HospitalInspections.org

Based on interview and document review the Community Access Hospital (CAH) lacked policy and procedure for patient notification if they had received blood that had been recalled. This had the potential to affect all patients receiving blood transfusions in the facility.

Findings include:

The laboratory policies, reviewed with the lab manager on 4/8/14, at 2:00 p.m., lacked direction for notification of patients with exposure to potentially tainted blood products.

The lab manager was interviewed on 4/10/14, at 8:15 a.m. and stated the American Red Cross would notify the CAH and provide direction for physicians to follow up with patients. The American Red Cross was contacted and provided a Traceback Recipient Status form that did not direct physician notification of patients in the event of tainted blood.

The director of nursing (DON), interviewed on 4/10/14, at 10:20 a.m. verified the lack of facility policy for patient notification regarding transfusion of tainted blood.

Based on the validation survey completed on 4/10/14, the facility was found not in compliance with Life Safety from Fire found at CFR §485.623(d).

Refer to Life Safety Code deficiencies; K56; K130; K144; K147 for additional information.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure safety from fire therefore they were unable to meet this condition.

Based on document review and interview, the critical access hospital (CAH) lacked a plan to ensure adequate water availability in the event of an emergency or disruption of the water supply. This had the potential of affecting all patients and services provided.

Findings include:

The CAH did not have an established formula or plan to determine the amount of potable and non-potable water that would be required to meet the needs of patients, staff, volunteers and the various departments each day.

The undated Utility Failure Operational Impact Chart was reviewed with the plant manager (PM) on 4/9/14, at 3:15 p.m.. The PM stated the CAH planned for a two hour supply of non-potable water and a 24 hour supply of potable water in the case of an emergency. The PM stated the non-potable water was in the lines and the bottled water from the cafeteria and kitchen was the supply of potable water. The PM stated there was no estimate of actual potable/non-potable water required for daily use in the CAH.

Based on observation, interview and document review, the facility failed to ensure the security of medical records in the cardiac rehabilitation (CR) department. This had the potential to affect all patients in the CR department.
During the initial tour of the cardiac rehabilitation (CR) department on 4/8/14, from 1:00 p.m. until 1:45 p.m. respiratory therapist (RT)-A and CR manager registered nurse (RN)-A revealed the medical records for the CR patients were kept in an unlocked filing cabinet at the open station within the CR department. RT-A confirmed the CR department is open to the public during business hours (8:00 a.m. - 4:30 p.m.) Monday through Friday.
On 4/9/14, at 8:07 a.m. until 8:25 a.m. the CR department was observed to be unattended. RT-A entered the department at 8:20 a.m., but stayed for less than a minute as he had been paged for a STAT (immediate) procedure outside of the department.
On 4/10/14, at 9:15 a.m. medical records (MR) director-A confirmed the facility's policy and her expectation was for all medical records to be locked in a secure area and accessible only to the staff who need to access the record.
On 4/10/14, at 9:18 a.m. RN-A stated the filing cabinet in the CR department, which housed the CR patient medical records, should be locked or the records placed in a locked office where they would be more secure.
The facility policy titled Secure Filing of Medical Records dated 3/13/14, indicated medical records should be maintained in a secure manner and restricted to authorized personnel.