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The Critical Access Hospital (CAH) reported two acute care patients and one swing bed patient. Based on observation, document review and staff interview, the CAH failed to ensure outdated, mislabeled and unusable drug are not available for patient use, failed to ensure medications are properly stored and failed to develop and implement a system to identify, report, investigate and control infections.

The cumulative effect of the systematic failure to ensure the CAH provides patient with drugs which are not outdated, mislabeled and unusable and to ensure medications are stored according to the CAH's policies resulted in the CAH's inability to provide quality care in a safe and effective manner.


Findings include:

- The CAH failed to ensure outdated, mislabeled, and unusable drugs are not available for patient use for one of one anesthesia cart and failed to assure unauthorized staff do not have access to one of one medication storage cabinet. See evidence at C-276, 42 CFR 485.635(a)(3)(iv).

- The infection control officer failed develop and implement a system to identify, report, investigate and control infections. See evidence at C-278, 42 CFR 485.635(a)(3)(iv).

- The CAH's policy titled "Pharmacy Maintenance", reviewed on 10/11/12 at 11:30am, revealed "Procedure, Responsible Person, 2. Stock all pharmaceuticals into the tower unless there is overflow. All overflow items are to be kept in the designated locked cabinet in the pharmacy".

- The materials management supply storeroom, observed on 10/11/12 at 8:10am, revealed two wooden cabinets with a lock. Staff E, the storeroom manager, who is not a nurse, opened the lock and cabinets. The cabinets contained:
1. Levofloxacin (an antibiotic) 500mg (milligrams)/100ml (milliliters) solution (IV)- ten 100ml bags
2. Levofloxacin 250mg/100ml, twelve 50ml bags
3. Nitroglycerin (opens blood vessels) 200 mcg (micrograms)/ml- six 500ml bottles
4. Nitroglycerin 200mcg/ml- six 250ml bottles
5. Magnesium sulfate (used to treat life-threatening convulsions) 500mg- ten 500ml bags
6. Metronid (an antibacterial)500mg/100ml- 20 bags
7. Cefazolin (an antibacterial) 1gm (gram)/50ml- 20 bags
8. Ceftriaxone (an antibacterial) 1gm/50ml- 10 bags
9. Calcium Chloride (a electrolyte) 10% solution, 100mg/ml- 30 bottles
10. Lidocaine (an anesthetic) jelly 200mg/10ml- 1/4 case
11. Zyvox (an antibacterial) 600mg/300ml, 1/2 case
12. Ciprofloxacin (an antibiotic) 400mg/200ml- 3 bags
13. Potassium Chloride (used to treat electrolyte imbalance) 20meq (milli-equivalents)- 275 30ml bottles
14. Potassium Chloride, 20meq/1000ml- five bags.

The CAH's policy titled "Key Policy", reviewed on 10/11/12 at 11:30am, failed to identify the Materials Manager as a person allowed to have access to the medications.

- Staff E's personnel file, reviewed on 10/15/12 at 10:30am, lacked evidence of licensure as a nurse.

- Administrative staff B and C, interviewed on 10/10/12 at 4:15pm, confirmed staff E is not a nurse and has a key to the locked medication storage cabinets in the materials storeroom.

- The CAH failed to implement their polcies to store, handle, dispense and administer drugs.







21996

The Critical Access Hospital (CAH) reported a census of two acute care patients and one observation patient. Based on observation, document review, and staff interview the CAH failed to ensure outdated, mislabeled, and unusable drugs are not available for patient use for one of one anesthesia cart and failed to ensure unauthorized staff do not have access to one of one medication storage cabinet.

Findings include:

- The CAH's policy titled, "Standard/Medication Administration" reviewed on 10/16/12 at 8:40am directed "...All multi-dose vials used for injection must be discarded after 30 days or in some cases 28 days, regardless of the expiration..."

- Nursing Inservice Agenda dated March 13th, 2012 at 5:00pm directed "...Reminder when you open a multi-dose vial, to label the vial with date opened. Vial is good for 28 days after opening."

- Observation on 10/10/12 at 2:45pm of the medication drawer in the anesthesia cart in the operating room revealed the following:
1. One partially used 10cc (cubic centimeter) vial of Rocuroneum (drug used for anesthesia) lacked a date when opened.
2. One partially used 10cc vial of Anectine (drug used for anesthesia) lacked a date when opened.
3. One partially used 10cc vial of Vecuronium (drug used for anesthesia) lacked a date when opened.
4. One partially used 10cc vial of Neostigmine (drug used for anesthesia) lacked a date when opened.
5. One partially used 10cc vial of Oxytocin (drug used for anesthesia) with an opened date on it of 8/7/12.
9. One partially used 30cc vial for single use sterile water with a label on it that read (NeoEphedrine). The vial lacked a dose, date, and time when they opened and mixed the medication .
10. One partially used 30cc vial for single use sterile water with a label on it that read (Ephedrine 1mg (milligram)/cc). The vial lacked a date and time when they opened and mixed the medication.
11. One partially used 30cc vial for single use sterile water with a label on it that read (Ephedrine). The vial lacked a dose, date, and time when opened and mixed the medications.

Staff L, Registered Nurse (RN), interviewed on 10/10/12 at 2:45pm acknowledged the open vials lacked a date when opened, anesthesia staff used single use vials of sterile water to mix medication for multiple patients and lacked a dose, date and time when mixed. Staff L confirmed the dated open vial of Oxytocin was past the 30 day discard date.

The Critical Access Hospital (CAH) reported a census of two acute care patients and one observation patient. Based on document review, observation, manufacturer's directions and staff interview, the infection control officer failed develop and implement a system for identifying, reporting, investigating and controlling infections for one of one cleaning of a discharged patient's room, one of one gait belt, one of one computer keyboard, four of five patient mattresses, two of two NuStep (a piece of equipment in Physical Therapy),
one of one Emergency Room (ER), four of four outpatient treatment rooms, one of one household washer and dryer and one ER, four outpatient rooms and one computed tomography (CT) scan rooms.

Findings include:

- The CAH's policy titled "Infection Prevention All Departments", reviewed on 10/11/12 at 11:45am, revealed departments directly involved in patient care "3.a. Practice good aseptic technique".

- The CAH's job description for the "Infection Control Person", reviewed on 10/11/12 at 11:45am, directs "1. The infection prevention nurse is to ensure general supervision of the Infection Prevention Program" and "17. The infection prevention nurse through direct observation...evaluates the general state of cleanliness in hospital, the skills used in practicing asepsis...and other matters relating to infection prevention".

- The manufacturer's instructions for the use of Re-Juv-Nal disinfectant, reviewed on 10/16/12 at 10:50am, directs "Allow to remain wet for 10 minutes..."

- Observation of nursing assistant staff N and nursing assistant staff O at 10/9/12 at 1:10pm revealed the cleaning of a discharged patient room. Staff N and O obtained a cloth, wet with Re-Juv-Nal disinfectant solution and wiped the patient's mattress. The surface remained wet for two minutes. Staff N re-wiped the mattress, which remained wet for two minutes. Staff N and O continued to wipe the surfaces in the room with the wet cloth with surfaces remaining wet for less than one minute. Staff N used the wet cloth to wipe the seat and rim of the toilet, the windowsill and toilet handle, with the surfaces remaining wet for less than one minute. Staff N did not disinfect a gait belt (a cotton cloth belt used to assist with patient transfer) placed on the counter. Staff N reported the surfaces are allowed to dry for 10 minutes.

Housekeeping staff P, entered the room at 1:40pm, and used a cloth with disinfectant solution to wipe the patient's chair. The surface remained wet for two minutes. Staff P obtained another cloth with disinfectant and wipe the sides of the trash can, the sink and counter and the gait belt. The surfaces remained wet for less than one minute. At 2:00pm, staff P sprayed the toilet and seat with disinfectant, and wiped the surfaces. The surfaces remained wet for less than one minute.

- Staff N, O and P failed to disinfect the computer keyboard, used by staff to document patient care at the bedside during the cleaning of the discharged patient's room.

- The nursing staff's daily cleaning schedule, reviewed on 10/11/12 at 8:00am, directs staff to "Clean computers in room (with) "Sani-Wipes" (a disinfectant wipe).

- The CAH's policy titled "Terminal Cleaning of a Patient/Resident Unit", reviewed on 10/11/12 at 8:00am, directs staff to clean "all horizontal and perpendular surfaces" with disinfectant.

The infection control nurse H, interviewed on 10/11/12 at 10:50am, acknowledged the computer keyboards are "waterproof" and should be disinfected during the cleaning of a discharged patient's room.

- The CAH's policy titled "Gait Belts", reviewed on 10/11/12 at 8:00am, directs staff that "Gait belts are single patient use, will be laundered between patients if used, and as needed if soiled".

- Patient mattresses, observed on 10/10/12 between 9:45am and 10:00am revealed the mattresses in room #2, #5 and the two beds in room #9 evidenced cracks and tears in the surface rendering the surface non-cleanable.

Housekeeping supervisor staff M, interviewed on 10/10/12 at 1:35pm, acknowledged cracks and tears in mattress surfaces renders the surface non-cleanable.

Infection control staff H, interviewed on 10/11/12 at 10:50am acknowledged the CAH failed to implement a plan to ensure staff use the chemical disinfectant as the manufacturer directs for disinfection of patient care surfaces.


21996

- The manufacturer's product information sheet reviewed on 10/16/12 at 5:00pm stated, "Neutra-Zyme...Enzyme Laundry Detergent..."

- The CAH's ploicy titled "USING AUTOMATIC WASHER IN HOSPITAL AND LTC" reviewed on 10/11/12 at 11:30am directed "Washer in hospital...will use enzyme laundry detergent. Surflex series neutra-zyme contains sodium tripolyphosphate...Nuetra-zyme will sterilize the tub of the washer..."

- Observation on 10/9/12 at 12:50pm of the soiled utility room on the patient unit revealed a household type washer and dryer. Staff S, Registered Nurse (RN) explained the facility uses the washer and dryer for the Obstetric (OB) breast feeding patient gowns using "Neutra-Zyme laundry detergent. Staff B, Administrative Staff, explained the CAH uses the washer and dryer to wash some clothes using the "Nuetra-Zyme" laundry detergent.

Staff S, RN, and Staff B, Administrative Staff, and Staff M, Maintenance Staff, interviewed on 10/9/12 at 1:15pm acknowledged they were not aware the product they used in the wash machine to wash the gowns and patient's clothes did not contain a disinfectant.

Staff M, Maintenance Staff, interviewed on 10/11/12 at 11:35am verified they received conformation from the manufacturer of the "Neura-Zyme" laundry detergent that it is an enzymatic detergent and does not contain a disinfectant.

- Observation on 10/9/12 at 1:45pm of exam rooms #1, and #2, revealed a Yankauer suction tip (a rigid hollow tube made of disposable plastic with a curve at the distal end used to remove thick secretions during oral pharyngeal suctioning) not in the packaging it comes in connected to the suction tubing. Observation on 10/9/12 at 1:50pm in exam rooms #3 and #4 revealed a Yankauer suction tip in the open packaging connected to the suction tubing. The Yankauer package label states, "sterile unless opened or damaged."

The ER, observed on 10/10/12 at 8:30am, revealed one opened Yankauer suction tip package opened and connected to the suction tubing. Registered Nurse I, acknowledged the opened suction tip.

The CT scan room, observed on 10/11/12 at 10:50am, revealed on opened Yankauer suction tip package opened and connected to the suction tubing.

- The CAH's "Annual CAH Service Assessment, Departmental Assessment", for the Infection Prevention Department, reviewed on 10/16/12 at 11:30am, revealed the CAH failed to identify surveillance of the physical environment, cleaning procedures, use of chemical for disinfection and patient care equipment as "Areas of Noncompliance".

- Infection control nurse H, interviewed on 10/15/12 at 10:50am acknowledged the lack of infection prevention activities and confirmed the CAH failed to perform surveillance of the physical environment, cleaning procedures, the use of chemicals for disinfection, and patient care equipment.

The Critical Access Hospital (CAH) reported a census of two acute care patients and one observation patient. Based on document review and staff interview the CAH failed to ensure physicians date and/or time all authenticated (signed) entries in the clinical record for 15 of 34 patient clinical records reviewed (patient #2, 7, 8, 11, 12, 19, 21, 22, 23, 24, 25, 26, 28, 29, and 30).

- The CAH's policy titled "Verbal Orders" reviewed on 10/16/12 at 8:40am directed, "The ordering practitioner or covering physician must date and time the order at the time he or she signs..." The CAH failed to include in their policy all entries in the clinical record must be timed and dated when authenticated.

- Patient #21's closed clinical record reviewed on 10/11/12 at 10:20am revealed an admission date of 9/14/12 for a scheduled Cesarean Section (C-Section). Patient #21's clinical record revealed between 9/14/12 to 9/17/12, five standing orders/protocols lacked a time when signed and dated by the physician and six verbal/telephone orders lacked a time when signed and dated by the physician.

- Patient #29's closed clinical record reviewed on 10/10/12 at 1:10pm revealed an admission date of 10/6/12 with Diarrhea, Congestive Heart Failure, and Renal Failure. Patient #21's clinical record revealed between 8/6/12 to 8/9/12, four verbal/telephone orders lacked a time when signed and dated by the physician.

- Patient #30's closed clinical record reviewed on 10/10/11 at 1:30pm revealed an admission date of 8/21/12 with diagnoses of Anemia (low blood count) and Left Hip Pain. Patient #30's clinical record revealed between 8/21/12 to 9/6/12, eleven verbal/telephone orders lacked a time when signed and dated by the physician.

Administrative Staff C, interviewed on 10/16/12 at 12:15pm acknowledged the clinical records lacked the date and/or time when the physician signs entries in the clinical record.

This deficient practice also affected patient #'s 2, 7, 8, 11, 12, 19, 22, 23, 24, 25, 26, and 28.

The Critical Access Hospital CAH) reported a census of two acute care patients and one observation patient. Based on document review and staff interview, the CAH failed to inform five of five swing bed patients of their right to participate in the planning of their care unless adjudged incompetent (patient #'s 11, 12, 13, 14 and 15).

Findings include:

- The CAH's document titled "Patient Rights", reviewed on 10/16/12 at 10:00am revealed the lack of information informing the patient of their right to work of refuse to work.

- Patient #11's clinical record, reviewed on 10/10/12 at 10:30am revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to participate in the planning of their care unless adjudged incompetent.

- Patient #12's clinical record, reviewed on 10/10/12 at 1:30pm revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to participate in the planning of their care unless adjudged incompetent.

- Patient #13's clinical record, reviewed on 10/10/12 at 1:55pm, revealed a swing bed admission date of 7/10/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to participate in the planning of their care unless adjudged incompetent.

- Administrative staff C, interviewed on 10/16/12 at 10:30am acknowledged the Patient Rights, document given to swing bed patients, failed to inform the patient of their right to participate in the planning of their care unless adjudged incompetent.

This deficient practice also affected patient #'s 14 and 15.

The Critical Access Hospital (CAH) reported a census of two acute care patients and one observation patients. Based on document review and staff interview, the CAH failed to ensure to inform five of five swing bed patients of their right to work or refuse to perform work (patient #'s 11, 12, 13, 14 and 15).

Findings include:

- The CAH's document titled "Patient Rights", reviewed on 10/16/12 at 10:00am revealed the lack of information informing the patient of their right to work or refuse to work.

- Patient #11's clinical record, reviewed on 10/10/12 at 10:30am revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to work or refuse to work.

- Patient #12's clinical record, reviewed on 10/10/12 at 1:30pm revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to work or refuse to work.

- Patient #13's clinical record, reviewed on 10/10/12 at 1:55pm, revealed a swing bed admission date of 7/10/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to work or refuse to work.

- Administrative staff C, interviewed on 10/16/12 at 10:30am acknowledged the Patient Rights, document given to swing bed patients, failed to inform the patient of their right to work or refuse to work.

The deficient practice also affected patient #'s 14 and 15.

The Critical Access Hospital (CAH) reported a census of two acute care and one observation patient. Based on document review and staff interview, the CAH failed to inform five of five swing bed patients of their right to send and promptly receive unopened mail and to have access to stationery, postage and writing implements (patient #'s 11, 12, 13, 14 and 15).

Findings include:

- The CAH's document titled "Patient Rights", reviewed on 10/16/12 at 10:00am revealed the lack of information informing the patient of their right to send and promptly receive unopened mail and to have access to stationery, postage and writing implements.

- Patient #11's clinical record, reviewed on 10/10/12 at 10:30am revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to send and promptly receive unopened mail and to have access to stationery, postage and writing implements .

- Patient #12's clinical record, reviewed on 10/10/12 at 1:30pm revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to send and promptly receive unopened mail and to have access to stationery, postage and writing implements

- Patient #13's clinical record, reviewed on 10/10/12 at 1:55pm, revealed a swing bed admission date of 7/10/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to send and promptly receive unopened mail and to have access to stationery, postage and writing implements.

- Administrative staff C, interviewed on 10/16/12 at 10:30am acknowledged the Patient Rights document given to swing bed patients, failed to inform the patient of their right to send and promptly receive unopened mail and to have access to stationery, postage and writing implements.

This deficient practice also affected patient #14 and 15.

The Critical Access Hospital (CAH) reported a census of two acute care patients and one observation patient. Based on document review and staff interview, the CAH failed to inform five of five swing bed patients of their right to retain and use personal possessions (patient #'s 11, 12, 13, 14 and 15).

Findings include:

- The CAH's document titled "Patient Rights", reviewed on 10/16/12 at 10:00am revealed the lack of information informing the patient of their right to retain and use personal possessions.

- Patient #11's clinical record, reviewed on 10/10/12 at 10:30am revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to retain and use personal possessions.


- Patient #12's clinical record, reviewed on 10/10/12 at 1:30pm revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to retain and use personal possessions.


- Patient #13's clinical record, reviewed on 10/10/12 at 1:55pm, revealed a swing bed admission date of 7/10/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to retain and use personal possessions.

- Administrative staff C, interviewed on 10/16/12 at 10:30am acknowledged the Patient Rights, document given to swing bed patients, failed to inform the patient of their right to retain and use personal possessions.

The deficient practice also affected patient #14 and 15.

The Critical Access Hospital (CAH) reported a census of two acute care patients and one observation patients. Based on document review and staff interview, the CAH failed to inform five of five swing bed patients of their right to share a room with their spouse (patient #'s 11, 12, 13, 14 and 15).

Findings include:

- The CAH's document titled "Patient Rights", reviewed on 10/16/12 at 10:00am revealed the lack of information informing the patient of their right to share a room with their spouse.

- Patient #11's clinical record, reviewed on 10/10/12 at 10:30am revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to share a room with their spouse.

- Patient #12's clinical record, reviewed on 10/10/12 at 1:30pm revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to share a room with their spouse.

- Patient #13's clinical record, reviewed on 10/10/12 at 1:55pm, revealed a swing bed admission date of 7/10/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to share a room with their spouse.

- Administrative staff C, interviewed on 10/16/12 at 10:30am acknowledged the Patient Rights, document given to swing bed patients, failed to inform the patient of their right to share a room with their spouse.

This deficient practice also affected patient #14 and 15.

The Critical Access Hospital (CAH) reported a census of two acute care and one observation patient. Based on document review and staff interview, the CAH failed to inform five of five swing bed patients of their right to be free of verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion (patient #'s 11, 12, 13, 14 and 15).

Findings include:

- The CAH's document titled "Patient Rights", reviewed on 10/16/12 at 10:00am revealed the lack of information informing the patient of their right to be free of verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.

- Patient #11's clinical record, reviewed on 10/10/12 at 10:30am revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to be free of verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.

- Patient #12's clinical record, reviewed on 10/10/12 at 1:30pm revealed a swing bed admission date of 7/27/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to be free of verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.

- Patient #13's clinical record, reviewed on 10/10/12 at 1:55pm, revealed a swing bed admission date of 7/10/12. The clinical record evidenced the patient received patient rights which lacked information regarding their right to be free of verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.

- Administrative staff C, interviewed on 10/16/12 at 10:30am acknowledged the Patient Rights document given to swing bed patients, failed to inform the patient of their right to to be free of verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion.

This deficient practice also affected patient #14 and 15.

The Critical Access Hospital (CAH) reported a census of two acute care patients and one observation patient. Based on document review and staff interview, the CAH failed to assure a qualified social worker provided medically related social services.

Findings include:

- Administrative staff C, interviewed on 10/11/12 at 8:30am, acknowledged the CAH failed to develop and implement policies and procedures assuring a qualified social worker provides medically related social services.

- Staff C, interviewed on 10/14/12 at 2:30pm, acknowledged the CAH failed to employ or contract with a qualified social worker for medically related social services.