HospitalInspections.org

Based on CAH document review, observation, and staff interview, it was determined the CAH failed to ensure medications used in treating emergency cases were made readily available. This had the potential for adverse patient outcomes during emergency treatment. Findings include:

An observation of the ED was conducted on 10/03/17, beginning at 1:30 PM, in the presence of the DON. The ED was assigned 1 crash cart, which was used for emergency cases. The DON opened the crash cart and the contents were examined. The following 7 emergency medications had expired:

- Nitropress, expired 9/2017

- Lidocaine, expired 6/2017

- Atropine, expired 4/2017

- Nitroglycerin, expired 5/2017

- Amiodarone, expired 8/2017

- Magnesium sulfate, expired 9/2017

- Dopamine, expired 5/2017

The DON was interviewed on 10/03/17, beginning at 1:40 PM. When asked who was responsible to ensure emergency medications were not expired, she stated the ED RN was to inventory the crash cart after each use and record findings on a log. The crash cart log documented the last check of the cart was on 5/2017. She stated there was no CAH policy which governed this process. The DON confirmed the crash cart was not being checked for expired medications and she removed the expired emergency medications.

The CAH failed to ensure medications used in treating emergency cases were readily available.

Based on observation and staff interview, it was determined the CAH failed to ensure emergency medical equipment was maintained. This failure had the potential for patients' health and safety to be compromised in the event of a medical emergency. Findings include:

An observation of the ED was conducted on 10/03/17, beginning at 1:30 PM, in the presence of the DON. The following 6 pieces of equipment, used for life saving procedures, had expired:

- 2 chest tubes, expired 10/2014 and 2/2017

- Olympus biopsy valve scope and kit, expired 10/2008

- Cricothyrotomy set, expired 4/2016

- Endotracheal tube, expired 4/2010

- 2 arterial blood gas syringes, both expired 7/2017

- Central venous catheter kit, expired 11/2016

The DON was interviewed on 10/03/17, beginning at 1:45 PM. When asked who was responsible to ensure emergency equipment was not expired, she stated the ED RN was to maintain the inventory. The DON stated there was no CAH policy which governed this process. She confirmed the emergency equipment was expired and had them removed.

The CAH failed to ensure equipment used for life saving procedures were maintained.

Based on medical staff bylaw review, medical staff rule review, and staff interview, it was determined the CAH failed to ensure mid-level practitioners participated in the development, execution, and periodic review of the CAH's written policies governing their services. This resulted in policy development and review without mid-level input. Findings include:

Medical staff bylaws, approved 2/07/05, were reviewed. They included a section titled "Allied Health Professional Responsibilities," however, CAH policy development, execution, and review for mid-level practitioners were not included.

Medical staff rules, revised 9/14/04, were reviewed. The rules included a section titled "Allied Health Professional Functional Rules and Regulations," however, CAH policy development, execution, and review for mid-level practitioners were not included.

The Director of Quality was interviewed on 10/04/17, beginning at 1:50 PM. When asked if mid-level practitioners participated in CAH policy development and review, she stated she was unsure, but believed they did not. She stated mid-level practitioners did not attend policy meetings. The Director of Quality confirmed the responsibility of mid-level practitioner participation in CAH policy development, execution, and periodic review was not outlined in the medical staff rules and bylaws.

The Nurse Practitioner was interviewed on 10/05/17, beginning at 3:15 PM. When asked if she participated in CAH policy development and review, she stated no. She stated she did not attend policy meetings and did not provide input regarding policy development.

The CAH failed to ensure mid-level practitioners participated in the development, execution, and periodic review of policies.

Based on CAH policy review and staff interview, it was determined the CAH failed to develop policies that described all services furnished. This failure resulted in a lack of organizational clarity. Findings include:

Policies which described the CAH's Physical and Occupational Therapy services were requested from the Director of Compliance on 10/05/17 at 2:25 PM. A Physical Therapy policy "Physician Oversight and Supervision of Physician Hospital Based Therapeutic and Diagnostic Services," approved 3/11/15, was provided. This policy did not describe the CAH's Physical Therapy service.

Occupational Therapy policies were not provided.

The Director of Compliance was interviewed on 10/06/17, beginning at 9:07 AM. She confirmed there were no policies which described the CAH's Physical and Occupational Therapy services.

The CAH failed to develop policies that described Physical and Occupational Therapy services.

Based on CAH infection control plan review and staff interview, it was determined the CAH failed to ensure a system to prevent potential transmission of infections and communicable diseases was fully implemented and involved all departments. This failure had the potential for infections to not be fully identified, reported upon, investigated, or controlled for all patients and personnel at the CAH. Findings include:

The CAH "Infection Control Program," dated 9/23/16, was reviewed. The plan did not include several key elements. Examples include:

1. Seven CAH departments were not represented under "Infection Control Committee Membership" of the infection control plan:

- Quality Assurance

- Compliance

- Surgical Services

- Radiology

- Maintenance

- Outpatient Clinic

- Therapy Services

3. The infection control plan did not include active surveillance methodology, data collection measures, or analysis methods.

4. The infection control plan did not include, or address, the following 5 CAH departments:

- Operating Room

- Radiology

- Therapy Services

- Respiratory

- Outpatient Clinics

5. Nationally recognized guidelines were not included or incorporated as part of the infection control plan.

The Infection Control Preventionist, Infection Control Nurse, and Director of Quality were interviewed together on 10/04/17, beginning at 10:00 AM, and the infection control plan was reviewed in their presence. They confirmed the plan did not include oversight of all departments, did not represent all departments in the infection control committee, and was not based on nationally recognized guidelines. The Infection Control Preventionist stated she was the designated staff member for active surveillance, but stated she had not performed that role for approximately 1 year.

The Infection Control Preventionist, Infection Control Nurse, and Director of Quality stated they were not aware the 2 outpatient clinics were departments of the CAH and confirmed there were no policies, oversight, or active surveillance governing infection control in those areas.

The CAH failed to ensure their infection control plan was facility-wide and involved all departments.

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to ensure medical records included complete and accurate medical record entries for 2 of 23 patients (#22 and #23) whose records were reviewed. This had the potential to interfere with the coordination and provision of patient care. Findings include:

1. A CAH policy titled "Procedural Sedation" dated 2/13/13, included the following guidelines for recovery and discharge of patients who had received procedural sedation:

"Recovery: Monitoring will be recorded at regular intervals until patient has regained his cough reflex, vital signs stable and returned to baseline mental mobility status...Recovery from sedation to pre-sedation baseline must be documented.

Discharge Criteria: The patient must be monitored until the following discharge criteria are met:

Respiratory: Retains the ability to maintain and protect the airway...displays no signs of respiratory distress...demonstrates the ability to cough, tolerates liquids or light nourishment...minimum of 30 minutes after the administration of the last dose of narcotic.

Consciousness: Fully oriented to time, person, place or return to baseline mentation.

Circulation: Stable vital signs for a minimum of 30 minutes.

Activity: Performs age-appropriate ambulation (walk, sit, stand)...Demonstrates controlled, coordinated movements...Presence of a responsible adult for discharge and home environment.

Oxygenation and Color: Maintains oxygen saturation greater than 95% on room air or attains pre-procedural oxygen saturation value...Pink skin color.

Pain: Minimal or no pain prior to discharge.

When the recovery nurse has determined that discharge criteria are met, this nurse may discharge the patient."

This policy was not followed. Examples include:

Patient #23 was a 67 year old male, who was admitted to the hospital as an outpatient, on 10/07/17, for a screening colonoscopy procedure. He was sedated for the procedure with 90 mg of Diprivan and 2 mg of Versed. The procedure ended at 9:15 AM and he was moved to a patient room at 9:20 AM for recovery.

Review of Patient #23's medical record showed no documentation of him being monitored at regular intervals. Vital signs were documented at 8:20 AM, the time of Patient #23's admission, and again at 11:32 AM. Additionally, the documented vital signs at the above stated times were identical.

There was no documentation he was assessed for his respiratory status, his ability to tolerate liquids or light nourishment, his return to baseline mentation, stable vital signs for 30 minutes, his ability to ambulate, his skin color, or his pain level.

Patient #23's discharge instructions were signed by the patient at 9:30 AM, acknowledging discharge instructions.

In an interview on 10/06/17 at 8:45 AM, the DON reviewed Patient #23's medical record and confirmed the missing post procedure assessment documentation.

Patient #23's record did not include documentation he was assessed post-sedation according to the CAH's policy.



37264

2. Patient #22 was a 76 year old female admitted on 6/28/17, with a small bowel obstruction. She had abdominal surgeries on 6/28/17 and 7/06/17. She was discharged on 7/15/17.

Patient #22's record included pre-printed "POST ANESTHESIA RECOVERY ORDERS," dated 6/28/17. The orders included the instructions "MARK ORDERS AS NEEDED. FILL IN AS DESIRED." The pre-printed order form was signed by the CRNA. The pre-printed orders included a section for "Analgesics," and the box in front of this was checked. However, the 4 medications listed underneath were not marked to indicate they may be given. It was unclear which analgesics were to be given for Patient #22 if she required pain medication.

The RN Coordinator for the OR was interviewed on 10/05/17, starting at 1:32 PM, and the pre-printed recovery order set was reviewed. He stated the medications were not always marked, and the PACU RN could determine what the patient might need. He confirmed there were no other instructions on the PACU orders for frequency of administration, or under what circumstances 1 medication should be given before the other 3.

The CAH failed to ensure medication orders in the PACU were clear and complete.

Based on medical record review and staff interview, it was determined the CAH failed to ensure informed consents were properly executed consents for 3 of 23 patients (#12, #13, and #14) whose records were reviewed. This resulted in a lack of clarity as to whether patients or their representatives were fully informed, or legally competent, to sign consents prior to treatment. Findings include:



25957

1. Patient #12 was a 26 year old male admitted to the CAH on 8/08/17, with a diagnosis of acute appendicitis. Surgical intervention occurred on the same date.

Patient #12's medical record included a consent for anesthesia services dated 8/08/17. The form was signed by a CRNA. However, Patient #12 did not sign the form.

In an interview on 10/06/17, at 8:45 AM, the DON reviewed Patient #12's record and confirmed the lack of his signature on the anesthesia consent. She stated the consent should have been signed by Patient #12 prior to the administration of anesthesia.

The CAH failed to ensure Patient #12's consent for general anesthesia was properly executed.


37264


2. Patient #13 was a 29 year old female admitted on 3/17/17, for placenta previa. She delivered at 1:13 PM on 3/17/17, and was discharged on 3/19/17.

Patient #13's medical record included a consent for "Postpartum Bilateral Fallopian Tubal Ligation." The word "Fallopian" had been written first in error, crossed through, and "Postpartum" written above. There were no initials indicating which staff member had corrected the error.

Additionally, on the same consent form, there was a line for the time of Patient #13's signature. There was no time documented, making it unclear when Patient #13 signed the consent.

The RN Coordinator for OR was interviewed on 10/05/17, starting at 1:32 PM. He confirmed there were no initials on the error on Patient #13's chart, and the time was not documented on the her consent.

The CAH failed to ensure Patient #13's consent for surgery was complete.

4. Patient #14 was a 21 year old female admitted on 8/06/17, for a Caesarean section. She was discharged on 8/08/17.

Patient #14's medical record included a consent for anesthesia. The consent included a section for marking the type of anesthesia to be used, the expected results, technique, and risks described for each of the 6 types of anesthesia listed. This section was left blank.

On the same consent, there was a "Blood Transfusions" section with areas to be marked regarding the likelihood of Patient #14 requiring a blood transfusion, and whether she would accept blood transfusions. This section was left blank. It was unclear what Patient #14 was consenting.

The RN Coordinator for the OR was interviewed on 10/05/17, beginning at 1:32 PM. He stated the CRNA was responsible for documenting the areas on the consent regarding the type of anesthesia and blood transfusions. The RN Coordinator for the OR confirmed they were not documented.

The CAH failed to ensure Patient #14's consent for anesthesia were complete.

Based on medical record review and staff interview, it was determined the CAH failed to ensure transfer forms were dated by the physician for 2 of 2 ED patients (#4 and #19) who were transferred to another facility and whose records were reviewed. This resulted in a lack of clarity regarding authentication of medical record entries. Findings include:

1. Patient #4 was a 41 year old male who was seen in the ED on 3/08/17, with a diagnosis of suicidal ideation. He was transferred to an acute care facility on 3/09/17.

Patient #4's medical record included a "TRANSFER OF PATIENT" form, signed by the physician. The physician's signature was not dated.

The DON was interviewed on 10/05/17, beginning at 8:50 AM, and Patient #4's medical record was reviewed in her presence. She confirmed the physician's signature on the transfer form was not dated.

The CAH failed to ensure the transfer form for Patient #4 was dated by the physician.

2. Patient #19 was a 38 year old female who was seen in the ED on 9/12/17, with a diagnosis of gun shot wound. She was transferred to an acute care facility on 9/12/17.

Patient #19's medical record included a "TRANSFER OF PATIENT" form, signed by the physician. The physician's signature was not dated.

The DON was interviewed on 10/05/17, beginning at 9:10 AM, and Patient #19's medical record was reviewed in her presence. She confirmed the physician's signature on the transfer form was not dated.

The CAH failed to ensure the transfer form for Patient #19 was dated by the physician.

Based on observation and staff interview, it was determined the CAH failed to ensure medical record information was safeguarded against destruction by water damage in their medical record storage area. This had the potential to result in water damage of original medical records. Findings include:

A tour of the Medical Records Department was conducted in the presence of the Director of Revenue Cycle and the Medical Records Supervisor on 10/03/17, beginning at 9:10 AM. During the tour, it was noted that original, non-archived medical records were organized in manilla folders which were placed on shelves. The medical records in the room were protected from fire damage due to the overhead sprinkler system. However, the exposed medical records were not safeguarded from potential water damage.

The Director of Revenue Cycle and the Medical Records Supervisor were interviewed together on 10/03/17, beginning at 9:27 AM. They confirmed the original, non-archived medical records were not safeguarded from potential water damage.

The CAH failed to ensure medical records were safeguarded against destruction by water damage.

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to ensure patients were discharged in the company of a responsible adult for 1 of 1 surgical outpatients (Patient #23) whose procedure was observed and whose record was reviewed. This had the potential for poor patient safety outcomes. Findings include:

A CAH policy titled "Procedural Sedation" dated 2/13/13, stated "The patient must be accompanied at discharge by a responsible adult, with written post-discharge instructions."

Patient #23 was a 67 year old male who was admitted as an outpatient on 10/07/17, for a screening colonoscopy procedure. He was sedated for the procedure with 90 mg of Diprivan and 2 mg of Versed.

Discharge instructions were signed by Patient #12 at 9:30 AM. However, there was no documentation showing a responsible adult had accompanied Patient #23 upon discharge.

In an interview on 10/06/17, at 8:45 AM, the DON reviewed Patient #23's record and confirmed there was no documentation he was accompanied by an adult at the time of discharge.

The CAH failed to ensure Patient #23 was accompanied by a responsible adult at the time of discharge.