HospitalInspections.org

Based on staff interview and policy review, the Critical Access Hospital (CAH) failed to develop a plan to ensure adequate water availability in the event of an emergency. This had the potential to affect all patients and staff of the CAH.

Findings include: During review of the CAH's emergency policies, it was noted the current policy and procedure for emergency potable water, dated 2/12/10, lacked determination of estimated amounts required for use by individual CAH departments. The procedure for CAH staff to follow in the event of an interruption of normal water supply included the purchase of water and ice "from grocery stores and Culligan (a local water vendor) for drinking water as soon as possible."

During interview with maintenance staff- J at 10:30 a.m. on 9/16/10, he stated he was not aware of any plan which identified estimated amounts of water required by individual CAH departments. He confirmed there was not a system to estimate the need for potable versus non-potable water in the event of an emergency. In addition, he stated he was unable to locate any documentation related to an agreement/arrangement for the procurement of potable/non-potable water for the CAH.

During further interview with maintenance staff- J at 11:00 a.m. on 9/16/10, he stated he thought there had been written agreements for emergency water in past years, but he was not sure of the current status of those arrangements.

Based on observation, medication inventory list review, and staff interview, the Critical Access Hospital (CAH) failed to ensure that medications located in the Emergency Room were locked for safe storage. This had the potential to affect all patients and visitors in this area.

Findings include: Medications were noted stored unlocked in the crash cart in the Emergency Room.

During observations in the Emergency Room (ER) at 3:00 p.m. on 9/14/10, during a tour with the director of nursing (DON) and an emergency room RN (registered nurse)-A, the medication/crash cart was observed to have been unlocked. A blue lever mechanism was located on the top of the cart which prevented the drawers from opening when pushed down and which released the drawers when lifted up. The medication cart was also noted to have a red plastic numbered break-away tab in place. During interview with the DON and RN-A at that time, they confirmed that an intact red plastic tab signified the contents of the cart had been stocked/restocked as per the physician approved medication list. When queried by the surveyor regarding security of medications stored in the cart, it was indicated the blue lever did not provide a locking system for the contents of the cart as it simply needed to be lifted up in order to open the drawers. It was confirmed that although the plastic red tab system allowed staff to track utilization of medications from the cart, it provided no physical security from unauthorized persons who could potentially break the tab, lift up the blue lever, and remove medications. During this observation the DON and RN-A confirmed the crash cart was not routinely locked. The Emergency Room was located in a hallway with an outside entrance/exit door at the far end.

The DON and RN-A were interviewed again at 3:00 p.m. on 9/14/10. They confirmed that there were times when staff would not be able to directly supervise the area where the emergency crash cart was stored.

Medications stored in the ER crash cart included: Epinephrine, Lidocaine Hcl, Valium, and Versed. The DON confirmed during interview at 3:30 p.m. on 9/14/10, that another crash cart was located in the intensive care room/coronary care unit (ICU/CCU). The DON stated that maintenance staff had immediately provided a security mechanism on the ICU/CCU cart when made aware of the unlocked ER crash cart. During observations at 11:45 a.m. on 9/15/10, the crash cart located in the ICU/CCU room was wrapped with wire.

The Registered Pharmacist was interviewed at 3 p.m. on 9/15/10. She confirmed that medications in the crash carts in the ER and in the ICU/CCU had been routinely stored unlocked prior to the survey. It was also confirmed there had been no system in place to prevent unauthorized persons from potentially removing medications in the event nursing staff would be unable to visualize/supervise this location.

Based on record review and staff interview, the Critical Access Hospital (CAH) failed to ensure that each medical entry was properly authenticated with a timed and dated signature for 20 of 20 inpatient records reviewed (I1, I2, I3, I4, I5, I6, I7, I8, I9, I10, I11, I12, I13,I14, I15, I16, I17, I18, I19, I20).

Findings include: Twenty (20) inpatient records reviewed lacked authentication of entries which included dated and timed signatures for I1, I2, I3, I4, I5, I6, I7, I8, I9, I10, I11, I12, I13,I14, I15, I16, I17, I18, I19, I20. The following documents in the medical records reviewed, lacked timed and/or dated signatures: Braden skin and fall risk assessments completed by nursing staff; pathology reports, physician progress notes, OT (Occupational Therapy) and PT (Physical Therapy) progress notes, handwritten physician orders and post anesthesia assessments completed by the CRNA (Certified Registered Nurse Anesthetist).

Upon interview with the HIM (Health Information Manager) at 1:30 p.m. on 9/16/10, she stated the lack of timed and dated signatures by the various disciplines (OT, PT, MD and RN) had been an ongoing problem.

Based on review of surgical privileges and staff interview, the Critical Access Hospital (CAH) failed to assure a current roster, listing each practitioner's surgical privileges, was updated and available in the surgical suite for 1 of 1 surgeon (A) who performed surgery on 9/15/10.

Findings include: An updated and current surgical privilege roster had not been available to the surgical staff.

Upon interview with the OR (operating room) manager at 9:15 a.m. on 9/15/10, she stated she had a notebook with the list of each practitioners' surgical privileges. However, upon review of the notebook, it was noted that none of the surgical privileges had been updated since 2006, including surgeon A, who had surgery scheduled on 9/15/10. The OR manager stated that she had not received a copy of the most current privileges for any surgeon since the last credentialing/reappointment time period.

Upon interview with the HIM (Health Information Manager) at 10:15 a.m. on 9/15/10, she confirmed the most recent roster listing each practitioner's surgical privileges (approved on 7/26/10 by the governing body), had not yet been copied and provided to the surgical staff.

Based on review of surgical patient records and staff interview, the Critical Access Hospital
(CAH) failed to ensure that a post anesthesia evaluation had been documented in 4 of 10 surgical records ( S7, S8, S9 and S10) reviewed, in which anesthesia was provided by Certified Registered Nurse Anesthetist (CRNA)- B.

Findings include: The post anesthesia evaluation was lacking in 4 surgical records reviewed
(S7, S8, S9 and S10).

During record review it was noted the Post Anesthesia note required the evaluator to mark either the following two (2) boxes: (1) No adverse anesthesia related complications noted, satisfactory progress and recovery and/or (2) See progress notes for anesthesia related concerns.

It was noted that CRNA-B failed to document a post anesthesia evaluation in four (4) of the surgical records reviewed. The area on the form designated for the Post Anesthesia Comment had been left blank in the following records: S7 had right bunionectomy on 7/28/10; S8 had left total hip arthroplasty on 5/24/10; S9 had a hemicolectomy on 3/3/10; and S10 had a hemorrhoidectomy on 1/12/10. The record lacked further evidence that a proper post anesthesia evaluation, including documentation of cardiopulmonary status, consciousness level, follow-up care/observations, or any post anesthesia complications had been completed by CRNA-B.

Review of the current CAH policies related to Anesthesia Standards of Care was conducted. It was revealed that a policy regarding the required documentation of a post anesthesia evaluation by the provider who administered the anesthesia was lacking. The OR (Operating Room) manager was unable to locate the policy. A policy had not been developed to ensure compliance with federal regulations; to include at a minimum, documentation of cardiopulmonary status, level of consciousness, follow-up care/observations, and any complications which may have occurred in the post anesthesia recovery period was not evident.

Interview with the Director of Nurses (DON) on 9/16/10, at 2:30 p.m. confirmed the lack of post anesthesia evaluation documentation.

Based on review of quality improvement information and staff interview, the CAH (Critical Access Hospital) failed to evaluate all hospital services including anesthesia, cardiac rehabilitation, and physical environment as part of the overall quality improvement program. This had the potential to affect any patients receiving services from the CAH.

Findings include: the CAH did not evaluate all patient care services as part of the overall quality improvement (QI) program.

During review of the QI information it was noted the services of anesthesia, cardiac rehab, and physical environment (which included maintenance, housekeeping, and laundry) had not reported quality data to the QI Counsel during the past year. The QI minutes were reviewed for the past year and they did not reflect evaluation of those services. Review of the current QI Plan dated 1/18/10 indicated:... "department managers and service supervisors are expected to develop/maintain departmental quality improvement plans, determine annual goals and project criteria, identify quality projects including at least one special departmental quality project on an annual basis."

Interview was conducted with the Quality Coordinator at 11:30 a.m. on 9/16/10. The Quality Coordinator confirmed the services provided by anesthesia, cardiac rehab, and physical environment had not reported data related to a quality project to the Quality Counsel during the past year. It was confirmed the QI Plan required participation of all services including submission of at least an annual quality project to the QI counsel.