HospitalInspections.org

Based on observation and interview the CAH (Critical Access Hospital) failed to ensure the Emergency Department's environment maintained patient safety as evidenced by failing to secure a soiled utility room that contained housekeeping chemicals. Findings include:

During a tour of the Emergency Department (ED) on 5/15/23 at approximately 3:00 PM with the Director of Quality and Director of the Emergency Department, a soiled utility room located near Exam Room #1 was noted to be unsecured and easily accessible to unauthorized individuals. The room contained a hopper ("Flushing-rim clinical service sink with a bedpan-rinsing device used for disposal of liquid clinical waste.") where two, one-quart bottles of Clorox bleach were located.

Per interview on 5/15/23 at 3:11 PM, the Director of the Emergency Department confirmed that the soiled utility room door should be locked and that "anyone" could access the contents of the room.

Based on interview and medical record review the CAH failed to ensure care was provided in accordance with written policies and procedures regarding the use of restraints for 1 applicable patient (Patient #2). Findings include:

Per review of an ED physician's note from 4/24/23 at 13:26, Patient #2 was brought into the ED by paramedics for alcohol intoxication. S/He was discharged from the ED earlier in the day into the care of his/her family member who took Patient #2 back to his/her apartment. While at his/her apartment, Patient #2 drank hand sanitizer and came back to the ED inebriated and violent. Upon physical exam, Patient #2 had a "disheveled" appearance; speech and movement were "agitated"; mood was "irritable"; and his/her attitude was "belligerent" which required chemical and physical restraints.

Per review of a nursing triage note from 4/24/23 at 13:42, it states, "Pt very combative, swearing at and threating to punch security in the face, spitting at "VSP" (State Police), very uncooperative and unable to reason with".

Per review of a restraint/seclusion assessment from 4/24/23 at 13:30 it states,
"Behavior requiring Restraints/Seclusion ...Harm to self & others ...
Alternatives Attempted ...De-escalation ...
Date of initiation: 4/24/23
Time of initiation: 13:30
Actions Taken Related to Restraints/Seclusion ...restraints initiated, MD notified, order obtained, evaluated by MD, medication administered ...
Restraint Type ...Neoprene Restraint Placement ...all extremities ...
Medication Administered ...Ativan (antianxiety) 2 mg (milligrams) Haldol (antipsychotic) 5 mg ...
Time of Administration ...13:30 ...
Effect of Medication ...patient resting quietly on stretcher".

Per review of a Patient Observation Record from 4/24/23, it states,
"13:30 Patient State ...Appears to be Sleeping ...pt is laying in bed".
"14:15 Patient State ...Appears to be Sleeping ...pt is laying down".
"14:30 Patient State ...Appears to be Sleeping, Cooperative ...pt is laying down sleeping".
"14:45 Patient State ...Appears to be Sleeping ...pt laying in bed".
"15:00 Patient State ...Appears to be Sleeping ...pt is laying in bed".

Per review of a restraint/seclusion assessment from 4/24/23 at 15:12, it states,
"pt resting quietly on stretcher with eyes closed ...
Criteria for Restraint Removal ...No longer immediate threat to self, No longer immediate threat to staff & others ...
Date Restraints Removed ...4/24/23 ...
Time Restraints Removed ...15:08".

Per review of the "Restraint and Seclusion Policy"-approved 2/26/20, it states, "1) When an order for restraint or seclusion has been obtained, the patient must be seen face-to-face within 1 hour after the initiation of the intervention by a licensed independent practitioner ...2) The one (1) hour face-to-face patient evaluation must be conducted in person ...Termination of Restraint or Seclusion 1) Restraint or seclusion will be terminated at the earliest possible time regardless of the length of time identified in the order. Restraint or seclusion may only be employed while the unsafe situation continues. Once the unsafe situation ends, the use of restraint or seclusion must be discontinued."

There is no evidence in the record that a licensed independent practitioner evaluated Patient #2 face-to-face after the initiation of restraints. Per interview on 5/17/23 at 9:15 AM, with an Informatics Nurse, S/He confirmed that a face-to-face was not performed by a licensed independent practitioner after the initiation of restraints for Patient #2.

Based on the information above, the restraints for Patient #2 were not terminated at the earliest possible time.
Per interview on 5/17/23 at 9:29 AM, with the ED Director, S/He confirmed that the restraints were not removed from Patient #2 at the earliest possible time.

Based on record review and interview, the facility failed to maintain medical records that are legible, complete, accurately documented, readily accessible, and systematically organized for 1 patient in a standard survey sample of 27. (Patient identifier #5).

Findings include:

Record review of patient #5's medical record, it was revealed that on 5/15/23 patient #5 had a gastroscopy. There was no evidence in the Electronic Medical Record (EMR) or the paper medical record of an operative report for this procedure. There is a completed anesthesia consent with pre, and post anesthesia evaluations conducted.

Interview on 5/17/23 at approximately 1:30 PM with an Informatics Nurse, s/he confirmed that the operative report was not located in the EMR or the paper medical record. S/he stated that she/he would check with medical records to see if the operative report was in the medical records department waiting to be scanned into the EMR. At approximately 1:45 PM, s/he returned and stated that medical records did not have this document and it "appeared the op [operative] note had not been done by the surgeon". S/he stated that the policy, according to medical records, was that operative notes be completed and in the patient's chart within 4 hours post (after) the surgical intervention.

A review of the facility's policy titled "Medical Staff Medical RecordsPolicy [sic]". This policy was approved on "01/16/23" and expires on "12/01/2023". This policy is a 5 page document and on page 2 read the following: "Reports of Operation Documentation requirements for operative and other high-risk procedures, as well as those procedures involving the use of moderate to deep sedation, or anesthesia Must Include:
Name and hospital identification number of the patient;
Date of procedure
Pre-operative and post-operative diagnosis
Procedure performed
Type of anesthesia administered;
Estimated blood loss,
Complications, if any;
A description of techniques, findings, and tissues removed or altered;
Surgeons or practitioners name(s) and a description of the specific significant surgical tasks that were conducted by practitioners other than the primary surgeon/practitioner (significant surgical procedures include: opening and closing, harvesting grafts, dissecting tissue, removing tissue, implanting devices, altering tissues); and
Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any.

When a full operative or other high-risk procedure report cannot be entered immediately into the patient's medical record after the operation or procedure, a progress note shall be entered in the medical record before the patient is transferred to the next level of care. This progress not shall include:
The name(s) of the primary physician and his or her assistant(s),
Procedure performed and a description of each procedure finding
Estimated blood loss
Specimens removed, and
Post-procedure diagnosis

If there was no blood loss or specimens removed, it is not necessary to include this documentation in the progress note."

Review of a 2 page document titled "CHART ANALYSIS HIM [health information management]" provided by the Director of the Medical Records Department (HIM) on 5/17/23. Under "Op (operative) Notes", on page 2 revealed the following:
All operations require a report of operation documented in the record immediately after surgery
If an Op Note is missing
Call provider/put in a deficiency
Email [proper name omitted] patient information for an incident report

Based on observation, interview, and record review the CAH failed to ensure the methods for preventing and controlling the transmission of infections were followed related to surgical attire, hand hygiene, and patient care supplies for 3 applicable staff members and 2 patient care areas (Surgical Suite and ED). Findings include:

1. During a tour of the Surgical Suite on 5/15/23 at 12:40 PM, during a patient's cataract surgery in OR#1, Staff #1 and Staff #2 did not have the hair at the nape of their necks fully covered with appropriate surgical attire. Per interview at that time with the Director of the OR S/He confirmed that all hair should be fully covered with appropriate attire.

Per review of the policy, "Surgical Attire"-approved 10/24/22, it states, "Purpose: Surgical Attire and appropriate personal protective equipment are worn to promote worker safety and a high level of cleanliness and hygiene in the perioperative environment. The expected outcome is that the patient will be free from signs and symptoms of infection .... Procedure Interventions ...All perioperative personnel will cover head and facial hair, including sideburns and the nape of the neck."

2. During a tour of the ED on 5/15/23 at approximately 3:00 PM, Exam Room #3 had an opened package containing a "Yankauer" (type) suction tip (removes secretions from one's mouth) on top of a suction canister. There was no indication when this package was opened and/or how long it had been in the room. Per interview on 3/15/23 at approximately 3:15 PM with the ED Director, S/He stated, "I wouldn't do this" and confirmed that it was not best practice to open patient care supplies without patients present.

3. Per observation of cleaning OR #1 after a surgical case on 5/16/23 at 11:57 AM, Staff #3 cleaned the OR table, removed gloves and without sanitizing his/her hands donned new gloves and proceeded to finish cleaning the OR table. Per interview on 5/16/23 with Staff #3 at that time S/He stated that whenever you remove gloves you need to "sanitize hands" prior to donning clean gloves.

Per review of the policy "Hand Hygiene"-approved 12/6/22, it states, "Hands Hygiene must take place: 6. After removing gloves."

4. During a tour on 5/16/23 at 1:46 PM of the Post Anesthesia Care Unit (PACU), the unit had three beds that were equipped with oxygen, suction, and cardiac monitors. In two of the three bed areas oxygen tubing was unwrapped, hanging over suction canisters and attached to the wall mounted oxygen supply. There was no indication how long the tubing had been open and/or how long it had been in the room. Per interview with a staff member at that time, S/He stated that was what they had "always done", the oxygen tubing was opened to be ready for the "next patient". Per interview on 5/17/23 at 11:51 AM with the Infection Preventionist, S/He confirmed that this was not a recommended practice.

Based on interview and record review the CAH failed to promote swing bed patients' rights related to choosing an attending physician. Findings include:

Per review of the CAH's "Swing Bed Patient Bill of Rights", there was no evidence that the CAH afforded swing bed patients the option to choose his/her own attending physician.

Per interview on 5/17/23 at approximately 1:00 PM, with the Care Manager, S/He confirmed that the CAH's "Swing Bed Patient Bill of Rights" did not contain all the required regulatory elements.

Based on interview and record review the CAH failed to develop comprehensive policies and procedures for Swing Bed patients that prohibit and prevent, abuse, neglect, exploitation, and misappropriation of property. Findings include:

Per review of the policy, "Suspected Abuse/Neglect of Vulnerable Adults"-active as of 5/15/23. There was no evidence that the policy and/or procedure contained the time frame in which allegations involving abuse, neglect, exploitation, or mistreatment, to include injuries of an unknown origin and misappropriation of residents' property were reported, and to the required officials. There was also no indication of the process in which these allegations were to be fully investigated and if substantiated the appropriate corrective actions that would be taken.

Per interview on 5/16/23 at approximately 10:30 AM with the Care Manager, S/He confirmed that the policy did not contain the above information and stated that S/He was not aware of these requirements.

Based on observation and interview, it was determined that the facility failed to ensure patient's personal privacy on the Medical Surgical - locked/secure Psychiatric unit/hall in a standard survey for 1 of 3 units.

Findings include:

Tour of the Medical Surgical unit with the Director of Medical Surgical/Pediatrics/Infusion units, revealed a locked/badge entry only hall/unit that contained 3 patient rooms. The Director of Medical Surgical/Pediatric/Infusion accessed this locked unit with her/his badge. Observation of each of the 3 rooms revealed a camera afixed to the ceiling of each room. Upon returning to the hall of this unit, observation of the computer monitor revealed each of these rooms were completely visible on this monitor to anyone in the hall of this unit.

Interview on 5/15/23 at approximately 1:35 PM with the Director of Medical Surgical/Pediatrics/Infusion units, s/he stated that at this time there were no patients being housed on this secure unit, however this is an open unit and does provide care to psychiatric patients and has done so in the recent past. S/he is fairly new to her/his role as the Director, s/he took this role on 1/1/23. S/he explained the office the computer monitor is in is used by the infusion team/staff and they are not privy to patient information on the psychiatric unit. The computer monitor is turned facing the hall of the psychiatric unit for the benefit of staff working on the psychiatric unit. S/he was asked if patients are required to stay in their rooms or if they are allowed access to the hallway, s/he stated that patients are not required to stay in their rooms and they do have access to the hallways if they choose to come out of their room(s). S/he was asked if patients coming in to the hallway can see the computer screen that is turned facing the hallway of the psychiatric unit, s/he stated, "yes, they are able to see the computer screen". S/he was asked if that is a breach of patient privacy rights - s/he confirmed that other patient should not have access to other patients rooms without proper consent.


Tour on 5/16/23 at approximately 10:35 AM, of the locked/secure psychiatric unit/hall with the Quality Improvement Specialist, it was noted that the computer monitor was still present in the infusion nurses station/office and the monitor was still facing the unit/hall of the psychiatric unit. S/he confirmed that the computer monitor on this unit was visible to anyone who had access to the psychiatric unit/hall, including patients being housed on this unit. S/he confirmed that this would be a violation of the hospital policy and patient rights but s/he would ask the Director of Medical Surgical/Pediatric/Infusion unit to come to the psychiatric unit to discuss further. The Director of Medical Surgical/Pediatric/Infusion unit arrived on the psychiatric unit on 5/16/23 at approximately 10:40 AM. S/he confirmed that the monitor placement had not changed since the surveyors original tour on 5/15/23 and that anyone on the secure psychiatric unit had access to each room, including patients who may be in the hallway. S/he explained that this computer monitor has been on this unit since she took the role as the Director of Medical Surgical/Pediatric/Infusion unit on January 1, 2023.

The Director of Medical Surgical/Pediatric/Infusion unit was asked about the computer monitor, s/he stated s/he could not really speak to why it was there. S/he stated that when there are patients on this unit, each patient is assigned a "sitter" who sits outside each room and has a constant visual of their patient to ensure safety. S/he confirmed that patients are free to stay in their room or come out into the hallway. S/he was asked about the use of the computer monitor and why it was facing the hallway of this unit. S/he explained that the office the monitor is in (nurses station) is for the infusion team/staff to do their documentation and discuss cases/patients. They are not part of the psychiatric unit/hall and would not be privy to what is happening on that unit, therefore, the monitor is turned so staff/sitters have a visual of each room on the computer monitor. This contradicts the original statement that each "sitter" sits outside the patient room and has a constant visual on the patient. The Director of Medical Surgical/Pediatric/Infusion was asked why a computer monitor is needed for the unit if each psychiatric patient has their own assigned "sitter". S/he stated she did not know.

Review of the hospital policy titled, "Patient Rights & Responsibilities" on page 2, number 12 states, "To expect privacy, to the extent feasible, during provision of care. Case discussion, consultation, examination, and treatment are confidential and shall be conducted discreetly. Those not directly involved in the patients care must have the permission of the patient to be present.......".