HospitalInspections.org

Based on documentation review, observation and interview it was determined the hospital failed to ensure mechanical and electrical equipment available for patient use was inspected and had routine maintenance. This has the potential to affect all patients receiving care at the hospital.

Findings include:

1. The policy titled "Maintenance of Equipment" (revised November 2009) was reviewed on 4/9/2015 at 12:15 AM. The policy indicated "Policy: All equipment will be maintained and tested on a periodic basis."

2. A tour of the sleep laboratory unit was conducted on 4/9/2015 at 11:00 AM with E#19 (Sleep Lab Coordinator). The following was observed:

In sleep room #1 and #2 there were two (2) Respironics Omni Lab Advanced CPAP
(continuous positive airway pressure) machines which had an inspection sticker dated 4/8/2009. Neither CPAP machine had a maintenance sticker.

In sleep room #1 there was a DeVilBiss 5 liter oxygen concentrator which had a inspection sticker dated 4/8/2009. There was not a maintenance sticker.

In sleep room #2 there was a Total O2 (oxygen) Delivery System oxygen concentrator with a inspection sticker dated 7/28/09. There was not a maintenance sticker.

In sleep room #2 an ALOHA Breeze Vintage Stand Fan had an inspection sticker dated 9/2/2009. There was not a maintenance sticker.

3. An interview was conducted on 4/9/2015 at 11:15 AM with E#20 (Maintenance Plant Operation Manager). E#20 stated "patient care equipment brought in by vendor's are serviced by the vendors and the equipment does not go thru the maintenance department. We are currently in the process of changing our policy to anything that is patient care equipment brought into the hospital will get a maintenance check and be put on the routine yearly maintenance inspection."

Based on document review and staff interview it was determined the CAH (Critical Access Hospital) failed to send a delinquent notification letter and suspend privileges for 8 of 8 (E#9, E#10, E#11, E#12, E#13, E#14, E#15, E#16) physicians with delinquent records greater than 30 days.

Findings include:

1. The Medical Staff Bylaws (revised 3/2015) were reviewed on 4/08/15 at 10:15 AM The Medical Staff Bylaws indicated under 7.1-6 Delinquent Medical Records "Medical records must be completed within thirty (30) days post discharge. A medical record will be considered delinquent if not completed within 30 days post discharge... A letter will be sent to the physician any time a chart is 21 days or older and they will have 9 days to complete them. If the records are not done within 9 days, the physician will be suspended from Medical Staff."

2. The Physician Deficiency Report was reviewed on 4/8/15 at 10:45 AM. It indicated E#9 had 8 deficient records, E#10 had 7 deficient records, E#11 had 1 deficient record, E#12 had 17 deficient records, E#13 had 8 deficient records, E#14 had 1 deficient record, E#15 had 1 deficient record, and E#16 had 12 deficient records as of 4/8/15.

3. A staff interview was conducted on 4/8/15 at 10:00 AM with the Medical Records Manager (E#8). E#8 verbalized "I do send delinquent notification letters to the physicians." E#8 also attempted to have records signed when the physicians are in the hospital working. E#8 had no documentation of delinquent letters/log. No documentation was found of any physicians suspended for delinquent records as of 4/8/15.

A. Based on document review, observational tour and interview the Hospital failed to ensure safe medication storage in 2 of 3 (room #317 and room #318) obstetric rooms.

Findings include:

1. The Hospital policy titled, "Drug Procurement/Inventory Control" was reviewed on 4/6/2015 at 4:00 PM. It required "2. Storage a. i. Medications are stored in a secure manner. iv. Medication rooms on patient care units used for storage of floor stock-medications will remain locked. Access is limited to licensed nursing personnel."

2. On 4/7/2015 at 11:00 AM an observational tour was conducted on the OB (Obstetric) unit. A locked emergency neonate crash box was observed on the radiant warmer in room #317 and room #318. The OB unit is a non secured area and room #317 and room #318 are not locked. The emergency neonate crash box contained the following:

* one (1), ampule Epinephrine 1:10,000/mg (milligram) injectable

* two (2), Narcan 0.4 mg/ml (milliter) injectable

* two (2), ampules Dextrose 10% injectable; and

* two (2), 4.2% 10 ml. syringe Sodium Bicarbonate injectable.

3. The Obstetric Manager (E#7) stated during the observational tour on 4/7/14 at approximately 11:30 AM, the neonate crash boxes should be locked in a secured area.

B. Based on documentation/record review, observational tour and interview it was determined the Hospital failed to ensure expired medication and biological's were not available for patient use. This has the potential to affect all patients receiving care at the hospital.

Findings include:

1. The Hospital policy titled "Outdated Supplies" was reviewed on 4/8/2015 at 10:30 AM. It required under "Policy: No outdated sterile supplies shall be maintained in stock or on the units at any time, and appropriate measure shall be taken to ensure that these supplies do not exist.

2. On 4 /7/2015 at 12:30 AM an observation tour was conducted with the Medical/ Surgical, Intensive Care and Obstetric Manager (E#7). The following expired biological's were found in the clean utility room on the Medical-Surgical Unit:

*four (4) Tracheostomy Clean and Care Tray Kits expired 09/2012

*three (3) 0.25% Acetic Acid Irrigation 1000 ml (milliter) expired 7/01/2014

*six (6) Power Loc Safety Infusion Set expired 3-2015

3. An interview was conducted with E#7 on 4/7/2015 at 1:30 PM. E#7 stated the expired items should have been discarded. E#7 stated "the Outdated Supplies policy refers to all biological's not just sterile supplies. We will need to change the policy."

Based on observational tour and interview, it was determined the hospital failed to ensure equipment was thoroughly disinfected prior to patient use. This has the potential to affect all patients on the medical surgical unit.

Findings include:

1. On 4/7/2015 at 14:00 PM an observational tour was conducted in the CT (computerized tomography) Department. In the CT room a table pad with rips/tears in the plastic on both ends of the pad and had exposed foam was observed. This reduces the potential for thorough disinfection.

2. On 4/7/2015 at 2:00 PM, an interview was conducted with Imaging Manager (E#17). E#17 stated the pad should be replaced.

Based on document review, observation and interview, it was determined that for 1 of 1 dietary departments observed, the Hospital failed to ensure the dietary staff followed established policies and procedures to maintain a sanitary food service environment. This has the potential to affect all patients receiving dietary food services in the hospital.

Findings include:

1. On 4/8/15 at 1:40 PM, hospital policy titled "Prevention of Food Contamination" was reviewed. The policy indicated "Procedure: 4. All Food service workers will practice good hygiene using frequent and appropriate hand washing techniques as well as the use of hairnet or an approved cap to completely cover all of their hair."

2. On 4/8/15 at 2:05 PM, hospital policy titled "Storage of food" was reviewed. The policy indicated "Procedure: 5. Leftovers will be placed into covered, labeled , and dated containers and stored in a refrigerator or freezer."

3. On 4/6/15 at approximately 3:30 PM an observational tour was conducted in the Dietary Department. E#18 (cook) was wearing a hat that covered the center of the head only leaving hair uncovered.

4. An interview with the Dietitian (E#5) at approximately 4:00 PM was completed. E#5 verbalized that female employees must wear a hairnet. However, males are allowed to wear a hairnet or an approved hat.

5. On 4/6/15 at approximately 3:30 PM, an observational tour was conducted in the dietary department. In a food storage area, two items were found opened and not dated; (1) 48 oz bottle of real lemon juice and (1) four lb jar of "Carriage House" raspberry preserves. In a refrigerated area (5) salads were observed covered with no date prepared or label.

6. E#5 was asked about the lemon juice and the preserves and verbalized they should have been dated on opening. E#5 removed both items from use in the kitchen. E#5 verbalized that the salads had been prepared today and had just not been dated yet.

Based on Observation and staff interview, it was determined the Hospital failed to ensure those staff utilizing the Computed Tomography (CT) room were protected from radiation hazards. This has the potential to affect all staff working in the CT room.

Findings include:

1. During a tour of the Radiology Department on 4/7/2015 at 2:00 PM, it was observed in the CT room, the shoulder of the lead apron was ripped and open to radiation exposure.

2. An interview was conducted with the Imaging Manager (E#17) on 4/7/2015 at 2:15 PM. E#17 confirmed the lead apron was ripped and did not provide adequate shielding from radiation.

Based on document review and staff interview it was determined the CAH (Critical Access Hospital) failed to ensure 37 medical records were completed within 30 days of patient discharge as of 4/8/15. This has the potential to affect all patients receiving care.
Findings include:

1. The Medical Staff Bylaws (reviewed 3/2015) were reviewed on 4/8/15. 7.1-6 Delinquent Medical Records indicated "Medical records must be completed within thirty (30) days post discharge. A medical record will be considered delinquent if not completed within 30 days post discharge."

2. The Physician Deficiency Report was reviewed on 4/8/15 at 10:45 AM. It indicated eight physicians have delinquent records greater than 30 days. E#9 had 8 deficient records, E#10 had 7 deficient records, E#11 had 1 deficient record, E#12 had 17 deficient records, E#13 had 8 deficient records, E#14 had 1 deficient record, E#15 had 1 deficient record, and E#16 had 12 deficient records as of 4/8/15.

3. A staff interview was conducted 4/8/15 at approximately 10:00 AM with the Medical Records Manager (E#8). It was indicated the policy for signing delinquent medical records was not followed. It was confirmed the Physician Deficiency Report dated April 8, 2015 had a total of 37 deficient medical records.

Based on document/record review and staff interview, it was determined that in 2 of 4 (Pt #5 and Pt #8) surgical patient records reviewed, it was determined the facility failed to ensure an updated history and physical was performed prior to surgery.

Findings include:

1. The Medical Staff Rules and Regulations (revised March 2015) was reviewed on 4/7/2015. The Rules and Regulations under section 7.3-1 required preoperative documentation to indicate an updated examination of the patient, including any changes in the patient's condition to be placed in the patient's medical record prior to surgery or a procedure requiring anesthesia services.

2. The medical record of Pt #5 was reviewed on 4/7/15. It indicated Pt #5 was admitted on 4/3/2015 with a diagnosis of left hip fracture. Documentation on the "History and Physical Update" sticker failed to indicate if there was no change or a change after the patient was examined since the initial history and physical was completed. The "History and Physical Update" sticker was not dated or have a time indicating completion.

3. The medical record of Pt #8 was reviewed on 4/6/2015. It indicated Pt #8 was admitted on 4/6/2015 with a diagnosis of total knee arthroplasty. Documentation on the "History and Physical Update" sticker failed to indicate if there was no change or a change after the patient was examined since the initial history and physical was completed. The "History and Physical Update" sticker was not dated or have a time indicating completion.

4. A staff interview was conducted with the Manager of the Medical Surgical Unit (E#7) on 4/7/2015 at 2:00 PM. E#7 stated the updated history and physical sticker should have a date and time indicating no change or a change in the patient's physical exam prior to going to surgery.

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Based on document/record review and staff interview, it was determined in 1 of 20 (Pt #5) medical records reviewed the facility failed to ensure physician orders were authenticated, dated and timed by the ordering physician.

Findings include.

1. The policy titled "Physician's Orders, Transcription Of" was reviewed on 4/8/2015. The policy indicated under "Policy 2. All telephone orders must be signed, dated and timed by the physician within 48 hour..."

2. The medical record of Pt #5 was reviewed on 4/7/2015 at 3:00 PM. Pt #5 was admitted to the Medical/Surgical Unit on 4/3/2015 with a diagnosis of left hip pain, fall. The Physicians Orders for 4/4/2015 indicated a telephone order was taken at 8:06 PM. As of 4/7/2014 at 3:00 PM this telephone order has not been signed, dated or timed by the physician.

3. An interview was conducted with the Manager of Medical/Surgical Unit (E#7) on 4/7/2015 at 3:15 PM. E#7 confirmed the telephone order was not signed, dated or timed. E#7 stated expectation of telephone orders are to be signed in 48 hours.

A. Based on document review and staff interview, it was determined the Critical Access Hospital (CAH) failed to ensure adverse events were reported and monitored for quality assurance. This has the potential to affect all patients receiving services by the CAH.

Findings include:

1. The policy "2015 Risk Management Plan" (reviewed 1/2015) was reviewed on 4/9/15. The policy stated the plan was designed to assist in identification of problems to expedite root cause analysis with the implementation of corrective actions and the information will be collected through unusual occurrence reports. The policy titled "Reporting of Occurrences" (no date) was reviewed on 4/10/15. The policy required occurrences such as medication errors, adverse drug reactions, patient/employee/visitor injury and sentinel events to be reported in the MEDITEC variance system or by completing a form.

2. During the entrance conference on 4/6/15, a list of unusual occurrences for the past six (6) months was requested. A list was not provided as of end of survey on 4/10/15.

3. During an interview on 4/9/15 at approximately 11:30 AM, E#2 (Quality Project Manager) stated the MEDITEC variance system was not well utilized by the CAH and information was mostly gathered verbally. E#2 stated the staff needed education on the use of the variance reporting system because the data collected was not all inclusive.

B. Based on document review and staff interview, it was determined the CAH failed to ensure complaints and grievances were documented, investigated and monitored for quality assurance. This has the potential to affect all patients receiving services by the CAH.

Findings include:

1. The policy "2015 Risk Management Plan" (reviewed 1/2015) was reviewed on 4/9/15. The policy stated the risk management program was responsible to identify, evaluate, trend and respond to inter-hospital and customer complaints. The policy titled "Complement/Complaint Management" (no date) was reviewed on 4/9/15. The policy stated a log will be maintained by the Risk Manager to include complaints received, actions taken, resolution and follow up. The policy stated summary reports will be provided quarterly to the Quality Improvement Committee, Chief Executive Officer (CEO) and Board of Directors.

2. The Quality Council/Credentials Committee meeting minutes dated 3/20/15 and 1/23/15, the Medical Staff Quality Improvement Committee meeting minutes dated 3/10/15 and the Hospital Departmental Quality Improvement and Clinical Safety Committee meeting minutes dated 1/14/15 were reviewed on 4/9/15. The meeting minutes lacked documentation that complaints were reviewed.

3. During an interview on 4/9/15 at approximately 11:45 AM, E#2 stated a complaint log or record of the investigation, resolution or review had not been maintained by the CAH. E#2 stated complaints are reviewed by the CEO but not trended or taken through committees.