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Based on document review and staff interview, the facility failed to ensure a physician reviewed the care provided by 2 of 2 sampled mid-level providers to patients at the facility (ARNP M and CRNA K). The Medical Staff at the facility included 2 ARNPs (Advanced Registered Nurse Practitioners), 6 CRNAs (Certified Registered Nurse Anesthetists), and 1 Physician's Assistant (PA) at the time of the survey.

Failure to ensure a physician periodically reviews, in conjunction with the mid-level providers, the care provided by the mid-level practitioners affects the facility's ability to assure the mid-level providers are consistently providing quality care to its patients.

Findings include:

1. Review of credential files for physicians and mid-level providers on 10/17/12 at 1:20 PM revealed:

- CRNA K's credential file lacked evidence a physician had reviewed the care CRNA K provided to facility's patients.

- ARNP M's credential file lacked evidence a physician had reviewed the care ARNP M provided to facility's patients.

2. Review of the "Horn Memorial Hospital Medical Staff Bylaws", approved 8/12, revealed the bylaws lacked a requirement for a physician to review the patient care provided at the facility by the mid-level providers.

- Review of the "MEDICAL STAFF RULES AND REGULATIONS OF HORN MEMORIAL HOSPITAL", approved 8/12, revealed the rules and regulations lacked a requirement for a physician to review the patient care provided at the facility by the mid-level providers.

3. During an interview on 10/17/12 at 11:35 AM, the Health Information Management Director acknowledged the credential files lacked documentation a physician reviewed the patient care provided by the mid-level providers at the facility . The Health Information Management Director stated the ARNPs and PAs would discuss the care they provided to hospitalized patients with a physician on an informal basis every day the mid-level provider provided care to a hospitalized patient. The Health Information Management Director acknowledged the credential files lacked documentation of a physician and mid-level providers meetings to review patient care.

The Health Information Management Director acknowledged CRNA K's credential file lacked evidence a physician met with CRNA K to review the care CRNA K provided to facility patients. The Health Information Management Director stated she did not have a physician review the care provided by the CRNAs because she had not considered the CRNAs as mid-level providers. The Health Information Management Director did acknowledged that CRNAs were mid-level providers, and required a physician to review the care the CRNAs provided to patients at the facility.

Based on document review and staff interview, the facility failed to ensure 2 of 2 sampled Mid-Level Providers (Advanced Registered Nurse Practitioner (ARNP M) and Certified Registered Nurse Anesthetist (CRNA K)) met with a physician to review the medical records of patients who received care from the Mid-Level Providers. The facility had 2 ARNPs, 6 CRNAs, and 1 Physician's Assistant (PA) on the Medical Staff at the facility.

Failure to ensure Mid-Level Providers met with a physician to review their medical records could potentially result in the Mid-Level Provider (ARNP, CRNA, or PA) providing inappropriate care, and the facility failing to identify the inappropriate care.

Findings include:

1. Review of credential files (personnel files for physicians and mid-level providers) on 10/17/12 at 1:20 PM revealed:

- CRNA K's credential file lacked evidence a physician had reviewed the care CRNA K provided to patients at the facility.

- ARNP M's credential file lacked evidence a physician had reviewed the care ARNP M provided to patients at the facility.

2. Review of the "Horn Memorial Hospital Medical Staff Bylaws," approved 8/12, revealed the bylaws lacked a requirement for a Mid-Level Provider to meet with a physician to review the care the Mid-Level Providers provided to patients at the facility.

- Review of the "MEDICAL STAFF RULES AND REGULATIONS OF HORN MEMORIAL HOSPITAL," approved 8/12, revealed the rules and regulations lacked a requirement for the Mid-Level Providers to meet with a physician, and review the care the Mid-Level Providers provided to patients at the facility.

3. During an interview on 10/17/12 at 11:35 AM, the Health Information Management (HIM) Director acknowledged the credential files lacked documentation of a meeting between the Mid-Level Providers and a physician to review the care provided to patients at the facility. The HIM Director stated the ARNPs and PAs would discuss the care they provided to hospitalized patients with a physician on an informal basis every day the Mid-Level Provider provided care to a hospitalized patient. The HIM Director acknowledged the credential files lacked documentation of the meetings between the Mid-Level Providers and a physician.

Additionally, the HIM Director acknowledged CRNA K's credential file lacked evidence of a meeting between CRNA K and a physician to review CRNA K's care to patients at the facility. The Health Information Management Director stated she did not have a physician review the care provided by the CRNAs because she had not considered the CRNAs as mid-level providers. The Health Information Management Director did acknowledged that CRNAs were mid-level providers, and required a physician to review the care the CRNAs provided to patients at the facility.

I. Based on observation, document review, and staff interview, the facility failed to ensure 1 of 1 Certified Registered Nurse Anesthetist (CRNA K) used a filter needle when drawing medication into a syringe out of a glass ampoule. The facility had an average of 55 surgical patients per month.

Failure to use a filter needle to remove the medication from a glass ampoule could result in the CRNA drawing tiny glass shards into the syringe with the medication. When injected, the tiny glass shards could potentially cause harm to the patient.

Findings include:

1. Observations of the anesthesia cart on 10/16/12 at 8:00 AM revealed several small glass ampoules filled with fentanyl, a anesthetic medication. An ampoule is a sealed narrow glass container of medication with a narrow area on the neck. The neck of the glass container has a small scored area for manually breaking the ampoule open to allow removal the medication from the container with a needle and syringe.

2. Review of the policy "Med-[Intravenous]/Intramuscular Injection," revised 6/11, revealed in part, "Ampoules: ... Break stem of ampoule, covering top with something to prevent cutting hand ... Open syringe and attach filter needle. Insert filter needle into ampoule. Tilt or invert ampoule to withdraw dose. Remove filter needle ... and replace with needle to be used for injection..."

3. Observations of a surgical procedure on 10/16/12 revealed the following:

- at 8:05 AM, CRNA K opened 2 glass ampoules of fentanyl and withdrew the fentanyl from an ampoule using a syringe with a needle. CRNA K repeated the procedure and withdrew the fentanyl from the other ampoule using the same syringe with the same needle.

- at 9:12 AM, CRNA K opened a glass ampoule of fentanyl by breaking off the top of the ampoule at the neck. CRNA K drew the fentanyl from the ampoule into a syringe with a needle.

4. During an interview at the time of the observations, CRNA K stated he did not use a filter needle to draw up the fentanyl.

- During an interview on 10/16/12 at 10:10 AM, the Outpatient Director acknowledged CRNA K should have used a filter needle to remove the fentanyl from the glass ampoules. The Outpatient Director acknowledged the facility's policies required CRNA K to use a filter needle when removing the fentanyl from the glass ampoule, but CRNA K failed to follow the facility's policy.

II. Based on observation, document review, and staff interview, the facility failed to ensure the CRNAs documented the date on 3 of 3 vials of Succinylcholine and 1 of 1 vial of Rocuronium to reflect the date the CRNAs removed the vials from the refrigerator. The facility had an average of 55 surgical procedures performed per month.

Failure to write the shortened expiration date on the medication vials could potentially result in use of the medication after it was no longer safe to use for patient care.

Findings include:

1. Observations during a tour of the surgical area on 10/15/12 at 10:15 AM revealed 1 of 1 anesthesia cart in the post-anesthesia care area. Further observations revealed 3 of 3 10-milliliter (ml) vials of ml Succinylcholine and 1 of 1 5-ml vial of Rocuronium, stored on the cart at room temperature.

2. Review of the policy "MEDICATION STORAGE, PHARMACY", revised 7/11, revealed in part, "All medications will be stored according to the manufacturer's guidelines listed on the medication package."

- Review of the manufacturer's directions for the Succinylcholine, revised 12/10, revealed in part, "Store in refrigerator ... vials are stable for up to 14 days at room temperature without significant loss of potency."

- Review of the manufacturer's directions for the Rocuronium, revised 1/11, revealed in part, "Rocuronium ... should be stored in a refrigerator ... Upon removal from refrigeration to room temperature storage conditions, use Rocuronium ... within 60 days."

3. During an interview on 10/15/12 at 12:40 PM, the Pharmacy Director acknowledged the vials of Succinylcholine and Rocuronium lacked documentation of the date the CRNAs removed the vials from refrigerated storage. The Pharmacy Director acknowledged the CRNAs should have documented the date they removed the vials from refrigerated storage, as required by the manufacturer to ensure the CRNAs used the medications within the time frames recommended by the manufacturer.


III. Based on observation, document review, and staff interview, the CRNAs failed to document the date they opened 5 of 5 multi-dose vials of medications (Succinylcholine, Rocuronium, 2% Lidocaine, and Labatalol) in the anesthesia cart. The facility had an average of 55 surgical procedures performed per month.

Failure to document the date the CRNA opened the multi-dose vials could potentially allow the drugs to be available for use when the drugs were no longer safe for patients.

Findings include:

1. Observations in the post-anesthesia care unit on 10/15/12 at 10:15 AM revealed an anesthesia cart. Further observation of the anesthesia cart revealed the following:

- 2 of 2 opened 10 mL multi-dose vials of Succinylcholine that lacked documentation of the date the CRNA initially opened the vial.

- 1 of 1 opened 20 mL multi-dose vial of 2% Lidocaine that lacked documentation of the date the CRNA initially opened the vial.

- 1 of 1 opened 20 mL multi-dose vial of Labatolol that lacked documentation of the date the CRNA initially opened the vial.

2. Observations in the post-anesthesia care unit on 10/15/12 at 10:15 AM revealed a medication refrigerator. Further observation of the medication refrigerator revealed 1 of 1 opened 5 mL multi-dose vial of Rocuronium that lacked documentation of the date the CRNA initially opened the vial.

3. Review of the policy "MULTIPLE DOSE VIALS, PHARMACY," revised 9/11, revealed in part, "Medications that are supplied from the manufacturer in a vial labeled 'multiple dose' have a preservative and are intended for reuse. Medication vials are stable and be used for patient administration for 28 days after initially ... opening ..."

4. During an interview on 10/15/12 at 12:40 PM, the Pharmacy Director acknowledged the multiple dose vials lacked documentation of the date the CRNAs opened the vials. The Pharmacy Director also acknowledged if the CRNAs failed to document the date they opened the multi-dose vials, they could not determine if the vial was within the 28 days timeframe for safe use, as required by the policy.

I. Based on document review, observation, and staff interview, the facility failed to ensure a Certified Registered Nurse Anesthetist cleansed the medication vial stopper prior to withdrawing medication from the vial (CRNA K). The facility's surgical services staff performed approximately 55 surgical procedures per month.

Failure to cleanse the medication vial stopper prior to withdrawing the medication from the vial could result in the CRNA contaminating the medication with micro-organisms and using the medication for patient care. Injecting contaminated medication could potentially result in harm to the patient.

Findings include:

1. Review of the policy "Med-IV/Intramuscular Injection," revised 6/11, revealed in part, "Prepare Drug: ... Rubber topped vials: a. Cleanse rubber topped vials with alcohol wipe, after removing cap..."

2. Observations, accompanied by the Outpatient Director, during a surgical procedure on 10/16/12, accompanied by the Outpatient Director, revealed CRNA K used multiple vials of medication to administer to the patient. Each vial consisted of a glass bottle to contain the medication, and a rubber stopper at the top to keep the medication sterile. Further observations revealed the following.

- At 8:05 AM, CRNA K drew 5 mg of Rocuronium from a medication vial, by inserting a syringe and needle through the rubber stopper. CRNA K failed to cleanse the rubber stopper prior to inserting the needle into the rubber stopper. CRNA K also drew up 120 mg of Succinylcholine from a medication vial by inserting a syringe and needle through the rubber stopper. CRNA K failed to cleanse the rubber stopper prior to inserting the needle into the rubber stopper.

- At 9:12 AM, CRNA K drew 200 mg of Propofol from a medication vial, by inserting a syringe and needle through the rubber stopper. CRNA K failed to cleanse the rubber stopper prior to inserting the needle into the rubber stopper.

- At 9:20 AM, CRNA K drew up Neostigmine and Glycopyrolate by inserting a syringe and needle through the rubber stoppers in the medication vials. CRNA K failed to cleanse the rubber stoppers prior to inserting the needle into the rubber stoppers.

3. During an interview on 10/16/12 at 10:10 AM, the Outpatient Director acknowledged CRNA K failed to cleanse the rubber stopper prior to withdrawing medication from the medication vials, as required by the facilitys policies.


II. Based on document review, observation, and staff interview, the facility failed to ensure 1 of 1 CRNA (CRNA K) cleansed the intravenous access port prior to administering medications to the patient. The facility surgical services staff members performed approximately 55 surgical procedures per month.

Failure to cleanse the intravenous access port prior to administering medications to the patient could result in the micro-organisms on the surface of the intravenous access port to enter with the medication and potentially harm the patient.

Findings include:

1. Review of the policy "DIRECT [INTRAVENOUS] MEDICATIONS", revised 11/11, revealed in part, "Wipe off lowest [intravenous] port site of the [intravenous] tubing or [short intravenous tubing] with alcohol swab and attach syringe with needle removed."

2. Observations during a surgical procedure on 10/16/12, accompanied by the Outpatient Director, revealed the following.

- At 8:40 AM, CRNA K administered 2 mg of Versed through the intravenous (IV) access port in the IV tubing. CRNA K failed to cleanse the IV access port with alcohol prior to administering the Versed.

CRNA K administered 200 mg of Fentanyl to the patient through the IV access port. CRNA K failed to cleanse the IV access port with alcohol prior to administering the Fentanyl.

CRNA K administered 5 mg of Rocuronium to the patient through the IV access port. CRNA K failed to cleanse the IV access port with alcohol prior to administering the rocuronium.

CRNA K administered 200 mg of Propofol to the patient through the IV access port. CRNA K failed to cleanse the IV access port with alcohol prior to administering the Propofol.

CRNA K administered 120 mg of Succinylcholine to the patient through the IV access port. CRNA K failed to cleanse the IV access port with alcohol prior to administering the Succinylcholine.

- At 9:20 AM, CRNA K administered Neostigmine and Glycopyrolate to the patient through the IV access port in the IV tubing. CRNA K failed to cleanse the IV access port with alcohol prior to administering the neostigmine and glycopyrolate.

3. During an interview on 10/16/12 at 10:10 AM, the Outpatient Director acknowledged CRNA K failed to cleanse the IV access port prior with alcohol to administering medications to the patient. Additionally, the Outpatient Director stated the facility's policies required CRNA K to cleanse the IV access port with alcohol prior to injecting the medication into the IV access port.

I. Based on observation, review of documents, and interview with dietary staff, the Dietary Department failed to maintain a clean and sanitary environment in the kitchen. The facility had a census of 17 inpatients.

Failure to maintain a sanitary environment in the Dietary Department could potentially cause foodborne illness.

Findings include:

1. Observation on 10/15/12 at 10:03 AM, during the initial tour of the Dietary Department with Staff A, Assistant Dietary Director, revealed the following:

- Food stored on the floor of the walk-in freezer.

- Plastic wrap on the black plastic shield over the fan blades in the walk-in freezer.

- One staff member's sack lunch stored in the walk-in refrigerator.

- Dried milk on the floor of the walk-in refrigerator.

2. The Dietary staff failed to implement the 10/12 cleaning schedule. Review of the 9/12 cleaning schedule included cleaning of the walk-in refrigerator.

3. The administrative staff of the Dietary Department failed to develop and implement policies and procedures for storing staff's sack lunches, cleaning the walk-in freezer fans, and proper food storage.

4. During and interview, at the time of the initial tour, of the Dietary Department on 10/15/12 at 10:03 AM, Staff A verified the above findings but did not comment on the dietary staff's failure to fulfill the facility's requirements for a sanitary environment.


II. Based on observation, review of documents, and Dietary staff interviews the Dietary Department failed to correctly use disposable gloves in the serving of 1 of 1 noon meals. The CAH administrative staff identified a census of 17 inpatients.

Failure to correctly use disposable gloves in the serving of meals could contaminate food potentially cause borne illness.

Findings include:

1. Observation on 10/16/12 at 11:10 AM, during the noon meal service revealed, Staff C and D, Dietary Aides, wearing disposable gloves and serving the noon meal. Staff C served the entree and vegetables and Staff D placed salads, beverages, and desserts on the patient room trays. Staff C cut up entrees and vegetables using two hands, one hand held the scoop and the other hand touched the entree or the vegetable to ensure the food did not fall from the plate. Staff C failed to change gloves during the noon meal service.

- Staff D touched various cooking/serving surfaces and the serving area 3 times. Staff D changed gloves 1 time during the noon meal service, and failed to wash her hands prior to donning on new gloves.

2. Review of the policy titled, "Use of Plastic Gloves," dated 5/23/06 stated in part ..."3. Remember gloves are just like hands, they get soiled, anytime a contaminated surface is touched, the gloves must be changed."

- Review of the "In-service Training Report" dated 5/22/12, verified that Staff C and D attended the in-service training titled, "Hand washing and Glove use Review."

3. During an interview on 10/16/12 at 11:30 AM, Staff B, Dietary Director, Staff C, and D verified the misuse of gloves and failure to wash hands prior to donning a new pair of gloves could lead to contamination of various foods.

Based on observation, document review, and staff interviews, the facility failed to maintain x-ray emitting equipment in 1 of 1 x-ray rooms to ensure the safety of personnel operating the equipment (Radiology). The length of the x-ray emitting control cord could allow the personnel operating the x-ray equipment to enter into the field of exposure. An average of 325 x-rays were completed every month with this equipment.

Failure to ensure the length of the x-ray exposure cord would prevent personnel operating the x-ray equipment from the entering the field of exposure while taking an x-ray could potentially result in unnecessary radiation exposure to staff.

Findings include:

1. Observation during tour of the Radiology Department on 10/16/12 at 1:20 PM, revealed a 6 foot long control cord on the x-ray emitting equipment in the Radiographic Room that could extend outside the safety barrier for the personnel operating the equipment.

2. Review of policy/procedure titled "Radiation Safety", dated 4/22/12, revealed, in part, "...Always stand inside the shielded control booth when initiating the exposure...."

- The policy/procedure failed to address the length of the exposure cord that could allow the personnel operating the x-ray equipment to enter into the field of exposure.

3. During an interview on 10/16/12 at 1:20 PM, Staff E, Radiology Technician/Sonographer, and Staff F, Radiology Technician/Mammographer confirmed the x-ray emitting equipment cord in the Radiographic Room could extend outside the safety barrier for the personnel operating the equipment. Staff E and F stated they perform general extremity and chest x-rays in the Radiographic Room and knew they were not to stand outside the safety barrier when completing an x-ray procedure.


27303


Based on document review, observation, and staff interview, the facility failed to provide dosimeter badges for 4 of 4 staff members present in the operating room during the operation of the C-Arm fluoroscope. The facility had an average of 4 surgical procedures per month that involved the C-Arm fluoroscope.

Failure to provide a dosimeter badge to all staff members in the operating room during the operation of the C-Arm fluoroscope could result in the staff member receiving excessive exposure to radiation.

Findings include:

1. Review of the policy "RADIATION SAFETY," reviewed 4/10, revealed in part, "A personnel radiation monitoring device (e.g. film badge) shall be worn during the exposure."

2. Observations during a surgical procedure on 10/16/12 at 9:05 AM revealed a C-Arm fluoroscope (an x-ray machine used to produce real-time x-ray images) in the operating room. During the surgical procedure, the patient received 58 seconds of exposure to radiation. Scrub Technician H was standing next to the C-Arm fluoroscope's radiation beam while the machine produced radiation. Circulator Nurse I was standing behind the C-Arm fluoroscope while the machine produced radiation. Surgeon J was standing 1 to 2 feet away, and directly across from the C-Arm fluoroscope's radiation beam while the machine produced radiation. Certified Registered Nurse Anesthetist (CRNA) K was standing about 4 feet away from the C-Arm fluoroscope's radiation beam while the machine produced radiation.

- Further observations revealed Scrub Technician H, Circulator Nurse I, Surgeon J, and CRNA K all lacked a dosimeter badge to measure the staff's exposure to ionizing radiation.

3. During an interview at the time of the observations, Scrub Technician H stated he was not offered or provided with a dosimeter badge. Scrub Technician H stated he wore a dosimeter badge while working for his prior employer.

- During an interview at the time of the observations, Circulator Nurse I stated she was not offered or provided with a dosimeter badge.

- During an interview at the time of the observations, Surgeon J stated he was not offered or provided with a dosimeter badge.

- During an interview at the time of the observations, CRNA K stated he was not offered or provided with a dosimeter badge. CRNA K stated he provided care at another facility, and facility had provided him a dosimeter badge.

4. Review of the Third Quarter "Radiation Dosimeter Report" (a report of staff members' exposure to radiation) revealed the report failed to include Scrub Technician H, Circulator Nurse I, Surgeon J, and CRNA K as staff members that were exposed to radiation at the facility or issued dosimeter badges.

5. During an interview on 10/16/12 at 10:10 AM, the Outpatient Director acknowledged Scrub Technician H, Circulator Nurse I, Surgeon J, and CRNA K were present in the room while the patient received exposure to radiation from the C-Arm fluoroscope. The Outpatient Director also acknowledged Scrub Technician H, Circulator Nurse I, Surgeon J, and CRNA K did not wear a dosimeter badge and they were not provided a dosimeter badge.

- During an interview on 10/16/12 at 10:15 AM, the Chief Nursing Officer stated the facility staff had identified the operating room staff members stayed in the operating room while the patient received radiation from the C-Arm fluoroscope and did not wear dosimeter badges a few years ago. The Chief Nursing Officer stated despite identifying the concern, they had failed to provide operating room staff members with dosimeter badges.