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Based on Surgery Department Temperature and Crash Cart Log review and interview, it was determined the facility failed to take corrective action in response to humidity readings outside the required range (30% to 60% per Rules and Regulations for Critical Access in Arkansas (2008 edition)) in two of two Operating Rooms and one of one Gastrointestinal (GI) Room from June 2012 through February 2013. Humidity levels outside the required range had the potential to affect the health and safety of all patients admitted for surgery due risk sparks from static electricity build-up associated with low humidity. The facility performed an average of 90 surgeries per month. The findings follow:

A. Review of the Surgery Department Temperature and Crash Cart Log on 02/26/13 at 1330 revealed the following:
1) In Operating Room #1, humidity outside the compliance range was documented on 121 of 269 days from June 2012 to February 2013.
2) In Operating Room #2, humidity outside the compliance range was documented on 104 of 269 days from June 2012 to February 2013.
3) In the Gastrointestinal (GI) Room, humidity outside the compliance range was documented on 138 of 267 days from June 2012 to February 2013.
B. In an interview on 02/26/13 at 1400, the Maintenance Director verified there was no documentation of corrective action taken for the documented humidity readings outside the required range.

Based on observation and interview it was determined the facility did not meet Life Safety Code requirements as follows:

A. The generator was not inspected weekly as required. Failure to perform weekly generator inspections had the potential to affect the health and safety of all patients because the reliability of the generator to provide power to the facility in the event of the loss of normal power was not assured. The facility had a census of 13 patients on 02/25/13. See CMS 2567, K144.
B. Line isolation panels were not tested monthly as required. Failure to test line isolation panels monthly had the potential to affect the health and safety of all patients in the surgical areas served by the monitors because proper functioning of the monitors to prevent electrical shock was not monitored and assured. The failed practice had the potential to affect all surgical patients and patients receiving treatment in the Acute Treatment room in the Emergency Department. The facility performed an average of 90 surgical procedures per month. See CMS 2567, K130.

Based on review of the Monthly Medication Storage Inspection Logs, review of facility policy and interview, it was determined the facility failed to inspect medication areas on a monthly basis for 2 (05/12 and 09/12) of 12 (02/12 through 01/13) months. By not inspecting the medication storage areas monthly, the facility could not assure that all floor stocks were controlled. The failed practice had the potential to affect all patients that received medications form the medication areas. Findings follow:

A. Review of the Monthly Medication Inspection Logs from 02/12 through 01/13 revealed monthly inspections were not performed in 05/12 and 09/12.
B. Review of the pharmacy policy titled "Drug Procurement/Inventory Control/ Expirations" revealed "Inspection-All drug areas within the hospital will be inspected monthly by the pharmacy. A report of the inspection will be maintained by the Pharmacy Department."
C. The findings were verified, through interview, with the Director of Pharmacy on 02/26/13 at 1335.

Based on observation and interview, it was determined the facility failed to ensure the floor stock of drugs was properly controlled in that they were unlocked in one (Surgery) of three (Surgery, Emergency Department, Patient Care Unit) areas observed. The failed practice did not ensure access was limited to licensed personnel and could not assure the integrity of the products for patient use. The failed practice had the potential to affect all patients who received the floor stocks. Findings follow:

A. During a tour on 02/25/13 between 1330 and 1530, observation of unlocked floor stock drugs in Surgery revealed:
1) Surgery Operating Room #1 had #1 Lidocaine 100 ml (milliliter) for oral use.
2) Surgery Operating Room #2
a) Three Xylocaine 30 ml SDV (Single Dose Vial) 1% for injection;
b) Three Lidocaine 30 ml SDV 1% for injection;
c) Fifteen Betadine 5% Ophthalmic Prep Solution 30 ml; and
d) One Sevoflurane 250 ml liquid for inhalation.
3) Sterile Core
a) Fifteen Sterile Water 500 ml for irrigation;
b) Fifteen 0.9% Sodium Chloride for irrigation; and
c) Eight Sodium Chloride 1000 ml bags for injection.
B. Findings were verified through interview on 02/25/13 at 1440 with Surgical Services Director.

Based on policy and procedure review and interview, it was determined the facility failed to have in place a mechanism to check the airflow for negative pressure rooms monthly when unoccupied to prevent and control the outbreak of communicable diseases per Centers for Disease Control (CDC) recommendations. The failed practice did not allow the facility to be knowledgeable and assure the negative pressure rooms where working correctly prior to patients being placed in the room. The failed practice affected had the potential to affect all patients, visitors and staff in the facility on 02/25/13. Findings follow:

A. Review of the policy and procedure titled Infection Control Air Flow Checks, #2, revealed air flow checks would be performed in January and June. Review of the policy and procedure revealed it did not include the CDC's recommendation of monthly checks for unoccupied rooms.
B. During an interview with the Respiratory Therapy Director/Infection Control Nurse at 1345 on 02/26/13, she stated the check of the negative air pressure room while occupied had begun in February of 2013 but none had been, or were being, performed for unoccupied rooms.
C. Review of CDC guidelines, Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 volume 54/RR-17, page 66 states AII (airborne infection isolation room) ...If the AII rooms are not being used for patients who have suspected or confirmed TB (Tuberculosis) diseases but potentially could be used for such patients, the negative pressure should be checked monthly ..."

Based on review of Medical Staff Meeting Minutes and interview, it was determined the facility failed to ensure the online diet manual was approved by the medical staff from February 2012 through February 2013. The failed practice did not allow the Medical Staff to ensure the diet manual was updated and reflected current practices. The failed practice had the potential to affect all patients in the facility. Findings follow.

A. Review of the Medical Staff Meeting Minutes for February 2012 through February 2013 revealed no evidence the diet manual had been approved.
B. Findings were confirmed by the Administrative Director on 02/27/13 at 1230.

Based on clinical record review and interview, it was determined the facility failed to ensure operative reports included the time of surgery and the date and time the report was signed by the physician for 13 of 13 (Patient #3-#13 and #29) operative reports; failed to ensure 4 (#4-#6, #11) of 13 operative reports contained the name of the physician performing the surgery (Patient #3 had two surgeries). The failed practice did not allow knowledge of which surgery happened first in the event of multiple surgeries in one day, did not indicate if the physician signed the operative report within 72 hours per hospital policy and did not allow knowledge of who performed the surgical procedure. The failed practices created the potential to affect any patient receiving an operation in the facility. Findings follow.

A. Review of policy titled "Documentation Elements & Analysis Requirements" stated that operative reports "includes date and time of procedure ...the name of the surgeons and any assistants ...and shall be signed within 72 hours."
B. Review of the operative reports revealed the following:
1) Time of the surgery was not documented for Patient #3-#13, and #29.
2) Date and time of the physician's signature Patient #3-#13, and #29.
3) The name of the physician performing the surgery was not documented for Patient #4-#6, #11.
C. Findings for Patient #3 were confirmed by the Health Information Management Director on 02/28/13 at 1000. Findings for all other patients were confirmed by the Health Information Management Director on 02/28/13 at 0900.

Based on clinical record review and interview, it was determined the facility failed to obtain consent for treatment for 5 (#1, #3, #13, #26 and #28) of 31 (#1-31) patients. Failure to obtain a signed consent for care did not afford the patient or their representative the opportunity to make informed decisions regarding his or her care. The failed practice affected Patient #1, #3, #13, #26 and #28 on 02/25/13. Findings follow:

A. Review of clinical records revealed Patient #1, #3, #13, #26 and #28 did not have a consent for treatment.
B. Review of the Health Information Management Department Policy Documentation Elements and Analysis Requirements, Section 3.B, stated "General Consent for Medical Treatment and Care- This shall be signed by the patient or guardian. Written or verbal consent shall not release the hospital or its personnel from upholding the rights of its patients including but not limited to the right to privacy, security, confidentiality, and freedom from abuse or neglect."
C. The above findings were verified by the Patient Financial Service Director at 1015 on 02/28/13.