HospitalInspections.org

.
Based on observation, interview, and review of documents, the hospital failed to implement a quality control system to prevent the use of emergency patient care equipment and supplies that were beyond the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed their expiration dates risks deteriorated or potentially contaminated supplies being available for patient use.

Reference: "2020 American Heart Association (AHA) Guidelines for CPR and ECC (Emergency Cardiac Care)." 2020 Guidelines are a comprehensive revision of the AHA's guidelines for adult, pediatric, and neonatal resuscitation education science, and system of care topics. Updated in 2020.

Reference: "American Academy of Pediatrics states that 2019 Broselow Reference Tape will be the most compliant with current PALS standards."

Findings included:

1. On 11/02/21 at 10:35 AM, Surveyor #9 and the Chief Nursing Officer (Staff #901) inspected an emergency supply cart located in the hospital's PACU area and observed the following:

a. CPR and ECG Guidelines from 2015.

b. Advanced Cardiac Life Support emergency treatment resources and emergency medication resources dated 2016.

c. Broselow pediatric algorithm cards (Emergency system that uses a color-coded system that helps provide quick and accurate medication dosing by utilizing length to categorize pediatric patients using color codes) dated 2007.

2. At the time of the observation, Staff #901 confirmed the finding and stated that new staff resource manuals would be ordered.

3. On 11/02/21 at 2:00 PM, Surveyor #9 and the Chief Nursing Officer (Staff #901) inspected an emergency supply cart located in the hospital's medical surgical area and observed the following:

a. Advanced Cardiac Life Support emergency treatment resources and emergency medication resources dated 2010.

b. Broselow pediatric algorithm cards (Emergency system that uses a color-coded system that helps provide quick and accurate medication dosing by utilizing length to categorize pediatric patients using color codes) dated 2007.

c. Pediatric Advanced Life Support emergency treatment resources and emergency medication resources dated 2003.

4. At the time of the observation, Staff #901 confirmed the finding and stated that new staff resource manuals will be ordered.

.

.
Based on observation and interview, the Critical Access Hospital (CAH) staff failed to inventory and maintain all equipment available for use by patients.

Failure to inventory and maintain patient care equipment puts patients at risk of harm from injury due to inadequate or inoperable equipment.

Findings included:

1. On 11/03/21 between the hours of 1:30 PM and 2:00 PM, Surveyor #1 observed the following patient care equipment that did not have inventory/asset tags located in the rehabilitation center:

a) Fitness Recumbent Bike
b) Precor Recumbent Bike
c) Precor Recumbent Bike
d) Fitness treadmill

2. On 11/04/21 between 10:30 AM and 11:00 AM, Surveyor #1 interviewed the Facility Maintenance Manager (Staff #103) regarding the hospital maintenance program. Staff #103 indicated that he did not have the manufacturer's instructions for use for the equipment and that the equipment was not part of the hospital's inventory list.
.

.
Based on observation and interview, the hospital failed to implement policies and procedures consistent with the Washington State Retail Food Code (Chapter 246-215 WAC) and FDA food code; (2009 FDA Food Code 3-501.14)

Failure to follow food safety standards places patients at risk from food borne illness.

Findings included:

1. On 11/02/21 from 11:40 AM to 12:15 PM, Surveyor #1 conducted an inspection of the hospital kitchen and cafeteria. During the inspection, the surveyor observed a thick soup 3 inches in depth cooling in a 4-inch stainless steel pan in the refrigerator. Using the facility's thin stem thermometer, soup temperature indicated 101degrees Fahrenheit.

2. During the observation, Surveyor #1 interviewed the kitchen manager (Staff # 101) regarding cooling of food items. Staff #101 stated that no cooling logs were present for the item. Staff #101 indicated that the soup had only been in the refrigerator for an hour. Staff #101 removed the soup and poured it into a 2 inch pan to facilitate rapid cooling.

Reference: Washington State Retail Food Code, WAC 246-215-03515 (1); Temperature and time control-Cooling (2009 FDA Food Code 3-501.14)
.

.

Based on observation, interview, and document review, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on Life Safety Code Inspection Report found at shell HFY111.


.

.

Based on interview, medical record review, and review of hospital policy and procedure, the hospital failed to ensure that they followed their approved policy and procedures for admitting patient for blood transfusions by Non-Credentialed Providers for 1 of 2 patients (Patient #508).

Failure to have processes in place to ensure that healthcare providers are qualified risks improper care, patient harm, and death.

Findings included:

1. Document review of the hospital's policy titled, "Outpatient Orders," no number, no date, showed the following:

a. Orders from providers who do not have Ocean Beach Hospital and Medical Clinic staff privileges will require authorization by a provider who has privileges.

b. The ordering provider will write the order and the authorizing provider will be the hospital provider who has reviewed the orders and the History and Physical.

c. If the provider does not agree with the treatment plan, they will not sign the orders and the treatment will not be given.

d. If the provider agrees with the treatment plan. They will sign off as the authorizing provider.

e. The authorizing provider will need to provide direct supervision for the initial treatment. Subsequent visits will be under general supervision.

f. Paper orders received and approved for treatment will be scanned into the electronic medical record for the encounter.

Document review of the Medical Staff document titled, "Policies and Procedures of the Medical Staff bylaws," no policy number, dated 11/13/02, showed the following:

a. All orders for treatment will be in writing or typed.

b. Orders will be signed within 24 hours.

c. Orders must be legible and complete and with sufficient content to clearly convey the intent.

d. Orders that are illegible or improperly written will not be carried out until rewritten or understood by the nurse.

2. On 11/04/21 at 10:30 AM, Surveyor #5 and the Clinical Manager (Staff #505) reviewed the medical record for Patient #508 who was admitted on 09/01/21 for blood transfusion. The record review showed the following:

a. The ordering provider (Staff #507) did not have medical staff privileges at the hospital.

b. The written order form for the blood transfusion completed by Staff #507 contained an unreadable possible initial that was undated and untimed.

c. The transfusion orders entered into the electronic medical record by a staff nurse were not signed by an authorizing provider with medical staff privileges.

3. At the time of the review, Staff #505 verified the finding. Staff #505 stated that the documentation on the written order for was a provider initial, but that the orders are to be placed into the hospital's electronic ordering system and the provider is to sign off on the orders.
.

.

Based on observation, interview, and review of hospital policy and procedures, the 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 hospital's pharmacy policy and procedure titled "Pharmacy, Access to Drugs Stored Outside of Pharmacy," no policy number, no policy date, showed that all drugs stored outside of pharmacy can only be accessed by healthcare professionals. The hospital's policy did not address security and monitoring of carts containing medications in patient care areas.

2. On 11/02/21 at 09:25 AM, Surveyor #9 observed an unlocked anesthesia cart located in OR #1 which contained five vials of propofol (an intravenous medication used for sedation during procedures), 19 vials of lidocaine (used for irregular heartbeat or to relieve pain and numb the skin), one vial of phenylephrine (used to increase blood pressure), 1 vial of ephedrine (used to increase blood pressure), 2 vials of glycopyrrolate (used to reduce saliva) , and one vial of naloxone (used to reverse effects of narcotics).

3. At the time of observation a Registered Nurse (Staff #902) confirmed the finding, and stated the cart is to be locked when not in use. Staff #902 locked the cart.

4. On 11/02/21 at 10:40 AM, Surveyor #9 observed an unlocked Malignant Hyperthermia cart in the hallway of the OR area. The top drawer of the cart contained 36 vials of Dantrolene (used to treat muscle spasms), atropine (used to increase heartbeat), sodium bicarbonate (used to decrease the acid in blood), and lidocaine (used for irregular heartbeat or to relieve pain and numb the skin).

5. At the time of the observation, Registered Nurse (Staff #904) confirmed the finding and stated the cart is to be locked. Staff #904 locked the cart.

.

.

Item #1 Preprocedural Assessments

Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure staff completed and documented a pre-procedure nursing assessment for 2 of 2 outpatient Endoscopy patients reviewed (Patient #502 and #503).

Failure to perform an initial assessment of the patient created risk that patients would not receive medical treatment appropriate to their care needs.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Preoperative Care," no policy number, revised 11/19/20, showed the following:

a. A nurse is responsible for performing patient assessment and ensuing collection, documentation, and communication of all data.

b. A nurse will:

i. Assess the patient's knowledge, perceptions, and expectations about the planned surgery.

ii. Screen and assess the patient's pain.

iii. perform educational, socioeconomic, cultural, and spiritual assessments to determine the patient's level of understanding about the procedure to identify any special needs.

iv. Assess for mobility limitations and disabilities including mental and physical impairments.

v. Assess and address the patient's safety needs, including risk of falling and implement fall prevention interventions.

vi. Assess the patient's risk of postoperative nausea and vomiting.

vii. Assess the patients cognitive and mental status, cardiopulmonary status, skin condition, functional and sensory limitations.

viii. Obtain other assessments pertinent to the surgical procedure.

ix. Perform a suicide risk assessment.

x. Identify risk factors including age, general health, medications, mobility, nutritional status, fluid and electrolyte disturbance and lifestyle that may interfere with expected outcomes.

xi. Provide pre-operative education.

c. The nurse will notify the surgeon or anesthesia provider about any abnormal assessment findings.

Document review of the hospital's policy and procedure titled, "Preoperative Patient Care Ambulatory Surgery," no policy number, revised 11/19/20, stated that Incomplete or inadequate preoperative patient assessment and care can result in cancellation of the surgical procedure, injury to the patient, and postoperative complications. The document showed the following:

a. The nurse will:

i. Assess the patient for signs of abuse or neglect.

ii. Assess and document the patients skin condition including skin wounds, rashes, or other preexisting conditions.

iii. Complete all appropriate preadmission forms and the appropriate documentation of preoperative care.

b. Include all patient assessments in the preoperative documentation.

2. On 11/02/21 at 11:05 AM, Surveyor #5 and the Manager of Information Technology and Medical Records (Staff #503) reviewed the medical records for Patient #502 and #503 who underwent endoscopic procedures in surgery with anesthesiology on 11/02/21. Surveyor #5 observed the following:

Patient #502

a. Surveyor #5 found no evidence staff completed a pre procedure assessment, skin risk assessment, suicide screen, nutritional assessment, or psychosocial assessment, as directed by hospital policy. The section of the medical record dedicated to assessment was blank.

Patient #503

b. The record review showed that staff had completed a cardiac and respiratory assessment but the remaining assessment was blank. Surveyor #5 found no evidence staff completed a pre procedure assessment, skin risk assessment, suicide screen, psychosocial assessment, or nutritional screen as directed by hospital policy.

3. At the time of the observation, Staff #503 confirmed that staff had not completed the pre-operative assessments.

4. On 11/04/21, at 1:40 PM, the Clinical Manager (Staff #505) reviewed the medical records for Patient #502 and #503 and confirmed that staff had not completed pre-operative physical, mental, social, and risk assessments, per hospital policy. Staff #505 provided the surveyor with documentation of the cardiac and respiratory assessments for Patient #503.

Item #2 Post Procedural Assessments

Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure staff completed and documented post-procedure assessments for 2 of 2 patient's reviewed in the outpatient cardiac recovery area (Patient #502 and #503).

Failure to perform a post-procedure assessment of the patient creates risk that patients would not receive medical treatment appropriate to their care needs.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Postoperative Assessment, PACU (Post Anesthesia Recovery)", no policy number, revised 11/19/20, showed the following:

a. Post anesthesia care is separated into phase I and phase II, and extended observation. Phase I is the recovery phase which requires assessment of the patient's stability and Phase II may include treatment of any lingering adverse effects from anesthesia.

b. Immediately after a patient arrives to the PACU, a rapid head to toe assessment is imperative and will include a review of all major body systems, including the respiratory system, gastrointestinal system, musculoskeletal system, neurologic system, cardiovascular system, renal system, and the integumentary system.

c. Subsequent ongoing assessments and interventions vary based on the findings of the rapid head to toe assessment.

d. Documentation of these assessments should include assessment findings, interventions and the patient's response to those interventions will be performed upon arrival and address any immediate changes in the patient's condition phase 2, perform all phase I head to toe assessments

Document review of the hospitals policy and procedure titled, "Discharge from PACU," no policy number, revised 11/19/20, showed that before discharge from the PACU a nurse will:

a. document a head to toe assessment findings stating whether the findings are within normal limits and listing any deviations.

b. Record the patient's intake and output and post anesthesia score.

c. Document the patient's pain and nausea levels and prescribed corrective actions.

Document review of the hospital's policy and procedure titled, "Discharge from Ambulatory Surgery," no policy number, revised 11/19/20, showed the following:

a. A comprehensive nursing assessment should be performed during the preoperative phase including an assessment of patient education that identifies barriers to learning, limitations, and safety.

b. The nurse will perform a thorough head-to-toe assessment, reviewing all body systems, to ensure no complications have occurred.

c. Ongoing documentation should include vital signs, and frequent nursing assessments including neurologic, cardiac, respiratory, and hemodynamic status assessments, assessment of surgical sites, ongoing pain, complications, and interventions.

d. Before discharging a patient home, a nurse should complete a final assessment to ensure that the patient meets discharge criteria and should include: airway patency, respiratory function, oxygen saturation, vital signs, pain level, sedation level, comfort level, ambulation, ability to swallow, skin color and condition, nausea or vomiting, ability to urinate, post anesthesia scoring scale if used, and education/discharge instructions.


2. On 11/02/21 at 11:05 AM, Surveyor #5 and the Manager of Information Technology and Medical Records (Staff #503) reviewed the medical records for Patient #502 and #503 who underwent endoscopic procedures in surgery with anesthesiology on 11/02/21. Surveyor #5 observed the following:

Patient #502

a. Surveyor #5 found no evidence staff completed a PACU head-to toe assessment, Ambulatory head-to-toe assessment, or discharge assessment as directed by hospital policy

Patient #503

b. Surveyor #5 found no evidence staff completed a PACU head-to toe assessment, Ambulatory head-to-toe assessment, or discharge assessment as directed by hospital policy

3. At the time of the observation, Staff #503 confirmed that the medical record did not contain evidence of post procedure assessments.

4. On 11/04/21, at 1:40 PM, the Clinical Manager (Staff #505) reviewed the medical records for Patient #502 and #503 and confirmed that staff had not completed post-operative physical, assessments per hospital policy.

.

.

Based on interview, medical record review and review of policy and procedure, the hospital failed to follow its established policy for suicide risk assessment.

Failure to perform a complete assessment risks potential for unmet care needs and/or negative patient health outcomes.

Findings included:

1. Document review of policy titled "Preoperative Care," revised 11/19/20, no policy number, showed that the nurse is responsible for performing a patient assessment and ensuring collection, documentation, and communication of all data including a suicide risk assessment.

Document review of policy titled, "Emergency Triage," no number, no date, stated that the nurse triaging the patient will assess suicide risk screening.

2. On 11/02/21 at 11:05 AM, Surveyor #9 and Staff #904 reviewed the medical record for Patient #901, and Patient #902. Surveyor #9 found no evidence that the staff completed a suicide risk assessment.

3. On 11/02/21 at 11:05 AM, the IT Manager (Staff #904) confirmed that the medical record did not contain a suicide risk assessment.

4. On 11/03/21 at 2:00 PM, Surveyor #9 and Registered Nurse (Staff #907) reviewed the medical record for Patient #903. Surveyor #9 found no evidence that staff completed a suicide risk assessment.

5. On 11/03/2021 at 2:00 PM, Registered Nurse (Staff #906), confirmed that the suicide risk assessment was not completed.

6. On 11/03/2021 at 4:30 PM, Surveyor #9 and Registered Nurse (Staff #907) reviewed the medical record for Patient # 904. Surveyor #9 found no evidence that the staff completed a suicide risk assessment.

7. On 11/03/21 at 4:30 PM, Registered Nurse (Staff #907), confirmed that the medical record did not contain a suicide risk assessment.

.

.


Based on interview and document review, the Critical Access Hospital failed to develop a process to ensure that nursing staff members developed an individualized plan of care for 4 of 4 patient care plans reviewed (Patient #504, #505, #510, and #513).

Failure to assess the patient's healthcare needs and develop an individualized plan of care can result in the inappropriate, inconsistent, and delayed treatment.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Care Plan Preparation," no policy number, revised 05/20/21, showed that a care plan consists of 3 parts: goals or expected outcomes, which describe behaviors or results to be achieved within a specified time, appropriate nursing actions or interventions needed to achieve the goals, and evaluations of the established goals. Staff should customize a standardized care plan to avoid "standardizing" the patent's care and allow staff to address the patient's individual concerns.

2. On 11/02/21 at 3:35 PM, Surveyor #5 and a Registered Nurse (Staff #506) reviewed the medical record for Patient #510 who was admitted on 10/31/21 for the treatment of shortness of breath. The patient history showed that the patient was legally blind, had insulin dependent diabetes, and was status post renal transplant with immunosuppressant medications. Review of the patient's plan of care showed that staff failed to individualize the plan of care to the patient. Surveyor #5 observed that care plan interventions were a standardized pre-developed canned text of interventions. Staff failed to individualize the canned text or add additional interventions specific to the patients identified care plan problems.

3. At the time of the review, Staff #506 confirmed that staff care plan interventions were not individualized to the patient's identified problems.

4. On 11/03/21 at 11:00 AM, Surveyor #5 and 2 Registered Nurses (Staff #506 and #508) reviewed the medical record for Patient #513 who was admitted for Sepsis secondary to a Urinary Tract Infection. The patient history showed the patient had Congestive Heart Failure, Chronic Kidney Disease, and the patient was placed on comfort care for end of life. The patient was receiving pain medication for pain and air hunger. The medical record showed that care plan interventions were a standardized, pre-developed, canned text of interventions. Staff failed to individualize the canned text or add additional interventions specific to the patients identified care plan problems.

5. At the time of the review, Staff #506 and #508 confirmed that the canned text was used, and the care plan problem interventions were not individualized.

6. On 11/03/21 at 11:50 AM, Surveyor #5, a Registered Nurse (Staff #506), and the Chief Nursing Officer (Staff #501) reviewed the medical record of a Patient #505 who was admitted on 10/20/21 for altered mental status and then discharged and admitted to the hospital's Swing bed program on 11/27/21. The review showed that the patient was placed on comfort care. The medical record showed that care plan interventions were a standardized, pre-developed, canned text of interventions. Staff failed to individualize the canned text or add additional interventions specific to the patients identified care plan problems.

7. At the time of the review, Staff #501 and #506 confirmed that the care plan problem interventions were not individualized to meet the needs of the specific patient problems.

6. On 11/03/21 at 3:00 PM, Surveyor #5, and a Registered Nurse (Staff #506) reviewed the medical record of a Patient #504 who was admitted to the hospital's Swing bed program on 10/19/21 for failure to thrive and weakness. The patient's history showed that he had a visual deficit that required staff to assist with feeding. The medical record showed that care plan interventions were a standardized, pre-developed, canned text of interventions. Staff failed to individualize the canned text or add additional interventions specific to the patients identified care plan problems.

7. At the time of the review, Staff #501 and #506 confirmed that the care plan problem interventions were not individualized to meet the needs of the specific patient problems.

.

.

Based on medical record review, document review, and interview the Critical Access Hospital failed to ensure that providers properly executed Informed Consents for Surgical/Invasive procedures, Anesthesia, and blood transfusions as demonstrated by 5 of 5 records reviewed (Patient #501, #502, #503, #508, and #511).

Failure to obtain a properly executed informed consent for care and treatment impedes the patient's participation in the care planning process.

Findings included:

1. Document review of the hospital's policy titled, "Consents and Releases," no policy number, no date, showed the following:

a. The treating physician is responsible for explaining medical treatment and procedures to the patient and for obtaining informed consent.

b. The treating physician should obtain a properly filled out and executed consent form consistent with the surgical and other special consent forms.

c. The treating physician should sign the form as a witness.

d. Procedures should be established requiring the floor supervisor or other designated personnel to see that the physician has obtained the appropriate special consent forms and are in the patient's medical record before treatment is undertaken.

Document review of the hospital's procedure titled, "Informed consent," no policy number, revised 11/19/20, showed that the person providing or ordering the care, treatment, and services holds the responsibility for the informed consent process and therefore must obtain signed informed consent.

Document review of the hospital's procedure titled, "Blood and Blood Product Transfusion," no policy number, reviewed 02/19/19, showed that nursing staff are to ensure that informed consent has been obtained and that the consent is in the medical record prior to initiating the transfusion, except in emergencies.

2. On 11/02/21 at 9:40 AM, Surveyor #5 and a Registered Nurse (Staff #502) reviewed the medical record for Patient #511 who was undergoing a procedure in surgery with anesthesia. Surveyor #5 observed that the surgical provider had not signed the procedural consent form. Surveyor #5 also observed that the anesthesia consent form did not list the credentialed anesthesiology provider performing the anesthesia, and the section for considerations was blank although the form instructed patients to write "none" or document the considerations.

3. At the time of the observation, Staff #502 stated that the nurse witnessed the surgical procedure consent and she did not know if the provider needed to sign the consent. Staff #502 verified that the anesthesia consent was not complete.

4. On 11/02/21 at 11:05 AM, Surveyor #5 and the Manager of Information Technology and Medical Records (Staff #503) reviewed the medical records for Patient #502 and #503 who underwent endoscopic procedures in surgery with anesthesiology. Surveyor #5 observed the following:

Patient #502

a. Surveyor #5 observed that the surgical provider had not signed the procedural consent form. Surveyor #5 also observed that the anesthesia consent form did not list the credentialed anesthesiology provider performing the anesthesia, and the section for considerations was blank although the form instructed patients to write "none" or document the considerations.

Patient #503

b. Surveyor #5 observed that the surgical provider had not signed the procedural consent form. Surveyor #5 also observed that the anesthesia consent form did not list the credentialed anesthesiology provider performing the anesthesia, and the section for considerations was blank although the form instructed patients to write "none" or document the considerations.

5. At the time of the observation, Staff #503 confirmed that the surgical and anesthesia consent forms were not complete.

6. On 11/04/21 at 10:30 AM, Surveyor #5 and the Clinical Manager (Staff #505) reviewed the medical record for Patient #501 and #508 who were admitted for blood transfusions. The record review showed the following:

Patient #501: The blood transfusion consent was not signed by a provider or witnessed by a hospital staff.

Patient #508: The blood transfusion consent did not identify the provider, or the condition being treated. The consent was not signed by a provider or appropriately signed by a hospital staff witness.

7. At the time of the observation, staff #505 verified the missing information and stated that the consents were not completed per hospital policy.

.

.
Item #1 Restraint Face to Face Evaluation

Based on record review, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff performed a face to face assessment within 1 hour as directed by hospital policy for 3 of 4 restraint episodes reviewed (Patient #506, #507, and #512).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Use of Restraint and Seclusion," no policy number, revised 03/20/19, showed that a physician or a nurse who has been trained will conduct a face to face assessment on each patient placed in restraint to control behavior within 1 hour.

2. On 11/04/21, Surveyor #5 and a Clinical Manager (Staff #505) reviewed the discharge medical records for 3 patients placed in restraint during their hospitalization. The review showed the following:

Patient #506

a. On 10/20/21, Patient #506 presented to the Emergency Room for the treatment of Diabetic Ketoacidosis and Acute Distress. On 10/20/21 at 9:10 PM, the patient was placed in physical restraint for 8 minutes and received chemical restraint. On 10/21/21 at 12:40 AM, Patient #506 received chemical restraint (Haldol) for Danger to Self and concerns for unintentional self-harm. Documentation showed that patient was removing monitoring equipment and yelling out. On 10/21/21 at 3:35 AM, a provider progress note showed that the patient's clinical care was complicated related to behaviors including ripping out intravenous lines causing delays in medication administration and lab draws. The patient blood glucose remained in the high 400's. Surveyor #5 found no evidence at face-to-face assessment was competed for the chemical restraint episode on 10/21/21 at 12:40 AM.

Patient #507

b. On 03/21/21, Patient #507 presented to the Emergency Department with Acute Alcohol Intoxication. At 11:00 AM, the patient was placed in 4-point physical restraint for combative behaviors including kicking, biting, and aggressive language with staff. The patient also received chemical restraint including Haldol (an antipsychotic medicine) and Ativan (benzodiazepines used to treat anxiety). Investigator #5 found no evidence that a physician or a nurse completed a face-to-face assessment within 1 hour.

Patient #512

c. On 05/09/21 at 1:16 AM, Patient #512 presented to the Emergency Department with Acute Alcohol Intoxication. The patient was placed in 4-point Violent Restraint for Danger to Self and Danger to Others. Investigator #5 found no evidence that a physician or a nurse completed a face to face assessment within 1 hour.

3. On 11/04/21 at 1:40 PM, Staff #505 confirmed that staff had not completed the face to face assessment as directed by hospital policy.

Item #2 Monitoring of Patients in Restraint

Based on record review, interview, and review of hospital policy and procedures, the Critical Access Hospital failed to ensure that staff monitored patients in restraint as directed by hospital policy for 3 of 4 restraint episodes reviewed (Patient #506 and #507).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Use of Restraint and Seclusion," no policy number, revised 03/20/19, showed that chemical restraints are those drugs used as a restraint to control behavior or restrict movement and are not a standard treatment for the patient's condition. A nurse will check the patients at intervals of at least once an hour. At each evaluation, attention will be given to circulations, skin condition, and range of motion. Documentation will include frequent monitoring of mental status, behavioral response, comfort measures, signs of injury, continuous observation, restrained limb documentations, vital signs, peripheral neurovascular assessment skin, range of motion, hydration, nutrition, and elimination.

2. On 11/04/21, Surveyor #5 and a Clinical Manager (Staff #505) reviewed the discharge medical records for 3 patients placed in restraint during their hospitalization. The review showed the following:

Patient #506

a. On 10/20/21, Patient #506 presented to the Emergency Room for the treatment of Diabetic Ketoacidosis and Acute Distress. On 10/20/21 from 9:10 PM until 9:18 PM, the patient was placed in a physical restraint. The patient received chemical restraint including Haldol (an antipsychotic medicine) at 8:55 PM, Ativan (a benzodiazepine used to treat anxiety) at 9:06 PM, Haldol 5 mg at 9:14 PM. Surveyor #5 found no evidence staff completed any patient monitoring related to chemical restraint after the physical restraint was removed at 9:18 PM.

b. On 10/20/21 at 9:24 PM, a provider note stated that the patient was a threat to himself and was in physical restraint and chemical restraints had been ordered.

c. On 10/21/21 at 12:40 AM, Patient #506 received chemical restraint (Haldol) for Danger to Self. Documentation showed that patient was removing monitoring equipment and yelling out. On 10/21/21 at 3:35 AM, a provider progress note showed that the patients clinical care was complicated related to behaviors including ripping out intravenous lines causing delays in medication administration and lab draws. The patient blood glucose remained in the high 400's. Surveyor #5 found no evidence staff competed the restraint log or assessed the patient during or after the episode of chemical restraint.

Patient #507

d. On 03/21/21, the patient presented to the Emergency Department with Acute Alcohol Intoxication. At 11:00 AM, the patient was placed in 4-point physical restraint for combative behaviors including kicking, biting, and aggressive language with staff. At 11:28 AM, the patient also received chemical restraint including Haldol 5 mg (an antipsychotic medicine) and Ativan (benzodiazepines used to treat anxiety). The patient was released from physical restraint at 12:20 PM. Investigator #5 found no evidence that staff monitored or assessed the patient and documented on the restraint flow sheet for the entire restraint episode (a period on 2 hours and 20 minutes).

3. On 11/04/21 at 1:40 PM, Staff #505 confirmed that staff had not completed restraint monitoring as directed by hospital policy.

Item #3 Restraint Order

Based on document review and interview, the hospital failed to ensure that a provider ordered restraints for 1 of 4 episodes of restraint reviewed (Patient #507).

1. Document review of the hospital's policy and procedure titled, "Use of Restraint and Seclusion," no policy number, revised 03/20/19, showed a provider must order restraints.

2. On 11/04/21, Surveyor #5 and a Clinical Manager (Staff #505) reviewed the discharge medical record for Patient #507. The review showed that on 03/21/21, Patient #507 presented to the Emergency Department with Acute Alcohol Intoxication. At 11:00 AM, the patient was placed in 4-point physical restraint for combative behaviors including kicking, biting, and aggressive language with staff. The patient also received chemical restraint including Haldol (an antipsychotic medicine) and Ativan (benzodiazepines used to treat anxiety). Investigator #5 found no evidence that a physician ordered violent restraints.

3. On 11/04/21 at 1:40 PM, Staff #505 confirmed at that the medical record showed no evidence that a provider had ordered the episode of restraint as directed by hospital policy.
.

.

Based on interview, observation, and document review, the Critical Access Hospital failed to develop and implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed the manufacturers expiration date risks deteriorated or potentially contaminated supplies being available for patient care.

Findings included:

1. Document review of the hospital policy titled, "Materials" no policy number, no date, stated that purchasing is responsible for the disposal of outdated or obsolete items.

2. On 11/02/21 at 09:30 AM, Surveyor #9 and Registered Nurse (Staff #902) inspected the Operating Rooms. The observation showed the following:

a. A disposable scalpel located in an Emergency tracheostomy on the supply cart in OR # 1 with an expiration date of 10/21.

3. At the time of the finding, Registered Nurse (Staff #902), verified the expired supply and removed it from the supply cart.

4. On 11/02/21 at 10:00 AM, Surveyor #9 and a Registered Nurse (Staff #902) inspected the anesthesia carts. Surveyor #9 observed the following:

a. Two Shroeder disposable, single use, 6.5-7, and 7.5-8 bougie endotracheal tube devices, not in packaging, laying in the anesthesia cart drawer.

b. One flexible endotracheal light, not in packaging laying in the anesthesia cart drawer.

c. Three bottles Bubble Gum Mask Spray with a manufacturer's expiration date of 01/11/21.

5. At the time of the finding, a Certified Registered Nurse Anesthetist (Staff # 903) verified the finding and removed the expired an unpackaged supplied from the anesthesia cart.

.

.
Based on observation, document review, & interview, the Critical Access Hospital staff failed to follow critical cleaning procedures when reprocessing an endoscope.

Failure to adequately reprocess endoscopes risks inadequate disinfection and patient exposure to infectious microorganisms.

Findings included:

1. Document review of the hospital's policy titled, "Endoscope Reprocessing, Automated Reprocessor," No policy #, revised 11/19, showed that endoscopes should be completely immersed in enzymatic solution and to keep the endoscope and its components immersed in the solution during the cleaning process.

2. On 11/02/21 at 10:30 AM, Surveyor # 1 observed a central sterile technician (Staff #102) reprocess an Olympus 190 colonoscopy scope. During the observation, the surveyor observed staff #102 clean an endoscope in a pan with very little enzymatic solution. Staff #102 tilted the pan to one side to dip the cleaning brushes into the enzymatic solution to disinfect the channels of the scope.

3. On 11/02/21 at 11:30 AM, Surveyor # 1 interviewed the central sterile technician (Staff #102) regarding the process for endoscope cleaning. Staff #102 indicated that the scope did not need to be submerged in enzymatic solution because they use a dry leak method to test the scope. Surveyor #1 asked if the scope needed to be submerged in the enzymatic solution when cleaning the channels with the brushes. Staff #102 reiterated that the brushes are dipped in the enzymatic solution and that the scope did not need to be submerged.
.