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Based on observation, record review, and interview, the hospital failed to ensure:

1. facility and patient care equipment was maintained for 16 (convection oven, dish machine, three Sigma Spectrum IV pumps, two glucometers, crash cart defibrillator ID #3807, patient medication refrigerator, Life Scope vital signs monitor ID #MOO4335, Life Scope vital signs monitor ID #MOO4336, Datascope vital signs monitor ID #MOO3025, deep freezer #1, home use griddle, two roasting ovens) of 18 pieces of equipment;

2. service records of non-biomed equipment maintenance were maintained for seven (convection oven, dish machine, patient medication refrigerator, deep freezer #1, home use griddle, two roasting ovens) of seven pieces of equipment;

3. equipment was inspected prior to first use for three (home use griddle and two roasting ovens) of 18 pieces of equipment;

4. a comprehensive and current facility and patient care equipment inventory list was maintained with the inclusion of ten (convection oven, dish machine, patient medication refrigerator, deep freezer #1, home use griddle, two roasting ovens, Datascope vital sign monitor ID# MOO3025, AED device #M004819 and switching unit model #SU-2 device ) of 18 pieces of equipment;

5. documentation of manufacturer's recommendations for 18 of the aforementioned 18 pieces of equipment.

This failed practice has the likelihood of placing patients at risk of limited or delayed access to safely functioning equipment that would impact their care or prevent needed care. (See Tag 914)

Based on observation, record review, and interview, the hospital failed to ensure:

1. facility and patient care equipment was maintained for 16 (convection oven, dish machine, three Sigma Spectrum IV pumps, two glucometers, crash cart defibrillator ID #3807, patient medication refrigerator, Life Scope vital signs monitor ID #MOO4335, Life Scope vital signs monitor ID #MOO4336, Datascope vital signs monitor ID #MOO3025, deep freezer #1, home use griddle, two roasting ovens) of 18 pieces of equipment;

2. service records of non-biomed equipment maintenance were maintained for seven (convection oven, dish machine, patient medication refrigerator, deep freezer #1, home use griddle, two roasting ovens) of seven pieces of equipment;

3. equipment was inspected prior to first use for three (home use griddle and two roasting ovens) of 18 pieces of equipment;

4. a comprehensive and current facility and patient care equipment inventory list was maintained with the inclusion of ten (convection oven, dish machine, patient medication refrigerator, deep freezer #1, home use griddle, two roasting ovens, Datascope vital sign monitor ID# MOO3025, AED device #M004819 and switching unit model #SU-2 device ) of 18 pieces of equipment;

5. documentation of manufacturer's recommendations for 18 of the aforementioned 18 pieces of equipment.

This failed practice has the likelihood of placing patients at risk of limited or delayed access to safely functioning equipment that would impact their care or prevent needed care.


Findings

FACILITY POLICY AND PROCEDURE

A review of a policy titled "Equipment History and Identification of Risk III, Risk II, and Risk I Devices" read in part, "ALL EQUIPMENT MUST have an electrical and performance test...A record of the evaluation, or a copy of it, shall be centrally maintained by Department of BioMed Technologies."

A review of a policy titled "Equipment History and Identification of Risk III, Risk II, and Risk I Devices" read in part, "All newly acquired equipment must be evaluated."


BIOMEDICAL AND EQUIPMENT RECORDS

A review of a document titled "Quintech, Inc. Biomedical Services Office Copy" from the facility's Biomed Book showed the last electrical safety and function checks inspection was on 07/23/19 and showed no inspection of the observed Sigma Spectrum IV Pumps, glucometers, or Datascope vital sign monitor.

A review of a document titled "QUINTECH, INC. McCURTAIN MEMORIAL HOSPITAL MASTER EQUIPMENT LIST BY DEPARTMENT 4/25/2017" showed no listing of the facility's convection oven, dish machine, patient medication refrigerator, deep freezer #1, home use griddle, roasting ovens, or Datascope vital sign monitor ID #MOO3025.

A review of a document titled "Quintech, Inc. Biomedical Services Office Copy" showed that on 07/23/19, Quintech, Inc inspected an AED device #M004819 and a switching unit model #SU-2 device that were not listed on QUINTECH, INC. McCURTAIN MEMORIAL HOSPITAL MASTER EQUIPMENT LIST BY DEPARTMENT 4/25/2017.

A review of a document titled "Quintech, Inc. McCurtain Memorial Hospital June Electrical Safety Check" dated 06/24/19 showed five Spectrum IV Pumps (#MOO4357, #MOO4375, #MOO4348, #MOO4355, #MOO4376) could not be located for inspection.

A review of a document titled "Quintech, Inc McCurtain Memorial Hospital July Electrical Safety Check" dated 07/23/19 showed no inspection of the five Spectrum IV Pumps (#MOO4357, #MOO4375, #MOO4348, #MOO4355, #MOO4376) and did not show they could not be located.


OBSERVATIONS:

On 03/05/20 from 10:18 AM to 11:55 AM in the Kitchen, the surveyor observed:

1. a convection oven with an inspection sticker that read "Electrical Safety Test Completed by AJ 4/2014" and

2. a dish Machine with no inspection sticker.


On 03/05/20 at 10:40 AM on the Obstetrical unit, the surveyor observed a Sigma Spectrum IV pump with an inspection sticker that read, "Due 12/19."


On 03/05/20 at 10:55 AM on the Medical Surgical unit, the surveyor observed two glucometers with Biomed inspection stickers with indecipherable writing.


On 03/06/20 from 9:13 AM to 11:04 AM on the Medical Surgical unit, the surveyor observed:

1. a Sigma Spectrum IV pump in use on a patient with no inspection sticker and;

2. a Crash cart defibrillator ID #3807 with inspection sticker that read "Biomedical Engineering Dept. Electrical Safety Test Completed by QT 7-19 Inspection Due 10-19;"

3. a Sigma Spectrum IV pump with inspection sticker that read "Biomed checked 8-5-14;"

4. a patient medication refrigerator with inspection sticker that read "Electrical Safety Test 4-20-14."


On 03/11/20 from 9:05 AM to approximately 9:25 AM on the Medical Surgical Unit, the surveyor observed:

1. a crash cart HeartStart XL ID #MOO3807 in use on a patient with inspection sticker that read "Biomedical Engineering Dept. Electrical Safety Test Completed by QT 11-19;"

2. a Life Scope vital signs monitor ID #MOO4335 with inspection sticker that read "Electrical Safety Test 5-19 Due 11-19;"

3. a Life Scope vital sign monitor ID #MOO4336 in use on a patient with inspection sticker that read "Due 11-19;"

4. a Datascope vital sign monitor ID #MOO3025 with inspection sticker that showed an inspection on 12/18 and read "Due 6-19."


On 03/11/20 at 2:50 PM in the Kitchen, the surveyor observed:

1. a deep freezer #1 with an inspection sticker that read "Electrical Safety Test Completed by AJ Date 08-20-15" and later shown another inspection sticker "3-7-20;"

2. a home use griddle with no inspection sticker;

3. two roasting ovens with inspection stickers that read "Electrical Safety Test 03/07/20 by SW."


INTERVIEWS

On 03/05/20 at 11:36 AM, Staff L stated electrical safety tests were to be done annually to ensure equipment was in good electrical condition to prevent electrical shock to employees.


On 03/05/20 at 11:55 AM, Staff L stated the dish machine should have had an inspection to ensure no electrical short and that the temperature could rise high enough to clean dishes.


On 03/06/20 at 9:20 AM, Staff A stated all IV pumps should have been labeled with inspection stickers, but Biomed did not come do the inspections because they did not get paid by the facility.


On 03/06/20 at 10:50 AM, Staff A stated the patient medication refrigerator should have had an annual electrical safety test to make sure it was functioning properly and to ensure medications were not thrown out of safety range for patients.


On 03/10/20 from 2:00 PM to 2:20 PM, Staff VVV stated:

1. Quintech, Inc. provided the facility with preventative maintenance of its biomedical equipment and that Quintech, Inc. was due to come inspect equipment but had to place the visit on hold until a payment could be made by the facility;

2. the last time they were at the facility was December 2019;

3. communication occurred with the facility and Quintech, Inc. on 03/05/20, 03/06/20, and 03/09/20 and that payment arrangements were pending. (Note: OSDH surveyors arrived at the facility on 03/05/20.)


On 03/10/20 from 2:47 PM to 3:00 PM, Staff WWW stated the following:

1. defibrillators were to be inspected every three months

2. the facility did not have the money to pay Quintech, Inc.

3. inspections were not completed

4. they (Staff WWW) saw a check on 03/06/20 to pay Quintech, Inc.


On 03/05/20 at 11:36 AM, Staff L stated there was no log showing when kitchen equipment inspections had taken place.


On 03/05/20 at 1:57 PM, Staff L stated the maintenance department was to inspect all hospital equipment except what Biomed was to inspect.


On 03/05/20 at 1:57 PM, Staff L stated new equipment was to be inspected initially and annually thereafter.


On 03/05/20 at 2:23 PM, Staff L stated besides replacement parts, he or she had no manufacturer's recommendations for the facility and patient care equipment for the hospital.


On 03/10/20 at approximately 3:40 PM, Staff L stated they would have to look to see if the facility had a list of equipment for inspection that was more current than 04/25/17 and did not return with another list on 03/10/20, 03/11/20 or 03/12/20.


On 03/10/20 from 3:38 PM to 3:55 PM, Staff L stated the following:

1. equipment that could not be located may have been in use for a patient

2. the hospital's process for ensuring the inspection of equipment that Biomed could not locate was for Biomed to inspect the missed equipment the next time they were out.


On 03/11/20 from 11:20 AM to 11:45 AM, Staff D stated the following:

1. at times, IV pumps were not located because they left during ambulance or helicopter transports and were not always returned;

2. the hospital did not document the items as lost;

3. the hospital did not know how to keep track of equipment;

4. equipment tracking was left to Biomed.


On 03/11/20 at 2:50 PM, Staff K stated the following:

1. they (Staff K) brought a griddle and two roasting ovens from home to the facility around November and December of 2019 to cook for patients and staff.

2. equipment with electrical components were not to be used at the facility unless first inspected.

3. the griddle had no electrical safety test sticker; was last used in the facility approximately two weeks ago for grilled cheese sandwiches; and he or she would put in a work order for it to be inspected.

4. the roasting ovens were used in the facility around Thanksgiving 2019 for employee celebration meals, but were not inspected until 03/07/20.

Based on record review and interview, the hospital failed to ensure:

1. a completed History and Physical examination (H&P) was recorded in the patient's health record within 24 hours of admission for two (Patient #1 and Patient #20) of 22 patients;

2. critical lab results were called to physician within 30 minutes for one (Patient #19) of 22 patients;

3. the hospital's governing body provided documentation of an internal review of the contracted doctors of medicine or osteopathy's performance to the distant site hospital for use in periodic appraisals for 49 (Staff U to JJJ, and LLL to RRR) of 49 doctors;

4. documentation of the completion of the Oklahoma State Department of Health Mandated Uniform Credentialing Application for three (Staff B, C, and S) of three providers;

5. three peer recommendations for two (Staff C and S) of two providers;

6. a request for specified privileges for three (Staff B, C, and S) of three providers;

7. temperature checks were completed and documented twice daily for two (refrigerators and freezers for patient food and for medication) of two refrigeratores and freezers located in the emergency room;

8. a Drug Enforcement Agency (DEA) Form 106 was filed with the Oklahoma Bureau of Narcotics and Dangerous Drugs on one (50 mg/ 0.5 ml syringe Ketamine) of one missing Schedule III drugs.


This failed practice has the potential for:

1. a delayed recognition of patient medical conditions that could influence recovery, functional status, quality of life.

2. inadequate care and potential abuse by failure to gather and review information regarding the past behavior and verification of training of providers before granting privileges at the hospital.

3. risk for illness and ineffective therapeutic benefits by not storing food and medication at recommended temperatures.

4. an unsafe environment by decreasing the accountability of tracking missing Schedule III drugs. (See Tag 106)


Based on observation, record review, and interview, the hospital failed to ensure expired supplies were removed from patient care areas for two (Medical Surgical Unit and Obstetrical Unit) of two patient care areas.

This failed practice has the likelihood to result in ineffective interventions or inaccurate diagnostic results for hospital patients. (See Tag 1024)


Based on observation, record review, and interview, the hospital failed to ensure crash carts were prepared for use for three (Emergency Department, Medical Surgical Unit, Obstetrical Unit) of three crash cart areas/units.

This failed practice has the likelihood to place patients who are in cardiac arrest at risk of receiving no or delayed life-sustaining treatment in an emergent situation, thereby reducing the possibility of survival. (See Tag 1032)


Based on record review and interview, the hospital failed to ensure:

1. verification of staff training following a sentinel event for two (10/22/19 and 11/11/19) of two training dates

2. governing body involvement for one (10/14/19 - 10/15/19) of one sentinel events

3. verification of staff training for two (08/02/19 and 02/09/20) of two grievances

These failed practices have the likelihood to result in hospital patients receiving care by staff with knowledge deficits, thereby placing patients at risk of a poor health outcome. (See Tag 1046)


Based on record review and interview, the hospital failed to ensure monitoring of vital signs for one (Patient #1) of 22 patients.

This failed practice has the likelihood to result in delayed recognition of patient condition deterioration and delayed implementation of interventions. (See Tag 1048)


Based on record review and interview, the hospital failed to ensure nursing staff reassessed patient following the administration of pain medication for 8 (patients #4, 5, 7, 8, 9, 10, 18, and 20) of 22 patients.

This failed practice has the likelihood to result in diminished quality of care and ineffective treatment outcomes. (See Tag 1049)


Based on record review and interview, the facility failed to ensure the POC was developed for one (Patient #10) of 22 patients.

This failed practice has the likelihood to result in the failure to receive individually designed care to improve patient health and outcomes. (See Tag 150)

Based on record review and interview, the hospital failed to ensure:

1. a completed History and Physical examination (H&P) was recorded in the patient's health record within 24 hours of admission for two (Patient #1 and Patient #20) of 22 patients;

2. critical lab results were called to physician within 30 minutes for one (Patient #19) of 22 patients;

3. the hospital's governing body provided documentation of an internal review of the contracted doctors of medicine or osteopathy's performance to the distant site hospital for use in periodic appraisals for 49 (Staff U to JJJ, and LLL to RRR) of 49 doctors;

4. documentation of the completion of the Oklahoma State Department of Health Mandated Uniform Credentialing Application for three (Staff B, C, and S) of three providers;

5. three peer recommendations for two (Staff C and S) of two providers;

6. a request for specified privileges for three (Staff B, C, and S) of three providers;

7. temperature checks were completed and documented twice daily for two (refrigerators and freezers for patient food and for medication) of two refrigeratores and freezers located in the emergency room;

8. a Drug Enforcement Agency (DEA) Form 106 was filed with the Oklahoma Bureau of Narcotics and Dangerous Drugs on one (50 mg/ 0.5 ml syringe Ketamine) of one missing Schedule III drugs.


This failed practice has the potential for:

1. a delayed recognition of patient medical conditions that could influence recovery, functional status, quality of life.

2. inadequate care and potential abuse by failure to gather and review information regarding the past behavior and verification of training of providers before granting privileges at the hospital.

3. risk for illness and ineffective therapeutic benefits by not storing food and medication at recommended temperatures.

4. an unsafe environment by decreasing the accountability of tracking missing Schedule III drugs.


Findings:

RECORD REVIEW

Facility Policies and Procedures

A review of a document titled "Medical Staff Rules and Regulations" stated in part, "H&P shall be completed in all cases within 24 hours."

A hospital policy titled "Physician Notification of Critical Tests Results and Critical Values" showed requirements for critical results to be reported to physician within 30 minutes of nursing receiving report.

A written agreement titled, "Memorandum of Understanding between McCurtain Memorial Hospital and DIA" documented requirements for McCurtain Memorial Hospital to provide DIA evidence of its internal review of each provider's performance of the contracted services, for use in DIA's periodic appraisal of the provider.

A review of Oklahoma State laws (OAC 310:667) showed requirements for physician credentialing and recredentialing to be based on criteria as provided in the Uniform Credentialing Application required by Section 1-106.2of this title with input from physicians and other healthcare providers.

A policy titled, "Hospital Medical Staff Bylaws" documented requirements for: "The names of at least three persons, of whom at least two will be physicians, who have recently worked with the applicant and directly observed his/her professional performance over a reasonable period of time and who can and will provide reliable information regarding the applicant's training, current clinical experience and ability, ethical character, ability to work with others and other qualifications for staff appointment."

A policy titled, "McCurtain Memorial Hospital Medical Staff Bylaws" (updated on 04-10-18) documented requirements for "Specified requests stating the staff category and clinical privileges for which the applicant wishes to be considered."


A hospital Temperature Log form documented instructions that: "temperature logs MUST be taken twice daily for both the refrigerator and freezer. Min/Max temps should also be documented DAILY. Write the exact temp number legibly sideways in the space provided. Place your initials and time in the boxes at the top of the day's column. Use a new form each month and save in a file at month's end for three (3) years. Take action immediately if temperature is too high or too low! (Acceptable ranges 35 degrees F to 46 degrees F for refrigerator and -58 degrees to 5 degrees F for freezer)."


A policy titled, "Shedule II - V Procedures (revised 06/20/18)" documented instructions for loss or theft of a drugs as follows:
"Upon loss or theft of a Controlled Substance the Director of Drug Room will fill out a DEA Form 106 and mail it to the Oklahoma Bureau of Narcotics and Dangerous Drugs (OBNDD), with a copy going to the Oklahoma State Board of Drug and a copy kept in our Narcotics Files. If a crime was committed (i.e. robbery or burglary), a police report must be filed. In the case of a loss of a controlled dangerous substance, the Director of Drug Room will use professional judgment to determine if it is necessary to file a police report."


History and Physicals

Patient #1

A review of the clinical record showed a hospital admission on 10/14/19 at 4:19 PM and an H&P signed by doctor on 10/18/19 at 11:17 AM (3 days late).

On 03/10/20 at 2:12 PM, Staff A reviewed the medical record for Patient #1 and stated the doctor should have signed the H&P within 24 hours of admission.


Patient #20

A review of the clinical record showed a hospital admission on 01/28/20 at 10:17 AM and an H&P signed by doctor on 01/30/20 at 7:37 AM (1 day late).

On 03/11/20 at 9:35 AM, Staff A reviewed the medical record for Patient #1 and 20 and stated "all H&Ps should be signed within 24 hours of admission."


Critical Lab Results

Patient #19

A review of patient record for 02/05/20 showed a blood glucose level of 501 mg/dl with no notification of physician documented.

On 03/11/20 at 10:30 AM, Staff A stated there was no documented physician notification of the critical blood glucose results for patient #19.


Internal Review

A review of Personnel Records showed no Internal Performancfe Review for Staff U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, KK, LL, MM, NN, OO, PP, QQ, RR, SS, TT, UU, VV, WW, XX, YY, ZZ, AAA,
BBB, CCC, DDD, EEE, FFF, GGG, HHH, III, JJJ, LLL, MMM, NNN, OOO, PPP, QQQ, and RRR.

On 03/11/20 at 5:00 pm, Staff H stated they had no knowledge of documentation of an internal review of the contracted doctors.


Uniform Credentialing Application

A review of facility credentialing records showed no completion of an Uniform Credentialing Application for Staff B, C, and S.

On 03/11/20 at 4:30 pm, Staff H stated they did not use the Oklahoma State Department of Health Uniform Credentialing Application every time they credentialed and re-credentialed providers.


Peer Recommendations

A review of personnel and credentialing records showed no Peer Recommendations for Staff C and S.

On 03/11/20 at 4:45 pm, Staff H stated three professional reference letters for credentialing were not requested. Staff H stated in 2018 their healthcare accreditation organization told them they only needed two professional reference letters and to change their medical staff bylaws. Staff H stated they had not gotten around to changing the medical staff bylaws.


Clinical Privileges Requested

A review of personnel and credentialing records showed documentation of specified previleges requested for Staff B,
C, and S.


On 03/11/20 at 4:40 pm, Staff H stated:

1. the changes to the Delineation of Privileges Form was changed and approved by the governing board without them seeing and reviewing it;

2. the healthcare accreditation organization told them the new Delineation of Privileges Form was not adequate and it needed to be changed back to the original form they had been using;

3. the forms and policies were approved by medical executive committee and never taken to the governing board for approval;

4. the board members were not medical doctors and don't know what to approve.


Documentation of Temperatures

A review of ER patient refrigerator/freezer documentation showed no twice daily temperature for:

1. January 1 - 31, 2020;
2. February 1 - 29, 2020;
3. March 1 - 5, 2020


On 03/05/20 at 10:45 am, Staff G stated the temperature logs did not indicate the temperatures of the refrigerators and freezers where patient food and emergency room medications were stored were checked twice daily.


Missing Medication

A review of an Incident/Variance Report completed by Staff ZZZ on 11/12/19 at 10:am showed, "50 mg (0.5 ml) Ketamine syringe missing from emergency room (ER). We discussed with director of nursing (DON) and risk Management. Doses of Ketamine secured to Rx Department in my desk drawer. Action Taken: Ketamine was kept with other stuff in office desk drawer." Document showed no completion a DEA Form 106 mailed to the OBNDD, no copy in the hospital's Narcotic Files, and no police report.


On 03/11/20 at 11:03 am, Staff ZZZ stated the Oklahoma Board of Narcotics and Dangerous Drugs were not notified of the missing Ketamine.

Based on observation, record review, and interview, the hospital failed to ensure expired supplies were removed from patient care areas for two (Medical Surgical Unit and Obstetrical Unit) of two patient care areas.

This failed practice has the likelihood to result in ineffective interventions or inaccurate diagnostic results for hospital patients.

Finding

During a tour of the Medical Surgical Unit on 03/06/20 at 10:05 AM, two packages of Philips Adult/Child Multifunction Electrode Pads with an expiration date of 02/28/20 were observed on the crash cart.


During a tour of the Medical Surgical Unit on 03/11/20 from 9:05 AM to approximately 9:25 AM, the following items were observed:

1. Kendall foam electrodes Lot #632811X were observed in a patient's room with an expiration date of 11/28/19;

2. 3M upper body warmer Lot #42268 was observed in the supply room with an expiration date of 11/2016;

3. four packages of Montgomery straps Lot #963 was observed in the supply room with an expiration date of 01/27/15.


During a tour of the Obstetrical Unit on 03/11/20 from 9:30 AM to approximately 9:45 AM, the surveyor observed
three packages of Kendall 133 foam electrodes Lot #700507X on the crash cart with an expiration date of 01/28/20.


On 03/11/20 from 9:05 AM to approximately 9:45 AM, Staff D and Staff E looked at the items from the 03/11/20 tours and stated they were expired.


A review of a document titled "Purchase Order #34563" read in part, "PHILIPS MEDICAL SYSTEMS... ELEC/PD DEFIB MULTI FNTN ADLT," and showed one case was ordered on 03/03/20 (two business days after expiration of supply on crash cart).


On 03/06/20 at 10:05 AM, Staff A reviewed the two packages on the crash cart from the 03/06/20 tour, acknowledged they were expired, and stated they were on backorder.


On 03/10/20 from 2:47 PM to 3:00 PM, Staff WWW stated department directors were responsible for ordering their supplies and that they sometimes forget, leading to a crisis.

Based on observation, record review, and interview, the hospital failed to ensure crash carts were prepared for use for three (Emergency Department, Medical Surgical Unit, Obstetrical Unit) of three crash cart areas/units.

This failed practice has the likelihood to place patients who are in cardiac arrest at risk of receiving no or delayed life-sustaining treatment in an emergent situation, thereby reducing the possibility of survival.

Finding

During a tour of the Obstetrical Unit on 03/11/20 from 9:30 AM to approximately 9:45 AM, an opened package of defibrillator pads was observed on the crash cart.

A review of a policy titled "Emergency Crash Cart and Medications" read in part, "Designated Licensed Staff Member is responsible for checking the crash cart, oxygen cylinder levels, defibrillator, and documenting compliance on crash cart checklist...Defibrillator load checks will be performed daily with the defibrillator plugged in and weekly unplugged."

A review of documents titled "24 Hour Crash Cart Check" showed no or partial documentation the crash cart was checked on the following dates:

Medical Surgical Unit:

January 2020: 2, 3, 7, 19, 28

February 2020: 4, 16, 27

March 2020: 1, 4


Emergency Department:

January 2020: 17, 28


Obstetrical Unit:

December 2019: 11, 12, 13

January 2020: 29, 30, 31


A review of documents titled "McCurtain Memorial Hospital Emergency Cart Check List" for the Obstetrical Unit read in part, "Once each week remove the numbered red tag and check all supplies in drawers. Check expiration dates on supplies. Validate that all laryngoscopes and blades are attached properly and that laryngoscope light is working...When emergency cart check is completely verified, record the red tag number removed and the new red tag number below." The documents showed the following:

Red tag replaced on 01/14/19 and removed on 02/04/19 (two weeks late)

Red tag replaced on 02/11/19 and removed on 02/25/19 (one week late)

Red tag replaced on 03/11/19 and removed on 03/25/19 (one week late)

Red tag replaced on 04/08/19 and removed on 04/29/19 (two weeks late)

Red tag replaced on 06/10/19 and removed on 06/24/19 (one week late)

Red tag replaced on 08/26/19 and removed on 09/16/19 (two weeks late)

Red tag replaced on 10/07/19 and removed on 10/21/19 (one week late)


On 03/06/20 at 10:10 AM, Staff A reviewed the 24 Hour Crash Cart Check documents for the Medical Surgical Unit and stated the cart checks were not done daily; and daily cart checks were to be done to protect patient safety.


On 03/06/20 at 10:30 AM, Staff O stated nursing staff was told they were never to crack the drawers on the crash cart to check for expired supplies.


On 03/11/20 at approximately 9:45 AM, Staff E stated the opened package of defibrillator pads were not to be used during a code and should not have been on the crash cart.

Based on record review and interview, the hospital failed to ensure:

1. verification of staff training following a sentinel event for two (10/22/19 and 11/11/19) of two training dates

2. governing body involvement for one (10/14/19 - 10/15/19) of one sentinel events

3. verification of staff training for two (08/02/19 and 02/09/20) of two grievances

These failed practices have the likelihood to result in hospital patients receiving care by staff with knowledge deficits, thereby placing patients at risk of a poor health outcome.


Finding

Staff Training

A review of a document titled "Staff meeting sign-in sheet Mock Code" dated 10/22/19 showed signatures of staff attendees. Documentation showed no record of time the training took place, objectives, goals, or effectiveness of the training.

A review of a document titled "Mandatory Meeting" dated 11/11/19 read in part, "Hemorrhage Cart now available. We will go through it tonite." Documentation showed no objectives, goals, or effectiveness of the training.

A review of a document titled "RFA Follow Up" dated 11/21/19 showed a list of training and process changes to be completed and read in part, "Develop a Maternal Hemorrhage Plan a.) Provide education to nursing--Completed and to Dr. for review." Documentation showed no plan timeline, no documentation of employees who had been or were to be trained, or documentation of how staff would be trained.

On 03/11/20 from 12:20 PM to 1:05 PM, Staff A reviewed the documents and stated they could not determine the training content and that there was no Maternal Hemorrhage Plan policy.


Governing Body

A review of a document tiled "Root Factor Analysis" showed a sentinel event for Patient #1 on 10/14/19 - 10/15/19.

A review of documents titled "Minutes" of the McCurtain Memorial Medical Management, Inc. Board of Trustees meetings dated 10/24/19, 11/21/19, and 12/19/19 showed no documentation of a sentinel event.

On 03/11/20 from 12:20 PM to 1:05 PM, Staff A stated the sentinel event for Patient #1 was reported to the board of trustees in the November 2019 meeting.


Grievance/Complaint

A review of documents titled "McCurtain Memorial Hospital Grievance/Complaint" dated 08/02/19 and 02/09/20 showed the following:

1. Patient dissatisfaction with nursing care received

2. The involved nurses were addressed

3. No documentation to reflect date, time, and receipt of the discussion by the nurses involved.

On 03/11/20 from 12:20 PM to 1:05 PM, Staff A reviewed the Grievance/Complaint documents and no further documentation was provided to show the date, time, and receipt of the discussion by the nurses involved.

Based on record review and interview, the hospital failed to ensure monitoring of vital signs for one (Patient #1) of 22 patients.

This failed practice has the likelihood to result in delayed recognition of patient condition deterioration and delayed implementation of interventions.

Finding

Patient #1

A review of a policy titled "Rapid Response Team" read in part, "Provisions shall be made to efficiently provide care for a patient who appears acutely ill, before cardiac arrest or adverse event occurs. To provide response by a team of clinicians who bring critical care expertise to the bedside...The Rapid Response Team shall be comprised of a Patient Care Director...along with a respiratory therapist...The ED physician and/or hospitalist will attend as needed...Possible criteria to activate RRT...HR greater than 130...Systolic BP less than 90 mmHg."


A review of the Patient Progress Notes showed the following vital signs and no call or activation of the Rapid Response Team:

10/15/19 at 6:30 PM Systolic BP - 70 HR - 148

10/15/19 at 6:38 PM Systolic BP - 82 HR - 143

10/15/19 at 6:43 PM Systolic BP - 66 HR - 139

10/15/19 at 6:53 PM Systolic BP - 66 HR - 142

10/15/19 at 7:03 PM Systolic BP - 57 HR - 142


Continued review of the Patient Progress Notes showed documentation of inability to obtain blood pressure readings using the datascope machine and no documentation of effective alternate means utilized for four of four blood pressure reading attempts, and read in part as follows:

10/15/19 at 6:56 PM "Datascope unable to read systolic pressure, --/37 reading, continuing to cycle continuously"

10/15/19 at 7:01 PM "Datascope unable to read BP at this time, continuous BP cycling continued"

10/15/19 at 7:35 PM "BP cuff has been moved from upper right arm to left FA, BP cycling continued, unable to obtain BP reading"

10/15/19 at 7:45 PM "BP cuff moved to pt's upper left arm and cycling continued, unable to read BP."


A review of the Chartllink Physician Entered Orders in the patient medical record showed an order dated 10/15/19 at 8:03 PM that read, "Vital signs every 15 minutes x 4 and til stable."


A review of the Patient Progress Notes in the patient medical record showed no documented vital signs on 10/15/19 from 8:32 PM to 9:35 PM (63 minutes). The 8:32 PM vital signs showed no documentation of oxygen saturation or temperature. The 9:35 PM vital signs showed no documentation of pulse, respirations, oxygen saturation, or temperature. At 9:45 PM, a code blue was called on the patient for respiratory arrest.


A review of Patient Progress Notes in the patient medical record showed no documentation of a pulse check at the start of a Code Blue and showed the following:

10/15/19 at 9:45 PM Code Blue initiated

10/15/19 at 10:15 PM Initial vital signs taken

10/15/19 at 10:32 PM CPR started

10/15/19 at 10:34 PM Pulse check performed


On 03/10/20 at 3:20 PM, Staff A reviewed the patient medical record and stated the vital signs should have occurred every 15 minutes per the order.


On 03/10/20 at 3:28 PM, Staff A reviewed the patient medical record and stated the expectation when a Code Blue was to called was to get a cardiac monitor and bag mask valve to the patient's bedside and to start CPR if the patient were pulseless which required feeling for a pulse; that he or she was unable to tell if anyone felt for a pulse at the start of the code.


On 03/11/20 at approximately 12:50 PM, Staff E reviewed the patient medical record and stated the Rapid Response Team policy was not followed.


On 03/11/20 from 12:20 PM to 1:05 PM, Staff A reviewed the patient medical record and stated staff should have tried to obtain the blood pressure reading manually or brought in another machine.

Based on record review and interview, the hospital failed to ensure nursing staff reassessed patient following the administration of pain medication for 8 (patients #4, 5, 7, 8, 9, 10, 18, and 20) of 22 patients.

This failed practice has the likelihood to result in diminished quality of care and ineffective treatment outcomes.

Findings:

Patient #4

A review of clinical records showed on 03/09/20 at 09:09 AM, hydromorphone was administered for pain. Documentation showed no reassessment for pain relief or medication effectiveness.


Patient #5

A review of clinical records showed on 03/10/20 at 02:32 AM, acetaminophen was administered for pain. Documentation showed no reassessment for relief or medication effectiveness.


Patient #7

A review of clinical records showed on 11/02/19 at 01:51 PM and 08:45 PM, acetaminophen was administered for pain. Documentation showed no reassessment for pain relief or medication effectiveness.

Continued review of the clinical record showed on 11/03/19 at 10:14 AM, acetaminophen was administered for pain. Documentation showed no reassessment for pain relief or medication effectiveness.


Patient #8

A review of clinical records showed on 11/03/19 at 10:01 PM, acetaminophen was administered for pain. Documentation showed no reassessment for pain relief or medication effectiveness.


Patient #9

A review of clinical records showed on 10/07/19 at 12:21 AM, 10:53 AM, and 07:41 PM morphine was administered for pain. A continued review of the clinical record showed on 10/07/19 at 01:00 AM, morphine was again administered for pain. Documentation showed no reassessment for pain relief or medication effectiveness with either administration of medication.


Patient #10

A review of the clinical record showed on 10/09/19 at 08:13 AM, Tramadol was administered for pain. Documentation showed no reassessment for pain relief or medication effectiveness.


Patient #18

A review of the clinical record showed on 02/12/20 at 12:39 AM and 04:11 PM, acetaminophen was administered for pain. A continued review of the record showed on 10/07/19 at 00:21 AM, 10:53 AM, and 07:41 PM morphine was administered for pain. Documentation showed no reassessment for pain relief or medication effectiveness with either administration of medication.


Patient #20

A review of the clinical record shoed on 01/18/20 at 10:40 PM, ketorolac was administered for pain. Documentation showed no reassessment for pain relief or medication effectiveness.

On 03/11/20 at 09:20 AM, Staff A stated documentation showed no reassessment for patients #4, 5, 7, 8, 9, 10, 18, and 20.

On 03/11/20 at 9:25 AM, Staff A stated the expectation was for the nurse to reassess pain within 1 hour after administration of pain medication.

Based on record review and interview, the facility failed to ensure the POC was developed for one (Patient #10) of 22 patients.

This failed practice has the likelihood to result in the failure to receive individually designed care to improve patient health and outcomes.

Findings:

Patient #10

A review of the patient record showed an admitting diagnosis of a TIA. The POC showed no instructions, interventions, or diagnosis of TIA as a patient problem.

On 03/11/20 at 9:47 AM, Staff A stated the expectation was to see a care plan addressing the neurological system.

Based on record review and interview, the hospital failed to document fit testing for employees who may have cared for or came in contact with patients with airborne infectious diseases for seven (Staff A, G, L, Q, TTT, BBBB, and CCCC) of ten employees.

This failed practice has the likelihood to place patients and employees at risk for airborne infectious diseases by not providing effective respiratory protection. (See Tag 1206)

Based on observation, record review and interview, the hospital failed to ensure:

1. opened foods were dated and unexpired for three (whipped topping in the Produce refrigerator, fries and hash browns in the #4 Deep Freezer) of three food items.

2. kitchen ceiling air vents were clean for three (two vents in front of the Dairy walk-in refrigerator and one vent in the Dry Food storage room) of three ceiling air vents.

3. metal shelves were clean for two (two shelves in the Dry Food storage room) of two metal shelves.

4. a package of styrofoam to-go containers were covered for one (package in the Dry Paper storage room) of one packages.

5. an electric receptacle was clean for one (electric receptacle behind the convection oven) of one electric receptacles.

6. maintenance of countertops in patient rooms for two (Room 209 and Room 234) of two patient rooms.

7. equipment was cleaned between patients or prior to storing.

8. patient care staff disinfected hands per policy after patient care.

9. sharps containers were replaced after they reached the full mark on two (ER Trauma Room #2 and 3rd Floor Nurse's Station) of six sharps containers.

This failed practice has the likelihood to place all patients, staff, and visitors at risk of exposure to infectious agents. (See Tag 1208)


Based on record review and interview, the hospital failed to ensure a system for tracking infection control for patients hospitalized in 2019.

This failed practice has the likelihood to place patients, staff and visitors at risk of hospital acquired infections. (See Tag 1225)


Based on record review and interview, the hospital failed to ensure documentation of infection control monitoring for 12 (10/2018, 11/2018, 12/2018, 01/2019, 02/2019, 03/2019, 04/2019, 05/2019, 06/2019, 07/2019, 08/2019, 09/2019) of 12 months.

This failed practice has the likelihood to place patients at risk of acquiring infections during a hospital visit. (See Tag 1235)

Based on record review and interview, the hospital failed to document fit testing for employees who may have cared for or came in contact with patients with airborne infectious diseases for seven (Staff A, G, L, Q, TTT, BBBB, and CCCC) of ten employees.

This failed practice has the likelihood to place patients and employees at risk for airborne infectious diseases by not providing effective respiratory protection.

Findings

A policy titled Fit Testing Guidelines (revised 03/12/18) documented requirements for "Annual fit testing to be conducted at set time by Employee Health Nurse.

A document titled Employee Health Index listed fit testing as an employee health requirement.

A review of administrative, personnel, and infection control records showed:

· An Annual Respiratory Fit Test Evaluation Form signed but undated for Staff A.
·
· No Fit Test or Annual Respiratory Fit Test Evaluation Form for Staff G.
·
· An Annual Respiratory Fit Test Evaluation Form neither signed or dated for Staff L.
·
· No Fit Test or Annual Respiratory Fit Test Evaluation Form for Staff Q.
·
· An Annual Respiratory Fit Test Evaluation form neither signed or dated for Staff TTT.
·
· An Annual Respiratory Fit Test Evaluation Form signed but undated for Staff BBBB.
·
· An Annual Respiratory Fit Test Evaluation Form neither signed or dated for Staff CCCC


On 03/12/20 Staff DDDD stated:

1. some of the employees did not have Annual Respiratory Fit Test Evaluation Forms signed or signed and dated by an employee health nurse and

2. some employees did not have documentation of fit tests or completed Annual Respiratory Fit Test Evaluation Forms.

Based on observation, record review and interview, the hospital failed to ensure:

1. opened foods were dated and unexpired for three (whipped topping in the Produce refrigerator, fries and hash browns in the #4 Deep Freezer) of three food items.

2. kitchen ceiling air vents were clean for three (two vents in front of the Dairy walk-in refrigerator and one vent in the Dry Food storage room) of three ceiling air vents.

3. metal shelves were clean for two (two shelves in the Dry Food storage room) of two metal shelves.

4. a package of styrofoam to-go containers were covered for one (package in the Dry Paper storage room) of one packages.

5. an electric receptacle was clean for one (electric receptacle behind the convection oven) of one electric receptacles.

6. maintenance of countertops in patient rooms for two (Room 209 and Room 234) of two patient rooms.

7. equipment was cleaned between patients or prior to storing.

8. patient care staff disinfected hands per policy after patient care.

9. sharps containers were replaced after they reached the full mark on two (ER Trauma Room #2 and 3rd Floor Nurse's Station) of six sharps containers.

This failed practice has the likelihood to place all patients, staff, and visitors at risk of exposure to infectious agents.


Finding

HOSPITAL POLICIES & PROCEDURES

A review of a policy titled "Infection Control: Rehabilitation Therapy In Patient and Out Patient" read in part, patient care equipment should be cleaned with disinfectant after use and/or before placing in storage area.


A review of a policy titled Hazardous, Infectious and General Waste Disposal (revised 04/23/18) documented instructions for "Needles and syringes be disposed of whole into the red hazardous materials and waste in the proper manner. When containers are ¾ full, they will be taken by housekeeping to the locked storage area."


A review of a document titled "Weekly Cleaning List" dated February 2020 read in part, "Walk-In - Sweep/Mop Saturday or Sunday...Storeroom - Sweep/Mop." Documentation showed no indication of cleaning anything above the floor in those rooms. (See observations below).


Review of a policy titled "Handwashing/Monitoring" read in part, "Hand Hygiene should be performed at least: Between handling of individual patients."


OBSERVATIONS

During a kitchen tour on 03/05/20 from 10:18 AM to 11:55 AM, the surveyor observed the following:

1. in the produce refrigerator, an opened 14 oz bottle of Sysso Reliance whipped topping with a best by date of 06/25/19 with no opened date marked.

2. in the #4 deep freezer, two bags of opened french fries and one bag of opened hash browns with no opened date marked.

3. in the kitchen prep area, brown debris on the slats of two ceiling air vents in front of the dairy walk-in refrigerator.

4. in the dry food storage room, brown debris on the slats of one ceiling air vent and two metal shelves.

5. in the dry paper goods storage room, an approximately 6-inch wide band of black substance from floor to ceiling on the right-hand wall from the door entrance where an approximately one foot high stack of nested styrofoam to-go containers were kept in an unsealed bag.

6. on the convection oven, brown and black debris on top of the electric receptacle behind the convection oven.


During a tour of the Medical Surgical Unit on 03/06/20 from 9:13 AM to 11:04 AM, the surveyor observed:

1. the left-hand corner of the bedside patient sink counter had an exposed porous surface from broken-off formica in rooms 209 and 234.

2. at 9:15 AM staff TTT did not disinfect hands between patients.

3. at 9:20 AM, Staff TTT did not disinfect equipment before placing equipment in storage area and before using on the next patient.


During a tour of the Emergency Trauma Room on 03/05/20 at 10:30 am, the surveyor observed a sharps container located in the emergency room trauma room #2 to be filled with sharps past the full mark on the container. The surveyor then observed Staff EEEE replaced full sharps container with an empty one and place full sharps container in a biohazard box in the locked biohazard room.

During a tour of the 3rd floor on 03/05/20 at 10:45 AM, the surveyor observed a sharps container located on a crash cart in the 3rd floor nurse's station to be filled above the full mark.


INTERVIEWS

On 03/05/20 at 10:25 AM, Staff K stated the whipped topping was expired; had been opened; and had no opened date marked.

On 03/05/20 at 10:30 am, Staff EEEE stated the sharps container was full and she would replace it.

On 03/05/20 at 10:43 AM, Staff K stated the bags (in the #4 deep freezer) were opened and should have been marked with an opened date to determine whether foods were safe to use.

On 03/05/20 at 10:45 AM, Staff FFFF stated the sharps container "should be taken away and a new one put in its place."

On 03/05/20 at 10:47 AM, Staff K stated the brown debris was dust; the vents were last cleaned in December of 2019 and he or she did not know how often the vents were supposed to be cleaned.

On 03/05/20 at 11:06 AM, Staff K stated the brown debris was dust; the shelving was last cleaned one month ago and was supposed to be cleaned every Saturday or Sunday with an expectation to remove dust when cleaning.

On 03/05/20 at 11:19 AM, Staff L stated the black substance was rust from an old roof and its cleaning had been placed on hold for nine years.

On 03/05/20 at 11:36 AM, Staff L stated the brown and black debris on top of the electric receptacle was several years of grease buildup.

On 03/06/20 at 9:23 AM, Staff A stated the porous surface could harbor germs and could be a risk to patients.

On 03/06/20 at 9:25 AM Staff UUU stated:

1. the expectation is equipment would be clean after each use and between patients and

2. "the therapist should disinfect hands before and after contact with each patient. "

Based on record review and interview, the hospital failed to ensure a system for tracking infection control for patients hospitalized in 2019.

This failed practice has the likelihood to place patients, staff and visitors at risk of hospital acquired infections.


A review of a policy titled "Infection Control Plan" read in part, "the goal...is...to ensure that the organization has a functioning coordinated process in place, to reduce the risks of endemic and epidemic nosocomial infections in patients and healthcare workers...Information from the ...Infection Control Committee will be reported every quarter...Minutes of these meetings are forwarded to the Medical Executive Committee...to assist in a timely and thorough implementation of recommended corrective measures and process outcome revisions."


A review of the medical staff bylaws read in part, "The infection control committee shall meet quarterly in conjunction with MEC...and report to the medical staff."


A review of the Infection Control Committee Meeting minutes showed meetings were held as follows:

1. January 3, 2019
2. April 30, 2019
3. September 24, 2019 (two months late)
4. December 10, 2019


A review of documents titled "Minutes of Medical Executive Committee Meeting" for the following dates showed:

1. April 18, 2019 - no documented report from the Infection Control Committee

2. June 18, 2019 - a documented report from the Infection Control Committee which showed data from January, February, and March of 2019 not reported to the Medical Executive Committee on April 18, 2019 (two months late)

3. July 16, 2019 - no documented report from the Infection Control Committee


A review of documents titled "Minutes" of the McCurtain Memorial Medical Management, Inc. Board of Trustees meetings showed no documentation of infection control in the year 2019 for the months of January, April, May, June, July, August, October, and November.

On 03/11/20 at 9:53 AM, Staff E stated the following:

1. Infection Control Committee was to meet quarterly

2. The data was to go to the Medical Executive Committee

3. The Chief of Staff was to report the data to the Board of Trustees

Based on record review and interview, the hospital failed to ensure documentation of infection control monitoring for 12 (10/2018, 11/2018, 12/2018, 01/2019, 02/2019, 03/2019, 04/2019, 05/2019, 06/2019, 07/2019, 08/2019, 09/2019) of 12 months.

This failed practice has the likelihood to place patients at risk of acquiring infections during a hospital visit.

A review of a policy titled "Infection Control Plan" read in part, "Infection control activities include...monitoring and evaluation of...nosocomial infections in Special Care Units, Class 1 post-op wound infections, Class 2 post-op wound infections, Device-related infections, Infections in neonate, Antibiotics-resistant organisms, Nosocomial TB, Other communicable diseases, Employee health trends, Postoperative pneumonia, Ventilator related pneumonia, Postpartum infections. Continuously collecting and/or screening data to identify isolated incidents or potential infectious outbreaks."

A review of documents titled "Minutes of Infection Control Meeting" dated 01/03/19, 04/30/19, 09/24/19, and 12/10/19 showed there were no healthcare acquired infections identified for the months of 10/2018 through 09/2019 and showed no documentation of the data collection.

On 03/11/20 at 9:53 AM, Staff E stated the hospital had logs of the number of days patients had central lines and urinary catheters, but didn't know if there were logs for patients with infection. No infection control logs were provided.