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Based on the certification survey completed on August 27, 2015, the facility was found not in compliance with Life Safety Code requirements at CFR §485.623(d).

Refer to Life Safety Code deficiencies at regulations: Building 1-K-0018, K-0029, K-0050, K-0052, K-0056, K-0069, K-0144, K0147; and Building 2: K-0050; K-0052, K-0062, K-0144 for additional information.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

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Based on interview and document review the critical access hospital (CAH) failed to develop a plan to ensure the amount of potable and non potable-water needed in the event of an emergency. This had the potential to affect all patients and staff who receive services of the CAH.

Findings include:

During review of the CAH's Emergency Water Plan, last revised 1-2015 " It is anticipated that the water demand for (CAH) is approximately 80 gallons per resident/patient per day and ten gallons per employee". This policy did not specify a water distribution plan for the amount of non-potable water needed, nor the amount of non-potable water needed in the laundry, housekeeping and dietary departments.

The CAH had contracts with the following businesses:

Glenwood Fire Department dated 3/15/2006; "In the event of a disaster/emergency involving potable water needs for Glacial Ridge Health System. Glenwood Fire Department will transport potable water for your facility. The hospital administrator or Maintenance Department will designate the amount needed depending on the type of disaster/emergency."

City of Lowry, dated, 3/15/2006: "The City of Lowry consents to assist in furnishing potable water to Glacial Ridge Health System in the case of an emergency or disaster. Their hospital administrator and Maintenance Department will designate the amount needed depending on the type of disaster/emergency".

City of Brooten dated, 3/15/2006, "The City of Brooten consents to assist in furnishing potable water to Glacial Ridge Health System in the case of an emergency or disaster. Their hospital administrator and Maintenance Department will designate the amount needed depending on the type of disaster/emergency".

City of Starbuck dated, 3/15/2006, "The City of Starbuck consents to assist in furnishing potable water to Glacial Ridge Health System in the case of an emergency or disaster. Their hospital administrator and Maintenance Department will designate the amount needed depending on the type of disaster/emergency".

None of the above contracts specified the actual amount of potable water they would be able to supply to CAH in the event of a disruption of water service .

During interview with the maintenance director on 8/26/15, at 8:45 a.m. it was stated their contracts lacked specifics as to the amount of water each business would supply.
He also agreed the "Emergency Water Plan" did not address the amount of potable versus non-potable water needed for patients, employees and the departments of dietary, housekeeping, and laundry.

Based on observation, interview, and record review, the Critical Access Hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tags: Building 1-K-0018, K-0029, K-0050, K-0052, K-0056, K-0069, K-0144, K0147; and Building 2: K-0050; K-0052, K-0062, K-0144 for additional information.

Based on interview and document review, the facility failed to investigate medical errors to determine the causal factors, and did not educate staff to prevent future errors for 4 of 4 patients (P23, P24, P25, P26) whose medication errors reviewed.

Findings include:

It was noted when medication variance report were reviewed that P23 had received additional antibiotic doses as there was no stop date identified on the physician order even though the order was for the patient to receive only 3 total doses of antibiotic. The report lacked information on the antibiotic involved, the dosing schedule (how often the antibiotic should be given), the nurse staffing at the time of the error and the number of extra doses administered. The incident report was marked as an error occurred that reached the patient but did not cause harm. The error was identified as a prescribing error and then changed to a transcription error. The Corrective Action Taken: "Notified pharmacist to discontinue off MAR [Medication Administration Record]. The Assessment and Summary of Error indicated "make sure the stop date is entered".

A medication error report reviewed for P24 indicated the patient did not receive scheduled non-steroidal anti-inflammatory medication (NSAID) and an antibiotic; when asked, the nurse stated she had given them but the antibiotic bag was not found in the patient room. The Corrective Action Taken: "give the next scheduled dose". The report lacked information on how many antibiotics had been dispensed for the patient, what the nurse staffing was at the time of the error and/or any staff follow up. The incident report was marked as an error occurred but the medication did not reach the patient. The error was marked as an omission error. The Assessment and Summary of Error was blank.

When interviewed on 8/26/15 at 10:00 a.m. the director of nursing (DON) stated "it looks like an incomplete investigation."

P25-Patient received a higher dose of pain killer than was physician ordered because the medication was given before checked against the physician orders to verify accuracy. The incident report was marked as an error occurred that resulted in the need for increased patient monitoring but no patient harm; documentation indicated, "frequent checks on patient, vital signs". The error was marked as an wrong dosage-form error, then changed to transcription error and improper dose error. The Assessment and Summary of Error indicated: "Double check new med orders with chart and/or second nurse if first administration." Evidence of futher investigation and follow up was lacking.

P26-Medication was entered into the electronic system incorrectly for a pain medication that should have been entered as every 8 hours as needed and was instead entered as a scheduled medication every 8 hours. A muscle spasm medication was as scheduled 4 times a day and should have been entered as every 4 hours as needed (ordered to receive up to 6 doses a day). The report lacked information of why the policy to check orders was not followed and what the nursing staffing and e-pharmacy staffing at the time of the error. The Corrective Action Taken: "updated OMAR. The incident report was marked as an error occurred that reached the patient but did not cause harm. The error was marked as transcription error. The Assessment and Summary of Error indicated: "nursing to double check pharmacy entries. Pharmacist to review e-pharmacy orders".

When interviewed on 8/26/15, at 10:00 a.m. the pharmacist verified that nursing should investigate medication errors and the pharmacist reported medication errors to the Pharmacy and Therapeutics Committee and the Medical Staff Committee as a brief type written report of errors, shortages, formulary additions, and adverse reactions.

On 8/27/15, at 9:00 a.m. an interview with registered nurse (RN)-E verified that orders should be checked against the written order prior to administration of the first dose of medication.

The facility failed to fully investigate medication errors as evidence was lacking to indicate they were analyzed for causative factors, identification of trends nor that follow-up occurred so that corrective actions were implemented/sustained to prevent future medication error.

Based on observation, interview and document review the Critical Access Hospital (CAH) was found not to be in compliance with the Condition of Participation of Surgical Services 485.639. The CAH failed to ensure the safe use of electrocautery devices resulting in a risk for fire in the operating room and/or risk for patient burns for 1 of 2 surgical patients (P22) observed where the surgeon and/or surgical staff failed to operate the electrocautery device [CAUTERY UNIT "Covidien Force Triad"] as directed by hospital policy and the manufacturer's recommendations during a surgical procedure.

Findings include:

On 8/25/15, at 8:18 a.m. the surgical scrub with Chlorexedine (antiseptic antibacterial agent) was completed; at 8:21 P22 was draped with the right arm extended 90 degrees away from the body at the shoulder line. P22 was receiving oxygen via mask under the surgical drape that extended above the head of the patient and was clamped to poles on the surgical bed. The electrocautery was in continuous use from 8:28 to 9:06 a.m. when it was placed on the surgical drape on the chest of the patient. A Kelly clamp was affixed to the drape at approximately the nipple line of the chest and the cautery tip was positioned on the Kelly clamp. The elctrocautery was on the surgical drape from 9:06 until 9:11 (5 minutes). The elctrocautery was placed on the drape again at 9:12 a.m. until 9:22 a.m. (10 minutes). The elctrocautery was placed directly on the patient from 9:24 a.m. until 9:27 (3 minutes) without the use of the Kelly clamp. The electrocautery was placed on the surgical drape a total of 18 minutes during the surgical procedure. The elctrocautery holster was never utilized during the entire procedure nor was it available for use within the sterile surgical field.

When interviewed on 8/25/15, at 9:32 a.m. the surgical Tech (ST)-A verified that an electrocautery holster was available in the surgical suite and had been left on the sterile preparation table off to the side of the room. ST-A indicated the Kelly clamp was used to prop up the electrocautery tip [a work around].

When interviewed on 8/25/15, at 9:30 a.m. at the surgeon verified that using the electrocautery holster was a safety standard of practice and the holster should have been used. Additional surgery staff present in the operating room included: the circulating registered nurse (RN)-A, ST-A, the certified registered nurse-anesthesia (CRNA)-A and CRNA-B. None of the staff had challenged the lack of cautery holster.

When interviewed on 8/25/15, at 10:00 a.m. the surgical services manager (SSM) stated the elctrocautery holster should have been used, as reflected in the policy.

At 10:15 a.m. registered nurse (RN)-F stated she had just added the surgical fire risk score to the electronic health record (EHR) that morning [the EHR did not have an option to indicate fire risk score].

A review of the surgical policy titled Operating Room Fires Prevention and Procedure dated 9/9/10, and reviewed 7/15, indicated...
Duty and responsibility of all staff....
policy reviewed and signed off on annually....
Fire requires all three elements-Fuel, ignition source and oxygen. Employees need to work as a team and take precautions to ensure that these elements do not come in contact with each other...
Never place the cautery pencil on the patient. Place the cautery pencil in the protective holster to prevent accidental activation of the cautery....