HospitalInspections.org

A. Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure patient care therapy equipment was maintained in accordance with its policy. This has the potential to affect all inpatients and outpatients serviced by the CAH therapy department.

Findings include:

1. The CAH policy titled "Medical Equipment Management" (reviewed 03/2016) was reviewed on 12/1/16 at approximately 2:00 PM. The policy stated "Procedure: B. Evaluation Criteria If equipment is... used to diagnose, treat, or monitor patients the Evaluation Criteria Section of the Bio-Medical Equipment Evaluation and Inventory Form will be completed to determine the appropriate risk level of the equipment... D. Initial Inspection Each piece of electrically powered Medical equipment shall be tested prior to initial use and the results documented... E. Preventive Maintenance ... The schedule for preventive maintenance will be determined by the risk level associated with the equipment and by the vendor specifications..."

2. An observational tour of the therapy department was conducted on 12/1/16 at approximately 9:35 AM with the Director of Medical Rehabilitation (E#6). One Eli Sports Medicine Power Tower (powered full total gym workout machine) and one Med X Strength Trainer (utilized for back and abdominal exercises) were observed to lack any preventive maintenance identifiers.

3. An interview was conducted with the Biomedical Technician (E#7) on 12/2/16 at approximately 12:10 PM. E#7 stated "We don't have any record (Bio-Medical Equipment Evaluation and Inventory Form) on those two (Eli Sports Medicine Power Tower and the Med X Strength Trainer) and we should have. I don't see where we have any information on either of them."

B. Based on observation, document review, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure Fluidotherapy and Paraffin therapy equipment were functioning within acceptable temperature ranges during use. This has the potential to affect all patients utilizing Fluidotherapy, two patients over the last three months and Paraffin therapy, one patient over the last three months.

Findings include:

1. An observational tour of the Medical Rehabilitation Department was conducted on 12/1/2016 at approximately 9:35 AM with the Director of Medical Rehab (E#6). One Fluidotherapy machine and one Paraffin Bath machine were observed. The machines were not currently in use. There were no temperature monitoring observed.

2. The CAH policies titled "Fluidotherapy- Medical Rehab 565" and "Paraffin Bath - Medical Rehab 655" (both reviewed 11/3/2016) were reviewed on 12/1/2016 at approximately 10:50 AM. The policy for Fluidotheray stated "F. Recommended temperature varies by body part, and by patient tolerance, but the range is approximately" 110 degrees Fahrenheit (F) to 125 degrees F. The policy for Paraffin Bath stated "Procedures: A. Immersion Bath 1. Check paraffin bath temperature to assure it is between 125 - 127" degrees F. There were no temperature monitoring sheets available for review.

3. An interview was conducted with E#6 on 12/1/2016 at approximately 9:45 AM. E#6 stated "We don't use them (Fluidotherapy machine and Paraffin Bath) very often and we don't keep logs of what the temperatures are when we use them, but we probably should like we do with the Hydocollator therapy."

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a Recertification Survey conducted on December 6, 2016 the surveyor finds the facility does not complies with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code.

See standard level deficiencies cited under the K-tags.

Based on document review and interview, it was determined for 4 of 8 (Pt #17, #18, #19, #20) patients who received sedation in the Special Procedures Department, the Critical Access Hospital (CAH) failed to ensure Moderate/Conscious Sedation was administered per policy. This has the potential to affect all patients who receive sedation in the Special Procedures Department.

Findings include:

1. The policy titled "Sedation Patients" (revised 10/16) was reviewed on 12/1/16. The policy noted "Medications-... Versed... Demerol are examples of... moderate and deep sedation medications... Patients may receive sedation as follows:... 2. Special Procedures- moderate and deep with the presence of an anesthesia provider..."

2. The clinical record of Pt #17 was reviewed on 12/2/16 at approximately 9:30 AM. The Conscious Sedation Flowsheet dated 11/30/16 noted Demerol and Versed were administered in the Special Procedures Department during an Endoscopy procedure without an anesthesia provider present.

3. The clinical record of Pt #18 was reviewed on 12/2/16 at approximately 9:45 AM. The Conscious Sedation Flowsheet dated 11/30/16 noted Demerol and Versed were administered in the Special Procedures Department during an Endoscopy procedure without an anesthesia provider present.

4. The clinical record of Pt #19 was reviewed on 12/2/16 at approximately 10:00 AM. The Conscious Sedation Flowsheet dated 11/30/16 noted Demerol and Versed were administered in the Special Procedures Department during an Endoscopy procedure without an anesthesia provider present.

5. The clinical record of Pt #20 was reviewed on 12/2/16 at approximately 9:15 AM. The Conscious Sedation Flowsheet dated 11/30/16 noted Demerol and Versed were administered in the Special Procedures Department during an Endoscopy procedure without an anesthesia provider present.

6. During an interview on 11/30/16 at approximately 11:30 AM, E#3 (Endoscopy Coordinator) stated Conscious Sedation was routinely administered to patients during endoscopic procedures by the nurse or physician.

7. During an interview on 12/2/16 at approximately 11:00 AM, E#1 (Director of Care Management) verbally agreed Moderate Sedation was administered to patients in the Special Procedures Department without an anesthesia provider and should not be per policy.

Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure outdated drugs and biologicals were not available for patient use. This has the potential to affect all inpatients (current census of 11 patients) and all outpatients serviced by the CAH.

Findings include:

1. The CAH policy titled "Stock Rotation Plan (Storeroom Inventory Rotation)... Materials Management Policy #410" (revised 09/2015) was reviewed on 12/1/16 at approximately 2:45 PM. The policy stated under procedure "D. Each department is responsible for using the FIFO (First-in, First-out) method when using supplies in their respective departments..."

2. An observational tour of the Dietary department was conducted on 11/30/2016 at approximately 10:15 AM. One full container Hydron (test strips for three sink sanitizer area), expired 8/15/16 and one full container Ecolab Antimicrobial Fruit and Vegetable Treatment Test Strips, expired 4/2015.

An interview was conducted with the Director of Food Services (E#9) on 11/30/2016 at approximately 10:40 AM. E#9 observed the outdated testing strips and stated "The strips should have been checked before being used. They are both outdated."

3. An observational tour of the Intensive Care Unit (ICU) was conducted on 11/30/2016 at approximately 11:25 AM. Three Remel Micro Test M4RT Transport tubes (utilized for nasal flu swab testing), two expired 7/7/2016 and one expired 8/31/2016, were observed in a storage box on the nursing station counter (where supplies and medications are stored).

An interview was conducted with the Acute Care Coordinator (E#11) on 11/30/16 at approximately 11:30 AM. E#11 observed the outdated nasal swabs and stated "The supplies are supposed to be checked at least monthly. These are all outdated and shouldn't be here."

The "Cleaning Logs" for September thru November 2016 were reviewed on 12/1/16 at approximately 9:45 AM. The Logs stated "Check for outdates..." Each area was initialed and/or identified as having been completed.

4. During a tour of the Endoscopy Suite on 11/30/16 at approximately 9:30 AM, the following expired item were observed in the phase 1 recovery area:
Upper Cabinet:
a) Lidocaine 1% 10 mg/ml 20 ml vial, expired 2/1/16
b) 1, 2-0 Prolene CT-1 (suture), expired 1/16
c) 1, 2-0 Prolene SH, expired 7/15
d) 1, 2-0 Silk SH, expired 1/13
e) 2, 4-0 Monocryl PS-2, expired 7/14
f) 1, 3-0 Prolene SH, expired 7/13
Lower Cabinet drawer:
a) 3, Insulin Safety Syringes, expired 4/16

During an interview on 11/30/16 at approximately 10:15 AM, E#3 (Endoscopy Coordinator) verbally agreed the Lidocaine, sutures and syringes were expired and should not have been available for patient use.



32189

A. Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure out of range temperatures of refrigeration units were followed up upon, in accordance with its policy to prevent potential microbiological hazards. This has the potential to affect all inpatients, outpatients, and visitors serviced by the CAH dietary services.

Findings include:

1. The CAH policy titled "Food and Nutrition Services" (reviewed 5/2016) was reviewed on 11/30/16 at approximately 11:00 AM. The policy stated "Temperatures of refrigerators and freezers are maintained within safe ranges to keep food wholesome and microbiologically safe... 2) Reports to maintenance any refrigerator or freezers not holding within accepted temperature ranges."

2. The "Refrigerator Temperature Log" for November 2016 was reviewed on 11/30/2016 at approximately 11:00 AM. The Log stated to ensure the temperature is between 36 degrees and 40 degrees Fahrenheit (F). The Log is checked in the morning upon opening the department and in the evening upon closing the department. 24 of 30 morning temperatures and 29 of 29 evening temperatures were less than 36 degrees F (ranging 30 to 34 degrees F).

3. An observational tour of the Dietary Department was conducted on 11/30/2016 at approximately 10:15 AM. The "Cooks Cooler" had various food items present, such as fresh fruits and vegetables, and the cooler temperature was observed to be 32 degrees F.

4. An interview was conducted with the Director of Food Services (E#9) on 11/30/2016 at approximately 11:00 AM. E#9 had observed both the Cook Cooler temperature log and the Cook Cooler temperature during the tour and stated "The log really doesn't say what to do if the temperature is below 36 degrees (F). It just says what to do if the food that you're cooling is not at the right temperature what to do. The food (fruits, vegetables) would be at risk for spoilage if they would freeze then thaw."

B. Based on document review, observation, and interview, it was determined the Critical Access Hospital (CAH) failed to ensure cleaning solutions were dated in accordance with its policy to assure proper disinfection. This has the potential to affect all inpatients, outpatients, and visitors serviced by the CAH.

Findings include:

1. The CAH policy titled "Solution Dating - Policy 607.00" (reviewed 9/2016) was reviewed on 12/1/2016 at approximately 10:50 AM. The policy stated "Procedure: A. Solutions received from Central Distribution will be labeled with a bright red label that reads "DATE OPENED"... E. Disinfectant solutions (i.e. [such as], Cavicide, Sanimaster)... should be dated upon opening. They may be used for up to 2 years or upon expiration date, whichever comes first."

2. An observational tour of the Radiology Department was conducted on 11/30/2016 at approximately 2:00 PM with the Interim Radiology Manager (E#8). In Radiology room #1, one bottle of 24 ounce Cavicide had a sticker that stated "date opened 6/3/13". In the Computed tomography room, one bottle of 24 ounce Cavicide was observed and stated "date opened 10/21/16".

3. An interview was conducted with E#8 on 11/30/2016 at approximately 2:15 PM. E#8 observed the Cavicide bottles and stated "The dates are probably when they were refilled. We refill the bottles from a larger container when they are getting empty. They should be putting the date they refill it on the bottle and I think, now that you're asking, we should be putting the expiration date of the container we're using to refill them. We do this in all the departments (of the CAH). "

4. An interview was conducted with the Director of Care Management (E#1) on 12/1/2016 at approximately 11:00 AM. E#1 reviewed the CAH policy for Solution Dating and stated "It doesn't say anything about refilling the bottles and what to do. We'll have to address that."



32189



C. Based on document review, observation and interview, it was determined for 2 of 2 patients (pt #19, #1) observed during an endoscopy procedure (procedure used to examine a person's digestive tract using a flexible tube), the Critical Access Hospital (CAH) failed to ensure Standard Precautions were utilized to prevent contamination. This has the potential to affect all patients who receive endoscopic procedures, approximately 90 per month and all staff.

Findings include:

1. The policy titled "Infection Control Manual... Special Procedures-Infection Control Guidelines" (reviewed 1/16) was reviewed on 12/1/16. The policy required that within the Special Procedures Area that each staff member follow general Infection Control Practices. The policy titled "Standard Precautions..." (reviewed 3/16) was reviewed on 12/1/16. The policy noted "Standard Precautions apply to (1) blood, (2) body fluids, secretions and excretions... D. Eye Protection, Face Shield 1. Wear a mask and eye protection or face shield... during procedures... that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Personal eyeglasses... are not considered adequate eye protection.... E. Gown 1. Wear a gown to protect skin and to prevent soiling or contamination during procedures... that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions...." The policy titled "Exposure Control Plan" (revised 3/15) was reviewed on 12/1/16. The policy noted in Section 4, page 6 "... All employees with risk of exposure... must follow all hospital guidelines designed for their protection... Compliance monitoring shall include the appropriate use of PPE (Personnel Protective Equipment) (fluid resistant gowns, gloves, masks, and protective eye wear)..."

2. During a tour of the Special Procedures Department on 11/30/16 at approximately 10:00 AM, 2 endoscopy rooms (room A and room B) were observed. Pt #19 was in room A being monitored after a screening colonoscopy conducted by MD#1 (Gastroenterologist). Pt #1 was in room B being prepped for a colonoscopy due to rectal bleeding. MD #1 donned a thin cloth patient gown which MD#1 wore during Pt #19's procedure, exited room A and entered room B with the same gown on and performed Pt #1's procedure. MD#1 who conducted the colonoscopy, E#3 (Endoscopy Coordinator) and E#12 (Registered Nurse) who both assisted MD#1 during the procedure on Pt #1 from 10:08 AM to 10:20 AM did not don PPE such as a fluid resistant gown, mask or protective eye wear.

3. During an interview on 11/30/16 at approximately 10:30 AM, E#1 (Director of Care Management) verbally agreed MD#1 did not change the gown after Pt #19's procedure and before Pt #1's procedure and should have.

4. During an interview on 12/2/16 at approximately 10:00 AM, E#5 (Infection Control Coordinator) stated Standard Precautions should be utilized by staff for all endoscopy procedures which included fluid resistant gowns, masks and protective eye wear.

Based on document review and interview, it was determined for 1 of 3 (Pt #4) patient, reviewed for Early Warning Signs Score (EWSS) assessment and monitoring, the Critical Access Hospital (CAH) failed to ensure it EWSS policy was followed. This has the potential to affect all inpatients serviced by the CAH with a current census of 11 patients and an average daily census of 7 patients.

Findings include:

1. The CAH policy titled "Critical Response Team- #100.85" (reviewed 9/2016) was reviewed on 12/1/2016 at approximately 2:00 PM. The policy stated the EWSS (Early Warning Signs Score) assessment was to be conducted every shift and reassessed in accordance with the score. A score of 2 to 3 required reassessment in 1 to 2 hours. A score of 4 to 5 required a Supervisor assessment/reassessment in 1 hour. A score of greater than or equal to 6 required the Critical Response Team to be called. The EWSS is based on temperature, heart rate, respirations, systolic blood pressure, and level of consciousness.

2. Pt #4's record was reviewed on 12/1/16 at approximately 1:20 PM. Pt #4 was admitted to the CAH on 11/26/16 with the diagnoses Chronic Obstructive Pulmonary Disease Exacerbation and Anemia. On 11/27/16 at 7:00 AM, nursing documentation stated the physician was "notified of critical lab (laboratory) results... hemoglobin of 6.5. Pt anemic upon admit at 8.1 and received IVF (intravenous fluids)... will require transfusion." At 7:24 AM, Pt #4's EWSS was zero (within range for all parameters). Pt #4 received two units of packed red blood cells, starting at 9:25 AM and ending at 2:55 PM. At 2:55 PM, Pt #4's EWSS was a five (systolic blood pressure 81 - 100, heart rate 111 - 129 beats per minute and respirations 21 - 29 breaths per minute) and required reassessment by the supervisor in one hour. There was no one hour reassessment. On 11/27/16 at 7:41 PM, Pt #4's EWSS was a two (heart rate 101 - 110 and systolic blood pressure 81 - 100) and required reassessment in one to two hours. There was no reassessment in one to two hours.

3. An interview was conducted with the Director of Care Management (E#1) on 12/1/16 at approximately 2:00 PM. E#1 reviewed Pt #4's record and stated "They didn't follow the policy (EWSS) and should have done the reassessments and made sure the reassessments were done by the right person (the Supervisor for an EWSS of 4 to 5). That person (Pt #4) could have overloaded (retained extra fluid) with the transfusion and should have been reassessed."

Based on document review and interview, it was determined in 4 of 4 (Pt #3, #17, #18, #21) patient's records reviewed with verbal orders obtained in the Special Procedure Department, the Critical Access Hospital (CAH) failed to ensure verbal orders were put into writing and authenticated per policy. This has the potential to affect all patients serviced by the special procedure Department.

Findings include:

1. The "Medical Staff Rules and Regulations" (amended 10/24/16) were reviewed on 12/1/16. The Regulations require verbal orders to be signed before the member of the medical staff leaves the area.

2. The clinical record of Pt #3 was reviewed on 11/30/16 at approximately 2:00 PM. Pt #3 was admitted on 11/30/16 for an Upper Gastrointestinal Endoscopy. The Conscious Sedation Flowsheet dated 11/30/16 was signed by MD#1 (Gastroenterologist) at 7:50 AM prior to the start of the procedure at 7:55 AM. The flowsheet noted Hurricaine 1 spray was administered at 7:52 AM by E#3 (Endocopy Coordinator) and Milk of Magnesia 30 ml (milliliter) was given orally at 8:35 AM by E#13 (Endoscopy Nurse). The record lacked a signed physician's order for the administration of the Hurricane and Milk of Magnesia.

3. The clinical record of Pt #17 was reviewed on 12/2/16 at approximately 9:30 AM. Pt #17 was admitted on 11/30/16 for an Upper Gastrointestinal Endoscopy and Colonoscopy. The Conscious Sedation Flowsheet dated 11/30/16 was signed by MD#1 at 10:20 AM prior to the start of the procedure at 10:30 AM. The flowsheet noted at 10:36 AM Demerol 50 mg (milligrams) IVP (Intravenous Push) was administered by E#3. The record lacked a signed physician's order for the administration of the Demerol.

4. The clinical record of Pt #18 was reviewed on 12/2/16 at approximately 9:45 AM. Pt #18 was admitted on 11/30/16 for an Upper Gastrointestinal Endoscopy. The Conscious Sedation Flowsheet dated 11/30/16 was signed by MD#1 at 10:50 AM prior to the start of the procedure at 11:02 AM. The flowsheet noted at 10:57 AM Demerol 50 mg IVP and at 10:59 AM Versed 2 mg IVP was administered by E#12 (Registered Nurse). The record lacked a signed physician's order for the administration of the Demerol and Versed.

5. The clinical record of Pt #21 was reviewed on 12/1/16 at approximately 10:00 AM. Pt #21 was admitted on 11/30/16 for an Upper Gastrointestinal Endoscopy. The Conscious Sedation Flowsheet dated 11/30/16 was signed by MD#1 at 8:00 AM prior to the start of the procedure at 8:13 AM. The flowsheet noted Hurricaine 1 spray was administered at 7:52 AM by E#3. The record lacked a signed physician's order for the administration of the Hurricane.

6. During an interview on 12/2/16 at approximately 11:00 AM, E#3 stated the Conscious Sedation Flowsheet the physician's sign prior to the procedure are blank and medication orders are not put into writing or signed by the physicians.

7. During an interview on 12/2/16 at approximately 11:05 AM, E#1 (Director of Care Management) stated verbal orders should be put into writing and signed by the physician prior to leaving the department.

Based on document review and interview it was determined in 9 of 10 (Pt #1, #2, #3, #17, #18, #20, #21, #22) patient's records reviewed with post operative notes, the Critical Access Hospital (CAH) failed to ensure pertinent information was accurately documented. This has the potential to affect all post operative patients.

Findings include:

1. The "Medical Staff Rules and Regulations" (amended 10/24/16) were reviewed on 12/1/16. The regulations noted on page 8 "G. Operative Notes... must be documented immediately after surgery... a written progress note must be entered into the record to include the name of the surgeon and any assistant, the procedure(s) performed, finding(s), post operative diagnosis, specimen(s) removed, if any, and estimated blood loss..."

2. The clinical record for Pt #2 was reviewed on 11/30/16 at approximately 11:30 AM. Pt #2 was admitted on 11/29/16 for a right total hip replacement. The record noted on 11/29/16 Pt #2's surgery began at 8:44 AM and ended at 10:08 AM. The "Orthopedic Post-Operative Note" was signed as completed by the physician on 11/29/16 at 8:10 AM, 34 minutes prior to the procedure start.

During an interview on 11/30/16 at approximately 12:00 PM, E#1 (Director of Care Management) verbally agreed the post operative note was completed prior to the surgery and should not have been.

3. The clinical records for patient 's (Pt #1, #3, #17, #18, #20, #21, #22) who all had an endoscopy procedure conducted on 11/30/16 were reviewed. The clinical records lacked a written or an electronic post operative note as of 12/2/16 at 12:00 PM.

During an interview on 12/2/16 at approximately 11:00 AM, E#3 (Endoscopy Coordinator) stated "I've never seen them (physicians) write a post op (operative) note after a scope procedure.

During an interview on 12/2/16 at approximately 11:05 AM, E#1 stated endoscopy procedures should have a post operative note written or dictated immediately after the procedure.