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Based on record review and interview this facility failed to provide qualified staff to complete the triage process for walk-in Emergency Department patients in 1 of 1 Emergency Department triage process and failed to follow Emergency Department policies and procedures for admission assessment to identify and ensure all services are offered in accordance with acceptable standards of practice in 6 of 7 Emergency Department charts reviewed (Patient #13, #14, #9, #11, #15, and #18) in a total of 20 charts reviewed.

Findings include:

The Emergency Department staff failed to follow Emergency Department policies and procedures. (See Tag C-0294)

The cumulative effects of these systematic failures resulted in the facility's inability to ensure emergency services provided standardized, quality healthcare in a safe environment.

Based on observation, record reviews and staff interviews the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0222 - Egress Doors
K-0321 - Hazardous Areas
K-0353 - Sprinkler System - Maintenance And Testing
K-0361 - Corridors - Areas Open to the Corridor
K-0363 - Corridor - Doors
K-0374 - Subdivision of Building Space

37419


Based on observation, record review, and interview, the facility failed to maintain equipment in 1 of 9 departments (Laboratory).

Findings include:

On 8/07/2018 at 1 PM during a laboratory tour with Laboratory (Lab) Director H, an eyewash/shower unit was observed. Lab Director H was asked how frequently the unit was flushed and stated, "they should be flushed weekly."

Review of the eye wash flushing log revealed the eyewash station was flushed on 6/1/18, 6/29/18, 7/06/18 and 7/14/18. There was no record of flushing since 7/14/2018.

On 8/07/2018 at 1:30 PM during a tour of the Pharmacy with Pharmacist I, during an interview Pharmacist I was asked how frequently eyewash stations were flushed and Pharmacist I stated "they are flushed monthly." Pharmacist I confirmed the facility had no policy for the flushing of eyewash stations.

Based on observation, record review, and interview, the facility failed to ensure drugs are secured. Medications were not secured in 1 of 9 departments (Medical/Surgical Department).

Findings include:

On 08/07/2018 at 3:45 PM observed eight 10 ml vials of 1% lidocaine on a shelf in the Medical/Surgical (Med/Surg) nursing station. The area was unsecured and was not continuously monitored by staff.

The facility policy "Medication Storage" (no date) was reviewed on 08/08/2018 at 11:00 AM and revealed "Medication storage areas outside of an Automated Dispensing machine must remain locked when not under direct observation of personnel."

On 8/07/18 at 3:45 PM during an interview at the time of observation of the Med/Surg nursing station, Registered Nurse G confirmed that medications were left out on the shelf.

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure life safety from fire. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0222 - Egress Doors
K-0321 - Hazardous Areas
K-0353 - Sprinkler System - Maintenance And Testing
K-0361 - Corridors - Areas Open to the Corridor
K-0363 - Corridor - Doors
K-0374 - Subdivision of Building Space

Based on record review and interview, the hospital staff failed to follow Emergency Department policies and procedures for admission assessment to identify and ensure all services are offered in accordance with acceptable standards of practice in 6 of 7 Emergency Department charts reviewed (Patient # 13, #14, #9, #11, #15, and #18) in a total of 20 charts reviewed, failed to perform annual review of their policies as evidenced by 525 of 1998 policies outstanding annual revisions in 1 of 1 of their policy revision process, failed to complete a periodic review of their Medical Staff rules and regulations in 1 of 1 Medical Staff, failed to monitor communicable disease in all employees and providers as evidenced in 7 of 7 staff (staff J, K, L, M, N, O and P) and 4 of 4 provider's (providers AA, BB,CC and DD) missing tuberculosis screening, failed to avoid sources and transmission of infection by unsafe transfer of medical equipment in 1 of 9 departments (Surgical Department), failed to administer medications safely in 1 of 5 observations (Patient # 21) and failed to ensure reusable patient care equipment is cleaned and reprocessed appropriately by using flash sterilization inappropriately in 1 of 9 departments (Surgical Department).

The hospital failed to ensure Emergency Department services are provided in accordance with acceptable standards of practice. (See Tag C-0271)

The Hospital failed to perform annual review of their policies and complete a periodic review of their Medical Staff Rules and Regulations. (See Tag C-0 275)

The hospital failed to maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases. (See Tag C - 0278)

The cumulative effect of these systemic failures has the potential to affect the health and safety of all patients receiving care at this facility.

Based on record review and interview, the facility failed to follow Emergency Department policies and procedures for admission assessment to identify and ensure all services are offered in accordance with acceptable standards of practice in 6 of 7 Emergency Department charts reviewed (Patient #13, #14, #9, #11, #15 and #18) in a total of 20 charts reviewed.

Findings include:

Review of policy "Sexual Assault - Evidentiary Exam and Treatment of the Sexual Assault Victim" # ED-28 (not dated) revealed "If the patient requires medical treatment as well as an evidentiary exam: 4. Document to ED [Emergency Department] standards... If the patient is here only for an evidentiary exam: 1. The patient will be offered a medical screening exam by the ED provider. If a medical screening exam is declined, a note should be entered into the patient record stating "Patient here for sexual assault exam only, medical screening exam offered and declined."

Review of policy "Patient Admission Assessment" #38 dated 8/01/1992, revision date 7/24/2018 under Procedure: 1.5 "ED - An immediate visual assessment is done on all patients upon entering the ED to facilitate triage. The actual assessment is to be completed on the ED Navigator within 15 minutes of arrival."

Review of policy "Documentation of Nursing Care and Plan of Care" #16, effective date 1/01/13, revised 2/13/18, Procedures: K. ED/OB 1. "For the ED they will utilize the ED Nursing Navigator."

Review of policy "Patient Reassessment and Reassessment Chart" #41, origination date 8/01/92, revision date 8/07/18, page 4, 3.7. Emergency Department 3.7.1. "An assessment will be completed by the RN [Registered Nurse] upon patient presentation, the content of which is defined by the EMR [electronic medical record] through the ED Navigator... 3.7.2.

During review of the hospital's electronic medical record (EMR) "Emergency Navigator" on 8/09/18 at 4:42 PM with ED RN KK, RN KK confirmed staff are to complete the entire ED Navigator section in the EMR on each ED patient consisting of the following: Arrival Information, Chief Complaint, Quick Assessment, Triage Notes, ED notes, Allergies, Vitals, OB/GYN (obstetrics and gynecology) status, Legal/Comm(communication)/Safety, Triage Complete, Home Medication, History, Immunizations, and Screening.

Review of Patient #13's emergency room record revealed Patient #13 came to the Emergency Department on 4/27/18 at 3:11 PM with the Chief Complaint of "assault." documented in the ED navigator and was seen by a SANE (Sexual Assault Nurse Examiner) Nurse. No information was documented in the EMR in the ED navigator under Arrival Information, Quick Assessment, Triage Notes, ED notes, Allergies, Vitals, OB/GYN status, Legal/Comm/Safety, Triage complete, Home Medication, History, Immunizations, or Screening. . There was no note indicating a medical screening exam was offered and declined.

Review of Patient #14's emergency room record revealed Patient #14 came to the ED on 1/14/17 at 4:54 PM with the Chief Complaint of "SART" [Sexual Assault Response Team] documented in the ED Navigator and "blood draw" under ED notes. There was no documentation in the EMR under the ED Navigator under Quick Assessment, Triage Notes, Allergies, Vitals, OB/GYN status, Legal/Comm/Safety, Triage complete, Home Medication, History, Immunizations, or Screening. There was no note indicating a medical screening exam was offered and declined.

Review of Patient #9's emergency room record revealed Patient #9 came through the emergency room 8/02/18 at 5:58 PM with a hip fracture and was admitted to the Medical Surgical Department on 8/02/18 at 8:50 PM. There was no documentation in the EMR under the ED Navigator under quick assessment.

Review of Patient #11's emergency room record revealed Patient #11 came through the ED on 8/07/18 at 1:30 PM with abdominal pain, was admitted for inpatient care, and had an appendectomy (removal of appendix) on 8/07/18 at 6:55 PM. There was no documentation in the EMR under the ED Navigator under quick assessment or family history.

Review of Patient #15's emergency room record revealed Patient #15 was a 51-year-old who came into the ED on 8/04/18 at 10:34 AM with the chief complaint of "SOB [shortness of breath] , Chest Pain" and was transferred to another acute care facility on 1/14/18. There was no documentation in the EMR under the ED Navigator under arrival information, OB/GYN status, home medication, history, screenings, or quick questions.

Review of Patient #18's emergency room record revealed Patient #18 came into the ED on 5/28/18 with respiratory failure, was admitted to the Medical Surgical Department and was discharged on 6/02/18. There was no documentation in the EMR under the ED Navigator under triage, home medication, history, immunizations, screenings, or quick questions.

On 8/07/18 at 1 PM during an interview, ED Manager JJ stated the ED staff is doing their extended training on the EMR - ED Navigator documentation requirements tomorrow (8/08/18) and they have not started their ED chart audits from their previous plan of correction.

On 8/07/18 from 3 PM to 3:20 PM during an interview with Clinical Specialist Quality X, during chart review of Patient #13 and Patient #14's medical records, Clinical Specialist Quality X stated the ED staff's documentation was limited in the medical record of patients who come in to see a SANE [Sexual Assault Nurse Examiner] case. X confirmed they did not follow their policy on ED documentation in the EMR.

On 8/09/2018 at 4 PM during an interview with Vice President (VP) Patient Care B, B stated that the ED staff had just started their documentation training and confirmed the ED staff remained deficient in completion of the ED Navigator documentation in the EMR.

Based on record review and interview, the facility failed to perform annual review of their policies as evidenced by 525 of 1998 policies outstanding annual revisions in 1 of 1 of their policy revision process and failed to complete a periodic review of their Medical Staff rules and regulations in 1 of 1 Medical Staff.

Findings include:

On 8/09/2018 at 8:35 AM during an interview with Compliance 360 Systems Administrator II, II stated this facility has been using the Compliance 360 System to organize and update their policies since January 2015. S/he stated the owner of each policy gets notified 60 days prior to the scheduled revision date, and then again at 30 days, and 1 day past due. S/he stated that "Senior Leaders" have access to monitor policy status with their direct report staff and are responsible for setting up one to one meetings with staff as necessary.

Review of record titled "Amery Policies Status Chart" run by Compliance 360 Systems Administrator II on 8/9/2018, under Workflow Status revealed "Approved - 1473, Due Soon - 185, Past Due 171, Pending Acceptance - 73, Planning - 89, Rejected - 7."

On 8/09/2018 at 12:50 PM during an interview with Clinical Specialist Quality, Registered Nurse (CNS Quality) X, X confirmed 9% of their policies were past due and greater than 26% have not been approved. CNS Quality X stated "there is no policy on how policies are reviewed and updated."

Review of "Amery Regional Medical Center Medical Staff Rules and Regulations" revealed last revision and approval date of August 2007.

On 8/9/2018 at 12:27 PM during an interview with Chief Medical Officer (CMO) D and Chief of Staff (COS) MM, COS MM stated that they have been working on review of the facilities policies "as prep for their upcoming [redacted] (accreditation) visit." Chief Medical Officer D stated that they have also been updating and aligning the Medical Staff Rules and Regulations with the updated policies and confirmed review of the Medical Staff Rules and Regulations have not been done since 2007 "in a while" but "are in the review process right now."

Based on observation and interview, the facility failed to provide a policy to address the safe administration of medication in 1 of 9 departments (Outpatient Therapy Clinic).

Findings include:

Review of policy "Extended Dating of Single Use and Multidose Vials" #SP-9 Effective Date 4/02/2011, Revision Date 5/22/2018 under Objectives revealed "a new, sterile needle and syringe should always be used to access the multidose vial."




20878


On 8/08/18 at 1:25 PM in the rehabilitation prep area, observed a 10 milliliter single use syringe, out of sterile packaging, stored in a locked cupboard with a multi-dose vial of Dexamethasone (a topical steroid used to decrease inflammation). The bottle of Dexamethasone had a plastic device punctured into septum that the syringe could be connected to draw up medication.

On 8/08/18 at 2:25 PM during interview, Pharmacist I stated there was no policy on the use of the needleless system used for the Dexamethasone.

37419



Based on observation, record review, and interview, the facility failed to monitor communicable disease in all employees and providers as evidenced in 7 of 7 nursing staff (staff J, K, L, M, N, O and P) and 4 of 4 provider's (providers AA, BB, CC and DD) missing tuberculosis screening, failed to avoid sources and transmission of infection by unsafe transfer of medical equipment in 1 of 9 departments (Surgical Department), failed to administer medications safely in 1 of 5 observations (Patient # 21) and failed to ensure reusable patient care equipment is cleaned and reprocessed appropriately by using flash sterilization inappropriately in 1 of 9 departments (Surgical Department).

Findings include:

During interview with Infection Control Coordinator (ICC) Q on 8/08/2018 at 1:22 PM, ICC Q stated that the staff adhere to the standards of practice for infection control, surgical services, and decontamination/sterilization from the following organizations: The Association of Professionals for Infection Control, Centers of Disease Control, The Association of peri-Operative Registered Nurses, and The Association for Advancement in Medical Instrumentation.

Tuberculosis Exposure:
Staff
Review of policy "Tuberculosis Exposure Control and Prevention Plan" #AHC-EH-400 (not dated) under Health Care Worker Screening and Evaluation of Exposures revealed "Employees and Providers will complete a communicable disease/TB [tuberculosis] screening annually."

Per review of personnel files on 8/08/2018 at 2:30 PM the following employees were missing tuberculosis or communicable disease screenings for the previous 2 years; J, K, L, M, N, O and P.

Per interview with Employee Health co-coordinator Q on 8/08/2018 at 2:45 PM, employees are asked about exposure to communicable disease at the time of their annual influenza injection, but this is not documented.

Providers
Record review of Provider/Nephrologist AA's credentialing file revealed last tuberculosis screening completed 4/06/2017.

Record review of Provider/Physician Assistant BB's credentialing file revealed last tuberculosis screening completed 9/01/2015.

Record review of Provider/Internal Medicine Physician CC's credentialing file revealed last tuberculosis screening completed 12/29/16.

Record review of Provider/Nurse Practitioner DD's credentialing file revealed last tuberculosis screening completed 4/24/17.

On 8/09/2018 at 10:15 AM during review of credentials with Quality Assistant L and Chief Medical Officer (CMO) Physician D, during an interview CMO D confirmed the Medical Staff Bylaws or Rules and Regulations do not include tuberculosis screening requirements.

On 8/09/2018 at 10:15 AM during review of credentials with Quality Assistant L, during an interview L stated tuberculosis screenings were done with credentialing and confirmed that annual tuberculosis screenings were not completed by providers AA, BB, CC or DD.

On 8/09/2018 at 11:15 AM during an interview with Clinical Specialist Quality I, I stated "I believe the providers follow the hospital policy for tuberculosis screening."


Scope Transportation:
Review of policy "Olympus Endoscope Manual Cleaning" dated 2/23/18, did not address transportation of scope to dirty utility room for cleaning.

Review of "Process for Transportation of Scope to Scope Cleaning Room", Origination date 12/07/17, hand dated 8/08/18 under Summary: "procedure that will be followed to pre-clean instruments and transport to scope cleaning room...Task sequence 1. Take red transportation container into room...2. Put instruments in red biohazard container and take to scope processing room."

On 8/08/18 at 8:20 AM after pre-cleaning scope, observed Surgical Tech GG wrap scope in blue bag and carry to the soiled utility room.

On 8/09/18 at 1:09 PM during an interview with ICC Q, ICC Q confirmed the proper procedure for scope transfer is to put the scope in the "red box" to transport.

Medication Administration:
Review of policy "Safe Practices for Injection, Infusions and Use of Multi-Dose Containers" #AHC-IP-50 dated 11/10/17. Description of policy revealed "To provide standard guidelines for practicing safe preparation, use and administration of substances that are injected, infused, poured, or topically applied." This policy did not address glove use with medication administration.

On 8/08/18 at 11:42 AM in the Medical Surgical Department, observed Registered Nurse HH administer Dilaudid into the intravenous line (IV) of Patient #21. RN HH did not wear gloves for this medication administration.

On 8/09/2018 at 3:30 PM during an interview with Infection Control Coordinator Q on expectations of when to perform hand hygiene, ICC Q stated "glove use is per nursing standards of practice" and s/he would expect nurses to wear gloves when giving IV medications. ICC Q confirmed RN HH did not follow those guidelines.

Flash Sterilization:
1. Centers of Disease Control Flash (Immediate Use) Sterilization 2008:
Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time.

On 8/08/2018 at 8:05 AM during tour and interview with Certified Surgical Technologist FF, FF stated that items were flashed occasionally, "a couple times a month maybe, if we drop something."

On 8/09/18 during review of Immediate Use Sterilization (Flash Log) with ICC Q it was noted that a laryngoscope instrument was brought in by physician on 3/16/18 and 6/29/18 and was flashed before use. During interview, ICC Q looked at the data and stated "we may need to get him one".

Based on record review and interview, this facility failed to provide qualified staff to complete the triage process for walk-in Emergency Department patients in 1 of 1 Emergency Department triage process.

Findings include:

Review of policy titled "Triage Procedure for Emergency Department" #ED-40 with revision date 8/7/2018, effective date 8/12/2018, under Policy revealed "All patients presenting to Amery Hospital and Clinic Emergency Department for emergency medical treatment will be assessed and triaged by a registered nurse (RN) upon arrival."

Review of training PowerPoint titled "Patient Access Training" dated 8/02/2018 revealed "All walk-in patients seeking urgent or emergency care will be referred to the Emergency Department after checking in at registration." Page 10 under Standard of Work revealed "Route & Schedule patients appropriately per policy."

Review of job description of the Patient Access Clerk revealed, Department: Patient Access Registration/Scheduling Under Education/Experience: "Education: High School Diploma or equivalent, Experience: 2 years related office experience."

Review of policy titled "Patient Access Scheduling and Registration Policy" #PA-01 under "Appointment Scheduling Reference List" "Non-Urgent/Non-Emergent Reason For Visit" revealed "Can schedule these appointment types in Primary Care, as well as Same Day Appointment openings" with the following conditions noted "Back pain, Cold, cough, sinus and flu symptoms (ear, nose, throat, congestion), Cuts, scrapes, Ear infection, Foreign objects in eye, ear, nose, skin, Genital infections/concerns, Headaches/Migraines, Insect bites (tick, spider etc.), pink eye, Possible fractures, Rash, Seasonal allergies, Sprains, strains, minor injuries, Sore throat and strep throat, Urinary tract/bladder infections (burning with urination, etc.) Yeast Infection."

On 8/08/2018 at 11:45 AM during an interview, Patient Access Clerk J stated when patients present to the registration desk, they are asked what they are there for. If the patient states they are there for one of the reasons listed on the non-urgent/non-emergent reason for visit list, they are asked to "register around the corner", otherwise they are placed on the Emergency Department "trackboard" to be seen. Patient Access Clerk J confirmed, if the walk-in patient is offered a "same day appointment", they are not seen by registered nurse prior to the appointment being made.

On 8/09/18 at 12:05 PM during an interview, Chief Executive Officer (CEO) A stated that it was her/his understanding that all walk-in patients were being screened by a registered nurse when this process was started. CEO A confirmed that "this step must have been dropped."

Based on record review and interview, the facility failed to provide a schedule of swing bed activities.

Findings include:

On 8/08/2018 at 1:20 PM during an interview with staff X a schedule of activities for swing bed patients was requested X stated "There is no printed schedule".

The facility was unable to provide a schedule of activities for swing bed patients. This was confirmed during interview with Patient #7 on 8/08/2018 at 4:30 PM, Patient #7 stated that s/he was unable to choose a level of activity and was not provided a schedule of activities.