HospitalInspections.org

The Critical Access Hospital (CAH) identified a census of 9 patients. Based on observation, policy review, and staff interview, the CAH failed to ensure medications were stored in locked areas, failed to secure medications and supplies in a Pediatric crash cart, and failed to ensure outdated and unusable medications and supplies were not available for patient use in the Critical Access Hospital areas of Cardiac Rehabilitation Unit, Laboratory, Emergency Room and Radiology Department.

Findings include:

- The Hospital Pharmacy policy for "CRASH CARTS, TACKLE BOXES AND MED TRAYS", reviewed on 1/10/13 revealed a plan of- "...3. Outdates will be checked by pharmacy monthly and restocked accordingly...4. Nursing will check the crash cart every shift verifying the locked and stocked status...".

- The Hospital Pharmacy policy for "CRASH CART TAGS", reviewed on 6/2012 revealed a plan for -..."Procedure. 1. All crash carts will be locked with a numbered yellow lock. The number should be logged on a crash cart log...2. Nursing staff will check and log the crash cart lock status every shift...3. In the event the cart is used or found unlocked, then the pharmacy should be notified. Pharmacy will then restock meds and reseal..."

Tour of the Hospital Laboratory department on 1/8/13 at 10:00am revealed the following opened and outdated supplies:

The blood collection room contained nine light blue laboratory blood collection tubes which expired on 3/12, one butterfly blood collection set out of it's sterile packaging, 0ne Povidone Iodine swab which expired 12/11, one purple top 50 Microgram Microtainer blood tube which expired 1/12, one blood collection Prep Kit with Tincture of Iodine which expired 5/10, one package of gauze label as "hypoallergenic" which expired 7/12, seven vacuette blood collection needles, six which expired on 6/09 and one which expired on 5/09, one Gentleheel lancet which expired 11/12, Microtainer lab blood container tubes, two green tops which expired 1/10, one expired on 2/11, and one expired on 1/12. On 1/8/12 at 10:15am Laboratory Supervisor staff member H stated that all of the laboratory staff checked for outdates.

The laboratory blood draw tray used by licensed laboratory staff member E, contained a 400 microgram green lab tube, that expired on 1/12

The laboratory blood draw tray used by licensed laboratory staff member I contained two light blue micro collection blood tubes which expired on 12/08, one tenderfoot heel incision device which expired on 6/07, and a green micro collection blood tube which expired on 3/12, a purple top microcollection blood tube which expired on 9/12.

The laboratory blood draw tray used by licensed laboratory staff member G, contained an open butterfly blood draw device (a device used to insert into the vein of a patient and attaches to the blood tube from the opposite end and when discarded has blood throughout the system), a Gentleheel lancet which expired on 11/12 and green top microtainer blood collection tubes one of which expired on 1/10, one expired on 10/10, one which expired on 2/11, and one which expired on 1/12. Licensed staff G, on 1/8/13 at 10:20am verified the cart contained open vacutainer devices and the supplies "should have been trashed..."

The Cardiac Rehabilitation Department, on 1/8/13 at 2:42pm contained a Crash Cart with medications and supplies for emergency treatment of patients. This cart contained two combivent endotracheal tubes which expired on 6/12, seven endotracheal tubes of varying sizes between 4.0 millimeter (mm) to 9.0 mm which expired between 3/11 and 11/12, two 18 gauge Insyte Intravenous Catheter one which expired on 4/12 and one which expired on 5/12, twenty one packages of Red Dot ECK electrodes which expired 12/12, four packages of Skintact EKG electrodes which expired on 12/10, one bottle of Aminophylline 250 milligrams which expired on 6/1/12, 4 sample boxes of Plavix 75 milligrams which expired between 2/12 and 6/12. The monitor record for staff verification of review for outdated supplies and medications was dated on 1/12/13, but failed to identify the above supplies and medications.

The Medication Box in the Computerized Tomography (CT) room on 1/8/13 at 9:06am contained 3 vials of Epinephrine for patient emergency treatment, which expired on 10/12.

The Pediatric Emergency Cart on 1/7/13 at 1:50pm had a broken numbered lock which made the cart contents available to anyone in the area. Licensed nurse J, interviewed on 1/7/13 at 1:55pm verified Hospital staff should check and document the cart remained locked once a shift. Review of the Pediatric Emergency Cart monitoring record on 1/10/13 at 10:10am revealed staff failed to document between 7/29/11 and 12/30/12 the lock in place 450 days of the last 601 days and on two occasions the cart was found unlocked.

- Tour of the hospital laboratory department on 1/8/13 at 10:00am revealed the following:

The blood collection room contained one opened sterile butterfly blood collection set.

The laboratory blood draw tray used by licensed laboratory staff member F, contained an open bin storage area with an open and potentially used leur adapter needle sheaths (the part of the collection set which connects to the blood collection tube and contains patient blood within the unit).

The laboratory blood draw tray used by licensed laboratory staff member I contained an opened sterile syringe. Under the handle of the blood draw tray were 5 used and discarded luer end caps from butterfly blood collection sets.

The laboratory blood draw tray used by staff member G, contained an open butterfly blood draw device out of it's sterile packaging. Licensed Laboratory supervisory staff member G, on 1/8/13 at 10:20am verified the cart contained open vacutainer devices and the supplies "should have been trashed..."

CAH laboratory administrative licensed staff member H interviewed on 1/8/13 at 10: 50am verified the CAH failed to have a policy and procedure which directed staff to discard the used blood draw devices.




20940

The Critical Access Hospital (CAH) reported a census of 9 patients. Based on document review, review of manufacturer's instructions for use and staff interview, the infection control officer failed to develop and implement policies for identifying, reporting, investigating and controlling infections in the dietary and laboratory departments.

Findings include:

- The dietary kitchen, observed on 1/8/13 at 10:30am revealed staff prepared food for patients, visitors and staff. Dietary manager B, interviewed on 1/8/13 at 10:45am, stated all cookware, dishes and utensils are disinfected by the dishwasher.

The dishwasher temperature monitoring log, reviewed on 1/9/13 at 11:00am, revealed the wash and rinse water temperature should be documented in the morning, at noon and evenings. The log contained documentation of the dishwasher temperature for eight of the 22 meals for January 1 through January 8, 2013. The temperature monitoring log for December 2012 contained documentation of the dishwasher temperature for 40 of the 93 meals served. The log for November 2012 revealed documentation of the dishwasher temperature for 45 of the 90 meals served. Staff B acknowledged the temperature monitoring documentation was incomplete and lacked consistent documentation of validating the dishwashers temperature to ensure sanitization of dishes.

The CAH's policy titled "Dietary Department", reviewed on 1/10/13 at 12:30pm revealed "the dietary supervisor directly supervises employees on daily sanitation".

Staff B, interviewed on 1/10/13 at 10:30am, acknowledge the CAH failed to assure dishwasher temperatures are monitored each meal to ensure the water temperature reached the required temperatures for sanitization.

The CAH failed to develop and implement infection control policies in the dietary department, ensure staff monitored the dishwasher water temperatures reached temperature recommended by the manufacturer for sanitization.

- The dietary kitchen, observed on 1/8/12 at 10:30am had a wall-mounted fan blowing air over the cookware, dish and utensil cleaning and disinfecting area. The fan blades was casing contained a heavy build-up of dust and debris.

Dietary administrative staff B and Infection Prevention nurse A, interviewed on 1/8/13 at 11:00am, acknowledged the fan had a build up of debris. Dietary administrative staff B stated they were unaware of any fan cleaning policies or who would be responsible for cleaning the dietary fan. and lacked knowledge of the policy or procedure for cleaning the fan.

The CAH failed to develop and implement an infection control policies to ensure staff provided a clean environment in the dietary department.

- The Laboratory department, on 1/8/13 at 10:00am, contained numerous stacks of "Crossmatch Result Forms" pre-signed by Physician K. These forms contained areas for documentation of blood vital signs, reactions, blood type, Crossmatch as well as patient specific information.

Licensed Supervisory Laboratory staff H, on 1/8/13 at 11:07am verified the pre-printed and and pre-signed forms result from printing. The cross match results forms were dated as approved 9/18/07, and Licensed administrative laboratory staff H stated they used the forms since that date. \

.- The medical record for inpatient #21, reviewed on 1/8/12, revealed the patient received 2 units of blood. The medical record contained Laboratory forms titled "Crossmatch Result Form" and "Transfusion Record". Both of these 2 part forms contained the signature of Physician K. All 4 of the signatures from these 2 forms were the same.

Licensed laboratory administrative staff member H, interviewed on 1/8/13 at 11:07am verified the CAH Pathologist approved the blood forms for use and that is what their pre-printed signature verified. Staff H stated the CAH laboratory staff have completed the forms in this manner since approval on 9/18/07. Staff H further stated the actual blood utilization post transfusion was reviewed monthly during Utilization review.

- The deficient practice of lack of date and time in every entry into the medical record also affected patient #'s 1, 2, 11, 12, 13, 14, 15, 16, 24, 26, 27, 28, 29, 30, 31 and 32).




20940

The Critical Access Hospital (CAH) reported a census of eight acute care patients and one swing bed patient. Based on document review and staff interview the CAH failed to ensure physicians date and/or time all authenticated (signed) entries in the clinical record for 19 of 34 patient clinical records reviewed (patient #'s 1, 2, 11, 12, 13, 14, 15, 16, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 and 32).

Findings include:

- Patient #22's medical record reviewed on 1/9/13 at 10:30am, revealed an admission date of 11/20/12 for labor and delivery of a baby. The clinical record lacked evidence of the time and date the physician signed the admission orders and the delivery note.

- Patient #23's medical record reviewed on 1/9/13 at 11:00am revealed an admission date of 8/9/12 for labor and delivery. The clinical record lacked evidence of the time and date the physician signed the admission orders, pre-operative orders, post- operative surgical notes and progress notes.

- Patient #25's medical record, reviewed on 1/9/13 at 10:40am revealed a delivery date of 12/3/12. The clinical record lacked evidence of the time and date the physician signed the admission orders.

- The CAH's medical record policy titled "Health Information Resources 2.7 Guidelines for medical Records Entries", reviewed on 1/10/13 at 1:20pm, revealed entries are to be "...clearly noted with date and time".

Administrative Staff member L and Medical Records Administration staff member M, interviewed on 1/10/13 at 2:15pm acknowledged all entries in the clinical record require the date and time the entry is authenticated.