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Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Recertification Survey conducted on March 6, 2018, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see C231.

Based on observation, document review and staff interview, it was determined the CAH (Critical Access Hospital) failed to ensure patient care equipment was maintained and safe for usage, potentially affecting all patients receiving therapy services.

Findings include:

1. During an observational tour on 2/21/18 at approximately 11:45 AM, the AED (Automatic External Defibrillator) was observed to be available for patient use. The AED lacked any documentation that that it was being monitored by staff to ensure the self test is performed to ensure a "state of readiness."

2. During an interview, while touring the therapy department on 2/21/18 at approximately 11:50 AM, E#4 (Regional Director of Rehabilitation Services) stated "the AED was only checked annually by the Biomedical department."

3. The "Manufacturers guidelines for the AED" was reviewed on 2/22/18 at approximately 1:00 PM. The guidelines included on page 5-2..."Caring for your defibrillator...Maintaining a state of readiness"...It performs an automatic self -test once a week and every time you turn it on...check to make sure that the OK symbol is visible in the readiness display..."

4. During an interview on 2/22/18 at approximately 2:15 PM, E#5 (Director of Imaging and Cardiopulmonary Services) verbally agreed that there is no documentation that the AED is being checked for the "OK" readiness symbol.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of a Recertification Survey conducted on March 6, 2018, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on document review and interview, it was determined in 3 of 3 (Pt #1, #2, #3) patient's records reviewed, the Critical Access Hospital (CAH) failed to ensure patients who received blood were monitored per policy. This has the potential to affect all patients who receive blood.

Findings include:

1. The Transfusion Record (reviewed during record reviews) required vital signs to be obtained and recorded prior to the start of the blood transfusion, 15 minutes after the initiation of the transfusion and post transfusion, scan the unit number into the electronic medical record to document the start of transfusion and record if a transfusion reaction occurred..

2. The clinical record for Pt #1 was reviewed on 2/22/18 at approximately 2:15 PM. Pt #1 was admitted on 2/20/18 with a diagnosis of Kidney Cancer. Pt #1 was transfused with 2 units of blood on 2/20/18. The second unit of blood was started at 10:42 AM although the record lacked documentation that a pre-transfusion assessment was conducted. The record lacked documentation if there was a transfusion reaction, after both units were transfused.

3. The clinical record for Pt #2 was reviewed on 2/22/18 at approximately 1:50 PM. Pt #2 was admitted on 2/12/18 with a diagnosis of Anemia. Pt #2 was transfused with 2 unites of blood on 2/12/18. The second unit of blood was started at 1:28 PM, although the record lacked documentation that a pre-transfusion assessment was conducted or if there was a transfusion reaction.

4. The clinical record for Pt #3 was reviewed on 2/22/18 at approximately 12:10 PM. Pt #1 was admitted on 1/31/18 with a diagnosis of Heart Failure. Pt #3 was transfused with 3 units of blood on 2/1/18. The second unit of blood was started at 10:00 AM, although the record lacked documentation that pre-vital signs were obtained. The Crossmatch Transfusion Tag (transfusion record) form labeled for Pt #3 noted the disposition of 1 unit of blood was issued on 2/1/18 at 2:05 PM. The record lacked a start time, but noted the 3rd unit of blood was completed on 2/1/18 at 5:32 PM and lacked a pre-transfusion assessment or documentation if there was a transfusion reaction after the unit was transfused.

5. During an interview on 2/22/18 at approximately 2:45 PM, E#6 (Medical Surgical Acute Charge Nurse) stated, with each unit of blood administered the patient should have vital signs obtained within 30 minutes prior to the initiation of the blood infusion and a pre-transfusion and post transfusion reaction assessment conducted and documented. E#6 reviewed Pt #1, #2 and #3's clinical record and verbally agreed the records lacked the above documentation