HospitalInspections.org

I. Based on observation and staff interview the Emergency Room (ER) staff failed to maintain a perpetual inventory for narcotics not kept in the Pyxis system.
The CAH had an average of 80 emergency room visits per month.

Failure to maintain a perpetual inventory of narcotics could potentially lead to an unidentified drug loss and/or diversion.

Findings include:

1.Observation, during the initial tour of the ER, on 9/27/10 at 11:30 AM, revealed the following medications stored in an ER cupboard:
a. 1 medication bottle that contained 6 tablets of Vicodin,
b. 1 medication bottle that contained 6 tablets of Darvocet N 100 milligrams (mg),
c. 1 medication bottle that contained 6 tablets of Xanax 0.25 mg, and
d. 1 medication bottle that contained 6 tablets of Tylenol #3.
During an interview, at the time of the tour and observation, Staff B, Registered Nurse (RN) confirmed the bottles contained individual narcotic tablets and that staff could "open the bottles and tamper with." Staff B stated, "I can see that could be a concern."

3. During an interview on 9/28/10 at 9:30 AM, the Pharmacist confirmed each bottle contained the respective narcotics and or anti-anxiety medications. He/she also reported neither the ER staff nor the Pharmacist count the narcotics stored in the ER cupboard. The Pharmacist stated, "I count the bottles of narcotics in the cupboard at the end of each month, but I don't confirm or count the tablets in each bottle. I don't document this practice, I just know I do it."

4. During an interview on 9/28/10 at 10:00 AM, the ER Manager, RN, confirmed the ER nursing staff do not count the narcotics in the ER cupboard. The ER manager stated, "We need to keep track of these narcotics, I am not sure how at this time but [I] will work on it."

5. During an interview on 9/28/10 at 11:05 AM, the Chief Nursing Officer (CNO) stated, "We have no policy at this time for narcotics not kept in the Pyxis system. We are implementing a sheet today for keeping track of the narcotics kept in the ER cupboard."

6. Review of documentation provided by the CNO on 9/28/10 at 1:26 PM revealed in part, "...We have instituted a count sheet for the ER that will ensure these medications are counted daily. We have developed a policy that enforces this practice..."



19125

II. Based on review of policies/procedures, manufacturer's directions, observation, and staff interview, the CAH Surgical Staff failed to ensure that expired CLOtest specimen slides stored in the surgery area were not available for patient use. Surgery staff used expired CLOtest slides on 5 of 5 patients tested during the July to September time-period (patients #1, 2, 3, 4, and 5).

Failure to monitor for and remove expired CLOtest specimen slides could potentially impact the accuracy of the diagnosis and/or the treatment of an H. pylori infection.

Findings include:

1. Review of CAH policy titled "Checking Outdated Materials" revised 6/10, revealed in part, "...assure that all drugs and materials are monitored for outdates. ...departments will be checked for outdated materials on a monthly basis...OR [operating room]."

2. Review of the CLOtest Manufacture's package insert revealed in part, "...do not use the product...if the expiration date has passed."

3. Observation, during tour of the OR, revealed 6 of 6 CLOtest specimen slides that expired on 6/10 in the refrigerator, available for patient use. Staff C, a Registered Nurse, verified the findings and reported that he/she would discard the expired CLOtest slides right away. Staff C said that it looked like the ER staff had completed five tests since July of 2010 using the expired slides. According to Staff C, the ER staff had completed monthly checks for expired supplies including the CLOtest specimen slides on 7/1/10 and 8/2/10 and documented this on the log sheet.

4. Review of the CLOtest log showed that 5 patients had undergone biopsy procedures from 7/19/10 through 9/20/10 where the surgical staff sent specimens for examination on CLOtest slides. Surgical staff sent all 5 of the specimens for examination on expired CLOtest slides.

a. On 7/19/10, surgical staff sent Patient #1 ' s specimen for examination on an expired CLOtest slide.
b. On 8/2/10, surgical staff sent Patient #s 2 and 3 specimens for examination on expired CLOtest slides.
c. On 8/23/10, surgical staff sent Patient #4 ' s specimen for examination on an expired CLOtest slide.
d. On 9/20/10, surgical staff sent Patient #5 ' s specimen for examination on an expired CLOtest slide.

5. During an interview on 9/29/10 at 9:30 AM, the Chief Nursing Officer presented a letter that stated in part, "...during inspection on 9/28/10...expired CLOtest [specimen slides] were found in our refrigerator [in the OR]...no one pulled the outdated ones from the refrigerator...We will continue to check the CLOtest on monthly basis...We will also do staff education to ensure that all outdated materials are pulled from stock...As another precaution, staff will check the expiration date on the CLOtest before it is used for each case to verify it is not expired."

Based on review of policies, dish machine temperature and operation log, and staff interviews, the Critical Access Hospital (CAH) dietary staff failed to monitor dishwasher temperature each shift in accordance with their policy. The CAH had an average daily census of approximately 4 acute and swing bed in-patients.

Failure to monitor dishwasher temperature could potentially lead to ineffective cleaning and sanitizing of dishes and utensils, increasing patient risk for foodborne illnesses.

Findings include:

1. Review of CAH dietary "Dish Machine Temperature" policy revised 6/8/09 revealed in part, "...Dish machine temperatures are logged in daily to ensure proper operation of dish machine and proper sanitizing of dishes. ...each shift is responsible for recording temperature reading of dish machine."

2. Review of the 7/2010 "Dish Machine Temperature and Operation Log" revealed a document where dietary staff documented, each day of the month, the AM, noon, and PM wash temperature, final rinse temperature, and their initials. Further review of the document showed that dietary staff failed to document temperatures 7 times in 31 days. Two (of the 31) separate times the dietary staff failed to document noon and PM temperatures for 2 consecutive days; Noon temperatures on 7/20-21/10 and PM temperatures on 7/27-28/10.

Review of the 8/2010 "Dish Machine Temperature and Operation Log" revealed a document where dietary staff documented, each day of the month, the AM, noon, and PM wash temperature, final rinse temperature, and their initials. Further review of the document showed that dietary staff failed to document temperatures 13 times in 31 days. Four (of the 13) separate times the dietary staff failed to document temperatures 2 consecutive times in a day; AM and noon temperatures on 8/1/10, noon and PM temperatures on 8/4/10, AM and noon temperatures on 8/9/10, and AM and noon temperatures on 8/28/10. Two (of the 13) separate times the dietary staff failed to document noon and PM temperatures for 2 consecutive days; PM temperatures on 8/4-5/10 and noon temperatures on 8/9-10/10.

Review of the 9/2010 "Dish Machine Temperature and Operation Log" revealed a document where dietary staff documented, each day of the month, the AM, noon, and PM wash temperature, final rinse temperature, and their initials. Further review of the document showed that dietary staff failed to document temperatures 13 times in 26 days. Three (of the 13) separate times the dietary staff failed to document temperatures 2 consecutive times in a day; AM and noon temperatures on 9/1/10, Am and noon temperatures on 9/10/10, and noon and Pm temperatures on 9/19/10. Two (of the 13) separate days dietary staff failed to document noon and PM temperatures for 3 consecutive days; PM temperatures on 9/13-15/10 and noon temperatures on 9/19-21/10.

3. During an interview on 9/27/10 at 12:20 PM, Staff A, dietary assistant, reported the staff monitored dish machine temperatures three times a day "for clean and sterilized dishes." He/she stated, "We're taught in orientation to monitor and record dish machine temperature and the dishwasher [person] is responsible [for monitoring and recording the temperatures]."

4. During an interview on 9/28/10 at 12:26 PM, Dietary Supervisor confirmed the dietary staff failed to monitor and record dish machine temperature. The Dietary Supervisor stated, "Obviously we monitor the dish machine temps to make sure temps are maintained for sanitizing purposes. I saw the gaps, [dietary] staff are trained to monitor and document dish machine temps. I'll be checking this daily in the next few days and there will be a general reorganizing of this. I have a meeting with [dietary] staff scheduled on 10/5/10 and I have spoken with [dietary] staff already, about this problem."

Based on policy review, observations and staff interview, the radiology staff failed to secure all patient radiological film information in a manner that prevented access by unauthorized personnel. The CAH had approximately 12 in-patient radiological procedures monthly. Problems identified with 1 of 1 radiology department film storage area.

Failure to secure medical records against unauthorized access could potentially result in identity theft or unauthorized disclosure of personal medical information.

Findings include:

1. Review of CAH policy "Protection of record information" revised 4/1/10 revealed in part "...shall maintain the confidentiality of patient information and record information and provide safeguards against...unauthorized use. ...To ensure that adequate precautions are taken to prevent physical or electronic altering, damaging, or deletion/destruction of patient records or information in patient records...."

2. Observations, during a tour of the radiology office, on 9/27/10 at 2:30 PM, revealed a room that contained 50 shelving units with 30 patient films per unit.

During an interview, at the time of the tour, the Manager for Radiology confirmed the patient films contained confidential patient information and that housekeeping staff cleaned, sometimes unattended, during the day. The Manager for Radiology stated, "I could see where that is a problem."

3. During an interview on 9/28/10 at 10:00 AM, the Manager for Radiology reported that during the day radiology staff is in and out of the office so they have not locked the doors. The Radiology Manager said that he/she spoke with maintenance staff to see if they could install a badge-locking scanner on the office door. In the interim, they are locking the door when they are not in the office.

4. During an interview on 9/29/10 at 8:30 AM, Staff B, Health Information Management Supervisor, reported, when the staff updated the old policy "Protection of Record Information," they accidentally left out the statement that required staff to secure all medical records and assure that access to patient records is on a need to know basis. Staff B stated that they have updated the policy to include this statement.

Based on review of credential files, policies/procedures, and staff interview, the Governing Body failed to ensure that an external peer review occurred for 2 of 2 Physician Assistants - Certified (PA-C).

The CAH had an average daily census of 4 inpatients.

Failure to perform peer review could potentially expose patients to inappropriate diagnosis and treatment by unqualified providers.

Findings Include:

1. Review of credential files on 9/30/10 revealed, the credential file for Practitioner A, a Physician Assistant, lacked documentation of an external peer review completed by a Physician. the documentation showed that a Registered Nurse (RN) completed the external peer review on 9/23/09.

Review of credential files on 9/30/10 revealed, the credential file for Practitioner B, a Physician Assistant, lacked documentation of an external peer review completed by a Physician. The documentation showed that a Registered Nurse (RN) completed the external peer review on 2/11/10.

2. Review of the "Medical Staff Peer Review" policy updated 9/08 stated in part, "...all external peer review charts require a physician sign-off."

3. During an interview on 9/30/10 at 9:45 AM, Staff D, Administrative Assistant (AA) reported that a physician did not perform the external peer review for Practitioners A, B and C that a Registered Nurse completed and signed off on the reviews. According to the AA, the external peer review personnel were running behind, so the RN was doing the external peer reviews. The AA stated that his/her understanding was external peer review personnel were doing that so they could get the peer reviews returned in time for reappointment.

At 1:35 PM, Staff D returned and reported having reviewed the information about the 3-credential files with the Chief Executive Officer and the Chief Nursing Officer and they had concluded that having an RN conduct external peer review for PA-Cs and DOs was not appropriate per their policy.

Based on review of credential files, policies/procedures, and staff interview, the Governing Body failed to ensure that an external peer review occurred for 1 of 3, sampled, Doctors of Osteopathy (DO), (Practitioner C).

The CAH had an average daily census of 4 inpatients.

Failure to perform peer review could potentially expose patients to inappropriate diagnosis and treatment by unqualified providers.

Findings Include:

1. Review of credential files on 9/30/10 revealed, the credential file for Practitioner C, a Doctor of Osteopathy, lacked documentation of an external peer review completed by a Physician. The documentation showed that a Registered Nurse (RN) completed the external peer review on 9/23/09.

2. Review of the "Medical Staff Peer Review" policy updated 9/08 stated in part, "...all external peer review charts require a physician sign-off."

3. During an interview on 9/30/10 at 9:45 AM, Staff D, Administrative Assistant (AA) reported that a physician did not perform the external peer review for Practitioners A, B and C that a Registered Nurse completed and signed off on the reviews. According to the AA, the external peer review personnel were running behind, so the RN was doing the external peer reviews. The AA stated that his/her understanding was external peer review personnel were doing that so they could get the peer reviews returned in time for reappointment.

At 1:35 PM, Staff D returned and reported having reviewed the information about the 3-credential files with the Chief Executive Officer and the Chief Nursing Officer and they had concluded that having an RN conduct external peer review for PA-Cs and DOs was not appropriate per their policy.