the stage with a new piece of lens paper.

6. Wipe off the top of the condenser with a clean lens tissue, moistened with lens cleaner, then dry the condenser with a dry piece of paper.


On 07/09/2019 at 4:30 PM, the Clinical Laboratory Supervisor and the Infection Control Coordinator informed the surveyor that an additional step was added to the hospital policy on the cleaning of the microscope. It states the following:

"7. Wipe the entire body of the microscope with a hospital grade germicidal disposable wipe after each use and allow the wet time listed on the canister."

The Clinical laboratory Supervisor stated that this step needs to be approved by the Laboratory Director.


On 07/10/2019 at 2:45 PM, the Clinical Laboratory Supervisor provided the cleaning guidance for the Olympus-Cx31 microscope. The supervisor stated the document was from the manufacturer. The one page document did not specify how to sanitize the body and the base of the microscope.


On 07/10/2019 the Laboratory Supervisor confirmed, she did not train the microscope users in the Women's Health Clinic to use the recommended mixtures to clean the microscope.


On 07/10/2019 at 3:00 PM, the Clinical Laboratory Supervisor verified that isopropyl alcohol prep 70% is used by the providers to clean and disinfect the microscope in the Women's Health Clinic. The Supervisor stated the hospital is purchasing a new sanitizer and they will begin using that product with the microscope.


On 07/09/2019 at 11:00 AM, an infection control hospital tour was conducted with the hospital Infection Control Coordinator, Maintenance Supervisor and Facility Assessment Officer.


On 07/11/2019 at 1:10 PM the Laboratory Supervisor stated that she did not have the Olympus Optical Maintenance Manual for the Cx31 microscope.



2. Dental Clinic:

The Dental Clinic has several carts with supplies that each dentist requests for their dental cases.

In the supply room, there was a pyrex glass container with gauze inside. The container had a lid that was labeled "isopropyl alcohol, rubbing alcohol, and Sam's West, Inc". There were no dates on the label indicating when alcohol and gauze was placed in container. During an interview with MD#3 at the dental clinic on 07/10/2019 at 11:05 AM, MD #3 stated, she prepared the mix approximately two months ago.


A supply cart contained one box of XRV Herculite Kerr B2 Enamel with an expiration date of 06/24/2019 and one box of Herculite D3 with an expiration date of 6/20/2019.


On 07/09/2019 at 11:15 AM, Dental Technician #1 was interviewed concerning the expired supplies. The Technician stated that the dental supplies are checked for expiration dates every Wednesday.


Record review of the Dental Clinic Responsibilities Check Log confirmed that all the supplies were checked for expiration dates on July 3rd, 2019.

In the same cart there was a drawer with dental scaler tips. They were in small plastic bag and each bag had approximately 10- 20 scalers. There was also a large tube full of additional scaler tips. This tube with the scaler tips did not have a date. Dental Technician #1 stated that the dentist needs one scaler tip for a case, but the bag has to be broken since the scalers do not come in individual packages. According to Dental Technician #1, the scaler tips that are not used in the small plastic bag are placed in the large tube in case they need more tips. When asked if different technicians and/or dentists had moved scaler tips from original package and placed unused ones in the tube, Dental Technician #1 stated, "we all did it".