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Based on interview and document review the Critical Access Hospital (CAH) failed to ensure the Governing Body Bylaws reflected current admission privileges and practices by mid-level practitioners for 1 of 20 inpatients (P8) reviewed who required admission to the CAH.

The current Governing Body Bylaws dated 4/18/11, indicated mid-level practitioners (nurse practitioners and physician assistants) did not have privileges to admit patients to the CAH.

On 8/15/12, at approximately 10:30 a.m., nurse practitioner (NP)-A stated he did not notify a physician of P8's CAH admission. NP-A stated that the physician is notified of admissions by email but there is no phone call to discuss the patient admission with the physician. The physician would note the patient was admitted through the electronic notification at the CAH the next day. The NP stated this was the normal practice if a patient required CAH admission during the night.

P8's Emergency Room record dated 8/14/12, lacked documentation of physician notification of admission to the CAH.

On 8/16/12, at 11:10 a.m. the director of nursing (DON) stated it was the CAH normal practice to allow the mid-level practitioners to admit patients without physician notification. The DON stated the Bylaws were incorrect and needed to be amended.

Based on observation, interview and document review, the hospital failed to ensure medication was disposed of in a secure manner for 3 of 3 patient rooms in the emergency department. Findings include:

Medications were observed to be accessible in unsecured areas of the hospital where patients, visitors and persons without legal access to drugs and biologicals were present.

During a tour of the emergency department at 11:45 a.m. on 8/15/12, containers were observed in emergency rooms one, two and three. The containers measured approximately 18 inches in height by 12 inches wide and 12 inches deep. An opening in the top of the container measured approximately 6 inches in diameter and many bottles and partially empty medication vials were observed in the waste containers. The containers were located in an unlocked cupboard below the sink in the rooms in the emergency room.

When interviewed at 11:45 a.m. on 8/15/12, registered nurse (RN-A) stated the hospital's policy was for all medications used, but no longer needed for patients, to be placed in this container for disposal. RN-A stated all discontinued medications were to be placed in this container except for controlled substances. RN-A stated the emergency department was not locked when patients were not present. She also stated that patients waiting in the emergency rooms were left unattended by nursing staff and the unsecured medications would be accessible to them.

During a tour of the hospital on 8/15/12, at approximately 10:00 a.m. the Maintenance Foreman was interviewed. He stated maintenance staff assisted nursing staff to close the top of the pharmaceutical waste containers. Maintenance staff then transported these containers to the trash room to await collection by the pharmaceutical waste disposal company.

The pharmacist was advised of the unsecured medications on 8/15/12, at 1:50 p.m. Medication vials, which had been discarded in the pharmacological waste containers, included Dexamethasone (corticosteroid), Thiamine (vitamin B1), Lidocaine (local anesthetic agent), and Hydromorphone (schedule II narcotic). At 2:00 p.m., the pharmacist was interviewed and stated vials containing schedule II narcotics are not to be placed in these containers. The pharmacist also stated these containers should be in a secured area and not accessible to patients or families waiting in the emergency department.

The hospital policy titled "Security of Medication Storage Areas", effective 8/1/2011, indicated all medication storage areas should be either locked or otherwise secured in such a way to prevent access to medications by unauthorized person, diversion of medications to unintended persons.... The hospital policy titled "Pharmaceutical Waste", effective 8/1/2011, indicated all vials, tablets, IV bags with or without tubing containing labeled medications, black labeled medication spill clean up, ampoules, oral medication without physical labels, and inhalers are to be placed in a hazardous container. This policy did not address the need for a secure location for the pharmaceutical waste containers.

Based on observation and document review, the facility failed to ensure proper infection control techniques were implemented with dressing changes for 1 of 1 patients (P7) observed. Findings included:

Infection control techniques were not implemented during P7's wound dressing change.

On 8/15/12, at 9:19 am, licensed practical nurse (LPN)-A was observed to enter P7's room with the supplies required for dressing changes. LPN-A did not wash her hands upon entering the room or donning gloves. LPN-A removed the dressing to P7's thigh wound. The wound was a clean skin graft with a significant amount of serous (bloody) drainage. LPN-A cleansed the wound several times with a 4 x 4 dressing and saline with the same gloves on. At 9:24 a.m. LPN-A did remove her dirty gloves and donned clean gloves without washing her hands. LPN-A was observed to place the new Mepitel dressing (a porous dressing), then remove her gloves. LPN-A then donned new gloves without washing her hands and removed the soiled dressing to P7's left foot. The old dressing had purulent (containing pus) drainage. LPN-A cleansed the wound with saline and changed gloves without washing her hands. At 9:34 a.m. LPN-A placed the Mepitel dressing to P7's foot. LPN-A was observed assist P7 with placing her socks and shoes with her dirty gloves on. LPN-A then wiped up an area of blood that had dripped on the floor with the same gloves. LPN-A was observed to touch her stethoscope and uniform with her same gloved hands. LPN-A then removed the gloves but did not wash hands and wheeled P7 in her wheelchair out in to her room from the bathroom, touching R7's clothes and various items in her room without washing her hands.

At 10:25 a.m. LPN-A stated she did not cleanse her hands when entering the room, in between changing her gloves or dressings or when she completed the dressing change. LPN-A stated she should have cleansed her hands at those times.

At 2:40 p.m. the director of nursing (DON) stated LPN-A should have cleansed her hands before, during and after the dressing change.

Based on observation, interview and document review, the critical access hospital (CAH) failed to properly sanitize equipment in the dietary department. This had the potential to affect 2 of 2 patients in the CAH.

Findings include:

During an environmental tour on 8/13/12, at 3:10 p.m. the three compartment sink water was observed to have a pH of 100 parts per million (ppm). The Multi-Quat Sanitizer specification document dated 4/26/11, indicated the ppm for sanitizing utensils should be between 200-400 ppm active quat.

Cook (C-B) indicated they check the ppm of the water in the 3 compartment sink three times a day. C-B further indicated they will add more Multi-Quat Sanitizer if the test strip color does not show the water to be at 100 ppm. She indicated they keep the water in the sink between 100 to 150 ppm. C-B stated she was not sure what the policy was for sanitizing dishes using the Multi-Quat Sanitizer.

Review of the log for the 3 compartment sink from January 2012, though the morning of August, 14, 2012, indicated the ppm of the water was consistently between 100 and 150 ppm during this time.

Interview with the dietary manager on 8/14/12, at 9:00 a.m. confirmed there was no policy that specified the required ppm. After calling the ECOLAB representative she confirmed the three compartment sink water ppm was should be 200 ppm to 400 ppm.

Based upon interview and document review, the Community Access Hospital (CAH) did not ensure a current roster listing specific surgical privileges was available in the surgical suite and the area where surgery scheduling occurred for 2 of 2 surgeons (MD-A and MD-B).

Findings include:

During a tour of the surgical suite on 8/14/12, at approximately 10:30 a.m., the Director of Nursing verified that a current roster listing each practitioner's specific surgical privileges was not available in the surgical suite and in the area where surgery scheduling occurred. The roster of surgical privileges for MD-A and MD-B, which was available in the surgical suite and in the scheduling area, was dated 2008.

A Registered Nurse (RN-B), who works in the surgical suite, was interviewed on 8/14/12 at 11:15 a.m. and was not aware of the location of the current roster of surgical privileges for MD-A and MD-B.

Based upon interview and document review, the pre-anesthesia and post -anesthesia evaluations were absent or incomplete for 6 of 6 patients who had received anesthesia for a surgical or diagnostic procedure (P-1, P-2, P-3, P-4, P-5 and P-6).

Findings include:

P-3 underwent a left breast biopsy as an outpatient under monitored anesthesia care (MAC) on 10/28/11. The anesthesia record indicated P3 received Propafol (an anesthetic agent) and Versed (a pre-operative sedative). Although the Certified Registered Nurse Anesthetist (CRNA-E) documented the patient's diagnoses which included chronic kidney failure, hypertension, increased blood cholesterol and a history of a cerebral vascular accident (CVA), there was no other pre-anesthesia evaluation documented. There was no post-anesthesia evaluation documented in the medical record.

Patient P-1 underwent an excision of a mass on the left shoulder under MAC as an outpatient on 7/13/12. The anesthesia record indicated the patent had received Propafol, Versed and Fentanyl (an adjunct to anesthesia). Although CRNA-C documented a pre-anesthesia evaluation, it did not include a notation of the patient's anesthetic risk, which included the American Society of Anesthesiologist risk classification (ASA). The post-anesthesia evaluation did not include an assessment of the patient's cardiopulmonary status or level of consciousness.

Patient P-2 underwent a laparoscopic choecystectomy under general anesthesia on 6/15/12. CRNA-D did not document the patient's level of consciousness as part of the post-anesthesia evaluation.

Patient P-4 underwent an inguinal hernia repair under MAC on 1/27/12. The anesthesia record indicated the patient had received Propafol and Versed. Although CRNA-A documented a pre-anesthesia evaluation, it did not include a notation of the patient's anesthesia risk, which included the ASA. The post-anesthesia evaluation did not include an assessment of the patient's level of consciousness.

Patient P-5 underwent a laparoscopic appendectomy under general anesthesia as an outpatient on 4/6/12. Although CRNA-B documented a pre-anesthesia evaluation, it did not include a notation of the patient's anesthetic risk, which included the ASA. The post-anesthesia evaluation did not include an assessment of the patient's level of consciousness.

Patient P-6 underwent a colonoscopy under MAC as an outpatient on 3/16/12. The anesthesia record indicated the patient had received Propafol and Versed. There was no pre-anesthesia evaluation documented on the anesthesia record by CRNA-E. The post-anesthesia evaluation did not include an assessment of the patient's level of consciousness.

The Director of Nursing provided a policy titled "Minimum Pre/Post-Anesthetic Requirements" for St. Mary's/Duluth Clinic Health System (SMDC) and Affiliates (last revised 2/2007). The policy indicated an assessment of the patient's anesthesia risk would be completed using the ASA classification. Although the policy indicated patients who received general anesthesia or MAC should belong to ASA class I, class II or class III, it did not identify other items a pre-anesthesia or post-anesthesia evaluation should include. The Director of Nursing (DON) contacted the Manager of Anesthesia Services at St Mary's Hospital on 8/16/12, at approximately 9:30 a.m. St. Mary's Hospital provided anesthesia services at the Critical Access Hospital. The Manager of Anesthesia Services stated a pre-anesthesia evaluation and post-anesthesia evaluation should be completed for any patient who received a general anesthesia or monitored anesthesia care (MAC).