HospitalInspections.org

Based on observation, policy review and staff interview the Critical Access Hospital (CAH) failed to ensure outdated supplies were not available for patient use in two of two crash carts.

Findings include:

- Observation on 11/29/10 at 11:00am of the nursing unit crash cart revealed the following outdated supplies;
1. Five-16 gauge intravenous catheters which expired on 12/09.
2. Five-18 gauge intravenous catheters which expired on 8/09.
3. Five-20 gauge intravenous catheters which expired on 5/10.
4. Five-22 gauge intravenous catheters which expired on 4/10.
5. One-Easy Cap II Carbon Dioxide detector which expired on 1/09.
6. One-18 French urinary catheter which expired on 1/10.

Staff D, interviewed on 11/29/10 at 11:05am, acknowledged the intravenous catheters, carbon dioxide detector and urinary catheter were outdated.

- Observation on 11/29/10 at 10:45am of the emergency room crash cart revealed the following outdated supplies;
1. One-28 French nasal airway which expired on 9/06.
2. One-26 French nasal airway which expired on 8/06.
3. One-22 French nasal airway which expired on 8/06.

Staff A interviewed on 11/29/10 at 11:30 acknowledged the nasal airways were outdated.

- The CAH 's policy titled " Crash Cart Restocking and Equipment Check " reviewed on 12/1/10/10 at 2:30pm instructed the night shift staff to open and check the crash cart weekly for outdated medications and supplies. The CAH failed to follow their Crash Cart Restocking and Equipment Check policy.

Based on policy review and staff interview the the medical staff personnel failed to participate in the development and periodic review of the CAH's policies.

Findings include:

- On 12/1/10 at 4:15pm review of the Medical Staff Bylaws revealed under section 8.2-2 "Duties", "The duties of the Medical Staff shall include, but not be limited to: (c) participating in the development of Medical Staff and Hospital policy, practice, and planning."

- Policy and procedure manuals reviewed between 11/29/10 to 12/1/10 lacked evidence of participation of the physician in the development, review, or approval of the policies and procedures by the medical staff.

Staff A interviewed on 12/1/10 at 2:00pm acknowledged the CAH failed to ensure the medical staff participated in the development and periodic review of the CAH's policies and procedures.

Based on policy review and staff interview the Critical Access Hospital (CAH) failed to develop policies with the advice of a group of professional personnel that included one or more doctors of medicine or osteopathy and one or more physician assistants, or nurse practitioners.

Findings include:

- Policy and procedure manuals for: Infection Control, Emergency Department, Dietary, Nursing, and Medical Records, reviewed between 11/29/10 to 12/1/10 contained a signature page in the front of the manuals with only one signature, the non-staff member of the CAH.

- The signature page of the manual reviewed between 11/29/10 to 12/1/10 lacked evidence that a group of professionals, including at least one doctor of medicine or osteopathy and one or more physician assistants and /or nurse practitioners, participated in the development of the policies and procedures.

Staff A interviewed on 12/1/10 at 2:00pm acknowledged policy development did not include the advice of a group of professional.

Based on observation, policy review and staff interview the Critical Access Hospital (CAH) failed to ensure outdated drugs and biologicals were not available for patient use in one of two crash cart.

Findings include:

- Observation on 11/29/10 at 11:00am of the nursing unit crash cart revealed the following outdated drugs and biologicals;
1. One-1 milliliter vial of Naloxone Hydrochloride (a drug used to reverse the effects of narcotics) with an outdate of 11/1/10.
2. One-250 milliliter bag of Dextrose 5% containing Dopamine 400 milligrams (a drug used to treat shock and low blood pressure) with an outdate of 4/1/10.
3. One-30 milliliter vial of Sodium Chloride 0.9% (a biological used to flush intravenous catheters and mix with other drugs for administration) with an outdate of 11/1/10.

Staff D, interviewed on 11/29/10 at 11:05am, acknowledged the Naloxone, Dopamine, and Sodium Chloride were outdated.

- The CAH 's policy titled " Crash Cart Restocking and Equipment Check " reviewed on 12/1/10/10 at 2:30pm instructed the night shift staff to open and check the crash cart weekly for outdated medications and supplies. The CAH failed to follow their Crash Cart Restocking and Equipment Check policy.

Based on policy review and staff interview the Critical Access Hospital (CAH) failed to ensure policies were reviewed by a group of professional personnel on an annual basis to ensure adequate patient care.

Findings included:

- Policy and procedure manuals reviewed between 11/29/10 and 12/2/10 lacked evidence of an annual review by a group of professionals personnel that included at least one doctor of medicine or osteopathy, and at least one midlevel practitioner (Advanced Registered Nurse Practitioner or Physician Assistant).

Staff A and staff B interviewed on 12/1/10 at 3:15pm acknowledged the CAH failed to include policy review in the annual program evaluation.

Review of the policy and procedure manuals provided during the survey between 11/29/10 and 12/2/10 lacked evidence of Medical Staff approval.

Based on program evaluation document review and staff interview the Critical Access Hospital (CAH) failed to include review of the health care policies in the program evaluation.

Findings included:

- The program evaluation document reviewed on 12/1/10 at 2:30pm lacked evidence the health care policies were included in the annual review.

Staff A on 12/1/10 at 3:30pm confirmed the CAH failed to include a review of the health care policies in the annual program evaluation.

The CAH failed to include review of the health care policies as part of the annual program evaluation.