HospitalInspections.org

Based on observation and interview, the hospital did not ensure that all patient care equipment was safely maintained, in that, expired equipment was available for patient use in 2 of 2 patient care areas.

Findings included:

During tours of the hospital's Medication Room located on the Medical/Surgical (M/S) Unit at approximately 11:00 AM on 12/08/10 with the M/S Unit Charge Nurse (Personnel # 24), and then the hospital's Emergency Department (ED) at 9:15 AM on 12/09/10 with the Director of Nursing (Personnel # 3), the surveyor observed the following expired equipment available for patient use in the following areas:

Medical/Surgical Unit:
1 - Aerobic culture bottle, expired 08/31/10.
1 - Aerobic culture bottle, expired 10/31/10.
1 - Anaerobic culture bottle, expired 08/31/10.
1 - Anaerobic culture bottle, expired 09/31/10.

Emergency Department:
1 - Sexual Assault Nurse Examination (SANE) kit, expired 01/02.

In separate interviews at approximately 11:00 AM on 12/08/10, and 9:15 AM on 12/09/10, both Personnel # 24 and Personnel #3 confirmed the above expired equipment had been available for patient use in those 2 patient care areas.

Based on interview and record reviews, the Critical Access Hospital failed to maintain complete medical records in that the medical records of 13 of 13 patients (Patients #4 through #17) treated and discharged from the hospital between 02/25/10 and 11/07/10 contained medical record entries that were not complete, dated, timed, and/or authenticated as required by 25 Texas Administrative Code (TAC) 133.41 (j)(5).

25 TAC 133.41 (j)(5): Medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

Findings included:

The "Direct Admission History & Physical" nurse practitioner's signature was not timed for the following patient:
Patient #12 - 10/12/10

The "Discharge Summary" nurse practitioner's signature was not timed for the following patients:
Patient #12 - 10/15/10
Patient #17 - 06/25/10

The "Patient Authorization Record" signature was not completed, timed, and/or dated by the hospital's witness for the following patients:
Patient #4 - 03/09/10 (not timed)
Patient #5 - 02/25/10 (not timed)
Patient #6 - 10/05/10 (not timed)
Patient #7 - 09/13/10 (not timed)
Patient #8 - Admitted 08/18/10 (no witness signature, date, and time)
Patient #11 - 07/29/10 (last name of signature was letter only, not timed)
Patient #12 - 10/12/10 (not timed)
Patient #13 - 08/07/10 (last name of signature was letter only, not timed)
Patient #14 - 07/13/10 (not timed)
Patient #15 - 06/18/10 (not timed)
Patient #16 - 10/29/10 (last name of signature was letter only, not timed)

The "Notice" record signature was not completed, dated, and/or timed by the hospital's "MMH" representative for the following patients:
Patient #4 - 03/09/10 (not timed)
Patient #5 - 02/25/10 (not timed)
Patient #6 - 10/05/10 (not timed)
Patient #7 - 09/13/10 (not timed)
Patient #8 - Signed by the patient 08/18/10 (no representative signature, date, and time)
Patient #11 - Signed by the patient's representative 07/29/10 (last name of signature was letter only, not dated, and not timed)
Patient #12 - 10/12/10 (not timed)
Patient #13 - 08/07/10 (last name of signature was letter only, not timed)
Patient #14 - 07/13/10 (not timed)
Patient #15 - 06/18/10 (not timed)
Patient #16 - 10/29/10 (last name of signature was letter only, not timed)
Patient #17 - 06/23/10 (not timed)

The "Emergency Department Adult Instructions" nurse's signature was not timed for the following patient:
Patient #7 - 09/13/10

The "Consent for Administration of Anesthesia by a Certified Registered Nurse Anesthetist" signature was not timed by the hospital's witness for the following patients:
Patient #4 - 03/11/10
Patient #5 - 02/25/10

The "X-Ray Report" electronic signature was not dated and timed for the following patient:
Patient #6 - "Interpretation Date: 10-06-2010 15:32," "Interpretation Date: 10-06-2010 15:40," and "Interpretation Date: 10-06-2010 15:43"
Patient #7 - "Interpretation Date: 09-14-2010 11:26"
Patient #8 - "Interpretation Date: 08-19-2010 22:09" and "Interpretation Date: 08-20-2010 13:28"
Patient #9 - "Interpretation Date: 06-27-2010 15:00" and "Interpretation Date: 06-27-2010 15:06"
Patient #10 - "Interpretation Date: 10-07-2010 21:47"
Patient #12 - "Interpretation Date: 10-18-2010 10:35"
Patient #14 - "Interpretation Date: 07-15-2010 13:59"

The "Authorization for family or friends to receive information" signature was not completed, dated, and/or timed by the hospital's witness for the following patients:
Patient #6 - Signed by patient 10-04-10 (not dated and not timed)
Patient #11 - Admitted 07/29/10 (last name of signature was letter only, not dated, and not timed)
Patient #14 - Signed by patient 07/13/10 (last name of signature was letter only, not dated, and not timed)
Patient #16 - Admitted 10/29/10 (last name of signature was letter only, not dated, and not timed)

The "Release of Siderails" signature was not timed by the hospital's witness for the following patient:
Patient #11 - Dated 09/02/10 and 09/02/10 (two signatures)

The "Graphic Record" entries that included vital signs, oxygen saturations, intake and output information, weights, diet information, and/or blood sugars were not signed by the person entering the information for the following patients:
Patient #6 - 10/05/10 through 10/06/10
Patient #10 - 10/11/10 through 10/12/10
Patient #11 - 07/29/10 through 08/02/10
Patient #13 - 08/07/10 through 08/08/10
Patient #16 - 10/29/10 through 11/01/10
Patient #17 - 06/23/10 through 06/26/10

The "Nursing Admission Database" signature was not timed for the following patient:
Patient #17 - 06/23/10

During an interview at approximately 11:45 AM on 12/09/10, the Director of Nursing (Personnel #3) was asked to review the above medical record information for Patients #4 through #17. The Director of Nursing (Personnel #3) confirmed that the signatures authenticating the medical record entries for Patients #4 through #17 were not dated, timed, and/or complete.

Review of the medical staff "Rules and Regulations" (07/09/09) noted, "...the attending physician is ultimately responsible for the timely, legible, accurate, and complete preparation of a medical record for each patient in the Hospital..."

Based on observation, interviews, and record review, the hospital had not followed their policy to ensure that drugs and biologicals: A) had pharmacy oversight for 2 of 3 drug storage areas in the hospital for security, or B) that were outdated, had been removed from 2 of 3 patient care areas so they were not available for patient use.

Findings included:

A) During tours of the hospital's Medical/Surgical (M/S) Unit's Procedure Room at 3:00 PM on 12/07/10 with the Director of Nursing (Personnel # 3), and then the Medication Room at approximately 11:00 AM on 12/08/10 with the M/S Unit Charge Nurse (Personnel # 24), the surveyor observed the following unlocked, unsecured drug storage areas:

Medical/Surgical Unit:
Procedure Room:
This room is located on a main patient/visitor hallway near the nurses's station. During the tour, the surveyor noted that the door to this room was open, and that drugs used for procedures were in an unlocked cabinet.

In an interview with the Director of Nursing (Personnel #3) at 3:00 PM on 12/07/10, she agreed that the drugs used for procedures were not locked or secured, and were easily accessible to unauthorized persons.

Medication Room:
This room is located a few feet from a main patient/visitor hallway near the nurse's station. During the tour, the surveyor observed that the door to the Medication Room was unlocked and open. The Medication Room which contained all the types of medications used for drug therapy in the hospital was unoccupied.

In an interview with the M/S Unit Charge Nurse (Personnel #24) at approximately 11:00 AM on 12/08/10, she verified that the Medication Room which contained all types of medications used to treat the hospital's patients, was open, unlocked and unsecured.

In an interview with the Director of Nursing (Personnel #3) at 11:30 AM on 12/08/10, she stated that they had been having trouble with the lock on the Medication Room door, and had recently requested maintenance to work on it . She said that graphite had been used on the lock, and then attempted to use several different keys to lock the door. However, none were operational and she was unable to lock the Medication Room door.

Review of the hospital's written drug policies and procedures, revealed that the process to ensure that drugs and biologicals are secured and/or locked, is located in their "Job Description - Director of Pharmacy/Consultant Pharmacist" policy, Reference No. 02-04, last reviewed 03/04/10, and noted the following:
-"the Pharmacist-in-Charge is responsible for all drug storage...in the hospital"...and, "ensures that the pharmacy...complies with all applicable policies, procedures, codes and standards of the hospital."
-The Pharmacist-in-Charge job duties and responsibilities include: "performs or assigns monthly nursing unit inspections," and to "comply with all applicable federal, state and local laws, rules and regulations."

In an interview with the Pharmacist-in-Charge (Personnel # 20) at 1:25 PM on 12/08/10, when asked if he was aware that there were unsecured and unlocked drug storage areas in the hospital, he said "no." He stated that he is a contract pharmacist and is in the hospital once a month, and usually checks the drug storage areas in the hospital.

B) During tours of the hospital's Medication Room located on the Medical/Surgical (M/S) Unit at approximately 11:00 AM on 12/08/10 with the M/S Unit Charge Nurse (Personnel # 24), and then the hospital's Emergency Department (ED) at 9:15 AM on 12/09/10 with the Director of Nursing (Personnel # 3), the surveyor noted the following expired drugs and biologicals were available for patient use in the following areas:

Medical/Surgical Unit:
Medication Room :
11- liter bags of 1/2 Normal Saline intravenous (IV) fluid, expired 11/10.
Room 115, Crash Cart:
1 -Procainamide injectable, 10 milliliter bottle, expired 12/01/10.

Emergency Department:
Crash Cart:
1 -Procainamide injectable, 10 milliliter bottle, expired 12/01/10.
1 -liter bag of Lactated Ringers intravenous (IV) fluid, expired 10/10.

In interviews at approximately 11:00 AM on 12/08/10 with the M/S Unit Charge Nurse (Personnel # 24), and then the hospital's Emergency Department (ED) at 9:15 AM on 12/09/10 with the Director of Nursing (Personnel # 3), both confirmed that the above drugs and biologicals were expired and available for patient use.

A review of drug policies and procedures, revealed the hospital's process for pharmacy monitoring and removing expired drugs and biologicals from patient care areas, was located in their "Job Description - Director of Pharmacy/Consultant Pharmacist" policy, Reference No. 02-04, last reviewed 03/04/10, and noted the following:
-"the Pharmacist-in-Charge is responsible for all drug storage...in the hospital"...and, "ensures that the pharmacy...complies with all applicable policies, procedures, codes and standards of the hospital."
-The Pharmacist-in-Charge job duties and responsibilities include: "performs or assigns monthly nursing unit inspections," and to "comply with all applicable federal, state and local laws, rules and regulations."

In an interview with the Pharmacist-in-Charge (Personnel # 20) at 1:25 PM on 12/08/10, when asked how expired drugs and biologicals were removed from patient care areas in the hospital, he said that the Pharmacy Technician (Personnel # 27) does monthly checks, and removes expired drugs and biologicals.

In an interview with the Pharmacist-in-Charge (Personnel # 20) at 1:25 PM on 12/08/10, when asked if he was aware that there were unsecured and unlocked drug storage areas in the hospital, he said "no." He stated that he is a contract pharmacist, that he is required to be on-site one day a month, and that he usually checks the drug storage areas when he is in the hospital.

Based on interview and record review, the regular insulin drug was not administered in accordance with the written and signed physician orders for 2 of 3 patients (Patients #16 and #20) hospitalized between 08/07/10 and 11/11/10.

Findings included:

1) Patient #16 (age 92) was admitted to the hospital on 10/29/10 for treatment that included "...diabetic control..." The 10/29/10 physician's orders for "Sliding Scale Insulin" noted blood sugars were to be recorded before meals (AC) and at hour of sleep (HS) with regular insulin injected subcutaneously based on blood sugar ranges that included "0" units for a blood sugar range of 70-150 AC and HS.

The "Medication Administration Record" was documented by the nurse as follows:
10/30/10 07:00 AM - nurse initialed with amount of regular insulin not recorded
10/31/10 07:00 AM - nurse initialed "0" units of regular insulin given
11/01/10 07:00 AM - nurse did not document
11/01/10 09:00 PM - nurse initialed "0" units of regular insulin given.
(There was no documentation on Patient #16's "Graphic Record" that indicated blood sugars for the above dates and times were drawn.) Note: The physician's order read "0" units for a blood sugar range of 70-150 AC and HS.

2) Patient #20 (age 53) was admitted to the hospital on 11/09/10 for treatment that included uncontrolled diabetes. The 11/09/10 physician's orders for "Sliding Scale Insulin" noted blood sugars every 6 hours with regular insulin injected subcutaneously based on blood sugar ranges that included "0" units of regular insulin for a blood sugar range of 70 - 150 and "3" units of regular insulin for a blood sugar range of 151-200.

The "Medication Administration Record" was documented by the nurse as follows:
11/10/10 11:00 AM - nurse initialed with amount of regular insulin not recorded (Patient #20's 11/10/10 11:00 AM blood sugar on the "Graphic Record" was documented as "151.") Note: The physician's order read "3" units of regular insulin for a blood sugar range of 151-200.
11/10/10 05:00 PM - nurse initialed with amount of regular insulin not recorded. (There was no documentation on Patient #20's "Graphic Record" that indicated blood sugar was drawn on 11/10/10 at 05:00 PM.) Note: The physician's order read "0" units of regular insulin for a blood sugar range of 70-150.

Patient #20's "Physician's Orders" dated 11/10/10 05:30 PM noted to change the blood sugar draws to AC and HS with before meal regular insulin coverage that included "5" units of regular insulin for a blood sugar range of 201-250.

On 11/11/10 at 07:00 AM, the nurse initialed "3" units of regular insulin as given. (Patient #20's 11/11/10 7:00 AM blood sugar on the "Graphic Record" was recorded as "206.") Note: The physician's order read "5" units of regular insulin for a blood sugar range of 201-250.

During an interview at 12:15 PM on 12/09/10, the Director of Nursing (Personnel #3) reviewed the insulin medication administration information for patients #16 and #20 with the surveyor and agreed that based on Patient #16 and #20's medical record documentation, the drug (regular insulin) was not administered by the nurse according to the physician's orders.

Based on interview and record review, the Critical Access Hospital did not maintain a clinical records system in accordance with written policy in that the "Memorandum of Transfers" for 3 of 3 patients (Patients #8, #9, and #18) transferred to a different hospital from 06/26/10 through 11/27/10 were not filed separately from the medical records of Patients #8, #9, and #18 according to their own "Transfer Policy" revised/reviewed 09/03/09.

Findings included:

The medical record of Patient #8 (age 47) included a "Memorandum of Transfer" that noted Patient #8 was evaluated for chest pain in the Emergency Department on 08/18/10 and that the hospital contacted another hospital on 08/18/10 to transfer Patient #8 for "cardiac" care.

The medical record of Patient #9 (age 53) included a "Memorandum of Transfer" that noted Patient #9 was evaluated for a fracture, dislocation of the left ankle in the Emergency Department on 06/26/10 and that the hospital contacted another hospital on 06/26/10 to transfer Patient #9 for a "higher level of care."

The medical record of Patient #18 (age 52) included a "Memorandum of Transfer" that noted Patient #18 was evaluated for chest pain in the Emergency Department on 11/27/10 and that the hospital contacted another hospital on 11/27/10 to transfer Patient #18 for a "higher level of care."

During an interview at approximately 10:30 AM on 12/09/10, the Health Information Director (Personnel #23) was shown the Memorandum of Transfers for Patients #8, #9, and #18 that were in their medical records and asked if the information was filed in a place separate from the medical records. Personnel #23 said that the hospital did not have a separate file for the "Memorandum of Transfer" information.

The "Transfer Policy" revised/reviewed 09/03/09 noted, "A copy of the memorandum of transfer will be retained and filed separately from the medical record and in a manner, which will facilitate its inspection."