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Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure all patient care equipment was maintained in safe operation condition as evidenced by failing to ensure the functionality of a nurse call button located on the handrails of the hospital's patient beds.

Findings:

Observation of the CAH patient ward on 7/23/18 at 10:15 a.m. revealed the call button on the bed's side rails in patient rooms b, c, d, e, f, g, and h.

During an interview on 7/23/18 at 10:35 a.m., S1DON confirmed the call buttons on the patient beds in rooms b, c, d, e, f, g, and h did not function.

Based on policy review, observation and interview, the CAH failed to ensure the proper handling of drugs and biologics. This deficient practiced is evidenced by failing to ensure only the pharmacist performed compounding of drugs by allowing nursing staff to prepare intravenous medications with multiple medication additives in the medication rooms behind the nurse's station.

Findings:

Review of hospital policy titled Intravenous Admixtures (PHA37) revealed in part the following:
-Location - IV admixture service is located in the main pharmacy.
-Objective - To prepare all inpatient IV dosages for admixture using aseptic techniques.
-Preparation of the Work Area - Only Pharmacy personnel or properly trained will have access to the IV compounding area. Nursing staff will perform compounding functions using proper technique to minimize contamination of the admixture.
-Processing of New IV Orders - All work should be done in the Isolator Glove Box Hood. Nurses may make admixtures when a pharmacist is not present. They must use the same procedure as the pharmacist.

Review of hospital policy titled Sterile Products: Aseptic Technique (PHA81) revealed aseptic technique shall be used to reconstitute and prepare sterile products. It was further revealed to choose a medication preparation area away from heavy traffic areas (in a laminar airflow hood when available).

Review of hospital policy titled Dispensing: Obtaining Medications When the Pharmacy is Closed or Otherwise Unavailable (PHA17) revealed the pharmacist is on-call at all times when the pharmacy is closed [5:00 p.m. to 8:00 a.m. Monday through Friday and 12:00 p.m. to 8:00 a.m. Saturday and Sunday.

The definition of compounding as that term is used in the USP is found in USP Chapter <795> (USP <795>): "The preparation, mixing, assembling, altering, packaging and labeling of a drug, drug-delivery device, or device in accordance with a licensed practitioner's prescription, medication order or initiative based on the practitioner/patient/pharmacist/compounder relationship in the course of professional practice. Compounding includes the following: Preparation of drugs and devices for prescriber's office use where permitted by federal and state law." Compounded medications, whether non-sterile or sterile, may be subject to physical and chemical contamination and unintended variations in strength. Microbial contamination and bacterial endotoxins are particularly hazardous with respect to compounded medications that are intended to be sterile.

On 07/23/18 at 2:00 p.m., in an interview with S9Pharm, she revealed staff nurses were trained by her to compound medications into IV fluids to make "banana bags." She verified the regulations (USP 797) state that nursing staff are allowed to compound medications in an emergency but the "banana bags" in this discussion were not an emergent medication. It was also verified the nurses mixed 3-4 different medications into the bag of fluids. S9Pharm stated the nurses are not allowed to prepare IV fluids in pharmacy under the air flow hood and verified there was no designated preparation area and no hood in the medication room used by the nurses to compound medications.

On 07/23/18 at 2:45 p.m., in an interview with S14RN, she stated if a patient was admitted after pharmacy hours, the nurses would compound the IV fluids ("banana bag") when ordered by the physician. She further revealed the IV bags would have 3 to 4 different medications to be compounded into the IV bag. S14RN said her procedure for mixing fluids in the nursing medication room would include wearing non-sterile gloves, she would not wear a mask, and she would prepare the medication on the counter next to the sink. She stated she would prepare the IV fluids and administer them to the patient within one hour and the average infusion time of the fluids was 10 hours.

Based on observations, record review, and interviews, the hospital failed to ensure its system for controlling infections and communicable diseases of patients and personnel by maintaining a sanitary environment was implemented and monitored for compliance, as evidenced by:
-Observations of breeches in hand hygiene by staff;
-Observation of reusable patient care equipment not cleaned/disinfected between patient uses;
-Infection control surveillance that did not included hand hygiene practices for all patient care areas of the hospital; and
-Failure to have policies and procedures that addressed safe injection practices or surveillance of injection practices practiced by staff and providers in all areas of the hospital; and
-Failure to maintain a sanitary environment in patient rooms.

Findings:

Review of hospital policy #IC-A-200, titled "Antiseptics, Hand Hygiene, Hand Washing Facilities" provided by S4Inf Prev as current, revealed in part that staff were to decontaminate hands before having direct contact with patients, after contact with a patient's intact skin when taking a pulse or blood pressure, after contact with inanimate objects to include medical equipment in the immediate vicinity of a patient, and after removing gloves.

Review of hospital policy # IC-P-100, titled, "Patient Equipment", provided by S4Inf Prev as current revealed in part the hospital had established guidelines to reduce the risk of disease transmission with use of single use and reusable patient care equipment. Further review revealed no process for cleaning equipment used on multiple patients (such as a mobile vital sign machine) after use on a patient.

An observation 7/23/18 at 3:00 p.m. revealed S8CNA enter Patient #4's room and assess the patient's vital signs using a rolling vital sign machine. S8CNA exited Patient #4's room, and proceeded to the Patient #6's room without performing hand hygiene, or disinfecting the vital sign machine and blood pressure cuff. S8CNA was observed to take the vital signs of Patient #6 without performing hand hygiene before or after contact with the patient.

In an interview 7/23/18 at 3:10 p.m. S8CNA verified that she had not performed hand hygiene before or after patient care for patients #4 and #6 . She verified that she should have performed hand hygiene before and after contact with the patients. She reported that she did not clean the portable vital sign machine because she did not have a container of disinfecting wipes on the machine. The CNA verified that she was supposed to clean the machine after use on a patient, before use on another patient.

In an interview 7/23/18 at 2:25 p.m. S4Inf Prev reported that infection control surveillance activities such as hand Hygiene, PPE use, and safe injection practices were not conducted and documented in the surgery/endoscopic, ED, lab, or radiology departments. S4Inf Prev reported that the unit clerks on the patient care unit are responsible for hand hygiene surveillance, as well as herself. She reported that the hospital did not have policies and procedures for safe injection practices and did not include these in their infection control surveillance. S4Inf Prev confirmed all hospital departments/areas and all disciplines should be included in the infection control surveillance, as well as safe injection practices.

On 07/23/18 at 10:00 a.m., observation of the "clean" patient rooms with S1DON (Director of Nursing) revealed the following infection control issues:
Room k - Old tape was observed on the side rails and overbed table
Room l - Old tape was observed on the side rails and a brown substance was on the bottom sheet of the bed
Room m - Old tape and grime was observed on the side rails and the television remote control had a brown substance on it
Room o - Old tape was observed on the side rails and the emergency call button in the bathroom was cracked with exposed wiring
Room p - Old tape was observed on the side rails, overbed table and televison remote control
Room q - Old tape was observed on the side rails and overbed table
Room r - Old tape was observed on the side rails

Observation on 7/23/18 at 10:40 a.m., accompanied by S1DON, revealed the following:
a. Dirty Kangaroo feeding pump room q;
b. Dirty intravenous pump room r ;
c. Used set of defibrillator pads on top of the crash cart room r;
d. Grime and hair on top of the crash cart's defibrillator;
e. 2 pairs of sterile gloves in the crash cart with an expiration date of 2015/07;
f. 2 pairs of sterile gloves in the crash cart with an expiration date of 2018/05;
g. A 6 French suction catheter expired in the crash care with an expiration date of 2014/04;

On 07/23/18 at 11:00 a.m., interview with S1DON confirmed that the above patient rooms were ready to have patients admitted, but were in need of cleaning.

Observation on 7/23/18 at 2:10 p.m., accompanied by S2RN Emergency Department Nursing Manager, revealed cracks/tears to the vinyl covering of the mattress in room s:

During an interview at this time, S2RN ED Mgr. acknowledged the cracks/tears to the vinyl covering on the mattress prevented it from being properly sanitized and was an infection control issue.






17450

Based on interview and observation, the CAH (Critical Access Hospital) failed to provide nursing care in accordance with the patient's needs and the specialized qualifications and competence of the staff available by failing to ensure the ED (Emergency Department) staff were trained in non-physical intervention skills for 15 of 19 ED staff members.

Findings:

During an interview on 07/25/18 at 12:35 p.m., S2RN ED Nursing Manager stated that only four staff members in the ED had attended and were certified in non-physical intervention skills. She further stated that all staff in the ED were subject to working with violent/psychiatric patients.

Based on record review and interview, the hospital failed to ensure all medications were administered in accordance with physician's orders and accepted standards of practice for 1 of 1 patients (Patient #5) reviewed who had a medication unavailable and for 1 (Patient #17) of 1 patients reviewed for medication administration errors out of a total sample of 21 patients.
Findings:

Patient #5
Review of the hospital policy titled, Medication Protocols, revealed in part that orders entered for patients by the physicians for non-formulary medications on the therapeutic equivalence chart approved by the medical executive committee will be automatically interchanged with the approved medication.

Review of the medical record for Patient #5 revealed an admit date of 07/20/18 with diagnoses including recent hip surgery, debility and history of breast cancer. Review of the admit physician orders dated 07/20/18 revealed an order for Anastrozole (used to treat breast cancer) by mouth daily. Review of the Medication Administration Record revealed that the nurses had been charting "unavailable" every day, with no documentation why the medication was unavailable.

On 07/24/18 at 3:15 p.m., interview with S9Pharmacist revealed that Anastrozole was not on the hospital's formulary and there was no equivalent to it. She stated that the nurses should have asked the patient to bring the medication from home to take at the hospital. When asked if she had notified the physician that the medication was not available, she stated no.

On 07/24/18 at 3:45 p.m., interview with the patient's nurse, S14RN, revealed that the patient had not received any of the Anastrozole medication since admit. When asked if the physician had been notified, she stated no.

Patient #17
Review of the record for Patient #17 revealed a hospital admission date of 04/23/18 with two antibiotic orders:
1) Ceftriaxone Sodium (Antibiotic) 2grams IV (intravenous) every 24 hours
2) Azithromycin 500 mg IV every 24 hours

On 4/23/18 at 12:00 p.m., S11RN documented in the Medication Administration Record Ceftriaxone Sodium not administered to Patient #17.

On 4/27/18 at 9:00 a.m., S12RN documented she administered Azithromycin to Patient #17.

On 7/24/18 at 9:00 a.m., medical record review with S10RN QM revealed and verified it was not documented in the medical records on 4/23/18 or 4/27/18 that S11RN or S12RN notified the physician of a medication error.

On 7/23/18 at 3:30 p.m. in an interview with S9Pharm, she verified there was no medication variance report regarding the medication error on 4/23/18. She also revealed she wrote an incident report on 4/27/18 for Patient #17. She stated she noted an un-administered antibiotic hanging in the patient's room, the antibiotic was documented by S12RN as administered. S9Pharm stated she did not notify the physician of this error and did not ask nursing staff to notify the physician.

Review of hospital policy titled Medication Errors (PHA42) revealed in part:
-Examples of medication error is an omission of a dose.
-Medication errors shall be reported in a timely manner to the practitioner who ordered the medication.
-The medication administered in error or omitted in error ant the action taken shall be properly recorded in the patient's medical record.
-The person who discovers the error shall prepare a medication error report on the facility's approved form.



39791

Based on record review and interview, the CAH (Critical Access Hospital) failed to ensure all medical record entries for patients receiving health care services at the hospital were complete. This deficient practice was evidenced by failure of the CAH to ensure all medical record entries were authenticated, dated, and timed for 1(#11) of 21 patients sampled for completed charts.

Findings:

Review of Patient #11's Nurse's Note dated 4/1/18 revealed thirty-two entries from 3:15 p.m. to 11:00 p.m. that was not signed by a nurse.

During an interview on 7/24/18 at 9:20 a.m., S3RN Director of Clinical Excellence confirmed Patient #11's 4/1/18 paper Nurse's Note that was scanned into the electronic chart was not signed.

Based on record review and interview, the hospital failed to ensure that for 3 of 3 (Patient #4, 5, 6) swing bed records reviewed, the Patient Rights failed to include the patient's right to work.

Findings:

Review of the medical records for Patients #4, 5 and 6 revealed they were current swing bed patients. Further review of the record revealed the list of Patient Rights given to them upon admit to swing bed failed to identify the right of the patient to work.

Interview with S13Social Worker revealed that she is responsible for informing the swing bed patients of their rights upon admit. She further stated that she gives them a paper hand-out explaining their rights. Review of this hand-out with S13Social Worker revealed it did not address the right to work. At that time, interview with S13Social Worker confirmed that the patient's right to work was not addressed.

Based on record review and interview, the hospital failed to ensure that for 3 of 3 (Patient #4, 5, 6) swing bed records reviewed, the Patient Rights failed to include the patient's right to receive mail.

Findings:

Review of the medical records for Patients #4, 5 and 6 revealed they were current swing bed patients. Further review of the record revealed the list of Patient Rights given to them upon admit to swing bed failed to identify the right of the patient to receive mail.

Interview with S13Social Worker revealed that she is responsible for informing the swing bed patients of their rights upon admit. She further stated that she gives them a paper hand-out explaining their rights. Review of this hand-out with S13Social Worker revealed it did not address the right to receive mail. At that time, interview with S13Social Worker confirmed that the patient's right to receive mail was not addressed.

Based on record review and interview, the hospital failed to ensure that for 3 of 3 (Patient #4, 5, 6) swing bed records reviewed, the Patient Rights failed to include the patient's right to personal property.

Findings:

Review of the medical records for Patients #4, 5 and 6 revealed they were current swing bed patients. Further review of the record revealed the list of Patient Rights given to them upon admit to swing bed failed to identify the right of the patient to retain and use personal property.

Interview with S13Social Worker revealed that she is responsible for informing the swing bed patients of their rights upon admit. She further stated that she gives them a paper hand-out explaining their rights. Review of this hand-out with S13Social Worker revealed it did not address the right to retain and use personal property. At that time, interview with S13Social Worker confirmed that the patient's right to personal property was not addressed.

Based on record review and interview, the hospital failed to ensure that for 3 of 3 (Patient #4, 5, 6) swing bed records reviewed, the Patient Rights failed to include the patient's right addressing married couples.

Findings:

Review of the medical records for Patients #4, 5 and 6 revealed they were current swing bed patients. Further review of the record revealed the list of Patient Rights given to them upon admit to swing bed failed to identify the right of the patient to share a room with his or her spouse when married.

Interview with S13Social Worker revealed that she is responsible for informing the swing bed patients of their rights upon admit. She further stated that she gives them a paper hand-out explaining their rights. Review of this hand-out with S13Social Worker revealed it did not address the rights of married couples. At that time, interview with S13Social Worker confirmed that all patient rights were not addressed on the hand-out.