HospitalInspections.org

Based on medical record review and staff interview; the CAH (Critical Access Hospital) failed to document that a physician or mid-level practitioner (physician assistant or nurse practitioner) was on site within 30 minutes for emergency care for 4 of 5 ER (Emergency Room) records reviewed (Patients 17, 19, 20 and 21) . This failed practice had the potential to affect all patients coming to the CAH emergency room (ER). The CAH had 1,785 ER visits between 1/1/18-12/31/18.

Findings are:

A. Review of Patient 17's ER record (5/15/19 at 7:45 AM) revealed the patient arrived at the ER at 7:49 AM for a fall with a head laceration (cut). Review of the entire medical record revealed a lack of practitioner notification and arrival time ensuring the practitioner was on site within 30 minutes.

-Review of Patient 19's ER record (5/15/19 at 8:05 AM) revealed the patient arrived at the ER at 1:50 PM for chest pain. Review of the entire medical record revealed a lack of practitioner notification and arrival time ensuring the practitioner was on site within 30 minutes.

-Review of Patient 20's ER record (5/15/19 at 8:10 AM) revealed the patient arrived at the ER at 5:59 AM for abdominal pain. Review of the entire medical record revealed a lack of practitioner notification and arrival time ensuring the practitioner was on site within 30 minutes.

-Review of Patient 21's ER record (5/15/19 at 8:20 AM) revealed the patient arrived at the ER at 12:56 PM for left sided weakness. Review of the entire medical record revealed a lack of practitioner notification and arrival time ensuring the practitioner was on site within 30 minutes.

B. Interview with the ER Manager confirmed the above medical records lacked the documentation of the practitioner being onsite within 30 minutes and stated the facility did not have a policy requiring the documentation.

Based on observation, staff interview, and lack of documentation; the CAH (Critical Access Hospital) failed to: 1) Provide endoscopy reprocessing in accordance with current standards of practice; and 2) Ensure the ice machines were cleaned in a manner to prevent potential infections. These failed practices had the potential to affect all patients coming to the CAH for endoscopic procedures and had the potential to affect any patients and staff at the facility utilizing ice from the ice machines. The CAH performed 229 endoscopic procedures between 1/1/18-12/31/18 and had a total of 331 acute inpatients for the last fiscal year.

Findings are:

A. During random observation (5/16/10 1:30-2:30 PM)an automated endoscope reprocessor (AER) was observed located on the counter in the procedure room where endoscopy services (tests to examine the lining of the esophagus, stomach, and first part of the small intestine; tests to examine the rectum and large intestine) are performed.

Review of Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopies, SGNA (Society of Gastroenterology Nurses and Associates, 2012) stated "Reprocessing of contaminated patient equipment must be done in an area designated and dedicated for this function. This must be a room separate from where endoscopic procedures are performed (AAMI (Association for the Advancement of Medical Instrumentation), 2010)."

Interview with the OR (Operating Room) Manager (5/17/19 at 9:05 AM) confirmed the automated reprocessor is located in the procedure room where endoscopy services are provided.



04526

.
B. Interview with the Maintenance Director of 5/16/2019 at 10:30AM revealed that a 'contracted service' was responsible for cleaning and sanitizing the ice machines located throughout the facility (cafeteria, third floor - nursing area, and in the cardiac rehabilitation area). The Maintenance Director indicated that he 'did not know' if the inlet and outflow pipes were sanitized during the cleaning process. He contacted the company and was provided written documentation stating 'the ice machines are cleaned in accordance with instructions on the inside of the lid'. Nothing was documented about whether or not the inlet or outlet pipes were cleaned and sanitized. Surveyor attempted to review the directions on the inside of the machine lids, however, none of the facility staff had keys to open the lids, therefore, this was unable to be reviewed.

Interview with the Director of Nursing (DON) on 5/17/2019 at 11:00AM revealed that when the DON called the contracted company, the DON was informed that cleaning the inlet and outflow pipes 'could not be done'.

Recommended cleaning instructions include cleaning with an EPA approved sanitizer or a 50 to 100 parts per million (ppm) sodium hypochlorite solution per gallon of water utilized for the inlet and outflow devices according to the Centers for Infection Control and Prevention, Healthcare Infection Control Practices Advisory Committee, June 6, 2003 - American Journal of Infection Control. Both the water inlet and outflow pipes of ice machines have the potential to harbor Pseudomonas and Legionella bacteria as they are both cold-loving. Both of these bacteria cause health care acquired infections in patients.

Based on medical record review, review of policy and procedure and staff interview; The CAH (Critical Access Hospital) failed to ensure that medical records contained documentation of the form containing general consent to Conditions of Inpatient Admission for 2 of 5 swing bed medical records (Patients 28 and 29) reviewed. This failed practice had the potential to affect all swing bed patients of the CAH. The CAH had 77 swing bed admissions in 2018.

Findings are:

A. Review of Patient 28's medical record (5/15/19 at 8:25 AM) revealed the patient was admitted to swing bed on 11/6/18 for continued physical and occupational therapy after an acute hospital stay for stroke (sudden death of brain cells due to lack of oxygen, caused by blockage of blood flow or rupture of an artery to the brain). Review of the entire medical record revealed a lack of a signed general consent and conditions of admission (a form that the patient or the responsible party for the patient signs to give the hospital and staff permission to provide the patient care and treatment while admitted).

-Review of Patient 29's medical record (5/15/19 at 8:45 AM) revealed the patient was admitted to swing bed on 12/13/18 for continued physical and occupational therapy after an acute hospital stay for back pain. Review of the entire medical record revealed a lack of a signed consent and conditions of admission.

B. Review of the policy and procedure titled Consent Forms - Registration (Reviewed 5/18) stated the following:
-For inpatient services, required consent form is called "Conditions of Inpatient Admission"...
-A new signature on this inpatient form is needed anytime a new chart is started for services. (Example: when a patient goes from Medical to Swingbed, a new chart is started for the Swingbed service. A signature on the "Conditions of Inpatient Admission" is needed for bot the Medical and Swingbed services.)

C. Interview with the HIM (Health Information Management) Manager (5/16/19 at 9:20 AM) confirmed the above medical records lacked consent for the swing bed admissions.

.
Based on medical record review, review of policy and procedure and staff interview, the CAH (Critical Access Hospital) failed to:
(1) Ensure the physician examined the patient immediately before surgery for 6 of 7 surgical records reviewed (Patients 1, 22, 23, 24, 26 and 27); and (2) ensure an anesthesia qualified practitioner evaluated each patient after surgery for proper anesthesia recovery before discharge for 5 of 6 outpatient surgical records reviewed (Patients 22, 23, 24, 26 and 27). These failed practices had the potential to affect all surgery patients of the CAH. Total surgical procedures/surgeries performed from 1/1/18-12/31/18 was 863.

Findings are:

A. Review of Patient 1's medical record (5/15/19 at 12:45 PM) revealed the patient had a left total knee arthroplasty (total knee replacement) on 4/30/19. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed.

-Review of Patient 22's medical record (5/15/19 at 10:35 AM) revealed the patient had an EGD (Esophagogastrduodenoscopy) (test to examine the lining of the esophagus, stomach, and first part of the small intestine) and colonoscopy (test to examine the rectum and large intestine) on 1/10/19. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed; and revealed no documented evidence that an anesthesia qualified practitioner evaluated the patient for proper anesthesia recovery before the patient was discharged from the CAH.

-Review of Patient 23's medical record (5/15/19 at 10:45 AM) revealed the patient had right eye cataract (lens of the eye gets cloudy) extraction with lens implant on 1/21/19. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed; and revealed no documented evidence that an anesthesia qualified practitioner evaluated the patient for proper anesthesia recovery before the patient was discharged from the CAH.

-Review of Patient 24's medical record (5/15/19 at 10:50 AM) revealed the patient had a colonoscopy on 2/1/19. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed; and revealed no documented evidence that an anesthesia qualified practitioner evaluated the patient for proper anesthesia recovery before the patient was discharged from the CAH.

-Review of Patient 26's medical record (5/15/19 at 11:10 AM) revealed the patient had a left knee arthroscopy (a surgical procedure to see inside the joint to diagnose and treat the joint) on on 3/6/19. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed; and revealed no documented evidence that an anesthesia qualified practitioner evaluated the patient for proper anesthesia recovery before the patient was discharged from the CAH.

-Review of Patient 27's medical record (5/15/19 at 11:20 AM) revealed the patient had bilateral (both sides) myringotomy (a tiny incision created in the eardrum to relieve pressure) with ear tube insertion on 1/21/19. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed; and revealed no documented evidence that an anesthesia qualified practitioner evaluated the patient for proper anesthesia recovery before the patient was discharged from the CAH.

B. Review of policy and procedure titled Anesthesia Responsibilities (no date) revealed "Postoperative visits must be made before the patient is discharged from the PACU (Post Anesthesia Care Unit)." "Documentation of the ...postoperative anesthesia visits must be done on the anesthesia evaluation sheet by a Certified Registered Nurse Anesthetist before the patient can be discharged."

C. Interview with CRNA (Certified Registered Nurse Anesthetist) A and CRNA B (5/17/19 at 8:45 AM) confirmed the above medical records (Patients 22, 23, 24, 26 and 27) lacked the post-anesthesia evaluations for proper anesthesia recovery before patient discharge. Interview with the OR (Operating Room) Manager (5/17/19 at 8:50 AM) confirmed the above medical records (Patients 1, 22, 23, 24, 26 and 27) lacked evidence of the patient examinations completed by the physician immediately before surgery to evaluate the risk of the procedure to be performed.

.
Based on medical record review, review of policy and procedure and staff interview; the CAH (Critical Access Hospital) failed to ensure all patients are discharged in the company of a responsible adult unless exempted by the physician who performed the procedure for 5 of 6 outpatient surgical records reviewed (Patients 22, 23, 24, 26 and 27). This failed practice had the potential to affect all surgery patients of the CAH. Total outpatient surgical procedures/surgeries performed from 1/1/18-12/31/18 was 807.

Findings are:

A. Review of Patient 22's medical record (5/15/19 at 10:35 AM) revealed the patient had an EGD (Esophagogastrduodenoscopy) (test to examine the lining of the esophagus, stomach, and first part of the small intestine) and colonoscopy (test to examine the rectum and large intestine) with MAC (Monitored Anesthesia care) sedation on 1/10/19. Review of the entire medical record revealed no documentation that the patient was discharged in the company of a responsible adult or documentation that the patient was exempted from having a responsible adult at discharge by the practitioner who performed the surgery.

-Review of Patient 23's medical record (5/15/19 at 10:45 AM) revealed the patient had right eye cataract (lens of the eye gets cloudy) extraction with lens implant with MAC sedation on 1/21/19. Review of the entire medical record revealed no documentation that the patient was discharged in the company of a responsible adult or documentation that the patient was exempted from having a responsible adult by the practitioner who performed the surgery.

-Review of Patient 24's medical record (5/15/19 at 10:50 AM) revealed the patient had a colonoscopy with MAC sedation on 2/1/19. Review of the entire medical record revealed no documentation that the patient was discharged in the company of a responsible adult or documentation that the patient was exempted from having a responsible adult at discharge by the practitioner who performed the surgery.

-Review of Patient 26's medical record (5/15/19 at 11:10 AM) revealed the patient had a left knee arthroscopy (a surgical procedure to see inside the joint to diagnose and treat the joint) with general anesthesia on 3/6/19. Review of the entire medical record revealed no documentation that the patient was discharged in the company of a responsible adult or documentation that the patient was exempted from having a responsible adult at discharge by the practitioner who performed the surgery.

-Review of Patient 27's medical record (5/15/19 at 11:20 AM) revealed the patient had bilateral (both sides) myringotomy (a tiny incision created in the eardrum to relieve pressure) with ear tube insertion with general anesthesia on 1/21/19. Review of the entire medical record revealed no documentation that the patient was discharged in the company of a responsible adult or documentation that the patient was exempted from having a responsible adult at discharge by the practitioner who performed the surgery.

B. Review of policy and procedure titled Surgery Discharge (Revised 2/19) stated "All patients are discharged in the company of a responsible adult, except those exempted by the practitioner who performed the surgical procedure or those who have received strictly a local anesthetic. Any exceptions to this requirement must be made by the attending practitioner and annotated on the clinical record."

C. Interview with the OR (Operating Room) Manager (5/17/19 at 9 AM) confirmed the above medical records lacked documentation of the patients being discharged in the company of a responsible adult unless excepted by the physician who performed the procedure

Based on review of the Swing Bed Program Bill of Rights and staff interview; the CAH (Critical Access Hospital) failed to include the resident has the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service in the Bill of Rights. This failed practice had the potential to affect all swing bed patients of the CAH. The CAH admitted 77 swing bed patients in 2018.

Findings are:

A. Review of the form titled 'Swing Bed Program Patient Bill of Rights' (no date) lacked evidence of the following documentation:

The Resident has the right to:
-Send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

B. Interview with the Vice President of Clinical and Regulatory Services (5/14/19 at 2:50 PM) confirmed the Residents Rights lacked the above information.

Based on medical record review and staff interview; The CAH (Critical Access Hospital) failed to ensure a comprehensive assessment of a Swing Bed patient's needs, strengths, goals, life history and preferences was completed within 14 calendar days after admission for 1 of 1 Swing Bed patients with a stay greater than 14 days (Patient 32) reviewed . This failed practice had the potential to affect all Swing Bed patients of the CAH who had a stay greater than 14 days. The CAH had 77 swing bed admissions in 2018.

Findings are:

A. Review of the below medical record (5/15/19 at 9:15 AM) revealed a lack of evidence of a completed comprehensive assessment for a Swing Bed patient's needs, strengths, goals, life history and preferences:
- Patient 32's medical record revealed a Swing Bed (3/9-3/26/19) admission of 17 days.

B. Interview with the Care Coordinator (5/16/19 at 9:15 AM) confirmed the missing comprehensive assessment in the above medical record.