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Based on personnel record review and interview, the CAH (Critical Access Hospital) failed to maintain current credentialing files with state background studies on 4 of 16 medical staff (MD-A, MD-E, MD-F and NP-G) records reviewed. Findings include.

MD-A, MD-E, MD-F and NP-G did not have state a background study on file.

A review of credentialing files for MD-A, MD-E, MD-F and NP-G were found to lack state background studies.

On 8/25/11, at 12:46 p.m. medical records employee (MRE)-A stated credentialing files have been taken over by the corporate office which is located in a neighboring state. MRE-A stated when she called the credentialing office looking for the complete credentialing file, they stated they do not complete background studies. She stated they were unaware of these not being completed and could not locate state background studies for MD-A, MD-E, MD-F and NP-G.

Based on personnel record review, review of the Medical Staff Bylaws, and interview, the CAH (Critical Access Hospital) failed to maintain current credentialing files with current licensure, certifications or registrations for 2 of 16 medical staff (MD-B and MD-E) records reviewed. Findings include.

The personnel files of MD-B and MD-E lacked documentation of current state licensure.

Record review of MD-B's personnel file indicated the CAH did not have a copy of the physician's current license. The license on file for MD-B had expired on 11/30/07.

Record review of MD-E's personnel file indicated the facility did not have a copy of the physician's current license. The license on file for MD-E had expired on 6/30/10.


On 8/25/11, at 1:30 p.m. medical records employee-A verified that the facility did not have a current copy of the physicians' license.

The unsigned 2010 Medical Staff Bylaws identified, "applicants must be currently licensed by the State of Minnesota."

Based on observation and interview, the CAH failed to maintain an adequate ventilation system in 1 of 1 soiled laundry rooms and did not ensure the area was free from peeling paint and dust. Findings included:

The ventilation system in the soiled laundry area was not working and the dust and peeling paint from the duct work had not been cleaned.

During the environmental tour of the facility at 9:45 a.m. on 8/23/2011, the ventilation system in the soiled laundry area was observed as not working. A copious amount of dust was collected on the vent grate as well as the surrounding pipes on the ceiling and several large pieces of paint peeling from the duct work. The director of maintenance (DM) verified the ventilation was not working by attempting to place a square of tissue to the vent and check for airflow.

At 10:00 a.m. on 8/23/2011, the DM confirmed the ventilation system to the soiled utility area had been turned off. The DM stated "we don't know how or when it got turned off but we turned it back on and we will re-educate the staff to not turn it off." The DM also verified the paint was peeling from the duct work and could fall into the dirty laundry bins. He stated he was unaware of the peeling paint.

At 9:55 a.m. on 8/23/2011 the housekeeping supervisor (HS) explained the laundry is brought into the room in plastic bags and included; mop heads, rags, infant receiving blankets, uniform scrubs for the obstetrics nurses and the scrub uniforms required to be worn by the patients admitted to the mental health unit. All other laundry from the hospital is sent out of the facility to be cleaned. The HS confirmed the laundry carts were placed directly under the area the paint was peeling and a copious amount of dust was clinging to the pipes overhead.

During an interview at 10:00 a.m. on 8/24/2011 the infection control officer (ICO) verified he did not review ventilation systems for infection control issues and stated, "I think it's unacceptable." At 12:03 p.m. on 8/24/2011 the ICO presented a work order for the repair and cleaning of the vent and duct work in the soiled laundry area.

Based on interview, Governing Body Bylaws, and record review, the CAH failed to obtain the necessary medical staff and governing board approval for the right to practice in the CAH for 5 of 16 medical staff (MD-B, DO-C, MD-D, MD-F, and NP-G) who would require medical staff and governing board approval. In addition, the facility failed to ensure medical staff bylaws were appropriately approved by the governing body. Findings included:

MD-B, DO-C, MD-D, MD-F, and NP-G lacked documentation related to medical staff and governing board approval of the credentialing process. In addition, MD-F lacked a credentialing file.

MD-B submitted an application for credentialing approval on 7/10/09. The credentialing file lacked governing board and medical staff approval to ensure MD-B had completed a application for and was granted privileges to work in the facility.

DO-C submitted an application for credentialing approval on 7/27/10. The credentialing file lacked governing board and medical staff approval to ensure DO-C had completed a application for and was granted privileges to work in the facility.

MD-D submitted an application for credentialing approval on 6/3/10. The credentialing file lacked governing board and medical staff approval to ensure MD-D had completed a application for and was granted privileges to work in the facility.

MD-F lacked a credentialing file to ensure the governing board and medical staff approval to ensure MD-F had completed a application for and was granted privileges to work in the facility.

NP-G submitted an application for credentialing approval on 6/24/10. The credentialing file lacked governing board and medical staff approval to ensure NP-G had completed a application for and was granted privileges to work in the facility.

On 8/25/11, at 1:06 p.m. medical record employee (MRE)-A stated MD-F was a contract staff and did not think these medical personnel needed to be credentialed. She verified MD-F currently was providing patient care through pathology. MRE-A verified governing board and medical staff approval was missing in the physician credentialing files.


The medical staff bylaws lacked approval from the governing body.
A review of the current governing body bylaws indicated the proposed date of approval of the bylaws was in 2010; however, no signature or day or month were indicated on the bylaws. The General Medical Staff meeting minutes dated 12/1/2010, indicated a motion was made to approve medical staff bylaws.

On 8/23/11, at 12:53 p.m. Chief Executive Officer (CEO) stated the medical staff bylaws had not been approved by the governing body. She stated an error was found and it went to be corrected. The CEO added the bylaws should have been approved by the governing body. She stated the medical staff is currently abiding by the unapproved bylaws.

Based on observation, interview, and policy review, the Critical Access Hospital (CAH) failed to ensure that all drugs and biologicals were secure in 1 of 2 inpatient departments (mental health) and in 4 of 9 of the clinic's outpatient departments (same day surgery, ears/nose/throat, internal medicine, family practice) where medications were utilized. In addition, the facility failed to ensure outdated medications were disposed of appropriately in 1 of 1 anesthesia rooms reviewed at the clinic. Findings included:


Medications were not secure.


During the environmental tour of the secured mental health unit at 10:15 a.m. on 8/23/2011, the crash cart was observed in an unsecured closet immediately adjacent to patient rooms that were equipped for a higher level of security. Medications stored included Verapamil, Lasix, aspirin, adensosine, epinephrine, atropine and lidocaine. LPN-A confirmed the crash cart was not behind locked doors and the patients from the high security area could have access to the medications in the cart. LPN-A verified patients could have access to the medications.

During an interview at 11:00 a.m. on 8/25/2011, the director of the mental health unit (DMU)-A verified the patients could have access to the medications in the crash cart and stated, "we have been talking about locking this door, maybe put a code lock on it." The DMU confirmed no patient has attempted to get the medications and added, "but the potential is there."



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On 8/24/11, at 8:15 a.m. a medication cart in the recovery unit of the same day surgery center was visible from the nurses station, but was unattended. The cart was unlocked and the key was on top of the cart. The cart was noted to have medication such as Toradol (pain medication), Phenergan, Benadryl, Zofran and Reglan (all for nausea). At the nursing station, another medication drawer was observed unlocked. The medication drawer included multiple medications such as antibiotics, nausea medications, blood pressure medications and pain medications (Toradol, Tylenol). At this time, registered nurse (RN)-H stated they get medications from the pharmacy and just tell the pharmacy when they need new medications. She stated they do not lock the medication drawer during the day, but they lock it at the end of the day. She stated this was not a good system to identify if medications go missing. She added the staff are close by to monitor the drawer during their shifts.


At 9:45 a.m. the clinic surgery/ears/nose/throat department was toured with the clinic nursing coordinator (NCC). The treatment room of the department had medications stored in a locked cabinet. Medication stored was various strengths of lidocaine (a local anesthetic). However, the key to the locked drawer was hanging on the wall next to the cabinet and was visible. The key was used to open and inspect the drawer. The NCC stated the key is kept there because they are afraid staff will bring home the key.

At 10:10 a.m. the crash cart on in the internal medicine unit was observed to be unlocked and unobserved by staff. Medications stored included Verapamil, Lasix, aspirin, adensosine, epinephrine, atropine and lidocaine. At this time, the NCC stated she had checked the crash cart the previous day and thought it did not get locked after she had checked it. She added it appeared the crash cart needed to be replaced if it was that hard to lock.

At 10:12 a.m. a vaccine fridge in the internal medicine department was noted to be in an unlocked fridge and unobserved by staff. Various vials were observed to be stored in the unlocked fridge including influenza, hepatitis and diphtheria vaccines.

At 10:15 p.m. the vaccine fridge in the family practice department was noted to be unlocked. Staff were present in the area of the vaccine fridge. The NCC stated the vaccine fridges remained unlocked during the daytime hours. Various vials were observed to be stored in the unlocked fridge including influenza, hepatitis and diphtheria vaccines.



The facility policy "Proper Storage of Medications requiring refrigeration or freezing" dated 1/11, indicated refrigerators used exclusively for medication storage...must be locked or maintained in a locked area." In addition, the policy identified, "non-narcotic floor stock medications...may be stored in a locked medications room or cupboard."




Outdated medications were not properly disposed.

At 9:10 a.m. 18 bottles of succinylcholine (a paralytic) vials were observed in the anesthetist medication room to have an expiration date of 1/2011. Certified Registered Nurse Anesthetist (CRNA)-A verified 18 bottles were expired. At 9:15 a.m. CRNA-A stated the medication was on back order and thought it had been kept in case they ran out. He stated the pharmacy now has a supply to replenish the medication. He added he does not frequently use this medication and he would check the expiration date prior to use.

The facility policy "Proper Storage of Medications requiring refrigeration or freezing" dated 1/11, indicated outdated medications shall be checked monthly by pharmacy staff monthly.

Based on observation, policy review and staff interview, the critical access hospital (CAH) failed to ensure that proper cleaning of the glucometer between multi-patient use had been routinely implemented for 2 of 2 inpatients (P20, P21) identified to receive blood glucose tests. This had the potential to affect all patients who required blood glucose readings at the bedside. In addition, the facility failed to ensure sanitary conditions were provided in the same day surgery department while performing procedures for 1 of 1 patient (P21 ) observed during an invasive procedure. Findings include:


Proper cleaning of the glucometer used for multiple patients had not been implemented as required by the CAH's policy on 8/24/11, and 8/25/11.

On 8/24/11, at 11:11 a.m., care technician (CT)-A checked the blood glucose level for P20 with the use of the CAH's glucometer. When finished, CT-A returned the glucometer to the storage area without cleaning it. At that time, CT-A indicated she was unsure who should clean the glucometer.


Interview with the charge nurse (CN)-A at 11:15 a.m. on 8/24/11, indicated the multiple use glucometer would be cleaned on the night shift. CN-A indicated that P20 received the blood glucose test four times a day. CN-A also identified P-21 used the same glucometer twice a day on 8/24/11, and 8/25/11. She further indicated that the laboratory manager (LM) was responsible to teach the CTs to use the glucometer.

Following this, the Glucose Advantage Quality Control Log, completed by the night shift, was reviewed and indicated when the glucometer was cleaned it should be recorded in the "Comment section." Review of the "comment section" indicated that the glucometer had not been recorded as being cleaned from 8/1/11-8/24/11. CN-A confirmed this finding at that time.

During interview, on 8/24/11, at 11:45 a.m., the LM indicated that staff should wipe off the glucometer as needed and when it is soiled. When asked who teaches the CT to do the glucometer test and cleaning, the LM indicated the laboratory technicians teach them. She indicated she would provide the policy and procedures for the cleaning of the glucometer.

The Laboratory Pathology Service Manual for the Accuchek Advantage Blood Glucose test revised 06/2011, page 5 indicated: "1. The outside of the meter is to be cleaned /disinfected after all patient testing." The information went on to explain how to clean the glucometer appropriately using a bleach solution or a bleach wipe.

On 8/25/11, at 11:10 a.m. registered nurse (RN)-A performed the blood glucose test on P-20. RN-A brought the glucometer and the box it was stored in into P-20's room and placed them on the bedside table. RN-A removed the blood filled glucometer test strip from the glucometer and threw it away. RN-A then handled a cotton ball with blood on it and applied a bandaide to P-20's finger. RN-A had not donned gloves. When RN-A had completed the blood glucose test, she had returned the glucometer to the glucometer's box and to the central location without cleaning it. On 8/25/2011, at 11:20 a.m., RN-A indicated she was unsure how often the glucometer should be cleaned or who was supposed to clean the glucometer.

Interview, with the Director of Medical Surgical Floor (DMS) on 8/25/11, at 11:30 a.m., confirmed staff should clean the glucometer after each patient use. The DMS further indicated the glucometer should be cleaned with bleach wipes.

Interview, with the Infection Control Practitioner on the morning of 8/25/11, indicated the laboratory manager was in charge of how or when the cleaning of the glucometer should take place.



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P21 was not provided with appropriate infection control procedures while receiving an invasive procedure on 8/24/11.

On 8/24/11, at 8:45 a.m. P21 was observed to be prepared for a colonoscopy procedure with assistance from RN-G and licensed practical nurse (LPN)-B. At 8:47 a.m. the physician (E-A), arrived to perform the procedure. A gastrointestinal (GI) scope was utilized to observe GI P21's colon. At 8:56 a.m. E-A was noted to have some difficulty with the GI scope used to perform the procedure. E-A handed the scope to LPN-B. LPN-B attempted to unclog the GI scope and handed the scope back to E-A. At this time, the GI scope fell to the floor. LPN-A picked up the GI scope and cleansed the scope with alcohol wipes. LPN-A handed the GI scope to E-A who then began the colonoscopy, an invasive procedure, without further cleaning.

At 9:05 a.m. the surgical service coordinator (SSC) stated it was acceptable to use the GI scope once it fell to the floor after cleaning it with alcohol. Upon request, the SSC stated there was no policy related to cleaning procedures if a scope was contaminated. The SSC stated the scope was not going into a clean area, so there would be no cross contamination.

At 2:50 p.m. the SSC stated she had thought about the incident and stated the staff should have run the scope through the full cleaning process. She provided a policy she had developed after the incident. The policy "Disinfecting and Processing Endoscopy GI Instruments after Contamination" dated August of 2011, directed staff to terminally clean and disinfect the contaminated GI scope.

Based on record review, interview and policy review, the Critical Access Hospital (CAH) failed to ensure time/date/signature of medical record entries for 10 of 15 inpatient (P6, P7, P9, P13, P14, P15, P16, P17, P18, and P20) medical records reviewed. Findings included:

Patient's medical records contained entries that were not timed and/or dated.

P6 was admitted 8/17/11, for a colon resection due to gastrointestinal bleeding. The consent for anesthesia services was not dated or timed. The physician's orders dated 8/17/11, 8/19/11, 8/20/11, 8/21/11, 8/23/11, 8/24/11 were missing the date, time or both date and time.

P7 was admitted 8/23/11, for a right total knee surgery. Physician's outpatients orders dated 8/22/11, did not include a time. The 8/24/11, inpatient physician's orders did not include a time.

P9 was admitted 8/23/11, for congestive heart failure (CHF). Physician's orders dated 8/23/11, for treatment of CHF were not dated or timed.

P13 was admitted 8/23/11, for a cesarean section. Physician's orders dated 8/23/11 and 8/24/11 did not include a time.

P14 was admitted 8/24/11 for an injury after a fall. Physician's admitting orders were not dated or timed.

P15 was admitted 8/24/11 for observation. Physician's admitting orders were not dated or timed.

P16 was admitted 8/18/11 with abdomen pain. Physician's admitting orders were not dated or timed. Physician's orders dated 8/19/11, 8/21/11, 8/24/11 and 8/25/11 did not include a time. Consent for surgery and invasive procedure was not signed, dated or timed by the physician.

P17 was admitted 8/24/11. Physician's admitting orders dated 8/24/11, did not include a time. Physician's orders dated 8/24/11 and 8/25/11 were not timed.

P18 was admitted 8/23/11. The Physician's admitting orders did not include a date or a time.

P20 was admitted 8/23/11. The Physician's Order Sheet did not include a date or a time. The Physician's orders dated 8/24/11 did not include a time and three additional physician's orders did not have a time or date on them.

The medical/surgical director, interviewed on 8/25/11, at 2:00 p.m., indicated that all provider orders should be timed, dated and signed.

The CAH's policy on rules and regulations for medical staff dated 8/11/11, identified all entries in the record should be dated, timed, and authenticated.

Based on observation, interview, and policy review, the Critical Assess Hospital (CAH) failed to ensure proper procedures, to reduce the risk of burns or fires related to the use of an electrosurgical pencil/blade (instrument used to cut and cauterize tissue during surgical procedures) were followed for 1 of 2 patients (P8) in the sample where an electrosurgical pencil/blade was utilized used during a surgical procedure. Findings include:


Standard safety procedures related to the use of an electrosurgical pencil/blade during surgery were not implemented on 8/23/11, for P8.


P8 was observed at approximately 8:19 a.m. on 8/23/11, during an incisional hernia repair. Oxygen was provided for P8 throughout the procedure. The holster for the cautery pencil was clipped to the drape above the surgical site. During observations from 8:29 a.m. through 8:41 a.m., the electrosurgical cautery pencil was not placed in the holster between uses by Surgeon-A. The cautery pencil was laid on the patient's surgical drape for time periods of 45 seconds to 4 and 5 minutes.


Interview with the circulating nurse (RN-4) on 8/23/11, at 12:30 p.m., indicated that she knew that the electrosurgical pencil /blade should have been placed in the holster when not in use; however, did not say anything.

On 08/23/11, at 12:25 p.m. the Surgical Service Coordinator (SSC) confirmed it was the expectation and the CAH's policy to holster the electrosurgical pencil/blade when not being used during surgeries to prevent fires. The policy " Prevention of Surgical/Procedure Fires " provided was dated 4/09, and indicated cautery was an ignition source and cautery "pencil in holster" was a fire prevention technique.


The 8/25/11, Product Information, "OR Safety Precautions" re: Electrosurgery, identified AORN (Association of periOperative Registered Nurses) "Recommended Practices for Electrosurgery 2003" that included: "The active electrode(s) should be placed in a clean, dry, well-insulated safety holster, when not in use." In addition, further precautions included: "The ESU should not be used in the presence of flammable agents (i.e., alcohol and/or tincturebased agents)" and "Avoid oxygen enriched environments".

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Based on review of facility policies, quality assurance documentation, and interview, the Critical Access Hospital (CAH) failed to ensure periodic evaluation and Quality review of all their services. Findings include:


The CAH failed to ensure a representative sample of active and closed inpatient and outpatient records were reviewed. (Refer to C333).

The CAH failed to evaluate its health care policies (Refer to C334).

The CAH failed to evaluate the appropriateness of services provided to patients (Refer to C335).

The CAH failed to have an effective quality assurance plan to evaluate the quality and appropriateness of diagnosis and treatment (Refer to C336).

The CAH failed to evaluate all patient care (Refer to C337).


The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to maintain effective quality assurance processes in order to ensure provision of quality health care. Therefore, the CAH was unable to meet this condition.

Based on interview and review of the Critical Access Hospital (CAH) Annual Review, the CAH did not review a representative sample of both active and closed records ensuring it was representative of services provided at the hospital. The findings include:

The CAH failed to ensure a representative sample of active and closed inpatient and outpatient records were reviewed.


A review of the CAH annual review dated 12/2/10, lacked indication a representative sample of inpatient and outpatient records had been reviewed. The facility failed to ensured a minimum of 10% of active and closed records for all services provided by the facility were reviewed. The CAH Annual Review meeting minutes on 12/2/10, indicated chart audits were completed for key nursing areas, but no issues were found so the process was discontinued.


On 8/25/11, at 9:50 a.m. the Quality and Compliance Coordinator stated nursing departments were the only record review completed for the Annual Program Assessment. She stated no outpatient records were reviewed and verified all departments of the hospital were not represented in the chart review.

Based on review of the Critical Access Hospital (CAH) Annual Review and interview, the CAH had not conducted a review of the health care policies as part of the annual evaluation. Findings include:

The facility failed to ensure policy and procedure review was conducted by the CAH Annual Review committee.

The CAH Annual Review dated 12/10/10, indicated policies were being placed to online status, but lacked any indication that the committee had reviewed CAH policies and procedures.

On 8/25/11, at 9:50 a.m. the Quality and Compliance Coordinator stated no policy review was completed by the committee at the Annual Review.

Based on review of the Critical Access Hospital (CAH) Annual Review, policy review, and interview, the CAH failed to determine whether the utilization of all services provided were appropriate. Findings include:

The CAH lacked documentation all services provided had been evaluated.

The Annual Review meeting minutes dated 12/2/10, indicated the CAH staff had evaluated some programs currently provided. The facility identified the volume of patient served; however, lacked an evaluation of services provided to those patients. Documentation was lacking related to the review of current services provided including clinic services, same day surgery services, nursing departments, occupational therapy, physical therapy, cardiac rehab, nutritional services and pharmaceutical services. Therefore, the CAH was unable to determine the appropriateness of the services offered including evaluation of policy implementation and/or if any changes were required.

The "Quality Assurance Program Policy and Procedures" dated 1/11, indicated all departments and services under contract are included in the Quality Assurance Program. The procedure further directed the CAH would provide "5. Ongoing monitoring and data collection to achieve and maintain improvement;" and "6. Data analysis, internally over time to identify levels of performance, patterns, trends, and variation and with external sources".

On 8/25/11, at 9:50 a.m. the Quality and Compliance Coordinator verified not all departments of the hospital had been reviewed at the Annual Program Assessment.

Based on interview and review of the Quality Assurance (QA) Plan, the Critical Access Hospital (CAH) failed to provide an effective quality assurance program to evaluate the overall ongoing quality and improvement of patient treatment and outcomes in the CAH. Findings include:

Although many of the departments of the CAH had identified their own quality improvement, the CAH failed to ensure ongoing monitoring, data analysis, corrective actions and evaluation of corrective actions were completed at the organization level.

The "Quality Assurance Program Policy and Procedures" dated 1/11, indicated all departments and services under contract are included in the Quality Assurance Program. The procedure further directed the CAH would provide "5. Ongoing monitoring and data collection to achieve and maintain improvement;" and "6. Data analysis, internally over time to identify levels of performance, patterns, trends, and variation and with external sources".

A review of the CAH's "Performance Improvement" plan dated 1/2011, indicated the CAH would conduct problem identification, identify corrective action, implement corrective action, evaluate correction actions, conduct ongoing monitoring and collect data to achieve and maintain improvements and conduct data analysis to identify performance, patterns and trends. The CAH conducted monthly "report outs" which was a meeting in which each department could discuss which quality projects they were conducting. An example of some tools utilized to conduct department "report outs" included patient satisfaction surveys, variance reports or unusual occurrences, and quality measures. However, a review of the "report out" meetings lacked specific data related to the overall QA program.

On 8/25/11, at 10:55 a.m. the QA meeting minutes were requested. The Quality Compliance Coordinator (QCC) stated the CAH conducts monthly meeting with each department, in which they each have 15 minutes to "report out" concerns. The QCC stated they do not have QA meeting minutes, and added this was done verbally. The QCC could not provide data related to any QA program other than what was performed at a few individual departments. She stated some departments are better than others in the completion and analysis of their data. She stated the follow up on the departments' QA is, "not tight at all." She added the administrative staff report the results of the "report out" meeting to the governing body, but could not provide minutes of what is presented to the governing body.

Based on record review, policy review, and staff interview, the Critical Access Hospital (CAH) failed to evaluate all patient care services to evaluate the quality and appropriateness of the treatment and services furnished in the CAH related to 5 of 11 departments (Anesthesia, Laboratory, Radiology, Pharmacy, Infusion Clinic). Findings include:


All of the CAH's patient care services were not evaluated.


ANESTHESIA
On 8/25/11, at 9:30 a.m. the Surgical Service Coordinator (SSC), confirmed anesthesia did not have a current QA plan in place. Interview with CRNA-A at approximately the same time indicated he was unsure but would provide further information.

CRNA-A provided a project title Anesthesia Awareness. This project was to decrease the number of patients that wake up during surgery or have some awareness of surgery and decrease the suffering of patients. Anesthesia did not have a plan or information on how this was monitored and did not have any data to support what they were trying to improve. The CAH had not identified any corrective actions. However, the CRNA-A indicated that this CAH did not ever have any patients that woke up during surgery or had any patients with awareness of what was going on in the surgery after waking up per interview at approximately 10 a.m. on 8/28/2011.


LABORATORY
On 8/24/11, at 1:50 p.m. the laboratory manager indicated that she had been monitoring a number of things over the past year. She added they have not done a QA project as of yet, but hoped to use the monitoring she has done over the last year to start a QA project.


RADIOLOGY
On 8/24/11, at approximately 2:30 p.m. the Radiology Coordinator (RC), confirmed Radiology Services did not have a current QA plan in place. Further interview with RC indicated that the Biomedical Sanford System staff come from Fargo to monitor their equipment and they monitor shielding aprons, gloves and badges. However, she confirmed she had not set up a QA program to improve patient care.


PHARMACY
Interview on 8/23/11, at approximately 2:30 p.m. with Pharmacist A, indicated that they did have a QA program to reduce medication errors within the pharmacy when mixing allergy serums. When asked to provide data analysis and monitoring of the problem, she was unable to provide monitoring or any data collection. She indicated that one of the pharmacy technicians had developed a new form that made it easier to read the physician's orders for the serum needed. She had no data on the errors that had been associated with the mixing of the serum or any measures of improvement. P-A further noted that they had never had an error with the mixing of the serum. No other medication error QA was provided.

Review of the medication errors reports for 6 months indicated that a high number of errors occurred when staff had to override the computer system to administered medications. The medication errors report had trends that were not being addressed.




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INFUSION CLINIC



On 8/24/11, at 3:25 p.m. the Surgical Service Coordinator (SSC), registered nurse (RN)-I and RN-J stated the infusion clinic did not have a current quality assurance (QA) plan in place. The stated they had completed the previous plan in February or March of 2011, and had nothing in place currently. They added they were due at the end of the year.



The "Quality Assurance Program Policy and Procedures" dated 1/11, indicated all departments and services under contract are included in the Quality Assurance Program. The procedure further directed the CAH would provide "5. Ongoing monitoring and data collection to achieve and maintain improvement;" and "6. Data analysis, internally over time to identify levels of performance, patterns, trends, and variation and with external sources".


On 8/25/11, at 10:55 a.m. the QA meeting minutes were requested. The Quality Compliance Coordinator (QCC) stated the CAH conducts monthly meeting with each department, in which they each have 15 minutes to "report out" concerns. The QCC stated they do not have QA meeting minutes, and added this is done verbally. The QCC could not provide data related to any QA program other than what was performed at a few individual departments. She stated some departments are better than others in the completion and analysis of their data.