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Based on observation, interview, and document review the Critical Access Hospital (CAH) failed to ensure ready to use intravenous solutions and supplies used for administration of intravenous solutions were not expired.

Findings include:

During a tour of the intermediate care area on 5/8/17, at 3:00 p.m. with the registered nurse (RN)-B and social services (SS) the following was observed in drawers nurses would use if needed rapidly:
- One 500 milliliter (ml) bag of D5% (dextrose 5% in water) intravenous solution (IV) with expiration date of 4/1/17
- One 250 ml bag of D5% IV with an expiration date of 2/17
- Two 100 ml NS 0.9% (normal saline) with expiration dates of 5/1/17
-One ADD-Vantage ADDaptor Connector-Non DEHP (use only with single-dose powdered drug vials and IV fluid) with an expiration date of 10/17/16

During an interview on 5/8/17, at 3:05 p.m. RN-B stated the IV solutions had expired. RN-B also stated the ADD-Vantage ADDaptor Connector-Non DEHP had expired.

During an interview on 5/11/17, at 10:18 a.m. RN-A stated the intermediate care area drawers were routinely used by the nurses. RN-A confirmed the expired solutions and supplies were available to use as needed.

A facility policy was requested and none was provided.

Based on observation, interview and document review, the Critical Access Hospital failed to ensure 1 of 1 pediatric airway carts in the emergency department (ED) was routinely monitored for expired emergency supplies. This had the potential to affect all pediatric patients who required emergency services.

Findings included:

On 5/8/17, during the ED tour from 3:00 p.m. until 3:45 p.m. the pediatric airway cart (Broselow cart) was located in the central supply area for the emergency department. Acute care manager registered nurse (RN)-A reported she was the director for the ED department and explained the cart was organized according to a chart that directed which drawer to pull supplies from based on a pediatric patient's size. RN-A reported the purpose of the cart was to easily access supplies needed for emergent pediatric cases.

The inspection of the Broselow cart reviewed the following expired emergency supplies:
-Seven whistle tip suction catheters 10 French (fr.) (used to remove respiratory secretions from a person's airway to keep it clear and prevent plugging) with a package use by date of 12/6/06.
-Six endotracheal tube (ET) 6.5 millimeter (mm) (catheter inserted into the trachea to establish and maintain a patent airway) with a package use by date of October 2010.
-Two ET 4.5 mm with a package expiration date of June 2006.
-Two duodenal tubes size Ch 14 (a long flexible rubber tube that can be passed through the esophagus and stomach into the duodenum) with an expiration date of June 2006.
-Two Duodenal tubes size Ch 12 with an expiration date of June 2006.
-Two duodenal tubes Ch 18 with an expiration date of March 2003.
-Three intravenous (IV) start kits with an expiration date of January 2016
-Two packages of 3 x 3 inch gauze with an expiration date of February 2007.
-Two pediatric ambu bags (hand-held device used to provide positive pressure ventilation to a patient who is not breathing or who is breathing inadequately) with the mask yellow/brown in color. The bags did not have an expiration or best used by date

At 3:45 p.m. RN-A verified the Broselow cart was accessible to all ED nurses and could be used for any pediatric cases that presented to the ED. RN-A was unsure if outdates of supplies would be checked prior to the use in emergent situations. RN-A verified the supplies were expired and stated the ambu bags should be thrown away. RN-A further acknowledged this cart may not get routinely used because pediatric supplies were also available in the other ED crash cart. RN-A indicated she was not aware of who was supposed to check the cart or how often the cart was supposed to be checked for outdates.

On 5/9/17, at 3:15 p.m. the vice president (VP) of patient care services indicated the cart should have been routinely checked, stocked, and ready for use as it was accessible to ED nursing staff. The VP explained the Broselow cart had been obtained some time ago and monitoring of that cart had never been added to the policy or routine checklist.

A CAH policy Crash Cart Stocking, Security, and Maintenance last reviewed on 4/17, indicated contents will be completely checked on a weekly basis to ensure supply items are appropriate.

Based on the Life Safety Code (LSC) survey. A Medicare-participating Critical Access Hospital (CAH), including all component parts or facilities of the CAH, must comply with the applicable LSC requirements.

Please refer to the life safety code deficiencies cited at: K0133, for additional information.

Based on interview and document review, the Critical Access Hospital (CAH). failed to implement systems to ensure a Malignant Hyperthermia kit was available in 1 of 1 operating room suites. This deficient practice had the potential to affect all current and future surgical patients of the CAH.

Findings include:

A tour of the surgical services area was completed on 5/9/17, at 10:00 a.m. during which registered nurse (RN)-A and RN-C were asked if the surgical suite contained a Malignant Hyperthermia kit (malignant Hyperthermia is an unexpected emergency situation that can occur when a patient is administered general anesthesia that is characterized by fast rise in body temperature and severe muscle contractions). RN-A pointed to the protocol to treat Malignant Hyperthermia which was posted in the surgical suite on the side of the anesthesia cart. However during further interview with RN-A, she stated the protocol that was posted was not the current facility protocol to treat Malignant Hyperthermia. RN-A stated the facility no longer used the medication procainamide as part of the Malignant Hyperthermia protocol that was posted and stated there were other changes to the current protocol also. RN-A could not verbalize what the changes to the protocol included and was unable to provide the requested current facility protocol for Malignant Hyperthermia. RN-A also confirmed the following items were not gathered together and immediately available for use in the operating room suite to treat Malignant Hyperthermia: procainamide IV (intravenous) if required for arrhythmia's; hypothermia blanket; catheters used for measuring urine output and iced lavage; and the medications Mannitol, sodium bicarbonate, and Lasix.

Based on observation, interview and document review, the facility failed to implement protocols for appropriate cleaning/disinfection of the surgical environment to minimize risk of infection. This had the potential to affect any surgical patients.

Findings include:

A tour of the surgical services area was completed on 5/9/17, at 10:00 a.m. during which registered nurse (RN)-A and RN-C established the hospital performed surgeries and diagnostic colonoscopy's; however, there were no surgical procedures scheduled during the survey. During interview with RN-C, (who was identified as the infection control officer) regarding the cleaning and disinfection of the surgical suite between patients, RN-C stated she was responsible for the cleaning and disinfecting of the surgical suite and also was responsible for ordering the appropriate product to use for the cleaning and disinfection of the suites. She identified the product the facility used was 3M HB Quat Disinfectant and did not identify any further products used for disinfection of the surgical suite. RN-C stated she was unaware whether the HB Quat Disinfectant was effective against Clostridium Difficile (C-Diff: a contagious bacterial organism that is prevalent in the gastrointestinal track).

When reviewed, the package insert of the HB Quat Disinfectant had not indicated effectiveness against Clostridium Difficile.

Review of the 3M technical data sheet titled HB Quat Disinfectant Cleaner, Product Number 25, dated 2005, listed the multiple types of organisms the product was effective against and killed which included methicillin resistant staphylococcus aureus, gram positive, AIDS virus and gram negative clinical isolates. However, the data sheet did not include C-Diff.

During a post survey telephone interview the 3M technical representative on 5/24/17, at 1:00 p.m., the representative confirmed the HB quat disinfectant technical data sheet was current and did not kill C-Diff. He stated a separate product, C-Diff tablet, was required to be used to kill the C-Diff bacteria. The technical representative stated the dwell times for each product separately needed to be followed; 10 minutes for the HB Quat and followed by the C-Diff tablet which had a 30 minutes dwell time in order to kill C-Diff.

Review of the facility's policy and procedure for Environment of Care: Preoperative Preparation dated as last reviewed 4/17, indicated on operative days, before the first case of the day, nursing staff wipe all horizontal surfaces surfaces off with anti-bacterial cleaner. The facility policy Environment of Care: Postoperative Cleaning dated as last reviewed 4/17, indicated all surfaces and equipment are wiped down with approved antibacterial cleaner. The policy did not identify the type of anti-bacterial cleaner, and did not indicate besides being antibacterial, that the cleaner should also be anti-fungal and viracidal in order to prevent issues such as C-Diff.

Based on staff interview and record review the facility failed to ensure that surgical consent forms and history and physical (H&P) documentation were documented in a timely manner with all appropriate details for 3 of 4 surgical records reviewed (S2, S3, S4).

Findings include:

S2's surgical record was reviewed and the following was identified: S2 had hardware removed from the left ankle on 4/3/17. The consent for surgery was dated 4/3/17, however the consent did not identify the time the consent was signed by S2. The preoperative history and physical failed to include: past history of allergies, current medication list, bleeding tendencies, past surgical procedures, list of current illnesses or past hospitalizations, social history, or a review of systems (cardiovascular system, neurological system, eye's nose and throat, integumentary system, eye's nose and throat).

S3's surgical record was reviewed and the following was identified: S3 had a Gastroscopy on 1/17/17. The preoperative history and physical was dated 6/10/16, (greater than 6 months previous to the surgical procedure), and failed to include: past history of allergies, current medication list, bleeding tendencies, past surgical procedures, list of current illnesses or past hospitalizations, social history, or a review of systems (cardiovascular system, neurological system, eye's nose and throat, integumentary system, eye's nose and throat).

S4's surgical record was reviewed and the following was identified: S4 had a colonoscopy to check for abnormal bleeding or blood loss on 4/11/17. The consent for surgery was signed on 4/11/17 however, the consent did not identify the time the consent was signed by S4. An undated preoperative history and physical failed to include: past history of allergies, current medication list, bleeding tendencies, past surgical procedures, list of current illnesses or past hospitalizations, social history, or a review of systems (cardiovascular system, neurological system, eye's nose and throat, integumentary system, eye's nose and throat).

Review of the CAH's Medical Staff Bylaws Rules and Regulations dated 2004, identified a H&P was to include the following elements (list not inclusive): chief complaint, history of present illness, current medications, allergies, past medical history, past surgical history, family history, social history, review of systems, physical examination, impression/diagnoses and plan, lab data, EKG, and radiographic studies. Additionally, the H&P for each patient was required to be completed within 30 days prior to a procedure or surgery and if the H&P was completed more than seven days but less than thirty days prior to the procedure, an interval admission note must be made to update any pertinent information.

The Vice President of patient services was interviewed on 5/11/17, at 11:30 a.m. and confirmed the issues identified with these surgical records.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to implement systems to ensure surgical services were provided in a safe manner, including appropriate cleaning/disinfecting of surgical suites and equipment; failed to ensure a malignant hyperthermia kit was available, and the facility's current malignant hyperthermia protocol was readily available; failed to ensure each surgeon's surgical privileges were appropriately available; failed to ensure a timely history and physical (H&P) and/or appropriately obtained consents had been completed for 3 of 4 surgical patients (S2, S3, and S4); and failed to ensure pre and post anesthesia evaluations had been completed appropriately for 4 of 4 surgical patients (S1, S2, S3, and S4). As a result of these findings, the CAH was found not to be in compliance with the Condition of Participation of Surgical Services 485.639. The cumulative effect of these systemic problems resulted in the CAHs inability to ensure the provision of safe surgical services.

The findings include:

Refer to C271: Based on interview and document review, the Critical Access Hospital (CAH). failed to implement systems to ensure a Malignant Hyperthermia kit was available in 1 of 1 operating room suites. This deficient practice had the potential to affect all current and future surgical patients of the CAH.

Refer to C278: Based on observation, interview and document review, the facility failed to implement protocols for appropriate cleaning/disinfection of the surgical environment to minimize risk of infection. This had the potential to affect any surgical patients.

Refer to C304: Based on staff interview and record review the facility failed to ensure that surgical consent forms and history and physical (H&P) documentation were documented in a timely manner with all appropriate details for 3 of 4 surgical records reviewed (S2, S3, S4).

Refer to C321: Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure each surgeon's surgical privileges were available in the operating room suite accessible for personnel who scheduled the surgeries. This deficient practice had the potential to affect all current and future surgical patients of the CAH.

Refer to C322: Based on interview and document review, the critical access hospital (CAH) failed to ensure anesthesia evaluations had been completed prior to, and following surgery, for 4 of 4 surgical patients (S1, S2, S3, and S4) reviewed. This deficient practice had the potential to affect all future surgical patients.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure each surgeon's surgical privileges were available in the operating room suite accessible for personnel who scheduled the surgeries. This deficient practice had the potential to affect all current and future surgical patients of the CAH.

Findings include:

A tour of the surgical services area was completed on 5/9/17, at 10:00 a.m. during which registered nurse (RN)-A and RN-C were asked where they maintained the roster that described each physician's surgical privileges. RN-A stated there were five physicians who had surgical privileges at the CAH, RN-A further verified the physician's privileges were not available in the surgical services area. RN-C stated that at one period in time, the surgical suite had a three ringed binder which listed each physician's surgical privileges however, she stated she was not aware what had happened to the binder. RN-C subsequently located the binder in an office outside of the surgical services area however when reviewed, the binder contained only identified privileges for 3 of the 5 physicians who currently perform surgery at the CAH. RN-A and RN-C also stated they were unaware whether the privileges identified in the three ring binder were current, and confirmed physician's surgical privileges were not available for review electronically. The surgical privileges for physicians who perform surgery at the CAH were not available in the area where the staff schedule procedures or surgeries.

A facility policy that included the need for each physician's surgical privileges to be available in the surgical suite and scheduling area was requested but not provided.

Based on interview and document review, the critical access hospital (CAH) failed to ensure anesthesia evaluations had been completed prior to, and following surgery, for 4 of 4 surgical patients (S1, S2, S3, and S4) reviewed. This deficient practice had the potential to affect all future surgical patients.

Findings include:

S1's surgical record was reviewed and the following was identified: S1 had a Colonoscopy on 4/28/17, due to chronic diarrhea. Review of the preoperative anesthesia evaluation revealed it was incomplete. The following areas were left blank and/or were not documented as having been assessed: Pre-anesthesia medications taken; Pre-op Diagnosis, Weight, Temperature, Respirations, Chest auscultation for respiratory status. Review of the post-anesthesia follow-up report revealed it failed to include: Level of consciousness, and any observations and/or complication's occurring during post-anesthesia recovery.

S2's surgical record was reviewed and the following was identified: S2 had hardware removed from the left ankle on 4/3/17. Review of the preoperative anesthesia evaluation revealed it was incomplete. The following areas were left blank and/or were not documented as having been assessed: Pre-anesthesia medications taken; Pre-op Diagnosis, Weight, Height, Chest auscultation for respiratory status, Medication's, Previous anesthesia problems; Potential airway problems. The post-anesthesia follow-up report was reviewed and did not include assessment of all required areas including: Level of consciousness, Cardiopulmonary status, and any Observations and/or Complication's occurring during post-anesthesia recovery.

S3's surgical record was reviewed and the following was identified: S3 had a Gastroscopy on 1/17/17. Review of the preoperative anesthesia evaluation revealed the following areas were left blank and/or not assessed: Pre-op Diagnosis, Proposed surgery, Weight, Height, Temperature, Medication's, Previous anesthesia problems; Potential airway problems, neuromuscular and GI assessment not completed. The post-anesthesia follow-up report failed to include assessment of: Level of consciousness, cardiopulmonary status, and any observations and/or complication's occurring during post-anesthesia recovery.

S4's surgical record was reviewed and the following was identified: S4 had a Colonoscopy to check for abnormal bleeding or blood loss on 4/11/17. Review of the preoperative anesthesia evaluation revealed the following areas were left blank and/or not assessed: Pre-anesthesia medications taken; Pre-op Diagnosis, Weight, Height, Chest auscultation for respiratory status, Current medication's, previous anesthesia problems; Potential airway problems. The post-anesthesia follow-up report failed to include assessment of: Level of consciousness, cardiopulmonary status, and any observations and/or complication's occurring during post-anesthesia recovery.

Review of the CAH's policy for pre-anesthesia evaluation dated as last reviewed 4/17, directed the certified registered nurse anesthetist (CRNA) to review the following for each patient prior to surgery: past medical history, the H&P, lab values, medications used by the patient, history of anesthetic complications, history of bleeding disorders, pre-operative medications and baseline vital signs.

Review of the CAH's policy for post-anesthesia evaluation dated as last reviewed on 4/17, directed the CRNA to make a post-anesthesia evaluation of each patient that included: cardiopulmonary status, level of consciousness, complications of the procedure and/or complications during the immediate recovery in the operating room.

The Vice President of patient services confirmed the issues with S1, S2, S3 and S4's anesthesia assessments when interviewed on 5/11/17, at 11:30 a.m.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure the contracted service of health information/medical records was incorporated into the overall CAH quality assurance/performance improvement (QAPI) program. This had the potential to affect all patients receiving services from the CAH.

Findings include:

During an interview on 5/9/17, at 8:454 a.m. with the health information management specialist (HIMS), it was verified there was no QAPI process currently being conducted in the medical records area.

During an interview with registered nurse (RN)-C on 5/10/17, at 9:27 a.m. RN-C verified the CAH's medical records department was a contracted service and the service was not part of the CAH's QAPI program.

During an interview on 5/10/17, at 3:53 p.m.the chief financial officer (CFO) confirmed the CAH had no QAPI being conducted for the medical records department.

The facility policy Quality Improvement Policy and Plan dated 4/17, indicated all patient care services and other services affecting patient health and safety, including services relating to patient care that are furnished by a contractor, must be evaluated. This included medical records and medical staff.