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Based on document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure nursing staff obtained a physician's order for the release of a deceased patient's body for 2 of 3 closed medical records (patient #3 and #4). The CAH administrative staff identified an average of 10 deaths per year.

Failure to obtain a physician's order for the release of a deceased patient's body could potentially interfere with the CAH's medicolegal obligations, result in the release of body to an unauthorized individual, and interfere with appropriate after-life care.

Findings included:

1. Review of the Rules and Regulations for the Medical Staff, approved 3/12/2001, revealed in part, "Release of body. The body may not be released until an entry has been made and signed in the deceased's medical record by a physician member of the Medical Staff or a physician member of the Medical Staff has ordered release of the body."

2. Review of Patient #3's medical record revealed:

a. Nursing staff documented on 1/8/10 at 9:10 AM, "Body released to funeral home... exited to funeral home per cart."
b. Patient #3's medical record lacked documented evidence of a physician's order for release of the body to the funeral home.

3. Review of Patient #4's medical record revealed:

a. Nursing staff documented on 5/13/10 at 10:17 PM, "Patient unresponsive, negative respiration, negative heart beat... funeral home notified."
b. Patient #4's medical record lacked documented evidence of a physician's order for release of the body to the funeral home.

4. During an interview on 8/18/10 at 9:50 AM, the Chief Nursing Officer (CNO) verified Patient #3 and #4's medical records lacked evidence of a physicians's order for the release of the body. The CNO reported the Medical Staff Rules and Regulations contained the requirement for nursing to obtain a physician order before releasing the body to a funeral home. The CNO also stated the CAH administrative staff needed to, "...follow this more carefully."

Based on observation, staff interview, and document review, the Critical Access Hospital (CAH) administrative staff failed to ensure Rehabilitation Services staff appropriately discarded single use medication vials after each use for 1 of 1 opened single use medication vial. The CAH identified an average of approximately 15 iontophoresis procedures per month.

Failure to discard the unused portion of the Dexamethasone in a vial could potentially result in growth of microorganisms in the vial between patients. If microorganisms grew in the vial, patients could potentially receive a healthcare acquired infection.

Findings include:

1. Observations during a tour on 8/16/10 at 2:30 PM of the Rehabilitation Therapy revealed 1 opened, single use, 1 mL vial of Dexamethasone.

2. During an interview at the time of the tour, the Director of Rehabilitation Services stated the iontophoresis equipment required 1.5 mL of Dexamethasone. The Rehabilitation Services staff removed 1 mL from a vial of Dexamethasone, and 0.5 mL from a second vial of Dexamethasone. The Rehabilitation Services staff then stored the opened vial of Dexamethasone with the unopened vials of Dexamethasone. The Rehabilitation Services staff used the partial vial of Dexamethasone the next time a patient required ionophoresis.

3. During an interview on 8/17/10 at 3:30 PM, the Pharmacist stated they did not know the Rehabilitation Services staff failed to discard the unused portion of the Dexamethasone in the vials after withdrawing part of the medication in the vial. The vials of Dexamethasone used in Rehabilitation Services lacked a preservative, and staff should have discarded the unused Dexamethasone, to prevent bacteria from potentially growing in the unused Dexamethasone.

4. Review of the policy titled, "iontophoresis protocol", effective 7/1/05, revealed the policy lacked instructions to discard the partially filled Dexamethasone vial after withdrawing the required medication for one patient.

5. During an interview on 8/17/10 at 4:00 PM, the Director of Rehabilitation Services acknowledged the policy lacked instructions to discard the unused Dexamethasone after removing the medication from the vial, and stated the Director of Rehabilitation Services revised the policy to require staff to discard the unused portion of the Dexamethasone in the vial.

Based on observation, document review, and staff interview, the Critical Access Hospital (CAH) Surgical Services administrative staff failed to ensure surgical staff tested the disinfecting solution in 2 of 2 Automated Endoscope Reprocessors before each use. Surgical Services administrative staff identified an average of approximately 40 endoscopy procedures per month.

Failure to test the disinfecting solutions prior to each use could potentially result in the disinfecting solution lacking sufficient strength of the active ingredient to kill all microorganisms, resulting in the spread of infectious microorganisms between patients.

Findings included:

1. Observations during a tour of the Dirty Side of the Cleaning Area on 8/16/10 at approximately 4:00 PM revealed 2 CER-1 Medivator Automated Endoscope Reprocessors.

2. Review of the "...Rapicide Testing Log" for both Automated Endoscope Reprocessors revealed surgical services staff tested the Rapicide once per day.

3. During an interview at the time of the tour, the Patient Care Manager of Surgery stated surgical staff tested the Rapicide once, at the start of the day, and did not test the Rapicide before each time staff reprocessed an endoscope. The Patient Care Manager of Surgery stated surgical staff reprocessed up to 5 endoscopes per day, and only tested the Rapicide for adequate levels of the active ingredient before staff reprocessed the first endoscope of the day.

4. Review of the manufacturer's directions for the Medivator CER-1 revealed, in part, "...Medivators recommends ...testing before every reprocessing cycle, to ensure an adequate level of active ingredient."

5. During an interview on 8/17/10 at approximately 9:30 AM, the Patient Care Manager of Surgery acknowledged the manufacturer recommended testing the Rapicide before each reprocessing cycle, and stated surgical staff would test the Rapicide before each reprocessing cycle.

Based on medical record review, Critical Access Hospital (CAH) Medical Staff Rules and Regulations review, and staff interview, the CAH administrative staff failed to ensure emergency medical providers dated and/or timed all medical record entries in 3 of 8 closed emergency room medical records (Patient #1, #2 and #3) reviewed. The CAH administrative staff identified an average of 1,625 emergency room visits per month.

Failure to date and time medical record entries potentially could cause harm to patients by a delay in treatment, actions, or assessments provided.

Findings include:

1. Review of closed emergency room medical records, on 8/16/10 at 10:40 AM, showed the emergency medical providers failed to date and time any medical record entries in 3 of 8 closed emergency room medical records (Patients #1, #2, and #3).

2. Review of the Ringgold County Hospital Amended and Restated Rules and Regulations of the Medical Staff, approved 3/7/01, showed the attending practitioner must sign and date all standing orders. The Rules and Regulations did not require the physicians to date or time handwritten orders.

3. During an interview on 8/18/10 at 9:10 AM, the Patient Care Manager stated the emergency room physicians did not date and time all emergency room physician records.

4. During an interview on 8/18/10 at 9:20 AM, the Chief Nursing Officer reported physicians did not date and time all emergency room medical record entries. The contract physicians mainly did not date and time the entries. The Medical Staff Rules and Regulations state to date the orders only, but the federal regulation require date, time and signature for all practitioner entries. The physicians should have dated, timed, and signed all entries.

Based on review of credential files and staff interview, the Critical Access Hospital (CAH) administrative staff failed to perform peer review for 1 of 1 Certified Registered Nurse Anesthetist (CRNA). The CAH administrative staff identified an average of 14 surgical procedures involving anesthesia per month.


Failure to perform peer review could potentially expose patients to inappropriate diagnosis and treatment.

Findings included:

1. Review of credential files on 8/17/10 revealed Practitioner A's (CRNA) credential file lacked documented evidence of external peer review.

2. During an interview on 8/17/10 at 1:20 PM, the Health Information Management (HIM) Director verified Practitioner A's credential file lacked documented evidence of external peer review. The HIM Director stated, "I should be doing this. I'm not following our hospital's ... requirements for [external peer review] of [the] medical staff. We do not have a written policy, but everyone who provides care to [our] patients should [receive external peer review]." The HIM Director stated the CRNA "slipped through the cracks", and should have
received external peer review on the care provided to patients at the CAH.