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Based on review of information provided to patients on admission, record review, and staff interview, the Critical Access Hospital (CAH) failed to provide the patient written notice of its policies regarding advance directives at the time of admission and failed to document issuance of the notice in the patient's medical record for 3 of 3 active inpatient and swingbed patient (Patient #1, #2, and #3) records reviewed and for 6 of 6 closed inpatient and swingbed patient (Patient #14, #15, #16, #17, #18, and #19) records reviewed. Failure to provide this information to patients limited the patients' ability to make informed decisions regarding medical treatment.

Findings include:

Review of information provided to patients at the time of admission occurred on 05/04/15. The information lacked the CAH's advance directive policy or written notice concerning the policy.

Review of Patient #1, #2, #3, #14, #15, #16, #17, #18, and #19's medical records occurred on all days of survey. The records failed to include evidence the CAH issued its advance directive policy or written notice concerning the policy.

During an interview on 05/06/15 at 3:25 p.m., an administrative staff member (#2) confirmed the CAH failed to provide written notice of its advance directive policies to the patient, therefore, failed to document issuance of this notice.

Based on observation, review of professional standards, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed proper maintenance/sterilization processes of medical equipment in 1 of 1 central sterilization and reprocessing (CSR) area used to sterilize endoscopes. Failure to ensure staff maintained equipment critical to patient health and safety in safe operating condition, such as an endoscope, could result in serious injury and/or infection if the equipment failed to function properly and/or contained contaminates.

Findings include:

Review of the Center for Disease Control's "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008," page 11, states "Rinsing endoscopes and flushing channels with sterile water, filtered water, or tap water will prevent adverse effects associated with disinfectant retained in the endoscope . . . Items can be rinsed and flushed using sterile water after high-level disinfection to prevent contamination with organisms in tap water . . . a tapwater [sic] or filtered water . . . rinse should be followed by an alcohol rinse and forced air drying. Forced-air drying markedly reduces bacterial contamination of stored endoscopes, most likely by removing the wet environment favorable for bacterial growth. . . ."

During observation of the CSR on 05/05/15 at 1:30 p.m., a supervisory staff member (#1) stated she did not use an alcohol rinse followed by forced air drying after flushing the endoscopes with tap water after sterilization.

Based on policy and procedure manual review and staff interview, the Critical Access Hospital (CAH) failed to ensure the required group of professionals annually reviewed their health care policies for 12 of 12 months reviewed (April 2014 through March 2015). Failure to annually review their policies limits the CAH's ability to ensure staff members properly treat and care for their patients.

Findings include:

Reviewed on May 04-06, 2015, the following policy and procedure manuals lacked evidence of annual review between April 2014 and March 2015 by a physician and a physician assistant, nurse practitioner, or clinical nurse specialist:
* Cardiac Rehab
* Maintenance
* Housekeeping/Laundry

During interview on the afternoon of 05/06/15, a supervisory staff member (#14) stated no review occurs annually of the maintenance and housekeeping/laundry manuals.

On the afternoon of 05/06/15, a managerial staff member (#13) confirmed the CAH failed to review the cardiac rehab, maintenance and housekeeping/ laundry policy manuals.

Based on observation, policy and procedure review, professional reference, and staff interview, the Critical Access Hospital (CAH) failed to ensure the removal of outdated medications and surgical supplies from 1 of 4 drug/supply storage areas (Operating Room) and failed to maintain adequate medication stock in accordance with accepted professional principles in 1 of 1 Operating Room (OR) requiring Dantrolene.

Findings include:

Review of the policy "Anesthesia Policy and Procedure" occurred on 05/06/15. This policy, revised June 1997, stated, ". . . ANESTHESIA SUPPLIES: Anesthesia personnel will maintain up-to-date stock of all supplies used in performance of anesthesia services . . . PHARMACY POLICY: Discontinued or outdated medication will be returned to the pharmacy for disposal. . . ."

Review of the policy "Malignant Hyperthermia" occurred on 05/06/15. This policy, revised June 1997, stated, " . . . POLICY: A malignant hyperthermia crisis will be treated following the guidelines as set forth by the Malignant Hyperthermia Association of the United States . . . EQUIPMENT/SUPPLIES NEEDED: . . . Dantrolene - 12 vials. . . ."

Review of the Malignant Hyperthermia Association of the United States (MHAUS) "Guide to Malignant Hyperthermia in an Anesthesia Setting," dated January 2010, stated, " . . . WHO SHOULD STOCK DANTROLENE AND HOW MUCH? All facilities, including ambulatory surgery centers and offices, where MH [Malignant Hyperthermia] triggering anesthetics (isoflurane, desflurane, enflurane, sevoflurane, methoxyflurane, halothane and succinylcholine) are administered, should stock a minimum of 36 vials of dantrolene, along with the other drugs and devices necessary to treat an MH reaction. . . ."

Observation of the OR took place on 05/05/15 at 1:30 p.m. with a supervisory nurse (#1). Observation identified, in the OR suite, an anesthesia cart and cabinet contained the following expired medications:
*One Epinephrine 30 milliliter (ml) vial expired December 2014
*Four Vasopressin 1 ml vials expired Feburary 2013
*Two Vasopressin 1 ml vials expired November 2014
*Two Neostigmine 10 ml vials expired November 2014
*Two Vecuronium Bromide 10 milligram (mg) vials expired July 2013
*Two Verapamil HCL 10 mg vials expired May 2013
*One Nalorone HCL 1 ml vial expired August 2012
*One Ondansetron 4 mg vial expired April 2014
*Ten Transderm Scopolamine 1.5 mg patches expired January 2015
*One Sevoflurane 250 ml Inhalation Anesthetic expired February 2015
*One Hurricaine Topical Anesthetic Spray expired May 2014
*Ten Vecuronium Bromide 10 mg vials expired August 2013
*Ten Alfenta 2 ml ampules expired March 2015

Observation of a supply room in the OR took place on 05/05/15 at 2:00 p.m. with a supervisory nurse (#1). Observation identified various sized suture packages with expiration dates from 2011 through April 2015.

During an interview, on the afternoon of 05/05/15, a supervisory nurse (#1) stated staff had no process to monitor for and dispose of expired anesthesia medications. The nurse (#1) indicated staff did not dispose of sutures when expired.

Further observation on 05/05/15 of the OR supply area, showed a box containing six vials of Dantrolene. The nurse (#1) stated the OR stocked only six vials of Dantrolene for the Malignant Hyperthermia protocol. This differs from the CAH's written protocol which requires 12 vials of Dantrolene. The CAH failed to have a protocol to address the need for access to 36 vials of Dantrolene.

Based on review of infection control reports, and logs, and staff interview, the Critical Access Hospital (CAH) failed to implement a system to identify, report, investigate, and control infections and communicable diseases for outpatients of the CAH for the past 6 of 6 months (November 2014 through April 2015) reviewed. Failure to identify and address incidents of infections among all patients and personnel has the potential for infections to go unreported, spread, or reoccur; affecting the health of all patients, personnel, and visitors of the CAH.

Findings include:

Reviewed on 05/06/15, the infection control records lacked evidence the CAH identified and recognized both nosocomial (hospital acquired) and community-acquired infections of outpatients receiving outpatient rehabilitation in physical therapy and cardiac rehabilitation. The infection reports/logs from November 2014 through April 2015 failed to include information and documentation of all outpatients with known or suspected cases of infections and/or communicable diseases.

During an interview on the morning of 05/06/15, an administrative staff nurse (#3) stated the facility does not receive or request infection control information from all outpatients, including outpatient rehabilitation patients and confirmed the CAH did not formally document and include all outpatients in infection control surveillance.

Failure to document all incidents of infection and communicable disease, and perform surveillance among all outpatients of the CAH limited the staffs' ability to identify, monitor, track, control, and prevent infections.

Based on observation, bylaws review, policy review, record review, meeting minutes review, and staff interview, the Critical Access Hospital (CAH) failed to ensure the quality assurance (QA) program evaluated all patient care services and other services affecting patient health and safety for 12 of 12 months reviewed (April 2014 - March 2015). Failure to ensure all departments report to the QA Committee as scheduled limits the CAH's ability to identify risk factors affecting patient care and implement corrective action if necessary.

Findings include:

Review of the CAH's Medical Staff Bylaws occurred on 05/04/15. The bylaws, approved 03/04/15, "ARTICLE X MEETINGS" identified the agenda for meetings to include "Reports of standing and special medical committee meetings" to include "Quality Assurance/Performance Improvement: Reviewed quarterly."

Review of the CAH's "Quality Improvement Plan" occurred on 05/04/15. This policy, revised 08/11/14, stated,
". . . Purpose: The purpose and intent is to provide a comprehensive Quality Improvement program for the Ashley Medical Center through the detection and correction of factors hindering the provision of quality and appropriateness of health care: Including developing and implementing actions with periodic re-assessment . . . and to pursue opportunities to improve patient/resident care. . . . Monitoring . . . Representatives or Department Heads from each department will present the indicators they are monitoring, on a quarterly basis as indicated by the monitoring schedule. . . ."

Review of the current "Quality Assurance Studies" monthly reporting schedule, undated, occurred on 05/05/15. This undated document identified quarterly reporting from the department of "PURCHASING/OR [operating room]" and lacked a schedule for quarterly reporting from the anesthesia department services. Review of QA meeting minutes and QA reports showed the OR department did no reporting the third quarter (October - December 2014) and reported on contracted services in the fourth quarter (January - March 2015). The reporting did not include any reporting on the anesthesia services.

Reviewed on 05/04/15, the April 2014 through March 2015 QA meeting minutes lacked evidence the anesthesia department submitted a QA report. Upon request, the CAH failed to provide evidence the anesthesia department reported for this timeframe.

Observation of the OR took place on 05/05/15 at 1:30 p.m. and identified thirteen different expired medications in the OR suite, the anesthesia cart and a cabinet in the OR. Refer to C 276.

During interview on 05/05/15 at 2:50 p.m., a staff member (#6) responsible for QA stated the operating room supervisor reports on anesthesia services, and confirmed that the anesthesia department does not.