HospitalInspections.org

Based on document review and administrative staff interview the CAH (Critical Access Hospital) failed to have the Blood Bank Agreement approved by the medical staff. The CAH administrative staff identified 108 units of blood were used in 2015.

Failure of the Blood Bank Agreement approved by the medical staff could potentially result in a lack of provider input for changes in the agreement.

Findings include:

1. Review of the document titled Blood Product Supply Agreement signed 7/13/13 by Provider H, pathologist revealed a lack of approval by the CAH medical staff.

2. During an interview on 8/8/16 at 11:45 AM, with Staff G, CEO (Chief Executive Officer) revealed the Blood Bank Agreement was approved by the pathologist. Medical Staff failed to approve the agreement and the medical staff meeting minutes revealed that lack of approval.

Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) failed to ensure outdated patient supplies are removed from 1 of 1 inpatient areas (Nursing) and 1 of 5 applicable outpatient areas (Emergency Room) of the CAH so expired supplies are unavailable for use in patient care. The CAH staff reported a current census of 12 patients at the beginning of the survey and an average of 325 emergency room patient visits per month.

Failure to remove outdated patient supplies from the CAH's supplies located in patient care areas following the date a manufacturer determined the supplies are no longer considered appropriate for patient care use.

Findings include:

1. Observations during tour of the inpatient nursing unit on 8/1/16 at 4:10 p.m., with Staff C, Nurse Manager, revealed the following expired patient care items in the Medical/Surgical Supply Room:

- 6 of 56 Hemocult cards with expiration dates of 7/31/2016
- 1 of 2, 32 ounce bottles of Hibiclens with an expiration date of 12/2015
- 1 of 2, 32 ounce bottles Hibiclens with an expiration date of 5/2016
- 1 of 4, 16 ounce bottles Hydrogen Peroxide with an expiration date of 7/2016
- 12 of 12, 8 ounce IsoSource 1.2 calorie Tube Feeding formula with an expiration date of April 7, 2016

Observations during tour of the emergency room area on 8/3/16 from 9:00 a.m. to 10:45 a.m., with Staff B, Emergency Room Nurse Manager, revealed the following expired patient care items in the Emergency Room area:

a. Trauma Room 1:
Broselow Cart - 1 of 1 Purple Pediatric Emergency System - Oxygen Delivery Module with expiration date 4/2016

Cupboard:
- Broselow Purple Pediatric Emergency System - IV Delivery Module with expiration date 12/2015
- 1 of 2 Shiley Trach Tube Cuffed with disposable inner cannula with expiration date 5/2016
- 1 of 1 Red Pediatric Emergency System - IV Delivery Module with expiration date 12/2015
- 1 of 1 Orange Pediatric Emergency System - IV Delivery Module with expiration date 3/2016
- 1 of 2 Iodoform Packing Strip 1" x 15' with expiration date 7/2016

Exam Tray:
- 1 of 1 Para Pak EcoFix for ova and parasite stool specimens with expiration date 6/2016
- 3 of 3 BD Insyte Autoguard 14 gauge with expiration date 1/2016

b. Trauma Room 2:
- 1 of 2 Curity Iodoform Packing Strip 1" x 15' with expiration date 7/2016
- 1 of 3 Para Pak C & S Stool Transport Solution for Enteric Pathogens with expiration date 6/2016
-1 of 5 BD Insyte Autoguard 16 gauge with expiration date 6/2016
-1 of 5 BD Insyte Autoguard 16 gauge with expiration date 3/2016

c. Exam Room 4:
- 1 of 1 Scrub Care Chlorhexidine Gluconate Solution 4% Surgical Hand Scrub with expiration date 5/2016
- 2 of 2 Chloraprep One Step 3 ml applicator with expiration date 7/2016
- 1 of 2 Red top vacutainer with expiration date 3/2016
- 1 of 1 Pink top vacutainer with expiration date 10/2015
- 1 of 2 Green top vacutainer with expiration date 5/2016
- 1 of 2 Green top vacutainer with expiration date 10/2015
- 1 of 1 25 gauge spinal needle with expiration date 7/2016

2. Review of CAH policies/procedures revealed the lack of a policy/procedure that addressed outdated patient care supplies.

3. During an interview on 8/1/16 at 4:25 p.m., Staff C, Nurse Manager, verified the outdated patient care supplies in the Medical/Surgical Supply Room. Staff C acknowledged the outdated patient care supplies were available for patient care use. Staff C stated purchasing department staff are responsible for checking and removing outdated patient care supplies in the Medical/Surgical Supply Room.

During an interview on 8/3/16 at 10:45 a.m., Staff B, Emergency Room Nursing Manager verified the outdated patient care supplies in the Emergency Room area. Staff B acknowledged the outdated patient care supplies were available for patient care use. Staff B stated purchasing department staff were responsible for checking and removing outdated patient care supplies in the Emergency Room area.

During an interview on 8/4/16 at 8:10 a.m., Staff D, Manager Materials Management, acknowledge the purchasing staff were responsible for checking and removing outdated patient care supplies in the Medical/Surgical Supply Room and the Emergency Room area. Staff D stated the CAH failed to have a policy/procedure related to checking for and removing outdated patient care supplies.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the physician periodically reviewed 2 of 2 mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner. (Staff I and J)

The CAH staff reported the volume of services provided by mid-level Staff I of 296 patient visits from January 1 to July 31, 2016.

The CAH staff reported the volume of services provided by mid-level Staff J of 359 patient visits from January 1 to July 31, 2016.

Failure to ensure a physician periodically reviewed 2 of 2 mid-level practitioner's patient medical records in conjunction with the mid-level practitioner could potentially result in misdiagnosing patient and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policies/procedures revealed the lack of a requirement to ensure the physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

2. Review of documentation revealed the lack of documentation of physician review of the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

3. During an interview on 8/9/16 at 10:20 a.m., Staff A, Registered Nurse (RN), of Performance Improvement/Utilization Review and Risk, acknowledged the lack of a policy to ensure a physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioners. Staff A stated a physician reviews mid-level practitioner's patient medical records, fills out a form that goes to quality and the Emergency Room (ER) Nurse Manager, and then the ER Nurse Manager reviews the physician review of records with the mid-level practitioner.

During an interview on 8/9/16 at 1:50 p.m., Staff B, RN ER Nurse Manager, stated a physician reviews mid-level practitioner's patient medical records, fills out a form that goes to quality and the Emergency Room (ER) Nurse Manager. Then the ER Nurse Manager reviews the physician review of records with the mid-level practitioner. Staff B acknowledged the physician failed to review the ER mid-level practitioner's medical records in conjunction with the mid-level provider.

Based on review of policies/procedures, documentation, and staff interviews, the Critical Access Hospital (CAH) failed to ensure the mid-level practitioner participated with a physician in the periodic review of 2 of 2 mid-level practitioner's patient medical records. (Staff I and J)

The CAH staff reported the volume of services provided by mid-level Staff I of 296 patient visits from January 1 to July 31, 2016.

The CAH staff reported the volume of services provided by mid-level Staff J of 359 patient visits from January 1 to July 31, 2016.

Failure to ensure the mid-level practitioner participated with a physician in the periodic review of the mid-level practitioner's patient medical records could potentially result in the mid-level practitioner misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of CAH policies/procedures reveled the lack of a requirement to ensure the physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

2. Review of documentation revealed the lack of documentation of physician review of the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioner.

3. During an interview on 8/9/16 at 10:20 a.m., Staff A, RN, acknowledged the lack of a policy to ensure a physician periodically reviewed the mid-level practitioner's patient medical records, in conjunction with the mid-level practitioners. Staff A stated a physician reviews mid-level practitioner's patient medical records, fills out a form that goes to quality and the Emergency Room (ER) Nurse Manager. Then the ER Nurse Manager reviews the physician review of records with the mid-level practitioner.

During an interview on 8/9/16 at 1:50 p.m., Staff B, RN, stated a physician reviews mid-level practitioner's patient medical records, fills out a form that goes to quality and the Emergency Room (ER) Nurse Manager. Then the ER Nurse Manager reviews the physician review of records with the mid-level practitioner. Staff B acknowledged the physician failed to review the ER mid-level practitioner's medical records in conjunction with the mid-level provider.

Based on observation, review of policies and documents, and staff interviews revealed the hyperthermia cart in surgery was lacking 2 vials of dantrium, the required amount of dantrium is 36 vials. The surgery lead Registered Nurse (RN) identified approximately 30 surgical cases were completed a month requiring anesthesia.

Failure of the Surgery department to have the required amount of dantrium available for a hyperthermia crisis could potentially result in death of the patient receiving anesthesia. Malignant hyperthermia is a genetic muscular skeletal disorder that is incited by anesthesia drugs. The disorder is particularly dangerous because it rapidly develops into a hypermetabolic state resulting in tachycardia, intense and unrelenting muscle contractions. Clinician and patient preparation are key in developing a plan of care for any patient having general anesthetic. Preparation also involves having emergency equipment and medications readily available to treat a malignant hyperthermia crisis.

Findings include:

Observation at 7:55 a.m. on 8/9/16, during the tour of the surgery department with Staff E, Lead Surgical RN, revealed a hyperthermia box in the sterile storage room of surgery. The box was sealed with a plastic numbered lock. Opening of the box revealed 34 vials of dantrium, medication used to reverse a hyperthermia crisis. The box lacked 2 vials for a total of 36, the required amount to treat a hyperthermia crisis. Staff E acknowledge the lack of 2 vials at the time of the observation. Additional information obtained from Staff E, at the time of the observation revealed the surgery department had a near miss hyperthermia event on 2/6/15 and gave 2 vials of dantrium.

Review of the log titled Malignant Hyperthermia Emergency Kit, dated 3/15 to present revealed the emergency kit is monitored daily for expiration of dantrium.

Review of policy titled Malignant Hyperthermia, revised 2/24/15 revealed a lack of information regarding the amount of dantrium to be kept in the hyperthermia box. Additional information provided by Staff F, Director of Pharmacy revealed an undated policy titled Malignant Hyperthermia Information, stated the required amount of dantrium is 36 vials. The dosage is determined by the weight of the patient.

During an interview on 8/9/2016 at 11:50 AM, Staff F revealed, the pharmacy lacks additional dantrium. The Director was unaware the hyperthermia cart lacked 2 vials of dantrium.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) staff failed to ensure the periodic evaluation of its total program included a representative sample of both active and closed clinical records for 11 of 15 patient care services provided. (Same Day Surgery, Outpatient Infusion/Chemotherapy, Wound, Respiratory Therapy, Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Diabetic Education, Laboratory, and Radiology) The CAH staff identified a current census of 12 inpatients at the start of the survey.

Failure to include a representative sample of both active and closed clinical records for all patient care services provided in the annual Total Program Evaluation could potentially result in failure to identify potential changes needed in services provided.

Findings include:

1. Review of CAH policy/procedure titled "Program Evaluation & Quality Assurance", dated 10/1/15, revealed in part, ". . . The annual program evaluation will include at a minimum:. . . An audit of a representative sample (at least 10%) of both active and closed clinical records. . . ."

2. Review of the "Annual Critical Access Hospital Committee Meeting Minutes" dated August 20, 2015, lacked documentation of review of a sample of both active and closed clinical records for Same Day Surgery, Outpatient Infusion/Chemotherapy, Wound, Respiratory Therapy, Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Diabetic Education, Laboratory, and Radiology.

3. During an interview on 8/9/16 at 9:20 a.m., Staff A, RN, verified the annual evaluation of the CAH Annual Program Evaluation lacked documentation of review of a sample of both active and closed clinical records for Same Day Surgery, Outpatient Infusion/Chemotherapy, Wound, Respiratory Therapy, Cardiac Rehabilitation, Physical Therapy, Occupational Therapy, Speech Therapy, Diabetic Education, Laboratory, and Radiology.