HospitalInspections.org

Based on observation, document review, and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure the staff removed outdated medication and supplies from the Cardiac Rehabilitation (Rehab) emergency crash cart. Failure to remove outdated medications and supplies from the CAH's supplies, available for patient use, could potentially result in the staff using expired medications and/or supplies for patient use after the manufacturer's expiration date, potentially resulting in the staff using medication on a patient after the date which the manufacturer guaranteed the sterility and efficacy of the medication and supplies. The CAH administrative staff identified a census of 5 inpatients on the day of the survey.

Findings included:

1. Review of the policy, "Stock Supplies and Outdates," approved on 12/2022, revealed in part, "... All drug storage areas in the nursing unites are inspected monthly of optimum supply levels and drug outdates ... Areas of inspection include ...crash cart in Cardiac Rehab ..."

2. Observations during a tour on 5/2/23 at approximately 1:45 PM of the Cardiac Rehab Department and inspection of the crash cart with the Cardiac Rehab Nurse (RN) A the Director of Nursing (DON), revealed the following:

One of one 500 milliliter (ml) 0.9% Sodium Chloride bag expired on 9/2022.

One of one AirLife nasal cannula oxygen tubing expired on 7/13/2021.

One of one BD 5 ml syringe expired on 3/31/2023.

One of one 20 gauge (GA) x 1.16 IN BD Insyte Autoguard expired on 2/28/2023.

Two of two 20 ml BD syringe expired on 2/28/2023.

One of one Glucagon Emergency Kit for Low Blood Sugar Injection 1 milligram (mg) per vial expired on 3/2023.

Two of two Atropine Sulfate Injection 1 mg/10 ml expired on 1/2023.

Four of four Chewable Aspirin Tablets expired on 4/5/2023.

Three of three 0.9% Sodium Chloride Injection 10 ml expired on 2/1/2023.

One of one Heparin Sodium Injection 5,000 USP units per ml expired on 3/2023.

One of one 20 ml Sterile Water for injection expired on 2/2023.

Two of two 0.4mg/ml Naloxone HCI Injection expired on 3/2023.

3. During an interview on 5/2/23 at approximately1:45 AM with the Director of Nursing and the Cardiac Rehab RN A verified the Cardiac Rehab emergency crash cart has not been checked for outdated supplies or medication. The Cardiac Rehab RN A acknowledged that she has not been checking the Cardiac Rehab emergency crash cart's supplies or medication per the CAH's policy.

Based on observation, document review, and staff interviews, the Critical Access Hospital ' s (CAH) administrative staff failed to ensure the CAH staff kept patient medical information secure from unauthorized access in the CAH's Laboratory Department. Failure to keep patient medical information confidential could potentially result in theft of a patient's information and potentially result in identity theft or unauthorized release of a patient's private medical information. The CAH's administrative staff identified an average monthly census of 442 laboratory patients from July 2021 to June 2022.

Findings include:

1. Review of the CAH policy "Information Security," approved 12/2022, revealed in part, " ...Information Security concerns the protection of confidential information regarding patients ...in both electronic and hardcopy format...Maintaining information Security is every employee's responsibility."

2. Observation on 5/3/23 at approximately 9:00 AM, during a tour of the Laboratory Department with the Laboratory Manager and the Director of Nursing (DON), revealed a 3-ring binder above the serology station stored patient information (patient name, date of birth, type of test and test results) was unsecured. The binder housed 344 patient test results from 1/2022 to present. The following are the type of test found in the 3-ring binder:

a. Human chorionic gonadotropin (hCG is a hormone that can be detected in your urine and blood when you're pregnant).

b. Rheumatoid factor (RF is a blood test that measures the amount of RF antibody in the blood).

c. Mononucleosis (Mono test is a blood test that look for antibodies that indicate mononucleosis).

3. During an interview on 5/3/23 at approximately 9:00 AM, with Laboratory Manager, it was revealed she utilized a 3-ring binder to record test results. This binder contained the patient's name and date of birth. The binder was left on the shelf in the laboratory. Staff is present until approximately 6:00 PM on 5:00 PM on Tuesdays through Fridays, returning at 7:00 AM. The Laboratory Manager verified that during that time, unauthorized personnel have access to the lab. The Laboratory Manager and the DON acknowledged this was against the CAH's policies to have protected health information unsecured for easily accessible by unauthorized persons.

Based on observation, document review, and staff interviews, the Critical Access Hospital's administrative staff failed to ensure a current roster listing each practitioner's surgical privileges was available in the surgical suite and area/location where the scheduling of surgical procedures is done. Failure to maintain a current list of procedures in the surgical suite available for surgical staff to access and verify a provider's privileges prior to scheduling and performance of a procedure may result in a provider performing a procedure for which they are not privileged to perform due to lack of training, skills, quality, and or sufficient knowledge and may result in a poor patient outcome. The CAH administrative staff identified an average monthly census of 19 surgical procedures performed in past fiscal year, 7/1/2021 - 6/30/2022.

Findings include:

1. Review of the policy, "Physician/Surgeon Privileges," approved 4/2023, revealed in part, " ...Privileges can be accessed and viewed through the Physician Privileges icon on the ...intranet site...If a physician attempts to exceed his/her privileges, the OR Nurse Supervisor shall notify the Administrator and the Chief of Medical Staff."

2. During a tour on 5/2/23 at approximately 10:00 AM of the surgical suite with the OR Supervisor and Director of Nursing (DON) revealed a Practitioner's privilege list was seen electronically on each computer desktop by surgery staff. But the information had not been updated with the credentialing information for 2 or 3 Certified Registered Nurse Anesthetists (CRNA D and CRNA E);1 of 1 Physician Assistant (PA F) that accompanied the Orthopaedic Surgeon, and Orthopaedic Surgeon G were not list.

3. During an interview on 5/2/23 at approximately 10:00 AM, at the time of the tour of the Surgical Department, the OR Supervisor and DON reported a list of current surgical practitioner's privileges is maintained by Human Resources and the Director of Quality and Risk. The file had not been updated with the surgical practitioner's privileges for all of surgical staff to see. The OR Supervisor and DON acknowledged these files should be maintained at all times and surgery staff should review these privileges prior to the scheduling or performance of a procedure.

Based on review of policies/procedures, medical record review and staff interview, the Critical Access Hospital (CAH) failed to ensure examination of the patient by a physician immediately before surgery to evaluate the risks prior to the performance of the procedure in 3 of 5 closed medical records (Patients #1, Patient #2,and Patient #3) reviewed. Failure of a physician to examine a patient immediately before surgery could result in surgery performed on an unstable patient. The hospital's administrative staff identified the surgical services staff performed an average of 2 surgeries and 17 procedures in the past fiscal year, 7/1/2021 - 6/30/2022.

Findings include:

1. Review of the policy, "Surgical Plan of Care and Documentation on Intra-Operative Short Form," approved 04/2023, revealed, "To provide safe, consistent, high-quality care to all patients by assessing and documenting individualized care for those receiving surgical services..."

1. Review of closed surgical records revealed the following:

a. On 4/6/23 at approximately 8:20 AM, Surgeon B performed a laparoscopic cholecystectomy (surgical procedure to remove the gallbladder) on Patient #1. Patient #1's medical record lacked documentation that Surgeon B examined Patient #1 immediately before surgery to evaluate the risk of the procedure to be performed.

b. On 3/22/23 at approximately 11:55 AM, Surgeon C performed a tonsillectomy and adenoidectomy (a procedure to remove tonsils is known as tonsillectomy, and removal of the adenoids is called an adenoidectomy) on Patient #2. Patient #2's medical record lacked documentation that Surgeon C examined Patient #2 immediately before surgery to evaluate the risk of the procedure to be performed.

c. On 3/22/23 at 8 approximately 8:21 AM, Surgeon C performed a right removal of tube with paper patch placement and left removal of tube (a procedure to remove ear tubes) on Patient #3. Patient #3's medical record lacked documentation that Surgeon C examined Patient #3 immediately before surgery to evaluate the risk of the procedure to be performed.

2. Review of the "Medical Staff Rules and Regulations", undated, revealed the document lacked a requirement for a physician to examine a patient immediately before surgery to evaluate the risks of the procedure to be performed.

3. During an interview on 5/3/23 at approximately 8:34 AM, with the OR Supervisor acknowledged the closed medical records for Patient #1, Patient #2 and Patient #3 lacked documentation of an examination by a physician immediately before surgery to evaluate the risks prior to the performance of the procedure. The OR Supervisor reported the CAH lacked a policy and procedure that required an examination by the surgeon immediately before surgery to evaluate the risks of the procedure to be performed.