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Based on policy and procedure, record review and staff interview it was determined in 1 of 6 (Pt #12) medical records reviewed with patients receiving blood, the CAH failed to ensure blood transfusion policies were followed. This has the potential to affect all patients receiving blood transfusions.
Findings include:

1. The CAH policy revised 3/13/13, titled "ADMINISTRATION OF BLOOD-BLOOD PRODUCTS" was reviewed on 11/5/15. The policy under "6. Routine Vital Sign Measurement and Assessment Frequencies: A. 2. Re-measure vital signs every one (1) hour..14. Documentation: Person initiating transfusion documents on transfusion record and parenteral flow sheet: ... e. Any patient reaction."

2. The medical record of Pt. #12 was reviewed on 11/4/15. Pt #12 was admitted on 7/24/15 for anemia. The physician ordered 3 blood transfusions on 7/24/15. The first unit was started on 7/24/15 at 1020 and completed on 7/24/15 at 1300. Documentation indicated that Temperature was taken at 1035 and not again until an hour after infusion completed. The second unit was started on 7/24/15 at 1405. The Temperature was taken at 1405. The blood transfusion was competed at 1645. The next Temperature documented was at 1745 an hour after blood transfusion was completed. Documentation after the first transfusion completion did not indicate if Pt #12 had a reaction.

3. On 11/4/15 at 3:00 PM, an interview was conducted with the Chief Nursing Executive (E#5). E#5 reviewed the blood transfusion record of Pt #12. E#5 stated, "these records should have the temperatures recorded hourly and the reaction should have been marked as yes or no".

Based on observation, and staff interview, it was determined that the Critical Access Hospital (CAH) failed to ensure used sharps were properly disposed of in the laboratory, potentially affecting all staff members who perform phlebotomy duties.
Findings include:

1. On 11/2/15 at 2:30 PM a tour of the laboratory was conducted. In the phlebotomy room there were 2 sharp containers with used needles protruding above the manufacture's marked safety line, potentially allowing staff to be stuck with contaminated needles when disposing of used needles.

2. On 11/2/15 at 2:40 PM, an interview with the Manager of Laboratory (E #3) was conducted. E #3 agreed the sharps container had used needles sticking up above the marked safety line. E #3 shook the container in an attempt to cause the needles to fall below the safety line. E #3 stated "See, there's a hole right there for more needles." After E #3 shook the sharps container, used needles still protruded above the marked safety line.

3. On 11/4/15 at 1:00 PM, an interview with the Chief Nursing Executive (E #5) was conducted. E #5 verbalized the sharps containers should have been removed from the laboratory area when the needles protruded above the manufacture's marked safety line.

Based on document review, and staff interview, it was determined the CAH failed to ensure the Administrator notified physicians of delinquent records per CAH Medical Staff Bylaws Rules and Regulations. This has the potential to affect all patients receiving care at the CAH.
Findings include:

1. On 11/5/15 at 11:00 AM, the CAH's "Medical Staff By-Laws Rules and Regulations" (dated July 2014) were reviewed. Under "16. The patient's medical record shall be complete within a period of time that in no event exceeds 30 days following discharge." "In the event of delinquent records, the physician will be notified and expected to complete records within 7 days. The Administrator shall notify the physician................that his privileges to admit patients shall be suspended, and remain suspended until the records have been completed."

2. A review of the Deficiency Report by Physician was reviewed 11/5/15. The report indicated a total of 1 delinquent record as of 11/5/15.

3. On 11/5/15 at 11:20 AM, an interview with the Health Information Manager (E #7) and the Medical Staff Secretary (E #6) was conducted. E #6 and E #7 verified there was no documentation to indicate the Administrator notified the physicians of delinquent records.

4. On 11/5/15 at 11:30 AM, an interview with the Chief Executive Officer (E #8) was conducted. E #8 verbalized that delinquent letters were not being sent to physicians by E #8's office.

Based on document review, observation and staff interview, it was determined the hospital failed to monitor all areas where drugs and biologicals are stored and the proper disposal of expired items to ensure these are not available for patient use. This failure has the potential to affect all patients receiving care at the CAH.
Findings include:

1. A review of the CAH (Critical Access Hospital) policy titled "Expired Medications" dated 7/11/12 was reviewed on survey date 11/4/15 at 2:00 PM. The policy indicates under "Purpose: The purpose of this policy is to ensure that expired medications are pulled from patient care areas on a timely basis..."

2. During a tour of the Radiology Department on 11/4/15 at 10:10 AM, it was observed in the emergency medication box, a multi unit package of ammonia inhalants with an expiration date of 9/2015.

3. A tour of the Medical-Surgical floor was conducted with the Quality Assurance/Risk Manager (E#10) on 11/2/15 at approximately 11:00 AM. In the medication room the following intravenous fluids were expired but available for patient use: (1) 1000 ml bag of dextrose 5% and lactated ringers (D5LR) expired May 2015 and (1) 1000 ml bag of Dextrose 5%/Water (D5W) expired March 2015.

4. A tour of the surgical department was conducted with E#5 on 11/3/15 at 3:30 PM. In the anesthesia supply room the following intravenous fluids were expired in May 2015 but available for patient use: (1) 100 ml bag of sodium chloride and (1) 1000 ml bag of sodium chloride.

5. During an interview with E#5 on 11/4/15 at 10:00 AM, E#5 stated "All areas are to be checked monthly or more often and expired medications and supplies are to be removed."

Based on document review, observation and staff interview, it was determined the CAH failed to ensure policies addressing reprocessing of patient care equipment were specific and followed current practices to ensure prevention of infection. This failure has the potential to affect all patients having ophthalmology surgeries.
Findings include:


1. A review of the CAH (Critical Access Hospital) policy titled "Steam Sterilization of Instruments and Supplies" dated 12/11/13 was reviewed on survey date 11/4/15 at 2:00 PM. The policy does not provide specific situations or guidelines for which the immediate use steam sterilization (IUSS) should be used.

2. A review of the "biological monitoring system for steam sterilization log" for the time period of June 2015 through present was completed on 11/5/15. The log indicates the IUSS is used for eye trays on days when more that 2 eye surgeries are conducted. The log indicates as many as 11 surgeries have been performed when the IUSS is utilized to sterilize the 2 eye trays.

3. An interview was conducted with E#5 (CNE) and E#11 (surgical tech) during the tour of the surgical department on 11/4/15 at 4:00 PM. E#11 stated "We have 2 eye trays which are sterilized after use and ready for the next procedures, if there are more than 2. One physician sometimes does as many as 10 eye cases so we will use the 2 trays, rotating to complete the schedule." Staff were not aware of the current guidelines to limit IUSS to rare situations and the need for additional equipment to provide adequate supply.



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Based on observation, document review, and staff interview, it was determined the CAH failed to provide and maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases in the sleep study lab. This has the potential to affect all patients receiving care in the sleep study lab.
Findings include:
1. On 12/2/15 at 10:10 AM, a tour of the sleep study lab was conducted. During the tour it was observed on the night stand, next to the sleep study bed, a bi-level positive airway pressure machine with a used water cartridge in the machine.
2. On 12/2/15 at 10:15 AM, CAH policy "Patient Care Equipment" revised 8/14/13, was reviewed. Under "1. Patient care equipment will be cleansed by department staff assigned to unit on each shift."
3. On 12/2/15 at 10:20 AM, an interview with the Manager of Sleep Lab (E #1) was conducted. E #1 indicated the water cartridge was from a previous patient and should have been changed when the patient was discharged.

Based on policy and procedure, record review and staff interview it was determined in 4 of 9 (E#12, 13, 14, 15) personnel files reviewed, the CAH failed to ensure competencies for CPR were maintained per policy. This has the potential to affect all patients who receive services at the CAH.
Findings include:

1. The CAH policy dated, 12/11/13, titled, "COMPETENCY ASSESSMENT PROGRAM" was reviewed on 11/5/15 at 2:15 PM. The policy under "E. 5. All employees providing direct patient care will be CPR Certified every (2) years."

2. A review of personnel files was conducted on 11/3/15. Documentation indicated E#12, #13, #14, and #15 did not have current CPR certification.

3. An interview was conducted on 11/5/15 at 11:30 AM with Human Resources (E#16). E#16 reviewed the personnel records of the employees missing CPR documentation. E#16 stated, "I need to follow-up better on CPR certifications." E#16 confirmed the above findings.

Based on document review, and staff interview, it was determined the CAH failed to ensure all medical records were completed within 30 days following discharge per the CAH Medical Staff Bylaws Rules and Regulations. This has the potential to affect all patients receiving care at the CAH.
Findings include:

1. On 11/5/15 at 11:00 AM, the CAH's "Medical Staff By-Laws Rules and Regulations" (dated July 2014) were reviewed. Under "16. The patient's medical record shall be complete within a period of time that in no event exceeds 30 days following discharge." "In the event of delinquent records, the physician will be notified and expected to complete records within 7 days. The Administrator shall notify the physician................that his privileges to admit patients shall be suspended, and remain suspended until the records have been completed."

2. A review of the Deficiency Report by Physician was reviewed on survey date 11/5/15. The report indicated a total of 1 delinquent record as of 10/16/12.

3. On 11/5/15 at 11:20 AM, an interview with the Health Information Manager (E #7) and the Medical Staff Secretary (E #6) was conducted. E #6 and E #7 verified there was no documentation to indicate the Administrator notified all physicians of delinquent records. E #7 also verbalized that delinquent medical records were only being monitored in the acute care department, emergency department and some of the out patient services departments but not in the infusion center/oncology department.

4. On 11/5/15 at 11:30 AM, an interview with the Chief Executive Officer (E #8) was conducted. E #8 verbalized that delinquent letters were not being monitored by E #8's office.

Based on document/record review and staff interview it was determined in 2 of 20 (Pt #4, #13) records reviewed, the CAH failed to ensure physician orders were signed, dated, and timed. This has the potential to affect all patients receiving care at the CAH.
Findings include:

1. On 11/2/15 at 11:15 PM, the medical record of Pt #4 was reviewed. On 9/21/15, Pt #4 received oncology medication in the infusion center. Verbal order dated 9/21/15 at 12:15 PM, had a physician signature with no date or time.

2. On 11/5//15 at 9:30 AM, the medical record of Pt #13 was reviewed. On 8/27/15, Pt #13 received one unit of packed red blood cells. Verbal order dated 8/27/15 at 11:20 AM had a physician signature with no date or time.

3. On 11/2/15 at 1:00 PM, the CAH's Medical Staff Bylaws Rules and Regulations were reviewed. The regulations indicated under "3 All orders pertaining to patient care must be documented, signed, dated and timed by the physician. Telephone orders will be signed by the individual accepting the orders and countersigned by the physician within 72 hours."

4. On 11/2/15 at 1:15 PM, an interview with the Manager of Infusion Services (E #2) was conducted. E #2 indicated the verbal order for Pt #4 was not dated or timed and should have been.

5. On 11/5/15 at 9:35 AM, an interview with the Chief, Nursing Executive was conducted (E #5). E #5 verbalized the verbal order for Pt #13 was not signed and dated by the physician and should have been.