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Based on interview and record review, the facility failed to ensure that the agency (Specialty Nurses, INC) providing supplemental staff was registered with the Minnesota Department of Health (MDH) Directory of Registered Supplemental Nursing Services Agencies (SNSA) and failed to develop an individual abuse prevention plan for each vulnerable adult in accordance with State law for 4 of 20 inpatient (P2, P3, P5, P6) records reviewed. Findings include:
The CAH obtained supplemental registered nursing staff from Specialty Nurses, INC on 6/22/2010 and 6/25/2010. Review of the MDH list of registered SNSAs indicated that Specialty Nurses, Inc, was not on the list.
The CAH Administrator, interviewed at 4:20 p.m. on 6/30/2010, verified Specialty Nurses, INC was not on the list of registered SNSAs.


12828

Vulnerable adult assessment screenings were not completed on all patients admitted to the CAH.

P2 was admitted to the CAH on 6/20/10. The record lacked completion of the vulnerable adult assessment areas on the Nursing Data Base/Care Plan dated 6/20/10, and on the Emergency Nursing Record dated 6/20/10.

P3 was admitted to the CAH on 6/26/10. The record lacked completion of the vulnerable adult assessment areas on the Nursing Data Base/Care Plan dated 6/26/10, and on the Emergency Nursing Record dated 6/264/10.

P5 was admitted to the CAH on 4/17/10. The record lacked completion of the vulnerable adult assessment areas on the Nursing Data Base/Care Plan dated 4/17/10, and on the Emergency Nursing Record dated 4/17/10.

P6 was admitted to the CAH on 2/11/10. The record lacked completion of the vulnerable adult assessment areas on the Nursing Data Base/Care Plan dated 2/11/10, and on the Emergency Nursing Record dated 2/11/10 and the undated Discharge Planning form.

On 6/28/10, at 4:00 p.m. the licensed social worker stated VA assessments used to be completed on the Discharge Planning form prior to a few months ago when the form had been revised. She stated everyone admitted to the CAH would be "somewhat vulnerable."

On 6/28/10, at 4:05 p.m. RN-A, along with the RN-C (director of nursing, long term care) on 6/29/10, at 3:25 p.m. verified these findings.

Based on interview and record review the facility failed to ensure emergency fuel/gas supplies in case of a break in regular supply. Findings include:

The CAH's emergency policy dated June 2004, lacked a comprehensive plan for emergency supplies of fuel/gas. The Emergency Fuel Plan stated the maintenance supervisor, or designee, would "immediately contact the contracted fuel vendor and request immediately delivery. If the contracted fuel vendor is unable to respond to the request, the maintenance supervisor or designee will proceed to contact other fuel distributors in this order: (a) fuel distributors located in Cook County; (b) fuel distributors in Lake County; (c) fuel distributors in Duluth." The CAH does not have an agreement or contract for an emergency fuel oil or propane supply in case of an emergency. The policy did not include the type of fuel or approximated amounts fuel/gas required at any given time.

Interview with the maintenance director at 4 p.m. on 6/30/2010, indicated there was no emergency fuel supply or back up plan to obtain sufficient quantities of fuel oil for the boiler or propane for cooking and laundry.

Based on observation, interview and record review the facility did not ensure that pharmacy security was maintained; that pharmacy staff were available at all times for emergency services; and to ensure that the cardiac rehab emergency crash cart and the emergency labor and delivery room crash cart was locked when not in view of the person needing access. Findings include:

At 4:25 p.m. on 6/28/10 the pharmacist and the surveyor were meeting in the pharmacy when a pharmacy technician came in the locked door from the hall way. She had her own badge key and let her self into the pharmacy. Interview with the pharmacist at that time indicated the pharmacy technician had not worked in the hospital for over a year. She confirmed that the pharmacy technician should not have a key to the hospital pharmacy. The policy and procedure, Pharmacy, Emergency Access, dated 12/19/2006, indicated that only a pharmacist may have access to the pharmacy except in emergency situations when limited amounts of medication may be withdrawn by a designated hospital registered nurse.

The pharmacy on call calendar indicated that no pharmacist works on Sundays and that there is not an identified pharmacist on call. The Pharmacy Emergency Access policy addressed what charge nurses how emergency medication orders would be filled and how to obtain a supply and set up newly ordered medications when a pharmacist is not available. The policy does not specify emergency pharmacist services 24/7.

The Agreement for Pharmaceutical Services dated March 2010, indicated the "pharmacist shall provide on-site pharmacy services for the hospital five days per week, Monday through Friday,..." The agreement did not indicate that pharmacists would be available 24/7 for emergency services. Interview with the Director of Pharmacy, at approximately 4:30 p.m. on 6/30/2010, stated hospital staff can call her at any time; however, there is no assigned "on call" pharmacist 24/7.

During the environmental tour at 8:30 a.m. on 7/1/2010, there were two pre-teen children in the cardiac rehab area. An adult was talking to some one behind a partition in a connected room. The maintenance director indicated the cardiac rehab space was shared with another service. The space was observed for approximately 5 minutes and no cardiac rehab staff entered the room. The crash cart was observed and the medication drawer was not locked. The maintenance director confirmed the medication drawer was not locked. The drawer contained the following medications:

1. Epinephrine 1:10,000 1 mg /ml (3 ampules) (adrenaline)
2. Atropine mg /10 ml (2 ampules) (antiarrhythmic)
3. Lidocaine 2% 20 mg/ml (antiarrhythmic)
4. Dextrose 25 g/50 ml (caloric supplement)
5. Furosemide 10 mg/ml (diuretic)
6. Nitroglycerine 0.4 mg tabs (antianginal)

Interview with the administrator at 9:30 a.m. on 7/1/2010, indicated the cardiac rehab crash cart should be locked when no one was attending it.


12828

During the tour of the emergency labor and delivery room and nursery on 6/29/10, at 10:45 a.m. unsecured medications were observed in an unlocked medication drawer of the red crash cart in the room. The room (room 6) had a door entrance from the nursing station and an unlocked doorway to the hallway of patient rooms and was unable to be visually monitored from the nursing station.

Medications in the unlocked and unsecured medication drawer included: Pitocin (3), epinephrine (2), Narcan (2), and sodium bicarb (2) ampules for injection.

On 6/29/10, at 10: 50 a.m. RN-A verified these findings. At this same time, RN-B stated the drawer should have been locked.


18617

During observation of the outpatient physical therapy clinic on 6/29/10 at 2:25 p.m. it was noted that the medication dexamethasone sodium 4mg/ml multi-use vial (expiration date September 2009) was stored in the locked filing cabinet Physical Therapist (PT)- A was interviewed at that time and stated that he had not used the medication in over a year, and would check for drug expiration prior to it's use. PT-A stated that he would return the unused portion of the expired medication to the pharmacy.

Based on interview, and policy review, the facility failed to ensure policy's that identified how the critical access hospital (CAH) were going to assess, identify, and complete surveillance of infection's; and failed to ensure the facility had ongoing monitoring and surveillance in the absence of the infections control officer. In addition, the CAH failed to maintain an adequate system to identify and implement appropriate interventions to prevent the spread of infection for 1 of 1 patient (P3) who received blood glucose testing by the use of a glucometer. The findings include:

Review of the Infection Control Manual, policies and procedures on 6/30/10, at 4:00 p.m. revealed that the infection control policy and procedures manual did not have a policy or procedure that identified how the facility was going to assess and identify infections, and how the facility was going to complete facility surveillance and monitoring of infections. Additionally the infection control logs for patient infections and employee illness were not available for review, in the absence of the director of nursing (DON) (who served as the infection control officer), and a facility staff person had not been delegated to continue infection control surveillance and monitoring during the director of nursings two week absence.

The DON was interviewed via telephone on 7/6/10, at 4:05 p.m. during which she confirmed that the facility had not established infection control policy's that identified how assessment, identification, and surveillance of infections were to be completed, and she had not delegated the duties of the infection control officer to another facility employee during her scheduled absence.


18617

The CAH failed to ensure adequate disinfection of glucometers used for multiple patients.

On 6/29/10, at 10:4:0 a.m. RN-A was observed to complete a blood glucose test with a glucometer for P3. Following this, RN-A was observed to take the glucometer out of the patient's room and return it to the base on a counter behind the nursing station. RN-A was not observed to cleanse the glucometer.

At this time, RN-A stated the glucometer was used for all the inpatients in the CAH. She verified no cleaning had been done and stated the glucometer would be cleaned when dirty or soiled. At 10:55 a.m. RN-A stated she was unable to obtain any policy related to cleaning or disinfecting of the glucometer. The nursing policy and procedure book's table of contents had a note written in: "Policy to consider creating" and identified "Blood glucose/bedside testing (finger sticks)."

On 6/29/10, at 3:20 p.m. RN-C stated she had found a policy on the electronic system and produced the policy "Equipment Sanitizing" dated 9/2008, that directed, "All equipment that comes in direct contact with patient must be wiped after each patient use with Sani-cloths. These items include......glucose monitor..."








12828

Based on observation, interview, and record review, the facility failed to ensure the ultrasound equipment used by the outpatient physical therapy clinic was given appropriate preventative maintenance, and failed to ensure that the supervision of out patient services was delegated in writing to one person. The findings include:

During observation of the outpatient physical therapy clinic in Grand Portage on 6/29/10, at 2:25 p.m. it was noted that the clinic used an ultrasound machine as a physical therapy treatment modality.

During interview with Physical Therapist (PT) A on 6/29/10, at 2:25 p.m. he stated that he was not sure when the ultra sound equipment had been provided preventative maintenance or calibrated.

Review of the ultrasound (Intellect Legend Series) user manual identified: "To fully maintain compliance with Federal Regulation Title 21 (21CFR), this unit must be recalibrated annually...The following should be checked at least monthly to ensure proper operation of this unit: 1. Power cord and plug...2. Sound head cable...3. Sound head face...4. Lead Wires."

The Physical Therapy Director was interviewed on 6/30/10, at 10:40 a.m. during which she confirmed that the ultrasound equipment used in the outpatient physical therapy clinic in Grand Portage was not provided preventative maintenance or calibration according to the manufacturer's recommendations.

The supervision of the critical access hospital outpatient services was not delegated in writing to one person.

The facility's out patient's department's included Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Radiology and Laboratory. Each department had a director responsible for the department, however, there was no indication that one person was responsible for all of the outpatient direct services. Review of the organizational chart revealed that the CAH's outpatient services were not delineated to one person's supervision.

The administrator was interviewed on 6/30/10, at 12:35 p.m. and confirmed the facility did not have documented identification of a person in charge of outpatient services, and did not have a written description that identified the coordination of outpatient services.

Based on staff interview and record review the CAH failed to ensure that emergency room treatment consent forms were signed by the patient or legal guardian for 2 of 6 (P9, P10) patients for whom emergency room records were reviewed. Findings include:

P9 was provided medical assessment and treatment in the emergency room on 6/25/2010; however, the emergency room record did not indicate that P9 or a guardian consented to general care and treatment, or had been notified of his/her privacy rights.

P10 was provided medical assessment and treatment in the emergency room on 4/16/2010. P10's emergency room record did include documentation regarding notification of his/her privacy rights or consent for general care and treatment was obtained from the patient or guardian.

Registered Nurse (RN)-B, interviewed at 10:05 a.m. on 6/29/2010, confirmed that P9 and P10 had not signed an emergency room consent for general care and treatment or verification regarding notification of privacy rights.

Based on record review, policy review, and interview, the CAH (Critical Access Hospital) failed to ensure all entries made in the medical record were timed, dated, and authenticated for 4 of 20 inpatients reviewed receiving services at the CAH. Findings include:

The following inpatient records were reviewed and had incomplete entries.

P4 was admitted to the CAH on 1/2/10. The physician order dated 1/13/10, lacked a signature. The verbal orders dated 1/4/10, and 1/6/10, lacked times and dates
of the physician signature.

P6 was admitted to the CAH on 2/11/10. The telephone orders dated 2/11/10, and 2/12/10, and 2/16/10, lacked times and dates of the physician signature.

P7 was admitted to the CAH on 3/15/10. The telephone order dated 3/16/10, lacked a time and date of the physician signature.

P8 was admitted to the CAH on 6/23/10, for observation. The 6/23/10 order by the physician lacked the time of the order.


12831

Based on observation, interview and record review, the CAH failed to maintain the confidentiality of record information and provide safeguards against loss, destruction, or unauthorized use in the radiology department. The findings include:

The CAH's radiology medical records were accessible to unauthorized personnel.

During the tour of the radiology department on 6/28/10, at 4:15-4:30 p.m., multiple shelves of radiology films were observed to be stored off to the side in the hallway entrance into the radiology department from the doorway of the attached clinic waiting area. Multiple shelves were also observed to hold patient EKG (electrocardiogram) reports that were located directed across from a second entrance into the department. This unlocked door was observed to open directly into a main hallway of the CAH.

During interview at this time, the radiology director stated the door was locked between 7:00 p.m. and 7:00 a.m. She also stated all the staff leave the department at 6:00 p.m. and verified the patient records would be accessible to unauthorized staff.




12831

Based on interview and review of quality assurance (QA) plans/programs the CAH failed to ensure, Pharmacy, Physical Environment, Ambulance and organ procurement services had QA plans to improve their services. Findings include:

The QA committee meeting minutes from 11/19/2008 through 6/16/2010 indicated that not all areas of the CAH had QA improvements plans. Although data collection and ongoing monitoring was noted in the minutes, there was no evidence that each area of the CAH had an identified problem with action plans to improve patient services.

The minutes indicated no pharmacy QA activity. The QA meeting minutes dated 4/21/2010, indicated a new medication administration record was initiated; however, there was no plan for problem prevention or data analysis to determine effectiveness. Review of the medication errors forms from January 2010 through June 2010 indicated no pharmacy reviews of medication errors. The pharmacy director, interviewed at 3:30 p.m. on 6/28/2010, stated the only QA provided was monitoring medication errors made by the pharmacist. She indicated she does not have a QA plan to decrease medications errors or to improve the pharmacy service. The QA coordinator, interviewed at 3:30 p.m. on 6/29/2010, stated it was the responsibility of each CAH department to develop a QA plan and there was none from pharmacy services.

Review of the QA minutes from 11/19/2008 through 6/16/2010 indicated the maintenance department had no identified QA activity. The maintenance director, interviewed at 4:15 p.m. on 6/30/2010, stated there was no maintenance QA plan. The QA coordinator, interviewed at approximately 3:40 p.m. on 6/29/2010, stated there was no maintenance QA activity in the past year.


18617

Review of the Quality Assurance (QA) minutes from 11/19/08 through 6/16/10 indicated the ambulance service had not been working on any QA projects since December 2009 when the goal had been met for the only QA project they had been working on. The director of the ambulance service was interviewed on 6/30/10, at 11:00 a.m. during which he confirmed that the ambulance service was not currently working on any QA projects.

Review of the Quality Assurance (QA) minutes from 11/19/08 through 6/16/10 revealed that the service of organ procurement had not been included in any QA projects. The Director of Nursing was interviewed on 7/6/10, at 4:05 p.m. during which she confirmed that the organ procurement organization had not been included in any QA activities.

Based on interview, and record review the critical access hospital failed to ensure that the facility staff had completed an approved educational course to become designated requestors for the organ procurement organization. The findings include:

During the survey from 6/28/10 through 7/1/10, documentation of staff education related to being a designated requestor for organ and tissue donation by the organ and tissue organization was requested. The CAH did not provide evidence that the facility staff had completed an approved course related to organ and tissue donation.

The Director of Nursing, interviewed on 7/6/10 at 4:05 p.m., stated that the facility staff completed some computer learning and completed a test related to organ and tissue donation; however, she did not provide any written evidence that identified which staff had been trained and when the staff were trained.



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