HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation, manufacturer's guidelines and staff interview the CAH failed to assure drugs and biologicals are stored according to the manufacturer's guidelines, administered according to the manufacturer's guidelines, and outdated drugs are not available for patient use for one of one Computerized Tomography (CT) room in the radiology department.

Findings include:

- The manufacturer's (Hospira, Inc.) guidelines for the Intravenous (IV) solution sodium chloride reviewed on 7/26/12 at 9:30am stated, "...is intended for only single-dose injection. When smaller doses are required the unused portion should be discarded."

- The manufacturer's (COEUR, Inc.) guidelines for the IV tubing used to connect the IV solution bag to the syringe reviewed on 7/25/12 at 3:00pm stated, "single use only".

- Observation on 7/25/12 at 1:55pm of the CT room revealed a 1000cc (cubic centimeter) bag of sodium chloride hanging on an IV pole with tubing attached. The bag contained 700cc of sodium chloride fluid. Staff H explained they use the fluid when administering the CT contrast. Staff H confirmed they use the fluid for multiple patients until the bag is empty and each patient receives 100cc of the sodium chloride fluid. The single use only 1000cc IV bag of sodium chloride could potentially be used on at least 10 patients.

Staff H interviewed on 7/25/12 at 2:00pm acknowledged they lacked knowledge the bag of fluids and IV tubing is labeled for single use only.

- The manufacturer's (GE Healthcare) guidelines for OMNIPAQUE injection contrast solution reviewed on 7/25/12 at 4:15pm stated, "OMNIPAQUE Injection in all presentations may be stored in a contrast media warmer for up to one month at 37 degrees C (Celsius) (98.6 degrees Fahrenheit)."

- Observation on 7/25/12 at 1:55pm of the CT room revealed a contrast media warming cabinet that contained two multi-use undated 500cc glass bottles of contrast solution and one multi-use undated bottle of contrast solution half full.

Staff I interviewed on 7/25/12 at 2:00pm acknowledged the bottles of contrast media lacked a date when placed in the warmer and the radiology department staff failed to monitor the temperature of the warming cabinet.

- Observation on 7/25/12 at 1:55pm of the CT room revealed a contrast media warming cabinet and a non-warming cabinet that contained the following:
1. 5- 200cc bottles of OPtiray contrast solution with an expiration date of October 2011
2. 1- 200cc bottle of OPtiray contrast solution with an expiration date of May 2011
3. 1- 200cc bottle of OPtiray contrast solution with an expiration date of February 2011.

Staff I interviewed on 7/25/12 at 2:00pm acknowledged the outdated contrast solutions. Staff I stated they no longer use this contrast solution and lacked knowledge why the contrast solution was still available for use in the CT room.

Staff K interviewed on 7/26/12 at 9:20am acknowledged they were unaware that the radiology department used single use IV solutions for multiple patients, failed to monitor the temperature of the media warming cabinet, failed to date the contrast solution when placed in the warmer, and failed to dispose of expired contrast solutions.

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation, staff interview, and directions for use of cleaning, the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices to ensure staff followed acceptable standards for one of one cleaning of a discharged patient room.

Findings include:

- Directions for use of the cleaning solution Virex 128 instructs " ...add the product (Virex 128) at 1 oz. (ounce) per gallon of water."

A bucket of disinfectant solution, observed on 7/25/12 at 9:00am, had been prepared by the surgical staff. Staff D acknowledged the solution is prepared with an unmeasured volume of water and an unmeasured amount of Virex 128.

- Staff D, interviewed on 7/25/12 at 9:05am, acknowledged the lack of knowledge of the manufacturer's instructions for the preparation of the Virex 128.

Surveyor: Finck, Lavonne

The Critical Access Hospital (CAH) reported a census of three patients. Based on observation, policy review, and staff interview the CAH failed to protect patient's identifying information from destruction for patient's medical records stored in the basement of the CAH and failed to protect patient's x-ray films from unauthorized use.

Findings include:

- The CAH's policy titled, "SECURITY OF MEDICAL RECORDS" reviewed on 7/26/12 at 12:50pm directed, "All records will be kept secure by being in a locked area. Only authorized personnel have access to such records."

- Observation on 7/25/12 at 9:25am of the medical record storage area in the basement of the CAH revealed 30 stacked boxes of patient's medical records stored in a locked area of a large storage room on the cement floor, with eight boxes directly stored on the cement floor.

- Staff N interviewed on 7/25/12 at 9:25am acknowledged the boxes of medical records stored on the floor and confirmed if the large sewer in the storage area would back up the boxes of medical records would get wet.

The Critical Access Hospital (CAH) reported two swing bed patients. Based on staff interview and document review, the CAH failed to employ a qualified professional to direct the CAH's swing bed activities program for two of two swing bed patients (patient #'s 10 and 11).

Findings include:

- Staff F's personnel file, reviewed on 7/25/12/12 at 3:0pm revealed the lack of evidence they are a qualified professional to direct the swing bed activities program.

- Staff C, interviewed on 7/25/12 at 3:10pm, confirmed the CAH failed to assure qualified staff direct the activities program.

The CAH failed to assure the swing bed patients are offered an activities program directed by a qualified activities professional.