HospitalInspections.org

.
Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to check and properly maintain emergency equipment and supplies.

Failure to properly maintain emergency carts places patients at risk of harm should equipment and supplies be needed and are not working properly.
.
Findings:

1. The hospital's policy and procedure titled "Crash Cart Policy" (Reviewed 8/6/2012) read: "The night shift charge nurse and the ER nurses are responsible for daily checking of the crash cart defibrillator, the cart lock status (which includes the color and number), and supply status. This is documented on the crash cart record located in a folder located on top of the code cart."

2. On 2/17/2015 at 11:50 AM during a tour of the medical-surgical unit, Surveyor #2 reviewed the daily pediatric crash cart record for the past 109 days and found 87 days between 11/1/2014 and 2/17/2015 in which there was no evidence of a crash cart checklist review.

3. On 2/18/2015 at 9:20 AM during a tour of the emergency department, Surveyor #2 reviewed the daily pediatric crash cart record for the past 110 days and found 38 days between 11/1/2014 and 2/18/2015 in which there was no evidence of a crash cart checklist review.

4. On 2/18/2015 at 9:20 AM during a tour of the emergency department, Surveyor #2 reviewed the daily adult crash cart record for the past 80 days and found 18 days between 12/1/2014 and 2/18/2015 in which there was no evidence of a crash cart checklist review.

5. The Chief Nursing Officer (Staff Member #1) confirmed these findings on 2/18/2015 at 9:20 AM.


THIS IS A REPEAT CITATION FROM 1/6/2012


.

.
Based on record review and review of hospital policy and procedure, the critical access hospital failed to ensure staff members performed blood transfusion procedures according to policy for 2 of 4 patients reviewed (Patients #1, #2).

Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.


Findings:

1. The hospital policy and procedure titled "Blood Transfusion Protocol" (Reviewed 3/11/2008) read under procedure: "A. The RN will verify physician's order as to type of blood/product to be given, number units the patient is to receive and rate of infusion. C. HAVE THE PATIENT SIGN CONSENT FOR THE BLOOD TRANSFUSION. . . Vital signs should be taken 15 minutes after blood starts, then 30 minutes x2 then hourly until infusion completed."

2. On 2/19/2015 at 8:10 AM, Surveyor #2 reviewed the records of 4 patients who received blood transfusions during their hospital stay and observed the following:

a. There was no documentation in the medical record that Patient #1 had a consent and physician order for blood transfusions. Additionally, nursing staff did not document vital signs for the last hour of blood administration as required by policy.

b. Nursing staff caring for Patient #2 did not document vital signs for the second thirty-minute block of time required by policy upon initiation of blood administration.


.

.
Based on interview, the critical access hospital failed to maintain an inventory of all patient care equipment.

Failure to maintain a complete inventory of patient care equipment puts patients at risk of having a lack of equipment when needed.
.
Findings:

1. On 2/17/2015 at 2:15 PM, Surveyor #1 interviewed a member of the facilities staff (Staff Member #6) about the hospital's process for ensuring all patient care equipment received preventive maintenance including those items with vendor contracts for maintenance. S/he reported that those patient care items maintained by the equipment's vendors were not included in the hospital's equipment tracking inventory.


.

.
Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.


.

.
Based on record review and review of quality assurance data, the critical access hospital failed to ensure that procedures implemented to monitor corrective actions for previous citations were sufficient to maintain an acceptable level of compliance.

Failure to adequately monitor corrective actions and maintain compliance puts patients at risk of harm due to inadequate care.
.
Findings:

During the current survey, the hospital received a citation related to compliance with the hospital's policies to ensure readiness of emergency equipment for patient use. This is a repeat citation from the 2012 CMS Critical Access Hospital re-certification survey.
.
Refer to : C0204




.

.
Based on record review, interview, and review of hospital policies and procedures, the critical access hospital failed to ensure staff members followed its policy for monitoring chemically restrained patients as demonstrated by review of 2 of 2 patients (Patients #7, #8.)

Failure to follow policies and procedures for monitoring chemically restrained patients risks physical and psychological harm, loss of dignity, and violation of patient rights.
.
Findings:
.
1. The hospital's policy and procedure titled "Restraints-Chemical Physical" (last reviewed 4/4/2012) read: "The Restraint Flow Sheet will record observation of the restrained patient at least every hour, with observations relative to the patient's physical and mental status. Patients exhibiting behavior that categorize them as high-risk will require every 15 minute observation."

2. Review of the records of two patients who had been chemically restrained revealed the following:

a. Patient #7 was a 67 year-old patient who was admitted on 5/17/2014 for pancreatitis and acute delirium. The patient became agitated and pulled out his/her intravenous lines and was chemically restrained with haloperidol on 5/19/2014 at 6:45 PM. The restraint flow sheet was initiated at 6:40 PM with the next annotation in the electronic medical record at 11:30 PM, a period of over four hours without documentation for restraint monitoring.

b. Patient #8 was a 55 year-old patient who was admitted on 6/7/2014 for acute mental status changes with acute psychotic event. The patient fled the room and attempted to leave the facility on 6/8/2014. The patient was chemically restrained with haloperidol at 8:49 PM. Surveyor #2 found no evidence that staff members initiated the restraint flow sheet. The next clinical nursing note was written at 12:00 AM, a period of over three hours without documentation for restraint monitoring.

3. Staff Member #4 confirmed the above findings on 2/19/2015 at 9:00 AM.

.

.
Based on document review, the critical access hospital failed to ensure that its patient care policies received an annual review by the hospital's professional health care staff.

Failure to conduct an annual policy review puts patients at risk of unsafe or inadequate care.
.
Findings:

On 2/17-19/2015, Surveyor #2 reviewed the hospital's patient care policies and found several policies had not been reviewed within the last year. Examples of the out-of-date policies include:

a. Hospital policy titled "Check of OB in Labor in ER" last reviewed 3/11/2008.

b. Hospital policy titled "Newborn Resuscitation" last reviewed 5/18/2009.

c. Hospital policy titled "Mental Health Evaluation" last reviewed 4/2/2008.

d. Hospital policy titled "Crash Cart" last reviewed 8/6/2012.

e. Hospital policy titled "Fall Prevention Program" last reviewed 12/2/2010.

f. Hospital policy titled "Braden Scale and Skin Integrity Standard of Care" last reviewed 12/2/2010.

g. Hospital policy titled "Respite Care Program" last reviewed 9/8/2012.



.

.
ITEM #1 - MEDICATION REFRIGERATOR TEMPERATURES

Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to follow its policy for verifying that medication refrigerator temperatures were within a safe range for medication storage.

Failure to store medications within an acceptable temperature range risks patients receiving medications that are harmful, ineffective or therapeutically substandard.
.
Findings:

1. The hospital's policy and procedure titled "Medication Storage and Handling " (Reviewed 1/29/2014) read: "A daily inspection of the medication refrigerator will be conducted by appropriate personnel to ensure pharmaceuticals are stored under proper conditions." The hospital's temperature-monitoring log states, "Check Temperatures Twice a Day!"

2. On 2/17/2015 at 11:50 AM during a tour of the medical-surgical nursing unit, Surveyor #2 reviewed the medication temperature-monitoring log for the past 17 days and found no evidence that staff members had checked temperatures for 10 of 33 shifts during the month of February.

3. On 2/18/2015 at 9:20 AM during a tour of the emergency department, Surveyor #2 reviewed the medication temperature-monitoring log for the past 18 days and found no evidence that staff members had checked temperatures for 15 of 35 shifts during the month of February.

4. During an interview with Surveyor #2 on 2/17/2015, the hospital's pharmacy director (Staff Member #2) confirmed that the annotation "Closed" on the temperature- monitoring log indicated that the pharmacy service was closed for that period and not available to check the medication refrigerator temperature.
.
ITEM #2 - UNLABELED SYRINGES

Based on observation, interview, and review of hospital policies and procedures, the critical access hospital failed to implement its policy that ensured intravenous medications prepared in pre-drawn syringes were labeled according to accepted standards of practice, as demonstrated by 1 of 1 anesthesia providers observed. (Staff Member #3).

Failure to label pre-drawn syringes of medications risks medication errors and transmission of communicable diseases to patients.

References: APIC position Paper: "Safe Injection, Infusion, and Medication Vial Practices in Health Care" (Association for Professionals in Infection Control and Prevention; 2010); ASA Statement on the Labeling of Pharmaceuticals for Use in Anesthesiology (American Society of Anesthesiologists, October 2009).

Findings:

1. The hospital's policy and procedure titled "Intravenous Compounding " (Reviewed 11/17/2014) read "Unless immediately and completely administered by the person who prepared it. . . the CSP (compounded sterile product) shall bear a label listing patient identification information, the names and amounts of all ingredients, the name or initials of the person who prepared the CSP, and the exact 1-hour beyond-use date."

2. On 2/18/2015 at 11:50 AM, Surveyor #2 observed a certified registered nurse anesthetist (CRNA) (Staff Member #3) draw up a white milky fluid into a syringe. S/he labeled the syringe with a piece of tape with the date, time, and initials of the preparer. The label did not include the name and strength of the medication as required by policy.

3. A subsequent interview on 2/18/2015 at 12:15 PM with Staff Member #3 immediately following completion of the diagnostic procedure, confirmed the syringe was not labeled with the name and strength of the medication as required by policy.

.

.
Based on observation, interview, and document review, the critical access hospital failed to ensure the proper processing/cleaning of semi-critical equipment.

Failure to process semi-critical equipment consistent with manufacturer's guidelines puts patients at risk from infection caused by improper disinfection.
.
Findings:

1. The Radiology department policy #11485 titled "Ultrasound Transducer Cleaning/Disinfecting" (Effective 09/08/2014) read in part: "High level disinfecting...Probe is wiped with clean, damp cloth to remove all excess gel and debris." Supplies: The current probe disinfectants recommended by the manufacturer of the ultrasound machine is the Sani-cloth HB. This disinfectant can be used for all of the following probes that are being utilized in the ultrasound lab. : 9L-D, ML6-15-D, M5S-D, S1-5, C1-5-D and IC5-9-D."


2. On 2/17/2015 at 1:20 PM, Surveyors #1 and #3 interviewed an ultrasound techician (Staff Member #5) about the cleaning and disinfection of trans-vaginal probes. The staff member explained that the probes were cleaned with a germicidal disposable wipe, SANI-CLOTH HB. At the time of the interview, the surveyors reviewed the product label for SANI-CLOTH HB, which read in part:

"This product is not to be used as a terminal sterilant/high level disinfectant on any surface or instrument that (1) is introduced directly into the human body, either into or in contact with the bloodstream or normally sterile areas of the body, or (2) contacts intact mucous membranes but which does not ordinarily penetrate the blood barrier or otherwise enter normally sterile areas of the body. This product may be used to preclean or decontaminate critical or semi-critical medical devices prior to sterilization or high level disinfection."

3. Surveyor #1 reviewed the device manufacturer's document titled "GE Transducer Cleaning and Disinfection Guidelines" which read in part: "Warning: Disinfectant wipes and topical spray products are not FDA-cleared, high-level disinfectants. These products do not provide adequate protection should the transducer become cross-contaminated or in contact with unhealthy or non-intact skin."

4. On 2/18/2015 beginning at 3:00 PM, Surveyor #1 interviewed the Infection Control Practitioner/Lab Manager (Staff Member #7) and reviewed the hospital's overall infection control program. During the review, the surveyor asked the staff member about the hospital policy identified in (1). The staff member indicated the Radiology department developed the policy and that s/he had not reviewed it prior to implementation.



.

.
ITEM #1 FALLS ASSESSMENT

Based on record review, review of hospital policies and procedures, and interview, the critical access hospital failed to ensure staff members completed admission fall assessments according to policy for 2 of 5 patients (Patients #3, #4).

Failure to assess patients for falls at admission places patients at risk of injury from falling.

Findings:
.
1. The hospital's policy and procedure titled "Fall Prevention Program" (Revised 12/2/2010) read: "As part of the admission assessment, all In-Patients and Observation patients will be assessed for fall risk by an RN using the Willapa Harbor Fall Risk Assessment Tool; the Morse Scale."

2. Review of the records of 2 inpatients revealed the following:

a. Patient #3 was a 60-year-old female who had been admitted on 7/30/2014 for cellulitis. The initial falls assessment had not been completed on admission.

b. Patient #4 was a 74-year-old female who was admitted on 10/2/2014 for pneumonia. The initial falls assessment had not been completed on admission.

c. During an interview on 2/19/2015 at 1:15 PM, the clinical informatics nurse (Staff Member #4) confirmed the above findings.

ITEM #2 SKIN ASSESSMENTS

Based on record review, review of hospital policies and procedures, and interview, the critical access hospital failed to ensure staff members completed admission skin assessments according to policy for 2 of 5 patients (Patients #3, #4).

Failure to assess patients for skin breakdown at admission places patients at risk of pressure ulcer formation.

Findings:

1. The hospital's policy and procedure titled "Braden Scale and Skin Integrity Standard of Care" (Revised 12/2/2010) read "The Braden Scale will be done upon admission. As part of the admission history, an assessment of the patient's skin will be conducted and documented."

2. Review of the records of 2 inpatients revealed the following:

a. Patient #3 was a 60-year-old female who had been admitted on 7/30/2014 for cellulitis and abscess of left axilla. The initial skin assessment and braden score had not been completed on admission.

b. Patient #4 was a 74-year-old female who was admitted on 10/2/2014 for pneumonia. The initial skin assessment and braden score had not been completed on admission.

c. During an interview on 2/19/2015 at 1:15 PM, the clinical informatics nurse (Staff Member # 4) confirmed the above findings.

ITEM #3 NUTRITIONAL SCREENING

Based on record review, review of hospital policies and procedures and interview, the critical access hospital failed to ensure admission nutritional screening and assessments were completed according to policy for 1 of 5 patients (Patients #5).

Failure to assess patients for dietary needs at admission places patients at risk for delayed treatment of nutritional deficiencies.
.
Findings:

1. The hospital's policy and procedure titled "Inpatient Nutrition Screening & Referral" (Revised 4/3/2012) read: "An admission nutritional screening will be performed on admission by the RN responsible for the patient."

2. On 2/19/2015 at 1:15 PM, Surveyor #2 reviewed the record of Patient #5 who was admitted on 10/1/2014 and underwent an abdominoperineal resection of the rectum. Surveyor #2 found no documentation that an admission nutritional screening had been completed.

3. During an interview on 2/19/2015 at 1:15 PM, the clinical informatics nurse (Staff Member #4) confirmed the above findings.

#4 INITIAL ADMISSION ASSESSMENT

Based on record review, review of hospital policies and procedures and interview, the critical access hospital failed to ensure staff members completed assessments and screening for 1 of 1 patients (Patient #6).

Failure to assess and screen patients upon admission risks health care needs of the patient not being met.
.
Findings:

1. The hospital's policy and procedure titled "Respite Care Program" did not include the patient assessment data or standards of care expected for patients who were admitted under respite care status.

2. On 2/17/2015 at 2:00 PM, Surveyor #3 reviewed the record of Patient #6 who was admitted on 2/6/2015 to the respite care program with a diagnosis of dementia and urinary tract infection. Surveyor #2 found no documentation that risk screening assessment for functional status, falls risk, skin breakdown, nutrition, or any other special patient needs (suicide, abuse) was completed.

3. A subsequent interview with the chief nursing officer (Staff Member #1) immediately following the record review confirmed the current hospital policy did not describe standards of care and corresponding documentation to guide staff on how to provide care for respite patients.

.

.
Based on document review and interview, the critical access hospital failed to ensure that contracted services are included in the overall quality program.

Failure to include contracted services in the hospital's quality program puts patients at risk for receiving inadequate care from all services provided under contract.
.

Findings:

On 2/19/2015 at 1:30 PM, Surveyors #1 and #3 interviewed the Chief Executive Officer (Staff Member #8) and the Director of Quality Improvement (via phone) (Staff Member #9) as part of the hospital's quality assurance and improvement program review. During the review of quality data, the surveyors were unable to find evidence that the hospital included an evaluation of contracted services in their quality program. Both staff members acknowledged this finding at the time of the interview.