HospitalInspections.org

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Sample Validation Survey conducted on February 24, 2014, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Sample Validation Survey conducted on February 24, 2014, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567.

Based on document/record review and staff interview it was determined in 1 of 2 (Pt # 22) patients requiring restraints, the physician failed to ensure restraint policies were followed potentially affecting all patients requiring restraints. Findings include:

1. The CAH policy titled "Restraint Policy -2", (dated approved 1/16/2014) was reviewed on 2/27/14. The policy indicated under " Procedure II A physician's order is required for each and every restraint episode. The order must include: A description of the behavior requiring the patient to be restraint (reason); type of restraints: beginning and ending time, not to exceed 24 hours".

2. The medical record of Pt #22 was reviewed on 2/27/14 at 2 PM . Pt #22 was admitted on 9/11/13 with a diagnoses of gastrointestinal bleed, anemia and urinary tract infection. Physician orders recorded on the "All Orders Report - Detail" dated 9/11/13 thru 9/19/13 indicate 3 physician orders for restraints. The first order was "Restraints removed every 2 hours" (9/13/13 at 1929) . Subsequent orders were "Wrist restraints (9/14/13 at 1751) " and "Wrist restraints" (9/18/13 at 1007). There was no order to initiate wrist restraints. There was no documentation on the 3 physician orders indicating the reason (need) for restraints and no 24 hour renewal order for restraint per CAH policy. The "Clinical Documentation Report" on 9/13/13 at 1930 under the "MS Restraint Flowsheet" indicated wrist restraints were applied to the patient and wrist restraints remained in use on Pt# 22 until discharged on 9/19/13.

3. During a staff interview conducted with the Clinical Practice & Informatics nurse, on 2/27/14 at 2:30 PM, the nurse reviewed the medical record of Pt.#22 and stated "the physician did not follow the restraint policy". The nurse confirmed the physician did not write an initial, subsequent orders within the 24 hour timeframe, or document the need for the restraints.

Based on document review, observation and staff interview it was determined the CAH failed to perform an inventory of C-II controlled substances per policy, potentially affecting all patients receiving care in the CAH. Findings include:

1. On 2/24/14 at 1:00 PM, the CAH policy "Accountability and Distribution of Scheduled II Controlled Substances", revised 10/9/12, was reviewed. Under "RESPONSIBILITY, There will be an inventory of the actual balance of C-II controlled substances accessed in the patient care areas at the change of each shift."

2. On 2/24/14 at 1:30 PM, a tour of the surgical department was conducted with the OR Manager. During the tour, a perpetual count of the narcotics was conducted with the Manager. There was no documentation to indicate an inventory of C-II controlled substances was being conducted by the CRNA or the nurses at the change of each shift.

3. On 2/24/14 at 1:30 PM, an interview with the OR Manager was conducted. During the interview, the OR Manager stated the "C-II medications were not inventoried at the end of the shift". During an interview with the Pharmacist on 2/24/14 at 1:20 PM, the Pharmacist reported, there was no documentation to indicate an inventory of C-II controlled substances was being conducted. The Pharmacist also confirmed an inventory was not being done by the Pharmacist or nursing staff at the change of each shift.

A. Based on document review, observation and staff interview, it was determined the CAH failed to ensure food items were identified and dated, potentially affecting the safety of patients receiving dietary services. Findings include:

1. The CAH undated, untitled policy was reviewed on 2/24/14. The policy indicated "Check refrigerator for outdates. Open containers must be closed and marked with the date container opened."

2. During a tour of the MS unit with the RN Manager on 2/25/14 at 9:00 AM, it was observed in the freezer, 4 styrofoam cups of an undated, unidentified substance.

3. During an interview with the RN Nurse Manager on 2/25/14 at 9:00 AM, the RN Manager stated "the containers should have been labeled with a date".

B. Based on document review, observation and staff interview, it was determined the CAH failed to ensure food items were discarded on the expiration date, potentially affecting the safety of patients receiving dietary services. Findings include:

1. The CAH undated, untitled policy was reviewed on 2/25/14. The policy indicated "Check refrigerator for outdates...Discard any item such as sandwiches, apple sauce, pudding after three days."

2. During a tour of the MS unit with the RN Manager on 2/25/14 at 9:00 AM, it was observed in the refrigerator (2) containers of pudding with a date of 2/9/14, past the the 3 day timeframe.

3. During an interview with the RN Nurse Manager on 2/25/14 at 9:00 AM, the RN Manager stated "the containers should have been discarded after the three (3) day timeframe".