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Based on the findings of the Sample Validation and complaint survey concluded on 01/25/10, it was determined Condition of Participation: Organizational Structure was not met. The facility failed to demonstrate that the governing body or the individual who assumes responsibility for Critical Access Hospital (CAH) operation was involved in the day-to-day operation of the CAH. Findings of a follow-up survey conducted on 02/12/10 determined the Condition of Participation:Organizational Structure continued not to be met.

Under Condition of Participation 485.627.
Refer to Standard Tag, C241















16845


Based on a follow-up survey conducted on 03/23-24/10, it was determined the Condition of Participation of Organizational Structure continued not to be met. The facility failed to demonstrate that the governing body or the individual who assumed responsibility for the Critical Access Hospital (CAH) operation provided sufficient involvement and supervision in the day-to-day operation of the CAH to ensure all Conditions of Participation were in compliance.

Refer to C241, C270, C276, C295, C330, and C336.

16845


Based on observations, interviews, and record reviews it was determined the facility failed to ensure the governing body or the individual who assumes responsibility for the Critical Access Hospital (CAH) provided sufficient direction and involvement to ensure quality health care was provided in a safe environment. The facility failed to ensure nursing care was provided in accordance with the facility's policies and procedures and in accordance with the patient's needs and provided quality care and treatment by competent nursing staff. The facility failed to meet the wound care, oral and intravenous (IV) medication administration, and infection control needs of patients #1 #2, #3, #4, #5, and #6.

The findings include:

The failure of the facility to ensure staff followed the facility's policies resulted in staff not providing quality care. Observations include the following:

1. Facility staff failed to follow facility policy on 03/23/10 at 1:10 PM and administer oral Carafate to Patient #2 one hour prior to the meal in order to ensure the maximum effectiveness of the medication.

2. Facility staff failed to administer Remeron properly (place on the patient's tongue and allow it to dissolve) to Patient #2 on 03/24/10 at 8:30 AM.

3 Facility staff failed to follow the facility's infection control polices to prevent the possible spread of the C-diff germ when providing care to Patient #3 on 03/23/10 at 1:20 PM.

4. Facility staff failed to follow the facility's procedure reference book related to the proper procedure in administering IV medications and the proper placement of an IV after infiltration on Patient #4 on 03/24/10 at 9:02 AM.

5. Facility staff failed to follow infection control protocols related to placing items of patient use on the floor.

6. Facility staff failed to maintain a sterile field when performing a dressing change on Patient #5 on 03/24/10 at 10:20 AM. Additionally, staff failed to follow the Physician's orders related to the dressing change on Patient #5.

7. Facility staff failed follow facility policies related to washing their hands when handling medications for Patient #1 on 03/24/10 at 8:15 AM and for Patient #6 on 03/24/10 at 8:25 AM.

An interview with the Chief Executive Officer on 03/24/10 at 6:00 PM revealed he had been involved in the day-to-day operation of the facility and he thought mechanisms had been put in place to identify and intervene with quality of care issues. He thought the issues related to infection control practice, wound care being provided as ordered, and medications administered appropriately had been corrected. He stated he was ultimately responsible for ensuring the facility provided quality care and treatment.






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Based on the findings of the Sample Validation and complaint survey concluded on 01/25/10, it was determined Condition of Participation: Provision of Services was not met. Findings of a follow-up survey conducted on 02/12/10 determined the Condition of Participation: Provision of Services continued not to be met.


Under Condition of Participation 485.635.
Refer to Standard Tags, C271, C276, C295, C296, and C298
















16845


Based on a follow-up survey conducted on 03/23-24/10 it was determined the Condition of Participation of Provision of Services continued not to be met.

The failure of the facility to ensure staff followed the facility's policies resulted in staff not providing quality care. Facility staff failed to follow facility policy and administer oral Carafate to Patient #2 one hour prior to the meal in order to ensure the maximum effectiveness of the medication. Staff failed to administer Remeron properly (place on the patient's tongue and allow it to dissolve) to Patient #2. Staff failed to follow the facility's infection control polices to prevent the possible spread of the C-diff germ when providing care to Patient #3. Staff failed to follow the facility's procedure reference book related to the proper procedure in administering IV medications and the proper placement of an IV after infiltration on Patient #4. Additionally, staff failed to follow infection control protocols related to placing items of patient use on the floor. Staff failed to maintain a sterile field when performing a dressing change on Patient #5. Additionally staff failed to follow the Physician's orders related to the dressing change on Patient #5.

Refer to C276 and C295.

Based on observation, interview and record review it was determined the facility failed to ensure staff follow their policies and procedures regarding appropriate handling and administration of drugs and biologicals for four patients (#2, #4, #1 and #6) in the selected sample of eight.

The findings include:

Review of the facility's policy "Standard Medication Times" revealed Carafate was to be administered before meals and at bedtime. Review of the facility's nursing reference drug book revealed Carafate was to be administered on an empty stomach one hour before or two hours after meals. Additionally, Remeron disintegrating tablets should be removed from the blister pack and immediately placed on the patient's tongue. Review of the facility policy "Medication Administration" revised 01/28/10 revealed medications are administered as prescribed in accordance with good nursing principles and practices. Personnel authorized to administer medications should do so only after they have familiarized themselves with the medications. Additionally, if liquid dosage forms may be a practical alternative to crushing medications. If the liquid form was to be used the physician "must be contacted for an order with the new medication, dose, etc." Medications are administered in accordance with written orders of the attending physician. The preparation portion of the policy detailed the following: When it is necessary to break a tablet to administer the proper dosage, hand-washing is done prior to the procedure, according to facility policy. A tablet-splitter is used to avoid contact with the tablet. If the tablet is scored, every attempt is made to break along score lines. Since unscored tablets may not be accurately broken, their use is discourage if a suitable alternative is available. (such as liquid or half-strength). Where possible, the pharmacy is requested to package half-tablets.

1. Observations during a medication pass on 03/23/10 at 1:10 PM revealed Registered Nurse (RN) #2 administered Carafate Suspension 1 Gram by mouth to Patient #2. Review of Patient #2's medical record revealed a physician's order on 03/19/10 at 9:13 AM for "Carafate 1 gram po (by mouth) qid (four times a day)." An additional observation of a medication pass on 03/24/10 at 8:30 AM revealed RN #1 administered Mirtazapine (Remeron) orally disintegrating tablet 15 mg by mouth mixed with seven other oral medications to Patient #2. Patient #2 and RN #1 dropped some of the medications on the medication administration sheet (MAR) and picked them up and handled the pills in their hands. The Remeron was administered with all of the other medications and followed with coffee.

An interview with the the Medical/Surgical Director on 03/23/10 at 4:10 PM revealed Patient #2 was served lunch between 12:00 PM and 12:30 PM. She stated it was the facility's policy for Carafate to be administered before meals. RN #2 did not follow facility policy. She stated she had observed some of the nurses administering medications but she had not identified the problem.

An interview with the Pharmacist on 03/25/10 at 11:30 AM revealed Carafate should be given one hour prior to eating. Administering Carafate after eating and on a full stomach causes the medication to be less effective. A second interview with the Pharmacist conducted on 03/24/10 at 3:15 PM revealed Remeron disintegrating tablet should be administered by itself to get the full effect.

2. A review of the facility's drug administration reference book revealed the following instructions when administering a medication IV: Assess the patient's IV site for redness, swelling, or pain. Wipe the injection port with an alcohol pad and insert a saline-filled syringe. Aspirate the syringe and observe for blood to verify the patency of the device. If no blood appears apply a tourniquet slightly above the site, keep it in place for about 1 minute and aspirate again. If the blood still does not appear remove the tourniquet and inject the normal saline solution slowly. Stop the injection if you feel any resistance because resistance indicates that the device is occluded. If this occurs insert a new saline lock. After a patent IV is established, saline solution should be administered slowly, followed by the medication, and then flush with saline solution again.

Observation of an administration of a IV medication to Patient #4 by RN #1 was conducted on 03/24/10 at 9:02 AM. RN #1 drew up Solumedrol 125 mg in a syringe and mixed it with normal saline. There was a total of 8 ml in the syringe. RN #1 cleaned the saline lock of Patient #4 and inserted the needle of the syringe containing the Solumedrol. RN #1 aspirated (attempted to draw blood back in to the tubing to determine if the needle was in the vein) the syringe and there was no blood return. RN #1 began pushing the Solumedrol/Normal Saline mixture slowly while observing and touching the IV site. RN #1 stated she was not sure the IV was in the vein. She proceeded with the administration of the drug slowly. After administering 2 ml of the Solumedrol/Normal Saline mixture (leaving 6 ml in the syringe) she determined the IV was infiltrated (not in the vein). She stopped the administration of the drug and discontinued the IV which was in the lower left forearm. RN #1 restarted the IV in the left hand of Patient #4, administered the Solumedrol/Normal Saline mixture (6 ml), and flushed the IV with Normal Saline.

An interview with RN #1 on 03/24/10 at 2:40 PM revealed she had always administered IV medication the way the surveyor observed. She was not aware she was not following facility policy.

An interview with the Chief Nursing Officer (CNO) and the Medical/Surgical Director on 03/24/10 at 3:20 PM revealed RN #1 did not follow appropriate protocol in administering IV medication. They stated it was not possible to know how much medication the Patient received IV (medication error).

3. Observations during a medication pass on 03/24/10 at 8:15 AM revealed RN #3 was in the medication room preparing to administer five (5) oral medications to Patient # 1 . The nurse did not wash or sanitize her hands before obtaining the medications from the medication cart. When obtaining Dexamethasone for administration, the tablet dosage was 4 mg. but the ordered dosage was 2 mg. The nurse obtained a pill splitter, cleaned it with water, and placed the tablet in the splitter. The nurse halfed the pill with the splitter, picked up the pill and placed half of the pill back into its blister pack container to deliver it to the patient's room. The nurse neither sanitized her hands nor wore gloves when handling the pill.

4. Further observation of medication pass by RN #3 on 03/24/10 at 8:25 AM revealed the nurse was preparing to administer four (4) medications to Patient #6. The nurse obtained a Betapase tablet from a drawer of the medication cart in a dosage that required it be split in order to deliver the ordered dosage to the patient. The nurse obtained the pill, split it with bare hands, and placed it in a medication cup. The nurse stated, "It was scored." The nurse neither washed or sanitized her hands nor wore gloves when handing the pill.

Interview with RN #3 on 03/24/10 at 2:00 PM revealed she should have washed her hands or used gloves when handling pills. She stated she thought she washed her hands when entering the medication room. However, she did not see the need for further washing before handling the pill. She admitted she did not consider that she opened medication cart drawers and removed medications with bare hands before handling the pills.

Interview with the CNO on 03/24/10 at 9:10 AM revealed that acceptable nursing practice for splitting scored pills was to "put on a clean glove and pop it" or use a pill splitter for non-scored pills. She said she did not know the facility's policy on pill splitting but felt that pharmacy should be requested to dispense pills in half when that dosage is ordered.










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21585

Based on observations, interviews and record reviews, it was determined the facility failed to ensure nursing care was provided in accordance with the patient's needs. The facility's failure to meet the wound care, oral and intravenous (IV) medication administration, and infection control needs of four patients (#2, #3, #4, #5) in the selected sample of eight, prevented patients from being monitored and provided quality care and treatment by competent nursing staff.

The findings include:

1. A review of the facility's medication reference book revealed Carafate should be administered on an empty stomach 1 hour before or 2 hours after meals. Remeron disintegrating tablets should be removed from the blister pack and immediately placed on the patient's tongue.

Observation of a medication pass on 03/23/10 at 1:10 PM revealed Registered Nurse #2 administered Carafate Suspension 1 gram by mouth to Patient #2. Patient #2 was served lunch between 12:00 PM and 12:30 PM. Observation of a medication pass on 03/24/10 at 8:30 AM revealed RN #1 administered Mirtazapine (Remeron) orally disintegrating tablet 15 mg by mouth mixed with seven other oral medications. Patient #2 and RN #1 dropped some of the medications on the medication administration sheet (MAR) and picked them up and handled the pills in their hands. The Remeron was administered with all of the other medications and followed with coffee.

An interview with the Medical/Surgical Director on 03/23/10 at 2:15 PM revealed RN #2 did not follow facility medication administration policies. Carafate should be administered one hour before meals.

An interview with the Pharmacist on 03/24/10 at 11:30 AM revealed Carafate should be given one hour prior to eating to make it the most effective. Additionally, an interview with the Pharmacist on 03/24/10 at 3:15 PM revealed Remeron disintegrating tablet should be administered by itself to get the full effect.

2. A review of the facility's signs that were posted on the doors of patient's who had "Contact Precautions" revealed gloves and gowns were to be worn when entering the room and removed prior to leaving the room. Additionally, dedicate the use of noncritical patient care equipment to a single patient and clean and disinfect any common equipment between patients. A review of the facility fact sheet regarding "Clostridium difficile" (C-diff) (the germ Patient #3 was infected with) was conducted. It revealed C-diff is a germ that can cause diarrhea. The spores can live outside the human body for a very long time and may be found on things in the environment such as bed linens, bed rails, bathroom fixtures, and medical equipment. C-diff infection can be spread from person to person on contaminated equipment and on the hands of doctors, nurses, and other healthcare providers and visitors.

Observations during a medication pass on 03/23/10 at 1:20 PM revealed Licensed Practical Nurse (LPN) #1 put on gloves and a gown outside of Patient #3's room. She entered Patient #3's room who was in "Contact Isolation" carrying medications and a clip board that had Patient #3's MAR on it. The LPN placed the MAR on the patient's bedside table and the clip board on the counter top by the sink. After administering the oral medications the LPN removed her gloves and washed her hands. The MAR was moved to the counter by the sink. LPN #1 put gloves on, lifted the folds of the stomach of Patient #3 and applied Nystatin topical powder under the folds of the stomach. The bottle in which the Nystatin powder was in was placed on the MAR. LPN #1 removed her gloves and washed her hands. The clip board and the MAR were lying close to the sink allowing for water to splash on the items. LPN #1 left the room with the clip board, the MAR, and the Nystatin powder and returned to the medication room. The Nystatin powder bottle was wiped off and placed back in to the medication cart. The MAR was placed in the book with the other MARs.

An interview with LPN #1 on 03/24/10 at 11:40 AM revealed she was not aware that C-diff spores could live outside of the human body for a long period of time and could be spread person to person so easily. She stated she should have cleaned the items before leaving the isolation room but there were no wipes in the room. Additionally, the facility policy instructs staff to take the MAR into the patient's room when administering medication.

An interview with the Chief Nursing Officer (CNO) on 03/24/10 at 12 :20 PM verified it was facility policy for nursing staff to take the MAR in the patient's room when administering medications. She stated they would have to re-evaluate the policy because she felt the practice could increase the chances of spreading infectious organisms.

3. A review of the facility's drug administration reference book revealed the following instructions when administering a medication IV: Assess the patient's IV site for redness, swelling, or pain. Wipe the injection port with an alcohol pad and insert a saline-filled syringe. Aspirate the syringe and observe for blood to verify the patency of the device. If no blood appears apply a tourniquet slightly above the site, keep it in place for about 1 minute and aspirate again. If the blood still does not appear remove the tourniquet and inject the normal saline solution slowly. Stop the injection if you feel any resistance because resistance indicates that the device is occluded. If this occurs insert a new saline lock. After a patent IV is established, saline solution should be administered slowly, followed by the medication, and then flush with saline solution again. Review of the facility's Nursing Procedure Reference book revealed when an IV infiltrates (out of the vein) a new IV should be restarted above the infiltration site or in another limb.

Observation of an administration of a IV medication to Patient #4 by RN #1 was conducted on 03/24/10 at 9:02 AM. RN #1 drew up Solumedrol 125 mg in a syringe and mixed it with normal saline. There was a total of 8 ml in the syringe. RN #1 cleaned the saline lock of Patient #4 and inserted the needle of the syringe containing the Solumedrol. RN #1 aspirated (attempted to draw blood back in to the tubing to determine if the needle was in the vein) the syringe and there was no blood return. RN #1 began pushing the Solumedrol/Normal Saline mixture slowly while observing and touching the IV site. RN #1 stated she was not sure the IV was in the vein. She proceeded with the administration of the drug slowly. After administering 2 ml of the Solumedrol/Normal Saline mixture (leaving 6 ml in the syringe) she determined the IV was infiltrated (not in the vein). She stopped the administration of the drug and discontinued the IV which was in the lower left forearm. RN# 1 obtained a tray with supplies to start an IV. She placed the IV tray on the patient's bed linen where the patient was lying. RN #1 started the IV in the left hand of Patient #4 (below the infiltration site), administered the Solumedrol/Normal Saline mixture, and flushed the IV with Normal Saline. After completing the care of Patient #4, RN #1 took the IV tray to the nurses station and sat it down on the counter, she then took it to the medication room where she sat the IV supply tray in the floor while opening the door, and it was then placed inside the medication room on top of a cabinet for patient use.

An interview with RN #1 on 03/24/10 at 2:40 PM revealed she had always administered IV medication the way the surveyor observed. She was not aware it was not following facility policy. Additionally, she felt she could have done things differently with the IV supply tray but she did not have anywhere to sit it.

An interview with the CNO and the Medical/Surgical Director on 03/24/10 at 3:20 PM revealed RN #1 did not follow appropriate protocol in administering IV medication or restarting an IV. They stated it was not possible to know how much medication the Patient received IV (medication error). When an IV infiltrated (out of the vein) it should be restated on the other arm or above the site of the infiltration. They stated RN #1 should not have placed the IV below the site of infiltration.

An interview with the Infection Control Nurse on 03/24/10 at 4:05 PM revealed that no items should be taken into a Contact Isolation room unless they are necessary. Items such as Nystatin powder should not be placed back into the medication cart nor should the MAR be taken into the room. All of those actions increase the risk of contamination and spreading it to other areas. Additionally, staff should not place items or trays being used for multiple patients on a patient's bed nor on the floor.

4. A review of the medical record of Patient #5 revealed a Physician's order on 03/21/10 at 6:00 PM to "clean open area to left lower arm with normal saline apply prescription cream as ordered, cover with 4x4, secure with tape."

Observations of a dressing change on Patient #5 performed by RN #1 was conducted on 03/24/10 at 10:20 AM. RN #1 removed the old dressing from the arm and discarded it. The dressing was a non-adherent dressing that had a large amount of yellow/green drainage on it. RN #1 set up a sterile field and placed all of the dressing supplies on the sterile field. There were two saline filled syringes and one of the syringes was hanging off of the sterile field and lying on the patient's bedside table. RN #1 put her gloves on, picked up the syringe that was hanging off of the sterile field, removed the top to the syringe, and dampened the gauze dressings with the saline. The wound was cleansed with the gauze and then a 3 inch by 4 inch non-adherent dressing with Silvadene cream was applied. RN #1 questioned during the dressing change weather a non-adherent dressing was the best dressing for the wound. RN #1 stated she felt the non-adherent dressing could be making the wound worse.

An interview with RN #1 on 03/24/10 at 10:35 AM revealed she looked at the Physician's order before she performed the dressing change on Patient #5 and was aware it said "4x4", but she replaced the same dressing with what was already on the wound. She stated she was not aware that the syringe was off of the sterile field.

An interview with the Medical/Surgical Director on 03/24/10 at 11:10 AM revealed the Physician's order stating "4x4" usually means a gauze dressing. The Physician should have been notified and the order clarified. Additionally, the non-adherent dressing that RN #1 applied to the wound of Patient #5 did not come in the measurements of 4x4. She stated RN #1 failed to follow Physician's orders for Patient #5 and she contaminated her sterile dressing.

The failure of the facility to ensure staff followed the facility's policies resulted in staff not providing quality care. RN #2 failed to follow facility policy and administer oral Carafate to Patient #2 one hour prior to the meal in order to ensure the maximum effectiveness of the medication. RN #1 failed to administer Remeron properly (place on the patient's tongue and allow it to dissolve) to Patient #2. LPN #1 failed to follow the facility's infection control polices to prevent the possible spread of the C-diff germ when providing care to Patient #3. RN #1 failed to follow the facility's procedure reference book related to the proper procedure in administering IV medications and the proper placement of an IV after infiltration on Patient #4. Additionally, RN #1 failed to follow infection control protocols related to placing items of patient use on the floor. RN #1 failed to maintain a sterile field when performing a dressing change on Patient #5. Additionally RN #1 failed to follow the Physician's orders related to the dressing change on Patient #5.




21585

Based on the findings of the Validation and complaint survey concluded on 01/25/10, it was determined Condition of Participation: Periodic Evaluation and Quality Assurance Review
was not met. The facility failed to demonstrate an effective quality assurance program that monitored and evaluated medication storage, medication labeling, wound care, infection control practices and medical records for completeness and accuracy. Findings of a follow-up survey conducted on 02/12/10 determined the Condition of Participation: Periodic Evaluation and Quality Assurance Review continued not to be met.


Under Condition of Participation 485.641.
Refer to Standard Tags, C336








16845


Based on the findings of a follow-up visit on 03/23-24/10, it was determined the Condition of Participation Periodic Evaluation and Quality Assurance Review continued to not be met. Although the facility developed new monitors or initiatives for their quality assurance program it was not effective in identifying continued quality of care issues.

Refer to C336.

16845


Based on observations, interviews, and record reviews it was determined although the facility had revised and developed new initiatives in their quality assurance program, it was ineffective in identifying continued problems with quality of care of patients. The quality assurance plan failed to identify the failure of nursing care to be provided in accordance with the facility's policies and procedures and in accordance with the patient's needs and provided quality care and treatment by competent nursing staff.

The findings include:

Observations made during the follow-up visit revealed the following:

1. Facility staff failed to follow facility policy on 03/23/10 at 1:10 PM and administer oral Carafate to Patient #2 one hour prior to the meal in order to ensure the maximum effectiveness of the medication.

2. Facility staff failed to administer Remeron properly (place on the patient's tongue and allow it to dissolve) to Patient #2 on 03/24/10 at 8:30 AM.

3 Facility staff failed to follow the facility's infection control polices to prevent the possible spread of the C-diff germ when providing care to Patient #3 on 03/23/10 at 1:20 PM.

4. Facility staff failed to follow the facility's procedure reference book related to the proper procedure in administering IV medications and the proper placement of an IV after infiltration on Patient #4 on 03/24/10 at 9:02 AM.

5. Facility staff failed to follow infection control protocols related to placing items of patient use on the floor.

6. Facility staff failed to maintain a sterile field when performing a dressing change on Patient #5 on 03/24/10 at 10:20 AM. Additionally, staff failed to follow the Physician's orders related to the dressing change on Patient #5.

7. Facility staff failed follow facility policies related to washing their hands when handling medications for Patient #1 on 03/24/10 at 8:15 AM and for Patient #6 on 03/24/10 at 8:25 AM.

An interview with the Chief Executive Officer (CEO) on 03/24/10 at 6:00 PM revealed he had hired a new quality assurance director but they had not been able to start and he had been in charge of the quality assurance department. He stated he thought mechanisms had been put in place to identify and intervene with quality of care issues. The CEO stated he reviewed the results of the monitors they had put in place and he thought there had been good progress with the care provided to the patients. He thought the issues related to infection control practice, wound care being provided as ordered, and medications administered appropriately had been corrected.

Interviews with the Chief Nursing Officer and the Medical/Surgical Director on 03/24/10 at 6:15 PM revealed they had been monitoring dressing changes and an occasional medication pass and thought the quality of care practices had been corrected. They were surprised by the problems identified by the surveyors. They stated they had not identified any of these problems with their observations and monitors they had put in place.