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The Community Access Hospital (CAH) was found out of compliance with 42 CFR 482.41, the Condition of Participation of Physical Plant and Environment for deficiencies issued as a result of a Life Safety Code inspection.

Findings include:

Please refer to Life Safety Code inspection tags: K17, K18, K29, K52, K56, K78.

Based on interview and document review, the Critical Access Hospital (CAH) failed to ensure hot packs were maintained at a temperature to prevent burns for 1 of 1 patient (R30) who sustained second degree burns following application of a hot pack.
Findings include:
R30 received outpatient occupational therapy three times a week for diagnoses that included right elbow and wrist pain. Treatment provided by occupational therapy included heat modalities and therapeutic exercises.
On 4/18/12, R30 was provided 10 minutes of hot pack treatment to the right elbow and right wrist by occupational therapist (OT)-B. R30 was noted to have substantial redness at the right elbow following the heat treatment. R30 telephoned OT-B following treatment, and informed him the reddened area had blistered. On 4/20/12, OT-B documented R30 had a blister over the right elbow.
On 11/8/12, at 9:10 a.m. the physical therapist, director of therapy services, (PT-A) stated the water temperature of the Hydrocollator (the heating unit for the hot packs) is checked prior to removal of the hotpacks, but the temperature is not recorded. PT-A stated the hot packs are stored in water with a temperature of around 160 degrees Ferenheit (F). PT-A stated if the temperature of the water was warmer than this, they would let the hot pack cool down prior to applying it on a patient. OT-B was present for the interview, and stated he remembered R30's burn from the hotpack, and felt R30 had hypersensitive skin.
On 11/8/12, at 11:00 a.m. registered nurse (RN)-E (director of quality assurance and risk management) stated she reviewed R30's burn, discussed it with PT-A and it was determined to be an isolated incident. RN-E verified no further investigation was completed and there was no increased monitoring of Hydrocollator temperatures to ensure appropriate temperatures for hot packs.
The manufacturer's instructions for the Hydrocollator recommended operating temperature of 160 degrees F to 166 degrees F, and the temperature of the water should be checked with a thermometer after every adjustment before using the hotpacks.

Based on policy review and interview the facility failed to develop an emergency water supply policy for the critical access hospital (CAH). This had the potential to affect all patients in the CAH.

The findings include:

The facility FAILURE OF WATER DISTRIBUTION SYSTEM policy dated April 1991, and revised last October 2011, did not include calculations to determine the amount of water needed for not only inpatients, but also staff and other persons who come to the hospital in need of care during emergencies.

The Lead Facilities Engineer was interviewed on 11/8/12, at 9:20 a.m. and confirmed that the FAILURE OF WATER DISTRIBUTION SYSTEM policy lacked the amount of water needed for inpatients as well as staff and other persons who come to the hospital in need of care during emergencies.

Based on observation, interview and document review, the Critical Access Hospital (CAH) failed to implement their own policy and procedures related to the monitoring and use of a blanket warmer in the radiology department. This practice had the potential to effect all patients using a heated blanket in radiology.

Findings include:

During the tour of the radiology department on 11/7/12, at 10:45 a.m. the blanket warmer dial was observed to be set at 150 degrees Fahrenheit (F). There was no thermometer indicating the real temperature of the warmer. The manufacturer's instructions on the side of the warmer indicated "Do not exceed 120 [degrees Fahrenheit]". Request to review tracking of the blanket warmer's temperatures indicated the radiology department did not track the temperatures of the blanket warmer.

The policy for Blanket and Solution Warming Cabinet Temperatures, last revised July 2011, indicated blanket warming temperatures should not exceed 150 degree F, the warming cabinet will be labeled with the desired temperature setting, and blanket cabinet temperatures will be documented every day the unit is open.

Interview with the radiology manager [RM] on 11/6/12, at 11:40 a.m. verified the temperatures were not being tracked or logged. When asked about the instruction not to exceed 120 degree F on the side of the blanket warmer and the dial set at 150 degrees F, the RM stated, "It doesn't look right, does it?"

Based on observation, interview and document review the Critical Access Hospital (CAH) did not ensure infection control procedures were implemented during 1 of 3 surgical (P1) procedures observed. In addition, soiled laundry was stored, uncovered, in a hallway accessible to all staff.

Findings include:

During observation of surgical procedures for P1, on 11/6/12 from 10:20 a.m. through 11:51 a.m., the Registered Nurse Anesthetist student (RNA-A)'s hair was not contained under the hat. Hair was observed at the nape of her neck and two inches of hair in a pony tail style was sticking out the back where the hat was tied on.

RNA-A was observed again on 11/07/12, at approximately 7:50 a.m., in the surgical suite with hair outside the hat at the nape of her neck and at the back of the head.

RNA-A, interviewed on 11/07/12, at approximately 9:10 a.m., stated she did not know her hair was out of her hat during P1's surgery.

Interview with the surgical manager on 11/07/12, at approximately 9:15 a.m. verified RNA-A hair was not contained in the hat she wore.

Review of the policy for Surgical Attire (undated) indicated: All head and facial hair must be covered. Rational: Hair is a gross contaminant and a major source of bacteria. Applying hair apparel first prevents contamination of surgical attire. Disposable bouffant and hood types are preferred. Skullcaps fail to cover the side hair above the ear and nape of the neck.


18617

A tour of the CAH was conducted on 11/8/12, at 9:20 a.m. with the lead facilities engineer. All of the CAH dirty linens were stored in large plastic receptacles along the wall of the common corridor in the basement.

The Lead Facilities Engineer, interviewed on 11/8/12, at 9:20 a.m., stated that the hospital was in the process of making a room specifically for soiled linen but the room had not been emptied or ready for storage of dirty linens. The lead facilities engineer further stated that the CAH did not have any patient care policies related to storage of dirty linens.

Based on interview and record review the critical access hospital (CAH) failed to ensure that telephone orders (TO) were signed by the prescribing physician in a timely manner for 3 of 23 patients ( P9, P7, P10) whose medical records were reviewed.

Findings include

P9 was admitted to the CAH on 10/30/12, to undergo a laparoscopic repair of an incisional hernia.
TO's dated 10/31/12, 11/4/12 and 11/5/12, were not signed by the prescribing physician when he saw P9 on 11/8/12.


P7 was admitted to the CAH on 11/5/12, to undergo a total abdominal hysterectomy.
Two TO's dated 11/5/12, were not signed by the prescribing physician when he saw P7 on 11/6/12, and 11/8/12.

P10 was admitted to the CAH on 11/5/12, to undergo a right parathyroidectomy.
A TO dated 11/5/12, was not signed by the prescribing physician when he saw P10 on 11/6, and 11/8/12.

On 11/8/12 at 9:15 a.m. the registered nurse manager of the medical surgical and obstetric services (RN-A) indicated that TO's should be signed by the physician within 48 hours or earlier if seen by the physician.

The CAH's undated Transcribing Practitioner Order policy indicated that verbal and telephone orders shall be authenticated by the practitioner within 48 hours

Based on interview and document review the critical access hospital (CAH) failed to ensure all physician entries were properly timed for 6 of 23 patients (P9, P7, P5, P10, P8, P20,) whose medical records were reviewed.

Finding include:

P9 was admitted to the CAH on 10/30/12, to undergo a laparoscopic repair of an incisional hernia.
P9's Post Operative Physicians orders and Glucose Monitoring orders dated 10/30/12, physician orders dated 11/3/12, 11/4/12, and 11/6/12, lacked the time the physician made the entries.

P7 was admitted to the CAH on 11/5/12, to undergo a total abdominal hysterectomy .
P7's Post Operative Physicians orders, Physicians Orders for Patient controlled Analgesia dated 11/5/12, and physician orders dated 11/6/12, and 11/8/12, lacked the time the physician made the entries.

P5 was admitted to the CAH on 11/6/12, due to a ruptured appendix.
P5's appendectomy Post Operative Physicians orders and Physicians Orders for Patient controlled Analgesia dated 11/6/12, lacked the time the physician made the entries.

P10 was admitted to the CAH on 11/5/12, to undergo a right parathyroidectomy.
P10's Post Operative Physicians orders dated 11/5/12, and physician orders dated 11/6/12, lacked the time the physician made the entries.

P8 was admitted to the CAH on 11/6/12, to undergo a gastric bypass.
P8's Post Operative Physicians orders dated 11/6/12, lacked the time the physician made the entry.

P20 was admitted to the CAH on 06/25/12, for a cesarean section.
Three physician orders dated 6/25/12 , Post Operative Physicians orders dated 6/26/12, and Discharge Physicians Orders dated 6/29/12, lacked the time the physician made the entries.

The registered nurse manager of the medical surgical and obstetric services (RN-A) was interviewed on 11/6/12, at 2:15 p.m. and verified all entries made in a patients chart needed to include the time the entry was made.

On 11/7/12 at 9:15 a.m. the CAH's registered nurse Risk Manger (RN-E) indicated the CAH did not have a policy that addressed the need to include the time a physicians order was written.

Based on interview and document review, the post-anesthesia evaluations were incomplete for 2 of 2 patients (P13, P14) who had received anesthesia for a surgical service.
Findings include:
P13 underwent a laparoscopic Roux-en-Y gastric bypass and umbilical hernia repair under general anesthesia on 11/6/12. The post-anesthesia evaluation did not include an assessment of the P13's cardiopulmonary status or level of consciousness.
P14 underwent an open revision of a Roux-en-Y gastric bypass and splenectomy under general anesthesia on 11/6/12. The post-anesthesia evaluation did not include an assessment of P14's level of consciousness.
On 11/7/12, at 9:00 a.m. the certified registered nurse anesthetist (CRNA)-C was interviewed and stated the facility did not have policies and procedures for post-anesthesia evaluations. CRNA-C stated professional standards are used.
The Scope and Standards for Nurse Anesthesia Practice (revised 2005) indicated the scope of CRNA practice includes discharging the patient from a post-anesthesia care area and providing post-anesthesia follow-up evaluation and care.
The CAH Medical Staff Rules and Regulations (updated 2/3/04) directed the post-anesthesia evaluation to include "a record of vital signs; level of consciousness; intravenous fluids administered including blood and blood products; all drugs administered; post-anesthesia visits by the CRNA; and any unusual events or post-operative complications, and the management of those events. "

Based on quality assurance review minutes and staff interview the critical access hospital (CAH) failed to integrate the organ, tissue and eye donation program into the QA program.

Findings include:

During review of the 2011, and 2012, Organ Donation Activity Report from Life Source (the CAH's organ procurement agency) it was noted that in 2011, there were 6 of 45 organ donation cases that were not reported timely (within 60 minutes) and from January to September of 2012, there were 2 of 24 organ donation cases that were not reported timely to Life Source.

The Quality Assurance (QA) minutes were reviewed and there was no evidence of QA activities to identify the problem or develop an action plan with improvement goals.

The Registered Nurse (RN) Director of Quality, interviewed on 11/6/12, at 11:00 a.m., verified the lack of timely reports. She stated the CAH was monitoring various activities related to the organ, tissue, and eye donation program; however, there was no current QA project to address the problem of late reports.