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Based on observation, document review, and staff interviews, the critical access hospital's (CAH) administrative staff failed to ensure staff performed preventative maintenance on 1 of 1 wall mounted Dynascope Cardiac Monitors in a Medical/Surgical Patient room, 1 of 1 Plum A IV infusion pumps in Ambulance #2711, and 1 of 1 Angiojet Ultra 5000 in the Surgical Department. Failure to perform preventative maintenance could potentially result in the equipment failing to function when needed for the care and treatment of a patient, and result in delayed care, treatment, and patient harm. The CAH's administrative staff identified an average of 2 inpatients per day, 190 ambulance transfers per month, and 20 vascular surgeries per year.

Findings include:

1. Observations during a tour of the Medical/Surgical unit on 12/3/18 at 12:45 PM. revealed a wall mounted Dynascope Cardiac Monitor (a machine that monitors the patient's heart rate and rhythm) in patient room 100, with a preventive maintenance sticker indicating the staff should inspect the device on 2/2016.

2. Observations during a tour of the Ambulance Garage on 12/3/2018 at 2:50 PM revealed, in ambulance #2711, 1 of 1 Plum A IV infusion pumps with a preventive maintenance sticker indicating the staff should inspect the device on 2/2016.

3. Observations during a tour of the Surgical Department on 12/4/2018 at 10:30 AM revealed an Angiojet Ultra 5000A (a machine that assists in surgery on blood veins) with a preventative maintenance sticker indicating the staff should inspect the device on 8/2018.

4. Review of "Appendix A" in the "Equipment Services Agreement," dated 2/2002, revealed in part,"... will provide electrical safety inspection and testing as part of scheduled preventive maintenance and repair for the Equipment.... procedures used will help verify that all Equipment meets or exceeds the highest possible safety level to ensure the proper care and well being of the patient."

5. Review of the policy "Medical Equipment Management Plan," reviewed 3/2018, revealed in part, "purpose of the Medical Equipment Management Plan is to support a safe patient care and treatment environment." "designed to assure continued availability of safe, effective equipment through a program of planned maintenance, timely repair and evaluation.."

6. Review of the policy "Medical Equipment Maintenance, Testing", reviewed 3/18 revealed in part, "biomed vendor will perform... periodic maintenance and inspections, preventive maintenance, and repairs on all medical equipment" "Medical equipment is defined as equipment used for the diagnosis, treatment, monitoring and care of patients."

7. During an interview on 12/4/2018 at 10:30 with the Biomedical Clinical Engineer (person responsible for doing the preventative maintenance on medical equipment) revealed he used the stickers as a reminder to check the equipment, and acknowledged he failed to check the Angiojet maching when it was due for service in 2/2016.

8. During an interview on 12/4/2018 at 11:20, the Biomedical Clinical Engineer revealed he performed preventative maintenance in this facility once a month. If the Biomedical Clinical Engineer was unable to locate a piece of equipment for 60 days, he deleted it from the inventory listing for him to check. The Biomedical Clinical Engineer did not provide the facility with verbal or written notification that he deleted the equipment from the list of medical equipment that required preventative maintenance.

9. During an interview on 12/4/2018, at the time of the Medical Surgical Department and ER Department tours, the Chief Nursing Officer (CNO) verified the wall mounted Dynascope Cardiac Monitor and the Plum A IV infusion pump preventative maintenance stickers indicated the staff should have inspected them in 2/2016.

10. During an interview on 12/4/2018 at 11:20, the CNO reported she did not know the Biomedical Clinical Engineer deleted medical equipment from his list of equipment to check if he could not find the equipment for 60 days. The Biomedical Clinical Engineer had not asked the CNO for assistance in locating any medical equipment he could not locate.

Based on document review and staff interviews, the critical access hospital (CAH) administrative staff failed to ensure a physician on staff at the CAH was notified when 1 of 1 patient (Patient #3) was admitted by an Advance Registered Nurse Practitioner (ARNP B) between 11/27/18 to 12/3/18. ARNP B admitted 1 patient between 11/27/18 to 12/3/18. Failure to notify a physician when a patient is admitted by an ARNP could potentially result in inappropriate diagnosis and treatment, and cause potential patient harm or death.

Findings include:

1. Review of "Medical Staff Rules and Regulations", adopted by Medical Staff on 7/17/2010 and approved by the Board on 7/25/2010, revealed in part, "Admission and Discharge of Patients.... 2. Whenever a patient is admitted to the CAH by a nurse practitioner, ... [a physician] on the [medical] staff of the CAH is notified of the admission."

2. Review of Patient #3's medical record on 12/4/18 at 11:40 AM revealed ARNP B admitted Patient #3 to the CAH for observation on 12/3/2018. Patient #3's medical record lacked evidence ARNP B notified a physician of Patient #3's admission to the hospital.

3. During an interview on 12/4/2018 at 11:30 Staff Nurse C verified she could not find documentation that ARNP B notified a physician of Patient #3's admission to the hospital.

4. During an interview on 12/4/18 at 4:00 PM, the CNO verified the medical record lacked documentation that ARNP B notified a physician of Patient #3's admission to the hospital.

Based on review of policy/procedure, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure the staff notified a physician in a timely manner following the occurrence of a medication error for 7 of 10 medication errors reviewed (Patient #4, Patient #5, Patient #6, Patient #7, Patient #8, Patient #9, Patient #10). The CAH administrative staff reported a census of 3 patients. Failure to notify the physician of medication errors could potentially result in the physician not knowing of the medical error, and potentially failing to change the patient's treatment course, potentially resulting in death or a life threatening side effect.

Findings include:

1. Review of the CAH Pharmacy policy/procedure "Medication Errors", reviewed 3/18, revealed in part, " When a medication error occurs, the following should occur in this order: ... Notify the physician and evaluate the patient." "... Record the notification of physician in the medical record with any resultant orders"

2. Review of medication errors from January 2018 to October 2018 revealed:

a. the nursing staff failed to give Patient #4 their ordered dose of Protonix (a medication to prevent stomach ulcers) on 8/20/18. The medication error form lacked evidence the nursing staff notified Patient #4's physician about the medication error.

b. the nursing staff gave Patient #5 their Synthroid (an artificial thyroid medication) at the wrong time on 1/20/18. The medication error form lacked evidence the nursing staff notified Patient #5's physician about the medication error.

c. the nursing staff gave Patient #6's Rocephin (an antibiotic) early on 1/22/18. The medication error form lacked evidence the nursing staff notified Patient #6's physician about the medication error.

d. the nursing staff failed to give Patient #7 their ordered dose of Protonix on 1/24/18. The medication error form lacked evidence the nursing staff notified Patient #7's physician about the medication error.

e. the nursing staff gave Patient #8 their meclazine (medication for dizziness) late on 1/28/18. The medication error form lacked evidence the nursing staff notified Patient #8's physician about the medication error.

f. the nursing staff gave Patient #9 the wrong dose of injectable acetaminophen (a pain medication) on 4/30/18. The medication error form lacked evidence the nursing staff notified Patient #9's physician about the medication error.

g. the nursing staff give Patient #10 twice the amount of Mirapex (a medication for Parkinson's disease) as Patient #10's physician prescribed on 5/17/18. The medication error form lacked evidence the nursing staff notified Patient #10's physician about the medication error.

3. During an interview on 12/5/2018 at 1:10 PM, the Chief Nursing Officer verified Patient #4's; Patient #5's; Patient #6's; Patient #7's; Patient #8's; Patient #9's; and Patient #10's records lacked evidence of the date and time the nursing staff notified the patients' physicians about the medication error.

Based on staff interviews, document review and observations, the hospital administrative staff failed to ensure 1 out of 5 surgical staff, including a surgeon, CRNA, RN, LPN and Interim Surgical Services Manager wore head covering which fully covered all of their hair. Failure to wear head covering that fully cover all hair could potentially result in bacteria, fungi, or viruses on the surgical staff members' hair entering the environment and potentially resulting in the patient developing a life-threatening surgical site infection. The hospital's administrative staff identified the surgical services staff performed an average of 39 surgical procedures per month.


Findings include:

1. Observation on 12/4/2018 at 8:50 AM in the operating rooms revealed Patient #2 was undergoing a surgical procedure. Surgeon A wore a skullcap during the surgical procedure. The skullcap consisted of a cap covering Surgeon A's forehead and central part of Surgeon A's hair. The skull cap did not cover the lower approximately one inch of Surgeon A's hair on the side of Surgeon A's head and the back of Surgeon A's hair.


2. Review of the AORN (Association of Peri-Operative Registered Nurses, a nationally recognized guideline agency) Guideline for Surgical Attire, copyright 2018, revealed in part, "A clean surgical head covering or hood that confines all hair and completely covers the ears, scalp skin, sideburns and nape of the neck should be worn." "Hair and skin can harbor bacteria that can be dispersed into the environment. The collective body of evidence supports covering the hair and ears while in the [operating rooms.]"

Review of the policy "Attire in the Operating Room," reviewed 3/2018, revealed in part, "All head and facial hair shall be covered while in the [operating rooms]." "The surgical hat or hood shall be clean, free of lint and confine the hair."

3. During an interview on 12/5/2018 at 8:30 AM, the Interim Surgical Services Director revealed the facility staff followed the AORN guidelines. The Surgical Services Director acknowledged Surgeon A failed to completely cover his hair during Patient #2's surgical procedure on 12/4/2018.

Based on observation, staff interviews and document review, the hospital's administrative staff failed to ensure 1 out of 5 surgical records reviewed contained appropriately timed and dated post-operative physician assessment for Patient #1. The hospital's administrative staff identified the surgical services staff performed an average of 39 surgical procedures per month.

Failure to ensure appropriately timed and dated assessments are being performed could potentially result in a change of condition in a patient not being detected, therefore resulting in a posed danger to the patient's health.

Findings include:

1. On 12/4/2018 at 3:10 PM, document review of operating room revealed Patient #1 underwent a surgical procedure with a start date and time of 10/9/2018 of 8:33 am.

During a review of facility document, titled "Physician Review" Surgeon A documented performing a pre-operative assessment on Patient #1 on 10/8/2018 at 7:00 am, 26.5 hours prior to the start of the procedure.

Review of facility policy titled Surgical Site Identification, effective date 5/15, reviewed 3/18 revealed " The correct patient, procedure and site shall be verified by the patient and/ or family ...and the surgeon, preoperatively, in the preoperative area and again immediately prior to the initiation of the surgical procedure."

2. During an interview on 12/4/2018 at approximately 3:20 PM, Surgeon A revealed the date and time were written correctly at 10/8/2018 at 7:00 am. When informed the procedure was not until the next day, Surgeon A again stated the date and time is what he interpreted it to be.

There was a lack of documentation proving the Surgeon performed another assessment immediately prior to the surgical procedure.

Based on review of the Quality Improvement Plan, Quality Improvement activities, and staff interviews, the Critical Access Hospital (CAH) quality improvement staff failed to evaluate all patient care services provided for 5 of 6 contracted patient care services (MRI, Magnetic Resonance Imaging, Nuclear Medicine, PET-CT - Positron Emission Tomography-Computed Tomography). Failure to monitor and evaluate all patient care services for quality of care could potentially expose patients to inappropriate and/or substantial care. The CAH administrative staff reported a census of 3 patients at the beginning of the survey. The CAH administrative staff reported the CAH staff performed the following number of procedures from July 1, 2018 to June 30, 2018 - MRI 199, Nuclear Medicine 110, PET-CT 26, Tele-Radiology 3,530, and Tele-Psychology 93.

Findings include:

1. Review of CAH "Quality Improvement and Patient Safety Plan 2018," revealed in part, "... All patient care services and other services affecting patient health and safety are evaluated. The CAH implements data collection processes to ensure ongoing quality and to identify safety or quality-related problems or concerns...."

2. Review of the Quality Improvement Committee Meeting minutes from March 15, 2018 through September 25, 2018 revealed the meeting minutes lacked evidence that the CAH staff monitored, evaluated, and reported quality improvement activities regarding patient care services for the contracted MRI - Magnetic Resonance Imaging, Nuclear Medicine, PET-CT, Tele-Radiology (when a radiologist not located at the CAH interprets radiology exams for patients at the CAH), and Tele-Psychology (when a psychiatrist not located at the CAH evaluates patients at the CAH with psychiatric problems).

3. During an interview on 12/5/18 at 8:50 AM, the Radiology Director acknowledged that the Quality Improvement Committee meeting minutes lacked evidence the CAH staff monitored, evaluated, and reported the quality improvement activities regarding patient care services for the contracted MRI, Nuclear Medicine, and PET-CT.

During an interview on 12/6/18 at 1:40 PM, the Quality Director acknowledged that the Quality Improvement Committee meeting minutes lacked evidence the CAH staff monitored, evaluated, and reported the quality improvement activities regarding patient care services for the contracted MRI, Nuclear Medicine, PET-CT, Tele-Radiology, and Tele-Psychiatry.