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Based on bylaws review, record review, and staff interview, the Critical Access Hospital's (CAH's) governing board failed to ensure granting of privileges followed the bylaws for 1 of 1 physician's assistant's file reviewed (Provider #1). Failure to follow the bylaws when granting privileges placed the CAH's patients at risk of receiving services from unqualified providers.

Findings include:

Review of the governing board's "Wishek Hospital-Clinic Association Bylaws" occurred on 05/30/23 at 02:10 p.m. These bylaws, dated 05/01/08, stated,
". . . Article IX. Duties of Board of Directors . . .
Section 8. Medical Staff Members. The appointment to . . . membership on the Medical Staff and approval . . . of clinical privileges in accord with the Bylaws, rules and regulations of the Medical Staff of the Association after first having received the recommendation by the Medical Staff . . ."

Review of the "Medical Staff Bylaws Wishek Hospital-Clinic Association " occurred on 05/30/23 at 1:35 p.m. These bylaws, effective 12/20/16, stated,
". . . Article III Membership . . .
Section 3. Conditions and Duration of Appointment . . .
3. Appointment to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted by the Board of Directors in accordance with these bylaws. . . ."

Review of providers' 2021-2023 credentialing files occurred on 05/31/23 and indicated the following:
- Provider #1 (a physician's assistant): the appointment approved by the governing body on 02/15/22 lacked evidence of delineation and approval of privileges.

Upon request on 05/31/23, the CAH failed to provide evidence medical staff recommended and the governing body approved delineated privileges for Provider #1's appointment on 02/15/22.

During interview on 06/01/23 at 8:20 a.m., an administrative staff member (#5) confirmed the CAH had not approved delineated privileges for Provider #1's appointment on 02/15/22 and the CAH had Provider #1 under contract to provide services for their patients.

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff developed nursing care plans to address the needs of the patients for 9 of 20 records reviewed (Patients #1, #2, #3, #4, #7, #8, #11, #12, and #17). Failure to address the needs of the patients on nursing care plans limited the CAH's ability to communicate treatment approaches, assist the patient to attain/maintain their highest physical, mental, and psychosocial well-being, and ensure continuity of care.

Findings include:

Review of policy titled, "Care Plans and the Nursing Process" occurred on 06/01/23. This policy, revised July 2021, stated, "Policy: The nursing process, including assessment, planning, intervention, and evaluation, will be documented for each hospitalized patient from admission through discharge. . . . The Nursing Care Plan will be completed for patients admitted to observation, inpatient, or swingbed. . . . The plan will include nursing measures that will restore, maintain, or promote the patient's well being. These measures should appropriately include: Physiological, Psychosocial, Environmental, Patient/family education, Patient discharge plan. . . . Nursing care plans will be revised as needs of the patient change."

Patient record review occurred on all days of survey and indicated the following:
- Patients #4, #7, #8, #11, #12, and #17 had no care plans noted in the medical record.
- Patient #1 admitted with diagnosis of diverticulitis, left lower quadrant pain and right atrial thrombus with use of oral coumadin. The care plan reflected problem and intervention for pain management. The care plan failed to reflect problems or interventions for the patient's use of anticoagulant or current illness.
- Patient #2 admitted with diagnosis of chronic obstructive pulmonary disease exacerbation, and pneumonia. The care plan reflected problem and intervention for fall risk and self care deficit. The care plan failed to reflect problems or interventions for the patient's current illness.
- Patient #3 admitted with diagnosis of pneumonia, inflammation of the right hand, and gram positive cocci in the blood. The care plan reflected problem and intervention for fall risk. The care plan failed to reflect problems or interventions related to the patient's current illness.

During interview the afternoon of 05/31/23, an administrative nurse (#2) confirmed the current care plans for Patients #1, #2, and #3 failed to address problems and interventions related to the patients' current illness and symptoms.

During interview on 05/31/23 at 5:30 p.m., an administrative nurse (#2) confirmed if the electronic medical record had no documentation under care plans, the nursing staff failed to enter a care plan for the patient.



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MULTI-DOSE VIALS
1. Based on professional reference review and observation, the critical access hospital (CAH) failed to ensure proper storage of a multi-dose medication vial in 1 of 1 treatment room (located in the clinic). Failure to properly store a multi-dose medication vial limited the CAH's ability to prevent contamination of the vial which could cause patient infections.

Findings include:

The Centers for Disease Control and Prevention "Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injections," updated 02/09/11, stated, ". . . 2. Can multi-dose vials be used for more than one patient? How? Multi-dose vials should be dedicated to a single patient when possible. If multi-dose vials must be used for more than one patient, they should only be kept and accessed in a dedicated medication preparation area (e.g., [for example] nurses station), away from immediate patient treatment areas. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters an immediate patient treatment area, it should be dedicated for single-patient use only. 3. . . . Examples of immediate patient treatment areas include . . . procedure rooms . . . and patient rooms . . ."

Observation of the treatment room located in the clinic occurred on 05/30/23 at 3:10 p.m. and identified one open vial of Lidocaine Hydrochoride 2% dated 05/30/23 in the locked treatment room cupboard.


DISINFECTANT SOLUTION
2. Based on observation, review of manufacturer's instructions, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed manufacturer's instructions for the use of a chemical for cleaning and disinfecting equipment and supplies for 1 of 1 equipment processing room (central processing). Failure to follow manufacturer's instructions for cleaning and disinfection of equipment and supplies limited the CAH's ability to ensure proper sterilization.

Findings include:

Observation of the central processing room occurred on 05/31/23 at 2:00 p.m. with a central processing certified nursing assistant (CNA) (#1) and an administrative nurse (#2). The CNA (#1) demonstrated the process for cleaning instruments and supplies prior to sterilization which included preparation of a sink of water with enzymatic detergent solution (Endozime AW) for manual cleaning prior to sterilization. The CNA (#1) stated she used three squirts of the Endozime AW detergent to an unmeasured amount of water in the sink. The CNA (#1) filled the sink to the level routinely used to clean and soak instruments and measured the volume as approximately three and one half gallons. The CNA (#1) then measured one squirt of the Endozime AW detergent that equaled three ounces. The CNA (#1) used a total of nine ounces of detergent to three and one half gallons of water.

The Endozime AW detergent manufacturer's instructions, reviewed on 05/31/23 at 2:25 p.m., stated, "use 1/2 ounce of solution per one gallon of water."

During interview on 05/31/23 during the observation of the central supply room, CNA #1 confirmed she did not measure the water or detergent prior to mixing the solution and cleaning the instruments. CNA #1 also confirmed she used the Endozime AW detergent in the Ultrasonic machine and did not measure the water or detergent.

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to ensure storage of patient equipment in a clean environment for 1 of 1 dirty utility room (located on the nursing unit) observed. Failure to follow appropriate infection control practices for patient equipment may result in transmission of organisms and pathogens from equipment to patients.

Observation of the dirty utility room on the nursing unit on 05/30/23 at 4:30 p.m. identified the room had a garbage container with a clear liner, a garbage container with a red liner (biohazard waste), a utility cart with dirty linen, a washing machine, cleaning supplies, and mop bucket. Observations of the dirty utility room for 2 of 3 days of survey identified the following:
- 05/30/23 at 4:30 p.m. showed two patient vital signs monitoring machines.
- 05/31/23 at 4:50 p.m. showed four patient vital sings monitoring machines.

During interview on 05/31/23 at 4:55 p.m., a registered nurse (#3) and a certified nursing assistant (#4) confirmed staff cleaned the vital signs monitoring machines when taken from a patient's room and before storing in the dirty utility room, but do not clean the machines when removing from the dirty utility room before entering a patient's room.

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the Quality Assurance and Performance Improvement (QAPI) program evaluated all patient care services affecting patient health and safety for 4 of 4 quarters reviewed (1st, 2nd, 3rd, and 4th Quarters 2022). Failure to ensure all departments participate in QAPI monitoring limited the CAH's ability to ensure the provision of quality care to the CAH's patients.

Findings include:

Review of the policy titled "Quality Assessment and Performance Improvement Plan" occurred on 05/31/23. This policy, revised 03/2022, stated,
"Policy: . . . The Quality Assessment and Performance Improvement Committee delegates the functional responsibility for quality improvement activities to the Manager of each department. The Department Manager is responsible for effective quality assessment mechanisms which are designed to monitor and evaluate services, identify, and resolve high priority care problems or make improvements in patient care. . . .
Procedure: All services and departments within South Central Health shall participate in the Quality Assessment and Performance Improvement Program. . . .
Monitoring: . . . Department Managers from each department are responsible to identify indicators and will present the indicators they are monitoring according [sic] quarterly. . . ."

Reviewed on 06/01/23, the CAH's 1st, 2nd, 3rd, and 4th quarter reports from 2022 failed to include reporting from the following departments: central sterilizing, housekeeping, and maintenance.

During interview on 06/01/23 at 08:45 a.m., an administrative staff member (#6) confirmed central sterilizing, housekeeping, and maintenance had not conducted QAPI monitoring in 2022.