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Based on observation, policy review, and staff interview, the Critical Access Hospital failed to safely store hazardous chemicals for 1 of 3 days of survey (January 10, 2018). Failure to safely store hazardous chemicals may result in cognitively impaired patients sustaining an injury.

Findings include:

Review of the policy titled "EC [Environment of Care] Plans - Hazardous Materials and Waste Management" occurred on 01/11/18. This policy reviewed/revised 01/27/17, stated, ". . . in place to achieve the lowest potential for adverse impact on the safety and health of patients, staff, and visitors to the organization. . . ."

Observation of the tub room and soiled utility room on 01/10/18 at 5:00 p.m. showed the following hazardous chemicals stored in unlocked areas:
* In the tub room a spray bottle of Quaternary (Quat) cleaning solution hanging on a shelf next to the tub. The bottle stated "Avoid eye and skin contact." During an interview, on 01/10/18 at 5:00 p.m., a nursing staff member (#2) indicated the tub room always remained unlocked and the Quat stored in an unlocked cabinet when not in use.
* In the soiled utility room a cabinet with a key placed in the lock:
- Big Gulp - an absorbent gel and deodorizer
- Ta Poff - liquid tape remover and clinical solvent. The bottle stated, "Danger Poison . . . harmful and fatal if swallowed. . . ."
-Yellow Z - Spill control. The bottle indicated to seek medical attention for contact with eyes, skin or if swallowed or inhaled.
- Quat spray bottle. The bottle stated, "Avoid eye and skin contact."

During an interview on 01/10/18 at 5:30 p.m., a nurse administrator (#1) confirmed staff should store the above listed chemicals in locked cabinets.

Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure appointment to the medical staff for 2 of 6 physicians' (#1 and #2) credentialing files requested. Failure to appoint physicians to the medical staff placed the CAH's patients at risk of receiving services from unqualified physicians.

Findings include:

Review of Sanford Hillsboro's medical staff bylaws occurred on 01/09/18 at 2:15 p.m. These bylaws, dated 01/29/13, stated,
". . . Article III - Membership
Section 1. Nature of Medical Staff Membership
Membership on the Medical Staff of the Hillsboro Medical Center is a privilege, which shall be extended only to professionally competent Practitioners who continuously meet the qualifications, standards, and requirements, set forth in these bylaws. . . .
Section 3. Conditions and Durations of Appointments
A. The Governing Body shall make initial appointments and reappointments to the Medical Staff. The Governing Body shall act on appointments, reappointments, or revocation of appointments after there has been a report from the Medical Staff as provided in these Bylaws.
B. [Name of network hospital] under contract with HMC [Hillsboro Medical Center] will perform the background investigation and application process. Upon approval from [name of network hospital], HMC will receive the advice and recommendation from [name of network hospital], review the documentation of background studies obtained, and present the information to the Medical Staff Committee. . . ."

Review of the "Seventh Ammended [sic] Corporate Bylaws of Hillsboro Medical Center" occurred on 01/09/18 at 3:25 p.m. These bylaws, dated 07/19/12, stated,
". . . Article VII. Medical Staff . . .
Section 2. Organization and Appointments. . . .
(C) All applications to the Medical Staff must be processed by the Medical Staff and approved by the Board of Trustees. . . ."

During an interview on 01/10/18 at 9:30 a.m., an administrative laboratory staff member (#6) stated Physician #1 was the CAH's laboratory director.

During an interview on 01/10/18 at 11:20 a.m., an administrative radiological staff member (#7) stated the CAH used the services of their network hospital's cardiology department for interpretation of electrocardiograms and Holter monitors for the CAH's patients.

Review of a list of the network hospital's cardiology staff occurred on 01/10/18. This listing, dated 01/10/18, included Physician #2.

Upon request on 01/10/18, the CAH failed to provide evidence the CAH's medical staff recommended and the governing body approved appointment of Physicians #1 and #2 to the CAH's medical staff.

During an interview on 01/10/18 at 3:50 p.m., an administrative staff member (#5) confirmed the CAH's medical staff had not recommended and the governing body had not approved appointment of Physicians #1 and #2.

Based on observation, policy and procedure review, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed professional standards for administration of medication in 1 of 1 therapy department. Failure to follow professional standards of practice regarding disinfecting medication vials, syringe use, and vial access devices placed patients receiving Iontophoresis treatments at risk of contracting an infection.

Findings include:

Review of the CAH policy titled "Multi-dose vials" occurred on 01/11/18. This policy, dated 10/03/17, stated, ". . . Cleanse the rubber stopper with alcohol before inserting a sterile device into the vial. . . ."

The APIC (Association of Professionals in Infection Control and Epidemiology) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health care (2016), stated, " . . . MEDICATION VIALS . . . * Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial. * Always use a new sterile syringe and new needle/cannula when entering any vial. Never enter a vial with a syringe or needle/cannula that has been previously used. . . . * Use multi-dose medication vials for one patient whenever possible. . . . * . . . always use a sterile syringe and needle/cannula each time the vials is accessed. . . ."

Review of the Centers for Disease Control and Prevention Frequently Asked Questions: Medication Preparation Questions, dated March 2011, stated ". . . 3. Is it acceptable to leave a needle or other device inserted in the septum of a medication vial for multiple mediation draws? No. A needle or other device should never be left inserted into a medication vial septum for multiple uses. This provides a direct route for microoganisms to enter the vial and contaminate the fluid. . . ."

Observation of the therapy department occurred on the morning of 01/11/18 with an administrative nurse (#1). Observation inside a locked cupboard showed a multi-dose vial of dexamethasone with a vial access device in place, which punctured the rubber stopper, and a syringe attached to the access device. A sticker, affixed to the vial, identified a discard date of 01/10/18. Further investigation showed when the nurse (#1) removed the syringe, the adapter left an open port in the vial.

During a telephone interview on 01/11/18 at approximately 10:15 a.m., an administrative therapy staff member (#8) stated the department had used the same vial access device on their multi-dose vials for about a year. She stated when the vial expired or was empty, therapy staff removed the vial access device from the present vial and punctured the new vial without cleansing the rubber stopper of the new vial or cleansing/changing the access device before reusing. She also stated they used the same syringe for more than one patient and multiple days.

Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to assess and document the reason for and/or the effectiveness of medications given to patients on an as needed (PRN) basis for 7 of 22 patient records (#1, #3, #8, #10, #12, #15, and #17) reviewed. Failure to evaluate the patient's need for and response to PRN pain/fever medications limited the nursing staffs' ability to assess whether the medication achieved the desired effect or if the patient experienced any side effects or adverse reactions from the medication.

Findings include:

Review of the CAH policy titled "Medication Administration & Documentation" occurred on 01/11/18. This policy, reviewed/revised 12/01/17, stated, ". . . 2. When "PRN" medications are administered, the reason for the medication shall be documented in the medical record a) The effectiveness of the medicine should be documented within sixty (60) minutes of being administered. . . ."

- Review of Patient #1's active inpatient medical record occurred on 01/09/18 and identified an admission date of 01/09/18 with a diagnosis of delirium and acute hyponatremia. Pain medications included Tylenol 650 milligrams (mg) every 4 hours. The record identified Patient #3 received Tylenol on 01/09/18 at 10:43 a.m. The record lacked a follow-up assessment of the medication's efficacy.


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- Review of Patient #3's active swing bed medical record occurred on January 9-10, 2018 and identified an admission date of 12/22/17 with a diagnosis of sepsis. Pain medications included tramadol 100 mg every 4 hours PRN. The record identified Patient #3 received tramadol on 01/04/18 at 11:51 a.m.; on 01/05/18 at 9:54 p.m.; on 01/06/18 at 9:28 p.m.; and on 01/07/18 at 8:35 p.m. Patient #3's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the PRN medication.

- Review of Patient #12's closed medical record occurred on January 9-10, 2018 and identified an admission date of 07/14/17 for a compression fracture. Pain medications included oxycodone 5 mg every 4 hours PRN. The record identified Patient #12 received oxycodone on 07/15/17 at 12:01 a.m. and at 12:54 p.m.; on 07/16/17 at 3:26 a.m.; on 07/17/17 at 3:04 a.m. and at 8:51 p.m.; and on 07/18/17 at 12:58 a.m. and at 5:16 a.m. Patient #12's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the PRN medication.

- Review of Patient #15's closed medical record occurred on January 9-10, 2018 and identified an admission date of 08/25/17 with a diagnosis of sepsis. Pain medications included Tylenol 325-650 mg every 4 hours PRN. The record identified Patient #15 received Tylenol on 08/26/17 at 1:57 a.m., 9:45 a.m., and at 11:09 p.m.; 08/27/17 at 9:27 p.m.; and on 08/28/17 at 5:44 a.m. Patient #15's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the PRN medication.

- Review of Patient #17's medical record occurred on January 9-10, 2018 and identified an admission date of 11/25/17 with a diagnosis of pneumonia. Pain medications included Tylenol 650 mg every 6 hours PRN, and Norco (hydrocodone and acetaminophen) 5/325 mg every 6 hours PRN. The record identified Patient #17 received Norco on 11/25/17 at 5:10 p.m. and Tylenol on 11/25/17 at 9:10 p.m. and on 11/26/17 at 8:51 p.m. Patient #17's record failed to include evidence nursing staff assessed and documented the effectiveness or the patient's response to the PRN medication.


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- Review of Patient #8's closed inpatient medical record occurred on 01/10/18 and identified an admission date on 12/18/17 for a diagnosis of pneumonia. Pain medication included Tylenol 325-650 milligrams (mg) every 4 hours PRN for pain/fever. The record identified Patient #8 received Tylenol on 12/19/17 at 11:09 a.m. and at 11:05 p.m. The record lacked documentation for the reason administered and a follow-up assessment for the medication's efficacy.

- Review of Patient #10's closed inpatient medical record occurred on 01/10/18 and identified a swing bed admission on 09/16/17 with a diagnosis of weakness following an inpatient stay for a urinary tract infection and idiopathic hypotension. Pain medication included Tylenol 500-1000 mg every 6 hours PRN for mild/moderate pain or headache. Patient #10 received Tylenol on 09/18/17 at 8:44 p.m. with no follow-up assessment for the medication's efficacy and on 09/19/17 at 8:40 p.m. with the reason for the medication documented as "0 pain." The record lacked documentation for the reason administered.

During an interview on the afternoon of 01/10/18, an administrative nursing staff member (#4) stated she expected nursing staff to conduct follow up pain assessments an hour after administering oral pain medications.

During an interview on 01/11/18 at 11:35 a.m., an administrative nursing staff member (#1) stated she expected nurses to document the reason for a PRN medication administration and complete a follow-up assessment of the medication's effect.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to annually evaluate 2 of 3 sampled contracted services (speech therapy and physical/occupational therapy) in 2017. Failure to evaluate contracted services limited the CAH's ability to ensure the provision of quality care to the CAH's patients.

Findings include:

Review of the CAH's "Quality Assessment and Performance Improvement Plan" occurred on 1/10/18. This plan, dated 03/02/17, stated, "Purpose . . . The purpose of the Quality Assessment and Performance Improvement (QAPI) Plan is: To be an ongoing facility-wide program to ensure provision of outstanding patient centered care and service that is effective, equitable, efficient, timely, cost-effective, and safe for patients . . .
Goals . . .
Evaluate all services, including contracted services, involved in the delivery of care through an annual evaluation of the QAPI plan. . . .
QAPI Committee . . .
Responsibilities . . .
Define, measure, analyze, and monitor QAPI indicators, indicator goals, data, and quality reports with each department and service including contracted services . . ."

Review of the CAH's list of services occurred on 1/10/18. This list, dated 10/2016, stated,
". . . Contracted/Arranged Services: . . .
PT/OT [Physical Therapy/Occupational Therapy] . . .
Speech Therapy . . ."

Upon request on 1/10/18, the CAH failed to provide evidence of an evaluation of contracted services for PT/OT and speech therapy in 2017.

During an interview on 1/10/18 at 10:45 a.m., an administrative nursing staff member (#1) confirmed the CAH did not have evidence of an evaluation of the contracted services of PT/OT and speech therapy in 2017.

Based on record review, policy and procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure documentation of notification of the organ procurement organization (OPO) for 1 of 2 patient records (Patient #20) reviewed who died in the CAH. Failure to notify the OPO prevented the opportunity to determine the medical suitability for organ donation.

Findings include:

Review of the policy titled "Tissue and Eye Donation Model (Cardiac Death)" occurred on 01/10/18. This policy, revised June 2017, stated, "Purpose: To provide guidelines to refer all patient deaths for potential tissue and/or eye donation assessment, and to define the donation process should the patient be a donation candidate. Policy: A. In compliance with the federal and state law, it is the policy . . . to refer all deaths, regardless of age . . . or medical history, to the regional procurement agencies. Timely referral of all deaths (within one hour) is mandated by law . . . B. While notifying the procurement agency of all deaths is required by law, it does not constitute commitment to donate on the part of the physician, nurse, hospital, patient or patient's family. . . . D. In all cases, the procurement agency Donation Coordinator in conjunction with transplant organizations will make the final determination of a patient's donation options. . . . RESPONSIBILITY: . . . 2. Nurse/Physician/Designee: Contact the Donation Coordinator (DC) after EVERY death and BEFORE mentioning donation [to] the family . . . Call within one hour after the patient death. You will be given a reference number to be documented in the patient's medical record as evidence of making the referral call. . . . 4. Nurse/Designee: If the patient DOES NOT meet medical or age criteria for tissue/eye donations: a) Document the contraindication(s) in patient's medical record. b) Tell the family, 'Usually the donation agency would talk with you about opportunities for tissue and eye donation, but because of . . . is not a candidate.' . . ."

Review of Patient #20's closed emergency department (ED) medical record occurred on 01/10/18. The CAH admitted the patient to the ED on 10/21/17, and the patient expired the same day. The electronic medical record identified a reference notification number to procurement agency but failed to identify the date/time of the notification; the name of the donation coordinator; and whether or not Patient #20 was a candidate for eye/tissue donation and if not, the reason.

During an interview on the afternoon of 01/10/18, an administrative nurse (#3) stated Patient #20's family refused organ donation, and the CAH failed to document their wishes.