HospitalInspections.org

Based on observation, document review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure all drugs are appropriately stored (properly locked) when it maintained controlled medications (medications that can cause physical impairment) in the operating room (OR) under a single lock. Failure to appropriately secure medication could result in unauthorized access to the medication and drug diversion for personal use. The CAH administrative staff identified an average daily census of 4 patients.

Findings include:

1. Review of "Security of Medications" policy, dated last revised on 4/2020, revealed in part, "Medication located in various department will be secured either by lock or security tag to prevent unauthorized access."

2. Observations, during a tour of the Operating Room on 9/21/21 at approximately 9:30 AM, revealed 4 vials of a muscle relaxant, Dantrolene Sodium Injectable Suspension, located in a Malignant Hyperthermia cart under a single key lock. The key to unlock this cart was located in an unlocked drawer in the adjacent the room in recovery, approximately 10 feet away.

3. During an interview on 9/21/2020, at 9:30 AM, the time of the tour, Peri-Op [Surgery] Nursing Director of the Surgery Center, acknowledged the Malignant Hyperthermia car should have been locked when staff was not present and that the key to the locked drawer was not secure. Unauthorized staff have access to the surgery department after hours unsupervised, such as housekeeping and maintenance.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure all patient care policies were reviewed annually, in accordance with facility policy, for 20 of 20 patient care departments (Anesthesia, Surgery, Emergency Room, Pharmacy, Laboratory, Respiratory Therapy, Speech Therapy, Occupational Therapy, Physical Therapy, Pain Clinic, Radiology, Nutritional Services, Nursing Services, Obstetrics, Diabetic Education, Cardiac Rehabilitation, Facilities, Health Information Management, Environmental Services, and Infection Control), including 4 of 4 contracted services (Nuclear Medicine, Magnetic Resonance Imaging [MRI], Sleep Lab, and Wound Clinic). The CAH administrative staff identified an average daily census of 4 patients for fiscal year 2021. Failure to ensure all patient care policies were reviewed annually by the required group of professionals could potentially result in the CAH staff failing to identify patient care needs not addressed in the CAH policies/procedures.

Findings include:

1. Review of the CAH policy, "Policy Committee", dated 5/2018, revealed in part, "Policies relating to patient care/patient safety will be reviewed on an annual basis by a Policy Committee to meet both state and federal regulations relating to Critical Access Hospitals... The Policy Committee will consist of at least one Board member representing the community, one physician, one mid-level practitioner, CNO [Chief Nursing Officer], DON [ Director of Nursing], and/or the CEO [Chief Executive Officer] and Compliance Officer...."

2. Review of the "Policy Committee Minutes," dated 9/3/20, 12/3/20, 3/4/21, and 6/10/21, revealed the Policy Committee failed to review and approved all policies for Anesthesia, Surgery, Emergency Room, Pharmacy, Laboratory, Respiratory Therapy, Speech Therapy, Occupational Therapy, Physical Therapy, Pain Clinic, Radiology, Nutritional Services, Nursing Services, Obstetrics, Diabetic Education, Cardiac Rehabilitation, Facilities, Health Information Management, Environmental Services, Infection Control, Nuclear Medicine, Magnetic Resonance Imaging [MRI], Sleep Lab, and Wound Clinic.

3. During an interview on 9/23/21 at 10:35 AM, the Compliance/Privacy Officer/ Informatacist confirmed the Policy Committee failed to review and approve all policies for Anesthesia, Surgery, Emergency Room, Pharmacy, Laboratory, Respiratory Therapy, Speech Therapy, Occupational Therapy, Physical Therapy, Pain Clinic, Radiology, Nutritional Services, Nursing Services, Obstetrics, Diabetic Education, Cardiac Rehabilitation, Facilities, Health Information Management, Environmental Services, Infection Control, Nuclear Medicine, Magnetic Resonance Imaging [MRI], Sleep Lab, and Wound Clinic.

Based on observation, document review, and interviews, the Critical Access Hospital (CAH) Administrative staff failed to ensure the surgery staff changed the sterile water flush bottles after endoscope procedures for each patient, in accordance with the manufacturer's directions. Failure to change the flush bottle of sterile water after each patient could potentially result in bacteria growing in the sterile water and potentially causing an infection in the next patient. The Administrative staff identified that the surgery staff performed an average of 33 endoscope procedures from 1/1/21 to 8/31/21.

Findings include:

1. Observations, during a tour of the surgery department on 9/21/2021 at approximately 9:33 AM, in Operating Room (OR) #1 revealed 1 of 1 ICUmedical 1000 mL (mililiter) bottle of sterile water for irrigation connected to the endoscope equipment (a nonsurgical procedure where a physician inserts a flexible camera into a patient's body to examine the digestive tract).

2. Review of the manufacturer's instructions indicated in part, "...is intended for use only as a single-dose or short procedure irrigation." " ...Unused portions should be discarded and a fresh container of appropriate size used for the startup of each cycle or repeat procedure." The hospital staff must discard any unused portions of the sterile water for irrigation after use on a single patient. The sterile water for irrigation did not contain any chemicals to prevent bacteria from growing in the sterile water once the hospital staff opened the bottles of sterile water for irrigation.

3. During an interview at the time of the tour, Peri-Op [Surgery] Nursing Director revealed the surgery staff opened the bottles of sterile water for irrigation each day for endoscope procedures that are scheduled and connected it to the equipment. The equipment contained a one-way valve to prevent backflow between patients to prevent contamination of the source bottle. The surgery staff changed the flush tubing between the patient and the one-way valve after each endoscope procedure, but did not change the tubing between the one-way valve and the bottle of sterile water for irrigation or replace the bottle of sterile water for irrigation between endoscope procedures. The surgery staff would only discard the bottles of sterile water for irrigation once they completed all of the endoscope procedures for the day or if the bottle ran empty.

4. During an interview on 9/21/21 at approximately 10:10 AM, the Peri-Op [Surgery] Nursing Director reviewed and confirmed the manufacturer's directions for ICU Medical 1000 milliliter of sterile water for irrigation. The Peri-Op Nursing Director acknowledged the manufacturer's product information did not support using the bottles of sterile water for irrigation for more than one patient.

Based on review of policy/procedure and staff interview, the Critical Access Hospital's (CAH) administrative staff failed to ensure 1 of 1 abuse policy contained the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for swing bed patients. The CAH administrative staff identified a monthly average of 3 skilled patients from January 2021 until July 2021. Failure to include the required language in the abuse policy could potentially prevent CAH staff from reporting alleged violations involving abuse to the CAH administrator and to other officials (including to the State Survey Agency) in a timely manner.

Findings include:

1. Review of the CAH's policy "Dependent Adult Abuse Prevention and Reporting," effective 5/2020, failed to include the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).

2. During an interview on 9/22/21 at 10:21 AM, the Chief Nursing Officer acknowledged the abuse policy failed to include the required language in the regulations that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency).