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Based on observation, interview and document review the facility failed to ensure staff followed infection control practices for 4/4 medication administrations. This had the potential to affect all patients in the critical access hospital (CAH).

Findings include:

Registered nurse (RN)-A was observed on 12/9/14, at 8:03 a.m. during a medication pass. RN-A entered a patient room without cleansing her hands with the provided foam sanitizer located outside the patient room. After removing the container housing the individually pre-packaged medications RN-A placed the container on a shelf below the bedside computer, which was not cleansed or sanitized. RN-A placed the packaged medication over the medication cup and each medication landed in the cup, except one medication rolled onto the shelf. RN-A picked up this medication with bare hands and placed it into the cup containing the other medications. After identifying the patient per protocol and scanning the bar codes, RN-A handed the medication cup to the patient and observed the patient swallow the contents.

During interview with RN-A on 12/9/14, at 11:47 a.m. verified that she picked up the medication, from an unclean surface, without a barrier on her hands, and administered it to the patient. RN-A further added she was taught to discard and replace all dropped medications and the pharmacy should have been called for a replacement.

During observation on 12/9/14, at 8:20 a.m. RN-F entered a patient room without sanitizing her hands. Following patient identification and bar code scanning, RN-F was noted to have difficulty opening the pre-packaged individually wrapped medication containers. RN-F removed a pen from her pocket and used the pen tip to open 3 medications prior to putting them into a medication cup and observing the patient taking the medications.

During interview with RN-F on 12/9/14, at 11:48 a.m. verified the use of a pen tip removed from her pocket to open the medications. RN-F added that this was not the usual and customary practice for opening medications.

During observations on 12/9/14, at 8:40 a.m. RN-E failed to sanitize her hands prior to entering a patient room. RN-E had difficulty opening the individually pre-packaged medication containers and used her fingernail to open the containers.

During interview on 12/9/14, at 11:59 a.m. RN-E verified that this practice was considered a breech in infection control standards.

During observation on 12/9/14, at 8:52 a.m. RN-I entered a patient room without sanitizing her hands, donned a pair of gloves, removed the partially eaten breakfast tray and emptied the contents from a urinal before removing the gloves. In an attempt to open pre-packaged medication containers, RN-I used her fingernail to open all of the medication containers except one that she was not able to open with her fingernail. RN-I left the room and did not sanitize hands prior to re-entering the patient room. RN-I placed a pair of scissors that were not observed to have been cleansed onto an unclean surface. RN-I used the scissors to open the pre-packaged medication container and administered the medications to the patient.

RN-I, interviewed on 12/9/14 at 12:55 p.m. ,verified using her fingernails and a pair of scissors to open pre-packaged medication containers prior to administering them to a patient. However, RN-I was certain that she had washed her hands prior to removing the gloves.

The infection control preventionist, RN-H was interviewed on 12/9/14, at 11:40 a.m. RN-H stated that RN-D (in-patient manager) who had been observing the morning medication passes on 12/9/14, from outside the patient rooms, verified that RN-A, RN-F, RN-E and RN-I failed to sanitize their hands by "foaming in" prior to entering the patients rooms. RN-H further added that the expectation was that all staff "foam in" prior to entering a patient room and "foam out" after leaving a patient room, and that the RN's who failed to "foam in" prior to entering a patient room were considered to have preformed a breach in infection control practice.

Review of the document titled EVALUATION OF INFECTION CONTROL PLAN 2014, undated, identified the following under the area: RISK ASSESSMENT:...
B. Hand hygiene has remained at a steady rate but the committee felt it could be considered a failure of prevention activities that could carry a high associated risk. Review of the Hand Hygiene Audits identified that opportunities for "foaming in" and "foaming out" dropped in the 3rd quarter of 2014 from 90% down to 86%.

Based on interview and document review the critical access hospital (CAH) failed to ensure a post-anesthetic evaluation had been completed for 4 of 10 surgical records reviewed (P11, P15, P16 and P21).

Findings include:

P11 had an inpatient surgical procedure on 10/13/2014 under general anesthesia administered by certified registered nurse anesthetist (CRNA)-C. The patient was transferred from the post-anesthesia care unit to the intensive care unit following the procedure due to respiratory complications which required the assistance of a medical device. The immediate post-anesthesia note, dated 12/8/2014 at 11:50 a.m., did not include an assessment of the patient's cardiopulmonary status, level of consciousness or any complication which had occurred during post-anesthesia recovery. CRNA-C completed a post-anesthesia note, dated 10/14/2014 at 7:05 a.m., which indicated the patient was off ventilatory assistance at this time. However, there was no assessment of the patient's level of consciousness or cardiopulmonary status. CRNA-A reviewed the medical record and verified the post-anesthesia assessment was incomplete.

P15 had an inpatient surgical procedure on 9/10/2014 under epidural and general anesthesia. There was no post-anesthesia evaluation documented in the medical record. CRNA-A reviewed the medical record and verified a post-anesthesia evaluation had not been completed.

P16 had an inpatient surgical on 10/1/2014 under general anesthesia administered by CRNA-A. There was no post-anesthesia evaluation documented in the medical record. CRNA-A reviewed the medical record and verified a post-anesthesia evaluation had not been completed.


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P21 had an surgical procedure performed under general anesthesia on 12/5/14. The general anesthesia had been administered by certified registered nurse anesthetist (CRNA)-A. The post anesthesia note was identified as having been written on 12/5/14, at 2030 (8:30 p.m.) and the documented end time of the general anesthetic was 2106 (9:06 p.m.). The note under the section titled: Post Anesthetic Note indicated it was documented 36 minutes prior to the end of the general anesthesia. No further post anesthesia evaluation was identified prior to the end of P21's observational hospital stay.

An interview conducted on 12/8/14, at 2:00 p.m. with CRNA-A verified the post anesthesia note was documented 36 minutes prior to the end of the surgical case.

The CAH did not ensure a post-anesthesia evaluation which included the patient's cardiopulmonary status, level of consciousness and any complications had occurred during the post-anesthesia recovery period.

Review of the Scope and Standards of Practice for Anesthesia Services, last revised July 2014, indicated a post-operative patient evaluation and treatment would be provided and would include determination of patient status on admission and of the post-operative surveillance period. The policy further specified that a patient would only be discharged from the post anesthesia recovery area or any other area where anesthesia was administered when discharge criteria was met. In addition the policy also indicated discharge documentation would include, but not be limited to, status of patient at discharge and compliance with discharge criteria.