HospitalInspections.org

A. Based on review of Critical Access Hospital (CAH) policy, clinical records, and staff interview, it was determined, that for 4 of 4 clinical records containing laboratory cultures (Pts. # 3, 5, 6, & 9), the Hospital failed to ensure laboratory culture results were reported at 24 and 48 hours.

Findings include:

1. On 9/1/11 at 2:50 PM, the Hospital policy titled, "Resulting Times of Microbiology" was reviewed. The policy included, "The reporting times for microbiology growth will happen at 24 hours for preliminary results and 48 hours for final reports."

2. On 9/1/11 at 12:35 PM, the clinical record of Pt. #3 was reviewed. Pt. #3 was a 66 year old male, admitted on 8/17/11, with diagnoses of Pulmonary Embolism, Hyperlipidemia, and Hypertension. Pt. #3's laboratory report for a nasal culture collected on 8/17/11 at 3:37 PM, included the "24 hour" results on 8/18/11 at 6:57 AM, only 15 hours after collection. Subsequent laboratory nasal culture results were not found.

3. On 9/1/11 at 1:00 PM, the clinical record of Pt. #5 was reviewed. Pt. #5 was a 77 year old male, admitted on 8/20/11, with diagnoses of Fever, Cough, and Probable Pneumonia. Pt. #5's laboratory report for a nasal culture collected on 8/20/11 at 12:12 PM, included "24 hour" results on 8/21/11 at 6:32 AM, and "48 hour" results on 8/22/11 at 6:58 AM. This was 18 hours and 42 hours after collection, not 24 and 48 hours. Subsequent laboratory nasal culture results were not found.

4. On 9/1/11 at 1:30 PM, the clinical record of Pt. #6 was reviewed. Pt. #6 was a 74 year old male, admitted on 8/14/11, with diagnoses of Urinary Tract Infection (UTI), Weakness, and Dehydration. Pt. #6's laboratory report for a urine culture collected on 8/14/11 at 6:50 PM included "24 hour" results on 8/15/11 at 7:09 AM and "48 hour" results on 8/16/11 at 6:32 AM. This was 12 hours and approximately 36 hours after collection, not 24 and 48 hours. Subsequent laboratory urine culture results were not found.

5. On 9/1/11 at 2:10 PM, the clinical record of Pt. #7 was reviewed. Pt. #7 was an 81 year old female, admitted on 8/9/11, with diagnoses of UTI, Weakness, and Dementia. Pt. #6's laboratory report for a urine culture collected on 8/9/11 at 6:39 PM included "24 hour" results on 8/10/11 at 6:59 AM and "48 hour" results on 8/11/11 at 6:45 AM. This was 12 and 36 hours after collection, not 24 and 48 hours. Subsequent laboratory urine culture results were not found.

6. An interview was conducted with the Laboratory Director on 9/1/11 at 2:55 PM. The Director stated that culture results are checked once each day and are recorded as 24 and 48 hour reports. These findings were confirmed by the Laboratory Director on 9/1/11 at 2:55 PM, during an interview.