HospitalInspections.org

Based on observation and staff interview the facility failed to maintain A stock of drugs, sterile supplies and biologicals for patient use in the Emergency Department (ED) that were in date and not expired. This has the potential to negatively affect all patients in the ED in regards to patient care and medication administration.

Findings include:

1. A tour of the emergency department, including ER #1 and ER #2, was conducted on 4/3/12 at 11:30 am. The following medications, supplies and biologicals were found to be expired:

a. Two (2) fifty (50) milliliter (ml) vials of Marcaine 0.25%. Date of expiration December 2011.

b. One (1) bottle of Ethyl Chloride. Date of expiration January 2011.

c. One (1) prepackaged Hibiclens scrub. Date of expiration June 2011.

d. One (1) fifty (50) ml bag of D5W. Date of expiration April 2011.

e. One (1) one thousand (1000) ml bag of D51/2 IV fluid. Date of expiration February 2012.

2. Upon interview with the ER Nurse Manager, who was present at the time of the tour, on 4/3/12 at 11:30 am, she concurred with the above findings.

Based on observation and staff interview, it was determined the hospital failed to maintain the physical plant in a manner to protect patients that are transported to the portable Computed Tomography (CT) trailer unit during inclement weather.

Findings include:

1. On 04/03/12 at approximately 10:40 a.m., the CT trailer was observed located near the front of the hospital. At this time, there was not an acceptable sheltered access route to protect patients from the elements of weather during transport.

2. These findings were discussed with the hospital facility director on 04/04/12 at approximately 9:00 a.m. and agreed that a shelter access was needed to protect patients from elements of weather during transport.

Based on document review and staff interview it was determined the hospital failed to ensure that all policies are developed by a group of professionals that includes Mid Level Practitioners such as Physician Assistant (PA) or Nurse Practitioner (NP) as required by regulation and hospital policy. Failure to include mid level Practitioners in the policy development process can result in missed opportunities for input from clinicians whose expertise could provide valuable input into patient care and management with resulting improved patient outcomes

Findings include:

1. Review of the policy/oversight committee policy (revised 1/2006) states in part there will be a committee called the "The Policy/Procedure Committee" which reviews all policies developed in the hospital. The committee will consist of five (5) - seven (7) members which includes Midlevel Practitioner.

2. Review of the policy review committee attendance records from June of 2010 to December of 2011 revealed a lack of documentation of participation by a Nurse Practitioner or Physician Assistant at any of these meetings.

3. The Director of Clinical Services was questioned on 4/4/12/at 0830 hours and agreed with the lack of documentation of any input from a mid level Practitioner in these meetings or policy development.

A. Based on document review and staff interview it was determined the hospital failed to ensure there is an active infection control program that includes surveillance activities with mechanisms that evaluate the effectiveness of the program and institute corrective measures when indicated. When there is not an active infection control surveillance program with corrective actions it can lead to a failure to recognize infections in patients or practices that may lead to the spread of these infections/diseases among patients or staff.

Findings include:

1. Review of the combined Infection Control and Quality Assurance Committee Minutes from January 2011 to present revealed no documentation of any health care acquired infections and no monitoring or surveillance actives that were conducted by infection control. There were no findings, recommendations or actions that were enacted relative to the infection control or to indicate the effectiveness of the program.

2. The Infection Control Nurse on 4/3/12 at 1150 hours was questioned as to what surveillance or infection control activities she performed and she said she does not do any surveillance activities. When asked if she ever went to the patient care areas to assess for staff compliance with infection control policies such as hand washing, isolation techniques or environmental cleanliness she indicated she did not perform any routine monitoring activities. The Infection Control Nurse was asked how she identified any health care associated infections and she stated the nurses on the patient care unit send her a written slip on patients who have infections.

3. The Nurse Manager on acute/swing bed unit was interviewed on 4/4/12 at 1030 hours about identifying infections. She stated she has no training on identifying health care associated infections and will just send a written notice to infection control when a patient has any type of infection.

4. Review of the job description for the infection control nurse states in part under the nature of the work the following requirements: Collects, prepares and analyzes health care associated infections, presents infection data and makes recommendations for actions, monitors compliance in use of barriers and infection prevention measures.

B. Based on observations and staff interview, it was determined that infection control failed to maintain a clean sanitary environment in all areas of the hospital, including floors, shelves, countertops, sinks and failed to ensure that all surfaces are smooth and intact which can be effectively cleaned. Additionally the facility failed to eliminate all possible sources of cross contamination by ensuring that clean items for patient use are separated from contaminated/soiled items such as linens. Failure to maintain a clean environment with smooth intact surfaces that can be effectively cleaned and prevent sources of cross contamination may lead to the proliferation of bacteria in these areas that could result in patient exposure with these contaminates and the possible development of infections or deterioration in condition.

Findings include:

1. A tour of the medication storage area on 4/2/12 at 1420 hours revealed that all medication storage shelves had a heavy layer of dust over the surface. The Director of Clinical Services and the Pharmacist were present during the tour and were questioned as to who performs the cleaning, how often and with what cleaning agent they use, neither were able to answer the question. The Clinical Director stated it was difficult to arrange cleaning with housekeeping since an authorized person needs to be with the housekeeper when they are in this area.

2. During a tour of the Emergency Department (ED) on 4/3/12 at 1100 hours, in patient room number two (2), was a crash cart in which the medication draws had a heavy layer of gray dust over the surface where the medications were stored. The ED Manager was present during the tour and agreed with the observations.

3. On 4/3/12 at 1145 hours a tour of the dietary department was conducted and revealed the following observations:

a. The mop closet located adjacent to this area where the cleaning supplies/equipment are stored had walls that were splattered and dirty.

b. The top of the utility sink had a heavy layer of black sticky dust and the sink was heavily soiled.

c. The floor of this room was an unsealed porous concrete that could not be effectively cleaned. The mop bucket had a mop in it and was filled with black water. The bucket was visibly dirty on the inner and outer surface.

d. The floor in the kitchen and dining room consisted of a textured tile that had areas where dirt had become imbedded and could not be removed with standard cleaning techniques.

e. There were floor tiles, especially in the dishwashing area where the tile joints were starting to separate which results in areas that can not be cleaned and allows for a buildup of dirt.

4. The Dietary/Housekeeping Manger was present during the tour of this area and concurred with all of the findings. She stated the floor in dietary is old and in spite of the staff cleaning the floor daily or more often, they are unable to get down into the worn areas.

5. The Clean room where instruments are reprocessed was toured on 4/3/12 at 1415 hours. The floor was dirty with scattered loose debris. The shelves in this room where clean/sterile supplies were stored were dusty. There was equipment stored in this area which was not identified as being clean or dirty.

6. The Director of Clinical Services was present during the tour and concurred with the findings. She added the equipment in this room must be cleaned before being put in there but agreed there was no system to identify if the equipment had been cleaned before being put into this area.

7. On 4/3/12 at 1430 hours the dirty/decontamination room was toured. Located on a counter next to the sink was a basin of solution that was not marked as to what the solution was and when it was mixed or expired. Located directly in front of this basin was a piece of tape on the counter that was marked as "good until 4/1/12 at 1 PM". The sink and counter top were dirty and splashed. The floor in this area was dirty.

8. The Director of Clinical Services was present during the tour and stated the solution in the basin must be EzZyme which is used to presoak instruments and after mixed is good for forty-eight (48) hours. When questioned as to supporting information/instruction for the forty-eight (48) hour expiration after mixing of the EzZyme she was unable to provide any documentation.
The Director agreed with the observations.

Based on document review and staff interview it was determined the hospital failed to ensure that all policies are reviewed at least annually by a group of professionals that include a Mid level Practitioner, such as a Physician Assistant (PA) or Nurse Practitioner (NP). This deficient practice was found in nine (9) of nine (9) manuals reviewed (Emergency Department,Critical Access, Cardiopulmonary Rehabilitation, Housekeeping, Outpatient Nursing, Pharmacy, Infection Control, Nursing and Swing Bed). Failure to include mid level Practitioners in the policy development process can result in missed opportunities for input from clinicians whose expertise could provide valuable insight into patient care and management with resulting improved patient outcomes.

Findings include:

1. Review of the medical staff members revealed that in addition to four (4) Physicians there are four (4) Physician Assistants and two (2) Nurse Practitioners.

2. Review of the policy/oversight committee policy (revised 1/2006) states in part there will be a committee called the "The Policy/Procedure Committee" which reviews all policies developed in the hospital. The committee will consist of five (5) - seven (7) members which includes Mid level Practitioners.

3. Review of the policy review committee minutes from June of 2010 to December of 2011 revealed a lack of documentation of participation by a Nurse Practitioner or Physician Assistant at any of these meetings.

4. Review of policy and procedure manuals revealed the following policy manuals were reviewed in 2011 and lacked documentation of input by a Mid Level Practitioner:
Emergency Department, Critical Access Hospital (CAH) Policies/Procedures, Cardiopulmonary Rehabilitation, House Keeping, Outpatient Nursing and Pharmacy.

5. The Nursing manual was reviewed in November 2010, Infection Control Manual was reviewed in January 2012 and Swing Bed manual was reviewed in March 2007. These manuals lacked documented evidence of review by a Mid Level Practitioner.

6. The above manuals were reviewed with the Director Of Clinical Services on 4/4/12 at 0830 hours and she agreed there was no documentation in any of the above policy manuals of participation in the review process by a PA or NP.

Based on review of documents, medical records and staff interview, it was determined the facility failed to ensure nursing care plans are developed and kept current for each patient. Eight (8) of ten (10) care plans reviewed were found to be incomplete or inappropriate (patient #1, 2, 4, 5, 14, 15, 17, and 18). This has the potential to negatively affect all patients by not accurately identifying and documenting actual and potential patient conditions which is crucial to developing appropriate nursing interventions and evaluating patient's ongoing needs, responses, and progress.

Findings include:

1. On 4/3/12 facility's "Nursing Plan of Care" policy was reviewed and in part states, "each patient's nursing care is based on identified patient needs and patient care standards and is consistent with the therapies of other disciplines." The policy further states the care plan will be reviewed by the nurse caring for the patient each shift, and each nurse will make revisions to the plan as necessary or as the patient's condition changes.

2. Patient #1 was admitted 1/1/12 with diagnosis of Upper Respiratory Infection (URI) with difficulty clearing mucus secondary to cerebral palsy (CP). Patient's admission assessment on 1/1/12 notes "unable to walk" in the musculoskeletal assessment portion. Admission orders, written by the physician on 1/1/12 state patient is "bed confined". Record review reveals patient is aphasic and incontinent. Patient was scored a seven (7) on "Braden Scale for Predicting Pressure Sore Risk" on 1/1/12. A score of seven (7) represents "severe risk". Skin Integrity is not addressed on the Interdisciplinary Plan of Care (IPOC). Elimination is not listed on the IPOC. Activity is not listed on the IPOC. Infection is not listed on the IPOC.

"Protection" is addressed on the IPOC, albeit incompletely. Potential for injury (related to gait, recent fall, decreased cognitive function, or impaired mobility) is not identified. Under Plan of Care/Interventions, the "check off box" is colored in. There is no date of initiation and no identifier (initials) as to who filled in the box. There are no initials or signature at the bottom of the page.

Pages two (2), three (3) and four (4) have no means of identifying whose care plan this is. There is no patient sticker or patient name written on these pages. Pages are loose and not attached to each other.

Page one (1) is incomplete. Advanced Medical Directives Section is blank. Immunization Assessment completed date is blank.

Page one (1), two (2) and three (3) bear no staff name or initials.

IPOC is, by definition, "interdisciplinary". Only one RN made entry in this IPOC. Patient was seen by Respiratory Therapy and a Social Worker during her stay.

3. On 4/3/12 at 1100, the Swing Bed Director was interviewed and agreed IPOCs presented are incomplete and inappapropriate. She states it is the expectation that IPOCs are dated and initialed, bear the patient's name on each page, all "blanks" should be completed or marked "none", each page should bear the name of staff caring for the patient, problems should encompass all patient issues; potential or actual, and IPOCs should be reviewed on each shift (per policy) with updates as needed.

4. Patient #2 was admitted 2/17/12 with multiple diagnoses of osteomyelitis to left foot, Insulin Dependent Diabetes Mellitus (IDDM), dementia, and Coronary Artery Disease (CAD). Patient's comorbidities and medical history include: renal cancer with left nephrectomy, bilateral amputation of great toes, recent fall with right hip fracture, non-ambulatory, multiple unstageable ulcers, chronic obstructive pulmonary disease (COPD), hypertension (HTN), chronic anemia, peripheral artery disease (PAD), cerebral vascular accident (CVA) with dysphagia, chronic renal disease, blind in left eye with decreased vision in right eye, coronary artery bypass graft of three vessels (CABG3v). Current problems of patient included patient had a foley catheter. Per nursing notes dated 2/20/12, patient was incontinent of loose stool on two (2) occasions. The "Webster County Memorial Hospital CNA Documentation" sheets dated 2/22/12 through 3/1/12 in the patient's "feeding" column reflects poor food intake. Patient's average consumption for twenty-four (24) meals in eight (8) days is 22.9% of food consumed per meal (range from 0% to 50%). History and Physical dated 2/19/12 states patient is "going to be needing some therapy and pain control while he is here".

Discharge Planning is not addressed on IPOC. Pain Management is not addressed on IPOC. Nutrition is not addressed on IPOC. Elimination is not listed on IPOC. Activity is not listed on IPOC. Cardiovascular is not listed on IPOC. Pulmonary is not listed on IPOC. Coping is not listed on IPOC.

Pages two (2), three (3) and four (4) have no means of identifying whose care plan this is. There is no patient sticker or patient name written on these pages. Pages are loose and not attached to each other.

Page one (1) is incomplete. Advanced Medical Directives Section is blank. Immunization Assessment completed date is blank.

IPOC is, by definition, "interdisciplinary". Patient was seen by Physical Therapy, and a Social Worker during his stay. Patient was in the facility from 2/17/12 to 3/1/12. Only one RN made entry in this IPOC. IPOC progress notes have daily entry from nursing only of "continue POC".

5. On 4/3/12 at 1100, the Swing Bed Director was interviewed and she agreed IPOCs presented are incomplete and inappapropriate. She states it is the expectation that IPOCs are dated and initialed, bear the patient's name on each page, all "blanks" should be completed or marked "none", each page should bear the name of staff caring for the patient, problems should encompass all patient issues; potential or actual and IPOCs should be reviewed each shift (per policy) with updates as needed.

6. Patients #4 and #5 exhibit an IPOC in which pages two (2), three (3) and four (4) have no means of identifying whose care plan this is. There is no patient sticker or patient name written on these pages. Pages are loose and not attached to each other. Page one (1) is incomplete. Advanced Medical Directives Section is blank. Immunization Assessment completed date is blank.

7. On 4/3/12 at 1100, the Swing Bed Director was interviewed and she agreed IPOCs presented are incomplete and inappapropriate. She states it is the expectation that IPOCs should bear the patient's name on each page and all "blanks" should be completed or marked "none".

8. Patients #14, 15, 17 and 18 exhibit an IPOC in which pages two (2), three (3) and four (4) have no means of identifying whose care plan this is. There is no patient sticker or patient name written on these pages. Pages are loose and not attached to each other. Page one (1) is incomplete. Advanced Medical Directives Section is blank. Immunization Assessment completed date is blank.

9. On 4/3/12 at 1100, the Swing Bed Director was interviewed and she agreed IPOCs presented are incomplete and inappropriate. She states it is the expectation that IPOCs should bear the patient's name on each page and all "blanks" should be completed or marked "none".

Based on review of meeting minutes and staff interview it was determined the CAH failed to maintain the quality assurance program by meeting quarterly to evaluate quality activities. This failure creates the potential for the quality of care and services provided to all patients to be adversely impacted.

Findings include:

1. Review of the Quality Committee Meeting Minutes for 2011 revealed the last meeting was held on 9/22/11. There were no meeting minutes for 2012.

2. An interview was conducted with the Director of Clinical Services and Quality at 0840 on 4/3/12. During this interview the Quality Minutes were reviewed and discussed. The Director stated the Quality Committee is expected to meet quarterly. She acknowledged the group has gotten behind in meetings. She confirmed the Quality Committee has not met to conduct activities since 9/22/11.

Based on review of quality reports and staff interview it was determined the CAH failed to ensure pharmacy services and physical therapy services were evaluated through the quality assurance program. This failure has the potential to adversely impact the quality of all patients who use pharmacy and physical therapy services.

Findings include:

1. The quarterly quality reports submitted to the Quality Committee for 2011 and 2012 were reviewed. There were no reports related to pharmacy or physical therapy services.

2. An interview was conducted with the Director of Clinical Services and Quality at 0830 on 4/3/12. The quarterly quality reports for 2011 and 2012 were reviewed and discussed at this time. She acknowledged there were no reports submitted for pharmacy or physical therapy services.