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The Critical Access Hospital (CAH) reported a census of two patients. Based on document review and staff interview, the CAH failed to develop and implement policies and procedures directing staff how to dispense medications for patients to take home from the Emergency Department (ED) in accordance with acceptable professional principles.

Findings include:

- Staff H, interviewed on 6/13/12 at 9:55am, revealed the nursing staff prepared medications to be taken home. The medications are removed from the manufacturer's container, placed in an envelope and give to the patient with instructions how to take the medication at home as the provider orders. Staff H acknowledged a professional nurse prepares the take home medications for the patient. The nurse enters the pharmacy removes the ordered medication from a multidose bottle, places the pills an envelope, and dispense to the patient.

- Pharmacist E, interviewed on 6/13/12 at 10:20am confirmed the CAH lacks policies and procedures to direct the CAH in the dispensing of medications for patients to take home.

- Document review of "Kansas State Board of Pharmacy Laws" updated march 2008 K.S.A. 68-7-11 Medical care facility pharmacy. (c) The pharmacist-in-charge shall be responsible for the maintenance of all emergency medication kits. (l) Inpatient services. Drugs may be obtained upon a prescriber's medication order for administration to the inpatient by a designated registered professional nurse or nurses with approval and supervision of the pharmacist-in-charge. Adequate records of these withdrawals shall be maintained. (2)Emergency outpatient services. (A) An interim supply of prepackaged drugs shall be supplied to an outpatient only by a designated registered professional nurse or nurse pursuant to a prescriber's medication order when a pharmacist is not on the premises and a prescription cannot be filled. The interim supply shall be labeled with the following information: The name, address, and telephone number of the medical care facility; the name of the prescriber; the full name of the patient;the identification number assigned to the interim supply of the drug or device by the medical facility pharmacy; the date the interim supply was supplied; adequate directions for use of the drug or device; the beyond-use date of the drug or device issued;the brand name or corresponding generic name of the drug or device; the name of the manufacturer or distributor of the drug or device, or an easily identified abbreviation of the manufacturers's or distributor's name; the strength of the drug; the contents in terms of weight, measure or numerical count; and necessary auxiliary labels and storage instruction, if needed. The interim supply shall be limited in quantity to an amount sufficient to supply the outpatient's needed until a prescription can be filled. (3) The designated registered professional nurse or nurses may enter the medical care facility pharmacy and remove properly labeled pharmacy stock containers, commercially labeled packages, or properly labeled prepackaged units of drugs. The registered professional nurse shall not transfer a drug from one container to another for future use, but may transfer a single dose from a stock container for immediate administration to the ultimate user."

- Staff A, interviewed on 6/13/12 at 12:30pm, acknowledged nurses cannot dispense medications to patients.

The CAH failed to develop and implement policies and procedures directing staff in assuring patient's medications are dispensed as ordered.

- Observation on 6/13/12 at 9:20am of ten mattresses in patient care rooms revealed a mattress in patient room #3 with cracks on the edges rendering the surface non-cleanable.

- The CAH's policy titled "Handwashing", reviewed on 6/14/12 at 9:20am, directed staff to "washing hands or use waterless cleaner after removing gloves, before leaving the room...".

- Staff L, observed on 6/12/12 between 11:15am to 12:10pm performed a terminal cleaning of a patient room. Staff L put on protective gloves, applied disinfectant spray to the door handles and removed trash. Staff L removed the gloves, and dusted the high surfaces. Staff L applied another pair of gloves and cleaned the sinks. Staff L removed the gloves applied another pair and wiped the plumbing fixtures. Staff L removed the gloves, applied another pair and sprayed disinfectant on the bed and rails and other surfaces. Staff L removed the protective gloves, and applied another pair of gloves to clean the trash can. Staff L removed the gloves, applied another pair and removed the trash can liner. Staff L prepared a wet mop and removed the gloves. Staff L obtained another pair of gloves, and dropped one glove on the floor. Staff L applied the dropped glove mopped the floor and removed the gloves. Staff L removed the protective gloves and failed to perform hand hygiene seven times during the room cleaning.

- Staff J observed on 6/13/12 at 1:20pm administered eye drops to patient #17. Staff J put on a pair of protective gloves to administer the eye drops, removed the gloves and exited the patient's room. Staff J failed to perform hand hygiene.

The CAH failed to assure staff perform hand hygiene as directed by the CAH's policies.








25604

The Critical Access Hospital (CAH) reported a census of two patients. Based on observation, staff interview, and policy review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices to ensure staff followed acceptable standards for one of two observed medication administrations, one of one cleaning of a discharged patient room, and two of eight observed patient care mattresses.

Findings include:

- Staff A interviewed on 6/13/12 at 2:45pm verified they were responsible for the management of the infection control program. Staff A acknowledged they do not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control practices.

- The CAH's Infection Control policy reviewed on 6/13/12 at 3:40pm directed "...There is an active facility-wide infection control program...Procedures on prevention, surveillance, and control relating to the environment, including sterilization, disinfection practices, housekeeping, maintenance...".

- The CAH's job description for the Infection Control Coordinator reviewed on 6/13/12 at 3:40pm directed "...Perform surveillance functions in all departments, reporting problem areas to the department supervisors...".

- Observation of the Physical Therapy department on 6/12/12 at 9:15am revealed a Hi-Lo bed mattress with a torn area approximately four inches with exposed foam.

Staff G interviewed on 6/12/12 at 9:15am acknowledged the non-cleanable surface on the Hi-Lo table due to the torn mattress with foam exposed.

The Critical Access Hospital (CAH) reported a census of two patients. Based on clinical record review, policy review, and staff interview, the CAH failed to assure medications are administered in accordance with a provider's written order for one of nine Emergency Department (ED) patients with medications administered to the patient (patient #7).

Findings include:

- The CAH's policy titled "Emergency Department", reviewed on 6/13/12 at 3:00pm, revealed, "No medication can be administered in the emergency department without a specific order from a physician or mid-level practitioner...".

- Patient #7's clinical record, reviewed on 6/12/12 at 3:40pm, revealed and ED admission date of 10/23/11 with complaints of nausea and vomiting. The nurse administered Zofran (used to treat nausea) 4mg (milligrams) intravenously. The clinical record lacked evidence of a provider's order for the medication.

Staff A, interviewed on 6/12/12 at 3:40pm, confirmed the clinical record lacks evidence of a physician's order for the medication. Staff A acknowledged a provider must order medications for the patient.

The CAH failed to assure medications are administered as ordered by a qualified practitioner.

The Critical Access Hospital (CAH) reported a census of two patients. Based on clinical record review, policy review and staff interview the CAH failed to assure medical staff date and/or time all authenticated (signed) entries in the medical record for 26 of 34 clinical records reviewed (patient #'s 1, 3, 4, 5, 6, 7, 8, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 28, 29, 30, and 34).

Findings include:

- The CAH's policy Medical Record Form Content reviewed on 6/13/12 at 3:45pm directed "...Proper date on every sheet in chart...".

- Patient #17's clinical record reviewed on 6/11/12 at 11:55am revealed an admission on 5/30/12 with a diagnosis of Cerebral Vascular Accident (stroke). Patient #17's clinical record revealed between 5/31/12 to 6/8/12, two written orders and four progress notes lacked a time when authenticated by the provider. Patient #17's clinical record contained an activities assessment that lacked a date and time when completed.

- Patient #18's clinical record reviewed on 6/12/12 at 1:10pm revealed an admission on 1/24/12 and discharged on 1/27/12 with a diagnosis of malnutrition with dehydration. Patient #18's clinical record revealed between 1/24/12 to 1/27/12, one written orders, four telephone/verbal orders, two progress notes, and a history and physical lacked a date and/or time when authenticated by the provider. Patient #18's clinical record contained an activities assessment that lacked a date and time when completed.

- Patient #19's clinical record reviewed on 6/12/12 at 1:30pm revealed an admission on 4/16/12 and discharged on 5/4/12 with a diagnosis of rehabilitation from a fractured left hip. Patient #19's clinical record revealed between 4/16/12 to 5/1/12, five written orders, eight telephone/verbal orders, ten progress notes, and a history and physical lacked a date and/or time when authenticated by the provider. Patient #19's clinical record contained an activities assessment that lacked a date and time when completed.

The CAH failed to have a policy directing staff on the requirement to date and time all entries into the clinical record.

Staff K, interviewed on 6/13/12 at 5:00pm acknowledged the CAH failed to assure medical staff dated and timed all entries in the medical record.

This deficient practice also affected patient #'s 1, 3, 4, 5, 6, 7, 8, 11, 12, 13, 14, 15, 16, 20, 21, 22, 23, 25, 26, 28, 29, 30, and 34.

The Critical Access Hospital (CAH) reported a census of two patients. Based on clinical record review, policy review, and staff interview the CAH failed to provide evidence of activities for five of five sampled swing bed residents (#'s 17, 18, 19, 20, and 21).

Findings include:

- The CAH's policy Activities for Swing Bed reviewed on 6/13/12 at 3:40pm directed "...The activities program is designed to provide diversional, therapeutic and recreational activities in a way to promote physical, mental, and psychosocial stimulation and enhance the patient's quality of life...Activities will be available seven days a week...".

- Patient #17's clinical record reviewed on 6/11/12 at 11:55am revealed an admission on 5/30/12 with a diagnosis of Cerebral Vascular Accident (stroke). The clinical record lacked evidence of a care plan addressing activities, scheduled activities or documentation activities were conducted.

- Patient #18's clinical record reviewed on 6/12/12 at 1:10pm revealed an admission on 1/24/12 and discharged on 1/27/12 with a diagnosis of malnutrition with dehydration. The clinical record lacked evidence of a care plan addressing activities, scheduled activities or documentation activities were conducted.

- Patient #19's clinical record reviewed on 6/12/12 at 1:30pm revealed an admission on 4/16/12 and discharged on 5/4/12 with a diagnosis of rehabilitation from a fractured left hip. The clinical record lacked evidence of a care plan addressing activities, scheduled activities or documentation activities were conducted.

Staff D interviewed on 6/13/12 at 11:15am acknowledged they were responsible for activities for swing bed residents and the swing bed clinical records lacked evidence of an activities care plan or that activities were conducted.

This deficient practice also affected patient's #20 and #21.

The Critical Access Hospital (CAH) reported a census of two patients. Based on medical record review, document review and staff interview the CAH failed to provide social services per the CAH's policy and failed to document appropriate interventions in the plan of care for five of five swing bed sampled patients (#'s 17, 18, 19, 20, and 21).

Findings include:

- The CAH's policy Social Services and Swing Bed reviewed on 6/13/12 at 3:40pm directed "...Objective-To contribute to total patient care recognizing that there are social and emotional needs...assist with...planning for post-discharge care...emotional needs...referral and consultation for direct services...".

- Patient #17's clinical record reviewed on 6/11/12 at 11:55am revealed an admission on 5/30/12 with a diagnosis of Cerebral Vascular Accident (stroke). The clinical record lacked evidence of a social service care plan focused on the psychosocial needs of the patient. The patient's clinical record lacked evidence of social service interventions.

- Patient #18's clinical record reviewed on 6/12/12 at 1:10pm revealed an admission on 1/24/12 and discharged on 1/27/12 with a diagnosis of malnutrition with dehydration. The clinical record lacked evidence of a social service care plan focused on the psychosocial needs of the patient. The patient's clinical record lacked evidence of social service interventions.

- Patient #19's clinical record reviewed on 6/12/12 at 1:30pm revealed an admission on 4/16/12 and discharged on 5/4/12 with a diagnosis of rehabilitation from a fractured left hip. The clinical record lacked evidence of a social service care plan focused on the psychosocial needs of the patient. The patient's clinical record lacked evidence of social service interventions.

Staff C interviewed on 6/13/12 at 10:00am acknowledged they were responsible for social services for swing bed residents and the clinical records lacked a social service care plan or evidence of social service interventions.

This deficient practice also affected patient's #20 and #21.