HospitalInspections.org

Based on interview, and document review, the facility failed to ensure the dietary manual was approved by the medical staff. This had the potential to affect all in-patients and swing bed patients.

Findings include:

During an interview on 8/5/15 at 1:09 p.m. registered dietician (RD)-C stated she had not had the diet manual approved by the medical staff. RD-C stated that previously, the facility had a computerized manual but it was not kept up. RD-C indicated she hadn't been with the facility long and "I don't think the manual had been approved before I came." RD-C stated she could not find any documentation on approval of the manual.

An undated form was provided entitled "Nutrition Care Manual Institutional Approval Form" which had a signature from a previous registered dietician. No medical staff member was identified as approving the manual or signing the form. Additionally, review of medical staff minutes revealed no approval was documented.

Review of the "Diet and Nutrition Care Manual Review and Approval" form indicated RD-C signed the form which was dated 7/28/15, however there was not medical staff approval on the form.

Based on observation, interview and document review, the critical access hospital (CAH) failed to follow safe medication administration practices for 2 of 2 medication passes observed for swing bed patient (SB)-3.
Findings include:
SB-3 was admitted to the CAH on 7/17/15, for generalized weakness following a recent hospitalization stay for pneumonia and congested heart failure (CHF - decrease in heart function to pump blood).
On 8/4/15, at 9:06 a.m. licensed practical nurse (LPN)-A obtained from the CAH's Omnicell (automated drug dispensing machine) SB-3's morning dose of digoxin (medication to treat CHF). LPN-A entered SB-3's room and reviewed his medication administration record (MAR) on the computer which was stationed in SB-3's room. LPN-A removed the hand held scanner from its holster beside the computer and proceeded to scan the barcode on SB-3's plastic identification armband which was located on the ledge of the computer above the keyboard. LPN-A then scanned the barcode on the medication. SB-3 had on a short sleeved shirt and no identification armband was observed on either of his wrists/arms.
On 8/4/15, at 11:58 a.m. LPN-A obtained SB-3's Novolog insulin pen from the Omnicell and entered SB-3's room to administer his afternoon dose of insulin based on SB-3's sliding scale insulin dosing parameters. LPN-A reviewed SB-3's MAR on the computer which was stationed in SB-3's room; removed the hand held scanner from its holster beside the computer; scanned the barcode on SB-3's plastic identification armband which still remained on the ledge of the computer above the keyboard. LPN-A then scanned the barcode on the Novolog insulin pen and proceeded to administer 5 units of Novolog insulin.
An observation 8/4/15, at 1:50 p.m. LPN-A indicated SB-3's armband was laying on the computer instead of affixed to the patient's arm. LPN-A stated the nameband was laying on the computer when I came to work.

An interview on 8/4/15, at 1:50 p.m. licensed practical nurse (LPN)-A confirmed when SB-3 received his medications this morning she used the hand held bar code scanner to scan his name band, but the nameband was not attached to P-3.
On 8/4/15, at 2:18 p.m. the pharmacist (P)-A stated the expectation for administering medications was for staff to obtain the medication from the Omnicell; go to the computer at the patient's bedside, scan the patient's armband and then scan the medication which was to be administered. P-A confirmed the armband should be attached to the patient - this was "not optional".
On 8/4/15, at 2:33 p.m. the director of nursing (DON) confirmed the staff utilized barcode scanning for administration of medications. The DON verified the patient's armbands should always be on the patient's wrists.
On 8/4/15, at 2:40 p.m. LPN-A confirmed SB-3 had not had his identification armband attached to his person; and that the armband had been sitting on the computer ledge above the keyboard when she administered the digoxin and Novolog insulin earlier in the day.
On 8/5/15, at 2:00 p.m. DON confirmed staff should have followed the CAH's barcode scanning policy when administering medications.
The Barcode Medication Administration policy dated 2/11/13, directed staff to scan the patient's personal identification armband prior to medication administration. In addition, [in bold lettering] identification bands that are not attached to the patient would not be used for barcode scanning.


33560

Based on interview and document review, the critical access hospital (CAH) failed to ensure 2 of 4 surgical outpatients (OPS-2, OPS-3) were accompanied by an adult upon discharge. This had the potential to affect all outpatient surgical patients.
Findings include:
On 3/6/14, OPS-2 had been admitted for a screening colonoscopy (test which allows a physician to look at the inner lining of the large intestine). OPS-2 underwent a colonoscopy under monitored anesthesia care (MAC) (local anesthesia together with sedation and analgesia). OPS-2 was discharged on 3/6/14, at 9:15 a.m., however the medical record lacked documentation of OPS-2 being discharged in the company of a responsible adult.
On 8/5/15, at 10:55 a.m. registered nurse (RN)-C, surgical services manager, confirmed the medical record lacked documentation of who had accompanied OPS-2 home at the time of discharge.
On 4/25/14, OPS-3 had been admitted for a colonoscopy. OPS-3 underwent the colonoscopy under MAC anesthesia. OPS-3 was discharged on 4/25/14, at 9:02 a.m., however, the medical record lacked documentation of OPS-3 being discharged in the company of a responsible adult.
On 8/5/15, at 11:05 a.m. RN-C confirmed OPS-3's medical record lacked documentation of who had accompanied OPS-3 home at the time of discharge.
On 8/6/15, at 12:21 p.m. RN-C confirmed it was standard of practice for patients who were discharged from outpatient surgery to be accompanied by a responsible adult and this information should be documented in the medical record.
The CAH's Outpatient Surgery pamphlet indicated that patients must not drive home from the hospital and arrangements would need to be made for a responsible adult to take them home. Although requested, no policy on discharge process for outpatient surgical patients was provided.

Based on interview and document review, the critical access hospital (CAH) failed to ensure quality assurance/performance improvement (QAPI) projects were current, comprehensively developed and incorporated into the CAH's QAPI program for the following departments: surgical services, anesthesia, maintenance, and dietary. This had the potential to affect all patient's in the facility.
Findings include:
SURGICAL SERVICES:
On 8/5/15, at 11:20 a.m. registered nurse (RN)-C, surgical services manager, stated she was unaware of any current QAPI surgical services project.
On 8/5/15, at 1:09 p.m. the director of nursing (DON), who oversaw the CAH's QAPI program, confirmed the surgical services department had been working on increasing their endoscopy (a procedure utilized to exam a person's digestive tract) service line. This had been an ongoing endeavor since 2013. The DON confirmed surgical services had not been working on a more current QAPI project. The DON verified each department was supposed to select a new project annually.
ANESTHESIA:
On 8/5/15, at 1:11 p.m. the DON confirmed the QAPI program anesthesia had been working on for the last couple of years was to increase the accuracy of anesthesia documentation. The DON provided audit information from 1/2015 - 3/2015, however, the information provided lacked documentation of goals, action plans for improvement, and data analysis. In addition, the audits indicated 100% compliance with anesthesia documentation since 1/29/15. The DON confirmed anesthesia should have selected a new QAPI project.
MAINTENANCE:
On 8/5/15, at 9:10 a.m. maintenance engineers (ME)-A and ME-B stated they were unaware of any other QAPI project other than the preventive maintenance (PM) program for wheelchairs which they had been working on for some time.
On 8/5/15, at 1:55 p.m. the DON confirmed the maintenance department's only QAPI project identified was the wheelchair PM program, which they had been working on over a year. The DON confirmed this was an old QAPI project and she was unaware of any more current QAPI projects for the maintenance department.
The CAH's Quality Assurance Plan reviewed 6/16/15, indicated all departments should have been involved in an ongoing QAPI monitoring and projects. The purpose of the QAPI program was to provide quality services through identifying, analyzing and resolving problems within and related to patient care.


33560

DIETARY:

During an interview on 8/5/15 at 1:09 p.m. registered dietician (RD)-C stated she could not find any documentation of a quality assurance program. RD-C stated they developed indicators for a dietary QAPI program on 6/15/15, but did not have any data at this time. RD-C indicated staff was to complete intermittent audits of the meal trays and track accuracy of trays.

Interview on 8/5/15, at 2:00 p.m. the DON stated dietary staff started collecting data on the accuracy of trays delivered to the nursing units on 6/15/15, however there were no results as of yet.

Based on interview and record review, the critical access hospital (CAH) failed to ensure notification to the organ procurement organization (OPO) was notified in a timely manner for 3 of 5 patients (P5, ERP-1, ERP-2) who died at the facility.
Findings include:
P5 had been admitted to the CAH on 6/26/15, for pneumonia and died on 6/28/15, at 5:57 p.m.
In P5's medical record the nurses note (NN) dated 6/28/15, at 6:15 p.m. indicated P5 had died at 5:57 p.m. The NN entry at 7:09 p.m. indicated the OPO had been contacted, determined to not be a donor candidate and the CAH had been provided a reference number.
On 8/4/15, at 10:00 a.m. registered nurse (RN)-B stated all deaths should be called into the OPO within one hour of the patient's death. RN-B confirmed P5's notification of death to the OPO was greater than the one hour (12 minutes beyond the one hour).
On 8/5/15, at 2:00 p.m. the director of nursing (DON) confirmed the CAH's expectation for notification of a patient's death to the OPO was within 60 minutes.


33560


Emergency room patient (ERP)1 was admitted to the emergency room and expired on 11/6/14, at 11:29 a.m.. The OPO was notified at 1:09 p.m. according to the medical record documentation. There was 1 hour and 40 minutes from ERP1's death until the OPO was notified.

ERP2 was admitted to the emergency room on 4/8/15, at 1129 with malignant neoplasm of lung with liver metastasis. The OPO was not notified according to the medical record documentation.

Chart review on 8/4/15, at 2:20 p.m. with registered nurse (RN)-A revealed for two patients the organ procurement organization (OPO) was not notified of their deaths in a timely manner. RN-A stated the OPO was notified 1 hour and 40 minutes after the death of ERP1. RN-A also confirmed there was no documentation of emergency room patient (ERP)2's death or notification to the OPO.

During an interview on 8/5/15, at 2:00 p.m. the DON defined timely notification being one hour after the death had occurred.