HospitalInspections.org

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Based on staff interviews and a lack of temperature monitoring information, the Critical Access Hospital failed to ensure all pharmaceuticals were stored in a climate controlled environment. This failed practice had the potential to affect all patients who received intravenous therapy at the hospital. The hospital census was 10on the first survey day.

Findings:

1. An interview conducted with the Consulting Pharmacist on 3/7/2019 at 10:30 A.M. revealed that intravenous solutions were stored in an area of the hospital, outside of the pharmacy and was not monitored for temperature control.

2. An interview with the Director of Plant Maintenance at 11:30 A.M. 3/7/19 confirmed the ambient temperature of the storage area was not monitored.

3. Examples of intravenous solutions stored in the materials management storage area were 5% Dextrose solution (sugar water), 0.9% saline(dilute salt water). Both both included manufacturer's instructions for storage at room temperature, 21 degrees Celsius or 70 degrees Fahrenheit.

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Based on medical record review, review of Medical Staff Rules and Regulations and staff interview, the CAH (Critical Access Hospital) failed to ensure that 2 of 6 Outpatient surgical medical records reviewed (Patients 18 and 22) contained a History and Physical. This failed practice had the potential to affect all surgery patients of the CAH. Total Outpatient procedures/surgeries performed from 10/1/18-3/1/19 was 201.

Findings are:

A. Review of Patient 18's medical record (3/6/19 at 9:30 AM) revealed the patient had a colonoscopy on 2/27/19. Review of the entire medical record revealed a lack of evidence of a documented History and Physical.

-Review of Patient 22's medical record (3/6/19 at 10:30 AM) revealed the patient had an anal mass removed on 1/08/19. Review of the entire medical record revealed a lack of evidence of a documented History and Physical.

B. Review of the Medical Staff Rules and Regulations (Approved 8/18) stated "For patients going to the O.R. [operating room], the following is required: History and Physical..."

C. Interview with the VP (Vice President) of Nursing (3/7/19 at 9:40 AM) confirmed the above medical records lacked evidence of the required History and Physicals.

Based on medical record review, review of Medical Staff Rules and Regulations and staff interview, the CAH (Critical Access Hospital) failed to ensure that 4 of 6 Outpatient surgical medical records reviewed (Patients 19, 20, 21 and 23) contained a physician order for discharge. This failed practice had the potential to affect all surgery patients of the CAH. Total Outpatient procedures/surgeries performed from 10/1/18-3/1/19 was 201.

Findings are:

A. Review of Patient 19's medical record (3/6/19 at 9:45 AM) revealed the patient had a bilateral Tonsillectomy and Adenoidectomy on 3/1/19. Review of the entire medical record revealed a lack of evidence of a physician order for discharge.

-Review of Patient 20's medical record (3/6/19 at 10:00 AM) revealed the patient had left carpal tunnel release (surgery used to treat carpal tunnel syndrome) on 2/11/19. Review of the entire medical record revealed a lack of evidence of a physician order for discharge.

-Review of Patient 21's medical record (3/6/19 at 10:15 AM) revealed the patient had a Dilation and Curettage (surgery used to treat a woman's uterus) on 2/8/19. Review of the entire medical record revealed a lack of evidence of a physician order for discharge.

-Review of Patient 23's medical record (3/6/19 at 10:45 AM) revealed the patient had hernia repair on 12/18/18. Review of the entire medical record revealed a lack of evidence of a physician order for discharge.

B. Review of the Medical Staff Rules and Regulations (Approved 8/18) stated "Patient shall be discharged only on written order of the attending physician..."

C. Interview with the VP (Vice President) of Nursing (3/7/19 at 9:35 AM) confirmed the above medical records lacked evidence of a discharge order written by a physician.

Based on medical record review, review of Medical Staff Rules and Regulations and staff interview, the CAH (Critical Access Hospital) failed to ensure the physician examined the patient immediately before surgery for 2 of 6 Outpatient surgical records (Patients 18 and 20) reviewed. This failed practice had the potential to affect all surgery patients of the CAH. Total Outpatient procedures/surgeries performed from 10/1/18-3/1/19 was 201.

Findings are:

A. Review of Patient 18's medical record (3/6/19 at 9:30 AM) revealed the patient had a colonoscopy on 2/27/19. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed.

-Review of Patient 20's medical record (3/6/19 at 10:00 AM) revealed the patient had left carpal tunnel release (surgery used to treat carpal tunnel syndrome) on 2/11/19. Review of the entire medical record revealed a lack of evidence that the physician examined the patient immediately before surgery to evaluate the risk of the procedure to be performed.

B. Review of the Medical Staff Rules and Regulations (Approved 8/18) stated "For patients going to the O.R., the following is required: ...Preoperative Patient Assessment just prior to surgery..."


C. Interview with the VP (Vice President) of Nursing (3/7/19 at 9:45 AM) confirmed the above medical records lacked evidence of the patient examinations completed by the physician immediately before surgery to evaluate the risk of the procedure to be performed.