HospitalInspections.org

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Re-Certification Survey conducted on March 8 - 9, 2016, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags.

A. Based on observation and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure all dietary practices were followed per their policy and food service standards, potentially affecting all patients/staff receiving dietary services.

Findings include:

1. On 2/29/16 at 2:45 PM, a tour of the dietary department was conducted with the Food Service Supervisor (E #2). During the tour, the following expired food items were found in the cooler:

Approximately 35 - individually packaged Italian dressings, expired March 2015.

2. On 2/29/16 at 3:00 PM, an interview with E #2 was conducted. E #2 verbalized "The dressing packages had expired and should have been removed from the cooler and disposed of."

B. Based on document review and interview, it was determined in 1 of 20 (Pt #14) clinical record reviewed for blood product administration, the CAH failed to ensure required pertinent information was completed and documented per policy. This has the potential to affect all patients requiring blood product administration at the CAH.

Findings include:

1. On 3/3/16 at 10:00 AM the medical record of Pt #14 was reviewed. Pt #14 was admitted on 3/1/16 with diagnoses of Chronic Anemia and Urinary Tract Infection. Documentation in the laboratory section indicate Pt #14's hemoglobin was 5.6 gm/dL (grams per deciliter) when tested while in the emergency department. Documentation indicated Pt #14 received a total of 5 units of packed red blood cells beginning on 3/2/16 at 1840. Review of the Blood Component Transfusion Forms indicated 2 of the 5 transfusion forms were not completed to indicate any reaction during the transfusion, the total amount infused and the person completing/ending the transfusion.

2. On 3/3/16 at 10:30 AM, the policy titled "Blood/Blood Product Transfusion and Suspected Adverse Reaction" (revision date 10/01/15) was reviewed. The policy indicates on page 5, "VI. Documentation, 1.0 Transfusion, 1.1 Document on the Blood Component Transfusion Form all pertinent information: D. Amount of blood/blood product transfused, F. Signature of person completing the transfusion, 1.3 A. Whether or not transfusion was completed and reason if not completed."

3. On 3/3/16 at 10:40 AM, an interview with the Risk Manager (E#4) was conducted. E#4 also reviewed the transfusion forms and agreed the information required was not completed.

Based on document review and staff interview, it was determined in 1 of 20 (Pt #15) patients, the CAH failed to ensure the medical records were completed per their policy. This has the potential to affect all patinets receiving care at the CAH.
Findings include:

1. On 3/3/16 at 10:30 AM, the medical record of Pt #15 was reviewed with the Quality Review Nurse (E #1). Pt #15 was admitted on 12/29/15 and transferred to an acute care hospital on 12/29/15. There was no documentation to indicate a Discharge Summary was dictated.

2. On 3/3/16 at 10:35 AM, the CAH policy "Medical Record Completion" revised 11/1/15 was reviewed. Under "Discharge Summary" it reads "Dictated within 2 days following inpatient discharge."

3. On 3/3/16 at 10:40 AM, an interview with E #1 was conducted. E #1 verbalized "The medical record does not contain a Discharge Summary and should have."