HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure that 2 (#s 11 and 30) of 42 reviewed patients were not kept in observation status for an extended period before admission or discharge. Findings include.

1. Patient #11, an 88 year old male was admitted to observation status on 8/12/2011 with complaints of back pain. The patient remained on observation status until the morning of 8/15/11 when he was admitted to acute services at the facility. The specific instructions for the observation admission included evaluation and treatment of pain and evaluation of neurological status with reporting of changes. Admission pain medication orders included intravenous doses of Nubain 10 milligrams every 4 hours as needed for pain control. The patient remained on "observation" status for a period of approximately 70 hours.

2. Patient #30, a 91 year old female, was admitted 10/31/10 with complaints of pain and status post fall.
The patient was discharged home on 11/2/10. The patient remained on "observation" status for a period of approximately 45 hours.

During an interview with staff member D on 8/16/11 at approximately 10:30 a.m., the staff member stated that observation status was supposed to be for 24 hours or until a decision was made for admission or discharge. Patients stayed on observation status too long.

Centers for Medicare/Medicaid Services stipulates that "Observation care is a well-defined set of specific, clinically appropriate services that include ongoing short-term treatment, assessment, and reassessment, that are provided before a decision can be made regarding whether a patient will require further treatment as an inpatient, or may be safely discharged. Observation status is commonly assigned to patients with unexpectedly prolonged recovery after outpatient surgery, and to patients who present to the emergency department and who then require a significant period of treatment or monitoring before a clinical decision is made concerning their next placement. The CAH should ensure that once there is sufficient information to render this clinical decision, the patient should be expeditiously admitted, appropriately transferred, or discharged."

Based on observation, staff interview, and the detergent label review, the facility failed to consistently sanitize the laundry. Findings included:

On 8/16/11 at 10:15 a.m., the surveyor toured the laundry area. A sign was observed hanging on the dryer side wall and the wall behind the washing machines which documented care instructions for the new bedspreads. The instructions stated to avoid prolonged contact with heat and to not use bleach.

On 8/16/11 at 10:55 a.m., staff member H was interviewed. She stated the staff had been directed to use bleach in all loads except colored items. She stated she had been told the detergent would take care of sanitizing the colored items. The detergent ingredients were reviewed. The detergent did not contain a sanitizing agent.

The surveyor was unable to locate documentation in which the heat of the water temperature was sanitizing the colored articles of clothes and linens.

Based on policy and document review and staff interviews, the facility failed to follow the facility policy for credentialing and privileging for all of the active providers on staff at the facility. Findings include.

During the review of provider credential files on 8/16/11 beginning at 3:00 p.m., the surveyor noted that none of the credential files included an initial request for specific privileges for each provider. Privileges granted to the providers were documented as admitting privileges.

According to the Ruby Valley Medical Review Bylaws adopted by the governing board in 2010, page 2, Definitions of Ruby Valley Hospital, item #7, reads "Clinical Privileges or Privileges mean the right granted to a member to provide those diagnostic, therapeutic, medical, surgical, dental, or podiatric services specifically delineated to him/her"

Page 6, Article IV, Appointment and Reappointment:
- Section 2 Application Content: item h reads "Staff category and specific clinical privileges requested."
- Section 4, Effects of Application, Item c reads "Agrees to abide by the terms of the bylaws, rules, regulations, policies and procedure manuals of the Medical Staff and those of the hospital if granted membership and clinical privileges, and to abide by the terms thereof in all matters relating to consideration of the application without regards or not membership and or privileges are granted;".
- Section 5 "Processing the Application". Item b labeled Credentials Committee Action: "The Credentials Committee presents the application and supporting documents to the Medical staff at its next regular meeting and makes recommendations as to approval or denial of or and special limitations on, staff appointment, category of staff membership and prerogatives, and the scope of clinical privileges."
- Section 5 "Processing the Application". Item c labeled Medical Staff Action: "The Medical Staff receives the report and recommendation of the Credentials Committee, reviews available additional information, if necessary, and makes a recommendation, as to approval or denial of, any special limitations on staff appointment, category of staff membership, prerogatives, and scope of clinical privileges."
- Section 6 "Reappointment Procedures". Item a reads "At least 60 days prior to the end of each odd-numbered calendar year, the member furnishes in writing: complete information to update his/her on the items listed in Article IV, Section 2; Specific request for the clinical privileges sought on reappointment, with any basis for changes."

During a discussion of the requirements for credentialing with staff member F on 8/16/11 at approximately 4:00 p.m., the staff member was not aware that specific privilege requests were required.

During the exit conference with the facility administrative team on 8/17/11 beginning at 1:30 p.m., provider #2 stated that the facility had gone back and forth on the requirement for specific privileges or blanket privileges for the providers, and had never required specific privilege requests for the providers in the past.

Based on document review, observation, and staff interview, the facility failed to ensure that medications in the facility were stored in a manner to ensure quality and safety. Findings include:

During the review of the temperature log for the medication storage refrigerator on 8/16/11 at approximately 8:15 a.m., the surveyor noted that staff had documented the temperature reading in the refrigerator at 32 degrees during the month of August, 2011. Further review of the documentation of the refrigerator interior temperatures revealed that documentation of temperature readings were not completed on a daily basis. When the temperature readings were outside of the policy specified parameters (36 - 48 degrees Fahrenheit), there was no documentation of corrective action taken by staff, or notification of maintenance personnel of the presence of a problem during any of the months reviewed. The refrigerator contained insulins*, toxoids**, and vaccines*** that were temperature sensitive.

August 2010:
8 days temperatures were not documented.
10 days with temperatures documented at or below 32 degrees Fahrenheit.
20 days where the documented temperature was below the specified acceptable range.

September 2010:
9 days temperatures not documented.
4 days with temperatures documented at or below 32 degrees Fahrenheit.
16 days where the documented temperature was below the specified acceptable range.


October 2010:
14 days temperatures not documented.
0 days with temperatures documented at or below 32 degrees Fahrenheit.
9 days where the documented temperature was below the specified acceptable range.

November 2010:
12 days temperatures not documented.
8 days with temperatures documented at or below 32 degrees Fahrenheit.
15 days where the documented temperature was below the specified acceptable range.

December 2010:
14 days temperatures not documented.
2 days with temperatures documented at or below 32 degrees Fahrenheit.
11 days where the documented temperature was below the specified acceptable range.

January 2011:
7 days temperatures not documented.
11 days with temperatures documented at or below 32 degrees Fahrenheit.
16 days where the documented temperature was below the specified acceptable range.

February 2011:
11 days temperatures not documented.
5 days with temperatures documented at or below 32 degrees Fahrenheit.
11 days where the documented temperature was below the specified acceptable range.
No documentation was made of repeat temperature measurements or notification of maintenance staff.

March 2011:
7 days temperatures not documented.
10 days with temperatures documented at or below 32 degrees Fahrenheit.
20 days where the documented temperature was below the specified acceptable range.

April 2011:
9 days temperatures not documented.
0 days with temperatures documented at or below 32 degrees Fahrenheit.
2 days where the documented temperature was below the specified acceptable range.

May 2011:
13 days temperatures not documented.
1 day with the temperature documented at or below 32 degrees Fahrenheit.
2 days where the documented temperature was below the specified acceptable range.

June 2011:
no areas of concern.

July 2011:
0 days temperatures not documented.
3 days with temperatures documented at or below 32 degrees Fahrenheit.
12 days where the documented temperature was below the specified acceptable range.

Review of the facility policy labeled "Division:Pharmacy. Subject Medication Storage (Refrigeration/Freezer)" revealed under definitions, "Refrigerator temperature range: 36 F to 46 F", and under the Procedure heading, "Medication storage refrigerator shall be inspected on a daily basis by nursing staff.
Bullet point: "If the temperature varies outside the normal range the person finding the variance will attempt an adjustment of the temperature dial and re-evaluate in two hours."
Bullet point: "If unsuccessful the Maintenance Department will be notified to adjust or repair the refrigerator."

During an interview with staff member D on 8/17/11 at approximately 7:30 a.m., the staff member stated that he/she was aware that the temperatures had not been documented consistently. It was documented in monthly summaries of compliance. Staff member D was unaware that the staff documenting temperatures outside of the normal range did not recheck the temperature, adjust the refrigerator, or notify maintenance staff as stated in the facility policy, and on the monthly temperature monitoring sheets.


* http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm085213.htm
Insulin Storage and Potency
Insulin from various manufacturers is often made available to patients in an emergency and may be different from a patient's usual insulin. After a disaster, patients in the affected area may not have access to refrigeration. According to the product labels from all three U.S. insulin manufacturers, it is recommended that insulin be stored in a refrigerator at approximately 35 to 46 degrees F. Unopened and stored in this manner, these products maintain potency until the expiration date on the package. However, all of the available insulin products may be left unrefrigerated (between 59 and 86 degrees F) for up to 28 days and still maintain potency.
As a general rule, insulin loses its potency according to the temperature it is exposed to and length of that exposure. Under emergency conditions, you might still need to use insulin that has been stored above 86 degrees F. Such extreme temperatures may cause insulin to lose potency, which could result in loss of blood glucose control over time.
In any case, you should try to keep insulin as cool as possible. Try to keep insulin away from direct heat and out of direct sunlight, but if you are using ice, also avoid freezing the insulin.

** http://www.rxlist.com/tetanus_toxoid_absorbed-drug.htm
Storage
Store between 2? - 8?C (35? - 46?F). DO NOT FREEZE.
REFERENCES
1. Recommendations of the Immunization Practices Advisory Committee (ACIP). Diphtheria, Tetanus, and Pertussis: Recommendations for vaccine use and other preventive measures. MMWR 40: No. RR-10, 1991
Manufactured by: Aventis Pasteur Inc. Swiftwater PA 18370 USA Product information as of April 1999. FDA Rev date: n/a

*** http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5242a6.htm

Recommended Storage Temperatures
The majority of commonly recommended vaccines require storage temperatures of 35?F--46?F (2?C--8?C) and must not be exposed to freezing temperatures. Introduction of varicella vaccine in 1995 and of live attenuated influenza vaccine (LAIV) more recently increased the complexity of vaccine storage. Both varicella vaccine and LAIV must be stored in a continuously frozen state <5?F (-15?C) with no freeze-thaw cycles (Table 1). In recent years, instances of improper vaccine storage have been reported. An estimated 17%--37% of providers expose vaccines to improper storage temperatures, and refrigerator temperatures are more commonly kept too cold than too warm (2,3).
Freezing temperatures can irreversibly reduce the potency of vaccines required to be stored at 35?F--46?F (2?C--8?C). Certain freeze-sensitive vaccines contain an aluminum adjuvant that precipitates when exposed to freezing temperatures. This results in loss of the adjuvant effect and vaccine potency (4). Physical changes are not always apparent after exposure to freezing temperatures and visible signs of freezing are not necessary to result in a decrease in vaccine potency.

Based on staff interview, policy review, and record review, the CAH failed to ensure that the nutritional needs of 5 (#s 1, 2, 3, 4, and 30) out of 5 swing bed patients reviewed were met in accordance with recognized dietary practices and failed to ensure a qualified dietitian supervised the nutritional aspects of patient care. The findings include:

Patient # 1 was admitted to a swing bed on 7/29/11. She was receiving antibiotic therapy through a picc (peripherally inserted central catheter) line. The doctor had ordered a regular low sodium diet. Her weight was 149 lbs on admit and on 8/15/11, her weight was 139 lbs, down 10 lbs.

Patient #2 was admitted to a swing bed on 5/4/11 with diagnoses including COPD, CHF, and generalized debilitation. The physician ordered a NAS (no added salt) diet and daily weights. Per the activity assessment, the patient had no teeth. On admit, patient #2 weighed 187 lbs. On 5/13/11, he weighed 177 lbs. He was down 10 lbs.

Patient #3 was admitted to a facility swing bed on 6/29/11, after an acute care stay at the CAH. Her diagnoses included CVA, dysphagia, dehydration, and HTN. The patient had a swallowing study on 6/25/11 and on 6/28/11, the PA-C ordered a pureed diet with nectar thick liquids with supervision. The diet would be advanced per the speech therapy recommendation.

Patient #4 was admitted to a swing bed at the CAH on 5/11/11 with the diagnoses of pneumonia, and fractured ribs. The physician ordered her a generalized diet. Her admit weight was 233 lbs and was not weighed after the admit. She was discharged on 6/1/11.

Patient #30 was admitted to the CAH on 1/24/11. On 2/19/11, the patient went to one of the facility's swing beds. On 2/28/11, the patient was on comfort cares. Her diagnoses included pneumonia with effusion and hypoxia, CHF, asthma, delirium, depression and atrial fibrillation. Originally, the physician had ordered a regular diet. Supplemental protein drinks were added. The patient had continual skin issues, isolation for a period, comfort cares and then to acute care during the hospital stay.

Review of patient #s 1, 2, 3, 4, and 30 medical records, revealed the lack of a nutritional assessment by a qualified dietitian. There was no documentation located which verified the contracted RD nor the DM had reviewed any of the sampled swing bed patients' records or interviewed the patients.

Staff member M was interviewed on 8/15/11 at 3:40 p.m. She stated the facility had a care team which met weekly and reviewed the patients. She stated the RD nor the DM ever attended the meetings.

The CAH had an agreement with a consulting dietician to provide :professional services as needed to "meet the dietary needs of hospitalized patients." There was no documentation revealing;
- the RD was assisting patients, family, and/or caretakers dietary counseling;
-that the RD was performing nutritional assessments and evaluating patients acceptance to therapeutic or mechanically altered diets;
- working as part of a team with other CAH services to plan and implement patient care as necessary in meeting the nutritional needs of the patients; and
- the RD was monitoring and maintaining the patients' data necessary to recommend, prescribe, or modify the patients' diets to meet each individual, nutritional needs.

Based on document review and staff interview, the facility failed to ensure that patient care policies were reviewed annually by the group of professional personnel as required. Findings include:

During the review of the facility policy manuals on 8/16/11 beginning at approximately 10:30 a.m., the surveyor noted that there was no evidence available of an annual review of the policies for operation of the facility.

During an interview with staff member D on 8/17/11 at approximately 7:45 a.m., staff member D noted that the policy manuals were in process of being reviewed, but the reviews had not been completed every year.

Based on document review and staff interview, the facility failed to ensure that patient care policies were reviewed annually as a part of the annual program evaluation. Findings include:

During the review of the facility policy manuals on 8/16/11 beginning at approximately 10:30 a.m., the surveyor noted that there was no documentation available that review of the facility policies were a part of the facility annual program evaluation.

During an interview with staff member D on 8/17/11 at approximately 7:45 a.m., staff member D noted that the policy manuals were in process of being reviewed, but the reviews had not been completed every year

Based on record review and interviews with both facility staff and a provider of contracted dietary services, the facility failed to ensure integration of the food and dietetic service into the facility-wide quality assurance program. Finding include:

On 8/14/11, at 9:30 a.m., the dietary manager, from the facility providing the dietary services to the CAH, was interviewed. When asked, she stated that she did not attend the quarterly quality improvement meetings held by the facility, and did not formally participate in the facility's quality improvement/assurance program. No evidence was given that the dietary manager had a quality assurance program specific to the CAH. At 2:00 p.m. on 8/17/11, the facility administrator confirmed that dietary management participation in the facility quality improvement program had not been ongoing.

Record review of the facility Quality Improvement Committee minutes supported a lack of participation of the dietary manager / dietary department in regard to quality improvement in the CAH.

Based on staff interviews and record review, the facility failed to ensure staff received education on prevention of abuse and neglect. Findings include:

Three staff members were interviewed about abuse prevention. Staff A was interviewed on 8/15/11 at 2:30 p.m., staff B was interviewed on 8/16/11 at 10:10 a.m., and staff C was interviewed on 8/17/11 at 8:10 a.m. Three of three interviewed staff members could not name all the types of abuse and they all stated they had received no training on abuse and neglect.

The facility's policies were reviewed. The facility did not have a policy which addressed training staff on abuse recognition, reporting, and prevention.

Based on policy review and staff interview, the facility failed to ensure that all patients receiving care at the CAH were free from all forms of abuse and harassment. Findings include:


The Patient Bill of Rights, which the facility gave to each patient to read and review, verified the patient would be free from mental and physical abuse. Documentation of receiving the form was in every patient's chart which were reviewed by the surveyors.

The CAH's policies was reviewed. The facility did not have a policy which addressed patient abuse from staff, visitors or other patients while a patient at the hospital. The CAH did not have a policy for recognizing, reporting, prevention and investigating allegations of abuse and neglect by the staff.

Per an interview on 8/15/11 at 2:30 p.m., with staff A, staff were trained on what to look for on patients who had been abused from outside entities, but not by staff or patients within the CAH. Annual training was directed toward noticing patients, who had signs of abuse, coming into the CAH.

Staff B was interviewed on 8/16/11 at 10:10 a.m. She stated she had never had abuse training. She was unable to explain the types of abuse. She was unaware of an abuse policy the facility might have.

Staff C was a new hire. Staff C was interviewed on 8/17/11 at 8:10 a.m. She stated the facility had not oriented her on recognizing and addressing abuse issues.

The staff new hire files were reviewed. None of the 6 files reviewed had any documentation that revealed the new hires had any training on recognizing, reporting or preventing abuse. Four out of six files review had no evidence documenting the facility had investigated the new hires background for possible abuse or neglect.