HospitalInspections.org

Based on observation, interview and record review the facility failed to ensure that food was being stored at adequate temperatures in 2 of 3 freezers. Findings included:

During the tour of the dietary department on 8/31/10, at 9:00 a.m. the soup freezer was found to have a significant amount of frost on the freezer coils. According to the dietary manager it had recently ( with in the past week) been defrosted. It was his opinion that the seal was no longer effective. The ice cream freezer was also not operating effectively as evidence by the foods in the freezer being on the soft side.
In review of the temperature (temp.) logs that were being maintained on the ice cream freezer it showed in July 2010 there were 23 out of 58 recorded temperatures greater than zero degrees Fahrenheit (F). In August 2010 there were 22 out of 57 temperatures recorded as greater than zero degrees F.
The soup freezer temperatures for the month of July 2010 had 26 out of 58 temperatures recorded as being greater than zero degrees F. In August 2010, the freezer had 33 of the 54 temperature recordings which were not within acceptable parameters.

According to the facility's policy " Proper Temperature for Refrigerators and Freezers" dated 8/31/2010, stipulated freezers should be left at "O degrees Fahrenheit or lower".

The dietary manager was not aware of the temperatures being so out of range.

In an interview with the maintenance director, on 8/31/10, at 12:40 p.m. he identified there the leaks in the freezers were the result of a bad seal which resulted the compressors not be as effective.

Based on interview, policy and record review, the CAH facility failed to ensure consistent approval of appointment of all providers by the governing body and medical staff in accordance with Governing Body bylaws amended 12/18/06 for 1 of 21 provider records reviewed. Findings included:

Review of credentials/board approval of providers identified Certified Registered Nurse Anesthetist CRNA-B, had been practicing as a relief staff (locum tenens) since 1/5/10, without a record of completion of the formal governing board and medical staff approval process.

During a review of credentials with the Credentialing/Quality director on 8/31/10, at 1:40 p.m., the director verified that CRNA-B was initially granted only temporary privileges from 11/15/09 through 1/5/10, to provide weekend relief services during that time; however, had not completed formal governing board/medical staff approval to provide services beyond that time.

CRNA-A additionally verified on 9/1/10, at 1:55 p.m., CRNA-B had continued to provide relief (locum tenens) services, "About every 2-3 months for vacation coverage and will usually work a month at a time."

Based on interview and policy review, the critical access hospital (CAH) failed to implement its policy and procedure for reporting changes in the medical director to the State agency. Findings included:

The CAH's policy on notification to the Minnesota Department of Health dated 8/04 identified the chief executive officer (CEO) was responsible to report to the State agency whenever there were: Changes in ownership; the person responsible for operations was changed; address was changed, and when the person responsible for medical direction was changed.

The Quality/Credentialing Director verified on 9/1/10 at 1:30 p.m., the medical director was appointed in April 2008 ; however, neither the Director nor the CEO were able to locate documentation of the notification to the required State agency at the time of the change and also verified the change had not been reported.

Based upon observation, interview and policy review, the hospital failed to ensure staff were adequately trained to prevent the spread of infection within the Surgical Suite for 1 of 1 (P-29) outpatients observed undergoing a surgical procedure. Findings include:

The hospital failed to ensure that debris which occurred during a preoperative shave prep was not transferred into the operating room.

P-29 was admitted to undergo a right knee arthroscopy as an outpatient on 8/31/2010. Registered Nurse (RN)-1 was observed completing a preoperative assessment of the patient on 8/31/2010, at 7:55 am. At 8:15 am, the RN used an electric shaver and began to shave the patient's right leg from midthigh to slightly above the patients's ankle. The debris (hair) from the patient's leg fell onto the carpeting in the room and on and around the patient's cotton slippers which had gripper soles on the bottom. There was nothing on the floor to collect the debris which had fallen onto the carpeting.

The Registered Nurse and the Licensed Practical Nurse (LPN) in the operating room had opened all of the sterile instruments needed for the surgical procedure at 9:05 am. The patient walked into Operating Room #1 at 9:20 am and assisted to lay down on the operating room table. A large amount of debris from the shave prep was present on the top and bottom of the patient's slippers. The surveyor intervened at this time and the RN removed the patient's slippers and threw them in a trash container.

The Operating Room Manager was interviewed on 8/31/2010, at 10:30 AM. She stated the RN, who had completed the preoperative shave prep, should have put something on the floor to collect the debris which was a result of shaving the hair on the patient's leg. She stated the patient should not have worn the slippers into the operating room due to the presence of debris from the surgical skin prep which was present on the slippers.

Based on interview, policy and record review, the facility failed to ensure for each patient that received health care services, entries in the medical record were authenticated with dated, timed signatures for 11 of 22 (IP16, IP17, IP1, IP3, IP7, IP8, IP10, IP 11, IP12, IP14, IP15) in-patient records reviewed; 5 of 5 (P1, P2, P3, P4, P5) patients seen in the emergency room; and 2 of 7 (OP27, OP28)out-patient. Findings included:

IP16 was admitted 5/25/10, with diagnoses that included orthostatic hypotension, headache and chest pain. The patient was admitted by nurse practitioner NP-I and reviewed by MD-L. The admission ordered dated 5/25/10, lacked an authenticating signature of the admitting NP that included date and time of entry. The order was electronically co-signed nearly two months later on 7/23/10, by MD-L; this order did record the time and date.

IP17 was admitted 8/11/10, with diagnoses of critically high prothrombin time and atrial fibrillation. The patient was admitted by NP-I. The admission orders of 8/11/10 lacked authenticating signature of the admitting NP that included date and time of entry. As of 9/1/10, during the survey, there was no evidence an MD had electronically co-signed these admission orders.


13611


IP-1 was admitted to the hospital on 8/28/2010, following a fall resulting in a head injury. Chart review indicated Physician-A had not indicated the date the "Physician's Orders" forms, dated 8/28/10, 8/30/10, and 8/31/2010, had been signed.

IP-3 was admitted to the hospital on 8/30/10, for a total knee arthroplasty. Physician-G had not indicated the date or the time postoperative "Total Knee Orders" had been written. A verbal order from Physician-G was written on the "Physician Orders's" form, transcribed 8/31/10, however there was no indication of the date or the time the verbal order had been received. Another note from Physician-G on the "Progress Notes" did not have a date or a time to indicate when the note had been written. Another progress note written by Physician-G, dated 8/31/10, did not indicate the time the progress note had been written. There was no indication on the "Authorization for the Treatment, Anesthesia and Operations/Procedures" form of the time Physician-G had signed the consent form.


IP-7 was admitted to the hospital on 8/30/10, with the diagnosis of an abscess. Physician-F had not indicated the time an immediate postoperative note had been written on the "Progress Notes", dated 8/30/10.


IP-8 was admitted to the hospital on 8/25/10, with the diagnosis of back pain following a fall. Physician-B had not indicated the time admission orders on the "Physician's Order" form had been written on 8/25/10, Physician-C had not indicated the time admission medication orders had been written on the "Home Medication List", dated 8/26/10.


IP-10 was admitted from the Emergency Department to the hospital on 8/29/10, with abdominal and chest pain. Physician-B had not indicated the time admission orders had been written on the "Home Medication List' dated 8/29/10. The physician also had not indicated the date or the time orders had been written on the "ER Physician Order Sheet".

IP-11 was admitted to the hospital on 8/27/10, with the diagnosis of weakness and hip pain. Chart review indicated Physician-I had not indicated the time an order had been written on the "Progress Notes" dated 8/29/10. There was no signature, date or time to identify who had written the physician order on the "Progress Notes" dated 8/28/10, at 7:50 AM. Physician-G had not indicated the time a progress note had been written on 8/29/10. Physician-J had not indicated the time a progress notes had been written on 8/30/10 and 8/31/10.

IP-12 was admitted to the hospital on 8/29/10 with diagnoses which included weakness and nausea. Chart review indicated Physician-B had not indicated the time the admission "Physician Orders" form, dated 8/29/10, had been signed. Physician-C had not indicated the time the "Home Medication List" had been signed.

IP-14 was admitted to the hospital on 8/28/10, with a diagnosis of shortness of breath and possible aspiration pneumonia. Chart review revealed Physician-B had not indicated the time "Adult Pneumonia Admission Orders", dated 8/28/10, and the time the admission orders on the 'Home Medication List", dated 8/28/10, had been signed. Chart review also revealed Physician-D had not indicated the time the discharge orders on the "Home Medication List", dated 8/28/10, had been signed. ,Physician-D had not indicated the time two physician orders on the"Physician Orders", dated 8/30/10, had been written. Physician orders, dated 8/31/10, did not indicate the time Physician-D hd written the orders.,

IP-15 was admitted to the hospital on 8/29/10, with diagnoses which included shortness of breath and pneumonia. Physician-B had not indicated the time "Adult Pneumonia Admission Orders" had been signed on 8/29/10. Physician-E had not indicated the time orders, dated 8/30/10, had been written on the "Physician's Order" form nor the time the admission orders had been written on the "Home Medication List", dated 8/30/10.

EMERGENCY DEPARTMENT PATIENTS

Patient (P)-1 was admitted to the Emergency Department on 6/12/10, with the diagnosis of an ear infection. Chart review indicated Physician-H had not indicated the time orders had been written on the "ER Physician Order Sheet" dated 6/11/10. The "ER Report" did not indicate the time Physician-H had dictated the report. Although the "Emergency Nursing Record" indicated the time the patient went to the emergency room, it did not indicate when the initial triage by the Registered Nurse had been completed. The "Emergency Nursing Record for Pediatric Illness" form did not indicate the date or the time the nurse had completed the initial nursing assessment.

P-2 was admitted to the Emergency Department on 7/1/10, with psychiatric symptoms and was subsequently transferred to another facility. Although the "Emergency Nursing Record" indicated the time the patient went to the emergency room, it did not indicate when the initial triage by the Registered Nurse had been completed. Chart review indicated there was no indication of the date or the time the initial nursing assessment had been completed on the "Emergency Nursing Record". There was no indication of the time a Crisis Team Practitioner" had completed the "Crisis Care Program Admission Information" form. There was no indication of the time Physician-H had written the order to transfer the patient on the "Physician Orders" form, dated 7/1/10. The physician also had not indicated the date or the time the "Transfer Consent" had been signed. There was no indication of the time Physician-H had dictated the "ER Report", dated 7/1/10.

P-3 was admitted to the Emergency Department on 5/31/10, following a motor vehicle accident with significant injuries. Chart review indicated there was no indication on the "Emergency Nursing Record" of the time or the date the initial nursing assessment had been completed. There was no indication of the date or the time Physician-B had signed the "ER Physician Order Sheet". There was no indication of the time Physician-B had dictated the "ER Report". A review of the "Certification of Removal and Transit Program", dated 5/31/10, did not indicate the time the patient's body had been released to the funeral home.

P-4 was admitted to the Emergency Department on 7/31/10, with the diagnosis of alcohol intoxication. Although the "Emergency Nursing Record" indicated the time the patient went to the emergency room, it did not indicate when the initial triage by the Registered Nurse had been completed. Chart review indicated there was no indication of the time or the date the initial nursing assessment had been completed on the "Emergency Nursing Record". There was no indication on the "Emergency Physician Order Sheet" of the name of the physician who had written the orders nor the date or the time the orders had been written. There was no indication of the time Physician-B had dictated the admission "History and Physical".

P-5 was admitted to the Emergency Department on 8/27/10, with the diagnosis of abdominal pain. Although the "Emergency Nursing Record" indicated the time the patient went to the emergency room, it did not indicate when the initial triage by the Registered Nurse had been completed. Chart review indicated there was no indication of the time or the date the initial nursing assessment had been completed on the "Emergency Nursing Record". There was no indication of the date or the time Physician-B had signed the "Physician Order Sheet". There was no indication of the time Physician-B had dictated the "ER Report".


The Emergency Department Clinical Manager was interviewed on 8/30/10, at approximately 2:00 PM. She verified that entries in the medical record had not been authenticated related to the dates and times entries had been made. She stated the time entered on the "Emergency Nursing Record" indicated when the patient went to the emergency room from the admission/ reception area. She verified this time did not indicate when the Registered Nurse had completed triage of the patient.

During a visit to clinic #2 on 9/1/10, at 8:15 a.m. OP27 was seen for seborrhea keratosis. The P's chart review indicated that Physician L, did not date or time his progress notes of 8/23/2010.

OP28's was seen at clinic #2 on 8/30/10, for treatment of asthma. The chart review indicated that physician M had not indicated the time the History and Physical exam of 8/30/10 was signed.

The hospital policy "Medical Record Documentation Requirements", reviewed 8/04, provided by the hospital was reviewed. The policy indicted all entries must be dated and authenticated but did not specify that all entries should indicate the time the entry had been made.

The Health Information Manager was interviewed on 9/1/10, at 11:45 AM. She stated the current system in medical records did not have a means to indicate the time physicians had dictated notes.

The Health Information manager (HIM) verified during interview on 9/1/10, at 2:15 p.m. there was no standard or policy on the length of time MD/DO co-signatories had to complete their entries. The HIM manager also verified the hand written entries seldom contained timed notation, but the new electronic medical record system would automatically enter the time of the entries.




15508

Based upon interview, policy and contract review, and record review, the Critical Access Hospital (CAH) was found not to be in compliance with the Condition of Participation of Surgical Services. The CAH did not ensure proper sanitation of surgical instruments for 8 of 8 outpatients (OPS-1-8) who underwent a cataract extraction with an intraocular lens implant by Physician-K. This potentially could affect every patient who underwent this surgical procedure at the CAH. Findings include:

The CAH failed to ensure that proper sterilization occurred for outpatients undergoing a cataract extraction with a lens implant due to the type of sterilization of instruments which occurred.

During a tour of the Operating Room suite on 8/31/2010, at approximately 9:30 am, the Operating Room (OR) Manager was interviewed regarding the use of flash sterilization. She stated that surgical eye instruments were washed between patients and then placed in the flash sterilizer in a tray which was not wrapped. The flash sterilizer was located in a small room between Operating Rooms 1 and 2. This room also contained the sink where the surgeon would perform a preoperative hand scrub. A review of the "Autoclave Service Notes", dated 8/18/10, indicated eye instruments had been flashed sterilized for eight patients of Physician-K (OPS 1-8) on 8/18/10. The log indicated the reason for flashing the instruments was "ASC", which the service notes indicated was an abbreviation for "Accepted Clinical Situation". The OR Manager stated the eye instruments were flash sterilized between patients as they had a contract with a company which provided three cases of eye instruments regardless of the number of patients who were scheduled for a cataract extraction.. The OR Manager stated Physician-K was scheduled about one day per month and had operated on as many as fifteen patients in a single day. She stated the average number of outpatients who had this procedure performed by Physician-K was approximately ten per day and the physician operated about one day per month.

A review of the "Flash Sterilization" policy, revised July 2010, indicated flash sterilization would only be used in selected clinical situations and in a controlled manner. The policy also indicated flash sterilization would be used only when there was insufficient time to process by the preferred wrapped or container method and/or according to manufacturers' recommendations.

A review of the contract with Sightpath Medical entitled "Agreement Mobile Cataract and Specialty Services", signed 8/9/2010, indicated SightPath Medical would provide three complete instrument sets with each visit. The contract indicated the initial term of the agreement would be for three years from April 1, 2010.

The OR Manager was interviewed via telephone on 9/2/2010, at 11:55 AM and stated that the notation ACS on the "Autoclave Service Notes" were the operating room standards related to accepted clinical situations and were not based on standards from any professional organization or governmental entity.

Based on interview and record review, the CAH hospital facility failed to ensure all patient care services and other services affecting patient health and safety were evaluated and included in an effective quality assurance (QA) program.
The quality and appropriateness of the diagnosis and treatment furnished in the CAH and the treatment outcomes were not effectively evaluated in all service areas for 5 of 10 departments and 3 of 3 offsite locations reviewed. Findings included:

During review of radiology services on 8/31/10 at 10:00 a.m., the radiology director reported most of the QA activity in the department consisted of "problem solving" the issues that presented day to day and the director maintained a log of some of these problems. In addition, the director had been doing some tracking fax reporting errors.
The director was unable to provide documentation of a comprehensive radiology department QA process that included data analysis, identification/implementation of corrective actions, evaluation of the corrective actions and measures to improve quality on a continuous basis. The only QA reports that were located had been performed by the contract providers that did nuclear medicine and mobile imaging.

The quality assurance (QA) director verified on 9/1/10 at 2:35 p.m. that there was no specific format for QA processes in the CAH and some departments had more detailed methods to monitor quality and treatment outcomes than others. The QA director also reported that most of the activity the past year had involved a transition to electronic medical records and that had been the main priority; however, the process had not been incorporated into a formal QA project.
The QA director also verified the off-site and clinic locations 1, 2, and 3 were also not included in the QA program of the CAH hospital.



15508

The quality assurance director verified on 9/1/10 at 2:35 p.m. that neither offsite clinic #2 nor clinic #3 were involved in a quality assurance and/or a quality performance program (QA). She agreed that this was an area which needed to be developed.

The RN who was responsible for the Organ Procurement program at the CAH verified in an interview on 8/30/2010 at 3:00 p.m. that there was not a formal QA program in this area. She stated the only aspect of QA that they worked on, was to obtain 100 % consistency in the reporting of deaths to the Organ Procurement Organization (OPO). There was not any other areas identified that may be improved by corrective action or have measures to improve quality on a continuous basis.
In an interview with the Director of Maintenance on 8/31/10 at 10:00 a.m. he acknowledged that aside from maintaining a variety of logs which ensured the physical plant systems are operating effectively there was not a formal QA program being conducted in this department.

The dietary manager verified on 8/31/10 at 9:00 a.m. the dietary department had not conducted any type of QA program in the past year.




13611

The Emergency Department lacked a quality assurance program which was based on identified problems and contained the necessary components of a comprehensive quality assurance program.

During review of the Emergency Department on 8/30/10 at 1:30 pm, the Emergency Room Nurse Manager reported most of the quality assurance activities in the department consisted of reviewing medical records to ensure their completion.. The Nurse Manager also stated they had been tracking the delay in transfer of psychiatric patients from the Emergency Department to other inpatient facilities, however, a formal quality assurance study which consisted of all of the necessary components had not been developed.

The Nurse Manager was unable to provide documentation of a comprehensive Emergency Department QA process which included problem identification, data analysis, identification/implementation of corrective actions, evaluation of the corrective actions and measures to improve quality on a continuous basis. The only quality assurance studies which had been completed related to completion/review of chart documentation.

The Nurse Manager was interviewed on 8/30/2010, at 2:00 PM and stated there had been no other quality assurance studies completed within the past two years which were comprehensive and based on identified problems.

Based on interview, policy and record review, the CAH hospital facility failed to ensure the quality and appropriateness of the diagnosis and treatment furnished by 9 of 9 (A,B,C,D,E,F,G,H,I) mid-level practicioners (nurse practitioners, clinical nurse specialists, and physician assistants) practicing at the CAH were evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy. Findings included:

Review of the medical staff policy on appointment/reappointment and clinical privileges approved by the medical staff and governing board (dated revised 4/2004) detailed the processing for application and assignment of clinical privileges; however, lacked procedures to document the evaluation of ongoing quality and appropriateness of the care provided by mid-level dependent and independent allied health professionals.
The actual medical staff by-laws and governing body by-law documents also did not identify any specific method or measures to evaluate mid-level provider care.

The CEO reported during interview on 8/31/10 at 10:30 a.m., all providers (MD/DO/Mid-level/CRNA) were selected randomly to undergo a "peer review" of their medical care; mid-level providers did not have a separate review process. The CEO verified this method of evaluation was not formally detailed or identified in the medical or governing board by-laws.

The Credentialing/Quality director verified during interview on 9/1/10 at 3:00 p.m., the CAH hospital had no specific review process for mid-level providers. There were no reports, written evaluations or QA meeting notes that demonstrated evidence of an ongoing evaluation of the care provided by mid-level practitioners. The director reported the CAH did not have a distinct or formalized review and evaluation process of mid-level providers by MD/DO providers, "Because they always work so closely together."

The Credentialing/Quality director provided a Health Information policy dated 8/04 that identified, "Patient records for each mid-level practicioner are regularly reviewed by a doctor of medicine or osteopathy and discuss findings and conclusions positive or negative with the mid-level practicioner. Questions of quality of care or patient safety will be referred to a peer reviewer for further review. In addition, any patient cared for by a mid-level practicioner who falls out in the hospital's normal QA process will be referred for peer review. "
The Credentialing/Quality director could not provide documentation or evidence a mid-level practicioner review process was completed or recorded on any of the 9 (nine) mid-level practicioners on staff.