HospitalInspections.org

Based on observation and staff interview the Critical Access Hospital (CAH) failed to implement a maintenance program to assure patient care equipment is maintained in a safe operating condition.

Findings included:

- Observation in patient room 106B on 6/2/10 at 1:35pm revealed a metal bedframe with approximately 12 inches by 12 inches of chipped paint and rust. Interview with staff D confirmed the presence of the rust and the lack of a cleanable surface under the mattress. Administrative staff A, on 6/3/10 at 9:30am confirmed rusted surface is non-cleanable and stated the bed should be removed from the patient care area.


21996


- Observation of patient rooms on 6/2/10 at 1:50pm revealed the following:
1. Room 102-an armchair with approximately two inch tears in the vinyl of the arm rests exposing the foam padding and approximately a two inch tear in the seam of the seat rendering the surfaces uncleanable.
2. Room 104-an armchair with approximately one to three inch tears in the vinyl of the arm rests exposing the foam padding, rendering the surfaces uncleanable.
3. Room 105-vinyl covering on the door of the room gouged and chipped with rough edges, the bottom rails of the bed with gouges and dents across the top of the rails rendering the surfaces uncleanable.
4. Room 110-a bed with a metal A frame at the head and foot of the bed used to support a trapeze bar (a triangle piece of equipment the patient can hang onto to lift themselves in bed) with multiple chips in the paint all over the metal frame exposing the bare metal, rendering the surfaces uncleanable.

On 6/2/10 at 2:00pm staff J acknowledged the tears in the vinyl chairs, the gouges in the door, the gouges and dents on the bed rails and the chipped paint on the metal A frame as uncleanable surfaces.

Based on observation, document review and staff interview the Critical Access Hospital, (CAH) failed to ensure that outdated and mislabeled drugs stored in the narcotic cabinet in the Pharmacy the "Orthopedic" and "Endoscopy" cabinets in the outpatient area were not available for patient use.

Findings include:

- Observation of the narcotic cabinet in the pharmacy on 6/3/10 at 2:45pm revealed 39 pre-filled syringes of Morphine Sulfate injection, 15mg (milligrams) per ml (milliliter) with an expiration date of November 2009.

Review on 6/3/10 of the CAH's Policy and Procedure for "Monthly Outdates/Returns" dated 7/30/08 states , "1. ...Beginning with the injectable medications, check the date of each medication package and pull the item from the shelf if the expiration date is at the end of the current month or the first day of the next month."

On 6/3/10 at 3:05pm Staff F acknowledged the pharmacy nurse is responsible to remove outdated drugs monthly per the CAH's Pharmacy policy. Staff F confirmed they failed to follow the policy and procedure for outdated drugs.


21996

- Observation of the outpatient treatment area on 6/2/10 at 1:00pm revealed two cabinets, one labeled "orthopedic" and the other labeled "endoscopy". The cabinets contained the following:
1. One vial of Depo-Medrol (injectable steroid) 80milligrams (mg) per cubic centimeter (cc) with an expiration date of 12/08, and lacked a date when opened.
2. One 30cc bottle of Lidocaine 1% lacked a date when opened.
3. One 16 ounce bottle of Isopropyl Alcohol 70% with an expiration date of 1/10.
4. One vial of Bupivacaine (injectable anesthetic) 50 cc, lacked a date when opened.
5. One 20cc bottle of Lidocaine 1%, lacked a date when opened.
6. One 5cc bottle of Celestone Suspension (injectable steroid), lacked a date when opened.
7. One bottle of Kenalog (injectable steroid) 40mg per 5ccs, lacked a date when opened.

On 6/2/10 at 1:00pm staff I acknowledged the CAH failed to monitor medications for outdates and date the vials of medications when opened.

Based on document review and staff interview the Critical Access Hospital failed to develop and implement a policy and/or procedure that directs staff to report adverse drug reactions to the physician and a process to report serious adverse drug reactions to the Food and Drug Administration (FDA).

Findings included:

- The CAH failed to provide evidence of an adverse drug reaction policy and/or procedure for review.

On 6/3/10 at 3:30pm staff B acknowledged the CAH lacked a policy
and /or procedure for adverse drug reactions. Staff B confirmed they lacked knowledge of the requirement for a policy and/or procedure for adverse drug reactions.

On 6/3/10 at 3:30pm staff F acknowledged the CAH lacked a policy and/or procedure for adverse drug reactions. Staff F confirmed they lacked knowledge of the requirement for a policy and/or procedure for adverse drug reactions.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to identify infection control issues and implement action to prevent the potential spread of infection.

Findings included:

- Document review of the CDC (Centers for Disease Control and Prevention) Guidelines for Hand Hygiene in Healthcare Settings-2002 requires healthcare workers to wash their hands after removing gloves.

- Review of the CAH policy, "Aseptic Handwashing Technique", directs staff when to perform hand hygiene, failed to provide instructions to the staff to perform hand hygiene following the removal of protective gloves.

- Observation of staff D, on 6/2/10 at 12:45pm, cleaning a discharged patient's room revealed Staff D spraying disinfectant on the room door, supply storage areas, patient use areas including the bed and over bed table. Staff D then sprayed the bathroom and shower surfaces. Staff D applied gloves and wiped the room door, sink, under the sink and closet drawers. Staff D removed the protective gloves and applied another pair of gloves without hand hygiene. Staff D then wiped the chair, under the chair cushion and dusted the high shelf. At 12:58pm, staff D removed the protective gloves and applied another pair of gloves without performing hand hygiene. Staff D wiped the footboard of the bed, removed the protective gloves and put on another pair of gloves without hand hygiene. Staff D spot cleaned the walls, wiped off the intervenous fluids pump and wiped the chair. Staff D then obtained another wiping cloth and re-sprayed the mattress with disinfectant. Staff D removed the protective gloves and applied another pair of gloves without hand hygiene. Staff D removed the trash from the room, removed the protective gloves and applied another pair of gloves without hand hygiene. Staff D wet mopped the floor, removed the protective gloves and left the room without performing hand hygiene. Staff D failed to perform hand hygiene for at least 6 protective glove removals.

- Observation of staff E, on 6/2/10 at 12:45pm, cleaning in the same room at the same time as staff D, revealed staff E applying protective gloves. Staff E cleaned the telephone, call light, over bed table, the bed frame under the foot of the bed, the headboard, side rails and top of the mattress. Staff E removed the protective gloves and applied another pair of gloves without hand hygiene. Staff E obtained another cleaning cloth and wiped the sink, shower walls, shower chair and cleaned the toilet. Staff E removed the protective gloves and applied another pair of gloves without performing hand hygiene. Staff E mopped the bathroom floor and removed the trash. Staff E removed the protective gloves and applied another pair of gloves without performing hand hygiene. Staff E obtained an intravenous (IV) fluid infusion pump cleaning kit from the housekeeping cart. Staff E used a two- inch by two- inch alcohol pad to clean the IV pole and exterior of the pump. Staff E obtained an unlabeled specimen container of clear fluid to finish cleaning the pump. Staff E stated the clear fluid was alcohol and confirmed the container lacked a label. Staff E removed the protective gloves and applied another pair of gloves without hand hygiene. Staff E replaced the trash can liners and finished mopping the floor, removed the protective gloves, performed hand hygiene with hand sanitizer from a pump container on the housekeeping cart and left the room. Staff E failed to perform hand hygiene for at least 4 protective glove removals.

Interview with staff H on 6/3/10 at 4:25pm confirmed the hospital failed to develop and implement a policy that directed staff when to perform hand hygiene, how to perform hand hygiene and failed to include the use of hand sanitizer as hand hygiene .


21996


- Observation on 6/3/10 at 9:30am revealed staff K entered a patient's room, washed their hands and applied gloves, removed the dressing covering the surgical wound on the right hip, removed gloves, applied sterile gloves to clean the surgical wound and apply a new sterile dressing, removed gloves and applied non-sterile gloves to tape the dressing in place. Staff K failed to perform hand hygiene after two glove removals.

On 6/3/10 at 9:45am staff K acknowledged they failed to perform hand hygiene between removing the gloves and putting on new ones.


21997


- Observation of the terminal cleaning of the Endoscopy Procedure Room on 6/3/10 at 12:05pm revealed staff L sprayed "Hepacide Quat II" on the counter-top, a table that held equipment for the procedure and the "endocart" (a cart used to place the dirty endoscope on) at 12:27pm. Saff L then took a dry cloth and wiped the Hepacide off the top and sides of the "endocart", the table and the counter-top at 12:30pm. The surfaces remained wet for three minutes.

On 6/3/10 review of the manufacture's label for the Hepacide Quat II states, "Apply Hepacide Quat II with a cloth, mop, sponge, or coarse sprayer. Treated surfaces must remain wet for 10 minutes. Wipe off with a damp cloth or rinse with water."

On 6/3/10 at 12:40pm Staff L acknowledge they were not aware of the required 10-minute wet contact time to disinfect the surfaces.

On 6/3/10 at 3:15pm Staff M acknowledged the CAH failed to have current policies for the cleaning of the procedure room and policies to follow the manufactures recommendations when using the chemical disinfectants.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to assure providers accurately timed, dated, and authenticated verbal, telephone, and written orders for 15 of 33 records reviewed requiring physician signature as directed in the medical staff rules and regulations, (record #'s 11, 12, 13, 15, 16, 17, 18, 20, 21, 22, 23, 27, 28, 29, and 30).

Findings included:

- Rules and Regulations of the Medical Staff, section "Medical Records", #5 states, "All clinical entries in a patient's medical record will be dated, signed, or initialed by the attending physician within 24 hours".

- Patient # 16's medical record revealed the following: two verbal orders written on 5/31/10, signed by the provider with no date or time when signed and one order on 5/31/10 and 6/1/10 signed and dated by the provider lacked a time when signed.

- Patient # 17's medical record revealed the following: two verbal orders written on 4/24/10, signed by the provider with no date or time when signed, two verbal orders on 4/25/10, signed and dated by the provider lacked a time when signed, two verbal orders on 4/26/10, signed and dated by the provider lacked a time when signed, four verbal orders on 4/27/10, signed by the provider with no date or time when signed, two orders on 4/29/10, signed and dated by the provider lacked a time when signed, and two orders on 4/30/10, signed and dated by the provider lacked a time when signed.

- Patient # 18's medical record revealed the following: admission orders on 12/16/09, signed and dated by the provider lacked a time when signed, three verbal orders on 12/16/10, signed and dated by the provider lacked a time when signed, five verbal orders on12/17/09, signed and dated by the provider lacked a time when signed, three verbal orders on 12/18/10, signed and dated by the provider lacked a time, two verbal orders on 12/20/10, signed and dated by the provider lacked a time, three verbal orders on 12/21/10, signed by the provider with no date or time when signed, four verbal orders on 12/22/10, signed by the provider with no date or time when signed, one verbal order on 12/24/10, signed and dated by the provider lacked a time when signed, one order written by the provider on 12/24/10 signed and dated, lacked a time when signed, and one verbal order on 12/24/10, signed and dated by the provider lacked a time when signed.

This deficient practice also affected patient #'s 11, 12, 13, 15, 20, 21, 22, 23, 27, 28, 29, and 30.

On 6/3/10 at 1:30pm Administrative Staff G acknowledged providers consistently fail to date and time orders on the medical record.

Based on observation and staff interview the Critical Access Hospital (CAH) failed to provide safeguards against loss or unauthorized use of medical records stored in the warehouse for 15 shelves of radiology films stored on two five foot high and 13 eight foot high shelves, and 280 boxes of patient medical records stored on 10 pallets with 28 boxes on each pallet.

Findings include:

- On 6/3/10 at 10:00am observation in the warehouse storage building revealed medical records stored in a 10-foot high plywood wall enclosure on the north side of the building. The enclosed area was open between the 10-foot wall and the building's ceiling. Observation revealed an opened east garage door into the warehouse.

Review on 6/3/10 of the policy titled "Scope of Service Health Information Management" states under, "...Procedure;... The scope of services also encompasses efforts made to provide:...Demonstrated balance of proper levels of security versus ease of access;..."

On 6/3/10 at 10:30am Staff G acknowledged the medical record storage area lacked security due to the absence of the ceiling and an open garage door that allowed the possibility of unauthorized assess in the storage area.

On 6/4/10 at 11:00am Staff G confirmed the records lacked safeguards from the possibility of loss or theft.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to include the patient's right, to refuse to perform work and/or services for the CAH, in the patient rights information provided to all swing bed patients upon admission.

Findings included:

- Review of the Ellsworth County Medical Center "Swing Bed Patient's Rights", revealed the CAH failed to included the right to refuse to perform work and/or services for the CAH in the patient rights information provided to all swing bed patients upon admission.

On 6/2/10 at 8:50am staff C acknowledged the patient rights information given to all swing bed patients upon admission lacked the patient's right to refuse to perform work and/or services for the CAH.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to include the patient's right, to send and receive mail that is unopened, in the patient rights information provided to all swing bed patients upon admission.

Findings included:

- Review of the Ellsworth County Medical Center "Swing Bed Patient's Rights", revealed the CAH failed to include the right to send and receive mail that is unopened in the patient rights information provided to all swing bed patients upon admission.

On 6/21/10 at 8:50am staff C acknowledged the patient rights information given to all swing bed patients upon admission lacked the patient's right to send and receive mail that is unopened.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to include the patient's right, to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, in the patient rights information provided to all swing bed patients upon admission.

Findings included:

- Review of the Ellsworth County Medical Center, "Swing Bed Patients's Rights", revealed the CAH failed to include the patient's right to be free from any physical or chemical restraints imposed for purpose of discipline or convenience in the patient rights information provided to all swing bed patients upon admission.

On 6/21/10 at 8:50am staff C acknowledged the patient rights information given to all swing bed patients upon admission lacked the patient's right to be free from any physical or chemical restraints imposed for purposed of discipline or convenience.

Based on document review and staff interview the Critical Access Hospital (CAH) failed to perform an activity assessment to determine the patient's activity interests and provide appropriate activities and interventions for 4 of 5 swing bed records reviewed, (#'s 11, 12, 14 and 15).

Findings included:

- Patient #11's medical record revealed an admit date of 5/28/10 with diagnoses of dehydration, hyperkalemia and mental status changes. The medical record lacked an activity assessment and documentation of activities provided and/or if the patient participated in any activities.

- Patient #12's medical record revealed an admit date of 5/26/10 with diagnoses of dehydration and pneumonia. The medical record lacked an activity assessment and documentation of activities provided and/or if the patient participated in any activities.

- Patient #14's closed medical record revealed an admit date of 12/14/09 with diagnoses of repair of a fractured hip and anemia. The medical record lacked an activity assessment and documentation of activities provided and/or if the patient participated in any activities.

- Patient #15's closed medical record revealed an admit date of 4/15/10 with a diagnosis of a cerebral vascular accident (CVA or stroke). The medical record lacked an activity assessment and documentation of activities provided and/or if the patient participated in any activities.

On 6/3/10 at 11:00am staff C acknowledged the medical records lacked documentation of an activity assessment and activities provided and/or activities the patient participated in.