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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff maintain supplies and equipment to meet patient care needs during an emergency for 2 of 4 emergency carts inspected.

Failure to maintain supplies and equipment risks patient injury or delays in emergency treatment.

Findings Included:

1. Document review of the hospital policy and procedure titled, "Crash Cart/ Emergency Cart Security," no policy number, last approved 07/16/19, showed that nursing staff will be responsible for checking emergency supplies and defibrillators daily. All emergency carts will be opened and checked monthly. All medications and supplies will be accounted for, and all outdates will be removed and replaced.

2. On 11/02/21 between 9:00 AM and 12:00 PM, Surveyor #2 and the Interim Director of Nursing (Staff #201) inspected the Acute Care Unit and the Emergency Department's emergency carts. The observation showed the following:

a. Acute Care Unit - Adult Crash Cart had one pediatric colorimetric CO2 detector package with an expiration date of 09/23/21. One endotracheal tube size 8.5 mm with an expiration date of 11/19, one endotracheal tube size 7.5 mm with an expiration date of 11/20 and one endotracheal tube size 6.0 mm with an expiration date of 6/20.

b. Emergency Department - Obstetric Emergency Cart with one imminent delivery obstetric emergency kit with an expiration date of 05/21. One package of non-latex sterile gloves size 7.5 with an expiration date of 02/21, and two packages of non-latex sterile gloves size 8 with an expiration date of 07/20 and 07/21, respectively.

3. At the time of the observations, Surveyor #2 interviewed the Interim Director of Nursing (Staff #201) and the incoming Director of Nursing (Staff #202) about the checking of emergency carts. Staff #201 and #202 confirmed the expired items found by the surveyor.
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Based on interview and document review the Critical Access Hospital (CAH) failed to track and document medical equipment within the hospital and keep an equipment list that would include confirmation of Preventative Maintenance (PM) services completed.

Failure to assure PM puts patients at risk of equipment failure and suboptimal patient outcomes.

Findings Included:

1. On 11/04/21, Surveyor #8 reviewed the hospital equipment list against a list of medical equipment randomly selected by the surveyors. Surveyor #8 was able to verify tracking of only 4 equipment items out of the of the original 11 equipment items selected on the list.

2. On 11/04/21, Surveyor #8 provided to the Maintenance Technician (Staff #810) the list of 11 medical equipment items collected during the clinical unit tours. Staff #810 looked for the same medical equipment items and was unable to confirm that any additional equipment items were on the equipment list.
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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 found at shell H0AC21.
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Based on record review, interview, and review of the hospital's policy and procedures, the Critical Access Hospital failed to develop a blood transfusion policy and procedure according to accepted standards of practice for 3 of 3 records reviewed (Patient #301, #302, #303).

Failure to follow blood transfusion procedures, according to acceptable standards of practice places patients at risk for potential transfusion reactions and complications.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Blood and Blood Product Transfusion", no policy number, last revised 08/19/21, showed that staff should monitor vital signs during transfusion as directed by the facility and as the patient's condition warrants. The policy did not specify the frequency that vital signs should be recorded.

Document review of the hospital's policy and procedure titled, "Nursing Procedures-Lippincott," no policy number, last approved 04/18/18, showed that the hospital utilizes "Lippincott Nursing Procedures" software program as the official nursing procedure manual. The policy directs staff to approach supervisors with questions and concerns for discrepancies between the hospital policy and Lippincott procedures to ensure they are in alignment with evidenced based best practices and national standards of care.

2. On 11/04/21, Surveyor #3 reviewed the medical records of 3 patients who received blood transfusions during their hospital stay. The review showed Patient #301, #302, and #303 vital signs were documented according to another local hospital's blood transfusion record protocol.

3. At the time of the review, Surveyor #3 interviewed the incoming Director of Nursing (Staff #301) about the hospital's policy for documenting vital signs measured during blood administration. Staff #301 stated the Lippincott software program served as the hospital's policy for the blood administration. When asked to identify what frequency vital signs should be measured, Staff #301 confirmed the current policy and procedure did not address the issue and needed to be updated.
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Item #1 - Ater Hours Access to the Pharmacy

Based on interview and document review, the Critical Access Hospital failed to ensure that medications were kept secure from potential unauthorized access.

Failure to secure medications risks potential diversion medication errors and patient safety.

Findings included:

1. Document review of the Critical Access Hospital's policy and procedure titled, "Removing and Documenting Medications from the Pharmacy when Pharmacist is Absent," no policy number, last approved 02/05/18, showed that if a medication is needed when the pharmacist is unavailable, the designated nurse (charge nurse for the shift) will obtain only enough medication from the pharmacy until a pharmacist is available again.

2. Document review of the Pharmacy log titled, "After Hours Medication Procurement Record," for 09/05/21 to 11/01/21 showed that 4 hospital staff not designated as the charge nurse accessed the pharmacy when a pharmacist was not available.

3. On 11/03/21 at 1:00 PM, Surveyors #2 and #3 interviewed the Director of Pharmacy (Staff #302) about after-hours access to the pharmacy when a pharmacist was not available. Staff #301 stated that access to the pharmacy is granted by an electronic badge stored in the automated dispensed cabinet (pyxis machine). The designated charge nurse is the only person authorized to enter the pharmacy when a pharmacist is not available. The Incoming Director of Nursing (Staff #301) reviewed the after-hours pharmacy log and confirmed that 4 personnel not designated as the charge had accessed the pharmacy.

Item #2 - Storage of Patient Owned Medications

Based on observation, interview, and review of hospital policy and procedure, the Critical Access Hospital failed to ensure that patient-owned medications not authorized for use were stored separately from hospital supplied medications.

Failure to store patient owned medications not authorized for use separately from hospital supplied medications puts patients at risk for medication errors and patient harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Patient's Owned Rx Medications," no policy number, last approved 06/22/21, showed that patient's prescription medications are secured in the acute care medication cabinet.

2. On 11/02/21 at 10:03 AM, Surveyor #3 and the Incoming Director of Nursing (Staff #301) toured the acute care unit's medication room. The observation showed that Patient #304's home medications (7 medications in total and not authorized for use while in the hospital) were being stored with the current hospitalized patients' bulk and overflow medication bins.

3. On 11/03/21 at 1:00 PM, Surveyor #3 interviewed the Director of Pharmacy (Staff #302) about patient owned medications. Staff #302 confirmed that patient owned medications not authorized for use should be stored separately from hospital supplied medications.
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Based on document review, observation, and interview, the Critical Access Hospital (CAH) failed to maintain the water temperature in washing machines used for laundry at a minimum temperature of 160 degrees Fahrenheit as required by CAH's policy and stated in CDC guidelines.

Failure to maintain an adequate hot water temperature for linens and laundry washing puts patients at risk of harm from infections.

Reference: CDC, Environmental Infection Control Guidelines, Background G. Laundry and Bedding Guidelines for Environmental Infection Control in Health-Care Facilities (2003). 4. Parameters of the Laundry Process

Findings included:

1. Document review of hospital policy and procedure titled, "Infection Control (Laundry)," no policy number, last approved 07/09/18, showed that all laundry items are to be washed in water at a temperature of 160 degrees Fahrenheit.

2. On 11/02/21 at 10:20 AM, Surveyor #8 interviewed the Facilities Director (Staff #801) and asked if the temperature of the laundry wash water was recorded. Staff #801 stated that these temperatures were not recorded and no temperature data were available.

3. On 11/05/21 between 9:07 AM and 10:10 AM, Surveyor #8 and the Maintenance Technician (Staff # 810) observed a laundry wash cycle in the laundry room. Surveyor #8 and Staff #810 were able to read water temperatures in the washer using instructions from the wash machine manufacturing company representative. Between 9:39 AM and 10:10 AM, (31 minutes in the wash cycle), the laundry water temperatures temperature ranged from 142 to 159 degrees Fahrenheit. The average temperature was approximately 153 degrees Fahrenheit.
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Based on interview and document review, the Critical Access Hospital (CAH) failed to implement routine sampling of water for measurement of residual chlorine as stated in the water management plan.

Failure to measure, track, and maintain residual chlorine puts patients and staff at risk of infection from Legionella and other water-borne pathogens.

Reference: Centers for Medicare and Medicaid Services (CMS) Survey & Certification Letter S&C 17-30, Subject line, "Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD)"- Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.

Findings Included:

1. Document review of the CAH's "Water Management Plan", effective date 06/01/18, showed that the hospital will weekly sample the drinking water and run a water analysis test for chlorine residual and record the results.

2. On 11/02/21 at 11:30 AM, Surveyor #8 interviewed the Facilities Director (Staff #801) regarding the CAH's water management program. Staff #801 stated that he was unaware of residual chlorine testing results and residual chlorine testing being done. Staff #801 stated that the hospital relies upon the City of Leavenworth to maintain and monitor water chlorine levels.

3. On 11/03/21 at 3:50 PM, Surveyor #8 participated in the Infection Control meeting and interviewed the Infection Preventionist (Staff #802). Surveyor #8 asked if the hospital samples, analyzes, and records the residual chlorine in the facility water. Staff #802 was unaware of the hospital sampling or testing for chlorine residual in the water.
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Based on interview, document review, and review of the hospital's quality and performance improvement program, the Critical Access Hospital failed to ensure that performance measures for all patient care services were developed, evaluated, and reported to the respective quality committees.

Failure to oversee the performance of all patient care services and departments risks provision of improper or inadequate care and adverse patient outcomes.

Findings included:

1. Review of the hospital document titled, "Quality Improvement Plan," approved 10/23/18, stated the quality improvement plan provides a systematic and organization-wide system for monitoring and evaluating the quality of care provided.

2. On 11/05/21 at 8:30 PM, Surveyors #2 and #3 interviewed the hospital's Director of Performance Improvement (Staff #303) regarding the hospital's quality program. The interview and review of the quality improvement plan confirmed and showed the following:

a. The program did not have current goals, objectives, or priorities for the hospital services.

b. The program did not include and assess performance metrics for all hospital services and departments which included rehabilitative, laboratory, acute/swing bed services.
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Based on observation, interview, and document review, the Critical Access Hospital failed to fully inform patients of their rights in a written statement, including their right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.

Failure to notify patients of all their healthcare rights risks violation of those rights and may result in suboptimal health outcomes.

Findings included:

1. On 11/04/21 at 12:00 PM, Surveyor #2 reviewed the hospital's document titled, "Patient Rights and Responsibilities" which is given to all hospitalized patients include those in swing bed status. The surveyor found that the document did not include the patient's right to be free from any physical or chemical restraints.

2. On 11/4/21 at 1:00 PM, Surveyor #2 interviewed the Director of Nursing (Staff #201) about the patient rights and responsibilities document given to patients receiving care at the hospital. Staff #201 confirmed that the hospital's rights and responsibilities document did not include the right to be free from restraints.

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Based on interview and document review the Critical Access Hospital (CAH) failed to include in the "Emergency Operations Plan" a process to cooperate and collaborate with agencies to assure an integrated response to an emergency.

Failure to prepare an integrated response could result in a less effective response to an emergency causing a delay and an inability to provide patient care.

Findings Included:

1. Surveyor #8 reviewed the CAH's "Emergency Operations Plan", approval date 06/15/20. The document showed no planned or ongoing activities with local, tribal, regional, State, and federal agencies to maintain a cooperative and collaborative response to an emergency.

2. On 11/02/21 between 1:00 PM and 2:35 PM, Surveyor #8 interviewed Facilities Director (Staff #801) regarding the CAH's emergency management program. Staff #801 searched the Emergency Operations Plan for a descriptions of cooperative efforts between the CAH and agencies and confirmed that the elements were missing.
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Based on interview and document review the Critical Access Hospital (CAH) failed to include in the emergency operations plan a system to track the location of on-duty staff when sheltered-in-place and when relocated during an emergency.

Failure to know the location of staff during an emergency could make them unavailable during a time of need and put staff at risk of injury.

Findings Included:

1. Surveyor #8 reviewed of CAH's "Emergency Operations Plan" approval date 06/15/20, and it showed no system to track the hospital staff when sheltered in place or relocated.

2. On 11/02/21 between 1:00 PM and 2:35 PM, Surveyor #8 interviewed Facilities Director (Staff #801) regarding the CAH hospital's emergency management program. Staff #801 confirmed that he was unable to find in the Emergency Operations Plan or in other documentation a system to track staff when sheltered in place or relocated during an emergency.
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