HospitalInspections.org

Based on observations, staff interview, and policy review the facility failed to ensure all supplies and medications were maintained to safely meet patients' needs for the day-to-day operations for one of two surgical anesthesia carts (procedure room 2), and one of one radiology CT rooms. This deficient practice placed all patients at risk for receiving ineffective supplies and medications that are no longer safe to use.

Findings include:



- Anesthesia medication cart in surgical procedure room 2 observed on 3/27/2017 at 2:00 pm revealed the following outdated medication:

1. One vial of epinephrine (used to treat severe asthma attacks and allergic reactions (including anaphylaxis) in an emergency situation) 1:200,00 and 1.5% expired 8/2016.

Certified Registered Nurse Anesthetist (CRNA) Staff M confirmed the outdated medication and disposed of it.


- Radiology CT room observed on 3/22/2017 at 2:35 PM revealed the following outdated supplies:

1. Two tubes of Surgical Lubrication with expiration dates on 2/2015 and 10/2016.
2. One 10-milliliter vial of Sodium Chloride (salt water solution) with an expiration date of 3/1/2017.

Radiologist Staff C interviewed on 3/22/2017 at 2:35 PM acknowledged the expired items and indicated staff are responsible for a checking for outdated medications and supplies monthly.

Policy "Drug Storage and Security" directs " ...a. All drug storage areas will be inspected and inventoried every month and b. All medications will be disposed of properly when their expiration date is passed ..."

Based on observations, staff interview, and policy review the facility failed to ensure all emergency supplies and medications were maintained to safely meet patients' needs for the day-to-day operations for one of one Emergency Department (ED) pediatric crash cart. This deficient practice placed all pediatric patients at risk for receiving ineffective supplies and medications that are no longer safe to use.

Findings include:

Emergency Department Broselow crash cart (color-coded tape measure of a child's height as measured by the tape to their weight to provide medical instructions including medication dosages, size of equipment and level of shock voltage when using a defibrillator-to treat threatening cardiac dysrhythmias to the heart) observed on 3/23//2017 at 11:00 AM revealed the following outdated supplies:

1. One endotracheal tube (an airway catheter used to provide an airway through the trachea and at the same time to prevent aspiration of foreign material into the bronchus-airway conducts air into the lungs) with expiration date of 12/2016.

2. Two endotracheal tubes with expiration date of 11/2016.

ED RN Staff V interviewed on 3/23/3017 at 11:00 AM confirmed the outdated supplies and disposed of them.

- Policy "Emergency Crash Cart/Defibrillator Daily Check directs " ...Crash carts will be checked daily: Adult ...Check for supply outdates on a monthly basis and document ... ...Pediatric ...Check for supply outdates on a monthly basis and document ..."

Based on documentation review, staff interview, and policy review the facility failed to ensure all elements required for medical staff appointment and reappointment were current as required per policy for 4 of 6 medical staff personnel reviewed (Medical Doctor (MD) Staff Q, MD Staff R, Nurse Practitioner (NP) Staff S, and MD Staff T). This deficient practice had the potential to provide unsafe and inadequate care to all patients resulting in poor patient outcomes.

Findings Include:

- Medical Staff Credentialing reviewed on 3/23/2017 at 10:00 am revealed MD Staff Q lacked evidence of current basic life support (BLS) and advanced cardiac life support (ACLS).

- Medical Staff Credentialing reviewed on 3/23/2017 at 10:00 am revealed MD Staff R lacked evidence of current BLS, advanced trauma life support (ATLS), and ACLS expired 2/8/2017.

- Medical Staff Credentialing reviewed on 3/23//17 at 10:00 am revealed nurse practitioner (NP) Staff S BLS expired 3/2017, ACLS expired 3/2015, and ATLS expired 2/9/2017.

- Medical Staff Credentialing reviewed on 3/23//17 at 10:00 am revealed MD Staff T lacked evidence of BLS and ATLS expired 2/9/2017.


Interview with HR Director Staff H and Quality Manager Staff A on 3/23/2017 at 12:00 PM acknowledged the missing and expired documents. "We just did not ensure that the medical staff followed through on keeping credentialed. All of the medical staff credentials that you reviewed work in the ER (Emergency Room)."

- Review of "Physician Job Description" directs " ...Certifications and Licenses: Current license (in good standing) with the Kansas Board of Healing Arts, ACLS (within one year of hire), BLS, ATLS (if working in the ER) (within one year of hire) ..."


- Review of "Mid-Level Provider Job Description" directs " ...Certifications & Licenses: Must be certified as mid-level provider in the State of Kansas ... ...BLS, ACLS (within one year of hire), ATLS (if covering ER) (within one year of hire) ..."

Based on observation, staff interview, and document review revealed the hospital failed to provide for the safety of patients in the Medical Gas storage room with an unsecured portable oxygen tank. This deficient practice had the potential to cause harm to patients and other staff members.

Findings include:

- Medical Gas storage room observed on 3/27/2017 at 3:00 PM revealed an oxygen tank stored on the floor. The oxygen tank failed to be secured in a cylinder stand or therapy apparatus.

Registered Nurse Staff D interviewed on 3/27/2017 at 3:00 PM acknowledged the unsecured oxygen tank in the Medical Gas storage room and indicated the tank should be in a cylinder stand and stated, "I think we have one on order".

The Joint Commission on Awareness and Education reviewed on 4/27/15 at 5:20pm indicated "...Oxygen tanks are stored under extremely high pressure. A sudden release of these gases may cause a cylinder to become a missile-like projectile...Cylinders or very hazardous when exposed to damage from falling over ..."

Policy titled "Oxygen Supply" reviewed on 3/38/2017 at 8:55 PM directed "... Small cylinders (A, B, C, E) in use must be attached to a cylinder stand or therapy apparatus.

Based on observation and staff interview the facility failed to ensure the generator was equipped with a manual safety stop. This deficient practice had the potential to cause harm during a failure of the equipment.
Findings include:

- Observation of the generator and surrounding area failed to reveal a manual safety stop.

- Maintenance Staff E interviewed on 3/27/2017 at 10:45 AM verified there was not a remote manual stop station for the generator.

NFPA 110, 5.6.5.6 regulation reviewed on 10/13/2016 at 12:15 PM states: "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building." An appendix item at A-5.6.5.6 suggests: "For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified."

Based on observations, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure there was a splash shield for the hopper (a flushable sink) or Personal Protective Equipment (PPE) (gloves, masks, eye protection, and gowns) immediately available for staff when handling potential infectious materials in the soiled utility room in the post anesthesia care unit. Failure by staff to wear PPE put them at risk of exposure to infectious agents through contact with soiled linen.

Findings Include:

- Tour of the Post Anesthesia Care Unit (PACU) on 3/27/2017 at 2:50 PM revealed a soiled utility room with a flushable hopper without a splash shield or PPE immediately available.

Administrative Staff A interviewed on 3/27/2017 at 2:50 PM acknowledged PPE was not immediately available in the soiled utility room and the hopper did not have a splash shield.

Policy titled "Standard Precautions" reviewed on 3/28/2017 at 9:00 PM directed "...PPE (i.e., gloves, gown) shall be worn and selected according to the level of anticipated contamination, when handling patient-care equipment and instruments/devices that is visibly soiled or may have been in contact with blood or body fluids.

Based on medical record review, policy review, and interview the facility failed to ensure nine of forty-four medical records reviewed (patient #'s 1, 3, 4, 5, 6, 20, 22, 23, and 25) provided evidence the patient signed acknowledgment of receipt of rights, failed to have a current history and physical in two of forty-four medical records reviewed (patient #39 and #14), failed to complete a discharge summary for three of forty-four medical records reviewed (patient #12, #13, and # 44), failed to have a physician sign a dictated discharge summary in one of forty-two medical records reviewed (patient #43), and failed to complete a timely surgical summary in one of forty-two medical records reviewed (patient #39). This deficient practice had the potential to cause incomplete or inaccurate medical records which could cause patient harm.


Findings include:


- Patient #1's medical record review revealed the patient was admitted to the emergency department on 2/14/2017. The medical record failed to contain evidence the patient was offered their rights upon admission.

- Patient #3's medical record review revealed the patient was admitted to the emergency department on 2/24/2017. The medical record failed to contain evidence the patient was offered their rights upon admission.

- Patient #4's medical record review revealed the patient was admitted to the emergency department on 2/24/2017. The medical record failed to contain evidence the patient was offered their rights upon admission.

- Patient #5's medical record review revealed the patient was admitted to the emergency department on 6/16/2016. The medical record failed to contain evidence the patient was offered their rights upon admission.

- Patient #6's medical record review revealed the patient was admitted to the emergency department on 11/20/2016. The medical record failed to contain evidence the patient was offered their rights upon admission.

- Patient #21's medical record review revealed the patient was admitted to the emergency department on 2/2/2017. The medical record failed to contain evidence the patient was offered their rights upon admission.

- Patient #22's medical record review revealed the patient was admitted to the emergency department on 1/20/2017. The medical record failed to contain evidence the patient was offered their rights upon admission.

- Patient #23's medical record review revealed the patient was admitted to the emergency department on 12/18/2016. The medical record failed to contain evidence the patient was offered their rights upon admission.

- Patient #25's medical record review revealed the patient was admitted to the emergency department on 2/14/2017. The medical record failed to contain evidence the patient was offered their rights upon admission


Administrative Staff A interviewed on 3/28/2017 at 3:45 PM indicated the inpatient consent forms were changed at some point, but the emergency department consent forms still lacked the acknowledgement of patient rights on their form.

Policy titled "Patient's Rights" reviewed on 3/28/2017 at 8:55 PM directed " ...A signed acknowledgement of the patient's receipt of the Patient's Rights document will be made part of the permanent medical record.



- Patient #39's medical record review on 3/28/2017 revealed the patient was admitted for transurethral resection of the prostate (TURP) (surgery procedure for enlarged prostate) on 1/12/2016. The history and physical was performed 11/10/2015 (approximately 60 days prior) and reviewed before surgery.

- Patient #14's medical record review on 3/28/2017 revealed the patient was admitted for breast needle biopsy on 5/2/2016. The history and physical was performed 3/21/2016 (7 days prior) and reviewed before surgery.

Review of "Medical Staff Rules and Regulations" directs " ...A complete history and physical examination shall be dictated within twenty-four hours after admission of the patient and on the chart within 48 hours. The history and physical for surgical and anesthesia patients will be on the cart or dictated prior to surgery ... ...When such history and physical examinations are not recorded before the time stated for surgical operations, the operation shall be canceled unless the attending surgeon states in writing that such delay would constitute a hazard to the patient ..."


- Patient #12's medical record review on 3/28/2017 revealed the patient was admitted 1/17/2017 and dismissed 1/18/2017. The medical record failed to contain evidence of a discharge summary.

- Patient #13's medical record review on 3/28/2017 revealed the patient was admitted 1/13/2017 and dismissed 1/14/2017. The medical record failed to contain evidence of a discharge summary.

- Patient #44's medical record review on 3/28/2017 revealed the patient was admitted 1/11/2017 and dismissed 1/12/2017. The medical record failed to contain evidence of a discharge summary.

Review of "Medical Staff Rules and Regulations" directed " ...the attending physician shall complete the record of the patient, including his final diagnosis within 96 hours after discharge of the patient ..."


- Patient #43's medical record review on 3/28/2017 revealed the patient was admitted 2/3/2017 and dismissed 2/5/2017. Documentation revealed RN Staff W dictated the discharge summary for the attending physician. The medical record lacked evidence the dictated discharge summary contained the attending physician's signature.

- Patient #39's medical record review on 3/28/2017 revealed the patient had a surgical procedure performed 1/12/2016. Medical record documentation reveals the procedure report was dictated 1/18/2016 (6 days after the surgery).

Review of "Medical Staff Rules and Regulations" directs " ...All operations performed shall be fully described by the operating surgeon either written or dictated within twenty four (24) hours following surgery ..."

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to safeguard patient medical records located in one unlocked radiology storage room and one basement medical records storage area. This deficient practice had the potential to compromise the privacy and protection from damage of patient records.


Findings include:

- Tour conducted on 3/27/2017 at 3:15 PM revealed a storage room in the radiology department containing patient medical records. The door latch was covered with tape to keep the door from being able to be secured.

Radiologist Staff C interviewed on 3/27/2017 at 3:15 acknowledged the door was unable to be secured due to tape on the door and there was medical records stored in the room. Staff C indicated they were unaware the door was not able to be locked.


- Medical Records storage room located in the basement observed on 3/28/2017 at 12:00 PM revealed a secured fenced in area with medical records stored in bankers boxes. One stack of three boxes was located directly on the floor.

Administrative Staff A interviewed on 3/28/2017 at 12:00 PM acknowledged the one stack of three bankers boxes contained patient medical records and was not stored off the floor as required to protect them from damage.


The facility failed to provide a policy directing staff to ensure patient information is stored in a secured location and protected from flood or pest damage.

Based on policy review and record review the facility failed to provide opportunity for patient notification of swing bed transfer 30 days prior to the transfer in five of five medical swing bed records reviewed (Patient #16, #17, #36, #37, #38). Failure to provide notification put all swing bed patients at risk of inappropriate transfer.

Findings include:

- Document review on 3/28/2017 at 2:00 PM of "Swing Bed Patient Rights" and "Acknowledgement of Swing Bed Patient Rights" revealed both documents lack a statement regarding the required 30 day notice to the resident of a transfer or discharge.

- Patient #16 admitted to swing bed on 3/19/2017 revealed patient rights, signed by the Durable Power of Attorney(DPOA), were provided to her/him and she/he was educated of those rights on 3/19/2017.

- Patient #17 admitted to swing bed on 1/8/2017, signed that a copy of patient rights were provided to her/him and she/he was educated of those rights on 1/9/2017.

- Patient #36 admitted to swing bed on 2/7/2017, signed that a copy of patient rights were provided to her/him and she/he was educated of those rights on 2/7/2017.

- Patient #37 admitted to swing bed on 10/13/2016 signed that a copy of patient rights were proved to her/him and she/he was educated of those rights on 10/13/2016.

- Patient #38 admitted to swing bed on 11/22/2016 signed that a copy of patient rights were provided to her/him and she/he was educated of those rights on 11/22/2016.

Based on record review and interview the facility failed to employ an individual with specific education and or training to perform the duties of activity director for swing bed patients. Five of five swing bed medical records reviewed (Patient #16, #17, #36, #37, #38) failed to have documentation of activities specific to patient interests, abilities, and skills. Failure to have a trained activity director available put all swing bed patients at risk of not receiving all patient rights.

Findings include:

- Medical record review of Patient #16 on 3/28/2017 at 12:00 pm revealed no documentation of activities provided
- Medical record review of Patient #17 on 3/28/2017 at 12:00 pm revealed no documentation of activities provided
- Medical record review of Patient #36 on 3/28/2017 at 12:00 pm revealed no documentation of activities provided
- Medical record review of Patient #37 on 3/28/2017 at 12:00 pm revealed no documentation of activities provided
- Medical record review of Patient #38 on 3/28/2017 at 12:00 pm revealed no documentation of activities provided


Nurse Assistant Staff K interviewed on 3/23/2017 at 10:00 am acknowledged that "I have been working about 3 years as an CNA and I have no background or formal training for activity director. My only training has really been on the job. I work in the assisted living facility and come to see the swing bed patients daily. I offer them word searches, puzzles, and magazines. They can come over to the Assisted Living side to participate in any activity they want. I work totally independently. I don't document in the patient record, but sometimes I think the nursing staff will put something in the care plan. My go to person is the Director of Nursing (DON)."