HospitalInspections.org

Based on document review and staff interview the Critical Access Hospital (CAH) failed to develop and implement a policies and procedure that directed staff to report adverse drug reactions to the physician and a process to report serious adverse drug reactions to the Food and Drug Administration (FDA).

Findings included:

- The CAH failed to provide policies or procedures for adverse drug reactions.


Staff D on 6/8/10 at 2:30pm acknowledged the CAH lacked a policy and/or procedure for adverse drug reactions. Staff D indicated they were unaware of the requirement for policies and/or procedures for adverse drug reactions.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to develop and implement a system to assure two staff members followed manufacturer's directions for disinfection of surfaces to prevent the potential for the spread of infections in one patient room.


Finding included:

- Observation on 6/8/10 at 4:30pm revealed staff I cleaning a patient room after discharge revealed Staff I used disposable cloth saturated with the disinfectant "Re-Juv-Nal" to clean the bedside table, the intravenous (IV) pole and pump, the metal dresser, door windowsill Staff I failed to ensure the surfaces cleaned with "Re-Juv-Nal" remained wet for at least 10 minutes to assure disinfection.

- Observation on 6/8/10 at 5:30pm revealed staff J cleaning a patient room after discharge. Staff J mopped the floor with "Re-Juv-Nal" solution. Staff J failed to ensure the floor cleaned with "Re-Juv-Nal" remained wet for at least 10 minutes to assure disinfection.

Review of the manufacturer's instructions for "Re-Juv-Nal" revealed surfaces must remain wet for 10 minutes to ensure disinfection.

- Observation on 6/9/10 at 10:15am revealed staff K cleaning after a patient treatment in the physical therapy department. Staff K wiped the mattress with "Coverage Germicidal Surface Wipe". Staff K failed to ensure the surface remained wet for 10 minutes.

The manufacturer's instructions for "Coverage Germicidal Surface Wipe" required surfaces to remain wet for 10 minutes to assure disinfection.

The CAH failed to ensure the surfaces remained wet according to the manufacture's instructions to assure disinfection.

Based on record review and staff interview the Critical Access Hospital (CAH) failed to assure providers timed, dated, and authenticated entries into the medical record for 11 of 22 records reviewed requiring physician signature as directed in the medical staff rules and regulations (record #'s 1, 2, 11, 13, 14, 17, 21, 22, 23, 24, and 25).

Findings included:

- The medical record for patient #11 reviewed on 6/8/10 revealed the CAH admitted the patient on 6/7/10 with diagnoses of increased Dyspnea and Edema. The physician failed to date and time the admission order.

- The medical record for patient #13 reviewed on 6/9/10 revealed the CAH admitted the patient on 1/20/10 with diagnoses of Urinary Tract Infection and Atrial Fibrillation and discharged the patient on 1/22/10. The physician failed to sign, date and time the discharge summary.

- The medical record for patient #21 reviewed on 6/8/10 revealed the CAH admitted the patient on 3/5/10 with diagnosis of Alteration in Mental Status. The physician failed to co-sign the Medical Screening Examination with the Physician Assistant and failed to date and time the radiology report.

- On 6/9/10 review of the "Rules and Regulations Addendum to Medical Staff Bylaws", states under #17, "...At the time of discharge, the attending physician shall see that the record is complete, state his/her final diagnosis and sign the record. A patient's record shall be considered delinquent if not completed within 14 days after discharge".

Staff E on 6/9/10 at 3:30pm acknowledged the medical records were incomplete and verified the providers failed to sign, time and date entries in the medical records as directed by the Medical Staff Bylaws.

The failure to sign, date and time entries in the medical record also affected patient #'s 1, 2, 14, 17, 22, 23, 24 and 25.

Based on document review and interview, the Critical Access Hospital (CAH) failed to assure all services effecting patient care were evaluated as part of the CAH's Quality Assurance (QA) program. The CAH's failed to include data from the business office, pharmacy services, housekeeping and maintenance for 2010. The CAH failed to assure the nursing department particiapted in the QA process for 2009 and 2010.


Findings included:

- Staff C on 6/9/10 at 3:50pm revealed the QA program lack of information from the business office, pharmacy, housekeeping and maintenance for 2010. Interview with staff C confirmed the lack of QA participation from the nursing department for 2009 and 2010.

The work calenders from each department's QA participation revealed since the CAH started the QA process in March of 2009, the housekeeping and nursing department failed to participate in the QA process.

Additional interview with staff C confirmed the CAH failed to assure all services affecting patient health and safety are evaluated for the quality and appropriateness of the services provided.