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Based on policy review and review of 3 of 4 medical records for patients (#s 29, 30 and 32) who received blood transfusion services, it was determined the hospital failed to ensure documentation of all of the elements required by the hospital's policy. Blood transfusion starting volumes, amount of blood transfused, and verification of donor blood products were not documented according to hospital policy.

Findings include:

1. Review of the policy titled, "Blood and Blood Products: Consent, Administration, and Transfusion Reaction - Pre and Post Epic," effective 10/2010, reflected the following internal requirements: The transfusionist documents the following...[Patient identification] Verified...Unit [Identification]#...Starting Volume and total infused...The verifying nurse or trained verifier cosigns on the EMR or Transfusion Record the following...[Patient identification] Verified...Donor [identification number]...When the transfusion is complete, document the following...Total infused..."

2. Patient record #29: Review of the record reflected the patient received one unit of blood on 06/27/2012 which was started at 0840 and stopped at 1045. The record lacked documentation of the blood transfusion starting volume and total amount of blood transfused.

Review of the record reflected the patient received a second unit of blood on 06/27/2012 which was started at 1100 and stopped at 1250. The record lacked documentation of the blood transfusion starting volume, the total amount of blood transfused, and verification of the donor unit identification number, as directed by hospital policy.

3. Patient record #30: Review of the record reflected the patient received one unit of blood on 06/29/2012 which was started at 1133 and stopped at 1324. The record lacked documentation that the donor unit identification number was verified and cosigned prior to the start of the transfusion.

4. Patient record #32: Review of the record reflected the patient received one unit of blood on 10/02/2012 which was started at 1200 and stopped at 1350. The record lacked documentation of the blood transfusion starting volume and total amount infused.

Review of the record reflected the patient received a second unit of blood on 10/02/2012 which was started at 1350 and stopped at 1550. The record lacked documentation of the blood transfusion starting volume and total amount infused.

5. These findings were reviewed with I1, the CNO, on 10/25/2012 at 1230. He/she reviewed the medical records for patient #s 29, 30 and 32, and acknowledged that the records lacked the documentation required by hospital policy.

Based on interview, policy review, and review of documentation, it was determined the hospital failed to ensure a policy for storing refrigerated medications was fully developed and implemented, including the monitoring of refrigerator temperatures and function, as required.

Findings include:

1. An interview was conducted with I7, the Diagnostic Imaging Director, on 10/23/2012 at 1400. He/she stated that contrast medium (a medication used in radiography to increase the contrast of an image) was stored in the imaging department refrigerator.

2. Temperature logs for the Imaging Department's refrigerator for May 2012 through September 2012 were reviewed. The top of the logs reflected the following directions: "Data-Tracker Is Sampling Temperature Every 12 Hours. If Out Of Range The Small Light Will Flash Red. Not Green...Data-Tracker must be checked as first opening task every morning to check night temperature...Contact Pharmacy Or House Supervisor Immediately If Flashing Red...If out of range, adjust the thermostat, and in one (1) hour, re-evaluate the new temperature[.] [If] still out of range then move any medications to a working refrigerator until the temperature is within range. All actions taken must be recorded in the comments section of this form...Maintain refrigerator temperature 2-8 [degrees] Celsius."

Review of the temperature log for May 2012 reflected that the red light was flashing 28 out of 31 days. On 05/12/2012 and 05/13/2012 the log reflected, "No lights," were flashing. On 05/28/2012 there was no documentation that the temperature or data tracker had been checked. The log lacked documentation that the pharmacy or house supervisor were contacted from 05/05/2012 through 05/31/2012, when either the red light or no light was flashing. On 05/03/2012, the temperature was recorded as one [degree Celsius]. Although the log reflected that the temperature was adjusted, there was no documentation that the temperature was re-checked in one hour, or that any items were removed from the refrigerator.

Similar findings were identified during review of the temperature logs for June 2012, August 2012, and September 2012.

3. Review of the policy titled, "Storage: Medications," effective 05/2011, identified the following internal requirements: "Medications shall be stored under the proper conditions of sanitation, temperature..." the policy was not fully developed to describe the steps that staff should take if the refrigerator was not functioning properly or if temperatures were out of range.

4. An interview was conducted with I6, the Pharmacy Manager, on 10/23/2012 at 1600. He/she stated the refrigerator temperature was out of range in the data tracking system, which was the reason the red light was flashing. Therefore, whenever the temperature was greater than 4 degrees Celsius, the red light would flash. He/she stated that the data tracking system had been adjusted to reflect the correct temperature range. However, he/she further stated the adjustment had not been completed until 10/23/2012.

5. An interview was conducted with I1 on 10/24/2012 at 1700. He/she presented an undated policy for monitoring refrigerator temperatures. He/she stated the policy was in the process of being developed because the hospital had recently identified the need to revise their policy for monitoring refrigerator temperatures. However, he/she stated that the person who had been working on the policy was on a leave of absence, and he/she did not know if the policy had been fully developed or approved.

6. An interview was conducted with I3 on 10/25/2012 at 0940. He/she stated the undated policy above was still in a draft form, and therefore had not been approved or implemented yet.

Based on interview, policy review, and review of documentation, it was determined the hospital failed to fully develop and implement a system for controlling infections, including a clearly defined policy that ensured blood glucose meters were disinfected in accordance with manufacturer's instructions, and in between patients, as required.

Findings include:

1. A tour of the ICU was conducted with I2, the DNS, on 10/22/2012 at 1600. During the tour, an interview was conducted with I4, an ICU nurse. The nurse stated the blood glucose meter in the ICU was used for multiple patients. He/she was asked what the procedure was for cleaning the meter. The nurse stated he/she cleaned the inside of the meter (the test strip holder) with alcohol and the outside of the meter with a disinfectant wipe.

A tote which was used to store the ICU blood glucose meter, was observed. The tote contained a manufacturer's instruction guide for the meter titled, "SureStepFlexx...Meter Quick Reference Guide," copy right date 2002. Review of the guide reflected the following manufacturer's instructions: "Clean the outside of the meter with a cloth dampened with a 10% bleach solution...Cleaning the Test Strip Holder...Caution: Do not use alcohol...to clean the test strip holder or lens area because it will damage the meter parts." This was reviewed with I2 and I4 on 10/22/2012 at 1610. I4 acknowledged the meter was not being cleaned in accordance with the instructions in the manufacturer's guide.

2. Review of the policy titled, "Cleaning Patient Care Equipment," reviewed by the hospital 11/09/2011, identified the following internal requirements: "...Follow the manufacturer's use guidelines for both equipment and product being used..." The policy included a list of patient care equipment, and corresponding cleaning agents and cleaning schedules. Review of the policy reflected that glucose meters were to be cleaned daily with a hospital disinfectant. The policy was not fully developed or implemented to ensure the glucose meter was cleaned in accordance with manufacturer's instructions. The policy was also not developed to ensure the meter was disinfected between patients in accordance with nationally recognized standards for controlling infections, as required.

3. An interview was conducted with I11, the IP, on 10/24/2012 at 1000. He/she stated that blood glucose meters should always be cleaned in between patients and the hospital policy for cleaning the meters was based on CDC standards. He/she reviewed the policy and acknowledged it did not require cleaning the glucose meter between patients as it should.

4. Review of the CDC website page titled, "Infection Prevention during Blood Glucose Monitoring and Insulin Administration," page last reviewed 03/02/2011 and last updated 05/02/2012, identified the following recommendations: "...Summary...CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements...Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared."

Based on interview and review of policies and procedures it was determined that the hospital failed to have a system in place to annually review patient care policies by a professional group per this regulation.

Findings include:

1. An interview with I1 on 10/22/201 at 1520, confirmed that the patient care policies and procedures were not reviewed annually.

2. During the CAH validation and State relicensure survey, it was determined that many policies were not reviewed or revised on an annual basis. A list of hospital patient care policies that have not been reviewed for more than a year includes but not limited to, the following:

-Providence Health & Services - Gorge Service Area PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL policy titled, "Critical Access Hospital Program Elements," reviewed 07/2011;
-Providence Health & Services - Oregon Nursing policy titled, "ADMISSION DATA - PRE EPIC," reviewed 03/2011;
-Providence Health & Services - Oregon Nursing policy titled, "AGENCY STAFF - PRE and POST Epic," revised 03/2011;
-Providence Health & Services - Oregon Nursing policy titled, "BLOOD and BLOOD PRODUCTS: CONSENT, ADMINISTRATION, AND TRANSFUSION REACTION - PRE and POST EPIC," effective 2010;
-Providence Health & Services - Oregon Nursing policy titled, "CRITICAL VALUE NOTIFICATION - PRE & POST EPIC," reviewed 04/2011;
-Providence Health & Services - Oregon Nursing policy titled, "IV: CENTRAL VENOUS CATHETER CARE AND MAINTENANCE, INCLUDING DRESSING CHANGE - PRE & POST EPIC," reviewed 04/2011;
-Providence Health & Services - Oregon Nursing policy titled, "IV: CENTRAL VENOUS CATHETER: REMOVAL - PRE AND POST EPIC," reviewed 04/2011;
-Providence Health & Services - Oregon Nursing policy titled ,"PLAN OF CARE - PRE EPIC," reviewed July 2011;
-Providence Health & Services - Oregon Nursing policy titled, "SCOPE OF PRACTICE FOR REGISTERED NURSES, LICENSED PRACTICAL NURSES, AND AUTHORIZED DUTIES FOR CERTIFIED NURSING ASSISTANT 2s AND TECHNICIANS - PRE & POST EPIC," effective 02/2008;
-Providence Health & Services - Oregon Nursing policy titled, "STAFFING PLAN POLICY PRE & POST EPIC," revised 08/2011:
-Providence Hood River Memorial Hospital (PHRMH) policy titled, "Cole Blue," last reviewed 07/10/2010;
-PHRMH policy titled, "Verbal Orders," last revised 05/27/2010;

Based on documentation in 18 of 42 clinical records reviewed (#s 1, 3, 6, 12, 13, 14, 16, 17, 19, 33, 35, 36, 37, 38, 39, 40, 41, and 42), it was determined that the hospital failed to ensure that all entries in the clinical records were dated and/or timed, and/or authenticated in accordance with the hospital's own requirements.

Findings include:

1. The CAH had a General Operating Policy # 335.00 titled "Content of the Medical Record" last reviewed by the CAH in March of 2012, that under "IV. Procedure, K Authentication" stated: "All entries in the medical record shall be dated, timed and authenticated."

The CAH had Patient Care Services policy # 10527 titled "Verbal Orders." This policy was last revised on 05/27/2010. It stated under the heading "Directions: ...8. Authentication of Verbal / Telephone Orders: Verbal orders shall be dated, timed and authenticated within 48 hours by the ordering health care practitioner or another health care practitioner who is responsible for the care of the patient."

2. Record # 1 contained a "Standard Pre-Operative Admission Orders - Adult" which carried the Providence Hood River Memorial Hospital logo and a line labeled "Date /Time" that was signed and dated but not timed.

This same record contained a "Perinatal IV Insulin Orders" which carried the Providence Health and Services logo and a line labeled "Date/Time..." that was signed and dated but not timed.

This same record contained a pre-printed "Oxytocin Induction/Augmentation Orders" which carried a line labeled "Date/Time..." that was dated but not timed.

This same record contained a pre-printed "Physician's Order Record" which contained lines for hand written orders. One space contained a telephone order that was signed by the physician but not dated or timed per hospital policy.

Record # 3 contained a pre-printed form which carried the Providence Hood River Memorial Hospital logo "Subcutaneous Insulin & Blood Glucose - Adult" which contained a line labeled "Date/Time" that was signed and dated by the provider but not timed.

This same record contained a pre-printed "Physician's Order Record" which contained lines for hand written orders. One space contained a telephone order that was signed by the physician but not dated or timed per hospital policy.

Record # 6 contained a pre-printed "Physician's Order Record" which contained lines for hand written orders. One space contained a telephone order that was signed by the physician but not timed per hospital policy.

Records # 12, 16, 17, 33, 35, 36, 37, 38, 39, 40, 41, and 42 contained an Emergency Department form for physician's orders that on the bottom of the form was a line labeled "Date / Time / Signature." All forms were signed but lacked the date and the time of the signatures.

Record # 13 contained an "Interdisciplinary Progress Record" pre-printed as "Immediate Post-Op Note:" which was neither dated or timed.

Record # 14 contained an "Interdisciplinary Progress Record" pre-printed as "Immediate Post-Op Note:" and the following bullet points: "Surgeon / Assistant(s):," "Procedure:," "Post-Op Diagnosis / Findings:," "Complications:," "Specimens:," and " Estimated Blood Loss:." There was no date or time written on this note.

This same record contained a "Standard Pre-Operative Admission Orders - Adult" which carried the Providence Hood River Memorial Hospital logo and a line labeled "Date /Time" that was signed and dated but not timed.

Record # 16 also contained a "PACU Anesthesia Order" form that was signed and dated but lacked the time when the form was signed.

Record # 19 contained a pre-printed "Admission Order" which carried the Providence Hood River Memorial Hospital logo and a line labeled "Date/Time" that was signed but not dated or timed.

Based on interview, review of documentation in 3 of 8 records of patients who underwent a surgical procedure with general anesthesia (Records # 11, 13, and 15), it was determined the hospital failed to ensure that the patient was evaluated by a qualified practitioner for proper anesthesia recovery before discharge from the CAH.

Findings include:

1. The hospital utilized a single form to document the pre-anesthesia evaluation, the PACU admit status, and the post anesthesia note. The area titled "Post Anesthesia Note" contained 10 check boxes. Three check boxes indicated the source of the information: "Pt. Interviewed," "Chart Reviewed," and "RN Report." The remaining check boxes were labeled:
"Satisfactory Pain Control Yes/No /10 [indicating the patient's pain level on a scale of 10];"
"Satisfactory Post Anesthesia Recovery;"
"D/C [discharge] Home from SDS [Same Day Surgery];"
"Satisfactory Hydration Yes/No;"
"Satisfactory PONV [Post Operative Nausea and Vomiting]Control Yes/No;"
"No apparent anesthesia comps [complications];" and
"Comments"
There was a line labeled "Anesthesia Provider Signature" and a line labeled "Date/Time."

2. Record # 11 - This patient was admitted on 08/18/2012 and discharged on 08/20/2012. On 08/20/2012, the patient underwent a surgical procedure requiring general anesthesia. A review of the medical record Post Anesthesia Note determined none of the boxes described above were checked. There was a note that stated "Chart reviewed; no apparent anes [anesthesia] comps reported by staff. - [CRNA's initials]" The note also contained an entry that stated "Authenticated by [CRNA's name] on 08/28/2012 09:47:26 AM." The date/time stamp indicated that the review was performed 8 days after the patient was discharged rather than prior to discharge as required by this regulation.

Record # 13 - This patient was a Same Day Surgery patient who underwent a surgical procedure requiring general anesthesia on 08/23/2012. A review of the medical record Post Anesthesia Note determined none of the boxes described above were checked. There was a note that stated "Chart reviewed; No apparent anes comps reported by staff. - [CRNA's initials]" The note also contained an entry that stated "Authenticated by [CRNA's name] on 08/28/2012 09:48:00 AM." The date/time stamp indicated that the review was performed 5 days after the patient was discharged rather than prior to discharge as required by this regulation.

Record # 15 - This patient was a Same Day Surgery patient who underwent a surgical procedure requiring general anesthesia on 09/06/2012. A review of the medical record Post Anesthesia Note determined none of the boxes described above were checked. There was a note that stated "Chart reviewed; No apparent anes comps reported by staff. - [CRNA's initials]" The note also contained an entry that stated "Authenticated by [CRNA's name] on 09/11/2012 10:53:48 AM." The date/time stamp indicated that the review was performed 5 days after the patient was discharged rather than prior to discharge as required by this regulation.

All three patients received anesthesia from one CRNA.

3. When asked for a copy of the policy and procedure on 10/25/2012 at approximately 09:30, the CNO stated that the policy was the same as the regulation in that the hospital's expectation was that the post anesthesia evaluation be performed before the patient was discharged from the CAH.

Based on interviews with administrative personnel and review of documentation, it was determined that the hospital lacked a periodic evaluation of the 2011 CAH total program.

Findings include:

1. An interview with I1 on 10/22/2012 at 1035, reflected the yearly CAH program evaluation had not been completed since 2010. I1 stated that the program evaluation had been put off due to the hospital's preparation for the accreditation organization survey that occurred 8 weeks earlier. I1 stated that the CAH 2011 annual program review "was still not completed."

2. Review of a policy titled, "Critical Access Hospital Program Elements," revised 07/2011, reflected "9. Providence Hood River Memorial Hospital will conduct an annual program evaluation of the Critical Access Program. The evaluation will include a review of applicable patient care policies for the Critical Access Program, and the results of the peer review conducted by a hospital's network hospital...The annual program evaluation will be conducted by a multidisciplinary team..."

3. Review of documentation revealed that the last "Annual Critical Access Review" was dated 2010. The hospital lacked documentation of a more recent CAH program evaluation.

Based on interviews with administrative personnel and review of documentation, it was determined that the hospital lacked a periodic evaluation of the 2011 CAH total program that included a review of the CAH's health care and patient care policies..

Findings include:

Refer to the findings listed at tag A 0331.

Based on policy review and review of 1 of 1 medical record (#22) of a hospital Swing-bed patient who received Swing-bed services for greater than 14 days, it was determined the hospital failed to ensure an on-going program of activities was provided, including an assessment of the patient's activities needs, in accordance with hospital policy.

Findings include:

1. Review of the policy titled, "Transfer of Patients," revised 12/22/2011, identified the following internal requirements: "If the patient is on a [Swing-bed] status greater than 14 days, an activities assessment will be completed by an activities director/delegate in conjunction with an Occupational Therapist."

2. Review of the policy titled, "Skilled Swing Bed," effective 07/01/2003, identified the following internal requirements: "...The hospital will provide for an ongoing program of activities designed to meet...the interest and the physical, mental, and psychological well-being of each patient...Activities will be provided as appropriate to the condition, needs, and desires of the patient."

3. Swing-bed patient record #22 was reviewed: The patient was admitted to a hospital Swing-bed on 05/15/2012 and was discharged on 05/30/2012. The record lacked documentation of an activities assessment as required by hospital policy.

4. These findings were reviewed with I1 on 10/25/2012 at 1240.