HospitalInspections.org

31195

Based on observation, policy and interview, it was determined the Critical Access Hospital (CAH) failed to ensure outdated medications/biologicals were removed from patient care areas, potentially affecting all patients on census.

Findings include:

1. The CAH policy titled "Disposal of Outadated & Non-Usable Drugs (last reviewed on 7/14) was reviewed on 8/6/14 at 11:00 AM. It indicated "All out-dated drugs are removed from floor stock..."

2. On 8/5/14 at 10:00 AM a tour of the Medical Surgical unit was conducted with the Medical Surgical Manager (E #3). During the tour, the following intravenous solutions were expired:

1- 1000 ml of Lactated Ringers Injection expired 4/14
3- 1000 ml of Dextrose 5 % with Sodium Chloride Injection expired 12/13
1 -500 ml of Dextrose 5% Injection expired 3/14

3. On 8/5/14 at 10:00 AM, an interview with the Medical Surgical Nurse Manager (E #3) was conducted. E #3 verified the solutions expired and indicated they should have been removed from the unit.

4. During a tour of the ED on 8/5/14 at 11:30 AM with the ED Manager (E #6), the following supplies were expired:

6- Lactated Ringers/Dextrose 5%/20% Sodium Chloride (located in supply room)
expired 3/2010
2-culture swab kits (located in trauma room) expired 3/2014

5. During a tour of the OR unit on 8/5/14 at 2:30 PM, the anesthesia cart contained the following expired items:

2- blue-top laboratory collections tubes expired 4/2012
1-red-top laboratory collection tube expired 4/2012
2-green-top laboratory collection tubes expired 11/2012
2-purple-top laboratory collection tubes expired 10/2012
1-marbled red-top laboratory collection tube expired 12/2011

6. An interview was conducted on 8/5/14 at 2:30 PM with the OR Manager (E #4). E #4 stated the blood collection tubes were expired and should be discarded.

7. During a tour of the Radiology Department on 8/6/14 at 11:30 AM, the following medications were expired:

2-10 mg/ml vials of Lidocaine 1% (located in ultrasonography) expired 12/2010
19-Magnevist 20 ml vials (located in clean storage) expired 5/2010

8. On 8/6/14 at 11:45 AM, an interview was conducted with the Radiology Department Manager (E #5). E #5 stated the medications were expired and should have been discarded.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Re-Certification Survey conducted on August 13 - 14, 2014, the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

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

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Re-Certification Survey conducted on August 13 - 14, 2014, the surveyor finds that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated 08/14/2014.

Based on observation, policy and staff interview, it was determined the CAH failed to ensure infection control measures were maintained to prevent potential cross contamination in patients receiving surgical services. This has the potential to effect 100% of the patients receiving care in the surgery department.

Findings include:

1. On 8/5/14 at 2:30 PM a tour of the Surgical department was conducted with the OR Manager (E #4). During the tour, it was observed in OR room #1, a disposable, laryngoscope blade, out of the sterile packaging, laying on top of the anesthesia cart.

2. On 8/6/14 at 8:40 AM a review of CAH policy "INFECTION CONTROL PROCEDURES DURING ANESTHESIA" (last reviewed 1/14), was reviewed on 8/6/14 at 12:15 PM. Under "PROCEDURE:" it indicated "Disposable supplies will be used whenever possible. This includes endotracheal tubes, laryngoscope........... . At the completion of the prodecure, these disposable items will be discarded...."

3. On 8/5/14 at 3:00 PM an interview with E #4 was conducted. E #4 verified the laryngoscope blade was out of the sterile packaging and should have been discarded.

Based on the CAH By-Laws, record review and interview, it was determined the CAH failed to ensure in 1 of 25 (Pt #7) medical records reviewed, physician orders were authenticated, potentially affecting all patients receiving care.

Findings include:

1. On 8/6/14 at 11:00 AM a review of the CAH By-Laws (revised 11/2012)) were reviewed. Under D. "General Conduct of Care , Verbal orders shall be signed before the member of the medical staff leaves the area ".

2. The medical record of Pt #7 was reviewed with E #3 on 8/5/14 at 10:00 AM. Pt #7 was admitted on 8/3/14 with a diagnosis of syncope. There was no documentation to indicate a physician signed the verbal order for a Holter Monitor that was written on 8/4/13 at 8:35 AM.

3. On 8/5/14 at 10:30 AM an interview with the Inpatient Manger (E #3) was conducted. E #3 verbalized the physician order should have been signed prior to the physician leaving the area.