HospitalInspections.org

I. Based on observation, policy/procedure review and staff interviews the Critical Access Hospital (CAH) failed to have a system in place to monitor water temperatures at 2 of 2 offsite clinics to ensure they were in an acceptable range from 110 to 120 degrees. Clinic A had a census of 100 patients a week. Clinic B reported a census of 500 a week.

Failure to monitor hot water temperatures could potentially cause serious scalding burns to patients. The depth of injury is directly related to the temperature and duration of exposure to the water. The length of exposure required for a third degree burn to occur is 15 seconds at 133 degrees, 1 minute at 127 degrees and 3 minutes at 124 degrees.

Findings include:

1. Observation during the environmental tour, (Clinic A), on 7/11/11 at 4:00 PM revealed the following water temperatures;
a. Minor procedure room- 128 degrees
b. Lab area- 130.6 degrees
c. Room 7- 129.7 degrees
Clinic A failed to have a water temperature monitoring log.

2. During an interview on 7/11 at 4:00 PM, Staff G, Office Manager stated neither clinic staff nor maintenance staff monitored the water temperatures at the clinic.

During an interview on 7/12 at 8:00 AM, Staff B, Director of Support Services said maintenance staff did not monitor water temperatures at Clinic A. Staff B confirmed the policy "Maintenance and Monitoring of Water Systems" did not specify how often to check water temperatures at the CAH.

3. Review of the CAH policy titled "Maintenance and Monitoring of Water Systems", dated 10/1/04, stated in part... "Hot water should be generated or stored at 120 degrees Fahrenheit and reduced as required for distribution."

II. Based on observation, policy/procedure review, document review and staff interview, the Critical Access Hospital (CAH) operating room (OR) staff failed to ensure staff completed the required test for 1 of 1 Life Pak defibrillator daily when checking the crash cart. The OR had a census of approximately 100 procedures a month.

Failure to test the Life Pak defibrillator daily could potentially result in the defibrillator malfunctioning during a patient emergency requiring cardiac stimulation.

Findings include:

1. Observation, during tour of the OR, revealed a crash cart located between operating room 1 and 2 with the Life Pak defibrillator on it.

2. Review of the "Boone County Crash Cart and Defibrillator Log" dated March 2011 showed staff last documented testing the defibrillator on 3/3/11. The log lacked documentation from 3/3/11 to 7/11/11.

3. Review of the CAH policy titled "Crash Cart and Defibrillator Check Policy" dated 11/05 revealed in part, "...A. Crash carts will be checked daily when the department is open."

4. During an interview on 7/11/11 at 2:00 PM, Staff F, Surgery Manager stated OR staff were not testing the Life Pak defibrillator daily and confirmed staff had not tested the defibrillator since 3/3/11.

III. Based on observation, review of records, and staff interview, the CAH (Critical Access Hospital) engineer staff failed to secure 3 of 10 oxygen tanks in the oxygen supply room. The CAH administrative identified a census of 20 inpatients.

Failure to secure oxygen tanks could potentially result in an explosion when the tanks fall.

Findings include:

1. Observation on 7/12/11 at 8:00 AM, with Staff A, Safety Officer, revealed a locked oxygen storage room contained 10 large tanks and 15 small tanks of oxygen. Three of the large tanks of oxygen lacked a mechanism for securing the tanks to prevent a fall. Staff A verified staff failed to secure 3 of 10 the large oxygen tanks.

2. Review of the policy, "Compressed Gas and Oxygen Use", dated 10/01/04, revealed in part "...Personnel that handle medical gases shall be educated about the possible hazards associated with medical gas use. All personnel concerned with the use and transport (handling) of compressed gas shall be trained in the proper handling of cylinders ....Cylinders must be secured at all times so they cannot fall ..."

3. During an interview on 7/12/11 at 8:00 AM, Staff B, Director of Support Services, verified the need to secure oxygen tanks at all times, and engineer staff were educated on the importance of securing oxygen tanks at all times.

IV. Based on observation, policy/procedure review and staff interview, CAH clinic management staff failed to ensure that expired medical supplies were not readily available for patient use in Clinic B, the CAH Operating Room, and CAH management staff failed to ensure staff completed required checks on 2 of 6 crash carts located on the nursing units. CAH management staff reported an inpatient census of 20 patients, approximately 100 surgical procedures per month, and approximately 2,300 clinic visits per month.

Failure to ensure medical supplies are within their expiration date could potentially result in use of equipment that lacks sterility and potency.

Findings include:

1. Observation, at Clinic B, on 7/11/11 at 4:25 PM, with Staff J, Clinic B Director, revealed the following expired medical supplies located in the basement storage room:
- 1 dozen Ethicon Vicryl 3-0 sutures expired 1/10
- 1 dozen Ethicon Vicryl 3-0 sutures expired 1/11
- 25 BD Intra syringes, 25 gauge, 3 milliliter
- 1 of 1 Bard Urethral Catheter Tray, 15 French expired 12/10
- 40 Duraprene sterile synthetic surgical gloves size 7 expired 12/10
- 7 of 7 bottles Medline Ultrasound gel expired 2/09
-10 of 10 Biopsy Punches, 6 millimeter expired 6/09

Observation on 7/11/11 at 5:00 PM, with Staff J revealed the following expired medical supplies located in exam room 16:
- 6 of 11 Hemoccult II testing cards expired 6/11
- 5 of 11 Hemoccult II testing cards expired 2/11

During an interview on 7/11/11 at 5:10 PM, Staff J verified the expiration dates of the above items and stated: "It is every clinic employee's responsibility to look for outdated supplies and dispose of them. We are not doing a very good job. "

2. Observation on 7/11/11 at 11:30 AM, with Staff E, Director of Inpatient Services, revealed 1 of 1 Medical/Surgical Crash Carts with 8 of 8 expired Vacutainer (tubes to draw blood) tubes. Two tubes expired on 12/10 and 6 tubes expired on 11/10. Additional observation revealed 1 of 1 ICU (Intensive Care Unit) crash carts with 2 of 8 Vacutainer tubes expired on 2/11. Staff E verified the expired Vacutainers at the time of the observations.

Review of policy titled, "Crash Cart and Defibrillator Check Policy" dated 5/02, states in part "...Boone County Hospital Staff will adhere to accepted practices for maintenance of the crash cart and defibrillator ..." The CAH administrative staff failed to develop and implement a policy that addresses checking for expired supplies and equipment housed in the crash cart.

Review of the document titled, "Boone County Hospital Crash Cart Log" dated 2/7/11, lacked documentation that showed staff had checked the equipment and supplies in the crash cart for expiration date.

3. Observation, during the tour of Operating Room (OR) #2, on 7/11/11 at 2:00 PM revealed 7 of the 13 BD Insyte Autogaurd 18 gauge needles (intravenous needle with a protective shield) expired 4/2011.

During an interview on 7/11/11 at 2:00 PM, Staff F, Surgery Manager, confirmed the BD Insyte Autogaurd 18 gauge needles were in the drawer ready for patient use.

Additional observation during the tour of the surgery department revealed a crash cart located between OR #1 and OR #2. A Conitube 41 French kit (Esophageal tracheal tube used to open airways for difficult or emergency intubation) stored on the top of the crash cart had an expiration date of 3/2011.

During an interview on 7/11/11 at 2:00 PM, Staff F stated staff stored the Conitube 41 French kit on the top of the crash cart for quick accessibility for patient use.

During interview on 7/13/11 at 11:45 AM, Staff L stated there is no hospital specific policy overall for checking for expired supplies, removing them from the patient care areas, and returning them to purchasing and failed to check the crash cart for expired supplies.



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Based on observation, policy/procedure review and staff interviews, the Critical Access Hospital Administrative staff failed to secure all medical records against unauthorized access in 7 of 14 clinical areas, the Same-day Surgery department, Surgery department, Off-site clinics, basement room of the hospital, Therapy Department and the Health Information area. Surgery manager stated approximately 100 surgical procedures per week.

Failure to secure medical records against unauthorized access could result in identity theft or unauthorized disclosure of personal medical information.

Findings include:

1. Observation during initial tour of the same day surgery area on 7/11/11 at 2:45 PM, revealed 12 medical records in the holder at the nursing station. Each medical record contained personal and medical information.

During an interview on 7/11/11 at 2:45 PM, Staff F, Surgery Manager, stated the staff kept the medical records in the holder at the nursing station until the morning when Health Information staff pick up the records. Staff F stated housekeeping cleans the area after hours unsupervised and would have access to the medical records.

2. Observation during initial tour of the surgery area on 7/11/11 at 2:50 PM, the surgery area revealed approximately 400 papers with personal and medical information on the counter at the nursing station.

During an interview on 7/11/11 at 2:50 PM, Staff F, Surgery Manager stated, staff keep the medical records on the counter until they have completed the billing information then place the papers in his office. Staff F stated housekeeping clean the area after hours unsupervised and would have access to the papers with medical and personal information.

3. Observation during the initial tour of Clinic A revealed 4,000 to 5,000 patient medical records located in the receptionist office. The medical records were stacked on open shelving along the wall and in the middle of the room.

During an interview on 7/11/11 at 4:00 PM, Staff G, Office Manager, stated staff removed the back door leading to the receptionist office. Staff G stated housekeeping staff cleaned the clinic, unsupervised at night, therefore housekeeping staff would have access to the patient medical files.

4. Observation during the initial tour of Clinic B, 7/11/11 at 4:15 PM, revealed approximately 10,000 patient medical records including radiology films located in the basement medical records room.

During an interview on 7/11/11 at 4:15 PM, Staff J, Clinic Director, said housekeeping staff cleaned the clinic, unsupervised at night. Housekeeping staff would have access to the patient medical files.

5. Observation on 7/12/11 at 8:00 AM, with Staff D, Director of Health Information, stated the Health Information Office contained approximately 42,000 patient medical records.

During an interview on 7/12/11 at 8:00 AM, Staff D stated housekeeping staff clean the office at the close of business, when Health Information staff was not present.

During an interview on 7/12/11 at 4:15 PM, Staff C, Housekeeper, said he/she cleans the Health Information office when no Health Information staff were present.

Observation on 7/12/11 at 8:00 AM, with Staff A, Safety Officer, revealed 1 of 1 locked medical record storage room in the basement that contained approximately 45,000 patient medical records.

During an interview on 7/12/11 at 8:00 AM, Staff A, stated administration, engineering, and housekeeping had access to the medical record storage room. Unauthorized access to the medical record storage room would include 7 engineering and 16 housekeeping staff, these staff did not have the "need to know" regarding the information found in the confidential patient medical record.

6. Observations during a tour of the therapy department on 7/11/11 at 3:35 PM revealed:

a. Nine standing file cabinets, located in the receptionist front office, with a total of 36 drawers which contained patient names, date of birth, diagnosis, social security number and all therapy procedures performed on the patient.

During an interview at the time of the tour, Staff H said housekeeping staff and non-hospital personnel would have access to the confidential patient information in the file cabinets. Staff H stated, "These have never been locked since I've been here for the past year." During a follow up interview on 7/13/11 at 10:15 AM Staff H stated, "We had keys for the cabinets, I located them last night. They will be locked at all times."

b. Two of 2 cabinets, located behind the receptionist desk, with a total of approximately 200 active patient records which contained patient names, date of birth, diagnosis, social security number and all therapy procedures performed on the patient. Staff H stated, "The cabinets are left open 24 hours a day, seven days a week. It makes total sense that they should be locked."

c. One of 1 file cabinet, located behind the receptionist desk, with a total of approximately 15 patient records which contained patient names, date of birth, diagnosis, social security number and all therapy procedures performed on the patient. Staff I said housekeeping staff and non-hospital personnel would have access to the confidential patient information in the file cabinets. Staff I stated, "This cabinet is never locked". During a follow up interview on 7/13/11 at 10:15 AM, Staff H stated, "We had keys for these cabinets as well, they are locked now."

Review of policy, "Release of Protected Health information," review date 5/11, revealed in part "...Boone County Hospital has an ethical, moral and legal responsibility to protect the patient's right to privacy and the confidential information contained in each patient health record
...it is the obligation of each employee to protect the confidentiality of any health information the employee may acquire about a patient from any source."

Review of the policy titled, "Confidentiality", review date 9/09, revealed in part "...To ensure that a patient's confidential health information is protected from use or disclosure that is in violation of the HIPAA Privacy Rule (the Rule) or other applicable federal or state requirements ....Unauthorized use and/or disclosure of PHI (patient health information) will result in appropriate disciplinary action..."

Review of "Schedule of Access to Protected Health Information" updated 4/2011, revealed engineering and environmental services failed to have access to PHI.












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