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Based on observation, interview and document review, the facility failed to ensure the defibrillator was checked to ensure proper functioning for 1 of 1 defibrillator units located at the offsite Obstetrics and Gynecology Clinic. This had the potential to affect all patients being treated at the clinic.

Findings include:

During a tour of the Dassel clinic on 1/31/18, at 10:30 a.m. with the hospital chief nursing officer (CNO) and licensed practical nurse LPN)-A, a crash cart that stored a defibrillator unit and oxygen cylinder was stored in a procedure room in the basement of the clinic. There was no documentation to identify the defibrillator had been checked to ensure proper functioning in the event of a cardiac arrest (heart stopping) nor had the oxygen cylinder level been checked. Interview with LPN-A indicated the defibrillator had been stored on the crash cart for over a year, but it had never been tested. LPN-A revealed she had never been trained to utilize the defibrillator if needed. LPN-A further included the physician was always in the procedure room during procedures, and would be able to utilize the defibrillator.

Review of the facility policy Crash Cart Checks dated 1/2018, directed the staff to check emergency equipment on days that the units are occupied to ensure equipment is available and functioning when needed. The policy directed the staff to follow manufacturers recommendations for testing the defibrillator and to document on the crash cart checklist if the defibrillator passed the test. The policy also directed the staff to check the oxygen cylinder to verify that the oxygen level was accurate.

The facility document titled Daily performance Test-Physio Control Defibrillator: model LifePak 12 BIOHASIC identified the following: 1.) Required Frequency: Performance test MUST be done at least once every 24 hours for maximum assurance of accurate performance. Test this equipment with each Cardio Pulmonary Resuscitation Cart Check required in this department. 2.) Maintenance and Testing schedule: This schedule may be used in conjunction with the internal quality assurance program of the hospital, clinic, or emergency medical services where the defibrillator is used.

Based on the Life Safety Code (LSC) survey. A Medicare-participating Critical Access Hospital (CAH), including all component parts or facilities of the CAH, must comply with the applicable LSC requirements.

Please refer to the life safety code deficiencies cited at:
Bld:01 K281, K291, K346, K354, K363, K372, K521, K711, K914, K918, & K920.
Bld:03 K345, K346.

Based on observation, interview, and document review, the provider failed to have parental consent prior to performing a minimally invasive surgical procedure on 1 of 1 out patient (OP-A) who was a minor and under age 18 years old.

Findings include:

Observation on 1/30/18 at 8:30 a.m. with registered nurse (RN)-G as she brought OP-2 back into the surgical suite pre-operative area, revealed OP-2 had been sitting by herself in the waiting room. OP-2 was asked by RN-G if her parents were there or if they were going to be in the building for the procedure. OP-2 replied her father had brought her, but she wasn't sure if her mother was picking her up or if anyone was staying during the procedure. RN-G continued to prepare OP-2 for her colonoscopy (bowel scope). The doctor (MD)-C then arrived and explained the procedure, advising OP-2 of her risks and benefits, without her parents being present, and OP-2 signed the consent form, along with MD-C and RN-G. OP-2 was prepped for the procedure, in which she was given narcotic pain medication and sedation.

Review of the medical record for OP-2 indicated she was under 18 years old and was not shown to be emancipated or otherwise considered an adult.

Interview on 1/30/18 at 2:15 p.m. with the surgical services RN supervisor indicated she was unaware PO-2 received a procedure without parental consent. She further agreed that was against facility policy as no minor patient may sign a consent for surgery. RN-G said, "should have caught that." OP-2 was to have a parent with her in the pre-operative area and staff should have ensured parents knew they needed to stay in the waiting room during the procedure. The RN supervisor stated it was a medical error and not acceptable.

Review of the facility's revised May, 2012 Surgical Consent Forms policy indicated minors needed to have parental or legal guardian signed consent for surgical procedures.

Based on observation, interview and document review, the facility failed to ensure medication storage in the crash carts were in a secured environment and monitored to prevent unauthorized access for 1 of 3 crash carts (CC-3) located on the medical surgical unit in the hospital and for 1 of 1 crash carts (CC-4) located at an off site clinic. Also the hospital/clinic policy/procedure regarding securing of medications from unauthorized access was not operationalize.

Findings include:

LACK OF SECURED ACCESS TO EMERGENCY CART WHICH CONTAINED MULTIPLE MEDICATIONS LOCATED IN THE CRITICAL ACCESS HOSPITAL:

Observations on 1/29/18, at 2:00 p.m., 1/30/18, at 8:30 a.m., 1/31/18, at 8:45 a.m., and 2/1/18, at 10:30 a.m. CC-3 cart located on the 3rd floor medical surgical unit was located in the center hall alcove between the door labeled Housekeeping closet, and the door labeled Data. The cart was across the hall from the staff restroom, and in direct sight of patient room 3017. This cart was not observable from either of the two nursing stations and there no method of observation/monitoring for the cart which contained medications and additional emergency supplies. The top of the cart was clear plastic, and the tray of medications was visible through the surface. The cart was secured by a red plastic lock which could be removed by twisting. Once the cart was unlocked the entire tray of emergency medications could be lifted out as a unit.

Registered nurse (RN)-G was interviewed on 1/29/18, at 12:56 p.m. and indicated the crash carts were checked daily during the night shift. RN-G indicated a person passing down the halls on either side of the center hall would be able to see the crash cart, but there was not a means of monitoring and/or observation unless someone was passing by.

During interview on 2/1/18, at 8:20 a.m. the chief nursing officer (CNO) confirmed the crash cart located in the center hall was not in a secure area and there was no ongoing monitoring, other than the daily night shift checks or if the cart was utilized. The CNO verified the security for the crash cart was the red plastic lock and once removed the entire tray of emergency could be taken from the cart.

On 1/31/18, at 10:00 a.m. the pharmacy manager (PM) was interviewed and provided a list of medications contained within the crash cart. The PM confirmed the method of securing the medications stored in the cart was the red plastic lock and once this was removed the entire tray of medication could be taken out of the cart.


28591

LACK OF SECURED ACCESS TO EMERGENCY MEDICATIONS LOCATED AT A CLINIC:

During a tour of the Dassel clinic on 1/31/18, at 10:30 a.m. with the hospital chief nursing officer (CNO) and licensed practical nurse (LPN)-A, CC-4 containing a variety of emergency medications was stored in a procedure room in the basement of the clinic. The door to the procedure room was unlocked and not supervised during the tour. The cart was secured with a numbered pull-away tab. There was no documentation to identify the cart had been monitored for the security of the medications other than a note by the pharmacy department dated 6/29/17, that the medications had been checked for expiration dates. Interview with LPN-A during this time, confirmed the procedure room door is open during clinic hours and is not always supervised when patients/visitors are in the area. LPN-A also verified that the pull away tabs are not monitored/logged for patency. LPN-A revealed the crash cart has been in the procedure room for over a year, and the clinic staff had not been monitoring the cart for patency.

Review of the facility policy Crash Cart Checks dated 1/18, directed the staff to verify the security seal number on the crash cart daily log for patency. This should be done on days the units are occupied.

The Nursing Services Procedure Title: Crash Cart Checks Attachments: a.) Crash Cart Checklist; b.) Defibrillator and Red Tag checklist with a Review date of 01/18 indicated: Verify that the red security seal number matches the red security seal number on the crash cart daily log form. If the security numbers do not match, notify Pharmacy of the discrepancy. There was no information on additional monitoring or securing of the cart.

Based on observation, interview and document review, an off site clinic failed to perform maintenance/monitoring efficacy of sterility of multi-use instruments/equipment to prevent the spread of infection. Also failed to develop policies and procedures based on the manufacturers recommendations for the use of an autoclave sterilizer used for Immediate Use Steam Sterilization (IUSS). In addition, the provider failed to develop policies and procedures in place to promote reduction of Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease. This had the potential to affect patients at the critical access hospital and at the off site clinic.

Findings include:

LACK OF MONITORING AND FOLLOWING MANUFACTURES DIRECTIONS FOR STERILIZING MULTI-PATIENT EQUIPMENT IN THE AUTOCLAVE STERILIZER:

During observation on 1/31/18, at 8:30 a.m. a tour of the Dassel clinic was done with the hospital chief nursing officer (CNO) and the clinic director (CD). A self-contained steam autoclave was being utilized at the clinic for steam sterilization on a rare occasion. There were no records or logs of cycle runs of instruments nor were there any logs for maintenance checks on the autoclave. Interview with the CD, indicated the autoclave is used for cleaning re-useable items such as stitch sets, speculums, forceps and equipment used for biopsies. The autoclave was used when there was not enough equipment and used rarely. The CD was unable to provide the frequency of the use because the clinic did not track when sterilizing was being done. The CD indicated the autoclave had been utilized in the clinic for more than 3 years and could not remember monitoring or logging the use. The CD further revealed a print out for validation of sterility nor a chemical or biological indicator strip had been used during the processing of the equipment. The CD revealed she thought the machine would not run if parameters for sterilization were not met, but confirmed that the machine had never been maintenanced since it had been placed at the clinic. The incident of infections was requested for the clinic and none were attributed to the use of the instruments/equipment sterilized by the autoclave sterilizer.

Interview on 2/1/18 at 11:00 a.m. with the infection control preventionist (ICP) regarding the above autoclave observation indicated she had never been to the Meeker Memorial Clinic. The ICP knew staff there were sterilizing instruments since she'd begun her position in October 2012, but had never herself performed any safety infection control rounds in that building to ensure staff there were performing that task appropriately, and had not monitored whether instruments were being sterilized. She agreed this was a concern for potential harm to patients if instruments were not sterilized appropriately.

Review of the manufacturers' instructions for the Midmark Self-Contained Steam Sterilizer, included guidelines to use chemical and biological indicators, designed for steam sterilization that are compatible with the particular sterilization cycle temperature and exposure time being monitored. Use sterility monitors with each sterilization load. If a sterilizing cycle is terminated prematurely, reprocess instruments to ensure sterility of the load. Review of the manufacturers' maintenance guidelines included a planned maintenance program, to assure proper operation and maximum sterilizer life. The autoclave will automatically display a weekly performance maintenance reminder on the electronic screen as well as a monthly performance maintenance check.


38687

LACK OF DEVELOPING AND OPERATIONALIZE REQUIRED LEGIONELLA ASSESSMENT/MONITORING:

During environmental rounds with the maintenance supervisor on 1/31/18 at 2:00 p.m. indicated the facility had no policy or procedure related to Legionella prevention. He was aware of the requirement to have that in place, but the facility had not completed that requirement and had just met one week ago with a company to begin the process.

The facility had no policy related to Legionella prevention.