HospitalInspections.org

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Based on record review and review of hospital policy and procedure, the critical access hospital failed to ensure staff members performed blood transfusion procedures according to policy for 2 of 3 patients reviewed (Patients #1, #2).
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Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.
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Findings:
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1. The hospital's policy and procedure titled "Blood and Blood Products" (Approved 3/9/2015) under the section "Administration of Lab-Acquired Blood Products" read in part: "6. Observe patient closely and frequently during transfusion for flow rate and unfavorable reaction. If transfusion reaction is suspected, see "SUSPECTED TRANSFUSION REACTION" section. a. Vital Signs are to be performed pre-transfusion, 15 minutes after starting transfusion, 30 minutes after start of transfusion, hourly, and post transfusion."
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2. On 7/8/2015 at 2:00 PM, Surveyor #2 reviewed the medical records of 3 patients who received blood transfusions during their hospital stay and observed the following:
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a. Patient #1 was admitted on 4/20/2015 for colon cancer and was given three units of packed red blood cells. During blood adminstration, nursing staff failed to record a temperature during the following intervals as required by their policy:
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i. The first 15 minutes for the second unit
ii. The first 30 minutes for the second unit
iii. The first 60 minutes for the second unit
iv. Upon completion of the transfusion
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b. Patient #2 was admitted on 4/30/2015 for left hip fracture and was given two units of packed red blood cells on 5/1/2015. During blood adminstration, nursing staff failed to record a temperature during the following intervals as required by their policy:
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i. The first 15 minutes for the first unit
ii. The first 30 minutes for the first unit
iii. The first 15 minutes for the second unit
iv. Upon completion of transfusion
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Based on observation, the critical access hospital failed to demonstrate a system to assure a maximum capacity of 25 inpatient beds, excluding rooms for patients on observation status.

Failure to identify designated rooms for inpatients creates a risk that the facility will exceed its designated capacity for patient care which may result in poor patient outcomes due to inadequate care or poor resource allocation.

Findings:

On 7/7/2015, Surveyor #1 conducted a physical bed count to determine how many acute care patient beds were available for patient use in the hospital. There were 28 acute care patient beds available, excluding beds identified as observation beds, and those used for the rehabilitation unit. This amount exceeded the maximum number of 25 acute care patient beds allowed under the critcal access hospital federal regulation.

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Based on observation and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.

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ITEM #1 - Surgical Attire

Based on observation, review of hospital policy and procedure and interview, the critical access hospital failed to ensure staff members followed the hospital policy for surgical attire.
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Failure to properly secure masks and maintain coverage of facial hair poses a risk to contamination of the sterile field.
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Reference: Association of Operating Room Nurses (AORN) Recommended Practices: "Implementing AORN Recommended Practices for Surgical Attire" (2012) - "Recommendation IV: All personnel should cover their head and facial hair when in the semi restricted and restricted areas. . . Recommendation VI: Masks should cover the mouth and nose and prevent venting. They should be secured at the back of the head and behind the neck to decrease the risk of transmitting nasopharyngeal and respiratory microorganisms to patients or to the sterile field."
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Findings:
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1. The hospital policy and procedure titled "AORN GUIDELINES" (Approved 3/12/2013) read in part: "For the following subjects, the guidelines suggested by AORN will be followed: a. Cleaning areas used for surgical procedures. b. Attire. . . PROCEDURE: The current AORN Perioperative Standards and Recommended Practices book is available in the surgical services department. Surgical Services staff are responsible for reviewing and being knowledgeable about the current guidelines."
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2. On 7/8/2015 between 12:30 and 1:30 PM, Surveyors #2 and #3 observed the following:
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a. A certified nurse anesthetist (Staff Member #1) entered an operating room with his/her mask tied at the top with the lower ties hanging down and not secured. Surgical personnel were opening sterile instruments and supplies at the time of the observation.
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b. A registered nurse (Staff Member #2) entered the operating room wearing a surgical hood covering but a significant portion of facial hair remained exposed. Surgical personnel were opening sterile instruments and supplies at the time the staff member entered the operating room.
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3. On 7/8/2015 at 1:30 PM, Surveyor #2 interviewed the director of surgical services (Staff Member #3) who acknowledged the described practices observed did not follow AORN standard practices adopted by the hospital.
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ITEM #2 - Safe Medication Injection Practices
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Based on observation, review of hospital policy and procedure and interview, the critical access hospital failed to ensure staff adhered to safe medication practices.
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Failure to ensure adherence to safe injection practices puts patients at risk for infection.
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Reference: Association for Professionals in Infection Control and Epidemiology (APIC) Position Paper: Safe Injection, Infusion and Medication Vial Practices in Healthcare." (2010) "Disinfect IV ports and vial stoppers by wiping and using friction with a sterile 70% isopropyl alcohol, ethyl alcohol, iodophor, or other approved antiseptic swab. Allow the port to dry before accessing."
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Findings:
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1. The hospital policy and procedure titled "Infection Control, Standard Precautions" (Approved 12/18/2014) read in part: "The following principles will also be observed with Standard Precautions: . . . Utilize safe injection practices including aseptic technique during injections." The policy did not specify how to adhere to safe injection practice.
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2. On 7/8/2015 between 12:30 and 1:30 PM in the operating room, Surveyor #2 observed a certified nurse anesthetist (Staff Member #1) administering an intravenous (IV) antibiotic to Patient #3 without first disinfecting the IV port.
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3. On 7/9/2015 at 9:16 AM Surveyor #3 observed a registered nurse (Staff Member #4) preparing an IV syringe containing diphenhydramine ( an antihistamine) for administration to Patient #4. The nurse did not disinfect the top of the vial after removing the dust cover. S/he proceeded to insert a needle thru the vial's diaphragm to withdraw the medication into a syringe.
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4. On 7/9/2015 at 9:30 AM, Surveyor #3 interviewed the nurse (Staff Member #4) who prepared the IV medication for Patient #4. Staff Member #4 acknowledged s/he did not know the rubber septum of the vial required disinfection prior to medication withdrawal.