HospitalInspections.org

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Based on observation and interview, the Critical Access Hospital failed to ensure that patient care supplies were not stored or available for patient use beyond the manufacturer's expiration date.
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Failure to properly maintain supplies places patients at risk for infection and delays in treatment.
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Findings:
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1. During the survey, the following observations were made:
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a. On 6/9/2015 at 10:00 AM in the emergency department, Surveyor #1 found the following: four packages of sterile gloves sized 8 ½ with an expiration date of 5/2015; two multi-lumen central venous catheter insertion kits with an expiration date of 1/2015; two bags of 0.9% sodium chloride 2000 ml irrigation solutions with an expiration date of 2/1/2015; three culture swabs with an expiration date of 4/2015; one culture swab with an expiration date of 5/2015; one 1000 ml intravenous bag of lactated ringers with an expiration date of 5/1/2015; one 22 gauge intravenous catheter with an expiration date of 5/2015; one 2oz tube of skin protectant containing aloe vesta with an expiration date of 1/2015; one 2 oz tube of skin protectant with an expiration date of 12/2014; eight gastroccult test cards with an expiration date of 12/2014; and one gastrocccult developer solution with an expiration date of 9/2014.
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b. On 6/9/2015 at 11:00 AM in the operating room area, Surveyor #3 found the following: three stryker blades with an expiration date of 3/2015; one blue topped specimen tube with an expiration date of 5/2015; and one stablecut surgical saw blade with an expiration date of 1/2015.
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c. On 6/9/2015 at 1:30 PM in the short stay surgery area, Surveyor #3 found one package of monitoring electrodes with an expiration date of 4/2015.
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d. On 6/9/2015 at 3:45 PM in the family birth center, Surveyor #3 found two green topped specimen tubes with an expiration date of 5/2015.
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2. On 6/9/2015 at 10:00 AM, Surveyor #1 interviewed the Manager of the Medical Surgical Unit and Emergency Department (Staff Member #1) who stated the nursing staff was responsible for checking for outdated or expired patient supplies on a monthly basis. At the time of survey, no hospital policy and procedure could be found describing this process.
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Based on observation, interview, and document review, the Critical Access Hospital failed to ensure that all facility and medical equipment is listed under their inventory and included in the facility's preventive maintenance program.

Failure to have all equipment included in the hospital's preventive maintenance program puts patients at risk from malfunctioning equipment.

Findings:

On 6/10/2015 at 3:50 PM, Surveyor #2 interviewed a plant mechanic (Staff Member #3) about the hospital's preventive maintenance program. The surveyor asked to see the preventive maintenance history for the facility's laboratory and radiology equipment. The staff member was unable to locate any maintenance history for these items and concluded that it was not part of the current facility inventory. S/he reported that the current inventory did not include all facility and medical equipment. Subsequently the surveyor asked to see a list of the facility's critical equipment. The staff member reported that the facility's critical equipment could not be readily identified on the current inventory.

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Based on observation and interview, the Critical Access Hospital failed to store food under the appropriate conditions to ensure compliance with the 2013 Food and Drug Administration (FDA) Food Code.

Failure to comply with the food service code puts patients, staff, and visitors of the facility at risk from food borne illnesses.

Findings:

On 6/10/2015 at 10:45 AM, Surveyor #2 observed one bulk container of sugar and one bulk container of flour without labels. When food is removed from its original container it must be labeled to identify the name of the food. The dietary manager (Staff Member #4) confirmed this finding at the time of the observation.

Reference: 2013 FDA Food Code 3-302.12

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Based on observation, interview, and review of hospital policies and procedures, the Critical Access Hospital failed to develop and implement an emergency water plan/agreement to ensure the safety and well-being of patients during emergency situations and/or events.

Failure to develop and implement an emergency water preparedness plan places the safety of patients, staff, and visitors of the facility at risk during non-medical emergencies.

Findings:

On 6/9/2015 at 1:36 PM, Surveyor #2 reviewed the hospital's emergency preparedness plan and interviewed the facilities manager (Staff Member #5) about emergency plans for fuel and water. The facilities manager reported that the facility did not have a plan or agreement for water during non-medical emergency events facing the facility and the surrounding community.
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Based on observation and interview, the Critical Access Hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE LIFE SAFETY CODE inspection reports.
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Based on record review and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that staff members followed its policy when caring for patients placed in restraints as demonstrated by 1 of 1 patient reviewed (Patient #4).

Findings:

1.The hospital's policy and procedure titled "Restraint" (Approved 4/13/2015) under Restraint Use for Aggressive /Self-Destructive Behavior read in part: "1. Use of restraint will be discontinued when identified criteria are met and the violent/aggressive behavior requiring the order is no longer evident. The patient will be removed from restraints as soon as possible regardless of how much time remains on the order."

2. Patient #4 was a 20-year old seen in the emergency department on 5/7/2015 for acute psychosis, agitation and aggressive behavior. The patient was placed in restraints at 7:50 PM with appropriate provider orders and documentation for restraint monitoring. However, the patient's documented behavior on 5/8/2015 from 12:00 AM to 7:45 AM was annotated as "sleeping". Surveyor #1 found no documentation in the medical record to indicate that Patient #4's behavior warranted continued application of restraints.

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ITEM #1 SECURITY OF CONTROLLED SUBSTANCES
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Based on observation and review of hospital policies and procedures, the Critical Access Hospital failed to assure proper storage and control of controlled substances.
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Failure to secure controlled substances according to hospital policy risks diversion and unsafe healthcare delivery.
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Findings:
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1. The hospital's policy and procedure titled "Controlled Substances: Storage and Control" (Approved 3/3/2015) read in part: "A limited supply of controlled substances is maintained on each nursing unit. . . 2. Schedule II to IV substances are maintained in Pyxis or locked refrigerators. 3. All Controlled Substances used on each nursing unit are documented and accounted for through the Pyxis cabinets."
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2. On 6/9/2015 at 3:45 PM in the Family Birth Center, Surveyor #1 found seven 2 ml vials of butorphanol tartrate 1mg/ml (a synthetic opioid analgesic) and one 10 ml vial of diazepam 5mg/ml (medication used to treat anxiety and seizures) stored in the "OB Cart" in the nursery room.
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ITEM #2 EXPIRED MEDICATIONS
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Based on observation and review of hospital policies and procedures, the Critical Access Hospital failed to ensure that all drug storage areas are completely inspected monthly to prevent administration of outdated medications.
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Failure to assure medication storage areas are void of outdated or otherwise unusable medications puts patients at risk for receiving medications with compromised sterility, integrity, or stability.
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Findings:
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1. The hospital's policy and procedure titled "Inspection of Drug Storage and Prep Areas" (Approved 6/17/2014) read in part: " The Pharmacy Department will conduct inspections of all Drug Storage and Preparation Areas in Whitman Hospital and Medical Center (WHMC) monthly for purpose of Quality Assurance . . . Multidose vials such as local anesthetics are allowed in medication preparation areas, but they will be discarded after 28 days when accessed, or immediately if found without date of use or if taken into a patient treatment area."
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2. On 6/9/2015 at 10:00 AM in the emergency department, Surveyor #1 found one opened 20 ml vial of 2% lidocaine with epinephrine dated 4/15/2015 and one opened vial of tuberculin purified protein dated 9/22/2014.
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3. On 6/9/2015 at 1:30 PM during a tour of the medical surgical unit medication rooms, Surveyor #1 found: one open 50 ml vial of 0.5% bupivacaine dated 3/19/2015; one open 5 ml single dose vial of diltiazem 5mg/ml; and one vial of varicella virus vaccine with an expiration date of 5/21/2015.

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Based on observation, interview and review of hospital policies and procedures, the Critical Access Hospital failed to ensure staff members performed hand hygiene according to hospital policy and accepted standards of care.
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Failure to perform proper hand hygiene can put patients at risk for health care-associated infections and potentially spread infections.
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Findings:
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1. The hospital's policy and procedure titled "Hand Hygiene" (Approved 9/20/2011) read in part: "4. Decontaminate hands: . . . h. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."
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2. On 6/10/2015 at 8:49 AM in the medical surgical unit, Surveyor #1 observed a registered nurse (Staff Member #6) during a medication pass. Staff Member #6 performed hand hygiene prior to entering the room and then administered an oral medication. Next, Staff Member #6 handled a water container and assisted the patient with drinking through a straw then repositioned an IV pump to bring it closer the patient. The registered nurse then reached into the lower front pocket of their duty uniform and retrieved both a medication syringe and a normal saline flush syringe then continued to reach under the patient's gown to locate the access port of the central line. Staff Member #6 failed to perform hand hygiene prior to administering the intravenous medications.
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3. In a subsequent interview on 6/10/2015 at 9:00 AM with the nurse manager (Staff Member #1), Staff Member #1 confirmed this finding of not following hospital policy for hand hygiene.
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Based on record review and interview, the Critical Access Hospital failed to ensure that staff members developed and implemented an activity program for 3 of 3 swing bed patients reviewed (Patients # 1, #2, #3).
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Failure to develop and implement an activities plan for swing bed patients risks impairment of physical, mental, and psychosocial well-being.
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Findings:
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1. During record review on 6/9/2015 and 6/10/2015, one of three swing bed patient records had no documentation of a comprehensive activities assessment being performed (Patient #1). Further, Surveyor #1 found no documentation to indicate the development of an activities plan or implementation of the plan to Patients #1, #2, or #3. The respective lengths of stay for the patients were 7 days, 20 days, and 35 days.
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2. On 6/11/2015 at 8:55 AM, Surveyor #1 interviewed the Social Work Manager (Staff Member #2) about the activities program. S/he confirmed it was facility policy for these patients to be assessed for activity interests and that an activities plan was to be developed for these patients. It was unclear who developed an individualized plan or monitored the delivery of activities to swing bed patients. Staff Member #2 stated the medical record did not indicate whether or not swing bed residents received those services.
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3. Review of the hospital's policies and procedures for swing bed patients at the time of interview revealed that there was no written policy and procedure regarding the facility's activities program.