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Based on observations, interview and document review, the facility failed to ensure Emergency room supplies did not exceed the manufacturer's safe use date for two of two trauma bays (trauma bay #1 and #2). This deficient practice has the potential to cause compromised, unsafe supplies to be used during the care and treatment of emergent patients.

Findings include:

- Observation of Trauma Bay #1 on 1/8/2018 at 1:42 PM revealed the following supplies in the Broselow Bag (a bag containing color coded kits to treat children in an emergency):

- The pink kit contained one 24g IV catheter with an expiration date of 11/2016, and one IV flush (used to flush an IV line) with an expiration date of 8/2016.
- The purple kit contained two 22g IV catheters with an expiration date of 3/2015, one 24 -gauge IV catheter with an expiration date of 3/2014, and one IV flush with an expiration date of 8/2016.
- The yellow kit contained one 22g IV catheter with an expiration date of 3/2015 and one IV flush with an expiration date of 8/2016.
- The white kit contained one 22g IV catheter with an expiration date of 1/2014, one cuffed endotracheal tube (a tube inserted to help someone breathe in an emergency) size 5.0 with an expiration date of 5/2011.
- The blue kit contained one 22g IV catheter with an expiration date of 6/2015, one 20g IV catheter with an expiration date of 7/2015, one IV flush with an expiration date of 8/2016, and one cuffed endotracheal tube size 5.5 with an expiration date of 2/2011.
- The red kit contained one 22g IV catheter with an expiration date of 6/2015, one 20g IV catheter with an expiration date of 7/2015, and one IV flush with an expiration date of 8/2016.
- The green kit contained one 18g IV catheter with an expiration date of 11/2016, one 20g IV catheter with an expiration date of 5/2015, one 22g IV catheter with an expiration date of 6/2015, and one IV flush with an expiration date of 8/2016.


Observation of the Trauma Bay #1 supply wall and cabinets on 1/8/2018 at 1:53 PM revealed:

- Eight bacti-swabs (used to take samples to test in the lab for infection) with an expiration date of 10/27/2017
- One Dura-Prep (medical-grade cleansing agent and sponge) with an expiration date of 4/2016
- Two blue-topped blood tubes (used to collect blood for laboratory testing) with an expiration date of 12/5/2017, five with an expiration date of 7/11/2017, and two with an expiration date of 10/2016
- Nine gray-topped blood tubes with an expiration date of 11/29/2017
- One EZ-IO (special needle used for bone) needle size 15mm with an expiration date of 9/2017
- One package of steri-strips (used to secure a wound closed) with an expiration date of 4/11/2017

- Observation of the Crash Cart in Trauma Bay #1 on 1/8/2018 at 2:00 PM revealed:

- Three 20g IV catheters with an expiration date of 12/2017
- One IV flush with an expiration date of 10/2017
- Two 22g 1-½ inch needles with an expiration date of 8/2017
- Two 23g 1-inch needles with an expiration date of 1/2017
- Two 18g 1-½ inch needles with an expiration date of 10/2017


- Observation of Trauma Bay #2 on 1/8/2018 at 3:28 PM revealed one bacti-swab with an expiration date of 1/16/2015, two with an expiration date of 9/2017 and six with an expiration date of 1/20/2017.

Interview with RN Staff B on 1/8/2018 at 2:28 PM acknowledged the supplies were expired.


- Policy titled, "Central Supply" reviewed on 1/9/2018 directed, when an item has expired it is returned to the Central Supply department and added to a monthly loss support. The expired items are disposed of in a proper manner.

Based on observation and interview, the facility failed to ensure patient room doorways were free of hazards for 2 of 2 random observations of inpatient rooms (room 101 and 111 for patients #29 and #30). This deficient practice has the potential to effect safety related to slips trips and falls for patients, staff and visitors.

Findings include:

- Observation on 1/9/2018 at 10:22 AM of inpatient rooms 101 for patient #29 and 111 for patient #30 revealed both patient room doors were propped open by a small trash can.

Staff D interview on 1/9/2018 at 10:22 AM indicated the doors were propped open due to inefficient heating throughout the hospital.

2012 National Fire Protection Association (NFPA) 101, Life Safety Code Standard 19.3.6.3.10 directed, Door shall not be held open by devices other than those that release when the door is pushed or pulled.

Based on observation, staff interview, policy and procedure review the facility failed to ensure 6 of 6 filled Biohazard containers (containers filled with infectious waste such as blood, body fluids, and human cell lines) were secured in accordance with Federal and State regulations. Failure of the facility to ensure biohazard containers are secured puts the community and facility at risk for contaminating the community and anyone in the facility with potentially infectious agents or other materials that are deemed a threat to the public health or the environment.

Findings include:

- Observation outside and behind the hospital, a 5-6 foot opened fenced area with a locked gate, 6 full containers of biohazard material from the facility that were locked. The fenced area was open above the 5-6 foot fence making it possible for someone to get a ladder to reach over the fence and remove the 6 full containers of biohazard materials.

Interview by the fenced area containing the biohazard material on 1/10/18 at 1:25 PM, Staff L, Maintenance acknowledged the 6 full containers behind the fenced area outside were easily accessible to the community. Staff L explained this is where the facility has always kept them until the bi-monthly pick up.

- Policy titled "Housekeeping Hazardous Materials and Waste Management Plan Handling Requirements" directed, the goals for the Hazardous Materials and Waste Management Plan include the following: to provide adequate space and equipment for the safe handling and storage of hazardous materials and waste...there is a list of approved storage areas for hazardous materials and waste describing their location and features kept in the Safety Office and Materials Management.

Based on observation, staff interview, policy and procedure review the facility failed to ensure Oxygen (02) cylinders were stored and labeled (full or empty) according to Federal and State regulations. Failure of the facility to ensure 02 tanks are appropriately stored puts all staff, visitors and patients at risk for burns and fires.

Findings include:

- Observation outside and behind the hospital in a closed locked gated area on 1/10/18 at 4:16 PM revealed 6 portable 02 tanks in a secured rack which failed to be stored and labeled as full or empty.

Interview by the 02 locked gated area on 1/10/18 at 4:16 PM, Staff L, Maintenance acknowledged the 6 portable 02 tanks that failed to be labeled as full or empty.

Policy titled "Oxygen/Combustible Gas Storage" directed, to ensure that oxygen and other combustible gas cylinders are stored in a safe manner within the company's physical plant in compliance with applicable laws, regulations and standards...full tanks shall be segregated from empty tanks and are clearly marked as such.

Based on lack of evidence and staff interview, the facility failed ensure that air exchanges were within safe limits for the facility's operating room. The facility failed to provide a log book with parameters and instructions for correcting out of range exchanges. This deficient practice has the potential to expose surgical and procedural patients to airborne microbes and potential infections.

Findings include:

Staff L, Maintenance in central supply, interviewed on 1/8/2018 at 12:15 stated, "We don't keep a log of air exchanges in the OR. I am not sure how to correct if out of safe parameters". Staff L added, "No one has come out since building was commissioned. I am waiting on a quote, and I am having someone come out to check".

- Policy and Procedure titled "Surgical Services" stated, 20 Air Change Hour (ACH) is required minimally. This is monitored by environmental services. (Mechanical Systems Handbook for Healthcare Facilities 2014).

Based on observation, interview, and document review, the facility failed to ensure that multiple dose vials (MDVs) of medications are properly labeled, and expired medications are disposed of properly in the nursing medication room and in the respiratory therapy department. This deficient practice has the potential to cause harm to the patient. The patient has increased risk of medication errors and infections.

Findings include:

- Observation in the Nursing Medication Room on 1/8/2018 at 2:17 PM revealed eight carpujects (a syringe device for the administration of injectable fluid medication) of Diazepam (a medication used to treat anxiety, muscle spasms, and seizures) with an expiration date of 11/1/2017.

Staff E, Registered Nurse (RN), interviewed in the Nursing Medication Room on 1/8/2018 at 2:17 PM, acknowledged the eight carpujects of Diazepam with an expiration date of 11/1/2017, removed them from stock and discarded them.

-Observation in Respiratory Therapy Department 1/9/2018 at 10:15 AM, one MDV of 1% Lidocaine (a numbing medication), and one MDV of Dexamethasone (a steroid used to decrease inflammation) were found to have no open date marked on the vials.

Staff F, Respiratory Therapy Department, interviewed on 1/9/2018 at 10:15 AM stated "The open vials of medication are good for 30 days".

- Policy titled "Use of Multiple Dose Vials (MDVs)" directed, The expiration date for multiple dose vials (MDV) will be manufacturer's recommended date listed...providing that there is no obvious contamination, aseptic technique has been followed when withdrawing the medication...if MPV does not have an expiration date on the vial...expiration will occur 28 days after vial is opened, providing the above have been followed.

- Policy titled "Unusable and Outdated Drugs" directed, all discontinued patient drugs; outdated drugs...shall be returned to the pharmacy for proper disposable...all drug storage areas of the hospital will be inspected...for outdated drugs...the pharmacy staff member conducting the inspection will remove all of these types of drugs from the area...nursing or other staff approved by license to administer medications, noting outdated drugs...will contact the Pharmacy Department.

Based on observation, staff interview and document review, the facility failed to: 1. Ensure sterile supplies were stored undamaged in the Materials Management room; 2. Remove opened supplies from patient use areas in the trauma bay; 3. Ensure hand hygiene was performed prior to and after medication administration for one of two medication administration observations (Staff D); 4. Ensure hand hygiene was performed prior to drawing blood during one of one lab draw observation (Staff U); 5. Ensure dietary staff were wearing proper hair restraint during one of one kitchen observations (Staff R); 6. Ensure biohazard containers (used to throw away trash that may be contaminated with blood or body fluids) had a lid securing it from spills for one of two patient room observations (Room #101); 7. Ensure storage of the endoscopes after high level disinfecting were in a manner preventing pooling of water and contamination of the scope for one of one scope hanging closet observations; 8. Ensure expired supplies were removed from patient use in seven of seven supply stock observation areas (Materials Management room, isolation supply cabinet, nursing area crash cart, anesthesia cart in the single operating room, two of two operating room supply closets, and in the respiratory therapy supply closet); and 9. Ensure staff wore surgical attire correctly during one random observation (Staff V). These deficient practices have the potential to expose patients, staff and visitors to infectious diseases in the form of bacteria, viruses, and spores.

Findings Include:

- Observation in the Materials Management room on 1/8/18 at 11:07 AM revealed one Finger/Toe dressing with an expiration date of 12/17.

Interview in the Materials Management room on 1/8/18 at 11:07 AM, Staff B, Materials Management acknowledged the Finger/Toe dressing with an expiration date of 12/17.


- Observation in the Isolation Room Supply cabinet on 1/8/18 at 1:43 PM revealed one safety needle with an expiration date of 11/16, 1 package of Povidine Iodine Swabs (an antiseptic/germicide used on the skin) with an expiration date of 7/17, and 1 package of Alcohol Swabs (used to disinfect the skin) with an expiration date of 7/17.

Interview in the Isolation Supply Room on 1/8/18 at 1:43 PM, Staff C, Registered Nurse (RN) acknowledged the expired safety needle with an expiration of 11/16, package of Povodine Iodine with an expiration of 7/17, and Alcohol swabs with an expiration of 7/17.


- Observation of the Nursing Area Crash Cart on 1/8/18 at 1:58 PM revealed two Blunt Filled needles (used to draw-up medications reconstituted and accessed into IV bags) with an expiration date of 10/17.

Interview in the Nursing Station on 1/8/18 at 2:06 PM, Staff D, RN acknowledged the two Blunt End needles with an expiration date of 10/17.


- Materials Management Storage Room observation on 1/8/2018 at 1:03 PM revealed one Three-way Med Pressure Rotating Adapter (a three-way valve that connects more than on IV tubing to connect to an IV site) with a punctured package, revealing a small hole.

Materials Management Staff B interview on 1/8/2018 at 1:03 PM acknowledged the package was damaged and that the item was now unusable. Staff B promptly removed it from the stock shelves.

- Label from the punctured Three-way Med Pressure Rotating Adapter reviewed on 1/8/2018 at 1:03 PM directed, Sterile in unopened, undamaged package.

As of 1/10/2018, the facility failed to provide a policy regarding damaged supply packaging.


- Trauma Bay #1 observation on 1/8/2018 at 2:15 PM revealed eight primary extension tubes (connects to an inserted IV catheter) out of their primary packaging, resting in a blood draw kit.

Interview with Staff D acknowledged the items were not in their original packaging and explained it was because one physician does not like for the staff to use them, but the facility should not be storing them for future use. Staff D promptly discarded the extension tubes.

Labeling from the IV start kit containing similar extension tubes reviewed on 1/8/2018 2:14 PM directed, Do not use if package is opened or damaged. Do not reuse, single use only.


- Dietary Department Observation on 1/8/2018 at 3:39 PM revealed Dietary Staff R working in the kitchen area without a hair restraint. Upon observation of the presence of a state surveyor, Staff R promptly donned a paper hair restraint.

- Policy titled, "Dietary Services" reviewed on 1/10/2018 directed, All employees shall: Wear hair restraints.


Dietary Department Observation on 1/8/2018 at 3:40 PM revealed sanitized dishware such as plates, bowls, cups, glasses, and serving basins for patient use being stored on open, bookcase style shelves, unprotected from dust, lint, chemicals or other sources of cross-contamination.

Dietary Staff R interview on 1/8/2018 at 3:40 PM explained that the dietician had recently discussed the open storage of sanitized dishes, but the decision was to not move them.

As of 1/10/2018, the facility failed to provide a policy regarding the storage of sanitized dishes for patient use.


- Medication Preparation and Administration Observation for Patient #29 on 1/9/2018 at 10:04 AM revealed RN Staff D failed to perform hand hygiene prior to preparing medications in the medication room. During medication administration, Staff D donned gloves and proceeded to give Patient #29 medications by mouth. After administration, Staff D touched the mouse and keyboard inside the patient's room prior to removing gloves (thus contaminating the computer mouse and keyboard). Staff D then removed his/her gloves and continued using the mouse and keyboard before exiting the room, failing to complete hand hygiene after patient contact, and after removing gloves, and touching objects in the patient's vicinity.

Staff D interview on 1/9/2018 at 10:15 AM acknowledged he/she failed to perform hand hygiene prior to preparing medications and after removing his/her gloves.

-Observation on 1/10/2018 at 2:15 PM, in Pre-Op holding area, Staff U, Phlebotomist, failed to perform hand hygiene prior to donning gloves for lab draw.

- Policy titled, "Infection Control - Hand Hygiene" reviewed on 1/10/2018 directed, If hands are not visibly soiled, use an alcohol-based hand rub for decontaminating hands in all other clinical situations. Examples: After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

- The World Health Organization in their Hand Hygiene Patient Safety Brochure reviewed on 1/14/2018 recommended performing hand washing before performing clean or aseptic procedures such as preparing sterile items, food, pharmaceutical products and medications, and after touching a patient, or their surroundings.


- In 2002, the Centers for Disease Control (CDC) recommended, After gloves are removed, hands should be washed with a non-antimicrobial or an antimicrobial soap and water or disinfected with an alcohol-based hand rub.


- Medication Preparation and Administration Observation for Patient #29 in room 101 on 1/9/2018 at 10:04 AM revealed a red biohazard medical waste container containing medical waste, and without a lid, allowing the contaminated contents to spill if it were knocked over.

Staff D interview on 1/19/2018 at 10:15 AM acknowledged the biohazard waste container lacked a lid.

- The Environmental Health and Safety and Security (EHSS) information reviewed on 1/14/2018 recommended, All containers, including benchtop containers, must be covered with a lid when not in use.

As of 1/10/2018, the facility failed to provide a policy regarding biohazard containers being covered by a lid when in use.


- Operating Room (OR) Anteroom observation on 1/10/2018 at 5:30 PM revealed a scope drying cabinet containing two sanitized endoscopes (medical equipment with a camera that enters the rectum to visualize the gastrointestinal tract), six surgical hoods with head lamps (used by surgical staff during procedures), one OR table headrest, and two limb straps (used to position patients during surgery) hanging inside the cabinet, and above the scopes was a shelf with a media receiver (for playing music). The camera tip of each of the two scopes had a foam cover on them and they coiled onto the base of the cabinet, potentially allowing droplets of water to pool.

Operating Room Manager Staff K interview on 1/10/2018 at 5:30 PM acknowledged the lack of sufficient space for adequate storage of the endoscopes and reports the facility has purchased a new cabinet, although a delivery date has not been determined. Staff K explainedhe inside of the cabinet is cleaned with sanitizer periodically.

- Policy titled, "Processing of Endoscopes - Steris" reviewed on 1/10/2018 directed, do not store the endoscopes coiled; hang the endoscopes vertically so they will dry. Store the endoscopes in a manner which will protect the endoscopes.

Association of periOperative Registered Nurses (AORN) in 2016 recommendsed, Flexible and semi-rigid endoscopes should be stored in a closed cabinet. Cabinets should have venting that allows air circulation around the endoscopes. Cabinets should have internal surfaces composed of cleanable material. Cabinets should have adequate height to allow endoscopes to hang without touching the bottom. Cabinets should have sufficient space for storage of multiple endoscopes without touching. Flexible endoscopes may be stored in a closed cabinet with HEPA-filtered air that provides positive pressure and allows air circulation around the flexible endoscopes, if a drying cabinet is not available. Flexible endoscopes that have been mechanically processed should be stored in a cabinet that is either sufficient height, width, and depth to allow flexible endoscopes to hang vertically, without coiling and without touching the bottom of the cabinet or designed and intended by the cabinet manufacturer for horizontal storage of flexible endoscopes. Storage cabinets used for flexible endoscopes should be cleaned and disinfected with an EPA registered hospital grade disinfectant when visibly soiled and on a regular basis (e.g., daily, weekly). Cabinets should be situated in a secure location in the clean workroom of the endoscopy processing room. Storage cabinets should have doors and be located at least 3' from any sink.


- Observation in the Materials Management room on 1/8/2018 at 11:07 AM revealed one Finger/Toe dressing with an expiration date of 12/2017.

Staff B, Materials Management, interviewed in the Materials Management room on 1/8/2018 at 11:07 AM acknowledged the Finger/Toe dressing with an expiration date of 12/2017.


- Observation in the Isolation Room Supply cabinet on 1/8/2018 at 1:43 PM revealed one safety needle with an expiration date of 11/2016, one package of Povidine Iodine Swabs (an antiseptic/germicide used on the skin) with an expiration date of 7/2017, and one package of Alcohol Swabs (used to disinfect the skin) with an expiration date of 7/2017.

Staff C, Registered Nurse (RN), interviewed in the Isolation Supply Room on 1/8/2018 at 1:43 PM, acknowledged the expired safety needle with an expiration of 11/2016, package of Povodine Iodine with an expiration of 7/2017, and Alcohol swabs with an expiration of 7/2017.


- Observation of the Nursing Area Crash Cart on 1/8/2018 at 1:58 PM revealed two Blunt Filled needles (used to draw-up medications reconstituted and accessed into IV bags) with an expiration date of 10/2017.

Staff D, RN, interviewed in the Nursing Station on 1/8/2018 at 2:06 PM, acknowledged the two Blunt End needles with an expiration date of 10/2017.


-Observation in Operating Room on 1/8/2018 at 2:00 PM, expired disposable supplies found in drawers of the anesthesia cart in operating room as follows:
-Two 18 gauge Introcan intravenous catheters, expiration date 4/2016
-Two 22 gauge spinal needles, expiration date 5/2017
-Two 24 gauge Introcan intravenous catheters, expiration date 11/2016
-One 16 gauge 1.25in. Jelco intravenous catheter, expiration date 5/2016
-Three Mini Spike Dispensing Pins, expiration date 11/2016
-One 60 ml syringe, expiration date 11/2017
-Two ET or endotracheal tubes (a tube that goes down the throat to help breathing), expiration date 12/2016
-One endotracheal tube stylet (used to stiffen the endotracheal tube to ease insertion into lungs), was found out of original packaging with no expiration date.


-Observation on 1/8/2018 at 1410 in supply cabinet located along wall in Operating Room, revealed additional expired disposable supplies as follows:

-Two 25 gauge 3.5in needle, expiration date 7/2016
-Two 22 gauge 1.5in. Eclipse Brand needles, expiration date 8/2017
-One 23 gauge 1in. Eclipse Brand needle, expiration date 1/2017


-Observation 1/8/2018 at 1420, in storage room between the Operating Room and Sterile Processing area, revealed expired disposable supplies located as follows:

-Two 3 Stage Esophageal Balloon Dilators (used to open the esophagus, a muscular tube that connects the throat to the stomach), expiration date 9/14/2017
-Six LMA (laryngeal mask airway, devices that are inserted into the back of the throat to assist breathing), expiration 11/2014


-Observation on 1/8/2018 at 1430, in Operating Room, revealed reusable supplies found in a drawer of the anesthesia cart as follows:

-One pair of Magill Forceps (used to remove foreign bodies from patient's airway, and to aid in passage of an ET tube) was also unwrapped in a drawer.
-Several laryngoscopes (an instrument used for examining the throat and voice box) and the handles that attach to the laryngoscopes were found unwrapped in a drawer.

Staff H, Surgical Services, interviewed on 1/8/2018 at 2:10 PM: "I will make sure the Magill forceps, laryngoscopes, and the handles get sterilized and packaged".


-Observation on 1/9/2018 at 10:15 AM, in Respiratory Therapy Department storage closet revealed expired disposable supplies as follows:

-Two 10 French (French indicates the size of instrument) stylets, expiration date 10/2012


-Observation on 1/10/2018 at 2:15 PM, in Pre-Op holding area, Staff V, Certified Registered Nurse Anesthetist, had surgical mask hanging around neck.

As of 1/10/2018, the facility failed to provide a policy on surgical attire and masks.

Association of periOperative Registered Nurses' (AORN's) "Guideline for Surgical Attire" reviewed on January 14, 2018 recommended, surgical masks should be replaced and discarded whenever it becomes wet, soiled, or has been taken down...filter portion harbors bacteria from nasopharyngeal airway. Contaminated mask may cross contaminate the scrub attire top or jacket when hanging around neck.

Based on record review, staff interview, policy and procedure review the facility failed to ensure verbal orders were rarely used in accordance with acceptable standards of practice for 3 of 30 records reviewed (Patient #13, #26, and #27), and failed to ensure verbal orders were authenticated by the physician within 72 hours for 7 of 15 orders reviewed (Patient #13). The facility also failed to adhere to standards for safe injection practices by not labeling injectable medications prepared in the medication room during one of two medication preparation and administration observations (Registered Nurse Staff N; Patient #30). These deficient practices place all patients at risk for medication errors causing harm or potentially death.


Findings include:


- Medical Record review for patients #13, #26 and #27 completed on 1/10/2018 revealed the following excessive use of verbal orders:

- For patient #13, 11 out of 17 physician orders placed on 3/3/2017 were placed as verbal orders.
- For patient #26, nine of nine physician orders placed between 10/18/2017 and 11/02/2017 were placed as verbal orders.
- For patient #27, four of four physician orders placed between 10/30/2017 and 11/1/2017 were placed as verbal orders.


Medical Records Staff I interview on 1/10/2018 at 4:45 PM explained that a majority of physician orders are placed as verbal orders in the computer because the physician (MD Staff W) on staff does not use the computer provider order entry system, but instead writes his/her orders on paper. Nursing staff must then transcribe the physician's orders into the computer system. Staff I confirmed the facility currently has an abundance of verbal order use.

As of 1/10/2018, the facility failed to provide a policy on the use of verbal orders.


As of 2018, The National Coordinating Council on Medication Error Reporting and Prevention makes the following recommendations to reduce confusion pertaining to verbal orders and minimize medication errors:


1. Verbal communication of prescription or medication orders should be limited to urgent situations where immediate written or electronic communication is not feasible.

2. Healthcare organizations should establish policies and procedures that do the following:

Describe limitations or prohibitions on use of verbal orders, Provide a mechanism to ensure validity/authenticity of the prescriber, List the elements required for inclusion in a complete verbal order, Describe situations in which verbal orders may be used, List and define the individuals who may send and receive verbal orders, Provide guidelines for clear and effective communication of verbal orders, and Employ read-back techniques for clarifying verbal orders.



- Record review in the Medical Records room on 1/10/18 revealed 7 of 15 verbal orders for patient #13 ordered on 3/3/18 and authenticated by the physician (Staff W) on 3/8/17 (120 hours later). The medications ordered were: Lipase (a blood test to diagnose several diseases primarily pancreatitis (inflammation of the pancrease a large organ behind the stomach that produces digestive enzymes and a number or hormones), Brain Natriuetic Peptide (BNP) test (a blood test that measures levels of a protein called BNP that is made by your heart and blood vessels), Troponin (proteins found in skeletal and heart muscle fibers that produce muscular contraction), D-Dimer (a test to help rule out the presence of an inappropriate blood clot), Normal Saline (water with 0.9% salt added), Keppra (medication used to treat seizures), and Amylase (an enzyme that changes starch into sugars).


Interview in the Medical Record room on 1/10/18 at 8:55 AM, Staff I, Medical Records acknowledged the verbal orders for Lipase, BNP, Troponin, D-Dimer, Normal Saline, Keppra, and Amylase were authenticated by the physician 120 hours after the verbal order was given.


- The CAH's Rules and Regulations for the Medical Staff directed, a "verbal order" is appropriate, if the verbal order is: signed by the responsible or covering practitioner within seventy-two (72) hours.


- Medication Preparation and Administration observation on 1/9/2018 at 10:37 AM revealed RN Staff N draw up injectable medication to be given IV push (injected directly into the patient's IV line) through the IV of patient #30. After preparation of the medication in the medication room, Staff N failed to label the syringe with the name of the medication, time, date, dosage and initials of the preparer.


Interview with Staff N on 1/9/2018 at 10:45 AM explained he/she would have labeled the medication if they had more than one to give, but since there was only one medication, they did not need to label it.


- As of 1/10/2018 the facility failed to provide a policy on safe injection practices including labeling of injectable medication syringes.


In 2010, the National Center for Biotechnology Information (NCBI) Library of Medicine recommended, Unlabeled syringes pose a significant risk when injectable products are prepared in clinical areas...Commercially available labels for syringes should be provided and should be routinely restocked in all drug-preparation areas (e.g., radiology, nuclear medicine). Nurses should be offered the opportunity to assess several label formats and to select one standard format that best meets their needs. Tape is not suitable for labeling syringes...Staff members should not assume that they know what is contained in an unlabeled syringe. All unlabeled syringes should be discarded, and the event should be reported as a hazardous condition. No syringe should leave the practitioner's hand unless it is labeled...The staff should reinforce and monitor compliance and should institute a policy mandating that all syringes containing injectable medications be properly labeled.

Based on medical record review, interview and policy review, the facility failed to ensure that a Physician completed a History and Physical for one of 30 records reviewed (Patient #7) prior to surgery. The facility failed to ensure authentication, by signature, within 48 hours of admission of a Patient's History and Physical for six of 30 medical records reviewed (Patient #10, #13, #14, #15, #16, and #18). The facility failed to ensure that a History and Physical was documented and put in the medical record for one of 30 records reviewed (Patient #12). The facility failed to ensure that a Physician authenticated a Discharge Summary within 30 days of discharge on one of 30 medical records reviewed (Patient #12). Failure to ensure that a Physician completes and authenticates a History and Physical correctly and within 48 hours after patient admission, as well as not authenticating a Discharge Summary within 30 days of discharge, deems the medical record incomplete and inaccurately documented.


Findings include:


-Record review on 1/10/2018 revealed the Short Form History and Physical for Patient #7, admitted for surgery on 12/8/2017 was authenticated by the Physician on 12/21/2017 (13 days after the surgery).

-Record review on 1/9/2018 revealed the History and Physical for Patient #10, admitted on 8/25/2017 was authenticated by the Physician on 8/31/2017 (204 hours after admission).

-Record review on 1/9/2018 revealed the History and Physical for Patient #13, admitted on 3/3/2017, was authenticated by the Physician on 3/6/2017 (72 hours after admission).

-Record review on 1/9/2018 revealed the History and Physical for Patient #14, admitted on 1/1/2017, was authenticated by the Physician on 1/20/2017 (20 days after admission).

-Record review on 1/9/2018 revealed the History and Physical for Patient #15, admitted on 3/17/2017, was authenticated by the Physician on 3/20/2017 (approximately 72 hours after admission).

- Record review on 1/9/2018 revealed the History and Physical for Patient #16, admitted on 2/25/2017, was authenticated by the Physician on 3/6/2017 (9 days after admission).

-Record review on 1/10/2018 revealed the History and Physical for Patient #18, admitted on 6/17/2017, was authenticated by the Physician on 7/13/2017 (26 days after admission).

-Record review on 1/9/2018 revealed no History and Physical for Patient #12 in the medical record.


Staff I (Medical Records), interviewed in the Medical Record Department on 1/9/2018 and 1/10/2018, confirmed that the History and Physical for Patients #10, #13, #14, #15, #16 and #18 were not authenticated by the Physician within 48 hours of admission. Staff I confirmed the Short Form History and Physical for Patient #7 is dated 12/21/2017, when surgery was performed on 12/8/2017.


Staff I also stated that the facility failed to provide documentation regarding the timeframe in which a Physician is required to authenticate the History and Physical. Staff I acknowledged that the History and Physical was not completed and made part of Patient 12's medical record. Staff I added that the facility uses the Emergency Room (ER) record for the History and Physical if the patient is only admitted for one day.

-Record review on 1/9/2018 revealed the Discharge Summary for Patient #12 was not authenticated by Physician within 30 days of Patient discharge.

Staff I (Medical Records), interviewed in the Medical Record Department on 1/9/2018, acknowledged that the Discharge Summary was not signed by Physician within 30 days of Patient #12's discharge from hospital.


-The CAH's Rules and Regulations for Medical Staff directed, .all physician signatures will be completed within thirty (30) days after the medical record has been made available to the physician.


-The CAH's Rules and Regulations of the Medical Staff directed, a completed admission history and physical is to be recorded within twenty-four (24) hours of admission...if the patient has been seen in the Emergency Room and an ER note has been dictated, the attending physician may update and validate the ER note as the admission history and physical.

Based on staff interview and document review the facility failed to complete an annual review of its total program for the last several years.

The cumulative effect of the Critical Access Hospital's (CAH's) failure to complete a periodic evaluation of its total program on an annual basis; provide a review of the utilization of services; evaluate a sample of both active and closed clinical records; review health care policies to ensure appropriate services, and ensure policies are followed with changes made as needed puts all patients at risk for poor quality, unsafe care below the federal and state requirements.


Findings inlcude:

- The facility failed to complete an annual evaluation of its total program for the calendar years 2014, 2015, 2016 and 2017. (See C-0331 for further details).

- The facility failed to ensure yearly program evaluation of all facility services to include the number of patients served and the volume of services provided for the years 2014, 2015, 2016, and 2017. (See C-0332 for further details).

- The facility failed to ensure review of both active and closed clinical records representing services furnished by the critical access hospital in a periodic annual review. (See C-0333 for further details).

- The facility failed to ensure their health care policies were reviewed as a part of the annual program evaluation. (See C-0334 for further details).

- The facility failed to ensure the utilization of services was appropriate and that established policies and procedures were being followed, and any changes made as needed based on the results of the annual program evaluation. (See C-0335 for further details).

Interview in the team conference room on 1/8/18 at 4:24 PM, Staff A, Administration acknowledged the facility failed to carry out a periodic evaluation of its total program for the years 2014, 2015, 2016 and 2017.

- The facility's Governing Body By-Laws directed, the authority and responsibility of the administrator shall include...preparing a plan for the achievement of the System's specific objectives and periodically reviewing and evaluating that plan.

Based on staff interview and document review the facility failed to complete an annual evaluation of its total program for the calendar years 2014, 2015, 2016 and 2017. Failure to ensure evaluation of the facility's total program puts all patients at risk for unsafe and poor quality care from each department.

Findings include:

Interview in the team conference room on 1/8/18 at 4:24 PM, Staff A, Administration acknowledged the facility failed to carry out an annual periodic evaluation of its total program for the years 2014, 2015, 2016 and 2017.


- The facility's Governing Body By-Laws directed, the authority and responsibility of the administrator shall include...preparing a plan for the achievement of the System's specific objectives and periodically reviewing and evaluating that plan.

Based on interview and document review the facility failed to ensure yearly program evaluation of all facility services to include the number of patients served and the volume of services provided for the years 2014, 2015, 2016, and 2017. Failure of the facility to evaluate facility services, patients served and the volume of services puts all patients at risk for receiving care, nutrition, treatments and supportive services that are inadequate to meet their needs.


Findings include:


Interview in the team conference room on 1/8/18 at 4:24 PM, Staff A, Administration acknowledged the facility failed to carry out a periodic evaluation of its total program for the years 2014, 2015, 2016 and 2017.


- The facility's Governing Body By-Laws directed, the authority and responsibility of the administrator shall include...preparing a plan for the achievement of the System's specific objectives and periodically reviewing and evaluating that plan.

Based on interview, and documents review the facility failed to ensure review of both active and closed clinical records representing services furnished by the critical access hospital in a periodic annual review. Failure to ensure review of active and closed clinical records puts all patients at risk for not receiving quality, up-to-date, and comprehensive care.

Findings include:

Interview in the team conference room on 1/8/18 at 4:24 PM, Staff A, Administration acknowledged the facility failed to carry out a periodic evaluation of its total program for the years 2014, 2015, 2016 and 2017.


- The facility's Governing Body By-Laws directed, the authority and responsibility of the administrator shall include...preparing a plan for the achievement of the System's specific objectives and periodically reviewing and evaluating that plan.

Based on interview and document review the facility failed to ensure their health care policies were reviewed as a part of the annual program evaluation. Failure of the facility to evaluate, review and revise health care policies puts all patients at risk for receiving care that is unsafe and below the standard of care from each profession potentially resulting in harm and poor outcomes.

Findings include:

Interview in the team conference room on 1/8/18 at 4:24 PM, Staff A, Administration acknowledged the facility failed to carry out a periodic evaluation of its total program for the years 2014, 2015, 2016 and 2017.


- The facility's Governing Body By-Laws directed, the authority and responsibility of the administrator shall include...preparing a plan for the achievement of the System's specific objectives and periodically reviewing and evaluating that plan.

Based on interview and document review the facility failed to ensure, based on the results from the annual facility program evaluation, that the utilization of services was appropriate and that established policies and procedures were being followed, and any changes made that are needed. Failure to ensure results from the annual program are evaluated puts all patients at risk for care that is unsafe and below the standard of care according to State and Federal guidelines.

Findings Include:

Interview in the team conference room on 1/8/18 at 4:24 PM, Staff A, Administration acknowledged the facility failed to carry out a periodic evaluation of its total program for the years 2014, 2015, 2016 and 2017.


- The facility's Governing Body By-Laws directed, the authority and responsibility of the administrator shall include...preparing a plan for the achievement of the System's specific objectives and periodically reviewing and evaluating that plan.

Based on staff interview and policy review, the facility failed to ensure provisions for emergency dental care for swing bed patients. This deficient practice has the potential to place all swing bed patients at risk for poor oral and dental health.

Findings include:


Interview with Swing Bed Coordinator Staff O on 1/10/2018 at 2:30 PM, explained that the hospital did not have an agreement with a dentist for swing bed patient emergent dental needs. Staff O shares they have never had a dental emergency since he/she has been at the facility.


- Policy titled, "Dental Services" reviewed on 1/10/2018 lacked evidence of a contract or arrangements for emergency dental services for swing bed patients.

Based on lack of evidence and staff interview, the facility failed to develop an emergency preparedness plan that specifies the population served and their vulnerabilities in the event of an emergency or disaster. This deficient practice affects the safety of all patients in the event of an emergency.


Findings include:


- Emergency Preparedness Plan review on 1/9/2018 at 11:30 AM revealed the plan lacked evidence that the patient population served by the facility and their accompanying vulnerabilities were incorporated.


Interview with Safety Officer Staff P on 1/9/2018 at 11:30 AM explained during the planning and the development of the health system's emergency preparedness plans, the patient population was determined for the rural health clinic, but not the hospital.


On 1/10/2018 the facility failed to provide a policy regarding the incorporation of patient population into the facility's disaster preparedness plan.

Based on observation, document review and staff interview, the facility failed to include provisions for adequate subsistence including water for all patients and staff in the event of an emergency, whether they evacuate or shelter in place. This deficient practice affects the health and welfare of all patients and staff in the event of an emergency.

Findings include:

- Observation of the Housekeeping Closet near Central Supply room on 1/8/2018 at 1:03 PM revealed one small case of bottled water sitting on the floor in the mop room.

Interview with Housekeeping Staff T on 1/8/2018 at 1:03 PM explained the bottled water in the mop room was used to refill the pop machine in the front lobby, and was not for staff or patients.


Interview with Safety Officer Staff P on 1/9/2018 at 12:00 PM, explained that the facility has on-site, enough water, food and medications to last up to 72 hours for patients and staff.

Observation and interviews with Safety Officer Staff P and Dietary Manager Staff M at 12:25 PM during a tour of disaster preparedness supplies, no emergency water stored on site, but there was a Memorandum of Understanding (MOU) to purchase water from a local grocery store in the event there was a water supply emergency.

- Document titled, "Artisan Valley Health System Emergency Operations Plan ... Utilities" reviewed on 1/9/2018 directs, "If [an water loss emergency is] under 24 hours, the facility should use the local resources and internal supplies and if longer than 24 hours, notify the Meade County Emergency Management Coordinator...Based on the determination above, delegate responsibility for mobilizing resources from facility staff, community and the neighboring communities. These resources will be mobilized to: develop alternate sources and methods of delivering a safe water supply...notify [local resident's name] to provide a 500-gallon supply of water. Notify [local grocery store name] for purchase of potable water supply.