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A. Based on a review of CAH policy, observation and staff interview, it was determined that the Critical Access Hospital (CAH) failed to ensure that outdated drugs and biologicals were not available for use in patient care areas.

Findings include:

1. The CAH policy titled, "Expiration Dates" was reviewed on 07/27/10. It indicated "7. Expiration Date Monitoring: b. Drug and device expiration dates will be checked during the monthly medication area inspections and all drugs and devices scheduled to expire during the month will be removed from stock."

2. During a tour of the CAH conducted with the Director of Surgery on 07/26/10 at 1:15 PM, the following were observed: On the Difficult Airway Cart in the Anesthesia Room (2- Intravenous Start Kits- expired 07/09, 1- 500 ml Dextrose 0.25% Normal Saline- expired 11/09, 2- Lavender top Vacutainer, 1- Red top Vacutainer- expired 03/10); In the Locked Cabinet in the Anesthesia Room (2- Spinal Trays- expired 05/10.) Upon the Certified Registered Nurse Anesthetist (CRNA) opening the cabinet, the CRNA verbalized "I will get a few of these things out of here before you see them." The CRNA proceeded to remove items out of the cabinet, while prohibiting surveyors from viewing them, and left the room. The surveyors observed items placed in pockets as well as in hands. This surveyor observed a plastic package with brown ampules protruding from the left hand as the CRNA left the room. The Director of Surgery was requested to obtain the items. An open Ventolin inhaler- expired 01/10 was the only item returned. In the Post Anesthesia Recovery Room (PACU) refrigerator, 1- open 10 ml vial of Novolog Regular Insulin- opened 06/18/10. In Endoscopy B Room: (1- Single Use Hot Biopsy Forceps- open, out of package, and on storage shelf with other packaged items; 1-Single Use Caesar CGF- 240 Grasping Forceps in a plastic baggie on the storage shelf with other packaged items.) In the Stress Lab Crash Cart, (2 Normal Saline Inhalation solutions- expired 5/10; 2 Adult Laryngeal Mask Airway Kits- 1 expired 09/29/09 and 1 expired 05/10.) During a tour of the Emergency Department (ED), conducted with the Director of ED on 07/27/10 at 2:45 PM, on the Respiratory Cart: 6 Ethilon 3.0 Black Monofilament Nylon sutures- expired 01/09 and 17 Chloroprep Swabstick Applicators- expired 03/09.)

3. During a staff interview conducted with the Chief Nursing Officer (CNO) on 07/27/10 at 3:00 PM, the above findings were confirmed.

A. Based on a review of Hospital policy and procedure and staff interview, it was determined that in 3 of 3 (Pt s #1, 12, 14) in which patients required a surgical site marking, the CAH failed to ensure that the surgeon performing the operation marked the site as indicated per CAH policy.

Findings include:

1. The policy titled, "Time Out-Site Verification Universal Protocol" was reviewed on 07/26/10. It indicated under, "II. Site Marking - Component 2, A. When possible, the site marking process should include involvement of the patient and/or family to verify the correct procedure and site." Also, under, "B. Surgeon/Invasive Procedure Physician, 1. Prior to sedation, the surgeon/invasive procedure physician or designee will mark the site with the word 'yes'. 2. The surgeon/invasive procedure physician or designee will mark the site with a permanent marker at or near the incision site."

2. The medical record of Pt #1 was reviewed on 07/26/10. Pt #1 was admitted to the CAH on 07/20/10 with the diagnosis of Right Hip Fracture and underwent surgical repair on 07/22/10. There was no documentation to indicate who, when, or how the site was marked, or that the site had been marked with the word "yes" with permanent marker.

3. The medical record of Pt #12 was reviewed on 07/27/10. It indicated that Pt #12 was admitted to the Hospital on 02/05/10 with a diagnosis of Fracture Neck of Femur. On 02/07/10, Pt #12 was scheduled for a Left Hemiarthroplasty of the Hip. There was no documentation to indicate who, when or how the site was marked, or that the site had been marked with the word "yes" with permanent marker.

4. The medical record of Pt #14 was reviewed on 07/28/10. It indicated that Pt #14 was admitted to the Hospital on 12/09/09 with a diagnosis of Fall, Fracture Hip. On 12/07/09, Pt #14 was scheduled for a ORIF of the Right Hip. There was no documentation to indicate who, when or how the site was marked, or that the site had been marked with the word "yes" with permanent marker.

5. During an interview on 07/28/10 at 11:00 AM with the Chief Nursing Officer, the above findings were confirmed.

A. Based on a review of Hospital policy and procedure, a review of anesthesia controlled medication logs and staff interview, it was determined that in 5 of 12 anesthesia controlled medication logs reviewed, the Hospital failed to ensure all wasted controlled medications were witnessed.

Findings include:

1. The Hospital policy and procedure titled, "CONTROLLED SUBSTANCES" was reviewed on 07/27/10. It indicated under, "POLICY: IX. Any controlled substance amount removed from storage that is not administered to a single patient must be witnessed, destroyed...and documented by 2 licensed professionals...."

2. Anesthesia controlled medication logs were reviewed that included the months of April through July, 2010. Five of the 12 logs indicated a controlled medication was wasted but did not have the 2 required signatures that witnessed the waste.

3. During interviews with the Director of Nursing and Pharmacist, conducted on 07/27/10 at 11:15 AM, the above findings were confirmed.

B. Based on a review of Hospital policy and procedure, a review of anesthesia controlled medication logs and staff interview, it was determined that in 3 of 12 anesthesia controlled medication logs reviewed, the Hospital failed to ensure the individual administering the medication always signed the log.

Findings include:

1. The Hospital policy titled, "CONTROLLED SUBSTANCES" was reviewed. It indicated under, "POLICY: VII. B. The administration and documentation of narcotic administration will follow the same policy as the other care units..." And under, "IX. ...When the amount of drug administered is less than contained in the drug delivery system, the professional giving the drug will complete the amount given and wasted, and then sign the first signature block...."

2. Anesthesia controlled medication logs were reviewed that included the months of April through July 2010. Three of the 12 logs failed to document the individual that administered the controlled medication as required for a total of 15 times.

3. During an interview with the Director of Nursing and the Pharmacist, conducted on 07/27/10, the above findings were confirmed.

C. Based on a review of Hospital policy and procedure, a review of anesthesia controlled medication logs and staff interview, it was determined that in 2 of 12 logs, the Hospital failed to ensure the counts were always correct.

Findings include:

1. The Hospital policy and procedure titled, "CONTROLLED SUBSTANCES" was reviewed. It indicated under, "POLICY: V. ...An inventory of these controlled substances will be completed at each shift change...by 2 licensed professionals and documented at the same time that the actual inventory will be compared to the theoretical inventory and signed by both."

2. Anesthesia controlled medication logs were reviewed that included the months of April through July 2010. The log with the time frame from 06/11 through 06/16 indicated that Fentanyl Citrate had a balance of 7. However, the counted balance was documented as 3. The log with the time frame from 06/30 to 07/2/10 indicated that Ketamine had a balance of 4. However, the counted balance was documented as 0.

3. During an interview with the Director of Nursing, conducted on 07/29/10 at 9:45 AM, the above findings were confirmed.

A. Based on observation and staff interview, it was determined that the CAH failed to ensure that patient care items were stored in a manner to prevent potential contamination/infection.

Findings include:

1. During a tour of the CAH, conducted with the Directors of the respective departments on 07/26/10 at 1:15 PM, the following were cleaning supplies were observed stored in the same cabinet with patient care supplies: In Operating Room #2- 1 Dispatch cleaner and 1 Ecolab All- Purpose cleaner in with surgical supplies. In the Difficult Airway Cart in the Anesthesia Room- 2 open 3 ml syringes with needles attached, 1 open 6 ml syringe with needle, 1 open 12 ml syringe with needle attached, and 1 open 20 ml syringe with needle attached- all laying in the drawer. In the Reclining Laboratory Room- 1 Command Air Odor Counteractor, 1 box of 100 packets of Castile Soap Towelettes, 1 foam Hand Cleanser refill container, 1 Inspire Deodorant Spray Freshener, and 2 Dial liquid soaps were all stored in the same drawer as the Glucose oral solutions and bottles of water for patient tests. In the Drug Screen drawer- 3 containers of RIT liquid dye and 3 packages of RIT dye concentrate were stored with Glucose oral solutions and bottles of water for patient tests. In the Fluoroscopy Room- 1 Clorox Clean Up was stored with 1 bottle of 1900 ml Liquid Polibar Plus Barium Suspension.

2. During a staff interview conducted with the CNO on 07/26/10 at 3:00 PM, the above findings were confirmed.

B. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 3 of 5 (Pts #1, #2 & #7) medical records reviewed, in which the patient required initiation of Contact Isolation, that the CAH failed to ensure that it's Infection Control policy was followed.

Findings include:

1. The CAH policy titled, "Isolation Principles" was reviewed on 07/28/10. It indicated under, "Procedure: 1. Contact Transmitted Disease: These patients are known or suspected of having a disease transmitted through either direct (person to person) contact or indirect (person to contaminated environmental surface) contact. A. Document the following items in the medical record. Reason for isolation; Type of isolation; Time and statement that Isolation was initiated; Every shift statement that isolation was maintained; Time, reason, and statement that Isolation was terminated..."

2. The medical record of Pt #1 was reviewed on 07/26/10. Pt #1 was admitted to the CAH on 07/20/10 with the diagnosis of Right Hip Fracture. On 07/26/10, Nursing documentation indicated that Pt #1 had a history of Methicillin Resistant Staphylococcus Aureus (MRSA). On 07/20/10, nursing documentation indicated that Pt #1 had a history of MRSA and a positive nasal screen and was placed on Contact Isolation. From 07/20/10 thru 07/25/10, nursing documentation failed to indicate that isolation was maintained 3 out of 12 shifts.

3. The medical record of Pt #2 was reviewed on 07/26/10. Pt #2 was admitted to the CAH on 07/23/10 with the diagnosis of Pneumonia Left Lower Lobe. Contact Isolation was initiated upon admission due to history of MRSA. From 07/23/10 thru 07/25/10, nursing documentation failed to indicate that isolation was maintained 3 out of 6 shifts.

4. The medical record of Pt #7 was reviewed on 07/27/10. It indicated that Pt #7 was admitted to the Hospital of 07/12/10 with a diagnosis of Cellulitis of the Buttocks, Infected Decubitus Ulcers and Metastatic Lung Cancer Stage IV. On 07/12/10 at 1835 a nurses note titled Initial Interview, indicated that Pt #7 was identified as "previous history of MRSA infection" and "previous admission to any healthcare facility within last 3 months." There was no documentation to indicate that isolation was initiated.

5. During an interview conducted on 07/28/10 at 11:00 AM with the Chief Nursing Officer, the above findings were confirmed.

A. Based on a review of CAH guideline, medical record review and staff interview, it was determined in 2 of 20 (Pts #1, #2) medical record reviewed, that the CAH failed to ensure all nursing care was provided as ordered or as per CAH approved Potter and Perry 6th Edition guidelines.

Findings include:

1. The medical record of Pt #1 was reviewed on 07/26/10. Pt #1 was admitted to the CAH on 07/20/10 with the diagnosis of Right Hip Fracture. On 07/22/10, there was a physician's order "Neuro check every 30 minutes times 4..." Nursing documentation failed to include every 30 minutes neuro checks times 4. On 07/22/10, Pt #1 underwent surgical repair of the hip fracture and had a Hemovac post operatively. There were no physician orders related to the Hemovac care/maintenance. The CNO indicated that when no physician order is present, the CAH follows the Perry and Potter 6th Edition guidelines which indicate "Chapter 37 Wound Care and Irrigations page 1252: 3. Empty drainage system and measure drainage... every 8 to 12 hours and as needed..." Chart in the nurses notes." From 07/22/10 thru 07/25/10, nursing documentation failed to indicate emptying and recording of Hemovac drainage every 8 to 12 hours.

2. The medical record of Pt #2 was reviewed on 07/26/10. Pt #2 was admitted to the CAH on 07/23/10 with the diagnosis of Pneumonia Left Lower Lobe. On 07/23/10, there was a physician's order "Accucheck before meals and at bedtime." There was no documentation of an Accucheck before lunch on 07/26/10.

3. During a staff interview conducted with the CNO on 07/27/10 at 3:00 PM, the above findings were confirmed.

B. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 1 of 1 (Pt #1) medical records reviewed, in which the patient required the use of restraints, the CAH failed to ensure care was provided as per the CAH restraint policy.

Findings include:

1. The CAH policy titled "Restraints (Physical) in the Acute Care Setting" was reviewed on 7/27/10. It indicated "XII. Restraint use in acute medical and surgical (Nonpsychiatric) care: D. Physician, Licensed Independent Practitioner, Registered Nurse... who has been trained will see the patient within one hour after initiation of the intervention to evaluate... F. Documentation in the patient's medical record will include the following: 1. One hour face-to-face..."

2. The medical record of Pt #1 was reviewed on 07/26/10. Pt #1 was admitted to the CAH on 07/20/10 with the diagnosis of Right Hip Fracture. On 07/20/10 at 8:06 PM, there was a physician's order for restraints. There was no documentation of a one hour face-to-face evaluation.

3. During a staff interview, conducted with the CNO on 07/27/10 at 1:00 PM, the above findings were confirmed.

C. Based on a review of CAH policy, medical record review, and staff interview, it was determined in 2 of 20 (Pts 1, #6) medical records reviewed, that the CAH failed to ensure that intravenous (IV) care was provided, as per CAH policy.

Findings include:

1. The CAH policy titled, "IV Therapy, Peripheral" was reviewed on 07/28/10. It indicated " 6. Routine Care: d. Peripheral IV. i. IV sites are changed every 72 hours or as needed... 11. Documentation: f. Document date, time, site condition, and condition of catheter when IV is discontinued."

2. The medical record of Pt #1 was reviewed on 07/26/10. Pt #1 was admitted to the CAH on 07/20/10 with the diagnosis of Right Hip Fracture. Nursing documentation indicated that Pt #1 had an IV initiated on 07/20/10 and restarted on 07/24/10, greater than the 72 hour timeframe.

3. The medical record of Pt #6 was reviewed on 07/27/10. Pt #6 was admitted to the CAH on 06/24/10 with the diagnosis of Acute Bronchiolitis. Nursing documentation indicated that and IV was initiated on 06/24/10 and was discharged on 06/25/10. There was no documentation to indicate whether or not the IV was discontinued prior to discharge.

4. During a staff interview, conducted with the CNO on 07/27/10 at 1:00 PM, the above findings were confirmed.

A. Based on a review of CAH policy, medical record review and staff interview, it was determined in 1 of 2 (Pt #1) medical records reviewed, the CAH failed to ensure blood transfusion documentation was completed, as per CAH policy.

Findings include:

1. The CAH policy titled, "Blood Product Administration" was reviewed on 07/27/10. It indicated "8. Transfusion of blood or blood products must be completed within 4 hours of release time from the laboratory... Documentation: a. Vital signs are recorded... at the completion of the transfusion."

2. The medical record of Pt #1 was reviewed on 07/26/10. Pt #1 was admitted to the CAH on 07/20/10 with the diagnosis of Right Hip Fracture. On 07/20/10, blood transfusion documentation indicated "Issued: 12:30 PM; time started: 12:43 PM; time stopped was blank; stopped by: was blank." There was no documentation to indicate what time the completion vital signs were taken or that the transfusion was completed within the 4 hour timeframe.

3. During a staff interview, conducted with the CNO on 07/27/10 at 1:00 PM, the above findings were confirmed.

A. Based on a review of medical records and staff interview, it was determined that in 2 of 20 (Pts #5, #11) medical records reviewed, the CAH failed to ensure that all records were legible, complete and accurately documented.

Findings include:

1. The medical record of Pt #5 was reviewed on 07/27/10. It indicated that Pt #5 was admitted to the CAH on 04/02/10 with a diagnosis of Pneumonia, COPD, Asthma, Cirrhosis of the Liver and Ascites. Documentation indicated that there were 2 consents scanned into the medical record both with no patient signature, date or time.

2. The medical record of Pt #11 was reviewed on 07/27/10. Pt #11 was admitted to the Emergency Department on 04/20/10 with Urinary complaints. There was no documentation as to the time that the Medical Screening Exam was completed.

3. During an interview conducted on 07/28/10 at 10:00 AM with the Chief Nursing Officer, the above finding was confirmed.

A. Based on a review of CAH guidelines, medical record review and staff interview, it was determined that in 2 of 6 (Pts #2, #18) medical records reviewed in which the patient received subcutaneous (sq) injections, the CAH failed to ensure nursing staff documented the injection site, as per CAH guidelines.

Findings include:

1. The CAH guideline "Potter and Perry 6th Edition" was reviewed on 07/28/10. It indicated "Chapter 21 Parenteral Medications Page 722: Recording and Reporting: Immediately after administration, chart medication dose, route, site, time, and date given on Mediation Administration Record."

2. The medical record of Pt #2 was reviewed on 07/26/10. Pt #2 was admitted to the CAH on 07/23/10 with the diagnosis of Pneumonia Left Lower Lobe. On 07/23/10, there was a physician's order "Accucheck before meals and at bedtime with sliding scale." From 07/23/10 thru 07/26/10, nursing documentation failed to document the site of injection in 1 out of 3 times, in which sq injection was required.

3. The medical record of Pt #18 was reviewed on 07/28/10. Pt #18 was admitted to the CAH on 06/23/10 with the diagnosis of Congestive Heart Failure. On 06/23/10, there was a physician's order "Lantus 10 units sq times one, Regular insulin 7 units sq times one." There was no documentation of the site of either injection.

4. During a staff interview conducted with the CNO on 07/27/10 at 3:00 PM, the above findings were confirmed.