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Based on personnel file review and interview, the Critical Access Hospital (CAH) failed to ensure all personnel were trained to manage non-medical emergencies for 9 of 15 (E1, E2, E3, E4, E5, E6, E7, E8, and E9) facility staff reviewed. Findings include:

E1's personnel record lacked documentation of training related to non-medical emergency procedures.

E2's personnel record lacked documentation of training related to non-medical emergency procedures.

E3's personnel record lacked documentation of training related to non-medical emergency procedures.

E4's personnel record lacked documentation of training related to non-medical emergency procedures.

E5's personnel record lacked documentation of training related to non-medical emergency procedures.

E6's personnel record lacked documentation of training related to non-medical emergency procedures.

E7's personnel record lacked documentation of training related to non-medical emergency procedures.

E8's personnel record lacked documentation of training related to non-medical emergency procedures.

E9's personnel record lacked documentation of training related to non-medical emergency procedures.

On 9/21/11, at 10:40 a.m. executive assistant (EA)-1 stated they had recently developed a new policy and procedure to ensure staff completed annual inservice training which would include training on non medical emergencies.

At 11:45 a.m. Medical Lab Technician (MLT)-A, who was responsible for emergency preparedness, stated the employees had not completed the annual non medical emergency inservice which was to be completed 5/2011.

Based on interview, and review of the Quality Assurance (QA) Plan and Governing Board meeting minutes, the Critical Access Hospital (CAH) failed to ensure QA activities were reported timely to the Governing Body. Findings include:

A review of the Governing Body (GB) meeting minutes from September 29, 2010 though August 2, 2011, lacked indication that the QA program activities had been presented to the GB.

On 9/21/11, at 1:45 p.m. Medical Lab Technician MLT)-A, who was responsible for the overall QA program, stated the QA Plan indicated the activities of the QA would be reported no less than annually to the governing body. She stated she had not presented the the QA activities within the past year. She stated this should have been done, but a lot had changed in the past year.

The facility policy "Quality Assurance Plan" dated 9/27/10, indicated "the Medical Staff and facility wide Quality Assurance activities shall be organized though the efforts of the Quality Assurance Committee and shall be reported to the Governing Board no less than annually."

Based on observation, staff interview, and policy review, the Critical Access Hospital (CAH) failed to ensure outdated drugs and biologicals were not available for patient use in 1 of 4 off-site clinic (CS-A) settings. Findings include:

A tour of clinic site-A was conducted on 9/20/11, at 10:10 a.m. with LPN-A. The following expired biologicals were observed in the medication/nursing work area and exam rooms.

-7 BBL Culture Swab Collection and Transport System expired on 8/11
-4 BBL Culture Swab Collection and Transport System expired on 4/11
-4 Influenza A & B Rapid Screen expired on 5/6/11
-2 bottles of hydrogen peroxide expired 6/11
-1 box of Optium Blood Glucose Test Strips with 17 strips left expired 6/30/10
-1 box of Optium Blood Glucose Test Strips that was full with 50 strips expired 7/31/11
-Providone Iodine swabsticks with 2 packages that expired 6/04 and 2 packages that expired 4/09
-14 assorted sized sutures with expiration dates ranging from 12/06 to 7/11
-1 SurgiSeal expired 11/10
-1 Compound Benzoin Tincture 10% swabstick expired 10/2010
-6 Quik Care antimicrobial foam expired 8/09
-1 Anoscope with central supply packaging that indicated expired 7/6/10


On 9/21/11, at 3:00 p.m. the Clinic Manager for this clinic provided the policy titled "Outdates: Sterile Supplies Infection Control." The policy indicated that sterile supplies and solutions utilized for patient care would be managed in order to provide safe products for patient care. The policy additionally indicated that all departments would check for outdated supplies every month.

Based on observation, interview, record review, and policy review, the critical access hospital (CAH) failed to ensure their Infection Control Program was being implemented according to the established policies. In addition, the CAH failed to ensure proper cleaning of the glucometer between multiple patient use for 2 of 2 inpatients (P2, P1) identified to receive blood glucose tests during the survey. This had the potential to affect all patients who required blood glucose readings at the bedside. Findings include:


The CAH lacked an effective Infection Control Program.

On 9/19/11, at 3:15 p.m. the Infection Control Coordinator, RN-F, provided a current infection control committee membership established September 2011. This list included representation from herself, two LPNs, one lab staff and one environmental services person. RN-F stated that she had just assumed the position in September and had re-started the committee as it had been done by varied staff in recent months. RN-F did not have any minutes of previous meetings and stated that the committee she identified would not be reviewing rates of facility acquired infections. RN-F stated this had been done at a quarterly meeting of the providers after a Medical Staff meeting. RN-F stated the RN Manager would have had any minutes from previous meetings, but the RN Manager was not available at that time as she was out of state. RN-F stated that her own background was in subacute and home care settings, but no hospital experience. RN-F stated her training in Infection Control had been listening to a couple of teleconferences. RN-F was not aware of any letter or form that designated her as the Infection Control Officer.

On 9/21/11, at 4:30 p.m. RN-A stated that since the nursing administrator had left in January or February of 2011, the infection control program had "hit a bump in the road." RN-A stated there had been a meeting with providers after a Medical Staff meeting, but she was not aware of what was covered. RN-A stated she would attempt to call the RN Manager who was currently out of state regarding any additional information available regarding Infection Control. RN-A was asked if there was any staff person at the facility with a background, experience or training in infection control and she stated "No." RN-A stated that the facility had looked at options with getting consulting oversight from an Infection Control Practitioner at another facility. RN-A stated the infection control program was in "disarray."

On 9/21/11, at 4:35 p.m. the Administrative Assistant, in response to a request for the job description for the Infection Control Coordinator, stated there was not a job description for this position.

No further information regarding the infection control program was submitted by the facility.

Review of the facility policy titled Infection Control Committee dated 3/1/2010, indicated "the Infection Control committee membership has representation from the major clinical services: Medical Staff, Administration, Nursing, Laboratory, Medical Records, Quality Assurance, Risk Management, and Facility Services." This policy indicated that the committee met bi-monthly and that minutes were recorded.




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Proper cleaning of the glucometer used for multiple patients had not been implemented on 9/20/11. The CAH's policy was to use 70% alcohol wipes for the cleaning of the glucometer if dirty, which does not destroy all blood born pathogens.

On 9/20/11, at 11:30 a.m. registered nurse (RN)-D performed the blood glucose test on P-2. RN-D brought the glucometer, gloves, cotton ball, alcohol wipe, testing strip and lancet to the patient's room. RN-D removed the blood filled glucometer test strip from the glucometer and threw it away then removed her gloves. When RN-D had completed the blood glucose test, she returned the glucometer to the glucometer's box and to the central location without cleaning it
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At this time, interview with RN-D indicated the glucometer should be cleaned with an alcohol wipe as was their policy. RN-D also indicated P2 received the blood glucose glucometer test four times a day from this glucometer. In addition, RN-D also identified P-1 as using the same glucometer twice a day for a blood glucose test. Record review of P1 indicated the patient had received the blood glucose checks twice a day from 9/16/11, through 9/21/11.

The policy for cleaning of the glucometer dated 10/08/10, indicated: "If the surface of the monitor is dirty, clean it. Per manufacturer's recommendation use the following acceptable cleaning solution: 70% Alcohol."
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Telephone interview with the manufacture staff of the Optium Blood Glucose Monitoring System at 10:45 a.m. on 9/30/2011, indicated that the User's guide did list 70% Alcohol as a acceptable cleaning solution, for the glucometer. He indicated that the user was responsible for following any regulatory laws regarding the cleaning of the glucometer and it would supersede their list of acceptable cleaning solutions. He was unsure if the 70 % alcohol was acceptable for multiple patient use for cleaning of the glucometer.

Based on observation, interview, and policy review, the critical access hospital (CAH) failed to ensure that proper temperature control of refrigerated foods for patient use was maintained in the dietary kitchen. In addition, the CAH failed to ensure that inpatients were screened for nutritional risk as identified in their policy and procedures. These practices had the potential to affect all patients residing in the CAH. Findings include:

Adequate temperature controls were not maintained in the dietary refrigerator for patient foods.

On 9/21/11, at 9:45 a.m. during the kitchen tour, the refrigerator temperature was reported as 26 degrees by the dietary manager (DM). The DM stated that the regulator knob for the refrigerator was broken and she was not able to adjust the temperature. The DM stated that when they used the top two shelves of the refrigerator. The DM added foods would sometimes freeze and there were times when they had to throw food items out as a result. The thermometer was on the second shelf from the top with this reading. The DM moved the thermometer to the lowest shelf at that time. The DM stated she had notified maintenance approximately six months ago that the regulator was broken, but it had not been repaired.


The facility's "Refrigerator/Freezer Temperature Recording Dietary" policy and procedure indicated fridge temperatures were to be checked daily to ensure proper food storage controls. In addition, the policy directed staff to notify maintenance staff or the dietary manager if a temperature was not within acceptable ranges of 32-40 degrees.

On 9/21/11, at 2:05 p.m. the dietary manager (DM) verified the temperature regulator knob was broke and stated, "We can't regulate the temperature" of the refrigerator. In addition, the DM manager stated food had frozen while stored in the fridge. The DM also stated she had personally informed maintenance of the broken temperature control knob.



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On 9/21/11, at 3:20 p.m. the refrigerator temperature was observed at 43 degrees. Dietary aide-A verified the temperature. Review of the "Refrigerator and Freezer Temperature Record" forms provided by the facility identified the parameters listed for the refrigerator were 32 to 40 degrees. For April 2011, 2 of 30 days recorded were outside of these parameters. For May 2011, 4 of 31 days recorded were outside of these parameters. For June 2011, 5 of 29 days recorded were outside of these parameters. July and August records were not submitted to the surveyor. For September 2011, 6 of 21 days recorded were outside of these parameters.


On 9/22/11, at 9:30 a.m. maintenance-A stated he was unaware of the storage fridge temperature control knob not working.



The CAH failed to ensure patients' nutritional needs had been identified so that appropriate nutritional interventions could be implemented.



On 9/21/11, at 10:30 a.m. the dietary manager (DM) stated that she did not do a nutritional risk assessment on any admissions to the facility and there were no other dietary staff doing this. The DM stated that the previous DM had done the nutritional risk assessment, but she did not because she had not completed her training as a dietary manager. The DM stated she thought it would be at least another year before she would complete the training. The DM was not aware of anyone else doing the nutritional risk assessment at this time including the contracted registered dietician (RD). The DM stated she was not referring any nutritional assessments to the RD on inpatients.

On 9/21/11, at 3:55 p.m. the consulting RD was contacted by telephone. The RD stated that she did not do any nutritional assessments routinely and that it would be "pointless" for her to come to the facility for just a couple assessments. The RD stated the previous DM did the nutritional assessments all the time and that the current DM would hopefully be able to do them when she was done with training. The RD stated that she would do a nutritional risk assessment "only if they call me." The RD was asked if this happened often and she stated "not really" and that she did not think she had been called in the last quarter.

Review of the facility policy titled "Admission Nutritional Interview" Dietary dated 3/10, indicated that "In-patients and swingbed patients will be screened for nutritional risk." Additionally this policy indicated that the DM completed an admission nutrition interview for all inpatients and swing bed patients.


Review of the facility policy titled "Nutritional Assessment" Dietary dated 3/10, indicated that "to determine the need for nutrition intervention, the DM will complete a nutritional assessment initial interview." The policy additionally indicated that the DM would determine the patient's nutritional status classification and would document it in the medical record.

Review of the facility policy titled "Interim Nutritional Assessment" Dietary dated 2/4/11, indicated that "Due to dietary staffing changes, nutritional assessments previously done by the Dietary manager as of February 4th will not be able to be completed by DM until later 2012." This policy indicated that any nutritional assessment or dietary screening must be referred to consulting dietician at Lake Region Hospital." The policy did not indicate an alternative staff person or discipline to complete any nutritional assessments for inpatients.

Based on observation, interview, and policy review, the critical access hospital (CAH) failed to ensure glucometers used to test blood glucose on 2 of 2 inpatients (P1, P2) and in 2 of 2 clinic sites (CS-A, CS-B) without onsite labs had appropriate quality control measures completed. Findings include:

During observation of a finger stick for blood glucose monitoring on 9/20/11, at 11:30 a.m. for P2, the charge nurse (RN-D) was observed to use the multiple patient use glucometer. She indicated that P2 needed blood glucose testing 4 times a day and P1 needed her blood glucose taken twice a day. The glucometer being used for these blood glucoses test had not been calibrated as the policy indicated was needed.

Review of the Data Entry for Blood Glucose Quality Control flow sheet indicated from 11/19/2009 through 9/30/2010, the calibration had been completed 19 times. However, from 9/30/10 through 9/22/2011, the flow sheet indicated the calibration had not been completed in that year.

Review of the undated policy titled "Documentation of Quality Control Results" indicated that the quality control testing should be completed weekly on Tuesday nights. Review of the Data Entry for Blood Glucose Quality Control flow sheet indicated the last time the glucometer had been checked was 9/30/2010.

On 9/22/11, at 11:40 a.m. charge nurse RN-A confirmed the quality control solution used to ensure the glucometer was giving accurate results had expired 8/11. RN-A confirmed the night staff should have been calibrating and recording the results of the glucometer on the flow sheet every Tuesday night. She confirmed that the expectation was that the Blood Glucose Quality Control solution should not be used after the expiration date.



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The glucometers in clinic sites A and B that did not have an onsite lab, had outdated strips and had no current quality control solutions.

On 9/20/11, at 10:10 a.m. clinic site-A was observed to have a glucometer machine that had two boxes of test strips that were dated as expired 6/30/10, for one partial box and 7/31/11, for one full box. There were no quality control solutions with the machine. LPN-C verified the strips were outdated and there were no control solutions with the machine to do the quality control checks. LPN-C stated that there was a policy on doing quality control checks, but she was not sure what the exact procedure was. LPN-C verified she had not done quality control testing on the glucometer at this clinic site.

On 9/21/11, at 8:15 a.m. clinic site-B was observed to have two glucometers with one bottle of test strips labeled as expired 8/11. There were no bottles of test strips available that were not outdated. One bottle of Aviva Level 1 Control Solution was with one glucometer and had an outdate of 10/09. LPN-D verified that there were no quality control solutions or test strips available at this clinic that were not outdated. LPN-D verified she had not done quality control testing on the glucometer at this clinic site.

On 9/21/11, at 1:30 p.m. policies were requested for all labs done at satellite clinic sites from the clinic manager for clinic sites A and B.

Review of the facility policy titled "Glucose Monitoring Clinic Nursing" dated 3/5/10, indicated that quality control testing would be performed on satellite units each day the clinic is open. The policy indicated additionally that the values would be recorded on a quality control sheet and this sheet would be collected for the glucose monitor each month and filed with the lab.

Based on record review, policy review, and staff interview, the critical access hospital (CAH) failed to evaluate all patient care services to evaluate the quality and appropriateness of the treatment and services furnished by the CAH in 6 patient care services (Laboratory, Environment, Podiatry Clinic, Dietary, Radiology, Nuclear Medicine). Findings include:


All of the CAH's patient care services were not evaluated.

LABORATORY

On 9/21/11, at 4:00 p.m. the medical laboratory technician (MLT-A) in charge of QA indicated that they had been monitoring that specimens had been coming in the laboratory with out physician's orders. She confirmed that they did not have data analysis of how frequent this had been a problem nor did they have information on what had been implemented to reduce this problem. She indicated that they had not have a QA improvement project that included analysis of data or corrective actions that was documented. They have also been monitoring contaminated urine cultures and mixed sensitivity culture plates that needed to be reset, however, no further information was provided for this monitoring.


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ENVIRONMENTAL SERVICES

Review of the environmental services (ES) department QA audits related to the cleaning and prepping of patient rooms, dated 1/10/11-4/11, revealed lack of data analysis, evaluation of corrective actions, and measures to improve quality on a continuous basis.

On 9/21/11, at 10:50 a.m. the ES director and MLT-A (medical lab technician) verified environmental services lacked an effective QA program.



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PODIATRY CLINIC

On 9/20/11, at approximately 1:30 p.m. RN-G, Clinic Manager for clinic site-C stated that Podiatry that was listed as a health care service through that clinic site. RN-G indicated this was a contracted service and she was not aware of any QA project for this service.


DIETARY

On 9/21/11, at 10:30 a.m. the Dietary Manager stated they had been monitoring time and temperatures being recorded daily on a log sheet. The Dietary Manager provided the data collected; however, she indicated they had not further analyzed the data to determine potential causes. The Dietary Manager stated their actions had been to "educate staff" and "remind staff" but she had no dates or specific interventions/corrective action plan that she had instituted.



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RADIOLOGY

On 9/21/11, at 11:00 a.m. the radiology supervisor (RS) stated they had been monitoring timing for x-ray reports and errors in their imaging system. The RS did provide data collected. However, the RS indicated they had not further analyzed the data or indicated what actions had been implemented to reduce the problem. She indicated that did not have a QA improvement project that included analysis of data or corrective actions documented.


NUCLEAR MEDICINE

On 9/21/11, at 11:45 p.m. Medical Lab Technician-A indicated the facility could not provide a QA for the nuclear medicine department. She was unsure the last time Nuclear Medicine had reported to QA. She verified it was not collected as part of the overall QA program.



The facility policy "Quality Assurance Plan" dated 9/27/10, indicated the QA Committee would meet at least quarterly with each department reporting their QA activities. The process of QA was defined as problem identification, action identification, evaluation and monitoring, documentation of QA activities and data records maintained for evaluation of results of QA activities.