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Based on staff 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. 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 there was a contract in place for safe drinking water in the event of a loss of city water. In addition plans were identified to get non-potable water for non-consumption use through the local city fire department. However, the policies lacked determination of estimated amounts required for use by individual CAH departments.

During interview with maintenance staff-C at 8:40 a.m. on 7/19/12, indicated he had not been aware of any plan which specified amounts of water required by the individual departments in the CAH, nor of the need to plan for specified amounts of potable versus non-potable water in the event of an emergency. Maintenance staff-C indicated that Culligan Water Conditioning and Filken's would provide potable water. He further stated that the local fire department would be utilized however, the facility had no further information about to how to activate this plan. Maintenance staff-C confirmed the CAH lacked written procedures including specific amounts of potable/non-potable water that may be required for use during an emergency situation.

Based on observation, interview and document review, the hospital failed to ensure medication was disposed of in a secure manner for 3 of 3 patient rooms in the emergency department and 1 of 1 nursing medication room.

Findings include:

Medications were observed to be accessible in unsecured areas of the hospital where patients, visitors and persons without legal access to drugs and biologicals, were present.

During a tour of the emergency department at 1:45 p.m. on 7/17/12, containers, which were labeled RCRA hazardous waste, were observed in emergency rooms one, two and three. The containers measured approximately 18 inches in height by 12 inches wide and 12 inches deep. An opening in the top of the container measured approximately 6 inches in diameter and many bottles and vials were observed in the waste containers.

When interviewed at 2:15 p.m. on 7/17/12, registered nurse (RN)-C stated the hospital's policy was for all medications used, but no longer needed for patients, to be placed in this container for disposal. RN-C stated all discontinued medications were to be placed in this container except for controlled substances. In addition, RN-C verified emergency room suite one was always unlocked, however emergency room suites two and three were kept locked except when patients were present. RN-C confirmed patients and visitors could be left alone in these emergency room suites and that housekeeping staff had access to these rooms.

During a tour of the emergency department at 9:15 a.m. on 7/18/12, accompanied by the emergency department supervisor, all of the RCRA hazardous waste containers were observed to be approximately one-half full of medication vials, many which still contained partial doses of medication. Some of the medications present in the waste container included Succinycholine (an anesthetic medication which causes muscle relaxation), Versed (used for conscious sedation or general anesthesia), Lidocaine (a local anesthetic), and Epinephrine (to treat allergic reactions).

The Emergency Department Supervisor was interviewed at 9:30 a.m. and verified patients and visitors might be left unattended in the emergency room suites and also verified other unauthorized staff (housekeeping) had access to these rooms. She stated emergency room suites two and three were locked when patients were not present because each of these suites contained a code blue cart which also contained medications. Although the code blue cart was secure until open, medication used during an emergency would be discarded in the RCRA hazardous waste container. The Supervisor stated the hospital was no longer permitted to discard medications into the city sewer system and the container system prevented that. She stated the containers were not sent to the company for disposal until they were full.

Another RCRA hazardous waste container, which contained numerous vials and bottles of medications, as well as intravenous (IV) bags, was observed in the unlocked medication area of the nursing unit. The medication area was located on a common hallway used frequently by patients, visitors and other hospital staff.

The Pharmacist was interviewed at 12:55 p.m. on 7/18/12. The pharmacist stated the hospital had used the RCRA container system for several years. She stated any medication which had been opened for a patient and not used completely was disposed of in these containers. The pharmacist verified this would include all medications except for controlled medications. After discussion, the pharmacist verified the current method of medication disposal was not secure.

The Patient Care Director was interviewed at 1:10 p.m. on 7/18/12, and verified any medication disposed of in the RCRA waste containers would not be considered secure as the containers could be accessed by patients, visitors and other unlicensed staff who would have access to them.

The hospital's policy, "Pharmaceutical Waste Disposal", approved by the Pharmacy Committed last reviewed 12/2007, was reviewed. The policy indicated the Melrose Hospital would dispose of pharmaceutical waste in a manner to minimize the known environmental impact. The policy indicated labeled collection containers would be provided in areas which generated pharmaceutical waste for the disposal of the waste. Housekeeping staff were to bring the containers to the collection area when the containers were full and maintenance staff would take the containers to the pickup area. The policy indicated pharmaceutical waste which was to be placed in the RCRA hazardous waste containers included all drug ampules/vials; medication bottles except those which were empty; and all non-narcotic tablets, capsules and oral liquid medications where medications had been opened and partially used. In addition, it also included all inhalers except those which were empty; all partially used ointments and creams; partially used syringes, and intravenous fluids bags with medications added. The policy did not address the secure storage of these containers which contained unused doses of medications.

Based on interview and document review, the facility failed to ensure the waterbath used in the outpatient radiation oncology clinic was appropriately sanitized. This had the potential to afect all outpatient radiation oncology clinic patients.

Findings Include:

The outpatient Radiation Oncology Clinic was reviewed on 7/17/12 from 3:00 p.m.-4:30 p.m. During a tour of the environment it was noted that the facility used a thermoplastic Medtec waterbath used for customized molded plastic to individual radiation patients. Looking at the inside of the waterbath the water was gray, the sides and bottom of the waterbath had large amounts of white lime scale and calcium build up, and the back right edge of the tank had a large patch of rust. Registered Nurse (RN)-B was interviewed at 3:30 p.m., she stated she was not sure how often the waterbath was supposed to be cleaned and showed this surveyor documentation entitled, "WATER BATH STATION LOG" which identified that the last time the waterbath had been cleaned as 2/22/12, and the date prior to that was identified as 12/5/11. The RN stated that the waterbath was not routinely cleaned after each use.

During review of the waterbath policy (undated), the following was included: "Warning. Users of this product have an obligation and responsibility to provide the highest degree of infection control to patients, co-workers, and themselves. To avoid cross-contamination, follow infection control policies established by your facility. Drain and clean waterbath periodically." The policy did not identify a frequency interval for the waterbath to be cleaned.

The Director of the Radiation Oncology Clinic was interviewed at 9:00 a.m. on 7/19/12, during which he verified the hospital/clinic did not have a policy that identified specific cleaning instruction for the waterbath. He further stated he had been cleaning the waterbath 3-4 times per year. The Director of the Radiation Oncology Clinic further stated that he would have the hospital infection control committee advise him on how often the waterbath should be cleaned to avoid cross contamination.

Based on observation, document review and staff interview, the critical access hospital (CAH) failed to ensure that 2 of 2 surgical in-patients (P4, P5), and 2 of 2 surgical out-patients (P1, P2) were evaluated for proper anesthesia recovery following surgery. This practice could affect all surgical patients served by the CAH.

Findings include:

Four surgical patients' records lacked documentation to support the patients had been evaluated for proper anesthesia recovery.

P4 had a surgical procedure under spinal anesthesia on 6/28/12. The documented end time of anesthesia was 8:12 a.m. The certified registered nurse anesthetist (CRNA)-C documented the post-anesthesia note at 8:12 a.m., the same time that anesthesia ended. The Post Anesthesia note was illegible.

P5 had a surgical procedure under general anesthesia on 4/24/12. Anesthesia stop time documented for this case was 2340 (11:40 p.m.). CRNA-A documented the post-anesthesia note at 2350 (11:50 p.m.), just 10 minutes following the documented end time of anesthesia. The post anesthesia note identified that the patient had not been intubated and had been able to maintain adequate airway. The note further indicated, "Nausea and vomiting absent. Vital signs stable. Patient tolerated the anesthetic without problems. No apparent anesthesia related complications at this time. Patient transferred from PACU to floor once VSS (Vital Signs Stable) and met discharge criteria." The note did not indicate the patient's cardiopulmonary status, level of consciousness, any follow-up care or observations nor whether or not there had been any complications during the post-anesthesia recovery.



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Patient P-5 underwent a right shoulder arthroscopy under general anesthesia as an outpatient on 7/18/12. The "Anesthesia Record" indicated the surgical procedure was completed at 3:07 p.m. and the patient was transferred to the post anesthesia care room (PACU) at 3:14 p.m. The anesthesia stop time was documented as 3:19 p.m. CRNA-B documented a post anesthesia note at 3:19 p.m., five minutes after the patient had been transferred from the operating room to PACU. The post-anesthesia note indicated the patient had tolerated anesthesia well, vital signs stable and airway patent. The note did not indicate the patient's cardiopulmonary status, level of consciousness, any follow-up care or observations nor any complications occurring during the post-anesthesia recovery. At 3:43 p.m. the registered nurse in the PACU had documented the patient had required oxygen administration as the patient's blood oxygen levels had dropped. The note also indicated the patient had been given pain medication per anesthesia, however these interventions were not reflected in the post-anesthesia note.

Patient P-6 underwent a right knee arthroscopy as an outpatient on 7/18/12. The "Anesthesia Pre-operative Progress Note," dated 7/18/12 at 11:13 a.m., indicated the patient was considered an ASA (American Society of Anesthesia) score of three, which indicated the patient had severe systemic disease for general anesthesia. The "Anesthesia Record" indicated the surgical procedure was completed at 12:17 p.m. and the patient was transferred from the operating room to the PACU at 12:27 p.m. Anesthesia stop time was documented as 12:27 p.m. CRNA-B wrote the post anesthesia note at 12:27 p.m., the same time the patient was transferred from the operating room to PACU. The post-anesthesia note indicated the patient had tolerated anesthesia well, vital signs were stable and the airway was patent. The post-anesthesia note did not indicate the patient's cardiopulmonary status, the patient's level of consciousness, follow-up observations or any complications which had occurred during the post-anesthesia recovery. A registered nurse had documented in the PACU record at 12:27 p.m. the patient's oxygen levels were stable while receiving oxygen, however these observations were not reflected in the post-anesthesia note.

The Patient Care Director was interviewed at approximately 9:45 a.m. on 7/19/12. She verified the post-anesthesia notes did not include an assessment of the patients' cardiopulmonary status, level of consciousness, follow-up care or observations, nor whether or not there had been any complications during the post-anesthesia recovery.

The hospital policy titled, "Anesthesia Risk-Preoperative and Post-operative Evaluation" last reviewed January 2010, indicated the CRNA was responsible to write a post-anesthesia follow-up note after the procedure which would include pain, medications administered, nausea, fever, sore throat, hoarseness, cough, intra-operative awareness and general condition as stated by the patient.