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Based on observations, record review and interview, the facility failed to ensure medications and supplies were secured in the facility's emergency department (ED). As a result, medications and supplies stored in the ED were readily accessible to unauthorized personnel. Findings:
Observations on 11/5/12 at 11:45 pm revealed the main entrance to the hospital was unlocked. Immediately inside the front door were the doors that served as the ED entrance, which were also unlocked. No clinical staff were in the area.

Observations in the ED treatment area from 11:45 pm to 12:15 am revealed the following medications and supplies that were unlocked and accessible to the general public: 1) several multidose vials of xylocaine, Sensorcaine, and lidocaine (local anesthetics) sitting on the counter; 2) needles and syringes located in unlocked drawers; 3) an intravenous tray containing needles and a multidose vial of lidocaine; and 4) an emergency crash cart with a plastic break-away lock. Inspection of the carts contents on 11/7/12 at 10:30 am revealed the the cart contained multiple cardiac and respiratory medications, incuding atropine (medication that increases the heart rate and can cause dizzyness and hallucinations). The back hallway of the ED was open and easily assessable from the downstairs, the outpatient clinic, and the laboratory department.

During an interview on 11/6/12 at 12:25 am, when asked if the ED was supposed to be open and unattended at night, LN #1 replied the doors to the hospital were to be locked at night, adding the staff tended to get a little "comfortable after tourist season ends".

During an interview on 11/6/12 at 10:30 am, LN #2 was asked to open the ED crash cart. LN #2 easily snapped off the plastic breakaway lock and opened the top drawer revealing multiple doses of the above listed medications.
On 11/6/12 at 2:30 pm, when the Surveyor questioned the Director of Nursing about the potocol for when the ourtside entrance doors were to be locked, the Director of Nursing (DON) stated the doors were to be locked at 10:00 pm by the "outgoing" Certified Nursing Aides. The DON confirmed the medications should have been secured.

Review of the facility's policy "Rules for storage, handling, dispensation and administration of drugs and biologicals", undated, revealed nursing staff were to have "Control over drugs and medications in all CAH [Critical Access Hospital] locations, including floor stock."



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Based on employee record review and interview the facility failed to ensure 4 Licensed Nurses (#s 2, 4, 5 and the Director of Nursing), who provided chemotherapy to patients, had their competency in administering chemotherapy evaluated. In addition, the facility did not provide evidence of 1 nurse (#5) having attended the chemotherapy training course. These failed practices placed patients who had received chemotherapy agents at risk for receiving cytotoxic (chemicals that can damage cells) agents from inadequately trained staff. Findings:


During an interview on 11/6/12 at 2:15 pm, when asked about what training the facility had provided for nurses administering chemotherapy, Licensed Nurse (LN) #2 replied 5 of the nurses working at the facility had received training from the Oncology Nursing Society (ONS). LN #2 further stated only the Director of Nursing (DON), LN #s 4 & 5, and herself currently administered chemotherapy.


During an interview on 11/7/12 at 11:00 am, the DON and LN #2 were asked how the nurses' training was evaluated to ensure competency in administering chemotherapy. Both nurses replied they had not developed a competency program yet.


Review of the employee education records revealed only the DON, LN #2, and LN #4 had evidence of attending the ONS education. There was no evidence of LN #5 having attended the training. Further review of the training revealed the education had been completed 5/10/11, almost 1 1/2 years ago.


Review of the facility's policy, dated 11/09, revealed "Only personnel who have received orientation and reviewed protocols for chemotherapy administration should administer it."





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Based on record review and interview the facility failed to ensure medical records were accurate for 5 patients (#s 1, 2, 3, 4, 5) out of 6 patients whose medical records were reviewed for treatment in the emergency department (ED). Findings:


Patient #1


Record review on 11/6-7/12 revealed Patient #1 had received services through the emergency room (ER) 10/31/12. Review of the triage information reviewed the Patient was seen 10/30/12 at 7:45 pm.


During an interview on 11/6/12 at 10:00 am, the Director of Nursing (DON) was asked if Patient #1 was in the ER for 24 hours. The DON stated the Patient came to the ER 10/31/12 and that the date of 10/30/12 was a mistake.


Patient #2


Record review on 11/6-7/12 revealed Patient #2 received services on 10/25/12. According to the documentation, the physician administered the first dose of Propofol (a hypnotic agent used for general anesthesia and procedural sedation). Further review of the documentation revealed LN #1 had documented administering the next three doses of Propofol.


During an interview on 11/7/12 at 1:30 pm, the DON was asked what training RNs (registered nurses) had received to be able to give anesthetic medications. The DON stated that the physician had administered the Propofol, and then added that the nurse had documented it incorrectly.


Patient #3


Record review on 11/6-7/12 revealed Patient #3 was admitted to the ER 7/28/12. Review of the medical record revealed the following areas were left blank: 1) time the physician arrived; 2) date/time of initial orders; 3) disposition time (discharge time); 4) time discharge vitals were taken; and 5) depart date and time.

When questioned by the surveyor on 11/7/12 at 4:10 pm, the DON confirmed the blanks on the ER forms should have been completed.


Patient #4


Record review on 11/6-7/12 revealed Patient #4 was admitted to the ER 8/14/12. Review of the medical record revealed the following areas were left blank: 1) date/time of initial orders; 2) disposition time; 3) time of primary assessment; and 4) depart date/time.


When questioned by the surveyor on 11/7/12 at 4:10 pm, the DON confirmed the blanks on the ER forms should have been completed.


Patient #5


Record review on 11/6-7/12 revealed Patient #5 had received services through the facility's ER on 11/5/12 at 10:53 am. Further review revealed the time the physician was notified of the Patient's arrival in the ER and the time the physician had arrived to see the Patient was not documented.


During an interview on 11/6/12 at 8:15 am, LN #3 confirmed the nurse had not documented when the physician was notified or when he had arrived to see the Patient.


Review of the facility's policy "Nursing Documentation On The ER Record", dated 1/09, revealed, "Write down the time that the Physician is notified and when they arrive to the ER...Note the time of discharge."


Review of the facility's policy "Nursing Documentation - Charting Guidelines" , dated 9/04, revealed, "Fill in any blanks on charting forms".