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Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure preventive maintenance was provided for the Therabath (paraffin wax bath) or for the hydrocollator heating unit. This had the potential ato affect inpatients and outpatients receiving physical therapy and/or occupational therapy.


Findings include:


During the tour of the physical therapy (PT) and occupational therapy (OT) departments two hydrocollators (heater for wet hot packs) were noted to lack monitoring preventive maintenance. The CAH policy on the wall above the hydrocollators indicated that hydrocollator water temperatures would be tested and documented daily.


Interview with the PT and OT director on 9/5/13, at 2:30 p.m., indicated hydrocollator temperatures were not being monitored and documented daily in OT or PT. The PT/OT director stated she did not know the correct water temperature or if there were manufacturer's guidance for preventative maintenance.


The hydrocollator manufacturer's guidance indicated the thermostat was extremely sensitive and the slightest adjustment could alter the temperature several degrees. The direction was to check water temperatures with a thermometer after every adjustment and before using the hot packs, and allow sufficient time for the water temperature to stabilize after adjustments.


During tour of the OT department on 9/5/13, at approximately 2:45 p.m. the paraffin wax bath was observed to have melted wax in it. The PT/OT director stated she was unaware of any monitoring/maintenance required by the paraffin wax bath.

Based on interview and document review, the Critical Access Hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency and/or disruption in supply. This had the potential of affecting all patient, staff, visitors and services provided.


Findings include:


The CAH policy for Emergency Water Preparedness dated as reviewed 2/7/14, lacked a calculation of the amount of potable water utilized on a daily basis. The policy indicated 50 gallons of potable water would be kept on hand. The policy indicated that 400 gallons of water from the national guard by calling the state capital; however, the policy did not indicate the water was potable. A Cafeteria policy dated 1/27/12, indicated residents and patients required 8 cups per day for drinking, but did not address the number of patients/residents expected to require fluids.


The maintenance supervisor, interviewed on 9/4/13, at 3:30 p.m., stated the amount of potable water required each day was not clear.

Based on interview and document review the facility did not ensure a system for tracking and trending employee infections and communicable diseases. The facility did not have systems that ensured employees did not report to work if still infected. This had the potential to affect all patients in the community access hospital (CAH).


Findings include:


Review of the facility infection control policies with the designated infection preventionist, RN-A, revealed there was no system in place to ensure staff did not report to work or render patient care if infectious.

Interview with the dietary manager, Registered Dietician-A (RD-A), on 9/5/13 at 10:15 a.m. revealed they "don't have a system to verify if it's ok for them to come back to work." Interview with RN-B and RN-C, both nurse managers, on 9/4/13 at 3:00 p.m. revealed there was no system to ensure employees were infection free prior to returning to work with patients. "We expect the employee to be responsible." RN-B and RN-C indicated there was no facility policy for staff return to work following illness. On 9/5/13 at 10:40 a.m. the director of nursing verified there was no policy or system for verifying employees were free of infection prior to return to work following an illness.



RN-A, interviewed on 9/4/13 at 2:00 p.m., stated staff called in to their manager or charge nurse and if calling in with an illness it was logged into the computer which generated a report to her. RN-A then reported monthly to the Medical Council any employee lost hours due to illness and identified which departments were effected. Regarding how employees were cleared to return to work if they had been out due to a potentially infectious illness, RN-A indicated she wasn't sure. She thought the department managers monitored employee work return. RN-A further stated that if an employee missed 3 working days they had to return with a slip from their physician indicating they could safely return to work. RN-A indicated she was unaware of any other processes. RN-A stated the data for hours missed and unit affected by employee illness was categorized as "respiratory, gastrointestinal, rash and sores, fever of unknown cause, and other" on her "Employee Infectious Illness Report". There was no indicated of specific symptoms, onset of symptoms, or if there was any correlation between the employee and the work station such as an infected patient, body fluids, or environmental exposure. There was no follow up with the employee in an effort to obtain information related to any cultures obtained during the illness that may assist in correlating exposure.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to provide resuscitation efforts for 1 of 3 patient (P20) medical records reviewed.


Findings include:


P20, according to the medical record, suffered cardiac arrest on 6/17/13. Further record review indicated R20's status as full code (resuscitation effort required). Resuscitation efforts were not initiated.


Patient #20 was admitted through the emergency department on 6/15/13 for treatment of pneumonia with respiratory precautions. Admission orders dated 6/15/13, indicated P20's status was full code. The history and physical examination, dictated on 6/15/13, stated, "Patient is FULL CODE based on discussion tonight."


Nursing notes dated 6/17/13, at 10:07 a.m., indicated P20 was found unresponsive to his name and to painful stimulation. The registered nurse (RN)-G, found no pulse present and notified the charge nurse. An addendum to the nursing note, dated 6/17/13, at 1:31 p.m., indicated no resuscitation was attempted.


The charge nurse (RN-H) note on 6/17/13, at 10:37 a.m., described having been called to the room and P20 was unresponsive with no heart beat and had no response to sternal rub. RN-H noted P20 was last seen alert approximately 45 minutes prior and death was unexpected. There was no documentation to indicate the the family was notified.


The undated Professional and General Liability Occurrence Report Form indicated the physician was notified on 6/19/13, at 11:30 a.m.. The report indicated a failure to follow P20's desire for resuscitation. P20 was a full code and no code was performed and and P20 expired. The form indicated a report was forwarded to risk management on 7/10/13, however, no further information was provided.


The CAH policy, dated as reviewed on 1/14/12, indicated that resuscitative efforts will be initiated on all cardiopulmonary arrest patients unless specifically ordered otherwise. The policy indicated the physician should determine the appropriateness of the do not resuscitate (DNR) order for any given medical condition.


The director of nurses (DON), interviewed on 9/4/13, at 3:20 p.m., stated a full code should have been called for P20. At 4:40 p.m. the DON stated the incident was discussed with other staff at the "Occurrence" meeting, because it went against policy not to start CPR for this patient. Review of the "Occurrence Meeting" documentation indicated there was no date or signature of any attendees. The staff making the "No Code" decision were identified on the report that indicated a full code should have been initiated. There was no evidence of a discussion of why resuscitation was not attempted.

Based on observation, interview and document review the facility did not ensure the nursing care plans were developed, maintained as current, and individualized for 3 of 20 inpatient (P9, P10, P21) records reviewed.

Findings include:


P9 did not have a current plan of care to address on-going respiratory issues. P9 was admitted on 8/31/13, with multiple diagnoses including delirium, anemia, falls and chronic obstructive pulmonary disease.


P9 was observed on 9/4/13, at 1:15 p.m. to be sitting up with the head of bed raised. P9 was leaning somewhat forward, minimizing lung expansion with shallow/even respirations. P9 received a nebulizer treatment at 1:20 p.m. and the registered nurse (RN)-F stated P9 was having course rhonchi throughout his lungs bilaterally. Following the nebulizer treatment P9 continued with coarse rhonchi in his bilateral lobes according to RN-F. P9 was asked to cough at which time he had a deep, non-productive loose cough. RN-F stated P9 had an oxygenation rate of 96% at 3 liters of oxygen per nasal cannula (NC). RN-F stated P9 had an order for the nebulizer treatment four times a day and as needed (PRN), "but nobody really gives the PRN." On 9/5/13 at 9:10 a.m. RN-E stated that, due to P9's delirium and dementia, he needed stand by reminders to "cough deep and get stuff up out of his lungs."


Review of chest x-ray results completed on 8/31/13, identified pneumonia in the left lung and small parapneumonia effusion. The radiologist further indicated concern with the volume loss in the left lung and recommended further physician review. The plan of care did not address respiratory concerns or treatment goals/interventions.


RN-B interviewed on 9/5/13, at 5:00 p.m., stated the charge nurse or admitting nurse initiated the care plan, selected the appropriate disease processes and interventions with a goal and goal dates. Other RN's were able to modify the care plan as needed including identified completion dates for goals or adding new problems/interventions. RN-B verified there was no problem or interventions in place for P9's respiratory issues.


P10 did not have a current plan of care in place to address ongoing pain. P10 was admitted on 9/3/13, with multiple diagnoses including hyponatremia and breast cancer with metastasis to bone. Metastasis to the spine was recently identified described P10 had current, on-going back pain.


P10's plan of care lacked interventions or goals for pain management. Although the generalized information with additional interventions identified adult pain monitoring there were no interventions identified or a goal for P10's pain management plan. Interview on 9/5/13 at 5:00 p.m. with RN-B verified P10 should have pain more thoroughly addressed in her care plan.


P21 did not have a current plan of care to address infectious disease. P21 was admitted on 1/4/13, with bilateral pneumonia, hypoxia, and probable influenza. P21 had a fever, chills, cough and body aches. Infection control standard of practice was to place the patient in droplet precautions to address the contagious nature of the probable influenza.


Review of the plan of care for P21 revealed there was a care plan for respiratory status, however there was no care plan developed for the influenza or the individualized infection control interventions P21 required during his stay. Interview with RN-B on 9/5/13 at 5:00 p.m. verified care plans should contain information on current individual needs of the patients. When interviewed on 9/6/13 at 8:00 a.m., infection preventionist, RN-A, stated she had located a place in P21's record that identified the use of the droplet precautions. RN-A further stated "Our care plans are different in the hospital-you won't find it [the needs for P21 related to the influenza] there."






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