HospitalInspections.org

ROOM CLEANLINESS

1. Based on observation, policy review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed the policy for patient room cleaning in 3 of 4 patient rooms (Room #111, #118, and #103) observed. Failure to provide and maintain a visibly clean and sanitary environment increases the risk of all patients to sources and transmission of infections and communicable diseases.

Findings include:

Observation on 12/05/18 at 9:45 a.m., showed a bed frame with visible dust, dirt and crumbs in an occupied patient room #111, a visibly soiled bed frame in unoccupied patient room #118, and dead bugs in a overhead light fixture in unoccupied patient room #103.

Review of the policy "Resident Room, Occupied, Monthly/Discharge Clean" occurred on 12/05/18. This undated policy stated, ". . . Use a Wet-Task Wipe along with a spray bottle of Quat Disinfectant #40L [liter] to wipe down all sides of mattress and every part of the bed frame. . . ."

During interview, on 12/05/18 at approximately 1:30 p.m., an administrative staff member (#5) confirmed the bed frames and overhead light were visibly soiled and needed cleaning.

MEDICATION VIALS

2. Based on observation, professional reference review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff followed professional standards of infection control for administration of medications in 1 of 1 Physical Therapy department. Failure to follow professional standards for withdrawing medication from a vial placed patients receiving Iontophoresis (delivery of medication through the skin by electrical stimulation) treatments at risk of contracting an infection from potential contamination of the medication.

Findings include:

The APIC (Association of Professionals in Infection Control and Epidemiology) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016) stated, ". . . SYRINGES AND NEEDLES: . . . Never use a syringe for more than one patient even if the needle has been changed between patients. Use a new sterile syringe and a new sterile needle for each entry into a vial . . . MEDICATION VIALS: . . . Always use a new sterile syringe and a new needle/cannula when entering any vial. Never enter a vial with a syringe or needle/cannula that has been previously used. . . ."

- Observation of the Physical Therapy department occurred on 12/04/18 at 2:45 p.m. with an administrative therapy staff member (#2). A cabinet in the supply room contained a box of single-use vials of dexamethasone and a plastic container which contained a syringe with an attached needle. The staff member (#2) stated therapy staff use the same needle and syringe when drawing up dexamethasone for all patients receiving Iontophoresis treatments. The staff member (#2) stated the department does not have a policy for Iontophoreses treatments.



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Based on observation, professional reference review, policy/procedure review, and staff interview, the Critical Access Hospital (CAH) failed to ensure staff correctly and timely administered insulin to 1 of 1 patient (Patient #7) observed receiving insulin via insulin pen. Failure to prime pens and timely administer insulin may result in patients receiving inaccurate doses of medication and increases the risk of susceptibility to hypoglycemic episodes.

Findings include:

Review of the manufacturer's instructions for NovoLog FlexPen occurred on 12/5/18. This insert, dated 2000, stated, ". . . Because NovoLog [a fast acting insulin] has a more rapid onset and a shorter duration of activity than human regular insulin, it should be injected immediately [within 5-10 minutes] before a meal . . . To avoid injecting air and to ensure proper dosing: . . . Turn the dose selector to select 2 units . . . Hold your NovoLog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of cartridge . . . Keep the needle pointing up, press the button all the way. The dose selector turns to zero. A drop of insulin should appear at the needle tip. If not, change the needle, and repeat the procedure . . . Because NovoLog has a more rapid onset and a shorter duration of activity than human regular insulin, it should be injected immediately [within 5-10 minutes] before a meal. . . ."

Review of the facility's policy titled "Insulin Substitution/Use of Insulin Pens 08:10" occurred on 12/04/18. The undated policy stated, ". . . Training of Staff: all nursing . . . administering insulin will be trained in the use of the Flexpen system. All staff will be familiar with both this policy and the nursing policy governing the administration of insulin. . . ."

- Observation on 12/04/18 at 11:10 a.m. showed a nurse (#6) administered insulin to Patient #7. The nurse (#6) dialed the dose selector on the patient's NovoLog FlexPen to the number of units prescribed by the provider. Prior to administering the ordered dose of insulin to Patient #7, the nurse failed to "prime" or expel the air from the attached needle with two units of insulin. At 12:01 p.m., the nurse (#6) delivered Resident #7's lunch tray to his bed side table. The nurse failed to ensure delivery of the meal within 5-10 minutes of insulin administration.

- Observation of medication pass on 12/04/18 at 4:22 p.m. showed a nurse (#7) administered insulin to Patient #7. During the observation, the nurse (#7) expelled two unit of insulin from the needle on the insulin pen pointing it down toward the garbage can, then dialed the dose selector on the patient's NovoLog FlexPen to the number of units prescribed by the provider. The nurse failed to prime the pen with the needle pointing up as per manufacturer's instructions. When asked what time staff delivered the evening meal, the nurse (#7) stated staff served the evening meal between 5:00 p.m. and 5:15 p.m. At 5:05 p.m. staff delivered the patient meal cart to the hospital floor. The nurse failed to ensure delivery of the meal within 5-10 minutes of insulin administration.

During interview, on 12/05/18 at 11:30 a.m., an administrative nurse (#4) stated she expected nursing staff to prime the insulin FlexPen per the manufacturer's directions and deliver meals to patients who have received fast acting insulin within 30 minutes of insulin administration (the manufacturer's instructions state Novolog insulin injections should be within 5-10 minutes before a meal).

Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to have a network hospital or a quality improvement organization (QIO) or equivalent evaluate the quality and appropriateness of the diagnosis and treatment furnished for 5 of 5 active medical staff physician's (Providers #1, #2, #3, #4, and #5) peer review records reviewed from November 2016 through November 2018. Failure to have a network hospital or a QIO or equivalent evaluate the quality and appropriateness of the diagnosis and treatment provided by physicians limited the CAH's ability to ensure the physicians furnished quality and appropriate care to the CAH's patients.

Findings include:

Review of the policy "Peer Review" occurred on 12/04/18. This policy, dated 02/23/11, failed to require evaluation of the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH by a network hospital or QIO or equivalent for all physicians.

Reviewed on 12/05/18, the medical staff peer review records failed to include evidence a network hospital or a QIO or equivalent evaluated the quality and appropriateness of the diagnosis and treatment furnished by Providers #1, #2, #3, #4, and #5 from November 2016 through November 2018.

During interview, on 12/05/18 at approximately 10:35 a.m., a health information services staff member (#3) confirmed the CAH had not sent records to a network hospital or QIO or equivalent to evaluate the quality and appropriateness of the diagnosis and treatment furnished by physicians since October 2016.