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Based on observation, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to remove outdated supplies from 1 (Ambulance Unit 2) of 2 Ambulances and 1 of 3 Emergency Room exam rooms. Failure to remove outdated patient supplies from the CAH's supplies, available for use in patient care, could potentially result in staff using the expired items for patient care after the manufacturers' expiration date, indicating the staff should not use the supplies for patient care. The hospital CAH administrative staff identified Ambulance Unit 2 transported a patient approximately 69 times per year and approximately 1,330 patients presented to the emergency department for emergency care per year.


Findings included:


1. During a tour on 7/01/2019 around 1:30 PM of the Ambulance rigs, an observation of the Ambulance Rig, Unit 2 revealed the following:

a. 1 of 1 Endotracheal tube 5.0 (a small tube inserted through the mouth or nose into the windpipe to establish an airway) expired 10/2018

b. 1 of 1 Yankaeur Suction Tip expired 12/2015

c. 1 of 1 suction tubing expired 6/2010

d. 1 of 5 3 ml 0.9% Sodium Chloride injection syringes for IV flush expired 5/1/2019

e. 1 of 5 22G X 1" IV catheter safety needles expired 12/2017

f. 1 of 1 BD Green top Vacutainer expired 2018-11-3

g. 1 of 1 BD Gray top Vacutainer expired 2019-2-28

h. 1 of 1 BD Blue top Vacutainer expired 2018-7-31

i. 1 of 1 BD Purple top Vacutainer expired 2019-2-28

j. 1 of 1 BD Red top Vacutainer expired 2018-12-31

j. 1 of 1 bottle Contour Blood Glucose Monitoring strips Expired 2015-4


2. During an interview at the time of the observations, EMT C and the EMS Manager verified the supplies had expired and EMT C reported the EMT's checked monthly for outdated supplies but did not utilize a checklist or document the date and time the supplies were checked.


3. During a tour on 7/1/2019 around 2:20 PM of the Emergency Department, an observation in Exam Room 3 revealed an open package of Rovers Cervix Brushes (utilized to obtaining a Pap smear) containing 20 in the 25 brush package, expired 2015-


4. During an interview at the time of the observations the Chief Nursing Officer (CNO) verified the supplies had expired and should have been pulled at the time the check was completed, and the staff should not use the supplies.





II. Based on observation, document review and staff interviews the Critical Access Hospital's (CAH) Ambulance EMS Staff failed to follow the manufacturer's instructions for the Ascensia Contour Blood Glucose Monitoring System when it failed to perform Quality Control checks on the Ascensia Contour Meter. Failure to follow the Ascensia Contour Blood Glucose Monitoring System manufacturer's instructions for use may result in inaccurate blood glucose readings. The CAH reported the Ambulance Staff EMT's performed approximately 52 blood glucose checks per year.

Findings include:

1. Observation on 7/1/2019 during a tour of the CAH's 2 Ambulances revealed an Ascensia Contour Glucose Monitoring Systems in each ambulance.

2. Review of the Ascensia Contour Blood Glucose Monitoring System manufacturer's User Guide, dated 9/2006, revealed in part, "Use ...control solutions to make sure the meter and the test strips are working properly."

3. Review of the policy "Bayer Contour Glucose Meter Procedure," effective 3/2018, revealed in part, "[Quality] Controls ... perform controls once every 24 hours and each time a new strip bottle is opened."

4. During an interview on 7/1/2019 at the time of the tour of the Ambulances, Emergency Medical Technician (EMT) C reported the staff did not perform quality control testing on the Ascensia Contour Blood Glucose meters.

4. During an interview on 7/3/2019, the CNO verified the Ambulance Staff EMT's failed to perform quality control testing of both Ambulances, Unit 1 and Unit 2, Ascensia Contour Blood Glucose Meters as directed in the CAH's policy and procedure.





III. Based on observations, document review, and staff interviews, the Critical Access Hospital (CAH) staff failed to maintain hot water temperatures between 110 and 120 degrees Fahrenheit in 2 of 6 CAH's Emergency Department rooms tested (Trauma Room 1 and Exam Room #3). Failure to maintain water temperatures between 110 and 120 degrees Fahrenheit in patient care areas could potentially result in skin burns. The CAH identified approximately 111 patients presented to the emergency department per month for emergency care and the average daily inpatient census was 1 patient.


Findings include:

1. Observations on 7/2/2019 at approximately 2:15 PM, with the Chief Nursing Officer (CNO), revealed the water temperature in Emergency Department Trauma Room 1 room was 122.4 degrees Fahrenheit and Exam Room #3's water temperature was 125.1 degrees Fahrenheit.

The CNO verified the water temperatures at the time of the water temperature checks.

2. Review of policy "Water Temperatures," effective 8/2017, revealed in part, "On a monthly basis, water temperatures will be monitored ... throughout patient care areas ... record ... on monthly log ... immediately report temperatures in excess of 124 degrees."

3. Review of the "Water Temperatures" log revealed the CAH staff last documented water temperature checks in a patient care area on 12/23/18.

4. During an interview on 7-2-19 at 3:10. the Human Resource Director/ Compliance verified water temperatures in patient care areas had not been checked since 12/23/18 as policy directed.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to include a physician (MD or DO), or one or more physician assistants, nurse practitioners (advanced practice providers), or clinical nurse specialists on their policy review committee. Failure to include an MD or DO, advanced practice provider, or clinical nurse specialist on their policy review committee resulted in policies that are reviewed and approved without medical or advanced practice provider input which may adversely affect patient care. The CAH administrative staff reported a census of 3 patients on entrance with an average daily census of 1.1 patients and approximately 1,330 Emergency Department visits per year.

Findings include:

1. Review of 2 of 2 Policy Committee meeting minutes, dated February 14, 2019 and May 9, 2019, revealed the CAH Policy Committee lacked representation from a physician, advanced practice provider, or a clinical nurse specialist.

2. During an interview on 7/3/19 at 9:45 AM, Director of Human Resources confirmed the CAH has physicians and advanced practice providers that provide care to CAH patients, and the Policy Committee does not include representation from either physicians or advanced practice practitioners.

Based on observations, policy review and staff interviews, the Critical Access Hospital (CAH) administrative staff failed to ensure pharmacy oversight of 32 boxes and 8 bottles of sample medications in 1 of 3 outpatient clinic (speciality clinic). Failure of pharmacy oversight in the dispensing of sample medications could result in outdated, recalled, or otherwise unusable medications being available for physicians and mid-level providers to give to patients, as well as, the potential for theft of medications by unauthorized persons. The CAH reported approximately 402 patients treated in the last year at the speciality clinic.

Findings include:

1. Observations during tour of the speciality clinic on 7/1/19 at 1:16 PM with the RN Out Patient Coordinator, revealed the sample medication supply room stored multiple oral medications.

2. During an interview, at the time of the observation, the RN Out Patient Coordinatior reported when the samples are received by the RN Out Patiet Coordinator, the RN Out Patient Coordinator entered the medications on log sheets, obtained the log sheets for review which showed separate sheets for each medication, and documented information about the sample and a record of dispensing the sample to a patient. RN Out Patient Coordinator reported the CAH pharmacist did not play a role in oversight of the sample medications in the clinic, although the CAH's pharmacist was aware the clinic stored and disbursed sample medications..

3. During an interview on 7/2/19, at 1:30 PM, the Director of Pharmacy confirmed she knew the speciality clinic stored sample medications but did not have a role in oversight of the medications.

4. During an interview on 7/2/19 at 4:50 PM, the CNO revealed the pharmacy does not have a policy on the management of sample medications.




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I. Based on observation, document review and staff interviews, Critical Access Hospital (CAH) surgical services staff failed to monitor and document temperature and humidity in the surgical suite (1 OR, 1 Endoscopy Procedure Room, 1 Post Anesthesia Recovery Room, 1 decontamination room, 1 central sterilizer room, and adjacent sterile storage area). Failure to monitor temperature and humidity in the surgical suite (1 OR, 1 Endoscopy Procedure Room, 1 Post Anesthesia Recovery Room, 1 decontamination room, 1 central sterilizer room, and adjacent sterile storage area) can potentially result in the buildup of humidity that contains bacteria that can fall onto sterilized surfaces, operating tools or possibly into an open wound potentially causing serious infections in patients. The CAH administrative staff reported the surgical services staff performed an average of 287 surgeries per year and 103 endoscopies per year.

Findings include:

1. Observations during a tour of the surgical suite on 7/2/19 at approximately 9:50 AM, revealed the surgical services staff lacked documentation the surgical services staff checked the temperature and humidity in all areas of the surgical suite.

2. During an interview at the time of the tour, both RN A and the Quality Manager confirmed that surgery staff did not do any type of temperature or humidity monitoring for OR 1, Endoscopy 1, the adjacent surgical instrument and endoscope cleaning room, and central sterilizer room. The Quality Manager also stated the CAH based their surgical policies on the AORN (Association of peri-Operative Registered Nurses, a nationally recognized guideline agency) guidelines.

3. Review of the AORN Guidelines for Environment of Care, copyright 2018, revealed in part: "The health care organization should create and implement a systematic process for monitoring HVAC [Heating, Ventilation, Air Conditioning] performance parameters and a mechanism for resolving variances...The HVAC system is intended to reduce the amount of environmental contaminates (eg, microbial laden skin squames, dust, lint) in the surgical suite."

4. During an interview on 7/2/19 at approximately 3:00 PM, Quality Manager acknowledged AORN standards require temperature and humidity monitoring in the surgical suite.


II. Based on observation, document review, and staff interview, Critical Access Hospital (CAH) surgical staff failed to thoroughly pre-clean an endoscope (an instrument which can be introduced into the body to give a view of its internal parts). Failure to thoroughly pre-clean an endoscope may result in inadequate removal of bacteria and/or other infectious agents from the endoscope which could result in cross contamination of these infectious agents from patient to patient, potentially causing severe illness and/or death. The CAH administrative staff reported the surgical services staff performed an average of 103 endoscopies per year.

Findings include:

1. Review of Olympus Reprocessing Manual, "Chapter 5. Reprocessing the Endoscope...," revealed, in part: "1. Fill a clean, large basin with the detergent solution...2. Immerse the endoscope in the detergent solution. Be sure to thoroughly brush the inside of the instrument channel, the instrument channel port, the suction channel and the suction cylinder of the endoscope. Insufficient brushing may pose an infection control risk."

2. Observations on 7/2/19 at 10:05 during endoscope pre-cleaning revealed RN A used a brush to clean the channels of the endoscope prior to submerging the endoscope in the cleaning solution.

3. During an interview on 7/3/19 at 8:30, RN A confirmed that RN A did not follow manufacturer's recommendations when cleaning the endoscope.


III. Based on observation, document review, and staff interview, Critical Access Hospital (CAH) surgical staff failed to monitor and document the temperature of the disinfectant when performing high level disinfection for surgical instruments used for cystocopy (procedure using a tube to examine the bladder) including a flexible cystoscope, rigid cytoscope, and stent graspers (instruments used during cytoscopies). Failure to monitor and document the temperature of the disinfectant when performing high level disinfection for surgical instruments used for cytoscopies, including a flexible cystoscope, rigid cytoscope, and stent graspers may result in inadequate removal of bacterial and/or other infectious agents from the instruments which could result in cross contamination of these infectious agents from patient to patient, potentially causing severe illness and/or death. The CAH administrative staff reported surgical services performs 23 cytoscopies per year.

1. Observations during a tour of the surgical suite on 7/2/19 at approximately 9:30 AM, revealed surgical staff used ReVital-Ox Resert High Level Disinfectant to clean flexible cystoscope, rigid cytoscope, and stent graspers.

2. Review of manufacturer's recommendations for ReVital-Ox Resert High Level Disinfectant stated, in part: "Revital-Ox Resert High level Disinfectant is a high level disinfectant when used...at a minimum temperature of 20 degrees C [Celcius]."

3. During an interview on 7/2/19 at 3:30 PM, RN B confirmed that the surgical services staff does not monitor the temperature of ReVital-Ox Resert High Level Disinfectant prior to disinfecting the flexible cystoscope, rigid cystoscope or stent graspers.

Based on document review and staff interviews, Critical Access Hospital (CAH) surgical services staff failed to have a list of each surgeon's privileges readily available in the surgical suite. Failure to have a list of each surgeon's privileges available in the surgical suite could potentially result in CAH staff allowing a surgeon to perform a procedure for which the surgeon is not qualified and/or not authorized to do at the CAH which could potentially cause patient harm. The CAH administrative staff reported the surgical services staff performed an average of 287 surgeries per year and 103 endoscopies per year.

Findings include:

1. Observation during a tour of the surgical suite on 7/2/19, at approximately 9:30 AM, revealed the surgical services staff lacked access to the privilege lists of the surgeons performing surgeries and other procedures in the CAH.

2. During an interview at the time of the tour, both RN A and Quality Manager acknowledged that surgery staff did not have access to a list of privileges for any of the surgeons performing surgeries and other procedures in the CAH.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure surgical services staff discharged patients that received anesthesia to the company of a responsible adult for 4 of 5 surgical patients reviewed (Patients #1, Patient #2, Patient #3, Patient #4). The facility staff reported an average of 18 surgical patients that received anesthesia per month. Failure to ensure surgical services staff discharged patients who received anesthesia in the company of a responsible adult could potentially result in the patient discharging and lacking someone to monitor them following surgery, and potentially allowing a life-threatening complication to occur unnoticed.

Findings included:

1. Review the policy "Discharge of the Outpatient Surgical Patient, revealed in part, "...Pateints are not allowed to drive themselves home at the time of discharge. .Pateints are educated on the need of a driver with the pre-operative teaching....."
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2. Review of patient medical records revealed the following:

a. Patient #1 received anesthesia for a surgical procedure on 2/26/19. The surgical services staff discharged Patient #1 on 2/26/19 at 11:20AM. Patient #1's medical record lacked documentation the surgical services staff discharged Patient #1 in the company of a responsible adult.

b. Patient #2 received anesthesia for a surgical procedure on 4/63/19. The surgical services staff discharged Patient #2 on 4/16/19 at 12:16 PM. Patient #2's medical record lacked documentation the surgical services staff discharged Patient #2 in the company of a responsible adult.

c. Patient #3 received anesthesia for a surgical procedure on 1/31/19. The surgical services staff discharged Patient #3 on 1/31/19 at 6:18 PM. Patient #3's medical record lacked documentation the surgical services staff discharged Patient #3 in the company of a responsible adult.

d. Patient #4 received anesthesia for a surgical procedure on 6/18/19. The surgical services staff discharged Patient #4 on 6/18/19 at 12:41 PM. Patient #4's medical record lacked documentation the surgical services staff discharged Patient #4 in the company of a responsible adult.

3. During an interview on 7/2/19 at 11:30 AM, the Chief Nursing Officer (CNO) confirmed Patient #1's, Patient #2's, Patient #3's, Patient #4's medical records lacked documentation the surgical services staff discharged the patients in the company of a responsible adult after the patients received anesthesia.

Based on policy and patient medical record review, and staff interviews, the Critical Access Hospital (CAH) staff failed to perform a comprehensive activities assessment for 5 of 5 closed swing bed patients (Patient #5, Patient #6, Patient #7, Patient #8, and Patient #9) which resulted in failure to ensure activity personnel developed and implemented an ongoing activity program that included an activities care plan for 5 of 5 closed swing bed patients (Patients #5, Patient #6, Patient #7, Patient #8, and Patient #9). Failure to provide a comprehensive activity assessment and an activity program that meets the physical and psychosocial needs of the individual patients could potentially impede the patient's progression toward attaining goals and achieving the highest level of well being and independence possible. The CAH administrative staff identified a census of 0 swing patient at the time of the survey and an average of 25 swing bed patients per year.

Findings include:

1. Review of policy, "Resident Quality of Life," dated effective 3/2018, revealed in part, "Activities..provides for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of each resident...the certified activity director provides skilled patients with the activities program, or by designee."

2. Review of 5 of 5 closed swing bed patient medical records revealed the following information:

a. A physician ordered swing bed services for Patient #5 on 7/20/18 and was discharged on 8/1/18. The Activity Coordinator failed to complete a comprehensive activity assessment for Patient #5.

Patient #5's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

b. A physician ordered swing bed services for Patient #6 on 10/16/18 and was discharged on 10/26/18. The Activity Coordinator failed to completed a comprehensive activity assessment for Patient #6..

Patient #6's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

c. A physician ordered swing bed services for Patient #7 on 11/20//18 and was discharged on 11/30/18. The Activity Coordinator failed to complete a comprehensive activity assessment for Patient #7.

Patient #7's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

d. A physician ordered swing bed services for Patient #8 on 12/22/18 and was discharged on 1/7/19. The Activity Coordinator failed to complete a comprehensive activity assessment for Patient #8.

Patient #8's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.

e. A physician ordered swing bed services for Patient #9 on 5/2/19 and was discharged on 5/9/19. The Activity Coordinator failed to complete a comprehensive activity assessment for Patient #9.

Patient #9's medical record lacked evidence of an activity care plan that directed staff to provide individual or group activities chosen by the patient.


3. During an interview on 7/2/19 at 11:07 AM, the Activities Coordinator acknowledged she provided activities for swing bed patients. The Activity Coordinator verified she failed to complete a comprehensive activity assessment and to develop and implement an ongoing activities program that included an activities care plan for swing bed Patient #5, Patient #6, Patient #7, Patient #8, and Patient #9. The Activity Coordinator reported she did not have access to document in a swingbed patient's medical record and documented the activities performed on a Skilled Patient Activities log for the Acute Services Manager/ Utilization Review.

4. During an interview on 7/2/19 at 11:07 AM, the Acute Services Manager/Utilization Review acknowledged she had the responsibility to ensure the activity program functioned in compliance with the hospital's policy. The Acute Services Manager/Utilization Review Manager verified the lack of documentation of a comprehensive activities assessment, activities, and activity care plans for Patient #5, Patient #6, Patient #7, Patient #8 and Patient #9. The Acute Services Manager acknowledged she was not familiar with the hospital's policy on Activity requirements.