HospitalInspections.org

Based on maintenance log review and staff interview, the facility failed to maintain updated preventative maintenance documentation for equipment and buildings for the hospital location and three of four clinics (Energy Basin Center Clinic, Women's Clinic, Wagon Circle Surgical Clinic). The findings were:

Review of the preventative maintenance (PM) logs for the facility revealed there was no documentation for the hospital or for three of four clinics concerning PM for 2018, and no PM for equipment at all. This review did not include the Laboratory or Radiology Department. Those departments kept their own PM logs with agreements from each manufacturer, and there were no issues identified. Interview with maintenance staff member #1 on 5/17/18 at 2 PM confirmed the facility failed to keep PM logs for equipment, and failed to keep PM logs current (no records for 2018) for the buildings with the exception of the Spruce Clinic, which had maintenance independent from the hospital maintenance staff.

Based on medical record review and staff interview the governing body failed to ensure 3 of 3 sample patients (#3, #7, #19) with identified behavior health needs received assessments, care, and services provided by a behavioral health professional. The findings were:

Review of the medical records for patients #3, #7 and #19 revealed all had identified behavioral health needs, but none had received the assessment, care, and services of a behavioral health specialist. Interview on 5/17/18 at 8:40 AM with the licensed clinical social worker revealed he was a mental health examiner for patients admitted on emergency detention. He stated he was appointed by a local governmental body and was responsible for making discharge arrangements for the patients. He stated his duties did not include utilizing clinical skills to address behavioral health needs. The following concerns were identified:

1. Review of the medical record showed patient #3 was admitted on 5/9/18 for care and treatment of a psychotic disorder. Further review revealed no evidence of an assessment or treatment by a behavioral health specialist. Review of the care plan showed the patient could be up as desired at the nurse's discretion and a goal was for the patient to be free of hallucinations. Interview on 5/17/18 at 8:40 AM with the licensed clinical social worker (mental health examiner) revealed he had arranged for the patient to be discharged on 5/22/18 (18 days after admission) to another facility with mental health professionals.

2. Review of the medical record showed patient #7 was an inpatient from 11/14/17 to 12/5/17 (21 days). Further review revealed no evidence of an assessment or treatment by a behavioral health specialist. Review of the care plan interventions showed interventions were implemented that addressed the patient's feelings of self-worth. Further review showed the interventions were ineffective because the resident refused them. Interview on 5/17/18 at 12:30 PM with the ESEHIP manager revealed staff should have revised the care plan to address the refusals and utilized the care-planning process to address the identified behavior.

3. Review of the medical record showed patient #19 was an inpatient from 5/3/18 to 5/7/18 with a diagnosis of schizophrenia. Further review revealed no evidence of an assessment or treatment by a behavioral health specialist. Review revealed a care plan was not developed for this patient. Interview on 5/17/18 at 12:30 PM with the ESEHIP manager revealed this patient was admitted for emergency detention and the usual practice was to not develop formalized plan of care interventions for patients admitted for detention.

4. During interview on 5/17/18 at 10:30 AM, the ESEHIP manager verified patients #3, #7, and #19 were admitted for emergency detention and all had identified behavioral health problems, were placed in the locked and secluded room with continuous video monitoring for safety, received medications as prescribed, and their physical health needs were met in this environment until the court-ordered detention was removed. She further verified the care patients #3, #7, and #19 received did not include a treatment plan or interventions provided by behavioral health professionals.

Based on observation, staff interview, professional standard review, manufacturer's manual review, and policy and procedure review, it was determined the facility failed to ensure opened medications were not outdated (C276); the facility failed to ensure adequate infection control practices were performed and quality controls were performed for a glucose meter (C278); the facility failed to ensure patients received adequate discharge plans (C294); and the facility failed to ensure a care plan was developed or revised for each patient. This system failure resulted in the inability of the critical access hospital to meet the necessary requirements for the Provision of Services Condition of Participation.

Based on observation, staff interview, and professional standard review, the facility failed to date opened medications available for use to ensure they were not outdated in 1 of 4 clinics (Women's Clinic) with medications available for use. The findings were:

Observation in the Women's Clinic on 5/15/18 at 2:10 PM revealed four 50 milliliter injectable medication vials were available for use. The following concerns were identified:
a. The observation of four 50 milliliter vials of injectable medication revealed each was opened without a date to show when the vials were opened. The four vials included Xylocaine (local anesthetic) 2% solution, Sodium Bicarbonate (alkalinizing agent) 8.4%, Xylocaine 1% solution, and Sensercaine (local anesthetic) 0.5% solution.
b. Interview with the clinic supervisor at that time confirmed the vials were not dated when opened and remained available for use. Her expectation was for the vials to be dated when opened.
c. According to the cdc.gov website (Centers for Disease Control) accessed on 5/22/18, "If a multi-dose [vial] has been opened or accessed (e.g., needle-punctured), it should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial."

Based on observation, staff interview, and manufacturer's manual review, the facility failed to ensure adequate infection control practices were performed for 1 of 2 operating rooms and the central sterile processing department. In addition, the facility failed to ensure quality controls were performed for a glucose meter for 1 of 4 clinics (Energy Basin Center Clinic). The findings were:

Infection control issues for the operating room and central sterile processing department:

1. Terminal cleaning of 1 of 2 operating rooms was observed on 5/16/18 at 10:34 AM. During the observation staff person #1, who was cleaning and disinfecting the operating room, started the procedure by moving all the instruments, equipment, and tables to the center of the room. She then began to clean and disinfect the walls with a long-handle mop. Interview with the staff person at that time revealed her usual practice was to do the walls, then the ceilings, and floors last. Interview on 5/17/18 at 3:15 PM with the ESEHIP manager revealed the standard of practice for terminal cleaning and disinfecting operating rooms was to start with ceiling, then walls and do the floors last.

2. Observation of the sterile processing area on 5/16/18 at 10:45 AM with sterile processing technician #1 revealed re-used cleaning brushes were positioned on the counter top. Interview with the sterile processing technician at that time revealed she did not know the manufacturer recommendations for use. She further stated she sterilized the cleaning brushes daily and re-used them for approximately 1 week before replacing them. Interview on 5/17/18 at 8:19 AM with the ESEHIP manager revealed the manufacturer recommended using the brushes for single-day use only.

3. Observation on 5/16/18 at 11:10 AM with sterile processing technician #1 revealed stored supplies in the sub-sterile room included a container of rapid readout biological indicator strips labeled with an expiration date of December 2017. At that time the sterile processing technician verified the expired strips had been used and were available for continued use.

Quality control issues for glucose meters:

Observation at the Energy Basin Center Clinic on 5/15/18 at 12:20 PM showed the clinic utilized an "Embrace" glucose meter for glucose testing. Review of the facility manuals showed no evidence the facility performed quality controls on the glucose meter. Review of the total patient census document for the clinic showed the facility saw 565 patients in 2017, and 161 patients to date in 2018. The following concerns were identified:
a. Interview by phone at that time with the ESEHIP showed the facility failed to perform quality control testing of the glucose meter, and there were no other glucose meters for use at the clinic. She was unsure how long the meter had been used, but confirmed it had been used for "years."
b. Review of the user manual for the Embrace glucose meter, accessed and printed on 5/21/18 showed "Control Solution Testing", "The purpose of the control solution testing is to make sure the Embrace No Code Meter and the Test Strip are working properly. You should perform Control Solution Testing when: Using the Meter for the first time, Using a new bottle of Embrace No Code Blood Glucose Test Strips, You left the test strip bottle cap open for a while, You dropped the meter, You suspect your Meter and test strips are not working properly, The blood glucose test results do not reflect how you feel, Practice the testing procedure."


27095

Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure an adequate discharge plan for 2 of 21 sample in-patients (#3, #32) reviewed for discharge planning. The findings were:

1. Medical record review showed patient #32 was admitted to the emergency department on 3/27/18 at 1750 [5:50 PM] after a motor vehicular accident. The review showed the patient had an "altered mental status" upon admission. Further review showed the patient also had left rib fractures from posterior ribs #8 through #10. The review showed the patient was admitted to "observation" status with diagnoses which included rib fractures, concussion, and scalp laceration. Review of a 3/28/18 Consultation Report showed the patient was confused at the place of the accident. The review showed the patient had a Glasgow [neurological scale to measure consciousness] number of 14, "with [him/her] just being confused at the time." The review showed the physician explained the impression of his/her status to the patient. Review of the 3/28/18 history and physical showed under Neurological: "The patient is alert, oriented to person, but not to place, time, or situation." The assessment showed: "1. May find dementia, 2. Left 8th, 9th, and 10th rib fractures, and 3. Minor scalp laceration, roughly 2cm [centimeters]." The plan was: "The patient was admitted overnight for observation to med-surg. Will give some hydration, see if [his/her] kidneys are back on line and to relieve the IV [intravenous] contrast received from [his/her] emergent CT scans. [The patient] was given one hour neuro checks and planned on having [his/her] relative come down from [Wyoming hometown] and go ahead and get [him/her] situated and return [him/her] home." Review of the 3/28/18 patient note timed 00:30 [12:30 AM] showed "Walked in patient room, patient had removed all of [his/her] clothes, removed [his/her] IV as well as [his/her] oxygen." Review of the 3/28/18 patient note timed 1:10 AM showed "Called [physician] at this time to report patient was ripping out IVs and that patient had ripped out the previous [IV] and left a skin tear..." The following issues with discharge planning were identified:
a. Review of the 3/28/18 consultation report showed no indication any significant other was with the patient when the physician described the patient's injuries to the patient.
b. Review of the Discharge Notes dated 3/28/18 at 1430 (2:30 PM) showed the following: "Please follow up with your primary care provider as needed for any new problems. The staples in the scalp need to be removed in 10-14 days as needed or for any new problems. Return to an ER if symptoms worsen on your travel home." The review further showed the facility had contacted a company that provided supplemental oxygen services in order to provide the patient with oxygen by physician order due to the patient having a reading of 81% for oxygen saturation on room air. The review showed the patient signed the document, with no indication any significant other received the information or had the discharge information explained.
c. Review of the patient care notes revealed the patient had no primary care provider in the state, as documented in a note dated 3/28/18 at 11 AM. Review of the entire medical record showed no discharge plan to assist with obtaining a primary care provider in the state, or for any other facility assistance with a discharge plan.
d. Review of the entire medical record showed no evidence a significant other for the patient was given discharge information concerning the patient, and no evidence a significant other was informed of a possibility the patient may have dementia.
e. Interview with RN #1 on 5/17/18 at 10:35 AM showed she had not formulated a discharge plan for the patient. She stated she was under the impression the patient would be at the facility longer, and she had more time to address a plan for the patient's discharge. Interview with the chief nursing officer on 5/17/18 at 11 AM showed his expectation was for all patients to receive an individual and adequate discharge plan.
f. Review of a 3/29/18 "Authorization for Release of Information" showed the patient was readmitted on 3/29/18 to another facility (the day after discharge from the facility).
g. Review of the policy titled, "Discharge Planning and Patient Services Departmental Objectives" last reviewed on 6/14/17, showed "Discharge Planning Objectives" included, "1. Patient is assessed upon admission to the hospital and discharge planning needs are identified...2. All appropriate referral resources are utilized in meeting the needs of patients and family for post hospital care. 3. Educational needs are identified and coordinated with the Patient Educator." "Outcome Standards" included, "1. Patient and family discharge planning needs are identified. 2. Coordination of community support systems enable the patient to return home. 3. Patient and/or family can provide post hospital care with specialized instruction and training. 4. Educational needs are brought to the physician's attention and ordered as appropriate."

2. Review of the medical record showed patient #3 was admitted on 5/9/18 for care and treatment of a psychotic disorder. Review of the care plan showed the patient could be up as desired at the nurse's discretion and a goal was for the patient to be free of hallucinations. This review also revealed interventions and additional identified needs were lacking. Observation on 5/1518 from 9 AM to 9:25 AM showed the patient was ambulatory in a locked and secluded room. Further observation revealed staff utilized a video monitor located at the nurse's desk for continuous monitoring. Interview with RN #2 at the time of the observation revealed the continuous monitoring was done to ensure patient safety. She further stated the resident was to remain at the facility until arrangement for transfer to another facility was completed. Review of the licensed clinical social worker's documentation, dated 5/10/18, revealed "Plan is to continue the emergency detention process through to commitment" to another facility. Interview on 5/17/18 at 8:40 AM with the licensed clinical social worker revealed he was a mental health examiner appointed by the county commissioner. He stated his role in the discharge planning process was to arrange transfer to another facility. He also stated the discharge date was scheduled for 5/22/18 (18 days after admission). Review of the medical record revealed a discharge plan had not been developed for patient #3. During interview on 5/17/18 at 10:30 AM the ESEHIP manager verified a discharge plan had not been developed for the patient.




27095

Based on review of policies and procedures and staff interviews, the facility failed to develop policies and procedures for administration of all drugs, intravenous and biological medications. The findings were:

Review of the policies and procedures titled, "Drug Distribution/Unit Dose #740-28", reviewed 5/13/10, revealed the following acceptable standards of nursing practice for medication administration had not been addressed in the medication administration policies and procedures:
a. A description of the situations in which verbal orders may be used as well as limitations or prohibitions on their use.
b. Best practices for medication administration that require confirmation of the "five rights" (right patient, medication, dose, route and time prior to each administration of medication).
c. Medications or categories of medication not eligible for scheduled dosing times.
d. Parameters within which nursing staff are allowed to use their own judgement regarding the timing of first and subsequent doses, which may fall between scheduled dosing times; retiming of missed or omitted doses; medications that will not follow scheduled dosing times, and patient units that are not subject to following the scheduled dosing times if applicable.
e. Actions to be taken when medications eligible for scheduled dosing times are not administered within their permitted window of time.
f. Identified parameters within which nursing staff are allowed to use their own judgement regarding the rescheduling of missed or late doses and when notification of the practitioner responsible for the care of the patient is required prior to doing so.
g. A process for determining whether specified scheduled medications are always time-critical, or only under certain circumstances and how staff involved in medication administration will know when a scheduled medication is time-critical.
h. The manner and frequency of monitoring, considering patient and drug risk factors, are determined, as well as the information to be communicated at shift changes, including method of communication.

During an interview on 5/15/18 at 3 PM, the ESEHIP manager verified the medication administration policies and procedures did not include the above standards of nursing practice for medication administration.

Based on observation medical record review, and staff interview, the facility failed to ensure a care plan was developed or revised to address identified areas of concern for 8 of 21 sample patients (#1, #3, #5, #7, #10, #15, #16, #19). The findings were:

1. Review of the medical record showed patient #3 was admitted on 5/9/18 for care and treatment of a psychotic disorder. Review of the care plan showed the patient could be up as desired at the nurse's discretion and a goal was for the patient to be free of hallucinations. This review also revealed interventions and additional identified needs were lacking. Observation on 5/1518 from 9 AM to 9:25 AM showed the patient was ambulatory in a locked and secluded room. Further observation revealed staff utilized a video monitor located at the nurse's desk for continuous monitoring. Interview with RN #2 at the time of the observation revealed the continuous monitoring was done to ensure patient safety. She further stated the resident was to remain at the facility until arrangements for transfer to another facility were completed. Review of the licensed clinical social worker's documentation, dated 5/10/18, revealed "Plan is to continue the emergency detention process through to commitment" to another facility. Interview on 5/17/18 at 8:40 AM with the licensed clinical social worker revealed he was a mental health examiner appointed by the county commissioner. He stated his role in the discharge planning process was to arrange transfer to another facility. He also stated the discharge date was scheduled for 5/22/18 (18 days after admission). During interview on 5/17/18 at 10:30 AM, the ESEHIP manager verified the care plan did not include identified needs, nursing interventions, and discharge planning.

2. Review of the medical record showed patient #10 was an inpatient from 5/5/18 to 5/8/18 for care and treatment for chest pain. Further review revealed a care plan was not developed for this patient.

3. Review of the nursing progress notes revealed the identified needs for patient #5 included elevate legs, strict intake and output, and protective skin care. Review of the care plan showed a system for "checking off" when care plan interventions were done. According to this care planning process, it was unclear whether the interventions were done as directed by the care plan, and an evaluation of the effectiveness of the interventions was lacking.

4. Review of the medical record showed patient #7 was an inpatient from 11/4/17 to 12/5/17. Review of the care plan interventions showed discharge planning was lacking; however, interventions were implemented that addressed the patient's feelings of self-worth. Further review showed the interventions were ineffective because the resident refused them. Interview on 5/17/18 at 12:30 PM with the ESEHIP manager revealed staff should have revised the care plan to address the refusals and utilized the care-planning process to address the identified behavior.

5. Review of the medical record showed patient #19 was an inpatient from 5/3/18 to 5/7/18 for care and treatment for schizophrenia. Further review revealed a care plan was not developed for this patient. Interview on 5/17/18 at 12:30 PM with the ESEHIP manager revealed this patient was admitted for emergency detention and the usual practice was to not develop formalized plan-of-care interventions for patients admitted for detention.

6. Medical record review showed patient #1 was admitted to the facility on 4/25/18 with diagnoses which included right lower lobe pneumonia, hyponatremia, sepsis, and cholelithiasis without cholecystitis. Review of the entire medical record showed the facility failed to identify patient needs to formulate in a care plan to address interventions for these diagnoses.

7. Medical record review showed patient #15 was admitted to the facility on 3/31/18 with diagnoses which included hypoglycemia, congestive heart failure, hypokalemia, and general weakness. Review of the entire record showed the facility failed to identify patient needs to formulate in a care plan to address interventions for these diagnoses.

8. Medical record review showed patient #16 was admitted to the facility on 1/3/18 with diagnoses which included entercutaneous and intestinal fistula. The record showed the patient had a colostomy. Review of the care plan showed the facility failed to address the patient's colostomy, which should include care and education.

9. Interview on 5/17/18 at 12:30 PM with the ESEHIP manager confirmed care plan development and revision had been identified as an issue. However, she stated the care plan issue had not been resolved.


27095

Based on observation and staff interview, it was determined the facility failed to protect medical records from unauthorized access in medical record storage areas (C308). This system failure resulted in the inability of the critical access hospital to meet the necessary requirements for the Clinical Records Condition of Participation.

Based on observation and staff interview, the facility failed to protect medical record information from unauthorized use in 1 of 1 on-site location (HIM Department), 1 of 1 off-site storage location (Nursing Dormitory building), and 1 of 3 off-site clinics (Wagon Circle Surgical Clinic). The findings were:

1. Observation in the HIM Department on 5/15/18 at 9 AM showed three rows of multiple medical records stored in the back room on shelves. The room measured 10 feet high by 24 feet deep and 24 feet across.

2. Observation off-site with maintenance staff member #2 on 5/15/18 at 9:20 AM at the Nursing Dormitory building showed medical records were stored there in the basement in boxes. At that time maintenance staff member #2 had a key and unlocked the medical record storage area. The most recent medical records stored were dated 2013. The boxes were stored in 5 separate rooms in such a way as to prevent entrance for measurement.

3. Observation on 5/15/18 at 1:50 PM with the clinic manager at Wagon Circle surgical clinic revealed medical records stored on shelves in 3 rooms. At that time the manager stated some of the medical records were 39 years old and they had talked about what they were going to do with them, but nothing specific had been decided. She further stated the housekeeping staff had access to the files after the clinic closed and the clinic staff were gone for the day.

4. Interview with four HIM staff members (#1, #2, #3, and #4) on 5/15/18 at 9 AM confirmed the maintenance staff had a key for access to the medical record storage areas in the HIM Department and the Nursing Dormitory. All four staff members confirmed the maintenance staff would not have a need to know what was in the medical records that were stored. However, each felt maintenance staff had access for safety issues such as fire risk.

Based on staff interview and review of the Quality Assurance and Performance Improvement (QAPI) program the facility failed to evaluate all services affecting patient care, health and safety. The findings were:

Interview on 5/15/18 at 10 AM with certified registered nurse anesthetist #1 and the interim manager revealed the QAPI activities for their department consisted of checklists to ensure various tasks were being done. They further stated they were not actively involved in a QAPI process that identified projects with goals, bench marks, and measures for improving quality care. The clinic manager for clinic #1 (Spruce Medical center) was interviewed on 5/15/18 at 12:50 PM. The clinic manager for clinic #2 (Wagon Circle Surgical Clinic) was interviewed on 5/15/18 at 1:45 PM. During the interviews both managers stated they did not participate in the QAPI program. Review of the QAPI information provided by the directory of quality showed not all areas of the hospital participated in the program, and for some areas, participation in the QAPI process consisted of submitting monthly checklists. Interview on 5/17/18 at 9:20 AM with the director of quality revealed he had identified some areas that needed to be addressed in the QAPI program, but at this time had not been able to complete all the needed changes. During the interview he identified the following areas that needed to be addressed utilizing the QAPI process:
a. The organ, tissue and eye procurement program did not have policies and procedures or a system for ensuring designated requestors received required training.
b. Some areas, including the clinics and anesthesia, did not have identified quality indicators, goals, interventions, and evaluations based on data analysis that were specific to the area and services provided.
c. The committee structure needed to be revised to better evaluate inpatient medical and health care services based on individual patient needs, but this process had not been completed.

Based on staff interview, review of organ, tissue and eye donor records, and review of policies and procedures, the facility failed to develop written policies and procedures that address its organ procurement responsibilities. The findings were:

When the surveyor requested review of the organ procurement policies and procedures, the ESEHIP manager provided the standard operating policies for "Organ and Tissue Donation", reviewed 6/20/17. Review of this information revealed it was a policy that described the mechanisms of brain death determination, Further review revealed information regarding Donor Alliance, education and training, designated requestors, and procedures and responsibilities related to the process were not included. On 5/17/18 at 8:19 AM, the ESEHIP manager verified the lack of written policies and procedures that addressed organ procurement responsibilities.

Based on staff interview, and review of organ, tissue and eye donor records, the facility failed to ensure 2 of 6 staff (RN #3, RN #4) who performed designated requestor tasks received the required training prior to performing the tasks. The findings were:

On 5/16/18 at 1:15 PM, interview with RN #5 showed the facility had an agreement with the Donor Alliance that included required education and training for designated requestors. Review of the organ, tissue, and eye donor records revealed 6 RNs were designated requestors at various times during 2017 and 2018. Further review revealed RN #4 performed the designated requestor tasks on 11/24/17 and RN #3 performed the same tasks on 5/8/18. On 5/17/18 at 8:19 AM, the ESEHIP manager verified RN #3 and RN #4 performed the tasks, and neither had completed a training course offered or approved by the Donor Alliance.