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Based on the Life Safety Code (LSC) survey. A Medicare-participating Critical Access Hospital (CAH), including all component parts or facilities of the CAH, must comply with the applicable LSC requirements.

Please refer to the life safety code deficiencies cited at: K0131, K0321, K0341, K0353, K0372, K0712, K0901, K0918 and K0920.

Based on observation, interview, and document review the facility failed to ensure nursing staff followed the policy for medication administration for 2 of 2 outpatients (OP2 and OP3) observed for medication administration. In addition, the CAH failed to ensure 2 of 2 facility adult crash carts on the patient care floor were secured or continuously observed. Further, the CAH failed to ensure receptacles for storing used needles (sharps containers) and medication waste containers were maintained in a secured fashion in 7 of 9 emergency department (ED) bays, 2 ED trauma rooms and 25 of 25 inpatient rooms. This had the potential to affect all inpatients and visitors of the CAH.

Findings include:

Medication Administration

Review of the facility policy titled Patient Identification and Wristband, revised 1/31/18 directed to use at least 2 patient identifiers (Name and Date of Birth (DOB)) whenever administering medication or blood products, taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures.

The policy identified all patients/residents would be accurately identified prior to any intervention in the provision of care, and directed ID bands would be placed on either of the patients wrists and if the patient was unable to wear a wrist band, the ID band would be placed on either of the patient's ankles. For patients receiving chemotherapy, IV therapy and PT/OT areas, the policy directed patients from these areas were required to register in admitting at the initiation of treatment plan. The admission clerk would verify patient identity by asking for Full name and date of birth [DOB]. Staff will request confirmation of name and DOB prior to administering care. Prior to the administration of chemotherapy and Blood Products verification would be needed and a second RN [registered nurse] would be required to provide additional verification, prior to the administration of medication.

On 9/11/18, at 2:07 p.m. during observations of care in the intravenous Infusion Therapy patient area, registered nurse (RN2) was observed to use a bar code scan with an identification armband attached to the outpatient (OP)-2's paperwork lying on top of the computer, then scan the bar coded medication. RN2 then walked approximately 6 feet over to the OP-2, asked the OP-2 to verify her name and the medication (Actemra- a medication for arthritis). RN2 proceeded to administer the medication. RN2 did not verify the name and DOB of the patient.

In addition, OP3 was observed to be receiving a medication infusion (Albumin- Albumin (Human) 20% is a sterile, liquid preparation of albumin derived from large pools of human plasma. All units of human plasma used in the manufacture of Albumin (Human) 20% are provided by FDA approved blood establishments only. Albumin is naturally occurring in the body and is replaced to prevent loss of fluid in the bloodstream, which supports blood pressure), RN1 verified she had bar code scanned the armband sitting on the computer, not applied to the patient, and had not double checked the patient's name and DOB prior to administering the blood product.

Both RN2 and RN1 stated that it was their standard practice not to put the armband on the patient in the infusion area, even though each time the patient arrived at registration, a new encounter number was generated and an arm band specific to that infusion service was printed. RN4, identified as the manager of the area, stated it had been a decision for patient satisfaction. She stated the facility had received complaints from patients about having to wear the armband just for an infusion. At 2:20 p.m. RN2 and RN1 verified medications had been administered without a properly identified arm band applied to the patient. At 2:30 p.m. the manager of the area verified the facility practice was not to place armbands in Infusion Therapy, staff checked name and DOB, but the arm band remained on the chart and was not applied onto the patient.

On 9/11/18, at 3:30 p.m. director of nursing/chief nursing officer (DON/CNO) stated it was the normal practice to apply the ID band, but further stated she felt the patient had been properly identified because she had verified her name and the medication was the right medication.

On 9/12/18, at 8:30 a.m. CNO and RN4 stated the usual practice in Infusion Therapy was not to apply the arm band and stated the use of the ID band had been changed after the facility had received some complaints on the use of the ID band with a patient satisfaction survey. CNO and RN4 indicated not putting the arm band on the patients was an effort to actively involve the patient in safety checks for medication administration. Both CNO and RN4 verified a new armband was generated for each individual encounter of Infusion Therapy, but was never applied to the patient. CNO stated the 5 rights of medication administration were not violated because RN2 had verified the patient name and the medication she was administering with the patient. CNO did verify scanning the arm band on the computer cart was defeating the bar code scanning technology safety features. CNO further agreed that generally the standard of care was to apply the armband to the patient for identification and patient safety.

On 9/12/18, at 9:30 a.m. the Pharmacy Director (PD) stated part of the process of medication administration would be to verify patient, by band and verbally. PD stated patients should be wearing the arm band for safety reasons.

On 9/13/18 at 1:00 p.m. during the Quality investigation, the CNO verified arm band scanning was being tracked by quality and the metric did include all outpatient units as well as inpatients. CNO stated this metric had been reported in quality meetings as not meeting the goal.

Review of the monthly Quality Meeting notes from 9/13/17 to 8/3/18 revealed the following:

-9/13/17, listed the pharmacy quality assurance plan which focused on high alert medication compounding, for medications that are at increased risk due t name similarities, dosing similarities, or a narrow window of where medication goes from helpful to harmful, often times chemotherapy products. The plan looked at the initial step of compounding and the dispensing process. The pharmacy utilized a technology based, bar code scanning process which removed human error, however identified it was only effective when used consistently and listed they had not met the goal of 95% in 2016, but felt due to improvements made the goal for 2017 was set at 97%.

-11/8/17, listed bar code scanning compliance had significantly improved, but did not include if the metric had met the goal.

-4/11/18, Infusion therapy had reviewed patient satisfaction scores, and identified the concern with the question: "how often the area around you quiet?" with various strategies to address this patient concern. The Outpatient Services reviewed cancellation rates for surgical procedures and developed a subcommittee to address the cancellation rates. The notes lacked documentation of patient complaints regarding use of the ID arm bands for infusion therapy or the outpatient areas of the CAH.

-7/13/18, pharmacy reviewed the bar code scanning process removed human error, was only effective when used consistently. The report listed the 2017 goal of 95% had not been met and due to process improvements implemented, had set the 2018 goal for 97%.

The meeting minutes lacked any further documentation of bar code scanning or patient satisfaction in the infusion therapy or outpatient areas.

Crash Cart

9/11/18, at 1:00 p.m. the adult crash cart in maternity care unit was located in a unlocked closet at the far end of the hallway, near room 231 which was located by an exit and a stairwell. This was observed on a tour of the maternity unit and verified by Obstetrics medical surgical/registered nurse(OB/RN) and further verified by Obstetrics nurse manager

On 9/12/18, at 9:30 a.m. the adult crash cart at the end of the ICU/Medical Surgical hallway, in the pass-through between rooms 207 and 209, was standing alone in the hallway, near a stairway exit and was unable to be observed by the nursing stations on the unit. The observation was verified by the nurse manager for ICU-medical/surgical and obstetrics nurse manager.

The nurse managers stated they felt because they were double locked (identification tab and 3 wheel combination lock) that the crash carts met the storage regulation.

The crash cart medications were not stored in a secure area to prevent theft or diversion of medications.


34088

Sharps Containers

A tour of the ED on 9/11/18, from 8:30 a.m. to 10:30 a.m. with the ED manager, registered nurse manager (RNM)-A present on the tour. The ED had nine (9) ED bays, two were reserved for mental health and two trauma bays. Each ED bay and both trauma rooms held plastic red sharps containers, which were approximately 9 inches in height, 11 inches wide and 3 inches deep, and were on the counters of each ED bay and both trauma rooms. At that time, RNM-A stated the red sharps containers were used to dispose of used needles and syringes. RNM-A confirmed all of the sharps containers on the counters were not secured.

On 9/11/18, at 12:30 p.m. RNM-A stated she was unaware of any incident in which any of the unsecured sharps containers had been removed from the ED. However, RNM-A confirmed the used needles and syringes had the potential to have medication left in them and indicated patients and visitors could remove the unsecured sharps containers. She indicated the ED did not have a process for changing out sharps containers, therefore the CAH would be unaware if any of the unsecured sharps containers had been missing.

On 9/12/18, at 10:10 a.m. the Pharmacy Director stated used needles and syringes usually had some medication left in them when they were disposed of in the red plastic sharps containers. He stated would expect sharps and biohazard containers to be secured in the ED and inpatient units of the CAH.

On 9/12/18, at 12:45 p.m. the director of quality stated the CAH had discussed leaving the sharps containers unsecured for staff convenience. She stated having sharps containers available to be moved in the ED could lessen staff incidents of a needle stick. The director of quality stated she felt the unsecured sharps containers did not pose a risk to most inpatients and visitors.

Inpatient rooms:

During observation and tour with the housekeeping manager on 9/13/18, at 9:56 a.m. of the Critical Access Hospital nursing unit located on the second floor of the facility and divided into two separate areas with one the Medical-Surgical and intensive care areas and the other containing the Obstetrical areas. The Obstetrical area had an unlocked room identified as a soiled utility room which contained one large red biohazard container and one large black container on a wheeled cart clearly labeled "unused Pharmaceuticals." access to these containers was via a round approximate 4 inch opening with a sliding plastic cover. The unlocked storage room was located across from patient rooms and would have been easily accessible to any persons who chose to enter the area.

Registered nurse (RN)- 5 was interviewed on 9/13/18, at 10:00 a.m. and confirmed the soiled utility room containing the red and black containers was not locked or monitored and could be accessed by unauthorized individuals if they chose to do so.

The Medical/Surgical portion of the unit was located on the other side of the floor and contained a second nursing station which faced the rooms on this portion of the floor. A wall was directly behind this nursing station preventing visualization of the area containing the copy machine and a second large red biohazard container and black "unused Pharmaceuticals" container. There was no signage or barrier which indicated this as a restricted area. Both of these containers were placed beneath the counter, but easily visible and accessible to anyone passing in the hall

All 23 patient rooms on the nursing unit had individual sharps containers setting unsecured within the rooms located on the counters beside the sink. The sharps containers were not secured to either the counter or wall and could be easily transported from one location to another. The housekeeping manager indicated the sharps containers should have been secured in a locking wall mounted holder which would have prevented spillage and/or removal by unauthorized persons. The housekeeping manager indicated she was not aware the sharps containers were not secured in the patient rooms. This issue was observed in all 23 patient rooms located on the medical/surgical, obstetrical, and intensive care areas of the facility. In addition to the unsecured sharps containers rooms: 201, 203, 204, and 212 contained black plastic unsecured containers labeled Nicotine and Warfarin. This container was also setting on the counter with the sharps containers and had the potential to be accessed by unauthorized persons. The housekeeping manager indicated she was not aware of this safety concern and would need to look into a holder to secure the containers to prevent unauthorized persons from potential access to the unused medication.

On 9/12/18, at 9:30 a.m. the Intensive Care/Medical Surgical and Obstetrics nurse managers, verified that the unlocked dirty utility room contained large red sharps and black pharmaceutical waste bins on wheels. This unlocked storage area was located in the pass through hallway between patient rooms 204-212, and could be assessed by unauthorized staff.

On 9/13/18, at 9:55 a.m. the housekeeping manager stated she would expect the sharps containers in locked wall mounted holders, to prevent diversion of medications.

A facility policy titled, Pharmaceutical Security and Storage, reviewed 8/25/17, lacked indication of sharps and biohazard security. The policy did identify it was the CAH's policy to ensure medications were stored in a secure manner.

Based on interview and document review the facility failed to provide ongoing nursing assessments for 1 of 3 emergency room patients (P1) who were in two point restraints and 1 of 1 pediatric emergency room patient who sustained head trauma.

Findings include:

During review of emergency room records for restraints, it was noted P1 was admitted and treated in the emergency department (ED) on 5/4/18, at 10:28 a.m. P1's medical record revealed the following:

-P1's history and physical revealed P1 presented to the ED via ambulance after calling 911 for suicidal activities. P1 had a history of self induced vomiting and had a history of inpatient psychiatric hospitalizations. The note revealed while P1 was in the ED, she continued to attempt to self induce vomiting by putting her fingers in her mouth and indicated facility staff attempted to intervene.

P1's nursing notes dated 5/4/18, revealed the following:

- 10:31 a.m. P1 arrived to the ED with her entire hand down her throat in an attempt to induce vomiting.

- 10:45 a.m. P1 continued to place her entire hand down her throat, an order was obtained for two point restraints and indicated the restraints were applied at 10:42 a.m

-11:06 a.m,. P1 had been able to place her fingers down her throat despite the 2 point restraints. The note revealed P1's restraints were tightened and was placed on a 1:1 (facility staff member would sit with patient on a 1:1 basis).

P1's nursing restraint assessments dated 5/4/18, revealed the following:

-10:42 a.m. P1's two (2) point restraints (restraints on 2 extremities, both arms) were applied.

-10:47 a.m. P1's restraints were checked and an assessment was completed.

-11:51 a.m. P1's restraints were checked and an assessment was completed.

- 11:58 a.m. P1's restraints were checked.

- 1:27 p.m. P1 restraints were checked and an assessment was completed.

-1:49 p.m. P1's restraints were checked.

-2:33 p.m. P1's restraints were checked and an assessment was completed.

-3:21 p.m. P1's restraints were checked and an assessment was completed.

-3:37 p.m. P1's restraints were checked and an assessment was completed.

-4:35 p.m. P1's restraints were released.

On 9/11/18, at 11:40 a.m. the ED manager, registered nurse manager (RNM)-A stated she expected a nursing restraint assessment to be completed every 15 minutes while a patient was in restraints of any type. RNM-A further stated it was the CAH's policy to complete routine, every 15 minute, assessments on patients in restraints regardless if they were on a 1:1 with facility staff.

During review of emergency room records, it was noted that a 1 yr. old (P10) was treated in the emergency department (ED) for head trauma after falling down 9 steps at home into an unfinished basement. The stairs was described as wooden with cinder blocks on both sides. After an initial nursing assessment of the child was performed on 5/3/18, at 9:42 a.m., no further nursing assessments were documented. Nursing documentation identified that P10 was discharged at 11:13 a.m. without any further vital signs and/or neurological checks/assessments performed prior to discharge.

When interviewed on 5/21/18, at 3:30 p.m. the emergency room manager confirmed that documentation was lacking to indicate nursing staff had performed any nursing assessments for P10 after the initial admission to ED. She verified this was not according to facility procedure and explained an assessment should have been completed prior to discharge.

A facility policy titled, Restraint Use of, revised 8/17/17, revealed patients in behavioral restraints were to be monitored every 15 minutes.

The policy titled, Documentation Guidelines, dated 3/20/18, indicated the minimum guidelines related to nursing assessments required in the ED included the following: on admission (initial), reassess (every 2 hours) and upon discharge. The policy identified these guidelines were a minimum standard; may be done more frequently as per physician order and/or as patient condition warrants.

Based on record review and staff interview the facility failed to provide emergency generator test documentation in accordance with the 2012, edition of the Life Safety Code (NFPA 101) section 9.1.3.1 and the 2010 edition of NFPA 110 the Standard for Emergency and Standby Power Systems. This deficient practice could affect the safety of all of the 68 residents and an undetermined amount of staff and visitors if the generator failed to operate during a power outage.

Findings include:

On the facility tour between 8:00 am to 9:30 am on 9/13/18, the state Fire Marshall it was revealed :
- The monthly generator log did not address the required testing data.


This deficient practice was confirmed by the Environmental Services Manager.

Refer to K0918