HospitalInspections.org

CONDITION: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Recertification Survey conducted on August 7-8, 2013 the surveyor finds that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the severity, variety, and number of Life Safety Code deficiencies that were found. Also see C 231

STANDARD: Based upon on-site observation, staff interview, and document review during the Life Safety portion of a Medicare Critical Access Hospital Recertification Survey conducted on August 7-8, 2013 the surveyor finds that the facility does not comply with NFPA 101 - 2000, the Life Safety Code

See Life Safety Code deficiencies that were cited Also see C220.

Based on review of policy and procedure, observation, and staff interview, it was determined the CAH failed to ensure expired supplies were not available for patient use. This has the potential to affect 100% of patients receiving services at the CAH.
Findings include:

1. The policy titled "Checking the expiration of inventory supplies" (reviewed date 7/13) was reviewed. The policy indicated under "Procedure: Any inventory supply that is marked with an expiration date by the Manufacturer will be checked monthly to ensure the date has not passed to prevent using expired supplies on patients."

2. During a tour of the Radiology Department conducted 7/30/13 at 1:30 PM, the following outdated supplies were identified:
a. Bard Foley Tray x 3, expired 12/2011.

3. During a tour of the Special Procedure Area conducted 7/31/2013 at 11 AM, the following outdated supplies were identified:
a. Special Procedure Room #2, LMA (Laryngeal Mask) size 4, expired 4/28/2013 and LMA size 5, expired 6/28/2013. Special Procedure Room #3, LMA size 4, expired 6/28/2013 and LMA size 5, expired 6/28/2013.

4. During a tour of the Laboratory facility, conducted on 7/31/13 at 2:45 PM, it was observed in the refrigerator in the microbiology there were 50 EMB agar petri dishes that all expired on 7/30/13. These petri dishes were still available for use by the laboratory technicians.

5. During a staff interview on 7/31/2013 and 8/2/13 with the CFO, it was confirmed the above supplies were expired and should have been removed from patient care areas.

Based on a review of CAH policy and procedure, a review of the minutes of the PAC, and staff interview, it was determined that the CAH failed to ensure its policies are developed with the advice of the PAC. This has the potential to affect 100% of those patients receiving services at the CAH.
Findings include:

1. The CAH policy and procedure titled, "Professional Advisory Committee" (with a review date of 5/11) was reviewed. It indicated under "POLICY: it is the policy of Perry Memorial Hospital to annually evaluate policies, procedures and guidelines promulgated as a result of PMH being designated as a Critical Access Hospital...PROCEDURE: The Professional Advisory Committee is responsible for the annual review."

2. The minutes of the PAC were reviewed for the last year. There was no documentation that indicated the PAC gave advice related to the development of the CAH's policies.

3. During an interview with the CEO, conducted on 8/1/13 at 8:15 AM, it was verbalized that the PAC is the group of professional personnel that give advice for the formulation of the CAH's policies; however the PAC committee (nor any other group of professional personnel) have been utilized in the development of policies for the past couple of years.

A. Based on review of policy and procedure, observation, and staff interview, it was determined the CAH failed to ensure expired medications and biologicals were not available for patient use. This has the potential to affect 100% of patients receiving services at the CAH.
Findings include:

1. The policy titled "Expired and Other Unusable Medications" (reviewed date 3/13) was reviewed. The policy indicated under "Procedure: 1. The Pharmacy Department shall monitor all the medications used in the hospital and...3. Storage areas for expired and unusable medications must be separated from active stock. The medications must be clearly labeled as "Outdated and/or Unusable-...."

2. During a tour of the Radiology Department conducted 7/30/13 at 1:30 PM, the following outdated drugs were identified:
a. 0.9 Sodium Chloride 500 ml bag x 2, expired 9/2012.

3. During a tour of the Nuclear Medicine Department conducted 7/30/13 at 1:30 PM, the following outdated drug was identified:
a. Bumetanide Injectable 1 mg/4 ml, expired 12/2012.

4. During a staff interview on 7/31/2013 and 8/2/13 with the CFO, it was confirmed the above drugs were expired and should have been removed from patient care areas.

B. Based on review of policy and procedure, observation and staff interview, it was determined the CAH failed to ensure respiratory therapy followed the CAH policy for medication administration to ensure the five rights of medication administration were performed. This has the potential to affect 100% of patients receiving medications administered by respiratory therapy.
Findings include:

1. The policy titled "Medication Administration" (revised 11/12) was reviewed 8/1/13. The policy indicated "Procedure II: Medication Verification Administration ... f. Take electronic MAR and medications to patient room...Scan patient armband; Verify this is correct patient; Scan each medication to be given to the patient..."

2. A tour of the Medical/Surgical Unit was conducted 7/31/13 at 1:30 PM. A Respiratory Therapist was interviewed prior to observation. The Respiratory Therapist indicated that the armband would not be checked because the patient was already known. The Respiratory Therapist was observed to enter the patient room, prepare and administer a nebulizer treatment without identifying the patient. After initiating the respiratory treatment, the respiratory therapist scanned the patient armband and then the medication.

3. An interview with the Director of Respiratory Therapy was conducted 7/31/13 at 1:45 PM. The Director of Respiratory Therapy indicated the respiratory therapists follow the same medication administration policy as nursing services. The Director of Respiratory Therapy confirmed the Respiratory Therapist should have identified the patient and the medication prior to administration.

A. Based on review of policy and procedure, a review of the Virex II 256 reference sheet, observation, and staff interview, it was determined the facility failed to ensure dirty laundry tubs were appropriately disinfected to ensure micro-organisms were killed and to prevent the potential of cross contamination. This has the potential to affect 100% of the patients who receive services at the CAH.
Findings include:

1. The CAH policy and procedure titled "Cleaning" with a review date of July 2012, was reviewed. It indicated under "PROCEDURE: A. Carts 2. Transportation carts shall be cleaned daily using chemicals that kill micro-organisms."

2. The Virex II 256 reference sheet was reviewed. It indicated "...Change cloth, sponges or towels frequently to avoid redeposition of soil. For disinfection, all surfaces must remain wet for 10 minutes."

3. During a tour of the laundry facility, conducted on 7/30/13 at 3:25 PM, it was observed that carts containing dirty linen are disinfected with Virex II 256, which is sprayed on the inside of the cart and on a cleaning rag. Then the interior of the cart is wiped down. Within 2 minutes of the inside of a cart being wiped down, it was observed that the interior surfaces of the cart were dry. This was verified by E-7. Prior to the cart being disinfected, the label on the disinfectant was read. It indicated that to kill all hazardous organisms, the surface being disinfected had to remain wet for at least 10 minutes.

4. During an interview with E-7, conducted on 7/30/13 at 3:45 PM, it was stated that the laundry does not use separate laundry tubs for clean and dirty linen. The tubs are cleaned daily with a disinfectant called Virex II 256. E-7 was asked what the minimum wet contact time was for the disinfecting agent to kill all potentially hazardous organisms. Three answers were given and all three were incorrect.

B. Based on review of policies and procedures, observation, and staff interview, it was determined the CAH failed to ensure potentially contaminated equipment in the patient's room was disinfected, prior to the equipment being moved to another patients room, to prevent the transfer of microorganisms to other patients or environments. This has the potential to affect 100% of the patients who receive services.
Findings include:

1. The CAH policy titled "INFECTION CONTROL - Subject: Standard Precautions / Isolation Guidelines" (revised 10/12) was reviewed on 8/1/13. Under "Procedure I: Transmission of infectious agents A. Source 1. Infectious agents transmitted during healthcare derive primarily from human sources but inanimate environmental sources also are implicated in transmission... Procedure II: Standard Precautions... A. Handwashing 2. Wash hands after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patients."

2. The CAH policy titled "INFECTION CONTROL - Subject: Handwashing and Hand Antisepsis" (reviewed 4/13) was reviewed on 8/1/13. Under Procedure I: B. Hands must be cared for by handwashing with soap and water or by hand antisepsis with alcohol-based handrubs... 1. Before and after patient contact."

3. During a tour of the medical surgical unit on 7/30/13 at 1:30 PM, this surveyor observed a Registered Nurse provide care to Pt #18 in Room 208. Pt #18 was admitted on 7/28/13 with a diagnosis of Congestive Heart Failure. During the course of providing care, the Nurse touched the patient, typed on a portable computer without washing hands or using a waterless antiseptic agent, then transported the portable computer into another patient's room and provided patient care without cleaning the key pad of the computer. This was witnessed by E-8.

4. During an interview with the Director of Nursing on 7/28/13 at 2:00 PM, it was confirmed that it was not a CAH practice to clean off the portable computer pad.

C. Based on review of policy and procedure, Occupational Safety and Health Administration's (OSHA) Blood Borne Pathogen Standards, observation and staff interview, it was determined the CAH failed to ensure a safe environment by having the sharp containers easily accessible for use. This has the potential to affect 100% patients and staff.
Findings include:

1. The policy titled "Sharps Disposal" (reviewed 5/11) was reviewed 7/31/13. The policy indicated "Procedure: A. Dispose of needles, syringes and other sharps in a box immediately following use to avoid injury to self or others. B. Containers to hold contaminated sharps must be.... meeting the requirements of 29 CFR 1920.1030 Occupational Safety and Health Administration's Blood Borne Pathogen Standard."

2. The OSHA guidelines were reviewed 8/2/13. OSHA guidelines "1910.1030 (d)(4)(iii)(A)(1) Contaminated sharps shall be discarded immediately or as soon as feasible in containers that are:... 1910.1030 (d)(4)(iii)(A)(2)(i): Easily accessible to personnel and located as close as is feasible to the immediate area where sharps are used or can be reasonably anticipated to be found."

3. A tour of the Medical Surgical unit was conducted 7/30/13 at 1:00 PM. When the Sharps containers were unable to be found, the Director of Nursing demonstrated the location to be behind a closet door on the back of a shelf which was difficult to access.

4. A staff interview was conducted with the Director of Nursing 7/30/13 at 1:00 PM. The Director of Nursing confirmed the sharps container locations are not easily identifiable and hard to access.

Based on a review of CAH policy and procedure, observation, and staff interview, it was determined that the CAH failed to ensure the proper measurement of the disinfectant used in the 3 tub sink to ensure proper sanitization of dietary items washed manually. This has the potential to effect 100% of the patients who receive dietary services.
Findings include:

1. The CAH policy and procedure titled, "3 Compartment Sink" with a review date of 5/13, indicated under "Procedure: 5. Use test strips provided to test parts per million (ppm). Reading should be 150 - 400 ppm." There was no documentation that indicated the temperature of the solution should be between 65 - 75 degrees Fahrenheit.

2. During a tour of the Dietary department, conducted on 7/30/12 at 2:00 PM, the area of the 3 compartment sink was observed. A plastic container of a test strip was observed in the sink area. The directions on the inside of the container indicated that the solution to be tested was to have a temperature of 65 to 75 degrees Fahrenheit.

3. A dietary staff member that utilized the 3 compartment sink was interviewed. During the interview, conducted on 7/30/13 at 2:15 PM, the procedure to disinfect pots and pans in the 3 compartment sink was verbalized. During the interview, the staff member was asked to state what the solution temperature was to be during the testing. The dietary staff member stated there was no knowledge of the solution needing to be in a specific temperature range to ensure accurate testing results.

Based on a review of the CAH's policy and procedures, a review of the minutes of the PAC, a review of the annual program evaluation, and staff interview, it was determined that the CAH failed to ensure the policies and procedures were reviewed on an annual basis by the PAC. This has the potential to affect 100% of those patients receiving services at the CAH.
Findings include:

1. The CAH policy and procedure titled "PROFESSIONAL ADVISORY COMMITTEE" with a reviewed date of 5/11 was reviewed. It indicated under "POLICY: It is the policy of Perry Memorial Hospital to annually evaluate policies, procedures and guidelines... PROCEDURE: The Professional Advisory Committee is responsible for the annual review."

2. The minutes of the PAC were reviewed for the last 2 years. There was no documentation that indicated the committee reviewed the CAH's policies and procedures.

3. The annual program evaluations for the last 2 years were reviewed. There was no documentation in the annual evaluations that indicated the CAH's policies and procedures were reviewed by the PAC.

4. During an interview with the CEO, conducted on 8/1/13 at 8:30 AM, it was verbalized that the CAH's policies and procedures were not being reviewed on an annual basis by the PAC which is the CAH's group of professional personnel.

A. Based on a review of policy and procedure, medical record review, and staff interview, it was determined in 1 of 1 (Pt #18) medical records reviewed in which the patient was to be weighed daily, the CAH failed to ensure physician orders were followed by ensuring the patient was weighed and that the weights were documented.
Findings include:

1. The policy and procedure titled "Patient Documentation" with a review date of 1/10, was reviewed. It indicated under "PROCEDURE I: ASSESSMENT: Definition: The assessment data is the initial collection of information about the patient and is the basis on which problems are identified and care is planned. The assessment data is gathered/documented on admission and periodically throughout the patient's stay. Professional judgment determines the specific depth and frequency of individual assessments."

2. The medical record of Pt #18 was reviewed on 8/1/13. It indicated Pt #18 was admitted on 7/28/13 with a diagnosis of Congestive Heart Failure. A physician's order, dated 7/28/13 at 17:23, was for Pt #18 to have "Daily weight and on admission." Another physician's order, dated 7/30/13, was for Pt #18 to have "Daily weight in AM's". In the 5 days between 7/28/13 and 8/1/13, there was no documentation that indicated Pt #18 was weighed on 7/28, 7/31, and 8/1/13.

3. During an interview with the DON, conducted on 8/1/13 at 3:30 PM, it was verbalized that Pt #18 should have been weighed daily according to the physician's orders.

B. Based on review of policy and procedure, medical record review and staff interview it was determined in 1 of 20 (Pt #15) medical records reviewed, the CAH failed to ensure the patient's condition was appropriately evaluated/revaluated and involved the physician.
Findings include:

1. The policy titled "Standards of Clinical Nursing Practice" (reviewed 3/13) was reviewed 8/2/13. The policy indicated "Standard VI Evaluation: The nurse evaluates the patient's progress toward attainment of outcomes. Measurement Criteria 1. Evaluation is systemic and ongoing. 2. The patient's responses to interventions are documented. 3. The effectiveness of interventions is evaluated in relation to outcomes. 4. Ongoing assessment data are used by the Registered Nurse to revise diagnosis, outcomes and the plan of care, as needed. 5. Revisions in diagnosis, outcomes and the plan of care are documented. 6. The patient, significant others and healthcare providers are involved in the evaluation process, when applicable."

2. The medical record of Pt #15 was conducted 7/31/13. Pt #15 was admitted 7/28/13 with a diagnosis of a skin tear left upper arm bleed. Pt #15's Progress Notes indicated the following assessments 7/29/13: 4:50 AM Isordil 10 mg orally was administered; 7:28 AM BP (Blood Pressure) 80/40, pulse 77; 8:59 AM Lisinopril 10 mg orally and Amiodarone 200 mg orally were administered; 9:00 AM "large amount bloody drainage left lateral forearm, dressing changed, supervisor notified."; 1:16 PM "patient is confused..."; 2:22 PM Isordil 10 mg orally was administered; 3:24 PM BP 98/62, pulse 120; 6:42 PM "MD (Medical Doctor) here to see patient." There was no documentation that the low blood pressure was re-evaluated for 8 hours, or that the patient's change in condition or large amount of bloody drainage was reported to the physician. The physician progress note dated 7/29/13 did not address the patient's change in condition. At 11:15 PM nursing assessment indicated Pt #15 was restless, confused, agitated, was refusing care, and threatened staff.

3. A staff interview was conducted 8/2/13 at 3:30 PM with the Director of Nursing. The Director of Nursing confirmed Pt #15's vital signs should have been revaluated and the physician notified.

Based on review of policy and procedure, medical record review and staff interview, it was determined in 2 of 20 (Pt #18 and #19) medical records reviewed the CAH failed to ensure the medical record accurately reflected the patient's allergies.
Findings include:

1. A review of the policy titled "Patient Documentation" (revised 3/13) was conducted 8/2/13. The policy indicated under "Procedure 1: Assessment: The assessment data is the initial collection of information about the patient and is the basis on which problems are identified and care is planned. The assessment data is gathered/documented on admission and periodically throughout the patient's stay..."

2. The medical record of Pt # 18 was conducted on 8/1/13. Pt #18 was admitted 7/28/13 with a diagnosis of Congestive Heart Failure. The electronic medical record listed allergies for this admission to present as Penicillin, Truxcillin and Amoxicillin. The initial nursing interview performed 7/28/13 does not indicate Pt #18's allergies were reviewed. The History and Physical completed 7/29/13 indicted Pt #18's allergies as "Penicillin, Niacin, Amoxicillin, Biaxin, Keflex and Cardura. Pt #18 also claims that she is allergic to cheese."

3. The medical record of Pt #19 was conducted on 8/1/13. Pt #19 was admitted 7/29/13 with a diagnosis of Sepsis. The electronic medical record listed allergies for this admission to present as "Morphine, Levaquin, Sulfa and Astromorph" from admission to present. The initial nursing interview performed 7/29/13 does not indicate Pt #19's allergies were reviewed. The History and Physical completed 7/31/13 indicted Pt #19 had "No known allergies."

4. An interview with the Director of Nursing was conducted 8/1/13 at 3:30 PM. The Director of Nursing confirmed the allergies listed in the electronic medical record and the History and Physical were different. The Director of Nursing confirmed the allergies should have been clarified and corrected.

Based on a review of CAH policy and procedures, observation, a review of AORN 2013 Book, a review of CDC "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008," a review of Flash Sterilization Monitor Sheets, manufactures labeling, and staff interview, it was determined the CAH failed to ensure sterilization was performed in a safe manner in accordance with acceptable standards of practice (C-320A) and failed to ensure single use sterile items were maintained and discarded according to manufactures recommendations (C-320B). The cumulative result of the failed practices has the potential to affect 100% of the surgical patients, both inpatient and outpatient, serviced by the CAH. As a result of failure to comply with acceptable standards of practice and manufactures recommendations, patients are at risk of developing potential infections due to failure of the CAH to keep the use of Flash sterilized surgical instruments to a minimum and failure to keep single use sterile supplies sealed in their original packaging until ready to use and then discarded after each surgical case.

A. Based on a review of CAH policy and procedures, observation, a review of AORN 2013 Book, a review of CDC "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008," a review of Sterilization Monitor Sheets, and staff interview, it was determined the Hospital failed to ensure sterilization was performed in a safe manner in accordance with acceptable standards of practice by keeping Flash sterilization to a minimum. This has the potential to affect 100% of the surgical patients, both inpatient and outpatient, serviced by the CAH.
Findings include:

1. The policy titled "Operating Room - Infection Control Guidelines" (revised 11/12) was reviewed on 7/31/13. Under "Procedure I: D. Operating Surgeon 1." It indicated "Adhere to established Operating Room Infection Control Standards. Refer to: The Association of Operating Room Nurses: Standard and Recommended Practices Manual."

2. During a tour of the Surgery Department, conducted on 7/31/13 at 10:00 AM with the Chief Financial Officer and Sterilization Technician, it was observed that Flash sterilization documentation indicated the use of Flash sterilization on instruments being used in surgical services. When asked what they used Flash sterilization for, the Sterilization Technician verbalized that "we have 2 eye trays and some days we have 4 cases scheduled, we have to use immediate sterilization on them."

3. The AORN 2013 Book was reviewed on 7/31/13. It indicated "Recommendation VII: Immediate use steam sterilization should be kept to a minimum and should be used only in selected clinical situations and in a controlled manner... VII.a. Immediate use steam sterilization should be used only when there is insufficient time to process by the preferred wrapped or container method intended for terminal sterilization. Immediate use steam sterilization should not be used as a substitute for insufficient instrument inventory..."

4. The CDC "Guidelines for Disinfection and Sterilization in Healthcare Facilities, 2008" was reviewed on 7/31/13. It indicated "13. Flash Sterilization b. Do not use flash sterilization for convenience, as an alternative to purchasing additional instrument sets, or to save time."

5. The Sterilization Monitor Sheets for 1/9/13 thru 7/10/13 were reviewed on 7/31/13. The Sterilization Monitor Sheets indicated that Immediate Use sterilization was performed for Eye instruments on 32 occasions with the notation "must be sterilized before use", on 35 occasions with the notation "loaner instruments needed for case", and on 23 occasions with the notation "terminal sterilization."

6. An interview with the Outpatient Services Director was conducted on 7/31/13 at 1:00 PM. The Outpatient Services Director confirmed the CAH used AORN and CDC as a resource for infection prevention. The Director also indicated flash sterilization should never be used as a substitute for not having appropriate equipment supplies for cataract surgery cases.

B. Based on review of policy and procedure, observation, manufactures labeling, and staff interview, it was determined the CAH failed to ensure a system for controlling infection was maintained in the surgery department, by ensuring that all emergency respiratory equipment was maintained in a sealed sterile package until needed for use and that single use items were discarded after use. This has the potential to affect 100% of patients requiring intubation.
Findings include:

1. The policy "Anesthesia Equipment", revised 12/11 was reviewed on 8/1/13. Under "PROCEDURE: D. Oral airways, endotracheal tubes, suction catheters should be disposed of after each patient use."

2. A tour of the Surgery Department was conducted on 7/31/13 at 9:30 AM. On the top of the anesthesia cart in the surgery suite there were five, opened tracheal tubes with stylets inserted in the middle of the tracheal tubes. There were no dates or times of when the packages were opened. The manufactures labeling on the Tracheal Tube packaging read: "Sterile unless package has been opened or damaged. Sterilized with ethylene oxide. Discard after single use". Stylet packaging read: "Sterile unless packaging is open or damaged. Single use only".

3. An interview was conducted with the CRNA, on 7/31/13 at 11:00 AM. The CRNA confirmed the tracheal tubes and stylets were opened to eliminate time when having to use them in emergency cases. The CRNA indicated the stylets were reused after being sterilized by "the sterilizing personnel".

4. A phone interview was conducted with the CRNA on 8/1/13 at 11:00 AM. During this phone interview, the Director of Outpatient Services was in the room with this surveyor. The interview was conducted by speaker phone. The CRNA indicated the tracheal tubes are only opened for each individual case and multiple tracheal tubes are opened for each individual, in case multiple sizes are needed for the patient. The tracheal tubes are disposed of after each case but the stylets are reused. The CRNA indicated that the stylets are reused because "they are sterilized by the sterilizing department" and "intubation isn't a sterile procedure." "I don't wear sterile gloves when I intubate so the stylet doesn't have to be sterile."

5. During an interview with the Outpatient Services Director on 7/31/13 at 2:00 PM, it was confirmed that tracheal tubes and stylets were single use and never to be reused and should be disposed of after every patient.

6. During an interview with the Sterilizing Technician on 8/1/13 at 1:00 PM, it was confirmed that tracheal stylets had been received by the sterilization department. The stylets were brought to the sterilizing room in a covered tub with other dirty equipment from surgery. The stylets were sterilized with a 50 minute cycle then removed. "Then we taken them to the anesthesia lounge and place them on their desk or table." When asked if the stylets are kept in a sterile cover, the Sterilizing Technician indicated, "No, I just place them on the desk, uncovered. I only sterilized about 6 stylets a year."