HospitalInspections.org

On the days of the Validation Survey based on interview, medical record review, and hospital policy and procedure review, the Critical Access Hospital (CAH) failed to ensure advance directive information was completed for 2 of 15 open patient records reviewed, (Patient #3 and #4) and 1 of 22 closed patient records. (Patient #3)


The findings include:


Record review(closed) conducted on 5/1/13 at 1240 revealed Patient #3 was admitted to the CAH on 2/25/13 with Diabetic Foot Ulcer and transferred to another hospital on 2/25/13. The form, titled, "CONDITIONS FOR SERVICES AT .... AREA MEDICAL CENTER", dated 2/25/13, did not have answers for these questions: "I have a Living Will (LW); I have a Healthcare Power of Attorney (HPOA); I would like assistance or more information regarding LW/HPOA; I have been informed and have been given the opportunity to receive written material on LW/HPOA; I understand that it is not required to have a LW/HPOA in order to receive treatment/services at AAMC; I have been informed and have been given the opportunity to receive a copy of the AAMC Notice of Privacy Practices; and I have received a copy of the Patient's Rights and Responsibilities." The findings were verified by Staff Member #6 on 5/1/13 at 1400.







30011

On 5/1/13 at 1310, open (concurrent) chart review for Patient #3 showed the patient was admitted on 4/25/13 at 1642. Review of the hospital form, titled, "CONDITIONS FOR SERVICES AT ..... AREA MEDICAL CENTER", showed the following questions were had no response: "I have a Living Will (LW); I have a Healthcare Power of Attorney (HPOA); I would like assistance or more information regarding LW/HPOA; I have been informed and have been given the opportunity to receive written material on LW/HPOA; I understand that it is not required to have a LW/HPOA in order to receive treatment/services at AAMC." The findings were verified by Staff Member #4.

On 5/1/13 1520, open (concurrent)chart review for Patient #4 showed the patient was admitted on 4/27/13 at 1841. Review of the hospital form, titled, "CONDITIONS FOR SERVICES AT .... AREA MEDICAL CENTER", showed the following questions had no response: "I have a Living Will (LW); I have a Healthcare Power of Attorney (HPOA); I would like assistance or more information regarding LW/HPOA; I have been informed and have been given the opportunity to receive written material on LW/HPOA; I understand that it is not required to have a LW/HPOA in order to receive treatment/services at AAMC; I have been informed and have been given the opportunity to receive a copy of the AAMC Notice of Privacy Practices; and I have received a copy of the Patient's Rights and Responsibilities".


Hospital policy # 34.001, titled, "Advance Directives" revised 3/2010, states, "...POLICY: The policy of .... Area Medical Center is to honor, in accordance with the law of the state of South Carolina, competent adult patient's right to make decisions regarding treatment, including an adult patient's right to consent to, refuse or alter treatment plans, and the right to formulate Advance Directives \-v11ich [sic]will govern if the adult patient should become incapacitated. In the absence of a written directive, the usual hospital policies and procedures should be followed. These include, but are not limited to policies governing assessment of patient decision making capacity, surgical consent, medical consent, the right to refuse treatment, family consent to treatment, withholding resuscitative services and conflicting resolution. When an Advance Directive has been accepted by the hospital as valid it is the responsibility of the attending physician or his/her designee to notify the agency of the immediate next - of - kin that the conditions to activate the Advance Directives have been met...PROCEDURE:...II...B. The advance directive information is to be reviewed by Admission personnel with each competent patient and/or responsible party. Admission personnel are responsible for each competent patient or responsible party reading the information and following the instructions in completing the form. Nursing will reassess the status of the patient's advance directive during the Nursing admission process. C. If the adult patient or responsible party does not have an Advance Directive and does not wish to receive further information this will be documented on the back of the Demographic Admission...".

On the days of the Validation Survey based on interview, review of the hospital policy and procedure, and review of personnel files, the hospital failed to ensure 5 of 9 employees whose files were reviewed were compliant with the hospital's own policy and procedure requiring certification. (Staff Member #18, #20, #22, #23 and #24)


The findings are:


On 5/2/13 at 1300, review of CAH personnel files revealed 5 of 9 staff members reviewed had expired Basic Life Support (BLS) training, Advanced Cardiac Life Support (ACLS) training, and/or Pediatric Advanced Life Support (PALS) training.
Staff Member #18- BLS expired 3/2013
Staff Member #20- BLS expired 3/2013
Staff Member #22- ACLS expired 3/2013 and PALS expired 1/2013
Staff Member #23- BLS expired 3/2013
Staff Member #24- BLS expired 3/2013
On 5/2/13 at 1345, the Chief Human Resources Officer verified the staff certifications were expired.

Hospital policy, BLS Certification and Re-certification, reads "....All clinical personnel will complete BLS classes as recommended by the American Heart Association or American Health and Safety Institute (every 2 years). BLS certifications and re-certifications will be provided by the .... Area Medical Center BLS instructor through the Industrial Medicine Department or AHEC. Emergency Department and Surgical Services require BLS, ACLS, NRP and PALS. Home Health requires BLS training every (2) years for all clinical personnel. Cardiac Rehab and ICU/CCU require BLS and ACLS every (2) years. Respiratory Therapy requires BLS and NRP every (2) years and prefers ACLS and PALS. Med-Surg (Medical - Surgical) and Radiology require BLS every (2) years. Non-licensed staff in clinical areas, i.e., Nursing Assistants and Techs require BLS....".

On the days of Validation Survey based on observation, interview, and review of hospital policy and procedure, the hospital failed to provide evidence for preventative maintenance for equipment at the hospital owned physician practice. (neurology)


The findings are:


On 5/2/13 from 1120 -1130, random observations of the hospital owned physician practice (neurology) revealed the practice had no evidence of preventative maintenance for a digital scale, otoscope, ophthalmoscope, electromyography (EMG) machine and electroencephalography (EEG) machine. On 5/2/13 at 1150, Staff Member #7 reported the medical practice equipment was inspected at the office, but there was no evidence to identify which equipment had been inspected and when the equipment was inspected.

On 4/30/13 at 1355, random observations of the anesthesia area revealed the freezer part had a thick block of ice. The finding was verified by Staff Member #3.

Hospital policy, titled, "Medical Equipment Management Plan", revised 10/06, reads, "Responsibilities: The Engineering Department is responsible for the safe and efficient maintenance, testing and inspections of all medical equipment....3. Written inspection, test and maintenance for medical equipment and device users....".

Manufacturer instructions, read, "Welch Allyn, 767 Diagnostic System, Maintenance,....Welch Allyn recommends inspections every six months, more often if used under adverse conditions....".

On the days of the Hospital Validation Survey based on observations, interview, and review of the hospital's policies and procedures, the hospital failed to ensure its central supply room had appropriate temperature ranges for its central supply room.

The findings are:

On 4/30/13 at 1520, review of the hospital's daily temperature/humidity log dated April 2013 revealed the central supply room had documented temperatures greater than the hospital's acceptable ranges of 68 to 73 degrees. The log showed:
April 01, 2013: 85 degrees,
April 02, 2013: 80 degrees,
April 03, 2013: 82 degrees,
April 04, 2013: 80 degrees,
April 05, 2013: 81 degrees,
April 06, 2013: 82 degrees,
April 07, 2013: 78 degrees,
April 08, 2013: 83 degrees,
April 09, 2013: 83 degrees,
April 10, 2013: 79 degrees,
April 11, 2013: 78 degrees,
April 12, 2013: 80 degrees,
April 15, 2013: 82 degrees,
April 16, 2013: 82 degrees,
April 17, 2013: 79 degrees,
April 18, 2013: 79 degrees,
April 19, 2013: 80 degrees,
April 22, 2013: 79 degrees,
April 23, 2013: 78 degrees,
April 24, 2013: 78 degrees,
April 25, 2013: 80 degrees,
April 26, 2013: 78 degrees,
April 29, 2013: 82 degrees, and
April 30, 2013: 79 degrees.

Interview on 5/2/13 at 1000 with Staff Member #7 revealed the temperature elevation in the central supply room was an ongoing problem for 5 years. Staff member #7 reported, "The more critical areas (OR) for air reduction is maintained than the peripheral areas. Possibly by Spring, before the humidity rises, we can have the issue resolved, but there's nothing in writing....".

On the days of the Hospital Validation Survey based on patient record review, interview, and hospital policy and procedure review, the Critical Access Hospital (CAH) failed to ensure adherence to its own restraint/seclusion policies by way of the physician writing as needed (PRN) restraint orders for 1 of 2 closed patient charts reviewed for restraint orders. (Patient #12)


The findings include:


Closed record review conducted on 5/2/13 at 1007 revealed Patient #12 was admitted on 2/1/13 and discharged on 2/5/13 with the diagnosis Altered Mental Status. Review of the physician orders dated 2/1/13/ at 2026 revealed, "Type of restraint: WRIST/ see Restraint Flow Sheet PRN AS NEEDED". The finding was verified with Staff Member #12 on 5/2/13 at 1415.

Hospital policy #2.304, titled, "Patient Restraint/Seclusion", revised 7/10, states, "...Orders...* The restraint order is NEVER written as a standing order or on an "as needed" (PRN) basis. Nursing staff will not accept any order for restraint that is PRN or "as needed." If an order of this type written, the nurse will contact the physician for clarification and correction to the order."

On the days of Hospital Validation Survey based on observation and interview, the hospital failed to remove expired supplies and medications from patient care areas. (Post Anesthesia Care Unit)

The findings are:

On 4/30/13 at 1440, random observations of the post anesthesia care unit (PACU) area crash cart revealed (2) Infant 4.2% (percent) Sodium Bicarbonate Epinephrine Injection expired 4/1/13. The findings were verified by Staff Member #3.

On the days of the Hospital Validation Survey based on observations, interviews, and review of the hospital policy and procedure, the Critical Access Hospital (CAH) failed to ensure staff followed its own standard infection control measures for 5 of 11 staff members observed providing care and services to patients. (Staff Member #27, Staff Member #8, Staff Member #1, Staff Member #3, and Staff Member #4)

The findings are:


On 4/30/13 at 1230, random observations in the Emergency Department revealed a nebulizer tubing from the previous patient hanging on the wall oxygen concentrator in Bay #6. On 4/30/13 at 1231, the CNO (Chief Nursing Officer) verified the tubing should have been disposed of when the patient was discharged. On 5/1/13 at 0930, random observations in the Wound Center revealed Staff Member #27 failed to perform hand hygiene prior to exiting the patient room and during a dressing change between glove changes.

Hospital policy, Infection Prevention, reads, "....I. Hand Hygiene A. 5. Hands can be cleaned by handwashing and using the sink with soap and water, by using alcohol based sanitizers, or by using antimicrobial impregnated towelettes. B. Indications for handwashing and hand antisepsis 10. Decontaminate hands after removing gloves....".




25877

Observation of Staff Member #8 on the medical surgical unit on 05/01/2013 at 1640 during medication administration showed after completion of flushing the patient's intravenous line and removing gloves, Staff Member #8 cleaned his/her hands with soap and water for less than 10 seconds, but not thoroughly cleaning all surfaces of his/her hands and fingers. Then, Staff Member #8 rinsed and dried his/her hands. On 05/2/2013 at 1410, the Infection Control Officer reviewed the findings. Observation of Staff Member #8 on the medical surgical unit was conducted on 05/01/2013 at 1715 during medication administration. During preparation of the patient's medications, Staff Member #8 dropped one unopened packet of a medication on the floor. After reaching to the floor to pick it up and dispose of it, Staff Member #8 retrieved a new packet from the medication cart outside of the room. Next, Staff Member #8 cleansed his/her hands with soap and water at the sink for 10 seconds but not thoroughly cleaning all surfaces of her hands and fingers. After donning gloves, Staff Member #8 administered the medications to the patient. At the end of medication administration, Staff Member #8 removed the gloves and cleansed his/her hands with alcohol sanitizer for less than 5 seconds but not thoroughly cleaning all surfaces of the hands and fingers.

Observation of Staff Member #1 on the medical surgical unit on 05/01/2013 at 1100 during medication administration showed Staff Member #1 finished documentation on the computer outside of the patient's room, cleansed his/her hands using an alcohol sanitizer for less than 2 seconds, but not thoroughly cleaning all surfaces of the hands and fingers. Then, Staff Member #1 entered the patient's room, proceeded to the sink, turned on the water, and stated, "I need to get this stuff (alcohol sanitizer) off of my hands", rinsed the hands under the water only, and then, Staff Member #1 dried his/her hands. Then, Staff Member #1 donned gloves, proceeded to open the medication packets, and put the medications in a medication cup. After administering the medications to the patient, Staff Member #1 took off his/her gloves and cleansed his/her hands and fingers with soap and water for less than 7 seconds but not thoroughly cleaning all surfaces of the hands and fingers. On 05/2/2013 at 1410, the Infection Control Officer reviewed the findings.

Review of the hospital policy and procedure, Hand Hygiene, reads, "Section 2- Infection Prevention...I. HAND HYGIENE Hand hygiene is generally considered the most single important procedure for preventing hospital acquired infections. Hand hygiene is important to aid in the prevention of contamination and cross transmission of microorganisms among patients and employees. Clean hands to protect both patients and healthcare providers... C. Hand-hygiene technique 1. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB). Follow the manufacture's recommendations regarding the volume of product to use. 2. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB)...".


Guidelines and standard nursing practice in the health care setting set forth in the Recommendation and Reports for the Centers for Disease Control, reads, "Morbidity and Mortality Weekly Report Recommendations and Reports October 25, 2002/Vol 51/No. RR-16 Guideline for Hand Hygiene in Health-Care Settings...2. Hand-Hygiene technique...B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacture to hands and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (lB) (90-92,94,411)...". Guidelines and standard nursing practice in the health care setting set forth by the Centers for Disease Control, reads, "...Hand Hygiene Guidelines Fact Sheet...When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry...".







30011

On 4/30/13 at 1340, random observation of the Operating Room sterile core area revealed Staff Member #29 in the sterile core area without scrub attire. The findings were verified by Staff Member #3.

On 5/1/13 from 1212 to 1218, random observations on the medical surgical floor revealed Staff Member #30 in the hallway going to the cafeteria with shoe covers on feet, scrub hat on head, and no cover-up donned. The findings were verified by Staff Member #4.

Hospital policy, reads, "Surgical Attire for Hospital Staff, Revised 8/99, Policy:....3. Lab coats will be worn if staff member is outside of the facility and removed upon reentering the OR (operating room). 4....a. If worn, shoe covers are removed prior to leaving the Operating Room and replaced with new shoe covers upon reentry to the Operating Room and crossing over the red floor lines....".

On the days of the Validation Survey based on observations and interview, the hospital failed to ensure its residents in swing beds had an activity calendar posted.


The findings include:

Observations for swing beds was conducted on 05/01/2013 at 1115 that showed there was no monthly activity calendar for swing bed residents posted. During an interview on 05/01/2013 at 1230 with the Activity Director/Occupational Therapist, Case Manager, and Physical Therapist for Swing Bed residents, the Activity Director stated he/she did not have a monthly activity calendar since the hospital may have only a census of 1 resident or none. The Activity Director reported that at the time of the resident's initial assessment, I introduce myself and let them know I will bring activities the next day, but I have no formal activity calendar posted.

On the days of the Validation Survey based on interview and review of patient charts, the Critical Access Hospital (CAH) failed to ensure the 24 hour plan of care review and revision was completed for 1 of 22 closed patient records. (Patient # 10).


The findings are:


On 5/2/13 at 1205, closed record review for Patient #10 showed the patient was admitted to the hospital on 11/12/16 status post (s/p) Cardiopulmonary Arrest, COPD (Chronic Obstructive Pulmonary Disorder), CHF (Congestive Heart Failure), and Atrial Fibrillation. Review of the patient record revealed no plan of care review and revision completed for the patient on 11/17/12 and 11/18/12. The findings were verified on 5/2/13 at 1315 with the Chief Nursing Officer.