HospitalInspections.org

A. Based on the Illinois Administrative Code, observation and staff interview, it was determined that 2 of 4 surgical staff in the surgical suite (Employee #2 and #5) failed to remove jewelry prior to the surgical scrub.

Findings include:

1. A review of the 77 Illinois Administrative Code 250 was completed on 5/31/11. The code indicates under section 250.1300 Operating Room, e) " All jewelry shall be removed prior to the surgical scrub. Jewelry shall not be worn in the operating room, except that anesthesia personnel may wear a watch."

2. During a tour of the surgical area on 5/25/11 at 11:45 AM, it was observed that Employee #2 did not remove rings or earrings before the surgical scrub or entering the surgical suite. It was observed that Employee #5 did not remove a ring, earring or necklace prior to the surgical scrub or entering the surgical suite.

3. During an interview with Director of Nurses on 5/25/11 at 1:00 PM, the above findings were confirmed.



B. Based on a review of the Illinois Administrative Code, CAH policy, observation and staff interview, it was determined that all physicians failed to remove surgical attire when leaving the surgical area.

Findings include:

1. A review of the 77 Illinois Administrative Code 250 was reviewed on 5/31/11. The Code indicates under section 250.1300 Operating Room k) "Shoe covers shall be worn when... They shall be removed and discarded before leaving the surgical area."

2. A review of the CAH surgical policies was completed on 5/25/11. The policy titled Attire, Surgical indicates under C. Shoe covers shall be worn for personal protection... If worn, they should be changed whenever wet or soiled and should be removed before leaving the department." The policy indicates under D.1. "Masks shall cover the nose and mouth and shall be discarded whenever removed."

3. During a tour of the hospital on 5/25/11 at 10:00 AM, it was observed that a surgical physician was outside the surgery department with shoe covers on and a surgical mask around his neck (not covering his mouth/nose).

4. During an interview with the Director of Nurses on 5/31/11 at 3:00 PM, the above findings were confirmed.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on May 25, 2011, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see C231.

.

Based on random observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Re-Certification Survey conducted on May 25, 2011, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated May 25, 2011.

.

A. Based on Critical Access Hospital (CAH) Rules and Regulations, policy and procedure, record review and staff interview it was determined that the CAH failed to ensure that the quality of services of the surgical department and anesthesia is monitored by the Governing Body. The cumulative effect of these systemic practices resulted in the CAH's inability to ensure patient safety for all surgical patients in the surgical department. Therefore the Condition of Participation for Organizational Structure was not met.

1. The CAH failed to ensure that the governing body provided ongoing evaluation of anesthesia services in the surgical department. See deficiency cited at C241.

2. The CAH failed to ensure scheduled drugs are recorded accurately when dispensed to patients in the surgical department. See deficiency cited at C276.

3. The CAH failed to ensure that medications are prepared and administered in a safe manner in the surgical department. See deficiency cited at C297.

4. The CAH failed to ensure that medical records are completed accurately and timely in the surgical department. See deficiency cited at C306.

5. The CAH failed to ensure in 1 of 7 patients to document a post op evaluation of anesthesia services by the Certified Registered Nurse Anesthetists (CRNA). See deficiency cited at 322.

6. The CAH failed to ensure that anesthesia services were evaluated for quality assurance and performance improvement. See deficiency cited at C337.

A. Based on CAH Rules and Regulations, record review and staff interview it was determined that the CAH failed to ensure that the governing body provides ongoing evaluation of quality care of the contracted anesthesia services.

Findings include:

1. The CAH Rules and Regulations were reviewed on 5/31/11. The Rules indicated that Under "E. Organization of Services Part B. Anesthesia Services 1. b. Ensuring ongoing evaluation of the quality of anesthesia care and participating in the development of clinical criteria to be used in the hospital's performance improvement/risk management program.".

2. The CAH "Organizational Chart" revised 10/6/2010 was reviewed on 5/31/11. There was no documentation to indicate that Anesthesia services were involved in the organizational structure of the CAH.

3. The CAH "Performance Improvement" minutes were reviewed for the past year on 5/31/11. There was no documentation of Anesthesia services being presented to the committee or that the contracted anesthesia services were being evaluated.

4. During an interview with Director of Nurses (DON) on 5.31/11 at 3:00 PM, the DON reported that CAH provides only contracted anesthesia services. The DON confirmed the above findings.

A. Based on Critical Access Hospital (CAH) policy, observation, record review and staff interview, it was determined the CAH failed to ensure health care services for medication preparation, administration and documentation were provided following hospital policies in the surgical department. The cumulative effect of these systemic practices resulted in the CAH's inability to ensure patient safety for all surgical patients in the surgical department, therefore the Condition of Participation for Provision of Services was not met.


1. The CAH failed to ensure that accurate and current records of the disposition of 1 of 4 scheduled drugs are maintained in the surgical department. See deficiency cited at C-0276.


2. The CAH failed to ensure all prepared drugs and biologicals in the surgical department are administered according to hospital policies. See deficiency cited at C-0297

A. Based on CAH policy, observation, document review, staff interview and record review, it was determined that in 1 of 4 scheduled drugs maintained (Demerol) , the CAH failed to ensure scheduled drugs are recorded accurately when dispensed to patients or wasted in the surgical unit.

Findings include:

1. A review of the CAH policy titled Surgery, Narcotic Count was completed on 5/25/11. The policy indicates under "Policy: A licensed nurse from the PACU is responsible to count narcotics at the completion of each day's surgery schedule. Records of counts and disposition of counted medication will be kept in the OPS/PACU nurses station."

2. During a tour of the surgical area on 5/24/11 at 10:30 AM, it was observed during a narcotic count performed with a surgical staff Registered Nurse, (2) prefilled syringes of Demerol 50 mg/ml were unaccounted on the narcotic control sign out record.

3. A review of the narcotic sign out records was completed during the tour on 5/24/11 at 10:30 AM. Documentation on the Demerol control sheet under the "Record of Waste and Spoilage", indicated only one entry of waste, dated 1/12/11, leaving 2 syringes not in the locked narcotic cabinet and no record of administration/waste. Documentation on the "Daily Narcotic and Emergency Cart Checklist" indicated the last check was 5/2/11 and the column for narcotics was not marked as counted.

4. During an interview with Employee #1 at 11:30 on 5/24/11, it was reported that the surgical staff have been responsible for the narcotic counts and no problems with count have been reported. During an interview with Employee #2 at 2:00 PM on 5/24/11, it was reported that she would locate the information related to the waste of the Demerol indicating she recalled 2 patients who were offered Demerol but did not get it for reasons she could not recall. During the interview when questioned, E #2 could not identify the patients involved. No reason was given for the lack of documentation of use/waste of the Demerol. On 5/24/11 at approximately 3:00 PM, E #2 presented the Narcotic Record which included entries in the "Record of Waste and Spoilage" section which was not present on the review of the document on 5/24/11 at 10:30 AM. The presented document indicated Demerol 50 mg was wasted on 4/29/11 due to "pt allergy" and 5/13/11 due to "pt refused." Documentation failed to provide patient identification. In further interview with E #1, she indicated she would review the surgery schedule and patient orders to locate charts that included Demerol orders. On survey date 5/25/11 at 9:30 AM, E #1 supplied medical records of the only 2 patients ( Pt. #7 and #9) with Demerol orders on the dates of 4/29/11 and 5/13/11.


5. The medical record of Pt. #7 was reviewed on 5/25/11. Pt. #7 was admitted for out-patient surgery on 4/29/11 with diagnosis of Right Inguinal Hernia with Hernia Repair and Excision of Left Upper Extremity Mass. Documentation on the Outpatient Surgery Preop Form indicated NKDA (no know drug allergies) with comment of "Demerol-nausea." The Routine Orders listed "Demerol 25-50 mg IV x 1 dose" under post op orders for pain. Documentation indicated the procedure was completed and Pt.#7 was taken to the recovery area at 9:45 AM. Documentation in the nurses notes post op indicated at 10:15 AM on 4/29/11 Pt.#7 reported "It doesn't seem to hurt anywhere" and at 11:15 "no c/o voiced." There was no documentation to indicate Pt.#7 reported pain or asked for pain medication. There is no documentation to indicate that Demerol was offered then wasted due to "pt allergy" as was documented on the narcotic record. Pt. #7 was discharge on 4/29/11 at 12:00 noon.

The medical record of Pt.#9 was reviewed on 5/25/11. Pt. #9 was admitted for out-patient surgery on 5/13/11 with diagnosis of Acalculous Cholecystitis/ Laparoscopy Cholecystectomy. Documentation on the Routine Order sheet indicated "Demerol 25-50 mg IV x 1 dose" under post-op orders for pain. Documentation indicted the procedure was completed and Pt. #9 was taken to the recovery area at 9:16 AM. Documentation at 9:16 AM indicates under "Pain--denies any" and at 9:55 AM "pt denies any c/o." There is no documentation Pt.#9 complained of pain or requested pain medication. There is no documentation to indicated Demerol was offered and "refused" as was documented on the narcotic record. Pt.#9 was discharged on 5/13/11 at 11:40 AM.

6. During an interview with the Director of Nurses on 5/24/11 at 3:00 PM, the above findings were confirmed.




25927

B. Based on policy and procedure, observation, and staff interview it was determined that in all patients receiving services, that the Critical Access Hospital (CAH) failed to ensure that all drugs and biologicals were safe for usage.

Findings include:

1. The CAH policy titled, "DISPOSAL OF OUTDATED & NON-USABLE DRUGS" was reviewed on 5/24/11. The policy indicated under "PURPOSE "1. All out dated, damaged, or contaminated drugs are removed from floor stock and pharmacy inventory monthly.".

2. During a tour of the Recovery Room on 5/24/11 at 10:00 AM, it was observed in the crash cart the following drugs were expired:

(2) Epinephrine 1:10,000 pre-filled syringes expired 5/1/11
(3) 10 ml vials of Normal Saline expired 3/11

3. During a tour of the Emergency Department (ED) on 5/24/11 at 2:30 PM, it was observed in the supply room that approximately 10 Compound Benzoin swabs had expired 10/09.

4. During an interview with the Director of Nurses on 5/24/11 at 3:00 PM, the above findings were confirmed.

A. Based on observation and staff interview it was determined that in the average daily census of 12 inpatients that the Critical Access Hospital (CAH) failed to ensure that food is properly stored and labeled for safety.

Findings include:

1. During a tour of the dietary department on May 26, 2011 at 1:00 PM, it was observed in the freezer that a white unlabeled styrofoam container was not dated. Also observed in the walk-in freezer were several bags of breaded food items and vegetables without an open date.

2. During an interview with the Dietician on 5/26/11 at 1:30 PM, she stated that their policy is to label all foods when opened. The above findings were confirmed.

A. Based on observation, Critical Access Hospital (CAH) policy, and staff interview, it was determined that for all patients requiring an intravenous line in the surgical department, the CAH failed to ensure that medications administered were prepared in a safe manner.

Findings include:

1. During a tour of the surgical area on 5/24/11 at 10:00 AM, it was observed in the clean utility room, a plastic cup with 13 - 1 ml syringes each labeled "Lidocaine" with no date, time or initials of who prepared the medication. When 2 surgical RN's were asked about the prefilling and purpose of the prefilled syringes, they stated they are filled in the morning and used to numb patient IV sites before starting an IV.

2. During an interview with Employee#1 on 5/31/11 at 2:00 PM, it was reported there was no written policy regarding prefilling syringes for future use. E #1 reported the practice of prefilling syringes for patient use at a later time is not acceptable and this standard is a known policy to nursing staff.

3. During an interview with Employee #2 on 5/24/11 at 2:00 PM, she was questioned about the prefilling of syringes. E #2 reported she prefills the syringes with Lidocaine for patients scheduled each day and those that are not used are discarded. E#2 was asked when the syringes observed were filled and she replied "yesterday" (5/23/11). During an interview with the Director of Nurses on 5/31/11 at 3:00 PM, the above findings were confirmed.

A. Based on policy and procedure, record review and staff interview the Critical Access Hospital (CAH) failed to ensure accurate documentation for surgical patients and clinical record completion for all patients at the CAH. The cumulative effect of these practices resulted in the CAH's inability to ensure patients care and treatment was under medical supervision. Therefore, the Condition of Participation of Clinical Records was not met.

1. The CAH failed to complete patient clinical records at time of discharge in accordance with written policies and procedures . Please see deficiency cited at C301.

1. The CAH failed to ensure that consents for blood were signed. Please see deficiency cited at C304.

2. The CAH failed to ensure that Post Operative evaluations are completed after the procedure. Please deficiency cited at C306.

A. Based on policy, record review and staff interview, it was determined that the Critical Access Hospital (CAH) failed to maintain clinical records in accordance with written policies and procedures.

Findings include:

1. The CAH "Rules and Regulations of the Medical Staff of Massac County Memorial Hospital District' was reviewed on 5/31/11. Under "B. Medical Records 18. The patient's medical record shall be complete at time of discharge...".

2. A review of the Delinquent Report was reviewed on survey date 5/31/11.. The report indicated a total of 259 delinquent records as of 4/30/11.

3. During an interview with the Director of Nurses on 5/31/11 at 3:00 PM, the above findings were confirmed.

A. Based on policy and procedure, record review and staff interview it was determined that in 1 of 4 (Pt. #6) medical records of patients receiving blood in the surgical department, the CAH failed to ensure that consents for blood were signed by the patient or legal guardian.

Findings include:

1. The CAH policy titled, "Blood Transfusion of Plasma, Platelets..." was reviewed on 5/31/11. Under "Procedure: 1. Verify order and obtain consent.".

2. The medical record of Pt. # 6 was reviewed on 5/25/11. Documentation indicated that Pt. #6 was admitted to the CAH on 6/19/09 with the diagnoses of Chronic Tonsillitis and Tonsillectomy and Adenoidectomy with Post Hemorrhage. Documentation indicated Pt. #6 had post operative complications of bleeding. Documentation indicated Pt. #6 was taken back to the surgical suite from the recovery area two times for bleeding after the oral packing was removed. Documentation indicated Pt.#6 received 1 unit of packed red blood cells on 6/20/09 per the physician's order. Documentation indicated Pt. #6's mother was present throughout the hospital stay and was available to sign the consent for blood administration. There was no documentation to indicate that a blood consent was signed. Pt.#6 was discharged on 6/20/09 at 1840.

3. During an interview with the DON on 5/31/11 at 3:00 PM, the above findings were confirmed.

A. Based on record review and staff interview it was determined that in 3 of 3 ( (Pt. #2,
#10, #14) surgical patients reviewed that the Critical Access Hospital (CAH) failed to ensure that the POSTOP EVALUATION documentation is completed after the procedure.

Findings include:

1. The medical record of Pt. #2 was reviewed preoperatively on 5/24/11 at 9:30 AM. Documentation indicated in the "Operative Record" that is completed by the Registered Nurse (RN), Pt #2 was to receive a colonoscopy with biopsies. Documentation indicated that the "POSTOP EVALUATION" was completed by E#2 prior to the surgical procedure. Documentation indicated that following areas were marked as completed prior to Pt#2 being transferred to the surgical suite: Skin integrity-(Cautery Pad Site checked-Unchanged), Dressings-(none), Wound Class-(Closed Contaminated (CC), Patient Condition- (stable), Spontaneous Respirations)-, Patient Disposition-(PACU), Nurses (Ns) Notes-(Transferred per RN and CRNA).

2. The medical record of Pt. #10 was reviewed preoperatively on 5/24/11 at 10:00 AM. Documentation indicated in the "Operative Record" that is completed by the RN, Pt #10 was to receive a colonoscopy with polypectomy. Documentation indicated that the "POSTOP EVALUATION" was completed by E#2 prior to the surgical procedure. Documentation indicated that following areas were marked as completed prior to Pt#10 being transferred to the surgical suite: Skin integrity-(Cautery Pad Site checked-Unchanged, and Other), Dressings-(none), Wound Class-(Closed Contaminated (CC), Patient Condition- (stable), Spontaneous Respirations)-, Patient Disposition-(PACU), Ns Notes-(Transferred per RN and CRNA).


3. The medical record of Pt. #14 was reviewed preoperatively on 5/24/11 at 11:00 AM. Documentation indicated in the "Operative Record" that is completed by the RN, Pt #14 was to receive an endoscopy. Documentation indicated that the "POSTOP EVALUATION" was completed by E#2 prior to the surgical procedure. Documentation indicated that following areas were marked as completed prior to Pt#14 being transferred to the surgical suite: Skin integrity-(Cautery Pad Site), Dressings-(none), Wound Class-(Closed Contaminated (CC), Patient Condition- (stable), Spontaneous Respirations)-, Patient Disposition-(PACU), Ns Notes-(Transferred per RN and CRNA).

4. During an interview with the Director of Nurses on 5/24/11 at 1:00 PM, the above findings were confirmed.

A. Based on record review and staff interview it was determined in 6 of 20 (Pt#4, #7, #8,
#13, #16, # 19) medical records reviewed the CAH failed to ensure that all entries are authenticated with date and time.

Findings include:

1. The medical record of Pt. #4 was reviewed on 5/26/11. Documentation indicated that Pt. #4 was admitted to the CAH 3/21/11 with the diagnoses of Closed Fracture of Neck of Femur and Pressure Ulcer Buttocks Stage 2. Documentation indicated the admission orders and multiple verbal orders had no date and time of physician signature.

2. The medical record of Pt. #7 was reviewed on 5/25/11. Documentation indicated that Pt.#7 was admitted to the CAH on 4/29/11 with the diagnosis of Right Inguinal Hernia with hernia repair. Documentation indicated the admission orders did not have a time when the orders were written.

3. The medical record of Pt. #8 was reviewed on 5/25/11. Documentation indicated that Pt. #8 was admitted to the CAH with the diagnosis of Acalculous Cholecystitis with Laparoscopic Cholecystectomy on 5/13/11. Documentation indicated the admission orders did not have a time when the orders were written.

4. The medical record of Pt #13 was reviewed on 5/31/11. Documentation indicated that Pt. #13 was admitted to the CAH on 2/21/11 with the diagnoses of Acute Renal Failure and Pressure Ulcer Lower Back. Documentation indicated multiple verbal orders had no date or time of physician signature.

5. The medical record of Pt. #16 was reviewed on 5/31/11. Documentation indicated that Pt. #16 was admitted to the CAH on 2/4/11 with the diagnoses of Chronic Obstructive Pulmonary Disease and Lung Cancer. Documentation indicated a physician order written on 2/4/11 had no date or time.

6. The medical record of Pt. #19 was reviewed on 5/31/11. Documentation indicated that Pt. #19 was admitted to the CAH on 1/27/11 with the diagnoses of Weakness and Atrial Flutter. Documentation indicated multiple orders had no date or time.

7. During an interview with the Director of Nurses on 5/31/11 at 3:00 PM, the above findings were confirmed.

A. Based on record review and staff interview, it was determined that in 1 of 7 patients receiving anesthesia (Pt.#10), the CRNA failed to document post operative evaluation of anesthesia recovery.

Findings include:

1. The medical record of Pt. #10 was reviewed on 5/31/11. Pt. #10 was admitted to the Outpatient Surgical Department on 5/24/11 with diagnosis of History of Colon Cancer/Colonoscopy. Documentation indicated Pt.#10 received monitored anesthesia including Versed and Diprivan during the procedure. There was no documentation to indicate a post op anesthesia follow up was completed by the CRNA.

2. During an interview with the Director of Nurses on 5/31/11 at 3:00 PM, the above finding was confirmed.

A. Based on CAH's Rules and Regulations, record review and staff interview it was determined that the CAH failed to ensure that Anesthesia services were monitored for quality assurance and performance improvement.

Findings include:

1. The CAH's "Rules and Regulations" were reviewed on 5/31/11. The Rules indicated that Under "E. Organization of Services Part B. Anesthesia Services 1. b. Ensuring ongoing evaluation of the quality of anesthesia care and participating in the development of clinical criteria to be used in the hospital's performance improvement/risk management program."

2. The CAH's "Performance Improvement" minutes were reviewed for the past year on 5/31/11. There was no documentation of contracted Anesthesia services being monitored for quality assurance.

3. During an interview with DON on 5/31/11 at 3:00 PM, the above findings were confirmed.