HospitalInspections.org

Based on observation and review of facility's infection control program, the facility failed to ensure that a system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.


Findings include:


During observation of blood administration and patient care on 02/06/13 at 12:50 p.m., the Registered Nurse (RN) entered into the patient's room without washing his hands prior to administering care to patient. During this care the RN picked up the nasal canula (used for oxygen administration) from the floor and put it into the patient's nose without cleaning it.


Review of the facility's Infection Control Plan revealed, "Prevention is emphasized in patient care guidelines such as hand washing, urinary catheter care, care of intravascular catheters, respiratory therapy equipment ...".

Review of the facility's nursing policy revealed no evidence of a policy and procedure for hand washing.

Based on observation and policy review, the facility failed to follow their own policy and ensure that the care provided for Patient #2 by the Registered Nurse (RN) was in accordance with the patient's needs and the specialized qualifications and competence of the staff available.


Findings include:

Review of the facility's "Blood and Blood Products: Administration of " policy revealed, "Policy - ...(2) Prior to administration, two appropriately licensed personnel should verify the blood/blood component against order/name and medical record number on the patient ID band and lab slip at the bedside."


During observation of administration of blood to Patient #2 on 02/06/13 at 12:50 p.m., a RN and a Licensed Practical Nurse (LPN) checked the blood with the lab slip at the nursing station. The RN took the blood to the patient's room and checked the blood with the patient's arm band. The RN failed to completely check the blood as stated in their policy.

Based on review of the Critical Access Hospital's (CAH's) policies and procedures and review of medical records, the facility failed to ensure that the general consents for medical treatment signed on admisstion were properly executed.


Findings include:


13 discharged medical records were selected from a list of discharges from July 1, 2012 through December 31, 2012, and reviewed along with three (3) inpatient medical records and the last two (2) discharges from the hospital, for a total of 18 medical records reviewed.


Eight (8) of the 18 medical records reviewed had a General Consent for Medical Treatment which had either not been timed or witnessed, or the person signing the consent for the patient had not been identified as to their relationship to the patient.

Based on review of the CAH's policies and procedures, review of the minutes of the Performance Improvement, Medical Staff and Governing Body meetings and staff interview, the facility failed to carry out an evaluation of its total program at least once a year.


Findings include:


There were no policies and procedures to review for an annual evaluation specifying how the CAH is to conduct the evaluation, who is responsible for conducting the evaluation, and what information is to be included in the evaluation.


Interview with the Director of Nursing on 02/07/13 at 10:30 a.m., revealed the CAH had not conducted an annual evaluation of its total program during the past year.

Based on review of the CAH's policies and procedures, minutes of the Performance Improvement, Medical Staff, and Governing Body meetings, the facility failed to review the utilization of CAH services, including the number of patients served and the volume of services as part of an annual evaluation.


Findings include:


Review of the facility's policies and procedures, and review of the minutes of the Performance Improvement, Medical Staff, and Governing Body meetings revealed that the facility had not performed a yearly annual evaluation that included all the CAH services, the number of patients served, and the volume of services provided.

Based on review of CAH's policies and procedures, minutes of the Performance Improvement, Medical Staff , and Governing Body meetings, the facility failed to ensure that a representative sample of both active and closed clinical records were reviewed as part of the annual evaluation.


Findings include:


Review of facility's policies and procedures, and review of the minutes of the Performance Improvement, Medical Staff , and Governing Body meetings, the facility had not performed a clinical record review of both active and closed records as part of an annual evaluation.

Based on review of the CAH's policies and procedures, minutes of the Performance Improvement, Medical Staff , and Governing Body meetings, the facility failed to ensure that the CAH's health care policies were reviewed as part of an annual evaluation.


Findings include:


Review of the facility's policies and procedures, and review of the minutes of the Performance Improvement, Medical Staff , and Governing Body meetings revealed there was no documented evidence that the health care policies had been reviewed as part of an annual evaluation of the Critical Access Hospital.

Based on review of the CAH's policies and procedures, and review of minutes of the Performance Improvement Medical Staff , and Governing Body meetings, the facility failed to ensure that an annual evaluation of the CAH's total program had determined that the utilization of services was appropriate, the established policies were follow and if any changes were needed.



Findings include:



Review of the CAH's policies and procedures, and review of minutes of the Performance Improvement Medical Staff , and Governing Body meetings the facility had not determined whether the utilization of services was appropriate, the established policies were followed and any changes were needed as a result of a program evaluation.