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Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to ensure emergency equipment and supplies had been routinely checked for 2 of 2 crash carts (emergency department and medical/surgical unit) and failed to ensure 1 of 3 (emergency department) defibrillators (emergency device which provides a dose of electrical energy to the heart in life-threatening situations) had been checked daily to assure life-saving equipment/supplies were readily available and working properly.

Findings include:

On 4/23/14, at 10:30 a.m. during the initial medical/surgical (M/S) unit tour, the crash cart was observed stationed in an alcove of the M/S unit hallway. The crash cart was observed locked with a pad lock and the defibrillator was located on the top of the crash cart. The log book on top of the crash cart indicated the defibrillator had been checked daily, however the log lacked documentation of the inventory of the other emergency supplies kept in the crash cart. Registered nurse (RN)-B confirmed the CAH did not have a log to document the inventory of the M/S crash cart supplies because the supplies were supposed to be restocked after each use.

On 4/25/14, at 8:05 a.m. registered nurse (RN)-A verified the defibrillator on top of the M/S crash cart was checked daily and documented in the log book. However, RN-A confirmed staff did not check the inventory of the crash cart daily.

The CAH's EMERGENCY SUPPLIES & CRASH CHART CHECKS policy revised 7/08, directed staff to check the defibrillator daily and confirm the lock was secure and indicated the crash cart the cart was to be filled after each use.

On 4/25/14, at 9:20 a.m. the service line leader confirmed the CAH's policy did not direct staff to check the emergency supply / equipment inventory of the crash carts daily to ensure availability.

Based on observation, interview and document review the Critical Access Hospital (CAH) failed to ensure preventive maintenance (PM) was performed on essential medical equipment as required. This had the potential to affect all patients who received care from the CAH who's average daily inpatient census was seven.



Findings include:



During the environmental tour on 4/23/14, at 1:00 p.m. the following equipment was observed to not have had PM performed:


In the Intensive Care Unit (ICU) there were 2 heart monitors without PM file numbers, which would have listed the last time these monitors were tested. The bio-medical numbers for these 2 machines was listed as 206830 and 206855.


Two Stryker Beds (beds with electrical apparatus which allowed them to be elevated or lowered) in the ICU without any PM's file numbers which would indicate if or when these beds were checked for safety.


One Natus brand fetal monitor did not have a PM file number to indicate if any preventative maintenance had been performed.


An Intravenous Pump (IV) with the bio-medical number 206919 and a PM file number which indicated the pump was to be re-checked 9/2013, and was not.


One treadmill in the cardiac rehabilitation department which did not have any evidence of a PM file number to indicate preventative maintenance had been performed.


An Automated External Defibrillator (AED) in the emergency room did not have a PM file number to indicate it was checked for proper functioning.


On 4/25/14, at 1:25 p.m. the director of maintenance verified PM on the identified essential equipment was not performed and missed during the transition from on biomedical company to another. He further stated he was unaware that some of this equipment had never been tested.


The CAH's policy titled "Medical Equipment Management Plan," revised on 3/03, indicated "First Care Medical Services (legal name for CAH) requires the accurate inventory, scheduled maintenance, repair and tracking of all medical equipment operated and located in it's facilities."

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to assure the required "time out" process was followed according to facility policy during 2 of 2 surgical procedures observed.

Findings include:

On 4/23/14, at 7:15 a.m. registered nurse (RN)-E was observed to transport patient (P22) into operating room #1. At 7:18 a.m. certified registered nurse anesthetist (CRNA)-A administered P22's spinal anesthetic. At 7:25 a.m. P22 was prepped and positioned for the procedure. At 7:30 a.m. RN-E initiated a "time out." RN-E was heard to state P22's name, date of birth, procedure to be completed and P22's allergies. CRNA-A repeated P22's name, date of birth, procedure to be completed and P22's allergies. Physician assistant (PA)-A stated "I agree." Surgical technician (ST)-B stated "I agree." ST-C nor surgeon (S)-A were heard to complete the "time out" process. Also, the surgical service manager RN-D, was present in the operating room at this time, but did not participate in the "time out" process, however, RN-D did exit the operating room prior to the start of the procedure. At 7:31 a.m. S-A was observed to begin the surgical procedure.

On 4/23/14, at 7:35 a.m. RN-E confirmed the time out process was done correctly by herself and the CRNA. RN-E verified PA-A and ST-B had stated "I agree" and confirmed ST-C nor S-A completed the "time out" process as required. RN-E stated "It's sometimes hard to hear when they have the hoods on."

On review of P22's Pre-Operative Verification form, listed under the Operating Room-Just Prior to Incision section of the form, RN-E left blank the portion of the checklist which indicated the surgeon had initiated the time-out verbally and that the surgeon had verbally verified the procedure including the side/site of the procedure.

On 4/23/14, at 1:03 p.m. P23 was observed to be transported into operating room #1. CRNA-A placed the heart-monitor and assisted in positioning P23 for the procedure. At 1:08 surgeon (S)-B informed the surgical team they were ready for "time out." RN-E initiated the "time out" and stated P23's name, date of birth, procedure being performed and that P23 had no allergies. RN-F repeated P23's name, date of birth, procedure being performed and that P23 had no allergies. S-B stated "that's right." CRNA-A and ST-B did not participate in the "time out" process. At 1:10 a.m. S-B was observed to begin the procedure.

On review of P23's Pre-Operative Verification form, under the Operating Room-Just Prior to Incision section of the form, RN-E initialed that the surgeon had initiated the time-out verbally, left blank that all other activity had ceased during the time out process and had drawn a line through the rest of the checklist.

Taped to the wall in operating room #1 was a poster titled Time Out - Preventing wrong site, wrong procedure, and wrong person surgery (Universal Protocol). This poster directed the physician to start the "time out" pocess and for other team members to participate by verbalizing agreement of the procedure to include the correct patient, correct side/site and correct procedure.

On 4/24/14, at 3:15 p.m. surgical service manager RN-D confirmed the "time out" posters should be followed and the "time out" process should be initiated by the physician and all team members, including the physician should participate by stating the patients name, date of birth, the procedure being performed, patient's allergies and if appropriate verification that the pre-operative antibiotic had been given. RN-D revealed he was aware that the "time out" process was not always being followed and the staff needed to continue to work on this.

On 4/25/14, at 9:15 a.m. service line leader RN-G verified the "Protocol for Surgical Procedures" was the facility's current policy which directed staff on the time out process and that a step in the process should not be missed.

The CAH's Protocol for Surgical Procedures policy review date 4/2009, directed staff to conduct a time out prior to the start of a procedure. The policy directed all staff to verbally participate in the verification process which should include identifying the patient, the procedure being performed, the correct patient position, correct procedure site or side and necessary imaging, equipment, implants or special requirements.