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Tag No.: C0151
Based on medical record review and interview, it was determined that the Critical Access Hospital (CAH) failed to document whether the patient has executed advanced directives or documented that the CAH provided the patient the opportunity to establish advanced directives to 2 of 20 patients admitted to inpatient at the hospital. (Patient identifiers are #7 and #8.)
Findings include:
Review on 1/29/19 of Patient #7's and Patient #8's medical record revealed no advanced directives and no documentation that the opportunity to establish advanced directives was offered to the patients.
Interview on 1/29/19 at approximately 1:00 p.m. with Staff E (System Director of Quality Services) confirmed the above finding.
Tag No.: C0276
Based on observation and staff interview, the critical access hospital (CAH) failed to ensure expired medication was not available for patient use and that personnel failed to wear personal protective equipment (PPE) properly during medication administration.
Findings include:
1) Observation on 1/30/2019 at 12:15 p.m. of the medication storage refrigerator located in North Country Rheumatology revealed two boxes of Copaxone medication with an expiration date of 12/2018. Each box was labeled with "professional sample" and contained six individually wrapped syringes.
2) Interview on 1/30/2019 at 12:15 p.m. with Staff C (System Director of Quality Service) confirmed the above finding.
27714
Observation on 1/30/19 at approximately 11:00 a.m. in the Oncology/Infusion unit revealed Staff F (Registered Nurse) initiating chemotherapy infusion to a patient. Staff F's gown was not over their shoulders or tied in the back.
Interview and observation on 1/30/19 at approximately 11:00 a.m. with Staff G (Oncology/Infusion Manager) revealed that the gown should be worn over the shoulders and tied in the back. Interview further revealed that the gowns are used as a protective layer from drug contamination exposure to the staff. Staff G also revealed there is no policy for the use of PPE during chemotherapy infusion and that they follow professional standards.
Tag No.: C0278
Based on observation, interview, and record review, it was determined that the CAH failed to follow infection control standards for flexible endoscope cleaning in the outpatient setting, for monitoring the expiration date of multidose vials of medications, and multiuse of single use saline bags.
Findings include:
Association of periOperative Registered Nurses, Guidelines for Perioperative Practice (2016).
Flexible Endoscopes, Sterilization and Disinfection, p728- 730. Relates:
X.b. Records related to flexible endoscope processing should include: the date and time, identity of the endoscope, results of cleaning verification testing, identity of the person performing the processing, and identity of the patient. Records of flexible endoscope processing enable traceability in the event of a processing failure. Records of endoscopes and processing solution provide a source of evidence for review during investigation of clinical issues including infections.
XI. Personal with responsibility for processing flexible endoscopes should receive initial and ongoing education and complete competency verification activities related to processing flexible endoscopes.
XII. Policies and procedures for processing flexible endoscopes should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting in which they are used.
Observation on 1/30/19 at approximately 2:45 p.m. at the Otolaryngology practice decontamination and disinfection room, revealed 4 flexible endoscopes laying on the counter on the clean side of the room.
Interview on 1/30/19 at approximately 2:45 p.m. with Staff A (Certified Medical Assistant.) revealed that two of the endoscopes were new and there had been an hour inservice on 12/13/18 but they do not do competencies on scope cleaning. Staff A was unable to provide a procedure or manufacturer's instructions for scope cleaning at the time of interview.
Review on 1/31/19 of the manufacturer's instructions for high level disinfectant used to clean the above scopes revealed the following instructions: 8 minute high level disinfection at 20 degrees celcius, 21 day reuse when hydrogen peroxide level is at least 1.5% hydrogen peroxide.
Review on 1/31/19 of the "Verify Chemical Monitoring Strip for Reset Solutions Log Sheet" for 12/26/18 through 1/30/19 revealed no temperature recorded, no indicator test result recorded, no identity of the endoscope, and no identity of the patient.
Observation on 1/29/19 at approximately 10:00 a.m. in the computerized tomography (CT) scan room revealed a spiked bag of saline hanging on an intravenous (IV) pole
Interview on 1/29/19 with Staff I (Clinical Supervisor of Diagnostic Imaging) revealed that saline is drawn off the saline bag to add to the device that mixes with the contrast and then administered by IV to patients for CT scan procedures. Interview revealed that it is the practice for radiology to draw saline off of one bag for multiple patients.
35333
1) Observation on 1/30/2019 at 1:30 p.m. of treatment room #2 located in General Surgery revealed one opened 50 milliliter (mL) bottle of lidocaine. The opened bottle was not labeled with an open date and/or a revised expiration date.
2) Observation on 1/30/2019 at 1:55 p.m. of the laboratory located within Urology Associates revealed one opened 20 mL bottle of lidocaine. The opened bottle was not labeled with an open date and/or a revised expiration date.
3) Interview on 1/30/2019 at 1:30 p.m. with Staff D (Office Manager) revealed multi-use bottles of lidocaine are stable for 30 days upon opening. Staff D confirmed at 1:30 p.m. and 1:55 p.m. the opened multi-use bottles of lidocaine observed in General Surgery and Urology Associates were not labeled with a revised expiration date.
Tag No.: C0283
Based on record review and interview, it was determine that the CAH failed to monitor the results of exposure test badges for 1 of 1 radiology technologist located at an offsite location.
Findings include:
Review on 1/31/19 of Radiation Dosimetry Reports for the offsite location revealed the most recent report of dosimetry badge results was dated 10/16/17. Staff H (Radiology Technologist) was the only radiology technologist on the report for that location.
Interview on 1/31/19 at approximately 9:00 a.m. with Staff I (Clinical Supervisor of Diagnostic Imaging) confirmed the above finding and revealed that Staff H did wear a badge that was read by the dosimetry company as scheduled since 10/16/17, but Staff H's result report from the dosimetry company had not been retrieved from online and reviewed since October of 2017.