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Based on policy review, record review, and staff interview, the Critical Access Hospital (CAH) failed to ensure documentation of the provision of the CAH's advance directive information to each patient and whether each patient had an advance directive for 9 of 13 acute inpatients' records reviewed (Patients #3, #9, #10, #11, #12, #13, #14, #15, and #16 ). Failure to document in the patients' records the provision of advance directive information and whether the patient has an advance directive limited the CAH's ability to ensure patients were aware of the CAH's advance directive policies and their right to make decisions regarding their care and may result in patients receiving undesired treatment.

Findings include:

Review of the policy "Advanced Directives" occurred on 01/16/19. This policy, revised 07/2013, stated, ". . . JMHCC (Jacobson Memorial Hospital Care Center) will present and provide to the patient/resident, information on Advanced Directives. JMHCC will recognize, comply with any advanced directive of a patient/resident, and facilitate the sharing of this information with the attending provider. . . ." The policy did not require CAH staff to document the provision of the information and whether the patients had an advance directive in the patients' records.

Reviewed January 14-16, 2019, acute inpatient records failed to include evidence the CAH staff provided the patients with the CAH's advance directive information and whether the patients had an advance directive for the following admissions:
- Patient #3 on 07/23/18
- Patient #9 on 09/30/18
- Patient #10 on 11/02/18
- Patient #11 on 07/29/18
- Patient #12 on 10/01/18
- Patient #13 on 01/01/19
- Patient #14 on 10/18/18
- Patient #15 on 08/30/18 and 01/08/19
- Patient #16 on 11/28/18.

During interview at approximately 8:45 a.m. on 01/16/19, an administrative nursing staff member (#1) confirmed the above listed medical records lacked evidence of the provision of the CAH's advance directive information and whether the patients had an advance directive.


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Based on policy manual review and staff interview, the Critical Access Hospital (CAH) failed to have the required members of a group of professional personnel annually review the CAH's health care policies in 2018 for 1 of 8 policy manuals (Health Information Management) reviewed. Failure to have the required group of professional personnel annually review the policies limited the CAH's ability to ensure the policies were current and followed regulations and standards of practice.

Findings include:

Review of the policy "Quality Assurance and Improvement Program" occurred on 01/16/19. This policy, revised 09/25/18, stated, ". . . Annual review of department policies will be completed in June . . ." The policy failed to include the members of the group of professional personnel required to perform the annual policy review.

Review of the CAH's policy manuals occurred on all days of the survey. The Health Information Management (HIM) policy manual lacked evidence of annual review in 2018 by a physician and a physician assistant/nurse practitioner/clinical nurse specialist (required members of a group of professional personnel). Upon request on 01/15/19, the CAH failed to provide evidence of the annual policy review in 2018 for HIM.

During interview at approximately 10:00 a.m. on 01/16/19, an administrative staff member (#7) confirmed the CAH failed to have the required group of professional personnel review the CAH's HIM policies in 2018.

Based on observation, record review, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to correctly label 2 of 2 medications (Tramadol and Novolog insulin pen) observed during medication pass and in the medication room refrigerator. Failure of the CAH to adequately label medications as per facility policy and physician order may result in inaccurate dosing of medication to the patient and administering medication to the wrong patient.

Findings include:

Review of the policy "Pharmacy Policy Manual" occurred on 01/16/19. The undated policy, stated, ". . . Dispensing of Medications . . . All medications dispensed shall be properly labeled with: Name of patient, Name of prescribing physician, Directions of administration, Name and strength of medication, Date dispensed, Sequence number. . . ."

- Observation of the medication pass on 01/15/19 at 7:30 a.m. showed a nurse (#4) removed a medication card from the cart for Patient #18 that contained Tramadol [Ultram] HCL 50 mg (milligram). Upon observation of the medication card label which read, ". . . TAKE 1 TABLET (50MG) BY MOUTH AS NEEDED EVERY 06 HRS [hours] . . ." and the eMAR (electronic medication administration record) which read ". . . ULTRAM TAB [50 MG] (TRAMADOL) 2 x [times] daily [0800, 2000]." When asked about the discrepancy between the medication card label and the eMAR regarding the frequency of the medication, the nurse (#4) turned over the medication card and pointed to a label that read, "ULTRAM TAB [50 MG] (TRAMADOL) Oral 2 x daily [0800, 2000] 1 Tablet = 50 mg Tablet DoseTimes: 08:00, 20:00. . . ."

Review of Patient #18's chart occurred on 01/15/19 and 01/16/19. The physician's order dated 07/01/18 stated, "ULTRAM TAB [50MG] (TRAMADOL) . . . 2 X daily (0800,2000) 50 mg. . . ."

During an interview, on 01/15/19 at 8:00 a.m., an administrative nurse (#1) agreed staff failed to label the medication appropriately.

- Observation of the medication room on 01/15/19 at 1:55 p.m. with an administrative nurse (#1) and pharmacy technician (#5), identified an unlabeled Novolog insulin pen. The insulin pen had no identifying information regarding patient name, prescribing physician, or directions for administration as per facility policy. The administrative nurse and pharmacy technician were unable to identify what patient the Novolog pen belonged to.



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MEDICATION ADMINISTRATION

1. Based on observation, review of policy and procedure, and staff interview, the Critical Access Hospital (CAH) failed to follow professional standards of care related to infection control practices for 1 of 4 patients (Patient #18) observed receiving medications. Failure to follow established infection control practices related to medication administration may allow transmission of organisms and pathogens from staff to patients, and from one environment to another.

Findings include:

Review of the policy titled " Medication Administration and Medication Cart Use" occurred on 01/16/19. This policy, revised October 2017 stated, " To ensure that medications are being administered appropriately by qualified staff . . . Wear gloves if contact with pills is necessary . . . Do not touch medication caplets, capsules or liquids with bare hands. . . ."

Observation on 01/15/19 at 7:20 a.m. showed a nurse (#4) removed a medication card from the medication cart. The nurse (#4) pushed one pill out of the card and used the palm of her bare left hand to guide the pill into the medication cup. The nurse (#4) then removed a bottle labeled Calcium plus vitamin D3 (a mineral supplement) from her cart, removed the lid, poured 1 tablet into her bare hand, then placed the tablet into the medication cup.

During interview at 3:00 p.m. on 01/15/19, an administrative nursing staff member (#1) stated she expected nursing staff to not touch the medications with bare hands during medication administration.




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MEDICATION VIALS

2. Based on professional reference review, observation, staff interview, and policy manual review, the Critical Access Hospital (CAH) failed to ensure staff followed professional standards of infection control for administration of medication in 1 of 1 Physical Therapy department. Failure to follow professional standards for obtaining and applying medication placed patients receiving Iontophoresis (delivery of medication through the skin by electrical stimulation) treatments at risk of contracting an infection from potential contamination of the medication.

Findings include:

The APIC (Association of Professionals in Infection Control and Epidemiology) Position Paper: Safe Injection, Infusion, and Medication Vial Practices in Health Care (2016) stated, ". . . SYRINGES AND NEEDLES: . . . Never use a syringe for more than one patient even if the needle has been changed between patients. Use a new sterile syringe and a new sterile needle for each entry into a vial . . . MEDICATION VIALS: . . . Always use a new sterile syringe and a new needle/cannula when entering any vial. . . ."

Observation of the Physical Therapy department at 9:00 a.m. on 01/15/19 showed a cabinet containing a puncture device and a syringe with an attached applicator tip.

During interview at approximately 9:00 a.m. on 01/15/19, an administrative therapy staff member (#8) stated therapy staff use the same puncture device, syringe, and applicator tip when obtaining and applying dexamethasone medication for all patients receiving Iontophoresis treatments.

Reviewed on 01/16/19, the therapy policy manual failed to include a policy for Iontophoresis treatments including acquisition and application of dexamethasone medication. Upon request on 01/16/19, the CAH failed to provide a policy for Iontophoresis treatments.

Based on record review, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to ensure a registered nurse (RN) evaluated and assessed the increased use of an as needed (PRN) pain medication for 1 of 1 patient records reviewed (Patient #2) who had pain. Failure of an RN to assess and act on the patient's pain resulted in unresolved pain and decreased quality of life.

Findings include:

Review of the facility's policy titled "Guidelines of Patient Care and Assessment" occurred on 01/15/19. This policy, revised October 2018, stated, ". . . Routine Care - Hospital Outpatient Observation/Inpatient/Skilled Swing Bed . . . pain screen and evaluation Every shift, with complaints of pain, reassess within 1 hour if treating pain. . . ."

Reviewed January 14-16, 2019 Patient #2's record indicated CAH staff failed to assess and evaluate the increased use of PRN Norco (hydrocodone/acetaminophen).

- The current physician's order dated 07/01/18 stated PRN Norco 5/325 milligrams (mg) one tablet as needed every four hours and an order dated 09/11/18 stated Duragesic Patch 12 micrograms (mcg)/hour every seventy two hours.
- The record showed PRN Norco was administered to Patient #2 five times in September, five times in October, two times in November, twenty-one times in December and six times in January.
- Pain was documented as crying, moaning, grimacing, and all over body.

During interview on 01/15/19 at 3:00 p.m., an administrative nursing staff member (#1) agreed an RN did not evaluate and complete a follow up assessment for the increase in PRN Norco administered to Patient #2.

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Based on record review, review of facility policy, and staff interview, the Critical Access Hospital (CAH) failed to assess the effectiveness of medications given to patients on an as needed (PRN) basis within the expected timeframe for 8 of 10 patient records reviewed (Patients #2, #3, #4, #6, #8, #13, #15, #16) who received PRN medications. Failure to evaluate the patients' responses to PRN medications within the expected timeframe limited the nursing staffs' ability to assess whether the medications achieved the desired effect.

Findings include:

Review of the CAH's policy titled, "Guidelines of Patient Care and Assessment" occurred on 01/16/19. This policy, revised October 2018, stated, ". . . Pain screen and evaluation: . . . Re-Assess within 30-60 min. [minutes] if treating acute pain with prn [as needed] medication. . . ."

Reviewed January 14-16, 2019, the following records indicated CAH staff failed to assess the efficacy of PRN medications within the expected 30-60 minutes after administration:
- Patient #2 received Norco eight times in December 2018 and six times in January 2019 with no follow-up assessments.
- Patient #3 received Clonazepam once in July 2018 with no follow-up assessment.
- Patient #4 received Tylenol five times in October 2018, three times in November 2018, and four times in December 2018 with no follow-up assessments.
- Patient #6 received Tylenol one time in October 2018 and three times in December 2018 with no follow-up assessments.
- Patient #8 received Morphine once and Oxycodone twice in July 2018 with no follow-up assessments.
- Patient #13 received Tylenol once in January 2019 with no follow-up assessment.
- Patient #15 received the following PRN medications with no follow-up assessments: Dilaudid five times in September 2018 and four times in January 2019; Morphine four times in August 2018; Tylenol once in August 2018; and Zofran twice in August 2018.
- Patient #16 received Tylenol on 11/28/18 at 8:04 p.m. with a follow-up assessment on 11/29/18 at 4:45 a.m. (8 hours and 41 minutes later); Ultram on 11/30/18 at 7:32 p.m. with a follow-up assessment at 9:35 p.m. (2 hours and 3 minutes later); and Tylenol and Ultram in November 2018 with no follow-up assessments.

During interview on 01/16/19 at 9:30 a.m., an administrative nurse (#1) stated she would expect staff to assess the effectiveness of PRN medications within 30-60 minutes of medication administration.










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